The education day started off with Dr Kruit speaking on ECMO in the COVID19 patient. Dr Natalie Kruit is a GSA HEMS Retrieval Specialist and a Cardiac Anaesthetist at Westmead Hospital, Sydney. To date there are around 360 COVID-19 patients worldwide being supported by ECMO, the predominance of which are on venous-venous circuits. Dr Kruit talked the group through ECMO experiences so far in COVID-19 and the challenges of its resource allocation during a global pandemic. The talk highlighted the current selection criteria being used in Australia to identify potential candidates for ECMO as well as the importance of optimising medical management as a pre-requisite to the therapy. It finished with the medical management of those patients who have been commenced on ECMO, focusing on issues experienced specifically with COVID-19 cases.
Intensive Care Unit Management of COVID-19
The second talk of the day was given by Dr Jill Lee, a Retrieval Specialist with GSA HEMS and Intensivist at Liverpool Hospital, Sydney. The talk focused around an update on the management of suspected and confirmed COVID-19 patients from a tertiary ICU perspective. The challenges of managing these patients in a period where evidence is short and there are still many unknowns was highlighted. Dr Lee spoke through the ‘new beast’ of COVID-19 and the local and literature documented challenges of testing, predicting clinical course and management of these patients. To finish there was discussion around the lessons learnt so far during this pandemic and what we can take forward with us in the fight to continue to keep our patients and staff safe.
Logistical Planning: Fitting a square peg in a round hole
The third speaker of the day was GSA HEMS Critical Care Paramedic Sam Immens, speaking about adaptive logistical planning using a recent case of a challenging patient extraction from a cruise ship. Sam talked through the process of the complex logistical planning surrounding what was a critically unwell patient, in a difficult access location, requiring significant interventions for medical stabilisation prior to transfer. It was highlighted that despite extensive planning unforeseeable new challenges were introduced including changes in invested parties and access options. However, through the use of pause points, adaptive logistics and anticipating potential issues these could all be overcome. A great mnemonic mentioned when considering these challenging logistical needs is PEEP CAMS:
Personnel (Qualified and Able)
Environment (Risks Assessment)
Safety Officer and Safety Plan
Thoughts on pre-hospital RSI in the era of COVID-19
The fourth speaker was Dr Clare Hayes-Bradley regarding considerations for our service in pre-hospital RSIs during the COVID pandemic. Dr Hayes-Bradley presented a summary of literature reviews around risk mitigation in potential aerosolising generating procedures (AGPs) relevant to the current pandemic. It was identified that team working to a known proven strategy of optimising first look while protecting ourselves with PPE is the overall aim. Given that we already team work to an optimised first look as standard, all we need to do is add PPE and we’re already well on our way to excellent practice. Pre-hospital services in other countries with higher community risk have adapted their practices more. Here, at GSA HEMS, we need to balance our responses against our risk – and be proportionate, otherwise we risk doing more harm than good. Our standard pre-hospital RSI with AGP PPE is appropriate currently.
The outcomes of these reviews were to recommend considering the following during prehospital anaesthesia:
Consider Plan A being VL and optimise screen position prior to first look
Be aware of potential for ‘red-out’ screen soiling with VL – suction as need
Control the bougie to avoid secretions spreading
Perform any AGPs in open well ventilated spaces where possible
Be intentional when placing down used airway kit (OPA/suction/bougie/laryngoscope) to limit contamination
Move unnecessary bystanders away and if can’t then ensure they are in appropriate PPE
HMEF with suction adaptors are available
Consider Thoracostomy as an AGP for now until evidence to say different
Emergency Medical Services Simulation Day at Killalea 2019
The final talk of the day was given by Dr Chris McLenachan, a Registrar with GSA HEMS and FACEM. The EMS simulation day is an multi-disciplinary simulation education day that last year gathered over 90 participants and observers from GSA HEMS, NSW Ambulance and the Emergency Departments of the Illawarra Shoalhaven Local Health District. The day centres around medical simulations involving critically unwell patients as their pathway moves through pre-hospital care to the emergency department. The goal of the day being to aid in familiarisation of the services in order to continually look to improve patient pathways. The origins of the day date back for years to Wollongong Base running simulations on the beautiful backdrop of Killalea. It has now grown to this regional event backed by the support and resources of GSA HEMS, NSW Ambulance and the Illawarra Shoalhaven Health Education Centre. The day yielded great positive feedback, local news coverage and plans for repeating as an annual event in 2020.
The day started with the GSA HEMS Education Team holding a Q+A on the new Inter-hospital transfer workflow for suspected or confirmed COVID19 patients. The links to the recorded demonstrations of the workflows by the team can be found in the communications book.
Staff Support from the Staff Psychology service
The first talk of the day was given by Louise Harvey, the Senior Staff Psychologist for NSW Ambulance Aeromedical Services. Louise spoke regarding the staff psychology service which provides support under the banners of employee support, trauma support and manager support. The reasons for referral are also broad and range through traumatic occupational exposures, workplace issues and personal issues. The staff psychological service provides confidential services in which needs can be assessed, voluntary support planning and referral occur and the provision of short term psychological support can be provided. In regards to significant events at the work the initial follows up occurs with Team Leaders, Peer Support Officers and chaplains. If further support or psychological support is required, then the staff psychology service can be referred to on a voluntary basis. The talk finished with Louise highlighting the importance of looking after ourselves and the self-care wheel.
Wellness and Moral Injury
The second talk of the day was given by Reverend Mark Layson, the NSW Ambulance Chaplain at Bankstown Aeromedical Unit. His current PhD thesis is focused around moral injury in emergency workers and is built upon his years of experience in the police force, as a firefighter and now as a NSW Ambulance chaplain. The issue of moral injury from medical decision making was discussed, in particular injury around resource allocation decisions that may occur during the CoViD19 pandemic. Mark spoke regarding the varying definitions of moral injury from the introverted definition of Litz to the extroverted definition of Shay. However, he led on to explain that despite the varying definitions they tend to agree that the result is the impairment or destruction of the capacity for trust, an injury that transcends the mind and body, to the soul.
The talk went on to discuss how we process these events with potential moral injury, moving away from injury and towards personal and moral growth, summarising with the NSW Ambulance stepped Approach to processing these;
Self: self-forgiveness and outward benevolence
Peer Support: companion to allow communalizing grief
Chaplaincy: expert companion and a dialogue with benevolent moral authority
Psychology: expert knowledge and directed support
Prone Positioning and Retrieval Medicine
The third talk was given by David Ransley, Intensive Care Specialist and Medical Retrieval Registrar with GSA Aeromedical Retrieval Unit.
The talk was an overview of prone positioning from an ICU perspective, a topic of interest for the retrieval unit in light of the CoViD19 pandemic and potential resultant increase in Acute Respiratory Distress Syndrome (ARDS) cases. It was highlighted that the literature and experience of transporting patients prone is sparse and that this talk was designed to generate discussion of its potential role in the upcoming months. The indications for prone ventilation in the acute were identified as refractory hypoxaemia in Acute Respiratory Distress Syndrome. The proposed benefit of the therapy being an improvement in oxygenation through increased V/Q matching and increased homogenous alveoli ventilation, as well as reducing ventilator associated lung injury. The talk went on to identify the risks associated with prone positioning including the initial physiological instability and the issues of managing adverse events such as extubation and cardiac arrest in these patients, all of which would be exacerbated by being in the transport environment.
The presentation generated discussion around the risk vs benefit and feasibility of prone position transport for the future. Additional discussion focused around the feasibility of aiming to transport these patients only during their period of supine ventilation, which is generally around 8 hours as opposed to the 16 hours they spend prone.
Ventilation with the T1 Hamilton
The fourth talk was given by Ben Porter on the T1 Hamilton ventilator, which are in the process of being rolled out in the NSW Ambulance Medical Retrieval Unit. Ben is an Intensive Care Specialist, Anaesthetist and a Medical Retrieval Registrar with GSA Aeromedical Retrieval Unit.
The talk started with a refresher in volume vs pressure control and their respective waveforms, with the general principles of Volume control being better for ventilation and pressure control for oxygenation. The Hybrid mode on the Hamilton T1 of SIMV+ was highlighted to deliver Volume control ventilation with a pressure control waveform possibly providing the benefits of both.
A couple of key points with the Hamilton T1 settings were clarified;
Importance of setting the patients height as part of ventilator set up as the ventilator will use this to calculate Ideal Body Weight (IBW) and thus predicted minute ventilation. The Hamilton T1 will use this to provide optimum ventilation parameters and alarm limits, and functions down to a minimum height setting of 30cm.
If changing the Respiratory Rate you need to review and adjust I:E ratio through Inspiratory Time, it does not adjust automatically.
In Pressure Control and Non-Invasive Ventilation settings the Psupport and Pcontrol are summative with the PEEP to give the inspiratory pressure.
At GSA HEMS the initial settings have been programmed to a male patient of height of 174cm (70kg) with 7mls/kg (TV 490mls), RR 12, PEEP 5cmH20, Fi02 100% and I:E ratio of 1:2.
The remainder of the talk used the Hamilton T1 online simulation ventilator to work through two cases of challenging ventilation.
The Hamilton ventilators are being rolled out currently and there is one for reviewing on the Bankstown Base. Ben is very happy to be contacted (either by email or phone) if anyone has any questions or wants further training.
Following the presentation at April 1st’s education day by Rev. Mark Layson, the Aeromedical chaplain, I thought it might be useful to cross-post this content from the St Emlyn’s blog. In these unusual and challenging times, this is a practical way to process some of the situations we might find ourselves in for the first time.
2019 was a bit of a mad year for me. I was appointed to a permanent post in Emergency Medicine in Sydney, I had a baby and I spent three weeks as a psychiatric inpatient in a mental hospital.
Wait. That’s not right.
I was appointed to a permanent post in Emergency Medicine in Sydney, I had a baby and I was fortunate enough to spend three weeks as a psychiatric inpatient in a mental hospital.
I hope you’re not too shocked. I’ll admit, I was a bit surprised myself – the first 24h as an inpatient were totally surreal. But I’m not ashamed. I’m incredibly fortunate to have had excellent support from two awesome EM friends, to have access to NSW’s only mother and baby inpatient mental health unit and to have been admitted early, so much so that I was able to turn my surviving into thriving. I promise I’ll share more on my experiences of postnatal anxiety and depression (PNAD), the insights and tools I accessed through CBT and why Emergency Medicine is excellent preparation for parenthood (and why it’s not) in due course.
My family is doing well; I am weaning my antidepressant dose and back at work, and my son is a happy healthy 9 month old.
For now, though, there’s something I learned in the unit that I really think you need to hear. In fact, it absolutely blew my mind to attend this session and I still can’t believe that this isn’t something we are taught in healthcare.
I want to talk about EMOTIONS.
I bet you thought this was going to be a talk about thoracotomy and trepanation, right? Well, don’t go anywhere just yet. I think this is going to be more useful to you on a daily basis and relevant to all of you. That’s right – everybody.
The following is based on a session delivered by an amazing psychologist during my inpatient stay (thank you Sarah!).
Growing up, we hear lots of messages about our emotions. Maybe you were told that “boys don’t cry”. Perhaps you’ve been accused of “moping around” or told that you have “an anger problem”. Maybe you struggle with “Catholic guilt”. Whatever your experience, I think most of us can relate to the idea that society would have us believe that some emotions are good and some emotions are bad.
But consider this: what would the world look like if there was no anger? Too much anger would be chaos and violence, but if there was none there would be no boundaries; anything could be done by anyone to anyone – and that’s chaos too.
What about sadness? If there was no sadness, life would be frivolous. And without guilt, we wouldn’t be motivated to do anything differently.
Psychologists tell us that there are six main emotions – this idea comes from the work of Paul Eckman in the 1970s although much of his work was around decoding facial expressions. Since then, work around understanding emotions has built on the idea of core emotions and there are several versions of this (Robert Plutchik described eight in pairs, and displayed them in a colour wheel) but the underlying principles are the same. Other words we use to describe how we feel can be sorted into one of these six categories, and each of the six main emotions serves a specific purpose.
The purpose of fear is to protect us from danger and ensure our survival.
If there was no fear, we would put ourselves into dangerous situations. Too much fear is debilitating; it prevents us from doing the things we want to do.
Anger exists to tell us that a boundary has been violated.
Without anger, we would not be able to protect ourselves and our interests. We would find others taking advantage of us. Too much anger can hurt those around us, destroying our relationships.
(Eckman called this DISGUST, but I think shame is easier to understand)
We feel shame in order to motivate ourselves to develop or improve certain parts of ourselves.
If we didn’t feel shame, we would continue to do things that harm ourselves and others. Too much shame is also paralysing; it would cause us to withdraw from society, to experience low self-esteem and to isolate ourselves from others.
The purpose of sadness is to show us what matters to us.
Without sadness, life would be superficial. We wouldn’t form meaningful relationships or realise the value of other people and things in our lives. Too much sadness prevents us from functioning, as those with depressive illnesses know.
Love helps us to form attachments and connections.
If we didn’t feel love, we wouldn’t meet our need for community and connection. Too much love can impair our logical thinking, particularly if we become infatuated.
We experience happiness to reward behaviour that benefits us.
Without happiness, we would lack enjoyment in life and particularly in social connections (think about the times you are most happy; they usually involve a moment of taking stock and often involve other people). Too much happiness means we wouldn’t understand our limits and we might prevent other people from being able to live their lives.
Why this – and why now?
We are living and working in unprecedented times.
As an Emergency Physician I have often thought that my emotions get in the way of my ability to do my job. I might even have described myself as “dead inside”, used so-called “black humour” in stressful situations or even walked from breaking bad news straight into a consultation where I play with a toddler. I’ve thought of myself as a “head” person far more than a “heart” person and I wonder how many of you can relate to this.
While the idea of emotions being a nuisance at work might be true in some ways, my approach of just pretending to myself I didn’t feel anything was not the most functional. It’s also an unfair way to treat myself, because I’m not a robot and I do feel things. There are tough resuscitations, failed resuscitations, horrible deaths and little moments of collateral beauty that stay with me. In truth, I have been afraid to open the box I’ve kept my emotions in because I was scared that they would never stop pouring out. I am fallible, imperfect and human, and so are you.
Logically, emotions do make sense; they are crucial to our survival as they drive us towards togetherness, towards a functioning social group – and that, I think we are about to find out – is the essence of our humanity. I’m bringing this concept to you now because I think we are going to find our emotional responses unavoidable in the coming days, weeks, months and years as we work and live through this crisis.
We often judge ourselves for “feeling”, especially when we have listened to society and attributed “good” or “bad” tags to particular emotions. As a psychiatric inpatient I learned about the concept of self-validating my emotions. Validation means not judging myself and not judging the emotion, simply accepting that I feel what I feel in a particular situation. Adding judgement often fuels further unhappiness. In this case, we might feel anger or fear as a secondary emotion in response to our primary emotion (for example, sadness).
The key is acceptance; this can prevent us from falling into the trap of allowing secondary emotional responses. Freeing up our emotional and cognitive processing power by accepting what we feel allows us to do more to change our situation (if we need to).
Self-validation has three stages. If this is totally new to you, you might not be immediately able to proceed to the third stage – and that is completely fine. I would, however, advise you to practice now. Self-validation is a skill, and like all skills the more you practice, the smoother and more natural it will become. That may be valuable in the ensuing weeks.
Step 1: acknowledge
This is perhaps the hardest and most important step; name the emotion that you feel and let go of any associations with feeling it.
I have talked a few people through this process in recent weeks and often when you ask someone “how do you feel?” they immediately begin talking about their judgement of the situation, eg “I can’t believe that he was so rude to me!” or “It’s so irritating that they did that!”
Try to let go of the judgement and discern how you feel. Put a name to that feeling and say it out loud.
“I feel angry.”
“I feel sad.”
If you are able to align your emotional state with one of the six main emotions, that’s great – if not, try to work out which main emotion the word you are using to describe the way you feel falls into.
Step 2: allow
Allow yourself to feel that emotion. It is the way you feel – and that is ok. Tell yourself that. Give yourself permission to feel what you feel; as we have already discussed, there are no “good” or “bad” emotions.
“I feel sad. It is ok that I feel sad.”
“I feel angry. It is ok that I feel angry.”
This might be as far as you can go initially. That is totally fine.
When you are comfortable naming and allowing your emotions, try to move to step 3.
Step 3: understand
Once you can identify which of the six main emotions you are feeling, you can refer back to the purpose of that emotion to try to understand where it comes from. Sometimes we do feel a mixture of things at once, so try to take them on one at a time.
“I feel sad. It is ok that I feel sad. It is understandable that I feel sad; sadness exists to show me what matters to me. It matters to me that I am good at my job and things here didn’t go the way I wanted them to. My family matters to me and I saw the pain of losing them reflected in the pain of my patient’s family.”
“I feel angry. It is ok that I feel angry. It is understandable that I feel angry; anger exists to tell me that a boundary has been violated. In this situation, that boundary is the respect I expect to be shown in my workplace by my colleagues.”
Understanding your emotional response goes beyond judgement and attempts to make sense of the way that we feel. This is difficult, but gets easier with practice. I would suggest taking a moment to self-validate your emotions at minimum once a day; as you are leaving work would seem to be a good time to check in with yourself, but as things get harder you might want or need to do this several times a day.
And that’s it. Acknowledge, allow, understand – three steps to help you to take care of yourself; to prevent things being bottled up inside and to check in with your emotional state in a non-judgemental way.
I hope this helps you to stay well. I suspect that you, like me, will be more whole, more productive, and more peaceful if you accept both head and heart – and trust yourself to open that box.
Our March education day was focused around the theme of burns, which was stimulated by the recent Australian bushfires. A BBQ lunch was had for all attendees and raised over $120 towards the RFS bushfire victims.
Surgical Airway Clinic
The morning started with one of our regular practical skill “pop-up clinics”; this month the skill was surgical airway. We discussed some of the potential causes of the rare “can’t intubate, can’t ventilate” (CICV) scenario including difficult airway, upper airway obstruction and massive facial trauma and discussed the importance of regular practical and mental rehearsal of the procedure given it is a low frequency, high importance intervention. Everyone had multiple opportunities to practice on one of our neck models which simulate the tactile nature of the procedure using fake blood to obscure any visible landmarks and making the procedure closer to the reality of the experience of the real-life cases handled by Sydney HEMS.
Bushfire Response by AUSMAT
Our first talk of the day was given by Clayton Abel, Team Leader of NSW Fire and Rescue’s Natural Disaster and Humanitarian Response Team and Kavita Varshney, Emergency Medicine Specialist and AUSMAT team member. Both Kavita and Clayton were part of the team asked by the Federal Government to respond to the bushfire crisis at Batemans Bay to support local medical resources. Clayton highlighted the importance of self-sufficiency and logistical organisation to avoid adding pressure to already stretched local resources. Kavita reinforced the huge impact and importance of getting to know your deployment colleagues in order to work effectively as a team and deliver maximum efficiency. Clayton and Kavita used the example of a large storm wreaking havoc through the tents and equipment as a great example how preparation and team training can reduce the hazards of complacency and high risk, low frequency events.
White Island Volcano Patients
The second talk of the day was given by Karsoon Lim, Anaesthetic Specialist and Peter Maitz, Burns and Plastics Specialist and Department Head, both at Concord Hospital. The focus of this talk was on the findings and management of the repatriated victims of the recent White Island Volcano eruption in New Zealand. We spent time discussing the mechanism of the burns and the atypical findings in this cohort of patients including very fine grit and dust ingrained in the eschar. The associated chemical injury from the noxious substances released from the volcanic rock grit proved to be highly toxic and rapid surgical excision of the eschar resulted in almost immediate reductions in vasopressor requirements. The Concord team also advised us that one of the other issues identified in this patient cohort was persistent hypocalcaemia and hypomagnesaemia secondary to hydrofluoric acid exposure. Fluoride binds cations such as calcium and magnesium rendering them unavailable for physiologic processes and thus leading to profound and life-threatening metabolic disturbances. The team reinforced the multidisciplinary nature of caring for burns patients and made particular note of the entourage of staff from a huge variety of allied healthcare professions that are involved in these patients care. These include, but were no means limited to; dieticians, physiotherapists, psychologists and speech and language therapists.
The Major Incident Response
The third lecture was given by Cameron Edgar, Director of Helicopter Operations who spoke about the role of the Incident Management Team in reference to the recent bush fire crisis. Cameron talked about the difference between command and control during a major incident and the importance of closed loop communication as well as allocation and clarification of roles. Cameron was able to give a summary overview of the incident management team structure and its divisions and the importance of the SMEAC (Situation, Mission, Execution, Administration and Command) document in communicating a incident response plan.
NSW Bushfire Patients
The final talk of the day was given by Justine O’Hara, Specialist Plastic and Burns Surgeon from Concord Hospital. She described the clinical course of the 48 bush fire victims who were treated on the Burns Unit. These were a diverse range of patients with burn surface areas of between 1.5% to 59% and an age range of 17 to 84 years. Justine focused on the benefits of novel skin replacement technologies that allow early eschar removal but delayed skin grafting. This delay in grafting allows the patient’s initial inflammatory response to subside and results in better graft success due to improve physiological stability, reduced vasopressor requirement and replete nutritional state. Early and prompt retrieval with appropriate acute management to the correct centre allows for rapid eschar removal (thus limiting toxin release), replacement of the skin with these new synthetic agents and a multidisciplinary team approach which together improve patient’s outcome.
This patient had quite noticeable pulmonary edema, easily fixed with suction prior to intubation.
Neurogenic pulmonary edema is said to occur rapidly post injury while pulmonary contusions typically evolve over time peaking over hours. These two entities have different etiologies but both will benefit from supportive care and positive pressure if needed. Once the initial insult has been attended, the pulmonary edema will usually resolve within 3 to 7 days.
Neurogenic pulmonary edema is said to be triggered broadly by neurohumoral sympathetic surge… however whilst animal models show some benefit with alpha and beta blockade, this is not as yet recommended due to issues with cerebral perfusion and cardiac arrhythmias.
Source: Wemple, M., Hallman, M., Luks, A. Neurogenic Pulmonary Edema In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2014