Clinical Governance Day – Wed 31st October

31 October

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Education Day Wed 17th October

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Pearls from Education Day – 19/9

Courtesy of Nick Scott:

Our education day commenced with an update on the current terrorism threat, delivered by the NSW’s Counter Terrorism & Emergency Management Department. Ambulance service NSW’s role is key in being the “eyes and ears” – if you witness something suspicious report it using the national security hotline 1800 1234 00. Further information can be found at https://www.secure.nsw.gov.au/what-you-can-do/.

We had the pleasure of inviting one of our previous Registrars back – Dr Preston Fedor to deliver a fascinating talk. Preston is an Emergency Physician, Assistant Medical Program Director for Clark County EMS and a Captain, USAF, MC – 304th Rescue Squadron.

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This lecture centered on a case, which involved not only complex and prolonged medical care, but also a complex rescue mission. The United State Air Force Pararescuemen (PJs) were tasked to access and care for two critically burned men aboard a ship more than 1000 miles out to sea, halfway between New York and Portugal. They flew out in an HC-130, parachuted into sea at night, boarded the ship from Zodiacs, and met their patients. Over the course of 32 hours the men cared for these patients, who required airway management (ETI for one, cricothyrotomy for another), escharotomies, continuous pain control and sedation, regular wound debridement and dressing changes, ventilator management, and more. All were eventually hoisted off the ship by a Portuguese coast guard helicopter.

As complicated as this all sounds (and it was a massive effort), the medical care was based on the adaptation of a relatively straightforward tactical medicine construct – MARCH. This is an acronym for the main priorities when caring for a patient in a tactical environment:

Massive Hemorrhage – Control it!

Airway – Open and maintain it by whatever means necessary

Respirations – Support ventilations if needed. Cover any holes in the chest. Make holes if needed.

Circulation – Access and fluids, blood, TXA

Head injury / Hypothermia – Think of head injury and avoid hypoxia/hypotension. Control the environment: get the patient off the ground, keep warm.

Over the years of wartime experience, the PJs learned that in order to fully use their paramedic skillset and better care for their patients in the tactical and prolonged care environment, that an addition to MARCH was needed. In comes MARCH / PAWS.

The PAWS stands for:

Pain control – early and often

Antibiotics (and) – antibiotics for battlefield wounds, and other meds as needed (think antiemetics)

Wounds – irrigate and debride battlefield wounds, burns as soon as feasible

Splinting – splint fractures, c-collars, spinal protection, eye shields

This framework as written is great in a tactical or prehospital environment when you can run through it, address the major issues, and then head right off to a trauma center. In the case of a prolonged care scenario (as in this case), when you may be with the patient for hours or days, MARCH / PAWS must necessarily become a cycle – continue to reassess, continue to manage these issues throughout the time you are caring for the patient. Keep going back to that airway, verify no tension pneumo is re-accumulating, tweak the vent as needed, continue sedation and pain control, clean and redress wounds, etcetera.

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More important than memorizing and using these acronyms is to anticipate that these prolonged care scenarios will happen to you. This could be your next mission. So train for these situations, prepare yourself and your team for this eventuality. Find a way to stay organized and calm, and not miss any important elements of your patient’s care in the complexity and stress of these scenarios. MARCH / PAWS is one excellent way to not only keep it together, but excel.

Additional references, videos, podcast links, and other resources for this talk can be found at operationalems.com/lecturenotes.

Examining the literature:

We critiqued two papers on the day – Gavrilovski et al https://www.ncbi.nlm.nih.gov/pubmed/29706249 article regarding isolated head injuries and their association with cardiovascular instability and  Rehn et al https://www.ncbi.nlm.nih.gov/pubmed/29141907 emergency vs standard response driving.

Have a read of the papers yourself – a few points brought out of our discussion was when does correlation imply causation and the use of DAG’s – Directed acyclic graphs (DAGs) are visual representations of causal assumptions and they can help to identify the presence of confounding.

Lessons from Cyclic 2:

Cyclic training had been very successful with abundant amounts of learning for the individuals taking part. One of the exercises was a night winch involving a big sick 45 yo male dirt bike rider accident, complicated by having his 12 yo son on scene. This was an unsupported scene 4 hours by foot.

These were just a few of the learning points to take away:

Before you set off on such a mission use the PEEP tool to assist mission planning:

Personnel

Environment

Equipment (CAMS -comms, access, medical, survival)

Plan B

These types are jobs are challenging with cold, dark, dirty and confined conditions. So, make sure you’ve the right PPE/clothing. Eye protection when walking through the Bush and don’t wear your torch hanging around the neck – think about illuminating what you’re doing!

You should mentally rehearse workflows with the team before you arrive on scene. Make decisions early about space creation, gear management, moving your patient vs temporising in sit u.

These are difficult conditions- don’t overlook optimizing the patient before interventions such as RSI. Consider using basket and immobilization equipment to help prep your patient for RSI e.g. combining the KED and basket creates a patient head up position -great for RSI but may limit access for thoracostomy. Utilize the bystanders.

All this and much more needs to be considered if the patient is to be effectively and safely treated and scene times are kept to a minimum.

The day concluded with ventilator groupwork designed to share learning about some of the finer nuances around our Oxylog 3000+ and Medumat Standard 2.

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Clinical Governance Day – Wednesday 3rd October

CGD Oct

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Education Day – Wednesday 19th September

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Clinical Governance Day – Weds 5th Sept 2018

CGD 5th Sept 2018

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Education Day Wrap Up – CBRN, Tactical Medicine and Major Incident Management…

(Courtesy of JP Favero)

CBRN

Associate Professor Dr David Heslop kicked off the day with a talk on CBRN Issues explaining the characteristics of these type of threats – usually deliberate, sometimes accidental, often used to kill or incapacitate military and/or civilian targets. They an be engineered to defeat defences with strategic and political effects. We noted the 5 Pillars of CBRN-D: Warning and Reporting; Detection, Identification and Monitoring; Physical Protection; Medical countermeasures and supports; Hazard management.

There was explanation of Mission Oriented Protective Posture (MOPP), types and levels of Personal Protective Equipment. We touched on the effectiveness of decontamination and principles to employ both pre and post this type of terrible event. Our senior doctors, many of whom lead major Sydney emergency departments, appealed for advice on who to call in real time.

The Grenfell Fire Experience

Laurence Ioannou gave us a first hand run down of his Grenfell Tower Fire experience as Ambulance Scene Commander. You probably know the story… A 24 storey block of flats in North Kensington, West London, went up in flames early on the morning of 14 June 2017. It took 60 hours to put it out. There were sadly 72 deaths, about 80 people were treated on the scene, 70 transported. At the peak there were 71 ambulance vehicles in play and approximately 30 patients had intensive care post the event.

The value of Joint Emergency Services Interoperability Principles (JESIP) was emphasised – 5 important principles for joint working in major incidents – Co-Locate, Communicate, Coordinate, Jointly understand risk, Shared situation awareness. Laurence found it was vital to brief and share info between agencies every 45 mins or so. He also explained the value of Pre-Determined Attendance. London Ambulance has PDA for ‘Significant’ and ‘Major’ Incidents – early declaration and resource activation saves lives. Simple things make a huge difference – disposable carry sheets / frameless transport devices for patients and coloured tarpolines on the ground for casualty clearing stations, weather allowing.

There’s a great deal of trust in managers and peers during this type of response. Paper log books and a scribe are a must if you find yourself in charge, and don’t forget it takes a long time to complete formal handover, an important consideration in a protracted incident alongside fatigue. Oversight is difficult. Delegate another senior colleague to walk through the casualty ‘journey’, optimise and report back. Control can do a lot to offload scene commander(s), determine hospital destinations and streamline communications – it’s next to impossible to receive information on multiple channels and properly monitor the radio when you’re the on scene boss.

Tactical Medicine

Later in the morning Oli Ellis and Scott McNamara had a chat about Tactical Medicine and the need to practice it in any incident that involves the risk of imminent physical harm to the responder(s).

Remember Rule No 1: Manage your own trauma and don’t willingly expose yourself to these environments without proper training

We know it’s about the correct intervention at the correct time, and that there’s a continuum of BLS to ALS dependent on threat. Unfortunately, when in the hot zone, a medically correct intervention at an incorrect time can lead to further injury. And it’s worth remembering a threat can shift, capturing you and your team in what may have been a previously clear or apparently benign environment. Increased Threat = Decreased Treatment

It was a shame Ben Roberston wasn’t there – he was probably out saving lives in the place where he lives, the danger zone. Meanwhile we noted its all about:

Hot – Danger – Threat suppression
Warm – Not Secure – Haemorrhage control, Rapid extrication
Cold – Safe – Assess and treat patient, Transport to Hospital

The boys made Tactical Emergency Casualty Care (TECC) look HOT, ready to rapidly treat or exclude the 3 big preventable causes of death Haemorrhage, Obstruction of the airway and Tension pneumothorax. They touched on RAMP Triage (Rapid Assessment of Motor and Pulse) and utility in predicting mortality from US military data.

Workshops

Our afternoon workshops covered off HEMS Team PPE, mask application, Tyvec suits and a real tasking cased based discussion. There were examples of PPE carried by the Special Operations Team, SOT tactical apparel and equipment. Scott gave us a demonstration of wound packing, great fish hook, tourniquet application and labelling. Oli provided an excellent look at patient assessment – radial pulse and simple assessment of level of motor function RAMP style along with a ‘sweep’ in the hostile environment. Integrating “tactical breathing” into the primary survey is something we can all do. We spoke a little about the utility of posturing expectant and deceased patients in a mass casualty scenario and sharing that with other services or those accessing the scene later. Positioning, maintenance of situational awareness, scanning, tactical breathing and great commentary were all on show.

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Oli demonstrating a primary survey in a tactical setting.

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Scott “fish-hooking” a wound prior to packing.

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