Major Incident Education Day

Our most recent HEMS Education Day on the 31st May, took a focus on Major Incidents and the role our service plays. The day commenced with some insightful talks, before leading into an exercise that saw our medical teams integrate with an Ambulance response to a timely scenario. Despite being crafted months ago, our scenario closely mirrored the events in London that unfolded 4 days later. Indeed, it was modelled from other recent world events such as in Melbourne, London, Nice and Berlin – the growing threat of “Intentional Vehicular Assault” (IVA).

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The learning from the day was immense. Below is just a summary of a few key points of the day.

The Exercise…

Scenario:

10.30am, Wednesday morning. Rogue driver has driven through Parramatta’s Church St Mall, intentionally hitting multiple pedestrians. Gunshots were also heard. Police on-scene and driver has been confirmed dead from gunshot wounds. Security threat now neutralised.

Tasking:

Following multiple “000” calls, initially 7 paramedic teams were tasked to the scene, along with one Inspector. A further 5 paramedic teams arrived during the scenario to assist with transport. From Bankstown Helicopter base, 2 road medical teams were dispatched via the Aeromedical Control Centre (ACC) based on initial reports. This was quickly followed a few minutes later with 2 helicopter teams being tasked. The Duty Retrieval Consultant (DRC) was tasked as the Medical Commander.

Response:

All teams arrived in a coordinated fashion over a 30 minute period. The initial triage sieve was done by road paramedic teams, utilising Smart Tags. Patients were grouped according to their triage category and brought into the Casualty Clearing Station (CCS). In total there were 30 casualties, with 2 declared dead on scene, and 2 deaths in transport. Another 10 patients had critical injuries.

Debrief & Learning Points…

Command & Control:

  • Prompt declaration on scene of Major Incident.
  • Ambulance Inspector arrived assuming the command role.
  • Medical Commander (DRC) arrived later and became co-located with Ambulance Commander – intersecting roles help to bridge the gap between pre-hospital and hospital response.
  • Noted that position of Medical Commander needs to be formally appointed by State HSFAC or Medical Controller.
  • AMPLAN not activated for this incident –  explanation ensued around line between a “bad day at the office” and the need to activate AMPLAN.
  • “Whispir” notification to all members of our service gave an idea of availability of extra staff.

Safety:

  • Security threat neutralised in this scenario, and was not supposed to play a large role in the incident. Brief discussion occurred to be mindful that further threats may still exist.
  • Some suggestions were made around improving visibility of medical teams with different tabards.

Communication:

  • Radio communications were all relayed through a central coordination point which for the purposes of the exercise functioned also functioned as the ACC.
  • The need for common terminology was noted with terms such as “Casualty Clearing Station” being utilised so that all staff can have a mutual understanding.
  • The importance of “sharing the mental model” was re-visited. The application of this to the more macro workings of a Major Incident was discussed along with the difficulties of disseminating the information in such a large group of staff, with multiple patients. The challenge is to have everyone working to the same “model.”

Assessment:

  • The creation of the CCS and its designated areas all occurred organically. The ability to fully utilise the space and environment that you are in to create a CCS was discussed. Every incident will be different – control your environment as best you can.

Triage:

  • This was noted to be a very dynamic process and the importance of having ways to record and keep tally of your patients is paramount.
  • Initial sieve done by paramedics out in the “hot zone” with the next stage of triage, “the sort,” completed back in the CCS. Sieve is based on mobility level/RR/HR, while the sort then utilises RR/GCS/SBP.
  • The usefulness of ultrasound in higher level triage was also touched on.

Treatment

  • Treatment in the hot zone consisted of simple airway interventions, positioning and placement of IV cannulae.
  • A number of life saving interventions were conducted in the CCS – chest decompression by needle and finger thoracostomy, tourniquets applied, LMAs inserted, blood and hypertonic saline were given.
  • The potential for reallocation of medical teams/resources under the direction of the Medical Commander was explored.

Transport

  • The range of methods available to transport patients from the “hot zone” was explored to reduce reliance on stretchers.
  • The appointment of a “loading officer” during the exercise was a helpful point of contact for the control centre. It allowed a definite end point of which patients and teams were being transported to where.
  • The importance of high level triage was discussed. This allows patients to get to the right place to begin with, thus alleviating the burden on retrieval services for subsequent transfers.

The talks…

Cam Edgar:

In a major incident, a range of documents from National/State level down to clinician level will guide our approach and importantly, normal tasking procedures remain in place (ie; all taskings via the ACC). An HEAS (Aeromedical) Incident Management Team (IMT) will be established to coordinate and provide advice on the aeromedical support to a major incident. Plans and broad awareness is well established, but regular training to ensure preparedness is crucial. This must also consider the psychological impact on staff equally to that of other aspects to enable a successful response (are they ready to respond?).

Gary Tall:

In NSW, medical retrieval teams have specific roles in the prehospital response to major incidents that expand upon their normal everyday role of advanced clinical treatment. These roles are written into NSW HEALTHPLAN and AMPLAN, both of which are undergoing revision in light of lessons learnt from recent terror attacks both locally and abroad.

Medical retrieval teams provide clinical leadership to the Casualty Clearing Station, adding a medical triage sort to the hot-zone paramedic triage sieve, and coordinating treatment of patients. In addition, the most senior doctor assumes responsibility for directing the priority of transport and ensuring an appropriate destination for each patient. Clinical information is communicated to the State Medical Controller and State HSFAC in the State Health EOC to facilitate the best possible system response by Health.

JP Favero:

The Royal College of Surgeons of Edinburgh’s Diploma of Retrieval and Transfer Medicine Syllabus includes an Operational Domain asking candidates to describe the roles and responsibilities of emergency services in retrieval, comparing the incident command structures & medical capabilities of these organisations.

NSW has an abundance of stakeholders who may be involved in the event of a major incident. This is dependent on the type and phase: Natural or Man-made; Simple or Compound; Compensated or Uncompensated; Acute or Chronic. Some of the key agencies, typically well established and substantively government funded, include our own NSW Ambulance; Police (State and Federal); Fire and Rescue; Rural Fire Service and the substantively volunteer staffed State Emergency Service. Each of these organisations will play the ‘combat’ or in-command agency role dependent on the type of major incident facing our community. Besides Ambulance these other organisations have rudimentary medical capability only. The range of agencies ensure there is redundancy and infrastructure in a range of locations throughout to state from which to coordinate emergency command and response.

We revisited phases as per the Major Incident Medical Management and Support (MIMMS) Course definitions:
1. Preparation – a. Planning b. Equipment c. Training
2. Response – our agency’s management and support priorities as per CSCATTT: Command; Safety; Communication; Assessment; Triage; Treatment; Transport.
3. Recovery – including broad and long lasting implications of secondary retrieval for our organisation

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Clinical Governance Day – Wednesday 14th June

June CGD Flyer

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Interview with Cameron Edgar

In this 25 minute podcast Dr Cliff Reid talks with Cameron Edgar, a senior helicopter critical care paramedic. Cameron has been a paramedic for 23 years, qualifying as an intensive care paramedic, then a special casualty access team paramedic, and then a helicopter critical care paramedic where he has a management and leadership role.

Topics discussed

  • Critical Care Paramedics are relatively new in Australia in terms of formalising the role.
  • In New South Wales CCPs work with physician. The helicopter paramedics have medical, rescue, and aviation skillsets
  • As well as emergency (‘triple zero’) response, they also conduct interhospital critical care transport as part of a medical team.
  • Examples of other skills that Helicopter CCPs must train in include: patient access, winching, survival, land based navigation, water rescue via winch, abseiling and rope rescue skills.
  • Staying sharp in all these areas along with clinical work is achieved by appointing highly motivated individuals to start with, and providing ongoing regular training ‘recencies’ eg. winching every 60 days, RSI currencies, and others.
  • On managing high performing type A personalities: they don’t need to be managed, they need to be led. Listen to them – they are experts in their field
  • Biggest challenge with high performing individuals is when they’re not busy. Fill time on base with clinical training, rope rescue training, coffee and cases
  • Working with physicians: paramedics and doctors together are synergistic – combine the logistic and prehospital expertise of the paramedic with critical care expertise of the doctor
  • Tips for paramedics who want to become helicopter critical care paramedics. Hone your skill set before taking on new skills. Be patient and be very good at what you do. Develop your non-technical skills.

Follow Cameron on Twitter – @CammoEdgar

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HEMS Education Day – Wednesday 31st May

May HED Flyer

The next HEMS Education Day (HED) will be an exciting opportunity for the organisation to examine our role in Major Incidents. The day will primarily revolve around a Major Incident Exercise which is being put together by our education team. However, we will still kick off the day with a talk from JP Favero that follows the Diploma of Retrieval and Transfer Medicine which will touch on the role that other services play in major incidents. Before launching into our exercise, we will also hear from Cameron Edgar and Gary Tall about the role our service plays in such events. As for the rest of the day – well you’ll just have to turn up to find out!

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Clinical Governance Day – Wednesday 17th May

May CGD Flyer

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Vomit control at Sydney HEMS

Karel Habig rigged up a SALAD simulator (Suction Assisted Laryngoscopy and Airway Decontamination – the brainchild of Airway Master Educator Jim DuCanto) and ran a vomit-control workshop at our recent HEMS Education Day.

Here are the learning points as summarised by Karel:

Management of massive emesis/Upper GIT Haemorrhage

Prevent – head-up position for all intubations to reduce passive regurgitation as specified in the Prehospital Emergency Anaesthesia Checklist

Plan – where apparent/likely – Double suction tested, briefed Airway Assistant, PPE esp eye protection for all staff – as specified in Prehospital Emergency Anaesthesia Checklist

Considerations
Prehospital Laerdal Compact Suction Unit – very effective BUT fills at 330mL and stops working if filter wet – ALWAYS use alternative suction from vehicles/venturi first

Understand the sucker – Yankauer with hole takes up one person’s hand and doesn’t work unless the hole is occluded. Not ideal.

Large bore suction with no hole is ideal or just use tubing (esp where vomitus is chunky or large clots)

A size 6.0 tracheal tube without airway adaptor can be inserted into all of our suction tubing – good alternative “suction catheter”

IF unexpected Massive Emesis/GIT Haemorrhage post induction:

Initial steps
1. Take a deep breath. Expect to become extremely task focused and lose situational awareness. Verbalise this. ALL staff running through SALAD noticed this

2. Consider log-roll to toilet airway immediately

3. Once returned to supine position – Suction to the cords (don’t try to clean the entire oropharynx) and intubate trachea with bougie (standard intubation)

4. Double suction – place fixed suction along left-hand side of laryngoscope, lock into groove of DL blade and use second device to suction to cords.

5. If not able to control rapidly then deliberately intubate oesophagus (blind placement) inflate cuff (may need 20mL air) and divert flow (take care to avoid spraying assistants)

6. Suction to cords and intubate

7. Large bore suction catheter or Size 6 tube attached to suction can be used to suction down to and then intubate the trachea. Tube change over bougie may be needed in large patients

8. Digital Intubation is an option for those who have practised it

9. Some airways are surgically inevitable.

Haven’t had enough vomit? Listen to EMCrit’s Having a Vomit SALAD with Dr. Jim DuCanto

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HEMS Education Day – Wednesday 3rd May

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