Clinical Governance Day – Wed 28th November

CGD 28:11

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Burns education day wrap up

(Courtesy of Dr Sandeep Gadgil)

Burns Education Day – Summary

On 14thNovember we had the pleasure of hosting members of the Concord Hospital Burns team for our Burns Education Day.

NSW Ambulance Burns Audit

Dr Clare Richmond kicked us off with data on burns patients from the last 3 years, prepared by Dr Efrem Colonetti. The key findings for this period (2015 to 2018) were:

  • 241 burns patients, 141 were intubated, 46 by the retrieval team
  • 8 escharotomies were performed by the retrieval team
  • 58% of cases were flame burns, 19% were flash / explosion
  • 67% of burns case sheets had a documented TBSA
  • 73% of those with documented TBSA were consistent with hospital findings
  • 95% of the burns patients did not have any significant concomitant trauma

These findings were compared with the Audit published by Dr Brian Burns last year (https://www.researchgate.net/publication/317316935_A_review_of_the_burns_caseload_of_a_physician-based_helicopter_emergency_medical_service).

The main take home points highlighted by Clare were to ensure documentation of TBSA and airway findings, assess for concomitant trauma and consider transfer to Concord if nil significant trauma. We were reminded of the feature on the ITIM app to assist in TBSA burns calculations (https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/ed-applications/trauma-apps)

Concord burns team

We had a fantastic set of presentations from the burns team covering burns assessment, pathophysiology, first aid, fluid resuscitation, airway considerations and surgical options. Throughout the day, the team emphasised that they want to be consulted early in relation to burns patients. For those interested in learning more about burns management they recommended the EMSB course (https://anzba.org.au/education/emsb/).

Dr Justine O’Hara (Plastics / Burns Surgeon) discussed the assessment and initial management of burns and provided some key messages:

  • Accurate assessment of burns area and depth can be difficult
  • Importance of good first aid (running or sprayed / sponged tap water for 20 minutes)
  • No ice or iced water, no antibiotics
  • Appropriately dress burns, do not debride (covering with cling wrap is ok)
  • Know the NSW burns transfer guidelines
  • If large burns (>15%) – IV fluids, analgesia, IDC & retrieve to burns unit

She also described a range of current and emerging surgical options (traditional debridement, fascial excision, hydrosurgical debridement) and wound closure options (allografts, xenografts and cultured epithelial autografts).

Dr Mark Kol (Intensivist) gave an overview of fluid management and the pathophysiology of shock in a burns patient. Points he highlighted were that fluid resuscitation in burns improves outcomes, the modified parkland formula (3ml/kg/%TBSA with half in the 1st8 hours) was an appropriate starting point with lactated ringers being the preferred fluid. Ongoing fluids are titrated to clinical endpoints, with urine output being commonly used.

He also gave a summary of the ventilation strategies used to manage the ARDS-like picture seen in burns patients.

Dr Kar-Soon Lim (Anaesthetist) spoke about airway considerations in burns patients. His take home points were:

  • In large TBSA burns, the airway will swell even without airway burns (consider early intubation)
  • An endotracheal tube is the definitive airway – have a low threshold for front of neck access if failed intubation (LMA likely to fail)
  • Use normal sized tubes (larger ETTs are not necessary and may cause future vocal cord morbidity)
  • Consider the need for chest escharotomy with trunk burns that are difficult to ventilate

Dr Andrea Issler-Fisher (Plastics / Burns Surgeon) gave an excellent description of burns wounds and the assessment of burn depth in relation to skin layers. She also described the indications and technique for performing an escharotomy (if in doubt, do it!) and contrasted this with performing fasciotomy (preferably in theatre by a surgeon).

The afternoon was spent with small group interactive workshops led by the Burns team consolidating three main topics covered in the morning lectures – airway considerations, fluid management and escharotomy. They provided valuable insights and tips from the Burns team and nicely rounded out a day addressing burns care in both the pre-hospital and hospital settings.

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Education Day – 14th November 2018

Education Day 14:11

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Clinical Governance Day Wrap Up 3rd Oct

The October CGD involved discussion of several outstanding examples of prehospital trauma care provided by teams within our service. These were explored by Dr Karel Habig in his ‘Learning from Excellence’ presentation and Dr Chris Partyka, Chris Wilkinson (critical care paramedic) and Dr Simon Keane in a review of major trauma cases requiring prehospital activation of the code crimson pathway. We use this pathway to provide rapid, streamlined transfer to definitive care, for exsanguinating haemorrhage that is refractory to standard resuscitation (more info here: https://www.aci.health.nsw.gov.au/networks/itim/clinical/trauma-guidelines/Guidelines/trauma-code-crimson-pathway).

Part of the code crimson guideline is a reminder of the importance of optimal prehospital trauma care and there were several useful discussion points, throughout the day, about the prehospital management of these patients.

  1. Point of care ultrasound (POCUS)

The group considered the benefit of utilising US on scene for initial assessment and stabilisation vs. concerns that it may increase scene time in a patient who requires transfer to definitive care. Our US audit team reported that GSA HEMS data suggests that the use of POCUS adds between 0-6 minutes to scene time. They suggested that in most cases it is appropriate to do a quick lung US to check for pneumothorax on scene, followed by the rest of the eFAST scan en-route to hospital.  The use of eFAST is highlighted in the Code Crimson guideline, and in the prehospital setting can allow early identification of likely bleeding source to facilitate rapid transfer to the correct intrahospital location and involvement of the correct teams.

Another use of POCUS discussed was the identification of injuries that may be amenable to prehospital intervention to allow early consideration of potential issues that may arise during transport. Awareness of a problem allows the team to team to pre-brief, prepare equipment and mark the patient, if required.  They may benefit from the opportunity to talk through and/or mentally rehearse the procedure and consider access and logistics issues early.

  1. Pre-RSI stabilisation

Another discussion was around the importance of optimising patients prior to RSI. This can be difficult in the prehospital setting, with limited people to perform interventions and will require careful consideration of the appropriate order of interventions to ensure this.  This may involve some time spent on resuscitation prior to RSI, consideration of procedures or management of agitation with judicious use of sedation to allow pre-oxygenation and usual preparation (i.e. delayed sequence intubation).

  1. Communication and coordination of care

We have multiple protocols that may be required in tandem with the code crimson guideline, such as a prehospital massive transfusion protocol (MTP), which can facilitate the delivery of blood products to the retrieval team en-route to hospital.  These protocols work well when there is rapid identification of exsanguinating haemorrhage and early communication to allow for logistical coordination.  Our MTP protocol suggests considering activation for scenes distant from major trauma centres, entrapped patients, rendezvous on route from scene, or patients bleeding in rural and remove hospitals.  The below poster summarises the process that our teams can utilise to arrange prehospital MTP activation. The use of the code crimson guideline and prehospital MTP have contributed to good patient outcomes, and highlight the benefit of clear early communication between different teams, applying organised processes within an integrated trauma service.

Further discussion was the regarding the effective use of communication within well-functioning teams. Chris Wilkinson described an excellent example of team communication as everything being “heard, visualised and discussed” between them. This allowed them to maintain a shared mental model and overview of the situation whilst they were independently managing multiple time critical tasks and maintaining momentum to definitive care. This was a great reminder that this continuous, open communication is what we should be aiming for in our teams.

The next CGD will occur on 31/10 – please see flyer below.

MTP protocol C.L.O.T handover tool:

CLOT poster

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Clinical Governance Day – Wed 31st October

31 October

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Education Day Wed 17th October

UNADJUSTEDNONRAW_thumb_2479

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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.

Picture1

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.

Picture2

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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