Scenario – 58yo male (Phil) with probable spinal injury following fall from height in the Blue Mountains.
Scene – Local paramedics have accessed remote bush scene by foot. AW139 responded with doc and para from Bankstown. Para & Doc winched into scene.
Patient – Denies any LOC but complains of lower leg parasthesiae and weakness. Local crew have already provided C-collar, bilateral IV access and 2.5mg morphine by time helo team arrive. Medical assessment consistent with isolated spinal injury, GCS 15, haemodynamically stable. Patient packaged accordingly with KED and “Roman” (a handled sleeping bag used for thermoprotection, comfort, and handling) into stretcher. Accompanied stretcher winch performed. En route to RNSH patient begins to vomit and becomes increasingly agitated. Loses both IV cannulae. Obstructs airway following emergency IM sedation.
Challenges –
Learning points from debrief for clinical practice :
Learning points from debrief for Simulation practice:
Thanks to Lucas Fox (doc), Greg Kirk (para), Pat Crowe(aircrew), Phil Parry(actor), Ruby (SRC), Rory (STAR)
Five prehospital & retrieval medicine physicians from Greater Sydney Area HEMS are excited about participating in a one day seminar at the Chinese University of Hong Kong’s A&E Academic Unit.
Led by Professors Tim Rainer and Colin Graham, the Accident & Emergency Medicine Academic Unit has furthered emergency medicine & trauma science. Not restricted to ED-based interests, they also run a successful Masters program in Prehospital & Emergency Care.
The One Day Prehospital & Retrieval Medicine Seminar will take place on Friday 31st May.
Presentations will be by Cliff Reid, Brian Burns, Anthony Lewis, Fergal McCourt, Oran Rigby, and Professors Rainer and Graham.
If you’re in Hong Kong and would like to come, reservations can be made by completing the reservation form on the flyer, which you can download by clicking below:
Scenario – Male snorkeler floating unresponsive in water, following likely intracerebral event.
Scene – Offshore recovery. Strop winch by paramedic into aircraft with initial assessment on board then further assessment and treatment at landing site on nearby headland.
Patient – Cold and wet in wetsuit. Poor airway control. Poor ventilation. Weak pulse. Progresses to seizures and recurrent vomiting.
Challenges – Airway control, vascular access, seizure management, requirement for RSI.
Learning points from debrief for clinical practice :
Learning points from debrief for Simulation practice :
Thanks to John (doc),Hugh(para), Shane(pilot), Richo(aircrew), Einar(actor), Fergal (SRC), Luke (STAR)
Thanks to Nirosha and John for another great Clinical governance day!
Highlights of M&M (thanks to Dr Sarah Coombs and Dr Chioma Ginigeme)
SIMWARS Highlights
Ollie and Bob did fantastic work intervening in a deteriorating patient many hours from a neurosurgical centre. The carpenter on the right of the picture is Dr Harrison armed with a Hudson Brace and a grim sense of determination in the face of an otherwise unsalvageable patient.
(Wilson et al give a fantastic ‘How to…’ summary for emergency burr holes in Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:24 doi:10.1186/1757-7241-20-24 – http://www.sjtrem.com/content/20/1/24)
Felicity and Richard were confronted with a chaotic sea of medical opinions surrounding a deteriorating, unstable patient . With a potpourri of ischaemia, hyperkalemia and pharmacology leading to a decompensated bradycardia our team had to balance their interventions against the ongoing PR blood loss and the persistent (but unintentional of course) attempts by our actors to derail their efforts.
Highlights from ‘other health systems’ presentations
SCAT Paramedic Bob Lisle gave us a great insight into the challenges of working as a medic in the highlands of Papua New Guinea with amazing footage of some aircraft being pushed to their limits and more snakes than you can shake a stick at (NB – never deal with a possibly venomous snake by shaking a stick at it).
Irish registrar Dr John Glasheen gave a great talk charting the rise and rise of the “Enhanced Aeromedical Service” of Ireland and the challenges of rationalising the tasking of operations when there are 7 regional ambulance control centres and an as yet variable level of awareness amongst all the pre-hospital players involved as to what the helicopter can and should be doing. The overall impression was of a service going from strength to strength even amidst the substantial financial pressures of recent years.
GSA-HEMS consultants and paramedics are deployed as part of the New South Wales Urban Search & Rescue Task Force. Although registrars are not deployed as part of this team, working in prehospital care requires preparation for work in disaster zones, and a basic understanding of Urban Search & Rescue (USAR) is helpful.
During a six month post we endeavour to provide USAR training to Category 1 level. This training is provided by the NSW Fire & Rescue Service.
Prior to attendance at the practical training, all delegates must complete the exercises on a training CD obtainable from the GSA-HEMS base secretary.
The next USAR Cat 1 training for GSA-HEMS registrars will be provided on 21 May 2013
The USAR Category 1 certificate is internationally recognised and transferable when working for other services. Please contact Dr Carissa Oh to register.
Booking now
22-23 October 2013
Open to doctors, nurses and paramedics fully registered in the UK with relevant retrieval experience
“With an increasing number of doctors, nurses and paramedics from a range of backgrounds undertaking high-risk critical care retrievals, there is a need to develop a benchmark assessment of skills, knowledge, attitudes and experience.”
– Dr Stephen Hearns, Consultant in Emergency and Retrieval Medicine
The closing date for registration is 19 July 2013.
For further information:
Tel +44 (0) 131 527 1600
Email RTM.exams@rcsed.ac.uk
Scenario – 25 year old male fallen down cliff face sustaining bilateral lower limb injuries and now caught in climbing apparatus. Remote location. Doctor and paramedic crew only able to insert from edge above. Suspended on cliff face for c.18hours.
Scene – Ledge beneath cliff. 5m height rope rappel both above and below patient. Helicopter stretcher winch possible from point below and distant to patient.
Patient – Hanging in semi-seated position in harness. Bilateral compound femur fractures. Responsive to verbal cues. Good respiratory and circulatory findings initially. Both lower limbs numb. Rapid deterioration due to hyperkalemia and haemorrhage.
Challenges – Difficult and high risk access and egress. Remote location with limited resources. Management of hyperkalemia secondary to rhabdomyolysis and soft tissue trauma. Treatment of traumatic cardiac arrest in austere environment.
Learning points from debrief for clinical practice :
Learning points from debrief for Simulation practice :
‘Reflow syndrome’, ‘Rescue death’, ‘Harness hang’, ‘Suspension intolerance’ :
The use of the term syndrome or multiple inverted commas may herald an area of medicine poor in evidence and rich in opinion. The climbing community and the emergency personnel who attend them when in extremis have long debated the effects and management of those left hanging for prolonged periods. The above terms are some of the labels given to theoretical processes that have been proposed over the years for how the body responds to hours spent immobile in harness.
Expert opinion for some decades had coalesced around the perceived threat of orthostatic fluid stasis in the lower limbs. Fainting happens. If prolonged this will result in ischaemic injury and potentially death. However, the presumption of rhabdomyolysis secondary to prolonged time in harness and fluid/electrolyte shifts proposed to occur when patients are returned to a supine position has remained unproven by any scientific study to date.
In the absence of any concrete evidence to support this theory, expert opinion (and the resulting consensus guidelines) have now swung back in the opposite direction. Recommendations are now made that those found hanging be treated according to universal algorithms applying to resuscitation and trauma.
Cardiovascular collapse is certainly recognised in passive suspension but in the absence of major crush or long term arterial ischaemia, hyperkalemia and re-perfusion injury appear to have moved out of the sights of those trying to identify what kills people left on the hang.
References
Dr. Roger Mortimer’s presentation at the 2012 NCRC National Seminar: http://www.youtube.com/watch?v=nEn4WQ5ShTo
UK HSE review by Prof Porter: http://www.hse.gov.uk/research/rrpdf/rr708.pdf
Australian Resus Council: http://www.resus.org.au/policy/guidelines/section_9/guideline-9-1-5july2009.pdf
http://www.wemjournal.org/article/S1080-6032(10)00402-3/abstract
Thanks to Luke(doc), Hugh/Cam(para), Christian(actors), Einar(STAR)
Scenario – 35 year old male kicked in head by horse. Found unconscious in stable (unstable-sic)
Scene – Fading evening light. Landing site 100m away at the top of a field. Stable interior not illuminated, only hand-held lighting available. Single road paramedic crew on scene.
Patient – Airway occasionally polluted by vomitus. Rapid breathing with right sided chest injury evident. Cool peripheries. GCS E3,V4,M5=12/15. PEARL. Facial, forehead and right chest bruising and abrasions. Becomes increasingly unstable and following intubation develops a righ-sided tension pneumothorax.
Challenges – Lighting, access and positioning all better at the aircraft than in a pitch dark stable. Complicating this were the unstable patient, the difficult terrain to traverse en route to the aircraft and the conflict between rapid extrication and more comprehensive assessment. The clinical challenges of identifying the obtunded patient requiring a secure airway, ventilation and a thoracostomy seemed less challenging to our super-slick team than the physical environment they encountered.
Learning points from debrief for clinical practice :
Learning points from debrief for Simulation practice :
Thanks to Helen (doc), Phil (para), Brendan (pilot), Mick (aircrew), Hugh/Christian/Bob (actors), Sarah (SRC), Nirosha (iSimulate), Luke (STAR)
AiR Videos
Greater Sydney Area HEMS 