There were several streams running simultaneously today which were interesting for prehospitalists, not least the PHEM/HEMS Programme. We tried to get to as many as possible to share some of the key learning points and interesting messages, and again we have recorded some interviews which we will share in future podcasts.
‘One RTC – 3 perspectives’ – Darren North
The fire service have only had a statutory duty to attend RTCs since 2004. Their role is to protect people from harm – patients and practitioners.
Strategy of the Fire Service at RTCs “The Team Approach”:
- Safe approach and control of hazards (risk assessment starts in the fire station and planning en route – share message with the team, role allocation)
- Stabilisation (car needs to be solid so the patient and initial rescuers are safe) and initial access. When a car is on it’s side, if fire service not yet there, consider placing one individual at either end of the car to stabilise it.
- SRS/Glass management – cover glass, open windows/sunroof (but wary of environment), make safety systems safe eg airbags
- Space creation – remove shopping, luggage, parcel shelves etc
- Full access – depending on plan, following liaison with medical service
- Patient extrication & transport (in some regions fire service have role in taking patients to hospital)
- Evaluate and training (hot debrief – at the back of the fire engine on scene, but this is limited to fire service as health providers have usually taken the patient to hospital)
What can the fire service offer the medics:
- A safe working environment
- Rapid initial access
- Free entrapment ASAP
- Extra pairs of hands
- Medical assistance/equipment
- Debrief (hot and structured)
- Identify who is charge, generally officer in charge will have Incident Commander tabard, not necessarily the ‘white helmet’
- Speak plain English
- Always try to be better
- Be honest about time frames
- Train together
- Be careful what you say
And then I moved into the Trauma in Children Programme, to listen to:
The Highs & Lows of Pre Hospital Paediatric Trauma – Dr Kevin Enright
We have interviewed Kevin to share in a future podcast but hear is a summary of his talk.
Very serious injuries in children is rare – so exposure to severely injured children prehospital is infrequent and the evidence is sparse – highlights the importance of shared experience.
Children are brave, honest and constructive. This should be remembered when assessing and treating seriously injured children.
Recent report covering the last 2 years of TARN data:
When children are injured/ill and scared they regress. Remember this, especially when managing adolescents; children may not be as interactive or as co-operative as you would expect for their age.
Significant cervical spine injury in children is exceptionally rare. Three cases described: high speed RTC, traumatic cardiac arrest. Patients had high cord injuries.
What do an advanced prehospital team offer at scene to a seriously injured/ill child?
- CRM (experience + discipline – there is one way to do this and we must do it fast and efficiently)
- Order & calm (slightly more exposure)
Policy that paediatric patients are not declared dead at scene. If the prehospital team consider the patient to be futile they will take them to the nearest local hospital. This has a huge impact on the local hospital – is that fair? It is hard enough for those who work in MTC paediatric centres. Should the prehospital team make the decision and not attempt resus in hospital at all?
Prehospital paediatric RSI
- We do it less despite similar injury aetiology/patterns
- Most children’s airways can be managed by basic manoeuvres
- However, children with a significant head injury deserve best airway care – ventilation, metabolic, haemodynamics, positioning. Must have appropriate training & experience otherwise risk/benefit balance is skewed.
- Children’s airways are different, be prepared for this (NB don’t even think about it though with children with craniofacial deformities)
Injured children are compensating to try and survive.
- Analgesia, warmth & splintage
- Confidence & rapport (the healthcare professional is the right person to do this, not the parent – how can they be constructive?)
- Mechanism of injury
- Clinical assessment
- Compensatory mechanisms (but they will be getting acidotic, coagulopathic)
- Fluids? (2-5ml/kg, ideally blood products but crystalloid ok)
- Scoop & run
The Evidence for Night HEMS – Leigh Curtis
This was a review of the 2 year trial KSS air ambulance conducted into night HEMS. If, like me, you thought that night HEMS is “Expensive … dangerous … pointless”, the data that Leigh presented was interesting. For their geography and population it turned out that they flew 1373 missions, and contacted 942 patients (1.9 missions on average per night), who had an average ISS of 23.5. Offline 15% of time due to weather minima.
Immersive Simulation in PHEM – Mark Forrest
We have interviewed Mark to share in a future podcast, but he had lots of great ideas, and recommended that we build SIM into everyday, using an example from Sydney HEMS; small and often.
Thinking about Pre-Hospital Death – Gareth Grier
This was an excellent talk which I recommend you watch when the video is available as it is difficult to reproduce the content here. One important point was:
We take a burden home with us when we have attended an incident when a patient has died. It can be a lonely place.
This is a topic we will revisit in future podcasts.
Pre Hospital Thoracotomy for Blunt Trauma – Tom Konig
We are going to catch Tom for a podcast tomorrow, but for now here is a taster:
Developing high performance through marginal gains – Adam Nash
Adam introduced the concept used by Team SKY and GP Olympic Cycling team: Focus on doing a few small things really well, once you do this aggregating these gains will become part of a bigger impact on performance.
To read/here more about it, try these St Emlyns resources:
Adam used the concept in a project to examine patient packaging. By working with some student paramedics to adjust techniques they were able to reduce packaging of a simulated time critical patient from nearly 13 minutes to just over 5.
Paediatric trauma patients: do they get a worse deal? – Phil Hyde
We were hoping to record a podcast on this for you – but Phil had to shoot off. We will catch up with him at a later date – but in the interim, here are the learning points.
In one word – yes: children get a raw deal.
- Trauma is the biggest killer of children, with two peaks of death – the under 1s (injuries inflicted by other humans) and 6 +.
- The mechanisms of trauma death in children are: RTCs, falls and other humans hurting them
- The main cause of death is due to severe head injury.
Providing PH care to little humans:
Data from the Confidential enquires into head injuries in children 2010
In patients with a GCS of 8 or less transported by ambulance:
- Oxygen not provided in 30%
- Saturations not measured in 70%
- BP not measured in 55%
This seems unbelievable – and definitely unacceptable.
Lots of ambulance services (in 2010) did not have appropriate kit to deal with small humans– including 92% not having appropriate sized supraglottic devices.
Phil raised his concerns around safe transport to the correct destination: very short drive times for low GCS patients – getting the balance right between this, and getting patients to the right centre first time is difficult – and we probably haven’t got the balance right yet.
In the UK our child mortality from trauma is high. We are performing very poorly compared to comparators, the mortality is 8.6% of children majorly injured, increasing to 18% when GCS<15. This is the same as Sweden in the early 1980’s the Swedish trauma systems have decreased mortality 3 fold during this time…
PH care is made more difficult as there is a fear of criticism from the paediatric fraternity. Children are considered very special / difficult and different – they require special training and equipment… This attitude is not helpful in the delivery of high quality Prehospital care. PH care delivery is generic in terms of training and experience of personnel – it is impractical to provide a ‘special’ service for children.
In PH care children require the same as adults – physiological support of their (injured) organs. Post PH care they can enter a paediatric specific system.
How we improve the care we offer to little humans:
- We become experts in supporting HUMAN physiology, HUMAN trauma care, HUMAN medical logistics.. (no matter how big the humans are).
What do we need:
- Generic, human SOPs
- To spend time around sick small humans – best place is PICU, many will offer observational placements on request.
- Airway / Breathing / Circulation Kit for humans
- Monitoring for humans
- Transport for humans
We are empowered to:
- Become expert in human trauma care
- Make our system fit for humans
- Make emotion positive
- Embrace injury prevention