Episode 25: Tension pneumothorax 2

tp2 fin

Where can you undertake decompression of a pneumothorax?

Be particularly careful when using the 2nd intercostal space mid-clavicular line that you are sufficiently lateral. For example, here are the locations identified as ‘2nd ICS mid clavicular line’ amongst 25 EM physicians in a 2005 EMJ paper.

emermed-2005-November-22-11-788-F1.large

From http://emj.bmj.com/content/22/11/788

The Three Kings: George Clooney’s recommended approach to decompression of a tension pneumothorax. Note – again please do not use this location!

Devices used for decompression:

 

Dressings available for covering an open pneumothorax +/- thoracostomy in a spontaneously breathing patient:

 

References

  • Ball, C. G., Wyrzykowski, A. D., Kirkpatrick, A. W., Dente, C. J., Nicholas, J. M., Salomone, J. P., et al. (2010). Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Canadian Journal of Surgery Journal Canadien De Chirurgie53(3), 184–188.
  • Barton, E. D., Epperson, M., Hoyt, D. B., Fortlage, D., & Rosen, P. (1995). Prehospital needle aspiration and tube thoracostomy in trauma victims: a six-year experience with aeromedical crews. The Journal of Emergency Medicine13(2), 155–163.
  • Beckett, A., Savage, E., Pannell, D., Acharya, S., Kirkpatrick, A., & Tien, H. C. (2011). Needle Decompression for Tension Pneumothorax in Tactical Combat Casualty Care: Do Catheters Placed in the Midaxillary Line Kink More Often Than Those in the Midclavicular Line? The Journal of Trauma71, S408–S412. http://doi.org/10.1097/TA.0b013e318232e558
  • Cullinane, D., Morris, J., Bass, J., & Rutherford, E. (2001). Needle thoracostomy may not be indicated in the trauma patient. Injury32, 749–752.
  • Ferrie, E. P., Collum, N., & McGovern, S. (2005). The right place in the right space? Awareness of site for needle thoracocentesis. Emergency Medicine Journal22(11), 788–789. http://doi.org/10.1136/emj.2004.015107
  • Fitzgerald, M., Mackenzie, C. F., Marasco, S., Hoyle, R., & Kossmann, T. (2008). Pleural decompression and drainage during trauma reception and resuscitation. Injury39(1), 9–20. http://doi.org/10.1016/j.injury.2007.07.021
  • Givens, M. L., Ayotte, K., & Manifold, C. (2004). Needle thoracostomy: implications of computed tomography chest wall thickness. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine11(2), 211–213. http://doi.org/10.1197/j.aem.2003.09.015
  • Harcke, H. T., Mabry, R. L., & Mazuchowski, E. L. (2013). Needle thoracentesis decompression: observations from postmortem computed tomography and autopsy. Journal of Special Operations Medicine : a Peer Reviewed Journal for SOF Medical Professionals13(4), 53–58.
  • Inaba, K., Branco, B. C., Eckstein, M., Shatz, D. V., Martin, M. J., Green, D. J., et al. (2011). Optimal positioning for emergent needle thoracostomy: a cadaver-based study. The Journal of Trauma71(5), 1099–103– discussion 1103. http://doi.org/10.1097/TA.0b013e31822d9618
  • Inaba, K., Ives, C., McClure, K., Branco, B. C., Eckstein, M., Shatz, D., et al. (2012). Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Archives of Surgery (Chicago, Ill : 1960)147(9), 813–818. http://doi.org/10.1001/archsurg.2012.751
  • Jadder, U., & McAuley, D. (2005). Transthoracic ultrasonography to diagnose pneumothorax in trauma. BestBETS.org, 1–3.
  • Jones, R., & Hollingsworth, J. (2002). Tension pneumothoraces not responding to needle thoracocentesis. Emergency Medicine Journal19, 176–177.
  • MD, A. R. M., MD, M. E. R., MD, C. S. C., & MD, J. L. M. (2015). Ultrasound determination of chest wall thickness: implications for needle thoracostomy. The American Journal of Emergency Medicine, 1–5. http://doi.org/10.1016/j.ajem.2010.06.030
  • MD, B. B., & MD, J.-M. T. (2012). Initial Management and Resuscitation of Severe Chest Trauma. Emergency Medicine Clinics of NA30(2), 377–400. http://doi.org/10.1016/j.emc.2011.10.010
  • MD, E. J. C., MD, C. H. C., BS, R. M., PHD, C. L. A., RDMS, C. A. K. M. M., RDMS, S. S. M., & RDMS, J. C. F. M. (2013). Ultrasound in Emergency Medicine. The Journal of Emergency Medicine44(1), 142–149. http://doi.org/10.1016/j.jemermed.2012.02.032
  • Netto, F. A. C. S., Shulman, H., Rizoli, S. B., Tremblay, L. N., Brenneman, F., & Tien, H. (2008). Are needle decompressions for tension pneumothoraces being performed appropriately for appropriate indications? The American Journal of Emergency Medicine26(5), 597–602. http://doi.org/10.1016/j.ajem.2007.08.016
  • Rathinam, S., Grobler, S., Bleetman, A., Kink, T., & Steyn, R. (2014). Evolved design makes ThoraQuik safe and user friendly in the management of pneumothorax and pleural effusion. Emergency Medicine Journal31(1), 59–64. http://doi.org/10.1136/emermed-2012-201821
  • Rathinam, S., Quinn, D. W., Bleetman, A., Wall, P., & Steyn, R. S. (2011). Evaluation of ThoraQuik: a new device for the treatment of pneumothorax and pleural effusion. Emergency Medicine Journal28(9), 750–753. http://doi.org/10.1136/emj.2009.082297
  • Sanchez, L. D., Straszewski, S., Saghir, A., Khan, A., Horn, E., Fischer, C., et al. (2011). Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine18(10), 1022–1026. http://doi.org/10.1111/j.1553-2712.2011.01159.x
  • Wax, D. B., & Leibowitz, A. B. (2007). Radiologic assessment of potential sites for needle decompression of a tension pneumothorax. Anesthesia and Analgesia105(5), 1385–8– table of contents. http://doi.org/10.1213/01.ane.0000282827.86345.ff
  • Yamagiwa, T., Morita, S., Yamamoto, R., Seki, T., Sugimoto, K., & Inokuchi, S. (2012). Determination of the appropriate catheter length for needle thoracostomy by using computed tomography scans of trauma patients in Japan. Injury43(1), 42–45. http://doi.org/10.1016/j.injury.2010.11.022
  • Zengerink, I., Brink, P. R., Laupland, K. B., Raber, E. L., Zygun, D., & Kortbeek, J. B. (2008). Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? The Journal of Trauma64(1), 111–114.  http://doi.org/10.1097/01.ta.0000239241.59283.03

Episode 24: Tension pneumothorax 1

tp1

Firstly, go and read Simon and Tim Harris’ great 2005 paper on the subject which we reference repeatedly in the podcast. It is available free open access here.

A pneumothorax exists when air accumulates in the potential space between the visceral and parietal pleura:

Pneumothorax during respiratory cycle

From: www.wisdomjobs.com

A tension pneumothorax exists when the air in the pleural cavity is under high pressure resulting in compression of the surrounding structures.

Simon mentions Rutherford’s diagram in the podcast. This is taken from a 1968 paper examining the progressive pathophysiology of a tension pneumothorax. The graph shows the changes in intrapleural pressure (on the ipsilateral and contralateral sides) in spontaneously breathing goats who had air injected into one side of their chest. We can’t find the full article free/open access anywhere I’m afraid. But this is the reference: THE PATHOPHYSIOLOGY OF PROGRESSIVE, TENSION PNEUMOTHORAX. Rutherford RB, Hurt HH, Brickman RD, Tubb JM. Journal of Trauma and Acute Care Surgery, March 1968,8(2):212-227

Diagram from Rutherford's 1968 paper on tension pneumothorax

The imaging findings of tension pneumothorax might look like this:

More plain film images are available in this article on the Radiopaedia website.

And you can see what a CT scan of a patient with tension pneumothorax looks like in this vimeo shared on the Life in the Fast Lane website.

If you want to know about ultrasound findings of pneumothorax, check out this great R.E.B.E.L.EM post.

References:

Leigh-Smith S, Harris T. Tension pneumothorax—time for a re-think? EMJ. 2005; 22:8-16.  doi.org/10.1136/emj.2003.010421

Roberts DJ, Leigh-Smith S et al. Clinical Presentation of patients with a Tension Pneumothorax – a systematic review. Annals of Surgery. 2015; 261: 1068-78. doi: 10.1097/SLA.0000000000001073

Episode 23: Intraosseus access

IO Access 2

The various devices which Tony discusses are:

This video shows the rapidity of infusion entering the circulation from a humeral IO.

This is the paper mentioned by Tony, which shows the stepwise improvement in mortality amongst combat casualties from military conflict 2003-2012, including the ‘unicorn’ graph:

Fig 2 from Penn-Barwell et al 2015

Anatomy of bones and the humerus related to intraosseus access

Long bone anatomy

Humeral anatomy

 

The surface anatomy of the shoulder

Surface anatomy of shoulder

The bony anatomy of the shoulder

Bony anatomy of shoulder

Muscular attachments of the shoulder

Muscular anatomy of shoulder

Blood vessels and nerves around the proximal humerus

A demonstration of the landmarking process for humeral intraosseus insertion is available here.

Want to know more about EZ-IO access?

The education resources which Tom mentions are available here.

 

Episode 19: Surgical Airway

surgical airway

 

The West Midlands surgical skills course offers cadaveric training for PHEM and EM practitioners on rare life saving procedures. Click here to go straight to their page.

Anatomy

Screen Shot 2017-06-22 at 13.43.36

The Guidelines

Screen Shot 2017-06-22 at 13.20.19

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. C. Frerk et al. Difficult Airway Society: Intubation guidelines working group. British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371

For more information, have a look at the Difficult Airway Society website.

AAGBI Safer Prehospital Anaesthesia

Click here for the 2017 guidelines

The Kit

Know what your service carries, practice with that equipment, then you will be familiar with the kit you are using in the heat of the moment.

always-carry-your-scalpel-7-638

Minimal kit: scalpel, bougie, tube

Tracheal dilators and tracheal hook

The Technique

For a demonstration of the DAS recommended technique for surgical front of neck access, have a look at this video, recorded by colleagues over at openairway.org:

Just a Routine operation

The video we mention in the podcast produced by Martin Bromiley after the death of his wife, Elaine, in a can’t intubate can’t oxygenate scenario is available here:

https://www.youtube.com/watch?v=JzlvgtPIof4

And have a look at the website for more of Martin’s work with the Clinical Human Factors group.

Other fantastic #FOAM resources regarding airway management are available:

From Nicholas Chrimes  at http://vortexapproach.org

From the fabulous people over at Life in the Fast Lane including a video demo from Scott Weingart from EMCrit: https://lifeinthefastlane.com/ccc/surgical-cricothyroidotomy/

References

This is Tim’s recent publication we mention in the ‘cast!: Nutbeam, T., Clarke, R., Luff, T., Enki, D. and Gay, D. (2017), The height of the cricothyroid membrane on computed tomography scans in trauma patients. Anaesthesia. doi:10.1111/anae.13905

Aslani, A., Ng, S.-C., Hurley, M., McCarthy, K. F., McNicholas, M., & McCaul, C. L. (2012). Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study. Anesthesia and Analgesia, 114(5), 987–992. http://doi.org/10.1213/ANE.0b013e31824970ba
Bair, A. E., & Chima, R. (2015). The Inaccuracy of Using Landmark Techniques for Cricothyroid Membrane Identification: A Comparison of Three Techniques. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine, 22(8), 908–914. http://doi.org/10.1111/acem.12732
Bennett, J. D., Guha, S. C., & Sankar, A. B. (1996). Cricothyrotomy: the anatomical basis. Journal of the Royal College of Surgeons of Edinburgh, 41(1), 57–60.
Boon, J. M., Abrahams, P. H., Meiring, J. H., & Welch, T. (2004). Cricothyroidotomy: a clinical anatomy review. Clinical Anatomy (New York, NY), 17(6), 478–486. http://doi.org/10.1002/ca.10231
Buonopane, C. E., Pasta, V., Sottile, D., Del Vecchio, L., Maturo, A., Merola, R., et al. (2014). Cricothyrotomy performed with the Melker™ set or the QuickTrach™ kit: procedure times, learning curves and operators’ preference. Il Giornale Di Chirurgia, 35(7-8), 165–170.
Cook, T., Woodall, N., & Frerk, C. (2015). Appendix 4 NAP4 Summary: major complications of airway management in the United Kingdom. British Journal of Anaesthesia (2011) 106 (5): 617-631. https://doi.org/10.1093/bja/aer058
Dover, K., Howdieshell, T. R., & Colborn, G. L. (1996a). The dimensions and vascular anatomy of the cricothyroid membrane: relevance to emergent surgical airway access. Clinical Anatomy (New York, NY), 9(5), 291–295. http://doi.org/10.1002/(SICI)1098-2353(1996)9:5<291::AID-CA1>3.0.CO;2-G
Frerk, C., Mitchell, V. S., & McNarry, A. F. (2015). Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia (2015) 115 (6): 827-848. https://doi.org/10.1093/bja/aev371
Hubert, V., Duwat, A., Deransy, R., Mahjoub, Y., & Dupont, H. (2014). Effect of simulation training on compliance with difficult airway management algorithms, technical ability, and skills retention for emergency cricothyrotomy. Anesthesiology, 120(4), 999–1008. http://doi.org/10.1097/ALN.0000000000000138
Langvad, S., Hyldmo, P. K., Nakstad, A. R., Vist, G. E., & Sandberg, M. (2013a). Emergency cricothyrotomy–a systematic review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 21, 43. http://doi.org/10.1186/1757-7241-21-43
Nakstad, A. R., Bredmose, P. P., & Sandberg, M. (2013). Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 21, 59. http://doi.org/10.1186/1757-7241-21-59
 Navsa, N., Tossel, G., & Boon, J. M. (2005). Dimensions of the neonatal cricothyroid membrane – how feasible is a surgical cricothyroidotomy? Paediatric Anaesthesia, 15(5), 402–406. http://doi.org/10.1111/j.1460-9592.2005.01470.x
 Prithishkumar, I. J., & David, S. S. (2010). Morphometric analysis and clinical application of the working dimensions of cricothyroid membrane in south Indian adults: With special relevance to surgical cricothyroidotomy. Emergency Medicine Australasia, 22(1), 13–20. http://doi.org/10.1111/j.1742-6723.2009.01245.x
 The clinical anatomy of several invasive procedures. American Association of Clinical Anatomists, Educational Affairs Committee. (1999). The clinical anatomy of several invasive procedures. American Association of Clinical Anatomists, Educational Affairs Committee. Clinical Anatomy (New York, NY), 12(1), 43–54. http://doi.org/10.1002/(SICI)1098-2353(1999)12:1<43::AID-CA7>3.0.CO;2-W

 

 

Episode 18: The Ventilator Part 2

Vent 2

Many apologies for the delay in the release of this podcast!

A second apology is due for the sound quality – it was recorded at a ‘live’ HEMS base – this has led to lots of background noise I am afraid. We have done our best to edit this out / reduce its effect but I’m afraid we are not experts in this area!

This podcast is part 2 of this series on the ventilator – and you should be familiar with the first in this series before progressing further!

Others have written excellent summaries of the themes of this podcast – please follow the links below:

In summary:

  • PEEP is important – you need to understand its benefits and potential harms.
  • If the patient is requiring more oxygen than you would expect try increasing the PEEP.
  • You really, really need to know your kit. Know what your ventilator can and can’t do –  know how it works and how its alarms work.

 

Episode 17: Broken? Impact on the rescuer

Broken...

This episode has been compiled over a year – many thanks to our four contributors, who have shared their stories and knowledge. They were interviewed at TraumaCare 2016, TraumaCare 2017 and the BASICS/FPHC Conference 2016.

If you ever need to talk about the impact of stresses and work experiences on you, please find a friend, colleague, GP, work Occupational Health Service, or one of the charities listed below.


Tony’s article describing his experience of providing medical care to those involved in the Shoreham air crash:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4758481/


Links to some of the resources Matt mentioned:

Mind Blue Light Campaign:

0j6q5p5Y

http://www.mind.org.uk/news-campaigns/campaigns/bluelight/

Watch this excerpt from the West Wing:

If you would like to check your own resilience score, you could use this tool recommended by Matt:

https://www.robertsoncooper.com/iresilience/

http://www.marchonstress.com

http://www.theredpoppycompany.co.uk


More information from Rusty’s interview:

MaslowsHierarchyOfNeeds.svg

By FireflySixtySeven using Inkscape, from Maslow’s A Theory of Human Motivation.

Want to know more about EMDR?

http://emdrassociation.org.uk/what-is-emdr/background-and-basics/

Rusty recommended The Howl – EMS Wolfpack podcasts for more on this subject:

https://itunes.apple.com/gb/podcast/the-howl/id1073333491?mt=2&i=364170004


This is the article written by fire fighter Rob Norman

https://www.theguardian.com/public-leaders-network/2016/jan/30/mental-health-dead-people-flashbacks-emergency-services-fireighters

Episode 16: “Blood”

blood

 

There is the potential for significant controversy in this month’s episode – and we would really appreciate the feedback of the prehospital community on this one.

We have held the ‘no clear fluids’ mantra close to our hearts for most of our prehospital careers. We ‘know’ that giving sea water to our patients, and diluting all of blood’s ‘good bits’ can’t be healthy. We believed in permissive hypotension – we were probably wrong.

Priorities for the bleeding trauma patient must include:

  • Minimum time to control of bleeding (tourniquets / haemostatics / knife / interventional radiology)
  • Normothermia
  • Appropriate choice of destination (knife / IR)
  • ? Early correction of hypotension (especially if blunt trauma / associated head injury)

The balances of harms in the context of blunt trauma between the negative effects of infusing saline versus the negative effects of hypotension are unknown and prehospital actions need to be customised to an individual patient and situation.

In systems in which a potentially less harmful resuscitation strategy can be delivered sooner – PH systems with packed red cells / fresh frozen plasma / whole blood or freeze dried plasma, then it seems pragmatic to aim for normotension (predicted normal blood pressure) sooner in the patient’s care timeline than we have been e.g. at one hour. In patients with penetrating trauma permissive hypotension may remain useful for longer or at least until a patient can be differentiated and the bleeding controlled.

Lots to think about!

 

References:

RePhill Trial Homepage: http://www.birmingham.ac.uk/research/activity/mds/trials/bctu/trials/portfolio-v/Rephill/index.aspx

  1. Smith IM, James RH, Dretzke J, Midwinter MJ. Prehospital Blood Product Resuscitation for Trauma. Shock. 2016 Jul;46(1):3–16.
  2. Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients. Powell EK, Hinckley WR, Gottula A, Hart KW, Lindsell CJ, McMullan JT. J Trauma Acute Care Surg. 2016 Sep;81(3):458-62.
  3. Penn-Barwell JG, Roberts SA, Midwinter MJ, Bishop JR: Improved survival in UK combat casualties from Iraq and Afghanistan: 2003-2012. J Trauma Acute Care Surg 78(5):1014–1020, 2015.
  4. Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, et al.: Prehospital transfusion of plasma and red blood cells in trauma patients. Prehosp Emerg Care 19(1):1–9, 2015.
  5. Weaver AE, Eshelby S, Norton J, Lockey DJ: The introduction of on-scene blood transfusion in a civilian physician-led pre-hospital trauma service. Scand J Trauma Resusc Emerg Med 21(Suppl1):S27, 2013.
  6. Bodnar D, Rashford S, Williams S, Enraght-Moony E, Parker L, Clarke B: The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells. Emerg Med J 31(2):93–95, 2014.

Episode 14: Thoracotomy

thoracotomy

 

Details of the surgical skills course mentioned in the podcast can be found here:

https://wmstc.co.uk/portfolio/phem-ess/

The Sydney HEMS Traumatic Cardiac arrest operating procedure can be viewed on their website, and there are a number of useful references within the document:

Policies and Procedures

An excellent ‘how to do it’ paper, published in 2005, by the London HEMS team, can be accessed via the link below:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726527/pdf/v022p00022.pdf

 

Equipment required for resuscitative thoracotomy:equipment-required-for-thoracotomy

Surface anatomy:

surface-anatomy-for-thoracotomy

Appearance of pericardial clot

pericardial-clot

A foley catheter being used to fill a cardiac wound – note how easily this could be pulled out.

foley-catheter-in-cardiac-wound

An open chest with aortic compression

open-chest-with-aortic-compression

Simulation of resuscitative thoracotomy by London HEMS team.

For an entertaining and insightful discussion about the impact of undertaking thoracotomy, listen to Dr John Hinds talk from SMACC 2015. Highly recommended.

http://intensivecarenetwork.com/hinds-crack-the-chest-get-crucified/

And for a summary of the evidence and recommendations, have a look at the St Emlyns blog:

http://stemlynsblog.org/jc-east-lets-be-blunt-about-ed-thoracotomy/

References

  • Smith JE, Rikard A, Wise D. Traumatic Cardiac Arrest. Journal of the Royal Society of Medicine 2015. 108(1): 11-16.
  • Wise et al. Emergency thoracotomy: “how to do it”. EMJ; 2005: 22-24.
  • Hunt et al. Emergency thoracotomy in thoracic trauma: a review. Injury; 2006 (37): 1-19.
  • Clay et al. Emergency Department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World Journal of Emergency Surgery; 2006: 1:4.
  • Rhee et al. Survival after Emergency Department thoracotomy: review of published data for last 25 years. J Am Coll Surg; 2000. 190(3): 288-298
  • ACS Committee on Trauma Working Group. Practice Management guidelines for ED Thoracotomy. J Am Coll Surg. 2001, 193 (3): 303-309.
  • Editorial. When should we stop resuscitative efforts after blunt traumatic arrest. Injury; 2008 (39): 967-969.
  • Joint Position Statement of Nat Assoc EMS Physicians and ACS Committee on Trauma. Guidelines for withholding or termination of resuscitation in prehospital cardiopulmonary arrest. J Am Coll Surg; 2003 (1): 106-111.
  • Tarney et al.Outcomes following military traumatic cardiorespiratory arrest: A prospective observational study. Resuscitation; 2011: 1194-1197

SMACC – Innovate, Explore, Connect, Belong, Inspire

 

2 weeks post SMACC and I have finally got around to sharing some thoughts. The first is to say that it is difficult to outline what I learnt during my 4 days in Dublin. To summarise, it was more about ‘how’ I practice medicine, than ‘what’ I do. But, here are some of my highlights.

The first session of day 1 was the John Hinds plenary. John Hinds was a prehospital doctor and anaesthetist who died shortly after SMACC last year in a motorbike crash. His lecture last year was one of my favourites – well worth a listen/watch.

HINDS: Crack the Chest. Get Crucified.

His partner, Janet, and colleague spoke wonderfully about the funny, committed and irreverent man they knew. One of the key messages from his talk last year was to ensure your intentions are always honourable, and they encouraged us to use the hashtag #whatwouldjohndo.

Feedback & developing performance

Victoria Brazil – so you think you are a resuscitationist?

Has there ever been a time when you were deluded about your performance? The Dunning-Kruger curve illustrates the relationship between experience and confidence and how we may think we are better than we are.

IMG_6908

This graph was taken from Sandra Viggars talk on Day 3

The counterbalance to this position is imposter syndrome: we don’t think we deserve to be in the position we are in.

So how do we close the gap? Victoria argued that it was through feedback, and described an incident from her early career when she had completely misread her performance at a prehospital incident and then demonstrated how to give good feedback.

She said the road to knowing how good we are (self-insight) lies with other people. And recommended the following top tips for giving and getting feedback:

  • be honest
  • do it often (get into the habit)
  • we need to actively seek feedback
  • Be a mirror, this is what I saw, this is what I thought, lets have a conversation….

She acknowledged that this can be quite hard as you become more senior (rather than trainees).

Kettlebells for the brain (Meditation)

Scott Weingart

Scott delivered a podcast live on stage about the role of meditation as a work out for your brain. It was really challenging and there were some interesting concepts which are best understood by listening to it yourself! It’s not out in full yet but here is the sneak preview:

EMCrit Wee – Vipassana Meditation

The case for HEMS

Gareth Davies

Started with admitting his bias! And acknowledged that evidence is scant. He emphasised that when we judge helicopters they should be delivering ‘full bore’ medicine – maximum commitment, maximum effort, uncompromising, full armourmentarium.

And encouraged the audience to ensure:

  • Do your best
  • Attention to the basics
  • Translation from other areas (require support of peers, delivering hospital care out of hospital eg REBOA)
  • Demonstrate a commitment to clinical excellence
  • The notes you write are beyond reproach
  • Governance package in ED/PHC that is second to none
  • Present at grand round, speak at cardiothoracic audit day (battle for credibility lies outside of the ED, outside of the EM journal)
  • Not just trauma

And to provide students with examples of exemplary care, inspirational clinicians and the best education experience of their training.

Elderly care

There were some themes from the Emergency Medicine stream which are relevant to PHEM – most notably, in my opinion, the growing population of older people requiring our care.

Suzanne Mason’s presentation was entitled ‘Acute Care of the Elderly’ and she advocated learning to love frailty!

Some idea of the numbers: patients in the over 65 age group represent approximately 25% of attendances to EDs; 90% of them are necessary and 60% are admitted. She shared the following video which is incredibly thought provoking:

http://www.hsj.co.uk/hsj-knowledge/commissions-and-inquiries/frail-older-people/video-what-went-wrong-with-mrs-andrews-care/5076842.fullarticle

We all have a role to play, and there is good evidence to support prehospital interventions. For example, paramedics trained to assess patients following falls – 25% reduction in ED attendances, and 6% reduction in subsequent admissions.

Adrenaline in cardiac arrest

Jim Manning reviewed progress in resuscitation and compared ‘artificial perfusion’ with the effective interventions of ‘artificial ventilation’ and defibrillation. He argued that artificial perfusion is where we are least successful and reviewed the evidence for adrenaline.

Adrenaline is given to try and improve coronary perfusion pressure, and research shows that coronary perfusion pressure > 15 mmHg is associated with ROSC. There is also a demonstrable improved ROSC rate and admission with adrenaline, but no difference in hospital discharge or neurological outcome vs placebo. Where does this leave us? Well, with quite a few questions!

  • Why doesn’t it work? Perhaps because we are giving it IV and in those with a poor coronary perfusion pressure it is sitting in the vein.
  • Should we give up?
  • How about intra-aortic/intra-arterial adrenaline?

Watch this space!

The Boston marathon bombing

Christina Hernon (@EMedTox) talked about her experience as an ‘Impromptu Immediate Responder’. She was already at the scene when the bombs went off but not in a formal immediate care role. It was an extremely powerful presentation and I would recommend listening to/watching it when it is released later in the year at http://intensivecarenetwork.com/smaccmedia/, but some of the things she talked about were:

  • Is the scene safe? – yes, no, I don’t know.
  • Shit can happen anywhere, you might be there.
  • How to be safe in an unsafe scene
  • Try not to move patients
  • Haemorrhage control and maybe airway opening manoeuvres are all you can do + set up some form of triage areas
  • Be very wary of your stress response

For those of us responding after an incident such as this, be kind to these Impromptu Immediate Responders.

From a bigger picture point of view, should we have some form of community preparedness? This might then have an impact then on recovery of those exposed.

Coaching for medicine

Tom Evens (@DocTomEvens) is a coach for British rowing and he talked about the similarities between medicine and sport, and what we can learn from the principles of coaching sport.

 Find your talented person and believe in them.

 As a senior clinician you are able to see what a trainee could become at the beginning of their career, when they are not. What is their goal? What is the standard required to reach that goal? Be humble in the face of that standard. Success comes from an aggregation of good choices – commit to a standard.

Marginal gains – questioning assumptions.

The reality of progress: increments, inches, persistence, progression. But there is a risk of concentrating on the small stuff at the expense of missing the big stuff – must focus on the basics.

Self compassion

Help people thrive in their training programme, not just survive. Athletes have to engage in their training. The danger of being a perfection driven person is if you don’t recognize your humanity. A negative response to a failure can impede your performance for days.

The Greatest Presentation in the World

Ross Fisher

As well as delivering a fabulous presentation entitled ‘Things that scare me’, Ross shared his presentation secrets in a very entertaining and inspiring talk. Rather than reading what I took home – have a look at his blog which covers everything you need to know about improving your presentations.

http://prezentationskills.blogspot.co.uk/2016/06/the-greatest-presentation-in-world.html

Further reading

For more reflections on the conference please see this St Emlyns post and their further reading list and the podcasts they recorded each day.

SMACCDUB – A Trainee’s Perspective. St.Emlyn’s

Episode 9: Maternal Collapse

Mat collapse-2

Apologies for the quality of the sound – we recorded in a very echo-ey office!

The Royal College of Obstetricians and Gynaecologists (RCOG) green top guideline is accessible here:

https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_56.pdf

We have talked about ramping previously, in Episode 6: Oxygenation. This is how a pregnant patient should be positioned for airway manoeuvres and interventions, for example induction of anaesthesia and intubation.

Screen Shot 2016-03-17 at 10.09.34

The ILCOR 2015 update pertaining to Cardiac Arrest Associated with Pregnancy is accessible here:

https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-10-special-circumstances-of-resuscitation/

Including this picture demonstrating manual displacement of the uterus:Manual displacement

The concept of deliberate practice is discussed in more details on these sites:

This is Cliff Reid (resus.me) talking about his lecture from the Royal College of Emergency Medicine Conference in 2015:

http://resus.me/rcem15/

And this is Simon Carley’s (St Emlyn’s) blogpost on the subject:

http://stemlynsblog.org/the-pursuit-of-mastery-through-deliberate-practice/

And last, but not least, Scott Weingart (EMCRIT) from SMACC 2013

http://emcrit.org/podcasts/path-to-insanity/

 

References

Advanced Life Support (7th Edition). Resuscitation Council UK. 2016.

Parry R, Asmussen T, Smith JE. Perimortem caesarean section. EMJ. 2016; 33: 224-229.

Clark SL, Cotton DB, Pivarnik JM et al. Position change and central hemodynamic profile during normal third trimester pregnancy and post partum. Am J Obstetrics & Gynaecology. 1991; 164: 883-887.

Bamber JH, Dresner M. Aortocaval compression in pregnancy: the effect of changing the degree and direction of lateral tilt on maternal cardiac output. Anaesthesia & Analgesia. 2003; 97: 256-258.

Lee SWY, Khaw KS, Kee WN, Leung TY, Critchley LAH. Haemodynamic effects from aortocaval compression at different angles of lateral tilt in non-labouring term pregnant women. British Journal of Anaesthesia. 2012; 109: 950-956.

Trauma Care Day 3

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”:

  1. Safe approach and control of hazards (risk assessment starts in the fire station and planning en route – share message with the team, role allocation)
  1. 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.
  1. SRS/Glass management – cover glass, open windows/sunroof (but wary of environment), make safety systems safe eg airbags
  1. Space creation – remove shopping, luggage, parcel shelves etc
  1. Full access – depending on plan, following liaison with medical service
  1. Patient extrication & transport (in some regions fire service have role in taking patients to hospital)
  1. 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)

Key messages

  • Identify who is charge, generally officer in charge will have Incident Commander tabard, not necessarily the ‘white helmet’
  • Speak plain English
  • IMG_6616
  • 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:

https://www.tarn.ac.uk/Content/ChildrensReport2/index.html

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)
  • Leadership
  • 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.

IMG_6618

Top tips

  • 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:

http://stemlynsblog.org/ed-need-matt-parker-st-emlyns/http://www.stemlynspodcast.org/e/marginal-gains-in-the-ed/

IMG_6625

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.

Epidemiology:

  • 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.
  • https://www.spottingthesickchild.com
  • 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

 

 

Trauma Care Day 2

Today has been a really good day at Trauma Care – there were several lecture streams running and I also gave a presentation on Pelvic Binders so I didn’t get to hear as many as I would like to have done, but here are a couple of summaries which I hope you will find interesting. We have also recorded a three interviews already which will feature in future podcasts. Many of the lectures were recorded today and will be available to view soon on the Trauma Care website.

All things Pre Hospital Ketamine – Minh Le Cong

Key point: patients remember if you manage their pain well.

Ketamine covers the full range of PH analgesia and anaesthesia, and can be administered IN, IV, IM, sublingual. It is highly lipophilic, rapidly absorbed, therefore particularly suitable for IN and SL admininstration.

Ketamine can be particularly useful in bariatric patients, where large doses of opiates in addition to past medical history of respiratory problems or chest injuries may not be ideal. Also good for patients on chronic pain long term opiate therapy with acute injury

Minh told a story about a patient who had undergone a prehospital amputation following the Christchurch earthquake – the full account can be heard here:

https://prehospitalmed.com/2014/06/23/urologist-anaesthetist-ketamine-prehospital-amputation-lifesaving-story/

He also talked about the outcomes of the SKEPTIC trial which was a retrospective review of patients who’d received ketamine vs those who had not, comparing shock index. The periscope video of the SKEPTIC trial presentation is accessible here:

https://prehospitalmed.com/2016/04/12/ketamine-for-prehospital-rsi-the-skeptic-trial-by-dr-faizan-arshad/

The Royal Flying Doctors Service (RFDS) use infusion of ketamine to manage agitated mental health patient without need for intubation. The paper published describing this and the protocol they use are linked below:

https://www.flyingdoctor.org.au/assets/files/Ketamine_Sedation_Acute_Agitation_Aeromedical_Retrieval.pdf

https://www.flyingdoctor.org.au/assets/files/Consensus_Statement_-_The_Acutely_Agitated_Patient_in_a_remote_location.pdf

Emergence phenomena – Minh reports 12 cases during his career. This possibility should be respected but not feared. Key is to consider environment, perhaps it is unsurprising that patient’s get agitated when the aircraft starts up!

Following the lecture I found this on Minh’s PHARM website: a review of prehospital ketamine administrations.

https://prehospitalmed.com/2016/01/16/adverse-event-profile-of-2008-prehospital-ketamine-administrations/

 

Extrication & Immobilisation continued…. – Rob Fenwick

Extrication – a patient centred approach

Why does extrication matter?

  • Trauma is a killer, road trauma is a killer (leading cause of death of people aged <40 yrs), 4-5 deaths per day in the UK, 20-30% have a significant entrapment
  • For each patient that dies, 10x more a significantly injured
  • 50% die in first hour, 18% die between 1-6 hours, 15% preventable

Brown et al – patients requiring prolonged extrication increases mortality

Life saving interventions cannot be delivered while the patient is in the car.

The longer the time a patient is in the car in cold weather, the colder they will get, and mortality increases for every degree reduction in temperature.

Physical vs medical entrapment: Only 11% of patients ‘requiring extrication’ were actually physically trapped

Why do we extricate the way we do?

  • fear of exacerbating spinal injury
  • fear of being sacked when we ‘cause’ a spinal injury
  • fear of being sued when we ‘cause’ a spinal injury
  • that is how we have been taught
  • based on expert opinion + isolated case reports

What are we trying to do?

  • Reduce secondary injury – by restricting movement
  • Limited case reports suggesting that patient’s injuries had got worse between their initial assessment in at scene and in hospital – BUT were these really just natural progression of disease with spinal oedema increasing signs/symptoms?

Spinal fractures occur in 2% of all major trauma. Unstable spinal fractures occur in all major trauma 0.7%. Remember this when you get on scene – 98% of patients will not have a spinal injury.

The awake patient will develop a position of comfort with muscle spasm protecting the injured spine. Hauwald, 2002

A co-operative patient does not require immobilization unless their conscious level deteriorates. Muscle spasm is superior to any artificial method. Blackham & Benger, 2009.

 

Immobilisation with cervical collar is not harmless

  • Uncomfortable
  • Causes delays
  • Increased ICP
  • Increased risk of aspiration
  • Pressure sores
  • Reduced airway opening
  • Reduced respiratory efficiency

Forget immobilisation, deliver spinal care

  • Stop hypoxia
  • Stop the bleeding
  • Minimize force
  • Minimse movement

 

Paris attacks

 

Screen Shot 2015-12-07 at 11.22.54

I have just finished listening to the excellent podcast produced by the St Emlyns team following the terrorist attacks in Paris. The interview with one of the receiving Emergency Medicine physicians, Youri Yordanov, is informative and thought provoking. Although they discuss the in hospital response to the attacks, there is still much of relevance to prehospitalists. I was really interested to hear Dr Yordanov talk about how he never thought it would happen to him and his department. We can probably all recognise this in ourselves, and as someone who was previously responsible for major incident planning, in our colleagues. The podcast highlights the value of reading and knowing your organisations major incident plan, so that, as Dr Yordanov describes, the actions to take are already embedded in your brain. At a time when your bandwidth will undoubtedly be overloaded, you can carry out the predetermined key actions to ensure your major incident response is effective from the beginning; bring order to chaos. Simon pulls out some really key features of an effective major incident response, the impact of which are described succinctly. It is reassuring to know that the planning and principles do work; huge respect to our colleagues in Paris for delivering good care in very challenging circumstances. If you are part of an organisation which may need to provide front line services in the event of a mass casualty event… everyone… have a listen, reflect and think about what it would be like. Then, if the worst happens, at least you will have exercised it in your mind.

http://stemlynsblog.org/learning-from-the-paris-attacks-with-dr-youri-yordanov-st-emlyns