Pre-Hospital Care Podcast

This is the second instalment of the conversation on the approach to major incidents with Keir Rutherford & Alec Wilding. We examine triage tools which have just come into practise which is around the TST - 10 second triage algorithm and the MITT - major incident triage tool and also look at enhanced levels of care on scene and what should be done in the casualty clearing station. We also examine at how we manage our emotions as senior clinicians both on scene and retrospectively and work we work with interdisciplinary teams around the fire brigade and the police on scene. Here are more resources from the conversation: London Bridge article: https://www.magonlinelibrary.com/doi/abs/10.12968/jpar.2017.9.12.512 Ten second triage: A novel and pragmatic approach to major incident triage: https://t.co/LXdO1MFRX4 New NHS Prehospital Major Incident Triage Tool: from MIMMS to MITT: https://emj.bmj.com/content/39/11/800.long NARU app: https://naru.org.uk/jesip-launched-free-app-emergency-responders/ Jesip aid memoir : https://jesip.org.uk/uploads/media/pdf/Aide_Memoires/JESIP_Aide_Memoire_2022.pdf

In this conversation we will examine some of the lessons learnt from anecdotal experiences in major incidents, together with the reflections from previous recommendations in major incident enquiries such as the Manchester bombings. We will examine the differentiation of terrorist attacks at point of call from an otherwise normal RTC or ‘typical’ incident. We also look at the initial approach to triage, who and how this should be done as well as the integration and relationship of the Ten Second Triage (TST) algorithm, the Major Incident Triage Tool (MITT) and levels of enhanced care at the scene. Also, the concept of casualty clearing and when and how this should be performed. We also examine the level/ceiling of intervention that is beneficial from the empirical research in such events and how this should be approached. We also examine inter-disciplinary working with other services such as police responders and fire brigade.  Keir Rutherford is an Advanced Paramedic Practitioner in Critical Care and also a flight paramedic with London’s Air Ambulance. Alec is also an Advanced Paramedic Practitioner in Critical Care and the Emergency Planning Resilience and Response (EPRR) lead for Festival Medical Services, who are a charity providing event medical cover including at Glastonbury and also a Specialist Paramedic for Hampshire Isle of Wight Air Ambulance. To read more on some of the information referred to in the Manchester Bombing inquiry please see here: https://manchesterarenainquiry.org.uk/ This is part 1 of a 2 part conversation as we felt there was too much to include in just one episode.

In this conversation we will examine the latest in non-invasive ventilation via the helmet interface. Recent empirical research has shown that ventilation via helmet can mean faster recovery time, shortening an ICU stay, reduces the need to intubate, lowers ICU mortality, and can result in minimal or no sedation of the patient.  Aurika Savickaite is a registered based in Chicago and was involved in the successful testing of the helmet ventilator in the ICU at the University of Chicago during a three-year trial study. Aurika has worked as a registered nurse and patient care manager at the University of Chicago Medical Centre, Medical Intensive Care Unit, and as a staff nurse at Vilnius University Hospital, in the intensive care unit. She earned a Bachelor of Rehabilitation and Nursing at Vilnius University Faculty of Medicine in 2001. Aurika is a recognized expert in noninvasive ventilation via the helmet interface and has garnered widespread respect within the medical community for her passionate work in this area. She was involved in a successful three-year trial study at the University of Chicago Medical Center that tested the effectiveness of helmet-based ventilation in the ICU. Drawing on this experience, Aurika founded HelmetBasedVentilation.com, a website that has become a valuable resource for medical professionals seeking to learn more about the benefits of helmets and their use in treating patients with respiratory distress. In the episode we cover: The story of exploration into NIV for Aurika and what did the covid pandemic reinforce?  The benefits of NIV in general. What are the benefits of helmet ventilation over NIV mask ventilation (greater alveolar recruitment).  The study - Effect of Non-invasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients with Acute Respiratory Distress Syndrome - A Randomized Clinical Trial. Commonly seen pathologies that benefit from NIV and the onward benefit.   What are some of the pre-hospital benefits in transport and retrieval. The indications and contraindications of NIV. What the masters program taught Aurika (level of critical analysis)  The paper that Aurika refers to in the interview can be found here: https://jamanetwork.com/journals/jama/fullarticle/2522693 Online course: https://www.helmetbasedventilation.com/Cesarano, M., Grieco, D.L., Michi, T. et al. Helmet noninvasive support for acute hypoxemic respiratory failure: rationale, mechanism of action and bedside application. Ann. Intensive Care 12, 94 (2022). https://doi.org/10.1186/s13613-022-01069-7

In this conversation we will examine the principles of coagulopathy and novel approaches to coagulopathy within pre-hospital care. We will examine the utility of fibrinogen concentrate, the distinct features of fibrinogen concentrate with cryoprecipitate, its longevity of use compared to other blood products, how you constitute fibrinogen concentrate for use in the pre-hospital environment amongst other topics.    To do this I have Ross Davenport with me, Ross is a Consultant Trauma & Vascular Surgeon at the Royal London hospital in the UK. He is also a Senior Lecturer in Trauma Sciences and has previously worked in prehospital care for both London and Essex & Herts Air Ambulance. His research has focused on trauma-induced coagulopathy, acute response to injury and the treatment of major trauma haemorrhage. His work in traumatic coagulopathy and massive transfusion, inflammation and organ dysfunction has had international renown. In the episode we examine: ·      Coagulation and the pre-hospital evidence  ·      Are we getting a handle on hypothermic induced coagulopathy  ·      What is fibrinogen concentrate and its mechanism of action? ·      How it differs from cryoprecipitate and whether we still need cryoprecipitate. ·      What the initial empirical research shows from CRYOSTAT 2 research. ·      It’s robustness within pre-hospital environments and how you reconstitute it for pre-hospital use.  ·      Current trials with Fibrinogen concentrate and early indications of effectiveness.  ·      ROTEM/thromboelastometry markers of effectiveness  ·      When to give it in the patient journey?  Please enjoy this episode.

In this conversation we will examine the concept of the performance pizza. This is a concept which examines three main domains of performance within pre-hospital care; the predictable routine, the predictable emergencies and the unpredictable emergencies. We will dig into each of these domains and examine what each constitutes, how you train for each state and how to navigate each.     To do this I have Stephen Hearns with me. Stephen is a consultant in emergency and aeromedical retrieval medicine. He works with Scotland’s Emergency Medical Retrieval Service (EMRS). This aeromedical retrieval service delivers pre-hospital critical care for major trauma patients, rural hospital secondary retrievals and major incident responses. Inspired by experience gained working on London’s air ambulance and in Queensland Australia, Stephen led the establishment of this team from a small voluntary service in 2004 to what is now a fully government funded aeromedical retrieval organisation with an international reputation. In the episode we discuss: ·      The three performance domains – how did Steve come to rest on these domains and how do they look in practice. ·      The predictable routine – Patients and/or skills that are executed everyday and are commonplace within practice. ·      The predictable emergencies – The High Acuity High Occurrence skills or patient presentations (RSI for example)  ·      The unpredictable emergencies – the High Acuity Low Occurrence (HALO) skills that might fall into the unpredictable spectrum (Surgical Airway) ·      Putting it all together in training and how simulation and case review plays into this. ·      How Core Cognition seeks to educate these areas within high performance teams. You can find more on Steve's Core Cognition website here: https://corecognition.co.uk/ The performance pizza can be seen here: https://corecognition.co.uk/performance-infographics/performance-pizza My thanks to Steve for an insightful and educational discussion.

In this conversation we will examine the career progression of Vicki Brown, who is an Advanced Practitioner in Critical Care, and is the first person in the country to get on the Faculty of Pre Hospital Care (FPHC) Register of Consultant Practitioners by qualifying from a purely paramedic background. We will trace her career pathway and the steps that have been taken by her to achieve such a pivotal role within pre-hospital critical care.  Vicki joined the ambulance service in 2002. And has had roles in management, learning and development and working on HEMS. She became the first ACP-CC for SWAST in 2020 and the first person to register as a Consultant (Level 8) Practitioners in Pre-Hospital Emergency Medicine in 2021.  ·      The start of Vicki's career – 2002 and what Vicki was doing previously to Paramedic Practice.   ·      What Vicki learnt on the road as a Paramedic  ·      What management taught her and she carried through ·      How training and education played a role in her progression  ·      The adage of learning every-day   ·      The educational pathway (DIMC, higher education, FIMC) ·      What working at GWAAC has taught her  ·      How governance looks within the team at GWAAC. ·      What responsibilities Vicki undertakes now as an Advanced Practitioner in Critical Care. ·      How she has changed over the years through her positions. ·      Where the profession is going, the pillars of advanced practice within the UK.  To see more on Vicki please see here: https://greatwesternairambulance.com/apcc-vicki-brown-breaks-barriers/ To see more on GWAAC please see here: https://greatwesternairambulance.com/ This episode is sponsored by MEQU. THE °M WARMER SYSTEM is a portable blood and IV fluid warming system. °MEQU has developed an IV-blood warmer for emergency transfusions. It’s a portable fluid warmer which warms up blood from cold to body temperature within seconds. The set-up time is less than 30 seconds, and the user-friendly design ensures that the °M Warmer System cannot be assembled incorrectly. Blood and other infusion fluids can be heated from 5°C to 37°C at flowrates up to 150 ml/min. One charged battery can heat up to 2 liters of cold fluids (5°C) or 4 liters of fluids at room temperature (21°C) to body temperature. The °M Warmer System has a compact design and weighs only 760 grams making it portable and ideal for prehospital use. The single-use warmer’s small size (10cm x 5cm x 2cm) allows it to be attached to the patient close to the infusion site, using its integrated adhesive pad. This secures infusion site and reduces heat loss in the tubing. The °M Warmer System is approved for use in ambulances, helicopters and fixed wing air frames. Please see here for further details: https://mequ.dk/product/?gclid=Cj0KCQjwy9-kBhCHARIsAHpBjHjgsgSlJ0bzKpZmNAs_OFdOEgYeeFKj0-Q-5XDJU5v-D5G15r23o_8aAoddEALw_wcB

This is a repost of an episode I recorded back in the early years of podcasting. It remains the most downloaded episode of the entire podcast. Steve Rashford is the medical director of The Queensland Ambulance Service (QAS) with 5,000 staff and 1,300 response vehicles. In the episode Steve gives some of his perspectives of a pre-hospital careers spanning over 20 years in duration within multiple services. QAS has a contemporary approach to clinical service delivery and innovation in prehospital trauma care. It also operates a tiered system of pre-hospital care with Advanced Care Paramedics (ACPs), Intensive Care Paramedics (ICPs) and a smaller cohort of HARU Paramedics. In this episode we discuss a variety of topics: High Acuity Response Unit (HARU) both its inception and the clinical remit for the HARU. Governance around the HARU program and provider quality assurance for some of the procedures (RSI, on-call advice, blood products and the bleeding patients). Quality improvement and where the program is heading The lessons learnt building the HARU and ICP schemes in QLD. I hope you enjoy this episode as I found it both insightful and helpful to look at how other systems approach high performing teams and continuous improvement. Please feel free to reach out to me at eoinwalker@hotmail.com as I always welcome feedback.

In this conversation we will examine the fundamentals of human factors within tasks with Jim Walmsley. We will focus on Human factors from a task perspective refer to the ways in which the design of a task or activity can affect the safety and performance of the individuals performing it. We will examine the concept of task complexity, task variability, task duration and demands, feedback mechanisms in place to learn from, clearly defined goals, and finally task design. We will also discuss some of the mitigation factors involved in environmental design, training and skill development, task analysis to error trap, and teamwork and communication.   To do this I have Jim Walmsley with me, Jim is a specialist paramedic in critical care. He has led expeditions for various Non-Governmental Organisations (NGOs) in and around Europe since 1996, and in 2001 he obtained his carnet as an International Mountain Leader, alongside additional outdoor qualifications in climbing, kayaking, and the rope access industry. As a qualified Critical Care Paramedic, he’s spent the last nineteen years specialising in pre-hospital critical care, after initially training and working in Sheffield. Having completed an MSc in clinical research and a PgDip in critical care, he now resides the Southeast of England. In the conversation we examine: ·      What is human factors from Jim’s perspectives  ·      How task human factors have affected Jim in the past - A case that is seminal and typifies the importance of human factors  ·      The classic offenders - unfamiliarity with the task, inexperience, a shortage of time, inadequate checking, poor procedures. ·      Task complexity & variability  ·      Task duration and demands.  ·      Feedback mechanisms in practice  ·      Defined and clear goal setting  ·      Design flow to mitigate  ·      Training skill and development  ·      Task analysis to error trap  ·      Teamwork and comms  I hope you enjoy this final episode in the series on human factors within practice.

In this conversation we will examine the concept of flash teams with Ben Watts. We will focus on why they can pose such a challenge in highly stressful situations. We examine the concepts and issues of ego, lack of team ethos, lack of shared understanding/clear plan, poor communications, name use, active listening issues, poor followship, anchoring and much more. We also examine when things are working well and some of the core fundamental components of this including collaboration, use of checklists, feedback mechanisms, closed loop communication, affirmation, shared mental models and overt followship and leadership. We also look at one of the key fundamental tenets of flash teams, that of consistently calm cadence of communication.   To do this I have Ben Watts with me, Ben is no stranger to the podcast and has spoken with me on a number of episodes, most recently around the bleeding patient. Ben is a critical care retrieval practitioner working with the Emergency Medical Retrieval Service (EMRS) in Scotland and also works as a World Extreme Medicine (WEM) faculty member. In the conversation we examine:   ·      The concept of flash teams  ·      When it goes right – what this looks like from a flow of communication ·      When it goes wrong and how can we correct it ·      The importance of effective communication  ·      Feedback mechanisms to course correct for future performance ·      Error detection – Ben’s approach to error trapping  ·      Distraction and environmental factors - signal versus noise  ·      Decision making paralysis and the concept of ‘overwhelm’. ·      Correcting poor teams when they are going wrong. ·      Training and education around flash teams  My thanks to Ben for an engaging and interesting conversation

In this session I am speaking with Clare Fitchett as we explore the fundamentals of human factors and the interplay of leadership. In the conversation we examine what human factors mean to Clare and how they affect her practice. We also look at leadership and how Clare perceives leadership can affect human factors for the better. We finally examine the concept and strategies of human factors mitigation and how we can offset the patent safety issues that human factors brings with it.  Clare graduated as a paramedic in 2011 having undertaken her student paramedic training with South Central Ambulance Service. She commenced her Specialist Paramedic (Critical Care) training in 2018 with Thames Valley Air Ambulance (TVAA) and holds the Diploma in Immediate Medical care (DipIMC) from the Royal College of Surgeons in Edinburgh and is completing an MSc in Advanced Clinical Practice. Clare also volunteers as an Expedition Medic with the British Exploring Society and is also a faculty member of World Extreme Medicine. She currently works for Hampshire and the Ilse of Wight Air Ambulance. In the conversation we explore: Overview of HF- why it is important to Clare and holistically How leadership can affect HF - the interplay between human factors and leadership Seminal leadership points that are useful/attributes of a good leader How we support more junior clinicians to lead in critical care circumstances Peer review and/or shared mental models Some of the mistakes and misconceptions that people make when relying on their own memory versus checklists Aspects of Clare's leadership that has changed over time Managing stressful environmental human factors on scene Some of the great leaders Clare has learnt the most from in regard to human factors mitigation Examples cases; seminal cases from Clare’s experience - 2 cases, one which went well and one which was challenging and valuable learning. Please find some valuable empirical research that underpins Clare's perspectives: Interventions to improve team effectiveness within health care: a systematic review of the past decade https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-019-0411-3 A standardised approach to pre-hospital RSI in the UK; utility, governance and content of current pre-induction checklists https://link.springer.com/article/10.1186/1757-7241-23-S2-A16  My thanks to Clare for an insightful and engaging interview