Building Community Resilience with Careflight

Rural trauma – a high-speed vehicle roll over, a farming accident with a chainsaw, a gas BBQ explosion at the family picnic.  These are all scenarios that may affect individuals & families…and the rural community.  Occasionally a multi-agency event such as a bushfire, extreme weather event or other natural disaster will cause traumatic injuries and impact on not just local community but also on State resources.

Whilst it is true that each State has well-developed retrieval services, whether land, fixed or rotary-wing, the reality is that the help they can offer is usually distant to rural folk; response times are measured in hours, not in minutes or seconds.

For all practical purposes these services might as well be on the moon in the face of truly urgent care (catastrophic haemorrhage, impact brain apnoea, compromised airway, delivery of effective analgesia etc).

The first link in the trauma chain of survival is invariably the first responder – he or she may be a rural volunteer in a service such as ambulance, fire, SES , coastguard…or may respond as part of their job role (eg: Parks officer, tour guide)…or may be a lay member of the public who comes across an incident and is thrust into the maw of trauma care.

This impromtu response what Christina Hernon defined as the ‘immediate responder’ in her excellent talk on ‘the disaster gap’ at smaccDUB.

The Disaster Gap is the time between the moment an incident occurs, through the first call for help, and until the first of the clearheaded First Responders arrives. In this definable time gap, the only available rescuers are people who are on scene when the event happens, who may be traumatized by their experience themselves, and who, regardless of tools or training, take immediate action to help another person or make the situation better.

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Of course many organisations insist on their members having an advanced first aid qualification; whilst these are useful, their proscribed content often lags behind current trauma care delivery. First responders are the initial link in the ‘trauma chain’ and there is no reason not to equip them with appropriate skills, knowledge and equipment – regardless of agency!

Whilst most interagency training is focussed on ‘mass incident’ exercises as a learning exercise, the reality is that these rarely, if ever, happen. Most of the work is in the usual business – a vehicle rollover or crash, an injured bushwalker, a farm accident, a patient needing medical care but unable to use the stairs, requiring SES and Ambulance teams etc – and yet do we ever train as a team for such circumstances?

Careflight MediSim – Delivering Necessary Trauma Education

This week we were privileged to have a visit from the Careflight MediSim team, to deliver the Trauma Care Workshop on Kangaroo Island, SA.

Launched in 2011, this innovative program from the Careflight organisation (mostly charity funded) delivers a world class trauma education system designed for rural first responders.

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MediSim training 2011-2015

Despite the session having to be rescheduled, willing first responders from Parks, CFS and SA Ambulance were able to come together for an interactive day of lectures, task-training and sim sessions under the credible instruction of the approachable MediSim facilitators.
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I’ve been banging on about the need for effective interagency training in rural communities for some time now.  My involvement in trauma nowadays is mostly limited to involvement via the SA RERN system (a doctor responding only when needed by volunteer ambulance officers, with the goal of value-adding by performing certain interventions), in the hospital when oncall for emergency or anaesthesia and of course in trauma education through ETMcourse and EMST etc.

Whilst RERN, SAAS and of course RFDS and SAAS-MedSTAR Retrieval have a role to play, the initial care at the roadside is invariably provided by a first responder.  If lucky he or she may be a part of an emergency system…or they may be in another capacity (CFS, SES, Police, Parks etc). Of course they may also be an immediate responder – a passerby who is caught up in the situation and expected to render help.

Most prehospital incidents will require input from several agencies

At a typical vehicle crash, there will be representatives from Road Crash Rescue (CFS or SES), Ambulance – typically these are unpaid volunteers in rural. Add to that Police, then RERN, and Retrieval…it can be hard to both know ‘who is who in the zoo‘ and more importantly what they can do!

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A typical rural road crash (source ABC)

 

Training together has clear advantages – it emphasises the need for simple interventions to make a difference and that such interventions can be performed by appropriately trained and equipped individuals regardless of agency. It also allows discussion of current protocols and equipment (such as the value of first responders, whether ambulance, fire or SES having access to tourniquets, and a suitable haemorrhage control device).

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Simple kit to deal with haemorrhage control – in my opinion this should be in every rural ambulance, SES or CFS truck, police car, parks vehicle and tour bus. Is it?

Understanding and sharing of each other’s treatment priorities (scene control & safety, patient extrication and medical needs) can be practiced by scenario training, allowing effective communication, a shared mental model and planning for ‘the real thing’

It’s time to ditch the notion of each agency training in silos and instead practice regular ‘real life’ multiagency scenarios

The MediSim team provided local Kangaroo Island first responders with a solid foundation to develop further local community resilience.  Lectures covered the concept of a ‘zero survey’, triage. effective handover and of course the nuts & bolts of trauma care.

 

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The Emergency Bandage (formerly known as the Israeli Bandage) – cheap and essential kit for any first responder

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Checking out the MediSim ‘crash car’ designed to be used for practice extrication – it would be a simple project to make one of these for local use on KI, potentially in partnership with TAFE & Crash Repairs

The day involved practical, hands on task-training sessions on triage, on helmet removal and immobilisation, on haemorrhage control and basic airway management.

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Helmet removal – can be done safely; either let patient do it themselves or perform if trained – but get the helmet off early, not late!

Skills learned in the workshop were reinforced by scenario-based training on managing a casualty, involving scene awareness, leadership, role allocation and the delivery of basic care in an effective manner (simultaneous extrication, treatment and packaging of the patient) underpinned by clear communication both on-scene and with central comms.

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Challenges of leadership and teamwork, under stress, with limited resources in an unfamiliar environment – one which KI local volunteer teams coped with exceptionally well

All in all, a wonderful effort by the CareFlight MediSIm team and by the local Kangaroo Island volunteers who gave up their own time to attend this trauma workshop.

I am hopeful that we can run similar exercises in the future using local expertise.  To my mind the benefits of team members who are aware of each other’s roles and operational capabilities, who have trained together and share a common goal offer immediate tangible benefits to victims of trauma.

Moreover we live in a small community – the more first responders who are trained and equipped, the more resilient our response can be – whether for an accident at home, at the roadside or in the case of a community-wide catastrophe.

 

A Kangaroo Island Resilience Model, akin to those overseas, is achievable if we work together.

Thanks again Careflight for visiting Kangaroo Island – come again next year!

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COI – I received a bottle of wine from the MediSim team as a reminder of my time in Orange NSW back in 2011 (anaesthesia training and trauma care). I am not influenced in my report by this gift…although there MAY be a subliminal message they want to convey…

 

Recommended Reading

Read more about Careflight MediSim HERE

Careflight are also active in sharing their knowledge through social media; check out the Careflight Collective blog here

Learn about how the Isle of Arran (Scotland) has developed a local resilience model for multi-agency training and trauma care

Principles of trauma care are taught on many courses; I recommend

Emergency Trauma Management (ETM) course – etmcourse.com (COI I instruct on ETM)

Anaesthesia, Trauma & Critical Care (ATACC) course – atacc.co.uk (COI am trying to persuade Mark Forrest to bring this course ‘down under’)

The Holmatro Rescue Experience (COI have facilitated with Holmatro extrication guru, Ian Dunbar on this in Australia, mostly teaching SES and CFS volunteers)

Many clinicians worldwide share knowledge and skills – regardless of whether background in emergency, anaesthesia, rural medicine, critical care or whether involved as doctor, nurse, paramedic or volunteer. Our common goal is to care for the patient from whatever background.  By sharing such knowledge we can all become better.

On simple research and the gift of sharing…

A nice little paper caught my eye in this months Emergency Medicine Australasia.  Entitled “Review of therapeutic agents employed by an Australian aeromedical prehospital and retrieval service” this is a really simple paper; basically an audit of the medications carried and used over a 12 month period by the Sydney HEMS service.

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Everyone likes playing with drug kits – but what REALLY needs to be in the bag?

There’s a fair chance that you may not be able to get passed the EMA ‘pay-per-view’ firewall, unless you have institutional access or can blag a copy off the author (thanks guys). So what did I like about this paper?

“Two is one, one is none”

First up, it’s a simple piece of research – a retrospective review of missions (2566 total; 848 prehospital, 1662 interhospital & 56 mixed) and the medications used.  The first author was a medical student at the time. The paper provides a useful summary of commonly used medications for both primary and secondary retrievals….more importantly, it also informs which medications are perhaps unnecessary to carry.

Why does this matter? Well a retrieval service needs to be able to function autonomously.  Kit space is limited and cost/weight considerations need to be made, especially for kit infrequently used. Cost and stability need to be factored in.

The maxim ‘two is one, one is none‘ is often applied in retrieval – place two IVs in case one is ripped out, carry spare batteries in case power fails, have redundancy in clinician skills and training….

WARNING <RANT MODE ON> Why some retrieval services don’t use a model that allows alternating RSI by doctor and RN/paramedic escapes me – better to have redundancy in airway management IMHO providing clinicians are trained to appropriate standard and operate under an agreed SOP <RANT MODE OFF>

Whilst the contents of kit packs are often determined by historical and expert opinion, as well as driven by SOPs, a retrospective audit of actual use can inform future stocking – more so if additional information from other services is shared.

Of course, the majority of cases reviewed in this paper were inter-hospital missions; it would be interesting to see how many of the medications were available at the referring institution (ie source of medication used in this retrospective analysis of case cards) as there may be scope to avoid carrying medications that are commonly available either on roadside (ambulance) or hospital eg: ipratropium, metoclopramide etc

Relevance to Rural?

Unlike the UK & NZ, only a very few rural doctors are involved in the prehospital space in Australia (a 2012 survey showed that over 50% of rural GP-anaesthetists had responded to a prehospital incident in the previous 12 months).  Worryingly such responses were informal – typically activated by ambulance comms; the clinicians attending had no formal agreement for call out criteria, equipment, training nor ongoing CPD.

Of course in South Australia we have the RERN system, designed to ‘value add’ in specific cases, typically where local (mostly volunteer) ambulance officer responders cannot offer the appropriate intervention and when State-based retrieval services are not available in a timely fashion. The tyranny of distance in Australia dictates that reliance purely on metropolitan-based retrieval services and volunteer-based ambulance responders represents a potential therapeutic vacuum, where appropriately trained and equipped rural doctors with ongoing skills in emergency care/anaesthesia could value add – akin to UK BASICS.

I will certainly be re-assessing the contents of my RERN prehospital packs based on this paper, although I suspect not much will change.  Similarly the results of this sort of publication may help inform the stocking of small rural hospitals.

More importantly, the published experience of Sydney HEMS in regard to post-intubation sedation protocols has immediate applicability to rural hospitals (if you can’t access the paper, my recommendation based on reading would be to use fentanyl>morphine and propofol>midazolam). Whilst my practice may not have changed, it MAY change the practice of other rural hospitals where M&M (morph/midaz) sedation may be the default. Development of a post intubation sedation SOP is one of the recommendations from this paper.

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A system built on excellence also inspires excellence in others. Except this chap. Obviously…

 

The real value is knowledge-sharing

Another thing I liked about this paper is that I know most of the authors! Luke Regan, John Glasheen and Brian Burns have all, at various times, supplied me with copies of their talks, their research and their ideas.  This is because of the commonality that comes from the FOAMed community. The commitment to share.

More than that, the service within which these individuals work also has a demonstrated commitment to sharing their experience, skills and knowledge – not only by publishing such low-hanging fruit as this (and let’s face it, reproducing such a paper is an easy ‘gimme’ for any service), but also by their commitment to sharing protocols and information through other channels.

Sydney HEMS use of Twitter, Blogs and even a YouTube channel is well-established.  The outcomes of their Clinical Governance Days are blogged online, along with relevant resources.  Despite the potential for concerns (often expressed by health administration), sharing such information has had little disadvantage and instead offered significant advantages to the quality of the service!

Why is this important? Because I think many of the lessons from prehospital are applicable not just to those in the prehospital space, but also the rural doctor cadre and of course the wider community working in ED. We all benefit when such knowledge is shared.

We’ve seen this with lessons on safety (human factors, sim training, resus room management, action cards, checklists) and in the commitment to excellence (metacognition, measurement and refinement of training to lead to incremental change). And these lessons are now shared on a global stage.

This of course echoes the words of Stephen Hearns at Glasgow pre-smaccDUB

Plan & Practice the Predictable

Reflect, Learn & Change 

Share Information

In short, there’s no point in any organisation planning and practicing excellence, unless also reflect and learn – and most importantly, to share this information with others.

This is where Sydney HEMS have set the lead for others to follow – by enot just a commitment to clinical excellence, but also by committing to share this information widely – their engagement in use of social media, at both an individual level and institutional, has reaped significant benefits to both sharers and recipients.

By sharing they not only raise the bar for others – they raise the bar for themselves by benchmarking

Globally, clinicians looking to attend a ‘finishing school’ in prehospital care will no doubt be applying to work at Sydney HEMS as a first choice, and rightly so.

In short, this paper (although very simple research) demonstrates a useful overview of appropriate medications in the PHARM environment.

However for me it also reflects as a demonstration of the value of SoMe and FOAMed at an institutional level.

Kudos.

 

Some of the Sydney HEMS SoMe resources here

YouTube – GSA HEMS

Blog Site – SydneyHEMS.com including lessons and resources from their Clinical Governance Days

Affiliated sites – Resus.me (the enigmatic Cliff Reid)

Twitter Accounts : @SydneyHEMS @jglash @HawkmoonHEMS @LukeARegan @drbear13 @DrGeoffHealy @cliffreid @karelhabig @allegorical (apologies – am sure there are others I’ve missed out)

Also cross-pollination with others…Natalie May currently on sabbatical ‘down under’ (let’s hope can keep her and partner) writs here for StEmlyns on the educational excellence of GSA-HEMS.

Bringing the Outdoor Classroom Indoors – #MedEd at #smaccFORCE #smaccDUB

References

Hayward M, Regan L, Glasheen J, Burns B (2016) Review of therapeutic agents employed by an Australian aeromedical prehospital and retrieval service Emergency Medicine Australasia (2016) 28, 329–334 doi: 10.1111/1742-6723.12584

Appendix 1 Number of patients receiving agent by mission, case and patient type
Appendix 2  Stock medications of the Greater Sydney Area Helicopter Emergency Medical Service.

Hearns S & Weingart S – On creating a system of excellence via emcrit.org blog

Leeuwenburg T & Hall J (2015) Tyranny of distance and rural prehospital care: Is there potential for a national rural respnder network? Emerg Med Australasia. 2015 Oct;27(5):481-4. doi: 10.1111/1742-6723.12432. Epub 2015 Jun 24.

It’s Not About the Helicopter

Just got back from #smaccDUB – I chose not to speak this year and that was a GOOD decision – it allowed me time to actually wander around and soak up some of the high quality talks, as well as to socialise with like-minded colleagues from around the world. FOAMed is the passion which inspires us all – smacc is an opportunity for those interested in resuscitation and critical care to come together unde the FOAMed banner.

Of course #smaccDUB allowed a catharsis for the passing of John Hinds; a moving tribute in the opening plenary set the scene for amore contemplative conference, with many repeating the themes of self-care as well as cutting edge resuscitation medicine.  Progress continues on the establishment of a Northern Island Air Ambulance, a mission which I wholeheartedly support (picture below is of Mark Forrest of ATACC Faculty and myself, modelling the launch of the #whatwouldjohndo T-shirts at the Guinness Storehouse smaccDINNER)

You can get yourself one of these ‘Craic the Chest / #whatwouldjohndo’ or Delta7 pins online and support the funding of a Northern Ireland Air Ambulance

 

Dr Mark forrest modelling the #whatwouldjohndo T-shirts, now available to support #Delta7

Dr Mark Forrest modelling new #whatwouldjohndo T-shirt – click HERE to order & support NI Air Ambulance

 

Thoughts on smaccTALKS?

Highlights (and there were many) include the numerous concurrents (espec the “Igniting Minds” session with longstanding internet colleague Ross Fisher on presentation skills, tips on performance coaching from London HEMS Tom Evens, tips on choreographing learning from Sandra Viggers and the powerful team from FemInEM, tacking gender inequality in emergency medicine – a lesson which equally applies to primary care!)

Many other talks resonated, all of which will be released in due course on the smacc podcast and affliliated blogs. Too many to cover here – monitor smacc.net.au and affiliated websites for both release of talks and various reviews of smaccDUB

I will focus on just one talk – Gareth Davies spoke at the opening session on ‘The Case for HEMS services’ – the title and content of this talk is one which I found somewhat lacking, as it seemed to emphasise the role of the helicopter over the value of the system behind it.

To my mind a good retrieval system is not about the transport platform, but about the quality of the care it delivers

 

This is important. I’ve long been saying that the lessons from mature prehospital services (Sydney HEMS is the leading example in Australia) could and indeed should be applied to other aspects of clinical systems.  This includes the use of appropriate SOPs, checklists for high-risk procedures such as RSI, action cards, understanding human factors relevant to resus room management, understanding of metacognition and heutagogy…as well as breaking down silo mentality and sharing ideas with other organisations for the benefit of both patients and services.

Clearly I am not the only one thinking this way – Scott Weingart picks up the theme in his latest EmCrit Wee on Creating a System of Excellence, discussing the work of Scotland’s EMR service.

Have a listen to the talk here – Scott’s intro and then Stephen Hearns’ talk.

 

 

Creating excellence, regardless of location, is something that resonates with me.  One thing is clear – a well-functioning retrieval service is able to deliver excellent care because it has pluripotency in stable team members and of course trains exhaustively.

It doesn’t rest on it’s laurels and always seeks to engage with other players in the clinical system. Of course this is made easier when there is effective clinical leadership and by the fact that such teams are small, with a fixed number of team members to enable rigorous training.

Plan & Practice the Predictable

Reflect, Learn & Change

Share Information

These lessons are, I believe, entirely translatable to the small rural hospital system in which I and many other rural doctors in Australia work. Despite not dealing with critical illness on a day-to-day basis, we are generally made up of small teams and have limited roles and equipment.

This can be an advantage compared to the ‘flash teams’ and plethora of equipment options available in tertiary centres.  Simplicity has advantages!  And yet we seem to suck at it – examples abound of poor management by rural hospitals, much to the chagrin of colleagues in both retrieval and tertiary care.

Part of this is of course the infrequency of such cases….another part is the difficulty of both achieving and maintaining competence, especially as it represents a tiny percentage of the work we do.  But the reality is that critical illness does not respect geography and thus rural clinicians need to be able to deliver the best care regardless of these difficulties.

In short, there is no excuse for the rural hospital team NOT to adopt lessons from prehospital services and incrementally achieve excellence – provided there is both leadership and governance within the system, features often sadly lacking due to the disconnect between clinicians and administration in many hospital systems, especially in rural.

I would like to encourage all rural doctors to listen and watch the vodcast above and then to advocate for improvement.  Some simple measures to implement include:

  • standardisation of equipment (eg: difficult airway, resus room set up) across sites
  • develop easily accessible SOPs for procedures, preferably driven by rural clinicians so content is contextually relevant and not inappropriately metrocentric
  • develop region specific action cards and checklists for high-stakes, infrequently performed procedures
  • explore the use of in situ simulation, preferably multidisciplinary, to refine aspects of what my friend and colleague Andy Buck of ETMcourse describes as Resus Room Management
  • use FOAMed to keep up-to-date and develop skills in metacognition to guard against individual error in diagnosis and management when treating the critically ill
  • audit retrieval or resus cases – not just in terms of clinical outcome, or driven by feedback from metro/retrieval service – instead develop LOCAL audit to consider whether all aspects of knowledge, training, equipment, teamwork were up to par or could be improved.

So rural doctors, let’s work together to raise the bar in rural resuscitation.  Our patients deserve being treated within a system of excellence.  There are some beacons of excellence out there (Casey Parker at BroomeDocs is one, there are many others).  But there are also rural hospitals that are under-performing, whether through lack of knowledge, lack of equipment, lack of team training or lack of leadership.

We need to raise the bar, regardless of the barriers. And the responsibility rests with us…

 

Safety in Resus – Use the Whiteboard!

There’s no doubt that for the small rural emergency department, a critically unwell patient can quickly overwhelm available resources.  Like many small rural hospitals in Australia, there is one doctor on call for emergency presentations, with the ward-based nursing staff (two in out location) responsible for ward care, assessment of outpatient attendances as well as care of patients in the ED. Not surprisingly this can be a big ask…and thankfully extra nursing and medical staff are available if needed (typically the oncall theatre team)

As we ramp up into the tourist season on Kangaroo Island, I’ve been thinking about how we deal with critical patients in our rural ED.  Having the appropriate training and equipment is obviously important – as well as an appreciation of resus room feng shui.

A recent retrieval case brought the issue of improved team communication to mind.  I wont go into details; suffice it to say that this case required the attention of two doctors, seven nursing staff, one paid paramedic and four volunteer ambulance officers….and subsequent retrieval.  The demands of one critically ill patient … plus several other ED attendees … plus ward care can quickly overwhelm local resources, without a robust oncall system.

But no matter how well equipped, how well trained or even how well staffed the ED is, there HAS to be effective communication between members. We did quite well, but on reflection afterwards I felt that it was hard to keep track of who did what and when. This is often the case in a resus team, particularly occasionalists or the ‘flash team’ or individuals who have not trained together.

The traditional and practiced role of a resuscitation team is based on that of team leader, with subsequent role allocation and closed-loop communication between members, all operating with a common goal or ‘shared mental model’.  This is the sort of stuff we teach on the ETMcourse, focussing not just on the technical skills of trauma care, but also on the nuances of effective teamwork in trauma.

In recent times I have become a fan of using the whiteboard as ‘glue’ to hold the resus team together.  In any resus, it is common to delegate one person to scribe.  It’s important to have a record of drugs given, interventions delivered and arrival/departure of team members etc. But many people, myself included, find that the furious writing by one team member of all events & drugs on a piece of paper that noone else can see does little to add to team effectiveness in a critically ill patient.  Scott Orman over at Auckland HEMS has posted a nice summary of why a whiteboard is so useful for prehospital handover – I think this applies equally for rural hospitals.

Why is that? Well – it’s pretty simple.  In a small team, we need every hand on deck – delegating a clinical member to scribe may take them out of circulation. But that’s a minor gripe – the main problem with the scribe is that noone else can see what he/she has written unless they take time out to read their notes. In short, there is no shared mental model when all documentation goes via the scribed notes.  Moreover, the scribe may accurately capture all the interventions and their timing from multiple sources – but this knowledge is not shared between team members.

“often the scribe has all the critical information – noone else does!”

This makes sense – the resus can be chaotic, especially when team members haven’t trained together and there is a lack of leadership or followership, unclear role allocation nor closed loop communication.  Instead there is frenetic activity, cross talk, repeated interruption and a requirement to re-hash essential elements of history and interventions with the arrival of each new team member…

This is where the resus whiteboard comes into play – I’ll be the first to admit that ours is not big enough – but it’s a start. I would hope that every rural ED has a whiteboard available at the head of the bed or adjacent.  Documenting initial prehospital handover, subsequent interventions and obs, as well as arrival/departure of key players can help the whole team.

A whiteboard gives a clear indication of who did what, when, and why…as well as response to intervention. New arrivals to the resus can stand back and get a summary without having to interrupt.

More importantly, I find that having a summary on the whiteboard where everyone can see it gives a shared mental model – of where the patient was on arrival, the therapeutic goals and the steps needed to get there – a readily available shared mental model for all team members without the need for repeated interruptions and cross-questionning which is inevitable as additional team members enter the resus.

“closed loop communication between team members and a dedicated scribe may work well in a single trauma team – but as team members come and go, vital information is lost.

Rather than have to re-hash information, the whiteboard can give a quick summary of where we started, where we are now…and where we want to be.

It can also help open up communication – how much easier is if for a team member to raise a hand and ask “Excuse me team leader…I see that we have a goal MAP of 70 but the current MAP is only 55. Do you want to do X, Y, Z?” or “Hey everyone, we’ve transfused four units of packed cells in the last 20 minutes – we’re now into the agreed trigger for massive transfusion protocol…can we organise as agreed earlier per protocol?

Of course we still need to keep a written record – I am not suggesting that the whiteboard alone will suffice – but in a resource-limited and time-critical resus, the whiteboard can truly be the glue to keep the team on target and ensure what needs to be done is done, and that everyone knows about it! Here’s how the ‘ideal’ resus flow of information would work via whiteboard…

Prehospital Notification

AT-MIST AMBO or ISBAR can be used as a structured handover tool, allowing anticipated needs to be identified and role allocation of team members.

AT-MIST : Age/Time/Mechanism/Injuries/Symptoms&Signs/Treatment provided&Trends

AMBO : Allergies/Meds/Background/Other

ISBAR : Identity/Situation/Background/Assessment/Response+Readback

Key equipment needs may be anticipated based on pre-notification eg: traumatic head injury means probably need blood, fluid warmer, TXA, RSI equipment.  Drugs such as ketamine (for both analgesia and induction) can be pre-drawn and emergency drugs doses calculated & written down (especially for paediatric cases or uncommon scenarios). This is a good time to call in other staff – especially if multiple injuries or if solo operator and one critical patient.  The more resus I do nowadays, the lower my threshold to call in a colleague. It’s just so much easier to share the cognitive load…

prehospital handover

Patient Reception & Pre-Hospital Handover

Unless in extremis, take 30 seconds for a structured handover from the ambos before the patient is transferred off their stretcher. This is a high risk time. There is usually a flurry of activity as well-meaning individuals attempt to take history, remove clothes, gain IV access and set up monitoring.  Seriously – stop!

Studies show that less than 50% of information relayed by prehospital services is retained by emergency department staff – this can be increased by use of a structured handover tool. Whichever handover method is used, this is a time for everyone to STFU and listen!

Unless the patient is in cardiac arrest or needs immediate intervention (airway at risk etc), take 30 seconds and use the whiteboard to confirm elements of prehospital handover history and baseline obs.

I use this to determine resus goals for the team.  You will be amazed at how much information is missed at handover – especially when the receiving team ‘get busy’ with lines, blood pressure and monitoring – when they should be listening and coming up with a game plan!  And don’t get me started on 1-2-3 vs ready-brace-move for the actual transfer!

Rural Resuscitation

Once obs are done and as the primary survey is completed (again, calling out the findings so can be scribed to whiteboard), ensure a shared mental model of early treatment goals is established. I don’t know about other rural docs, but I find that a rural resus is hard work – we do this stuff infrequently, yet attention to detail can make all the difference. Critical care is mostly about doing the basics, well.

Treatment goals may be as simple as “let’s keep the patient warm, maintain oxygenation, target MAP >70 and stop the bleeding” or may be a little more nuanced “Let’s secure the airway – we’ll optimise position and pre-oxygenate; use the challenge-response checklist whilst drawing up drugs – then once intubated immediately perform a finger thoracostomy and ongoing resuscitation with warm blood whilst packaging for transfer

Obs can be scribed to show trends and response to interventions.  Key times & doses of drugs given are recorded.

Having a shared mental model allows opening up of communication of goals aren’t being achieved.  Rather than challenge the team leader (which can be difficult where there is an actual or perceived authority gradient), this approach allows truly patient-centric team collaboration.

Of course this will be concomitant with closed-loop communication between team members, something that is easily practiced on courses such as ETM.  Subsequent or parallel scribing to clinical notes is possible when time allows.

Handover to Retrieval Team

As mentioned above, the whiteboard can serve as a good global summary for the arriving retrieval team (or indeed anyone who arrives to the resus after a period of time) and allows a structured handover with salient points highlighted.  A photo of the whiteboard summary can be forwarded to the receiving facility as an initial SITREP.  Whilst the camera is out, there’s also the chance to catch some selfies with long-lost friends…

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Handover with retrieval – important time to exchange clinical info…and catch up with old colleagues (NB : this photo taken AFTER handover complete and patient stabilised!)

Before team arrival use any spare time to ensure all documentation is in order (if not already performed) and for notes to be written (often as the referring clinician I have been too busy to write anything until retrieval team arrive!).  An ABC type transfer checklist can be a useful summary (mine runs from the letter A to the letter O!). Of course patient care should take precedence over documentation! In a real rush I’ve been known to write on the patient!

Debrief

A hot debrief can be useful after a resus.  At this stage Country Health SA doesn’t routinely audit resus cases locally, which means there is little chance to improve performance not have open and honest communication on what went well and what didn’t.  Most improvement will be about aspects of communication, equipment availability and use, as well as practice as a team for realistic scenarios. The feedback from peripheral team members can be very important – the volunteer ambos, the cleaner, the ward clerk…and again the whiteboard debrief can help identify any problems in patient care and improve team resilience.

“without honest feedback from team member on cases, there can be no audit…

…and without audit, no improvement in clinical care”

In short, the whiteboard can help improve individual situational awareness via the early establishment of a shared mental model, opening up communication between team members.  There should be one in every rural ED – use it!

Whiteboards have been shown to aid the following in a resus:

  • task management
  • team attention management
  • task articulation and tracking
  • resource planning and tracking
  • synchronous and asynchronous communication
  • multidisciplinary problem solving and negotiation
  • team building

References

Prehospital to ED Handover (inc use of whiteboard) from Auckland HEMS http://aucklandhems.com/2012/11/26/pre-hospital-to-ed-handover/

Talbot R & Bleetman A (2007) Retention of information by emergency department staff at ambulance handover: do standardised approaches work? Emerg Med J. 2007 Aug;24(8):539-42. http://www.ncbi.nlm.nih.gov/pubmed/17652672

The Importance of Shared Mental Model from TEAM STEPPS http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/igsitmonitor.html#m4SL13

Xiao Y et al (2007) What whiteboards in a trauma center operating suite can teach us about emergency department communication Ann Emerg Med. 2007 Oct;50(4):387-95. Epub 2007 May 11. http://www.ncbi.nlm.nih.gov/pubmed/17498845

Transfer Checklist A-O https://ruraldoctorsdotnet1.files.wordpress.com/2013/04/transfer-abc.pdf

TRANSFER CHECKLIST

Airway

Breathing

Circulation

Disability

Exposure

Fluids given

Gut (fasted/NG)

Haematology

Infusions

JVP (filled/under-filled)

Kelvin (temp)

Lines

Monitoring

Notes & Next of Kin

Other Stuff…

DAS 2015: Ditch the FastTrach?

It’s no secret that I am concerned with management of the difficult airway, especially as pertains to the rural/remote/austere context.  This may be either as a rural GP providing anaesthesia in the Operating Theatre, in the Emergency Department or at the roadside.  Whilst many of us learn and regularly upskill in anaesthesia via the comfortable environment of the OT (usually under the tutelage of a FANZCA), the reality is that rural practice is limited by lac of immediate backup and often a paucity of equipment.

Airway difficulty may be encountered unexpectedly in the OT, or be anticipated in the dynamic airway of a critically ill patient in the ED or prehospital environment

Back in 2012 I published on the availability of equipment to manage the difficult airway in rural Australia, driven by the publication of ANZCA PS56 “Guidelines on Equipment to Manage the Difficult Airway”.  As a result, recommendations could be made regarding airway equipment in an austere environment, especially on a budget – this might include standard direct laryngoscopy, videolaryngoscopy, both standard LMA and an intubating LMA as well as equipment to manage the emergency surgical airway. Similar setups are found in some prehospital services, with the FastTrach iLMA being the standard ‘go to’ device for rescue intubation attempts.

So I was interested to see the 2015 update on management of unanticipated difficult intubation in adults from the UK Difficult Airway Society (shout out to them by the way – interested airway enthusiasts can join DAS for a nominal fee and have their say in future guideline development).

So – what’s new in DAS 2015?

The 2015 Guideline can be accessed here. These guidelines are driven by published evidence where available; where evidence is lacking, is directed by expert opinion via DAS.  I think the paper is worth reading by ANY rural clinician, as well as those involved in airway management whether in prehospital, emergency department or operating theatre. Many of the topics discussed in FOAMed circles over the past few years are distilled into the DAS guidelines, finally.

Key features include :

  • planning for failed intubation in both routine intubation and RSI
  • extra emphasis on airway assessment including assessment of emergency surgical airway (ESA) or front-of-neck access (FONA)
  • preparation, positioning, pre-oxygenation, maintenance of oxygenation via apnoeic diffusion oxygenation/NODESAT and minimising repeated attempts causing trauma
  • importance of skills in both direct laryngoscopy and video-laryngoscopy for all anaesthetists
  • use of second-generation supraglottic airway devices (SAD) to maintain oxygenation & ventilation
  • importance of maintaining adequate muscle relaxation throughout difficult airway management, particularly to facilitate not only intubation attempts, but placement of SAD, face-mask ventilation and ESA/FONA.
  • emphasis on scalpel cricothyroidotomy as the preferred ESA/FONA technique over needle techniques.

It’s particularly gratifying to see mention of cognitive aids for crisis management such as The Vortex, the technique of apnoeic diffusion oxygenation (NODESAT), use of rocuronium to give rapid onset of intubation conditions and to maintain adequate relaxation during subsequent airway management, as well as use of the laryngeal handshake’ – all topics familiar to the FOAMed community.

“DAS make it explicit that adoption of guidelines and professional acceptance alone are insufficient – such techniques need to be practiced and understood by all members of the anaesthetic team”

On top of this, there is emphasis on the value of human factors, with this contributing to at least 40% of adverse outcomes identified in NAP4.  The new guidelines mention the impact of cognitive overload in a crisis, the need for structured communication tools such as PACE, the value of setting limits on intubation/SAD attempts, use of cognitive waypoints (“stop and think”), having a shared mental model and so on.  Again this is nothing new, but it is worth pause and consideration of how often we actually train together – many of the airway courses are aimed at the airway operator (typically a doctor) and it is actually quite rare for teams to train together for crisis, unless part of a high-functioning unit such as a retrieval service or forward-thinking ED or ICU.

“I would be interested to hear from rural doctors – how many of you have the chance to train together fro crisis management using ALL team members via in situ sim?”

DAS Airway Plans A-B-C-D

Full discussion is best left to the actual 2015 guideline published 10-11-15 in BJA.

Screen Shot 2015-11-15 at 12.48.18 pm

DAS 2015 Guidelines for Management of Unanticipated Difficult Intubation in Adults

In brief the guidelines include:

PLAN A : Facemask Ventilation & Laryngoscopy

  • Importance of head-up positioning and ramping are highlighted
  • Preoxygenation for all patients; apnoeic diffusion oxygenation for high-risk patients
  • Role for VL in addition to DL recognised, with statement that “all anaesthetists should be skilled in use of a videolaryngoscope”
  • Cricoid pressure is stated as ‘a standard component of RSI in the UK’ and should be applied correctly (*)
  • Maximum of three attempts, changing something between attempts (a fourth attempt by more experienced colleague is included as permissable’)

I won’t bore you all with the nuances of different VL devices, suffice it to say that DAS suggests their use be familiar to anaesthesia providers. In rural, we are often limited by available funds, making a compromise in cost and function. Many devices give excellent views of the glottic opening, which does not always translate into effective ETT delivery unless trained and practiced repeatedly.

“I think DAS missed a trick here – they mention cricoid pressure rather than taking the opportunity to describe it correctly as cricoid force”

Application of cricoid pressure is stated as ‘a standard component of RSI in the UK‘. The 2015 DAS guidelines acknowledge that cricoid needs to be applied properly to be effective and that is often inexpertly applied, thus making mask ventilation, direct laryngoscopy and SAD insertion more difficult. There is no mention of accepted modifications to RSI, including omission of cricoid, as practiced elsewhere in the world and accepted by certain airway providers as acceptable practice in airway management of the critically ill.

If fails, pre-agreed plan to move swiftly to:

PLAN B : Maintaining Oxygenation : Supraglottic Airway Device (SAD) Insertion

  • Limiting insertion to three attempts, changing size/device
  • Cricoid pressure should be removed during SAD placement
  • Maintenance of oxygenation & ventilation
  • Successful placement of a SAD creates a cognitive waypoint to “stop and think”
  • All anaesthetists should be trained to use and have immediate access to second generation SADs

Subsequent options at the ‘stop and think’ stage may include :

  • awakening the patient if possible
  • make a further attempt at intubation via LMA s a conduit
  • continue anaesthesia on SAD without placement of an endotracheal tube
  • proceed directly to surgical airway

I think this is terribly exciting. First up, the DAS Guidelines make it explicit that we should be using second-generation supraglottic devices. I have reviewed some of these previously eg: Supreme & iGel in A Love Supreme and AirQ in Desert Island Airways.

anaesthesia_shot_i-gel-011ef8e1abdec213c9654b907b88b4bd
The ideal device is characterised by reliable first-time placement, high seal pressure, integral bite block, separation of respiratory and gastrointestinal tracts and compatibility with fibreoptic devices. The latter is important when considering a ‘staged airway approach eg: placement of SAD in the field by trained EMS providers, allowing rapid intubation in the ED via FO using same SAD as a conduit.

“One could also consider the need for an integral bite block and lack of need for an inflatable cuff to be recommendations for a rescue SAD device”

The DAS algorithms previously advocated use of an intubating LMA to facilitate blind intubation as a rescue technique.  Many theatres, emergency department sand even retrieval services have relied upon the FastTrach device.  Whilst it has reportedly better blind intubation success than alternatives (eg: the Cook Gas Air-Q II device), I find the FastTrach to be bulky, expensive, fiddly to use unless specifically-trained. It also lacks a gastric drainage port – and whilst the device can be removed to leave an ETT in situ, this is a high-risk procedure which can result in inadvertent loss of the airway (for example, see the Gordon Ewing case).

In the past I have been a fan of the Air-Q device, mainly because it obviates the need for cuff inflation, has integral gastric drainage and is a great conduit for fibreoptic intubation, either by stylet or flexible scope. DAS acknowledge the many types of SADs on the market and make specific reference to the iGel, Proseal and Supreme LMAs as being supported in practice by large-scale longitudinal studies, literature reviews or meta-analyses.

“Is the FastTrach iLMA redundant under DAS 2015?”

One can argue the toss between iGel, Supreme and AirQ devices, but one thing seems clear from the 2015 DAS Guidelines – there is NO ROLE for blind intubation through an iLMA. Instead PLAN B necessitates use of a second generation SAD and pause to consider options as above (ie: awaken, place ETT, continue on SAD or perform ESA).

Most places where I have worked have kept the FastTrach as the accepted go to device, including in theatre, ED and in retrieval.  I was always puzzled by the inclusion of a single size 4 FastTrach in the intubation pack of South Australia’s retrieval service – logic would dictate that a variety of sizes be carried, rather than rely on a single device. The lack of gastric drainage also irked me!

“Is there an excuse NOT to intubate using fibreoptic device via SAD as a conduit?”

But now the way forward is clear and appears supported by DAS 2015 – use a SAD for Plan B, and one which allows fibreoptic placement of an ETT over blind techniques which are “not recommended”.  Logically this could be achieved via carrying a variety of second generation SADs as both rescue devices and as conduits for fibreoptic intubation – to my mind this could be via either the iGel, the Supreme or the AirQ…but of course now requires consideration of training and skills maintenance with a fibreoptic device.  Whilst their availability is taken as a given in DAS, the reality is that very few rural doctors, EDs or even some prehospital providers will have access to what was traditionally expensive equipment.  Of course there are low-cost solutions, such as the use of the Levitan intubating stylet or the AmbuAscope.

I think that these devices will see renewed interest and form part of a robust airway plan for use in rural and austere environments.  Whilst AFOI techniques are hard to learn and maintain for occasional intubators, the placement of an ETT via SAD as conduit using eg: the Ambu Ascope is releatively straightforward and affordable even for cash-strapped rural hospitals.

For me the equation seems simple : second generation SAD + fibreoptic = robust safety

Here’s a video of my mate Geoff Healy at SydneyHEMS demonstrating the AmbuAscope for both awake fibreoptic intubation and via the iGel SAD as a robust technique in a mature and innovative prehospital service.  These scopes are affordable and fairly straightforward to use when combined with the SAD as conduit technique. I think every rural hospital and ED should consider it to allow staged airway management in case of difficulty.

Thus I think it may be time to retire the FastTrach for blind intubation and switch to use of a SAD-fibreoptic combo.  But promise me one thing – don’t throw out the Parker tip ETTs that come packed with the FastTrach – they are great for avoiding hangup on the right arytenoid!

PLAN C : Facemask ventilation (FMV)

If effective ventilation has not been established after three SAD insertion attempts, then Plan C should be enacted.  By this stage Plans A & B have failed and the only remaining options are to awaken the patient with full reversal of neuromuscular blockade or to continue and perform an emergency surgical airway with ongoing paralysis.

Plan D : Emergency front-of-neck access (FONA)

In the past, various techniques for ‘needle’ vs ‘knife’ have been advocated. Most of us in Australia are familiar with the excellent work by Andy Heard and colleagues in WA, describing needle, knife and open techniques for cricothyroidotomy (see links at youtube channel here). Even in the post NAP4 era, it was not uncommon debate to hear experienced anaesthetists express a preference for needle cricothyroidotomy and a relaiance on the surgeon to perform a surgical airway with scalpel.

DAS 2015 make it clear that the scalpel technique is an expected skill of all anaesthetists, which must be learned and have regular training to avoid skill fade.

The laryngeal handshake is a technique I have been teaching on various airway courses & workshops, as well as on the ETMcourse, after being shown by Levitan on a cadaver course. It is simple to teach and reliable. Thus it is pleasing to see DAS 2015 make explicit this technique of identification of the cricothyroid membrane and subsequent entry.

DAS 2015 offer two options for FONA :

  • identifiable anatomy – stab, twist, bougie, tube
  • if unsuccessful or no identifiable anatomy – scalpel, finger, bougie, tube

To be fair, DAS 2015 does mention cannula techniques as options, but maintains that surgical cricothyroidotomy s both faster and more reliable – and again, emphasises that the scalpel technique is an expected skill of all anaesthetists, which must be learned and have regular training to avoid skill fade.

As an added extra, mention is made of the use of ultrasound as part of airway evaluation, with recommendation that training in it’s use is recommended for anaesthetists. I have certainly found it useful for identification of the trachea and cricothyroid membrane in difficult anatomy where time permits.

Summary

So, a quick rattle through the DAS 2015 guidelines for management on unanticipated difficult intubation (for both routine and rapid sequence intubation) in adults.

What does this mean for rural clinicians or those practicing in an austere environment?  Perhaps no change from what many of us have been advocating for several years, namely

  • be prepared for unexpected difficult airway management
  • understand the importantce of human factors in crisis management and train accordingly
  • use an agreed plan, articulated to team members regularly practiced with in situ sim
  • be competent in both direct and videolaryngoscopy techniques
  • minimise repeated attempts at intubation and SAD insertion; make FIRST attempt the BEST attempt using appropriate positioning (head up, ramping) and use apnoeic diffusion oxygenation in high-risk patients
  • use a second generation supraglottic airway device
  • maintenance of oxygenation and ventilation via SAD is a cognitive way point for the team to ‘stop and think’ before proceeding further
  • blind intubation through an iLMA is no longer recommended; rather, place a SAD with integral gastric drainage and use as a conduit to intubate using a fibreoptic device
  • maintenance of paralysis is essential to optimise intubation, SAD insertion, face-mask ventilation and ESA/FONA
  • use of a scalpel to perform surgical cricothyroidotomy is an essential skill for anaesthetists and should be practiced regularly

A lot of this is covered in the ‘Airways on a Budget’ talk for rural doctors from a few years back

There are plenty of other pearls in the 2015 Guidelines – have a browse and think how you will implement in your practice. We’ll be discussing some of this in the forthcoming Critically Ill Airway (CIA) course hosted by Chris Nickson at The Alfred in December.  I will be one of the Faculty for what promises to be an interesting mix of task-trainign and hands on in situ simulation.

Game on…

 

References

Chrimes N & Fritz P The Vortex Approach Access here

Frerk et al (2015) Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults British Journal of Anaesthesia doi 10.1093/bja/aev371

Leeuwenburg T (2015) Airway management of the critically ill patient: accepted modifications ot traditional rapid sequence induction & intubation Critical Care Horizons 1 Access here

Leeuwenburg T (2012) Access to difficult airway equipment & training for rural GP-anaesthetists in Australia Rural & Remote Health Access here

Sydney HEMS Fibreoptic Intubation using iGel and AmbuAscope – trainign video Access here

Weingart S. & Levitan R. (2011) Preoxygenation and prevention of desaturation during emergency airway management Annals of Emergency Medicine Access here

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