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.
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.
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
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.
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.
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
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.