Weinmann ‘Medumat Transport’ Ventilator

These slide sets were provided by Weinmann for training purposes.

The following 3 slide sets cover use of the ventilator, ventilator modes, and how to interpret the monitors on the display

1) Medumat Transport Product Training – Essential viewing – overview of switching on, function test, and placing patient on ’emergency’ ventilation (preset IPPV parameters for adult/child/baby) and more advanced ventilation modes, including NIPPV

2) Ventilation – Review of different ventilation modes

3) Monitoring – Review of monitoring available on ventilator display and how to assess quality of ventilation

—————————————————————————————————————–

The following 3 slide sets review respiratory anatomy and physiology

1) Anatomy – Review of anatomy relevant to ventilation

2) Physiology & Pathophysiology – Review of respiratory physiology relating to ventilation

3) Physiologic basics of respiration

Podcasts – needle versus knife

Still listening to the Backstreet Boys on the way to work? Clearly urgent intervention is required.

Here are some excellent podcasts, with blog pages including discussion, videos, and references:

Needle versus knife I – discussion between Minh Le Cong (prehospitalmed.com) and Scott Weingart (emcrit.org) about interventions for can’t intubate/can’t ventilate

“One of the best things Minh expressed is the need to say OUT LOUD: “This is a can’t intubate/can’t oxygenate situation.” Saying it out loud lets everyone in the room know, there will be no more screwing around with attempts at direct laryngoscopy.”

Podcast is here

Needle versus knife II – chest decompression – from Scott Weingart

“Anterior approach is not where you think it is”

“ED Docs got it wrong a lot!”

Podcast is here

Is there more to meets the eye to pre-hospital intubation than just a tube?

In a recent review of the literature about pre-hospital intubation in traumatic brain injury (TBI) and the potential impact of hyperventilation, Gaither et al. explore the potential confounders for outcomes in previous studies. 

The authors provide a nice overview about the “old school” rationale for hyperventilation in TBI and why it is unlikely a good idea!

Why hyperventilation thought to be beneficial in TBI: 1) decreases arterial PaCO2 with CNS vasoconstriction 2) decreased cerebral blood flow. Net result is improved cerebral perfusion pressure (CPP). However, hyperventilation after intubation may increase intrathoracic pressure, increase JVP and subsequently decrease CPP. Hypocarbia may also lead to free radical formation and cellular damage. So net result is PaCO2 of 25 isn’t a good idea! Probably best to target into something like 35.

The authors then outline the historical concerns about pre-hospital intubation (low success rates, long scene times and complications like hypoxia). However, they argue that perhaps its not the intubation itself that may confound these “worse” outcomes, but perhaps the greater potential for hyperventilation! And the detrimental effects may in fact occur post-intubation.

There’s some evidence that in pre-hospital settings where end-tidal CO2 is closely regulated (assuming high intubation success…which probably requires well-trained personnel) that patients do better if they’re intubated…just so long as we keep their ETCO2 under control! The following is a direct quote from the article:

There is a strong possibility that the negative effects of intubation that have been identified in several clinical trials may be due to a paradox: intubation may protect the airway and prevent hypoxia, but it also makes it easier to inadvertently hyperventilate. Consequently, although intubation is intended to reduce secondary brain injury, it may enhance it if specific, intentional measures are not taken to ensure proper post intubation ventilation

A nice conclusion is provide (which I fits well within the general tone of the article).

When properly performed, intubation is effective for airway protection and ensures adequate oxygenation; it also makes hyperventilation (and associated negative outcomes) easier and more likely. Optimal outcomes require choosing the right patients, achieving the highest success rates through training, and avoiding hyperventilation after intubation in patients with traumatic brain injury

This article makes a great case for well trained medical personnel who perform pre-hospital intubations and then provide the best post-intubation care possible.

Full text pdf is available here (secure area limited to ADHB staff only – ADHB has subscription access for staff to these journals through the Philson Library at the University of Auckland School Of Medicine)

Pre-Hospital to ED handover

One of the benefits for ED doctors involved with HEMS is that is gives us a different perspective on our own speciality by observing it from the outside.

During one recent job, I delivered a moderately unwell trauma patient to a trauma centre. The patient was unwell enough to require pre-hospital radio notification and was met by a team in resus. The hospital in question deals with a lot of trauma, and deals with it well.

On this occasion however, the ED was heaving, and on arrvival I got the impression that the receiving team had been cobbled together at the last minute out of all available resources. Everyone looked busy and stressed. There was not a clearly identified team leader. On our arrival, there was a request to get the patient onto the ED bed immediately, although no immediate intervention was required.

The result?

-A flurry of activity  – airway, breathing, circulation, nudity (there is always someone running amok with a pair of scissors!)

-A lot of noise but not much effective communication

By this stage I had (sort of) figured out who the de facto team leader was, and delivered a handover. The team leader was distracted repeatedly during the handover by the flurry of information and noise being directed at him by the people performing tasks on the patient.

It stuck me at the time that me giving a handover under those circumstances was pretty ineffectual, and relatively high-risk – it would have been very easy for crucial pre-hospital information to be lost into the ether.

I don’t wish to be too critical of the receiving team – I have no doubt that I have been involved in similar situations on the ED side over the years. Being involved in the handover process from the pre-hospital side however provided a unique insight, and made me think “there must be a better way“.

The literature clearly shows that there are significant issues with handover of clinical information from pre-hospital providers to ED teams. This study found that despite ambulance officers adopting a structured handover format to convey information, at least HALF of the relevant information was NOT retained by the ED team. Another study found that over a quarter of patient records had errors or omissions in transmission from ambulance documentation to ED documentation regarding pre-hospital events and treatment.

Translation: We (the ED team) may have a major listening problem!

The authors of this paper surveyed pre-hospital and ED staff to identify the specific issues with handover, and identified the following problems:

  • difficulties in creating a shared cognitive picture
  • tensions between ‘doing’ and ‘listening’
  • fragmented communication

So how can we do it better?

The following video shows a handover model, including use of a whiteboard, that we (the HEMS Educational Group) believe is highly effective.

The steps involved:

1. Prehospital notification and assembly of team

(including delegation of roles and responsibilities within the team PRIOR to the patient’s arrival)

2. Clear identification of the team leader

The team leader has an important role in generating space/quiet for handover to occur. In the event that pre-hospital staff wish to pass on further information after the initial handover, there must be a clear go-to person who is not task focused, and is therefore in a position to listen to new information.

3. Decision to handover PRIOR to transfer to ED bed

We all know that when the patient hits the ED bed, the ED team can’t help themselves! Unless the patient requires urgent transfer to the ED trolley for immediate intervention (a minority of resus patients), an effective way of ensuring that everyone listens to the handover is to stop the stretcher next to the ED bed and deliver handover PRIOR to transfer. In this way a) everyone listens, and b) everyone has a shared mental model from the outset, before individual task fixation occurs.

The decision about handover prior to transfer versus immediate transfer is best made by the prehospital team.

4. Handover

There are a variety of methods of structured handover. MIST-AMBO is one commonly in use by St Johns staff that provides a concise and relevant summary of pre-hospital information.

5. Use of a whiteboard

Whiteboards are an effective way of ensuring that all team members have access to relevant pre-hospital information.

While in an ideal world all team members would be in resus prior to the arrival of the patient, in practice this does not happen ,and people come and go. For a trauma case in Auckland ED, for example, we routinely have the ED consultant, the ED registrar, the ICU registrar, the general surgical registrar, the trauma fellow, the trauma consultant, the trauma coordinator, and occasionally orthopods and intensivists coming in and out of resus. Use of a whiteboard populated with relevant information is a powerful tool for building a shared mental model without the trauma team leader having to provide the same information to multiple individuals in succession.

A paper discussing the use of whiteboards in improving ED communication can be found here.

Full text pdfs for this post are available here (secure area limited to ADHB staff only – ADHB has subscription access for staff to these journals through the Philson Library at the University of Auckland School Of Medicine)

Paramedics in high-stress simulation: performance may be affected

In a recent study from Toronto, researchers studied paramedics in two similar scenarios. Both scenarios involved a 50 year old patient suffering from chest pain. The patient develops pulmonary edema, hypotension and an ECG reveals a STEMI. All study participants (paramedics) performed interventions based on their established local protocols.

In the “high stress” scenario, there was an actor playing the patient’s partner who was visibly distressed and challenging the paramedic’s actions. Also, all alarms were turned up to full volume and there was constant 2-way radio communication going on in the background. None of this occurred in the “low stress”  scenario.

Paramedics were assessed using a global rating scale, a checklist scale and their salivary cortisol levels were measured before and after each scenario (as a response to stress).

The authors noted that “When faced with clinically relevant stressors, paramedics demonstrated significant increases in subjective (anxiety) and physiological
(salivary cortisol) measures of stress. These stress responses were accompanied by impairments in some aspects of clinical performance and in the ability to accurately recall information from the case. Although the paramedics demonstrated no impairments in
their ability to complete each individual action required for the particular scenario, decreased scores on the global rating scale indicate that overall they did so more poorly, with less organization and poorer communication or interpersonal skills.” 

Overall, paramedics did feel more stressed in the “high stress” scenario – this was measured both by a survey and cortisol levels. And while they were able to complete all relevant tasks, their global performance assessment was reduced as was their ability to recall specific case details.

Fascinating study! We must recognize the high potential for error among clinicians when faced with stress.This data should guide us towards the increasing use of emergency checklists so that things are not forgotten in stressful environments,  Such findings will lead nicely into a new video by Scott Orman about the use of whiteboards in handovers and the potential for inaccurate data transmission (unless there’s protocols in place to document better!).

These authors also did a similar study with residents – with similar findings! We need to do better as clinicians & educators in recognizing stress as a huge factor leading to errors and implement interventions to manage these potential threats and errors.

Here’s the abstract

The impact of stress on paramedic performance during simulated critical events.Prehosp Disaster Med. 2012 Aug;27(4):369-74. Epub 2012 Jul 25. Leblanc VR, Regehr C, Tavares W, Scott AK, Macdonald R, King K.

Abstract

OBJECTIVES:

Substantial research demonstrates that the stressors accompanying the profession of paramedicine can lead to mental health concerns. In contrast, little is known about the effects of stress on paramedics’ ability to care for patients during stressful events. In this study, we examined paramedics’ acute stress responses and performance during simulated high-stress scenarios.

METHODS:

Twenty-two advanced care paramedics participated in simulated low-stress and high-stress clinical scenarios. The paramedics provided salivary cortisol samples and completed an anxiety questionnaire at baseline and following each scenario. Clinical performance was videotaped and scored on a checklist of specific actions and a global rating of performance. The paramedics also completed patient care documentation following each scenario.

RESULTS:

The paramedics demonstrated greater increases in anxiety (P < .05) and salivary cortisol levels (P < .05) in response to the high-stressscenario compared to the low-stress scenario. Global rating scores were significantly lower in the high-stress scenario than in the low-stress scenario (P < .05). Checklist scores were not significantly different between the two scenarios (P = .12). There were more errors of commission (reporting information not present in the scenario) in the patient care documentation following the high-stress scenario than following the low-stress scenario (P < .05). In contrast, there were no differences in omission errors (failing to recall information present in the scenario) between the two scenarios (P = .34).

CONCLUSION:

Clinical performance and documentation appear vulnerable to the impact of acute stress. This highlights the importance of developing systems and training interventions aimed at supporting and preparing emergency workers who face acute stressors as part of their every day work responsibilities.

Full text pdf is available here (secure area limited to ADHB staff only – ADHB has subscription access for staff to these journals through the Philson Library at the University of Auckland School Of Medicine)

HEMS: Lessons from Helicopters to Fast Response Cars

This video shows a superb talk by Dr Gareth Davies, Clinical Director of the London HEMS. Topics covered include the role and structure of the service, the risks involved, and how those risks are mitigated with lessons learned from aviation.

This video comes from Risky-Business.com, a collaboration between various UK and USA hospitals and institutions which focuses on risk management and human factors in the medical setting.

Click here to watch the video.

Niki T34 Syringe Pump

ARHT has just purchased 5 of these. After having a play with one of these last Thursday, I am very impressed. They are simple, intuitive, easy to use, and will be useful on both primary missions and interhospital transfers.

Click here for the interactive training session

Standardised drug infusion protocols coming soon… (thanks Sam!)

 

Summer in New Zealand

The New Zealand summer runs from December to February inclusive. At midnight on the 30th of November, the following rules come into effect:

1) the entire population must spend as much of the summer at the beach as possible

2) Living in New Zealand for more than three days qualifies you to operate a powerboat or yacht

3) alcohol hones your water safety skills and judgement

4) wearing life jackets, using fins with your bodyboard, swimming between the flags, and using dive decompression tables are all signs of weakness

Here is someone from Christchurch who clearly believes rules 1,2,3, and part of 4:

With these rules in mind, here are some slide sets regarding pathology that we may have to deal with over the summer:

Key issues for Auckland HEMS:

1) The hyperbaric chamber is at the Devonport Naval Base. They have minimal medical equipment and DO NOT have the capability to receive critically ill patients directly from the prehospital setting (I have discussed this with them before!). Critically ill patients will require transport to hospital with a subsequent trip to the decompression chamber.

2) our helicopter is not pressurised – transportation of patients with DCS or AGE should occur below 1000 feet of altitude

The contact number for the decompression physician (24 hours) is 0800 4 DES 111

Patients with submersion injuries may have been treated by Surf Lifesaving New Zealand. A link showing the tiers of Surf Lifesaving prehospital medical care is here. They may have access to AEDs, oxygen, monitoring, and cervical collars, but do not generally have access to advanced airway management.

Own the resus – by Cliff Reid

This is a superb presentation from Cliff Reid about ‘owning the resus’. Leadership, psychology, simulation, mental rehearsal, team management, situational awareness, shared mental models, task fixation, graded assertiveness, “fake it till you become it”, and lots more good stuff.

While it refers to the hospital setting, the principles are equally applicable to prehospital emergencies.

So go ahead – OWN THE RESUS!

Pre-hospital thoracotomy in the Journal of Trauma

Recently Scott put up a post on this topic and given it’s infrequent occurrence, we don’t mean to spend lots of time but this editorial/article came up so I couldn’t resist mentioning it once more (plus, let’s be serious emergency thoracotomies are pretty awesome especially given they can be life-saving).

I’m not sure how I feel about the idea of pre-hospital thoracotomy (followed by helicopter transport), especially given the often dismal outcomes and the potential for considerable harm. Nevermind the fact that once you performed the procedure, you then have to pack up the patient who has an open chest and get them via helicopter to the ED (wow…).  I have to say I’m not particularly in favor of it, but willing to look at the evidence, which this article presents. The authors review the literature and summarize that among those with penetrating trauma (a key distinction), that there’s a survival rate of 11%. Looking at this superficially, that means that there’s a bunch of people that were actually dead who were subsequently saved. What we don’t know is much about the potential for harm (e.g needlestick injuries to healthcare provides, prolonged ICU stays without benefit). In summary, the authors cite the successes from London HEMS and they are clear supporters of this procedure but correctly address the minimal role in blunt trauma. Furthermore they suggest that additional research is needed…realistically, probably hard to gather much more than case series unfortunately. I won’t hold my breath for a large randomized trial in the New England Journal.

An editorial critique follows the article by Dr. Ken Mattox (the world renowed surgeon from Houston of permissive hypotension fame). In looking at both sides he uses the Altemeier axiom “sometimes a solution to a problem creates 4 times as many problems” and I think that definitely could be applied to this procedure. However, he doesn’t exclude the possibility that pre-hospital thoracotomies might have a role in the correct circumstances. He mentions the following overriding principles that would have to be applied

  • Protocol overseen by established trauma program and approved by IRB
  • Adequate training and appropriate instruments and equipment
  • Ability to have communication with the trauma center and trauma surgeon in case of any “surprises”
  • All cases must be carefully reviewed by the trauma program for quality assurance

So while it remains controversial, there’s some new discussion among the leaders in trauma resuscitation about pre-hospital thoracotomy. As Scott, has pointed out that it unlikely has much role in Auckland, its definitely interesting to see what’s being discussed.

Source: Roberton and Bulstrode,  Emergency department thoracotomies: Is it time we took them to the field? J Trauma vol 73 (no 5): 1070.

Full text pdf is available here (secure area limited to ADHB staff only – ADHB has subscription access for staff to these journals through the Philson Library at the University of Auckland School Of Medicine)

Delayed sequence intubation, apnoeic ventilation, and preventing desaturation (plus podcast)

‘Delayed sequence intubation’ and ‘apnoeic ventilation’ are two of the hottest topics in ED airway management at the moment. Details and discussion of these topics are all over the internet currently (multiple links coming below!) so what I will provide now are BRIEF summaries of the concepts.

The relevance to our HEMS is that both of these techniques for delaying the time to desaturation during intubation should (in theory!) translate well to the prehospital environment, and provide additional weapons in the prehospital airway management arsenal.

Traditional Rapid Sequence Intubation involves:

1) a period of pre-oxygenation

2) simultaneous administration of an anaesthetic induction agent and a paralytic

3) intubation once sedation and paralysis is adequate

The problem with rapid sequence induction in the ED setting is that the sicker the patient is, the quicker they will desaturate once they are paralysed, and the less time the intubating clinician has to pass an ETT. This is the case particularly in patients with severe lung disease.

So how can we give ourselves longer to pass the ETT before the patient desaturates?

Apnoeic ventilation, the evidence behind it, and other significant considerations in intubation are described in this landmark paper by Scott Weingart (emcrit.org) and Richard Levitan (airway guru). They make the following points:

1) pre-oxygenation using non-invasive ventilation will recruit collapsed alveoli and provide more of a reservoir of oxygen in the lungs – especially useful in high risk patients, or those who are hypoxic to start with

2) prexoygenation provides a longer time to desaturation when the patient is sitting up

3) during the apnoeic period (after the administration of a paralytic) doing a jaw thrust will maintain a patent connection between the mouth and the glottis, and the patient will continue to oxygenate (although CO2 will rise)

4) having a nasal cannulae running at 15L/min during the apnoeic period (after a paralytic has been administered) will provide near 100% oxygen to the pharynx

(Items 3 and 4 above comprise APNOEIC VENTILATION)

4) during the apnoeic period, having the patient positioned with their ear at the same level as their sternum will provide the best view for laryngoscopy

DELAYED SEQUENCE INTUBATION is described in this paper by Scott Weingart. It is an unfortunate fact that many of the patients who most desperately need effective preoxygenation (hypoxic, hypercarbic) are unable to receive it because they are too agitated and combative.

One of the models Dr Weingart uses to describe DSI is “a procedural sedation, the procedure in this case being effective preoxygenation”.

The DSI procedure involves administering ketamine (chosen for its safety profile and preservation of airway reflexes and spontaneous respiratory effort) at a dose of 1-1.5kg, followed by pre oxygenation (with consideration of NIV pre oxygenation), followed by administration of a paralytic and intubation.

This podcast from prehospitalmed.com is a great interview of Scott Weingart by Minh Le Cong, discussing DSI in detail.

Minh Le Cong has also collated some resources regarding DSI here, including a formal protocol incorporating DSI and apnoeic ventilation and a detailed slide set from Dr Rob Bryant, Emergency Physician in Salt Lake City, Utah (note – decision-making regarding suitability for intubation/ICU admission is clearly different in the northern hemisphere!)

Aided greatly by the internet, these techniques have “gone viral” amongst emergency physicians and are being used with success in the ED setting. They are also making their way into the prehospital world.

With regards to the Auckland HEMS, the following considerations may be relevant:

1) For patients with lung disease, fitting a PEEP valve will allow delivery of CPAP pre oxygenation. In the setting of trauma and potential pneumothorax however, there may be significant risks

2) A jaw thrust during the apnoeic period and adminstering O2 at 15L/min via nasal cannulae are easy interventions prehospital. Given that all our prehospital RSIs to date have occurred at scenes with St John’s ambulance already in attendance, we are highly likely to have additional oxygen sources available for apnoeic ventilation beyond what we carry in the helicopter

3) While delayed sequence intubation has been described for patients with agitation due to hypoxia, there is no reason we can’t use it for patients with agitation due to other causes, for example the intoxicated patient with a moderate TBI. Even in the ED setting these patients are difficult to intubate, with a traditional RSI typically requiring multiple security guards/orderlies, and a rather desperate ‘quick and dirty’ one!  The particular relevance to HEMS is that the DSI procedure is targeted at the patient group (agitated, combative)  who are probably the WORST group to transport in a helicopter without intubating them (cramped environment, difficult ergonomics for restraint/sedation, more difficult monitoring, lots of equipment/emergency exists in close proximity…)

There are some caveats to us adopting these techniques however, especially DSI. The prehospital evidence base currently is (probably!) nil. In the podcast above, pod Scott Weingart describes his concern that someone will modify the DSI procedure (either via drugs or technique), cause a catastrophe, and ruin DSI’s reputation forever. Certainly there is significant concern from some anaesthetists who feel that the concept is “crazy”.

Prehospital RSI remains a controversial topic, mainly because the evidence base that it is beneficial is small compared to the evidence base that done badly it worsens outcomes (great summary of these issues in a slide set here by Tony Smith, one of our HEMS doctors who is both an intensivist and the medical advisor to St Johns ambulance).

Auckland HEMS trains extensively in RSI to ensure that it is safe and effective. St John’s Ambulance also have a good understanding of the procedure, with the result being that they can be valuable assistants when we perform an RSI. They also share with us the ‘mental model’ of what we are doing and why we are doing it. If we attend a scene, attempt the novel and relatively unproven DSI procedure based on good sense but little evidence, and have a poor outcome, we would probably be judged fairly harshly.

Prehospital Trauma Life Support Course Manual

The Prehospital Trauma Life Support Course (PHTLS) is an education program developed between NAEMT (National Association Of Emergency Medicine Technicians) and the American College of Surgeons.

The course manual is available (somewhat inexplicably, because this manual is for sale online!) from the website of the French PHTLS group:

Chapters are here (and are NOT hosted at aucklandhems.com)

1) PHTLS – Past, present, and future

2) Injury prevention

3) The science and art of prehospital care: Principles, preferences, and critical thinking

4) Kinematics of trauma

5) Scene assessment

6) Patient assessment and management

7) Airway and ventilation

8) Shock

9) Head trauma

10) Spine trauma

11) Thoracic trauma

12) Abdominal trauma

13) Musculoskeletal trauma

14) Burn injuries

15) Paediatric trauma

16) Geriatric trauma

17) Golden principles of prehospital trauma care

18) Disaster management

19) Explosions and weapons of mass destruction

20) Environmental trauma I: Heat and cold

21) Environmental trauma II: Drowning, lightning, diving, and altitude

22) Wilderness trauma care

23) Civilian tactical emergency medical support (TEMS)

24) Glossary

Principles of extrication


While the involvement of doctors and paramedics in extrication of trapped patients from cars is limited to medical rather than demolition aspects, it is important for us to understand the general process of extrication.

In particular, the two broad types of extrication are immediate extrication, which is used when patient demise is imminent, and controlled extraction, which is slower but carries less risk. Which of these two techniques the Fire Service use will depend partly on the medical advice they are given after entrapped patients have been assessed.

This paper provides a nice overview of extrication methods.

The photos below are from the ‘extrication’ section of the Careflight Prehospital Trauma Course, conducted in Auckland in 2012.

Leon Ford – the man to see for all your car demolition needs!

You won’t find these tools at Bunnings! Rusty Clark

Auckland ED Clinical Director, Tim Parke, trials a new device for chest drain insertion

Petro’s Prehospital Practice (session #2) A success!

Thursday’s have turned into our structured simulation day at the helicopter base. Part of my learning objective at ARHT (in Auckland) is to improve my abilities in running and debriefing simulation scenarios. While the group has (and continues) to run impromptu simulation sessions we have moved to a structured aspect that will allow us to be creative and try new things. We have the luxury of our Rescue Helicopter Trust being the subject of a TV show so there’s an abundance of footage of previous jobs. Today we selected a scenario from a previous episode that was viewed by the sim team before starting (check it out all the episodes here). This set the scene and we immediately jumped right into the scenario. The team stormed out to the scene and within minutes were immersed within the scenario. Check out a few pics from the scenario below.

Scott and Ati working hard during a V. Fib arrest. Great to see Scott providing some solid CPR!

The debrief – doing my best to keep people interested! Do you think they were listening?

The duty crew for the day formed today’s team and it was comprised of three members who did an awesome job! We had great teamwork from all three; Ati (crewman), Ross (Advanced paramedic), Scott (HEMS physician). Two key themes emerged from the day:

1) Role assignment and leadership: sometimes pre-assignment of a leader in the pre-hospital setting can be disrupted depending on available personnel (or lack thereof). The team decided as long as it’s well verbalized that there’s going to be a transition in leadership that it shouldn’t be an issue

2) Ergonomics: Placement of equipment and personnel is super important for being efficient and maximizing speed. Following the scenario we examined the set up the team had established then looked at ways to improve it. Chris Denny (HEMS physician supervising the scenario) spoke of using the stretcher as “table” and the use of angles as a strategy to improve scene ergonomics.

This session was a great opportunity for me to practice my debriefing skills using some stuff from the Harvard Simulation group. The idea of advocacy-inquiry method moves away from the idea that we shouldn’t judge during debriefings. Instead, the debriefer can provide an opinion but at the same time they try to understand how/why the learner decided to make such a decision even it may have been incorrect or controversial. “The instructor can help the learner reframe internal assumptions and feelings and take action to achieve better results in the future” (Rudolph JW et al. Simul Healthcare 2006).

Scenario based simulation

Despite a rather battered mannequin that requires at least a roll of duct tape a week to keep limbs and head attached, the Auckland HEMS group has adopted scenario-based simulation with enthusiasm. Involvement from doctors, paramedics, and crewmen working as a team allows opportunities to improve clinical skills, communication, and CRM elements.

Regularity and quality of simulation has improved with the importation from Canada of Dr Andrew Petrosoniak, who is completing a Master’s degree in education. ‘Petrosoniak’s Prehospital Practice’ is now offered to/inflicted upon whichever duty crew is rostered on Thursdays.

This sort of simulation has been described in print by the London HEMS group, who use it as an integral part of their training – read more here.

Petro’s detailed report on the session shown below is here.

“No matter how many times we shocked him, his head just kept falling off…”