Newest addition to the ARHT simulation equipment!

Sim and Choppers

One of my medical education interests is looking at how we train and practice rarely performed procedures. For these situations, simulation offers an excellent method of training. The challenge, however, is recreating the fidelity of such situations since many rarely performed procedures are quite invasive.  Often we’ll start the training with a task-trainer like model and then progress to a full size manikin. Task-trainers are simulation models specifically designed for one type of procedure. 

In emergency and pre-hospital medicine, the cricothyroidotomy is among the most invasive, time critical yet rarely performed procedures. In addition to the potential technical challenges of this procedure, the decision to perform a cric might be even more difficult.  Identifying a “can’t intubate, can’t ventilate” scenario and then to “pull the trigger” may be one of the hardest cognitive leaps we face in resuscitation.  For example, last week, in the  Auckland emergency department we ran an…

View original post 448 more words

Does every patient who gets pre-hospital needle decompression need a chest tube?

The authors of a recent study tried to answer this question. The authors evaluated patients who got needle decompression in the field using prospective, observational methodology (though I wonder if truly prospective given the lack of data). Anyways, they noted that in their population very few patients (5/52 decompressions) escaped without requiring a follow-up chest tube. Only 1/15 penetrating trauma patients did not get a chest tube.  A few important questions remain including how many of the needle decompressions actually reached the pleural cavity or the technique used for decompression (appears later in Q&A that it was probably anterior axillary line). 

The authors conclude to have a low threshold for chest tube insertion based on CXR however, not shockingly a CT chest will provide more information. This study certainly doesn’t support withholding a chest drain if needle decompression is performed in the field. There was a nice suggesting by another surgeon who commented they leave all the needles in place during CT scan to see if it actually reached the pleural cavity. For the stable patient that doesn’t need immediate intervention, this is probably sound advice. Wait for the CT then make decision based on clinical and radiographic data.

There should probably be further study on this topic but for now, this is all we have! Here’s the abstract below.

Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax? KM Dominguez et al. Am J Surg 2013; 205(3): 329-332 

BACKGROUND:

Thoracic needle decompression is lifesaving in tension pneumothorax. However, performance of subsequent tube thoracostomy is questioned. The needle may not enter the chest, or the diagnosis may be wrong. The aim of this study was to test the hypothesis that routine tubethoracostomy is not required.

METHODS:

A prospective 2-year study of patients aged ≥18 years with thoracic trauma was conducted at a level 1 trauma center.

RESULTS:

Forty-one patients with chest trauma, 12 penetrating and 29 blunt, had 47 needled hemithoraces for evaluation; 85% of hemithoraces required tube thoracostomy after needle decompression of the chest (34 of 41 patients [83%]).

CONCLUSIONS:

Patients undergoing needle decompression who do not require placement of thoracostomy for clinical indications may be assessed using chest radiography, but thoracic computed tomography is more accurate. Air or blood on chest radiography or computed tomography of the chest is an indication for tube thoracostomy.

The importance of simulation in usability testing and hazard identification

photo-14

Auckland ED is conducting a lot of simulation training currently, with a recent focus on airway management.

Last week a teaching session was delivered by Sam Bendall (an Auckland HEMS doctor) on ‘intubation as a team sport’, which covered human factors in ED airway management and included the use of adjuncts like airway checklists. While Auckland HEMS has an RSI checklist, a similar tool has not been finalized for Auckland ED – this is under consideration currently. Following that teaching session, several airway checklists had nonetheless made their way into our resuscitation areas.

High-fidelity simulation training took place this afternoon, led by Sam, Mike Nicholls (another HEMS doctor), and Nancy Mitchell (Nurse Educator).

The first scenario involved a relatively junior team undertaking an emergent RSI. They performed admirably, and the outcome in practice would have been safe and successful. As an observer however, it was apparent that an airway checklist would have contributed to their confidence and comfort levels. (My personal opinion is that we should start using a checklist for ALL ED RSIs, independent of team seniority)

While watching the simulation I spotted a checklist taped to a whiteboard on a side wall. I assumed that was the airway checklist, and thought ‘that’s a clever position – it means the airway assistant can read out the checklist immediately prior to the RSI. They haven’t used it, I must bring this up at the debrief’.

At the end of the debrief, I inspected what I thought was the airway checklist, and found this:

HCA checklist

It wasn’t an airway checklist at all, but a restocking checklist!

The actual airway checklist was here…

photo(3)

Tray following RSI (this is NOT how we set up!) Airway checklist bottom left

taped to the top of the airway trolley (logical) but unfortunately covered up by the airway tray, which is removed from the trolley and placed on top when setting up for airway management. This is a good example of a latent hazard.

I found a second copy of the checklist taped to the desk at the entrance to the resus bay – this is where the scribe (usually one of the senior nurses) stays during a resuscitation:

photo(2) copyAlthough this desk is frequently cluttered with paperwork during a resuscitation, accessing the checklist would be a simple matter, and would be done so by a senior person.

After looking at the positioning of these checklists, I came to two conclusions:

1) Simulation is a powerful tool for testing the usability of a new item or technique and identifying hazards

When considering logistics/ergonomics/equipment what actually happens in real life may differ from what we envisage mentally when we introduce something new. Simulation introduces stress, time-urgency, ergonomic elements and personnel elements that can rapidly reveal whether something new is going to be useful or not, or whether its introduction has inadvertently created hazards

2) We need to actively manage the environment we work in

When confronted with a critically ill patient, it is easy to focus on the scenario in front of us (there is usually quite enough to think about there!) and accept the physical environment as it is. By going a step further and ACTIVELY managing our environment to improve logistics and ergonomics we can increase our chances of a good outcome. This can occur both BEFORE we are confronted with a patient (eliminating the latent hazard above, for example) and DURING a resuscitation. This is particularly important in the pre-hospital setting, where both the relatively unforgiving helicopter and roadside environment provide a range of challenges not encountered in a resuscitation bay. As doctors I believe we have a lot to learn from our paramedic colleages in this area.

(NB – if someone becomes angry because that restocking checklist mysteriously disappears this week, I had NOTHING to do with it, nothing at all)

Needle Cricothyroidotomy with Minh Le Cong

One of the perennial debates in medicine is the choice between a surgical technique versus a needle technique for a can’t intubate/can’t ventilate situation.

The issue is discussed in this podcast by Scott Weingart and Minh Le Cong, and useful data has been produced by the NAP4 audit in the UK, as discussed in this post.

The video below shows Minh Le Cong demonstrating some approaches to needle cricothyroidotomy. What struck me was the how simple and fast the ‘minimalist’ approach is , whereby oxygenation is provided (very rapidly) by simply pressing the oxygen tubing up against the cannula hub – no furious hunting for suitable connection devices!

This is worth seeing, it looks like a very useful ‘get out of jail’ card! In the prehospital setting it could be a bridge to further attempts at laryngoscopy (in the podcast above Minh describes several occasions where this has occurred in a retrieval setting) or a more definitive surgical airway prior to transport.

FOAMing at the mouth

(an introduction to FOAM, for people who have no idea what I’m talking about)

Foam03

The rise of the internet over the last 20 years has had a profound impact on both practice and education in medicine. Working in the ED, there is not a shift that goes by without my consulting The Oracle to look something up (usually something that I once knew but have long since forgotten).

Medical material on the internet previously consisted mostly of static web pages and images akin to online reference texts (quality variable!) Now, with widespread access to high speed internet services and newer internet-based forms of communication and information dissemination (twitter, facebook, youtube, podcasts….), the store of medical information on the internet has expanded rapidly. More importantly however, multiple means of communicating online AROUND medical information have led to an international explosion of collaboration on knowledge and ideas. This phenomenon has become known as FOAM (free open-access meducation).

The term FOAM was apparently coined over a pint of Guinness in Dublin in 2012. Surprisingly the people who came up with the idea managed to remember it until the morning, and FOAM has become the term that ties together multiple online sources of medical education. Life In The Fast Lane have a great page describing FOAM here, and describe it thus:

FOAM resources are sophisticated, cutting edge learning resources that enable clinicians and students to update their knowledge and improve their understanding in a fun, motivating and time efficient way. It is all free, and can be accessed by anyone, at anytime, anywhere. We believe that together with asynchronous learning and the flipped classroom, FOAM is the future of medical education and lifelong learning

I am a relative neophyte when it comes to FOAM, having heard the term only since setting up this site (late 2012) and scouring the internet looking for resources that may be helpful for our service.

What has struck me about FOAM is how powerful it is at rapidly promoting, refining, and disseminating knowledge that changes practice.

This landmark paper by Richard Levitan and Scott Weingart was published in the Annals of Emergency Medicine in 2012. It provides a superb review of evidence around preventing desaturation during ED airway management, and contains multiple practical (and evidence-based) tips, as well as introducing some lesser known but highly effective concepts like apnoeic ventilation.

While changes in practice would be expected to result from the publication of a landmark paper in a respected and widely circulated journal, FOAM allows even faster dissemination    of knowledge worldwide. Scott Weingart’s podcast, for example, is downloaded by over 100000 people per episode! The techniques described in the paper above are already being used on a daily basis in the Auckland ED, and are equally relevant to our pre-hospital airway management.

Such a rapid evolution in clinical practice would not be possible without FOAM. Changes of practice that rely on textbooks and journals require a timeframe of years rather than weeks or months. FOAM allows people to learn in a time and manner of their choosing.

FOAM also allows people to add their own personal perspectives and stories to medical educational material. Much of the training performed by Auckland HEMS involves airways (RSI being arguably the most important technical skill the addition of doctors to the helicopter has provided). As such I have read, listened to, and scrounged a lot of FOAM resources regarding airway management for this site. With surgical airways in particular, FOAM has provided me with the following pearls that I would probably never have found in a text or journal:

  • announcing loudly “I can’t intubate, I, cant ventilate, I am doing a surgical airway” is a great technique for honing the focus of the team and getting everyone ‘on the same page’ (and it sounds a but more professional than ‘F$@#’)
  • there is a lot of bleeding during a surgical cricothyroidotomy – so much so that some people have abandoned the procedure! Be prepared for this
  • when performing a needle cricothyroidotomy, setups involving syringes/3 way taps/ETT connectors are not necessary – have a look at this!

Snippets of information like these could make the difference between a good outcome and  death in the event of a failed airway – and yet the chances of finding them outside a FOAM format are probably pretty small. Many thanks to Minh Le Cong and Scott Weingart!

To quote Joe Lex (a highly respected emergency medicine educator):

“If you want to know how we practiced medicine 5 years ago, read a textbook.

If you want to know how we practiced medicine 2 years ago, read a journal.

If you want to know how we practice medicine now, go to a conference.

If you want to know how we will practice medicine in the future, listen in the hallways and use FOAM.”

If you wish to learn more about FOAM, this page is a great place to start.

This is a talk about FOAM by Mike Cadogan at ICEM in 2012:

Plus, of course, SMACC is less than a month away…

A medical student’s perspective at Auckland Rescue Helicopter Trust

For those of you who might have missed a few posts on here, you may not realize that HEMS has picked up a straggler along the way. I am a 5th-year medical student interested in pre-hospital and retrieval medicine, as well as anything high-stress and involving trauma and emergency. My role down at the base is to help out the HEMS doctors with setup of simulation scenarios, as well as keeping the simulation equipment and all our training packs stocked and ready to go. I am also keen to learn from everyone at the base on topics ranging from pre-hospital ultrasound to flying on instrument flight rules (IFR), as well as trying to convince myself and all the paramedics that one day I will be able to do a full-extension pull-up. Watch this space.

Today we unveiled our beautiful new manikins from Laerdal by using them in a simulated scenario on beta-blocker overdose.  We recruited the duty crew from the base, with the understanding that if a job came in they could easily leave the simulated scenario and go. We set it up as if the patient was in a remote medical centre after being retrieved by on-site paramedics from her home. The crew arrived to find a paramedic (yours truly) with the patient who had HR 30-35, bp 70/40, sats 97% on air, and RR 16/min. She had also had a 4-second period of asystole en route to the medical centre.

The team moving the patient onto the stretcher - ready for transport. Pads in place and ready for anything! Picture is a bit blurry because the team was moving with such efficiency & speed!

The team moving the patient onto the stretcher – ready for transport. Pads in place and ready for anything! Picture is a bit blurry because the team was moving with such efficiency & speed!

The remote control of the new manikin allowed us to simulate the heart rate and resps, whilst still maintaining fidelity of the scenario. This manikin also has the ability to moan, cough and respond yes or no, meaning the GCS could be fairly adequately ascertained. We used a sim technique we call ‘veining’ for cannula placement, which involves taping IV extension tubing up the arms of the manikin using skin-like tape with a cannula in the ACF, and then attaching an empty saline bag to the tubing to act as a reservoir. This allowed the participants to push drugs and run fluids, again preserving the fidelity of the scenario. We also used a piece of software called SimMon (for iPad), which can be set up to look like a regular monitor and will make appropriate noises when remotely controlled from iPhone (including that sweat-inducing desaturation beep). Our manikin can generate heart rhythms on our cardiac monitors but we use SimMon technology to supplement O2 saturation and blood pressure values.

The manikin with "veins" taped along the arms. It allows for actual IV starts and fluid administration. Everything is collected into the empty 1L NS bag.

The manikin with “veins” taped along the arms. It allows for actual IV starts and fluid administration. Everything is collected into the empty 1L NS bag.

This scenario utilized many things that I’m coming to realise are important in in-situ simulation. Firstly we used the duty crew, meaning that we didn’t have to get anyone to come in on their days off. But also that if a call came in for a job, our crew remains operational and can respond to that at any moment. So this makes our training highly efficient.   Secondly, this scenario was run on-site, including in the back of the chopper itself. Again excellent for fidelity and also for practicing techniques in a confined space. We are also vigilant about our labeling of training gear with bright red tags to ensure nothing from our training gear gets mixed with operational equipment.. A debrief time is equally as important as scenario-time, and this can be hard to facilitate if everyone disappears halfway through!

As a student, I found this scenario enlightening from both a simulation and medical point of view. I did some reading around beta-blocker overdoses and I found an excellent review about the use of high-dose insulin. Insulin has an increased inotropic effect on the heart, and clinical experience has shown that this has beneficial effects on patients who have overdosed on beta- and calcium-channel blockers. It’s also relatively cheap, readily available, and the dose to remember is easy – 1IU/kg bolus, then follow with 1-10IU/kg/hr infusion. Of course glucose needs to be monitored and a D5 infusion should be run whilst giving the insulin, and may need to be continued for up to 24h after the insulin has stopped. Monitoring the potassium is equally important, but remember the hypokalaemia is more due to cellular shift than overall potassium loss. There isn’t much data on the use of insulin in pre-hospital settings for such overdoses but it likely could be used during long flight times like inter-facility transfers. During our debrief, the clinicians felt it was more important to initiate early transport than high-dose insulin therapy in the field. But the discussion is pertinent and worth having.

All in all today was a good day for learning some key simulation techniques and some good emergency medicine. And apart from that, I managed to ask at least 14 irrelevant questions and steal 2 coffees, a yoghurt and half a banana from the lunchroom. So really a most successful morning.

Rossi Holloway

___________________

Full-text pdf for the reference above can be found here (secure area limited to ADHB staff only – ADHB has online subscription access to this journal via the Philson Library at the University of Auckland School Of Medicine)

Inattentional Blindness – does this apply to pre-hospital medicine?

A recent study (not sure if it’s been published yet but will be soon) studied the ability of radiologists to accurately identify abnormalities on a CT scan. We’re talking board-certified, full fledged radiologists! I can’t take credit for coming across this paper – check out @TechnicalSkillz, ED physician in Toronto who tweeted the link. He has a real interest in cognitive biases and medical decision making. Anyways…I digress.

gorilla CT scan

This image was presented to radiologists after they were told to look for abnormalities including lung nodules. Do you see the abnormality? Don’t worry…you don’t need to be an expert at reading CTs…it should be obvious!

24 radiologists examined this image and 20 were not able to identify the gorilla in the upper right corner! 20/24 didn’t see it! that’s unbelievable. They’re so focused on looking for other things that they glazed right over it. Using eye tracking technology, the reserachers were able to show that impressively 12 looked directly at the gorilla but still they didn’t see it!

This concept of inattentional blindness (or perceptual blindness) is

failure to notice an unexpected stimulus that is in one’s eyesight when other attention demanding tasks are being performed (Wikipedia)

I think this happens not infrequently in pre-hospital medicine and the emergency department. How many times does the patient turn out to have an entirely different presentation from what we hear over the radio call out or what’s written on the triage note. Right from the beginning we’re biased by the what we hear…it may be the local clinic calls with “a 73yr old with pneumonia”. Maybe there’s some shortness of breath to reaffirm this diagnosis but just as the radiologists were looking for nodules, we might be looking for pneumonia and miss the pneumothorax because we didn’t find out the patient fell earlier today. It could have been obvious if we just auscultated the lungs more closely but because we were thinking about crackles, we didn’t anticipate there would be absent breath sounds.

I think we’re especially vulnerable in the pre-hospital setting to inattentional blindness. We receive limited and often wrong information. Add that to time pressures to reduce scene times and it’s very easy to succumb to such cognitive biases.  We must implement cognitive checks to ensure that diagnoses are not missed. Standardized approaches to common presentations can help to ensure that critical diagnoses are considered regardless of the presentation. Efforts to ensure strong team communication will also enhance diagnostic abilities – maybe someone else on your team saw something you didn’t but failed to mention it.

Awareness of pitfalls around diagnostic errors must extend to pre-hospital clinicians. This will help us identify those gorillas! Check out some of the work by Pat Croskerry who’s a world leader in medical decision making, cognitive biases and diagnostic error (plus he’s Canadian, so he must be great!). Please note, the author of this post is Canadian which may be the reason for this conflict of interest!

 

Paediatric prehospital trauma care resources

whoops

 

With over half the Auckland HEMS team coming from a hospital that serves age 15 and up (and therefore not dealing with children on a daily basis), prehospital management of paediatric patients is a field to which we must pay considerable attention in our training. Simulation exercises have included paediatric scenarios on several occasions – our thanks to Mike Shepherd and Trish Wood from Starship Hospital for their assistance!

Below are some useful resources regarding prehospital care of paediatric trauma patients:

Podcasts from Dr Jeffrey Guy, Medical Director of PHTLS (right-click to download)

(he has also produced other PHTLS podcasts – found here)

A 2012 review of prehospital paediatric trauma from the Harbourview Medical Centre in Seattle can be found here. Take-home messages:

  • falls and MVA are the most common causes of paediatric trauma morbidity
  • despite a lot of research and intervention paediatric trauma patients are under-resuscitated on arrival compared to their adult counterparts
  • children have very different airways anatomically to adults; with full cervical spine immobilisation airway view can be improved with a towel under the shoulders to bring the neck into a neutral position
  • with a higher surface area/size ration children are more prone to hypothermia
  • due to their smaller blood volume a small amount of blood lost can represent a large percentage of their blood volume
  • contrary to traditional teaching, cuffed ETT are increasingly used at half a size smaller than the appropriate uncuffed ETT