Crisis Resource Management – from Academic Life in Emergency Medicine

Sim

From ALiEM:

CRM and SBT… just another set of acronyms in the world of medical education?  Don’t we already have enough??

Not quite!  Rather, Crisis Resource Management (CRM) is a complementary approach to Simulation Based Training (SBT). It can enhance current ongoing medical simulations or provide foundation for a vigorous curriculum when launching new simulation programs.

WHAT IS IT?

Crisis Resource Management is the ability to translate medical knowledge to real world actions, in the setting of an emergency.

Rather than a separate entity from medical simulation, CRM principles can be looked at as a way to focus and shape medical simulation curriculum and especially the objectives of each case to focus upon development of critical skill-sets that contribute to optimal team function and success during crisis.”

Read the rest HERE

See Auckland by air for FREE!*

*Conditions apply: You ARE required to have a medical qualification that was not purchased over the internet, and you WILL occasionally have to share your flight with a patient or patients with varying pathologies. Oh, and you will occasionally have to make an appearance at the hospital too (which fortunately has a top-notch helipad)

Auckland ED Specialist

Auckland ED Fellow

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Advanced Wilderness Life Support

Recently I had the pleasure of attending a superb AWLS course in Queenstown. The course was run by a group of intrepid clinicians who decided several years ago to import AWLS from the United States. You can read about the group (and more importantly, book a place on the course!) here:

wildmed

Wilderness medicine is in may ways the ultimate in prehospital care – it involves providing care to patients in an frequently austere environment with often very limited personnel, equipment, and communications. For emergency department doctors like myself, it also separates us from the security of readily accessible diagnostic investigations.

At its core wilderness medicine represents the same pathologies as emergency medicine, although environmental issues are obviously more common than in our urban ED and regional HEMS (check out this article about some recent lightning strike patients treated in Waikato ED!). The challenges encountered by treating clinicians however are very different, and solutions rely on communicationimprovisation, adaptation, clinical judgement, and common sense… plus (of course!) duct tape and a pocket knife.

The course itself included a variety of teaching formats including interactive lectures, group discussions, practical skill stations, and in-situ simulation. The organizers successfully arranged significant rainfall on one of the simulation afternoons – ever tried running a trauma resuscitation in the rain under a tarpaulin? (Credit is also due here to some of the local medical students, who were quite willing to become hypothermic for the sake of medical education)

Without giving away too much of the detail on the course, here are some examples of the material covered:

Single rescuer rolling a trauma patient with cervical spine control:

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Improvised rope sling carry for patient unable to walk

Improvised cervical collar

Improvised cervical collar

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C-spine immobilization with Sam splint/backpack, alternatively device for restraining combative ED consultant – Logan Stuckey from Nambour

Splinting of fractured femur with ski pole

Splinting of fractured femur with ski pole

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In situ simulation: Body on the shore – what will you do?

Pre-hospital external warming device (at least, that was the explanation given)

Pre-hospital external warming device (at least, that was the explanation given)

Resuscitation team in the rain!

Resuscitation team in the rain!

Prehospital blood product use

When prehospital blood storage goes bad...

When prehospital blood storage goes bad…

Auckland HEMS is currently exploring the use of blood products in our prehospital environment.

Two interesting papers regarding prehospital blood product use were recently published by the Queensland Ambulance Service. The Queensland Ambulance Service maintains a 24/7 doctor/paramedic trauma response team that is dispatched to significant trauma cases in the greater Brisbane area.

Despite the fact that the prehospital service in these studies is road-based, the patient cohort (predominantly blunt trauma), prehospital staffing (often initially ambulance crew followed by doctor/paramedic team), and prehospital times are highly applicable to our service.

The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells

This paper examined the feasibility, limitations, and costs involved in providing prehospital trauma teams with blood products (2 units of O-negative red cells)

  • Of 500 units of RBCs provided to the service over 18 months, 26% were transfused
  • 97.8% of non-transfused units were returned to the blood bank and were available for reissue
  • The wastage rate of RBC units was 1.6%, which compares favourably with emergency department data
  • The cost per unit transfused was calculated at $A551
  • Stringent logistical and clinical governance was require to ensure that RBC units were stored, exchanged, and used appropriately

Characteristics and outcomes of patients administered blood in the prehospital environment by a road based trauma response team

  • During the same 18 month period above, the trauma response team was activated 1584 times
  • 719 of these patients had interventions performed that were outside the Intensive Care Paramedic scope of practice
  • 73 patients required transfusion, 71 of which were for haemorrhagic shock due to trauma
  • Trauma patients who required transfusion were severely injured, with a median ISS of 32
  • 73% of these trauma patients had a blunt mechanism, most commonly due to MVA
  • 72% of these trauma patients had a prehospital ultrasound, 40% of these were FAST positive; positive FAST scan prehospital was associated with a significantly faster time to definitive intervention after arrival at hospital
  •  82% of patients who received RBCs prehospital required more blood products after arrival to hospital, 26% required massive transfusion
  • No patient with an RTS less than 2 survived
  • Mean prehospital time was 64 minutes

On average, patients had access to RBCs 45 minutes before their hospital arrival. Survival of patients who received prehospital RBCs was 3.6% higher than predicted by TRISS, with the authors stating that there ‘may be a survival benefit’. They also concluded that an RTS less than 2 (can be calculated based on prehospital vital signs) may indicate that transfusion is futile.

Click HERE for access to the full-text pdfs (secure area limited to ADHB staff only – ADHB has online subscription access to this journal)

 

Prehospital amputation

Auckland HEMS has recently added a Gigli saw to the medical pack in case a patient requires prehospital amputation. Fortunately the team has not yet been required to perform this procedure. Anecdotally, prehospital amputations that have been performed by paramedic staffed EMS in the Auckland area in recent years have involved near-total amputation due to injury itself, with limbs attached with minimal skin or soft tissue.

EMJ published an excellent review article of the procedure in 2010, which covers indications, contraindications, and technique. Click HERE for the full pdf (secure area limited to ADHB staff, who have access to this journal via the Philson Library at the University of Auckland School of Medicine) 

The Medical College of Wisconsin has produced 3 educational videos, and made available a field manual for physicians who provide assistance to fire crews and EMS in the field.

Click HERE for a brief case report of a prehospital amputation performed by an anaesthetist and a urologist using a torch, some ketamine, and a Leatherman tool following the 2013 Christchurch earthquake.

Sydney HEMS has also produced a video, complete with a maudlin French musical accompaniment (!) demonstrating use of the Gigli saw on a deer limb:

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FIELD AMPUTATION: Introduction

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FIELD AMPUTATION: Upper limb

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FIELD AMPUTATION: Lower limb

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FIELD AMPUTATION: Australian deer has a rough day 

These resources were collated from pages on emcrit.org, prehospitalmed.com, and resus.me

Trauma airway in prehospital and retrieval medicine – Minh Le Cong

This presentation is from the ANZCA Airway Management and Trauma Special Interest Group Meeting in June 2013. It is delivered by Minh Le Cong (RFDS medical officer, Assistant Professor in Retrieval Medicine, and the world’s most ardent advocate for ketamine..)

If you haven’t already checked out Minh’s superb prehospital website, click HERE

Human factors in aviation errors – The Dirty Dozen

DirtyDozen_Silent_giants

Following a spate of aviation accidents in the 1980’s and 1990’s, Transport Canada and the aviation industry came up with the aviation ‘Dirty Dozen’ – human factors in aviation maintenance that commonly lead to errors.

Consider these in the context of your prehospital or emergency service:

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(thanks to Tim Leeuwenburg at KIdocs.org for this one!)

Greater Sydney Area HEMS podcasts

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Our colleagues from Sydney have created an excellent group of podcasts about pre-hospital and retrieval medicine:

NEUROPROTECTION – covers retrieval of patients with neurological and neurosurgical emergencies; also view their helicopter operating procedure HERE

INTERHOSPITAL PATIENT ASSESSMENT – overview of the assessment of a critically ill patient requiring transfer from one facility to another

THE TRAPPED PATIENT – overview of the approach to a patient trapped in a vehicle

INTRODUCTION TO SYDNEY HEMS