Author Archives: petro82

ARHT Surgical Airway Skills Session

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One of the challenges of resuscitation and pre-hospital medicine is that there are multiple high-risk but rarely performed procedures that clinicians must be ready to perform. The difficulty is that we may go our entire careers and only perform them once or even more likely never. However, the difference from success and failure for these procedures can mean life or limb. Consequently we must remain competent despite the challenges with practice.  There is an excellent article that articulates these issues by Cliff Reid & M Clancy which I highly recommend reading (for anyone interested in the topic).

(a primer video I integrated into a recent cric teaching session to get our participants into the mood!)

These life-saving, rarely performed procedures happen to be an interest of mine. It’s a fascinating exercise in education and cognition to maintain competence in performing these procedures yet have virtually no real-life patient practice. The likely result is that clinicians are not competent or they do not remain competent in performing them. More optimistically, some clinicians will maintain their skills through simulation. However, I would bet that a survey of most staff emergency physicians would reveal virtually no hands on practice of many of these life-saving procedures. One of the most talked about and important of these procedures is the surgical airway (or cricothyroidotomy). This is only performed when a patient who requires emergency airway management but they cannot be intubated or ventilated. For most of us, we’ll go through our careers never performing one. But every time we intubate a patient, there’s a risk that this scenario could develop and we’ll have to act accordingly.

At ARHT last week, I ran an inter-professional session for the paramedics, doctors and crewman on surgical airway performance (or cricothyroidotomy). The goal was to integrate our new cricothyroidotomy task trainers into the educational curriculum and combine them with some group discussion and simulation. For those looking to do replicate the event or simply looking for ideas, I will outline our session.

In addition to the introduction of our new task-trainers we also used this opportunity to review our performance of surgical airway. From an educator’s perspective, the most important step for success of this session is preparation. Those who know me, know that I’m not a detail oriented person but planning for everything from big picture stuff to the smallest detail can make a huge difference. In an effort to encourage the sharing of information (FOAMed) I’ll describe our itinerary.

Before the session I sent 2 emails. Our group is relatively new to the flipped classroom, or sending material first then promoting discussion within the classroom/learning site. Something I took home from SMACC 2013 is start with videos (easy to digest material) if you’re implementing a flipped classroom approach for the first time. A follow up email was sent with the videos again and this time along with 2 articles:

  1. Cricothryoidotomy bottom-up training review: battlefield lessons learned
  2. Emergency Surgical Airway: 24 successful cases leading to a simple “scalpel-finger-tube” technique 

Introduction

  • The learning outcomes were outlined
  • The MOST important aspect was to outline the ground rules and expectations. In our case, we were not using this session as an evaluation but instead as an opportunity to practice and engage our entire team. If you are evaluating learners, let them know!
  • We used  both task trainers and simulation to ensure an environment that promotes psychological safety  and learning for all participants

Content Presentation (using powerpoint)

  • I kept this short – about 20min so that everyone remained engaged (some of our doctors have fairly short attention spans!)
  • Review the indications (contraindications…not really any), complications and considerations in performing a surgical airway
  • Review the controversies regarding surgical airway (more to come on this in a later post)
    • preferred technique (surgical vs. percutaneous)
    • vertical vs. horizontal incision
    • team positioning
    • Integrated 2 videos – the impact of engaging the audience is impressive…especially when you have the luxury of using some pretty amazing footage
No better way to encourage participation than some pointing and asking people directly! (not my finest picture during a lecture...)

No better way to encourage participation than some pointing and asking people directly! (not my finest picture during a lecture…)

Task Trainers

  • We had 3 stations of task trainers with inter-disciplinary teams (paramedic, doctor, crewman)
  • Teams rotated every 15 minutes
  • Station 1 – pediatric needle airways
  • Station 2 – open/surgical cricothyroidotomy using a variety of tools & instruments
  • Station 3 – participants were blindfolded, relying on their tactile sense and team communication to complete the procedure
Our cric station set up. A variety of equipment that allowed participants to try various methods

Our cric station set up. A variety of equipment that allowed participants to try various methods

Our crew practicing a surgical airway on a task trainer

Our crew practicing a surgical airway on a task trainer

Several participants trying out a needle jet ventilation technique

Several participants trying out a needle jet ventilation techniqu

Brainstorming session

  • While we already have a cric kit in our packs, we used this opportunity to discuss the equipment that participants used in the task-trainer session
  • Then we packed a cric kit following this discussion (based on consensus) for a team to use in the next section – an outdoor simulation
  • This usablity testing allowed participants to directly observe their decisions for kit composition in practice!

Simulation

  • 3 volunteers (crewman, doctor, paramedic) representative of our duty crew at ARHT
  • Participated in a simulation of a patient with a trapped patient, unable to be extricated and deteriorating mental status and respiratory status. There was considerable
Debriefing after the manikin was successfully rescued from under the trailer! He got a cric and was ventilated by our team! Disclaimer...no manikins were harmed during this educational session (except a few cuts to their necks)

Debriefing after the manikin was successfully rescued from under the trailer! He got a cric and was ventilated by our team! Disclaimer…no manikins were harmed during this educational session (except a few cuts to their necks)

Debriefing

  • Debriefing of the simulation and the entire day
  • We used this opportunity to ask participants what equipment, methods and preferences they would like integrated into our standard operating procedure

This entire process included usability testing for participants – allowing them to use different techniques & equipment they may otherwise not try.  This also provides an additional opportunity for inter-professional education that is extremely important for such a high risk, rarely performed procedure. Proper planning and training for all team members involved will only make the process better.

The role of the physician during winch rescues – new data and our simulation experience

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In Helicopter Emergency Services (HEMS) around the world, winching to critically ill patients is an important aspect for those in patients otherwise inaccessible by road transport.

Most HEMS services have paramedics as the primary medical responders who are winched to patients, however, in some services physicians who are on-board are also winched resulting in a two clinician operation. For a North American (like myself, Andrew Petrosoniak) this idea of physicians on board the helicopter, nevermind winching to patients is completely foreign! But in HEMS operations around the world, this is a reality.

At ARHT we routinely winch highly trained paramedics to patients but less commonly are physicians required to be winched during a job. However, all our physicians are trained and ready depending on our task assignment. I wrote this post after conducting a recent simulation involving a two-clinician stretcher winch. The simulation was designed after discussion with our paramedics and also review of several recently published articles.

Our two clinicians preparing the patient for a stretcher winch

Our two clinicians preparing the patient for a stretcher winch

The Greater Sydney Area HEMS group, a service with a well-established physician winch program, just published their experience over the past 3 years. They reported 130 missions (8% of total missions) where a physician was winched along with a paramedic. Interestingly, in less than 50% of cases was a physician only intervention performed. Most of these interventions involved the administration of ketamine. If we compare this to our service, our numbers would certainly be different since our paramedics are trained to administer ketamine. Some of the comments & editorials following this publication did focus on this fact. Questions emerged as to the need to winch physicians if most of the requirements involves the administration of ketamine? What could be argued is that frequently involving physicians in winching improves experience levels and potentially reduces risk to the providers – furthermore there could be other important factors for physician presence that I articulate below.

There was a small but important number of other interventions like RSI and orthopedic procedures that required physician expertise. What wasn’t well described was the importance of having two clinicians to treat the patient. In many instances, having two sets of hands and a second set of eyes for patient assessment can be crucial. It’s difficult to formulate any significant conclusions based on this data but it’s important in evaluating the tasking and training necessary to integrate a physician within the winch rescue team.

Stretcher winch simulation in action.

Stretcher winch simulation in action.

This data will be helpful for those services who currently or are planning on integrating physicians within their existing winch system. A second paper, which I won’t review, also reports positive outcomes from their winch rescues involving physicians.  Finally, the Sydney HEMS group must be commended for describing a bag valve mask failure during a job. We should encourage reporting such as this as it contributes to the culture of safety that is vital for helicopter rescue services.

Based on these papers during a winch of an intubated patient, we conducted a simulation of our protocols for winching intubated patients. Several pictures are included below that were taken during the simulation. This exercise was extremely successful as it combined a review of the evidence with a review of our protocols. Implementing in-situ simulation as a training method offers an excellent opportunity to practice high-risk procedures in our own work environment. We were able to evaluate our experience using an evidence-based approach.

A birds eye view of our team preparing our patient for a stretcher winch

A birds eye view of our team preparing our patient for a stretcher winch

The merits of physician winches during HEMS rescues will be subject to further debate. The data that I outlined above is far from conclusive, however, these publications are important pieces to incorporate into training curricula for other HEMS operations. Our in-situ simulation training is only enhanced by having access to the experiences of others.

 

 

 

 

 

 

 

SonoWars at SMACC – the Auckland HEMS Team perspective

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This past week, several of the Auckland HEMS team travelled across the Tasman to attend the first conference on social media & critical care (SMACC)

Our fearless leader Dr. Chris Denny entered us into the ultrasound competition (SonoWars) on day 2 of the conference. Following a qualifying round of 8-10 teams, the two finalists were chosen for a 2 hour ultrasound competition in front of the entire conference. The 2 teams competed in what can only be described as madness/awesome all rolled into one.

We entered the competition not thinking that we would have much chance advancing beyond the first round but thought the process would be fun regardless.  Somehow, despite our efforts, we managed to make our way to the finals of the competition. Our team comprised of our Auckland HEMS personnel included Scott Orman, Chris Denny & me (Andrew Petrosoniak). We also had participation from Rossi Holloway.

The SonoWars competition involved a combination of skills including speed tests performing ultrasound, image review, teaching an ultrasound technique and finally performing procedural skills.

Each team was given an ultrasound topic that we had to teach to the audience. We were graded on teaching styles, content and ability to captivate the audience. Our competitors were assigned to teach ocular ultrasound while our job was to teach transvaginal ultrasound. In our unbiased opinion, we had the harder job! Transvaginal ultrasound is not a skill we use in pre-hospital ultrasound which instead focuses on abdominal, cardiac and lung imaging. Though we were up to the challenge and set forth with our plan!

Pictures can often tell a better story than words so below is a sequence of photos from the event with some commentary.

First, both teams received a 30min pre-briefing for the event. Shown here is the coordinator demonstrating ocular ultrasound using oversized teaching tools!

First, both teams received a 30min pre-briefing for the event. Shown here is the coordinator demonstrating ocular ultrasound using oversized teaching tools!

 

Our team was introduced to the teaching props we were required to use. The red figure represents a uterus with yellow ovaries while the ultrasound probe is in the foreground. We were required to incorporate these into our teaching session.

Our team was introduced to the teaching props we were required to use. The red figure represents a uterus with yellow ovaries while the ultrasound probe is in the foreground. We were required to incorporate these into our teaching session.

 

A view from the back of the auditorium as the audience was introduced to Sonowars for the first time!

A view from the back of the auditorium as the audience was introduced to Sonowars for the first time!

The ref with the flag in the air as I completed a lung exam. Once the red flag dropped I could move on to a different view

The ref with the flag in the air as I completed a lung exam. Once the red flag dropped I could move on to a different view

Going into the teaching event we were in the lead.

Our team teaching the skill of transvaginal ultrasound on stage. A challenging topic.

Our team teaching the skill of transvaginal ultrasound on stage. A challenging topic. The screen in the background has ultrasound images which correspond to what we’re teaching on stage

We gave up a few points in the teaching event but still had a 2 point lead in the final event. It was a procedural skills race that required ultrasound use to perform several procedures directly competing against the other team. Unfortunately we were so focused on the event that we didn’t take pictures and sadly we gave up 3 points and lost to our deserving opponents.

Immediately after we came 2nd...my disappointment in the refs was captured! All in good fun.

Immediately after we came 2nd…my disappointment in the refs was captured! All in good fun.

 

A team pic after the event. A great experience!

A team pic after the event. A great experience!

Overall, this was a great event with lots of learning, fun and ingenuity. The organizers should be proud as they set a standard for combining entertainment with education. It was extremely well organized which allowed it to go smoothly. We’ll be looking forward to redeeming ourselves next year at SMACC!

 

 

The benefits of HEMS – more evidence!

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This post was prompted by two new studies about the benefits of HEMS. For those of you with short attention spans, I’ll give a one-liner on each study then describe them more thoroughly later on.

  1. U.S database study: among severely injured trauma patients (Injury Severity Score >16), HEMS is associated with improved survival rates 
  2. Dutch database study: Reduced mortality among polytrauma patients especially those with abnormal vital signs

The debate surrounding the benefit of patient-oriented outcomes for HEMS is nothing new.  In much of the world, HEMS (helicopter emergency medical services) includes physicians on board the helicopter though in North America often HEMS clinicians are advanced care paramedics. In each country, different models exist and as a result extrapolating findings to our setting is difficult.

One of our BK's that we fly at ARHT

One of our BK’s that we fly at ARHT

It’s easy to imagine that that HEMS (with or without a physician on board) benefits our patients. We bring highly trained clinicians to a scene where we can perform advanced interventions and then rapidly transport the patient to hospital for definitive care. However, studies have demonstrated variable results regarding patient outcomes with HEMS. These differences are undoubtedly affected by the variability amongst HEMS systems around the world. Each HEMS group operates with different thresholds for activation, variable relationships with the local land EMS and then there are a range of geographic and patient characteristics that will affect patient outcomes.

I mentioned above two recent studies that provide additional evidence into the benefits of HEMS. I’ll focus on the Dutch study from the European Journal of Emergency Medicine primarily. They included a consecutive cohort of trauma patients that either HEMS or land EMS responded. It’s not  They used some fancy statistics to calculate lives saved due to HEMS response. It would have been nice to have a more detailed description about their setting as it would allow for more robust comparisons to other centres. It should be noted they had <5% penetrating trauma in their population. It’s unclear how this impacts the statistics but likely critically ill patients who suffered penetrating trauma should be transported to hospital quickly since operative management is likely to be required. They also intubated a large number of their patients when HEMS was on scene (58%). This number was quite surprising. In our setting, we would intubate <10%. Again, whether they have an standard operating procedure or set of criteria for intubation – it would have been good for some discussion about this.

They had fairly reasonable scene times as well. While I don’t think scene times are as important as sometimes they’re made to be especially when necessary interventions are being performed, they at least didn’t spend hours on scene! Interestingly, when we compare the EMS vs. HEMS pre-hospital time there was a 7min difference (42min vs 49min). This is almost entirely accounted for by the extra 7 min that HEMS spends on scene. The authors describe short transport times which suggests that if there truly is a HEMS survival advantage then this isn’t the result of faster transport.

In the U.S study, which has a very different EMS system, they found survival benefit among the most seriously injured trauma patients. I believe there weren’t physicians part of the U.S HEMS model but they probably had advanced care paramedics. Unfortunately the study doesn’t describe the system well. Nonetheless, again using some statistics to account for injury severity, HEMS in the U.S appears to benefit sick patients with altered physiology. It is challenging to interpret U.S data as there’s considerable heterogeneity and financial drivers for HEMS use.

Ultimately we need more prospective data that isn’t fraught with the challenges of using retrospective data – each of these above studies suffer from these limitations. However, there is an emerging trend that HEMS benefits severely injured patients and more importantly, this could be independent of the transport time benefits. This is growing evidence that HEMS is not just an expensive, fast taxi service. Instead, improved patient outcomes may be the result of better clinical expertise brought to the scene.