Author Archives: petro82

Pre-hospital thoracotomy in the Journal of Trauma

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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)

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

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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).

Use of video in real-time video resuscitations

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Could this footage be used as part of a regular review of team and medical performance? Read on to find out!

At ARHT we have the benefit of having a camera crew on board most flights as part of a partnership with the TV show: Rescue 1. The beneficial exposure of the on-board footage has documented well how we function as a team and provide high quality medical care. The TV show has helped increase the Trust’s exposure at both a local and national level.

With such an abundant and powerful resource (all this footage!) is there a way it can be maximized any further? It might be worthwhile discussing how footage of jobs could be used within an educational context either for debriefing, learning techniques or review of team function. Looking through the literature there’s been some discussion of the benefits of using real-time video footage to analyze team functioning and make processes better!

A recent survey of all US trauma centres revealed 20% currently use trauma video review for their trauma teams. Of those, 100% of programs using it reported improvements in their trauma process! While some programs had previously used it, the most common reason for discontinuation was “technical reason”- this is unlikely to problem in our setting given the outstanding team from Rescue 1 that runs our cameras. Interesting that medico-legal was NOT considered the main issue. And more importantly, of all the current programs using it, none had had medico-legal issues.

Another study looked at using real-time video for feedback in CPR performance. I really like this one. They video recorded all resuscitations that required CPR in their ED for 45 consecutive cases. Once video was implemented they used once weekly team review sessions to look at how they could improve. They divided the resuscitations into 3 groups: the first 15 patients, the second 15 patients and the last 15 patients. Comparing the 3 groups, they found significant improvement in time to first chest compression by the 3rd group. Overall, they also found improvement in hands-off time too. While they couldn’t show patient benefits, we must build on this study and from what we know already, early CPR and more CPR will eventually lead to better outcomes! A great little study that shows the utility of using video review among a team of skilled professionals.
Finally, there has been an attempt to use some video review in the pre-hospital setting but data is limited. We’re well positioned to utilize this awesome resource and continue to lead NZ in pre-hospital care. Video review in the context of retrieval medicine is novel and certainly would put us at the forefront!
Up front, we need to acknowledge a few potential issues and considerations:

1. Patient privacy: this would not be shown to anyone outside the ARHT team and is analogous to reviewing a case except video would now be used to supplement the discussion

2. Team privacy: It would be crucial that each member of the team approve discussion and review of the footage. Any concerns by a team member would prevent the footage from being used.

3. Goals: well established protocol, goals and objectives and a predefined time to review this footage would be needed.

4. Established policies: all stakeholders from pilots, crewman, paramedics and physicians will be needed to provide insight into how this can move forward .

This post is a way of starting the discussion! Would love to hear comments, concerns/criticisms and especially enthusiasm!

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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)