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)

The first ARHT case-based learning session!

This past week, we conducted the first ARHT case-based learning session for the duty crew!

While “case-based learning” may seem like a bunch of educational jargon…it can be rephrased to “sit around the table, discuss a previous job and consider the “what if” “.

I think at this point I was trying to convince people that I wasn't full of BS!

I think at this point I was trying to convince people that I wasn’t full of BS!

We assembled the team for the day which included the crewman, paramedic and doctor for a 45-50 minute session in the board room.  A huge thanks to Russell C, Leon, and Scott O. who all participated and they generated a great discussion about several aspects of this case. (next time we’ll be looking to get our pilot involved too!)

I had the opportunity to facilitate the session which was based on a relatively straight forward job that I had selected. The job involved a patient with a head injury and the focus was on the management of traumatic brain injury in the pre-hospital setting. But amazingly, the discussion covered tons of ground and we discussed all different aspects from before we leave the base, to the time we arrive at the hospital. Much of the discussion focused on CRM ideas which was very interesting.

Our team's paramedic and crewman in deep thought! We must have just been getting to the interesting part! At least the team isn't asleep!

Our team’s paramedic and crewman in deep thought! We must have just been getting to the interesting part! At least the team isn’t asleep…

Here’s a summary of our lively discussion!

Pre-job briefing: unless it was a water job (or extra equip is required) that this could/should be done en route
On scene time: Something we need to address as a team given some growing evidence that scene time doesn’t impact mortality in blunt trauma
Decision making for RSI: time to hospital played considerable role in whether to perform an RSI
Role assignment in RSI: crewman should probably be tasked with RSI checklist and scene management rather than involved in being hands-on during RSI. The doctor should hand the bougie & endotracheal tube to paramedic though  good discussion resulted about this and may be situation dependent
Team position in flight: discussion whether person who intubated should remain at head of bed (even if it was MD) during flight. Consensus that if patient is requiring infusions etc…then MD should be at the side, with paramedic at the head and crewman to his right.

We’ll be looking to roll out a few more sessions in the new year.

Some feedback from the session regarding logistics

  • Using previous jobs to generate discussion is good
  • Focus will be on picking jobs at random to improve learning but this will NOT be a means of quality assurance or control
  • Short sessions will be the goal: 20-30 minutes
  • Getting the whole team together is best, that includes the pilots!
  • All members felt this was a valuable exercise and would participate in future sessions

Again, thanks to the duty crew that day and Scott O for the pictures. See you all in the New Year.

What? There are FIVE patients?!

Minor fender-bender in Dubai

One of the earlier jobs I did with the Auckland HEMS proved to be one of the most educational for me. The paramedic and I were tasked to an MVA with two patients. On arrival we discovered there were actually five patients – two with abdominal injuries and abnormal vital signs, one with an open femur fracture, one with a trivial head injury but anti-coagulated, and one with minor injuries. Several St Johns ambulance crews were already on scene, and managing things admirably. The two patients with abdominal injuries were transported by helicopter (this proved to be the correct decision), but as a doctor not familiar with chaotic scenes and multiple patients, I learnt some valuable lessons:

1) Doctors and paramedics assess patients differently

Initially the paramedic and I attempted to ‘divide and conquer’, with us splitting the patients between us for initial assessment. Coming from different backgrounds, the focus of our assessments was different, with the result being that I ended up assessing his patients as well, and he ended up assessing mine. This was clearly inefficient.

With the main function of the HEMS doctor being to provide additional resuscitation and medical skills to patients who need them, a more efficient way of us assessing which patients would benefit from my intervention would have been for us to briefly assess all five together, identify the two sickest for helicopter transport, and leave me to manage/package them while the paramedic assisted the ambulance officers with scene management and care of the other patients, who were destined for road transport. There would be a clear exception to this however when the scene controller directs the doctor to the sickest patient(s) on helicopter arrival.

2) Doctors need to be familiar with ambulance hierarchies and skill mixes

Some of the St Johns staff on scene were volunteer ambulance officers without the authorisation to perform certain interventions (giving morphine or splinting the femur fracture for example). I was unaware of this, and mistakenly assumed that such interventions would be taking place without input from the helicopter paramedic, myself, or the senior paramedic at the scene. The fact that these interventions did not happen at the time I assumed they would contributed to my perception of chaos (I take my hat off to paramedics who do this regularly!). ASKING about the skill set of ambulance officers is crucial to ensure that the patient gets the right care at the right time with maximum efficiency – assume nothing!

3) A scene with multiple patients provides significant equipment challenges

The HEMS doctors bag that we carry contains equipment for advanced medical interventions and surgical procedures. It is NOT well suited to more basic first aid functions, obtaining IV access, providing analgesia, and commencing IV fluid. For the patients at this scene, interventions like this were all that were required pre-hospital. With patients spread apart over the scene, several raids on the Thomas pack were required – this was time-consuming and inefficient. Our equipment needs work to make it more amenable to splitting it between multiple patients, but in the interim I now carry a small pack in my pocket with some basic equipment (cannulae, leur locks, flushes, drawing-up needles, gloves, tape etc). A thigh pouch has also made its way into use.

4) With two stretchered patients in the helicopter, intervention is difficult

The two patients we transported were both on stretchers wearing cervical spine collars. the paramedic and I were tucked at the front under a hefty pile of equipment. Performing any significant intervention on a patient in-flight would have been virtually impossible. If a patient is unwell enough to require significant intervention in-flight, the risks and benefits of taking a second patient on the same flight need to be seriously considered.