Auckland HEMS app under development

In the last few days there has been talk on the twittersphere about retrieval apps.

First mock-up - content required!

First mock-up – content required!

Auckland HEMS is currently developing an app for use in our service. For the first iteration we have chosen a DIY web-based application (ibuildapp.com) to create the app. Examples of features that we can (in theory) include are:

  • text and image pages for checklists, SOPs, and paediatric resuscitation formulae
  • custom HTML forms for job debriefs, RSI audits etc – these can be filled in on the phone and then emailed to a designated collection person
  • live displays of webpages including aucklandHEMS.com, weather/tide information
  • live display of a google calendar for HEMS training and events
  • a personal training log for clinicians

Clearly offline functionality will be essential – 3G coverage on the far side of Great Barrier Island may be patchy at best…!

Custom html form - for job debrief

Custom html form – for job debrief

The current plan is to build the app online and test it through the online iPhone simulator prior to testing on devices and eventually distributing it through the app store.

Currently we hope to create a relatively simple (and advertisement-free) version 1.0, test it, and refine it into a more functional version 2.0 which may require input from a professional app developer (and no doubt some $..)

An excellent podcast from SMACC 2013 about medical app development can be found HERE.

Do any readers of this blog have any experience with app development? Please feel free to share pearls and pitfalls using the comments section below.

We will keep you posted on how this project progresses – watch this space!

ARHT Surgical Airway Skills Session

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.

New clinical simulation lab at ARHT and our newest team member!

Over the past few months at ARHT, we’ve been working to secure a location that can be used as our clinical sim lab. While most of our sim is done outside, this will allow for a “think tank” and location to keep all of our supplies. A spot like this will have a huge positive impact on improving our ability to run effective in-situ simulation.

Rossi, our Emergency Medicine award winning medical student (and newest team member) While it may not be the exact replica of the EM award...it's pretty close!

Rossi, our Emergency Medicine award winning medical student (and newest team member) While it may not be the exact replica of the EM award…it’s pretty close!

In addition, we plan to use this site for task training and trialling new equipment. While it has taken some time to get it organized, we’ve made huge progress recently. One of the main reasons we’ve had such success can be attributed to our newest education team member, Rossi, who is a senior medical student at the University of Auckland. She has a keen interest in emergency medicine, retrieval medicine and trauma. Her enthusiasm has been crucial to getting us up and running with a fully functional sim lab. We should also acknowledge her recent achievement as the recipient of a special mention in Emergency Medicine for dedication & teamwork at U of Auckland Medical school. Welcome Rossi, and we look forward to all that you bring!

I also felt it would be great to show the progress we’ve made with the sim lab. This will be an outstanding location to think, work and practice. We’ll be able to re-pack packs for simulations and engage in task training modules.

Here’s a few pics of the progress…and completion!

Sim lab: the beginning

Sim lab: the beginning

Rossi doing her best Vanna White impersonation

Rossi doing her best Vanna White impersonation

Sim Lab: the current state! Ready for use!

Sim Lab: the current state! Ready for use!

Sim Lab: airway task trainers...clearly needing a cric to be performed!

Sim Lab: airway task trainers…clearly needing a cric to be performed!