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!

Ever done an RSI in a helicopter? Here’s a recent simulation experience!

Recently at the base, we’ve been discussing the concept of improving our ergonomics and making our workspace (e.g. the helicopter) as functional as possible. We are continually looking to optimize our equipment to best serve our patients.  Any procedure in-flight will be considerably more difficult than if performed in a well controlled environment like the hospital so in-situ training within the helicopter is essential.

Today, Karl (one of our advanced paramedics) and I did some in-situ simulation of an RSI within the helicopter. We ran through a scenario with an unpredicted deterioration of a patient in flight that required an RSI. A review of the literature provides little guidance on the emergency airway management of patients while in-flight so approaches to such situations currently must be derived from simulation and retrospective reviews within your own program.

We discussed a few key concepts that should be considered as we move forward in pre-hospital airway management and overall care for acutely ill patients:

1. Patient positioning: ample evidence that patient’s should probably have some head elevation if possible during intubation (If you don’t believe me…check out this must read paper). This IS possible within the BK and it actually provided Karl with the best view when it was up near 40-45 degrees! Check out the following pics which demonstrates feasibility within the BK.

Patient is fully supine. Experts advocate "ear to sternal angle" but in our traditional position of supine you'll note that the ear is NOT at the sternal angle!

Patient is fully supine. Experts advocate “ear to sternal angle” but in our traditional position of supine you’ll note that the ear is NOT at the sternal angle!

And now, for a clear demonstration of “ear to sternal angle”. A position we should strive to do either to avert intubation or in preparation of an advanced airway.

A picture perfect view of the cords!

A picture perfect view of the cords! Patient at 40 degrees, and still able to intubate with a great view…even with the helmet on. Let’s integrate this!

2. Pack position: we decided that the airway/BMV pack would be removed from the Thomas pack and given to the intubating clinician immediately upon patient deterioration. This allowed the paramedic to have all necessary equipment for excellent airway management. The physician could then focus on drug administration and clinical decision making. We opened the Thomas pack fully beside the physician and placed the drug pack on the patient’s legs.

Note the drug pack on the patient's legs and the Thomas pack spread out to the right of the physician. This worked best in our setting.

Note the drug pack on the patient’s legs and the Thomas pack spread out to the right of the physician. This worked best in our setting.

Here’s what DIDN’T work.

This set up was very cumbersome if the drug pack is lying on a partially open Thomas pack. Another issue was the Thomas pack was still upright...and not lying flat.

This set up was very cumbersome if the drug pack is lying on a partially open Thomas pack. Another issue was the Thomas pack was still upright…and not lying flat. Also harder since we had to turn each time to get drugs rather than in front.

3. Apneic oxygenation: this is a bit trickier and something we’ll have to look at more closely to see what would be feasible since it will require 2 O2 sources. It was definitely challenging to get it set up when time constrained. (another must read paper on the value of apneic oxygenation).

Huge thanks to Karl for running through the sim case and providing value feedback on the ergonomics of the situation…what worked and what didn’t! We will all learn from this.

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

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).