Pre-Hospital Care Podcast

In this episode, we examine how to approach systems strengthening in clinical practice within the context of Sierra Leone with Aneesah Peersaib. We will look at her recent deployment to support Continued Professional Development at local, regional and national level and her role in leadership development whilst in post in Sierra Leone. We will examine how she disseminated education & training, policy, and governance and how she approached cultural change from the ground up. Finally, we will examine how she built and maintained safe systems of practice, and how you can embody a culture of educational leadership and empower coproduced with in-country clinicians to provide solutions to wider systems development work. To do this, I'm speaking with Aneesah Peersaib. Aneesah has recently held the post of Nursing Education Advisor to Chief Nursing and Midwifery in Freetown, Sierra Leone. She collaborates across NGOs to work with the Sierra Leone Ministry of Health and Sanitation to standardise nursing education and support national strategic delivery. She has been a senior Nurse both inside and outside of the UK NHS working for Health Education England as a clinical lead and clinical advisor supporting education and workforce development across London. Aneesah is an Emergency nurse by trade and has experience leading central London Emergency departments before going on to wider systems leadership roles. If you want to reach out to Aneesah about the episode please contact her through LinkedIn here: https://www.linkedin.com/in/aneesah-peersaib-9153725a/?originalSubdomain=uk

In this next period, we will be recording a mini-series on addiction starting with this first episode with Specialist Addiction Therapist Mark Dempster. In 2013, the Centre for Social Justice determined that the level of addiction in the UK made it the “addiction capital of Europe.” This includes the use of legal substances, mainly ⁠alcohol⁠, and the use of Class A drugs, which include ⁠heroin⁠, ⁠cocaine⁠, ⁠meth⁠, and ⁠hallucinogens⁠. £36 billion is spent by the nation every year on treatment relating to drug and alcohol abuse. At the time of filing their report, titled 'No Quick Fix', the UK had the highest rate of addiction to ⁠opioids⁠ and the highest lifetime use of amphetamines, cocaine, and ⁠ecstasy⁠ across Europe. Many view addiction as something that only affects the users themselves but, in reality, casualties from substance abuse are taxing entire communities and society as a whole. Addiction in the UK affects everyone from loved ones to clinicians and the everyday public. In the conversation, we examine the five stages of addiction, common cognitive pitfalls, habit Vs. addiction, and Mark's organic story through his lived experience with addiction. We also look at the 12-step process of Narcotics Anonymous (NA). Mark is a specialist addiction therapist and a recovery coach within a Harley Street Counselling Practice. He has witnessed chemical and behavioural addictions both personally and within his circle of family and friends. Learning the practice of psychotherapy for addiction helped Mark reach out to all types of addicts, from programmes working with prisoners, helping at homeless shelters, and to wealthy bankers from Canary Wharf.  According to Mark, the addict’s circumstances varied but their addictions had a lot in common. In the conversation, we also cover: Defining Addiction & UK stats  - The health burden & impact on the individual and extended families  Origins – how people become addicted (habit Vs addiction)  Dual diagnosis  The 5 stages of addiction  The NA & AA 12-step model (origins and application) Common cognitive pitfalls  Breaking the cycle – different types of therapy (CBT, DBT, ACT, +/- PET for PTSD)  Anecdotal experiences and cases from Mark’s perspectives  You can find out more about Mark here: https://markdempstercounselling.com/about/ You can find out more about Narcotics Anonymous here: https://ukna.org You can find out more about Alcoholics Anonymous here: https://www.alcoholics-anonymous.org.uk    

In this conversation, we will examine the various types of trauma scores that feature both out-of-hospital and in-hospital to measure trauma – those of anatomical, physiological and combined trauma scores. We will look at why these are important, the three broad types of trauma scores, the origins, reliability and sensitivity of these. We will also examine the pros and cons of the GCS together with the history behind the GCS. We will examine the trauma score, revised trauma score, APACHE and CRAMS scales, Abbreviated Injury Score, Injury severity score, New Injury Severity Score (NISS), TRISS (Trauma and Injury Severity Score), and finally the ASCOT (A Severity characterisation of trauma). We will also examine the limitations to these scores and also some of the more long-term reasons for use.  Mark Faulkner is a Consultant Paramedic and associate medical director with the London Ambulance Service NHS Trust, Mark is also the clinical advisor for Major Trauma within the LAS and as such sits on the Pan London Trauma Steering Group, as well as number of national trauma groups.  Mark has been involved in major trauma for over 12 years, since the inception of the London Trauma System and has developed and refined the London Trauma Triage Tool. In the conversation, we examine: 1.     Why we look at and create these scores. 2.     The three broad types  3.     The GCS – origins, sensitivity/specificity & the limitations   4.     Trauma Score & revised trauma score  5.     APACHE & CRAMS scales  6.     AIS  7.     ISS 8.     NISS & TRISS score  9.     ASCOT  10.  Final thoughts  My thanks to Mark for an insightful and engaging conversation.

In this conversation, we will examine the current state of NHS ambulance service delivered care and how we can approach this with a different perspective. We will examine the current models of operation and how over the next 10 to 20 years this needs to be flipped on its head. We will explore the numbers of See, treat and convey versus see, treat and refer, versus telephone consult and close and how this can be flipped on its head. We will also explore how the adage of modern technology can we can meet these needs througg technology and how the progressive Paramedic Career Framework supports this through advanced urgent care practitioners & more pathways to refer patients to. We will also explore some of the innovations that Jason has initiated to work toward this goal.   Jason Killens is the Chief Executive of the Welsh Ambulance Services NHS Trust, which is the national provider of 999, 111 and non-emergency patient transport services for Wales. Jason has spent his career working in Ambulance Services in the UK and Australia. He progressed through the ranks in London Ambulance Service from an Emergency Medical Technician to Executive Director of Operations. He was appointed as the Chief Executive of the South Australia Ambulance Service in 2015 before joining the Welsh Ambulance Service as Chief Executive in September 2018. In the conversation, we examine: Jason’s journey through healthcare  The current state of activity  The future state of activity  Why hear and treat has come to the fore.  Risks of this proposed model  How modern tech supports this vision The Paramedic Career Framework and how this also supports future state operations (urgent care ambassadors)  New innovations that Jason is looking at  What happens if we don’t adopt this flipped model of care? Final thoughts My thanks to Jason for his reflections and thoughts on this topic. To see more of the inverted pyramid of care, please see here: https://www.linkedin.com/posts/jasonkillens_nhs75-teamwast-activity-7082261899463028736-DDTJ?utm_source=share&utm_medium=member_desktop

In this conversation, we will examine the challenges of exposure to high-stress situations, the principle of ‘psychological stunning’ and how to deal with the concepts of ‘amygdala highjack’. We will reflect with Tash on a seminal case that she experienced and her reflections on it. We will also reflect on how to harness and control these psychological and physiological stressors in practice to get the best out of yourself in a situation such as this. We will also look at the cognitive switches that Tash uses to de-escalate from the stress of the shift and finally how she approaches self-care within her practice.  Natasha Adams is a Senior Critical Care Paramedic (CCP) with the Queensland Ambulance Service, working on the Woodridge CCP POD and with the High Acuity Response Unit (HARU).  Her clinical interests include progressive out-of-hospital care clinical education, and leadership development. Natasha is currently working on a project with graduate paramedic induction programs but will soon progress into a full review of Queensland Ambulance Services' clinical education and operational areas. In the conversation, we examine: The case & reflections on the case  Why and how a ‘state of startle & overwhelm’ occurs.  The senses that shut down – hearing, vision, spatial awareness, concept of time     Mental imagery and rehearsal    Metacognition on the scene (thinking about thinking and mental awareness on the scene)  The trajectory of the HPT when the rails are coming off  Cognitive triggers (end of shift cognitive switching – going home mindset)  The hot debrief – contextualising the scene and emotions – permission to exhale  Nuances of NTS – permission to fail/miss information (self and crew)  Reflection on care and Self-care  My thanks to Tash for an engaging and insightful interview.

In this conversation, we will examine the utility and functions of ultrasound within air ambulance services. We look at how the aggregation of data and familiarity with ultrasound is narrowing down and assisting time to intervention and time to definitive care. We look at the scans of preference and some of the data around pneumothoraces, tamponade and positive findings under ultrasound in the critical care patient. Importantly we will get Dan’s perspective on where ultrasound is affecting patient care and where he sees the future of ultrasound going within pre-hospital care.    Dan Nevin is a PHEM consultant with London’s Air Ambulance and an Anaesthetist with Barts and the Royal London NHS Trust. Dan has years of experience working in pre-hospital care in both South Africa, where he originally trained, and in the UK. His special interests include trauma, critical care anaesthesia and PHEM. Dan is also the ultrasound lead for LAA and has been leading the use of POC ultrasound within the service. In the conversation we exam: Why ultrasound has become a useful tool in trauma. Data collected on scans and relationship with intervention (surgical or otherwise). The protocol that LAA prescribe to in practice. The governance around image acquisition and decision -making. USS within Standard Operating Procedures (SOPs) and where it should sit in practice. KPIs and frequency of scanning. Where ultrasound is going and the future of USS within critical care. Take home messages My thanks to Dan for an insightful and engaging interview.

In this conversation we will examine the anatomy of the Advanced Paramedic Practitioner in Urgent Care (APPUC) scheme as it currently stands within London. We will examine the discharge to the community rate, Alternative Care Pathway referral rates and where they are being referred to, commonly seen pathology for the group, advances in the scheme (innovation and where they are looking to innovate), and finally aligned training that the scheme receives.   Kate Hardy is an advanced paramedic practitioner in urgent care working in London. She gives us insights into what the anatomy of work looks like, the types of pathology, and the Multi-Disciplinary Team (MDT) approach that the scheme takes. The range of topics in the conversation include: The concept of Urgent Care Advanced Paramedics   What a day in the life of an APPUC looks like  The discharge rate of the scheme  Commonly seen pathologies for the scheme  Training that the Advanced Paramedics receive. Master’s level training and what that brings in terms of critical thinking ability.  Clinical governance and how that looks on an individual and collective level. How Kate has changed as a clinician through the scheme. Alignment with the Multi-professional framework for advanced clinical practice in England Please find a link to the Multi-professional framework for advanced clinical practice in England here: https://www.hee.nhs.uk/sites/default/files/documents/multi-professionalframeworkforadvancedclinicalpracticeinengland.pdf My thanks to Kate for an engaging and insightful interview.

In this conversation we will examine the recent recommendations and development of a national out-of-hospital transfusion protocol for critical care services. We will unpack the recent modified RAND Delphi study that sets out the guidance of clinical governance and recommendations for out of hospital transfusion services. We will dig into the recommendations on the initiation of transfusion, the types of blood components and products, the delivery and monitoring of out of hospital transfusion, the Indications for and use of transfusion adjuncts and finally the resuscitation targets to halt ongoing transfusion.    Adam Greene is a Unit Chief and Critical Care Paramedic working at British Columbia Emergency Health Service. He is also an honorary lecturer at Cardiff University on the Masters in Critical Care. He amongst others has recently published the Development of a national out-of-hospital transfusion protocol: a modified RAND Delphi study which will form the basis of our discussion.  The study can be found here: https://www.cmajopen.ca/content/11/3/E546 Adam's contact details can be found here: Adam.Greene@bcehs.ca

This is the second instalment of the conversation on the approach to major incidents with Keir Rutherford & Alec Wilding. We examine triage tools which have just come into practise which is around the TST - 10 second triage algorithm and the MITT - major incident triage tool and also look at enhanced levels of care on scene and what should be done in the casualty clearing station. We also examine at how we manage our emotions as senior clinicians both on scene and retrospectively and work we work with interdisciplinary teams around the fire brigade and the police on scene. Here are more resources from the conversation: London Bridge article: https://www.magonlinelibrary.com/doi/abs/10.12968/jpar.2017.9.12.512 Ten second triage: A novel and pragmatic approach to major incident triage: https://t.co/LXdO1MFRX4 New NHS Prehospital Major Incident Triage Tool: from MIMMS to MITT: https://emj.bmj.com/content/39/11/800.long NARU app: https://naru.org.uk/jesip-launched-free-app-emergency-responders/ Jesip aid memoir : https://jesip.org.uk/uploads/media/pdf/Aide_Memoires/JESIP_Aide_Memoire_2022.pdf

In this conversation we will examine some of the lessons learnt from anecdotal experiences in major incidents, together with the reflections from previous recommendations in major incident enquiries such as the Manchester bombings. We will examine the differentiation of terrorist attacks at point of call from an otherwise normal RTC or ‘typical’ incident. We also look at the initial approach to triage, who and how this should be done as well as the integration and relationship of the Ten Second Triage (TST) algorithm, the Major Incident Triage Tool (MITT) and levels of enhanced care at the scene. Also, the concept of casualty clearing and when and how this should be performed. We also examine the level/ceiling of intervention that is beneficial from the empirical research in such events and how this should be approached. We also examine inter-disciplinary working with other services such as police responders and fire brigade.  Keir Rutherford is an Advanced Paramedic Practitioner in Critical Care and also a flight paramedic with London’s Air Ambulance. Alec is also an Advanced Paramedic Practitioner in Critical Care and the Emergency Planning Resilience and Response (EPRR) lead for Festival Medical Services, who are a charity providing event medical cover including at Glastonbury and also a Specialist Paramedic for Hampshire Isle of Wight Air Ambulance. To read more on some of the information referred to in the Manchester Bombing inquiry please see here: https://manchesterarenainquiry.org.uk/ This is part 1 of a 2 part conversation as we felt there was too much to include in just one episode.