Pre-Hospital Care Podcast

In this episode we kick off a mini-series on human factors in practice. I will be speaking with a cross section of clinicians on what human factors means to them and the impact it can and has had on their practice. In this episode I discuss the fundamentals of human factors including; a working definition of human factors, why human factors are important, the history of human factors, the main domains of human factors, Individual Human factors & mitigation, task human factors & mitigation, environmental/System human factors F& mitigation, NASA's approach to human factors and finally three seminal cases in human factors. Medical errors can have significant costs both in terms of patient health outcomes and financial costs. While it is difficult to estimate the precise global costs of medical errors, studies have suggested that they can be substantial. In the United States alone, medical errors have been estimated to cost between $17 billion and $29 billion annually in direct costs, such as additional medical expenses, lost income, and disability. This figure does not include the indirect costs associated with lost productivity or quality of life. A study in the UK estimated that preventable medical errors cost the National Health Service (NHS) around £1 billion each year. On a global scale, a report by the World Health Organization (WHO) estimated that 10% of hospital admissions worldwide result in adverse events, and around half of these are due to errors. These errors are estimated to cause between 6 and 10% of hospital admissions in developed countries, and up to 20% of admissions in developing countries. The report also estimated that medication errors alone affect at least 1.5 million people globally each year, resulting in 100,000 deaths annually.  Here are the links mentioned in the episode: REMOTE MEDICAL EMERGENCIES RGS - https://www.rgs.org/CMSPages/GetFile.aspx?nodeguid=6643dce6-a321-4002-b117-28d26897ab59&lang=en-GB   https://www.youtube.com/watch?v=5C59910SWyw  To err is human documentary    https://emcrit.org/wp-content/uploads/ElaineBromileyAnonymousReport.pdf  – Elaine Bromiley report https://www.theverge.com/2019/5/2/18518176/boeing-737-max-crash-problems-human-error-mcas-faa  - The Boeing 737 human factors   https://sma.nasa.gov/sma-disciplines/human-factors  https://www.dmp.wa.gov.au/Documents/Safety/MSH_TB_HOF_Woodside_HOFOilnGas.pdf Please feel free to reach out to me on eoinwalker@hotmail.com for future content and feedback

In this episode I am speaking with Debs Swann on her recent deployment to the Turkey Earthquake disaster. It is the deadliest earthquake in what is present day Turkey since the 526 Antioch earthquake, making it the deadliest natural disaster in its modern history. As of 20 March 2023, more than 57,300 deaths were confirmed: more than 50,000 in Turkey, and more than 7,200 in Syria. In Turkey alone there were at least 50,096 deaths and 107,204 injured across 11 provinces of Turkey. By 23 February 2023, the Ministry of Environment, Urbanization and Climate Change conducted damage inspections for 1.25 million buildings; revealing 164,000 buildings were either destroyed or severely damaged. A further 150,000 commercial infrastructure were at least moderately damaged. At least 15.73 million people and 4 million buildings were affected. About 345,000 apartments were destroyed. More than 2 million residents in the affected provinces were evacuated to nearby provinces including Mersin, Antalya, Mardin, Niğde and Konya. More than 20 percent of Turkey's agriculture production was damaged. The United Nations said crops, livestock, fisheries, aquaculture and rural infrastructure were also heavily damaged. The international organisation for migration estimated about 2.7 million people were made homeless. In the conversation we examine her anecdotal experience of deploying with the UK international Search and Rescue Team near the cities of Nurdağı and Gaziantep in Gaziantep Province, just outside the regional capital. We examine the reflection on cases she witnessed, the pattern of injuries, the use of search and rescue dogs, the hot and cold brief of the group, the near death experiences that she had and much more. Debs Swann is an Advanced Clinical Practitioner (ACP) working in the Cambridge area, she is also a PHEM practitioner working with the Birmingham care teams. Debs is also a World Extreme Medicine faculty member and is an active member of the UKISAR team. In the episode she reflects on her time both within the deployment and her reflections afterward. She also reflects on her near death experiences and how that translates to her perspectives on time horizons. My thanks to Debs for this candid and honest interview and her overall insights.

In this conversation we will examine the recent changes in spinal immobilisation within pre-hospital practice. We will look at the historic literature, prevalence of spinal injury in reality, the RCSEd recommendations, and other international guidelines and also the current practice of C-spine collars and extrication advice. To do this I have Jim Walmsley with me, Jim is a Critical Care Paramedic at South East Coast Ambulance Service NHS Foundation Trust. Jim has a 19-year history with the ambulance service and has focussed his career on clinical practice, research, under-graduate teaching, as well as managerial duties. In the episode we discuss: • The culture and historic research of spinal immobilisation. • Pre-hospital prevalence & cultural shift • What are the main considerations in the pre-hospital phase of care • Pre-hospital assessment (sensitive? Valid?) main information to take note of (MOI & other factors) • Immediate treatment options – to immobilise or not immobilise • Latest recommendations • Seminal cases where the application of the above has worked well • Final thoughts & take-home messages. Some of the references that Jim referred to can be found here: https://fphc.rcsed.ac.uk/media/1757/pre-hospital-spinal-immobilisation.pdf Canadian C spine rules: https://www.sira.nsw.gov.au/resources-library/motor-accident-resources/publications/for-professionals/whiplash-resources/SIRA08109-Canadian-C-Spine-Rule1117-396476.pdf NEXUS guidelines: https://www.ebmedicine.net/media_library/files/Trauma-Imaging-Resuscitation-CD.pdf Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3494329/ My thanks to Jim for an engaging and insightful interview.

In this conversation we will examine the immediate, mid-term and long-term effects of sexual assault. We will also examine the short-term treatment that pre-hospital clinicians should consider. We will also examine some of the long-term support that is available for victims of sexual assault. We will also examine elements of safeguarding, care pathways, and forensics that work on a co-aligned basis with psychological support mechanisms. To do this I have Jayne Butler with me. Jayne is the CEO of Rape Crisis and an experienced voluntary sector leader with a strong background in frontline service delivery. Jayne has worked in social justice-focused organisations for almost 20 years. These include organisations working on asylum and immigration, mental health, child sexual exploitation and access to justice. Before moving into infrastructure and influencing work, Jayne was involved in designing, fundraising for and managing a range of frontline services. She has worked strategically as a consultant in a range of voluntary sector organisations, and as a staff member or trustee in a number of membership and infrastructure organisations. These include The Comfrey Project, North East Law Centre, Relate Northumberland and Tyneside, Newcastle United Foundation and The Children’s Society. Prior to joining RCEW, Jayne was Head of Income and Development for Law Centres Network, the national membership body for Law Centres. During her time there, she led on the Network's response to the Covid-19 pandemic. Jayne is a Fellow of the RSA. In the conversation we discuss: • The need for psychological support as an immediate intervention • The pre-hospital prevalence • What are the main considerations in the pre-hospital phase of care • Pre-hospital assessment when a patient has been sexually assaulted • Forensic assessment • Immediate treatment options, midterm, and long term • Safeguarding needs of this patient group • Care pathways available for these patients • Example case of when services work well together. • Final thoughts & take-home messages from Jayne. Services that Jayne sign posts to in the episode includes: 24/7 help line: https://247sexualabusesupport.org.uk/ Rape Crisis website: https://rapecrisis.org.uk/ Statistics on sexual assault & rape: https://rapecrisis.org.uk/get-informed/statistics-sexual-violence/ My thanks to Jayne for an informative and insightful interview.

In this conversation we will examine the prevalence, types, and challenges of pelvic trauma. We will also look at some of the pre-hospital and Emergency Department management of pelvic trauma and why it can be such a critical injury to treat. To do this I am speaking with Ash Vasireddy. Ash is a fellowship-trained Orthopaedic Trauma Surgeon specialising in the management of complex upper limb, lower limb, pelvic and acetabular fractures. He works at King’s College Hospital (Major Trauma Centre) in London. He completed further specialist Orthopaedic Trauma training at The Royal London Hospital, as well as Orthopaedic Trauma Fellowships at Queen’s Medical Centre in Nottingham and King’s College Hospital in London. In addition, Ash has also completed travelling fellowship visits to multiple major trauma centres in America, including the Shock Trauma Centre in Baltimore and Harborview Medical Centre in Seattle. Ash also has extensive experience in Emergency Medicine, Intensive Care and Anaesthesia. He is also a Consultant at Essex and Herts Air Ambulance (EHAAT) and research lead for EHAAT. In the conversation we examine: Why a pelvic fracture is so critical The pre-hospital prevalence What are the main types / classifications The spectrum of injury – pain to life threatening blood loss Pre-hospital assessment of the pelvis  Some of the common issues seen as an Orthopaedic Trauma Surgeon IR vs OR Possibilities of REBOA within the Air Ambulance Service Lessons learnt from practice (pre-hospital and in-hospital) Seminal cases  Final thoughts & take-home messages. In the conversation Ash mentions the two common types of Pelvic classification, these are: TILE: https://litfl.com/classification-of-pelvic-fractures/ Young and Burgess classification of pelvic ring fractures: https://radiopaedia.org/articles/young-and-burgess-classification-of-pelvic-ring-fractures?lang=gb My thanks to Ash for an insightful and engaging interview. 

In this session I am speaking with Robbie Lendrum on the Myocardial Hypoperfusion & injury in Trauma. We examine the Windkessel concept of pulsatile flow to constant flow, reservoir pressure as an analogue of diastolic pressure, coronary perfusion in diastole. We also explore blood pressure targeted intervention, the disparity between NIBP and IBP, the precision of diagnostics versus intervention, and individually patient centred intervention. We finally fundamentally drill down into the true importance of diastolic blood pressure in trauma care and how this is a succinct shift in mindset and teaching to traditional systolic blood pressure measurements and cut offs. To do this I have Robbie Lendrum with me. Robbie is a consultant in cardiac anaesthesia and critical care. He is also a consultant in Pre-Hospital Care working with London’s Air Ambulance. Robbie is an honorary senior lecturer at Queen Mary university London and an Endovascular Resuscitation Researcher within the UK. Within the conversation we also examine: Cardiac hypoperfusion – pathophysiology The Windkessel concept – converting pulsatile flow into constant flow, the generation of pressure. Reservoir pressure equal to diastolic pressure Coronary perfusion in diastole and the fundamental importance of diastole in trauma  Arterial injury and respective diastolic hypotension – wide pulse pressures  - Effect on coronary perfusion pressure & flow CVD – Cardiovascular Dysfunction with early death/72 hour boundary. Physiological targets (targeted intervention) Why should we move on from blood transfusion and drive faster to hospital.  The secondary effects on the heart & essentially outcome. Arterial shock and the proximal thoracic aorta. The two main types of patient and how we approach these (Tamponade and exsanguination) My thanks to Robbie for this interview. This is a fundamental shift in teaching and mindset and is seminal in how we see and approach trauma care in the future. The key pieces of research that Robbie mentions in the interview includes:  Importance of the aortic reservoir in determining the shape of the arterial pressure waveform. The forgotten lessons of Frank. https://www.sciencedirect.com/science/article/abs/pii/S187293120700155X The Underlying Cardiovascular Mechanisms of Resuscitation and Injury of REBOA and Partial REBOA https://pubmed.ncbi.nlm.nih.gov/35615678/ Trauma Laparotomy in the UK: A Prospective National Service Evaluation https://pubmed.ncbi.nlm.nih.gov/34015456/ My thanks to Robbie for his insights and reflections. 

In this session I am speaking with Mark Hannaford, Luca Alfatti, and Alione Hlivco around the current logistical aid efforts, implementation, climate and anecdotal reflections in Ukraine. We also want to dig into the cadence of change in the current climate from an infrastructural perspective, logistical effort and the real need on the ground from the guest’s experience. Our guests include Mark Hannaford, Mark is the CEO and founder of World Extreme Medicine. Since its inception WEM has trained over 20,000 medics in extreme medicine and has a global platform that also hosts the first MSc in extreme medicine at Exeter University in the UK. Welcome Mark to the podcast. We also have Alione Hlivco, Alione is a former MP in Ukraine. She is a regular contributor at Chatham House, Monocle24, CapX and is a TEDx Speaker. Finally, Luca Alfatti. Luca is the Head of Operations for #Medics4Ukraine, who has delivered over 1.7 million pounds worth of medical aid to Ukraine, as well as several trauma medical courses to frontline soldiers and medics. He is also an advanced paramedic in the UK. Aspects of the conversation include:  ·  The current climate & significant elements of recent change ·  Multi-factorial risk profile of the country currently ·  The existing and emergent needs as seen by the guests ·  Cross section of clinical cases ·  Recent education delivered & aspirations ·  Recent activity within the #Medics4Ukraine initiative within the UK ·  Information governance ·  Aspirations within the next few months (broad & not area specific) ·  Logistical challenges ·  Diversity of medical distribution World Extreme Medicine can be found here: https://worldextrememedicine.com/ The Medics4Ukraine initiative can be found here https://www.gofundme.com/f/medics4ukraine This episode is published with kind permission from World Extreme Medicine

In this session we will examine the latest perspectives and insights into recreational drug toxicology with Dima Abdulrahim. I wanted to unpack some of the recreational drug toxicology with reference to drugs that seem to be in favour with youth and have pre-hospital touch points from an acute perspective. Dima Abdulrahim has been working in the field of substance use treatment for 30 years. She is currently the Quality Lead in the Addictions department of CNWL NHS Trust. Dima was the Principal Researcher and Programme Manager of the NEPTUNE Project, based in the Club Drug Clinic. She is the author of two books on novel psychoactive substances and club drugs and other publications and has developed as a series of e-learning and mobile-learning modules, with co-author Owen Bowden-Jones. Dima was a council member of the Advisory Council for the Misuse of Drugs (ACMD) for many years. Topics covered include a deep dive into: • Some of the most addictive recreational substances Dima has seen in practice  • Poly-pharmacy and the associated incremental risk profile to the user • The combined use of sildenafil with other drugs within the chem-sex context • GHB addiction and profile and the narrow therapeutic window and GABA-B stimulation/sedation (and over sedation) in overdose • The half-life of GHB  • Serotonin linked harms and syndromes, mainly within MDMA and ecstasy • The incumbent fentanyl crisis (unwarranted and unregulated cutting of drugs with fentanyl) • The false economy of safety around drugs bought online • The contemporary issue around fake ketamine distribution • The circulation of fake pregabalin and benzodiazepines and the related deaths • Take home Naloxone campaigns  • Other emergent synthetic recreational drugs seen within the clinic Resources that Dima has written include:  Books:  Abdulrahim D and Bowden-Jones O: Textbook of Clinical Management of Club Drugs and Novel Psychoactive Substances Cambridge University Press Medicine. October 2022 (book) Bowden-Jones and Abdulrahim: Club Drugs and Novel Psychoactive Substances. The Clinical Handbook. Cambridge University Press Medicine. November 2020 (book) Resources (available free of charge) NEPTUNE e-learning modules on club drugs and novel psychoactive substances http://neptune-clinical-guidance.co.uk/e-learning/ Neptune guidelines and resources http://neptune-clinical-guidance.co.uk/ ATOMIC- Addiction to Medication: Improving Care. Mobile-learning modules on the harms and management of non-medical prescription drug use. https://addiction-to-medication.org/atomic/ My thanks to Dima for an engaging and insightful interview.

In this session I will be talking with Neil Jeffers on CRM or Crew Resource Management. We will examine a working definition of CRM, why it’s of fundamental importance to Neil, the history of CRM, the symbiotic link between human factors and CRM, and the detrimental aspects of collective agreement. In the conversation we will also examine some of the theory, threat and error management, CRM tools that Neil uses and advocates, and finally how debrief can be a fundamental tool to improving CRM. Neil has been a Pilot with London’s Air Ambulance for 16 years and has been Chief Pilot for the last 8 years. Neil has flown over 8,000 hours since he started flying in 1997 and has over a 5,000-hour track record in instructing and examining. Neil was also an experienced crew resource management instructor and a certified first responder and has been a volunteer emergency responder with London Ambulance Service for 5 years. In the interview we cover: A working definition of CRM Why CRM is so fundamental to high performing teams  Brief history of CRM from aviation into medicine Flash points within a scene that mandate good CRM The linkage between CRM and Human Factors Deep dive on the hierarchy of CRM in order of importance - Decision Making, Leadership & Management, Situational awareness, communication (Closed loop, chunked, tone & intonation). Negative aspects of collective agreement Threat and error management Dunning Kruger effect CRM tools that Neil deploys and recommend Debriefing; The utility of debriefing Some of the concepts that Neil mentions includes: Threat/error management: https://www.easa.europa.eu/en/downloads/22642/en Dunning-Kruger effect: https://thedecisionlab.com/biases/dunning-kruger-effect Cognitive Dissonance: https://www.verywellmind.com/what-is-cognitive-dissonance-2795012 My thanks to Neil for an insightful and engaging interview. 

In this session we will examine the fundamentals of the pre-hospital airway from airway assessment all the way through to the difficulties posed in practice. We will also look at the management from a stepwise concept all the way through to the use of invasive surgical techniques to manage the airway. We will also examine some of the optimal methods used to monitor the respiratory effort and when and when not to intervene. We will also examine the current utility and debate around Direct Laryngoscopy (DL) and Video Laryngoscopy (VL) and whether VL is around to stay within practice.  To do this I have with me John Chatterjee.  John is a consultant anaesthetist with an interest in pre-hospital care and difficult airway, thoracic and high-risk anaesthesia. He has worked with and educated clinicians around the world in various ambulance and hospital services including places like New Zealand, Sydney, Liberia, Ethiopia, Ukraine and in the UK where he has worked with HEMS and BASICS. John is as an anaesthetist at Guys and St Thomas', and a Consultant with London's Air Ambulance at the Royal London. In the episode we examine:  The challenges of the pre-hospital airway How to assesses the difficulty of an airway from sight and brief assessment Declaration of the findings and plan VL vs DL and where VL is going from a SOP and utilisation tool. Stepwise management and understanding where to come in on the management plan.  Assessment of respiratory effort Thoughts on RSI compared to retrospective practice. Tips on surgical airways Seminal airway research in the last 10 years – Impact Brain Apnoea Seminal cases that John has learnt a lot from  Final thoughts from John and take-home messages. John mentions these two papers within the conversation: Difficult Airway Society (DAS) 2015 guidelines for management of unanticipated difficult intubation in adults: https://aimeairway.ca/userfiles/26556848_Difficult_Airway_Society_2015_guidelines_for_management_of_unanticipated_difficult_intubation_in_adults.pdf Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians https://academic.oup.com/bja/article/113/2/220/1745948 My thanks to John for an insightful and engaging conversation.