Pre-Hospital Care Podcast

In this session I am speaking with Claire Park on a new primary triage tool developed by Claire and a research team. It has been accepted and agreed by NHS England for use by all UK ambulance services and prospectively by National Police and Fire Services. It has also been adopted by the UK MOD to roll out across all UK military personnel internationally. Claire Park is a Consultant in Pre-hospital Emergency Medicine for London HEMS, and Anaesthesia and Critical Care Medicine at Kings College Hospital in London. She also is an army consultant with over 20 years of deployed military experience. Claire is the medical adviser to the Specialist Firearms teams of the Metropolitan Police Service (MPS), and has worked closely with all of the emergency services in London on developing the joint response to high threat incidents, in particular following the attacks of 2017. She is also the Chief Investigator on a UK nationally funded research grant looking at evidence for improving patient outcomes in the hot zone in major incidents and has developed relationships in this area with many members of the Committee Tactical Emergency Casualty Care CTECC over the last 4 to 5 years. In the conversation we examine: 1.  Definition of triage as a fundamental baseline. 2.  Why need for change - Current standards (START and SMART triage) and the existing and emergent needs from a triage tool. 3.  Empirical literature 4.  Changes to current practices - Challenges in design/Physiology or not physiology/Bleeding not bleeding/talking/breathing. 5.  Design considerations and the inclusion of penetrating injury. 6.  Testing of the tool  7.  Adoption - Adoption of the tool by various institutions. 8. Improvements expected to be seen on the ground. 8.  What’s next - Future projects for Claire. The new TST tool can be found here: https://twitter.com/seanharris999/status/1582382980902723584 My thanks to Claire and the team for this insightful interview. 

In this episode we are examining the recent strikes and pay freeze that frontline paramedics have been experiencing. This is on the background of increased cost of living and operational pressures across the emergency care system. We will focus both on Carl’s recent reflections of the issue and also the sense of community within the current strikes. We will also examine how this strike is different to others and indeed how the climate of the NHS is vastly different to that ever seen before. Carl Betts is no stranger to the podcast, he has been a paramedic for over 10 years and currently working in Quality Improvement. He has also written a recent blog on his reflections of the strike action, the sense of unity and the multi-factorial climate of pressures that paramedics work in within the UK. This was an episode recorded for World Extreme Medicine (WEM) and aired with kind permission from WEM. World Extreme Medicine are providers of specialist environment and expedition medical education and can be found here: https://worldextrememedicine.com/

In this session I am speaking with Andrew Pearce on the concept of the trauma handover. We examine the definition of the handover, the commonly expected barriers to effective handover, and the recall of handover information. We will also examine where the handover occurs, standards and recommendations, tools and templates, how we can measure effectiveness, and finally whether it works in practice. We will also dig into some of the empirical literature to examine some of the evidence behind the handover. Andrew Pearce is an Emergency Physician and pre-hospital retrieval medicine specialist. He is currently the Clinical Director and a Medical Retrieval Consultant coordinator at MedSTAR Emergency Medical Retrieval Service based in Adelaide, Australia. In the episode we examine: 1.  Definition of the clinical handover. 2.  Commonly expected barriers to information handover. 3.  Recall of information and some of the errors in recall.  4.  Empirical findings on handover from the literature.  5.  Where the handover occurs and bias attached to handover information. 6.  Current standards & recommendations (Standard 6, ACSQHC) 7.  Templates and Tools used and advocated.  8.  Measuring effectiveness/quality assurance of handover. 9.  Summary from Andrew.  Some of the empirical papers and standards mentioned in this episode can be found here: Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members https://pubmed.ncbi.nlm.nih.gov/20702445/ Expectations differ between senders and receivers of patients in transition - Joint commission centre for Transforming Healthcare 2017 https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_58_hand_off_comms_9_6_17_final_(1).pdf?db=web&hash=5642D63C1A5017BD214701514DA00139&hash=5642D63C1A5017BD214701514DA00139 Clinical handovers between prehospital and hospital staff: literature review https://emj.bmj.com/content/32/7/577.short Australian Commission on safety and quality in healthcare: Standard 6: Clinical Handover  https://www.safetyandquality.gov.au/sites/default/files/migrated/Standard6_Oct_2012_WEB.pdf My thanks to Andrew for an engaging and insightful interview. 

In this session I am speaking with Aggie Rice on the concept and tool of Schwartz rounds and her journey of implementation within the NHS. Schwartz rounds can be described as a structured forum where all staff, clinical and non-clinical, come together regularly to discuss the emotional and social aspects of working in healthcare. In the session we wanted to explore the purpose of Schwartz Rounds and some of the potential benefits to staff that participant in them. We also wanted to look at the evidence and staff feedback as to their utility and ability to flatten the hierarchies of management within an organisation. The underlying premise for Rounds is that the compassion shown by staff can make all the difference to a patient care, but also in turn, make staff feel supported in their work. We want to dig into this principle and get the thoughts from Aggie who is implementing them at a local and national level. Aggie Rice is a mentor and trainer on the Schwartz Rounds and Team Time programmes. After working for the Point of Care Foundation for a few years as an Associate, Aggie joined the Foundation in this full-time role in 2021. Aggie has worked on the Schwartz Round programmes since 2016 and has a keen interest in organisational culture, storytelling and the emotional wellbeing of health and social care staff.  In the episode we cover:  1.  Why Schwartz rounds are important in the contemporary healthcare climate.  2.  The power of narrative and the anatomy of the Schwartz round 4.  The principle of psychological safety 5.  Whether they can be used as a surrogate for counselling  6.  Opening up and flattened hierarchy 8.  Adoption and rate limiting steps/barriers to participation 9.  Progress within the Ambulance Service versus other healthcare settings 10.Take home messages You can learn more about Schwartz Rounds here: https://www.pointofcarefoundation.org.uk/our-programmes/staff-experience/ You can learn more about Aggie Rice here: https://www.pointofcarefoundation.org.uk/about-us/people/aggie-rice/ I hope you enjoy this episode with an insightful and engaging guest. 

In this session we will examine the latest research to emerge from Zane Perkins and Mike Christian around Resuscitative Thoracotomy (RT). The research has been led by Zane and Mike examined over 600 retrospective thoracotomy cases from the LAA database spanning 20 years, looking at the survivors, the pathology (exsanguination versus tamponade), the pre-arrest rhythms, the morbidity and mortality, the time of intervention versus outcome as well as other markers. I wanted to explore the results of this research and the potential implications on practice. Zane Perkins is a consultant Trauma and General Surgeon at the Royal London Hospital, a consultant Physician for London's Air Ambulance, and an Honorary Senior Lecturer at the Centre for Trauma Sciences, Queen Mary’s University London. Current thinking on Thoracotomy practice Examine the research in more detail from primary & secondary outcomes Survival rates - Who are the current survivors? What are the main domains of pathology Exsanguination: Results of outcome and pre-arrest rhythms What it shows around intervention and decisions around exsanguination Tamponade: results of outcome and pre-arrest rhythms  What it shows around intervention and decisions around tamponade Differentiated decision making and prospective changes to SOP Final thoughts and take-home messages. The study has yet to be published but we will publish the results as they are published. My thanks to Zane for an engaging and insightful interview. 

This is the second part of the lecture series on building effective teams and dealing with difficult people. The concepts taught here involve models of teamwork (Action centred Leadership, the five dysfunctions of a team), trust - both as a concept and a pre-requisite, culture, homeostatic teams and finally tools and techniques for fostering good team work.  In the second half of the podcast we examine dealing with difficult people from the perspective of understanding the triggers, root cause analysis, rapport building, the energy investment model, the ELCR framework, self awareness, humility and insight. Some of the resources and models can be found here:  Energy investment model: https://careerresilience.wordpress.com/2021/06/03/how-are-you-investing-your-energy-in-times-of-change/ Action Centred Leadership: https://www.businessballs.com/leadership-styles/action-centred-leadership-john-adair/ The Five Dysfunctions of a team: https://tomorrowsleadership.nl/how-to-overcome-the-5-dysfunctions-of-virtual-teams/ Empathic communication: https://hbr.org/2022/08/4-ways-to-communicate-with-more-empathy I hope you get something from this episode that you can use either within clinical practice or within general work-based situations. I'm always keen for feedback on sessions, please feel free to reach out to me at eoinwalker@hotmail.com - please also rate, review and subscribe to the podcast. This episode will be aired across the Pre-hospital Care Podcast and Restore Podcast platforms.  Many thanks, Eoin

In this session we will examine Exertional Heat Injury (EHI) within individuals undertaking endurance races, military exercises, or extreme activity. We will draw contrast and parallels to acute behavioural disturbance, what is happening both at the physiological level and some of the autonomic positive feedback mechanisms within EHI. To do this I have Harvey Pynn with me, Harvey is a Lieutenant colonel within the British Military and an Emergency Medicine and air ambulance consultant with GWAAC. In the episode we examine:  ·  Definitions, spectrum of disease – EHI as a broad definition and spectrum of states ·  How are thinking has changed on heat illness and what is happening on a physiological level ·  Incidence of EHI; anecdotal and empirical ·  The hierarchy of ‘exercise-state’ heat loss – evaporative, convective, conduction, then radiation. ·  Heat acclimatisation: Salt concentration (aldosterone mediated), sweating initiation and rate. ·  Risk factors (individual, environmental)- concomitant disease or drugs (dehydration, alcohol, co-morbid disease, medication) ·  Subtle and not so subtle prodromal signs and symptoms of heat injury & why urine colour isn’t a great marker (lack of micturition during     dehydration). ·  Preventative measures and treatment modalities in severe EHI  ·  Analogues of comparison and symptomatology – ABD, drug induced hyperthermia. ·  Differential diagnosis and an anecdotal case from Harvey  Please find some related research produced by Harvey pertaining to measuring dehydration and the sequlae of EHI: https://www.researchgate.net/publication/327822126_The_Compensatory_Reserve_Index-potential_uses_in_a_military_context Please also see relevant empirical literature that is congruent with the podcast: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819979/ Please enjoy this episode with an engaging and informative guest. 

In this episode I examine the art of active listening. It is a slightly different episode and one of a number to come where I give a series of lectures. In this episode I wanted to do two things: 1. Build awareness of the factors that affect our listening ability. 2. Build and create the conditions that can produce good listening habits. One of the main problems is caused by the fact that we think much faster than we talk. The average rate of speech for most of us is around 125 words per minute. In contrast we process and think at about 800 words a minute. This is a fundamental mis-match which can cause a deficit in receiving information. The human brain is made up of more than 13 billion cells and operates in such a complicated but efficient manner that it makes any comparison to computers seem insignificant. It might seem logical to slow down our thinking when we listen so as to coincide with the 125-word-per-minute speech rate, but slowing down thought processes seems to be a very difficult thing to do. When we listen, therefore, we continue thinking at high speed while the spoken words arrive at low speed. In the act of listening, the differential between thinking and speaking rates means that our brain works with hundreds of words in addition to those that we hear, assembling thoughts other than those spoken to us. The latency of this mis-match is often taken up by internal dialogue rather than integration of the spoken, but more importantly inferred meaning behind words. In this episode I examine:  The definition of active listening.  The 'classic' example - one which we all fall prey to.  The anatomy of the received message. The why and what of ‘Active Listening’. Triple A listening (what triple A listening actually is).  Kinesthetics of listening – what it feels like to be heard amongst other aspects.  Models of active listening: Four ears of communication, the communication triangle.  The power of silence The quality of listening - The hierarchy of active listening  Chunking information as an adjunct to active listening  Closed loop communication  The power of agreement Please let me know what you think of the content at eoinwalker@hotmail.com and also feel free to recommend future topics. Please also feel free to rate and review the podcast and I always welcome feedback. 

In this session we will examine one of the common greatest human factors challenges within pre-hospital care, that of acute fatigue within clinical practice. The ambulance services are trying out different ways of working to help staff feel less tired at work and safer on scene, but these actions are often localised and have no empirical underpinning, and also we don’t know whether they are making working environments safer. Kristy is investigating whether patient and staff outcomes can be improved through development and implementation of a fatigue risk management system (FRMS), as is done in other safety-critical industries like aviation and transport.  The evidence suggests individual components of a FRMS which may be effective, Kristy is currently investigating the optimal packaging of these interventions. Kristy believes that FRMS adoption in the NHS needs local tailoring and understanding of barriers and facilitators. Kristy is looking at a way to integrate a comprehensive fatigue risk management system for the UK NHS ambulance sector that is acceptable, feasible, and likely to improve patient outcomes and staff wellbeing and experience. Within the episode we will examine: 1.  Kristy’s research approach to an agreed set of evidence-based and emerging components of a FRMS for the UK ambulance sector that are considered feasible and acceptable. 2. The wider CATNAPS study and its wide ranging primary and secondary outcomes.  2.  The components of a comprehensive FRMS that are in use and why. 3.  The ways in which front-line staff and patients experience current fatigue actions and potential to improve safety culture and reporting. 4.  Development and usability testing of the FRMS and its implementation guide that allows tailoring to organisational and local context and is underpinned by a new theory of change and logic model. 5. The 12 hour day and and night shift, both pros and cons of this pattern of working.  6. Fatigue mitigation and how the FRMS may serve to support this. 7. Second and third order effects of fatigue.  More on CATNAPS and Kristy's research can be found here: https://arc-eoe.nihr.ac.uk/research-implementation/research-themes/mental-health-over-life-course/catnaps-fighting-fatigue-nhs Please enjoy this episode with an engaging guest. 

In this session we will examine the bleeding patient in the tactical and combat environment. We will dig into some of the fundamental education that has changed practice in recent years, we will also look at the sequential approach to bleeding control, second and third generation haemostatics, pharmacological agents, tourniquets, neck zones and injuries, blunt injury and junctional wounds, hypotensive management and finally pain management in the combat arena. We also examine the utility and success of highly interventional skills at or near point of wounding such as REBOA. Finally we will examine Traumatic Cardiac Arrest (TCA) and the utility (or not) of an algorithmic approach to management. To do this, Ed Barnard joins me. Ed is an emergency medicine consultant within Cambridge University hospital and has undergone sub-specialty training in pre-hospital EM, working in more than five EMS systems, educating and mentoring medical students and doctors in training, giving national and international lectures, delivering a national research and clinical innovation meeting, completing a PhD from a top-100 research university, publishing over 30 journal articles, receiving five national-level research awards, and being appointed as a Senior Lecturer for the military. Topics covered:  Sequential approach to arresting bleeding Look at second/third/fourth generation haemostatic compounds (celox, quik-clot) Utility of tourniquets (origins, usage and types) Neck zones and wounds Blunt injury and junctional wounds Hypotensive mx - utility of this Critical Hypovolaemia and tx modality Interventions at point of wounding - REBOA TCA management and algorithmic approaches Ed's reflections and perspectives over the past 5 years on bleeding  Some of the concepts and evidence that Ed mentions in the episode can be found here:  A comparison of Selective Aortic Arch Perfusion and Resuscitative Endovascular Balloon Occlusion of the Aorta for the management of hemorrhage-induced traumatic cardiac arrest: A translational model in large swine https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5526509/ The outcome of patients in traumatic cardiac arrest presenting to deployed military medical treatment facilities: data from the UK Joint Theatre Trauma Registry https://militaryhealth.bmj.com/content/164/3/150.abstract Prehospital determinants of successful resuscitation after traumatic and non-traumatic out-of-hospital cardiac arrest Epidemiology and aetiology of traumatic cardiac arrest in England and Wales — A retrospective database analysis https://www.sciencedirect.com/science/article/abs/pii/S030095721630538X  Please enjoy this episode with an insightful and engaging guest.