Pre-Hospital Care Podcast

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.

In this conversation we will examine the latest in non-invasive ventilation via the helmet interface. Recent empirical research has shown that ventilation via helmet can mean faster recovery time, shortening an ICU stay, reduces the need to intubate, lowers ICU mortality, and can result in minimal or no sedation of the patient.  Aurika Savickaite is a registered based in Chicago and was involved in the successful testing of the helmet ventilator in the ICU at the University of Chicago during a three-year trial study. Aurika has worked as a registered nurse and patient care manager at the University of Chicago Medical Centre, Medical Intensive Care Unit, and as a staff nurse at Vilnius University Hospital, in the intensive care unit. She earned a Bachelor of Rehabilitation and Nursing at Vilnius University Faculty of Medicine in 2001. Aurika is a recognized expert in noninvasive ventilation via the helmet interface and has garnered widespread respect within the medical community for her passionate work in this area. She was involved in a successful three-year trial study at the University of Chicago Medical Center that tested the effectiveness of helmet-based ventilation in the ICU. Drawing on this experience, Aurika founded HelmetBasedVentilation.com, a website that has become a valuable resource for medical professionals seeking to learn more about the benefits of helmets and their use in treating patients with respiratory distress. In the episode we cover: The story of exploration into NIV for Aurika and what did the covid pandemic reinforce?  The benefits of NIV in general. What are the benefits of helmet ventilation over NIV mask ventilation (greater alveolar recruitment).  The study - Effect of Non-invasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients with Acute Respiratory Distress Syndrome - A Randomized Clinical Trial. Commonly seen pathologies that benefit from NIV and the onward benefit.   What are some of the pre-hospital benefits in transport and retrieval. The indications and contraindications of NIV. What the masters program taught Aurika (level of critical analysis)  The paper that Aurika refers to in the interview can be found here: https://jamanetwork.com/journals/jama/fullarticle/2522693 Online course: https://www.helmetbasedventilation.com/Cesarano, M., Grieco, D.L., Michi, T. et al. Helmet noninvasive support for acute hypoxemic respiratory failure: rationale, mechanism of action and bedside application. Ann. Intensive Care 12, 94 (2022). https://doi.org/10.1186/s13613-022-01069-7

In this conversation we will examine the principles of coagulopathy and novel approaches to coagulopathy within pre-hospital care. We will examine the utility of fibrinogen concentrate, the distinct features of fibrinogen concentrate with cryoprecipitate, its longevity of use compared to other blood products, how you constitute fibrinogen concentrate for use in the pre-hospital environment amongst other topics.    To do this I have Ross Davenport with me, Ross is a Consultant Trauma & Vascular Surgeon at the Royal London hospital in the UK. He is also a Senior Lecturer in Trauma Sciences and has previously worked in prehospital care for both London and Essex & Herts Air Ambulance. His research has focused on trauma-induced coagulopathy, acute response to injury and the treatment of major trauma haemorrhage. His work in traumatic coagulopathy and massive transfusion, inflammation and organ dysfunction has had international renown. In the episode we examine: ·      Coagulation and the pre-hospital evidence  ·      Are we getting a handle on hypothermic induced coagulopathy  ·      What is fibrinogen concentrate and its mechanism of action? ·      How it differs from cryoprecipitate and whether we still need cryoprecipitate. ·      What the initial empirical research shows from CRYOSTAT 2 research. ·      It’s robustness within pre-hospital environments and how you reconstitute it for pre-hospital use.  ·      Current trials with Fibrinogen concentrate and early indications of effectiveness.  ·      ROTEM/thromboelastometry markers of effectiveness  ·      When to give it in the patient journey?  Please enjoy this episode.

In this conversation we will examine the concept of the performance pizza. This is a concept which examines three main domains of performance within pre-hospital care; the predictable routine, the predictable emergencies and the unpredictable emergencies. We will dig into each of these domains and examine what each constitutes, how you train for each state and how to navigate each.     To do this I have Stephen Hearns with me. Stephen is a consultant in emergency and aeromedical retrieval medicine. He works with Scotland’s Emergency Medical Retrieval Service (EMRS). This aeromedical retrieval service delivers pre-hospital critical care for major trauma patients, rural hospital secondary retrievals and major incident responses. Inspired by experience gained working on London’s air ambulance and in Queensland Australia, Stephen led the establishment of this team from a small voluntary service in 2004 to what is now a fully government funded aeromedical retrieval organisation with an international reputation. In the episode we discuss: ·      The three performance domains – how did Steve come to rest on these domains and how do they look in practice. ·      The predictable routine – Patients and/or skills that are executed everyday and are commonplace within practice. ·      The predictable emergencies – The High Acuity High Occurrence skills or patient presentations (RSI for example)  ·      The unpredictable emergencies – the High Acuity Low Occurrence (HALO) skills that might fall into the unpredictable spectrum (Surgical Airway) ·      Putting it all together in training and how simulation and case review plays into this. ·      How Core Cognition seeks to educate these areas within high performance teams. You can find more on Steve's Core Cognition website here: https://corecognition.co.uk/ The performance pizza can be seen here: https://corecognition.co.uk/performance-infographics/performance-pizza My thanks to Steve for an insightful and educational discussion.

In this conversation we will examine the career progression of Vicki Brown, who is an Advanced Practitioner in Critical Care, and is the first person in the country to get on the Faculty of Pre Hospital Care (FPHC) Register of Consultant Practitioners by qualifying from a purely paramedic background. We will trace her career pathway and the steps that have been taken by her to achieve such a pivotal role within pre-hospital critical care.  Vicki joined the ambulance service in 2002. And has had roles in management, learning and development and working on HEMS. She became the first ACP-CC for SWAST in 2020 and the first person to register as a Consultant (Level 8) Practitioners in Pre-Hospital Emergency Medicine in 2021.  ·      The start of Vicki's career – 2002 and what Vicki was doing previously to Paramedic Practice.   ·      What Vicki learnt on the road as a Paramedic  ·      What management taught her and she carried through ·      How training and education played a role in her progression  ·      The adage of learning every-day   ·      The educational pathway (DIMC, higher education, FIMC) ·      What working at GWAAC has taught her  ·      How governance looks within the team at GWAAC. ·      What responsibilities Vicki undertakes now as an Advanced Practitioner in Critical Care. ·      How she has changed over the years through her positions. ·      Where the profession is going, the pillars of advanced practice within the UK.  To see more on Vicki please see here: https://greatwesternairambulance.com/apcc-vicki-brown-breaks-barriers/ To see more on GWAAC please see here: https://greatwesternairambulance.com/ This episode is sponsored by MEQU. THE °M WARMER SYSTEM is a portable blood and IV fluid warming system. °MEQU has developed an IV-blood warmer for emergency transfusions. It’s a portable fluid warmer which warms up blood from cold to body temperature within seconds. The set-up time is less than 30 seconds, and the user-friendly design ensures that the °M Warmer System cannot be assembled incorrectly. Blood and other infusion fluids can be heated from 5°C to 37°C at flowrates up to 150 ml/min. One charged battery can heat up to 2 liters of cold fluids (5°C) or 4 liters of fluids at room temperature (21°C) to body temperature. The °M Warmer System has a compact design and weighs only 760 grams making it portable and ideal for prehospital use. The single-use warmer’s small size (10cm x 5cm x 2cm) allows it to be attached to the patient close to the infusion site, using its integrated adhesive pad. This secures infusion site and reduces heat loss in the tubing. The °M Warmer System is approved for use in ambulances, helicopters and fixed wing air frames. Please see here for further details: https://mequ.dk/product/?gclid=Cj0KCQjwy9-kBhCHARIsAHpBjHjgsgSlJ0bzKpZmNAs_OFdOEgYeeFKj0-Q-5XDJU5v-D5G15r23o_8aAoddEALw_wcB

This is a repost of an episode I recorded back in the early years of podcasting. It remains the most downloaded episode of the entire podcast. Steve Rashford is the medical director of The Queensland Ambulance Service (QAS) with 5,000 staff and 1,300 response vehicles. In the episode Steve gives some of his perspectives of a pre-hospital careers spanning over 20 years in duration within multiple services. QAS has a contemporary approach to clinical service delivery and innovation in prehospital trauma care. It also operates a tiered system of pre-hospital care with Advanced Care Paramedics (ACPs), Intensive Care Paramedics (ICPs) and a smaller cohort of HARU Paramedics. In this episode we discuss a variety of topics: High Acuity Response Unit (HARU) both its inception and the clinical remit for the HARU. Governance around the HARU program and provider quality assurance for some of the procedures (RSI, on-call advice, blood products and the bleeding patients). Quality improvement and where the program is heading The lessons learnt building the HARU and ICP schemes in QLD. I hope you enjoy this episode as I found it both insightful and helpful to look at how other systems approach high performing teams and continuous improvement. Please feel free to reach out to me at eoinwalker@hotmail.com as I always welcome feedback.