Pre-Hospital Care Podcast

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. 

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.