I had never really had an urge to work in the prehospital environment, I’ll be honest. As someone scared of flying the idea of helicopters did not appeal and on the whole I was quite happy in my temperate, well-lit resuscitation room with fabulous ED nurses and many hands to help look after the sickest patients.
Applying for Sydney HEMS does seem like an unusual step, then – so let me explain my reasoning.
Firstly, this service has an international reputation for its commitment to medical education – induction training now attracts delegates from all around the globe including other HEMS services, eager to benefit from the combination of simulation, reflection and discussion with respected experts in prehospital care. As a medical education
geek enthusiast I wanted not simply to be trained by the service but also to look at what it is they are doing that works so well – this informed my talk at smaccFORCE (link below).
Secondly, I’m scared of quite a lot of things and to be honest I really wanted to get over the flying thing.
Thirdly, as an ED physician, we often take for granted the conditions our prehospital colleagues work in and what care is reasonable to deliver under those circumstances. We see only the patient and their illness or injuries; we do not see the cliff face, the ocean, the drunk relatives, the baking sunshine, the pouring rain. I definitely needed a little humility in this regard.
So off I went, in January 2016, to commence a year of prehospital and retrieval medicine with New South Wales Ambulance Service at the rescue helicopter bases in Bankstown, Wollongong and Orange. Here are the things I’ve learned in the last 12 months – about education, human factors, clinical retrieval medicine & critical care, self-care, leadership and life itself 🙂
It’s been a crazy, intense and fun-filled year.
Part One – Education
Many of my reflections on medical education are captured in my talk at #smaccFORCE at #smaccDUB: Bringing the Outdoor Classroom Indoors (you can watch the video of the talk or find the podcast version below). These are summarised in my learning points below.
Knowing your team is focused on your safety first and foremost means you can do the scary stuff. As someone scared of flying, the idea of winching out of a helicopter (which I had come to think of as quite a safe place) was even more counter-intuitive. The only way I could do that was by trusting our aircrew. This picture is me – halfway up a 250ft winch with a patient in the stretcher. We regularly practice “static” winching in either the winch simulator or the helicopter itself. To date I have been winched out for real three times – in each case I’d practiced static winching with the aircrewman who was operating the winch at the time and I can’t tell you how much this helped me to trust them.
Train with your team
Training alongside the people you are going to be in tough situations with builds a rapport you will want to fall back on, flattening hierarchies and creating safer and more effective teamwork. In addition to induction training, we use simulation to explore clinical scenarios with the paramedics with whom we work closely – there are so many occasions I have been reliant on the paramedics to flag issues to me when we’ve been looking after patients. I want to work in a team where someone says “hey, did you mean that?” or “do you think we should consider…?”
Rehearsal leads to readiness
Prioritise common, risky and important situations for training so that when you do them for real, you are as ready as you can be. One of the focus points of induction was life, limb and sight-saving procedures – when I was tasked to retrieve a patient with impending airway obstruction, I felt ready and, even though we didn’t ultimately need to proceed to surgical airway, I was ready (and so was the patient – consented, site marked, topicalised, positioned, equipment laid out…!).
High risk procedures might be high risk for the patient – or for you
Both need investment of your time. We have less exposure to high risk procedures in hospital but even if we don’t work in the prehospital environment we should appreciate that our prehospital colleagues are often in very risky situations.
What are the risks to YOU, in-hospital? These may be related to violent or difficult patients – have you invested time for training in de-escalation techniques?
Everyone offers something you can learn from
The service I’ve been privileged to work for has some staff who have been working as paramedics since before I was born. They know absolutely bucketloads about all sorts of things. Having an open mind about everyone you meet will massively enhance your educational experiences – everyone can teach you something.
Train Across Domains
Training across domains – as per Bloom – is more memorable and more likely to stick – induction embodies this. Is there a way you can do this in your service?
Non-clinical needs matter too
When welcoming new staff, consider their non-clinical as well as clinical needs – how can you help them slot into your service? There’s a strong focus on human factors training in the service – is this something you need to allocate some time to in the Emergency Department?
Governance culture matters
As a boss, set the tone. As a trainee, be involved. Believe in a collective responsibility for service development and improvement. You can find out more about the Clinical Governance Days here on the SydneyHEMS website. What’s in your clinical governance day? Is it open to all to contribute and learn in a non-judgemental environment?
Sometimes cases are tricky
There’s an enormous amount we can learn from talking about specific cases. This is one of the huge challenges of the FOAM movement – it’s difficult to anonymise sufficiently to maintain confidentiality without losing the details, but your local service can set up from this (Schwartz rounds are a good example). You can learn from what has felt difficult or uncomfortable – mature services recognise this and discuss without judgement. This builds and equips all team members, not just those who were there.
We are big fans of celebrating A&A at St Emlyns. I’ve learned, however, that this means allowing yourself to be celebrated. At a recent job members of the public stopped to tell us how much they appreciate the work we do. It’s a natural British trait (and one found in many women everywhere) to try to diminish such compliments. Don’t. Learn to absorb them and say thank you.
Reflection is healthy
The contents of these lists have come from a reflective notebook I started back in February to help me learn from the various missions I’d been involved in. I’d advise you to reflect regularly and formally in some form [I think I’ll write a post on this soon]. Facilitated reflection, as we undertake in weekday “coffee and cases” sessions, is particularly useful.
Design simulation based on outcomes
In planning sim, consider what exactly you want your team to achieve, learn or reflect on. Start from there and find the clinical scenario to fit, not the other way around. It can be tempting to start from “this is a really cool case… what if this happened too?” but there’s no point in this approach unless the team develops from it in a coherent way. The tremendous Clare Richmond has a sim scenario pro forma we use – I’ll ask her if she can make a generic version and link to it here.
Make a sim scenario bank
Building a bank of simulation scenarios helps sustainability of your simulation practices, particularly if you have rotating staff (as most EDs do). We use Google Drive for this – it’s a useful way to share documents.
Post sim team debrief matters too
As well as debriefing the sim participants, it’s important to debrief the sim team on the scenario itself. Did it work the way you expected? What would you do differently next time? Our burns sim turned out quite differently from the way we had originally planned it as part of its natural evolution – this was definitely worth discussion and the initial scenario plan sheet was changed to reflect the learning points we’d identified in the context of running the sim itself.
Coming next: Part Two – Human Factors
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