It’s conference week, and although we started it in Birmingham with the Intensive Care Society State of the Art, we’re now in London at the Royal Geographical Society for the London Trauma Conference.
This blog has the key messages from Wednesday’s pre-hospital care conference, and there will be another covering the final two days.
The opening session was all about cardiac arrest. Pre-hospital end-of-life decisions are a huge issue, made all the more difficult as these are patients we’ve never met before, often with unknown medical issues and unknown views on resuscitation. Espen Fevang recommends a pragmatic view, choosing to start CPR whilst gathering information. You can always stop, however from his experiences you’ll regularly be criticised no matter what you do, so go with your gut and document your decision-making thoroughly.
Laurie Morrison started her talk on ROSC with a reminder to do the basics well. Effective chest compressions, early defibrillation and use of end-tidal CO2 monitoring. She has done a huge amount of work mapping cardiac arrests in her city of Toronto in order to try to give people the best chance to survive through education and research.
One point that caught my interest was that high-rise buildings are a particular problem and a study in 2016 by Drennan showed greatly decreased survival from cardiac arrest above the 16th floor, and no survival above the 25th. This led to defibrillators being placed in the lifts rather than the lobbies to make access easier. Further data in Toronto allowed mathematicians to model the best places to put AEDs.
The intraosseous approach is becoming more frequently used, but does it actually make a difference? It’s hard to know. Jerry Nolan took us through the data, which show that the humeral route is more effective at delivering more drug centrally at higher concentrations (in animal models). Unfortunately the tibial route is more commonly employed in practice, so (human) observational studies suggesting better patient outcomes with IV over IO are difficult to interpret, as maybe we’re just using the wrong IO site… In his view, there is still clinical equipoise when it comes to IO vs IV, so just use what you can get, as long as you’re sure it’s in the right place.
It’s not a real pre-hospital conference unless there’s a French clinician from SAMU Paris talking about ECMO, and in true fashion Lionel Lamhaut was here to oblige. Along with the usual photos of ECMO alongside works of art, he also discussed the algorithms they use to determine whether ECPR is the right intervention to use; the main indication for which is whether the patient has signs of life such as breathing or movement at the time of the decision.
We had two great talks on the recent events in Salisbury and then how the fire service respond to major incidents. Of course a lot of the material presented was sensitive and won’t be discussed here, however there were some good general points to learn from.
Pre-hospitally we use the STEP 1-2-3 Plus system for patients incapacitated for no obvious reason, and it’s important to remember to do this for patients who arrive in our emergency departments as well. Don’t forget that those three patients arriving separately by ambulance may have come from the same place, been exposed to the same environment, and potentially have something unusual going on. Listen to the handover, ask questions, and do consider that this isn’t just the usual drink or drugs.
One of the learning points from recent major incidents, and in particular terrorist attacks, was to ensure a reserve of resources is kept as one attack is likely to be followed soon after by another. It’s important to ensure that you don’t send all your personnel and equipment to the first one, and this can be a hard thing to do, not just for those in charge, but also those on the ground who want to go and help. The balance between ensuring safety of responders vs a desire to get in there to save lives is also a difficult one with no easy answers in such dangerous situations.
Tracy Appleyard gave one of the best talks I’ve seen here at LTC, combining exceptional humour with fantastic clinical content. She took us through the response to obstetric emergencies both pre-hospitally and in hospital. Key points from her talk:
- All women are pregnant until proven otherwise
- Pregnant women compensate well then crash quickly
- Get help quickly for that MDT approach
- CABC primary survey in trauma
- Displace the uterus – manually, not with a tilt
- Sim with your obs/gynae teams so you’re prepared before that complex trauma comes in
Finally, Stephen Hearns took us through pre-hospital communication. There are so many cognitive and practical problems that cause overload in a pressured environment.
But how do we overcome this? There are a few techniques that we can employ, such as using physical contact to break that focus. Pausing before you give information to ensure concentration. Using defined key words, repeating what you’ve said, and closing the loop with two way communication.
Just being aware of the issues that exist can help to identify these and overcome them.
A good day in the RGS, see you again for the LTC proper!