Ambulance Today Autumn 2012 by Declan Heneghan

Autumn 2012 - Issue 4 | Volume 9

TODAY

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SEE INSIDE FOR WORLD EXCLUSIVE REPORT ON ARCTIC COUNCIL SAREX 2012 MEDEVAC EXERCISE Produced in partnership with

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Large-scale Medevac Needed in the High Arctic Could we avert a 21st century Titanic-type catastrophe in the world's coldest waters?

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A Titanic Undertaking! Declan Heneghan Editor, Ambulance Today

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Welcome to the Autumn 2012 edition of Ambulance Today.This issue leads with a special feature on a highly-unusual military/medical exercise which took place recently in the High Arctic which I was lucky enough to take part in – SAREX 2012, an ambitious attempt to see what response could be mounted in the event of a Titanic-style shipping accident in the remote High Arctic region. As the only non-military journalist invited to participate in this ambitious medical evacuation exercise in one of the world’s most challenging environments this was a great opportunity to see at close-range how different countries can work together in the event of a major incident. However, despite the fact that this project allowed me a rare opportunity to do such exciting things as sleep under canvass in the Arctic, travel on a C-130J Hercules military aircraft and sail down a fjord on an Icelandic tug-boat with Lynx helicopters zooming by overhead, I can genuinely say that by far the most interesting element of the trip was witnessing the good-natured cooperation displayed by a varied group of medics who were passionately-focused on finding out whether or not they could deliver high-levels of clinic care in what, in a real life scenario, would be about as testing a situation as one could possibly imagine.

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Led by the almost implausibly calm and unflappable Major Lasse Brinck, the Royal Danish Air Force’s 690 Medical Evacuation Squadron flew out from Aalborg Air Force base in Jutland, Denmark to see how they would cope if tasked to provide medical care to the crew and passengers of the Arctic Victory, a Danish Inspection frigate, especially renamed for the ocassion, with a manifest of 160+ cheerful Greenlanders onboard, who themselves travelled a week by boat to perform the role of ‘casualties’ for the exercise. The primary mission objective was to see how effectively medics from the eight Arctic Council nations could treat large numbers of potentially severe hypothermia victims who, as the scenario dictated, had been trapped on a stranded vessel in the chilly Arctic waters for 24 hours before being extricated for treatment. My own invitation, which ironically landed in my email tray while I was sat enjoying an alfresco breakfast during my annual August holiday in the 40°C heat of Northern Greece, came about through my good friend, Professor Sir Benedict Kjærgaard, a world-leader in the treatment of hypothermia, whose own team of hypothermia specialists, were an invaluable asset for the exercise. With vague daydreams of polar bears, the Northern Lights and huskies howling to the Moon, saying ‘Yes’ wasn’t difficult – especially since I was comforted by the reassurance given in my invitation that: “In September, it isn’t too cold in the High Arctic – temperatures don’t usually drop below -10 °C.” Well, let me tell you that 10 °C is plenty cold enough when you’re sleeping on a

groundsheet with a tent-flap slapping against your head in a high wind! All of which I honestly don’t mention to grumble. Anyone miserable enough to grumble about slightly rough sleeping conditions when given such a once-in-a-lifetime opportunity, deserves to be dipped in jam and left standing in a beehive for an hour or two. No. I mention this because, as so often can happen in life, the most memorable aspect of this truly ‘Boy’s Own’ adventure came not from witnessing the astonishing medical evacuation exercise at close quarters – though I hope you’ll agree after reading my report, that the team really did do a brilliant job – but from meeting the truly amazing and very modest guys whose job it is to spend 12 months at a time living on the barren and remote station Mestersvig in a two-man team, who acted as our hosts while we stayed there, setting up and running the squadron’s casualty staging unit. Mestersvig is literally one of the remotest inhabited places on earth and only exists because the Danish government needed one decent-sized landing strip to fly in supplies for the numerous mining teams that have worked in the region for decades. It is usually run by just two men who put in a 12 month stint together, including through the deepest winter months, simply to keep the landing strip operational. It was my deep honour and great fortune to spend a bit of time with these guys – Leif, Kim and Aksel – and let me tell you a more interesting and impressive group of people you’re unlikely to ever meet. Living in such conditions takes an amazing range of high-level practical skills and an even more amazingly strong mindset. So impressed was I by their life and work that I couldn’t resist writing up a special report on what they do and how they survive their living conditions. So, although not strictly speaking an ambulance or prehospitalrelated article, I hope you find time to read my report on life in Station Mestersvig. If you do, you’ll never again moan about digging your car out of snow on an early January morning! All that remains is to thank the wonderful men and women of Squadron 690 for letting me share their exceptional experiences during SAREX 2012 and, of course, to offer you my usual reminder – especially as we’re now in the interminably long run-up to Christmas, to please remember your own special ambulance cause, the Ambulance Services Benevolent Fund (ASBF). Details on how to make a preChristmas donation by text can be found on the left of this page so please text them a fiver and help them make Christmas happier for one of your workmates who may need a helping hand as winter draws in! Warm wishes, Declan Heneghan Editor, Ambulance Today

EDITOR: Declan Heneghan email: editor@ambulancetoday.co.uk CORRESPONDENCE: All correspondence should be sent to: The Editor, Ambulance Today, 41, Canning Street, Liverpool L8 7NN DESIGN & PRODUCTION: Wordplay Graphics email: mark.mcalister@merseydocks.co.uk FOR ADVERTISING ENQUIRES CALL: +44 (0)151 703 0598 OR +44 (0)151 708 8864 COPYRIGHT: All materials reproduced within are the copyright of Ambulance Today. Permission for reproduction of any images or text, in full or in part, should be sought from the Editor. PUBLISHER’S STATEMENT: Ambulance Today magazine is published by Ambulance Today Ltd, 41 Canning Street, Liverpool L8 7NN. The views and opinions expressed in this issue are

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not necessarily those of our Editor or Ambulance Today. No responsibility is accepted for omissions or errors. Every effort is made to ensure accuracy at all times. Advertisements placed in this publication marked "CRB Registered" with the organisation's "CRB Registration No." means that the Organisation/Company meets with the requirements in respect of exempted questions under the Rehabilitation of Offenders Act 1974. All applicants offered employment will be subject to a Criminal Record Check from the Criminal Records Bureau before appointment is confirmed. This will include details of cautions, reprimands or final warnings, as well as convictions and information held by the Department of Health and Education and Employment.

August 2012 | Ambulancetoday

Volume 9, Issue 4: October 2012 Next Issue: December 2012

CONTENTS

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I N S I D E YO U R A U T U M N I S S U E P7 - Mayday! Mayday!

P39 - Dutch call to honour fallen colleagues

Find out about SAREX 2012 a unique air and sea medical evacuation exercise in the High Arctic designed to test whether medics could deal with large numbers of severe hypothermia casualties

Our Dutch correspondent, Thijs Gras, launches an appeal to fund a memorial for Dutch ambulance workers who have died while on duty

P28 - March with us for a future that works UNISON’s Hope Daley invites you to march for a future that works

P31 - Optima Predict™ brings significant savings for South Central Ambulance Service Optima yielded operational savings of £400K for SCAS. Find out how

P33 - Is the Precordial Thump an endangered skill? Sophia Rozario reviews the history and use of the Precordial Thump and Precordial Percussion, discussing their origins and likely effectiveness as CPR strategies

College of Paramedics CPD Workshops Visitors to the Emergency Services Show, Stoneleigh Park this year will have the chance to build on personal development by attending the CPD accredited workshops that are being held by the College of Paramedics. Two separate areas will focus on different ways of learning; Area 1 offering a hands-on practical workshop and Area 2, lecture style presentations. Taking place over the two days of the show, each session will be free to attend and will last 20-30 minutes. CPD Certificates will be available for those attending. The topics covered include:

P40 - Help promote your ASBF charity In the run-up to Christmas ASBF Chairman, Paul Leopold, encourages all ambulance staff to become fundraisers and PR campaigners

P41 - It’s time to overhaul our EMS payment system! Our American correspondent, Jerry Overton, offers a beginner’s guide to the complexities of US ambulance funding Also Inside:

P42 - Out & About The latest news from services around the UK

P46 - Products & Suppliers News Latest in new products, services & technology

Picture supplied by Edge Hill University

Day 1 – Trauma Care Extrication Basic life support Primary assessment and triage Spinal immobilisation – pelvic splint demonstration Day 2 – Pre-hospital Care Emergency childbirth Management of minor injuries Diabetic emergencies Mental health

Registrations for the workshops will take place at the show so please visit the College of Paramedics Demonstration Area in Hall 2 to sign up. For more information on how to become a member of your professional body you can also visit The College’s promotional stand which is E71. To register to attend the Emergency Services Show visit their website www.emergencyuk.com

Focus on SAREX 2012 Medevac Exercise in the High Arctic

“Mayday! Mayday!... Large-Scale Medevac Urgently Required in the High Arctic!” Declan Heneghan reports on a unique medical and military first – SAREX 2012 - a two day air and sea medical evacuation exercise involving the eight member nations of the High Arctic Council, which took place in mid-September off the Eastern coast of Greenland. Two years in the planning and at a cost of £15M, the daunting mission objective was to see if a stricken vessel with an unknown manifest of crew and passengers could be medically evacuated as quickly as possible in a region where temperatures can plummet to -70 °C in deep winter and travel time to the target site can take up to 8 hours even by air. It’s just over a century since the Titanic sank on the 14th April 1912 with the loss of 1,517 lives. Yet, amazingly, until just a few weeks ago, no nation had launched a large-scale rescue exercise to ensure that a similar catastrophe can be averted in the event of a shipping accident in the sub-zero waters of the High Arctic region. All that changed on 12th September 2012 when a combined rescue force, led by Greenland Command and comprised of six of the eight nations making up the Arctic Council mounted a unique training exercise in the waters off Ella Ø, a small island on the Southern coast of East Greenland. Supported by Lieutenant Colonel Sir Benedict Kjærgaard, Medical Lead for the Royal Danish Air Force’s Sea Air Rescue arm, who is Lieutenant Colonel globally recognized Sir Benedict Kjærgaard as an expert on the treatment of hypothermia, the evacuation exercise would include two members of his team from Aalborg hospital, as testing whether or not his treatment techniques for severe hypothermia victims would work in such a harsh climate and seeing if their medical equipment could function effectively in severe Arctic conditions was a key objective of the exercise. August 2012 | Ambulancetoday

The Distress Signal: At 04.05 hrs zulu time on Wednesday 12th September a distress signal was received in the Situation Room of Major Lasse Brinck Air Transport Wing at the Royal Danish Air Force base in Aalborg, Jutland by 46 year old Major Lasse Brinck, Commander of ESK 690 Medevac Squadron. The information received was scant, stating only that an unidentified vessel in coordinates 72°512 N 25°002 W was in extreme distress and that a full-scale medical evacuation was required – Casualty numbers were unknown but the vessel was reportedly stranded in waters off Ella Ø

[Danish word for ‘island’], a small island, at the mouth of Kempe Fjord in the northern end of King Oscar Fjord, some 200 kms off the Eastern coast of Greenland and around 60 km North off Mestersvig, a small military station with a 1,800m gravel runway and the only airstrip in the entire region capable of landing a fully-loaded C-130J Hercules transport aircraft. 690 Squadron must depart for Mestersvig immediately, with all transportable medical equipment and supplies. Their Hercules aircraft would be carrying the squadron’s medical module, four large pallets of medical supplies and all other provisions needed by their specialist team of 19 medics for the anticipated 48 hour exercise. On-board would be one third of the squadron’s full medical complement, all those who the squadron’s records showed were immediately available for rapid deployment.

Focus on SAREX 2012 Medevac Exercise in the High Arctic

which, due to the limited number of medical personnel on-board – only five (consisting of one doctor, two nurses and two flight medics) – means that while they could transfer a higher number of grade ‘2’ (lowrisk stabilized casualties), realistically, because of the intensity of stabilization care required by the more urgent grade ‘1’ (most severe casualties), it wouldn’t be possible to transport more than three severe casualties. Leader of AE Team - Flight Medic, Allan Fuglsang

Major Brinck returned to the hangar, where his unit had bedded down for the night in sleeping bags, after a day checking and loading medical supplies in readiness for a call-out, and instructed his Squadron to reset their time-pieces to ‘Zulu time,’ the Universal time coordination employed by military forces globally, and preparation for immediate departure began. The team structure: Working in conjunction with Major Claus Lie, Medical lead for the squadron, but unavailable to participate in this evacuation exercise, Major Brinck assesses the medical skills available to him for the exercise and, taking into account the number of doctors, nurses, paramedics and flight medics available to him and their respective individual specialist skill-sets, he organizes them into three teams which, together, form a chain of medical care for the evacuation process. His priority is to utilise the ‘medical assets’ at his disposal as efficiently as possible in order to achieve the exercise ‘s specific medical objectives while supporting the overall exercise objectives. With four doctors, five nurses, four flight medics and six paramedics, each with a specific medical speciality ranging from anaesthesia to trauma care and, vitally important for this exercise, hypothermia care, the objective is to ensure that from the moment of arrival chains of treatment and information can be established which will, with the assistance of the various logistical and military teams who will also be on-scene, ensure that casualties can be safely evacuated from the target vessel, transferred to a CSU (Casualty Staging Unit) which will be established close to the Mestersvig landing strip, continue treatment and either discharge or stabilize casualties, and finally, effect the long-haul evacuation of any critical casualties to the nearest receiving hospital in Keflavik, Iceland.

The Mobile team – their role is to work at the target site, providing immediate medical treatment to the casualties once they have been safely removed from the target vessel and then organizing their transfer (complete with available but brief medical notes) to the Casualty Staging Unit. Leader of Mobile Team - Paramedic, Johan Brus Mikkelsen The CSU team – their role is to use the more extensive medical resources and equipment in the CSU to administer more complex care to casualties and, in the case of critical cases, prepare and stabilize them for the lengthy (C4 hour) air transit to the receiving hospital in Keflavik. Leader of CSU Team - Paramedic, Jesper Ægidius– The Medevac team – their role is to transfer critical patients to Keflavik while continuing treatment en route. Using the C-130J they arrived in they will have access to the Mobile Medical Module which has stretcher space for up to 12 patients but

The main exercise objectives for SQN 690, were to: * Deploy a full chain of medical evacuation capability (forward air evacuation, casualty staging unit and air evacuation to major hospital) from this remote arctic location. * Achieve effective evacuation operations and cooperation between nations and other involved units. * Achieve effective medical support and cooperation between nations and other involved units. * Achieve effective use of air capabilities for medical evacuation Outward flight to Mestersvig: Just two hours later at 06.05 hours Zulu time, after quickly loading their fully-stocked Medical module, the size of a typical A&E ambulance body, four pallets of additional medical equipment and two pallets of kit and rations, the squadron departed. Also on board were five members of the Danish Emergency Management Agency(DEMA) tasked with the search and rescue of the target vessel. Using small zip watercraft, capable of transporting up to eight passengers, their role would be to use sonar listening technology from outside the vessel to ascertain the conditions onboard and to try and determine how many casualties were inside.

August 2012 | Ambulancetoday

Focus on SAREX 2012 Medevac Exercise in the High Arctic

They would work with Canadian Air Force parachutists, who were to be air-dropped directly on to the vessel, and assist in the evacuation from the vessel to dry land. Conditions inside the aircraft are, as you would expect, not quite as comfortable as on a commercial airliner. Only about a third of its 97 ft length was set aside for seating of passengers and this was divided into two sets of facing benches divided by a framework of hooks and supports, upon which were hung kit bags, life jackets and back-packs. To the rear of this double row of cramped benches in the central position were four elevated stretchers which, as the flight progressed, gradually became occupied by people sharp-eyed enough to spot the opportunity of a good lie-down and the possibility of 40 winks. The middle section was taken up by the looming presence of the Medical Treatment Module, which, being fitted with lighting, was busy throughout the transfer with medics checking on stocks and equipment or, again, taking advantage of its stretchers to grab cat-naps. Then, at the very rear of the craft, was the main cargo hold, containing a tightlyAugust 2012 | Ambulancetoday

strapped set of pallets wrapped in webbing, with a jumble of hefty medical chests, layers of kit-bags and sundry other supplies. Capable of storing a maximum payload of 34,000 pounds, or six large pallets, while still flying a maximum range of 2,071 miles without refueling, it’s even possible to transport a small utility helicopter or a sixwheeled armored vehicle in its hold. However, the cost of such power is that the noise of its four enormous Rolls Royce turboprop engines, each with 4,700 horsepower, is thunderous, making ear-plugs essential and normal conversation virtually impossible. Spotting C-130 frequent-flyers is easy as they sport flashy, hi-tech headphone mufflers which completely eliminate noise but make conversation amusing as they have a tendency to shout rather LOUDLY! The flight, manned by Captain Jesper Kristensen and two Co-Pilots, Steffen Bo Jensen and Christine Plenge departs. Flying at 24,000 ft, some 10,000 ft lower than civilian aircrafts, and after a short 45 minute re-fuelling stop at a Naval base in Keflavik, Iceland, it reaches Mestersvig at 14.00 hours Zulu time. The total flight time was 8 hours and the distance covered was 1,577 miles.

Arrival and Set-Up: Mestersvig is 42 miles south of the target site, Ella Ø, and it was here that 690 Medevac began to equip a large three-tent CSU – Casualty Staging Unit – which had been quickly erected for them by Ice-SAR, the highly-respected Icelandic international Association for Search and Rescue, who had themselves arrived on an American C-130J only minutes earlier and who were already engaged in installing power supplies and heating as well as other specialist requirements such as feeds for oxygen and other medical gases likely to be needed for treatment. Major Brinck set his team to unloading key medical equipment, assisted by a heavy-duty loader to speed up the process of transporting the equipment on pallets, direct to the CSU location. Accompanied by Captain Michael Treschow, a Doctor and anaesthetist specialist, he headed straight for the station’s own small Command tower to set up a command centre with radio comms to immediately coordinate helicopter and boat transport to the target site so that casualties could be airlifted back

Focus on SAREX 2012 Medevac Exercise in the High Arctic

Medic with thirty years Air Force and prehospital medical experience. Working from the Medical Centre at Aalborg in Jutland, the home of 690 Squadron’s Medevac team, Claus oversees the procurement, maintenance and strategic planning needed to ensure that the Medevac team can fly out fully-equipped for whatever mission they are given, with only a couple of hours notice and sometimes even less.

the full-scale receiving hospital at Keflavik which Michael was acutely aware was also on stand-by and would be waiting for clear information on how many casualties they were likely to receive some hours down the line. Although 505 miles away from the target site Ella Ø, with its Naval base and a small population of 15,000 people, Keflavik was still the nearest fully-equipped hospital to the target site, capable of treating the as yet unknown number of casualties due to pass through Mestervig’s CSU. Medevac Preparation and General Logistics: Even before Major Brinck receives a Mayday call his Squadron, as always, has in place a rigid and proven protocol that allows them to respond with the utmost speed to an instruction to deploy. to the CSU for stabilization before the most seriously injured would be evacuated on the C-130J onward to Keflavik Naval Air base before being transported on to Reykjavik for full treatment. Michael was tasked with gathering accurate clinical intelligence by radio to analyse and then pass on to the CSU team leader, Flight Medic,Jesper Ægidious, to help the CSU medical team determine triage priorities and identify what medical resources might first be required when the first wave of casualties arrived. He was understandably keen to get down to works, but a major problem emerged – no radio link had yet been established between Mestersvig control and the target site, despite the fact that the plan had been to set up a radio link with one of three Danish and Icelandic vessels that had recently arrived on-site and which were anchored less than half a kilometer away from the target vessel in thankfully calm waters. The lack of radio comms also created a potential problem in establishing a link with August 2012 | Ambulancetoday

ESK 690 Medevac Squadron is a unit comprised of medics from all backgrounds, a mix of full-timers and reservists, who can be called upon at a moment’s notice and rapidly deployed to any war or crisis zone across the world. In recent times they have provided medical support to the British army in Afghanistan and the Balkans and medical aid to civilian victims of the conflict in Libya. The squadron is twinned with the Air Transport Wing of the Royal Danish Airforce, which makes good sense, as in order to provide medical expertise in adverse situations, they face the logistical challenge of maintaining and transporting vast amounts of sensitive hi-tech medical equipment around the globe and ensuring that they can put them to use immediately in hot-spots, regardless of whatever environment they find themselves in and usually without any immediate fixed source of power. The person responsible for ensuring these daunting logistical challenges can be met is Lance Corporal Claus Larsen, a Flight

I asked Claus what the equipment manifest for this exercise included and how long it took to ensure that his own ‘make-ready’ procedure was in place, in order to allow the squadron to scramble at a moment’s notice. “As soon any mission is completed, my first task is to audit what has come home with our medical team. Obviously some disposables will have been used and will need replacing. All items need checking to make sure that they are operating properly and haven’t suffered any damage during transit and, as will probably happen during this exercise, we often find that some equipment has been left behind and we need to ensure that it is recovered as swiftly as possible, unless it has been left for continued use in the field.” Claus continues: “ The most likely reason for leaving equipment behind – usually cylinders and other heavy units – is that the return flight manifest has taken on extra passengers and, of course, it isn’t safe to try and fly overburdened, so we then plan to recover our equipment at the next opportunity.” As for equipment, Claus explained, “ It usually takes about three days for me to carefully audit and check the assets that have returned and to replenish any items that need replacing. Once this has been done, it will take another day to repack them within the module and onto pallets, so that they are all ready in the hangar for the next mission. Occasionally, when we are preparing for an exercise, the squadron medic members involved will assemble 24 hours before and actively participate in the preparation. This is very important as it not only familiarizes them with what assets we have and where they will be stored, but it means that they have a clear idea of where things can be found when they arrive so that the unpacking and set-up process can take place quickly and effectively. This is particularly important since my role is a supporting one and I don’t fly out with the Squadron, so it’s necessary they have a clear idea of what assets are needed and what they are taking with them. It’s also a vital opportunity to ensure that small but essential items are not overlooked. If you’re

Focus on SAREX 2012 Medevac Exercise in the High Arctic

dimensions, by the way, were arrived at purely to ensure that it would fit snugly into the hold of a C-130 . From the outside it looks like just another freight container, but yank open its heavy rear door and you’re entering a tight but completely workable treatment space. And, as I saw in the early morning light, when the unit was scrambled for its flight to Mestersvig, with the help of a full-scale military hoisting unit, it can rapidly be lifted from its storage place in the hangar, driven the few hundred metres to Aalborg’s massive military air-strip and slid securely into the cavernous hold of a C-130J Hercules! For the record, I timed it, and the whole operation took just eleven minutes – not much longer than is needed to stock up an A&E ambulance before the start of a busy shift!

in the High Arctic, you can’t simply pop next door to a stock-room for a pair of scissors or a blood pressure cuff. You either have them, or you don’t!” For this exercise the squadron was also detailed to supply real medical back-up in the event that it was required so the major medical items to be taken included:16 syringe pumps, four Lifepack 12 defibrillators with surveillance monitors, six Oxylog ventilators, eight Propacs, 50 Stretchers, three large transportable medical bags containing a variety of prefilled ampules. Drugs carried include morphine and other strong pain-relief drugs, Fentanyl for anaesthesia and, since there is an expectation that there may be an unknown number of smoke-inhalation casualties, also Acetylcysteine, a drug which breaks down mucus and lubricates vital organs, such as the lungs. But as Claus explains: “This is only some of the equipment and drugs that we bring along. The hypothermia team from Aalborg hospital and ICE-SAR, the Icelandic logistical support team, will each bring along additional medical equipment and drugs.”

then, of course, there’s our Medical Treatment Module.” The module Claus is referring to is the crowning glory of the Squadron - a vast 3,000 Ibs unit, similar in appearance to the kind of temporary shell unit you see on building sites. The only difference is that this 6 metre long, 2.5 metre wide and high, strengthened medical storage unit, comes complete with 12 stretchers, customized cabinets for the storage of everything from syringes to stethoscopes and full hygienic wash-up facilities. Since the stretchers can be removed, although space is tight, it’s even possible to undertake invasive operations in its relatively confined space – though, as Dr Ulrik Edelmann, one of the squadron’s doctors, stressed: “Of course this would only happen under the direst circumstances.” Commissioned and designed by the Royal Danish Air Force’s Medical Corps in 1992 in response to the medical evacuation needs identified in the first Gulf War, the module, one of just four ever built, is a truly unique one-off medical treatment space. Its

Among the anaesthesia, pain killers and relaxants taken along were Dehydrobenzperidol (2,5mg/ml and Amp a 2ml), Haldid/Fentanyl (50mikrog/ml, Amp a 2ml and Amp a 10ml), S-Ketamin (25mg/ml and Amp a 2ml), Pentothal-natrium (subs,0.5g), Rapifen (0,5mg/ml and Amp a 2ml), Propolipid (10mg/ml and Htgl a 50ml), (Driprivan 10mg/ml), Dormicum (5mg/ml) and Midazolam (5mg/ml and Amp a 1ml). The Mobile Team Overview: Johan Brus Mikkelsen, a Paramedic from SQN 690, led the Mobile team that flew in to Ella Ø on a twelve-seat, twin-engine Otter fixed-wing aircraft only moments after landing at Mestersvig. His team’s function was to immediately move onward to the target site, assist in the transfer of casualties from the target vessel to dry land, triage them and ensure that, according to medical priority, they were moved onward to the CSU at Mestersvig for further treatment, stabilization if required, and, in the most serious cases, full medical evacuation onward to Keflavik’s General hospital. Camping by the water’s edge overnight, by the second day Johan and his team of one

For Claus the work supporting each mission or exercise is an ongoing task – the medical equivalent of painting the Forth Bridge, but with stricter infection Lance Corporal control requirements. Claus Larsen “It’s my job to order all medical materials required and to make sure that the team is properly equipped and resourced for the duration of each mission – everything from uniforms, sleeping bags, kit bags and rations must be prepared. And August 2012 | Ambulancetoday

Focus on SAREX 2012 Medevac Exercise in the High Arctic

knots per hour, the sixty-plus Km journey up King Oscar Fjord takes over four hours. The other bonus however is that, in daylight hours especially, so long as you are not seriously injured and in urgent need of medical care… the views are stunning! The medical view from the Command Tower Captain Dr Michael Treschow, who assisted in the command post also worked as part of the CSU team, explained: “I think we were all amazed by this exercise as none of us have had the experience of being quite so far away from our usual medical facilities. The target area was so remote. Libya gave us some experience of transporting large amounts of medical equipment but here we also had to set up quickly and find out how effectively we could do our job in a remote location. The experience of learning how to work with logistical partners like Ice-SAR was also really useful for us as, in a real-life scenario, working out what should go where and what medical equipment should be powered up first, can determine the effectiveness of the whole mission. I had the opportunity to receive and treat a few patients in the CSU during one particularly busy period and, looking back, we could always wish for more space and manpower. But, thankfully, we successfully treated all the casualties that came through. One wonders though whether, if we had to sustain a patient flow for 24 hours, we could manage to handle a high-volume of patients in this environment. We physically treated about 26 casualties over both days and that in itself was a big strain on our manpower.”

doctor, Rene Bleeg, one nurse, Martin, and two other paramedics, Johnnie and Michael, had processed 162 casualties, including three ‘severely injured’ and a high number of level ‘3’ ‘non-injuries’ which they sent forward to Mestersvig at a more leisurely pace by boat, on the nearly brand-new August 2012 | Ambulancetoday

£29M Icelandic Tug-boat, Thor, which, having travelled on it, I know to be about as warm and comfortable a transfer as it is possible to enjoy. With comfortable seating and restaurant quality hot food available for over 200 passengers if required, the only downside to this mode of travel is that at 7

Michael added: “Throughout the exercise our focus was on initial treatment and stablilization so that casualties could be evacuated as soon as possible. I’ve no doubt though that in a real-life situation and in more adverse weather conditions – snow, much lower temperatures, harsh winds… many of the procedures that we managed this time might be much harder and, in some cases, probably impossible. We’d definitely need a much bigger team. One valuable thing we learnt was that the only way to function was to put aside external factors and distractions and just do our best to focus – to concentrate as best as we could on simply giving our usual medical care – assess, treat, monitor… on with the next task, and to do this no matter how unusual the situation or challenging the environment.” Reflecting on the environment, Michael continued: “Other skills that we developed as we went along included the ability to improvise, sometimes making do with

Focus on SAREX 2012 Medevac Exercise in the High Arctic

Sarah signed a four year contract which she is currently midway through. “Joining up has been a fantastic decision and, even though it sometimes takes me away from my husband and two teenaged daughters for a period, it’s worth it as I don’t only get to keep my existing clinical skills sharp but I’m also learning new skills, such as how to deliver care in extremely challenging situations. Next January I’m doing a four month tour on attachment to the British Army in Helmand Province, where I will be using my nursing skills in an environment that I know will be testing but which will make a positive difference.”

needed to be elevated, wrapped in more blankets and also in hypothermia wraps to protect them from the cold and the wind. With real hypothermia victims, lifting them up and making them comfortable as quickly as possible would be a big priority. We learnt much of this on Day One so things went far better on Day Two. I’m sure we’ll continue to analyse and digest what we learnt on this exercise so hopefully even more ideas for improvement will come out. You realize that in such situations, noticing small things and attending to them can make a vital difference to the patient’s wellbeing.” Lessons learnt in the CSU: whatever was to hand, and to respond quickly to the environment. For example, early on when the first casualties were brought into the CSU we put the level ‘2s’ and ‘3’s’ on stretchers placed directly onto the tent’s groundsheet, at ground-level. Realizing that even though it was nowhere near as cold as it could have been, our patients were still very uncomfortable, we soon saw that all the patients on stretchers

August 2012 | Ambulancetoday

Sarah-Lynn Marshall has been a nurse anaesthetist for over twenty years and her full-time nursing experience includes cardiac, gastric and EMT at the Gentofte hospital on the outskirts of Copenhagen. “I enjoy my regular work,” she explains, “but I wanted a new challenge so when a friend told me about 690 Squadron I applied immediately.” After a five week boot camp

So how did Sarah find the SAREX experience? “The exercise was really valuable for us all in one key respect”, she explains. ”You’re faced with learning how to apply your clinical skills in a setting with a whole new set of obstacles and demands. We’ll need a chest-tube and if we don’t have it we have to find a way to get the job done anyway. Also, you have to try and predict what drugs and equipment you think you’re most likely to use but then, when you get there, you find out whether or not your thinking and planning was helpful. Anticipating the possibility of having to treat a large number of casualties suffering smokeinhalation, we brought along a particular drug, Acetylcystein, but as it happened, in relation to the actual setting, and taking all factors into account, we probably wouldn’t bring it in a real-life situation, as we learn it wasn’t the ideal drug to use.” Sarah continued: “In the same way, we brought along oxygen catheters but learnt that we’d be better off using oxygen nebulisers and masks. So this exercise was really useful in terms of allowing us to narrow down the equipment we should bring along and to learn which factors, both medical and practical, we should focus on when planning for a major evacuation. Weight, for example, is a really important factor so if you’re unsure which of two units to bring along – go with the lighter one. You also have to be very clear `about what the key drugs are that you’ll need as, once you’re on-scene, you only have those drugs available that you actually brought along. We took lots of saline for hypothermia and burns treatment and we brought along lots of Fentanyl for anaesthesia, but in fact we only needed this for a couple of patients. Logical evaluation of the type of situation you are responding to is a simple but important factor. The type of incident should dictate what drugs you bring. With an earthquake, for example, you’d anticipate lots of crush injuries and broken bones so you’d bring along more pain relief drugs. In a fire, obviously more burns

Focus on SAREX 2012 Medevac Exercise in the High Arctic

Sarah continued: “Some of the things we learnt may seem clinically insignificant, but getting the small details right can make a big difference. We had problems with the labeling of some boxes not being clear enough, making it difficult for us to find respiratory equipment. Equally, the system in place for tagging patients as they flowed through the CSU from the target site and then on to being evacuated to Keflavik could also have been improved. The casualty management system did work… but it could have been better so we were working out ways to refine it even as we were using it. Particularly with a view to improving the information flow on patients to sharpen up their treatment. When patients were being checked out from the CSU we didn’t have a reliable system in place to get the right level of patients passed on to the Evacuation team. We didn’t find a clear answer to that one but we know now that we need to work on it so that’s a ‘problem identified’. Equally, for patient identification and storage of their case information we were using a camera and then printing out info and passing these along the treatment chain. Perhaps we could have done all of this by using an IPAD?”

treatments. The scenario for this exercise led us to anticipate that lots of hypothermia treatment would be required as the casualties would have been stranded in subzero temperatures for prolonged periods. For this trip with hypothermia and smokeinhalation expected as a major theme we brought along lots of oxygen. It sounds basic but, as Michael pointed out, getting the stretchers off the ground was an important lesson and, to add to that, next time we’d definitely need to bring along a lot more blankets.” I asked Sarah what logistical lessons she had learnt? “We all agreed on one key point”, she replied. “Even on the scale of this exercise, with just around 160 potential casualties, we would need much higher numbers of August 2012 | Ambulancetoday

medical staff to cope. The numbers of medics on-scene even affects what type of drugs and equipment you should bring since, if you anticipate carrying out high numbers of certain procedures, such as hypothermia treatments, you need bigger teams, particularly for stabilizing and monitoring each patient when they are in transit. Another issue we all agreed upon was that it would have been helpful if the information flow had been better from the outset of the exercise. Lasse [Brink] did a good job of briefing us clearly throughout but since there was a radio comms problem from the start and throughout from Greenland Command we were working in the dark on casualty numbers and weren’t being told clearly when casualties would arrive, or what to expect when they did.

Sarah also recognized that working under pressure with unfamiliar workmates also brought other problems not usually encountered in the hospital setting. “Another fundamental lesson we learnt was that we should make the identification of all the medical team clearer. We all wore bibs marked ‘Medic’ but this wasn’t clear enough and it meant that people couldn’t automatically tell who they were dealing with. In future we need bibs that say what we are: ‘doctor’ or ‘nurse’ or ‘paramedic’ or ‘flight medic’. At one point, for example, we had a very highly-skilled nurse overseeing the registration of patients on arrival at the CSU. This wasn’t an ideal use of our resources as they could have been used better as part of a treatment team - somebody less medicallytrained could have managed the arrivals. Overall, we definitely needed a lot more nurses and ideally with a wider mix of specialist nursing skills, to ensure we could respond to a wider range of injuries. I also think that since we had four doctors with us, we should have had a doctor situated at all three sites right the way through.” Sarah’s conclusion? “Finally, another big lesson we all learnt was giving thought to the actual positioning of the CSU facility. On this exercise it was about 300 metres away from the runway and up a slight incline. If you allow for the fact that a different scenario might include transferring the casualty through heavy snow in much colder conditions, then placing the CSU much

Focus on SAREX 2012 Medevac Exercise in the High Arctic

SAREX 2012 to explore how well their team’s experimental procedures for the treatment of advanced hypothermia would work in the challenging setting provided by the High Arctic. Of particular interest was whether or not their miniature heart lung machine (HLM) would perform in adverse climactic conditions. Lars only works with Benedict these days on a part-time basis as he is also completing his surgeon-training in cardiothoracic surgery while working as a Major in the Danish army, but the opportunity to participate in this exercise was too exciting to resist.

closer to the runway would help. Obviously, there’s a minimum distance, as you can’t be too close to the runway for safety, but cutting down the distance which casualties need transporting when being stretchered for evacuation is an important aspect of keeping them stabilised and warm.” Sarah finished: “ Overall though I do feel that this was a very well-prepared exercise and that we all learnt some very valuable lessons from it. If it sounds like I’ve given a long list of things that could be improved, then that’s good - because learning about these problems and how to overcome them is exactly why we did this exercise on this scale. You don’t want to be learning these things when real lives are on the line so now we’ll have these systems in place in the event of a real situation arising!” Jesper Ægidius broadly agreed: “We treated 26 casualties in the CSU over the two days, with the majority, 16 of them, treated on

Day One. However, all eight casualties on Day Two were Priority ‘1’ casualties that needed evacuating forward urgently and, in view of the small number of medics we had, I think we did well to treat them all. The whole logistics set-up was a test for us because it was new. The good thing that shone through though was that the background that each member of the team brought with them was a great help. We had Michael, the doctor, Jan, the Flight Medic, and, Sarah and Vibeke, the nurses. Even though we hadn’t all worked together before, I think we came together well as a team.” The Hypothermia team - Lars and Torben: Perfusionist, Torben Nielsen and Cardiothoracic surgeon, Dr Lars Møller work together as part of Benedict Kjærgaard’s hypothermia team at Aalborg Hospital. Both were keen to participate in

As he explained: “In a real catastrophe in extremely cold conditions, our primary job would be to protect people from hypothermia. Basics such as providing tents and blankets to keep people warm are essential. Warm drinks and blankets are vital too, as we can treat far more people this way than with chest tubes, central warming or even the HLM. Our biggest challenge would be severe hypothermia and the biggest question would be whether or not we could intubate, perform perfusiuon, etc as we’re dependent on power to use our equipment so we really need a protected environment – we need to be inside – so we can get on and treat patients. We also need the right team, the right logistics and the right equipment. Not a lot to ask! Thanks to this exercise we now know we can do it. Definitely, we can do it! “Lars addeds: “ICE-SAR gave us a perfect environment – heating tents and 9,000 watts of power in just an hour and a half so their role was vital.” Torben explained that the miniature heart lung machine (HLM): “Consists of a Maquet August 2012 | Ambulancetoday

Focus on SAREX 2012 Medevac Exercise in the High Arctic

Rotaflow Centrifugal Pump weighing 14.4 kgs and measuring just 179 × 385 × 243 mm, it’s very compact. We brought along a dummy setup as well as a sterile setup for the machine, both cannula and pump and oxygenator. This equipment was for the treatment of patients with ventricular fibrillation caused by hypothermia. The medicine we brought for this treatment was Heparin - to prolong bleeding time - and Sodium Bicarbonate to correlate acidosis in the hypothermic patient.” Torben added: “For treatment of moderate hypothermia we also brought a setup for warming through the pleura, consisting of pleura drainage instruments as well as connections so we could warm the patient with 43 degree C warm Saline ½ a litre per side passive running in and out after giving some warmth to the patient. This Is one of the main treatments I would suppose we would use if we were to treat the patients in a real life situation. Only a few patients can be treated by the HLM, but quite a lot can be heated by pleural lavage.”

conditions for the region - with sun, rather than ice and snow, and with almost no wind. And even despite these factors, the casualties started freezing when they were placed on the stretcher after being stabilized. In the case of real casualties they might not be able to alert us to this issue, and some would really suffer, so we learnt that we need to be more aware of this.” I asked Lars on his views regarding casualties and survivors: “It’s difficult to tell, but some of the ‘patients’ we transported to Keflavik on the second day were severely injured. I don’t think all of them would have survived as we were in need of extra hands at both the CSU and during the Medevac. Some of the people playing the casualties presented with quite severe symptoms so, in reality, no – I don’t think all

of them would have survived”. Lars added: “In a real situation there would be no breaks and we would not know what to expect on arrival. We had a lot of communications problems so it took a while to find out what was happening and how many casualties we would receive. But finally our own command post succeeded in communicating with the ship and the forward mobile team. There were only 3 hypothermic patients on Day one – with temperature of about 35 degrees – so not too severe. They were clear and responsive and only really needed blankets and warm drinks. From an exercise viewpoint I’d have liked some severe patients, ideally in cardiac arrest, as this would have allowed us to test our systems and equipment more fully.”

Torben explained the treatment further, saying: “All the patients we might treat would then be intubated by the Medevac team, but in the case of treatment with the HLM, we give the patient both cardiac and lung support, CPS, draining the blood by the femoral vein, circulating with the rotaflow, oxygenating through the oxygenator, and delivering the blood back to the patient through the femoral artery.” He added: “But looking back at the setup we had in the CSU at Mestervig, you must remember that we were there in very mild August 2012 | Ambulancetoday

Focus on SAREX 2012 Medevac Exercise in the High Arctic

but here it’s very different. As a team we talked about emergency surgery. Should we bring blood? If we were to do an emergency thoracotomy, you’d need blood and a complete team. Maybe one thing we’ve learnt is not to expand our horizons unrealistically.” Torben gave the final comment, saying: “Other treatment elements that were issues for us were the transport between the CSU and the evacuation aircraft – which could have been improved – and the general shortage of equipment and staff.” The Medevac team – Allan and Ulrich’s overview: Allan Fugslang, an RDAF flight medic with 25 years experience of major incident and battle trauma medicine led the Medevac team, but even with experience serving in Bosnia and Afghanistan this was a new experience for him. “I think this exercise could have been planned a little better, especially the patient flow through the whole system. But I think that every team got something out of this exercise. It was a little chaotic on the first day but that’s always the case, especially in real life situations. At one point we joined the CSU team to help out as we didn’t have a Hercules available yet to take casualties on to Keflavik.”

I asked Lars what procedures they would follow in a real live situation. “Well, first we need background info and we need some indications – such as, ‘the patient was seen falling in water but was alive’. So first we start basic CPR, we give hand massage to the heart, ventilation on a mask and we intubate them quickly and apply the Lukas automatic chest compression system. That gives us some time to work on them and to find out if they can be saved. Next, we take a blood sample and measure their potassium blood levels. We have an automatic blood gas level analyser (ABL device). Here, of course, we have a small modified mobile device. If it reads above ‘10’ in adults or ‘12’ in children we can’t save them. Below that level though we’ll continue with advanced resus using the HLM. From the minute we start to completion it takes about 10-15 minutes to apply the HLM in the groin and in that time we expect to get the patient back into full circulation. In a setting like this we need a team of minimum 3 people – a nurse to intutabe and ventilate, me and Torben to do heart massage and the blood samples and then to apply the HLM.” Commenting on

the exercise, Lars noted: “Our patients recovered with no problems but, according to the scenario, they were mild.” So what were the benefits of the exercise? “There were a lot of really valuable lessons – especially working with the ICE-SAR team. We’ve also seen how our equipment can work. One lesson we learnt is that initially it was planned that there should only be two nurses and one medic. The Medevac team didn’t go to Keflavik on the first day so they stayed and helped us in the CSU, and even with them we would still have needed more manpower, so I think we’d need a team of at least eight people.”

Allan finished: “I was a little worried about how well the role-players were briefed who played the casualties. I don’t think they were well-instructed on how to present their conditions so that made it a bit more difficult for us to treat them. Language wasn’t a problem as, being Greenlanders, they all spoke either good English or Danish. As a squadron though I think it has been a really positive learning experience.” Ulrik Edelmann, the Medevac team’s doctor, agreed, adding: “We had a team of just five

Lars added: “The equipment worked okay but if we tried to raise the level of care and had to use even more advanced equipment I’m not sure we could do this over such a long transport distance as you’d need at least one medic per person to keep them stabilized. If we chose to intubate two or three patients we’d lock down two or three people from the team. In the hospital we’re used to having more or less unlimited resources if there’s only a few patients… August 2012 | Ambulancetoday

Focus on SAREX 2012 Medevac Exercise in the High Arctic

people so if this was a real situation I don’t think we would have managed too well as we carried a manifest of 16 casualties on the one flight we took to Keflavik, which included six priority ‘1’s and four priority ‘2’s. Fortunately the three most severe casualties had been stabilized well and were all inside the module. This included one acute hypothermia patient who was being supported on the HML. We were also transporting a skull trauma patient, unconscious on an oxylock respirator, a couple of chest traumas and four casualties with severe fractures. Just the first four cases would have been difficult to manage. If it had been a real incident, going up would have been unrealistic as we wouldn’t have been able to keep all our casualties stabilized throughout the long flight.” Ulrik continued: “Another problem we had was that because of the constraints of flight regulations for the crew we had to depart as quickly as possible or not take off at all. This meant that there may have been some casualties we would want to evacuate but that weren’t stabilized yet so had to be left in the CSU. Of course, leaving them behind was preferable to taking them when they weren’t stabilized. Our team consisted of Charlotte, Tatyana, Peter, Allan and myself and, despite the fact they are all very highlyskilled nurses and medics, this wouldn’t have been enough to look after all the casualties we had on-board.” Summing up the exercise as a whole, Ulrik observed: “Being realistic, I’m not sure that all the casualties would have survived as many of them were fairly severe hypothermia cases and we would not have been able to keep them all warmed up sufficiently. Equally, a lot of patients who were on stretchers were supposed to be suffering from carbon monoxide poisoning and were receiving oxygen, yet we couldn’t put them all on respirators.” Ulrik finished: “My overall view of the exercise though is that it was very satisfactory as it gave us a chance to identify the lessons we need to learn – particularly in terms of how to run a Casualty Staging Unit. And we had many lessons to learn. We need to improve in many areas but we will do that in the future.” The Commander’s Appraisal: Major Lasse Brinck was generally satisfied with the outcome of the exercise and the lessons learnt saying: “Since it was the first full chain deployment with Squadron 690, preparation, staffing and the deployment phase were quite intense and with many uncertainties. The execution was August 2012 | Ambulancetoday

satisfactory, despite problems concerning on-site communication, particularly satelite comms, which created real difficulties in establishing an effective on-scene chain of command.” Lasse went on: “On the tactical level, evacuation, medical support and the use of air capabilities were executed well. Factors delaying the evacuation of regular passengers and injured passengers were mainly related to exercise conditions, such as crew rest regulations and limitations in deployment of capacities. One area that would need addressing would be our total airlift capacity as we definitely needed more and better-suited air transport. Helicopters that could carry more stretcher patients per transfer was an asset we were definitely short of and this would have a real impact on the speed of treatment in a real life scenario.” He added: “For Squadron 690, learning aspects that we now know need addressing as a priority include staffing of the different subunits. It became obvious to us quite quickly that our casualty staging unit (CSU) would have been understaffed in terms of the sheer volume of casualties requiring urgent treatment, so it would have been a huge advantage if the team would have been twice the size. Furthermore, the CSU should have been extended to include a small administration cell capable of handling registration issues of the patients in support of the police. This admin cell should be equipped with sat based data communication equipment and would provide the medics with the info and data needed to get on with the patient-care in a quicker and more efficient manner.” Lasse finished: “However, the overall appraisal of the exercise for squadron 690

was very positive. We have been confirmed in our ability and capability to conduct a medical evacuation in a very remote arctic region and that was our primary objective. The squadron has not officially been tasked with preparing this capability, but we are very certain that with a proper order to prepare for such a task, we could develop an invaluable asset for arctic emergency preparedness.” Special thanks to OS Thomas Blanke of RDAF Photo Section who took all the photographs for this special feature.

Focus on SAREX 2012 Medevac Exercise in the High Arctic

Reviewing the High Arctic Situation in the Long-Term Rear Admiral Sir Nils Wang, Commandant of the Royal Danish Defence College, is acknowledged globally as a leading expert on the maritime economic make-up of the Arctic. He gave Ambulance Today a brief overview of the High Arctic maritime issues which made SAREX 2012 a a vital buildingblock in increasing the safety of the region for all shipping traffic As Admiral of the Danish Fleet from 2005-10 Nils Wang has extensive knowledge of the economic, environmental and political issues affecting the High Arctic region. Commenting on the SAREX exercise he told Ambulance Today: “If we want the Arctic region to be managed wisely in the future than joint-working between all the member states of the Arctic Region is vital so, in that context, SAREX 2012, which was organized to improve the safety of all shipping traffic in the region, is a tremendously positive move in the right direction.” As well as contributing the Patrol Frigate ‘Triton’, which acted as the target ship for the exercise, the Royal Danish Navy also contributed two other ocean patrol vessels equipped with helicopter landing pads, which formed the main sea rescue force, along with a newly-built Icelandic Coast Guard vessel. ‘Thor’. Admiral Wang explained: “As the multiyear ice progressively melts each year the Polar Sea Routes of the Arctic Ocean is increasingly opening up as major new global sea lanes. It is fully navigable and it will become an alternative to the Suez Canal. Traffic is already increasing in the region every year but for now, while it is still not densely populated by traffic, it is important that we have strategies and resources in place to ensure that if an incident does happen we can respond as quickly and effectively as possible. We have a duty to protect and preserve human life.” Commenting on the reasoning for mounting the £15M joint-exercise, Admiral Wang said: “Despite the increasing ice-melt

in the region generally it must be remembered that only about 3-5% of the waters closest to the shores around the Greenland Sea are charted even today, so about 97% is still uncharted. It is still very remote and therefore very dangerous to navigate, so using high technology to chart this vast expanse will be a high priority in the coming years as the ice-melt continues and the sea traffic increases exponentially. In the meantime, we all have a shared responsibility to do all we can to protect vessels passing through these waters.” Admiral Wang explained how the ice melt will affect the economic and maritime

landscape of the region, saying: “It’s somewhat of a media myth that the region is beset by disputes between nations over oil and rare earth element resources. Actually, for the most part, border lines are very clearly established and the UNCLOS agreement forged by the United Nations in 1982 means that ownership of only about 3% of all the known resources is still under discussion and, even those negotiations are being arbitrated in a structured and harmonious fashion. NO, the biggest challenge we have is that when the ice melts and this significant new sea lane opens up, this new passageway might increase maritime activity in the area significantly. Bearing in mind that China currently exports about 50% of its annual GDP by ship you can imagine how this will affect this new faster, more direct and more cost-effective route to their marketplaces.”

August 2012 | Ambulancetoday

Focus on SAREX 2012 Medevac Exercise in the High Arctic

Admiral Wang predicts the route might be in systematic use within a decade, saying: “This new route is opening up quickly. It’s the multi-year ice which is now melting – those layers of ice which typically stay yearround growing thicker each year. But since the year 2000 it has been reducing. Up until 2000 multi-year ice accounted for 50% of the area in the High Arctic – making it impossible to travel through – however it’s already down to just 10% now and when that final portion melts completely it will create a navigable sea lane that will reduce the sailing distance from, for example, Rotterdam to Okahama in Japan, by 40% distance. That’s a huge saving in terms of both sailing time and fuel costs – also about a 40% reduction. Ironically, one major benefit it will bring is that it will massively reduce carbon emissions significantly. Another benefit for those using the newly-opened route is that, whereas now its very remoteness, coupled with its challenging and dangerous climate, makes the High Arctic a very risky place to travel through; of course, as it becomes more widely used, especially by commercial cruise traffic, it will in the long-term actually become safer as there will be far more vessels in the area to respond to a distress signal if a ship actually gets into

August 2012 | Ambulancetoday

difficulties.” Admiral Wang finished: “ Clearly the best way to create synergy in the region is to cooperate with each other, so by working together on important issues such as maritime safety, we are improving the prospects for the region generally and ensuring continued stability in the region for

the years ahead. To that extent, the SAREX exercise has been a great achievement and the lessons we will have learnt from it will definitely make the High Arctic region a far safer place to navigate until nature plays its part and opens it up for more shipping traffic.”

Focus on SAREX 2012 Medevac Exercise in the High Arctic

Meet the happiest man alive! Only your own thoughts and one co-worker for company for 365 consecutive days… in December the temperature can drop to -45C… Polar bears are your only visitors…it’s dark day and night for months on end… and over 2 metres of snow falls every 24 hours... But sat smoking a pipe on a rooftop terrace on a beautiful crisp, clear Autumn morning, Station Mestersvig operative, Leif Beermann, tells Ambulance Today why running operations in the remote High Arctic is the best job in the world

Leif Beerman

Leif’s two co-workers are Aksel Jensen, 50, and Kim Eckert, 25. During the Sarex exercise all three men work constantly on the station from early morning until late at night, either directing incoming and departing aircraft or busily loading and unloading pallets of supplies and equipment. Once the Sarex exercise is completed Aksel and Kim will remain here alone for another six months, braving out the winter conditions to keep the station running day and night. Looking out over a landscape dominated by snow-capped mountains are two boulders marked by a roughly-made cross close to the Control Tower, I ask Leif, from Saeby in Denmark, what they are there for? “Two guys died here together 20 years ago” he explains. “They made the mistake of going out in a dog-sled for a bit of fun at the wrong time of year. They went out too far onto King Oscar Fjord and the ice broke. This was in October when the ice hadn’t completely frozen over yet… By December the whole area is frozen over solidly but they should have realized the ice wasn’t safe yet. One of the guys was due to fly home

the next day so it looks like they were tempted by the idea of one last dog-sled ride. The point is you have to be very careful when you work here – Here you do things carefully to avoid accidents and you absolutely never take unnecessary risks. If you do… the cost can be very high.” So what precautions do you take when you’re one of two men running the daily operations of remote Station Mestersvig? “We call in twice a day. If you miss two consecutive contacts with the Sirius guys at Danneborg – twice daily at 8am and 8pm – they’ll be on alert.” Before he was recruited for a year-long stint working as one of just two facility overseers on the station, Leif , 50, had also worked for two years as a member of the highly-regarded Sirius Patrol, the rangers

who oversee over 16,000 kms of coastline alone along the High Arctic’s national park area. The highlight of his two years with Sirius involved a 3,600 km dog-sled journey which took 14 weeks and during which time he and his partner didn’t encounter a single human being, except with one stop-off at Station North. A trim, deeply-tanned exNavy engineer, he completed his official year’s service at Mestersvig in March but returned this August to help Aksel and Kim coordinate the SAREX exercise as a third specialist was needed to help cater for the unusually high number of visitors coming to the station to take part in the exercise. “All the guys chosen to work here have a military background or have been with either the Sirius patrol or Station North” says Leif. “Before arriving we’re given special

August 2012 | Ambulancetoday

Focus on SAREX 2012 Medevac Exercise in the High Arctic

training to maintain the station. Our main job is to keep the runway operational as there’s no other landing strip capable of receiving large aircraft between here and Station North, which is C1200 kms north and is the closest point to the North pole occupied by humans.” As Leif explains: To run this place you must be very practical – an engineer, plumber, electrician, builder and vehicle mechanic combined and then, of course, on top of that you need electronic radio skills. To work here you must have all these skills to a pretty high-level” then, he modestly adds. “You learn some skills simply by doing them. “If the sink won’t work…suddenly you’re the plumber… you learn because you must!” Communications with the outside world are primarily conducted with their Sirius colleagues in Danneborg and with their mates at the even more remote Station North. “We have UHF comms and a bit of Internet comms, but the internet breaks down a lot, so we mainly get by using iridium satelite comms. We check in every day, we use it when either aircraft are due to land or when cargo ships are dropping oil off via the Fjord and, of course, on special occasions, such as Christmas day, we get a hook-up to say ‘hi’ to our families.” Station Mestersvig was built by the Danish government in the 1950’s. It is 1.8 km long and 2.5 km across – so about 5 km’s in area. It is on Kong Oscar Fjord and branches out into five other fjords by Ella Ø and then out into the Greenland Sea. The station was built to provide a landing strip capable of taking large aircraft to fly in supplies to support the various mining groups from the High Arctic region busy in the area. “It was nearly closed in ’89 when mining declined”, says Leif, “but it was kept open when common-sense prevailed and it was decided to leave a two-man crew here permanently to maintain the landing strip in this most remote part of the High Arctic as it is still badly needed - if only in case a ship might get into difficulties in the region and a base is needed to fly in rescuers and medics.” The two-man team sign up for a contract of 12 months and get paid a modest stipend on top of their regular military pay in recognition of the fact that they are always on duty 7 days a week and 24 hours a day. Summer begins in June but only lasts until mid- August – that’s 2 months of full light. “You sleep with the blinds shut”, explains Leif. The warmest it gets in summer is between 10-15 Celsius but during that period the whole area is, surprisingly, besieged by mosquitos. So what are the daily duties? ”Every day you must go out check the generator, feed August 2012 | Ambulancetoday

Kim Eckert

the dogs, keep the runway clear. We have a summertime rush-hour for landings as we support Australian, Chinese and Polish mining crews. Also changing navy crews fly in and out. We also get a few cruisers in the Fjord. A large amount of time is spent constantly maintaining and repairing ” Kim, the youngest member of the team, explains. “Another of our tasks is keeping Ella Ø,and Danneborg stocked with supplies as we’re the only place where heavy loads can be landed. In February and March, the worst part of winter, whole buildings can be submerged in snow but we have a big yellow snow-blower to keep the runway clear. We raise the shovel, go into the snow and blow it away. The thing is that it takes both men up to two weeks, working 14 hours a day, as you’ll be clearing two metres of snow off a runway that’s 1800 metres long and 40 metres wide. It can take an hour and a half just to go from A to B! After using the snow blower you then have to prepare the runway and make sure its level and clear – so clearing the snow is only half the work. You have to make sure its solid for the plane to land. For the other jobs, we have an MPV [Multi-purpose vehicle] we can attach various tools to– shovel, crane, etc and we use it for all sorts of jobs – especially for the lifting.” ”I ask Leif how structured their daily life is? “We work about 8 hours a day – but every day. We’re always up before 8am but we keep a strict daily routine – painting, repairing, maintenance. We work until about 5pm then break off to eat. Then we

have normal evenings – we watch DVd’s we read, we talk. We clean the tower every Saturday from top to bottom – toilets, kitchen, bedrooms, workspaces, every inch. It’s important to have a routine here and to stick to it or else you lose track of time which is very bad for you mentally.” I then ask what happens if there is an accident when working? “We have good basic medical training – you have to look after yourself and your workmate. This even involves doing dentistry, stitching, etc – even small operations. We sometimes have to operate on the dogs if needed. We have morphine and medications for all types of infections. Of course, we also have a phoneline to a doctor who can advise us. But it could take a week for a doctor to fly in – depending on the weather. We can be grounded for a week – so we must be capable of taking care of ourselves and each other. We even have our own small medical room/operating theatre!” Leif Beermann may well be one of the happiest people I’ve ever met. Have you ever thought of having another life, I ask him? “If I could go back again and choose any life… I wouldn’t change a thing”, he replies quietly, smiling.

UNISON Update

Unison

March with us for a future that works HOPE DALEY is UNISON’s Ambulance Sector Lead. Read on to find out about the key policy areas UNISON will be addressing on your behalf in their fight to prevent the many threats to ambulance services across the UK.

The Ambulance service as well as the wider NHS is currently going through massive structural changes with the privatisation of services, changes to pensions and budget cuts on a scale we have never seen before. Across the NHS there is tremendous pressure to make 20 billion pounds of efficiency savings by 2014 and this pressure to cut costs and make savings has led to radical plans by Ambulance Trusts up and down the Country. In other parts of the sector, employees are

also facing outsourcing to the private sector, reorganisation, redundancies and threats to their current pay, terms and conditions. Meeting the demands of these cost improvement programmes has resulted in a number of recent proposals for cuts to be made to ambulance staff, to stations and to changes in the way in which work is carried out. The East of England Ambulance Trust has proposed reducing the number of staff and vehicles delivering emergency response services across its area at a time when demands on its service continue to increase and its population also continues to rise. The proposals also come at a time when the Trust's own figures show that in many areas, staffing levels will be far below what is needed. In rural areas, this could lead to patients having to wait longer for emergency care where some of the worse response times to life-threatening 999 calls are recorded.

It is worth noting that while national guidelines say that at least 75% of the most serious 999 calls – category A – should be responded to within eight minutes, figures for the first four months of 2012-13 show that some areas within East of England met only 68.00 per cent of those calls on time. In addition, the cuts would worsen the work life balance of staff. In the West Midlands it has just been announced that more than 200 jobs will be lost over the next five years. And although the Director of Workforce has suggested that the jobs would be lost through natural wastage rather than redundancies it is a worrying time for staff and members of the public alike. In East Midlands a number of ambulance stations across the region face the axe under a major cost-cutting programme. Here employers are drawing up a “rationalisation” programme which would see most of the region’s ambulance stations shut. Instead around a dozen main centres could

be created in a “hub-and-spoke” model, with most 999 crews operating from standby points or locations shared with other emergency services. Managers claim the plans, which are unlikely to be fully implemented in more rural areas, will cut staff downtime and release resources tied-up in land and property, as well as improving emergency responses. Cash savings and proceeds from site sales would be funnelled to frontline care. All of these moves come at a time of unprecedented financial pressures leaving the

ambulance service, in common with other NHS organisations, requiring cost savings of at least four per cent each year at the same time as demand for emergency care increases at an estimated three per cent. UNISON is seriously concerned about a strategy which could see front line ambulances removed or reduced in many parts of the country at a time when demands on the service is rising. In our view many of these cuts are based on cost savings, rather than improvement to patient care and response times. We believe Ambulance Trusts across the country should be investing in more staff and vehicles to improve response times, not closing stations and, putting patients at risk. Bryn Webster, UNISON Ambulance Sector Chair, believes that: “These cuts are going to have a devastating impact on patient care and UNISON members working within the Ambulance Service. Demand on the service is rising whilst jobs are being lost which can only have a negative effect on the government’s own targets. The increase on demand is fuelled by other support services being axed within the NHS and Local communities, closing stations and cutting front line services is not the answer.” ‘No’ to postcode pay The NHS that we know and love is under threat. One of the biggest challenges is the pressure to cut costs and make savings. To meet these savings some employers are making threats around Agenda for Change (AfC) by seeking to cut or reduce terms and conditions. In the South West 20 NHS Trusts have got together to do just this by collaborating on radical changes to pay and conditions and the creation of a regional pay system. Agenda for Change (AfC) is the national pay, terms and conditions agreement for all NHS staff, apart from Doctors, Dentists and very senior managers. AfC seeks to ensure equal pay for work of equal value, harmonise terms and conditions of service and provide better pay progression. The agreement sets out pay rates, incremental pay progression, what constitutes unsocial hours or overtime, maternity arrangements, annual leave, sickness

August 2012 | Ambulancetoday

UNISON Update Unison Comment

absence, facility time and many others. Proposed plans could lead to cuts of up to 15%. Additionally, AfC is a national agreement rather than a local one. If we let individual employers break away from this national agreement it will be easy for them to drive down the quality of terms and conditions. Local negotiations on terms and conditions will create a situation with varying outcomes across the country which will be bad for the NHS, bad for patients and bad for all NHS staff across the UK. Local pay hurts the local economy, compromises patient safety, seriously damages staff morale and creates instability in the workforce at a time when the NHS is going through unprecedented change. But patients will pay the ultimate price as workers who can move to areas where wages are higher will do so, leaving NHS trusts in low wage areas struggling with staff shortages. Not only are their plans unfair – health workers are already facing years of pay restraint – they also threaten to destabilise ongoing national negotiations, covering pay and conditions for health workers across the

AmbulanceTODAY

UK. Breaking national pay agreements will undo years of work creating a level playing field for pay and conditions across the NHS. UNISON is working to convince these 20 Trusts to roll back on their plans and instead focus on protecting patients, staff and our economy. Not only are their plans unfair – health workers are already facing years of pay restraint – they also threaten to derail ongoing national negotiations, covering pay and conditions for health workers across the UK. Breaking national pay agreements will undo years of work creating a level playing field for pay and conditions across the NHS. We are also asking people to sign an epetition calling on the Government to do the same. Sign the petition here: http://epetitions.direct.gov.uk/petitions/36063 March on 20th October for a future that works The threat to ambulance services is an example of the sort of cost-cutting that is leading UNISON members throughout the

country to publicly show their concerns. On 20 October hundreds of thousands of people will gather in central London, Glasgow and Belfast to march for a future that works. They'll be taking to the streets because they believe that government spending cuts and privatisation are not the way to get us out of recession. Instead, these cuts are standing in the way of delivering the jobs and growth that we need. UNISON members believe cutting vital public services hurts the most vulnerable members of our society. People who can least afford to pay the price of the recession caused by the bankers. We also know that austerity isn't working and most forecasts suggest that we face years of economic stagnation. The coalition government has got it wrong and they need to replace austerity with policies to create a future that works. We care about healthcare, and other public services. That's why we are marching in London on 20 October. If you care too, join us.

Baus to showcase new disaster management bespoke vehicle offering at ESS 2012 Baus AT UK will be showing their new frontline A&E ambulance and a new Disaster Management Unit on stand 0S9 at ESS 2012 “Thanks to a recently-agreed distribution agreement with leading German manufacturer of bespoke disaster management vehicles, Ewers, we’re delighted to announce we’ve been able to expand our offering to UK customers to include disaster management units,” explained David Brophy. “We are very conscious of the diverse range of specialist vehicles typically required by UK Emergency Services partners so it became obvious to myself and, proprietor, Franz Baus that we needed to identify a relationship which could offer our UK and Ireland customers a "onestop" solution to even more of their vehicle requirements”, said David. “So the Distribution Agreement we’ve reached with Ewers, another well-respected family business based in Germany, is great news for us and our loyal UK customers. Their experience of supplying several hundreds bespoke units to Emergency Management operators across Germany made Ewers our only choice.”

with Ewers, who are a wellrespected bespoke build specialist for disaster management vehicles, came up, it made perfect sense to seize it. Whether for trailers or boxbodied vehicles, the quality of their build is superb, which is why they’ve built-up a fantastic customer base across all Emergency Services in Germany.” David finished: “ We know Ewers’ build really well and we already share a number of key clients with them so we know exactly how they operate. Just take a look at http://www.ewers-online.com/vehicles-fordisaster-management.html to see an example of what they produce in this field already." BAUS AT is delighted to be showing a new UK Specification front-line Ambulance alongside a typical Disaster Management unit for consideration by all the UK Disaster Management organisations. To find out more about this and the full range of BAUS vehicles, speak to David Brophy who will be happy to show you both vehicles on stand 0S9 at ESS 2012 or call him on: 0044 (0)7974 940121

UK MD, David continued: "At Baus AT UK we want to serve all Emergency Services in some way, so when the opportunity to work October 2011 | Ambulancetoday

Focus on The Optima Corporation

Optima Predict™ used to realise significant savings for South Central Ambulance Service The Optima Corporation has completed a pilot study for South Central Ambulance Service NHS Trust (SCAS) which resulted in the realisation of operational savings in the region of £400,000. The study using Optima’s planning and simulation technology, Optima Predict, also identified other ways to make further efficiency savings in the future without having a negative impact on performance. By accurately simulating possible operational changes, SCAS was able to understand whether it could continue to

Displaying the performance impact of a change in Optima Predict

Comparing two scenarios in Optima Predict Summer 2012 | Ambulancetoday

deliver optimum performance with differing levels of resource and demand. A number of recommendations were put forward, some of which have now been implemented, realising a confirmed saving to SCAS of £400,000. Andy Jones, Assistant Director of Planning at South Central Ambulance Service said “We were delighted with the results of this project. It represented an unprecedented return on investment which has enabled us to push ahead with the full deployment of Optima Predict.”

Moving forward with Predict SCAS has a number of cost improvement scenarios that are to be modelled using Predict, to help identify further performance improvements, resource efficiencies and cost savings.

Implementation and training Optima Predict was purchased by Hampshire prior to amalgamation but a solution has now been implemented which will enable planning and simulation to be carried out across the entire SCAS region. Optima worked closely with SCAS to extract all the necessary historical data from its systems and used this data to produce a highly accurate model. Predict is now fully implemented and SCAS staff have received comprehensive training to enable them to use the system in house. “Before going ahead with the purchase of Predict, we went through a competitive tender process. “ Andy Jones explained “Optima was the only company that offered accurate, intuitive software that has been specifically designed for emergency services.”

Andy Jones commented “We are going to be making frequent use of Predict in these challenging times for a number of specific projects; from the way we manage meal breaks and the impact of roster changes to looking at response and conveyance ratios. With this technology to help us quickly and easily simulate and model various scenarios and situations, we not only gain valuable insight into possible further service improvements, we also have the ability to effectively deliver a robust evidence base to our stakeholders allowing them to plan for the future.” Optima Predict is being used by Ambulance and Emergency Services all over the world to improve patient care and streamline service delivery. For more information, please call +44 1189 036602, email info@theoptimacorporation.com or visit www.theoptimacorporation.com 31

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Focus on clinical education

Is the Precordial Thump an endangered skill? Sophia Rozario, Second year Paramedic student at Oxford Brookes University, reviews the history and use of the Precordial Thump and Precordial Percussion, discussing their origins and likely effectiveness as CPR strategies, and asks whether the traditional Precordial Thump technique for resuscitation of cardiac arrest patients should be consigned to clinical history or revived as a limited but useful technique for the resuscitation of patients when more modern cardiac resuscitation devices are unavailable Introduction: Recent Resuscitation Council guidelines (2010) ‘de-emphasized’ the use of a Precordial Thump for treatment of Pulseless VT or VF, observing that it has a very low success rate compared to external defibrillation.1 However a defibrillator may take time to set up and apply the pads and, although it is undeniably essential to prioritise the use of the defibrillator, situations may occasionally arise when a defibrillator is unavailable and where a Precordial Thump becomes the most time-effective alternative, as it can provide a quick route to Return Of Spontaneous Circulation (ROSC) when it is successful (Pellis, Khol 2009). 2 This article explores the physiology of the Precordial Thump and its success rate, and expands on why the Resuscitation Council made the decision to de-emphasize it. The use of Precordial Percussion will also be compared to the Precordial Thump and I will explore the reasoning behind why the Precordial Thump is a skill in danger of becoming obsolete. I will also consider whether or not student paramedics and new ambulance clinicians should be taught the Precordial Thump (PT) and whether it is in fact a technique at risk from skill decay. Keywords: Precordial thump, Precordial percussion, Ventricular Tachycardia, Commotio Cordis, Manual Cardiac Impact Origins of the technique: The Precordial Thump is a technique that came into popular use in the 1920’s and was widely discussed in European medical literature after E. Schott identified that a sharp blow to the lower sternum could August 2012 | Ambulancetoday

re-pace an asystolic heart (Pellis, Khol 2009).2 Based on a technique used by the ancient Chinese, it must also be stated however that other contemporary studies viewed it as a last desperate attempt to sustain life (Miller, Bhatka 2007).3 Since the 1920s our understanding of how a PT works has developed and since 1992 the Resuscitation Council Guidelines have recommended that PT is not used to treat asystole (Pellis, Khol 2009).2 Today’s recommendations are that a single PT is to be used in a witnessed and monitored arrest when the rhythm is pulseless ventricular tachycardia or ventricular fibrillation: but this action must not delay defibrillation (Resuscitation Council 2010).1 Such a situation may arise if a patient is being monitored en route to hospital and it may be the quickest treatment to hand. In other circumstances, it may be the only treatment available to alter the outcome (Hodgetts, Castle 1999). 4

How do you perform a Precordial Thump? A PT is delivered with a clenched fist, using the ulnar edge of the fist to strike the lower part of the sternum from a height of 20cm and then retract the fist (Resuscitation Council (UK) Nolan, Soar, Lockey 2006).5 Studies suggest that the success of the PT is determined by what stage of the rhythm the impact occurs; this perhaps explains why the success rates of the technique are sporadic and why it varies from study to study. The thump needs to produce enough force to cause 15-20mmHg of pressure on the right ventricle to be effective (Miller, Bhatka. D 2007).3 This mechanical impact transfers to an electrical current which opens stretch-activated ion

channels (Pellis, Khol, 2009), causing depolarization of enough ventricle cells to retain an organized rhythm (Bledsoe et al 2011). 2,6

Success Rate/ Advantages: The overall success rate of a PT has ranged from 1-60% throughout available literature within pre-hospital and hospital environments (Miller, Bhatka 2007).3 This may be because VF is a common rhythm that causes the arrest and the PT is not as effective on this rhythm as it is on VT. A study that had been collected from a range of reports summarised their findings by stating that the cardioversion of VT with a single PT was successful in 19% of cases. However another report from the American Heart Association proclaimed that 49% out of 187 patient cases reverted to a normal sinus rhythm from VT, VF or supraventricular tachycardia, asystole or complete heart block (Nursing Times. net 2006).7

The safety of performing a PT is also highly rated as one study suggested that 97% of their outcomes reverted to a normal sinus rhythm or had no rhythm change at all (Pellis, Khol 2009).2 So if a PT is not successful then there has been no defect to the rhythm; however the manoeuvre will delay the start of compressions. Another appealing factor of the PT is that, compared to the typical life saving devices stored in the ambulance, this particular life saving strategy requires nothing more than your own hand, which may be attractive to some clinicians in the rare event of any mechanical CPR aid being available. For the variant percentage of patients who do respond to a PT, it is a quick method of restoring ROSC; which means there is minimal neurological damage and a greater

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Focus on clinical education

chance of survival (Pellis, Khol 2009). 2 Disadvantages/ Complications: A Precordial Thump is unlikely to be successful once pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) has been present for over thirty seconds (Colquhorn, Jevon 2001), which is why the guidelines advise the PT for witnessed cardiac arrests (Resuscitation Council 2010).8,1 Therefore the timing of delivering a PT needs to be prompt and the clinician must not delay defibrillation. Other clinician errors are likely to occur if the attendant has not been trained or updated on how to perform a PT because it is a technique that is at risk of skill decay, due to the fact that it is not used as often as compressions or taking a blood pressure. This is something that could be resolved by the paramedic taking a few minutes to reread over the manoeuvre to ensure that they are aware of when it should be used, the location of impact (impact must be to the lower sternum), strength and that it must not delay the defibrillator being collected, attached and a shock delivered. Research has shown that a Precordial Thump can induce a condition called Commotio Cordis. This is a rare phenomenon where sudden cardiac death in young healthy individuals is caused by a blow to the chest (most commonly previous incidents have been caused whilst playing sport) (Cavalli 1999).9 The impact to the chest causes the heart to stretch if it is during the first ventricular escape rhythm, and this leads to VF. The PT occasionally has the same effect and decreases a patient’s chance of survival (Cayla 2007) if their initial rhythm was VT.10 A literature search revealed a small minority of studies which criticised the PT for having safety risks and a lack of consistent successful outcomes; however none provided statistics on how often PT induces Commotio Cordis. On the other hand, another piece of research looked into the ineffectiveness of using a precordial thump to treat VT and their study only consisted of eighty participants who underwent electrophysiological study or whom had a cardio defibrillator fitted through surgery. These patients entered a period of having a range of ventricular tachyarrhythmia’s. Out of the eighty participants only one patient returned to a normal sinus rhythm by a PT and the other seventy-nine patients had to be treated using an external defibrillator (Amir et al., 2007).11 Although the study only uses a small amount of participants in a hospital environment, it is one of the very few pieces of research that highlights through statistics how uncommon it is for a PT to be an effective method of treatment and this causes us to favour the August 2012 | Ambulancetoday

Resuscitation Council’s decision to demote its use. Another disadvantage of using a Precordial Thump was briefly touched upon after a report indicated that one patient gained a sternum fracture and later had osteomyelitis for life, after being treated with a Precordial Thump (Ahmar et al 2007).12 However, the study does not state whether the Precordial Thump was successful or whether defibrillation was required. This incident calls into the safety of the Precordial Thump and also the long-term effects on the quality of patient life post-administration. Precordial Percussion: Precordial Percussion appears to be a very similar skill to the precordial thump; however it is used for different reasons. Precordial Percussion is used instead to pace an asystolic rhythm or to sustain symptomatic Bradycardia (Monteleone et al 2011).13 The ambulance clinician would use the technique on a conscious or unconscious patient by hitting the lower left sternal edge at a rate of 50-70 times a minute (Pellis, Khol 2009) to produce mechanoelectric feedback.2 The differences between this and PT is that Precordial Percussion has a lower energy impact and is delivered repetitively. There is very little mention of Precordial Percussion within clinical literature and nothing has been included within the Resuscitation Council UK or the European Resuscitation Council guidelines. Available literature on the subject indicates that the manual pacing technique has proved efficient in preventing patients experiencing severe Bradycardia diminish to complete AV block (Pellis, Khol 2009).2 The time of efficiency has varied from thirty minutes to two hours and forty-five minutes (Pellis, Khol 2009); however this would depend on the clinician’s impact, the patient, and potentially the environment, as it would be more effective to perform Precordial Percussion on a flat surface instead of in the back of a moving ambulance; which is most likely to be transferring on blue lights.2 An advantage which has been suggested by Monteleone et al is that precordial percussion is at less risk of causing blunt trauma because a lower impact is required (2011).13 However, this has not been proved by use of evidence but is rather a theory of theirs, though we could consider this a valid argument, when viewed in light of the earlier stated point relating to the possibility of PT causing a sternal fracture and future osteomyelitis. From what little literature there is on Precordial Percussion, it appears as if it has a potential place in the pre-hospital setting. If the right situation arises en route to hospital it could provide a bridge to temporary pacing of the heart.

Models are: Casey Pennington and James Murray, both paramedic students at Oxford Brookes. On the other hand, a mere three case studies were found to test Precordial Percussion, and if the concept was to be seriously considered for introduction to UK Resuscitation Guidelines, one might reasonably argue that a larger and much more thorough out-of-hospital study first be undertaken. It must also be questioned if this would be unpleasant for both clinician and the conscious patient to perform and receive, however the benefits should perhaps at least be considered and discussed. This is a technique that perhaps should primarily be viewed as second line treatment after Atropine. Alternatively, if the patient is symptomatic of Bradycardia and hypothermic (JRCALC Guidelines 2006) the

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August 2012 | Ambulancetoday

Focus on clinical education

Precordial Percussion could be the next best thing.14

Biography: Sophia Rozario Aged 20, Sophia Rozario is a second year paramedic student at Oxford Brookes University and is currently on placement with South Central Ambulance Service (SCAS). In the past she has been on placement at Oxford City ambulance station. Prior to joining the Paramedic Emergency Care Foundation Degree, Sophia studied health and social care at college and it was this that stimulated her strong interest in becoming a successful paramedic. Sophia has developed a strong academic interest in furthering her clinical knowledge within her second year of study and it was this which led to her researching and writing upon the issue of the precordial thump and precordial percussion.

such as defibrillators and Auto External Defibrillators are widely available these days and can be used to better effect. However, the concern still stands as to whether the Precordial Thump is at risk of knowledge decay as it is used so infrequently. Its use is therefore a choice that is left to the ambulance clinician. As for student paramedics and other new employees joining the ambulance service for the first time, it is left to their lecturers and teachers to weigh up the value of these skills and to decide if they warrant a place in future guidelines.

Conclusion: Looking at the Precordial Thump and Precordial Percussion, could it be argued that these are skills best left in the past in view of the fact that more advance treatment options are now available? Will new employees of the ambulance service be taught these potentially life saving skills? As mentioned earlier there may arise the occasional and highlyunusual situation where the defibrillator or drugs bag is not available, so arguably if there is even a chance that these techniques could save lives - even though the odds have proven slim for the Precordial Thump - they are skills worth reviving or learning. Although this does not apply to Precordial Percussion, the Precordial Thump is part of the latest resuscitation guidelines which proves the skill is still a significant treatment option. On the other hand, should Precordial Percussion be considered in the prehospital environment? If there is evidence that it has sustained a life for two hours and forty-five minutes I believe there is a need for further evidence-based research in the pre-hospital or hospital environment. To conclude, it does seem as though there can be a place for the use of the

Precordial Thump technique in the prehospital environment. According to literature, it has a safety rate of 97% and it does not affect the rhythm negatively if it fails. The Resuscitation Council has summarised the skill and put it in a suitable place for use because other treatments

Precordial Thump is a technique that is at risk from skill decay because it is not used frequently due to the fact that it has been superseded by more modern defibrillation techniques.

References: 1. Resuscitation Council 2010, Adult Advanced Life Support, http://www.resus.org.uk/pages/als.pdf, Accessed 22/11/11 2. Pellis.T, Khol. P (2009) Extracorporeal cardiac mechanical stimulation: Precordial thump and Precordial percussion, British Medical Bulletin, Volume 93 (no issue given) Pages 161-177, http://www.ncbi.nlm.nih.gov/pubmed?term=Pellis. %20and%20Khol.%20P%20(2009)%20Extra corporeal%20cardiac%20mechanical%20 stimulation%3A%20Precordial%20thump%20and %20Precordial%20percussion, Accessed 22/11/11 3. Miller. J, Bhatka. D (2007) The Precordial Thump: Convertio Cordis, Commotio Cordis or Neither?, The Authors. Journal Compilation, Volume 30 (no issue given) Pages 151-152, http://www.ncbi.nlm.nih.gov/pubmed?term=Miller. 20J%2C%20Bhatka.%20D%20(2007)%20The%20 recordial%20Thump%3A%20Convertio%20Cordi %2C%20Commotio%20Cordis%20or%20 Neither%3F%2C%20,Accessed 22/11/11 4. Hodgetts. T, Castle. N 1999, Resuscitation Rules, London: Published by BMJ Books 5. Resuscitation Council (UK) Nolan. J, Soar. J, Lockey. A 2006, Adult Advanced Life Support

(5th Edition), Published in London, Published by the Resuscitation Council (UK) 6. Bledsoe. B, Porter. R, Cherry. R 2011, Essentials of Paramedic Care, (2nd Edition), Boston, Columbus, Indianapolis, Published by Pearson 7. Nursing Times. Net (2006), Resuscitation SkillsPart Five- Precordial Thump, Nursing Times, Volume 102, Issue 29, Page 28,http://www.nursingtimes.net/ nursing-practice-clinical-research/resuscitation-skillspart-five-precordial-thump/203136.article, Accessed 24/11/11 8. Colquhorn. M, Jevon. P 2001, Resuscitation In Primary Care, Oxford: Published by Reed Educational and Professional publishing Ltd. 9. Cavalli. A (1999) Letters to the Editor, Heart,Volume 4, Issue 82 pages 534-536, http://heart.bmj. com/content/82/4/534.2.full, Accessed 30/11/11 10. Cayla. G (2007) Precordial Thump in the Catheterization Laboratory: Experimental Evidence for Commotio Cordis, Circulation: Journal of the American Heart Association, no volume, issue or page numbers provided, http://circ.ahajournals. org/, Accessed 08/11/11 11. Amir. O, Schliamser. J, Nemer. S, Arie. M (2007), Ineffectiveness of Precordial Thump for Cardio

Version of Malignant Ventricular Tachyarrhythmia’s, Pace, Volume 30, Issue 2, pages 153-156, http://onlinelibrary.wiley.com/doi/10.1111/j.1540 8159.2007.00643.x/abstract, Accessed 30/11/11 12. Ahmar. W, Morley. P, Marasco. S, Chan. W, Aggarwal. A (2007), Sternal Fracture and Osteomyelitis: an unusual complication of a Precordial thump, Resuscitation, Volume 75, issue 3, pages 540-542,http://pubget.com/paper/ 17697738?cb=1320595816, Accessed 30/11/11 13. Monteleone. P, Alibertis. K, Brady. W (2011), Emergent Precordial percussion revisited- pacing the heart in asystole, American Journal of Emergency Medicine, Volume not given, Issue 29, pages 563-565, http://www.ncbi.nlm.nih.gov/pubmed? term=Monteleone.%20P%2C%20Alibertis.%20K %2C%20Brady.%20W%20(2011)%2C%20 Emergent%20Precordial%20percussion%20 revisited%20pacing%20the%20heart%20in%20 asystole%2C%20American%20Journal%20of%20 Emergency%20Medicine, Accessed 06/11/11 14. JRCALC Guidelines 2006, Atropine, http://www2.warwick.ac.uk/fac/med/research/hsri/ emergencycare/prehospitalcare/jrcalcstakeholder website/guidelines/atropine_atr.pdf, Accessed 30/01/12

Key Points In brief: The Precordial Thump is a manual cardiac pacing technique which has been ‘de-emphasized’ in the latest Resuscitation Council Guidelines 2010. It is a skill that has a high safety profile but which a variety of research papers indicate has sporadic success rates. Precordial Percussion is another cardiac pacing method used to pace an asystolic or sustain symptomatic Bradycardia on the conscious or unconscious patient.

To find out more about the Paramedic Emergency Care Foundation Degree at Oxford Brookes University please visit www.brookes.ac.uk/paramedic2013 or email query@brookes.ac.uk August 2012 | Ambulancetoday

August 2012 | Ambulancetoday

Thijs Gras’ Letter from Amsterdam

It’s time that we in the Netherlands should also honour our fallen colleagues In a touching reflection on the ultimate sacrifice that some ambulance workers make – those mercifully few who die in the course of duty, Ambulance Today’s Netherlands Correspondent, Thijs Gras, explains why he feels that the time has come for the Dutch ambulance community to follow the lead of our own Ambulance Services Benevolent Fund (ASBF) and create a lasting monument to commemorate those frontline ambulance staff who have died while actively serving their communities We on the ambulance frontline are called to accidents so frequently yet we rarely dwell on the fact that we place ourselves in danger too. Why should accidents only happen to other people? Recently a National Monument dedicated to firemen that fell in the line of duty since the 5th of may 1945 (our end of WW II) was unveiled in the Netherlands. It is not only a tribute to the nearly 100 fallen men who are mentioned, but is also a valuable public symbol of the dedication shown every day by our Dutch Fire Fighters. But sadly, even today, no such monument exists for Dutch ambulance personnel. I personally am aware of 12 incidents over the years that have resulted in Dutch ambulance workers dying while at work. The first incident is recorded in 1949. An ambulance crossed the rail track and was hit by a train, severely injuring the driver and the nurse. Both were brought to the hospital where the driver died a couple of days later. During the big Flood of 1953 that afflicted the South West part of Holland, an ambulance was struck by a wave. Both the driver and the attendant managed to climb out of the vehicle and fled to a house. Unfortunately this house collapsed. The attendant held on to rubble and reached another house where he waited three days for help. The driver was taken away by the streaming water and never found. When the water receded, they retrieved the ambulance full of mud. As far as I know, to date, three ambulance staff have died on the job, suffering fatal heart attacks, all of these occurred in the 1960s and 1970s. In one case in 1965 the ambulance was transporting a heart patient when in the middle of a polder road [ a road built on

UK Ambulance Memorial

marshy land reclaimed from the sea] the driver – who was on his own, not unusual in those days – was struck by a heart attack. The wife of the patient managed to manoeuvre the ambulance to the bank of the road and there she was, literally in the middle of nowhere. No mobile phones back then, but she was lucky that a taxi passed with a driver who worked once in a while on the ambulance and therefore knew the deceased. He drove her and the patient to the hospital in the ambulance, leaving the deceased’s body in his taxi so it could later be collected. In the eighties there were three accidents: an ambulance hit a truck in 1986 killing the ambulance attendant. That same year an ambulance attendant crashed into a bus while rushing to the station during his ‘on-call-at home’ shift. Two years later an ambulance in the city of Leiden collided with a car while driving with lights and sirens to an accident through a red traffic light. The ambulance driver was killed. Thankfully, the only incident in the 1990s occurred in Friesland in 1997 when an ambulance on its way to the station was hit by a van that came from the opposite side and suddenly went to the wrong side of the road. In the last decade two ambulance nurses have been killed while they were on-scene at accidents, busy attending to casualties. The first happened in 2002 on a motorway whena car bumped into a marked accident scene, hitting the nurse and a slightly

injured patient that was then shoved into the ambulance. Both were killed. In 2007 a nurse was sitting near a crashed car examining a victim when a police car, also attending the accident, crashed and hit the nurse. He was severely injured and died a couple of days later in the hospital. The most recent accident in 2009 involved an ambulance nurse who was training to become a Rapid Responder. He crashed and, despite immediate care from his colleagues, he died on the spot. I recently found on the internet a site honouring UK ambulance staff killed whilst still in employment (http://www.freewebs.com/nationalambulance-memorial/). It contained 41 names since 1950. On the list were similar incidents, such as a paramedic killed during motor training. Luckily we have not yet suffered an air ambulance crash here in the Netherlands, such as that awful tragedy which happened in the UK in July 1986, claiming the lives of three ambulance men, as I learned from the list. I greatly respect this initiative and hope to be able to do likewise for The Netherlands. I think every country should have a national monument for fallen ambulance personnel - a place with a beautiful tribute that provides a spot, both physically and digitally, where the deceased are honoured. Apart from offering comfort for grieving family and friends, it also shows the appreciation of society to those people – our people - who take risks every day in order to save others. Editor’s Note: If you are a Dutch ambulance worker who shares Thijs’ viewpoint and would like to discuss helping him create such a monument, please feel free to email him at: th-gras@hetnet.nl

This edition of Ambulance Today goes out to all 25 Dutch Ambulance Regions courtesy of Procentrum

PROCENTRUM - LEARN TO FEEL THE DRIVE www.procentrum.eu August 2012 | Ambulancetoday

Focus on

Can you help us spread awareness of the ASBF? Below Paul Leopold, Chairman of the Ambulance Services Benevolent Fund (ASBF), reflects on the daunting challenge faced by the charity when constantly trying to raise awareness of its work and objectives and explains what you can do to help spread awareness among work colleagues and the general public When you are constantly trying to generate interest, involvement, or maybe even mere curiosity about a particular cause to more or less the same audience there is always a danger of becoming repetitive and thereby having the opposite effect to the positive one that you are endeavouring to create. That is a risk that I am going to have to take. Ever since the Ambulance Services Benevolent Fund was created back in 1986 a major task has been to get the existence and purpose of the Fund known about both within and without the Ambulance Services of our country. The purpose of bringing the Fund to notice is of course twofold - Firstly, to let people know what the Fund can do for them and who to contact if they need the type of help that can be provided; and secondly, to encourage people to recognise the benefits that the Fund can bring in alleviating difficulties that some people, i.e. their colleagues, face, and to contribute towards supporting the Fund both financially and by encouraging others to do the same to assist in that aim. Despite the Fund having been in operation for over a quarter of century it is still the case that many members of our Ambulance Services are unaware of its existence. This was perhaps understandable in the early days when compared to today communication was somewhat more difficult, email;

websites; social networking to all intents and purposes were non-existent. On the other hand back then, between calls, ambulance service personnel spent time together in “crew rooms” talking to each other over a cup of tea or coffee. Todays operational arrangements with, “Make Ready Bases”, “Hubs” and “Standby Points” mean that the opportunities for personal interaction of the crew-room type, in the main, no longer exist and thereby the opportunity for a member of staff who does know about and wants to spread the word about the ASBF or indeed anything else, to his or her colleagues, has to take a different format. I am sure that there is no lack of ingenuity amongst members of the Ambulance Service and that our growing numbers of ASBF Champions are finding ways of overcoming those barriers and spreading the word and encouraging others to do the same but I have to confess I am impatient. I want every member of the Ambulance Service to not only be aware, right now, of the existence of their Fund, but to be actively promoting it at every opportunity. Have you got an idea of how we could do this more effectively? If you have, please get in touch and let us know. The other audience that needs to be educated about us is of course the wider public. It would be great to see our

striking new logo become as readily recognised as that of the RNLI, the Red Cross or even the Olympics and with this recognition an understanding of who we are and what we do and a belief that what we are doing both needs to be done and, hopefully, like you dear reader, deserves support.

If you have any positive awareness ideas you’d like to share with the ASBF or if you’d like to become one of the growing number of ASBF Champions, helping us raise awareness and fundraise around the country, please get in touch with us at enquiries@asbf.co.uk

AMBULANCE SERVICES BENEVOLENT FUND. WILL YOU CHAMPION THE AMBULANCE SERVICES BENEVOLENT FUND? Proud to be serving, proud to have served! Relieved to receive support when dealing with a personal crisis or period of hardship? Your support today will help the ASBF to provide that extra help when the unforseen has happened, whatever your role, whether serving or retired. This support comes at a price of course so we have to attract donations.To help with this we need volunteer representatives at all ambulance sites and localities to ensure staff are aware of our existence and to help raise funds so that we can continue being there for all the unsung heroes of Britain’s ambulance service who are asking for our help in their time of need. Remember, you may think that an unforseen personal crisis may never happen to you, but when it does, a period of hardship can be tough to handle.

WE NEED YOUR HELP TODAY! We need your support NOW to raise funds to develop our Care for the Carers programe. Can you help the ASBF by volunteering as a representatives to champion its work, raise awarness to colleagues about the charity and to help with the challenges of fundraising? To find out more please visit the ASBF Stand #E6. For further information about the ASBF please visit our website: www.asbf.co.uk Or email the Secretary Simon Fermor: enquiries@asbf.co.uk “AFTER OVER 26 YEARS THE AMBULANCE SERVICES BENEVOLENT FUND IS STILL CARING FOR THE CARERS BUT TOGETHER WE WILL MAKE THE DIFFERENCE!.” PATRON: SIMON WESTON OBE. REGISTERED CHARITY # 800434

Enter 70070 into the "to" box - Write in the code 'ASBF44' and then add the amount you want to donate which can be £1, £2, £3, £4, £5 or £10 - Your text might look like this 'ASBF44 £5' Press 'Send' - Congratulations, you've just donated to the ASBF...it's that simple! 40

August 2012 | Ambulancetoday

Jerry Overton's Letter from America

It’s Time to Overhaul our EMS Payment System! If you’ve ever puzzled over the complex calculations required to determine precisely ‘who pays for what’ in various European models of ambulance delivery, spare a thought for our American EMS cousins who must navigate a financial payments system for ambulance care that makes most European models of payment seem as simple as ABC. Our long-suffering friend from America, Jerry Overton, explains in more detail… For those of you who might remember a musical group from the ‘60’s and ‘70’s that placed the editor of Ambulance Today’s hometown on the map, they had a Number 1 hit with a very popular refrain: “Money, yeh, that’s what I want!!!” For those of you who do not remember, they were called the Beatles. The topic of money may not be the most exciting subject you will ever read about, but it is one of those necessities that are a requirement for every EMS system. And certainly, that is the case here in the United States. However, unlike many other places in the world where EMS is actually part of the health care system, ours is in a state of identity crisis and the result is a myriad of misconceptions about who pays, and who does not, and how our systems are actually funded (See my first ‘Letter from America’ for a more detailed rant). First, and foremost, let me lay to rest once and for all a myth, concern, misconception, or however you wish to call it, that in America, if you do not have insurance, you do not get transported. False, false, false!!! Nothing is further from the truth!!! If you, the patient, or a bystander call 9-1-1 for any medical need, be it an emergency or an “emergency,” an ambulance is on the way. In fact, in most states, the law requires that there can be no interrogation of the caller regarding the patient’s ability to pay during call taking process. Patients ARE protected and ambulances DO respond, patient care is the priority. What is true is that our sources for funding are limited, and antiquated. The report Accidental Death and Disability issued by the National Academy of Sciences was published in 1966 and is considered to be the foundation for modern EMS. What many do not realize is that in the same year August 2012 | Ambulancetoday

Congress passed, and the President signed, legislation to cover the health needs of senior citizens, Medicare, and the indigent, Medicaid. While out of hospital care has experienced rapid advancement in training, care delivery, technology, and performancebased system design features, Medicaid and Medicare reimbursement remain essentially the same programs as they were in 1966. You, dear reader, might be wondering why this is so important. The reasons are multiple. First, and foremost, for any reimbursement to be received, the Medicare law requires that the patient must be transported. Paramedics that “hear and treat,” and “see and treat” were never envisioned 40 years ago but they are here today and functioning in many part of the world, especially in the U.K. However, because over 40 percent of our patients are over 65, and that number is rapidly growing, EMS systems in America became dependent on this funding source. Now that we can do more, neither Congress nor the Federal agency that oversees Medicare have shown any interest in making changes. As a result, we continue to transport, progress is impeded, and the local A & E is overloaded with nonacute patients. Second, the other types of reimbursement sources, Medicaid and insurance companies, have both followed the lead of Medicare. Again, the problem of traditional payment for traditional services leads to “no progress”. Third, transporting ALL of these patients, and overloading the A & E has actually raised health care costs for the entire system. Now, even the hospitals are losing money as a result of the number of nonacute patients that are transported. This has an impact on

what we call “downstream health costs” and it clearly has a cause and effect. And, finally as, if you like, “the icing on the cake,” none of these sources, with the exception of specific insurance companies, cover our actual costs!!! In almost all systems, every time we transport, we lose money. That leads to what is called “cost shifting,” which means the ambulance service must charge more to those who do pay to collect revenues to cover the losses from those sources, especially Medicare and Medicaid, that do not. If this seems confusing and dated, it is because it is. And, with our political system embroiled in an election (you may have noticed!!!), there is absolutely no hope of funding change on the horizon. That is not to write that there is no hope of change, period. A couple of our more innovative systems, one in Louisville, Kentucky, and the other in Fort Worth, Texas, have realized that there might be ways to actually partner with hospitals, and hospital savings can be used to fund EMS system’s new “hear and treat” and “see and treat” programs. Currently, optimism is guarded, but it just might work. So... while indeed we do transport every patient, we truly transport EVERY patient. Hopefully this “Letter” has helped explain, in a somewhat simplistic way, the complex ways in which we receive funds to continue to operate our systems. However, until our different factions here work together and unite towards a much needed overhaul of the financing on which we need to care for our patients, I shall quote again that group from Liverpool and close by predicting that it will be: “A Hard Day’s Night.” 41

Out & About News Visit the only daily ambulance news site on the net at: www.ambulancetoday.co.uk

London Ambulance Service appoints new Chief Executive

The London Ambulance Service has announced the appointment of Ann Radmore

as the organisation’s new Chief Executive. Ann, who is currently the Chief Executive of NHS South West London, started her NHS career as a national management trainee. She was appointed Sector Chief Executive for South West London in 2009 and was previously Chief Executive of NHS Wandsworth. Speaking about her appointment, Ann said: “I am delighted to have been appointed and look forward to a new set of challenges that this important role will bring. “I very much look forward to working with the London

Ambulance Service to play my part in taking these essential services for Londoners from strength to strength and developing them as part of the integrated care services of the future. “I have lived in London all my life and worked in the NHS since 1983 and feel privileged to have the opportunity to work for this crucial, lifesaving service.” Chairman Richard Hunt said: “I am delighted to have been able to appoint Ann to the role of Chief Executive for the Service. “Ann is a highly experienced and successful CEO who will bring not

only a wealth of experience but also a very strategic outlook from her various NHS roles, which will help ensure that the Service is at the centre of emergency and urgent care in the capital over the coming years. “Ann is passionate about patient care and is looking forward to working with the Service to ensure that it continues to play its part in improving care on a pan-London basis.” Ann will take up the role around the end of the year. She will replace Peter Bradley, who left in September to become Chief Executive of St John in New Zealand.

Award-winning NEAS project aimed at reducing £2.3 billion cost to the NHS of treating injuries caused by falls wins national praise More than 100 people from across the UK attended a conference on falls prevention at the Centre for Life in Newcastle on Friday 28 September.The conference was organised by the North East Ambulance Service (NEAS) NHS Foundation Trust to share best practice from their experiences in preventing falls. . The Falls Project is based on all agencies who come into contact with individuals who could be at risk of a fall sharing information – so preventative measures can be taken. Forms of intervention range from installing hand rails in the patient’s home, or ensuring help is provided to

carry out certain tasks. The project – pioneered by NEAS and other health professionals in the North East – has since been adopted by bodies elsewhere in the UK.These include three borough councils in London. Earlier this year, the Falls Project won a national NHS award. Jo Webber, Director of Ambulance Service Network, said: “When we heard what the North East region has been doing to prevent falls, we wondered why no-one else in the country has done this.The preventative work on falls in the North East has been a fantastic effort when you look at the scale of the problem of falls nationally.

“The evidence from the North East is compelling that the model here really does work. But no organisation can do this on their own. It needs whole systems collaboration.” She said that one in three people aged over 65 (and one in two people aged over 85) fall each year nationally. This costs the NHS £2.3 billion. For people aged over 75, falls is the leading cause of mortality from injury and she said that one in five people die within three months of a hip fracture in this age group. Prof Julia Newton, Associate Dean of Clinical Developments & Clinical Professor of Aging and Medicine, Newcastle University, said: “Falls is the most common cause of accidents in

Mr Simon Featherstone CEO NEAS, Nigel Dawson Falls Champion Paramedic, Tracey Varty NEAS Control Falls Champion, Phil Kyle NEAS Falls Lead, Kim Rigby Falls Champion Paramedic, Maureen Jordan Regional Face of the faller, Dan McGarrie Falls Champion Control, Ann Fox Director of Clinical Care and Patient Safety NEAS, Gary Mayne Falls Champion Control, Lou Bailey Falls Champion Paramedic.

SCAS shortlisted for Social Media Award South Central Ambulance Service NHS Foundation Trust’s (SCAS) ‘999 Misuse Costs Lives’ campaign has been shortlisted in 3 categories of the Some Comms Awards 2012 (UK Social Media Communications Awards). Now in their third year, these awards celebrate the best in UK social media, recognising the individuals and organisations that are using on-line to communicate in

cool and creative ways. This year the Some Comms Awards have received more entries than ever before in eighteen categories. Your local ambulance service has been shortlisted in 3 of these categories – Best use of YouTube, Public Sector and Best Viral Campaign. SCAS’ ‘999 Misuse Costs Lives’ campaign is multi media Public Relations campaign which includes a viral video to reduce hoax and inappropriate calls to South Central

Ambulance Service NHS Foundation Trust and in doing so to help to ensure that resources are available to respond to genuine life threatening medical emergencies amongst a resident population in excess of 4 million throughout the counties of Buckinghamshire, Berkshire, Hampshire and Oxfordshire 24/7. SCAS Area Manager Paul Jefferies, a highly experienced paramedic with over 18 years service, said: ‘Inappropriate calls I

older people. Up to 45% of fallers aged over 65 attend an A&E department, but they suffer far more than just broken bones. “They sustain a lack of confidence; they are less likely to stay in their own home; and less likely to remain independent; and more likely to become isolated. Older people fear losing their independence by going to a home after falling, so the people we see in our falls clinics are really just the tip of the iceberg. “There is also a perception among the elderly that falling is part of the aging process. It’s not.The North East Ambulance Service should be credited for what they have done in this area and I applaud them for this. There are not many organisations that would think outside their own area of work to make a real difference.” She said that in 2005, a study between NEAS and Newcastle University showed that 48 hours of ambulance crews’ time was used in responding to elderly people who had called 999 after falling in the Newcastle City area over a seven month period.This cost the ambulance service approximately £172,000 in that time. have regularly experienced include responding to the emergency of a man in "severe pain" and on arrival he wanted me to pass him some paracetamol from a table less than two metres away; people calling 999 because they want a lift to visit a relative in hospital; or people injured with say a broken finger, which is not life threatening, but they have no money to get to A&E.‘

August 2012 | Ambulancetoday

Out & About News If you want your service news here or on our ‘Rolling News’ website email us at: www.ambulancetoday.co.uk

Lions Message in a Bottle is a life saver South Central Ambulance Service NHS Foundation Trust (SCAS) is recommending that older persons and younger people living with a disability or long term health condition get their hands on the Lions’ ‘Message in a Bottle.’ The Lions ‘Message in a Bottle’ is a simple idea that encourages people to keep their basic personal and medical details including a list of the medication they are taking or a repeat prescription form in a common place at home where these can easily be found in a medical or other emergency. Your information is kept on a sheet of

paper provided in a plastic bottle in the fridge and the bottle comes with two labels – one to be displayed on the inside of your front door or the main entrance to your home and the other on the door of your fridge. Why keep the bottle in the fridge? Because it’s the last thing that burns in the event of fire. SCAS Clinical Mentor Karen Skillicorn-Aston said: ‘You don’t have to be old or infirm to be unwell. For your local ambulance service having access to a ‘Message in a Bottle’ in a patient’s fridge can be a real lifesaver. When a patient is in pain or distressed the last thing they need is to be quizzed about their life.

Often we have to waste valuable time in rummaging around for a patient’s medication, time that could be much better spent in getting them definitive care at hospital. ‘A Stroke can prevent a person speaking and result in a reduced level of consciousness. If any patient has a condition that we need to know about and is not in a position to tell us having a ‘Message in a Bottle’ in their fridge can make a real difference to the outcome for them.’ ‘Whilst having a ‘Message in a Bottle’ is great, patients should remember to update this every time they are prescribed a new

medication or are diagnosed with a further health complaint. It’s also the best place to keep a passport sized photo, details of any allergies, and a repeat prescription, ‘do not resuscitate’ form or living will.’

Motor Racing Legend thanks London's Air Ambulance In 2010 Sir Stirling Moss suffered a terrible fall in his home in London . Within minutes the specialist London 's Air Ambulance doctor and paramedic trauma team were at his side providing advanced medical care. Sir Stirling has since made a full recovery and recently visited the London 's Air Ambulance operational helipad on the roof of the Royal London Hospital in White chapel to thank the team and find

out more about this lifesaving service to London . Sir Stirling said: "So few Londoners realise that this fantastic service is provided by a charity. London 's Air Ambulance helped me in my time of need and it is wonderful to come and meet the team and hear about the great work they do on the streets of London every day. Accidents can happen to any of us and this charity is vital for anyone seriously injured in London ."

Out & About News Visit the only daily ambulance news site on the net at: www.ambulancetoday.co.uk

Need Latest Information to Manage Ambulance Service Response? There’s an App for that! Commanders have better decision-making in the palm of their hands Great Western Ambulance Service (GWAS) commanders attending incidents now have comprehensive information at their fingertips thanks to a new app. Called the GWAS app – and thought to be the first ambulance app in the country – it houses all relevant documents, policies and procedures as well as mapping, cordons, visual imaging, Dictaphone log. The app also provides access to factsheets for specific types of incidents – such as from the Health Protection Agency (HPA) for managing chemical incidents. Pete Brown, GWAS Resilience Manager, said: “The app puts relevant, up-to-date information in the palm of commanders’ hands when they are on scene managing an incident, allowing them to make well-informed, structured decisions.

“For ambulance personnel, operating to clear policies and procedures is second nature – the challenge is making sure that wealth of information is current and portable. Now there’s an app for that.” The GWAS app has been developed with Bristol-based mobile marketing agency, My Oxygen. The first of three phases of the app went live at the beginning of September and allows commanders to share information – via email or messaging service – with other areas of the trust to support a response. Phase 2 will incorporate trust data such as performance and the availability of specialist staff groups such as SORT personnel. Phase 3 will include clinical learning and development information. Although initially focused on GWAS commanders, the app is available to all trust staff – who are also being

encouraged to suggest further content for phase 3 – via a link from the resilience team. The eventual plan is to make it available to other ambulance trust via the app store. Minimum specifications for the app are an iPad 2, wi-fi/3G access, IOS5, 16GB. The app has already been trialled in a recent live incident –

when emergency services had to evacuate much of Bristol city centre for a bomb scare. Pete Brown said: “Better decision-making in support of ambulance clinicians on scene ultimately means better care and outcomes for patients, which is at the heart of everything we do.”

Michael Wins Gold at Games A member of West Midlands Ambulance Service staff has won a Gold medal at this year’s British Transplant Games. Michael Horton, who works within Patient Transport Services at the Trust, took the gold medal for Archery (within his age category) during this year’s Transplant games which were held in Medway, Kent. The British Transplant Games first began in 1978 and are organised by Transplant Sport UK (TSUK)*. During the games, 62 year old Michael from Coventry, who has undergone two kidney transplants,

also competed in the Lawn Bowling, Darts and Ten Pin Bowling events. Talking about the games Michael said: “There were some 600 competitors at the games this year, all of varying in ages, from under 5 to over 70, who have all received transplants. “The purpose of the games is to show that to receive a transplant is a gift of life. It is a great way to not only celebrate, but to also highlight that there is still a great need for more donors, who too could provide someone in need of a transplant with the opportunity of a new life.

“The event warmly welcomes the attendance of donor families, as without their support, through their time of grief, these games would not happen.” The last few months have been an extremely busy time for Michael, alongside taking part in the transplant games, Michael was selected to represent Coventry as an Olympic Games Ambassador. He was the team leader for 6 of the 12 football matches held in Coventry during July and August and he has been selected to represent Coventry and the Ambassador’s at the Olympic athlete’s parade in London

John’s Giant Leap for Ambulance Service Sixty year old Cheadle resident, John Dean, recently jumped 10,000ft from an aeroplane in a bid to raise money for ambulance responders. John, who has lived in Cheadle for 30 years, took on the tandem skydive in Whitchurch last month and managed to raise a massive £875 for the ambulance service. Talking about the parachute jump Mr Dean said: “Unfortunately I lost my wife Carol earlier this year. When she collapsed I called 999 and literally within a minute a responder car was outside my house. Unfortunately my wife later passed away in hospital and it was decided that the donations from

her funeral would be given to West Midlands Ambulance Service for the Cheadle First Responders. “Following the donation, I received a lovely thank you letter from the service and it encouraged me to think about raising more money. I decided to do a skydive, as it is something I have always thought about doing but had never got round to. Following the events of this year, I have really been driven on to do it and raise some money for a good cause. The Skydive was amazing and is something I’d love to experience again.” Matt Heward, West Midlands Ambulance Service Community Response Manager said: “I would

like to say a huge thank you Mr. Dean on behalf of the Service. His

fundraising efforts really could help to save lives within Cheadle.”

August 2012 | Ambulancetoday

Out & About News If you want your service news here or on our ‘Rolling News’ website email us at: www.ambulancetoday.co.uk

Patients and staff reunited in SECAmb’s second survivors’ event

South East Coast Ambulance Service NHS Foundation Trust, (SECAmb), staff have celebrated with patients and their families and friends at the Trust’s second survivors’ event. Eight patients whose lives were saved by the clinical interventions of SECAmb staff were reunited with their lifesavers on Sunday 23 September. The event, held at Woodlands Park Hotel near Cobham, Surrey recognised the life-saving skills of SECAmb staff, celebrated the lives of everyone SECAmb has helped save and emphasised the importance of early cardiopulmonary resuscitation (CPR). Along with SECAmb chief executive Paul Sutton and Chairman Tony Thorne, staff were able to hear each patient’s amazing recovery first hand. A moving short film telling each

patient’s story has been made and uploaded to YouTube. It can be found by searching for ‘SECAmb Survivors 2012’ or via the following link: http://www.youtube.com/ watch?v=oIW0GdODs1g While paying tribute to SECAmb staff and celebrating each patient’s recovery, the film also aims to encourage more people to understand the importance of learning CPR and basic life support. Also attending the event and receiving a small token of the Trust’s appreciation for their outstanding contribution to SECAmb were Consultant Cardiologist Professor Douglas Chamberlain, and Paramedic Dave Fletcher. Douglas Chamberlain’s contribution to the development in cardiac care cannot be underestimated. Among his long list of achievements was a revolutionary

move in the early 1970s to train ambulance personnel to become skilled technicians in resuscitation - a move which led to the introduction of the UK’s first paramedics. Dave was among the first cohort of these new clinicians. He worked closely with Douglas throughout his career to improve out-of-hospital resuscitation survival rates across SECAmb’s region of Sussex, Surrey and Kent and from early on in his career acquired a reputation as one of best pre-hospital clinicians. Earlier this year he became one of just five ambulance personnel across the UK to be put forward to receive a Queen’s Ambulance Service Medal in this year’s Queen’s Birthday Honours - the first year the medal has been awarded. He was nominated for his commitment and pioneering work on resuscitation at SECAmb with Professor Chamberlain which led to the introduction of a new resuscitation technique, Protocol C, across the Trust. He is set to receive his honour in November. The compressions-only CPR, supported by early defibrillation, has hugely improved outcomes for patients across SECAmb’s region of Sussex, Surrey and Kent. Chief Executive, Paul Sutton said: “This event was once again a

tremendous opportunity to recognise and pay tribute to our highly-skilled staff and at the same time celebrate the lives which have been saved as a result.These stories are just a few examples of the many successes which take place across our region every day. “SECAmb is just one part of these patients’ amazing recoveries but without the calm advice of our staff on the phones in our emergency operations centres, the actions of our clinicians at the scene and indeed the quick-thinking of members of the public to provide vital life-saving CPR in the minutes before our arrival, many lives would not be saved. We want to encourage everyone to take the time to learn how to save a life. “I’d also like to pay tribute and personally thank Douglas Chamberlain and Dave Fletcher for the commitment and dedication they have given the ambulance service over so many years.” Survivors’ Event 2012 stories: John Munn, Maidstone, Kent Lisa Corke, Minster (Sheppey), Kent Linda Bedson, Shoreham-by-sea, West Sussex Carol Good, Crawley, West Sussex Paul King, Brighton, East Sussex Bronwen Drake, Farnborough, Surrey Joe Goodchild, Walton-onThames, Surrey Sarah Fyander, Guildford, Surrey

Romanian ambulance companies to follow IAA strategy Private ambulance services in Romania are to take a strategic lead from the Independent Ambulance Association in their campaign for a bigger share of the state healthcare budget. Lucan Florea,Vice President of The Association of Private Ambulance Services in Romania said after a recent conference in Poaina Brasov: “Like the IAA, we do not want to compete with the state; we say that the introduction of private ambulances in the national emergency system will lead to less intervention and the development of the system with zero-cost from the state”. ASPAR which was set up in 2009 claims that the €3 million a year state allocation to the country’s estimated 50 private ambulance companies is simply not enough for handling its task – 700,000 patient journeys covering 24 million kilometers a year. ASPAR openly admits that the IAA has achieved more in nine months in England than it has in three years in Romania in reducing the tension between the public and private ambulances and is studying the IAA strategy of more constructive campaigning. David Davis, the IAA’s Director of

Communications, was the only foreigner invited to speak at the conference which was organized specially for government and independent healthcare executives to debate the public/private issue. He told delegates that there was a wind of change blowing in Britain creating a closer working relationship between the public and private ambulance companies and now, as a result of the recently introduced NHS reforms, some healthcare commentators have suggested that in 5 years Britain will have a national ambulance service, bringing together as business partners the best skills and resources of the NHS and the independent sector. “This is neither a pipedream nor is it a reality but the latest reforms now make the prospects of a closer working relationship between the two not only more of a possibility than ever before but a necessity. The cold facts are that both need each other to exist: n NHS ambulance trusts need to call up the resources of the private sector to help them meet the demand for emergency ambulances; it is estimated that independents handle about 50% of all NHS hospital transfers

August 2012 | Ambulancetoday

AXIS home care doctor’s car

every year. n Equally, independents need the large NHS contracts, to stay in business, to meet shareholders expectations, to justify continuing investment in modernizing their fleets and introducing new operational technology.” In practice, they are both complementary and competitive to one another but Davis added, the IAA believed “that in a relatively short period of time this mutual historic and unjustified mistrust will be replaced by a professional working relationship built on the most important principle of all - the patient comes first” Formed in January this year, the IAA was already the leading trade association for the independent ambulance industry with more than

45 member companies. Davis said that the IAA’s achievements were being built on a strong working relationship with the Government’s Care Quality Commission, regulators of health and social care services as well as “talking with and listening to” all public and private constituent parts in the ambulance service. Recently the IAA and CQC agreed a series of measures to further strengthen the relationship, including timely and effective exchange of information, discussion and resolution of issues of mutual concern to protect the interests of the organisations and the companies which they regulate and/or represent.”

Products & Suppliers News

Intersurgical® i-gelO2 Resus Pack Four things in one pack, one less thing to think about In emergency medicine, you need equipment that’s easy and rapid to use. The i-gel O2 Resus Pack contains everything you need to prepare, insert and secure the i-gel O2 quickly and efficiently: an igel O2 supraglottic airway, a sachet of lubricant, airway support strap and a suction tube. The i-gel O2 has been specially designed to facilitate ventilation as part of standard resuscitation protocols, such as those designated by the European Resuscitation Council (ERC). However, the i-gel O2 also incorporates a supplementary oxygen port for the delivery of

passive oxygenation, or Passive Airway Management (PAMTM), as part of an appropriate Cardio Cerebral Resuscitation (CCR) protocol. A number of case reports and clinical studies have highlighted the potential advantages our standard i-gel device offers in the resuscitation scenario1,2,3,4, where seconds can make all the difference. With its unique, soft, non-inflatable cuff, valuable time is not wasted deflating and inflating a cuff.This allows a patent airway to be established in the quickest possible time. In many cases, insertion can be achieved in less than 5 seconds5. With our new i-gel O2 Resus Pack, you have all the advantages of a

standard i-gel in the new i-gel O2, along with everything you need to prepare, insert and secure the device in one pack, allowing you to stay focused on what really matters during resuscitation – the patient. References: 1. Gatward JJ,Thomas MJC, Nolan JP, Cook TM: Effect of chest compressions on the time taken to insert airway devices in a manikin: Br J Anaesth. 2008 Mar;100(3):351-6 2. Gabbott DA, Beringer R:The i-gel supraglottic airway: A potential role for resuscitation?: Resuscitation. 2007 Apr;73(1):161-2. 3. Soar J:The i-gel supraglottic airway and resuscitation - some initial thoughts: Resuscitation. 2007 Jul;74(1):197. 4. UK Resuscitation Council Advanced Life Support Guide (5th Edition). Revised June 2008. 5. Bamgbade OA, Macnab WR, Khalaf WM: Evaluation of the i-gel airway in 300 patients. Eur J Anaesthesiol. 2008 Oct;25(10):865-6.

Intersurgical, Crane House Molly Millars Lane,Wokingham, Berkshire RG41 2RZ England Tel: +44 (0)118 9656 300 Email: info@intersurgical.com Web: www.intersurgical.com

Caring For You Pts Ltd takes delivery of EZ-Glide PowerTraxx chair Ferno EZ-Glide chair can manage stairs and rough terrain reducing risk of injury Caring for You Pts Ltd, the patient transport service group, has taken delivery of an EZ-Glide PowerTraxx chair from Ferno, the world leading manufacturer of medical equipment to the emergency services. The EZ-Glide chair had been designed to meet the demanding needs of medical and disaster response services and allows patients to be moved safely up and down stairs. Caring for You Pts Ltd was the first company in the UK to take delivery of the EZ-Glide chair. Its director Carl Carter said: “Our investment in the new EZ-Glide chair means that we can continue to deliver the highest standards of patient transfer ensuring the safe movement of patients as well

as the well being of our staff. “The EZ-Glide has a robust seat and can carry larger-than-average patients – which is particularly important as Britain’s growing obesity problem means that we are increasingly required to move patients with bariatric issues.” Caring for you Pts Ltd was formed in 1995 and therefore has extensive experience in providing Non Emergency Patient Transport Services as well as providing the more specialist services for the movement of patients whilst delivering a modern patient transport service. The company has held numerous non-emergency patient transport service contracts and serves both the public and private sector throughout the UK. Ferno Managing Director Jon Ellis

said: “This is the first chair of its kind in the industry. It has multiple uses as a stair chair, evacuation chair or transport chair, capable of maneuvering over kerbs and rough terrain, and comes with powered tracks that deploy easily to eliminate the need for lifting or carrying while ascending or descending stairs, reducing the risk of injury to medical staff.” Patients can be moved up and down stairs safely and the operator has full control at all times; able to slow, stop or even reverse direction at the touch of a button. A patented built-in safety circuit limits downhill speed, even when power has been lost. The EZ-Glide leads the industry with its 227kg weight capacity and large seating area which along with the extending footrest, provides a more comfortable experience for larger

patients while the innovative features work with the caregivers to ensure a safer transport for all. Ferno is recognized as the global leader in the manufacturing and distribution of emergency patienthandling equipment and mortuary products and exports to more than 75 countries worldwide.

Class Professional Publishing are Delighted to Announce... Class Professional Publishing, representatives of Jones & Bartlett Learning in Europe, have some exciting news! Adding to our already impressive catalogue of titles, we are delighted to announce that Jones & Bartlett Learning have recently acquired the Emergency Medical Services (EMS) publishing division of Elsevier. We are all very excited about this acquisition and believe that the addition of the

Elsevier EMS products to our existing EMS division will bring even greater value and convenience to our customers. This newly acquired range of books includes: Prehospital Trauma Life Support (PHTLS), the comprehensive, internationally renowned resource for learning basic and advanced prehospital trauma skills and concepts. AMLS Advanced Medical Life Support, the only textbook approved

for use by NAEMT's Advanced Medical Life Support course, providing comprehensive, evidencebased coverage of basic and advanced concepts with an emphasis on critical thinking, leading to better outcomes for patients. The UK and USA versions of the Mosby’s Paramedic Textbooks.

All are now in our UK warehouse and ready to order! For further enquiries, please call Kate Anderson on + 44 (0)1278 427800 or email her at kate.anderson@class.co.uk. And don’t miss our fantastic reader offer on page 25 giving you the opportunity to win a copy of the best selling text, PHTLS Trauma First Response.

And many, many more ... August 2012 | Ambulancetoday

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