Resus today summer 2015

Volume 2 No. 2

Summer 2015

Resuscitation Today A Resource for all involved in the Teaching and Practice of Resuscitation Supported by CPRO

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CONTENTS

CONTENTS 5

EDITORS COMMENT

6

EDUCATION

16

EDUCATION NEWS

28

EVIDENCE

33

EQUIPMENT NEWS

Resuscitation Today This issue edited by: David Halliwell MSc Paramedic Flfl c/o Media Publishing Company Media House 48 High Street SWANLEY, Kent BR8 8BQ ADVERTISING & CIRCULATION: Media Publishing Company Media House, 48 High Street SWANLEY, Kent, BR8 8BQ Tel: 01322 660434 Fax: 01322 666539 E: info@mediapublishingcompany.com www.MediaPublishingCompany.com PUBLISHED TRI-ANNUALLY: Spring, Summer and Autumn

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PUBLISHERS STATEMENT: The views and opinions expressed in this issue are not necessarily those of the Publisher, the Editors or Media Publishing Company.

Next Issue Autumn 2015 Subscription Information – Summer 2015 Resuscitation Today is a tri-annual publication published in the months of March, June and September. The subscription rates are as follows:UK: Individuals - £12.00 inc. postage Commercial Organisations - £30.00 inc. postage Rest of the World: Individuals - £60.00 inc. postage Commercial Organisations - £72.00 inc. postage We are also able to process your subscriptions via most major credit cards. Please ask for details.

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RESUSCITATION TODAY - SUMMER 2015

“Resuscitation Manikins provide an excellent tool to anyone interested in learning Basic Life Support. I was delighted to be given the opportunity to demonstrate the Brayden manikin. This device has an additional function which helps both the instructor to demonstrate and, the end user to visualise what happens to the flow of blood to the brain. This is based on the, speed & depth of compressions using a lighting function which will only illuminate when both compression depth, and speed are effective. This becomes a fantastic opportunity and will provide confidence and the ability to the end user, in the event they may have to provide real life CPR to a patient.”

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3

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EDITORS COMMENT

EDITORS COMMENT This copy of the journal appears at a time where many of us are awaiting the announcement of the 2015 resuscitation consensus. Like many of you, we have booked our tickets to Prague, and will be looking forwards to regrouping with colleagues from around the world. We will also be at the UK release of the Guidelines.

This journal continues with its themes of education, equipment and evidence and gives an outline of some of the existing UK based projects that are being transferred into the Middle East. Many countries within the Middle East have recently taken on the ERC guidelines, rather than those of the AHA and therefore UK teams are at the forefront of many regional developments.

This journal commences with a review of 2 conferences - the IPHEC conference and Teesside trauma event - we are very grateful to the authors for sharing not only their reviews but also some of the key speakers have provided their thoughts...

We go on to cover the work we undertook with Alan Batt, and wider teams working in Abu Dhabi and have jointly written a review of the current resuscitation evidence and explain the ways that they are targeting the little things in the United Arab Emirates - UAE - within the sphere of resuscitation to actually make a difference. The paper focusses upon history of ambulance resuscitation to underpin the rationale behind some of today’s decisions. The paper also suggests new ways of working to reduce pre and post shock pauses.

We look at the new forthcoming Atacc conference- proposed by Dr Mark Forrest and his team and Simon greenfield discusses the Nepalese earthquake response.

Phil Quirk and his team of human factors specialists have written a small paper looking at the role of culture within human factors, Phil and his team are world leaders in developing tools to strengthen team behaviour, and have recently started focussing on resuscitation and surgical teams.

Thanks

David Halliwell MSc Paramedic FIfL

RESUSCITATION TODAY - SUMMER 2015

“Many countries within the Middle East have recently taken on the ERC guidelines, rather than those of the AHA and therefore UK teams are at the forefront of many regional developments.”

June sees our teams heading over to a SESAM for simulation and heading over to the SMACC conference in Chicago. The SMACC (Social a Media and Critical Care) conference will have 2500 of the leading clinicians with an interest in sharing and developing clinical practice. We will post reviews in our Autumn Edition.

5

EDUCATION

INNOVATION FOR PRE HOSPITAL EMERGENCY CARE – IPHEC 2015 Inspiring international best practice conference in pre-hosptial cardiac care and resuscitation.

Over 1000 people packed the American Express stadium in

Asked about the fundamental differences in approach between

Brighton to debate... Is ultrasound the stethoscope of the future

the UK and New Zealand models of care, Dr Ellis said: “In the UK,

in treating patients in cardiac arrest in the pre-hospital field?

clinical education is much more superior, how ever the downside is that you are still very much limited in terms of scope of practice

This was just one of the many thought-provoking messages which

which is a shame.”

came out of the Trust’s first-ever conference which was hosted in the UK birthplace of the paramedic profession, Brighton!

“The UK is much more risk adverse than we are in New Zealand.

I think this is historic and cultural and while things are changing it

Captivating a packed auditorium for the first Innovation in Pre-Hospital

will take time.”

Emergency Care conference (IPHEC), New Zealand’s St John Ambulance Deputy Medical Director, Dr Craig Ellis took to the stage.

With Dr Ellis leaving soon after his presentation to jet back to New Zealand, the conference continued as Consultant Cardiologists

To challenge existing practices for treating patients in cardiac arrest,

Dr Adam de Belder and Dr Ali Dana and then Consultant Nurse,

Dr Ellis posed a series of questions such as ‘should we shock a

Chris Walker took to the stage to drive home the message that for

patient who is asystolic?’ and ‘can we be sure a patient is in PEA by

STEMI patients A&E is not the place to go as it adds 60 minutes on

simply checking someone’s pulse at two separate intervals when the

average to get to a cath lab. The take home message was direct

electric activity may be very random?’

referral from ambulance crews was to the lab saved time and in turn saved muscle. Drug therapies to block platelet receptors are

For us to really understand what is going on in the heart, Dr Ellis

a key component in the successful treatment of STEMI patients and

suggested we should not expect a one-case-fits-all solution, and

when delivered in the pre-hospital setting significant improve the

believes that ultrasound equipment in the pre-hospital setting could

outcomes for these patients.

prove to be a valuable tool in tailoring the treatment provided. He showed a transesophageal echocardiography video of a patient

Homage was then paid to the godfather of the paramedic

that was in ‘asystole’ on the ECG monitor and you could clearly see

profession in the UK when Professor Douglas Chamberlain

fibrillation activity that was not picked up on the ECG.

provided an informative talk on ‘the golden rules of a normal ECG reading in adults’.

He added that where a clinician places their hands on a patient’s

RESUSCITATION TODAY - SUMMER 2015

6

chest could have a significant impact on how effective CPR is

Professor Chamberlain said that the profession has come a long

delivered. He continued by saying that tilting the patient by 30

way, adding that “Conferences such as these are good for the

degrees can also improve oxygenation to the brain.

profession. I may not agree with everything which is discussed but they are igniting debate which is useful.”

This led onto a discussion about pain relief, and whether ketamine should be used, particularly in cases where good CPR leads to the

And with Day One of the conference coming to a close, Dr Richard

patient becoming conscious and combative during treatment – as we

Lyon (HEMS Doctor and Clinical Lecturer in Emergency Medicine

know CPR is not without pain!

& PHC) had a tough task of ensuring that he kept everyone interested and he certainly did not fail. Providing a very interesting

Speaking after his presentation, Dr Ellis, who has a keen interest in

and touching talk to a still packed auditorium, the key message

the development of the Critical Care Paramedic programme, said he

to come from him was get the basics right! One of the messages

was delighted to have been asked to speak at the conference.

he delivered was to ensure that our traumatic cardiac arrests were HOT – Hypovolemia, Oxygenation and Tension pneumothorax

He said: “I’ve been asked to attend a few conferences in the UK

must be addressed as quickly as possible. There was also some

in the past but this is the first of this kind within this sector, and it’s

discussion around the need for CPR in haemorrhagic cardiac

encouraging to see there is an appetite for such events.”

arrest.

EDUCATION He presented compelling evidence that the most successful

of insertion. Interestingly he stated that to be a competent user of

outcomes are delivered through good CPR, which can be regularly

SGA you would need to put down 70. To become an expert user he

reviewed by individual audit and update training. He said: “To be

recommends 150 insertions. Food for thought with current numbers

awesome at your job you need to practice.”

for recommend competence!

CPR was a key theme for Day Two when Professor Freddy Lippert

Mark Whitbread, London Ambulance Service’s Clinical Practice

(Chief Executive Officer of Emergency Medical Services in Denmark’s

Manager, spoke on understanding PEA, advocating more use

Capital Regioninsert) opened day-two of the event which focused on

of ultrasound to give clinicians a better understanding of what

cardiac arrests. Putting the community at the heart of this success,

was happening to the heart. He discussed the different type of

the role bystanders have in delivering better outcomes came across

PEA causes, mechanical and metabolic and the need for tailored

loud and clear.

treatment for both. He suggested that additional algorithms maybe of benefit to these patients. Not one algorithm fit all!

Professor Lippert emphasised that emergency call takers needed to take command to inspire bystanders to provide crucial early CPR that

Professor Charles Deakin, a member of the Resuscitation Council

he said was the key to improving outcomes.

and JRCALC, spoke of resuscitation in drowning, and ethics in resuscitation was a lively topic for Dr Zoe Fritz (Consultant Physician,

“There is a lot of science now in the chain of survival but the area that

Cambridge University Hospitals) who tackled the thorny subject of

most needed improvement was that first step – getting bystanders to

DNACPR documents and the difficulties clinicians faced dealing with

have the confidence to start early CPR and deliver effective CPR.”

and applying them at cardiac arrests.

“Make no mistake - even bad CPR is better than no CPR but that is

The final two speakers were Advanced Nurse Practitioner Samantha Brace-

the key area to improving survival rates,” he said.

McDonnell from Warwick University who spoke on the work being done to develop the national cardiac registry and finally the well-known Kent Surrey

He referred to a small island in Denmark which had not had a single

and Sussex Air Ambulance doctor, Magnus Nelson, delivered a very well

survivor from a cardiac arrest until they initiated a programme of

attended session dealing with traumatic cardiac arrest management.

targeted education which saw survival boosted to up to 47 percent and 74 percent for a witnessed cardiac arrest.

SECAmb Chief Executive Paul Sutton said the Trust was committed to innovation in clinical equipment and the development of professional

“Changing the mind-set of the people and getting the public engaged

roles and added that the conference had been a great forum to learn

is essential.”

from others.

Survival rates in Denmark have also doubled after a determined

“There is a lot still to learn and we learn through conferences like this

campaign at getting AEDs in as many public places as possible and

to establish best practices and make it common practice through the

teaching CPR in schools.

ambulance service.”

Professor Lippert strongly advocated CPR education in all schools

The IPHEC Conference caused a storm on Twitter with tweets and

and was fully supported in that by Professor Chamberlain who reinforced this in his workshop on Protocol C. Professor Lippert said

re-tweets spreading the word far and wide, and feedback from delegates and speakers was excellent over both days.

there were many good similarities between SECAmb’s operation and his Copenhagen service.

“In Copenhagen we are looking to be innovative like SECAmb and that is part of our strategy. We want to be the best in Europe.”

Paramedic Practitioners is a very good idea that I would like to expand that in our service. Working with GPs is the right direction and integrated care is essential.”

“I think our strength has been engaging with the general population but we are smaller than SECAmb. Your CFR network is excellent but I think you could increase your AED network and that could have a major impact in survival rates.”

Consultant Anaesthetist Dr Massimo Micaglio from Florence in Italy put forward a strong case for the advantages of the supraglottic

RESUSCITATION TODAY - SUMMER 2015

“I think SECAmb’s development of Critical Care Paramedics and

airway use in particular the i-gel. He discussed the advantages of SGA use in cardiac arrest including ease of incursion and speed

7

EDUCATION

3RD ANNUAL TEESSIDE TRAUMA SYMPOSIUM CONFERENCE REPORT Flight Sergeant Andy Thomas, Academic Research Fellow (Paramedic), Academic Department of Military Emergency Medicine Mr Lee Fairman, 2nd Year Paramedic Student BSc (Hons) Paramedic Practice, Teesside University Contact: andy.thomas2@nhs.net

The 3rd Teesside Trauma Symposium took place at the

movement required in application of a cervical collar. The ILCOR

academic centre, James Cook University Hospital in

draft guideline was also discussed in which it was noted that the

Middlesbrough on Thursday 21 May 2015. The conference was

recommendations included, “benefits do not outweigh harms, and

chaired my Professor Ian Greaves and Flight Sergeant Andy

routine application of cervical collars is not recommended”.

Thomas, with the aim of bringing together those involved in trauma care across the North East and beyond. The event had

Conclusion

200 delegates registered free of charge and in keeping with

With the lack of Level 1 evidence around the use of cervical collars

providing Free Open Access Medical Education (FOAM), and

and on the balance of existing the routine use of cervical collars is now

was attended by a mixture of hospital and pre hospital based

difficult to justify and has potential to cause patient harm. However, any

practitioners from those involved in voluntary aid societies,

changes to practice must be in a well governed system with alternate

ambulance paramedics and pre hospital and hospital based

and clear patient care pathways for patients with suspected spinal injury.

consultants.

Next up was Dr Rachel Hawes discussing the introduction of blood on Speaking first was Co-chair Andy Thomas who’s title Cervical Collars: To be or not to be? started the debate and the presentation is outlined in a brief abstract below:

Cervical Collars: To be or not to be

board in the region’s air ambulance service.

Pre-hospital Blood Transfusion – A Practical Approach for the North East and Cumbria R Hawes1, H Watson2, Y Scott3, S Avery4, J Wallis5

Introduction Cervical collars have become standard practice around the world for over 30 years when treating suspected spinal injury in the pre-hospital

RESUSCITATION TODAY - SUMMER 2015

8

1 Consultant Anaesthetist, Royal Victoria Infirmary, Newcastle & Great North Air Ambulance Service

setting. This is despite very little evidence to support collar use, whilst a

2 Senior Biomedical Scientist, Royal Victoria Infirmary, Newcastle.

growing, if not limited level of evidence has built showing the potential to

3 Transfusion Manager, Royal Victoria Infirmary, Newcastle.

cause harm.

4 Transfusion Practitioner, Royal Victoria Infirmary, Newcastle.

5 Consultant Haematologist, Royal Victoria Infirmary, Newcastle.

Aim The lecture aimed to ignite the current debate by presenting the

Background

evidence around using cervical collars as part of spinal restriction

Haemorrhage remains one of the leading causes of death in trauma and

measures and get delegates to consider individual current practice in

is associated with significant morbidity. Developments over recent years

this area.

have lead to advances in best practice in haemorrhage resuscitation including haemostatic resuscitation and implementation of early

Discussion

resuscitation in the prehospital setting with blood and blood products.

Evidence around the biomechanics involved in Spinal Injury was

However, maintenance of the cold chain for blood products in the

presented to set the scene for the forces required to cause harm and

prehospital environments remains a challenge.

show that a great amount of force is required to both cause the initial injury and in causing further harm. Areas touched upon included

Method

the risk of raising intracranial pressure, increased difficulty in airway

This article describes the challenges and practical solutions used to

management, pain and discomfort to the patient and additional

adapt a technique for delivery of blood from other military and civilian

EDUCATION environments to a solution suitable for a HEMS service in North East

based on the physician/paramedic model. Conceptually we can apply

and Cumbria.

a multidisciplinary approach to these critical patients with road crews undertaking the ‘initial actions’ of extrication, haemorrhage control,

Results

oxygenation, access and some packaging to then be followed by

In the first 4 months after implementation, 242 cool boxes were

‘critical interventions’ delivered by the HEMS team such as blood, RSI

prepared & delivered with 100% delivery record, 100% accuracy of cool

and surgical interventions.

box tracking, 100% maintenance of cold chain (even at 48hrs). 20 units of blood were administered with 100% traceability and no transfusion

Timeframes for both urban and rural incidents were then mapped out

reactions. 3 units of blood have been wasted and 461 units recycled to

based on average scene and transport times to show how much earlier

the hospital supply.

the patient receives these critical interventions when HEMS is deployed to these incidents.

Conclusion

The talk highlights that when road crews and HEMS crews work closely

Methods used in alternative military and civilian HEMs environments

together then a high level of pre-hospital care can be achieved.

have been successfully adapted to provide a safe and effective solution for delivery of blood products to a HEMS Service in the North East and

Following lunch Professor Bob Jarman discussed the use of pre hospital

Cumbria.

ultrasound and bay far presented the most humorous and entertaining talk of the day. Professor Jarman briefly outlines his talk below:

Following refreshments the delegates where introduced to our key note speaker Professor Karim Brohi of the Royal London Hospital. His talk entitled: Trauma Medicine of Systems Management.

Pre Hospital Ultrasound

Trauma Medicine of Systems Management

Professor Bob Jarman, Consultant in Emergency Medicine, Royal

Within this presentation Professor Brohi discussed the London

Bob Jarman’s talk discussed how clinical skills should be augmented by

experience in setting up the first UK trauma network and noted that although much has been done to improve patient outcomes we must continue to push harder for more success and integrated services. He also noted that elderly trauma is an area in which we can continue to improve in the future. He touched on the additional support patients may need who survive severe trauma and the extra support they may need. He sign posted the www.aftertrauma.org website and encouraged people to take a look. This talk had the audience captivated throughout and resulted in many post presentation questions.

Following this speaker is no easy task and this was the Job of aircrew paramedic Andy Mawson who summarises his talk: Trauma: who comes, below.

Victoria Infirmary, Newcastle.

adjuncts and how technologies of the past should really be superseded by modern compact applications such as point of care ultrasound.

He reviewed the continued miniaturisation of ultrasound systems and corresponding reduced costs; how they may complement managing emergency and trauma cases, which is especially pertinent in the pre-hospital environment. Already GNAAS has incorporated handheld ultrasound machines into the HEMS service; it’s also been incorporated in the cardiac arrest car operated by NEAS. This was then followed by Dr Jeff Doran discussing the lessons learned with pre-hospital anaesthesia.

Andy Mawson, Aircrew Paramedic, The Great North Air Ambulance

Jeff Doran, Consultant Anaesthetist / PHEM, James Cook University

Service (GNAAS)

Hospital & Great North Air Ambulance

The concept of Trauma: Who Comes? is based on a review of pre-

GNAAS was an early adopter of the Doctor Paramedic model. We

hospital trauma management focused on data from the North East

have been delivering training in prehospital anaesthesia from 2007.

since the NCEPOD report ‘Trauma: Who Cares? (2007) and the NAO

Prehospital anaesthesia has a relatively short history, an article from

report ‘Major Trauma in England’ (2010). It specifically examines how

1975 in the journal anaesthesia, outlining what an anaesthetist might

Ambulance Services have responded to these reports and at ‘skill mix’

do at the scene of an accident, outlined several clinical intervention but

amongst road based resources that are responding to major trauma.

does not mention administering general anaesthesia.

Basic research found that although the North East Ambulance Service

We outlined what we believe are the main lessons we have learnt from

got a paramedic to most incidents of major trauma by reviewing the

the delivery of prehospital anaesthesia over the past 10 - 12 years.

current skill set of UK paramedics it was found that there are a number of reversible pathologies that cannot be appropriately managed. This

1. The need Documents like the 2007 NCEPOD report and the

is compounded by the very low incidence of critically ill/injured patients

fact that several patients every day are anaesthetised at the

encountered by road crews. A recommendation is made for each

roadside has demonstrated the need for a robust prehospital

Ambulance Service to have access to a well governed HEMS team

anaesthesia service

RESUSCITATION TODAY - SUMMER 2015

Trauma: Who comes?

Lessons learnt: 10 Years of Prehospital anaesthesia

9

EDUCATION 2. It’s more than just intubating with drugs The evidence shows that training paramedics to intubate with a standard drug regime increases mortality 3. Some things don’t change This includes the weather, environmental factors, scene safety issues etc. Training in PHA must take these issues into account.

4. Somethings do change The process is still the same but we presented evidence about small changes in practice such as drug preference 5. Standardising practice is a good thing Allows consistency of equipment, training etc. Also reduces decision making and cognitive burden in high stress environments Figure 1. Regional and local survival rates by survival band %.

6. Quality isn’t just about intubation success It is delivery of the other components of critical care and expert decision making including consistent avoidance of hypotension and hypoxia, targeted control of ventilation, manipulation of intracranial pressure and avoidance of unnecessary delays on scene.

GNAAS has recently introduced a series of quality indicators against which all cases are reviewed.

7. The changing relationship with hospital practice An increased number of survivors in our trauma system is not down to the choice of a particular anaesthetic drug. t is about

Results 7216 trauma cases were recorded for the whole region, with 2080 attending our local Trust. The relationship between severity of injury and mortality across each of the survival bands was as expected for the whole region (see Figure 1). Outcomes were noted to be outside of the expected trend for the whole region in the moderate injury survival band, and for our own Trust in the mild-moderate injury band. These extra death were attributed to the inpatient management of co-morbidities and complications of trauma.

building into an effective system where critical care skills are delivered to those who need them, when they need them, but those skills are then able to be continued as seamlessly as possible in receiving hospitals.

Dr Paul Hunt spoke next about trauma care bundles and his presentation abstract below highlights the key points.

Multidisciplinary Trauma Care Bundles – from Roadside to Rehabilitation: A ‘Whole System’ Concept for Improving Outcomes in Major Trauma Dr Paul Hunt, Military Emergency Medicine Consultant, James Cook

Conclusion The concept of “Multidisciplinary Trauma Care Bundles” is discussed as an innovative and ‘whole system’ strategy that uses agreed clinical practice standards within each of the common themes that are designed to be patient-centred and built on existing best practice (example - Figure 2).

These would be applied to each patient as required depending upon the individual pattern of injury and care needs; the aim being to standardise care and ensure continuity throughout the whole patient journey.

Having had a packed day of speakers discussing clinical topics Andrew Ormerod finished the day explaining and demonstrating how technology can help you maintain a portfolio fit for practice in the least amount of time.

Maintaining CPD fit for practice

University Hospital.

RESUSCITATION TODAY - SUMMER 2015

Background The management of major trauma has undergone considerable change in the last few years with the notable development of Regional Trauma Networks in England that became active in April 2012. The key to success of these networks is the use of agreed principles of care using local models and effective implementation in each geographical area.

Methods Trauma Audit and Research Network (TARN) data tables for the two Trauma Centres and all Trauma Units within our regional network

The presentation was a brief discussion and demonstration of maintaining a ‘Portfolio for for Practice’. Andrew discussed that being ill prepared is a common occurrence in current day practice and that the concept of keeping folders full of unorganised certificates and evidence of CPD is ritualised Further reflection revealed that individuals “are not alone” - a survey of 5000 professionals revealed less than 3% (150) kept an accurate record of their CPD if called for interview or audit.

were examined for the period 1st January 2011 to 31st December 2014. Rates of unexpected (“extra”) deaths were calculated comparing regional and local outcomes in each survival band.

10

Andrew Ormerod, Paramedic North West Ambulance Service and Founder of CPDMe.com

The key to being organised with documenting your development is ”just get started” Deciding a time and place, sit down and set an initial

EDUCATION 1 to 2 hours aside to create the framework. Once you have done this,

Andy Thomas asked a number of headline questions and presented a

maintaining an accurate record of your CPD can take as little as 15 mins

range of research evidence that demonstrates cervical collars do not

per month with no surprises when it comes to interviews or audits.

significantly reduce neck movement and that issues around airway management arise, that collars raise ICP in head injured patients and

It was also noted that individual engagement is crucial. In order to

that transfer times to definitive care increased with collar use. While

consider a new approach to recording CPD, a change in mindset is

acknowledging research that suggests collars are beneficial in reducing

important. Maintaining a portfolio should not just focus on HCPC or NMC

movement during self-extrication and that no level one evidence existed

audit but see the CPD portfolio’s as an extension of professionalism.

he explained that the low level evidence was still evidence and called for a culture change in prehospital collar use. In summary suggesting

The talk reflects upon a social network approach for maintaining a

that the collar presented more risks than benefits to patients in most

record of development engaging like you would on twitter, facebook or

scenarios where standard practice would have them applied.

even amazon. The reward being a record of achievement rather than a tweet, poke or package delivered.

Andy Mawson Senior Aircrew Paramedic with the Great North Air Ambulance highlighted the benefits of having HEMS coming to the

Andrew initially created www.CPDme.com owing to the lack of market

aid of major trauma patients. Andy Mawson suggested due to limited

presence to support health and social care professionals in maintaining

exposure to major trauma and restricted scopes of practice road

their continued professional development. Using the dedicated CPD

crew paramedics are not best placed to provide major trauma care

Portfolio builder, it is argued makes recording CPD quick and simple.

emphasising that definitive care only occurs in hospital. He described

Andrew quoted “It takes less time to update your CPD using the FREE

a system where road crews are skilled at managing the scene and

iPhone app than it does to brush your teeth!”.

extrication of patients and providing initial lifesaving interventions then alongside this comes HEMS that can buy patients more time with

Furthermore the system will remind you of expired certificates and also

advanced interventions being provided earlier. HEMS can also provide

how you can forward date planned learning events and be reminded to

a faster transfer to definitive care in major trauma centres from many

record what you have learnt the following day. Andrew demonstrated

areas of the region to give victims of major trauma the best chance of

what future CPDme Portfolios will look like with digital links to supporting

survival. Andy Mawson discussed a single vehicle RTC scenario where

evidence suggesting that you won’t ever lose an original certificate again.

a patient was in a critical condition, he discussed road crews having this

Final Debate

patient prepared for HEMS arrival, having the patient skin to scoop with a pelvic binder applied and bi-lateral vascular access but in addition to this is the benefit of communication and updating the air crew about

With all the speakers conclude the final session was an open forum

a patient’s condition that would allow for preparation like drugs to

for questions and debate. Much was discussed and debated

be drawn up on route reducing on scene time and speeding up the

which allowed delegates to further question and reflect on the day’s

transition to definitive care.

proceedings. This leaves us now with a final opinion of Lee Fairman a student paramedic who reflects on his view and experience of the day.

The correct resources theme was echoed by Dr Chris Smith who discussed the role of advanced care teams and having a regional

Students Reflection A warm welcome was extended to all attendees by Professor Ian Greaves, his introduction to the event deliberately short thanking those in his team who made the event possible with their hard work and to the events supporters and sponsors who had enabled such an event to be provided free of charge.

trauma care, how this has been developed by a variety of organisations and professions with speakers providing evidence to show that the current systems and interventions are saving lives and that more patients with injury severity scores deemed un-survivable are surviving. As a student paramedic my interest was around pre-hospital interventions I am presently able to perform and what interventions may

Dr Smith produced evidence that major trauma and traumatic cardiac arrests that occur at night have an increased mortality rates. The new project being led by the Great North Air Ambulance service is being rolled out across the north east and Dr Smith feels this will help deliver an enhanced service to patients with the most critical needs.

At the Teesside Trauma Seminar 2015 I discovered it can often be the simplest of interventions that could make the greatest difference to patient outcomes and that it was not all about enhanced skills of surgical airways or the use of portable ultrasound. Simple interventions such as not applying a cervical collar or getting the right resources to the patient and communication could have the greatest affect on the patient outcome and these were the stand out areas of the conference for me.

be available in the future to provide the best possible care to patients.

Summary

Andy Thomas Paramedic Academic Research Fellow took to the lectern

The 3rd Annual Teesside Trauma Seminar grew in statue from previous

to discuss a topic aimed at questioning current practice by examining

years and is now well established as the primary trauma event within

current research with his presentation entitled Cervical Collars: To be

the North East of England. This years event had over 1 million twitter

or not to be. Andy Thomas likened the debate around the use of the

impressions, was entirely free to delegates thanks to our sponsor

cervical collar to the suffering of Hamlet as Hamlet questioned what he

support and should you wish more information on next year’s event or

should do when faced with difficulties in life or the uncertainty of death.

smaller CPD opportunities follow it on twitter @teessidetrauma.

RESUSCITATION TODAY - SUMMER 2015

The whole event provided a great insight into the current system of

response car to provide the interventions of HEMS available at night.

11

EDUCATION

RESUSCITATION REVIEW Batt A, Halliwell D and Clark R Employers - National ambulance UAE and MDT Global Solutions This paper outlines the current position for those of us awaiting the new ILCOR guidelines in October 2015. It serves as an aide memoir of the evidence and is suggestive of some of the newer resususcitation strategies which may come later this year.

Introduction One in three deaths in the United States is from ischemic heart disease, (Go et al 2013), whilst UK survival statistics are often quoted at 8.6% survival, whilst our colleagues in the North of Holland and Norway appear able to achieve far higher results of up to 25%. Maybe it’s the first aid education given to children at school, or maybe the public access defibrillator schemes, or maybe there are other considerations such as diet, exercise or geography!

We know that the incidence and outcome of cardiac arrest varies

Fig 1 Photo of a London Ambulance vehicle circa 1974

around the globe but given that survival from out of hospital cardiac arrest is <15% in most countries, it appears that sudden cardiac arrest is seen as one of the most prevalent of health problems.

1. Targeting CPR performance

Resuscitation science continues to advance, and AHA and ERC

To deliver high-performance CPR the essential components to be

guidelines are currently updated in a 5-yearly cycle in order to reflect these developments and advise healthcare providers on latest best practice. Whilst we await publication of the 2015 guidelines, it’s perhaps a good time to reflect upon the old days, to review the science of what used to happen, since many of the latest developments on cardiopulmonary resuscitation (CPR) are focusing on optimising the

considered are chest compression fraction (CCF), chest compression rate, chest compression depth, maximising chest recoil (residual leaning), and controlling ventilation.

Chest Compression Fraction Chest compression fraction is the proportion of time that chest

quality of CPR in order to maximize survival from cardiac arrest.

compressions are performed during a cardiac arrest.

In the 1970’s the Ambulance crews in Bournemouth (UK) had access

Interruptions in chest compressions are usually made for victim’s initial

to only one defibrillator, which was brought to the scene of cardiac

assessment, call for help, prolonged intermittent ventilation and pre and

arrest patients in the town catchment area- only once cardiac arrest was

post shock pauses.

confirmed by crews on scene This resulted in a delay of many minutes,

RESUSCITATION TODAY - SUMMER 2015

12

yet our colleagues working in the 1970’s and 80’s recall that successful

Evidence suggests that A CCF lower than 80%, is associated with

defibrillation in those days was commonplace, maybe because the

decreased return of spontaneous circulation (ROSC) and survival to

quality of the ambulance crews was excellent and the heart was suitably

hospital discharge (Christenson et al 2009).

‘primed’ for the defibrillation attempt.

Our current strategies include strategies to commence chest Ambulance crews of the 70’s and 80’s were masters of quality CPR

compression without need for pulse checking, to commence CPR in the presence of gasping respirations and a number of high

These days we link survival from cardiac arrest to the chain of survival

profile cardiac arrest recognition strategies from the British Heart

(Field et al 2010) with an emphasis on early recognition, immediate

Foundation, American Heart Association and other organisations

activation of the emergency response system, but equally critical is the

around the world encouraging us to focus solely on compression

quality of CPR delivered.

only/hands-only CPR.

We know that poor CPR quality has detrimental effects on victim’s

There is strong emphasis on minimising pre shock pause and ventilation

survival and post resuscitation neurological status, and quality CPR

time, and immediate chest compression resumption after every shock

performance, monitoring and feedback (for both victim and resuscitation

delivery without subsequent rhythm analysis. These concepts have now

team) and developing team approach and quality-improvement

become standardised and commonplace in Advanced Life Support

strategies are seen as key strategies to cardiac arrest survival.

(ALS) teaching. This should allow for increasing CCF ratio through the

EDUCATION Chest Recoil In the 1980s and 1990s paramedics had to perform 2-3 minutes of textbook CPR with 100% correct hand placement to re qualify-each year, we had to achieve the desired rate and we were failed our assessments if we had a single incomplete hand release! (chest decompression phase)

continuation of chest compressions during defibrillator charging and ensuring rapid rescuer swap over when a resuscitation team is present.

Recently whilst teaching a group of Paramedic clinical team leaders, we have realised that post shock pauses may now be longer than the pre shock phase (further research is required), and will this year examine a few data downloads and video evidence to establish causation.

Regular rotation of compressors whilst doing chest compressions is an

Paramedics were obsessed with good quality CPR and although our

area that is gaining a lot of attention, and it was Hightower 16 in 1995

understanding of the effects of incomplete hand release were not clearly

who first showed the need to swap over and the effects of fatigue. We

understood we were able to identify it as poor practice.

currently are advised to swap at 2 minutely intervals, (Hightower 1995) but the reality is that as the compression rate increases the point of early

Not allowing the chest to fully recoil after each compression by leaning

fatigue decreases. (the faster we go the more tired we get).

onto the victim’s chest, decreases the venous return and subsequent the cardiac output ( Niles et al 2011)

In pre hospital teams it is often difficult to swap through the chest compression phase, because of perceived skill mix and other practical

In the early 2000’s we began to use the Active Compression

issues, with the paramedic often focussing on performing critical

and Decompression (ACD) device to maximise chest recoil, and

resuscitation tasks rather than performing BLS. This practice has been

effectiveness of recoil irrespective of rib fractures!

questioned for many years with all members of the resus team needing to take their turn at the CPR phase.

ACD is physically demanding, but research continues into the effects of the so called ‘sink plunger’ CPR method as a way of enhancing elastic recoil.

Alan Batt a Clinical Educator and prehospital researcher at National Ambulance LLC in Abu Dhabi recently presented a paper at the Middle East Clinical Simulation Conference in Dubai which demonstrated potential improvements in key high-quality CPR indicators by implementing six simple changes to CPR performance, including swapping the compressor mid cycle, rather than combining it with the defibrillation attempt.

Improvements in chest compression depth, rate of compressions, compression fraction, hands-off time and time to first shock were seen in all participants in the study. He demonstrated that this not only saved time but also allowed for the paramedic to commit time within each two quality BLS provider.

Chest Compression Rate Our current guidelines suggest we should have a compression rate of at

Minimising ventilations

least 100 but not greater than 120 compressions per min. Experimental

Excessive ventilation volumes and positive-pressure ventilation directly

data suggest optimum coronary perfusion pressure within the above

affect venous return - so we are encouraged to ensure that the tidal

range and marked haemodynamic dropping for rates below or above

volumes we deliver should produce no more than visible chest rise.

these values. (Idris et al 2012)

However, in the case of the increasing obeseity issue in our populations in developed countries, delivery of ventilation volume to produce chest-

Chest compression depth

rise may result in over-inflation of the patient’s lungs thus causing

The aim should be to push to a depth of at least 5 cm. Rescuers often

potential pulmonary damage, and ultimately reducing preload.

do not compress the chest deeply enough despite recommendations.

A depth of <38 mm is associated with a decrease in ROSC and rates of

Thus a conservative approach of delivery of somewhere between 5-8 ml/kg

survival (Steill et al 2012).

of IDEAL body weight is the recommended strategy for these patients.

RESUSCITATION TODAY - SUMMER 2015

minute cycle to be both an advanced life support clinician and a high-

13

EDUCATION Focusing on high-quality ventilation skills via BVM should be a priority in

Team monitoring tools

Paramedic-delivered resuscitation.

Modern sophisticated devices (such as those using accelerometers ( CPR pucks etc) can monitor CPR performance. Early fatigue and

There are so many other effects that are potentially negative relating to

rescuer-patient (size) mismatch should be reviewed. Some resus rooms

ventilation.

are using video as a debriefing tool, and some of the very newest technology uses science similar to that found in the Xbox kinect to

Gastric insufflation and aspiration of gastric contents caused

measure the depth of CPR on real people. These tools are used both

by hyperventilation ( rate or volume) can further complicate the

Live and in the debrief phases.

resuscitation effort. Long pauses for ventilation efforts ( squeezing the bag) and airway management (tracheal intubation) affect the CCF decrease the probability of successful defibrillation.

We have recently been reviewing the clinical skills of paramedics here in the UK who are following the Protocol C algorithm, and not ventilating for the first few minutes of a cardiac arrest – These teams have a very good understanding of the haemodynamic effects of ventilations.

We know that if we are dealing with a primary cardiac cause to the cardiac arrest event the oxygen content is initially sufficient, and highquality chest compressions are crucial in circulating this oxygenated blood. ( that’s why compression only CPR is ok) Data downloads But

Once purely the remit of researchers, the data download has become the most commonplace tool for reviewing the effectiveness of our CPR.

When asphyxia is the cause of the arrest (children, drowning, toxins)

We can spot changes in chest compression rate, we can review pre

or in prolonged resuscitation efforts (depletion in oxygen content), the

shock and post shock pauses, we can monitor transthoracic impedance

combination of compressions and assisted ventilation are considered

and the subsequent effects of ventilation.

essential.

To avoid hyperventilation especially in witnessed victims of cardiac arrest the ventilation rate (breaths per minute) must be under 12 per minute.

Tailoring a resuscitation attempt to causation may become a significant theme in future years, adapting our techniques to the changing clinical pictures!

2. Feedback tools for CPR

3. Team approach to resuscitation The pit stop CPR system is becoming the focus for many CPR providers with evidence suggesting that every resuscitation event (in or out of hospital cardiac arrest, with two or more rescuers) should be organised by a team leader (Dine Et al 2008) and (Yeung et al 2012) The team leader prioritizes the team actions and directs all its members with a central focus on high quality CPR. The team leader should ensure leadership and consistency with best practice.

Short CPR checklists can provide invaluable feedback information

One of the most significant advances in resuscitation is monitoring CPR

and improve further team’s effectiveness - these have become

parameters. This can enhance CPR quality and feedback science.

commonplace with many pre hospital care teams now dispatching specific cardiac arrest team leaders to ensure the best possible care

Patient monitoring and feedback RESUSCITATION TODAY - SUMMER 2015

14

is provided.

The primary determinant in effective resuscitation is coronary perfusion pressure (CPP), which is the difference between aortic diastolic

Quality-improvement can be also achieved by using simulated team-

pressure and right atrial diastolic pressure. Many studies have shown

training exercises and refreshment courses ( Yang et al 2012) .In situ

that a CPP of greater than 15mmHg is required to obtain a ROSC.

training - in the department, on the ward, in the helicopter before

However our problem is monitoring that CPP.

or during every shift is the gold standard, adopted by many of the leading resuscitation teams worldwide.

When only an arterial line is present experts recommend rescuers to optimize chest compression so that a diastolic blood pressure >25 mm

Often the role of the senior clinician or resuscitation officer, best

Hg can be maintained.

practice dictates that debriefing can improve resuscitation quality.

(Dine 2008)

But for most of us, titrating CPR performance to a goal end tidal CO2 (ETCO2) of >20 mm Hg reflects good quality CPR when neither an

Additional Tools

arterial nor a central venous catheter is in place. Capnography is also

Mechanical compression devices continue to be evaluated for their

good as an indicator of ROSC when there is an abrupt increase to

effectiveness, with both the LINC and Paramedic studies being

normal levels (35 to 40 mm Hg).

published in recent years.

EDUCATION It seems a lifetime ago (2003) that Lucas 1 (oxygen driven) mechanical

greatest benefit for our patients. And research into the Physiological

CPR first appeared and began to transform our understanding of

aspects of moving patients Post Rosc should be evaluated.

chest compression. By controlling the variables associated with chest

Resuscitation science continues to advance, and now includes a

compression we can see the changes on the rest of the CPR process.

far greater understanding of human factors and we are seeing the development of resuscitation clinical guidelines which reflect these

Mechanical CPR using Autopulse or Lucas continue to be studied and

developments.

although we can see evidence of use building (health and safety during transportation, prolonged cardiac arrest, optimising compression rate and depth and in the case of Lucas maintaining elastic recoil.)

We are seeing the role of drugs being deemphasised, and we await the guidelines in a few months to see what will happen next with the use of drugs in resuscitation.

The Future Recent animal study papers have been advocating success with head inclined (head-up) resuscitation, and we are now seeing techniques and strategies appearing to transfer these strategies into human clinical trials, we are also seeing projects associated with measuring transthoracic impedence using defib pads.

Post resus care We are seeing many pre hospital teams moving away from transporting patients in cardiac arrest, maintaining a 10 minute stabilisation period in the ROSC phase before any attempt to move the patient is made, thereby reducing likelihood of re-arrest.

We despair when we see on the television post arrest patients roughly handled or moved in a seated position on an ambulance carry chair in a post ROSC phase to get them down a flight of stairs. The physiology of moving post resuscitation patients should be better understood and evaluated. But sitting post ROSC patients up at 90 degrees appears to

Refs.

Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression fraction determines survival in patients with out- of-hospital ventricular fibrillation. Circulation 2009;120:1241– 1247.

Dine CJ, Gersh RE, Leary M, et al. Improving cardiopulmonary resuscitation quality and resuscitation training by combining audiovisual feedback and debriefing. Crit Care Med 2008;36:2817– 2822 Field JM, Hazinski MF, Sayre MR, Chameides L,Schexnayder SM,et al.

Part1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Circulation. 2010 Nov; 122 (18 Suppl 3): S640-56.

Go AS, Mozaffarian D, Roger VL, et al. AHA Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2013 update: a report from the AHA. Circulation 2013;127:e6–e245.

Hightower D(1), Thomas SH, Stone CK, Dunn K, March JA.;26(3):300-3.

Decay in quality of closed-chest compressions over time. Ann Emerg Med. 1995 Sep Idris AH, Guffey D, Aufderheide TP, et al. Resuscitation Out- comes Consortium (ROC) Investigators. Relationship between chest compression rates and outcomes from cardiac arrest. Circulation 2012;125:3004–3012.

Iwami T, Kawamura T, Hiraide A, et al. Effectiveness of by- stander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest.

Circulation 2007;116:2900–2907.

Linc - A comparison of conventional adult out-of-hospital cardiopulmonary resuscitation against a concept with mechanical chest compressions and simultaneous defibrillation (LINC Study). ClinicalTrials.gov Web site. http:// clinicaltrials.gov.

be an unwise proposition.

Niles DE, Sutton RM, Nadkarni VM, et al. Prevalence and hemodynamic effects of leaning during CPR. Resuscitation 2011;82(suppl 2):23–26.

The concept of a bundle of care similar to that provided to sepsis

Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary.

Resuscitation 2010;81:1219–1276

patients is perhaps where the future of resuscitation lies, with no one intervention being used in isolation. A good example of the benefit of a bundle of care was the results of the recent “CHEER” trial in Australia which saw neurologically intact survival rates from refractory arrest greater than 50% through a bundle of care that included mechanical CPR, ECMO and post-ROSC cooling (Stub et al 2015) Cooling and other strategies are still being reviewed.

is gaining respect in large scale national observational studies as equal or some times more effective than standard ALS algorithms (Iwami et al 2007, and SOS KANTO 2007).

Conclusion We look forward to the new guidelines, but our observations on resuscitation are that we often find ourselves in positions where we can often learn from the past, before getting too excited about the technologies and advances of the future. Personalising care based on cause of cardiac arrest and age of patient may be of even greater emphasis in the future, with far more technical education given to those who will be specialists in resuscitation, team leaders and resuscitation officers. Bundles of care need to be further researched to find the

SOS-KANTO Study Group. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an ob- servational study.

Lancet 2007;369:920–6.

Stiell IG, Brown SP, Christenson J, et al. What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation? Crit Care Med 2012;40:1192–1198.

Stub D, Bernard S, Pellegrino V, Smith K, Walker T, Sheldrake J, Hockings L,Shaw J, Duffy SJ, Burrell A, Cameron P, Smit de V, Kaye DM. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation. 2015 Jan;86:88-94. doi: 10.1016/j.resuscitation.2014.09.010. Epub 2014 Oct 2. PubMed PMID: 25281189.

Yang CW, Yen ZS, McGowan JE, et al. A systematic review of retention of adult advanced life support knowledge and skills in healthcare providers.

Resuscitation 2012;83:1055 Yeung JH, Ong GJ, Davies RP, et al. Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation. Crit Care Med 2012;40:2617–2621.

RESUSCITATION TODAY - SUMMER 2015

We are great advocates for Compression only CPR (Sayre et al 2008)

Sayre MR, Berg RA, Cave DM, et al. Hands-only (compres- sion-only) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest. A science advisory for the public from the AHA ECC Committee. Circulation 2008;117;2162-2167.

15

EDUCATION NEWS Papworth Hospital on the Cambridge Biomedical

Adrenaline trial offered to cardiac arrest patients

Campus. Construction will start on site

An ‘adrenaline trial’ – offering saline instead of adrenaline to cardiac arrest patients – is being rolled out by ambulance services across West Berkshire and North Hampshire this week.

“We want the NHS to be a world-leading

immediately and the new hospital will be open to patients in early 2018.” said Professor Wallwork.

health service, and that includes building and maintaining state-of-the-art infrastructure like the new hospital at Papworth. This important investment contribution from the European Anyone wishing to opt out should wear this bracelet for the duration of the trial.

be signed and construction can begin. Many

one of five services taking part in research

The bracelets can be requested by filling

European Investment Bank has played in

about the use of adrenaline in cardiac arrest

in a form, available via the South Central

after scientific evidence suggested that

Ambulance Service (SCAS) website,

although adrenaline may be better at restarting

http://www.southcentralambulance.nhs.uk/

South Central Ambulance Service (SCAS) is

the heart for a few minutes to hours, it can cause severe brain damage, resulting in death.

During the trial, if a person has a cardiac saline solution.

Initially involving Reading and Basingstoke ambulance crews, the pilot phase of the adrenaline trial will last until the end of March, followed by a full roll-out from April onwards, involving all the trust’s ambulance crews According to SCAS, in one recent study from the United States, less than half the number of people treated with adrenaline survived to go home from hospital, compared to those that did not receive adrenaline.

This concern has led the International Liaison Committee on Resuscitation, a worldwide collaboration of resuscitation experts and

important hospital building schemes, such as Alder Hey Children’s Hospital in Liverpool and the new Southmead Hospital in Bristol.” said Health Minister Lord Howe.

a bracelet, telephone 02476 151164, or email:

Papworth Hospital is the largest providers

paramedictrial@warwick.ac.uk

of cardiothoracic healthcare in the UK and a leading global centre for development of

European backing for new Papworth hospitals The European Investment Bank (EIB) has agreed to provide GBP 46 million for the new 310 bed Papworth Hospital to be constructed on the Cambridge Biomedical Campus next to Addenbrooke’s Hospital.

The 31 year loan from Europe’s long-term lending institution for the new Papworth Hospital is the third new hospital to be supported by the EIB in UK this year following confirmation of support for the new Royal Hospital for Sick Children in Edinburgh and the Dumfries and Galloway Royal Infirmary.

new heart and lung disease diagnosis and treatment. Already a majority of clinicians at Papworth participate in research and the new hospital will build on this research focus to benefit from stronger collaborative links and development of new research programmes with the University of Cambridge, the Medical Research Council and Addenbrooke’s Hospital.

The new Papworth Hospital will have 310 beds providing combining inpatient, day case and critical care and almost all inpatient rooms will be single bedroom accommodation with en-suite facilities that will significantly increase both patient privacy and flexibility.

Construction of the new Papworth Hospital on the Cambridge Biomedical Campus will make

scientists, to call for urgent studies to find out the effects of adrenaline in cardiac arrest.

patients are already benefiting from the role

Alternatively, contact the trial team to request

arrest, they will receive either adrenaline or

“The European Investment Bank is committed

a significant contribution to strengthening

RESUSCITATION TODAY - SUMMER 2015

to supporting long-term investment that

Cambridge’s role as a world class centre for

In emergency situations, such as cardiac

improves lives in the UK and recognises

clinical and biomedical science. The new

arrest, there are specific legal requirements to

that investment in new hospitals is essential

purpose built buildings with have state of the

ensure that patients’ rights, dignity and safety

for high quality healthcare and continued

art healthcare facilities. Papworth Hospital,

are protected.

research into new medical treatment. We are

working in collaboration with Addenbrooke’s

pleased to support investment in the new

Hospital, will ensure that patients will receive a

The legal basis for entering a patient into the

Papworth Hospital that will benefit patients

full range of specialist services on one site.

trial prior to informed consent in an emergency

from across the country and support research

situation is set out in Statutory Instrument

of international importance. Moving Papworth

Design of the new hospital will allow patients

2006 No. 2984, The Medicines for Human

to the new site will improve collaboration on

to benefit from calm and peaceful landscaped

Use (Clinical Trials) Amendment (No. 2)

the Cambridge Biomedical Campus and

environment. Visitors will find access easier as the

Regulations 2006.

strengthen a wide range of specialist medical

new hospital will be located on the Cambridge

research.” said Jonathan Taylor, European

Guided Busway and will benefit from a recently

Investment Bank Vice-President.

opened direct road link to the M11, whereas the

Members of the public can choose to opt-out

For moresteel information of the trial by requesting a stainless

or to book your place for this event visit: site is set in a rural existing please Papworth Everard

bracelet which has the words ‘No study’ “We are very pleased that theor EIBcall has agreed to www.atacc.co.uk/events 03333 engraved on it.

16

Investment Bank means that contracts can

provide funding for the development of the new

www.atacc.co.uk/events/

location 222 999with limited public transport. A new multi-

story car park will also be built for staff and visitors.

>>>

continued on page 21

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EDUCATION NEWS

DE-CODING THE FUTURE OF ANAESTHESIA TRAUMA AND CRITICAL CARE 21/10/15 – 22/10/15 LIFE CONNECTIONS 2015 Ke tter i n g Co n f e r e nc e C e nt r e , Ke t t e r i ng , No rthants NN15 6PB

Over the two days of this conference the ATACC Faculty will take us on a journey from the present day to somewhere around 10 years into the future.

Carefully selected for their knowledge and ability to present in a passionate and inspirational style, these are the doctors, scientists and specialists who are creating the future today.

Simon Carley, Mark Wilson, James Tooley, Kevin Shakesheff, Mike Tipton, Paul Trafford, John Hinds, Neil Greenburg and Gareth Davies from the UK will join Lionel Lamhaut, Sven Kili, Raed Arafat, Joe Landolina, Ian Dunbar, John Glasheen, Mathias Duschl, and Dr. Sergio Canavero from across the globe to create one of the greatest Faculties to gather in the UK within the fields of Prehospital, Emergency, Critical Care and Rehabilitation.

Embrace the words & wisdom of some of the greatest modern minds in healthcare.

Why are resuscitationists & crit care doctors doing the same resuscitation as the skin doctors?

– Scott Weingart, 2014 I believe we have a responsibility to stay at the cutting edge of resuscitation, and I want to share what I learn.

– Cliff Reid, Sydney HEMS The first principle of Leadership is Excellence. The most important thing for an educational leader is that they are clinically credible. – Prof Simon Carley Why repair when we could regenerate - We’re developing a material that has the right porosity and architecture to form new tissue – Prof Kevin Shakesheff Over the two days of this conference the ATACC Faculty will take us on a journey from the present day to somewhere around 10 years into the future.

CALL FOR ABSTRACTS Abstract submission is now open. Prizes for the best presentations in all categories are available.

For more information please visit: www.atacc.co.uk/events For more information or to book your place for this event please visit: www.atacc.co.uk/events or call 03333 222 999

www.atacc.co.uk/events/

EDUCATION NEWS

ATACC De-coding The Future Day 1 TECHNOLOGY – BRINGING SCIENCE TO THE PATIENT

EDUCATION – THE GREAT TEACHER INSPIRES

PREVENTATIVE TECHNOLOGIES

A breath-taking session kicks off our conference with a number of leading technological breakthroughs from across the globe. Speakers from Romania, USA and the UK will present their work in a passionate and exciting way. Some technologies are already here, but not yet fully embraced clinically, whilst others are just out of the laboratory and beginning clinical trials with incredible potential for many aspects of our future practice.

It has been said that, the Textbooks are decades behind, Journals are years behind, Conferences are months behind but the Medical world of Social Media is here now and moving faster and faster! What role will it play, alongside blogs, podcasts and live streaming? How do we pick the good from the bad, the anecdotal, the dogma and the out-dated from the wealth of high quality material, to take us forward?

Car design and New Vehicle Technology have made huge advances in terms of both safety and performance. Systems to protect, minimise injury or even prevent collisions are still developing and will continue to develop well into this century.

However, these systems offer their own challenges and some would say that there is little point making cars even safer as trauma care is the weak link and not vehicle design. We have a group of experts in the fields of Extrication, Medical Rescue and Trauma who will dissect todays’ preventative technologies, before wowing us with what the future holds.

VETIGEL – STOPPING BLEEDING Mr Joe Landolina

This session will kick-off the 1st of 2 open Twitter lead forums, with the resuscitation question we’re all itching to debate: “Why are we doing the Same Resus Training as the Skin Doctors?”

TELE-MEDICINE THE NEXT STEP Dr Raed Arafat

MEDUCATION, FOAM AND BEYOND Professor Simon Carley St Emlyns

INERT GASES & THE FUTURE OF ANAESTHESIA Dr James Tooley

BRAIN REHABILITATION – DOES COUNSELLING WORK? Prof Neil Greenburg

Paediatric Anaesthesia & Critical Care Retrieval Physician, UK

SIMULATING AND STIMULATING THE FUTURE Dr Mark Forrest - ATACC RESUSCITATION TODAY - SUMMER 2015

18

VEHICLE DESIGN – WHEN WILL CASUALTY CARE CATCH UP? Mr Ian Dunbar

CARS THAT WON’T LET YOU CRASH Dr Paul Trafford

MAKING 2 WHEELS SAFER Dr John Hinds

CALL FOR ABSTRACTS CREW COURSES – MORE THAN NOTECHS Dr John Glasheen

Abstract submission is now open. For more information please visit: www.atacc.co.uk/events For more information or to book your place for this event please visit: www.atacc.co.uk/events or call 03333 222 999

www.atacc.co.uk/events/

EDUCATION NEWS

ATACC De-coding The Future Day 2 RESUSCITATION REKINDLING THE FLAME

TOP GUN – PRESIDENTIAL DEBATE

RECOVERY, RECONSTRUCTION, REGENERATION

In this session we will not only look at the achievements in the initial response, but also at the very latest methods, such as roadside ECMO, which truly represent ‘advanced’ level resuscitation. With the latter but an introduction, we will explore future trends in basic science research, gaining a greater understanding of our cardiovascular responses to various stresses and situations. This promises to be a session which will challenge the norms and truly define the future of Resuscitation.

This will be the showcase event of the conference, with representatives of some of the worlds’ leading Emergency Medical Systems on stage in an open forum debate, led by questions from delegates and around the world, through live Twitter Feed.

We are now achieving some incredible results in reconstructive surgery and rehabilitation. Whilst these specialties continue to move forward, others are questioning the value of such focus on repair and would suggest that we would be better focussed on regeneration instead. This last session will attempt to present an overview of the remarkable field of regenerative medicine, beyond just stem cells, but into the regeneration of the complex architecture of individual tissues and organs.

70% SURVIVAL IN OUT OF HOSPITAL CARDIAC ARREST Mr. Mathias Duschl GOOD SAM & CROWD SOURCING Mr Mark Wilson DECODING THE FUTURE THROUGH PHYSIOLOGY Prof Mike Tipton

ECMO IN THE STREETS – ‘THE REANIMATEUR’ Dr Lionel Lamhaut,

SMURD – ROMANIA Dr Raed Arafat CAREFLIGHT RETRIEVAL MEDICINE QUEENSLAND, AUSTRALIA Dr John Glasheen SAMU – FRANCE Dr Lionel Lamhaut HEMS – LONDON Dr Gareth Davies

STEM CELL-ORTHO Mr Sven Kili TISSUE REGENERATION Prof Kevin Shakesheff THE FIRST HUMAN HEAD TRANSPLANTATION WITH SPINAL LINKAGE, GEMINI – PROJECT Dr Sergio Canavero

CALL FOR ABSTRACTS Abstract submission is now open. For more information please visit: www.atacc.co.uk/events For more information or to book your place for this event please visit: www.atacc.co.uk/events or call 03333 222 999

RESUSCITATION TODAY - SUMMER 2015

SUSPENDED ANIMATION Dr Gareth Davies

Chaired by Prof Simon Carley our speakers will give opinions on everything from major trauma systems to critical care in the streets. Do not miss this amazing session and the chance to ask a world authority your most burning questions about 21st century medicine.

19

EDUCATION NEWS

DE-CODING THE FUTURE OF ANAESTHESIA TRAUMA AND CRITICAL CARE RESUSCITATION TODAY - SUMMER 2015

2 1 / 1 0 / 1 5 â&#x20AC;&#x201C; 22 / 1 0 / 1 5 LIF E CONNE CTIONS 2 0 1 5 K E T T E R I N G CON F E R E N CE CE N TR E Simon Carley, Mark Wilson, James Tooley, Kevin Shakesheff, Mike Tipton, Paul Trafford, John Hinds, Neil Greenburg and Gareth Davies from the UK will join Lionel Lamhaut, Sven Kili, Raed Arafat, Joe Landolina, Ian Dunbar, John Glasheen, Mathias Duschl, and Dr. Sergio Canavero from across the globe to create one of the greatest Faculties to gather in the UK within the fields of Prehospital, Emergency, Critical Care and Rehabilitation Medicine.

For more information or to book your place for this event please visit: www.atacc.co.uk/events or call 03333 222 999

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www.atacc.co.uk/events/

EDUCATION NEWS The new hospital will be funded from Private

to cope and with the multitude of aftershocks

constantly. By late afternoon the death toll

Finance Initiative (PFI) funding and public sector

and damage to the roads delaying search and

was reported to be about 4000. In my mind I

funding. PFI provides a way of funding public

rescue operations, the Nepalese government

knew that HF would send a team, and in the

buildings such as hospitals and schools by

put in a call for international assistance.

late evening an email confirmed that we would

attracting private investment and therefore avoiding

deploy. I have been in the ambulance service

the need for public funds for capital expenditure.

On that sunny Saturday morning I was packing

for over nineteen years and have been involved

A group of private firms including architects

and moving boxes with my fiancée Lucy, in

in humanitarian work in one form or another for

and construction companies are contracted to

the process of moving to our new home that

well over a decade in countries such as Sierra

design, build and maintain the building over

weekend. Late morning I received a phone call

Leone, Chad and Mozambique to name a few.

the lifetime of the contract - typically 30 years.

from a colleague from Humanity First (HF), an

But this was the first time that I had been to a

international NGO, telling me that an earthquake

disaster. Thoughts and emotions of excitement

Across the UK the EIB has recently supported

had occurred in Nepal, that international

mixed with fear and anxiety. We would be

significant investment at the new Royal

assistance had been requested and that HF

going into the unknown, the risks of further

Hospital for Sick Children in Edinburgh,

were in the assessment stage of putting a

aftershocks, landslides, dealing with human

Royal Liverpool and Alder Hey hospitals,

medical team together for deployment. Lucy

suffering at its worst and the fact that we could

Southmead hospital in Bristol and the Royal

was within earshot of the conversation and

become casualties ourselves went through my

Stoke University Hospital. Future financing of

obviously knew what was being said. I put

mind. Would I cope? How would I feel once

development at the new Midland Metropolitan

the phone down, briefly told her what had

there? Would I be able to offer some support,

hospital in the West Midlands is currently being

happened, and without any hesitation she

comfort and care to those that needed it?

examined and expected to be confirmed in the

simply said to me “go”. Within a few minutes

coming months.

an official HF email had been sent out asking

The next couple of days were spent sorting

for availability from its personnel to be a part of

the new house, building furniture, packing

Last year the European Investment Bank

a team to deploy at short notice. A few frantic

for my trip and trying to spend what quality

provided a record GBP 6 billion for long-term

emails and phone calls were sent and within

time I could with my family before travelling

investment in key infrastructure across the UK.

an hour, I had been granted permission to take

to London on the Tuesday morning, ready to

leave from work at short notice and I replied to

fly out from Heathrow that evening. Lots of

Background information:

the email as being “available”.

hugs and cuddles were given to Lucy and my

The European Investment Bank (EIB) is the

The next few hours were spent packing,

playing “Star Wars” with my older stepson and

moving and cleaning the old house

explaining to him what I was going to do and

interspersed with nervous conversation (mainly

showing him on a globe where I was going

on my part) about the fact that I would be

to. The realisation of the support that I had

going out to a disaster. I kept looking at the

from my family was on the Monday afternoon,

news and for any updates on my phone;

when after school my “jedi knight” proudly told

casualties started low then as the hours ticked

me that he had told all of his school friends

by the numbers of those injured or killed grew

that I was going to “go and save some lives”.

seven month old son, while time was spent long-term lending institution of the European Union owned by its Member States. It makes long-term finance available for sound investment in order to contribute towards EU policy goals.

Nepal Earthquake

And it is where on 25th April 2015, an earthquake measuring 7.8M occurred approximately 80km northwest of the capital Kathmandu. Within a few short minutes the Global Disaster Alert and Coordination System (GDACS) issued a “Red” alert meaning that due to the depth, magnitude and vulnerability of the population a high humanitarian impact would possibly occur. Reports soon came in of heavy damage to roads and buildings and multiple casualties, particularly in the rural

RESUSCITATION TODAY - SUMMER 2015

Mystical. Spiritual. Breath-taking scenery. Full of culture and vibrant.

Just a few of the words to describe the landlocked country with China to the North and India to the South; home of the highest mountain in the world and the land of the Gurkha. Nepal.

areas but also in the capital. It quickly became apparent that the hospitals were struggling

21

EDUCATION NEWS

Resuscitation Today Conference Programme

Thursday 22nd October 2015

Kettering Conference Centre, Kettering, Northants NN15 6PB Time

RESUSCITATION TODAY - SUMMER 2015

22

Presentation

Speaker

Position

Professor in Clinical Traumatology, University Hospital, Birmingham

08.30 – 09.30

Registration

09.30 – 09.35

Introduction

09.35 – 10.15

Trauma…… 30 per cent More Lives Saved

Professor Sir Keith Porter

10.15 – 10.45

New Resuscitation Guidelines A Summary of New & Important Elements

Sheila Turner

Co-Opted Member Resuscitation Council (UK)

10.45 – 11.15

New Resuscitation Guidelines Q&A

Sheila Turner

Co-Opted Member Resuscitation Council (UK)

11.15 – 12.00

Tea/Coffee, Exhibition

12.00 – 12.30

Resus – Defining the Dream Team

Dr Nicholas Crombie

Clinical Lead for Resuscitation Service QEHB

12.30 – 13.00

Difficult Airway and Cardiac Arrest

Andy Thurgood

Consultant Nurse in Pre-Hospital Medicine

13.00 – 13.45

Introducing the “Pit Stop Strategy for Cardiac Arrest Management”

Andy Swinburn FCPara MSc BA(Hons)

Consultant Paramedic

13.45 – 15.30

Lunch and Exhibition

15.30 – 16.00

Incorporating Non-Technical Skills in Life Support Teaching

Mike Davis FAcadMEd

Consultant

16.00 – 16.30

Immersive Simulation and Resuscitation Theories

Rob Clark MSc Paramedic MlfL

Managing Director MDT Global Solutions

16.30 – 17.00

“Termination of Resuscitation”

Matthew House MSc BSc(Hons) LL B(Hons)

Consultant Paramedic

Topics & Speakers correct at the time of press but may be subject to change.

Delegate Rates: £48 inc VAT (Student rate: £36 inc VAT) Cost includes: delegate bag, refreshments and the opportunity to visit over 50 trade stands.

Final Early Bird Offer – Book by 31st July to secure a reduced delegate rate of £36.00 or pay £60.00 to also attend the Paramedic Conference taking place the previous day (saving £36.00)

To register call 01322 660434 or visit

www.lifeconnections.uk.com

EDUCATION NEWS The support from my family, friends and

their business in the markets and tourist

Within a couple of days we were on a hired

colleagues was astounding with a multitude

areas selling trinkets, woollen goods and

bus, the roof loaded with our medical kit, tents

of good wishes and “tear provoking”

pictures, the constant sound of vehicle

and supplies heading into the province of

messages coming my way.

horns and the chaos of traffic that you would

Gorkha at the request of the Health Ministry,

encounter in any city and the general hustle

close to the epicentre. After a few hours

The Tuesday afternoon was spent at the

and bustle of city life. All of this was mixed in

travelling along winding roads we reached

Humanity First HQ in London where all the

with groups of police and soldiers searching

the town of Gorkha where we went to the

buildings and clearing debris, dust filling

local hospital. A Swiss Red Cross team were

the air. Seeing all of this was sobering. The

already at the hospital working closely with the

myriad of thoughts filling my mind of what we

staff. The hospital was well maintained, staffed

would encounter over the next few days. We

and with a steady flow of patients all appeared

would soon find out.

in good order.

team got together, equipment sorted and a full briefing was held. The team was made up of twelve people including surgeons, a GP, A&E consultant, paramedics, a firefighter, pharmacist and a logistics support member.

We set off to Heathrow, our spirits high, confident and hopeful that we would be able

MEDITECH GLOBAL

to do all that we could for the people of Nepal.

Twelve hours later, we were in Kathmandu and registered with the government as a UK Foreign Medical Team (FMT). We were given accommodation on the outskirts of the city, a local family providing us with a roof over our heads while we checked equipment and gained as much

Motorsport Medicine Workshop Wednesday 21st October & Thursday 22nd October 2015 Motorsport pre-hospital support can be just as challenging as it can be exciting. Our CPD day is open to all those providing medical or rescue cover during motorsport events and will include relevant information sharing with industry experienced doctors and paramedics, discussing current best practise along with hands-on medical/rescue workshop sessions. Only 25 places are available at £72 per person !

information as possible about

PROGRAMME

the country, infrastructure and casualties. It’s important to note that in a disaster a foreign team can’t just “turn up”. The affected country has to ask for help and once there it isn’t just a case of picking where you want to go, go there and get on with your job. If only it was that simple. Time was spent form filling, registering with the Health Ministry and attending

Details

Concussion in Motorsport & Return to Competition

FIA Affiliated doctor to present paper on appropriate recognition and return to competition following motorsport related head injury.

Casualty Extrication.

A New Way Forward?

Workshop delivered by motorsport paramedic demonstrating the new Medirol Vacuum Vest and its potential benefits in casualty extrication. Also discussion on use of cervical collars.

A Life of Medical Support During Competitive Motorbike Racing

Light-hearted but frank discussion from paramedic with a lifetime of medical experience supporting world famous motorbike racing events.

Motorsport Medical Support – The Past/ Present/Future.

Discussion on lessons learnt from previous motorsport accidents / review of current guidelines / best practices / what the future holds.

meetings (hosted by various United Nations departments and the World Health Organisation).

A walk around Kathmandu was eye opening. A city full of history and culture where the force of nature had shown no mercy and did not discriminate. Ancient temples and modern buildings destroyed, people sleeping in open spaces, scared of going inside in case there were further aftershocks, buildings cordoned off in case of further collapse, the smell of funeral pyres where the mass cremation of those killed had taken place. Yet everyday

Earlybird birdoffer offer ––Book Bookby byMay July31st 31st to also secure Early secure aa FREE FREEdelegate delegate place place on on our our Paramedic Paramedic Conference Conference on on st nd st nd 21 21 October October or or our our Resuscitation Resuscitation Conference Conference on 22 October October(value (value £48). £48).

To Register call 01322 660434 or visit www.lifeconnections.uk.com

RESUSCITATION TODAY - SUMMER 2015

Topic

life went on. People going about

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EDUCATION NEWS After a few discussions it was decided to carry

there was by a mountain bus in a treacherous

from the Nepalese army who were helping to

on deeper into the province, higher into the

three hour journey. The hazards to the team

clear damaged buildings. The school had been

mountains to a village called Badasse. We had

were high. Aftershocks, landslides, poorly

damaged and many of the houses had been

no idea what we would find but reports stated

maintained vehicles and the risk of an accident

destroyed. We were told that those that had

that there was significant damage, that a high

were to name just a few. But the benefits far

been injured had already been cared for by the

number of casualties were likely and that so far,

outweighed the risks. We were there to do a job

locals or had been taken by their families to the

no medical teams had yet reached the area.

and we intended to get on with it.

This was the place to get to. However getting there was the issue. The tarmac had ran out in

A few hours later after a bumpy, nerve racking

Gorkha. We were faced with dirt track roads

but scenic ride through the hills of Nepal we

barely wide enough for a single vehicle, rutted,

arrived in the late afternoon at Badasse. We

rocky and crumbling. The only way to get

were met by some villagers and a small unit

hospital in Gorkha. However, it was possible that there was a need for medical assistance in the area. As time was getting on and the sun was setting over the spectacular scenery of the hills, we decided to make camp for the night and prepare a medical centre the next morning.

We had no idea if we were needed but we had come this far and

The Difficult Airway Course : EMS Thursday 22nd October 2015 Learn the full range of airway management techniques including use of extraglottic devices, video assisted intubation and surgical cricothyrotomy. Only 16 places are available at a delegate rate of £108 (50% below normal course costs).

PROGRAMME

we intended to stay and offer assistance to those who needed or wanted it. Weariness took hold of us and we spent our first night under canvas, the first of many.

Word had spread throughout the area that a medical team had arrived and early the next morning we were met by a small group of villagers requiring medical assistance. This group steadily

Time

Details

08.30 – 09.30

Registration

09.30 – 10.00

Introduction & Airway Algorithms

10.00 – 10.45

Prediction of the Difficult Airway

with the help of the locals and

10.45 – 11.30

Tea, Coffee, Exhibition

a hundred people with a whole

11.30 – 12.15

BVM & Laryngoscopy

12.15 – 12.30

Self-Scope Video

babies and the elderly, mobile

12.30 – 14.00

Lunch / Exhibition

makeshift medical centre had

14.00 – 15.00

Skills Station I & II – BVM/ETI and EGD’s & Rescue Airways

grew and it quickly became apparent that we would be doing what we came to do. We built our medical centre with tarpaulins, para-cord and bamboo sticks the army and, by lunchtime over host of injuries and illnesses were waiting patiently to be seen; young and infirm, male and female. Our a reception and seating area, triage and basic assessment, pharmacy, consultation and a

RESUSCITATION TODAY - SUMMER 2015

15.00 – 15.30

Tea, Coffee, Exhibition

majors area with full resuscitation

15.30 – 16.30

Skills Station III & IV – Needle/Surgical Airway & Video Laryngoscopy

in Nepal, we were providing an

16.30 – 17.00

Final Moulages

Final Early bird offer – Book by July 31st to also secure a FREE delegate place on our Paramedic Practice Conference taking place the previous day (value £48).

To Register call 01322 660434 or visit www.lifeconnections.uk.com

facilities. On that hillside deep A&E department with a full scope of medical care to people who had been subjected to one of the earths most powerful and destructive events.

By the end of that first day there was a quiet sense of achievement and comfort knowing that we had given help, support and treatment to well over one hundred people.

The spectacular lightning storm that evening with a similarly

24

EDUCATION NEWS striking sunset was surreal; in one direction the setting sun casting a warm glow over the terraces of the hills, in the other direction a partially collapsed school and homes flattened.

There was frustration. Some of the patients told us that medical aid was still needed further on. Nearly a week after the earthquake there were still villages that hadn’t received any help, medical or otherwise. The problem was getting to them. The roads were treacherous at best.

The aftershocks were frequent and at times gut wrenching. One aftershock that we felt had caused a landslide in the next valley sweeping three buses off the road, the fate of those we could only imagine. The only other real option was to use helicopters. However there were “red tape” issues. Our contacts who attended the cluster meetings in Kathmandu and who were in regular contact with us were literally begging for the use of a helicopter. We even marked out a landing pad in the hope that sometime soon our request would be granted. on medical need but also on food and shelter.

With daylight rapidly fading, a storm looking

The next few days were physically and mentally

The journey back was cramped and hot on a

highly likely and doubts about if there was a

challenging. Ninety degree heat, humidity, a

public bus; people standing and also on the

medical need at the village discussions took

hole in the ground as a toilet, dodgy bellies and

roof. It was a true adventure taking in the sites

place about whether we should continue.

a tap to wash under were minor discomforts

and imagining what it would be like to explore

We were due to fly home in two days and

compared to what the Nepalese had been

this stunning country. Back in Kathmandu we

there was a significant risk that we could

through, and given that on that hillside we had

endured yet another “whacky races” taxi ride

easily become stranded in the village due

provided care to over a thousand people we

back to our lodgings. No obvious highway

to the location and weather. The pros and

didn’t mind the discomforts. The majority of

code, compulsory use of the horn and a

cons were deliberated, but, in the end with

patients presented with medical problems such

general free for all on the roads.

heavy hearts, the team made the decision

as respiratory and mental health. People were

to head back to Kathmandu. The risks far The next day was spent at the cluster meetings

outweighed the benefits. Our work in Nepal

know what had happened to their families.

and continual trying to get a helicopter.

for now, was done.

There were traumatic injuries, infected wounds

However it became quickly apparent that the

and dental problems. Whatever the injury

helicopter would be a “no go” for a multitude

The flight home was tinged with mixed

or illness, concern or anxiety, we did all that

of reasons. The initial response phase seemed

emotions of sadness at leaving, not knowing

we could. IV fluids and pain relief or simply

to be coming to an end. The concern of the

what was going to happen to the people

holding a hand we gave what was needed.

UN and government was that in a few short

we had seen, and the happiness at seeing

The strength and resilience of the people was

weeks the monsoon season would have

our families. We had seen devastation and

humbling. They walked through the mountains

started. Food and shelter was slowly becoming

heartbreak. We had made friends with the

overnight for many miles or were carried on

the priority and medical aid taking a backseat.

locals and the family that gave us a roof over

peoples backs or on makeshift stretchers to

We trekked back to the house where we were

our head. The stunning sunrises and sunsets.

reach us. No one complained, no one pushed

staying and met the rest of the team who came

The “Top Gear” mountain drives. The elderly

or shoved. They waited patiently to be seen

back after spending another day treating even

man who had walked through the night, bent

and gave their thanks when they left.

more patients.

double with age and using a walking stick

On our fifth day at the village, despite repeated

Our time in Nepal soon came to an end. Back

be ok”. The toddler with fear in his eyes. The

requests for the use of a helicopter we were

in Kathmandu when it became clear that we

snoring in our communal tent. Endless mickey

told that out best bet would be to return to

wouldn’t get a helicopter we attempted to get

taking of each other. The images of the crashed

Kathmandu and “hopefully” catch a helicopter

to another village, approximately two hours

buses and lorries on the mountain sides.

there. A team of four (including myself) set off

outside of Kathmandu. After a three hour

The thoughts of going into the unknown and

early the next day on a six hour bus journey

journey to a town where we met elders from

apprehension at the start of the trip and that

back to the capital, leaving the rest of the team

the village we were hoping to go to, we were

first phone call. But, we had done it. We had

to carry on with the work in the mountain. The

told that the journey was “possibly another four

given some support, comfort and care to those

plan for us was to get a helicopter to Lapu and

or five hours” on a mountain road, worse than

people. A group of strangers with a common

carry out an assessment of the area, not just

the one that we had encountered in Gorkha.

goal going out to help complete strangers.

to get to us just to hear someone say “you’ll

RESUSCITATION TODAY - SUMMER 2015

scared about further quakes and many didn’t

25

EDUCATION NEWS

Why did I do it? We are lucky in this country. We have the resources, knowledge and expertise. We have a health care and welfare system.

We have a special number that anyone can call at any time in times of distress in the knowledge that someone will come to help. And we

Resuscitation & Emergency Care

have our families who support us on every step when we go into the unknown. Our families who will always have that help and support when needed. Many countries, for whatever reason don’t have that due to politics, economy or geography. Would I do it again? Try and stop me. www.uk.humanityfirst.org

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simon.greenfield@uk.humanityfirst.org About me……..

Born and bred in the Market Bosworth area and now living in South Staffordshire I’ve spent the last nineteen years in the ambulance service starting in Warwickshire (mainly at Dordon and Nuneaton), before training to become an Emergency Care Practitioner. In 2008 I joined the Hazardous Area Response Team with the newly amalgamated West Midlands Ambulance Service which is where I have been ever since.

I joined Humanity First Medical in 2010 after seeing their report about the Haiti earthquake. I am now a part of the faculty and have been involved in a development project in The Gambia before deploying to Nepal in April 2015. I have a young family and am due to get married in August this year.

New Resuscitation Guidelines RESUSCITATION TODAY - SUMMER 2015

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A special delegate rate of just £36.00 (including VAT) is available to those booking before July 31, this price includes lunch, tea/coffee, etc. Over 60 places have already been reserved, therefore, it is recommended that you book early to avoid disappointment as limited places are available.

Registrations can be made online at: www.lifeconnections.uk.com or,

Quality, innovation and choice lnteract with us

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A senior member of the Resuscitation Council will be presenting the New Resuscitation Guidelines at the Resuscitation Today Conference taking place on Thursday 22 October at The Kettering Conference Centre, Kettering, Northants. The full programme can be viewed on: www.lifeconnections.uk.com

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EVIDENCE

CREATING A CULTURE FOR DECISIONS DURING RESUSCITATION Philip Quirk – Director – HBP Training ltd – HF specialist Steven Shackleton – Clinical Tutor – South Western Ambulance NHS Trust Key words – Human Factors, Team development, Transactional Analysis Succinctly summarised, Human Factors is the study of the non-technical skills (NOTECHS) present in accidents. Perhaps more importantly than this though it also develops measures of prevention against such occurrences.

Human Factors concerns itself with how the central human operative interacts with several other components: such as environment, hardware, software and also other humans – colloquially known as the SHELL model1.

Human to human interface The human interface with other humans is understood as the most complicated relationship since both parts are continuously changing from moment-to-moment, and also perhaps occasionally unpredictable!

The care environment is a dynamic constantly shifting continuum whereby likely outcomes change from minute to minute and information is often slow to arrive or reliant on diagnostic testing, it is full of unseen potentials unfolding along the timeline. The most complicating factor perhaps is that healthcare teams are often not close nit units familiar with the ways each other operate but more likely An ad hoc group thrown together for a shift , or in the case of resuscitation team called together to perform and this can also including staff unfamiliar even in the surroundings such as agency staff. In the pre hospital world there is also the multi agency approach and the individual good Samaritan to deal with.

At the centre of these safety critical collaborations is the requirement for complimentary communication, which in itself is atypical of the humanto-human interface.

Lessons can, and should be learned between different industries. There is much for health professionals focussing on resuscitation or other

Environmental considerations within a resuscitation event are now being studied and our relationship and that of fellow clinicians relating to the placement of equipment is a fascinating area to research, design of resuscitation areas and space creation are coming to the fore in many of our hospitals.

RESUSCITATION TODAY - SUMMER 2015

28

critical events to gain from understanding how aviation has embraced and developed Human Factors. The aim of this is to identify where improvement has been made following incidents that aid future delivery and avoid negative outcomes There have certainly been challenges in Aviation’s Human Factors

In prehospital care, specific techniques are taught to crews to enable

journey - and some still remain. Notably pilots scepticism of the

the smooth running of a cardiac Arrest - such as the airway kit

psychological component of HF, sometimes known affectionately as

going on the patients Right hand side - (dictated by the fact that the

‘psychobabble’ within pilot online chat forums.

laryngoscopes is a left handed tool) which enables the ET tube to passed into the intubators free hand (the right).

This is almost certainly similar In medicine and the field of resuscitation, clinicians tend to be rightly proud of their clinical ability and focus on

These basic techniques all assist with the smoothness of the lifesaving

technical aspects of their role to improve their performance. There

event.

remains some scope for developing human factors training that uses examples to tease out the failures not of technical competence but of

Throughout medicine there are other examples of how adaptation

the interactive process and identify methods for reducing likelihood of

following failure / critical incident that was attributable to Human factors

error. This is supported by the work Professor Pat Crosskerry and Dr Mark

has taken place. The development of checklists, processes for challenge

Graber who have both pushed the importance of de-biasing strategy

and response and development of new hardware such as the colour of

to avoid diagnostic error this work certainly overlaps, whether it is the

resus drug boxes all come from and understanding that Human Factors

success or failure of a group task such as resuscitation or an individual

and human fallibility play a significant part in the delivery of critical care.

diagnostic error there will often be a human factors element to it.

1

Ebermann HJ, Scheiderer J. Human Factors On The Flight Deck. Frankfurt, Germany: Springer, 2013.

EVIDENCE There are however, without doubt, effective models that can be migrated from Psychology to better improve safety critical communication, notably Dr Eric Berne’s Transactional Analysis (TA)2.

Viamed VM-2500 range of high performance Capnographs address the growing emphasis on the use of Capnography during resuscitation and intubation

Within aviation there is an identified barrier to effective communication,

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known as Cockpit Authority Gradient.

Without doubt this authority gradient is required to ensure a needed hierarchical structure remains in place to protect against a demographic assault on effective decision making processes. Rather the discussions and debates centre on the situational steepness of the gradient.

This authority gradient can become counter productive in any industry where the established authority, by definition of itself, can compromise effective safety critical communication.

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hierarchies, but also within their own professional communities, overlaying the nursing hierarchy and other healthcare professionals.

Many now acknowledge this and recent confidential enquiries have caused us to question the established norms. The aim of human factors training and discussion is to provide awareness to those

ips

Call us today for more information T: (01535) 634542 E: resus@viamed.co.uk

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RESUSCITATION TODAY - SUMMER 2015

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within the organisation to ensure an understanding of how this may 2

Hay J. Transactional Analysis For Trainers. Hertford, UK: Sherwood Publishing, 2009.

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29 03/06/2015 17:11:36

EVIDENCE affect their behaviour, to attempt culture change and accept that

and Air Traffic Control (ATC), heightened by dense fog on the runway

whilst hierarchical systems are useful for clinical seniority, expertise

and the closure of Gran Canaria Airport after a bomb explosion.

and accountability there still needs to be a freedom for all involved to communicate and provide a human backstop to error when the

The authority gradient was very steep in the KLM flight3. Captain Van

potential is identified.

Zanten was the highest ranked pilot in KLM, his co-pilot did not feel empowered to communicate the mistake he had noticed about the

This shift in culture can only begin once an understanding of the

permission to take off from ATC.

human factors affecting outcomes is widespread. It involves the most senior and the most junior in equal measure.

There is a psychological reason for the co-pilots lack of assertiveness, even in the presence of such catastrophic danger. The answers

Many of us have realised that the best person to be leading a cardiac

potentially lie in Dr Berne’s Transactional Analysis – a psychological

arrest is often not the most senior clinician, or the greatest clinical

pill for a psychological ill.

brain, but may in fact be one of their juniors who specialises in ALS or Paediatric ALS. Their confidence to take charge, to speak out and

There are 3 ego states in Transactional Analysis model the Parent,

dictate a course of action that over rules the established rules.

Adult and Child.

Perhaps the most devastating example of a Human Factors failure

The Parent can further be divided into Critical Parent and Nurturing

/ communication failure can be found in Aviation. On Sunday 27th

Parent, the Child ego state also can be further divided into Free Child,

March 1977 two Boeing 747’s, one from Pan Am and one from KLM,

Little Professor & Adaptive Child.

collided on the runway of Los Rodeos Airport, Tenerife.

The Adult ego state remains singular, this is because this ego state is It is still regarded as the worst aviation disaster of all time with the loss

rational, in the now conscious thought process without contamination.

of life standing at 583. Although as always with a major accident there

This is also the most rational ego state for effective communication.

were many contributing factors, one of the most subtle, yet crucial was the steep Cockpit Gradient on the Dutch KLM flight.

The barrier to communication on the KLM flight was the established Capt. who was operating from a Critical Parent ego state, the co-pilot

Many breakdowns in communication took place between both planes

had been forced into Adaptive Child, which is complimentary.

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RESUSCITATION TODAY - SUMMER 2015

30

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education

Grech M, Horberry T, Koester T. Human Factors in the Maritime Domain. Boca Raton, Florida: CRC Press, 2008.

equipment

enterprise

EVIDENCE When in an Adaptive Child state the person can lack assertiveness and

encourage the questioning of any decision the trainee feels is unsafe.

becomes passive in decision-making. The results from this can be as

This is because statistically it is the senior pilot who will cause the plane

disastrous as they are entirely avoidable.

to crash through cockpit gradient.

A basic understanding of how authority gradient can produce passive

Below is an example of a medical emergency in aviation in which the

participants in important decisions could prevent many accidents from

Professor visibly shallows the authority gradient to produce the right diagnosis.

occurring. Human Factors training gives organisations the opportunity to engage directly with employees about how they may implement change

Orthopaedic surgeon, Professor A.W Wallace, showed thorough and

to avoid error such as checklists, a process of challenge and response

creative option checking when he was travelling from Hong Kong to LHR

for critical skill intervention or simply an improved reporting process and

on an aeroplane.

less punitive approach to serious incident review.

He was asked to care for a passenger who had developed chest pain The fallibility of humans can never be overlooked and unfortunately

(who had been involved in a motor cycle accident before boarding the

this fallibility does not recognise the seniority of qualifications and

plane). The passenger rapidly became seriously unwell. A pneumothorax

experience, furthermore the most competent humans are capable of the

was suspected by the Professor (this happens when a damaged lung

biggest accidents.

leaks air into the pleural space, between the chest wall and the lung; when the air becomes trapped, the lung collapses and threatens life).

When we acknowledge this fallibility we immediately step closer to a safety culture by recruiting the balanced views of supporting

With minimal aids to diagnose, the Professor asked for a second opinion

professionals, this is best achieved by Adult-Adult transactions. By

for a junior doctor. Dr T. Wong, who was also on the plane, agreed with

offering Human factors training an organisation ensures staff are aware

the diagnosis. They then improvised a chest drain set using a urinary

of this fallibility and mindful on the effect it may have on decision making

catheter, a coat hanger as a trocar, adhesive tape, oxygen tubing and a

and outcomes. It produces an environment open to change and a

plastic bottle of mineral water as a water trap. They also used five-star

willingness to engage in system improvement.

brandy as a disinfectant. The patient made a full recovery.4

There has been a cultural development within the Royal Air Force RAF

The professor felt comfortable to seek the advice of a junior and between

in which the flying instructors first words to the trainee pilot is to actively

them a solution was developed.

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Easy to use

Portable

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Your training sessions will have never been so realistic.

Featuring a gesture-based control panel that is built to provide advanced functionality without the complexity of traditional systems, ALSi uses the best of mobile technology to provide an easy to use and seamless user experience from start to finish.

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You can even go outside in the rain as the full ALSi system is supplied with element proof iPad cases to fully protect your iPad’s from the elements wherever your training session takes you and against whatever the weather throws at you.

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What’s included?

1 x ALSi Software License 2 x iPad Air WiFi 16GB (Black) including charger 1 x iPad Facilitator Case (Black) 1 x Monitor Display Case (Yellow) 1 x Apple AirPort Express 1 x Mobile Wireless Router 2 x Waterproof Case for iPad 1 x Waterproof Case for Router 1 x 4-Plug Extension Cable 1 x BP Cuff (Adult) 1 x ECG Cable 1 x Electrodes (Adult) 1 x SpO2 Sensor (Adult)

RESUSCITATION TODAY - SUMMER 2015

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31

EVIDENCE Effective communication is central to the success of modern day businesses,

more than a group with a vague knowledge of each other. It is probably

especially those who work in the presence of high risk and consequence. Any

here that an understanding of how Human Factors can influence

body of knowledge that improves safety critical communication should be

outcome would be paramount and also where some of the useful

researched, understood and if appropriate taught. It is often simply a matter

preventative measures such as checklists are useful to set the standard

of raising the subject and promoting discussion.

and reduce the opportunity for error. This is perfectly illustrated in the Resuscitation Council UK ALS algorithm.

Resuscitation experts are now being taught the importance of human factors, teams who work together are trained together, and

In pre- hospital care many interactions involve hierarchical, human and

communication and critical incidents are simulated and practiced. Team

environmental factors, decisions about when to move patients, how

briefings, in situ simulation and recreating critical incidents and debriefing

to move patients, looking after relatives and the safety of the scene,

are all seen as essential components of the modern resuscitation team.

ourselves and other crews are all areas that can and will need to be

The real difficulty comes when, as mentioned earlier, the team are nothing

considered and communicated.

As the clinical science of resuscitation grows so will the focus on the other aspects that impact on patient care. Human Factors training has the potential

 

   

help organisations and teams accept and manage the unseen challenges of human interaction in the high risk dynamic environment of Resuscitation and Critical Care.

About HBP-Training

 Early bird offer – book by July 31st to also secure a FREE delegate place on our  Resuscitation Conference taking place the following day (value £48) see page 22

Whether working with South Pole

 

financial sector bankers, HBP-

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

adventure teams, fast jet pilots or Training understands the importance of the central human component of the SHELL model and strives for excellence in all levels of

             

performance across industries.

Their unique ability to design, deliver and measure bespoke developmental training interventions ensures they target specific areas in order to create the most positive and

RESUSCITATION TODAY - SUMMER 2015

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

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safe working environment possible.

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  

We strive to ensure that we take

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

also impact upon patient care

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       

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We are keen to share our knowledge

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     

To Register call 01322 660434 or visit www.lifeconnections.uk.com

time to understand the occupational cultures and national cultures that and the hierarchies within the organisations we support.

with teams of clinicians who seek to develop safe ways of working.

Phil Quirk – Co-Director of HBPTraining. www.hbp-training.com phil.quirk@hbp-training.com

32

EQUIPMENT NEWS Nepal - The Effects of a Disaster One Month On SP Services Following the devastating news of the large earthquakes that struck Nepal, International medical supplies company SP Services have been contacted by a number of charities and NGO’s for medical supplies to be sent out to aid with relief efforts in the region. SP is have also been able to help with a number of supplies to charities for remote medical aid workers, paramedics, doctors and nurses flying out to help with search and rescue efforts, medical treatment, first aid, triage and pre-hospital care in the affected areas.

Local Shropshire nurse Gill Bradbury flew out to Nepal from Birmingham International Airport just a day after the news of the first earthquake

to provide medical aid and treatment assistance within the affected areas such as Nepal’s capital, Kathmandu.

In addition, Shropshire paramedic Ed Hullah opted to utilise his accrued holiday days by flying out to Nepal and aid with medical relief delivery efforts for the many people injured following the destruction, Ed finished a 12 hour shift and came straight to SP Services HQ at Bastion House to stock up on medical supplies and do a press interview before flying out the following day.

SP also made a donation to Disaster Medics who flew out just 3 days after the first earthquake struck near Kathmandu with a team of remote medics to help locate missing people and deliver first aid and pre-hospital treatment to those who have not yet reached hospitals or temporary medical centres.

Now, a month on from the initial quake in Nepal and villages still need to be relocated; shelter and livelihoods provided for at least three million people in the danger zone. Relief haven’t reached the remote valleys. There are 25,000 schools destroyed - 1.7 million children are affected. Health posts and hospitals are barely coping with the vast amounts of wounded men women and children. The task of reconstruction is beyond comprehension; 600,000 homes were destroyed.

Amidst the vast tent cities across Kathmandu, for those displaced or afraid to return to their homes the Folkestone Ghurkha and Nepalese Earthquake Appeal Team have been working

RESUSCITATION TODAY - SUMMER 2015

supplies promised from around the globe still

hard to rally donations of food, clothing and medical supplies.

33

EQUIPMENT NEWS SP Services teamed up with Folkestone

The devastating effects of a major incident

SP Services supply medical equipment

Ghurkha and Nepalese Earthquake Appeal

or natural disaster have been thrust to

and consumables for everything you need

Team to get pallets of donated SP medical

the forefront of many individuals and

in an emergency, providing you with a

supplies sent out to Nepal to help with

organisations minds in recent times, most

one-stop-shop for consumables such

their relief and restoration efforts. Teams of

recently with the Ebola outbreak in West

as bandages and plasters, foil blankets

volunteer staff are working around the clock

Africa, rioting and terror threats across the

and water purification tablets, off the

to help with not just the immediate issues

globe and the recent earthquakes in Nepal.

shelf and bespoke kits from first aid to

following the disaster such as medical

By having a disaster preparedness plan in

mass evacuation and disposable health

attention, food and clothing but also to help

place on a business and personal level you

protection, transport from evacuation chairs

rebuild sound environments for the thousands

can be better equipped and prepared for

to stretchers, vacuum mattresses and

of displaced people that have lost their loved

the short, mid and long term effects of a

portable treatment units and Diagnostic

ones, livelihoods and homes.

major incident.

equipment from stethoscopes to blood pressure monitors and the latest state-of the-art AED’s

NAEMT TRAUMA FIRST RESPONDER COURSE Wednesday 21st October 2015 Only 16 places are available on this course offered at £108 (50% below normal course costs). Delegates will also receive a free NAEMT TFR manual (worth £25) courtesy of Class Publishing

PROGRAMME

RESUSCITATION TODAY - SUMMER 2015

34

and defibrillators.

With a 32,000 sq ft warehouse and a tremendous stock inventory SP’s capabilities at Bastion House allowing them to run a 24/7 operation if and when required. SP have a dedicated team of product experts to ensure you get what is needed when it is needed with our rapid deliveries available both nationally and internationally.

Time

Details

08.30 – 09.30

Registration

major incident plan, for more

09.30 – 10.00

Principles of Assessment & Management

contact now:

10.00 – 10.45

Airway / Oxygenation & Ventilation

10.45 – 11.30

Tea, Coffee, Exhibition

sales@spservices.co.uk

11.30 – 12.00

Circulation & Shock

Bastion House, Hortonwood 30,

12.00 – 12.30

Traumatic Brain Injury & Spinal Trauma

12.30 – 14.00

Lunch / Exhibition

14.00 – 15.00

Interactive Skills Scenarios I

15.00 – 15.30

Tea, Coffee, Exhibition

15.30 – 17.00

Interactive Scenarios II / Golden Principles & Assessments

Early to also also secure secure aa Early bird bird offer offer –– Book Book by

by May July 31st 31st to FREE delegate place on our Resuscitation Conference taking place the following day (value £48).

To Register call 01322 660434 or visit www.lifeconnections.uk.com

Make SP Services part of your details on how SP can help you,

www.spservices.co.uk 01952 288 999 Telford, Shropshire, TF1 7XT

EQUIPMENT NEWS

Visit PROACT Medical at ESS 2015 – Stand J17 Visit us to see PROACTS range of innovative Airway Management and Monitoring Products. We will be showcasing the new range of Creative Multi-Parameter and Hand Held EtCO2/SpO2 Monitors offering high technology and affordability.

On show will be the Creative PC-900B handheld Capnograph / Oximeter which has an extremely simple user interface with a bright clear colour display. Its robust design, free of charge Silicone Boot and Case options make it ideally suited for paramedic and tough environment use.

The PC-3000 Multi Parameter Monitor, a compact and lightweight device with a very simple to use interface. The 7 inch high resolution Full Colour TFT display offers selectable display modes – BIG Number display and Waveform Mode display.

The PC-3000 has Adult and Paediatric Modes with auto presets which are user adjustable for all parameters. The PC-3000 also offers field upgrade to 3/5 lead ECG. We will also be showcasing our award winning Naso-Flo Nasopharyngeal Airways, which offer the unique benefits of supplementary O2 feed and optional EtCO2

Combine the Naso-Flo with optional respiratory indicator and the PC-900B to give an ideal bundle for use in: • EMS, Transport, Trauma and Helimed • On patients who are intoxicated or under the influence of drugs • Patients in pre hospital who require monitoring and a secure airway

RESUSCITATION TODAY - SUMMER 2015

Monitoring Connector.

• For use on patients undergoing IV sedation

35

EMMA - Capnograph an essential tool for every RESUS grab bag

Provides more than just confirmation of efficacy of endotracheal tube placement & proof of intubationP

Adult/Paediatric

Infant/Neonate [Reduced deadspace]

EMMA Airway Adapters [Disposable Single Patient]

CO2 values, waveform display and respiratory rate will..

Need Capnography?

Call us and Quote Offer code RTSU15

9 9 9 9 9

Provide feedback of early signs of ROSC Provide feedback of CPR, depth & effectiveness of chest compressions Provide early indication of Hypercapnia & Hypocapnia Reduce the risk of false proof of intubation Provide COPD/Outreach assessment monitoring

Designed for emergency resuscitation & patient transfer 9 9 9 9 9

Accurate Infrared breath by breath measurement: C02 & Respiratory rate Alarms [audible, visual, configurable] C02, Apnoea, Airway, Battery Battery powered [2 x AAA] ~ 8 hours of continuous use Available in kPa or mmHg Lightweight 60 grams & Low cost

MEDACX LIMITED • FREDERICK HOUSE • 58 STATION ROAD • HAYLING ISLAND • HAMPSHIRE • PO11 0EL

02392 469737 info@medacx.co.uk www.medacx.co.uk

RESUS Today Summer 2015 -EMMA Capnograph Outside BC.indd 1

29/05/2015 09:49:38