Clinical Connections

Clinical Connections 1

Edition 4 | Spring 2017

Clinical Connections PROMOTING A CULTURE OF EXCELLENT CLINICAL PRACTICE & INNOVATION WITHIN NAS

Clinical Magazine from the National Ambulance Service Medical Directorate

Clinical Audit Ketamine Trial Communication is Critical Mechanical Chest Compression

2 Clinical Connections

Contents 3 Welcome

Welcome to edition 4

4 Meet The Team

Biographies & new contributors

5 Ask The Medical Director

Q&A with the MD

6 Clinical Case Review

Case 1 Sepsis - EMT

Case 2 Wellens Syndrome - AP

Case 3 Baclofen pump - Paramedic

11 Communication is critical

A typical day at the office

14 One Life

Mechanical chest compression

16 MEDICO Cork

Tales from the telemedical support unit

17 RESEARCH

Statistics made easy

18 Flying High – Ketamine Trial

20 Ketamine Case Review

Ketamine the AP perspective

21 The Newly Qualified AP

Thoughts of the new AP

22 Major Trauma Audit in Ireland

TARN Data

23 NAS Clinical Audit

New clinical audit committee

24 In MY View

YOUR service, YOUR region and YOUR workmates.

Ketamine trial in the EAS

Clinical Connections 3

The National Ambulance Service would like to express our deepest condolences to our colleagues in the Coast Guard following the tragic loss of Irish Coast Guard Helicopter Rescue 116 in the early hours of Tuesday 14th March 2017.

Our thoughts and prayers are with the families, colleagues and friends of; Captain Dara Fitzpatrick, Captain Mark Duffy, Paul Ormsby and Ciarán Smyth. We continue to hold out hope that Paul and Ciarán will be returned to their families.

Suaimhneas síoraí ar a n-anamacha

Welcome to our spring edition of Clinical Connections, as per usual a big thank you to all our contributors; it’s excellent to see a range of practitioner getting involved. In this edition we have cases from an ICV perspective on Sepsis, a great catch of a Wellen’s Syndrome that was accepted to PPCI and the introduction to the Baclofen pump.

Welcome

We will also look at the importance of non-technical skills in prehospital care with articles from Denise Forde AP on the importance of good communication and another instalment from Dr Jason Van De Velde on cognitive bias and lessons learned from the Tele medical Support Line.

Dr Cathal O’Donnell provides us with an update on the introduction of Ketamine in the Emergency Aeromedical Service and we have a look at the dramatic rise in the use of mechanical chest compression since 2015 and the importance of managing both the machine and the patient.

If that’s not enough we also have articles on the life of the newly qualified

AP, our regular column on research, a snapshot of the Major Trauma Audit Report and the inauguration of the clinical audit committee.

As a new publishing that is still developing and finding its path, as always all comments and feedback is welcome. It’s so important that we get your input and cases to continue to make this publishing relevant to you the frontline practitioner. So if you are interested in contributing please drop us an email to medicaldirector.nas@ hse.ie. We will be happy to support you in developing the concept and structure for your chosen subject or case.

Enjoy………..

This publication was made possible with the kind support of

4 Clinical Connections

Meet The TEAM CONTRIBUTORS THIS EDITION Daniel O’Hara

DR CATHAL O’DONNELL Cathal is an Emergency Medicine Consultant and is the Medical Director of the National Ambulance Service. A medical graduate of University College Cork, he completed his Emergency Medicine training in a number of Irish hospitals in Cork and Dublin, and subsequently completed a Clinical Fellowship in Emergency Medical Services at the University of Toronto in 2005. This involved working with both Toronto EMS and the Ontario Air Ambulance Base Hospital Programme.

DR CONOR DEASY Conor is Deputy Medical Director of NAS and Chair of the NAS Research Committee. He is a Consultant in Emergency Medicine working at Cork University Hospital, Senior Lecturer in Emergency Medicine at University College Cork and Associate Adjunct Professor at the School of Primary Care, Monash University, Australia.

Daniel is originally from Sligo. He started his EMT career in the UK where he spent a year working for the ambulance service.

He joined NAS over four years ago first stationed in Donegal and then transferring to Limerick where he currently works on an ICV. “Outside of work I am heavily involved in the music scene as a Musician and have played and continue to play with many bands around the country as a drummer during my time off”.

Brian Hassett

Brian is from Limerick city and a qualified paramedic since 2014, he completed placements in Limerick Ambulance base and has been based in Tipperary town and Cashel since 2014. He thoroughly enjoys working in these bases. Prior to joining the Ambulance service he worked as a taxi driver in Limerick city. He recently completed the Bsc Paramedic Degree program in the University of Limerick and will graduate later this year with an Honours Degree. ”I find every day brings new learning and every call brings new research opportunities”

Damien Gaumont

DAVID HENNELLY David is the Clinical Development Manager for the National Ambulance Service and chief editor of Clinical Connections he works closely with the NAS Medical Directorate to develop and research enhanced systems of care and improved clinical pathways such as, Cardiac Arrest Management, STEMI Care and Major Trauma Care.

David also works with the Emergency Aeromedical Service and supports the clinical governance and clinical leadership of MEDEVAC112.

Damien “Frenchy” Gaumont is a practitioner for over 16 years mainly in Limerick; an Advanced Paramedic for 10 years and Flight Paramedic with the EAS programme. He has a keen interest in advancing the prehospital care with education and new technology; he is an Assistant Tutor at the Paramedic Studies, GEMS (UL), and is associated with the Centre of Prehospital Research in UL, where he has been conducting research and project reviews. He is also a contributor to FOAMed via Facebook® and Twitter®.

He has 13 years’ experience in Restaurant Management in France and UK. On his time off, Damien enjoys spending time with his 3 children, gardening and cooking.

Denise Forde

Denise Forde is an Advanced Paramedic working out of Cork city base. Denise has almost 13 years experience in pre-hospital care, working in Cork city for the last 7 years and before that the wider Cork area. Denise joined the service in 2004 and completed the Advanced Paramedic programme in 2010. A communications instructor with the Civil Defence she has always had a keen interest in communications within the emergency services. In her free time Denise likes to travel and is looking forward to a return trip to Australia in May 2017. The last trip provided an opportunity to visit the Queensland Ambulance Service and the Aeromedical retrieval service in Brisbane.

Kieran Minihane

Kieran Minihane is based in Cork City and has worked as a paramedic with NAS for the past 8 years; he has a keen interest in photography, both on the ground and from the air with emerging drone technology. Kieran is married with one child and is the local Health & Safety and CISM Rep, he also represents his local area on the National Communications Working Group; He is president of the White Knights motor cycle club. Kieran has contributed some amazing images of our service and staff and without him this magazine would look like a dictionary.

Dr Jason Van De Velde

Jason is a Prehospitalist and the Medical Director and founder of West Cork Rapid Response.

He manages MEDICO Cork – the HSE National 24 hour Emergency Telemedical Support Unit run out of Cork University Hospital Emergency Department. Jason is also the Anaesthesia Trauma and Critical Care (ATACC) course disaster response team co-ordinator.

Clinical Connections 5

Viv Forde

Viv is now an Advanced Paramedic working in Cork City. She has been in the service for 12 years, worked in every Cork station and half of Kerry. She is a huge fan of Twitter and FOAMed/FOAMems and #IrishEMS. Her Twitter handle is @VivForde Viv is also the administrator of the Cork City Ambulance Event Tree; A Christmas tree that is decorated throughout the year because all at the base are too lazy to take it down. Since this article has been written she has successfully completed an internship and now a fully-fledged Advanced Paramedic.

Paul Gallen

Paul is the Quality & Patient Safety Manager for the NAS, chair of the NAS Clinical Audit Committee and a member of the NAS Leadership Team. Since joining NAS in 1991, he has transitioned from a Paramedic to Paramedic Supervisor, to Ambulance Officer in Donegal and from there to roles as Assistant Chief and Chief in North Leinster and the South respectively. He holds a MSc. Leadership & Management; BA in HR Management; Dip Emergency Care; PHECC Paramedic; Chartered Associate of CIPD, is qualified mediator and executive coach, and has recently completed studies in Corporate Governance at UCD. Paul’s interests are in the area of quality improvement, patient safety, clinical governance and leadership.

Pat Moran

Pat is based in Roscommon and has over 16yrs experience in prehospital care with the NAS. He completed his Advanced Paramedic training in 2006 and has worked for many years as a solo responder on an RRV. Pat has been seconded to the Emergency Aeromedical Service since it's initiation and has been salient in its evolution. He holds a private pilots helicopter licence and enjoys all things aviation, particularly the incorporation and benefits of crew resource management (CRM/Human factors) within NAS and prehospital care in Ireland.

Ask The MEDICAL DIRECTOR

Q

Damien Gaumont Advanced Paramedic, Limerick

GENERAL TONIC-CLONIC SEIZURE IN THE ADULT AND ADOLESCENT ARE EASILY RECOGNISED, AND THE TREATMENT MODALITIES ARE WELL LAID OUT IN THE CPGS. But seizures in young children can be less obvious, presenting as lip smacking or nystagmus. Other older patients may present distressed with persistent focal seizures or on a single side of the body (Jacksonian march or seizure (https://www.ncbi.nlm.nih.gov/books/NBK2511/ (I.A.1.PartialSeizure)).

We need to strike a balance between the powerful sedative effect of Midazolam and the brain damages caused by prolonged seizures. Is it appropriate to administer Midazolam to patients not displaying the classic generalised tonic-clonic seizures characteristics?

Thank you.

A

Dr Cathal O’Donnell Medical Director

Damien, thank you for your question.

You are correct in saying that seizures can present in ways other than the most commonly encountered tonic – clonic seizure. Seizures in both adults and children can present in many different ways. If a practitioner is confident that the patient is having a seizure that is not resolving (remember many seizures are short-lived and resolve spontaneously), it is appropriate to administer midazolam. However the practitioner should be certain that the abnormal movements are seizure activity – remember midazolam, as well as being an anti-convulsant, is also a powerful respiratory depressant.

6 Clinical Connections

CLINICAL CASE REVIEW

Initial Call: 88 Year old male - Chest infection - Not alert Shift:11:00 – 23:00 Crew: Intermediate Care EMTs

Adult In-Patient Sepsis Patient Screening Form Guidance to be read in conjunction with National Clinical Guideline No. 6 Management of Sepsis in Ireland 4/5/6.4.24

ADULT PATIENTS

Sepsis Screening Form

There is separate sepsis criteria for women in pregnancy

(ALWAYS USE CLINICAL JUDGEMENT)

Complete this form and apply if the National Early Warning Score (NEWS) is ≥ 4 (5 on supplementary O2), or if infection is suspected CLINICIAN TO COMPLETE THIS SECTION

Date:

NEWS:

Clinician’s Name:

Name of Doctor contacted:

Clinician’s Signature:

If temperature > 38.3 C consider

Patient label here

Paracetamol 1 g PO or

Signs of Systemic Inflammatory Response Syndrome (SIRS) - Temperature < 36 or > 38.3oC - Heart rate > 90 No - Respiratory rate > 20 - Acutely confused - Glucose > 7.7 (not diabetic) Has the patient two or more signs (SIRS)

Paracetamol 1 g IV

Yes Could this be a severe infection?

For example - Pneumonia - Meningitis/ meningococcal disease - UTI - Abdominal pain or distension - Indwelling medical device - Cellulitis/ septic arthritis/ infected wound - Chemotherapy < 6 weeks - Recent organ transplant - On immune-suppressant medication

MCRN/NMBI PIN:

Doctor must review within 30 mins (use ISBAR). DOCTOR TO COMPLETE REMAINDER OF THIS DOCUMENT AS APPROPRIATE

Are any 2 or more modified Systemic Inflammatory Response Syndrome (SIRS) criteria present Respiratory rate > 20 (bpm)

WCC < 4 or > 12 x 109/L

Heart rate > 90 (bpm)

Temperature <36 or >38.3 (oC)

Acutely altered mental status Bedside glucose >7.7mmol/L

+ INFECTION SUSPECTED

(in the absence of diabetes mellitus)

Note: Some groups of patients, such as older people, may not meet the modified SIRS criteria, even though infection is suspected.

Where this occurs check for signs of organ dysfunction and raised biomarkers such as C-reactive protein (CRP)

NO

Following a history and examination, and in the absence of suspected infection, staff may proceed with using the NEWS protocol

Doctor’s Name:

MCRN:

Doctor’s Signature:

Date:

YES. THIS IS SEPSIS

Sepsis Six Regimen must be completed within 1 hour

Has a decision been made NOT to escalate care (excluding further treatment)?

TAKE 3

NO

SEPSIS SIX – aim to complete within 1 hour

1. Blood cultures before giving antibotics Do not delay antibiotic administration >1 hour if blood cultures are difficult to obtain. Send samples from potentially infected sites eg. sputum, urine, wounds, IVC/CVC. Consider source control.

4.

O2 (94-98% SpO2 or 88-92% in COPD patients) IV fluid resuscitation (500ml bolus - give up to 30ml/kg) & reassess (target systolic BP>90/MAP>65) Monitor response to IV fluids and titrate to effect

6.

IV antibotics according to local guidelines

Laboratory tests must be requested as EMERGENCY and aim to have results available and acted on within the hour

Look for signs of organ dysfunction:

Look for signs of septic shock (following administration of fluid bolus)

Systolic BP < 90 or Mean Arterial Pressure < 65 or Systolic BP more than 40 below patient’s normal

Lactate > 4 mmol/L

New need for oxygen to achieve saturation > 90%

Hypotensive (Systolic BP < 90 or MAP < 65)

Lactate > 2 mmol/L (following administration of fluid bolus) Urine output < 0.5ml/kg for 2 hours – despite adequate fluid resuscitation Acutely altered mental status Glucose > 7.7 mmol/L (in the absence of diabetes) Creatinine > 177 micromol/L Bilirubin > 34 micromol/L PTR > 1.5 or aPTT > 60s Platelets < 100 x 109/L

Any organ dysfunction: THIS IS SEVERE SEPSIS Registrar or Consultant to review immediately.

Reassess frequently in 1st hour.

Consider other investigations and management File this document in patient notes - Document management plan.

If meningitis suspected ensure appropriate PPE is worn; Mask and goggles

Yes

Oxygen therapy

Risk stratifier SBP < 90 mmHg or MAP < 65 mmHg Signs of poor perfusion

GIVE 3

5.

2. Lactate and FBC 3. Urine output measurement

do not YES proceed

proceed

No

ECG, SpO2 & BP monitoring

Give three O2 titrate to sats > 94% IV fluids IV antimicrobials

Time:

P AP

Patient unwell

o

Time:

EMT

Sepsis – Adult

Version 4, 03/2016

Request ALS

NaCl 0.9% 500 mL IV/IO

Yes If history of penicillin allergy assess the severity of the reaction and if not lifethreatening, i.e. rash, proceed with Ceftriaxone.

Ceftriaxone 2 g IV/IO/IM

Yes NaCl 0.9% 500 mL IV/IO Repeat x 3 prn

Indication for antibiotic No

Signs of poor perfusion No

If Sys BP < 100 mmHg consider aliquots

If either present: THIS IS SEPTIC SHOCK

Indication for antibiotic Septic shock Severe sepsis Meningitis suspected At risk of neutropenia

Signs of shock/ poor perfusion Mottled/ cold peripheries Central capillary refill > 2 sec SBP < 90 mmHg Purpuric rash Absent radial pulse Heart rate > 130 RR > 30 Altered mental status Oligo or anuria

NaCl 0.9% 250 mL IV/IO

Critical care consult required

Consultant referral Consider transfer to a higher level of care Critical care consult requested

A critical care review may be requested at any point during this assessment, but is required for patients with Septic Shock. In a hospital with no critical care unit, a critical care consult must be made and transfer to a higher level of care considered, if appropriate, following the consult.

Doctor’s Name:

MCRN:

Doctor’s Signature:

Date:

Pre alert ED if; severe sepsis septic shock meningitis suspected at risk of neutropenia

If SIRS + infection advise Triage nurse

Time: Reference: National Clinical Guideline No. 6: Sepsis Management, National Clinical Effectiveness Committee, Department of Health, November, 2014

Further information www.health.gov.ie/patient-safety/ncec www.hse.ie/sepsis www.hse.ie SCENE:

We were dispatched to a nursing home 35 minutes away for an AS2 call. On arrival we were escorted to an 88 year old male patient who appeared agitated and distressed, the gentleman was moaning and groaning but not fully alert. An O2 nasal cannula was on but hanging down by his side.

HX: Patient was recently admitted to hospital for a chest infection over four weeks previously. He was discharged to a community hospital for five days before being sent back to the nursing home he came out of. Staff noted since returning that he was not himself. The patient appeared agitated, distressed, was not eating or drinking and not tolerating oxygen, he had a history of COPD and was cyanosed at times. Beyond the COPD the Patient also had history of, Gout, Gastritis, Dementia and recurrent chest infections.

INITIAL ASSESSMENT / CLINICAL IMPRESSION: We explained to the Patient who we were and what we were doing. Assessment revealed a Heart Rate of 110 (I). Respiratory Rate of 40. Blood pressure

140/104. Pupils 3+/3+. Temperature 37.6 and blood glucose level of 2.9. Patient appeared dehydrated.

Skin Colour appeared normal. SPO2 82% on room air. No monitor for ECG. INTERVENTIONS: I asked my crew mate to take out some glucose gel while I attempted to administer O2. I also asked the Nurse if they had any sugary drinks we could ask the Patient to take. The Patient would not take the drink from the Nurse so my crew mate attempted to administer glucose gel. The Patient accepted the glucose gel - only small amounts at a time but this was good enough for us. We were aware that we were dealing with a dementia Patient - who can be challenging Patients at times. I had also attached the O2 cannula successfully and titrated O2 to the COPD guidelines. O2 saturations gradually improved along with blood sugar levels. I took the rest of the handover from the Nurse and transferred the Patient to the stretcher and out to the ambulance. Once in the ambulance the Patient seemed to become calm and less agitated.

Clinical Connections 7

ON DEPARTING SCENE: Because the Patient also met the SIRS / Sepsis pathway, I decided to request AP backup to meet us enroute. We were 30 minutes out and this Patient was quite sick. As circumstances would have it we did not end up meeting the AP prior to getting to hospital. During the transfer I took a set of vital signs again and observed that the Patient had moved his cannula away from his nose. When I attempted to reposition it the Patient stopped me. As it was just under the Patients nose I was happy that he was at least getting some amount of O2. Blood glucose level rose to 3.5 after administering glucose gel but the Patient would not accept any more. At 5 minutes away from Hospital I pre-alerted the Emergency Department because although the Patient appeared stable, he had more than two of the SIRS criteria. I did not administer a nebuliser for this patient (RR40 – wheeze) as he had a heart rate of 110 (I) and I was aware this would / could increase his HR even more.

The Patient would also not tolerate the mask – only nasal cannula. The Patient was accepted in resus and transferred there on our arrival.

LEARNING POINTS / REVIEW: I felt it was important to highlight this case to our peers across the country for two main reasons; 1. Understanding the importance of early recognition and pre-alert to ED of the sepsis patient.

2. Understanding the limitations in training in Sepsis at the EMT level and the potential amount of cases managed within the ICS setting.

Sepsis is a common time- dependent medical emergency. It can affect a person of any age, from any social background and can strike irrespective of underlying good health or concurrent medical conditions. Internationally, approaches to sepsis management care based on early recognition of sepsis with resuscitation and timely referral to critical care have reported reductions in mortality from severe sepsis/septic shock in the order of 20-30%.

(HSE)

Daniel O'Hara EMT

The HSE webpage on sepsis; http://www.hse.ie/eng/ about/Who/clinical/natclinprog/sepsis/ have some good links including an eLearning section specific to Sepsis on HSELand https://www.hseland.ie/dash/ Account/Login The new PHECC Guidelines have a newly developed Sepsis CPG which is available for free download at: http://www.phecit.ie/PHECC/Clinical_resources/ Clinical_practice_guidelines/2017_edition_CPGs/ PHECC/Clinical_Resources/Clinical_Practice_ Guidelines__CPGs_/2017_edition_CPGs. aspx?Hkey=6fe87354-a1f5-4818-a098-7767551a68cf

WE NEED YOUR CLINICAL CASES!!!

To make this initiative effective and practitioner focused I would ask all staff to become part of the content, We are asking YOU the frontline NAS Practitioners to submit Medical or Trauma Clinical Case Presentations to the Medical Directorate to be published in Clinical Connections.

We hope you find this format of reflective learning in which cases of actual patients with a specific diagnosis are shared will increase clinical knowledge and professional development.

And as if that was not enough motivation Each published case will receive a station / personal profile. So get writing……….

To maintain consistency we would request that you use the headings shown here for your clinical case.

Cases should be concise with the focus on the key reflective learning points or new knowledge garnished that can be shared. Please do not include any private information that would identify the patient or images of patients. Inclusion of hi resolution stock images, anonymised ECGs and information tables are encouraged. Content will be reviewed by the Medical Directorate and credited to the submitting practitioner.

Please forward clinical cases to medicaldirector.nas@ hse.ie with the title “Clinical Connections Clinical Case and your name”

TITLE OF CASE PRESENTATION PRESENTATION Set The Scene 1 Phase of Shift 2 RRV /Crew 3 Weather 4 Distance 5 Information available PATIENT Patient Characteristics 1 Age 2 Gender 3 Occupation 4 PMHx INITIAL EXAMINATION On Examination 1 Initial Findings 2 Physical Examination 3 Vital Signs / Tests CLINICAL IMPRESSION Summarisation of Examination Findings & Working Diagnosis INTERVENTIONS Clinical and/or Non Clinical Interventions OUTCOMES Initial Response and /or Response over time DISCUSSION & LEARNING POINTS Can include related findings in the literature, key aspects of the condition / injury, potential impact on clinical practices, Key learning outcomes and shared knowledge.

8 Clinical Connections

CLINICAL CASE When the T waves tell the REVIEW story of an occlusion On a weekday morning we responded to the house of 47 year old man complaining with chest pain and shortness of breath; dispatch code 10D02 On arrival we found a well-dressed gentleman lying on the top of the bed, pale, hyperventilating and anxious.

We managed to control his breathing rate with coaching and adapting a Fowler position. Once settled he described a retrosternal chest pressure with radiation to his left arm for the previous half an hour while he was on the phone.

His vital signs were with in normal limits: Heart rate of 65bpm with a blood pressure of 132/80mmHg,a respiratory rate of 18bpm,with an SPO2 100% on room air, tympanic temperature35.7°C, capillary blood sugar 6.2 mmol/L, without any significant changes throughout the period under our care. His pain score had dropped from 8/10 during the hyperventilation state, to 2/10 once relaxed.

Damien Gaumont Advanced Paramedic

Sinus rhythm of 64bmp, narrow QRS 96ms, normal PR interval 170ms, QTc425ms and QRS axis -44°.

The ST elevations on V1, V2 and V3 have increased to 0.70, 1.74 and 0.74 mm respectively, still outside the STEMI criteria, but with deep T waves inversions on V3, V4, V5.

Still no reciprocal changes are observed. (figure 2).

Secondary assessment revealed clear lung sounds, a soft non-tender abdomen without any gastro intestinal or urinary symptoms and a normal mental status.

A 12 lead ECG shows a sinus rhythm at a rate of 60bpm, narrow QRS 100ms, PR interval of 160ms, QTc 425ms and a normal QRS axis -26°. Slight elevations are noted on V1 (0.56mm), V2 (0.87mm) and V3 (0.38mm) the T waves are inverted in V1 (could be normal pattern) and absent in V2.

No reciprocal changes are found (figure 1).

After a lengthy discussion with intervention from his wife, the patient agrees to be assessed in the local university hospital. Once in the ambulance the vital signs are repeated, including a 12 ECG The patient denies any pain or pressure at this time.

Concern about this dramatic change in the space of 30 minutes, we elected to contact the PCI centre to voice our observations and concerns. On foot of the clinical picture, ECG changes and review of the patient’s files, the cardiology consultant accepted to receive the patient immediately under STEMI protocol. Ticagrelor 180mg PO was ordered (Aspirin 600mg PO was administered prior to our arrival) and an IV access inserted.

The patient states he experienced previous similar episodes in the past years with cardiology assessment (ECGs, echocardiography and stress resulted in test negative findings). They are usually exacerbated with an unusual dermatitis related to scarlet fever since childhood, for which immunologists’ investigations, diagnostic or treatment had been found unsatisfactory (his only medical history).

He smokes 20 cigarettes a day for 25 years, has occasional alcohol, has no family history of cardiac diseases and works as a telecommunication engineer.

He comments on the dissipation of the pressure and ill feeling. Advising that he had coped with similar episodes in the recent past, he declines transportation to ED on foot of work commitments abroad.

Fig 3. Pre-intervention The angiogram revealed a 99%, 4.6 mm long occlusion of the Left Anterior Decending (figure 3 and 4). The Consultant congratulated the crew for recognising this condition named Wellens’ syndrome

Clinical Connections 9

The relevance to pre-hospital care is not just about recognising the ECG characteristics, but also the timing of the acquisition of a 12 lead ECG. The PHECC CPG (5/6.4.10) proposes to acquire and interpret a 12 lead ECG after considerations for oxygen therapy, Aspirin and GTN.

KEY LEARNING POINT

Fig 4. Post-intervention According to the treating consultant cardiologist, if our patient had been brought to the Emergency Department, the ECG will have been close to normal, and cardiac enzymes blood test will be negative; this patient will have been discharged with a cardiology follow up, but would have suffered a, likely fatal, anterior wall Myocardial Infarction within a couple of days.

DISCUSSION: Wellens’ syndrome is associated with critical disease of the Left Anterior Decending (LAD), a pre-infarction state and a high rate of mortality. Described initially as an inverted U wave syndrome in unstable angina by Gerson et al in 1980, Wellens’ and colleagues in 1982 were the first to describe ECG characteristics associated with LAD stenosis: Mild or no ST elevation during the chest pain period, negative cardiac enzymes results, and T wave inversion on precordial leads during the pain free phase, when other evidences of ischaemia (ST depressions) or unstable angina may be absent too. Other criteria include prior history of chest pain, no pathologic precordial Q waves, no loss of precordial R waves, and little or no cardiac enzyme elevations. Those ECG changes are found in 60% of patients with LAD stenosis. Two types of T waves inversions are reported: Type 1, deep T wave inversion (76% of case) on V2-V3 (occasionally on V1 and /or V4, V5, V6).

Type 2, biphasic T waves (starts above the isometric line and deeps below it) (24%) on V2-V3.

Recent case studies support a call for aggressive management with prompt angioplasty rather than conservative management with medication1, 2, 3.

Wellens’ syndrome may show some mild ST elevation in three highlighted cases on the anterior leads (V1-V4) when the patient experiences pain, but ST elevation will disappear completely during the pain free state, been replaced instead by deep inverted T waves.

The opportunity to document a period of ST elevation can be lost if following the traditional algorithm.

A previous report assessing the time delay caused by paramedics performing an ECG on scene suggest that acquisition lengthens the time on scene by only 5 minutes; the ECG electrodes can be placed on the patient while the other crew member organises the previously mentioned medications4. It is worth to remember that a single 12 lead ECG is one picture, and is only 55% sensitive (find the Acute Myocardial Infarction)5.

The other interesting point in the patient’s medical history was the adult scarlet fever. Scarlet Fever is usually caused by a streptococcus infection (of group A) that commonly affects children between five and fifteen years of age. It is associated with a sore throat, fever, a red rash that feels like sandpaper, and the tongue may be red and bumpy (strawberry appearance). It may also affect adults who have either strep throat or streptococcal skin infections (as in our patient’s case). If left untreated, it can progress into Acute Rheumatic Fever, which in turn can cause inflammation of the myocardium (carditis), pericarditis, cardiac enlargement, cardiac valves damage or congestive heart failure failure6.

CONCLUSIONS: This case study shows the importance of repeated ECGs (serial ECG) to find and document dynamic changes. Dynamic changes are very concerning even if they do not meet the STEMI criteria. ECG acquired in the premedication state may document a different picture.

REFERENCES AND FURTHER READING: Tandy TK. Bottomy DP. Lewis JG. (1999) ‘Wellens’ syndrome’, Ann Emerg Med, 33(3), 347-351.

Rhinehardt J. Brady WJ. Perron AD. Mattu A. (2002) ‘Electrocardiographic Manifestations of Wellens’ Syndrome’, Am J Emerg Med, 20, 638-643.

Mead NE. O’Keefe KP. (2009) ‘Wellens’ syndrome: An ominous EKG pattern’, J Emerg Trauma Shock [online], 2, 206-8. Available: http://www. onlinejets.org/text.asp?2009/2/3/206/55347 [accessed 20 Feb 2017].

Ting H. et al. (2008) ‘Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome. A scientific statement from the American heart association interdisciplinary council on quality of care and outcomes research, emergency cardiovascular care committee, council on cardiovascular nursing, and council on clinical cardiology’, Circulation [online], 118, 1066-1079, available: https:// doi.org/10.1161/CIRCULATIONAHA.108.190402, [accessed 20 Feb 2017].

Fesmire F. et al. (1998) ‘Usefulness of automated serial 12-Lead ECG monitoring during the initial Emergency Department evaluation of patients with chest pain’, Annals of Emergency Medicine, 31, 3-11.

Jones, TD. (1944) ‘The diagnosis of rheumatic fever’, JAMA [online], 126(8), 481-484, available doi:10.1001/jama.1944.02850430015005 [accessed 24 Feb 2017].

10 Clinical Connections

CLINICAL CASE BACLOFEN REVIEW PUMP PRESENTATION I was working in a rural station and it was a Tuesday shift which starts at 11.00 and finishes at 18.30 and I was part of a two person paramedic crew working on an ambulance .The day was busy and we had been going since 11:30 when we got dispatched at 16:30 to a Town which was 20 miles away for a AS1 GP referral call for a 19 year old female and the doctor was querying sepsis.The weather was dry and driving conditions were good.

Brian Hassett Paramedic

PATIENT On arrival at scene we introduce ourselves to the patient's mother who stated that her daughter is the patient and that she has Cerebral palsy which is a term used to describe a group of conditions that effect movement and posture because of damage to or failure in the development of the part of the brain that controls movement (Services, 2016).The patient's mother states that her daughter has been getting repeated infections for the last couple of months and that the doctor wanted her to go to UHL for further assessment.

I entered the patients room with mom while my partner was getting the stretcher, I introduced myself to the patient who is in bed and at this stage is non verbal but does make eye contact and a gives a smile. The GP had visited earlier and left a letter which was querying sepsis based on the patients body temp and respirations and heart rate .On Carrying out our primary and secondary surveys (PHECC, 2014) the patients vital signs were as follows INITIAL EXAMINATION HR

RESP

BP

ECG

TEMP

GCS

BG

PUPILS

86

18

126/78

NSR

36.8

15

6.4

2+

CLINICAL IMPRESSION The patients mother has stated that she has just administered 1g of paracatamol 1 hour prior to our arrival and now the patient has improved as a result but due to the repeated episodes of infection she still wants to travel to the hospital .On carrying out my Sample history I discovered the patient is fitted with a Baclofen pump which was fitted 6 years earlier to control the spasticity by delivering baclofen from a pump directly into the spinal fluid at a steady interval both day and night which helps to control the spasticity ,as

this was my first time ever coming across this device I learnt what it was from the patients mother who showed me were the pump was fitted in the abdomen .On finishing the call I did my own research in to this device and how it works (Medtronic, 2014).While transferring the patient to UHL all her vital signs were monitored and maintained and on arrival the handover was carried out using the IMIST â&#x20AC;&#x201C;AMBO handover protocol (service, OCT 2016)

OUTCOMES

DISCUSSION AND LEARNING

Patient was admitted for two days and discharged home with antibiotics and a referral for the baclofen pump to be checked as they can become a source of infection (AL, 2014)

For me this call provided valuable learning and reflection and reinforces the importance of carrying out a full and proper SAMPLE history taking. Every call brings learning and while it may be a long time before I come across a similar call again but if so I will know what a baclofen pump is and how it works and the possible complications and infections that can be associated with it.

REFERENCES: AL, J. P. E., 2014. Complications of intrathecal baclofen pump:A case report. Annala of Physical and rehabiliation medicine, 57(1), p. 50.

Medtronic, 2014. What is a Baclofen pump?. [Online] Available at: http://www.medtronic.com [Accessed 20th January 2017].

PHECC, 2014. Primary survey medical -Adult,Secondary survey medical - Adult.. In: B. Power, ed. Clinical practice guidelines. Kildare: PHECC, pp. 17,18. service, Q. A., OCT 2016. Clinical practice guidelines. [Online] Available at: http://ambulance.qid.gov.au/clinical.html [Accessed 22th Jan 2017].

Services, S. E. S., 2016. Special Education Support Services. [Online] Available at: http://info@sess.ie [Accessed 2017]

Clinical Connections 11

COMMUNICATION A typical day IS CRITICAL at the office After years working as a pre-hospital practitioner in Ireland, this is how many of us describe our working day to family and friends.

While many in the general population would see our profession as extraordinary, for us the extraordinary becomes the very ordinary and we go to work every day not giving it a second thought.That is until one day you’re asked if you would be willing to allow a TV crew to film while you work.. Yikes! Suddenly you become very aware of every word you say, every interaction with patients, their families, colleagues both pre-hospital and in the Emergency Departments, and the public. You realise we are all constantly developing a valuable set of communication skills throughout our whole careers.

Communication plays a major part in our jobs, whether its communicating with control, silent communication with your partner through glances during those calls where you know the patient is in big trouble but you want to avoid heightening their anxiety by verbalising it, or simply sitting with a patient’s relative when you’ve just ceased resuscitation efforts on their loved one - the list is endless. Dealing with mental health emergencies requires a very different approach, as does communicating with children.

During the filming of TV3’s ‘Paramedics Series 2’ we were sent to a call involving a ten year old boy who had fallen from a trampoline and had what sounded like an open fracture to his forearm. With TV crew in tow we set off and enroute to the call I was very aware of how this could be a recipe for disaster, a child in severe pain, no doubt (understandably) anxious parents and a TV crew filming the whole thing, what could go wrong? I set my expectations to deal with chaos.

As soon as we arrived on scene, those communication skills that have become second nature to me, that have been honed over the last 13 years got to work, a calm approach and a cheery ‘hello’ quickly brought the anxiety levels of the patient and his parents down a notch. A quick introduction, a little joke or two, a calm patient assessment, lots of reassurance and prompt administration of pain relief and

we were on a winner. We now had a much happier pain free patient who was more interested in the TV cameras than his broken arm. Job done.

The chaos I had anticipated never showed up. During the patient assessment and treatment the TV crew never entered my head, all credit to them for simply standing back and capturing events as they unfolded and they actually inadvertently played a role in the patients outcome being a welcome distraction after the injury was treated. Good communication is something we cannot learn from a book, not everyone has the gift of the gab and it comes easier to some than others, but each of us have them, that special set of skills, constantly evolving and they have played a bigger part in our careers than any of us acknowledge.

LEARNING POINTS: It’s striking how quickly outside influences are forgotten when dealing with an emergency.

All in all a good patient outcome. Clinical skills, pharmacology and personal interactions play an equally important role in dealing with patients. Which particular set of communication techniques apply to which patient is something that develops with experience. Calming reassurance and good communication can be equally as effective as the pharmacological action of medication in treating patients.

Even though pharmacology is important, including parents/ guardians in decisions and the treatment process is of significant psychological benefit when dealing with the paediatric patient.

Denise Forde Advanced Paramedic

12 Clinical Connections

EMSG 2017 On behalf of the EMSG17 Team, we would like to thank all those who supported us recently in Kinsale, Co Cork, for what we believe was a very successful coming together of many national and international emergency medical services, disciplines and agencies all in the name of education, inspiration and collegiality.

We would like to acknowledge our many supporters and contributors including the National Ambulance Service who helped us put together such a top class event and allowed us to make it as affordable and inclusive as possible.

The speakers and educators this year were of such high calibre, they brought their expert focus on very relevant topics in an enlightening way and we would like to thank

them sincerely for their efforts and enthusiasm shown to all.

On that note, we would like to get your thoughts on EMS Gathering 2017 and the different elements which you may have attended. We will feed this back to our speakers/ educators and also to our Team. If I could ask you to fill in our short survey using the link below, then that would be greatly appreciated. http://prehospitalresearch. eu/research/index. php/828566/lang-en Finally it is our hope that you had a good experience at EMS Gathering 2017 and that you learned, were inspired and enjoyed yourself, we certainly did.

Kieran Henry, Advanced Paramedic EMS Gathering Organiser

Clinical Connections 13

14 Clinical Connections

One Life

EVERY ACTION COUNTS

Mechanical CHEST COMPRESSION David Hennelly Advanced Paramedic

Pic: Kieran Minihane

The National Ambulance Service has invested significantly in a national managed monitor / defibrillator solution and is continuing to rollout the Physio Control LIFEPAKÂŽ 15s across the country. In conjunction with this the mechanical compression device of choice is the LUCAS 2 chest compression system.

The integration of mechanical chest compression devices into a high performing well rehearsed resuscitation can be almost seamless and can continue to provide safe and effective chest compressions at the scene and during transportation.

Clinical Connections 15

With the rapid and dramatic upsurge in the use of mechanical chest compression in the National Ambulance Service it is imperative that practitioners of every grade are familiar with the application and ongoing management of the LUCAS device. The key to this is to remember that the device is simply a robot and requires inputs and adjustments by you the user to optimize performance, your robot is not aware if it has moved to the wrong location, nor does it know if it is producing adequate blood-flow to sustain coronary and cerebral perfusion. You as the practitioner must ensure the device is fitted appropriately and working effectively throughout the resuscitation.

This can be achieved by assessing central pulses and ETCO2 after application and at regular intervals throughout the resuscitation.

Another trick used by some of our international counterparts is

to marking the first and correct location location of the suction cup on the skin of the patient early in the resuscitation, therefore it becomes obvious if the suction cup moves at any stage. It is also vital that the neck strap which is provided with each LUCAS is applied immediately and is left in situ throughout the resuscitation, this stops the device from moving around during defibrillation and transfer.

The introduction of LUCAS is a significant step forward for the NAS, providing consistent rate and depth of chest compressions while stationary or moving, minimizing risk to practitioners during transport and optimizing cerebral and coronary blood-flow while managing reversible causes but always remember the clinical care of the patient is the responsibility of the intelligent responsive human not the robot.

The importance of MANAGING YOUR ROBOT 1. EARLY AND TIMELY DEFIBRILLATION must always take precedence over application of LUCAS. Your immediate priority upon arrival at the scene of an OHCA is to ensure high quality manual chest compressions are sustained with minimal interruption while the defibrillator pads are applied and the initial rhythm is analysed and subsequent defibrillation (VF/VT) occurs.

2. Upon application of the LUCAS, you must ensure the DEVICE IS APPROPRIATELY POSITIONED AND CREATING AN EFFECTIVE OUTPUT. The efficacy of the device can be assessed by palpating a femoral pulse and assessing ETCO2. This should be assessed on an ongoing basis in case the device moves away from the optimal position.

3. Consider MARKING THE FIRST AND CORRECT THE LOCATION OF THE SUCTION CUP on the skin of the patient early in the resuscitation, therefore it becomes obvious if the suction cup moves at any stage.

Top tips to optimise delivery of care and practitioner safety.

4. THE NECK STRAP WHICH IS PROVIDED WITH EACH LUCAS SHOULD BE APPLIED IMMEDIATELY and is left in situ throughout the resuscitation, this stops the device from moving around during defibrillation and transfer.

6. Decisions to continue resuscitation and instigate transportation of a patient in cardiac arrest is based on the CLINICAL DISPOSITION AND SUSPECTED AETIOLOGY of the Patient. Decisions around conveyance, transport and destination should be managed on a caseby-case basis.

5. Defibrillation can be carried out while the LUCAS IS ON and continuing compressions, however it is the responsibility of the practitioner who is defibrillating the patient to ensure they are satisfied that they have clearly identified the underlying rhythm and that they ensure all practitioners are clear during each defibrillation attempt.

In-service training is being conducted on an ongoing basis to support the rollout of the LUCAS 2 Chest Compression System, but there are also supportive videos and reference material available on the following link; http://www.physio-control.com/ LUCAS/

16 Clinical Connections

COGNITIVE BIAS in Telemedicine

Dr Jason Van De Velde Pre-hospitalist and the Medical Director

To utilise its full potential of telemedicine, it is important to understand some of the risks associated with Cognitive Bias.

Confirmation bias is the tendency of people to favour information that confirms their beliefs or hypotheses.

People display this bias when they gather or remember information selectively, or when they want to present information in such a way as to get a particular response.

This is particularly dangerous in telemedicine and can lead to wholly inappropriate advice being dispensed, if based solely on information provided.

Doctors in MEDICO Cork, are instructed to satisfy themselves that all alternative options are considered.

Unfortunately, this line of questioning has the risk of coming across as condescending. It is important to understand that this is done for everyone’s protection.

Doctors taking calls are asked to actively avoid ‘anchoring.’

Framing occurs when someone adopts a too-narrow approach or satisfies themselves with a too-narrow description of the situation or issue. The bias is normally attributed to media reporting or politics. It is however not always a negative bias.

Framing is engrained in Irish Pre-hospital care, both by the very structure of PHECC Clinical Practice Guidelines and the nature of Pre-hospital training. Framing is an integral part of conveying and processing data on a daily basis. CPGs essentially teach successful framing techniques, and are vital in reducing ambiguity, by contextualising information in a way the recipient can connect to what they already know, thereby reliably reproducing a standardised, safe response. We only become aware of the ‘frames’ that we always use when something forces us to replace one frame with another or if an adverse event occurs because a patient was incorrectly categorised to a particular treatment strategy.

Audit of telemedical calls frequently highlight where practitioners have come to the end of the scope of a particular CPG, having convinced themselves of a particular clinical pathway to follow, when in reality they are entirely off track and an alternative CPG may have been more appropriate. This by no means highlights deficits in CPGs, but highlights the problem with categorising any pathophysiological process simply by signs and symptoms alone or forcing a practitioner to fit a patient into a care plan when one doesn’t quite accurately fit.

The challenge is for practitioners to appreciate early that a patient is not quite fitting into a particular CPG, and call early to explore alternatives. The beauty of a distant source of physician support, is that they are forced by virtue of not having examined the patient to rule out or in, a list of differential diagnosis before suggesting a care plan. The classic example being “Chest Pain,” which could have originated from a range of sources e.g. GI, Muscularskeletal, neurogenic, Vascular, Respiratory, Cardiac, etc.

Be very aware that the doctor’s decision making itself is subject to framing bias, and is highly influenced by the way the caller presents a patient to them. To prevent this, try to avoid stating that you have a patient with, eg. “cardiac sounding chest pain,” rather simply state that they have pain in their chest, and then go on to describe the pain in a standardised manner. Actively asking for alternative possibilities, displays a high level of professionalism and is safe practice.

Anchoring or focalism is the tendency to rely too heavily, or ‘anchor’ on one trait or piece of information when making decisions (usually the first piece of information that we acquire on that subject). Two types of thinkers are typically described, ie. Type 1 thinkers are fast, automatic, frequent,

Clinical Connections 17

emotional, stereotypic, subconscious whilst Type 2 are typically slow, effortful, infrequent, logical, calculating and conscious. Whilst Type 1 traits make by far the greatest errors, they are far better suited for emergency work. To improve their practice, they need to consciously question their decision making and be mindful of the tendency to naturally ‘anchor’ to a fact and to use an Irish EMS example, try to make a patient fit into a CPG. The best way to avoid anchoring is when working with a partner, to actively develop a system of working through presentations, challenging each other that the chosen pathway is indeed correct at regular intervals. If the doctor challenges you during a telemedicine call, eg. “are you sure this is...” they are not questioning your ability, it is an attempt for you to openly vocalise all options that have

been considered and why you’ve come to a particular conclusion.

The Ambiguity effect is the tendency to avoid options for which missing information makes the probability seem ‘unknown.’ A safe practitioner will use the unknown as a powerful learning tool, actively seeking out the answer through telemedicine; sharing the gap in their knowledge or simply the fact that something doesn’t quite add up.

The unsafe practitioner will see the unknown as a failure on their part and actively disguise the fact that they don’t know. When establishing MEDICO Cork, the ethos from the start has been one of support and non-judgment. If you don’t understand what’s going on and carry on regardless, the chances for patient harm are very high.

Statistics made easy For many of us, statistics represents an area where we feel very out of our depth. This is justified – it is an expert area. However, a working knowledge of certain statistical concepts can be helpful and important.

Statistics help us quantify the degree of certainty or uncertainty of outcome associated with the outcomes from studies. measurement. For example, evaluating the effectiveness of a drug compared REAL LIFE EXAMPLE with placebo would involve asking: What is the effectiveness of this drug The reason cooling for cardiac arrest 1. Hypothesis testing (p values) compared with placebo? The study would has been abandoned in favour of 2. Estimation (confidence intervals) estimate the risk reduction associated targeted temperature management Many journals prefer confidence with using the drug and use confidence is because in an international intervals to be reported rather than p intervals to indicate uncertainty around multicentre trial including nearly values because it reflects the numbers of this estimate. Conventionally the 95% 1000 patients found 54% in the patients involved in a study. confidence interval is used. The 95% cooled group compared to 52% in the confidence interval is a range of normothermic group had died or had In earlier articles we discussed PICOS and values around an estimate that have a poor neurological outcome (relative asking an answerable question. Related 95% probability of encompassing the risk 1.02: 95% CI 0.89 -1.14) Nielsen, to this is creating a hypothesis. We “true” value of that estimate i.e. the true NEJM, 2013. have also discussed chance - random value probably lies within the confidence occurrences that can influence the interval range. The confidence interval You can see here (as well as the outcome. A research question is phrased will tell you how precise an estimate is. percentages) that the confidence in the form of a hypothesis and the data The wider the confidence interval, the interval here around the relative risk are collected to determine whether the less precise is the estimate. The result is 0.89-1.14 includes 1, the point of no hypothesis is true or the outcome is significant if the confidence interval does effect. due to chance. For example, if we were not encompass the value for no effect. evaluating the effectiveness of a drug The value for no effect differs based on compared with placebo, we would want whether the study is reporting absolute risk reduction or to know is this drug more effective than placebo or is the relative risk reduction. The absolute risk reduction is the risk outcome due to chance? The study hypothesis is that the difference between two treatments and if the risk difference drug is better than the placebo. The study null hypothesis is or could include 0 then the treatment is not effective. is that there is no difference between the drug and placebo.

The p value is the probability that the null hypothesis is true.

The relative risk is a proportion, the numbers of positive So, in this case, if the study reports that the p value for an outcomes in the treatment group divided by the number of outcome associated with drug administration compared to positive outcomes in the control group – if the outcome to placebo administration is 0.01 this means that the there is a this is 1 or in a range including 1, that is you are 1 times more 1 in 100 chance that the null hypothesis is true, that there is likely to have a positive result from the treatment versus no difference between the drug and placebo. You will agree placebo – 1 times more likely means it isn’t useful! that is a small chance. Convention is to accept a reported p value of <0.05 as meaning the outcome is not likely due to chance. That is, that there is a less than 1 in 20 chance that Dr. Conor Deasy the outcome is due to chance.

Deputy Medical Director of NAS and Chair of the NAS Research Committee Often a research question can be phrased as a measurement and the data collected to provide an estimate of the Statistics can be used to address uncertainty in two ways, depending on the way the research question is asked:

18 Clinical Connections

FLYING HIGH – TRIALLING KETAMINE IN THE Dr Cathal O'Donnell Emergency Medicine Consultant Medical Director National Ambulance Service

KETAMINE TRIAL

In November 2016, the NAS Medical Directorate commenced a trial of the prehospital use of ketamine by EAS Advanced Paramedics for analgesia and sedation. EAS was chosen for this on the basis that the EAS casemix tends to be high acuity, and there was a high likelihood of suitable patients being encountered during the trial period. The advantages of ketamine over existing agents (opioids and midazolam) is its haemodynamic effect. Unlike morphine or midazolam, ketamine is not a hypotensive agent or respiratory depressant – it has sympathomimetic properties and so slightly increases heart rate and blood pressure. In addition, unlike morphine or midazolam, airway reflexes are maintained. On this basis, it is an ideal agent for either analgesia or sedation in seriously injured patients who may have had significant blood loss.

RESULTS

During the trial period, ketamine was administered to 16 patients – 9 for analgesia and 7 for sedation. Dosage regimen was 0.1mg/kg for analgesia and 1mg/kg for sedation. The analgesic group were mainly patients with multiple fractures, and the sedation group were almost all agitated combative head injuries.

Ketamine was synthesised in the 1960s by a pharmaceutical company searching for an ideal anaesthetic agent with analgesic properties. The first clinical studies were published in 1965, and ketamine quickly became established in both hospital medical settings and veterinary practice for analgesia, sedation and the induction of anaesthesia. Because of its hallucinogenic properties, it also became a drug of abuse, particularly so in the 1990s.

Ketamine is a drug with many areas of use – induction of anaesthesia, epilepsy, psychiatric diseases and chronic pain syndromes are some of the clinical uses of this drug. Its use in the emergency setting is twofold - as an analgesic agent for severe pain, and at much higher doses, as a sedative agent.

It may also be used in the induction of general anaesthesia.

The main side effects of ketamine are nausea and vomiting, hypersalivation, emergence phenomena (dysphoric or hallucinogenic effects experienced when ketamine is wearing off, rapidly dispelled by small doses of midazolam), laryngospasm and temporary apnoea if given in large doses or quickly.

Figure 1 Numeric Rating Scale

Effectiveness was measured by pre and post admin pain scores (Numeric Rating Scale) for analgesia and pre and post admin scores on the Richmond Agitation Sedation Scale for sedation.

The Richmond Agitation–Sedation Scale Score

Term

Description

+4

Combative

Overtly combative or violent; immediate danger to staff

+3

Very agitated

Pulls on or removes tube(s) or catheter(s) or has aggressive behaviour toward staff

+2

Agitated

Frequent nonpurposeful movement or patient–ventilator dyssynchrony

+1

Restless

Anxious or apprehensive but movements not aggressive or vigorous

0

Alert and calm

Spontaneously pays attention to caregiver

-1

Drowsy

Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice

-2

Light sedation

Briefly (less than 10 seconds) awakens with eye contact to voice

-3

Moderate sedation

Any movement (but no eye contact) to voice

-4

Deep sedation

No response to voice, but any movement to physical stimulation

-5

Unarousable

No response to voice or physical stimulation

Figure 2 The Richmond Agitation – Sedation Scale

Clinical Connections 19

EMERGENCY AEROMEDICAL SERVICE

Figure 1 Reduction in pain scores pre- and post- analgesic dose of ketamine

ANALGESIC EFFECTIVENESS The mean pre – administration NRS for this group was 8.22.

The mean post – administration NRS was 2.88, giving a mean reduction in NRS for the analgesic patient group of 5.34. This is a significant reduction in pain score and indicates that the patient group experienced effective analgesia. In addition, in the judgement of the treating Advanced Paramedic, all 9 patients achieved effective analgesia from the administration of ketamine.

SEDATION EFFECTINESS The mean pre – administration RASS was 2.42. The mean post – administration RASS was -4.42, giving a mean reduction in RASS of 6.84. These results indicate that all patients in this cohort were effectively sedated: 4 patients had an RASS of -5, the deepest level, with two at each -4 and one at -3. In addition, in the judgement of the treating Advanced Paramedic, all 7 patients achieved effective sedation with the administration of ketamine.

PATIENT SAFETY Of the sixteen patients administered ketamine, side-effects were observed in 3, 2 of which were in the analgesia group and 1 in the sedation group. 1 patient vomited on arrival at the receiving Emergency Department. 2 patients experienced a brief period of apnoea – 1 in the analgesic group and 1 in the sedation group. This was managed in both instances by supporting breathing with bag-mask ventilation and in both instances the patient resumed spontaneous breathing after approximately 1 minute, with an otherwise uneventful transport to hospital. The remaining thirteen patients did not experience any side effects.

Figure 2 Reduction in RASS pre- and post- ketamine administration

FLIGHT SAFETY Of the 16 patients in the study, none of the patients experienced emergence phenomena at any time, either during flight or otherwise. Of the 6 patients sedated with ketamine for transport, 3 of these were deemed by both the Advanced Paramedic and the pilot as being too agitated to safely fly prior to administration of ketamine. Having been sedated with ketamine, these 3 patients were flown uneventfully to a receiving hospital with a neurosurgical unit.

Without ketamine, they would have been taken by ground ambulance to the nearest Emergency Department – in all 3 cases, this was a hospital that did not have a neurosurgical service on site and was a significant distance from such a hospital. Ketamine sedation ensured that these patients with serious head injuries were primarily transported to a specialist neurosurgical unit, the best facility for their needs.

CONCLUSION The experience in this trial has been very positive.

Ketamine can be safely and effectively used by Irish Advanced Paramedics, and has significant patient benefits. The data gathered will be submitted to the Medical Advisory Committee of PHECC for consideration of extending ketamine use for both analgesia and sedation to all APs.

20 Clinical Connections

CLINICAL CASE REVIEW SCENE On a morning in late autumn we were the duty crew with the Aeromedical service based in Custume barracks Athlone. The service is provided during daylight hours only and directly tasked by the National Aeromedical Control Centre (NACC) who are collocated in theNational Emergency Operations Centre (NEOC). The aircraft type is an AgustaWestland AW 139 and is crewed by two Aer Corps pilots, EMT crewman and NAS Advanced Paramedic. Shortly after 10am we were simultaneously dispatched to a DELTA call in the North East of the country, some 70 nautical miles away from our location. Initial information described a construction worker in a collapsed state, query head injury, with ALS ground crew arrival on scene in approximately 10 minutes. Following flight and landing site location planning we were airborne in 6 minutes and settled into our flight which would take 31 minutes.

PATIENT The patient was a 32yo male with an unknown medical history who was employed as a steel erector/fabricator on a construction site. At some stage whilst operating a cherry picker at height his colleagues noticed he was unresponsive in the machines basket.

INITIAL EXAMINATION On our arrival the patient had been removed from scene to the rear of the ambulance and on entering we were greeted by obviously agitated and combative casualty. The patient was supine on a long board on the ambulance stretcher and was being subdued by two firemen. The patient was obviously self-ventilating and had good colour with intermittently available but acceptable SPO2 readings so hypoxia was initially discounted as to the cause of the agitation. The A/P on scene communicated that he had witnessed what appeared to be seizure like activity but due to the inability to cannulate because of the patient’s state and following medical oversight 10mg of buccal midazolam was administered. »» HR 116 »» RR 26 »» SP02 97 »» BP N/A »» ETCO2 N/A »» GCS 8 (2.2.4) »» Eyes PERRL »» No obvious trauma to head or body and moving all limbs. »» RASS +3 (Richmond Agitation-Sedation Scale) CLINICAL IMPRESSION T.B.I. or C.V.A KEY INTERVENTIONS »» Humeral head IO Access was obtained with assistance. »» Sedative dose of Ketamine administered which was repeated x1 to achieve effect. »» Established IV access x2. »» Administered Antiemetic. »» Placement of OPA and NPA devices. »» Application of Cervical collar.

Ketamine introduction to EAS OUTCOMES Following the initial dose of Ketamine (adults 1.0mg/kg loading dose) the desired effect was not observed and the patient was subsequently administered an incremental dose (0.5mg/kg) before dissociative sedation(A trancelike cataleptic state induced by the dissociative agent Ketamine ,characterized by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability) was seen.

Within a period of thirty seconds or less from the second Ketamine bolus we were presented with a sedated (RASS -5) patient who could be easily evaluated and treated.

Following further assessment and packaging the patient was transferred to the nearby aircraft. On scene time for EAS was approximately 25mins. The patient was transferred to Beaumont Hospital with a flight time of 12mins during which he received a further incremental Ketamine dose to maintain effect.

No clinically relevant complications including emergence phenomena were observed post Ketamine administration or during our time with the patient in the prehospital phase of care.

DISCUSSION & LEARNING POINTS Agitated and/or combative head injury patients pose a serious challenge for NAS personnel. Rapid control of these patients is paramount to successful prehospital evaluation and also for the safety of both the patient and crews. This concern is amplified by the use of aeromedical transport for this group of patients. In this case the patient’s location was approximately ten minutes by road to a general Hospital but all practitioners present recognised the need to transport to a specialist Neurosurgical centre for definitive care. Had ketamine not been available it was agreed by the EAS crew that transportation by air could not have occurred.

The intramuscular route may have been indicated for safety reasons in this case but as this was an initial ketamine administration the need to titrate was felt to be an overriding concern and the results proved the intraosseous route to be effective. The use of Ketamine allowed for rapid control of the patient’s A B C‘s and minimisation of a secondary brain insult due to hypoxia, hypotension etc.

Following CT and subsequent lumber puncture the patient was found to have suffered a spontaneous Sub Arachnoid Haemorrhage.

FURTHER REFERENCE http://www.tamingthesru.com/blog/prehospital-medicine/ ketamineintbi http://dx.doi.org/10.1136/emj.2007.052753 http://dx.doi.org/10.1016/j.annemergmed.2010.11.030

Pat Moran Advanced Paramedic

Clinical Connections 21

THE NEWLY QUALIFIED Advanced Paramedic My name is Viv and I have been working for The National Ambulance Service in Cork for almost 12 years now, and I am almost at the end of my internship year as an Advanced Paramedic.

Since starting my Post Graduate Diploma in Emergency Medical Science in April 2015, it's been a roller coaster of emotions from balancing study and work, case studies, critical appraisals, and additional pressure of being the clinical lead as an advanced paramedic.

I was lucky. Before starting this journey into a higher level of practice, I was partnered with several great advanced paramedics. This allowed me to learn by watching them practice their skills in advanced patient assessment and treatment which made some of the learning and decision making during my training a lot easier at times.

THE TRAINING Study and training to become an AP is tough. It’s intense.

Basically two years of learning is thrown at you in 10 months. The training is beneficial. I found the content taught is great in patient assessment. I discovered this even after Block 1 of the course. The teachings in anatomy & physiology as well as pharmacology & therapeutics lead to a better understanding of the body systems and the effects of medications on the patient. Lectures and practical sessions on Block 2 also teach a more in depth understanding of various medical conditions and traumatic injuries and their treatments and assessment. Block 3 is the internship weeks where you are assessed on calls working from an RRV under supervision for a while. This again is daunting and exciting, where everything you’ve learned hopefully falls in to place.

BEING THE CLINICAL LEAD AND THE BACK UP Now that I am the clinical lead on actual calls now, at times it can be stressful. I am now the one that is called when ALS assistance is required. Now, I don’t have the comfort of thinking what treatment is needed and whether I was right or wrong, as the ALS was my partner. I am NOW the ALS (Yikes)! This can be particularly daunting when you're the back up for the paediatric patient. Trying to calculate medication doses and treatment plan en route is fine- if you’re not the one driving. Luckily, I currently have a great partner that helps in doing this when I’m driving.

Also, having to take over from your partner on certain calls can be tricky. Of course your approach to this type of situation is the key. You need to show your partner respect and explain why you need to stay in the back and they drive to the hospital. Again, I’m lucky my partner is understanding and does not take this as a personal insult.

After all, it’s about the patient and not egos.

At times, there is the pressure of being the one that others look to you for the answer in what to do and what is wrong.

At times you may not have the answer or be able to do what is required for the patient because it’s not within your scope of practice or you failed at an intervention. That can be a deflating experience. But, ultimately the best care is sticking to the ABCs and sometimes that’s all you can do.

NEW SKILLS AND MEDICATIONS Having a new skill set to work from is definitely exciting. I think every newly qualified AP is anxious to get as much done as soon as possible. We are all bursting at the seams to cannulate, intubate etc. But is it required for every patient to carry out an advanced skill?No- not every patient needs advanced skills. The important thing to be able to do, is to recognise the patient that DOES require these skills. The same applies to the additional medications that advanced paramedics can give. The thing to remember is, you have to use these new skills and treatments appropriately. You have to weigh up is it right to do this or give something just because you can as opposed to, is it right for the particular patient. This is the challenging part of being an AP. Personally, I’m a “treat the patient- not the numbers” person and I’d rather have one reason not to give a medication than 10 reasons to give it. That one reason not to give a medication could be very important.

THE FUTURE Well, hopefully I’ll successfully finish my internship year!

I hope to be a confident practitioner who will, when required, be able to make the right treatment decisions and be willing to listen to suggestions from my fellow paramedics and advanced paramedics. I want to continue to learn and advance our ambulance service on clinical evidence based treatments and international guidelines.

Perhaps, maybe further my studies, because doing the AP course definitely does start the desire to keep learning.

THINKING ABOUT DOING THE AP COURSE? Would I recommend others to do this course? Definitely.

I’ve made best friends on this course. My class (AP22) are a great bunch. We are all still in touch every week.

From small talk to talking/asking questions about calls we’ve encountered. I do feel that what I was taught and experienced on this course has definitely benefited me and hopefully some of the people I have treated since. If you’re willing to concentrate on studying hard and having little or no social life (and a little weight gain) for the duration of the course- then go for it. It’s worth it!!

22 Clinical Connections

Major TRAUMA AUDIT in Ireland MAJOR TRAUMA AUDIT IN IRELAND Major Trauma Audit (MTA) is now carried out in 26 trauma receiving hospitals. It evaluates the care trauma patients receive in pre-hospital and within hospital settings against recognised clinical standards and quality indicators. In December 2016 The Minister for Health, Simon Harris, TD launched MTA as the first national clinical audit to be endorsed and mandated by the National Clinical Effectiveness Committee, highlighting the importance of this audit to the health care system. The first MTA National Report was launched at the National Patient Safety/Clinical Effectiveness Conference held in Dublin Castle.

The National Office for Clinical Audit (NOCA) was established in 2012 to create sustainable clinical audit programmes at national level.

NOCA enables those who manage and deliver healthcare to improve the quality of care through national clinical audit. Major Trauma Audit (MTA) uses the established the Trauma Audit and Research Network (TARN) methodology. It is overseen by a Governance Committee comprising representative stakeholders involved in the delivery of major trauma care including pre-hospital representation from both PHECC and NAS. A/Prof Conor Deasy, Deputy Medical Director of the NAS is the Clinical Lead for MTA. The MTA National Report focuses specifically on the most severely injured patients treated in the Irish healthcare system. It presents findings from MTA in 2014 and 2015, and examined data from a total of 6185 patients. This is the first report published by MTA and includes pre-hospital data and 24 trauma receiving hospitals which commenced at staggered periods over 2014/2015.

This report informs policymakers, hospital management and a wide range of healthcare professionals about how well trauma care is delivered in Irish hospitals.

KEY FINDINGS »» MTA highlights a high incidence of older patients sustaining major trauma – 40% of patients were 65 years of age or older, 75% of which sustained a fall of less than 2 metres. »» 54% of major trauma patients were between the ages of 16-64 years. This group accounts for the largest proportion of patients suffering major trauma and results in a high cost burden to the healthcare system and to society. »» 30% of patients had to be transferred to another hospital for on-going care as their care needs could not be provided by the initial receiving hospital. »» 58% of patients arrived to the Emergency Department out of hours between 4pm-8am. »» 35% of major trauma patients had multiple injuries.

For further information see https://www.noca.ie/major-trauma-audit

Clinical Connections 23

NAS CLINICAL AUDIT The Health Information Quality Authority 2012 defines Clinical Audit as “A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.

Most commonly, the word audit has been associated with financial audit, in which the financial performance of an organisation is evaluated. Audit however, is now part of most quality control systems and forms part of good clinical governance.

There is, however, fundamental difference between financial audits and clinical audit, in that the former are performed by external auditors, in contrast it is important in clinical audit that healthcare professionals have ownership of the audit, and

Paul Gallan Quality & Patient Safety Manager

Clinical Audit is a cyclical process that aims to improve patient care and outcomes by a systematic, structured review and evaluation of clinical care against explicit clinical standards”.

design, participate, and act upon the results relating to their own team performance.

Clinical audit is a cyclical process designed to improve the quality of care. It is used to review clinical care delivery, make changes against agreed standards and reassess clinical performance in light of changes made. Clinical audit aims to ensure quality; it is a way of finding out, are we doing what we are supposed to be doing.

Sustaining improvements

Planning for audit

Making improvements

Standard/ criteria selection

Measuring performance

CLINICAL AUDIT MAY BE REPRESENTED AS AN AUDIT CYCLE OR SPIRAL, OR AS A SERIES OF STAGES: Clinical audit is used to compare current practice with evidence of good practice. It is used to make changes that improve the delivery of care. Benefits of clinical audit include:

Involvement in clinical audit can expose us to new knowledge and provide evidence of our reflection and commitment to continuing professional development.

»»

It provides evidence of current practice against clinical practice guidelines or standards

»»

It provides information about the outcomes of a healthcare service

»»

Assesses how closely local practice resembles recommended practice

In order to enhance our clinical governance and continuously develop our quality of care, NAS has established a Clinical Audit Committee.

The purpose of the committee is to

»»

Enables, Are we actually doing what we think we are doing?

»»

It provides evidence/assurances about the quality of care in a service to establish confidence amongst all of its stakeholderspractitioners, patients, carers and managers.

oversee clinical audit activity within the National Ambulance Service and to ensure an integrated systematic approach to clinical audit.

The scope of the Clinical Audit Committee includes all clinical audit activity undertaken within NAS and the aims of the Clinical Audit Committee are

The committee currently has 12 members and is awaiting the addition of a staff representative, bringing the number to 13 members. The role and responsibilities of the committee is to:

»»

to oversee all clinical audit activity within NAS

»»

»»

to ensure that clinical audit is co-ordinated and has a strategic service wide approach

Plan for audit: choosing audit topics, collaborating with stakeholders, planning audit implementation.

»»

»»

to ensure clinical audit activity is aligned with the NAS Operational Plan, Vision 2020, and the strategic direction of NAS as determined by the NAS Leadership Team

Standard/criteria selection: choosing best practice standards, level of performance needed to reach said standard, criteria of care.

»»

Measuring performance: data collection, analysis, conclusions and results.

to ensure that the quality improvement plans identified by clinical audit are put in place and monitored

»»

Making improvements: Quality Improvement Plans (QIPs)

»»

Reviewing audit findings and approving publication

»»

Setting out realistic Clinical Quality Improvement Plans (C-QIP)

The committee will plan for a number of audits for 2017, and it is intended that the NAS Medical Director will communicate the specific detail of the identified audits in the coming period.

»»

Sustaining improvements: Monitoring performance, re-audit.

»»

Continuous evaluation of the NAS and assessing clinical competences

»»

24 Clinical Connections

In MY View We are looking for stunning images of YOUR service, YOUR region and YOUR workmates.

This magazine and National Ambulance Service communications need these lasting images of Prehospital care in Ireland, From Gweedore to Hook Head, From Carlingford Lough to Castletownbere and from Belmullet to Dublin City.

Pic: Ciaran O’Connor

We are asking all of you with a keen photographic eye to seek out those shots and forward them to: medicaldirector.nas@hse.ie Please use the title “Clinical Connections in My View Photo” and supply your name and contact details.

We ask that all images are sent at the highest resolution and print ready. All images will be credited to the photographer.

It is important that staff do not take any images of Patients or at the scenes of an incident. All images of your peers should be appropriately consented.

Pic: DJ O Callaghan

Pic: David Hennelly

Pic: Roger Hayes

Pic: Kieran Minihane