Clinical Connections Issue 5

Clinical Connections 1

Edition 5 | Spring/Summer 2018

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

Clinical Magazine from the National Ambulance Service Medical Directorate

Kindness ePCR Update The Science of Submersion

2 Clinical Connections

Contents 3 Meet The Team

Biographies & new contributors

4 Kindness

The Importance of kindness

6 Clinical Case Review

Clinical Case 1 Understanding concussion

Clinical Case 2 Paediatric cardiac arrest

14 Developing Research Skills

Research is simply defined as the creation of new knowledge.

15 One Life Project

Survivor story

16 Healthy Living

19 Science of Submersion

Understanding the pathophysiology of drowning

22 ePCR Update

Keeping up to date with ePCR rollout

24 In MY View

EAS special

Achieving a healthy work life balance

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Meet The TEAM CONTRIBUTORS THIS EDITION

PROF 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. He completed a Masters in Leadership at RCSI in 2017 and was recently appointed Adjunct Clinical Professor in Emergency Medicine by the University of Limerick. This involved working with both Toronto EMS and the Ontario Air Ambulance Base Hospital Programme.

PROF 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.

DAVID HENNELLY AP MSC 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.

Kieran Minihane

Kieran Minihane is based in Cork City and has worked as a paramedic with the 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.

David Willis

For the past three years David has worked with the Medical Directorate as the NAS Clinical Information Manager. He has over 15 years’ experience in prehospital emergency care as a registered paramedic, 2 years as Quality, Safety and Risk Manager and has an unquenchable appetite for statistics, audit processes and anything IT. He is NAS lead for the implementation ofElectronic Patient Care Report (ePCR) system and scannable paper PCR record. David is also the NAS lead for Clinical Audit and is a member of the NAS Research Committee. He is also assisting with the rollout of 12-Lead ECG Transmission. As a Kerryman living in Cork his visa application process was lengthy but he appears to finally be accepted into the Rebel County.

Áine Fleming

Áine is a paramedic for the past 7 years with the National Ambulance Service based in Thurles.

Prior to joining NAS, she was a fire fighter with Limerick County Fire and Rescue. Áine enjoys spending time with her husband and 12 year old son on her time off. She also enjoys outdoor activities such as hillwalking, running and cycling. Áine also loves to travel.

Dave Irwin

Dave joined the National Ambulance Service in 2008 and is currently working as an Advanced Paramedic in Loughlinstown Station.

He currently splits his time between clinical practice on the road, as a member of the NAS North Leinster training team during the CPG 2017 upskilling and PHECC’s Medical Advisory Committee.

Dave has a keen interest in resuscitation, ECG interpretation and prehospital coronary care and splits his time teaching these subjects between the current Advanced Paramedic programme and ACLS programmes nationally.

He is a father of two, husband of one, walker of two dogs, Land Rover enthusiast, Low Whistle musician and goes by the Twitter handle @ Dave_Irwin1 !

Shane Mooney

Shane Mooney is an Advanced Paramedic who has been working for the National Ambulance Service and its predecessors for the past 27 years.

He is a station supervisor in Wicklow, but has worked for many years providing clinical education as part of the Education and Competency Assurance Team in the East.

Shane was part of the first MSc class in UCD. As a member of PHECC council, he is Chair of the Quality & Safety Committee and sits on the Medical Advisory Committee.

Outside of the NAS, Shane runs the SAFE Rugby programme for the Irish Rugby Football Union and has a special interest in concussion education and pitch side immediate care training.

4 Clinical Connections

KINDNESS

Cathal O’Donnell, Medical Director

Welcome Welcome to or fifth edition of Clinical Connections, after a brief break since our last edition we are back in full swing.

This time we bring you an excellent article on Kindness

by Prof Cathal O'Donnell, We have two very different Clinical Cases thanks to Shane Mooney and David Irwin, one on concussion and the other on a challenging Paediatric Cardiac Arrest, both have some excellent learning points.

We also have a really great piece from Áine Flemming on the struggle we all face on trying to maintain the balance of a healthy work life balance and an update on NAS projects like the ePCR. As it's Summer time we also have an article on the science of submersion which is an all too common incidence whenever we get fine weather in Ireland.

I hope you enjoy our efforts and please remember to make this publishing relevant to you. It is vital the we get you input and cases. 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 and sharing your article.

Enjoy.......

This publication was made possible with the kind support of

Our job is increasingly being governed by metrics and measurements and key performance indicators– response times, cardiac arrest survival rates, staff sickness and absenteeism rates and so on.

This is an increasing feature of healthcare generally, and broadly speaking I think this is a good thing – we all need to be accountable for what we do. This move to increased accountability however does bring with it a potential downside. The human aspect of what we do can get squeezed out - as we strive to keep up with the measurable, that which cannot be measured may be perceived as being less important. Being kind and considerate to our patients is a fundamental part of what we all do, and needs to be central to every patient contact – here, then, is a call to kindness.

WHAT IS KINDNESS? Look in the dictionary and you will find lots of definitions – here is one that I like (no better or worse than the others): “The quality of being friendly, generous and considerate”.

If you delve a little deeper into the origin of the word kindness, you find that it derives from the Old English word “cynd”, meaning nature, family or lineage – in other words, kin. This implies that we are all related or have things in common, which motivates us to treat each other well because we recognise in each other something of ourselves. In prehospital care, we meet people every day who are sick, injured, apprehensive, afraid, worried - as well as attending to their medical needs, treating them kindly and compassionately can often help them as much as giving them a medication or transporting them to hospital. I know that all of you strive to incorporate kindness into your patient care each and every shift, but did you know that it is good for patients’ clinical outcomes, good for us as healthcare providers, and good for the National Ambulance Service?

KINDNESS – GOOD FOR PATIENTS Intuitively, being kind to patients feels like the right thing to do. But there is

evidence that it actually can improve patient outcomes in an objective way. The Centre for Compassion and Altruism Research and Education (CCARE) at the Stanford University School of Medicine were commissioned

by Dignity Health, a California based hospital network, to do a scientific literature review on the impact of kindness on health care1. They found that post – operative patients treated kindly by anaesthetists healed faster, had reduced length of hospital stay, and a had a 50% less post-op narcotic analgesic requirement. Patients with cold or flu symptoms that experienced empathy in their medical consultation had a 16% reduction in symptom severity, and patients attending ED that were treated kindly by ED staff were less likely to return to the ED. In some instances, the statistical significance of kindness-oriented care on improved outcomes was larger than the effect of aspirin on reducing a heart attack, or of smoking cessation on male mortality.

KINDNESS – GOOD FOR US As well as helping others, being kind to others can actually help us.

We all are familiar with that feeling of wellbeing we feel after an act of kindness to someone, but there is a scientific basis to this. Performing an act of kindness causes an increase in serotonin – serotonin is thought to be one of the neurotransmitters that influences mood (one widely used class of anti-depressant medication, selective serotonin re-uptake inhibitors, or SSRIs, increase the effect of serotonin in the brain). Additionally, compassionate people seem to have higher levels of DHEA, a hormone secreted by the adrenal gland. There is some suggestion that DHEA can help slow the aging process, although the evidence for this is mixed.

KINDNESS – GOOD FOR NAS The Dignity Health study also looked at how a culture of kindness affected organisations and those working for them. They found that organisations

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KINDNESS

with a culture of kindness and compassion had lower levels of absenteeism, increased levels of employee engagement and greater employee well-being and commitment.

INTELLIGENT KINDNESS Penelope Campling, a retired UK psychotherapist, has written an interesting article on what she terms “intelligent kindness”2, in response to the Mid-Staffordshire report and other reports into neglectful and abusive behaviour in the NHS (we have had our own instances here – Áras Attracta, for example). She makes a compelling argument for actively building a culture of kindness and compassion within healthcare organisations, and describes the concept of intelligent kindness. Intelligent kindness is not a soft or sentimental concept, rather an acknowledgement that individuals and organisations can think about and practice kindness in a sophisticated and systematic way.

She illustrates this using the concept of the virtuous circle (figure 1). Campling summarises this in the following way - “Simply put, the more attentively kind staff are, the more

their attunement to the patient increases; the more that increases, the more trust is generated; the more trust, the better the therapeutic alliance; the better the alliance, the better the outcomes.”

A CALL TO KINDNESS At a very basic human level, being kind to both ourselves and others is an innate behaviour. It can become eroded by the pressures of modern life, both personal and professional. The pressures on healthcare staff are well described, and the paramedic profession has its own unique pressures – rising call volumes, greater patient expectations, shift work, and dealing with all manner of human tragedy. If we let it, this can insidiously blunt our natural tendency to compassion. Here then, a call to kindness – let’s all actively work at ensuring kindness is something that we practice to our patients, our co-workers, our families, our friends, and ourselves. The benefits to both ourselves and others are endless.

1 https://www.dignityhealth.org/about-us/press-center/press-releases/scientific-literature-review-with-stanford 2 Reforming the culture of healthcare: the case for intelligent kindness. BJPsych Bulletin (2015) 39, 1-5, doi: 10.1192/pb.bp114.047449

6 Clinical Connections

CLINICAL CASE Concussion, are you on REVIEW the ball?

Half way through a relatively quiet day shift, you are dispatched to a 14-year-old male who has fallen from his mountain bike on a popular bike trail about 15 minutes from your station. When you arrive on scene and after a short hike, you come across a young man who, apart from a few minor scrapes and a buckled wheel, seems to be in good shape. He’s a bit sore but is alert and talking as you begin your assessment. An unremarkable rapid primary survey and no real primary complaint leads you towards a more focused assessment of all systems.

As you start your assessment, it becomes clear that although alert, he is not as orientated as it seemed initially. He complains of a headache, which he scores as 4/10, and says he feels a little nauseous.

He provides you with his name and address, but is not orientated to date or place. He asks you where he is and what happened. You give him as much information as you can, but are surprised when

he asks the same questions again within a minute, this pattern continues all the way to the emergency department.

His vital signs are unremarkable and after cleaning and dressing his minor wounds you begin your transport to the ED. On the way, he has one episode of vomiting and becomes a little more frustrated and emotional as he realises that he cannot remember anything that happened during the past several hours.

Concussion is a common presentation to emergency departments in Ireland each year, estimates of between 1 in every 165 from the World Health Organisation (Cassisdy et al. 2004) and 1 in every 2000 people (HSE) show that it is something that pre-hospital practitioners are likely to experience on a regular basis. Concussion has been described as an injury to the brain that results in temporary loss of normal brain function.

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There are many other variations in that descriptor with the most recent one coming from the International conference on concussion in sport that was held in Berlin in October of 2016 (McCrory et al. 2017).

The Berlin consensus document stated that “Sport related concussion (SRC) is a traumatic brain injury induced by biomechanical forces”. In a further expansion of that description, it described several common features that may be useful in clinically defining the nature of a concussion.

They talked of concussion being caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head, typically resulting in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. Concussion, whatever the cause, normally results in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies (CT Scanning) It results in a range of clinical signs and symptoms that may or may not involve loss of consciousness.

The Berlin Consensus statement (and its predecessors) are important documents in the Irish setting as a lot of the emergency department management of concussions by our medical and nursing colleagues, for both sport related concussion and otherwise, are drawn from these guidelines and its Irish variant (Duignan, 2015).

If we look at the basic anatomy of the brain and it protective case, we know that the relatively soft organ of the brain is protected by the scalp, bones of the cranium and the various meningeal layers. We know that it is bathed by cerebrospinal fluid which acts somewhat as shock absorber. While this gives us some protection in the case of a direct blow to the head, it does not provide the same degree of protection against the complex forces at play in a concussion.

Normal brain function, in fact our every thought, conscious or otherwise relies on the swift passage of electrical

currents along the axon to the terminal synapse where the electrical current is converted to a chemical, a neurotransmitter, which crosses the gap to neighbouring dendrites where the process of electrical movement starts again. In concussion, this process is disrupted, as brain cells, in significant numbers are disrupted and lose the ability to transmit electricity normally.

The cause can be a direct blow, causing a coup – contra coup type injury but often the injury is caused by the rapid acceleration and or deceleration of the brain, causing the partially elastic brain tissue to stretch, producing the diffuse axonal damage. We do know that rotational movement of the head and neck at the time of injury increases the likelihood of concussive symptoms. Just to make it more complicated, we also know that cerebral blood flow is reduced causing a reduction in glucose delivery to the brain cells, neurotransmitters are released in excessive amounts causing the neurons to fire excessively which in turns causes an imbalance in the normal calcium / potassium regulation (Iverson, 2005) Depending on the area and extent of axonal damage, the injured person may complain of a range of symptoms from a temporary loss of consciousness, nausea and vomiting, dizziness, anterograde and/or retrograde amnesia, headache, balance and/or visual disturbances.

While the signs on this list are normally obvious to those in attendance at the time of injury, some symptoms can take up to 48 hours to become apparent.

So how do we diagnose a concussion in our 14-yearold who has come of his bike? Concussion will, for the foreseeable future, remain primarily a clinical diagnosis.

There is no “point of care” test for us as pre-hospital practitioners, in fact even the imaging available in the emergency department is of little value in concussion as the damage occurs at a cellular level and therefore is not seen on conventional CT or MRI. Rates of imaging in the ED vary considerably in Ireland and internationally and often depends on the clinical presentation of the injured

8 Clinical Connections

person, the possibility of a more significant traumatic brain injury (TBI) and the experience of the medical practitioner.

Imaging should be guided by reference to a number of documents like the Canadian CT rule or the more recent NICE guidelines (NICE, 2017). The recently published SCAT5 (Sports Concussion Assessment Tool) is used by medical professionals to measure baselines immediately after the event and during the recovery period and may give some indication on the need for imaging.

What there is broad consensus on, is that most concussions are regarded currently as self-limiting, recovery being described as a symptom free return to normal activities such a school or work. For the majority, this will occur with a month with many describing themselves as well in about 10 to 14 days. Normal time frames for an adult is 1-2 weeks and up to 4 weeks for a child. This 2-week period corresponds to some animal studies that show brain chemistry and blood flow return to normal in this time frame. However, there are those outliers who will take longer to recover and as expected, children and adolescents should be given a longer break from sporting activity (McCrory et al. 2017).

There is no agreed position between the various sporting bodies in Ireland regarding return to play (RTP) timelines.

The IRFU adopted the most conservative RTP policy in January 2014 that keeps adult players out of full contact games for 21 days while those younger players (u20) must complete a 23 day programme. The Berlin Guidelines advocate for a Rest, Rehabilitate, Refer, Recovery model, which can be adopted to any sporting or non-sporting concussion. Of note is the change to the initial 2-week rest period where up to now those with concussion were advised to avoid all physical activity for the first 14 days and all cognitive loading for the first 48 hours. While the advice to give the brain some rest for the first 1-2 days is still valid, the research over the last few years has found that a prolonged break from physical activity compounded the problem in many cases.

The newest guidance is to facilitate some activity after the first 48 hours providing it does not reproduce any previous symptoms or elicit any new ones. Activity after this point should be encouraged as long as it remains below a cognitive and physical exacerbation threshold. After this 14-day period, most sporting organisations would suggest a slow gradual increase in activity aimed at increasing heart rate and blood pressure and then adding movement and more complex drills until the player can be judged to be fully recovered.

So back to our 14-year-old, are we happy to make a working diagnosis of concussion? Yes… maybe, what else could it be.

He complains of a headache which was not there before and says he feels a little nauseous. He’s not orientated to date or place. On the journey, he vomits once and gets a little bit more upset by the whole incident. Could he be suffering from a more significant TBI? How are his vital signs? Is there any evidence of Cushing’s triad, increasing blood pressure with a decrease in heart rate and some respiratory disturbances which would suggest worryingly increases in intra cerebral pressure?

Generally, concussion symptoms tend to get better reasonably quickly with at least a partial return to pre-injury state within a short time frame. A more significant TBI clearly will not and the patient will not improve and / or will get worse. Any more than one episode of vomiting should have some alarm bells ringing as will increasing confusion, a drop in the AVPU or GCS assessment, worsening headaches or significant behavioural changes as well as the more obvious seizure type activity.

The science around the vomiting is interesting as it is mainly retrospective; those patients who did have more than one episode of vomiting were more likely to have evidence of a more significant intra cerebral issue after imaging.

So, our young man probably has a concussion, with no worrying signs at present. While our role as NAS practitioners is well defined in terms of our assessment and treatment, many of those who suffer a concussion will never have an ambulance called. The guidance for all major sporting bodies worldwide is that everyone with a suspected concussion should be medically assessed, most don’t say exactly when this should happen. Clearly the more worrying the signs and symptoms, the quicker the medically assessment should happen.

In many cases the family general practitioner will see the concussed person in the first instance, with a follow up if required. When the ambulance service is called, that first medical assessment will invariable be in the emergency department.

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Although it may seem obvious, many parents still do not understand that if you are concussed playing one sport, you are concussed for all sports and activities. You cannot be concussed playing hurling on a Tuesday evening and go to rugby training on Thursday and PE in school on Friday lunchtime!

Concussion is a common occurrence in sporting and nonsporting activity in this country. Although it has always existed, the media spot light on this injury has increased the public’s awareness and has increased the numbers attending for medical assessment over the last five years. Pre-hospital practitioners will be exposed to concussion on a regular basis and should have some understanding of the pathophysiology at play as well as the knowledge to reassure the worried family member that most concussions are short lived and a full recovery can be expected in a short timeframe.

What’s around the corner? Well there is a huge debate about links to concussions, sub- concussive impacts and the possibility of degenerative brain disease in later life. Despite the growing amount of research taking place worldwide, we simply don’t have evidence to show the link today.

Point of care testing is being developed where perhaps in a few years we will be able to take a blood sample from a finger prick test and look for chemical biomarkers to help us form a diagnosis.

For now, it’s simple, stop the concussed person from whatever activity they have been doing, get them medically assessed, manage their pain and allow them to rest. Ensure a period of “time out” and then build them back up to full fitness after they have returned to school or work.

Cassidy JD, Carroll LJ, Peloso PM, Borg J, von Holst H, Holm L, et al. (2004). “Incidence, risk factors and prevention of mild traumatic brain injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury”. Journal of Rehabilitation Medicine. 36(Supplement 43): 28–60. http://www.hse.ie/eng/health/az/C/Concussion/ McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016 Br J Sports Med Published Online First: 26 April 2017. doi: 10.1136/bjsports-2017-097699

Two areas which have always been the subject of some concerns to parents or family members are sleep and pain relief. Paracetamol, at the age appropriate dose, is regarded as safe and appropriate for those suffering from concussion related headache or discomfort, it will not mask the more worrying signs of a TBI. Rest, including sleep is an important part of the recovery phase. The current accepted norm in an Irish ED would be to evaluate the injured person fully, then allow them to sleep while re-evaluating them every few hours for about eight hours. Sleep is good, having a decreasing level of consciousness is not!

Many concussed young athletes will go home with Mom or Dad, have some mild analgesia and then be dispatched off to bed, with the wireless router turned off to ensure cognitive rest! Mom or Dad will wake them a few times during the night to ensure that they are acting normally and are alert and orientated. The vast majority will be relatively well the next morning, but should still have a formal medical assessment as soon as is practical. Any worrying issues should prompt a drive to the ED or a call to the ambulance service.

Martin Duignan, Niall O’Connor, Concussion management in the ED: Beyond GCS, International Emergency Nursing (2015), doi: 10.1016/ j.ienj.2015.11.005 Iverson GL (2005). “Outcome from mild traumatic brain injury”. Current Opinion in Psychiatry. 18 (3): 301–17. doi:10.1097/01.yco.0000165601.29047. ae. PMID 16639155.

National Institute for Health and Care Excellence (2017) Head injury: assessment and early management. Clinical guideline [CG176] www.irishrugby.ie/downloads/IRFU-Guide-toConcussion%282%29.pdf

Shane Mooney Advanced Paramedic

10 Clinical Connections

CLINICAL CASE REVIEW

Initial Call: Toddler – Cardiac Arrest – CPR in progress Shift: 08:00 – 20:00 Ambulance Crew A: AP & AP Ambulance Crew B: AP & P RRV Crew C: AP Additional Resource: Doctor (ED Consultant)

DISPATCH Both crews and a response car were on station when NEOC alerted us to report of a “(X) year old Child, Cardiac Arrest – 09-Echo-01. CPR in progress.”

Both Ambulances responded along with the RRV and all crews arrived on scene within 2 minutes.

ON SCENE - STREET On approach, the first crew relayed an “open channel” radio message to simultaneously update NEOC and the following crews that CPR was being performed in the street.

On arrival, we observed the child’s parents performing chest compressions under the guidance of NEOC Emergency Call takers.

The scene was noisy, uncontrolled, emotionally charged and heavily crowded with bystanders.

We quickly confirmed that the child was pulseless & apnoic and all agreed that resuscitation was more appropriate inside the environment of the ambulance.

INTERVENTIONS – ON SCENE Defibrillator pads were placed, Anterior – Posterior, and rhythm was assessed as potentially perfusing.

A further pulse check revealed that the rhythm was Pulseless Electrical Activity (PEA) at a rate of 110. CPR was immediately resumed.

One of our AP’s gained tibial Intra Osseous (IO) access but prior to Epinephrine 1:10,000 being administered, a Pulse check revealed the presence of a palpable brachial pulse.

Vital Signs at ROSC: HR 101 , BP 98/62, RR 0, BGL 5.3, GCS 3 Due to the emotionally charged nature of the scene,

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several members of the crew were forced to provide crowd management while treatment was ongoing, prior to the arrival of Gardai.

The patient remained apnoic, and the airway was heavily soiled with stomach content, which required significant suctioning. A supraglottic laryngeal tube airway was placed but was ineffective due to aspirated emesis present in the trachea.

With the patient apnoic, airway heavily soiled and GCS 3 following ROSC, it was decided that an Endotracheal tube was warranted. Direct laryngoscopy was performed by one of our APs with another AP assisting with preparation, suctioning and monitoring.

Suctioning and laryngoscopy provoked a significant vagal response and the assisting AP noted a relative bradycardia.

The defibrillator’s QRS tones were changed to an audible setting to alert us to any further bradycardia.

At the time of incident, the crew were equipped with Macintosh laryngoscope blades only, which provided some difficulty in adequately visualizing the vocal cords fully. The intubation difficulty was assessed as Cormack & Lehane grade 3. An ETT was prepared but the adult sized gum elastic bougie was noted to be incompatible with the paediatric ETT. A Voluntary Doctor Response vehicle arrived on scene and provided a paediatric gum elastic bougie and provided guidance during the intubation.

Intubation was successful, quickly assessed as patent by auscultation and ETCO2 and secured appropriately.

Our BVM was exchanged for a Mapleson C-Circuit flow inflating bag mask device. Instructions on the use of this device were provided by the on-scene Doctor and PEEP was adjusted accordingly.

When departing the scene, our patient had a palpable pulse, was apnoic, intubated, ventilated, with IO access.

HISTORY Patient Hx: Allergies – None Medication – None Previous medical Hx - None Last oral intake - Unknown Event -Child was napping in bedroom. Last seen 1 hour before being found apnoic by parents.

Family Hx: Medications at home: Prescribed Methadone at home.

INTERVENTIONS- EN ROUTE TO ED Due to signs of poor perfusion, NaCl 0.9% (weight specific dose) was slowly infused to maintain palpable peripheral pulses.

History was obtained from the patient’s mother en route.

Having learned of the presence of methadone in the home, combined with the presentation, persistent apnoea, and pupils (Left) 2- / (Right) 2-, we elected to administer Intraosseous Nalaxone.

The patient experienced an immediate increase in heart rate, pupillary response increased (Left) 5+ / (Right) 5+ .

Shortly afterwards, the patient experienced a Tonic Clonic seizure. Intraosseous Midazolam was administered twice without effect.

Direct medical oversight was provided by the Doctor present which allowed us to administer additional doses of Midazolam, however, without effect.

The patient again began vomiting while seizing, requiring significant suctioning and ventilations were becoming ineffective with minimal chest expansion during seizure activity.

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The voluntary Doctor in attendance prepared Intraosseous Rocuronium Bromide, a neuromuscular blocking agent, when additional Midazolam failed to arrest seizure activity and ventilation was no longer possible.

Rocuronium Bromide was administered with immediate and good effect and ventilations were again possible.

The remainder of our journey to Paediatric ED was uneventful and the patient remained ventilated with a palpable pulse.

At Paediatric ED, the patient was handed over to Resuscitation room staff where anaesthesia was maintained for treatment and diagnostic imaging.

OUTCOME Due to the potentially identifiable nature of this case, details regarding the patient’s outcome have been intentionally withheld.

DISCUSSION / LEARNING In the context of the critical care nature of the call and the multiple responding resources, the first crews “open channel” TETRA update allowed all responding crews to receive vital clinical information in real time.

The age of the patient, combined with the nature of the call and the volume of distressed relatives provided a significant challenge to providing a safe and controlled environment to perform critical care and resuscitation. Our crews performed excellently when trying to balance scene management with resuscitation in difficult circumstances.

Following ROSC, suctioning elicited a vagal mediated bradycardia. This was only observed by the assisting AP. As a result, we now advocate turning the Lifepak 15 monitor

QRS “beeps” on to aid monitoring heart rate, even when not looking at the screen.

Laryngoscopy was possible but not adequate with a Mac blade. The curved nature allowed the tip to sit comfortably in the epigolotic vallecula, however the size of the epiglottis prevented an ideal view of the trachea through the vocal cords. As a result, we have now trained our AP’s in the use of Miller straight blades during our yearly regional upskilling education.

Similarly, our adult gum elastic bougie did not facilitate the use of a pediatric ETT. This was provided by the on scene voluntary Doctor and intubation was possible. This has also been resolved in regional upskilling with all of our AP’s having the opportunity to simulate paediatric intubation with the use of a Miller blade and Paediatric Bougie.

Tube depth was established based on clinical assessment of bilateral chest rise and ETCO2 presence, however on reflection we learned that tube depth in paediatrics is determined by a formula determining the “At the lips” (ATL) depth. This formula has now been taught to all APs during upskilling.

Our BVM was exchanged for a Mapleson C Circuit device and our crews were provided with guidance under medical direction in its use. This allowed us to monitor any signs of spontaneous respirations, limit excessive ventilation and control PEEP. The uncuffed nature of the ETT provided us with great difficulty in maintaining tube depth. The provided ribbon tie device was not adequate to grip the tube and vehicle motion resulted in the tube shifting depths multiple times. Additionaly, vomiting resulted in a significantly

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contaminated airway which would have been more secure with a cuffed tube. A literature review revealed that many prehospital services have now adopted cuffed tubes for the resuscitation phase of the paediatric airway, pending a change to an uncuffed tube in the ED. ETCO2 readings were significantly higher than expected, even during ROSC of a potentially acidotic patient. This was later observed to be due to the ETCO2 detector being applied to the patient prior to the “CO2 initializing” phase being complete as displayed by the Lifepak 15 monitor. As a result, we have reminded all staff to observe a brief pause for “CO2 initializing” and the presence of a ETCO2 baseline waveform on screen. Failure to await this, will result in a higher than normal ETCO2 level as CO2 within the ETT is detected and assumed by the Lifepak 15 to be ambient CO2 levels, prior to connection.

The Field Guide, while invaluable for memory recall of medications and procedures, required us to search for multiple pages between WETFAG, Advanced Airway, Epinephrine, Nalaxone, Midazolam, etc. Given the critical nature of the call, an “Age per Page” layout would have been preferred to limit potential for error on multiple pages. This has been suggested to the PHECC Medical Advisory Committee for future Field Guide editions.

Lastly, we observed the importance of a post resuscitation debrief for the purposes of CISM and indeed professional reflection. While this call was professionally and personally difficult for all involved, it is our hope that the lessons learned may serve to educate our colleagues and guide future developments in our profession.

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……….

Dave Irwin Advanced Paramedic

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.

14 Clinical Connections

DEVELOPING Research Skills Completing good quality research in pre-hospital care requires reflection, planning and perseverance.

Research is simply defined as the creation of new knowledge.

To do this we need to first generate an answerable question.

There are an infinite number of research questions the answers to which would help improve patient care and staff well-being pre-hospital. For example, what combination of analgesia is better for different types of pre-hospital presentations associated with pain? What factors are associated with practitioners delivering effective pain relief to patients? What educational initiatives are most effective in delivering good quality sepsis care/pain care/geriatric care/ addiction care/end of life care/paediatric care? What effect does the implementation of certain devices/equipment have on resuscitation outcomes? The list of potential answerable research questions is endless.

Pre-hospital practitioners are better positioned than anybody else in addressing knowledge deficits that exist in the management of patients during their pre-hospital phase of care; we understand the issues in a way that researchers from outside simply don’t. If we don’t choose to accept the challenge, often no one else will, and our profession will not evolve and emergency care provided to our patients will not improve.

Life threatening conditions, vulnerable populations and time sensitive conditions are what we treat – these are high priority areas for research and for the creation of new knowledge.

When tackling a research questions think about the specific patient or population (P) that is relevant, the specific intervention (I) or exposure being considered, the comparison (if any) (C) and the precise outcome (O) of interest. Refining the PICO so it is absolutely clear, logical and answerable is vital.

The next step is to review the relevant literature – find out what is known on the subject; there is no point re-inventing the wheel; it is vital to read broadly on the subject matter and understand it before tackling a study design and ethics application. The world has become a small place in the context of social media and it can be helpful to message an investigator who has published in your area of interest to explore nuances and sense check your plans in advance of investing your energy.

Some people come to me and describe being stuck for ideas for research projects. My suggestion is to scan Prehospital and Emergency Medicine Journals - every paper will mention in its discussion areas where there is a knowledge vacuum and a need for further research. It is also of value to scan journals outside of the specialties of pre-hospital and emergency medicine for ideas – for example, near patient testing also called point of care testing was first developed and described in the General Practice literature – we use point of care blood gas, pregnancy, troponin testing all the time now in Emergency Departments.

Having a mentor and enthusiast who has research experience is invaluable - even the most experienced professor will not work in isolation and will team up with people who bring different skills to the table; equally important to that team is someone to provide enthusiasm and a willingness to champion a project. Identifying a

feasible, interesting, novel, ethical and relevant research question is best done in collaboration and discussion with your research team.

Having a questioning, skeptical, reflective mind is necessary in developing research questions. Observing and reading up on issues that arise day-to-day inevitably identifies research that is crying out to be done.

There are certain courses that are easily acquired and will help provide the skillset required if research is something you wish to do. Excel and word courses are widely available and receiving tuition in their use is very helpful. There are opportunities through evening classes, the HSE, the acute hospitals, the universities etc. to receive training in these programs. Searching pubmed or medline is also a key skill to acquire if you wish to read up on the literature on a subject - the librarian in your medical library at the hospital or university usually runs such courses or will guide you to where you can access such a course. Endnote is a reference management system that takes much of the toil out of managing references – again, the medical librarian will provide tuition courses in use of this program which will, over your professional life time, save you hours of sweat and tears.

Many people engaging in research are petrified of the statistical component; a reasonably simple biostatistics course will teach you what statistical test is required for a particular type of data or data set; if you are engaged in research as part of a university course expertise is made available through the university. SPSS and Stata programs are used to do the statistical tests on your data – get tuition here to make life easy – again, these courses are available on line and through the universities.

When writing up your research the first step is to design your results tables. Ideally table 1 should describe your patients, their age, sex, comorbidities, and the various confounders that could be perceived to influence the outcomes – for example in a cardiac arrest research project you would include initial rhythm, whether the arrest was witnessed, whether there was provision of bystander CPR, the ambulance response time. Table 2 then contains your primary and secondary outcomes. The essence of the research is contained in these two tables and the reader should be able to establish your findings by simply reading these. Your project’s write up flows from these tables.

Research requires a skill set, but so does anything in life.

If you’re the type that wants your job to be dynamic and sustainably fresh then you will want to be involved in investigating better ways of doing things and creating this knowledge for the betterment of patients and staff; research is not just for nerds – if it was, humans would still be swinging from trees.

Prof Conor Deasy Deputy Medical Director of NAS

Clinical Connections 15

One Life

Cardiac Arrest Survivor

EVERY ACTION COUNTS

The One Life Project focuses not only on improving how we manage each Out of Hospital Cardiac Arrest but also on the person behind the Patient. I am greatly honoured to have met Rosaleen White, a Mother, a wife, a Nurse and a Cardiac Arrest Survivor, she gives us an insight into the day she suffered a cardiac arrest and the importance of the Chain of Survival.

Saturday March 12th 2016 was like any other day in our house. Our four children were up and ready for action at 7am! My husband was bringing the older two children to basketball training in Sligo. Routinely I brought the girls every week and helped out at the training sessions however this weekend I was going to Westport to meet my brother as we were doing the Westport Granfondo cycle together. Thomas had only recently taken up the bike and so we opted for the shorter 70km route.

Pat and the kids waved me off that morning, I drove to Westport, met Thomas and we made our way to the Castlecourt hotel for the start of the race. We headed off at 10.30am and made our way out the Leanne road. It was a fabulous spring morning, ideal for cycling and I felt great. Thomas and I chatted for the first 15kms, we were not watching the time or our speed, just travelling at a leisurely pace!

After 15kms Thomas paired up with another cyclist just in front of me however quite quickly he was moving further away. All of a sudden I began to feel very fatigued and I knew I did not have the energy in my legs to catch up with him. I contemplated turning back to Westport and took out my phone to ring Thomas to say that I would meet him at the finish line however there was no mobile coverage. At that point I realised there were no houses either! Just fabulous countryside! In own my mind I knew that the 1st water stop wasn’t far and decided I would ask the stewards for a lift back to Westport from there.

However, I never made that water stop. From that point I developed an overwhelming shortness of breath and was gasping for air, this was followed by a crushing tightness in my chest. I remember feeling like the beautiful mountains and hills were rapidly closing in around me and I had a horrible sense of impending doom. It happened so fast that I didn’t even have time to get off my bike! At that point I collapsed onto my right side, cracking my helmet with the force. And there I lay on the road, a fit and active 38 year old in cardiac arrest.

Other cyclists had witnessed what happened and began to ring for emergency assistance, however this was proving difficult due to the lack of mobile phone coverage. Through no fault of their own, those in my immediate vicinity were unsure of how to help me. However, at that point my luck began to change! Jeanette Gray cycled into the scene, a nurse from Westport who had reluctantly and by chance registered for the cycle that day. She dropped her bike

and rolled me over. I was cyanoised, not breathing with no palpable pulse, she began CPR. And there knelt on the Westport-Leanne road for 10mins alone, providing me the best possible chance of survival I could ever wish for. From there Therese O Grady, a nurse from Castlebar arrived and together they provided two rescuer CPR. At that point contact had been made with the emergency services and the emergency centre for the cycle in Westport. They had alerted the Mayo Civil Defence who were supporting the race and had an AED on board their jeep which they deployed to the scene. Two shocks later and I was back in Sinus Rhythm, unconscious but alive.

I was airlifted to Galway University Hospital and woke later that night trying to figure out in my own mind why I had an ET tube coming out of the right side of my mouth!

I could hear voices and I knew I was ventilated. I began to think of Westport and the cycle and the best possible explanation I could come up with was that I was knocked down. I remember trying to wiggle my toes, I was afraid I had a spinal injury as I could feel the collar around my neck. It’s a very surreal experience to be extubated and told that you have suffered a cardiac arrest. Even now there are times I think did that really happen to me! From Galway, I was transferred to St Vincent’s Hospital in Dublin and I had an ICD fitted. I still have no reason for the arrest, just a random run of VF. The recovery has been slow, it has taken almost a year to get back to normal living again. Physically you have to rebuild yourself again but psychologically even more so. The whole event has had a huge impact my family, especially my children. Sarah is 11 now, Emma 9, Claire 8 and Conor 4. As much as we tried to protect them, their lives were turned upside down.

I can never thank the people who helped me, the emergency and advanced care services. Jeanette Gray said to me some time later that when she rolled me over that day she saw a young face and she instantly thought I was somebody’s daughter. I certainly was somebody’s daughter, but I was also somebody’s sister, wife and most importantly mother. The person you find in cardiac arrest will not have any further recollection of events once they collapse, it is the families who are left to deal with the devastation.

Some people say to me how lucky I was and some say how unlucky! And so often I wished to win the lotto! However on March 12th 2016 my 6 numbers came in!

16 Clinical Connections

Achieving a healthy lifestyle against the battle of shift work My name is Áine Fleming, I have been working as a paramedic for 7 years and a firefighter for 5 years previously. When I’m not working as a paramedic or at home, I like outdoor activities such as hillwalking, running and cycling.

As a person working in the frontline emergency services for the past 10 years, I have become very interested in the health and well-being of myself as a paramedic. With this job in particular we have a lot of exposure to traumatic and challenging situations, unsociable and long shifts coupled with the normal personal and family life stressors and inconsistent sleep patterns.

I have made changes over the past few years to combat mental and physical injury. I believe that if we look after our physical and mental health on an ongoing basis, stressful situations are easier to deal with in life. For me everything starts with mind-set. If I don’t have goals and a positive outlook I find I am not going to see progress.

Training and nutrition fall into place when I’m in a positive mind-set to begin with.

Mindfulness has become a trendy word that we hear a lot about but maybe don’t understand. Really it is simply noticing what’s happening right now. When you live in the moment you are more aware of senses like how your body feels right now, what you see, hear, smell, what your emotions are. When you are aware and notice what’s happening around you, you are more likely to respond rather than react to a situation.

In general we tend to be reactive. For example, if someone says something we disagree with or are hurt by, we react

and maybe say something that we would like to take back the moment it’s said. If we can create a small space between what was said and our action, we can respond in a better way, without hurting our own feels and the other person’s. When we get into the habit of slowing actions down, we become more balanced to deal with any issues arising and we bounce back faster when we are knocked down.

Mindfulness also works well to improve the quality of good things in our lives, for example make time to go for a walk without headphones or any distractions and just take in what’s going on around you. What can you hear, smell, feel and see? Enjoy the moment. If you take your kids to the playground, put away the phone, enjoy that half hour watching them play, or maybe join in.

“It had been said, a warrior’s most formidable weapon is his mind, the sharper the commanders mind, the sounder the decisions” – Boin et al., The Politics of Crisis Management I start each day with what I am grateful for and during most days I find time to mediate, I find it helps me to switch off and recharge, this can last 10-30 minutes depending on how much free time I have. I write down my goals, giving myself a few months’ notice for each. For instance I knew I wanted to climb mountains so I started small, (Keeper Hill

Clinical Connections 17

Áine Fleming Paramedic

in Tipperary) but planned a trip to Ben Nevis in Scotland, knowing that it would push me into a training regime that required regular hillwalking. After successfully completing that challenge I have set my sights on Everest Base-camp this October and to achieve this goal I will need to keep up my running and weights. The mini goals in between keep me fit and healthy on my journey.

I make a conscious decision every day to eat healthy, to exercise and to mediate. It doesn’t always go according to plan but I find that consistency is the key to success. I find that the best way to ensure that I eat healthy is to prepare my food and portion it ready for work. I also always carry healthy snacks such as nuts and fruit in case of not being able to stop for food, this at least will tide me over till I get a proper meal. Not getting overly hungry at any stage is also key to successful healthy eating. If I have to eat from a shop/deli, I try to choose a healthy option and stay away from sugar laden items. I also drink 2-2.5L water per day keeping hydrated with a maximum of 2-3 tea/coffee and low carb options work well for me.

While nutrition is very important, I find that exercise has a real feel good factor. Exercise can be incorporated in many ways such as walking, cycling, running, weight lifting, cardio classes, yoga and many more. The key is to find something you enjoy doing and that you can in reality make time for.

It’s good to get involved in exercise groups if you feel that you need that extra motivation.

A study in Boston found that among new recruits for fire and emergency medical services, 22% were a healthy weight, 44% were overweight and 33% were obese. (1) Also in a study of the Belfast ambulance service from a total of 230 staff, 105 volunteered to take part in a series of fitness tests. Results measured by body mass index showed that 52% were classified as overweight and 10% were obese.

(2) The rise in sedentary lifestyles carrying extra weight has put a significant strain on our health resulting in the rise of diseases; these include type 2 diabetes, high blood pressure, cancer and heart problems. Our health should always be to the fore front of our priorities. (3) With our hectic life schedules we can often put ourselves last on the priority list.

According to other studies, Paramedics are also more likely to have higher blood pressure, smoke and have higher cholesterol than the general population (4-6). Clinical care can be negativity impacted, for example physical fitness has been identified as an important component in assisting the rescuer to perform adequate chest compressions during Cardiopulmonary resuscitation (CPR) (7,8). Therefor a paramedic’s fitness level has an impact on patient care. It is difficult with shift work to find time for food preparation

18 Clinical Connections

and exercise but it can be done. Shift work is part of a paramedic’s lifestyle and that’s not going to change.

Paramedic alertness at work and clinical performance increased through exercise. At least 20 minutes of physical activity before a shift will boost mood and combat fatigue while working. If that’s not suitable, the best time for paramedics to work out is when they feel like it, whether it be pre or post shift. Circuit weight training will burn more calories than interval training, and significantly more than steady cardiovascular activity (9).

Other advantages of a fit and healthy work force include; Improved work performance , Reduced absenteeism and sick leave, Improved staff moral and motivation, Increase in physical health and mental wellbeing, Increase in health awareness and knowledge, Greatest opportunity to enjoy life both in and outside the workplace.

We often find ourselves relying on fast food, snacks and sometimes skipping meals altogether, as a result of busy shifts and lack of resources. Identifying ways to reduce the risk of adverse health effects should be a priority for the paramedic and their service. Healthier lifestyle choices, including healthy eating and increasing physical activity can help promote the best possible health in the paramedic.

As a nation I think we have started to treat ourselves with food much more than is necessary or beneficial for us.

Treating ourselves once in a while is important, healthy and fun. It shows that we value ourselves—but when we use food as a reward too often, an occasional treat can turn into a bad habit, thus defeating the whole purpose of a treat.

What I have found is that making small changes and noticing you feel the benefits that for instance drinking water rather than minerals has on your body will push you to make other changes because as paramedics we need to be kind to ourselves. Eating healthy and living an active life is all about making mindfulness, clean eating and exercise, as high a priority as the other responsibilities in your life.

You have to make yourself a priority which so many of us don’t do. If you want to be mentally and physically fit you must make time each day to prepare.

Other small changes to help would be to make a decision to maybe eat a healthy breakfast every morning, eat one healthy meal per day, don’t take sugar in tea, drink more water, take the stairs instead of the lift, park a little walk from the shops, pick one small change and when you feel better for doing that, pick another and little by little you will be on you way to a healthier body and mind. Be patient with yourself, every good choice and every extra step you take makes a difference.

REFERENCE Tsismenakis AJ, Christophi C a, Burress JW, Kinney AM, Kim M, Kales SN. The obesity epidemic and future emergency responders.

Obesity (Silver Spring). Nature Publishing Group; 2009;17(8):1648–1650.

Gamble RP, Stevens AB, McBrien H, Black A, Cran GW, Boreham CAG. Physical-Fitness and Occupational Demands of the Belfast Ambulance Service. Br J Ind Med. 1991;48(9):592–596.

National Heart Lung and Blood Institute.

(Nov.11,2010). What are overweight and obesity? In National Heart Lung and Blood Institute Retrieved March 11 2017 from www.nhlbi.nih.gov/health/ health-topics/topics/obe/.

Buzga M, Jirak Z, Buzgova R. State of physical health and fitness of paramedics in Czech republic. Wulfenia.

2015;22(3).

Tsismenakis AJ, Christophi C a, Burress JW, Kinney AM, Kim M, Kales SN. The obesity epidemic and future emergency responders. Obesity (Silver Spring). Nature Publishing Group; 2009;17(8):1648–1650.

Gamble RP, Stevens AB, McBrien H, Black A, Cran GW, Boreham CAG. Physical-Fitness and Occupational Demands of the Belfast Ambulance Service. Br J Ind Med. 1991;48(9):592–596.

Lucía A, Heras JF De, Pérez M, Elvira JC, Álvarez AJ, Chicharro JL, et al. The Importance of Physical Fitness In the clinical investigations in critical care The Importance of Physical Fitness In the Performance of Adequate Cardiopulmonary Resuscitation *. Chest.

1999;115(1):158–64.

Gutwirth H, Victoria A, Williams B, Boyle M. CPR compression depth and rate in relation to physical exertion in paramedic students. 2007;4(2).

Paoli A, Pacelli QF, Moro T, Marcolin G, Neri M, Battaglia G, et al. Effects of high-intensity circuit training, low-intensity circuit training and endurance training on blood pressure and lipoproteins in middle-aged overweight men. Lipids Health Dis. 2013;12(1):131.

Folkins, Carlyle H.; Sime, Wesley E. Physical fitness training and mental health. American Psychologist, Vol 36(4), Apr 1981, 373-389.

Clinical Connections 19

The Science of Submersion

David Hennelly Advanced Paramedic, Clinical Development Manager

Each year, drowning accounts for at least 450,000 deaths worldwide Irish Water Safety figures (Table 1) shown below average 132 deaths in Ireland each year.

Statistics for nonfatal drowning are more difficult to obtain, but nonfatal drowning events may occur several hundred times as frequently as reported drowning deaths. In this article we will discuss the science of submersion and the associated treatment in the prehospital setting.

DEFINITION Firstly let’s get to grips with the language we should be familiar with; there have been multiple definitions and subdefinitions of drowning in the past which have resulted in confusion and inability to compare studies on management and outcome. To try and simplify matters, an advisory statement from the International Liaison Committee on Resuscitation (ILCOR) was published in 2003. In it drowning was defined as a process rather than an event: DROWNING IS A PROCESS RESULTING IN PRIMARY RESPIRATORY IMPAIRMENT FROM SUBMERSION/ IMMERSION IN A LIQUID MEDIUM Implicit in this definition is that a liquid/air interface is present at the entrance of the victim’s airway, preventing the victim from breathing air. The victim may live or die after this process, but whatever the outcome, he or she has been involved in a drowning incident.

Non-fatal drowning is where the drowning process is interrupted and the person survives.

Fatal drowning is where the person dies during the drowning process (at any stage).

COLD WATER Vs WARM WATER This article will focus heavily on the physiological effects of drowning and the prehospital care, later in the year we can discuss the significant impact of Hypothermia on the body but even in Ireland’s coldest waters, due to protective body responses, core hypothermia can still take around 30 minutes to occur. This is due to the relatively mild climate and Atlantic Gulf Stream which keeps the average seawater temperatures in Ireland between 8-16°C and the inland waterways between 4-16°C. However it is estimated that cold water shock effects can account for over 50% of open water deaths in the UK and Ireland within the first three minutes of immersion. Cold shock results from a sudden cooling of a large area of skin following sudden contact with cold water. Its effects may be seen in temperatures below 25°C but are most notable in water at 10°C or less.

Cold shock predominantly affects the respiratory and cardiovascular systems via a huge sympathetic nervous system stimulus. Your initial reaction is to take a large gasp followed by rapid uncontrolled respirations, if unmanaged it can result in involuntary intake of water causing Laryngospasm. This can rapidly cause the victim

Statistics for 2007 - 2016 *this data is provisional and subject to revision

Year

2016*

2015*

2014

2013

2012

2011

2010

2009

2008

2007

Accidental

82

66

58

55

76

59

49

51

64

59

Suicide

29

33

46

35

51

44

50

60

53

76

Undetermined

12

23

22

19

17

19

26

33

20

32

Assault

0

0

0

1

0

0

0

1

0

0

Other Causes

0

0

0

0

0

0

0

0

0

1

Total

123

122

126

110

144

122

125

145

137

168

20 Clinical Connections

to lose consciousness and may explain the inability of victims to self-rescue if submerged or if trapped in rising water, this process can also account for an impaired ability to coordinate breathing with swim stroke, which is why we sometimes hear of experienced swimmers drowning if rapidly immersed in cold water.

Advice from the RNLI / Coast Guard and Irish Water Safety is to fight your initial instinct to immediately swim and simply try to float, just for a short time. The effects of cold water shock will pass quite quickly, within 60–90 seconds.

Floating for this short time will let you regain control of your breathing and your survival chances will greatly increase.

The immediate cardiovascular effects can also have devastating consequences causing peripheral vasoconstriction, Increase in venous return leading to pulmonary artery hypertension, cerebral hypertension impairing cerebral function and potentially precipitating CVA. There is also a conflict between the Sympathetic and Parasympathetic autonomic nervous systems, the sympathetic response causing tachycardia and the Mammalian diving reflex driving the Parasympathetic response which can lead to profound bradycardia, in animal studies this has been shown be the precursor to fatal arrhythmias.

SALT WATER VS FRESH WATER In the past we would have spoken about the importance to differentiate between salt water vs fresh water non-fatal drowning.

In large amounts, salt water (hypertonic solution) can cause plasma to be drawn into alveoli, leading to massive pulmonary oedema, fresh water was thought to create the opposite effect, with aspirated water (hypotonic solution) rapidly passing through the lungs and into the intravascular compartment causing disruption of alveolar surfactant, volume overload and dilution of electrolytes in the bloodstream.

Subsequently, researchers have recognized that these finding are predominantly noted only in the post mortem setting, as it takes aspiration of more than 11 mL/kg of body weight must occur before blood volume changes occur, and more than 22 mL/kg before electrolyte changes take place. Because it is unusual for nonfatal drowning victims to aspirate more than 3 to 4 mL/kg, the distinction between salt water and fresh water drowning is no longer considered important.

In practice both salt water and fresh water nonfatal drowning result in decreased lung compliance, ventilation-perfusion mismatching, and intrapulmonary shunting, leading to hypoxemia that causes diffuse organ dysfunction. These processes result in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS).

PATHOPHYSIOLOGY OF DROWNING So what is the sequence of events that occur following submersion where cold water shock is not a factor?

Consider a group of swimmers enjoying the recent fine weather at their local beach, a surfer, a fisherman or even a swimmer at the local swimming pool. The process typically begins with a period of panic or fatigue, the swimmer has been pulled out of their depth in a rip, the fisherman has slipped from the rocks or the surfer has endured a two wave hold-down and is trying to figure out which way is up or the toddler has drifted into deep water in the swimming pool.

You lose your normal controlled breathing pattern and obviously try to breath hold when submersed, this leads to air hunger and an increased sense of panic or fatigue and a struggle further exacerbating the rapidly evolving hypoxic and hypercarbic state.

By now the victim has swallowed a significant amount of water which will become pertinent in our care later on. Eventually you will have an involuntary inspiratory reflex even if you are fully submersed in water leading to hypoxemia by means of either aspiration or reflex laryngospasm.

Hypoxemia in turn affects every organ system, with the major component of morbidity and mortality being related to cerebral hypoxia. If they lose consciousness at this point they rely fully on rescue from bystanders / lifeguards.

Without rescue involuntary spasmodic movement of the intercostal and diaphragmatic muscles can be noted Approximately 10-15% of individuals maintain tight laryngospasm until cardiac arrest occurs and inspiratory efforts have ceased. These victims do not aspirate any appreciable fluid.

PREHOSPITAL TREATMENT SCENE SAFETY / RESCUE Any rescuers primary concern must be scene and personal safety often we hear of well-intentioned bystanders who attempt a water rescue without the appropriate training or equipment and end up requiring rescue themselves, which can further hamper the primary rescue. When working around water it is vital that all staff wear the appropriate safety equipment.

In many cases the victim has first to be rescued to dry land before definitive treatment can start, this can be very quick in the event of an incident a pool or may be protracted if surfing in isolated areas. Respiratory impairment must be present for drowning to have occurred therefore rescuers who train and work around water are encouraged to focus on their first intervention targeting Airway and Breathing with between 2 to 5 rescue breaths prior to commencing CPR, patients with purely respiratory arrest may respond following a few rescue breaths.

Clinical Connections 21

UPON EMS ARRIVAL Be mentally prepared for a soiled airway, in the case of Respiratory / Cardiac Arrest you should have suction at hand and may need to turn the patient on their side if large amounts of water are being expelled from the stomach. The priority early in the arrest should be to secure an unprotected airway with a cuffed Endotracheal Tube, Cuffed Supra-Glottic Airways excellent devices but understanding their limits are very important. SGA’s are designed to stop

passive regurgitation of stomach contents; it will not protect the victim from aspiration of large volumes of fresh/salt water post submersion / immersion. *If tracheal intubation is performed, an orogastric / nasogastric tube should be placed to relieve gastric distension, which occurs from passive passage of fluid and is common in nonfatal drowning patients. (OG/NG insertion is not currently within the scope of the PHECC AP).

Immediate Positive Pressure Ventilations via Bag-Valve-Mask (BVM) may be difficult due to increased resistance caused by water in the airways and pulmonary oedema however the key objective is the recruitment of alveoli to combat the hypoxic state. In symptomatic patients who are spontaneously ventilating, supplemental oxygen should be provided to maintain the SpO2 above 94 percent.

In addition, noninvasive positive pressure ventilation via CPAP (continuous positive airway pressure) can improve oxygenation and decrease ventilation-perfusion mismatch * Note that positive airway pressure

increases intrathoracic pressure and patients must be carefully monitored for possible hypotension. Contact Telemedical Support if considering this option.

C

Arrhythmias can be common post submersion / immersion predominately secondary to hypothermia or hypoxia common rhythms to expect are sinus tachycardia, sinus bradycardia, and atrial fibrillation, PVC’s may also be present. ECG

changes of a small number of patients following submersion / immersion that suggest myocardial ischemia may be due to takotsubo cardiomyopathy, coronary artery spasm, or hypothermia, in addition to myocardial ischemia.

D

Hypoxic brain injury or traumatic brain injury may be present post submersion / immersion. This may lead to the Patient exhibiting all the common symptoms of these conditions, agitated combative

behaviour, irregular erratic respiratory pattern and or seizure activity. These should be treated as per GPG with consideration for telemedical support to support the sedation decision /process.

Having removed the patient from the environment every effort should be made to remove wet clothing to prevent further cooling of the Patient which will exacerbate the already fragile state, consideration should be given to the already profoundly Hypothermic patient in this case gentle handling is important when moving the patient or removing clothing as excessive movement can precipitate Ventricular Fibrillation.

undetected traumatic injuries. Cervical spinal cord injury is uncommon in nonfatal drowning victims, UNLESS there are clinical signs of injury or a concerning mechanism (eg, dive into shallow water). As the Irish Water Safety figures clearly show the incidence of suicide by drowning are all too common an occurrence, therefore always consider the possibility of overdose (alcohol/ benzos etc) in association with suicide attempts involving water.

A

Airway

B

Breathing

Circulation

Disability

E

Expose / Enviornment.

As discussed earlier fluid aspiration results in varying degrees of hypoxemia, Both salt water and fresh water wash out surfactant, often producing noncardiogenic pulmonary oedema and the acute respiratory distress syndrome (ARDS) Pulmonary insufficiency can develop insidiously or rapidly; signs and symptoms include shortness of breath, crackles, and wheezing.

In exposing the patient take the opportunity to assess fully for underlying or previously

REFERENCES Papa L, Hoelle R, Idris A. Systematic review of definitions for drowning incidents. Resuscitation 2005; 65:255.

Salomez F, Vincent JL. Drowning: a review of epidemiology, pathophysiology, treatment and prevention. Resuscitation 2004; 63:261.

Bierens JJ, Knape JT, Gelissen HP. Drowning. Curr Opin Crit Care 2002; 8:578.

Idris AH, Bierens JJLM, Perkins GD, et al. 2015 revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related resuscitation: An ILCOR advisory statement. Resuscitation 2017; 118:147.

22 Clinical Connections

ePCR UPDATE

David Willis Paramedic, Clinical Information Manager

The National Ambulance Service (NAS) has moved upward and onward since June 2017 with the rollout of our electronic patient care report (ePCR) system. This project is part of the eHealth strategy for the HSE and is also forms part of the NAS Vision 2020 strategy. Almost three year into the project the enthusiasm of all practitioners to date has brought a vibrant energy to this key patient centered project. This project rollout began on 29th June in Mallow Ambulance Station.

Practitioners in Mallow showed tremendous courage and belief when embracing this new technology. Thank you sincerely for your persistence in taking on this new change to your practice. Practitioners from the very first day adjusted many hurdles and bumps in the road were they identified and overcame these challenges by providing through and accurate comprehensive feedback.

Thisfeedback took many forms, nevertheless every element of feedback received helped shape a positive change to embedding ownership of this project by all practitioners.

We began in Mallow and moved across north county Cork (4 stations) over the next 10 weeks. We took these valuable lessons learned from all challenges into consideration as we moved forward. This helped our project team to plan with a greater level of detail to ensure milestones can be achieved.

Practitioners received 16 hours training before they began to use this new technology in an Emergency Ambulance.

The core message to all practitioners before using this new

technology is that “Patient Care� comes first. Recording relevant information for all calls can be entered from recall.

This new ePCR technology is designed to work completely independently while facilitating interoperability with other technologies in the vehicle. The integration of Mobile Data Terminal (MDT) and the technologies behind this new system helps to give practitioners insight into call specific information while populating the ePCR at key times within each call. The next biggest interoperabilitychallenge achieved was sharing patient vitals information captured on the LifePak 15 defibrillator. Here practitioners can receive an initial rhythm, 12 lead ECG, pre and post defibrillator shocks as well as heart rate, BP, SpO2, ETCO2 etc. Elements within the vital observations that must be manually entered are Reps. Rate, Temp., Blood Glucose, GCS and Pain Score.

With the integration of allthese new systems approximately between 50% - 65% of all call information can populate the patients ePCR record.

There are prompts within the Siren4 application to help practitioners complete the best possible clinical ePCR record. These prompts are not a definitive list as practitioners are allowed to practice autonomously, however within their scope of practice.

The project has just completed rollout in all ambulance station in Cork City and County, Kerry, Waterford, Kilkenny and Carlow, Longford, Westmeath. Partial completing has been delivered in Wexford and Offaly. Training has been delivered to over 370 practitioners as the end of May 2018.

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There has been over 18,000 documented patient contacts entered into Siren4. The South East has progresses well with 6 of 11 station completed before the summer break. The Midlands has also helps in making a significant impact with the rollout of this project. Portlaoise will be the only station left to complete before the summer break.NAS West will be the next area to rollout ePCR. We will be starting in North Tipperary first.

To support students during their training the National Ambulance Service College (NASC) will also have access to necessary systems, tablets and technology to enable students operate the Siren4 ePCR system. With almost twelve months of data collected now, we are beginning to lay the foundations for reporting clinical activities based on information captured within Siren4 ePCR system. The ability to mine data so that improving patient outcome can be measured as well as focusing towards NAS service needs is central to this evolutionary transition for patients, NAS and the HSE. A tremendous effort has being made by all those involved within this project, NAS practitioners using Siren4 ePCR system, Education Officers delivering this comprehensive training programme, Operations Officers assisting and planning for the release of practitioners to attend training, all managers who have supported this project rollout in their area of responsibility. Members of the OcCIO (IT Dept.) helping to guide the project and ensuring key items are delivered to ensure success to this project.

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

After 6 years of Service and over 2000 completed missions we would like to give a big shout out to the Emergency Aeromedical Service and dedicate this EAS "In My View" special to everyone who has been involved in this excellent service.

We are asking all of you with a keen photographic eye to seek out those pictures that give us an insight into "your NAS" 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.

Photos: Tadgh Weadick, Irish Aer Corps