QAS Insight Magazine - Winter 2016 edition

QAS

INSIGHT Winter 2016

1991

C E L E BR AT I NG QA S A N D L AC S I N T H E C OM M U N I T Y

25 years of service | Meal management software Diabetes referral pathway | ECG Masterclass

2016

Contents

FROM THE COMMISSIONER

25 YEAR ANNIVERSARY

SELF CARE

04

06

10

SEQ PTS REALIGNED

HARU CASE STUDY

SELFLESS VOLUNTEER

14

18

20 New software to manage meal breaks

ECG MASTERCLASS

DIABETES REFERRAL PROGRAM

22

38

5

Putting your mind to it

12

It’s a wrap for uniform pilot

15

Lifeline to the field every second counts

16

The germ buster

32

Sepsis 34 Warfarin 40 Triathlon champ set to

PEDAL4PARAMEDICS

THANK YOU QAS

46

50

QAS Insight is published by the Queensland Ambulance Service Media and Communications Unit. August 2016 edition contributors: Michael Augustus, Michael Franks,

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Joanne Mitchell, John Murray, Leah Watson, Dr Stephen Rashford, Eileen Stead, Dr Daniel Bodnar, Natalie Schutt.

Editor: Edda Mwangi. Graphic Design: Nejien Creative

conquer AP&ES games

44

Appointments and farewells

48

Editorial and photographic contributions are welcome and can be submitted to: QAS.Media@ambulance.qld.gov.au or +61 7 3635 3900.

Minister’s Message The Queensland Ambulance Service delivers a highly professional service to the people of Queensland.

In the 2015-16 financial year, the QAS attended over 985,000 incidents covering 1.7 million square kilometres from 290 locations.

In acknowledging the breadth of the service the QAS provides, the Palaszczuk Government increased the 2016-17 Queensland Ambulance Service budget by $39.9 million to $673.1 million.

Since coming to government, we have increased funding to the QAS by nearly $84 million.

This record funding recognises the vital part QAS plays in putting patients first in the health service.

We also committed to funding the recruitment of an extra 110 ambulance officers and the commissioning of 170 new and replacement ambulances in the recent budget.

We will be building new stations and upgrading existing stations around the state, including at Collinsville, Rainbow Beach, Yandina, Bundaberg, Birtinya, Kenilworth, Coral Gardens, Wynnum and Thursday Island.

As Minister, I want to ensure that our hard working ambulance officers and paramedics have fair pay and working conditions. That is why the Government will be co-funding a remuneration enquiry to review how ambulance officers and paramedics in Queensland are paid.

While the enquiry undertakes this important work, ambulance officers and paramedics received a 2.5 per cent interim pay increase, effective from 1 August this year. This will ensure the enquiry has the time it needs and paramedics and ambulance officers will not be disadvantaged while the enquiry is underway.

I cannot stress enough my personal appreciation and the Government’s for the work that you do for Queensland.

The work the QAS does for many communities is about more than just patient care – it is key to the fabric of community building.

This was particularly evident when I welcomed a new wave of Indigenous paramedic cadets at a ceremony in Townsville in June.

The cadets completed the Indigenous Paramedic Program which aims to improve health outcomes in Indigenous communities and increase diversity in the QAS workforce.

Programs like this help bridge the gap between Indigenous and non-Indigenous Queenslanders by building a closer relationship and understanding between the QAS and the communities it serves.

A total 14 recruits have already begun working in regional and rural areas from Cape York to Bundaberg.

The work that they do not only delivers health outcomes, it builds their communities and provides inspiration to others who will follow in their footsteps.

The recruits will help strengthen community engagement and improve delivery of services by contributing to local knowledge and cultural understanding.

I congratulate the new recruits and commend the QAS on this one-of-a-kind program.

Hon. Cameron Dick MP Minister for Health Minister for Ambulance Services

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From the Commissioner An independent remuneration review jointly co-funded

by QAS and United Voice Queensland will be looking into the pay and conditions for ambulance officers over the coming months. With the current determination due to expire on October 2, 2016, the review will give all stakeholders a great chance to engage in a meaningful and constructive way. In the interim, a wage increase of 2.5 per cent came into effect on August 1, 2016 for eligible employees.

On the subject of our working conditions, the results are in for the Working for Queensland Employee Opinion Survey and I am pleased to say the results are generally positive. We had a large number of staff completing the survey this year with 1,781 returned equating to 40 per cent of all QAS staff. I’d like to thank those of you who took the time to provide your valuable feedback.

The results show that from a statewide perspective our workplace climate has improved on the 2015 survey results. Of the 10 strategic priority categories measured in the survey, eight showed an improvement or maintained the positive results from last year.

The areas with the most improvement when measured against 2015 survey results were the complaints management process, job security, organisational leadership, job empowerment and anti-discrimination.

On another important note, July marked the beginning of celebrations commemorating the 25th anniversary of Local Ambulance Committees (LACs) and the QAS. On July 1, 1991 the Ambulance Service Act 1991 took effect and 96 individual Queensland Ambulance Transport Brigades (QATBs) were amalgamated into one statewide ambulance service. At that time LACs were introduced to maintain the ambulance service’s close connection to the community.

Today we have more than 1,300 LAC volunteers and it is in large part thanks to their efforts that the QAS has continued to maintain a strong connection to the community it serves over the past quarter century.

Celebrations will be running through to December this year and LACs and LASNs are coordinating community events showcasing the services we deliver to Queensland communities. I encourage all staff to take part.

The QAS Strategy 2016-2021 will also be out soon. The strategy details our vision for ‘Excellence in ambulance services’ and sets out a road map on how we will continue to achieve a better quality of life for our patients, the community and our employees.

This forward thinking is especially critical in light of the complex challenges posed to our health system from an ageing population, greater impacts of chronic illness and increased demand for service.

I am committed to achieving this vision and objectives outlined in the QAS Strategy and encourage all staff to review it once released.

While the results are positive, there is always room for improvement.

Over the coming months, we will continue to further analyse the results to identify broader strengths and high-achieving behaviours that can be shared across the organisation, and areas that require further attention. This was also discussed with Local Ambulance Service Network (LASN) managers at the face-to-face meeting in August.

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Russell Bowles QAS Commissioner

New software

to manage meal breaks

A new meal management software program has been deployed across all Operations Centres, along with revised procedures to help staff and supervisors better manage and record access to meal breaks.

Acting Operations Director David Hartley said the software works by providing real-time information on meal break access, fatigue scores and shift completions to Operations Centre staff, supervisors and Officers-inCharge (OICs).

“The software aids decision-making during ambulance deployment as Operations Centre staff can quickly look at the range of factors to dispatch the closest most appropriate paramedics,” David said.

“It was first trialled in Townsville in August 2015, followed by Maroochydore, Brisbane, Southport and Cairns with positive results.

“There is minimal input required by the user as it relies on Computer Aided Dispatch (CAD) data and roster information uploaded by Local Ambulance Service Networks.

“Staff will also benefit from a feature that generates an automatic email at the end of a shift to help employees enter details in their e-timesheets.”

The software complements the Meal Management Guidelines released in May this year.

“While the software provides oversight to allow better decision-making and dispatch, the Meal Management Guideline remains a valuable tool for all staff to actively commit to accessing meal breaks,” David said.

The software program is the result of several months of collaboration by the Meal Management Working Group whose membership included Emergency Medical Dispatchers (EMDs), paramedics, operational supervisors and OICs. The working group also reviewed policies and procedures around meal breaks, to ensure they were more contemporary and reflected the joint responsibility required by both ambulance officers and EMDs. The development of new policies, procedures and software by the Meal Management Working Group should further assist all staff in the administration of meal breaks.

“It’s been a long journey but collaboration between all involved including the working group, staff, managers, supervisors, paramedics and EMDs will have a positive impact on staff health and add value to patient care,” David said.

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25 years

of statewide service Celebrations are in full swing as we mark 25 years of the Queensland Ambulance Service (QAS) and Local Ambulance Committees (LACs).

The anniversary commemorates the July 1, 1991 amalgamation of 96 individual Queensland Ambulance Transport Brigades (QATB) into one statewide ambulance service, and the introduction of LACs to maintain the ambulance service’s close connection to the community.

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We’ll be showcasing the QAS, LACs and the services we deliver to Queensland communities with community events through to December hosted by Local Ambulance Service Networks (LASNs) and LACs.

25 YEARS OF STATEWIDE SERVICE

Connection to community With the strong support of the Queensland community, especially our LAC volunteers, the QAS has come a long way over the past 25 years.

From improvements to our level of patient care with services now delivered to more than four million Queenslanders, to new technology, equipment and training, the QAS has taken great strides over the past quarter century.

Throughout this period of growth and change, the QAS has continued to maintain a strong connection to the community it serves, in large part thanks to the efforts of more than 1,300 LAC volunteers.

At July 1, 1991, the 96 QATB Committees became LACs. Today, QAS is supported by more than 150 LACs in locations across Queensland.

Just as emergency and pre-hospital care has evolved over the past 25 years, LACs have also changed, moving from a predominantly fundraising role to now actively helping build resilient communities by partnering with frontline QAS staff to deliver life-saving CPR skills.

LACs also continue to fund professional development opportunities for frontline staff, purchase equipment enhancements for local stations, and financially contribute to organisations that support our officers such as the Kenneth James McPherson Foundation and QAS Legacy.

LACs continue to be an important and highly valued community network supporting ambulance service delivery in Queensland.

Putting patients first The move from the QATB structure to the structure we know today, supported by LACs was a big step for patient care, QAS Heritage and History Volunteer Manager Mick Davis told QAS Insight.

“The new statewide model meant the closest ambulance could attend an incident as opposed to the QATB model where each ambulance could only attend incidents in its local area,” Mick said.

Clinical practice also evolved significantly over the past quarter century with QAS role moving very quickly from ‘taking the patient to medical care’ to ‘bringing the care to the patient’.

25 years ago paramedics carried out basic life support with minimal formal training and now contemporary practice is underpinned by tertiary educated paramedics who are capable of providing a very sophisticated level of care.

“More recently, we transitioned back to Queensland Health after a period of 24 years under Emergency Services from 1989 to 2013. This essentially made us more streamlined in the health system and our paramedics became more accepted as clinicians,” Mick said.

“During that transition, Local Ambulance Service Networks were formed to align with the Hospital and Health Services, and we began to actively share data with Queensland Health.”

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25 YEARS OF STATEWIDE SERVICE

Skilling-up One of the biggest developments in education and training over the past 25 years has been the introduction of the degree-level qualification.

The role of the Medical Director has also evolved, with clinical governance enhanced after the role of Director, Clinical Quality and Patient Safety was established.

These and other enhancements in training led to a more evidence-based approach to our treatment of patients.

Training was also extended to include a Rural Remote Program, a paramedic practitioner program and improvements in Emergency Medical Dispatcher (EMD) courses.

Other breakthroughs in training included the first graduation of Intensive Care Paramedics that led to improvements in clinical care and intensive practice.

This program later evolved to the Critical Care Paramedics program.

An Advanced Care Paramedic level was also established to raise the general standard of patient care across the state.

Major training advancements: •

July 1, 1991 – Associate Diploma introduced.

This was the first nationally accredited training in the QAS.

•

1996 – the Associate Diploma was upgraded with the launch of a Diploma for Paramedics in Queensland.

•

1997 – Intensive Care Paramedic program replaced the Coronary Care Program.

Technology The QAS has been at the forefront of cutting-edge developments in technology over recent years.

operational iPads and developing software that provides operational information in real-time.

With the introduction of smartphones, developing mobile device applications that deliver important clinical content to our frontline staff, to issuing

Patients can also provide more accurate information on the location of an incident thanks to GPS on smartphones and the Emergency+ app.

Getting it right While we are used to seeing the standard QAS wagon and 4-wheel drive vehicles on the road, paramedics have trialled some interesting modes of transport in the past:

Hovercraft trial on Thursday Island in the early 2000s, the trial stopped due to issues with the impact of wave heights.

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Motorbike paramedics trialled in the late 90s and early 2000s . Trained by police motorcycle instructors, the trial ended due to restrictions around responding to incidents at night and in wet weather.

25 YEARS OF STATEWIDE SERVICE

A walk down memory lane – then and now

Communications centre staff in the 90s.

The modern technology we have in our communications centres today.

Collapsible stretcher used by QATBs.

Powered stretchers the QAS uses now. Better for patient safety and better for our paramedics.

Raising CPR awareness in the 90s.

CPR Awareness programs delivered by our LACs today.

QAS legacy vehicle fleet.

QAS modern vehicle fleet.

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Looking after yourself

by John Murray

Whether working in the Operations Centre, on road, or in many of the important administrative and support roles in the QAS, making sure you look after yourself is critical to your current wellbeing as well as longevity in the job.

It’s no secret that ambulance workers frequently deal with confronting and often highly emotive situations where it may take significant energy to regulate emotional reactions and bring calming support to a situation.

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The reactive nature of much of the work may also erode a sense of control and shift work has the potential to reduce buffers to coping.

So how you sustain yourself over the long term is largely dependent on how you care for yourself in the short term. And while ambulance staff tend to go the extra mile to put patients first, good ‘patient care’ is dependent on ‘self-care’.

Ambulance staff need to be cognitively engaged, emotionally flexible, physically healthy and not fatigued. In ambulance work ‘self-care’ is not optional and it is not selfish.

If we look at people who have worked within the ambulance service for 20 to 30 years, who still love their work and manifest a sense of wellbeing, we can learn how to ‘self-care’ well.

Here’s a list of some of the intentional practices and personal attributes that sustain these folk.

1. They are very disciplined in ensuring they get sufficient sleep. This is important in preparation for their mission critical work. It is also found to be an important component in processing traumatic experiences. In particular, during REM sleep our brains are making sense of our experiences, enabling a greater clarity of thought without worries and other intrusions playing havoc. This could be likened to defragging a computer.

2. They have healthy boundaries around work roles and personal roles. They will remove their uniforms as soon as arriving home. They realise that their way of being as a partner or parent is very different from their way of being as a paramedic, Emergency Medical Dispatcher, Patient Transport Officer or administrative person. They are aware of these differences and intentionally ‘shift gear’. In other words, they do not interact with family and friends as if they were in an ambulance role.

3. They value and practise recreational activities.

Recreation activities are those that enable you to create yourself in ways that are totally separate from the workplace. As human beings we are constantly creating who we are through what we choose to engage in and how we choose to engage. Our experiences become our feedback measure to our sense of self. So when we engage in activities that provide a sense of pleasure, enjoyment, relaxation and gratitude, we are actually cultivating our sense of wellbeing. These activities can range from fishing to skydiving, reading to socialising, and good sleep and exercise.

4. They have adequate physical exercise. They may not be super fit people but they engage enough in activities that exercise their bodies. This often is intentional jogging, swimming or gym work.

However other recreational activities such as bush walking, surfing and other sports, are often preferred and usually quite sufficient. Exercise helps in many ways. It promotes endorphin release, the body’s intrinsic anxiolytic, meaning it breaks down anxiety. Also exercise trains the parasympathetic nervous systems and importantly it is the only means of actively reducing cortisol, the hormone that is produced with chronic stress.

5. They develop emotional flexibility. They are aware of their emotional reactions to situations and able to appropriately regulate them. But beyond this and very importantly, these folk will talk at a later appropriate time about how their experience was for them and in doing so are open to healthy emotional expression for themselves and others.

Emotional connection is an integral aspect of meaningful relationships. By staying engaged with their personal emotions, these folk stay emotionally engaged in the important relationships in their lives, including workplace relationships.

6. They have self-compassion. This means they are honest and kind to themselves, when they make a mistake or do not perform as well as they would have liked. They do not deny their human failings, but accept that mistakes are part of their learning and development, and so they do learn from their less-than-perfect moments. They do not ‘beat up on themselves’, nor do they deny when matters have been less than ideal. They are not arrogant or grandiose about themselves either, because the sense of self is not founded upon outcome, achievement or prosperity, but on an internal knowing that one is living with a high degree of internal integrity. This ability comes from a healthy sense of self, being more than defined by behavior and outcome.

Making a habit of practising the above strategies brings about a sense of ‘Being Well’. With feeling good about oneself there develops affirming self talk, a greater appreciation of life and psychological buffering so that when things get tough there is sufficient ‘charge in the battery’ to cope.

Valuing your downtime, sleep, exercise and other recreational activities is essential to your longevity in the job.

It is the responsibility of the individual to ensure they self-care well. It is respectful to yourself to do this, selfcare is crucial.

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Putting your mind to it

by Leah Watson

For Critical Care Paramedic (CCP), Christian Harch, meditation is the key to keeping grounded during emergencies.

Throughout his four years as a CCP, Christian has been actively using the meditation form of Nei Gong to improve his clinical practice.

“As a CCP, the better I can communicate, the smoother things will go and the better off the patient will be.”

“It’s really about accessing and harnessing energies present in the universe,” Christian told QAS Insight.

This unique outlook led Christian to be invited to speak at the Woodford Folk Festival last December, which he did after being spurred on by a friend.

“In the heat of the moment I feel that meditation really helps me to communicate better with the patient, the patient’s family, bystanders and the clinical team on scene.

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Christian co-presented a talk with Dr Fiona Reilly from Lady Cilento Children’s Hospital, which focused on the importance of meditation and mindfulness in emergency situations.

“It was such an interesting dynamic to present with Fiona. She was able to show the real medical research that supports the Biomedical Model and the impact of mindfulness,” he said.

“Being mindful allows you to stay present in the moment and keep a clear head, which means you make great decisions for not only the patient, but for how you communicate and reassure the patient’s family, as well as allowing you to function highly with the clinical team.”

Christian believes mindfulness should be part of all emergency services’ practise.

“It’s really important, especially in emergency situations, to be present because people inherently respond very positively to that sort of personal interaction,” he said.

“I’d love to have more people accessing meditation and mindfulness, and not just in the medical industry.

“That’s the next step in my plan, once the Paramedic Project is up and running.”

Paramedic Project is the YouTube channel that Christian runs in his spare time. It aims to provide helpful advice for new paramedics.

“I’m trying to provide practical information about on-road work to make the transition for new paramedics a little easier,” he said.

Currently Paramedic Project has more than 200 subscribers.

“There’s a big cross section of people who watch the Paramedic Project videos. Most of them, about 70 per cent, are from Australia and New Zealand and the rest, I believe, are from the UK and the USA,” he said.

“A lot of views are from student paramedics and those just starting on the road, but I know a couple of experienced paramedics who also watch the channel.”

Paramedic Project is not the only source of medical information on social media being run independently by medical professionals.

Recently there has been an increasing surge of YouTube channels, Twitter accounts and Facebook pages internationally.

“Social media is a fantastic tool for exchanging information and expressing yourself,” he said.

“The ambulance service is a very mobile workplace, so it’s very difficult to get people into a classroom to learn and brush up on the basics. That’s why it’s great that the QAS is embracing online education and social media – you can check up on things on your phone or iPad on the way to work.”

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SEQ Patient Transport Services realigned Patient Transport Services (PTS) in the south east has had a revamp with the merger of non-urgent call taking and deployment activities into a single South East Queensland (SEQ) PTS Operations Centre at Spring Hill.

QAS has gone out to tender for a software package that integrates with the QAS Computer Aided Dispatch software to enable online booking requests by external health providers.

SEQ PTS Director Peter Wood said the centralised strategy started with the Brisbane Operations Centre coordinating the Gold Coast and West Moreton PTS deployment activities on May 17, and was soon followed with the relocation to Spring Hill by the nonurgent SEQ PTS work unit on June 21.

“This will allow doctors and health workers to directly place their Authorised Transports into the software to synergise with the Computer Aided Dispatch program and prevent double handling of these bookings,” Peter said.

“The aim is to ensure an improved service for our patients and clients by having all areas coordinated at Spring Hill,” Peter said.

“Once the full transition is completed, the merger will consolidate non-urgent call taking through the 131 233 number and non-urgent deployment activities for the Brisbane, Maroochydore, Southport and Toowoomba centres.

“This will make it easier to identify deployment requirements and patient movements for all areas and allow the dispatcher to better coordinate resources across all areas.

“The SEQ PTS Operations Centre Spring Hill also has sufficient operational terminals and software that provides Kedron with an operational business continuity plan.”

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To support the centralised deployment strategy, the SEQ PTS management team has also been realigned with the appointment of Robert Shillam as Operation Readiness Officer and three in-field SEQ PTS Operations Supervisors – Patient Transport Officer Stuart Smith, Officer in Charge (OIC) Shaun Doyle and OIC Todd Horne.

As part of the realignment, four extra Patient Transport Officer afternoon shifts have been implemented - two shifts at North Lakes and two shifts at South Brisbane.

The SEQ PTS management team falls under Assistant Commissioner State Operation Centres Gerard Lawler.

It’s a wrap for

uniform pilot The QAS uniform pilot is now complete.

Ten officers, including on-road and Operations Centre staff from across the state tested the new clothing items over four weeks from June 13 to July 8, 2016.

More than 340 officers provided written feedback on their preference for the pilot design. The 10 piloting officers also captured initial staff reaction in video diaries which garnered more than 10,000 views on the QAS Portal.

Based on the feedback received, some key decisions have been made, including: • • • • • •

the teal colour for uniforms to remain silver detail to be adopted polo shirt with the spliced design to be adopted epaulettes to remain fabrics tested to be adopted - this has been professionally reviewed by the supplier QAS crest will be adopted on the front of the uniform, with QAS rondel badges to be placed on sleeves.

To ensure the optimum fit and comfort for each individual, ‘fit kits’ will be distributed in midNovember around the state to assist the supplier in obtaining uniform sizes for all staff.

Uniforms will then go into full production and will be distributed on a replacement basis only. It is anticipated that the first uniform items should be available in February 2017. Officers will be able to order their own uniforms online and receive them at their station or home.

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Lifeline to the field every second counts Every

48

seconds a call is received by our Emergency Medical Dispatchers

3000

cases handled each day by ambulance crews statewide

The point of entry to the QAS begins at the Operations Centre. With every key stroke, Emergency Medical Dispatchers (EMDs) aim to provide the quickest most appropriate responses to a call for assistance.

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60,429

Triple Zero (000) calls received in June 2016

7

Operations Centres with a total of

497

staff managing and supporting emergency calls

Road crews play a vital part in ensuring EMDs have the latest information on an incident and can then make decisions on whether additional resources are required or if some should be reallocated to a higher priority incident. “Every second counts in the field. Although we have specific dispatch response matrices, we do not have eyes on the scene until an operational crew arrives,�

Assistant Commissioner State Operations Centres Gerard Lawler told QAS Insight.

Triple Zero (000) Call

Receive request for service

“Getting an up-to-date situation report (SitRep) to EMDs provides an overview of the situation as quickly as possible, assisting the EMD to make an informed decision on whether to dispatch back-up or support, or redirect crews to a higher priority incident.

“It makes a big difference in an emergency situation and to the ongoing coordination of all resources”.

A SitRep is vital to provide an overview of the situation and provide the EMD with further information on subsequent deployment of resources to the scene or the reallocation of resources to another incident.

Prioritise

Dispatch ambulance response

Coordinate resources

Essential information for operational crews to relay to EMD 1. On arrival, ensure on scene time (the time of staging at an incident) and at patient time (time you begin assessing a patient) is relayed back to the Operations Centre via voice or the Mobile Data Network.

2. Provide rapid acknowledgment of incident details, and confirm: • location of incident • number of patients • nature of incident • if back up is required • if allied services (QPS/QFES) are required.

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HARU Report High Acuity Response Unit case study

by Dr Stephen Rashford

Paramedics were called to an individual who had been allegedly stabbed in the left upper quadrant by an assailant.

The first crew arrived to find the patient with a 1 centimetre incisional wound to the left subcostal region. There was no obvious external blood loss.

The patient was noted to have a GCS 14 (slightly drowsy), no palpable blood pressure and a heart rate of 140 beats per minute. The SpO2 was 96 per cent, with equal AE being present and no signs of surgical emphysema. The Critical Care Paramedic (CCP) arrived a short time after the Advanced Care Paramedic (ACP) crew.

A decision was made to extricate the scene quickly, with further interventions en route to a major trauma centre. The HARU had been dispatched, as torso penetrating trauma is a mandatory dispatch.

liver

blood clot

pericardial cavity

heart

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The HARU paramedic met the transporting crew a short distance from the scene and immediately performed a Focused Abdominal Sonography for Trauma (FAST) ultrasound.

The FAST revealed significant pericardial blood, with radiological evidence of right ventricular compression. The clinical picture of shock with a positive ultrasound confirmed a direct cardiac wound. The major trauma centre was contacted, with the provisional diagnosis being provided that included the supportive ultrasound finding.

The patient was met in the emergency department by a consultant trauma surgeon and full resuscitation team. They were then transferred to the operating room approximately five minutes after arrival at hospital. A right ventricular wound was successfully repaired. The patient made an uneventful recovery, being discharged on day five.

HARU audit lessons learnt: 1.

Assume any stab wound located between the sternal notch and the umbilicus (“the box”) is serious until fully assessed in hospital, no matter how small or superficial looking.

6.

Occasionally cardiac wounds decompress through the pericardial incision into the pleural cavity.

7.

Blood will clot within the pericardial sac. It forms a jelly like clot. This makes pericardiocentesis often ineffective, with the need for an emergency thoracotomy as the treatment of choice.

2.

Wounds appear small because they close over when the cutting instrument is removed.

3.

The majority of stab wounds to the heart hit the right side, given the orientation of the heart.

8.

Prompt prehospital diagnosis and referral results in reduced time to definitive surgical care.

4.

Right ventricular wounds cause a low pressure bleed (RV pressure 25/8 mmHg), resulting in slower blood loss that may take 30 – 60 minutes to develop clinical signs. Don’t be fooled by no significant clinical signs. Left ventricular wounds usually present as catastrophic collapse within less than 10 minutes of the injury.

9.

A two minute ultrasound may reduce the time to definitive care by 30 minutes by ensuring appropriate hospital response e.g. having the consultant surgeon standing there 24/7 on arrival.

5.

Most patients who die from acute cardiac wounds associated with a pericardial tamponade will not suffer significant blood loss. The cause of the cardiac arrest is obstructive shock, with the right atrium and ventricle being compressed due to its low pressure.

10. All stab wounds within “the box” should have the following diagnoses considered, in this order to stop the paramedic missing critical injuries: i.

mediastinal injury with cardiac tamponade

ii. l ung injury with tension haemo or pneumothorax iii. intra-abdominal injuries.

11. Treat all stab wounds as serious.

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Selfless volunteer prioritises care of others Helen Kable of Carindale has made caring for others her handiwork.

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SELFLESS VOLUNTEER PRIORITISES CARE OF OTHERS

For 11 years she has delicately and thoughtfully knitted close to 600 trauma teddies to give to sick and injured children, making their experience in our care a more pleasant one.

It is a vocation that she has also passed onto her granddaughter, who shares her threads with the New South Wales Ambulance Service.

Despite her own personal battle after being diagnosed with terminal cancer and given just days to live, Helen’s focus to improve the care of others has never faltered.

The recent anti-assault campaign against emergency and health care staff resonated deeply with her and in her own very special way, she wanted local paramedics to know they too are cared for.

Helen has been knitting trauma teddies for each of the families at Carina Ambulance Station, because she believes everyone deserves to know they will go home to the ones they love and hug them at the end of their work day.

Carina Officer-in-Charge Todd Horne and Acting Capalaba Officer-in-Charge Ingrid Wulff thought there was no better time than National Volunteer Week (May 9-15) to thank Helen for the difference she makes to put smiles on little dials.

They visited Helen and husband Jim at home to present her with a Certificate of Appreciation and say thank you on behalf of the service.

is currently looking forward to celebrating 60 wonderful years with Jim in January 2017, when they will mark their diamond wedding anniversary.

Many months since doctors gave her little hope, Helen has not lost her sparkle and positive view on life. She

In the best way she knows how, she continues to put the needs of the smallest members of the community ahead of her own.

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ECG masterclass

by Eileen Stead

Whether you need to revise your knowledge or start from scratch, this masterclass will assist officers of all clinical levels with improving their ECG interpretation skills

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ECG MASTERCLASS

ECGs, you either love them, or hate them. Those bewildering and mystifiying strips spewing out from the monitor, holding information on your patient’s condition - just waiting for you to decipher.

The art of ECG interpretation is not an easy feat. It requires dedicated determination and commitment to methodically chipping away at this monster of a language. And it is just that, a language. It has all the basic fundamentals that you can read and understand: for example the presence of a P wave tells me that the atria have depolarised and the myocardium has contracted, squeezing blood into the ventricles. But then work into that, a departure from the ‘normal’ waveform due to disease, injury, individual variance, and suddenly it’s a language that you cannot understand.

Like all languages, the only way you can ever become ‘fluent’ is to keep on prasticing. You cannot learn ECG interpretation in a semester and walk away ‘nailing it’, unless you commit yourself to regular - I would recommend daily - exposure to interpreting ECGs. The more you look at, collect, and talk about, the better you will become.

In 1997 I commenced the Associate year of the Institute of Cardiopulmonary Technology’s Cardiac Technician program. This was eventually converted into the Bachelor of Sonography program through Sydney University, with other universities commencing programs soon after.

I had been a paramedic for four years in western Sydney and believed I had a pretty good handle on interpreting basic Lead II rhythms, and was looking forward to studying 12 Lead ECG interpretation, because in NSW Ambulance in 1997, 12 Lead ECGs were nowhere to be seen.

The first year concentrated purely on 12 Lead interpretation, with the second year studying cardiac cath, paediatric cardiology, pacing, holter monitor, and third year electrophysiology studies and echocardiograph.

I was halfway through my second semester and felt like I was getting nowhere. I’d collected countless 12 Leads that were accumulating nicely in a box, I was studying every moment I could, and I was completing the mandatory 10 hours a week placement in a medical investigations unit at a major trauma hospital - and still, I was falling behind.

Out of pure frustration one afternoon, I decided to abandon my study and go and sort out the ‘box’, which was overflowing with hundreds of 12 leads. It was the best four hours I’d spent in the whole year.

Firstly, I thought I’d sort them out into batches of what looked the same, because I certainly couldn’t decipher which were which...

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Suddenly I could see patterns in each of the readings: wide QRSs, narrow QRS, big P’s, weird Ps, no Ps, sections moving up, sections moving down, the language revealing itself to me. I grabbed a highlighter and started tracing over the waveforms that were not normal - because in seven months of study, that’s all I seemed to be able to nail: what was ‘normal’. I grouped these ECGs into little silos based on their similar abnormality. Afterwards, I took the top from each pile, slid over my trusty Huszar’s and worked my way through until I found a match for the abnormal ECG. Once done, I looked at all the ECGs with the same, highlighted abnormality and presto! - Pattern Identification 101.

There was no turning back from that point. I went on to successfully complete the program, landed a parttime job as a Cardiac Technician and have over the last 22 years as a paramedic, taught ECG interpretation to many paramedics and students.

The aim of these ECG Masterclasses is to show you the ‘shortcuts’ that I found that afternoon, sorting through all of those ECGs. Essentially, we all want to be able to pull out an ECG as it’s being printed from the monitor and just go bam! it’s a left anterior hemiblock. And let’s face it, we’re all a little impatient when it comes to learning about 12 Leads, we want to be able to just ‘eyeball’ it and know. Unfortunately, the conventional methods of teaching ECG interpretation involves wading through all of the science behind it, the pathophysiology involved, the vectors, the amplitude, the axis - exhausting!

These masterclasses will teach you, in reverse.

Identify first, know what’s happening second. Over the years I’ve found that if you feel the gratification of successfully interpreting an ECG, it will encourage you to want to learn more about what’s going on in the background and in turn, through further study, consolidate your interpretation knowledge and skills.

In this edition, we’re going to start with left bundle branch blocks (LBBBs), because I’ve found that these are the most common ECG abnormality other officers have expressed trouble in interpreting. These LBBBs are ‘middle of the road’ left bundles. Next edition, I’ll go over the not-so-common left bundles.

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ECG MASTERCLASS

The LBBB Pattern:

A complete LBBB will feature the following traits (listed from most common to least): Lead I: Wide, notched (or sloping tip) QRS with a downsloping ST segment and an inverted T wave

Leads V1, V2, V3: Very deep, wide S waves, small r wave, ST segment elevation, and asymmetrical tall T waves

Lead aVL: Often mirrors Lead I with wide notched or sloping QRS, downsloping ST segment and inverted T wave. May present with rSR pattern in this lead

Left Axis Deviation: (see ‘eyeball axis’ identification section on page 29)

Lead V6: Wide, notched (or sloping tip) QRS with a downsloping ST segment and an inverted T wave (these findings in V6 are not reliable - see examples to follow. The V1 and V6 pairing is not as reliable as the Lead I and V1-V3 pairing of patterns).

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The following ECGs have been obtained online, with the initial ECGs showing the LBBB pattern highlighted in blue:

a

ECG image credit: Dr Smith’s ECG Blog

b ECG image credit: ECG Medical Training

c

ECG image credit: Dr Smith’s ECG Blog

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ECG MASTERCLASS

d ECG image credit: Life in the fast lane

e ECG image credit: Dr Smith’s ECG Blog

f

ECG image credit: ECG Medical Training

g ECG image credit: Dr Smith’s ECG Blog

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Can you see the pattern in Leads I, aVL, V1, V2, and V3?

Note that the LBBB morphology in V6 is not the same in each ECG? This is why it is not a reliable lead to look for the LBBB pattern.

Ask yourself: what is it about an ECG that you have obtained that would make you even look for the presence of a LBBB? Answer: a wide QRS complex. If you have captured an ECG and you notice that the QRS complex is wide (>0.12 sec), then the first three things that you must rule out are: 1: Does the patient have a pacemaker?

2: Is it a bundle branch block (left or right)?

3: Is there evidence of a third degree AV block?

The presence of a pacemaker will widen the QRS because the pathway of the impulse generated by the device’s electrode (at the tip of the catheter and inserted into the (R) ventricle), differs from the normal, intrinsic pathway that is generated when the impulse follows the SA node - AV node - Bundle Branches Purkinje network pathway.

For similar reasons, the QRS widens in the presence of a complete bundle branch block.

Since the normal pathway through the bundle branches is blocked in one branch, the impulse must find an alternate pathway through to the purkinje network, to achieve depolarisation of the ventricle/s. This results in a delay and prolongation of the time to depolarise the ventricles, and therefore widening the QRS complex.

In the case of a third degree AV block (also referred to as a complete AV block), the QRS is widened due to an escape rhythm arising out of the ventricle. Should the electrical communication between the atria and ventricles become blocked, then a slower, intrinsic rate will initiate within the ventricles. This primordial safety mechanism ensures that the heart will continue to pump blood to the body, albeit at much slower rate.

Identifying a LBBB is actually quite simple. In no time at all, you will be spotting the wide, bizzare complexes as they start printing out from the monitor. To assist you in becoming proficient in ECG interpretation, you should endeavour to collect as many 12 Lead ECGs as you can. Even if you cannot interpret them today, put them aside, because the more you collect; the more you can compare with and this will not only improve the speed (and accuracy) with which you can interpret, but also strengthen your knowledge and skills with identification of more difficult and rarer rhythms.

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ECG challenge Test your knowledge with our challenge ECG It’s 07:55 and you’ve been called to a residential address for a 54-year-old woman vomiting.

On your arrival you find your patient sitting in a recliner with her eyes shut, hand to her forehead and a plastic container on her lap, containing vomit. Your patient responds to you and reports that she has a violent headache and quite forceful vomiting.

The patient’s husband states that she was bending over to show her grandchild a model car when she collapsed. The patient regained consciousness within approximately 30 seconds.

The following are the vital signs and observations that you note: • • • • •

HR 118, RR 24, BP 168/92, SpO2 93%RA GCS 15 Pupils - L>R 4mm and 3mm respectively Skin - pallor, diaphoretic ++ BGL - 9.2mmol/L post prandial

Relevant pmhx includes hypertension, cholecystectomy (four years prior). Current medications are Olmetec 20mg and Cartia 100mg.

You collect the below 12 Lead ECG. What is your interpretation?

Answer in next edition

ECG MASTERCLASS

Eyeball Axis A quick and easy to use guide in axis deviation identification

Axis deviation refers to the direction of an electrical impulse or signal as it travels through the heart.

The QRS complex is commonly and importantly focused upon because, determining the axis will reveal if the ventricles are depolarising normally.

However other waveforms, such as the P wave and the T wave, for instance, have an axis that can be measured.

Departure from the normal electrical axis of the heart may indicate an underlying pathological condition, but it can also be a benign and incidental finding in a normal, healthy heart.

Axis deviation, more specifically QRS axis deviation is an important component of 12 Lead ECG interpretation.

However, determining the axis deviation can be quite labourious; selecting perpendicular leads, plotting the heights and depths of QRS complexes on a graph, measuring the degree of the axis - noone has time for that in the back of an ambulance.

However, there is a way to quickly ‘eyeball’ the ECG and determine the axis in a glance, without having to plot and measure. The best leads to look at the QRS axis are Leads I and aVF. Outlined below are four ECGs with the QRS complexes highlighted, revealing which configurations correlate with which axis deviation.

The presence of a Normal Axis Deviation does not rule out that there may be an abnormality with the ECG. For example, left ventricular hypertrophy can have a normal axis deviation, only some of the these ECGs will have a left axis, so don’t assume that it cannot be a certain condition, purely based on the presence or absence of an expected axis or waveform.

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ECGs showing a Left Axis Deviation can be a sign of other underlying conditions such as: LBBB; a transmural Inferior AMI; the presence of a ventricular pacemaker (where the pacing lead is placed in the apex of the right ventricle); regular ventricular ectopic beats; a left anterior fascicular (hemi) block; and sometimes Wolff-Parkinson-White Syndrome. Take a look at the article on LBBB and determine the axis!

While abnormalities found with the QRS axis may suggest the presence of a pathological condition, sometimes it can be caused by the way the heart sits within the thorax. For instance, a tall, thin person may have a vertically orientated heart and this may show a right axis deviation, without an underlying condition. However, this isn’t always the case and frequently a Right Axis Deviation (RAD) may suggest the presence of either of the following conditions: acute right ventricular strain as seen with pulmonary embolism; atrial septal defect; COPD; right ventricular hypertrophy; left posterior fascicular (hemi) blocks; and a RAD is usually seen on paediatric ECGs.

An Indeterminate Axis (or Extreme Right Axis Deviation) is less common, and usually accompanied with a positive QRS in Lead aVR (which is abnormal in this lead) and the majority of the rest of the leads also presenting with negative QRSs. Conditions where an Indeterminate Axis is usually found are: VT; Acclererated Idioventricular Rhythm (AIVR); Hyperkalaemia; and severe Right Ventricular Hypertrophy. Interestingly, the most common cause of an indeterminate axis is incorrect placement of the upper limb leads - so always check!

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ECG MASTERCLASS

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The germ buster QAS recently welcomed Fiona Randall as its Clinical Nurse Consultant (CNC) for Infection Control.

Fiona, a self-confessed mysophobe and germ nerd, will provide infection prevention control advice and support for the QAS executive and staff.

She’s already off to a flying start with the Infection Control Framework now available on the infection control page of the staff portal.

The framework guides Local Ambulance Service Networks in establishing systems, processes and behaviours when delivering safe clinical care.

Also in the works is new interactive content on infection control for the QAS Field Reference Guide (FRG) smartphone and iPad application.

Fiona brings a wealth of knowledge having spent the first part of her nursing career working in operating theatres in Australia and the UK.

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In 2001 she commenced the role of Infection Control Clinical Nurse Specialist for the Kingston Hospital NHS Trust in the UK. Since then she has worked as a Clinical Nurse Consultant for Uniting Care Health, Wesley Mission Brisbane and in the role of Public Health Nurse - Communicable Diseases and Immunisation for Queensland Health.

“Infection control is constantly evolving as we’ve seen recently with the management of Zika and Ebola, so it’s important to stay up to date on infection control methods.

“Across the span of my nursing career I have witnessed and been involved in implementing changes in infection control practice in response to new and evolving diseases,” Fiona told QAS Insight.

Role at QAS

“This included witnessing the early years of the introduction of universal precautions in response to HIV, and the impact of the Variant CreutzfeldtJakob Disease (vCJD or mad cow disease) crisis on sterilisation processes in the UK.”

• •

Fiona also got to see first-hand the international SARS outbreak and the impact it had on international travel and the management of travellers with respiratory infections.

“Closer to home, I was involved in responding to and investigating a local Hendra virus outbreak. The lessons learned from that outbreak were used to implement changes to infection control practice in response to Hendra outbreaks,” she said.

“As time has passed each of these events has led to new knowledge and understanding that has improved the provision of safe health care.”

Fiona has pencilled in an ambitious list for her time at QAS, including:

• • •

reviewing the Infection Control Framework establishing an Infection Prevention and Control Committee setting up an infection prevention and control paramedic interest group developing guidelines and procedures for cleaning QAS vehicles developing and publishing infection control resources on the QAS portal. For example what to do following contact with patients who have infectious diseases such as TB, Measles, Meningococcal disease.

To view the Infection Control Framework visit the QAS Portal website at: http://ow.ly/bjD2302gpbt

Infection control tips Protect yourself, your loved ones and your patients from infectious diseases: •

Remember to wash your hands or use alcohol hand rub before and after each patient contact or procedure.

•

Remember to wear PPE to protect yourself from infectious diseases and follow additional precautions when you suspect a patient may have an infectious disease.

•

Clean equipment following completion of transport or treatment of patients

•

Make sure you are fully vaccinated for Measles, Mumps, Rubella, Chicken Pox and Hepatitis B.

•

Don’t forget to have the dTpa vaccine booster every 10 years. This vaccine protects against Diphtheria, Tetanus and Whooping Cough.

•

Have the annual seasonal influenza vaccine to reduce the likelihood of you becoming unwell and transmitting the disease to loved ones, patients and colleagues.

•

Report workplace incidents related to infection prevention control to your supervisor and in the SHE reporting system.

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Sepsis in adults:

A pre-hospital perspective

by Dr Daniel Bodnar

Case It is the end of a busy shift, you put your feet up and reflect on 5 of the patients you treated: • • • • •

a 60-year-old man with a big, uncomplicated, inferior STEMI that went to PCI a 27-year-old man that was pretty banged up after a car accident (the hospital said something about an ISS>15), a 59-year-old female that had vomited blood with a BP=90/60 a confused 74 year old lady that was a bit cold (T=35oC), but otherwise looked ok (HR=65, BP=100/60, RR=24) and an 18-year-old female with new onset DKA

You wonder who was the sickest.

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SEPSIS IN ADULTS: A PRE-HOSPITAL PERSPECTIVE

What is sepsis?

Sources of sepsis

The consensus definition of sepsis has just changed.

It is defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection”1 or more simply “a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs.”1 This definition is simpler than the previous definition based on the Systemic Inflammatory Response Syndrome criteria. The criteria for septic shock are now defined as “sepsis and vasopressor therapy needed to elevate mean arterial pressure >= 65mmHg and lactate>2mmol/L despite adequate fluid resuscitation.”1

The infectious cause of sepsis will depend on the population being examined. In an Australian-New Zealand study of adults who presented to the Emergency Department with sepsis, the most common cause was pneumonia4 (see Figure 2).

This definition is simpler than the previous definition based on the Systemic Inflammatory Response Syndrome (SIRS) criteria (see table 1). A SIRS response is not specific to infection and may occur with other physical and physiological insults (see Figure 1).

Figure 2: Sources of infection in ARISE study4

Two or more of: • • • •

Temperature >38°C or <36°C Heart Rate >90/min Respiratory Rate >20/min or PaCO2<32mmHg White blood cells count >12,000/mm3 or <4000/mm3 or >10% immature bands

The cause of sepsis will not only depend on host factors (such as age, immunosuppression and co-morbidities), but also the infectious agents present in the community (e.g. malaria endemic areas).

Table 1: Systemic Inflammatory Response Syndrome Criteria2

Figure 1: Relationship between infection, Sepsis and SIRS3

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Recognition of sepsis

High risk groups

The key to good pre-hospital management of sepsis is recognising it. The early recognition of sepsis is difficult and its onset can be subtle.

A good clinical examination, paying attention to vital signs is extremely important. One of the earliest signs seen is tachypnoea, and interestingly 30 per cent of adult patients don’t have a fever with 13 per cent being hypothermic5 (see Figure 3).

Clinicians need to be aware that some members of our community are more prone to infection.

They may have weakened immune systems secondary to disease or medications, or have social factors that make them more prone to infection (see Table 3). It is important for healthcare professionals to be aware of their biases and prejudices and recognise that some members of our community are more at risk to sepsis.

Chronic Illness: • • •

Diabetes Chronic liver failure Chronic kidney disease

Immunosuppressed: • • Figure 3: Vital sign abnormalities in adult sespis.5

The Sepsis-3 collaboration has promoted the use of the Quick Sequential Organ Failure Assessment (qSOFA) as a screening tool for identifying patients with suspected sepsis1. The tool consists of 3 variables—a respiratory rate, mental status and systolic blood pressure1 (see Table 2). This quick screening tool could predict outcomes similar to that of formal SOFA score conducted in ICU1.

Suspected infection and any two of the following: • • •

Respiratory rate>=22/min Altered mentation (GCS<15) Systolic Blood Pressure≤100mmHg.

Table 2: qSOFA criteria for sepsis1

•

Recent chemotherapy Chronic corticosteroid use (e.g. patients with COPD) Elderly

Social/Multifactorial: • • •

Alcohol dependence Intravenous drug users Lower Socio-economic status

Table 3: High risk groups for sepsis

Pre-hospital management As already mentioned, the key to management of sepsis in the pre-hospital environment is timely recognition. Once the potential for sepsis has been recognised, the priority moves to supporting tissue perfusion. This involves ensuring adequate amounts of oxygen and glucose reaches the tissues. The mainstay of therapy is the appropriate administration of fluids to improve tissue perfusion, avoiding hypoxia and avoiding hypoglycaemia (see Table 4).

• •

Recognise it Administer fluid boluses and reassess after each bolus: • 500ml 0.9%NaCl non elderly adult • 250ml 0.9%NaCl to elderly • Ensure SpO2>92% • Ensure Blood sugar level>4mmol/L • Pre-notify the hospital especially if Systolic Blood Pressure <90mmHg. Table 4: Key principles of the pre-hospital management of sepsis

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SEPSIS IN ADULTS: A PRE-HOSPITAL PERSPECTIVE Pre-notification of receiving hospitals, especially with patients exhibiting signs of cardiovascular compromise is essential, as mortality from septic shock increases with time if effective antibiotics are not given (see Figure 4).

Conclusion Sepsis is a silent, subtle killer. Pre-hospital clinicians have a vital role in the management of sepsis by using their clinical skills to diagnose and prenotify the receiving hospitals beginning to optimise the patient’s condition before they get to hospital.

Case conclusion You realise that the 75-year-old lady had a qSOFA of 3/3, and you are glad that you notified the hospital.

You heard from the duty consultant that she “fell of the perch” just after handover, needed a noradrenaline infusion and she was admitted to ICU. You do some reading and you are surprised that she potentially has a 21% chance of mortality, higher than any other patient you treated.

Figure 4: Mortality risk with time to effective antimicrobial therapy (dots above the dotted line represent increased risk of death)6

In special circumstances (e.g. suspected meningococcal septicaemia) it is appropriate to administer antibiotics en route to hospital prior to the taking of samples to culture.

The future In the future it is likely that more accurate pre-hospital screening tools for sepsis will be validated. The QAS is currently doing work in this area. If accurate prehospital tools are identified, there is potential for appropriate antibiotics to be administered in the prehospital environment in select cases.

References: 1 Singer M, Deutschman C, Seymour C, et al. “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)”. JAMA 2016;315(8):801-810 .

2 10;304(16):1787-1794 . 9 . Bone RC, Balk RA, Cerra FB, et al.

American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;20(6):864-874 3 Kaplan LJ. (2015). “Systemic Inflammatory Response Syndrome” . Retrieved from http://emedicine.medscape.com/ article/168943-overview

•

A 60 year old man with a big, uncomplicated, inferior STEMI that received thrombolysis (in hospital mortality= 6.3%) 7

•

A 27 year old man that was pretty banged up after a car accident the hospital said something about an ISS >15,(mortality rate=19%)8

•

A 59 year old female that had vomited blood with a BP=90/60,(Rockall score=6, mortality 11-17%)9

•

A confused 75 year old lady that was a bit cold (T=35oC), but otherwise looked ok (HR=65, BP=100/60, RR=24) (21.7% mortality)10

•

A 18 year old female with new onset DKA (Mortality=2.4%) 11

4 Peake SL, Delaney A, Bailey M, et al. “Goal-Directed Resuscitation for Patients with Early Septic Shock” NEJM. 2015; 371(16):1496-506

8 Giannoudis PV, Harwood PJ, Gourt-Brown C, et al “Severe and multiple trauma in older patients; incidence and mortality” Injury. 2009;40:362–7

5 Brun-Buisson C, et al Incidence, Risk Factors and Outcome of Severe Sepsis and Septic Shock in Adults: A Multicentre Prospective Study in Intensive Care Units JAMA: 274(12), 27 Sept, 1995

9 Vreeburg EM, Terwee CB, Snel P et al “Vadliation of the Rockall risk scoring system in upper gastrointestinal bleeding” Gut 1999;44:331–335

6 Kumar A, Roberts D, Wood K, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34; 1589-1596 7 Nicod P, Gilpin E, Dittrich H, et al “Long Term Outcome inPatients with Inferior Myocardial infarction and Complete atrioventricular Block” JACC 1988:23(3)589-94

10 Kaukonen K, Bailey M, Suzuki S “Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patients in Australia and New Zealand, 2000-2012” JAMA. 2014;311(13):1308-1316 11 Venkatesh B, Pilcher D, Prins J, et al “Incidence and outcome of adults with diabetic ketoacidosis admitted to ICUs in Australia and New Zealand” Critical Care (2015) 19:451

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Partnership tackles diabetes management With the support of paramedics on the frontline, Officers-in-Charge Michelle Holsworth and Jacqueline Quigg have been making a difference for patients both Type 1 and Type 2 Diabetes in Metro North.

The LASN responds to about 400 diabetes-related cases each financial year and of these cases, more than 50 per cent require transport to hospital.

Research shows that most of these patients will present to a General Practitioner, emergency department or call for an ambulance again within 24 to 48 hours following an original incident. It places a strain on health care resources and fails to help these patients in the ongoing management of their condition.

Together Michelle and Jacqueline established a referral pathway to capture patients at risk of passing through the gaps, and close the loop on an efficient management model between all health care stakeholders.

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The pathway has led to patients who frequent the service being referred to Metro North Subacute and Ambulatory Care Specialist Diabetes Service, where patient engagement is undertaken over a 12-week period through a program tailored to each individual.

This program may include education about the disease, medication, diet and exercise factors as well as the impact of any recent lifestyle changes.

In some cases patients may also require mental health and/or social care at the outset of the program.

Discharge is also discussed with the patient at the initial visit to enable a self-management approach by the patient.

Having managed his condition for decades, Kallangur resident Stuart Bennett thought he had it in his grasp.

Upon his fifth call to emergency services, paramedic Chris Howarth suggested Stuart consider the diabetes referral service to get it back under control.

By participating in the program, Stuart discovered that recent lifestyle changes had negatively impacted upon his condition. He was supported by Metro North’s Diabetes Service in making changes to his diet and exercise. His condition is now steady under the ongoing management of his General Practitioner and he encourages others to utilise the initiative.

From a more efficient utilisation of ambulance and hospital resources to achieving better outcomes for patients, this all-in approach taken by Michelle and Jacqueline has provided a positive domino effect for all involved.

Diabetes is often described as the greatest epidemic facing our healthcare system, but if we are to tackle the hurdles ahead, it starts with recognising the problems on a grass roots level and working to resolve them.

Following its success in Metro North, the diabetes referral program is being utilised by the Central Queensland LASN and started in the Cairns and Hinterland LASN on August 8, 2016 with an objective to look at further expansions around the state in the future.

Referral process: • • • • •

Attend case and treat as per CPGs/DTPs. Explain referral to patient so that an informed decision can be made.

Fill out Diabetes Service Referral Form (available on the QAS Portal).

Fax (received as an email) to diabetes service at the next appropriate opportunity.

Place referral and a copy of the eARF on OIC desk for collation.

Fast Facts: •

• • •

An estimated 1.7 million Australians are living with the condition, while only 1.2 million have been diagnosed 60 Queenslanders are diagnosed with type 2 diabetes every day 2 Queenslanders are diagnosed with type 1 diabetes every day Gestational diabetes occurs in 5 to 10 per cent of Australian women during pregnancy

(Source: Diabetes Queensland)

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Warfarin Introduced in 1948 as a pesticide, rapidly found to be useful and safe in the treatment of thromboembolitic disorders

by Natalie Schutt

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WARFARIN

Warfarin is a competitive inhibitor of the vitamin K enzyme, therefore inhibiting the synthesis of vitamin K dependent clotting factors and anticoagulation proteins.

Warfarin Brands: â&#x20AC;˘ â&#x20AC;˘

Marevan Coumadin

These brands are not interchangeable.

Image credit: Aspen Pharmacare Warfarin Education booklet

Indications for use:

Monitoring:

Prevention and treatment of Venous Thromboembolism (VTE) and Pulmonary Embolism (PE).

Warfarin is difficult to dose due to the inter- and intraindividual variability. Therefore, Warfarin dosing is adjusted via blood test, according to the International Normalised Ratio (INR) which is a standardised method used to calculate a clotting ratio time.

Chronic Atrial Fibrillation (AF) with a high risk of stroke or systemic embolism.

Prevention of thromboembolism in patients with prosthetic heart valves.

The INR in a person who is not taking Warfarin is equal to 1. However, for a patient who is taking Warfarin to prevent or for treatment of VTE, it is recommended that the INR be maintained between 2 and 3. This means that it will take two to three times longer for the blood to clot in comparison to someone who is not taking Warfarin.

Patients who are taking Warfarin for prevention of thromboembolism with prosthetic heart valves may have a different INR target and are under specialist advice.

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Once a stable INR is achieved, the number of blood tests will decrease. However, no less than one month should lapse without a blood test, even if the INR is stable.

Patients are educated that if they are unwell, change their diet or start or stop any medication, they will require regular INR’s until stable. Patients are to consult their Doctor or Pharmacists before commencing complementary medications or over the counter medications as this may also alter their INR.

Drug interactions and drugs to avoid taking with Warfarin, unless under medical advice: (Not an

Food interactions: It is recommended that the patient maintains a balanced diet and with a consistent intake of vitamin K-rich foods. A drastic change in diet may alter the INR.

Foods high in Vitamin K include: • • • • •

Spinach Broccoli Brussel sprouts Silverbeet Kale

exhaustive list)

Patients can include the above food group in their diet however, the key is consistency in diet.

Increase risk of bleeding:

Side effects:

• • • • • • • • •

NSAIDs (Celecoxib, Ibuprofen) Antiplatelets/Anticoagulants (Aspirin, Clopidogrel, Enoxaparin) Antithrombiotics (Tenecteplase, Alteplase) Some antibiotics Selective Serotonin Reuptake Inhibitors (SSRIs) Amiodarone Increase risk of clotting: Rifampacin Dicloxacillin

Complementary and alternative medications interactions: (Not an exhaustive list) Increase risk of bleeding (includes but not limited to): • • • • • • • • • •

Cranberry juice Fish oil Garlic supplements Ginkgo Glucosamine Vitamin E Increase risk of clotting: Co-enzyme Q10 Ginseng Vitamin K (includes multivitamins that contain vitamin K)

• •

Bleeding Clotting (if the patient’s INR is sub-therapeutic there is an increased risk of clotting)

Signs and symptoms of bleeding: If a patient notices : • • • • •

haematuria coffee-ground vomit bloody stools unusual bruising or obvious signs of bleeding

it is recommended to seek immediate medical attention.

Additionally, if a patient has had a recent fall and sustained a head injury, a medical review is recommended.

Is Warfarin reversible?

The effects of Warfarin are reversed with Vitamin K.

Warfarin ball and stick model – image by Vaccinationist

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WARFARIN

Oral Anticoagulants Factor Xa Inhibitors, such as Rivaroxaban and Apixaban, are oral anticoagulant medications that may be used as an alternative to Warfarin. Unlike Warfarin, these oral anticoagulant medications do not require routine pathology monitoring, have a favourable pharmacokinetic profile and have fewer drug interactions.

Prior to commencing a Factor Xa Inhibitor, a bleeding risk assessment must be completed as there is no readily available method for measuring or reversing the activity

Apixaban (Eliquis)

of this class of medication. This requires consideration when a patient presents with a complication such as a major bleed. Supportive measures including mechanical compression and fluid replacement should be considered.

As with all anticoagulant medications, concomitant use with an antiplatelet, Non-Steroidal Anti-inflammatory and other anticoagulant medications may potentiate the risk of bleeding and is therefore not recommended.

Rivaroxaban (Xarelto)

Mode of action

Selectively inhibit factor Xa, blocking thrombin production, the conversion of fibrinogen to fibrin and thrombus development.

Indications

Prevention of DVT in patients who have undergone elective total hip or knee surgery.

Prevention of DVT in patients who are undergoing major orthopaedic surgery - hip replacement (treatment up to five weeks) - knee surgery (treatment up to two weeks) Treatment of DVT and PE and prevention for recurrent DVT and PE.

Reduce the risk of stroke and embolism in patients with non-valvular atrial fibrillation.

Reduce the risk of stroke and embolism in patients with non-valvular atrial fibrillation.

Tablets

Tablets

(2.5mg and 5mg)

(10mg, 15mg and 20mg)

Dosing

Twice daily

Maintenance dose - Daily

Side effects

Bleeding

Bleeding

Nausea

Peripheral oedema

Preparation

Itch Contraindications

Hepatic disease associated with coagulopathy Clinically relevant bleeding risk i.e. any sign of active bleeding Renal function < 30mls/min

Drug interactions

•

• • • Clinical Considerations

Renal function < 15mls/min

Concomitant use with medications that have a side-effect/risk of bleeding is not recommended due to the increased associated risk of bleeding. For example: Warfarin, Aspirin, Clopidogrel, Ticagrelor, NSAIDs Calcium Channel Blockers (Diltiazem, Verapamil) *May increase risk of bleeding Amiodarone Erythromycin

Currently, there is no reversal available for Factor Xa Inhibitors.

There is no blood test available to monitor blood levels.

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Triathlon champ set to

conquer AP&ES games Gympie stationâ&#x20AC;&#x2122;s Emily Bevan will be one to watch as she competes at the Australasian Police and Emergency Games (AP&ES) on the Sunshine Coast this October.

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Emily is anything but a novice.

She’s been competing for the past decade and had the distinct honour of representing Australia on the world stage during the 2012 ITU Junior Women World Triathlon Championships.

“The best aspect of triathlons and duathlons is that it's a fun social sport that anyone can participate in,” she said.

“You can train for the sport in any location at any time and it promotes a healthy lifestyle.

“I prefer the run leg out of the three disciplines, as this has always been my strength. I am definitely not a natural swimmer, but I will keep using the excuse that Gympie doesn’t have water in their pool during the colder months.

“I’ve had the opportunity to take part in a few international races including the ITU Premium Asian Cup, Chengdu (China), ITU Asian Cup, Osaka (Japan), and

OTU Oceania Championships, Wellington (New Zealand).”

Emily only stopped competitive racing to take on an even bigger more rewarding challenge two years ago, becoming a paramedic.

“I became a paramedic because I liked the idea of every day being different and it’s an interesting field that continues to grow,” she said.

“I think being a paramedic shares similar attributes to being an athlete, such as the ability to

shoes and wheels just yet; her competitive streak is still alive and ready to take on the AP&ES games.

“This is the first time I will be competing in the AP&ES games.

They’re sure to provide plenty of friendly rivalry between the different emergency services, which will be fun to be part of,” she said.

“The Sunshine Coast is also one of my favourite race locations.”

There are more than 50 sports on offer at this year’s AP&ES games,

perform under pressure, and being able to work cohesively with the network of people around you.

ranging from triathlon to cycling, boxing, cricket, squash, netball, ten pin bowling and darts.

“So far the job has been an enjoyable experience that has taught me a lot and allowed me to meet some extraordinary people.

Go cheer one of our own as they cross the finish line or participate yourself and enjoy a great visit to the Sunshine Coast. Events run from October 8-15.

“It’s rewarding to be able to help people, and there is no other job I’d rather do.”

Emily hasn’t hung up her racing

For more information on the AP&ES games visit www.apandesgames.com.au

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Entries open for

2017 Pedal4Paramedics Challenge Do your bit for ambulance officers and their families in times of need and take on the 2017 Pedal4Paramedics Challenge on the beautiful Sunshine Coast.

The challenge helps raise funds for QAS Legacy, a fund that provides a range of services to families of ambulance officers who have lost their lives or are retired.

Pedal4Paramedics and QAS Legacy were born out of the Jamie Jackway Appeal – an event that aimed to raise funds for flight paramedic Jamie Jackway, who was injured during a helicopter rescue in the Torres Strait.

In the close to 10 years since its formation, QAS Legacy has been supported by donations and fundraising from current QAS officers, retired personnel and members of the public expressing appreciation for the great work done by QAS.

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Tour of the tropics In this year’s ride in May, six officers raised more than $6,000 as they pedalled a 570-kilometre loop over seven days from Cairns through the hinterland in the ‘Pedal4Paramedics Challenge – Tour of the Tropics’.

Riders and their support crew departed from Cairns Ambulance Station on May 4 and stopped at Port Douglas, Mareeba, Malanda, Ravenshoe, Silkwood, Gordonvale and at Lake Morris before returning to Cairns on May 10.

The route was drawn up by Adrian House from Mission Beach and the riders got to enjoy the hospitality of various Local Ambulance Committees and station staff along the way.

Highlights included rainforest and beach rides as well as a refreshing swim at Lake Eacham, and a free tour of the award winning Paronella Park.

The event garnered widespread media coverage and helped raise awareness for QAS Legacy across the state.

Sunshine Coast challenge Next year’s Sunshine Coast Pedal4Paramedics Challenge is set to be just as good with entries now open for the seven-day ride.

Entry forms are available on www.facebook.com/Pedal4ParamedicsChallenge

If you’d like to help QAS Legacy continue to provide its valuable programs, you can donate by direct deposit to: BSB: 704 052 QBANK (formerly QPCU) Account Number: 1024555 Account Name: Queensland Ambulance Legacy Scheme

Start:

Bribie Island Ambulance Station

Ref: (your name)

Date:

May 3, 2017—May 9, 2017

Donations of $2 or more are tax deductible.

If you require a receipt, please email details of your deposit, such as date, amount, name and mailing address, to qaslegacy@ambulance.qld.gov.au.

Time: 07:00 Entry Fee: $300 for the full ride $60 single day

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Appointments and farewells Weâ&#x20AC;&#x2122;ve welcomed and said goodbye to some members of the QAS family in the past few months.

In July we said farewell to three Cairns officers who together notched up more than 100 years in the QAS. Rodger Ellis retired after more than 35 years as an Operations Centre Supervisor, paramedic and Patient Transport Officer.

Husband-and-wife Critical Care Paramedics Paul and Lorraine Oliveri each have around 33 years in the service. They have parked lengthy on-road careers to shape the next generation of paramedics as senior lecturers at the Central Queensland University.

Family, friends and colleagues farewelled the trio at a barbecue on July 8 at the Cairns Ambulance Station.

Others in the QAS whoâ&#x20AC;&#x2122;ll be sorely missed include:

Name

Position Title

Years of service

Division/Location

Robert Medlin Senior

Manager Business Support

47 years

Central Queensland LASN

Neil Waite

Patient Transport Officer

39 years

Ipswich Patient Transport Services

Rodger Ellis

Patient Transport Officer

38 years

Cairns

Mark Davis

Paramedic

32 years

Ingham

Wayne Stanley

Patient Transport Officer

31 years

Metro South LASN casual

Iain Bowen

Officer-in-Charge

23 years

Texas

Pauline Dallon-Dodds

Emergency Medical Dispatcher

23 years

Maroochydore

Owen Collins

Paramedic

22 years

Rosewood

Neil Robinson

Patient Transport Officer

18 years

Logan West

Jason Dunbury

Paramedic

17 years

Metro North casual

Ian Twomey

Patient Transport Officer

15 years

Metro North PTS

James Darling-Filby

Patient Transport Officer

14 years

Cairns

Simon Humphreys

Paramedic

13 years

Injune

Michael Holmes

Paramedic

12 years

Metro South casual

Gillian Smith

Administration Officer

11 years

Fleet and Equipment

Jacqueline Taylor

Emergency Medical Dispatcher

10 years

Maroochydore

Pierre Van Blommestein

Project Officer

10 years

Operational Support Unit

Melda Dunning

Health and Safety Advisor

10 years

Metro North LASN

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A fond welcome to the following new QAS officers who have taken on permanent appointments over the past three months:

Name

Appointment Date

Position Title

Division/Unit

Kellie Henderson

4/07/2016

Operational Support Officer

Operational Support Unit

Robert Alexander

4/07/2016

Manager Clinical Education

Darling Downs LASN

Robert Shillam

4/07/2016

Manager PTS

Operational Readiness

Caleb Moore

27/06/2016

Manager

Toowoomba Operations Centre

Kym Meredith

24/05/2016

Manager

Southport Operations Centre

Tracey Britton

2/05/2016

Officer-in-Charge

Tara

Stuart Smith

30/06/2016

Operations Supervisor

Patient Transport Service

Todd Horne

30/06/2016

Operations Supervisor

Patient Transport Service

Shaun Doyle

30/06/2016

Operations Supervisor

Patient Transport Service

Karel M Malcolm

23/05/2016

Clinical Standard and Quality Officer

Clinical Quality and Patient Safety

Lisa Oâ&#x20AC;&#x2122;Mahoney

04/07/2016

Manager Communications Education

QAS Education Centre

Nathan Williamson

11/07/2016

Director Corporate Strategy

Corporate Strategy

Anthony Finn

4/07/2016

Infrastructure Program Coordinator

Infrastructure and Procurement

James P Williams

30/05/2016

ICT Enterprise Architect â&#x20AC;&#x201C; Planning

ICT Governance Strategy and Performance

*Names include only permanent appointments and retirements from May 1, 2016 till July 31, 2016

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Thank you :) Sam and Danielle were both absolutely amazing in a very scary time for both Madison (3 year old daughter in Ipswich) and myself. Madi had dislocated her elbow and was in a lot of pain.

Both Sam and Danielle were professional, patient, kind and caring and I was so thankful with how terrific they were in calming and interacting with my little girl. Thank you so much, what amazing people you are doing incredible things every day. I've always had a lot of respect for all emergency workers but seeing firsthand what amazing wonderful people they are just makes me regard them even higher. So thanks again, happy to report Madi is 100% back to her cheeky self today with just her excited memories of her ambulance ride with Sam and Danielle.

- Dani

Both of the gentlemen (Lou Roza and Wayne Stengel from Eatons Hill) were helpful and so nice and caring. Never thought Iâ&#x20AC;&#x2122;d need an ambulance but I am

I would like to thank Gene and Greg from

so thankful they were quick.

the Buderim Ambulance Station as they had

- New mum Stacy

to take me to hospital this morning (June 21). As I have a bent screw and non-union of the fused bones from the operation I had last February. I found out today that the screw has now broken. I was transported by these two paramedics in the new ambulance it had the new automated stretcher. Very comfortable...which made their job at lot easier with the loading and unloading of patients.

- Wendy

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I would like to say a big THANK YOU to the 3 ambulance people who attended to my daughter at my house at Bracken Ridge on Friday afternoon (June 3). My daughter was in SVT with beats of 200. They were brilliant looking after her as she has never had to have a cannula put in and they were great with her.

With all that was going on in the emergency room, I didnâ&#x20AC;&#x2122;t get to thank them. You guys are amazing people, we are blessed to (have) this amazing service available to usâ&#x20AC;Ś. Last week (week of July 18) I had to call you guys 3 times. Each and every member that treated her last week were fabulous, I cannot thank you guys enough for the work you do. Thanks again QAS - Kylie

Yesterday (July 28) #thanksambos was trending because it was Thank a Paramedic Day. Politicians and community members tweeted their thanks to our first responders.

From the Daily Mercury too, thank you to the Queensland Ambulance Service.

- Daily Mercury

Massive thank you to (Emergency Medical Dispatcher) Belinda for remaining calm and keeping us all cool. Also our (Burpengary) neighbour (nurse) Sam Masters is an angel and we can't speak highly enough of her friendship and support throughout. We are grateful beyond words. Amazing experience for all involved. We are the proudest parents and we couldn't have done it without the help of these two special ladies.

Charlie will always know the roles you both played in bringing him into this world.

- Nick

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