Clinical Connections Issue 2

Clinical Connections 1

Edition 2 | Summer 2016

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

Clinical Magazine from the National Ambulance Service Medical Directorate

2 Clinical Connections

Contents 3 WELCOME

Welcome to Edition 2

4 MEET THE TEAM

Biographies & New contributors

5 ASK THE MEDICAL DIRECTOR

Q&A with the Medical Director

6 CLINICAL CASE REVIEW

Clinical Case 1 Managing your Resources

Clinical Case 2 STUCK ON “A” back to basics.

10 ONE LIFE PROJECT

High Performance Resuscitation & Lucas

14 Acute Coronary Syndromes & STEMI Care

ECG Transmission & ACS Report 2014

16 BEST of FOAMed

What’s new and interesting in the world of FOAMed

17 THE INTERNATIONAL

19 ECAT CPAP REVIEW

Introduction of CPAP

19 MEDICO CORK

Telemedicine as an enabler

20 RESEARCH UPDATE

Tips when reading a paper

21 EMS Gathering 2016

Conference update and images from the EMS gathering 2016

A view from down under

Clinical Connections 3

Welcome

Our goal is to create a robust archive of shared clinical knowledge to enhance your clinical development Welcome to our second edition of Clinical Connections, the NAS Medical Directorate quarterly publishing. We have had some great comments from our first edition, so a big thanks for all the feedback and suggestions.

I would also like to take the opportunity to thank all the contributors.

Our goal for this publication is to create a robust archive of shared clinical knowledge to enhance your clinical development. The publication targets three key areas to achieve this goal.

The first is directly focused on the connection between the practitioner and the patient, reviewing challenging clinical cases, learning lessons from tele-medical support, listening to feedback from other healthcare professionals and collating reflections of our peers. We can do this by discussing direct clinical interventions, new clinical procedures and specific clinical cases.

Another component of our professional development is to have a greater understanding of the wider service targets such as; new clinical pathways, quality improvement projects and clinical key performance indicators. A wider understanding of our service goals are key to ensuring frontline practitioners connect with the strategic goals of our service.

And finally the third goal is connection between you the practitioner and your professional development and educational needs. We are targeting this area by supporting you to understand how to conduct research, how to seek out and find free open

access medical content online (FOAMed) and by keeping you up to date with relevant educational content such as our ECG section and our Education & Competency Assurance Team (ECAT) updates.

To continue to make this magazine successful and relevant we need YOU to get involved, feedback, clinical case reviews, ECG’s, questions to the Medical Director, interesting research papers, pictures of where you work and who you work with, items you feel we should address. We hope you enjoy our next edition.

This publication was made possible with the kind support of

News from the Medical Directorate “NAS will be moving to an electronic Patient Care Report in 2016 – we plan on having the first phase roll-out commencing in the Autumn, and rolling out nationally through 2017. The product is called Medusa Siren – we are currently working with Medusa to configure how the product will be customised for NAS use, including using the PHECC dataset from the existing PCR. There will be huge advantages for patients, in that all their data will now be electronic, meaning

it can be integrated with other electronic health records. Hospitals will be able to view the record on a web viewer, and incorporate the record into the hospital health record.

NAS can start to do high quality systematic clinical audit, and individual staff will be able to access their own call records (important when CPD becomes mandatory for PHECC re-registration).

More information in future editions.”

4 Clinical Connections

Meet The TEAM CONTRIBUTORS THIS EDITION James Ward

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

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

James is an Advanced Paramedic in Midleton, Co. Cork. Before joining the National Ambulance Service in 2008, James was an Emergency Department nurse, working in Cork University Hospital and The Royal London Hospital.

James holds the Twitter handle @ IrishParamedic and has been salient in ensuring the evolution of Pre-Hospital Social Media use remains engaging, challenging and always professional.

Dr Jason Van De Velde

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

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

Stephen Flaherty

Stephen is a Paramedic in the South West, he has been with the National Ambulance Service for 4 years. He is currently studying for his BSc in Paramedic Studies in UL. He has a professional interest in Pre-Hospital Ultrasound, Twitter and Human Factors. In his time off he likes to get out on the water, rock climbing and snowboarding.

Brigid Wall

DAVID HENNELLY David is the Clinical Development Manager for the National Ambulance Service, 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.

Brigid Wall is an Advanced Paramedic from Cork who has over 13 years’ experience in Prehospital Emergency care and has always been at the forefront of her chosen profession.

She departed Ireland in 2013, she now lives in Brisbane and works for Queensland Ambulance Service.

Brigid is our first contributor to what we hope will become a regular article called “The International”, where we will explore the wider world of EMS and how our international counterparts manage their systems.

Gary Gardiner

Gary Gardiner has been working with the National Ambulance Service (NAS) for over 13 years now, he is currently an Advanced Paramedic and a NAS tutor based in Letterkenny in Co. Donegal. “I have great faith in learning from our experiences both on and off the road and believe that sharing these experiences is a key element in the enhancement and progression of our service”. Gary has contributed a great case on decision making and interoperability amongst NAS Practitioners.

Richard Pepper

Richard has been an Advanced Paramedic in Limerick City for the past 3 years.

Prior to joining the service in 2009, he spent 15 years as a primary school teacher and outdoor educator. “If you find a job you love you never work a day in your life” and as an AP he believes he has found it. Richard is a BLS & ACLS instructor and is a passionate educator and mentor within the service, constantly striving for clinical excellence. Out of work Richard enjoys the outdoor life including sailing, kayaking and of course BBQs.

Kieran Minihane

Kieran Minihane is based in Cork City and has worked as a paramedic with NAS for the past 8 years; he has a keen interest in photography, both on the ground and from the air with emerging drone technology. Kieran is married with one child and is the local Health & Safety and CISM Rep, he also represents his local area on the National Communications Working Group; He is president of the white Knights motor cycle club and completed his first full marathon this year, as he will proudly tell you that he “walked it, not ran it, in 9 hours even”. Kieran has contributed some amazing images of our service and staff and without him this magazine would look like a dictionary.

Clinical Connections 5

Please email questions titled “Ask the Medical Director” to: medicaldirector.nas@hse.ie

Vincent Wiggins Paramedic, Kenmare

Ask The MEDICAL DIRECTOR

Q

Aidan Mc Entee Paramedic, Monaghan

I am a paramedic in the north east area currently based in Monaghan on a 16 week roster.

I am, I suppose still fairly new to emergency medicine only starting the paramedic course in 2011. I should say at 47 and because of my family situation I do not think I would be able to do the current AP course and would like to be the best paramedic I can. However I feel that paramedic skills and medication is below the skill level we could be providing and sometimes that is felt out on the road as we carry out our duties. In this area where I am currently working, distance to Cavan and Drogheda hospitals from patients homes vary from 45 minutes to over an hour. I am sure this is also common around the country.

Anyhow my questions /query is: Is there any plan to bring in more pain relief for paramedics as I find we are very limited to our current pain relief options?

For some elderly they cannot take Entonox properly. For some patients it doesn’t work well and for some it only takes an edge off the pain. Also considering the distance of most of the journeys to hospital, I think an anti-emitic would also help with patient care. I feel that cannulation is something we could do well and perhaps it would open a door to some of these medications that would help paramedic patient care. I do realise our CPG’s guide us on requesting AP assistance but more often than not there is none available or by the time we meet assistance we are so close to the hospital it’s better to continue on. I enjoy the job; I guess I would like to be doing more to help the sickest patients and not sometimes feeling inadequate in my treatment. I appreciate the chance to forward my thoughts as per Clinical Connections and I know of many more paramedics with in the ambulance services who have similar thoughts.

A

Dr Cathal O’Donnell Medical Director

The 2016 edition of PHECC Clinical Practice Guidelines will include a new drug called methoxyflurane (Penthrox), which we hope to introduce later in the year. Methoxyflurane is an inhaled analgesic which comes in a small single patient use cartridge (unlike entonox, so no cylinders). It has been widely used in Australia and has been shown to be very effective. We have been keen to use it for quite some time, but it only became licensed in Ireland recently. It will be authorised for use by Advanced Paramedics, Paramedics and EMT’s.

With regard to an antiemetic for paramedic use, the IM route for antiemetic’s can be unreliable and the duration of onset may vary in some patients, however the 2016 PHECC CPG’s will also see the introduction of IM antiemetic administration by Paramedics.

Some services internationally are trialling intra nasal (IN) and sub lingual (SL) routes of administration but they are not yet licenced for use in Ireland.

Regarding IV cannulation at Paramedic level, there are currently no plans to introduce this. The mechanical skill of putting in an IV cannula is not the issue – that is easily learned. It is the knowledge of the medication being administered, the side effects, contra-indications, the drug interactions etc. that are important, and which make up a significant part of the AP programme.

By the way, don’t write off participating in the AP programme – it is a significant commitment certainly, but with a bit of application and discipline, I would be confident any practicing paramedic could comfortably come through it and become an AP. Great to hear you enjoy the job, your enthusiasm comes through in your letter, keep it up.

In STEMI patients should we be considering right ventricle myocardial infarction before administering G.T.N? I know it is not contraindicated however if there is ST elevation in V1 and ST elevation in lead III greater than lead II, ST Elevation V4r etc. would it be best practice to mention to the receiving PCI Physician first? Especially if there is no AP or Doctor available to administer fluids.

Q

Dr Cathal O’Donnell Medical Director

A

Great question, and I know exactly what you mean! Firstly for all those who have not yet pondered this question, you are correct that there is a higher chance of seeing a drop in the patients’ blood pressure when you administer GTN to an Inferior STEMI. Why is this so? Well if we have a RCA occlusion and a poorly perfused right sided heart our ability to react to changes in our preload will invariably be compromised. As you say, IV fluids will correct this in most cases. But if you do not have IV access practitioners should be cognisant of the potential effects of GTN administration. We can do this by trying to ensure the patient is seated in a secure position or preferably semi recumbent position with the ability to recline the patient and raise their legs if necessary, this is easily achieved on the ambulance stretcher.

So how can we tell if someone is having an Inferior STEMI with posterior wall involvement? As you have stated try a right sided ECG (Image Attached) and specifically look for changes in V4R. Life in the Fast Lane has a good resource on this topic http://lifeinthefastlane.com/ecg-library/ right-ventricular-infarction/ In relation to the discussion with the receiving PPCI Physician, it will probably not change your treatment for the patient, but if you have gone to the trouble of completing a right sided ECG and confirming posterior wall involvement then I would most certainly pass on that very relevant information.

6 Clinical Connections

CLINICAL CASE REVIEW

INITIAL CALL RTC Patient Trapped.

PHASE OF SHIFT Call was at 1500 hrs into a 0800 to 2000hrs shift.

CREW CONFIGURATION Emergency Ambulance (EA) AP/P crew WEATHER Sunny and dry with a mild wind.

INFORMATION AVAILABLE & DISTANCE FROM INCIDENT. Initial crew on scene was returning from a sports injury with a 17 year old stable patient on board, the patient was complaining of neck pain he sustained in a hurling match. He was spinally immobilised with a spinal board and accompanied by his mother. National Emergency Operations Centre (NEOC) had alerted the crew that they would come across a RTC. Crew arrived on scene before any further information was given.

THE SCENE On scene was a two vehicle RTC, one car and a van. Heavy frontal impact, the car was on the road, the van was on its

Managing your Resources

side lodged in the hedge at the side of the road. There were three casualties from the RTC, two male adults from the van, one female in the car. Patient NO.1 had self-extricated from the van, Patient NO.2 was still in the van, and patient NO. 3 was trapped in her car.

Responders were the initial AP/P crew with a loaded stable patient (and mother), an ICO crew EMT/EMT, ETA 5 mins, a second emergency ambulance with an AP/P crew ETA 8mins Fire service with an ETA of 10 mins, Garda 10 mins ETA, an off duty paramedic on scene and an off duty nurse on scene.

Patient Characteristics- Both male patients were stable apart from minor lacerations and limb pain. Patient no.1 was spinally immobilised, patient no.2 had by then self-extricated and was spinally immobilised, and patient no.3 was trapped in her car. For the purpose of this study we will concentrate on patient no.3, who was a 25 year old female, pmhx of anxiety.

INITIAL FINDINGS Patient no.3 was trapped by both legs which were confined by the dashboard of the car, she had a full GCS and was mainly complaining of severe pain to her legs.

Clinical Connections 7

OUTCOMES INITIAL RESPONSE: Logistics and management of resources were paramount at the scene, the clinical lead had to accommodate four casualties in three vehicles with limited equipment. Stable patient in initial emergency ambulance was moved into ICO vehicle, Patient no.1 was moved into ICO vehicle, Patient no.2 was moved into second emergency ambulance. ICV crew was spilt with the second emergency ambulance crew to leave an AP/EMT crew and a P/EMT crew. The AP/EMT crew travelled to E/D in the ICV with two stable spinally immobilised patients, the P/EMT crew travelled to the E/D with patient no.2, stable male patient, spinally immobilised, which left the initial AP/P crew at scene with the female trapped patient who was transported to E/D when extricated.

RESPONSE OVER TIME: Initial Patient with the neck pain from the hurling injury was discharged same day, no fractures.

Patient no.1, male who self extricated received treatment for minor lacerations and was discharged same day.

Patient no.2, discharged same day with treatment and stitches to lacerations, again, no fractures.

Logistics and management of resources were paramount at the scene, the clinical lead had to accommodate four casualties in three vehicles with limited equipment PHYSICAL EXAMINATION Airway clear, equal bilateral air entry, tachycardia at 115 bpm, Pupils PEARL. Vital signs RR 22, HR 115, BP 124/85 GCS 15.

CLINICAL IMPRESSIONFindings and Working Diagnosis- Surgical Emphysema around base of neck and clavicles bilaterally, possible developing pneumothorax, left humerus fracture, right midshaft femur fracture, possible left proximal shaft femur fracture or neck of femur and right open Patellar wound.

CLINICAL INTERVENTIONS Oxygen Therapy 100% via non-rebreather mask, I.N. fentanyl administered, I.V. access gained, while patient still in car, I.V. morphine administered, I.V. cyclizine administered.

Patient reassurance was a priority as she was becoming increasingly anxious, spinal precautions taken, Fire service removed the roof and performed dash roll to facilitate extrication. Ambulance crew used fire service spinal equipment to extricate and transport patient. Traction splint ruled out due to possible patella complications, Pelvic binder ruled out due to possible neck of femur complication.

Patient no.3, the trapped female had sustained right midshaft fracture, left high femur fracture, cervical vertebral fracture, small right sided pneumothorax (leading to the surgical emphysema) and a small Intra Cerebral Haemorrhage which resolved non-surgically. Patient is undergoing substantial rehabilitation work and is coping well at last update.

DISCUSSION AND LEARNING On reflection the two key areas of discussion and learning on this incident was the scene management and use of available resources and the decision to immobilize the patients who had self extricated .

Many times we as practitioners find ourselves waiting on extra resources to come and help, but we must consider the possibility of when that extra help is not available. In this case the next resource was 40 miles away. Splitting up the crews on scene, use of equipment from what is available and utilising fire service equipment to ensure best patient care possible was the challenges put forward at this scene. Clear clinical leadership, utilising all clinical levels and multidisciplinary communication were the key elements of this call.

The other aspect of the case was the decision to immobilize the patients who had self extricated, there is a significant amount of debate surrounding appropriate prehospital immobilization techniques, with multiple factors influencing the decision making process. This single incident presented us with a combination of patients of whom some who were found to have radiological findings on X-ray and others who were released the same day with minimal interventions. Multi patient scenarios such as this one, with limited time and resources present both opportunities and challenges in the debate surrounding prehospital spinal immobilisation. I would consider that this is also an area to explore further in future editions of Clinical Connections. PHECC will be releasing a position paper on spinal care along with the 2016 CPG’s which will outline and support the current best practice and growing international evidence base.

Gary Gardiner Advanced Paramedic, Letterkenny

8 Clinical Connections

CLINICAL CASE REVIEW

SCENE We were an ALS ambulance day crew, backing up a solo RRV, to a house within the city. The nearest receiving hospital was a 10 minute drive. We had been dispatched on a DELTA call, but prior to arriving the call had been upgraded to an ECHO call (cardiac arrest). The patient was in a small upstairs bedroom. We were informed that a second ambulance crew had been dispatched to the scene.

PATIENT The patient was a 58 year old male with a history of Multiple Sclerosis (MS). Of significance was the patient’s general oral hygiene and issues with ‘swallow’. He had ongoing issues with oral secretion and aspiration. The patient had recently undergone dental surgery and had become progressively ill since leaving the hospital. The initial call had been made by the patient’s family due to their concern for the man’s deterioration in health.

INITIAL EXAMINATION The solo responder reported entering the bedroom to find the man extremely cyanosed with agonal breaths. The patient went into cardiac arrest and the AP on scene moved him to the floor next to the bed in order to carry out resuscitation.

CLINICAL IMPRESSION »» GCS 3 »» No respiratory effort »» No palpable pulse

STUCK ON “A” -back to basics….

»» »» »» »»

Extremely cyanosed No visible vomitus/secretions No obvious trauma VF rhythm on the monitor

INTERVENTIONS The lone AP had carried out BLS including delivering one shock at 200j prior to our arrival (6minutes after him). He had also introduced a supraglottic airway (SGA). Return of Spontaneous Circulation ROSC had been achieved after the initial shock and the AP was attempting to ventilate the patient via BVM. On our arrival in the room the patient still had a GCS of 3 and was making no respiratory effort. The paramedic in the crew gathered a base line set of observations, IV access was gained. Due to significant difficulty maintaining the airway with the SGA preparations were made to intubate the patient.

THE PATIENTS AIRWAY WAS OF GREAT CONCERN TO ALL CREW MEMBERS. From the beginning of the call it was clear that there was an issue with the patient’s airway and how occluded it seemed.

A foreign body had been considered and ruled out. The patient remained cyanosed throughout and a large mass was noted to the left side of the patients mandible. After initial

Clinical Connections 9

assessment and Laryngoscopy of the airway on scene intubation was not attempted, as the patient had a mallampati Grade IV view and was being successfully ventilated with basic interventions albeit with great difficulty.

Minimal chest rise was instigated with use of the BVM. As the second ambulance crew arrived the patient was transferred to the vehicle.

Due to the ‘delicate’ nature of the patient’s airway and the significant difficulties oxygenating him, two members of the team were allocated to airway management during the move and throughout the transfer to the hospital. Our ASHICE included a clear message as to the troublesome nature of the patient’s airway. The patient was handed to the resuscitation team and remained in the same condition.

DISCUSSION POINTS AND QUESTIONS AFTER THE CALL All crew members discussed the call after. It was agreed that there was excellent CRM, staffing and scope was of gold standard, communication within the team was precise clear and direct……. and yet there was ‘uneasiness’ about the patient’s airway. There were a number of ‘what ifs?’…longer travel time, fewer team members etc.

SO; 1. Can cerebral perfusion be maintained with the most basic airway management in the pre hospital setting, with a compromised airway?

2. What were/are our options?

3. Are guidelines robust enough to ensure crew have adequate options?

4. If ROSC had not been achieved would compression only CPR have been acceptable We all agreed we were in fact……… ‘stuck on A’.

The patient was experiencing LUDWIG’S ANGINA a condition not experienced by any of the staff present. Ludwig’s angina is a skin infection that occurs on the floor of the mouth, underneath the tongue. This bacterial infection often follows a tooth abscess (a collection of pus in the centre of a tooth) or other mouth infection or injury.

This contribution was submitted to Clinical Connections by way of a peer discussion point and I would welcome any and all comments, advise and input.

Web reference; http://emj.bmj.com/content/21/2/242.full http://www.medicinaoral.com/pubmed/medoralv15_ i4_p624.pdf http://ijbamr.com/pdf/March%202015%20266-269. pdf.pdf http://lifeinthefastlane.com/ent-equivocation-003/

Richard Pepper, Advanced Paramedic, Limerick

WE NEED YOUR CLINICAL CASES!!!

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

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

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

To maintain consistency we would request that you use the headings shown here for your clinical case. Cases should be concise with the focus on the key reflective learning points or new knowledge garnished that can be shared. Please do not include any private information that would identify the patient or images of patients.

Inclusion of hi resolution stock images, anonymised ECGs and information tables are encouraged. Content will be reviewed by the Medical Directorate and credited to the submitting practitioner.

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

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

10 Clinical Connections

One Life

EVERY ACTION COUNTS

Build community resilience by developing complementary models of OHCA response and expand Community First Responder (CFR) Schemes. Expand the National Ambulance Services role in public health promotion and education.

Refine call taking, resource allocation and dispatcher assisted CPR of OHCA cases by the National Emergency Operations Centre (NEOC) and promote the vital role they play in outcomes of the OHCA patient.

Enhance the quality of care delivered by Emergency Medical Services at the scene and cultivate a coordinated approach to Return 0f Spontaneous Circulation (ROSC) Care.

Refine the process and quality of data management, clinical audit and research for OHCA and improve feedback to all stakeholders.

High Performance Resuscitation High quality and well-choreographed Cardio Pulmonary Resuscitation (CPR) is a means to improve survival from cardiac arrest. Minimal breaks in compressions, full chest recoil, adequate compression depth, and adequate compression rate are all components of CPR that can increase survival from cardiac arrest. Together with nontechnical elements such as predesignating roles, clear leadership and good communication, these components combine to create High Performance Resuscitation.

In order to create an environment of sustained High Performance Resuscitation, everyone must be on board.

The first practitioners on scene must take responsibility or “OWNERSHIP� of high quality, minimally interrupted CPR. When Advanced Paramedics arrive, they will perform the Advanced Life Support (ALS) measures of the resuscitation but must also remain focused on maintaining high standards of Basic Life Support (BLS). In some circumstances a Paramedic/Advanced Paramedic team may arrive first at the scene, it vital in these situations that the primary focus of the crew in the first five minutes of a cardiac arrest is high quality BLS. The goal is for additional resuscitation care such as medication therapies or advanced airway management to compliment CPR. High quality CPR should be the default action at all times.

In the following two editions of Clinical Connections we will discuss the key principles of High Performance Resuscitation under the following headings;

SUMMER EDITION 1. Pre Arrival Planning & Equipment 2. Standardised Positions and Initial Care 3. Key Components Of High Performance Resuscitation 4. Mechanical Chest Compression (LUCAS 2) AUTUMN EDITION 1. Understanding Human Factors in Resuscitation 2. Post ROSC Care 3. Post Event Debrief and Learning In association with these articles the One Life Project is releasing posters for each base and individual pocket cards for each practitioner to support the principles of High Performance Resuscitation. We will also be releasing a comprehensive position paper on the optimal scene management of an Out Of Hospital Cardiac Arrest (OHCA), later this year.

PRE ARRIVAL PLANNING & EQUIPMENT It is important that practitioners discuss their roles and plan pre arrival to minimize delay in appropriate patient care. It is also vital that crews standardize equipment they bring into the scene of a suspected or confirmed cardiac arrest.

Pre arrival planning is an essential component of a high performing team. Practitioners should discuss who is taking each role prior to arrival at scene and in turn who is bringing in each piece of equipment. In order to achieve the best outcomes for each individual patient each person involved must work as a team, not as separate entities. This concept

Clinical Connections 11

has been described as “PIT CREW” Resuscitation. Pre designation of roles during training and ownership of each important role is the key to the “PIT CREW” approach. This process can also be of benefit to supporting crews arriving on scene, who will be aware the minimum standard of kit is already by the patient’s side at each OHCA. ILCOR guidelines 2015 identified the importance of minimising interruptions to chest compressions and stress the importance of rapid defibrillation of VF/ VT in both adult and paediatric cardiac arrest patients. Some studies have also shown increasing efficacy of higher energy levels of biphasic energy in defibrillation. With this in mind we have introduced a Clinical Directive to support a change of practice to adult defibrillation energy on LIFEPAK® 15 monitor/defibrillator.

The NAS has modified the settings on all Physio Control LIFEPAK® 15 monitor defibrillators to an initial energy selection of 360J. The aim of this process is to minimise the delays that may occur during the pre-shock pause, minimising interruptions to chest compressions through streamlining the energy selection process and increase first shock success rates of VF/VT arrests.

The previous initial sequence of defibrillation for an adult patient when using LIFEPAK® 15 incorporated escalating the energy from 200 – 300 – 360 joules. The Clinical Directive instigates a non-escalating dosing regime for adult patients, commencing at 360 Joules from the first shock and remaining at 360 Joules throughout the resuscitation.

Each LIFEPAK® 15 is having its software settings amended to facilitate this change, the default settings in both Manual and AED mode will be 360 joules. In the incidence of Paediatric Defibrillation the practitioners should defibrillate in manual mode at 4J/kg as per CPG and CD 01/2016 paediatric Defibrillation

STANDARDISED POSITIONS AND INITIAL CARE The National Ambulance Service is striving to introduce highperformance resuscitation principles into each OHCA. This includes a well-planned, well-rehearsed and often choreographed approach to caring for the victim of sudden cardiac arrest with an increased focus on using a team approach during resuscitation at the scene. Understanding your role and taking ownership of that role will improve performance at each resuscitation. By having predetermined positions and roles many CPR interventions can be performed simultaneously.

TEAMWORK IS KEY COLLABORATE-COMMUNICATE-COORDINATE!

Each Person has an assigned role and practices again and again

Welcoming the newest member of our team- LUCAS The National Ambulance Service has invested significantly in mechanical compression devices.

This year we have the accolade of placing the single largest order of LUCAS 2 chest compression systems in the history of their production. We will be one of only a handful of services that are striving to provide the option of mechanical chest compression at each OHCA we attend. The benefits of mechanical chest compression are highlighted to most when you have limited numbers of practitioners at scene to provide continuous high quality chest compressions, when you are running a protracted resuscitation and when you instigate transportation of the OHCA patient.

The integration of mechanical chest compression devices into a

high performing well rehearsed resuscitation can be almost seamless and can continue to provide safe and effective chest compressions during transportation.

It is however imperative that decisions to continue resuscitation and instigate transportation of a patient in cardiac arrest is based on the clinical disposition and suspected aetiology of the Patient.

Decisions around conveyance, transport and destination should be managed on a case-by-case basis.

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

12 Clinical Connections

One Life

EVERY ACTION COUNTS

Initial Response

AS EXAMPLE 2 PERSON HIGH PERFORMANCE RESUSCITATION ARRIVAL AT SCENE - INITIAL STEPS

1 Identification: Position 1 Role: Airway and ventilatory support & initial team leader Location: Inside BLS Triangle at patient’s head

1

1. Position defibrillator /monitor.

2. Attach defibrillator pads and operate defibrillator /monitor (If awaiting arrival of P3) 3. Basic airway management (manoeuvre, suction & adjunct) 4. Assemble ventilation equipment and ventilate (30:2) 5. Insert advanced airway (ventilate once every 6 sec / ETCO2 ) 6. Team leader (until P4 assigned)

NATIONAL AMBULANCE SERVICE

NATIONAL AMBULANCE SERVICE

2 NATIONAL AMBULANCE SERVICE

NATIONAL AMBULANCE SERVICE

2 ns ati o nd RF ou

Improved Survival

Qu

ali

ty

CP

1. Position BLS response bag and suction 2. Initiate patient assessment 3. Commence compression only CPR (Continue until P1 ready to ventilate) 4. Alternate chest compressions with P3 (P1 until P3 arrival)

Clear Leadership

na

ge

sH

igh

Intubate if clincally warrented

Gain Vascular Access IV/IO

Switch compressors every 2 min

Insert Supra Glottic Airway Monitor ETCO2

Treat Reversible Causes

Pa ra

Allow Full Chest Recoil

Rate between 100 and 120 / min

s

Minimise interruptions

Prioritise compressions C.A.B

on

me

dic

Pra ct

itio

ne r

Ma

Rapid rhythm analysis

Compress > 2 inches

ti en erv Int ns LS tio s A da ge un na Fo Ma PR er y C ion ualit tit rac h Q ic P Hig ed ing ram ta Pa ain ed ile m nc va wh Ad

Identification: Position 2 Role: Chest compressor Location: Inside BLS Triangle at patient’s side

Clinical Connections 13

NAS EXAMPLE 5 PERSON HIGH PERFORMANCE RESUSCITATION ROLE DELEGATION UPON ARRIVAL OF ADDITIONAL PRACTITIONERS

Team Arrival

5

5 Identification: Position 5 Role: Family & Team Support Position: Outside the BLS triangle 1.

2.

3.

4.

5.

Identification: Position 1 Role: Airway and ventilatory support & initial team leader Location: Inside BLS Triangle at patient’s head

NATIONAL AMBULANCE SERVICE

Family Liaison Patient Hx / meds Manage Equipment Documentation Plan removal (if transporting)

1. Position defibrillator /monitor.

2. Attach defibrillator pads and operate defibrillator /monitor (If awaiting arrival of P3) 3. Basic airway management (manoeuvre, suction & adjunct) 4. Assemble ventilation equipment and ventilate (30:2) 5. Insert advanced airway (Ventilate once every 6 sec / ETCO2 ) 6. Team leader (until P4 assigned)

1

NATIONAL AMBULANCE SERVICE

NATIONAL AMBULANCE SERVICE

2

3

NATIONAL AMBULANCE SERVICE

NATIONAL AMBULANCE SERVICE NATIONAL AMBULANCE SERVICE

NATIONAL AMBULANCE SERVICE

4

NATIONAL AMBULANCE SERVICE

Identification: Position 2 Role: Chest compressor Location: Inside BLS Triangle at patient’s side

NATIONAL AMBULANCE SERVICE

2

1. Position BLS response bag and suction 2. Initiate patient assessment 3. Commence compression only CPR (Continue until P1 ready to ventilate) 4. Alternate chest compressions with P3 (P1 until P3 arrival)

4 Identification: Position 4 Role: Cardiac Arrest Team Leader Location: Outside the BLS Triangle (ideally at the patient’s feet with a clear view of the patient, team and Monitor)

Identification: Position 3 Role: Chest compressor & AED operator Location: Inside BLS Triangle at patient’s side

1.

2.

3.

4.

5.

1.

2.

3.

4.

6.

7.

8.

9.

10.

Positive exchange of Team Leader Position ALS bag (AP) Take Handover from P1 Monitor BLS quality.

Initiate IV/IO access & administers medications (AP) Intubate if clinically warranted (AP) Communicate with family / Family Liaison.

Identify and treat reversible causes (Hs + Ts) Provide clinical leadership.

Conduct post event debrief.

Alternate compressions with P2 Operate AED/ monitor Turn on metronome (if available) Monitor time / cycles

3

1

14 Clinical Connections

Acute Coronary Syndromes & STEMI Care

What all staff may not be aware of is the sheer scale of the program and how the professional delivery of this service

by YOU the frontline Call Takers, Dispatchers, Paramedics, Advanced Paramedics and EMT’s has had a dramatic impact on Heart Attack Care in Ireland. In this article we will review the figures, discuss the impact it’s having on our patients today and explore the future of STEMI Care in the National Ambulance service.

Earlier this year the ACS program entered the 2016 Health Service Excellence Awards. They were the runner up in a highly competitive final from an original entry of 426 projects. They were chosen by the Selection Panel after 39 projects were invited to make presentations detailing their projects aims and objectives. The link below highlights some of the excellent work from the ACS program and NAS staff; http://www.hse.ie/eng/staff/ HealthServiceExcellenceAwards2016/ACS.html NEXT STEPS FOR NAS AND STEMI CARE The ACS Programme is continuing to work with HSE/NAS communications to develop further public awareness campaigns which promote the early recognition of ACS symptoms and instigates an appropriate 999/112 calls.

In 2016, a new cross-border development will ensure that Donegal patients suffering from a STEMI heart attack have direct access to services in Altnagelvin Hospital in Derry. This will represent a big saving in terms of treatment time and also distance, as well as delivering better outcomes for patients.

The Optimal Reperfusion Strategy is running concurrently with a significant investment by the NAS in a single monitor /defibrillator solution for the entire service (Physio Control LIFEPAK® 15). This investment is providing our service with the opportunity to standardise the equipment used during the management of each STEMI patient and for the first time is offering our service the ability to implement a standard process of STEMI transmission into each of the PPCI centres.

This also offers us the ability to capture data, archive our transmissions and analyse our performance via the LIFENET® System.

The important element to consider in this process is that since 2011 NAS practitioners have been working without ECG transmission, our current model is built on highly professional, well trained practitioners who are capable of interpreting 12-Lead ECG’s, identifying STEMI patients, instigating appropriate treatments, consulting with receiving PPCI Physicians and implementing the appropriate pathway for each of those patients. This standard of decision making and level of professionalism places our service at the forefront of ACS care internationally.

ECG transmission will provide us with a greater opportunity to attain the highest standards of care for the patient, it will allow us to reduce the false positive rate of Code STEMI activation and allow us to critically appraise our performance on a service wide level with the ability to review cases remotely and provide appropriate feedback to practitioners.

Internationally many services have built models of care that rely on ECG transmission and Physician led ECG interpretation prior to acceptance and direct admission to PPCI. The NAS has taken the decision to introduce ECG transmission to support our current model of NAS Practitioner led 12-Lead interpretation and Code STEMI activation.

The NAS Education & Competency Assurance Team will be releasing supporting documentation on 12 Lead transmissions but in general the sequence of events will follow the process outlined below; The important item to note is that we will still expect our practitioners to interpret the 12 Lead ECG and only activate PCI and transmit the ECG if they have identified a STEMI or new onset LBBB.

12 Lead Aquisition

ACS TREATMENT

STEMI care in Ireland has changed dramatically in the past 5 years, as frontline practitioners and NEOC staff. One of the greatest changes to practice over the past number of years has been the introduction of the Optimal Reperfusion Strategy (ORS) as part of the Acute Coronary Syndrome (ACS) Programme. We are acutely aware of the pivotal role the National Ambulance Service plays in ensuring patients suffering from a STEMI have direct access to standardised services in designated centres around Ireland.

12 Lead Interpretation

by Practitioner STEMI Identification 12 Lead Transmission Code STEMI Activation

Clinical Connections 15

REF Heart Attack Care In Ireland 2014 ACS Report

1,247

MEAN AGE OF STEMI PATIENTS

62.4

PATIENTS WITH STEMI Were recorded from eight out of the nine PCI centres STEMI patients

STEMI patients

MALE

FEMALE

78%

22%

62

68

Mean age

86% First myocardial infarction

MEDIAN TIME FROM SYMPTOM TO FIRST HOSPITAL WAS

Mean age

2011 ONLY 50% OF STEMI PATIENTS RECEIVED PPCI. IN 2014 92% OF STEMI PATIENTS GET PPCI

92%

150 MIN (2 hours 30 mins)

TYPE OF TREATMENT:

78% PPCI

FIRST POSITIVE ECG 48% EMERGENCY DEPARTMENT 42% AMBULANCE 6% GENERAL PRACTICE 4% ANOTHER LOCATION

12%

CONTRAINDICATED

7%

THROMBOLYSIS

4%

NO ACUTE REPERFUSION THERAPY

16 Clinical Connections

EAS Update 2015 has again proved to be a busy year for the Emergency Aeromedical Service now averaging approx.500 missions annually with a broad spread across the country, the highest usage

of the service is in the West and Mid-West and Galway University Hospital is the largest receiving facility with almost half of all EAS missions terminating in Galway.

County

County

Completed Tasks

Carlow 4 Cavan 15 Clare 31 Cork 10 Donegal 25 Dublin 0 Galway 32 Kerry 17 Kildare 6 Kilkenny 1 Laois 11 Leitrim 7 Limerick 11 REF Figures IAC/NAS 2015

Completed Tasks

Longford 15 Louth 11 Mayo 55 Meath 10 Monaghan 6 Offaly 22 Roscommon 30 Sligo 11 Tipperary 32 Waterford 3 Westmeath 13 Wexford 6 Wicklow 10

Monaghan

Sligo

Cavan

Meath

Westmeath Offaly

Dublin

Kildare Wicklow

Laois

Carlow

Tipperary Limerick

Kilkenny Wexford

Kerry

Waterford Cork Paed 5%

The breakdown of the calls as per clinical disposition displays an almost equal 1/3 split on the calls from between general Medical, Trauma and STEMI care. In the forthcoming editions we will keep you informed of the continued learning from EAS and will reflect in more detail on specific cases.

Since the 1st Edition of Clinical Connections hit the press one of the biggest topics in Emergency Care has been the publication of new Sepsis definitions, the definitions that we have known to date, such as SIRS and Sepsis 6 may become things of the past, to be replaced by acronyms like SOFA and qSOFA… To read the pros and cons on the new sepsis definitions on these websites; http://lifeinthefastlane. com/ccc/sepsis-definitions/ and http://emcrit.org/ pulmcrit/problems-sepsis-3-definition/

Check out @paramedicCPD on Twitter and their website www.paramediccpd.wordpress.com

Louth

Roscommon Longford

Clare

WHAT’S NEW?

There’s no shortage of ‘for profit’ CPD sources available through the internet or as smart phone apps, however, there are many free resources too. I did say that I’d include a few Twitter recommendations so I’ve chosen a few with additional blogs or websites that cover various topics.

Leitrim

Galway

JAMES WARD

FREE CPC

Donegal

Mayo

FOAMed Update

Other 2%

STEMI 29% Trauma 30%

Medical 34%

And for a paediatric focus, there’s www. dontforgetthebubbles.com, as far as I remember, the name refers to the untold benefits of blowing bubbles for sick kids, possibly the ED version of our glove balloons. Despite the name, it’s actually a really good resource for all things paediatric. @freeemergtalks freeemergencytalks.net is a good resource for a range of ED presentations and if you want to challenge yourself with more critical care subjects, check out @ccpractitioner or criticalcarepractitioner.co.uk UNDERSTANDING HASHTAGS The key to getting the most out of Twitter is understanding how to use hashtags. A hashtag is a shortcut to finding everything on a particular subject. Some hashtags are very obvious, #IrishWater will give you every tweet related to Irish Water, or #GameOfThrones will get you every tweet about Game of Thrones. Most conferences will have a hashtag, and you may need to do a bit of searching or ask someone on Twitter what the hashtag is. Although if you know the dates of the conference, you can search on www.symplur.com as most healthcare hashtags are registered here. Many other subjects, discussions and forums can be followed and the content can be read in your own time. Twitter is littered with chat and discussion and most use a hashtag to keep track of the conversation. In fact we now have a weekly twitter based discussion. Each Monday evening we host a chat on a different EMS topic with an Irish focus, if you search #IrishEMS on twitter or Symplur you can view previous chats.

Clinical Connections 17

THE INTERNATIONAL As a rugged little island on the west coast of Europe, travel and adventure is part of our culture, we like to know what is over the horizon. Through the eyes of Irish medics “The International”, explores the wider world of EMS and how our international counterparts care for their patients and evolve their systems. Brigid Wall is an Advanced Paramedic from Cork who departed Ireland in 2013; she now lives in Brisbane works for Queensland Ambulance Service.

BRIGID WALL QUEENSLAND AMBULANCE SERVICE

Where are you from? I never thought that could be such a difficult question! Ireland, Cork, Whitegate, depending on who’s asking. Or is the answer Capalaba (my home station), or Belmont- where I live?

Being an Irish paramedic in Queensland is quite a talking point, as so many people here in Brisbane have Irish heritage and the Irish community is highly respected.

I left Ireland in 2013 to join the Queensland Ambulance Service (QAS). After almost 10 years working in Cork city and county it was a wrench to leave my ambulance family behind.

My EMT New Entrant 24, and AP 10 classmates are spread far and wide around the world now. The education we were afforded in Ireland has proven invaluable to me.

Queensland is a big place. The population of the state is about 4.8 million people, similar to Ireland, but spread over 20 times the area. Three quarters of the people live in the South East corner - Brisbane, Toowoomba, The Gold Coast and Sunshine Coast. The other 1.2 million people live in small towns, islands, mining communities and vast rural farming properties. Providing an ambulance service to all of these people is quite a challenge.

QAS is one of the largest ambulance services in the world.

They employ almost 4000 people and over 3000 of them are frontline staff. There are also 1600 volunteers known as ‘honorary officers’. They are the community first responders and volunteer drivers. They provide an essential service in rural and remote communities, and they wear the QAS uniform with pride!

QAS officers (all frontline staff are known as officers, not just the managers!) work at a number of different clinical levels Doctor, Critical Care Paramedic, Advanced Care Paramedic, Extended Care Paramedic, Paramedic, Patient Transport Officer. Most of the new staff have completed a degree in Paramedical Science before joining the service. QAS works closely with the aeromedical services, such as the Royal Flying Doctor Service and Careflight, and QAS paramedics also crew the rescue helicopters.

Since 1892, when the Queensland Ambulance Transport Brigade held its first meeting in Brisbane the service has been developing and adapting to meet the challenges of providing prehospital emergency care in such a huge and diverse state.

One of the recent initiatives to reduce the workload on the emergency departments has been the introduction of the Low Acuity Response Unit (LARU) in urban areas. Experienced paramedics are selected to work on the LARU. They respond alone in a sedan type cars (currently Hyundai Santa Fe). These vehicles are marked with the QAS logo, but don’t have lights and sirens.

LARU runs from 8am to midnight. It is reserved for jobs that don’t require an emergency response, and is dispatched to people who are able to mobilise. Secondary triage by a clinical officer in the communication centre will usually have taken place after the initial 000 call. This is to ensure that a low acuity response is appropriate and that the LARU officer will be safe attending the scene alone. The LARU officers have access to all active calls on an iPad and they can self-dispatch to appropriate jobs.

18 Clinical Connections

ECAT CPAP Review

You name it, I’ve seen it on the LARU! A big proportion of the calls fall outside the direction of the clinical practice guidelines. Experience and common sense are essential. Dental problems, lumps, bumps, rashes and fevers, spider bites, medication errors, parenting issues, pains, strains, finger and toe amputations and even a paper cut that had healed by my arrival. The most bizarre job was to a patient on hunger strike because his wife wouldn’t have sex with him!

The LARU is fully equipped to respond to a 000 call. If the vehicle is identified as the closest resource to a life threatening emergency it will be dispatched, at road speed. Responding alone, to a nearby serious emergency call is an interesting change of pace!

LARU officers are offered extra training in patient assessment and minor injuries, and they do ED and GP clinic placements. The scope of practice for LARU officers will be further extended in the near future, to allow them to give more oral medications and manage more patients at home.

Working on the LARU is a temporary secondment, with officers regularly rotating back to an emergency ambulance.

ED attendance is avoided in more than 50% of LARU cases. Patients can be treated and discharged on scene, with appropriate advice.

Suitable follow up can be arranged by the LARU officer, for example direct referral to a diabetic clinic, mental health services etc. If transport is necessary, the patient can be taken to an appropriate ED, GP clinic or other support facility.

Completing the patient care record for cases where the patient has been discharged on scene, or advised to self manage is very important.

Often the paperwork takes as long as the patient interaction. The patient’s capacity to understand, remember and follow the advice given needs to be fully documented. Often a full transcript of the conversation between the paramedic and the patient or the patient’s family member will be written down. Thankfully the patient care record is in electronic form on a laptop computer, so space is not an issue.

The LARU is a small, but very important part of the service provided by QAS in the heavily populated areas of the state. It has been effective in reducing workload on the emergency ambulances, and has reduced the number of ED attendances.

I have enjoyed the challenge of working on LARU, and I’m looking forward to my next adventure as a QAS Critical Care Paramedic.

Pre-hospital emergency calls involving Shortness of Breath (SOB) are quite common. When patients present breathless, as a result of Acute Pulmonary Oedema (APO), our options for intervention are effectively limited to medications.

These, we hope will reverse, or at least stabilize the symptoms in the field. CPAP or Continuous Positive Airway Pressure is a non-invasive intervention that has moved into the EMS arsenal and can effectively treat a patient with SOB secondary to APO. CPAP is a treatment that uses mild air pressure to help keep a patient’s airways open. Equipment and training is currently being rolled out by the National Ambulance Service (NAS) to allow paramedics to use this intervention when presented with patients in respiratory distress secondary to APO. The thin walls of each alveolus are kept open due to air pressure and surfactant.

When this becomes disrupted by excess fluid, gas exchange may be compromised and the alveoli can collapse.

If this occurs, the patient can become breathless and may become unresponsive to O2 therapy. The small rise in air pressure delivered via CPAP can result in the alveoli opening up and the fluid being shifted out, hopefully allowing gases to cross over and the patient to breathe a little easier.

Currently, the Pre-Hospital Emergency Care Council (PHECC) provides guidance for use of CPAP through their APO CPG which provides for basic and advanced interventions along with both inclusion and exclusion criteria for CPAP. We received a call, given as a 6D2 (Shortness of breath), involving a 68 y/o man. On arrival, we found him in a very distressed state and unable to catch his breath.

We initially gave 100% O2 and

gathered some vitals. He was tachypnoeic (36), tachycardic (128) and hypertensive (150/110) with an SP02 of 86%. The man was also sweating and had crackles in both lungs with an audible wheeze.

His saturations did not improve with the oxygen alone and we decided to give him GTN and considered Salbutamol. After a couple of minutes, he improved enough to get him to move to our stretcher and we moved to the ambulance. His condition deteriorated following the move and we decided to try CPAP with the nebulizer.

Our journey time to the Emergency Department (ED) was 40 minutes.

He wouldn’t tolerate the mask initially and chose to hold it against his face himself. Over 10 minutes his condition began to improve regarding his breathing although we still considered him unstable. On arrival at the ED he was relatively comfortable but still considered unstable and was admitted to the resus area.

The patient’s short term prognosis was favourable but his current obesity and underlying comorbidity of diabetes, Congestive Heart Failure (CHF) and a history of Myocardial Infarction (MI) would not give him good long term prospects.

When patients present with SOB as a result of different pathologies, it can be sometimes difficult to decide on a treatment regime. Our knowledge of pulmonary physiology and pathophysiology will dictate our intervention choices. I believe that the introduction of CPAP to our repertoire gives us a powerful noninvasive method to treat the patient with APO. As there is growing evidence for pre-hospital use of CPAP to intervene with pathologies such as COPD and Bronchospasm, we may see the scope of its use expand in the future.

Eoghan Connolly & Richard Shanahan

Clinical Connections 19

MEDICO CORK Tales From the Telemedical Support Unit Telemedicine as an Enabler - Dr Jason Van De Velde Analgesia Management accounts for 33% of calls to MEDICO Cork, the HSE’s National 24 hour Emergency Telemedical Support Unit. The latest edition of PHECC CPGs is due for imminent release, and includes a raft of new agents on the medication formulary for all grades of practitioner.

Telemedicine enables the novel use of existing agents, the introduction of new agents and by its very nature, identifies where existing CPGs could be enhanced based on real Irish case data.

The big news is the imminent introduction of IV Paracetamol, Ketamine and Methoxyflurane. When anything new is introduced into the system, MEDICO Cork’s call volume predictably increases with trends towards support for clinical applications surrounding the change in practice. A good example of this was the first introduction of Morphine. For months’ practitioners were looking for support to go beyond their maximal dose. The whole system eventually settled on a realistic higher dosing regimen.

Fentanyl added another layer of complexity. Initially introduced only for paediatric practice, the ease of administration intranasal, coupled with its potency and rapid onset (and indeed offset), provided a useful a tool to support practitioners in managing painful procedures such as extrication, splinting, irrigating or packaging in the adult population. This appears to be resulting in an overall decrease in total opioid consumption.

The paradox of choice will soon become a reality for every prehospital practitioner in Ireland. We believe the most fundamental change is not simply additional agents, but the

Other 11% Analgesia Mx 33%

Sepis Mx 2% Logistics 2% Nausea & Vomiting Mx 4% Respiratory Failure Mx 6% Termination of Resus 8%

Agitated Pt Mx 12%

Cardiac Mx 11% Seizure Mx 11%

REF Medico Cork necessary and much welcomed swing towards holistic pain treatment strategies. This shifts emphasis towards a primary decision on non-pharmacological interventions, eg. Splinting, Positioning, Irrigation, Covering, Traction, etc. A practitioner needs to decide how they are going to remove the stimulus, not simply dampen its transmission. The secondary decision being what pharmacological combination of agents will best achieve the primary aim. MEDICO Cork recognises this is actually a stressful time, particularly for established practitioners. We will of course be right behind you in support of this and any change.

TO DRILL or NOT TO DRILL that is the Question?

INTRAOSSEOUS COMPLICATIONS Two recent cases reported to the Medical Directorate have demonstrated the absolutely lifesaving use of intraosseous access through the prehospital administration of cardiac drugs to an adult in cardiac arrest, and fluids and antibiotics to a baby with severe sepsis.

But these cases also highlight that drilling into a leg is not an entirely benign process. Both these cases went on to develop compartment syndrome through extravasation of fluids into muscle tissue plains.

As practitioners we should carefully consider each intervention we undertake and ask ourselves; firstly is this procedure that I need to do? And if so am I undertaking each procedure with the upmost care? The routine use of intraosseous (IO) access during out of hospital cardiac arrest has been advocated during AP training for some time now and it is undoubtedly leading to a trend of IO as a default during OHCA, at times without appropriately assessing the option of intra venous access.

Figures from OHCAR 2014 Annual Report demonstrate Of the 1972 cases for which data was available, some form of cannulation was performed in 1431 cases (73%). Intraosseous cannulation only was performed in 42% of cases (n=817), while

intravenous cannulation only was performed in one in five cases (n=397; 20%). A combination of both techniques was used in 197 cases (10%) THE QUESTION WE SHOULD ASK OURSELVES IS; ARE WE SACRIFICING QUALITY FOR SPEED? Do we need to take that extra moment to assess the potential likelihood of establishing a stable IV access point before we gain IO access?

The surgeons performing the fasciotomies commented that it may be helpful to remind prehospital practitioners of correct IO placement in the tibia. Some useful links are; https://www.youtube.com/watch? v=mpnroZi8t0A&index=11&list=PL66D7D32FB152333E https://www.youtube.com/watch? v=-d7DpV7Jx2k&index=10&list=PL66D7D32FB152333E Admitting teams had nothing but praise for the prehospital practitioners concerned; as both these patients would have certainly died without their interventions and will both go on to make a good recovery.

David Hennelly, Clinical Development Manager

20 Clinical Connections Our resident research guru Dr Conor Deasy will be taking the opportunity over the forthcoming editions to provide us with some research tips; we start this series with an article on reading papers and developing the skills to decide whether it’s one for the top shelf or the bin.

Research DR CONOR DEASY Systematic Reviews and Meta-analyses Randomised Controlled Double Blind Studies Cohort Studies Case Control Studies Case Series Case Reports Ideas, Editorials, Opinions Animal research In vitro (’test tube’) research TIPS WHEN READING A PAPER Many people in healthcare find the process of reading a medical or scientific paper off-putting – some would prefer to read a telephone directory. It is nice to sometimes dig deeper to understand why we do things the way we do or not as the case may be. We live in a world of information overload – keeping up with cutting edge practice is a challenge for the greatest minds – it’s like drinking water through a water hydrant. Like anything, there is training required so you know how to orientate yourself to get the most out of the time you spend reading a paper.

There are many resources on the net or if you prefer to read it in a book Trisha Greenhalgh’s ‘How to Read a Paper’ is probably right up there with Meat Loaf’s Bat out of Hell for sales.

Here are a few tips for the next time you decide to do the deep dive and pull out a paper to find out why the

hell we do what we do; stopped cooling post cardiac arrest patients, decided to invest in Lucas chest compression devices, use checklists to reduce errors etc.

An important step in finding an answer to a question either in the existing literature or by performing original research to answer the question, is formulating the question into an answerable question. There are certain questions that we will never be able to answer – it may be impossible to do the research in that group of patients for example, or to use that particular intervention. One way of thinking about the research question is using the mnemonic PICOS which stands for; P patients or populations I interventions C comparison group(s) or «gold standard» or «standard of care» O outcome(s) of interest S study design

When you are thinking about your conundrum ask yourself who are the patients or populations you are interested in. Take sepsis for example, if they are patients that you attend pre-hospital in Ireland, they may well be very different to the African American population in Detroit on whom Dr Rivers published his famous sepsis work showing aggressive early goal directed treatment was associated with a decrease in mortality from 46.5% to 30.5% (in patients with severe sepsis or septic shock). We sometimes see hospital-based practice being extended to patients in the pre-hospital environment when in fact the research may be lacking to show benefit for our (pre-hospital) group of patients. So when you are reading a paper ask yourself, does this paper examine patients similar to those I see in terms of age, co-morbidities, and ethnicity?

The second thing to look at is the Intervention – what was done to the patients – did they receive just what it said on the tin or were the beans baked by Gordon Ramsay, tinned, warmed and served with toast and a kiss on the cheek by Rosanna Davidson. Was it the beans, the toast, the butter on the toast, the kiss or Rosanna Davidson made the difference? A common source of bias in pre-hospital research is when the intervention or change in practice is associated with or delivered by a practitioner who may have got more training or be more motivated or enthusiastic about the intervention and so it is the Practitioner or their training that is making the difference rather than the intervention itself.

Comparison groups are important to consider – back in the bad old days Pharmaceutical Companies would compare their new fancy drug with a placebo rather than the current practice. No wonder the new drug looked better! Nowadays, if we were to set up a trial to look at the effect of furosemide on the management

Clinical Connections 21

EMS Gathering 2016

of pre-hospital diagnosed congestive cardiac failure (CCF) for example, we would not get ethical approval to compare it with a 10 ml normal saline flush as a placebo because we know the answer already with a large degree of certainty already. There is a lack of ‘clinical equipoise’ to support such a trial is what the ethics committee will tell you – they are essentially telling us ‘we know the answer, don’t waste your time’. I would be interested in whether furosemide or nitrates individually or combined and in what doses are the best treatment for pre-hospital shortness of breath due to cardiac failure. This brings me on to outcome measures.

Outcome measures must be relevant to the patient and the practitioner. Alive or dead is easy and reliable to recognise but is a very crude way of measuring whether something is effective or not depending on the condition. It would be an important outcome measure for our nitrates versus furosemide study but what might be better might be the patient’s dyspnoea score on arrival to hospital, or their serial ‘comfort’ scores based on a 1-10 likert scale where 10 is very uncomfortable and 1 is ‘happy as’ – these could be taken at intervals during their journey to hospital. Outcomes like how long the patient needed close monitoring once at the hospital or how long the patient needed to be hospitalised might also be related to the intervention and may influence whether you decide a treatment is worthwhile.

The best study to answer a particular question depends on the question being asked. The Evidence Based Pyramid places systematic reviews and meta-analysis of randomised controlled trials at the peak. This is where high quality, scientific, carefully performed randomised controlled trials, carefully designed to minimise bias, are combined to achieve greater numbers of study participants. Its worth your while keeping this pyramid in mind and noting that ideas and editorials and opinions are lower down in the pyramid in believability. Bear this in mind in particular when someone is getting very excited on social media about a new way of doing something. Think about it, juggle it about in your brain, and wonder how you would design a trial to see if it really worked.

The EMS Gathering 2016 was held in Killarney on the 9th and 10th of June. It saw 300 people descending on the Malton Hotel from all around the world and from many clinical backgrounds. We had First Responders, EMTs, Paramedics, Advanced Paramedics, Nurses and Doctors all sharing a common interest, providing world class PreHospital Care.

The Gathering had a great mix of inspirational talks in the mornings from some of the foremost experts from Ireland and abroad.

The morning session on Thursday was a spectrum from the “Cradle to the Grave”. The talks focused on the challenges we face from the birthing process, during Neonatal Resuscitation to developing systems of OHCA response in Ireland to End of Life care.

The talks were delivered like TED talks but with a Top Gear room set up - comfy couches, musical entertainment - there was a real feel good element designed to inspire.

Each afternoon there was a multitude of novel learning with leisure activities to choose from including a farm injury workshop, a tactical EMS workshop, an ultrasound workshop, immersive simulation and high performance resuscitation workshops. There were of course

the old favourites, the Sepsis Bus, mountain climbs on Torc and Mangerton, golfing and cycling.

It is impossible to do justice to each component of the two day conference in this brief summary, but we can at least give you some snippets from James Ward and Stephen O’ Flaherty FARM INJURIES WORKSHOP (James Ward) The farm injuries workshop was very popular and was the first “Learning with Leisure” activity to be sold out on each of the days of this year’s EMS Gathering. It took place on a farm outside Farranfore which allowed delegates to experience the full sights, sounds and smells of a working farm.

There were 4 different stations where participants took part in a scenario lasting 40 minutes each.

The scenarios involved; A fall from height with a head injury, which discussed Impact Brain Apnoea and resulted in Rapid Sequence Intubation (RSI).

An incident at a slurry pit highlighted the dangers of slurry pit gases and the need to ensure scene safety in collaboration with Fires Service to avoid death by hydrogen sulphide. The principles of high performance resuscitation were also highlighted The dangers of responding to a paediatric patient gored by an

Pics: Kieran Minihane

22 Clinical Connections

Clinical Connections 23

animal in a pen full of livestock brought home key messages when dealing with an incident involving livestock and tips to avoid getting hurt yourself as the Responder. A patient trapped in a machine with a massive haemorrhage requiring the use of tourniquets and challenging extrications.

The scenarios were full of realism, with plenty fake blood and some very convincing actors from the team at www.atacc. co.uk. As a true high fidelity simulation workshop, the aim was to immerse the participants in a stressful environment which simulates the real world of prehospital care and of course the significant issues of rescuer safety. First responders, EMTs, paramedics, advanced paramedics and doctors from all over the world teamed up for the scenarios and it was fascinating to see true international prehospital care coming together for the benefit of the patients! The farm workshops were also attended by groups from the Irish Farmers Association, Teagasc and the Health & Safety Authority with camera crews from RTE’s Ear to the Ground. This collaboration allowed us all to learn from one another.

POCUS WORKSHOP (Stephen O’ Flaherty) I attended the ultrasound workshop; it was hosted by the folks from emspocus.com a free open access medical education resource for paramedic/pre-hospital focused ultrasound.

The workshop had the prestige of being the first paramedic ultrasound workshop in Ireland and was sold out both days.

We were shown the different uses of focused ultrasound by paramedics including some of the impressive evidence of its benefits for ruling in certain pathology. The uses that we looked at and had a chance to get “hands on 2” were focused ECHO in Cardiac Arrest for identifying cardiac wall motion in PEA and asystole. They also mentioned that these views could be obtained while the Lucas was in place thus reducing the hands off time to a few seconds. We also looked at the FAST and RUSH scans for trauma and Medical shock respectively, allowing for possible causes of shock to be ruled in in the undefined shock patients. The last thing we covered was the use of focused ultrasound for ruling in a pneumothorax and/or pulmonary oedema. Overall it was a very interesting workshop about a technology that is seeing greater utilisation in ambulance services around the world by paramedics. For more information check out emspocus.com.

On the Thursday evening the racecourse in Killarney was transformed into a mass display of NAS Emergency Response Teams and both The Emergency Aeromedical Service and the Coast Guard helicopters were present. The evening culminated in the assembly of a comprehensive aeromedical panel discussion with experts from HEMS in Ireland and abroad including London, Sydney and the USA. Fridays sessions focused on Trauma Care with speakers from London, Australia the US highlighting their systems of care and response to major trauma. The session concluded with a most intimate and powerful talk from Damien McGovern from his personal experience of a Major Trauma and his journey and reflections from the incident through rehabilitation and to his life today.

The relaxed style and intimacy of the EMS Gathering is becoming well renowned, but you don’t create that amazing atmosphere without significant preplanning and an amazing team keeping the show running smoothly. So well done to the entire EMSG 2016 Crew who again delivered a superb conference that is well worth attending, if you have not already had the pleasure make sure it’s on your to do list. Particularly a big thanks to Kieran Henry and Dr Conor Deasy the EMSG co-creators who continue to innovate and craft amazing learning and networking opportunities for our profession, true leaders and inspirational people to work with.

24 Clinical Connections

In MY View

Pic: David Hennelly

Pic: Mick Kavanagh

Pic: Faizan Arshad

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

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

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

View Photo� and supply your name and contact details.

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

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