Clinical Connections

Clinical Connections 1

Edition 3 | Winter 2016 / 17

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

Autonomic Dysreflexia Pain Management ePCR

Paediatric Trauma Pearls

Clinical Magazine from the National Ambulance Service Medical Directorate

2 Clinical Connections

Contents 3 WELCOME

Welcome to edition 3, looking towards 2017

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 Pain management in the non-verbal patient Clinical Case 2 Autonomic dysreflexia.

10 ONE LIFE PROJECT

Understanding human factors in cardiac arrest

14 ECAT Update

HSE Land

16 MEDICO Cork

Tales from the telemedical support unit

17 REASEARCH

18 PENTHROX

Coming soon

18 ePCR Update FAQs

20 HOW-TO GUIDE

Cardiac Arrest Downloads

21 ‘Not Just Little Adults’

Paediatric Trauma Pearls

Chance, bias and confounding factors

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EMS Gathering 2017 Come and join us on the 4th and 5th of May for the EMS Gathering 2017, where you will be treated to an inspiring few days with colleagues and friends in the beautiful surroundings of Kinsale, County Cork.

The two-day programme

will have something for all those interested in prehospital emergency care irrespective of qualification or experience.Top class national and international experts will deliver education in a style and location that will leave a lasting impression.

Welcome

Welcome to our autumn/winter edition of Clinical Connections, the NAS Medical Directorates clinical magazine. We have really positive feedback from our first two editions, so a big thanks for all the feedback and suggestions.

It’s so important that we get your input and cases to continue to make this publishing relevant to you the frontline practitioner.

So if you are interested in contributing please drop us an email to medicaldirector. nas@hse.ie. We will be happy to support you in developing the concept and structure for your chosen subject or case.

On the other hand if you think you have it roughly nailed, then don’t doubt yourself…. just send it on and we can work through the fine details between editions.

I would also like to take the opportunity to thank all the contributors. In this edition we have a broad mix of subjects, two great cases, one on pain management of the non-verbal patient and another on Autonomic Dysreflexia. We have articles on paediatric trauma care, human factors in resuscitation, the introduction of the Electronic Patient Care Report (ePCR), Penthrox and some excellent learning from the tele-medical support line. Once again we have some great pics from around the country.

We hope you enjoy our next edition.

This publication was made possible with the kind support of

News from the Medical Directorate Over the past few years the use of prehospital Ketamine for analgesia and sedation has increased by our international EMS counterparts. The 2016 PHECC Clinical Practice Guidelines introduce IV Ketamine as an analgesic option for use by Advanced Paramedics.

The rollout will commence with the release of the CPG’s and associated upskilling in 2017.

In advance of this development the NAS Medical Directorate is trialling the use of Ketamine by

Emergency Aeromedical Service Advanced Paramedics. The trial allows EAS APs to use Ketamine for both analgesia and sedation where required.

This is a significant step forward in patient care and in Advanced Paramedic practice. As we go to print we have had seven successful cases recorded, five analgesic doses and two sedations. We are looking forward to providing a detailed article on our progress in the next issue of Clinical Connections.

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Meet The TEAM CONTRIBUTORS THIS EDITION Frank Malone

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.

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.

Frank is a paramedic based in, Limerick City. Frank has been with the National Ambulance Service for 8 years. Prior to joining NAS Frank worked in various fields of maintenance & engineering from Planes to Trains and Automobiles.

When not at work he likes any out door activity from hill walking to kayaking......”Switch off or burn out”.

Frank likes any practical changes that make noticeable improvements to a patients care and outcome. Pet hate.... an empty kettle on a busy day

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.

Damien Gaumont

Damien “Frenchy” Gaumont is a practitioner for over 16 years mainly in Limerick; an Advanced Paramedic for 10 years and EAS AP. He has a keen interest in advancing the prehospital care with education and new technology; he is an Assistant Tutor at the Paramedic Studies, GEMS (UL), and is associated with the Centre of Prehospital Research in UL. He has 13 years’ experience in Restaurant Management in France and UK. On his time off, Damien enjoys spending time with his 3 children, gardening and cooking.

David Willis

David works with the Medical Directorate as the NAS Clinical Information Manager.

He has over 15 years’ experience as a registered paramedic, 2 years as Quality, Safety and Risk Manager

and has an unquenchable appetite for statistics, audit processes and anything IT. He is NAS lead for the implementation of Electronic Patient Care Report (ePCR) system. David is also the NAS lead for Clinical Audit and is a member of the NAS Research Committee. He is also assisting with the rollout of 12-Lead ECG Transmission He currently is undertaking an MSc in Public Health in UCC. As a Kerryman living in Cork his visa application process was lengthy but he appears to finally be accepted into the Rebel County.

Kieran Henry

Kieran Henry is an Advanced Paramedic with the NAS where he divides his time between frontline emergency work in Cork City and also as an AP on Ireland’s Emergency Aeromedical Service.

He holds a Masters Degree in Emergency Medical Science from UCD and also teaches paediatric and newborn resuscitation, he has been involved in projects in both Sudan and Nigeria. His professional interests include non mainstream methods of education and human factors. He is the creator and one of the organisers of EMS Gathering.

Lawrence Kenna

Lawrence joined the Eastern Region as an Ambulance Attendant in 1980. He worked in Naas, Maynooth and Loughlinstown ambulance stations before becoming an Ambulance Officer in 1993. Lawrence worked in the National Ambulance Training School until 1999 and then returned to an operational role as an In-service Training Instructor. He completed the first AP course in 2005 and Completed a Professional Diploma in Teaching and Learning in UCD last year. “The part of the job I love most is responding to emergencies with my ambulance colleagues and the patient interaction.”

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Ask The MEDICAL DIRECTOR

Q

Brian Hassett Paramedic, South East

I wish to query the reason why we cannot administer Midazolam through the intranasal route as in the PHECC guidelines for Adult Seizure 5/6.4.23 Version 3,02/14 page 46 as well as the paediatric seizure 5/6.7.33 version 3,02/14 page 87 it clearly states that for paramedics it can be either the buccal or IN route? I also wish to ask are there any plans to introduce any other medications that paramedics could administer intranasally as with the ability to cannulate been just an AP skill the intranasal route presents a safe and effective route that is proven and evidence based.

Regards Brian Hassett.

A

Dr Cathal O’Donnell Medical Director

Brian thanks for your question.

When the CPGs you reference were published we analysed the implications of authorising both routes of administration or just one, based on both being equally effective. The main consideration was that midazolam is a controlled drug as per the Misuse of Drugs Act, which puts certain requirements on us regarding its storage and use, as well as record keeping and drug reconciliation. Had we introduced intranasal midazolam, because it is supplied in an ampoule, we would need to replicate existing procedures for Advanced Paramedic use of midazolam ampoules, including putting in a second drug safe in every station. Because the two routes of administration are equally effective, we chose to implement the buccal route only – the medicines management requirements of the buccal midazolam are more straightforward.

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

UL CENTRE FOR PREHOSPITAL RESEARCH For the past few years the Centre for Prehospital Research UL, have been running workshops to support prehospital practitioners to develop their skills and knowledge base in how to conduct relevant Irish research. They have been kind enough to share their workshop dates for next year.

So if your interested in getting started in research or refreshing your skills check out the following dates or check out their website; http://www.ul.ie/cpr/ Wednesday 15/02/2017: Searching the prehospital literature Wednesday 05/04/2017: Critical Appraisal of the prehospital literature Wednesday 13/09/2017: Searching the prehospital literature Wednesday 08/11/2017: Critical Appraisal of the prehospital literature

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CLINICAL CASE REVIEW

Pain management in the non-verbal patient

As practitioners, we need to increase our awareness of pain in the non-verbal or dementia patient and be strong advocates for those patients We were dispatched to a heath care facility requesting to transfer a patient who had dislodged his urinary catheter.

On arrival to the bedroom, we found a large elderly man with cognitive impairment trying to remove a Foley catheter, physically being prevented to do so by multiple nursing staff.

The patient was non-verbal but obviously distressed, agitated and grimacing.

The handover included a report of a non flowing urinary catheter with haematuria in the previous hours, a full bladder and a recent CVA without any other significant comorbidity.

In consultation with the referring doctor, we administered Fentanyl 50mcg Intra-Nasally. Within a couple of minutes the patient was relaxed enough to be safely transferred onto the ambulance stretcher, have his vital signs obtained and an IV access gained. A gram of paracetamol IV was administered on route to the receiving hospital with urology surgery capabilities.

The patient remained comfortable and haemodynamically

stable during the transport. The patient remained comfortable the next few hours in the Emergency Department without the addition of any other analgesia.

A Suprapubic catheter was inserted in the ED by urology surgeons with infiltration of local anaesthetic.

LEARNING POINTS Analgesia in the nonverbal patients (dementia, paediatric and special needs) is being reported as suboptimal in prehospital systems, Emergency Departments and other health care settings around the world. The barriers to administration of analgesic agents to this population are still not well understood. Some suggestions that have been put forward are educational (lack of pain management education in medical schools, reliance by heath care professionals to Numerical Rating Scale and Verbal Descriptors Scales for determination of analgesia needs), and psychological factors (dismissal of patient’s pain rating based on own experience, fear to overdose and fear of being seen to over use opioids).

Irish prehospital care is one of the very few worldwide to have a pain management strategy beyond chest pain, we,

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FOR FURTHER READING Gabrick J. (2016) ‘PAINAD scale offers alternative to assessing pain in the dementia patient.’ JEMS [online], 40(40), available http://www.jems.com/articles/print/volume-41/issue-40/ features/painad-scale-offers-alternative-to-assessing-pain-inthe-dementia-patient.html [accessed 20 August 2016]. http://www.thelancet.com/pdfs/journals/laneur/PIIS14744422(14)70103-6.pdf REFERENCES Alonso-Serra,H .M., Wesley K. (2003 ) ‘Prehospital Pain Management, Position Paper for the National Association of EMS Physicians Standards and Clinical Practices Committee’.

Prehospital Emergency Care.[online], 7(4), available https:// www.nh.gov/safety/divisions/fstems/ems/training/documents/ prehosppain.pdf [accessed 10 March 2016].

Duplessis-Grimson S. (2015) ‘Is IV paracetamol as effective an analgesic as IV morphine for patient in non-cardiac pain?

A literature review.’ Journal of Paramedic Practice. 8(1):26-33 (available in the ambulance stations).

Jennings PA, Cameron P, Bernard S (2011) ‘Epidemiology of prehospital pain: an opportunity for improvement.’

Emerg Med J. [Online] 28(6):530-1. available: doi: 10.1136/ emj.2010.098954 [accessed on 20 April 2016].

Herr K. et al. (2006) ‘Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations.’ Pain Management Nursing. 7(2):44-52.

PHECC (2014) ‘Clinical Practices Guidelines. 4/5/6.2.6 Pain Management – Adult, 4/5/6.7.5 Pain management – Paediatric.’ Pre Hospital Emergency Care Council. Kildare

as practitioners, need to increase our awareness of pain in the non-verbal or dementia patient, be strong advocates for those patients and improve our education around understanding pain, pain management options and analgesic agents.

Titration of opioid analgesic agents is very important in the elderly population due to the change in their renal and hepatic function, particularly when it comes to repeating the agent. The literature is suggesting a titration between 25% and 50% of the loading dose until desired effect are reached.

Using medical oversight consultation to maximise the patient outcome; in this case the refereeing and treating physician was still on location, was able to confirm the indication, lack of contraindication, and appropriateness of the analgesia plan with an alternate route of administration (IV paracetamol).

This interaction also allowed to showcase the Ambulance Service’s range of skills, medications and the equipment (MAD device).

Damien Gaumont Advanced Paramedic, Limerick

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illustration: Doug Davis

CLINICAL CASE REVIEW AUTONOMIC DYSREFLEXIA

INTRODUCTION: At approximately four o’clock in the morning we were dispatched to a private residence for 70 year old man with a severe headache. The location was 18 km from the receiving hospital.

On arrival we were presented with a tetraplegic patient in a nursing bed, complaining of an acute onset of headache starting approximately an hour prior to call.

For once the patient’s home was well laid out with purpose built double doors leading to an open plan interior. The patient’s bed, with hoist, was positioned in the middle of a large living room with all necessities and modern conveniences such as phones and controls to hand.

Our assessment revealed a blood pressure (BP) of 210 mmHg systolic with a regular pulse of 90bpm, apyrexic, GCS 15/15, capillary blood glucose 14.2 mmol/L, respiratory rate of 20bmp unlaboured, 96% oxygen saturations, pale in colour.

The patient was overweight but not obese.

Previous medical history: stroke 14 months earlier, tetraplegia from RTC 30 years previously (car versus pedestrian).

Medications: GTN, Warfarin, atenolol, paracetamol. Also had recently finished an antibiotic course for a respiratory tract infection. No known allergies.

The patient’s full time carer stated that there was a reduced outflow from the urinary catheter in the previous 8 hours.

She was very aware of the complications and dangers of a blockage or compromise of a catheter in a tetraplegic patient and therefore called for the emergency services on first noticing the associated symptoms.

Autonomic dysreflexia The patient was moved to ambulance stretcher and ambulance. En route the patient’s BP decreased to 190mmHg systolic while in a sitting position on the stretcher.

Patient was relaxed and talkative but the headache remained. A FAST assessment was of limited use at this stage but there was no noticeable deficit to speech or GCS according to the carer. Concern was heightened due to the fact that the patent was bed bound, Tetraplegic and had history of previous stroke.

The transport until the handover to the Emergency Department was uneventful. The nursing staff were cognisant of Autonomic Dysreflexia symptoms and attended promptly to the patient.

PATHOPHYSIOLOGY: Autonomic dysreflexia is a potentially life-threatening episodic hypertension that develops in 50-90% of people with tetraplegia or high paraplegia.

Autonomic dysreflexia occurs after spinal cord injury at or above the T6. Because injury at this level leaves the sympathetic nerve branch of the extensive abdominal circulation isolated from the brain stem, spinal reflexes are left unrestricted. Stimulus or pain releases substances such as noradrenaline and dopamine which cause severe vasoconstriction with skin pallor, goose pimples and sudden rise of blood pressure below the spinal injury. The rise in blood pressure is detected by baroreceptors in the aortic arch and the carotid bodies, triggering a parasympathetic response via the vagus nerve in form of compensatory bradycardia and vasodilatation.

However both of these mechanisms are insufficient to control extensive vasoconstriction in the relatively larger body area below the spinal cord injury.

If unrecognised or untreated promptly the patient can develop intracranial haemorrhage, seizures and coma, or cardiac arrhythmia such as atrial fibrillation, other re-entrant type of arrhythmia or myocardial infraction, and death.

Signs and symptoms includes: »» Rapidly increasing headaches. »» Rapidly rising blood pressure. »» Bradycardia, new onset of atrial fibrillation or other arrhythmia. »» Flushing and sweating above the spinal cord injury and, below the SCI, pallor, gooses pimples. »» Some patient may have other warning signs specific to them.

Blood pressure is deemed elevated if at least 20 -40 mmHg above the normal resting systolic reading. It is important to remember that a BP for individuals with paraplegia or tetraplegia may usually be low, around 90 -100 systolic lying

Clinical Connections 9

down and possibly lower in a seating position. Be sure to inquire about the patient’s baseline reading, as they may become symptomatic with “normal range reading”.

Common triggers include: »» Bladder (distended or severely spastic bladder, urinary tract infection, bladder or kidney stones). »» Bowel (constipation, faecal impaction, rectal irrigation, haemorrhoids). »» Skin (tight clothing, pressure area, ingrown toenail, burns). »» Others (any irritating stimulus below the level of SCI including fractures, testicular inflammation, distended stomach, labour or severe menstrual cramping). Women with SCI, who are pregnant, may experience autonomic dysreflexia as the first sign of the commencement of labour. »» Iatrogenic (inserting, clamping or kinking a catheter, or other urological procedure).

Prehospital treatment: »» Ask patient or carer if they suspect the cause. »» Monitor BP every 2-5 minutes. »» Elevate the patient’s head and lower the legs (may help to lower the BP) »» Loosen any constrictive clothing, belts, and supports. »» Check bladder drainage equipment for kinks or other obstructions to flow. »» Avoid pressing on the bladder. »» Initiate rapid transport with Advanced Paramedic intercept (Medical Oversight may give advice on using GTN and analgesia). »» Pre-alert Emergency Department.

CONCLUSION: Autonomic Dysreflexia is a rare occurrence in the prehospital area and may be more prevalent during routine transfers. Just like in the case illustrated above, the patient and carers are usually aware of the condition; they have been trained and advised by the Spinal Injury Rehabilitation staff to frequently monitor the blood pressure and the urinary catheter flow.

We, as practitioners, need to understand the danger of this condition and recognise the need for prompt transport, treatment and ED pre-alert.

REFERENCES: Middleton, J. Ramakrishnan, K. Cameron, I. (2014) “Treatment of Autonomic Dysreflexia for adults and adolescents with spinal cords injuries.” Sydney: New South Wales Agency for Clinical Innovation [online] available at https://www.aci.health.nsw.gov.au/__data/ assets/pdf_file/0007/155149/Autonomic-DysreflexiaTreatment.pdf [accessed 18 September 2016].

Vaidyanathan S. et al (2012) “Autonomic dysreflexia in a tetraplegic patient due to a blocked urethral catheter: spinal cord injury patients with lesions above T-6 require prompt treatment of an obstructed urinary catheter to prevent life-threatening complications of autonomic dysreflexia.” International Journal of Emergency Medicine [online], 5:6, available at http://www.intjem.com/content/5/1/6 [accessed 01 September 2016].

Frank Malone 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.

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David Hennelly, AP MSc Clinical Development Manager

One Life

EVERY ACTION COUNTS

Understanding Human Factors in Cardiac Arrest The skills of chest compressions, defibrillation, intravenous cannulation and rhythm recognition are considered typically to be the most important factors in managing a cardiac arrest. These are all technical skills that are learnt from books, lectures, courses and peers. Although they are important for the successful resuscitation of a patient, there is another group of skills that is becoming increasingly recognised in resuscitation - human factors or non-technical skills. Nontechnical skills can be defined as the cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance.

The 2015 ILCOR guidelines now recommend leadership training in ALS and ACLS courses, to support the leadership role in OHCA Management the National Ambulance Service is restructuring its Cardiac Arrest Management Module to support the principles of High Performance Resuscitation and Team Leadership.

Crew Resource Management (CRM) encompass expertise, experience and research from the aviation industry to improve the safety and efficiency of organizations involved in risky work. CRM teaches us about human limitations and involves participants in assessments of their own behaviour and the behaviour of peers. CRM encompasses a wide range of knowledge, skills and attitudes including;

»» »» »»

Situational awareness (SA) Decision-making.

Teamwork, including team leadership and communications

Additionally, participants in CRM training learn to understand how cognitive errors occur and are how external stressors such as fatigue, crisis management and work overload can contribute to human error.

Training in Human Factors and nontechnical skills, such as teamwork, communication and leadership, have been identified as important contributory factors influencing CPR performance.

SITUATIONAL AWARENESS. This can be described as an individual’s awareness of the environment at the moment of an event and the analysis of this to understand how an individual’s actions may impact on future events. This becomes particularly important when many events are happening simultaneously, e.g. at a cardiac arrest. High information input with poor situational awareness may lead to poor decision making and serious consequences.

At a cardiac arrest, all those participating will have varying degrees of situational awareness. In a well-functioning team, all members will have a common understanding of current events, or shared situational awareness. It is important that only the relevant information is shared otherwise there is too much distraction or noise. At a cardiac arrest, important situational awareness factors include:

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Decision Making

Leadership

Team Work

»» »» »» »» »» »» »» »» »»

Consideration of the location of the arrest, which can give clues to the cause; Obtaining information from bystanders/ family about the events leading up to the arrest; Confirmation of the diagnosis; Determining who is present - including names, roles, and who is leading; Noting the actions already initiated, e.g medications administered; Communicating with the team, gathering information; Implementing any immediate action necessary, treating reversible causes; Consideration of the likely impact of interventions; Determining the immediate needs.

DECISION MAKING This is defined as the cognitive process of choosing a specific course of action from several alternatives. At a cardiac arrest, the many decisions to be made usually fall to the team leader. The leader will assimilate information from the team members and from personal observation and will use this to determine appropriate interventions. Typical decisions made at a cardiac arrest include: »» »» »»

Diagnosis of the cardiac arrest rhythm; Likely reversible causes of the cardiac arrest; How long to continue resuscitation.

Once a decision has been made, clear unambiguous communication with the team members is essential to ensure that it is implemented.

TEAM WORKING, INCLUDING TEAM LEADERSHIP This is one of the most important non-technical skills that contribute to successful management of critical situations.

A team is a group of individuals working together with a common goal or purpose. In a team, the members usually have complementary skills and, through coordination of effort, work synergistically. Teams work best when everyone knows each other’s name, when they are doing something they perceive to be important, and when their role is within their experience and competence.

THERE ARE SEVERAL CHARACTERISTICS OF A GOOD RESUSCITATION TEAM MEMBER: »» Competence – has the skills required at a cardiac arrest and performs them to the best of their ability. »» Commitment – strives to achieve the best outcome for the patient. »» Communicates – openly, indicating their findings and actions taken, and be prepared to raise concerns about clinical or safety issues, but also by listening to briefings and instructions from the team leader. »» Supportive – allows others to achieve their best. »» Accountable – for their own and the team’s actions. »» Prepared to admit when help is needed. »» Creative – suggests different ways of interpreting the situation. »» Participates in providing feedback.

A team leader provides guidance, direction and instruction to the team members to enable successful completion of their stated objective. They lead by example and integrity.

Team leaders need experience not simply seniority. Team leadership can be considered a process; thereby it can become available to everyone with training and not restricted to those with leadership traits.

There are several attributes recognisable in good team leaders: »» »» »» »» »» »» »» »»

Knows everyone in the team by name and knows their capability.

Accepts the leadership role and is able to delegate tasks appropriately.

Is knowledgeable and has sufficient credibility to influence the team through role modelling and professionalism.

Stays calm and keeps everyone else focused and controls distractions.

Is a good communicator – not just good at giving instructions, but also a good listener and decisive in action. Is empathic towards the whole team.

Is assertive and authoritative when appropriate.

Shows tolerance towards hesitancy or nervousness in the emergency setting.

Has good situational awareness; has the ability to constantly monitor the situation, with an up to date overview, listening and deciding on a course of action.

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During a cardiac arrest, the role of team leader is not always immediately obvious. The leader should state early on that they are assuming the role of team leader. Cardiac Arrest Team leader should: »»

Follow current resuscitation guidelines or explain a reason for any significant deviation from standard protocols.

»»

If they are unsure, he or she should consult with the team or contact Tele medical Support advice and assistance if appropriate.

»»

Play to the strengths of team members and allow them some autonomy if their skills are adequate.

»»

Allocate roles and tasks throughout the resuscitation and be specific. This avoids several people or nobody attempting the task!

»»

Use the two-minute periods of chest compressions to plan tasks and safety aspects of the resuscitation attempt with the team.

»»

At the end of the resuscitation attempt, thank the team and ensure that staff and relatives are being supported. Complete all documentation and ensure an adequate handover.

»»

Debrief the team.

CHALLENGE & RESPONSE CHECKLISTS IN CARDIAC ARREST Effective communication and teamwork is essential for the delivery of high quality, safe patient care at the scene of an OHCA. The complexity of managing an OHCA, coupled with the inherent limitations of human performance, make it critically important that NAS Practitioners have standardised communication tools. Using these tools create an environment in which individuals can speak up and express concerns, and share common ‘‘critical language’’ to alert team members to unsafe situations.

Understanding the limitations of the human brain in these stressful environments has led to the development of Challenge & Response Checklists.

Originally a concept unique to aviation, they are used to ensure simple cognitive errors do not occur during pre and post flight checks and in the high stress environment of emergency situations. Prehospital emergency care has seen the development of similar checklists for use during the management of Cardiac Arrest, Return of Spontaneous Circulation (ROSC), Post Intubation Care, and the management of major haemorrhage. It is with this in mind that the office of the Medical Directorate has developed a Cardiac Arrest checklist to support practitioners in the care of the OHCA patient.

POST RETURN OF SPONTANEOUS CIRCULATION (ROSC) CARE Prehospital return of spontaneous circulation (ROSC) is considered to be one of the strongest predictors of survival to hospital discharge.

Upon achieving ROSC in the prehospital setting it is imperative that practitioners provide specific targeted interventions to this highly unstable sub group. The following headings outline the areas that NAS practitioners should focus their care for the Post ROSC Patient. Interventions which address one or more of these components may improve survival and neurological outcome.

TARGETED CARE INTERVENTIONS: Optimization of Ventilation Post ROSC Optimization of Oxygenation Post ROSC Optimization of Hemodynamic Status Post ROSC Optimization of Temperature Post ROSC Control of Seizures Control of Blood Glucose Level Acute Coronary Syndrome (ACS) Management post ROSC Optimisation of Ventilation Post ROSC Patients with decreased level of consciousness, persistent hypoxia or agonal respiratory pattern following ROSC should have their airway managed and positive pressure ventilation instituted. There is a well-documented association between hypocarbia and cerebral ischaemia after cardiac arrest. Ventilation to a ETCO2 of 35-40mmHg is appropriate and should be documented on the PCR. Excessive ventilation should also be avoided because of the potential for reduced cerebral blood flow and the risk of high intrathoracic pressures which can lead to adverse hemodynamic effects during the post arrest phase. Quantitative waveform capnography can be used to regulate and titrate ventilation rates during the post-arrest phase.

Clinical ClinicalConnections Connections1313 NAS Cardiac Arrest Checklist Optimise / Establish the basics 360° access – optimise available space ❏ High quality compressions ongoing ❏ Defibrillator attached / Manual mode / Clearly visible ❏ O2 cylinder attached / O2 sufficient / BVM reservoir inflating ❏ Chest rise adequate ❏ Optimise structure PIT crew approach Activate additional resources (if required) ❏ Team leader identified ❏ Identify roles (clear designation) ❏ Optimise High Quality Compressions/ Minimal Interruptions <10sec »» Correct hand position ❏ » Correct depth (min 2 inches) ❏ »» Full chest recoil ❏ » CPR feedback device/ metronome turned on (if available) ❏ Optimise airway & ventilatory management / Stepwise approach ETCO2 waveform is present and monitored (Target value is at least 10-20 mmHg) »» If absent check SGA/ETT placement ❏ »» If ETCO2 remains <8-10 check CPR quality ❏ Optimise ventilation rate »» 30:2 without SGA/ETT or 1 ventilation every 6 sec with SGA/ETT ❏ »» Monitor bilateral air entry / Gastric distention ❏ Optimise haemodynamic support & manage reversible causes IO or IV access obtained (all appropriate medications considered) ❏ Mechanical compression device considered & applied (if available) ❏ Hypoxia ❏ Tension pneumothorax ❏ Hypovolemia ❏ Tamponade ❏ Hydrogen ion (Acidosis) ❏ Thrombus (Cardiac/Pulmonary) ❏ Hypothermia ❏ Toxins ❏ Hypo/ Hyperkalaemia ❏ Trauma ❏ If considering cessation of resuscitation »» Review presenting history ❏ » Ensure team discussion ❏ »» Consider family presence ❏ » Consider patient / Family wishes ❏

NAS Post ROSC Checklist (Prior to moving patient) Optimise / Establish the basics Review & verbalise Airway Breathing Circulation Disability status Establish baseline vital signs prior to moving the patient Consider aeromedical support (if applicable)

❏ ❏ ❏

Optimise ventilation post ROSC Monitor ventilation rate (1 ventilation every 6 sec / avoid hyperventilation) Monitor continuous ETCO2 (target 35-45 mmHg) Facemask travels with bag-valve no matter what airway is in place

❏ ❏ ❏

Optimise oxygenation post ROSC Titrate O² to SpO2 between 94 – 98%

❏

Optimise hemodynamic status post ROSC If SBP< 90mmhg, IV NaCL 250ml bolus (consider passive leg raise) ❏ If symptomatic bradycardia consider atropine 0.5 - 0.6mg (3-5 min intervals PRN) ❏ If symptomatic tachy-arrhythmia consider amiodarone infusion (150mg over 10min in 5% Dextrose) ❏ Profound hypotension, cardiogenic shock, consider epinephrine 0.01mg ONLY if SBP remains <90mmhg + HR remains <100 + No radial output Repeat PRN ❏ Maintain supine position during extrication / 10° head up as soon as practical ❏ Optimise neurological status & temperature post ROSC Maintain temp <36°c ❏ Check blood glucose and treat accordingly ❏ Optimise Acute Coronary Syndrome (ACS) management post ROSC Obtain 12-lead ECG Consider is receiving facility PPCI capable Consider if patient is PPCI appropriate Contact numbers AP Tele-medical support CUH CODE STEMI

❏ ❏ ❏ 071 9834264 1800 742222

Optimisation of Oxygenation Post ROSC

Control of seizures

During the post-cardiac arrest phase inspired oxygen should be titrated to maintain an SpO2 of ≥ 94%. This reduces the risk of oxygen toxicity. The ILCOR guidelines recommend titrating Fi02 down to give oxygen saturations > 94%. Oxygen saturations throughout transport should be documented on the PCR.

There is an increased risk of seizure in patients post cardiac arrest. Any suspected or diagnosed seizures should be treated immediately as per CPG.

Optimisation of Hemodynamic Status Post ROSC Survivors of cardiac arrest frequently experience haemodynamic instability which may persist several hours after ROSC. It is important to maintain myocardial, cerebral and end-organ perfusion during this time. Hypotension, a systolic blood pressure < 90 mmHg should be treated aggressively post ROSC; It has been shown that the administration of fluids and/or vasoactive medications can be used to optimize the patients hemodynamic status. While the optimal blood pressure during the postcardiac arrest phase is not known, the primary objective is adequate systemic perfusion, and a mean arterial pressure of ≥ 65 mmHg should accomplish this Systolic BP >90-100mmhg).

Post cardiac arrest ventricular arrhythmias that are symptomatic should be managed with an infusion of the anti-arrhythmic drug that successfully restored a stable rhythm during resuscitation although prophylactic antiarrhythmic drugs have not shown to improve survival.

Optimisation of Temperature Post ROSC Targeted Temperature Management is another key component of Post ROSC care. 2015 ILCOR Guidelines has moved away from aggressive cooling of the patient to a system of targeted temperature management, this process involves maintaining temperature at 32-36 degrees Celsius and avoiding Hyperthermia post arrest. This is achieved in the prehospital setting by passive environmental management.

Control of blood glucose level Hyperglycaemia is common following cardiac arrest. Although there is no proven survival benefit to tight glycaemic control, there is an association between high glucose and poor neurological outcome after cardiac arrest. Check the blood sugar level, and consider treating Hyperglycaemia or Hypoglycaemia.

Acute Coronary Syndrome (ACS) Management Post ROSC Post ROSC patients from undifferentiated cardiac arrests with suspected underlying cardiac aetiology may benefit from being transported directly to a PPCI capable facility. In this cohort of patients the practitioner must also consider the risks associated with potential increased transport times and bypassing non PPCI capable facilities. If a patient requires advanced airway support, continued sedation or management of non-cardiac and traumatic issues they should initially be transported to an appropriate receiving ED for stabilisation prior to Primary Percutaneous coronary Intervention (PPCI) referral.

For Post ROSC patients from undifferentiated cardiac arrests with suspected underlying cardiac aetiology or diagnostic ECG identifying a STEMI or new LBBB, the practitioner should contact their regional PPCI Physician on 1800 742222 to discuss appropriate facility decisions.

14 Clinical Connections

ECAT Update

Have you logged on to the PHECC’s eLearning Academy recently? Maybe you have completed all of the modules in your level, or only half completed them. At present there are just under 4000 registered users on the website. Yet the average monthly user in 2016 is 96. A big increase from 2015, which was 54 users, but still low numbers. So why are we not utilising this site.

While most of the cases on the site are related to Advanced Paramedic practice, some of these cases may be available to the paramedic and EMT level, however they cannot complete the end assessment.

The Paramedic level includes the Ambulance Handover, Lily’s Case and Paediatric Pain Management The EMT level include a section on IM injection.

If you are still interested in accessing this eLearning site login from the PHECC’s website. If you have never used the site or are having any difficulties accessing the cases contact Dillon Productions. They are a very helpful team.

Sean’s story – Trauma

For those who have never used HSELand or who accessed this site during their paramedic internship, this site is a well worth a visit. You need your personnel number to register.

The site has a hub specifically for National Ambulance Service staff, however there is also access to excellent training programmes such as:

Katie’s story – pediatrics

Infection Prevention and Control,

Ciara story – respiratory

National Sepsis eLearning Programme,

Lily’s story – Acute Coronary Syndrome

Identification of memory problems in the Older Patient and many more excellent programmes.

These include the following:

There is no doubt that video can become dated, particularly with changes in treatment regimes, however the assessment and professional practice elements of these productions are always relevant.

If you have managed to get through most of this material you will probably have moved on to the BMJ Library. This is an excellent site which gives you access to publications such as

Clinical Connections 15

the Emergency Medicine Journal. This is an excellent journal which generally has a paper on Prehospital Emergency Care in each publication. You will need an Athens Login password to gain free access to this website. You can acquire the Athens access through the HSE Library which is available to all staff with a HSE email account. If you don’t have a HSE email account, talk to your local Manager.

If you are looking for something more specific, look at lifeinthefastlane.com, this has excellent features on 12 lead ECG If you are interested in podcasts and twitter, try Andy O Neill’s introduction on emergencymedicineireland.com. Especially for those who haven’t started to utilise FOAMed (free openaccess Medical Education) it provides an easy to understand introduction into Twitter, Facebook and podcasts etc.

If you are into the Facebooky thing, which I’m not, for those who wanted to be my friend!! I’m told the following pages are excellent http://www.facebook.com/groups/ivegottherhythm/ This site is mainly clinical cases and real 12 leads with discussion from members

http://www.facebook.com/the ecg/educator/ This is mainly a blog that aims to teach rhythms Thanks to David Irwin for the above.

Anyway if you are not into online education, get started!

I’m off to start working on my podcasts. Hopefully some of our FOAMed experts will gives us a little more insight in the coming editions.

Dillon Productions 01-2980736 www.hseland.ie www.lifeinthefastlane.com www.emergencymedicineireland.com

Lawrence Kenna AP Education & Competency Assurance Manager

16 Clinical Connections

MEDICO CORK Tales From the Telemedical Support Unit Telemedicine as an Enabler - Dr Jason Van De Velde aggression. Remember our data represents a unique subset of practitioner-patient interactions where the existing CPGs have not fully addressed the needs of either party. If we look at our preliminary data by perceived aetiology, it is very clear that you can’t simply write a CPG for agitation, but rather need to approach agitation from within existing CPGs. We always start with the premise that agitation or aggression is secondary to pain, hypoxia, circulatory compromise, hypoglycaemia or head injury. For example, the head injury CPG might offer an agitated pathway that begins at pain management.

AGITATED PATIENT MANAGEMENT Agitated Patient Management accounts for a quarter of all calls to MEDICO Cork, the HSE’s National 24 hour Emergency Telemedical Support Unit. Agitated Patients present a significant logistical, emotional and resource challenge for prehospital practitioners. They are a subset of patients with a high, particularly in the case of Traumatic Brain Injury, mortality rate. Timely and appropriate intervention in this subset of patients can make a significant difference to long term functional outcome. A great deal of time and thought has gone into several iterations of a PHECC CPG aimed at better streamlining the prehospital practitioners’ approach to agitation. It is a challenging CPG to write, particularly as there are multiple aetiologies for agitation.

On our last Audit of 1761 telemedical calls, we found a year-on-year, exponential increase in frequency in practitioners looking for support to manage agitation or

There has been considerable discussion on the telemedical support line around voluntary versus involuntary patients. We have frequently to clarify whether the patient has capacity or not. We are keen to emphasise the need for practitioners to keep themselves up-to-date with the legislation surrounding capacity; and when the Mental Health Act applies and just as importantly, when it does not and the patient is better served under common law. As per the Act, if the patient is deemed to lack capacity through mental illness, and they are refusing the offer of care, then we are advising Physician intervention, i.e. GP to scene or Garda detention under Section 12 of the Act and transport of the patient to an Emergency Department for further assessment of capacity.

The “Other” category represents a significant plethora of presentations, including those in which no clear aetiology is evident. At 11% of all agitated patient management calls, it’s no wonder that these patients are so challenging to manage.

We are currently undertaking a formal review of Agitated Patient telemedical interactions, with the support of UCC final year Medical Student Jennifer Bevan. This is a significant undertaking, which will see prehospital Irish data presented to further support the evidence based development of PHECC Clinical Practice Guidelines.

Clinical Connections 17

Research

Chance, bias andconfounding factors In the last edition we discussed tips on reading a research paper, creating an answerable question using the ‘PICOS’ format to focus our thinking, and the ‘hierarchical evidence pyramid’ that helps us know what types of studies are more reliable.

At the top of the evidence pyramid sits systematic reviews and metaanalysis of randomised controlled trials (RCT). The reason these studies are most reliable is because they are designed to minimise the potential for chance, bias and confounding factors influencing the outcome. In this edition we are going to explore these three key concepts so when you are reading papers or thinking about a research project you can ask yourself, am I satisfied that the results I am reading are not influenced by this trifecta.

Chance relates to random occurrences. When comparing two treatments, any differences in results may simply reflect the play of chance. The way to avoid being misled by the play of chance in treatment comparisons is to base conclusions on studying sufficiently large numbers of patients and use statistics to measure the potential for chance being the cause of the observed result (p values and confidence intervals are a measure of chance). For example, in a study of 20 patients, 4 out of 10 patients (40%) died after receiving Treatment A compared with 6 out of 10 (60%) similar patients who received Treatment B. Based on these small numbers, would it be reasonable to conclude that Treatment A was better than Treatment B? Probably not. Chance might be the reason that some people got better in one group rather than the other. Or by chance, they may not have been as sick, by chance they may have been a few younger patients in the experimental group, by chance they may have been treated more quickly, by chance they may have been treated by a paramedic who was having a good day etc. If the comparison was repeated in other small groups of patients, the numbers who died in each group might be reversed (6 against 4), or come out the same (5 against 5), or in some other ratio – just by chance.

But what would you conclude if exactly the same proportion of patients in each treatment comparison group

(40% and 60%) died after 100 patients had received each of the treatments?

Although the risk ratio is exactly the same (40%/60% =0.67) as in the earlier comparison, 40 deaths compared with 60 deaths is a more impressive difference than 4 compared with 6, and less likely to reflect the play of chance.

Bias is the systematic distortion of the estimated intervention effect away from the “truth”, caused by inadequacies in the design, conduct, or analysis of a trial and cannot be reduced by sample size. Unlike

...the association between coffee drinking and lung cancer; without considering that often folks drink a coffee and smoke a cigarette the coffee may get blamed for the lung cancer rather than the 20 cigarettes a day smoked with the coffee, the cigarette being the confounding factor

random errors caused by chance, bias will tend to produce results that are consistently wrong in the same direction (i.e. overestimating or underestimating the true value). There are many types of bias – identifying the type of bias isn’t as important as recognising that the study outcomes may have been influenced by bias. For example, selection bias occurs when the selection of patients to enter a study is very different to those not selected. If we were to do a study on a pain killer for use in pre-hospital trauma pain but say the paramedics found it much easier to consent young men and women with certain

DR CONOR DEASY

long bone fractures because they were more articulate and veered away from consenting the elderly with fragility fractures such as neck of femur or distal radius this would represent a selection bias. You might get a hint of this in Figure 1 in the results section of the RCT known as the consort diagram; it describes who was screened for inclusion in a trial and why they were excluded as well as describing those included and the numbers who were lost to follow up. In comparing one treatment with another in a head to head trial, it is very important to figure out whether the patients receiving the experimental treatment were the same as those receiving the standard care – this is always reported in table 1 in the Results section of the RCT. This table demonstrates the patient demographics; their age, sex and key features that may influence the outcome or effect of a treatment.

Confounding factors are an error of interpretation. The results of a study may be due to something unmeasured but wrongly attributed to the intervention. The example often quoted in this context is the association between coffee drinking and lung cancer; without considering that often folks drink a coffee and smoke a cigarette the coffee may get blamed for the lung cancer rather than the 20 cigarettes a day smoked with the coffee, the cigarette being the confounding factor. In our own pre-hospital context, again using the example of a study looking at the effect of a new painkiller for injury related pain, if we did not take into account the use of nonpharmacological approaches to pain relief such as kindness, reassurance, splintage in reducing the pain score then we would not get a fair appreciation of the effect of the new drug. That said, kindness and reassurance are extremely difficult to measure in a scientific way – that’s a topic for another day.

18 Clinical Connections

ePCR Update The National Ambulance Service (NAS) will be implementing an electronic patient care report (ePCR) nationally over a 12 month period which will commence early in 2017.

Penthrox

(methoxyflurane)

By Kieran Henry AP MSc Pain is the most common symptom in the emergency setting and alleviating this remains a challenge for pre-hospital emergency services.

Through pharmacological and non-pharmacological methods we can enhance the patient experience by reducing and in some cases eliminating their pain.

The greater the arsenal of analgesic options available to the practitioner the better, as some barriers may prevent certain medications being used for particular cases e.g. contraindications, challenges with administration routes etc.

Penthrox (methoxyflurane) is an inhaled analgesic option that has just recently arrived in the Irish setting having been well established in the Southern Hemisphere with an estimated 5 million uses over the past 3 decades in Australia.

It is a Patient Controlled Analgesia (PCA), which is lightweight, disposable and non-invasive.

Penthrox (methoxyflurane) is indicated for the emergency relief of moderate to severe pain in conscious adult patients with trauma and associated pain.

It is fast and effective, bringing onset of pain relief within 6-10 inhalations.

It is easy to administer, maintenance free and disposable.

The feedback so far from those already using it has been very good and we look forward to its roll out within the National Ambulance Service.

This is very positive development for NAS and gives us the ability to examine how well we care for our patients and thereby improve how we care for them. This is part of the NAS commitment to investment within the National Service Plan. It is also a result of a significant collaboration between NAS and the Office of the Chief Information Officer in technology and working together.

The implementation of ePCR is dependent on the co-operation and enthusiasm of all NAS staff. This will inevitably present challenges for us all, but we are confident that, with your support and co-operation, this will change how NAS delivers patient care for the better.

NAS will transition to an electronic patient record over the next 12 months. NAS practitioners will, once implemented, record patient data electronically using a ruggedized tablet onto an electronic record via a bespoke software platform. The existing paper PCRs that NAS staff are familiar with will no longer be used; instead patient data will be recorded electronically. This represents a significant change in how NAS conducts it’s business. The following information is designed to inform NAS colleagues about how ePCR will function.

Why are NAS implementing an electronic patient care report?

NAS have over 300,000 patient contacts annually. Our ability to do comprehensive data analysis or clinical audit from 300,000 paper records (including collection from 102 locations) is limited. A modern ambulance service must be able to analyse clinical performance – ePCR will give us the ability to do this.

Patient data will be captured electronically in a standardised manner – the dataset significantly exceeds that which is currently collected on the paper form. NAS will capture much more accurate patient information such as presenting complaint, past history, medications, clinical signs, mechanism of injury, presumptive diagnosis and treatments administered prehospital. This will mean that a more complete picture of each individual

patient’s acute episode can be provided to the receiving ED by NAS. It also will allow NAS to have a very detailed overview of trends in patient demographics, patient presentations as well as how well NAS assesses and treats patients.

How will ePCR work?

Each NAS vehicle will have a Panasonic Toughbook with the ePCR software provided. The ePCR product is called Medusa Siren (see www.medusamedical.com). NAS practitioners will input clinical data to the ePCR application electronically (drop-down menus, tick-boxes and free text). This will create an electronic patient record for each patient. The information recorded will incorporate that currently recorded on the paper PCR and we are basing the data fields in the ePCR on the PHECC dataset.

The patient demographics, dispatch code, allocation and mobile times etc will be prepopulated on the electronic record by an electronic push from CAD, so some information currently being recorded manually will be automatically entered on the ePCR record. The ePCR and the LIFEPAK® 15 monitor/defibrillator can communicate electronically via Bluetooth connection.

This means that vital signs recorded on the LP15 and/or a 12 lead ECG can be added to the electronic record.

Has there been any staff input into the ePCR project?

Yes. The ePCR Project Team has had two NAS staff members, nominated

by IARC, as team members. They have provided very valuable input into all aspects of the project design and proposed implementation. A number of other NAS staff members have also been involved in subgroups of the main project team, and NAS staff members in the first implementation area, the South, have also contributed.

How will NAS benefit from ePCR? NAS will be able to do the following »»

Systematic clinical audit (eg STEMI care, pain management etc)

»»

Quality assurance (compliance with clinical practice guidelines, national standards etc)

Clinical Connections 19

»»

Analysis of patient trends, changes in demographics or illness/injury patterns

»»

Early identification of important patient safety issues

»»

Early identification of public health issues (eg new street drugs emerging)

»»

Contribution to national health data analysis (eg changes in road traffic accident injury or death rates).

How will practitioners benefit from ePCR? In many ways.

comes with a protective case with a glove like attachment that allows users to hold the unit comfortably while inputting patient information.

The unit has a touchscreen which will allow input via screen interaction, a traditional keyboard to assist with freetext input, as well as a stylus.

A rigorous process to identify the optimum positioning in the vehicle has been carried out. This process took note of considerations from staff representatives, tablet providers, vehicle manufacturers and others as well as an independent health and safety expert and an assessment by an ergonomist.

Practitioners will be able to access all records on which they are part of the attending crew. When Paramedic and Advanced Paramedic CPD come on stream from PHECC, this will be useful for individual practitioners in fulfilling their CPD requirements to PHECC. We are also exploring the opportunity of putting additional resources on the tablet – for example CPGs, medication formulary, and other clinical resources that may assist practitioners on calls.

NAS will be able to analyse how the service delivers patient care which will allow us to identify clinical initiatives that should be implemented, clinical issues that need greater emphasis in training, upskilling opportunities, or patient pathways that can be improved upon or updated.

Will ED staff still get a paper record at patient handover?

How will ePCR work in practice?

NAS will be able to provide much more comprehensive data to EDs – for example patterns of ambulance borne patient attendance, data on particular clinical issues of interest, quicker and more detailed responses to queries on individual patient issues that may arise.

The ePCR unit is a tablet which has a detachable keyboard. A docking unit (which also charges the unit) will be placed in the back of the vehicle, and the unit will stay in this docking unit while not in use (allowing the battery to remain charged). The unit also

Yes. As part of the project implementation NAS will install printers in each ambulance, allowing the crew to print the electronic record for the purposes of patient handover prior to entering the ED. For some patients, clinical care will preclude ePCR completion prior to arrival at ED – in this instance clinical handover will happen, and the ePCR can be completed and handed over afterwards. Patient care will always be the priority. There will also be a web - viewer installed on PCs in each ED, allowing staff to view the record electronically.

How will EDs benefit from this?

Will there be challenges or issues with this change?

Inevitably. This is a major change in how NAS does its business, and there will naturally be issues that arise as we implement the product. Each area will have designated ambulance managers and supervisors as points of contact for staff with questions or suggestions on the roll-out as it happens. We also hope to identify ePCR “champions” in stations that are implementing the ePCR, who will provide peer assistance if required.

Where will the ePCR be implemented first? ePCR will be implemented first in Cork city and then to the greater SouthWest, followed by the South – East. ePCR will then be phased in nationally over approximately 12 months. The roll-out is linked to the Mobile Data Terminal roll-out, as the two systems are linked.

Will we still get the old paper PCR? The intention is that ePCR will be the default clinical record for NAS from 2017 onwards. We will still carry paper PCRs as a resilience measure (eg technical issue where ePCR solution fails), but use of paper PCRs should be very small.

In advance of the implementation, we are happy to be contacted with any queries or observations.

David Willis Clinical Information Manager

20 Clinical Connections

HOW-TO GUIDE Cardiac Arrest Downloads The introductions of the LIFEPAK 15 will, for the first time allow comprehensive and accurate analysis of cardiac arrest performance by National Ambulance Service practitioners.

elements within the cardiac arrest, including CPR ratio, compression ratio and compression rate all in an easy to understand dashboard display.

As the system evolves our goal is to provide feedback to practitioners as swiftly as possible. This exciting development will be able to provide details to each staff member on key

Prior to sending the data please enter the patients details including an incident number / Name / DOB (if available).

Following each cardiac arrest practitioners are asked to transmit the cardiac arrest data from your LIFEPAK® 15 monitor/defibrillator.

Before transmitting any data please enter the patient details.

1. Press OPTIONS 2. Select PATIENT. Complete the fields including incident number/ Name / DOB (if available).

If you have not yet turned your Lifepak off, here is how to transmit a current patient report: 1. Press TRANSMIT. 2. Select REPORT and filter to ALL. 3. Under SITE please select CARDIAC ARREST 4. Select SEND. The Status of transmission appears at the bottom of screen.

What is the code summary telling you? CPR gauges display CPR statistics calculated during the entire event. The goal is to have needles within green parameters CPR RATIO This determines the overall performance of CPR. It shows the proportion of time uninterrupted CPR was performed for the entire case, accounting for CPR related interruptions shorter than 10 seconds.

COMPRESSION RATIO (HANDS ON TIME) This determines the “hands on time”.

It gives the proportion of the time uninterrupted chest compressions were performed. Interruptions greater than 3 seconds in chest compressions will count against overall figure.

COMPRESSION RATE This determines the rate in which chest compressions were performed.

If you have turned your LIFEPAK® 15 off, the patient record is saved in the archives.

Here is how to transmit from an archived patient record: 1. Select OPTIONS. The options menu appears.

2. Select ARCHIVES. 3. “Enter patient archives?” message will appear. Select YES. 4. You can then send, edit, print or delete archived records. Select EDIT if you have not entered any patient details and fill in the relevant fields.

5. Once patient details are entered, or if they already are, select SEND DATA. On selecting SEND DATA. 1. Select PATIENT. A list of patients will appear select which one you would like to send.

2. Select REPORT and filter to ALL. 3. Under SITE please select CARDIAC ARREST. 4. Select SEND The transmission status appears at the bottom of the screen.

COMPRESSIONS PER MINUTE This determines the average number of chest compressions delivered within one minute. This will usually be less than the compression rate as it includes pauses for ventilations and pulse checks.

CPR QUICK VIEW This determines the average number of chest compressions delivered in one minute. This will usually be less than the compression rate as it includes pauses for ventilations and pulse checks.

TIMINGS Each line across the table represents one minute, as indicated down the left hand side. represents 10 seconds. You are then able to see pauses (no red lines) in compressions and estimate how long this was for.

INTERVAL STATISTICS This table to the right of your CPR quick view contains the CPR statistics calculated for each section of the CPR attempt

Clinical Connections 21

‘Not Just Little Adults’ The Paediatric Trauma Patient

DAVID HENNELLY, AP MSc Clinical Development Manager

Ask any medic to describe their top three “Out of their comfort zone moments” and I can pretty much guarantee at least one will involve a paediatric patient. As paediatric trauma is relatively uncommon (thankfully), contributing to circa 6% of all TARN eligible major trauma patients, it requires regular case reflection and training to ensure that when the call comes that we are adequately prepared to manage the unique needs of the paediatric trauma patient.

This article describes how a paediatric physiology differs from that of the adult patient. We will review unique aspects of paediatric trauma patients including airway, respiratory and cardiovascular response to haemorrhage, spinal injuries, traumatic brain injuries, thoracic injuries and blunt abdominal trauma. Understanding the many differences between adult and paediatric trauma patient and having a systematic approach is critical to providing excellent care, preventing secondary insult and avoiding oversight of potentially significant injuries.

A

Airway

Airway compromise, respiratory reserves, hypoxia and inadequate ventilation are the most common causes of paediatric cardiopulmonary arrest following trauma, therefore, efficient and effective airway management is a critical aspect for paediatric trauma. The unique features of infant and paediatric airway anatomy and respiratory physiology make airway management one of the most challenging components of paediatric trauma care.

Infants are nose breathers »»

Trachea is more cartilaginous and soft »»

The cartilaginous nature of the paediatric airway makes it more prone to collapse and obstruction than the adult airway if the child is not positioned appropriately.

»»

The tonsils in toddlers and young children may be enlarged, contributing to airway obstruction and making insertion of an endotracheal tube difficult.

Paediatric airway is smaller »»

In the small airway, there is greater risk of airway obstruction from small foreign bodies.

»»

Children with loose deciduous teeth may have one dislodged into the airway.

»»

Small amounts of swelling of the smaller paediatric airway will result in a relatively greater reduction in airway diameter than would occur in the larger airway of the adult.

Larynx is higher and more anterior and the epiglottis is larger »»

The larynx sits at the level of the 2nd 3rd cervical vertebrae in the young child, compared with the 6th -7th cervical vertebrae in the adult.

»»

The positioning of the larynx makes its visualisation in the paediatric airway more difficult than in the adult.

»»

The epiglottis of the young child larger and less rigid than that in an adult. This makes the technique of tracheal intubation more difficult.

Relatively larger tongue and smaller oral cavity »»

The relatively larger tongue and smaller oral cavity means that, in the child, the tongue is more likely to obstruct the airway than in the adult. This makes it essential that there is correct positioning of the head jaw to open the airway.

Infants have a relatively larger occiput »»

»»

The large occiput of the infant flexes the head forward when he/ she is placed prone on a flat surface. This is important in airwayopening manoeuvres and cervical spine immobilisation. Simple procedures such as positioning a small blanket roll on the spinal board / vacuum mattress in line with the scapula prior to moving the patient can greatly assist with ongoing airway management.

Care must be taken not to hyper-extend the neck, as this may result in airway obstruction or spinal cord damage in the event of a cervical spine fracture.

In the first 4-6 months of age infants breathe exclusively through the nose, and will experience respiratory distress if the nose is blocked. Care must be taken to ensure that the nares are patent in cases of infant trauma.

Cricoid ring is the narrowest point in the airway and the trachea is short »»

This also has implications for endotracheal intubation.

»»

The clinician is not able to confirm endotracheal tube size by viewing the tube pass through the narrowest section of the airway, as in adult intubation.

»»

The paediatric trachea is comparatively shorter than that of the adult, which increases the risk of dislodgement of the endotracheal tube.

22 Clinical Connections

B

Breathing

often see nasogastric tubes inserted in the ED to decompress the stomach, to stop it impinging on diaphragmatic excursion.

Thoracic Injuries are the second leading traumatic cause of death in children; Chest wall more compliant. »»

The ribs and sternum are not fully ossified until late in adolescence so the chest wall provides less protection to underlying vital structures, thus a significant amount of energy is transferred to the lungs, heart and great vessels.

Increased mobility of the mediastinal structure. »»

The increased mobility of the mediastinum increases the likelihood that the injured child may develop a tension pneumothorax from a simple pneumothorax, or transect a small mediastinal vessel as the mediastinum shifts.

Diaphragmatic breathing »»

In infancy, the diaphragm is the most significant respiratory muscle. This is why we

»»

The greater compliance of the chest wall in infants and young children also explains the significant intercostal retraction that occurs in children when the airway is obstructed, or there is a decrease in lung compliance.

Respiratory and heart rates varies with age and physiological insult »»

Young children have significantly higher metabolic rates than adults, and therefore have a higher oxygen demand, which in turn results in higher respiratory rates. Respiratory rates will often be the first significant sign of a change in the paediatric patient’s condition.

»»

Heart rate will be influenced by respiratory insufficiency. Infants become bradycardic when hypoxic.

Clinical Connections 23

C

Circulation

D

Disability

Blood volume is relatively larger, but absolute volume is smaller 80-90ml/kg in the paediatric patient vs 65-70ml/kg in the adult patient.

Relatively small volumes of blood will constitute significant blood loss in small children, ie: a 100ml haemorrhage experienced by a 5 kg child represents the loss of approximately 10% of their total blood volume. Monitor and record all blood loss, including amounts that would be insignificant in the adult patient.

Expose & Examine

»»

Furthermore, infants and small children must increase their heart rates to increase stroke volume and improve cardiac output.

Therefore, any interventions or medications that decrease heart rate may cause a rapid and detrimental loss of perfusion.

Fluid Replacement

»»

Fluids should be administered at 10ml/kg as per CPG but Practitioners should remain cautious to avoid clot disruption in patients with active internal hemorrhage.

Cardiovascular Response to Haemorrhage Children are better able to maintain relatively normal blood pressure despite significant blood loss, compared to adults. Studies have shown that paediatric patients can maintain a

Traumatic brain injury is the leading cause of death in paediatric trauma patients. While the best management is prevention, once the injury has occurred, it is critical to prevent secondary insult to the brain from hypoxemia and hypotension.

»»

The cranial sutures do not fuse until the head has reached adult size, providing some limited protection to the brain tissue by allowing limited expansion.

Open sutures, presence of fontanelle

Thinner cranial bones and head relatively larger

»»

»»

The thinner cranial bones of children do not afford as much protection to the brain tissue as the thicker bones of the adult skull.

»»

The proportions of head to body in the infant and small child are significantly larger than in the adult. This will result in greater heat loss from the surface of the exposed head.

»»

The size of the head relative to the body also results in a higher centre of gravity, which in turn contributes to a higher incidence of head trauma in children.

The anterior fontanelle can be palpated in most children up to the age of 12 - 18 months before it closes permanently, and the posterior fontanelle may be palpated in some children up to the age of 2 months.

It is important to recognise a bulging or sunken fontanelle and the relevance of these findings. In the trauma setting, the bulging fontanelle will suggest a rise in intracranial pressure, which may be a result of intracranial bleeding. The sunken fontanelle may suggest significant intravascular losses.

The smaller the child, the greater the likelihood that a single impact will injure multiple organ systems. It is vital to expose and assess the patient appropriately to assess for occult injuries.

Blunt abdominal trauma is the third most common cause of paediatric trauma deaths, but is the most common unrecognized fatal injury. Many serious abdominal injuries have non-specific or subtle external signs, so a systematic approach is important to avoid a missed diagnosis. Splenic and hepatic injuries are the most common followed by renal, small bowel and pancreatic injuries.

Children have very compliant chest and abdominal walls, and a relatively larger volume of viscera with less fat within a smaller diameter. As a result, the liver and spleen are less protected by the rib cage, placing them at increased risk of injury during blunt trauma. Concerning exam findings include abdominal wall abrasions or bruising, seat-belt marks, tenderness or rigidity, distension, referred

F

»»

G

Increased glucose requirements but decreased glycogen stores

Fahrenheit

Glucose

Fixed-stroke volume

Hypotension is a late sign

»»

E

perfusing pressure with up to 35-40% blood loss prior to becoming hypotensive

»»

shoulder pain from diaphragmatic irritation, and emesis. Abdominal wall bruising is a significant finding as one study of restrained children in RTC’s found that those with a “seatbelt sign” were 232 times more likely to have intra-abdominal injuries than those without.

Spinal injuries are relatively uncommon in the paediatric trauma patient, and make up <2% of all paediatric trauma patients. About one half of patients with vertebral fractures have no neurologic findings. Conversely, some patients have spinal cord injuries without radiographic abnormality (SCIWORA), where the normal laxity of the soft tissues of the child’s spinal column leads to damage of the spinal cord without fracture or ligamentous injury. In contrast to adults who are more likely to suffer lower c-spine injuries, most spinal injuries in young children involve the upper c-spine due to their relatively larger heads that create a fulcrum-like effect on the upper c-spine region.

Due to the lack of subcutaneous fatty tissue and larger surface-area to body-mass ratio paediatric patients are prone to becoming rapidly hypothermic, although thorough assessment is vital, it is imperative that

A higher metabolic rate results in increased glucose usage.

all patients temperature be managed appropriately and they should be protected from the elements and moved to a warm environment as soon as possible. »»

Infants have relatively small glycogen stores when compared with those of an adult. For this reason, it is essential to monitor blood sugar levels in sick and injured infants.

24 Clinical Connections

In MY View

2

1: Two Dundalk Vehicles during their pre-shift check at sunset.

2: Denise Ford, NAS AP, no patient too small or too fluffy.

3: The staff from Wicklow Ambulance taken outside the ‘old’ base on the day we moved into our new base.

4: Below is a picture of our new base located in the primary care centre on the port road in Wicklow town.

5: Rob Fitzgerald, a NAS Paramedic, and his family at a Road Safety Authority day in Drogheda.

1

Pic: Paul Ruigrok

3

Pic: Maggs Casey

Pic: Ian Thompson

5

4

Pic: Shane Mooney

Pic: Rob Fitzgerald

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.