A HEMS experience from a resident perspective (and a few pictures from my last flight)

This post is being written while on a plane back to Toronto…I’m just settling into some serious jetlag so I figured no better time than put down a few thoughts on my experience in Auckland. For the past 6 months I’ve worked in NZ with the Auckland Rescue Helicopter Trust as the HEMS education fellow and flight physician. Coming from Canada where putting physicians on-board helicopters to work in a pre-hospital environment is about as foreign as …. I came to Auckland with little knowledge about what to expect.

Posing for the photo op. Realized a modeling career isn't in my future.

Posing for the photo op. Realized a modeling career isn’t in my future.

To say the least, the entire experience was amazing and unforgettable! And much of this must be attributed to amazing group who work at ARHT. My supervisor and HEMS medical director, Chris Denny, got me organized and met with me weekly. We set out a plan, established learning outcomes and gradually implemented an advanced simulation plan at ARHT. Amazingly the ARHT facilitated this with the purchase of several brand new simulation manikins which only enhanced the learning possibilities. I worked alongside several talented physicians (Sam Bendall and Scott Orman) who mentored me in advanced simulation techniques, e-learning, integration of social media and blogging into education.

My time at ARHT was divided between educational endeavours and work as the HEMS duty doctor. Both allowed me to work and learn with the entire ARHT team who taught me more than they can imagine! While I can’t possibly thank everyone in this format, I developed great relationships with Barry Watkin (chief paramedic) and Herby Barnes (head crewman) who both worked to help me implement some of our educational objectives!

A view of Auckland at sunset

A view of Auckland at sunset

As the HEMS education fellow, I ran weekly simulations (often based on jobs we had recently done or questions that had come up), case-based learning sessions and finally task training sessions. We described our learning online both through the aucklandhems.com blog and via Twitter. We flew across the Tasman to practice our pre-hospital ultrasound skills at SMACC2013 (an impressive 2nd place…despite our less than optimal subject matter we had to teach)! (link). We implemented new standard operating procedures based on (and tested in) simulation. There was collaboration with teaching and simulation with the Auckland City ED as I worked there part-time as well.

On the west coast outside Auckland

On the west coast outside Auckland

Finally, I had the opportunity to practice pre-hospital & retrieval medicine. This opportunity to learn from some amazing doctors, paramedics, crewmen and pilots in a setting that previously was entirely unfamiliar, was awesome! I gained an entirely new appreciation for ergonomics as practicing medicine in the back of a helicopter is entirely different than even the craziest of emergency departments! I had opportunities to do winch rescues (both practice and operational), jumping from helicopters, rock swims with surf rescue, run resuscitations in remote areas and the list goes on.

What stood out however, was the theme of safety. In medicine, safety is sadly a relatively new topic…but for many of our pilots and crewmen, safety has been a part of their work since they started. In fact, those in aviation who don’t embrace safety…tend not to have very long work careers (for obvious & unfortunate reasons). Working in a helicopter is among the highest risk occupations around so it’s not surprising the ARHT team take safety so seriously. I spoke with the crewmen and pilots as much as a could to better appreciate their perspective…so that perhaps in medicine I can borrow and learn from their obsession. I suspect (as others have as well) that medicine lags in safety management because bad outcomes don’t harm clinicians directly…in a helicopter however, lack of concern for safety does affect everyone onboard. Thus the entire team has a vested interest in promoting and ensuring safe procedures. We run safety briefings, we have an online safety management system in place and just like the rest of aviation we incorporated checklists for both routine & high-risk procedures. As HEMS doctors, we tried to emulate the pilots/crewmen so we also use a checklist for our high-risk procedures like rapid sequence intubation…this is just starting to catch on in the ED but in my opinion there’s much room for improvement! I once asked one of our pilots about checklists and why they use them… I told him that in medicine, people fear checklists because they think it will take away their ability to think…he laughed and replied:

“we have checklists not so that we stop thinking…but so we can start thinking during a crisis and not worry about forgetting small details”.

And that brings me to the end of my last blog post at ARHT. A huge thanks to the entire team at HEMS & ARHT for inviting me to Auckland, helping me learn and trying new things! I will continue blogging but likely with a shift towards simulation and education. I’ll still be collaborating with the HEMS team at ARHT and hopefully posting some stuff on aucklandhems.com. So that’s it for now…back to my inflight movie, Argo.

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Cricothyroidotomy training for the pre-hospital setting

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Newest addition to the ARHT simulation centre. Cricothyroidotomy task trainers built from old manikins. Rolled them out successfully last week with our paramedics using them for the first training session.

One of my medical education interests is looking at how we train and practice rarely performed procedures. For these situations, simulation offers an excellent method of training. The challenge, however, is recreating the fidelity of such situations since many rarely performed procedures are quite invasive.  Often we’ll start the training with a task-trainer like model and then progress to a full size manikin. Task-trainers are simulation models specifically designed for one type of procedure. 

In emergency and pre-hospital medicine, the cricothyroidotomy is among the most invasive, time critical yet rarely performed procedures. In addition to the potential technical challenges of this procedure, the decision to perform a cric might be even more difficult.  Identifying a “can’t intubate, can’t ventilate” scenario and then to “pull the trigger” may be one of the hardest cognitive leaps we face in resuscitation.  For example, last week, in the  Auckland emergency department we ran an in-situ simulation scenario for the registrars that required the performance of a cricothyroidotomy. The goal of the simulation was only to perform a cric…in fact, we even gave the registrar team a heads up that the patient would required a cric. Amazingly while we only used a task trainer that didn’t even allow for intubation, the trainees still tried to proceed with intubation. There was considerable reluctance to finally acknowledge that it was a “can’t intubate, can’t ventilate” situation.  I don’t think we train enough to practice taking that cognitive leap to the final step in the failed airway algorithm. Even this short little scenario provided evidence that such scenarios require practice and should be simulated.

This past week at the base we rolled out our cricothyroidotomy task trainers. We constructed our trainers based on a model created by Agnes Ryzynski & Dr. Jordan Tarshis at Sunnybrook Health Sciences Centre. They described the creation of such task trainers using old/broken manikin heads and some innovation using easily found products within the hospital. The value of such a trainer extends beyond its simplicity as it also  maintains good fidelity, it costs less than $30 to make and it recycles old manikin heads! 
Such a trainer might supplement an even lower fidelity construction depending on the setting. At the ARHT, our go-to method for cricothyroidotomy is a bougie-assisted technique which is described in this article and video. We’ve selected this technique based on simplicity in the field and relatively minimal equipment required. But there’s good debate out there whether these should be performed using the needle or surgical approach. Scott Orman (ED physician and blog author for aucklandhems.com) wrote about the topic last week with some great links.

You can see from the pictures, that the paramedics have set up on the left side of the patient. We were trying out different approaches and set ups to find out what works best. Personally, I prefer the right side of the patient. In our setting within the helicopter  we only have access to the patient’s right side. As a result, there may be some benefit to be on the right side. The ergonomics of such a high stakes procedure are probably understated so training in the same way that you’ll perform the procedure is essential. I acknowledge that you might need to be a bit flexible regarding setup but in general, the airway team should be well prepared and anticipate where equipment and personnel will be placed.

Here’s a few more pictures of our training day.

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Next post will have a bit more about the evidence base around cric performance.

 

Is it time for tranexamic acid in the pre-hospital setting?

Recently, we had an elderly patient brought into the ED after being involved in a fairly substantial motor vehicle collision. As we began treating her, I asked the trauma surgeon who was taking over the patient’s care whether he wanted tranexamic acid given (TXA). As she was relatively hemodynamically stable (despite several  transient hypotensive episodes), he declined providing her with TXA without elaborating.

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In my view, this patient was definitely someone who would have benefited from TXA especially after later imaging revealed retroperitoneal bleeding. I also wondered, whether this patient could have been given TXA in the pre-hospital setting? At ARHT, we’re not currently using TXA but there’s some question as to whether the pre-hospital setting may be an optimal place for initiation of therapy.

In 2010, the Crash-2 study was published. It was an unbelievably impressive undertaking that randomized trauma patients (a very broad cohort) to TXA or placebo. More than 20,000 patients were enrolled in 40 countries, many of which were resource poor settings. The results were quite remarkable with an absolute risk reduction in all cause mortality from 16% (placebo) to 14.5% (TXA). The authors concluded that “TXA should be considered for use in bleeding trauma patients”.

A closer look at the data suggests that this benefit is primarily if TXA is administered within 3hrs of injury. More recently, additional analysis revealed that death due to bleeding was significantly reduced when administered in <1hr (NNT 42) and between 1-3hrs. This re There was concern about harm if there was a delay >3hrs.

This time dependent effect has considerable ramifications for pre-hospital health care providers. As far as I can tell, there’s no data to support the use of TXA in the prehospital setting but our existing data would support early administration which could easily be provided for patients before arriving in hospital. In particular, patients with prolonged extrications, longer scene times or longer transport times may benefit the most.

A recent retrospective study (MATTERs) study looked at the use of TXA in a combat setting among patients who received at least 1 unit of red cells. They found an association with lower mortality for those who received TXA. Clearly the methodology of the study precludes immediate clinical adoption but it provides additional evidence of the possible benefits.

My bias is that if this was a drug that wasn’t off patent and that there was some pharmaceutical company that could make billions then we would be much more aggressive with its use. In cardiology, most statins have numbers needed to treat of 100-200 and yet with massive (an apparently effective) marketing campaigns, I’ve heard some cardiologists say it should be in the drinking water! I digress.

I think it’s time to consider TXA in the pre-hospital trauma setting in a well defined protocol. The relatively broad inclusion criteria used in Crash-2 which still resulted in impressive outcomes suggests that it would be reasonable to consider in many of our suspected bleeding patients prior arrive in hospital.  And clearly, there needs to be a move within the hospitals and trauma bays to actually implement protocols and give TXA early. Based on existing evidence, we will only be providing better patient care.

Helicopter Underwater Escape Training (HUET) course

It’s been a busy week so I’ve been a bit delayed getting up this post.

Our choppers at the base are extremely well maintained by a whole crew of super experienced staff, but regardless, there remains the possibility that we’ll “ditch” into the water during a flight. Ideally this occurs in a “controlled” manner but it’s possible that it happens suddenly. This unlikely occurrence has been the impetus for the HUET course that’s occurred at the base for the past 20 years. This course really highlights lots of stuff we can be doing in medicine – practicing rarely performed, high-stakes procedures in a simulated setting. The concept is fantastic and what’s great is that not only do we discuss what to do, we actually go out and practice.

We just finished up a really solid day at the base where we completed our Helicopter Underwater Escape Training (HUET) course. There was a combination of flight crewman, pilots, physicians, paramedics and surf rescue guards who all came together for an excellent day of training.

We started off the day with a full review of our lifejackets, seat belts and exit from the chopper.

Letting off flares over the bay

Then we headed out to the pier where we channelled our inner caveman, got to play with fire and let off  a bunch flares (ones usually kept in our life vests). I think there’s a genetic element (left over from the prehsitoric era) that provides us with great satisfaction from setting off fire into the air and watching fireworks launch into the air. Nothing quite like challenging your manhood with “my flare went further than yours”.

We then headed up to the local dive pool to practice our underwater escape plans. The Trust has a great training apparatus – a mini chopper known as the “dunker”! This thing functions as a practice model for escaping as the chopper is flipped upside down. As it was described in our course, we have to wait at least 7 seconds once we hit before we escape. By then all the chopper blades will have stopped and it will be safer to exit. This simulation process helps you gain appreciate for the complete clusterf*#)@ that it would be if the helicopter crashed into the water. While we couldn’t recreate the likely injuries you’d suffer, the gasoline in the water, the inability to see, the hectic ocean swells, we were at least able to go through the motions of our exit plans. When my wife asked, “how was your day?”, I started explaining what we were up to.  Judging by her reaction on my training for a possible helicopter crash, it appears that such things are best left on the list “things not to tell your wife”.

We had 4 divers in the water watching us as we got dunked under and to help us escape if we ended up down too long.

Two crewman getting the dunker back to “right side up” for another simulation

Imagine being in a set of rapids, hanging upside down without an idea of which way is up and completely disoriented while not being able to breath. This is exactly what we went through today…except in real life we’d then probably have to get to the surface (some 30-50m away). There’s little around to help you navigate except the simple technique of opening the door first then seat belt (otherwise you can float away and have no idea of your bearings).

This was a fascinating experience that helped emphasize the importance of in-situ training. When experiences are vastly different than what we’re used to, we must engage this environment and practice in a foreign situation.

A nice side-profile of the dunker! What a sweet ride!

I’ve included a video of the dunker, so that it can be observed in action! You’ll see the two that were belted in, pop up right at the end of the clip! Another successful escape!

http://youtu.be/OF1NuZFJZIk

Another day at the office…

We just got back from a beautiful day working at ARHT. Not a super busy day but we did get out flying for a few jobs. We enjoyed amazing weather, great crew and got the patients safely to the hospital. Weather was about 20 degrees, sunny without much wind. We had a stunning trip out to Great Barrier Island…I’ve just posted a few pics from the day.

View during the flight home with Waiheke Island in the background.

Great Barrier Island

Doing my best Topgun look…maybe I should have a more serious face

Me and Leon (crewman). Probably the best guy to have on your team. Keeps us all under control and has tons of experience! Plus fairly certain he can bench 300lbs…not bad to have on your side

Surf Rescue Videos

Just put together my first iMovie! This is an edited clip from part of the rock swim at Muriwai that we did with the Surf Rescue Life Guards last week.

http://youtu.be/criFEz9UwL4

At the beginning of the clip you’ll see the video pan over to a large hole in the rocks, known as the blowhole. This has been the site of several rescues recently where the team has winched down to rescue people that fall in. As you can imagine it could get a little hectic. Luckily when we were there the waves we’re relatively calm. But even climbing out once after you jump in can be tough – I learned this the hard way. You’ll see me jump in (wearing the blue & black wetsuit)…pretty much the tallest and lankiest guy there. I didn’t get out successfully the first time but I did completely shred my hands. They continued to bleed for the rest of the swim. After we all got out, we walked around the point and did the most advanced part of the swim. Unfortunately I dont have footage, but it was pretty wild, you swim like an idiot then body surf through this cave.

Also, I re-posted this video of the static line rescues that we were doing. Amazing opportunity to jump out of the helicopters into the ocean, get lifted by a 50ft static line and brought to shore!