Last week was the international Trauma Care Conference, based at Yarnfield, Staffordshire, UK. It ran for several days, with something for everyone in the management of trauma, from the moment of impact to the long difficult process of rehabilitation. I attended the PHEM/HEMS stream on the Thursday, and the Major Trauma in the ED stream on Friday. Below are my notes for the PHEM/HEMS stream. Some of these points I tweeted live from the conference, but much of it may be new. My notes from day 2 are here.
Extreme physiology meets trauma
Dr Paddy Morgan @drpaddymorgan
Started off with a brief look at the massive physiological stresses that can be exterted on the body of the prehospital clinician over the course of a busy day, imagine performing CPR in the house of elderly person during winter, with the heating on, in your flight suit and heavy boots, getting tired and sweaty, dehydrated, and then going outside to an RTC extrication, where you are relatively still, now getting cold from your wet clothes! Absolutely draining. These changes, particularly dehydration and fatigue can have a real impact on critical functions, including decision making. Paddy stressed the point that we need to look after ourselves as rescuers, take the time to dry off and have a drink after an exerting job, in order to ‘reset your physiology’.
Exhaustion – of both the rescuer and the patient can be divided into various physiological phases:
- Fluid – dehydration, bleeding, fluid shifts
- Thermal – hypo/hyperthermia
- Oxygen – hypoxic, not only blood oxygen tension, but cellular too
- Energy – cellular respiration, ATP, energy stores, lactate production, etc
Each level takes a different amount of time to exhaust, but also to replenish.
We should be realistic about thermal warming capability in the prehospital phase, the analogy being getting 80kg of meat from your fridge and putting it on the barbecue; it will take a very long time to effect any meaningful warming, compare that with the air-activated heat pads for thermal output and recognise their limitations. Preventing heat loss is much more efficient.
Heat loss compounded by anaesthesia, hypovolaemia, plus removal of clothing, loss of behavioural compensatory mechanisms, and being wet. Paddy presented data which showed that the accuracy of a tympanic thermometer was dramatically reduced when the ear was a bit wet.
Best method for preventing heat loss in a comparison of three different wrapping methods – the ‘Hibler’ method – plastic bag then insulation, stops moisture and heat loss, the other methods were an ambulance blanket or bubble wrap.
During UK prehospital transit times it is unrealistic to expect any meaningful warming of the patient, as explained above – you may only achieve thermal comfort level, but this may reduce sympathetic stimulation, something which is associated with worse outcome. Less shivering may improve analgesia.
The human body is excellent at adaptation to its environment, simple examples of this include PPE, putting on warm clothing to facilitate a trip out in the cold. There are more discrete, cellular adaptive mechanisms afoot too. Adaptive responses very important in extreme conditions – eg cold water swimming and altitude.
Paddy told us there are two groups of people – those whose mitochondria will recover from a hypoxic/low ATP threat and those who won’t, h-genes are the key, and are under investigation. Future development – will it be possible to measuring peripheral oxygen tension and then titrate oxygen delivery, especially if based on mitochondrial response determined at the bedside? Exciting possibilities, but a long way off at the moment.
Farmers – we know they are amazingly hardy, but is there a genetic or adaptive change to make this happen? There are cross-adaptive changes – those exposed to cold conditions regularly may tolerate hypoxia better due to changes in the autonomic tone, perhaps ischaemic preconditioning. Does this make them more likely to survive a major traumatic event?
Those with bradycardia after trauma (excepting spinal cord trauma!) have better outcomes, could be adaptive change.
Motion sickness causes decreased vasoconstriction, increased heat loss, hypotension, worsened g-tolerance. Consider anti-emetics for anaesthetised patients as well as awake when transferring.
Acute Stress in PHEM
Dr Clare Bosanko @clarebosanko
Clare’s talk raised awareness of the negative impact excessive stress can have on ourselves and our performance in acutely stressful situations. Increasing heart rate in acutely stressful situations is associated with cognitive disfunction, along with loss of bodily control:
I learnt more about auditory exclusion and tunnel vision, that loss of focus when excessive stress creeps in, otherwise known as a loss of bandwidth and breadth of focus.
If resources (personal or otherwise) exceed the perceived demand, this is perceived as a challenge and performance could increase, if demand greater than resource, perceived as a threat, causing detrimental performance.
There are ways to combat stress:
- mental rehearsal, the mind is the best (also cheapest) simulator you can have, running through scenarios in your mind can reduce cognitive load when it happens for real see Cliffs Reid’s “Own the Resus Room”
- breaking steps down into manageable chunks
- tactical breathing to break cycle of sympathetic stimulation in yourself
- imagine yourself awesome, a positive mental attitude
Stress inoculation training, exposure and practice make it better in the end!:
- educate – the person on what will happen, how a stressor will make things worse
- rehearse – simulate scenarios with worse stressors to distract and reduce performance
- apply – in real life
A national major trauma triage tool?
Rod Mackenzie @RodMack2
5 years into the UK based trauma network system, and each region is working independently, following their own systems of trauma triage, with the minimum of learning across boundaries. Rod’s talk discussed the process underway to try to develop a national Major Trauma Triage Tool, and the pitfalls discovered along the way.
Any tool developed must be based on evidence, and should ideally get the right patients to the right place at the right time. Over and under triage to the Major Trauma Centre (MTC) should be minimised, but also the unsafe bypass of Trauma Units (TUs) for those patients who need to call in for life-saving therapies before onward transfer to the MTC.
Injury Severity Score is the most common descriptor to designate a patient as having sustained major trauma, ISS>15 yields a 10% mortality. 15-20% improvement in survival if transferred to MTC. Unfortunately is a retrospective scoring system, we need something prospective, to be used at the point of injury. It must be simple, ideally with binary decisions.
Trauma tools around the country are currently based on:
- Special circumstances
Current evidence base: papers to read:
Sensitivity/Specificity wide ranges, most of these papers from retrospective data bank studies, a technique which is inherently flawed, the patients included are ones who made it into the data bank, so there must be ones who missed data entry, eg died at scene, under-reported/recognised, went somewhere else.
NICE couldn’t recommend a specific tool, but suggested a national tool.
The question was raised, a national tool doesn’t take into account regional network setup and distances/ hospital capabilities, so might not be the holy grail after all.
A Delphi process was undertaken, a consensus of experts: opinion of what is useful. Most useful are listed in the box to right (apologies for the poor quality of photo, the list is found again below):
Result of consensus, and a possible tool:
How do we get the data collection and evidence base to improve, so prospective studies can become a real possibility? If triage were made an ambulance service quality indicator, data would improve.
Psychological support in PHEM services:
Matt Thomas @mjcthomas74
A wonderful talk. There seems to be a growing recognition that rescuers and health professionals are vulnerable to mental health problems, both in the acute and chronic phases of stressful careers. In essence we are all vulnerable, and should take it seriously.
Prehospital doctors are more likely than in hospital to commit suicide, around 30 per 100,000!! Same as paramedics, other doctors around 10:
The culture we work in expects us to be strong and resilient, making it difficult to speak up when we recognise we are in trouble.
Matt recommends we all get our own I-resilience report done, to give us insights into where our stressors are likely to come from, and take a test to measure our ‘EQ’ or emotional intelligence. The concept is that if you know yourself, you can manage your mental health and communication with colleagues/patients.
Our independent research shows that members of the emergency services are even more at risk of experiencing a mental health problem than the general population, but are less likely to seek support. (Mind.org.uk)
Another useful tool – TRiM – trauma risk management:
It was explained that military service personnel, and emergency service providers are similar, and that they are much more likely to want to confide in a peer, someone who has seen the same things as them, over a friendly coffee, than go to a superior, or worse a mental health professional; the fear of stigma and labelling is too great to admit formally that one is struggling with what one has seen or done. TRiM is a way of training peers to look out for signs that someone is struggling – perhaps through behavioural change, or increase in drug/alcohol use, something even as simple as excessively exercising – is there a gym at work that your colleague stays behind for hours to use before going home? It then aims to arm you with the communication skills to sensitively ask open questions to gently tease out what is going on, and help the person get a load of their chest. This sounds really useful; I was supposed to be at the MedTRiM course today, but unfortunately it was cancelled. I will have to wait to see what it’s all about.
Another course, with a similar programme is called “Sustaining Resilience at Work (StRaW).
Bizarrely, their is a treatment for PTSB called Eye Movement Desensitisation and Reprocessing , a REM-sleep substitute eye movement treatment. Not mainstream.
Swearing at work allows a permissive leadership culture!
But, watch out for politeness in normally prolific swearers, they maybe stressed out! This point was my most re-tweeted point from the whole conference!
I think it makes sense, and I’ve seen it happen. Just another cue that someone may be in trouble, and losing their bandwidth in a stressful situation. Combined with @ClareBosanko‘s talk, there are many things to keep an eye on.
PHEM –> PHARM
Stephen Hearns @StephenHearns1
A great talk about the importance of maintaining a fully operational critical care transfer service along side prehospital emergency medicine. There was a lot of material on the importance of standardisation of equipment, drugs, SOPs, and communication. The Scottish EMRS system is based from one place, covers all of Scotland, and is, in the main, Consultant delivered care. They are also training advanced retrieval nurses/paramedics to be able to manage some of the critical care transfer work with distant supervision.
The point I took home most though from this talk was that scenario simulation is good and very important at putting everything together in a realistic fashion, but not at the expense of task specific skills drills – making some tasks automatic will reduce cognitive burden at times of acute stress. The way to practice this is to take small tasks eg Ventilator setup, arterial line transducer set run-through, fluid warmer setup, or RSI kit dump preparation, and do it in isolation until it becomes automatic. That way, when the time comes you can keep some bandwidth open for other inputs.
Horse or motorbike?
Lynda Dykes @mmbangor
A video heavy presentation, taking us through how people fall from horses, what an eyeopener! I learnt a lot from this talk, particularly how important it can be to take a thorough history – the height of horse, exact fall dynamics, PPE worn, safety devices used and whether they functioned properly.
The height of a horse is often reported in ‘hands’, one of which is 4-inches. So divide a number of hands by 3 to get height in feet.
There are many different types of Personal Protective Equipment, or PPE, hard hats, hats that look hard but aren’t, padded jackets, airbag jackets, boots, etc, all of which provide varying levels of protection when used.
Perhaps the most dangerous mechanism for falling comes from show-jumping, the “Rotational fall and drag”, which is a fall with a roll that potentially crushes the rider, and then drags the casualty along the ground afterwards, see below:
Mental capacity act 2005: When trauma meets psychiatry
Rob Cole, West Midlands Ambulance Service
A complicated topic. The principles of act were reviewed so we were all on the same page, including the presumption of capacity, The requirement to act in the patient’s best interest – not the best interest of your organisation, yourself or the patient’s family. One must choose the least restrictive option.
It seems more complicated than I first thought. A patient may seem to have the ability to weigh information but the outcome of the decision making may be affected by underlying mental impairment, organic or psychiatric; if the patient states that their intention was to commit suicide, and they realise that the outcome of not going to hospital will be their death, it could be that they have capacity, or it could be that their decision making process has been impairment by clinical depression. It was made clear that the person undertaking the assessment is the person who ultimately decides on capacity, not someone over the phone.
If a patient is found to lack capacity for a certain decision (not a blanket decision, capacity is decision specific), any action taken must be reasonable, and proportionate. Decisions may not conflict with a lasting power of attorney.
It is now a criminal offence to neglect a patient who lacks capacity.
The Emergency doctrine of necessity – common law for life-saving techniques still exists and is in effect, and can be used to save a life before a mental capacity assessment is made, but such an assessment must occur and be documented.
Intoxication doesn’t immediately mean not capable. Possible head injury, with alcohol – this yields a temporary dysfunction, the least restrictive option could be to make the patient safe with family/friends in case of deterioration. Intervention must be proportionate to clinical state. It is possible to leave patients who refuse treatment, so long as adequate safety nets are put in place – eg family/friends, calling GP, calling back in later (welfare checks).
A learning point for me was that the Mental Health Act does now allow the treatment of the consequences of mental illness eg self-harm, or overdose, it is possible to section a patient in order to treat injury/medical consequences.
The section 136 is changing on 1st April – being covered by the new Police and Crime act – 136 will be outside of a private dwelling, in immediate need of care and/or control.
Gareth Davies @LDNairamb
“The need for precision medicine, not prehospital medicine”
The day was closed by London Air Ambulance’s Gareth Davies, who spoke at length about the history of prehospital care, and how it is still in its infancy compared with most other hospital based specialities. The research base is well behind, the governance is well behind. There are so many topics within prehospital emergency medicine that require further scrutiny, and we need to get on and research them properly, rather than just extrapolate data from in-hospital.
We need the data to start being able to differentiate patients, and provide tailored care to individuals, not just pattern recognition and algorithms.
I hope you have found my notes useful, I enjoyed attending the day, and have taken some really valuable points away. I shall be posting my notes from the Friday, Major Trauma in the ED, hopefully in the near future.