Category Archives: All Updates


Hilar Twists & Human Error

This engaging scene from ‘Code Blue‘ demonstrates a Helicopter Emergency Medical Service team managing a patient with major thoracic haemorrhage. They have done a right thoracotomy and want to clamp the hilum but there’s some kit missing from the pack.

This scene has some great discussion points for prehospital professionals, even if the specific scenario is somewhat unlikely for most people’s practice:

  • Non-compressible haemorrhage is possibly the biggest single clinical challenge when you’re a long way from hospital
  • Agitated friends and family can be disruptive – allocate a rescuer to look after them
  • Having blood products to give is essential
  • Don’t rely on the memory of individuals, who are fallible, to pack your equipment. “I was sure I put them in” didn’t cut it when the team needed forceps to clamp the pulmonary hilum and stop the bleeding. Checklists are the in thing, for good reason.
  • Luckily, you don’t need to clamp the hilum (which is tricky) in massive unilateral thoracic haemorrhage. You can just twist the lung 180 degrees on the hilum so it’s upside down. This can prevent further haemorrhage and air embolism.

 

What’s a hilar twist then?

The hilar twist manoeuvre, as it’s called, is worth learning if you’re a clinician who is prepared to do resuscitative clamshell thoracotomy for penetrating traumatic cardiac arrest. The clamshell is quick and provides excellent exposure(1) and is preferred to lateral thoracotomy(2).

The primary purpose of clamshell thoracotomy in penetrating traumatic arrest is to relieve cardiac tamponade and control a cardiac wound(3). It is well described and continues to save lives in the prehospital setting(4).

However, sometimes you’ll open the chest and the pericardium will be empty (other than containing the heart of course), and there will be massive haemorrhage on one side of the chest. Although most of these patients will be unsalvageable outside a trauma centre’s operating room, it’s worth trying something once you’ve gone to all the trouble of opening the chest. The hilar twist(5) is probably the best option for the non-surgeon, especially when some muppet’s forgotten to pack a clamp.

In order to make the lung mobile enough to twist, it’s first necessary to cut through the inferior pulmonary ligament. This is also known as simply the pulmonary ligament (because there’s no superior equivalent) and sometimes the inferior hilar ligament. It’s not actually a ligament, but an extension of the parietal pleura extending downwards in a fold from the hilum. Some describe it as hanging down from the hilum like a ‘wizard’s sleeve’, which invariably gets a giggle from some of our trainees from the United Kingdom for some reason.

Hilar Twist

 

After cutting the ligament completely to the level of the inferior pulmonary vein, the lung is then twisted ‘lower lobe towards you’, ie. lower lobe is rotated anteriorly over the upper lobe until the lung is oriented ‘upside down’. The twisted vessels around the hilum become occluded and further haemorrhage from that side should be limited. Other priorities in the arrested patient will be aortic occlusion, internal cardiac massage, and blood products. Packs may be required to keep the lung from untwisting, and if return of spontaneous circulation is achieved, there is a risk of dysrhythmia, right heart failure, and refractory hypoxaemia.

I’ve only done this on pigs and human cadavers so am not speaking from any reassuring level of experience or competence. The literature is out there to read, and it’s up to you to decide how you want to expand or limit your options when you’ve cracked that chest in an arrested patient.

References

1. Flaris AN, Simms ER, Prat N, Reynard F, Caillot J-L, Voiglio EJ. Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited. World J Surg. 2015 May;39(5):1306–11.

2. Simms ER, Flaris AN, Franchino X, Thomas MS, Caillot J-L, Voiglio EJ. Bilateral Anterior Thoracotomy (Clamshell Incision) Is the Ideal Emergency Thoracotomy Incision: An Anatomic Study. World J Surg. 2013 Feb 23;37(6):1277–85.

3. Wise D. Emergency thoracotomy: “how to do it.” Emerg Med J. 2005 Jan 1;22(1):22–4.

4. Davies GE, Lockey DJ. Thirteen Survivors of Prehospital Thoracotomy for Penetrating Trauma: A Prehospital Physician-Performed Resuscitation Procedure That Can Yield Good Results. The Journal of Trauma: Injury, Infection, and Critical Care. 2011 May;70(5):E75–8.

5. Wilson A, Wall MJ Jr., Maxson R, Mattox K. The pulmonary hilum twist as a thoracic damage control procedure. The American Journal of Surgery. 2003 Jul;186(1):49–52.

Convergent Evolution in the Jungles of Critical Care

boss-of-the-mob-1400090-1279x1923By Stuart Duffin
Expat Brit, intensive care physician and anaesthetist at Karolinska University Hospital in Stockholm, Sweden. Stuart trained in the UK, and spent some time working Australian emergency departments.

One of the most striking things for me about our new/old pan-specialty of critical care, brought into focus by the world-shrinking effects of FOAM and twitter, is just how differently it falls into the domains of the established specialities in different parts of the world. This leads inevitably to comments like, “emergency physicians shouldn’t intubate”, “anaesthetists cant do sick”, “nurses cant be doing such and such”, and so on. All of these statements are clearly equally rubbish because obviously, in certain parts of the world, they do. And they do it really well. Sure there are differences between countries and continents, populations and environments, but when it comes down to it, it doesn’t matter where you are, people still get sick, infected, pregnant, run over, stabbed or hit around the head with heavy things.

All over the world, in our previously quite isolated environments, these same ‘selection pressures’ have forced healthcare providers to evolve by the process of convergent evolution. Although obviously not strictly darwinian, the undeniable effects of simultaneous evolution by survival of the fittest-to-practice can be seen.

Convergent evolution is the process by which, in different parts of the world, completely different species have evolved in parallel to fill similar roles and have similar features. It didn’t matter whether it was a deer, a wildebeest or a kangaroo, there was a vacancy for a fairly big animal who liked eating grass and moved in big groups, and someone stepped up.

Unsurprisingly, critical care resuscitationists are also a little different from country to country and from continent to continent. They have different titles and work in slightly different ways. But when you really look at a critical care doc in action, or talk to one, or follow one on Twitter, we are all cut from the same cloth. I would argue that FOAM has created a critical care zoo in which the kangaroos and antelopes, lemurs and monkeys, aardvarks and echidnas and anaesthetists and emergency physicians are all chucked into the same cage. They’re all looking at each other thinking, “you look like me, but somehow not. We seem to do the same stuff, but we’re not identical – it cant be right!”.

In The United States, the idea of an anaesthetist doing a clamshell thoracotomy would be a little strange. In Scandinavia, an emergency physician doing central lines and fiberoptic intubation in resus would be just as eyebrow raising. A Swedish intensivist and anaesthetist spent some time working in Australia as an ICU senior reg. When attending a patient in resus the emergency physician there announced “we need an airway guy”. My colleague answered “I’m the airway guy”. “No an anaesthetist” replied the emergency physican. “I am an anaesthetist!” “No an….” and so it went on.

The effects of this process are of course by no means limited to doctors. Nurses, paramedics and physiotherapists are all part of this still changing ecosystem. A colleague of mine was showing a visiting Australian emergency physician our trauma bay and describing how major trauma is managed here without the involvement of emergency physicians at all. “When it’s really urgent, it’s anaesthesia and surgery” he explained. I wonder how that went down? There is an element of truth to the statement but the words are wrong. It should have been “When it’s really urgent, it’s airway, access, transfusion, invasive procedures and resuscitation thinking”.

The job title of the person who actually holds the knife/laryngoscope/needle and has what it takes to get it done isn’t important. When the push comes to shove and the bad stuff bounces off the fan, it’s more about skillset and mindset, and less about the collection of letters under your name on your badge, or after your name on your CV.

Awesome Conference on the Sunshine Coast

The Spring Seminar on Emergency Medicine is going to Noosa in September 2016!

In case you haven’t been to an SSEM before – this is a boutique Australasian emergency conference run by a not-for-profit organisation. It is squarely aimed at EM clinicans who like to get their hands dirty. The emphasis is on practical stuff: SSEM is legendary for the quality of its workshops.

It is legendary too for its venues! The last three SSEMs have been held in the Barossa Valley, Darwin and Rotorua. The extracurricular activities are brilliant and the conference draws bright, outward-going, active clinicians from all around Australasia.

This year the academic programme has been expanded with keynotes from 3 leading EM figures, deliberately controversial panel sessions and hot topics, and six awesome workshops on Snakebite (in Australia Zoo), Wilderness Medicine (in the National Park), Difficult Ventilation, Emergency Dentistry, Focused Echocardiography and Lung Ultrasound.

Extracurricular activities include a Welcome Reception with celebrity chef Matt Golinski, early morning activities on Noosa Beach, trips to Eumundi Market and the Spirit House Cooking School and a Beach Party Conference Dinner.

The conference starts with a reception in the Boat House on Tuesday 26 September and wraps up at midday on Friday 30 September with Townsville vs Nambour Simulympics.

There are concessional rates for generalists, trainees, nurses and students. Early bird rates apply until 10 July however the workshops are booking out fast so – book now!

Declaration of interest: I have no involvement in this conference, but I wish I was going!

Why And How I Teach

the teaching hospitalsmI love education. As a trainee, I was lucky to be guided by a handful of excellent mentors along the path. The truth is however, in many places I worked inspiration and good education were hard to find.

I am driven by the desire to make my trainees and colleagues better than me. As a critical care physician, I can only save so many lives in one career. But as an educator I have an opportunity to influence patient care in regions of spacetime to which I will never have personal access.

A massive investment has gone into my medical education. My parents worked their butts off to allow me to study. State funded university education in England got me my medical degree. Taxpayers’ money paid my salary throughout my training. Most importantly, thousands of patients put their trust in me as I did my best to learn medicine by treating them, sometimes getting it right, often getting it less than optimal. I owe all of them. I owe it to them, and to myself, to make it all count as much as possible.

If I can ignite a spark in a trainee’s mind that inspires them to improve, or share a memorable clinical tip that gets recalled and applied at a critical point in a resuscitation months or years from now, then all that investment, all that sacrifice, is so much more worth it. 

Here’s a list of the principles I try to apply, especially when running courses. Underlying all of this is the goal to provide the kind of training I would have loved to have received myself.

Cliff’s Clinical Teaching Tips

Keep it case-based

This allows the nurse, the specialist, and intern to be in the same classroom. When we’re considering patients, everyone can learn something that is relevant to their professional perspective and experience.

Respect the learner

Allow everyone to question the teaching and express their opinion. Never humiliate anyone. The less threatened people feel, the more exploratory their questions will be, and the better they are able to make sense of the information discussed.

Have regular breaks, with food, water, and caffeine

If people have travelled to learn, they need to be protected from fatigue, dehydration, neuroglycopaenia and caffeine withdrawal. If they know you care about these things, they know you care about an effective learning environment, and will be more engaged.

How to make it memorable

Make it fun

Learning is great fun. We should have a good time together. If you’re bored, you won’t learn effectively. Funny or unusual stuff is more memorable, too.

Connect emotionally

Critical care is emotive. During resuscitation we have powerful interactions with ourselves and with our colleagues, sometimes negatively. Learners who are experienced clinicians have all felt pain or frustration in the resuscitation environment. Addressing these issues, by focusing on what could be done better, from a self, team, environment, or systems point of view frames the clinical teaching in more realistic and more applicable context. Sharing my own feelings about cases I’ve managed shows the learners how similar we all are inside, and I’ll be better able to convince them that they are just as capable of applying what is taught as I am. We can advise learners more effectively how to think and behave if we immerse the teaching in the reality of human experience.

Keep it simple

A quotation often misattributed to Einstein is “If you can’t explain it simply, you don’t understand it well enough”. Resuscitation and critical care concepts, certainly as applied to the initial resus room evaluation and therapies, can all be explained in uncomplicated ways. It behooves any resuscitation educator to adhere to this.

Have a framework that you continually refer back to

Knowing where to ‘store’ new information and how it relates to existing knowledge or other concepts being taught is important for understanding and retention. A classic example of such a framework is the ABCDE trauma assessment, but many more can be created. It also facilitates communication of ideas though mindmaps or note taking via sketchnotes.

Tell stories

This relates to connecting emotionally, as recommended above, but there is more to it. Humans have communicated information and ideas through storytelling since the dawn of civilisation. We are hardwired so that our attention is captured by stories.

Use mnemonics

Mnemonic tools like acronyms are helpful for information that needs to be rapidly accessed, like the one I made for possible causes of a raised lactate when you’re looking at a blood gas from a patient in the resus room with a lactate of 12 mmol/l.

I’ve been in the privileged position of being able to apply these principles in courses I’ve run in various countries for over a decade. In 2016 I get to do it again in the Netherlands, Sweden, and England. I’m one very lucky educator!

 

 

Related posts and content:

How I train our Prehospital & Retrieval Medicine Team

Resus.ME courses in the UK

Education Theory for the #MedEd Clinician

Advice To A Young Resuscitationist

Advice-to-Young-Resuscitationist

This talk was the opening plenary given at smacc Chicago. The title they gave me was ‘Advice To A Young Resuscitationist. It’s Up To Us To Save The World‘ but I ditched the last half because, as I point out later in the talk, I don’t think it is up to us to save the whole World. Some AV muppetry at the conference centre prevented the smacc team from being able to include the slides, so I’ll post those too at some point. You can hear the talk as a podcast at the ICN or on iTunes

The references for the talk are here

 

Learning To Speak Resuscitese

team-sm

In the resus room, clarity of communication between team members is critical to patient safety and effective resuscitation. We are used to following standardised clinical algorithms for cardiac arrests and many other emergency presentations, but there is no standardisation of vocabulary or communication style. Communication failures are a major source of error in resuscitation, suggesting this is an area in which we need to improve.

Defining your lexicon

A contrast with the aviation industry was drawn by neonatologist Dr Nicole Yamada, who points out that pilots and air traffic controllers use an effective, concise, standardised set of words and phrases that are universally understood, for example ‘stand by’, ‘unable’, ‘read back’, and ‘cancel'(1).  She proposed adapting a similar resuscitation-specific lexicon modelled after aviation communication which ‘would aid in streamlining communication during time-pressured clinical situations when seconds count and errors can kill.‘(2)

table3Yamadasm

Dr Yamada tested this approach in a small study of simulated neonatal resuscitation. Standardised communication techniques were associated with a trend toward decreased error rate and faster initiation of critical interventions.(3)

Avoiding the fluff

In the absence of standardised approaches to communication, humans in the resus room often choose language which indirectly acknowledges social hierarchies. For ad hoc teams, phrases may be chosen which are least likely to offend people with whom we’re unfamiliar, or may be deferential in cases of real or presumed authority and expertise gradients. The consequence of this is the use of ‘mitigating language‘. Examples might be:

“Any chance you could pop a line in?”

“Would someone mind letting me know if they can feel a pulse?”

“Do you want to have a think about setting up for intubation?”

“How about we get some bag-mask ventilation happening at some point?”

“If you could have a look at his abdomen that would be awesome”

These commands (imperatives) phrased obliquely as questions or suggestions are know as ‘whimperatives‘ and are found throughout resus room dialogue, when the team leader does not wish to convey the assumption of a power relationship over her colleagues. These whimperatives are an example of ‘mitigating speech’, which refers to language that ‘de-emphasises’ or ‘sugarcoats’ the command.

In the words of Peter Brindley:

‘The danger of mitigating language illustrates why, during medical crises, we should replace comments such as “perhaps, we need a surgeon” or “we should think about intubating” with “get me a surgeon” and “intubate the patient now.”’(4)

Conclusion

There’s nothing wrong with being polite and respectful, and mitigating language may be helpful in the team building phase. However the more critical the situation, the more an authorative/directive leadership style that clearly delegates critical tasks  is required(5). Standardised terminology (with closed loop communication) is likely to enhance clarity of the message and accelerate the sharing of a team mental model. Avoiding whimperatives and excessive mitigating phrases may further prevent ambiguity and imprecision, reducing the time to critical interventions.

These components of the content of resus room communication – unequivocal, standardised, and direct – should go hand in hand with the delivery of the words. Effective delivery requires optimal delivery speed and ‘command presence’. These factors will be discussed in a future post.

I’d be interested to hear what standard phrases or words you think should be in the resus-room lexicon.

 

1. Yamada NK, Halamek LP. Communication during resuscitation: Time for a change? Resuscitation. 2014 Dec;85(12):e191–2.

2. Yamada NK, Halamek LP. On the Need for Precise, Concise Communication during Resuscitation: A Proposed Solution. The Journal of Pediatrics. 2015 Jan;166(1):184–7.

3. Yamada NK, Fuerch JH, Halamek LP. Impact of Standardized Communication Techniques on Errors during Simulated Neonatal Resuscitation. Am J Perinatol. 2016 Mar;33(4):385–92.

4. Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. Journal of Critical Care. 2011 Apr;26(2):155–9.

5. Bristowe KK, Siassakos DD, Hambly HH, Angouri JJ, Yelland AA, Draycott TJT, et al. Teamwork for clinical emergencies: interprofessional focus group analysis and triangulation with simulation. Qual Health Res. 2012 Sep 30;22(10):1383–94.

Reflections on an ass-kicking

cliff-mullered-sm

 

Last weekend I got my butt handed to me and I’m feeling really good about it. I entered my first Brazilian Jiu Jitsu competition, and was beaten unequivocally, having had to submit to avoid having my arm broken after about three minutes into the fight. So what’s to be so cheerful about? Essentially, the whole endeavour was an experiment, and the experiment was a success. I learned a heap about learning, and about myself. Lessons that can be applied to learning resuscitation medicine, or learning anything.

The 10000 hours fallacy: not all hours are created equal

I’ve been doing Brazilian Jiu Jitsu (BJJ) for about a year, and am not very good at it. I started it because my (then) five year old son started it, and I thought it would be nice if we could share an interest in something healthful and useful for self protection. For most of that year I made 1-2 sessions a week, usually rushing to class after an emergency department or retrieval medicine shift and not really having my ‘head in the game’. Turning up. Just like it’s possible to turn up to work, get through your shift, and go home and forget about it.

I noticed something interesting about the people who started around the same time as me. Those who were entering competitions – as inexperienced and ill-prepared as they were in the beginning – progressed much faster than me. They would break down techniques and work on specific movements or positions they knew they needed to improve because of their competition experience, and they’d ask targeted questions of the coaches, aimed at maximising feedback for them to work on. It dawned on me that I was witnessing something I’d described in a lecture on Cutting Edge Resuscitation performance at the Royal College of Emergency Medicine Conference last year:

What seems to be apparent is that although many hours of practice are important, pure exposure or experience alone does not predict those who will master their subject. We may have all encountered colleagues who have many years under their belt who lack that spark you’d expect of a cutting edge expert. So merely turning up to work every day doesn’t make you better, it just makes you older. You reach a certain level where you can manage the majority of cases comfortably, after which more exposure to the same experience fails to improve performance expertise.

What differentiates the cutting edge performers from the majority in all these domains (studied areas such as chess or sports or music) appears to be the amount of deliberate practice, or effortful practice, in which individuals engage in tasks with the explicit goal of improving a particular aspect of performance, and continue to practice and modify their performance based on feedback, which can come from a coach or mentor or the results of the performance itself.

“Competence does not equal excellence” – Weingart

 

With this realisation, I decided to enter a competition I was extremely unlikely to win. I knew that committing (publicly) to a deadline would force me to improve my game, and I turned up more, studied the notes I’d made, and started asking more questions. In the space of a few weeks I felt that my BJJ was progressing faster than before.

The powerful combined forces of deadlines and public commitment

There’s nothing like a deadline or a high stakes test or exam to focus the mind. I’ve done several postgraduate fellowships and diplomas by examination, some of which were optional, and I’m sure each one raised my knowledge and clinical ‘game’ more than any other educational intervention I can think of.

The reality of the competition day approaching forced me to tackle my training, fitness, diet and timetable in a way I otherwise would not have found the motivation for. I had a strange moment when I took off my teeshirt in the changing rooms prior to the match and caught sight of my reflection in the mirror. I barely recognised how different my physique was compared with months earlier. Previously, I’d exercised for its own sake and not made much progress losing the middle aged paunch. But the public commitment to a BJJ fight, in a certain weight category, instilled the drive to exercise and monitor my diet. Commitment to this deadline physically restructured me!

Stress exposure training WORKS!

I’ll be 49 this year. The only people available in my weight category to fight me were aged 36-40. Age can make a big difference. Injuries are not uncommon and a significant one could put me out of training or out of work. My wife and son and friends were going to watch me, and I didn’t want to let them down or put on a pathetic performance. All my buddies who had competed before warned me of the overwhelming nervousness that can disorientate you and cloud your concentration. There were plenty of potential negative outcomes to focus on, but I ignored them all. I knew the simple formula. Breathe. Talk. See.

This basic mantra, assisted by the mnemonic ‘Beat The Stress’ (BTS) developed by Michael Lauria, is something we teach and apply in the training department of Sydney HEMS. Breathe means control and pay attention to your breathing, allowing you to reduce sympathetic hyperactivation and be ‘in the moment’. Talk means positive self-talk: a silent internal monologue that reminds yourself of all the preparation you’ve done and the potential positive outcomes of the task about to be performed. See means visualise: run through in your mind a successful performance, imagining yourself overcoming any anticipated obstacles – a practice which prepares your mind and body for effective task execution.

Less than a week ago I was running workshops on human factors for Sydney University Masters of Medicine (Critical Care) students, and covered how we submit our new HEMS clinicians to stress exposure training in order for them to practice Lauria’s BTS approach. Throughout these workshops I couldn’t wait for the opportunity to test what I teach.

On the day, my only interpretation of my adrenal surge was excitement. Even in the ‘holding pen’ after weigh-in where you wait with other competitors to have your bout, there was no anxiety, no fear. I couldn’t wait to get on the mat. The whole thing was an exhilarating buzz, and even when the can of whoopass was being unloaded on me I felt cognitively ‘available’: aware of my surroundings (and predicament!) and able to control my breathing while I self-talked my way through my limited and ever dwindling options.

Conclusion

It might be slightly unusual to be singing from the rooftops about a defeat, but the educational principles I’m re-learning are worth re-sharing. I took myself out of a comfort zone, and made a public commitment to be tested. This focused my learning and made me practice in a different way and more proactively seek feedback. I no longer was ‘turning up’, I was training towards a goal. This renewed sense of ownership of my training transformed my level of engagement in the learning process, instilling an enthusiasm and craving to understand and test principles rather than rote learn techniques.  I had an opportunity to test ‘Beat The Stress’ in a non-clinical setting and this mindware tool proved itself yet again. And despite the uninspiring outcome on the day, I was back sparring the following evening, with an even greater hunger for specific answers from the coaches, and with senior students remarking ‘you’ve got better’.

Further reading and listening:

Sydney HEMS training (Reid)

Achieving mastery (Weingart)

Cutting edge performance in resuscitation (Reid)

Stress exposure training (Lauria)

Martial arts and the mind of the resuscitationist – do it like you f***ing mean it’.

Gracie Barra Crows Nest

The Best Gift This Season

richRwandaDuring the holiday season, most of the people I know acquire more ‘stuff’ and enjoy an abundance of food and drink. That’s because most of the people I know do not belong to the 1.3 billion people in the world who earn less than $1.25 a day.

This season is about giving, and yet most of us spend it giving to people who don’t need anything.

Richard Johnson and his family have a better grip on global reality. Rich is an emergency physician and retrievalist based in Australia’s Red Centre. He had a life-changing experience working in Rwanda where he was shown the difference that can be made to communities stricken by poverty when you combine a relatively small amount of money with a lot of effort and love.

You can read his full story here, which is truly inspiring. In 2004, having treated a premature infant, Rebecca, who was expected to die, and subsequently seeing her nursed to full health, Rich dedicated some of his time, energy, and money to seeing that Rebecca and other orphaned children could have a chance at a safe home, medical care, and education.

He recently returned and sent this email to his friends:


I have returned from my trip to Rwanda and have a mind spinning with thoughts and possibilities. I spent three weeks visiting families and communities and seeing very difficult things and making very difficult decisions as to who we can support and who we won’t be able to.

The level of poverty that I witnessed with overt physical signs of malnutrition, poor housing, cholera outbreaks was at times overwhelming. Even though I have lived there and seen it before it seems all the more real and vivid when it is affecting people that you know and care about.

I have left money for emergency food aid, solar lights, paid for a boat to be built and fishing net, arranged for some roof repairs to weather proof houses (it is the rainy season) and arranged for primary and secondary education for some of the children. I have also employed a local man, Prince to manage the projects on the ground and whose family will be providing residential care for Rebecca during school term times to ensure her education. He is an ex-orphan and a truly remarkable man. I will personally pay his salary, the overheads costs of the project and Rebecca’s living costs. All funds raised will go to education and community support projects.

Other projects pending are further housing improvements to allow more efficient fuel use for cooking and sanitary latrines. Water security initially using filters and eventually pumps and wells. Agricultural land investment and the setting up of food and cash crop co-operative. Fishing materials. Secondary school scholarships and board to allow long term life choices via education and qualifications. Micro-finance and investment initiatives to support local enterprises.

I will be compiling a full report for those of you who wish to read it and it will be published through our website here

I estimate that we need around $15000 to set up and between $5000-$10000 per year for ten years to achieve what we are setting out. More will allow us to expand our assistance further through the community.

We have set up a crowd funding website to receive donations so please give what you feel you can and tell everybody you know about it. For those of you in Australia who would like to contribute for whom it would be cheaper to do a direct bank transfer please contact me for my account details or postal address to send a cheque; both of these latter forms of payment can be entered manually onto the website for transparency and clarity and you will receive an email confirmation and thankyou.

 

As I sat in my safe comfortable house with my full belly surrounded by my well nourished, hydrated, educated and immunised family I couldn’t help be inspired by a man giving a shit and sharing his energy and resources to help those who really need it. It was a tiny effort on my part to make an online donation. I’m not going to miss a few hundred dollars but a kid gets to go to school for a year for that. The next time I see a 92 year old dementia patient from a nursing home who’s been sent in with a blocked gastrostomy tube I might stop deluding myself about the ‘massive difference’ I’m making at work and consider that truly massive differences really can be made when we contribute to projects such as Richard’s.

So if you’re wondering whether you’ve given enough this season, feel free to consider a mosquito net, or a roof, or some schooling.

A Life Less Ordinary Facebook Page

We’re all African

Effective altruism – ensuring your charity donations are not wasted

Louisa in London – Prehospital Lessons from LTC2015

The London Trauma Conference remains up there on my list of ‘must go’ conferences to attend. It marks the end of the year, fills me with hope and inspires me for the future. Unfortunately this year I was torn between the conference and the demands of clinical directorship so I could only get to the “Air Ambulance & Prehospital Care Day”. At least this way I’m saved from the dilemma of which sessions to attend!
So what were the highlights of the Prehospital Day? For me, they were Prehospital ECMO,’Picking Up the Pieces’, and the REBOA update.

Prehospital ECMO
Professor Pierre Carli gave us an update on prehospital ECMO. Professor Carli (not to be confused with the equally awesome Professor Carley) is the medical director of Service d’Aide Médicale Urgente (SAMU) in Paris. They’ve been doing prehospital ECMO in Paris since 2011 and the data analysed over three years reveals a 10% survival to hospital discharge rate. We know from the work in Asia that successful outcome following traditional cardiac arrest management and ECPR is related to the speed of the intervention. Transposing the time to intervention from his 2011 – 2013 data onto the survival curve that Chen et al produced explains why the success rate is limited:

LTC2015

The revised 2015 process aims to reduce the duration of CPR, reduce time to ECMO and therefore improve survival to discharge rates. They are doing this by dispatching the ECMO team earlier.

The eligibility criteria for ECPR is also changing; patients >18 and <75years, refractory cardiac arrest (defined as failure of ROSC after 20min of CPR), no flow for < 5 minutes with shockable rhythm or signs of life or hypothermia or intoxication, EtCO2 > 10mmHg at time of inclusion and no major comorbidity.

Already there appears to be an improvement with 16 patients treated using the revised protocol with 5 survivors (31%) – although we must be wary of the small numbers.
A concern that was expressed by the French Department of Health was the fear of a reduction in organ donation with the introduction of ECPR – it turns out that rates have remained stable. In fact the condition of non heart beating donated organs is better when ECMO has been instigated; the long term effects on organ donation are being assessed.

I’m without doubt that prehospital ECMO/ED ECMO is the future although currently in the UK our hospital systems aren’t ready for this. If you want to learn more then look at the ED ECMO site or book on one of the many emerging courses on ED ECMO including the one that is run by Dr Simon Finney at the London Trauma Conference, or if you want to go further afield you could try San Diego (although places are fully booked on the next course).

Picking Up the Pieces
The Keynote speaker was Professor Sir Simon Wessely. He is a psychiatrist with a specialist interest in military psychology and his brief was to describe to us the public response to traumatic incidents. He has worked with the military and in civilian situations. After the 7/7 London bombings the population of London was surveyed: those most likely to be affected were of lower social class, of Muslim faith, those that had a relative that was injured, those unsure of the safety of others, those with no previous experience of terrorism and those experiencing difficulty in contacting others by mobile phone. Obviously there are many factors that we cannot influence however on the basis of the last risk factor our response to incidents has changed – the active discouragement to make phone calls has been changed to a recommendation of making short calls to friends and relatives.
The previous practice of offering immediate psychological debriefing to those involved in incidents was discounted by Prof Wessely – his research demonstrated that this intervention was not only not required but could actually result in harm: only a minority have ongoing psychological distress that can benefit from formal psychological input, which should occur later.
The approach that should be taken is to allow that individual to utilise their own social networks (family, friends, and colleagues) and to accept that in some cases the individual may not want or need to talk. This has led to the development of the Trauma Risk Management (TRIM) system which provides individuals within organisations that are exposed to traumatic events the skills required to identify those at risk of developing psychological problems and to recognise the signs and symptoms of those in difficulty. To a certain extent we naturally do this for our peers – I have spent many a night sitting in the ‘Good Samaritan’ pub with colleagues from the Royal London Hospital and London’s Air Ambulance – but having a more formal system is probably of benefit to enable those who have ongoing difficulties to access additional support.

REBOA update
Finally, the REBOA update – Resuscitative Endovascular Balloon Occlusion of the Aorta. One year on, Dr Sammy Sadek informed us that there are now more courses teaching the REBOA technique than there are (prehospital) patients that have received it. Over the last year only seven patients have qualified for this intervention in London, far fewer than they had anticipated. Another three patients died before REBOA could be instigated. All patients had a positive cardiovascular response. Four of the seven died from causes other than exsanguination. Is it worth all the effort and resource to deliver this intervention when such a select group will benefit?

Obviously there was much more covered in the day, this is just a taste. If you’ve never been to the London Trauma Conference then I definitely would recommend it and even if you have been before there are so many breakout sessions now there is always something for everyone.

More on the London Trauma Conference:

Merry Christmas and see you next year!

Louisa Chan

Why Do Emergency Medicine?

I was in Edinburgh two weeks ago, examining for the Diploma in Retrieval and Transfer Medicine. From there I flew to Slovenia, where I ran a critical care course and then was invited to give a talk entitled ‘Why I Do Emergency Medicine’.

Little did I realise that I’d left behind in Edinburgh a department full of people who had also considered this question and provided an inspiring answer:

 

Wishing our colleagues and patients a safe and fulfilling Christmas & New Year