Last time Jodie Martin, Flight Nurse extraordinaire dropped by she shared one of our most popular posts ever. Jodie returns with a little on the Top End experience of sepsis.
Time for a look at some remote medicine again.
CareFlight provides the aeromedical service for the top half of the Northern Territory (NT) in Australia. The area covered by the service is the same size as France but has only 160,000 people. And less vineyards.
As 115,000 of this population are in Darwin which is serviced by road ambulance services this leaves CareFlight to provide services to about 45,000 people in very remote and widely scattered centres, most of which are small Indigenous communities. The catchment area has only two rural hospitals which are non-referral centres with care otherwise provided in remote health clinics. Even then not everyone lives close to a rural hospital or remote health clinic. Some rural folk still have to drive several hours or even a few days to any level of health care. Access to health care is a real challenge when someone becomes sick.
The Top End of the Northern Territory may be sparsely populated with 0.2 persons per square km, but it has the highest incidence of sepsis in Australia and five times higher rates than those recorded in the US and Europe 1,2. It has been suggested that one of the reasons for the high incidence of sepsis is related to the higher Indigenous population in the Top End 2. The incidence of sepsis requiring ICU admission in the Top End of the NT for Indigenous people is reported to be 4.7 per 1,000. In the non-Indigenous population there are 1.3 admissions per 1000 people. When compared to the rest of Australia, the rate of admission to an ICU for sepsis is 0.77 per 1,000 2 with national 28 day mortality rates of 32.4% 1.
The Top End – Not Just Popular with People
Human-invading bacteria and viruses love the warmth and moisture of the tropics. To make things even harder, the Top End has the highest rate in the world of melioidosis, a very nasty pathogen found in the wet tropics of Australia. Melioidosis has been classified as a Type B bioterrorism agent by the Centre for Disease Control in the US and kills up to 40% of infected patients often from rapidly fulminant disease. However most sepsis is of the more common garden variety, but still causes severe, life threatening illness.
When you add the challenges of distance and retrieval times, meeting targets for sepsis treatment which are time-based would seem an impossible task. Given this, we were keen to review the retrieval of septic shock patients in our service to see what the outcomes are like and whether we could improve the process. The results have just been published in the Air Medical Journal which you can find here.
The patients were sick. A third of patients required intubation and 89% required inotropes. Median mission time however was 6 hours and the longest case took 12 hours. Given the remoteness and time delays inherent in retrieval over such distances with a population known to have worse health outcomes, you would expect mortality to be high. Surprisingly however the 30 day mortality in this group of 69 patients, which are predominately Indigenous, was only 13%. This is lower than previous rates described for both sepsis in Australian Indigenous populations and for patients in Australian and New Zealand intensive care units.
That’s Excellent, But Why?
It is interesting to speculate on the possible reasons for such good outcomes. Reasons might include:
The relatively young age of the patients compared with many series. Perhaps the better physiological reserves of younger patients are still a key factor despite the higher rates of co-morbidities.
Early antibiotics – these are almost always given by the end of the referral call. Good clinical coordination has a role to play in this too.
Early aggressive fluid resuscitation – the median volume of crystalloid administered was 3L during the retrieval process.
Inotropes administered following fluid resuscitation occurred in the vast majority of patients.
Early referral – recognising when a patient is sick. This is something we’d like to gather more data on. We didn’t record how long a patient was in a remote health centre before a referral call was made, but we have a suspicion early referral might have played a part here.
It is also interesting to note the good outcomes that were achieved without invasive monitoring in approximately half the patients retrieved. Perhaps there are shades of the findings of the ARISE study here where fancy haemodynamic monitoring really did not seem to make much difference either – what matters in the retrieval context is early antibiotics, aggressive fluid resuscitation and early intubation when indicated.
We did not randomise patients to invasive versus non-invasive monitoring and it is possible that the sicker patients and those with longer transport times received the invasive version. But it is also possible that we get too hung up on this stuff and it is the basics that really matter whether you are in the city or a really remote health clinic.
The Australian Indigenous population have poorer health outcomes than the general community. Outcomes are even worse for those residing in remote areas than those in urban areas. In our small study it is pleasing to see such good outcomes despite remoteness and long retrieval times. Our young patient cohort recovered well considering how sick they were but what would be even better is preventing sepsis in the first instance. The incidence and burden of sepsis in young Indigenous people requires preventative strategies and appropriate and timely health care resources. Improving access to health care, improved housing and decreasing overcrowding, decreasing co-morbidities and decreasing rates of alcohol and tobacco use are hopefully just some of ways we can possibly decrease the incidence of sepsis and contribute to closing the gap.
That croc with almost enough teeth came from flickr’s Creative Commons area and is unchanged from Jurgen Otto’s original post.
Here’s the link to the paper that’s just been published:
At the recent Student Paramedics Australasia International Conference 2016 held in Sydney, Dr Andrew Weatherall was given the topic of “things paramedics can do to produce better long-term outcomes after traumatic brain injury”. This is a version of that talk modified for the blog.
This topic, that someone else came up with, gets it.
So much of the time in prehospital medicine we focus on things we measure in the first hour or so. The stuff we do before we hit the doors of the hospital. That fairly bogus ‘golden hour’.
Those things matter. But the big picture of trauma care isn’t the first hour. It’s the rest of the patient’s life.
Everything we do in the prehospital setting is really about whether they get back to what they were dreaming of doing. It’s not up to us what those dreams are. Your patient might dream of playing big time sport. They might dream of creating the world’s great collection of corn chips that look like ex-Prime Ministers. They might want to fly on the first trip to Mars (and almost certainly die of cancer because everyone seems to be forgetting about deep space radiation). When we care for them we sort of have to want their dream to happen for them.
So on the days when I get to hang out with paramedics instead of getting paid by the government to wear pyjamas and give drugs to kids, this is the aim. And traumatic brain injury is worth looking after well.
We could dive into traumatic brain injury by starting with a bunch of graphs from a physiology text. Let’s dive into something to make it relevant.
This is the scene we’ll be going to. You’ll end up looking mostly at the patient who was driving the SUV. It looks like they had an initial collision, rolled over and then nudged up against the hatch that was veering off the road. Emergency services have been called by a passing pharmacy student who has done a First Aid course. They tried shaking and shouting and got no response. They thought about feeling for a pulse and they’ve found one.
This patient is clearly one who might have a traumatic brain injury (TBI). They could end up as one of the patients with moderate or severe TBI who lead to a cost to the system of around $8.6 billion each year. That comes from a report prepared for the Victorian Neurotrauma Initiative released in 2009. It estimated that for 2008 Australia would have around 1400 in the moderate TBI group and 1000 in the severely injured group.
And each one of those people doesn’t get back to their planned life. Some of them end up needing help with simple things for their whole life.
So this is the job and the clock started 5 minutes ago. What should we focus on? Is it all about RSI? Is it about early TXA? Is about the sort of stuff you need an advanced medical team for?
Well that could be the basis of discussion but we should start with a reality check.
If you look at the NSW Institute of Trauma and Injury Management report of the 2014 trauma database stats, there were 3458 severely injured trauma patients. 66% of the patients had an injury to the head. 3 of the top 5 severe injuries were subdivisions of subdural haematomas.
Of those arriving straight to a trauma centre, 80.4% arrived in an ambulance (vs 12.6% in a helicopter).
Even allowing for some of those ambulances having an accompanying advanced prehospital team, I think this grouping of numbers says something pretty significant: the vast majority of “big” trauma patients will get their care from paramedics.
This also means that if we want to save the most brain cells we should focus on making sure the patients getting those transports have the possible care that those paramedics’ training can make happen. That’s more important across the population than the advanced team’s contribution.
There is a separate chat to have some day about trying to get advanced teams to the jobs where they might really help or the best way to do pointy end stuff. That’s just not the focus for this particular bit.
It does brings us to the first key thing that trained paramedics can do to improve long-term neurological outcomes – be there.
The nature of their training and their ability to focus on getting the vital things done and get moving means that paramedics will invariably lift the standard of care of the patient when they turn up and do their job.
Now exactly what they should do we’ll get onto in a bit but there will only ever be a small number of meaningful interventions to do for the patient so it makes sense to get it done as efficiently as possible and get moving. And of course while neurosurgery is mostly not an urgent requirement, about 1 in 5 patients will need some form of early head-cutter work. That 20% of patients really want professionals who are trained to make things move.
So it might seem like there’s not much meat on just saying “be there”, but I think it’s worth noting as we go that the standard way professional paramedics go about their business represents a step up compared to what was managed in the past.
Now that you’re there …
Back to the patient. When you get there, the patient looks to be in their mid-30s, is making breathing efforts and there is some air moving but it is fairly noisy respiration. Initial peripheral saturations read at 85% and the measured blood pressure of 95 mmHg is somewhere near what you would have guessed by palpating the radial pulse. The patient’s GCS is 7, the pupils are equal and reactive. A quick glance suggests the right femur looks like it’s adopting a more meandering course than usual on the way down to the knee.
So what should our aim be for these patients? What targets do we have that are the best evidence-based ones available?
Somewhat disappointingly we don’t have that much evidence for discrete targets. What evidence there is hasn’t really shifted much over the last couple of decades. Most of the stuff we do leans heavily on a general understanding of physiology as much as firm numbers.
But let’s focus on the numbers we do have. They’re based mostly on retrospective looks at info from big data banks. And the number to remember is 90. That’s the breakpoint because:
90% saturations is around 60 mmHg pO2 and we know that patients who have a reading below that value have worse long-term neurological outcomes.
90 mmHg is the magic BP number for adults – a measurement below this is associated with worse outcomes.
And these markers kind of make sense. We often think about the primary injury already having happened when we get to the patient and focus on avoiding secondary injuries which we view as discrete and separate extra insults. Add new injuries and you make the outcome worse.
It’s probably more accurate to say that the primary injury evolves over a number of hours. In that traumatised brain there will be excitatory neurotransmitters looking to party way too much for the cells to recover. There will be inappropriate triggering of cell death. Calcium will be getting places it shouldn’t and generally grabbing onto cell elements it should leave alone. Each secondary injury ramps up processes like these as they continue to evolve. It’s one of those times all evidence-based practitioners need to try and stop evolution from being a thing.
There are a few other things worth keeping in mind:
The brain is pretty simple in its demands. It wants oxygen and nutrients delivered.
Things that make blood flow decrease aren’t good (remember that the injury itself is quite likely to drop blood flow well below normal).
Intracranial pressure that is high isn’t great. It compromises blood flow.
Oh, and it’s also worth mentioning that there aren’t many things inside the head that we influence the volume of prehospitally:
There’s the brain tissue (and the associated fluid that goes with it).
There’s blood. Blood can be inside vessels which gives us some scope to manipulate how much flow is occurring. Occasionally it will be outside vessels and the vast majority of times that patient will get their definitive care at the hands of a neurosurgeon.
There’s CSF (which we have less influence over).
So if our aims are basic do we have to wait for advanced techniques to try and reach this target? Of course not.
This brings us to the second important “thing that we can do right now” – be basic.
Consistent delivery of basic measures has the potential to save huge numbers of brain cells. It’s more meaningful than waiting to try and develop the infrastructure and expertise to get more people doing advanced things like RSI.
The perfect example is impact brain apnoea. This has really only been described in any detail fairly recently by Wilson et al but there are accounts throughout medical history and the animal literature that describes a phenomenon of subjects forgetting that whole breathing malarkey in the immediate aftermath of trauma.
The suggested treatment? Open the airway and support ventilation. Those simple steps are meaningful.
They’re meaningful for all patients with TBI too. Which is why it’s worth getting back to the simple message of “A-B-C” which some sage once told us was as easy as “1-2-3”. Simpler than the transition to adulthood from child stardom if you were that individual anyway.
So let’s work through those simple little letters.
1. How’s your “A” game?
Failure to do the basic bit of airway well is one of the commonest issues we see when welcome people training at the kids’ hospital. It’s such an important foundation though. So ask yourself whether you do the basic version of “A” well. Is your jaw thrust good enough to get those bottom teeth in front of the top teeth? Do you reach for adjuncts like oropharyngeal or nasopharyngeal airways as an aid? Are you quick enough to move to a two hand technique?
Most importantly do you make sure that you create a good seal with your mask? The value of a good seal is actually highlighted by work looking at pre oxygenation techniques. A colleague from CareFlight, Dr Chris Groombridge, did a nifty study with volunteers evaluating the maximum expired oxygen level you could achieve with different techniques. Anaesthetic circuit vs bag-valve mask (either alone or with nasal cannulae or PEEP valve or both) vs non-rebreather mask (with and without nasal cannulae).
And at the end of 3 minutes you still couldn’t beat either the anaesthetic circuit or the bag-valve mask with a well-maintained seal.
Hayes-Bradley et al did some work with a slightly different focus, evaluating the impact of nasal cannulae on pre-oxygenation with a bag-valve mask set-up or non-rebreather. Nasal cannulae helped only where there was a deliberately created leak in the seal.
Now you could take the line that it’s just pragmatic to assume you’ll end up with a leak. But why should we accept doing the technique anyway other than perfectly? Let’s focus on getting the seal right.
We’ve really taken that to heart at work, making the effort to maintain that seal throughout pre-oxygenation. It’s all part of ensuring that our focus on is on the main game – maximising oxygenation throughout the RSI rather than pushing on to the laryngoscopy and intubation step without optimising things up front. The brain wants oxygen more than it wants laryngoscopy.
That some prioritisation of the basic step of managing “A” well – perfect performance of basic airway manoeuvres, suction and use of adjuncts – can apply to all of us, whether we intubate or not. It’s the first step to delivering on our first aim – get those peripheral saturations above 90.
It also feeds seamlessly onto …
“How good are your “B” moves?”
What about those patients who need support for the breathing part of the equation. That might be via that bag-valve mask set-up or you might have supraglottic airways as an option you’ve been trained to use.
The question here is not just how well do you do it but do you take steps to make sure you’re using that skill set in the best interests of the patient?
So if you think a supraglottic airway might be appropriate for a patient do you quickly assess if they’re ready for it with a firm jaw thrust and a deep suction before placing it? Do you check what the seal is like once it’s in?
And how do you measure your effort with the bag you hook up to that SGA? Because it’s easy to puff away like your hand is a talking sock puppet. We should really all be hooking up capnography wherever we can (for bag-valve mask work too). It might not provide a trace like the intubated patient but it will be more accurate than a guesstimate. And without having a sense of where you’re at with the CO2, how do you know if you’re not creating hypocapnoea when hypocapnoea is associated with reduced cerebral blood flow (and of course hypercapnoea could cause raised ICP)?
Doing the “basics” well requires a bit of attention. Who knew?
But you might well say, what about RSI? Shouldn’t we be figuring out how to train people to do that? Well while there is a probable role for RSI it is really hard to demonstrate the positive benefit. That is probably partly because prospective research in prehospital medicine is very hard. But the evolution of the research that’s out there suggests that getting that high stakes procedure done well enough to have the benefit outweigh the potential complications will take a very long and concerted effort.
Take for example just 3 studies:
The San Diego RSI paper – this suggested worse outcomes but subsequent analysis revealed performance of the procedure with significant periods of hypoxia (57% of those analysed had a desaturation with an average time of 160 seconds and a median fall in saturations of 22%).
HIRT – which took long enough in recruitment that the system changed all around it, rendering it very difficult to keep arms of the study in their planned arms. Those that received the advanced interventions team as intended did have a 14% reduction in mortality but it’s not robust enough to bank your house on.
The Victorian paramedic RSI paper – this showed benefit but there were more patients in the control group lost to follow-up and you’d think that those who did better would be the ones you’d lose. Just one different outcome in the control group would have made the findings insignificant. So it’s not robust enough but for different reasons.
So RSI makes physiological sense and most would still say it has a role. But it’s hard to make it pay off. We can all do the basics right every day from today.
What should we see when people are doing “C”?
It’s not like there’s some study out there saying “this particular prehospital intervention related to circulation and haemorrhage leads to better TBI outcomes” but we can focus on maintaining that blood pressure above 90 mmHg. So things that cause catastrophic hypotension (say, pneumothorax with haemodynamic consequences) need treatment with whatever the provider is trained for.
If there is external haemorrhage that has to be controlled so we can focus on doing that particularly excellently. If you’re putting on a tourniquet, think about providing proximal occlusion of flow first with your whole weight (e.g. a knee not just into the groin but leaning in and twisting a bit to really slow down flow before the tourniquet goes on). Really provide pressure to stop bleeding if pressure is the treatment you’ve chosen. Splint that femoral fracture to reduce loss of blood volume.
At the same time it’s worth noting that some of the evidence base for things we do is less strong than we might assume. As covered by Dr Alan Garner in the series starting here, the evidence base for pelvic splints improving haemodynamics isn’t based on huge reams of work.
Other options will probably come through for lots of practitioners soon. Haemostatic dressings or granules are likely to make a difference for some patients. With a little more evidence TXA might roll out across the land. And while there are very interesting concepts like prehospital REBOA out there to be wielded by a select few, something like the Abdominal Aortic Junctional Tourniquet might be a far more significant option on a population level. Judicious use in the exsanguinating patient with due regard to the potential downsides (particularly if it might take a while to get to somewhere else) could be an option for an awful lot more practitioners.
The Other Simple Things
That’s not the end of the simple things of course. Think about whether you can sit your patient up to drop the ICP. Is there a better way to maintain C-spine stability then a rigid collar? Is there anything constricting the neck?
Add a lot of simple steps together and you have pretty comprehensive efforts for those brain cells that just want blood to flow and nutrients to turn up.
The Group Who Doesn’t Get the Simple Things
And while we’re at it, there is one group who tend to get much less of all of the things, including the basics.
Which is not great if you’re trying to think about how to provide better long-term outcomes. Their long-term is even more long-term.
Bankole et al provide just one example of a study demonstrating this. They looked at prehospital care around a New Jersey centre and compared the care received by kids with TBI to that received by adults. The numbers are pretty stark (though some of the headline items relate to interventions like intubation).
69.2% of the kids intubated had complications at intubation. 20% of kids with a GCS under 8 had no attempt at intubation. Failed intubation rates were 29.03% (vs 2.27% in adults). Kids also had higher rates of the dislodgement, oesophageal intubation, wrong size of tube choice and a requirement for multiple attempts.
Even intravenous access was placed less (adults had a prehospital cannula 85.9% of the time whereas in kids with the same spectrum of pretty severe injuries it was 65.7%).
More recently advanced practitioners in Switzerland published around the topic of advanced airway management in kids and while they did well initially, wrong tube sizes and wrong depth of the tube turned up again.
There are lots of reasons we do less well with kids. We see them less for a start and there can be additional scene distractions. But ultimately we need to recognise this and figure out a way to make sure we step up to the mark.
Back to the Scene
The patient has been making respiratory efforts but you can see the chest see-sawing a bit with diaphragmatic effort with an added breathing buzzsaw soundtrack. You jaw thrust and the airway improves. A suction improves the airway still further. You add a bag-mask set-up and really focus on a great seal. The saturations rise above 95%. The femur looks like it’s taking a meandering the scenic route towards the knee but it’s soon splinted and a big wound in the calf gets pressure to slow the bleeding. You’re on your way…
Now that sounds pretty easy. When you’re in a lecture theatre or reading a lesser known blog it sounds even easier. But we all know that the scene isn’t actually that easy. We’re assailed by all sorts of things and there is plenty of work in simulation sessions (like here) showing that when faced with high stress situations we tend to omit things we ordinarily wouldn’t, do things we’d normally not contemplate and remember all of it less.
This touches on the next thing prehospital practitioners have to do to provide better care for the brain – be the same with your care, everywhere. (The astute reader will notice that not only did I match the formatting to the other “be” statements, I made it internally rhyme. I’m really trying to make it seem meaningful.)
Beyond starting by acknowledging the risks of a deterioration in performance depending on the day or the job or the other stuff in our lives, we have to figure out how to be consistently excellent with our care. That’s what the patient expects. Their brain cells aren’t very interested in your back story or your motivation. They’d like you to do your job.
The strategies to try and make sure you always step up are way too many to go in right here, so it’s worth looking around. But use the team, communicate well, share your plans with those around you, use checklists or practice tactical breathing or other focus techniques or whatever it is that works for your good self.
Just don’t accept that you have to be a hostage to all those other factors.
And part of not accepting the status quo is striving to always provide better than we can do right now. That requires all of us to be a leader.
If we want to be able to provide capnography for all those patients whose A and B we’re managing then we might need to advocate for that. If we want to be able to look back in detail at how well we did, then monitors that only store information every 2 minutes (which is so often the case with prehospital monitors) aren’t up to scratch and we need to lead those demands. We need to provide leadership in governance and education to keep our standards constantly improving. We might even need to advocate solutions to issues in other areas of health that would free up paramedics to be out on the roads so they can work on that being there bit.
While this topic is mostly about what we can do right now we obviously have to keep an eye out for what comes next. And I could well be wrong but my guess is that the thing that comes next that makes a big difference across the population to those who suffer a TBI won’t be one of the magic bullets being tried like progesterone, or EPO, or even TXA.
What would be really great is to actually know what the brain wants right now. Is the blood pressure of 100 mmHg actually adequate for this person’s brain or are they usually hypertensive and critical cerebral ischaemia is being added to your mix?
Does this patient actually need their CO2 a little higher than you might have thought because blood flow isn’t so great? Is their evidence of haematoma developing on one side that hasn’t shown up clinically?
That’s part of why we’re researching tech like near-infrared spectroscopy tissue oximetry. Now I’m not convinced that particular technology will provide that information reliably enough, but I do think that the most meaningful thing we could add to prehospital TBI care is more info about what this patient’s individual brain would like, rather than being stuck with population-based gross numbers.
And if we find that device the ultimate result will probably be that it tells us how to do the basics just that little bit better for this particular patient.
Because they might have big plans for corn chips that look like ex-Prime Ministers.
OK, this was a really long post, but when you put a talk into post form it can be like that.
Here are just a few things from along the way you might like to go and look at.
Oh, and I put stuff over on the blog site at www.songsorstories.com relating to kids anaesthesia. If you look at the categories “airway” and “tips and tricks” and “cannulation” you’ll find some basic tips for working on things.
All the images here are from flickr creative commons and unaltered.
Dr Alan Garner has a blog post in the context of a report just published. A catastrophe during a winching operation highlights the physiological challenges we sometimes add in the work we do.
The death of a patient during a winching incident in Victoria in 2013 was distressing for everyone concerned. I was asked by the Victorian Coroner’s Office to provide an expert opinion on the death based on some previous research I had conducted with one of our registrars, Dave Murphy, looking at the effects on respiratory function of various methods of helicopter rescue. I’m pretty sure at the time we were the only group in Australia who had published in this area so I guess we were the obvious choice.
As part of trying to avoid a similar incident the coroner’s office agreed to us publishing the case in an appropriate scientific journal so that operators worldwide would benefit from the lessons learned rather than just the industry in Australia. That report has just been published in Aerospace Medicine and Human Performance and can be found here.
The details of the case are now on the public record in both the coronial inquest and the ATSB investigation. Our case report focuses more on the physiology of hoisting than either of these forums needed.
For those not aware of the case the brief version is that a man of approximately 60 years of age and BMI of 45 with borderline cardiac failure injured his ankle whilst on a hunting trip in Victoria about a kilometre from the nearest road. Carrying him was considered risky for the rescuers (the terrain was steep) and a hoist extrication by helicopter was organised. An accompanied single sling technique was utilised.
Unfortunately as they approached the aircraft skid the patient became combative and then unconscious. He slipped from the strop despite the best efforts of the paramedic and crewman and fell to his death. I can only imagine the distress of the crew when this occurred.
The actions of the crew on the day were consistent with their company/Ambulance Victoria procedures and were within the specifications of the equipment utilised. They were just doing their best to provide their best care as they’d been trained. Neither was any of the equipment found to be faulty. The obvious question then is why did the fall happen?
What happens when you put someone in that hoist?
You need to go looking in the climbing literature to find the physiological effects of suspension with chest compression which is what happens when you are in a single strop. As you would expect, there is a constrictive effect upon respiration but there is also a considerable decrease in cardiac output resulting from the decreased venous return with raised intrathoracic pressure. The decrease in cardiac output has been demonstrated to be as much as a third in fit young climbers. The decrease in respiratory function parameters is similar (in both the Murphy paper and the one referenced in the link in the previous sentence).
Given that the chest compression associated with hoist rescue is of short duration it is generally adequately tolerated long enough to complete the rescue in fit young people. Having said that one of the best studies of the physiological effects of suspension in a chest harness was precipitated by the death of a 25 year old soldier who was left suspended in a single strop for just 6 minutes. Cardiovascular collapse can occur surprisingly rapidly. The man in the Victorian incident with his significant comorbidities was however not able to tolerate even a short period of thoracic compression and rapidly became unconscious.
The effects of single strop rescue in people who have been immersed even where they are otherwise fit and young is perhaps better known and the second sling under the knees (or hypostrop as it is often called) is in widespread use in this situation. For winches of non-immersed persons it seems that the physiological consequences of various rescue techniques are not well known in the industry however.
Subsequent actions by Ambulance Victoria, the helicopter operator, the Victorian Coroner, CASA and the Australian Transportation Safety Bureau (ATSB) all rightly concentrated on determining how a repeat of the incident could be avoided by better educating both clinical and operational crews about the physiological implications of hoisting techniques.
What are the options?
We have previously published on the use of the Coast Guard Rescue Basket due to its benign effect on physiology compared with other techniques (Murphy). It remains a surprise to us that this device is not in more widespread use. Ambulance Victoria has now introduced a sit type harness which is definitely to be preferred in hoists over land. The Rescue Basket can be used in winches out of water as well and we think is the more flexible option.
Should the single strop technique be banned entirely? We don’t believe so. Every rescue is a balance of risks and sometimes the risk to either the patient, aircraft or both means that an immediate single sling extrication may be the safest option overall. We certainly have not banned its use within CareFlight. Knowing about the physiological downsides we have discouraged its use for many years and encouraged use of the rescue basket. We have not removed it from the armamentarium however. If a crew elect to use it they have to provide a report in writing to the chief pilot about why they chose that technique. Knowing that there is that little bit of extra documentation required is enough to make teams make sure they’ve covered their options and risks carefully before they go ahead, but the option remains on the table.
Hoisting is risky for lots of reasons. We train for a range of safety considerations. And equally we have to make sure we’re aware of the physiological changes we might inflict on our all important patients.
Conflict of Interest Statement:
Neither I, nor either of my employers have any interest, financial or otherwise, in the manufacturer or distribution of the Coast Guard Rescue Basket.
Greg Brown, the person with the job of coordinating education at CareFlight on things anyone with a bit of background can do to help make the wide, brown land feel a little less remote.
It is a dark and stormy night. It had been a long day at work and you are now driving home from a nearby town where you have been holding fort at what is loosely termed a “hospital”. Your mind drifts to all that is warm, dry and welcoming – family, a comfortable lounge, re-runs of your favourite show (obviously it’s Helicopter Heroes…) – only 40km to go…
These were your last conscious thoughts before you hit a kangaroo, lost control of your Tesla (okay, maybe a Camry) and crash into a tree.
A passer-by calls emergency services. They are on their way – but it’s a dark and stormy night and you don’t live in NSW (that’s Newcastle, Sydney or Wollongong) and the response will be made up of volunteer emergency services.
Meanwhile, a page goes out back in your hometown. Members from various volunteer agencies drop their food and head to their respective depots, don their respective protective uniforms (usually coloured yellow, orange or white), jump in their respective response vehicles and head to the scene where you are now cold, wet and sore.
You are still in your car – you cannot get out because the dashboard has collapsed into your lap. The passer-by tells you that the first response vehicle has arrived. You twist your head to see who it is – Police, Fire or Ambulance? It’s none of those – you don’t live in NSW (again, that’s Newcastle, Sydney or Wollongong) and the response is made up of volunteer emergency services: State (or Territory) Emergency Service, the volunteer bush fire brigade and some others that you didn’t even know existed.
“Where’s the ambulance?” you ask – but the nearest ambulance is at least another half an hour away – maybe more! They tried calling the local doctor but it turns out that was you.
Damn those “dark and stormy nights” you sigh……
If this scenario sounds far fetched then I encourage you to head out of the big smoke and go bush for a while. Situations such as this are not only real – they are an almost daily occurrence in Australia and many other parts of the world. Conservative estimates reveal that volunteer emergency services personnel outnumber their paid (professional) compatriots by a ratio of 20:1 in Australia with similar comparisons reported abroad.
But all is far from lost. The reality is that the vast majority of emergency services volunteers in Australia are highly capable, appropriately resourced and widely respected for the unpaid yet vital roles that they perform in serving their communities in times of need.
But (yes, there is always a but) those roles rarely include the provision of medical first response unless they are trained community first responders or volunteer ambulance officers. As such, it is also a reality that in non-metropolitan Australia the victim of trauma (vehicle, industrial or other) is likely to be treated initially by a volunteer with nothing but a generic first aid kit and some non-specific training – good if you need a splint or sling, not so good if you are seriously injured. What’s more, many of these volunteers lack the confidence to engage in the provision of medical first response.
Whilst it would be nice if an expertly trained and equipped pre-hospital care team was available in every postcode every hour of the day, we all recognise that this is simply not possible. But (yes, another but) we can do something to help the volunteers that are out there in regional and remote areas. It’s called training.
In the mid 2000’s a small group of “greybeards” at CareFlight were discussing the ways of the world over a few decaf-soy-mochaccinos (probably more likely double macchiatos…) and collectively voiced that if only those volunteers in regional and rural Australia felt appropriately trained and empowered to do a few extra small things for their casualties then they could make even more of a difference to the survivability of the people that they treat. Thus, the concept of the Trauma Care Workshop (formerly termed the Volunteer Trauma Course) was born. With this concept came a list of expectations. These included:
The training was to augment the participants’ current training content and systems, not replace them;
It needed to bridge the gap between high quality first aid and the care provided by professional medical responders;
The educators providing the training needed to be expert clinicians that were clinically current – credibility was going to be important;
The training needed to occur in the locations where the responders live – not in Sydney; and
Since the participants were likely to comprise mainly volunteers, the training had to be for free (or at least at no charge to the individuals).
Nothing like a good challenge to get the neurons firing…
The Role of AeroMed in Regional Trauma Training
There is little doubt that the sound of an aeromedical flight (helicopter or fixed wing) provides reassurance to both the injured patient and their carers, especially in regional and remote areas. The very sound of an inbound flight conjures up images of advanced medical care, expert clinical decision makers and the opportunity to whisk the patient away to a shiny hospital filled with white lab coats and machines that go “ping”.
The reality is that most trauma patients do not get better at the place their injury happens; they get better in hospitals. So the presence of an aeromedical retrieval team on scene does not in and of itself guarantee survival for the patient – but it can help. So too can that group of volunteer emergency services personnel – if they are trained and empowered to do so.
Herein lies the opportunity. Aeromedical providers owe it to the volunteers that they support to build local capacity and resilience within the regional and remote areas that they service. After all, at some point we all must recognise that we all exist for the same purpose – that is to save lives, speed recovery and serve the community. It is not about the colour of your uniform, nor is it about the company that pays you – it’s about people.
The same is true for clinicians working in regional and remote areas but not associated with an aeromedical provider. Clinic staff are often the second line of defence in the battle against trauma related morbidity and mortality. Supporting the local emergency response team in many ways makes your job easier, and who doesn’t want that?
So what can we offer? To me, we can offer three things: time, knowledge and support.
Never underestimate the power of offering your time. I know you are busy – heck, we are all busy. But finding the time to head bush and conduct clinical teaching for those who are rarely exposed to it is one of the most powerful gifts that you can offer.
Emergency services personnel, particularly those of the volunteer varieties, want to know what you are thinking when you are presented with a casualty – any casualty. For you it may be a simple, run of the mill, seen it a thousand times before type of patient; but for the local volunteer emergency services personnel it will likely be new, difficult, unexpected, or perhaps all three! What are YOU thinking when you fly overhead? What goes through YOUR mind when you step onto the pre-hospital scene? How does YOUR clinical assessment process differ from that of a first aider? They can never learn from you if you don’t ever find the time to visit their locations and teach them. Your time is important – to both you and them.
Most readers of this article will have at some point in their careers been subjected to a training session delivered by an individual who knows their content but nothing more. This is all-too-often the case in first aid. The reality is that the process for teaching accredited first aid in Australia is highly regulated within the AQTF (that’s the Australian Quality Training Framework – if you’re having trouble sleeping you could look right about here). To pretend you can change or ignore this is perilous.
So aeromedical providers need to embrace the fact that the emergency services personnel that they work with already hold first aid skills and therefore seek to deliver complimentary training. In other words, fill the gaps but eliminate duplication.
What are the elements of casualty care that are easy to perform by a non-clinician yet not covered by the majority of first aid courses? Consider topics such as arterial tourniquets, the difference between crush injury and release syndrome, and the elements of aeromedical evacuation that they need to know (e.g. like not using flares when you’re flying on night vision goggles).
The need to build resilience amongst emergency services personnel in Australia is well publicised (if you don’t believe me check out this or this or this).
Building this resilience is a long and involved process, but simple things can and do make a difference in the lives of emergency services personnel. It can be as simple as: acknowledging effort; involving them in decisions; asking them their opinions; and explaining what you are doing / thinking. But you can build resilience during training by offering your time to answer questions or “fill in the blanks”.
For example, in 2015 I taught a bunch of volunteer and professional emergency response personnel at a resort in an extremely remote part of Australia (note: details kept purposely vague). Whilst there we heard of a horrendous job that the local team attended which involved the death of a tourist. In 2016 our team taught a different bunch of response personnel in a different part of Australia and had the opportunity to informally debrief an individual who was effected particularly badly by the aforementioned incident – essentially, this individual volunteered to accompany and protect the deceased tourist overnight in the bottom of a canyon until a repatriation team could fly from the nearest urban centre.
This is an extreme example, but every time I teach I am afforded the privilege of hearing these personal stories. I like to think that every time an individual vents their job related emotions to me that “black dog” is pushed ever so slightly out of the picture.
CareFlight’s Trauma Care Workshop
As previously mentioned, the Trauma Care Workshop (TCW) concept was born out of numerous conversations had by the “greybeards” of CareFlight. It took a few years to secure the funding, purchase the equipment and, of course, write the content, but between January 2011 and June 2016 a total of 174 TCW’s were delivered to a total of 2711 emergency services and first response personnel across Australia – at no cost to the individual attendees.
The TCW is an eight hour interactive workshop that is delivered either as a single day session or over two consecutive nights. Utilising the principles of adult learning (look up andragogy or Knowles’ principles of adult learning – or just go here) the content is delivered by professional pre-hospital care providers, many of whom also hold post-graduate or vocational qualifications in clinical education, training or assessment.
Any contemporary medical training that is worth the paper it is written on is interdisciplinary in nature. Therefore, the TCW works best when members from different services (e.g. state emergency services, bush fire brigades, rescue agencies, police, park rangers etc) all attend. After all, when was the last time you attended a pre-hospital scene and saw only one colour uniform?
The reality is that pre-hospital scenes are like an open bag of Skittles – every colour under the rainbow all mixed in together. But this goes for the Educators too. Where possible, the three Educators on any given TCW will come from diverse clinical backgrounds – critical care doctors, specialist flight / emergency nurses and professional paramedics.
Importantly, all content is evidence based and research centred. The content itself is delivered through a combination of pre-readings, didactic lessons, interactive skill sessions and immersive scenarios which cover the essentials of pre-hospital trauma care:
Patient assessment techniques;
Basic airway management;
Mass casualty triage;
Teamwork and communication strategies (including the need for a shared mental model); and,
The essentials of aeromedical evacuation.
But what the TCW does NOT do is change anybody’s scope of practice; the TCW is designed to augment previous training, not replace it. We are not there to take over the world or supersede anyone’s service – it’s about the patient, not the uniform.
If individuals who complete a TCW wish to see their scope of practice altered in light of their newfound knowledge and skills then the responsibility for achieving these changes rests with them (although we are always happy to provide the evidence to back up their case).
But what about you?
Whilst at CareFlight we love delivering high quality evidence based training in locations that are off the beaten track the reality is that we cannot be everywhere. But if you are living and working as a clinician in regional areas then you can help.
Head down to the depot of your local volunteer emergency services agency and introduce yourself. Whilst there, ask them how you can help. They will most likely be looking for more volunteers but the purpose of this article is not to recruit those (although that would be a welcome side effect); instead ask them what medical-based training they’ve been looking for and seek to fill the gaps.
You may find this to be a challenge, especially if pre-hospital care is not your forte. However, the benefits for the community – you, the volunteers and the constituents alike – will be huge. You will need to conduct research, refresh some long forgotten knowledge and perhaps step outside of your comfort zone – all great professional development benefits.
The volunteers will benefit from the networking and the opportunity to expand their base of knowledge via education delivered by a local healthcare professional. This will lead to increased confidence within the volunteer group and therefore positively affect their willingness to commence appropriate clinical treatment (even when their primary role is not a medical one). The community will benefit by having local emergency responders who are better trained, more empowered and have increased resilience.
In the words of Mr Dylan Campher (from Queensland Health’s Clinical Skills Development Service), “Economy of scale is produced by having a single agreed model and adapting that to the local needs”. In other words, training and working together makes sense. There are some caveats though:
Don’t expect to change the world overnight – believe me when I say that the wheels of change turn slowly in highly regulated environments.
Don’t attempt to teach something that you have no credibility in – differentiate between what you know (based on experience, training and research) versus what you think.
And perhaps most importantly, don’t ever discredit their previous training. Is it perfect? Probably not. But has it helped serve the community prior to your arrival? Absolutely!
Remember: fill the gaps, eliminate duplication.
That dark and stormy night …
All is not lost. It turns out that the volunteers in their various coloured suits have trained for this very incident – in fact, judging by their shared mental model, it appears that they have trained together!
They rapidly assess the scene and make it safe then apply a “zero survey” to you. This “zero survey” has allowed them to sort any oxygenation issues and expedite your extrication from the car using appropriate spinal precautions. They then applied all the relevant clinical interventions within their scopes of practice including binding your pelvis and protecting you from the elements; all you need now is for the volunteer ambulance crew to arrive on scene so that you can be taken back to work (no re-runs of Helicopter Heroes for you tonight).
You gaze up at the volunteer in the yellow / orange / white uniform and ask “Who are you people, and where did you learn to do all of that?” Her response? “We are just the local volunteers – and your predecessor taught us.”
The Post Script:
If you want to know more about the CareFlight Trauma Care Workshop then go here.
If you would like to know about the other clinical education delivered by CareFlight then check out this spot.
If you would like to keep up with where we are and what we are doing then consider following us on Twitter where we travel under @MyCareFlight_Ed
The image of the kangaroos was posted by Mando Gomez under Creative Commons and is unchanged from the original post. All those appearing in the other photos have given previous permission.
We can debate the value of this advanced team model vs that advanced team model. We can debate videolaryngoscopy vs direct laryngoscopy for days. People do. Its all chump change compared to the real challenge. Getting that team where they need to be. Dr Alan Garner and Dr Andrew Weatherall have a bit reviewing a paper they’ve just had published trying to add to this discussion.
You may just have noticed that there are things happening in Brazil. They are called Olympics and they are a curious mix of inspiring feats of athleticism and cynical marketing exercise inflicted upon cities that can probably barely afford them and which will be scarred for a generation afterwards. I’d hashtag that but it turns out the IOC will take you on if you mess with their precious sponsor money.
Now, you might think the obvious segue from a mention of the Olympics at the start there would be to mention drugs. The sort of drugs that enhance performance. It’s just that this feels too obvious. We’d rather make a very tangential link to kids. In particular, let’s talk about kids who are very, very injured.
One of the bits of the Olympics that is a bit fascinating is the logistics of getting highly specialised teams into the right place at the right time in the sorts of cities that don’t usually get anything to the right place at the right time.
Maybe this is unfair but I don’t immediately think “super efficient transport infrastructure” when I think of Rio de Janeiro. And when I’m on a commute in the early hours of a Sydney workday, the fact that anyone was able to get a rowing team out of the stacking rack and to a patch of water in the hillock-shaded nirvana of Penrith during our local Olympics is astounding.
That’s kind of central to the whole circus though. Everyone is getting their right team to the right start line at the right time. It would probably be more entertaining if you dropped the table tennis team at the volleyball court but that’s not how it works when you’re trying to get the best of the best doing what they are built for.
Which is the cue to make this lumbering patchwork monster lurch back to the segue.
Right Place, Right Time
Advanced EMS needs to achieve the same goals of right place and right time. (Never said it would be a pretty link, but there it is.) Whatever your model of staff might be for delivering advanced prehospital care (paramedic/physician, paramedics across the board, St Bernard with an alcohol supply) there would be no one who doubts that the key to the whole thing is to get them to the right jobs at a time when those advanced skills have a role in making a difference.
You might be able to put one of those snorkels in the airway hanging upside down while drilling an intraosseous with particularly agile toes but if you’re back at base that’s not going to help the patient out there who is injured.
For a while now we’ve been really exercised by that problem. How do we make the tasking process better? Because tasking is not about the team at base. It’s not about which location the vehicle comes from. Tasking is always about the patient waiting for the care they need. They’re just wishing you’d been waiting there already, not still somewhere else.
That paper suggested that when you had a team actually delivering HEMS involved in identifying and tasking of cases, they were far more likely to identify cases where their skills might help (meaning they were more likely to identify cases of severely injured kids from the initial emergency call information in the system) than a single non-HEMS tasker working away in the office.
The involvement of the HEMS team got removed though, so it seemed timely to revisit this area to look at the time before the changes where the two systems worked together and the subsequent time period where it was just left to that one paramedic in the office.
Kids and the NSW System
It is going to help you to know a bit of background here. For a while now in New South Wales, there has been a stated goal in the trauma system to get kids straight to a paediatric trauma centre (PTC). Interest in this first came about because of overseas evidence that maybe this was the best option for kids. This was later followed by local work. This established that kids who went to other centres before the PTC tended to wait a long time in the first place they went to. Like 5 hours in that initial hospital before there was any movement.
Another study also suggested that kids who went to an adult trauma centre first had 3 to 6 times the risk of a bad outcome. And by bad outcome I mean a dying sort of outcome. Now, there are issues with being too firm on those numbers, particularly as not many kids die from traumatic injuries over any measured time period in our system so one or two kids surviving in the adult centre would make a big difference to those stats. But these were the sort of figures that made people keen to get kids straight to the specialist kids centres.
So the system is supposed to be designed to get kids to the kids’ hospitals as a priority. Do not pass go, do pass the adult centre.
Around the same time as that was becoming a talking point, the Head Injury Retrieval Trial was getting moving. As part of that trial, there was an agreed setup for the HEMS crew (including the aviators) to have access to the emergency call info on the ambulance computer screens on about a 90 second delay from when it hit the ambulance system.
For the trial (only adults), you’d look at the highest urgency trauma cases and look for specific trigger mechanisms which would lead to a protocolised response – either an immediate decision to randomize or a callback and interrogation step.
For kids, a different request was made. The request was just to respond to severely injured kids (where it seemed like the severity matched the initial call info or the mechanism was a super bad one; something like “kid vs train” for example). No randomisation as they were not in the trial; we just went.
So the crew screened for paediatric cases too, as requested. And went to paediatric cases. There was some real learning in that too, as the HEMS crews started making it to a much higher proportion of severe paeds trauma (and drowning) than had historically been the case. This was partly due to the higher rate of recognition of cases, and partly due to the fact that the HEMS team was really fast getting to the patient, arriving before the road paramedics had already moved on. You can read more about the kind of time intervals the HEMS team achieved here. As far as we are aware from the published literature the whole end-to-end process was the fastest ever reported for a physician staffed HEMS system, while still offering the full range of interventions when indicated.
A third of the way through the HIRT thing happening, the ambulance service introduced a role within ambulance which hadn’t been there before. The Rapid Launch Trauma Coordinator. Their role? To look at the screens as jobs came in and try to identify cases where advanced EMS might help.
As it turned out they elected to include the trial area as well as other areas in the state in the roving brief for this paramedic sitting in at the control centre. While that was an issue for the trial, for kids it was just a bonus, right? Another set of eyes trying to find kids who might need help sounded perfect.
The bonus in kids was that there was no need to try and have the person doing the RLTC work blinded to whether the case had been randomised or not, so if the HIRT crew in their screening saw a case with a kid, they’d call quickly and see if the RLTC knew of a reason they shouldn’t go. It was a nice collegial cross-check.
This also ensured that only one advanced team went unless they thought there were multiple casualties (in the trial double tasking was common due to the blinding of the RLTC to the randomization allocation). So the cross-check avoided double ups and maximized use of resources too.
It was in this context of the systems for screening cases operating alongside each other that the first bit of research was done . Over a two year period cases with severely injured kids occurring while the HEMS was available were reviewed to see if either screening process picked them up.
There were 44 kids fitting that bill (again, the numbers are low in the Sydney metro area). 21 weren’t picked up by anyone. 20 were picked up by that HIRT crew and 3 were picked up by that person working on their lonesome in central control.
When you looked more broadly at times the HIRT system wasn’t available compared to those it was, the proportion of patients directly transferred to the PTC was much lower. This fits with other stuff showing that advanced EMS teams tend to be more comfortable bypassing other sites to make it to a PTC, while also performing more interventions.
Another thing this research threw up was to do with time of a different kind: when HIRT was available the median time to reach the PTC was 92 minutes, compared to 296 (nearly 5 hours again) when they weren’t available.
So on that first round of research the message seemed to be that there was something about that case screening process that picked the severely injured kids more often. Maybe it was the extra eyes and regular rotation. Maybe it was better familiarity with the nature of the operational work for advanced EMS on the ground. Either way that screening process seemed to support the goals of the trauma system pretty well.
Things You Take Away
Come March 2011, the screens were taken away from the HIRT set-up as the trial wrapped up. No more screening by the actual HEMS crew. Back to centralised control screening back in the office.
As the HIRT screening process seemed to have such a dramatic effect on the trauma system in Sydney we wanted to keep it going as did the trauma people in the Children’s Hospital at Westmead. They had particularly noted the change as by virtue of geography they are the closest kids centre to most of the Sydney basin. The increase in kids arriving straight to the ED even led them to revise their internal trauma systems. But away the screens went.
So the question for this subsequent bit of research was really pretty simple: did we lose anything going back to the centralised process alone? More crucially, do the patients lose anything?
This time the comparison wasn’t the two screening processes working alongside each other. It was before and after. What didn’t change was the sort of paeds patients being looked for. It was any kid with severe trauma. This might include head injury, trunk trauma, limb injuries, penetrating injuries, near drownings, burns and multi-casualty incidents with kids involved.
So in the ‘before’ epoch there were 71 cases of severely injured kids (covering 34 months) that fitted the bill. For the ‘after’ epoch there were 126 cases (over 54 months).
In the ‘before’ epoch with the systems working alongside each other, 62% of severely injured kids were picked up and had an advanced EMS team sent.
In the ‘after’ phase? It fell. To 31%.
And while the identification rate halved it also took kids longer to reach the PTC going from 69 to 97 mins. 28 minutes might seem small but then most of us have probably seen how much can change in a severely injured patient in less time than an episode of Playschool runs for.
Things that didn’t change? Well the overtriage rate for the CareFlight crew was pretty much the same. And whether advanced EMS teams or paramedic only teams reached the kids, their respective rates of transfer direct to PTC were pretty much the same as in the ‘before’ time. It seems that once crews get tasked they treat the patients much the same as their training sets them up to do.
It certainly seems that the right team in our system is a physician/paramedic crew (in NSW the doctor/paramedic mix is the advanced EMS set-up used across the board) as the kids get much more intensively treated at the scene and then get transported directly to a kids centre. In other words faster access to advanced interventions and much faster access to the specialist kids trauma people. Right team to the right patient at the right time.
So we’re left with a few things to consider. There is an acceptance locally that severely injured kids are more likely to get time critical interventions if an advanced EMS team is sent (and advanced EMS teams could come from different backgrounds in different places, it just happens to be physician/paramedic here). There is a belief that those who’ve had that extra training and exposure will feel more comfortable with kids, who can be challenging.
The system has set a goal of getting those advanced teams to severely injured patients, and in this case we’re talking about kids. These two papers suggest that a model where those who are directly involved in advanced EMS are part of the screening process will identify more severely injured kids and get more of them straight to the PTC and definitive care.
Should this be a surprise? As the paper mentions this isn’t the only example of a model where clinicians who do advanced EMS work being part of the screening process seems to be a success above and beyond those who specialise in screening all calls. It may be that knowing the lay of the land when it comes to service capability counts for a whole lot. There is also work suggesting that telephone interrogation of the emergency caller by a flight paramedic is accurate when compared to assessment by on-ground ambulance crews when trying to figure out whether advanced care might help.
This was the experience with the HIRT screening process too, where structured callback was part of the game. The HIRT system also had some unique features. It is the only one we have heard of where the crew sitting next to the helicopter identified the cases they responded to. This seemed to create added benefits in shortening the time to getting airborne because parallel activities come to the fore (see the paper for more). A very consistent six minutes from the beginning of the triple zero call (emergency call from the public) to airborne is pretty quick.
Does this have any implications for adults too? Back in 2007 when the RLTC was introduced the local ambulance admin made the decision that sending advanced EMS teams to severely injured patients was the standard in Sydney and the RLTCs job was to make that happen. From the time the RLTC started till the screens were removed in March 2011 the HIRT system identified 499 severely injured adults. The RLTC also spotted 82 of these, or 16%. So the HIRT spotting system appears to be even more effective for adults than in kids.
Right now there are a bunch of different advanced EMS teams in Sydney, all wanting to get to that right patient and offer top notch care. Those patients would be very happy to have teams with the full range of skills coming. And all those teams have the skills to add the sort of screening that involves protocols that operated during HIRT. They’re sitting waiting for someone else to look their way.
So let’s work it through again.
Let’s say you were trying to meet that thorny challenge of right team, right place, right time. Let’s say you had ended up trying out a screening system similar to some others around the world but with some tweaks that made it even better, particularly for local conditions.
Let’s say that system hugely improved the way that severely injured kids were cared for. Let’s say that system was also even better at spotting severely injured adults too. Let’s say that system was part of the fastest end-to-end physician HEMS system yet described in the world literature.
Let’s say when you moved away from that screening system you didn’t pick up as many of the severely injured kids as you wanted to so they missed out on early advanced care, the kids didn’t get to your preferred destination first up as often and they took longer to get there.
You might ask why such a hugely effective system was discontinued in the first place.
You might ask why it has not been reinstated given the subsequent evidence.
And they would be very good questions.
The image of Charlie in his guises was on the Creative Commons area of flickr and posted by Kevin O’Mara. It’s unchanged here.
We’re back with the second post in a series on tactical medicine in the civilian setting, written again by one of our CNCs Mel Brown. We’re going back to back with these ones (you can find part one here) though you might have to wait a little for part three.
The tactical environment is dynamic and can change in an instant. That is why it is imperative that everyone involved in such an incident knows and thoroughly understands both the tactical and medical processes along with the mental model that will be used within this environment. The first time you work together should not be once the incident has occurred. More bad things happen if agencies don’t train together prior to a high threat incident happening.
In part one of this series we looked at what tactical medicine is, some of the history of tactical medicine (both military and civilian) and the three preventable causes of death within the tactical environment. In part two we look at some of the models of infiltration for medical teams, specifically the “whos, hows and whats” of this topic. I had thought I’d get straight onto the phases as part of this post but once I got into it I realised there’s quite a bit to cover when talking about people and teams. People, huh? So deep.
So what is the current thinking? Questions worth considering include:
Who should make up tactical medical teams?
When should they enter the tactical environment?
In what style of team should they enter?
Should they be armed or unarmed?
I am sure there have been (and will continue to be) some very robust discussions and even some controversy about these questions. But, let’s look at some of the current thinking both in Australia and internationally.
Current Tactical Team Models
Generally speaking there seems to be three core models of how the tactical medical team may be setup and inserted within the civilian setting. Each one of these team models comes with their own set of advantages and disadvantages. The most important thing with any of these models is that all local agencies must know, understand and have practiced as a multiagency team within the chosen framework to be used in these incidents. Any model that isn’t known and tried will fail within such a high stress, high threat environment and more injuries and death will occur as a result (Levy MJ et al, 2016).
Option one – Primary Officer with a Secondary Role:
The first model we will look at is the law enforcement officer embedded within the response team that has a secondary role as the team medic. This is the most commonly used model within Australia. Generally speaking in this model the medic’s primary role is to complete the mission (neutralise the threat) as part of the tactical team. His or her secondary role is to treat his / her team members (if they are injured). Once the tactical environment allows then the medic may treat civilian casualties.
The difficulty with this model is that the primary role of the medic is not to treat civilian casualties. Therefore, this may lead to extended time delays until the civilian casualties receive medical treatment if the tactical / mission phase is prolonged. This prolonged time between point of injury and treatment may lead to increased deaths amongst the casualty group.
Option two – Dedicated Rescue Task Force (into the Hot Zone)
The second model that is used is that of the rescue task force which is made up of 2 – 4 law enforcement officers with 1 – 2 professional (medical) first responders (EMT or fire). In this model the professional first responder is inserted into the “hot” zone (direct threat care phase) or “warm” zone (indirect threat phase) with the protective support of designated law enforcement officers. In this case the professional first responder’s primary responsibility is the treatment of casualties (both civilian and law enforcement). The professional first responders do not carry weapons; rather the law enforcement officers provide force protection for them.
This model allows for rapid assessment and treatment of all casualties which helps minimise the total number of deaths. This decrease in deaths is due to there being minimal delay between the point of injury and medical treatment for casualties.
One point to consider with this model is that there will be an increased risk to the medical first responders as part of the rescue task force as they are entering the high threat environment whilst the direct threat still exists. This is one of the reasons why there is often four law enforcement officers instead of only two. This allows for two law enforcement officers to “drop off” to pursue and neutralise any threat, whilst the remaining two law enforcement officers continue providing force protection for the professional first responders within their team.
Option three – Rescue Task Force, Warm Zone Only
The third model is that of two or more professional first responders that have law enforcement support and only enter the “warm” zone (indirect threat phase) to treat casualties with a view to removing them further from the area of engagement. In this model the professional first responder doesn’t progress through the scene to clear other casualties. These are usually strategic insertions with plans for rapid extrication of the casualty and professional first responders to a safe zone or pre-staged evacuation area. These medics do not carry weapons as their primary role is the treatment of casualties whilst under the force protection of law enforcement.
Let’s Discuss This a Bit …
Do these models suit all high threat environments? How do these current law enforcement focused models work when there are either multiple active shooter / IED / hostage incidents or if the high threat environment is a building collapse or advancing fire line? Sometimes we become so focused on the single active shooter / IED / hostage scenario that we forget about all of the other high threat environments that need us to use the same tactical mindset for assessing and treating the casualties. Currently the focus seems to be on the “kinetic” and not on the “routine” high threat environment.
This is why it is imperative that all emergency services (police, fire and ambulance) are provided with C-TECC training. For example if you look at the Paris attacks in November 2015 it was the fire department that lead a lot of the tactical medical response for the multiple attacks. Law enforcement officers are potentially going to be targeted as they respond to such incidents. As such they need to know how to treat themselves and their teammates if harm comes their way. Furthermore if law enforcement agencies become overwhelmed with multiple scenes to secure it may become necessary for other emergency agencies to step up and take over the casualty care side of things.
It is also time for Australia to think about teaching potential “lay” first responders (bystanders) the life saving skills of catastrophic haemorrhage control (arterial tourniquets [commercial and improvised] and pressure dressings etc) and airway management. According to the fourth Hartford Consensus these lifesaving skills should be commonplace, just as community CPR programs are becoming.
We should be collaborating with our international counterparts and learning from what they have experienced. Paris and North America are already running numerous public education sessions on haemorrhage control (arterial tourniquets & haemostatic dressings) and CPR (which may not help in the traumatically injured casualty, but is beneficial to society all the same as out of hospital cardiac arrest is still one of the leading causes of death in adults). In these moments of horror whether terrorism or natural disaster related all emergency care providers are going to be absolutely overwhelmed and may not be able to immediately access the casualties. We need the public to help us treat the casualties as soon as possible after the injuries occur, as this will decrease the death rate amongst the casualty group.
The current thinking within tactical medicine is that we should be striving for the “platinum 10” and not paying too much attention to the good old “golden hour”.
“What’s the platinum 10?” I hear you electronically asking. Well, the patterns of injury and the potential for extended time before receiving definitive care means that it is a struggle to get the casualties to hospital within the “golden hour”.
In tactical medicine a better gold standard might be that casualties need to receive initial care within 10 minutes of injury (hence the term “Platinum 10” because that 10 minutes is even more valuable than gold and diamonds just make no sense). Bystanders play a major role in ensuring this “platinum” standard can be met.
Who should make up the tactical medical team?
The tactical environment is an interesting one from the medical point of view as all medical interventions must be high yield but require a limited time investment to complete. The right intervention must also be performed at the right time within the tactical flow of the mission. After all if the right medical intervention is done at the wrong time more injuries and potentially deaths will occur to either the casualty or the responder. This is the essence of tactical medicine.
If you look at the medical interventions recommended by C-TECC they are simple but very effective interventions that require minimal time to implement. There are also clear guidelines as to when these interventions should be performed (there will be more on the phases of care in part three).
If you remember back to part one of this series, the medical interventions recommended are simple (but lifesaving) ones aimed at treating the three causes of preventable death (extremity haemorrhage, airway, tension pneumothorax). These simple interventions include:
Nasopharyngeal airways (NPA)
Effective bandaging techniques (direct pressure)
Direct and indirect threat phases
If we keep in mind what medical interventions need to be applied in this situation it is easy to see what personnel are needed within the medical aspect of the tactical environment. Within the direct threat and indirect threat phase the skills needed by the professional first responder lend themselves to either the paramedic’s or even nurse’s skill set (yes….I just went there….a nurse).
The extra skills a doctor would bring cannot be implemented within such a high threat dynamic environment; the continued threat level and the dynamic nature of this environment makes it impossible to setup for and complete higher-level interventions. Therefore, I am a firm believer that doctors should not enter the initial tactical medical space (direct threat or indirect threat phases) unless they are specifically trained and possess the right (minimalist) mindset.
Evacuation care phase
As for the evacuation care phase, who should make up the medical teams within this stage of the tactical environment? I think this decision is less black and white and has many influencing factors on the day. The most important thing to remember here when deciding who should make up the medical team in the evacuation area is that this area exists to facilitate the patient being transported to the appropriate hospital.
This means that casualties should only stop here if the medical system (hospitals, transport) is so overwhelmed that transport is not an option or if the casualty needs a lifesaving intervention now. An example of this is the casualty with chest injuries requiring repeated needle decompression. They should have a chest tube placed prior to transport (if such medical skills are available).
The patient should not stop here if the medical interventions are not necessary as this leads to a “choke point” within the flow of casualties and will blowout casualty transport times to definitive care. This will lead to further casualty deaths. It is important to remember we can’t make the casualty “better” on the “road side”, we’re aiming to make sure the immediately threatening situations don’t get worse.
The forgotten resource
One team of medical assistants that has not been mentioned and is often forgotten about is that of the “bystander”. The Hartford Consensus III & IV recommend that community training is put in place the ensure that “bystanders”, or as the Hartford Consensus calls them Immediate Responders, can recognise catastrophic haemorrhage and stop (or at least slow) the flow of bleeding as well as recognising and treating airway problems. Learning such skills will empower immediate responders to help casualties, will build community resilience and will save countless lives at the point of injury.
This group of non-professional immediate responders are often a forgotten resource vital in the fight to save lives within these high threat environments. Let’s return to Paris and the Bataclan theatre to consider just one example of the delay in help for casualties by professional first responders.
It took over 160 minutes from the time of the first shot to when professional first responders were able to reach the casualties inside the venue. This is too long between the point of injury and treatment being received (but is an indication of the level of planning that went into the attack).
Because of such experiences America and Paris have already implemented community-based courses that equip civilians (immediate responders) with the skills necessary to save lives. As a result they have seen countless lives saved by these personnel; such as in the aftermath of the Boston Marathon bombings, active shooter events, French attacks, but also in the aftermath of hurricanes, industrial accidents or everyday incidents (e.g. motor vehicle accidents).
It is imperative that Australia also starts tapping into this large resource that can make a huge difference to the survivability of casualties within a high threat environment. It will take time for professional medical help to arrive and start treating casualties, especially under Australia’s current model.
Time of entry of the tactical medical team
This topic is one that is rather controversial and both sides of the discussion are very passionate about their beliefs. I guess all we can do is look at both arguments and encourage the departmental bodies making these decisions to weigh up all of the advantages and disadvantages. We should also learn from our international colleagues. They’ve been there a lot more often. So let’s look at those two sides….
The Front Side
The first side we will look at is that of the “no medical personnel will enter the direct threat phase and will preferably never enter the indirect threat phase” group. This is the current stance taken by most organisations within Australia at present, except for tactical police that have one member within their teams that has a secondary role as the team medic (to primarily treat his / her team members).
There are some advantages to this thought process, the main one being safety. This model ensures that only highly trained law enforcement officers enter the direct threat phase and minimises the entry of medical personnel into the indirect threat phase. It is rarely seen in Australia that medical teams are even inserted into the indirect threat phase. This minimises the risk of harm or death to medical personnel.
Some disadvantages of this model are that there will be extended timeframes until casualties receive medical attention, as seen at the nightclub shootings in Orlando. This extended time until treatment will lead to higher death rates amongst the casualty group.
The Flip Side
The second side in this discussion says that medical personnel should be at least inserted into the indirect threat phase (with law enforcement protection) and potentially into the direct threat phase (this is due to the possibility of a new threat arising or the old threat returning).
In general terms a clearing team (law enforcement only) will advance into the scene first with a rescue task force (law enforcement officers and medical personnel) following shortly after to clear rooms of casualties and to treat them for the life threatening conditions as soon as tactically possible. These casualties may then be moved to a pre-arranged casualty collection point if tactically feasible to do so. Through reviewing the literature and in discussions with experts this appears to be the leading model of choice in USA.
Some of the advantages of this model are that professional medical responders can be inserted early to ensure casualties receive medical care as soon as possible. This in turn leads to less preventable deaths occurring within the casualty group. The medical personnel are afforded a high level of protection from the law enforcement officers ensuring that the threat to their lives is minimised.
The main disadvantage to this model is that there will be some increased risk of injury or death to the professional medical responders simply by the fact they are entering a high threat environment. There is also an increase in responsibility on the law enforcement officers that are charged with the safety of the professional medical personnel, as they now have a group of people (most likely unarmed) that they now need to provide protection for. In Australia where we have limited law enforcement resources (when compared to the USA for example) this allocation of force protection will further decrease the law enforcement officer numbers available to pursue and neutralise the threat. Herein lies the problem – what takes precedence, the law enforcement officer’s responsibility to protect the profession medical personnel and casualties or neutralising the threat and thereby eliminating the risk of additional casualties?
No matter what model is used there needs to be more interdepartmental training so that all emergency personnel share the same mental model, whether they are ambulance, fire, police or medical. This means that everyone involved in the incident will have an understanding of each group’s capabilities, strengths and weaknesses. This in turn allows everyone to effectively support each other no matter what the situation presents. This can only benefit the casualties and the emergency service personnel.
Should the tactical medical team be armed?
This is yet another controversial topic within the tactical space. This is a very difficult question to answer and once again there are two very distinct groups within this argument. One side is furiously opposed and one is furiously in favour of professional first responders carrying weapons. All we can do once again is look at the current thinking and their associated advantages and disadvantages.
In the ideal world we would all like to think that not even the “bad guys” would hurt or kill the person who is just trying to save lives. However, we don’t live in that ideal world and even though humans are meant to be one of the cleverest of the animal kingdom we see more and more that we certainly can be the most inhumane to our own kind.
Unfortunately we see the “bad guys” killing any emergency response personnel so that they can’t stop them or fix the people they have hurt. I guess this is where the first group sits and as such they believe that all professional first responders should be armed to protect themselves and the casualties they are treating. Think about the Geneva Conventions – military medical personnel are allowed to bear arms for the purpose of self protection (and the protection of their casualties) in combat.
The main advantage of professional first responders carrying weapons seems to come simply down to their safety and the safety of their casualties. There seems to be the belief that a weapon would simply be another tool in their bag to help treat their patient’s safely. I must admit I am not yet convinced it is as simple as that, and the reader of this blog from military backgrounds would understand this well.
One of the disadvantages associated with this argument is the question where does the professional first responder’s responsibility end? Imagine they are at the local coffee shop (whilst on duty) and there is an armed robbery. What is their responsibility then? Do they simply try and call it in or do they try and overpower the offender with their weapon? It becomes very cloudy very quickly.
Carrying a weapon also requires a lot of extra skill acquisition and effort to keep current. It is not as simple as just carrying a weapon and doing a once off course. There are many responsibilities that come with carrying such a tool; it requires a huge commitment by the professional first responder. To be skilled in weapons handling requires hours of practice both in a range to develop target accuracy but also in scenario based training working in the teams and environments that you may find yourself. Safety is also a major concern; no one wants to accidentally discharge his or her weapon and harm an innocent bystander or lose control of their weapon to the “bay guys”.
Another point to consider if professional first responders carry weapons is what does their primary focus become: casualty treatment or neutralising the threat? This may become a disadvantage if the professional first responder becomes more focused on their weapon than they are on their casualties. Brigadier Boutinaud had some very good advice (I think) during his presentation in Sydney on the Paris attacks in May. This was that if professional first responders carry weapons then they will lose sight of what their primary role is…….to treat the casualties.
Please don’t get me wrong; I am a firm believer that all professional first responders need to be kept safe. However, I feel that this can more often than not be achieved by wearing the appropriate protective clothing (body armour, helmet) and by only entering the direct or indirect threat phase as part of a rescue task force (law enforcement officers and professional first responders). I guess this is where the second group sits when they firmly believe that professional first responders should not carry weapons.
Some of the advantages to this argument are that the core business of the professional first responder (treating casualties) stays their core business. It also minimises the chance of first responders entering environments that they shouldn’t as they will need to wait for law enforcement to arrive and provide them with force protection. As such the professional first responder will need to maintain situational awareness within the tactical environment, but the responsibility of true tactical awareness remains the responsibility of the law enforcement officers.
The main disadvantage in my mind is that the professional first responder may feel less empowered and safe as they have a perceived limitation in the control of their own safety. Another disadvantage may include that there could be a delay in casualties receiving treatment if law enforcement takes some time to respond to the same incident.
I think this argument is quite a difficult one to solve. The arguments often appear fairly even and as the tactical environment becomes more and more prevalent within society the argument for professional first responders to carry weapons seems to gain favour.
What does all this all mean?
If nothing else comes out of this series on the CareFlight Collective I hope that it facilitates open discussion about this topic within Australia and abroad. Australia, thus far, has been lucky in the terrorism stakes. However, we do experience many other high threat incidents (bush fires to name one). It is time that all emergency services work together for what is important…….best possible patient outcomes and that “we” the professional first responders (EMT or fire) or law enforcement officers get to go home to our families at the end of every shift.
A Bit More Reading:
Here are a bunch of relevant things to read you might find interesting.
With events such Dallas and its ongoing grief, it is a little timely to introduce a new series on tactical medicine in the civilian setting. We also welcome a new contributor to the site: Melanie Brown. As one of CareFlight’s Clinical Nurse Consultants for Medical Education and with a background as an Emergency Nurse and independent practitioner in various high risk prehospital environments Mel is passionate about ensuring the “right” patients get the “right” treatment at the “right” time.
Civilian tactical medicine is a rapidly evolving area within Australia. And while you may think “surely it’s not that much different, you just have to keep your wits about you more” here’s the thing: the injuries seen and the environment involved are very different to the “normal” civilian trauma setting. In fact, 94% of the preventable causes of death rely on appropriate haemorrhage control and appropriate recognition and management of tension pneumothorax.
But how many of us are trained to function well in this situation and deliver that care? There is a distinct knowledge gap between prehospital trauma training and civilian trauma training
In response to this gap CareFlight Education has drawn on many years of experience in conducting the pre-deployment medical training for the Australian Defence Force and the individual experiences of our educators in tactical environments to develop a course that is designed to bridge the gap between “normal” civilian trauma and the tactical trauma casualty. This real life experience in conjunction with our agreement with the Committee for Tactical Emergency Casualty Care (C-TECC) has lead to CareFlight Education developing the Tactical and Hostile Response, Emergency Access and Treatment (THREAT) course. It’s a subject we’re a bit passionate about so we thought we’d take the chance to share a few thoughts here as well.
As this topic is quite large I’m going to break this into two instalments. Part one will look at what tactical medicine is, some of its history of (both military and civilian) and the three preventable causes of death within the tactical environment. Part two will look at the three phases of care within the tactical environment (direct threat care, indirect threat care and evacuation care). So, let’s get started on part one…..
What do we mean by “tactical medicine”?
When most people are asked what they think tactical medicine is they jump to improvised explosive devices (IED), terrorist attacks, hostage situations or active shooter incidents. However, these examples are only a small representation of the civilian tactical / high threat environment.
Within the civilian setting a high threat situation that requires a tactical medicine mindset is of course all of the situations mentioned above (IED & active shooter etc.) but it may also include incidents such as advancing fire lines, building collapse or civil unrest (the sort of protests / riots that go beyond folk guitar protest songs). All of these situations require a different mindset and / or approach to what “we” are used to in the medical profession.
Australia as a whole has certainly been lucky thus far in the terrorism stakes when compared to many other countries. Many believe that the mantra now is “when and not if” there will be a terrorist attack on Australian soil. This change in thinking, the international experience and the continuing threat of incidents such as bush fires means that Australia needs to get on board with the tactical emergency medicine way of thinking.
Comparison of civilian and military trauma
When most people are asked what they think tactical medicine is they jump to improvised explosive devices (IED), terrorist attacks, hostage situations or active shooter incidents. However, these examples are only a small representation of the civilian tactical / high threat environment.
Within the civilian setting a high threat situation that requires a tactical medicine mindset is of course all of the situations mentioned above (IED & active shooter etc.) but it may also include incidents such as advancing fire lines, building collapse or civil unrest (the sort of protests / riots that go beyond folk guitar protest songs). All of these situations require a different mindset and / or approach to what “we” are used to in the medical profession.
Australia as a whole has certainly been lucky thus far in the terrorism stakes when compared to many other countries. Many believe that the mantra now is “when and not if” there will be a terrorist attack on Australian soil. This change in thinking, the international experience and the continuing threat of incidents such as bush fires mean that Australia needs to get on board with the tactical emergency medicine way of thinking.
What can we learn from others?
It is important to look upon some of the lessons learnt by our defence and overseas law enforcement colleagues when trying to understand how tactical medicine fits into the Australian civilian setting. After all we shouldn’t just go making a new wheel. Let’s learn from experts.
We learn a lot both tactically and medically from these groups as their personnel are exposed to these high stress situations (and the MOIs that come with these environments) far more frequently than the average civilian emergency medical provider.
Perhaps some numbers can help make this clear. Studies in America suggest that once an active shooter incident commences 1 casualty is shot every 15 seconds. That’s 4 casualties per minute.
The average active shooter incident lasts 1 – 12 minutes with the average response time of the first officer on scene being 3 minutes. 60% of active shooter incidents end before police arrive. 30% of officers that enter as solo operators are shot. Stop and consider how many casualties have already occurred before reinforcements even arrive.
These studies conducted in America found that these tactical incidents occur in public environments; the list of locations includes businesses, schools, universities, government buildings, open spaces, homes, hospitals and even places of worship (FBI, 2013 and Aberle et al, 2015). Unfortunately these incidents (especially active shooter) are increasing. In fact the FBI reports in their study from 2000 – 2013 on active shooter incidents a large increase. In the first 7 years of the study the USA averaged 6.4 active shooter incidents per year. However, in the last 7 years of the study they averaged 16.4 active shooter incidents per year.
The Journal of Special Operations Medicine published a study by Aberle et al in 2015 which found that USA Emergency Medical Services (EMS) average 11 responses in support of law enforcement tactical operations per day. Unfortunately Australian statistics are difficult to find in relation to civilian tactical incidents. However, in a 5 year period from 2005 until 2010 police report that they were injured 6, 423 times (APJ, 2015). This statistic does not include public injuries or assailant injuries and not all injuries were serious. However, this number easily demonstrates the need for law enforcement agencies to have a full understanding of tactical medicine guidelines, knowledge and skills.
As for our Australian Defence Force colleagues, they have found that the average combat casualty has 2.4 life threatening injuries. However fatality rates amongst wounded soldiers have dropped from 20 – 30% pre Vietnam to just 8.8% during the Middle East Area Operations.
This decrease in the fatality rate can be attributed to many factors some of these being:
Tactical Combat Casualty Care (TCCC) / Care of the Battle Casualty (CBC) training (note: this is the military version of TECC)
Advances in body armour
Availability and training in life saving equipment (arterial tourniquets, haemostatic dressings, bandaging techniques etc.)
Deployed trauma systems
Introduction of antibiotics and hypotensive resuscitation.
What does this mean to us?Just as we should learn from others’ experiences it is important to understand the factors that influence the care that we can give within the tactical environment. Those of us that have ever worked in the pre-hospital setting know how different this working environment is when compared to the hospital setting. The tactical medicine setting introduces another unique set of challenges. Some of these include:
Presence of a direct and continued threat
Darkness / light / uncontrolled surroundings
Heat / cold
Limited medical equipment – the equipment that you can carry is limited by the need to be highly mobile (i.e. huge packs)
Length of evacuation times
Mission intent / tactical flow
Preparedness of medical providers
C-TECC is the leading international body on civilian tactical medicine and they work closely with the Committee of Tactical Combat Casualty Care (Co-TCCC), the international military focused tactical medicine body. C-TECC presented at the recent Special Operations Medical Associations (SOMA) Scientific Assembly held in Charlotte, North Carolina in May with the overarching message regarding civilian tactical medicine continuing to be the three goals of tactical emergency casualty care (TECC). These three goals are:
Save preventable deaths
Prevent additional casualties / injuries
Complete the mission.
But how do we meet these three goals?
Let’s look at these three goals in more detail, firstly saving preventable deaths. There are three preventable causes of death within the tactical environment, these being:
With a little training these causes of preventable deaths can be very easily recognised and treated. Treatments provided within the tactical space are designed to be high yield without being time intensive or resource heavy. Tactical medics do not enjoy the luxury of working within a safe and secure environment and as such they must be able to complete any interventions rapidly so that if the need to move arises due to renewed threat, they can move themselves (and the casualty) quickly and efficiently.
Extremity haemorrhage, which makes up 61% of preventable causes of death in the tactical environment, can be rapidly treated with the application of an arterial tourniquet. The Combat Application Tourniquet (CAT) is the most widely used arterial tourniquet within the tactical environment and is closely followed by the Special Operations Tactical Tourniquet – Wide (SOFT T – W).
Both of these tourniquets have limiting factors. However, when used correctly they have been proven to save countless lives both here in Australia and internationally. The Therapeutic Goods Administration (TGA) has approved both the CAT and the SOFTT – W for use in Australia.
Tension pneumothorax accounts for 33% of preventable causes of death in the tactical environment. It is paramount to the survivability of the casualty that tension pneumothoraces are recognised and treated early. If you need a refresher then check out this post with a podcast from a little while back.
In the tactical environment, once a tension has been recognised treatment is as “simple” as conducting a needle thoracocentesis. This is an intervention that takes very little time and can be life saving in this environment – but remember, it is a temporising measure and not definitive treatment. However, working in the tactical environment requires a constant awareness that the threat to all personnel is likely to be high and ongoing. This strongly influences the choice of treatment and in this setting training and experience suggests the “simple” option of needle thoracocentesis – you don’t have time to consider more technical and time intensive interventions (e.g. tube thoracostomies); besides, you won’t have the necessary equipment with you anyway.
Airway obstruction is the final preventable cause of death within the tactical environment and accounts for 6% of the overall numbers. Simple measures such as opening the airway, inserting an nasopharyngeal (NPA) or allowing a patient with extensive facial injuries to sit up and forward can be life saving. Once again there is no time within this environment to consider more technical and time intensive interventions (e.g. intubation).
The second goal of TECC is to prevent further injuries or casualties. This is an important concept and dictates how and when a casualty should be treated within the tactical environment. A good mantra to abide by is “never treat the casualty on the street” (or “on the X”). If the casualty is able, get them to move themselves (this is preferred). If they can’t move they can be moved by someone else to a place of relative safety prior to being treated. If you treat where the casualty was injured there is a higher chance that you yourself will be injured compared to moving to a place of relative safety.
When moving the patient to an area of relative safety you must consider both concealment and cover from the continued threat. It is important to think about what you choose as your cover as not all choices are equal. Just because an object provides good concealment, it may not provide good cover (e.g. corrugated iron provides very little protection from high velocity projectiles or fire, but it may stop you being seen).
Another concept that needs to be considered along with not treating on the street is that the correct intervention needs to occur at the correct time in the continuum of tactical care. The flipside of this is that a medically correct intervention performed at the incorrect time in the incident may lead to further casualties or deaths. The tactical environment is highly dynamic and it may change at any time. Therefore, tactical medics (be they paramedics, nurses or doctors) must always keep situational awareness and take this into account prior to commencing any medical intervention.
The third and final goal of TECC is completing the mission. This is very foreign to most civilian medical providers, as our focus has always been on treating the casualty first and foremost. However, in the tactical environment the completion of the mission and the maintenance of situational awareness must take precedence over caring for casualties as this helps minimise casualties, injuries and loss of life. Highly trained law enforcement officers will provide the advice for this side of tactical medicine and as the medical providers we must follow their instructions.
There are varying models and thoughts of how we should integrate medical response into these high threat environments. The biggest recommendation in this area really is that no matter what model is followed there must be interagency preplanning, understanding of processes and these methods must be practiced (Levy et al, 2016). It is imperative that Australian and international agencies support each other so that we may learn from one another in order to give our casualties and ourselves the best chance at surviving such an incident.
To that end posts like this aren’t designed to be a one way conversation. We’ve come up with a course that we really like but that doesn’t mean we don’t want to learn from any others with experience or knowledge in this area. So please, speak up and let us all share the wisdom.
Then we’ll come back with a few more of our own thoughts on the three phases of care in these challenging situations.
Notes and Extra Reading:
Are you after a bit of reading on this topic? Well here you go …
Continuing the series of sharing Carebundles, Alan Garner moves on to go through the stuff to include in multiple blunt trauma.
OK, part 2 in our Carebundle series. This time we will take a look at our multiple blunt trauma bundle. This excludes isolated head injury which we dealt with in the previous post. Why that order you may ask? Our Sydney service started life as a trial evaluating the management of severe head injury so TBI is front if mind for us. It is also more straightforward as there are not the competing priorities that occur in multiple trauma. And in the end we don’t just want survivors but neurologically intact survivors so starting with TBI and brain resuscitation makes sense. The multiple blunt trauma bundle has conditional targets that are modified by the presence or absence of brain injury acknowledging that brain resuscitation is our major goal.
So multiple blunt trauma is next. This has many bits of intrigue to it. It is multiple. We’re moving into the bits of the body where the pathology can be buried in the large splodgy bit in the middle. The diagnostic stuff can be pretty challenging at the side of the road. Oh, and because it’s multiple there’s always that threat of a new competitor emerging in the pathophysiology parade.
We won’t touch on penetrating trauma, burns and immersion all of which have their own bundles of joy for another time.
The Common Touch
All of the mandatory items overlap with the TBI bundle so we won’t waste any time on them here:
Venous access – yes we reckon that still makes sense.
Analgesia – opioids/ketamine – yes we’re really trying to stress that analgesia is a vital component of care, pretty much every time.
Monitoring: SpO2, NIBP, ECG
Spine immobilisation – note we’re just sticking with immobilisation.
SpO2 > 93% by ED arrival
Scene time < 25 min – again, this isn’t always possible which is part of why Carebundles provide guidance but need clinician judgment on each job. What we’re aiming for is a background enthusiasm for keeping momentum throughout the time we’re looking after patients so we can get them to the hospital with all those eager people waiting.
Transport direct to trauma centre – this would be the house for the eager people.
The conditional items however vary from the TBI bundle and we will now go through these.
Checking the Terms and Conditions
Long bone fractures splinted
There is no evidence I am aware of that this changes outcome but it is standard ATLS teaching and makes pain control easier. We carry lots of excellent drugs and the Carebundle makes a point of mentioning them but everything is easier if you manage the physical elements contributing to the painful situation. Really this is the original multimodal analgesia. It’s just that one of the modes is “physical things that stop hurting things from exercising a right to freedom of movement”.
Massive external haemorrhage controlled
There is strong cohort level data that this saves lives, although more so in the penetrating trauma context where it is more common. Certainly data from recent conflicts supports this as a primary aim of prehospital care. So we’re carrying tourniquets, dressings, chitosan gauze and granules (though the latter are more for penetrating wounds).
TXA if episode of SBP < 90mmHg, or below normal for age
CRASH 2 inclusion criteria were felt to be a little vague to include in our bundle. After all the inclusion criteria in this study was any trauma patient who was at risk of haemorrhage. To make the bundle we felt the item needed to identify the cases where TXA really should have been given because the risk of life threatening haemorrhage is so high. There is some evidence that just a single episode of documented hypotension is enough to identify a group of very high risk patients so we adopted this as our criteria. As another mental trigger point, some of our team have expressed a process when they consider packed cell transfusion – “If I’m reaching for blood, I should reach for that drug.”
If shocked, SBP at ED arrival (refer fluid guideline)
No head injury: palpable central pulses/obeying command
With head injury: Palpable peripheral pulses, or SBP > 90mmHg / lower limit of normal for age
In setting our blood pressure targets we differentiated between those with and without head injuries. Without a head injury permissive hypotension is our strategy. With a head injury we adopted the lowest level identified in the Brain Trauma Foundation Guidelines i.e. SBP of 90mmHg as our target. This is lower than our target for isolated severe TBI where our target is a MAP of 90mmHg or SBP of 110mmHg (see the TBI bundle post for further details). That last modification is obviously for paediatric patients where the guidelines are a little harder to attach specific numbers to.
If GCS < 9:
Intubation and mechanical ventilation
EAM above JVP (head elevation)
30-35mmHg if no chest trauma/shock
25-30mmHg if chest trauma/shock present
This is similar to our isolated severe TBI bundle but we finesse our etCO2 targets in the presence of other injuries that might affect the gradient between arterial and alveolar levels. There is some evidence that adopting a lower prehospital etCO2 target in patients with chest trauma and/or shock is reasonable as these patients have predictably higher gradients. My own personal experience is that in patients who have both chest trauma and shock the target needs to be even lower. I have achieved an etCO2 by ED arrival in the mid-twenties in patients where both these factors are present only to find the first blood gas reveals an arterial level in the 50s. I would certainly be interested in hearing other people’s experience on this one. Of course in our rapid response urban trauma work we don’t carry a POC blood gas analyser like we do in our interfacility transport operations. Actually measuring the arterial CO2 would be ideal but we don’t think this is practical for both time and weight reasons in our urban response service.
Thoracic decompression if hypoxic/shocked & clinical or US suspicion of pneumothorax
I don’t think this one is rocket science. Even if we know a pneumothorax is present on ultrasound we usually leave it alone if they are not compromised. If compromise is present however then we expect it to be decompressed.
If GCS <13, BSL documented
All patients with an altered level of consciousness get their blood glucose documented.
Pelvic binder if shock and:
possible AP compression / Vertical Shear injury or signs of pelvic #
We don’t expect pelvic binders to be placed prophylactically. There is no evidence to support such a practice. We do however think that binders are helpful on AP compression and possibly vertical shear type injuries and the patient is shocked.
So that is it for our multiple blunt trauma bundle. It’s what we came up with on a review of the evidence but we’re always open to clever thoughts from others. If you have comments or suggestions we would love to hear from you.
And next time we return to the Carebundles it might just be time to get to the pointy end of penetrating trauma.
As always, we’re very happy to hear other people’s clever takes on things that are worth doing. It helps us re-examine our thinking.
Here’s the PubMed link again for the “a single low blood pressure” matters paper linked above:
Sometimes really simple questions don’t get asked. Here’s a joint post from Alan Garner and Andrew Weatherall on places you end up when you ask simple questions about ways of warming blood.
Carriage of packed red blood cells (PRBC) by HEMS crews has become increasingly common in the last several years in both Europe and North America. CareFlight was an early adopter in this regard and has been carrying PRBCs to prehospital incident scenes since the 1980s. We reported a case of a massive prehospital transfusion in the 1990s (worth a read to see how much Haemaccel was given before we arrived on the scene and how much things have changed in fluid management). In that case we tried to give plasma and platelets as well but the logistics were very difficult. This remains the case in Australia with plasma and platelets still not viable in a preparation that is practical for prehospital use.
Returning to the PRBCs however the issue of warming them was something that always vexed us. We experimented with a chemical heat packs in the late 1990s and early 2000s but could not find a method that we felt was reliable enough. We also looked at the Thermal Angel device from the US when it appeared on the market nearly 15 years ago, but as the battery weighed the best part of 3kg we decided that it still had not reached a point where the technology was viable for us to be carrying on our backs (battery technology has moved on a long way in the last 10 years and Thermal Angel now have a battery weighing 550gms).
Hence we were pretty excited when we found that there was a new device available in the Australian market, the Belmont Buddy Lite, where the whole set up to warm blood or fluid weighs less than a kg. We have been using the device for 3 years now, and our clinical impression was somewhere between impressed and “finally”.
Still, one of our docs, James Milligan, thought it worth validating this new technology. Part of that was about checking that the machine does what it says on the box. Is it just marketing or is it really that good?
The other thing we wanted to assess was how a commercial device compared to all those old techniques we were once stuck with. Traditional methods used by EMS in our part of the world include:
Stuffing the unit under your armpit inside your jacket for as long as possible prior to transfusion.
Putting it on a warm surface (black spine board in the sun or bonnet of a vehicle). Yep, baking.
That chemical heat pack method we had tried 10 years ago.
The Nuts and Bolts
Now, how would you go about testing this? The first thought bubble included a pump set, a theatres wash bowl and a standard old temperature probe that you might use at operation. Oh, and some blood. Like most bubbles that don’t involve property, it didn’t last long.
So we were left with a question: how do you try and set things up to test a system for the real world so it is actually like you’d use it in that real world, while still allowing measurements with a bit of rigour? How consistent are you when you deploy a blood-giving pump set?
Enter Martin Gill, perfusionist extraordinaire from The Children’s Hospital at Westmead. Because when we thought “how do we test prehospital blood warmers” obviously we thought about heart sugery in newborns. We turned to Martin with the following brief:
We want to test prehospital blood warming options.
We want to measure temperature really well.
We’re keen on being pretty rigorous about as many things as we can actually. Can we guarantee flow rate reliably?
We figure we could use units of blood about to be discarded and we want to be able to do the most with what we’ve got. So we want to be able to use a unit for a bunch of testing runs.
And Martin delivered. He designed a circuit (check the diagram) that would guarantee flow, measure in 3 spots, cool the blood once it had run through, and run it all through again. There are some things you could never come up with yourself. That’s just one.
You might wonder how hard is it to get blood? Well actually it was pretty easy (thank you Sydney Children’s Hospital Network Human Research Ethics Committee and Haematology at The Children’s Hospital at Westmead).
As you will note, the commercial warmer was the only method that reliably warmed the blood to something like a physiological level.
The change in temperature as the products pass through the line itself was more than we’d expected. Even the measurement of temperature just a little bit distal to the bag of blood showed a sharp step up temperature (that mean was 9.40C).
Any of the options that weren’t the commercially available device here guaranteed very cold blood reaching the end of the line. After all, 180C is the temperature we aim for when setting up deep hypothermic circulatory arrest in the operating suite. It is very cold. Should you even consider packed red blood cells if you aren’t going to warm them effectively?
In some ways, these aren’t super surprising items but small things like this can still be valuable. This was a humble little bench study of a simple question. Still, finding out that a device does what it says on the box by direct observation is reassuring. But …
We Have Questions
Research is very often an iterative process. Ask a question, provide answers to one small element of the initial puzzle, find another puzzle along the way and define a new question to explore. Each new question contributes more to the picture. On top of that, finding our way to the lab set-up and squeezing in the measurements around other work has taken a bit of time and things have moved along. This itself suggests new questions to ask.
Will everyone’s questions be the same? Well here are ours, so you tell us.
Now that we’ve come up with a lab set-up to test the manufacturer’s recommended use, what about testing a situation that more closely matches how the warming device is used at the roadside? As noted in the discussion, we don’t use machines pumping blood at a steady rate of 50 mL/min. How will a warmer perform at the much higher flow rates we demand in prehospital use? Will it still be a warmer or more of a tepid infusion system?
Are all devices the same? We didn’t choose the Buddy Lite because we were after a sweet, sweet money deal. It was the only prehospital fluid warmer with Therapeutic Goods Administration registration in Australia. There are now at least 2 other devices weighing less than 1 kg on the international market. They also advertise an ability to work at higher flow rates of up to 200 mL/min.
Are there are other potential problems when you warm the blood with these low dead space solutions? Let’s just imagine for a second you’re a red blood cell rushing through a warmer. In a pretty small area you’ll be put through a temperature change of over 200C within a system aiming to maximise that heat transfer in a very small bit of space. That implies the pressure change across the warming device could be pretty sizeable. When you get to the end of that little warming chamber having effectively passed through a very high pressure furnace, is there a chance you might feel like you’re going to disintegrate at the end of it all? What we’re alluding to is maybe, just maybe, does making red blood cells change temperature quickly while rushing through the system at up to 200 mL/min leave those red cells happy or is haemolysis a risk? If it was a risk, would the patient benefit from receiving smashed up bits of red cell?
Now that we’ve established a good model that will let us do rigorous testing,we can ask those new questions. Without the simpler first question, we wouldn’t be so ready to get going. Those new questions would seem to be how do modern devices perform at flow rates useful for the clinician rather than the marketing pamphlet? And what happens to the red cells in the process?
That’s the space to watch. Because that’s where we’re going next.
Notes and References:
Here’s the link to the prehospital massive transfusion case report mentioned near the start.
That image of the fire is from flickr’s Creative Commons area and is unaltered from the post via the account “Thomas’s Pics”.
And did you get this far? Good for you. Much respect to all those who read to the end of a thing. For this you get a reminder that you can follow along by signing up to receive updates when we post.
You also get the word of the week: colophon [kol-uh-fon] which is a publlisher’s or printer’s distinctive emblem used as an identifying device on books or other works. Alternatively it can be the inscription at the end of a book or manuscript.
As a follow up to our blog about Carebundles and their general utility in Prehospital and Retrieval Medicine we thought we might go through each of the bundles that we are using in Sydney and discuss our rationale for why we included the items we did and the evidence base for them. We hope this process will provide us with some open peer review of our criteria across an international cohort of our colleagues which can only be good for us.
The first thing to note is simply a repeat of my previous post. It is hard to get good evidence in the space we work in and much of the data is extrapolated forward from in-hospital practice. Mere geography alone should not affect pathophysiology so this approach is biologically plausible but we acknowledge it is not ideal. To quote from the previous post:
“We then turned to the evidence based consensus guidelines, Cochrane reviews and good quality RCTs to define the Carebundle items. This is a sobering process as you realise just how few interventions there are that have good evidence to back them up. This is particularly true for prehospital care where we are often operating in an evidence free zone. In many cases we had no choice but to go with the consensus (or best guess as I like to call it). We decided that we would include intubation for unconscious trauma patients for example despite the evidence not being all that strong and in many cases contradictory.”
So let’s look at our bundle items for isolated severe head injury (GCS <9) and why we chose them:
Intubation and mechanical ventilation
As I have already stated the evidence here is not strong. However it certainly allows better control of both oxygenation and ventilation (PaCO2) so it makes sense and is the in-hospital standard of care. We also know that we can do this safely and extremely rapidly without delaying in-hospital care (CT scan in particular). Given we are not delaying subsequent care it seems reasonable to intubate these patients on scene given the other advantages.
Again see Davis’ papers on this subject. We are wanting low normal range (in the 35-40mmHg range) but we don’t have formal blood gases available to us in our rapid response urban operation in Sydney (we do in our longer distance transports in other parts of Australia and internationally). We therefore assume there will be a small gradient from arterial to alveolar and aimed for an ETCO2 that was likely to get our arterial level in the zone we were aiming for.
Our minimum is ECG, SpO2, non-invasive blood pressure and waveform, quantitative ETCO2. These are the minimum standards for managing an intubated patient in our part of the world as covered by the specialty colleges. .
There is definitely no randomised controlled trial that shows that prehospital venous access improves outcome from severe head injury (or anything else that I know of either). However it really goes with intubation as above. We aim for pharmacologically smooth intubations without desaturation or hypotension. We need a line to achieve this.
Note that this does not say a rigid collar, just immobilisation which can be achieved in a number of ways. There is of course evidence that collars impede venous return and therefore it is possible they have an adverse effect mediated by effects on cerebral perfusion pressure. The consensus guidelines still cite the evidence of C spine injury associated with severe head injury so neck immobilisation made our list. We’re actively reviewing what to do when we arrive at a patient already with a rigid collar in place.
No evidence that I am aware of that prehospital analgesia changes outcome for patients with severe TBI, even in terms of subsequent post traumatic stress disorder in survivors. Unconscious (but not completely obtunded patients) still feel and respond to pain however. Of course it may also mitigate the risk of hypertension potentially exacerbating intracranial haemorrhage so again a biologically plausible mechanism for a benefit. I think we mainly included this one as it is what we would want for ourselves & our families.
Head elevation (External Auditory Meatus above JVP)
This is again extrapolated forward from standard in-hospital care. We need to get the brain above the effect of venous pressure to maximise cerebral perfusion. No prehospital studies on outcome (recurrent theme) but seems reasonable.
All the large observation data sets about this quote 90% as the magic number (See Randal Chestnut and Michael Fearnside’s classic papers on this topic for example). We were simply conservative and aimed a bit higher at the inflection point of the Hb dissociation curve as desaturation occurs so rapidly below this point. I note that the Germans (ADAC) are aiming for 95% presumably due to similar thinking.
Systolic Blood Pressure >110mmHg
Again the classic papers talk about 90mmHg for this item, although if you look at the Brain Trauma Foundation guidelines, they suggest a preference for a higher target, even though they can’t say exactly where to land. Guidelines out of Italy have also recommended this sort of target previously. Again this seems to make sense from a cerebral perfusion pressure point of view.
Blood sugar level
We mandate that this be documented for all patients. Our trauma population like most other parts of the developed world is becoming older and co-morbidities are increasingly common. This one is too embarrassing to miss.
Scene time <25 mins
One fifth of patients with severe head injury have a drainable haematoma. We want to maintain a sense of urgency among our teams. Again, we recognise that there are times when circumstances stop the team achieving this. The key thing is maintaining that sense that forward momentum can be significant for the patient.
Transport direct to trauma centre
All based on observational data but taking severe trauma patients direct to designated specialist trauma centres is standard of care internationally. Even the UK have got in on the act recently.
Hypertonic saline if neurologically deteriorating or lateralising signs
This one is going to be controversial. Again based on beneficial effects on ICP in the ICU setting rather than hard evidence of improved outcomes. We chose hypertonic saline over mannitol as there is less electrolyte disturbance and hypotension. We are targeting the neurologically deteriorating and lateralising signs group as they may have drainable lesions and we are trying to buy time to surgical evacuation. That is the theory anyway.
This is our audit sheet that the doctors complete post mission. You will note that it contains space for the team to comment on variations from the bundle so that we can identify the reasons that we are unable to meet our management targets.
Although the bundle is designed for patients with GCS<9 in reality we intubate a lot of head injury patients with GCS 9-12 as well for various reasons. We do not consider application of the bundle mandatory in this group but if they do intubate the patient we encourage our teams to apply all the bundle items as well as completing an audit sheet post mission.
Did we get it right? As I said the lack of good evidence makes this process very sobering, so we would particularly welcome feedback. Next time I will have a look at our blunt multiple trauma bundle.
Notes and References:
One of the papers suggesting letting CO2 rise isn’t great: