Same, same? Actually different

More of the operational data from the Head Injury Retrieval Trial has just been published. By luck more than anything else this has occurred within 24 hours of the publication of the main trial results which you can find here.

Some operational data about systems used in the trial has already been published. A key part of HIRT was a dispatch system where the operational crew were able to view screens with case information as they were logged to spot patients who may have severe enough injuries to warrant advanced care. They could then use the available information or call the initiating number for further details. If the available information matched the criteria for consideration of an advanced care team, the randomisation process then swung into action. The whole idea was to streamline the process of activation of an advanced care team to severely injured patients.

A study looking at this dispatch system in the context of identifying severely injured children has already been published here. This study compared the trial case identification system with the Rapid Launch Trauma Coordinator (RLTC) system in NSW. When the trial dispatch system was operating the paediatric trauma system in Sydney performed significantly better than when the trial system was not available. This was a combination of the dispatch system and the rapid response capability of the trial HEMS. The speed and accuracy of dispatch was a key component however.

So what’s this new paper about?

In this new paper we had the opportunity to explore the HIRT data set to look at the times it took various team models to treat patients and get them to the hospital, and then through the ED to CT. The data is unique as far as I know as we had the unusual situation of two physician staffed services operating in parallel sometimes being dispatched to the same patients.

You can find the paper here.

Getting to a CT scanner in a more timely fashion than this was a way of tracking patient progress through their care. [via telegraph.co.uk]
Getting to a CT scanner in a more timely fashion than this was a way of tracking patient progress through their care. [via telegraph.co.uk]
First comment is that this appears to confirm some European data that physician teams do not significantly affect prehospital times when compared with paramedics although the intubation rate is much greater. Papers such as that by Franschman from the Netherlands make interesting comparisons with this paper. The Dutch Physician staffed HEMS system closely mirrors the HIRT rapid response system in time intervals (and many other factors too). The fact that we have such similar results half a world apart suggests some generalisability of the data.

So are there some differences?

This study did show some differences between the physician teams in those time markers through the patient pathway. It’s worth making a couple of comments that might help to interpret that data.

This is not about individual performance but about systems. There were doctors and paramedics who worked across both systems. Their times followed the pattern of the system they were operating in on any given day.

If you look in the study discussion, the two physician HEMS systems are quite different. The Greater Sydney Area (GSA) HEMS forms part of the State ambulance helicopter system. It has to be all things to all people all the time. They have a wide range of tasks including interfacility transports, hoisting operations, ECMO and IABP transfers etc and they may potentially be tasked anywhere in NSW and perhaps up to 100nm off the coast. By necessity they are multirole and they have to be able to respond to any of these mission types when the phone rings without any notice.

The rapid response HEMS system that was set up for the trial is not constrained in the same way. It is a specialist service where every mission follows the same basic pattern. This data indicates that it is very, very good at doing one thing. Indeed as far as I am aware the scene times for intubated patients are the fastest achieved for a physician staffed HEMS anywhere in the world, even slightly faster than the published data from the Netherlands. The price of specialisation however is that this service cannot perform the range of tasks that the multirole GSA HEMS undertake.

Put simply the services are not interchangeable. The data indicates that the specialist rapid response model will arrive at patients first compared with the multirole GSA HEMS model anywhere in the greater Sydney area, except at the extreme edges of their operating range where rural bases may be faster, or within a couple of km of the GSA HEMS Sydney base.

The differences also apply to scene times where the HIRT rapid response system had scene times of half that or less observed in the GSA HEMS teams, even when confounders such as entrapment and requirement for intubation were considered. We speculate on some reasons for this such as the relative team sizes for the two operations. There may well be advantages in highly familiar teams. There is certainly some evidence for this in other areas of medicine.

What do we make of this?

Overall however I think specialisation is the key. If we again compare the HIRT rapid response model to the Dutch physician staffed HEMS system the similarities are striking. Like the HIRT system, the Dutch only perform prehospital cases, they only operate within a limited radius of their operating base (including urban areas) and they do not have hoists. Like most European HEMS they have small team sizes. And their times are remarkably similar to that achieved by the HIRT HEMS system in our study. It is all about how the services are structured and their role definition which makes them good at what they do.

There are clear implications for the task allocation system in Sydney from this data.

The current pattern of tasking appears to allocate physician teams primarily on who is closest. This allocation only makes sense if the two teams are interchangeable in capability. This is very clearly not the case. The two systems are quite different. The relative strengths of each service should be taken into account in the dispatch policy so that patients will get the most rapid and most appropriate response possible given their location and clinical condition.

The patient doesn’t care who started out closer. They want the service they need for their situation. The different strengths of the two services should form a complimentary system that ensures the fastest and highest quality care to patients, whether they are on the roadside, already in a smaller hospital, at the base of a cliff or on a ship off the coast.

What about dispatch?

The evidence from this study combined with the previous study on the Sydney paediatric trauma system also indicates that the HIRT case identification system significantly outperformed the RLTC in both speed and accuracy.

The trial case identification system operated for nearly 6 years without a single report of any type of safety incident, even of a minor nature. Once the RLTC came into being in 2007 the RLTC and HIRT systems operated collaboratively to identify severely injured children and ensure a speedy response. When HIRT identified a paediatric case, they checked with RLTC who retained tasking control to ensure that there was no additional information or competing tasks that might affect the dispatch decision. In this way Ambulance retained central control and oversight of the system and a double up of tasking to paediatric patients was averted. This would seem to be the ideal system with patients benefiting from the increased speed and accuracy of the parallel case identification process when the HIRT and RLTC systems were operating together, but Ambulance retaining central control so that competing tasks could be balanced. The HIRT dispatch system was however discontinued in 2011 when the last patient was recruited into the trial.

The practical difficulties of applying this level of sophistication to resource allocation, given the sheer volume and variety of demands on the centralised despatch system, need to be acknowledged. Nevertheless it might be time for a rethink.

Here’s those references again:

HIRT.

The comparison of dispatch systems in paeds patients.

The times paper.

The Dutch study.

 

 

HIRT – Studying a Non-Standard System that Ended up as Standard

There’s always a bit of extra reflection you can’t include in the discussion of a research paper. Dr Alan Garner reflects more on some of the challenges of doing research in prehospital medicine. 

The main results of the Head Injury Retrieval Trial have now been published on-line in Emergency Medicine Journal. We have paid the open access fees so that the results are freely available to everyone in the spirit of FOAM. This was an important study that was eagerly awaited by many clinicians around the world.

The summary from my point of view as the chief investigator: an enormous opportunity wasted.

It is now nearly ten years since we commenced recruiting for the trial in May 2005. Significant achievements include obtaining funding for a trial that was ultimately to cost 20 million Australian Dollars to run. I am not aware of another prehospital trial that has come anywhere close to this. Hopefully this is a sign that prehospital care is now seen as worthy of the big research bucks.

In the subsequent ten years world events have helped to drive increasing investment in prehospital trauma research, particularly conflicts in Iraq and Afghanistan and the perception that there were many preventable deaths.   The US government has become a big investor in prehospital research that might lower battlefield mortality. The Brits on the other hand typically made some assumptions based on the evidence they had and got on with it. Higher levels of advanced interventions during evacuation as exemplified by the British MERT system in Afghanistan seem to be associated with better outcomes but the evidence is not high quality.

I am the first to acknowledge that randomised trials are inherently difficult when people are shooting at you. Most prehospital care is not quite that stressful but there remain significant barriers to conducting really high quality prehospital research. Taking the evidence you have and getting on with it is a practical approach but it is not a substitute for meticulously designed and executed high quality studies. Such studies often disprove the evidence from lower level studies. We all bemoan the lack of good data in prehospital care and recognise the requirement for better research.

When you’re only left with signals

The Head Injury Retrieval Trial taken in this context really is an opportunity wasted. There is a strong signal in the as-treated analysis of unconscious trauma patients that there is a significant difference in mortality associated with physician prehospital care. The Intention to treat (ITT) analyses was not significant however.

The potential reasons for the lack of difference in the Intention to Treat group is really best appreciated by looking at the difference in intervention rates in Table 2. Both treatment teams (additional physician or paramedic only) could intubate cold so we only report the rate of drug assisted intubation. This was by far the most common physician only intervention, and the one we have been suspecting to make the most difference to head injured patients. When you look at the rates receiving this intervention it was 10-14% in the paramedic only group due to the local ambulance service sending their own physician teams in a good percentage of patients, compared with 49-58% in the treatment group. If this really is the intervention that is going to make the difference, our chances of demonstrating that difference are not great unless the treatment effect is absolutely massive.

When the system you study changes

The Ambulance Service in NSW decided two and half years into the trial that they considered physician treatment to already have sufficient evidence to make it the standard of care. They partially replicated the trial case identification system to enhance identification of patients that they believed would benefit from dispatch of a physician (there’s more detail in the HIRT protocol paper).

This is not the first time that such a thing has happened. In the OPALS study of prehospital advanced life support in Canada in 2004 the original study design was a randomised trial (Callaham). It was however done as a cohort study owing to the belief of paramedics that it was unethical to withhold ALS despite absence of proof of its efficacy. We bemoan the lack of evidence but belief in the efficacy of established models of care make gathering high quality evidence impossible in many EMS systems. NSW has proved to be no exception.

Sydney remains a good place to do this work of course.
Sydney remains a good place to do this work of course.

Where are we then?

So where does this leave Sydney? I think a quote from Prof Belinda Gabbe best sums up the situation. Prof Gabbe is a trauma researcher from Monash who has published much on the Victorian trauma system and was brought in as an external expert to review the HIRT outcome data during a recent review of the EMS helicopter system in New South Wales. Her comment was:

“As shown by the HIRT study, physician staffed retrieval teams are now an established component of standard care in the Sydney prehospital system. The opportunity to answer the key hypothesis posed by the study in this setting has therefore been lost and recommendation of another trial is not justified. Future trials of HIRT type schemes will therefore need to focus on other settings such as other Australian jurisdictions, where physician staffed retrieval teams are currently not a component of standard care”.

The only jurisdiction in Australia with enough patients to make such a study viable that does not already use physicians routinely is Victoria. Such a study would be particularly interesting as the recent randomised trial of paramedic RSI from that state found absolutely no difference in mortality, the area where the HIRT trial indicates there well may be a difference. Any potential trial funder would want some certainty that history would not repeat itself in the standard care arm however.

In NSW though, the question of whether physician care makes a difference to patient outcome is now a moot point. It is now the standard of care – HIRT has definitively demonstrated this if nothing else.   All we can do now is determine the best way of providing that care. We have more to publish from the data set that provides significant insights into this question so watch this space.

References:

In case you missed them above:

HIRT

The HIRT Protocol Paper

Callaham M.   Evidence in Support of a Back-to-Basics Approach in Out-of-Hospital Cardiopulmonary Resuscitation vs “Advanced” Treatment. JAMA Intern Med. 2015;175(2):205-206. doi:10.1001/jamainternmed.2014.6590. [that one isn’t open access]

A Bit About Paeds Trauma for Those Who Do A Bit of Trauma

This is a post put together by Dr Andrew Weatherall as background preparation for a talk at the SPANZA Paeds Update from March 14, 2015. This is an update for the occasional paeds anaesthetist. It’s not about covering it all but hopefully there’s a few useful points in there to prompt a little thought and discussion.

For lots of people who do a bit of paediatric care, there’s a bit of nervousness around little people. It’s a bit disproportionate to the numbers of actual cases of course because paeds trauma is not common. In fact, rates are slowly going down.

There is also a common paediatric conundrum to deal with – what do you do with adult evidence? This is because overwhelmingly trauma literature deals in the bigger, smellier version of Homo sapiens.

So the challenge is to provide a refresher on something that is getting less common for most of us, using evidence for other patients.

This might be easier with a story, weaved from a bit of experience and not that much imagination.

Crash copy

The Call Comes In

You get a call from the emergency department that they are expecting a paediatric patient from a crash, not too far from your hospital out on the far edges of the city. The road speed limit is around 80 km/hr and they have a 6 year old child who was sitting in the rear right passenger seat, in a booster seat. He’s probably too small for this booster seat. It doesn’t look like he was well secured.

The child was initially GCS 12/15, with a heart rate of 145/min, BP 85/58, a sore right upper quadrant, and a deformed right upper leg. Initially SpO2 was 96% but is now 100% on oxygen.

Where Should They Go?

Of the schools of thought (big kids’ centre vs place where they do lots of trauma but not lots of kids), NSW has gone for the hospitals with the pretty waiting rooms.

Probably the most relevant local research on the topic is from Mitchell et al. who looked at trends in kids going to paeds trauma centres or elsewhere. They found kids getting definitive care at a paeds trauma centre had a survival advantage 3-6 times higher those treated at an adult trauma centre.

There are issues with this. Mortality as a sole marker when you’re only discussing about 80 kids across 6 years may not be the most reliable marker of quality care. You only need one or two cases to shift from one column to the other to significantly skew the picture.

Possibly the more significant finding was the delay created by making that one stop. Stopping at another hospital (even within the metropolitan area) delayed arrival at the paediatric trauma centre by 4.4-6.3 hours. Early discussions to transfer obviously need to become a priority.

In NSW, the policy is now for ambulance officers to go directly to the paeds trauma centre if it’s possible within 60 minutes. Unless they don’t think they’ll get there.

The impact on the doctor working outside the kids trauma centres is two-fold:

  • There’s less paeds trauma to see.
  • The paeds trauma you do see will be the bad stuff.

Great mix.

The room with the international colour coding of "kids bay"
The room with the international colour coding of “kids bay”

At Emergency

So the patient, let’s call him  Joe, arrives. For the sake of discussion I’m going to assume he did come to the paeds trauma centre, but there’s a whole separate (possibly more interesting) scenario you could think through where he goes to a smaller metropolitan hospital.

Joe arrives with an IV cannula in place and Hartmann’s running. He has a hard cervical collar in place. His GCS has improved to 14/15 (he’s closing his eyes but he seems a little scared) but his heart rate is now 155/min and his BP is 78/50. Peripheral oxygen saturations are still 100% on oxygen (they were 96% off oxygen). He is sore and tender in his right upper quadrant just like they promised. That right femur does look broken. There’s also a lump on the right side of his head, towards the front just on the edge of the hairline.

The New Alphabet

We all remember the alphabet, whether  first drummed in by the fluffy denizens of Sesame Street, or mostly embedded by a trauma course. A then B then C.

Anyone working in trauma knows this is only the older version. So 1900s. The trauma alphabet now has a bunch of variations (C-A-B-C,  MH-A-B-C, choose your edit) to highlight the need to think about arresting blood loss early.

A lot of this shift in thinking is surely related to the vast amount of knowledge gained in managing trauma from military conflict where stopping haemorrhage is one of the most effective things you can do to save lives.

The causes may be different (especially in kids), but some of the thinking can be transferred.

This makes sense not just because bleeding is not great for patients. It’s also because many of the measures required to stop it take more than a couple of minutes. Not so much in the case of tourniquets or fancy dressings that make you clot. Things like surgery, or interventional radiology, or blood product management.

If you’re an occasional paediatric trauma practitioner, there’s a few points worth remembering if you’re going to elevate the importance of haemorrhage control, even while getting the other stuff done:

  • Find the blood early – better rapid diagnostic options, particularly ultrasound, need to be deployed early to figure out where blood loss might be happening.
  • Decisions need to support stopping bleeding – if the patient is bleeding, it is more than a bit important to progress continually towards making them not bleed. This is particularly relevant to arranging radiology and surgery as quickly as possible where indicated.
  • Transfusion – bleeding patients don’t need salty fluids. They need blood. And given what we know about acute traumatic coagulopathy, they probably need it in a ratio approaching 1:1:1 (red stuff: plasma:platelets).
  • Give TXA – after CRASH-2 and MATTERs, tranexamic acid has also made it to kids. A fuller discussion is over here (and there’s also the Royal College of Paediatrics and Child Health thing here though as I mention in that other post, I think they’ve got the doses not quite right).
Set 1 from The Children's Hospital at Westmead Massive Transfusion protocol (obviously, check local policies).
Set 1 from The Children’s Hospital at Westmead Massive Transfusion protocol (obviously, check local policies).

 

And here's the next delivery pack. (And check it out in full context, don't just rely on this screengrab.)
And here’s the next delivery pack. (And check it out in full context, don’t just rely on this screengrab.)

Joe is Getting Better

Ultrasound confirms some free fluid in the abdomen. The fractured femur is reasonably well aligned but you’ve started warmed blood products early. Joe is responding to his first 10 mL/kg of products with his heart rate already down to 135/min and a BP of 88/50. Respiratory status is stable. GCS is 15/15 and you’ve supplemented his prehospital intranasal fentanyl with IV morphine. 

You decide to go to the CT scanner to figure out exactly what is going on with the abdominal injury. Once around there Joe vomits and starts to get agitated. CT confirms a right front-temporal extradural haematoma. As he’s deteriorating you head up to theatres. 

photo 2

Now I’m going to assume anyone reading this is pretty happy with an approach to rapid sequence induction with in-line stabilisation to manage spinal precautions (not that we’d have a hard collar anyway, because those are on the way out in the draft ILCOR guidelines). We’d all agree on the need for ongoing resuscitation. I’ll also assume no one is going to stop the surgeons from fixing the actual problem while you mess about getting invasive arterial blood pressure measurement and a central line sorted.

What would be nice is some better evidence on what are the right blood pressure targets.

What BP target for traumatic brain injury?

Still, the best the literature can offer is a bit of a ¯\_(ツ)_/¯

If you look at this review from 2012 the suggestions amount to:

  • Don’t let systemic mean arterial pressure go below normal for age.
  • It might be even better to aim for a systolic blood pressure above the 75th percentile.
  • If you do have intracranial pressure monitoring and can therefore calculate cerebral perfusion pressure, then aim for > 50 mmHg in 6-17 year olds and > 40 mmHg in kids younger than that.

Hard to escape the thought we need more research on this.

The Rest of Joe’s Story

Everyone performs magnificently. Joe’s extradural is drained. His femur is later fixed and his intra-abdominal injuries are managed conservatively. The next most important thing might just be that you remembered to give him good analgesia.

Not Forgetting the Good Stuff

I might have some professional bias here, but I think remembering analgesia is just as important as the rest of it. Studies like this one suggest surprisingly high rates of PTSD symptoms even 18 months after relatively minor injury (38% though it was a small study). Although the contributors to PTSD are complex there is some evidence (certainly in burns patients)  that early use of opioid analgesia is associated with lower rates of PTSD symptoms.

This stuff matters. A kid with PTSD symptoms is more than just an anxious kid. They are the kid who is struggling with school, struggling with social skills and generally struggling with the rest of the life they were supposed to be getting on with. Pain relief matters.

So it is worth prioritising good analgesia:

  • Record pain scores as a vital part of the record.
  • Block everything that is relevant (no child with a femur fracture should have an opportunity for a femoral block of some description missed).
  • Remember treatment as analgesia (don’t just leave the fracture like you found it, for example).
  • Give rapidly acting,titratable drugs as a priority with regular checks of efficacy.
    • For example, fentanyl 5 mcg/kg in a 10 mL syringe gives you 0.5 mcg/kg/dose if you give 1 mL at a time. Do this and reassess every 3 minutes.
    • Likewise, ketamine 1 mg/kg in 10 mL provides a dose of 0.1 mg/kg each time you give 1 mL (though some would say you should use midazolam to offset dysphoria too).
    • Don’t forget novel options – methoxyflurane anyone?

The Wrap

Paeds trauma may not be as common, but it needs to be done to the same high standards we expect of trauma care anywhere. Most of the stories in resuscitation are well worn tales. But there are a few things to really take away:

* Think about doing everything to stop bleeding early.

* More blood for resuscitation, but more sensibly too.

* Never forget pain relief.

 

And with any luck, most of this is already old news.

 

Postscript: Just after I put this together, the always excellent St Emlyn’s blog put up something covering the latest changes to APLS teaching. To my immense relief a lot of it is the same. It’s worth checking out.

After the postscript: This isn’t designed to be too prescriptive and everything should be figured out in local context. Obviously any thoughts anyone has to share would be very welcome. 

A Bit of New Evidence on Drowning

An opportunity for a quick post to point to a new publication with something useful on drowning. From Dr Alan Garner.

Unfortunately we attend a number of paediatric drownings in the Sydney area every year. Many recover well. Some do not. Some do unexpectedly well. We have had a patient who was GCS 3 at our arrival and asystolic on the monitor make a full recovery. Most children in this situation however either die or are severely impaired.

This brings us to a vital question – when is it reasonable to stop resuscitation? Well, here’s some evidence to help inform the chat.

The Dutch Study

Over at the BMJ a new paper has just hit the screen:

Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study. 

This study is a nationwide observational study in the Netherlands of children with cardiac arrest due to drowning. The authors have put together ten years of data collected in a country with more than 30 million people. It seems unlikely we’ll see a bigger study.

The study indicates that no child resuscitated for more than 30 minutes had a good outcome. There were good outcomes in those resuscitated for less than 30 minutes.

This matches our experience. Our patient with the GCS 3/asystole combination and a subsequent good outcome had a return to spontaneous circulation while still on scene.

The other point of interest is that it is from an environment where water temperature is presumably a fair bit colder than the coastal fringes of Australia, but the results would appear to be similar.

It would appear that discontinuing resuscitation after 30 minutes in those with no neurological improvement or stuck in asystole is a reasonable practice.

It still comes down to time.

 

Revisiting Old Stories About Little Airways

Dr Andrew Weatherall returns to stuff about paediatric airways, a bit of a companion to an earlier post with some practical tips. 

There are some things you’re taught from a very young age to believe in. Then it turns out it’s just plain wrong. Santa Claus. The Tooth Fairy. The Public Holiday Numbat. (Well, the last one might be specific to my upbringing.)

And in medicine there are plenty of examples those too. Oxygen is always good. You can’t manage trauma without a cervical collar. Then of course there’s pretty much everything about the paediatric airway. As if managing kids didn’t come with challenges anyway, we all get to work with information that is just plain wrong.

And there’s no mistaking that clinicians find paediatric airways difficult. The staff from Royal Children’s Hospital Melbourne have recently published a sizeable prospective study of emergency department intubations. This is from a big, clinically excellent tertiary kids’ hospital receiving 82000 patients in their ED every year. In 71 intubations across a year (only 71!), 39% had adverse events (most commonly hypotension in 21% and desaturation in 14%) and the first pass success rate was 78% (only 49% had a first pass intubation with no complications).

Now lots of things will contribute to those figures. But at least part of pondering that has to be making sure we understand what we’re dealing with.

"Please, go on" says Public Holiday Numbat [unchanged via quollism on flickr under CC]
“Please, go on” says Public Holiday Numbat [unchanged via quollism on flickr under CC]

Old Truths

Some old historical truths are harder to pull away than a spider web stuck to a bear with superglue. There’s a recent review that appeared in Pediatric Anesthesia written by Dr J Tobias  which steps through some of this dogma.

It points out that some of the classic teaching on the paediatric airway come out of a 1951 report by a Dr Eckenhoff. This includes the issues of the position of the larynx, the shape of the epiglottis and the funnel-shaped airway. Actually, to really trace the story, you have to start a little earlier.

Stepping Back

It’s 1897. Waistcoats aren’t ironic yet. Pipes aren’t an affectation they’re an expectation. Jack the Ripper is part of shared memory, not fevered historical narratives. And Bayeux was making casts of the airways of dead children. 15 casts actually in kids aged 4 months to 14 years.

Taking measurements of the circumference of the airway at the glottis, cricoid level and trachea, the cricoid ring was noted to be narrower than other parts of the airway (the topic of the shape of the airway wasn’t mentioned). This is the work that led to the idea that kids under the age of 8 had a conical larynx, with the cricoid ring as the narrowest point.

Consider for a second the qualities of plaster poured into a distensible tube. Wait, it’s not entirely distensible because the cricoid can’t distend. Is it maybe possible that the plaster may have distorted the anatomy? I’ll leave that with you for a bit.

This suggestion of the conical airway made its way into Eckenhoff’s later paper (though with a specific note that cadavers may not represent the living accurately). There were also some descriptive points raised:

  • The larynx moves down from the C3-4 level in the neonate to C4-5 in the adult (I’ve always been under the impression this move is brought about both by the need to phonate properly for speech and the loss of the need to breathe and breastfeed at the same time, but this point doesn’t feature in airway descriptions and I’m happy to be corrected).
  • A stiffer and more “U” or “V”-shaped epiglottis with an angle to the anterior pharyngeal wall of around 45 0 rather than lying close to the base of the tongue.
  • A case report of a 2 year old with airway complications thought to be related to an inappropriately sized tube, feeding the idea of uncuffed endotracheal tubes in kids under the age of 8.

All these points that form part of so much teaching lead to another question – would such a descriptive effort get a run in modern publishing?

 

Newer Tools Means Better Understanding

The answer of course is probably not. Of course you can only use what you have and it’s absurd to judge Eckenhoff (or Bayeux) for their accuracy against modern modalities. All we can do is revisit our thinking when new information becomes available.

We now have the significant advantage of radiological techniques (CT or MRI) and bronchoscopy to evaluate airways in children who aren’t dead. Again the Tobias article goes into more details but there are some key things to take from this modern literature:

  • In spontaneously breathing and muscle relaxed patients, the cricoid was not the narrowest part of the airway. That honour belongs to the vocal cords.
  • There is no change in the ratios of the cross sections over age – the cricoid doesn’t start relatively smaller and enlarge by the time you hit 8.
  • The cross-section looks like an ellipse (there’s more distance between the anterior and posterior bits than the two side bits).

 What should we do then?

Well for starters we should probably settle the tube choice thing. This is just more support for the argument to use a cuffed tube. For starters, the old “leak” test seems pretty dubious when you could be snug against the lateral walls but still leaking around the anterior or posterior areas. And I’m guessing no one has had their “leak accuracy assessment” externally audited.

It makes more sense to use an appropriately sized cuffed tube with the cuff pressure kept < 20 cm H2O. There’s now fairly convincing evidence that appropriately used cuffed tubes don’t cause big issues in recovery. Better ventilation, better monitoring, less flows and gentler tube material in contact with the mucosal wall. Makes sense.

What you can’t do is ignore the cricoid. It is still an unyielding bit of the anatomy and anyone can turn a high volume-low pressure cuff into a high volume-high pressure cuff – the difference is a couple of mL. And swelling in an airway that starts with a much smaller cross-sectional airway still means less margin for flow obstruction.

So choose the right tube, use it safely and you can get on with things.

 

While We’re At It, Let’s Forget One Blade to Rule Them All

Seeing as we’re talking about things that aren’t things, you may have also come across the idea that you should use a straight blade for the smaller kids (say, kids under 2). I’ve mentioned elsewhere that I think this is baloney but here’s a little bit of evidence.

Varghese and Kundu have published something on exactly this issue. 120 kids aged from 1-24 months had laryngoscopy (once anaesthetised and given muscle relaxation) with either a Miller or Macintosh blade, and then crossed over to the other type of blade. (Note they used both with the tip in the vallecula.)

The findings? The views were pretty much the same. The rates of difficulty were about the same. In fact, it’s a pretty beige set of numbers where being beige is actually as cool as things could be.

Some where the view wasn’t so great with a Macintosh had a better view with the Miller blade. Some went in reverse. The message though is a pretty resounding “same, same”.

 

So there’s just some truths that needed revisiting. There are no funnel-shaped airways. The airway isn’t round. There’s not one correct blade for the under 2s.

I still resent having to give up on the Public Holiday Numbat though.

References:

Here are the PubMed links for those mentioned in this post.

Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Pediatric Anesthesia 2014;24:1204-11. doi: 10.1111/pan.12490

Tobias JD. Pediatric airway anatomy may not be what we thought: implications for clinical practice and the use of cuffed endotracheal tubes. Pediatric Anesthesia 2015;25:9-19. doi: 10.1111/pan.12528

Varghese E and Kundu R. Does the Miller blade truly provide a better laryngoscopic view and intubating conditions than the Macintosh blade in small children? Pediatric Anesthesia 2014;24:825-9. doi: 10.1111/pan.12394

Why? How? What? Big Questions for Prehospital Simulation

At CareFlight another round of training many people is about to come up so it seemed like a good chance to ask Dr Sam Bendall for her first contribution. 

Sam is an Emergency Physician who is passionate about education, particularly all things simulation. She works half-time at Royal Prince Alfred Hospital in Sydney in the Emergency Department where she helped develop and teaches the RPA Trauma Team Training program, teaches on the CIN nurses programs and helped develop the ED Essentials program. 

At CareFlight she is a retrieval doc (the other half-time) and the Deputy Director of Education. The CareFlight Education Team are always up to interesting things – from training the Australian Defence Force medical on how to look after all things ballistic, medical, surgical and paediatric, to running the Pre-Hospital Trauma Course both in Sydney and other locations (Malaysia, anyone?), to running Trauma Care Workshops all over the country. Oh, and of course all those working with CareFlight too. 

Anyway, here’s Sam …

 

As a passionate advocate for simulation I look around and see this amazing tool appear in many guises, all under the same blanket term. It certainly seems to mean many things to many people depending on their previous experiences. In some ways it is the SWISS ARMY KNIFE   of kinesthetic education. The coolest knife has pliers and scissors. However, just like a Swiss army knife, it can be a harmful weapon (hence the name!), just plain useless (like when you want the one with pliers but you only have the single blade), or a bit uninspiring and encourage automatic behaviours – e.g. all Swiss army knives are red and you should have one.

This clearly rubbish version doesn't even have the magnifying glass.
This clearly rubbish version doesn’t even have the magnifying glass.

Simulation has almost become the learning apparatus du jour – everyone has to do it but some are not sure why or how to really make it work. A bit like having a Swiss army knife so you can be part of the Swiss army, but it lives in the drawer.

I will put a disclaimer in at this point. The following are my own opinions – the musings of a dedicated simulation-phile after several years of training in simulation and doing simulation exercises for anywhere from 2 – 150 people.

So what’s the point?

WHW copy                                            

I’m going to put a slightly different spin on it, with an emphasis on simulation for the pre-hospital environment. Simon Sinek, in his TED talk in 2009 titled “Start with Why” made a very powerful case for asking yourself WHY you want to do something… in this case, simulation, at the outset. The HOW and the WHAT will follow if you drill down onto the why and firmly establish WHY you want your participants to do simulation.

Simulation is a journey, for both the instructors and participants. Hopefully a journey towards some constructive learning, but one that will have many interesting twists and turns along the way. Being sure of WHY you are undertaking this part of the journey, gives you the freedom to explore the twists and turns of the journey without losing sight of the original intent. So my step 1 in building a simulation, is to ask yourself why? WHY are you doing this?

In our organisation, our WHY? is to create a mission-ready workforce.

Pre-hospital medicine throws out so many variables – communication, teamwork, environmental, situational awareness, medical challenges, geographical challenges and the list goes on.

In order to make our workforce mission ready, we need them to be critical thinkers, able to choose the right skill, equipment and approach for the right case at the right time.

Though if we had one of those shapeshifting Terminator ones could we program it to be friendlier?
Though if we had one of those shapeshifting Terminator ones could we program it to be friendlier?

We also need them to be aware of the variables they will need to deal with on real jobs so that they can manage them consciously. In order to do this we need to replicate as many of these variables as possible so they can address them in a training environment. We aim to send our participants out on jobs that feel just like the scenarios they have done in training. No pressure!

HOW? – choose your weapon

Weapon copy

The simulation menu is fairly extensive and limited only by your creativity and ability to structure it in a way that is true to the learning objectives and easy to follow for your participants. The key elements of creating a scenario, whether it be for 2 or 50 participants, is that they need to know the rules, boundaries, and premises for the scenario….. hmm sounds like parenthood!

So first decide on your structure. Is it an audience that is learning a concept for the first time and you need to do it for real, but slow it down? Well “pause and discuss” is your man. Do you need to see where your participants’ critical decision making is at and where the deficits lie? Immersive, relatively high fidelity simulation, with key variables built in, is the tool of choice.

Do you need to occupy 30 participants in a large scale simulation? – Create foci so the participants will need to form their own teams within the simulation. This will bring out all of the teamwork, communication and leadership points from the start.

Whatever weapon you choose, it needs to be appropriate to the audience, their experience and what you are trying to teach by doing the simulation exercise.

WHAT …the final frontier

Well this depends on what you are trying to deliver in your simulation. If, for example, your aim is to test and consolidate a new protocol, then the scale of your simulation can be quite limited. You may not need to bring in as many variables, or much fidelity. As long as the key prompts are there for the participants and they have the knowledge, skills and equipment to fulfill the protocol, then a limited scenario is fine.

BUT…. and there is a BIG but in this one. Be realistic in developing your scenario. If you are testing an ALS protocol, doing a bog standard ALS protocol with a patient in a bed may tick your box. BUT ….. in 20 years of medicine I think I have been to less than 10 arrests in ward beds and way more than 30 in other places – the toilet, the CT scanner, theatre, the foyer of the hospital, the waiting room, the beach etc. etc. You get the picture. So I would argue here that a bog standard ALS type scripted scenario has its place, but should be followed up by the application of the protocol where it is likely to happen and bring in the teamwork and communication aspects that we know actually make ALS protocols work in real life.

At CareFlight we educate using a “crawl, walk, run” paradigm.

  • First you crawl – i.e. you learn the skill or concept in isolation.
  • Then you walk – using relatively low fidelity simulation with limited learning outcomes, you learn to apply that skill appropriately.
  • Then you RUN. In our “RUN” scenarios, we introduce many more variables that replicate the environment they will have to operate in. We increase the fidelity and prompt the participants to evaluate the situation, decide whether that skill or concept is appropriate, apply it if it is or find an alternative if it is not. This layering approach helps to consolidate skills and knowledge and develops critical decision-making processes in a way that is directly applicable to the job we do.

When you get to the RUN scenario you are trying to bring out multiple learning points across many categories, for example:

  • Teamwork and communication (CRM)
  • Leadership skills (CRM)
  • Graded assertiveness and conflict resolution (CRM)
  • Scene safety and situational awareness (CRM, environmental and logistics)
  • Management of a multitrauma patient in an isolated environment (medical)
  • Packaging and preparation for transport (logistics, medical)
  • How to carry a patient out of the bush safely (logistics, medical)
  • Planning for contingencies e.g. weather etc. (logistics)

Then the scenario has to be much higher fidelity and be crafted in a way that replicates those key learning objectives – CRM, medical, environmental and logistic. You need to recreate the key environmental elements that will impact on the participants’ decision-making, bring in the key teamwork elements, replicate the equipment or types of equipment they will use and think about the team structures they will be given. Even simple tweaks to the scenario such as limiting access to the patient’s head, can improve the problem solving and CRM elements of the scenario so the devil is very much in the detail here. AND SO IS THE FUN …

Why yes that is a mobile rollover simulator that some clever people built ...
Why yes that is a mobile rollover simulator that some clever people built …

A Short Video About Bleeding Airways

Managing the airway in prehospital and retrieval medicine is a challenge and has inspired many a discussion in many a setting. And anyone working in the area would appreciate the additional challenge when there’s lots of blood getting in the way.  As a result everyone has tips and and tricks to try and manage things.

This is by no means the first time people have come up with an approach (or shared an approach) but in the spirit of wide-ranging discussion, here’s a suggestion from Dr Alan Garner recorded for posterity in video.

It runs for about 10 minutes and you’ll note that at the end there’s an update as the approach evolved.

All thoughts, feedback and experience very welcome.

Keeping Things Calm: Remote Retrieval of the Psychiatric Patient

Jodie Mills, RN works with CareFlight’s Top End Medical Retrieval Service, flying out of Darwin across vast stretches of the Northern Territory. She grew up in the Royal Melbourne Hospital ICU before moving to Darwin 8 years ago where she completed midwifery studies.  She joined CareFlight 4 years ago and slightly pities all those who don’t get to fly in the top end. 

 

When asked to contribute to a blog and write about psychiatric aeromedical retrieval all I heard was my colleagues’ collective signs of “not another psych job!!”

The thing is, I’ve developed a bit of an interest in these patients after closely looking at the psychiatric retrievals in NT for the last 3 years. This specialised patient group presents a huge challenge to both the flight crew and our remote colleagues when presenting acutely unwell in our communities.

By the Numbers

I recently presented at the ASA/FNA/ASAM Aeromedical Retrieval Conference in Brisbane. I thought maybe we had a few psychiatric patients but I quickly realised after my presentation that the number of psychiatric retrievals we undertake in the top end is well above average i.e. its extremely high (15% of our total missions).

From Feb 2012 to the 20th October 2014 we retrieved 651 psychiatric patients, averaging 22-24 per month  – it’s an almost daily occurrence. Demographically the patient population remains consistent with approx. 90% of patients Indigenous Australians, with male to female ratio if 1.45:1. The mean age is 31, however our youngest was 12, our oldest being 74 years.

We have only intubated 3% of this population which has led to expedited admission to the singular psychiatric facility at Royal Darwin Hospital (RDH). The inpatient psychiatric ward at RDH has a catchment area of 700,000 square kilometres.

It’s Not Just a Local Thing

Mental illness throughout the world is on the increase with the WHO (2014) predicting mental illness to be second only to cardiovascular disease for burden of disease by 2030. The stigma associated with mental health issues remains the greatest obstacle to such patients accessing appropriate care. This stigma may be even more pronounced in remote Indigenous communities. Drug induced psychosis, predominantly cannabis (397 patients), followed by suicidal ideation/ hanging (224) were the most common diagnosis with the remaining patients having bipolar, mania or behavioural disturbances.

At the ASA conference I asked my aeromedical peers “How do you transport your psychiatric patients?” the answer was “we don’t, they go by road”. I quickly realised then that CareFlight and other retrieval services working in truly remote areas provide a unique service.

The small window view of a big country.
The small window view of a big country.

The Perfect Storm

We all know too well the challenges involved in the aeromedical transport of compliant patients who are unwell. However if we add delusions, hallucinations, physical aggression a tendency to physical violence and homicidal thoughts into the mix we have a potential aviation disaster on our hands. These are the just some of the symptoms the majority of our psychiatric patients display when referred to CareFlight. We then face the task of transporting such patients in a small aircraft where we will place seatbelts and wrist and ankle restraints on them, we will sit approximately 50cm away from them and the tell them they cannot smoke, they cannot go to the bathroom, they cannot eat or drink. I can’t imagine how stressful this must be for a patient that is already thought disordered.

What We Do

The biggest challenge for the aeromedical clinician is assessing the need and amount of sedation that will be required for safe retrieval of the acute psychiatric patient. If we have learnt anything it is definitely that “one-size DOES NOT fit all” when it comes to choosing sedative combinations to safely retrieve acute psychiatric patients. However we have found that pre-flight sedation with an atypical antipsychotic (olanzapine) and a sedative (diazepam) is of the utmost importance. As we become better skilled at treating psychiatric patients we have increased the pre-sedation (Olanzapine & Diazepam up to 20mg oral) which seems to be decreasing inflight sedation requirements. This enables the psychiatric patient to be admitted to the appropriate ward in a timely manner.

Top Tips for What to Do:

  1. Start sedation early:

As mentioned above, premedication prior to retrieval is vitally important. In most cases an antipsychotic (Olanzapine 10mg) and a benzodiazepine (Diazepam 10mg) is the premedication of choice. However, acute psychiatric patients presenting with drug induced psychosis (be it first or subsequent presentations) routinely require up to 20mg- 30mg of both Olanzapine and Diazepam orally. The first dose of sedation is given prior to the crew departing Darwin and then half an hour prior to the crews landing at the communities/ regional hospitals. This administration is overseen by the Medical Retrieval consultant (MRC) on duty. If the patient is not responding to the Olanzapine and Diazepam, the likelihood of requiring in-flight sedation is increased as is the probability of intubation for transport.

  1. In-Flight sedation:

We find in flight we tend to use midazolam, propofol and ketamine. The drug of choice is directly related to the flight doctor’s area of expertise. The ED Registrars tend to use midazolam and ketamine, whereas the ICU and Anaesthetic registrars head for the propofol and midazolam.

On arrival at the referral centre the patients are assessed for the need for further sedation prior to flight.

  1. Pre-Flight Sedation: Midazolam 2-5mg IV
  2. In-flight Sedation:
    • Propofol Infusion 0.2-0.5mg/kg/hr and titrate as required
    • Ketamine Infusion 0.5-1mg/kg/hr and titrate as required

A Richmond Agitation Sedation Scale (RASS) of -3 (Moderate) to -4 (Deep) or a Ramsey Sedation score of 5 indicates the level of sedation required for safe transport.

The ability to discontinue the sedative and allow the patient to wake prior to admission at the receiving centre is extremely important. If the flight crew are able to deliver an acute psychiatric patient to the receiving centre awake and ready for assessment this expedites the patients’ admission to the in-patient facility from the emergency department or, optimally allows for direct entry into the inpatient facility at the receiving centre.

Richmond Agitation Sedation Scale:                                                                               

Richmond copy

Ramsey Sedation Scale:

Ramsey copy

  1. Managing the environment:

Managing the stressors of flight is extremely important when retrieving an acute psychiatric patient. Using ear plugs, blankets to keep patients warm, positioning for comfort when heavily sedated, limiting cabin conversation and ensuring physical restraint are fastened appropriately ensures the acute psychiatric patient does not experience any extraneous stressors throughout their flight.

  1. Local law enforcement:

On occasion the local law enforcement will be involved with the acute psychiatric retrieval. The resource poor environment of the community clinic necessitates the presence of police to help control patients as documented under the section 9.

  1. Coordination:

The coordinating Medical Retrieval Consultant will liaise with the Consultant Psychiatrist on call at the hospital, alerting them to the impending admission.   The Consultant Psychiatrist then coordinates  with their in-patient team to ensure timely assessment of the patient if they are to be admitted through the emergency department.

 

Although the collective groan when another psychiatric retrieval arises resonates through the base we remain steadfast in our support to our rural and remote colleagues and we will continue to play a vital role in maintaining safety of the community, the families and the patients who are all touched by mental illness in the top end of the NT.

 

DIY to Stop the Blood

This thing comes from Dr Andrew Weatherall, paediatric anaesthetist and prehospital doc. He also blogs over at www.theflyingphd.wordpress.com

 

I don’t do DIY. This is partly because in the same way I wouldn’t expect a carpenter to have a crack at fixing their kids’ bones in preference to seeing an orthopod, I think it makes sense to use professionals.

It’s also because I’m just not that great at it. Anything I did make would end up looking like something trying to squeeze itself into the shape of the thing it is sort of supposed to be. And I’m fond enough of my family to want to protect them from the risks of my own handiwork.

Here's one I prepared earlier (via CC and flickr user mhlradio)
Here’s one I prepared earlier (via CC and flickr user mhlradio)

Anyway, I do paediatric anaesthesia. I get to spend more than enough time trying to make things that aren’t quite right for the situation fit in with what I need. Why DIY at home when you have to DIY at work?

 

Making Things Fit

The problem with paeds practice is that kids are sometimes kids and sometimes little adults and often forgotten in research. Or if not forgotten put in the category of “the ethics and logistics of that will be so painful I’d rather remove my spleen via my auditory canal”. And in trauma care we’re also dealing with total numbers that are lower than is the case for adults.

So what we end up with is lots of extrapolation from adult data and lots of retrospective studies sprinkled with the occasional fairy dust of a small case series. Then we have to try and mash those leftovers together to come up with a plan for a very specific situation.

An example: how about tranexamic acid in trauma?

 

Making It Up

Following on from CRASH-2 and MATTERs, what to do in the younger generation is an obvious question. A big prospective study in kids after trauma would be perfect. And a pipe dream.

So if you turn to the literature what you see is a large number of people trying out archery on summer camp and hitting many, many different targets while all shooting vaguely in the same area.

To corral some of them in one spot, take the review by Faraoni and Goobie looking at antifibrinolytics in non-cardiac surgery in kids. All of the following values are listed as loading doses in the scoliosis and craniofacial groups: 10, 15, 20, 50, 100 and 1000 mg/kg with infusions anywhere from 1 mg/kg/hr up to 100 mg/kg/hr. In the scoliosis patients there are total numbers of up to 80 patients and slightly baffling figures suggesting total blood loss is decreased but transfusion requirement pretty much the same. Or that in the craniofacial surgery group it seems like probably there might be slightly less blood loss and transfusion needs.

But in paediatric cardiac surgery there might be more seizures too, even though the overall safety profile looked pretty good. Nothing definitive though. Such clarity.

So now the job is to consider how to take this magnificently imperfect evidence and apply it to a specific and different clinical scenario, trauma.

Go.

 

The Pragmatist

The Royal College of Paeditrics and Child Health and the National Paediatric Pharmacists Group Joint Committee had exactly this challenge back in 2012. It’s the intellectual equivalent of trying to catch pancake batter. Messy.

Ultimately they chose what they termed the pragmatist’s option – 15 mg/kg loading (up to 1 g) over 10 minutes then an infusion of 2 mg/kg/hr. Maybe enough to do something, but with a homeopathic infusion so you were unlikely to get complications. Entirely rational in the absence of evidence too.

But what if there was another approach?

 

Another Way

What they didn’t have access to was some recent data out of the UK military Afghanistan experience in Camp Bastion. TXA had become standard for adult trauma patients under certain conditions after the release of CRASH-2 and both editions of MATTERs. These sort of treatment centres don’t just receive adults though and they must have been wrestling with what to do in smaller patients.

What they describe is another type of pragmatic approach. Rather than any adjustment they just did what they were already doing. Tranexamic acid in a 1 g dose for all comers and more on the basis of medical assessment (though it looks like no one got another dose).

This gets past lots of problems, particularly with getting accurate weights or ages and the need to learn different treatment regimes. It also comes with a certain amount of glee, not because you’re sort of saying “kids are just little adults” and you know that would break plenty of people. You’re actually saying “kids are adults”. If you say that 3 times while drawing a pentagram in a circle of candles, somewhere a paediatrician will be woken with a pain between their shoulder blades.

They describe a breakdown of 66 patients under 18 getting TXA and 700 without TXA. Having severe abdominal or extremity injuries and showing evidence of severe metabolic acidosis were significant predictors that TXA would be used. TXA use was independently associated with reduced mortality but no great difference in packed red blood cell/fresh frozen plasma transfusion ratios. Intriguingly in those getting a large volume transfusion, receiving TXA was associated with greatly improved neurologic status at the time of discharge (now that opens up a need for more work). They didn’t note an increased risk of thromboembolic complications (but they probably don’t have the numbers to be sure about that).

Overall, we’re talking about kids with an average age of 11 so using the equation of (3 x age) + 7, the weight might be about 40 kg (though I’m not certain if the weights might be a bit less than algorithms from developed countries). That would mean a starting dose averaging round 25 mg/kg.

 

The Other Extra Bit

That 2014 review also mentions an additional titbit that’s a little useful. Some pharmacokinetic work has been done in patients with craniofacial surgery patients and it appears that an upfront dose of 10 mg/kg then an infusion of 5 mg/kg/hr is optimal for establishing appropriate drug levels. This is far more useful information than cardiac surgery pharmacokinetics where additional considerations of dilution by bypass circuits, potential for pre-existing cyanosis and a variety of other factoids make it hard to draw comparisons. So 10 mg/kg might be enough initially but the subsequent infusion should probably be more than a scattering of holy water (as in more than 2 mg/kg).

 

The Bottom Line

We’re still stuck with not enough information about paediatric patients. Will there be a bigger study in paeds trauma soon? Probably not. But we can say with more confidence than before that doses that are pretty big seem to be OK.

So what would I do now? I’d modify the pragmatic plan and go with a 20 mg/kg loading dose (or 0.2 mL/kg of our current stock) and once in hospital I’d go with an infusion of 5-10 mg/kg/hr.

And I’d still hope someone is going to try to build a better shack.

 

References:

Are you after that review? It’s Faraoni D and Goobie SM. The Efficacy of Antifibrinolytic Drugs in Children Undergoing Noncardiac Surgery: A Systematic Review of the Literature. Anesth Analg 2014;118:628-36.  

Or maybe the RCPCH statement on using TXA in trauma – try here.

And here’s the Pubmed listing for the newer trauma study – Eckert MJ, Wertin TM, Tyner SD et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: The pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014;77:852-8. 

And in case you didn’t have it already, here’s the spot for the [(3 x age) + 7] calculation. Luscombe MD, Owens BD, Burke D. Weight estimation in paediatrics: a comparison of the APLS formula and the formula ‘Weight = 3(age)+7’ Emerg Med J 2011;28:590-3. 

Thoughts from the Control Tower

This is the first of what we hope will be a series of posts from Dr Paul Bailey who works as a Medical Director for CareFlight International Air Ambulance. Paul will try to provide insights into the challenges of managing retrievals across oceans. Here’s the starter. 

In his real life, Paul Bailey is an Emergency Physician based in Perth, Western Australia who dabbles in the Greyhound racing industry (having owned 10 dogs and never been to the track).  He can often be found in the outer at an Aussie Rules football oval, most commonly critiquing the performance of the umpires in an entirely constructive manner.  Past lives include a molecular biology PhD – in Jellyfish venom – don’t ask – and being a glassy in various drinking establishments in Western Australia. 

 Paul has previously undertaken international retrievals, helicopter work supporting Australian Army exercises and time with Queensland Rescue at Cairns. He now makes cameo appearances on the International Medical Director roster, as a medical director for retrievals in the NT and the Inpex oil and gas business.

 

If you’ve decided to be involved in retrieval, why think local when you can think global? After many years of toiling through school, then medical school, and then advanced training in the acute care specialty of your choice, you’re now in the hot seat ready to go.

Living the Dream

You’ve always fancied yourself as an airborne medico ever since you sat on your Dad’s knee watching “The Flying Doctors” in the late ‘80s and thinking how cool that would be. Truth be told, you also liked Top Gun and from time to time have drawn a laugh with the immortal line: “Negative Ghostrider, the pattern is full.” But you still buzzed the control tower anyway.

Fly Past copy

Or perhaps more likely you rode that little bit too close to your Mum on your BMX. You’ve also heard, along the way that everyone in retrieval gets a nickname and you’re tossing up between Maverick and Goose.

Top Gun copy

And it’s safe to say you have bought the Ray Ban Aviators already.

 

Living the Reality

So what’s it really like? Different to that, not surprisingly.

CareFlight International Air Ambulance (CFIAA) is an ever changing beast, with our clinical teams and aircraft based in Darwin and Sydney. Over the journey we have also had aircraft in Perth and Cairns. Depending on where the team is on duty, they are most likely to be flying between Indonesia, East Timor, Papua New Guinea, Darwin and Adelaide (for Darwin crews) and Fiji, Noumea, Norfolk Island, Sydney and Brisbane if you are based in Sydney. Of course, it’s international so there actually isn’t a spot on the globe that shouldn’t be thought of as up for grabs.

Co-ordinators and Medical Directors sit behind the team at all times and, due to the miracle of mobile phones and the internet can be almost anywhere. Many of these folk never meet in person but are always looking over everybody’s shoulder.

More of that later, in this awe inspiring opening to the series I though I’d start with how it all gets going – who pays for it all?

 

The People with the Deep Pockets – Travel Insurers and Governments

When your average citizen takes out travel insurance, it is most likely to protect against such tragedies as losing an iPhone overseas, dropping a wallet in the ocean or perhaps finding himself in Vietnam and his luggage in downtown Boston. Having been in this game a while now, it is my opinion that if losing your iPhone is the worst thing that happens on your holiday you’ve had a pretty good time.

Recliners copy

It may surprise you to know that a travel insurance policy is, by and large, a health insurance policy. Greater than 95% of the spend of travel insurance companies relates directly to health costs.

Each travel insurer has a series of service providers sitting behind them, one of which is an assistance company. There are a relatively small number of assistance companies that engage in this type of work. They have 24h call centres with co-ordinators, nurses and doctors (much like us).

In the event that John Q Citizen becomes unwell or is injured whilst they are away – by getting gored by a bull in Pamplona for instance – they or their relatives call the assistance company and a whole train of events unfolds, which might include directing patients towards local health care facilities to help with their medical problems.

The assistance company will maintain contact with the now patient and their family, and depending on how things in the event that the medical issue is of a serious nature, things tend to pan out in one of two ways that relate to the quality of health care available locally and the underlying urgency of the patient’s medical condition.

Let’s focus on the sicker end of the spectrum because clearly many issues are of a minor nature and never come anywhere near us.

If “definitive care” is available locally AND the quality of local medical care is high AND treatment of the matter is urgent assistance companies will usually head down the route of electing to keep the patient where they are for treatment in the theory that that is both (a) best for the patient and (b) cheaper than an international medical retrieval.

If “definitive care” is NOT available locally OR the quality of local medical care is questionable it is then the key decisions become urgency and mode of transport.  There are, again, an array of transport options available but seeing as we are in the Air Ambulance business, again we might focus on that.

 

Send in the Big Bird

The assistance company, having decided that medical evacuation is required and that this is most appropriately by air ambulance asks its panel of Air Ambulance providers for a quote. At this stage, the available information usually consists of the patient location and their ultimate destination. No clinical information is available.

Our co-ordinator submits a quote, and due to the price of aviation fuel the retrieval company with the aircraft that has to do the least amount of flying to get the job done is usually cheapest. Paperwork is exchanged and the job confirmed.

Clinical information is then available and at this stage the CFIAA Medical Director is brought into the discussion – to liaise with treating clinicians at the hospital of origin as well as the destination unit. How many times is it quick and easy to have a chat with someone you’ve never met in the hospital? Well, it is fair to say that these conversations can be difficult – finding the right person in an overseas hospital at a sometimes odd times of day and surmounting the language barrier is not straightforward.

We are often going to locations where the quality of the medical and nursing staff are excellent but the broad array of diagnostic equipment that many of us consider routine are just not available. Similarly there are many locations where the patient will have a problem that is unable to be treated effectively with the resources available locally. It’s part of the game, and in many ways it’s why we are needed in the first place. A lot of the legwork for the coordinator is about trying to construct a story that is useful for the retrieval team and help plan for every contingency.

So, that’s a summary of all the things that happen before you get to find out about a case. We haven’t even got to the challenges of the actual patient yet.

I might finish off with a thought for the day:

If you can open your packs blindfolded, upside down and in a thunder storm – and know where everything will be, you have satisfactorily completed orientation.