The Faculty of Pre-Hospital Care

2016 Conference Blog

Dr Caroline Leech has written a blog of her highlights of this year's conference supplemented by tweets from the day that were sent in on the #BASICSFPHC hashtag.

Conference Blog 2016

The Annual BASICS & FPHC Joint Conference was held at Woodlands Grange in Leamington Spa on 14-15th October 2016.

Over 300 delegates attended over the two days: this included the main programme of talks, seven different workshops, a Diploma of Immediate Medical Care revision session and a specific Student programme. Here is a snapshot of just a few of the fantastic talks we heard.

'Guess or Gestalt' in Clinical Decision Making 

Professor Simon Carley

Medicine is a science of uncertainty and an art of probability - William Osler

The reality is that we use Evidence Based Medicine only where it is available and if we believe in it! Simon described a complex clinical case where no single guideline would help.

Clinicians are not diagnosticians, they are problasticians where they use the anticipated probability of outcomes to make a management plan.

In the pre-hospital environment we see patients early in their disease process and therefore our probability of error in clinical judgement is greater.

At the end of the talk Simon gave us some ideas for pre-hospital clinicians to use to improve their clinical judgement:

1. Think about your thinking
2. Have an Awesome and Amazing meeting, not just M&M meetings
3. Arrange some peer review
4. Ask yourself if you are lucky, skillful or both
5. Ask why things happened, not just what happened
6. Follow up some of your routine patients

The Ambulance Response Program: Improving Ambulance Service Clinical Response
Prof Jonathan Benger

Established in January 2015, the ARP has been operating in all ambulance services in England to change the way we dispatch ambulances and improve response times. There is no evidence base for ‘60 seconds to phone triage’ or the 8 minute response target for Red calls.

The key elements of the programme include:
1. The use of a new pre-triage set of questions to identify patients who need the fastest response immediately (Nature of Call eg cardiac arrest)
2. Dispatch of the most appropriate vehicle and trained staff to each patient in a timeframe that meets their clinical need (Dispatch on Disposition)
3. A new set of clinical codes evidence based on historic data from previous codes/outcomes to better describe the patient’s condition and resource requirements.
4. Giving call handlers an extra 2 minutes to obtain more information to enable selection of the most appropriate resource.

Evidence so far demonstrates that with the new system more appropriate resources are being sent to the patients first time, with less mileage, less stand downs, less long-waiters (a smaller stack) and a more appropriate level of clinician arrives at the patient first time.

Some ambulance systems have 40% cars in their fleet to arrive at all jobs within 8 minutes. Under new proposals, the optimal response would be with a fleet of 15% cars and 85% Double Manned Ambulances.

You can read more about the Ambulance Response Programme at https://www.england.nhs.uk/ourwork/qual-clin-lead/arp/

The FPHC Consensus Statement on the Pre-hospital management of Burns
Emir Battaloglu

This presentation covered the main learning points from the FPHC consensus meeting held earlier this year which is due for publication soon. The draft recommendations include:

• Large bore endotracheal tube intubation is recommended for definitive airway management in burns patients with airway compromise. (D)
• Prophylactic intubation is recommended when suspicion of impending airway compromise is accompanied by full thickness facial burns, stridor, respiratory distress, swelling on laryngoscopy, smoke inhalation or singled nasal hairs. (D)
• A longitudinal skin incision is recommended for surgical airway placement in burns patients. (D)
• High flow oxygen should be initiated through the use of a non-rebreathing reservoir mask at 10 – 15 l/min and aim for oxygen saturations within the range of 94–98%. (D)
• Intraosseous circulatory access is recommended for burns fluid resuscitation and drug administration, when intravenous access fails. (D)
• The use of the Lund & Browder chart (or electronic equivalent) is recommended as the optimal method for accurate burns severity estimation. (D)
• A recommendation is given to estimate burns severity between the following categories; <20%, 20-50% & >50% TBSA. (D)
• Initiation of fluid resuscitation is recommended for adult and paediatric burns >20% TBSA, guided by the threshold method for determining fluid requirements. (D)
• The use of cool running water for a period of 20 minutes is recommended for burns first aid and should be conducted at the earliest opportunity, up to three hours from injury. (B)
• Ice water cooling is not recommended for burn cooling. (B)
• The use of polyvinyl chloride (cling film) dressing is the recommended method of burns wound care. (D)
• In chemical burns, it is recommended to provide wound irrigation for as long as practically safe and possible, at any opportunity regardless of delay in presentation. (D)
• Amphoteric solutions are not recommended for use in chemical burn first aid. (C)
• Non Steroidal Anti-Inflammatory Drugs (NSAIDs) are not recommended for burns analgesia. (C)
• Escharotomy is only recommended for circumferential or near circumferential eschar with impending or established respiratory compromise, due to thoraco-abdominal burns. (C)

The PARAMEDIC-2 Trial

Helen Pocock

Helen is a Research Paramedic with SCAS who is working on the PARAMEDIC-2 trial: a RCT comparing Adrenaline with placebo for OOHCA. Whilst currently standard practice, previous studies in the literature suggest that use of Adrenaline may actually be associated with a reduced survival to hospital discharge.

As well as being a fantastic study to answer an important clinical question, this trial has eloquently demonstrated some of the challenges of pre-hospital research. For this trial it was about ensuring members of the community could refuse to be recruited in the event of a cardiac arrest by wearing a ‘no study’ bracelet and the HPC issuing a statement which gave ambulance crews the confidence to deviate from ‘standard practice’. Data gathering with paper records, training all of the frontline ambulance staff, and addressing massive media interest also were addressed successfully.

The Transport Research Laboratory
Adam Barrow

Adam gave a fantastic lecture describing the work of the Transport Research Laboratory who provide in-depth collision investigation to make recommendations for improvements to road safety.

The research team are notified of serious collisions by police or the ambulance service in the Thames Valley region and attend by response vehicle to capture forensic evidence at the scene. This includes assessing environmental factors (eg highway features, weather), human factors (eg distraction) and vehicle factors (eg road worthiness, crash worthiness of the vehicle design). This information is matched up with hospital records and post-mortem data to assess how injuries occur.

Several examples were given, how injury patterns have influenced car design. Historical data showed in a frontal impact, the intrusion into the vehicle was the main mechanism of injury and therefore crumple zones and airbags were modified. Whilst seatbelts prevent thoracic injury from impacting with the steering wheel, there is also now an increased risk of sternal injury with seatbelt pre-tensioners. If airbags deploy too late eg if a car goes under the rear of a lorry and impacts with the A post not the bonnet, there is a risk of cervical spine injury.

Adam also described how the windscreen is much stiffer towards the edges so if you see a bullseye near or on the A post this is more likely to be associated with a fatal head injury.

You can read more about RAIDS at https://www.gov.uk/government/publications/road-accident-investigation-road-accident-in-depth-studies/road-accident-in-depth-studies-raids

Workshop – Media Management www.amtvmedia.com
Alistair Macdonald

The top tips when giving a media briefing following an incident are:
1. Never speculate or apportion blame
2. Never name the victims
3. Never embroider or elaborate
4. Never say “no comment” – this sounds like you are guilty!
5. Always keep promises to the media (eg times of meetings or they might make up the story)
6. Always be human and sympathetic (but not using cheesy lines)
7. Always tell the truth!
8. Whilst maintaining confidentiality, you need to give the media some information to work with. Say something without giving anything away!

The FPHC Myles Gibson Lecture: Extreme Pre-hospital Medicine
Kevin Fong

Professor Myles Gibson founded and was the first Chairman of the FPHC in 1996, laying the foundation of PHEM as a medical sub-specialty. The Annual Myles Gibson lecture was presented at this conference by Dr Kevin Fong.

“Space is the ultimate pre-hospital environment”- Kevin Fong
Kevin gave a fascinating talk on the impact of space living on physiology, how healthcare in provided in the space environment and how astronauts might evacuate in a medical emergency. He highlighted the essential interface between human performance and technology for providing exemplary pre-hospital care.

White Space - Antartica
Dr Beth Healey

Dr Beth Healey is a junior doctor from London who spent 14 months on the Concordia Research Station in Antarctica. The centre conducts research into the human physiology and psychology for isolation that crews would experience in space. The thirteen European crew members spend nine months of complete isolation and have four months in the Antarctic winter where there is complete darkness. The outside temperature falls to as low as minus 80C and at 3200 metres altitude even after acclimatization the crews Sa02 is 88% during exercise. Beth described some of the research which is being conducted on bacteria in snow samples, impact of artificial lighting on eyesight, how to recycle water, and effects of altitude on physiology. There are also some interesting neuropsychology experiments on identifying red-flag signs for astronauts in isolation such as using video diaries, cognitive testing and monitoring movement and interactions around the base.

Pre-hospital Research: The RESCUER and RePHILL Studies
Jim Hancox

Jim is a Research Paramedic from WMAS who is leading on the introduction of the multi-centre RePHILL trial comparing pre-hospital blood products with normal saline for hypovolaemic trauma patients. This trial is controversial for some pre-hospital practitioners who believe that pre-hospital blood is already the gold standard for management and therefore there is no equipoise. Jim described that there is no clear benefit in the literature that pre-hospital blood provides a survival benefit as illustrated in this systematic review: https://www.ncbi.nlm.nih.gov/pubmed/26825635.
The pilot study is due to start in the West Midlands in Autumn 2016.

Jim also presented preliminary findings of the RESCUER study: an observational audit to identify the resuscitation fluids (eg blood or saline or Hartmanns) and fluid volumes currently used by air ambulances in the UK to resuscitate hypotensive trauma patients. There are 22 air ambulance organisations with 34 airframes. Twenty-four (71%) have a doctor on board and 13 (38%) deliver blood products. Unfortunately 6/22 air ambulances declined to participate and these were all services which are already carrying blood leading to a bias in the data. The average fluid resuscitation in the literature was 750mls of normal saline for a hypotensive trauma patient.

Injury Prevention
Clarissa Chase

Despite the development of trauma networks and improved pre-hospital clinical care, there are still paediatric trauma patients who die before pre-hospital providers arrive at scene. There is currently no national collaboration on reducing deaths from trauma, for example road safety television broadcasts, and so trusted health care professionals have a responsibility to lead the public in injury prevention campaigns. Mipmap (http://www.wessexccp.org/about/#mipmap) is a multi-agency scheme in Wessex to develop injury prevention which has already collaborated with local schools, councils and families to deliver safety education programmes. As pre-hospital practitioners we all have a responsibility to support these sort of interventions in our local regions.

Pre-hospital Care in Rural Scotland
David Hogg & Richard Price

David works on the Isle of Arran where 90% of his work is as a normal GP but 10% is providing emergency care. The island has a population of 5000 people, with one ambulance staffed by one paramedic, and a community hospital. Only 20-30% of the emergencies in rural communities are trauma.

The majority of the care in emergencies is provided by volunteers including 200 first responders. One of the interesting aspects of the talk was how the team provide education to a large remote group of people. There is a Clinical Skills Mobile Unit which visits rural areas to provide training for individuals in their normal working teams, a Google group for communication, tele-education tutorial based programmes with kit posted to the teams, and a mobile app which include a GPS system for hospitals and alert messages. The key message was about optimizing local resources and making training local with innovative use of technology.

FPHC Poster Competition
Congratulations to Simon Dady, the winner of the FPHC Poster competition who won a RCSEd quaich and £100 cash prize, and to Harriet Hubbard and Christopher Lewis who were ‘highly commended’ for their posters.

The local air ambulance crew from The Air Ambulance Service flew in to join us in their Augusta 109!

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We look forward to seeing you at next years conference in Autumn 2017: date and venue to be confirmed!

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