A Hitchhiker’s Guide to PHEM
In June 2021 I had the privilege of completing the Faculty of Prehospital Care’s HEMS Elective with the Warwickshire & Northamptonshire Air Ambulance Team. During my elective period I had the opportunity to experience all aspects of Prehospital Emergency Medicine (PHEM) thanks to the programme organised by my elective lead Dr Caroline Leech. I am very grateful to Dr Leech, the FPHC and all the team members at the East Midlands Ambulance Service and Helimed 53 who welcomed me on board as a team member and provided me with this unique insight into prehospital medicine.
Chapter 1: “Preparation is Key…”
During the first week of my elective, I was invited to assist with the delivery of two regional trauma training days with The Air Ambulance Service (TAAS). This experience was invaluable to me as it provided me with the opportunity to become familiar with the type of equipment used by the local ambulance services and HEMS teams. The two days covered a range of topics including major trauma, silver trauma and difficult airway management. I was invited to join paramedics in high fidelity simulations to put into action the material we had covered. This was a great opportunity to work alongside the paramedic crews, some of whom I would encounter on the road in later weeks.
To complete my elective, I was invited to Edinburgh to play the role of a simulated patient for the DIMC & FIMC examinations run by the Faculty of Prehospital Care. Being a simulated patient for theses exams provided with a unique insight into the advanced level of clinical care and knowledge required to fulfil a role in prehospital medicine. During the week of examinations, I had the pleasure to meet various fellow medical students with a similar interest in PHEM as well as various healthcare professionals working in prehospital medicine who were eager to share their own career journeys and offer advice for prospective students.
Chapter 2: “Hello East Midlands Ambulance Service is the patient awake…”
This phrase echoes around the EMAS control room as I’m guided around the various areas of the building from the call handlers triaging calls, to the teams coordinating the allocation of crew resources, to the clinical desks providing enhanced triaging and allocation of specialist resources. I’m invited to join the doctor for my shift as they triage calls and provide advanced clinical decision making. In front of us the ever-growing list of calls appears with each call being allocated its appropriate triage priority. Large screens around the room highlight the pressures on the service indicating the calls waiting, resources on the road and available ambulances.
I pull up a socially distanced chair, the doctor passes me a headset and we start working our way through the list of calls. From the offset I’m impressed with how the service is utilising technology, using the GoodSam app and various traffic camera systems to get eyes on scene and aid triage and crew allocation. We receive a call from a crew requesting additional clinical advice, within a few seconds we have the electronic Patient Report Form (ePRF) details in front of us, we can see the patients ECG taken 2 minutes before and all their vital signs. We can see the patient’s blood pressure is dropping significantly as they stand indicating postural hypotension and advise the crew accordingly.
As we finish a call the highest priority call flashes on screen, a patient is in cardiac arrest. We listen in on the call as the call handler advises appropriately and across the control room I can hear an ambulance and rapid response paramedic being assigned to the call. Twelve people across the control room are listening in on the call allocating resources and providing clinical advice and activating an alert on the GoodSam app, which will trigger any first responders who are nearby. As the resources are allocated, we stop listening to the call and move on to the next call on our screen.
It’s now just after 9am and we being to target lower priority calls that could be resolved by other resources such as community pharmacies, general practice, or minor injury units. Throughout my shift I observed the doctor contact patients to obtain detailed histories enabling them to provide appropriate treatment options and free up crew resources to attend patients requiring an emergency ambulance. Prior to today I was unaware of this role in control, and it was fascinating to see how over the remainder of the shift the doctor was able to resolve patient issues efficiently and reduce the pressures on crew resources.
Chapter 3: ‘You must walk before you can fly…’
It was now time for me to take to the road with the East Midlands Ambulance Service. I was welcomed at Gorse Hill ambulance station in Leicester as I was shown around the station and introduced to the team. During my week at Gorse Hill, I had the opportunity to spend time with a Specialist Practitioner (SP) responding in a rapid response car. Prior to this experience I was unfamiliar with the role of a SP but over the next few days I observed how this new role with additional skills such as antibiotic prescribing, diuretic prescribing and wound closure skills allowed patients to be managed safely at home and avoid the need for hospital attendance.
Following my shifts on the SP car I was invited to join a crew on an emergency ambulance, we sign on at 8am and we are instantly allocated a call. A wife has just awoken to find her husband may be having a stroke, 999 mode is activated and we make our way to scene. On arrival it is clear the patient has suffered a stroke; we work together to assess the patient and quickly convey him to the local emergency department where the stoke team is assembled and awaiting us on arrival. Over the remainder of my ambulance shifts we attended a range of calls from strokes to cardiac events to mental health calls, to RTCs and traumatic injuries.
Chapter 4: ‘Here you go Doc, you have 5 minutes, start cutting…’
I was lucky to have the unique opportunity to spend a day at Canley Fire Station in Coventry with the fire and rescue team. This day provided me with a detailed insight into scene management and safety and the highlight of the day was having the opportunity to perform some extrication myself. Following orientation and demonstration of airbag deployment and seatbelt tensioners, I was taken to a car rolled on to its side and presented with the scenario of a patient trapped in the driver seat. We discuss the condition of the patient and I’m asked as a trainee doctor how quickly I’d like the patient extricated from the car. The patient’s observations are stable but we’re unable to fully assess the patient’s condition and the mechanism of injury is concerning so I suggest within 5 minutes for the patient to be fully extricated… with this statement I’m passed the jaws of life and the timer starts.
Laden with full protective gear, helmet, cutting tools and in 27 degrees heat I start cutting and four and half minutes later I have a newfound appreciation for the challenges presented to the fire service at major road traffic collisions. Scene management and extrication decision making are important skills for a prehospital clinician and a few weeks later I would observe how these skills were assessed at the faculty exams. I am grateful to all the crew at Canley who welcomed me and put on such a show for me!
Chapter 5: ‘Have you ever flown in a helicopter before…’
As I arrived at Coventry airport, the home of Helimed 53, I was made to feel very welcome as I was taken on a tour of the airbase and introduced to the various members of the team and issued my uniform. The service operates 24 hours a day, 7 days a week providing medical cover via helicopter during daylight hours and by RRV at night. I had opportunity over the weeks spent at the airbase to work with various critical care paramedics and doctors each of whom had a passion and enthusiasm for prehospital medicine and teaching. Between calls on shifts I was very grateful to receive a lot of teaching from the crews learning about various PHEM topics, practicing scenarios, and getting hands on with the various pieces of equipment used by the service. On my first day at the base the PHEM trainee doctor had setup a simulation for me based around the principles of managing traumatic cardiac arrest. In the scenario a motorcyclist had been thrown from their motorbike resulting in polytrauma, we ran through the scenario and the ‘HOT’ principles of traumatic cardiac arrest.
As I began my first observer shift with the team, I didn’t have long to wait for my first call. As the phone rang it was surreal to hear the call information, a motorbike vs car, police have arrived on scene and have commenced CPR on the motorcyclist. As we approach the scene 6 minutes later, sets of blue lights can be seen heading to the destination from various routes and as we arrive its clear ambulance resources have only arrived on scene in the last minute.
Met by a wall of blue lights, the patient is lying on the road in front of us, but we can’t see them as we’re blinded by the array of lights. There are 3 ambulances, multiple police cars and an RRV present. As we approach the scene, we glimpse the patient on the ground surrounded by the remains of his motorbike. There are conflicting stories about what happened and who’s to blame but it doesn’t matter to us as we make our way to the patient. The HEMS doctor asks, “who’s in charge?”, various faces look at one another then back to him “I think you are…”
Crew resource management and human factors play a significant role in the prehospital arena, and I was about to witness a masterclass. ‘Stop CPR please…’ 20 seconds later the HEMS doctor has established the patient is “unconscious, breathing but agonal, pulses present, GCS 6, significant head injury and query pelvic injury…this patient is going to need an RSI”. With this information tasks were assigned to various team members as me and the CCP commence a ‘kit dump’ in the chosen ambulance. 90 seconds later the stretcher is being wheeled into the back of the ambulance. The patient is being ventilated with aid of a BVM and OP airway, a pelvic binder is in place and intravenous access in each arm is obtained. A few minutes later and the patient is anaesthetised, RSI drugs given, intubated, ventilated and TXA given. Final checks are performed, the stretcher is tilted to 30 degrees and we’re ready to transfer to the local major trauma centre.
Throughout the remainder of my time with Helimed 53, I would have the privilege to observe the efficient, high-quality level of care delivered by the HEMS crews on various call taskings. I was impressed with the professional and calm approach each crew brought to difficult, and often traumatic scenes, and how they worked alongside various members of the prehospital team to deliver the highest level of care to patients. I am very grateful to all the critical care paramedics, doctors and pilots who invited me to be a part of the team and for all their teaching during my time with Helimed 53.
Due to essential systems maintenance and upgrades there will be intermittent interruptions to some on-line services on Saturday 27th of February. There will be further interruption to some core services on Wednesday 2nd and Thursday 3rd of March.
We apologise for any inconvenience caused.×