PHEMCAST

PHEMCAST

By Tim Nutbeam and Clare BosankoMedicine
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PHEMCAST episodes

  • Episode 18: The Ventilator Part 2

    https://phemcast.co.uk/wp-content/uploads/2017/06/vent-final.mp3

    Many apologies for the delay in the release of this podcast!

    A second apology is due for the sound quality – it was recorded at a ‘live’ HEMS base – this has led to lots of background noise I am afraid. We have done our best to edit this out / reduce its effect but I’m afraid we are not experts in this area!

    This podcast is part 2 of this series on the ventilator – and you should be familiar with the first in this series before progressing further!

    Others have written excellent summaries of the themes of this podcast – please follow the links below:

    • These from Life in the Fast Lane (LITFL), PEEP and the Open Lung Approach to Ventilation
    • And these from derangedphysiology.com

      • In summary:

      • PEEP is important – you need to understand its benefits and potential harms.
      • If the patient is requiring more oxygen than you would expect try increasing the PEEP.
      • You really, really need to know your kit. Know what your ventilator can and can’t do –  know how it works and how its alarms work.

        •  

        35 min
      • Episode 17: Broken? Impact on the rescuer

        https://phemcast.co.uk/wp-content/uploads/2017/03/broken.mp3

        This episode has been compiled over a year – many thanks to our four contributors, who have shared their stories and knowledge. They were interviewed at TraumaCare 2016, TraumaCare 2017 and the BASICS/FPHC Conference 2016.

        If you ever need to talk about the impact of stresses and work experiences on you, please find a friend, colleague, GP, work Occupational Health Service, or one of the charities listed below.

        Tony’s article describing his experience of providing medical care to those involved in the Shoreham air crash:

        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4758481/

        Links to some of the resources Matt mentioned:

        Mind Blue Light Campaign:

        http://www.mind.org.uk/news-campaigns/campaigns/bluelight/

        Watch this excerpt from the West Wing:

        If you would like to check your own resilience score, you could use this tool recommended by Matt:

        https://www.robertsoncooper.com/iresilience/

        http://www.marchonstress.com

        Home

        More information from Rusty’s interview:

        By FireflySixtySeven using Inkscape, from Maslow’s A Theory of Human Motivation.

        Want to know more about EMDR?

        http://emdrassociation.org.uk/what-is-emdr/background-and-basics/

        Rusty recommended The Howl – EMS Wolfpack podcasts for more on this subject:

        https://itunes.apple.com/gb/podcast/the-howl/id1073333491?mt=2&i=364170004

        This is the article written by fire fighter Rob Norman

        https://www.theguardian.com/public-leaders-network/2016/jan/30/mental-health-dead-people-flashbacks-emergency-services-fireighters

        1 hr 16 min
      • Episode 16: “Blood”

        https://phemcast.co.uk/wp-content/uploads/2017/01/blood-final-27012017-11-55.mp3

         

        There is the potential for significant controversy in this month’s episode – and we would really appreciate the feedback of the prehospital community on this one.

        We have held the ‘no clear fluids’ mantra close to our hearts for most of our prehospital careers. We ‘know’ that giving sea water to our patients, and diluting all of blood’s ‘good bits’ can’t be healthy. We believed in permissive hypotension – we were probably wrong.

        Priorities for the bleeding trauma patient must include:

        • Minimum time to control of bleeding (tourniquets / haemostatics / knife / interventional radiology)
        • Normothermia
        • Appropriate choice of destination (knife / IR)
        • ? Early correction of hypotension (especially if blunt trauma / associated head injury)

          • The balances of harms in the context of blunt trauma between the negative effects of infusing saline versus the negative effects of hypotension are unknown and prehospital actions need to be customised to an individual patient and situation.

          In systems in which a potentially less harmful resuscitation strategy can be delivered sooner – PH systems with packed red cells / fresh frozen plasma / whole blood or freeze dried plasma, then it seems pragmatic to aim for normotension (predicted normal blood pressure) sooner in the patient’s care timeline than we have been e.g. at one hour. In patients with penetrating trauma permissive hypotension may remain useful for longer or at least until a patient can be differentiated and the bleeding controlled.

          Lots to think about!

           

          References:

          RePhill Trial Homepage: http://www.birmingham.ac.uk/research/activity/mds/trials/bctu/trials/portfolio-v/Rephill/index.aspx

          1. Smith IM, James RH, Dretzke J, Midwinter MJ. Prehospital Blood Product Resuscitation for Trauma. Shock. 2016 Jul;46(1):3–16.
          2. Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients. Powell EK, Hinckley WR, Gottula A, Hart KW, Lindsell CJ, McMullan JT. J Trauma Acute Care Surg. 2016 Sep;81(3):458-62.
          3. Penn-Barwell JG, Roberts SA, Midwinter MJ, Bishop JR: Improved survival in UK combat casualties from Iraq and Afghanistan: 2003-2012. J Trauma Acute Care Surg 78(5):1014–1020, 2015.
          4. Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, et al.: Prehospital transfusion of plasma and red blood cells in trauma patients. Prehosp Emerg Care 19(1):1–9, 2015.
          5. Weaver AE, Eshelby S, Norton J, Lockey DJ: The introduction of on-scene blood transfusion in a civilian physician-led pre-hospital trauma service. Scand J Trauma Resusc Emerg Med 21(Suppl1):S27, 2013.
          6. Bodnar D, Rashford S, Williams S, Enraght-Moony E, Parker L, Clarke B: The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells. Emerg Med J 31(2):93–95, 2014.
            7. 48 min
          7. Episode 15: Paediatric Trauma & How to Do Sim

            https://phemcast.co.uk/wp-content/uploads/2017/01/end-of-year-30122016-16-33.mp3

            Paediatric Trauma

            TARN report: Severe Injury in Children

            Simulation

            ATACC:The Anaesthesia Trauma and Critical Care course

            Thanks to Mark Forrest (@ObiDoc) for sharing these videos:

            References

            1. Spurr J, Gatward J, Joshi N, Carley SD. Top 10 (+1) tips to get started with in situ simulation in emergency and critical care departments. EMJ. 2016.
            2. Bredmose PP, Habig K, Davies G, Grier G, Lockey D. Scenario based outdoor simulation in pre-hospital trauma care using a simple mannequin model. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2010.
            3. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Quality & Safety. 2013; 22: 468-477.
            4. Boet S, Bould MD, Layat Burn C, Reeves S. Twelve tips for a successful interprofessional team-based high-fidelity simulation educational session. Medical Teacher. 2014; 36: 853-857.
              5. 29 min
            5. Episode 14: Thoracotomy

              https://phemcast.co.uk/wp-content/uploads/2016/12/final-thora.mp3

               

              Details of the surgical skills course mentioned in the podcast can be found here:

              https://wmstc.co.uk/portfolio/phem-ess/

              The Sydney HEMS Traumatic Cardiac arrest operating procedure can be viewed on their website, and there are a number of useful references within the document:

              Policies and Procedures

              An excellent ‘how to do it’ paper, published in 2005, by the London HEMS team, can be accessed via the link below:

              Click to access v022p00022.pdf

               

              Equipment required for resuscitative thoracotomy:

              Surface anatomy:

              Appearance of pericardial clot

              A foley catheter being used to fill a cardiac wound – note how easily this could be pulled out.

              An open chest with aortic compression

              Simulation of resuscitative thoracotomy by London HEMS team.

              For an entertaining and insightful discussion about the impact of undertaking thoracotomy, listen to Dr John Hinds talk from SMACC 2015. Highly recommended.

              HINDS: Crack the Chest. Get Crucified.

              And for a summary of the evidence and recommendations, have a look at the St Emlyns blog:

              http://stemlynsblog.org/jc-east-lets-be-blunt-about-ed-thoracotomy/

              References

              • Smith JE, Rikard A, Wise D. Traumatic Cardiac Arrest. Journal of the Royal Society of Medicine 2015. 108(1): 11-16.
              • Wise et al. Emergency thoracotomy: “how to do it”. EMJ; 2005: 22-24.
              • Hunt et al. Emergency thoracotomy in thoracic trauma: a review. Injury; 2006 (37): 1-19.
              • Clay et al. Emergency Department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World Journal of Emergency Surgery; 2006: 1:4.
              • Rhee et al. Survival after Emergency Department thoracotomy: review of published data for last 25 years. J Am Coll Surg; 2000. 190(3): 288-298
              • ACS Committee on Trauma Working Group. Practice Management guidelines for ED Thoracotomy. J Am Coll Surg. 2001, 193 (3): 303-309.
              • Editorial. When should we stop resuscitative efforts after blunt traumatic arrest. Injury; 2008 (39): 967-969.
              • Joint Position Statement of Nat Assoc EMS Physicians and ACS Committee on Trauma. Guidelines for withholding or termination of resuscitation in prehospital cardiopulmonary arrest. J Am Coll Surg; 2003 (1): 106-111.
              • Tarney et al.Outcomes following military traumatic cardiorespiratory arrest: A prospective observational study. Resuscitation; 2011: 1194-1197
                • 37 min
              • Episode 13: The Ventilator

                https://phemcast.co.uk/wp-content/uploads/2016/12/vent-final.mp3

                Ventilation – a dark art. Difficult to be a master, easy to be average (or terrible)!

                This is “part 1”, which includes some of the basic (and not very basic) concepts behind ventilation.

                We recorded over 60 minutes of excellent content with George – we will post more below as soon as it is edited. .

                Check out Georges powerpoint – its excellent!

                introduction-to-mechanical-ventilation-11nov2016-podcast

                31 min
              • Episode 12: Breaking Bad News

                https://phemcast.co.uk/wp-content/uploads/2016/09/breaking-bad-final.mp3

                YouTube videos:

                From the police officer’s perspective: https://www.youtube.com/watch?v=toaA_TNwcxg

                From the mother’s perspective: https://www.youtube.com/watch?v=0KJZXOKStao

                The paper about watching resuscitation is this one:

                http://www.nejm.org/doi/full/10.1056/NEJMoa1203366#t=article

                This is a section taken from the London Ambulance Service clinical bulletin, from 2011, which includes the SPIKES mnemonic:

                The alternative mnemonic mentioned in the podcast is GRIEV_ING, which has been developed for use in the ED.

                References

                Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. Spikes – a six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist. 2000; 5: 302-311.

                Hobgood C, Harward D, Newton K, Davis W. The educational intervention “GRIEV_ING” improves the death notification skills of residents. Journal of Academic Emergency Medicine. 2005; 12: 296-301.

                Jabre P, Belpomme V, Azoulay E et al. Fanily presence during cardiopulmonary resuscitation. The New England Journal of Medicine. 2013: 368 (11): 1008-1018.

                32 min
              • Episode 11: Gentle Patient Handling

                https://phemcast.co.uk/wp-content/uploads/2016/07/final-gentle-patient-handlig.mp3

                 

                The paper we mentioned by Jonathan Benger and Jules Blackham can be accessed here:

                https://sjtrem.biomedcentral.com/articles/10.1186/1757-7241-17-44

                Stable versus unstable spinal injury

                The location of an injury and involvement of different structures defines the stability of a spinal injury.

                Anterior column: anterior longitudinal ligament and the anterior half of the vertebral body/disc.

                Middle column: posterior half of the vertebral body/disc and the posterior longitudinal ligament.

                Posterior column: facet joints, ligamentum flavum, the spinous processes and the interconnecting ligaments.

                An injury involving only the anterior column is considered to be stable, as will an isolated fracture of a spinous or transverse process. An unstable injury is one which involves all 3 columns and often one in which 2 columns are disrupted.

                References
                1. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25;349(26):2510–8.
                2. Oteir AO, Smith K, Stoelwinder JU, Middleton J, Jennings PA. Should suspected cervical spinal cord injury be immobilised?: A systematic review. Injury. Elsevier Ltd; 2015 Apr 1;46(4):528–35.
                3. Smyth M, Cooke MW. Value of a rigid collar: in need of more research and better devices. Emergency Medicine Journal. 2013 May 13;30(6):516–6.
                4. Crane T, Cooke MW, Wellings R, Wayte S, Higgins J. MRI study of effectiveness of cervical spine immobilisation- a pilot study. The University of Warwick. 2007 Aug 1;:1–18.
                5. BOAST2: SPINAL CLEARANCE IN THE TRAUMA PATIENT. British Orthopaedic Association Standards for Trauma (BOAST); 2008. 1 p.
                6. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 2008 Apr 15;5(3):214–9.
                7. Prasarn ML, Horodyski M, Dubose D, Small J, Del Rossi G, Zhou H, et al. Total Motion Generated in the Unstable Cervical Spine During Management of the Typical Trauma Patient. Spine. 2012 May;37(11):937–42.
                8. Gill DS, Mitra B, Reeves F, Cameron PA, Fitzgerald M, Liew S, et al. Can initial clinical assessment exclude thoracolumbar vertebral injury? Emergency Medicine Journal. 2013 Jul 19;30(8):679–82.
                9. Leech C, Porter K, Bosanko C. Log-rolling a blunt major trauma patient is inappropriate in the primary survey. Emergency Medicine Journal. 2013 Dec 22;31(1):86–6.
                10. Horodyski M, Conrad BP, Del Rossi G, DiPaola CP, Rechtine GR II. Removing a Patient From the Spine Board: Is the Lift and Slide Safer Than the Log Roll? J Trauma. 2011 May;70(5):1282–5.
                11. I J, A M, Yu E, Tulman D, Jones C, Stawicki S. A systematic review of the need for MRI for the clearance of cervical spine injury in obtunded blunt trauma patients afternormal cervical spine CT. Journal of Emergencies, Trauma, and Shock. 2014 Feb 11;7(4):251–5.
                12. Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review. J Neurotrauma. 2014 Mar 15;31(6):531–40.
                13. Armstrong BP, Simpson HK, Crouch R, Deakin CD. Prehospital clearance of the cervical spine: does it need to be a pain in the neck? Emerg Med J. 2007 Jul 1;24(7):501–3.
                14. PhD JRE, PhD JWS, OTD TLS, MSOT JLE, EMTP JSSM, MD RSN. Selected Topics: Prehospital Care. J Emerg Med. Elsevier Ltd; 2013 Jan 1;44(1):122–7.
                15. Connor D, Greaves I, Porter K, Bloch M, consensus group Faculty of Pre-Hospital Care. Pre-hospital spinal immobilisation: an initial consensus statement. Emerg Med J. 2013 Dec 1;30(12):1067–9.
                16. Fattah S, Johnsen AS, Andersen JE, Vigerust T, Olsen T, Rehn M. Rapid extrication of entrapped victims in motor vehicle wreckage using a Norwegian chainmethod – cross-sectional and feasibility study. 2014 Jul 3;14(1):1–5.
                17. Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, et al. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ. 2008 Apr 22;178(9):1141–52.
                18. Edwards MA, Verwey J, Herbert S, Horne S, Smith JE. Cervical spine clearance in the elderly: do elderly patients get a bad deal? Emerg Med J. 2013 May 23.
                19. Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review. J Neurotrauma. 2014 Mar 15;31(6):531–40.
                20. Shafer JS, Naunheim RS. Cervical spine motion during extrication: a pilot study. West J Emerg Med. 2009 May;10(2):74–8.
                21. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. J Trauma. 1993 Mar;34(3):342–6.
                22. Hale DF, Fitzpatrick CM, Doski JJ, Stewart RM, Mueller DL. Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger. Journal of Trauma and Acute Care Surgery. 2015 May;78(5):943–8.
                23. Benger J, Blackham J. Why do we put cervical collars on conscious trauma patients? Scand J Trauma Resusc Emerg Med. 2009;17(1):44.
                  24. 34 min
                24. Episode 10: Stress Inoculation

                  https://phemcast.co.uk/wp-content/uploads/2016/06/stress-2.mp3

                  Big thanks to Anand Swaminathan @EMSwami, Chris Nickson @precordialthump, Jesse Spurr @Inject_Orange, Chris Hicks @HumanFact0rz, and Tom Evens @doctomevens

                  Their pre-workshop reading/listening recommendations:

                  http://stemlynsblog.org/englishman-south-africa-robert-lloyd-st-emlyns/

                  http://emcrit.org/podcasts/toughness-michael-lauria-i/

                   

                  Bandwidth

                   

                  Visualisation tips:

                   

                  21 min
                25. Episode 9: Maternal Collapse

                  https://phemcast.co.uk/wp-content/uploads/2016/06/maternal-collapse-06062016.mp3

                  Apologies for the quality of the sound – we recorded in a very echo-ey office!

                  The Royal College of Obstetricians and Gynaecologists (RCOG) green top guideline is accessible here:

                  https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_56.pdf

                  We have talked about ramping previously, in Episode 6: Oxygenation. This is how a pregnant patient should be positioned for airway manoeuvres and interventions, for example induction of anaesthesia and intubation.

                  The ILCOR 2015 update pertaining to Cardiac Arrest Associated with Pregnancy is accessible here:

                  https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-10-special-circumstances-of-resuscitation/

                  Including this picture demonstrating manual displacement of the uterus:

                  The concept of deliberate practice is discussed in more details on these sites:

                  This is Cliff Reid (resus.me) talking about his lecture from the Royal College of Emergency Medicine Conference in 2015:

                  http://resus.me/rcem15/

                  And this is Simon Carley’s (St Emlyn’s) blogpost on the subject:

                  http://stemlynsblog.org/the-pursuit-of-mastery-through-deliberate-practice/

                  And last, but not least, Scott Weingart (EMCRIT) from SMACC 2013

                  http://emcrit.org/podcasts/path-to-insanity/

                   

                  References

                  Advanced Life Support (7th Edition). Resuscitation Council UK. 2016.

                  Parry R, Asmussen T, Smith JE. Perimortem caesarean section. EMJ. 2016; 33: 224-229.

                  Clark SL, Cotton DB, Pivarnik JM et al. Position change and central hemodynamic profile during normal third trimester pregnancy and post partum. Am J Obstetrics & Gynaecology. 1991; 164: 883-887.

                  Bamber JH, Dresner M. Aortocaval compression in pregnancy: the effect of changing the degree and direction of lateral tilt on maternal cardiac output. Anaesthesia & Analgesia. 2003; 97: 256-258.

                  Lee SWY, Khaw KS, Kee WN, Leung TY, Critchley LAH. Haemodynamic effects from aortocaval compression at different angles of lateral tilt in non-labouring term pregnant women. British Journal of Anaesthesia. 2012; 109: 950-956.

                  34 min

                About PHEMCAST

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                A UK Prehospital Emergency Medicine Podcast.