Tag Archives: education


London Trauma Conference 2014 Part 1

I’ve travelled almost the entire length of England to get to the London Trauma Conference this year. What could be more important than attending one of the best conferences of the year? Examining for the DipRTM at the Royal College of Surgeons in Edinburgh

So was it worth the 4am start? Absolutely!

tomMy highlights would be Tom Evens explaining why trauma can be regarded like an elite sport. His background is as a sports coach in addition to his medical accomplishments and walking us through the journey he went through with the athlete he was coaching demonstrates the changes that need to occur when cultivating a performance culture and the results speak for themselves.

I can see similarities in the techniques used by athletes and those we are using in medicine now. Developing a highly performing team isn’t easy as anyone involved in the training of these teams will know.

 

 

jerry3Dr Jerry Nolan answered some questions about cervical spine movement in airway management. The most movement is seen in the upper cervical spine and there is no surprise that there is an increased incidence of cervical spine injury in unconscious patients (10%). The bottom line is that no movement clinicians will make of the cervical spine is greater than that at the time of injury. And whether it be basic airway manoeuvres, laryngoscopy or cricoid pressure the degree of movement is in the same ball park and unlikely to cause further injury. He states that he would use MILS like cricoid pressure and have a low threshold for releasing it if there are difficulties with the intubation. Of course many of us don’t use cricoid pressure in RSI anymore………..

 

After watching Tom and Jerry we heard that ATLS has had its day. Dr Matthew Wiles implores us to reserve ATLS for the inexperienced and move away from this outdated system and move to training in teams using local policies. The Cochrane reviewers found an increase in knowledge but no change in outcomes.

And finally Dr Deasy has convinced me that I will be replaced by a robot roaming around providing remote enhanced care. On the up side I might be the clinician providing that support.

More from me on this fantastic conference soon. In the meantime follow it on Twitter!

telemed

 

SMACC Chicago – don’t miss the boat!

smacc chicago.002sm

If you’ve attended a SMACC conference or heard anything about them, you will be aware that it is the most exciting, inspiring, interesting, and educational critical care conference ever.

It is a non-profit venture dedicated to getting the best educators, clinicians, and researchers in intensive care, emergency medicine, prehospital/retrieval medicine and anaesthesia to share their knowledge, for free, through the medium of FOAM, embracing physicians, nurses, paramedics, and students.

You can access most of the content through podcasts after the event, but there is NOTHING like actually BEING THERE to experience the vibe.

And in 2015 it’s in Chicago. In the United States. It will be AMAZING.

You can’t look at the program without being blown away. Just look at the preconference workshops and you’ll become vertiginous trying to get your head around the the fact you can’t be in two places at once.

Why am I raving about this? What’s in it for me?

Like the other presenters I make no money from this – I dedicate my time, energy and passion for critical care and am so privileged to be a part of it. But as a do-everything-at-the-last-possible-minute emergency physician, registering for a conference is the kind of thing I’m often inclined to leave a few weeks until I can get round to it. But you CAN’T AFFORD to do that for SMACC Chicago. Not only will you waste money by missing the early registration discount, you might miss out completely: I anticipate registrations will be oversubscribed fast (this is the most anticipated conference EVER) and if you leave it too late you won’t be able to come and will be confined to the crowd who are forced to hear how great it was after the event from the people who were organised enough to actually get there.

So don’t miss out! You’ll feel like a muppet! Treat yourself to the best education at the best conference ever – pull your finger out now and register. And I’ll see you there.

Not Your Average Conference

DevEM2014

An amazing conference program, amazing speakers, in an amazing part of the world:

Imagine a line-up that includes FOAM Master Joe Lex and Matt & Mike from the Ultrasound Podcast, and it isn’t even a SMACC event!

I wish I was going, but I already committed to speaking at a great conference elsewhere!

Listen to organisers Mark and Lee talk about this and last year’s fantastic DevelopingEM conference in Cuba:

Here Mark and Lee explain how it works and what to expect:

After the success of our last two conferences in Sydney and Havana we’re taking the DevelopingEM concept to Brazil where Emergency Medicine is quickly evolving as a new specialty.

Our core focus remains the provision of high quality clinically relevant critical care information and with an expanded program and the addition of Sambafest, a 2 day Ultrasound Workshop, run by the team at Ultrasound Podcast, we think this will be our best conference to date.

With an expanded program covering Adult Emergency Medicine and Critical Care, Paediatrics, Trauma, Global Health, Emergency Medicine in Brazil, a LLSA session covering a review of EM and Critical Care Literature and a unique Communication and De-escalation workshop we’re sure there’s something for everyone in our program.

Our 42 hours of education is accredited by ACEM and ACRRM and DevelopingEM is endorsed by IFEM and supported by ASEM so time will be a valuable addition to your yearly continuing professional development.

We’re also repeating the highly successful local delegate sponsorship system that allowed 65 Cubans clinicians to attend DevelopingEM 2013 free of charge. With our connections in the Brazilian Association of Emergency Medicine (ABRAMEDE), presentations on Emergency Medicine in Brazil by some of the leading EM practititioners in Brazil and continuous real time translation of presentations we hope to once again have a distinct local flavour to DevelopingEM 2014.

We have maintained our not for profit financially unsponsored model so you know your education will be untainted ’cause we know you like it that way.

 

Check out the program and register here

These guys are my prehospital & retrieval medicine colleagues and run the DevelopingEM project in a not-for-profit capacity. I have no financial interest in this or any other conference.

How You Train is How You Fight

Simulation makes us more effective. I think it’s good to consider how one would deal with emergency situations in every day life, and practice the response. There are ALWAYS learning points.

My four year old son Kal brought along his rubber red bellied black snake on a New Year’s Day bush walk with my family. Too good an opportunity to miss, so we practiced managing a snakebite scenario. What we did and what we learned are summarised in this three minute video:

 
This was a worthwhile exercise. Learning points were:

1. Carry a knife to help cut up the teeshirt (if you don’t carry bandages)

2. Call for help early – it takes several minutes to apply the pressure immobilisation bandage, so ideally these things are done in parallel rather than series.

3. Know how to get your coordinates from your smart phone. Several free apps are available.
On an Apple iPhone, they are displayed on the ‘Compass’ app but ONLY if you have enabled location services (Settings->Privacy->Location Services->Compass)

location services compass-10

 

 

 

 

 

 

 

 

 

Learn more about pressure immobilisation technique and its indications from the Australian Resuscitation Council

London Trauma Conference Day 4

London Trauma Conference Day 4 by Dr Louisa Chan

It’s the last day of the conference and new this year is the Neurotrauma Masterclass running in parallel with the main track which focuses on in-hospital care.

We heard a little from Mark Wilson yesterday. He believes we are missing a pre-hospital trick in traumatic brain injury. Early intervention is the key (he has data showing aggressive intervention for extradural haemorrhage in patients with fixed dilated pupils has good outcomes in 75%).

Today he taught us neurosurgery over lunch. If you have a spare moment over then go to his website and you too can learn how to be a brain surgeon!

Dr Gareth Davies talks about Impact Brain Apnoea. Many will not heard of this phenomenon. Clinicians rarely see patients early enough in their injury timeline to witness

Essentially this term describes the cessation of breathing after head injury. It has been described in older texts (first mentioned in 1894!) The period of apnoea increases with the severity of the injury and if non fatal will then recover to normal over a period of time. Prolonged apnoea results in hypotension.

This is a brain stem mediated effect with no structural injury.

The effect is exacerbated by alcohol and ameliorated by ventilatory support during the apnoeic phase.

Associated with this response is a catecholamine surge which exacerbates the cardiovascular collapse and he introduces the concept of Central Shock.

So how does this translate into the real world?

Well, could we be miscategorising patients that die before they reach hospital as succumbing to hypovolaemic when in fact they had central shock?

These patients essentially present with respiratory arrest, but do well with supported ventilation. Identification of these patients by emergency dispatchers with airway support could mean the difference between life and death.

Read more about this at: http://www.sciencedirect.com/science/article/pii/S0025619611642547

Prof Monty Mythen spoke on fluid management in the trauma patient after blood (not albumin, HES or colloids) and Prof Mervyn Singer explained the genetic contribution to the development of MODS after trauma.

LTC-BrohiProf Brohi gave us the lowdown on trauma laparotomies – not all are the same! With important human factors advice:

1. Task focus kills
2. Situational awareness saves lives
3. The best communication is non verbal
4. Train yourself to listen

Prof Susan Brundage is a US trauma surgeon who has been recruited into the Bart’s and the London School of Medicine and the Royal College of Surgeons of England International Masters in Trauma Sciences for her trauma expertise.

She tells us that MOOCs and FOAM are changing education. Whilst education communities are being formed, she warns of the potential pitfalls of this form of education with a proportion of participants not fully engaged.

The Masters program is growing and if you’re interested you can read more here.

This has been a full on conference, with great learning points.

Hopefully see you next year!

Even the dead exhale CO2

cadaverETCO2iconCardiac arrest patients sometimes have unrecognised oesophageal intubations because clinicians omit capnography, based on the assumption that circulatory arrest leads to an absence of exhaled CO2. This is wrong, and reassuringly the latest ILCOR cardiac arrest guidelines recommend waveform capnography during resuscitation.

Of interest is the fact that even corpses have CO2 in their lungs. While not clinically relevant, this may have value when fresh frozen cadavers are used for airway training, since we might be able to supplement the realism of airway instrumentation with the realism of connecting the capnography adaptor and circuit and seeing confirmation on the monitor.

This preliminary study, completed by my Sydney HEMS colleagues, needs further work, but it’s an interesting area.

Sustained life-like waveform capnography after human cadaveric tracheal intubation
Emerg Med J doi:10.1136/emermed-2013-203105


Introduction Fresh frozen cadavers are effective training models for airway management. We hypothesised that residual carbon dioxide (CO2) in cadaveric lung would be detectable using standard clinical monitoring systems, facilitating detection of tracheal tube placement and further enhancing the fidelity of clinical simulation using a cadaveric model.

Methods The tracheas of two fresh frozen unembalmed cadavers were intubated via direct laryngoscopy. Each tracheal tube was connected to a self-inflating bag and a sidestream CO2 detector. The capnograph display was observed and recorded in high-definition video. The cadavers were hand-ventilated with room air until the capnometer reached zero or the waveform approached baseline.

Results A clear capnographic waveform was produced in both cadavers on the first postintubation expiration, simulating the appearances found in the clinical setting. In cadaver one, a consistent capnographic waveform was produced lasting over 100 s. Maximal end-tidal CO2 was 8.5 kPa (65 mm Hg). In cadaver two, a consistent capnographic waveform was produced lasting over 50 s. Maximal end-tidal CO2 was 5.9 kPa (45 mm Hg).

Conclusions We believe this to be the first work to describe and quantify detectable end-tidal capnography in human cadavers. We have demonstrated that tracheal intubation of fresh frozen cadavers can be confirmed by life-like waveform capnography. This requires further validation in a larger sample size.

GOLDen Educational Opportunity!

smacc-gold-logo-2

 

SMACC was my all-time favourite conference ever. Its sequel, smaccGOLD, promises to be even better, as you’ll see from the program

The smaccGOLD online registration goes live this Monday 16th September at 8am in Sydney

This will be 11pm Sunday 15th in London, and 6pm Sunday 15th in New York

Make sure you don’t miss your chance to register for the best critical care conference ever!

Also check out the preconference workshops – a jawdropping line-up of medical masters covering everything you’d want to learn. The only difficult part is deciding what you won’t go to! Places are limited and expected will sell out quickly. Registration is on a first come basis.

Hopefully we’ll see you there.

smaccGOLD is a not-for-profit venture and I receive no payment for any participation in the conference or its promotion

Upstairs vs Downstairs: an EPIC Conundrum

A new breed, and new terminology

USAflagb&WResusScott Weingart MD and colleagues have published a discussion paper [1] outlining the role of emergency physicians who have completed additional critical care training – ED intensivists – and the potential benefits these individuals might bring to patients, emergency departments, and their emergency physician colleagues.

The paper also introduces a glossary of new terms which might help clarify future discussion of this practice area:

Emergency medicine critical care a subspecialty of emergency medicine dealing with the care of the critically ill both in the ED and in the rest of the hospital
EP intensivist a physician who has completed a residency in emergency medicine and a fellowship in critical care
ED critical care emergency medicine critical care practiced specifically in the ED
ED intensivist (EDI) EPIs who practice ED critical care as a portion of their clinical time
Resuscitationists EPs who have additional knowledge, training, and interest in the care of the critically ill patient
EDICU a unit within an ED with the same or similar staffing, monitoring, and capability for therapies as an ICU
RED-ICU a hybrid resuscitation area and EDICU allowing a department to adopt the ED intensive care model with minimal cost and no changes to the physical plant

Potential benefits of ED-intensivists – and associated adequately staffed areas within ED that facilitate ongoing critical care delivery – include:

Full intensive care provided to patients unable to be moved to ICU (usually due to bed unavailability)
Development of protocols and care pathways that allow other EPs to deliver enhanced critical care
Gaining of advanced skills for ED nurses
Removal of need for ICU bed for conditions that can be improved in a few hours (eg. some overdoses, DKA, acute pulmonary oedema)
Cost saving due to decreased ICU stay (if the above ‘short term critical care’ patients are admitted to ICU, ward bed unavailability can make it difficult to discharge them from ICU)
Additional airway skills in ED (and training around that)
Improved invasive and non-invasive ventilatory management (and training) in ED
Gaining of ED experience in ventilator weaning and extubation
Gaining of ED experience in haemodynamic monitoring, vasoactive support, and even mechanical circulatory support (balloon pumps and ECMO)
Improved sepsis care
Improved post-cardiac arrest care
Improved trauma management
Greater exposure to invasive procedures
Improved end of life care
Better critical care exposure for trainees

Improved ED-ICU communication and shared protocols

Scott’s whole mission is about bringing ‘upstairs care downstairs’, and educating others to do that, at which he is a true master. No doubt he will singlehandedly have inspired a large cohort of emergency physicians to train in critical care. Examples of ED intensivists and their roles are listed here on the EMCrit site.

Emergency physician intensivists in the Old Country

epic__logoUKflagAs an ‘ED-intensivist’ myself, I do believe many of those advantages can be realised. In the UK when I originally trained in both EM and ICM there was a small number of similarly trained individuals and we collectively called ourselves ‘EPIC’ – ‘Emergency Physicians in Intensive Care’.

Our shared energy and enthusiasm led to a dedicated conference in 2011 and it’s possible that our proselytizing combined with publications like Terry Brown’s ‘Emergency physicians in critical care: a consultant’s experience‘[2] may have made some small contribution to the subsequent explosion in interest in dual accreditation in EM & ICM in the UK.

Disappearing upstairs

AusflagWhen I moved to Australia in 2008 I was excited to hear that emergency docs now made up the largest proportion of dual trained new intensivists. When I asked a leading member of this group whether he saw any role for an ‘EPIC’ community in Australia I was surprised and disappointed with the response:

‘Nice idea but I don’t see the point. I can’t think of anyone who dual trained who’s still working in emergency medicine’

So it seems those who were in the best position to bring upstairs care downstairs had all disappeared upstairs. Many will admit it’s not just because they find critical care more interesting than emergency medicine; the combination of a significantly higher income (through private practice) with better working conditions plays a significant role.

There are other opportunities in Australia for emergency physicians to practice critical care. Prehospital & retrieval medicine services undertake interhospital critical care transport of patients from small and often remote facilities where all of the first few hours of intensive care must be delivered by retrieval teams in often challenging environments with limited personnel and equipment. In some cases it’s these retrieval physicians who are able to fulfil the role of ED-intensivist in their own EDs.

Integrated critical care models and SuperDoctors

ChrisTIconAnother Australian example is the ‘integrated critical care’ model pioneered in some regional centres in rural New South Wales where emergency physicians with critical care training aim to provide seamless care to patients in the prehospital, ED, ICU and ward environments. I was lucky enough to do some locum shifts in one of these centres – Tamworth – where the service is delivered by some of the most highly skilled and dedicated physicians I’ve ever met. Check out their registrar job ad for a flavour of their work. This model was described in a 2003 publication[3] by my Sydney HEMS colleague Craig Hore which lists its features as follows:

Features of integrated critical care
Multiskilled critical-care specialists trained and experienced in the various aspects of critical care in rural hospitals.

Multidisciplinary critical-care teams that provide:

A more seamless interface between the various phases of critical care and between its respective disciplines;

A rapid response to, and a continuum of care for, critically ill and injured patients;

Clinical leadership in evaluating and managing critically ill and injured patients, both in the hospital (including the emergency department, critical-care unit and hospital wards) and in the community (including retrievals, and support for ambulance crews, peripheral hospitals and general practitioners); and

Training of medical students, medical staff, nursing staff and allied health professionals to recognise and provide a systematic approach to critical illness and injury.

Team members who are empowered to work beyond perceived traditional boundaries, but within the realms of their clinical expertise and credentials, to enable the best use of available resources.

So it appears the benefits to patients, hospitals, and team skills of ED-intensivists have been espoused for some years in the Anglo-Australian setting, and different practice models evolve to best serve local need.

Resuscitating the resuscitationists

UKflagIs it time to revive EPIC? I chased up my UK buddies who co-founded it, and here are extracts from their replies (note ‘CCT’ refers to certificate of completion of training – the UK equivalent of specialist accreditation or board certification):

“Interesting to hear that most Aussies leave EM, my experience of [our regional] trainees is the opposite; of 4 EM / ITU dual CCT over last 5 years, I’m the only one still doing a little bit of CCM, the rest have all ended up in full time EM posts, despite all doing periods of locum consultant work in CCM. (Although, after last 4 winter months of UK EM, I’m beginning to appreciate that I backed the wrong horse! (In the wrong country!!))”
“Having recently dropped ICU/ED 40/60 mix for full time ED i think those gravitating to ICU have a point – an error on my part. The ED represents much more intense work with fewer staff and a work load that far far exceeds resources. As such time to deliver care falls and skills with it. I have just spend 5 weeks [overseas]. I spent time with several directors who pointed out they no longer look to the UK for high quality ED docs as they manage depts as opposed to caring for patients, lack critical care skills and lack the experience to review and manage patients as they improve or deteriorate – a sad state of affairs indeed.”
“I would like to see EPIC back in force and do see an increasing role. around 1 in 4 of our trainees here are looking to joint qualify and we have 3 in their last 2 years. two are currently looking for posts but struggling to find any with a 50-50 mix and are been told to choose one or the other both by prospective ED and ICU employers.”
“I am concerned that dual trained folk here will, like in Australia gravitate to ICU. Whether that is a reflection of where EM is currently in the UK or a personal reflection I’m not sure. Where as I still have days in the ED where I come home and think ‘best job in the world’ these are overshadowed by the stresses of trying to deliver quality care in a failing system. My impression is that urgent care in the UK may well implode soon as ever decreasing workforce meets an over increasing work load. Inevitable closures of units will speed up this process. I currently have a 50/50 ICM/ED job split but that might change to become more ICU.”
“The ED/ICU community in the UK is growing and it wlll be interesting to see the effect of the ICM CCT has on this. There is sadly still a paucity of ED/ICU jobs in the UK and we probably missed a trick with the trauma centres.”
“It would be great to re-create EPIC to make it a real player for the future.”

So it appears emergency physician intensivists are growing in number, but employment prospects in both specialties are not guaranteed. If we are to recruit them to work as ED intensivists (ie. providing critical care in the ED) we have a challenge in making such posts attractive and sustainable. Emergency medicine in the UK is suffering at the moment, and we’ll have to work hard to stop those who are dual trained from disappearing upstairs.

Your comments on this are invited. Should there be more critical care- trained EPs? Shouldn’t ALL EPs have the right critical care skills to manage the first few hours of critical care? Can you call yourself an emergency physician and not be a ‘resuscitationist’? Where do retrievalists fit into this spectrum? How do we help motivate those who are dual trained to stay in the ED for some of their time? Is there a need for a body like EPIC to guide those who are considering dual training, and to provide recommendations to employers and physicians on models of care and job planning? I would love to get more of an international perspective on this issue.

1. ED intensivists and ED intensive care units
Am J Emerg Med. 2013 Mar;31(3):617-20
Full text link available from here

2. Emergency physicians in critical care: a consultant’s experience
Emerg Med J. 2004 Mar;21(2):145-8
Full text link available from here


There is a growing interest in the interface between emergency medicine and critical care medicine. Previous articles in this journal have looked at the opportunities and advantages of training in critical care medicine for emergency medicine trainees. In the UK there are a small number of emergency physicians who also have a commitment to critical care medicine. This article describes a personal experience of such a job, looking at the advantages and disadvantages. Depending upon future developments in the role of emergency medicine in the UK, together with the proposed expansion in critical care medicine, such posts may become more common.

3. Integrated critical care: an approach to specialist cover for critical care in the rural setting
Med J Aust. 2003 Jul 21;179(2):95-7


Critical care encompasses elements of emergency medicine, anaesthesia, intensive care, acute internal medicine, postsurgical care, trauma management, and retrieval. In metropolitan teaching hospitals these elements are often distinct, with individual specialists providing discrete services. This may not be possible in rural centres, where specialist numbers are smaller and recruitment and retention more difficult. Multidisciplinary integrated critical care, using existing resources, has developed in some rural centres as a more relevant approach in this setting. The concept of developing a specialty of integrated critical-care medicine is worthy of further exploration.

Beherrsche die Reanimation

TLsm-icon The whole purpose behind my career and this blog is to save life. Like most emergency physicians I don’t see a huge number of resuscitation patients myself in a given week, so my best hope in making a difference is to develop my teaching skills so that I can motivate and inspire others to improve their ability to manage resuscitation.

The highlight of my week therefore has been the receipt of some email feedback from a colleague in Germany. An intensivist, internist, and prehospital doctor (I like him already) who tells me he found my ‘Own the Resus‘ talk helpful:


Dear Dr. Reid,

Few days ago, too tired too sleep after a long shift on my ICU (18 beds internal medicine ICU, I am specialist in internal medicine specialized in intensive care and prehospital emergency medicine in a major German city) I watched your talk via emcrit podcast. I was immediately caught, I soaked in every word, I was fascinated, watched it twice in the middle of the night and next afternoon I listened to it in my car driving to work.

At this very day I did some overdue crap beyond the end of my shift when I heard the ominous shuffling of feet and rolling of the emergency cart from the other end of the ward… “I think we need your help….”

There it was, difficult airway situation. Patient crashing.

Then what followed was a kind of “out of body experience”. I did what was necessary, made things happen like calling anesthesia difficult airway code, calling the surgeons, organizing fiber optics and meanwhile trying to secure that airway myself until i could dispatch anesthesia to the head and surgeons to the neck. Within few minutes there were 6 doctors and 5 nurses shuffling on 9 square meters…

I found myself 1 meter behind the foot end of the pts bed and with your talk in my head I found me consciously controlling the crowd. There was suddenly the messages of your talk and there was me. I don’t know how to put it into words, I wouldn’t have done something else in medical terms but thanks to your talk I had the vocabulary, the tools to reflect myself as the leader to be in charge of the situation somehow with more distance, and after a successful resus the 10 people involved in this code went off with a good feeling that everybody contributed in what they could and all for the pts benefit.

Your talk was a kind of transition to the next level for me: from the colleague who asks how to get out of trouble in many situations because he was often deeply in trouble, to the one who leads out of trouble.

With your talk many things suddenly became clear and I am looking forward to be able to work harder on this role of leading.

Thank you very much.

D

London Calling – part 2

Notes from Days 2 & 3 of the London Trauma Conference

Day 2 of the LTC was really good. There were some cracking speakers who clearly had the ‘gift’ when it comes to entertaining the audience. No death by PowerPoint here (although it seems Keynote is now the presentation software of choice!). The theme of the day was prehospital care and major incidents.

The golden nuggets to take away include: (too many to list all of course)

  • ‘Pull’ is the key to rapid extrication from cars if time critical from the Norweigan perspective. Dr Lars Wik of the Norweigen air ambulance presented their method of rapid extrication. Essentially they drag the car back on the road or away from what ever it has crashed into to control the environment and make space (360 style). They put a paramedic in the car whilst this is happening. They then make a cut in the A post near the roof, secure the rear of the car to a fire truck or fixed object with a chain and put another chain around the lower A post and steering wheel that is then winched tight. This has the effect of ‘reversing’ the crash and a few videos showed really fast access to the patient. The car seems to peel open. As they train specifically for it, there doesn’t seem to be any safety problems so far and its much quicker than their old method. I guess it doesnt matter really how you organise a rapid extrication method as long as it is trained for and everyone is on the same page.
  • Dr Bob Winter presented his thoughts on hangings – to date no survivor of a non-judicial hanging has had a C-spine injury, so why do we collar them? Also there seems no point in cooling them. All imaging and concern for these patients should be based on the significant soft tissue injury that can be caused around the neck.
  • Drownings – if the patient is totally submerged probably reasonable to search for 30mins in water that is >6 degrees or 90mins if <6 degrees. After that it becomes a body recovery (unless there is an air pocket or some exceptional circumstance). Patients that have drowned should have early ventilatory support if they show any signs of resp distress.
  • Drs Julian Thompson and Mark Byers reassured us on a variety of safety issues at major incidents. It seems the risk to rescuers from secondary bombs at scene is low. Very few terrorist attacks world wide, ever, have had secondary devices so rescuers should be reassured (a bit). Greatest risk to the rescuer, like always, are the silly simple things that are a risk every day, like tripping over your own feet! With reference to chemical incidents, simple PPE seems to be sufficient for the vast majority of incidents, even fairly significant chemical ones, all this mucking about in full air tight suits is probably pointless and means patients cant be treated (at all). This led to the debate of how much risk should we, as rescue staff, accept? Clearly there are no absolute answers but minimising all risk to the rescuer is often at conflict with your ability to rescue. Where the balance should lie is a matter for organisations and individuals I guess.
  • Sir Prof Keith Porter also gave us an update on the future of Prehospital emergency medicine as a recognised medical specialty. As those in the know, know, the specialty has been recognised by the GMC and the first draft of trainees are currently in post. More deaneries will be following suit soon to begin training but it is likely to take some time to build up large numbers of trained specialists. Importantly for those of us who already have completed our training there will be an option to sub specialise in PHEM but it will involve undertaking the FIMC exam. Great, more exams – see you there.

 

Day 3 – Major trauma
The focus of day 3 was that of damage control. Damage control surgery and damage control resucitation. We had indepth discussions about how to manage pelvic trauma and some of the finer points of trauma resuscitation.

Specific points raised were:

  • Pelvic binders are great and can replace an ex fix if the abdomen needs opening to fix a spleen for example.
  • You can catheterise patients with pelvic fractures (one gentle try).
  • Most pelvic bleeds are venous which is why surgeons who can pack a pelvis is better than a radiologist who can mainly only treat arterial bleeds.
  • Coagulopathy in trauma is not DIC and is probably caused by peripheral hypoperfusion.
  • All the standard clotting tests that we use (INR etc) are useless and take too long to do. ROTEM or TEG is much better but still not perfect.

Also, as I am sure will please many – pressure isn’t flow so dont use pressors in trauma!

 

 

Chris Hill is an emergency and prehospital care physician based in the United Kingdom