A Beginners Guide To Pre-Hospital Emergency Medicine PDF
A Beginners Guide To Pre-Hospital Emergency Medicine PDF
A Beginners Guide To Pre-Hospital Emergency Medicine PDF
0 -
11/11/16
A BEGINNER’S GUIDE TO
PRE-HOSPITAL
EMERGENCY MEDICINE
Unofficial delegate report of the
2016 IBTPHEM Induction Course
Editor-In-Chief of the Bangor ED Conference reports - Linda Dykes, Consultant in EM, Bangor
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A Beginner’s Guide to PHEM: unofficial report of the 2016 IBTPHEM Induction Course
INTRODUCTION
GLOSSARY
The prehospital world has its own set of acronyms & abbreviations which we have decoded for you here:
AVLS Automated Vehicle Location System HEMS Helicopter Emergency Medical Service
CCC Clinical Contact Centre KTD Kendrick Traction Device
CCP Critical Care Practitioner NARU National Ambulance Resilience Unit
CCS Casualty Clearing Station PCS Patient Care Services
DAS Difficult Airway Society PTS Patient Transport Services
DCA Double Crewed Ambulance RLO Rail Liaison Officer
ECA Emergency Care Assistant RRV Rapid Response Vehicle
ECP Emergency Care Practitioner
EOC Emergency Operations Centre
EMS Emergency Medical Services
EMT Emergency Medical Technician
FPHC Faculty of Prehospital Care
HART Hazardous Area Response Team
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A Beginner’s Guide to PHEM: unofficial report of the 2016 IBTPHEM Induction Course
CONTENTS
Page Topic
CHARITY APPEAL
Specialist Resources
• The Hazardous Area Response Team (HART) consists of ambulance clinicians who are specially trained
to go into hazardous areas. These can include confined space, heights, public disorder and water. They are
equipped to deal with each of these types of incident and have specialist vehicles to carry their equipment.
Initially formed as part of the terrorism response network, the bases are located near large cities.
• Helicopter Emergency Medical Services (HEMS) are helicopter-based critical care teams which respond
to the sickest patients.
THE POLICE
EMS professionals in the UK inevitably end up working regularly with
police forces, whose main priority is to protect life, followed by
protecting property, followed by preserving order.
Each force consists of different departments including local policing, investigation, special
operations and custody. There are 5 levels of medical training within the UK police forces:
4. CLINICAL SNIPPETS
Primary Survey Traumatic Cardiac Arrest
• Make your first primary survey your best primary • It can be a difficult decision which algorithm to
survey! go down: did the patient have a medical cardiac
• Don’t keep going back and forth to check: did arrest and then fall or crash, or did the trauma
you listen properly to the back of the chest? Are cause the cardiac arrest?
you sure there isn't abdominal tenderness? • In a traumatic cardiac arrest, ventilation, volume
replacement and chest decompression are
Photo- SEC ambulance important initial interventions.
• There is fairly robust evidence for resuscitative
thoracotomy in penetrating traumatic cardiac
arrest.
• The evidence for resuscitative thoracotomy is less
robust in blunt trauma, but this may be
considered within 10 minutes of cardiac arrest.
• One of the more difficult discussion topics was
chest compressions during cardiac arrest: course
participants discussed different approaches to
dissuading members of the team, and their risk
vs. benefit in a medical vs trauma cardiac arrest.
Pre-Hospital practicalities
• Create a designated area for ‘kit dump’: this should ideally allow you enough space
around your patient to access them from all angles.
• Make sure your kit isn’t going to blow away - especially if working near helicopters!
• In the prehospital environment, you aren’t just juggling clinical decisions. You also have to factor in
logistics, egress, travel times, and where to take the patient (e.g. is going to a PCI centre more
appropriate?) and sometimes whether the patient actually needs to go to hospital at all.
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A Beginner’s Guide to PHEM: unofficial report of the 2016 IBTPHEM Induction Course
During the course we found that although theoretical knowledge, technical skills and clinical judgement are
really important aspects of PHEM, a detailed knowledge of human factors is vital to navigating the many
risks that unpredictable teams and environments can throw up.
Humans are prone to committing unsafe acts. We need to be vigilant to avoid, trap and mitigate error. High
reliability organisations undertake tens of thousands of high reliability operations per year with few errors
(e.g. airlines, formula 1 pit crews etc). We should aim to operate in a similar way. By demonstrating hyper-
vigilance we assume that the worst will happen so that we are prepared for adverse events.
• Distraction • Assertiveness
• Complacency • Awareness
• Fatigue • Communication
• Norms • Knowledge
• Pressure • Resources
• Stress • Teamwork
All of us have a limited mental bandwidth, and the need to assess a critically ill patient, manage a scene,
control team members, concentrate on practical tasks and make decisions regarding transport can easily
overload this bandwidth. The result can be getting distracted from keeping an overview of the patient’s
condition, so it is essential to delegate this task at
times.
6. PRACTICAL SKILLS
Catastrophic Haemorrhage
• Catastrophic haemorrhage should be treated in a stepwise manner.
• Field dressings are large pads with bandages (often elasticated) attached, and
some types have plastic cups to apply pressure over a particular point.
• As always it’s important to know the ones available in your kit and how to apply
them quickly.
• If pressure isn’t doing the trick, a haemostatic gauze such as Celox can be used.
This is used to pack a cavity (not brain tissue, but everything else) and direct
pressure then needs to be applied for 3 minutes.
• Tourniquets save life but can cause problems, and should only be used if bleeding is uncontrolled via other
means.
• Don’t be afraid to gain initial control with a tourniquet, then release it once an alternative solution is in place.
• There are a couple of different types available so be familiar with both.
RSI
Airway management
• Optimise your position; you need 360 degree access. when you can’t do the RSI:
• Don’t perform RSI in the back of an ambulance! decisions you need to
• Have an RSI kit dump at the ‘head end’ with your assistant. mentally prepare for
• If the sun is too bright, use an umbrella or create a shield/
shadowed area to ensure that both patient & intubator are in • Most paramedics, and some doctors in non-RSI
assets, will be limited to profoundly
the shade. unconscious/cardiac arrest patients to consider
• Sometimes, the intubation is so urgent that there is no time ETT, and needle cricothyroidotomy instead of
for a full checklist: most services will have a reduced surgical.
checklist of about 4 items to use in extremis.
• If faced with a patient who really ought to be
• The decision to perform a paediatric RSI must be made RSI’d, you will have to decide very quickly
with top cover approval (if time allows) and the checklist whether to request urgent support from
completed. another asset or service with RSI capability, or,
to scoop and run to the nearest suitable ED
Surgical Airways (e.g. major trauma unit).
• Remember Difficult Airway Society (DAS) algorithms. • There’s no point in hanging around at scene
waiting for HEMS back-up if you could be in a
• Surgical airway (scalpel, dilators +/- finger, bougie, tube) is suitable ED resus room with a tube down
best for front of neck access. before HEMS colleagues have arrived and
done anything useful.
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A Beginner’s Guide to PHEM: unofficial report of the 2016 IBTPHEM Induction Course
Splinting
Collars Pelvic splints
www.mountainmedicine.co.uk
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A Beginner’s Guide to PHEM: unofficial report of the 2016 IBTPHEM Induction Course
7. EXTRICATION
Extrication terminology
D Post A Post
C Post B Post
If the patient’s condition is immediately life threatening, the priority is to get the patient out as
quickly as possible by whatever means.
Stages of extrication
Fire & Rescue Services in the UK have standard plans for extricating patients trapped in vehicles in a variety
of positions. All their extrication plans follow a standard 6 staged approach:
Upright car
Confined spaces
• All confined spaces are potentially
hazardous low oxygen
environments.
• Do not enter, no matter the
urgency, until the fire service or
HART have attended, with gas
monitoring equipment and Photo: SEC ambulance
breathing apparatus.
• Often the confined space will need
to be vented by the fire service to make the area safe.
• Don’t send in a team mate as a canary, they risk
becoming another casualty!
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A Beginner’s Guide to PHEM: unofficial report of the 2016 IBTPHEM Induction Course
Railways
• Contact the Railways Incident Officer (RIO) prior to your
approach.
• They offer advice on the line i.e. stop train flow, ensure power is
‘turned off’ and that it is safe to approach. Some lines may have
a third electrified rail or overhead power lines: ensure these
have been turned off prior to approach.
• Avoid walking on the metal railway line or the wooden sleepers
as they can be very slippery.
• The best place to cross the track is on the ballast (stones) in-
between the sleepers.
• When travelling along the railway line, the safest passage is via
the “cess” or the grassy area at the side of the track (if a train is
coming you should be safe there).
Photo:
Photo: RAF SARF Abersoch RNLI
Sea King approaching Warwick Castle to winch out a patient from Preparing to winch casualty out of riverbed
top of a the castle tower below the bridge in Abersoch, North Wales
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A Beginner’s Guide to PHEM: unofficial report of the 2016 IBTPHEM Induction Course
Wanna make a
start in PHEM?
Our Clinical Fellows send their friends to us, ask to
stay longer, and return as HSTs or consultants: we’re
probably are the UK ED with the happy “problem” of
too many middle grade doctors rather than too few!
www.mountainmedicine.co.uk
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A Beginner’s Guide to PHEM: unofficial report of the 2016 IBTPHEM Induction Course
9. MAJOR INCIDENTS
• Major Incident planning and management is Command & Control
governed by the Civil Contingencies Act.
• Category One responders (i.e. police, fire, NHS) • Co-ordinate walking people into one
need to prepare and plan based on local risks as space
per the community risk register.
• Create cordons with police tape
• Make sure you know what is likely to happen in
your local area. • Identify a leader and use tabards to
• Where are major transport hubs, chemical sites, identify them
military bases etc? • Make contact with the commanders from
the other emergency services ANCE
UL
AMB
SE
RVIC
• If you are on scene in the immediate after-
HS
N E
ANNEX 6
UL
AMB
SE
RVIC
chaos by using a CSCATTT approach:
HS
N E
ANCE
SE
UL AIRWAVE
INCIDENT OPERATIONAL
AMBULANCE AMBULANCE
RVIC
AMB
TACTICAL
SE
HS
COMMANDER COMMANDER
RVIC
E
ADVISOR
N
HS
INCIDENT OPERATIONAL
N
ANNEX 6
COMMANDER COMMANDER
ANNEX 6
ANNEX 6
Who’s who? Tabards at major incident scenes
COMMAND TABARDS
Communication Photo:
SEC Ambulance
After a very brief assessment of the situation, provide a
METHANE report to ambulance control:
Major incident declared
Exact location
Type of incident
Hazards
Access and egress
Number and type of casualties
Triage
Further reading
• Carry out simple interventions only, e.g. tourniquets,
haemostatic dressings, OP airways, placing patients in the The National Ambulance Resilience Unit
recovery position. (NARU) website has loads of useful
• Use the NARU triage sieve (below) to triage patients into information about major incident
P1, P2, P3 and Dead to determine treatment and management and some e-learning
extrication priority. modules www.naru.org.uk and also visit
• Use a more detailed triage sort at the casualty clearing the JESIP website - www.jesip.org.uk
station to determine transport priority.
That’s it folks - the end of our unofficial report of the 2016 IBTPHEM Induction
Course. Please tell us what you thought of what we’ve produced: firstly, it’s all good
fodder for our appraisal/revalidation folders but much more importantly, we also
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