London Trauma Conference addresses key questions in emergency medicine

The ninth London Trauma Conference took place at the Royal Geographical Society, Kensington Gore, between 8 December and 11 December 2015. A main programme of presentations, where speakers addressed a number of topical questions in trauma and emergency medicine, was supplemented by breakaway sessions held parallel to the main conference. The concurrent London Cardiac Arrest Symposium also returned for another year. The Journal of Paramedic Practice once again attended the Air Ambulance and Pre-hospital Care Day held on 10 December, which focused on trauma issues directly relevant to professionals working in the pre-hospital setting.

Proceedings began with Prof Pierre Carli discussing pre-hospital extracorporeal membrane oxygenation (ECMO). Carli gave an overview of how the treatment works in Paris, providing results and considering its role in the future. Interestingly, it was found in France that transferring into hospital for ECMO with ongoing cardiopulmonary resuscitation (CPR) had very poor results, and so the need for earlier intervention and pre-hospital ECMO became apparent.

Dr Thomas Lindner then spoke on CPR in helicopter emergency medical services (HEMS) and the new European Resuscitation Council Guidelines. He explained how the key message in cardiac arrest remains minimal interruption of high-quality chest compressions. He also emphasised how an automated external defibrillator takes 20 seconds to shock, and so clinicians should use that time to decide if a patient needs shocking so they can continue compressions.

Dr Marius Rehn then gave a talk on rapid response cars (RRCs) and whether they are more dangerous than aircraft. Rehn highlighted how London’s Air Ambulance attends around five jobs a day, 32% by aircraft and 68% by RRC. He pointed out that while aviation is heavily regulated, RRCs are not. He noted that one of the easiest ways to improve safety in RRCs is to strap the equipment and ensure passengers are restrained and seated.

Assoc Prof Andrew Pearce followed with a talk on making the best of long distance critical care. Pearce explained how the remoteness of much of Australia makes the provision of pre-hospital care challenging. However, he emphasised that as pre-hospital practitioners you are ‘never alone’, as there is always someone you can call for help and advice. He went on to say that the need for a retrieval service is not just about transport, but about being able to bring critical and definitive care to patients.

After coffee, Mr Andy Thurgood gave an engaging talk on the agitated trauma patient, considering causes, rules and practicalities. He explained how agitation is a feeling of aggravation or restlessness brought on by provocation or a medical condition. Thurgood suggested it is important as a health professional to consider what may cause the provocation of a patient. For example, an agitated patient could be ‘a dying patient that is trying really hard to stay alive.’ One of the most interesting take home points from Thurgood’s talk was that there is not always a medical cause for agitation in the trauma patient. He suggested that trapped agitated patients may have nothing wrong with them and simply want to be talked to and reassured.

Dr Leif Rognas discussed setting up a national retrieval service in Denmark, where the brief was to set up a state-of-the-art pre-hospital care service, with rapid access to highly specialised hospital treatment, to the entire Danish population. This was followed by Dr Rhys Thomas, who discussed setting up a retrieval service in Wales. Thomas explained that starting a national retrieval service takes a good story, organisation collaboration, hard work and persistence. The clinical model of the Welsh national retrieval service consists of pre-hospital critical care, adult and paediatric time-critical stabilisation and transfer, neonatal and maternal support to free-standing midwifery-led units and home births, and major incident and mass-casualty support. An interesting comparison: governmental funding for the retrieval service in Denmark means the service is more dependent on government, but acquiring funding is easier and it offers a higher degree of political awareness.

Dr Per Kristian Hyldmo gave the final pre-lunch talk on a reconsideration of spinal immobilisation, including when it may be appropriate. The discussion surrounding immobilisation remains ambivalent; however, Hyldmo closed with the amusing question: ‘When there is little evidence what are your options: Cochrane? Or GOBSATT (good old boys sitting around the table talking)?’

Mr Tom Judge gave the first talk after lunch on US air ambulances. Judge explained how in the US, if ambulance services transport the patient you get paid, whereas if you do not, you get no money. As a result, this has led to unhealthy competition, where contemporary HEMS in the US is driven by demand. But, with a market-driven system medical necessity often goes down and costs go up. This sparks the question as to whether this is an aviation business or a medical service? However, Judge presented evidence to suggest there is reasonable cost benefit in having air ambulances. He also argued that helicopters should be seen as instruments of time: time to team, time to tertiary centre, and total time.

The keynote talk for the day was delivered by Prof Sir Simon Wessely on the myth of panic. Wessely’s entertaining talk highlighted how approximately 10% of the population think their health is at risk no matter what is going on at the time. Considering associations of distress, Wessely emphasised how people who cannot reach friends or family following major incidents find themselves more affected than those who can. Debriefing has been used whenever something bad happens; however, it does not always work. Not everyone wants or needs to talk re-traumatisation, it interferes with the recovery process, and it impedes people talking to who they want, when they want. Wessely also argued that debriefing increases post-traumatic stress disorder. He said that only 1% of Londoners thought they needed professional help after the 7/7 bombings. The immediate mental health measures that are needed after mass-casualty incidents, such as bombings, are accurate and timely, practical information; communication; security, food, warmth, shelter and transport; and practical assistance with the legal system, employers, authorities etc. And if people want to talk it should be when they want to, and to who they want to. Wessely noted that less than 10% of soldiers want to talk to medical professionals or welfare services about traumatic incidents. Most want to talk to friends and family.

Prof Kai Zacharowski then spoke on pre-hospital sepsis, considering how to make a diagnosis, what interventions count, and whether biomarkers are the future. Zacharowski emphasised that sepsis should be a serious consideration among ambulance services, as care can begin pre-hospital. By raising suspicions of possible sepsis to hospital staff, the patient can be prioritised correctly.

Prof Zacharowski followed with a quick fire session on point-of-care testing in pre-hospital haemorrhage.

Dr Julian Thompson then questioned if pre-hospital crew resource management (CRM) and standard operating procedures (SOPs) can be implemented in the hospital. Defective judgement and poor teamwork affects ability to provide successful airway management, so can pre-hospital CRM and SOPs be implemented in hospital? Thompson concluded that it is probably not possible across an institution, it is highly applicable to high-risk situations, and that clinicians should select a small well-governed team and aspire to excellence at the point of greatest need.

Dr Samy Sadek then looked at pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) a year on, considering whether or not it works. Sadek presented results of REBOA by London’s Air Ambulance since being introduced 2 years ago. He reported seven cases of successful placement and four deaths (none due to exsanguination). The lack of REBOA cases illustrates how it is only considered in the sickest patients. A year on from last year’s talk that Sadek gave, a number of questions can be answered. In terms of potential complications, London’s Air Ambulance have reported one dissection, no ruptures, a thrombus, and no cases of displacement. Tolerance remains unknown—the maximum length of time undertaken by London’s Air Ambulance was 2 hours and 47 minutes. Diagnostic certainty is still unclear as there have been a few cases that were missed. While the definite benefit of REBOA is still unclear, Sadek offered a very sincere reflection of his own REBOA experience, where he feels he has definitely saved the lives of people who would otherwise have died.

Dr Matt Thomas then spoke on pharmacologically assisted laryngeal mask insertion (PALM), considering whether it was an elegant rescue technique or a dangerous compromise. Thomas concluded that it is a rescue technique rather than a primary technique, and should be considered as a plan B. However, if you are considering PALM then the patient probably needs a rapid sequence induction.

Mr Tom Judge closed the day with a talk on videolaryngoscopy, asking whether it is the standard of pre-hospital airway care. Judge highlighted that use of videolaryngoscopes increased first tube and overall intubation success rate. However, it remains expensive and in-hospital clinicians are already good at endotracheal intubation, with a 95% success rate.

The Air Ambulance and Pre-hospital Care Day represented a fraction of the packed programme of presentations on offer at this year’s London Trauma Conference. The invited speakers had a truly international breadth, offering an unparalleled excellence in the level of learning on offer. It is therefore with great anticipation that we look forward to the London Trauma Conference 2016.

Taken from Journal of Paramedic Practice, published 8 January 2016.

Ambulance Service Institute celebrates excellence at annual awards ceremony

Ambulance Service Institute president, Dr Peter Griffin, welcomes guests to the 2015 ASI annual awards. Photo Credit: Brian Aldrich

Ambulance Service Institute president, Dr Peter Griffin, welcomes guests to the 2015 ASI annual awards. Photo Credit: Brian Aldrich

Friends and family gathered at the Cholmondeley Room and Terrace, House of Lords, on 25 June to celebrate the Ambulance Service Institute (ASI) annual awards. The occasion recognised those in the pre-hospital care sector who have performed above and beyond the call of duty, in their dedication to saving lives.

The awards were presented by Dr Peter Griffin, president of the ASI, who gave a brief welcome address before proceeding with the awards.

The ASI was formed in 1976 and has members throughout the UK NHS ambulance services and in various overseas ambulance services. It is an independent institute whose membership is dedicated to improving, monitoring and raising the standards and quality of ambulance provision and thereby improving the professionalism and quality of care available to patients.

Set up in 2000 and originally held at AMBEX in Harrogate, the ASI Awards were initially only for NHS ambulance service personnel. However, the awards now incorporate accolades for military, private and voluntary services.

The Paramedic/Emergency Care Practitioner Award went to Alex Watts of East of England Ambulance Service NHS Trust, who was first on scene at a multiple fatality road traffic collision on the Colchester Road at Gosfield in December last year. Watts was commended for his actions in the initial management of the scene, placing himself at risk to organise and effect a rescue of at least three patients.

Speaking to the Journal of Paramedic Practice, Alex said:

‘It’s nice to get something.’

However, the event undoubtedly had a lasting effect, as he added:

‘The whole job did leave a bit of a mark to be honest, it wasn’t the nicest of jobs. [But] you’ve got to do what you’ve got to do and that’s just the way it is unfortunately, it was just my turn.’

Paramedic Clive Parnham receives President's Commendation from Baroness Angela Browning. Photo Credit: Brian Aldrich

Paramedic Clive Parnham receives President’s Commendation from Baroness Angela Browning. Photo Credit: Brian Aldrich

President’s Commendations went to motorbike paramedic Steve Harris of West Midlands Ambulance Service NHS Trust and paramedic Clive Parnham of East of England Ambulance Service NHS Trust.

Steve, affectionately known as ‘Forrest’ by colleagues as well as fans of Channel 5’s Emergency Bikers, recently retired from 18 years as a motorcycle paramedic. Although taking life at a slower pace, he still patrols the streets of Birmingham on a part-time basis, all in the name of patient care.

Clive was nominated for being a dedicated and supportive member of staff who is always willing to assist. His citation referred to him as a great model to others and a great support to all new staff in his care. It was mentioned that if you were to cut him in half he would read ambulance service through the middle.

Commenting on receiving the award, Clive said:

‘I feel very humbled. It’s always nice to be recognised for the work that you put into things. 32 years in the ambulance service I have seen an awful lot of changes, but it has been a really fantastic career.’

The Innovation Award went to the West Midlands Mental Health Response Unit, collected by Robert Cole, head of clinical practice at West Midlands Ambulance Service NHS Trust, and chief inspector Sean Russell of West Midlands Police. Starting as a trial scheme in January last year, the inter-agency mental health triage unit has seen a dramatic reduction in the number of people suffering from mental health who ended up in police custody in the local area.

The Control Room Award went to Heather Wilson of East of England Ambulance Service NHS Trust, whose passion to her role and her commitment to improving the quality of the service provided to patients has led to her rapidly progressing from call handler, to dispatcher, to dispatch team leader in a little over two years.

The First Aid/Community First Responder Award went to Rossendale Community First Responder Group. The award was collected by Brian Pickup and Dawn Taylor who organise the local group. Their nomination was based on their dedication and professional approach to volunteering, and the way they work in partnership with the North West Ambulance Service NHS Trust.

The Patient Transport Service Award went to Stephen Dines and Justine Newton of East of England Ambulance Service NHS Trust for the way they dealt with an unusual and difficult incident. They were said to have showed professionalism and remained calm and reassuring to their patient until help arrived.

The Special Incident Award went to paramedic Louise Smith and technician Joanne Taylor of East Midlands Ambulance Service NHS Trust, who were commended for their actions after being involved in a crash while transporting a patient.

The Air Ambulance Award went to Sergeant David Currie, a search and rescue winchman at RAF Valley. Currie received his reward in recognition of his assistance to a man who had fallen into a quarry in the vicinity of Horseshoe Pass, Wrexham. Displaying exceptional clinical skills, clarity of thought under pressure and outstanding management of his winch operator, it was felt his action unequivocally saved the life of his casualty.

The Front-line Ambulance Award was given to technicians Neil Ashmore and Sarah Lawrence of West Midlands Ambulance Service NHS Trust, who attended a severe fire in Tipton in August 2014. They were praised for their bravery at the scene, where they acted above and beyond the call of duty, at great personal risk, to care for the two patients injured as a result of the fire.

The Military Award was presented to Sergeant Simeon Tomlinson, a senior non-commissioned officer paramedic with 4626 Aeromedical Evacuation Squadron, RAF Brize Norton. Tomlinson is the only reserve paramedic to have undertaken three deployments as part of the rotary Medical Emergency Response Team (MERT) and was recognised as a super clinician, admired by his fellow colleagues and noted for providing the best paramedic care on a daily basis.

Billy McPhail and Gareth Acres received the Public Spirited Award for an incident at Strood Railway on 28 May 2014, where they rescued a woman who had slipped and fell on the railway line.

In a closing address to guests, Baroness Browning congratulated all of the winners:

‘What a privilege it is to hear these wonderful accounts of the bravery, professionalism and dedication of the people who have received their awards today and of course the people in the teams that they work for. The Ambulance Service Institute does a good job in recognising, each year, people who have done more than just the normal 9–5 role that so many people regard as work. I just want to say, on behalf of those of us in the public…thank you very much to all of you, and your colleagues who aren’t here today, for what you have done, and many many congratulations to those of you who are award winners here today.’

Speaking to the Journal of Paramedic Practice after the event, Dr Peter Griffin, president of the ASI, said:

‘This is the fifth year we have done the awards at the House of Lords. We started at that end [House of Commons] in 2002 and moved to this end in 2010. We did quite well this year. We had some pretty good nominations. We didn’t have quite as many as last year but I think they were of similar quality.’

Speaking of the awards, Dr Anthony Marsh, chief executive officer of both East of England Ambulance Service NHS Trust and West Midlands Ambulance Service NHS Foundation Trust, and chairman of the Association of Ambulance Chief Executives, said:

‘These are staff who are doing a wonderful job for patients day in, day out and I’m so proud of them. That the ASI are recognising their efforts in this way is testament to their dedication to what they do, and it’s staff like this who help the ambulance service put the very best it can into delivering high-quality patient care for the region.’

Taken from Journal of Paramedic Practice, published 3 July 2015.

Air ambulance and pre-hospital care day tackles key topics in trauma medicine

The eighth London Trauma Conference took place at the Royal Geographical Society, Kensington Gore, between 9 December and 12 December 2014. In a similar vein to previous years, a main programme of presentations was supplemented by breakaway sessions held parallel to the main conference. Speakers addressed a number of topical questions in trauma and emergency medicine. This year, conference organisers decided to run the concurrent London Cardiac Arrest Symposium over two days rather than the usual one, and an advanced paramedic masterclass was introduced covering areas such as analgesia, education, governance, plus a variety of clinical topics. The Journal of Paramedic Practice attended the Air Ambulance and Pre-hospital Care Day held on 11 December, which focused on trauma issues directly relevant to professionals working in the pre-hospital setting.

Proceedings began with Prof Wolfgang Voelckel outlining challenges to pre-hospital critical care. Voelckel argued that the ‘golden hour’ of emergency medicine has little scientific basis, and that rather than the traditional trimodal distribution of death that is often referred to in advanced trauma life support, there is a mono-modal peak of mortality in trauma in the first hour from time of injury.

Assoc Prof Cliff Reid then gave a talk on quality education in pre-hospital care. Highlighting that medicine needs evidence to improve clinical outcome, he stressed that pre-hospital critical care can be improved through clinical competence. One of the standout talks of the day, he emphasised that education is not about teaching people knowledge, but training people to perform.

Prof Guy Rutty then delivered a fascinating presentation on the way road traffic collisions are examined by forensic pathologists. Rutty highlighted how the role of the pathologist is to answer questions of who, where, when and how the person involved in a fatal accident came by their death. This includes medical interventions at scene/hospital, survivability, restraint systems, speed and direction of impact. Rutty gave an overview of post-mortem imaging using CT scans, explaining that the level of detail in imaging is so detailed that one could argue that a real autopsy is no longer necessary.

Dr Samy Sadek replaced the planned talk by Prof Ben Bobrow, and gave a presentation on the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in the management of trauma patients. Sadek highlighted the benefits of using REBOA for shocked pelvic and junctional injuries, explaining how half of these patients that die do so before intervention. Pre-hospital options in London before REBOA were pre-hospital transfusion and/or thoracotomy, yet evidence suggests that REBOA causes less harm than thoracotomy. Sadek emphasised that REBOA is not a standalone intervention but part of a system response; however, complications include dissection, rupture, emboli and misplacement.

Dr Andreas Krüger followed with a discussion on the current status of physician-manned emergency medical services. Krüger established that the benefits of having a health professional qualified in advanced pre-hospital care include: the ability to carry out advanced procedures, manage more difficult cases, and administer a wider range of analgesics.

Dr Dan Ellis and Prof Mårten Sandberg then debated clinical governance in pre-hospital care under the motion ‘tight systems are best’. Ellis argued for the value of tight governance, while Sandberg defended loose governance. Ellis highlighted that both Australia and UK critical care guidelines include ‘good’ clinical governance and argued that if we advocate the use of clinical governance then surely we should do it well? Sandberg countered this by defending the benefit for having permanent staff. Besides the need for regularly training new staff, Sandberg argued that experienced staff offer the ability to tailor treatment to each individual patient and not rely on checklists, strict SOPs and rigid algorithms. A vote taken at the end of the session showed a unanimous preference for tight clinical governance; however, perhaps this was due to a biased, predominantly UK audience.

Dr Stefan Mazur gave the final pre-lunch talk on the transport of difficult patients, taking into account psychiatric patients, obese patients and infectious patients. For the acutely unwell psychiatric patient, Mazur highlighted the potential benefit of an anaesthetic in these patients to facilitate transport. He argued that ketamine sedation for those who are acutely psychotic is apparently safe and doesn’t worsen mental outcomes. Consideration for the transport of obese patients includes limitations of your airframe—will the patient actually fit?; loading and unloading; and using a vac mat for ramping a patient to allow for ear-to-sternal notch positioning. With regards the transportation of infectious patients—of notable relevance given increasing reported caes of ebola patients—aeromedical considerations include correct PPE, aircrew protection, and an awareness that motion sickness may increase your exposure to patients’ body fluids.

The post-lunch sessions looked at the disquieting subject of managing EMS disasters, with two tremendously brave presentations.

In the first talk, Mr Syver Leivestad and Ms Siv Tonje Solfjeld outlined the Norwegian Air Ambulance crash which occurred on 14 January 2014 and the crisis plan that was implemented following the incident. With the first photos of the accident published online by media within 10 minutes, the need for a robust, well-practised crisis plan and a good handling of communication cannot be understated. As well as a plan for updating the service’s website and Twitter account, publishing press releases, and holding a press conference, it was integral that there was a focus on supporting families, honouring colleagues and involving employees.

Dr Stephen Hearns followed with an equally harrowing overview of the Glasgow Police crash which occurred on 29 November 2013. Hearns’ emotional and heartfelt presentation emphasised the emotional impact of treating colleagues, and the priorities that are required beyond the initial response, including: the welfare of colleagues, flight safety and confidence, and business continuity.

The day concluded with a selection of 10 minute ‘quick fire’ sessions on topics related to pre-hospital trauma medicine.

Dr Per Kristian Hyldmo outlined the increasing doubt about the future of cervical collars due to the distinct lack of clinical evidence supporting the claim that they improve neurological outcome. Alternatively, evidence appears to suggest that spinal immobilisation is better with a vacuum mattress.

Dr Jostein Hagemo questioned whether pre-hospital blood without supporting products is bad. He concluded that if you really need red blood cells, then you really need coagulation support.

Dr Dan Ellis followed by asking whether pre-hospital blood gases or electrolytes would change the management of a patient? The i-STAT allows most blood gas results to be deliverable in the pre-hospital setting, so it is theoretically achievable. Ellis argued that even if you don’t have time to act on blood gas results, it can aid decision-making and prove useful at handover.

Dr Stefan Mazur looked at the benefits of pre-hospital tranexamic acid. The CRASH-2 trial indicated that the administration of tranexamic acid up to 3 hours following an incident has clear benefits for the trauma patient; however, this is in contrast to data from the Australian Trauma Registry. The benefit of pre-hospital tranexamic acid administration might therefore be overstated. It is hoped the current Study of Tranexamic Acid during Air Medical Prehospital Transport (STAAMP) trial, and Pre-hospital Anti-fibrinolytics for Traumatic Coagulopathy and Haemorrhage (PATCH) study, will establish whether or not pre-hospital administration of tranexamic acid really is beneficial.

De Stefan Candelfjord then gave an engaging presentation on pre-hospital diagnosis for stroke and trauma patients using microwave technology. Initial (in vitro) trials suggest that microwave technology seems to be promising in the detection of, and estimation of, size of haematoma.

Mr Mark Wilson then spoke on improving first responder responses to cardiac arrest and trauma through the Good Samaritan smartphone application. The app allows community ‘alerters’ to send out a distress signal to the nearest medically-trained Good Samaritan, while at the same time automatically dialling 999. Medics who are within a few hundred metres can then proceed to the emergency on foot to help before the arrival of emergency services.

This was followed by Assoc Prof Cliff Reid discussing apnoeic oxygenation in pre-hospital RSI. Reid claimed apnoeic oxygenation for preoxygenation in RSI can double time to desaturation, and explained how nasal oxygen during efforts securing a tube (NO DESAT) allows the continued benefits of apnoeic oxygenation while tracheal intubation techniques are performed.

Chief pilot Neil Jeffers of London’s Air Ambulance spoke on considerations regarding night HEMS. He highlighted that the additional cost of running a night service is of notable concern, with many aircraft not being night vision equipped, and thus presenting a notable increase in cost. Not only this, but there are very few appropriately lit helipads on or near hospitals in the UK.

Dr Nils Petter Oveland gave the final talk of the day on novel techniques to diagnose pneumothorax. Oveland outlined promising preliminary results for microwave assessment of pneumothorax. A sensitivity and specificity of 100% was evident in a small animal model study. Clearly more research is needed but it is apparent that it may be a useful clinical tool.

An undeniably action-packed day, providing much food for thought, those who felt they weren’t quite ready to go home headed to the Stand Up Science Evening, an event which allows 5 minutes to convey the significance of a submitted work, and 5 minutes for questions in a busy but informal session.

Taken from Journal of Paramedic Practice, published 9 January 2015.

Sir Bruce Keogh admits health system is ‘creaking’ and ‘under pressure’

Prof Sir Bruce Keogh, medical director of the NHS, has admitted the National Health Service is ‘creaking’ and ‘under pressure’, at a conference held at the King’s Fund on 19 December.

The Urgent and Emergency Care Conference, hosted by the King’s Fund, provided an update on progress with the Urgent and Emergency Care Review, as well as exploring the immediate challenges facing urgent and emergency care services.

Prof Chris Ham, chief executive of the King’s Fund, opened the event by asking delegates: what kind of urgent and emergency care system do we need in the future? Ham proposed that we need a much more joined up and integrated system than the one that is currently in place.

Prof Sir Bruce Keogh delivered the keynote speech on the future of urgent and emergency services in England, placing an emphasis on the long-term vision for transforming urgent and emergency care. Keogh explained that over the past year there has been a steady and relentless growth in the number of A&E attendances, and in light of reports of additional pressures placed on services during the Winter months, he admitted:

‘The system is creaking. A&Es are having to address increasing demand, the ambulance services are struggling in many parts and we have a number of issues to deal with, which we are tackling.’

Keogh acknowledged that responsive services need to be provided closer to home and that highly specialised centres must be made available. It is only through this way that we can ensure patients in life-critical conditions receive the right level of treatment at the right place.

Keogh outlined that the current urgent care system is complex and confusing, and so a simple and intuitive system is needed if patients are to access the right care, at the right place, at the right time. The introduction of urgent care networks, as a means to dissolve boundaries between hospitals and community services, and join up pathways of care, will be integral to ensuring this is possible.

Dr Robert Varnam, head of General Practice Development for NHS England, followed with a talk on the contribution of primary care in the provision of urgent and emergency care. Varnam stressed the need to develop more responsive and joined-up approaches from general practice, noting that only by seeing the whole system can the needs of patients be properly met. He also stressed the importance of primary care colleagues collaborating with the urgent care pathway, and the need to think about access in primary care. Varnam questioned what the point in quick access is if what you get access to doesn’t address need.

Dr Clifford Mann, president of the College of Emergency Medicine, gave the final talk before delegates broke for coffee on the next steps for emergency medicine. Following on from the publication of the College of Emergency Medicine’s CEM10, which outlined 10 priorities for resolving the crisis in emergency departments, Mann gave an overview of the College’s STEPs to rebuilding emergency medicine. These consist of staffing, tariffs and terms, exit block, and primary services.

After coffee, procedings were separated into two streams: one on urgent care, the other on emergency care. Within the urgent care stream, Richard Hunt, chair of the London Ambulance Service NHS Trust, delivered the first talk on supporting the development of ambulance services as out-of-hospital providers. This was given on behalf of the Association of Ambulance Chief Executives (AACE).

After giving a background to the AACE, Hunt outlined the potential role of ambulance services in transforming urgent and emergency care. Through the development of the paramedic workforce—to include more specialist and advance paramedic roles—it is hoped that ambulances could be used as mobile urgent treatment services capable of dealing with complete episodes of care without transport to hospital. Improving the range of clinical assessment and decision-making skills of paramedics so that they can manage patients closer to home, and the introduction of independent prescribing for paramedics could help achieve this.

This was followed by a panel discussion on providing a highly responsive urgent care service outside of hospital. Panellists included: Dr Chaand Nagpaul, chair of the General Practitioners Committee, British Medical Association; Adam Duncan, chief operating officer, London Central and West Unscheduled Care Collaborative; Dr Simon Abrams, GP and chair, Urgent Health UK, Federation of Social Enterprise Out of Hours Providers; and Ashok Soni OBE, clinical network lead, Lambeth Clinical Commissioning Group and president, Royal Pharmaceutical Society.

Key issues discussed in this session included: improving access for patients to ensure they can easily navigate the system; developing and implementing plans to meet predictable surges in demand; the role of GPs in urgent care now and under new plans for two types of urgent care networks: strategic and operational; and aligning 999 and NHS 111.

After lunch, Rob Webster, chief executive of NHS Confederation, spoke on new models for urgent and emergency care. Webster offered a system perspective on challenges and opportunities for urgent and emergency care networks, outlining that urgent and emergency care networks provide increased access to a simplified urgent and emergency care system, and better integration between urgent and emergency care services.

Examining existing evidence on networks, Webster looked at functions for network models, including strategic leadership for urgent and emergency care; to coordinate operational implementation at a local level; and to address fragmentation within the urgent and emergency care pathway.

This was followed by a panel discussion, where speakers gave an overview of existing networks and coordination at local level. Dr Nav Chana, chairman of the National Association of Primary Care, gave an interesting talk where he argued primary care should be defined by its function not its membership.

Stephen Dalton, chief executive of the Mental Health Network, delivered a talk on mental health and crisis care. Explaining that mental health service users have double the A&E attendance rate of the general population, Dalton gave an overview of the Mental Health Crisis Care Concordat, whose vision is for services to work together to deliver a high-quality response when people—of all ages—with mental health problems urgently need help.

Solveig Sansom, head of commissioning for integration, South Devon and Torbay Clinical Commissioning Group spoke on the Newton Abbott Frailty Hub, an initiative aiming to increase the number of patients who are proactively case-managed at home. Utilising a joined-up approach for frail elderly care, its predicted outcomes include a reduction in long-term care placements, as well as a reduction in emergency admissions from care homes.

The closing session of the day saw Adrian Masters, managing director, sector development for Monitor, speak on implementing a new payment approach to support improved delivery of urgent and emergency care. Masters highlighted that payment needs to change to support the service reforms and that Monitor are working with their partners on a wider programme of work on payment, which offers a coordinated and consistent payment approach across all parts of the urgent and emergency care network.

The final talk was given by Prof Keith Willett, director for acute episodes of care, NHS England, on progress made with phase two of the Urgent and Emergency Care Review. Outlining the next steps in delivering change following the review, Willett explained how emergency care networks will connect all services together into a cohesive network so that the system is more than just the sum of its parts. NHS England is now at the stage of moving from design to delivery; however, it faces a number of significant challenges, including payment system reform, information sharing, workforce and skills shift.

Taken from Journal of Paramedic Practice, published 9 January 2015.

AAA Conference sees Keith Willett call for more evidence-based research in HEMS

Photo Credit: Association of Air Ambulances

This year’s Association of Air Ambulances (AAA) National Conference took place once again at the Millennium Gloucester Hotel in Kensington, London. In a departure from last year, the organisers removed one theatre to deliver a more interactive workshop programme. Featuring 23 speakers, the one-day conference looked at the future developments of air ambulance fundraising, operation and clinical activity.

Following a brief welcome from AAA national director, Clive Dickin, Hannah Sebright, AAA vice chair, gave delegates an outline of the AAA’s key issues. These included the AAA supporting the call for the European VAT Directive to be amended so all European charities are able to reclaim VAT charges from carrying out their approved activities, and support for local air ambulances and ambulance services through the provision of both financial and clinical help at a local level.

Prof Keith Willett, director for acute episodes of care, NHS England, then gave an update on the Urgent and Emergency Care Review. Explaining developments, findings and the likely impact on pre-hospital aeromedical care, he commended the collaborative work of AAA and the various air ambulance charities. He concluded by highlighting the need for more evidence-based research in helicopter emergency medical services (HEMS).

Mike Shanahan, head of special operations, Yorkshire Ambulance Service NHS Trust (YAS), then provided a review of the preparation and deployment undertaken by YAS for the Grand Départ of the Tour de France.

After the first coffee and networking break of the day, Steve Wheaton, assistant chief ambulance officer, West Midlands Ambulance Service NHS Foundation Trust, gave a report on the Joint Emergency Services Interoperability Programme (JESIP), outlining progress so far and lessons learned from the Exercise Joint Endeavour held in September.

This was followed by an update on the European Aviation Safety Agency by Brian Baldwin, helicopter flight operations, Civil Aviation Authority.

Nicola Stewart ended the pre-lunch talks with a Care Quality Commission update on changes to regulation of care.

Throughout the day there were a number of breakout sessions and workshops, offering delegates the opportunity to discuss key topics and areas of interest. Some of the highlights of these sessions include Dr Paddy Morgan, anaesthetist/intensivist, Great Western Air Ambulance giving a review of the drowning process, and Alistair Wood, GE Medical systems looking at portable ultrasound in the pre-hospital care environment.

After lunch, communications trainer Mark Hogan, who required air ambulance care following a fall, gave an alternative yet engaging talk on how he took on a bet to put on a comedy show at the Edinburgh Fringe Festival.

Lt Col Chris Wright, defence consultant advisor, then spoke on lessons from the theatre of war. A clinician who has spent years treating injured soldiers and civilians, he outlined how lessons learnt in the field can be applied in a civilian setting.

Nigel Hare, operations director, Devon Air Ambulance Trust, gave an overview of European Standards, explaining what they are and issues relevant to them. He explained how he identified a potential problem in EN 13718, the European minimum standard for safety and a specific one for air ambulances, as none of the UK air ambulances services met the standard.

Prof Keith Willett gave an update on the Urgent and Emergency Care Review, explaining developments, findings and the likely impact on pre-hospital aeromedical care

Prof Keith Willett gave an update on the Urgent and Emergency Care Review, explaining developments, findings and the likely impact on pre-hospital aeromedical care. Photo Credit: Association of Air Ambulances

Dr Ben Singer of Royal Brompton Hospital then gave a talk on potential pre-hospital applications of extracorporeal membrane oxygenation (ECMO). He provided an outline of a possible model for pre-hospital ECMO, as well as circumstances where it may be used in the future.

Finally, Dr Gareth Davies, consultant London’s Air Ambulance, spoke on resuscitative endovascular balloon occlusion of the aorta (REBOA) in the pre-hospital environment.

Speaking after the event, Clive Dickin said:

‘Our conference speakers covered not only detailed topics but also higher level strategic subjects from clinical, air operational and fundraising subjects. This is exclusive to our conference, giving a unique perspective and knowledge base for aeromedical teams, charity staff, management, directors’ trustees. The event is designed as one of the key activities that delivers the Association’s strategy of sharing knowledge across the sector, not only looking at lessons learnt but also new innovation, further improving pre-hospital critical care.’

Awards of Excellence

This year saw the Association of Air Ambulances’ second Awards of Excellence. Held in the evening following the conference, the awards were open to all air ambulance operations within the UK and nominations were made from patients, staff, management and the general public.

BBC television presenter Louise Minchin returned to host the awards, with actor and comedian Robert Llewellyn also on hand to provide support and comic relief.

Nigel Hare, operations director, Devon Air Ambulance Trust, picked up two awards for the evening, including Charity Staff Member of the Year and the AAA Chairman’s Award. He was recognised for his input, commitment and passion in his work not only at Devon Air Ambulance Trust but nationally, including as a director of the Association of Air Ambulances.

The Lifetime Achievement Award went to Gerry Hermer, aviation adviser to the East Anglian Air Ambulance (EAAA). Hermer was recognised for a great number of achievements, including his commitment to continue to develop and improve the aviation capacity of EAAA, despite his supposed retirement.

Air Ambulance Paramedic of the Year went to Mark Fuszard of Cornwall Air Ambulance Trust, Air Ambulance Doctor of the Year went to Dr Rik Thomas of Essex and Herts Air Ambulance Trust, and Air Ambulance Pilot of the Year went to Captain Paul Smith of Lincolnshire and Nottinghamshire Air Ambulance Trust.

Other winners were Jayden ‘JJ’ Butcher for the Outstanding Young Person Award; Janice Flower, who was named Charity Staff Member of the Year; and Gladys Tingle, who was named Charity Volunteer of the Year.

The Air Ambulance Campaign of the Year went to London’s Air Ambulance for their ‘25th Anniversary Campaign’, and the Special Incident Award went to Midland’s Air Ambulance Charity.

Taken from Journal of Paramedic Practice, published 5 December 2014.

Emergency Services Network: looking at the future of mobile communications

Last year the Home Office announced that the Emergency Services Mobile Communications Programme (ESMCP) will be replacing services provided by Airwave Solutions Ltd with a new national mobile communication service. The Emergency Services Network (ESN) will feature voice and on-demand data services, including specific public safety features.

The cross-departmental programme began in 2011 and seeks to develop and implement a secure and interoperable mobile communications solution for the three emergency services and other category 1 and 2 responders.

The reason for this change is because contracts with the current supplier, Airwave, and other commercial providers using the next generation commercial network (4G LTE), will start to expire from 2016. According to the ESMCP, it is felt that Airwave is expensive when compared with similar systems more recently deployed in other countries. Additionally, although Airwave was the first national public safety network based on the TETRA technology standard, the technology used by the existing TETRA system is not capable of delivering broadband data services, which users are acquiring directly from the telecoms market.

Key objectives

The key objectives for ESN are to establish a communication system that is:

• Cheaper—to ensure ESN is delivered cost-effectively and able to take advantage of future technological developments
• Better—users are increasingly relying on commercial providers to provide broadband data services. ESN intends to provide this as a core service with appropriate security and availability
• Smarter—Different users will use ESN in different ways so the service will be flexible to allow users to choose only the services relevant to them.

The next phase

On 7 July 2014, the ESMCP released information concerning the next phase of the new communication system, where companies were formally invited to tender for ESN. It was explained that the core procurement for ESN will be divided into four lots:

• Lot 1—ESN Delivery Partner (DP)—transition support, cross-lot integration and user support: a delivery partner to provide programme management services for cross-lot ESN integration in transition; vehicle installation design and assurance; training support services; and delivery support during the implementation of ESN. Companies invited to tender for Lot 1 include Atkins Limited; Kellogg Brown and Root Limited; KPMG LLP; Lockheed Martin UK Ltd; and Mott MacDonald
• Lot 2—ESN User Services (US)—a technical service integrator to provide end-to-end systems integration for the ESN: to develop and operate the public safety applications; the necessary telecommunications infrastructure; mobile device management; customer support; and service management. Companies invited to tender for Lot 2 include Airwave Solutions Ltd, Astrium Limited, CGI IT UK Ltd, HP Enterprise Services UK Ltd; and Motorola Solutions Ltd UK
• Lot 3—ESN Mobile Services (MS)—a resilient mobile network: a network operator to provide an enhanced mobile communications service with highly available full coverage in the defined Lot 3 area (in GB/UK), highly available extended coverage over Lot 4 telecommunications infrastructure, and technical interfaces to Lots 2 and 4. Companies invited to tender for Lot 3 include Airwave Solutions Ltd, EE Limited, Telefonica UK Limited, UK Broadband Networks Limited, Vodafone Ltd
• Lot 4—ESN Extension Services (ES)—coverage beyond the Lot 3 network: a neutral host to provide a highly available telecommunications infrastructure in the defined Lot 4 areas to enable the Lot 3 supplier to extend their coverage, and technical interfaces to the Lot 3 supplier. Companies invited to tender for Lot 4 include Airwave Solutions Ltd, Arqiva, EE Ltd, Telefonica UK Limited, Vodafone Ltd.

Tenders will be submitted in Autumn 2014 and will then be subject to detailed evaluation. Contracts will be awarded in 2015 and the new ESN, designed to help the emergency services protect the public and save lives, will go live from 2016/17.

Minister of State for Policing, Criminal Justice and Victims, Damian Green, said:

‘Interest in providing the new emergency services network and its supporting elements has been strong, with 34 organisations completing in-depth pre-qualification questionnaires. After rigorous evaluation by the Home Office and representatives of the emergency services we are now inviting those organisations we consider to be best suited to tender formally for the work.

‘We remain on track to deliver this key part of our critical national infrastructure by the end of 2016 and today marks another step towards the emergency services having the modern communications network they need to protect the public and save lives.’

Approximately 250 000 operational staff across the three emergency services will use ESN when it is rolled out. Therefore, it is essential that the new communication system offers extensive coverage, high resilience and enhanced security, to ensure public safety can be maintained.


Home Office (2013) Emergency Services Mobile Communication Programme. The Stationery Office, London

Taken from Journal of Paramedic Practice, published 1 August 2014.

Ambulance Service Institute Annual Awards 2014


South East Coast Ambulance Service’s Thameside Ambulance Station team celebrate winning the Special Incident Award.      Photo Credit: Simon Hayward

Friends and family gathered at the Cholmondeley Room and Terrace, House of Lords, on 8 May to celebrate the Ambulance Service Institute (ASI) Annual Awards. The occasion recognised those in the pre-hospital care sector who have performed above and beyond the call of duty, in their dedication to saving lives.

Presented by Lord Ian McColl, professor of surgery and politician, the opening words of his address commended the great work being carried out by ambulance services up and down the country:

‘It’s been a great joy for me to be here and to hear all the amazing things that you have done. It must be absolutely horrendous; some of the situations you have had to deal with. We are just so grateful that you risk your lives to do all these wonderful things. Greater love hath no man who gives his life for another—or risks doing so.’

Set up in 2000 and originally held at AMBEX in Harrogate, the ASI Awards were initially only for NHS ambulance service personnel. However, the awards now incorporate accolades for military, private and voluntary services, and an international award was introduced in 2011.

2014 saw a 55% increase in nominations over the 11 award categories, resulting in the awards committee being split into six smaller committees deciding on two to three categories each.

Among the winners, Fellowship was awarded to past ASI president Carl Ledbury, and Honorary Fellowship to Prof Ian Greaves, professor of emergency medicine at James Cook University Hospital, Middlesburgh; and Prof Sir Keith Porter, clinical service lead for trauma services at the Queen Elizabeth Hospital Birmingham.

The President’s Commendation for Long Service went to Dennis Oakes of South Western Ambulance Service NHS Foundation Trust, who retired recently after 50 years of service. Oakes was praised for dedicating his entire life to caring for others.

The Innovations Award went to East Midlands Ambulance Service NHS Trust for the use of USB ECG leads linked to Toughbook PCs to improve efficiency and governance, as well as to reduce cost.

The Control Room Award went to Fiona Dinkel of Yorkshire Ambulance Service NHS Trust, who was noted as an outstanding emergency medical dispatcher with an almost exemplary audit history.

The First Aid/Community First Responder Award went to Craig Singleton of West Midlands Ambulance Service NHS Foundation Trust for his management of an incident in Gnosall involving a 4-year-old child who had been attacked at home by a Staffordshire Bull Terrier.

Recalling the event, Singleton said:

‘It was a traumatic experience. At the time, when I was in the house with the family and when the paramedics arrived I kept it together, but when I got outside it hit me how traumatic it was.’

The Private/Voluntary Ambulance Service Award was presented to St John Ambulance, District 5, South East Region for exceptional contributions made in support of a number of critical incidents.

The Patient Transport Service Award went to Alex Laston and Louise Ormsby of West Midlands Ambulance Service NHS Foundation Trust for their involvement in attending to a road traffic collision involving a female pedestrian and a large goods vehicle.

The Special Incident Award went to South East Coast Ambulance Service NHS Foundation Trust for their management of the Sheppey Bridge Incident, the biggest road traffic accident in Kent’s history, with more than 300 cars caught up in the early morning crash.

The Air Ambulance Team of the Year Award was presented to Helimed 03 and Helimed 09 from Midlands Air Ambulance, who demonstrated excellent team work in treating a 33-year-old male worker trapped in a tunnel under a large potato-sorting machine.

The Front-line Ambulance Award was given to Lance Corporal Malcolm Martindale of the Royal Army Medical Corps for his provision of front-line ambulance medical support to deployed British forces in Afghanistan.

The Military Award was presented to Sergeant Ryan Briggs, an RAF medic who helped form a small quick response force which treated casualties of the Taliban raid of Camp Bastion in Helmand Province, Afghanistan on 14 September 2012.

The Paramedic/Emergency Care Practitioner Award went to Paul Gibson of East of England Ambulance Service NHS Trust, who selflessly saved a woman from a flat in Ipswich that was engulfed in flames after learning that she was trapped inside.

George Reader, dock master at Watchet Mariner in Somerset, received the Public Spirited Award for his bravery in saving a 6-month-old baby who was plunged into the icy waters at Watchet Harbour when a gust of wind swept the child’s buggy into the water.

Speaking to the Journal of Paramedic Practice after the event, Dr Anthony Marsh, chief executive officer of both East of England Ambulance Service NHS Trust and West Midlands Ambulance Service NHS Foundation Trust, and chairman of the Association of Ambulance Chief Executives, said:

‘I think this event is a fantastic opportunity to publicly recognise the great work of ambulance staff and all those people that support the ambulance service in our country.

‘Our staff do a fantastic job every day, often in difficult circumstances, so to have an event such as today, where we can recognise excellence, thank them personally, but also their families, is a great occasion.’

Dr Peter Griffin, president of the Ambulance Service Institute, added:

‘I have been responsible for chairing the ASI Awards Committee and reading out the Award Citations since 2002 and I never cease to be amazed by the outstanding professionalism and often extreme acts of bravery that are detailed in the nominations.

‘Typically, the ambulance personnel concerned make light of their actions with comments like “I was only doing my job” or “it is all in a day’s work”. I see the ASI Awards as a way of making these dedicated people feel special for a day with a trip to London and a visit to the House of Lords. It is my greatest wish to get more publicity for the ASI Awards Ceremony so that these actions and the people involved can get the wider publicity that they most rightly deserve.’

Taken from Journal of Paramedic Practice, published 6 June 2014.

Report highlights inadequate UK landing facilities for air ambulances

A report produced by the Association of Air Ambulances (AAA) has highlighted that 60% of air ambulance landing facilities are inadequate in the UK, raising concerns that this could lead to greater morbidity and mortality.

The report, which was produced by the AAA after the issue was raised at the All Party Parliamentary Group for Air Ambulances (APPGAA) Annual General Meeting in October 2013, focuses on the treatment of major trauma—the biggest killer of people under 50 years of age.

On average, 70 people are treated by air ambulances in any one day. Patients attended will often be critically ill, suffering from major trauma, burns, cardiac or neurological illness. However, despite the severity of the conditions presented, air ambulances frequently have to land some distances from the hospital in inadequate facilities, which require a land ambulance to complete the journey to definitive care.

The report reviewed the 29 Major Trauma Hospitals for adults and children in the UK and concluded that only seven have suitable helipads. A further eight have landing facilities with operational issues and the remaining 15 sites require a secondary land transfer by land ambulance or vehicle.

The effect this has on the delivery of care to patients is clear: while the care itself isn’t generally affected, it is the delays to the provision of that care that can be potentially life-threatening for the patient.

According to Clive Dickin, National Director of the AAA, one of the ways in which these delays can be reduced is by looking at the most value for money landing facilities:

‘The simple thing you have to consider here is that it is not always about sticking a helipad on a roof. It is important when developing landing facilities to consider a helipad that will be fit for the majority of aircraft that will use it, not the minority.’

Many hospitals have taken a ‘one size fits all’ route so they look for a very large landing facility that can accommodate larger aircraft. However, if you look at the number of actual missions that air ambulances carry out each year (just over 20 000, in comparison to approximately 1 000 for search and rescue), the facilities that are needed are for small helicopters, not large.

The factors that dictate the location of helipads is also something that has to be taken into consideration. ‘There is always restrictions on sites,’ says Dickin.

‘If you look at Addenbrookes [Hospital Cambridge], for example, the hospital has developed and grown over the years, but the actual ED, the MTC, is at the heart of the hospital, so the only option they potentially have is building a rooftop helipad. Apparently that is cost-inhibitive and the hospital cannot justify that at the moment. So you have a landing site that is about half a mile away on the extremities of the actual campus of the hospital, and ultimately you have to have a land ambulance meet the aircraft to convey the patient for about half a mile. And, of course, that takes time.’

The key factor then is about looking at locations such as car parks and considering more sensible ground-level approaches that could be more cost-effective. But as Dickin highlights, not all hospitals have found the right balance of what is cost-effective yet best for the patient:

‘If you look at the University Hospital Coventry, car parking has actually taken priority over the landing facilities. If you look at an aerial photo it shows the helipad beyond the car park. Why was it not the other way around and the helipad put closer to the emergency department? Instead it is some 150 metres. That’s not a huge distance, but when you’re having to push a patient, potentially who is in cardiac arrest and not on a chest compression device, that is quite a distance and those minutes are extremely important.’

Some hospitals have found innovative ways in which to combat this problem. For example, Southampton General Hospital has built a raised platform above a car park. Helipads built more than 3 metres from the ground require the presence of fire marshals when helicopters are taking off and landing, which involves an additional revenue cost. However, by building a helipad approximately 2.4 metres above ground, Southampton General Hospital has been able to eliminate this unnecessary cost. A number of hospitals have built helipads only to have restrictions on their operation, resulting in them not being fully manned 24/7. This obviously presents a problem when you have a patient who is treated by a night HEMS aircraft.

The APPGAA have shared the information from the report with all MPs and members of Lords, as well as liaising with the Department of Health, highlighting the report findings and seeking clarification on whether the provision of air ambulance helipads can be addressed. However, in terms of who can implement the change in the provision of helipads, MPs and the Department of Health do not have direct control. Instead it is up to the Boards of the hospitals to recognise that these facilities are extremely important. That being said, this does not mean that MP’s and the Department of Health cannot play their part. As Dickin comments:

‘Through the MPs and Department of Health we are highlighting the fact that you can find very cost-effective, very sensible, but also extremely useful ways of positioning helipads so that they are nearby to the actual entrance to the Major Trauma Centre or the correct care pathway.’

Both the APPGAA and the AAA are calling on the Government to endorse a policy of recognition of parity for all patients arrival facilities. The report argues that it is unacceptable and not in keeping with the principle of ‘Equality of Care’ for patients to have reduced access to definitive care, in comparison to a patient arriving on a land ambulance. This is heightened by the fact that air ambulance patients are typically in need of time-critical care. Just over 50% of patients treated by air ambulances go to MTCs each year, so although it is important to focus on land ambulances, it is equally important to put in as much focus on helipads.

Looking to the future, the AAA is planning to publish a further report in Autumn 2014 exploring all care pathways within England. Once that report is published, it will again be highlighted to the Department of Health. The conversations the AAA is having with the relevant organisations is described by Dickin:

‘We have an ongoing process at the moment, engaging with the Department of Health and the hospitals through the air ambulance charities, that includes also the HELP [Helicopter Emergency Landing Pads] appeal, who are obviously specifically fundraising for helipads throughout the country and we will be looking to step up the profile through this report in making sure landing facilities are treated as high a priority as land transport facilities at these centres.’

Although there are well-developed plans for landing facilities at a number of UK hospitals, including: Bristol Royal Infirmary/Bristol Children’s Hospital/Bristol Southmead; Derriford Hospital, Plymouth; Hull Royal Infirmary; and St George’s Hospital, London, it is clear that improvements are still needed within other areas of the country if appropriate care is to be given.

Taken from Journal of Paramedic Practice, published 2 May 2014.

Emergency Medicine 2014

The sixth national Emergency Medicine 2014 conference took place at the Hallam Conference Centre, London, between 23 January and 24 January 2014. Co-organised by the Journal of Paramedic Practice and British Journal of Hospital Medicine, the two days were split across issues in pre-hospital care and management in the emergency department. Delegates included paramedics, specialists in emergency medicine and anaesthetists, who came together to consider the current state of emergency medicine in the UK. Journal of Paramedic Practice attended the first day.

Day one

Following a welcome from the morning’s chair, Prof Fiona Lecky, ScHARR, University of Sheffield and honorary consultant in emergency medicine, Taunton and Somerset NHS Foundation Trust, the conference began with a discussion of the state of emergency medicine services in the UK by Dr Clifford Mann, president, College of Emergency Medicine and consultant in emergency medicine, Taunton and Somerset NHS Foundation Trust. Dr Mann alluded to the media attention surrounding emergency care professionals in 2013, which arose as a result of widespread concern regarding delays in ambulance handovers, breaches of the four hour target and incidents of poor care. In response to the competing challenges of rising patient attendances, the College of Emergency Medicine published 10 priorities for resolving the crisis in Emergency Departments (also referred to as ‘CEM 10’), which clearly sets out the action which needs to be taken to address the current crisis in A&E.

Prof Lecky then delivered a talk on the Head Injury Transportation Straight to Neurosurgery (HITS-NS) Trial, for which she is the chief investigator. The study aimed to assess the feasibility of conducting a clustered randomised clinical trial of early neurosurgery in patients with traumatic brain injury.

After morning coffee, Prof Christoph Redelsteiner, scientific director, Emergency Health Services Management Program, Danube University, Austria, addressed the question: is there a need to standardise paramedic practice throughout Europe? Considering differences in the delivery of pre-hospital care of European nations and comparing commonalities, Prof Redelsteiner discussed criteria for a future pre-hospital care provider in a larger European context, that might help to deliver a more equal and balanced system.

Drew Wemyss, head of strategy implementation, Scottish Ambulance Service, then discussed different alternative systems of care offered by the Scottish Ambulance Service as a result of strategic aims outlined in their framework document: Working together for better patient care. Focusing on the pre-hospital management of older frail people, Mr Wemyss highlighted the role of the ambulance service in providing high-quality clinical care and navigating patients to the right care, either through telephone or face-to-face clinical assessment.

Following lunch, Dr Anil Hormis, consultant in anaesthesia, critical care and pre-hospital emergency medicine, Rotherham NHS Foundation Trust, gave a talk on simulation training and non-technical skills in pre-hospital emergency medicine. Outlining the importance of simulation training in the pre-hospital environment, Dr Hormis explained how it can be used to help cement skills such as decision making and task management in an environment where many different teams are required to work together. Dr Gareth Grier, consultant in emergency medicine and pre-hospital care, the Royal London Hospital and London’s Air Ambulance, also delivered a talk on simulation, instead outlining the Royal London Hospital approach. Reiterating the difficulties faced by pre-hospital clinicians when placed
in challenging environments, Dr Grier highlighted the benefit of high-fidelity scenario simulation. Perhaps the most thought-provoking take home message of the talk came when he said: ‘you get an expert and change them to a non-expert just by changing the environment.’

The final talk of this session was delivered by Dr Kudakwashe Dimbi, mental health clinical lead, London Ambulance Service NHS Trust, on mental health difficulties in the pre-hospital environment. Given that patients suffering from mental health disorders make up a notable portion of the London Ambulance Service’s workload, Dr Dimbi highlighted some of the considerations to take into account when providing care to patients suffering from a mental health disorder.

The remaining talks of the day were intended as interactive treatment case studies; however, due to a somewhat apprehensive room of delegates, seemed to lack the ‘interactive’ element. That being said, this did not detract from the engaging content that was presented. Dr Mark Bloch, consultant anaesthetist, Aberdeen Royal Infirmary and Aberdeen Royal Children’s hospital spoke on difficult airway management; Gareth Mallon, paramedic, East Midlands Ambulance Service NHS Trust, spoke on sudden cardiac arrest; and Dr Ron Daniels, chair, UK Sepsis Trust and chief executive, Global Sepsis Alliance closed the day with a talk on the management of sepsis.

Taken from Journal of Paramedic Practice, published 7 February 2014.

London Trauma Conference 2013


Photo credit: Lee Parker

The seventh London Trauma Conference took place at the Royal Geographical Society, Kensington Gore, between 10 December and 13 December 2013. Consisting of a main programme of presentations supplemented by breakaway sessions held parallel to the main conference, the speakers addressed a number of key questions in trauma and emergency medicine. The Journal of Paramedic Practice attended the London Cardiac Arrest Symposium held on 10 December, which returned for the second time following its success in 2012, and the Air Ambulance and Pre-hospital Care Day held on 12 December, which focused on some of the wider trauma issues faced in the pre-hospital setting.

London Cardiac Arrest Symposium

Dr Richard Lyon discussing the TOPCAT study. Photo Credit: Lee Parker

Dr Richard Lyon discussing the TOPCAT study. Photo Credit: Lee Parker

The conference kicked off with a discussion from Dr Richard Lyon on the TOPCAT study. Looking at the rationale behind the trial and some of the problems that arose, the interim results presented by Dr Lyon suggested a number of indicators for potential improvements in the management of pre-hospital cardiac arrest.

Prof Simon Redwood spoke on post-cardiac arrest syndrome, outlining its cause, how it should be treated and how it can be prevented. Prof Redwood emphasised the need to develop and adopt a systems approach to all events of pathophysiological processes.

Prof Tim Harris then gave a talk on the use of ultrasound (USS) in cardiac arrest. Considering whether USS can aid resuscitation, Prof Harris illustrated training requirements for its use and its potential application in the pre-hospital setting.

After the first coffee break, Prof Charles Deakin delivered a presentation on cardiogenic shock after return of spontaneous circulation (ROSC). The key elements of his talk looked at how cardiogenic shock should be treated pharmacologically, how it should be treated mechanically, and what treatments are on the horizon—suggestions he alluded to included synchronised pacing, therapeutic hypothermia, extrathoracic ventilation and gene therapy.

Prof Bryan McNally spoke on the Cardiac Arrest Registry to Enhance Survival (CARES), considering evidence for whether cardiac arrest registries improve survival and whether they should be implemented regionally, nationally or locally. He outlined how registries allow for communities to determine OHCA outcomes and identify risk groups and neighbourhoods, as well as enabling clinical benchmarking to identify opportunities and track the diffusion of new therapy.

David Zideman

Dr David Zideman delivers the Douglas Chamberlain Lecture on the challenges of providing field of play (FOP) medical care at the London Olympics. Photo Credit: Lee Parker

The Douglas Chamberlain Lecture was given by Dr David Zideman on the challenges of providing field of play (FOP) medical care at the London Olympics. Dr Zideman was the lead clinician for the emergency medical services at the London Organising Committee of the Olympic and Paralympic games. He outlined how FOP care is different depending on the sport and so knowledge, preparation and training was essential in providing the best care at London 2012.

Following lunch, Prof Karim Brohi discussed open chest cardiac massage. After alluding to the fact that external chest compressions have been around since the 1960s, Prof Brohi went on to question whether they are the best way to generate a cardiac output. In canine models, coronary perfusion pressure has been seen to be five times better with internal cardiac massage, although there are few studies showing the outcome in humans. Prof Brohi therefore questioned whether it is time to do a trial of open cardiac massage.

Dr David Menzies then spoke on community first responder schemes, considering challenges they face and their potential solutions. One of the predominant issues concerns the maintenance of skills and interest, especially as training is not always standardised. Given the high level of cardiac arrests that occur at home, the continued need for CFR schemes is evident.

After the afternoon coffee break, Dr Matt Thomas spoke on neuroprotective strategies for post-cardiac arrest syndrome. Dr Thomas highlighted the importance of controlled re-oxygenation as well as considering therapeutic hypothermia, a treatment that has received much debate recently. The main take home message from the talk was to not prognosticate too early, as improvements patients following OHCA can be seen as late as 72 hours.

Dr Eldar Soreide spoke on recent advances in improving OHCA in the Stavanger region of Norway. Dr Soreide mentioned how we are obsessed with medical breakthroughs rather than follow-throughs, and how focusing on bystanders can improve outcomes of OHCA.

Prof Daniel Davis gave the final talk of the day on what makes up a high-performing hospital team. Highlighting the work of the UC San Diego Center for Resuscitation Science, he emphasised the importance of advanced resuscitation training, inpatient/technology-specific algorithms and the need for an organised approach to data analysis.

Air Ambulance and Pre-hospital Care Day

The Air Ambulance and Pre-hospital Care Day, which was co-hosted by the Norwegian Air Ambulance Foundation, began with a talk from Prof Bryan McNally on US emergency medical services and bad weather. Prof McNally stressed the importance for health communities to be prepared for cases of extreme weather. By having a plan in advance, good decision-making can be enabled.

Dr Rasmus Hesselfeldt then spoke on introducing HEMS to a well-organised urban trauma system in Denmark and whether it has improved outcomes for patients. Hesselfeldt conducted an observational study looking at data five months before the trial and 12 months after. While the time to primary hospital didn’t see a notable improvement, time to trauma centre was significantly improved.

Hans Morten Lossius

Prof Hans Morten Lossius speaking on physician-staffed pre-hospital critical care. Photo Credit: Lee Parker

Prof Hans Morten Lossius then gave a talk on physician-staffed pre-hospital critical care. Providing a defence of the need for pre-hospital physicians, he argued that it is a matter of competence not profession. This competence comes through adequate training and qualifications. However, he did stress that paramedics are the backbone of the pre-hospital team and that without them the system would fail.

Prof Daniel Davis gave a talk on the US experience of pre-hospital intubation by paramedics, which acted as a counter to Prof Lossius’ previous talk. Prof Davis argued that the question of pre-hospital intubation is one of training, and that confidence and competency comes through adequate practice, whether through simulation or carrying out the procedure on patients.

Dr Geir Arne Sunde then gave a talk on the results of the prospective observational HEMS study, AIRPORT. Conducted in six countries and involving 21 HEMS services, the findings indicated that intubation success rates are high (98%), with a complication rate of 10–12%.

Dr Matt Thomas spoke on the pre-hospital feasibility study REVIVE, which looked at airway management in OHCA, comparing the I-gel, LMA Supreme and standard care. The study assessed the feasibility of a prospective cluster randomised clinical trial, indicating that research in this area is possible.

Prof Wolfgang Voelckel gave the final talk before lunch on the role of video laryngoscopy in pre-hospital care. Comparing the different models of video laryngoscopes available, he concluded that video laryngoscopy is the future, but that training and skills are needed.

Following lunch, Dr Matt Thomas gave a talk on pre-hospital advanced cardiac care. Considering echocardiography, automated mechanical CPR devices, cooling and vasoactive drugs, Dr Thomas emphasised that the key to improving pre-hospital cardiac care lies in the aggregation of marginal gains.

Dr Erik Dietrichs then spoke on inotropic support during rewarming in the treatment of hypothermia. Dr Dietrichs highlighted that Milrinone and Levosimendan both have good effects on preventing rewarming shock.

After the afternoon coffee break, a number of rapid fire sessions were given, looking at a wide range of topics. Mr Jan Jansen spoke on pre-hospital amputation, providing indications and an outline of the procedure. He concluded that pre-hospital amputation is necessary. Dr Ross Davenport discussed the desirable kit to have on-board a helicopter to treat haemorrhage. Dr Nils Petter Oveland spoke on the feasibility of pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA). Showing the manikin he developed for REBOA training, his team were able to achieve an average skin to balloon time of 3.3 minutes. Mr Mark Wilson spoke on the need for a culture shift concerning fixed dilated pupils and how there is a low threshold for surgery in bilaterally fixed extradural haematoma. Chief pilot for the Norwegian Air Ambulance, Erik Normann, gave an inspirational talk on the steps taken to reduce the number of deaths of HEMS workers. Between 1988 and 1996, 13 people died, leading to concerns on whether the HEMS system could be continued, and if so, how it could be done safely. Improved training and the addition of night vision goggles and advanced maps has helped to make this possible. Dr Malcolm Russell spoke on the provision of medical care in the tactical environment, considering its viability. While there is no risk-free option,

Dr Russell emphasised the importance of knowing your plan and following it, and highlighted the benefit of having training as realistic as possible.

Prof Hans Morten Lossius gave the final rapid fire session on on-board CT scanners, illustrating how they are more cost-effective than stroke units.

The final talk of the day was given by Dr Gareth Grier and Mrs Marte Ramborg on balancing charity-PR against patient privacy in the hot zone. They emphasised the need for public exposure for funding but highlighted a number of the concerns involved, including whether care is compromised in patients who are filmed, the fact that many patients are not able to give consent to be filmed, and whether they should shoot first and ask later.

Although the Journal of Paramedic Practice was only able to attend a small portion of the London Trauma Conference, its breadth of speakers and level of detail make it an integral part of the calendar for any pre-hospital practitioner.

Taken from Journal of Paramedic Practice, published 10 January 2014.