The need for optimism at a challenging time for the NHS emerges as key theme of Ambulance Leadership Forum

The Association of Ambulance Chief Executives’ (AACE) annual Ambulance Leadership Forum (ALF) took place this year on 9–10 February at the Hinckley Island Hotel in Leicestershire. Designed to stimulate debate and ideas about the on-going development of emergency and urgent care, delegates were encouraged to share best practice and discuss issues pertinent to the sector.

The theme for this year’s event focused around the future look and feel of ambulance service provision and was largely based on AACEs document published last year, A vision for the ambulance service: 2020 and beyond. This vision presents ambulance services as mobile healthcare providers operated in an extended range of care settings, doing more diagnostic work, more treatment, more health promotion, and providing patients with more services that before.

Delegates were welcomed to the conference by AACE chair and West Midlands Ambulance Service NHS Trust CEO, Anthony Marsh, who called on attendees to embrace the new ambulance initiatives on offer and improve outcomes. He noted that ‘the challenge we are confronted with now [in the NHS] offers us a real opportunity,’ and hoped proceedings for the day would help influence national policy.

The landscape of urgent and emergency care: implementing the Five Year Forward View

The opening address was given by Chris Hopson, CEO of NHS Providers, who asked whether the provider sector had the capacity to deliver the changes outlined in NHS England’s Five Year Forward View? Hopson said that all Trusts would be under pressure to achieve their financial targets in 2016–2017 and that one of the biggest debates would be over standards and performance, especially for ambulances. He highlighted that the majority of providers have found themselves in the ‘needs improvement’ box in terms of Care Quality Commission rating, and that we cannot fix many problems found in the NHS unless we have more vertical integration of health and care and horizontal collaboration.

Prof Keith Willett, national director for acute episodes of care for NHS England, then spoke on the new landscape for urgent and emergency care. He started by mentioning he sat on a sharp fence between the clinical world of service providers and Whitehall, and noted it is a sharp fence. The current provision of urgent and emergency care services sees 24 million calls to the NHS and 7 million emergency ambulance journeys a year. Willett said for those people with urgent but non-life threatening needs we must provide ‘highly responsive, effective and personalised services outside of hospital, and deliver care in or as close to people’s homes as possible.’ For those people with more serious or life-threatening emergency needs, he said: ‘We should ensure they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery.’ As we move into the final phase of the Urgent and Emergency Care Review, the focus is on implementing new models of care and ways of working. He stressed that the ambulance service needs to come to the fore and drive change, and that no paramedic should make a decision in isolation, but should have support from whole of the NHS.

Transforming health and social care: innovation and leadership

Following the first coffee break of the day, Bob Williams, CEO of North West Ambulance Service NHS Trust, spoke on devolution in Manchester. After providing a background to the health and social care system in Greater Manchester and the Greater Manchester Devolution Agreement, Williams outlined the principles around the Greater Manchester devolution plan, which include: radical upgrade in population health prevention, transforming care in localities, standardising acute hospital care, and standardising clinical support and back office services. Williams said Greater Manchester devolution offers an opportunity to transform health and social care, and that ambulance service has the tools, the players and the crucial elements to help make the healthcare system changes needed.

Prof Paresh Wankhade of Edge Hill University then spoke on leadership in the emergency services, focusing on interoperability and innovation. Wankhade first set the scene by outlining the leadership challenges faced by emergency services, before highlighting the key issues impacting workforce development, the need for suitable leadership for empowering and motivating staff, provided a critical overview of the state of interoperability, and closed by speaking about innovation in an era of uncertainty. For the ambulance service, he noted an increasing demand but lesser proportion of life-threatening calls, and that performance and quality are unsustainable with current levels of funding. He went on to say that there is very little evidence to suggest that enough is being done to support the workforce for new challenges and performance pressures, and that there is an important role for the College of Paramedics to prepare practitioners for the future.

Leading in challenging times

After lunch, delegates heard a recorded message from Lord Prior of Brampton, parliamentary under secretary of state for NHS productivity, who commended the work that is being done by ambulance services across the country, and apologised on behalf of the secretary of state for health, Jeremy Hunt, who had to pull out the conference last minute.
This was followed by Rob Webster, CEO of NHS Confederation, who gave one of the most engaging talks of the day on leading in challenging times. He began by explaining there has been a 24% increase in activity for Category A calls for ambulance services since 2011. He went on to stress the need for values-based leadership and system leadership, and that leading should come from every seat in the NHS. If senior ambulance managers do not understand the organisation’s values, then it is difficult to expect staff to understand them. He closed by noting that the NHS is made of people, and that it is the collective commitment, drive and energy that make up an organisation, and what makes a successful future.

Janette Turner, director of the medical research unit at the University of Sheffield, then spoke on managing urgent care outside hospital. Looking at data from March 2015, 27.9–57.6% of 999 calls were not conveyed to emergency departments in England. On population utilisation of emergency ambulance services the UK receives 13 calls per 100 population, compared to Belgium, which has the highest number of calls per population in Europe at 33. Turner said that outcomes of evidence on telephone-based service involved accuracy, compliance, satisfaction, costs, service impact and access. While accuracy is high for minimising risk, inaccuracy tends to come in the form of over triage. Considering the role of management by ambulance clinicians outside hospital, Turner said a small number of high-quality studies support extended paramedic roles as they offer safe decisions, reduced emergency department transports, high satisfaction and are cost effective. However, she did note that decision-making is complex and needs to be underpinned by the right education.

Introducing new delivery models

After another coffee break, Richard Murray, director of policy at the King’s Fund, spoke on new delivery models for urgent and emergency care and NHS Planning Guidance. Murray outlined the key features of NHS Planning Guidance before discussing the implications for urgent and emergency care and ambulance providers. He said it was a game of two halves: a one-year plan for 2016/17, with existing organisations as the key building block, switching to place-based plans for 2017/2018 to 2020/2021. Taken together, Murray said they offer a radical re-drawing of the boundaries in the NHS.

The final talk of the day was delivered by Dr Phil Foster, assistant medical director for Yorkshire Ambulance Service NHS Trust, who spoke on the West Yorkshire Urgent and Emergency Care Vanguard. He explained how the service’s collective local vision was for all patients with emergency and urgent care needs within West Yorkshire to get ‘the right care in the right place—first time—every time.’ The aim was to give patients access to urgent and emergency care through 999 and 111 and given an improved experience with care provided closer to home. This would be a standard service offering across West Yorkshire.

Celebrating excellence at the AACE Outstanding Service Awards

The evening saw delegates celebrate the AACE Outstanding Service Awards. Sponsored by Ferno UK Ltd in aid of the Ambulance Services Charity, ambulance service employees form across England who have gone above and beyond the call of duty were recognised and commended for their outstanding service. The Outstanding Paramedic Award went to Abigail Evans, a cycle response unit paramedic for London Ambulance Service NHS Trust. The Outstanding Mentor or Tutor Award went to Chris Mathews, a critical care paramedic with South East Coast Ambulance Service NHS Foundation Trust. Outstanding Innovation and Change Awards went to Adam Aston, a paramedic with West Midlands Ambulance Service NHS Trust and Thomas Heywood, a clinical manager for Yorkshire Ambulance Service NHS Trust. The Outstanding Non-Paramedic Clinician Award went to Steve Wainwright, and emergency care assistant for East of England Ambulance Service NHS Trust. The Outstanding Control Services Employee Award went to Craig Foster, a call operator for North East Ambulance Service NHS Foundation Trust. The Outstanding Manager Award went to Karen Gardner, operations manager for North East Ambulance Service NHS Foundation Trust. The Outstanding Support Services Award went to Tez Westwood, Hazardous Area Response Tram support technician for East Midlands Ambulance Service NHS Trust. The Outstanding Senior Management Award went to Tracy Nicholls, head of quality governance for East of England Ambulance Service NHS Trust and the Outstanding Welfare and Wellbeing Award went to Ben Lambert, a team leader for South Central Ambulance Service NHS Foundation Trust.

Workshops allow delegates to discuss emerging themes

The second day, co-hosted by NHS Confederation, featured a morning of facilitated workshops, concluding with a conference summary and forward view. Delegates were given a choice to attend workshops on the themes of ‘our workforce’, ‘technological and digital enablement’, and ‘vanguards and innovation’.

A summary of the main themes discussed in the workforce workshop include the need to engage with staff meaningfully, understanding culture but also taking change, collaboration, and a recognition of whether or not we are doing as much as we can on mental health and race equality.

The technology workshop had a key theme around innovation, and an emphasis that ambulance services are much more than a transportation service. There was a strong feeling that there needs to be better capture and use of data in technological advancements, that procurement needs to be looked at as a whole-systems approach, and that ambulance services should embrace social media.

Within the vanguard workshop there was a clear sense of the great work that is being done across the country. It was recognised that a lot of the components of a really good system are in place, but that we have to learn from each other’s organisations. There was also an emphasis on ensuring that the right culture is in place within services.

With difficulty comes opportunity

The conference came to a close with Anthony Marsh commending the optimism shared by delegates during what is a challenging time for the NHS. He quoted the BBC programme Inside Out, saying there is ‘no need to be miserable, we are winning the war.’ Martin Flaherty, managing director of AACE, then remarked on how sobering it was to hear about the challenging times ahead, particularly around finance. However, he said with difficulty comes opportunity and that as a sector we are always doing our best when in difficulty.

Delegates left with much food for thought and plenty of ideas for implementing change within their own services. Feedback has been positive, with one delegate saying: ‘Excellent conference, completely relevant to our practice in emergency medicine,’ while another remarked: ‘I think the organisation was superb and the quality of speakers and breadth of subject matter was really relevant.’ Congratulations must be extended to AACE for an engaging two days, and delegates can look forward to returning for another year.

Taken from Journal of Paramedic Practice, published 4 March 2016.

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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 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.