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.

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.

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.