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.

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Minister for Civil Society assures air ambulances his ‘door is always open’

L to R Bill Sivewright AAA - Nick Hurd MP Minister for Civil Society - G...

From left to right: Bill Sivewright, NIck Hurd MP, Guy Opperman MP, Clive Dickin. Photo credit: Association of Air Ambulances

The Minister for Civil Society, Nick Hurd MP, has told members of air ambulance charities that his ‘door is always open’.

Speaking at a reception held by the All Party Parliamentary Group for Air Ambulances (APPGAA) on 9 June on the House of Commons Terrace, Westminster, Mr Hurd MP extended an open invitation to all air ambulance charities:

‘My offer is this, it is a very simple one: my door is always open. Please come and see me. My job is to advocate on behalf of civil society on behalf of the voluntary sector. If you don’t feel you’re getting heard, if you feel you have got an argument that you really want to make, or you have got a brilliant creative idea, please come and see me.’

Mr Hurd MP praised the work being undertaken by air ambulance charities in the UK, who together raised £96.4 million last year through public donations and on average treat 70 patients a day by the 20 charity-funded services.

He expressed his admiration for air ambulance services as a result of the passion and enthusiasm underlying the organisations, as well as their pride and desire to do more to help people. In a sector that relies on public generosity, and people’s willingness and ability to give time and money, Mr Hurd MP said:

‘There is a lot the Government can do to make it easier to give.’

The event, hosted by the chairman of the APPGAA, Guy Opperman MP, allowed local air ambulance charities and ambulance services from the UK to meet with members of Westminster to discuss their operations and key issues affecting the industry.

The APPGAA, a cross-party group of MPs, was set up in 2010 to support air ambulances. Its aim is to raise the quality of care, effectiveness and efficiency of air ambulance services through closer engagement with policy leaders and policy makers. It recently led a successful campaign in the House of Commons on the relief of VAT on air ambulance aviation fuel, and is currently calling on the Government to endorse a policy of recognition of parity for all patients arrival facilities, following a report published by the APPGAA, which highlighted that 60% of air ambulance facilities in the UK are inadequate.

In his opening speech, Mr Opperman MP explained how he had needed an air ambulance following a horse riding accident during his days as a jockey. He went on to explain how the group acts as a champion for air ambulances, ensuring that they have a strong voice in the House of Commons. By bringing members of Westminster together with the various air ambulance charities, Mr Opperman MP said that air ambulances could:

‘Promote innovation, different ideas, and take what I consider to be the fourth emergency service and then say: how can these incredible voluntary organisations harmonise, work together, come up with innovations, look to learn the lessons—whether it is from 7/7 or individual disasters and accidents that take place—so that there is a cohorted body working together and pushing forward the standards, because we are the best in the world?’

Nick Hurd MP addresses the reception

Nick Hurd MP addresses the reception. Photo credit: Association of Air Ambulances

The Association of Air Ambulances (AAA) supported the reception for the second year, bringing patients, charities, ambulance services and legislators together.

Bill Sivewright, chairman of the AAA, welcomed the Minister’s comments and thanked everyone in attendance, before issuing a challenge to all those present:

‘We must rise to the challenge of ensuring that the patient remains the focus for all our efforts. Air ambulances need to work with their local NHS Trusts, leveraged through the influence of local MPs when appropriate, to ensure that the patient journey from the point of injury or medical incident through to leaving the hospital is as seamless as possible.’

Speaking to the Journal of Paramedic Practice after the event, Graham Hodgkin, chief executive of London’s Air Ambulance, said:

‘As active supporters of the AAA, we’re always appreciative of the opportunity to meet with our sector colleagues, as well as some key supporters. The APPGAA reception is an important event where we can collectively highlight the common issues that impact on our operations and funding to our stakeholders in public office that can positively influence outcomes on our behalf. The APPGAA was instrumental in securing the recent VAT rebate on aviation fuel and it was really encouraging to hear the Minister for Civil Society, Nick Hurd MP, say his door is always open to us as charities.’

Mike Page, emergency care practitioner and critical care paramedic for Great Western Air Ambulance, added:

‘This has been an excellent opportunity for the Great Western Air Ambulance Charity (GWACC) and our team of critical care paramedics to meet with and discuss with our local members of parliament some of the important issues affecting the organisation’s ability to deliver the patient-centred care that is so gratefully funded by the kind donations of members of the public.

‘We in the GWACC area are extremely lucky to have the support of so many of the local MPs, a number of whom have visited the base and provide a good level of support. It is always good to know that they have an open door policy for us and are willing to support our charity when needed.’

Looking to the future for air ambulances, Clive Dickin, national director of the AAA, said:

‘The work on our key issues continues. We are in dialogue with NHS England on the issue of helipads and look for continued support through the members of the All Party Parliamentary Group in delivering appropriate landing facilities within the National Health Service Trusts. On other key issues, we continue to lobby for all VAT, not just that on aviation fuel, to be recoverable for charities, and again, we are working hard with the All Party Parliamentary Group to ensure that that actually materialises. At a local level, we encourage our air ambulance members to be engaging with their local MPs and pressing home those messages and reassuring the fundraisers, the volunteers and the patients that we are constantly improving services.’

Mr Opperman MP, added:

‘I think they [air ambulance charities] need to lobby their MPs more, without a shadow of a doubt. They need to to try to realise they’ve got a great deal more critical mass and force then they have actually exercised previously.

The reception was undoubtedly a success, giving the air ambulance community a rare opportunity to engage with legislators and members of Westminster, and make their issues heard.

Taken from Journal of Paramedic Practice, published 4 July 2014.

London’s Air Ambulance first to perform roadside balloon surgery

London’s Air Ambulance (LAA) has become the first organisation to perform roadside balloon surgery to control internal bleeding. The technique, Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), was first used in the UK at The Royal London Hospital, to control haemorrhage in trauma patients.

REBOA works by controlling or preventing further blood loss. The balloon is fed into the bottom end of the aorta, and then inflated, cutting off blood supply to damaged blood vessels. Patients who undergo REBOA by LAA are then transported rapidly to the Royal London Hospital to undergo further vital interventions. The technique can be used on patients suffering severe pelvic haemorrhage, an injury most commonly associated with cycling incidents and falls from height.

Dr Gareth Davies, medical director for LAA, commented on the use of REBOA to treat trauma patients:

‘Our aim is to provide our patients with the world’s most innovative and effective pre-hospital care. Being able to effectively manage blood loss at the scene is a significant advancement in pre-hospital medicine.

‘We believe the use of REBOA can lead to a reduction in the number of patients who quite simply bleed to death before they have the chance to get to hospital where there are highly developed systems for stabilising and preventing blood loss.’

Clinical staff from LAA worked closely with The Royal London Hospital, developing the skills necessary to perform REBOA safely in A&E, before transferring their knowledge to the pre-hospital setting.

Professor Karim Brohi, consultant vascular and trauma surgeon at Barts Health NHS Trust, commented on the partnership between LAA and The Royal London Hospital:

‘We have to stop people bleeding to death— it’s one of the world’s biggest killers. Over 2.5 million people bleed to death from their injuries each year around the world. The Royal London Hospital Major Trauma Centre and London’s Air Ambulance have together led the way in developing new strategies and treatments to reduce this death toll.

‘While it sounds relatively simple it is an extremely difficult technology to deliver in the emergency department in hospital, never mind at the roadside. This successful deployment of REBOA represents nearly two years of development work by our staff. We are excited about the potential for REBOA to reduce death and suffering after trauma and will continue to evaluate and develop the technology into the future.’

Mayor of London, Boris Johnson, said:

‘London’s Air Ambulance delivers a world-class service for a world-class city. It’s astonishing to see how these stunning advances in medical care are helping people survive serious injury in London, injury that they probably wouldn’t survive elsewhere in the world. That change is being pioneered and delivered by an incredible group of men and women—the doctors, paramedics, pilots and support staff of the London Air Ambulance.’

Taken from Journal of Paramedic Practice, published 23 June 2014.

London’s Air Ambulance celebrates 25 years

On 9 January, London’s Air Ambulance celebrated 25 years of service to London.

The air medical service, which was formed following a report by the Royal College of Surgeons that stated too many people were dying in the street unnecessarily, has delivered advanced trauma care, including roadside open chest surgery, anaesthesia and blood transfusions that have been adopted throughout the world.

Graham Hodgkin, chief executive of London’s Air Ambulance, said: ‘It is thanks to the generosity of the people of London that we are here today commemorating this milestone. 30,000 people have benefited from our life saving service and many of our critically injured patients have returned to their families and communities to live healthy lives.’

Prime Minister, David Cameron, said: ‘I would like to thank everyone involved in the vital work London’s Air Ambulance has done over the last 25 years to help deliver life-saving treatment to thousands of people. It is a charity that has become very close to the hearts of all Londoners, as I am sure the many dedicated people who help to run the service to keep it operating will attest.’

Taken from Journal of Paramedic Practice, published 27 January 2014.

London’s Air Ambulance are high-flyers at Awards of Excellence

 

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From left to right: Dr Gareth Davies, Capt Neil Jeffers, Graham Chalke, Dr Anne Weaver. Photo credit: Association of Air Ambulances

London’s Air Ambulance (LAA) has received notable recognition at the Association of Air Ambulances’ inaugural Air Ambulance Awards of Excellence, held on 18 November 2013 at the Millennium Gloucester Hotel in Kensington, London.

Hosted by BBC television presenter Louise Minchin and GP/comedian Dr Phil Hammond, four of the independently judged awards were presented to LAA, including Air Ambulance Paramedic of the Year, Air Ambulance Doctor of the Year and Air Ambulance Pilot of the Year.

The Lifetime Achievement Award went to LAA’s Dr Gareth Davies, who was recognised for his role in pioneering the ‘doctor on board’ model for air ambulances, taking life-saving surgery and advanced pain relief from the hospital to the roadside.

The Awards are open to all air ambulance operations within the UK and nominations were made from patients, staff, management and the general public.

Bill Sivewright, Chairman of the Association of Air Ambulances, said:

‘Celebration of success, innovation and commitment of staff and volunteers is a central strategy of the Association, and these Awards are a clear demonstration of the strategy in action. It is intended that they will encourage competition and best practice across all disciplines of pre-hospital care and deliver real improvements in patient outcomes. So, every winner should be immensely proud of their success this year as trailblazer.’

The 2014 awards ceremony will take place on 17 November, with nominations being taken via the AAA website from 1 January until 1 September.

The full list of winners is as follows:

AAA Chairman’s Award
Clive Dickin, national director, AAA

Outstanding Young Person Award
Sponsored by Bond Air Services
Poppy Young, Essex and Herts Ambulance

Charity Staff Member of the Year
Sponsored by Milestone Aviation Group
Janice Flower, Essex and Herts Air Ambulance

Air Ambulance Paramedic of the Year
Sponsored by Prometheus Medical Ltd
Graham Chalke, London Air Ambulance

Air Ambulance Doctor of the Year
Sponsored by Boundtree Medical
Dr Anne Weaver, London Air Ambulance

Air Ambulance Pilot of the Year
Sponsored by Quadrant Events
Captain Neil Jeffers, London Air Ambulance

Air Ambulance Campaign of the Year
Sponsored by Lottery Fundraising Services
Devon Air Ambulance—‘Devon Air Ambulance on Tour’

Charity Volunteer of the Year
Sponsored by Donorflex
Jenny Ashman, Midlands Air Ambulance

Special Incident Award
Sponsored by Eurocopter UK
Dorset and Somerset Air Ambulance
Captain Max Hoskins; Paramedic Greg Peacock; Paramedic Steve Freeman

Lifetime Achievement Award
Sponsored by Medical Aviation Services
Dr Gareth Davies, London Air Ambulance

Taken from Journal of Paramedic Practice, published 26 November 2013.

London’s Air Ambulance introduces on-board blood transfusion

On March 2012, London’s Air Ambulance introduced pre-hospital blood transfusion.During the first 12 months of this innovation, the service has delivered over 100 pre-hospital transfusions.

London’s Air Ambulance responds to severely injured patients within the greater London area. The physician paramedic team attends over 2000 mission per year using an aircraft and rapid response vehicles.

Within this population, approximately 200 patients per year are dying from serious blood loss and a percentage of this group die before reaching hospital.

For medical teams like those provided by London’s Air Ambulance, the ability to give a pre-hospital blood transfusion to patients who are also hypovolaemic, will increase the survival rate from this procedure.

London’s Air Ambulance has already seen patients resuscitated successfully using these techniques.

There is strict legislation and extensive guidance on blood transfusion to ensure that patients are protected from transfusion errors and that products are not wasted or used inappropriately.

A standard operating procedure for pre-hospital blood transfusion ensures that all personnel understand the requirements and responsibilities which are associated with the administration of blood.

Since London’s Air Ambulance introduced pre-hospital blood transfusion other air ambulances have followed its lead, including teams from Kent, Surrey and Sussex Air Ambulance Trust.

Dr Anne Weaver, lead clinician at London’s Air Ambulance and emergency medicine consultant at Barts Heath NHS Trust, said: ‘We were confident that carrying blood would make a big difference to our patients but it has exceeded our expectations. Our team continually push the boundaries in medicine to save lives. London’s Air Ambulance also pioneered pre-hospital roadside open-heart surgery and we have the world’s highest survival rates from this procedure.’

Taken from Journal of Paramedic Practice, published 25 June 2013.