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.