Innovation for Pre-Hospital Emergency Care 2015 - Day 1
by Annelies van Wamel
Since the late 1970s, there has been an understanding that the role of pre-hospital care has become a specialised role. The two-day conference focused on the developments in pre-hospital cardiac care in myocardial infarcts and cardiac arrests. An astonishing development over the past 45 years has seen it develop from ‘scoop and run’ in now antique vehicles to state of the art interventions on scene.
Attending the first day, I was presented with a well-equipped venue (American Express Community Stadium in Brighton), a variety of knowledgeable speakers, several exhibitors and roughly 1000 attendees.
The conference was opened by the Chief Executive of SECAmb, Paul Sutton, who claims to be the only operational CE of a UK ambulance Trust. Although some areas of the Trust see him more frequently than others, rumour has it he still responds regularly, as do several of the senior managers. I wish somebody would invite him to do a few shifts in our remote corner of SECAmb (lovingly indicated as ‘deepest, darkest Kent’ by one of the speakers) which struggles with a so-called rest day rota in which all goes and only your rest days are set in stone. It poses major issues for staff with stress levels increasing dramatically.
The first speaker was Dr Craig Ellis, a Specialist Pre-hospital and Emergency Physician based in New Zealand. As he introduced himself he commented he was in the unique position to be able to drop a few bombs quite safely because he had to leave to catch his plane back to New Zealand immediately after his presentation. He was true to his word.
Dr Ellis told us that one rule doesn’t fit all patients; by rolling out a standard protocol regardless the etiology of the cardiac arrest we miss opportunities to improve outcomes which haven’t changed for the last several years. He showed us how PEA isn’t always a PEA and why we shouldn’t abandon a ‘chronic VF’ as unviable. He made an interesting point about good CPR with a 30 degree head tilt to relieve ICP: it can perfuse the brain to the point where the patient can vocalise and even object to (painful) CPR even though the patient is still in arrest. What do we do about pain relief for these patients? His main message was: think about the causes, we need more pragmatism and less dogmatism. I loved his departing message: ‘If you rush a miracle man you get rotten miracles!’
The second speaker was Dr Adam de Belder, Director of Cardiac Services at Brighton and Sussex University Hospitals. He took us on a tour about what we thought and think about the cause of Acute Coronary Syndrome and how treatment equally evolved. One of his slides showed how patients were once advised to be semi-starved or put on a diet of fruit, sugar and a bit of milk and left in bed for weeks, guarded and assisted by nursing staff to prevent any form of exercise or exertion. One wonders about the prevalence of DVTs and PEs! Having moved on from that view we now focus on the inflammation of arterial walls, plaque forming and the body’s response. Interesting little detail: ‘infarcire’, of which our ‘infarct’ is derived, means ‘to stuff’!
Having digested this it was time for coffee, tea and refreshments after which there was a choice of workshops. I attended the EZ-IO workshop which focused on the proximal humerus insertion. It led to a demonstration of how to define the landmarks and we all had a go at each other. The advantage of this site is that the flow rate is fast, with approximately 3 to 4 seconds to the heart, allegedly the pain is less (less requirement for analgesia), and if you are working at the head end of the patient you have immediate access to the drugs route. Adrenaline free Lidocaine is advocated when inserting in conscious patients yet this would take several minutes and does that not defeat the object of a quick vascular access? There were four other workshops but unfortunately only one could be attended.
Dr Ali Dana is Consultant Cardiologist at Portsmouth Hospitals NHS Trust. He gave us an interesting presentation on the pros and cons of several anti-coagulants and why cardiologists are not necessarily happy with our doped up with morphine patients even though they arrive pain-free, relaxed and their blood pressure under control; sadly, opioids have a tendency to delay gastric emptying and hence absorption of anti-coagulants given before the angioplasty procedure! There was a touch of political debate when he stated he didn’t care whether Clopidogrel was cheaper than Ticagrelor – that was for procurement and NICE to debate but he, as a doctor, preferred Ticagrelor mainly because the re-occlusion rate was lower and it worked faster. An interesting point of view if you work in a service which, for cost reasons, insists to provide its clinicians with the lower dose of Clopidogrel so that patients in their miserable state are regularly required to take at least 8 tablets to make the total dose!
After an excellent lunch Chris Walker, Nurse Consultant at Queen Alexandra Hospital, Cosham, took up the baton and advised us that the Emergency Department was a bad place to go with our ACS patient. Taking care not to alienate his predominantly SECAmb audience he showed us how going to A&E presents major delays in definitive care for ACS/STEMI patients whether they selfpresent, are taken there by ambulance or just decide to develop a STEMI on the spot. Shockingly, ending up at the wrong department (A&E in this case) was shown to add on average 60 minutes delay in definitive care! Bearing in mind the ‘mind minute myocardium’ slogan this costs the patient dearly in lost cardiac tissue. Chris advised to make sure patients were adequately dosed up with Ondansetron: Cardiologists tend to have an expensive taste and their shoes are in a vulnerable position next to the patient...
Next, fondly and humorously introduced, Professor Douglas Chamberlain, retired cardiologist and ‘father of the UK paramedic profession’, warned us that he was a fan of ‘Teaching by Terror’: every attendee he spotted with the eyes closed at the end of this day would be publicly asked a question and woe betide if he couldn’t answer! We all shot upright and paid close attention to his 10 rules of a normal ECG. We often forget the basics but it makes sense to start with knowing what is normal. I will take the ‘Bear Test’ away from his presentation: He stressed that limb electrodes should be on the limbs i.e. arms. To make sure this was the case he advocated a positive Bear Test: if a bear were to come in, rip off the patient’s arm, he should be running off with the electrode on that arm as well... He continued by showing us some ECGs with ‘weird’ complexes; simply because the electrodes were wrongly placed!
Unfortunately, I missed the presentation of Dr Richard Lyon, Registrar in Emergency Medicine and Prehospital Care. His interests include prehospital resuscitation, therapeutic hypothermia and trauma care, working closely with Helicopter Emergency Medical Services (HEMS), event and expedition medicine.
It was a long but interesting day, with many aspects of our profession highlighted. Looking at how quickly and professionally our young branch of the medical tree has matured I couldn’t help look at the gathered attendees, many of which were estimated under 35 years of age. Fresh faces, but there was also the West Sussex Retirement Association, with many pictures of ambulance material which seemed to stem from a former century. It made me wonder how we cope, how we manage to adapt, develop and maintain our professional knowledge and attitude. These men and women are all so proud of such different professional stages. All aimed to serve the public as well as they could offer.
The reverence of the flag bearer at the opening of the conference was touching; his salute to the flag made me quietly wonder: who salutes him, who has seen so much?