Pre-hospital and retrieval medicine from the junior doctor’s perspective

Pre-hospital and retrieval medicine from the junior doctor’s perspective

Feb 12, 2019 0
emergency,onthepods,rural and remote medicine

Robert Mitchell, Emergency Physician, chats to Patrick Gillespie and John O’Neill about pre-hospital and retrieval medicine from the junior doctor’s perspective and how to cope with rural rotations and emergency situations.

Summary Writer:  Jane McDonnell

Script Writer:  Rob Mitchell

Editor:  Rob Mitchell

Interviewee: Patrick Gillespie, John O’Neill

About Dr Patrick Gillespie

Dr Pat Gillespie is an Emergency Medicine registrar. He completed his medical degree at the University of Queensland and has worked across a number of disciplines including Emergency, Intensive care, Anaesthetics, Paediatrics, and Pre-Hospital Medicine in Cairns and South East Queensland. He is currently working as a retrievals registrar for Lifeflight Queensland and is studying to complete his Emergency Medicine Fellowship in 2019. He is passionate about pre-hospital care and medical education. He loves spending his working days flying over the beautiful landscape of Far North Queensland and his spare time exploring its beaches, reefs and rainforests.

About Dr John O’Neill

Dr John O’Neill is an Emergency Physician and the Clinical Lead for Lifeflight Retrieval Medicine in Cairns.
After completing Emergency Medicine training in the United Kingdom and Australia he decided the grass really was greener and moved to Cairns five years ago.

After many years in pre-hospital and retrieval medicine he has developed a keen interest in the challenges of providing critical care in remote environments. This started somewhere in the desert of Western Australia and continued in the United Kingdom and New Zealand working for a number of Helicopter Emergency Medical Services (HEMS), before returning to the reef and the rain forest in Far North Queensland with the Royal Flying Doctors Service and Lifeflight.

John is part of a group developing the regional trauma service at Cairns Hospital and has published work on trauma and resuscitation.

When he’s not crying over the fate of the England rugby team John is an optimistic triathlete.

Pre-hospital and retrieval medicine from the junior doctors perspective

With Dr Patrick Gillespie, Advanced Trainee in Emergency Medicine at Cairns Hospital & Lifeflight Retrieval Medicine and Dr John O’Neill, Emergency and Retrieval Consultant at Cairns Hospital & Lifeflight Retrieval Medicine, Queensland, Australia

 

Introduction

It is common for junior doctors to feel apprehensive about embarking upon a rural rotation. Apart from having to work in a new environment, rural rotations often require more independent decision-making, often without the resources available at large teaching hospitals. In Queensland, junior doctors may be rotated to small rural hospitals, where they may be first on call for Emergency Department presentations, so it is not uncommon for junior doctors to have to refer a patient from retrieval. In Queensland, high acuity transfers are coordinated by Retrieval Services Queensland. There are equivalent organisations in other states. The principles discussed in this podcast apply to all settings, not just Queensland.

  • Local teams – nursing, administrative and senior doctors – are very helpful so use their experience
  • Ask for advice early; you are not alone
  • There’s always a point of contact for further clinical advice (e.g. the clinical co-ordinator via phone or telehealth)
  • When engaging with a retrieval service, take a moment to summarise the key points and talk it through with a colleague
  • You do not have to have made a diagnosis, but have a structured handover of the patient’s issues
  • Structure the handover and the details (e.g. ISBAR)
  • Introduction: start with introducing yourself and where you are calling from
  • Provide the name, age, sex and weight of the patient
  • Situation: e.g. A 65 year old man presented with 2 hours’ chest pain with new haemodynamic instability and there is concern regarding new ECG changes
  • Don’t forget background, assessment and recommendation
  • It is important for a retrieval coordinator to triage retrieval based on incoming traffic from other service providers
  • Time to retrieval is based on acuity of patient and what assets are available
  • Other aspects of the patient (e.g. patient weight, particular injuries) may have an impact on the patient’s ability to fly on an aircraft
  • If you have specific questions about ongoing treatment prior to retrieval, use retrieval resources
  • Telehealth is also an asset in this setting
  • The first priority is to focus on resuscitation: DRSABCD
  • If possible, establish IV access (preferably 2x IVC)
  • Photocopy any relevant documentation including ECGs, ABGs/VBGs, advanced care directives, etc
  • Prepare the family and the patient – leaving a patient’s hometown may be a big step particularly with elderly patients or Indigenous patients and retrieval may be a pre-terminal event
  • Ensure it is appropriate for the patient to be transported – are their goals of care consistent with transfer?
  • Keep handover systematic, succinct and simple
  • Use ISBAR or similar
  • Write down the key issues especially if the patient has been in hospital for a few days and their situation is complex
  • Practice your handover to the nurses before the retrieval team arrives
  • If you are unsure about why the retrieval team is doing something, ask – use the opportunity to learn
  • The duration of the patient’s transfer and expected or possible treatment requirements
  • Retrieval team takes note of access and security of IVCs (harder to put in in the air)
  • They may ask for some additional drugs to be prepared in the event of deterioration
  • Factors around the retrieval itself – e.g. flying patients to altitude can exacerbate respiratory failure so retrieval team may have a lower threshold for intubating

Case 1 – A 50 year old patient has presented to your rural hospital at 10am with a 2 hour history of central, crushing chest pain. You are the sole doctor on site but there is a senior medical officer on call. One of the two nurses has performed an ECG which demonstrates an anterior STEMI. The referral hospital is a 2 hour drive away or a 30 minute flight by helicopter.

 

  • Resuscitate and call for help early
  • If the patient is having a STEMI, expect them to become unstable – become hypotensive, develop an arrhythmia, etc. (even if they don’t, you’ll be prepared)
  • Put pads on early, get IV access, give judicious fluid boluses (as clinically appropriate) and move them to the resuscitation bay
  • May be appropriate to engage with the local cardiologist and send off the ECGs
  • Start initial analgesia and antiplatelet therapy and oxygen if required
  • If discussing with metropolitan colleagues, make it clear what investigations / management strategies are available to you at your rural facility
  • The main question will be around time for reperfusion (primary PCI vs thrombolysis)
  • Have other drugs prepared e.g. adrenaline

Case 2 – A 25 year old male has fallen off his motorbike at high speed at 2pm. He is brought in to the rural hospital where you are working. His vitals are: GCS 12, SaO2 100% on high-flow O2, HR 100 and SBP 100. He has a head injury and, clinically, it looks as though he has a left-sided pneumothorax. On the basis of extensive bruising over the left upper quadrant of his abdomen, you’re worried about a splenic injury. There are no apparent limb injuries. The retrieval team is only 5 minutes away because they were notified by the ambulance service.

 

 

  • Find an appropriate space for the patient – a resuscitation bay
  • Arrange a team including other medical team members and nursing staff
  • Organise equipment
  • Call senior staff early
  • If a pre-alert has not been made to a retrieval team, they should be notified immediately
  • The algorithm for resuscitation of trauma is slightly different from the algorithm used for other resuscitation
    • Life-threatening haemorrhage is managed first: CABCD
  • Maintain spinal precautions
  • Splint any fractures
  • Give good analgesia
  • Prepare equipment for a chest drain
  • The retrieval team assesses the haemodynamic stability of the patient and then performs a head to toe secondary survey
  • If a patient has a pneumothorax, need to be mindful of pressure changes when traveling at altitude
    • Consider Boyle’s law and the changes of the volume of gas with pressure changes
    • Entrapped gas will expand with altitude particularly in a helicopter (unpressurised vehicle) – haemothorax may expand leading to instability
  • Interventions on the ground (e.g. chest drain insertion) may be performed to avoid risks
  • There is limited evidence to inform achieving the balance between time-critical and treatment-critical interventions
  • Preparation is key: take time to secure IV access and stabilise the patient prior to transfer
  • Analgesia is key: fentanyl +/- ketamine quite effective
  • Sometimes patients need to be anaesthetised to achieve adequate analgesia
  • After initial resuscitation, make a referral early
  • Think ahead and pre-empt complications
  • Practice handover before the retrieval team arrives and use a systematic format (e.g. ISBAR)
  • Stay and be involved when the retrieval team arrives – use the opportunity to learn more

Related Blogs

Tags: #DRSABCD,#emergency department,#Emergency Medicine,#HEMS,#high acuity transfers,#ISBAR,#junior doctors,#Lifeflight,#pre-hospital and retrieval medicine,#resuscitation,#retrieval medicine,#retrievals registrar,#RFDS,#rural,#rural and remote medicine,#telehealth

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