#smaccFORCE – You don’t have to be the best – just do your best!
I was lucky enough to attend the #smaccFORCE at the Dublin Social Media and Critical Care conference. We go to conferences to learn more about what is new, what is old, what is still practiced and what should no longer be practiced. The #smaccFORCE workshop focus on everything in the out-of-hospital environment and although I would not be able to regurgitate every point, I will try and share some points that stood out for me from most of the speakers. Speakers had 8 minutes in which to bring message across to the audience, however for some only 2 minutes were allocated for a “RANT”
SIMULATIONS
Two great simulations were done during the duration of the day. Wow great job guys!
Simulation 1 – The active shooter scenario was depicted by the @ATACCfaculty. With a quick unexpected flashbang in the background followed by rapid AK47 gunfire & some good Emergency Response from both the local GARDA & medics, even I from South Africa was well impressed with the realism.
This is a real problem for us in South Africa, with our prehospital works being exposed to violence on a daily basis. Check out our poster recently published at #ICEM2016 on how a local South African company is preparing their staff for this eventuality.
Simulation 2 – Prehospital motorsport response is significantly different to what we do every day. This was a passion for the late Doctor John Hinds, & this simulation was a real tribute to his days work.
Mike Abernethy – @FLTDOC1
Mike had a “rant” on the importance of pain relief. Basically the take home point was if you are going to treat a patient make sure that the pain relief & sedation of the patient is adequately addressed.
With scares resource in the LMIC this is a reality, we are often under-staffed with too little monitoring devices with very sick patients.
Gareth Davies – What I have learned in 20 years of EMS
- Your detractors are your friends. – Understand what your critics are saying, listen to it & adjust your practice if appropriate.
- Be able to change your mind. – what we might believe in today might not be true tomorrow.
- If you read EM Journals you are reading the wrong journals. – Be sure to fetch the excellence data from the individual specialties. (EM will never know everything about neonatology)
- Spending time in other specialties is where you learn.
- Do your best for every patient. – Don’t try & be the best, that is something else & will come naturally.
- Look at the past for the answers. – Learn from your & others’ past experiences. Even old literature might have very relevant answers.
- Understand that practitioners will make mistakes. – This will happen guide actions to the learning environment.
- If you get a thoracotomy cake for your birthday, your life is messed up.
Use Social Media – we can disseminate information quickly.
Ryan Wubben – @medflightdoc – Standards in HEMS – What standards?
“Something is rotten in the state of Denmark”
- In the US a fee structure was introduced for private HEMS in 2002 with no provision for regulation. Since 2003 till 2014 the amount of private HEMS in the US has risen to over 1000.
This is extremely relevant to the South African ground EMS system, where we have seen a large increase of private service with very little to no governance of these service. The question that one should ask is whether or not this potentially produces an unsafe environment for patient & practitioner.
Per P Bredmose – @vikingone_ Advocating for your patient.
An awesome ‘RANT’ by Per on the fact that we should be advocating for our patients. (Some of it in some crazyman language.) Practitioners should know protocols, guidelines & evidence to be able to fight the good fight for their patients.
Marius Rehn – @drrehn – Prehospital Research
“The academic in a flightsuit”
- You can’t just take in-hospital research & apply it in the out-of-hospital setting. There are many factors that are unique to this setting such as; kit, diagnostic equipment & crew.
- Diseases in the out-of-hospital environment is evolving minute by minute.
- Asking the correct questions for the correct environment is key.
Seek evidence where it is lacking & build up research networks in you environment.
Lionel Lamhaut – @lionellamhaut – ECPR in France
Lionel gave the crowd a quick rundown on ECMO. For the purposes of this summary I will just refer you to the blog post by: Chris Nickson from Life in the fast lane on ECMO.
- Most studies out there are observational studies.
- What we do know is even with scoop & run policy, EMS can still not get to hospital within 60min of cardiac standstill.
- France uses a mixed surgical & percutanous approach. As no surgical has higher rates of failure, but surgical needs surgeon involvement.
- Positive outcomes in 30% of patient, a further 30% of patients have agreed to organ donation.
Take home point: “Select your patient, get to the patient in the correct time.
- Victoria has one of the largest cardiac arrest registries in the world.
- LUCUS2 was implemented for all patients in persistent VF. Patient were taken to cath lab or ECMO.
- Very little patients actually survived
Bottom line: If you don’t have ECMO don’t PANIC.
I think this is important for us in the LMIC. If a first world country has tried this & with all its resources, short response times & integrated systems could not show significant benefit. Then we should probably be focusing our energy & limited financial layout somewhere else.
Gareth Grier – @uncgiggaz – What is an expert?
- That person that sees a call from a 10000foot view on what going on.
- When you start treating the extended patient.
- The person that are able to almost automate the routine technical stuff & more involve in the emotional involvement of the patient’s family.
- Do you have a clear plan about where you expertise will be. Remember you can’t be an expert in everything.
- Finally, if you want to be good at something, work out what that means for you!!
Gareth Grier – @uncgiggaz – Who should we intubate?
- Each patient needs a well understood risk/benefit assessment.
- Has to be well governed system.
- Don’t be a cow-boy! Every patient with a low GCS does not need intubation.
“Why do unexpected survivors survive?”
- Change from ABCD to <C> ABCD
- Use of the CAT tourniquet
- Haemostatic gauze – Celox gauze.
- Take your hospital to the patient with the correct staffing.
“Train hard, fight easy.” Pre-training and rehearsal makes the job easier with a well trained team.
Understand that you CANNOT safe every patient.
LEARN YOUR LESSONS WELL – every patient will teach you something.
Pierre Carli – The 2015 Terrorism attack in France
Terrorism is not a natural or technological disaster. – It is a calculated precise attack on life to kill people.
You are working in a dangerous environment, this is not a normal disaster scenario & should be handled in a different manner. – “It is no longer the good book, it is the toolbox”
– There was one overlying comment during the discussion. – Cross training between law enforcement & medical staff is key.
What happens when you are the victim?
– RUN –> HIDE –> FIGHT
John Glasheen – @jglash – On Scene Trade Off
- “an exchange, or more so compromise”
The Efficiency – Thoroughness – Trade Off is often referred to as scoop and run or stay and play. Should really be an risk/benefit assessment of what will make a difference in that circumstance at that time.
“Protocols are powerful” – “Individual insight is invaluable”
We need our industry (the entire medical industry) to have a culture of not getting enough rest.
WOW – this was a excellent and really touching talk, thank you MJ for mentioning the close to home case that I was involved in last week.
We are responsible to change this…… Thank you for speaking up Dr John Roos.
YOU ARE IN A BATTLE, WAKE UP, FIGHT BACK, AND GO TO SLEEP.
Kieran Henry – @paramedichen – Handover
So I have a huge opinion on EMS handover as many of you know already. (
click here to read full post)
This really adds some value:
- Be a preacher – Cool and Concise
Remember: Speak to believers & non-believers.
Geoff Healy – @drgeoffhealy – Preoxygenation is not just about oxygenation
- Preoxygenation only addresses hypoventilation – what about the rest:
- Shunting
- V/Q mismatch
- Diffusion limitation
Can you recruit the patient’s lungs before intubation?
Michael Perlmutter – @ditchdoc14 – Defeating Sepsis in EMS
- Sepsis is a time depending issue, early intervention is key!
- There are some confusion on the criteria to use for diagnoses of sepsis.
- ETCO2 as a surrogate of lactate in sepsis?
Early aggressive intervention:
- Fluids
- Adrenaline (nothing else)
- Antibiotics
Natalie May – @_NMay – Taking the outdoor classroom indoors
Natalie, I am truly impressed. You have have gone out of your way to apply & move halfway across the world to just learn something new. Well-done & you have the respect of a lot of us by this kind of commitment.
I cannot explain your post better than you have so I will merely paste your post here. Well done, you are an inspiration to the rest of us!!!
James Tooley – @jamestooley – The challenges in prehospital management of sick kids.
- Is your equipment correct
- Use a cognitive aid for your drug dosages, you don’t have to remember it.
Treat Paediatrics as well as adults.
Take control of yourself
- Recognize your shortcomings
- Deal with these short comings
- Train to prevent your emotions to influence your treatment.
Treatment of small children:
- Primary
- Intranasal Ketamine or Fentanyl
- Work as a team
- Do not scoop & run. Do what you can & will do for an adult
- Debrief.
#smaccFORCE was truly a inspiration & I would encourage all out-of-hospital practitioners to attend this workshop in future.
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