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SMACC, the FOAMed Highlight of the Year

3264 2448 Kirsten Kingma

 

It has been of interest to note that the vast majority of the traffic on #badEM has been via Facebook sharing rather than twitter. This may mean that many of you guys haven’t discovered the full potential of the FOAM (Free Open Access Medicine) community. The SMACC (Social Media And Critical Care) conference is in its third year now as was held in June in Chicago, USA. SMACC is one of the big highlights on most FOAMers calendar; it is essentially the heart and soul of FOAM. SMACC over the past 2 years has had such a big impact on my medical education and mind-set that I decided that I was going to attend this year even if it meant sleeping on the streets. The next few posts will summarise the key points that I took away from the conference. This post aims to give an overview of what it is all about and how medical education is in my mind, is evolving.

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In the simplest of terms, SMACC is a medical conference with an emphasis on critical care; the talks are all done in a Ted talk style. The audience is encouraged to participate in the talks through use of twitter; this is used as a platform to ask the speaker’s questions as well as share key points to others not present in the session. The speakers are chosen based on both their academic backgrounds as well as on their ability to present to an audience. The talks are informative but in a non traditional way; slides consists predominantly of pictures with minimal or no text, graphs and complicated slides are discouraged, speakers are talking on topics that they are passionate about and there are no intimidating suits and ties. It creates an environment where the audience can sit back, listen and engage with the topic at hand. Some of the talks I attended went to all new levels of extremes to engage with their audience; there was beer drinking during sessions, mechanical bulls, Milo given to the audience, passionate slips of profanity, and even some nudity. None of this distracts from the main topic at hand, it becomes clear that the speakers put months of thought and effort into how they can convey their message in the best possible way. The speakers are a heterogeneous mix of professions, cultures, genders and opinions. Debate and conflicting ideas is encouraged, often the talk carries on for many days through the Twitter platform. As a medical student, the best analogy would be to imagine one had been eating rice their entire life and now they had been exposed to the finest cuisine around, it becomes impossible to satisfy ones cravings and all you want to do is over indulge.

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In addition to the presentations there were multiple pre-conference workshops. This is where the magic happened. The workshops covered a variety of topics both clinical and non-clinical. The value in the workshops is that is creates an environment to interact with the varying experts on topics that interest you. The smaller groups allow for networking and socialising while simultaneously learning. I was involved with the emergency airway, emergency ultrasound and cadaver skills workshop. Pre-reading and video content were sent to attendees to encourage a flipped classroom scenario and post workshop surveys were sent out for future improvement. The stations were designed to give off core knowledge and skills in a practical hands-on manner with faculty members giving assistance and advice.

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The conference really distinguishes itself from any other through the emphasis on networking and socialising. Faculty, attendees, volunteers and students were all mingling constantly. Months before the conference #smaccRUN was created where everyone was welcomed to join in on a 5/10km run around Chicago. A constant buzz of open invitations to dinner circulated twitter daily. The gala dinner to which everyone attended was nothing short of a rocking music concert. A massive venue situated on Navy Pier housed many of the attendees till the early hours of the morning.

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While FOAM tends to create “super stars” of the industry, it was refreshing to see how approachable and “normal” everyone is. It is often frowned upon to socialise within the work environment, especially with ones mentors. I left Chicago with my mentors now as some of my close friends. The level of discussion and open communication drastically improves when people are able to connect with each other. The removal of hierarchy and constricting boundaries creates an interesting situation where the real things that we often hide from honestly discussing can be approached. While many may argue that it is essential to keep “professional boundaries” between mentors and mentees, I now tend to disagree. My opinion has changed more to the need for mutual respect for ones roles rather than restrictive boundaries.

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I would like to thank the organisers Roger Harris, Oliver Flower and Chris Nickson for giving me the opportunity to attend this one of a kind conference. If you haven’t seen any of the SMACC podcasts, check out:

Next year is #smaccDUB, I would highly recommend it to everyone! This has really been a paradigm shifting, mind-altering experience that I would recommend to every healthcare professional.

  • #smaccDUB: Dublin Convention Centre; 13 – 16 June 2016. Limited to 2000 attendees so if you’re keen be sure to register early (Registration should open around November but follow @smaccteam on Twitter to find out more)

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If you are not on Twitter: then I recommend you join today! A post will be out soon on “How to Get Your FOAM On” (and Twitter).

No electrodes, no problem

1224 1632 badEM

The 2015 AfJEM Resource Innovation Competition

In the preparation for the 19th World Congress on Disaster & Emergency Medicine held in Cape Town – AfJEM asked African Emergency Medicine lovers something interesting –

“Can you hack, concoct, devise or contrive a wanted resource using only locally available materials? You can..? Really..? Now you can show it off & win some amazing prizes”

The rules of engagement we were given were:

  1. You can only use materials that are locally available
  2. Your end-product should have comparable functionality to the product it aims to replace
  3. It should be simple to hack, concoct, devise or contrive
  4. It should be novel (not have been described before)

#badEM authors & friends quickly went hard at work to submit our “tricks of the trade” & were excited to hear about the entries at the conference. After numerous entries Dr Stevan Bruijns & the AfJEM team voted for a Top 5; described below.

1st Place – Emmanuel Acheampong – ED Nurse – Ghana @achiegh

No electrodes, no problem

This is what Emmanuel had to say about his innovation: “There are times in the emergency department (ED) when there are no electrodes available to place patient on a monitor. In resource limited settings like Ghana, it is very expensive to replenish disposable electrodes and it is quite common to run out of electrodes in the ED. Improvisation in medicine has become a solution to daily problems encountered in resource limited settings. You can use cotton swab as a replacement for your electrodes.
1. Get three moderate sized cotton swabs and make it slightly moist.
2. Place the cotton swabs in position as you would electrodes for monitors.
3. Attach the probes of the monitor to the swabs and tape over the probe and swab as shown in pictures.
4. Turn on the monitor and inspect the ECG tracings”

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The 2015 AfJEM Resource Innovation Competition

A resourceful shoulder to lean on

1100 612 Kat Evans

The 2015 AfJEM Resource Innovation Competition

In the preparation for the 19th World Congress on Disaster & Emergency Medicine held in Cape Town – AfJEM asked African Emergency Medicine lovers something interesting –

“Can you hack, concoct, devise or contrive a wanted resource using only locally available materials? You can..? Really..? Now you can show it off & win some amazing prizes”

The rules of engagement we were given were:

  1. You can only use materials that are locally available
  2. Your end-product should have comparable functionality to the product it aims to replace
  3. It should be simple to hack, concoct, devise or contrive
  4. It should be novel (not have been described before)

#badEM authors & friends quickly went hard at work to submit our “tricks of the trade” & were excited to hear about the entries at the conference. After numerous entries Dr Stevan Bruijns & the AfJEM team voted for a Top 5; described below.

2nd Place – Lauren Lai King

A resourceful shoulder to lean on…

Shoulder dislocations are a common acute orthopedic complaint presenting to emergency centres throughout South Africa. Post reduction immobilisation is essential in the recovery and rehabilitation period. This core management step is not always implemented as a result of resource limitations, most commonly the unavailability of shoulder braces.

I propose the innovation of makeshift shoulder braces utilising easily accessible resources.

1. Improvised “polysling with shoulder stabiliser” from collar and cuff – Foam bandage is folded around the neck from which the sling can be suspended. Cable ties are used to secure the foam bandage into a support sling for the arm. Free edges of the sling are tied around the trunk to provide stabilisation and ensures that the upper limb is securely adducted to the torso. The sling can be untied with the free, uninjured hand to release the injured limb as necessary. Assistance is required during the initial fitment process and during each application of the sling.

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2. Even more low resourced T-shirt shoulder stabiliser: In more resource limited settings, a shoulder sling can be created with the free edge of a t-shirt and 2 safety pins. The free edge of the t-shirt is folded up until the injured arm is supported in the shirt crease. The free edge is secured in place with a minimum of two safety pins. This creates an effective and user friendly solution. All aspects of the design can be completed by the injured individual with the uninjured hand.

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EC Nurse from Malawi Lucia’s trick of the trade for O2 administration

916 1632 Kat Evans

The 2015 AfJEM Resource Innovation Competition

In the preparation for the 19th World Congress on Disaster & Emergency Medicine held in Cape Town – AfJEM asked African Emergency Medicine lovers something interesting –

“Can you hack, concoct, devise or contrive a wanted resource using only locally available materials? You can..? Really..? Now you can show it off & win some amazing prizes”

The rules of engagement we were given were:

  1. You can only use materials that are locally available
  2. Your end-product should have comparable functionality to the product it aims to replace
  3. It should be simple to hack, concoct, devise or contrive
  4. It should be novel (not have been described before)

#badEM authors & friends quickly went hard at work to submit our “tricks of the trade” & were excited to hear about the entries at the conference. After numerous entries Dr Stevan Bruijns & the AfJEM team voted for a Top 5; described below.

3rd Place – Lucia Mbulaje – ED Nurse – Malawi

No wall/tank oxygen.. 1x oxygen concentrator.. multiple patients needing oxygen..

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This is what Lucia has to say about her solution: “Working in a resource restrained situation is so devastating but not for someone who has a sharp mind and good innovative skills. Being a resuscitation nurse at the emergency department offers a quite range of excitement for workers who have sharp mind and good innovative skills. It offers some kind of fund in adventure of finding ways to achieve desired outcomes with the absence of real equipment. For one to perform a procedure, it takes knowledge and skill about the procedure and how to use the equipment. On the other hand, it’s one thing to know how to perform a procedure and another thing to understand the mechanism of the equipment. That’s where innovation lies.”

“The resuscitation room is a four bedded space with equipment like oxygen concentrators matching the number of beds. Most often, we do have over four patients who need resuscitation at once. As a result we are forced to bring in extra beds in the resuscitation room. Since we do not have extra concentrators for the extra patients, improvising is the only option to save the lives. Ideally, one oxygen concentrator can be used for more than one patient if splitters are available e.g. “Y connector”, but the case is not the same in my situation because the splitters are not available. So we use the readily available cheap resource to achieve the same outcome and the resource we use is a “GLOVE”.
“The open part of the glove that we use when donning is attached to the outlet of the oxygen humidifier outlet. Then it is well secured with tape. The finger tips of the gloves are cut and nasal cannulas are connected and secured with tape. So when the machine is switched on, oxygen flows from the humidifier outlet into the glove where it is splitted to the five fingers and from the fingers into the nasal annuals something which enables up to five patients to benefit from one concentrator.”

Homemade Needle Thoracentesis Simulation Vest – 4th Place – AfJEM Resource Innovation Competition 2015

3264 2448 Kat Evans

The 2015 AfJEM Resource Innovation Competition

In the preparation for the 19th World Congress on Disaster & Emergency Medicine held in Cape Town – AfJEM asked African Emergency Medicine lovers something interesting –

“Can you hack, concoct, devise or contrive a wanted resource using only locally available materials? You can..? Really..? Now you can show it off & win some amazing prizes”

The rules of engagement we were given were:

  1. You can only use materials that are locally available
  2. Your end-product should have comparable functionality to the product it aims to replace
  3. It should be simple to hack, concoct, devise or contrive
  4. It should be novel (not have been described before)

#badEM authors & friends quickly went hard at work to submit our “tricks of the trade” & were excited to hear about the entries at the conference. After numerous entries Dr Stevan Bruijns & the AfJEM team voted for a Top 5; described below.

4th Place – Jamie Higgins @jr_higgins

Homemade Needle Thoracentesis vest, made from old wetsuit and bladders of two old manual blood pressure cuffs.

The vest is designed to be either: worn by a classmate, applied to a CPR doll or the wetsuit can be stuffed with newspaper. It is used for students to practice the above skill in a learning environment where expensive simulation training dolls are not available.

The vest is designed with the back slit open, for easy application. The anterior left and right chest wall have pockets stitched on the inside to allow for placement of BP cuff bladders. A hard piece of plastic with horizontal cut outs simulating intercostal spaces is inserted overlying the bladder. A complete piece of plastic is inserted behind the bladder to protect the wearer. On the outside of the vest, additional pieces of wetsuit material are applied with velcro allowing for replacement when they become worn through.

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Below elbow POP video

3264 2448 Kat Evans

Below Elbow POP

This video aims to give simple steps in the procedure of paediatric below elbow plaster of paris (POP)

  • Equipment: ortho wool, 2x medium rolls of POP, 1x large roll of POP
  • Apply ortho wool: intervals covering 50% of your last throw, down the arm
  • Applying the first POP: start at the wrist and work down the hand, and back up the arm
  • Second roll of POP: apply to the midpoint and cover the whole forearm and hand
  • Fold the wool: giving enough room to flex at the elbow
  • Reinforcement: cover the length of the forearm with a wider roll of POP
  • Smooth the POP: paying attention to the thumb area
  • Finished POP: there should be room to flex the arm, and the thumb should be free to move with the pop smoothed to prevent abrasions/ pressure areas

Additional basic tips for newbies

  • Children don’t liked to sit still – ensure adequate analgesia (paracetamol, ibuprofen, tilidine drops aka valoron) and if needed sedation prior to procedure
  • When wetting the POP rolls in water ensure you maintain hold of the loose end
  • Wait for the majority of bubbles to cease before removing the POP (insert vertically into water). Squeeze out excess water for the POP roll prior to application
  • When smoothing over ensure not to apply pressure with finger tips (avoid pressure areas at all costs). Dunking hands in water prior to smoothing helps
  • Remember to advise family about danger signs to watch out over the next 24 hours and when to return for follow-up

Using condoms to avoid PPH related maternal deaths in Africa – Not what you think!

425 282 Willem Stassen

Reducing maternal death is the fifth Millennium Developmental Goal as Identified by the World Health Organisation (WHO) and has been a priority in Africa for many years.  In Africa, the maternal mortality rate is still unacceptably high – one woman dies every 7 minutes in Africa from birth-complications. The leading cause of maternal death is post-partum haemorrhage (PPH) accounting for up to 35% of cases. In Sub-Saharan Africa, approximately 1 in 10 mothers will suffer from post-partum haemorrhage.  The WHO guidelines for the management of PPH can be found here. In addition to administering oxytocin, tranexamic acid and other conservative management strategies, a recommendation is made to place an intra-uterine tamponade balloon in cases of uncontrolled haemorrhage until specialist care may be accessed. Yet, commercial tamponade devices, such as the Bakri Balloon may not be cost-effective and feasible within the resource-limited settings of Africa. These may cost up to $250! This problem is compounded when considering the relative shortage of blood and the geographical hurdles to overcome in order to access specialist gynaecological care.  These devices may be welcome temporising measures that prevent massive haemorrhage during transfer to these facilities. So, what is the #AS2AP? (African Solution to African Problems)

Who would have thought that the very device that may prevent pregnancy, may also prevent death from delivery?  Above is a novel African innovation that employs low cost equipment to effect uterine tamponade.

The 2015 AfJEM Resource Innovation Competition

Nasal atomisation without the device – 5th place – AfJEM resource innovation competition 2015

1100 612 Kat Evans

The 2015 AfJEM Resource Innovation Competition

In the preparation for the 19th World Congress on Disaster & Emergency Medicine held in Cape Town – AfJEM asked African Emergency Medicine lovers something interesting –

“Can you hack, concoct, devise or contrive a wanted resource using only locally available materials? You can..? Really..? Now you can show it off & win some amazing prizes”

The rules of engagement we were given were:

  1. You can only use materials that are locally available
  2. Your end-product should have comparable functionality to the product it aims to replace
  3. It should be simple to hack, concoct, devise or contrive
  4. It should be novel (not have been described before)

#badEM authors & friends quickly went hard at work to submit our “tricks of the trade” & were excited to hear about the entries at the conference. After numerous entries Dr Stevan Bruijns & the AfJEM team voted for a Top 5; described below.

5th Place – Kat Evans @kat__evans

Nasal Atomisation without the Device

1__Equipment_Required

2__Preparation 3__Administration

There is a need for rapid administration of analgesia to certain groups of patients who present to the Emergency Centre, however frequently this is delayed whilst awaiting intravenous access. Intranasal drug administration is an alternative rapid, low tech option which requires minimal training. Commercially designed ‘Mucosal Atomisation Devices’ are not often available in Western Cape Emergency Centres which likely leads to this option not being frequently utilised.

An adapted technique of intra-nasal drug administration is demonstrated in the attached photographs utilising a 3 way stopcock, IV cannula, oxygen/air source & syringe. See images attached.

Uses of Intranasal medications:
1. Analgesia
2. Sedation / Seizure control
3. Antidotes eg Naloxone
4. Epistaxis management
5. Topical anaesthetics
6. Hypoglycaemia management eg glucagon

Check out www.intranasal.net for more information on the intranasal route of drug administration.

Introduction to out-of-hospital emergency systems in South Africa

710 384 Kirsten Kingma

Out-of-hospital Emergency System in South Africa

Craig and Minh recently did a great podcast discussing many of the above points: listen to it here on the PHARM

 

 

South Africa has a unique out-of-hospital healthcare system, it is by far one of the more developed when compared to neighbouring countries and many standards meet that of first world norms however we are by all means still a developing country and still have many steps to go. We rely on a two-tiered system of government and private medical facilities; this counts for both in and out of hospital systems. The large private organisations provide services are often comparable to first world standards whereas our government system, which is under far greater burden, excels in certain fields but also suffers from the excessive strain.

 

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Practitioners

  • Paramedics predominantly provide services out of hospital. Doctors and nurses working in the out-of-hospital environment are the exception.
  • Paramedics are trained at different levels
    • Basic Life Support (BLS): 5 week course equipping the provider in basic life sustaining measures (basic ventilation, CPR, how to recognise varying conditions and limited treatment (glucose, activated charcoal, oxygen, nitrous oxide). They are registered by the Health Professions Council of South Africa (HPCSA) in the supervised practice category and thus usually have an ILS or ALS practitioner working with them
    • Intermediate Life Support (ILS): This is a 6 month course (requires BLS and practical experience prior). The provider is equipped to manage any patient requiring basic life support, in addition they can place IV lines for fluid therapy as well as administer certain medications as indicated (aspirin, beta2 stimulants, ipratroprium bromide, dextrose, and BLS medications). They are registered as independent practitioners and can treat and make decisions at their own discretion.
    • Advanced Life Support (ALS): this can be done through continuation from the ILS qualification or via a program at a tertiary institution. In South Africa ALS practitioners are referred to as paramedics. All can give varying levels of Advanced Life Support medications and perform procedures however each is limited by a specific protocol. As an example an ECP is capable of RSI & fibrinolysis while the other qualifications are restricted in this field.
      • Critical Care Assistant (CCA): Course method consists of +- 11months as well as practical experience (in addition to having previous ILS qualification).
      • Emergency Care Technician in Emergency Medical Care (ECT) – 2 year full time at a University (this includes practical rotation during the course)
      • National Diploma in Emergency Medical Care (NDip) – 3 year full time at a University (this includes practical rotation during the course)
      • Bachelors in Emergency Medical Care (B.Tech/B.EMC) also known as ECP – 4 years full time at a University (this includes practical rotation during the course)

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Methods of transport

  • Road ambulance transport is the most common means of transport. While the standard of equipment on ambulances varies, the national department of health is making an effort to standardise minimum requirements for ambulances. In general ambulances are regular transport vehicles that are converted to accommodate a stretcher. Most ambulances have space for two patients on stretchers. In certain areas with a heavy burden of patients its is not uncommon for multiple patients to be transported simultaneously to a health care facility.
  • Aeromedical transport has a presence but is often heavily burdened and reserved primarily for transportation when distances are excessive for road transport. While there are cases where ambulances travel over 800km (Springbok to Cape Town) with patients, the aeromedical services reduce the incidence of these type of cases. The aeromedical services also provide a rescue service in the form of rotor-wing retrieval. Fixed wing services are also available in certain areas.

 

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Additional Services

  • Fire service: they have predominantly ILS trained practitioners at each station and roaming ALS practitioners. They do not transport patients however they often provide assistance at motor vehicle collisions as well as giving temporary care in medical rooms based at the fire station. They play a major role in rescue operations throughout the country.
  • Rescue services: these are a linked to the state ambulance service in the Western Cape, they provide support for motor vehicle extrication, structural collapses, wilderness rescues as well as others incidents which require specialised equipment and resources.
  • Volunteer organisations provide an important resource that supplements the full time services. These include organisations such as Wilderness Search and Rescue, Sea Rescue, volunteer ambulance services as well as others.

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Where the gaps hide

While we have a system that overall provides an essential service that is accessible to most, some of the biggest challenges include:

  • Interprovincial variation on equipment, personnel resources and standards
    • Response times to primary emergency calls can take over an hour till the 1st resources arrive on scene in rural regions
    • Inter-hospital transfers to a higher level of care can take hours to be processed even in urban areas (this includes critical patients)
  • Densely populated urban areas with good resources and under-resourced rural areas
  • Poor socioeconomic circumstances (lack of transportation, formal employment) putting additional strain on the road ambulance services (many individuals utilise ambulance transport for primary healthcare needs – not a problem unique to the developing world)

These restraints lead to a burdened service however provides an environment which encourages practitioners to work hard, find simple cost effective solutions for everyday problems.

Links to the various scope of practice policies

Summary table comparing different qualifications

BLS protocol

ILS protocol

ECT protocol

ALS protocol (primarily for NDip and CCA. Bachelors degree paramedics/ECPs have the added scope of RSI medications as well as thrombolytic drugs)

 

Links to tertiary universities offering paramedic degree programs

Cape Peninsula University of Technology

Durban University of Technology

University of Johannesburg

Nelson Mandela Metropolitan University – Port Elizabeth

Central University of Technology – Bloemfontein

The art of the EMS Handover

1367 618 Craig Wylie

 

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“Handover of care is one of the most perilous procedures in medicine, and when carried out improperly can be a major contributory factor to subsequent error and harm to patients.” – Professor Sir John Lilleyman, Medical Director, National Patient Safety Agency, UK

Scenario

A patient with blunt traumatic brain injury was intubated prehospital using Ketamine and Rocuronium, (thank you @ketaminh). The patient was placed on a ventilator, post-intubation analgesia and sedation was administered, ETCO2 was maintained at 38mmHg and the patient was transported to Ubuntu Hospital. On arrival at Ubuntu: the patient was verbally handed over to the registered nurse and emergency centre doctor and copies of EMS documentation taken to the reception area to ‘open a file’ (which is standard practice across many South African healthcare facilities).

The team jumped straight into patient care and paid very little attention to the handover given. About 20 minutes later I overheard them discussing that the patient was not a candidate for CT Scan or Neurosurgery intervention due to the GCS of 2T. I politely reminded them of the Rocuronium given 20 minutes prior.

The training, capability and scope of practice of South African out-of-hospital practitioners have increased dramatically over the last 10 years allowing practitioners to perform more complicated interventions, such as rapid sequence intubation (RSI) and thrombolysis. This does however bring a new safety concern to light. There is a vast amount of literature and discussion in Emergency Medicine & Patient Safety circles regarding the dangers of hand-over as a high risk arena. The majority of literature surrounds internal handover practices inside hospital with significantly less on EMS handover. Verbal handover is a skill that as EMS providers should become just as proficient with as they are with intravenous access. Experience alone does not by default give proficiency in this skill, which could arguably been viewed as an art rather than a skill. A novice paramedic may initially be mistaken in thinking that a good handover includes every detail of the entire patient care journey, when instead it is a brief summary of only important positives and negatives.

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Correct team members present:

Before starting your handover it is critical to ensure that you are, in fact, handing over to the correct person. I have, on more than one occasion, given my entire detailed handover to someone, only to discover 10 minutes later that this was a medical student or doctor from unrelated speciality.  Also ensure from the EMS team only one person is assigned to give verbal handover to keep messages clear. Classic example is a junior EMS staff member who is busy in the sluice room cleaning equipment before leaving, and doctor ‘popping in’ to confirm points that they forgot from handover, risk of incorrect information being conveyed.

“Healthcare professionals sometimes try to give verbal handovers at the same time as the team taking over the patient’s care are setting up vital life support and monitoring equipment. Unless both teams are able to concentrate on the handover of a sick patient, valuable information will be lost.” – Junior Doctors Committee, British Medical Association

Structured approach – DeMIST PAD

The Emergency Medicine Society of South Africa (@emmsaorgza) has recommended a standard approach using the pneumonic DeMIST, we would like to disseminate this tool further (with slight #badEM twist to DeMISTPAD).

Demographics Age, estimated weight (if paediatric), location of pick up, presence of accompanying family member, relevant chronic illnesses/allergies

Mechanism or insult that occurred.

Injuries – Use a Head—>Toe Approach

Signs & symptoms Vital signs.

Treatment provided for the patient. Consider using the ABCDE approach to listing this

Pending urgent interventions (EMS perspective)
Interventions that EMS recognise need to be done as a priority but no time in ambulance – e.g. IV line or ETT currently needs re-securing (strapping loose), another dose analgesia/sedation needed now,

Adverse events – eg. important to handover if airway was CL4, possible tooth aspiration during intubation, incorrect dosing,

Documentation
Needs to be left behind (& legible!) – this is not only critical from a medico-legal perspective but also for team members who arrive later in the patients care journey who were not present for verbal handover. A good example would be a neurosurgeon who would like to review the GCS on scene & presence of absence of a hemiplegia prior to intubation / sedation / paralysis. In patients not falling into ‘Red’ triage category, frequently the doctor who takes your verbal handover may not ultimately end up treating the patient as the patient gets triaged and joins the ‘queue’, so it is important to include all pertinent facts onto paperwork.

Two-Way-Traffic

Are you RECEIVING handovers from EMS?

Great advice from Natalie May summarised below (@_NMay) from @stemlyns – (read full article here for detail)

Sit Up = Pay attention, active listener, ask others to be quiet

Shut Up = Don’t interrupt

Sure Up = Once verbal handover complete – ask any remaining questions you have

Sum Up = Make your own verbal summary for EMS staff to ensure you understood correctly

Supplement = Make sure you go on later to read EMS notes.

  1. Troyer L, Brady W. Barriers to effective EMS to emergency department information transfer at patient handover: A systematic review. Am J Emerg Med [Internet]. Elsevier Inc.; 2020;38(7):1494–503. Available from: https://doi.org/10.1016/j.ajem.2020.04.036
  2. http://stemlynsblog.org/chinese-whispers-miscommunication-and-handover/
  3. Ashley Liebig at Resuscitate NYC17. St.Emlyn’s,” in St.Emlyn’s, January 20, 2017, https://www.stemlynsblog.org/ashley-liebig-at-resuscitate-nyc17-st-emlyns/
  4. Makkink AW, Stein COA, Bruijns SR, Gottschalk S. The variables perceived to be important during patient handover by South African prehospital care providers. African J Emerg Med [Internet]. Elsevier B.V.; 2019;9(2):87–90. Available from: https://doi.org/10.1016/j.afjem.2019.01.014