Why I think MARCHPAWS is the best Memonic out
A quick and dirty explanation on how I use MARCHPAWS. I became quite fond of this assessment and packaging checklist/memory aid while in defence, having learned it of some US medics, JOURNAL OF SPECIAL OPERATIONS MEDICINE published an article on the updates in Combat care including the MARCHPAWS system.
Massive bleeding the top of any trauma assessment, find the bleeding stop thr bleeding
Airway, enough said
Resps includes exposure and assessment of the chest wall
Circulation for IV Access and circulatory support his includes delegation/prep femur traction or pelvic splinting.
Head and Hypothermia, think head injury hypothermia and I like to add, hypoglycemia, to promp me te get a BLG if that hasn’t already happened.
Pain management with appropriate indicated agents.
Antibiotics, rarely used prehospital in my service but if you have them use them.
Wounds, assess and cover
Splinting of non long bone fractures.
This is not only a checklist and order in which to do your procedures, it also used to be how I packed my aid bag as a defence force medic, pack how you treat.
I feel if you run down the list you get your effective interventions in without missing things. This is by no means exhaustive, you need to figure out where skills are best served (eg, pelvic and femur splinting being in the circulation heading for me)
Obviously this is by no means exhaustive, nore does is constitute medical advice and views expressed are my own and don’t represent hr views of agencys I work for.
Towards cardiopulmonary resuscitation without vasoactive drugs
A paper from the latest Current Options in Critical Care, or thats how this started, what it ended up being was me dumping a few of the current papers on Adrenaline and the CIRC trial, all this should put you in good sted to be up to speed on the trends in the literature. This is by no means comprehensive.
Emphasis is placed on avoiding the unproven ACLS drugs, does this analysis mean the death of ACLS medications. Probably not, doubts have been cast on the effectiveness of the current regimes in my service we’ve seen the removal of everything but adrenaline for Cardiac Arrest.
This is just more fuel to the fire, maybe one day with enough evidence we’ll see a change or removal of adrenaline therapy. Until then we’ll just keep doing it.
Below are a few of my favorite papers regarding adrenaline in cardiac arrest. As well as broader cardiac arrest refinements
From the most recent literature. These are all fairly current( IE, last two years).
I started as one paper, then I started to read up, theres been quiet a movement in the direction of changing what we are doing for our cardiac arrest patients, the study of Automated CPR via machine and has become a new pathway for research with both the devices currently showing no benefit and future research planned in this area.
We’re now at a point where we are looking at removing the perishock pause, rapid defibrillation at the advantage of the LUCAS 2 and Auto pulse offer the ability to transport, shock with a minimum pause, hopefully with read through monitors (monitors that show the thw underlying cardiac rhythm not the white lead movement, I’m sure that’s way above my paygrade but I look forward to it), with a read through monitor there may be the ability to shock without stopping CPR, speaking to a ZOLL rep they are not far off introducing this to he market.
A quick look at these, should put you in a competitive sted.
Towards cardiopulmonary resuscitation without vasoactive drugs
http://europepmc.org/abstract/MED/24739267
Evaluation of pre-hospital administration of adrenaline (epinephrine) by emergency medical services for patients with out of hospital cardiac arrest in Japan: controlled propensity matched retrospective cohort study
http://www.bmj.com/content/347/bmj.f6829
Effects of adrenaline on rhythm transitions in out-of-hospital cardiac arres
http://onlinelibrary.wiley.com/doi/10.1111/aas.12184/full
Adrenaline for out-of-hospital cardiac arrest resuscitation: A systematic review and meta-analysis of randomized controlled trials
http://www.sciencedirect.com/science/article/pii/S0300957214001312
Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial.
http://www.ncbi.nlm.nih.gov/pubmed/24642406
Beyond the pre-shock pause: the effect of prehospital defibrillation mode on CPR interruptions and return of spontaneous circulation
http://www.ncbi.nlm.nih.gov/pubmed/23337112
Issues around conducting prehospital research on out-of-hospital cardiac arrest: lessons from the TOPCAT study.
http://www.ncbi.nlm.nih.gov/pubmed/20511637
The Smart (Phone) Clinician
Smart phones play a huge part in our lives. Every since I was a student I relied on the internet as a prime source of information ( I studied the big journals started to come online and a few first generation e-readers entered the market)
however the I-pad and I phone weren’t an option for me, I think they came to fruition in my final year at university. Unfortunate because I think they may have changed the way I learned, I disliked lugging my 3 kg laptop to class, with a tablet it would have been far simpler to take notes, search the web and catch up on Facebook.
However since I have begun working in the Prehospital Field I have whole hardheartedly embraced tech and all it can offer me in the way of a knowledge repository.
I’ve been blown away by the response to my question on who uses a table/smart phone regularly in paramedic practice, people have been tweeting/sharing my question and some of the replies I’ve gotten have inspired me to grab a few new apps I’d not heard of.
A little on my set up, I use a Samsung Note 8.0 Tab and a Galaxy S4. These have been adequate, while I enjoy the format of the Android devices I don’t enjoy the incredible amount of time it can take to get really good apps from IOS to Android.
In addition to the pictured Apps, Twitter, Beyond Pod for pod-casts, chrome for general internet browsing, a LITFL short cut, Kindle for a number of textbooks/must have prehospital papers, a hand full of games, pocket on both devices which allows me to save social media references and links for later viewing (no more…. wheres that paper on blah?).
Cleanliness is also a point, both my Note and S4 live in Life venture cases, which are waterproof and easily cleaned by alcohol swabs or in more extreme cases (ie, I googled something with my gloves on)
I used to have far more apps, however I gradually started trimming them down to the ones I used, I’m quite impressed with the QAS FRG v2 I wish we had something similar in NSW.
By far the most used “app” isn’t even an app is the shortcut to LITFL http://lifeinthefastlane.com/ on my home screen.
Speaking of Life in the Fastlane, check out the tech tool Thursday page for some amazing medical apps.
Agile MD with the ALiEM PV cards is invalable for some quick study on the train or long car trips where I’m not driving, even when stuck in hospital corridors, best of all it and the content from ALiEM is free!
Show me what you use @jrparamed on Twitter I’ve already added a few apps off people recommendation. The tablets still fairly new so I’m also looking for must have apps for the prehospital provider.
Teaching is also another huge advantage, I use my tablet for patient education, I find it easier to diagram some concepts. I also have a number of apps on their for the inevitable transfer of the child with appendicitis to the children’s hospital for surgery its a long, uncomfortable scary trip for them, I like to think popabubble and angry birds make it a bit easier, takes moms mind of comfort and allows her to make phone calls, sleep, regain her calm.
Could I just mention another advantage of the Smart Phone, Its a phone! Poisons Information a nice little phone call to make if you don’t know what to expect, even just a phone call to make for some education on that particular medication. I’ve called poisons info a number of times and every time I do I learn something new.
Some say that the smart phone/tech has no place in practice, I personally think it has a place in practice with appropriate use, obviously sitting there texting your friends and taking facebook selfies is inappropriate but for looking up a condition or medication the patient can’t describe to me, its a must.
I’ll often preface pulling out my phone with a statement similar to ” I’m unable to recall that condition/medication, if you don’t mind I’m just going to have a quick look on my phone” I don’t know if patients appreciate this but I think its just plain manners.
No thus far has denied me phone use, in fact few have commended it, especially mothers who get a break from little Jonny while we drive up to the kids hospital.
I have no financial interests to disclose in relation to this post.
Peer Support (again)
I wanted to talk about two recent incidences where I’ve been involved in #Guerrillapeersupport
This is when Peers talk, comment and listen to stories, cases and what went wrongs, mostly just as an outlet
While I’m not saying completely abandon you services peer support system (use it if you have it)
What I have found is by talking to and receiving feedback from other paramedics I work with I feel we build a stronger team.
The free and open exchange of ideas and feedback helps disseminated a shared experience. While the Peer support officers do a wonderful job of taking care of the psychological first aid, I’m thankful that I have such open and available work colleagues.
Sometimes after tough jobs, its nice to lie down on the metaphorical resuscitationists couch and talk about the job, with an experienced provider and talk work for 30 or 40 minutes receive some “maybe next time or did you consider” they are always welcome, I’m still new, and I’ll take good advise from anyone up until the day I retire.
I’ve recently been lucky enough to use my Guerrilla Peer Support, the Debrief as its often called, where providers get together and discuss everything right after a job while the paperwork is being filled out and equipment cleaned, then we talk life, then we go back to work.
We have quite good peer support here with very proactive management and very well respected peer support officers its quite disappointing to learn that this isn’t the case in all services however. This is where the idea of learning a little about peer support is invaluable especially if your an advanced provider. Learn the basics of debrief after a case, for experienced providers this shouldn’t be a problem its probably all things you are doing already, but if your recognising that people aren’t responding to debriefing it might be a good idea to see if you can pickup some more skills.
There’s the very simple yet effective What Did we do? What did we do well? What can we do better?
Its forces audience engagement and interaction, taking the focus away from you providing all the talk and brings it back to the team.
As any member of the team encourage
“The Post-resus mantra: ensure loose ends TIED up!
Team check
Imbibe/ ingest
Equipment resupply
Debrief”
From Chris Nickson; http://lifeinthefastlane.com/ on the EMCRIT 118 Podcast Comments
While at uni we had very little support, most of our support was between each other at the coffee shop, this is still the case for me, I often undertake the coffee and case chat with colleagues whenever the opportunity comes up.
Two examples of this informal peer support;
I by accident came upon one of the first paramedics I met when I first did my ride along with university. He backed me and my partner up for some extra hands and after a particularly difficult, prolonged job with a sick patient, he sat down in the ambulance for a great period of time and talked about whatever, taking my mind away from the job and bringing it back to real life. The man always knew how to make me feel valued as a student and now as a paramedic.
He knows the art of steering the treatment and conversation where he wants it to go. Skills that can’t be taught but have to be passed from Paramedic to Paramedic. Skills that make a good person to talk to about difficult jobs.
The importance is on using it appropriately. Its always an idea to ask your Partner if they are okay, this is where it helps to learn about your partner, learn about their kids, learn about their likes and dislikes, it may surprise you, you may actually make a new friend.
Speaking of the coffee shop, I have a friend who works in Victoria, we often meet up when we travel to each others states and have a 6 month catch up, its sometimes nice to get his ideas on cases I’ve attended and he throws some cases back at me, we give each other some thoughts and then carry on with multiple coffees and Eggs Benedict. This is not only a great way for us to catch up but the 2 person meeting has rules, no gripes about the job, open access to coffee is a must, just me and him, no girlfriends, just him and me talking cases. Its become a common occurrence, and both of us find it a useful way to get up to speed and decompress about our paramedic lives (both of us have partners who aren’t medical as much as they try they can’t understand some of the troubles)
Post Resus Mantra; http://emcrit.org/podcasts/emcrit-book-club-on-combat-by-grossman/
If you want to read something truly well written read Jess’s (@EMS_jess) Textbooks, Tears & Trauma series over on Prehospital Research http://prehospitalresearch.eu/?cat=333
http://prehospitalresearch.eu/?p=2408
Down Stairs Care Out there
That’s right, I’m doing a self titled post.
The name of this Blog is downstairs care out there, this post will relate to first aid equipment. That I used to carry and still occasionally carry when I take a trip into the bush, To put it in context, I used to for a period after finishing my Paramedic degree work for an outdoor company as a guide/camp setup. While out and about in areas of the upper and lower blue mountains we would often be far outside the range of conventional ambulance. We would at least be waiting 2 or 3 hours for a road ambulance or in bad cases a helicopter. We also needed to be able to take care of any sprains/strains/boo boos within our own group.
All my gear is contained within these two bags. Well worn and over worked Summit Gear First Aid bags.
A bag of Paracetamol/ Ibuprofen
Thermal Casualty blanket
A Black Diamond Headlamp
2x Large Elastic Bandages for Snake bites
2x OLAES Bandages 4 inch
1x SOF Tourniquet
3x Saline Tubes
2x Large bandages
4x Triangular bandages
2x Punch and shake icepacks
1x Glucose Tube
Various styles of Bandaid/wound cover
Coban for strapping various sprains and strains.
Blue Bag, for defense coverage.
Burnaid Dressing for when water is unavailable
500mL Hartmanns
IV Kit (containing Cannulas)
Trauma Sheers
SOF Tourniquet
4 poly amps of Saline for wound cleaning
Large combine style dressings and bandages for wound covering.
These two bags make up most of my long distance kit, Red for the Car, and the blue kit for when I require more kit or am a bit further out or Car mounted, not carried regularly.
Its just basics at this point, but weight and size are a huge consideration, the Summit Gear bags are a quality item. As with all there kit! Its bomb proof, its practical, the kit carries everything I need, easy to find/recognise because of the strong color and fluro strip, even right at the bottom of a crowded boot.
Who regular carries medical kits out in the remote rural regions?
Do you see it as valuable.
Why do it, people regularly carry First aid kits, I’m just carrying a more professionally appropriate kit.
Mitchell Thomas is eagerly awaiting your replies on twitter @jrparamed
A university graduate Paramedic from Charles Stuart University and amateur bush-walker/bush-walking casualty.
Scottish Ambulance Service; Major Trauma Clinical Coordination Evaluation Report
Hot off the press the Major Trauma report from the Scottish Ambulance Service. An interesting read on the trial system, challenges and a breakdown of improvements and sustains by the Scottish Ambulance/ NHS Scotland in their prehosptial trauma HEMS system.
“Summary of key findings
• A substantial (160%) increase in
deployment of Prehospital Critical Care
Teams with a significant increase in the
number of patients receiving life and limb
saving interventions,
• A clinician focusing on patients suffering
from Major Trauma improves activation
times of Prehospital Critical Care resources,
• Stand down of Prehospital Critical Care
Teams after activation to calls identified
by the Trauma Desk is less than that of
other staff within the Ambulance Control
Centre (ACC),
• MPDS codes assign a level of response
to a 999 call. They are not always
sensitive to those patients sufferingfrom Major Trauma without further
interrogation by a clinician,
• Critical Care Teams are being stood
down on occasions where patients could
have benefited from Prehospital Critical
Care Intervention,
• Challenges exist in communication when a
multi-agency response is required,
• A small team of clinicians being utilised
from small specialist teams provides
challenges around resilience of staffing the
desk and base locations,
• Communication of the crew configuration
for Helimed 5 primary missions has
improved,
• The current ability for only one person
being able to listen to an incoming
emergency call can inhibit the Trauma Desk
from rapidly identifying Major Trauma or
inhibit other aspects of ACC operations,
• Identification of geographical areas where
there are sporadic, or no Prehospital
Critical Care resources,
• Current data collection relating to
Prehospital Critical Care resources by the
Scottish Ambulance Service is not optimal”
From report.
Click to access MAJOR%20TRAUMA%20REPORT%2005.pdf
CRISTAL trial: Colloids vs crystalloids in critically ill patients presenting with hypovolemic shock
Some more quality work from the Team at Prehospital Research.
Alan you are a Machine! I started to think it during SMACC but now I know. Keep up the good work!
CRISTAL trial: Colloids vs crystalloids in critically ill patients presenting with hypovolemic shock.
On Combat, response
Have you read on combat? If not turn away right now, you need to at least listen to the EM-Crit Podcast on it (http://emcrit.org/podcasts/emcrit-book-club-on-combat-by-grossman/) as your intro. A number of points were covered here and its the perfect starting point.
During a pre Emcrit book club world Ian Miller of @Thenursepath tweeted back and forth regarding David Grossmans OnCombat in responses to a tweet by Cliff Reid about his (unknown to us) upcoming Podcast on EMCrit.
While obviously not negative Ian mentioned some of the more unfavorable outcomes of military style training and in particular asked why we would take training points from organisations with such a high PTSD rate.
Thanks to Ian for giving me the opportunity to talk about why On Combat meant to me.
Obviously healthcare workers aren’t the target Grossman was writing for, so large sections of the book can be discounted or read for interest only.
The target audience is combat soldiers, special forces and those preparing for combat or leadership roles in the military. However I put that one aspect of our jobs is similar we can go from routine to high performance in seconds, without warning.
Now obviously having read the book a few years ago while in the Army I took a lot of valuable lessons from the book that have changed the way I do business throughout that time and now that I’m out in the streets a number of lessons have stuck with me.
TRAIN HOW YOU FIGHT! A point bought up in the book is the transition from round “bullseye” targets to human shaped targets increased the number of soldiers that would fire at the enemy, this brings home the point about training how you fight. Whats the significance of this, that changing the way solders trained to more closely mirror the combat environment with engagement of humanish targets lead to greater success. The idea was to build a reflexive response instead of a cognitive one. Why can’t we learn from this, or do we do it daily, think about how you set up for cannulas everything in the same place? Knowing when you put your hand down the item you want will be there, reliance on muscle memory when your eyes are busy. We plan our resus bays so everything is in the same place, the MET team uses their own equipment ensuring they have their requirements taken care of and know where everything is to maintain control of their environment and team. For the most part in some places we are already doing this. The introduction of talking, vomiting, fitting manikins into sim ensures we don’t have to do the awkward pause, look at the educator await a response. Because guess what, do it in practice you’ll do it under the pump. At my first cardiac arrest as a student I walked into the room doing the cursory head bob/traverse for “Scene Safe” with my blue hands in the air and pointing to my eye ware (want a way to make Paramedics think your weird as a student, do that).
Mentioned in the pod cast is the officers that would catch brass in their pockets leading to them being killed with and empty weapon and a pocket full of brass. The fought how they trained.
Under stress you do the same thing you always did in training, why? Its familiar its comfortable its safe to you, its tough to think when your mind is racing and your pulse pounding its what you’ll fall back to.
The book talks on time dilation and compression, reminding people that in times of extreme stress, that tunnel vision, auditory exclusion and memory loss (among other things can occur) but we all know this. I’ve been victim to this my self a few times. In the military we used to train to look over and around out weapon systems during and after a contact, because of this tunnel vision, training to look around was an stratigy to maintain situational awareness. Which I still do to this day, I look away from my patient, I look at my team I look at bystanders and back onto my patient, orienting me to my surrounds, ensuring no-one has entered the room that I didn’t know about and ensuring my partner is on track with what they are doing (and I’m sure they do the same to me). This process of ensuring to monitor my surroundings obviously didn’t come from the book, but its mentioned.
The book also talks about Stress Inoculation training. Having undergone training involving fatigue and stress inoculation I think I came out all the better, this was mirrored in my ambulance class the military individuals felt more in control, had a greater perception of the teams actions and were able to effectively lead the small team better. Obviously we didn’t get this all from reading a book, the benefit was gained from going through the training. Small stress inoculation sessions in my opinion have a place in training of Emergency Service personnel and emergency hospital staff. Notice how the experienced staff let nothing bother them, the old hands are calm and collected in a crisis, because they’ve been through this before. The old hands have in essence stress inoculated themselves through past experience and previous stressful situations. Surely there’s benefit to be gained from performing this in a controlled environment for junior staff and providing them with relevant teachings and feedback. Recording and re-watching the sessions would also show them how their memory and the actual timeline and events match up( I was amazed the first time I did this how they didn’t match up in a huge way).
This book isn’t going to competently revolutionize the way you practice your particular branch of medicine. What it will serve as is a primer for you to think about the things you do. Think about trialing some combat breathing and trying to undo some of your bad habits that will cause you to come unstuck in an emergency or high stress situation.
Most of the benefit I’ve gained from this book wasn’t in the book, it was in seeing the lessons learned from the book applied to real world training. This book will not make you a better Doctor/Nurse/Paramedic/Firstresponder what it will do is stimulate thoughts on how you do things, how you can do them better and how you and your coworkers can train better, simulate better and prepare yourselves for the rare, unexpected and uncommon situations.
The idea of this post isn’t to get you to join the Army to improve your situational awareness. Its to get you to think about reading a book, which may give you pause to think about how you do things and maybe change a few of your practices so they work better in the heat of the moment. Maybe if your a NUM, Manager, Consultant, ICP, Educator (Doctor,Nurse, Paramedic) you can use this to think about how you train people and what your delivering in terms of training them for the uncommon stressful situations.
What I loved about this book was the science and explanation it put behind routine things. In training the explanation as to why we did these things was often just “because we do, now just do it”. The book puts all of that in perspective and being more mindful of why each of the minor things we did was important lead to a greater compliance on my part with the basics. By bringing it out of the realm of “because that is the way we’ve always done it” and into the “this is why” made for a greater adherence on my part. My Army coworkers reported a similar effect if they had read the book
I’m often thinking about how fortunate I am to have had situational awareness and mindfulness under stress drilled into me over the course of my training, I think its makes me better as a Paramedic, where environmental control and awareness in a stressful situation can be the difference between losing control of the team or environment and yourself as an individual.
Thanks again to Ian for providing the kindling for this post. As I’m sure you know I’m a huge fan of your work on Social Media.
Mitchell Thomas
Mitchell has served 4 years in the Army Reserve as an Infantry Soldier and a Medic, Now working for an Ambulance Service having completed his degree in Clinical Practice (Paramedicine) through Charles Stuart University. Mitchell Enjoys Headlamps and Human factors, reading books on various topics, bush walking and thinking about various things both related and unrelated to Prehospital Care.
Resouces
ON COMBAT: The psychology and physiology of deadly conflict in war and peace
EM-Crit Podcast 118 and associated show notes. http//emcrit.org
Prehospital airway management : training, governance and evidence
Nice write up on where Pre Hospital RSI is at the moment. Ultimately driving home the point of its not what title you hold, but the skills you have and your maintenance of those skills that defines your Airway ability.
Photo courtesy of Dr Nicholas Chrimes
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THATS HOW I (WAS) ROLL(ED) from SCANCRIT
This is what teaches us lessons, human stories. SO LISTEN! If it was a clinical pearl you would, so take some rarely received patient feedback and put it to practice.
Can’t even imagine the pain of multiple rolls on a # Pelvis.
Evidently its quite painful. If you think your doing good by securing people to boards and performing prehospital log rolls its time to have an adjustment.
Thanks to the author for sharing his story.
THATS HOW I (WAS) ROLL(ED).
DOWNSTAIRS CARE OUT THERE BLOG 
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