Lessons From Pre-Hospital Care
Author: Steven Rainey, Consultant in EM & Pre-Hospital Care
@RaineySteven
24/10/2018
Managing critically ill and injured patients can be the most challenging and rewarding roles of a clinician in the Emergency Department. It is often what draws us into this career path.
Managing this same patient group in a small GP led island hospital or at the roadside presents even more challenges. How can this be achieved and what lessons from the Pre-Hospital environment can we take to our Emergency Departments?
Training
Knowing your equipment and exactly where to find it is vital, especially as it may be different in every hospital you rotate through. In the Pre-Hospital setting we lay our equipment out in the same manner for each RSI and we use checklists to reduce the risk of error. Procedures that are undertaken regularly such as blood administration and RSI, and procedures that are undertaken less frequently but are extremely important, such as surgical airway or resuscitative thoracotomy, are drilled regularly so that we have the muscle memory to perform these skills well when required. These skills are further tested with simulated scenarios with the team that will be working together that day.
Daily simulation is something that is realistically difficult to achieve in the ED but any sim is invaluable and we recognise the importance of this at St Mungo’s. It is important to know your equipment in resus. Have you thought about and rehearsed the technique you would use to perform a surgical airway or thoracotomy or any number of critical care interventions? By practicing individually and as a team you will perform better when it is required.
Debrief
If a job went well, what were the factors that made it go well? Conversely if things were challenging or went badly why was this and what can be learnt? In the Pre-Hospital service I work for we debrief every job and there are always learning points. In the ED we frequently forget to debrief as we rush from patient to patient or only reserve debrief for when things went badly. You should ask your team or consultant for feedback and discuss as many cases as possible as a team. There will always be something to learn.
Communication
In high pressure situations, clear communication is critical. We have all seen someone shout to the room “can someone get me ...” meanwhile people run in different directions looking for the same thing, wasting time and losing important team members, or worse the same drug is given twice.
Using someones name, looking them in the eye or directing your hand towards them if you can’t remember their name will stop the example above from happening. Speaking clearly, confirming numbers eg “sixty milligrams, six-zero milligrams” will prevent your instruction being mis-heard as sixteen milligrams. Very simple tips which can reduce the risk or error significantly.
I will often broadcast my thoughts and plans to the team so everyone is aware of the plan, the next steps that need to be taken and how we are going to get there. It is also important that team members feel comfortable to raise concerns or ideas and contribute to the plan.
Cognitive offloading
When caring for a critically unwell patient you want to have as much cognitive capacity available as possible to concentrate on resuscitating and safely transporting your patient. In the Pre-Hospital setting the use of action cards, checklists and a bespoke app with contact numbers, drug doses and calculators and guidelines helps achieve this. I keep lots of useful medical apps on my phone so I don’t have to rush around the ED looking for a paediatric BNF or trying to recall the parkland formula or trying to find the most up to date version of a guideline on the intranet.
Also by repeatedly drilling commonly occurring procedures, as discussed earlier, they will then require less cognitive capacity freeing your mind for other potentially more complex decision making.
Looking after yourself
We don’t want our pilots to fly us if they are tired, hungry or sick yet we may be all three when we are at work. You will perform better if you are well rested, well hydrated and not hungry. We are all guilty of not looking after ourselves as well as we should, but we owe it to ourselves and our patients. The ED is always busy. Make sure you take breaks and look after yourself!
Steven Rainey is a consultant with the Emergency Medical Retrieval Service and an Emergency Medicine consultant at Glasgow Royal Infirmary.
If you are interested in reading more about ‘Cognitive Offloading’, see the Core Cognition blogs, which discuss this and other high performance cognition topics- by Stephen Hearns- Lead consultant for EMRS Scotland
