Pre-Hospital Care Podcast

In this conversation, we will explore some of the lessons learned through years of major incident attendance in Scotland from the Emergency Medical Retrieval Services (EMRS). We examine the Scottish Trauma Network, the demographics of healthcare in Scotland, and some of the recent and seminal major incidents that have informed EMRS’s approach. We also include some of the lessons learnt through the Manchester bombings – that of paediatric triage and treatment in Mass Casualty incidents. We examine some of the lessons learnt through using CSCATTT, METHANE, activation and tasking, communications both remotely and at site, preferred triage tools and much more.

To do this I have John Paul Loughrey with me. JP is a Consultant in Emergency Medicine at the QEUH in Glasgow and has worked with EMRS in a variety ous roles since 2011. He is the Major Incident lead for ScotSTAR and is Vice-President of the Royal College of Emergency Medicine. In addition, his other main professional interests include major trauma care, teaching and training and organising large-scale CPD events and conferences.

Reflex Medical

This podcast is sponsored by Relex Medical. Whether you need syringes and steri-strips or Littmann stethoscopes and advanced life support training manikins, Reflex Medical are here to help. When you’re restocking your ambulance or checking your paramedic equipment list there is only one place you need to go for your medical supplies – Reflex Medical. To see more of their innovative diagnostics and medical devices please click here:

In this conversation, we will examine the concept and the reality of psychological burnout among Paramedics. The effects of burnout are estimated to cost over $300 billion annually, with the WHO forecasting a burnout pandemic in the next decade. Within pre-hospital organisations, burnout can generate reduced quality, high absenteeism, increased turnover rates and substandard productivity. In the conversation, we examine the definition of burnout, the factors that increase the risk of burnout, models of burnout, the symptoms of burnout, possible mitigation strategies to avoid burnout, some of the emergent themes from the research and much more. To do this I have Liz Thyer with me. Liz is an Associate Professor in the WSU Paramedicine program and Associate Dean (Learning and Teaching) for the School of Health Sciences.  She was an advanced life support paramedic with Ambulance Victoria for 11 years including roles as a clinical instructor and peer support officer. She has previously worked at Victoria University with the Paramedic programs and at Deakin University in Learning Futures.  She is an active member of the Australasian College of Paramedicine and is the inaugural chair of the ACP Professional Standards Committee. Liz Thyer's work can be found here:

Review article: Prevalence of burnout in paramedics: A systematic review of prevalence studies

In the conversation, we examine the definition of addiction, the meta-substances (stimulants, sedatives, opioids), the time horizon of an addicted person (instant gratification), the triggers of addiction, the diagnosis of dependence, what dependence means, and the types of addictions (work, sex, drugs, diet, exercise).  We explore two of the most addictive substances, alcohol and tobacco, and their second-order effects on health, family, and relationships. We will also look at the complications of addiction and lastly, the modern treatments and monitoring post-treatment that can be beneficial to the individual.

To do this I have Consultant Psychiatrist Dr Brian Wells with me, Brian specialises in Substance Disorders and has an international scope of clients.  He leads a bespoke, discreet, service that works closely with most of the 'quality'​ addiction treatment facilities globally. His specialities include addictive disorders and medical and surgical referrals where appropriate.

In this conversation, we will explore some of the nuances and challenges of Exercise Associated Collapse (EAC) with Luca Carenzo. The basis of this interview was the recent publication in the Journal of Science and Medicine in Sport of An Unusual Case of Marathon-related Exercise-associated Collapse: Case Report and Some Considerations for Medical Care at Endurance Mass Participation Events. We will explore the case and some empirically proven treatments that form the mainstay of treatment within EAC. We will also visit some of the reflections on the case and how it has changed Luca’s thinking on the list of differentials within EAC. We also examine patient-focused research, intra-speciality collaboration and EAC collated databases.

In this conversation, we will examine whether point-of-care ultrasound is a reliable predictor of outcome during Traumatic Cardiac Arrest (TCA). We will dig into the recently published systematic review on the topic with Tim Harris, who is one of the authors of the paper. We will examine why the authors decided to look at TCA and POCUS, the number of studies and patients examined, the type of Mechanism Of Injury (MOI) leading to TCA, what the results showed, and how this is relevant to practice. We also look at the other adjunctive markers in the pre-hospital domain to inform the Termination Of Resuscitation (TOR) based on the results found in this paper. We will also dig into another recently published paper related to the diagnostic performance of POCUS in resuscitative outcomes published in April of this year on a systematic review and meta-analysis of 3265 patients and outcomes with POCUS.  

To do this I have Tim Harris with me. Tim is a Professor of Emergency Medicine and Programme Director for the Emergency and Resuscitation Medicine programme at the Blizard Institute, Queen Mary University of London. He has trained extensively overseas, training in Emergency Medicine and Intensive Care Medicine in the UK, Australia, Africa, India and Samoa. The papers we examine include:

In this conversation, we will look at the research examining methods of safe sedation by Advanced Paramedic Practitioners within London and examine the research published on this looking at sedation of Acute Behavioural Disturbance (ABD). We will examine; what the retrospective cohort study of pre-hospital agitation management showed regarding the sedation of the ABD patient. Also, the origins of ABD according to the paper, the Sedation Assessment Tool used to measure pre- and post-intervention, the approaches that senior clinicians can take to sedate patients and more. 

To do this I have Tim Edwards with me, Tim is a Consultant Paramedic with the London Ambulance Service NHS Trust and a visiting lecturer at the University of Hertfordshire. Tim has been a paramedic since 2000 and has undertaken various roles including working as a flight paramedic, senior lecturer, and advanced paramedic practitioner and is currently working as a Consultant Paramedic in London. 

The study that the conversation is based on can be found here:

In this podcast, we will look at the benefit and utility of Methoxyflurane, more commonly known as Penthrox. Penthrox is a volatile, self-administered inhaled analgesic indicated for short-term pain relief. Penthrox is a portable, lightweight, non-invasive inhaler for self-administration of the Methoxyflurane vapour. Penthrox provides analgesia when inhaled at low concentrations giving analgesic therapeutic doses, but can also reduce and mitigate even severe pain yet has a short half-life. We will examine its use and limitations within the expedition environment and how and when it can be optimally used as either a sole adjunctive pain relief agent or as part of a larger pain relief strategy. We also get Will's reflections from use in practice and where and when Penthrox is useful.

Joining me is Dr Will Duffin, Will is the co-medical director of World Extreme Medicine and is an NHS GP. He is also an expedition, TV/film doctor and father of two. He lectures around the UK for NB Medical Education and is a digital host of the World Extreme Medicine podcast. Many thanks to World Extreme Medicine for kindly agreeing to the use of this audio.

You can find more on Penthrox here:

In this episode, we examine how to approach systems strengthening in clinical practice within the context of Sierra Leone with Aneesah Peersaib. We will look at her recent deployment to support Continued Professional Development at local, regional and national level and her role in leadership development whilst in post in Sierra Leone. We will examine how she disseminated education & training, policy, and governance and how she approached cultural change from the ground up. Finally, we will examine how she built and maintained safe systems of practice, and how you can embody a culture of educational leadership and empower coproduced with in-country clinicians to provide solutions to wider systems development work.

To do this, I'm speaking with Aneesah Peersaib. Aneesah has recently held the post of Nursing Education Advisor to Chief Nursing and Midwifery in Freetown, Sierra Leone. She collaborates across NGOs to work with the Sierra Leone Ministry of Health and Sanitation to standardise nursing education and support national strategic delivery. She has been a senior Nurse both inside and outside of the UK NHS working for Health Education England as a clinical lead and clinical advisor supporting education and workforce development across London. Aneesah is an Emergency nurse by trade and has experience leading central London Emergency departments before going on to wider systems leadership roles.

In this next period, we will be recording a mini-series on addiction starting with this first episode with Specialist Addiction Therapist Mark Dempster. In 2013, the Centre for Social Justice determined that the level of addiction in the UK made it the “addiction capital of Europe.” This includes the use of legal substances, mainly ⁠alcohol⁠, and the use of Class A drugs, which include ⁠heroin⁠, ⁠cocaine⁠, ⁠meth⁠, and ⁠hallucinogens⁠. £36 billion is spent by the nation every year on treatment relating to drug and alcohol abuse. At the time of filing their report, titled 'No Quick Fix', the UK had the highest rate of addiction to ⁠opioids⁠ and the highest lifetime use of amphetamines, cocaine, and ⁠ecstasy⁠ across Europe. Many view addiction as something that only affects the users themselves but, in reality, casualties from substance abuse are taxing entire communities and society as a whole. Addiction in the UK affects everyone from loved ones to clinicians and the everyday public.

In the conversation, we examine the five stages of addiction, common cognitive pitfalls, habit Vs. addiction, and Mark's organic story through his lived experience with addiction. We also look at the 12-step process of Narcotics Anonymous (NA). Mark is a specialist addiction therapist and a recovery coach within a Harley Street Counselling Practice. He has witnessed chemical and behavioural addictions both personally and within his circle of family and friends.

Learning the practice of psychotherapy for addiction helped Mark reach out to all types of addicts, from programmes working with prisoners, helping at homeless shelters, and to wealthy bankers from Canary Wharf.  According to Mark, the addict’s circumstances varied but their addictions had a lot in common. In the conversation, we also cover:

• Defining Addiction & UK stats  - The health burden & impact on the individual and extended families 
• Origins – how people become addicted (habit Vs addiction) 
• Dual diagnosis 
• The 5 stages of addiction 
• The NA & AA 12-step model (origins and application)
• Common cognitive pitfalls 
• Breaking the cycle – different types of therapy (CBT, DBT, ACT, +/- PET for PTSD) 
• Anecdotal experiences and cases from Mark’s perspectives 

You can find out more about Mark here:

In this conversation, we will examine the current state of NHS ambulance service delivered care and how we can approach this with a different perspective. We will examine the current models of operation and how over the next 10 to 20 years this needs to be flipped on its head. We will explore the numbers of See, treat and convey versus see, treat and refer, versus telephone consult and close and how this can be flipped on its head. We will also explore how the adage of modern technology can we can meet these needs througg technology and how the progressive Paramedic Career Framework supports this through advanced urgent care practitioners & more pathways to refer patients to. We will also explore some of the innovations that Jason has initiated to work toward this goal.

Jason Killens is the Chief Executive of the Welsh Ambulance Services NHS Trust, which is the national provider of 999, 111 and non-emergency patient transport services for Wales. Jason has spent his career working in Ambulance Services in the UK and Australia. He progressed through the ranks in London Ambulance Service from an Emergency Medical Technician to Executive Director of Operations. He was appointed as the Chief Executive of the South Australia Ambulance Service in 2015 before joining the Welsh Ambulance Service as Chief Executive in September 2018. In the conversation, we examine:

• Jason’s journey through healthcare 
• The current state of activity 
• The future state of activity 
• Why hear and treat has come to the fore. 
• Risks of this proposed model 
• How modern tech supports this vision
• The Paramedic Career Framework and how this also supports future state operations (urgent care ambassadors) 
• New innovations that Jason is looking at 
• What happens if we don’t adopt this flipped model of care?
• Final thoughts

My thanks to Jason for his reflections and thoughts on this topic. To see more of the inverted pyramid of care, please see here:

In this conversation we will examine the anatomy of the Advanced Paramedic Practitioner in Urgent Care (APPUC) scheme as it currently stands within London. We will examine the discharge to the community rate, Alternative Care Pathway referral rates and where they are being referred to, commonly seen pathology for the group, advances in the scheme (innovation and where they are looking to innovate), and finally aligned training that the scheme receives. 

 Kate Hardy is an advanced paramedic practitioner in urgent care working in London. She gives us insights into what the anatomy of work looks like, the types of pathology, and the Multi-Disciplinary Team (MDT) approach that the scheme takes. The range of topics in the conversation include:

• The concept of Urgent Care Advanced Paramedics  
• What a day in the life of an APPUC looks like 
• The discharge rate of the scheme 
• Commonly seen pathologies for the scheme 
• Training that the Advanced Paramedics receive.
• Master’s level training and what that brings in terms of critical thinking ability. 
• Clinical governance and how that looks on an individual and collective level.
• How Kate has changed as a clinician through the scheme.
• Alignment with the Multi-professional framework for advanced clinical practice in England

Please find a link to the Multi-professional framework for advanced clinical practice in England here:

In this conversation we will examine the recent recommendations and development of a national out-of-hospital transfusion protocol for critical care services. We will unpack the recent modified RAND Delphi study that sets out the guidance of clinical governance and recommendations for out of hospital transfusion services. We will dig into the recommendations on the initiation of transfusion, the types of blood components and products, the delivery and monitoring of out of hospital transfusion, the Indications for and use of transfusion adjuncts and finally the resuscitation targets to halt ongoing transfusion. 

Adam Greene is a Unit Chief and Critical Care Paramedic working at British Columbia Emergency Health Service. He is also an honorary lecturer at Cardiff University on the Masters in Critical Care. He amongst others has recently published the Development of a national out-of-hospital transfusion protocol: a modified RAND Delphi study which will form the basis of our discussion. 

This is the second instalment of the conversation on the approach to major incidents with Keir Rutherford & Alec Wilding. We examine triage tools which have just come into practise which is around the TST - 10 second triage algorithm and the MITT - major incident triage tool and also look at enhanced levels of care on scene and what should be done in the casualty clearing station. We also examine at how we manage our emotions as senior clinicians both on scene and retrospectively and work we work with interdisciplinary teams around the fire brigade and the police on scene.

Here are more resources from the conversation:

In this conversation we will examine some of the lessons learnt from anecdotal experiences in major incidents, together with the reflections from previous recommendations in major incident enquiries such as the Manchester bombings. We will examine the differentiation of terrorist attacks at point of call from an otherwise normal RTC or ‘typical’ incident. We also look at the initial approach to triage, who and how this should be done as well as the integration and relationship of the Ten Second Triage (TST) algorithm, the Major Incident Triage Tool (MITT) and levels of enhanced care at the scene. Also, the concept of casualty clearing and when and how this should be performed. We also examine the level/ceiling of intervention that is beneficial from the empirical research in such events and how this should be approached. We also examine inter-disciplinary working with other services such as police responders and fire brigade. 

Keir Rutherford is an Advanced Paramedic Practitioner in Critical Care and also a flight paramedic with London’s Air Ambulance. Alec is also an Advanced Paramedic Practitioner in Critical Care and the Emergency Planning Resilience and Response (EPRR) lead for Festival Medical Services, who are a charity providing event medical cover including at Glastonbury and also a Specialist Paramedic for Hampshire Isle of Wight Air Ambulance.

In this conversation we will examine the latest in non-invasive ventilation via the helmet interface. Recent empirical research has shown that ventilation via helmet can mean faster recovery time, shortening an ICU stay, reduces the need to intubate, lowers ICU mortality, and can result in minimal or no sedation of the patient. 

In this conversation we will examine the concept of the performance pizza. This is a concept which examines three main domains of performance within pre-hospital care; the predictable routine, the predictable emergencies and the unpredictable emergencies. We will dig into each of these domains and examine what each constitutes, how you train for each state and how to navigate each.  

To do this I have Stephen Hearns with me. Stephen is a consultant in emergency and aeromedical retrieval medicine. He works with Scotland’s Emergency Medical Retrieval Service (EMRS). This aeromedical retrieval service delivers pre-hospital critical care for major trauma patients, rural hospital secondary retrievals and major incident responses. Inspired by experience gained working on London’s air ambulance and in Queensland Australia, Stephen led the establishment of this team from a small voluntary service in 2004 to what is now a fully government funded aeromedical retrieval organisation with an international reputation. In the episode we discuss:

·      The three performance domains – how did Steve come to rest on these domains and how do they look in practice.

·      The predictable routine – Patients and/or skills that are executed everyday and are commonplace within practice.

·      The predictable emergencies – The High Acuity High Occurrence skills or patient presentations (RSI for example) 

·      The unpredictable emergencies – the High Acuity Low Occurrence (HALO) skills that might fall into the unpredictable spectrum (Surgical Airway)

·      Putting it all together in training and how simulation and case review plays into this.

·      How Core Cognition seeks to educate these areas within high performance teams.

In this conversation we will examine the career progression of Vicki Brown, who is an Advanced Practitioner in Critical Care, and is the first person in the country to get on the Faculty of Pre Hospital Care (FPHC) Register of Consultant Practitioners by qualifying from a purely paramedic background. We will trace her career pathway and the steps that have been taken by her to achieve such a pivotal role within pre-hospital critical care. 

Vicki joined the ambulance service in 2002. And has had roles in management, learning and development and working on HEMS. She became the first ACP-CC for SWAST in 2020 and the first person to register as a Consultant (Level 8) Practitioners in Pre-Hospital Emergency Medicine in 2021. 

·      The start of Vicki's career – 2002 and what Vicki was doing previously to Paramedic Practice.  

·      What Vicki learnt on the road as a Paramedic 

·      What management taught her and she carried through

·      How training and education played a role in her progression 

·      The adage of learning every-day  

·      The educational pathway (DIMC, higher education, FIMC)

·      What working at GWAAC has taught her 

·      How governance looks within the team at GWAAC.

·      What responsibilities Vicki undertakes now as an Advanced Practitioner in Critical Care.

·      How she has changed over the years through her positions.

·      Where the profession is going, the pillars of advanced practice within the UK. 

To see more on Vicki please see here:

This is a repost of an episode I recorded back in the early years of podcasting. It remains the most downloaded episode of the entire podcast. Steve Rashford is the medical director of The Queensland Ambulance Service (QAS) with 5,000 staff and 1,300 response vehicles. In the episode Steve gives some of his perspectives of a pre-hospital careers spanning over 20 years in duration within multiple services. QAS has a contemporary approach to clinical service delivery and innovation in prehospital trauma care. It also operates a tiered system of pre-hospital care with Advanced Care Paramedics (ACPs), Intensive Care Paramedics (ICPs) and a smaller cohort of HARU Paramedics.

In this episode we discuss a variety of topics:

• High Acuity Response Unit (HARU) both its inception and the clinical remit for the HARU.
• Governance around the HARU program and provider quality assurance for some of the procedures (RSI, on-call advice, blood products and the bleeding patients).
• Quality improvement and where the program is heading
• The lessons learnt building the HARU and ICP schemes in QLD.

I hope you enjoy this episode as I found it both insightful and helpful to look at how other systems approach high performing teams and continuous improvement.

In this session I am speaking with Clare Fitchett as we explore the fundamentals of human factors and the interplay of leadership. In the conversation we examine what human factors mean to Clare and how they affect her practice. We also look at leadership and how Clare perceives leadership can affect human factors for the better. We finally examine the concept and strategies of human factors mitigation and how we can offset the patent safety issues that human factors brings with it. 

Clare graduated as a paramedic in 2011 having undertaken her student paramedic training with South Central Ambulance Service. She commenced her Specialist Paramedic (Critical Care) training in 2018 with Thames Valley Air Ambulance (TVAA) and holds the Diploma in Immediate Medical care (DipIMC) from the Royal College of Surgeons in Edinburgh and is completing an MSc in Advanced Clinical Practice. Clare also volunteers as an Expedition Medic with the British Exploring Society and is also a faculty member of World Extreme Medicine. She currently works for Hampshire and the Ilse of Wight Air Ambulance. In the conversation we explore:

• Overview of HF- why it is important to Clare and holistically
• How leadership can affect HF - the interplay between human factors and leadership
• Seminal leadership points that are useful/attributes of a good leader
• How we support more junior clinicians to lead in critical care circumstances
• Peer review and/or shared mental models
• Some of the mistakes and misconceptions that people make when relying on their own memory versus checklists
• Aspects of Clare's leadership that has changed over time
• Managing stressful environmental human factors on scene
• Some of the great leaders Clare has learnt the most from in regard to human factors mitigation
• Examples cases; seminal cases from Clare’s experience - 2 cases, one which

went well and one which was challenging and valuable learning.

Please find some valuable empirical research that underpins Clare's perspectives:

Interventions to improve team effectiveness within health care: a systematic review of the past decade

In this session, I am speaking with Neel Bhanderi on the advantages of high-fidelity training within clinical practice. In the conversation, we examine the concepts of analogs of reality and how it has multifactorial benefits through the integration of handover simulation, debriefing, stress inoculation, skill acquisition under stress, communication under applied stress, and much more. To do this I have Dr. Neel Bhanderi with me. Neel is the Head of Education and Training at MedSTAR retrieval HEMS service based in Adelaide. He is also a Consultant in Emergency Medicine at the Royal Adelaide Hospital. Neel trained as an Emergency Physician and worked as a Consultant at St George’s Hospital Major Trauma Centre in London for several years and for Kent Surrey and Sussex (KSS) Air Ambulance. In 2016, Neel emigrated to Australia where he works as an Emergency Specialist at the Townsville Hospital in North Queensland and is currently the head of education for MedSTAR retrieval service. In the conversation, we examine:

• Why high-fidelity simulation is useful & Neels approach to multi-modal simulation. • What components of training do MedSTAR focus on (Skills based, assessment-based, comms based or all three) – templates of training outcomes used. • How Neel approaches the training debrief. • How Neel creates incremental training stressors within the operational teams. • Environmental stress training methods (operational Task and environmental noise). • Approach to micro versus macro tasks • Comms under pressure within the training environment • Handover and how MedStar simulates this (filming, use of the checklist, analyzing) • Training relationship with case review (identifying training needs from case review). • How Neel is changing training in the short term (other elements such as personality and characterological traits).

Please enjoy this wide-ranging conversation with a fantastic guest. For more on MedSTAR and the work they do please see here:

In this episode we kick off a mini-series on human factors in practice. I will be speaking with a cross section of clinicians on what human factors means to them and the impact it can and has had on their practice. In this episode I discuss the fundamentals of human factors including; a working definition of human factors, why human factors are important, the history of human factors, the main domains of human factors, Individual Human factors & mitigation, task human factors & mitigation, environmental/System human factors F& mitigation, NASA's approach to human factors and finally three seminal cases in human factors.

Medical errors can have significant costs both in terms of patient health outcomes and financial costs. While it is difficult to estimate the precise global costs of medical errors, studies have suggested that they can be substantial. In the United States alone, medical errors have been estimated to cost between $17 billion and $29 billion annually in direct costs, such as additional medical expenses, lost income, and disability. This figure does not include the indirect costs associated with lost productivity or quality of life. A study in the UK estimated that preventable medical errors cost the National Health Service (NHS) around £1 billion each year. On a global scale, a report by the World Health Organization (WHO) estimated that 10% of hospital admissions worldwide result in adverse events, and around half of these are due to errors. These errors are estimated to cause between 6 and 10% of hospital admissions in developed countries, and up to 20% of admissions in developing countries. The report also estimated that medication errors alone affect at least 1.5 million people globally each year, resulting in 100,000 deaths annually. 

Here are the links mentioned in the episode:

In this conversation we will examine the recent changes in spinal immobilisation within pre-hospital practice. We will look at the historic literature, prevalence of spinal injury in reality, the RCSEd recommendations, and other international guidelines and also the current practice of C-spine collars and extrication advice. To do this I have Jim Walmsley with me, Jim is a Critical Care Paramedic at South East Coast Ambulance Service NHS Foundation Trust. Jim has a 19-year history with the ambulance service and has focussed his career on clinical practice, research, under-graduate teaching, as well as managerial duties. In the episode we discuss: • The culture and historic research of spinal immobilisation. • Pre-hospital prevalence & cultural shift • What are the main considerations in the pre-hospital phase of care • Pre-hospital assessment (sensitive? Valid?) main information to take note of (MOI & other factors) • Immediate treatment options – to immobilise or not immobilise • Latest recommendations • Seminal cases where the application of the above has worked well • Final thoughts & take-home messages.

Some of the references that Jim referred to can be found here:

In this conversation we will examine the immediate, mid-term and long-term effects of sexual assault. We will also examine the short-term treatment that pre-hospital clinicians should consider. We will also examine some of the long-term support that is available for victims of sexual assault. We will also examine elements of safeguarding, care pathways, and forensics that work on a co-aligned basis with psychological support mechanisms. To do this I have Jayne Butler with me. Jayne is the CEO of Rape Crisis and an experienced voluntary sector leader with a strong background in frontline service delivery. Jayne has worked in social justice-focused organisations for almost 20 years. These include organisations working on asylum and immigration, mental health, child sexual exploitation and access to justice. Before moving into infrastructure and influencing work, Jayne was involved in designing, fundraising for and managing a range of frontline services. She has worked strategically as a consultant in a range of voluntary sector organisations, and as a staff member or trustee in a number of membership and infrastructure organisations. These include The Comfrey Project, North East Law Centre, Relate Northumberland and Tyneside, Newcastle United Foundation and The Children’s Society. Prior to joining RCEW, Jayne was Head of Income and Development for Law Centres Network, the national membership body for Law Centres. During her time there, she led on the Network's response to the Covid-19 pandemic. Jayne is a Fellow of the RSA. In the conversation we discuss:

• The need for psychological support as an immediate intervention • The pre-hospital prevalence • What are the main considerations in the pre-hospital phase of care • Pre-hospital assessment when a patient has been sexually assaulted • Forensic assessment • Immediate treatment options, midterm, and long term • Safeguarding needs of this patient group • Care pathways available for these patients • Example case of when services work well together. • Final thoughts & take-home messages from Jayne.

Services that Jayne sign posts to in the episode includes:

In this conversation we will examine the prevalence, types, and challenges of pelvic trauma. We will also look at some of the pre-hospital and Emergency Department management of pelvic trauma and why it can be such a critical injury to treat. To do this I am speaking with Ash Vasireddy. Ash is a fellowship-trained Orthopaedic Trauma Surgeon specialising in the management of complex upper limb, lower limb, pelvic and acetabular fractures. He works at King’s College Hospital (Major Trauma Centre) in London. He completed further specialist Orthopaedic Trauma training at The Royal London Hospital, as well as Orthopaedic Trauma Fellowships at Queen’s Medical Centre in Nottingham and King’s College Hospital in London. In addition, Ash has also completed travelling fellowship visits to multiple major trauma centres in America, including the Shock Trauma Centre in Baltimore and Harborview Medical Centre in Seattle. Ash also has extensive experience in Emergency Medicine, Intensive Care and Anaesthesia. He is also a Consultant at Essex and Herts Air Ambulance (EHAAT) and research lead for EHAAT. In the conversation we examine:

• Why a pelvic fracture is so critical
• The pre-hospital prevalence
• What are the main types / classifications
• The spectrum of injury – pain to life threatening blood loss
• Pre-hospital assessment of the pelvis 
• Some of the common issues seen as an Orthopaedic Trauma Surgeon
• IR vs OR
• Possibilities of REBOA within the Air Ambulance Service
• Lessons learnt from practice (pre-hospital and in-hospital)
• Seminal cases 
• Final thoughts & take-home messages.

In the conversation Ash mentions the two common types of Pelvic classification, these are:

In this session I am speaking with Robbie Lendrum on the Myocardial Hypoperfusion & injury in Trauma. We examine the Windkessel concept of pulsatile flow to constant flow, reservoir pressure as an analogue of diastolic pressure, coronary perfusion in diastole. We also explore blood pressure targeted intervention, the disparity between NIBP and IBP, the precision of diagnostics versus intervention, and individually patient centred intervention. We finally fundamentally drill down into the true importance of diastolic blood pressure in trauma care and how this is a succinct shift in mindset and teaching to traditional systolic blood pressure measurements and cut offs.

To do this I have Robbie Lendrum with me. Robbie is a consultant in cardiac anaesthesia and critical care. He is also a consultant in Pre-Hospital Care working with London’s Air Ambulance. Robbie is an honorary senior lecturer at Queen Mary university London and an Endovascular Resuscitation Researcher within the UK. Within the conversation we also examine:

• Cardiac hypoperfusion – pathophysiology
• The Windkessel concept – converting pulsatile flow into constant flow, the generation of pressure.
• Reservoir pressure equal to diastolic pressure
• Coronary perfusion in diastole and the fundamental importance of diastole in trauma 
• Arterial injury and respective diastolic hypotension – wide pulse pressures  - Effect on coronary perfusion pressure & flow
• CVD – Cardiovascular Dysfunction with early death/72 hour boundary.
• Physiological targets (targeted intervention)
• Why should we move on from blood transfusion and drive faster to hospital. 
• The secondary effects on the heart & essentially outcome.
• Arterial shock and the proximal thoracic aorta.
• The two main types of patient and how we approach these (Tamponade and exsanguination)

My thanks to Robbie for this interview. This is a fundamental shift in teaching and mindset and is seminal in how we see and approach trauma care in the future. The key pieces of research that Robbie mentions in the interview includes: 

In this session I am speaking with Mark Hannaford, Luca Alfatti, and Alione Hlivco around the current logistical aid efforts, implementation, climate and anecdotal reflections in Ukraine. We also want to dig into the cadence of change in the current climate from an infrastructural perspective, logistical effort and the real need on the ground from the guest’s experience. Our guests include Mark Hannaford, Mark is the CEO and founder of World Extreme Medicine. Since its inception WEM has trained over 20,000 medics in extreme medicine and has a global platform that also hosts the first MSc in extreme medicine at Exeter University in the UK. Welcome Mark to the podcast. We also have Alione Hlivco, Alione is a former MP in Ukraine. She is a regular contributor at Chatham House, Monocle24, CapX and is a TEDx Speaker. Finally, Luca Alfatti. Luca is the Head of Operations for #Medics4Ukraine, who has delivered over 1.7 million pounds worth of medical aid to Ukraine, as well as several trauma medical courses to frontline soldiers and medics. He is also an advanced paramedic in the UK. Aspects of the conversation include: 

·  The current climate & significant elements of recent change

·  Multi-factorial risk profile of the country currently

·  The existing and emergent needs as seen by the guests

·  Cross section of clinical cases

·  Recent education delivered & aspirations

·  Recent activity within the #Medics4Ukraine initiative within the UK

·  Information governance

·  Aspirations within the next few months (broad & not area specific)

·  Logistical challenges

·  Diversity of medical distribution

In this session we will examine the latest perspectives and insights into recreational drug toxicology with Dima Abdulrahim. I wanted to unpack some of the recreational drug toxicology with reference to drugs that seem to be in favour with youth and have pre-hospital touch points from an acute perspective. Dima Abdulrahim has been working in the field of substance use treatment for 30 years. She is currently the Quality Lead in the Addictions department of CNWL NHS Trust. Dima was the Principal Researcher and Programme Manager of the NEPTUNE Project, based in the Club Drug Clinic. She is the author of two books on novel psychoactive substances and club drugs and other publications and has developed as a series of e-learning and mobile-learning modules, with co-author Owen Bowden-Jones. Dima was a council member of the Advisory Council for the Misuse of Drugs (ACMD) for many years. Topics covered include a deep dive into:

• Some of the most addictive recreational substances Dima has seen in practice 

• Poly-pharmacy and the associated incremental risk profile to the user

• The combined use of sildenafil with other drugs within the chem-sex context

• GHB addiction and profile and the narrow therapeutic window and GABA-B stimulation/sedation (and over sedation) in overdose

• The half-life of GHB 

• Serotonin linked harms and syndromes, mainly within MDMA and ecstasy

• The incumbent fentanyl crisis (unwarranted and unregulated cutting of drugs with fentanyl)

• The false economy of safety around drugs bought online

• The contemporary issue around fake ketamine distribution

• The circulation of fake pregabalin and benzodiazepines and the related deaths

• Take home Naloxone campaigns 

• Other emergent synthetic recreational drugs seen within the clinic

Resources that Dima has written include: 

Books: 

Abdulrahim D and Bowden-Jones O: Textbook of Clinical Management of Club Drugs and Novel Psychoactive Substances Cambridge University Press Medicine. October 2022 (book)

Bowden-Jones and Abdulrahim: Club Drugs and Novel Psychoactive Substances. The Clinical Handbook. Cambridge University Press Medicine. November 2020 (book)

Resources (available free of charge)

NEPTUNE e-learning modules on club drugs and novel psychoactive substances

In this session I will be talking with Neil Jeffers on CRM or Crew Resource Management. We will examine a working definition of CRM, why it’s of fundamental importance to Neil, the history of CRM, the symbiotic link between human factors and CRM, and the detrimental aspects of collective agreement. In the conversation we will also examine some of the theory, threat and error management, CRM tools that Neil uses and advocates, and finally how debrief can be a fundamental tool to improving CRM.

Neil has been a Pilot with London’s Air Ambulance for 16 years and has been Chief Pilot for the last 8 years. Neil has flown over 8,000 hours since he started flying in 1997 and has over a 5,000-hour track record in instructing and examining. Neil was also an experienced crew resource management instructor and a certified first responder and has been a volunteer emergency responder with London Ambulance Service for 5 years. In the interview we cover:

• A working definition of CRM
• Why CRM is so fundamental to high performing teams 
• Brief history of CRM from aviation into medicine
• Flash points within a scene that mandate good CRM
• The linkage between CRM and Human Factors
• Deep dive on the hierarchy of CRM in order of importance - Decision Making, Leadership & Management, Situational awareness, communication (Closed loop, chunked, tone & intonation).
• Negative aspects of collective agreement
• Threat and error management
• Dunning Kruger effect
• CRM tools that Neil deploys and recommend
• Debriefing; The utility of debriefing

Some of the concepts that Neil mentions includes:

In this session we will examine the fundamentals of the pre-hospital airway from airway assessment all the way through to the difficulties posed in practice. We will also look at the management from a stepwise concept all the way through to the use of invasive surgical techniques to manage the airway. We will also examine some of the optimal methods used to monitor the respiratory effort and when and when not to intervene. We will also examine the current utility and debate around Direct Laryngoscopy (DL) and Video Laryngoscopy (VL) and whether VL is around to stay within practice. 

To do this I have with me John Chatterjee.  John is a consultant anaesthetist with an interest in pre-hospital care and difficult airway, thoracic and high-risk anaesthesia. He has worked with and educated clinicians around the world in various ambulance and hospital services including places like New Zealand, Sydney, Liberia, Ethiopia, Ukraine and in the UK where he has worked with HEMS and BASICS. John is as an anaesthetist at Guys and St Thomas', and a Consultant with London's Air Ambulance at the Royal London. In the episode we examine: 

• The challenges of the pre-hospital airway
• How to assesses the difficulty of an airway from sight and brief assessment
• Declaration of the findings and plan
• VL vs DL and where VL is going from a SOP and utilisation tool.
• Stepwise management and understanding where to come in on the management plan. 
• Assessment of respiratory effort
• Thoughts on RSI compared to retrospective practice.
• Tips on surgical airways
• Seminal airway research in the last 10 years – Impact Brain Apnoea
• Seminal cases that John has learnt a lot from 
• Final thoughts from John and take-home messages.

John mentions these two papers within the conversation:

Difficult Airway Society (DAS) 2015 guidelines for management of unanticipated difficult intubation in adults:

In this session I am speaking with Claire Park on a new primary triage tool developed by Claire and a research team. It has been accepted and agreed by NHS England for use by all UK ambulance services and prospectively by National Police and Fire Services. It has also been adopted by the UK MOD to roll out across all UK military personnel internationally.

Claire Park is a Consultant in Pre-hospital Emergency Medicine for London HEMS, and Anaesthesia and Critical Care Medicine at Kings College Hospital in London. She also is an army consultant with over 20 years of deployed military experience. Claire is the medical adviser to the Specialist Firearms teams of the Metropolitan Police Service (MPS), and has worked closely with all of the emergency services in London on developing the joint response to high threat incidents, in particular following the attacks of 2017. She is also the Chief Investigator on a UK nationally funded research grant looking at evidence for improving patient outcomes in the hot zone in major incidents and has developed relationships in this area with many members of the Committee Tactical Emergency Casualty Care CTECC over the last 4 to 5 years. In the conversation we examine:

1.  Definition of triage as a fundamental baseline.

2.  Why need for change - Current standards (START and SMART triage) and the existing and emergent needs from a triage tool.

3.  Empirical literature

4.  Changes to current practices - Challenges in design/Physiology or not physiology/Bleeding not bleeding/talking/breathing.

5.  Design considerations and the inclusion of penetrating injury.

6.  Testing of the tool 

7.  Adoption - Adoption of the tool by various institutions.

8. Improvements expected to be seen on the ground.

8.  What’s next - Future projects for Claire.