The latest in Trauma Care

The 16th International Trauma Conference took place at the Park Inn Hotel, Telford, Shropshire, on the 18-24 April 2015. This included first aid, and community first responder days in recognition of the key roles these two groups play in patient outcomes within the community. This was then followed by five days with three conference programmes running each day. The paramedic programme ran on Monday 21 April.

Risky business
Dr Marietjie Slabbert kicked things off with her talk, ‘Risky Business: Zen like strategies in trauma care’. With pre-hospital experience from around the world she described how it all began with her first pre-hospital care experience. Whilst a very junior doctor in South Africa, she describes been woken in the night by a loud bang from the road outside and how woefully ill-prepared she was in dealing with multiple seriously injured patients outside the hospital and gave a gripping and heart felt account of the emotions, and isolation you can experience in pre-hospital care.
    
It was this experience, in addition to being well practiced in pre-hospital care around the world, that lead her to develop a six step Zen like strategy to manage this unpredictable environment.

Firstly, Step One is pause and breathe, which allows a safe assessment of the task in hand, followed by Step Two – control your environment, don’t let it control you. Step Three is have a reason for what you do: Question current (out dated) practice, which was supported by the Zen proverb of ‘knowledge is learning something everyday, whilst Wisdom is letting go of something everyday’ and reflects the increased pace at which we must continue to change to improve patient care.
    
Step Four revolves around the concept that one + one = infinity, encouraging people to think outside the box and reach for the sky. Step Five maintains that the patient is the centre of the universe no one else, whilst Step Six reminds us to do the laundry even after enlightenment.
    
The speaker touched on areas such as CPR in traumatic arrests, use of collars and some of the general dogma around outdated practice, thus setting the scene for the remaining speakers to expand.

Traumatic cardiac arrest
Next up the conference chair spoke about Traumatic Cardiac Arrest (TCA). Using a blend of lessons learned from unexpected survivors on military operations, excellent work from enhanced UK teams such as HEMS, whilst noting the key role more specialist paramedics such as advanced, critical care and trauma paramedics have in outcome. With the use of case examples, Porter proposed a TCA survival triangle of Sustain, Slice and Survive. He focused on the non specialist paramedics who arrive on scene first as part of a standard response and the key role needed in sustaining patients prior to the arrival of increased levels of care.
    
This included priority to addressing the reversible causes of the TCA, empowering the first paramedic on scene not to let external chest compressions (ECC), prevent life saving treatment especially in hypovolaemia, tension pneumothorax and cardiac tamponade as they would be ineffective without prior interventions. Provide adequate but not over ventilation and not using adrenaline routinely, as in trauma the patient would have already maximised individual catecholamine release.
    
Slice referred to the critical surgical interventions that teams like MERIT and HEMS bring to the patient, who thus improve the patients chance of a positive outcome. This would include finger thoracostomies and resuscitative thoracotomy when indicted. By working together to each individuals skill level and reversing the cause it is possible to sustain, slice and survive.

NHS response
Andy Mawson from the Great North Air Ambulance Service (GNASS) challenged the concept that a standard NHS response is insufficient in trauma. He raised concerns about the variant ambulance response including private and volunteer aid societies in trauma, and whether we really know ‘who comes’. Mawson presented a passionate case to the delegates that we must accept our limitations and call for expert help in trauma situations. This was the third speaker in a row who noted it’s not about clinicians, but moreover about the patient and maximising that patient outcome.

Through a blend of enhanced care, advancing pre-hospital interventions and the carriage of ‘blood on board’, GNASS and other HEMS services are vital in continuing the upward trend of patient outcomes in pre‑hospital trauma and nationally work must continue to ensure the service achieves this standard 24/7 for all within the UK and reduce the post code lottery.
   
Professor Sir Keith Porter spoke about ‘spinal immobilisation and changing with tradition’. Sir Keith provided background biomechanics, discussing the forces involved and stressed that for the spinal injured patient, movement within the normal range without excessive force involved will not result in further injury. He further discussed some of the disadvantages of immobilisation including pain, reduced respiration, increased ICP and general patient distress supported by a wide range of studies. Extensive evidence was provided that during extrication if the patient is able then the patient can self extricate independently which is the best and safest option. The patient can then be immobilised once this has been done.
    
The need for tissue and global oxygenation to prevent hypoxia is key in improving patient outcomes and spinal immobilisation in penetrating trauma is associated with a two fold in mortality rates. The use of cervical collars was touched on and Porter concluded that these are not necessary in pre-hospital care, whilst stating: “I’d rather invest in a beer than a cervical collar.” This concluded the morning session and left delegates with lots to discuss over lunch prior to the next talk, which would look further at the collar debate.

The collar debate
Andy Rosser, a paramedic with the West Midlands Ambulance Service (WMAS), presented a talk on ‘Cervical Collars: Should they stay or should they go?’ He explored the evidence again, pointing out the many risks of cervical collar use including all those discussed by Sir Keith.
    
Rosser expanded by presenting studies showing how the use of collars can increase intracranial pressure in the head injury patient. This argument further compounded the opinion that cervical collars do more harm than good, and although we have limited level 1 or 2 evidence, the existing evidence points to harm. In context, the use of collars appears to be historic dogmalysis, based on little evidence against a growing wave of evidence against its use. ILCOR draft guidelines have also noted that the routine use of cervical collars cannot be supported. You are now less likely to see people in collars, but it may take more time to see all adopting such practices as the collar is engrained, and almost expected by the public.
    
Paul Younger, an advanced paramedic with the North East Ambulance Service (NEAS) and a member of the trusts cardiac arrest response unit (CARU), guided the delegates through the work being conducted which highlighted increased survival rates in a paramedic lead system. This delivers advancing procedures such as pre-hospital ultrasound, advanced airway management, and definitive post‑resuscitation care including inotropes and post ROSC sedation when required. He also debated the concept of specialist cardiac arrest centres, similar to the Major Trauma Centre concept in trauma, and how they could improve the outcomes of those who survive the pre‑hospital arrest. Some thought provoking points and similar schemes are being used around the country, but as yet its not universally available.

The modern day paramedic
Chris Jones, a senior paramedic lecturer with Teesside University, presented how we prepare the 21st Century paramedic. He gave an insightful look at the three year BSc (Hons) programme and how they no longer just train paramedics for NHS practice with such a wide range of employment opportunities.  
    
The biggest surprise came when Jones asked whether paramedics should be degree trained, and less than 20 per cent of the audience agreed. This was an unexpected response and may be something that the College of Paramedics may want to investigate further, or support a campaign to highlight the potential benefits of higher education to improve the profession.
    
The final speaker of the day was Michelle Sanderson, a former military paramedic living with PTSD. Sanderson gave an emotional and personal account of her journey, whilst trying to highlight key signs and methods to spot concerns within NHS environments, which was well received by all delegates. Watching out for key symptoms in colleagues, whilst demands on paramedics is ever increasing was a beneficial note to finish the programme on.

Further information
www.traumacare.org.uk/conference