Veterinary High-Stakes Immersive Simulation Training With Repeat Practice Following Structured Debriefing Improves Students' Ability to Cope With High-Pressure Situations.

INTRODUCTION: Immersive simulation is used increasingly in medical education, and there is increasing awareness of the impact of simulation scenarios on emotional state and cognitive load and how these impact learning.1 There is growing awareness of the requirement to equip veterinarians with skills for managing high-pressure environments and provide training on human factors. METHODS: Veterinary students participated in a high-fidelity immersive simulation of a road traffic collision involving multiple casualties. The students took part in the same simulation twice, the second time after a debrief. Each participant's emotional state and cognitive load were assessed after participating in each simulation. Each participant was asked to score the effect of pressure on their performance. RESULTS: One hundred twenty-five students participated and demonstrated a higher cognitive load with more positive emotional states during the second scenario after the completion of a structured debrief and discussion focusing on pressure relief techniques (cognitive load - ¯µ Scenario run 1 = 4.44 ± 1.85 [SD], ¯µ Scenario2 = 5.69 ± 1.74 [SD]). Most (63%) participants described being in a low-performance state of frazzle during the first scenario compared with most (61%) who described being in a high-performance state of flow during the second. CONCLUSION: Immersive simulation scenarios, with structured debriefing, may allow the measurement of emotional state and cognitive load in participants. Furthermore, this study suggests that curriculum training in human factors and pressure relief techniques, coupled with immersive simulation and debrief, may improve future performance in high-stakes and high-pressure scenarios.

Prehospital critical care is associated with increased survival in adult trauma patients in Scotland.

BACKGROUND: Scotland has three prehospital critical care teams (PHCCTs) providing enhanced care support to a usually paramedic-delivered ambulance service. The effect of the PHCCTs on patient survival following trauma in Scotland is not currently known nationally. METHODS: National registry-based retrospective cohort study using 2011-2016 data from the Scottish Trauma Audit Group. 30-day mortality was compared between groups after multivariate analysis to account for confounding variables. RESULTS: Our data set comprised 17 157 patients, with a mean age of 54.7 years and 8206 (57.5%) of male gender. 2877 patients in the registry were excluded due to incomplete data on their level of prehospital care, leaving an eligible group of 14 280. 13 504 injured adults who received care from ambulance clinicians (paramedics or technicians) were compared with 776 whose care included input from a PHCCT. The median Injury Severity Score (ISS) across all eligible patients was 9; 3076 patients (21.5%) met the ISS>15 criterion for major trauma. Patients in the PHCCT cohort were statistically significantly (all p<0.01) more likely to be male; be transported to a prospective Major Trauma Centre; have suffered major trauma; have suffered a severe head injury; be transported by air and be intubated prior to arrival in hospital. Following multivariate analysis, the OR for 30-day mortality for patients seen by a PHCCT was 0.56 (95% CI 0.36 to 0.86, p=0.01). CONCLUSION: Prehospital care provided by a physician-led critical care team was associated with an increased chance of survival at 30 days when compared with care provided by ambulance clinicians.

Epidemiology and location of primary retrieval missions in a Scottish aeromedical service.

INTRODUCTION: Prehospital critical care teams comprising an appropriately trained physician and paramedic or nurse have been associated with improved outcomes in selected trauma patients. These teams are a scarce and expensive resource, especially when delivered by rotary air assets. The optimal tasking of prehospital critical care teams is therefore vital and remains a subject of debate. Emergency Medical Retrieval Service (EMRS) provides a prehospital critical care response team to incidents over a large area of Scotland either by air or by road. METHODS: A convenience sample of consecutive EMRS missions covering a period of 18 months from May 2013 to January 2015 was taken. These missions were matched with the ambulance service information on geographical location of the incident. In order to assess the appropriateness of tasking, interventions undertaken on each mission were analysed and divided into two subcategories: 'critical care interventions' and 'advanced medical interventions'. A tasking was deemed appropriate if it included either category of intervention or if a patient was pronounced life extinct at the scene. RESULTS: A total of 1279 primary missions were undertaken during the study period. Of these, 493 primary missions met the inclusion criteria and generated complete location data. The median distance to scene was calculated as 5.6 miles for land responses and 34.2 miles for air responses. Overall, critical care interventions were performed on 17% (84/493) of patients. A further 21% (102/493) of patients had an advanced medical intervention. Including those patients for whom life was pronounced extinct on scene by the EMRS team, a total of 42% (206/493) taskings were appropriate. DISCUSSION: Overall, our data show a wide geographical spread of tasking for our service, which is in keeping with other suburban/rural models of prehospital care. Tasking accuracy is also comparable to the accuracy shown by other similar services.

Comparison of factors associated with desaturation in prehospital emergency anaesthesia in primary and secondary retrievals.

OBJECTIVE: To investigate the incidence and factors associated with desaturation related to emergency intubations within an aeromedical retrieval service pertaining to both primary prehospital and secondary interhospital missions. METHODS: A retrospective analysis of all rapid sequence intubations (RSI) was performed by the Emergency Medical Retrieval Service over a 4.5-year period (June 2008-November 2012). For each RSI, clinical indication for RSI, age, sex, traumatic or medical diagnosis, team leader specialty, Cormack and Lehane (C-L) grade of laryngoscope view, attempts at intubation, desaturation and hypotension was analysed. A multiple logistical regression analysis was constructed using the factors identified in the univariate logistical regression using a backward stepwise model. RESULTS: During the study period, a total of 1423 missions were carried out. 1088 of these missions were secondary retrievals and 335 were primary prehospital missions. 208 patients required RSI during the study period. Our data show that 15.4% of all anaesthetised patients had a desaturation during emergency anaesthesia. This included 11.3% of primary prehospital patients and 16.8% of secondary retrieval patients (95% CI -5.0% to 15.8%). 7.9% of patients had an episode of hypotension during RSI. Univariate associations for desaturation were more than one attempt at intubation and a C-L grade III or worse view. Multivariate analysis showed only C-L grade III or worse view as an independent risk factor for desaturation. CONCLUSIONS: Desaturation was not more common in secondary retrieval patients. Multiple attempts at intubation and a poor laryngoscopic view at intubation were associated with desaturation during RSI.

Use of prothrombin complex concentrates: 4-year experience of a national aeromedical retrieval service servicing remote and rural areas.

INTRODUCTION: Prothrombin complex concentrates (PCCs) are recommended as first-line treatment for acquired or congenital factor II, VII, IX and X deficiencies in situations of major haemorrhage. The Emergency Medical Retrieval Service (EMRS) provides critical care and aeromedical retrieval to patients in remote and rural Scotland. It has an important role in the care of these patients. METHOD: We sought to determine the incidence of haemorrhage requiring PCC administration in our cohort of patients, and to assess compliance with current national guidelines regarding their storage and use. We searched our database for all patients that received PCCs, or met current guidelines for their administration, and followed them through to hospital discharge. We also conducted a telephone survey of all hospitals served by the EMRS to determine compliance with national standards. RESULTS: During the 42-month study period, 1170 retrieval missions were conducted. Twenty-six retrieved patients had a congenital or acquired clotting factor deficiency and seven met criteria for PCC administration. Of these, only three received PCCs prior to transfer to definitive care. Telephone survey revealed that all the rural general hospitals were served by the EMRS stock PCCs, but only one out of 15 GP-led community hospitals had access to PCCs. CONCLUSIONS: In the remote and rural setting where access to definitive care may be limited or delayed, timely administration of PCCs in appropriate patients may improve outcomes. As many rural hospitals do not have access to PCCs, the ability of the EMRS to provide this treatment may improve patient care.

Performance measurement in British Helicopter Emergency Medical Services and Australian Air Medical Services.

BACKGROUND: Performance outcome measures are an essential component of health service improvement. Whereas hospital critical care services have established performance measures, prehospital care services have less well-established outcome measures and this has been identified as a key issue for development. Individual studies examining long-term survival and functional outcome measures have previously been used to evaluate prehospital care delivery. There is no set of standardised patient outcome measures for Helicopter Emergency Medical Services (HEMS) in the UK or Air Medical Services (AMS) in Australia. The aim of this study is to document the patient outcome measures currently in use within British HEMS and Australian AMS. METHODS: This is an observational study analysing point prevalence of practice as of November 2009. A structured questionnaire was designed to assess the method of routine patient follow-up, and the timing and nature of applied patient outcome measures. RESULTS: Full responses were received from 17/21 (81%) British services and 6/7 (86%) Australian services. The overall response rate was 82%. CONCLUSIONS: HEMS in Britain and Australian aeromedical retrieval services do not have uniform patient outcome measures. Services tend not to follow-up patients beyond 24 h post transfer. Patient outcome data are rarely presented to an external organisation and there is no formal data comparison between surveyed services. Services are not satisfied that the data currently being collected reflects the quality of their service.

On-scene times and critical care interventions for an aeromedical retrieval service.

BACKGROUND: The Emergency Medical Retrieval Service (EMRS) provides an aeromedical retrieval service to remote and rural communities. Most of these facilities are unable to deliver Critical Care Interventions (CCI). CCI are delivered by the EMRS team prior to transfer of the patient to definitive care. This study addresses correlation between total on-scene times (TOST) and level of intervention delivered, and whether there is any variation in TOST between medical and trauma emergencies. METHODS: Prospective data were collected on EMRS secondary retrievals over a 5-year period from GP-led facilities. Data were collected on the CCI undertaken by EMRS during TOST prior to transfer of the patient. Interventions undertaken were scored using TISS-76. Correlation was analysed using Spearman's coefficient and differences between groups analysed using Mann-Whitney tests. Statistical significance was defined as p<0.01. RESULTS: EMRS retrieved 308 patients suitable for inclusion. Complete data were available for 97% of patients (n=300). Underlying diagnosis was trauma in 26% (n=72) and medical in 74% (n=228). There was a significant correlation between TOST and TISS-76 for all EMRS patients. Spearman's coefficient of rank correlation was (ρ)=0.616 with p<0.0001. The median TOST for the medical group was 60 min and for the trauma group 60 min (point estimate for difference 0 min, 95% CI 10 to 10, p=0.951). CONCLUSION: This study demonstrates a significant relationship between TOST on-scene by the retrieval team and the level of intervention delivered to patients. The present data do not support the assertion that there is a difference in TOST for medical and trauma patients.

The UK helicopter ambulance tasking study.

INTRODUCTION: Helicopter ambulances are a scarce and expensive resource and their use carries significant risk for crew and patients. AIMS: To establish and compare the tasking criteria, dispatch arrangements and crew configuration for all helicopter ambulance services in the United Kingdom. METHODS: Structured telephone interview of all helicopter ambulance services in the United Kingdom. RESULTS: Replies were received from all 16 UK air ambulance services. Crew configuration varies between services. Nine services had paramedic only crew, 3 had physician/paramedic crew and 4 had a paramedic crew with variable physician input. Only 2 of the 16 services used a paramedic in the dispatch process. There were 67 different tasking criteria used for air ambulance dispatch across all air ambulances with a range from 4 to 23 for individual air ambulance services. CONCLUSION: Given the financial burden and physical risk of air ambulance use, there should be a more standardised approach to the tasking, dispatch and crew configuration of air ambulances in the UK.

Spinal injuries in Scottish mountaineers.

OBJECTIVE: To identify the frequency and pattern of spinal injury sustained in mountaineering accidents. METHODS: All patients with spinal injuries sustained while mountaineering who were treated at the Queen Elizabeth National Spinal Injuries Unit from 1992 to 2001 were studied. Information was obtained from hospital notes, and each patient completed a questionnaire. RESULTS: Twenty-one patients with spinal injuries sustained in mountaineering accidents were identified. Fourteen patients (67.7%) were experienced mountaineers. Four (19.0%) were rock climbing, 6 (28.6%) were winter climbing, 6 (28.6%) were hill walking, and 5 (23.8%) were winter walking. Ten patients (47.6%) sustained cervical injuries, 5 (23.8%) sustained thoracic injuries, 5 (23.8%) sustained lumbar injuries, and 1 (4.8%) sustained cervical and lumbar injuries. Nineteen patients (90.5%) sustained fractures, 1 (4.8%) sustained a dislocation, and 1 (4.8%) sustained a fracture dislocation. Seventeen patients (81.0%) were neurologically intact, 2 (9.5%) sustained complete cord injury, and 2 (9.5%) sustained incomplete cauda equina lesions. Ten patients (47.6%) required internal fixation of their fractures. Fourteen patients (57.1%) sustained other significant injuries. CONCLUSIONS: This is the first study specifically aimed to describe patterns of spinal injuries and their outcomes in mountaineers. The group we studied had sustained fractures at differing spinal levels with no specific injury pattern. The incidence of cord injury was lower than in other spinal injury patient groups. The majority had also sustained other significant and potentially distracting injuries. Prehospital care providers should maintain a high suspicion of spinal injury in this group.