Against the clock

A session blog from Day 1 of State of the Art, London December 2015. See the full list

Blogger Jack Wong

Chairs:  Steve Mathieu, Rob Mac Sweeney

Learning from pre-hospital care

Mark Forrest

Summary/Key messages

Back to the past

  • Contrast to 25 years ago from personal experience – Limited understanding and guidance at the scene of RTA
  • Development of pre-hospital care overtime with sub-specialty training in emergency medicine

Clinical Issue – Same principles – different methods

  • Safety first
  • Situational awareness
  • Haemorrhage control: simple things first in trauma – direct pressure / tourniquet / haemostatic agents
  • Coagulopathy related to hypothermia and shock
  • Pre-planning
  • Keep it simple!!
  • Optimise O2 – Agree bail out / Safe Apneoa time during airway management
  • Shared mental model / Combat breathing / Team work
  • Challenge response check list – DAS 2015 vs Pre-hospital 2015


Ideas / Practice

  • Ketamine + Rocuronium + Fentanyl (oral transmucosal) for intubation
  • iGel for airway management
  • Methonyflurane – The Green Whistle for analgesic
  • ICU monitoring, telemedicine, rugged, ultrasound scanner, video-laryngoscope
  • Local anaesthetic blocks
  • Kit dump
  • Ultrasound chest assessment
  • Thoracotomy with simple toolkit

Team Issue

  • Coordination by team leader
  • Stay focus by team member


  • Be nice!
  • Life isn’t about waiting for the storm to pass. It’s about learning to dance in the rain.

Critical care in the field

Andy Johnston

Summary/Key messages

  • Critical Care starts in the ED
  • Whole hospital high fidelity simulation training
  • Front loaded expertise – Consultant Crit Care at front line

Case series:

  • Balistic injury in the young
  • Blast Injury – Butterfly lungs (haemorrhage in parenchymal) – High risk of bleeding day 1-3


  • Polytrauma
  • IED patient


Screen Shot 2015-12-09 at 08.06.06

Other problems

  • Limited supplies
  • Need for repatriation


Screen Shot 2015-12-09 at 08.06.17

It’s not just what you do, but when: Tempo, pace and sepsis

Ron Daniels

Summary/Key messages

  • Case studies – Sepsis gone wrong – Have we done enough?
  • 37000 per year mortality in the UK – ICNARC
  • Some sepsis survival get on with their daily life with normal function eg. Lily Allen
  • Cognitive impairment – 17% of moderate to severe impairment post sepsis
  • Blanket approach therapy is needed before we fully understand sepsis and host response.
  • Challenge: Grey area patient – Patient who seem well but not get picked up as having sepsis
  • Concept Red Flag Sepsis for grey area patient rather than using trial definition


Screen Shot 2015-12-09 at 08.06.26


  • Reason for delayed presentation = patient not seeking help early hence needing better public awareness and patient education

Fixing the system

  • Sepsis Six Bundle
  • Checklist helps but it is not everything
  • Using F1 pit stop as example of systematic improvement akin to sepsis managemenet bundle: Year 1950 1 minute vs Year 2013 3 seconds

Are you sepsis Savvy?

  • Value of POC lactate, CRP, PCT especially for primary care.
  • Future aim to reduce mortality.