Community CPR, AEDs & Out-of-Hospital-Cardiac Arrests

The value of Bystander CPR and Public Access AED use is shown nicely in this NEJM article

http://www.nejm.org/doi/full/10.1056/NEJMoa1601891

What does this mean?

I think it means that a sensible approach to out-of-hospital cardia arrest is NOT about hospitals and helicopters (although post ROSC transport and critical care is vital!)

Rather, we need to ensure robust systems such as

– training the public in ‘hands only’ CPR

– making Public Access Defibrillators available as the norm, not the exception

– using smartphone technology to alert and crowdsource trained BLS-providers in the vicinity (such as GoodSAMapp)

– integrate such technology into existing systems

All of which is eminently do-able – and I am pleased to see that some Ambulance Services overseas and interstate have managed to do this

Hoping the remaining Ambulance Services in Australia will be able to follow suit!  Word is that New Zealand and Victorian ambulance services will be going live with GoodSAMapp.org in 2018…

 

Making Communities HeartSafe

Meanwhile at a local level I’ve been busy, along with other concerned clinicians, to ensure our local community becomes ‘Heart Safe’

The Heart Safe community concept is from the USA and again something that would seem relatively easy to apply to Australia.

We’ve pushed ahead in our small Island community to get public access AEDs into the townships, followed by tourist hotspots…..at the same time training community members in hands-only CPR.

Read more about the project at Facebook.com/heartsafeKI & twitter @HeartSafeKI – give us a follow!

Integration with smartphone apps such as GoodSAMapp is also an easy target to achieve.

And if you want to see proof that such a system works, look no further than this local success story from Kangaroo Island.

Read more about Heart Safe Communities here

Resus At The Park


Hi all
 
I know you’re in the midst of last-minute Christmas shopping and feverish planning, but I wanted to ensure that this got to you so that at least if you are sitting down over the vacation with a full stomach and a spare 5 minutes, you could perhaps forward the email onto your departments, contacts and any other colleagues who may be interested. We would like to get this out to all doctors, nurses, allied health, paramedics, first responders and anyone potentially involved in the management of patients needing resuscitation.
 
After postponing the 2016 Resus @ The Park conference because of potential health concerns (which I am happy to say are not concerning any more), [email protected] is back in 2017 and is bigger and better than planned! Not only are we raring to go to organise a stunning resuscitation conference for Sydney and NSW, but we have also had the opportunity to recruit emergency and critical nursing representatives to the conference organising committee, as well as colleagues from paramedicine.
 
[email protected] is being held to benefit Take Heart Australia, the charity we formed to decrease mortality from cardiac arrests across Australia, the only charity we know that is run solely by working clinicians, and which has garnered a lot of traction and attention in the past couple of years. We are on track to make great changes in awareness, HQ-CPR training and AED numbers across NSW and Australia, and to increase the numbers of people we see with a return of cardiac output and who may go home, rather than solely look after cardiac arrest patients whose chance has long gone.
 
We have confirmed the conference dates as the 1st and 2nd of June 2017, with a preceding workshop day on the 31st May. We plan not only to run with the conference program we already had, featuring luminaries from prehospital, emergency medicine and critical care, both local and international, but also to expand it to include more tracks, ensuring that not only is it contemporary and evidence-based, but truly multidisciplinary. We are determined to make this a state-of-the-art conference, with wide media and social media coverage, with speakers on-site and also talking from overseas via streamed video, and streaming all content out to those who are unlucky enough not to be able to attend.
 
This email has a Save The Date EDM attached to it, and I would be really grateful if you could send it on to as many people as possible. Finally, many apologies if you receive this email twice, or that you receive it out of the blue. I have tried to be accurate and not send it to the wrong people, but the pre-Christmas delirium is taking hold!
 
Grateful for your help and support, and have a very Merry Christmas and Happy New Year.
 
Thanks
Paul
Paul M Middleton
RGN MBBS DipIMCRCS(Ed) MMed(Clin Epi)
MD FRCS(Eng) FANZCP FRCEM FACEM
Chair, Take Heart Australia
Director, Emergency Medicine Research Unit, Liverpool Hospital
Clinical Associate Professor, Discipline of Emergency Medicine, University of Sydney
Conjoint Associate Professor, Graduate School of Biomedical Engineering, University of New South Wales
Principal Investigator, DREAM Collaboration
Director, Australian Institute for Clinical Education
Immediate Past Chair, Australian Resuscitation Council, NSW Branch
 

SALAD on the beach

It’s hotting up ‘down under’ and we are planning to spend summer on the beach as is traditional at Xmas/New Year.  It is going to be a hot one … Adelaide (nearest city) is supposed to be the hottest city in the world for Xmas Day!

Meanwhile plans for #DAS smacc airway workshop are shaping up for Berlin in June.  As usual the airway workshop is fully booked, but there are plans to host a series of ‘pop up’ events in some of the venues around the conference during smacc week….The SALAD sim (suction-assisted laryngoscopic airway decontamination) will feature – this is the brainchild of evil genius Jim DuCanto and has been enthusiastically adopted by many worldwide to practice management of the soiled airway.  Many of us are refining airway trainers to ensure the ‘SALAD Sim’ popups are fun and memorable for all in Berlin.

What then could be more Australian than a beach BBQ?  An esky full of beer…some ice…and SALAD?

Dr Tim’s Beer and SALAD Sim

In true summer style, I have been experimenting with a traditional beach esky – filled with ice, cold ‘Dr Tim’s’ beer and cunning use of a 12V battery and bilge pump to deliver a constant stream of simulated vomitus to the airway mannikin. The entire set up is portable – and better still, can carry beer!

Make one yourself – you KNOW you want to!

 

DasSMACC Ticket Release – 26 October 2016

das-smacc-ticket-syd-release-26-10-16The world’s best critical care conference is off to Berlin in 2016.  I’ve been lucky enough to attend SMACC events since the origin in Sydney (2013), Gold Coast (2014), Chicago (2015) and Dublin (2016).  KIdocs is proud to be a smacc-affiliated website and maintains that critical illness is an entity not bound by geography – meaning the work of the Australian rural doctor inevitably intersects with this niche.  FOAMed means there is no longer any excuse for rural docs to be up to speed with the latest in critical care, albeit limited by equipment and personnel!

SMACC has been an interesting journey for me – I’d love YOU to take part in 2017. Finally we now know what DasSMACC has in store…here are some inside tips from the SMACC organising committee that will help you prepare for the ticket release which is scheduled for Wednesday 8.00 am 26th October (Sydney Australian EST), or 22.00 London, 17.00 New York on the 25th of October for those on that side of the world.

Das SMACC Ticket Release

Delegate numbers are capped at approximately 2000 registrations again this year  as we believe this is the best  size to maintain our FOAM community atmosphere.  In an attempt to be as fair as possible here are the basics of how it will work:

  1. Registration will open on Wednesday, 26th October at 0800 Sydney EST – see here for your local time.
  2. There will be 3 separate ticket releases: the major release will be as above on Wednesday, 26th October, a smaller allocation will be released on Wednesday, 7th December and a final limited release on Wednesday, 1st February
  3. Your best chance will be with the first release, but if you really need to wait until you have leave confirmed then you can chance your hand on the February release
  4. All prior delegates will receive an email reminder the week before tickets go on sale, but there is no other preference (first in best dressed!)
  5. Owing to the limited number of spots there will be no DAY ONLY registrations issue
  6. Workshop registration also opens on Wednesday, 26th October and like last year will be on a first come first served basis
  7. If you miss out on a ticket there will be a waiting list
  8. If you miss your preferred workshop there will also be a waiting list

What ’s in the program and registration at a glance for 2016?

We have taken all your feedback into consideration and planned for:

  • Another massive day of workshops on Monday, 26th June 2017 (WORKSHOPS)
  • A single stream format only featuring the best of the best (PROGRAM)!
  • The most incredible venue: the Tempodrom
  • Fabulous accommodation deals which are essential this year as Das SMACC is just before fashion week (ACCOMMODATION)
  • Registration details are here
  • The continued innovation and convenience of onsite childcare (crèche)
  • A bigger and better SMACC party. Yes, it will be massive.

https://vimeo.com/186508216

Das SMACC – Berlin

The Social Media and Critical Care Conference continues to harness the immense energy of FOAM and dasSMACC in Berlin June 26-29 2017 promises to be the best one yet.

SMACC has seen spectacular growth since its humble beginnings. The Conference has grown from an enthusiastic idea into a global leader amongst critical care events. Whilst SMACC is primarily a high quality, academic meeting, the real reason behind this growth is the enormous and inspiring energy of the critical care community itself. A community that crosses traditional hierarchies, professional barriers and international borders. This is a community dedicated to innovation, teaching and learning. A community based around the pursuit of excellence in patient care, and a passion for sharing this as widely as possible.

What Makes SMACC Different?

So, why did the SMACC conference SELL OUT all 2000 delegate registrations in minutes?

To begin with, the affiliated websites supporting SMACC represent a comprehensive list of the “who’s who” in the FOAM world. The talented clinicians behind these websites have come together and harnessed their innovation, vitality and expertise to create the SMACC experience. The strong social media connections inherent to SMACC result in an ongoing, online conversation, which in turn, empowers the delegate and enhances their experience. SMACC is focused on being a conference truly for the delegates. Delegates have a say in every aspect of the meeting, including the speakers chosen, program topics, themes and styling, social events, and the questions asked in sessions. This level of delegate interaction with the conference is unparalleled in critical care.

There have also been many positive lessons learned from the FOAM world, which have now been translated into the SMACC Conference. Lessons on how to engage, inspire and make critical care education enjoyable. We keep the talks short (15-20 minutes), choose the topics carefully, handpick speakers who we know can both educate and inspire, and discourage reliance on power point presentations. Of course, all the sessions are recorded and podcast to be released in a FREE series – creating more great FOAM!

But SMACC isn’t just about the academic presentations. SMACC is an experience. The opening ceremony, the themes of the exhibition hall and welcome events, the teas and lunches provided in the breaks and the massive Gala night, all of which are included in the one registration price, are designed to bring the group together and enhance the feeling of belonging to one critical care
community.

Why Berlin?

Berlin is an amazing and vibrant city and has the energy capable of hosting SMACC. It is no surprise that it has become the artists’ capital of Europe. There is an intriguing combination of grittiness, openness, willingness and enthusiasm in the Berlin community, which make it a perfect destination for the FOAM community. Of course that’s to say nothing of the history, museums and bars.

Berlin is also perfectly situated in the heart of Europe to springboard any European adventure.

Portable Vomit Simulator

I’ve just got back from another Critically Ill Airway (CIA) course at The Alfred, run by intensivist Chris Nickson of LITFL.  This packed two day course is designed for anaesthetic, emergency, intensive care and rural doctors and combines a multitude of hands-on task training with immersive simulation scenarios.  Great fun and highly recommended, although heavy demand means that there is a wait list for places!

For the first time, I brought along the ‘SALAD sim’ – this is the brainchild of Milwaukee anaesthetist Dr James DuCanto; we’ve used it at smaccCHICAGO and smaccDUB airway workshops and it’s nice to see the paradigm being adopted by many enthusiasts around the globe.

Suction-assisted laryngscopic decontamination (SALAD) is a task-training technique to cope with massive emesis (whether vomit or blood).  Instructions on how to make one have been well-described by the inventor, Dr DuCanto.  See a guide here from Airwaynautics.

In past few months I’ve been looking to refine my version for easier transport and obviate problems of large pumps and power supplies.  At the Critically Ill Airway course, several people asked me how to make one.  Here’s a quick guide to parts.

The Compact Vomiquin

screen-shot-2016-10-01-at-2-12-55-pm

 

PELICAN STORM CASE IM2500

I like this case as it has wheels and a handle, making it useful for lugging around the countryside.  It contains power supply, a bilge pump, on/off switch mounted in casing, reservoir for fluid and is large enough to carry airway head and assorted airway kit.

img_3876

I’ve drilled a couple of holes in the case

(i) to accommodate a marine grade rocker on/off switch (with light)
(ii) a tank fitting to connect internal pump & hose to the airway head, via socket/collar quick connect fitting
(iii) a threaded cap port in lid to allow rapid filling of reservoir with case closed

img_3901
Port in lid for rapid “hot refill” of reservoir even when in use & lid closed

AIRWAY HEAD

I am using the Laerdal trauma head (kindly donated by Dr Andy Buck of ETMcourse.com). This head has a metal bar that can slide via the right cheek across the mouth (obviating bag-mask ventilation, supraglottic insertion and impeding laryngoscopy) and an inflatable tongue.

img_3838
I’ve kitted mine out with a cheap USB-camera on a 2m long cable, which is placed via the left nares to allow video of the oropharynx via Quicktime recording on a Macbook.

img_3861
USB camera placed in oropharynx with long cable to Macbook for video of rising tide

VOMIT RESERVOIR

Jim DuCanto uses a separate reservoir for his ‘simulated airway contaminant’.  I found that having another container to carry took up too much space, so have made a reservoir within the Pelican case using a sheet of perspex (plywood is fine) cut to shape and then secured with waterproof sealant.  Initial experiments with Sikaflex were OK from a waterproofing perspective but failed under rough handling.  I’ve now fibreglassed the divider into place, which adds to both waterproofing and strength. So far no problems with leaks despite multiple plane trips.

Internal divider for reservoir, reinforced with fibreglass
Internal divider for reservoir, reinforced with fibreglass & contains Rule 360 bilge pump

Simulated emesis can be made simply with water and food colouring – green for vomit, red for GI bleed.  One can thicken it up using xantham gum powder, but to be honest I’ve found liquid vomit teaches the skill as much as using thickened versions.  Omitting the use of xantham also saves on tedious pre-mixing and is easier on the pump!

cthqvxduaaaicpc-jpg-large
Barfume used by Sim Ninja in paramedic training (chunky vomit too)

To simulate the smell of vomit, one can either use white vinegar or add ‘Barfume’ (available online from the makers of ‘Liquid Ass’ faeces odour, this is s potent ‘simulated vomit’ odour which can be mixed in with the coloured water). Kudos to sim ninja Michael Borrowdale for this one!

Using barfume means props are small and easily packed, as opposed to having to carry around litres of white vinegar or source at destination!

PUMP & HOSE CONNECTORS

Rather than use a large grey water pump and variable control rheostat to control the flow,  I’ve found that a simple Rule Bilge Pump (360-500) is more than able to cope with pumping simulated vomit/blood.  Flow rate is adjusted by an inline valve which can be turned from full on (impressive spurting out of mouth, nose, eyes) through to intermittent bursts, down to a steady trickle or just ‘off’.

img_3894
Head connected to inline valve, which then connects rapidly to tank-fitting on case

The inline valve is connected to a simple threaded hose fitting placed in the oesophagus of the airway head and secured with a worm-screw clip.  The lungs can be left in situ, or removed and bronchi plugged with barb caps (saves on subsequent cleaning of the lungs).

img_3858

With the head stored in the Pelican case, it’s important to be able to connect/disconnect easily.  I have used standard plumbing fittings from the local hardware store.

A tank fitting is placed in a hole drilled at one end of the Pelican case and connected to the pump via flexible hose, secured with worm screw clip.  The inline valve (flow control) is then attached to the head and the whole assemblage can be attached to the tank fitting. Importantly neither head nor tank need to be rotated; the collar/cap fitting allows connection with a few turns only until tight.

POWER SUPPLY

I took advice from the local marine store and have used a 12V MotoBatt battery which can be recharged.  It’s secured in place with bungee and connected to a marine-grade rocker switch on the side of the Pelican case.  This means the vomit reservoir can be filled, the head connected and case closed – with pump turned on/off via the switch out of view.

img_3889
Less than 100 Wh – check with airlines & CASA regarding specific carriage regulations

Having portable power means I don’t have to carry cables, worry about power supply at destination nor risk electrocution.

The MotoBatt battery is able to be carried in both ‘carry on’ and ‘checked’ baggage with airlines if is considered part of installed equipment, but do check beforehand as limits may apply based on Watt/Hours (typically less than 100 Wh).  Rules regarding carriage of batteries as ‘spare’ or not connected to equipment should be checked before travel.

The Australian Government Civil Aviation Safety Authority have a ‘dangerous goods’ app for iOS, or check out the information on batteries online, as well as with individual carriers.

I make a point to disconnect the battery from switch, protect terminal, cover switches (secure in off position) and discuss with airlines/border protection if any concerns. especially as am also carrying what appears to be a human head onto the aircraft…

Put it all together and you have a portable ‘vomiquin’.  

There’s space in the box for a couple of laryngoscopes (both DL and VL), spare suckers, bougies, ETTs, syringes, Barfume, food colouring, collapsible buckets and so on.

img_4339
I have been trialling different suckers – the traditional Yankauer sucker vs open tubing vs the SSCOR Hi-D and ‘oral evacuation tool’ suckers.  Some fascinating preliminary results for flow rates of various options…

screen-shot-2016-10-01-at-3-03-38-pm
Sadly the current set up doesn’t have space for a suction unit – ideally this is available on site, but if not it will need to be carried in another bag.

img_3900

 

So – that’s it.  How to make your own vomiquin using parts in most hardware store, and which can be easily packed up and transported (just empty the vomit reservoir using suction and dispose down sink). I can generally get this set up in under five minutes and pack away in same time (provided the suction works and a sink is handy!)

Was it a success at the Critically Ill Airway course?  Judge for yourself? I think Chris Nickson’s smile says it all…

Coming next on KIDocs :

– comparison of different suction devices (Yankaeur, Hi-D, S3, tubing)

– other techniques for dealing with massive emesis (intubation in head down position to avoid aspiration, intubation in left lateral, deliberate intubation of oesophague with 9.0 ETT to divert GP bleed etc)