Trauma Care questions current practice, engages in debate and looks to the future

The 16^th International Trauma Care Conference took place at the Park Inn Hotel, Telford, Shropshire, between 18–24 April 2015. The conference 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 5 days featuring three conference programmes running each day. The paramedic programme ran on Monday 21 April and the trauma care conference chair for this programme was flight sergeant Andy Thomas, who reports on the day's presentations, key debates and conference take-home messages.

Proceedings began with Dr Marietjie Slabbert delivering a talk on the topic ‘Risky Business: Zen-like strategies in trauma care’. Slabbert recalled her first pre-hospital care experience in South Africa as a very junior doctor, when she was woken in the night by a loud bang from the road outside. She described how woefully ill prepared she was in dealing with multiple seriously injured patients outside the hospital, and gave a gripping and heartfelt account of the emotions and isolation you can experience in pre-hospital care. It was this experience, in addition to being well practised in pre-hospital care around the world, that led her to develop a six step Zen-like strategy to manage pre-hospital care. Step one is to pause and breathe, by doing this you can safely assess the situation and understand your priorities. Step 2 is to control your environment and to not let it control you. Step 3 is to have a reason for what you do and to question current (outdated) practice. This was supported by the Zen proverb: ‘Knowledge is learning something every day, while wisdom is letting go of something every day.’ Step 4 follows the expression 1+1=∞. Within pre-hospital care this alludes to how you must think outside the box and maximise your resources. Step 5 is all about the patient, emphasising that they are the centre of the universe and how all involved in pre-hospital care should leave egos at home. Finally, step 6 follows the adage: ‘Even after enlightenment you still have to do the laundry.’ The speaker touched on areas such as CPR in traumatic arrests, use of collars and some of the general dogma around outdated practice, thus setting the scene for the remaining speakers to explore the detail and evidence further.

Next up, the conference chair spoke about traumatic cardiac arrest (TCA). Thomas used a blend of lessons learned from unexpected survivors on military operations, the excellent work in the UK from teams such as London HEMS, and touched on the scoop of more specialist paramedics such as advanced, critical care and trauma paramedics. He blended military and civilian case examples, and proposed a TCA survival triangle of sustain, slice and survive. He suggested that outwith of specialist teams and advancing paramedics, those paramedics who first arrive on scene have a key role to play in sustaining patients prior to the arrival of increased levels of care. This key role 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. Thomas highlighted the importance of providing adequate but not over ventilation, and how adrenaline should not be used routinely, as in trauma the patient would have already maximised individual catecholamine release. By embracing these simple steps, requesting advanced teams carrying blood and having the skills to provide critical surgical interventions, these patients can be sustained. Slice refers to the critical surgical interventions teams like MERIT and HEMS bring to the patient, and thus improving the patient's chance of a positive outcome. This would include finger thoracostomies and resuscitative thoracotomy when indicated, which are procedures that require a surgical slice. By working together to each individual's skill level and reversing the cause, it is possible to sustain, slice and survive.

Next to the podium was senior aircrew paramedic Andy Mawson from the Great North Air Ambulance Service (GNASS). Mawson challenged the concept that a standard NHS response is insufficient in trauma. With an ever-expanding range of ambulance response including private and volunteer aid societies in trauma, he asked whether we really know who comes. He recalled his first experience as a road paramedic when dealing with helicopter crews and described it as less than positive due to his own attitude that ‘everyone can do this’. This has now changed and he 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 emphasised that it is not about clinicians but about the patient, and maximising that patient outcome. Through a blend of enhanced care, advancing pre- hospital interventions and the carrying of blood on board, GNASS and other HEMS services are vital in continuing the upward trend of patient outcomes in pre-hospital trauma. Nationally, work must continue to ensure the service achieves this standard 24/7 for all within the UK.

Next up was Prof Sir Keith Porter, who talked on ‘spinal immobilisation, and changing with tradition’. Sir Keith started the presentation with an image of a patient being lifted by his feet by one person and by his arms by another. He stated if this patient had a spinal injury and was moved this way he would unlikely come to any harm from the movement. He gave background biomechanics, discussed the forces involved and stressed in the spinal injured patient movement within the normal range without excessive force involved will not result in further injury. Sir Keith presented some of the disadvantages of immobilisation including pain, reduced respiration, increased intracranial pressure (ICP) and general patient distress, supported by a wide range of studies. Robust evidence was provided that during extrication, if the patient is able then the patient can self extricate, independently, and this has been proving to provide the least movement. The patient can then be immobilised at this stage. 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 double in mortality rates. The use of cervical collars was touched on and Sir Keith concluded these are not necessary in pre-hospital care, stating: ‘I'd rather invest in a beer than a cervical collar.’ This concluded the morning session and left delegates with a lot to discuss over lunch prior to the next talk, which would look further into the collar debate.

Following lunch, Andy Rosser, a paramedic with the West Midlands Ambulance Service NHS Trust (WMAS), presented a talk on cervical collars which questioned whether they should stay or go. He presented a large amount of evidence, pointing out the many risks of cervical collar use. Rosser expanded further by presenting studies on ICP, which highlighted that there was a significant rise in ICP following the application of a collar, but if removed this would normalise to pre-test levels within 5 minutes. 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 no evidence against a growing wave of evidence against its use. Draft guidelines from the International Liaison Committee on Resuscitation have also noted that the routine use of cervical collars cannot be supported. The challenge for paramedics remains the interface with emergency departments. As noted within the presentation, hospital-based emergency physicians may be behind the evidence, which can cause friction between the paramedic and the doctor on handover. The take-home point from the two consecutive presentations at this conference is that patients should not be arriving at hospital with a collar in situ as the cause for harm does not justify its use.

Paul Younger spoke next, an advanced paramedic with the North East Ambulance Service NHS Foundation Trust (NEAS) and a member of the Trust's cardiac arrest response unit (CARU). Younger guided the delegates through the work conducted, which highlighted increased survival rates in a paramedic-led system delivering advancing procedures such as pre-hospital ultrasound, advanced airway management, and definitive post-resuscitation care including inotropes and post-ROSC sedation when required. The team is exposed to regular training and checks and it takes about a year to complete the necessary training and mentorship. A further point was considered of whether it is time ROSC patients are taken direct to specialist cardiac arrest centres, similar to the major trauma centre concept in trauma, as opposed to the nearest hospital. Some thought-provoking points were raised and delegates asked how this could be rolled out for all patients and not just restricted to small areas in a postcode lottery.

Chris Jones, a senior paramedic lecturer with Teesside University, presented a talk on how to prepare the 21^st century paramedic. He gave an insightful look at the 3-year BSc (Hons) programme and how the university no longer simply trains paramedics for NHS practice, instead preparing them for a wide range of employment opportunities. The biggest surprise came when Jones asked whether paramedics should be degree trained and less than 20% of the audience agreed. This came as an unexpected shock and something the College of Paramedics may want to investigate further, or support a campaign to highlight the potential benefits.

The final speaker of the day was Michelle Sanderson, a former military paramedic living with PTSD. Sanderson gave an emotional personal account of her journey, while trying to highlight key signs and methods to spot concerns within NHS environments. This was well received by delegates and a beneficial note to finish the programme on.

The day ended with an open delegate and Twitter Q&A session, where many of the topics raised throughout the conference were discussed.