The Beating Heart of South American Ambulance Care

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By Declan Heneghan, Editor
Published in Ambulance Today, Issue 4, Volume 15, Memoriam Edition, Winter 2018

My fact-finding visit to Quito, capital of Ecuador and home of ISTCRE and CREMYAP took place over Easter, an important time in the South American calendar, since the region is still predominantly and passionately Catholic. My travelling companion was my 15-year-old son, Isaac. Our mission during our week-long visit was to learn more about the workings and mission of ISTCRE, South America’s biggest and best paramedic training organisation, and its off-shoot, CREMYAP, which now leads the way in developing prehospital clinical research across the region. Witnessing ambulance delivery in a country where resources are scarce reminded us that the best people in ambulance are those working in the harshest conditions, facing the most difficult challenges. Along the way we fell in love with a country whose ambulance people possess a spirit as rugged and beautiful as its imposing volcanic Andean landscape.

First Impressions

We landed in the Pichincha province in the Northern Sierra region of Ecuador during the late afternoon on Holy Thursday. We were met by our hosts, Dr Mauricio León, Director of International Relations (and one of the founding team of ISTCRE) and Iván Moya, their International Relations Representative and also a working paramedic.

During the half-hour drive through La Sierra, the Andean highland region of Ecuador, into the centre of Quito we were struck by the sheer beauty of the towering snow-capped volcanic mountain ranges that surrounded us on either side. Despite the fact that the weather was cloudy, rainy and exceptionally grey it was breath-taking. Exhausted, we booked into our hotel and went straight to bed.

Good Friday Daytime: Crowds, Religious Spectacles and Sun-Burn

We awoke on Good Friday to be met with bright Spring sunlight. Our host, Mauricio León, met us after breakfast. We were to spend the day observing Cruz Roja providing medical cover for the second biggest annual public festival in Ecuador, Quito’s Jesús del Gran Poder, or “Jesus of Great Power” procession, which over five decades has grown into one of the largest and most colourful Roman Catholic Holy Week events in Latin America.

Attracting over 300,000 visitors from all around the country and beyond, the procession celebrates the Agony of Christ and consists of around 40,000 participants, most clad in purple silk robes, who proceed from the Basilica in the Old Town to the city’s most impressive cathedral, San Francisco, situated in a vast square, reminiscent of the Vatican.

Many of the participants carry staggeringly heavy crucifixes, others wear barbed-wire which cuts into their naked skin, while still others flagellate themselves as they proceed through the Old Town’s steep and narrow cobbled streets to the echoes of scratchy religious music which blare out of randomly-placed speakers scattered along the route.

Remarkably though, participants pay a fee of between $15-30 US dollars for the privilege of putting themselves through this ordeal which, to put it into context, is a week’s wages for some locals. Those who crowd the pavements to watch the procession treat the day as a jolly Bank Holiday festivity, bringing hampers or buying snacks off the numerous street vendors who jostle for position on every street corner.

ISTCRE’s role involved supplying a number of Command & Control units and other EMS vehicles carefully positioned at key points on the route and providing a couple of hundred fully trained paramedics or volunteer medics who keep an eye on the ever-increasing crowds for those who faint, suffer sun-stroke, sprain an ankle or worse yet, are unfortunate enough to find that today is the day for their long overdue but unexpected cardiac arrest.

As Maurice explained when we arrived at the Basilica where the main unit was stationed: “Our main concentration is on hydration so throughout the route we position booths which gave away free bottles of water.”

The Basílica del Voto Nacional where the main unit was stationed

In fact, despite the massive crowds the day mainly consisted of treating sprained ankles and dispensing water. Thankfully no serious crimes or medical incidents occurred so the Cruz Roja team could pack up and go home for a rest before preparing for an equally busy evening. Our memory of the day was of the colour, the friendly atmosphere, the sheer exuberance of the crowds and the cheerful efficiency of the Cruz Roja team along the route.

Along the way we fell in love with a country whose ambulance people possess a spirit as rugged and beautiful as its imposing volcanic Andean landscape.

As we followed Maurice and Ivan around the route we were spell-bound by the sights and sounds, particularly some of the colourful, intricate and huge religious icons festooned with flowers which were carried on the shoulders of teams of up to 20 people depicting Christ or the Virgin Mary.

Good Friday Night: Ride-Along from the Inca Station

After a couple of hours rest and a light dinner Ivan picked us up from our hotel and took us to one of Quito’s two main ambulance stations, the Inca base station on Avenue 6th Decembre in the North of the city; based within a socially mixed neighbourhood, it serves some of the poorest and most troubled communities on the fringes of the city, both economically and socially.

At the Inca base station

Normally housing two ambulances, one of which is a specially-equipped rescue vehicle used particularly when tourists or locals get lost in the surrounding mountain ranges, the Inca station is usually manned by around 10 people per shift, consisting of a mix of qualified paramedics and volunteers—usually ISTCRE paramedic trainees at various stages of their training—it’s modestly scaled with two of those personnel manning a dispatch desk in the corner of the small recreation room while the others either sleep in an adjacent dormitory or drink coffee and watch TV in the same neat and cosy but simply decorated room. But like every ambulance station the world over, all the clinical personnel remain poised to dash to their ambulance the moment a call is taken.

Recognising that Isaac was slightly too young to either go out on-vehicle or stay on his own at the hotel the charming young females in the team quickly took him under their collective wing, inviting him to play cards and making sure that he had a sleeping bag and a pillow ready for when he decided to get his head down for the night.

The wide age range of the team was immediately noticeable, as was the fact that the youngest members were not necessarily the most inexperienced. For example, Gabriel Chapaca, just 20, had qualified as a full paramedic at just 19, while Stalin Landazuri, 44, was a full-time teacher and a psychology counsellor who has been volunteering 1-2 days per week with Cruz Roja for over a decade.

Married to Veronica and with 4 daughters, Stalin is trained to the level of Advanced Search & Rescue skills and happily joked to me that as the sole male in a noisy household of women he looked forward to his night-time voluntary work as a means of getting some “peace and quiet”.

Pleasingly though the gender balance for the shift favoured females, with both dispatchers, Gabriella Franco (24) and Fanny Angelita Inlago (22) and five of the clinicians being women—Vanessa Pallo (21), Denise Vielardo (23), Carolina Jacho (24), Ivonne Quinones (25) and Belen Candela (27).

Between them they ranged from ‘Assistants’, students in the first couple of semesters, up to ‘Advanced’, those such as Belen and Denise who were nearing the end of their course and were due to qualify as registered paramedics.

Leading the team for the night was our friend and escort, Ivan, whose job it was to introduce us to the crew. As Isaac and I were already learning, the two features which distinguished staff, trainees and volunteers across ISTCRE and the wider Cruz Roja family were their boundless good cheer and their amazing enthusiasm for saving lives and improving their life-saving medical skills.

This baby-faced paramedic could, I considered, give Lewis Hamilton a run for his money. Though I doubt that Mr Hamilton would have been capable of getting the ambulance safely to its destination so quickly.

Freddy Baque, a 30-year-old fully- qualified paramedic with the Rescue team explained that he’d begun his relationship with Cruz Roja as a 15-year-old volunteer and was proud to be among the first cohorts of fully-qualified paramedics trained by ISTCRE during its start-up period.

The other senior member for the shift was Edwin Davila, an ISTCRE training professor and also a coordinator with CREMYAP. It struck me as impressive that a course instructor was working on shift with his pupils.

While waiting for the first call of the night Edwin explained the pattern of responses dealt with from the station. As always weekends were busiest but, overall, the surprising thing was how relatively few calls came in.

Six to eight calls on a night shift were considered busy. When I explained to him that UK city-centre crews might handle over 30 calls during a 12 hour shift he was taken aback but explained that since the local population was still not used to having a free ambulance service they rung it only when they considered they had a genuine emergency.

Oh, for such courtesy!

Some of the calls were referrals from the police after, for example, an RTC. Before ISTCRE introduced their service only 4% of patients arrived at hospital by ambulance and these would be wealthier citizens signed up to a private ambulance service. Now 68% of all patients arriving at the ED were transported by Cruz Roja.

The goal, he explained, was that within five years, 90% of all patients would be transported by Cruz Roja. In terms of numbers last year Cruz Roja responded to 5,480 patients, of which only 80% were transported to Quito’s eight public hospitals and 20 clinics after examination.

The prediction for 2019 is that they will respond to 8,000 calls – an increase in call volume of 32%. The big question, he pointed out, is: where will the additional funding come from?

And in terms of those families fortunate enough to subscribe to a private ambulance service what was the average unit cost per transport, I inquired? Around $20 US dollars.

Now, while this may seem cheap to a North American or European person, to put this into context, this is a city where a cab will take you across its entire centre in rush-hour for just $2 US dollars and the average weekly wage for unskilled workers is only about $50.

Last but not least in the team was Daniel Robalino (22) who had qualified as a paramedic the previous year and who was one of two drivers for the night. As I found out later, Daniel was the most skilled ambulance driver I’ve ever spent a shift with. As predicted by Edwin the night was indeed typical.

After a couple of hours’ much-needed rest in the dark dormitory on a very comfortable bed we were roused by Gabriella for our first call. Driven by Daniel, with Ivan acting as lead and Vanessa on-board we were called to an elderly female (80) with hypertension and high blood pressure who’d been seen earlier that day by her doctor.

After a careful examination by Ivan, which included testing blood pressure, heart rate, blood oxygen levels and pupil reaction, it was determined that her condition was caused by a recent change in medication and that she was in no immediate danger. The patient wasn’t transported.

Had she been in Copenhagen, Amsterdam or London she undoubtedly would have been—if only to ensure that the crew were adhering to standard European protocols, which I sometimes feel are designed to avoid blame for the ambulance service, rather than considering the patient’s comfort and best interests.

But as Vanessa explained to me, recognising how scant their actual paramedic and vehicle resources are, ISTCRE-trained paramedics, many of whom have volunteered with Cruz Roja since early adulthood, are taught to both respect the patient’s needs but to also bear in mind that the next call may be more urgent and, if possible, the ambulance and crew should be free to respond.

The next call came in soon after our return to base. By now it was past 01.00 hrs. The only information we had was that the patient was a young male possibly suffering a drug overdose. As we rushed to the vehicle Ivan gave me the option of staying on-station, explaining that the neighbourhood they were heading to, La Volta (‘the Boot’—so called because of its shape) was considered highly dangerous by both ambulance and police.

It was not uncommon he said for gangs to either approach the vehicle and intimidate the crew or, worse yet in his opinion, to wait until they were inside the patient’s home treating them and steal vital medical equipment from the vehicle. Explaining that I was content to take responsibility for my own safety, I joined them anyway, and it was during the high-speed 25-minute drive through dense fog along narrow, poorly-paved and cracked roads up steep mountain paths with sharp curves that I realized that Daniel had far from ordinary driving skills.

This baby-faced paramedic could, I considered, give Lewis Hamilton a run for his money. Though I doubt that Mr Hamilton would have been capable of getting the ambulance safely to its destination so quickly. The home of the patient was in one of the poorest neighbourhoods I have ever visited. Consisting of a couple of thousand homes in various states of decay, many boarded-up but still occupied, and most on roads scattered with refuse and with pot-holes the size of buses, they were poorly-lit, if lit at all and there was something else that jarred.

Eventually I realized what it was. “Why are there no shops… no shops at all?” I asked Ivan. He looked at me ruefully and explained: “Sadly, they just don’t work around here. Some have tried to open small grocery stores but they are looted and robbed within hours… often with violence. So as a business model it just doesn’t work.”

When we arrived at the house on a steep narrow road overlooking scrubland, I asked Ivan how Daniel had found it. The area was so dangerous and remote that it literally couldn’t be found via Sat-Nav and the small road didn’t even have a name. “Simple”, he replied. “We develop our own local knowledge because we need to.”

We entered the home to find the concerned family (a mother, a brother, an aunty and a grand-mother) waiting anxiously in the kitchen. With the walls crowded with the Catholic paraphernalia that I had noticed was the norm everywhere in Quito—shops, offices, homes, even street-side kiosks—the first thing that struck me was how immaculately clean and cosy this home was.

After a brief discussion with the brother it was established that the patient, his 20-year-old brother, had spent the evening in an unofficial bar, probably a neighbour’s living room, smoking cannabis and drinking a concoction popular among the local youth – a fruit drink purposefully spiked with methylene.

Why, I asked Daniel, was this a popular drink? His reply made sense: “There aren’t that many bars or liquor stores so young people find their own alternatives. Plus, this drink gets you really high… But it is dangerous, very easy to overdose on!”

When we entered the small, cramped bedroom, two mattresses were on the floor pushed together and the young patient was lying limply on one side with his arms flopping by his side and his eyes closed. Ivan spoke to him gently while encouraging him to do his best to sit up.

After careful questioning to establish the night’s events and a very thorough set of examinations, Vanessa was able to reassure the visibly shaken brother that the patient would be fine. “Keep him awake and give him lots of water” was the simple prescription. The patient wasn’t transported.

“Not necessary”, explained Ivan. “He’s not at any real risk and if he deteriorates, which he won’t, I’ve told his brother to call us back immediately. But it’s Easter weekend and the hospitals are super-busy and to be honest, they can’t offer him anything. He doesn’t need his stomach pumping and the toxins will leave his system if he rehydrates.”

On the way back to base another strange fact struck me. Unlike all other ambulance crews I have observed the world over, the Cruz Roja team behaved differently on arrival. In most cities I’ve visited—from Jerusalem to Las Vegas or from Copenhagen to Quebec—this crew didn’t begin by dragging in stretchers, carry chairs, defibs or whatever else was on-board they could lay their hands on into the patient’s house on arrival.

Ivan explained this to me very simply. “Yes, we’ve got all the basic kit and equipment. Not the most expensive, I know, but it’s all in working order. But the thing is this. Firstly, we know that most of the time we probably won’t be transporting the patient; and, secondly, we really feel that the less dramatic we are when we enter the patient’s home the less stressful it is for them and their family. If we need the carry chair we can always go back out and get it.”

Our final call of the night came in at 4.32 hrs and it was to an even more remote and poor neighbourhood, also in the remote North of the city. During the 15-minute drive I noticed that many of the more populated arterial routes were already awake—if indeed their residents had even been to bed yet. I saw homeless people with their belongings in shopping carts, groups of middle- aged men sat on stoops smoking and drinking and more than one prostitute openly plying her trade by shabby shop fronts, making her pitch to anyone who would make eye-contact.

This time the patient was a 45-year-old man living in a shack on a concrete terrace above the house of a farming family in an oddly rural village-like area, Naxon. It must have been on the very outer Northern border of Quito. The report said the patient had been suffering seizures since the early hours.

When Ivan spoke with his wife it emerged that he had long-term mental health problems and had spent the night kneeling by his bed in prayer and reporting that he was in actual conversation with Jesus Christ who had appeared to him to instruct him to embark on a mission to spread the Good Word. It was after this that the seizures began.

Again Ivan, Daniel and Vanessa embarked on the most careful and sympathetic diagnosis, asking about his prescribed drug regime, and gently asking if there were any issues with either alcohol or any un-prescribed drugs.

The room he and his wife shared was literally a breeze-block shed with a flat roof­—the size of a freight container it was undecorated except for rosary beads, a crucifix and a large image of the Virgin Mary. It had bare concrete walls, no carpeting and was crowded with bin-liners overflowing with clothing and knick-knacks. With room for only one rickety bed and a cabinet, this was their home.

Toilet facilities and drinking water were shared with a downstairs neighbour and all cooking and laundry took place on the terrace, regardless of the weather or the time of day. After a long 40 minutes we left and, again, the patient wasn’t transported.

Ivan explained that the priority, which he’d attended to on the spot, was to speak to the patient’s doctor and ensure that later that same day he would be taken to a clinic to meet with a clinical psychologist who could determine the current state of his mental health. Thankfully, he wasn’t suicidal and didn’t represent a risk to anybody around him.

His wife had explained that her husband’s mental health problems had begun 9 months earlier when he lost his labourer’s job and was, despite strenuous efforts, completely unable to find new work. As time passed, due to lack of money, he spent most of his time isolated at home, praying for work. Earlier that day they had found a lift into the centre of Quito to watch the Easter procession. But, as his wife explained, he was bereft that for the first year in many he was forced to watch as an observer since he didn’t have the required $20 needed to participate as a concelebrant.

This she felt, might have been the final trigger to his collapse. He was, I decided, just a very poor and mentally exhausted man who had perhaps lost all hope and self-esteem. Maybe conjuring up visions of his own special and exclusive conversation with his Lord was the only salvation he felt capable of creating.

Despite the kindness shown by Ivan it was impossible to leave without feeling depressed. Sadly, despite their best efforts the Cruz Roja team could offer their patient nothing except compassion and, at least for a short while, a feeling of worth and dignity.

Another Parade, a Panel Discussion and an Unexpected Pop Concert

On Monday morning we went to the Inca Base station, one of ISTCRE’s two main campus sites in the heart of the city. This was the beginning of our official research. Expecting an introductory cup of coffee and a series of scheduled meetings around ambulance training, we were overwhelmed on arrival to see that the entire Institute had prepared an elaborate and impressive parade for us to inspect.

Javier Sotomayor and Mauricio took us around an enormous courtyard where ambulances, rapid response cars, responder motorbikes and entire platoons of staff were stood in orderly ranks so we could greet them and begin learning about their various roles. Everyone was in smart uniforms and smiling and, sometimes in halting English, delighted to explain about their particular role.

We met teams from their specialist motorcycle responder unit, from their driving school and their specialist rescue team as well as numerous students and instructors. This was followed by a guided tour through their classrooms where we saw students at various stages in their paramedic training engaged in everything from basic first aid, to advanced CPR, to advanced trauma management and even rescue at height, in water, and vehicle extrication.

In every classroom the atmosphere was concentrated and disciplined, yet overwhelmingly enthusiastic with a clear bond of trust and respect between all students and professors.

Next on the agenda was our first contact with CREMYAP – the prehospital research body affiliated to the training organisation which only last year launched Ecuador’s first ever prehospital journal—‘Revista De Investigacion Academica Y Educacion’—an excellent clinical research publication which encompasses both the clinical, psychological and social aspects of national and international ambulance care. One of its excellent first research papers on Burnout among health-care workers is reprinted in English later in this edition.

ISTCRE is a superbly well-organised academic institution—bustling and busy but with teaching staff and students all moving around in a constant blur of happy chatter and camaraderie. Although not notified in advance we found ourselves taken to a main assembly hall with rows of chairs and a stage where I was informed that I was to be a guest panellist on a debate on the future of South American paramedicine comprised of myself and the editorial panel for CREMYAP’s already successful journal.

The hall was thronged with students at all stages of their six-semester degree and the debate was chaired by then Deputy-Rector, but now Rector, of ISTCRE, Dr Victor Daniel Malquin Fueltata. Also among the panel were Dr Jaime Flores Luna, Dr Eric Enriquez Jimenez, Dr Gustavo Cevallos Parades and Dr Wagner Naranjo Salas.

With Mauricio chairing and translating patiently, over 50 minutes we covered a broad and impressive range of issues with me mainly doing my best to offer ad hoc feedback on the current research and thinking on these issues in other parts of the world such as Europe, India, Australasia and Africa.

Topics covered included the latest developments on prehospital pain management (which took in an enthusiastic discussion on the introduction of Penthrox from Australia to the UK), the measurement of standard competencies of EMTs and their global variances, advances in simulation training (which focused mainly on the USA and Denmark), the use of technology in dispatch, which covered the role of IAED (the International Academies of Emergency Dispatch) as a disseminator of best practice protocols globally, and the exceptional achievements of Israel’s MDA (Magen David Adom) ambulance service who have developed possibly the best technology for the control room of any ambulance service in the world—all built in-house!

Other topics covered included mental healthcare for paramedics and remote learning. But the most impressive part of the debate was the fact that the panel encouraged the students not only to ask questions but to express their opinions and ideas frankly and confidently—all of which were listened to and responded to in the most respectful manner.

By late morning I was looking forward to a strong cup of Ecuadorian coffee, a sneaky cigarette break and maybe even a sandwich. But no, not yet. As soon as the team of august clinical academics left the podium the tables and chairs were cleared and to our surprise a full band layout was installed, including amps, speakers, drum-kit and microphone stands. The time was 12pm so I assumed the stage was to be used for a student activity of some type.

I was wrong and I was right. Isaac and I were now invited to take front row seats among the students and informed that the ISTCRE’s own Rock band was about to perform a special concert in our honour. Imagine our surprise when the bass guitarist and co-leader stepped out with a bunch of seven students… only to be revealed as Rector, Javier Sotomayer.

There followed a joyous half-hour jamming session which concluded with their signature tune, the Scorpions ‘Wind of Change’. And they were good. Really, really good. But we weren’t allowed to sit down. Instead a group of cheerful and attractive young students dragged me and Isaac up from our seats and got us dancing. If only BBC’s Question Time ended the same way every week I’m sure its ratings would rise astronomically!

Lunch followed and then another very positive editorial meeting with the journal’s Board. Every part of the day was exciting and memorable and Isaac and I both came away impressed and uplifted by the special relationship which clearly exists between the ISTCRE’s teaching staff and its students.

A Bright Future Ahead Thanks to Dedication, Passion and Hard Work

ISTCRE trains over 2,000 paramedic students a year from its two campuses. As well as providing paramedics for Ecuador it also trains paramedics for around 9 other South and Central American countries, including neighbouring Peru, Colombia, Brazil and Honduras—all under the auspices of Cruz Roja.

Its passionate commitment to improving evidence-based clinical education across South America is undoubted since, as well as establishing CREMYAP and its own already highly-respected clinical research journal, its next ambitious project is to establish South America’s first paramedic university—a project which is enthusiastically supported by Cruz Roja Ecuatoriana and the wider global Red Cross community.

While in Quito I gained a crucial insight into the amazing and dedicated work that Cruz Roja Ecuatoriana is doing to care for the people of Ecuador and also for many of its neighbouring countries. Not only does it provide ambulance care but it also responds to natural disasters, rescuing victims and treating entire communities who have been displaced—most recently after the 2016 earthquake which devastated the country.

It also offers support to migrants entering Ecuador from neighbouring countries, and, as we reported on in our last edition, one of the most vital things it does in this area is reuniting families who have lost contact with each other. On top of this it trains Ecuador’s military in medical and general healthcare so they can respond better to disasters and also provide a better level of support to the population day-to-day.

It also plays a vital role in healthcare education and, at a time when AIDS and HIV are on the rise across South America, simply teaching people about the risks and how to avoid harm is a vital but very challenging undertaking.

Add onto this the work it does inoculating children and providing a working blood transfusion service nationally and you begin to get an understanding of what a vital role the National Red Cross in Ecuador plays in the life and well- being of its all-too often hard-pressed population.

Since our visit the charismatic and inspirational founder of ISTCRE and CREMYAP, Javier Sotomayor, has departed from his role of Rector.

But the beating heart of Cruz Roja Ecuatoriana is most certainly ISTCRE and CREMYAP. They are the ones that are not only providing free ambulance care across this very proud nation but also bringing hope for the future by training more and more paramedics and doing more and more prehospital research so that the overall quality of ambulance care continues to rise.

However, his former deputy, Dr Victor Daniel Malquin Fueltata has taken up the role of Rector and, as well as ensuring much-needed stability to both organisations, he is determined to use his own impressive medical knowledge and leadership skills to carry on the blazing flame of innovation and improvement that his friend and predecessor lit for Ecuador back in 2004. Their next project is to form a much-needed university of paramedic science. I have every confidence they’ll deliver on this as well. So, in closing, I urge as many of Ambulance Today’s friends in the global ambulance family to please make contact with ISTCRE and CREMYAP and offer them any support that you possibly can.

Ambulance Today was started by Declan Heneghan on Sept. 11th 2001 and to this day our sole goal is to strive to support and promote EMS and the fine work undertaken by ambulance services across the globe at every opportunity. To keep up to date with the latest, most innovative and interesting prehospital emergency news, feel free to join one of our WhatsApp groups where you will recieve regular content and discussion with like-minded, passionate EMS professionals:

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John Thanks Lifesavers After Heart Stops

A father-of-two has been reunited with the off-duty doctors who saved his life when his heart stopped beating at his local squash club.

John Savage, 56, from Bath, went into cardiac arrest during fitness training at Lansdown Tennis Squash & Croquet Club in the Northfields area of the city on 13 October.

Bristol GP, Mark Byron, realised John had stopped breathing and called for help.

He carried-out CPR with Dr Richard Dixon, and they gave John three shocks with a defibrillator.   

Local businessman, Andy Ewings, called 999 to alert South Western Ambulance Service NHS Foundation Trust (SWASFT) who arrived within four minutes.

John soon regained consciousness, and has gone on to make a fantastic recovery.

John made a special visit to Bath Ambulance Station on Tuesday 26 November to thank his lifesavers in person. 

He said: “I felt my heart flutter and thought it was going to pass out. The next thing I remember is Paramedic Ed leaning over me. I felt like I was in the eye of my own storm.

“There was a lot of concern for me, but I’m practically back to normal now.

“I survived because of the great response and treatment I received. I’m incredibly lucky to be alive.

“I’m not religious, but it’s miraculous.”

Dr Byron said: “It was an upsetting event. But I went into autopilot, and thankfully the ambulance crew arrived quickly.”

999 Call Handler Vicki Hodgon and other staff in the Control Room organised for crews to respond to the emergency.

Paramedics Ed Hill and Rosemary Cherry treated John at the scene, and conveyed him to the Royal United Hospital in Bath. They were supported by Paramedic Matthew Jenkins and Operations Officer Michael Anning.

John was transferred to the Bristol Heart Institute for surgery.

Ed said: “As we arrived John had just received his third shock and had begun making a recovery, resulting in him talking to us.

“This was such a fantastic example of early CPR and defibrillation which deserves recognition.

“I can’t describe the emotion of reuniting the patient with his two young daughters after his dad had been clinically dead for five minutes.”

SWASFT Operations Officer, Michael Anning added: “This incident demonstrates the real worth of publicly accessible defibrillators. The quick action of bystanders and the prompt transfer to hospital have ensured the best possible outcome.”

Volunteer Lifting Service To Help More Patients

South Western Ambulance Service NHS Foundation Trust (SWASFT) has been given significant funding to extend a pioneering volunteer-run project in local communities.

Gloucestershire Strategic Housing Partnership has provided £50,000 to support patients in six communities across the county have non-injury falls, are unable to get up, and call 999.

The scheme involves trained volunteers, called Community First Responders (CFRs), attending these incidents and assessing patients with support from clinicians in the Control Hub.

In each incident, the volunteer uses an emergency lifting chair to move patients from the floor to a sitting or standing position, and the clinician decides if an ambulance is required.

The initiative reduces patient wait times and enables frontline crews to be available for life-threatening incidents.

Kevin Dickens, SWASFT County Responder Officer for Gloucestershire, said: “We are delighted to have received this funding from the Strategic Housing Partnership.

“The lifting scheme enables our trained volunteers to further support patients at home in their local community in a robust and safe way. It means our patients can be helped back onto their feet in a safe and more-timely manner.

“Our volunteers give their time freely to help support SWASFT and our patients. This funding helps them to provide more enhanced care for those in need.”

Dr Hein Le Roux, Deputy Clinical Chair at NHS Gloucestershire Clinical Commissioning Group, said: “Falls are common and can lead to serious health issues, particularly for older people. They can cause distress and pain, and often result in people losing their confidence and independence.

“We are delighted to be working with our colleagues in South Western Ambulance Service to help people who have fallen at home.

“Responding promptly to help the person get up from the floor and ensuring they are assessed quickly is really important as it can often avoid them having to go to hospital.”

Around a third of people aged 65+ and about half of people aged 80+ fall at least once a year.

The lifting concept was developed in 2017 as a way to attend and assess non-injury falls patients more quickly, developing the skills and experience of CFRs with help from clinicians.

The new funding has enabled the service to be launched in the following new areas: Bishops Cleeve, Cheltenham, Quedgeley/ Tuffley, Tidenham and Cirencester. A second scheme has also been rolled-out in Stroud.

It brings the total number of lifting schemes in Gloucestershire to 13.

During an eight-week trial involving 17 groups across the South West waiting times for non-injury falls patients were cut by 12.5%.

Of the incidents attended by a CFR 77% did not need support from a paramedic, saving 148 hours of frontline resource time.

SWASFT was given the Best Care of Older People accolade at the Health Service Journal’s 2018 Patient Safety Awards for the initiative.

CFRs are trained volunteers who attend emergency incidents and deliver care in their local communities, on behalf of SWASFT, while an ambulance is on its way.

As well as non-injury falls incidents, they respond to 999 calls where it is essential for the patient to receive immediate lifesaving care. These include conditions such as cardiac arrest, chest pain, breathing difficulties, unconscious patients, fitting and stroke.

There are around 800 CFRs providing lifesaving support to patients across the region.

Edesix Body Worn Cameras To Protect Ambulance Staff

Edesix, a leading supplier of Body Worn Camera (BWC) solutions, are having their VideoBadge VB-300 cameras trialled by South Western Ambulance Service NHS Foundation Trust (SWASFT) to better protect their ambulance crews against violence and aggression.

Crews in Exeter, Plymouth and Bristol are wearing the cameras during the three-month trial which began in October. The use of cameras is intended to deter abuse and obtain evidence of offences against the ambulance crews. If the trial is successful, the cameras could be rolled out across the Trust.

There were 1,285 recorded incidents of violent or aggressive behaviour towards SWASFT staff between August 2018 and August 2019, which is an increase of 24% compared to the previous year.

Ken Wenman, Chief Executive of SWASFT, said: “Like all our emergency services colleagues, our crews and control staff work in extremely difficult circumstances. They are often under threat of attack or abuse, and staff members are assaulted every day. That is totally unacceptable.

“We want to take every possible measure to ensure our employees are safe at work. Using body worn video cameras will discourage people from abusing and assaulting our staff. They will also enable us to provide evidence of abuse or assaults when they do happen so the police can bring more prosecutions against people who assault our staff.”

Edesix’s BWC solutions are designed to deter abuse, protect workers and record evidential-quality footage for review or to secure prosecutions. This all-encompassing solution, which includes the VideoBadge and VideoTag cameras, and VideoManager software, is proven in industries from retail to policing, prison and emergency services.

For further information please contact us at sales@edesix.com or give us a call on 0131 510 0232

British Red Cross calls for change in law to improve response when UK emergencies or disasters strike

The British Red Cross is calling for the law to be updated to give individuals and communities more say in how they are treated and the support they get in an emergency.

Currently emergency services, government bodies and councils, who together are responsible for planning for emergencies, aren’t legally bound to involve voluntary and community groups.

As a result, local knowledge about needs, vulnerabilities and sensitivities may not always be known or taken into consideration.

In its latest report, People Power in Emergencies, the charity looks at how far local resilience forums, which lead local council emergency planning, factor in the knowledge, skills and capacities of the voluntary and community sector.

Emergency response volunteer providing hot drinks for the community from British Red Cross Emergency vehicle in Fishlake near Doncaster.

It reveals that collaboration is variable, meaning responses to emergencies tend to focus chiefly on “command and control” mechanisms, which of course are important.

At the same time, this can mean missed opportunities to mobilise people power encouraging communities to build their resilience and support their recovery from within.

The report highlights the very different needs of individuals and how those needs can best be met.

One of the report’s key recommendations is for an urgent review of the 2004 Civil Contingencies Act.

The British Red Cross is calling on whoever wins the election to update the act to enshrine in law the role of the voluntary and community sector in emergencies. 

Other recommendations in the report include:

·         A “people at the heart of planning” checklist for local resilience forums, produced by the British Red Cross, and championed by the recently formed voluntary and community sector Emergencies Partnership

·         A further amendment to the Civil Contingencies Act, Regulations and Guidance to require local resilience forums, in partnership with the voluntary and community sector, to plan what the report calls a more ‘person-centred’ approach to preparing for and dealing with disasters and emergencies.

British Red Cross volunteers were out in force providing support to many communities after widespread flooding swept across northern England. Thousands of people were forced from their homes across Yorkshire and the East Midlands due to flooding in November 2019. Within hours of floods occurring, emergency response volunteers were deployed to hard-hit communities across parts of Derbyshire, Lincolnshire, Nottinghamshire, Humberside/East Riding, and South Yorkshire, after parts of the country were inundated with a month’s rainfall in just 24 hours. In the days following the flooding, volunteers were checking on vulnerable people in the community, manning rest centres for evacuees and distributing much-need donations. The British Red Cross also released £50,000 from its Disaster Fund to help people who have been most affected by the flooding.

Previous research by the British Red Cross has shown how involving grassroots organisations in responding to emergencies ensures people and communities feel listened to and more empowered and in the face of disaster.

As every individual will react differently, it is unrealistic to ask councils and emergency services to adopt a ‘one size fits all’ approach.

The British Red Cross is calling on local authorities and the voluntary and community sector to work with it on the report’s recommendations, and to see the law amended urgently.

British Red Cross CEO Mike Adamson said: ‘Our own response to the recent floods across Yorkshire and the Midlands has shown the value we bring, whether supporting fire and rescue to distribute sandbags, or welcoming people who’ve been flooded out of their home into rest centres. 

“This is about showing how we complement the work of our partners.

“It’s also about giving a voice to those affected by emergencies and highlighting local challenges, sensitivities and opportunities to help people survive and recover better. 

“It’s people and communities who know best what their needs are and how they want them addressed.

“They are the experts in who may be seriously ill, have a disability or mobility issue, or face difficulties because of language barriers, poverty, immigration status or anything else.

“By listening harder and tapping into that resource, people will have the best possible chance of survival and recovery.

“By updating the law so that statutory agencies work more with communities and the voluntary sector, people’s immediate needs will be met more easily, in the most appropriate way.”

Dr Andy Johnston, Chief Operating Officer of the Local Government Information Unit (LGIU), and Convenor of the Local Government Flood Forum, has welcomed the report: “It is very timely, given the recent emergency response to flooding in the North of England and the Midlands. 

“Emergencies in the UK are evolving, with climate change and threats of terrorism, and are very complex, affecting both communities and councils.

“I am therefore pleased to see the recommendation for reviewing the legislation to better guide the local agencies in their planning for emergencies.

“In my roles as part of the LGIU and Convenor of the Local Government Flood Forum, I very much look forward to working more closely with both councils and the voluntary and community sector to take forward these insights and recommendations to ensure community insight is key to local government emergency planning.”

Women Exceed Men in Ultra-Endurance

World Extreme Medicine Conference provides platform for Female Doctors rowing Atlantic to prove a point

It is an exciting time for women in sport, in particular women are increasingly meeting or exceeding male performances in ultra-endurance events.  The World Extreme Medicine Conference 23-25 November 2019 in Edinburgh is providing a platform for the “Emergensea Girls” to announce their research project and talk about their plans for taking on the world’s toughest rowing race – the Talisker Whisky Atlantic Rowing Challenge 2020.

A&E doctors at the Royal Devon and Exeter NHS Foundation Trust and Extreme Medicine MSc Fellows at Exeter University Medical School, Rosie Alterman and Charlie Fleury are going to use the challenge to carry out some preliminary research that they hope will support the theory that women are better than men at ultra endurance events.

The girls will be rowing across the Atlantic from La Gomera in the Canaries to Antigua in a 24ft boat. In addition to conducting research on themselves and simply staying alive they are aiming to smash the current women’s pairs record, and reach Antigua in under 50 days. All proceeds from their venture will be going to Devon Air Ambulance Trust.

Charlie Fleury and Rosie Alterman

Prof. Mark Hannaford, Co-Founder of the MSc Extreme Medicine programme at Exeter and Founder of World Extreme Medicine and Conference said

“I’m delighted to see real research advances being made as a result of the establishment of the MSc in Extreme Medicine at the University of Exeter Medical School in a partnership with World Extreme Medicine.   

This area of medicine has been poorly researched in the past, especially in the area of female psychological response to extremes, and I’m delighted that progress in this area is being made by two exceptional Clinical Fellows enrolled on the course partners with the Royal Devon & Exeter Hospital in Devon.”

There are numerous hypotheses as to why women are increasingly outperforming men ranging from evolutionary roots as child-bearers through to the composition of female muscles. 

During the race Charlie and Rosie will be conducting original research into women and endurance sports as part of their MSc in Extreme Medicine. They will be using data collected from the rowers participating in the Atlantic crossing events in 2019 and 2020 – looking for trends from this year which they can input into the research planned for next year. They will be examining body composition and muscle fatigue pre and post the rows and during the crossings there are two questionnaires that the rowers will complete each day which will profile mood states and provide the rating of perceived effort ( a common method used in sports to measure the individual’s perceived exertion at a point in time).

Charlie, who recently had major surgery on her pelvis, said

“Rosie and I have shared many challenges in the past – ranging from hiking in snake-infested Costa Rica to camping in -20°C in Norway, to surviving a Friday night shift in Exeter’s Emergency Department. What we lack in rowing experience, we more than make up for in determination! 

In addition to long-distance triathlons and running marathons Rosie volunteers with the RNLI – so is well aware of the unpredictability of the sea and the respect crossing an ocean demands. 

We will be training with James Parkes, strength and conditioning coach at Exeter Chiefs Premiership rugby team, and have a variety of other supporters to help us prepare physically and mentally for the challenge for which we are immensely grateful”

The duo will be running a rowing competition at the World Extreme Medicine conference in Edinburgh and are also planning a 24 hour row in their hospital foyer next March in aid of Devon Air Ambulance.

From the Africa Desk of Ambulance Today: A Case Presentation of Electrical Alternans in the Field

https://chat.whatsapp.com/AfricaDeskFeedback

By Michael Emmerich
Published in Ambulance Today, Issue 1, Volume 16, Around the World in 80 Questions, Global Clinical EMS Special, Autumn 2019

For this Africa quarterly, I will be discussing a cardiac patient encountered on a remote site in Africa and the unique challenges faced by the paramedic and his support team.

Patient Presentation: A patient presents at a remote site in the Southern DRC around 07:15 on a Saturday morning, with the patient’s chief complaint being shortness of breath (SOB) and swollen legs. The patient is brought into the emergency room and the consultation process commences. On first examination the findings are as follows:

Observations/Vital Signs on Initial Assessment

  • Heart Rate: 108 – Regular
  • Blood Pressure: 158/91
  • Temperature: 36.8
  • Pupils: PEARL
  • Oxygen Saturation: 75% on an FiO2 of room air
  • Respiratory Rate: 32 bpm
  • Respiratory Effort: Rapid and labored
  • Skin Colour & Appearance: Flushed and warm
  • Blood Sugar: 7.1 mmol/li
  • Malaria Rapid Diagnostic Test: TDR –

Physical Examination

  • Head & Neck: NAD
  • Chest: Cardiac Auscultation detects Miåtral Regurgitation – Lungs clear Abdomen Distend, Pitted Oedema on all Quads – No Ascites
  • Pelvis: NAD
  • Upper Limbs: Oedema in fingers and wrists – no pitting
  • Lower Limbs: Pitted Oedema up to the knees
  • Back: NAD
  • ECG – 12 lead: Electrical alternans and Atrial hypertrophy
  • Other: Pulsus Paradoxus noted in both radial pulses

Preliminary Diagnosis

  • Date/Time: Acute Pericardial Effusion
  • Date/Time: Differential Diagnosis of Mitral Regurgitation

The ECG findings of electrical alternans are usually associated with pericardial effusion (with the potential to lead to pericardial tamponade) and is due to the periodic wobbling of the heart in the pericardium. The significance of the pulsus paradoxus adds strength to this initial diagnosis. Without access to an ultrasound or X-ray, a definitive diagnosis could not be made and based upon the entire patient presentation, including excessive weight, short neck and history of two malaria positive tests over the past 7 months, a decision is made to evacuate the patient off-site to a cardiac ICU unit in Johannesburg, South Africa. In further consultation with the top cover support Dr, palliative care, maintaining oxygen saturation by means of supplemental oxygen (done via nasal prongs at 3 to 4li/min to maintain Sat’s of 90 to 93%) and the insertion of a TKVO IV line is agreed upon.

Initial 12 Lead ECG Done at Mine Clinic

If this patient was in an urban setting or even a rural setting with rapid access to a Cardiac ICU, a definitive diagnosis and ACLS treatment could be initiated forthwith in a controlled multi-team clinical setting.

The Challenges Faced by the Team

Plans are put in place to begin evacuating the patient, the nearest landing strip only has daylight landing rating, so the patient would need to be there before 16:00 to facilitate the fixed wing evacuation. Before this can happen, multiple processes need to be initiated: approval gained from the insurers, an evacuation company needs to be appointed to do the flight, landing clearances must be granted by the DRC aviation authorities and the patient needs to be taken there by road—a 2-hour road trip in a 4X4 ambulance on a muddy, wet and potholed gravel road. In this instance, for a variety of reasons, landing clearances are taking longer than usual so a decision is made to charter a light aircraft—the Cessna Caravan (non-pressurised)—and to move the patient from the landing strip to the nearest largest town with night landing capability (so clearances can be obtained for that evening and because it has a good hospital nearby where the paramedic can keep the patient stable).

It must be noted that once the paramedic leaves the work site, he is working alone with the patient, with only the equipment he chooses to take for the road transfer, the chartered flight and the hospital stay. They eventually arrive at the neighbouring large city in the DRC and move the patient from the airport to the nominated holding hospital, where the paramedic settles the patient in—managing, monitoring, and continuing to co-ordinate the evacuation with various flight and insurance desks. Due to ongoing political instability in the region, the airport with night landing capability is shut down for the evening and the paramedic must sit it out until sunrise with his patient.

At sunrise the whole process starts all over again, to get clearances and wait for the fixed wing ICU jet from South Africa.

The Patient on (Ongoing) Re-Examination

Throughout the night the paramedic kept watch, monitoring and keeping the patient attached to the various monitors he dragged with him from the work site. Upon early morning re-examination a few new flags have popped up: abdominal cellulitis, a raised fever (37.8 C) and a positive malaria test result. They are also able to do a chest X-ray and notice a widened mediastinum and the presence of early pulmonary oedema developing in the base of the lungs. A third 12 lead ECG is done to see if there is developing ischemia or signs of an infarct – none are present. The fever is managed with IV parfalgan (paracetamol) while oral antibiotics and coartem are started for the infection and malaria. The paramedic discusses the ongoing care with his top cover Dr life line, and a Dr in the hospital. The diagnosis does now appear to be definitive – that of pericardial effusion.

Chest X-Ray of the EA Patient

The Flight Evacuation

Finally landing clearances are obtained (which is another story in itself) and a landing ETA is finalised, for around 17:00 on the Sunday afternoon. The patient is loaded into an ambulance with the paramedic and all his medical gear and is moved to the airport. As the plane is on final approach, the heavens open and it starts raining. After a detailed, comprehensive and wet handover, the patient is loaded onto the jet and they depart for the awaiting Cardiac ICU team in Johannesburg, South Africa.

En Route in the Cesena Caravan, Fixed Wing Evacuation

Case Close Out

12 Lead ECG the following day, taken at a local hospital

34 hours have now elapsed since the patient was initially seen by the paramedic back at the work site. Throughout this time the medic has been by his patient’s side, giving comfort, reassurance and medical care as needed. Finally, sleep is possible but getting out of the wet and dirty work clothes, followed by a hot shower and a decent meal, must happen.

The patient arrived in Johannesburg and was admitted into care at around 23:00 on the Sunday evening – almost 40 hours since the original provisional diagnosis was made. Treating and moving the sick and injured in Africa presents one with unique challenges not normally encountered in the developed world, or discussed at most cardiac symposiums. Welcome to the life of the remote and austere paramedic in Africa.

Tell Michael what you think about this article through WhatsApp via the following link:

https://chat.whatsapp.com/Africa Desk Feedback

Equally, if you have any news items you would like us to run either in our magazine or digitally then please email the editor via: joseph@ambulancetoday.co.uk

TAKING MENTAL HEALTH CARE TO THE NEXT LEVEL

Supporting patients living with mental health problems and/or dementia, North West Ambulance Service (NWAS) has officially launched its new Mental Health and Dementia Strategic Plan (2019 – 2022). 

Put in place as part of the trust’s aim is to be the best ambulance service in the country by delivering the right care, at the right time, in the right place; every time; the plan supersedes NWAS’ previous Mental Health Improvement Plan (2017–2022).  It details 17 recommendations, including a range of actions for each of these recommendations, which collectively aim to shape and transform mental health and dementia care within the trust over the next three years.  

The plan is reflective of the relevant mental health and dementia related aspirations detailed within the Five Year Forward Plan for Mental Health (2016), the NHS Long Term Plan (2019) and the Prime Ministers Challenge for Dementia (2015).

The recommendations and associated actions are based on extensive scoping and appraisal of care provision between January and July 2019 including feedback from staff, patients and partners within mental health across the North West region.

One example of the 17 recommendations is to review and learn from the mental health triage car pilots currently taking place within the Merseyside and Lancashire areas, and agree a trust wide plan for the future.   

The current pilot operating in Lancashire is called Psynergy and was launched last December in Blackpool, Fylde and Wyre, and involves a paramedic, a senior mental health nurse from Lancashire Care and a police officer coming together as a crew in a vehicle to jointly respond to people experiencing a mental health crisis.  The aim is to provide appropriate triage, offer the right care and advice, improve patient experience and avoid unnecessary hospital admissions.

The pilot has already proven to improve outcomes for appropriate patients, and results in better use of ambulance resources and multi-agency working, ultimately leading to financial benefit to the wider NHS.    

In year one of this particular recommendation, the trust will undertake a detailed and comprehensive review of the two pilots and work collaboratively with partners and commissioners to secure funding streams to widen this excellent service. 

Gill Drummond, Mental Health and Dementia Lead for NWAS said: “The work regarding mental health and dementia care already being undertaken by the trust is fantastic, but there is so much more we can do to.  The number of related 999 calls is increasing significantly, which is why one of the trust’s key priority areas is to improve care in this area, and why we have developed a plan to take this forward.”

To read more about the other 16 recommendations, the full plan is available to download here.

Dementia patients of the Welsh Ambulance Service to benefit from dementia cannula sleeves

THE Welsh Ambulance Service has received its first dementia cannula sleeves, devised and made by volunteers at Handmade for Dementia. The sleeves have proven to keep dementia patients calm and stop them from pulling needles out of their arms during treatment.

Ambulance staff on both emergency and non-emergency services will be using them when they are out on the road treating patients. It is the first time that the Trust will be using such objects to care for our patients.

During the mid to late stages of dementia, a person can become very anxious and fidgety. Having a cannula sleeve knitted with different wools, with different textures and ‘twiddle’ detail, has proven to make a difference in keeping patients calm.

Each sleeve is knitted following a copyrighted pattern and are individually risk-assessed before being donated to NHS Trusts across the UK.

Alison Johnstone, Dementia Manager at the Welsh Ambulance Service said: “Donations of such innovative items enable us to support our patients and provide person centred-care to people living with dementia.

Alison Johnstone, Dementia Manager at the Welsh Ambulance Service said: “Donations of such innovative items enable us to support our patients and provide person centred-care to people living with dementia.

“We cannot thank Handmade for Dementia enough for providing us with their dementia cannula sleeves as these will improve the experiences of people living with dementia at times of anxiety.

“As we’ve learned, it’s not necessarily the facts of the experience a person with dementia will retain, but the emotion, and these will go a long way to improving the emotional experience of using our service.”

Sharon (Wallace) Holdstock founded Handmade for Dementia in 2016 and started by recruiting a knitter to make ‘twiddle mits’ before moving on to devising and making dementia cannula sleeves following the suggestion of retired District Nurse, Eileen Copeland.

The group, which today has more than 5,000 members has knitted close to 8,000 cannula sleeves since January 2018.

Sharon Holdstock, founder of Handmade for Dementia said: “I am thrilled that our dementia cannula sleeves are making such a difference to people affected by dementia across the UK, saving the NHS thousands of pounds.

“After having sent thousands of sleeves to hospitals, now collaborating with the Welsh Ambulance Service is really exciting for us.  We hope that that result of our work will prove to be just as efficient on the road as it is in hospitals.”

Everyone can join Handmade for Dementia as long as they can knit. To do so, they must first join the group’s Facebook Page. If you would like to do so, head to – https://www.facebook.com/groups/HandmadeForDementia/

The Welsh Ambulance Service hopes to develop its partnership with Handmade for Dementia in the months and years to come.

The i-view™ Video Laryngoscope from Intersurgical: The Key Considerations

By David Chapman,
Airway Group Product Manager,
Intersurgical Ltd.
Published in Ambulance Today, Issue 3, Volume 13, Ahead of the Curve, Education and Technology Special, Autumn 2019

Video laryngoscopy represents one of the most significant advances in airway management in recent years. With the increased emphasis placed on ensuring the first attempt at intubation is the best attempt, the role of video laryngoscopy in airway management seems secure, at least for the foreseeable future1.

Video laryngoscopes utilise the latest video and camera technology to provide an optimal (indirect) view of the larynx during the process to insert an endotracheal tube in to the patient’s trachea. There are many video laryngoscopes available, but the i-viewTM from Intersurgical is the first single use adult video laryngoscope with a Macintosh type blade. i-viewTM provides the option of video laryngoscopy, wherever and whenever the clinician may need to intubate, whether in a pre-hospital setting on a patient with a difficult airway or in the emergency room on a patient with respiratory failure. Where availability of a video laryngoscope may be limited due to the cost implications of purchasing reusable devices for multiple sites, i-viewTM provides a cost-effective solution, by combining all the advantages of a fully integrated video laryngoscope in a single use, disposable product. As i-viewTM incorporates a Macintosh blade, it can be used for direct as well as video laryngoscopy, making it ideal for use in the emergency sector, where there may be a greater potential for the airway to become soiled with blood or other fluids, obscuring the view on the screen. In such circumstances, the operator can immediately switch from indirect to direct laryngoscopy.

As with all medical devices, whether single use or reusable, deciding on the most appropriate video laryngoscope to use is not straightforward, and consideration may need to be given to a number of factors. These may include evaluation of financial, environmental and infection control related issues, as well as the clinical requirements, evidence and preferences. It is important to recognise this assessment may change according to where, when and how often the device is to be used.

The i-viewTM

Financial

Whilst a single use video laryngoscope may not initially appear to be the optimal choice from a financial perspective, in circumstances where multiple units are required, but it may not be used frequently, it may prove to be the most economic option. This might include use by a Helicopter Emergency Medical Service (HEMS) or by a paramedic on an ambulance.

Infection Control

In their safety guideline booklet (2008), ‘Infection Control in Anaesthesia 2’, The Association of Anaesthetists of Great Britain and Ireland (AAGBI)2, confirmed that, in relation to standard laryngoscopes, ‘Current practices for decontamination and disinfection between patients are frequently ineffective, leaving residual contamination that has been implicated as a source of cross-infection.’ They went on to note that, ‘Blades are also regularly contaminated with blood, indicating penetration of mucous membranes, which places these items into a high-risk category.’ They concluded that the use of single use blades was ‘to be encouraged’.

Laryngoscope handles may also become contaminated. The AAGBI’s recommendation in relation to laryngoscope handles is that they should be, ‘washed/disinfected and, if suitable, sterilised by SSDs after every use.’

There is no reason to believe the same considerations and arguments that apply to standard laryngoscope blades & handles regarding infection control, would not also apply to video laryngoscopes, since all laryngoscopes, whether direct or indirect, incorporate some form of blade and handle.

In the EMS sector, where it can be particularly difficult to determine the potential cross-infection risk prior to treatment, a single use video laryngoscope offers an ideal solution.

I understand new infection prevention and control guidelines from the AAGBI are in the final draft stage, and after comments from members have been reviewed, a final version is to be presented to the Associations Board for approval.

Environmental

Environmental considerations are more complex and less easily assessed. Whilst it is appropriate for healthcare professionals, as well as anyone else with environmental concerns, to consider the implications of using single use devices in relation to product disposal, any assessment of the environmental impact of any medical device, whether single use or reusable, needs to consider a number of factors. This should include disposal of single use devices, and reprocessing or decontamination of reusable devices, in the context of a complete Life Cycle Assessment (LCA). The considerations of an LCA may vary depending on the type of product being assessed, the range and type of information and data available and the objective of the assessment. However, typically, an LCA will usually consider the following areas:

  • Raw material acquisition
  • Processing & manufacturing
  • Distribution & transportation
  • Use, reuse and maintenance
  • Recycling
  • Waste management

Assessing just one element of an LCA, such as waste management, may result in misleading conclusions as to the overall environmental impact of a device. A decision also needs to be taken as to what impact factors are to be assessed and how much weight is to be given to each. Is the focus primarily on climate change and water use, or is there an interest in assessing other or additional factors, such as, ecotoxicity, eutrophication, ozone depletion or urban and natural land transformation?

A number of LCA’s have been conducted for anaesthetic and airway devices. Their conclusions vary, and the complexity of any such assessment means the LCA usually needs to be considered as hospital or organisation specific; any variation in reprocessing practices, such as the volume of water used during manual washing, the electricity consumption of different types of washer/disinfection unit, or the type of packaging material used for repacking after reprocessing, will all have an effect on the overall environmental impact. Decisions also need to be taken as to what to include and exclude. For example, should energy recovery from waste incineration or the environmental impact of Personal Protective Equipment (PPE) used by healthcare workers involved in reprocessing be included?

The i-viewTM in use

Of course, all products have an impact on the environment, but it is important to ensure the environmental assessment is considered alongside other key factors, such as infection control considerations and the clinical benefits offered by the device.

For example, the weight given to the clinical benefit of having a single use video laryngoscope available in a life-threatening road-side emergency, perhaps when this might be the only viable VL option economically, might be quite different than the assessment made for regular routine use in the operating theatre.

In an interesting paper published in the British Journal of Anaesthesia, entitled, ‘A national survey of video laryngoscopy in the United Kingdom’, Cook & Kelly3 reported on the results of an electronic survey sent to all UK National Health Service Hospitals. With regard to availability of video laryngoscopy (VL) by clinical area, 91% of operating theatres reported availability of VL. In contrast, only 55% of Obstetric departments, 54% of Intensive Care Units and 35% of Emergency departments reported availability of VL. The authors noted that, ‘The distribution of availability is notable because the incidence of difficult or failed intubation increases in those places where video laryngoscopy is less available; in order, main theatres, obstetric, ICU, and the ED.’

It is not known why VL was less available in these areas, but it is possible that with less frequent use than in the OR, the financial implications of purchasing a reusable VL may have been a factor. If so, availability of a single use device might provide a more economically viable option due to its lower unit cost, which as discussed earlier, may be more economic when use is infrequent.

In summary, the i-viewTM video laryngoscope from Intersurgical is the first single use adult video laryngoscope with a Macintosh type blade. It provides the option of video laryngoscopy, wherever and whenever the clinician may need to intubate. This makes VL a viable option in places where the higher initial costs of purchasing a reusable device may previously have been prohibitive. With the new focus in airway management of ensuring the first attempt at intubation is the best attempt, i-viewTM may have a contribution to make to support this objective. Whilst it may not be suitable in all situations, such as when a hyper-angulated blade is required, it may be ideal in situations where use is infrequent, standard blade geometry is preferable and the nature of use makes it a more viable option economically.

Image taken at the ATACC Course in May 2019

Deciding on the most appropriate video laryngoscope to purchase and use is not straightforward, and in addition to the clinical requirements and preferences, consideration may need to be given to a number of other factors, including financial, environmental and infection control related issues. It is important to recognise this assessment may change according to where, when and how often the device is to be used.

Make a direct enquiry about Intersurgical’s i-viewTM here

References:
1. Cook TM & Kelly FE. Seeing is believing: getting the best out of videolaryngoscopy. British Journal of Anaesthesia 117 (S1): i9–i13 (2016)
2. Infection Control in Anaesthesia 2. Association of Anaesthetists of Great Britain & Ireland. 2008
3. Cook TE & Kelly FE. A national survey of videolaryngoscopy in the United Kingdom. British Journal of Anaesthesia, 118 (4): 593–600 (2017)