Integrated major haemorrhage management in the retrieval setting: Damage control resuscitation from referral to receiving facility.

Major haemorrhage is a leading cause of death in critically ill or injured patients requiring medical retrieval and presents significant clinical and logistic challenges irrespective of patient location, primary pathophysiology or mode of transport. It is essential that all care providers involved in the retrieval patient pathway, including referring hospitals, ambulance services, retrieval teams and tertiary receiving centres, adopt a common approach to the management of this complex patient group through the use of retrieval-specific, integrated protocols. These should incorporate the latest clinical evidence base, recognise the differences between primary and inter-facility missions and clearly define the roles and responsibilities of the retrieval clinical coordinator. By unifying the response across services, the aim is to facilitate seamless transition of care with ongoing damage control resuscitation from point of referral, during transfer and on arrival at the receiving centre.

Specialty trainee-led intensive care unit induction.

BACKGROUND: Junior doctors from varied medical specialties are increasingly undertaking placements in intensive care units (ICUs). They may have minimal previous experience in the provision of advanced organ support, yet may have high levels of clinical responsibility. Traditional ICU induction has been consultant led, and has focused on local procedures and policies. A survey of trainees highlighted low levels of preparedness and confidence at managing advanced organ support, and dissatisfaction with the existing induction format. METHODS: Based on survey feedback and personal experience, a focus group of specialty trainees identified five core topics to be covered in a half-day of interactive lecture-based teaching presentations and a trainee handbook. A systems-based approach to advanced organ support and ICU emergencies was adopted. In cycle 2, formal written pre- and post-induction exams provided a more objective assessment of knowledge. RESULTS: Two cycles of the new induction programme were delivered during consecutive junior doctor intakes, and yielded improved satisfaction and improved self-assessed confidence in routine and emergency management of advanced organ support and in the understanding of the principles of advanced organ support. DISCUSSION: Specialty trainee-led induction may be better tailored to the needs of incoming junior doctors. This study demonstrated increased trainee satisfaction with induction and provided a legacy of teaching opportunity within the department, highlighting the potential for our near-peer model of induction. Safe and effective induction is paramount in the high-stakes ICU environment, but the principles described may also be transferrable to other clinical specialties. Traditional ICU induction has been consultant let, and has focused on local procedures and policies.

Improving the safety of remote site emergency airway management.

Airway management, particularly in non-theatre settings, is an area of anaesthesia and critical care associated with significant risk of morbidity & mortality, as highlighted during the 4th National Audit Project of the Royal College of Anaesthetists (NAP4). A survey of junior anaesthetists at our hospital highlighted a lack of confidence and perceived lack of safety in emergency airway management, especially in non-theatre settings. We developed and implemented a multifaceted airway package designed to improve the safety of remote site airway management. A Rapid Sequence Induction (RSI) checklist was developed; this was combined with new advanced airway equipment and drugs bags. Additionally, new carbon dioxide detector filters were procured in order to comply with NAP4 monitoring recommendations. The RSI checklists were placed in key locations throughout the hospital and the drugs and advanced airway equipment bags were centralised in the Intensive Care Unit (ICU). It was agreed with the senior nursing staff that an appropriately trained ICU nurse would attend all emergency situations with new airway resources upon request. Departmental guidelines were updated to include details of the new resources and the on-call anaesthetist's responsibilities regarding checks and maintenance. Following our intervention trainees reported higher confidence levels regarding remote site emergency airway management. Nine trusts within the Northern Region were surveyed and we found large variations in the provision of remote site airway management resources. Complications in remote site airway management due lack of available appropriate drugs, equipment or trained staff are potentially life threatening and completely avoidable. Utilising the intervention package an anaesthetist would be able to safely plan and prepare for airway management in any setting. They would subsequently have the drugs, equipment, and trained assistance required to manage any difficulties or complications. We suggest that this should be the gold standard of airway resource provision and is in line with NAP4 recommendations.

Deltoid compartment syndrome as a complication of lateral decubitus positioning for contralateral elbow surgery in an anabolic steroid abuser.

Compartment syndrome as a result of patient positioning for surgery is a rare but serious complication. Compartment syndrome as a result of anabolic steroid use is more rare. We present a unique case of compartment syndrome related to anabolic steroid use and patient positioning for complex distal humerus fracture fixation and also provide a review of the literature related to this topic.