Ambulance Today Autumn 2012

AmbulanceSEE INSIDE FOR WORLD EXCLUSIVE REPORT ON ARCTIC COUNCIL SAREX 2012 MEDEVAC EXERCISE

Large-scale MedevacNeeded in the High Arctic

Could we avert a 21st centuryTitanic-type catastrophein the world's coldest waters?

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Autumn 2012 - Issue 4 | Volume 9

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Editor’s Comment

3August 2012 | Ambulancetoday

Welcome to the Autumn 2012 edition of AmbulanceToday. This issue leads with a special feature on ahighly-unusual military/medical exercise which tookplace recently in the High Arctic which I was luckyenough to take part in – SAREX 2012, an ambitiousattempt to see what response could be mounted inthe event of a Titanic-style shipping accident in theremote High Arctic region.

As the only non-military journalist invited to participate inthis ambitious medical evacuation exercise in one of theworld’s most challenging environments this was a greatopportunity to see at close-range how different countriescan work together in the event of a major incident.

However, despite the fact that this project allowed me a rareopportunity to do such exciting things as sleep under canvassin the Arctic, travel on a C-130J Hercules military aircraft andsail down a fjord on an Icelandic tug-boat with Lynxhelicopters zooming by overhead, I can genuinely say that byfar the most interesting element of the trip was witnessingthe good-natured cooperation displayed by a varied group ofmedics who were passionately-focused on finding outwhether or not they could deliver high-levels of clinic care inwhat, in a real life scenario, would be about as testing asituation as one could possibly imagine.

Led by the almost implausibly calm and unflappable MajorLasse Brinck, the Royal Danish Air Force’s 690 MedicalEvacuation Squadron flew out from Aalborg Air Force basein Jutland, Denmark to see how they would cope if tasked toprovide medical care to the crew and passengers of theArctic Victory, a Danish Inspection frigate, especially renamedfor the ocassion, with a manifest of 160+ cheerfulGreenlanders onboard, who themselves travelled a week byboat to perform the role of ‘casualties’ for the exercise. Theprimary mission objective was to see how effectively medicsfrom the eight Arctic Council nations could treat largenumbers of potentially severe hypothermia victims who, asthe scenario dictated, had been trapped on a stranded vesselin the chilly Arctic waters for 24 hours before beingextricated for treatment.

My own invitation, which ironically landed in my email traywhile I was sat enjoying an alfresco breakfast during myannual August holiday in the 40°C heat of Northern Greece,came about through my good friend, Professor Sir BenedictKjærgaard, a world-leader in the treatment of hypothermia,whose own team of hypothermia specialists, were aninvaluable asset for the exercise. With vague daydreams ofpolar bears, the Northern Lights and huskies howling to theMoon, saying ‘Yes’ wasn’t difficult – especially since I wascomforted by the reassurance given in my invitation that: “InSeptember, it isn’t too cold in the High Arctic – temperaturesdon’t usually drop below -10 °C.” Well, let me tell you that -10 °C is plenty cold enough when you’re sleeping on a

groundsheet with a tent-flap slapping against your head in ahigh wind!

All of which I honestly don’t mention to grumble. Anyonemiserable enough to grumble about slightly rough sleepingconditions when given such a once-in-a-lifetime opportunity,deserves to be dipped in jam and left standing in a beehivefor an hour or two. No. I mention this because, as so oftencan happen in life, the most memorable aspect of this truly‘Boy’s Own’ adventure came not from witnessing theastonishing medical evacuation exercise at close quarters –though I hope you’ll agree after reading my report, that theteam really did do a brilliant job – but from meeting the trulyamazing and very modest guys whose job it is to spend 12months at a time living on the barren and remote stationMestersvig in a two-man team, who acted as our hosts whilewe stayed there, setting up and running the squadron’scasualty staging unit.

Mestersvig is literally one of the remotest inhabited places onearth and only exists because the Danish governmentneeded one decent-sized landing strip to fly in supplies forthe numerous mining teams that have worked in the regionfor decades. It is usually run by just two men who put in a 12month stint together, including through the deepest wintermonths, simply to keep the landing strip operational. It wasmy deep honour and great fortune to spend a bit of timewith these guys – Leif, Kim and Aksel – and let me tell you amore interesting and impressive group of people you’reunlikely to ever meet. Living in such conditions takes anamazing range of high-level practical skills and an even moreamazingly strong mindset. So impressed was I by their life andwork that I couldn’t resist writing up a special report onwhat they do and how they survive their living conditions. So,although not strictly speaking an ambulance or prehospital-related article, I hope you find time to read my report on lifein Station Mestersvig. If you do, you’ll never again moan aboutdigging your car out of snow on an early January morning!

All that remains is to thank the wonderful men and womenof Squadron 690 for letting me share their exceptionalexperiences during SAREX 2012 and, of course, to offer youmy usual reminder – especially as we’re now in theinterminably long run-up to Christmas, to please rememberyour own special ambulance cause, the Ambulance ServicesBenevolent Fund (ASBF). Details on how to make a pre-Christmas donation by text can be found on the left of thispage so please text them a fiver and help them makeChristmas happier for one of your workmates who mayneed a helping hand as winter draws in!

Warm wishes,

Declan HeneghanEditor, Ambulance Today

A Titanic Undertaking!Declan HeneghanEditor, Ambulance Today

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PUBLISHER’S STATEMENT: Ambulance Today magazine is published by Ambulance Today Ltd, 41 Canning Street, Liverpool L8 7NN. The views and opinions expressed in this issue arenot necessarily those of our Editor or Ambulance Today. No responsibility is accepted for omissions or errors. Every effort is made to ensure accuracy at all times. Advertisements placed in thispublication marked "CRB Registered" with the organisation's "CRB Registration No." means that the Organisation/Company meets with the requirements in respect of exempted questions under theRehabilitation of Offenders Act 1974. All applicants offered employment will be subject to a Criminal Record Check from the Criminal Records Bureau before appointment is confirmed. This willinclude details of cautions, reprimands or final warnings, as well as convictions and information held by the Department of Health and Education and Employment.

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This Issue is Supported by :CONTENTS

P7 - Mayday! Mayday!Find out about SAREX 2012 -a unique air and sea medicalevacuation exercise in theHigh Arctic designed to test whether medics could dealwith large numbers of severehypothermia casualties

P28 - March with us for a future that worksUNISON’s Hope Daley invites you to march for a future that works

P31 - Optima Predict™ brings significantsavings for South Central Ambu lance ServiceOptima yielded operational savings of £400K for SCAS. Find out how

P33 - Is the Precordial Thump an endangeredskill?Sophia Rozario reviews the history and use of the PrecordialThump and Precordial Percussion, discussing their origins andlikely effectiveness as CPR strategies

P39 - Dutch call to honour fallen colleaguesOur Dutch correspondent, Thijs Gras, launches an appeal to funda memorial for Dutch ambulance workers who have died whileon duty

P40 - Help promote your ASBF charityIn the run-up to Christmas ASBF Chairman, Paul Leopold,encourages all ambulance staff to become fundraisers and PRcampaigners

P41 - It’s time to�overhaul our EMS paymentsystem!Our American correspondent, Jerry Overton, offers a beginner’sguide to the complexities of US ambulance funding

Also Inside:P42 - Out & AboutThe latest news from services around the UK

P46 - Products & Suppliers NewsLatest in new products, services & technology

I N S IDE YOUR AUTUMN I S SUE

College of Paramedics CPD WorkshopsVisitors to the Emergency Services Show,Stoneleigh Park this year will have the chanceto build on personal development by attendingthe CPD accredited workshops that are beingheld by the College of Paramedics. Twoseparate areas will focus on different ways oflearning; Area 1 offering a hands-on practicalworkshop and Area 2, lecture stylepresentations. Taking place over the two daysof the show, each session will be free to attendand will last 20-30 minutes. CPD Certificateswill be available for those attending. Thetopics covered include:

Registrations for the workshops will take place at the show so please visit the College of ParamedicsDemonstration Area in Hall 2 to sign up. For more information on how to become a member of your

professional body you can also visit The College’s promotional stand which is E71.To register to attend the Emergency Services Show visit their website www.emergencyuk.com

Day 1 – Trauma CareExtrication

Basic life supportPrimary assessment and triage

Spinal immobilisation – pelvic splint demonstration

Day 2 – Pre-hospital CareEmergency childbirth

Management of minor injuriesDiabetic emergencies

Mental health

Picture supplied by Edge Hill University

It’s just over a century since theTitanic sank on the 14th April 1912with the loss of 1,517 lives. Yet,amazingly, until just a few weeks ago,no nation had launched a large-scalerescue exercise to ensure that asimilar catastrophe can be averted inthe event of a shipping accident in thesub-zero waters of the High Arcticregion. All that changed on 12th September2012 when a combined rescue force,led by Greenland Command andcomprised of six of the eight nationsmaking up the Arctic Councilmounted a unique training exercise inthe waters off Ella Ø, a small island onthe Southern coast of East

Greenland.Supported byLieutenant ColonelSir BenedictKjærgaard, MedicalLead for the RoyalDanish Air Force’sSea Air Rescuearm, who isglobally recognizedas an expert on the

treatment of hypothermia, theevacuation exercise would includetwo members of his team fromAalborg hospital, as testing whetheror not his treatment techniques forsevere hypothermia victims wouldwork in such a harsh climate andseeing if their medical equipmentcould function effectively in severeArctic conditions was a key objectiveof the exercise.

The DistressSignal:

At 04.05 hrs zulutime onWednesday 12thSeptember adistress signal wasreceived in theSituation Room ofAir Transport

Wing at the Royal Danish Air Force base inAalborg, Jutland by 46 year old Major LasseBrinck, Commander of ESK 690 MedevacSquadron.

The information received was scant, statingonly that an unidentified vessel incoordinates 72°512 N 25°002 W was inextreme distress and that a full-scalemedical evacuation was required – Casualtynumbers were unknown but the vessel wasreportedly stranded in waters off Ella Ø

[Danish word for ‘island’], a small island, atthe mouth of Kempe Fjord in the northernend of King Oscar Fjord, some 200 kms offthe Eastern coast of Greenland and around60 km North off Mestersvig, a small militarystation with a 1,800m gravel runway andthe only airstrip in the entire region capableof landing a fully-loaded C-130J Herculestransport aircraft. 690 Squadron must depart for Mestersvigimmediately, with all transportable medicalequipment and supplies. Their Herculesaircraft would be carrying the squadron’smedical module, four large pallets ofmedical supplies and all other provisionsneeded by their specialist team of 19medics for the anticipated 48 hour exercise.On-board would be one third of thesquadron’s full medical complement, allthose who the squadron’s records showedwere immediately available for rapiddeployment.

“Mayday! Mayday!... Large-Scale Medevac UrgentlyRequired in the High Arctic!”

Declan Heneghan reports on a unique medical and military first – SAREX 2012 - a two day air and sea medical evacuationexercise involving the eight member nations of the High Arctic Council, which took place in mid-September off the Easterncoast of Greenland. Two years in the planning and at a cost of £15M, the daunting mission objective was to see if a strickenvessel with an unknown manifest of crew and passengers could be medically evacuated as quickly as possible in a region wheretemperatures can plummet to -70 °C in deep winter and travel time to the target site can take up to 8 hours even by air.

August 2012 | Ambulancetoday

Focus on SAREX 2012 Medevac Exercise in the High Arctic

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Major Lasse BrinckLieutenant Colonel Sir Benedict Kjærgaard

Major Brinck returned to the hangar, wherehis unit had bedded down for the night insleeping bags, after a day checking andloading medical supplies in readiness for acall-out, and instructed his Squadron to re-set their time-pieces to ‘Zulu time,’ theUniversal time coordination employed bymilitary forces globally, and preparation forimmediate departure began.

The team structure:Working in conjunction with Major ClausLie, Medical lead for the squadron, butunavailable to participate in this evacuationexercise, Major Brinck assesses the medicalskills available to him for the exercise and,taking into account the number of doctors,nurses, paramedics and flight medicsavailable to him and their respectiveindividual specialist skill-sets, he organizesthem into three teams which, together,form a chain of medical care for theevacuation process. His priority is to utilisethe ‘medical assets’ at his disposal asefficiently as possible in order to achievethe exercise ‘s specific medical objectiveswhile supporting the overall exerciseobjectives.With four doctors, five nurses, four flightmedics and six paramedics, each with aspecific medical speciality ranging fromanaesthesia to trauma care and, vitallyimportant for this exercise, hypothermiacare, the objective is to ensure that fromthe moment of arrival chains of treatmentand information can be established whichwill, with the assistance of the variouslogistical and military teams who will alsobe on-scene, ensure that casualties can besafely evacuated from the target vessel,transferred to a CSU (Casualty StagingUnit) which will be established close to theMestersvig landing strip, continue treatmentand either discharge or stabilize casualties,and finally, effect the long-haul evacuation ofany critical casualties to the nearestreceiving hospital in Keflavik, Iceland.

The Mobile team – their role is to workat the target site, providing immediatemedical treatment to the casualties oncethey have been safely removed from thetarget vessel and then organizing theirtransfer (complete with available but briefmedical notes) to the Casualty Staging Unit.

Leader of Mobile Team - Paramedic,Johan Brus Mikkelsen

The CSU team – their role is to use themore extensive medical resources andequipment in the CSU to administer morecomplex care to casualties and, in the caseof critical cases, prepare and stabilize themfor the lengthy (C4 hour) air transit to thereceiving hospital in Keflavik.

Leader of CSU Team - Paramedic,Jesper Ægidius–

The Medevac team – their role is totransfer critical patients to Keflavik whilecontinuing treatment en route. Using the C-130J they arrived in they will have accessto the Mobile Medical Module which hasstretcher space for up to 12 patients but

which, due to the limited number of medicalpersonnel on-board – only five (consistingof one doctor, two nurses and two flightmedics) – means that while they couldtransfer a higher number of grade ‘2’ (low-risk stabilized casualties), realistically, becauseof the intensity of stabilization care requiredby the more urgent grade ‘1’ (most severecasualties), it wouldn’t be possible totransport more than three severe casualties.

Leader of AE Team - Flight Medic,Allan Fuglsang

The main exercise objectives forSQN 690, were to:* Deploy a full chain of medical evacuationcapability (forward air evacuation, casualtystaging unit and air evacuation to majorhospital) from this remote arctic location.* Achieve effective evacuation operationsand cooperation between nations and otherinvolved units.* Achieve effective medical support andcooperation between nations and otherinvolved units.* Achieve effective use of air capabilities formedical evacuation

Outward flight to Mestersvig:

Just two hours later at 06.05 hours Zulutime, after quickly loading their fully-stockedMedical module, the size of a typical A&Eambulance body, four pallets of additionalmedical equipment and two pallets of kitand rations, the squadron departed. Also onboard were five members of the DanishEmergency Management Agency(DEMA)tasked with the search and rescue of thetarget vessel. Using small zip watercraft,capable of transporting up to eightpassengers, their role would be to use sonarlistening technology from outside the vesselto ascertain the conditions onboard and totry and determine how many casualtieswere inside.



8

They would work with Canadian Air Forceparachutists, who were to be air-droppeddirectly on to the vessel, and assist in theevacuation from the vessel to dry land.

Conditions inside the aircraft are, as youwould expect, not quite as comfortable ason a commercial airliner. Only about a thirdof its 97 ft length was set aside for seatingof passengers and this was divided into twosets of facing benches divided by aframework of hooks and supports, uponwhich were hung kit bags, life jackets andback-packs. To the rear of this double row ofcramped benches in the central positionwere four elevated stretchers which, as theflight progressed, gradually became occupiedby people sharp-eyed enough to spot theopportunity of a good lie-down and thepossibility of 40 winks. The middle sectionwas taken up by the looming presence ofthe Medical Treatment Module, which, beingfitted with lighting, was busy throughout thetransfer with medics checking on stocks andequipment or, again, taking advantage of itsstretchers to grab cat-naps.

Then, at the very rear of the craft, was themain cargo hold, containing a tightly-

strapped set of pallets wrapped in webbing,with a jumble of hefty medical chests, layersof kit-bags and sundry other supplies.Capable of storing a maximum payload of34,000 pounds, or six large pallets, while stillflying a maximum range of 2,071 mileswithout refueling, it’s even possible totransport a small utility helicopter or a six-wheeled armored vehicle in its hold.However, the cost of such power is that thenoise of its four enormous Rolls Royceturboprop engines, each with 4,700horsepower, is thunderous, making ear-plugsessential and normal conversation virtuallyimpossible. Spotting C-130 frequent-flyers iseasy as they sport flashy, hi-tech headphonemufflers which completely eliminate noisebut make conversation amusing as theyhave a tendency to shout rather LOUDLY!

The flight, manned by Captain JesperKristensen and two Co-Pilots, Steffen BoJensen and Christine Plenge departs. Flyingat 24,000 ft, some 10,000 ft lower thancivilian aircrafts, and after a short 45 minutere-fuelling stop at a Naval base in Keflavik,Iceland, it reaches Mestersvig at 14.00 hoursZulu time. The total flight time was 8 hoursand the distance covered was 1,577 miles.

Arrival and Set-Up:

Mestersvig is 42 miles south of the targetsite, Ella Ø, and it was here that 690Medevac began to equip a large three-tentCSU – Casualty Staging Unit – which hadbeen quickly erected for them by Ice-SAR,the highly-respected Icelandic internationalAssociation for Search and Rescue, who hadthemselves arrived on an American C-130Jonly minutes earlier and who were alreadyengaged in installing power supplies andheating as well as other specialistrequirements such as feeds for oxygen andother medical gases likely to be needed fortreatment.

Major Brinck set his team to unloading keymedical equipment, assisted by a heavy-dutyloader to speed up the process oftransporting the equipment on pallets,direct to the CSU location. Accompanied byCaptain Michael Treschow, a Doctor andanaesthetist specialist, he headed straight forthe station’s own small Command tower toset up a command centre with radiocomms to immediately coordinatehelicopter and boat transport to the targetsite so that casualties could be airlifted back



9

to the CSU for stabilization before the mostseriously injured would be evacuated on theC-130J onward to Keflavik Naval Air basebefore being transported on to Reykjavikfor full treatment.

Michael was tasked with gathering accurateclinical intelligence by radio to analyse andthen pass on to the CSU team leader, FlightMedic,Jesper Ægidious, to help the CSUmedical team determine triage prioritiesand identify what medical resources mightfirst be required when the first wave ofcasualties arrived. He was understandablykeen to get down to works, but a majorproblem emerged – no radio link had yetbeen established between Mestersvigcontrol and the target site, despite the factthat the plan had been to set up a radio linkwith one of three Danish and Icelandicvessels that had recently arrived on-site andwhich were anchored less than half akilometer away from the target vessel inthankfully calm waters.

The lack of radio comms also created apotential problem in establishing a link with

the full-scale receiving hospital at Keflavikwhich Michael was acutely aware was alsoon stand-by and would be waiting for clearinformation on how many casualties theywere likely to receive some hours down theline. Although 505 miles away from the targetsite Ella Ø, with its Naval base and a smallpopulation of 15,000 people, Keflavik wasstill the nearest fully-equipped hospital tothe target site, capable of treating the as yetunknown number of casualties due to passthrough Mestervig’s CSU.

Medevac Preparation and GeneralLogistics:

Even before Major Brinck receives a Maydaycall his Squadron, as always, has in place arigid and proven protocol that allows themto respond with the utmost speed to aninstruction to deploy.

ESK 690 Medevac Squadron is a unitcomprised of medics from all backgrounds,a mix of full-timers and reservists, who canbe called upon at a moment’s notice andrapidly deployed to any war or crisis zoneacross the world. In recent times they haveprovided medical support to the Britisharmy in Afghanistan and the Balkans andmedical aid to civilian victims of the conflictin Libya. The squadron is twinned with theAir Transport Wing of the Royal DanishAirforce, which makes good sense, as inorder to provide medical expertise inadverse situations, they face the logisticalchallenge of maintaining and transportingvast amounts of sensitive hi-tech medicalequipment around the globe and ensuringthat they can put them to use immediatelyin hot-spots, regardless of whateverenvironment they find themselves in andusually without any immediate fixed sourceof power.

The person responsible for ensuring thesedaunting logistical challenges can be met isLance Corporal Claus Larsen, a Flight

Medic with thirty years Air Force andprehospital medical experience. Workingfrom the Medical Centre at Aalborg inJutland, the home of 690 Squadron’sMedevac team, Claus oversees theprocurement, maintenance and strategicplanning needed to ensure that theMedevac team can fly out fully-equipped forwhatever mission they are given, with only acouple of hours notice and sometimes evenless.

I asked Claus what the equipment manifestfor this exercise included and how long ittook to ensure that his own ‘make-ready’procedure was in place, in order to allowthe squadron to scramble at a moment’snotice. “As soon any mission is completed,my first task is to audit what has comehome with our medical team. Obviouslysome disposables will have been used andwill need replacing. All items need checkingto make sure that they are operatingproperly and haven’t suffered any damageduring transit and, as will probably happenduring this exercise, we often find that someequipment has been left behind and weneed to ensure that it is recovered as swiftlyas possible, unless it has been left forcontinued use in the field.”

Claus continues: “ The most likely reason forleaving equipment behind – usually cylindersand other heavy units – is that the returnflight manifest has taken on extrapassengers and, of course, it isn’t safe to tryand fly overburdened, so we then plan torecover our equipment at the nextopportunity.”

As for equipment, Claus explained, “ Itusually takes about three days for me tocarefully audit and check the assets thathave returned and to replenish any itemsthat need replacing. Once this has beendone, it will take another day to repackthem within the module and onto pallets, sothat they are all ready in the hangar for thenext mission. Occasionally, when we arepreparing for an exercise, the squadronmedic members involved will assemble 24hours before and actively participate in thepreparation. This is very important as it notonly familiarizes them with what assets wehave and where they will be stored, but itmeans that they have a clear idea of wherethings can be found when they arrive sothat the unpacking and set-up process cantake place quickly and effectively. This isparticularly important since my role is asupporting one and I don’t fly out with theSquadron, so it’s necessary they have a clearidea of what assets are needed and whatthey are taking with them. It’s also a vitalopportunity to ensure that small butessential items are not overlooked. If you’re



11



13

in the High Arctic, you can’t simply pop nextdoor to a stock-room for a pair of scissorsor a blood pressure cuff. You either havethem, or you don’t!”

For this exercise the squadron was alsodetailed to supply real medical back-up inthe event that it was required so the majormedical items to be taken included:- 16 syringe pumps, four Lifepack 12defibrillators with surveillance monitors, sixOxylog ventilators, eight Propacs, 50Stretchers, three large transportablemedical bags containing a variety of pre-filled ampules. Drugs carried include morphine and otherstrong pain-relief drugs, Fentanyl foranaesthesia and, since there is anexpectation that there may be an unknownnumber of smoke-inhalation casualties, alsoAcetylcysteine, a drug which breaks downmucus and lubricates vital organs, such asthe lungs. But as Claus explains: “This is onlysome of the equipment and drugs that webring along. The hypothermia team fromAalborg hospital and ICE-SAR, the Icelandiclogistical support team, will each bring alongadditional medical equipment and drugs.”

For Claus the worksupporting eachmission or exercise isan ongoing task – themedical equivalent ofpainting the ForthBridge, but withstricter infectioncontrol requirements.“It’s my job to order

all medical materials required and to makesure that the team is properly equipped andresourced for the duration of each mission– everything from uniforms, sleeping bags,kit bags and rations must be prepared. And

then, of course, there’s our MedicalTreatment Module.”

The module Claus is referring to is thecrowning glory of the Squadron - a vast3,000 Ibs unit, similar in appearance to thekind of temporary shell unit you see onbuilding sites. The only difference is that this6 metre long, 2.5 metre wide and high,strengthened medical storage unit, comescomplete with 12 stretchers, customizedcabinets for the storage of everything fromsyringes to stethoscopes and full hygienicwash-up facilities. Since the stretchers canbe removed, although space is tight, it’s evenpossible to undertake invasive operations inits relatively confined space – though, as DrUlrik Edelmann, one of the squadron’sdoctors, stressed: “Of course this wouldonly happen under the direstcircumstances.”

Commissioned and designed by the RoyalDanish Air Force’s Medical Corps in 1992 inresponse to the medical evacuation needsidentified in the first Gulf War, the module,one of just four ever built, is a truly uniqueone-off medical treatment space. Its

dimensions, by the way, were arrived atpurely to ensure that it would fit snugly intothe hold of a C-130 . From the outside itlooks like just another freight container, butyank open its heavy rear door and you’reentering a tight but completely workabletreatment space. And, as I saw in the earlymorning light, when the unit was scrambledfor its flight to Mestersvig, with the help of afull-scale military hoisting unit, it can rapidlybe lifted from its storage place in the hangar,driven the few hundred metres to Aalborg’smassive military air-strip and slid securelyinto the cavernous hold of a C-130JHercules! For the record, I timed it, and thewhole operation took just eleven minutes –not much longer than is needed to stock upan A&E ambulance before the start of abusy shift!

Among the anaesthesia, pain killers andrelaxants taken along wereDehydrobenzperidol (2,5mg/ml and Amp a2ml), Haldid/Fentanyl (50mikrog/ml, Amp a2ml and Amp a 10ml), S-Ketamin (25mg/mland Amp a 2ml), Pentothal-natrium(subs,0.5g), Rapifen (0,5mg/ml and Amp a2ml), Propolipid (10mg/ml and Htgl a 50ml),(Driprivan 10mg/ml), Dormicum (5mg/ml)and Midazolam (5mg/ml and Amp a 1ml).

The Mobile Team Overview:

Johan Brus Mikkelsen, a Paramedic fromSQN 690, led the Mobile team that flew into Ella Ø on a twelve-seat, twin-engineOtter fixed-wing aircraft only moments afterlanding at Mestersvig. His team’s functionwas to immediately move onward to thetarget site, assist in the transfer of casualtiesfrom the target vessel to dry land, triagethem and ensure that, according to medicalpriority, they were moved onward to theCSU at Mestersvig for further treatment,stabilization if required, and, in the mostserious cases, full medical evacuationonward to Keflavik’s General hospital.

Camping by the water’s edge overnight, bythe second day Johan and his team of one

Lance Corporal Claus Larsen

doctor, Rene Bleeg, one nurse, Martin, andtwo other paramedics, Johnnie and Michael,had processed 162 casualties, includingthree ‘severely injured’ and a high numberof level ‘3’ ‘non-injuries’ which they sentforward to Mestersvig at a more leisurelypace by boat, on the nearly brand-new

£29M Icelandic Tug-boat, Thor, which, havingtravelled on it, I know to be about as warmand comfortable a transfer as it is possibleto enjoy. With comfortable seating andrestaurant quality hot food available for over200 passengers if required, the onlydownside to this mode of travel is that at 7

knots per hour, the sixty-plus Km journey upKing Oscar Fjord takes over four hours. Theother bonus however is that, in daylighthours especially, so long as you are notseriously injured and in urgent need ofmedical care… the views are stunning!

The medical view from theCommand Tower

Captain Dr Michael Treschow, who assistedin the command post also worked as partof the CSU team, explained: “I think wewere all amazed by this exercise as none ofus have had the experience of being quiteso far away from our usual medical facilities.The target area was so remote. Libya gaveus some experience of transporting largeamounts of medical equipment but here wealso had to set up quickly and find out howeffectively we could do our job in a remotelocation. The experience of learning how towork with logistical partners like Ice-SARwas also really useful for us as, in a real-lifescenario, working out what should gowhere and what medical equipment shouldbe powered up first, can determine theeffectiveness of the whole mission. I had theopportunity to receive and treat a fewpatients in the CSU during one particularlybusy period and, looking back, we couldalways wish for more space and manpower.But, thankfully, we successfully treated all thecasualties that came through. One wondersthough whether, if we had to sustain apatient flow for 24 hours, we could manageto handle a high-volume of patients in thisenvironment. We physically treated about26 casualties over both days and that initself was a big strain on our manpower.”

Michael added: “Throughout the exerciseour focus was on initial treatment andstablilization so that casualties could beevacuated as soon as possible. I’ve no doubtthough that in a real-life situation and inmore adverse weather conditions – snow,much lower temperatures, harsh winds…many of the procedures that we managedthis time might be much harder and, insome cases, probably impossible. We’ddefinitely need a much bigger team. Onevaluable thing we learnt was that the onlyway to function was to put aside externalfactors and distractions and just do our bestto focus – to concentrate as best as wecould on simply giving our usual medicalcare – assess, treat, monitor… on with thenext task, and to do this no matter howunusual the situation or challenging theenvironment.”

Reflecting on the environment, Michaelcontinued: “Other skills that we developedas we went along included the ability toimprovise, sometimes making do with



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whatever was to hand, and to respondquickly to the environment. For example,early on when the first casualties werebrought into the CSU we put the level ‘2s’and ‘3’s’ on stretchers placed directly ontothe tent’s groundsheet, at ground-level.Realizing that even though it was nowherenear as cold as it could have been, ourpatients were still very uncomfortable, wesoon saw that all the patients on stretchers

needed to be elevated, wrapped in moreblankets and also in hypothermia wraps toprotect them from the cold and the wind.With real hypothermia victims, lifting themup and making them comfortable as quicklyas possible would be a big priority. Welearnt much of this on Day One so thingswent far better on Day Two. I’m sure we’llcontinue to analyse and digest what welearnt on this exercise so hopefully evenmore ideas for improvement will come out.You realize that in such situations, noticingsmall things and attending to them canmake a vital difference to the patient’s well-being.”

Lessons learnt in the CSU:

Sarah-Lynn Marshall has been a nurseanaesthetist for over twenty years and herfull-time nursing experience includescardiac, gastric and EMT at the Gentoftehospital on the outskirts of Copenhagen. “Ienjoy my regular work,” she explains, “but Iwanted a new challenge so when a friendtold me about 690 Squadron I appliedimmediately.” After a five week boot camp

Sarah signed a four year contract which sheis currently midway through. “Joining up hasbeen a fantastic decision and, even though itsometimes takes me away from my husbandand two teenaged daughters for a period,it’s worth it as I don’t only get to keep myexisting clinical skills sharp but I’m alsolearning new skills, such as how to delivercare in extremely challenging situations.Next January I’m doing a four month touron attachment to the British Army inHelmand Province, where I will be using mynursing skills in an environment that I knowwill be testing but which will make a positivedifference.”

So how did Sarah find the SAREXexperience? “The exercise was reallyvaluable for us all in one key respect”, sheexplains. ”You’re faced with learning how toapply your clinical skills in a setting with awhole new set of obstacles and demands.We’ll need a chest-tube and if we don’t haveit we have to find a way to get the job doneanyway. Also, you have to try and predictwhat drugs and equipment you think you’remost likely to use but then, when you getthere, you find out whether or not yourthinking and planning was helpful.Anticipating the possibility of having to treata large number of casualties suffering smoke-inhalation, we brought along a particulardrug, Acetylcystein, but as it happened, inrelation to the actual setting, and taking allfactors into account, we probably wouldn’tbring it in a real-life situation, as we learn itwasn’t the ideal drug to use.”

Sarah continued: “In the same way, webrought along oxygen catheters but learntthat we’d be better off using oxygennebulisers and masks. So this exercise wasreally useful in terms of allowing us tonarrow down the equipment we shouldbring along and to learn which factors, bothmedical and practical, we should focus onwhen planning for a major evacuation.Weight, for example, is a really importantfactor so if you’re unsure which of two unitsto bring along – go with the lighter one. Youalso have to be very clear `about what thekey drugs are that you’ll need as, onceyou’re on-scene, you only have those drugsavailable that you actually brought along. Wetook lots of saline for hypothermia andburns treatment and we brought along lotsof Fentanyl for anaesthesia, but in fact weonly needed this for a couple of patients.Logical evaluation of the type of situationyou are responding to is a simple butimportant factor. The type of incident shoulddictate what drugs you bring. With an earthquake, for example, you’danticipate lots of crush injuries and brokenbones so you’d bring along more pain reliefdrugs. In a fire, obviously more burns



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treatments. The scenario for this exerciseled us to anticipate that lots of hypothermiatreatment would be required as thecasualties would have been stranded in sub-zero temperatures for prolonged periods.For this trip with hypothermia and smoke-inhalation expected as a major theme webrought along lots of oxygen. It sounds basicbut, as Michael pointed out, getting thestretchers off the ground was an importantlesson and, to add to that, next time we’ddefinitely need to bring along a lot moreblankets.”

I asked Sarah what logistical lessons she hadlearnt? “We all agreed on one key point”, shereplied. “Even on the scale of this exercise,with just around 160 potential casualties, wewould need much higher numbers of

medical staff to cope. The numbers ofmedics on-scene even affects what type ofdrugs and equipment you should bringsince, if you anticipate carrying out highnumbers of certain procedures, such ashypothermia treatments, you need biggerteams, particularly for stabilizing andmonitoring each patient when they are intransit. Another issue we all agreed uponwas that it would have been helpful if theinformation flow had been better from theoutset of the exercise. Lasse [Brink] did agood job of briefing us clearly throughoutbut since there was a radio comms problemfrom the start and throughout fromGreenland Command we were working inthe dark on casualty numbers and weren’tbeing told clearly when casualties wouldarrive, or what to expect when they did.

Sarah continued: “Some of the things welearnt may seem clinically insignificant, butgetting the small details right can make a bigdifference. We had problems with thelabeling of some boxes not being clearenough, making it difficult for us to findrespiratory equipment. Equally, the system inplace for tagging patients as they flowedthrough the CSU from the target site andthen on to being evacuated to Keflavikcould also have been improved. The casualtymanagement system did work… but itcould have been better so we wereworking out ways to refine it even as wewere using it. Particularly with a view toimproving the information flow on patientsto sharpen up their treatment. Whenpatients were being checked out from theCSU we didn’t have a reliable system inplace to get the right level of patientspassed on to the Evacuation team. Wedidn’t find a clear answer to that one butwe know now that we need to work on it -so that’s a ‘problem identified’. Equally, forpatient identification and storage of theircase information we were using a cameraand then printing out info and passing thesealong the treatment chain. Perhaps we couldhave done all of this by using an IPAD?”

Sarah also recognized that working underpressure with unfamiliar workmates alsobrought other problems not usuallyencountered in the hospital setting. “Anotherfundamental lesson we learnt was that weshould make the identification of all themedical team clearer. We all wore bibsmarked ‘Medic’ but this wasn’t clear enoughand it meant that people couldn’tautomatically tell who they were dealingwith. In future we need bibs that say what weare: ‘doctor’ or ‘nurse’ or ‘paramedic’ or ‘flightmedic’. At one point, for example, we had avery highly-skilled nurse overseeing theregistration of patients on arrival at the CSU.This wasn’t an ideal use of our resources asthey could have been used better as part ofa treatment team - somebody less medically-trained could have managed the arrivals.Overall, we definitely needed a lot morenurses and ideally with a wider mix ofspecialist nursing skills, to ensure we couldrespond to a wider range of injuries. I alsothink that since we had four doctors with us,we should have had a doctor situated at allthree sites right the way through.”

Sarah’s conclusion? “Finally, another biglesson we all learnt was giving thought tothe actual positioning of the CSU facility. Onthis exercise it was about 300 metres awayfrom the runway and up a slight incline. Ifyou allow for the fact that a differentscenario might include transferring thecasualty through heavy snow in much colderconditions, then placing the CSU much



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closer to the runway would help. Obviously,there’s a minimum distance, as you can’t betoo close to the runway for safety, butcutting down the distance which casualtiesneed transporting when being stretcheredfor evacuation is an important aspect ofkeeping them stabilised and warm.”

Sarah finished: “ Overall though I do feelthat this was a very well-prepared exerciseand that we all learnt some very valuablelessons from it. If it sounds like I’ve given along list of things that could be improved,then that’s good - because learning aboutthese problems and how to overcomethem is exactly why we did this exercise onthis scale. You don’t want to be learningthese things when real lives are on the lineso now we’ll have these systems in place inthe event of a real situation arising!”

Jesper Ægidius broadly agreed: “We treated26 casualties in the CSU over the two days,with the majority, 16 of them, treated on

Day One. However, all eight casualties onDay Two were Priority ‘1’ casualties thatneeded evacuating forward urgently and, inview of the small number of medics we had,I think we did well to treat them all. Thewhole logistics set-up was a test for usbecause it was new. The good thing thatshone through though was that thebackground that each member of the teambrought with them was a great help. Wehad Michael, the doctor, Jan, the FlightMedic, and, Sarah and Vibeke, the nurses.Even though we hadn’t all worked togetherbefore, I think we came together well as ateam.”

The Hypothermia team - Lars and Torben:

Perfusionist, Torben Nielsen andCardiothoracic surgeon, Dr Lars Møllerwork together as part of BenedictKjærgaard’s hypothermia team at AalborgHospital. Both were keen to participate in

SAREX 2012 to explore how well theirteam’s experimental procedures for thetreatment of advanced hypothermia wouldwork in the challenging setting provided bythe High Arctic. Of particular interest waswhether or not their miniature heart lungmachine (HLM) would perform in adverseclimactic conditions. Lars only works withBenedict these days on a part-time basis ashe is also completing his surgeon-training incardiothoracic surgery while working as aMajor in the Danish army, but theopportunity to participate in this exercisewas too exciting to resist.

As he explained: “In a real catastrophe inextremely cold conditions, our primary jobwould be to protect people fromhypothermia. Basics such as providing tentsand blankets to keep people warm areessential. Warm drinks and blankets are vitaltoo, as we can treat far more people thisway than with chest tubes, central warmingor even the HLM. Our biggest challengewould be severe hypothermia and thebiggest question would be whether or notwe could intubate, perform perfusiuon, etcas we’re dependent on power to use ourequipment so we really need a protectedenvironment – we need to be inside – sowe can get on and treat patients. We alsoneed the right team, the right logistics andthe right equipment. Not a lot to ask!Thanks to this exercise we now know wecan do it. Definitely, we can do it! “Larsaddeds: “ICE-SAR gave us a perfectenvironment – heating tents and 9,000watts of power in just an hour and a half sotheir role was vital.”

Torben explained that the miniature heartlung machine (HLM): “Consists of a Maquet



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Rotaflow Centrifugal Pump weighing 14.4kgs and measuring just 179 × 385 × 243mm, it’s very compact. We brought along adummy setup as well as a sterile setup forthe machine, both cannula and pump andoxygenator. This equipment was for thetreatment of patients with ventricularfibrillation caused by hypothermia. Themedicine we brought for this treatment wasHeparin - to prolong bleeding time - andSodium Bicarbonate to correlate acidosis inthe hypothermic patient.”

Torben added: “For treatment of moderatehypothermia we also brought a setup forwarming through the pleura, consisting ofpleura drainage instruments as well asconnections so we could warm the patientwith 43 degree C warm Saline ½ a litreper side passive running in and out aftergiving some warmth to the patient. This Isone of the main treatments I wouldsuppose we would use if we were to treatthe patients in a real life situation. Only afew patients can be treated by the HLM,but quite a lot can be heated by pleurallavage.”

Torben explained the treatment further,saying: “All the patients we might treatwould then be intubated by the Medevac team, but in the case of treatmentwith the HLM, we give the patient bothcardiac and lung support, CPS, draining theblood by the femoral vein, circulating withthe rotaflow, oxygenating through theoxygenator, and delivering the blood backto the patient through the femoral artery.”

He added: “But looking back at the setupwe had in the CSU at Mestervig, you mustremember that we were there in very mild

conditions for the region - with sun, ratherthan ice and snow, and with almost nowind. And even despite these factors, thecasualties started freezing when they wereplaced on the stretcher after beingstabilized. In the case of real casualties theymight not be able to alert us to this issue,and some would really suffer, so we learntthat we need to be more aware of this.”

I asked Lars on his views regardingcasualties and survivors: “It’s difficult to tell,but some of the ‘patients’ we transportedto Keflavik on the second day wereseverely injured. I don’t think all of themwould have survived as we were in need ofextra hands at both the CSU and duringthe Medevac. Some of the people playingthe casualties presented with quite severesymptoms so, in reality, no – I don’t think all

of them would have survived”.

Lars added: “In a real situation there wouldbe no breaks and we would not know whatto expect on arrival. We had a lot ofcommunications problems so it took a whileto find out what was happening and howmany casualties we would receive. But finallyour own command post succeeded incommunicating with the ship and theforward mobile team. There were only 3hypothermic patients on Day one – withtemperature of about 35 degrees – so nottoo severe. They were clear and responsiveand only really needed blankets and warmdrinks. From an exercise viewpoint I’d haveliked some severe patients, ideally in cardiacarrest, as this would have allowed us to testour systems and equipment more fully.”



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I asked Lars what procedures they wouldfollow in a real live situation. “Well, first weneed background info and we need someindications – such as, ‘the patient was seenfalling in water but was alive’. So first westart basic CPR, we give hand massage tothe heart, ventilation on a mask and weintubate them quickly and apply the Lukasautomatic chest compression system. Thatgives us some time to work on them and tofind out if they can be saved. Next, we takea blood sample and measure theirpotassium blood levels. We have anautomatic blood gas level analyser (ABLdevice). Here, of course, we have a smallmodified mobile device. If it reads above‘10’ in adults or ‘12’ in children we can’tsave them. Below that level though we’llcontinue with advanced resus using theHLM. From the minute we start tocompletion it takes about 10-15 minutes toapply the HLM in the groin and in that timewe expect to get the patient back into fullcirculation. In a setting like this we need ateam of minimum 3 people – a nurse tointutabe and ventilate, me and Torben to doheart massage and the blood samples andthen to apply the HLM.” Commenting on

the exercise, Lars noted: “Our patientsrecovered with no problems but, accordingto the scenario, they were mild.”

So what were the benefits of the exercise?“There were a lot of really valuable lessons– especially working with the ICE-SARteam. We’ve also seen how our equipmentcan work. One lesson we learnt is thatinitially it was planned that there should onlybe two nurses and one medic. The Medevacteam didn’t go to Keflavik on the first day sothey stayed and helped us in the CSU, andeven with them we would still have neededmore manpower, so I think we’d need ateam of at least eight people.”

Lars added: “The equipment worked okaybut if we tried to raise the level of care andhad to use even more advanced equipmentI’m not sure we could do this over such along transport distance as you’d need atleast one medic per person to keep themstabilized. If we chose to intubate two orthree patients we’d lock down two or threepeople from the team. In the hospital we’reused to having more or less unlimitedresources if there’s only a few patients…

but here it’s very different. As a team wetalked about emergency surgery. Should webring blood? If we were to do anemergency thoracotomy, you’d need bloodand a complete team. Maybe one thingwe’ve learnt is not to expand our horizonsunrealistically.”

Torben gave the final comment, saying:“Other treatment elements that were issuesfor us were the transport between the CSUand the evacuation aircraft – which couldhave been improved – and the generalshortage of equipment and staff.”

The Medevac team – Allan andUlrich’s overview:

Allan Fugslang, an RDAF flight medic with25 years experience of major incident andbattle trauma medicine led the Medevacteam, but even with experience serving inBosnia and Afghanistan this was a newexperience for him. “I think this exercisecould have been planned a little better,especially the patient flow through thewhole system. But I think that every teamgot something out of this exercise. It was alittle chaotic on the first day but that’salways the case, especially in real lifesituations. At one point we joined the CSUteam to help out as we didn’t have aHercules available yet to take casualties onto Keflavik.”

Allan finished: “I was a little worried abouthow well the role-players were briefed whoplayed the casualties. I don’t think they werewell-instructed on how to present theirconditions so that made it a bit moredifficult for us to treat them. Languagewasn’t a problem as, being Greenlanders,they all spoke either good English or Danish.As a squadron though I think it has been areally positive learning experience.”Ulrik Edelmann, the Medevac team’s doctor,agreed, adding: “We had a team of just five



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people so if this was a real situation I don’tthink we would have managed too well aswe carried a manifest of 16 casualties onthe one flight we took to Keflavik, whichincluded six priority ‘1’s and four priority‘2’s. Fortunately the three most severecasualties had been stabilized well and wereall inside the module. This included oneacute hypothermia patient who was beingsupported on the HML. We were alsotransporting a skull trauma patient,unconscious on an oxylock respirator, acouple of chest traumas and four casualtieswith severe fractures. Just the first four caseswould have been difficult to manage. If ithad been a real incident, going up wouldhave been unrealistic as we wouldn’t havebeen able to keep all our casualtiesstabilized throughout the long flight.”

Ulrik continued: “Another problem we hadwas that because of the constraints of flightregulations for the crew we had to departas quickly as possible or not take off at all.This meant that there may have been somecasualties we would want to evacuate butthat weren’t stabilized yet so had to be leftin the CSU. Of course, leaving them behindwas preferable to taking them when theyweren’t stabilized. Our team consisted ofCharlotte, Tatyana, Peter, Allan and myselfand, despite the fact they are all very highly-skilled nurses and medics, this wouldn’t havebeen enough to look after all the casualtieswe had on-board.”

Summing up the exercise as a whole, Ulrikobserved: “Being realistic, I’m not sure thatall the casualties would have survived asmany of them were fairly severehypothermia cases and we would not havebeen able to keep them all warmed upsufficiently. Equally, a lot of patients whowere on stretchers were supposed to besuffering from carbon monoxide poisoningand were receiving oxygen, yet we couldn’tput them all on respirators.”

Ulrik finished: “My overall view of theexercise though is that it was verysatisfactory as it gave us a chance to identifythe lessons we need to learn – particularlyin terms of how to run a Casualty StagingUnit. And we had many lessons to learn. Weneed to improve in many areas but we willdo that in the future.”

The Commander’s Appraisal:

Major Lasse Brinck was generally satisfiedwith the outcome of the exercise and thelessons learnt saying: “Since it was the firstfull chain deployment with Squadron 690,preparation, staffing and the deploymentphase were quite intense and with manyuncertainties. The execution was

satisfactory, despite problems concerningon-site communication, particularly satelitecomms, which created real difficulties inestablishing an effective on-scene chain ofcommand.”

Lasse went on: “On the tactical level,evacuation, medical support and the use ofair capabilities were executed well. Factorsdelaying the evacuation of regularpassengers and injured passengers weremainly related to exercise conditions, suchas crew rest regulations and limitations indeployment of capacities. One area thatwould need addressing would be our totalairlift capacity as we definitely needed moreand better-suited air transport. Helicoptersthat could carry more stretcher patients pertransfer was an asset we were definitelyshort of and this would have a real impacton the speed of treatment in a real lifescenario.”

He added: “For Squadron 690, learningaspects that we now know need addressingas a priority include staffing of the differentsubunits. It became obvious to us quitequickly that our casualty staging unit (CSU)would have been understaffed in terms ofthe sheer volume of casualties requiringurgent treatment, so it would have been ahuge advantage if the team would havebeen twice the size. Furthermore, the CSUshould have been extended to include asmall administration cell capable of handlingregistration issues of the patients in supportof the police. This admin cell should beequipped with sat based datacommunication equipment and wouldprovide the medics with the info and dataneeded to get on with the patient-care in aquicker and more efficient manner.”

Lasse finished: “However, the overallappraisal of the exercise for squadron 690

was very positive. We have been confirmedin our ability and capability to conduct amedical evacuation in a very remote arcticregion and that was our primary objective.The squadron has not officially been taskedwith preparing this capability, but we arevery certain that with a proper order toprepare for such a task, we could developan invaluable asset for arctic emergencypreparedness.”



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Special thanks to OS ThomasBlanke of RDAFPhoto Sectionwho took all the photographsfor this specialfeature.

As Admiral of the Danish Fleet from2005-10 Nils Wang has extensive knowledgeof the economic, environmental and politicalissues affecting the High Arctic region.Commenting on the SAREX exercise hetold Ambulance Today: “If we want the Arcticregion to be managed wisely in the futurethan joint-working between all the memberstates of the Arctic Region is vital so, in thatcontext, SAREX 2012, which was organizedto improve the safety of all shipping traffic inthe region, is a tremendously positive movein the right direction.”As well as contributing the Patrol Frigate

‘Triton’, which acted as the target ship forthe exercise, the Royal Danish Navy alsocontributed two other ocean patrol vesselsequipped with helicopter landing pads, whichformed the main sea rescue force, alongwith a newly-built Icelandic Coast Guardvessel. ‘Thor’.Admiral Wang explained: “As the multi-

year ice progressively melts each year thePolar Sea Routes of the Arctic Ocean isincreasingly opening up as major new globalsea lanes. It is fully navigable and it willbecome an alternative to the Suez Canal.Traffic is already increasing in the regionevery year but for now, while it is still notdensely populated by traffic, it is importantthat we have strategies and resources inplace to ensure that if an incident doeshappen we can respond as quickly andeffectively as possible. We have a duty toprotect and preserve human life.”Commenting on the reasoning for

mounting the £15M joint-exercise, AdmiralWang said: “Despite the increasing ice-melt

in the region generally it must beremembered that only about 3-5% of thewaters closest to the shores around theGreenland Sea are charted even today, soabout 97% is still uncharted. It is still veryremote and therefore very dangerous tonavigate, so using high technology to chartthis vast expanse will be a high priority in thecoming years as the ice-melt continues andthe sea traffic increases exponentially. In themeantime, we all have a shared responsibilityto do all we can to protect vessels passingthrough these waters.”Admiral Wang explained how the ice melt

will affect the economic and maritime

landscape of the region, saying: “It’ssomewhat of a media myth that the regionis beset by disputes between nations over oiland rare earth element resources. Actually,for the most part, border lines are veryclearly established and the UNCLOSagreement forged by the United Nations in1982 means that ownership of only about3% of all the known resources is still underdiscussion and, even those negotiations arebeing arbitrated in a structured andharmonious fashion. NO, the biggestchallenge we have is that when the ice meltsand this significant new sea lane opens up,this new passageway might increasemaritime activity in the area significantly.Bearing in mind that China currently exportsabout 50% of its annual GDP by ship youcan imagine how this will affect this newfaster, more direct and more cost-effectiveroute to their marketplaces.”



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Rear Admiral Sir Nils Wang, Commandant of the Royal Danish DefenceCollege, is acknowledged globally as a leading expert on the maritimeeconomic make-up of the Arctic. He gave Ambulance Today a brief overview ofthe High Arctic maritime issues which made SAREX 2012 a a vital building-block in increasing the safety of the region for all shipping traffic

Reviewing the High Arctic Situation in the Long-Term

Admiral Wang predicts the route mightbe in systematic use within a decade, saying:“This new route is opening up quickly. It’sthe multi-year ice which is now melting –those layers of ice which typically stay year-round growing thicker each year. But sincethe year 2000 it has been reducing. Up until2000 multi-year ice accounted for 50% ofthe area in the High Arctic – making itimpossible to travel through – however it’salready down to just 10% now and whenthat final portion melts completely it willcreate a navigable sea lane that will reducethe sailing distance from, for example,Rotterdam to Okahama in Japan, by 40%distance. That’s a huge saving in terms ofboth sailing time and fuel costs – also abouta 40% reduction. Ironically, one major benefitit will bring is that it will massively reducecarbon emissions significantly. Anotherbenefit for those using the newly-openedroute is that, whereas now its veryremoteness, coupled with its challenging anddangerous climate, makes the High Arctic avery risky place to travel through; of course,as it becomes more widely used, especiallyby commercial cruise traffic, it will in thelong-term actually become safer as there willbe far more vessels in the area to respondto a distress signal if a ship actually gets into

difficulties.”Admiral Wang finished: “ Clearly the best

way to create synergy in the region is to co-operate with each other, so by workingtogether on important issues such asmaritime safety, we are improving theprospects for the region generally andensuring continued stability in the region for

the years ahead. To that extent, the SAREXexercise has been a great achievement andthe lessons we will have learnt from it willdefinitely make the High Arctic region a farsafer place to navigate until nature plays itspart and opens it up for more shippingtraffic.”



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Leif’s two co-workers are Aksel Jensen,50, and Kim Eckert, 25. During the Sarexexercise all three men work constantly onthe station from early morning until late atnight, either directing incoming anddeparting aircraft or busily loading andunloading pallets of supplies and equipment.Once the Sarex exercise is completed Akseland Kim will remain here alone for anothersix months, braving out the winterconditions to keep the station running dayand night.Looking out over a landscape dominated

by snow-capped mountains are twoboulders marked by a roughly-made crossclose to the Control Tower, I ask Leif, fromSaeby in Denmark, what they are there for?“Two guys died here together 20 years ago”he explains. “They made the mistake ofgoing out in a dog-sled for a bit of fun atthe wrong time of year. They went out toofar onto King Oscar Fjord and the ice broke.This was in October when the ice hadn’tcompletely frozen over yet… By Decemberthe whole area is frozen over solidly butthey should have realized the ice wasn’t safeyet. One of the guys was due to fly home

the next day so it looks like they weretempted by the idea of one last dog-sledride. The point is you have to be verycareful when you work here – Here you dothings carefully to avoid accidents and youabsolutely never take unnecessary risks. Ifyou do… the cost can be very high.”So what precautions do you take when

you’re one of two men running the dailyoperations of remote Station Mestersvig?“We call in twice a day. If you miss twoconsecutive contacts with the Sirius guys atDanneborg – twice daily at 8am and 8pm –they’ll be on alert.”Before he was recruited for a year-long

stint working as one of just two facilityoverseers on the station, Leif , 50, had alsoworked for two years as a member of thehighly-regarded Sirius Patrol, the rangers

who oversee over 16,000 kms of coastlinealone along the High Arctic’s national parkarea. The highlight of his two years withSirius involved a 3,600 km dog-sled journeywhich took 14 weeks and during which timehe and his partner didn’t encounter a singlehuman being, except with one stop-off atStation North. A trim, deeply-tanned ex-Navy engineer, he completed his officialyear’s service at Mestersvig in March butreturned this August to help Aksel and Kimcoordinate the SAREX exercise as a thirdspecialist was needed to help cater for theunusually high number of visitors coming tothe station to take part in the exercise.“All the guys chosen to work here have a

military background or have been witheither the Sirius patrol or Station North”says Leif. “Before arriving we’re given special

Meet the happiest man alive!Only your own thoughts and one co-worker for company for 365 consecutive days… in December the temperature can dropto -45C… Polar bears are your only visitors…it’s dark day and night for months on end… and over 2 metres of snow fallsevery 24 hours... But sat smoking a pipe on a rooftop terrace on a beautiful crisp, clear Autumn morning, Station Mestersvigoperative, Leif Beermann, tells Ambulance Today why running operations in the remote High Arctic is the best job in the world



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Leif Beerman

training to maintain the station. Our mainjob is to keep the runway operational asthere’s no other landing strip capable ofreceiving large aircraft between here andStation North, which is C1200 kms northand is the closest point to the North poleoccupied by humans.”As Leif explains: To run this place you

must be very practical – an engineer,plumber, electrician, builder and vehiclemechanic combined and then, of course, ontop of that you need electronic radio skills.To work here you must have all these skillsto a pretty high-level” then, he modestlyadds. “You learn some skills simply by doingthem. “If the sink won’t work…suddenlyyou’re the plumber… you learn becauseyou must!”Communications with the outside world

are primarily conducted with their Siriuscolleagues in Danneborg and with theirmates at the even more remote StationNorth. “We have UHF comms and a bit ofInternet comms, but the internet breaksdown a lot, so we mainly get by usingiridium satelite comms. We check in everyday, we use it when either aircraft are dueto land or when cargo ships are droppingoil off via the Fjord and, of course, onspecial occasions, such as Christmas day, weget a hook-up to say ‘hi’ to our families.”Station Mestersvig was built by the

Danish government in the 1950’s. It is 1.8km long and 2.5 km across – so about 5km’s in area. It is on Kong Oscar Fjord andbranches out into five other fjords by Ella Øand then out into the Greenland Sea. Thestation was built to provide a landing stripcapable of taking large aircraft to fly insupplies to support the various mininggroups from the High Arctic region busy inthe area. “It was nearly closed in ’89 whenmining declined”, says Leif, “but it was keptopen when common-sense prevailed and itwas decided to leave a two-man crew herepermanently to maintain the landing strip inthis most remote part of the High Arctic asit is still badly needed - if only in case a shipmight get into difficulties in the region and abase is needed to fly in rescuers andmedics.”The two-man team sign up for a contract

of 12 months and get paid a modeststipend on top of their regular military payin recognition of the fact that they arealways on duty 7 days a week and 24 hoursa day. Summer begins in June but only lastsuntil mid- August – that’s 2 months of fulllight. “You sleep with the blinds shut”,explains Leif. The warmest it gets in summeris between 10-15 Celsius but during thatperiod the whole area is, surprisingly,besieged by mosquitos. So what are the daily duties? ”Every day

you must go out check the generator, feed

the dogs, keep the runway clear. We have asummertime rush-hour for landings as wesupport Australian, Chinese and Polishmining crews. Also changing navy crews flyin and out. We also get a few cruisers in theFjord. A large amount of time is spentconstantly maintaining and repairing ”Kim, the youngest member of the team,

explains. “Another of our tasks is keepingElla Ø,and Danneborg stocked withsupplies as we’re the only place whereheavy loads can be landed. In February andMarch, the worst part of winter, wholebuildings can be submerged in snow but wehave a big yellow snow-blower to keep therunway clear. We raise the shovel, go intothe snow and blow it away. The thing is thatit takes both men up to two weeks, working14 hours a day, as you’ll be clearing twometres of snow off a runway that’s 1800metres long and 40 metres wide. It can takean hour and a half just to go from A to B!After using the snow blower you then haveto prepare the runway and make sure itslevel and clear – so clearing the snow is onlyhalf the work. You have to make sure itssolid for the plane to land. For the otherjobs, we have an MPV [Multi-purposevehicle] we can attach various tools to–shovel, crane, etc and we use it for all sortsof jobs – especially for the lifting.””I ask Leif how structured their daily life

is? “We work about 8 hours a day – butevery day. We’re always up before 8am butwe keep a strict daily routine – painting,repairing, maintenance. We work untilabout 5pm then break off to eat. Then we

have normal evenings – we watch DVd’s weread, we talk. We clean the tower everySaturday from top to bottom – toilets,kitchen, bedrooms, workspaces, every inch.It’s important to have a routine here and tostick to it or else you lose track of timewhich is very bad for you mentally.”I then ask what happens if there is an

accident when working? “We have goodbasic medical training – you have to lookafter yourself and your workmate. Thiseven involves doing dentistry, stitching, etc –even small operations. We sometimes haveto operate on the dogs if needed. We havemorphine and medications for all types ofinfections. Of course, we also have a phone-line to a doctor who can advise us. But itcould take a week for a doctor to fly in –depending on the weather. We can begrounded for a week – so we must becapable of taking care of ourselves and eachother. We even have our own small medicalroom/operating theatre!”Leif Beermann may well be one of the

happiest people I’ve ever met. Have youever thought of having another life, I askhim? “If I could go back again and chooseany life… I wouldn’t change a thing”, hereplies quietly, smiling.


August 2012 | Ambulancetoday 27

Kim Eckert


UNISON Update

28

AmbulanceTODAYUnison Comment

The Ambulance service as well as the widerNHS is currently going through massivestructural changes with the privatisation ofservices, changes to pensions and budget cutson a scale we have never seen before. Acrossthe NHS there is tremendous pressure tomake 20 billion pounds of efficiency savings by2014 and this pressure to cut costs and makesavings has led to radical plans by AmbulanceTrusts up and down the Country.In other parts of the sector, employees are

also facing outsourcing to the private sector,reorganisation, redundancies and threats totheir current pay, terms and conditions.Meeting the demands of these cost

improvement programmes has resulted in anumber of recent proposals for cuts to bemade to ambulance staff, to stations and tochanges in the way in which work is carriedout. The East of England Ambulance Trust has

proposed reducing the number of staff andvehicles delivering emergency responseservices across its area at a time whendemands on its service continue to increaseand its population also continues to rise. The proposals also come at a time when

the Trust's own figures show that in manyareas, staffing levels will be far below what isneeded. In rural areas, this could lead topatients having to wait longer for emergencycare where some of the worse responsetimes to life-threatening 999 calls arerecorded.

It is worth noting that while nationalguidelines say that at least 75% of the mostserious 999 calls – category A – should beresponded to within eight minutes, figures forthe first four months of 2012-13 show thatsome areas within East of England met only68.00 per cent of those calls on time. In addition, the cuts would worsen the

work life balance of staff. In the West Midlands it has just been

announced that more than 200 jobs will belost over the next five years. And although theDirector of Workforce has suggested that thejobs would be lost through natural wastagerather than redundancies it is a worrying timefor staff and members of the public alike.In East Midlands a number of ambulance

stations across the region face the axe undera major cost-cutting programme. Hereemployers are drawing up a “rationalisation”programme which would see most of theregion’s ambulance stations shut.Instead around a dozen main centres could

be created in a “hub-and-spoke” model, withmost 999 crews operating from standbypoints or locations shared with otheremergency services.Managers claim the plans, which are unlikely

to be fully implemented in more rural areas,will cut staff downtime and release resourcestied-up in land and property, as well asimproving emergency responses. Cash savingsand proceeds from site sales would befunnelled to frontline care.All of these moves come at a time of

unprecedented financial pressures leaving the

ambulance service, in common with otherNHS organisations, requiring cost savings of atleast four per cent each year at the same timeas demand for emergency care increases at anestimated three per cent.UNISON is seriously concerned about a

strategy which could see front lineambulances removed or reduced in manyparts of the country at a time when demandson the service is rising.In our view many of these cuts are based

on cost savings, rather than improvement topatient care and response times. We believeAmbulance Trusts across the country shouldbe investing in more staff and vehicles toimprove response times, not closing stationsand, putting patients at risk.Bryn Webster, UNISON Ambulance Sector Chair,believes that: “These cuts are going to have a

devastating impact onpatient care andUNISON membersworking within theAmbulance Service.Demand on theservice is rising whilstjobs are being lostwhich can only havea negative effect onthe government’s owntargets. The increase

on demand is fuelled by other support servicesbeing axed within the NHS and Localcommunities, closing stations and cutting frontline services is not the answer.”

‘No’ to postcode payThe NHS that we know and love is under

threat. One of the biggest challenges is thepressure to cut costs and make savings. Tomeet these savings some employers aremaking threats around Agenda for Change(AfC) by seeking to cut or reduce terms andconditions. In the South West 20 NHS Trustshave got together to do just this bycollaborating on radical changes to pay andconditions and the creation of a regional paysystem.Agenda for Change (AfC) is the national

pay, terms and conditions agreement for allNHS staff, apart from Doctors, Dentists andvery senior managers. AfC seeks to ensureequal pay for work of equal value, harmoniseterms and conditions of service and providebetter pay progression. The agreement setsout pay rates, incremental pay progression,what constitutes unsocial hours or overtime,maternity arrangements, annual leave, sickness

HOPE DALEYis UNISON’s AmbulanceSector Lead. Read on to findout about the key policyareas UNISON will beaddressing on your behalf intheir fight to prevent themany threats to ambulanceservices across the UK.

March with us for a future that works

absence, facility time and many others. Proposed plans could lead to cuts of up to

15%. Additionally, AfC is a national agreementrather than a local one. If we let individualemployers break away from this nationalagreement it will be easy for them to drivedown the quality of terms and conditions.Local negotiations on terms and conditionswill create a situation with varying outcomesacross the country which will be bad for theNHS, bad for patients and bad for all NHSstaff across the UK. Local pay hurts the localeconomy, compromises patient safety,seriously damages staff morale and createsinstability in the workforce at a time when theNHS is going through unprecedented change.But patients will pay the ultimate price asworkers who can move to areas where wagesare higher will do so, leaving NHS trusts inlow wage areas struggling with staff shortages.Not only are their plans unfair – health

workers are already facing years of payrestraint – they also threaten to destabiliseongoing national negotiations, covering payand conditions for health workers across the

UK. Breaking national pay agreements willundo years of work creating a level playingfield for pay and conditions across the NHS.UNISON is working to convince these 20

Trusts to roll back on their plans and insteadfocus on protecting patients, staff and oureconomy. Not only are their plans unfair –health workers are already facing years of payrestraint – they also threaten to derailongoing national negotiations, covering payand conditions for health workers across theUK. Breaking national pay agreements willundo years of work creating a level playingfield for pay and conditions across the NHS. We are also asking people to sign an e-

petition calling on the Government to do thesame. Sign the petition here:http://epetitions.direct.gov.uk/petitions/36063

March on 20th October for a futurethat works The threat to ambulance services is an

example of the sort of cost-cutting that isleading UNISON members throughout the

country to publicly show their concerns. On20 October hundreds of thousands of peoplewill gather in central London, Glasgow andBelfast to march for a future that works. They'll be taking to the streets because

they believe that government spending cutsand privatisation are not the way to get usout of recession. Instead, these cuts arestanding in the way of delivering the jobs andgrowth that we need. UNISON members believe cutting vital

public services hurts the most vulnerablemembers of our society. People who can leastafford to pay the price of the recessioncaused by the bankers. We also know that austerity isn't working -

and most forecasts suggest that we face yearsof economic stagnation. The coalitiongovernment has got it wrong and they needto replace austerity with policies to create afuture that works. We care about healthcare, and other public

services. That's why we are marching inLondon on 20 October. If you care too, joinus.

AmbulanceTODAYUnison Comment

29October 2011 | Ambulancetoday

UNISON Update

Baus to showcase new disaster managementbespoke vehicle offering at ESS 2012

“Thanks to a recently-agreed distribution agreement with leadingGerman manufacturer of bespoke disaster management vehicles, Ewers,we’re delighted to announce we’ve been able to expand our offering toUK customers to include disaster management units,” explained DavidBrophy.

“We are veryconscious of thediverse range ofspecialist vehiclestypically required byUK EmergencyServices partnersso it became

obvious to myself and, proprietor, Franz Baus that we needed to identifya relationship which could offer our UK and Ireland customers a "one-stop" solution to even more of their vehicle requirements”, said David.“So the Distribution Agreement we’ve reached with Ewers, anotherwell-respected family business based in Germany, is great news for usand our loyal UK customers. Their experience of supplying severalhundreds bespoke units to Emergency Management operators acrossGermany made Ewers our only choice.”

UK MD, David continued: "At Baus AT UK we want to serve allEmergency Services in some way, so when the opportunity to work

with Ewers, who are a well-respected bespoke build specialistfor disaster management vehicles,came up, it made perfect sense toseize it. Whether for trailers or box-bodied vehicles, the quality of theirbuild is superb, which is why they’vebuilt-up a fantastic customer base

across all Emergency Services in Germany.”

David finished: “ We know Ewers’ build really well and we already sharea number of key clients with them so we know exactly how theyoperate. Just take a look at http://www.ewers-online.com/vehicles-for-disaster-management.html to see an example of what they produce inthis field already."

BAUS AT is delighted to be showing a new UK Specification front-lineAmbulance alongside a typical Disaster Management unit forconsideration by all the UK Disaster Management organisations.

To find out more about this and the full range of BAUSvehicles, speak to David Brophy who will be happy to showyou both vehicles on stand 0S9 at ESS 2012 or call him on:0044 (0)7974 940121

Baus AT UK will be showing their new frontlineA&E ambulance and a new DisasterManagement Unit on stand 0S9 at ESS 2012

Summer 2012 | Ambulancetoday

Focus on The Optima Corporation

31

The Optima Corporation hascompleted a pilot study for SouthCentral Ambulance Service NHSTrust (SCAS) which resulted in therealisation of operational savings inthe region of £400,000. The studyusing Optima’s planning andsimulation technology, OptimaPredict, also identified other ways tomake further efficiency savings inthe future without having a negativeimpact on performance.By accurately simulating possible

operational changes, SCAS was able tounderstand whether it could continue to

deliver optimum performance withdiffering levels of resource and demand. A number of recommendations were putforward, some of which have now beenimplemented, realising a confirmed savingto SCAS of £400,000.Andy Jones, Assistant Director of

Planning at South Central AmbulanceService said “We were delighted with theresults of this project. It represented anunprecedented return on investmentwhich has enabled us to push ahead withthe full deployment of Optima Predict.”

Implementation and training

Optima Predict was purchased by Hampshire priorto amalgamation but a solution has now beenimplemented which will enableplanning and simulation to becarried out across the entireSCAS region. Optima workedclosely with SCAS to extract allthe necessary historical datafrom its systems and used thisdata to produce a highlyaccurate model. Predict is nowfully implemented and SCASstaff have receivedcomprehensive training toenable them to use the systemin house. “Before going ahead with the

purchase of Predict, we wentthrough a competitive tenderprocess. “ Andy Jones explained“Optima was the only companythat offered accurate, intuitivesoftware that has beenspecifically designed foremergency services.”

Moving forward with Predict

SCAS has a number of costimprovement scenarios that are to bemodelled using Predict, to help identifyfurther performance improvements,resource efficiencies and cost savings.

Andy Jones commented “We are goingto be making frequent use of Predict inthese challenging times for a number ofspecific projects; from the way we managemeal breaks and the impact of rosterchanges to looking at response andconveyance ratios. With this technology tohelp us quickly and easily simulate andmodel various scenarios and situations, wenot only gain valuable insight into possiblefurther service improvements, we alsohave the ability to effectively deliver arobust evidence base to our stakeholdersallowing them to plan for the future.”Optima Predict is being used by

Ambulance and Emergency Services allover the world to improve patient careand streamline service delivery.

For more information, please call +44 1189 036602, [email protected] visitwww.theoptimacorporation.com

Displaying the performance impact of a change in Optima Predict

Comparing two scenarios in Optima Predict

Optima Predict™used to realisesignificantsavings for South CentralAmbulanceService

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Introduction:

Recent Resuscitation Council guidelines(2010) ‘de-emphasized’ the use of aPrecordial Thump for treatment ofPulseless VT or VF, observing that it has avery low success rate compared toexternal defibrillation.1 However adefibrillator may take time to set up andapply the pads and, although it isundeniably essential to prioritise the use ofthe defibrillator, situations may occasionallyarise when a defibrillator is unavailable andwhere a Precordial Thump becomes themost time-effective alternative, as it canprovide a quick route to Return OfSpontaneous Circulation (ROSC) when itis successful (Pellis, Khol 2009). 2

This article explores the physiology of thePrecordial Thump and its success rate, andexpands on why the Resuscitation Councilmade the decision to de-emphasize it. Theuse of Precordial Percussion will also becompared to the Precordial Thump and Iwill explore the reasoning behind why thePrecordial Thump is a skill in danger ofbecoming obsolete. I will also considerwhether or not student paramedics andnew ambulance clinicians should be taughtthe Precordial Thump (PT) and whether itis in fact a technique at risk from skilldecay.Keywords: Precordial thump, Precordialpercussion, Ventricular Tachycardia,Commotio Cordis, Manual Cardiac Impact

Origins of the technique:The Precordial Thump is a technique thatcame into popular use in the 1920’s andwas widely discussed in European medicalliterature after E. Schott identified that asharp blow to the lower sternum could

re-pace an asystolic heart (Pellis, Khol 2009).2

Based on a technique used by the ancientChinese, it must also be stated howeverthat other contemporary studies viewed itas a last desperate attempt to sustain life(Miller, Bhatka 2007).3 Since the 1920s ourunderstanding of how a PT works hasdeveloped and since 1992 theResuscitation Council Guidelines haverecommended that PT is not used to treatasystole (Pellis, Khol 2009).2 Today’srecommendations are that a single PT is tobe used in a witnessed and monitoredarrest when the rhythm is pulselessventricular tachycardia or ventricularfibrillation: but this action must not delaydefibrillation (Resuscitation Council 2010).1 Sucha situation may arise if a patient is beingmonitored en route to hospital and it maybe the quickest treatment to hand. In othercircumstances, it may be the onlytreatment available to alter the outcome(Hodgetts, Castle 1999). 4

How do you perform a PrecordialThump?A PT is delivered with a clenched fist, usingthe ulnar edge of the fist to strike thelower part of the sternum from a height of20cm and then retract the fist (ResuscitationCouncil (UK) Nolan, Soar, Lockey 2006).5 Studiessuggest that the success of the PT isdetermined by what stage of the rhythmthe impact occurs; this perhaps explainswhy the success rates of the technique aresporadic and why it varies from study tostudy. The thump needs to produceenough force to cause 15-20mmHg ofpressure on the right ventricle to beeffective (Miller, Bhatka. D 2007).3 Thismechanical impact transfers to an electricalcurrent which opens stretch-activated ion

channels (Pellis, Khol, 2009), causing depolarization of enough ventricle cells toretain an organized rhythm (Bledsoe et al2011). 2,6

Success Rate/ Advantages:The overall success rate of a PT hasranged from 1-60% throughout availableliterature within pre-hospital and hospitalenvironments (Miller, Bhatka 2007).3 This maybe because VF is a common rhythm thatcauses the arrest and the PT is not aseffective on this rhythm as it is on VT. Astudy that had been collected from a rangeof reports summarised their findings bystating that the cardioversion of VT with asingle PT was successful in 19% of cases.However another report from theAmerican Heart Association proclaimedthat 49% out of 187 patient cases revertedto a normal sinus rhythm from VT, VF orsupraventricular tachycardia, asystole orcomplete heart block (Nursing Times. net2006).7

The safety of performing a PT is also highlyrated as one study suggested that 97% oftheir outcomes reverted to a normal sinusrhythm or had no rhythm change at all(Pellis, Khol 2009).2 So if a PT is not successfulthen there has been no defect to therhythm; however the manoeuvre will delaythe start of compressions. Anotherappealing factor of the PT is that,compared to the typical life saving devicesstored in the ambulance, this particular lifesaving strategy requires nothing more thanyour own hand, which may be attractive tosome clinicians in the rare event of anymechanical CPR aid being available. For the variant percentage of patients whodo respond to a PT, it is a quick method ofrestoring ROSC; which means there isminimal neurological damage and a greater

Sophia Rozario, Second year Paramedic student at Oxford Brookes University, reviews the history and use of the Precordial Thumpand Precordial Percussion, discussing their origins and likely effectiveness as CPR strategies, and asks whether the traditionalPrecordial Thump technique for resuscitation of cardiac arrest patients should be consigned to clinical history or revived as alimited but useful technique for the resuscitation of patients when more modern cardiac resuscitation devices are unavailable


Focus on clinical education

33

Is the PrecordialThump an

endangered skill?

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chance of survival (Pellis, Khol 2009). 2

Disadvantages/ Complications:A Precordial Thump is unlikely to besuccessful once pulseless ventriculartachycardia (VT) or ventricular fibrillation(VF) has been present for over thirtyseconds (Colquhorn, Jevon 2001), which is whythe guidelines advise the PT for witnessedcardiac arrests (Resuscitation Council 2010).8,1Therefore the timing of delivering a PTneeds to be prompt and the clinician mustnot delay defibrillation.

Other clinician errors are likely to occur ifthe attendant has not been trained orupdated on how to perform a PT because itis a technique that is at risk of skill decay,due to the fact that it is not used as often ascompressions or taking a blood pressure.This is something that could be resolved bythe paramedic taking a few minutes to re-read over the manoeuvre to ensure thatthey are aware of when it should be used,the location of impact (impact must be tothe lower sternum), strength and that it mustnot delay the defibrillator being collected,attached and a shock delivered. Research has shown that a PrecordialThump can induce a condition calledCommotio Cordis. This is a rarephenomenon where sudden cardiac deathin young healthy individuals is caused by ablow to the chest (most commonly previousincidents have been caused whilst playingsport) (Cavalli 1999).9 The impact to the chestcauses the heart to stretch if it is during thefirst ventricular escape rhythm, and thisleads to VF. The PT occasionally has thesame effect and decreases a patient’schance of survival (Cayla 2007) if their initialrhythm was VT.10 A literature searchrevealed a small minority of studies whichcriticised the PT for having safety risks and alack of consistent successful outcomes;however none provided statistics on howoften PT induces Commotio Cordis. On the other hand, another piece ofresearch looked into the ineffectiveness ofusing a precordial thump to treat VT andtheir study only consisted of eightyparticipants who underwentelectrophysiological study or whom had acardio defibrillator fitted through surgery.These patients entered a period of having arange of ventricular tachyarrhythmia’s. Outof the eighty participants only one patientreturned to a normal sinus rhythm by a PTand the other seventy-nine patients had tobe treated using an external defibrillator(Amir et al., 2007).11 Although the study onlyuses a small amount of participants in ahospital environment, it is one of the veryfew pieces of research that highlightsthrough statistics how uncommon it is for aPT to be an effective method of treatmentand this causes us to favour the

Resuscitation Council’s decision to demoteits use. Another disadvantage of using a PrecordialThump was briefly touched upon after areport indicated that one patient gained asternum fracture and later had osteomyelitisfor life, after being treated with a PrecordialThump (Ahmar et al 2007).12 However, thestudy does not state whether the PrecordialThump was successful or whetherdefibrillation was required. This incident callsinto the safety of the Precordial Thump andalso the long-term effects on the quality ofpatient life post-administration.

Precordial Percussion:Precordial Percussion appears to be a verysimilar skill to the precordial thump;however it is used for different reasons.Precordial Percussion is used instead topace an asystolic rhythm or to sustainsymptomatic Bradycardia (Monteleone et al2011).13 The ambulance clinician would usethe technique on a conscious orunconscious patient by hitting the lower leftsternal edge at a rate of 50-70 times aminute (Pellis, Khol 2009) to producemechanoelectric feedback.2 The differencesbetween this and PT is that PrecordialPercussion has a lower energy impact and isdelivered repetitively. There is very little mention of PrecordialPercussion within clinical literature andnothing has been included within theResuscitation Council UK or the EuropeanResuscitation Council guidelines. Availableliterature on the subject indicates that themanual pacing technique has provedefficient in preventing patients experiencingsevere Bradycardia diminish to completeAV block (Pellis, Khol 2009).2 The time ofefficiency has varied from thir ty minutes totwo hours and forty-five minutes (Pellis, Khol2009); however this would depend on theclinician’s impact, the patient, andpotentially the environment, as it would bemore effective to perform PrecordialPercussion on a flat surface instead of inthe back of a moving ambulance; which ismost likely to be transferring on bluelights.2An advantage which has been suggested byMonteleone et al is that precordialpercussion is at less risk of causing blunttrauma because a lower impact is required(2011).13 However, this has not been provedby use of evidence but is rather a theory oftheirs, though we could consider this a validargument, when viewed in light of theearlier stated point relating to thepossibility of PT causing a sternal fractureand future osteomyelitis. From what littleliterature there is on Precordial Percussion,it appears as if it has a potential place inthe pre-hospital setting. If the right situationarises en route to hospital it could providea bridge to temporary pacing of the heart.

On the other hand, a mere three casestudies were found to test PrecordialPercussion, and if the concept was to beseriously considered for introduction to UKResuscitation Guidelines, one mightreasonably argue that a larger and muchmore thorough out-of-hospital study first beundertaken. It must also be questioned ifthis would be unpleasant for both clinicianand the conscious patient to perform andreceive, however the benefits shouldperhaps at least be considered anddiscussed. This is a technique that perhapsshould primarily be viewed as second linetreatment after Atropine. Alternatively, if thepatient is symptomatic of Bradycardia andhypothermic (JRCALC Guidelines 2006) the



35

Models are: Casey Pennington andJames Murray, both paramedic students atOxford Brookes.

August 2012 | Ambulancetoday36

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Precordial Percussion could be the nextbest thing.14

Conclusion:Looking at the Precordial Thump andPrecordial Percussion, could it be arguedthat these are skills best left in the past inview of the fact that more advancetreatment options are now available? Will new employees of the ambulanceservice be taught these potentially lifesaving skills? As mentioned earlier theremay arise the occasional and highly-unusual situation where the defibrillator ordrugs bag is not available, so arguably ifthere is even a chance that thesetechniques could save lives - even thoughthe odds have proven slim for thePrecordial Thump - they are skills worthreviving or learning. Although this does notapply to Precordial Percussion, thePrecordial Thump is part of the latestresuscitation guidelines which proves theskill is still a significant treatment option.On the other hand, should PrecordialPercussion be considered in the pre-hospital environment? If there is evidencethat it has sustained a life for two hoursand forty-five minutes I believe there is aneed for further evidence-based researchin the pre-hospital or hospitalenvironment.To conclude, it does seem as though therecan be a place for the use of the

Precordial Thump technique in the pre-hospital environment. According toliterature, it has a safety rate of 97% and itdoes not affect the rhythm negatively if itfails. The Resuscitation Council hassummarised the skill and put it in a suitableplace for use because other treatments

such as defibrillators and Auto ExternalDefibrillators are widely available thesedays and can be used to better effect.However, the concern still stands as towhether the Precordial Thump is at risk ofknowledge decay as it is used soinfrequently. Its use is therefore a choicethat is left to the ambulance clinician. Asfor student paramedics and other newemployees joining the ambulance servicefor the first time, it is left to their lecturersand teachers to weigh up the value ofthese skills and to decide if they warrant aplace in future guidelines.

Key Points In brief:

The Precordial Thump is a manual cardiacpacing technique which has been ‘de-emphasized’ in the latest ResuscitationCouncil Guidelines 2010.

It is a skill that has a high safety profile butwhich a variety of research papers indicatehas sporadic success rates.

Precordial Percussion is another cardiacpacing method used to pace an asystolicor sustain symptomatic Bradycardia on theconscious or unconscious patient.

Precordial Thump is a technique that is atrisk from skill decay because it is not usedfrequently due to the fact that it has beensuperseded by more modern defibrillationtechniques.



37

Biography: Sophia Rozario

Aged 20, SophiaRozario is a secondyear paramedic studentat Oxford BrookesUniversity and iscurrently on placementwith South CentralAmbulance Service

(SCAS). In the past she has been onplacement at Oxford City ambulancestation. Prior to joining the ParamedicEmergency Care Foundation Degree,Sophia studied health and social care atcollege and it was this that stimulated herstrong interest in becoming a successfulparamedic. Sophia has developed a strong academicinterest in furthering her clinicalknowledge within her second year ofstudy and it was this which led to herresearching and writing upon the issue of the precordial thump and precordialpercussion.

To find out more about the Paramedic Emergency Care Foundation Degree

at Oxford Brookes University please visit

www.brookes.ac.uk/paramedic2013or email [email protected]

References:1. Resuscitation Council 2010, Adult Advanced LifeSupport, http://www.resus.org.uk/pages/als.pdf, Accessed 22/11/112. Pellis.T, Khol. P (2009) Extracorporeal cardiacmechanical stimulation: Precordial thump andPrecordial percussion, British Medical Bulletin,Volume 93 (no issue given) Pages 161-177,http://www.ncbi.nlm.nih.gov/pubmed?term=Pellis.%20and%20Khol.%20P%20(2009)%20Extracorporeal%20cardiac%20mechanical%20stimulation%3A%20Precordial%20thump%20and%20Precordial%20percussion, Accessed 22/11/113. Miller. J, Bhatka. D (2007) The Precordial Thump:Convertio Cordis, Commotio Cordis or Neither?,The Authors. Journal Compilation, Volume 30 (noissue given) Pages 151-152,http://www.ncbi.nlm.nih.gov/pubmed?term=Miller.20J%2C%20Bhatka.%20D%20(2007)%20The%20recordial%20Thump%3A%20Convertio%20Cordi%2C%20Commotio%20Cordis%20or%20Neither%3F%2C%20,Accessed 22/11/114. Hodgetts. T, Castle. N 1999, Resuscitation Rules,London: Published by BMJ Books5. Resuscitation Council (UK) Nolan. J, Soar. J,Lockey. A 2006, Adult Advanced Life Support

(5th Edition), Published in London, Published by theResuscitation Council (UK)6. Bledsoe. B, Porter. R, Cherry. R 2011, Essentials ofParamedic Care, (2nd Edition), Boston, Columbus,Indianapolis, Published by Pearson 7. Nursing Times. Net (2006), Resuscitation Skills-Part Five- Precordial Thump, Nursing Times, Volume102, Issue 29, Page 28,http://www.nursingtimes.net/nursing-practice-clinical-research/resuscitation-skills-part-five-precordial-thump/203136.article,Accessed 24/11/118. Colquhorn. M, Jevon. P 2001, Resuscitation InPrimary Care, Oxford: Published by ReedEducational and Professional publishing Ltd.9. Cavalli. A (1999) Letters to the Editor,Heart,Volume 4, Issue 82 pages 534-536,http://heart.bmj.com/content/82/4/534.2.full, Accessed 30/11/1110. Cayla. G (2007) Precordial Thump in theCatheterization Laboratory: Experimental Evidencefor Commotio Cordis, Circulation: Journal of theAmerican Heart Association, no volume, issue orpage numbers provided, http://circ.ahajournals.org/, Accessed 08/11/1111. Amir. O, Schliamser. J, Nemer. S, Arie. M (2007),Ineffectiveness of Precordial Thump for Cardio

Version of Malignant Ventricular Tachyarrhythmia’s,Pace, Volume 30, Issue 2, pages 153-156, http://onlinelibrary.wiley.com/doi/10.1111/j.15408159.2007.00643.x/abstract, Accessed 30/11/1112. Ahmar. W, Morley. P, Marasco. S, Chan. W,Aggarwal. A (2007), Sternal Fracture andOsteomyelitis: an unusual complication of aPrecordial thump, Resuscitation, Volume 75, issue 3,pages 540-542,http://pubget.com/paper/17697738?cb=1320595816, Accessed 30/11/1113. Monteleone. P, Alibertis. K, Brady. W (2011),Emergent Precordial percussion revisited- pacingthe heart in asystole, American Journal of EmergencyMedicine, Volume not given, Issue 29, pages 563-565, http://www.ncbi.nlm.nih.gov/pubmed?term=Monteleone.%20P%2C%20Alibertis.%20K%2C%20Brady.%20W%20(2011)%2C%20Emergent%20Precordial%20percussion%20revisited%20pacing%20the%20heart%20in%20asystole%2C%20American%20Journal%20of%20Emergency%20Medicine, Accessed 06/11/1114. JRCALC Guidelines 2006, Atropine,http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/atropine_atr.pdf, Accessed30/01/12

August 2012 | Ambulancetoday38

It’s time that we in the Netherlands shouldalso honour our fallen colleagues

In a touching reflection on the ultimate sacrifice that some ambulance workers make – those mercifully few who die in thecourse of duty, Ambulance Today’s Netherlands Correspondent, Thijs Gras, explains why he feels that the time has come forthe Dutch ambulance community to follow the lead of our own Ambulance Services Benevolent Fund (ASBF) and create alasting monument to commemorate those frontline ambulance staff who have died while actively serving their communities

Thijs Gras’ Letter from Amsterdam

We on the ambulance frontline arecalled to accidents so frequently yetwe rarely dwell on the fact that weplace ourselves in danger too. Whyshould accidents only happen toother people? Recently a NationalMonument dedicated to firementhat fell in the line of duty since the5th of may 1945 (our end of WW II)was unveiled in the Netherlands. It isnot only a tribute to the nearly 100fallen men who are mentioned, butis also a valuable public symbol ofthe dedication shown every day byour Dutch Fire Fighters. But sadly,even today, no such monumentexists for Dutch ambulancepersonnel.I personally am aware of 12 incidents

over the years that have resulted in Dutchambulance workers dying while at work. The first incident is recorded in 1949. An

ambulance crossed the rail track and washit by a train, severely injuring the driverand the nurse. Both were brought to thehospital where the driver died a couple ofdays later. During the big Flood of 1953that afflicted the South West part ofHolland, an ambulance was struck by awave. Both the driver and the attendantmanaged to climb out of the vehicle andfled to a house. Unfortunately this housecollapsed. The attendant held on to rubbleand reached another house where hewaited three days for help. The driver wastaken away by the streaming water andnever found. When the water receded, theyretrieved the ambulance full of mud. As far as I know, to date, three

ambulance staff have died on the job,suffering fatal heart attacks, all of theseoccurred in the 1960s and 1970s. In onecase in 1965 the ambulance wastransporting a heart patient when in themiddle of a polder road [ a road built on

marshy land reclaimed from the sea] thedriver – who was on his own, not unusualin those days – was struck by a heartattack. The wife of the patient managed tomanoeuvre the ambulance to the bank ofthe road and there she was, literally in themiddle of nowhere. No mobile phonesback then, but she was lucky that a taxipassed with a driver who worked once in awhile on the ambulance and thereforeknew the deceased. He drove her and thepatient to the hospital in the ambulance,leaving the deceased’s body in his taxi so itcould later be collected.In the eighties there were three

accidents: an ambulance hit a truck in 1986killing the ambulance attendant. That sameyear an ambulance attendant crashed into abus while rushing to the station during his‘on-call-at home’ shift. Two years later anambulance in the city of Leiden collidedwith a car while driving with lights andsirens to an accident through a red trafficlight. The ambulance driver was killed.Thankfully, the only incident in the 1990soccurred in Friesland in 1997 when anambulance on its way to the station was hitby a van that came from the opposite sideand suddenly went to the wrong side ofthe road.In the last decade two ambulance nurses

have been killed while they were on-sceneat accidents, busy attending to casualties.The first happened in 2002 on a motorwaywhena car bumped into a marked accidentscene, hitting the nurse and a slightly

injured patient that was then shoved intothe ambulance. Both were killed. In 2007 anurse was sitting near a crashed carexamining a victim when a police car, alsoattending the accident, crashed and hit thenurse. He was severely injured and died acouple of days later in the hospital.The most recent accident in 2009

involved an ambulance nurse who wastraining to become a Rapid Responder. Hecrashed and, despite immediate care fromhis colleagues, he died on the spot.I recently found on the internet a site

honouring UK ambulance staff killed whilststill in employment(http://www.freewebs.com/national-ambulance-memorial/). It contained 41names since 1950. On the list were similarincidents, such as a paramedic killed duringmotor training. Luckily we have not yetsuffered an air ambulance crash here in theNetherlands, such as that awful tragedywhich happened in the UK in July 1986,claiming the lives of three ambulance men,as I learned from the list.I greatly respect this initiative and hope

to be able to do likewise for TheNetherlands. I think every country shouldhave a national monument for fallenambulance personnel - a place with abeautiful tribute that provides a spot, bothphysically and digitally, where the deceasedare honoured. Apart from offering comfortfor grieving family and friends, it also showsthe appreciation of society to those people– our people - who take risks every day inorder to save others.

Editor’s Note: If you are a Dutchambulance worker who sharesThijs’ viewpoint and would like todiscuss helping him create such amonument, please feel free toemail him at: [email protected]


This edition of Ambulance Today goes out to all 25 Dutch Ambulance Regions courtesy of Procentrum PROCENTRUM - LEARN TO FEEL THE DRIVE www.procentrum.eu

UK Ambulance Memorial

Focus on

40 August 2012 | Ambulancetoday

When you are constantlytrying to generate interest,involvement, or maybe evenmere curiosity about aparticular cause to more orless the same audience thereis always a danger of becomingrepetitive and thereby havingthe opposite effect to thepositive one that you areendeavouring to create. Thatis a risk that I am going tohave to take. Ever since the Ambulance

Services Benevolent Fund wascreated back in 1986 a majortask has been to get theexistence and purpose of theFund known about both withinand without the AmbulanceServices of our country. Thepurpose of bringing the Fundto notice is of course twofold- Firstly, to let people knowwhat the Fund can do forthem and who to contact ifthey need the type of helpthat can be provided; andsecondly, to encourage peopleto recognise the benefits thatthe Fund can bring inalleviating difficulties that somepeople, i.e. their colleagues,face, and to contributetowards supporting the Fundboth financially and byencouraging others to do thesame to assist in that aim. Despite the Fund having

been in operation for over aquarter of century it is still thecase that many members ofour Ambulance Services areunaware of its existence. Thiswas perhaps understandable inthe early days when comparedto today communication wassomewhat more difficult, email;

websites; social networking toall intents and purposes werenon-existent. On the otherhand back then, between calls,ambulance service personnelspent time together in “crewrooms” talking to each otherover a cup of tea or coffee.Todays operationalarrangements with, “MakeReady Bases”, “Hubs” and“Standby Points” mean thatthe opportunities for personalinteraction of the crew-roomtype, in the main, no longerexist and thereby theopportunity for a member ofstaff who does know aboutand wants to spread the wordabout the ASBF or indeedanything else, to his or hercolleagues, has to take adifferent format. I am surethat there is no lack ofingenuity amongst members ofthe Ambulance Service andthat our growing numbers ofASBF Champions are findingways of overcoming thosebarriers and spreading theword and encouraging othersto do the same but I have toconfess I am impatient. I wantevery member of theAmbulance Service to notonly be aware, right now, ofthe existence of their Fund,but to be actively promoting itat every opportunity. Have you got an idea of

how we could do this moreeffectively? If you have, please get in

touch and let us know. Theother audience that needs tobe educated about us is ofcourse the wider public.It would be great to see our

striking new logo become asreadily recognised as that ofthe RNLI, the Red Cross oreven the Olympics and withthis recognition anunderstanding of who we areand what we do and a beliefthat what we are doing bothneeds to be done and,hopefully, like you dear reader,deserves support.

Enter 70070 into the "to" box - Write in the code 'ASBF44' and then add the amount you wantto donate which can be £1, £2, £3, £4, £5 or £10 - Your text might look like this 'ASBF44 £5' -Press 'Send' - Congratulations, you've just donated to the ASBF...it's that simple!

AMBULANCE SERVICES BENEVOLENT FUND.

Proud to be serving, proud tohave served! Relieved toreceive support when dealingwith a personal crisis orperiod of hardship?Your support today will help theASBF to provide that extra helpwhen the unforseen has happened,whatever your role, whetherserving or retired.This support comes at a price ofcourse so we have to attractdonations.To help with this weneed volunteer representatives atall ambulance sites and localities toensure staff are aware of ourexistence and to help raise fundsso that we can continue beingthere for all the unsung heroes ofBritain’s ambulance service whoare asking for our help in theirtime of need.Remember, you may think that anunforseen personal crisis maynever happen to you, but when itdoes, a period of hardship can betough to handle.

WE NEED YOUR HELPTODAY!We need your support NOW toraise funds to develop our Carefor the Carers programe.Can you help the ASBF byvolunteering as a representativesto champion its work, raiseawarness to colleagues about thecharity and to help with thechallenges of fundraising?To find out more please visit theASBF Stand #E6.

For further information about theASBF please visit our website:www.asbf.co.uk Or email theSecretary Simon Fermor:[email protected]

“AFTER OVER 26 YEARS THEAMBULANCE SERVICESBENEVOLENT FUND IS STILLCARING FOR THE CARERS BUT TOGETHER WE WILL MAKE THE DIFFERENCE!.” PATRON: SIMON WESTON OBE.

REGISTERED CHARITY # 800434

WILL YOU CHAMPION THE AMBULANCESERVICES BENEVOLENT FUND?

Can you help us spreadawareness of the ASBF?Below Paul Leopold, Chairman of the Ambulance ServicesBenevolent Fund (ASBF), reflects on the daunting challenge facedby the charity when constantly trying to raise awareness of itswork and objectives and explains what you can do to help spreadawareness among work colleagues and the general public

If you have any positiveawareness ideas you’d liketo share with the ASBF orif you’d like to become oneof the growing number ofASBF Champions, helpingus raise awareness andfundraise around thecountry, please get in touchwith us [email protected]


For those of you who might remember amusical group from the ‘60’s and ‘70’s thatplaced the editor of Ambulance Today’shometown on the map, they had a Number1 hit with a very popular refrain: “Money,yeh, that’s what I want!!!” For those of youwho do not remember, they were called theBeatles.The topic of money may not be the most

exciting subject you will ever read about, butit is one of those necessities that are arequirement for every EMS system. Andcertainly, that is the case here in the UnitedStates. However, unlike many other places inthe world where EMS is actually part of thehealth care system, ours is in a state ofidentity crisis and the result is a myriad ofmisconceptions about who pays, and whodoes not, and how our systems are actuallyfunded (See my first ‘Letter from America’for a more detailed rant). First, and foremost, let me lay to rest once

and for all a myth, concern, misconception,or however you wish to call it, that inAmerica, if you do not have insurance, youdo not get transported. False, false, false!!!Nothing is further from the truth!!! If you,the patient, or a bystander call 9-1-1 for anymedical need, be it an emergency or an“emergency,” an ambulance is on the way. Infact, in most states, the law requires thatthere can be no interrogation of the callerregarding the patient’s ability to pay duringcall taking process. Patients ARE protectedand ambulances DO respond, patient care isthe priority.What is true is that our sources for

funding are limited, and antiquated. Thereport Accidental Death and Disabilityissued by the National Academy of Scienceswas published in 1966 and is considered tobe the foundation for modern EMS. Whatmany do not realize is that in the same year

Congress passed, and the President signed,legislation to cover the health needs ofsenior citizens, Medicare, and the indigent,Medicaid. While out of hospital care hasexperienced rapid advancement in training,care delivery, technology, and performance-based system design features, Medicaid andMedicare reimbursement remain essentiallythe same programs as they were in 1966.You, dear reader, might be wondering why

this is so important. The reasons aremultiple. First, and foremost, for anyreimbursement to be received, the Medicarelaw requires that the patient must betransported. Paramedics that “hear andtreat,” and “see and treat” were neverenvisioned 40 years ago but they are heretoday and functioning in many part of theworld, especially in the U.K. However,because over 40 percent of our patients areover 65, and that number is rapidly growing,EMS systems in America became dependenton this funding source. Now that we can domore, neither Congress nor the Federalagency that oversees Medicare haveshown any interest in making changes.As a result, we continue to transport,progress is impeded, and the local A& E is overloaded with nonacutepatients. Second, the other types

of reimbursement sources,Medicaid and insurancecompanies, have both followedthe lead of Medicare. Again, theproblem of traditional payment fortraditional services leads to “no progress”.Third, transporting ALL of these patients,

and overloading the A & E has actually raisedhealth care costs for the entire system.Now, even the hospitals are losing money asa result of the number of nonacute patientsthat are transported. This has an impact on

what we call “downstream health costs” andit clearly has a cause and effect.And, finally as, if you like, “the icing on the

cake,” none of these sources, with theexception of specific insurance companies,cover our actual costs!!! In almost allsystems, every time we transport, we losemoney. That leads to what is called “costshifting,” which means the ambulanceservice must charge more to those who dopay to collect revenues to cover the lossesfrom those sources, especially Medicare andMedicaid, that do not. If this seems confusing and dated, it is

because it is. And, with our political systemembroiled in an election (you may havenoticed!!!), there is absolutely no hope offunding change on the horizon. That is notto write that there is no hope of change,period. A couple of our more innovativesystems, one in Louisville, Kentucky, and theother in Fort Worth, Texas, have realized thatthere might be ways to actually partner with

hospitals, and hospital savings can beused to fund EMS system’snew “hear and treat” and“see and treat” programs.Currently, optimism is guarded,but it just might work.So... while indeed we do

transport every patient, wetruly transport EVERY patient.

Hopefully this “Letter” has helpedexplain, in a somewhat simplistic way,the complex ways in which we receive

funds to continue to operate our systems.However, until our different factions herework together and unite towards a muchneeded overhaul of the financing on whichwe need to care for our patients, I shallquote again that group from Liverpool andclose by predicting that it will be: “A HardDay’s Night.”

It’s Time to Overhaul our EMS Payment System!

If you’ve ever puzzled over the complex calculations required to determine precisely ‘who pays for what’ in various Europeanmodels of ambulance delivery, spare a thought for our American EMS cousins who must navigate a financial payments system forambulance care that makes most European models of payment seem as simple as ABC. Our long-suffering friend from America,Jerry Overton, explains in more detail…

Jerry Overton's Letter from America


Out & About NewsVisit the only daily ambulance news site on the net at:www.ambulancetoday.co.uk

The London AmbulanceService has announced theappointment of Ann Radmore

as the organisation’s new ChiefExecutive.Ann, who is currently the Chief

Executive of NHS South WestLondon, started her NHS career asa national management trainee.She was appointed Sector Chief

Executive for South West London in2009 and was previously ChiefExecutive of NHS Wandsworth.Speaking about her appointment,

Ann said: “I am delighted to havebeen appointed and look forward toa new set of challenges that thisimportant role will bring. “I very much look forward to

working with the London

Ambulance Service to play my partin taking these essential services forLondoners from strength to strengthand developing them as part of theintegrated care services of thefuture. “I have lived in London all my life

and worked in the NHS since 1983and feel privileged to have theopportunity to work for this crucial,lifesaving service.”Chairman Richard Hunt said: “I

am delighted to have been able toappoint Ann to the role of ChiefExecutive for the Service.“Ann is a highly experienced and

successful CEO who will bring not

only a wealth of experience but alsoa very strategic outlook from hervarious NHS roles, which will helpensure that the Service is at thecentre of emergency and urgent carein the capital over the coming years.“Ann is passionate about patient

care and is looking forward toworking with the Service to ensurethat it continues to play its part inimproving care on a pan-Londonbasis.”Ann will take up the role around

the end of the year. She will replacePeter Bradley, who left in Septemberto become Chief Executive of StJohn in New Zealand.

London Ambulance Service appoints new Chief Executive

More than 100 people fromacross the UK attended aconference on falls preventionat the Centre for Life inNewcastle on Friday 28September. The conference wasorganised by the North EastAmbulance Service (NEAS)NHS Foundation Trust to sharebest practice from theirexperiences in preventing falls. .The Falls Project is based on allagencies who come into contact withindividuals who could be at risk of afall sharing information – sopreventative measures can be taken.Forms of intervention range frominstalling hand rails in the patient’shome, or ensuring help is provided to

carry out certain tasks.The project – pioneered by NEASand other health professionals in theNorth East – has since been adoptedby bodies elsewhere in the UK. Theseinclude three borough councils inLondon.Earlier this year, the Falls Project wona national NHS award.Jo Webber, Director of AmbulanceService Network, said: “When weheard what the North East regionhas been doing to prevent falls, wewondered why no-one else in thecountry has done this. Thepreventative work on falls in theNorth East has been a fantastic effortwhen you look at the scale of theproblem of falls nationally.

“The evidence from the North East iscompelling that the model here reallydoes work. But no organisation cando this on their own. It needs wholesystems collaboration.”She said that one in three peopleaged over 65 (and one in two peopleaged over 85) fall each year nationally.This costs the NHS £2.3 billion. For people aged over 75, falls is theleading cause of mortality from injuryand she said that one in five peopledie within three months of a hipfracture in this age group. Prof Julia Newton, Associate Dean ofClinical Developments & ClinicalProfessor of Aging and Medicine,Newcastle University, said: “Falls is themost common cause of accidents in

older people. Up to 45% of fallersaged over 65 attend an A&Edepartment, but they suffer far morethan just broken bones. “They sustain a lack of confidence;they are less likely to stay in their ownhome; and less likely to remainindependent; and more likely tobecome isolated. Older people fearlosing their independence by going toa home after falling, so the people wesee in our falls clinics are really justthe tip of the iceberg. “There is also a perception amongthe elderly that falling is part of theaging process. It’s not. The North EastAmbulance Service should becredited for what they have done inthis area and I applaud them for this.There are not many organisationsthat would think outside their ownarea of work to make a realdifference.”She said that in 2005, a studybetween NEAS and NewcastleUniversity showed that 48 hours ofambulance crews’ time was used inresponding to elderly people whohad called 999 after falling in theNewcastle City area over a sevenmonth period. This cost theambulance service approximately£172,000 in that time.

Award-winning NEAS project aimed at reducing £2.3 billion costto the NHS of treating injuries caused by falls wins national praise

Mr Simon Featherstone CEO NEAS, Nigel Dawson Falls Champion Paramedic, Tracey Varty NEAS Control Falls Champion, Phil KyleNEAS Falls Lead, Kim Rigby Falls Champion Paramedic, Maureen Jordan Regional Face of the faller, Dan McGarrie Falls Champion Control,Ann Fox Director of Clinical Care and Patient Safety NEAS, Gary Mayne Falls Champion Control, Lou Bailey Falls Champion Paramedic.

South Central AmbulanceService NHS FoundationTrust’s (SCAS) ‘999 MisuseCosts Lives’ campaign hasbeen shortlisted in 3categories of the SomeComms Awards 2012 (UKSocial Media CommunicationsAwards).Now in their third year, these

awards celebrate the best in UKsocial media, recognising theindividuals and organisations thatare using on-line to communicate in

cool and creative ways.This year the Some Comms

Awards have received more entriesthan ever before in eighteencategories. Your local ambulanceservice has been shortlisted in 3 ofthese categories – Best use ofYouTube, Public Sector and BestViral Campaign.SCAS’ ‘999 Misuse Costs Lives’

campaign is multi media PublicRelations campaign which includes aviral video to reduce hoax andinappropriate calls to South Central

Ambulance Service NHSFoundation Trust and in doing so tohelp to ensure that resources areavailable to respond to genuine lifethreatening medical emergenciesamongst a resident population inexcess of 4 million throughout thecounties of Buckinghamshire,Berkshire, Hampshire andOxfordshire 24/7.SCAS Area Manager Paul

Jefferies, a highly experiencedparamedic with over 18 yearsservice, said: ‘Inappropriate calls I

have regularly experienced includeresponding to the emergency of aman in "severe pain" and on arrivalhe wanted me to pass him someparacetamol from a table less thantwo metres away; people calling 999because they want a lift to visit arelative in hospital; or people injuredwith say a broken finger, which is notlife threatening, but they have nomoney to get to A&E.‘

SCAS shortlisted for Social Media Award

Out & About NewsIf you want your service news here or on our ‘Rolling News’website email us at: www.ambulancetoday.co.uk

South Central AmbulanceService NHS Foundation Trust(SCAS) is recommending thatolder persons and youngerpeople living with a disabilityor long term health conditionget their hands on the Lions’‘Message in a Bottle.’The Lions ‘Message in a Bottle’ is

a simple idea that encouragespeople to keep their basic personaland medical details including a list ofthe medication they are taking or arepeat prescription form in acommon place at home wherethese can easily be found in amedical or other emergency. Yourinformation is kept on a sheet of

paper provided in a plastic bottle inthe fridge and the bottle comeswith two labels – one to bedisplayed on the inside of your frontdoor or the main entrance to yourhome and the other on the door ofyour fridge. Why keep the bottle inthe fridge? Because it’s the last thingthat burns in the event of fire.SCAS Clinical Mentor Karen

Skillicorn-Aston said: ‘You don’t haveto be old or infirm to be unwell. Foryour local ambulance service havingaccess to a ‘Message in a Bottle’ in apatient’s fridge can be a reallifesaver. When a patient is in pain ordistressed the last thing they need isto be quizzed about their life.

Often we have to waste valuabletime in rummaging around for apatient’s medication, time that couldbe much better spent in gettingthem definitive care at hospital.‘A Stroke can prevent a person

speaking and result in a reducedlevel of consciousness. If any patienthas a condition that we need toknow about and is not in a positionto tell us having a ‘Message in aBottle’ in their fridge can make areal difference to the outcome forthem.’‘Whilst having a ‘Message in a

Bottle’ is great, patients shouldremember to update this everytime they are prescribed a new

medication or are diagnosed with afurther health complaint. It’s also thebest place to keep a passport sizedphoto, details of any allergies, and arepeat prescription, ‘do notresuscitate’ form or living will.’

Lions Message in a Bottle is a life saver

In 2010 Sir Stirling Mosssuffered a terrible fall in hishome in London . Withinminutes the specialist London's Air Ambulance doctor andparamedic trauma team wereat his side providing advancedmedical care.Sir Stirling has since made a full

recovery and recently visited theLondon 's Air Ambulanceoperational helipad on the roof ofthe Royal London Hospital in Whitechapel to thank the team and find

out more about this lifesavingservice to London .Sir Stirling said: "So few

Londoners realise that this fantasticservice is provided by a charity.London 's Air Ambulance helpedme in my time of need and it iswonderful to come and meet theteam and hear about the greatwork they do on the streets ofLondon every day. Accidents canhappen to any of us and this charityis vital for anyone seriously injuredin London ."

Motor Racing Legend thanks London's Air Ambulance


Out & About NewsVisit the only daily ambulance news site on the net at:www.ambulancetoday.co.uk

Commanders have betterdecision-making in the palmof their handsGreat Western Ambulance

Service (GWAS) commandersattending incidents now havecomprehensive information at theirfingertips thanks to a new app.Called the GWAS app – and

thought to be the first ambulanceapp in the country – it houses allrelevant documents, policies andprocedures as well as mapping,cordons, visual imaging, Dictaphonelog. The app also provides access tofactsheets for specific types ofincidents – such as from the HealthProtection Agency (HPA) formanaging chemical incidents.Pete Brown, GWAS Resilience

Manager, said: “The app putsrelevant, up-to-date information inthe palm of commanders’ handswhen they are on scene managingan incident, allowing them to makewell-informed, structured decisions.

“For ambulance personnel,operating to clear policies andprocedures is second nature – thechallenge is making sure thatwealth of information is currentand portable. Now there’s an appfor that.”The GWAS app has been

developed with Bristol-basedmobile marketing agency, MyOxygen. The first of three phasesof the app went live at thebeginning of September and allowscommanders to share information– via email or messaging service –with other areas of the trust tosupport a response.Phase 2 will incorporate trust

data such as performance and theavailability of specialist staff groupssuch as SORT personnel. Phase 3will include clinical learning anddevelopment information. Althoughinitially focused on GWAScommanders, the app is available toall trust staff – who are also being

encouraged to suggestfurther content for phase 3 – via alink from the resilience team.The eventual plan is to make it

available to other ambulance trustvia the app store. Minimumspecifications for the app are aniPad 2, wi-fi/3G access, IOS5, 16GB.The app has already been

trialled in a recent live incident –

when emergencyservices had to evacuate much ofBristol city centre for a bombscare.Pete Brown said: “Better

decision-making in support ofambulance clinicians on sceneultimately means better care andoutcomes for patients, which is atthe heart of everything we do.”

Need Latest Information to Manage Ambulance ServiceResponse? There’s an App for that!

A member of West MidlandsAmbulance Service staff haswon a Gold medal at thisyear’s British TransplantGames.Michael Horton, who works

within Patient Transport Services atthe Trust, took the gold medal forArchery (within his age category)during this year’s Transplant gameswhich were held in Medway, Kent.The British Transplant Games

first began in 1978 and areorganised by Transplant Sport UK(TSUK)*. During the games, 62 year old

Michael from Coventry, who hasundergone two kidney transplants,

also competed in the LawnBowling, Darts and Ten Pin Bowlingevents.Talking about the games Michael

said: “There were some 600competitors at the games this year,all of varying in ages, from under 5to over 70, who have all receivedtransplants. “The purpose of the games is to

show that to receive a transplant isa gift of life. It is a great way to notonly celebrate, but to also highlightthat there is still a great need formore donors, who too couldprovide someone in need of atransplant with the opportunity ofa new life.

“The event warmly welcomesthe attendance of donor families, aswithout their support, throughtheir time of grief, these gameswould not happen.” The last few months have been

an extremely busy time for Michael,alongside taking part in thetransplant games, Michael wasselected to represent Coventry asan Olympic Games Ambassador.He was the team leader for 6 ofthe 12 football matches held inCoventry during July and Augustand he has been selected torepresent Coventry and theAmbassador’s at the Olympicathlete’s parade in London

Michael Wins Gold at Games

Sixty year old Cheadleresident, John Dean, recentlyjumped 10,000ft from anaeroplane in a bid to raisemoney for ambulanceresponders.John, who has lived in Cheadle

for 30 years, took on the tandemskydive in Whitchurch last monthand managed to raise a massive£875 for the ambulance service.Talking about the parachute

jump Mr Dean said: “UnfortunatelyI lost my wife Carol earlier thisyear. When she collapsed I called999 and literally within a minute aresponder car was outside myhouse. Unfortunately my wife laterpassed away in hospital and it wasdecided that the donations from

her funeral would be given to WestMidlands Ambulance Service forthe Cheadle First Responders.“Following the donation, I

received a lovely thank you letterfrom the service and it encouragedme to think about raising moremoney. I decided to do a skydive, asit is something I have alwaysthought about doing but had nevergot round to. Following the eventsof this year, I have really beendriven on to do it and raise somemoney for a good cause. TheSkydive was amazing and issomething I’d love to experienceagain.” Matt Heward, West Midlands

Ambulance Service CommunityResponse Manager said: “I would

like to say a huge thank you Mr.Dean on behalf of the Service. His

fundraising efforts really could helpto save lives within Cheadle.”

John’s Giant Leap for Ambulance Service


Out & About News

45

If you want your service news here or on our ‘Rolling News’website email us at: www.ambulancetoday.co.uk

South East Coast AmbulanceService NHS Foundation Trust,(SECAmb), staff havecelebrated with patients andtheir families and friends at theTrust’s second survivors’ event.Eight patients whose lives were

saved by the clinical interventions ofSECAmb staff were reunited withtheir lifesavers on Sunday 23September.The event, held at Woodlands Park

Hotel near Cobham, Surreyrecognised the life-saving skills ofSECAmb staff, celebrated the lives ofeveryone SECAmb has helped saveand emphasised the importance ofearly cardiopulmonary resuscitation(CPR).Along with SECAmb chief

executive Paul Sutton and ChairmanTony Thorne, staff were able to heareach patient’s amazing recovery firsthand. A moving short film telling each

patient’s story has been made anduploaded to YouTube. It can be foundby searching for ‘SECAmb Survivors2012’ or via the following link:http://www.youtube.com/watch?v=oIW0GdODs1gWhile paying tribute to SECAmb

staff and celebrating each patient’srecovery, the film also aims toencourage more people tounderstand the importance oflearning CPR and basic life support.Also attending the event and

receiving a small token of the Trust’sappreciation for their outstandingcontribution to SECAmb wereConsultant Cardiologist ProfessorDouglas Chamberlain, and ParamedicDave Fletcher.Douglas Chamberlain’s

contribution to the development incardiac care cannot beunderestimated. Among his long listof achievements was a revolutionary

move in the early 1970s to trainambulance personnel to becomeskilled technicians in resuscitation - amove which led to the introductionof the UK’s first paramedics.Dave was among the first cohort

of these new clinicians. He workedclosely with Douglas throughout hiscareer to improve out-of-hospitalresuscitation survival rates acrossSECAmb’s region of Sussex, Surreyand Kent and from early on in hiscareer acquired a reputation as oneof best pre-hospital clinicians. Earlier this year he became one of

just five ambulance personnel acrossthe UK to be put forward to receivea Queen’s Ambulance Service Medalin this year’s Queen’s BirthdayHonours - the first year the medalhas been awarded. He wasnominated for his commitment andpioneering work on resuscitation atSECAmb with ProfessorChamberlain which led to theintroduction of a new resuscitationtechnique, Protocol C, across theTrust. He is set to receive his honourin November.The compressions-only CPR,

supported by early defibrillation, hashugely improved outcomes forpatients across SECAmb’s region ofSussex, Surrey and Kent.Chief Executive, Paul Sutton said:

“This event was once again a

tremendous opportunity to recogniseand pay tribute to our highly-skilledstaff and at the same time celebratethe lives which have been saved as aresult. These stories are just a fewexamples of the many successeswhich take place across our regionevery day.“SECAmb is just one part of these

patients’ amazing recoveries butwithout the calm advice of our staffon the phones in our emergencyoperations centres, the actions of ourclinicians at the scene and indeed thequick-thinking of members of thepublic to provide vital life-saving CPRin the minutes before our arrival,many lives would not be saved. Wewant to encourage everyone to takethe time to learn how to save a life.“I’d also like to pay tribute and

personally thank DouglasChamberlain and Dave Fletcher forthe commitment and dedication theyhave given the ambulance serviceover so many years.”Survivors’ Event 2012 stories:John Munn, Maidstone, Kent LisaCorke, Minster (Sheppey), Kent LindaBedson, Shoreham-by-sea, WestSussex Carol Good, Crawley, WestSussex Paul King, Brighton, EastSussex Bronwen Drake, Farnborough,Surrey Joe Goodchild, Walton-on-Thames, Surrey Sarah Fyander,Guildford, Surrey

Private ambulance services inRomania are to take a strategiclead from the IndependentAmbulance Association in theircampaign for a bigger share ofthe state healthcare budget.Lucan Florea, Vice President of The

Association of Private AmbulanceServices in Romania said after arecent conference in Poaina Brasov:“Like the IAA, we do not want tocompete with the state; we say thatthe introduction of privateambulances in the nationalemergency system will lead to lessintervention and the development ofthe system with zero-cost from thestate”.ASPAR which was set up in 2009

claims that the €3 million a year stateallocation to the country’s estimated50 private ambulance companies issimply not enough for handling itstask – 700,000 patient journeyscovering 24 million kilometers a year. ASPAR openly admits that the IAA

has achieved more in nine months inEngland than it has in three years inRomania in reducing the tensionbetween the public and privateambulances and is studying the IAAstrategy of more constructivecampaigning.David Davis, the IAA’s Director of

Communications, was the onlyforeigner invited to speak at theconference which was organizedspecially for government andindependent healthcare executives todebate the public/private issue.He told delegates that there was a

wind of change blowing in Britaincreating a closer working relationshipbetween the public and privateambulance companies and now, as aresult of the recently introducedNHS reforms, some healthcarecommentators have suggested that in5 years Britain will have a nationalambulance service, bringing togetheras business partners the best skillsand resources of the NHS and theindependent sector.“This is neither a pipedream nor is

it a reality but the latest reforms nowmake the prospects of a closerworking relationship between thetwo not only more of a possibilitythan ever before but a necessity.The cold facts are that both need

each other to exist:n NHS ambulance trusts need tocall up the resources of theprivate sector to help them meetthe demand for emergencyambulances; it is estimated thatindependents handle about 50%of all NHS hospital transfers

every year.n Equally, independents need thelarge NHS contracts, to stay inbusiness, to meet shareholdersexpectations, to justify continuinginvestment in modernizing theirfleets and introducing newoperational technology.”In practice, they are both

complementary and competitive toone another but Davis added, theIAA believed “that in a relativelyshort period of time this mutualhistoric and unjustified mistrust willbe replaced by a professional workingrelationship built on the mostimportant principle of all - the patientcomes first”Formed in January this year, the

IAA was already the leading tradeassociation for the independentambulance industry with more than

45 member companies.Davis said that the IAA’s

achievements were being built on astrong working relationship with theGovernment’s Care QualityCommission, regulators of health andsocial care services as well as “talkingwith and listening to” all public andprivate constituent parts in theambulance service.Recently the IAA and CQC

agreed a series of measures tofurther strengthen the relationship,including timely and effectiveexchange of information, discussionand resolution of issues of mutualconcern to protect the interests ofthe organisations and the companieswhich they regulate and/orrepresent.”

Patients and staff reunited in SECAmb’s second survivors’ event

Romanian ambulance companies to follow IAA strategy

AXIS home care doctor’s car


Products & Suppliers News

46

Ferno EZ-Glide chair canmanage stairs and rough terrainreducing risk of injuryCaring for You Pts Ltd, the patient

transport service group, has takendelivery of an EZ-Glide PowerTraxxchair from Ferno, the world leadingmanufacturer of medical equipment tothe emergency services.The EZ-Glide chair had been

designed to meet the demandingneeds of medical and disaster responseservices and allows patients to bemoved safely up and down stairs.Caring for You Pts Ltd was the first

company in the UK to take delivery ofthe EZ-Glide chair. Its director CarlCarter said: “Our investment in thenew EZ-Glide chair means that we cancontinue to deliver the higheststandards of patient transfer ensuringthe safe movement of patients as well

as the well being of our staff.“The EZ-Glide has a robust seat

and can carry larger-than-averagepatients – which is particularlyimportant as Britain’s growing obesityproblem means that we areincreasingly required to move patientswith bariatric issues.”Caring for you Pts Ltd was formed

in 1995 and therefore has extensiveexperience in providing NonEmergency Patient Transport Servicesas well as providing the more specialistservices for the movement of patientswhilst delivering a modern patienttransport service.The company has held numerous

non-emergency patient transportservice contracts and serves both thepublic and private sector throughoutthe UK. Ferno Managing Director Jon Ellis

said: “This is the first chair of its kind inthe industry. It has multiple uses as astair chair, evacuation chair or transportchair, capable of maneuvering overkerbs and rough terrain, and comeswith powered tracks that deploy easilyto eliminate the need for lifting orcarrying while ascending or descendingstairs, reducing the risk of injury tomedical staff.”Patients can be moved up and

down stairs safely and the operator hasfull control at all times; able to slow,stop or even reverse direction at thetouch of a button. A patented built-insafety circuit limits downhill speed, evenwhen power has been lost.The EZ-Glide leads the industry

with its 227kg weight capacity andlarge seating area which along with theextending footrest, provides a morecomfortable experience for larger

patients while the innovative featureswork with the caregivers to ensure asafer transport for all.Ferno is recognized as the global

leader in the manufacturing anddistribution of emergency patient-handling equipment and mortuaryproducts and exports to more than 75countries worldwide.

Caring For You Pts Ltd takes deliveryof EZ-Glide PowerTraxx chair

Class ProfessionalPublishing,representatives ofJones & BartlettLearning in Europe,have some excitingnews! Adding to ouralready impressivecatalogue of titles, we are delightedto announce that Jones & BartlettLearning have recently acquired theEmergency MedicalServices (EMS)publishing division ofElsevier. We are allvery excited aboutthis acquisition andbelieve that theaddition of the

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standard i-gel in the new i-gel O2,along with everything you need toprepare, insert and secure the devicein one pack, allowing you to stayfocused on what really matters duringresuscitation – the patient.References:1. Gatward JJ, Thomas MJC, Nolan JP, CookTM: Effect of chest compressions on thetime taken to insert airway devices in amanikin: Br J Anaesth. 2008Mar;100(3):351-6

2. Gabbott DA, Beringer R: The i-gelsupraglottic airway: A potential role forresuscitation?: Resuscitation. 2007Apr;73(1):161-2.

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4. UK Resuscitation Council Advanced LifeSupport Guide (5th Edition). RevisedJune 2008.

5. Bamgbade OA, Macnab WR, KhalafWM: Evaluation of the i-gel airway in300 patients. Eur J Anaesthesiol. 2008Oct;25(10):865-6.

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Documents

Ambulance Today Autumn 2012