Coronaanpassade kurser 2021; v 20 och v 21

2021 års ordinarie kurs går v 20, denna är fullbokad
2020 års kurs blev flyttad till 2021, v 21. De som var anmälda till kursen 2020 har alla fått plats på denna (ni behöver inte anmäla er igen)

Bägge kurserna 2021 är "coronaanpassade". Vi hoppas förstås alla på att vi skall vara i genom detta till våren. Trots detta har vi planerat kurserna 2021 så att vi kan genomföra dom även med eventuella restriktioner på hur många som får samlas i en lokal.
Kurserna kommer i omfattning och innehåll vara väsentligen oändrade men alla moment under veckan kommer genomföras i små grupper. Kurserna kommer också kompletteras med några hemuppgifter att genomföra innan kursveckan
Väl mött v 20 och v 21.

Ordinarie kurs 2021 v 20 är full men det finns fortfarande några platser lediga v 21 2021

2016 > 08

No effect..
We have all seen and read it: Yet another RCT that failed to show any significant outcome effect of MD delivered PHETI or perhaps yet another large study where ALS got beaten by BLS. We have all read them and probably also taken part in the frantic discussions of why that particular study failed. Frustratingly, the interventions studied are often accepted to improve outcome in hospital, such as TBI RSI or balanced fluid therapy or lately transfusions for bleeders.

In spite of same interventions..
Yet, it is really hard to understand why a resuscitative intervention that clearly benefits the patient when done in hospital would not be of benefit to the same patient earlier. Unless of course the intervention is done with reduced quality or done slower and hence with time lost. Could that perhaps be the case - we fail to prove effect of our interventions in prehospital critical care because we don’t deliver care of enough quality?

Hospital Quality as gold standard?
It is intuitively attractive to see critical care of hospital quality as the standard to strive for. After all, the hospital is where we deliver our critical patients.
How would this translate to real life? Wouldn’t it be satisfying to deliver our post-ROSC patients in a neuroprotective anesthesia, stable hemodynamics with beat to beat invasive monitoring of blood pressure, optimal ventilation on an ICU quality respirator with capnography. Diagnostics with 12 lead and UCG done, going for the cath lab or, rarely administering thrombolytics. The TBI patient safely anesthetized without hemodynamic instability, stable on a respirator, sedating drugs and possibly inotropes on the syringe drives. The MVC bleeder in deep, neuroprotective and dilating anesthesia getting blood products and procoagulative drugs while being delivered without delay to a level 1 trauma center. The septic meningitic patient sedated in a respirator getting EGDT and antibiotics/cortisone. The ICU transport getting the receiving hospitals level of care already during transport.
With the ability to deliver hospital quality prehospital critical care this is all quite possible.

Have we had the wrong focus?
Perhaps in the past we have been to eager to look at the effect of our interventions and in doing so forgotten about the quality of the interventions per se.
Instead of looking at the quality of our care per se we have been bogged down by meaningless arguments* of “what category of prehospital providers deliver the best prehospital critical care”.

If You do it, Make sure You do it well!
By accepting that the indications for prehospital critical care interventions are dependent not only on the pathology and the condition of the patient but also on our quality of care we can instead move forward together.
Let’s assume that the indication for a specific intervention is also proportional to the quality of the prehospital care compared to that of the hospital critical care. If we deliver critical care with the same quality as in the hospital where we will deliver the patient, clearly any early resuscitative measures we can take will benefit the patient (possibly even more than the, by necessity, later hospital intervention). Conversely, if we deliver care with reduced quality or with time lost we should probably be more cautious with the indications? At the extreme with only very low quality of care available, BLS is probably the best option?

With an accepted and common ambition of delivering hospital quality critical care, perhaps it is time to look at a process that has potential to lead to meaningful and beneficial such care? Importantly, this can of course be done regardless of the type of prehospital provider one uses.

What is HospQPHCC?
The first step in such an ambition would be to look at the components and abilities that make up hospital quality critical care. In itself, of course a very complex process. In its most simple form however this can probably be done in some sort of “activity” list. Defining the “toolbox” if you will.

Step 1-Activities in Hospital quality prehospital critical care
·      Comparable medical competence
·      System parameters, QA - M&M, CG etc
·      Specific training
·      Tailored treatment (as opposed to strict “protocols”)
·      TBI Neuroprotective anesthesia (as opposed to protocolized drugs)
·      Difficult airway capability – LMA, VL, surgical airway etc.
·      Ability to perform advanced procedures – thoracostomies, -tomies and REBOA
·      Capability to deliver “load&play” care enroute

​​·      ICU quality respirators (as opposed to manual “bagging”)
·      Syringe drives (as opposed to iterative boluses)

·      Invasive blood pressure monitoring
·      Capnography
·      PRBC+FDP+TXA for bleeders
·      Blood/Fluid warmers
·      Topical hemostatics + Tourniquets
·      “Hi-end” drugs, I.e. Inotropes, Thrombolytics, TXA, other procoagulative drugs, antibiotics, anesthetics, relaxants, analgesics etc.
·      Diagnostics – Ultrasound, 12 lead ECG, ABG etc.
·      etc.
The next step would be to look at the quality of care we deliver per se. One popular example is the first pass success rate with PHETI, but of course it is possible and probably necessary to identify several other quality indicators. For instance, even if a service delivers 100% first pass PHETI success rate, RSI desaturations and induction hypotensions as well as 30 min  prolonged scene time may be harmfull to their TBI patients.
Continuing on the same metaphor quality indicators like this measure the ability to use the toolbox.

Step 2-Measurable quality indicators of hospital quality critical care
·      First pass success rate with PHETI
·      Correct indication for PHETI
·      Desaturation with RSI
·      Hemodynamic stability with TBI RSI
·      Scene time for time critical conditions
·      Correct PH triage
·      etc.
The final step in this process would be to look at the effect of step one and two, i.e. mortality and morbidity studies. By not doing this until we have ascertained that we have the necessary “tools” for hospital quality PHCC (step 1) and the ability to use them properly (step 2) we maximize the likelihood of producing relevant studies

Step 3-RCTs comparing outcome of hospital quality critical care
·      Mortality
·      Morbidity
·      Cost effectiveness

What we get out of it
Agreeing on accepted quality indicators would also enable us to better compare ourselves against each other and perhaps also define different levels of PHCC (in accordance with different levels of trauma and cardiology care) With a process like this and mutual inspiration it would allow different systems with varying prehospital providers to embark on a common journey that will produce better care and in the end the outcome studies we are all waiting for. Ultimately this will all benefit the patient.
Joacim Linde, MD, MSc

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Etiketter: hospqphcc

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Senaste FOAM

2016 > 08

En bra podcast av Scott Weingart och Mike Lauria som pratar med Gary Klein om erfarenhetsbaserat beslutsfattande. En del ideer om hur man kan öva beslutsfattande i kritiska situationer.

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Etiketter: beslutsfattande

En lysande artikel av Stuart Duffin, anestesiläkare på Karolinska som beskriver hur den medicinska världen krymper med FOAM & sociala medier.. Detta ger oss möjlighet att på ett helt annat sätt ta del av andras lösningar på universella problem. I ett större perspektiv och med syftet att utvecklas är det sannolikt också meningslöst att låsa fat sig i stridigheter om vilken specialitet eller personalkategori som löser ett visst problem bäst.. Fokusera på gemensama ambitioner istället?
För PHCC tror jag som sagt att PHCC av sjukhuskvalitet är vägen framåt.
Interventioner som gagnar patienten på sjukhus gagnar förstås patienten tidigare (PH) Förutsättningen är förstås att vi kan utföra interventionen med samma kvalitet som på sjukhus.. HospQPHCC oansett typ av vårdpersonal.

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En av FOAM communityns mest drivande inom utbildning (the teaching course bla) använde sin egen infarkt för - utbildning. Här är EKGt:
45 år gammal berättar han hur det är att hamna på andra sidan, och vilken betydelse det har. Tänkvärt.

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Senaste artiklar

2016 > 08

Artikel där i en retrospektiv studie ej lyckades påvisa effekt av prehospital transfusion (PBT).. Som det står, kontraintuitivt.. Kanske en påminnelse om att samma intervention & indikation kräver samma vårdkvalitet för samma resultat. Lyckas vi inte hålla sjukhuskvalitet på  våra PH interventioner minskar indikationen jämfört med indikationen på sjukhuset!!

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Hundstudie förvisso men ändå intressant. Notera att hypovolemt hjärtstopp dock bara är en undergrupp till TCA gruppen där exempelvis hypoxiskt hjärtstopp också återfinns och för dessa patienter (som exempelvis fått sitt hypoxisk hjärtstopp pga ofri luftväg) är kompressioner och ventilationer av största betydelse!

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Eller rättare sagt, kommentaren på Twitter  från Per Bredmose om att man i artikeln inte inkluderade effekten av kompetensen hos vårdande personal. Denna ledde till mer än 1000 kommentarer och väldigt mycket känslor. Att påstå att läkare behövs lika mycket prehospitalt som på sjukhus och att samma etiska och kvalitetsmässiga krav råder är inte okontroversiellt och skadar sannolikt många egon.. Själva artikeln diskuterades inte så mycket vilket väl också är talande.. 

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