‘It was now night time and as we pitched up at scene, I noticed the debris scattered all over the road with signs of a potential fuel leak nearby, there was a massive ‘bulls-eye’ on the windscreen and there were sirens wailing and bright blue lights flashing as Police and Fire Service crews worked hard to secure the scene. Bystanders, including family members were crying out for help and screaming for something to be done as they witnessed their loved one go into traumatic cardiac arrest. This was the first job I attended with EHAAT and it was a motorbike vs van collision at high speed. ‘Welcome to pre-hospital medicine’, I briefly thought to myself’
After returning from my trauma elective in South Africa, I had another SUPER exciting elective lined up. The day after returning from SA, I moved to Essex to start a 4-week attachment with the Essex and Herts Air Ambulance Trust (EHAAT).
I felt so grateful for this opportunity but also had major ‘imposter syndrome’ and up until my first day with EHAAT, I kept feeling like this was all a dream and that when I’d turn up for my first shift, they would be like ‘who the heck are you?!’
Thankfully, my worst fears weren’t confirmed and I was officially part of the student elective programme!
So for those who don’t know, Essex & Herts Air Ambulance Trust is a Charity Air Ambulance service providing a free, life-saving Helicopter Emergency Medical Service for the critically ill and injured of Essex, Hertfordshire and surrounding areas (around 3-4 million people). It is not funded by the NHS – only by charitable donations and it costs around £6 million a year to fund the service.
As part of my elective, a typical week consisted of two clinical shifts, two shifts where I would focus on a project and a day of clinical governance/death & disability discussions. I really appreciated the variety on the timetable because it gave me a much more realistic insight into what life is like for a pre-hospital doctor.
The jobs we attended were quite mixed; from road traffic accidents and suicide attempts to medical cardiac arrests and paediatric choking incidents. One of the main decisions that need to be made in the pre-hospital environment is deciding which hospital the patient should go to. Essex/Herts is a large area and there are not many major trauma centres (MTC) within a small area like there is in London. For this reason, the decision to bypass a trauma unit for a MTC requires more clinical acumen. Moreover, for those with specific injuries such as head injury or conditions such as MI, they need to transferred to the appropriate hospitals based upon what the hospital specialises is. I vividly remember transferring a cardiac arrest (secondary to STEMI) patient to Harefield hospital and I was so impressed with how the cath lab team greeted us at the door for the handover and allowed us to watch the Primary PCI (procedure to restore the blood flow to the block coronary artery). Also, their staff room had Nutella which was an added bonus!
Although flying in a helicopter to jobs was very exciting, it was the actual ‘job’ itself that provided the most cognitive-stimulation and excitement. It was incredible to be a part of the team deployed to critical cases. My duties included exposing the patient fully with the help of shears, getting the monitoring equipment on and providing traction to fractures etc. Seeing a patient in the pre-hospital setting adds a whole different element to your decision-making process. You have to use all of your senses and experience to figure out the mechanism of injury and the most likely subsequent injuries. This allows you to preemptively treat, package and triage the patient. I found this whole process both incredibly challenging and enjoyable. I feel that the experience I had in the ED and during my trauma elective allowed me to keep a cool head when confronted with dying patients to ensure I was thinking through the clinical situation as clearly as possible. Being able to remain calm in critical situations is definitely a skill that can be learnt and practised and I hope to continue doing this.
Another case that was extremely critical was a motorbike collision which led to a catastrophic pelvic bleed. The patient’s blood pressure was very low and continued to be unstable and venous access was difficult. We were also the first on scene which meant we were starting from scratch. We had to move quickly because it was clear that this patient needed blood and blood products. We packaged him after getting a line in and reducing his fracture and flew him to the local MTC.
Then in the ED, I noticed a lot of human factors issues such as a lack of situational awareness from the trauma team leader, there was also a faff with the Belmont Rapid Infuser and there was no closed loop communication. Moreover, there also made a comment about there being only one venous access. This raise an important point. The ED teams who receive a patient from the pre-hospital team don’t always fully appreciate how difficult it is out on the road where resources and time are extremely limited. So although, patients may arrive via HEMS nicely packaged with all the monitoring on etc, it takes a lot of work to achieve this so I had renewed appreciation for the HEMS team.
One of my favourite days of this elective was my shift with the Hazardous Area Response Team (HART). To me, HART is basically the SAS of paramedicine and they attend all the chemical incidences, difficult extrication jobs and jobs involving water, tunnels or even terrorism. They are highly-trained and highly-skilled paramedics and on my shift we attended a variety of jobs which I won’t go into for confidentiality reasons but I learnt a lot about their crucial role.
It was always an incredible privilege to be a part of the team in the pre-hospital environment and it was truly beautiful to see how well the emergency services worked together to ensure the best outcome for the patient
Clinical Governance Days (CGDs)
Pre-hospital teams take quality improvement and feedback from colleagues very seriously. I feel that to be a successful member of the pre-hospital team, you need to be somewhat of a perfectionist – someone who is constantly striving to improve their practice with the help of others.
Part of this learning is achieved with the help of monthly CGDs which involved auditing patient cases from the past month and seeing what went right and what could have been improved. There are also sessions on latest guidelines and important learning issues. All of this results in an enjoyable and interesting day of learning.
Alongside the CGDs, there are weekly D&D’s which is where cases from the previous week are discussed, particularly focusing on death or disability and if anything could have been improved or done differently. I always found it super humbling to be allowed to sit in on these conversations where doctors discuss their cases in an open and honest way, all in the hope of improving patient care going forward.
As part of this elective, students undertake a project/audit alongside a doctor/paramedic in order to answer a question or improve practice. I looked at the drowning victims that were attended to by EHAAT and analysed outcomes to figure out what interventions were being used and to what effect. With the help of my EHAAT mentors, I managed to create a poster and presentation which I presented at the D&D and I hope to submit my poster to future pre-hospital conferences.
All in all, I had the most incredible month in the pre-hospital environment. This experience definitely confirmed for me that I want to pursue pre-hospital medicine as a career because of the variety in the cases, the incredible nature of the teamwork and the constant desire to improve. I feel really appreciative that I was able to have this opportunity as a medical student and feel so grateful to all the staff at EHAAT for guiding, helping and teaching me. I learnt an awful lot about what true teamwork is all about in addition to clinical decision-making and patient assessment.
Now I’m back at my normal medical school for my final year and life is definitely a lot more mundane now that I’m back on the wards – I miss emergency and pre-hospital medicine a lot!!