First Aid Saves lives! part one Airways

Just got back from a mandatory first aid course at work, being a medical student and having done first aid courses before, it was easy to think I already knew it all. I was surprised at how much I learnt from the experience. 
The first thing I learnt was some shocking statistics;

• Two thirds of people in the British public couldn't save a life in the event of an emergency.
• over a quarter of people who said they knew first aid would of done the wrong thing in an emergency (for example if someone was choking they would put their fingers in the persons throat to relieve the obstruction (pushing the obstruction further down))
• In the UK, less than one in ten will survive a heart attack while in Norway over 25% will, most likely due to the fact most people in Norway are able to perform CPR (First aid training being mandatory in Norwegian schools). 

I'll try an give a concise summary here about what was covered. also big thanks to Actual First Aid for the excellently run course. 

When approaching an emergency or an unconscious individual the mnemonic to use is:

DR ABC

D is for Danger. 

First, make sure its safe to approach, we dont want to generate another casualty for the ambulance to deal with. A classic example would be a car crash situation and oncoming traffic, a second crash?

R is for Response

You need to determine if the casualty is conscious, check this by asking a simple question."are you ok", perhaps they cannot respond verbally, so ask "can you open your eyes". if there is no response, you should call for help and contact the emergency services and move onto ABC. 

A is for Airway

The tongue is an incredible muscle, unlike the muscles in your arms and legs, the tongue is only attached at one point. The picture below highlights the tongue (purple) and its singular attachment at the bottom of the mouth in a cadaver. When someone loses consciousness the tongue relaxes completely and falls back slightly covering up the airway (not the thin route to the airway in the cadaver).(By the way its impossible to swallow your tongue, just try it).

The airway can be opened by gently tilting the head back by applying pressure to the forehead with your hand. HOWEVER, its possible in many situations that the casualty may have sustained a spinal or cervical spinal neck injury. In this case movements of the head and neck are to be avoided if there is any suspicion of neck injury. So how do you open the airway?
The best way to open the airway in this case would be by dislocating the jaw and bringing the jaw forward the so called 'jaw thrust' maneuver.
This is performed by placing three fingers behind the angle of the jaw close to the ear and with your thumbs applying pressure to the cheek bones below the eye, you pull the jaw forward and out so that the head doesn't move. (the movement of the jaw, pulls the attached tongue forward as well, allowing air to pass).

B is for Breathing
not breathing? you should consider CPR see part two...

C is for Circulation
no pulse? you should consider CPR see part two...

'I did the training, got the T-shirt, but are you willing to be your life on me?' The Medical simulation revolution

Attended a fantastic lecture by Mark Bowyer an ex trauma and combat surgeon, now professor of surgery at Uniformed University (where American Army doctors study medicine). 

The lecture was all about the different types and benefits of medical simulators available, particularly in surgery and combat medicine. 

Dr Bowyer started off by talking about the current state of medical training, a world where most medical students learn from books and lectures and are expected to perform without mistakes on real patients when they start work. Does written performance translate to technical performance? He showed a video of a fifth year medical student who had passed all the life support courses and written exams and in a practical exam on intubation put the laryngoscope in the mouth of the simulation doll the wrong way round.  The old mantra of 'see one do one teach one' that I myself have heard many times on the surgical ward is outdated and even dangerous. In fact healthcare itself is one of the most dangerous professions, up there with bungee jumping and mountain climbing. He jokes 'I did the training got the T-shirt are you willing to be your life on me?' Surgeons have to know around 120 procedures to pass their board exams and be described as proficient. 60 of these procedures surgeons practice on average less than 1 time per year.  We all want doctors that are safe, competent and proficient. Many doctors will only get the opportunity to 'practise' on patients themselves and with stats like those above they may not even get that opportunity often. In fact these days there is less tolerance for errors and on top of that training times have shortened, what's the solution? Dr Bowyer believes the answer is medical simulation.
An important thing about simulation is that you can allow people to fail, because well like it or not, it does happen. You can repeat interventions as many times as you like, develop goal orientated practise and use it as a teaching tool. These days most methods are expensive, (medical education is expensive in general though) but as the industry grows, hopefully we will be seeing more of it. It's a powerful tool and we are probably just entering a new age of medical education as it grows. Dr Bowyer spent the second half of the presentation describing the various methods of solution available and their pros and cons. Before starting medical school I was a simulated patient for the UK OSCE exams, I had to pretend to have various symptoms like hearing loss, blindness and at one point some respiratory condition. Simulated patients provide an optimum human experience; history taking, physical exams and re-enacted disaster scenes, you can't get much more real than dealing with a living breathing human being. Dr Bowyer had a volunteer simulated patient who had already lost his legs in battle enacting a scene that his legs were blown off with fake blood on the ends, a powerful image for new army doctors. How do you prepare someone for the 'image' of trauma.? Part task trainers is another method of simulation for example peritoneal lavage (simPL) simulation. Students can puncture a synthetic membrane (made to look like abdomen, with umbilicus etc) with a needle that is tracked on a computer screen in front, the simulator mimics the pop of crossing the fascia and the peritoneum. Another way this technique can be trained is on a pig. Animals however do not have human anatomy and a small study comparing the computerised synthetic membrane to pig for peritoneal lavage showed better site selection and seldinger technique with the synthetic model. Working with the gaming industry and virtual reality technology, there is an expanding market of surgery simulation games. Some less professional like the very entertaining Surgeon Simulator 2013 but some more more didactic and professional as Touch surgery.

Dr Bowyer showed some incredible examples of 'virtual environments', another new medium for medical simulation. In these virtual environments you can simulate sounds, smells, scenery, noise, smoke, gun fire and much more (air cannons were used to simulate bombs going off nearby). One such environment had a helicopter platform that tipped and rolled just like a real helicopter, where the soldier could simulate getting a patient aboard and then treating him/her while the helicopter 'flew'. Just check out this WAVE (wide area virtual environment) simulator: https://www.youtube.com/watch?v=ineGH9Smce0

With the enrolment of multiple actors and simulated patients, you can simulate mass casualties and disaster zone situations using this technology.

When it comes to surgery, there are already simulators available for laparascopic and robotic surgery but the real challenge is open surgery simulation. A model of open surgery needs to act like human tissue, be anatomically correct and bleed in a realistic fashion. There has already been some success with visco-elastic foam models. One such model was used to teach doctors going out to Irag the correct procedure for fasciotomies and will have saved many legs from amputation. wouldn't you rather train on a simulator before performing an amputation tomorrow?

Now there are even simulators in development for teaching c-sections to third world countries.

Medical simulation is the new revolution in medical education! hopefully we will see one day a standardized curricula based on physical models that is consensus driven, validated, proficiency-based, offers remediation strategies and assessable to all. 

Cricothyroidotomy training simulator