Fusion stories: Tikka Masala, Bluegrass and Prehospital Critical Care

Chicken Tikka Masala was invented in Glasgow by fusing tomato soup with chicken cooked in a Tandoor oven. Bluegrass music arose in Appalachia from the fusion of Irish folk and African jazz. Prehospital critical care similarly arose from the fusion of hospital-based emergency medicine with the incident management skills of paramedicine. 

Doctors with critical care skills have their cultural locus in the hospital. As such, they see the clinical course of disease and injury and develop hard-wired reference points to interventions that sometimes play out badly over the days following admission. Protracted weaning from ventilation, empyema or persistent air leak from chest drains, neurological damage from hypoxia or hypotension during intubation to name a few. They also tend to be at the front edge of new techniques, from point-of-care ultrasound to video laryngoscopy and on to ECMO and REBOA. The same is true of new approaches to intensive management such as early inotropes in sepsis, multi-component blood transfusion and protective ventilation strategies. Some prehospital situations however can be complicated by medical staff who don’t see the big picture. I’ve been stuck literally in a hole more than once wanting to provide impractical medical care when the priority (clear to the experienced paramedic) was evacuation from a deteriorating and dangerous situation.

Paramedics with critical care skills (CCPs) conversely have their cultural locus out-of-hospital. As such they see how an incident might play out in several different ways and instinctively choose a course of action based on hard-wired reference points that balances risk versus potential gains. This may include expediting care that relies on speed to definitive intervention such as damage control surgery or delaying immediate “scoop and run” because they can better deliver the most urgent intervention on scene such as post-cardiac arrest stabilisation, relocating a badly displaced fracture, giving an antidote to tricyclic poisoning, or providing emergency sedation to an unmanageable patient. Other situations though require the longer or broader view of the physician, like sitting out intubating the critical asthmatic while the bronchodilators work, anticipating the profound bradycardia that accompanies pressors in spinal shock, or spotting digoxin toxicity driving complex arrhythmias. 

Some high acuity situations might be perfectly well managed either by two suitably skilled doctors or by two advanced practice CCPs. (Having only one skilled practitioner for a badly injured or critically ill patient who is paralysed and ventilated is clearly far from ideal). Both disciplines have similar skills to be deployed – intubation, ultrasound, surgical procedures, vascular access, ventilation. Who is better at any one skill is clearly a matter of individual experience, training and practice. But when the situation is non-standard, or where normal processes are overwhelmed as in a major incident, the best solutions arise from the cultural fusion of a well-drilled and experienced multidisciplinary team. Ideas can be blended from different places when the recipe book has a missing page or when a crucial ingredient is missing.

Arguments against multiculturalism in society in general or multidisciplinary teams in prehospital critical care often run along the same lines: societies or services must be protected from the very forces that allowed them to develop and flourish in the first place. In the case of prehospital critical care teams, professionals may be afraid of losing status or career opportunities, and the cheapest team configuration is vaunted as being the most cost-effective. Evolution and innovation however rely on access to a deep gene pool of different ideas, talents, experience and cultures in which creative DNA is regularly exchanged. As for value, the investment in sustainable, versatile, high quality prehospital care reaps real dividends in terms of avoidable death and preventable costly long-term disability for patients. 

The success of the Scottish Trauma Network has been largely built on the relationships forged between different professional groups across the chain of survival and recovery. At one end, stands the strong collegial relationships between a high-performing stand-alone CCP cadre, and the multi-disciplinary physician/practitioner critical care teams. Staff move between the two teams and are tasked by the same critical care desk in Ambulance Control. Both help the other to be better, innovation thrives, skills are shared, and jobs are scrutinised together for improvement opportunities. At the other end of the patient journey, the prehospital section of the network advocates strongly for investment and growth in the rehabilitation services, because without them the prehospital wins are dissipated. In return, the rehab teams argue that good prehospital critical care delivers them patients with the potential for a full recovery.

Planning prehospital critical care services might therefore be best done over a great Chicken Tikka Masala and with Bluegrass music playing to set the scene. The assembled multidisciplinary team can then lever all their diversity and passion to achieve the most successful evolutionary trick of all – collaboration in pursuit of a shared objective. In this case, excellent patient care.

A Wasted Weekend of Fruitful Effort

Just finished a weekend of late shifts in a busy urban emergency department. Pretty tired but worked with a good team and we got some stuff done. Felt like taxpayer got a reasonable deal paying for us to be there, especially the old folk who were part of a generation that fought to have the NHS there for them later in life when they needed help, and the patients who would otherwise have been dead or badly disabled without rapid on-site intervention.

According to some clever folk, however, we were part of a failed system that needs to be changed urgently to save the NHS. We didn’t meet our targets, and our very existence encouraged people to come to a hospital when they could be equally or better cared for at home. We are the past. In the future, we can sit in a call centre, consult by video call, organise home teams to provide treatment, and then get a private company to deliver electronic tags to the patients’ homes so that we can watch them recover remotely.

Questioning my own lived experience, I went back through my patients across the three shifts in the different areas of the department. Resuscitation first. Cardioversion, major trauma management, intubation and ventilation, inotropic support, joint reduction under sedation, transfer to theatre for immediate surgery. Some patients were obviously unwell or badly injured from the start, but a few came in through from minors as potentially low risk, with presentations such as syncope or dizziness.

Next, the Majors area. I admitted many of these patients to hospital. Severe abdominal pain requiring titrated narcotic analgesia, asthma requiring back-to-back nebulisers and a bed near an ICU, fractured hips needing pain-relieving nerve blocks then surgery, and acute cardiac conditions with a risk of malignant arrhythmias potentially needing cardioverted or angiography to prevent long term heart failure. Three patients had severe delirium requiring emergency sedation. A handful of isolated frail elderly with acute medical decompensation who were now unable to mobilise safely or attend to basic self-care needs without immediate 24hour care.

Finally, the Minors area. I sent most of these patients home. Some came in with “red flag” presentations like thunderclap headache, cardiac sounding chest pain or paracetamol overdose. Scan, blood test, home with good negative test, done. Some had injuries needing x-rays or sutures. Done and away. Some had new presentations that had resolved like GI bleeding, DVT, TIA or seizures. Basic stuff done, discharged, specialist clinic follow-up. One had a deterioration in complex neurological disease and was admitted for tertiary care. A couple were sent through to majors or resus from triage with higher acuity illness, and two were removed by police in the triage or waiting areas for violent conduct.

I suspect most patients were reasonably happy with their care, except the ones that waited ages to be seen in minors because we were short staffed and providing default care to ward patients stranded in ED due to bed block. We are told however that 66% of this effort was wasted on “inappropriate” people who don’t need to be there, and who should be treated virtually in the future to free up capacity. 

Reviewing the shifts, this is puzzling. We admitted those who needed critical care immediately, and those who had the potential to deteriorate and need defibrillated, ventilated, or invasively monitored. We investigated for potentially life changing conditions using readily available x-rays, CT scans and batteries of blood tests to allow the negatives to be safely discharged with a completed episode. Some definitive treatments were provided, all patients had the therapeutic effect of an in-person consultation, and some vulnerable patients were brought into a place of safety from precarious social circumstances.

Perhaps this is clinging on to the past and just throwing virtual sabots around. The dehumanisation of care is maybe just another part of the systemic social disconnection and downgrading of shared public spaces and services. For a patient to reap the benefits of virtual healthcare however will require living in a decent house, speaking English as a first language, and being young and educated enough to be able to make a monitored Avatar of yourself. Homeless, mental health problems, asylum seeker, elderly, no internet, illiterate, lonely? Please form a small queue for remaining hospital bed in the margins. The cost in terms of money and environment of all this innovation relative to centralised medical care is disputed. Certainly, a very large number of staff will spend a fair bit of time driving about or watching computer screens. A few private companies will make a lot of money supplying vast quantities of equipment. 

Once the transformation is complete, the patient left alone at home who collapses and triggers their remote monitor will flag up to one of the redeployed Emergency Medicine staff in the call centre. They will then try to find a critical care response to send and what remains of a real hospital bed to put them in. At least if/when they arrive at the down-sized real-world facility, they won’t be labelled as inappropriate – at least until the next innovation.