Communicating clearly

Cite this article as:
Liz Herrieven. Communicating clearly, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32916

The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) produces guidance for ambulance services across the UK. I was thrilled to be asked to contribute to this in the form of a new chapter on patients with communication difficulties. This post expands on that guidance, which was written to support pre-hospital clinicians in providing the best possible care to their patients who face challenges with communication. This may be due to a wide variety of underlying conditions, including learning disability, autism, hearing loss, dementia and dysphasia.

Communication is vital to all that we do – from the first contact with a patient, through history taking and examination, to initiating treatment and explaining procedures. We have to do our very best to get it right. This is perhaps even more important, and more difficult, in the pre-hospital field, where stress levels are high, the environment can be unpredictable and time is short. Clinicians meeting patients for the first time need to quickly assess the situation and also win trust and gain understanding.

Communication is a two-way thing. It sounds obvious, but it becomes even more important when patients find communication difficult. Not only do we have to try our best to make ourselves understood, but we also have to try our best to understand our patient.

It’s also important to remember that communication and understanding are two very different things. Someone may be able to communicate quite well but understand very little. Conversely, someone may not be able to communicate but may have a very good understanding, including things being said about or around them. Dysphasic or dysarthric patients may appear to be unable to understand when actually their difficulty is in expressing themselves.

So, how can we improve our communication?

Minimise fear and anxiety

Communicating and understanding become more challenging when there is fear and anxiety. The first step is to keep calm and reassure the patient. The specific nature of any communication difficulty needs to be recognised quickly then addressed. Patients with a learning disability may not understand what is happening so careful explanations may help. Some autistic patients may have difficulty interpreting information verbally or non-verbally, or they may have significant sensory processing difficulties which means that loud noises, bright lights and physical touch can be distressing or even painful. Deaf patients may be able to better understand if they can see the clinician’s mouth – difficult with PPE.

Make simple adjustments

Communication might be made easier with simple changes such as speaking slowly and clearly and avoiding jargon. And give time – time for your patient to respond. For some patients, including those with Down syndrome, it can take several seconds to respond – time to receive the auditory information, decode it, understand it, formulate an answer and produce that answer as the right set of noises. We’re all busy so that seven or eight seconds can feel like an age. It’s absolutely worth the wait, though.

Adapt the environment

Can we do anything to make the environment less distracting, quieter, less stimulating? Would it be better to assess the patient in familiar surroundings rather than in the ambulance? Can noisy, scary or flashing equipment be switched off, removed or covered? If the patient has to be moved can they bring something, or someone, familiar with them?

Pay attention to non-verbal communication

Would eye contact help? It often does, but for some autistic patients it can be distressing. Some people respond well to a reassuring touch (I’m a toucher and a hugger) but others find it really uncomfortable – check before extending that hand! Do we need to support our verbal communication with gesture or sign? Pictures or symbols might help to explain what we are saying, but if we don’t have any to hand then pointing to body parts or pieces of equipment can help. We absolutely need to pay attention to our non-verbal communication, body language, posture, facial expression and so on, and also watch for non-verbal cues from our patient. Those who know our patient best might be able to help with this – how would their loved one usually let someone know they were in pain, for example? Pain is often poorly assessed and managed in people with a learning disability (LeDeR – the Learning Disability Mortality Review Programme). We often hear about people having a “high pain threshold” and whilst it’s true that pain is perceived differently by different people, we can’t assume that someone does not feel pain just because they can’t verbalise it.

Play to your patient’s communication strengths

Some patients may have particular strengths and weaknesses when it comes to communication. People with Down syndrome often find it more difficult to understand and remember auditory information, due to a variety of issues including fluctuating hearing impairment and poor short term auditory memory. They may, however, find it much easier to remember and understand information presented in a visual format. Using gesture, sign language (such as Makaton), photos or symbols (such as PECS) may support the verbal information and make things much easier for both the patient and the clinician.

Family and carers can help to identify how best to communicate with the patient but consider other resources too – is there a hospital passport that can give you some clues? These are often used to list medications and past medical history, but their real beauty is in detailing likes, dislikes, behaviours associated with pain, interventions that might be difficult to tolerate, and so on. A care pathway can also give great clinical information and guide management.

Adapt your examination

Your standard examination might need to be altered a little. Give clear warnings before touching the patient, particularly if they have any visual impairment or a sensory processing disorder. Start with those parts of the examination that are less intrusive – watching and observing position, demeanour, breathing pattern, and movements can all give a huge amount of information before you even get your stethoscope out. Distraction might be useful for some patients but for others, including those who may have had previous bad experiences, it might not work. Family and carers may know how best to support your patient through the more distressing parts of the examination and any following interventions.

LeDeR has also found that early warning scores were less likely to be calculated in people with a learning disability, and they were less likely to be acted on if abnormal. There are many likely reasons behind this, including clinicians being reluctant to cause distress to their patients. Things like blood pressure or oxygen saturation measurement can be very uncomfortable, particularly for those who may not understand what is being done or who may have sensory processing difficulties. Those patients still need to be assessed and treated appropriately. If a BP or sats, or any other part of your assessment for that matter, is likely to give important information then it should be done. There may, however, need to be some thought about how best to carry it out. Explanation, communication, visual information, distraction – what will help your patient tolerate the examination?

There is a common misconception that patients with chronic health problems always have an abnormal early warning score, so what’s the point? Any score, normal or abnormal, in a previously healthy patient or not, should be taken in context with the rest of the examination. It can be helpful to know what the patient is like (behaviour, level of alertness, comfort, interaction, early warning score) when well, to help to identify how ill they may be now. Again, family and carers can give vital information about this.

Be attuned to “soft signs”

“Soft signs” can help, too. These are things that family might notice long before health professionals. They are not specific to any particular illness or disease process, but give an indication that the patient isn’t well. For example, someone might be a little paler than usual, not want to get out of bed, not want to finish their favourite meal and not want to watch their favourite TV programme. A family member would know that these things mean their loved one is not themselves, and likely to be unwell. Healthcare professionals can learn a lot by listening out for soft signs.

Beware diagnostic overshadowing

It’s really important to watch out for diagnostic overshadowing. This happens when a patient has a pre-existing diagnosis, and any new symptoms are assumed to be down to this diagnosis. For example, an autistic person might present as being quite agitated, carrying out repetitive, stereotypical movements and it might be tempting for us to assume that this is all because they have autism. However, if we do that, we may miss the fact that they are in pain or feeling unwell. Again, we have to find out more about what our patient is like when they are well, to know how ill they may be now.

All of this boils down to making reasonable adjustments, which are required by law (Equality Act 2010). We can sum it up with the TEACH mnemonic:

Time: assessing someone with communication difficulties may take more time, but that time is absolutely worth it.

Environment: pick the best environment to assess your patient in. Keep things quiet and calm, remove distractions. Keep things familiar to the patient if you can, or let them have something familiar with them.

Assume: don’t assume anything about understanding – communication aids understanding, but someone who has difficulties with communication may still have very good understanding.

Communication: how can you best communicate with your patient? How can you help them make themselves understood? Would symbols or signs help? Pictures or gesture? Writing things down?

Help: what help does your patient need? What help do you need??

None of the interventions suggested are particularly tricky or difficult, but all have the potential to make a huge difference to our patients. For those working in UK ambulance services, the JRCALC guideline chapter will hopefully help as a prompt. For others, whether pre-hospital or not, I hope this blog helps a little.

https://www.jrcalc.org.uk

https://www.bristol.ac.uk/sps/leder/

Trauma education at RCH

Cite this article as:
Andrew Tagg. Trauma education at RCH, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11996

If you are critically injured as a child in Victoria, Australia, the chances are that you will end up at the Royal Children’s Hospital in Melbourne. Every year they see approximately 320 severely injured children from all over Victoria.  177 of these are brought in by helicopter. #RCHTrauma2017 was a joint educational evening put on by the trauma service and the great team from Air Ambulance Victoria. As well as capacity crowd across two lecture theatres it was  live-streamed to 64 sites across Victoria and Tasmania.

 

Utilising a case based format the MICA (Mobile Intensive Care Ambulance) paramedics ran through a series of challenging cases.

Case 1

Ben Meadley went through  some of the challenges of extrication faced in rural Victoria. Winch rescues are some of the most dangerous performed by paramedics (and doctors). When advanced airway management is required there can be a trade off between intubating a critically unwell child in a precarious position with minimal staff and a short winch to a staging area with 360° access and more staff.

Ben was followed by clinical neuropsychologist, Debbie Houston, talking about the rarely mentioned sequelae of a traumatic brain injury. She spoke about the importance of cognitive rest in a low stimulus environment early in the recovery period – low light, low sound and minimal visitors. The RCH has a great resource for parents and health care providers alike. She reminded us that the the road to recovery is a long one that is only started in hospital. The harder work takes place later as the family and child come to terms with challenges in a number of cognitive domains including:-

  • Attention and concentration
  • Flexible thinking
  • Impulsive and inappropriate behaviour
  • Problem solving skills
  • Memory and learning

 

Case 2

Next Matt Shepherd presented a case of post-drowning cardiac arrest and some of the challenges experienced in the field. Even the most experienced amongst us can have challenges in obtaining intravenous access in the warm, brightly lit trauma bay. Ambulance Victoria Clinical Practice Guidelines allow MICA paramedics 90 seconds to obtain IV access before turning to the intraosseous route. Unfortunately, this route can still fail despite training. We can all have bad days and it is incumbent on all of us to be aware of our limitations.  If we are having a bad day when every cannula fails it is important to not let pride or ego take over and allow somebody else to have a go.  Just make sure you have not already tried both hands, both cubital fossae and tried IO’s in both legs first. You need to give others a fighting chance. MICA paramedics have recently introduced ultrasound into their skill set, initially for eFAST and now, with the introduction of a linear probe, vascular access.

Trauma fellow, Keith Amarakone, then reminded the audience of global, as well as the local, impact of drowning. Despite many public health appeals there were 43 drowning deaths in Victoria last year. The basic tenets of resuscitation hold true, with an emphasis on ventilation, but we can have just as big an impact if we focus on prevention and awareness. Instead of public pools most of the non-fatal drownings I have been involved with have been unsupervised toddlers in the bath.

 

Case 3

The final challenging case was presented by AAV poster boy, Darren Hodges. He discussed the medical details behind this case…

This case involved the first paediatric prehospital finger thoracostomy in Victoria coupled with a prehospital blood transfusion. Even with these life saving measures he still showed significant signs of shock when he arrived at RCH.

Warwick Teague, the Director of Trauma, took over the microphone to discuss Jordan’s in-hospital course. The main focus of his talk was that non-operative management is the mainstay of paediatric truncal trauma and the Royal Childrens experience. Despite a high incidence of severe chest injuries, less than 2% of severe thoracic injuries (with an AIS of 3 or more) required a thoracotomy and only 15% needed insertion of an intercostal drain.

He also showed the latest RCH data regarding management of solid organ injuries. Over a 10 year period they have had a 100% splenic preservation rate (n=185). Only 5 laparotomies for liver lacerations (n=172) occurred in a 10 year period and there have been just 3 angio-embolisations (n=499).

With so many patients arriving by helicopter, how do the paramedics deal with parents requesting to fly with their seriously injured child? Toby St Clair reinforced that it might not be in the patient or parents best interest. Even the AW-139 is not fitted out as an Uber of the sky and space in the back is limited.  The seriously ill child might deteriorate in transit and require further intervention. We know that parental presence can be beneficial in resuscitation so this often causes a degree of moral distress for all involved.

The evening ended with Kat Baulch, a senior emergency social worker, talking about the response to trauma and dealing with distressed families. She highlighted the importance of performing psychological first aid.

  • Promote safety
  • Promote calm
  • Promote connectedness
  • Promote self-efficacy
  • Promote hope

If you want to read more about this then read this guide from the Australian Red Cross.

For some more great #FOAMed resources on paediatric trauma check out the following links:-

Emergency Medicine Cases: Anton Helman chats with Dr Sue Beno and Dr Faud Alnaj about all things trauma related.

Pediatric Emergency Playbook: In this two part series, Tim Horeczko talks about massive transfusion and more besides.

Asthma for ambos HEADER

Asthma for Ambos

Cite this article as:
Andrew Tagg. Asthma for Ambos, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9592

Tonight I had the privilege to talk to the team at the Werribee branch of Ambulance Victoria. I was given the brief to talk on something to do with paediatric respiratory problems so I thought I would focus on one of their most common presentations – asthma.

Asthma is a common condition and affects one in ten Australians. Approximately 17.2% of all kids in Victoria have been diagnosed with it. The incidence in Aboriginal or Torres Strait Islanders is higher at around 20%. Whilst a large number of these will never need to go to hospital, of those that do go, 43% per cent need admission. This is much higher than their adult counterparts. A large number can be safely managed at home with their pre-written asthma action plan (though only 41% of kids under 15 years of age have one) but some children are more at risk of critical or life-threatening asthma than others. Fortunately, the death rate in the under 15-year-old sub-population is around 0.2 per 100,00 people.

Risk factors for a more severe attack include:-

  • A previous severe asthma attack requiring an ICU admission
  • Two or more hospital stays because of asthma in the last year
  • Use of more than two reliever inhalers in the last month
  • Exposure to tobacco smoke
  • Previous allergic rhinitis, food allergies or hay-fever

There is a seasonal peak in ED visits in late summer and autumn for children, whereas more adults present in the winter. This may possibly be due to the increased incidence of viral upper respiratory tract infections among grown-ups at this time of year.

Some people are more likely to call an ambulance than others. They include those with :-

  • Poor knowledge about asthma
  • No asthma action plan
  • Poor self-management skills
  • Limited access to primary care

Paramedics are very experienced in managing it because asthma is such a common condition. I want to focus on some areas where what should happen and what does happen might diverge.

Myth – Oxygen saturations are useful in the management of asthma

An acute attack is characterised by bronchospasm, coupled with mucosal oedema and hypersecretion of mucus. This leads to aV/Q mismatch as there is hypoxic vasoconstriction and decreased blood flow to the under-ventilated lung in order to match pulmonary perfusion with alveolar ventilation.

In the hospital setting, oxygen saturations of less than 91% may predict the need for prolonged bronchodilator therapy.

Hypoxaemia and hypocarbia only occur in the presence of life-threatening asthma. If you take into account the haemoglobin-oxygen dissociation roller-coaster it is easy to see how many children may teeter on the precipice of collapse before critical desaturation occurs. Whilst low oxygen saturations mean that a patient is unwell it should be clinically obvious at this point.  On the flip side, normal oxygen sats do not mean the patient is fine.  There is a concern that oxygen administration may lead to a delay in recognising clinical deterioration. Low oxygen saturations may also represent a degree of mucus plugging that may be helped with repositioning.

Hyperoxia can lead to absorption atelectasis as well as intra-pulmonary shunting with a subsequent reduction in cardiac output. As the 78% nitrogen in the alveoli gets washed out with increasing amounts of supplemental oxygen, tt is resorbed. This leads to a reduction in alveolar volume and collapse.

Myth – Nebulizers are better than spacers

A recent Cochrane review comparing nebulizers with spacers found that there was no real difference in hospital admission rate with either mode of delivery. Lung function tests and oxygen saturations were also unaffected by the mode of medication delivery. What was different, however, was the adverse effect profile. If you used a nebulizer you were much more likely to see tremor and tachycardia.

Old British Thoracic Society guidelines suggested using up to 50 puffs of salbutamol via spacer but this is probably a bit excessive.  The current recommendation is that 400mcg of salbutamol via spacer is probably equivalent to 2.5mg via nebulizer.

So do you know how to use a spacer? I took the Werribee team through the procedure.  If you are not sure then take a look at this great instructional video from Asthma Australia:-

Whilst spacers are cheap, those of you with the MacGyver instinct may want to make your own.

These jerry rigged spacers have certainly been shown to be as effective as conventional devices in resource poor settings.

Myth – You can never give enough salbutamol

Inhaled B2 agonists relieve bronchospasm and improve oxygenation.  The minor side effects that we have all seen include tremor, anxiety, headache, dry mouth and palpitations. If given, without oxygen, they have also been shown to cause or worsen hypoxaemia. Pulmonary vasodilation leads to a worsening ventilation-perfusion mismatch.

Inhaled salbutamol may also cause metabolic acidosis even when the mechanical work of breathing has been improved with paralysis and ventilation this still occurs. In the non-paralysed patient, the body compensates for this acidosis by increasing the respiratory rate to blow off the CO2. Be mindful that the tachypnoea in your asthmatic patient may be due to excess beta-agonist and not their asthma.

So how does one recognise potential salbutamol toxicity in the pre-hospital setting? Consider it in all children who are wheezy, restless, tachycardic and have had large doses of beta-agonist.

Normal doses of inhaled salbutamol have been shown to cause hypokalaemia but the clinical significance of this is unknown. Hypokalemia, coupled with worsening respiratory and metabolic acidosis can have catastrophic cardiac effects.

Myth – Adrenaline is dangerous in asthma

One of the most most obvious reasons for using adrenaline in the setting of apparent severe or life threatening asthma is that the diagnosis may be in doubt.  Asthma and atopy often co-exist. Patients with known food allergies and asthma are much more likely to die due to anaphylaxis than those without asthma.  A child with severe anaphylaxis may initially have no more signs than a wheeze and worsening air hunger that is mistakenly treated as asthma. The diagnosis of anaphylaxis should be considered in all who fail to respond to initial therapy.

Nebulized adrenaline may be helpful in acute asthma via direct beta adrenoceptor mediated bronchodilatation. It is possible that there are also some alpha effects via reduction in localized oedema and reduction in microvascular leakage. Small studies have shown no difference between nebulized adrenaline and nebulized salbutamol in terms of increased peak expiratory flow. The may also be less of a drop off in PaO2 due to the V/Q mismatch seen with salbutamol use due to alpha action.  In younger children, bronchospasm may be less of an issue than mucosal oedema.
Remember all inhaled therapies are ineffective if they don’t go anywhere. If the child is so tight that they can barely inhale then salbutamol or nebulized adrenaline are likely to be of benefit and so alternative route should be sought.  IM adrenaline can be given quickly to the critically ill asthmatic whilst IV access is obtained.  At the time of writing a clinical trial into the potential benefit of IM adrenaline as an adjunct to inhaled B2 agonists is recruiting in the US

Myth – If the child is wheezing, they have asthma

Around 17% of infants experience wheeze with the first three years of life. Not all of these end up with a diagnosis of asthma. By the age of 4-5 the incidence of wheeze is around 21.7% which is almost double the incidence of asthma (11.5%) in this population. By the school years, the incidence of wheeze and asthma are near identical.
Wheeze is characterized by “a continuous whistling sound during breathing that suggests narrowing or obstruction in some part of the respiratory airways.” With that definition in mind, there are a number of clinical entities that may cause a wheeze. There is a grey area between those children with obvious asthma and obvious bronchiolitis. Whilst bronchodilators would be appropriate in asthma a large Cochrane review found them to be ineffective in bronchiolitis.  Most clinicians would give a one-off trial of salbutamol as long as it did not interfere with other management.  There is also no evidence of benefit for the use of systemic corticosteroids in pre-school wheeze.  Other potential diagnoses to consider include inhaled foreign bodies, pneumonia or pneumonitis, tracheomalacia or complications of congenital conditions.

So the presence of wheeze does not guarantee that the child has asthma. It is also worthwhile mentioning that the absence of a wheeze does not rule it out either. If there is severe bronchospasm and mucosal oedema not enough air entry will occur to cause a wheeze

Selected References

Asthma in Australia: with a focus chapter on chronic obstructive pulmonary disease. 2011 Full text

Oxygen saturations are useful in the management of asthma

Mehta SV, Parkin PC, Stephens D, Schuh S. Oxygen saturation as a predictor of prolonged, frequent bronchodilator therapy in children with acute asthma. The Journal of pediatrics. 2004 Nov 30;145(5):641-5.

Inwald D, Roland M, Kuitert L, McKenzie SA, Petros A. Oxygen treatment for acute severe asthma. British Medical Journal. 2001 Jul 14;323(7304):98.

Helmerhorst HJ, Schultz MJ, van der Voort PH, de Jonge E, van Westerloo DJ. Bench-to-bedside review: the effects of hyperoxia during critical illness. Critical Care. 2015 Aug 17;19(1):1.

Nebulizers are better than spacers

Zar HJ, Brown G, Donson H. Are spacers made from sealed cold-drink bottles as effective as conventional spacers?. Western Journal of Medicine. 2000 Oct;173(4):253.

Castro-Rodriguez JA, Rodrigo GJ. β-Agonists through metered-dose inhaler with valved holding chamber versus nebulizer for acute exacerbation of wheezing or asthma in children under 5 years of age: a systematic review with meta-analysis. The Journal of pediatrics. 2004 Aug 31;145(2):172-7.

You can never give enough salbutamol

Tomar RP, Vasudevan R. Metabolic acidosis due to inhaled salbutamol toxicity: A hazardous side effect complicating management of suspected cases of acute severe asthma. medical journal armed forces india. 2012 Jul 31;68(3):242-4.

Yousef E, McGeady SJ. Lactic acidosis and status asthmaticus: how common in pediatrics?. Annals of Allergy, Asthma & Immunology. 2002 Dec 31;89(6):585-8.

Udezue E, D’Souza L, Mahajan M. Hypokalemia after normal doses of nebulized albuterol (salbutamol). The American journal of emergency medicine. 1995 Mar 31;13(2):168-71.

Starkey ES, Mulla H, Sammons HM, Pandya HC. Intravenous salbutamol for childhood asthma: evidence-based medicine?. Archives of disease in childhood. 2014 Jun 17:archdischild-2013.

Adrenaline is dangerous in asthma

Coupe MO, Guly U, Brown E, Barnes PJ. Nebulised adrenaline in acute severe asthma: comparison with salbutamol. European journal of respiratory diseases. 1987 Oct;71(4):227-32.

If the child is wheezing they have asthma

Ducharme FM, Tse SM and Chauhan B. Asthma 2: Diagnosis, management, and prognosis of preschool wheeze. Lancet. 2014. 383:1593-604.

Okpapi A, Friend AJ, Turner SW. Acute asthma and other recurrent wheezing disorders in children. American family physician. 2013 Jul;88(2):130-1.

Goldstein H, Tagg A, Lawton B, Davis T. Easing the wheeze. Emergency Medicine Australasia. 2015 Oct 1;27(5):384-6.

Gadomski AM, and Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database of Systematic Reviews. 2014;6:CD001266