PROFILE Medicine on the C


OGNITIVE overload is not a risk that most of us oſten have to contend with in our jobs – or at least not as it


is defined by Dr Stephen Hearns, lead consultant at the Scottish Emergency Medical Retrieval Service (EMRS). Consider the scenario: a paraglider piles


into a 500-foot cliff on the island of Arran. He is leſt dangling from his chute with a broken lumbar spine and some cord compromise. A helicopter approaches for a rescue but gusts from the rotor fill the chute and threaten to blow the casualty off the cliff. So an emergency medical consultant is lowered down from the clifop to assess the patient, administer analgesia, secure him into a stretcher as the chute cords are cut and he is winched up into the helicopter. Dr Hearns likes to characterise the


psychological factors at work here using a concept known as the Yerkes-Dodson law, which describes the relationship between performance and arousal (see graph opposite). Rising levels of stimulation in the medic lead to a point of peak performance but beyond that excess stress causes increasing anxiety with a serious drop in performance. Says Dr Hearns: “In this situation I think most of us would be quite far over to the right of the curve and quite dysfunctional.” And he should know as this scenario happened to him just over a year ago. I recently visited Dr Hearns at the EMRS


base of operations in a hangar next to the main runway at Glasgow Airport. Te team is part of SCOTSTAR (Scottish Specialist Transport and Retrieval), which is a division of the Scottish Ambulance Service and is funded by NHS Scotland to provide critical care and safe transfer to definitive treatment for patients in remote healthcare locations and at accident scenes across the country – from the Shetland islands to the Borders.


Flying ICU EMRS employs 28 retrieval consultants (nine whole-time equivalents) who are all specialists in emergency medicine, anaesthetics or intensive care. It also employs six critical care practitioners and two registrars.


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“You are offloading the cognitive burden by planning what’s predictable and practising that”


Jim Killgore speaks with Dr Stephen Hearns of the Scottish Emergency Medical Retrieval Service (EMRS)


“Two teams are on duty every day,” says


Hearns. “Both are consultant-delivered. We never go out with anyone less than a consultant. Te second member of the team is either a trainee doctor or a nurse or paramedic with advanced critical care training.” EMRS carries out over a thousand


retrievals each year and is tailored to the particular needs of Scotland where over 10 per cent of the population live more than an hour away from a hospital with an intensive care unit or an emergency department – many of these in remote and rural areas. “Tere are 24 small hospitals in Scotland


that don’t have on-site intensive care,” says Dr Hearns. “So if somebody comes into those hospitals critically unwell or seriously injured there are not the facilities to


provide definitive care for them. Our job is basically to take an intensive care unit with us in the helicopter or plane, fly out to that small hospital, stabilise the patient and then transport them safely to definitive care. We call these secondary retrievals.” EMRS also has a vital role in carrying


out “primary retrievals”, which usually involve flying to the site of serious accidents and providing prehospital care. Says Dr Hearns: “Tis might be a car accident or where someone has fallen from a building and is seriously injured. We can bring the emergency department to the patient. Tat includes securing airways, providing emergency anaesthesia, blood transfusions and some types of surgical procedures and then stabilising them and taking them to a major trauma centre.” Te team is also on-call for major


incidents involving multiple casualties. EMRS provided emergency medical support at the 2013 Clutha bar helicopter crash in Glasgow and recently at a major accident on a rollercoaster at an amusement park in North Lanarkshire.


Avoiding cognitive overload It is in delivering time-sensitive, life-saving care in such high-pressure circumstances that cognitive overload can become a serious risk and challenge for the team. “Retrievals are basically unpredictable,” says Dr Hearns. “It’s very easy for our guys to become overloaded in trying to carry out lots of interventions and assessments in a small team. But there are predictable components. So what we do is plan and practise the predictable components so that during an actual retrieval we don’t have to think so much about those.” Rigid procedures and protocols with


constant drilling and simulations are therefore key to the service. Te team has 148 standard operating procedures (SOPs) covering the various clinical scenarios they might face in any retrieval. Tese have been worked out in the “cold light of day”, says Dr Hearns. “You want to be able to perform a number of procedures that are predictable but with the minimal amount of thought or cognitive function so that the rest of your brain is leſt to say: ‘Right, how


SUMMONS


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