Interview: Paul Swinton on high performance airway management
Air Ambulance Paramedic and co-inventor of SCRAM™ Paul Swinton spoke to Mandy Langfield about his work for ScotSTAR, the Scottish medical retrieval service, and his innovative approach to critical airway management equipment
Could you tell us a bit about your background and training to become a HEMS paramedic, and where you currently work?
I have been a paramedic for the past 20 years, joining the Scottish Ambulance Service Special Operations Response Team based in Glasgow in 2010, after re-locating from the West Midlands in England. I am originally from South Africa, where I qualified and worked as a paramedic on the road, in emergency departments, and as a flight paramedic flying to some of the remotest parts of Africa. I have a special interest in emergency airway management, and have developed the concept of Structured CRitical Airway Management (SCRAM™ – see below).
I hold an MSc in Trauma Sciences (Military and Humanitarian) through Queen Mary University of London. My research examined the impact of drug and equipment preparation on pre-hospital emergency anaesthesia procedural time, error rate and cognitive load. I have also been engaged in research conducted at the Royal London Hospital to compare the relative efficiency and safety of current practice versus the use of the SCRAM™ system. A further study is underway at the Royal Hospital for Children and Young People in Edinburgh, where we compared standard practice (resuscitation trolley) vs Paediatric SCRAM using Tobii Glasses eye-tracking technology to investigate the cognitive burden during pediatric emergency airway management.
Currently, I am a paramedic for the Scottish Air Ambulance Division based out of Glasgow, involved in critical care and retrieval medicine, working alongside the trauma teams and medical retrieval services of Scotland (ScotSTAR).
What were the key differences you noticed about HEMS operations in other countries, and what have you brought to your current role as a result of those experiences?
In South Africa, most HEMS are run by private service providers in collaboration with provincial health services, and transport private patients as well as state-funded patients. The cost of transporting state-funded patients is recovered from the provincial health services.
In the UK, all HEMS are charitably funded, and aircraft either directly owned by the charity, or operated under contract with a private provider. The ambulance staff and doctors crewing these flights are generally seconded from the local NHS ambulance service and NHS hospitals. Scotland, by contrast, has the only publicly funded air ambulance service, operating two Airbus H145 helicopters and two fixed-wing aircraft in this role, alongside two charity-funded EC135 helicopters, operated by Scotland’s Charity Air Ambulance.
In South Africa, the crew configuration differs, in that most have a double paramedic crew and a single pilot, while HALO Aviation is the only HEMS operator in South Africa that operates a doctor-led service. When tasked, the same team will be deployed, whatever type of mission the aircraft is sent to.
In Scotland, the team makeup depends on the type of mission we are tasked on, whether an air ambulance, HEMS, adult retrieval, paediatric retrieval or neonatal retrieval, so the team makeup changes depending on the mission. So, for example out of Glasgow, if we were tasked to a major trauma, we would deploy two paramedics (each being a technical crew member), an advanced retrieval practitioner or registrar and a doctor with a single pilot, on the mission.
In addition to working as a paramedic in South Africa, I also worked offshore running a hospital onboard a seismic research vessel. My role involved primary and emergency care, which included diagnosis and treatment of illness and minor injury, management of trauma and cardiac emergencies, management of seriously injured personnel and medical evacuation. This insight into remote medicine has helped me with the logistical and clinical demands required of the various missions I attend in Scotland’s dispersed and remote rural island communities.
Could you explain what the SCRAM System is, and why you decided it was necessary for pre-hospital medics?
My experience in trauma management has made me passionate about exploring ways of enhancing the care of trauma patients in the critical pre-hospital period. This has led to the development of SCRAM™ , of which I am the co-inventor, to optimise the provision and safety of airway management in adult and paediatric patients.
Delays in access to emergency care can have significant impact on a patient. The complex nature of on-scene care is associated with significant risks, and is a recognized cause of such delays.
The SCRAM™ system promotes the delivery of safe, timely, well-governed emergency anaesthesia
The SCRAM™ system promotes the delivery of safe, timely, well-governed emergency anaesthesia by standardizing, and optimally organizing, equipment and drugs prior to the procedure being required, thus significantly cutting down the delays and risks of error through the specific layout and pre-preparation of equipment and drugs. This is designed to ease the cognitive burden of healthcare professionals performing emergency anesthesia.
The SCRAM™ System becomes a meaningful cognitive offloading tool, and facilitates airway planning by reducing the time to intervention, reducing error, standardizing practice and promoting good governance. This is of particular importance now during the 2019 novel coronavirus (Covid-19) pandemic with increased cognitive demands of managing oneself, the team, the environment, the associated risks of error and time to intervention.
The SCRAM™ System is currently being used for advanced airway management by teams in both the pre-hospital and hospital environments in the UK and other parts of the world, with distributors in the UK, USA, Australia, and soon Canada and the Middle East.
What are the latest changes and adaptations that you are making to the SCRAM portfolio?
We have recently launched three new products to the SCRAM portfolio, with a further two planned to be launched in the USA early this year. Community demand prompted further development of the SCRAM™ portfolio, which are Tactical SCRAM™, a compact unit designed to enhance the performance of emergency airway management within the tactical environment. Meanwhile, Rx SCRAM™ & Tactical Rx SCRAM™ aim to prevent drug error during emergency anaesthesia. Upcoming products focus on systems that offer video laryngoscopy as a primary modality.
It has been asserted in the past that airway decontamination is a ‘poorly defined step in airway management’; how are the latest techniques and equipment addressing this problem?
New generation suction catheters provide greater efficiency in clearing the airway
New generation suction catheters provide greater efficiency in clearing the airway. Dr James DuCanto, MD, is a well-known anaesthetist with a special interest of innovating and improving airway management, is the inventor of the SALAD (Suction Assisted Laryngoscopy & Airway Decontamination) simulator and the SSCOR DuCanto Catheter.
During simulation, Jim noticed that the HI – D catheter was awkward to work with when using hyper-curved laryngoscopes. So, he modified the design of the HI – D catheter, which allows for very efficient suctioning of contaminants (thick liquid, blood and small particles) and made a series of prototypes of different shapes that follow the anatomic curve of the tongue. Then through a process of refinement, testing and development, the current SSCOR DuCanto Catheter was born. This suction catheter allows for decontamination of the hypopharynx and oropharynx with the minimal amount of moves in the minimal amount of time. The larger internal diameter of the suction catheter plays an important part to affecting flow speeds for the removal of airway contaminants. The rigid nature of the catheter also allows for manipulation of the airway structures.
Collaboration and partnerships between pre-hospital medical organizations around the world are key to ongoing improvements in medical services; who do you work with regularly in order to develop and improve your
services / products?
As the community of clinicians and institutions using SCRAM™ has grown, so too has the feedback that we receive. Community feedback is an integral part of the development of SCRAM™. I am also currently collaborating with a Professor Scott Weingart on two new products that are planned to be launched early this year. Dr Weingart is an emergency department (ED) intensivist from New York. He did fellowships in trauma, surgical critical care, and extra corporeal membrane oxygenation. He is best known for his podcast on resuscitation and ED critical care called the EMCrit Podcast; which has been downloaded more than 20 million times.
A number of organizations and operations, both in hospital and prehospital environments, are trialling / implementing various versions of SCRAM™. These include, for example, the Royal Hospital for Children and Young People in Edinburgh, where Paediatric SCRAM™ has been integrated into their airway management strategy. Liverpool John Moores University in the UK and Mid-State Technical College in the USA are two further examples of how university programs are integrating SCRAM™ to teach the importance of systemization, standardization, cognitive offloading, human factors and good governance within airway management.
I have also developed a Critical Care Education platform: Critical Care Ed. This is an in-house platform for critical care education that serves as an environment to build a community to share critical care education and, additionally, to provide insight into aviation and logistics within HEMS missions. The app not only provides a platform for sharing education, but also provides a framework for clinicians to easily revalidate and log their competencies (appropriate to their practice) and maintain currencies. An additional feature of this app is a newly developed HEMS podcast that aims to share learning within and across our teams. The podcast has a focus on aviation and logistics within HEMS missions to enhance safety though a ‘just culture’ and ‘learning from experience’. We also include some ‘clinical nuggets’ and lessons learned from clinicians to provide a wider clinical perspective. The latest episode focuses on the Cepheid GeneXpert, which is a rapid, near-patient test that we use for the detection of Covid-19.
Airway management is a very particular skill in pre-hospital medicine; how important is recurrent training in this particular discipline, and for you in particular, how often do you train?
There are significant risks involved in the tracheal intubation of critically ill patients.
If intubation attempts are prolonged or have to be repeated, there is an increased risk of complications
If intubation attempts are prolonged or have to be repeated, there is an increased risk of complications. Getting the intervention right first time is therefore a prime goal in airway management of such patients. This means that the level of clinician proficiency is vital and must be maintained by continuous training, if safe, efficient and optimum care is to be delivered consistently. Training is therefore built into our regular routine, whereby both simulation and drill are practised on a daily basis.
How has Covid affected training and operations for you and your team?
Certainly, Covid-19 has made everything far more challenging, from training, to the management, and logistics of moving critically ill patients. We have had to make adjustments to the way we train and work to avoid occupational exposure to Covid-19, and thereby ensure our prime objective of delivering an uninterrupted aeromedical retrieval service during the pandemic.
You’ve got a masters in trauma sciences (military and humanitarian); what do you think that civilian pre-hospital medical services can take from military services and apply to their operations – either in terms of medical equipment, or training?
It has always been the case that war and conflict have triggered rapid advances in the emergence of new techniques and surgical enhancements, such as methods of blood transfusion, haemorrhage control, and damage control surgery. These advances occur very rapidly in wartime and are then adopted into civilian environments, albeit at a steadier pace. The lessons learned in civilian settings are then fed back into the military context, creating something of a symbiotic relationship between the two. The Covid-19 pandemic has made this relationship very visible, as civil governments have activated military methods to help curb the spread of the disease, as, for example, in the rapid construction of emergency hospitals and the mass rollout of vaccination programs. The benefits of such military-style interventions then pass over in peacetime into civilian society, enabling a ‘fast-forward’ phase in the evolution of medical practice and more effective planning for potential future surges and health crises by civilian government.