Arndt Melzer
Arndt is a consultant anaesthetist at UCLH and retrieval consultant at ACCESS, London. He has set up and led critical transfer services in London and Germany. He was medical lead of an ADAC HEMS base
Location University College London Hospital
Activity
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You are right, it requires a lot of prep. Once you have the team trained and all the adequate equipment available its actually not that challenging anymore. The risk is still increased but with meticulous preparation, planning and training its doable and safe.
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It is indeed hard when things go wrong. We always tried to learn from any incident or mishap to prevent it to happen again and to make transfers safer in future. Psycological support, especially when something went wrong, was immediately provided within the transfer teams, especially during debriefing and from the leadership team in the time of formally...
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Arndt Melzer made a comment
Welcome everyone to comment, question, discuss and engage with the articles! Our international team of educators will be happy to get back to you and engage with our participants all over the world!
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Arndt Melzer replied to Rianne Brand
If you live somewhere near London you could book observer shifts at the North Central London Adult Critical Care Transfer Service
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Arndt Melzer replied to Peter Farkas
That is a good idea. We use a function called "handover for the next day" in our electronic platform to communicate those issues with the next days teams
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Some services do use this system, however it is not suitable for long transfer times
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Arndt Melzer replied to Mats Muckel
You could also consider the RAAS score to measure and document the level of sedation. Many ICU's are using this score anyway which improves communication and hand over as well.
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It makes sense to have at least one blood gas about 10min after connecting the transfer ventilator to identify any problems before departing and to have evidence of appropriate ventilation in case something would go wrong.
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We are now using an electronic platform. The form has been integrated and is visible for the entire team at any stage of the transfer. Since we do not use a form anymore we can't share it with you but will try to include it for the next run of this course.
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That is a very efficient and cost effective system. The system in England is differing from service to service. The current service in London has a single point of access in each sector. This is usually an experienced consultant or senior registrar who is taking the call and facilitating the entire tranfser. They do all the phone calls with sending and...
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Arndt Melzer replied to Mark Clayton
Agree to both comments. We have started to combine the daily team brief with a "action card" based teaching session. Most people enjoy that a lot and it increases the knowledge in the team over time
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Arndt Melzer replied to Robert Smith
That is true, we use blue light driving for a smooth ride without frequent accelleration and deceleration rather than fast driving
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Arndt Melzer replied to Alice Humphreys
That is a very good practice. We follow up every patient 72h post transfer and learn a lot from this
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Arndt Melzer replied to Helen Moore
Thanks for that comment, we will talk much more about paediatric transfers in week 4
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Arndt Melzer replied to Kam Khan
Thats interesting, if you would like to share some more information or pictures with us for further runs of this course please do get into contact
You can use our service email and refer to "MOOC": uclh.nccritcaretransfer@nhs.net -
Arndt Melzer replied to Sam Heaton
Absolutely agree to all of this, Sam.
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Arndt Melzer replied to Helen Hysted
Every team is doing their own briefing unless they start at the same time
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I am sure you will enjoy week three when we talk about aeromedical retrievals and week four where we look at pediatric transfers
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That is very interesing and we will talk about long distance repatriations more detailed in week 3. This story shows how important the good preparation and planning is especially in international transfer medicine
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Arndt Melzer replied to Anthony Blake
That is correct. This is course is free and you will be able to access the content for 8 weeks and than again during the next run later this year. If you pay than you will have permanent access to the resources and will be awarded a certificate at the end.
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Arndt Melzer replied to Elmar Rollwage
That is good medical practice. Would be interesting to know if anyone is using non-invasive cardiac output monitoring during transfers instead of the invasive blood pressure measurement
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Arndt Melzer replied to Stephen North
That is true. COVID has been another big driver to develop more robust transfer services as well as the advances in the care of stroke and early neuroradiological intervention. Advances in medicine will lead to more demand of specialised transfer services.
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Arndt Melzer replied to Francisca Maldonado Calvo
That is very true. Unfortunately sending hospitals frequently try to sell the patient different to what they really are and the initial clinician to clinician phone call is crucial to plan the transfer. We will talk more detailed about this next week
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Arndt Melzer replied to Richard Orrill
Agreed, it will always be a case to case decision within the team. We keep it patient focused and pragmatic. Some patients will need a fast transfer but in the majority of cases we can apply the progressive and steady speed which is safer for the public, the crew and the patient
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Thank you for your comment and for highlighting the need of formal training and education in the area of tranfser medicine which includes perfusionists as well as all the other professional groups involved. We hope to move from "just do it" to a professionally set up and recognized service worldwide. Transfer Medicine is so much more than just a radom team on...
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Arndt Melzer replied to Elmar Rollwage
To integrate the intensive care transfers into the local ambulance system is a very interesting concept and very different to having dedicated and specialised services
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Thanks Peter for this comment, I agree that well set up transfer teams can reduce the mortality significantly. Please do give us feedback if this course helps to achieve this goal
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Arndt Melzer replied to Alice Humphreys
Thats correct and I agree with both of you. However, NIV transfers are done frequently worldwide and are generally possible. It just needs meticulous planning, a coorperative patient and as you said sufficient oxygen reserve
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Arndt Melzer replied to Alice Humphreys
Thats really interesting. We will talk about aeromedical retrievals more detailed in week 3!
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Thats correct, in some countries there is even another division into "emergency" transfers and "urgent" transfers which have to be started within 2 hours compared to immediate blue light response for emergency transfers.
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Sorry to hear that you have problems with the video link. Which one failed to play?
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Arndt Melzer replied to Anita Velkova
That is correct, it is the tremendous lack of trained staff which makes it so challenging in most countries
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That is true, there are more and more simulator training programs in place for LMIC which is a great way to train this
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I agree with you, this is why training of the whole team is so paramount. Role allocation in the morning brief helps to manage the scenes better
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I agree with you. This child has a critical subglottic stenosis and it would have been dangerous to proceed without more tests. It shows how crucial the initial examination is for a safe airway management.
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These results confirm our clinical experience in bariatric surgery. Intubation in obese patients is rarely more difficult than in the general population. However, the challenge is high risk of rapid desaturation. Therefore, a familiar technique is likely to be the safest
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Arndt Melzer replied to bethani clegg
HFNO is primarily used for oxygenation. Even if it removes a bit of CO2, it still accumulates carbondioxide over time
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Arndt Melzer replied to Stephen W
The use of standardized procedures is especially useful for emergency cases and hostile environments. If the whole team is trained it further reduces the risks of human error
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There are different concepts for the choice of induction agents for emergency cases and for COVID-patients around the world. If there are local protocols in place it is good to follow those. It increases safety if agents are used which are well known to the team.
In cardiovascular instable patients the use of Ketamine might be beneficial but not... -
This is important, especially in low resource settings. Emphasis should be on regular refresher courses and life long learning. Team training improves patient safety especially where equipment is scarce.
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Arndt Melzer replied to Pierre Berger
Absolutely! Preparation and training helps to decide fast in a real airway emergency. This will gain precious time for the patient and the team.
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Arndt Melzer replied to Jane Hopkins
Hi Jane, there are portable videolaryngoscopes available for the prehospital settings! One example is MacGrath
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Given the fact of higher mortality in obese patients every surgical intervention has to be considered carefully. The definitve treatment of OSA would be weight loss which is generally safer and more effective than upper airway surgery.
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TIVA is an abbreviation for Total Intravenous Anaesthesia. It´s a technique in which inhalative agents are exchanged against intravenous drugs typical poropfol continuous infusion. Frequently remifentanil is used as a continuously administered opioid.
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Interesting dilemma between high risk of aspiration and potential spinal nerve damage. In those cases a video laryngoscope is very helpful to prevent c-spine extension and a fast intubation. Alternatively you need to consider awake fiberoptic intubation.
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NMB are used to facilitate intubation which is especially useful if you are less experienced. Difficult airway situations might occur more frequent without using NBM's
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Arndt Melzer replied to Andy Geelan
Thanks Andy for your question. It's really relevant and we have scheduled this to be discussed in one of the modules a bit later in this course.
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Arndt Melzer made a comment
My cultural identity is my base, like the soil I am standing on. When I interact with others I do this based on that identity and through the lenses of my culture and upbringing. I shape relationships in the context of this unique cultural background of each individual.
My cultural identity is a mosaic of the cultural history of my country, the faith, the... -
I think that´s a very important question. Do we want to leave perioperative care to a team of subspecialists or do we want this to be practiced by all anaesthetic/surgical care providers? It might be desirable that every patient undergoing surgery is treated by a perioperative team rather than a few by a group of subspecialists?
