Hello everyone and welcome to the Quorum podcast.
This is where academic medicine meets remote, austere and
resource limited areas. Welcome back to the broadcast,
This is Avico Kelly. This week we are again with
Alfredo Leo who is our clinical coordinator for Quorum.
Alfredo, welcome back to the programme.
Hello everybody. Thank you every.
It's a pleasure to be here again.
So tell us a bit about yourself and what's keeping you busy.
A lot of stuff. So I'm still a firefighter, a
fire officer in Portugal. I joined the fire service in 95
and I started also as AMT and then became a paramedic in my
paramedic course. Just we need of course in
Denmark and then moved to UK when I joined start work with
NHS National Health Services United Kingdom as a paramedic
and then I decided I want to do something else.
After 10 years on and off working with the ambulance, I
decided I want to do initially offshore, spent some time in
vessels and oil rigs like the one I'm currently on.
I'm offshore of also the Mediterranean Sea.
So we're doing some work here and the weather is actually
quite good in comparison to the North Sea.
And did some work in Afghanistan in the work in, in Palestine
slash Israel, also in Gaza and the West Bank with The Who and
also in Ukraine in a place called Severo Donetsk when the
times are not that rough as they are right now.
Currently, I'm working offshore doing some members work in
Portugal and also in the United Kingdom.
And as you said, working with Korum as, as a clinical
placement coordinator. And I think it's me in a
nutshell. So Alfredo, you got a job with
the World Health Organisation as a paramedic.
How, how did that work? How did you get that?
It was not specific as a paramedic was as the title was
pre hospital consultant. So I was hired to go to
Palestine is divided into 3 per SE West Bank, Gaza Strip and
there's another part that it doesn't count as Golden Heights.
But again these two mainly the West Bank and also Gaza Strip.
I was asked to go there for three months and assess the
service over there. Mainly the Palestinian Red Cross
in society and Ministry of Health and other organisations
were working over there. Of course was before the the the
war starts several October. So it was before that it was
some tensions going on, but not as this right now.
So if I'm going back everything that I assess, it could be
completely different. Still a great experience.
It was. It was.
And you've been in the east of Ukraine.
What would you be comfortable discussing about that
deployment? So I was hired to go to Ukraine.
They can call Icarus to work to give support to OSC as an
organisation. This is similar to the United
Nations but different got a different mandate.
The the idea was to you to be there to monitor the peace
agreement, called the Minsk agreement at the time that it
was not having its faults. It was every day we had some
conflicts going on and we're there to monitor it.
And I was there to cover the monitors.
Pretty much all over Europe and other parts of the world were
there monitoring the conflict. And if something happened, I'll
be there to give care and the fire eventually throughout this
mission, before I left, the only person that actually died on
duty was actually paramedic with this kind of strange, but yeah,
it was it was easy job per SE until it isn't.
So if we get caught in a in a fight, firefight be much great
per SE. But again, it's part of the job.
I imagine those jobs will be back again once Ukraine gets
their country back. They're going to have to be
monitors on their border. I presume so.
Hopefully it'll it'll happen as
soon as possible. Not I'm not talking about
myself, but for the people of Ukraine and also people of
Russia. I know it's a conflict.
People tend to take sides for what it was.
War is always bad and always give casualty and suffering and
suffering. Ideally we want to get this over
as soon as possible. Not soon enough though.
Alfredo, you and IA Fortune night ago went to Ireland to
take the advanced Medical Life Support course, the AMLS.
And we had to do this in order for you and me to become AMLS
instructors next month during our official NAAEMT site visit
for the college. And I brought you on to the
podcast today because you have years and years of experience
teaching NAMT and now that forum is becoming a training centre.
I wanted to pick your brains. But how was your deployment to
my country? Yeah, it was great.
If into the Republic of Ireland many times it is.
It's a great place and we had the chance to do the advanced
medical life support. For me, it's the third time as a
provider. I think my first time that I did
it was the year 2010. It was back in Portugal,
although the course is older than that.
So I think the course originally was conceived in the year 2000,
and this course kind of changed who I am as a healthcare
professional because it changed me actually, because it gave me
some tools and it changed the way I think.
Every time I look at the patient.
It's like the Dunning Truger effect, you know, this
interesting graphic that goes up and down South at the beginning.
I think I know everything right after finish the course or after
finish paramedic course of the degree.
So your confidence is quite high.
But then you realise that you don't know much yet and even in
the same time you start become complacent.
And why? Because the job that you go,
most of them are medical and it's not trauma so it's not sexy
and that's what sex is not. Mine actually comes from the
MLS. So we go to lots of
non-emergency calls and most of the times the way we approach
another one another call, someone that actually doesn't
need an Amos. However, we never, we normally
don't think about what was the reason for the person to call
us. So they need some support, they
need some help. And we sometimes think, OK,
she's not life threatening, why am I here?
But I think medical emergency is a lot more than that.
At the time, in 2010, I was a technician working in Portugal
and I was always told, OK, it's not your job to think, it's just
to transport the patient from A to B and no questions asked.
If you want to think you need to become a doctor.
That was the mindset. And actually it still is a
little bit nowadays with the course, with MLS course, I
learned that we technicians, now paramedics, learn by pattern
recognition, by experience. So we see a shortness of breath
and then you recognise, you see the patient posture, you know
that patient assessment triangle coming up with the theatrical
assessment triangle, look at the patient, see something wrong and
then years later you're going to go to another shortness of
breath and straight away you're going to recognise that pattern
and you know what's going on. However, you need to recognise
that, confirm what your gut feeling is telling you.
And the AML MLS gave me the tools to process and organise
all these spots in the right way for the best of the patient.
It's not for myself because myself as a clinician, I'm not
important. Import is the patient and if I
can give the best possible assessment and treatment to the
patient, the better. That's true.
And I was just thinking back as you were saying that on my
career since the late 80s and how much focus there is in
trauma. So, so my first trauma course
was in the late 80s with the sheriff's Academy and we didn't
even have a name. There was no PHDLS or Itls or
anything. It's just yeah, blood red
stuff's coming out. Push on the red stuff.
There's no talk of blood or tourniquets or anything like
that. It's all been trauma.
And in the Army, it was all, all trauma.
And then as a paramedic and, and now a critical care paramedic,
it's, it's trauma, trauma. I've taught more trauma than I
have medical. And it's always been the focus.
And you said the word sexy is it's just fun, right?
It's easy. It's, it's CNBC push for the red
stuff is give more red stuff. All right, we're good.
And there are a few courses out there that focus on medical.
And of course, corn had to design a bunch like the eye care
and things like that because there was a deficiency.
But AMLS focuses on this. And you took this, what, 50, 15
years ago? 16 years ago?
So what is it about AMLS that made you a better medic?
So it's still really assess the patients and how to play with
sample. For instance, now we call
sampler the last R risks associated and with Coral Way
recent travels, it's also important.
But again, imagine if someone is taking beta blockers, right?
We know that probably that person is not going to have a
tachycardia if he goes into shock set to shock, for
instance, and you know that the beta block is going to prevent
the patient goes to tachycardia. If he that thing that
information gives you this false sense of of comfort is that the
patient's stable and you don't understand what's going on with
the map arterial pressure. You don't give much importance
to the entitle CO2, even the pulse pressure if he's less than
1/3. You don't normally those inputs
that the monitor tells you that it looks all right, but it
isn't. And then all of a sudden the
patient crashes and you don't know why.
So I think MLS put everything together all together and made
you think, OK, things can't go wrong due to XY and Z.
So playing with medication and past medical history I think was
the most take home stuff, the most important thing for me to
become a medic and to work probably as a medic medication
and past medical history. Another one patient got asthma
and taking a non selective beta blocker for headaches and it's
got asthma attack. Albuterol will work because
patient is taking Propranolol. So those tiny things that's made
all the difference because then you need to change your
strategy, how to treat the patient.
And then all there's something else at the ends of the course
called differential diagnosis or field diagnosis.
We need to come up with three probable causes.
Again with the college. This is something that we do
commonly do to our courses. OK, what's the differential
diagnosis? However, in countries that I
used to work, if you use the words diagnose, this is
considered a blasphemy by if you're another doctor.
So you need to be very careful the the words that you use or
else it starts looking you and who are you to sign the word
diagnosed? Are you a doctor?
So no, I'm a paramedic and this is what I have.
This is what I think it is. I cannot fully say this is
definitely diagnosed because I don't have all the tools on the
roads. But this is my rationale to
treat the patient as it is and to take the patient this
specific hospital and not the the other one across the street.
That's, that's a good point that we push heavily on five
differential diagnosis. And, and we teach this to
students. And I haven't spent a lot of
time thinking about what are our graduates going to do in a
country where they're not allowed to say the word
diagnosis and it's just a word in it.
So we can just say what are the five possible ailments that your
man's going to have? Yeah, it's, it's a question of
wording of course, but you're treating a patient with a
fracture, an open fracture, different for a patient having
heart attack from the patient having a stroke.
So you have to to do some sort of diagnose was suspicious of to
give the patient the right treatment.
I understand 20-30 years ago that was a specific profession
that's got the rights and is protected to just to do diagnose
and the paramedics and nurses cannot use that port, at least
in Portugal is how it is still today.
But actually pre hospitally you need to make a decision in order
to give the best treatment for the patient.
If a patient have a patient with a heart attack, you're going to
take him to a hospital with a cat lab.
You're not going to take to the to the GP surgery across the
street for all the opposite is to have a a broken fracture or a
or the other way around. The chassis infection probably
could be dealt with the doctor with the General practitioner.
So we are doing diagnosis regardless.
But sometimes the wording is yeah.
Each country has their way of doing things.
In the UK you can't call yourself paramedic unless you're
a CPC. I completely agree with that.
So for this AMLS and, and mainly because we have an assessor
coming to to grade us to make sure that we're up to an AEP
standards. I spent a tonne of time learning
the AMLS patient assessment. Did you you and we didn't hardly
use it at all during the course. Do you find that useful or or is
that something that you just look through like yes, yes, I
cover that in my own assessment and I'm going to do it my own
way. What AMLS in most of the courses
are telling us, telling us they're showing us a structured
way to do our assessment, but in reality is not how it works.
So sometimes you go to a job, you arrive at the door, it's got
a relative bombarded with information about the patient's
past medical history and the patient is the other side of the
house. So you're not yet seen the
patient. You're already doing sample
approaching the the the patient, the patient.
Bear in mind you're not seeing the patient yet.
On the left hand side, you see an oxygen cylinder.
In your mind, you're just saying probably the patient's got COPD.
And again, you're not yet seen the patient and you're doing
sample and there's scene safety. So everything is dynamic.
So the MLS schematic, right approach to the patient, like
the PHLS, they're nice tools for us to not forget some elements.
So at the ends, right before we leave the scene, everything
needs to be fulfilled. But the way we gather
information has to be dynamic because we're going to be
bombarded information and there's some information that
you know is not right. And sometimes the relatives give
us the wrong or less correct information.
I'm not saying they're from to lie, but there's sometimes
information gives us not correct and we need to all say dance
with all the information, make sure that we get them the
correct information to give the appropriate treatment.
That's the beauty of of AMS. That's a valid point.
Like PHT less is linear. Well, to be fair, we do jump
around from CABC back to A to put it's linear CABCEF.
Well, and we do G&H for we won't get into that.
Well, AML S and all medical if you just jump around a bit and
and it's harder to. So when I was looking at that
AML S assessment there, there's five categories.
There's a lot of jumping around and it's, it's not as easy to
remember all the aspects where I'm finding the, the quorum
chart mnemonic or in, in the US Army, we called it SOAP and I
expanded that SOAP and created chart because I'm, I'm a knuckle
dragger and it's easy for me to remember that for our medical
that I, we do get everything within the AMLS system
eventually, but trauma is just, you just follow your CABCS.
Absolutely. Trump is it's kind of easy
because going to do CABC or XABC and then DE and follow, follow
college, the rest of alphabet up to Hitman and then beyond
Hitman. So there's a lot of is isn't
mnemonic is a schematic. And as you rightly said,
sometimes you need to jump around if the place is, is it's
in shock, right? But their way is not.
It's not clear. We need to secure the airway
first. But sometimes their way now the
patient is breathing is not great.
We come up down to C and then they need to go back to A to fix
and then put an advanced airway because at the moment the MPA is
there, but the patient is vomiting and you know, vomiting
blood and you know, there needs to be section again.
So it's dynamic such as MLS, you need to get the information that
you can and and sometimes the patient on purpose don't tell
the information because they want to give this specific
information that is a more quite sensitive in front of the the
relatives. But any ambulance on the way to
the hospital, if you ask again, you're going to have a
completely different answer. And Speaking of the CABC quorum,
we we adopted to CABC and I, I taught that on battles with the
British military and I just kind of brought that on board to make
sense. The NAMT uses XABCDE for the
Amls and PHTLS. What are your thoughts?
Cuz you've used both haven't you?
So which is there any benefit on either one?
Sorry, say again. CABC and XABC.
Yeah, right. Actually that's an interesting
story because you go back to got PHDLS that is getting
information from Atls that was created a long time ago, right,
was Doctor Norman Mcswain that creates APHDLS in 84 I think.
And then all the information that we have nowadays with PHDLS
came from Atls. However, there's some
competitors and it was one time that a competitor came up with
the sea for catastrophic bleeding and it was adopted and
then the, I think it was a 90 edition, 8 or 90 edition.
PHDLS brought the X for xanguination because they need
to put something else and it cannot be catastrophic bleed at
the same time. So the the rationale is there.
However, if you go and do PHDLS in the United Kingdom, the
British version, they're going to use CABC, but you're going to
use, you're all going to buy the American version, you're going
to see XABC. So it's exactly the same.
Even the course is the same, just that the word is different.
One other thing I noticed on our Amls is is there wasn't a lot of
discussion on map and it was just systolic and it's for
medical course. So in eye care we teach MAP
pretty strictly. MAP and urine output.
Those are the things that you really need to keep an eye on
and there there was little discussion on either in the
AMLS. True.
MLS mapped military pressure with PHDLS, we always think
about patient going to hypothalamic shock and we've got
a minimal of 65 to to make sure that the the brain is profused
in your 65 of minimal pressure MLS.
We're dealing with medical patients.
This is also important, but because we can have hypothalamic
shock in medical patients, that is diarrhoea and vomiting.
We talk about cholera and malaria and then patients become
dehydrated. It's even burns, again, burns
going towards trauma. But the map it is important.
I think we need to consider about what is about the blood
pressure. The blood pressure means to
refuse the normal organs, mainly the brain and heart and you need
to have a mean of 65. If he goes below that, you're
going to have problems. Something that MLS brought as
well and PHLS also covers is the pulse pressure, the systolic
minus the diastolic and if the systolic diastolic become too
close, it means that the heart is not pumping as it should.
So it means that the flood flow, the flow is not is not going and
the risk of the patient goes downhill and goes into cardiac
arrest is also real. So those those are things that
we need to monitor to see if the patient actually is improving or
deteriorating. Alfredo, you've been an NEMT
instructor for a very long time. What courses have you taught?
Right PHLS was my my main course again.
I first PHLS as a provider was 2005, that became a start
afterwards and run courses in Portugal and UK and now.
Going to run to my first in Malta.
There's other courses MLSI never actually run the MLSI run one of
the similar, but now I'm glad I'm going to finally became an
instructive MLS after my third or fourth third third provider
course. This other courses and AMT also
teach one is is quite dear to me.
It's called all other disaster response, the RDSDRAHDR, that's
the one all others disaster response and it covers more mass
casual incidents. As you know, I focus in last
2011 onwards in mainland triage. Of course, this course got dear
to me because it shows how we're supposed to manage mass casual
incidents and what kind of what type of of incident it is
actually. You can stapulate to from from a
house fire to even to to have a problem cholera problem in the
middle of of a village in a country a little bit far away.
So we need to have multiple casualties.
So we need to or casualty or injuries or I'll, I'll, we need
to classify them, come up with a destination for them.
What do we actually need? What kind of hospital they need
and and how can we manage the scene, especially with not much
many resources. Sometimes we think and
especially in new case, it's common to think about that.
I'm getting deployed to a site that I know eventually I'll have
20 ambulance in the next half an hour.
But if your work on island for instance, you only have two,
three ambulances, if you have 15 patients, that's it.
You need to find a way to classify them using the.
The triage system that is implemented will be a 10 second
triage or a or any others and transport the patient, the
patient in terms of of condition and also if they're able to
survive the trip. Because if you allocate an
ambulance to take a patient is is going to die.
You know that the patient is expected and is going to take
this patient and ask about 1/2 an hour drive an ambulance.
What's going to happen? Probably the patient going to
die on the way and you lost an ambulance and now we don't know
when the ambulance is going to come back.
And you still have about 10 patients on scene to go to
hospital get the the the they need.
This is 1 course. Another one is what also to me
is the emergency of the course. The EPC is similar to a course
and I will say competitor, but they work hand by hand called
paediatric education professionals.
And I'm saying that because sometimes the EPC use the PEP
manual, they use the same language per SE.
How to assess the patient, the paediatric patient, the
something that I already mentioned, the paediatric
assessment triangle, look at the appearance work of breathing
circulation to the skin and in seconds, even without talking to
the mother to see what's going on or get information
whatsoever. Just looking at the child can
confidence say if the child is critical or not critical and
from that moment on act upon what what you're saying.
So those two courses, there are other such as Ms Safety is also
a good course that they give you some tools to prevent accidents
from happening especially in the pre hospital environment.
The ambulance work ergonomics and seatbelts and driving
assessment, the dual conditions of the ambulance and many other
things that we need to take in consideration.
But these two, AHDR and EPC, are, as I mentioned, dear to me.
So you're already an instructor for those, so we're we'll be
able to get those pretty easily, is that right?
Yes, I am. I'm also looking at the
geriatric, the gems, gems course that might be beneficial, but
we're starting with PhD less and AMLS, the two big hitters.
And as I was discussing things within AMTI, was looking around
Europe. There's not a lot of people that
offer AMLS. Oh, here in Germany, I live in
Germany, there's tonnes, but it's all in German,
unfortunately. But every other country there,
there's very few and very if you in English.
So I'm hoping that maybe we can create a centre of excellence of
AMLS there in Malta. I hope so that you mentioned I
came across I'm always looking for how dangerous tree is in
terms of jobs and a job offer passed again my my least for a
offshore nurse in Norway. I'm not a nurse, I'm paramedics.
I will never apply to that job, but again for similar role as as
I am as an offshore medic. They were asking for that
specific role, the MLS, of course.
So it's it's something that it comes up depending on the robot
for offshore nurses in Norway, at least that particular
contract, the client was asking for MLS.
So it's something that's could be an option in the future.
And this will be your again. Some offshore nurses may be
interested to the MLSI. Think it's going to be a good
benefit for a paramedic students, your 1° paramedic
students to to get PhD less than AMLS.
Currently they're getting IT less and we are now looking at
offering PHDLS, so we'll see if Doctor Tom Mallinson will accept
PHDLS and AMLS into his paramedic students.
Perfect, looking forward to it and looking forward to to run
the the courses in in Malta next month.
So, Alfredo, you've been with an EMT for ages.
Tell me, what do you like about them?
What do they do well? An AMT the National Association
of of Emergency medical Technicians.
They were created to cut paramedics together and start
producing knowledge. I know paramedics don't tend to
dedicate much time on research and there are always some
courses that start feeding an AMT with knowledge for them to
adapt to the press with the world.
So PHDLS is an example. You've got the advanced internal
life support that feeds all the information to PHDLS to pass
towards the pre hospital environment.
T triple C is the military version.
We also have not just ATLS but other arts, especially the
experience in the recent, most recent wars are feeding the
course because it's not just for the pre hospital professional
paramedics per SE, but for the tactical medics, the soldiers to
go out and need to deal with, with wooden soldiers.
And then we have the TCC. It's the the version civilian
version of T Triple C for imagine for police or if we have
a tactical operation, a police tactical operation, active
shooter. So we've got a few people got
shots and now we need to have their paramedics or or EMT's,
police MTS to intervene. So we receive all that knowledge
and apply and train the right stuff, stuff to give, provide
the right care is mainly that because if you think about the
timeline, right, it's got several branches.
So for medical is a MLS for the paediatrics will be EPC and and
then many others. So it kind of cover, it does
what used to call emerges 360 degrees.
So he covers pretty much most of the patients that we attend in
the pre hospital setting, including some of us that go
out, go abroad to attend wars. And then and that place it will
also give us those skills for example, three people see to
deliver the right care where we are.
So we'll be the civilian or a battlefield or whatever.
Let me throw you a wee bit of a curveball.
So you are now CEO of NAEMT for a day.
You have God's status with an NAMT.
What programme would you add to their portfolio?
Mean question. There's a few.
I just mentioned that the
emergency 360° is an exercise I tend to do to cover the patient
the moment they were born until they die.
So we almost covered the moment they die with gems genetically.
For AMS, I think there's a few areas that already exist with
American Art Association. That's an AMT.
Never want to go in, but they'll link.
They'll link. So the newborn life support
advances life support and theatric life support.
Again, the life support is briefly covered with the APC, so
it's not neglected, but the resuscitation part, I think
that's something that AMT could consider.
There's some other part of course, it's quite dear to us is
the wilderness and remote applications that the remote
area is something that NAMT not as far as I'm aware not yet
approach, but I don't know who knows in the future.
Yeah, they've kind of steered cleared of the the whole ACLS
option, even though on the NAMT website they do have the
ECSIACLS options. So they they've kind of steered
near it, but they haven't embraced that at all.
I don't know how it is at the moment.
There's a few organisations, they were running advanced
cardiac life support and also theatric advanced life support,
but they're kind of moving, slowly moving away.
The other one is HSI, another organisation is to run, I think
they still running ACLS, but that's moving away.
And I think American Association is, are the ones who actually
have that niche in terms of, of, of delivering training and
knowledge. Again, every five years the
guidelines change that we need to adopt ourselves, especially
with the, with the ILCOR. If you're European, you need to
follow the European guidelines with the European Research
Council. If you're AmeriCorps, dealing
with the American guidelines will be the American Art
Association. And there are five other
organisations worldwide that also create their own guidelines
in conjunction in synchrony with ILCOR.
So it's a niche, but again, it all depends if an Ant wants to
go down that route or not. So it's it's it's political.
So you mentioned about CEO, that's all I'll do.
But as I said is a mean question because it's many information
I'm not aware and CEO needs to see everything.
Yeah, that is a challenge. And, and you're right, it's
interesting that they haven't touched the wilderness and
remote at all. Yep, the option, the option who
knows Rome, it's is expert in that area.
So who knows? Eventually a partnership with
AMT and could produce a course for AMT to run Worldwide
Challenger. And in all fairness, IBSC has
cornered that market with their Wilderness Paramedic Board
certification, which a lot of us at Quorum has has helped to
write that and help create that. But that's the only thing at the
moment. Correct.
Doctor Mollison produced that that manual and actually it was
very good. I managed to to certify this
Wellness paramedic with IBSC and thanks to that manual.
So it means that Quorum is producing knowledge.
Alfredo, my final question for you is this.
What advice do you have for the pneumatic, the new nurse, The
new Doctor who is just starting out from their career in austere
medicine? It is to adapt and to learn as
much as you can before going to the field and prepare yourself
before going to the field. Because depending where you're
going, if he's Amazon or the Arctic Circle or the desert, you
need to understand what going to be your challenges, what kind of
disease or trauma or what kind of the emoji that you want to
find over there. So it means that you need to
come up with a pack of medication that's going to be
appropriate over there and your own kit.
So it's pointless to bring loads of clothing to the desert, but
you need to bring appropriate clothing to the desert.
The same thing goes worse for for the Arctic Circle.
So you need to adopt yourself to protect yourself and try to
understand what are you going to find over there?
Who you going to cover to prepare?
Because I think the keyword in wilderness environment is
preparedness. If you're not prepared, you're
gonna fail. And if you're gonna fail, you're
not just fail yourself, you're gonna fail the ones that are
counting on you. And also there's another
problem, another detail about meant.
So you need to prepare yourself mentally for what you're going
to find times, third world countries going to find a
different culture. You're going to see things that
you're not expecting to see. And you need to prepare yourself
to cope with that information that that's those scenarios to
not regret afterwards. I think it's what I think.
This is my advice. That's, that's good advice,
Fredo. It's great to have you back on
our podcast. I'm sure you'll be back for your
third time eventually. I also personally, I would like
to appreciate the push you've had for an AMT programme.
So you went out of your way, you got your AMLS along with me in
Ireland fortnight ago and you are coming to visit.
So you're there to support us and as a course, as clinical
manager, you are making our students have a, a better option
as they go through the programme.
So Alfredo, everything you touch within the college has been
golden and I appreciate your time.
Always a pleasure, thank you for having me.
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