Interview: Mr. Hieatt

Edward:	Hi there, I think we've said who we are already, on the phone and what we are doing! So, what are your medical qualifications?
Mr. Hieatt:	I qualified from Guys & St. Thomas' Medical School in November 1997 and that was an MBBS (Medical Bachelor Bachelor of Surgery) I've been working as a doctor for 10 years nearly, and I've got my membership for the Royal College of Surgeons and as far as Life Support courses go, I am a provider of Advanced Adult Life Support, Advanced Paediatric Life Support and Advanced Trauma Life Support.
Edward:	Why did you become a doctor?
Mr. Hieatt:	Because I think two reasons: human biology was my favourite subject, I was best at it at school, and secondly because I wanted to help people and make a difference, save lives, so that's what I am doing
Edward:	Why a doctor as opposed to a paramedic? Was it ever a choice to be a paramedic?
Mr. Hieatt:	Making diagnoses, treating patients also because its in the family, my mum's a doctor and I decided at the age of 6 that's what I was going to be.
Edward:	Have you ever had to use your skills when you were not on duty as such, when you were out and about?
Mr. Hieatt:	Yes, there was one incident, when I was in Colchester driving home, and there was a car pulled over in a lay-by on the side of the road and there was a lady collapsed on the grass verge with a very worried looking partner so obviously I stopped, pulled over, got out of the car had to use my basic life support in terms of safe approach and assessing. Fortunately she hadn't gone into cardiac arrest, she'd probably just had a subarachnoid haemorrhage, a bleed into the brain and collapsed. So I just put her into the recovery position and monitored her pulse until the paramedics arrived. That was the only incident I had to use the skills outside of the hospital setting.
Edward:	You don't have to answer this if you don't want to: is there any truth in the rumour that nurses and doctors are told that if they are ever asked “is there a nurse or doctor around?” never to volunteer?
Mr. Hieatt:	No, I think we are duty bound to help and to use our skills, certainly that's what I feel that we are obliged to use our skills, certainly that's what the General Medical Council advises to people in need. There have been odd case reports of people trying to sue because people have resuscitated them and they have cracked a rib in the process and despite them bringing them back to life they then sue them for the cracked rib, I think that's happened in the States, but certainly nothing like that has been reported in this country. Generally people tend to just go and use their skills if they feel they are needed.
Edward:	When you are working, are you concerned by the legal aspect to it, whether you would be sued?
Mr. Hieatt:	It depends on the situation really, there is always a risk someone is going to sue you if you don't do things properly, in whatever setting, but certainly, especially in an out of hospital situation, I think you are duty bound to provide basic life support as a minimum. You haven't got your kit or drugs with you to provide advanced life support, but to go ahead and provide basic life support I feel is part of my duty as a doctor.
Edward:	Is it useful to have this website as reference?
Mr. Hieatt:	Yes, I think it is very useful to have it easily accessible, set out in an easily understandable format on the web. There are lots of training companies who make money out of teaching people basic life support skills and they have some websites, but obviously they are not going to put everything they are going to teach you up on their website. It needs to be in the public domain, as it were. However, I would never recommend that anybody just read a book or read a website and then went out to use these skills. I think the best thing that you go on a recognised course, be it through the Red Cross, St. John's Ambulance or RLSS, with recognised instructors, so that you can be properly certified.
Chris Hill:	What sort of things would be useful to have on the website?
Mr. Hieatt:	I think for the basic life support skills, you are going to have basic things that must be covered. Obviously the collapsed patient, a safe approach to the patient, emphasising that you must be safe yourself as you don't want a second casualty, initial assessment, when to go for help, how to do chest compressions, cardiac arrest. Things you can't really practice - head tilt. Recovery Position, choking patient. A section on drowning, can have rescue breaths and CPR before going for help. That bit is a challenge because it makes it more complicated. Lots of links to other websites, UK Resuscitation Council is the governing body behind the certifying - this is the working party in this country that is linked with multiple other international organisations that looks at the evidence and decides all these algorithms that we have for resuscitation, be it advanced or basic and they are the body that actually decides what we should be doing, basically. Links to those websites are important, and emphasising that this is a site for reference, you really need a disclaimer, emphasising that you must go and do a proper course. It takes practice to get things right. I don't know really what else would be helpful, certainly from my point of view, the most common cause of a cardiac arrest in this country is an elderly person with ischemic heart disease to go into ventricular fibrillation and collapse. That is by far the most common cause, and doing CPR is all basic life support and is useful, certainly in the first five minutes because usually when the patient collapses the blood is quite well oxygenated still and even if you just do chest compressions, you are keeping the brain perfused, stopping ischemic injury so that oxygen can get to the brain cells, after that period of time, the longer period of time between the collapse and the paramedics arriving with their electricity - i.e. their defibrillator the less chance you've got of getting the patient back, basically. So certainly you are providing a useful function of keeping the brain and the coronary arteries perfused for the first five minutes whilst you are waiting for the paramedics, who can then put the monitoring equipment on and deliver a shock to basically stun the heart back into a normal rhythm. That's what saves people's lives ultimately, but what keeps them intact neurologically is effective chest compressions and basic life support. So even in a hospital setting, good basic life support, good ventilations and good chest compressions to keep the brain and coronary arteries well perfused is essential.
Edward:	Do you know any occasion where chest compressions have restarted the heart without defibrillation. It's something we have been told is very rare, but possible, and more possible on a child casualty than an adult casualty.
Mr. Hieatt:	Because of the causes of cardiac arrest are different largely between adults and children, adults the most common cause is a primary cardiac problem - they've got ischemic heart disease, angina or had a heart attack and the heart has gone into an abnormal rhythm and they've lost their cardiac output and can't perfuse their brain therefore they collapse. Whereas in children the most common cause is because of hypoxia, i.e. a respiratory problem, they've got very bad pneumonia or some obstruction in their airway or they have severe septicaemia or a really bad infection, that's why most children go into cardiac arrest. So, certainly a respiratory problem, by doing the chest compressions and above all giving them ventilations, getting air into their lungs, getting oxygen back into their system then you would get an output back. Certainly in my experience I have never seen chest compressions alone bring anybody back. I've certainly defibrillated people with a pericardial thump, do you know that? Where you have a witnessed cardiac arrest, and they are monitored and they suddenly slip into ventricular fibrillation or what is called VT, ventricular tachycardia and then they lose consciousness, you can knock a chest and you deliver 8 joules of energy to the heart. That can be enough to flip the heart back into a normal rhythm, I've done that before. I've certainly heard of cases where just providing CPR can cause the heart to go back into a normal rhythm as you are pumping up and down on the chest, you are providing work and energy, some of that energy is going to impact the pericardium and could cause the electrical rhythm to change back to normal, but I've never witnessed it myself.
Mr. A. Hieatt is shown the second draft of the menu structure.
Edward:	Is there anything we might have missed or anything really valuable in the basic life support?
Reads list
Mr. Hieatt:	...shock - what are you going to talk about in shock?
Edward:	Not electrocution style shock, but insufficient blood going to the major organs, so elevate the legs So hypovolemic shock, because there are five different types of shock. The public say “he must be really shocked”, what they mean is psychological trauma, rather than physiological shock. You've got anaphylactic shock, cardiogenic shock, hypovolemic shock, neurogenic shock, sceptic shock and redistributed shock - that one is basically something like cyanide poisoning or carbon monoxide poisoning.
Chris Hill:	Do you think the shock one needs to be renamed?
Mr. Hieatt:	Yeah, you're thinking more of hypovolemic shock, someone is bleeding a lot or dehydrated.
Edward:	Whenever we pull somebody out of the pool, even if they are fine, we treat them for shock anyway, that's how we do it.
Mr. Hieatt:	Usually for that its hypovolemic shock, the patient has been submerged or immersed in water for a long time, then the water has a squeezing effect on the circulation, because of the weight of the water around the lower extremities. When you pull someone out, they found this in the second world war - drowning in the sea for ages with life jackets on and got hypothermic, when they are vertical they pass out, because the circulating volume in their system has been squeezed and reduced so when they are pulled out they have lost the weight of the water on their legs and all the blood passes into the legs and they pass out. You have to pull them out horizontally rather than vertically consequently. I would call it hypovolemic shock, technically speaking. Signs of shock would be looking pale, very fast, thready pulse, sweating, clammy.
Edward:	Would you be able to briefly outline what the advanced life support is, because although we can't cover it on this website, it might be something to add under 'Home' - “if you already have these qualifications, you might be interested in...”
Mr. Hieatt:	Advanced Life Support is essentially adding in advanced airways skills, getting intravenous access, the use of drugs, use of a defibrillator, whether that's an automated external defibrillator (one that analyses the heart rhythm itself and shocks itself, basically a computer) or one of the ones we use in hospitals and the paramedics use, which is just a straight forward defibrillator that you have to make a decision on, as to whether the patient needs an electric shock and stun the heart back into a normal rhythm. That's the main difference really, with basic life support in itself can't change the patient's outcome in terms of whether they will live or die, in the setting of the most common rhythm which is ventricular fibrillation, ultimately what you need to do is to provide advanced life support, but basic life support is critical in keeping the brain and coronary arteries supplied with some oxygen whilst you are waiting for the life support to be available.
Edward:	If extra information about the casualty's situation is reported during the emergency call does this feed back to you in the A+E or the paramedics?
Mr. Hieatt:	It would certainly all go via ambulance control, initially, and we wouldn't receive any initial information in A+E from ambulance control until the paramedic team had arrived. But certainly, in terms of what the paramedics are told, they would be very grateful for any additional information, certainly when they are on their journey to the scene, to know what to expect. Usually, once the paramedics had arrived they will start doing the advanced life support. We would get a call in A+E when they are on their way in, saying, you know, “we've got an adult cardiac arrest, coming in”. They may tell us the rhythm that the heart is in, and life support is being undertaken or not, and when they are expected to arrive. The A+E wouldn't receive any information directly just from the caller at the scene.
Edward:	I think we've answered this question already - do you think it is valuable to have somebody with Life Support skills available to give swift care before the paramedics arrive?
Mr. Hieatt:	Yes. I do. As many people should be trained as possible. Anyone can do it as long as they are relatively physically fit, and most importantly, competent. It doesn't matter about your age or anything like that, but as long as you are found to be competent and you pass the course there is no reason why anybody shouldn't do it.
Edward:	Do you think that by having more people qualified in Life Support, ambulance call outs could be minimised?
Mr. Hieatt:	I don't think it's going to make any difference to the callouts, because ultimately if somebody is collapsed, they are unwell and will have to be in an emergency department. The best way to get them there is by ambulance.
Edward:	But even in things just as choking, bleeding, do you think it could make a difference?
Mr. Hieatt:	It certainly could help with more minor things, if someone has had a choking episode - it depends on the circumstances. If they are eating and it gets stuck, and someone ends up having to do the Heimlich manoeuvre on them and that clears their airway and they feel fine then that person doesn't necessarily need to go to the A+E department. There are some incidences where you might be able to dislodge something in the airway but not completely clear it. Certainly, if you have a serious episode of choking, I still advise going to the emergency department for a check up. Likewise for bleeding, if a cut is severe enough that it needs pressure and elevation then it will certainly need a few stitches and someone to look at it in the emergency department.
Edward:	Do you think it should be compulsory for everyone or just students to learn Life Support skills?
Mr. Hieatt:	I don't think it should be compulsory, certainly within some organisations there should be nominated people, and you should make sure you have at least one person in the vicinity who is trained in Life Support, whether it be a school or working in a factory. Most places should have a nominated First Aider, but there should be someone on shift who can do basic Life Support. You don't want to drag people in and force them.
Chris Hill:	This is a question we should have on the website - what's the difference between first aid and life support?
Mr. Hieatt:	First Aid is things like a broken arm, a cut - pressure and elevate, reassure someone with a nasty bang on the head - put an ice pack on, whereas Life Support is you are physically breathing for the patient and keeping the circulation going by doing chest compressions.
Chris Hill:	So the more serious?
Mr. Hieatt:	... yes
Edward:	I had a problem explaining that to the team... Do you think it shows a certain character or type of person who actively goes out and learns Life Support skills? That doesn't sound modest does it...
laughing
Mr. Hieatt:	I think, yes, it does take a certain character, certainly people who go into emergency medicine tend to be of a certain personality, as people who become psychiatrists obviously don't like the sight of blood and don't like excitement so go for the boring field. Anyway, yes there are certain character traits present that make people go out and learn these sorts of things.
Edward:	Is there a lack of lifesavers or people qualified in Life Support?
Mr. Hieatt:	Obviously not in the setting that I work, but I think in general from my experience in hearing what has happened at the scene when people have had a cardiac arrest there aren't people there. You could be in a situation where the ambulance is 5 minutes away and you've done nothing for 5 minutes, but it could have made a huge difference if someone provided basic life support for that person. You make the difference between having brain damage and not having brain damage. And also, because you keep the blood going to the coronary arteries it could be the difference between the paramedics being able to shock them out of the rhythm back into a normal heart rhythm. Normally that is not able to happen because the time elapsed has been too long.
Edward:	Are you aware of any places that offer life support / lifesaving / St. Johns Ambulance tuition?
Mr. Hieatt:	No, certainly locally I don't know of anywhere that would do it, apart from the local St. Johns organisation. There are companies which will do it for a profit and advertise on the web, various training companies - there's one in Raleigh in Essex for example. Otherwise, I don't really know.
Edward:	Are there any other helpful resources that might be good to link to on our website?
Mr. Hieatt:	I'm not aware of any 'good videos' - the page that I would advise is the Resuscitation Council UK (www.resus.org.uk), and the Emergency Life Support webpage on the St. John's site. Those are the ones I would advise other people to follow. Everything I know from Advanced Life Support, both adult and paediatric, comes from the Resus. Council website. That is what is recommended by the NHS and are the standards that everybody follows. I don't know enough about other organisations to be able to comment.
Edward:	I think that's all of it!
Chris Hill:	In terms of trying to get an international aspect of the site, do you know of any places we could get any information on about life support worldwide? Obviously, humans are the same worldwide, but legal implications in certain countries etc.
Mr. Hieatt:	I would just do a Google search, certainly in terms of medical influence worldwide, Britain and the States have profound influences worldwide. There are some subtle differences in the way they do things on the continent, in Europe, all these organisations will have a webpage with information that is very freely available. And I'm sure the page will cover the legal aspects. If you go onto the UK Resus. Council website, it will cover the legal aspects, and the British Medical Council, the BMA website, they will have contact details and might be able to provide you with more information. Certainly in an out of hospital setting, I am no expert.
Edward:	We would really like to get in touch with a paramedic, if there is anyone you know of who might be interested, we would really appreciate any contact details you could provide.
Mr. Hieatt:	Someone local would be better, I work in Southend, but I still know a few people, I might be able to help you out.
Edward:	Thanks!
Mr. Hieatt:	It looks good, certainly what you've got here is what I want to see, and its good that you cover those extra little sections. The current guidelines for drowning is that you go ahead and do chest compressions straight away for an adult, and you don't mess about.
Edward:	The drowning section will look at the different types of drowning - dry drowning etc.
Mr. Hieatt:	Excellent, I look forward to seeing what it looks like in the end.
Edward:	Thanks very much.