Just got back from #smaccDUB – I chose not to speak this year and that was a GOOD decision – it allowed me time to actually wander around and soak up some of the high quality talks, as well as to socialise with like-minded colleagues from around the world. FOAMed is the passion which inspires us all – smacc is an opportunity for those interested in resuscitation and critical care to come together unde the FOAMed banner.
Of course #smaccDUB allowed a catharsis for the passing of John Hinds; a moving tribute in the opening plenary set the scene for amore contemplative conference, with many repeating the themes of self-care as well as cutting edge resuscitation medicine. Progress continues on the establishment of a Northern Island Air Ambulance, a mission which I wholeheartedly support (picture below is of Mark Forrest of ATACC Faculty and myself, modelling the launch of the #whatwouldjohndo T-shirts)
Highlights (and there were many) include the numerous concurrents (espec the “Igniting Minds” session with longstanding internet colleague Ross Fisher on presentation skills, tips on performance coaching from London HEMS Tom Evens, tips on choreographing learning from Sandra Viggers and the powerful team from FemInEM, tacking gender inequality in emergency medicine – a lesson which equally applies to primary care!)
Many other talks resonated, all of which will be released in due course on the smacc podcast and affliliated blogs.
Gareth Davies talked on ‘The Case for HEMS services’ – the title and content of this talk is one which I found somewhat lacking, as it seemed to emphasise the role of the helicopter over the value of the system behind it; to my mind a good retrieval system is not about the transport platform, but about the quality of the care it delivers.
This is important. I’ve long been saying that the lessons from mature prehospital services (Sydney HEMS is the leading example in Australia) could and indeed should be applied to other aspects of clinical systems. This includes the use of appropriate SOPs, checklists for high-risk procedures such as RSI, action cards, understanding human factors relevant to resus room management, understanding of metacognition and heutagogy…as well as breaking down silo mentality and sharing ideas with other organisations for the benefit of both patients and services.
Clearly I am not the only one thinking this way – Scott Weingart picks up the theme in his latest EmCrit Wee on Creating a System of Excellence, discussing the work of Scotland’s EMR service. Have a listen to the talk here – Scott’s intro and then Stephen Hearns of EMRS talk.
Creating excellence, regardless of location, is something that resonates with me. One thing is clear – a well-functioning retrieval service is able to deliver excellent care because it has pluripotency in stable team members and of course trains exhaustively. It doesn’t rest on it’s laurels and always seeks to engage with other players in the clinical system. Of course this is made easier when there is effective leadership and by the fact that such teams are small, with a fixed number of team members to enable rigorous training.
These lessons are, I believe, entirely translatable to the small rural hospital system in which I and many other rural doctors in Australia work. Despite not dealing with critical illness on a day-to-day basis, we are generally made up of small teams and have limited roles and equipment. this can be an advantage compared to the ‘flash teams’ and plethora of equipment options available in tertiary centres. Simplicity has advantages!
And yet we seem to suck at it – examples abound of poor management by rural hospitals, much to the chagrin of colleagues in both retrieval and tertiary care.
Part of this is of course the infrequency of such cases….another part is the difficulty of both achieving and maintaining competence, especially as it represents a tiny percentage of the work. But the reality is that critical illness does not respect geography and thus the rural hospital team need to be able to deliver the best care regardless of geography. In short, there is no excuse for the rural hospital team NOT to adopt lessons from prehospital services and incrementally achieve excellence – provided there is both leadership and governance within the system, features often sadly lacking.
I would like to encourage all rural doctors to listen to the podcast above (and many others) and then to advocate for improvement. Some simple measures to implement include:
- standardisation of equipment (eg: difficult airway, resus room set up) across sites
- develop easily accessible SOPs for procedures, preferably driven by rural clinicians so content is contextually relevant
- develop region specific action cards and checklists for high-stakes, infrequently performed procedures
- explore the use of in situ simulation, preferably multidisciplinary, to refine aspects of what my colleague Andy Buck describes as Resus Room Management
- use FOAMed to keep up-to-date and develop skills in metacognition to guard against individual error in diagnosis and management hen treating the critically ill
So rural doctors, let’s work together to raise the bar in rural resuscitation. Our patients deserve being treated within a system of excellence as outlined by Weingart and Hearns. There are some beacons of excellence out there (Casey Parker at Broome Docs is one, there re many others). But there are also rural hospitals that are under-performing, whether through lack of knowledge, lack of equipment, lack of team training or lack of will.
We need to raise the bar, regardless of the barriers.