Resus Room Feng Shui

It’s been a pleasure to present at the biannual EMSA2014 (Emergency Medicine South Australia 2014) in Adelaide, South Australia.

Like smaccGOLD (social media & critical care conference, Gold Coast 2014), the audience was an nice mix of clinicians – grizzled old rural doctors, hardcore emergency physicians, vastly experienced emergency nurses and paramedics…as well as a nice smattering of students.

As always, I suffer from a degree of ‘imposter syndrome’ – what can a rural doctor possibly have to say of interest to this sort of audience?

Spot the Imposter
Spot the Imposter

Unlike smaccGOLD, many of the audience were naive to the concept of #FOAMed (free open access medical education) – so I opted to tell a personal story of how my practice as a rural clinician has changed in the past 2 years, shaped by the mentors in the photo above

“as a rural clinician, FOAMed means there is no longer an excuse for my lack of knowledge to be the weak link in patient care”

In order to close the loop, I’ve made a commitment to put my slides and relative links up on the blog for new FOAMed acolytes to explore.

This whole talk is of course based around the concept of managing oneself, the team, the environment as well as the patient – a concept taken from Cliff Reid’s excellent ‘Making Things Happen’ talk from smacc2013 in Sydney. Worth watching this talk as well as many of the other talks from the smacc conferences past, present…and future.

FOAMed weblinks

smacc.net.au

RAGE podcast (resuscitationists awesome guide to everything)

BroomeDocs

PreHospitalMedicine

Intensive Care Network

Lifeinthefastlane

smacc podcast on iTunes

AmboFOAM

EMCrit

Levitan & Weingart on apnoeic diffusion oxygenation

Emergency Trauma Management course

We’ve ALL got great talks, great slides, great ideas which we share in tutorials, at rounds, at conferences – the ethos of FOAMed is to share this educational content with colleagues around the world.

The concept has been enthusiastically taken on by clinicians in emergency medicine and critical care, who recognise the value of a means of rapidly disseminating information to discuss cutting edge concepts.

Of course once still needs didactic teaching, to read textbooks and to peruse journals as the foundation of medical education – but once one has achieved a degree of competency in the field and is looking to keep abreast of new ideas, FOAMed opens up a world of self-directed learning. It’s for finesse and mastery, not the basics.

Added to this are the advantages of learning asynchronously – listening to a podcast on the morning commute or at the gym…watching a video to reinforce the details of a practical procedure or to watch a conference talk…or even reading clinical conundrums posed on the myriad of EM and CC blogs out there.

As one explores the global FOAMed community, discussions are had with colleagues around the globe, allowing informal ‘corridor conversations’ with like-minded colleagues. Not only that, but experts in various fields give freely of their time and experience – it’s nice to be able to tap into (and even discuss) ideas with people like Karim Brohi, Scott Weingart and so on…

Finally FOAMed helps break down tribalism – we’re all interested in patient care and advancing clinical knowledge (whether our own, or the global sum). Some of the best contributors come not from ‘eminence-based’ medics…but from other arenas. I’ve learned a helluva lot from my colleagues in prehospital care, with many lessons applicable to rural, Ed and ICU environments. Ditto the involvement of nurses, paramedics, students, social workers, administrators – people with a different spin on the work we do.

So – don’t be scared – dive in, explore the FOAMed (free open access medical education).

Gar Pask – Anaesthetic Hero

I’ve been doing a bit of thinking about life-jackets after spending a few hours bobbing around in a heated pool during last week’s HUET (helicopter underwater escape training) course.

Whilst practicing in a pool is one thing, I did wonder how well one would cope if ditching in the cold waters of the Southern Ocean wearing a switlik & flight suit or immersion suit. Probably quite well – modern safety equipment has come a long, long way from it’s origins (the first description dates back to 870 B.C., with a stone carving showing Assur-Nassur-Pals’ army crossing a river wearing inflated animal skins as flotation devices).

“the bravest man in the RAF never to fly an aeroplane”

The development of modern lifejackets includes a vital contribution by British anaesthetist, Edgar ‘Gar’ Pask. His story is fascinating, not least for the fact that, like true eccentrics, he performed experiments using himself as a test subject.

pask03

Pask in flotation device

Pask is famous for having been asleep whilst completing most of the research for his thesis

In essence, Pask made three vital contributions, spurned on in part by necessary developments during WWII.

(i) the problem of ‘downed & drowned’ aircrew

Most of us are familiar with the “Mae West” – a US lifejacket considered the cutting edge in the war years. Whilst it did a great job of keeping downed aircrew afloat, sadly many airmen were found in a face down position. They survived bailing out of their aircraft, but drowned despite being kept afloat.

Edgar Pask was a British anaesthetist, seconded to the Physiological Laboratory in the RAR Research Station at Farnborough, UK under the encouragement of another anaesthetic great, Professor Macintosh. Pask’s doctoral thesis is infamous for being performed with the author mostly asleep – the reason being that Pask used himself as a test subject. He was anaesthetised and placed, unconscious, in a swimming pool whilst on a breathing circuit. By simulating an unconscious airman, Pask and colleagues were able to test a variety of different lifejackets, refining techniques such that modern lifejackets ensure the victim floats face up, rather than risk ending up face down in the Mae West lifejacket.

The video footage of this research is fascinating – a short clip is shown below. The experimental subject is Pask, intubated and breathing ether on a double-lumen, corrugated anaesthetic circuit, the tubing of which was weighted to neutral buoyancy. Essentially a Mapelson D circuit. He was then unceremoniously dunked in the pool, whereby he promptly sank.

(ii) the efficiency of different artificial respiration techniques

If downed aircrew were recovered, many expired when pulled form the water. The real problem here was actually cold water immersion syndrome – the redistribution of blood volume in a weightless water environment meant that cardiac output dropped markedly when aircrew were pulled (usually vertical) from the water. Attempts at artifical respiration were employed – in the 1940s, the Schafer method was most popular.

The second part of the above video shows an anaesthetised Pask undergoing various methods of artificial respiration whilst paralysed (at the 9:08 mark). They demonstrate Silvester’s method, Schafer’s method & Eve’s rocking method. Not currently approved by the Resus Council!

Silvester's Method
Silvester’s Method
Schafer's Method
Schafer’s Method
Eve's Rocking Method
Eve’s Rocking Method

These experiments are remarkable (and a little unsettling) – Pask was paralysed and then underwent two hours of artificial respiration, during which time measurements were made of ventilation rate, tidal volume and O2 consumption. This was in the days before apnoeic diffusion oxygenation!

(iii) high altitude decompression ‘time of useful consciousness’

The RAF leased B17 ‘flying fortress’ bombers from the USA. These lightweight aluminuim-skinned aircraft apparently flew at the height of Everest, unpressurised – posing hazards of cold & hypoxia to the crew. Pask explored the effects of bailing out at such high altitudes – again, using himself and colleagues as test subjects. They were exposed to various hypoxic mixtures in a decompression chamber – the records are disturbing, essentially describing young men being asphyxiated and then allowed to recover.

Here is a description of Gar Pask being asphyxiated, whilst hanging vertical in a parachute harness in a hypoxic mix in a decompression chamber. Extreme hyperbaric medicine!

The period of anxiety was more prolonged than in the ‘descent’ from 55,000 ft, with the subject sitting, and not until the sixth minute was it certain that the ‘descent’ could be completed.

The subject [Pask] made two attempts to raise himself in the harness by pulling on the parachute risers during 1 1/8 to 1 ½ mins. These attempts he could not remember afterwards. At 1 ½ minutes., the subject became limp and relaxed, the head falling forward, but although it must have been merely a matter of chance, it was not thought that laryngeal or pharyngeal obstruction actually developed, although vigorous inspiratory efforts were made.

Sweating was very profuse and liquid sweat fell from the forehead and formed a noticeable pool on the floor. Muscular twitching of the left arm was seen between 5th and 9th minutes. The pulse was not rapid – indeed a good deal slower than in previous ‘descents’ with this subject, but between 2nd and 6th minutes it was recorded as very feeble.

[the experimental record of one of Pask's 'descents']

The upshot of all this was that Pask demonstrated that 30,000 feet was the highest survivable altitude to bail out without supplemental oxygen. I somehow doubt that such experiments would get past a modern day Ethics committee!

Post War Years

Pask’s bravery was recognised with award of the OBE (Military Division) in 1944. His meticulous approach to experimentation ensured the success of his 1947 thesis, although public publication of his wartime research was delayed until 1957, no doubt for both secrecy reasons and also in view of the justifiable outrage concerning similar experimentation on non-willing volunteers by the Nazi’s at Dachau.

It is a tragedy of man’s inhumanity to man that the Luftwaffe used human prisoners in these experiments. An account of the abhorrent work of Nazi Dr Sigmund Rascher is here. A disturbing thought is whether the data from these brutal crimes could be used subsequently – an issue explored in the NEJM. Ironically Rascher was executed on the orders of Himmler, in part for falsifying his data.

Recognising the folly of ongoing human self-experimentation, Pask was instrumental in developing Sierra Sam, the forerunner of modern crash test dummies. This proved a safer method for testing modern lifejackets than anaesthetising Gar Pask!

Sierra Sam
Sierra Sam

Pask died in 1966, age 54 – no doubt the toll of a lifelong smoking habit and the high likelihood of aspiration during the ‘flotation tank trials’ contributed to his early demise.

References

You can read more about the amazing exploits of Gar Pask below :

History of lifejackets

Professor Pask

Edgar Pask – a hero of resuscitation

Pask – the bravest man never to have flown an aeroplane

 

 

 

HUET & Lessons for Medicine

I was a little apprehensive about undergoing HUET training, mostly due to some gentle winding up by the likes of Minh le Cong in Queensland & some of the GSA-HEMS mob. Comments about eliciting cremasteric reflexes, sinus douching and so on seemed to be setting the scene – made worse as undertaking HUET in the middle of Adelaide winter.

Augsburg
“Back in the day” – a young Dr Tim posing whilst C1 slalom training – Augsburg, Germany

Actually, I don’t know why I was concerned about being dunked. ‘Back in the day’ I was a keen (and expert) whitewater canoeist. I rose through the ranks in both kayak and canadian classes, competing regularly at premier level in slalom events in the UK and representing my country overseas. Being flipped over in the dark whilst training in the ice cold waters of the Thames weirs or on the grade IV rapids of Scottish rivers was no problem.

Competing at that level of performance, the difference between boat-body-blade was indiscernible, with movements practiced and fluid such that one could quickly (<1 second) roll up from an inverted position with barely an interruption to forward paddling movement.

Augsburg2
Boat-Body-Blade – it’s a bit like Arm-Laryngoscope-Epiglottis

But that was a long time ago. Being stuck inside a metal airframe and dunked upside down is completely different. And unlike a low volume carbon-kevlar canoe, there’s no element of control when a helicopter ditches…

Training took place at the heated (27 degrees, thank you) pool at the Adelaide Dive Centre, under the expert guidance of the team from RHO aviation.

Why bother with HUET?

Brian Burns of Sydney HEMS tweeted this slide today from the concordant HUET exercise in Sydney, demonstrating why it is vital that anyone being transported by a helicopter platform knows what to do in the event of ditching in water.

Butq1A8CYAAoZdI
Slide tweeted from GSA-HEMS training by Brian Burns @HawkmoonHEMS

Whilst it is possible to perform a controlled ditch on water, this will be subject to water conditions, aircraft performance and so on. Some helicopters have floats – but helicopters are inherently top heavy and are highly likely to invert. Or be attacked by sharks as in this clip below from Jaws 2 :

That said, helicopter transfer is reasonably safe. The most pertinent reference that I could find dates back almost 10 years and is from Dave Cooksley and (then registrar) Jim Holland when in Townsville, both nice FACEM chaps. However problems can occur and it makes sense to be prepared. Helicopter Underwater Escape Training (HUET) is designed to improve the chances of surviving a ditching episode.

As can be seen from the footage below, an uncontrolled ditch in water poses risks of disorientation, impact with unsecured equipment and debris from the impact. Add to this the confusing elements of inversion, cold water and poor/zero visibility, and it is easy to see why occupants can become disorientated and fail to survive. Add to this the myriad of different harness & door release mechanisms (over 35 of the latter, with no industry-standard!). HUET training is designed to increase chances of survival in an unlikely emergency.

US-Navy CH-46 Sea Knight crashes while landing on USNS Pecos

https://www.youtube.com/watch?v=CdlqCeQfGmo

Controlled ditching onto water, then disaster as rotor blades enter water

https://www.youtube.com/watch?v=2NiPbQVQrC4

So what did we learn?

The facilitators from RHO aviation were really good, working through educational material in a solid, stepwise manner with a clear goal (lessons there for meducationalists). They emphasised the importance of a pre-flight safety brief :

  • seat belts
  • loose items (secured)
  • lifejackets
  • identifiying primary & secondary exits, with reference points

It is no secret that I am a fan of checklists in a crisis – when there is time. But the regular performance of a safety brief reinforces safety, mitigates against complacency and is something that I try to instil into the resus bay of my local hospital when awaiting a patient – checkling O2, suction, confirming presence of airway and crash carts, setting up vent and anticipating likely clinical needs…as well as backup plans. Cliff Reid has talked about the value of having a resus room safety officer….perhaps it’s not such a bad idea, especially in EDs where the resus is performed by a flash team (members who may never have worked together, or are used to another ED’s equipment/procedures). Minh le Cong (who never sleeps) has proposed a pre-ED RSI safety brief, albeit tongue-in-cheek.

Once the aircraft inverts, the importance of WAITING for cessation of violent movement was emphasised (to reduce risk of disorientation, injury), then calm performance of a well-rehearsed sequence :

  • orientate (use one hand to anchor as a fixed reference eg: underside of seat, with inboard hand)
  • locate (primary exit, use body movement eg knee or shoulder to locate door, then use outboard hand to locate exit release)
  • release (once exit open, keep outboard hand fixed on frame and then release inboard hand to undo safety harness)
  • vacate (use a low profile, pull inboard hand to join outboard hand at exit & pull head through – body will follow)
  • inflate (clear the surface of debris and inflate lifejacket if safe & appropriate to do so)

It was certainly easiest to perform this drill with eyes shut, avoiding the potential added disorientation of visual cues whilst inverted. Obviously an emergency ditching is a high stress environment – there will be a catecholamine surge and removing factors likely to add to panic is sensible

What’s the parallel in resus? There are probably a few. I was immediately reminded of similarity with CICO crisis training. I’ve had the misfortune of doing a few of these in real life, and have learned (by hard experience) to perform surgical airways as a tactile procedure (scalpel-finger-[bougie]-tube). But body mechanics are important in other things we do – threading a catheter onto a seldinger wire (use palmar aspect of both wrists to form a stable bridge, giving fine motor control) or effective laryngoscopy (understanding different mechanics of Mac 3 vs 4, elbow and wrist position to maximise force – a plug here for Rich Levitan’s airway course which certainly helped my airway technique).

Here’s a demo of the HUET in action – experimental test crash dummy Dr Francis Lockie uses his secondary exit, as the primary exit is blocked.

In summary

Despite the ‘wind up’ about HUET, I thought it was a well run course, delivered exactly what it was supposed to and has given a structure to dealing with a ditching crisis.

Could such lessons be applied to medicine? Absolutely – building muscle memory, relying on simple drills and regular sim are key.

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Dr Michael Edmonds (creator of the rather excellent adelaideemergencyphysicians website) keeps grinning despite the forthcoming dunking
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Dr Rhea S. Canavan assumes the position : brace-brace-brace!
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Forming a group huddle with new-found chums. Apparently the trick is to PEE INTO THE MIDDLE to create warmth…
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Thank God medSTAR kids rep Dr Naomi Spotswood is light as a feather, hauled aboard the life raft
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Survivors! Drs Paul Spedding, Naomi Spotswood & Kat Shelley after HUET completion. That yellow patch around Paul is sea dye….we think….

Sabbatical with Retrieval

It’s pretty obvious that I see the benefit of FOAMed for rural doctors as in the ability to ensure rapid knowledge translation, particularly in fast-moving fields such as emergency medicine. Although the work of rural docs encompasses predominantly primary care, our work intersects with emergency medicine when on call for out small rural hospitals…and of course some practice obstetrics, anaesthetics or surgery.

I am keen to apply best evidence to care of the critical patient; caring for these patients is something that rural doctors do relatively infrequently and it can be hard to maintain both skills and knowledge. There are some rural doctors with high end skills (particularly those who practice procedural medicine) – but such work may be very much out of the comfort zone for some doctors working in the country.

It’s very easy to fall into the trap of criticising patient management by others – we’ve all seen (or worse still, been part of) the ‘ICU-puts-down-ED-management-which-puts-down -primary-care-failings‘. It’s easy tribalism. I’ve blogged about this before in the “Be a ZERO not a HERO” post.

Anyone who’s seen the movie ‘Trainspotting‘ will understand this spoof EM leaflet

Aussie-Emergency-medicine-mission-statement1
From http://lifeinthefastlane.com/choose-emergency-medicine/

Whilst there is no shortage of muppetry across disciplines, I am more interested in ways to improve delivery of care in rural Australia, despite the problems of regular skills maintenance, relative infrequency, staffing, equipment and so on. Less criticism and tribalism, more solutions…

FOAMed is one way of helping to rural doctors to avoid being the ‘weak link’ in both EM as well as other areas of medicine. Having excellent support (iCCNet, medSTAR retrieval etc) is essential – but I think it behoves rural docs to avoid a therapeutic vacuum, even whilst awaiting the retrieval ‘cavalry’ to arrive. To whit : doing the simple things, well. Training for the occasional emergency. Using appropriate cognitive aids (action cards, checklists etc). Understanding the value of regular in situ sim-training with all players (doctors, nurses, admin volunteer ambulance officers etc) involved. Critical illness may be infrequent – all the better to be prepared.

Time to learn from the experts…

With this in mind, I am taking 6 months off to work as a retrieval clinician.  MedSTAR, South Australia’s retrieval service have very kindly offered this opportunity and I look forward to soaking up as much knowledge and skills as I can in the time.

Whilst it’s a bit of a jolt (and pay cut!) to move from my own private practice as a rural doctor to a salaried role, I reckon the experience gained will be worth it…

Learning from a high-performance organisation like medSTAR should have flow on benefits to delivery of care in the bush. So I need to get out and learn more…and there is no doubt in my mind that I have lots to learn from the experts in delivering critical care to rural South Australians.

 

Rural hospitals are well supported by retrieval services in Australia
Rural hospitals are well supported by retrieval services in Australia – medSTAR landing near wharf [photo from KI registrar, Dr Jeremy Wells]
In keeping with SA Health’s social media policy, I won’t be describing any of the cases I am involved with during this time (not that I’d discuss any case on this site, other than ‘hypotheticals’ for education purposes)

There may be an occasional sporadic post on clinical topics of interest to rural clinicians, but I do not expect to post much over the next six months. Ditto use of Twitter under the @KangarooBeach handle, unless appropirate.

So … if you see me in your ED (whether rural or metro) please take time to say “G’day”…

Meanwhile I’ve got HUET training to look forward to….

Safety of Helicopter Aeromedical Transport in Australia : a retrospective study

 

KIDocs will be relocating to a super secret hideaway, with kayak access to the ocean on the Adelaide sea shore
KIDocs will be relocating to a super secret hideaway, with kayak access to the ocean via Adelaide seashore

 

Snake, Snake, Snake!

No, not a rant about the use of pulmonary artery catheters…was out walking recently & came across this fellow.

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As it’s winter, the snakes come out onto road surfaces to warm up. This is a tiger snake – Kangaroo Island has two snakes, the tiger and the pygmy copperhead. KI tiger snakes don’t have the usual tiger stripes, being black to help absorb heat quicker. As is common with island speciation, the tiger snakes here are larger and more venomous that their mainland counterparts. You can see the ‘hood’ on this fellow as he makes himself appear more threatening.

We don’t see that many snake envenomations locally…the vet sees more, as dogs and snakes don’t mix. Generally snakes will avoid humans…although in the colder months I take especial care when collecting logs from the woodpile, as snakes like to rest there. Come summer, they are generally more active at night – hunting mice and frogs – and occasionally engaging in fights-to-the-death with local Rosenberg’s goanna.

It’s worth thinking about how YOU are going to manage a snake bite in your community – both from immediate first aid (pressure immobilisation, keep still) through to assessment (was this a true envenomation, a ‘dry bite’ or even a ‘stick bite’?) as well as use of snake-venom detection kit to aid decision-making as to which anti-venin to use (clue – if it’s a tiger snake or copperhead, use tiger snake antivenin!) and subsequent resuscitation.

Few quick Qs :

  • who is most likely to get envenomated by snakes?
  • how do you apply pressure-immobilisation?
  • how do determine envenomation or not in a rural setting?
  • how to use a venom-detection kit? to guide choice of antivenin?
  • are there any pitfalls in resuscitation of the snake bite victim?

Rural docs coming along to the RDASA Education Event Aug 8-9th at Wirrina Cove, South Australia will get a chance to quiz Prof Julian White on this topic. I’d recommend the CSL Antivenom Handbook, although I am not at all convinced about counting anal scales in the middle of a resus!

Might also be asking Prof White for his views on use of redback antivenom!

Eminence vs evidence-based medicine? Great review here from AdelaideEmergencyPhysicians.

 

The More I Know, The Less Certain I Am

I’ve recently had cause to re-examine Dale Edgar’s ‘Cone of Experience‘. Like that fabulous educator from iTeachEM, Rob Rogers (@EM_Educator), this concept seems intuitive and demonstrates nicely the benefit of learning via different formats. I use it in talks to explore different learning styles.

Screen Shot 2014-07-24 at 3.28.00 pm

Except it’s bunk. Dale never ascribed percentages to the retention rate for each different mode of learning; rather the ‘cone of experience’ demonstrates the varying abstraction potential for each learning mode. Understanding that Dale’s model was centred around understanding the concretness of different material, not retention rates.

Why is this important? Because it’s not uncommon in medicine to come across the view that “there is only one correct way to do X

When I was a junior, following such rules made sense – they reduced the burden of having to ‘think’ too hard … and when such rules were imposed from a higher authority (invariably a gruff Consultant), failure to comply risked raising their ire! Of course it’s not just lack of years or having a steep authority gradient that encourages sticking to such rules. As humans we tend to seek the comfort of familiarity and our own experience when making decisions – hence the “I’ve always done it this way…” or “Textbook X (authored by eminent expert Y) tells us to do it this way, so I’m sticking with that…” or even the “The teaching is to do procedure X this way – anything else is negligent” conundrums.

Nowadays when someone asks me how to do something, I seem to find myself pausing more and more as I reflect on previous experience. No longer do I say “Chest drains? They’re easy, let me show you how” – instead I pause “Well…it can be difficult…let’s talk about it, then I’ll help & guide you through one” as I recall not the vast majority of easy ones, but the difficult cases, the errors made, the complications…and am keen to relay this tacit experience bro e through mistakes to my colleague.

Some recent debates on social media have been relevant. Over on doctors.net.ukfora, we’ve had examples of :

- experienced clinicians ‘told off’ by physios for eliciting lower limb reflexes in a seated patient “the ONLY way to do reflexes is with patient laying down”

- anaesthetists laying into emergency physicians over options for safe sedation of the haemodynamically compromised patient in VT (with the usual cliched ‘needs RSI‘, through ‘mustn’t use ketamine because of strain on heart‘ through to ‘just zap them and apologise‘). Kudos to Cliff Reid & Ed Valentine for keeping their cool in that debate!

Meanwhile there’s been a useful Twitter and Google+ exchange on dogma around use of femoral traction devices (FTDs) for splinting of femoral fractures in the presence of a pelvic fracture

There are plenty of other discussions that crop up – cricoid force, checklists for crisis, thrombolysis in stroke, acceptable modifications to RSI etc etc

In all of these discussions, it’s not uncommon to see people looking for “rules”. In the recent examples,

- physio wanted a rule that all lower limb reflexes are elicited in supine patient

- anaes colleagues wanted to use propofol RSI for the patient in VT and berated use of ketamine

- traditional teaching is to avoid use of FTD in presence or suspected presence of pelvic fracture; some paramedics were lookign for guidance on rules whether to use a FTD or not. Wise words from experienced paramedic/retrieval practitioner Dave Tingey “clinical judgement is the key – especially where there is little or no evidence” – he emphasised focussing on patient outcome, not rules for a process!

FOAMed – tacit knowledge sharing with global community

People ask me why I use social media for learning. For me the attraction of FOAMed is that it addresses the issues where there is clinical uncertainty. If you are looking for absolutes (as when learning the craft of medicine or to pass exams) then stick to the textbook teachings. If you are looking to test yourself and continue to explore the expanding frontiers of knowledge, then use FOAMed. It opens up the world of #dogmalysis and enables corridor conversations with clinicians worldwide. Some of what you encounter is bunk…some is golden. The trick is to filter, engage, question and unlike politicians, don’t stick to one party line.

Even if “the more you know, the less certain you are!”

"My way or the highway" Guessing PM Abbott would not be amenable to uncertainty
“My way or the highway”
Guessing PM Abbott would not be amenable to uncertainty

Rural Prehospital Care Survey

The phrase “critical illness does not respect geography” is often quoted, reflecting the fact that mishap can affect anyone, anytime, anywhere.

We are lucky to have excellent tertiary level emergency departments & intensive care units in Australia to deliver specialist care. Developments such as FOAMed help to narrow the knowledge-translation gap from publication to practice. Furthermore, the widespread dissemination of information via asynchronous learning (such as slide sets, podcasts, videos hosted on websites, or corridor conversations via twitter) means that geographical isolation alone is no excuse for the rural clinician to be the ‘weak link’ in provision of care.

But Australia is a vast continent – making the provision of immediate care problematic in the more rural & remote areas. Certainly we have excellent prehospital & retrieval services; but although road and rotary-wing responses are rapid, they are limited in timely response when distances are large. The sheer size of Australia means that even responses by fixed-wing aircraft may take hours to arrive. My job as a rural doctor is to deal with ‘anything & everything’. We offer primary care as a core skill, along with a smattering of emergency care. Many rural doctors have advanced skills in obstetrics, anaesthetics and surgery. ACRRM considers involvement in local disasters and emergencies as part of the rural doctor primary curriculum skill set. It makes sense that the doctors with ongoing exposure to resuscitation & airway management (typically rural GP-anaesthetists) are called when there is a rural emergency.

But is the involvement of rural doctors a good thing?

Perhaps not. The experts in delivery of prehospital care are those with specific training and resources – classically State-based ambulance services, supported by services with retrieval expertise (eg: RFDS, CareFlight, HEMS, medSTAR etc). As a hypothetical, I think that if I was involved in a vehicle rollover, I would want to be looked after by the experts, not an ‘enthusiastic amateur’ GP.

So there is the dilemma. The further from a tertiary centre, the longer it will take for retrieval services to arrive. The more remote you are, the more likely that ambulance responders will be unpaid volunteers, not career intensive-care level paramedics…and the more likely that local clinicians will need to be involved in care.

A 2012 survey of rural GP-anaesthetists surprised me; just under 60% of responders stated that they had been involved in some form of pre-hospital incident in the previous 12 months. However of those responding, very few had training in prehospital care, very few had equipment to deliver care and most were tasked to the scene in an ad hoc manner (no formal call out criteria). As a consequence, the quality of responder on scene is highly variable – you may get a senior rural doctor with regular exposure to advanced airway management…or you may get a relatively inexperienced GP with very little emergency experience, let alone skills useful to prehospital care.

I can certainly empathise with the notion of ‘no room for enthusiastic amateurs, leave it to the experts’. Yet interestingly, the request for rural clinicians to attend such incidents came from the experts in prehospital care – ambulance comms and retrieval coordinators, usually because of the severity of the incident and dearth of readily available resources.

You can watch a summary of the issue here from the smacc2013 conference.

Role of the rural clinician in prehospital care?

There are several systems worldwide aimed to deliver immediate care when and where needed.

At a basic level, community first responder schemes such as PulsePoint and GoodSAM (smartphone activated medics) allow crowd-sourced delivery of basic life support to patients even before ambulance services arrive. Responders are typically volunteers, with senior first aid, paramedic, nursing or medical qualifications who are prepared to respond if an incident (cardiac arrest, impact brain apnoea) happens in the immediate vicinity. Activation is via the GPS in smartphones.

At the top end of prehospital care are ambulance and retrieval services, with trained teams, dedicated equipment and service delivery aimed solely at best practice.

Somewhere in-between are systems integrate appropriately-trained volunteers to support ambulance services and deliver care before retrieval services arrive. Examples include the UK BASICS (British Association of Immediate Care Schemes) and NZ’s PRIME (Primary Response in Medical Emergencies). Responders are typically nurse or doctor, with high-level resuscitation skills (typically rural GP, emergency physician, intensivist). They are tasked under defined activation criteria and are trained, equipped and audited. UK BASICS are generally unpaid and work is taken on additional to NHS duties; PRIME is paid.

South Australia has an embryonic scheme, RERN (Rural Emergency Responder Network), utilising experienced rural doctors to respond to prehospital incidents in their community, only when attendance of a doctor will ‘value add’. This can be useful where local ambulance responders are volunteers, when local expertise (career paramedic) resources are overwhelmed and/or when arrival of specialist retrieval services will take some time. As such RERN responders are equipped with standard prehospital equipment, undertake ongoing training and case audit. Participation (and indeed attendance) is voluntary; remuneration is on a fee-for-service basis. You can download a presentation from Dr Peter Joyner here or watch a youtube video from CountryHealthSA featuring medSTAR’s Bill Griggs on the RERN model here.

Some other States have standardised Hospital ‘emergency bags’ for use in a disaster (such as Western Australia’s Parry Pack); yet no formal training for their use or clinician involvement in such incidents. NSW is leading the way with not just standardised equipment bags but also open-access training for rural clinicians.

So is the BASICS-PRIME-RERN model one which could be applied elsewhere in rural Australia? I think so, but only in certain locations and in certain circumstances. Clearly the ethos of rural doctors responding to local emergencies is congruent with that of ACRRM. Historically rural doctors were called as default; this has (sensibly in my opinion) been superseded by delivery of specialist care via ambulance or retrieval services, offering a far higher level of care.  Yet rural doctors are still being called, often by the same experts!

To continue with ad hoc responses by whichever local GP is available is nonsensical, especially without appropriate training and equipment. Equally to ignore the fact that many rural doctors have ongoing experience in initial emergency management and airway skills via work in local hospital ED and Theatre may deny rural patients access to lifesaving skills. Of course one has to be mindful that experience in the Operating Theatre or ED does not translate to the roadside and the experts remain paramedics and retrievalists…when available.

Other countries recognise the fact that there is a therapeutic vacuum between initial incident and arrival of retrieval services; that geographically-constrained countries such as the UK and NZ have these systems and yet Australia does not is puzzling, especially when considering the tyranny of distance and unique skill set of Australian rural clinicians.

Take the Survey

What do you think? The link below is to a survey which will go to rural doctors registered with ACRRM and the RDAA; however it would be good to get feedback from a wider cohort – from established retrievalists, from paramedics, from nurses – in fact, ANYONE who is involved in critical care.

CLICK HERE TO TAKE THE RURAL PREHOSPITAL SURVEY (5-10 MINS)

As Karel Habig said at smaccc2013: “Good critical care is good critical care, wherever you are.”

I think it would be good to ensure systems to deliver appropriate care where gaps exist. But it has to be something that rural doctors are prepared to engage in – and has to be embraced by other services.

To put it bluntly, either we include rural clinicians in the system or we do not. The latter may be ideal from a metrocentric perspective, insistent on gold-standard specialist-lead prehospital care. This is the service I would want as a rural patient! But a pragmatic approach recognises that there will be temporary service gaps due to distance or lack of available personnel and that plugging these gaps already involves rural clinicians – yet in an unstructured, unequipped and untrained manner.

I reckon that we can and should do better than that in Australia.

PROS

  • recognise that rural clinicians are already being called to attend prehospital incidents; ensure that such responses are by trained/equipped/audited responders, not ad hoc
  • utilise those rural clinicians with ongoing experience in trauma, emergency medicine and anaesthesia, who maintain skills through regular exposure in hopsital ED and Theatre
  • task rural clinicians only when their presence will ‘value add’ to the prehospital scene eg: IV access, ketamine for extrication, needle/finger/tube thoracostomy, prehospital airway management
  • establishment of State or Nationwide cadre of rural responders may provide extra resilience in case of disaster eg: earthquake, bushfire, flooding [and may be acceptable to existing State-based agencies]

CONS

  • prehospital environment is very different to hospital; requires skills best delivered by ambulance and specialist retrieval services, not amateurs
  • presence of a rural clinician may not value add (local GP arriving in boardshorts and thongs with no kit/training is worse than useless), detract from delivery of care by local resources
  • potentially high cost to equip and activate responders (PPE, prehospital kit, pagers etc)
  • relative infrequency of incidents carries risk of skill fade

Really interested in perspective from others.

https://docs.google.com/forms/d/1mWneu8ijC64O1yLblEFrNTFZ0xEDnNXD5JKzTfE6orQ/viewform?c=0&w=1&usp=mail_form_link

RSI Checklist App – Review

It is no secret that I am a fan of checklists. Not because they are a ‘how to guide’ (they’re not), but because of their proven potential to mitigate against error in high-risk tightly-coupled procedures. One such procedure is RSI. The consequences of omitting a single step (eg: failure to check ETT cuff, availability of back up equipment or appropriate drugs) can lead to disaster.

This year’s smaccGOLD saw Minh le Cong and myself go head-to-head in the infamous “Do Real Airway Experts Use Checklists?” debate. You can read more here - the answer being “of course airway experts should use checklists!”

Since then I am pleased to see that others in ED have been inspired to implement checklists in their ED…and for the creators of the Vortex Approach consider adding a checklist to their cognitive tool.

 

Checklist to complement The Vortex Approach
Checklist to complement The Vortex Approach

But a sensible checklist is more than a ‘tick and flick’ exercise – it should only contain key steps and ensure that the user does not lose situational awareness. Having audible cues (akin to an aircraft terrain alert warning to “pull up, pull up”) would be useful during preoxygenation and during intubation attempts.

Screen Shot 2014-07-16 at 2.37.44 pm
$1.29 on the Australian App store – it’s a UK-based app so presume available internationally

So I was delighted to be able to beta test the iRSI app. This is the brainchild of Dr Ben Taylor, a UK doctor who is near to completion of specialist training (I struggle with the notion of calling such doctors trainees). You can download the iRSI app via iTunes – it’s optimised for iPhone and listed as an iPhone iOS app, but works perfectly well on iPad.

 

iRSI checklist app - brainchild of Dr Ben Taylor, irsi.co.uk
iRSI checklist app – brainchild of Dr Ben Taylor, irsi.co.uk

 

The app itself is simple – four main checklist screens which can be run through during a standard period of pre-oxygenation.

 

IMG_4200
RSI App Start Screen

 

Once select ‘RSI’ as an option, the user is guided through four screens – checks of patient, drugs, equipment and team.

 

Step 1 - PATIENT
Step 1 : PATIENT

 

Step 2 : DRUGS
Step 2 : DRUGS

 

Step 3 : EQUIPMENT
Step 3 : EQUIPMENT

 

Step 4 : THE TEAM
Step 4 : THE TEAM

Running through the checklist takes around 60 seconds and can be achieved during preoxygenation. There are additional submenus for airway assessment, adjuncts for difficulty, prevention of desaturation and crisis management if needed.

What makes the app more useful, are the inclusion of :

  • integrated calculators for paediatric doses, emergency drugs and equipment sizes
  • tidal volume calculations based on ARDSnet for weight, height and IBW
  • integrated protocols for airway assessment, optimising oxygenation, failed intubation & anaphylaxis (references emcrit.org and resus.me FOAMed sites)
  • audible, tactile and visual alarms at preset intervals during preox and intubation attempts.

The latter takes advantage of the built-in audio alarm, vibrate and torch functions of the iPhone (iPad), corresponding to audio-tactile-visual cues as RSI progresses. I think this is invaluable, as offers a predetermined cue to encourage the intubator (or assistant) to consider alternative strategies as time progresses. This may help mitigate against task fixation, a problem in many airway catastrophes.

 

The Roc Clock - alarms during prolonged efforts to secure airway
The Roc Clock – alarms during prolonged efforts to secure airway

Nice touches are the ability to pre-select preferred choice of induction agents (from thiopentone-propofol-ketamine-etomidate-midazolam) and neuromuscular blocker (suxamethonium or rocuronium).

Thio-Sux traditionalism or Rocketamine? Your choice.
Thio-Sux traditionalism or Rocketamine?
Your choice.

Whilst the inclusion of propofol may induce apoplexy in some, hopefully the ability to either turn on or off cricoid pressure as a default will assuage them.

 

Cricoid ON or OFF? Your choice with iRSI
Cricoid ON or OFF? Choice is yours with iRSI

One thing I was concerned about was the potential to become too focussed on the app itself, rather than the intubation. I think that Ben’s done a good job – the user can preselect options appropriately and dip in/out of the app for critical stages eg: checklist alone or intubation attempt timer.

I don’t think that the app aims to replace proper airway evaluation and training, nor management of airway crises – but it does offer a readily-accessible form of an RSI checklist, useful drug and equipment calculators as well as timers with alarms for critical steps.

Future modifications might include

  • use of fentanyl as coinduction agent
  • calculators for standard infusions (particularly relevant for post-RSI sedation in ED, ICU or PHEC)
  • data logging to allow audit of intubation, offering possible synergy with the airwayregistry.org.au study and similar audits overseas.

So have a look at the RSI app and feedback any suggestions to Dr Ben Taylor. He’s done a GREAT job….

More details at iRSI.co.uk

BELOW IS A DEMO USING REFLECTOR APP AIRPLAY from iPAD to MACBOOK AIR.

Audio was overdubbed during a rainstorm on a remote beach – sorry about the background of heavy surf and rain!

https://vimeo.com/100875493

 

I think iRSI app opens the way forward – we all have smartphones and tablets to hand – integrating cognitive aids, audio/tactile/visual alerts, checklists, crisis algorithms and data-logging is a powerful way to improve safety.

Stroke Unit – Decision Makers Away with the Fairies

I’ve never been a fan of the term ‘cerebrovascular accident’. The term accident implies that there is no underlying reason for the pathology. Indeed, there was a push some years ago by the BMJ to ban the term ‘accident’ in medicine, as it implies that they are a chance occurrence or an ‘act of God’.

Stroke

It is actually interesting to explore the etymology of the term ‘stroke’. In times gone past, it was not unknown for formerly fit members of the community to head off into the fields or forest for a hard day’s work…then be discovered at the end of the day with a unilateral paralysis and difficulty speaking. Yet there was no visible injury. Hence the concept of having been attacked by the Faery Folk or ‘Elf-struck’ – subsequently contracted to ‘stroke’.

Whilst we learn about the pathophysiology & workup of stroke, I used to be somewhat nihilistic about outcome. I often tell patients and their relatives that one of three outcomes is likely – to get better, to get profoundly worse….or to stay the same. That’s not to say that I skimp on history and examination, appropriate investigations nor aggressive treatment of modifiable of risk factors. As a rural doctor I am well-placed to address risk factors well before people progress to cerebrovascular disease, as well as to have the ‘difficult’ discussions with them & family regarding prognostication if and when a stroke occurs.

All this changed with advances in stroke care.

The topic of thrombolysis in stroke is often discussed in FOAMed circles, with differing opinion on effectiveness between emergency and stroke physicians. One thing though has always seemed clear  the benefit of dedicated stroke pathways offering streamlined access t one-stop investigation and management of stroke patients, as well as use of validated triage systems such as the ROSIER score to enable direction of such patients to the stroke unit.

The best results appear to come from those which are based in a dedicated ward

By doing the LITTLE things well (timely recognition, early assessment and investigation, bundled care), it seems that stroke networks and stroke units offer patients the best chance. This is akin to the ‘aggregation of marginal gains’.

A 2013 Cochrane Review highlighted the benefit of dedicated stroke units. This review of 28 trials, involving 5855 participants, showed that patients who receive stroke unit care are more likely to survive their stroke, return home and become independent in looking after themselves.

So – best care is to send your stroke patient to a stroke unit. Or so I thought.

I recently admitted a stroke patient. Prior to this she was independent in her own home. She has controlled hypertension and a pacemaker. She’s had a previous stroke, managed in a tertiary hospital stroke unit, from which she made a full functional recovery after some weeks in rehabilitation. So when she presented, several hours after likely onset of her second stroke, it seemed only sensible to send her away to a stroke unit. She and family are loathe to leave the community, but understood that her best chance of recovery lies with all the benefits that a stroke unit can offer, not least rehab. So they are prepared to take a trip to the tertiary hospital for best care.

I spoke to a very lovely stroke registrar who apologised profusely and told me that, due to funding cuts, the stroke unit is now only able to accept patients under the age of 70.

That’s right – 70 years of age

Let’s face it – this is a financial decision, not a clinical one. Age doesn’t factor into the ROSIER score. It certainly didn’t factor into my patient’s eligibility for stroke unit care on the last occurrence. Whilst I can understand denying stroke unit care on the basis of poor premorbid function and poor chance of meaningful recovery, it seems nonsensical to exclude patients from stroke unit care on basis of age alone.

I have no doubt that my patient will be well cared for on a general medical ward. They may even receive visits from the same stroke physicians, physiotherapists and speech therapists as on the stroke unit. But studies suggest that it is the provision of a defined geographically separate unit dedicated to stroke care is the deciding factor in improving functional discharge.

As clinicians we may obsess over implementation of tools such as the ROSIER score, pros/cons of thrombolysis and need for bundled care in stroke networks and stroke units. But ultimately all this comes to nought if there are no beds, and decisions to admit to a stroke unit are made on basis of age, not other clinical criteria.

The stroke registrar encouraged me to make a noise about the limitations on beds. For most people, this issue will not be one that concerns them – until a family member is affected. Meanwhile politicians do not have to look these patients in the face. An honest political system would be prepared to put these issues front and centre, to acknowledge that rationing is needed and to explain why, despite encouragement to work until 70 until you are eligible for a pension, if you have a stroke in retirement you won’t get stroke unit care.

Making decisions based on age alone and not premorbid function seems inherently ageist – and is a policy I find hard to defend.

Should age alone be a reason to deny stroke unit care?

What do YOU think?

Is age alone a valid cutoff for stroke care?

If you are going to argue that equivalent care can be offered on a general medical ward, then it begs the question – why have stroke units? Has Cochrane got it wrong?

 

ETM course coming to Adelaide, SA

I am delighted to hear that Dr Andy Buck and team are running an ETM course in Adelaide in October this year. ETM is a great course for anyone involved in the trauma team – EM docs, anaesthetists, rural docs, surgeons, intensivists.

I teach and Direct on the international ATLS-EMST programme – and whilst I believe in the usefulness of the ATLS approach for the initial management of trauma, it frustrates me that the ATLS course is aimed at a fairly basic level, doesnt cover anything to do with trauma team management and omits much of the useful #FOAMed quality education that is available.

ETM covers all this. You can read a review of ETM by Dr Jeram Hyde from one of the early  Melbourne-based courses in November last year.

http://kidocs.org/2013/12/etm-course/

Better still, get yourself along to ETM in Adelaide this October – its way cheaper than EMST, shorter wait list to get on a course and has way better content for modern trauma management!

Details at http://etmcourse.com/first-interstate-etm-course/

I hope to see some of you there! Get in quick though….