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.
- 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]
- 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.