Building Community Resilience with Careflight

Rural trauma – a high-speed vehicle roll over, a farming accident with a chainsaw, a gas BBQ explosion at the family picnic.  These are all scenarios that may affect individuals & families…and the rural community.  Occasionally a multi-agency event such as a bushfire, extreme weather event or other natural disaster will cause traumatic injuries and impact on not just local community but also on State resources.

Whilst it is true that each State has well-developed retrieval services, whether land, fixed or rotary-wing, the reality is that the help they can offer is usually distant to rural folk; response times are measured in hours, not in minutes or seconds.

For all practical purposes these services might as well be on the moon in the face of truly urgent care (catastrophic haemorrhage, impact brain apnoea, compromised airway, delivery of effective analgesia etc).

The first link in the trauma chain of survival is invariably the first responder – he or she may be a rural volunteer in a service such as ambulance, fire, SES , coastguard…or may respond as part of their job role (eg: Parks officer, tour guide)…or may be a lay member of the public who comes across an incident and is thrust into the maw of trauma care.

This impromtu response what Christina Hernon defined as the ‘immediate responder’ in her excellent talk on ‘the disaster gap’ at smaccDUB.

The Disaster Gap is the time between the moment an incident occurs, through the first call for help, and until the first of the clearheaded First Responders arrives. In this definable time gap, the only available rescuers are people who are on scene when the event happens, who may be traumatized by their experience themselves, and who, regardless of tools or training, take immediate action to help another person or make the situation better.

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Of course many organisations insist on their members having an advanced first aid qualification; whilst these are useful, their proscribed content often lags behind current trauma care delivery. First responders are the initial link in the ‘trauma chain’ and there is no reason not to equip them with appropriate skills, knowledge and equipment – regardless of agency!

Whilst most interagency training is focussed on ‘mass incident’ exercises as a learning exercise, the reality is that these rarely, if ever, happen. Most of the work is in the usual business – a vehicle rollover or crash, an injured bushwalker, a farm accident, a patient needing medical care but unable to use the stairs, requiring SES and Ambulance teams etc – and yet do we ever train as a team for such circumstances?

Careflight MediSim – Delivering Necessary Trauma Education

This week we were privileged to have a visit from the Careflight MediSim team, to deliver the Trauma Care Workshop on Kangaroo Island, SA.

Launched in 2011, this innovative program from the Careflight organisation (mostly charity funded) delivers a world class trauma education system designed for rural first responders.

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MediSim training 2011-2015

Despite the session having to be rescheduled, willing first responders from Parks, CFS and SA Ambulance were able to come together for an interactive day of lectures, task-training and sim sessions under the credible instruction of the approachable MediSim facilitators.
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I’ve been banging on about the need for effective interagency training in rural communities for some time now.  My involvement in trauma nowadays is mostly limited to involvement via the SA RERN system (a doctor responding only when needed by volunteer ambulance officers, with the goal of value-adding by performing certain interventions), in the hospital when oncall for emergency or anaesthesia and of course in trauma education through ETMcourse and EMST etc.

Whilst RERN, SAAS and of course RFDS and SAAS-MedSTAR Retrieval have a role to play, the initial care at the roadside is invariably provided by a first responder.  If lucky he or she may be a part of an emergency system…or they may be in another capacity (CFS, SES, Police, Parks etc). Of course they may also be an immediate responder – a passerby who is caught up in the situation and expected to render help.

Most prehospital incidents will require input from several agencies

At a typical vehicle crash, there will be representatives from Road Crash Rescue (CFS or SES), Ambulance – typically these are unpaid volunteers in rural. Add to that Police, then RERN, and Retrieval…it can be hard to both know ‘who is who in the zoo‘ and more importantly what they can do!

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A typical rural road crash (source ABC)

 

Training together has clear advantages – it emphasises the need for simple interventions to make a difference and that such interventions can be performed by appropriately trained and equipped individuals regardless of agency. It also allows discussion of current protocols and equipment (such as the value of first responders, whether ambulance, fire or SES having access to tourniquets, and a suitable haemorrhage control device).

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Simple kit to deal with haemorrhage control – in my opinion this should be in every rural ambulance, SES or CFS truck, police car, parks vehicle and tour bus. Is it?

Understanding and sharing of each other’s treatment priorities (scene control & safety, patient extrication and medical needs) can be practiced by scenario training, allowing effective communication, a shared mental model and planning for ‘the real thing’

It’s time to ditch the notion of each agency training in silos and instead practice regular ‘real life’ multiagency scenarios

The MediSim team provided local Kangaroo Island first responders with a solid foundation to develop further local community resilience.  Lectures covered the concept of a ‘zero survey’, triage. effective handover and of course the nuts & bolts of trauma care.

 

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The Emergency Bandage (formerly known as the Israeli Bandage) – cheap and essential kit for any first responder

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Checking out the MediSim ‘crash car’ designed to be used for practice extrication – it would be a simple project to make one of these for local use on KI, potentially in partnership with TAFE & Crash Repairs

The day involved practical, hands on task-training sessions on triage, on helmet removal and immobilisation, on haemorrhage control and basic airway management.

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Helmet removal – can be done safely; either let patient do it themselves or perform if trained – but get the helmet off early, not late!

Skills learned in the workshop were reinforced by scenario-based training on managing a casualty, involving scene awareness, leadership, role allocation and the delivery of basic care in an effective manner (simultaneous extrication, treatment and packaging of the patient) underpinned by clear communication both on-scene and with central comms.

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Challenges of leadership and teamwork, under stress, with limited resources in an unfamiliar environment – one which KI local volunteer teams coped with exceptionally well

All in all, a wonderful effort by the CareFlight MediSIm team and by the local Kangaroo Island volunteers who gave up their own time to attend this trauma workshop.

I am hopeful that we can run similar exercises in the future using local expertise.  To my mind the benefits of team members who are aware of each other’s roles and operational capabilities, who have trained together and share a common goal offer immediate tangible benefits to victims of trauma.

Moreover we live in a small community – the more first responders who are trained and equipped, the more resilient our response can be – whether for an accident at home, at the roadside or in the case of a community-wide catastrophe.

 

A Kangaroo Island Resilience Model, akin to those overseas, is achievable if we work together.

Thanks again Careflight for visiting Kangaroo Island – come again next year!

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COI – I received a bottle of wine from the MediSim team as a reminder of my time in Orange NSW back in 2011 (anaesthesia training and trauma care). I am not influenced in my report by this gift…although there MAY be a subliminal message they want to convey…

 

Recommended Reading

Read more about Careflight MediSim HERE

Careflight are also active in sharing their knowledge through social media; check out the Careflight Collective blog here

Learn about how the Isle of Arran (Scotland) has developed a local resilience model for multi-agency training and trauma care

Principles of trauma care are taught on many courses; I recommend

Emergency Trauma Management (ETM) course – etmcourse.com (COI I instruct on ETM)

Anaesthesia, Trauma & Critical Care (ATACC) course – atacc.co.uk (COI am trying to persuade Mark Forrest to bring this course ‘down under’)

The Holmatro Rescue Experience (COI have facilitated with Holmatro extrication guru, Ian Dunbar on this in Australia, mostly teaching SES and CFS volunteers)

Many clinicians worldwide share knowledge and skills – regardless of whether background in emergency, anaesthesia, rural medicine, critical care or whether involved as doctor, nurse, paramedic or volunteer. Our common goal is to care for the patient from whatever background.  By sharing such knowledge we can all become better.

Safety in Resus – Use the Whiteboard!

There’s no doubt that for the small rural emergency department, a critically unwell patient can quickly overwhelm available resources.  Like many small rural hospitals in Australia, there is one doctor on call for emergency presentations, with the ward-based nursing staff (two in out location) responsible for ward care, assessment of outpatient attendances as well as care of patients in the ED. Not surprisingly this can be a big ask…and thankfully extra nursing and medical staff are available if needed (typically the oncall theatre team)

As we ramp up into the tourist season on Kangaroo Island, I’ve been thinking about how we deal with critical patients in our rural ED.  Having the appropriate training and equipment is obviously important – as well as an appreciation of resus room feng shui.

A recent retrieval case brought the issue of improved team communication to mind.  I wont go into details; suffice it to say that this case required the attention of two doctors, seven nursing staff, one paid paramedic and four volunteer ambulance officers….and subsequent retrieval.  The demands of one critically ill patient … plus several other ED attendees … plus ward care can quickly overwhelm local resources, without a robust oncall system.

But no matter how well equipped, how well trained or even how well staffed the ED is, there HAS to be effective communication between members. We did quite well, but on reflection afterwards I felt that it was hard to keep track of who did what and when. This is often the case in a resus team, particularly occasionalists or the ‘flash team’ or individuals who have not trained together.

The traditional and practiced role of a resuscitation team is based on that of team leader, with subsequent role allocation and closed-loop communication between members, all operating with a common goal or ‘shared mental model’.  This is the sort of stuff we teach on the ETMcourse, focussing not just on the technical skills of trauma care, but also on the nuances of effective teamwork in trauma.

In recent times I have become a fan of using the whiteboard as ‘glue’ to hold the resus team together.  In any resus, it is common to delegate one person to scribe.  It’s important to have a record of drugs given, interventions delivered and arrival/departure of team members etc. But many people, myself included, find that the furious writing by one team member of all events & drugs on a piece of paper that noone else can see does little to add to team effectiveness in a critically ill patient.  Scott Orman over at Auckland HEMS has posted a nice summary of why a whiteboard is so useful for prehospital handover – I think this applies equally for rural hospitals.

Why is that? Well – it’s pretty simple.  In a small team, we need every hand on deck – delegating a clinical member to scribe may take them out of circulation. But that’s a minor gripe – the main problem with the scribe is that noone else can see what he/she has written unless they take time out to read their notes. In short, there is no shared mental model when all documentation goes via the scribed notes.  Moreover, the scribe may accurately capture all the interventions and their timing from multiple sources – but this knowledge is not shared between team members.

“often the scribe has all the critical information – noone else does!”

This makes sense – the resus can be chaotic, especially when team members haven’t trained together and there is a lack of leadership or followership, unclear role allocation nor closed loop communication.  Instead there is frenetic activity, cross talk, repeated interruption and a requirement to re-hash essential elements of history and interventions with the arrival of each new team member…

This is where the resus whiteboard comes into play – I’ll be the first to admit that ours is not big enough – but it’s a start. I would hope that every rural ED has a whiteboard available at the head of the bed or adjacent.  Documenting initial prehospital handover, subsequent interventions and obs, as well as arrival/departure of key players can help the whole team.

A whiteboard gives a clear indication of who did what, when, and why…as well as response to intervention. New arrivals to the resus can stand back and get a summary without having to interrupt.

More importantly, I find that having a summary on the whiteboard where everyone can see it gives a shared mental model – of where the patient was on arrival, the therapeutic goals and the steps needed to get there – a readily available shared mental model for all team members without the need for repeated interruptions and cross-questionning which is inevitable as additional team members enter the resus.

“closed loop communication between team members and a dedicated scribe may work well in a single trauma team – but as team members come and go, vital information is lost.

Rather than have to re-hash information, the whiteboard can give a quick summary of where we started, where we are now…and where we want to be.

It can also help open up communication – how much easier is if for a team member to raise a hand and ask “Excuse me team leader…I see that we have a goal MAP of 70 but the current MAP is only 55. Do you want to do X, Y, Z?” or “Hey everyone, we’ve transfused four units of packed cells in the last 20 minutes – we’re now into the agreed trigger for massive transfusion protocol…can we organise as agreed earlier per protocol?

Of course we still need to keep a written record – I am not suggesting that the whiteboard alone will suffice – but in a resource-limited and time-critical resus, the whiteboard can truly be the glue to keep the team on target and ensure what needs to be done is done, and that everyone knows about it! Here’s how the ‘ideal’ resus flow of information would work via whiteboard…

Prehospital Notification

AT-MIST AMBO or ISBAR can be used as a structured handover tool, allowing anticipated needs to be identified and role allocation of team members.

AT-MIST : Age/Time/Mechanism/Injuries/Symptoms&Signs/Treatment provided&Trends

AMBO : Allergies/Meds/Background/Other

ISBAR : Identity/Situation/Background/Assessment/Response+Readback

Key equipment needs may be anticipated based on pre-notification eg: traumatic head injury means probably need blood, fluid warmer, TXA, RSI equipment.  Drugs such as ketamine (for both analgesia and induction) can be pre-drawn and emergency drugs doses calculated & written down (especially for paediatric cases or uncommon scenarios). This is a good time to call in other staff – especially if multiple injuries or if solo operator and one critical patient.  The more resus I do nowadays, the lower my threshold to call in a colleague. It’s just so much easier to share the cognitive load…

prehospital handover

Patient Reception & Pre-Hospital Handover

Unless in extremis, take 30 seconds for a structured handover from the ambos before the patient is transferred off their stretcher. This is a high risk time. There is usually a flurry of activity as well-meaning individuals attempt to take history, remove clothes, gain IV access and set up monitoring.  Seriously – stop!

Studies show that less than 50% of information relayed by prehospital services is retained by emergency department staff – this can be increased by use of a structured handover tool. Whichever handover method is used, this is a time for everyone to STFU and listen!

Unless the patient is in cardiac arrest or needs immediate intervention (airway at risk etc), take 30 seconds and use the whiteboard to confirm elements of prehospital handover history and baseline obs.

I use this to determine resus goals for the team.  You will be amazed at how much information is missed at handover – especially when the receiving team ‘get busy’ with lines, blood pressure and monitoring – when they should be listening and coming up with a game plan!  And don’t get me started on 1-2-3 vs ready-brace-move for the actual transfer!

Rural Resuscitation

Once obs are done and as the primary survey is completed (again, calling out the findings so can be scribed to whiteboard), ensure a shared mental model of early treatment goals is established. I don’t know about other rural docs, but I find that a rural resus is hard work – we do this stuff infrequently, yet attention to detail can make all the difference. Critical care is mostly about doing the basics, well.

Treatment goals may be as simple as “let’s keep the patient warm, maintain oxygenation, target MAP >70 and stop the bleeding” or may be a little more nuanced “Let’s secure the airway – we’ll optimise position and pre-oxygenate; use the challenge-response checklist whilst drawing up drugs – then once intubated immediately perform a finger thoracostomy and ongoing resuscitation with warm blood whilst packaging for transfer

Obs can be scribed to show trends and response to interventions.  Key times & doses of drugs given are recorded.

Having a shared mental model allows opening up of communication of goals aren’t being achieved.  Rather than challenge the team leader (which can be difficult where there is an actual or perceived authority gradient), this approach allows truly patient-centric team collaboration.

Of course this will be concomitant with closed-loop communication between team members, something that is easily practiced on courses such as ETM.  Subsequent or parallel scribing to clinical notes is possible when time allows.

Handover to Retrieval Team

As mentioned above, the whiteboard can serve as a good global summary for the arriving retrieval team (or indeed anyone who arrives to the resus after a period of time) and allows a structured handover with salient points highlighted.  A photo of the whiteboard summary can be forwarded to the receiving facility as an initial SITREP.  Whilst the camera is out, there’s also the chance to catch some selfies with long-lost friends…

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Handover with retrieval – important time to exchange clinical info…and catch up with old colleagues (NB : this photo taken AFTER handover complete and patient stabilised!)

Before team arrival use any spare time to ensure all documentation is in order (if not already performed) and for notes to be written (often as the referring clinician I have been too busy to write anything until retrieval team arrive!).  An ABC type transfer checklist can be a useful summary (mine runs from the letter A to the letter O!). Of course patient care should take precedence over documentation! In a real rush I’ve been known to write on the patient!

Debrief

A hot debrief can be useful after a resus.  At this stage Country Health SA doesn’t routinely audit resus cases locally, which means there is little chance to improve performance not have open and honest communication on what went well and what didn’t.  Most improvement will be about aspects of communication, equipment availability and use, as well as practice as a team for realistic scenarios. The feedback from peripheral team members can be very important – the volunteer ambos, the cleaner, the ward clerk…and again the whiteboard debrief can help identify any problems in patient care and improve team resilience.

“without honest feedback from team member on cases, there can be no audit…

…and without audit, no improvement in clinical care”

In short, the whiteboard can help improve individual situational awareness via the early establishment of a shared mental model, opening up communication between team members.  There should be one in every rural ED – use it!

Whiteboards have been shown to aid the following in a resus:

  • task management
  • team attention management
  • task articulation and tracking
  • resource planning and tracking
  • synchronous and asynchronous communication
  • multidisciplinary problem solving and negotiation
  • team building

References

Prehospital to ED Handover (inc use of whiteboard) from Auckland HEMS http://aucklandhems.com/2012/11/26/pre-hospital-to-ed-handover/

Talbot R & Bleetman A (2007) Retention of information by emergency department staff at ambulance handover: do standardised approaches work? Emerg Med J. 2007 Aug;24(8):539-42. http://www.ncbi.nlm.nih.gov/pubmed/17652672

The Importance of Shared Mental Model from TEAM STEPPS http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/igsitmonitor.html#m4SL13

Xiao Y et al (2007) What whiteboards in a trauma center operating suite can teach us about emergency department communication Ann Emerg Med. 2007 Oct;50(4):387-95. Epub 2007 May 11. http://www.ncbi.nlm.nih.gov/pubmed/17498845

Transfer Checklist A-O https://ruraldoctorsdotnet1.files.wordpress.com/2013/04/transfer-abc.pdf

TRANSFER CHECKLIST

Airway

Breathing

Circulation

Disability

Exposure

Fluids given

Gut (fasted/NG)

Haematology

Infusions

JVP (filled/under-filled)

Kelvin (temp)

Lines

Monitoring

Notes & Next of Kin

Other Stuff…

The Infamous Barbie Doll Story

If you haven’t already, listen to self-proclaimed “hottie” Liz Crowe, social worker from the Mater, delivering a blistering smaccTALK on ‘swearing your way out of a crisis‘.

I met up with her just before the session for a bit of advice on swearing before my own smaccTALK; she did suggest that gratuitous use of the c word in the checklist debate would be better re-phrased as ‘C U next Tuesday’. I think I managed to weave this into the debate…listen yourself when the Checklist debate is put out to air (unless it gets edited)…

Liz gave a hilarious talk, not least because she acknowledges the use of humour & swearing in medicine – as a form of metaphorical armour, as a psychological re-set mechanism and way of stepping back from the horror of critical care. She also made repeated reference to an unfortunate episode of rectal Babushka dolls …

Which made me remember a story on rectal FBs of my own.

I have deferred putting this story out for some time. It refers to the issue of rectal foreign bodies…in particular, one memorable episode. Of course this incident happened in a hypothetical hospital to a hypothetical patient. If it DID ever happen, it was certainly in a different country…and over 10 years ago. And of course I was NOT involved.

So…hypothetically…here is the infamous ‘Barbie Doll’ story.

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Somewhere in an ED many years ago

I am a big fan of triage nurses and paramedics. They are generally hard-as-nails types, unfazed by adversity and have ‘seen it all’. Which is why this particular Friday was odd. I was the Emergency Registrar on, and became distracted from the hassles of simultaneously managing seven acute patients and supervise the RMOs queueing up to discuss their cases. There was an audible kerfuffle going on over at triage…

So I ambled over. And there was Jude, the tough-as-nails Kiwi triage sister, doubled up in tears of laughter. And the cool-as-cucumber ambos were similarly giggling. Laying between them was a young chap, face down on the barouche.

What the?” I mumbled. “Is this what I think it is?”

RN Jude nodded vigorously…still laughing.

Pulling a curtain around, we moved the barouche into the resus room. Things like this don’t come up every day. With good light and 360 access, I performed a careful examination…

Sure enough this unfortunate chap had managed to wedge a Barbie Doll up his arse. Head first. All that was visible were poor Barbie’s feet…and with every painful spasm of his sphincter, Barbie’s legs would waggle as if to say “Get me out of here!”

Attempts to pull Barbie out with some sedation were unfruitful – pulling on the legs caused Barbie’s two arms to extend, rather like a fancy corkscrew device. She was embedded.

We rang the surgical registrar who was, of course, scrubbed in some abdominal horrendectomy and not going to be available for at least another 2-3 hours. This was not untypical. The Surgical Registrar on duty that day had a reputation as a “bit of a cock” – generally obstructive to referrals, usually uncontactable in theatre and usually very brusque with ED. There was bad blood between the Surgical and ED tribal leaders that day…

Meanwhile we placed the poor chap in a side cubicle and carried on with our work, enjoying the humour of the occasion. By this stage the poor chap had become the “butt” of all our jokes (groan). X-rays were taken, conversations were had and general humour was enjoyed.

Finally, getting on towards midnight, the surgeon appeared. He refused to listen to the elaborate but somewhat sarcastic verbal referral that I had been crafting all shift, but instead disappeared behind the curtain.

I’ll sort this out myself if you amateurs in ED can’t” he announced to the ED.

Wanker” I muttered, whilst the assembled registrars, RMOs, RNs, ENs, orderlies and students assembled behind the curtain to listen.

Bugger me! The usually terse surgical registrar took a crisp, concise surgical history. He EVEN took an anaesthetic history! He explained in calm and non-judgmental words the nature of the problem, the need for surgical removal and the potential complications. His clerking was a model of empathy, concern. I am not 100% certain, but I am pretty sure he even used #HelloMyNameIs, a good 10 years before this meme became a phenomenon…

By now we were all pretty chastened. I was feeling very guilty about the earlier behaviour and inappropriate humour of the ED team.

On the plus side, our patient had certainly brightened up – after several hours of being the focus of everyone’s attention and the laughing stock of the shift, here at last was a doctor who was prepared to take him seriously…thank heaven for the professionalism of the surgeon!

And then the denouement…

Well Mr X” said the Surgical Registrar “I have explained what we need to do – I’ll push your trolley upstairs myself…the anaesthetist is ready…we’ll have you fixed up in no time. Do you have any questions?

Dumbfounded with gratitude the poor lad just stammered “No…thank you…for looking after me

No worries” says the surgeon “Just one LAST question….I can see what you did with Barbie….but where’s Ken?

With that the assembled masses in ED erupted with laughter. The surgeon emerged, grinning, pushing ahead of him the poor lad on the trolley. That day the surgeon became a hero to us all – from then on the surgical and ED tribes were at peace.

Hypothetically.

Wanna learn more about rectal FBs?

 

Well, I daresay there is always Google….but that might not be safe for work! Perhaps better to stick to the journals. Try this classic :

Management of Rectal Foreign Bodies from Coskun et al (2013) World Journal of Emergency Surgery

Rectal Foreign Bodies from Goldberg & Steele (2010) Surg Clin N Am

I daresay there are more. More importantly, listen to Liz Crowe’s talk on humour and swearing from smaccGOLD. It’s a beauty.

See you next Tuesday!

 

 

 

Zen & the Art of ED Management



There has been a lot of discussion this week regarding pressure on the Emergency Department at Flinders Medical Centre in South Australia.

Rack ’em and stack ’em!

I have a ‘soft spot’ for Flinders. I worked there as a junior resident and then registrar in the late 90s/early naughties and like to think that I learned a bit. The Consultant staff were excellent and engaged in training. The nursing staff were fantastic. And the work was great fun – I certainly enjoyed the immediacy of emergency/critical care but was seduced away to rural medicine by the lifestyle advantages and variety that this work offered. More importantly, the one thing that affected my decision not to complete training in ED/ICU was the lack of control over factors in my work (some might say that dealing with Country Health SA is similar, and you would be right, but more of that in another post).

The big issue for the ED is ‘access block’ – the inability to efficiently deal with emergency patients because there are insufficient beds in the ED..because there are patients waiting for beds ‘upstairs’ ie: in medical and surgical wards. And why are there no beds? Because the medical and surgical wards are either run at 100% capacity leaving no room for ‘surge capacity’…and/or that medical beds may be clogged with patients awaiting discharge to home, nursing home or country hospital.

Because there is no slack in the system, the clogging of ward beds filters back to the ED causing access block. And when the ED is full, the unhappy situation arises when ambulances cannot handover their patients because the ED is full and ambulances are ‘ramped’(literally wait on the ramp outside the ED). And tying up ambulances waiting outside EDs means there are not enough ambulances to deal with emergencies in the community.

Ramping has been a common phenomenon at Flinders Medical Centre in the past few weeks. Last Friday I was at an EMST course at Flinders and heard that the Director of ED, Dr Di King had resigned after being called into the CEOs office and asked to guarantee that ramping would not occur.  Of course this is impossible – Dr King has no more control over this than anyone else – the solution lies with the CEO and Minister of Health, not the ED Director. And so Di resigned, putting more pressure on a beleaguered Health Minister.

Yesterday Dr Dave Teubner came out and said it was safer for people to remain in an ambulance than to be seen in the ED. Dave is a passionate ED doc…he is not some hopeless academic, but a chap who really gives a damn. He is of course correct – it is better for people to be at least in an ambulance with oxygen, suction and a paramedic than lost in a corridor in the ED, unobserved and awaiting assessment or treatment with access to neither.

In essence, the whole idea of a well run health service should be to ensure that care is escalated with every referral. It is frankly dangerous to have care take a step downwards from ambulance to ED, as is the case at FMC when under bed pressure.

This is a concept that is a particular hobby horse of mine – the idea of ensuring there is never a ‘therapeutic vacuum’ or ‘inertia of care’. Every single thing we do should improve patient care, not stall it or even detract from it.



Certainly people admitted to an ED should see an increase in the level of care delivered to them. And so on…every single doctor, nurse, paramedic is doing his or her utmost to make this happen.

But the system seems to conspire against us.


And of course this is not just about ramping in the ED. It also applies to rural medicine, to the operating theatre, to in-patient care and to discharge.

Like many people working in health, I get hot-under-the-collar bemoaning failures in ‘the system’ where things could (and should) be better. Particular bugbears include 
  • lack of equipment to manage a difficult airway in rural EDs and theatres
  • lack of ownership of equipment and emergency training for rural staff
  • cost-shifting between State and Commonwealth coffers for ED patients
  • lack of discharge summaries from people who have been admitted and discharged from metro hospitals
…and so on.


What can we do to improve things?


Well, political pressure is one – I would imagine that Dr Di King’s resignation has served to highlight the issue locally and perhaps prod the Health Minister into action. 


More so, we can engage and try to make things better. I’ve been revitalised in the past few months by some of the information coming through the blog-o-sphere, with concepts of relevance to my practice that one is not going to get from a textbook or clinical placement. So I’ve done a survey on difficult airway equipment for rural GP-anaesthetists. I’ve offered to run some small group scenario-based sessions for nursing staff at the end of each of my anaesthetic lists and whenever I am on call for A&E. And I’ve been developing a web-based repository of emergency training for local use…how to set up the oxylog, where to find and use the rapid rhino kit for dealing with an epistaxis, a dump mat for RSI etc.


Another new idea is borrowed from the UK – a ‘one minute wonder’ fortnightly update on topics of relevance for our multiskilled rural nursing staff – basically a single A4 poster explaining how to find/set up/use a piece of ED equipment – displayed on the wall above the iStat machine to give people something to read whilst waiting for the iStat or Troponin reader to do it’s stuff.


Small things, but they might make emergency management in the bush easier.


Of course, the astute reader would wonder why these initiatives are not flowing ‘top down’. It would seem intuitive to have a minimum standard of airway equipment in rural hospitals, to have standardised ED kit and protocols, to train staff in equipment use beyond the token annual ALS refresher.


But this doesn’t happen. Change takes time, there needs to be initiative and drive, and solutions need to be appropriate to the local situation.



Anyone else got any pointers to drive change and improve emergency management in rural areas?

Emergencies & GP after hours

Well there’s an interesting article this week from Emergency Medicine Australia (Nagree et al 2012 ‘Telephone triage is not the answer to ED overcrowding’ EMA 24 123-126) as well as a media release from the Australasian College of Emergency Medicine regarding triage.

Before rural medicine I was an EM trainee. I’m pretty passionate about emergency medicine – sadly one of the reasons I got out of the specialty was frustration with things I could not control, not least the phenomenon of ‘access block’ – too many people in the ED, waiting for beds on the ward. I must admit that as a junior doctor I would bemoan ‘GP-type’ patients clogging up the ED…but as time went on and I matured clinically, I realised that:

(a) these low acuity problems were quick and easy to fix
(b) they were not a burden on time or resources
and
(c) often even the low acuity patients had complex health needs that required admission to a hospital for sorting out.

As a rural doctor I do my utmost to avoid turfing patients unnecessarily to my overworked colleagues in the ED, trying to smooth my patients’ admission to the appropriate unit without them having to be stuck on a trolley in the ED awaiting review.

Whilst it is tempting to imaging the ED clogged up with non-urgent problems, the reality is that such presentations are easily dealt with (even the most junior of resident medical officers can treat a UTI or reassure parents of a child with otitis media). What clogs up the ED are complex patients requiring investigation and admission, as well as the labour and resource-intensive presentations such as critical illness.

It’s also relevant to the ongoing issue of what is and what isn’t an emergency – with a blatant cost-shift between State and Federal funds trying to classify many ED attendees as ‘inappropriate GP-type attendances’.

But there is a problem.

Politicians need to be seen to ‘do something’. They have latched onto the concept of the idea of triage 4 and 5 patients as being GP-type attendees and in a non-evidence based approach have poured hundreds of millions into schemes such as GP after hours, co-located clinics and the disastrous healthdirect phone line.

Phone triage sounds good. But it doesn’t work – experience from overseas (not least the ill-fated NHS-direct in the UK proves this). Put simply, a nurse or a GP following a protocol will not be able to diagnose over the phone 100% reliably. It may be a sop to the worried well, but my grandmother can do this job just as well and won’t cost the estimated $200 million that healthdirect costs the taxpayer.

The Health Minister has stated that healthdirect has deterred 30,000 patients from a million calls from visiting the ED. Sounds good…but that’s only 3% of calls…surely better to spend that money on beds and more clinical staff…not a phone service.

We don’t do phone triage in the ED, instead advising patients to present to the ED for a face-to-face assessment – because it is a safe approach – history and examination cannot be done reliably over a phone. In fact, the more medicine I do the more I realise how medicine doesn’t fall into neat protocols or boxes. The skill of a good Emergency Physician or GP is to spot the severely abnormal amongst the morass of mostly normal. A protocol (or my grandmother) will get things right most of the time – but will miss the more unusual or atypical presentations. The UK’s NHS-direct has learnt this, with several lawsuits after missed diagnosis – the headache that was a subarachnoid, the febrile child with meningitis etc.

So Prof Nagree’s paper neatly debunks the idea that phone triage alleviates pressure on Emergency Departments. What then of triage as a measure of ED vs GP-type attendances?

Triage is a score of urgency of treatment – not complexity. Many triage 4 or 5 patients have been sent to the ED by GPs. To then proclaim that they are ‘GP-type’ attendances misses the point that such patients are complex, require extensive investigation (usually using facilities not present in a GP surgery, such as X-ray, bloods etc) and often require admission.

This may not sound like a big deal – but it is an issue in the country where patients who are not admitted are charged a fee for attending the ED, on the spurious basis that they represent routine General Practice.

Which then raises the issue of GP After Hours services – what is the appropriate level of service needed after hours and will pumping money into GPAH alleviate pressure on EDs?

The Government clearly thinks so and is throwing around money like a drunken sailor. We met with the Medicare Locals mob last month on Kangaroo Island (formerly they were the Southern Division of General Practice in Adelaide, then GP-Network South, and now the unwieldy Southern Adelaide-Fleurieu-Kangaroo Island Medicare Local). They were canvassing opinion on GPAH services but seemed to have no grasp of the issues locally nor how to address them.

I always think of GPs like plumbers – you need us during working hours for scheduled things like routine maintenance…but we might have to deal with the occasional urgent job like a dripping tap. However you don’t really need these things fixing at 3am. On the other hand, if the hot water service blows up or a water main bursts, this needs to be dealt with. These are the medical equivalent of an emergency medicine service and as rural GPs we provide this too. However is this routine GP or is this an emergency?

I’m a simple chap – I think that primary care generally deals with most things…but if it cannot wait 12 hours or needs the services of a hospital then the problem is ipso facto an emergency.

Nagree’s paper establishes that phone triage does not alleviate pressure on EDs – the issue is access block, not inappropriate attendees. The corollary is that most patients are in ED because they belong there – throwing money at afterhours services by GPs doesn’t really address their complex health needs requiring hospital services (imaging, same day bloods etc)

However the issue of non-admitted emergency patients remains unaddressed. I can cite numerous examples (not least from the current busy Easter weekend oncall as I type) of people presenting appropriately to the ED – but being forced to pay for their attendance because they are not admitted (State Govt cost shifts to Medicare)

Examples include

– fall from a roof, 25 cm incisional wound requiring formal debridement under local anaesthesia and repair taking 90 minutes

– fall from a horse with possible cervical spine injury

– four tourists in a medium speed (60kph) rollover on unsealed road, presenting to hospital for forensic blood alchohol, assessment of injuries

– 13 year old fall from skateboard with angulated Colles fracture requiring manipulation and casting

– mental health patient brought in by Police for assessment

– 45 yo with ?fracture-dislocation shoulder requiring analgesia, X-ray and reduction

All of these patients chew up a few hours of time. I think they were appropriately seen within the ED and not deferred for a routine 15 min GP appointment in the week.

However the false reliance on triage as a marker of GP vs ED attendance will continue to encourage misguided strategies to reduce ED overcrowding that are doomed to fail. It also allows cost-shifting from State (emergency) to Medicare (GP) budgets.

As ACEM say “it is in the political interest of State governments to ensure that any definition of general practice patients seen in EDs yields high numbers. This helps perpetuate the myth that EDs have too many GP patients’

Quite.

What do others think?