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.

Barbie-as-the-Princess-and-The-Pauper-Erika-doll-and-Book-Giftset-barbie-movies-26992568-1500-1500

 

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!

 

 

 

The Four Yorkshiremen

Some of you may have read Ian Beardsell’s parody “What has Twitter ever do for us” (a take on Monty Python’s “What have the Romans ever done for us?”) – a nice synergy of humour and Emergency Medicine at StEmlyns

I had always thought that “The Four Yorkshiremen” was vintage Python – but the original pre-dates Python and comes from “At Last the 1948 Show” with John Cleese, Graham Chapman, Tim Brooke-Taylor and Marty Feldman.

The sketch is simple – four wealthy Yorkshiremen reflect on their current good fortune relative to their childhood humble beginnings, with each trying to out-do the other in terms of hardship.

This is EXACTLY what happens when a bunch of senior doctors get together and reminisce about their times as junior doctors. I trained in the UK and am still bitterly resentful of a system that saw overtime paid at 1/3rd of usual hourly rate on the basis that were ‘on-call’ only.

Whilst this may have worked for pre-1950s medicine when thngs were quiet, my recollection of on-call was a shift that started 7am Friday and ran through til 7pm Monday, resident in-hospital and working as a Firm (Registrar-Senior House Officer-House Officer) admitting in-patients. Each day we walked 10 miles of wards, admitted 20-30 patients and sleep was rarely more than 2-3 hrs at most, interrupted by bleeps to either do mundane chart re-writes, re-site IVs…or else be involved in managing critical patients. Why, my first night on-call as an inten, I was taught how to put in an IJV central line by my reg…then left alone to do another three on the wards within the next six hours, unsupervised.

Of course, you tell that to the young doctors of today and they wont believe you…

 

How might the Four Yorkshiremen Medicos discuss their junior doctor years?

 

The Scene:

Four well-dressed men are sitting together at a vacation resort. ‘Farewell to Thee’ is played in the background on Hawaiian guitar

 

FIRST YORKSHIREMAN: Aye, very passable, that, very passable bit of risotto.

SECOND YORKSHIREMAN: Nothing like a good glass of Château de Chasselas, eh, Josiah?

THIRD YORKSHIREMAN: You’re right there, Obadiah.

FOURTH YORKSHIREMAN: Who’d have thought thirty year ago we’d all be sittin’ here drinking Château de Chasselas, eh?

FIRST YORKSHIREMAN: In them days we were just young interns, glad to be getting our first pay cheque

SECOND YORKSHIREMAN: Aye, we were paid a pittance mind

FOURTH YORKSHIREMAN: Aye, I remember the more we worked, the less we got paid!

THIRD YORKSHIREMAN: Paid? I would’ve done it for free

SECOND YORKSHIREMAN: But you know, we were happy in those days, though we were poor.

FIRST YORKSHIREMAN:Because we were poor. My old Consultant used to say to me, “Money doesn’t buy you happiness, lad”.

FOURTH YORKSHIREMAN: Aye, ‘e was right.

FIRST YORKSHIREMAN: Aye, ‘e was.

FOURTH YORKSHIREMAN: I was happier then and I had nothin’. We used to live in this tiny old hospital flat with great big holes in the roof.

SECOND YORKSHIREMAN: Flat! You were lucky to live in a flat! We used to live in one room, all twenty-six of us, no furniture, ‘alf the floor was missing, and we were all ‘uddled together in one corner for fear of falling.

THIRD YORKSHIREMAN: Eh, you were lucky to have a room! We used to have to live in t’ corridor!

FIRST YORKSHIREMAN: Oh, we used to dream of livin’ in a corridor! Would ha’ been a palace to us. We used to sleep in the sharps bin!

FOURTH YORKSHIREMAN: Well, when I say ‘flat’ it was only a hole in the ground covered by a sheet of tarpaulin, but it was a flat to us.

SECOND YORKSHIREMAN: We were evicted from our ‘ole in the ground; we ‘ad to go and live in the sluice room. Every shift change we’d be woken up by the ward matron pouring a steaming pile of shite onto our heads.

THIRD YORKSHIREMAN: You were lucky to have a sluice! There were a hundred and fifty of us camping out in the ED.

FIRST YORKSHIREMAN: In the ED?

THIRD YORKSHIREMAN: Aye.

FIRST YORKSHIREMAN: You were lucky. At least you got to work when living in ED. On my surgical rotation we lived for three months in an occupied box in the Morgue. We used to have to get up at six in the morning, clean the corpses, eat a crust of stale bread, go to work in Theatre, fourteen hours a day, week-in week-out, for sixpence a week, and when we got back to the Morgue the senior Consultant would thrash us to sleep wi’ his belt.

SECOND YORKSHIREMAN: Luxury. We used to have to get out of the sluice at six o’clock in the morning, clean the toilet pans, eat a handful of ‘ot gravel, work twenty hour day on Geriatric ward for tuppence a month, come home, and Consultant would thrash us to sleep with a broken bottle…if we were lucky!

THIRD YORKSHIREMAN: Well, of course, we had it tough. We used to ‘ave to get up out of ED at twelve o’clock at night and lickthe patients clean wit’ tongue. We had two bits of cold gravel, worked twenty-four hours a day in ED for sixpence every four years, and when we finished the Nurse Practitioner would slice us in two wit’ bread knife.

FOURTH YORKSHIREMAN: Right. I had to get up in the morning at ten o’clock at night half an hour before I went to bed, drink a cup of sulphuric acid, work twenty-nine hours a day in ICU, and pay that prick Monty Mythen [*] for permission to come to work….and when we finished, the Senior Reg would kill us and dance about on our graves singing Hallelujah….then defibrillate us and start all over again

FIRST YORKSHIREMAN: And you try and tell the young doctors of today that ….. they won’t believe you.

ALL: They won’t!

 

[*] with apologies to Monty Mythen – most definitely NOT a prick! Along with Mervyn Singer & Monty as supervisors, I was privileged to have one of the first ever rotations in anaesthesia/ICU as a house officer in UCL (tradition was for 6/12 medicine, 6/12 surgery rotations – I am grateful that my 6/12 surgery sentence was halved to 3/12 surgery and 3/12 anaes/ICU). Monty & co were great…I think I’ve managed to get most of the methylene blue out of my scrubs since…

More smaccTALKS

Well the smaccGOLD talks are gaining momentum – I was gutted to miss John Hinds on the cricoid debate (so many good concurrents, so little time), but thankfully smaccTEAM are doling out the FOAMed love by making all talks available for sharing.Here’s Hinds on cricoid, Mallemat on fluid responsiveness and Weingart on cardiac arrests.

Gold, pure Gold.

JOHN HINDS – CRICOLOL

HANEY MALLEMAT – FLUID RESPONSIVENESS

SCOTT WEINGART – INTRA-ARREST CARE

 

Log Roll “1-2-3″ or “Ready-Brace-Roll”?

The topic of log rolling is one that rises it’s head from time to time in trauma discussions; we teach it on EMST as a routine … and there is often heated discussion on these courses about when to do a log roll (is it part of ‘C for Circulation’ to identify the hidden stab wound in the back? Or is it part of ‘E – Exposure’ to ensure full undressing and inspection for wounds, with a segue into the secondary survey?)

Log Roll - another dogma in trauma management. Now - who is going to do the PR?
Log Roll – another dogma in trauma management

To be honest, I don’t really mind when a log roll is done. Sooner rather than later, providing it doesn’t impact on initial assessment and the primary survey (whether you use ABCDE, C-ABC or my preferred, the MARCH approach).

Given that it is best to avoid repeated handling of the trauma patient (I am a big fan of scoop mattresses and early application of ‘splint-to-skin’), it makes sense to me to get the clothes off and inspect the back of the patient as soon as possible…assuming other priorities such as airway protection, finger or tube thoracostomy & fluid resuscitation are under control.

 

scoopstretcher
Forget rigid ‘spinal boards’ – use a scoop mattress and vac mat for your trauma patients

 

In a rural location, I am often dealing with well-meaning volunteers (ambulance officers and fire brigade, or even passers-by).

Even in the relative luxury of a rural hospital, the art of moving a patient whilst maintaining spinal precautions is not something we ever practice. Which raises a problem – how to clearly communicate the necessary steps

“OK everyone, we’re going to roll on the count of THREE…one…two…three”

How often have you heard this instruction? It seems clear enough, right?

Maybe it is…maybe it isn’t. My experience is that even when this command is clearly articulated, about 50% of people will roll on THREE…and 50% will roll on the implied fourth beat (“1-2-3-roll”). Which can be disastrous when the patient has a spinal injury. It can also injure team members who may not be ready themselves. I remember one anaesthetist who used to just bark  ‘Right 1-2-3-go’ and woe betide anyone who wasn’t ready. Lines got pulled out, staff got back injuries. Did he notice? Of course not, he was Team Leader and a Consultant – who could dare challenge his authority?.

 

Bomb on the toilet? Adds more stress to a pre-resus 'battle crap'
Bomb on the toilet? Adds more stress to the ‘battle crap’ notion

 

It’s a bit like that infamous scene from Lethal Weapon 2 (25 years ago…OMG) when Detective Roger Murtaugh (Danny Glover) discovers a bomb hidden on the toilet and fellow Detective Martin Riggs (Mel Gibson) decides on the bold move of pulling him off the toilet seat…the whole scene revolved around the question of whether to go on ’3′ or not?

Of course it’s not just about safely log-rolling the trauma patient…clear instructions are essential in theatre when sliding the patient from operating table to recovery trolley, when lifting a patient from the floor onto a bed after a fall…or in the resus room when sliding the patient from ambulance trolley to bed..as well as in the CT scanner. So many potential moves, so much potential for harm.

Which is why I abandoned the ’1-2-3′ crap many years ago and instead always use the command ‘ready-brace-roll’ (or slide/lift etc).

I think this works really well. First up, it offers a stop point (is everyone ready?). Second, it is clear what we are going to do (lift/roll/slide) and more importantly WHEN we are going to do it. And for my menopausal nursing staff, it protects their sagging pelvic floors (I’m gonna pay for that jibe…). So, here’s how I do it :

“OK everyone, we are going to move Mr Creosote from the theatre trolley to the barouche. The command is going to be “ready-brace-slide”, with us moving on “slide” [said in a loud voice]

Now then, is everyone READY? [pause and wait for verbal acknowledgment from ALL team members - it is amazing how often this allows someone to say "No, I am not ready" - which is a good thing as this helps avoid inadvertent line displacement or back injury]

“OK everyone, BRACE” [ensure pelvic floors braced, backs ready, arms tensed]

“OK everyone, let’s SLIDE” [patient slid across on "slide"]

I do this for every case in Theatre…and although my colleagues may take the piss 9there is some resistance to this, amazingly), I find that it translates well to ED and to the roadside, especially when working with an unfamiliar team.

Of course you can substitute SLIDE with ROLL or LIFT as appropriate. Try it – it may make log rolling of your trauma patient just that little bit less random…and save both your continence and your lower back for the future!

In a trauma, clench those buttocks & maintain pelvic  floor integrity
In a trauma, clench those buttocks & maintain pelvic floor integrity

“Sleeping with the Fishes” smaccUS June 2015

Sleepin' with da fishes
Sleepin’ with da fishes

 

Sydney’s smacc2013 was hailed by Mike Cadogan as “the birth of FOAMed” (the conception being ICEM2012); rather than just ‘five guys in a bar talking about Twitter’, this conference raised the bar for inspiring those who care for the critically unwell patient.

smaccGOLD built upon this – breaking down the traditional tribal barriers that are inherent in medicine and drawing on experiences of not just doctors, but nurses and paramedics. The interlinking of likeminded persons via social media in the lead up ensured that the conference was abuzz with interactivity and minimal displays of traditional hierarchy.

Ugly Mug
Where else could a rural doctor mix it up with intensivists?

2015 sees the conference head overseas – smaccUS in Chicago.

NOTE THE DATE HAS CHANGED – SMACC WILL NOW BE IN CHICAGO – JUNE 23-26 2015

SMACC 2015 Move to June (1)

[Please note that KIDocs.com on the flyer is incorrect - use KIDocs.org &/or RuralDoctors.Net instead!]

FOAMed is now embedded in the critical care and emergency medicine fields; yet it has so much more to offer outside of this. It was god to see a smattering of rural doctors at smaccGOLD – I hope that there will be a larger contingent at smaccUS, especially from our Canadian rural doctor cousins … the workload and skillset of rural Aus and Canadian docs appears very similar.

Regardless, other specialities could learn a LOT from how smacc is run – inclusive, clinically relevant, interactive and fun!

Hope to see some of you there! With old mates like Mark Wilson there, it’s going to be a KNOCKOUT event…

…if you can’t make it – might as well be “sleeping with da’ fishes” as Al Capone would say.

Last word to Damian Roland commenting from smacc2013 via Rob Rogers…

 

End of Life Care

Here is another of the excellent talks from the smaccGOLD conference. Breaking down the ‘tribal’ barriers, this panel presentation included intensivists, emergency physicians and a social worker

A glaring omission was a general practitioner – it was good to see a fair few fellow rural doctors at smaccGOLD – and as well as intersecting spheres of interest in intensive care, our very ethos is cradle-to-grave care

It is a privilege as a rural doctor to be involved in palliative car e- as well as primary care, in-patient care and emergency presentations. I think that primary care doctors can do a LOT to pre-empt difficult conversations – by early discussion of reasonable treatment ceilings and advanced care directives.

We may discuss these in our primary care…then re-visit them at the ‘pointy end’ when on call for emergency – then be involved in either pushing for maximally aggressive care via resuscitation and retrieval…or by appropriate palliation – often the preferred option for rural patients who may value a dignified death in own location over an protracted and invasive barrage of procedures in a tertiary ICU.

Hopefully smaccUS will include some input form rural practitioners in similar discussions where spheres of interest overlap.

The highlight of this talk was the very wonderful Liz Crowe – she really wowed the audience…

See if you agree!

 

ADDIT : @SarahWerner_NZ has correctly identified that there was nurse representation on this panel – a good point. It was however a wonderful thing to see that smaccGOLD overall was incredibly inclusive – doctors, nurses, paramedics, students etc all with something to give. Highlight for me was Tamara Hill’s short pecha kucha submission, entitled ‘17 Minutes

Brazil on Medical Tribalism (smaccGOLD)

Whilst firmly aimed at clinicians with an interest in critical care, smaccGOLD was unique in that it was a high-level critical care conference that aimed to break down barriers between the various medical tribes – regardless of whether one is an intensivist, an emergency physician, a doctor, a nurse, a paramedic, a student – heck, even a rural doctor – we ALL share an interest in this field.

Vic Brazil opened with a powerful Keynote on tribalism in medicine – worth a watch, even if you are not a critical care clinician :

Hopefully more medical conferences will adopt the smaccGOLD format – short, inspirational lectures acrss disciplines and breaking down traditional professional boundaries.

Damian Roland put this well in a short interview with Rob Rogers from the smacc conference, setting the scene for smaccUS in Chicago, 2015

 

 

Thanks Minh!

Reckon it’s been a couple of years since I came across this “promiscuous blogger” who continues to impress me with knowledge, critique and good sense

 

So was delighted to receive a DM from Aidan @LittleMedic :

5O0twAGM.jpg-large

 

Keep up the good work – thanks Minh!

Rural Critical Care Pearls

The work of a rural doctor includes not just primary care but also emergency medicine, palliative care, obstetrics, anaesthetics and some surgery. Often with no option to refer to specialist colleagues immediately to hand, rural doctors have to train to be a true ‘swiss army knife’ rather than a finely-honed scalpel. Casey Parker covered this nicely last year at smacc2013 in his ‘Macgyver Dilemma’ talk.

Readers of this blog, or anyone who was unfortunate enough to hear my profanity-laden talks at smaccGOLD, will know that I am a fan of the maxim “critical illness does not respect geography’.

My mission is to improve the quality of critical care in the bush – inspired mostly by colleagues like Minh le Cong in Queensland and Casey Parker in Broome. Dealing with critical care, whether polytrauma, sepsis or cardiac catastrophe can be stressful for the occasional operator – nevertheless, it is a core skill expected of rural clinicians and one which I am determined to make better. With no disrespect to my intensivist colleagues and their machines that go ‘ping’, it seems that most critical care comes down to doing the simple things well. The results from the ProCess trial reinforces this concept, as do easy to remember acronyms such as FAST HUGS.

The initial management of critical illness should not be feared by rural clinicians

Courses such as ATLS-EMST, APLS, RESP (REST) and ELS set a minimum standard, usually for credentialling purposes. But they do little to advance skills in managing critical patients. Thankfully FOAMed helps – the sharing of tacit knowledge amongst clinicians, as well as shortening the knowledge-translation gap.

For me, the past 2-3 years have been evolutionary & revolutionary – learning and applying techniques such as apnoeic diffusion oxygenation, tweaking ventilation strategies, exploring dogma around C collars, log rolls, sepsis and so on have reinvigorated my thirst for knowledge. I’ve also delved into areas such as human factors and the science of checklists, which I would never have expected. Difficult airway management and kit for the bush has become my passion.

So here are some (hopefully humorous) collection of tacit knowledge for the occasional operator – the rural clinician who deals with critical care infrequently but needs to sort out his or her patient and package them for retrieval. You can find more solid stuff over at ruraldoctors.net or take the plunge and dive into the FOAMed community – blogs such as lifeinthefastlane.com or via Twitter. There is also an excellent podcast on patient preparation over at prehospitalmed.com from last year

 

The ABCs – Always Be Cool

Have a system to give structure to your resuscitation of the critically ill. The ABC approach works for most and is fairly uniform across the LS courses. You can extend the ABC paradigm all the way down to N as part of a transfer checklist

The cool kids are using C-ABC now (control of massive haemorrhage ie : circulation before airway) …or you may decide to get radical and use the ATACC mnemonic for trauma, MARCH

  • Massive haemorrhage
  • Airway
  • Respiration
  • Circulation
  • Head trauma & other serious injury

Systems and checklists are useful – particularly in a crisis. They are a ‘check done’ for experts, not a ‘how to’ for novices. Don’t get me started on checklists – if Minh hears. there might be another twitter war…

So – Airway, Breathing, Circulation. Or Arrive, Blame, Criticise. Or Always Be Cool. Your choice. One of my more cynical colleagues used to say “if you are stuck with a critical patient and have no idea what to do, wait ’til he/she arrests – then you’ll have an algorithm to follow”. This nihilistic approach kind of distills all of clinical medicine into one algorithm, but is NOT recommended!

Its easy to poke fun at ATLS-EMST. It provides a system for entry-level trauma management, but is slow to respond to change and doesn't cover trauma team management. I'd recommend ATLS-EMST initially, then graduate to ETMcourse or ATACC
Its easy to poke fun at ATLS-EMST. It provides a system for entry-level trauma management, but is slow to respond to change and doesn’t cover trauma team management. I’d recommend ATLS-EMST initially, then graduate to the ETMcourse or ATACC. Follow sites such as trauma.org, resus.me, scancrit.com, prehospitalmed.com for more discussions

Be aware of new developments and controversies – the concept of dogmalysis. Are cervical collars needed for all trauma victims? What about log rolls and the ATLS-mandated rectal exam? Click the links to read more from the excellent ScanCrit.com

 

You Are Never Alone

Australia is blessed with excellent Statewide retrieval services. Pick up the phone and speak to a colleague if you have concerns. Even if your patient doesn’t need retrieval, speak to a friendly ED consultant in ay of the major teaching hospitals.

Use adjuncts like a handsfree telephone so you can talk whilst still doing things (placing lines, drawing up drugs); better still, use a video link so that colleagues can assist you by seeing the patient as well as yourself.

I had a play around with GoogleGlass during smaccGOLD and there are plans afoot to run collaborative resus using this novel technology.

GoogleGlass - could revolutionise remote area resus
GoogleGlass – could revolutionise remote area resus…depending on the muppet wearing ‘em!

Of course, if you do ask for and receive expert advice, for heaven’s sake follow it! There’s nothing worse than a therapeutic vacuum…

 

Avoid Clinical Inertia or a Therapeutic Vacuum

I could wax lyrical about ‘anticipated clinical course’ for hours. But put simply, make sure that everything you do ‘value adds’ to patient care.

Similarly do not delay performing essential steps – nothing summons the ‘red mist’ more than a clinician who defers performing a simple procedure (like placing an arterial line or IDC) on the logic that ‘the retrieval team will do it for me’ (unless of course you are not competent to do the procedure – in which case, wait for someone who can!)

  • If you even think of intubating, you probably should set up for an RSI
  • No one ever regrets putting in a large IV; plenty regret putting in a small one
  • You’ll never regret putting in an extra cannula
  • Or an arterial line

 

Beware the Tangle Fairy

The monitoring cables & lines always seem to be totally tangled by the time the patient gets to ICU no matter how careful you are in ED. As well as ensuring two functioning (wide-bore) IVs, use minimum volume extension sets to run infusions and for small titrated doses. Plumb these to the head end, for easy access during transfer.

 

Secure All Tubes & Lines

This is obvious – I knot my ETT tubes (but make sure shears are to hand for removal); I am obsessive about securing IVs (I occasionally use a dab of use histacryl glue – and routinely use a mesentery on lines in at least two places to avoid accidental dislodgment)

 

Remember Mad-Eye Moody – practice Constant Vigilance!

Just when you think everything is under control & relax a bit, the Gods of EM will kick you in the teeth. Very hard. Usually on the ‘easy’ patient not the one you are worried about.

Act like the Mad-Eye Moody character (from Harry Potter) and practice ‘constant vigilance’ against the dark forces

I rarely get to meet the medical retrieval consultants (they are just a voice on the line) - but I reckon there's a couple who might look like this
I rarely get to meet the medical retrieval consultants (they are just a voice on the line) – but I reckon there’s a couple who might look like this

 

Trust Noone, Assume Nothing

Speaking of dark forces, whether handing over to retrieval or taking over care from a colleague, make sure that you have the history and examination findings firmly embedded in you mind. Don’t be afraid to ring ahead even when retrieval takes your patient away, and speak to the clinician at the receiving hospital

 

The patient is the one with the disease

That is of course a direct quote from the ‘House of God’. For the critically unwell patient, I think of it as :

“I can make a good pig out of a bad pig, but I can’t make a pig out of sausages”

Generally if the patient is awake, warm, pink and dry, they`re alright. Or you can use Clifford Reid’s 4W’s of sepsis

  • warm
  • wakeful
  • weeing
  • wactate

 

Look after Yourself & your Team

The enemy of success is HALT – being Hungry, Angry, Late or Tired. If you are going to be in a prolonged resus or retrieval, make sure you have an empty bladder and a full stomach. Don’t turn down the offer of a coffee.

Similarly if you are a rural doctor on for the interminable Fri-Sat-Sun shift and have had a big resus eeping you up all night, delay the morning ward round by a few hours and ensure the triage RN doesn’t call you for trivia – catch a few zzzzzz’s.

 

Learn from your Mistakes…or use FOAMed

Experience allows you to make good decisions. But experience is often gained by making bad decisions…be proactive and use FOAMed to tap into the collective wisdom of clinicians worldwide.

“Experience is what you get just after you needed it”

I believe that tapping into FOAMed helps make me a better clinician – simple things, like action cards in the ED, use of a crisis checklists, team training and use of sim, apnoeic diffusion oxygenation, difficult airway planning & kit, minimal volume resus, tranexamic acid and so on – these are all things that I’ve picked up through FOAMed, not annual refreshers or mandatory credentialling.

Similarly learn directly from the experts – make sure you are there to handover the patient to retrieval (yes, yes..I know – if a patient is sick enough to be retrieved then you’d think that a doctor would remain with them, but occasionally once stabilised the attending rural doctor will be called away to other patients).

I think it’s important for rural doctors to be involved in audit of difficult cases. Our local Health Service mandatory annual audit mostly consists of making sure appropriate paperwork has been completed for expected deaths in the nursing home – not audit of critical care & retrieval cases! Changing that culture is but one way to strive to improve, not just individual clinician care but a whole systems approach (right equipment, training etc). Again FOAMed delivers tangible benefits much quicker.

Any more pearls from the collective?

FOAMed & Homeopathy

FOAMed is powerful medicine. I recently tweeted on ‘what I love about FOAMed’ :

#1 : information is a commodity…yet everything is free. Share the love…

#2 : sense of community, common passion for improved patient care & advancing via education

#3 : adding finesse, refining practice based on shared tacit knowledge..

#4 : it’s asynchronous. I can keep updated in own time, podcasts/vodcasts/blogposts rather than in real time

This is all well and good – free open access medical education helps experienced clinicians share information..and is invaluable for me as a rural doctor. But how about our patients?

The more enlightened I am as a clinician, the better I can deliver effective remedies. Which makes the recent report from the NHMRC on Homeopathy even more interesting.

Put simply, there is no evidence for the homeopathy as an effective remedy, compared to placebo. This is explained more at the ‘how does homeopathy work?’ website or the ten:23 site

I believe that as clinicians we need to educate our patients about this. Similarly we need to encourage health insurers to stop funding these remedies from our premiums.

Point your patients to the report HERE

We have medicine and alternative medicine.

What works, we call medicine. The rest – alternative.

When alternative medicine works, we call it…medicine

It’s time to stop subsidising these unproven “therapies”.  Tim Minchin summaries this in his infamous ‘Storm’ beat poem & animated video :

If you want to have a bit of fun, write to your health insurer and ask them to stop subsidising homeopathy with your premiums. Ditto stroll into the local pharmacist and ask them why they are selling placebo.

Let’s not kid ourselves, homeopathy and indeed other “alternative medicine” is big business. Whilst some patients are sceptical of ‘Big Pharma’, it is worth reminding them that the Alternative Medicine industry is equally a business with ulterior motives – and in the case of homeopathy, is selling water to the gullible.

It behoves us to critically appraise claims (both established and alternative) and to seek to improve based on the available evidence.

That is the essence of FOAMed – to improve clinical practice through critical appraisal to apply effective treatments.