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.

 

 

Are you a Good Samaritan?

I am sure everyone is familiar with the parable of the ‘Good Samaritan’. But consider this scenario :

It’s been a busy day. On the way home you notice a small knot of people gathered around a middle-aged person, prostrate on the pavement. The bystanders look uncertain of what to do.

Do you stop and help? 

Lay public are often uncertain what to do in an emergency - if you were nearby, wouldn't you want to help?
Lay public are often uncertain what to do in an emergency – if you were nearby, wouldn’t you want to help?

As clinicians we are trained in basic and advanced life support. Indeed for GPs, BLS is a mandatory component of triennial accreditation in Australia. Whilst there is as yet no legal duty to render assistance, I think there is a professional and ethical duty to assist, notwithstanding considerations of one’s own safety and training. Indeed Minh le Cong has blogged about some of the legal and professional obligations to render assistance over at the PHARM website. We know that early bystander BLS makes a difference, hence the successful campaigns to encourage lay public to ‘push hard, push fast’ (see videos at the bottom of this blogpost). But supposing this incident happened in the next street and was not witnessed by you. Wouldn’t it be great if there was a way to alert ‘good samaritan’ clinicians to such events?

Enter the GoodSAM App for smartphone

A group of smart clinicians are launching the GoodSAM app (SAM for Smartphone Activated Medics). The premise is simple – using the GPS-technology embedded in every smartphone and tablet, to create a network of credentialled BLS providers who can be activated to an incident and ‘crowdsource’ BLS before the arrival of statutory providers. If there is an out-of-hospital emergency, nearby registered GoodSAM responders are alerted via push notifications to smartphone. They can then elect to attend or not. The app is only active when turned on, so there is no onus to be ‘on call’ 24:7. Rather it plays to the inherent altruism in us all – after all, who would NOT assist if you were aware of an emergency in the immediate vicinity? The app is available as an ‘alerter’ and ‘responder’ version – only credentialled clinicians can activate as ‘responders’ – basically anyone with a BLS or clinical qualification can register (by showing proof of clinical registration or BLS/ALS credentialling)

GoodSAM app - goodsamapp.org
GoodSAM app – goodsamapp.org

But what’s the point? Aren’t the ambos supposed to do this?

Well yes – the last thing we want in the prehospital environment is a mob of “enthusiastic amateurs”. But the reality is that from activation to arrival of a paramedic response may take minutes – and if a cardiac arrest happened in a coffee shop next door, wouldn’t you feel guilty knowing that you had the skills to provide BLS but were unaware? If you are a paramedic, nurse or doctor it would be tragic to be sat next door, unaware of the crisis until you heard the sirens as paramedics arrive… There is a short (2 mins 30 secs) video from the developers of GoodSAM here https://vimeo.com/84266406 as well as FAQs from their UK and International websites below: http://goodsam.co.uk http://goodsamapp.org

Sneak Peek of GoodSAM at #smaccGOLD

"Neurosurgery for Everyone" from London HEMS Open Day
“Neurosurgery for Everyone” from London HEMS Open Day

I caught up with Dr Mark Wilson at the #smaccGOLD conference last month. Mark and I were in medical school together & podcasted last year on “Burr Holes in the Bush”. He has published a useful guide on “Emergency Burr Holes – How to Do It“. https://vimeo.com/64985630 Mark ran a slimmed down version of his ‘neurosurgery for everyone’ on stage at #smaccGOLD (I was the muppet doing the Burr holes). It’d be good to entice him to smaccCHICAGO – who knows, #simwars might include some more hands-on skills next year… Whilst Mark spent his medical school elective with NASA, is part of the Centre for Altitude, Space & Extreme Environment Medicine (CASE), conducted research on everest (Xtreme Everest) and carved out a postgraduate career in neurosurgery and as a HEMS doctor, I became a rural doctor on Kangaroo Island. Quite how his career derailed so badly I can’t say, but nevertheless Mark was gracious enough to show off the GoodSam app both in his excellent smacctalks and over breakfast. I reckon it took less than 30 seconds to get up and running; register on the website, punch in your AHPRA details and download the GoodSAM app – wham, you are good to go. GPS technology will alert you if there is a GoodSAM alert and guide you to the location. You can opt in/out according to availability.

GoodSAM pushes alerts to your smartphone, then guides you via maps
GoodSAM pushes alerts to your smartphone, then guides you via maps

Impact Brain Apnoea

Of course the GoodSam app is not just confined to cardiac arrest; Mark spoke about the phenomenon of traumatic impact brain apnoea – put simply, if sufficient force is delivered to the skull, then apnoea will be induced for a period of time, during which critical hypoxia will cause irreversible damage. The delivery of basic measures, such as jaw thrust and assisted ventilation by a BLS-accredited GoodSam responder, can bridge this gap and help ensure more favourable outcomes for neurotrauma.

Where to get it?

The App can be downloaded from the App Store and is available for iOS platforms – an Android version is expected soon. I should stress that the App is in soft launch phase currently – I would expect that avid users of #FOAMed and #smacc aficionados would be early adopters, with more mainstream uptake in months to come. When browsing the App store, just search for “GoodSam” responder app – be sure to look under the ‘iPhone’ tab (iTunes App store tends to classify by apps available either for iPad or iPhone – it will work on either, but is optimised for iPhone)

 Screen Shot 2014-04-05 at 10.01.47 am

Other applications

Smartphone technology is changing the way we work as clinicians. Most users of #FOAMed resources are using their smartphone or tablet to pull up clinical guidelines, useful websites, videos, podcasts and so on on a daily basis. I use my iPad in theatre and ED most days, showing short videos to stimulate discussion, running sims, accessing clinical resources or just keeping up to date. But the embedded GPS-capabilities allow extra function – Many retrieval services are on board with regularly updated SOPs, drug doses and location of landing sites for their retrieval practitioners. The Scottish EMRS service is a good example. It is also gratifying to see the more enlightened retrieval services placing their SOPs online for dissemination – this is invaluable for us rural clinicians who wish to meet the same standard of care for our patients as delivered by dedicated critical care services. HEMS SOPs from London GSA-HEMS SOPs (see under Resources tab) I was speaking last week with David Hogg, a remote area doctor on the Isle of Arran in Scotland about the UK BASICS scheme – smartphone location and activation of BASICS responders offers significant advantages over bulky pagers or expensive vehicle-location systems. However such applications are limited by mobile reception – this is a real issue in rural areas.  See the NO BARS initiative from ruralGP.com to improve the issue of limited mobile coverage. I think we will see more and more use of the embedded technology within our smartphones to deliver better patient care. GoodSAM is an interesting app – it would be wonderful to have good uptake of this by willing clinicians in both metro and rural areas, reducing time to BLS. Extension of the concept could allow much faster mobilisation of expertise in other scenarios, for example - smartphone location and activation of RSI-positive, equipped & trained RERN members to prehospital incidents (equivalent to BASICS UK) - smartphone activation of emergency responders for mass casualty or other incidents (bushfire, earthquake, tsunami etc) etc

My recommendation?

Download the GoodSAM responder app and have a talk to colleagues and lay public – they may wish to use the GoodSAM alert app for their friends & family. Through connectivity, we grow… GoodSAM website – International Contact via Twitter The developers seem very open to feedback. In Australia there is a slight hiccup, in that registration of doctors, nurses & paramedics requires supply of AHPRA registration – yet paramedics are not (yet) registered with AHPRA. Don’t worry – just register online and email GoodSAM who will authenticate by other means. As far as I know, registration is also available to other BLS providers eg: students, community first aiders etc on production of valid BLS credentialling. The potential to crowdsource BLS is huge. What a great idea!

Disclaimer

I am not an employee nor a beneficiary of GoodSAM.  There are other similar crowdsourcing BLS apps available – the PulsePoint Foundation app is a similar concept, costing between $5K-$25K depending on population covered. As far as I am aware, GoodSAM is free and as such should appeal to users of #FOAMed ! Other apps exist to guide the lay public through the process of BLS eg: the AHA first aid & CPR smartphone app or this from Ambulance Victoria

Ambulance Victoria App for lay public - learn CPR
Ambulance Victoria App for lay public – learn CPR

GoodSAM does not teach you how to do CPR – it is an app to deliver trained responders to the scene, not to assist novices.

CPR videos for the Public

There is concerted effort by National bodies to educate the lay public in hands only CPR. I see GoodSAM as complementary to this, adding trained responders to lay responders. After all, BLS – even hands only – is what matters.

There is no point in pre-hospital ECMO for OOHCA if the brain is dead through lack of early CPR!

American Heart Association – Ken Jeong “Hands Only CPR”

UK  British Heart Foundation – Vinnie Jones “Hard & Fast”

..and of course the “Mini-Vinnie’ spoof

Australian Resus Council – ‘Hands Only CPR – It’s Not Aeroscience

…which is much more sensible than the infamous ‘Chopper Reid’ CPR demo https://vimeo.com/91276464

Canadian Heart & Stroke Foundation – ‘The Undeading’

(actually – not so sure about that last one; it implies that CPR produces brain dead zombies…perhaps I will stick with a DNR decision)

You gotta have love…

I was 14 when I nearly considered deliberate defenestration. It’s probably the closest I’ve ever been to suicide, but the memory of the angst that made me contemplate this action is still vivid.

The Headmaster had asked each of the 30 pupils in our class to give a talk. I cannot even remember the details now, but the prospect of standing in front of my peers caused me so much distress that jumping out of a fourth floor window seemed easier. Kind compassionate man that he was, he recognised my distress and engineered the situation such that I did not have to speak…hence I am still here.

Since then I have struggled with confidence … particularly confidence in public speaking. I have worked to overcome this, such that now I quite enjoy giving a talk on something which I am passionate about (trauma, airway, rural medicine). But talking on the big stage at smaccGOLD was a huge hurdle for me.

Spot the Imposter. From L to R : LeCong, Leeuwenburg, Greenland, Weingart, Levitan & Reid
Spot the Imposter. From L to R : LeCong, Leeuwenburg, Greenland, Weingart, Levitan & Reid

For those that don’t know, smaccGOLD was the second ‘social medic and critical care’ conference, following the debut in Sydney last year at smacc2013.

 “Innovation, education and creativity at the cutting edge and beyond the confines of convention. This conference was delivered by passionate patient focused, idea-nurturing visionaries” 

via Dr Bishan Rajapakse’s #smaccGOLD reflections

As Mike Cadogan said, if FOAMed was conceived (like many great ideas) in a Dublin bar at ICEM2012, then smacc2013 in Sydney marked FOAMed’s birth. I spoke at smacc2013 on my passion of rural prehospital care & was invited back to smaccGOLD. Thanks to the convenors, I was privileged to be invited to help teach in the pre-conference Airway Workshop, to enter into a debate with Minh le Cong and to deliver another presentation on rural resus room management.

Like all of the other presenters, I poured my heart and soul into preparation, yet with the spectre of my fears on public-speaking still present.

You can see narrated slideshows of the checklist debate and rural resus room management talks by right-clicking highlighted links, or download PDFs from these links

“Real airway experts use checklists – pro” slide set and “Rural Resus Room Feng Shui” slide set.

Preparation for speaking at smaccGOLD was one thing; being nominated to participate in #SimWars was another…all the stress of being on a stage, with the challenge of overcoming fear of public humiliation due to failure. I was pushed far out of my comfort zone – and this was a good thing.

The crowd
The Crowd : 1300+ attendees at smaccGOLD
SimWars fracas
Team leader – this resus is really “grillin’ my corn!

Many people have asked me what makes smacc special. From fears such as those of Scott Weingart at smacc2013 that it was going to be “just five guys in a bar talking about Twitter”, smacc has evolved into THE leading critical care conference and is a wonderful demonstration of the power of FOAMed & Social Media.

Those who engage in FOAMed share a passion for advancing their craft, for sharing ideas and for education – in short, they strive to make themselves and the care of their patients “better”.

At the same time, it is not uncommon for people to experience fears – fear of sharing thoughts and work in a free, open-access format; fear of criticism of our expertise by those operating in another arena, fear of difficulty. My passion for FOAMed was predominantly driven by fear. Fear that as an isolated rural clinician I would be at risk of being the weakest link in management of my patients and friends.

My obsession about difficult airway management and critical care was borne from a ‘lesson hard learned’ – and a commitment to overcome both my own fear and ensure that harm does not befall any patient through lack of training, equipment or expertise. FOAMed resources, harnessed through the power of social media, enable us to engage in asynchronous learning from experts worldwide – and there is no longer any reason nor excuse not to be aware of the latest medical developments relevant to my practice.

“Fear is what drives much behaviour.

But I think we are best when driven by love”

The most important lesson that I’ve learned in medicine is to love your patients (no, not in that way!). A colleague taught me the power of a handshake when I was an ED registrar – not just as a formal introduction to each patient, but also to emphasise the symbolic nature that I am genuinely here to help you.The handshake is an affectation that I have carried on into my work in primary care…and along the way I’ve added other tools – sitting at patient level, giving the patient time, not being afraid to have the difficult conversations, showing empathy and ensuring we use names, not bed numbers.

This isn’t just about the doctor-patient relationship; it is also about how we interact and look after each other – we operate in different systems, and it is too easy to criticise colleagues or different craft groups without understanding their circumstances or challenges. And love is what mades smaccGOLD such a good conference.  Sure there were inspiring speakers, great slide sets and some excellent hardcore critical care research. But there was also love – a shared passion for critical illness, a willingness to laugh and cry and play together, sessions on end-of-life care and bariatric medicine that challenged us to really think about our values as clinicians.

smaccGOLD was set modelled around a tribal theme – a main stage set that mimicked a tropical island (akin to an episode of ‘Lost’ or ‘Survivor’).  Delegates and speakers strove to break down the traditional silos between us, to consider aspects of critical care from different perspectives – and to unite in common love for critical care and celebration of the joy of discovery.

Tribal opening
smaccGOLD – breaking down the silos in critical care – we are but one tribe!

 

Ultimately we are all human – and the power of empathy, compassion and shared humanity is what binds us. Was it practice-changing? Yes! The rapid dissemination of ideas via FOAMed and the global community of enthusiasts dedicated to bringing “quality care, out there” is achieving its goal.

“smaccGOLD – grilled my corn!”

I simply cannot think of another critical care, emergency medicine or indeed any medical conference that came even remotely close.

Thank you to all – the organisers, those who helped me overcome my fears, those who shared their love of critical care & humanity – and everyone who made time to come up and say “G’day”.

One tribe – we are critical care!

 

More reviews can be found at :

ITeachEM (Rob Rogers) Friendship, Motivation, Altruism

Manu et Corde (Eve Purde) Lessons from smaccGOLD

RoloBot Rambles (Damian Roland) smaccGOLD – it hurts!

LifeInTheFastLane day 1 – 3 summaries

PreHospitalResearch – Lessons learned from smaccGOLD  “bye,bye dogma – hello best practice”

NomadicGP (Penny Wilson) Pure Gold

Rebel EM (Salim Rezaie) – social media & critical care

Injectable Orange (Jesse Spurr) – smacc : punk rock, paeds, palliation & people

 

 

ONE TRIBE
One Tribe

Ugly Mug
Ugly Mug
Opening Ceremony
Opening Ceremony
Mark Wilson & GoogleGlass
Mark Wilson & GoogleGlass
Minh - a real airway expert
Minh – a real airway expert
John Vassilliadis' corn is grilled
John Vassilliadis’ corn is grilled
Ian Beardsell "does he have chronic pain?"
Ian Beardsell “does he have chronic pain?”
Cornered between Carley & Nickson "Is your swear box broken Tim?"
Cornered between Carley & Nickson “Is your swear box broken Tim?”

Rich Levitan in airway workshop, nasoendoscopy stream
Rich Levitan in airway workshop, nasoendoscopy stream
Neurosurgery for Everyone with mate Mark Wilson - Burr Hole demo
Neurosurgery for Everyone with mate Mark Wilson – Burr Hole demo

 

You're gonna do WHAT with that Cric-Key? Weingart plays fast n loose
You’re gonna do WHAT with that Cric-Key? Weingart plays fast n loose
Who's gonna be the mummy & who is the daddy? Karel Habig & Anthony Lewis arrive in same Jabba-the-Hutt costumes for #SimWars
Who’s gonna be the mummy & who is the daddy? Karel Habig & Anthony Lewis arrive in same costume for #SimWars
"Might as well shove it up your arse" from John Hinds in Cricoid debate
“Might as well shove it up your arse” from John Hinds in Cricoid debate
The laryngeal handshake - LeCong vs Chrimes
The laryngeal handshake – LeCong vs Chrimes
Rural Resus Room Mx
Rural Resus Room Mx
Carley goes wild
Carley goes wild
"Punk Rock, Top Gun & Emergency Medicine" - from Deniz Tek of Radio Birdman
“Punk Rock, Top Gun & Emergency Medicine” – from Deniz Tek of Radio Birdman