Capnography & Procedural Sedation

I’ve been a convert to use of ETCO2 monitoring for not just anaesthesia in the OT or ED, but also for procedural sedation. This is driven in part by results of the NAP4 audit and also from colleagues in the FOAMed world. Perhaps I am over cautious, but my use of ETCO2 extends to monitoring of the sedated psych patient, for whom I consider administration of agents such as IV midazolam (or occasionally ketamine) once olanzapine wafers have failed, to be a standard of care.

So I was surprised by the statement over at EMTrends.org suggesting “no benefit to routine capnography in procedural sedation”. You can read a summary of the paper here or look up the reference in Anaesthesia & Analgesia (2014) 119(1) 49-55.

This paper looks at patients undergoing minor gynae procedures by non-anaesthetists in a Dutch hospital. Interestingly NONE received supplemental oxygen (despite being administered propofol). The authors state that the incidence of hypoxaemic incidents in the 206 patients with ETCO2 monitoring was not significantly better the 209 patients for whom ETCO2 was not used.

Fair enough – until you look at the rate of hypoxaemia (SpO2 < 91%) in both groups:

25.7% with capnography

vs

24.9 without capnography

That is pretty poor IMHO.

 

For the record, I think I will continue to advocate for :

- routine use of supplemental oxygen if using neuroleptics

- routine use of capnography

 

You can read more about ETCO2 here - as my friend Casey Parker of BroomeDocs says “It gives you A-B-C in one squiggly line”

The Trainee Is Going To Land the Plane Today

I am obviously something of a medical dinosaur. I trained in the UK. Once qualified as a doctor, I spent a year as a ‘House Officer’ befoer being granted full registration with the UK General Medical Council (the term House Officer based on the time when newly qualified doctors were compulsorily resident on the hospital grounds). Career progression was fairly straightforward, from House Officer…to Senior House Officer…to Registrar (post Membership exams)…then Senior Registrar…then finally Consultant. The Australian system is similar, from Intern…through to Resident…Senior Resident…Registrar…Consultant (post Fellowship). I gather the Americans run along the lines of Intern-Resident-Attending.

But all has changed. Speaking to Brits looking to migrate to Australia to escape the imminent collapse of the NHS, I am increasingly befuddled by the newspeak nomenclature of doctors-in-training. They seem to refer to themselves as FY1/FY2s (or F1s, F2s), CT1s, STs. They are forced to jump through arcane hoops (what the Dickens is an ARCP?). Moreover, they seem to be universally referred to as ‘trainees’.

 

trainee

 

Hearing a doctor being introduced as ‘Steve the ST4 trainee’ makes it sound as if Steve is here on work expereince from the local school, rather than a fully-qualified doctor, with several years postgraduate training under his belt, Membership of the College of Physicians and only a few months away from being a Consultant.

Meanwhile, every other man-and-his-dog seems to be granted some sort of increasingly long job title - it seems that everyone is a Consultant nowadays, or a Specialist – even if that means they are a ‘Consultant Specialist Podiatric Surgeon’ (or podiatrist to you and me) or a ‘Senior Specialist Nutritional Consultant’ (or dietician).

Some Human Resources officers in NHS Trusts even insist that doctors are not allowed to put the title ‘Doctor’ (Dr) on their name badges as this ‘would be confusing for patients’ as they are ‘just trainees’.

This, for some reason, makes me sad. It also cements in my mind the utter crassness of ‘Human Resources’, implying that people are objects to be manipulated, like widgets…rather than individuals. Highly trained and professional individuals in the case of those undertaking postgraduate training in the NHS.

In these days of #hellomynameis, one would think that it would be important to be clear not just about one;s name, but also about one’s seniority (or otherwise) in the medical hierarchy. The progression from House Officer through Registrar to Consultant was fairly clear, even to the lay public.

I can only gather that the abandonment of the title ‘Doctor’ and the confusing mishmash of names, as well as the general all-encompassing naming of these doctors as ‘trainees’ is about control. It certainly isn’t about being clear to patients.

“Good evening ladies and gentleman. We hope you have enjoyed your flight on British Airways flight 4567. Jane the trainee will be landing the aircraft shortly”

Which would you prefer as a patient? To be operated on by “Steve the trainee” or “Steve, Senior Registrar to Mr Spratt”?

Names are important, as are titles. Use them. A recent survey on Doctors.Net.UK supports the profession’s preference for the abandonment of the generic term of ‘trainee’. Yes these doctors are still undergoing training – but lets not forget that they are already qualified as doctors and are undergoing an arduous postgraduate training. Referring to them as ‘trainees’ really does imply that they have wondered in off the street for a few weeks work experience and are not to be trusted.

You can access the survey results and comments here.

The author is on DNUK and remains anonymous.

 

EVO competition now open

Wondered what all the fuss is about regarding smacc, the critical care conference held in Sydney 2013 (#smacc2013), Gold Coast 2014 (#smaccGOLD) and due again in June 2015 in Chicago (#smaccUS)?

It sure is a great conference, full of cutting edge resuscitation and critical care, along with a dollop of educational subversion, innovation and just plain good fun. The content is relevant to any who care for critical patients – not just intensivists, but ED docs, rural clinicians, paramedics, nurses, students. No hierarchy, just quality meducation and passion.

If you haven’t yet considered attending, check out the smacc content online – in the true spirit of FOAMed, the content from smacc is available online as podcasts, downloadable slidesets and videos.

You can access the videos via the VIMEO channel HERE - or if you prefer to listen as you run, drive, walk, shovel snow or laze on a beach – you can get the audio podcast version via iTunes HERE.

Content is also available via RSS feeds from various affiliated websites – try the excellent Intensive Care Network (ICN), PreHospital&RetrievalMedicine (PHARM), RuralDoctorsnet (RDN) and of course LifeIntheFastLane (LITFL).

Equipment Videos Online

To continue the theme of a gift that keeps on giving, the EVO competition was announced today. The premise is simple – get together a team (can be from 1 to 5 members) and create a short (< 5 mins) video to showcase a piece of equipment relevant to critical care. It can be a ‘how to use’, a ‘how to troubleshoot’ or even a ‘how to improvise’.

Instructions are HERE

EVO-Logo-on-White

Why bother? Well, each month a winner will be announced – from 1 Aug 2014 through to 1 June 2015, a few weeks before smaccUS. And the prize each month? A ticket to smacc!

This is genius – not only does this encourage smacc participation – it also generates more quality FOAMed content. I am looking forward to seeing the videos as they come online.

This is the very essence of FOAMed – generation of quality educational material, available to all. The EVO competition is one way to achieve this. So get your video kit out, get a few mates and shoot a quick video for EVO.

If you’re looking for inspiration, then there’s plenty out there. I’ve got a few short videos in the ’50 Shades of Brown’ section on KIDocs

The Australian College of Rural & Remote Medicine ran a similar competition last year with their #JAMIT series (just a minute instant tutorial) – here’s one from Minh on setting up a quick n dirty adrenaline infusion.

So come on – I’m looking forward to seeing some of the tips n tricks out there from the FOAMed world.

Oh – and if anyone has already made a short video on troubleshooting the Oxylog 2000+ for the ‘occasional user’, do me a favour and bung up online – it’s the workhorse of rural EDs here in Australia and I haven’t (yet) got around to doing this. Beat me to it!

 

 

 

 

You’re Amazing – Keep it Up!

So I was grinning from ear-to-ear when I received an airmail envelope from the UK – inside was a message. No name, just a card. UK-stamp, sent from London…

Mystery Card - along with many other EM colleagues in UK, USA & Oz
Mystery Card – along with many other EM colleagues in UK, USA & Oz

Card 2

 

As far as I can gather, many other clinicians around the globe have received one of these – mostly amongst the EM & Crit Care community.

So far no-one has owned up to this delightful surprise.

 

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I’m pretty sure plenty of other clinicians have received one of these little boosters

If you have, don’t be shy – send a photo for the collage

 

Of course there are rumours – Rob Rogers (@EM_Educator) showed a slide at smaccGOLD of cards given out at Starbucks coffee with a similar message (I think it was in the ‘Get Creative’ workshop I attended).

 

BpItT6fIYAAX3GW

 

So it is not a huge leap to assume it was one of the smacc attendees…most likely one who lives or has been in the UK recently. I have my theory as to the identity – more theories abound in the twittersphere…

No matter who sent these cards (and I thank you for mine), it was a lovely gesture of camerarderie and a nice little morale booster.

“I kind of don’t want to know who’s sending them. Anonymity is part of the kindness”

Jesse Spurr @Inject_Orange

Which makes me wonder – how often do we we acknowledge & say ‘thank you’ for the efforts of others in our work? One of the earliest lessons I learned as an intern (or housedog in the UK), was to befriend the porters, the ladies in the hospital shop, the cleaners, laboratory, admin and nursing staff. We talk about ‘making things happen’ in emergency medicine – wise clinicians realise that our efforts in the resus room require the support of a whole raft of people.

Similarly in the FOAMed community, I am grateful for the help I have had with my learning and professional development. This is delivered via inspirational blogs, listening to inspirational speakers, lovingly-crafted talks made available for free download – and supported by ongoing global ‘corridor conversations’ with like-minded folk through social media.

As much as I have been supported by this, I try to pay back – this week has been notable by a collaborative review of sim apps, a to-&-fro exchange on refinements to an exciting new cognitive aid from an anaesthetic colleague, getting a letter in the British Journal of Anaesthesia and mentoring an EM trainee who was inspired by my talk at smaccGOLD and wishes to implement an RSI checklist in his own organisation.

This is what I love about the FOAMed ethos – the willing sharing of ideas and the ever present enthusiasm to ‘pay on’ the meducational love within the FOAMed community

Already the offers of a shared beer and catch up are trickling in for smaccUS in Chicago.  Due to the expected numbers of attendees and the need to ensure a truly top shelf event surpassing even smacc13 and smaccGOLD, the dates have been pushed back to June 23-26 2015. Read about the reasons for the SMACC 2015 move to June.

 

So – to you all – thank you

You’re awesome

Keep it up!

 

I am working on a small surprise for colleagues in the FOAMed community

Catch up with me in Chicago for a special gift

smaccUS 23-25 June 2015
See you at smaccUS 23-25 June 2015

Simulation Apps – Review

This review of iOS apps for simulation use was conducted by Dr Tim Leeuwenburg (@KangarooBeach) and Dr Jonathon Hurley (DrJHurley). Tim is a rural GP-Anaesthetist in South Australia and a passionate advocate of ‘guerilla sim’. Jonathon is an EM trainee in the UK and keen on human factors and simulation in EM. We reviewed :

Jonathon has prepared a SPREADSHEET for download, comparing the features of all Apps reviewed

Pre-publication peer review of the post was kindly provided by Jesse Spurr (@Inject_Orange)

 


Why use in situ Sim at work?

Many clinicians are embedding simulation training into their practice.If it is done well, sim training allows :

  • exploration of team work and human factors
  • exposure to infrequent but high-stakes crisis situations
  • development of tacit knowledge
  • development of  ‘stress inoculation’
  • interdisciplinary team training using all clinicians who are involved in a case – doctors, nurses, paramedics, orderlies etc

High-performing teams, such as those in retrieval services, incorporate sim into their day-to-day practice. To my mind there is far more ‘bang for buck’ in delivering regular on site sim using own team, equipment and protocols than the notion of once yearly ‘upskilling’ or the use of expensive course and sim centre sessions which occur away from the workplace. This approach is inspired by experts such as Jon Gatward & Jesse Spurr, who espouse the concept of mobile sim

This is borne out by evidence, showing only a 1-2 % difference between high-fidelity and low-fidelity sim training. The 2012 paper from Rosen provides an excellent review of in situ simulation and is recommended reading (J.Cont. Ed Hlth Prof 32(4) 243-254). Click on the link to view a PDF.

There are plenty of resources out there in the #FOAMed world for those of you considering sim. I would recommend :

Some useful papers include :

Eppich et al (2011) Simulation-BasedTeam Training in Healthcare. Sim Healthcare 6 S14–S19

Kennedy, C. C., Cannon, E. K., Warner, D. O., & Cook, D. A. (2014). Advanced Airway Management Simulation Training in Medical Education. Critical Care Medicine, 42(1), 169–178.

Lorello, G. R., Cook, D. A., Johnson, R. L., & Brydges, R. (2014). Simulation-based training in anaesthesiology: a systematic review and meta-analysis. British Journal of Anaesthesia, 112(2), 231–245

Marshall SD & Flanagan B. (2010) Simulation-based education for building clinical teams. J Emerg Trauma Shock : 360-8

Petrosoniak, A., & Hicks, C. M. (2013). Beyond crisis resource management. Current Opinion in Anaesthesiology, 26(6), 699–706.

Rosen et al (2012) In Situ Simulation in Continuing Education for the Health Care Professions: A Systematic Review. (2012) Journal of Continuing Education in the Health Professions 32(4) : 243–254

Shapiro, M. J., Gardner, R., Godwin, S. A., Jay, G. D., Lindquist, D. G., Salisbury, M. L., & Salas, E. (2008). Defining Team Performance for Simulation‐based Training: Methodology, Metrics, and Opportunities for Emergency Medicine. Academic Emergency Medicine, 15(11), 1088–1097

Schmutz & Manser (2013) Do team processes really have an effect on clinical performance? A systematic literature review. British Journal of Anaesthesia 110(4) 529

Tannenbaum S et al (2012) Teams Are Changing: Are Research and Practice Evolving Fast Enough? Industrial and Organizational Psychology 5:2–24

Weaver SJ, Salas E, King HB. (2011) Twelve Best Practices for Team Training Evaluation in Health Care. Jt Comm J Qual Patient Saf.  37(8) : 341-9


 

You can see how GSA-HEMS use sim training from this video, submitted as their smaccGOLD SIMWars entry

There are a few options for delivering sim in the workplace – what Jon Gatward calls mobile sim (I prefer ‘guerilla sim’). Key to this is the ability to deliver focussed sim sessions in the workplace – whether at the end of each ward round, as a scheduled session during the ED shift, in the operating theatre, in the ICU etc.

Such sessions do not need to incorporate expensive technology and are WAY easier (and I would argue, more relevant) than visiting a dedicated sim lab. Principles of mobile sim are :

  • it is done during the working day, in the workplace
  • it is interdisciplinary
  • it can be done ‘on-the-fly’
  • it can be done on the cheap
  • it delivers the same quality learning as traditional sim
  • it is flexible to workplace and clinician needs

This wonderful slide showing the ‘pharmacology of sim’ – shows the clear benefits of repeated low fidelity mobile sim vs a one off high-fidelity sim session ie: as “spaced review”

The Forgetting Curve - repetition (lo fi, high rep sim) aids Retention
The Forgetting Curve – repetition (lo fi, high rep sim) aids Retention

 

Considerations for in situ  Sim

Planning, Time, Location

Every simulation session should have a defined lesson plan and allow sufficient time for both the simulation scenario and debrief. Rather than focus on tasks (how to insert an IV, how to defib) the real power of sim is to explore cognitive bias and other human factors – in a crisis, it’s often not what you know, but how effectively you can apply it that matters. There is a considerable cost differential in sim delivered on a dedicated course (eg: Effective Management of Anaesthetic Crises, EMAC) in a dedicated facility (eg: simulation centre) vs a short session (planned or opportunistic) delivered in the workplace, preferably using the usual resus bay, theatre or ward environment.

Equipment

Use of the standard equipment used in your location is necessary (there is no point practicing IO access with an EZ-IO drill if your facility only has the Bone Injection Gun); a training box of expired kit (ETT, LMAs, PEEP valves and so on) is easy to procure.

Similarly expired drug stock (dantrolene, adrenaline vials etc) ensure that participants get to practice drawing up and preparing drugs under situations of a simulated crisis. Opening glass vials and preparing infusions is worth practicing under a simulated crisis – I am a huge fan pf ‘action cards’ at the head of the resus bed to aid this process, rather than having to search through the A4 compendium of drug protocols held t the Nursing staiton.

Patient

Some centres use simulated patients – actors or stray medical students who are briefed to the scenario. They are expensive and it isn’t ethical to defibrillate them or cannulate them, let alone perform CPR. Hence most use mannikins. There are expensive models which can simulate voices, breath sounds, heart sounds, collapsed lungs and have add ons to allow cannulation, central line insertion, catheterisation and so on – such as Laerdal’s Sim Man - but the are NUTS expensive, with ballpark costs $17K to $110k. Crazy.

Most hospitals have access to a Resuscitation Mannikin of some sort, with ResusciAnne (modelled on the death mask of an unidentified woman drowned in the River Seine, L’Inconnue de la Seine) the most popular CPR trainer out there.  I am still waiting for Tor Ecleve’s proposed update as displayed on lifeinthefastlane, namely Resusci Sharon & CPR Tracey.

In a push, ANYTHING will function as a patient; at smaccGOLD our SimWars team trained using Simon Carley’s conference satchel as a patient – we didn’t need to practice procedures…but we did need to practice teamwork, and rehearsing a scenario around a ‘bag patient’ sufficed, even to the point of inducing stress overload in the team leader. I’ve run sim training sessions using a cheap clothes mannikin purchased on eBay to run a perimortem C-section scenario…a $5 toy doll to practice neonatal resuscitation….and even a teddy bear as mock patient. However even the simplest sim can benefit from use of real equipment and a simulated monitor…

SimWars fracas at smaccGOLD :  "Team leader, this scenario is grillin' my corn"

 

Finesse

It’s the little things that make or break a good sim scenario. This might include the use of a confederate (covered nicely by Jesse Spurr in the ‘Plants in Simulation‘ post), the use of appropriate adjuncts (X-rays, labs, clinical photographs), use of moulaged blood, amniotic fluid and so on.

Some of the sim apps allow some nifty features – being able to flash up an X-ray, ECG, lab results or a clinical photograph to the monitor can help prompt the participants.

One of my favourite additions is that of patient phrases - these can be streamed to a small bluetooth speaker hidden within the mannikin (‘Am I having a heart attack?”). I have a vision of collecting some soundbites from various celebrities amongst the critical care community (can you imagine Minh le Cong asking “have you used the RSI checklist?” or John Hinds saying “Please use cricoid pressure!”).  I can but dream…

“…sound effects from confederate taking photos of the “birth” blew the midwives minds when they put the Doppler on a cloth sack and heart fetal heart rate. The crying neonate adds realism to successful resus and then subsequent ambient noise for maternal resus”

Jesse Spurr (nurse educator and sim gur who blogs at The Injectable Orange) has a great pearl – use your smartphone to host a foetal Doppler sound and newborn crying sound during obstetric or neonatal resus sims; a confederate can pretend to take photos using the smartphone and unleash the relevant sound effect.

Simulation Monitors

This is where modern technology comes to the fore; pretty much everyone has access to a smartphone or tablet nowadays. Numerous commercial apps allow one to convert an iPad screen into a simulacrum of a patient monitor, controlled via Bluetooth or Wi-Fi from another iPad or smartphone. There is no longer a need for an expensive ‘Sim Man’ or sim centre; one can instead deliver realistic realtime practice using the technology in your pocket.

Below I review several of the available options, with particular consideration to affordability, ease of use, fidelity and functionality. Links to associated websites are provided.

NOTE : Neither reviewers have shares or a financial interest in any of the products shown.  iSimulate kindly provided a $100 iTunes gift card to facilitate download of the various simulation apps on trial.

 


Trialling the Sim Apps

Here I review five different sim apps. Sadly the budget didn’t run to purchase of a Sim Man ($17K to $110K) …and to be honest, I do not think that the SimMan product can be justified except in the larger dedicated sim centres. Again it is far better to run ‘guerilla sim’ in your location, as low fi, high rep sim. The following iPad / iPhone apps were trialled :

Key review items include COST – EASE OF USE – FIDELITY – FUNCTIONALITY aspects. I scored each aspect out of five :

  • 0 – avoid
  • 1 – low bang for buck
  • 2 – functional, but needs improvement
  • 3 – average
  • 4 – actually, quite good
  • 5 – GRILLS MY CORN

I have also included a short video of each in use, mostly showing student monitor screens. The videos were made using AirPlay (built into iOS devices and streamed to a macBook Air running the program “reflector” to record video. It’s probably the easiest workaround for capturing an iPad screen, other than by using a standard recorder.

Reviewers were Dr Jonathon Hurley (Emergency Medicine, UK) and Dr Tim Leeuwenburg (Rural GP-Anaes, Australia)


 

EKG TRAINER (Walter Crittenden)

Tim : This app was only $2.99 from the app store, and at first glance appears to compare well with the SimMon app, albeit with only one option for a monitor (to be honest, I don’t think this matters – in my hospital alone there are four different monitors and it’s not useful to get hungup on expecting sim apps to mimic all commercial products).

There appear to be displays for ECG, SpO2, NIBP and RR. The lack of ETCo2 may be a limiting factor for those in ED, ICU, Theatre or Prehospital. Sadly I was unable to get anything to display other than ECG. This allowed selection of several waveforms including :

NSR-A/flutter-Sinus Brady-1st degree AVB- 3rd degree AVB-Sinut tach, A/fib-ST elevation, SVT- Bigeminy-VT-VF-Asystole

There also appears to be an option to connect two iPads via Bluetooth, but I was unable to make this work over the 72 hour trial period of testing. Linking to the developer’s website didn’t reveal any more clues on how to make this work and indeed the website appeared neglected.

So – at first glance this offers more ECG waveforms than SimMon, but lacks connectivity, ability to select other parameters and omits ETCo2. For the price this is not bad, but I could probably do as well with a few laminated photos of different monitor screens and run a sim like that! That way I would have saved $2.99 for a coffee…

  • COST – $2.99
  • EASE OF USE – 1/5
  • FIDELITY – 1/5
  • FUNCTIONALITY – 1/5 (essentially ECG strip only) on iPad, 2/5 on iPhone
  • TOTAL SCORE – 1/5

 

Jonathon :  I had the same experience.

iPad: Appears to be a ‘work-in-progress’ with just the ECG simulation working. The screen to change the other parameters wasn’t even finished, with ‘Label’ displaying instead of the value of the parameter.

iPhone: All parameters work, although there are no waveforms for sats / BP / RR.

I could connect iPhone (teacher) to iPad (student) and the displays mimcked each other, but when connecting the other way around sats, BP and RR just read zero. Connectivity was slow and the app would frequently hang trying to connect.

VF wouldn’t work.

Would maybe give this 2/5 for functionality (iPhone version) but otherwise agree with the scoring.

  • COST – $2.99
  • EASE OF USE – 1/5
  • FIDELITY – 1/5
  • FUNCTIONALITY – 2/5  on iPhone, 1/5 on iPad
  • TOTAL SCORE – 1/5

 

 

DART SIM (ECG RHYTHM & MONITOR SIMULATOR, STAR CPR San Diego)

Tim : The DART Sim app seemed to have good reviews on iTunes. It was fairly easy to start up, but the monitor screen appeared very cluttered an was hard to navigate. Swiping one’s finger across numerics allowed entering and change of values via keyboard; swiping over waveform hide/shows the waveform for each of ECG, BP, SpO2 and ETCO2.

Whilst ETCO2 waveforms could be changed via a drop down menu which was clearly labeled, the ECG waveform was controlled from a ‘keypad’ in bottom left of screen numbers 1-25.

By preselecting a number, different ECGs can be displayed – but this of course requires one to know which number corresponds to which ECG. I found this annoying, as reliance on a ‘key’ made rhythm switches on the fly almost impossible.

There are options to pace and to defibrillate; I gather there are also options to purchase scenarios, ECGs, CXRs and labs – I could not justify this, as the screen clutter and general difficulty in navigating the app made me immediately discount this as an option for sim.

I was also unable to make a connection with a controller iOS device via either WiFi or Bluetooth; there is a free DART remote app available which I gather is used in the suite of DART products.

On the positive side, there was a help function within the app which led to several splash screens of info in dense type, and a PDF manual.

  • COST – $16.99
  • EASE OF USE – 2/5
  • FIDELITY – 1/5
  • FUNCTIONALITY – 2/5
  • TOTAL SCORE – 1.5/5

Jonathon : this is the one I’m least keen on.  It doesn’t look like a real monitor screen at all.  It can do basic monitoring such as heart rate and rhythm, sats and respirations, but most of the more advanced features are premium add-ons, including the ability to remote control the simulator.  It does have a simulated defib and pacing unit, but the clunkiness of the interface lets this down as a potential positive.  

Doesn’t simulate a generic monitor so will likely confuse students. DART remote allows scenarios to be built but appears quite complex, requiring a lot of time to input.

I quickly discounted D.A.R.T Sim from my options for use in teaching.

  • COST – $16.99
  • EASE OF USE – 2/5
  • FIDELITY – 1/5
  • FUNCTIONALITY – 2/5
  • TOTAL SCORE – 1.5/5

 

 

SIM MONITOR (Med-eSim Apps)

Tim : I struggled initially to get SimMonitor to work, but was aided by the funky video below.

Sadly however I could only tolerate about 45 seconds of this before the soundtrack made me want to hurl the iPad across the room. Thankfully by this stage I had gleaned enough to at least work out how to connect the student and teacher iPads and display waveforms.

Connection was relatively easy; the teacher screen allows selection of a wide variety of ECG waveforms and ABP, SpO2 and ETCO2. These changes are rapidly reflected on the student monitor. The next ECG can be selected and ‘queued;, allowing rapid progression through rhythm changes without fumbling. A CPR option displays the typical ‘CPR hump’ seen. There is a defib button, but this just discharges a fierce crackling (think mad scientists and Igor) rather than the usual ‘charge-ready-defib’ of more sophisticated trainers.

I also struggled to get the ETCO2 to display and to turn on/off other waveforms, other than by maniacally swiping at the monitor and hoping that waveforms would appear/disappear – hardly conducive to a good sim.

I understand that there are options to purchase more ECGs, image libraries and lab results – I did not pursue this, as although the app worked, it didn’t seem worth the money to pursue this further, given the poor fidelity of the monitor screen and difficult navigation.

There is a small sound library which was quite fun to use. This app is clearly better than the EKG trainer and DART SIM already reviewed, but lags behind the next app (which can be confused with SimMonitor, namely SimMon)

  • COST – $17.99
  • EASE OF USE – 2/5
  • FIDELITY – 2/5
  • FUNCTIONALITY – 2/5
  • TOTAL SCORE – 2/5

Jonathon : SimMonitor is a little better than the previous (DART SIm/EKG Trainer); it looks like a monitor screen and can be remote controlled by Bluetooth.  However, it is quite limited in its options e.g. the number of different sats traces that can be displayed. There is no defib or pacing function. It does however have a limited sound library, although these are not particularly high fidelity.

  • COST – $17.99
  • EASE OF USE – 2/5
  • FIDELITY – 2/5
  • FUNCTIONALITY – 2/5
  • TOTAL SCORE – 2/5

 

 

SIM MON (Castle Anderson Apps)

Tim : At $21.99 SimMon is clearly affordable. It is also incredibly easy to set up; it can either be run on two iOS devices (iPhone or iPad to control, another iPad as monitor screen) or as a standalone device (waveforms and numerics can be changed by touching the screen and selecting appropriately).

Initially I was very excited to see option to select one of four separate monitors in the ‘settings’ menu (Datex Ohmeda AS3, Nellcor N100, DataScope Passport 2 & Agilent ACMS M1177A) – however the actual screen displays do not change, just the audible tones, The only other thing that can be changed in this menu was the units for ETCo2 – as either kPa, mmHg or as a percentage (not a unit I am familiar with for this variable).

The display allows FOUR waveforms (ECG, SPO2, Arterial Waveform & ETCO2), with numeric values by the side. Additionally RR and a timer can be activated.

Available waveforms include :

  • ECG : NSR-AF-A/flutter-Junctional-LBBB-RBBB-ST elevation-SVT-VF-VT
  • SpO2 : Normal & Poor Perfusion
  • Arterial : Normal-Poor Perfusion-Under Dampening-Over Dampening
  • ETCO2 : Normal-Broncospasm [sic]-Severe broncospasm [sic]-Leaky Tube-Subsidising Relaxant-No reading

Touching on either waveform or numeric allows changes; waveforms are selected by menus, numerics changed by swiping up (increase) or down (decrease). Maybe I have got fat fingers, but I found it too easy to inadvertently change the parameter above or below the desired setting, which could be a problem.

In fact, the more I think about it, this IS a problem – the SimMon does not allow pre-recording of scenarios – all changes are made ‘on the fly’ either from the controlling iOS device or from the display monitor. This it is vital that any changes are made quickly and accurately.

Interestingly the ONLY alerts that I could elect to deterioration were changes in the audible tone of measured values – no alarms, which is in contrast to the usual in-built alarms on most monitors.

I could use this app for teaching on courses – it is cheap and allows changes to be made rapidly. I have seen it used on the ETMcourse to good effect. However the lack of functionality is frustrating and the lack of ability to trend values over time, to select from pre-planned options and flip rapidly from one rhythm (and associated values) to another is frustrating. Similarly absence of alarms and defib/pacing/AED options limits utility.

  • COST – $21.99
  • EASE OF USE – 4/5
  • FIDELITY – 2/5
  • FUNCTIONALITY – 2/5
  • TOTAL SCORE – 2.5/5

Jonathon : SimMon has many more options for sats and ETCO2 traces.  Again it can be remote controlled by another iPad or iPhone, and I find this the best out of the reasonably priced apps. It looks like a real monitor and the parameters can easily be adjusted and enabled / disabled as needed.  There are no built-in scenarios so parameters have to be changed individually, and there is no pacing or defib function. S

cores are as above, except I’d give this 3/5 for functionality. As it stands this is my choice for teaching until I can convince the Trust to invest in ALSi!

  • COST – $21.99
  • EASE OF USE – 4/5
  • FIDELITY – 2/5
  • FUNCTIONALITY – 3/5
  • TOTAL SCORE – 3/5

The SimMon demo is below :

Video review is below :

Auckland HEMS comment here on their experience of using SimMon – as a bridge until purchase ALSi !

 

ALSi (iSimulate)

Tim : Along with their CTG app (CTGi), ALSi is a fully-functioned app from iSimulate. It is an order of magnitude more in cost than the other apps, but certainly delivers in functionality and fidelity.

It comes neatly packaged with two iPads, wi-fi base station (bluetooth connectivity is OK), housed in a tough transport monitor bag from Neann (makers of excellent prehospital bags) and encloses chargers, power cords and sphygmanometer cuff, ECG leads and pulse oximeter. There is enough space inside the bag to store a few adjuncts such as ETT, laryngoscope, EZ-IO, IVs , LMAs and other adjuncts. Or your lunch…

Connection is simple via wi-fi or Bluetooth. Once started the app opens a huge variety of options, including

  • huge library of ECGs (electrolyte abnormality atrial and ventricular dysrhythmias, arrest rhythms, paeds rhythms, trauma, conduction abnormality etc)
  • variety of ETCO2, SPO2 and NIBP waveforms
  • quickpick library of scenarios which allow change of ECG, SpO2, ETCo2 and BP); these can either be activated immediately or allowed to trend over as little as 10 secs to as much as 15 minutes
  • sound libraries, which can be customised (add own sound effect, brilliant for streaming to a bluetooth speaker hidden in mannikin)
  • image and lab libraries, fully customisable
  • option of monitor, AED or defib screen modes
  • -pause, alarm mute and screen invert functions

It’s probably best to just download and have a play – ALSi offer a free 28 day trial. You will need two iPads to make this work – but it is worth it.

  • COST – $4.9K for lifetime licence, or $1K per annum subscription
  • EASE OF USE – 4/5
  • FIDELITY – 5/5
  • FUNCTIONALITY – 5/5
  • TOTAL SCORE – 4.5/5

Jonathon :  ALSi is definitely the premium simulator.  It resembles a monitor, has defib and pacing functions, and scenarios which include steps which can be auto-activated by the defib – no more obvious clues about when a rhythm is about to change.  It simulates CPR and PEA with one tap of a button.  Custom parameters can be added.  The sound library is good and can be added to. The big down side of ALSi is the price – buy in to lifetime licences is thousands of pounds, which is only within reach of institutions.  The full kit is only a little more, and truly resembles a monitor in a bag with ECG and sats leads, although they are not functional – could achieve this with out-of-date kit from medical electronics.

Its price means this would be an institutional purchase rather than a personal one, so may have implications for sim practitioners in institutions where sim isn’t a budget priority.

  • COST – $4.9K for lifetime licence, or $1K per annum subscription
  • EASE OF USE – 4/5
  • FIDELITY – 5/5
  • FUNCTIONALITY – 5/5
  • TOTAL SCORE – 4.5/5

 


 

THE VERDICT?


 

  • ALSi                       4.5/5
  • SimMon                2.5/5
  • SimMonitor          2.5/5
  • DART SIM            1.5/5
  • EKG Trainer          1/5 (NB: iPhone version scored 1.1/5)

 

Any decision on purchase of a sim app will be guided by needs, functionality and affordability.

Although not trialled, Laerdal’s SimMan seems to be the traditionally preferred choice by standalone simulation centres. But SimMan is CRAZY expensive and not suited to mobile sim – a major drawback, as concentration of simulation in a dedicated centre fails to address the peculiarities of different teams, equipment and locations. Far better to have an option that allows sim on the floor in ED, OT, ICU, wards or even consulting rooms and pre-hospital. There is just no point in having one-off sim in a sim centre unless supported by regular low-fi repetitive sessions as mobile sim.

ALSi is in a league of it’s own amongst the iOs apps tested - yes it’s more expensive than the other iPad based apps, but the sheer range of options, the personalised support and the future vision make it the preferred choice of serious resuscitationists. ALSi is used for training in Australasian ALS course, by leading retrieval services such as RFDS, medSTAR and GSA-HEMS, by paramedic training organisations and by tertiary hospitals.

SimMon is a distant second, but far less functioned than ALSi – think of it as an old kiddies pushbike compared to the Mercedes-Benz of ALSi. It is clear that are comparing apples with oranges when put ALSi up against it’s rivals.

The other apps are little more than toys – cheap, but nowhere near approaching the fidelity or functionality of ALSi. Not Mercedes-Benz, not even pushbikes – perhaps those little plastic toys you get in Xmas crackers…

Jonathon : Overall, ALSi is the highest-fidelity sim app and is great for institutions.  As I’m a trainee and rotate all around the region, it’s unlikely that I’m going to be able to convince every Trust to buy it so for me, SimMon is my favourite.  It’s the best of the reasonably priced apps and adds a lot of realism to scenarios.

Tim : Although it may seem pricey, ALSi offers a robust and realistic training package at fraction of the cost of only serious rival (SimMan, $17-110K). The after sales support is superb and the price is easily covered from most educational budgets and is easily affordable by an institution. I quarantined two days worth of rural upskilling grant to purchase mine. I would recommend it if you are serious about running sim in the workplace or as on courses. Whilst pricier than the other apps, it is still far, far, far cheaper than the only other contender, Laerdal’s SimMan. It is also highly portable allowing regular repetition of sim training in the workplace rather than in a sim lab.

In short, ALSi “grills my corn”

 

DOWNLOAD THE COMPARISON SPREADSHEET HERE

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…