RERN Kit

This week MICA paramedic Rob Simpson put up contents of his prehospital kit for all to see – nice set up, with impressive slide out drawers for kit and even a gas-piston life to make shouldering a backpack that little bit easier.

Seeing Rob’s colour-coded drug vials made me re-visit the contents of my own RERN kit (rural emergency responder network) and do a little labelling & re-ordering of near expired stock.

I’ve posted a video on “what’s in your emergency bag” previously, although my own bag has undergone some revisions since then. Many doctors (particularly rural doctors) ask me about what kit to carry in their car. There are commercially available kits (such as GPKit) but to be honest I think the best kit remains a mobile phone, gloves and simple airway adjuncts such as Guedel’s and bag-mask valve (preferably with PEEP valve).

As a RERN member my role is to support (not replace) existing ambulance officers in rural SA – many of whom are volunteers trained to Cert IV level and supported in turn by career paramedics, intensive care paramedics and extended care paramedics. They are the experts in prehospital care – not passing-by doctors or ‘enthusiastic amateurs‘. Indeed one of my bugbears is the notion that having any old doctor on scene value adds to care – to my mind, the prehospital environment is VERY different to the ED or consulting room, and most doctors have little to add unless they have undertaken specific training in this field. Karel Habig talks about this in the most recent RAGE podcast (No 2) and is worth a listen.

Thus my role is to perform a very limited set of interventions – IV or other drug administration when ICP/ECP not available, facilitating extrication through judicious use of ketamine, needle-finger-tube thoracocentesis through to (very rarely) pre-hospital RSI. So what kit have we got?

PPE

Boots – Eye Protection – Hard wearing trousers with reflective strips & knee-pads – Jacket with reflective stripes and ‘Doctor’ ID. Interestingly no gloves or hat…

Vehicle

Most RERN members respond in their own vehicles or arrange to be met by the local ambulance crew en route to a scene. Some locations keep their RERN kit at the local hospital. Due to the geography of my location (KI is 150 x 50km) I keep my kit with me and respond by pager or mobile phone activation. At this stage we do not have a GPS-enabled solution, although I have been looking with interest at the mobile phone-GPS solution being used by BASICS doctors in Scotland.

Equipment

RERN doctors are supplied with two bags – a green ‘oxygen and basic airway’ bag and a red ‘circulation, IV access & drugs & advanced airway’ bag. We don’t carry a defib or monitor – the Phillips MRX is the standard on SA Ambulances and we would be dependent on the volunteer crews having this to hand. Ditto adjuncts like extra oxygen, IV fluids, dressing, suction etc.

The bags are supplied by SA Ambulance and restocked through RERN. The bags are made by NEANN and are of excellent quality – waterproof, removable ‘boot’ on bottom and with sturdy zips and carry handles.

 

Green Bag – OXYGEN – BASIC AIRWAY – ADJUNCTS (collars, splints)

This contains oxygen, BMV, oro and nasopharyngeal airways, sphygmanometer, stethoscope, glucometer, Abbotcaths, 3-in-1 masks, nebulisers etc.

OXYGEN - BASIC AIRWAY - ADJUNCTS BAG

OXYGEN – BASIC AIRWAY – ADJUNCTS BAG

 

I’ve customised mine to a degree, adding a CT-6 femoral traction splint and a Prometheus pelvic binder to the side-pockets, as well as an assortment of Air-Q II intubating LMAs.

OXYGEN CYLINDER runs the lengt of the green bag/backpack

OXYGEN CYLINDER runs the lengt of the green bag/backpack

 

IDE POCKETS hold cervical collar, pelvic binder, CT-6 femoral traction device and AirQ II intubating LMAs

IDE POCKETS hold cervical collar, pelvic binder, CT-6 femoral traction device and AirQ II intubating LMAs

 

Red Bag – CIRCULATION, IV & DRUGS, ADVANCED AIRWAY

The red bag contains more serious kit :

Circulation, Drugs & Advanced Airway

Circulation, Drugs & Advanced Airway

 

Side pockets hold :

(i) formulary, pens, gloves (always carry a Sharpie)

(ii) local anaesthetic and suture kit

(iii) combines, dressings, bandages

(iv) Tranexamic acid, OLAES/Israeli bandages, combat-application tourniquet, RapidRhino

 

IMG_3019

 

Main compartment has skin staples, local anaesthetic and more sutures in the zipper top lid (useful to control scalp lacs etc), with individual bags within for ADVANCED AIRWAY and IV ACCESS/MEDICATIONS.

Snuck alongside are some extras – two 500ml bags of N/saline, giving sets and an EZ-IO drill. The latter was a bit of a push to get 0 the local hospital stocks the Bone Injection Gun (a useless piece of kit, no tactile feedback, errors made with deployment even after training) and I was able to badger RERN to supply needles for the EZ-IO if I supplied the gun. used it four times in past 6 months, so reckon it’s worth it. There’s also a pre-packed Guedel’s oropharyngeal airway set.

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IV ACCESS & MEDICATION

The yellow IV access / medication module is quite neat, with vial holders, enough room to stash IVs, a mucosal-atomisation device for IN drug delivery plus assorted ventolin inhalers, GTN spray, penthrox inhaler as well as minimal volume extension lines, more tape, a couple more Sharpie pens and as much ketamine as I can cadge.

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Drugs include : ketamine, morphine, fentanyl, tramadol, midazolam (5mg per ml and 5mg/5ml), naloxone, adrenaline, atropine, amiodarone, metoprolol, frusemide, metoclopramide, tropisetron, promethazine, chlorpromazine, hydrocortisone, benzylpenicillin, cefazolin.

I tend to stash a couple of vials of propofol, some ephedrine & metaraminol and of course GTN spray, salbutamol and Methoxyflurane (Penthrox) inhalers along with the IVs. Hidden amongst this lot are some 3ml syringes and ‘snot rocket’ mucosal-atomisation devices.

Needless to stay these are kept locked and a written record of S8s maintained.

I will probably ditch the metoclopramide and chlorpromazine soon, and get some droperidol instead.

After talking to Robbie recently, I reckon some wafers of both ondansetron and olanzapine might be useful…

RSI drugs (specifically, induction and neuromuscular blocking drugs) are kept refrigerated.

RSI KIT – ADVANCED AIRWAY

The grey advanced airway bag contains Mac & Miller blades, classic LMAs, emergency surgical airway kit (scalpel, bougie, size 6.0 ETT). I’ve added a pocket bougie as well as the supplied Frova oxygenating bougie and rapi-fit connectors (O2 or BMV), as well as the medSTAR kit dump and challenge-response checklist.

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I am not afraid to use cognitive aids in a crisis; the side pockets of the bag contains ‘action cards’ for mixing inotrope infusions, RSI drugs and paediatric calculations.

Note the kit dump (yellow) and Introes "pocket bougie"

Note the kit dump (yellow) and Introes “pocket bougie”

I also carry the KingVision VL and both channelled and non-channelled blades. Of all the VLs I’ve tried, this works best in sunlight (less glare than the McGrath) BUT I should be clear that VLs do not cope well with blood/vomit (the sensor chip is easily contaminated) and DL remains the core skill. I carry mine as a back up, the logic being that may be useful if performing RSI in back of (stationary) ambulance rather than at the roadside. I also carry the AirQ-II iLMA in a side-pocket of the green bag – these are less bulky than the FastTrach iLMA, less fiddly to deal with (less parts) and allow gastric drainage unlike the FastTrach.

KingVision VL - but DL remains the core skill!

KingVision VL – but DL remains the core skill!

 

So that’s my kit. My wish list remains for :

- pelvic binders to be carried by SA ambulance crews

- GPS-smartphone to enable location & targetted activation of RERN members

- consider prehospital CPAP device

- common kit between services with recycling of near-expiry stock

- interagency training

 

 

 

GP to chase…

OK, listen up. I have had a gutful of ‘GP to chase’ discharge summaries from our local centre of excellence tertiary hospital. AMA guidelines are quite clear about this – if you order a test, you are responsible for the result including followup and patient management.

It is not uncommon for patients to spend a week or so in the tertiary hospital, then lob up in my clinic a week later – without a discharge summary, list of medications – basically not a Scooby-Doo about what happened during their hospital admission and battery of investigations, let alone what the discharge diagnosis (if any) was.

Not cardiac” is NOT a diagnosis for the patient sent in with chest pain for investigation ?ACS. I am glad that the patient can recall that they passed their stress test and angiogram … but puzzled why they’ve been discharged on a statin, ACE-inhibitor and beta-blocker with cardiac clinic review if the diagnosis is not their heart – and given their ongoing chest pain, perhaps consideration of other causes might be warranted? Were these even considered?

Worse still is the arrival of the discharge summary some six weeks later…suggesting that the patient needs an urgent CT pulmonary angiogram and “GP to chase serum homocysteine and D-dimers”.

I am a rural doctor. I usually know my patients quite well. Give me a call, send me a letter – even give the patient a scrap of paper to bring to me – but DO NOT ask me to chase results on test you’ve ordered or neglect to convey important information. It’s 2014 and even in rural Australia we have got access to phones, fax, email. Use them to communicate!

…and do NOT ask me to chase your investigations. I am not your community intern.

Meanwhile, here is a quick quiz for junior doctors who seem to be confused over the difference :

JUNIOR HOSPITAL DOCTOR QUIZ

CAN YOU SPOT THE DIFFERENCE?

This is a labrador.

He likes to “chase things’ and will roll over on command.

This is a GP.

Generally friendly but do not ask him to chase or rollover for you

WARNING – HE MAY BITE !!!

 

 

 

Grrrrrrrrr!

 

 

ETM Course – REVIEW

My blog profile mention that I am an instructor and course director for the ATLS-EMST course. ATLS-EMST is something in which I believe – a structured approach to trauma management training for doctors. But over the years I have become frustrated with the tardiness of knowledge translation – concepts that I learn about via FOAMed will take many years to trickle down onto courses such as these. There needs to be something better. For the rural doctors, we conducted a FOAMed-based ‘rural masterclass’ on Kangaroo Island which was well-received. On the same weekend, Drs Amit Maini and Andy Buck held the inaugural Emergency Trauma Management course in Melbourne. I managed to get along to the second course along with 23 other doctors including Dr Jeram Hyde. He has kindly consented to write a review of ETM. Now read on…

"Seen some strange shit in Melbourne"

“Seen some strange shit in Melbourne”

 

EMERGENCY TRAUMA MANAGEMENT COURSE – REVIEW

Dr Jeram Hyde is a Critical Care Registrar in ICU, ED & retrieval medicine, who loves working in regional trauma centres. He collects watches & naps whenever he can. Views are his own, & in no way reflect the views of his employers or professional Colleges.

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“High on content, low on lectures, pragmatic approach rather than dogmatic, huge emphasis on modern best practice & #FOAMed concepts. Amazing facilities & stunning food”

On the weekend I had the pleasure of doing the new Emergency Trauma Management Course (aka the ETM Course) in Melbourne, and finally managed to catch up with Tim after a bit of a twitter bromance over the past while. We’ve both been extremely excited about the course and I’m happy to say it didn’t disappoint! If you haven’t already checked out the courses website, check some of their content e.g. Thoractomy Critique and their course manual.

What is ETM?

ETM is a brand new trauma management course, the brainchild (lovechild even?) of 2 of the nicest guys out there: Andy Buck and Amit Maini. Andy and Amit are both FACEMs and trauma nuts from Melbourne and have only just started running ETM in late 2013 after over a year of planning.

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Why ETM?

The question everyone has been is asking is why ETM? Surely trauma has been covered more than enough through ATLS/EMST running all over the world? Well I’d beg to disagree, and thankfully the guys at ETM do too.

ATLS has done an amazing job in bringing standardised trauma care around the world, and gives an excellent grounding in trauma management for junior doctors in surgery, ED, ICU, anaesthetics etc who will be managing trauma. But it’s own simplicity and generalizability is ATLS’s greatest strength and weakness.  ATLS provides a solid grounding, but it does leave a gap in the ongoing education of doctors in managing trauma, namely – how do you function and manage trauma when you are no longer in the idyllic single doctor rural ATLS scenario. What about when you’re instead a senior ED Reg or consultant in a busy trauma centre, having to manage a trauma team you’ve never met before ? How does the linear ABCDE alphabet approach work then, when there are competing priorities, personalities and top level decisions to be made between theatre, imaging, angioembolisation or retrieval elsewhere?

Andy and Amit have tried to develop the course to help fill the perceived gap out there in advanced, up to date, trauma management and team leading skills. The course was born out of an experience the two of them had a few years ago whilst working in a trauma centre where they witnessed a senior, and otherwise extremely competent, ED registrar bungle a straightforward trauma. On debriefing afterwards it became clear that despite having done ATLS/EMST and having a theoretical framework for trauma management, the registrar was having difficulty translating that into real world practice with difficult personalities within the trauma team and competing urgent management decisions. This is obviously a common experience held by many around the country, judging by my own experience and Cliff Reid’s excellent  talk at SMACC this year on Making Things Happen in resus.

Where is the course? 

ETM has a perfect location: right in the CBD of Melbourne. 1 block from Flagstaff train station. Those who’ve been to ACEM headquarters before will be familiar with the area, as ETM’s headquarters is only 2 blocks away.

For those cofee addicts out there – don’t worry, being Melbourne there is coffee provided at the course, and some great coffee available on the walk from the train station to the course. Tim was more delighted about the nearby Japanese restaurants and numerous bars.

The guys have obviously put a huge amount of effort into the course, and it shows.  The course is run in a dedicated office space that the course has rented and developed, with a lecture room and multiple sim rooms.

So how was the course?

In short, well worth it. It was an absolute thrill to attend a trauma course designed for modern day practice and written and run by people who actually are doing trauma management daily. I particularly found it exciting to see so much up to date medical practice pervading the course.  Just on the first day alone the course covered so much recent #FOAMed content and modern practice such as apnoeic oxygenation in the trauma intubation,  1:1:1 blood product resuscitation, airway checklists, The Vortex,  CABC approach to massive haemorrhage in trauma, use of PEEP valves in pre-oxygenation etc etc.

One of the key themes that came through the course over the 3 days was a the key of having a “pragmatic not dogmatic” approach to trauma management. The course is also quite high on content and ‘doing’ in sim scenarios, rather than the death by powerpoint approach some other courses take.

Day One covered the basics of resus room setup, and trauma reception. There were skill workstations on the trauma basics of finger thoracostomies, insertion of rapid infusor cannulas (RIC lines – a personal favourite of mine), IO insertion, pelvic splinting, bougie intubation etc . The simulation scenarios on day 1 were quite basic with only single “life threats” (e.g. trauma pt with only a tension ptx). These initial sims and lectures were extremely well run and the workshops were valuable to anyone who hadn’t put in IO’s or RICs before, but to be honest by the end of day one I was a bit worried the course being being pitched a bit too low for what I was expecting. The sim scenarios on day 1 were pitched at the level of final day test sims on a ATLS course, and were run with just 1 doctor and 1 assistant.

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(ignore the anterior placement – we ran out of rib spaces)

Needless to say these fears were allayed promptly by the course taking everyone out to the pub for drinks (on them!) at the end of day one.

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(Clockwise from bottom left – me, Andy, Tim)

My concerns disappeared faster than roadkill on Kangaroo Island at the beginning of day two. The sim scenarios jumped up a gear, and the ‘single doctor + assistant’ team morphed into a 4 doctor advanced trauma team. The ‘patients’ became sicker and had 2 or more life threats. No longer could the trauma team afford to do things sequentially – simultaneous RIC access, decompressive thoracostomy and setting up for a difficult intubation for a traumatic brain injury in a hypotensive patient were required, with the team leader now finally able to stand back and not be physically involved, but rather lead as we do in real life. Xrays and FAST images were displayed when requested, and not every cannulation or intubation attempt was successful in the scenarios. It was great to see difficult airway management (rightly!) become a trauma management issue as well, as the team leader has to weigh up risk/benefits of the TBI with low GCS and multiple facial fractures being intubated now by ED RSI, or in 20 minutes by anaesthetics.

But even more exciting than the realistic sim scenarios was the huge emphasis placed on Resus Room Management (RRM) and the huge gap between the usually taught ‘Crew Resource Management’ (CRM) techniques used in stable teams such as the airline industry, and the dynamic teams (or flash mobs of strangers) that often make up the rotating roster of trauma teams. Sessions were spent practicing closed loop communication, and a lot of educational effort was put into helping us develop better leadership and communication skills that translate back into our own busy and chaotic resus rooms.

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Final day workshops included surgical airways, ED resuscitative thoracotomy (always a crowd pleaser!), difficult airway management and retrieval considerations for trauma patients. The thoractomy workshop was great fun as expected, with the chance to crack open their resident skeleton Bob’s chest. Understandly animals weren’t used – as you’d need a single sheep per participant for everyone to be able to do their own thoracotomies.

Thoracotomy moulage from the London Trauma Conference Dec 2013

Thoracotomy moulage from the London Trauma Conference Dec 2013

Overall I ended up loving the course, despite my initial reservations after the first day. Whilst it started out at a EMST/ATLS level course on day one, that was simply the building blocks for diving into more complex and realistic trauma cases over the next 2 days. By the end of day three, the scenarios would have 3 concurrent life threats that all required immediate action, as well as ongoing assessment and management decisions. I particularly valued the change up that happened on day three, when they took us out of the group of 5 doctors you’ve been with for the past 2 days, mixed up the groups and threw us into even harder sim scenarios with strangers you haven’t worked with before. Great way to practice clear, closed loop, communication.

Which brings me to a few final points:

The lack of animals… initially I thought the course would suffer for this, but after the weekend I didn’t miss them at all. ETM Course has invested heavily in some great models  and the time saved from not having to travel to an animal lab was well spent on other workshops.

The food –was amazing! Provided by the Asylum Seeker Resource Centre, we had stunning vegetarian & halal food (and sometimes vegan) meals provided 3 times daily. As a devoted carnivore myself, I thought this would grow tiresome as vegetarian food I usually find repetitive… but the variety and flavours of the food were endless. Rather than the endless supply of sausage rolls and party pies like some courses provide, I actually looked forward to the meal breaks!

The instructors – Andy and Amit lead a great team of instructors. Predominantly FACEMs from around Melbourne, some surgeons and pre-hospital guys also made some appearances for specific workshops and the Q&A session (which was a great chance to pick the minds of some senior guys)

The course manual – is worth the cost of the course alone I think! Provided both in PDF and iBook format (which I highly recommend) the course manual has been written by an international group of authors including Scott Weingart, Matt and Mike from the Ultrasound podcast and local FOAMed gurus like Casey Parker & Minh Le Cong  as well as Andy and Amit themselves. The manual is brilliantly written, informative, easy to read and has integrated videos throughout it. E.g whilst discussing how to do a thoracotomy, clicking on the imbedded video in the manual will play a 3 minute instructive video demonstrating a cadaveric thoracotomy – without even taking you outside the manual or requiring an internet connection. The same goes for looking at CT’s of chest trauma – rather than just displaying a static image like a normal text book, clicking the picture of a sternal fracture will automatically scroll through the entire CT chest to give you a better picture of what this looks like in real life.

 

And now finally the big 2 questions…

 

Who is this course for?

I think this is the question the course is wrestling with itself. Currently there is a huge range of people attending the course, and I think this will settle down over the coming year. My answer would be though: is this course for:

A FACEM or Senior Reg who deals with trauma daily in a major trauma centre and is competent and comfortable? – probably not, but will be a valuable refresher

An intern or inexperienced PGY 2-3? – no, most of the concepts and skills were pitched well above intern level.

But how about the middle ground? How about a FACEM who works in a trauma bypass centre, who is going locuming in regional trauma centres? Or the ED Advanced trainee with minimal previous hands on/in charge experience with trauma? Or the rural GP who covers ED and manages trauma by themselves, has completed ATLS-EMST and needs an up-to-date refresher? Or the provisional ACEM 3 junior doctor just starting out in ED? Well all of this range turned up at the course in December, and all seemed to enjoy it and get something out of it.

Did I as an ED/ICU trainee who deals with trauma daily in a regional trauma centre come across anything mind shatteringly new? No, but it was still a great course in helping cement in my approach to trauma, and a great opportunity to work on communication and resus room management/leadership skills in a supportive environment.  I’ve already recommended this course to my fellow registrars, and will continue to recommend it to anyone interested in improving their trauma management skills, whether they be an ED, ICU, Surgical doctor or rural GP.

Is it a replacement or competitor for EMST?

This is the hardest question… Andy and Amit say no, they aren’t trying to compete with EMST, but rather build on top of it. It’s true that pretty much the entirety of EMST is assumed knowledge in the ETM course, but briefly covered again on day one.

That said, I do think EMST has some serious competition here in Australia at least from ETM. ETM is cheaper, the waiting list is 1 month, rather than 2-3 years, it’s more up to date, and focuses on the advanced skills and thought processes needed for leading major traumas. It obviously won’t replace EMST for the surgical trainees who are required to do EMST… but for the rest of us in other specialties without mandatory requirements to do EMST/ATLS it’s an interesting question. I’d personally still recommend people do both, doing EMST around PGY2-3 and ETM a little later (or around the same time depending on where you work). But for those cash strapped and only interested in doing 1 course… I think ETM has the distinct advantage here in terms of content, delivery, cost, waiting list and of course the all important food. And EMST would never take you out and buy you a beer at the pub after a long day of thoracostomies and surgical airways ;-)

I’m excited to see how ETM continues to adapt their course. One of the great benefits of being a smaller, locally run course, is that it can be tweaked and updated month by month as new evidence comes out, and as their own experience in delivering the course grows.

Dr Jeram Hyde

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FINAL NOTE FROM DR TIM LEEUWENBURG

Thanks Jeram for an excellent and thorough review. I agree with the sentiments on ETM – a great course and an advancement on the usual ATLS-EMST.

This course is something new, uses early exposure to simulated scenarios (the least complex on day one would have been the ‘most complex’ on a typical ATLS-EMST) and focusses on building both practical skills and effective management of the trauma team. Equally importantly, Amit and Andy (& their colleagues) are committed to embedding relevant #FOAMed throughout he course content which will rapidly evolve.

I don’t think this is a course for newbies…as a Director for EMST I think that most of the candidates we get on  a typical EMST course would have struggled on ETM. So this is a course for those who have at least some pre-existing experience in trauma or those looking for a ‘masterclass’ refresher from an enthusiastic and credible faculty (I was invited to join the instructors for dinner on day two, which was a hoot).

Will I be jumping ship from EMST to ETM? Well, Amit and Andy have offered a post as an instructor and their ethos and philosophy aligns closely with mine re: FOAMed and helping to deliver ‘quality care, out there’. So yes, I’ll be glad to instruct on ETM in future for an Australian-grown, FOAMed trauma course relevant for real world trauma.

ETM will fully meet the needs of ED CMOs, rural GP proceduralists and others who have to manage trauma teams (anaesthetic & ICU registrars etc)…but I’ll still be directing on EMST for those who need to tick it off or want an entry-level approach. And don’t worry – courses I direct tend to be a little subversive from the usual College of Surgeons mantra…

Be a ZERO, Not a HERO

DISCLAIMER : This post is about how medics interact within the various tribes. It is NOT about primary care vs teaching hospital, ED vs medics, surgeons vs anaesthetists. I've had some people comment on twitter that this is 'about being a GP undermined by colleagues'. It's not. It's about clinicians, of whatever ilk, either undermining each other OR failing to work effectively within a team as too busy showing off how good they are. It's a piece inspired by astronaut Chris Hadfield's book and the concept of new team members being either a'plus one', a 'zero' or a 'minus one'. Now read on...

 

Medicine attracts bright people. I am constantly amazed at the smartness of some of my colleagues…and the ongoing exposure to brilliance via the FOAMed community. Not that you have to be smart to be a medic. Before medicine I trained as a research scientist, with undergraduate, Masters and PhD in an arcane area of immunology. But a life at the bench wasn’t for me – I enjoy interacting with people too much – hence the drift into medicine as a mature-age graduate. At medical school it struck me that medics were NOT particularly smart – the ability to absorb, memorise and regurgitate several phone books worth of information seemed to be the prerequisite, rather than original thinking. But insistence on high grades and academic excellence are just a cut-off to limit intake into the over-subscribed medical schools…and this encourages competition at a very early stage.

“Doctors are ingrained to compete – there is competition to get into medical school, competition for intern posts, competition for residency programmes, competition in Fellowship exams, competition for the desired consultant post…plus the inevitable competition between specialties”

Don’t get me wrong. I am all in favour of clinicians who are high-achievers and keen to move themselves to the right of the Gaussian distribution curve (mindful of the fact that 50% of all doctors are, by definition, below average). FOAMed helps us achieve that goal and strive to be better. For guys like myself in rural practice, than means to aim to bring “quality care, out there”.

But there is an ugly side to this competition. We all have tales of colleagues who have fallen by the wayside – whether through alcohol or drug addiction, failure of relationships, mental illness (including suicide). I am pretty sure that most of us have engaged in badmouthing colleagues, whether in the same discipline or in other specialties. Some of this is good-natured banter (think anaesthetists vs surgeons)…but it can become ugly, particularly when detracts from patient care or is a result of stressors perceived as being outside our control (bed pressure, busy workload etc). Both Dr Gerry Considine and myself have blogged about this from the perspective of rural practitioners – but it works both ways – primary care vs tertiary & vice versa as well as between in-hospital disciplines.

It never ceases to amaze me that medical training fails to expose junior doctors to primary care, given that this is where most patient encounters occur. And of course the bullshit perception of ‘just a GP’ continues to be promulgated within the tertiary centres leading to the comment ‘just a GP, not a specialist‘. Dr Penny Wilson blogs nicely on this. From my perspective, the more savvy tertiary colleagues turn pale when I suggest they sit in my shoes – they understand the skills needed to spot illness in undifferentiated primary care patients and would rather the security of preselected narrow-focus work.

“before you criticize a man, walk a mile in his shoes…then you will be a mile away from them & have their shoes”

I have certainly been guilty of critiquing colleagues without understanding their work. Before making the move to rural medicine I was a dual-trainee in EM & ICU. It was VERY easy to sit back and criticise the perceived failings of other doctors, especially as EM & ICU generally see a narrow selection of cases that have not been caught in primary care – blissfully ignorant of the wonderful “saves” out there. Add to this a complete lack of awareness of what different specialties actually do, and the system creates perfect conditions for disharmony. One of my shorthands as an ED reg over 10 years ago was ‘GPFI’ – GP is a ****ing idiot. My how we laughed. Now I am older and wiser.

A recent article in the NY Times captures this problem well, describing a paper in the Journal of Internal Medicine “Physicians Criticising Physicians to Patients” which has been re-tweeted by myself and others. The NY Times article on doctors badmouthing other doctors is worth a read.

“doctors will throw each other under the bus”

As a more grownup clinician in rural practice, a salutary experience for me was managing a patient presenting with acute-on-chronic back pain. I admitted him for analgesia..then 24 hrs later his BP dropped suddenly and the underlying sepsis from his epidural abscess declared itself – the source from an infection picked up a week or so prior whilst gardening. His retrieval & intensive care stay was prolonged and complicated, with devastating sequelae.

A single comment from an ICU nurse “you should sue your doctor for missing this” drove a three-year wedge between myself, the patient and family – very difficult in a small rural community, but eventually healed once the time course and decision-making had been explained. Systems failings (no ‘early warning’ notification, failure to appreciate significance of raised respiratory rate and falling urinary output so deterioration not communicated to doctor) all had their part to play, as did cognitive bias ‘just a flare of usual back pain’. But that chance comment from an ICU nurse undermined the therapeutic relationship.

That’s one example. I am sure you will all have similar stories. The ‘barndoor’ appendicitis referred to the medics as gastro by an ‘idiot ED reg’. The flail chest mismanaged as an infective exacerbation of COPD on the Care of the Elderly ward after a patient has fallen against bed rails. Mistakes happen, diagnoses are revised. But we are often quick to hang our colleagues out to dry with the benefit of the retrospectoscope.

Beware critique of others - but NEVER be afraid to apologise for an error

Beware critique of others – but NEVER be afraid to apologise for an error

The more medicine I do, the less certain I am. As a senior doctor I have more appreciation of the myriad presentations of disease, the understanding that patients don’t always ‘follow the textbook’. Contrast this to the cocksure certainty of a relatively junior doctor. The old adage rings true – “How do I avoid making mistakes? By getting experience! How to get that experience? By making mistakes!

FOAMed helps broaden that experience, sharing experiences and clinical discussions with colleagues worldwide. “Doing the simple things, well” is the essence of not just critical care, but all branches of medicine – particulalry in resource-limited rural Australia. Meticulous attention to obs (especially RR), use of bedside testing such as point-of-care lactate, having a heightened sense of “what if?” all contribute to better outcomes.


To be a ‘plus one’ a ‘zero’ or a ‘minus one’? Your choice…

All of which brings us full circle and (finally) to the purpose of this post. As ultra-competitive clinicians, trained to be better than our colleagues in order to progress in a system that seeks to limit entry at every waypoint, it is all to easy to fall into the trap of self-aggrandisement and for want of a better word “pissing on perceived competitors”. But does this REALLY help anyone? Of course not. we are all players in the healthcare team, yet it is almost de rigeur to criticise the perceived failings in other specialties without any understanding of what they do.

How then does a team function well when all the members are highly competitive? I’ve just finished reading Chris Hadfield’s book “An Astronaut’s Guide to Life on Earth“. It’s not a bad read, although I suspect is a springboard for former International Space Station Commander Hadfield’s retirement from the space programme into motivational speaking.

Hadfield talks about initial assessment of team members as ‘plus ones’, ‘zeroes’ and ‘minus ones’

Astronauts are all ‘plus ones’ – highly competitive, incredibly skilled across disciplines (he describes a typical day as performing ocular & cardiac ultrasound on fellow astronauts, fixing a malfunctioning toilet, playing Bowie’s ‘Space Oddity’ on guitar and Commanding the ISS). ‘Plus ones’ add value to the situation – they are leaders. Everyone wants to be the ‘plus one’ in a situation, in order to demonstrate their value to the team. That’s only natural when you are used to competing.

It should go without saying that there is no room in space (or in healthcare teams) for ‘minus ones’ – people who detract from the team plan. They cause problems, whether through laziness, inefficiency or lack of awareness.

But Hadfield outlines the BEST astronauts as the ‘zeroes’ – people whose input is neutral and doesn’t tip the balance one way or the other. Typically they quietly get on with the business of ‘making things happen’ – helping colleagues not for personal gain but because it helps the team overall. Reflective before acting. Competent information sponges.

In medicine we all strive to be ‘plus ones’, often by being the first to answer in a small group session, the first to critique patient management until the patient came under your brilliant care, or to blame ‘the GP’ or ‘those clowns in ED’ for dumping a patient on the already busy acute medical take. But declaring yourself as a ‘plus one’ in a situation almost guarantees that you will be perceived as a ‘minus one’ regardless of the skills you have. we see this when selecting instructors for EMST – we don’t want the flashy know-it-all, we are looking for the quiet, reflective achiever (the ‘zero’) who helps others become ‘plus ones’.

The take home message? I paraphrase from Commander Hadfield’s book :

When you have some skills but don’t fully understand your environment, there is no way you can be a ‘plus one’. At best, your can be a ‘zero’. But being a ‘zero’ is not a bad thing to be. You are competent enough not to create problems or make more work for everyone else. And you have to be competent, and prove to others that you are….

…even later, when you do understand the environment and can make an outstanding contribution, there’s considerable wisdom in practicing humility. If you really are a ‘plus one’, people will notice – and they’re more likely to give credit when you’re not trying to rub their noses in your greatness

Our environment as clinicians is the entire health care system. We occupy different ecological niches (with some amazing psychopathology between us) – primary care – emergency – surgery – medicine etc. yet we often have little understanding of what happens in other disciplines and are quick to critique. Even more so when all we see is other people’s mistakes (ED, ICU).

But unless you understand the nuances of another discipline, be slow to critique and quick to praise.

Be a ‘zero’ not a ‘hero’. Wise clinicians know this.

 

 

COMMENTS FROM TWITTER  - keep ‘em coming or (better still) add a comment below :

@KangarooBeach Great stuff, spot on! The consultants I respect most: play zeroes, step up to heroes if need. Love the vid, @Cmdr_Hadfield !

Brilliant article from @KangarooBeach about badmouthing colleagues: Be a ZERO, Not a HERO

“Be a Zero, Not a Hero” Great stuff by the inimitable @KangarooBeach MT @emcrit: great read feedly.com/k/1euyYLb

Brilliant post from @KangarooBeach: Be a Zero, not a Hero. kidocs.org/2013/12/zero-h… #FOAMed

Such an excellent post Tim!!! Ironically a ‘plus one’ précis about some pervasive concepts :-) @KangarooBeach

Simon Carley @EMManchester

@AndyNeill @KangarooBeach Thanks for this piece – time to reset to 0

@KangarooBeach “Be a ZERO not a HERO” is a brilliantly written article, thank you. (def going to check out @Cmdr_Hadfield‘s book) #FOAMed

@KangarooBeach hey nice article on zero vs hero! maybe we can get @Cmdr_Hadfield to do a podcast about it?

@johnboy237: Follow this link ‘Be a ZERO not a HERO’ wonderful & truthful insight @KangarooBeach kidocs.org

@KangarooBeach @Cmdr_Hadfield Absolutely Tim! You enjoying the book too?

Andrew wrote: “Good one Tim, but would love to use GPFI on triage screen.”

From Tacloban to Antarctica

I’ve just caught up with former KIDoc, Dr Jamie Doube – Jamie is special for doing his GP registrar years in part on Macquarie Island with the Australian Antarctica Division as both Station Doctor but also as a major player in the program there to eradicate rabbits from this pristine environment.

He is way to humble to mention that he got the Antarctica Medal in 2011 for this work. He is also a useful doctor – trained as both rural & remote doctor, plus GP-surgeon and GP-anaesthetist. Not sure if I can convince him to get the trifecta of GP-obstetrics…

Like many rural proceduralists, Jamie is a ‘multi-tool’ – adaptable to many situations. I had a conversation with Dr Minh le Cong about the value of rural generalists last week on an RFDS STAR course. As you know, Minh is a country doctor-turned retrievalist, and cites many examples where rural doctors have proved their worth in the prehospital environment (with skills in EM, obstetrics, primary care, trauma and anaesthesia). Jamie and I had a similar conversation after the podcast (below) and are keen to encourage rural generalism as an excellent career path, opening doors into a variety of specialties.

Jamie was with me on KI when he got the call to be part of Team Alpha as part of the Australian Medical Assistance Team (AusMAT) response to the ‘super-typhoon’ that decimated the Philipines in November.

AusMAT is one of a number of agencies, both Govt and NGO, who respond to disasters. Ironically AusMAT training had occurred on Kangaroo Island the week prior, but this exercise was no comparison to the Philipines disaster response.

Tacloban Disaster after "super-typhoon"
Tacloban Disaster after “super-typhoon”

You can read more about AusMAT and the Australian National Critical Care Response Centre below.

AusMAT courses

I spoke to Jamie last week after he got back – and he sounded buggered after some extraordinary work in Tacloban treating victims.

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But since then he’s been off on another adventure, as part of the Australian Antarctica Division response to a helicopter crash on the ice with three seriously injured expeditioners. The sheer logistics of retrieving survivors from a crevasse-laden ice field, using a variety of aircraft, to the nearest AAD Base and then transfer to an airstrip is phenomenal – a five day retrieval of over 5000km. By all reports the expeditioners are doing well, a credit to the expertise of the AAD. No doubt an ATSB report will be released in due course – but to survive a crash on a remote ice field is impressive.

station_map

The A319 used to transport injured expeditioners is on a groomed ice runway

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Have a listen to Jamie talk about his experiences.

 

Click HERE to download

Why FOAMed?

There is a slow move towards FOAMed from rural doctors – a good thing, as we have the most to gain by virtue of both the nature of our work (spanning arenas of primary care, emergency medicine and procedural skills) as well as isolation.

There’s a nice vodcast from Chris Nickson over at lifeinthefastlane.com – take 20 minutes to watch it – there’s a youtube link (below) or via the LITFL website

http://lifeinthefastlane.com/foam-facts-fallacies-foibles/

 

In essence, FOAMed allows

- rapid dissemination of new ideas relevant to your practice

- sharing of resources

- corridor conversations with colleagues around the country and overseas

- asynchronous learning – updates in your time, not having to travel

- rapid delivery of pertinent medical information tot he bedside

- better learning, better teaching

- an ethos of collaboration & sharing

 

Watch Chris’ video and see how you go…

 

 

Trainee questions? Flip “ASK” into “KSA”

A recent supervisors workshop has made me think about how I structure teachjng sessions – often a medical student or registrar will come along and say ‘teach me something’ – My teaching is often shaped by what I am interested in, by events that have happened recently or by the desire to finish teaching ASAP and get to the pub.

Even when the subject matter seems clear, it may be hard to give structure to teaching rather than ‘winging it’.

This week I was exposed to the KSA approach. We’re all familiar with the ‘flipped classroom’ – as well as pre-teaching preparation, if you are bailed up on the run or in the corridor then:

“flip the trainee’s ASK to KSA”

Consider these three domains relevant to any topic :

  • ‘knowledge’
  • ‘skills’
  • ‘attitude’

…or KSA.

Then consider what you wish to impart :

  • the learning objectives
  • the desired competencies that need to be reached
  • how you will achieve this (strategies).

Then apply them across each of the KSA domains.

 

Screen Shot 2013-11-28 at 6.04.24 pm

 

As an example, let’s say we sit down to have a chat after dealing with an emergency psychiatric presentation requiring intravenous sedation, detention and transfer.

Knowledge might include

  • assessment of the acute psychiatric patient
  • focused history & examination of agitated patient
  • pharmacology and rationale selection of ‘take down’ medications
  • understanding risks of procedural sedation inc psychiatric risk vs anaesthetic risk
  • knowledge of appropriate mental health criteria for detention

Skills might include

  • confidence with assessment and history
  • ability to consider IN-IM-IV-PO routes of drug administration, pros/cons
  • use of ETCO2 in monitoring sedated patient
  • completion of appropriate mental health paperwork
  • use of Richmond Agitation Sedation Scale
  • use of appropriate suicide risk scores

Attitude might include

  • understanding how to manage own feelings towards psychiatric emergency
  • human factors in emergency team work
  • interagency attitudes with police, ambulance, retrieval, mental health teams

Using this matrix has helped me consolidate my teaching approach.

Thanks to Adelaide-to-Outback for suggesting this tool.

 

So much hot gas – ETCO2 for non-anaesthetists

End-tidal CO2 is increasingly becoming used outside of the Operating Theatre and it is prudent for the rural doctor to have an appreciation of what it is, how to measure it, when to measure it and it’s utility in common scenarios.

“you get A, B & C in a single squiggly line” 

Casey Parker, BroomeDocs.com

It is my belief that ETCO2 should be used not just in intubated patients, but as a valuable adjunct for procedural sedation, for monitoring patients ‘at risk’ and to help guide resuscitation.

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What is end-tidal CO2?

Unlike plants, we breath in oxygen and exhale carbon dioxide – we can measure this as ‘end-tidal CO2’ (ETCO2). ETCO2 represents the partial pressure or maximal concentration of CO2 at the end of exhalation. The principle determinants of ETCO2 are:

(1) alveolar ventilation,

(2) pulmonary perfusion (cardiac output)

(3) CO2 production (and elimination)

How can I measure it?

We can measure ETCO2 in several ways

(i) colorimetric

Devices such as the Easy-Cap or Pedi-Cap are designed to confirm the presence or absence of expired CO2 – a pH detector (metacresol purple on filter paper) detects pH shifts and changes to the colour yellow in the presence of expired CO2.

Colorimetric ETCO2 device connect to endotracheal tube

Colorimetric ETCO2 device connect to endotracheal tube

GOLD IS GOOD

“GOLD IS GOOD”
colour change from purple to yellow indicates presence of CO2 > 2%

 

(ii) waveform capnography – during BMV or mechanical ventilation

A sample line is placed as a sidestream to the breathing circuit (usually via the HME filter at intersection of endotracheal tube and breathing circuit). Exhaled gas is sampled by a dedicated analyser (anaesthetic monitor or some defibrillators).

Typically such methods generate both a waveform (capnograph) and a number (ETCO2).

 

wave-2

The ETCO2 capnograph – consider the baseline, height, shape, frequency, rhythm

 

The normal capnograph trace can be divided into distinct phases

I – the end of inspiration & the beginning of expiration, when the Co2-free gas occupying dead space in airway is exhaled. Hence in theis phase the ETCO2 = 0 mmHg

II – there is a rapid rise in measured CO2 as alveolar gas appears

III – expiration continues but CO2 doesn’t rise much further – a plateau in normal lungs. ETCO2 total is derived from the maximum on this plateau

IV – a sharp drop in CO2 to zero, representing inspiration

 

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Propellor heads can get excited about different phases. Be aware of them.

 

 

The capnograph gives us lots of information in addition to the absolute number of ETCO2 (aim 35-45 mmHg). It is easiest to consider the waveform baseline, height, frequency, rhythm & shape.

You can correlate changes in patient or equipment as being reflected in the ETCO2 trace eg:

baseline – non-return to zero caused by re-breathing

height – increasing ETCO2 due to excess production eg: malignant hyperthermia

frequency – decrease or increase in ETCO2 peaks in hypo- and hyperventilation respectively

rhythm – patient breathing vs mechanical ventilation as neuromuscular blockade wears off

shape – obstructive ventilation pattern causes a slow phase II upstroke

 

There are some must know waveforms in the ‘rogues gallery’ later below. The ones I worry about most are the absent or rapidly disappearing ETCO2 rtace seen in inadvertent oesophageal intubation…and the falling ETCO2 waveform with loss of cardiac output.

 

(iii) waveform capnography – during spontaneous ventilation

As an alternative to sampling expired gas directly from the anaesthetic circuit or HME filter attached to an endotracheal tube, it may be useful to monitor ETCO2 for spontaneously ventilating patients, whether on room air, nasal specs or oxygen mask.

I use this routinely during endoscopy, colonoscopy in the operating theatre, as well as when performing procedural sedation in the ED. I am increasingly using ETCO2 monitoring to confirm ventilation in other situations – particularly to confirm ongoing ventilation of the agitated psychiatric patient who has been effectively sedated with agents such as benzodiazepines, haloperidol or ketamine – mindful that hypoventilation or apnoea may be missed.

Remember that relying on SpO2 to confirm ventilation is inadequate – measured oxygen saturation may remain elevated for some time after cessation of breathing-  and once a fall in SpO2 has been detected, your patient is already hurtling down the oxy-haemo-coaster.

Beware the falsely reassuring statement “He must be breathing – the sats are OK” - use ETCO2 to gauge ventilation

In ED ot theatre, there are different gizmos. Most ETCO2 sampling equipment is dedicated to sit in-line as either an adaptor between ETT and circuit, or as a filter line to attach to HME filter. There are also sampling devices designed to sit under nares like nasal specs.

I tend to just take the sampling line from the HME filter, attach to a microfilter and then attach to either blunt cannula or plastic tube of an IV – this can be pushed through the holes in a Hudson mask to detect ETCo2 for patients receiving sedation NB: the ETCo2 will be LOW as diluted by oxygen.

Ubiquitous Dr Minh le Cong offers some hints on MacGyvering ETCO2 setups below :

Prehospitalmed.com “Capnography with LifePak 15” – Dr Minh le Cong

Noninvasive Capnography Setup (PK talk) – Dr Minh le Cong

http://www.youtube.com/watch?v=EJNqMKnd050

as do the mob from the EM resource ‘Standing on the corner minding own business’ (SOCMOB)

how to make your own end-tidal CO2 detector

When should I measure ETCO2?

End-tidal CO2 is classically considered as the standard of care when performing intubation. Either colorimetric or waveform capnography can be used to confirm the presence of exhaled CO2 and hence confirm desired tracheal vs inadvertent oesophageal intubation.

The waveform also gives clues to alveolar ventilation (hypo- or hyperventilation), airway resistance, cardiac output, CO2 production & elimination, as well as the obvious confirmation of tube placement within the trachea – both initial & ongoing.

Other uses include :

  • confirmation of tube placement & efficiency of compressions during CPR
  • sudden increase in ETCO2 during CPR may indicate ROSC
  • during sedation to confirm ventilation when direct observation of the patient may be difficult (eg: under drapes/blankets/on side)
  • in psychiatric sedation to achieve effective sedation & avoid apnoea
  • during transfer to confirm presence of cardiac output & adequate ventilation
  • as a numeric target to aim for eg: in treating the head-injured patient where normocarbia, normotension and avoidance of hypoxia are key goals to avoiding rises in ICP.

 

Thus we can summarise ETCO2 measurement as :

  • to confirm tube placement
  • to confirm ventilation & perfusion of patients during mechanical ventilation
  • to confirm ventilation of patients who SHOULD be self-ventilating (but at risk of hypopnoea or apnoea)

 

The clinical bottomline?

End-tidal CO2 monitoring is mandatory not just for the intubated patient, but should be used whenever using a neurolept eg: sedation in ED, monitoring of psychiatric patient etc.

Even if you are not performing anaesthesia, know how to hook up ETCO2 monitoring for your spontaneously ventilating patients at risk of hypopnoea or apnoea.

Dedicated ETCO2 monitors exist, but most capnographs will hook up to existing monitors in OT, ED and ward defibs.

Insist on the use of ETCO2 monitoring in your shop.

 

ETCO2 waveform capnography is now available in handheld monitors - along with SpO2, HR, RR etc

ETCO2 waveform capnography is now available in handheld monitors – along with SpO2, HR, RR etc

 

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ETCO2 monitoring is available for the Phillips Heartstart MRX used in most rural EDs and with SA Ambulance

M3536A-2T

Where can I find out more?

Life in the Fast Lane posts on capnography and interpreting waveforms

Check out Prof Kodali’s website capnography.com & read his excellent paper entitled “Capnography outside operating rooms” (download here)

You may also be interested to read those Norse Gods of resus (ScanCrit) on capnography in cardiac arrest & Cliff Reid’s post on ‘even the dead exhale CO2′ – explaining why you MUST use waveform capnography in resus

 

 

ROGUES GALLERY OF ‘MUST KNOW’ ETCO2 WAVEFORMS

 

NB: these images downloaded from Google. I haven’t been able to find the author to attribute, so apologies if unattributed. I reckon an American source (who else omits the diphthong in oesophagus?)

 

OESOPHAGEAL INTUBATION

HYPOVENTILATION

HYPERVENTILATION

 

REBREATHINGONSTRUCTION CUFF LEAK

FAULTY VALVE

INADEQUATE NEUROMUSCULAR BLOCK

 

SUMMARY OF CAUSES & ETCO2 CHANGES

 

FLAT ETCO2 TRACE

  • Capnograph not connected
  • Oesophageal intubation
  • Airway (ETT) misplaced
  • Respiratory or cardiac arrest
  • Capnograph sampling tube kinked or blocked
  • No ventilation – either forgot to bag the patient or there is a ventilator malfunction

SUDDEN DROP IN ETCO2 TO ZERO

  • Kinked ET tube
  • CO2 analyzer defective
  • Total disconnection
  • Ventilator defective

SUDDEN CHANGE IN BASELINE (NOT TO ZERO)

  • Calibration error
  • CO2 absorber saturated (check capnograph with room air)
  • Water drops in analyser or condensation in airway adapter

SUDDEN INCREASE IN ETCO2

  • ROSC during cardiac arrest
  • Correction of ET tube obstruction

ELEVATED INSPIRATORY BASELINE

  • CO2 rebreathing (e.g. soda lime exhaustion)
  • Contamination of CO2 monitor (sudden elevation of base line and top line)
  • Inspiratory valve malfunction

INCREASED ETCO2

CO2 production

  • Fever
  • Sodium bicarbonate
  • Tourniquet release
  • Venous CO2 embolism
  • Overfeeding

Pulmonary perfusion

  • Increased cardiac output
  • Increased blood pressure

Alveolar ventilation

  • Hypoventilation
  • Bronchial intubation
  • Partial airway obstruction
  • Rebreathing

Apparatus malfunction

  • Exhausted CO2 absorber
  • Inadequate fresh gas flows
  • Leaks in ventilator tubing
  • Ventilator malfunctioning

DECREASED ETCO2

CO2 production

  • Hypothermia

Pulmonary perfusion

  • Hypotension
  • Hypovolemia
  • Pulmonary embolism
  • Reduced cardiac output
  • Cardiac arrest

Alveolar ventilation

  • Hyperventilation
  • Apnea
  • Total airway obstruction (high airway pressures)
  • Extubation

Apparatus malfunction

  • Circuit disconnection (low airway pressures)
  • Leaks in sampling tube
  • Ventilator malfunctioning

 

RFDS STAR course

Readers of the KIdocs.org blog will be aware of my feelings re: courses for rural doctors. There are a plethora of ‘alphabet soup’ or ‘merit badge’ courses out there for entry-level as a rural registrar or doctor – ALS, APLS, ALSO, ATLS(EMST) etc.

As career progresses, we are required to maintain continuing professional development. Most of us find it easiest (and most productive) to spend a fortnight upskilling in a tertiary centre – doing emergency medicine, epidurals, elective anaesthesia or obstetrics as appropriate to our skill mix and needs. There are also courses such as REST (in SA RESP) – indeed I understand that RESP is going to become mandatory to complete every three years to maintain credentialling to work in SA rural hospitals.

I did a RESP course back in August – and whilst content was relevant for rural EM, it sets the bar pretty low. It was salutary that relevant topics such as NIPPV were ostensibly ‘covered’ – yet delegates reported inability to practically apply this modality on a real patient a few weeks later. Box ticked – but functionally useless.

An ideal course would target content for the rural proceduralist, incorporating relevant FOAMed material and allow hands-on opportunities that translate into practice. The pilot ‘rural masterclass’ was one such endeavour, there are plenty more.

Tim @ RFDSSTAR

I’ve just got back from the RFDS STAR course. Held in Brisbane at the Queensland Combined Emergency Services Academy (QCESA), this three day course is aimed squarely at those involved in the aeromedical environment. I am not a retrievalist, but am interested in prehospital medicine (my work occasionally requires involvement) as well as managing critical illness in the rural environment. So there are intersecting spheres of expertise making this course relevant for the rural doctor. Here’s a summary :

 

Course : Essential Aspects of Aeromedical Retrieval, RFDS STAR programme

The RFDS STAR program (specialised training in aeromedical retrieval) is a QLD RFDS initiative. They run two courses – “essential aspects of aeromedical retrieval” and “pre-hospital anaesthesia & airway management“.

 

Cost & Manual: $2600

Course cost is $2600 for the course inc meals, course manual etc. Procedural grants apply for those eligible. One also needs to factor in flights, accommodation, incidentals. NB: Whyte Island is some distance from the CBD and taxi fares are of order $50-75 each way.

The course manual is well-written, encourages reflective practice and is well-referenced. FOAMed concepts are spread throughout, along with challenging case scenarios and commentary from the authors. A few ‘holy cows’ of emergency medicine are examined and debunked – cricoid pressure, ketamine in head injury, COETT for psychiatric retrieval, permissive hypotension etc. As such it is aimed at the sharp end of prehospital care and I imagine content evolves to reflect this.

 

Location : QCESA Facility, Whyte Island, Brisbane QLD

This is a dedicated multiagency training centre. Not only are there conference rooms and break out rooms, but also a whole ‘play area’ covering several acres comprising gantries, industrial areas, hospital emergency room, houses, earthquake zone, shops and banks, gas station, car wrecks etc – all of which can be used to simulate training including

  • fire department
  • paramedics
  • small rural ED
  • urban search & rescue (USAR)

The course is well-catered, with functional mess room and provision of on site breakfast, lunch and dinner as well as morning/afternoon tea. 3G reception was patchy.

The QCESA facility with mock ED, houses, earthquake, shops, industrial

The QCESA facility with mock ED, houses, earthquake, shops, industrial

 

Accreditation : ACEM, ANZCA, CICM, ACRRM, RACGP, CASA

Australian College of Emergency Medicine – 42 points

ANZCA – 2 points per hour

College of Intensive Care Medicine – 2 points per hour

RACGP – 40 points

ACRRM – 30 points plus 10 Anaes, 6 O&G & 30 Emergency Med MOPS points

Civil Aviation Authority – 13 hours of DAME CME

 

Delegates : 24 per course

The course I attended had a mix of RFDS doctors and flight nurses, intensivists, anaesthetists, emergency doctors, paramedics, rural proceduralists and DAME doctors. Some of the most impressive attendees were those from existing HEMS services – in particular ICPs from the Perth Rescue chopper.

Minh demonstrates SMACC2013 conference bag as airway kit bag

Minh demonstrates SMACC2013 conference bag as airway kit bag

 

I KNEW IT ! Minh demonstrates the KIdocs version of kit dump - and RSI challenge-response checklist

I KNEW IT ! Minh demonstrates the KIdocs version of kit dump – and RSI challenge-response checklist

 

CONTENT :

 

Day One : 08:00-17:30

- History of aeromedical retrieval

- Aeromedical physiology theory and cases

- Choice of transport platform

- Human factors in aeromedical retrieval

- Tricks of the trade (interactive)

- Skills stations & Case studies x3 (45 mins each) : bariatric, paediatric, psychiatric

 

Day Two : 08:00-24:00

Morning based at RFDS base, general aviation

- Skills stations x 3 (50 mins each) : stretchers & manual handling, drugs & equipment, preparation and interfacility transfer

Transfer back to Whyte Island facility

- Real world case studies

- Becoming ‘scene savvy’ – surviving prehospital environment

- Transport of trauma patient

- Stay & Play vs Load & Go, case discussions

- International retrieval

- Primary Response Scenarios (6pm to midnight)

 

Day Three : 08:30-15:00

 

Debrief from previous Primary Response exercises

Breakout sessions on airway management (two hours) and obstetric emergencies (two hours)

Military aeromedical retrieval

OLYMPUS DIGITAL CAMERA

USS identification of the cricothyroid membrane

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Breech deliveries, shoulder dystocia, TPL and PPH practice

SIM SESSION DAY TWO

The primary response scenarios were challenging and fun; conducted in the ‘kill zone’ of Whyte Island, small groups rotated through nine difference scenarios…in the dark…with unexpected challenges and using first responder kit – enough for advanced airway management and haemostasis, splinting and stabilisation. Strong winds and thunderstorms added an air of realism.

 

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Pre-exercise briefing

 

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Flash teams dealing with … the unexpected.

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Anticipated clinical course – extricating the crushed patient. Will bicarb help?

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It’s just a small splinter. Photo doesn’t show that are on top of a 30 m gantry…

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Crystalloid not colloid, titrated to radial pulse…

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You’ll be needing the tourniquet and some tranexamic acid then?

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CICO in the back of an ambulance

 

The SIM house - beware the unattended baby!

The SIM house – beware the unattended baby!

 

Some of the scenarios were real bus wrecks...

Some of the scenarios were real bus wrecks…

Recommendations

I would recommend this course to the rural doctor with an interest in prehospital medicine. Note that the content is  predominantly skewed towards aeromedical retrieval, rather than rural medicine. Interestingly three of the Faculty were rural generalists (Drs Minh le Cong, Tonia Marquardt & Shaun Parish), reinforcing my belief that rural generalism is the best ‘swiss army knife’ for prehospital and retrieval.

Even though geared towards the needs of RFDS staff, there is sufficient useful information and training in patient preparation, understanding decision-making in retrieval and tips on trauma, psychiatric retrieval, prehospital airway management and obstetric crises to be useful.

It would be worth considering the separate ‘prehospital anaesthesia’ STAR course for rural doctors with involvement in prehospital emergencies, those dealing with airways in ED or GP-anaesthetists looking for a challenge.

It certainly is at a level above the usual EMST-ALSO-RESP-APLS courses.

 

Criticisms

 

Relatively few. A credible Faculty, lots of opportunity for discussion.

I would have preferred some more emphasis on difficult airway planning and perhaps formation of small ‘flash teams’ to practice use of kit dump, RSI challenge-response checklist, difficult airway drill and extrication PRIOR to the evening exercises, in order to embed skills first within teams and to then test them under challenging circumstances. This could start from day one and perhaps allow shortening or abandonment of sessions on aeromedical physiology and history.

Rural Docs ‘Value Adding’ Pre-Hospital?

Last year I was amazed to discover that over 50% of my rural GP-anaesthetic colleagues stated that they had been called out to some form of prehospital incident in the previous 12 months. I think we need to be very clear that the pre-hospital environment is VERY different to that of the resus bay or ED, let alone the operating theatre or consulting room!

The experts in prehospital care are the State-based paramedics and retrieval services; indeed we should all be agreed that this is no place for ‘enthusiastic amateurs’. But there’s the problem – rural Australia suffers from the tyranny of distance and it can take many hours for expert retrieval help to arrive. Add to that the fact that the more rural you go, the more likely it is that the ambulance will be staffed not by career paramedics, but by volunteers – local farmers, office workers, business people who have undergone training to a Cert IV level in ambulance.

Yet in the background there is the realisation that critical illness does NOT respect geography. Rural trauma is not uncommon and tends to be severe – the high-speed, unrestrained rollover – the arm degloved by a PTO shaft – the fall in isolated bushland etc.

Kerang Disaster & Rural Doctors

A recent illustration of this was the Kerang train crash – local doctors, many with advanced airway and resus skills – were disappointed at not being allowed on the scene. The Coroner seems to have fudged this issue, calling for ‘emergency management coordinators to be aware of the importance of including representatives of all the support services involved in the emergency response in the emergency Management Team

PHARM - Kerang train crash 2

Kerang Train Crash in 2007 – local docs not involved

You can read more of the Coroner’s report into Kerang here and download the findings here

The RDAA put out a press release at the time and it was reported that there was some angst about not utilising local doctors at the scene.

Enthusiastic Amateurs vs Tyranny of Distance

I understand that ambulance & retrieval services do not want enthusiastic amateurs on scene – and agree with this sentiment entirely. There is, frankly, little point in the local GP arriving at a rollover with no PPE, no kit and no understanding of the prehospital environment – let alone the fact that rural docs are a heteroegeneous bunch – some have advanced airway skills, some do not….and yet it is the same ambulance and retrieval services who call the rural doctor out when they cannot respond as soon as needed.

So it has always puzzled me – there appears to be NO formal system to involve rural proceduralists (“not just a GP” but doctors with skills in resus and airway management) to ‘value add’ to the scene.

The UK has BASICS (british Association of Immediate Care Schemes) – New Zealand has PRIME (Primary Response in Medical Emergencies) – and yet these are small countries with relatively shorter retrieval distances than rural Australia. Both are designed to get the RIGHT PERSON to the RIGHT PLACE at the RIGHT TIME ie : utilise a cadre of trained clinical staff (doctors, nurses) to respond to an incident to SUPPORT ambulance staff prior to transport &/or retrieval.

SA leads the way with Rural Emergency Responder Network

We had nothing like this in Australia – and seemingly no push for this sort of network from either RACGP (as expected), ACRRM (bit disappointing) or RDAA (surprising!).

But in recent years the SA Health department has created the Rural Emergency Responder Network – and in Nov 2013 RERN won a prize in the SA Health awards.

You can read more about RERN & prehospital care by clicking HERE or watch the short video below.

One of the things that sets RERN apart from other agencies (such as BASICS) is that doctors are paid for their time (at rates better than usual call out fees) AND the system allows “opt out” – if unavailable or committed elsewhere. Doctors are also kitted with PPE and equipment.

Call outs are infrequent. There is really NO place for calling a RERN doctor unless he or she can value-add to the scene – such as delivering an aliquot of ketamine to facilitate extrication, performing finger thoracostomy or advanced airway management including drug-assisted prehospital RSI. This is tiger territory for the ‘occasional intubator’ or untrained/unequipped rural doctor.

The challenge will be to extend this paradigm across rural Australia – because sure as hell, rural emergencies will continue to happen and local doctors will be called – better that such responses are coordinated and audited, and delivered by trained & equipped personnel.

Of course one can intuitively suggest that such a cadre of rural proceduralists may be mobilised in other disaster – bushfire, earthquake etc. and offer an extra resource of emergency care and LOCAL knowledge in Australian disaster management.

I guess it will be up to rural doctors to drive this – because rural emergencies will continue to happen and we have to decide either to opt out and leave it to the experts (folly in a country the size of Australia) or be serious about how rural docs can deliver best care.

Because if we are not serious about delivering emergency care, no-one will take us seriously.

http://vimeo.com/61989468

 

RERN map