Keeping it Simple

One of the enjoyable challenges of rural & remote medicine is delivering high-quality care within the constraints of a health system that is cash-strapped, and where rural doctors often work between private clinic (own business) and public (State-run hospital) domains.

Sadly there exists a health-gap between rural and metropolitan Australians. For many services, health outcomes are worse in the country than in the city. This is in part to the tyranny of distance – the nearest specialist unit may be hundreds or even thousands of kilometres away. It’s also about limited resources.

Conversely some things are done very well in the country – birthing services for selected (low risk) mothers are excellent when delivered by local midwives and GP-obstetricians, as are local surgical services which can offer an almost bespoke service rather than the ‘sausage-factory’ of a major tertiary hospital.

My particular interest is in emergency medicine and the particular problem of how to deliver high-quality emergency care in the bush. The ‘gold standard’ for delivery of emergency medicine in Australia is Fellowship of the Australasian College of Emergency Medicine (FACEM). But FACEMs, like other specialists, tend to congregate in the city hospitals where they can share workload with colleagues and also deal with the stuff they are trained to do on a daily basis.

Meanwhile staffing of the ‘accident and emergency’ department of a rural hospital can be variable – usually there is no on-site doctor, but a service is provided by one of the local doctors in primary care. He or she may have lots of EM experience….or very little. Which can be a challenge for medical and nursing staff who may only see this sort of emergency infrequently.

Well-trained rural doctors take this sort of thing in their stride. Ideally rural doctors have spent a year or so gaining experience in each of obstetrics, anaesthetics and emergency medicine. Excellent courses like EMST, APLS, ALSO, RESP and MOET help to keep rural doctors in touch with current practice.

More important is anticipation of the likely caseload, with planning & training for the worst.   This is not a new thing – recently guidelines for a minimum prehospital equipment setup have been suggested and such standardisation has many advantages. The lack of agreed standards is one of my bug bears.

Perhaps one of the hardest emergencies to deal with is the difficult airway. Training helps, but most of the training on anaesthetic rotations is in elective anaesthesia – I’d argue that the emergent airway is a very different beast!

In South Australia there is no agreed standard on ‘difficult airway’ equipment between the 30 or so rural hospitals. It seems bizarre to insist on appropriate credentialling for doctor’s working in these areas, but not to insist on an agreed standard for the equipment they use.

Perhaps that is a bit harsh. ANZCA has outlined a technical guide on ‘equipment to manage a difficult airway‘ and it is suggested that individual hospitals determine what is best for them.

Recent discussion on a hypothetical case from Minh Le Cong in FNQ made me think about this. Often experts in tertiary centres will ask why adjuncts such as non-invasive ventilation, heliox or fibreoptic intubation were not employed. Simple – we may not have them in the bush.

Hospitals often don’t decide on what equipment is needed until it’s too late i.e. after a critical incident, usually through the lens of a Coronial investigation (the case of blood product availability in the Riverland is a case in point). More problematic, the equipment often costs tens of thousands of dollars, which means local CEOs having to plead a case for their hospital, for a piece of equipment that may only be used once in a blue moon – but when needed, is indispensable. Such is the nature of emergencies.

Rather than the local CWA having to sell a few thousand scones and woolly teddy-bears in their annual fundraiser for the local cash-strapped hospital, I wonder if it might be better to invest in economies of scale. Agree a minimum standard between health units, train medical staff in how to use it, and allow recycling of stock that is infrequently used to the major tertiary centres. In South Australia, integration with the Statewide retrieval service (MedSTAR) would seem logical, with common protocols for low-volume infusions, difficult airway and other emergencies shared across the State.

Thankfully there is light at the end-of-the tunnel. New products on the market offer potential to turn a difficult airway (Cormack-Lehane Grade III/IV into a CL I or II). I am of course talking about videolaryngoscopes and the new disposable fibre optic devices. There’s good discussion here, here anhere on these, which I won’t repeat….check them out for yourself!

I think it is now at a stage where it is indefensible for rural hospitals not to have good quality, easily set-up and maintained equipment for managing the difficult airway, to a standard similar to that of a metropolitan ED.

Costs are coming down, and it would seem logical for health units to agree on a standard (which should be locally-driven) and purchase devices in bulk. Equipment which is used infrequently could be rotated through higher-use centres, much as we currently cycle expensive thrombolytic drugs before expiry dates.

Moreover, medical staff rotating between sites (whether GP-anaesthetist locums or retrieval staff) would be familiar with the equipment used, allowing easier setup and use – often the main problem when in a difficult airway scenario.

What would I recommend? Well, the KingVision VL is cheap and easy to use. The video screen affords good views which can be watched by others in the room. It is going to be my default device if failed direct laryngoscopy.

I’ll also lobby for the Ambu Ascope – a relatively cheap disposable fibreoptic scope than could be an asset for awake nasal or oral intubation…or as a bailout tool to pass an ETT via intubating LMA.

Having the kit is one thing – using it is another. The annual rural doctors conferences (whether State or National) are a chance for both GP-anaesthetists and GPs providing emergency care to meet and discuss equipment, with opportunity for hands-on workshops.

But there’s no substitute for using the gear on a routine elective theatre ist, which again means an investment in training with the kit with a view to ensuring that it’s usable when needed.

What do others think?

3 thoughts on “Keeping it Simple”

  1. Great post TimTotally agree with you on trying to standardise difficult airway gear across all centresSadly I think its not going to happenI asked a senior ICU colleague of mine about this and he said "Why do you think everyone has got a different mobile phone?"Fact is these airway toys become a bit personal for many of us. Some like one toy and others like another. Did you know MedStar were looking at getting the Ambuscope earlier this year? They do have a FOB they can take out on retrieval. I don't think they got the Ambuscope though. But they did have a case earlier this year where the FOB was used successfully on retrieval to Kapunda I think and evacuated a bronchial clot that was causing major problems.

  2. Ah yes, but when it's a mobile phone paid for from Govt coffers, you may not get a choice!Heard a rumour that medSTAR were looking at AmbuAscope, but not sure where they are at currently – feel free to pass my blog comments onto any of your insiders there…I'd be particularly interested if Matt Hooper or colleagues felt that concordance on both equipment and protocols across the board from ambulance-retrieval-rural would be of benefit. Difficult airway, infusion pumps (the Niki T34 is my fav) and low-volume infusions would seem a good place to start and I'd be keen to push this across rural hospitals in SA.Interestingly, one of my former interns who went on to locum as a GP-anaesthetist in SA recently pulled out – his issue? Too much variety in equipment between centres which made him feel unsafe as moved from one locum post to another!

  3. I don't think they got it..doesn't have suction channel but what do you expect from a disposable scope.Its a good idea to have a standard list of gear for airway management. For the moment its probably going to have to be done at an individual level. I don't know about you but I carry my own laryngoscope LED handle and a couple of decent blades. I also carry a Fastrach ILMA disposable set..and now my KINg vision VL. any basic ED setup or country hospital should have the gear to do a surgical airway…even a needle cric. So for <$1500 AU I have my own difficult airway kit, its portable, I know it works because I check it every retrieval shift. If I lose it it can be quickly replaced without selling one of my children.Walk into any ED and you will find different kit, from McCoy blades to Airtraqs to Glidescopes to FOB. Until everyone agrees that a minimum list of kit is actually a good idea, it will be up to individuals to promote best practice in their own practice.

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