If nothing goes wrong, is everything alright?

Big shout outs this month to fellow rural doctors, Casey Parker of Broome Docs and his “lesson’s hard learned” series of podcasts…also to Minh le Cong for discussing various cases from the Coroner.

I have just been compiling a list of Coroner’s cases that I think are salutory reading for rural doctors. Delving through Coroner’s cases may seem intrusive, uncomfortable and voyeuristic. The reality is that the Coroner often makes recommendations … which may not be translated into practice for some time, wither due to systems issues (not least resource limitations) and lack of awareness. As rural doctors we have a tough remit – practicing the breadth of medicine, often without the backup and resources enjoyed by metropolitan specialists.

I believe that FOAMed can help bolster traditional sources of learning – particularly to “help bring quality care, out there” to rural Australians. Even more so when we recognise that ‘critical illness does not respect geography’ and so despite our resource limitations, we need to be able to at least initiate management for the whole gamut of clinical presentations.

Part of that process requires not just technical skills, but also awareness of non-technical skills and understanding limitations/difficulties inherent in our practice. Relevant Coroner’s findings can help shape our practice and are useful, if lessons learned are translated into tangible application in the bush.

One of my favourite papers is “If Nothing Goes Wrong is Everything Alright?‘ – an examination of statistical and psychological factors around rare events in medicine. If we accept that our work involves some degree of risk, for both doctor and patient, then we need to be able to assess this risk, manage it and ideally to mitigate against it.

But if such events are rare, then there may develop an attitude of ‘why bother? It won’t happen!’ amongst individual doctors, nursing staff or even hospital admin.

Worse still, doctors may fall back on anecdote ‘I have never had difficulty with intubation!’ – whilst factually true, may be falsey reassuring when the numbers of procedures performed is low.

The Elaine Bromiley case is one with which most GP-Anaesthetists will be familiar. For me this translated into examining not just my technical competence in airway management, but a long hard look at other factors which I had not really considered. From this I have taken it upon myself to develop

  1. a crisis manual for use in the rural OT and ED, with adjuncts like ED prompt cards & an RSI kit dump
  2. use of a difficult airway trolley in my hospital, backed up with signage and protocols
  3. team training in crisis management with ED and OT staff
  4. a survey of rural GP-anaesthetists and their access to difficult airway equipment, presented at RMA2012, SMACC2013 and published in Rural & Remote Health
  5. FOAMed resources like this for sharing between rural doctors

…and that is just on one area of practice!

In the past week I have taken time to set up a new site – RURALDOCTORS.NET – not so much a blog, more a collection of FOAMed resources for rural clinicians.

I’ve focussed mostly on our work covering EM, Obstetrics and Anaesthetics. There is of course FOAM4GP.com for general primary care stuff, and some excellent blogs rich with educational resources already out there.

RURALDOCTORS.NET is aimed to showcase what is current relevant FOAMed. I will update it, and as Minh suggested, it may form the basis for a rural doctor masterclass. Have a read and if you are familiar with everything there already, congratulations – you have embraced FOAMed. I reckon most of us will find something new – and of course I welcome suggestions of good FOAMed resources specifically for rural clinicians.


But why FOAMed?


Well, if we return to the basic premise :


  • many events in medicine are rare
  • the rural environment has lesser caseload volume, hence less exposure to serious presentations
  • nevertheless, “critical care does not respect geography”
  • preparing for them requires acknowledgment that it could happen, even to you despite previous success
  • preparedness encompasses yourself, your team and the environment
  • technical skills are a given for most of us; what lets us down are non-technical factors
  • we can learn from a variety of sources, but corridor conversations & anecdote are powerful, especially for ‘rare’ events
  • FOAMed and SoMe extend our range, allowing corridor conversations with clinicians around Australia and worldwide, sharing experience
  • this may help mitigate against uncommon presentations and so improve patient outcomes
  • thus delivering “quality care, out there”


I should probably try and whittle that down to a few summary points and put it on a T-shirt!

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