Still a long way to go…

Readers of the KIDocs.org blog and the RuralDoctors.Net site will be in no doubt that I am a firm convert to the FOAMEd or free open access medical education concept. Much of the FOAMed material out there has been heavily biased towards resuscitation themes – such as airway management, massive haemorrhage, inotropes etc.

Why is this of interest to a country doctor? Because our work intersects not just primary care and perhaps a procedural skill, but also emergency medicine. It is important for both bush doctors and the team around them to be able to manage infrequent but serious patient presentations.

It is simply not good enough for rural doctors to wash their hands of these patients and rely upon another service (retrieval or RFDS) to swoop in and rescue the day. We need to be able to perform initial resuscitation to a high standard, despite the barriers of infrequency, de-skilling and resource limitations.

I’ll nail my colours to the mast and state that I think FOAMed has the potential to revolutionise the maintenance of knowledge beyond traditional methods such as EMST-APLS-RESP courses. My efforts to collate relevant FOAMed material on RuralDoctors.Net and to establish a ‘rural doctor masterclass’ are a direct result of this.

However I fear that the remains much work to be done. Recently I was chatting to colleagues involved in retrieval work, both in SA and interstate – and it seems that there are STILL major deficiencies in how critical patients are managed.

I was aghast to hear horror stories of patients with intracerebral bleeds left in left lateral, Guedel’s in situ and on a propofol infusion monitored by an RN for several hours…or the patient in complete heart block, profoundly hypotensive and about to be ‘executed’ by attempts to intubate using propofol before attempts to resolve the heart rate and BP.  Both managed not by inexperienced GPs, but (allegedly) by GP-anaesthetists.

All of which made me think – are their common errors that are being made by some rural docs? And are these a ‘memorable minority’ deserving of criticism, or are their wider problems afoot? I think there’s ALWAYS room for constructive feedback to individuals or health units, but it never ceases to amaze me that there’s no case audit of retrieval cases within CountryHealthSA. Nor is there a good package of education to rural doctors, which is something I am keen to address.

A call to the Twitterati yielded some interesting responses : “@KangarooBeach: Retrieval docs! What are common errors/frustrations with transfer from Oz rural docs?”

Comments in italics, my thoughts in square brackets

  • Secure lines, good sit rep, enough drugs drawn, contingency plans discussed, BMV in hand, safety brief for all [sound advice]
  • Requesting retrieval and asking management advice and then not following the advice given [oh my God, really? That’s poor…]
  • Requesting retrieval for patients when should be having end of life/ NFR discussion with them and family instead [Yep, agree with that. Rural docs shouldn’t be afraid of making the hard choices]
  • Not actually seeing the patient before requesting retrieval [WTF? I can’t believe people would do that! But is from an authoritative source. I’d be kicking their arse…]
  • If pt condition changes, let us know. We send most appropriate skillset for what you tell us. If much sicker problems ensue. [Sound advice from an experienced ambo/dispatcher]
  • Too much propofol to put the patient to sleep, too little propofol to keep them asleep! [Ah, Cliff Reid would be spinning – this is the classic ‘propofol assassin‘ rant and needs to be addressed]
  • Have the pt ready when you say you will. We understand some delays inevitable, but frequently many hours as misc stuff done. [Yep, when there’s time try and package patient before retrieval team arrive – lines secured, tubes in every orifice, paperwork complete – use the transfer checklist….]

All good points – not necessarily comfortable reading for some of us – but if this is how rural docs are perceived, then we need to raise our game…after all “critical illness does not respect geography”

Clearly FOAMed resources can be of use here, at a minimum

  • use of checklists
  • RSI kit dump
  • team training
  • resus room management
  • DASH-1a / NODESAT RSI
  • common protocols between rural hospitals and retrieval services

…the mission will be to embed these in small health units and engender a sense of ownership of resus for rural clinicians, both doctors and nurses.

I’m off next weekend to spend a day with medSTAR on their ‘major incident’ prehospital extrication course for rural docs; all very useful, although I’m not sure how the idea of rural docs responding to prehospital incidents sits within the organisational framework. As it stands, there’s no specific training in resus and packaging for the many rural docs out there.

So….I’ll be working on putting together a video on ‘packaging the retrieval patient’ in the next few weeks. Meanwhile have a listen to this podcast from Karel Habig, Cliff Reid from GSA-HEMS via Minh le Cong at PreHospitalMed.com – an oldie, but a goodie.

PODCAST – PHARM #66 Patient Packaging & Retrieval

Also have a look at the ABC checklist for transfer to give a structure to packaging and handover…

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