Readers will be aware that I often have a (therapeutic) whinge via KIDocs blog – not least because of the constant battle to get equipment in our small country Hospital.
It never ceases to amaze me that equipment deemed ‘essential’ elsewhere is considered an unnecessary frivolity in rural areas by the Health Bureaucrats. Of course there are competing demands – low case load and infrequency of use – countered against the cold reality that ‘critical illness does not respect geography’. Reliance on excellent State-based retrieval services such as RFDS and HEMS (medSTAR locally) is all well and good – unless they take some time to arrive or (rarely) are weathered in.
Regardless the rural doctor needs to be able to manage most presentations, if only for the first hour or so. But they need the right tools for the job, even if infrequent. My passion is airway management and trauma, so I focussed last year on availability of difficult airway kit for rural GP anaesthetists, more in an effort to drive change than anything else. When I arrived, our difficult airway kit was a piece of fencing wire fashioned into a stylet. typically country, but not acceptable.
A further question is whether purchase of equipment is made at a local level, or as part of an organisation-wide policy. Ideally there should be local consultation, coupled with strong leadership within the Health Dept. For example, purchase of a new drug or piece of kit should be made with the clinicians who will actually use it, but also take into account the need for similar kit in other Hospitals, preferably with a top-down approach and purchase in bulk to minimise expenditure. Most medical kit is expensive – and some devices (IO, VL etc) are used infrequently – so allowing recycling of stock between sites or rural-tertiary hospitals would seem to be sensible.
In the news this weekend were concerns from SA ‘health advisory committees’ that funds raised by local communities were being held back by the centralised Health Bureaucracy, a decision that may well be reviewed shortly. As it stands for purchases over $1000 we usually have to plead a case locally, with little leadership from EM or Anaes consultants in CHSA.
It has been interesting this week to read Prof Simon Carley’s thoughts on equipment choice compared to new drug treatments – an entertaining debate. This lead into a wider discussion of how equipment is selected and purchased – do we compare kit the same way we do drugs? Ditto techniques, with the ongoing needle vs knife debate also coming down firmly in favour of knife by London HEMS, as per NAP4.
In a blizzard of available toys, it can be hard for cash-strapped units to make rationale decisions. Moreover any purchase will be confounded by the operator’s experience – for example, a device may work perfectly well when users are trained and maintain skills – but fail when used by a novice. We’ve had issues locally with the Bone Injection Gun IO device. The hyperangulated curve of Bullard-type videolaryngoscopes is another potential hazard. Ditto devices like the QuickTrach for surgical airway – I still reckon a scalpel-bougie/finger-ETT is best.
So one needs to plan for the LOWEST common denominator – I am a fan of planning for locum doctor, agency RN and least experienced EN – having to manage a crisis alone at 3am. If they can manage, anyone can!
So, here are my questions for the ‘truly sick patient’
– if CICO scenario, would you use needle cricothyroidotomy, commerical kit such as QuickTrach or scalpel-bougiefinger-ETT
– if need IO access, which is best – Cook needle, EZ-IO, Bone Injection Gun or other?
– if difficult airway, FastTrach or AirQ-2 iLMA? VL or Miller/McCoy blades?
I have my preference for technique & kit – but as always like to see it backed up by solid evidence. FOAMed helps