Keep it simple


Things are coming together for the Rural Doctor Masterclass on Kangaroo Island in November. We’ve got a great series of speakers – but more than that, an action-packed tentative programme that will focus on small-group hands-on scenario testing. The whole purpose is to translate some of the new FOAMed concepts from abstract to practice for the rural doctor across EM, Anaes, Surgery, Obs & Psych.

I am mindful that for most of us, knowledge translation is a slow process – not because we are lazy or dumb – but because the system in which we work does not embrace change. This is apparent in our credentialling process. In order to be allowed to provide emergency medicine services in Country Health SA hospitals, rural doctors are required to complete one of a number of life support courses each triennium – such as RESP, APLS, EMST, ALSO and their ilk. All good courses – but the content is slow to change and caters for the lowest common denominator. They don;t come cheap either – $2500 or more each PLUS travel and accommodation – the campaign is desperately seeking submissions to try and reverse this shortsighted decision by politicians to cap self-education expenses at $2K per year. A great demonstration of how SoMe has united the profession. Of course this move will hit not just rural doctors hard, but ANY professional group that is required to undertake self-educaiton as a legitimate business expense – pharmacists, midwives, nurses, paramedics, architects, pilots, tradies….the list goes on.

I’m all for capping profligate waste. But I don’t know ANY colleagues who undertake frivolous overseas jollies at five star resorts as a tax dodge, as implied by the ATO. Instead I see hardworking people trying to advance themselves and the care they deliver.

Acknowledging Error

As time goes on, I am appreciating more and more that the best solution to delivering complex care is to ‘keep things simple’. There’s lots to learn in that regard from the prehospital retrieval community who adopt well-practiced simulation training and simplicity of kit to allow them to function. So it will be interesting to throw out a series of challenging cases during the masterclass and see what solutions the medical Macgyvers come up with…

There’s been some congruent twitter discussion this week – Nick Chrimes & Martin Bromiley commented on the importance of simple cognitive aids to help clinical staff when managing an emergency – “under stress staff tend to forget what and how to do tasks” which spawned a debate on cognitive aids and my pet love of checklists.

It is simply not reasonable to expect clinicians (particularly rural doctors & nurses who may deal with critical illness relatively infrequently) to remember what and how to do things. That’s not a criticism – it’s a fact of how humans function under pressure, despite training.

So I’ve been toying with a few simple interventions in our local ED in the past few weeks. These include :

– rearrangement of emergency stacker boxes to enable easier location of equipment under pressure (colour-coding, large labels etc)

  • creating 360 degree access around the resus bay bed to diminish ‘cable clutter’ from monitor leads, suction & O2 tubing, OxyLog circuit and IV lines.
  • re-orientating the alignment of the bed to allow situational awareness of whiteboard, clock, monitors & wall-charts. Why is it that most resus bays have monitors inconveniently located over right shoulder or worse still BEHIND the airway doctor?
  • review of drugs & infusions. Wins have been introduction of tranexamic acid for haemorrhage and calcitonin for hypercalcaemia. Still working on chucking out the gelofusine! Keeping common infusion protocol doses readily to hand as ‘prompt cards’ helps nursing staff who traditionally either disappeared to the distant nursing station to check infusion regimens, or asked the doctor who may be less familiar

We’ve had recent occasion to use the ‘Bone Injection Gun’ for interosseous access. Sadly in 3 of 4 cases there has been failure to deploy (including one inadvertent sharps injury of clinician using the device – wrong-way-around). Whilst I have no doubt that the BIG device works well, the reality is that in a crisis it has failed us and training has failed to mitigate this. The advice from the lead consultant for EM in CHSA is clear – use the EZ-IO device. This is mirrored by colleagues in retrieval and ED, as well as other services interstate. Moreover the EZ-IO is the device most doctors get to train with on their mandatory RESP-ALSO-APLS-EMST courses …. making the decision to purchase a BIG locally all the more perplexing.

Things are at the stage where I’m ready to buy the EZ-IO drill myself and access the (phenomenally expensive) needles through RERN/medSTAR. Better have a device that works in inexperienced hands than a device that works, on past record, 1 time in 4 under real emergency situations. Not because the device is crap – but because humans make errors & we need to acknowledge this and engineer solutions around it.

It is ironic that may have to purchase kit oneself. I made the decision last year to buy a videolaryngoscope for our airway trolley from my own funds as there was no clear direction from the Health Department. Of course in this case the device purchased is a balance of function and cost – the gold standard remains the C-MAC, although at $15K it is hard to justify purchase from my own income. Good to read Simon Carley’s post on DL vs VL over at StEmlyn’s this weekend – I don’t think VL will replace DL, but it’s good to have one available if there is difficulty as both colleagues & myself have found in OT and ED.

Of course, having the kit is half the battle – being prepared cognitively for a crisis is the most important. In the past 18 months and after courses like the excellent EMAC, I have become a fan of sim training to embed skills – logistics over strategy as Weingart would say (echoed by French & Le Cong), or ‘making things happen‘ as Reid teaches. I’ve shelled out locally from own funds to buy an iSimulate package – and I try to add a case onto the end of each theatre list and when teaching our PRCC students. But there’s potential to also co-train with the hospital nursing staff – sadly I am running up against a brick wall which I suspect relates back to the usual ‘private doctors’ vs ‘paid hospital staff’ barriers – as VMOs we have little say in the running of the hospital. Things are getting better over the years, but it’s a slooooooow process. I’ve offered to give up a few hours on my day off each week and come in to run a low fidelity, high frequency sim session on simple emergencies – more to test processes and human factors in a crisis. Previous sessions have highlighted simple deficiencies (a bed that wouldn’t fit through the door to theatere during PPH sim; equipment moved but noone told where had gone). All simple stuff, but not uncovered until either a real or simulated crisis. Sadly enthusiasm from Hospital has been lacklustre, with training emphasis more on theory than practice. Perhaps that’s why noone ever seems to know where the infusion pump or fluid warmer is, despite being trained. Bah!

I’d recommend listening to Weingart and Reid’s talks…

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