Under Pressure

As time goes on, I’ve become increasingly aware that the delivery of good medical care, particularly in a crisis is not so much about knowing facts (although this is important!). Rather other factors come into play.

Recent events are illustrative. Our small rural ED deals with critical illness relatively infrequently. However “critical illness does not respect geography” and this combined with infrequency poses challenges for effective delivery of care.

Local nursing staff are trained in all the available equipment – and although I may grizzle about not having all the kit – we generally have the kit to deal with most crises that present. Such training is usually delivered annually (think CPR/ALS updates) but is not context sensitive or updated other than usual mandatory training.

I’ve long been a critic of the courses available for doctors – APLS, EMST, ALSO, RESP etc – despite being a course director for one of these, I recognise that they are entry level only and not usually up-to-date with concepts familiar in the FOAMed world.

A few weekends I attended a RESP course – the mandatory course required for credentialling in Country Health SA hospitals. I am pleased to say that the pre-course material was excellent and the course objectives delivered – but the course doesn’t really help the experienced rural doctor. It was fun (as always) to manage patient scenarios and debate pros/cons of various ACLS protocols…no mention of apnoeic diffusion oxygenation, occasional intubation strategies, DSI or the subtleties of C-spine and PE criteria. Kudos to the organisers – they achieved their goal – but one has to question the value in having rural doctors repeat the same ‘entry level’ course every few years rather than extending their skills.

One of the topics covered was CPAP (box ticked) – so on paper the attending rural doctors were trained, along with the nursing staff with their in-house training….

..so it was a surprise to be called into hospital a week later as neither duty doctor nor attending nursing staff were confident with delivering CPAP. This is in no manner meant to criticise the clinicians involved. But it does demonstrate the problems of delivering training that is infrequent and not delivered on-the-floor using realistic scenarios….and expecting people to be able to apply this knowledge when under pressure.


It was interesting to attend, re-arrange the resus bay to allow 360 degree access, use the CPAP prompt card to help set up the machine and educate staff as well as have RSI kit dump & checklist available as back up. Getting control of self, team, environment & patient were key. As Cliff Reid would say, this turned a ‘chicken bomb’ into a successful resus.

But it makes me think – what we are doing with existing staff training and rural doctor annual updates isn’t working.

We could do so much better. But until FOAMed is embraced by those who are NOT yet users, such system problems will continue.

And the feedback? Mostly positive…but we could do so much more…

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