It’s Not About the Helicopter

Just got back from #smaccDUB – I chose not to speak this year and that was a GOOD decision – it allowed me time to actually wander around and soak up some of the high quality talks, as well as to socialise with like-minded colleagues from around the world. FOAMed is the passion which inspires us all – smacc is an opportunity for those interested in resuscitation and critical care to come together unde the FOAMed banner.

Of course #smaccDUB allowed a catharsis for the passing of John Hinds; a moving tribute in the opening plenary set the scene for amore contemplative conference, with many repeating the themes of self-care as well as cutting edge resuscitation medicine.  Progress continues on the establishment of a Northern Island Air Ambulance, a mission which I wholeheartedly support (picture below is of Mark Forrest of ATACC Faculty and myself, modelling the launch of the #whatwouldjohndo T-shirts at the Guinness Storehouse smaccDINNER)

You can get yourself one of these ‘Craic the Chest / #whatwouldjohndo’ or Delta7 pins online and support the funding of a Northern Ireland Air Ambulance

 

Dr Mark forrest modelling the #whatwouldjohndo T-shirts, now available to support #Delta7
Dr Mark Forrest modelling new #whatwouldjohndo T-shirt – click HERE to order & support NI Air Ambulance

 

Thoughts on smaccTALKS?

Highlights (and there were many) include the numerous concurrents (espec the “Igniting Minds” session with longstanding internet colleague Ross Fisher on presentation skills, tips on performance coaching from London HEMS Tom Evens, tips on choreographing learning from Sandra Viggers and the powerful team from FemInEM, tacking gender inequality in emergency medicine – a lesson which equally applies to primary care!)

Many other talks resonated, all of which will be released in due course on the smacc podcast and affliliated blogs. Too many to cover here – monitor smacc.net.au and affiliated websites for both release of talks and various reviews of smaccDUB

I will focus on just one talk – Gareth Davies spoke at the opening session on ‘The Case for HEMS services’ – the title and content of this talk is one which I found somewhat lacking, as it seemed to emphasise the role of the helicopter over the value of the system behind it.

To my mind a good retrieval system is not about the transport platform, but about the quality of the care it delivers

 

This is important. I’ve long been saying that the lessons from mature prehospital services (Sydney HEMS is the leading example in Australia) could and indeed should be applied to other aspects of clinical systems.  This includes the use of appropriate SOPs, checklists for high-risk procedures such as RSI, action cards, understanding human factors relevant to resus room management, understanding of metacognition and heutagogy…as well as breaking down silo mentality and sharing ideas with other organisations for the benefit of both patients and services.

Clearly I am not the only one thinking this way – Scott Weingart picks up the theme in his latest EmCrit Wee on Creating a System of Excellence, discussing the work of Scotland’s EMR service.

Have a listen to the talk here – Scott’s intro and then Stephen Hearns’ talk.

 

 

Creating excellence, regardless of location, is something that resonates with me.  One thing is clear – a well-functioning retrieval service is able to deliver excellent care because it has pluripotency in stable team members and of course trains exhaustively.

It doesn’t rest on it’s laurels and always seeks to engage with other players in the clinical system. Of course this is made easier when there is effective clinical leadership and by the fact that such teams are small, with a fixed number of team members to enable rigorous training.

Plan & Practice the Predictable

Reflect, Learn & Change

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These lessons are, I believe, entirely translatable to the small rural hospital system in which I and many other rural doctors in Australia work. Despite not dealing with critical illness on a day-to-day basis, we are generally made up of small teams and have limited roles and equipment.

This can be an advantage compared to the ‘flash teams’ and plethora of equipment options available in tertiary centres.  Simplicity has advantages!  And yet we seem to suck at it – examples abound of poor management by rural hospitals, much to the chagrin of colleagues in both retrieval and tertiary care.

Part of this is of course the infrequency of such cases….another part is the difficulty of both achieving and maintaining competence, especially as it represents a tiny percentage of the work we do.  But the reality is that critical illness does not respect geography and thus rural clinicians need to be able to deliver the best care regardless of these difficulties.

In short, there is no excuse for the rural hospital team NOT to adopt lessons from prehospital services and incrementally achieve excellence – provided there is both leadership and governance within the system, features often sadly lacking due to the disconnect between clinicians and administration in many hospital systems, especially in rural.

I would like to encourage all rural doctors to listen and watch the vodcast above and then to advocate for improvement.  Some simple measures to implement include:

  • standardisation of equipment (eg: difficult airway, resus room set up) across sites
  • develop easily accessible SOPs for procedures, preferably driven by rural clinicians so content is contextually relevant and not inappropriately metrocentric
  • develop region specific action cards and checklists for high-stakes, infrequently performed procedures
  • explore the use of in situ simulation, preferably multidisciplinary, to refine aspects of what my friend and colleague Andy Buck of ETMcourse describes as Resus Room Management
  • use FOAMed to keep up-to-date and develop skills in metacognition to guard against individual error in diagnosis and management when treating the critically ill
  • audit retrieval or resus cases – not just in terms of clinical outcome, or driven by feedback from metro/retrieval service – instead develop LOCAL audit to consider whether all aspects of knowledge, training, equipment, teamwork were up to par or could be improved.

So rural doctors, let’s work together to raise the bar in rural resuscitation.  Our patients deserve being treated within a system of excellence.  There are some beacons of excellence out there (Casey Parker at BroomeDocs is one, there are many others).  But there are also rural hospitals that are under-performing, whether through lack of knowledge, lack of equipment, lack of team training or lack of leadership.

We need to raise the bar, regardless of the barriers. And the responsibility rests with us…

 

5 Comments

  1. Really interesting post and thanks for the retrospective SMACC insights. Had severe FOMO but look forward to the highlights being posted online.

    Agree entirely regarding trying to reduced variation and with Stephen Hearns’ insights that while resuscitations are complex but you can relegate each component into a relatively simple and manageable portion.

    A

    Reply
  2. Having been at Gareth’s #smaccforce talk the previous day, I heard him express a slightly different perspective. In his words, building an excellent HEMS (or any other) service isn’t about having REBOA, ECMO, prehospital thoracotomy or any of the bells and whistles. It’s about doing the basics consistently well. Don’t strive to be the best, strive to be YOUR best all the time, and the rest will follow.

    I think the emphasis on the helicopter in the plenary was in tribute to all the work John Hinds had done on establishing HEMS for NI, and that’s a bit unfortunate because I thought his talk on the previous day was more generalizable to everyone’s practice. Helicopters allow you to do some great things, but it’s meaningless if you’re not doing the basics well.

    Reply
  3. I think rural hospitals can also utilise the skills of the paramedics in their area. We are a team and w do have skills and insight to offer. This does happen at times, but is not uniform. Nursing staff have often welcomed the help, as we have theirs. We can all work together as a team for the patient’s benefit.

    Reply
    • No argument from me. This does however require interdisciplinary training – in an ideal world, we’d see

      (a) interdisciplinary training at the roadside between eg: SA Ambulance, CFS, SES, RERN – the sort of thing the Holmatro Rescue Experience offers

      (b) interdisciplinary training in rural hospitals – preferably with regular in situ simulation, utilising appropriate team members including doctors, nurses, ambulance officer volunteers. Effective resus room management requires, as alluded to, understanding human factors, use of shared mental models, closed-loop communication, cross-training in equipment and understanding each others capabilities.

      This sort of thing can drive improvements. Silo mentality benefits noone.

      Reply
  4. Good Decision indeed.

    I chose to talk on stage a little and talk on Podcast a LOT. ( 28 Jellybeans!)

    I saw the opening session each day.

    And only one other talk.

    The talk I saw was Kass Thomas speaking about being bombed by the US Military in a MSF Hospital.

    I cried. Then I had to leave.

    Reply

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