I’ve long held the option that the experts in prehospital care are the clinicians who are trained for it – whether volunteer ambulance officers, career paramedics or specialist retrieval services. Doctors don’t always have the capability to ‘value add’ on scene, unless they’ve undergone additional training in prehospital care. Skills from the well-equipped and staffed ED or OT environment don’t always translate to the roadside or austere environment.
We often hear it said that ‘the prehospital environment is no place for enthusiastic amateurs‘ – which is all well and good when ambulance resources are nearby and able to offer maximal care.
But here is the problem. With increasing rurality in Australia, there are less ambulance resources and…sometimes…the ambulance responders may be limited by organisational protocols to fairly low treatment ceilings. More advanced interventions may have to wait for career crew(s) and the arrival of the retrieval service.
It frustrates me to see patients with relatively simple trauma (eg a snapped femur) be limited to two doses of penthrane during extrication and transport in rural locations….whereas in the city they’d get a decent dose of IV analgesia whilst limb splinted to anatomical alignment and transported. But it saddens me still more when multiple injured patients, or those with special needs (traumatic brain injury, burns etc) are denied life-saving interventions until the arrival of intensive care paramedics or retrieval services.
In this wide brown land, such tyranny of distance significantly disadvantages rural patients who suffer a major emergency. Local ambulance resources may be limited and retrieval services may take hours to arrive. Yet Rural Generalist doctors are usually in the community and have ongoing skills maintenance through this hospital work. Moreover they are willing to be called for their community…
This fact is often recognised by clinical coordinators in ambulance services, and they may decide to ‘call the local GP’ despite the general organisational paradigm of ‘prehospital is no place for amateurs‘. Indeed a 2012 survey showed that around 55% of rural GP-anaesthetists had been called to a prehospital emergency in the previous 12 months…but here’s the problem – such responses occurred without formally agreed activation criteria, no standardisation in equipment nor specific training in prehospital care.
So – we have a general ethos in most of Australia, where local doctors are excluded from State-based trauma systems….until the needs of the patient exceed capacity/availability…and then the local GP is called….without equipment, training nor clinical governance. Moreover there are no agreed activation criteria or inclusion into trauma systems, which may mean the skills of rural doctors are overlooked – this was noted by the Coroner in the Kerang rail tragedy, where rural doctors were prevented from attending the scene and trauma services relied solely on available ambulance and the (prolonged) arrival of retrieval services.
This is nonsensical. I firmly belief that rural patients deserve better care if they are involved in a prehospital incident. The level of care should not be limited by geography if there are trained clinicians nearby and available. They should be called upon ONLY when their presence can value add on scene – typically through delivery of a limited suite of meaningful interventions.
The skillset of the Rural Generalist clinician is more than that of #justaGP. Typically they have ongoing exposure to emergency medicine through their on-call hospital work and may have advanced skills through work in operating theatre, including advanced airway and resuscitation capabilities.
To the credit of SA Health in South Australia, a small number (approximately 40) Rural Generalist doctors have been quietly providing support to the South Australian Ambulance Service as part of the ‘Rural Emergency Responder Network’ (RERN). The clinicians are activated by pager. They have been equipped by SA Ambulance and SA Health with bags, equipment and medications and undergone formal induction and ongoing CPD.
RERN doctors are typically activated ONLY in circumstances when they can ‘value add’ on scene – to support volunteer ambulance officers, or as an extra pair of hands in complex or multiple injured emergencies. As doctors they may have the flexibility to perform advanced interventions such as needle or finger thoracostomy, advanced airway (including surgical airway), upgrade IV access or obtain IO access, appropriate use of ketamine and fentanyl analgesia, or just to provide extra clinical insight.
The system has been running for over ten years on a modest budget (reportedly around $45K per annum) under CountryHealthSA as an extension of clincians emergency work under hospital fee-for-service.
Despite this, no similar scheme exists in other States in Australia – which is frustrating. Heck, even the Poms and Kiwis do it!
Looking overseas, both the UK and NZ have schema to incorporate volunteer clinicians to respond to prehospital incidents and support the ambulance service in defined circumstances (UK BASICS, NZ PRIME). That these geographically small countries see the value of such a service and Australia does not, despite the tyranny of distance, is puzzling and perhaps reflects the metrocentric nature of State-based trauma service decision-making.
In 2015 Dr John Hall and I surveyed rural doctors and confirmed a willingness from respondents to participate in a National Rural Emergency Responder Network. As well as an article in Emergency Medicine Australasia, the call for a national system was supported by a Joint Position Statement from the RDAA and ACRRM, peak rural doctor bodies in Australia.
And still nothing from the other States, with the exception of South Australia’s RERN scheme. So if it won’t come from the top-down, we’ll have to build it from the bottom-up…
Which is why we will be promoting Sandpiper Australia in 2020 with generous support from the RDAQ Foundation and donations from rural communities and business, as well as support from RDAA and ACRRM.
Looking overseas, we have been struck by the success of the Scottish Sandpiper model. Established in 2001, the Sandpiper Trust has equipped rural clinicians across Scotland with over 1000 ‘Sandpiper Bags’, and clinicians undergo training through BASICS-Scotland.
Like many successes, it was borne from underlying tragedy. Sandy Dickson (aged 14 years) died in a tragic accident in a remote area and emergency services were unable to respond in a prompt manner. In their grief, the Dickson family channeled their efforts into doing some good – specifically, to ensure that timely help was available to rural communities despite difficulties in geography or available personnel.
Sandpiper was chosen as the name of the charity – the sandpiper being a light-hearted, cheeky bird who plays near water, in memory of Sandy Dickson.
Now in its third iteration, the Sandpiper Bag Mk III is a purpose-designed pre-hospital bag containing sufficient equipment to allow trained responders to deliver meaningful interventions on scene. The clinicians are trained via the Scottish branch of the British Association of Immediate Care Schemes (BASICS), with successful training a prerequisite before taking delivery of the Sandpiper Bag.
The Sandpiper model has been an outstanding success in Scotland and is immediately applicable to the context of rural Australia. A small team of Australian clinicians, under the aegis of the Rural Doctors Association of Australia, have partnered with The Sandpiper Trust (UK), to establish a similar not-for-profit entity, Sandpiper-Australia.
Sandpiper Australia aims to promote advocacy and funding for a network of Sandpiper Bags. These prehospital bags will be stocked with appropriate emergency responder equipment, enabling rural clinicians to respond to incidents in their community when appropriate to ‘value add’ on scene.
We envisage that the Sandpiper Bag will become a focal point of community fundraising and advocacy to improve trauma care across rural Australia.
Use of a standardised Sandpiper Bag supports development of a National Rural Emergency Responder Network; a system of rural clinicians equipped and trained to ‘value add’ to prehospital incidents in rural communities. Standardised kit and raining means that the Sandpiper clinician wil be recognised as a ‘known quantity’.
This is consistent with position statements of both RDAA and ACRRM in regard to the role of rural clinicians in prehospital care.
- Statewide retrieval services and other organisations responsible for emergency response and disaster management planning should formally recognise local rural doctor and hospital facilities and staff as important and integral components of the pre- hospital and disaster response team, and document their roles accordingly.
- Jurisdictions should seek rural medical input in the development of their strategic plans and disaster response management strategies. These plans should include recognition of ACRRM and RDAA (or its State member associations) as key stakeholders, and mandate their participation in the development and evaluation of any disaster response policies and plans.
- Rural doctors should be trained and supported so they can effectively respond to emergency situations. This includes specific training programs and/or curricular for rural doctors and ongoing CPD requirements.
- A nationwide Rural Emergency Responder Network should be developed to identify and document the location of rural doctors with advanced emergency response and retrieval skills to provide an additional level of community resilience in the face of pre- hospital incidents such as multi-trauma and State/National disasters. These doctors should be appropriately equipped and supported.
It’s an exciting time. We’d love you to be involved – whether an existing rural clinician, a rural community member, a leader in trauma services in your State or a business willing to support us with donations (Sandpiper Australia is now registered as a charity with DGR status ie any donations made can be offset against tax).
We are still in the early stages at Sandpiper Australia – indeed the ink is still wet on our paperwork as a charity! But we’re looking forward to 2020 and hope to be raising funds to help supply Sandpiper Bags to eligible clinicians in rural Oz…and continue to provide training in prehospital care with the Sandpiper Bag as the focus of ACRRM’s ‘prehospital care course’. We’re also keen to come and talk to you – whether at annual rural doctor conferences in each State, or other fora.
I would love it if you could challenge the decision-makers in your State. Why are Rural Generalists not included in State-based trauma systems such as DISPLAN etc? Why is it OK to rely solely on metro-based retrieval services for time-critical interventions when there are clinicians in the community who are willing to provide prehospital care – but need training and equipment? Why is it acceptable to exclude rural doctors from the scene….until it’s decided they may be needed, but then to send them without training or kit to support ambulance?
Rural Australia deserves better. Sandpiper Australia hopes to help by providing a ‘known quantity’ in terms of training and equipment. Talking to the Scots, they encountered similar issues in the really stages of set up. Now the ‘Sandpiper Bag’ and ‘Sandpiper Clinician’ are valued assets for Scottish ambulance and rural communities. Indeed Prof Laird Colville (former medical director of BASICS Scotland) has been recognised in the 2019 Queens Honours List for services to rural Scotland, whilst the Sandpiper Trust in Scotland has royal patronage.
Read more about Sandpiper Australia via the links below:
WEBSITE www.sandpiperaustralia.org Email [email protected]
FACEBOOK www.facebook.com/sandpiperaustralia @sandpiperaustralia
TWITTER www.twitter.com/sandpiperaus @sandpiperaus
MJA INSIGHT ARTICLE Sandpiper – a rallying point for rural trauma care
VIMEO Sandpiper Australia
RDAA / ACRRM Joint Position Statement on Rural Prehospital Care
EMA Paper “Tyranny of distance and prehospital care – time for a national rural responder network”
Involvement of rural GP-anaesthetists in prehospital care (over 55% involved in an event in previous 12 months) is mentioned in this paper
South Australia’s RERN (rural emergency responder network) system