Category Archives: Paul Baker

Difficult Airway Equipment and Rural GP Anaesthetists in Australia

Well, it’s been almost just over 9 months since I put out a survey to rural GP-Anaesthetists (GPAs) in Australia….was surely tempted to put the results up on this blog back in April/May once the data had been crunched, but I stood on academic convention and deferred discussion until the paper came out – which was this week….click here to download a printable PDF version.

Another argument for the power of #FOAMed over traditional textbook-journal-conference methods of disseminating information, perhaps?

 

 

So, what was this all about? Well, it was only last year that I spent 12 months upskilling in anaesthetics before returning home to Kangaroo Island, SA. Whilst the training I received was invaluable, and to the standard required of the ‘Joint Consultative Committee in Anaesthesia” (JCCA), I think there is a gap between the reality of rural practice and that in the city. Don’t get me wrong. Rural GPAs do a great job. They provide elective anaesthesia to appropriately screened and case-selected patients…as well as manage emergency airways in challenging circumstances.

But I found two things that troubled me in my year of upskilling and attendance at rural anaesthetic conferences in NSW and SA

(i) many specialist anaesthetists did not ‘get’ the realities of rural anaesthesia. Some were dead against the notion of GPAs full stop (yeah right fellas – I’ll stop giving anaesthetics once you guys commit to providing specialist services in the bush).

Others accepted the idea of appropriately-trained GPAs delivering services – but expected us to have access to all the gizmos and resources of a tertiary centre, not understanding the limitations of rural practice and that the work of a rural GPA encompasses not just elective anaesthesia, but also emergency airway management in the absence of immediate backup.

(ii) There is a plethora of new airway devices and algorithms to manage difficult airways – but this equipment may not be available in cash-strapped rural hospitals. This is despite guidelines from ANZCA on difficult airway equipment availability.

So I decided in Jan 2012 to conduct a survey of rural GPAs in my home State of South Australia. Once I’d worked out my questionnaire, it seemed not too difficult to extend the questionnaire to rural GPAs in other States. Sadly no one seems to have a clear idea of how many GPAs there are ‘out there’ – there is no central database, and conflicting data from RACGP and ACRRM on humber of GPs registered under the procedural grant program for anaesthesia (Medicare of course declined to release data). A National Minimum Dataset from 2010 suggested 448 rural GPAs in Oz and so I targetted these through invitations to complete survey via ACRRM/RACGP/RDAA and State-based rural doctor workforce agencies.

Apparently a 65% response rate is good for an internet-based survey; respondents were broadly representative in terms of RA 2-5 distribution, demographics and experience in anaesthesia. Open and closed-question responses were interesting – only 58% of rural GPAs had access to dedicated difficult airway equipment. Many were frustrated with their access to such equipment. Importantly, many did not have access to the appropriate equipment to manage each of the stages of recognised Difficult Airway Algorithms.

This is surprising – there are published Standards for difficult airway equipment in locations where elective anaesthesia is performed, as well as guidelines on difficult airway algorithms. Yet many respondents indicated non-compliance. Moreover, there are AFFORDABLE and ROBUST solutions out there – I’ll post some suggestions on an affordable rural GP-Anaesthetist toolkit in a few weeks or so. Suffice it to say, affordable & robust equipment is out there for less than $5K and there is really no excuse no to have this kit in your OT or ED.

My survey also looked at the involvement of rural doctors in prehospital emergencies – I reckon this is bread n butter for rural docs, but it was interesting that although over 50% of rural GPAs reported their involvement in such work, the majority had had no training in this arena, did not have concordance of protocols with RFDS/retrieval services and furthermore such responses were often ad hoc, not a formal arrangement. Overseas modes such as the UK’s BASICS suggest better models that perhaps Australia (with it’s tyranny of distance) could and should emulate….

By all means have a look at the paper – it’s in Rural & Remote Health online or come and hear me talk at the Rural Medicine Australia conference in Fremantle later this month (#RMA2012). More importantly, examine your own difficult airway equipment and have a look at some of the suggestions on sites like Broomedocs.com and Prehospitalmedicine.com, from whom I am grateful to have drawn inspiration.

For an overview see the VIMEO video here or have a look at the paper here.

As always, comments or criticisms are invited.

Teaching old dogs new tricks

I have just got back from the Airway Skills course held in Sydney and run by Paul Baker (airwayskills.com). Unlike other courses, this was was genuine small group learning with plenty of opportunity to discuss cases, get hands on with a variety of equipment and was suitable not just for anaesthetists, but also intensivists, ED docs and rural proceduralists.

Its amazing how much one can learn even when one is doing a job on a daily basis. Paul Baker is well known as the author of numerous papers and the ANZCA ‘difficult airway’ equipment recommendations. As such, he brings a calm authority to discussion of airway and was a patient teacher.

I got a chance to play with a variety of equipment, including understanding the vital difference between proseal and supreme LMAs, play with combitubes, fiddle with Frova’s, Aintree catheters and confirm my choice of scalpel-bougie-tube for surgical airways. Also a great session on AFOI, as well as discussion of using 15l/min O2 via nasal specs as an adjunct to preoxygention/RSI and Levitan’s excellent airway book…

Only one thing was missing – a ‘soiled airway’ mannikin, to simulate the emergency airway that is the province of trauma and emergency docs…I know Minh le Cong has been muttering about such a simulator, but I reckon it’d be a great chance to wet test some ideas like Weingart’s ETT as suction catheter.

Rural docs have a plethora of courses to choose from – EMST, APLS, ELS, RESP, MOET, ALSO etc, as well as clinical attachments for procedural upskilling. I’ve blogged previously about the excellent Rural Doctors NSW procedural conference (combined with a day at the sim lab for GP-anaesthetists) and how I’d love to bring a conference with similar content to South Australia. The Baker airway skills course is so good that I reckon it’ll soon become oversubscribed, and the rural proceduralist cohort may miss out…wouldn’t it be great to bring this paradigm to a wider audience, rather than just 3-4 courses per annum on Oz and NZ?