Category Archives: Pre-Hospital

Pecha-kucha SMACC 2013

Well my three ‘pecha kucha’ talks have been uploaded to the SMACC website at http://smacc.net.au/category/pk-talk

Quite a novel format – only 20 slides, 20 secs each – 400 sec only for each talk

Better than ‘death by powerpoint’ @ffolliet would be proud.

SMACC2013 looks to be fun as well as bringing together critical care enthusiasts. Even though a humble rural doctor, I am mindful that critical care does not respect geography. So managing critical care comes under our remit.

Too often we see a divide between super-specialist tertiary centres and the reality of delivering healthcare in rural Australia. Rural docs are often resource limited, and we deal with critical illness relatively infrequently.

Casey Parker and I had a natter about this in Perth at the ACRRM 2012 conference…both committed to rrying to help bring ‘quality care, out there’ – neither of us is prepared to accept a lesser standard of healthcare in the country, purely because of geography.

So my three PK-talks are

- a rant on affordable difficult airway equipment options for bush doctors (but equally applicable to small EDs and ICUs

- a rant on the failure of Australia to adopt an immediate care scheme akin to the UK’s BASICS … Whilst we have outstandingly good retrieval services in Oz, the tyranny of distance means that there is inevitably a gap in the bush, especialy when paramedics in the bush may be volunteers. Rural docs with airway skills are well-placed to fill the gal – but if involved in prehospital work they need to be equipp, trained and audited. I may get drummed out of EMST directorship for some of my comments on this entry-level course…

- a rant on wildlife-vehicle collisions on Kangaroo Island and a novel strategy to reduce the trauma. Classic prevention, not cure – ultimately primary care applied to trauma

Enjoy!

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.

Country Driving

I’ve recently driven back from Orange (NSW) to Kangaroo Island (SA) – one of those long, two-day road trips that is characteristic of driving in Australia. I counted less than 200 vehicles between Orange and Tailem Bend – over 1200km of road over two days…and of course whilst driving you tend to think about stuff. Some things struck me…
  • Australia is vast
  • rural areas are sparsely populated
Hence If you have a crash out here, you are likely to face a long time before help arrives. And even then :
  • the major cities are a LONG way away (>500km)
  • there are smaller rural hospitals; some are little more than first-aid posts & some have capabilities for surgery (which implies the presence of a doctor with anesthetic skills)
Add to this :
  • the prehospital response may be initially composed of volunteer paramedics/first responders, with more more advanced practitioners few-and-far between
All together it is no surprise that the outcomes from a motor vehicle crash are worse than in the city, with one Australian study demonstrating a four-fold mortality for rural vs metropolitan areas. Not surprisingly, mortality increases the longer the time to care…and concepts like the “platinum ten minutes” and “golden hour” of trauma become academic when crash victims may not be discovered or receive help for a considerable time.

As rural doctors, it behoves us to examine best practices to try and improve survival. Certainly we need to have to skills and equipment to provide appropriate medical care in our hospitals..and some may provide an extended role at the roadside. I’ve blogged before about the concept of training and equipping rural docs to provide a coordinated prehospital response…and the more doctors I speak to, the more seem to think this is a ‘good idea’. Implementation however may take longer, and there will be hurdles to overcome (not least the oft cited response that such work is best left to experts, not enthusiastic amateurs).

Of course, the best ‘bang for buck’ is not necessarily in the delivery of expert medical care. I remember Karim Brohi making this point at one of the Australian Trauma Society annual conferences a few years back – “it’s better to build a fence at the top of the cliff, rather than provide an ambulance at the bottom to pick up the injured“. 

Locally we’ve had some small success with the ‘Roadkill Recipes‘ project – recognising that many rural traffic injuries on Kangaroo Island were caused by wildlife-vehicle collisions, a satirical cookbook of local wildlife served as a medium to convey a road safety message to locals and tourists.  Places like Kangaroo Island (and Tasmania) are interesting in that roadkill (and hence wildlife-vehicle collisions) is abundant. But for most rural areas the notorious “fatal five” of speed, inattention, drink/drug-driving, driver fatigue and lack of seatbelts are the culprits in many road crashes. 

Which is why I was heartened to see new signage as I crossed the border into South Australia (below). The Motor Accident Commission’s “matemorphosis” country roads programme aims to target country drivers, particularly male drivers who may respond to mateship peers.

The MAC campaign includes references to wankers, cocks, knobs and tossers.

I wonder if as rural doctors we need to be more proactive in injury prevention – especially when our work comprises mostly primary care as well as the ‘fun stuff’ like airways, trauma and emergency medicine. Driving change can be hard, but if we’re serious about injury prevention we need to be active in local road safety groups, at sporting events, with families and spreading the road safety message. But concomitantly we need to ensure our training and local resources are fit for purpose.

So in 2012 my projects will be:

- actively engage the local community in primary prevention health strategies,

- work with colleagues around the country to develop a ‘rural doctor masterclass’ course, showcasing latest concepts, equipment and techniques relevant to rural proceduralists,

- try and establish a more formal framework for rural doctors attending prehospital incidents (as a minimum, appropriate training, equipment and maintenance of standards) – existing retrievalist courses like RFDS STAR (RFDS Qld) and the medSTAR short course seem to be appropriate building blocks, bolstered by some online case discussion and commonality on procedures/protocols,

- work on developing a bespoke airway skills course for rural docs in South Australia, with concomitant development of minimum standards for difficult airway equipment in our rural hospitals.

    What are your News Year resolutions?