Category Archives: Retrieval

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.

Back to BASICS

South Australia is huge & not surprisingly this poses problems providing a response to serious trauma in the country. Thankfully rural doctors are mostly well-trained and thrive on the challenge of delivering excellent emergency care in their local hospitals…and if needed, can call upon the retrieval service to transfer critically unwell patients. The Statewide retrieval service has been re-invented in recent years, with MedSTAR now offering a world class service rivalling other States. Certainly the improvement in service delivery has been noticed from where I stand, as a rural doctor in country SA.


However, I wonder if there’s scope to improve things even further? In the UK, an entity called BASICS (British Association Immediate Care Scheme) enlists the skills of doctors with an interest in prehospital medicine & trauma to provide medical expertise at the roadside. BASICS personnel don’t replace paramedics or retrieval services – rather they “value add” to a situation – particularly when paramedic skills are exhausted and retrieval services have yet to arrive (see the BASICS DOC blog for more details). In Australia, the failure to call local doctors (many with critical care/anaesthetic skills) has been slammed in the response to the Kerang train crash disaster in 2007.


If the UK, with it’s small landmass, huge population and plethora of aeromedical and land-based retrieval services has a need for a service like BASICS, surely there’s more of a need in rural Australia where distances are greater and retrieval may take hours, not minutes? I posted on this recently on RRMEO, the excellent educational resource from ACRRM.


Currently, most trauma cases are dealt with by paramedics (and in the bush, these are often volunteers, not paid personnel) and a decision made to either retrieve direct from the scene (primary retrieval) or else transfer the victim to a rural hospital (where they may require secondary retrieval to definitive care). On occasions, local rural doctors may be called to assist at the roadside. Or not, as in Kerang. It’s an informal process which invites problems.


There’s a potential problem with relying on the local doctor. Emergency Medicine training in rural Australia is not formalised. Some doctors have a wealth of EM experience – some have barely any. Calling the local doctor may be a good thing…or it may not add much. Dr Peter Arvier in Tasmania has championed the need for EM training in rural Australia (demonstration of training is needed for rural docs practicing obstetrics, anaesthetics and surgery). Improving EM training is probably a good thing for the bush, although I hope old farts like me can be grandfathered if they bring in a rural EM diploma!


On top of this, a doctor attending an incident as the ‘oncall’ is still responsible for patients presenting to the local hospital. I’ve been called out to incidents 60km away from the hospital…and whilst happy to attend, I’ve had to ensure that someone else can cover in my absence.


In South Australia there has been an embryonic scheme developed by Dr Peter Joyner, known as RERN (Rural Emergency Responder Network) drawn from the ranks of rural doctors. These guys make themselves available to be called by SA Ambulance at the roadside, in addition to their usual oncall responsibilities. It’s a good idea, but I think doesn’t go far enough…the rural doctor workforce represents a hugh asset which is underused. Sure there are ad hoc arrangements (‘Help! We need a doc’) but without formalised training and equipment appropriate for the prehospital environment, doctors risk becoming ‘enthusiastic amateurs’ (I’m one!).


KI DOC is ready and waiting for your trauma call!





Whilst many rural doctors keep up-to-date by attending courses such as EMST, APLS, MOET, RESP etc, it has to be acknowledged that the prehospital environment is quite different to operating in the safety of a resus bay in the hospital. Prehospital doctors need to be familiar with rapid response driving, radio use, scene safety, extrication and working in austere environments etc. The UK BASICS scheme recognises this, encouraging training such as the UK’s DipIMC (although having read what’s involved, I reckon this could be more of a disincentive to us rural docs…better to just ensure they’ve got the right kit, understand the prehospital environment, then get them out there making a difference!)


I’ve alluded to the need for more crossover in training & equipment between various services (ambulance-retrieval-rural workforce) elsewhere on this blog (see Keeping It Simple). On RRMEO this topic was discussed with John Mac, who felt that it would be resisted by State ambulance services. I think this then begs the question – how much is the rural workforce integrated with State/National resources when a disaster strikes? As Dr Chris Swan recently opined in Australian Doctor :

“GPs form a vital, invaluable component of the emergency response resource in a disaster. Yet they too often are an afterthought, considered somewhere beyond the police, fire services, SES, hospital response and the military. Their clinical skills are broad, and they may well have facilities and staff at their disposal, but they are not as easily marshalled and they may be spread out”



I am particularly interested in how this sort of scheme would be received in rural Australia. What do others think? Has this idea got legs?


Bottom line – rural doctors are not infrequently called to attend to backup the ambos. Better that the doctors attending are well-trained, well-equipped and enthusiastic…not the present ‘we don’t need you…oh hang on, yes we do‘ approach which relies on the oncall A&E doctor. 


That’s just not good planning.