Category Archives: Training

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.

Rural GP Anaesthetists – a ‘special needs’ mob?

As a rural doc I’m very lucky to have a job that is varied. I tell students and junior doctors that rural medicine offers all the stimulation and challenges of all the ‘best bits’ of medicine.

Currently I practice primary healthcare, emergency medicine and anaesthetics (I gave up obstetrics last year).

So this weekend just gone was a highlight – a chance to attend an annual GP-anaesthetics conference at one of the mainland tertiary hospitals. I’ve had this date ruled off in my diary for 12 months now…so you can imagine my disappointment when the ferry to/from Kangaroo Island sustained damage in the recent storms and the replacement therapy had to be hurriedly re-surveyed, launched and pressed into service. Needless to say all Rex flights were booked out days ahead and despite lots of people needing to get to/from KI, Rex declined to put on extra flights.

Noone can control the weather, but the lack of a contingency plan was disappointing. Not that Rex have a strong history of customer service…

Anyway, I missed the first day of the two day conference. But although I made it to the second, I was somewhat underwhelmed by what I did attend, cementing further my belief that there needs to be content tailored to the rural GPA delivered by people who ‘get’ rural medicine.

To backtrack, I went to my first rural GP-anaesthetist in NSW last year. It was really good, a day and a half of lectures, plus a half day in the sim lab doing emergency scenarios. But what struck me there was the disparity in equipment and resources available between city and rural anaesthetists…as well as between rural GPAs in different parts of the State. Lectures by some of the FANZCAs were all very interesting…but often they did not realise the conditions in which rural GPAs work (isolated, minimal equipment, no backup, cash-starved). At the same time I was getting increasingly inspired by blogs such as Resus.me, BroomeDocs.com, Prehospitalmed.com and LifeInTheFastLane – all of which seemed highly relevant to my practice.

So I resolved to look at some quality improvement in my own practice on my return to SA, mindful of the fact that it made sense to have commonalities in equipment and protocols available to rural anaesthetic providers. Setting up a GoogleDocs survey was relatively easy, and I was gratified to get a 2/3 response rate from rural GP-anaesthetists around Australia on my topic of difficult airway equipment availability. I’ll be talking about this at the Fremantle Rural Medicine Australia conference and my paper should be out in the Oct-Dec volume of Rural & Remote Health. Stay tuned…

So, a year down the track I had really high hopes of further upskilling in SA. Whilst most of the content was good, there was an alarming propensity of some lectures to cover topics like cell salvage, lab-markers in major transfusion and the like – all very interesting, but not translatable to the rural practice environment where such resources aren’t available. Questions on topics such as delayed sequence intubation and whole blood live donor panels were unfamiliar ground for the FANZCA experts, although very pertinent to many of the rural doctors.

Small group sessions made up for it, with hands on experience and chances for case discussion.

But a common theme amongst the people I spoke to was that city anaesthetists task with lecturing had very little idea of the resource limitations in country areas. The vast majority of us don’t have remifentanil..or desflurane..or BIS…or access to FFP/cryo/platelets…or labs..or $15K videolaryngoscopes. The FANZCAs who visit rural hospitals, whether for elective lists or retrieval, did at least have an idea of our circumstances Yand ‘special needs’

So, what does the rural GPA really need?

- lectures from experienced anaesthetists? Hell yes.
- small group sessions and case discussions? Even better.
- topics targetted to the audience and suggestions for improvement. Absolutely!

…and to top it off, perhaps consideration be given to sharing the knowledge base by holding two sessions per year (allows more docs to attend…as if one doc is at the conference, the other needs to be oncall)

…and even better, consider delivering content in rural areas by taking some of the ideas on the road.

The other thing that concerns me is the lack of communication between rural docs. Locally the RDASA has a ‘rural anaesthetists’ email group, but it has been inactive for a few years. It seems that many of us have the same issues with respect to equipment procurement, training and upskilling – yet operate in silos. Moreover there is little ‘top-down’ direction – certainly I have no sense of direction from the ‘Country Health SA Anaesthetic Consultant’ and it would be nice to see some more dynamism.

Maybe next year will be better…I’m going to keep pushing the barrel for local delivery of leading edge concepts in EM/anaesthesia that are rurally relevant for myself and other doctors.

Email me if you have any thoughts on this.