Category Archives: Trauma

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!

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.

Advances in Trauma?

Well I’ve just got back from an EMST Refresher course in Adelaide.  This is the first time I’ve taught on a refresher course and it was nice to meet other experienced faculty as well as (mostly) rural doctors doing this refresher course. The Provider courses that I usually teach on are not usually so filled with rural doctors – more junior RMOs doing EMSt as a requirement for surgical training ANZCA no longer has EMST as a requirement for their trainees).


EMST is very much an entry-level course, but is well suited to the needs of rural doctors who often have to manage trauma as a solo doctor with limited resources. It should be borne in mind that over 40% of major trauma originates in rural Australia, so there is real bang for buck in getting effective trauma care delivered to these patients, whether y rural GPs or aeromedical services.
On this Refresher course, the hands on scenario-based skills stations seemed well received. I also had an hour after the MCQ to talk about ‘Trauma Teams and Advances in Trauma’ – a golden opportunity to chat about things like human factors in trauma team dynamics, as well as to draw on experiences from the group about well-run and not-so-well run traumas.
But what about ‘advances in trauma’ that are not covered in the EMST Provider course? Well, I reckon they can be broken down by category and it was this approach I used to guide discussion in the 30 minutes or so available to me for each group:
AIRWAY
Videolaryngoscopy as an adjunct for difficult intubation
Ketamine for trauma intubation
Andy Heard’s excellent youtube videos on CICV
Cliff Reid’s notorious ‘propofol assassins’ rant
Weingart/Levitan’s paper on preoxygenation
BREATHING
Finger thoracostomy
Ultrasound for evaluation of pneumothorax
CIRCULATION
Minimal volume resuscitation
C-ABC and tourniquets for catastrophic compressible haemorrhage
Tranexamic acid, CRASH II trial & applicability to rural Australia
Managing major traumatic bleeding in rural hospitals (big shout out to Casey Parker’s excellent blog on this at Broome Docs)
We didn’t get as far as DISABILITY but I daresay that discussion of hypertonic saline in head injury would have come up…
The discussion really made me think just how knowledge-hungry the rural doctors I met were, but how hard it was for information to be disseminated to these guys.   It cemented my belief that a  rural masterclass course would have a willing audience. There’s lots of new stuff to discuss in trauma alone, but add in other (non-trauma) areas of interest to the rural proceduralist and you’d have a gutsy, useful, evolving course with enough content for 2-3 days. I could rant about this for ages…
All I could do was relate my own experience in past year or so, and the value of internet-based learning and discussion which has re-vitalised my own enthusiasm for learning. Big shout outs to the rural docs for the education resources below :
Minh le Cong’s retrieval resources for ACRRM members at www.rrmeo.com and his new PreHospital And Rural Medicine (PHARM) blog at www.prehospitalmed.com
Cliff Reid’s excellent blog at www.resus.me
Casey Parker’s excellent Broome Docs, the central repository for all things relevant to the rural proceduralist
Those UCEM rascals over at Life In The Fast Lane
Scott Weingart’s EM-crit blog
Common themes amongst the rural proceduralists I spoke to remained
  • difficulty accessing medical equipment (videolaryngoscopy, infusion pumps and fluid warmers were common ‘wish lists’)
  • difficulty with triage and training for nursing staff in rural hospitals
  • desire for cross-training with RFDS/Retrieval service in terms of infusion regiments, SOPs and equipment
In Country Health SA, there are nominated rural doctors as ‘consultants’ in each of the areas of emergency medicine, anaesthetics, obstetrics & surgery. According to CHSA, their role is to :

  • be responsible for providing clinical system advice and broad support to rural resident medical practitioners in country South Australia, in their identified area of expertise
  • act as a point of contact for clinicians in country regarding system issues, as related to their specialty area, and participate in problem resolution
  • participate in the development of policy and procedures that guide clinical practice in country. In addition, the Chief Consultants will work with the Chief Medical Adviser, Country Health SA and other country health staff related to decision making and policy setting as related to their speciality area 

With the exception of obstetrics, for which there seems to be a proactive rural proceduralist, it is hard to point the finger firmly at any positive attempt to address the above issues by present incumbents. In fact the rural doctors I spoke to (those with EM or anaes skills) were not aware of any initiatives in past year or so by the CHSA EM or Anaes consultants.
Which is a shame, as it seems these rural docs were struggling with similar issues in their own institutions, but lacking a top-down approach to streamline equipment, protocols & training. Rather they were having to push for equipment/training by dealing with local DONs of the hospital, usually being rebuffed as ‘no money’ in CHSA. It seems that my problems on Kangaroo Island with equipment/training are the same as those in Port Lincoln, the Riverland, the South East etc…and we are all trying to fix in our own manner, which mostly comes down to enthusiasm for a particular issue at any one time. No wonder things are fragmented.

Meanwhile not a week goes by without another meaningless diktat arriving in rural doctors email from CHSA detailing the latest policy. Useful stuff…for example I’ve learned that dabigatran can cause bleeding (well, duh!)…and that I probably should not inject chlorhexidine down an epidural catheter. I only wish the same regard for safety was applied to trauma management and crisis management in theatre or the ED of rural hospitals…
Phil Tideman of iCCNet has revolutionised how cardiac patients are cared for in rural South Australia, with an initiative over past decade to place point-of-care troponin, proBNP and iStat machines into all rural EDs, as well as standardised protocols for management of ACS/STEMI & heart failure patients relevant to rural practitioners. Whilst I am not a huge fan of centralisation of services, such standardisation in equipment and protocols has had demonstrable benefits for these patients…similar with obstetrics under Steve Holmes’ wise guidance. Why not extend the same to trauma, emergency and theatre patients by assessing needs of rural doctors and addressing their common issues?


A simple issue, like availability of difficult airway equipment or new advances like tranexamic acid could and should be addressed by these consultants.


Perhaps it’s time for some new blood in CHSA to represent the rural proceduralists in SA?