Rural Docs getting FOAMed

Why FOAMed?

Readers of the blog will be in no doubt that I am a fan of FOAMed, the revolution in medical education that has swept through the Emergency Medicine & Critical Care world. Like may others, I have got back from the SMACC2013 conference with renewed enthusiasm for cutting edge medicine and promulgating ideas amongst colleagues.

SMACC2013

To be truthful, as a rural doctor one can feel left out at conferences – particularly those with an EM or crit care focus, as working in a rural area may be seen as lacking in rigour. Of course this is far from the truth – after all, critical illness does not respect geography. Fellow rural physicians Dr Casey Parker of BroomeDocs and Dr Minh le Cong of Prehospitalmed.com bring concepts of relevance to us rural docs.

Parker_Casey

Casey Parker, promiscuous FOAMed blogger and nom-de-plume of a Panamanian porn star (not related)

I try to do this with KI-docs, although the focus is more about dealing with an intransigent health bureaucracy and thoughts on airway stuff than 100% hardcore critical care. The “50 Shades of Brown” section is aimed at rural doctors who are keen to embrace FOAMEd concepts relevant to resuscitation in the bush…

I hope that my talk at SMACC2013 went down OK, despite the cringeworthy jokes. You can access it HERE.

Leading on from SMACC2013, I’ve set out my manifesto for 2013-14, namely to try and achieve the following:

- to spread the FOAMed paradigm amongst rural proceduralists & help develop new FOAMed content relevant to rural doctors

- to complete the “50 shades of brown” series of “what to do when sh** hits the fan”

- ensure simple resources like RSI kit dump, checklists and awareness of NODESAT/DASH-1a are used by rural ED docs and GP-anaesthetists in Australia

- to try and badger Country Health SA into adopting an airway registry to compare rural vs metro outcomes

- similarly to incorporate more sim into training using iSimulate

- to keep plugging away on development of a rural doctor ‘masterclass’ via ACRRM

and

- to firming up rural doctors as vital members of prehospital response where gaps exist in rural Australia

I also promise to work on decreasing my scatology!

Where to from here?

I think that FOAMed has the most to offer to rural doctors – traditionally isolated by virtue of the tyranny of distance – we can now engage in high quality, relevant education and help to deliver “quality care, out there”

One of the criticisms of the current FOAMed content is that it is heavily-skewed towards resuscitation themes. I don’t think this is unreasonable – after all EM & CritCare have these at their core – so this is where most debate, controversy and innovation happens. At SMACC2013 Victoria Brazil illustrated the lack of FOAMed resources on Indigenous Health and vital public health areas such as hand-washing. I reckon we should give it time – as the FOAMed paradigm is taken up by more and more specialities (dang it, even the urologists have come on board), these topics & more will be incorporated.

Mike Cadogan’s Global Medical Education Project (GMEP) is fast becoming the repository for FOAMed resources – check it out if you have not already done so.

How to use FOAMed?

Whilst SMACC2013 was a great EM/CC conference, there were a sizeable number in the audience who had no idea of how to incorporate social media (SoMe) into their practice. Understandably they fear information overload and the hurdle of having to grapple with technology in lives that are already bursting at the seams with important things to do. Fair concerns, but can be easily overcome with perhaps a 2hr investment in time to get set up.

With that in mind, I would recommend the following

(i) Get your head around FOAMed – see http://lifeinthefastlane.com/foam/

(ii) Set yourself up with some sort of mobile device (I like the iPad) and download relevant apps – Mail and Safari will allow Email and Browsing, use GoodReader to store and read PDFs and other documents for reading later.

The iPad makes a repository of all things medical and non-medical

The iPad makes a repository of all things medical and non-medical

Store apps in folders

Store apps in folders

According to usage

According to usage

I use GoodReader to collate media for browsing anytime

I use GoodReader to collate media for browsing anytime

(iii) Selecting sites – choose wisely

You should then navigate to blogs or sites of interest and subscribe to their content via RSS. You can get this content pushed to you and collated in an easy display, rather like a constantly updated newspaper, using FlipBoard – makes browsing content from several different blogs or sites a cinch.

FlipBoard acts like online newspaper - of all YOUR preferred content

FlipBoard acts like online newspaper – of all YOUR preferred content

A common criticism of FOAMed is that is is not peer-reviewed in the same way as a journal article. That’s specious, as Richard Smith (former Editor of the BMJ) demonstrates in this article on the process of peer-review.

I reckon that peer review by putting a concept out there via FOAMed and then the ensuing debate from the worldwide community of critics is a far more robust method – good ideas will rise to the top, bad will sink.

I put out a paper last year on difficult airway equipment – the journal process took nine months – whereas FOAMed allowed me to get the concept ‘out there’ in a few minutes. I still went for the perceived kudos of getting a paper published…but in the future, I don’t know if I would bother, unless there were consequence for not doing so (plagiarism by others, loss of research funding or other penalty).

(iv) Connect in real time when it suits you

As well as getting content pushed to you via RSS/email, you may want to take the plunge and get yourself a Twitter account. To be honest I would not bother with FaceBook (it’s so last year) – I was so sceptical about Twitter, thinking it was all about Paris Hilton inanity. Instead it allows real time communication between colleagues on subjects of interest. That is powerful and highly useful for physicians – we can now connect in real time.

Twitter

To whit, during the SMACC2013 conference I was listening to Brian Burns (@hawkMoonHEMS) talking about life-&-limb saving interventions used at GSA-HEMS. He mentioned exciting stuff like thoracotomy, lateral canthotomy, field amputation, resuscitative hysterotomy and surgical airway (three of which procedures I’ve done so far)…but did not mention decompressive procedures for extradural. If you think about it, all of these are about making holes – so why not include craniostomy? A quick tweet to my mate Mark Wilson (former rural doc, anaesthetist, London HEMS doctor and now neurosurgeon) and Mark kindly sent through to me (and a few followers) a PDF of his recent ‘How to do it’ paper on Burr holes.

Wilson

That is gold – to be getting this content from a respected specialist from the other side of the world, whilst sitting in a conference in Sydney.

Similarly Minh le Cong got feedback from Karim Brohi of trauma.org on the usefulness of ROTEM/TEG in Cath Hurn’s talk on massive transfusion, after a few questions from Casey and myself on value (or not) of point-of-care INR in determining progression of ACOTS.

Brohi

Summary

So Twitter is allowing clinicians with a like mind to share conversations. I am humbled to be able to talk to respected EM people like Simon Carley, Cliff Reid, Minh le Cong, Joe Lex, Mike Cadogan, Karim Brohi, Casey Parker and get a response – truly FOAMed is a meritocracy.

Lex

Fayaz

But to be honest, I wish that I could share these conversations with other rural doctors – there is but a handful of us involved in FOAMed – and yet the true power of FOAMed will not necessarily be in the cutting edge ‘sexy’ arenas of resuscitation – but in sharing experiences and frustrations that affect front line doctors. Traditionally operating in relative isolation, perhaps coming together once a year for an annal refresher conference, we could be so much more connected … to the benefit of our patients.

A shout out here to Gerry Considine of the Rural Flying Doc website and others like him – they are using FOAMed to cover course content in twitter study groups, to allow remote supervision (exemplified by Dr Tim Senior & Dr Michael Bonning’s forays as “supertwision”) and to effect change.

Rural doctors need to get on board and embrace the FOAMed. I am more than happy to help get you started…

Come on in and join us!

SMACC2013 – critical illness does not respect geography

About 6 months ago I posted about the ‘end of the medical conference‘ after a fairly humdrum experience at Rural Medicine Australia 2012 in Perth. This negativity was picked up by others, notably EM-IM Doc

SMACC2013 has changed all that.

No doubt Minh over at prehospitalmed.com and the lifeinthefastlane.com crew will feed out snippets, so I won;t give an exhaustive breakdown.

Suffice it to say, SMACC2013 was noticeable for

- incredible collegiality between ED, ICU, prehospital and rural clinicians, be they student, paramedic, nurse or doctor

- opportunity for meritocracy-type interaction between colleagues from both Australia and overseas

- memorable for Gerard Fennessy delivering part of his anaphylaxis talk in song (ya’ muppet)

- moving and inspiring talks from the likes of Weingart, Lex and Reid

- SCAT paramedics abseiling in from the rafters as GSA-HEMS (lead by Karel Habig) made a surprise last minute showing in SimWars

- excellent organisation and venue. Thanks to the organising committee for all their hard work.

SMACC2014 will be in Brisbane 17-19 March 2014. Book now. Rural doctors – you NEED to embrace FOAMed. Casey “not the porn star” Parker and I have been banging on about this now for sometime – we need to raise the bar and bring “quality care, out there”

So, my mission for 2013-14

(i) to try and persuade ACRRM and RDAA that we need to embrace FOAMed as rural doctors

(ii) to try and implement an Australian version of BASICS – to improve the current gap in rural prehospital care (rural docs with airway/resus skills are well placed to provide appropriate interventions before retrieval arrive – but need to be equipped, trained and have formal call out criteria)

(iii) to ensure that EVERY small rural ED (and better still , every ED, ICU in Australia) is familiar with and engaged in processes such as

- Toby Fogg’s excellent airway registry

- RSI kit dump and checklists

- adequate difficult airway kit and knowing how to use it

- checklists for crisis management and ‘logistics not strategy

- regular sim and resus room management training

- NO-DESAT apnoeic diffusion oxygenation and DASH-1a for all RSIs, whether in ED, OT, ICU or prehospital

None of the above ideas (and more) will be unfamiliar to FOAMites – indeed, they’ve been bounced around for a few years now..but still they are not out there where they are most needed. This must change.

Concomitant with that will be more FOAMed relevant to rural docs – not just ‘airway’ and ‘shock’ but of relevance to critical care in the bush

Might seem a big ask..but I can dream.

After all, critical illness does not respect geography!

SMACC Day One

I am pleased to say that day one of SMACC2013 has not failed to deliver – blistering talks from the likes of Joe Lex, Scott Weingart, John Myburgh and Cliff Reid were much appreciated by the audience. Highlights for me were Weingart’s suggestion of the sweet harmonies of Nine Inch Nails for trauma RSI (just so long as wasn’t the song “Closer“), Reid asserting that propofol is ‘semen of Satan’ and Myburgh confusing me utterly on fluids. Forget the crystalloid vs colloid debate – he reckons al ICUs should be re-named “The Swamp’ as we are drowning patients with saline.

So was good to put names to a few faces (and apologies to those I have not yet caught up with). Importantly it is good to see a coming together of intensivists, emergency physicians and a smattering of country doctors – all with a common theme – using FOAMed to improve the delivery of patient care. ‘Quality care, out there”

The T shirts also got a few laughs…

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Screen Shot 2013-03-05 at 7.28.40 PM


THEY WANT TO MODERATE FOAMed

I was a little perplexed to hear a lot of … well fear is perhaps too strong a word..but concern is too weak… whatever, there seems to be a desire to regulate the FOAMed community. If you don’t know what FOAMed is, take a wander over to LIFE IN THE FAST LANE for a crash course. As Joe Lex pointed out, the concept of free meducation has been with us since Hippocrates and is embedded in the eponymous Oath “…and to teach them this art – if they desire to learn it – without fee and covenant; to give a share of precepts and oral instruction and all the other learning”

Simon Carley from BestBets and St Emlyn’s gave an inspiring talk on the perils of SoMe – not so much from within, but the fact that it may unsettle existing power bases and be subject to a set of rules by those who do not understand it. He also warned of the danger of ‘preaching to the converted’ – we need to get the message out to a wider audience and, as Joe Lex suggests, lead by example.

So here are my thoughts on some of the criticisms of FOAM. NB: Minh le Cong has blogged on the future of FOAMed recently.

Criticism No 1 : FOAMed is not really free – people will want to get paid (in money, or in kind) for their time.

I hear this a lot. After all, sharing info for free in an open environment is antipathy in the cut-throat grant-based world of academia. Whilst there will be some who blog for self-aggrandisement (although I am hard pushed to think of any), most FOAMites do so because they believe in sharing knowledge, enjoy debating (especially those of us, like rural docs, who operate in isolation) or have a genuine desire to help their colleagues. Me, I have a self-interest at heart – if I can persuade colleagues in rural medicine to adopt some of the practices I have learnt about through FOAM, my job will be so much easier as I move around the country. Not just doctor s- but fellow clinicians like nurses and radiographers…and institutions.

Criticism No 2 : There is no ‘quality’ – how do we know that people blogging are who they say they are, do the things they say they do etc?

Um, not really. If using Twitter, can click on a user to see his/her name. Like a hawker selling his/her wares in the marketsplace, you will soon develop an eye for the trustworthy ones. People who use real names behind their twitter handle, give a good descriotion of who they are and what they do are generally to be trusted. Similarly, those with lots of followers are probably worth reading. But beware group think…

As for quality…well, this is the old Encyclopaedia Brittanica vs Wikipedia debate. I know which one has most share nowadays – the strength of FOAM lies in rapid ability to change and peer-review. Which leads on to …

Criticism No 3 : FOAM has no peer-review. How can it be trusted?

Well it DOES have peer review – the crowd. When people say daft things, or there is major dissent, then the crowd (usually through online comments to blogs) will allow discussion.

I’ve been involved with Doctors.Net.UK since it’s inception back in 1998. The power of that medium (essentially a bulletin board) is active (and sometimes heated) discussion between the 180,000 UK Doctors who use it. But that is where the BEST learning happens.

Besides, is the learning from wise old professors of medicine peer-reivewed? I had a gutful of ‘my way or the highway’ teaching as a junior – in fact, I encountered it again recently when doing a year of anaesthetic upskilling in NSW – not just learning via humiliation, but an insistence that ‘their way’ was best way despite evidence to contract from literature (and colleagues). Yet such behaviours tolerated as ‘good at blocks’ or ‘just his way’. All I learn from these individuals is how NOT to be!

Criticism No 4 : Without a curriculum, FOAM may encourage novices to do “crazy things”

An example was cited of an ED reg ‘doing something unfamiliar because they’d read about it on a blog’ with the implicit suggestion that FOAMed content needs to be moderated.

Oh bollocks!

Look, for me the whole POINT of FOAMed is that it caters to the discerning palate. It is NOT entry-level – that’s what medical school, textbooks, journal clubs and primary/exit examinations are for. They give you the framework to practice the art of medicine.

But along with getting one’s ‘ticket’ in whatever field, is the commitment to lifelong learning. We won’t get that from books..nor conferences. Information moves too quick. Same with the process of publishing papers (don;t get me wrong – this is important, just takes a while)

I can illustrate with examples from my experience of FOAMed – in past 18 months, concepts such as apnoeic oxygenation during RSI, use of checklists, switch to rocuronium over sux for trauma RSI, considering resus room management and human factors have changed the way I practice medicine. I think that is a good thing. But theses concepts have been gleaned by conversations with experts via the blog-o-sphere….not through books/conferences.

Reputed drunkard Alan Grayson used the illustration of a kitchenhand moving from scut work, through sous-chef to masterchef. We are all on that journey – and whilst initially have to learn the ropes, FOAMEd helps masterchefs share recipes. Over time the info will be disseminated downstream into protocols etc … but FOAMed is really about keeping the pot bubbling and generating new innovative dishes for the discerning palate. It ain’t McDonalds!

Which leads on to…

Criticism No 5 : Without moderation, people will say ‘bad’ things.

Yes, they will. But people may say ‘bad things’ anyway. As one who approaches almost Gordon Ramsay-like profanity at times, I recognise the need to exercise caution.

That said, sometimes people NEED to say things. Those in the UK may be familiar with the ‘Scot Junior’ affair a few years back, where a relatively junior trainee made criticism of a senior member of the medical establishment on a closed forum (Doctors.net.uk) under a pseudonym. When pulled up, he immediately apologised and withdrew the comments…but was subject to a witchhunt by senior meducationalista that affected his career and went well beyond the bounds of acceptable reprimand. Sadly the mediculationalista involved lack insight into their own behaviours – and it is these sort of people who are watching FOAMed VERY closely. Still sometimes as TISM say, you have to call a spade a spade.

But is moderation really needed? We already have a code of conduct – guidelines of ‘being a good doctor’ from the likes of GMC and AHPRA. Stick to those, don;t say anything that you wouldn’t mind either prefacing with “M’lud” or splattered over the front page of local paper, and you will be right. Karel Habig from GSA-HEMS suggested that the journalism code of conduct might be best way forward. As long as it’s not leading to a ‘News of the World’ scandal we should be alright.

Actually, perhaps the ‘masterchef’ analogy is incorrect – we should compare ourselves to cub reporters, then specialist reporters in different arenas…then those who have the courage to go off (FOAMEd) and do something different – perhaps picking up a Pulitzer on the way.


Criticism No 6 : Without a curriculum, we will miss important topics.

An example as given of the fact that AIRWAY and SHOCK predominate in FOAMed resources. I agree, but I think FOAMites have enough insight to realise that there are far more topics that could (and should) be discussed. But the uptake has mostly been by EM and ICU docs – who, guess what, mostly want to talk about airway and shock. This will change – Mike Cadogan’s GMEP project will allow a fine repository of all sorts of info – and up-and-coming stars like Gerry Considine will be pumping out content.

Actually, the more I think about it, I reckon the broad brush knowledge base of the true generalist (the rural doc or EM physician) is the best mining ground for more material.

But you know what – the danger of FOAMed is not that it is anarchic and unmoderated – that is it’s strength. The danger is that the users are converts…we DO need some form of body to articulate the strengths of FOAMed to other agencies…and we do need to get the message out there to other doctors.

Most of all, we need to lead by example. So tomorrows talk at SMACC2013 will be my last nod to Anglo-Saxonisms in a presentation…

What do YOU think about FOAMed? Comments welcomed….