Monthly Archives: January 2013

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!

“Smoking the Blue Cigar”

Two great things this week

– first up, a new display arrived for my KingVision VL courtesy of the Australian distributors. Thanks guys

– second, Dr Jamie Doube (former KI doc, often-time Antarctica medico and errant GP-surgeon) was back on KI for a few days before heading off on another Antarctic foray

Did a quick podcast each with Casey Parker over at BroomeDocs…but spent a few minutes prior playing around with makeshift airway topicalisation…placing RapidRhino’s, LMAs and generally mucking around

IMG_2155

Also managed to get Jamie to use the KV to see his cords…not bad considering he’d never used the device before

Indeed there is no finer experimental subject than a rural doctor …. so in a separate session we’ve filmed Jamie having a RapidRhino nasal tampon inserted (my own nose being too full of polyps from KI hayfever)

Wander over to the ’50 Shades of Brown’ section or look below

Airway Audit

It’s a funny thing, working as a private practitioner but on contract to a hospital for anaesthetic and emergency services. For one, there’s a constant tension between demands of running own business and the need to be available to the Hospital when required. Effective triage is key to this. Clarity over what is and what is not an emergency is valuable not only for timekeeping, but also for billing!

But one of the hardest things is to establish effective control to help make change happen in the Hospital. Unlike some of my tertiary hospital colleagues, I don’t get paid to participate in education, nor audit. I also have no control over spending decisions – current bugbear is a Hospital that has spent $17K on a new anaesthetic monitor – that we didn’t need..and yet not purchasing an extra monitor for our ED. Such top-down decision-making without consultation is frustrating. Bottomline is that as private rural doctors, we are engaged to provide a service – but not to effect change in the institution – that is ‘not our remit’

I’d love to spend an hour or so each week doing team-training with nursing staff and have recently started running sims in Theatre at the end of each list. Rural nurses have a tough time as they are frontline for whatever comes through the door, and have to manage the patient until the doctor arrives. That said, I am making an effort this year to improve educational resources for rural clinicians (whether doctor, nurse or paramedic) via the ‘Fifty Shades of Brown’ section on KI-Docs.

Audit is one of the areas that has traditionally frustrated me. Our local ‘Principal medical Officer’ (neither local, nor a frontline rural doctor) used to hold compulsory audits every year – I gave up when I realised that all he was doing was auditing expected deaths in the adjacent nursing home, not looking at near-misses or critical incidents in ED or Theatre.

A few months ago I was in email correspondence with Dr Toby Fogg, an ED Physician & Retrievalist over at the Royal North Shore in Sydney – I was fascinated to see that he and colleagues were setting up an Australian Airway registry and wondered if collective data from rural doctors in small rural hospitals would be useful.

It’s no secret that I am mildly obsessional about airway management, particularly as pertains to availability of equipment to manage a difficult airway in an isolated rural environment. Given that critical illness does not respect geography, I don’t think it is good enough to accept a lower standard of care or a higher complication rate in the bush than in the city.

Truth be told, we don’t know if things are worse. Intuitively, I feel that well-trained rural doctors do a good job – both of elective intubations but also for emergency airway management. But we don’t really have the data one way or the other. Although I’ve approached Country Health SA to pursue the idea of a rural airway audit, there was a lack of interest – the sceptic in me says that in these cash-strapped times, Health Depts would rather ‘not know’ than be presented with data that might require them to spend on appropriate kit!

Anyhow, 2013 has started well with results from the RNSH ED airway audit becoming available. You can check results out at http://www.airwayregistry.org.au/results-of-first-18-months/ and see comments over at Cliff Reid’s http://www.resus.me site via http://resus.me/lifting-the-fogg-on-ed-intubaton/ [sic]

But I reckon it’d be interesting to get collective data from rural EDs – despite the well-worn comments from various experts that there is ‘no room for enthusiastic amateurs’, the reality is that in the bush we HAVE to be able to manage such situations…and on the whole we do a good job…

Don’t we?