Category Archives: Trauma

iSimulate

Well, finally my wife’s iPad3 with the spanking retina display has arrived. I’m a tad jealous, but more importantly it now means I have two iPads to play with…


…and that has been vital for running a groovy piece of software called iSimulate.


I dunno about the rest of you medicos, but I’ve been to a fair few simulation training sessions, mostly as a junior doctor doing basic and advanced life support. More recently I’ve been through the simulation lab at the Royal North Shore, doing the thoroughly excellent ’emergency management of anaesthetic crisis’ or EMAC course.


These sims are high fidelity and rely on life-like mannikins, realistic environments with monitors, emergency room or operating theatre equipment etc. Moreover, such training tends to only happen as part of a dedicated training session – which may be only a few days every few years.


So I was intrigued when I saw a pre-launch version of iSimulate a few months ago at an EMST course – in fact, there were a bunch of senior EMST instructors there (intensivists, emergency physicians, surgeons and self) who all agreed that the concept was brilliant. 


iSimulate is an app for the iPad – using two iPads and a wireless netowrk connection, one iPad serves as a monitor and the other is driven by the instructor.


The beauty is that the iPad screen has been set up to look just like a standard monitor, with displays for ECG, SpO2, invasive BP, ETCO2, RR and manual BP. The iPad also has realistic alarms, just like standard monitoring equipment. Pressing the ‘BP’ button even causes a realistic ‘cuff inflation’ sound which will be familiar to anyone who’s worked in resus or theatre.



So now one can run a realistic simulation ‘on the run’ – at anytime, in any place.


No more reliance on a simulation lab, purpose-built mannikin or dedicated time off to run turgid BLS/ALS courses – with this app one can run a mock resus every shift, or at the end of a theatre list in the standard work environment, in the clinic, at the roadside.


I think it’s a game changer potentially. And my baby roo (Boo) thinks it’s a wonderful device…

What’s that Skip? He’s in haemorrhagic shock?
Instructor iPad on left, Student iPad on right



There is however one drawback – it’s $2000 initially then $500 per annum thereafter…and you’ll need to buy two iPads and a wireless connection (would be mayhem if ran over 3G).


There is a version for $4900 which gives ‘lifetime’ support and licensing. You can see more and a video using a teddy bear (Hugh Grantham’s idea) of the app in action at iSimulate.com.au


However, I think this price still puts the app out of reach of small country hospitals and individuals. The big organisations will be able to afford this easily…but no doubt organisational issues will mean that simulation training continues to be rolled out in the usual ‘once a year compulsory training session’ covering just ALS and BLS.


Which is a shame, because the portability and flexibility of this app mean that meaningful sim could be delivered whenever and wherever needed


I’m in theatre next week, and I reckon we’ll use the demo version to run a mock malignant hyperthermia or anaphylaxis under anaesthesia scenario, just for a giggle.


That would be brilliant. But $4900 to educate the hospital staff at my own expense? Probably not…

Boo the Roo explores the possibilities of iSimulate
…but baulks at the price tag


A Course..a Course! My Kingdom for a Course!

[adapted from King Richard III, Shakespeare, W 1594]

Well, this week I am up in Darwin teaching on an EMST course. The Early Management of Severe Trauma course is the Australasian version of the worldwide Advanced Trauma Life Support course from the American College of Surgeons. The history behind it is interesting, but the bottom line is that this course teaches a uniform, practical and structured approach to the management of trauma…identifying and treating immediately life-threatening injuries (hence early management of severe trauma).

I’ve been teaching on this for a few years now and I enjoy the interaction with other Faculty. Although badged under the College of Surgeons, Faculty are a hotch-potch of surgeons, anaesthetists, intensivists, retrievalists, emergency physicians and the odd rural doctor. I think they put me on the Faculty for comedy value.

But I always learn something from fellow doctors who teach…and hopefully the 16 Candidates on each course benefit from our combined experience. It’s something I am pretty passionate about…and later this year I will be taking up the mantle of Course Director which will be interesting.

EMST is just one of the many courses ‘out there’. For rural doctors like me, who need to be able to manage pretty much whatever comes through the door (at least initially until the cavalry arrive), there are many entry-level courses such as:
Advanced Paediatric Life Support (APLS)
Emergency Life Support (ELS)
Rural Emergency Skills Training (REST)
Advanced Life Support Obstetrics (ALSO)
Major Obstetric Emergencies & Trauma (MOET)
…plus a few courses run by State agencies such as rural doctor workforce groups and trauma/retrieval services. Minh le Cong’s RFDS STAR programme looks interesting and I’ve done some components of the James Cook University ‘Aeromedical Skills course’ along with colleagues at MedSTAR. But they are aimed at the prehospital/retrieval audience.

When I am teaching on EMST I often feel constrained by the limitations of the course. Don’t get me wrong, it’s a great programme, and aimed squarely at junior doctors who are developing their skills and involvement in trauma management. But there is just so much more out there…and a lot of ‘current’ thinking is not taught on these courses as it takes time to translate through course manuals, materials and instructors.

I’ve just been reading about finger thoracostomy over on the Scancrit.com blog. It’s a technique I always try to explain & demonstrate in the animal lab and on thoracic trauma skills stations, but it’s not (yet) in the standard EMST teaching.  So I reckon there’s scope for a ‘masterclass’ course, constantly evolving and reflecting some of the topics and discussions that one comes across on the net or that are used day-to-day by experienced practitioners.

After all, medicine evolves and our learning should be lifelong. Why then just have a series of entry-level courses for the rural docs – especially when access to hands-on learning for them is often difficult. Rather than repeat the course, better to advance to a new level.

Such a course would be a great addition to the entry-level courses…the knowledge of which is assumed. It’d be aimed squarely at the experienced rural doctor and could be delivered by our College, ACRRM. Of course they also deliver the REST course – so an advanced course would frighteningly be called something like ‘advanced rural & remote skills training’ or ARREST!


Regardless of the name (and I think something along the lines of ‘rural masterclass’ or ‘current topics in…’ etc work better), one can imagine a two day course covering things like:
  • ECG phenomena such as Brugada etc
  • use of ultrasound inc FAST/RUSH
  • difficult airway gadgets and protocols
  • what’s new in paeds/O&G
Content would be delivered by experienced rural or specialty docs, with content shaped by participant’s needs and reflecting current thinking. Getting along a few of the reps such as KingVision, Ambu, Laederal, iSimulate and SonoSite would seem sensible and allow hands on of equipment that your cash-strapped, time-poor rural health service would not otherwise have had access to.

Now THAT would be worth the $2K a day procedural upskilling grant that is available.

Country Driving

I’ve recently driven back from Orange (NSW) to Kangaroo Island (SA) – one of those long, two-day road trips that is characteristic of driving in Australia. I counted less than 200 vehicles between Orange and Tailem Bend – over 1200km of road over two days…and of course whilst driving you tend to think about stuff. Some things struck me…
  • Australia is vast
  • rural areas are sparsely populated
Hence If you have a crash out here, you are likely to face a long time before help arrives. And even then :
  • the major cities are a LONG way away (>500km)
  • there are smaller rural hospitals; some are little more than first-aid posts & some have capabilities for surgery (which implies the presence of a doctor with anesthetic skills)
Add to this :
  • the prehospital response may be initially composed of volunteer paramedics/first responders, with more more advanced practitioners few-and-far between
All together it is no surprise that the outcomes from a motor vehicle crash are worse than in the city, with one Australian study demonstrating a four-fold mortality for rural vs metropolitan areas. Not surprisingly, mortality increases the longer the time to care…and concepts like the “platinum ten minutes” and “golden hour” of trauma become academic when crash victims may not be discovered or receive help for a considerable time.

As rural doctors, it behoves us to examine best practices to try and improve survival. Certainly we need to have to skills and equipment to provide appropriate medical care in our hospitals..and some may provide an extended role at the roadside. I’ve blogged before about the concept of training and equipping rural docs to provide a coordinated prehospital response…and the more doctors I speak to, the more seem to think this is a ‘good idea’. Implementation however may take longer, and there will be hurdles to overcome (not least the oft cited response that such work is best left to experts, not enthusiastic amateurs).

Of course, the best ‘bang for buck’ is not necessarily in the delivery of expert medical care. I remember Karim Brohi making this point at one of the Australian Trauma Society annual conferences a few years back – “it’s better to build a fence at the top of the cliff, rather than provide an ambulance at the bottom to pick up the injured“. 

Locally we’ve had some small success with the ‘Roadkill Recipes‘ project – recognising that many rural traffic injuries on Kangaroo Island were caused by wildlife-vehicle collisions, a satirical cookbook of local wildlife served as a medium to convey a road safety message to locals and tourists.  Places like Kangaroo Island (and Tasmania) are interesting in that roadkill (and hence wildlife-vehicle collisions) is abundant. But for most rural areas the notorious “fatal five” of speed, inattention, drink/drug-driving, driver fatigue and lack of seatbelts are the culprits in many road crashes. 

Which is why I was heartened to see new signage as I crossed the border into South Australia (below). The Motor Accident Commission’s “matemorphosis” country roads programme aims to target country drivers, particularly male drivers who may respond to mateship peers.

The MAC campaign includes references to wankers, cocks, knobs and tossers.

I wonder if as rural doctors we need to be more proactive in injury prevention – especially when our work comprises mostly primary care as well as the ‘fun stuff’ like airways, trauma and emergency medicine. Driving change can be hard, but if we’re serious about injury prevention we need to be active in local road safety groups, at sporting events, with families and spreading the road safety message. But concomitantly we need to ensure our training and local resources are fit for purpose.

So in 2012 my projects will be:

– actively engage the local community in primary prevention health strategies,

– work with colleagues around the country to develop a ‘rural doctor masterclass’ course, showcasing latest concepts, equipment and techniques relevant to rural proceduralists,

– try and establish a more formal framework for rural doctors attending prehospital incidents (as a minimum, appropriate training, equipment and maintenance of standards) – existing retrievalist courses like RFDS STAR (RFDS Qld) and the medSTAR short course seem to be appropriate building blocks, bolstered by some online case discussion and commonality on procedures/protocols,

– work on developing a bespoke airway skills course for rural docs in South Australia, with concomitant development of minimum standards for difficult airway equipment in our rural hospitals.

    What are your News Year resolutions?