Category Archives: Videolaryngoscopy

Networking and Silos

Well, just got back from the excellent GP Anaesthetists conference held in Sydney under the auspices of the NSW Rural Doctors Network. Apparently it’s an event they hold every other year (alternating with an obstetric workshop) and manage to do each workshop twice in each year – delivering quality education to approx 80 of the 150 or so rural GP proceduralists in NSW. It’s an extensive event that would go down well back in South Australia…although I reckon we’ll have to get Dr Minh Le Cong and Dr Casey Parker along to emphasise the ‘rural connection’.

What makes this event stand out was a day spent in the simulation lab at the Royal North Shore Hospital, with hands on quality simulation training in a variety of anaesthesia-relevant emergencies, then a conference dinner and the next day spent with a variety of speakers pitching content to the rural audience.

It was good for me to meet with other rural doctors, mostly from NSW and a few from Victoria. Interestingly, once they knew I was from Kangaroo Island, all were interested in the events of 2009 and our stoush with Country Health SA and the ACCC debacle (details of which I really should blog one day, as I should about upcoming contract negotiations with Rural Doctors in South Australia).

What I found interesting was that many of us rural doctors have the same problems – such as ongoing skills maintenance, lack of funding for nurse training and essential equipment, ongoing threats of hospitals being downsized and procedural services cut, remuneration for on call hospital work, as well as poor relationships with health bureaucrats. Most worryingly, many said that they were having to find own solutions to these shared problems, rather than a ‘top down’ approach. Basically, we’re all operating in our little silos, rather than solving problems and lobbying for changes en masse.

It was particularly illuminating to hear some of the speakers (mostly metro-based anaesthetists) talk about difficult scenarios and resources to cope. In a few instances the speakers seemed aghast that many of the rural GP anaesthetists did not have access to equipment that their metro counterparts considered essential – things like suggamadex, desflurane, remifentanil, FFP, fibre optic intubation, modern anaesthetic ‘workstations’ etc. Sure, some of the rural docs had some of this stuff. But by no means all, in fact more like fingers of one hand. Out of 40 doctors.

Why? Cost, as always I am afraid. But that’s OK. I think the key to being a good rural doctor is to “adapt-improvise-overcome”. Luckily we stand on the shoulders of giants and most of the hard work is already done – providing we are well-trained, and equipment is well-maintained, it’s perfectly possible to deliver a safe service using tried-and-tested agents.

So…anyone still using nitrous? I’ve been told that ‘no ANZCA trainee uses nitrous’ yet it’s been around for ages and remains on the anaesthetic machines in most places.

Keeping it Simple

One of the enjoyable challenges of rural & remote medicine is delivering high-quality care within the constraints of a health system that is cash-strapped, and where rural doctors often work between private clinic (own business) and public (State-run hospital) domains.

Sadly there exists a health-gap between rural and metropolitan Australians. For many services, health outcomes are worse in the country than in the city. This is in part to the tyranny of distance – the nearest specialist unit may be hundreds or even thousands of kilometres away. It’s also about limited resources.

Conversely some things are done very well in the country – birthing services for selected (low risk) mothers are excellent when delivered by local midwives and GP-obstetricians, as are local surgical services which can offer an almost bespoke service rather than the ‘sausage-factory’ of a major tertiary hospital.

My particular interest is in emergency medicine and the particular problem of how to deliver high-quality emergency care in the bush. The ‘gold standard’ for delivery of emergency medicine in Australia is Fellowship of the Australasian College of Emergency Medicine (FACEM). But FACEMs, like other specialists, tend to congregate in the city hospitals where they can share workload with colleagues and also deal with the stuff they are trained to do on a daily basis.

Meanwhile staffing of the ‘accident and emergency’ department of a rural hospital can be variable – usually there is no on-site doctor, but a service is provided by one of the local doctors in primary care. He or she may have lots of EM experience….or very little. Which can be a challenge for medical and nursing staff who may only see this sort of emergency infrequently.

Well-trained rural doctors take this sort of thing in their stride. Ideally rural doctors have spent a year or so gaining experience in each of obstetrics, anaesthetics and emergency medicine. Excellent courses like EMST, APLS, ALSO, RESP and MOET help to keep rural doctors in touch with current practice.

More important is anticipation of the likely caseload, with planning & training for the worst.   This is not a new thing – recently guidelines for a minimum prehospital equipment setup have been suggested and such standardisation has many advantages. The lack of agreed standards is one of my bug bears.

Perhaps one of the hardest emergencies to deal with is the difficult airway. Training helps, but most of the training on anaesthetic rotations is in elective anaesthesia – I’d argue that the emergent airway is a very different beast!

In South Australia there is no agreed standard on ‘difficult airway’ equipment between the 30 or so rural hospitals. It seems bizarre to insist on appropriate credentialling for doctor’s working in these areas, but not to insist on an agreed standard for the equipment they use.

Perhaps that is a bit harsh. ANZCA has outlined a technical guide on ‘equipment to manage a difficult airway‘ and it is suggested that individual hospitals determine what is best for them.

Recent discussion on a hypothetical case from Minh Le Cong in FNQ made me think about this. Often experts in tertiary centres will ask why adjuncts such as non-invasive ventilation, heliox or fibreoptic intubation were not employed. Simple – we may not have them in the bush.

Hospitals often don’t decide on what equipment is needed until it’s too late i.e. after a critical incident, usually through the lens of a Coronial investigation (the case of blood product availability in the Riverland is a case in point). More problematic, the equipment often costs tens of thousands of dollars, which means local CEOs having to plead a case for their hospital, for a piece of equipment that may only be used once in a blue moon – but when needed, is indispensable. Such is the nature of emergencies.

Rather than the local CWA having to sell a few thousand scones and woolly teddy-bears in their annual fundraiser for the local cash-strapped hospital, I wonder if it might be better to invest in economies of scale. Agree a minimum standard between health units, train medical staff in how to use it, and allow recycling of stock that is infrequently used to the major tertiary centres. In South Australia, integration with the Statewide retrieval service (MedSTAR) would seem logical, with common protocols for low-volume infusions, difficult airway and other emergencies shared across the State.

Thankfully there is light at the end-of-the tunnel. New products on the market offer potential to turn a difficult airway (Cormack-Lehane Grade III/IV into a CL I or II). I am of course talking about videolaryngoscopes and the new disposable fibre optic devices. There’s good discussion here, here anhere on these, which I won’t repeat….check them out for yourself!

I think it is now at a stage where it is indefensible for rural hospitals not to have good quality, easily set-up and maintained equipment for managing the difficult airway, to a standard similar to that of a metropolitan ED.

Costs are coming down, and it would seem logical for health units to agree on a standard (which should be locally-driven) and purchase devices in bulk. Equipment which is used infrequently could be rotated through higher-use centres, much as we currently cycle expensive thrombolytic drugs before expiry dates.

Moreover, medical staff rotating between sites (whether GP-anaesthetist locums or retrieval staff) would be familiar with the equipment used, allowing easier setup and use – often the main problem when in a difficult airway scenario.

What would I recommend? Well, the KingVision VL is cheap and easy to use. The video screen affords good views which can be watched by others in the room. It is going to be my default device if failed direct laryngoscopy.

I’ll also lobby for the Ambu Ascope – a relatively cheap disposable fibreoptic scope than could be an asset for awake nasal or oral intubation…or as a bailout tool to pass an ETT via intubating LMA.

Having the kit is one thing – using it is another. The annual rural doctors conferences (whether State or National) are a chance for both GP-anaesthetists and GPs providing emergency care to meet and discuss equipment, with opportunity for hands-on workshops.

But there’s no substitute for using the gear on a routine elective theatre ist, which again means an investment in training with the kit with a view to ensuring that it’s usable when needed.

What do others think?