Tag Archives: Emergency

What’s In Your Bag?

The subject of doctors bag contents has come up recently, with comments from a respected Emergency Physician that several of the drugs supplied for use in doctors bags are outdated





I was a little perplexed by the RACGP’s insistence on keeping diazepam and their pitch for oral vitamin K as essential for the doctors bag, but then again I am a FACRRM member and much of what the RACGP does perplexes me.


My preference would be to use midazolam to terminate seizures (intranasal or IV). As for the RACGP’s insistence that oral vit K be given intravenously for warfarin overdosage by rural doctors – well, I am not sure I follow their logic – someone who is bleeding and on warfarin – sure, they may need some Vit K (but they may also need more care than I can give in their living room) – I’d rather be doing this in my local hospital, with a point-of-care INR to guide me…and access to blood products if haemorrhage continues.


Don’t get me wrong – anyone who remembers the BBC’s ‘Cardiac Arrest’ series will remember the shocking episode of the haemophiliac guy with epistaxis and the immortal line from Dr Claire Maitland – “Yes your daddy’s going to stop bleeding very soon indeed“. 


If there was ever an argument for rural doctors possessing skills in emergency medicine and access to blood products for major transfusion, this sort of emergency is it. Interestingly those of us who trained in the UK prior to 2000 will remember ‘Cardiac Arrest’ as the most realistic portrayal of the utter shit that being an NHS junior doctor was. In fact I thought it was a documentary! But I digress…


So my feelings on doctor’s bags vary. 


I think there is a very real limit to what can be carried, and the contents of a day-to-day doctors bag will vary considerably from the contents of a prehospital pack for emergency use. I reckon that for doing home visits in an emergency the most useful device a doctor can carry is his/her phone – to summon help from an ambulance or retrieval service…


Doctors who do house visits are probably better off with a phone, script pad, BP cuff, stethoscope and a huge folder of Medicare forms…on the basis that the days of giving patients a shot of pethidine for ‘migraine’ are thankfully over and such patients are better served by IV fluids, high dose aspirin, chlorpromazine…ditto the renal colics – they need an indocid suppository stat and may even need parenteral opiates – again, in a hospital setting.


However doctors in the bush may be called to attend prehospital emergencies such as car crashes (I won’t call them accidents) or other incidents. Besides calling for help with a phone, the prudent rural doctor will carry an extensive prehospital pack – either stocked from local hospital, through a scheme such as RERN, or cobbled together from bits n pieces over the years. Considering that such emergencies may call for interventions up to prehospital anaesthesia, the contents need to be extensive and are bulky.


For what it is worth, here are the contents of my RERN packs…bear in mind that such callouts are to back up local volunteer ambulance officers, so monitoring equipment, extra pairs of hands, stretcher and a warm/dry/well-lit ambulance are taken as already present. RERN members are supplied with the excellent Neann bags via SA Ambulance.


BAG ONE (GREEN) – FIRST RESPONDER

C SPINE/OXYGEN/BASIC AIRWAY inc. BASIC DRUGS
Cervical Collars (adjustable) – adult and paediatric
Oxygen Cylinder C type (490 litres) & O2 tubing
Hudson Mask – 3:1 mask – Nebuliser reservoir
Guedel Airways 0/1/2/3/4
Ambu Bag, Mask & PEEP Valve
12G DwellCath cannula
Sphygnomanometer and Stethoscope
Gauze, Saline, Pads
Glucometer and test strips
LED headlight
Multitool

Drugs
Midazolam (2 x 5mg)
Naloxone (1 x 400mcg)
Glucagon (1 x 1mg)
Adrenaline 1/1000 (1mg)
GTN spray
Ventolin nebs (5 x 5mg)
Penthrox inhaler


BAG TWO (BLUE) – ADVANCED AIRWAY inc. INTUBATION DRUGS
Pouch 1 : Foot-operated Suction
Pouch 2: Chest Drains and Heimlich Valves
Pouch 3 : KingVision Videolaryngoscope & Blades, AirQ II iLMAs x 3


Intubation Pack

ETT/LMA/Surgical Airway Kit
Laryngoscopes with Mac and Miller blades, batteries AA and C
Size #3 and #4 LMA Supreme’s
Tapes, Gauze, Ties, Syringes
Ventolin inhaler connector
EzyCap and PediCap ETCO2 (“gold is good”)
Cophenylcaine spray and atomiser
Pulse oximeter
RSI checklist and kit dump mat

Drugs


Propofol 2mg/kg
Ketamine 1.5 mg/kg
Suxamethonium 2mg/kg
Rocuronium 0.6 -1.2 mg/kg
Fentanyl 100mcg x 3
Morphine 10mg x 2


BAG THREE (RED) – CIRCULATION inc. FLUIDS and EMERGENCY DRUGS


Sharps Bin
Pouch 1 : Dressing pack – Gauze – Bandages
Pouch 2 : Waste Bag – Vomit Bag – Gloves – Mask – Glasses – Aqium Gel
Pouch 3 : Pens, MedSTAR handbook, Stethoscope – Reflective Vest (DOCTOR)


Internal side pockets


Combat Application Tourniquet
Trauma Shears
Rapid Infuser catheters (RIC) 7 and 8.5 Fr


Main compartment
IV cannulae 2 x 14G – 16G – 18G – 20G – 22G – 24G & bungs
Intraosseous Needles (Bone Injection Gun, adult and paed)
500ml N/saline x 2
Giving sets
Splints
Spare dressing pack
Suture Material and Local Anaesthetic


Drugs
Adenosine
Adrenaline
Amiodarone
Aspirin
Atropine
Benzyl Penicillin
Cefazolin
Glucagon
Hydrocortisone
Lignocaine
Metaraminol
Metoclopramide
Metoprolol
Midazolam
Naloxone


I’d prefer the EZ-IO but locally we’ve been supplied with the B.I.G IO device instead.

I reckon that spending some recent time in anaesthetics has made be a bit ‘OCD’ – I tend to check my bags weekly and am constantly looking for ways to improve the set up. 


Any suggestions for improvements? What’s in YOUR bag?

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.