An Affair of the Heart – Valentines Day Message

 to Clinicians

Community leadership.  As clinicians we have a wonderful opportunity to educate – not just in the consulting room and on the wards…but also to get out there and make a difference.  On 14th Feb (Valentine’s Day) it’s only appropriate that we consider the importance of the heart!

Sudden cardiac death is estimated to affect over 15,000 Australians per year – that’s one person every 26 minutes

.  Such events are most common in the home…but can also occur in the workplace…or at school or sporting events…type ‘cardiac arrest’ into google or youtube and you will be confronted with images of often fit young people collapsing on the footy pitch, basketball court

…or it can even happen in Ambulance Comms with a TV crew present, as in this video!

Of course most of us think that survival is as portrayed on the TV and films, where ridiculously high success rates on TV belie the fact that survival from out-of-hospital cardiac arrest in this country is less than 10%.

Often even emergency clinicians think that delivering primary health care messages and community training aren’t considered important!

Many people also think that survival depends on ‘hospitals and helicopters’ – expensive machinery, paramedics leaping into action

It’s certainly true that a rapid prehospital system and access to life-saving interventions such as cardiac stenting, cardiac bypass and so on are important…

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…but the first stage in the ‘chain of survival’ requires early CPR and use of a defibrillator.

And that is a problem – typical ambulance response times in the city are around 8 minutes for a ‘priority one’ call…longer in rural areas.   Sadly for every minute that goes by, the chances of survival drop by 10%…

We need community members to act as the first links in the chain of survival – to know what to do if someone collapses.

Bystander CPR and Public Access Defibrillators are key

Public education programs such as Vinnie Jones ‘Push Hard and Fast’ or the more recent Australian “Shock verdict’ campaigns can help educate the public in ‘hands only’ CPR and use of an defibrillator.

These simple steps mean that success rates as low as 7% in Australia can be improved to approaching 70% in countries where a ‘HeartSafe Community’ system has been implemented.

Kangaroo Island – Australia’s First HeartSafe Community

This is what we’ve been doing on Kangaroo Island – educating the community in how to deliver ‘hands only’ CPR, encouraging organisations to purchase defibrillators and ensuring that a certain number are made available 24/7 as ‘Public Access Defibrillators’.  You can read about HeartSafeKI here.

We have had our first success, a resuscitation on the bowling green – and this encouraged others to get on board, such that Kangaroo Island is now recognised as Australia’s first HeartSafe community and received a shout-out in National Parliament in Feb 2018

Of course many other communities have trained up schools, sports clubs and business members to deliver CPR, and purchased Public Access Defibrillators for their townships.  There is even a nascent National Program for HeartSafe Communities run by the Heart Foundation – from little things, big things grow!

AED Registers and Smartphone Apps

The system can be further bolstered by maintaining a register – we do this locally with the HeartSafeKI register, to remind organisations when replacement pads and batteries are due for their defibrillator.

Additional registers of AED locations exist – SA Ambulance has one, meaning that callers can be directed to the nearest available AED.

On a wider scale, free social enterprise ventures such as the GoodSam app are available globally – using smartphone technology to alert off duty CPR doctors/nurses/paramedics or CPR-certified responders to a cardiac arrest in the nearby vicinity BEFORE the ambulance arrives.


So – what can YOU do this Valentines Day?



As a doctor, nurse or paramedic, consider getting involved to make your neighbourhood a ‘HeartSafe’ community

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– if you are CPR trained, please register as a GoodSAM responder.

– 

if you are able to train others in CPR, then please consider running sessions to train the community in CPR and use of a defibrillator

 (any doctor should be able to do this!)

– if you are a community leader, help advocate for Public Access Defibrillators to be made available

 where you live

If you are not clinically trained, but are concerned about the possibility of sudden cardiac death in your school, workplace, sports club or community, then help campaign for training in CPR and a network of Public Access Defibrillators.

You can become a HeartSafe Community by training >10% of residents in CPR and instituting a network of Public Access Defibrillators, integrating into existing ambulance and cardiac care services…

Come on Australia – let’s do this.  As clinicians you have a wonderful opportunity to engage in a public health campaign.

Further Reading

Heart Foundation Australia – Sudden Cardiac Death

Sydney Morning Herald – TV Portrayal of Resuscitation Success is Ridiculously High

HeartSafe Communities – the USA HeartSAFE Program

Heart Foundation Australia – HeartSafe Communities

SA Ambulance AED Register – log your AED here

GoodSAM App Crowdsourcing via Smartphone – read more here

Community CPR, It Works! – heartwarming tale from survivor of a sudden cardiac arrest & his rescuers

Kangaroo Island is Australia’s First HeartSafe Community – Parliament statement by Rebecca Sharkie, MP

HeartSafe KI – info on HeartSafeKI program

 

Snake Bite in Rural Hospital

We’ve had a spate of snake bites on Kangaroo Island over the holiday period.  So I thought it would be worth reviewing snake bite management.  Not least because I’ve had some sensible suggestions from my colleagues at Raptor Domain / KI Birds of Prey who run South Australias only ‘in-flight’ bird display AND offer a FANG-tastic session on snakes, scorpions and spiders and more in their Venom Pit.  Management of snake envenomation is a question often asked by tourist visitors to KI.

Who gets bitten?

Snakes may come close to humans to hunt mice, steal eggs or be close to water.  Warm weather, increased tourists on the Island..plus of course alcohol, late nights, farm activity etc mean that there is more chance for humans and snakes to coincide.

But despite their reputation, snakes are generally shy creatures and would prefer to evade humans than interact with them.  To be frank, humans are not primary prey for snakes!  They’d rather conserve their venom for something they can eat…like a mouse, small lizard or similar.

A snake’s first defence will be to move AWAY from a human if possible.  If threatened, they may rear and hood, to make themselves look large and threatening.

Not surprisingly most snake bites happen when people either surprise a snake (tread on it!) or provoke it (try to kill it, relocate it or generally muck with it).

What should I do if bitten?

First thing to do in a suspected snake bite is to apply a pressure immobilisation bandage

Every home, car or workplace should have access to a pressure immobilisation bandage.  A simple crepe bandage or two would work fine.  Apply firmly over the bite site, then wrap the limb from distal (fingers or toes) to proximal (up the limb as far as can go).

The bandage should be applied firmly – as if for a sprained ankle – not so tight as to stop blood flow to the peripheries!  Unlike bandaging or splinting traumatic wounds (where we ‘splint-to-skin’), it’s probably best to leave clothes on and apply the bandage over clothing….

Some neat dedicated snake bite bandages have visual markers to help guide how firmly to apply the bandage.

For my money, a simple OLAES Modular Bandage or Israeli/Emergency Bandage would suffice for rural community members, and also doubles as an excellent device for other uses.

Splint the limb if possible to reduce movement – the venom typically spreads through the lymph initially.

Do NOT apply a tourniquet.
Do NOT try to cut out or suck out the venom.
If in doubt, ring 000 and take the call handlers advice.

Once PIB is on and splint applied, the next priority is to transport the casualty to Hospital.

First point of call should be SA Ambulance – they may send a local crew or, if remote, organise a primary retrieval from the scene.

Should I capture or kill the snake? For identification purposes?

No.

People often think that it is necessary to bring snakes in to the Hospital for identification purposes and to help guide the choice of antivenin.  It’s true that herpetologists might want to count anale scales to identify the snake.  But not most doctors.

Of course we’ve got it relatively easy on Kangaroo Island – we only have two types of snake (the tiger snake and the pygmy copperhead)….and the antivenin we use is the same for both!  Of the two, the tiger snake is reportedly more likely to bite.

In other locations in Australia, there are far more options for envenomation – the brown snake is responsible for most snake bite deaths Australia….and of course we have more deadly snakes here than in the rest of the world!

But we don’t need to see the snake.

All hospitals have access to a venom detection kit – this doesn’t actually tell us if the victim is envenomated or not…rather it helps us to identify WHICH antivenin to use.

Many hospitals have polyvalent antivenin which will cover major local snake species.

So – how do I know if I’ve been bitten?

Short answer?  You don’t.

It can be really tricky.  Presentations may vary from the so-called “dry bite” (snake+fang marks but no venom injected) through to sudden collapse with no warning (unwitnessed bite or unreliable historian, with severe envenomation and death).

Caption : YES there was a snake.  YES there is a bite mark.  But is there envenomation?  Who knows….

Hopefully most snake bite presentations will be somewhere in the middle “There was a snake – it struck me – there’s a bite mark – I feel unwell”.  But long and short, if you THINK you’ve been bitten by a snake, we will believe you!

What happens at the Hospital?

As mentioned above, the Venom Detection Kits aren’t used to determine if envenomated or not – they are used to guide choice of antivenin.

If someone arrives in the Rural Hospital with a PIB in place, we are unlikely to remove it – there have been reports of sudden collapse as the previously contained venom is now disseminated.

Instead the patient is transported to a place that can monitor the patient.  This means regular blood tests for coagulopathy and requires a 24/7 lab. This is why pretty much all suspected snake bites in rural South Australia will be transported to a tertiary centre (sites with on site antivenin AND 24/7 lab facilities may elect to monitor stable patients).

Of course there ARE ways to check for envenomation – most snakes will give rise to either neurotoxicity or coagulopathy.  Nerve or blood problems.

A patient with slurred speech, blurred vision or obvious neurological symptoms and signs on background of suspected snake bite can be assumed to be envenomated and antivenin may need to be given – usually in conjunction with the State-based Toxinology experts (Julian White & Scott Weinstein) based at the Women’s & Children’s Hospital in Adelaide.  these guys offer a 24/7 service and are always super helpful and friendly when discussing possible snake bite and management.

Ditto someone who has evidence of bleeding disorder e.g. : bleeding from gums, blood in urine etc.  This may indicate coagulopathy and antivenin may be required.  NB Rural doctors should be aware that point-of-care INR testing is NOT reliable for demonstrating clotting disorders due to envenomation.

If there are clear signs of envenomation, don’t panic – the Hospital has antivenin.  So we can treat you. But antivenin is not something we’d give ‘in case’.  Rather we reserve use for those who have signs of envenomation.

What’s with the glass test tubes?

An old rural doc trick is to use ‘whole blood clotting time’ – take a 10ml sample of the patients blood and at same time, take a 10ml sample of a colleagues blood and place each in a glass test tube (with no additive/preservative). Gently agitate over twenty minutes, then invert.  A marked disparity between clot formation may indicate a consumptive coagulopathy in the patient blood.

Of course this takes 20 mins or so to do and should NOT delay resuscitation and transfer.  It certainly can’t be used to ‘rule out’ envenomation…rather to perhaps fill in the time whilst waiting for the transport platform to arrive and perhaps allow early consideration of antivenin administration before things turn ugly…

I don’t think that performing this test is something that should delay transfer.

Caption : Dr Donna Weckert (ACRRM Registrar) bravely donates a ‘control’ set of blood to compare with patients’ blood whilst awaiting urgent transfer. This test should NOT delay transfer & a normal test does not mean all is well!

So, in SUMMARY – you’re saying that if I get bitten I should…

– stay still and call 000
– apply a Pressure Immobilisation Bandage
– splint the affected body part
– don’t attempt to kill or capture the snake
– expect to be transported to a tertiary hospital ASAP; this may be via local rural hospital
– don’t let anyone faff around with fancy blood tests or ‘whole blood clotting’ as a prelude to transport – if thinking ‘snake bite’ we need to move you

If you have evidence of envenomation, the local Hospital has antivenin for local snakes.  We will only give this if there is clear evidence of envenomation and in conjunction with the Toxinology experts at WCH

Don’t let anyone take the bandage off until you’re in a tertiary hospital

Even once the badge is off, walk around a bit to make sure previously contained venom isn’t now free to circulate!

Further Reading

Pressure Immobilisation Technique – from the Australian Resuscitation Council

Pressure Immobilisation Bandage & Splinting – Youtube video from Australian Venom Research Unit

Tiger Snake Envenomation & Antivenin – from the CSL Antivenin Handbook

Most Dangerous Snakes in the World – Australian species feature highly!!!

Adelaide Women’s & Children’s Hospital – Clinical Toxinology Department and TOXINOLOGY.COM

A bit dated now, but SA Health has Snakebite & Spider Bite Management Guidelines

Of course snake bite is a huge issue globally, particularly in tropical countries.  Snakebite affects the lives of around 4.5 million people worldwide every year; seriously injuring 2.7 million men, women and children, and claiming some 125,000 lives – see Global Snakebite Initiative 

 

Rural Generalist, Swiss Army Knives & Waiting Lists

I’m proud to be a rural doctor.  My training is in not just Primary Care but also in Emergency Medicine, Obstetrics and Anaesthesia.

To be able to serve their communities best, rural doctors need broad brush skills across the board.  Rather than the finely-honed precision instrument of the specialist (akin to a scalpel), rural generalists are comfortable adapting to various needs, whether in clinic, hospital or at the roadside (akin to a Swiss army knife).

It’s an exciting time; former rural doctor and fellow South Australian Paul Worley has recently been awarded the role of Australia’s first Rural Health Commissioner and is focussed on ensuring a pathway from medical school, internship, junior medical officer training, registrar training and speciality training to become a specialist rural doctor with sufficient skills to meet community needs.  These might include the ‘obvious’ procedural skillset of emergency medicine, obstetrics and anaesthetics…but also non-procedural sub-specialism such as paediatrics, palliative care, mental health and so on.

Rural Anaesthesia Down Under

My focus in recent years has been on rural anaesthesia; we’ve suffered in recent years from fragmentation of GP-anaesthetists between the silos of regional health services, States and traditional RACGP vs ACRRM divides.  A recent GP-anaesthetist conference in WA was the nidus for the formation of a ‘Rural Anaesthesia Down Under’ Facebook group, which has already captured over 200 of the estimated 450 rural GP-anaesthesia in Australia!  We’re having conversations on safety and quality, on clinical procedures, on training and upskilling – all with the emphasis on rural doctors being the experts to contextualising the discipline of anaesthesia to our rural environment.

There’s even talk of establishing a National Audit of Rural Anaesthesia practice, in terms of determining demographics of GPAs, of caseload and of course of safety compared to our FANZCA colleagues!

Establishing such baseline data may help us when arguing for the ongoing viability of anaesthetic services in the bush, as it’s unrealistic to expect FANZCAs to service rural Australia – indeed replacing the ‘Swiss army knife’ of the rural generalist with the partialist FACEM, FRANZCOG or FANZCA costs a health service far more – as these clinicians are generally uncomfortable to switch from anaesthesia to obstetrics to emergency medicine to primary care.

The experts in rural medicine are rural doctors!

In a similar vein, I’m really excited to see that Queensland is now asking for Expressions of Interest for training of rural generalists in endoscopy to GESA standards (Gastroenterology Society of Australia).  The EOI can be read here and is a wonderful initiative to drive accessible services to rural Australians under the rural generalist model.

More and more rural doctors are gaining skills to enable them to best service their communities and relieve the pressure on tertiary centres in the city.  It makes no sense to send uncomplicated cases, whether deliveries, endoscopy/colonoscopy or general surgery cases to the city when there are rural clinicians able to deliver the service…and rural hospitals with operating theatre capability which is under-utilised! Heck, I’d love to see city patients who are stuck on long waiting lists for elective surgery being offered the chance to have their surgery done in a rural area – can you imagine if the Government supported city folk to travel to Kangaroo Island to have their procedures done!

Of course, it’s not just doctors – remote area nurses (RANs) and nurse practitioner models are increasingly being used to broaden the skill set and scope of practice of nursing colleagues in the country.  We need to move away from craft group and tribalism, and focus on the skillset required to ‘get the job done’

Are you a Rural Generalist who wants to learn endoscopy?

Expressions of interest from Rural Generalists are now invited, with two training positions available in 2018. The training program will take place over 48 weeks, including two placements in a high volume setting, with the remainder of the training taking place in the rural setting. Applicants are requested to complete the attached self-assessment tool and return it to us at HIU@health.qld.gov.au by COB Friday 19 January 2018.

Click HERE to read more….