Over the weekend just gone, Chris Nickson of Lifeinthefastlane threw down a challenge – the idea of a debate of ‘real anaesthetists don’t need checklists’ between Dr Minh le Cong and myself at next year’s SMACC14 conference on the Gold Coast (#SMACCGOLD).

Not withstanding the obvious inequalities between Minh’s masterful martial arts technique and my more traditional wrestling style, I reckon this will be a kick ass debate and lead nicely into some breakout discussions.

It’s no secret that I am a fan of checklists and other cognitive aids to help us in our work. I;ve been blogging about this since my post on ‘aviation & anaesthesia’ back in 2011 at the old KIDOCs blogsite (http://ki-docs.blogspot.com.au/2011/11/anaesthesia-aviation.html) and linking to usual resources see ‘Resources’ menu tab above)

Familiarity breeds contempt, and there is a benefit to introducing checklists into everyday routine BUT HIGH RISK procedures

- the WHO Surgical Checklist (more than the standard ‘surgical time out’ should incorporate checks in anaesthesia room, before knife-to-skin and before leaving the OT)

- an RSI kit dump and challenge-response checklist, as used by many retrieval services but with application to occasional intubators in the ED, ICU and rural environment

- checklists for management of crises, in OT, in ED, in Labour Ward

Not only that, use of checklists fosters teamwork, humility, discipline rather than the usual independence, self-sufficiency and autonomy that underlies most medical training.

Not convinced?

Listen to Atul Gawande talking about ‘the checklist manifesto’ (thanks to Dr Stefan Mazur of medSTAR SA for getting on board with Twitter and sharing this link)

TED talk – Atul Gawande – How do we heal medicine?

Meanwhile, bring it on…

I am delighted that the SMACC 2013 podcast is out – you can download via iTunes from this link.

First up is Scott Weingart’s excellent talk on bringing “upstairs care, downstairs” – addressing the need to bring high-level critical care skills to the emergency room, for which FOAMed such as emcrit.org and other blogs have been pivotal.

For the rural doctor, Casey Parker’s BroomeDocs website, along with Minh le Cong’s PreHospitalMedicine.com, have become the go-to place for quality FOAMed material in aspects of relevance to the rural doctor.

Building on that, I set up KIDocs.org – and there are now a wealth of other blogs from rural doctors covering various aspects in the spirit of quality FOAMed. You can browse a collection of FOAMed material for rural doctors at ruraldoctors.net

Casey, Minh and I are obsessed with the concept of bringing “quality care, out there” – we see no reason why the limits of rural work (isolation, resource limitation) should make a difference in the ability to deliver the best possible care to our patients.

There are plenty of better doctors than me out there. But one of our jobs as doctors is to bring the BEST quality care we can – and that requires us to keep up to date. The standard annual conferences, APLS/EMST/RESP courses etc take us so far – but the power of FOAMed through tools of social media can help us broaden our discussion on cutting edge medicine for our patients to the benefit of all. Some of this is more about telling stories, challenging perceptions and striving to achieve mastery in our field rather than mediocracy. As individuals we can only do so much. Together we can change systems and attitudes – delivering ‘quality care, out there’.

If you are in any doubt, listen to Scott’s podcast from SMACC2013 – and as a rural doctor, think about coming to SMACC2014 on the Gold Coast 19-21 March 2014 – and help us bring “quality care, out there”

It isn’t all about EM and Crit Care – there’s quality FOAMed to be found across the breadth of rural procedural medicine and general practice.

My last post on GANFYD syndrome created some questions about the whole sick note system in Australia, which are perhaps worth exploring.

Let me be absolutely clear – doctors have no problem issuing sick notes when appropriate – such as the patient who presents with a lower respiratory tract infection and, at the time of consult, requests a note as unable to work 9or poses a health risk to co-workers). Similarly the patient with a broken limb who may be unable to perform his/her duties. Nor is there a problem with completing notes for WorkCover compensable injury – a prescribed medical certificate with details of illness and proposed treatment/rehabilitation is helpful for both employer and worker to achieve a successful return to duties.

The AMA and RACGP have issued guidance on sick notes – which you can access from the links below. A read of these should alert the doctor to the requirements for

- confidentiality
- accuracy
- veracity

However, there are still a few grey areas. Let’s take an example

A patient attends on Thursday 18/3 with a LRTI since the previous Monday. You examine them, confirm the presence of a LRTI and advise three days of time off work.

They would receive a note along the lines of :

“TO WHOM IT MAY CONCERN
I write to confirm that I examined PATIENT X on 18/3 and diagnosed them with a medical condition. He/she will be unable to work from 18/3 to 20/3.
Yours sincerely
Dr Y”

There you go – this note confirms their attendance and examination on 18/3, your advice for time off for three days…and as was part of the patient consult for their illness, is Medicare-compensable. It doesn’t specify the reason, other than ‘medical condition’ as the patient has a right to confidentiality.

The following Monday, the patient rings in (or attends) requesting a further note. They feel fine and have returned to work. But their employer now wants “a note to explain why they were ill, to cover the time off from previous Monday and to guarantee that they are fit for work duties.” The patient is bemused as they feel fine.

This is a classic “GANFYD” and raises several issues

- the importance of doctor-patient confidentiality
- the request for a note to cover time off that the doctor cannot confirm
- the request for a determination of ‘fitness for work’
- the fact that the employer requests this information, not the patient…as usual the doctor charges a private fee – but should there be a Medicare rebate?

There is a growing concern about GANFYD syndrome (“get a note from your doctor” syndrome) – the ever-increasing requests from employers/outside agencies for a note. Usually these requests are NOT at the patient’s wish – instead they are requested by organisations who wish to either absolve themselves of responsibility or to fulfil a bureaucratic, not a medical requirement. Max Kamien writes well on this and gave an excellent interview with the ABC.

The doctor may write something along the lines of

“To WHOM IT MAY CONCERN.
Patient X attended the clinic today at the request of his employer. I direct you to my previous note confirming sickness from 18/3 to 20/3 due to a medical condition. Patient X tells me that he/she was unable to work from the previous Monday 15/3 and now feels fit to return to work. I have no reason to doubt his/her veracity.
Love & kisses, Dr Y”

…and then the doctor might struggle to determine whether employer or patient pays for the consult. I see no reason to discount my fee for a professional service (would a lawyer?), but if there was genuine hardship the doctor may be inclined to bulkbill the consult to Medicare…so the taxpayer is effectively paying for the employer’s request for a note. Hardly a good use of the Medicare system, propping up an unnecessary doctors consultation for an essentially bureaucratic matter. Note that pharmacists can issue sick notes (for a fee) – but that no Medicare rebate applies. So unless there is a genuine medical need, I would tend to bill privately and encourage the worker to present the bill to their employer.

Later that day the doctor receives (via his/her receptionist), an angry phone call from the Human Resources manager at the patient’s workplace. They express dissatisfaction that the ‘sick note’ does not explain why the patient was unwell, nor does it cover them as an employer should the worker be unfit for return to work. They demand an explanation of the precise nature of the medical condition and that the doctor provide a statement that the worker is fit for their duties which apparently include maintenance of a sausage-factory production line and “insufflator-hyfrecator cleansing technician”. They also complain that the doctor has suggested that the workplace pay for the previous note.

How do you respond?

First up, unless there is signed consent from the patient, the employer has no right to details of the medical condition (it may be blindingly obvious in case of a broken arm or amputation, but this may not dissuade HR). Demand that the employer furnish you with the patient’s written consent. Next they require an assessment of the worker’s fitness to perform his/her duties. We are now firmly in the territory of providing an expert occupational medical opinion. Are you prepared to do this? I always imagine how I would defend myself if the patient came to harm and was being interrogated by a barrister or the Coroner. To be absolutely certain, I might require a full hour long occupational medical examination, a workplace site assessment or perhaps referral to an occupational physician for a specialist opinion. I won;t tell you my hourly rate, but for this sort of private medical one may be guided by a lawyer’s fees for appropriate billing (taking into account training, professional qualifications, admin costs etc)

All this takes time, is taking the Doctor away from core business (being a doctor, seeing sick patients) and is being requested by the employer – who needs to be prepared to pay for it. It is a hell of a lot more than ‘just a note’ and is nothing to do with Medicare.

As always, I would encourage the use of the universal GANFYD deflector letter – originally from the UK, but easily adapted to Australian circumstances. It is included below.

GANFYDS

One should bear in mind that the vast majority of GPs are private practitioners. They charge fees for consults and the patient may be able to claim back a portion of those fees under the Medicare rebate system.

Generally requests for notes or medical reports are NOT a Medicare service, more so when requested by the employer.

If there is doubt, or if the employer (or another agency) requests a medical report then be prepared to deploy the GANFYD deflector.

Otherwise you will drown in unnecessary paperwork – and patients who do need to see you will be unable to do so. And keep Medicare out of it, unless there is an underlying medical need for the consult. We are in deficit and health costs are rising – such requests should not be propped up by the taxpayer unless appropriate.

As Prof Max Kamien has pointed out, it’s unlikely anyone REALLY needs these certificates – they are fulfilling a bureaucratic or ‘cover your ass’ need. He reckon’s he’s written over 20,000 bland certificates and only had 2 challenged. Indeed there is an industry in providing fake certificates – such as DoctorsNoteStore.com !

Consider the following examples:

The 16yo school child who misses an exam due to vomiting during class, witnessed by teacher. She sensibly goes home and recovers within a few hours. Three days letter needs to book an urgent appointment as ‘school requires a note’

[Should be able to self-certify. Not needing to see doctor at time of illness. School should be able to act based on student, parent or even teacher's assessment.]

The worker who was unable to work on a Friday due to a migraine. Presents on the following Tuesday on instructions of employer who ‘want a note so say was unwell on Friday – wouldn’t normally need a note but because was sick on day prior to weekend, employer needs a note”

[worker should be able to self-certify. Doctor unable to determine veracity of illness on Friday when examined 4 days later and now well. Can generate bland note to this effect - but charge privately to employer. Legislation to allow self-certification would be helpful]

The employer who requests a note “stating that worker is fit to return to duty” after a previous injury for a non-work related injury (eg: broken toe).

[this is a request for an occupational medical assessment. The assessor needs to be fully informed of the worker's duties and perform an examination directed at their fitness to perform these tasks. Needs will vary eg: desk worker vs deep-sea diver vs professional dancer. A site visit, list of all work duties and a good hour long medical plus a few hours for report/workplace assessment would be required at commensurate rates]

The patient who requires a note from gym/diet agency/sports body stating ‘that is medically fit to undertake task’ eg: parachute jump for charity, crash diet, gym programme, diving

[the agency is essentially asking the doctor to take responsibility for an activity over which they have no control. Two choices - either a quick note (with signed consent) confirming the patient's past medical history and suggesting that the agency make own assessment of risk...or a full on medical examination targeted to task proposed (preferably by a clinician with experience in the field), privately charged...with same comment that risk remains that of individual and agency]

THE UNIVERSAL GAFYD DEFLECTOR

Date:

Dear Sir/Madam

Regarding Name:

Patient Address:

My patient has requested that I send you details of his/her medical history in so far as this is related to employment / workplace needs. I would be grateful if you would confirm your need for this information and complete the details below:

Precise information required (please be specific):

I consent to the above information being given by my GP to my employer.

Patient’s signature:
Print Name :
Date :

Date by which GP response is required (at least 7 days from receipt of your reply to this request):

The employer accepts responsibility for the fee payable for this service depending on requirements. This may require payment for a clinical examination, generation of medical report, specialist consultation & investigation, workplace assessment and administrative fees.

PLEASE NOTE THAT THIS IS NOT A MEDICARE-COMPENSABLE SERVICE AND THAT THE EMPLOYER IS RESPONSIBLE FOR ALL FEES (fee schedule attached)

Signature (employer):

Date :

Please print name and position:

In the event that this information is not required I will assume that the patient themselves can supply you with all necessary details.

Yours faithfully etc

Dr XXXX

LINKS

AMA Guidelines for issuing sickness certificates

RACGP – Sickness Certification

The Sick Saga of Sickness Certificates

Pharmacists can issue sick notes

Doctor’s certificates are a sick joke

Should GPs have to write sick notes?

No surprises in the recent Budget, with a huge deficit and not surprisingly significant cuts to be made across the board. Given the ever-increasing cost in health, some deductions have been announced, including

- an increase in the Medicare safety net to $2ooo payable by patients before the Govt provides assistance

- freezing of Medicare rebates to patients, with likely increased charges for patients

One of the common problems in medicine relates not so much to clinical management, but to the potential for cost-shifting; whether from State to Federal funding & vice versa, or from medicare-rebateable services to non-rebateable private fees.

Most days in my role as a primary care provider, I am asked to complete paperwork for third parties

• Insurance Companies
• Workcover
• School or University
• Employers
• Centrelink

…and medical exams for activities such as diving, sponsored-parachute jumps, commercial driving activities etc

It seems that there is a constant demand for ‘the Doctor’ to just complete same paperwork for a third party – but that this work should be billed to Medicare.

As I understand it, Medicare is a rebate system for patients to claim back a portion of the Doctor’s private fees. On some occasions the Doctor may choose to accept the Medicare rebate for the service (so-called bulk-billing). However Medicare rebates have fallen by a third over the past decade and are now frozen. Hence there is a widening gap between the Doctor’s fee and the rebate – the ‘gap’ fee.

Of course the tax-payer is funding the Medicare rebate…and this raises the issue of why on earth the taxpayer should, via Medicare, fund the generation of medical reports or letters for non-Medicare compensable conditions.

One of my bugbears is that of GANFYD Syndrome (or “Get A Note From Your Doctor” Syndrome); as suggested above, there are a wide variety of requests for notes from various agencies, often to ‘cover themselves’ – essentially a request to abrogate responsibility for an activity on the basis of a doctor’s assessment.

Such services should be viewed as private services. Moreover, the Doctor may decline to provide them if he/she is asked to provide an assessment out-with their expertise (a diving medical is a classic example, unless the doctor is specifically-trained in dive medicine). Similarly requests for a note that “Is Mr X safe to undertake a parachute jump for charity?” are likely to be declined on the basis that it is inherently unsafe to jump put of a perfectly functioning aircraft, and that this is an activity over which the doctor has no control.

Prof Max Kamien has written on this & reviewed by the ABC “the sick saga of sickness certificates“, commenting on the ridiculous request from employers for sick notes for even a single day of absence from work. Clogging up GP surgeries with people who should be tucked up in bed with their fu-like illness makes no sense – nor does taking up GP appointments for self-limiting illnesses “just for a note” make much sense.

Worse still, the employer is rarely prepared to pay for such a note – either asking for the patient to pay or expecting Medicare to pick up the tab.

I reckon I get 3 requests like this per day. I presume other doctors have similar rates. Multiply this by the number of doctors across Australia and the associated burden on Medicare…and I reckon Mr Wayne Swan could save a few hundred million there alone by either banning sick notes or insisting that the employer pays for this non-Medicare service which, in general, the patient does not want.

There is a handy GANFYD deflector from the doctors over in the UK – easily adaptable to use in Australia. Copy it into your medical notes software as a macro and deploy it whenever possible – along with a private invoice.

You can download as a Word Doc format or PDF format by clicking.

Mr Swan will be proud of your efforts to reduce Medicare costs…

Anxiety disorder makes up a fair part of my caseload in primary care and ED.

Help is out there.

Amidst all the trumpeting about the National broadband Network and the benefits of TeleHealth, I learned at the SMACC2013 conference from ACRRM that the hugely successful and useful TeleDerm service may be axed.

For those who don’t know, TeleDerm is an initiative from ACRRM that has been around for a few years. It allows rural and remote doctors such s myself to photograph a skin lesion then email it, along with a brief precis of the patient, to a specialist dermatologist who can give advice – usually within 12 hours.

That is fantastic – waiting to see a specialist dermatologist can take weeks or months, costs a small fortune. Whereas this simple initiative works a treat and ‘does exactly what it says on the tin’

From what I can gather, ACRRM submitted an application to DoHA last year, with approval due in March 2013…

…and they have heard nothing.

There is a real fear that this service will be axed, which carries a huge impost for rural patients.

So – a service that works – is cheap – may be axed and replaced with – well, what? An expensive NBN? A telehealth consult that is mired in red tape?

If tou work in a rural community or are affected by this (given skin cancer’s proclivity, this affects pretty much ALL rural Australian’s), then get active – follow the #savetelederm hashtag on Twitter, make your voice known to @Tanya_Plibersek – or email this page to colleagues, friends and family.

TeleDerm really is too good a service to lose. See also discussion at FOAM4GP.com

http://foam4gp.com/save-telederm-in-2013/

Here is more information about TELEDERM via the Department of Health and Ageing website

BACKGROUND

PROGRAM STRUCTURE

RRMEO ONLINE PORTAL

FUNDING

USAGE

DERMATOLOGIST EXPERIENCE

BENEFITS OF STORE AND FORWARD

RELATIONSHIP BETWEEN VISITING SERVICES AND TELEDERM

IMPROVEMENT AND EXPANSION

FUNCTION AND FUTURE DIRECTIONS

Regular readers of this blog will be in no doubt that I love the work of a rural doctor – but am not shy to express my frustration with some of the systems within which we are constrained.

Not least is the never-ending onslaught of safety directives from Country Health SA – kind of ironic that barely a week goes by without an email reminder not to inject chlorhexidine into the intrathecal space, to be careful with shoddy Chinese-knock off titanium hip screws and not to mix noxious chemotherapy agents in my consulting room.

But when it comes to meaningful issues, like the complete disinterest of CHSA in tangible risks such as the lack of difficult airway equipment in rural hospitals, the paucity of functioning cardiac monitors locally and the lack of enthusiasm for team-training and use of checklists, there seems to be no direction from top down.

A recent proposal to audit ED intubation in SA rural hospitals – perhaps the most high risk procedure that a rural doctor  will do (by default an occasional intubator), has been knocked back as ‘not necessary’.

Meanwhile in-house compulsory ‘morbidity & mortality’ audit by the CHSA-appointed Principal Medical Officer (a non-rural GP who operates out of metro Adelaide) was focussed on – no, not retrieval cases, not near-misses on the wards – but on the proper completion of paperwork for deceased nursing home residents.

The mind boggles. So much for meaningful quality improvement. Yes I know that paperwork is important – but to focus on this area and not the issue of improving quality in how critical illness is managed in rural EDs seems somewhat lacking in vision.

I believe that this is symptomatic of a system that is prepared to measure everything but knows the value of nothing.

The office stapler – a high risk instrument

So what about the stapler?

Well, I reckon it was about three years ago that the stapler was removed from the doctor’s office at the local hospital.

The reason? Apparently because staples are a safety risk – someone might cut themselves!

Now the only reason I use a stapler is to bind together a wedge of transfer paperwork when sending patients off the Island, either as a rotary-wing retrieval or as a fixed-wing transfer. Bundling together my letter, copies of the in-patient notes and nursing obs plus relevant letters/ECGs/X-rays etc as one parcel should make it easier for this information to be read and retained by the receiving team.

Now there is no stapler. So bits of paper get lost…and patient care suffers if vital information is mislaid.

Yes, I know that I could use a paperclip – but somehow there is never one around. But never mind – we are 100% compliant with a 0% stapler-induced-major haemorrhage death rate amongst the staff. We should be proud…

I find it hard to believe that I can be trusted with sharp scalpels, mind-altering drugs, laryngoscopes and other sharp/pointy/dangerous things – but not a desk stapler.

Somehow I bet there is a stapler in the CHSA CEO’s office…

It’s on!

This latest from SAPMEA…

Dates Confirmed for Masterclass in Rural Practice
Friday 15th & Saturday 16th November 2013 on Kangaroo Island

sapmea is holding a Masterclass in Rural Practice on Kangaroo Island, with a focus on teamwork, hospital based equipment, checklists, protocols and a higher level of management of psychiatric, medical, airway, trauma and obstetric difficulties.

There will be a  Trauma Surgeon, Obstetrician, Psychiatrist, Paramedics and the fabulous MedSTAR team as well as key rural GP’s on tap to discuss and work through the issues.

Please email Erin Gray cme@sapmea.asn.au with your registration of interest.

Hope to see some of you there…

I had the opportunity to speak to Mr Mark Wilson – a consultant Neurosurgeon and HEMS doctor in London, with a background including NASA, Everest Base Camp, rural medicine and significant input into medicine in the developing world.

Mark and I were at University College Hospital in London many moons ago. As times have moved on, so have our respective careers. According to information from the St Mary’s Hospital (Imperial College) website :

Mark underwent self imposed prolonged training, as an anaesthetist and a GP, before his neurosurgical career, but even now likes to maintain a broad medical interest. He has worked extensively overseas (India, Nepal, South Africa, as a GP in Australia, researcher for NASA and as an expedition doctor on Arctic and Everest expeditions). He wrote The Medics Guide to Work and Electives Around the World and runs www.medicstravel.org. His research is mainly into the brain in hypoxia (using it as an injury model) in humans.

I believe Mark even did a stint as Dr Mike Cadogan’s wedding photographer! Small world…

You can see his impressive CV here..and be sure to check out his talks (freely available, just credit appropriately).

Now I don’t know how Mark’s career went so badly wrong, but thank my lucky stars that my own career path at least has lead to the life of a simple country doctor in rural & remote Australia (TFIC).

Joking aside, there are common themes for Mark’s work as a neurosurgeon and pre-hospital specialist and that of the rural & remote doctor from which we can learn. And Mark was gracious enough to say that he wishes he was working as a rural doctor in Oz! So we hooked up today to chat about neurosurgical issues and the bush – you can watch the VODCAST below.

One of the classic ‘brown trousers’ scenarios in medicine is that of the seriously head-injured patient with an extra-axial haemorrhage (subdural or extradural) – the resultant compression of the brain by expanding haematoma causes brain injury and death…a mechanism that is amenable to targeted placement of a burr hole. Put simply, placing a hole in the skull allows the drainage of blood.

This is not a new concept – indeed skull trephination has been with us from Neolithic times onwards – with bone trephination used as primitive emergency surgery to remove shattered bone and blood clots typical for weapons such as slings and clubs. trephination is shown in Hieronymous Bosch’s work (below)

In 2012, Cliff Reid published on ‘life & limb’ saving procedures that should be within the remit of any Emergency Physician (and hence with which rural doctors need to be au fait). Similarly I heard Brian Burns speak on ‘Always Carry A Scalpel’ at SMACC2013 – but neither mentioned drainage of extra-axial haematoma as a core skill for ED or PHEC docs.

This is a shame as the principle is the same as other limb/life saving procedures such as finger thoracostomy, surgical airway, thoracotomy, lateral canthotomy etc – make a hole and relieve or stop the bleeding. Not a terribly complex procedure – in fact, according to comedy duo Mitchell & Webb “it’s not exactly brain surgery!”.

Extra dural haematoma

Of course the preference is to transfer such patients to a dedicated neurotrauma facility. But every now and then, especially in this large brown land, there are reports of bush doctors having to perform emergency burr holes / craniotomy to save a life. Indeed there are some reports that outcomes may be better by general surgeons in the bush than by transfer and treat approaches, due to the worsening of prognosis with delay – which can be significant in rural Australia.

see the excellent ‘Primary Surgery’ guide for burr hole surgery (reference at the end of this post)

Not to be gung ho about this – the preference is very much that the procedure is done by a neurosurgeon, with CT confirmation of the sire of bleeding….but every now and then it does need to be performed in outback Australia. Dr Jeff Taylor in Naracoorte, SA had to do this as did Dr Rob Carson in Maryborough, Vic also – in the latter case using a hand held drill form the hospital maintenance shed! I’ve been involved with one in rural NSW a few years back when locumming in the bush – scary to get started, but not so hard once you get going! A bit like a surgical airway…

So – have YOU got a Hudson brace, perforator drill bit and a burr hole bit in your hospital?

Better still a drill bit with a clutch mechanism as suggested by Mark and colleagues? And do you know how to use the kit?

Who is YOUR local neurosurgeon in a crisis and can you get hold of them quickly?

REFERENCES

Mitchell & Webb Brain Surgery video

Guide from the excellent austere environment guide “Primary Surgery Vol 2″ on extra-axial haematoma’s and how to perform the surgery

Extra and subdural bleeds, both extra-axial

Account of Dr Rob Carson in Maryborough using an electric drill in rural Victora
http://www.squidoo.com/Dr-Rob-Carson-Maryborough

and a similar account of Dr Jeff Taylor in Naracoorte doing the same in rural South Australia at http://www.abc.net.au/news/2004-06-08/boy-saved-as-gp-gets-surgery-tips-via-phone/1988972

Rural doctors should be aware of The Canadian Journal of Rural Practice and the excellent paper on “The Occasional Burr Hole”. The advice ‘if you are in a hurry, just read the bold type’ is classic Canadian understatement of this ‘how to do it’ guide…

For a more up-to-date guide, see Mark’s paper “Emergency burr holes: how to do it” – which emphasises the need for a clutched drill bit to avoid ‘plunge into brain’.

You may also be interested in Mark’s websites on Medics Travel and General Info inc CV etc

There’s also a section on “Teach yourself brain surgery” !

Bit of a discussion on twitter this week re: the ideal contents of a doctors bag.

I’ve posted about this before on the old KI-Docs.com site (now surpassed with move to WordPress and Mike Cadogan’s revamping of the site as KIDocs.org)

Here’s a 25 min video on the doctors bag – mostly from the perspective of a RERN kit. Bear in mind that this kit is used alongside existing ambulance – I don’t carry a defib – so SpO2 and ECG monitoring is taken as a ‘given’ via the ambulance. My kit just carries drugs, IV access and airway kit to ‘value add’ to existing responses.

FWIW, I would not bother with the commercially available ‘kit for GPs’ supported by the RACGP…I can’t quite see the logic in having surgical airway kit for one population of patients and not for another.

To my mind, the ideal kit for most GPs is : script pad, Medicare forms, means of accessing and recording notes, BP/Stethoscope, otoscope…and a $20 hard case from local hardware store to keep it in.

For those intending to do first responder or emergency work, then proper bags and kit tailored to purpose are the go…

What’s in YOUR bag?

So this week was Gynae list – a good list for me as I get to put in spinals +/- GA for vaginal hysterectomy and intubate everyone having a laparoscopy – much better than the hum-drum sedation lists for colonoscopy…also delighted to hear that RDASA president Dr Scott Lewis has nominated as the GP-Anaesthetist rep for ANZCA – Scott is eminently pragmatic and hopefully will bring the voice of rural GPAs to the table. Scott was over on KI for the Feastival (food and wine event) and was good to catch up, if only for a short time.

Scott Lewis “and friend” flying to & from KI

Meanwhile some disappointments in South Australia regarding “quality & safety”.

Last year I was excited that Dr Toby Fogg and colleagues in NSW were setting up an Australia & NZ Emergency Dept Airway Registry. Tedious though audit and data collection can be, the reality is that airway management remains one of the ‘high risk’ procedures in medicine, more so for the isolated rural GPA without immediate backup and with limited resources.

So I thought it would be interesting to compare metro vs rural ED stats – especially as the audit of a respected metro ED showed that ED intubation was not as good as we thought it was (yes the tube was passed, but not on first attempt and with risk of desaturation and hypotension – the killers of critical patients) – read more by downloading the paper or read this post from LITFL

I have been trying to pressure the lead Consultant for Anaesthetics in Country Health SA to get an airway registry going in rural South Australia – speaking to colleagues there seems to be a dearth of meaningful input into rural anaesthesia in this State, with concepts like apnoeic diffusion oxygenation, difficult airway equipment and airway audit or sharing of cases/difficulties alien to many rural doctors. I reckon that bemoans a lack of leadership…

To be fair, Sara Norton (CHSA lead for rural anaesthesia) has emailed me saying that she thinks this “is a worthy project” – but is unable to advance as “the CHSA safety & quality committee were not keen to provide resources or backing”

What the?

It seems that every time I open my email, there is a weekly ‘safety advisory’ message from Adelaide advising me not to use a certain type of titanium hip joint or not to use rare monoclonal antibody cancer therapy in my small rural hospital…

…yet calls for improved equipment and resources for rural hospitals go unanswered. And to my mind these are not airy-fairy “wants not needs”…they relate to safe provision of services.

To whit, current unresolved safety issues in rural SA include

• the above failure of any meaningful leadership in SA rural anaesthesia and the CHSA quality/safety committee putting the kybosh on a rural Ed airway audit – despite fact this is the highest risk thing we do in ED and Toby Fogg’s audit demonstrating failings in a major metro ED in NSW

• the 2012 survey demonstrating the lack of equipment to manage a difficult airway in rural Australia, despite clear professional standards from ANZCA (PS56). Calls for a videolaryngoscope or ED training in difficult airway remain adrift

and

• ongoing problems with monitors. On KI we have (or rather had) three options – a Phillips MRX defib/monitor for use in ED, a new Phillips touchscreen monitor in OT and ward telemetry. Yesterday the Phillips OT monitor went into standby mode in the middle of a major case and deleted all data prior to this! The ward telemetry unit has been ‘in service’ since Feb 2013 and still not replaced, and a new memo today advises that the Phillips MRX defib is involved in a product recall and may not be able to deliver shocks until software is upgraded. This means we have no reliable means of monitoring a sick patient. On an island…

Bloody hell. You would think this would be the sort of ‘never event’ that would spark immediate action…

…but sadly my calls for a spare monitor remain unanswered and we will instead be reliant upon the CWA selling enough teddy bears and scones to finance purchase of equipment.

I reckon rural patients deserve better!

One of my favourite papers is “If Nothing Goes Wrong is Everything Alright?‘ – an examination of statistical and psychological factors around rare events in medicine. If we accept that our work involves some degree of risk, for both doctor and patient, then we need to be able to assess this risk, manage it and ideally to mitigate against it.

It seems pointless to have trained staff but to lack the resources to enable them to do their job or mitigate against potential risk.

The solution? A commitment from the Health Dept to adequately resource rural Hospitals, to listen to clinicians and to conduct meaningful audit of processes would be nice. Concomitant would be effective clinical leadership and a commitment to ongoing training and upskilling of all clinical staff, whether VMO doctors or salaried nurses.

Better that than memos about titanium hip screws and the latest moxifliximab!

I won’t hold my breath.

I’ve updated the previous ‘Rural Hospital Theatre Checklists’ which many users have downloaded. I was delighted to hear from a rural GPA colleague that this resource was being recommended by instructors on one of the EMAC courses…

It is, of course, a collation of mostly previously published guidelines, adapted for local use on Kangaroo Island. Feel free to download and share.

The NEW 2013 VERSION is designed to be printed out on A4 paper and used with a standard Avery A4 20 index binder and 2-hole A4 ring binder.

Content useful for crisis management in ED and OT, predominantly aimed at the rural doctor

Enjoy !

Big shout outs this month to fellow rural doctors, Casey Parker of Broome Docs and his “lesson’s hard learned” series of podcasts…also to Minh le Cong for discussing various cases from the Coroner.

I have just been compiling a list of Coroner’s cases that I think are salutory reading for rural doctors. Delving through Coroner’s cases may seem intrusive, uncomfortable and voyeuristic. The reality is that the Coroner often makes recommendations … which may not be translated into practice for some time, wither due to systems issues (not least resource limitations) and lack of awareness. As rural doctors we have a tough remit – practicing the breadth of medicine, often without the backup and resources enjoyed by metropolitan specialists.

I believe that FOAMed can help bolster traditional sources of learning – particularly to “help bring quality care, out there” to rural Australians. Even more so when we recognise that ‘critical illness does not respect geography’ and so despite our resource limitations, we need to be able to at least initiate management for the whole gamut of clinical presentations.

Part of that process requires not just technical skills, but also awareness of non-technical skills and understanding limitations/difficulties inherent in our practice. Relevant Coroner’s findings can help shape our practice and are useful, if lessons learned are translated into tangible application in the bush.

One of my favourite papers is “If Nothing Goes Wrong is Everything Alright?‘ – an examination of statistical and psychological factors around rare events in medicine. If we accept that our work involves some degree of risk, for both doctor and patient, then we need to be able to assess this risk, manage it and ideally to mitigate against it.

But if such events are rare, then there may develop an attitude of ‘why bother? It won’t happen!’ amongst individual doctors, nursing staff or even hospital admin.

Worse still, doctors may fall back on anecdote ‘I have never had difficulty with intubation!’ – whilst factually true, may be falsey reassuring when the numbers of procedures performed is low.

The Elaine Bromiley case is one with which most GP-Anaesthetists will be familiar. For me this translated into examining not just my technical competence in airway management, but a long hard look at other factors which I had not really considered. From this I have taken it upon myself to develop

1. a crisis manual for use in the rural OT and ED, with adjuncts like ED prompt cards & an RSI kit dump
2. use of a difficult airway trolley in my hospital, backed up with signage and protocols
3. team training in crisis management with ED and OT staff
4. a survey of rural GP-anaesthetists and their access to difficult airway equipment, presented at RMA2012, SMACC2013 and published in Rural & Remote Health
5. FOAMed resources like this for sharing between rural doctors

…and that is just on one area of practice!

In the past week I have taken time to set up a new site – RURALDOCTORS.NET – not so much a blog, more a collection of FOAMed resources for rural clinicians.

I’ve focussed mostly on our work covering EM, Obstetrics and Anaesthetics. There is of course FOAM4GP.com for general primary care stuff, and some excellent blogs rich with educational resources already out there.

RURALDOCTORS.NET is aimed to showcase what is current relevant FOAMed. I will update it, and as Minh suggested, it may form the basis for a rural doctor masterclass. Have a read and if you are familiar with everything there already, congratulations – you have embraced FOAMed. I reckon most of us will find something new – and of course I welcome suggestions of good FOAMed resources specifically for rural clinicians.

But why FOAMed?

Well, if we return to the basic premise :

• many events in medicine are rare
• the rural environment has lesser caseload volume, hence less exposure to serious presentations
• nevertheless, “critical care does not respect geography”
• preparing for them requires acknowledgment that it could happen, even to you despite previous success
• preparedness encompasses yourself, your team and the environment
• technical skills are a given for most of us; what lets us down are non-technical factors
• we can learn from a variety of sources, but corridor conversations & anecdote are powerful, especially for ‘rare’ events
• FOAMed and SoMe extend our range, allowing corridor conversations with clinicians around Australia and worldwide, sharing experience
• this may help mitigate against uncommon presentations and so improve patient outcomes
• thus delivering “quality care, out there”

I should probably try and whittle that down to a few summary points and put it on a T-shirt!

Sadly we cannot care for everyone in our small rural hospital – oftentimes patients may need an investigation which we cannot offer (eg CT scan, angiogram) or have complex needs requiring tertiary level care.

So we often need to talk to our metropolitan colleagues to arrange transfer – whether by commercial carrier, RFDS fixed-wing or occasionally rotary-wing retrieval with the excellent medSTAR.

I was taught ISOBAR (recently contracted to ISBAR) for handover – not a bad tool. I like it because it introduces a level of both formality but also structure to our communication.

Identify                                               (yourself and patient)
Situation                                            (brief description of the problem)
Observations                                    (relevant obs)
Background                                      (relevant PMHx)
Assessment                                      (what you think is going on)
Response/Readback                      (what needs doing & a verbal readback of handover)

But this doesn’t always happen.

This week was a classic example; I had to transfer a patient up to two with an acute abdomen. After a few minutes at switchboard, I was put through to the Duty Surgical Registrar.

Me : “Hello”

DSR : “Yes?”

Me : “Hi there. It’s Dr Tim from Kangaroo Island. I need to talk to you about a patient with an acute abdomen. Is that the duty surgical registrar?”

DSR : “….”

Me : “Hello?”

DSR : “…yes?”

Me : “Are you the duty surgical registrar”

DSR : “Have you spoken to ED?”

Me : “No, not yet – this patient has a surgical problem and I ned to tell the surgical team – are you the registrar I need to talk to?”

DSR : “I am on for hepatobiliary”

Me : “Great. Does that mean you are the admitting surgical team of the day?”

DSR : “……maybe. Has he been seen by Emergency?”

Me : “No. He would be an interhospital transfer.
Can I tell you about this patient?”

DSR : “I am on for HepBil until 5”

Me : “OK, he’s a 72 yo man with a 24 hr history of acute abdominal pain, jaundiced, raised LFTs and requiring opiate analgesia. Clinically I suspect pancreatitis and want to ….

DSR : “Just send him to emergency”

Me : “Oh….OK….can I just get your name, so that ED know who I have spoken to”

DSR : CLICK – HANG UP

So much for ISBAR.

I don’t want to ‘point the bone’ at any particular hospital doctor or specialty – or indeed fellow primary care doctors. We all have bad days, we are all busy.

It is more of a system failure than an individual failure – so we need to embed tools like ISBAR into our day-to-day work…a sort of ‘handover checklist’ if you like.

This is important, as I reckon many medical errors are due to failure to communicate between clinicians. A recent Coroner’s report from communication failure is illustrative.

http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/545/MAY%20Terrill%20Anthony.pdf

Regardless of who is at fault, we all need to do better.

Free Open Access Medical Education (FOAMed) and the tools of Social Media (SoMe) have a lot to offer the isolated rural doctor…but to be honest, once people hear the words ‘blog’, ‘twitter’ or ‘podcast’, many of them are turned off.

Reality is that FOAMed and SoMe have a lot to offer – essentially the chance for asynchronous, high-quality learning and interaction with other doctors around the world, on selected topics – using the technology to tailor content and stream it to you rather than have to chase it

I think that FOAMed has revolutionised the field of EM and CritCare…and for the small degree of overlap as a rural GP doing Em and Anaesthesia, FOAMed has helped me

…but there is much potential for FOAMed to change the way GPs 9both metro and rural) do their work and keep up-to-date. Perhaps more so for the rural doctor who may struggle to access upskilling events and also has to perform at a high level in procedural or oncall roles.

So over the weekend I chatted to Dr Casey Parker of Broome Docs about how SoMe and FOAMed have helped him. The video also has some pointers on getting started for rural GPs.

Enjoy

Interesting and enthusiastic debate on Twitter last night from a variety of sources in response to Minh le Cong’s question “How can we get more rural doctors to SMACC2014?”. The reality is that social media (SoMe) has negative connotations for many doctors…indeed one wit even suggested that whilst doctors are considered conservative, rural doctors are somewhere to the right of Thatcher. Not a view I subscribe to, but hey…. Regardless, most doctors’ eyes glaze over once they hear ‘social media’ – not surprising, as the expectation is crap from Facebook, inane tweets about Paris Hilton or fear of yet another stream of unfiltered information to assimilate.

I used to think like that. But exposure to high quality blogs like LITFL, BroomeDocs and Resus.me that were relevant to my practice changed all that about two years ago. Concomitantly Minh gained a reputation as a promiscuous blogger, starting up the PHARM and encouraging wide-ranging debate on a variety of topics. SoMe has enabled even a country doc in the sticks like me to engage in discussion on topics relevant to my practice, with hard hitters around the world – Karim Brohi, Scott Weingart, Cliff Reid etc as well as rural docs with a strong EM/Anaes focus (Casey Parker, Minh le Cong).

#SMACC2013 was notable for bringing the tools of SoMe and FOAMed to bear on cutting edge EM/critical care. There was lots of useful stuff here for rural generalists – and paramedics, nurses etc – not just hardcore ED and ICU docs. I’d encourage rural docs to get along to #SMACC2014 if they have ANY involvement with emergency or critical care – and most of us do, through our work on call and without immediate back up in the bush.

But it is important to realise that #FOAMed is much more that EM/CC – it’s just that the EM/CC community have embraced it already.

So in answer to Minh’s question, some suggested a ‘rural stream’ or ‘making #SMACC2014 for rural doctors”. I think that’s wrong. SMACC is a critical care conference. There are overlaps relevant to rural medicine…but there are also overlaps with obs, with paeds, with primary care, with dermatology, with ENT etc etc

Better to embed FOAMed into existing content for GPs – whether rural or metro. Let’s hope that both the RACGP’s GP13 conference in Darwin and ACRRM’s RMA2013 conference in Cairns will embrace not just SoMe, but the power of #FOAMed.

Bright spark Dave Townsend summarised it in one simple formula (which I’ve plagiarised) :

A formula for the future in rural medicine?

Let’s hope RACGP, ACRRM and the various Rural Doctors Associations will embrace the FOAMed paradigm…it is an excellent way to both keep up-to-date, to discuss relevant medical matters and overcome some of the barriers of isolation in the bush.

Of course this does require both Leadership and Followership…readers will know that I’ve been a critic of both turgid medical conferences and farcical ‘upskilling’ sessions in the past, where subject material has lagged years behind what is being discussed in #FOAMed.

So you can imagine my disappointment – contacted by a potential speaker for the rural doctor masterclass – a senior anaesthetist – who asked “What’s DSI?”. Illustrates the problem of experts in one field talking to practitioners in another – yes, there is much to learn from a senior FANZCA…but also a need to understand the audience and have a firm grasp on #FOAMed material that is of relevance.

Ho hum.

Sad news yesterday (30-3-13) – Dr Conrad Williams (FACEM) passed away peacefully Sat morning in hospice after a short illness.

Conrad taught me a lot in the ED a decade or so ago and I know he has been inspirational to colleagues and juniors in Emergency Medicine in Adelaide. It was a privilege to teach with Conrad on EMST and he recently enthused about the Clements-Leeuwenburg-Williams doctrine of making teaching fun, interactive and memorable (Pete Clements is another rural doc and a mentor to both Conrad and myself in EM and rural practice respectively). I remember vividly Conrad’s EMST video and voiceover of ‘rapid infusion catheter‘ to the soundtrack of “Debbie Does Dallas”, as well as numerous memorable events in the ED.

Conrad will be missed by all those who knew him in the emergency medicine community – he epitomised ‘quality care, out there’.

Sincerest condolences to Chris.

Now on to this weeks blog…

A couple of things this week have caught my interest and build upon topics previously discussed over past 18 months.

I caught the excellent Horizon episode on “How to Avoid Mistakes in Surgery’. Narrated by Dr Kevin Fong, this excellent episode covers issues such as loss of situational awareness in crisis management, acknowledgment in many industries that human error is inevitable and discussed the use of checklists and high-fidelity simulation in training.

I was at medical school and an intern with the Fongster (click on photo below). He’s memorable for doing his student elective with NASA (including riding on the ‘vomit comet’) and it is truly a pleasure to see that his career has blossomed, now a Consultant in Anaesthetics & ICU back at University College where we graduated. Kevin’s book ‘Extremes’ was also launched this month and is a thoroughly good read.

Whereas Fong has made a career out of photogenic presentations for Horizon, Extreme A&E, been named on Esquire’s list of “100 most influential men under 40″  and continues to make great strides in space medicine, I have become a rural doctor practicing ‘anything & everything’ on Kangaroo Island, Australia. How could his career have derailed so badly? Looking at the photo below (me second row, scrubs and stethoscope round neck, Fong same row left of pic) I wonder how the other interns fared?

Click on photo for detail

Career differences aside (& gentle joshing – Kevin is a nice and unassuming bloke, like Weingart and Reid), the show articulates well some of the issues that I have been passionate about & discussed in previous posts on this blog.

Taking the infamous Elaine Bromiley case (CICO), he explores human factors and ways in which as doctors we should mitigate against error. Importantly it is NOT about how bright you are – it’s about having systems in place, using appropriate aides and training. This might sit raw with some doctors who persist in the ‘I am a brilliant docor and don’t make mistakes’ school of thought, but is salutary for those of us striving to bring quality care, out there – not just through personal endeavours but by trying to improve the systems in which we work.

Like all doctors I have strengths and weaknesses. Moreover if you think about it, half of all doctors are below average! So we need to both acknowledge this and look for ways to improve. Checklists, sim training and #FOAMed all help.

Andy Buck has done a lot of work on this over at Resus Room Management and I am eagerly awaiting his course for EM physicians, incorporating human factors, sim training and #FOAMed into a course that promises to raise the bar significantly over existing EMST-ALSO-REST-APLS courses.

In a similar vein, I am delighted that SAPMEA re going to support a ‘rural doctors masterclass’ on Kangaroo Island in November this year – something I have been agitating for a long time, but (frankly) struggling to persuade as useful with key bodies in rural medicine like ACRRM and RDAA.

Put simply, the existing courses out there set a minimum standard. They are useful and give a structure. Heck, I direct on EMST so I reckon there is some value. But there is a yawning chasm between the standardised info taught on these courses and the cutting edge of #FOAMed. Of course there ARE more advanced courses – MOET for obstetricians, STAR for retrievalists, Difficult Airway for anaesthetists/EPs – but wouldn’t it be wonderful to incorporate some of these ideas into a course for the huge cadre of experienced rural docs who are striving to bring ‘quality care, out there’?

In my area of interest (GP-anaesthesia), I have attended annual anaesthetic upskilling in NSW and SA, and although the course content was solid, felt frustrated with lack of coverage of new issues such as apnoeic diffusion oxygenation, delayed sequence intubation, dynamic airway and crisis management etc etc which are bread & butter for those following #FOAMed. I am sure there are plenty more topics in other arenas which are relevant to rural generalists…

So the RURAL DOCTOR MASTERCLASS will be a tentative foray into this world.

We hope to offer a bespoke course aimed at rural doctors, showcasing some of the useful tips and tricks discussed in the #FOAMed community. If successful I reckon this is a model that ACRRM or RDAA could take and promulgate – a course that continually evolves, is small-group and focussed on case scenarios and hands-on material.

Essential to this is evolving course content and a syllabus that embraces #FOAMed concepts – rather than a series of lectures, this masterclass will be more of a “getting together” of experienced country doctors, prepared to discuss openly successes and failures in their work. Unashamedly aimed at topics around resuscitation – the hardest part of our job, as we mostly work alone & are unsupported in resource limited environments – yet our patients are still sick. After all, critical illness does not respect geography!

Likely topics to be covered include :

- Resus room set up

- RSI for the occasional intubator (DASH-1a, NODESAT apnoeic diffusion oxygenation)

- Delayed sequence intubation

- Checklists and crisis management

- Difficult airway tips & tricks relevant to rural doctors

- Hands on with videolaryngoscopes, intubating LMAs, malleable stylets and flexible fibreoptic scopes

- Extreme obstetrics – PPH, cord prolapse, resuscitative hysterotomy, neonatal resus

- Ketamine focus session

- Intranasal medications

- Managing massive haemorrhage in rural setting

- Team training – sepsis, cardiac, neonatal, trauma

- Prehospital / mass casualty exercise

Sadly I don’t think that there will be sufficient scope to cover the use of ultrasound – although a discussion of it’s use in eg: diagnosis of pneumothorax and other examples for time-poor rural docs in emergencies would be appropriate.

At this stage it is looking like a two day course in mid-late November. More details TBA…

Interested? Register NOW with SAPMEA or email Erin Gray at SAPMEA

Other IDEAS FOR topics for inclusion are welcomed.

Another interesting week following on from #SMACC2013 and the increasing interest in #FOAMed amongst not just critical care and EM physicians, but the rest of medicine.

First up, the launch of a new website FOAM4GP.com - an idea that a few of us had been bouncing around for a while, in or enthusiasm to bring quality free open access medical education to a wider audience – not least primary health care clinicians.

As time goes on, Minh, Casey and I hope that more GPs will embrace the #FOAMed concept and contribute – particularly registrars and newly-qualified docs who have much to offer.

So – if you haven’t already – check out FOAM4GP.com

Meanwhile, Casey Parker over at BroomeDocs.com has commenced a new series “Lessons Hard Learned” as a series of podcasts.

This is a topic dear to my heart (but sadly, living in a small community and with easily identifiable patients, I dare not contribute content – yet).

The issue of error in medicine was discussed at some length at SMACC2013 – Prof Simon Carley (author of BestBETS.org and leader of successful Team GB in SimWars, as well as a nice chap) spoke well on difficulties of diagnosis in EM. Others spoke on medical error, human factors and checklists…

In the anaesthetic community, the Elaine Bromiley case is often used to discuss crisis management and the dreaded CICO situation. If you haven’t already seen the video, you can watch or download here from the ‘Resources’ section of KI-Docs.com.  However I think that one of the most interesting bits of Martin Bromiley’s discussion is that of uncertainty around the error rate in medicine. We simply DO NOT KNOW what error rates are for our trade.

An old adage is that the only way to avoid mistakes as a doctor is by experience … And the only way to get experience is by making mistakes ! Which is why “Lessons Hard Learned” is useful – it allows sharing of important, personal messages between clinicians with the shared goal of improving patient quality. Yes these are anecdotes, but sharing these intensely personal experiences has an educational benefit.

That said, if we are serious about reducing medical error, the real solution lies in recognising that as doctors we WILL make mistakes. Better to engineer safety into the system, to allow a chance to remedy physician error. Of course in a health system under pressure to churn through patients, with financial and resource limitations and with emphasis on medicolegal channels to pursue individuals when error occurs (rather than a no-fault system), this may be unrealistic. But one can dream…

For what it is worth, my ‘top tips’ on hard lessons are below. They may not be revolutionary, but they are errors that one sees again and again, even in experienced clinicians

• Don’t ever forget to measure a glucose
• Consider doing a pregnancy test in any female between 10-50 years of age
• Respiratory rate is a good marker of ‘being unwell’ yet is often poorly recorded. Ask for the Resp Rate and act if up or down.
• Trust your instincts. If a little voice is nagging at you, listen to it
• Never let the sun set on pus
• Remember that if you are either hungry, angry, late or tired (HALT) then your performance will be affected
• When you are in a rush, make an effort to SLOW DOWN
• Just because someone works in a teaching hospital, doesn’t mean that he/she knows more than you. As the clinician on the spot, you are best placed to determine if someone needs to be seen or not.
• Sepsis can sneak up on you and patients deteriorate with terrifying speed. Look for sepsis. Then look again.
• Beware the automatic BP reading in a resus – remember to set the frequency of recording at the start of a resus – otherwise you will be falsely reassured by seeing the same rock-solid BP. That’s because it hasn’t been measured since initial set of obs
• Don’t be afraid to ask for advice
• Use cognitive aids like checklists and #FOAMed resources
• It is OK to say “I don’t know” – whether to colleagues or your patients. Dealing with diagnostic uncertainty is challenging, but often things are NOT clear and opening up communication between doctor-patient to acknowledge this and establish criteria for concern/re-presentation/follow-up are vital

Finally, as one wise intensivist said to me “If you don;t know what to do with a sick patient, wait until he/she arrests – THEN you’ll know what to do” – kind of distills all of clinical medicine down into the one algorithm !