It was back in 2001 that I read a piece in the British Medical Journal entitled “BMJ bans accidents” – hardly a new idea (it dates back to at least 1993) – yet we still hear reference to “road traffic accidents” (RTAs) or “motor vehicle accidents” (MVAs).
Words are important; I have been convinced of the BMJ argument for the past decade. I am not alone – others say “if you care, use the term crash“. The premise is simple – use of the term “accident” implies a sense that bad outcomes are due to fate and luck, rather than factors within our control. Indeed use of the term “accident” almost absolves anyone of culpability.
I am currently working in the prehospital environment. Like colleagues, I do not judge my patients – they are invariably critically unwell and my job is simple – to ensure they receive the best possible care with the minimum of delay, working within a well-governed organisation of trained clinical professionals.
However Christmas and New Year are fast approaching, and there is a sense of inevitability; namely that this holiday season will again be marred by tragedy on our roads, often due to drink- or drug-driving.
What would be the best Christmas gift for colleagues and myself this year? That we did not have to respond to roadside primaries, nor for community members to experience personal tragedy.
With this in mind, I’d recommend the following video – a montage of road safety videos from the TAC in Victoria, Australia (ironically, this stands for Transport Accident Commission)
It is sobering stuff. I remember hearing trauma surgeon Karim Brohi talk at the Australian Trauma Society conference in Melbourne, 2006 – he commented that “it’s better to be the fence at the top of the cliff, ratehr than the ambulance at the bottom”. In trauma medicine we tend to get very excited about the sexy things – prehospital REBOA, clamshell thoracotomy, helicopters etc and debate is always heated on chestnuts such as subclavian vs IO access, fluid resuscitation, skill mix of retrieval teams etc.
There is no doubt that the downstream consequences of trauma are horrific.
Instead I wonder if the greatest gains in trauma medicine remain with the unsexy – with primary prevention (um, that’s the GPs) and with rehabilitation (thats rehab physicians, physiotherapists and other allied health). we don’t often consider the contributions from primary care and rehabilitation in trauma care – perhaps we should.
Prevention is indeed better than cure. Please, this Christmas – don’t drink or drug-drive.
Some recommendations are available HERE and include :
acceptance of gentle mask ventilation during RSI
use of videolaryngoscopy as an option in initial intubation plan
apnoeic diffusion oxygenation
didactic technique and training for emergency surgical airway
One other recommendation caught my eye – namely to use second generation LMAs
Now the Classic LMA (cLMA) was the brainchild of Archie Brain; it is a wonderful device and has been in commercial use since 1987. It is easy to use and affords the ability to ventilate – although does not protect the airway. Some critics would argue that the LMA has deskilled a generation of anaesthetists, who may use the cLMA for routine cases rather than bag-mask or intubate. I disagree – it is just another tool in the armamentarium.
However I made a decision a few years ago to switch to the Supreme LMA – a lovely second generation LMA that is a step up form the ‘initial’ second generation LMA (the ProSeal). The Supreme combines an integral bite block with a gastric drainage channel in the tip, unlike the ProSeal.
But there is a problem – once in place, it is almost impossible to pass an ETT tube through the Supreme.
Many people will be familiar with the Intubating LMA (iLMA) – the brand most use ins the FastTrach. It’s not a bad device – it allows blind intubation rates of up to 90%, using the LMA as a rescue ventilation device and then as conduit for an ETT.
The large handle on the device is designed to facilitate manoevuring of the iLMA in the oropharynx, ideally allowing the bowl of the LMA to align with the glottic opening and hence allow blind passage of an ETT. There is a great paper from the originator of these maneouvres, Chandy Verghese. A description is available HERE – anyone using the FastTrach should be able to perform the “Chandy Manouevre(s)”
I like the FastTrach – it is a good ‘go to’ device for rural and remote doctors as allows both rescue ventilation and possible intubation – no pissing around with fancy fibreoptics or calling for help – none is available in the bush! However there are some problems – it’s expensive and it doesn’t have a gastric drainage channel. Furthermore, one can get into a world of hurt if attempting to remove the iLMA over the ETT per instructions. This might include stripping off the pilot cuff of the ETT or ‘losing the airway’…one should read the infamous ‘exploding scrotum‘ case for a masterclass in airway catastrophe.
So problems with the FastTrach are not uncommon in inexperienced hands – precisely the time when you least want to have an additional problem after failed intubation. My advice? Once in, leave both iLMA and ETT in situ until the patient is either awake or you are somewhere with backup!
Furthermore, the FastTrach has a somewhat hyperacute angle, meaning that even if you have a basic fibreoptic device (such as a malleable FO stylet), this cannot be used to turn blind intubation into fibreoptic intubation via the iLMA conduit.
What we need is a device combining the benefits of a second generation LMA (eg Supreme) with an intubating LMA. Enter the second generation iLMA, the AirQ-II
useful as a rescue ventilation device ie 2nd generation LMA
able to be used as an intubating LMA for blind intubation
less acute curvature of the tube will allow passage of both flexible and malleable stylet fibreoptics, for visual intubation
integral bite block and gastric drainage channel
I’ve replaced the FastTrachs with Air-Q IIs in both my RERN prehospital pack and also on our hospital difficult airway trolley. Indeed, for the finance-limited environment of a small rural hospital, the combination of the AIrQ-II along with a fibreoptic device such as a Levitan FPS scope offers a fairly robust option for difficult intubation – drop in an AirQ-II, then wither blindly intubate or use the malleable fibreoptic stylet to pass the tube under direct vision. Then leave the ETT-LMA in site and pop down an orogastric (difficult to do with the FastTrach). James DuCanto writes well on this with a simple guide and Weingart explains how to mould a malleable stylet to conform to the AirQ anatomy.
If you don’t need an intubating LMA, then follow the guidance of DAS2015 and go with a second generation supraglottic device – like the Supreme.
But if you want to allow maximum flexibility including integral intubating-LMA capability, it’s hard to beat the Cook Gas AirQ-II – especially of trying to put together an affordable yet robust difficult airway kit for rural/remote.
DISCLAIMER – I HAVE NO FINANCIAL TIES OR INTERESTS TO THE DEVICES DISCUSSED
I just have to give a shout out to the RAGE PODCAST this week. If you have been living under a rock, the RAGE podcast is a semi-regular “resuscitationists awesome guide to everything” featuring top quality FOAMed contributers who are credible in their field.
“Do not go gentle into that good night
Rage, rage against the dying of the light“
This months session is entitle neuroRAGE and deals with all things to do with neurosurgical emergencies. It features Mark Wilson who speaks authentically on experiences as a HEMS physician, neurosurgeon and with some significant anaesthetic experience. I managed to talk with Mark on “Burr holes in the bush” a couple of years ago and since then the idea of prehospital Burr holes has been enthusiastically mooted elsewhere. Is this something that a prehospital service clinician needs to be able to do? Is an extradural the ‘tension pneumothorax of the skull?
Mark gives good talks (if you saw him at smaccGOLD and were impressed, the good news is that he’s back at smaccUS). He’s also prepared to share – he gave a great talk at medSTAR clinical governance day earlier this month and was a major contributor to Sydney HEMS themed neurotrauma session earlier this year – content from the latter is available online. He also runs the AcuteBrain website and is a coninventor of the GoodSAMApp
Also on RAGE, Cliff Reid also gives a lovely description of being on the end of both an LP and in the K-hole, reinforcing the need for concomitant benzos and (where possible) a calm, low stimulus environment to avoid emergence phenomena.
I’ve certainly noticed similar tales of spiral ‘helter skelter’ sensations amongst my dissociated patients…to me this emphasises the need to be familiar with ketamine for both induction, dissociation and analgesia – something all trainees should endeavour to gain experience with in their anaesthetic placements or in ED.
Here’s a video of the potential nasty dissociative effects of ketamine – I love the drug, but consider adding some benzo if appropriate
The program looks HOT – some old favourites and some new allsorts. The genius that is Mark Wilson will be cohosting a fabulous “it’s a Knockout” neurotrauma session….and there are many concurrent sessions and “cage matches” on topical issues.
Plus there’s an excellent round of pre-conference workshops and a chaotic but entertaining social calendar; I am already looking forward to catching up with old friends and making new ones – all united by a common interest in critical illness, from a variety of perspectives (intensivist, emergency, rural, prehospital, medical, nursing, paramedic, social worker etc)
Chicago is a great venue and the first time smacc has ventured overseas. If you missed macc2013 in Sydney and smaccGOLD in 2014 and are wondering what makes this conference different, check out the commentaries at :
I am delighted to be sandwiched in a session with EM giant Joe Lex, Scandanavian powerhouse from ScanCrit Thomas Dolven and my old mate from BroomeDocs, Casey Parker – all under the watchful eye of Minh le Cong.
Like most clinicians, my time spent in anaesthesia drilled me in the importance of performing routine pre-anaesthetic machine checks, of keeping the workspace tidy and paying meticulous attention to detail. ‘
These lessons translate well into other areas of practice – at the start of every on call period in emergency, I check the resus trolley and store boxes to ensure we have the right kit available. In recent times I’ve begun to think more and more about resus room ‘feng shui’ – the concept of making sure that the components of the room are ordered correctly, eg :
resus & airway trolley on the intubator’s right side so as not to impede visual axis during intubation
all monitoring/O2/suction cables & tubes running from single point, allowing almost complete 360 degree access
orientation of bed so that clinicians can see monitors, clocks, whiteboard, equipment etc
colour-coding of equipment so as to group kit together for those unfamiliar with set up or in a crisis
clear signage to essentials such as defib, difficult airway trolley, paediatric kit etc
Working with MedSTAR retrieval builds on this and I get to indulge by obsessive compulsive disorder (it’s called OCD, but aficionados know that it should be called CDO – you…have…to get…letters…in…right order).
Every day starts off with a full kit check (using a challenge-response checklist), then kit tagged and labelled – anything with a broken seal gets a full re-check. Packs are colour coded to aid recall in a crisis (it’s easy to ask a firefighter to get the ‘small red pack sitting in the big blue pack’ rather than tell ‘em to get the arterial line kit). MedSTAR uses an RSI kit dump plastic bag that doubles as a clinical waste repository, with an integral challenge-response checklist.
One of the two-person team (typically doctor-nurse or doctor-paramedic) carries a drug pouch with Schedule 8 drugs (fentanyl, ketamine etc). The team always carry pagers, GRN radio and an iPhone (the latter contains checklists for daily kit checks, contact numbers and SOPs).
In recent times an iPad Mini has become available as an option – although no good as a communication device (unless use FaceTime or Skype!), it is easier to use for performing checklists and reading SOP PDFs. It also allows for addition of useful clinical apps such as Matt & Mike’s excellent Bedside Ultrasound iBook and pre-loading with FOAMed content (podcasts, vodcasts etc). The problem though had been where to carry it – the iPad mini JUST fits into a pocket on the flight suit. Stuffing it into a pack means you’re never likely to use it – it’ll be stored in the back of ambulance, tied down in flight or otherwise inaccessible.
Despite initial scepticism, I have been using Twitter for the past 18 months to connect with #FOAMed enthusiasts – it’s a great tool for signposting and sharing information from likeminded people around the world, some of whom I have met, some not. Retrieval clinician Natasha Burley (@skimightythings) put out a tweet of the GridIt system in use with Careflight, Queensland a few weeks ago…a sensible idea so good that I had to try it!
So for the past few shifts I have been experimenting with the GridIt system. This is basically a neoprene sleeve and folder for phones, phablets, tablets and PCs, with a series of interlocking bands forming a grid into which chargers, connectors etc can be placed. It’s marketed to power users who carry lots of kit. I find it quite useful for giving presentations as I can make sure I’ve got my projector controller, VGA/HDMI adaptors, power cords, audio cable and other sundries available when giving a talk off home ground.
DISCLAIMER – I HAVE NO PROPRIETARY INTEREST IN GRID-IT NOR IS THE DEVICE ENDORSED BY MedSTAR RETRIEVAL SERVICE. THIS REVIEW IS MY OWN OPINION.
The question is as to whether it would ‘value add’ for the retrieval setting. I managed to snaffle an iPad Mini GridIt pouch (had to hunt for the MedSTAR red version on eBay) and experiment with it during a typical shift.
I was pleasantly surprised. The neoprene pouch is easy to carry and non-slip despite the recent hot weather (temperatures in the 30s). The iPad Mini fits snugly in the pouch and is further protected by a fold over sleeve. Having the iPad Mini available at all times (rather like the President of the United States ‘football’ of nuclear access codes) meant that I was more inclined to actually USE the device for kit checks and SOPs, as well as afford the potential for mini-tutes on ultrasound and listening to podcasts from my FOAMed mates (eagerly awaiting Mark Wilson & co with neuro edition of RAGE podcast). Listening to content or refreshing knowledge is always possible on the outward leg of a mission, whether by road, rotary or fixed wing.
We carry our S8s on our person already, but the syringes and caps are kept in our kit, making it impossible to draw up drugs en route unless remember to get the large major drug/IV pack out before travel. By keeping a few syringes, saline and red caps plus vial access cannulae in the pouch, I found that could mix up basics (ketamine, fentanyl) at anytime using the kit on my person. Once pre-drawn, syringes were kept protected by the neoprene sleeve and readily available.
I did wonder how we would go in transit WITH a patient, especially in the crowded space of a helicopter. The photos probably don’t do it justice (lots of vibration!) but I found I could secure the GridIt system to the stretcher using the velcro cuffs – or just stuff the darn thing into a pocket if I was worried.
Depending on the aircraft and configuration with stretcher, I found could secure to either the side of the stretcher so that iPad and drugs were within easy reach (basically between legs if sitting side on to stretcher)…or secure to the head end where we already stash bag-valve-mask in a pouch.
The ability to reverse the neoprene sleeve and loop around the stretcher rail then secure with velcro worked well – but for added security one could easily add a carabiner.
We already have a system of securing pre-drawn syringes (for bolus dosing) on a hoop system on our ventilator. Many missions don’t require a ventilator, just standard monitoring, so the options have usually been to stuff syringes into a pocket on flight suit.
Adding an iPad to the mix means pockets get full or tend to either stash in a pack bag (inaccessible) or just leave the thing behind… a shame as having an iPad available could value add to missions, I feel.
Combining the iPad Mini and syringes in one system seemed to work well. I am interested in other options available out there!
And what else should we put on the ipad Mini?
The next question will be which apps and FOAMed content should be included on a tablet. MedSTAR has it’s own proprietary app for checklists and SOPs. My preference would be to add :
useful apps for clinical conditions including neonatal, paeds, adults calculators, pharmacy support, emergency medicine resources, burns calculators etc
Who knows? Perhaps in the future my mate Mark Wilson’sGoodSAMapp could be added to not just individual clinicians smartphones, but also to institutional devices – as it allows tracking of location and ‘push’ alerts integrated with comms CAD; potentially very useful in a MAJAX situation
Hey! If you are a Paramedic, Nurse, Doctor or Registered First Aider who can hold open an airway or do BLS, please take time to register with GoodSAMapp for Android or iOS. It’s FREE
Tapping into the collective wisdom of tacit knowledge sharing and asynchronous learning via the #FOAMed community has markedly changed the way I practice. A few years ago, I would jump through the necessary hoops of continuing professional development (CPD) or personal development programmes (PDP) with my College. To be honest, as a rural proceduralist, it was relatively easy to accrue points and meet the necessary number required each triennium (three year cycle).
But the reality is that these points were met by doing the minimum necessary standard ie attending a few of the alphabet courses like EMST/APLS/REST, attending an annual conference, perhaps attending a workshop or local educational session, usually delivered by a metrocentric specialist. Within a year or so I had accrued enough points for the three-yearly triennial cycle. I am sure that there was some learning at these events – but I was not being stretched. Which is kind of odd. It seems that the educational focus of the Colleges is more about training registrars, but not necessarily about ongoing training of Fellows, other than to ensure that a minimum standard is met.
So the involvement in the FOAMed world re-ignited my passion for learning … and for teaching. I wont re-hash the concept of FOAMed here – it’s well-described elsewhere – suffice it to say, it allows asynchronous leaning, tacit knowledge sharing amongst peers and is ideal for discussing mastery or finesse in the craft, rather than the minimum educational requirements or becoming a slave to protocols and guidelines which are not necessarily applicable to the individual patient in front of us (90 yos on statins anyone?).
I started off by reading blogs from fellow rural doctors…then dipping my toes into making a few tentative comments on hypothetical case discussions…then creating my own content to reflect on own activities and perhaps help educate others…then build on this via content creation, collation, curation and communication.
Dipping in and out of FOAMed is another mode of learning, useful for finesse, with ability to access the global medical community hive mind for information.
FOAMed – free, open access medical education – anywhere, anyplace, anytime
But there is a problem with FOAMed or indeed any learning that occurs via social media interactions – this form of learning is not recognised, despite the fact that it offers a more advanced and self-reflective adult learning style (in fact FOAMed moves one into understanding HOW to learn (the concept of heutagogy). Different media – video vodcasts, audio podcasts, links to reevant papers, online discussion fora and ability to interact both online and offline allow asynchronous learning. Moreover this learning is not constrained by geography – interactions occur with colleagues globally – and as if that wasn’t enough, traditional silos break down – I find myself discussing aspects of care with not just fellow rural proceduralists, but with specialists, with academics, with social workers, with paramedics, with students. It’s a true meritocracy.
There was some recent chatter on GPSDownUnder (a closed facebook community) about the concept of accruing CPD points for this sort of activity, with no real answers (although over 154 comments). Interestingly other online platforms (notably the UK’s online community of over 200,000 doctors, Doctors.Net.UK allows accumulation of points for engaging in online debate, and is recognised in the UK’s revalidation programme. I have no doubt that revalidation will, in some form, be imposed on us in Australia – and reflective practice is part of this.
Those who are already active in FOAMed are not just users of content, but are interested in creating it. It would be good to get points for this sort of activity. Of course the irony is that these people already have accrued sufficient points for the triennium and are engaged purely for the love of learning and desire to be ‘better’. To make this sort of learning attractive to others, it needs to have a demonstrable advantage over existing modes of learning. For me the hook is that FOAMed allows me to refine my practice through tacit knowledge sharing and develop finesse….to engage in ‘corridor conversations; with colleagues worldwide and allow me benefit from decades of experience to apply to the patient in front of me, not just blindly follow a guideline. it’s about art as well as science!
What better way to meet requirements than to seek true mastery and finesse in one’s craft, with reflection, by use FOAMed and SoMe?
So I was thrilled to be invited to a breakfast meeting with RACGP educational reps and fellow GP bloggers/twitterati, Drs Karen Price, Ewen McPhee & Tim Senior.
It is clear that having a College control content is contrary to the ethos of free-flowing and cutting edge FOAMed.
We decided that a useful framework for accreditation (ie : collection of points for CPD/PDP activities online) needed to embrace the following concepts
(i) define principles of what is/what is not relevant educational activity
At the minimum, recognition of an activity for points should require that the activity is relevant to practice (might be across domains of clinical, practice admin, ethical etc), requires a degree of interactivity and a degree of reflection
(ii) create a tool to log activity
People have talked about ‘endorsing’ websites or activities, or using loggers to demonstrate time spent in an activity. However as adult learners this is too constraining. there are existing templates (we use one in ACRRM for logging of clinical attachment activities) which would suffice.
Such a template should encompass
the nature of activity (eg: reading blog, listening to podcast) and the learning objectives thereof,
a comment on specific learning outcomes
encouraging comment (reflective practice) on how this is relevant to one’s practice and
the documentation of these, with supporting evidence if appropriate (eg: screenshot of comments page, link to content etc)
Having a form either online or easily downloadable would allow clinicians to document learning activities outwith the usual College program and apply for points.
Ultimately it is up to the user to define his/her learning and also to be able to defend their activity in case of audit. There is concern of ‘gaming’ the system – I would argue that this happens already, with many educational activities being low quality and gamed to some degree. Negative feedback on low quality educational activity is not always forthcoming, due to the inherent conflict of attendees not wanting to jeopardise their own points by feeding back that an event was crap! Better to accrue the points and move on…
(iii) signpost relevant content to target audience
Each College (ACRRM, RACGP) already has regular newsletters. Using a panel of SoMe and FOAMed enlightened primary care physicians, it would be very easy to collate a regular (fortnightly or monthly) round up of relevant and interesting FOAMed content – the EM crew at lifeinthefastlane.com have been doing this every week for a few years now via their LITFL review. this is a wonderful way to signpost content to clinicians, leading to more interactivity and acceleration of the learning paradigm.
Docere – to teach – innit?
So – there you have it. A proposal for recognition of online FOAMed learning for primary care physicians in Australasia. Start off with links to interesting FOAMed material, disseminated through the Colleges. As time goes on, encourage clinicians to accrue points via interaction in this space. And hopefully such interaction will create more connectivity and community, as well as more content creation.
It would be awesome if both ACRRM and RACGP got on board with this – as this is the space where true learning is occurring. Too often medical education is either about the basics required for Fellowship and the maintenance of a minimum standard, with most research focussed on GP training pathways or recruitment/retention.
I would argue that we should be working together on the finesse to achieve mastery…always seeking to be better.