The More I Know, The Less Certain I Am

I’ve recently had cause to re-examine Dale Edgar’s ‘Cone of Experience‘. Like that fabulous educator from iTeachEM, Rob Rogers (@EM_Educator), this concept seems intuitive and demonstrates nicely the benefit of learning via different formats. I use it in talks to explore different learning styles.

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Except it’s bunk. Dale never ascribed percentages to the retention rate for each different mode of learning; rather the ‘cone of experience’ demonstrates the varying abstraction potential for each learning mode. Understanding that Dale’s model was centred around understanding the concretness of different material, not retention rates.

Why is this important? Because it’s not uncommon in medicine to come across the view that “there is only one correct way to do X

When I was a junior, following such rules made sense – they reduced the burden of having to ‘think’ too hard … and when such rules were imposed from a higher authority (invariably a gruff Consultant), failure to comply risked raising their ire! Of course it’s not just lack of years or having a steep authority gradient that encourages sticking to such rules. As humans we tend to seek the comfort of familiarity and our own experience when making decisions – hence the “I’ve always done it this way…” or “Textbook X (authored by eminent expert Y) tells us to do it this way, so I’m sticking with that…” or even the “The teaching is to do procedure X this way – anything else is negligent” conundrums.

Nowadays when someone asks me how to do something, I seem to find myself pausing more and more as I reflect on previous experience. No longer do I say “Chest drains? They’re easy, let me show you how” – instead I pause “Well…it can be difficult…let’s talk about it, then I;ll guide you through one” as I recall not the vast majority of easy ones, but the difficult cases, the errors made, the complications…and am keen to rely this tacit experience to my colleague.

Some recent debates on social media have been relevant. Over on doctors.net.ukfora, we’ve had examples of :

- experienced clinicians ‘told off’ by physios for eliciting lower limb reflexes in a seated patient “the ONLY way to do reflexes is with patient laying down”

- anaesthetists laying into emergency physicians over options for safe sedation of the haemodynamically compromised patient in VT (with the usual cliched ‘needs RSI‘, through ‘mustn’t use ketamine because of strain on heart‘ through to ‘just zap them and apologise‘). Kudos to Cliff Reid & Ed Valentine for keeping their cool in that debate!

Meanwhile there’s been a useful Twitter and Google+ exchange on dogma around use of femoral traction devices (FTDs) for splinting of femoral fractures in the presence of a pelvic fracture

There are plenty of other discussions that crop up – cricoid force, checklists for crisis, thrombolysis in stroke, acceptable modifications to RSI etc etc

In all of these discussions, it’s not uncommon to see people looking for “rules”. In the recent examples,

- physio wanted a rule that all lower limb reflexes are elicited in supine patient

- anaes colleagues wanted to use propofol RSI for the patient in VT and berated use of ketamine

- traditional teaching is to avoid use of FTD in presence or suspected presence of pelvic fracture; some paramedics were lookign for guidance on rules whether to use a FTD or not. Wise words from experienced paramedic/retrieval practitioner Dave Tingey “clinical judgement is the key – especially where there is little or no evidence” – he emphasised focussing on patient outcome, not rules for a process!

FOAMed – tacit knowledge sharing with global community

People ask me why I use social media for learning. For me the attraction of FOAMed is that it addresses the issues where there is clinical uncertainty. If you are looking for absolutes (as when learning the craft of medicine or to pass exams) then stick to the textbook teachings. If you are looking to test yourself and continue to explore the expanding frontiers of knowledge, then use FOAMed. It opens up the world of #dogmalysis and enables corridor conversations with clinicians worldwide. Some of what you encounter is bunk…some is golden. The trick is to filter, engage, question and unlike politicians, don’t stick to one party line.

Even if “the more you know, the less certain you are!”

"My way or the highway" Guessing PM Abbott would not be amenable to uncertainty
“My way or the highway”
Guessing PM Abbott would not be amenable to uncertainty

Rural Prehospital Care Survey

The phrase “critical illness does not respect geography” is often quoted, reflecting the fact that mishap can affect anyone, anytime, anywhere.

We are lucky to have excellent tertiary level emergency departments & intensive care units in Australia to deliver specialist care. Developments such as FOAMed help to narrow the knowledge-translation gap from publication to practice. Furthermore, the widespread dissemination of information via asynchronous learning (such as slide sets, podcasts, videos hosted on websites, or corridor conversations via twitter) means that geographical isolation alone is no excuse for the rural clinician to be the ‘weak link’ in provision of care.

But Australia is a vast continent – making the provision of immediate care problematic in the more rural & remote areas. Certainly we have excellent prehospital & retrieval services; but although road and rotary-wing responses are rapid, they are limited in timely response when distances are large. The sheer size of Australia means that even responses by fixed-wing aircraft may take hours to arrive. My job as a rural doctor is to deal with ‘anything & everything’. We offer primary care as a core skill, along with a smattering of emergency care. Many rural doctors have advanced skills in obstetrics, anaesthetics and surgery. ACRRM considers involvement in local disasters and emergencies as part of the rural doctor primary curriculum skill set. It makes sense that the doctors with ongoing exposure to resuscitation & airway management (typically rural GP-anaesthetists) are called when there is a rural emergency.

But is the involvement of rural doctors a good thing?

Perhaps not. The experts in delivery of prehospital care are those with specific training and resources – classically State-based ambulance services, supported by services with retrieval expertise (eg: RFDS, CareFlight, HEMS, medSTAR etc). As a hypothetical, I think that if I was involved in a vehicle rollover, I would want to be looked after by the experts, not an ‘enthusiastic amateur’ GP.

So there is the dilemma. The further from a tertiary centre, the longer it will take for retrieval services to arrive. The more remote you are, the more likely that ambulance responders will be unpaid volunteers, not career intensive-care level paramedics…and the more likely that local clinicians will need to be involved in care.

A 2012 survey of rural GP-anaesthetists surprised me; just under 60% of responders stated that they had been involved in some form of pre-hospital incident in the previous 12 months. However of those responding, very few had training in prehospital care, very few had equipment to deliver care and most were tasked to the scene in an ad hoc manner (no formal call out criteria). As a consequence, the quality of responder on scene is highly variable – you may get a senior rural doctor with regular exposure to advanced airway management…or you may get a relatively inexperienced GP with very little emergency experience, let alone skills useful to prehospital care.

I can certainly empathise with the notion of ‘no room for enthusiastic amateurs, leave it to the experts’. Yet interestingly, the request for rural clinicians to attend such incidents came from the experts in prehospital care – ambulance comms and retrieval coordinators, usually because of the severity of the incident and dearth of readily available resources.

You can watch a summary of the issue here from the smacc2013 conference.

Role of the rural clinician in prehospital care?

There are several systems worldwide aimed to deliver immediate care when and where needed.

At a basic level, community first responder schemes such as PulsePoint and GoodSAM (smartphone activated medics) allow crowd-sourced delivery of basic life support to patients even before ambulance services arrive. Responders are typically volunteers, with senior first aid, paramedic, nursing or medical qualifications who are prepared to respond if an incident (cardiac arrest, impact brain apnoea) happens in the immediate vicinity. Activation is via the GPS in smartphones.

At the top end of prehospital care are ambulance and retrieval services, with trained teams, dedicated equipment and service delivery aimed solely at best practice.

Somewhere in-between are systems integrate appropriately-trained volunteers to support ambulance services and deliver care before retrieval services arrive. Examples include the UK BASICS (British Association of Immediate Care Schemes) and NZ’s PRIME (Primary Response in Medical Emergencies). Responders are typically nurse or doctor, with high-level resuscitation skills (typically rural GP, emergency physician, intensivist). They are tasked under defined activation criteria and are trained, equipped and audited. UK BASICS are generally unpaid and work is taken on additional to NHS duties; PRIME is paid.

South Australia has an embryonic scheme, RERN (Rural Emergency Responder Network), utilising experienced rural doctors to respond to prehospital incidents in their community, only when attendance of a doctor will ‘value add’. This can be useful where local ambulance responders are volunteers, when local expertise (career paramedic) resources are overwhelmed and/or when arrival of specialist retrieval services will take some time. As such RERN responders are equipped with standard prehospital equipment, undertake ongoing training and case audit. Participation (and indeed attendance) is voluntary; remuneration is on a fee-for-service basis. You can download a presentation from Dr Peter Joyner here or watch a youtube video from CountryHealthSA featuring medSTAR’s Bill Griggs on the RERN model here.

Some other States have standardised Hospital ‘emergency bags’ for use in a disaster (such as Western Australia’s Parry Pack); yet no formal training for their use or clinician involvement in such incidents. NSW is leading the way with not just standardised equipment bags but also open-access training for rural clinicians.

So is the BASICS-PRIME-RERN model one which could be applied elsewhere in rural Australia? I think so, but only in certain locations and in certain circumstances. Clearly the ethos of rural doctors responding to local emergencies is congruent with that of ACRRM. Historically rural doctors were called as default; this has (sensibly in my opinion) been superseded by delivery of specialist care via ambulance or retrieval services, offering a far higher level of care.  Yet rural doctors are still being called, often by the same experts!

To continue with ad hoc responses by whichever local GP is available is nonsensical, especially without appropriate training and equipment. Equally to ignore the fact that many rural doctors have ongoing experience in initial emergency management and airway skills via work in local hospital ED and Theatre may deny rural patients access to lifesaving skills. Of course one has to be mindful that experience in the Operating Theatre or ED does not translate to the roadside and the experts remain paramedics and retrievalists…when available.

Other countries recognise the fact that there is a therapeutic vacuum between initial incident and arrival of retrieval services; that geographically-constrained countries such as the UK and NZ have these systems and yet Australia does not is puzzling, especially when considering the tyranny of distance and unique skill set of Australian rural clinicians.

Take the Survey

What do you think? The link below is to a survey which will go to rural doctors registered with ACRRM and the RDAA; however it would be good to get feedback from a wider cohort – from established retrievalists, from paramedics, from nurses – in fact, ANYONE who is involved in critical care.

CLICK HERE TO TAKE THE RURAL PREHOSPITAL SURVEY (5-10 MINS)

As Karel Habig said at smaccc2013: “Good critical care is good critical care, wherever you are.”

I think it would be good to ensure systems to deliver appropriate care where gaps exist. But it has to be something that rural doctors are prepared to engage in – and has to be embraced by other services.

To put it bluntly, either we include rural clinicians in the system or we do not. The latter may be ideal from a metrocentric perspective, insistent on gold-standard specialist-lead prehospital care. This is the service I would want as a rural patient! But a pragmatic approach recognises that there will be temporary service gaps due to distance or lack of available personnel and that plugging these gaps already involves rural clinicians – yet in an unstructured, unequipped and untrained manner.

I reckon that we can and should do better than that in Australia.

PROS

  • recognise that rural clinicians are already being called to attend prehospital incidents; ensure that such responses are by trained/equipped/audited responders, not ad hoc
  • utilise those rural clinicians with ongoing experience in trauma, emergency medicine and anaesthesia, who maintain skills through regular exposure in hopsital ED and Theatre
  • task rural clinicians only when their presence will ‘value add’ to the prehospital scene eg: IV access, ketamine for extrication, needle/finger/tube thoracostomy, prehospital airway management
  • establishment of State or Nationwide cadre of rural responders may provide extra resilience in case of disaster eg: earthquake, bushfire, flooding [and may be acceptable to existing State-based agencies]

CONS

  • prehospital environment is very different to hospital; requires skills best delivered by ambulance and specialist retrieval services, not amateurs
  • presence of a rural clinician may not value add (local GP arriving in boardshorts and thongs with no kit/training is worse than useless), detract from delivery of care by local resources
  • potentially high cost to equip and activate responders (PPE, prehospital kit, pagers etc)
  • relative infrequency of incidents carries risk of skill fade

Really interested in perspective from others.

https://docs.google.com/forms/d/1mWneu8ijC64O1yLblEFrNTFZ0xEDnNXD5JKzTfE6orQ/viewform?c=0&w=1&usp=mail_form_link

RSI Checklist App – Review

It is no secret that I am a fan of checklists. Not because they are a ‘how to guide’ (they’re not), but because of their proven potential to mitigate against error in high-risk tightly-coupled procedures. One such procedure is RSI. The consequences of omitting a single step (eg: failure to check ETT cuff, availability of back up equipment or appropriate drugs) can lead to disaster.

This year’s smaccGOLD saw Minh le Cong and myself go head-to-head in the infamous “Do Real Airway Experts Use Checklists?” debate. You can read more here - the answer being “of course airway experts should use checklists!”

Since then I am pleased to see that others in ED have been inspired to implement checklists in their ED…and for the creators of the Vortex Approach consider adding a checklist to their cognitive tool.

 

Checklist to complement The Vortex Approach
Checklist to complement The Vortex Approach

But a sensible checklist is more than a ‘tick and flick’ exercise – it should only contain key steps and ensure that the user does not lose situational awareness. Having audible cues (akin to an aircraft terrain alert warning to “pull up, pull up”) would be useful during preoxygenation and during intubation attempts.

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$1.29 on the Australian App store – it’s a UK-based app so presume available internationally

So I was delighted to be able to beta test the iRSI app. This is the brainchild of Dr Ben Taylor, a UK doctor who is near to completion of specialist training (I struggle with the notion of calling such doctors trainees). You can download the iRSI app via iTunes – it’s optimised for iPhone and listed as an iPhone iOS app, but works perfectly well on iPad.

 

iRSI checklist app - brainchild of Dr Ben Taylor, irsi.co.uk
iRSI checklist app – brainchild of Dr Ben Taylor, irsi.co.uk

 

The app itself is simple – four main checklist screens which can be run through during a standard period of pre-oxygenation.

 

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RSI App Start Screen

 

Once select ‘RSI’ as an option, the user is guided through four screens – checks of patient, drugs, equipment and team.

 

Step 1 - PATIENT
Step 1 : PATIENT

 

Step 2 : DRUGS
Step 2 : DRUGS

 

Step 3 : EQUIPMENT
Step 3 : EQUIPMENT

 

Step 4 : THE TEAM
Step 4 : THE TEAM

Running through the checklist takes around 60 seconds and can be achieved during preoxygenation. There are additional submenus for airway assessment, adjuncts for difficulty, prevention of desaturation and crisis management if needed.

What makes the app more useful, are the inclusion of :

  • integrated calculators for paediatric doses, emergency drugs and equipment sizes
  • tidal volume calculations based on ARDSnet for weight, height and IBW
  • integrated protocols for airway assessment, optimising oxygenation, failed intubation & anaphylaxis (references emcrit.org and resus.me FOAMed sites)
  • audible, tactile and visual alarms at preset intervals during preox and intubation attempts.

The latter takes advantage of the built-in audio alarm, vibrate and torch functions of the iPhone (iPad), corresponding to audio-tactile-visual cues as RSI progresses. I think this is invaluable, as offers a predetermined cue to encourage the intubator (or assistant) to consider alternative strategies as time progresses. This may help mitigate against task fixation, a problem in many airway catastrophes.

 

The Roc Clock - alarms during prolonged efforts to secure airway
The Roc Clock – alarms during prolonged efforts to secure airway

Nice touches are the ability to pre-select preferred choice of induction agents (from thiopentone-propofol-ketamine-etomidate-midazolam) and neuromuscular blocker (suxamethonium or rocuronium).

Thio-Sux traditionalism or Rocketamine? Your choice.
Thio-Sux traditionalism or Rocketamine?
Your choice.

Whilst the inclusion of propofol may induce apoplexy in some, hopefully the ability to either turn on or off cricoid pressure as a default will assuage them.

 

Cricoid ON or OFF? Your choice with iRSI
Cricoid ON or OFF? Choice is yours with iRSI

One thing I was concerned about was the potential to become too focussed on the app itself, rather than the intubation. I think that Ben’s done a good job – the user can preselect options appropriately and dip in/out of the app for critical stages eg: checklist alone or intubation attempt timer.

I don’t think that the app aims to replace proper airway evaluation and training, nor management of airway crises – but it does offer a readily-accessible form of an RSI checklist, useful drug and equipment calculators as well as timers with alarms for critical steps.

Future modifications might include

  • use of fentanyl as coinduction agent
  • calculators for standard infusions (particularly relevant for post-RSI sedation in ED, ICU or PHEC)
  • data logging to allow audit of intubation, offering possible synergy with the airwayregistry.org.au study and similar audits overseas.

So have a look at the RSI app and feedback any suggestions to Dr Ben Taylor. He’s done a GREAT job….

More details at iRSI.co.uk

BELOW IS A DEMO USING REFLECTOR APP AIRPLAY from iPAD to MACBOOK AIR.

Audio was overdubbed during a rainstorm on a remote beach – sorry about the background of heavy surf and rain!

https://vimeo.com/100875493

 

I think iRSI app opens the way forward – we all have smartphones and tablets to hand – integrating cognitive aids, audio/tactile/visual alerts, checklists, crisis algorithms and data-logging is a powerful way to improve safety.

Stroke Unit – Decision Makers Away with the Fairies

I’ve never been a fan of the term ‘cerebrovascular accident’. The term accident implies that there is no underlying reason for the pathology. Indeed, there was a push some years ago by the BMJ to ban the term ‘accident’ in medicine, as it implies that they are a chance occurrence or an ‘act of God’.

Stroke

It is actually interesting to explore the etymology of the term ‘stroke’. In times gone past, it was not unknown for formerly fit members of the community to head off into the fields or forest for a hard day’s work…then be discovered at the end of the day with a unilateral paralysis and difficulty speaking. Yet there was no visible injury. Hence the concept of having been attacked by the Faery Folk or ‘Elf-struck’ – subsequently contracted to ‘stroke’.

Whilst we learn about the pathophysiology & workup of stroke, I used to be somewhat nihilistic about outcome. I often tell patients and their relatives that one of three outcomes is likely – to get better, to get profoundly worse….or to stay the same. That’s not to say that I skimp on history and examination, appropriate investigations nor aggressive treatment of modifiable of risk factors. As a rural doctor I am well-placed to address risk factors well before people progress to cerebrovascular disease, as well as to have the ‘difficult’ discussions with them & family regarding prognostication if and when a stroke occurs.

All this changed with advances in stroke care.

The topic of thrombolysis in stroke is often discussed in FOAMed circles, with differing opinion on effectiveness between emergency and stroke physicians. One thing though has always seemed clear  the benefit of dedicated stroke pathways offering streamlined access t one-stop investigation and management of stroke patients, as well as use of validated triage systems such as the ROSIER score to enable direction of such patients to the stroke unit.

The best results appear to come from those which are based in a dedicated ward

By doing the LITTLE things well (timely recognition, early assessment and investigation, bundled care), it seems that stroke networks and stroke units offer patients the best chance. This is akin to the ‘aggregation of marginal gains’.

A 2013 Cochrane Review highlighted the benefit of dedicated stroke units. This review of 28 trials, involving 5855 participants, showed that patients who receive stroke unit care are more likely to survive their stroke, return home and become independent in looking after themselves.

So – best care is to send your stroke patient to a stroke unit. Or so I thought.

I recently admitted a stroke patient. Prior to this she was independent in her own home. She has controlled hypertension and a pacemaker. She’s had a previous stroke, managed in a tertiary hospital stroke unit, from which she made a full functional recovery after some weeks in rehabilitation. So when she presented, several hours after likely onset of her second stroke, it seemed only sensible to send her away to a stroke unit. She and family are loathe to leave the community, but understood that her best chance of recovery lies with all the benefits that a stroke unit can offer, not least rehab. So they are prepared to take a trip to the tertiary hospital for best care.

I spoke to a very lovely stroke registrar who apologised profusely and told me that, due to funding cuts, the stroke unit is now only able to accept patients under the age of 70.

That’s right – 70 years of age

Let’s face it – this is a financial decision, not a clinical one. Age doesn’t factor into the ROSIER score. It certainly didn’t factor into my patient’s eligibility for stroke unit care on the last occurrence. Whilst I can understand denying stroke unit care on the basis of poor premorbid function and poor chance of meaningful recovery, it seems nonsensical to exclude patients from stroke unit care on basis of age alone.

I have no doubt that my patient will be well cared for on a general medical ward. They may even receive visits from the same stroke physicians, physiotherapists and speech therapists as on the stroke unit. But studies suggest that it is the provision of a defined geographically separate unit dedicated to stroke care is the deciding factor in improving functional discharge.

As clinicians we may obsess over implementation of tools such as the ROSIER score, pros/cons of thrombolysis and need for bundled care in stroke networks and stroke units. But ultimately all this comes to nought if there are no beds, and decisions to admit to a stroke unit are made on basis of age, not other clinical criteria.

The stroke registrar encouraged me to make a noise about the limitations on beds. For most people, this issue will not be one that concerns them – until a family member is affected. Meanwhile politicians do not have to look these patients in the face. An honest political system would be prepared to put these issues front and centre, to acknowledge that rationing is needed and to explain why, despite encouragement to work until 70 until you are eligible for a pension, if you have a stroke in retirement you won’t get stroke unit care.

Making decisions based on age alone and not premorbid function seems inherently ageist – and is a policy I find hard to defend.

Should age alone be a reason to deny stroke unit care?

What do YOU think?

Is age alone a valid cutoff for stroke care?

If you are going to argue that equivalent care can be offered on a general medical ward, then it begs the question – why have stroke units? Has Cochrane got it wrong?

 

ETM course coming to Adelaide, SA

I am delighted to hear that Dr Andy Buck and team are running an ETM course in Adelaide in October this year. ETM is a great course for anyone involved in the trauma team – EM docs, anaesthetists, rural docs, surgeons, intensivists.

I teach and Direct on the international ATLS-EMST programme – and whilst I believe in the usefulness of the ATLS approach for the initial management of trauma, it frustrates me that the ATLS course is aimed at a fairly basic level, doesnt cover anything to do with trauma team management and omits much of the useful #FOAMed quality education that is available.

ETM covers all this. You can read a review of ETM by Dr Jeram Hyde from one of the early  Melbourne-based courses in November last year.

http://kidocs.org/2013/12/etm-course/

Better still, get yourself along to ETM in Adelaide this October – its way cheaper than EMST, shorter wait list to get on a course and has way better content for modern trauma management!

Details at http://etmcourse.com/first-interstate-etm-course/

I hope to see some of you there! Get in quick though….

Capnography & Procedural Sedation

I’ve been a convert to use of ETCO2 monitoring for not just anaesthesia in the OT or ED, but also for procedural sedation. This is driven in part by results of the NAP4 audit and also from colleagues in the FOAMed world. Perhaps I am over cautious, but my use of ETCO2 extends to monitoring of the sedated psych patient, for whom I consider administration of agents such as IV midazolam (or occasionally ketamine) once olanzapine wafers have failed, to be a standard of care.

So I was surprised by the statement over at EMTrends.org suggesting “no benefit to routine capnography in procedural sedation”. You can read a summary of the paper here or look up the reference in Anaesthesia & Analgesia (2014) 119(1) 49-55.

This paper looks at patients undergoing minor gynae procedures by non-anaesthetists in a Dutch hospital. Interestingly NONE received supplemental oxygen (despite being administered propofol). The authors state that the incidence of hypoxaemic incidents in the 206 patients with ETCO2 monitoring was not significantly better the 209 patients for whom ETCO2 was not used.

Fair enough – until you look at the rate of hypoxaemia (SpO2 < 91%) in both groups:

25.7% with capnography

vs

24.9 without capnography

That is pretty poor IMHO.

 

For the record, I think I will continue to advocate for :

- routine use of supplemental oxygen if using neuroleptics

- routine use of capnography

 

You can read more about ETCO2 here - as my friend Casey Parker of BroomeDocs says “It gives you A-B-C in one squiggly line”