Clinician Self Care : Wheelbarrows, Batteries & Tents

It’s good to see the topics of clinician self care being more commonly discussed, both in FOAMed circles and at regular conferences.  At the recent RDASA Masterclass in SA, Thinkwell psychologist Hugh Kearns and myself delivered a short session on self care, and I was thrilled to hear Dr Roger Sexton of Doctors Health SA talk at a recent GPex session for supervisors.

doctorshealthsa.org.au
A service of ‘doctors for doctors’ in SA and emulated interstate doctorshealthsa.com.au

Roger has done much to establish a network of ‘doctors for doctors’ here in South Australia, with the Doctors Health SA providing a bespoke service to doctors and medical students, a group that famously fail to look after their own health.  Some pearls from Dr Sexton’s talk deserve a wider audience.  The following is based on my synthesis of his expertise from a talk he delivered recently to GP supervisors. Check out more at the Doctors Health SA website


Look after the Wheelbarrow, the Battery & the Tent

Have a hard look at HOW you work in your practice. Many of us are busy, making numerous decisions in a time-pressured environment.  Whilst many people think decision-making in an emergency is stressful, I find that my work in ED or prehospital environment is far less stressful than that in the consulting clinic.  The former situation (let’s say a resus or sorting out an unwell patient) is relatively straightforward – there’s a simple algorithm (ABC…), there are established techniques to help teamwork (shared mental model, closed-loop communication, use of cognitive aids and appropriate resource allocation etc) and the momentum is usually upwards (from critically sick, to stabilised).

Whereas in clinic (especially in primary care), the problem is often poorly-defined (early stages of disease are far-removed from textbook descriptors), there is a huge element of gestalt and risk (sieving the important from the inconsequential) and there are limitations of time and resources (no pan scan or immediate access to investigations).  No small wonder that doing good primary care well is an intellectual challenge – often underestimated by those who’ve not done it – and sadly all too east to do poorly.

Whichever situation (whether a prehospital clinician, an emergency room clinician or a primary care clinician), one thing is certain – you have limited time, limited resources and important decisions need to be made with safety-netting. Three concepts can help you in your busy day.
Wheelbarrow
THE WHEELBARROW : like this garden tool, you only have a finite carrying capacity. In short, there is only so much load you can carry.  The lighter the load, the easier it is to get ahead.  Problem is, everyone wants to dump THEIR problems into your barrow. Therefore you need effective tools avoid unsustainable load from being dumped in your barrow!

A common strategy is the idea of ‘sticky fingers’.  Imagine if someone dumps a problem or task into your barrow.  With ‘sticky fingers’ you HAVE to pick it up and look at it – but here’s the trick – once picked up (or accepted) you must do ONE of only three options

  • deal with it (this is YOUR problem to deal with so sort it out)
  • delegate it (tasks that can be devolved to others should be, where possible)
  • dump it (unnecessary work should be declined or dumped)
Always look for an opportunity to dump your load...
Always look for new opportunities to dump your load…

As doctors we are inculcated through training to try and be helpful – to solve problems. Moreover as (mostly) successful high-achievers, we tend to thrive on problem-solving and are used to taking on extra work.  This a trap for new players – particularly in the first year or so post-Fellowship, when there is a natural temptation to take on exra work on committees, running rosters or running projects.

My advice? Play the long game. Take on small bite-sized chunks of work and be effecctive with them. And learn the art of saying ‘No’ (the phrase…”I’ll have to check my diary and get back to you” is an effective strategy to avoid the natural temptation to please others and say ‘yes’ to new work).

Try and recharge through the day...
Try and recharge through the day…

THE BATTERY : ever got home at the end of a busy day and felt mentally and physically exhausted? Of course.  decision-making and stress can pound the adrenals.  Getting home exhausted may lead to slumping on the couch and ‘vegging out’ – an inevitable result of the batteries being run down throughout the day. Why is this? As a clinician, we are a source of energy for others. Our decisions, our leadership are important parts of the team.  But giving off energy, especially in multiple repeated consults, can rapidly deplete the battery.

So – try not to let the battery run down!  Make an effort to recharge throughout the day and keep your batteries charged.  Take breaks. Book ‘catch up’ slots. Get out of the office in lunch break and take time to walk around the block.  Spend some time in the sun. Interact with work colleagues where possible. When rushed, make an effort to slow down. Breath. Be mindful and ‘in the moment’.  Spending 10-15 mins a day in meditation or ‘being mindful’ is beneficial.

Make a conscious effort to find something positive in every interaction, even if ostensibly challenging from outside appearances.  We are privileged to deal with patients throughout life’s rich tapestry. Appreciate this.

Resilience - the tent canvas is the outer protection. The guy ropes are supports
Resilience – the tent canvas is the outer protection. The guy ropes are our supports

THE TENT : clinician resilience is something I am interested in.  I think we need to develop skills in both cognitive resilience (making decisions under pressure) as well as emotional resilience (dealing with the impact of our work).  Although challenging, being comfortable to demonstrate our soft vulnerability (rather than a hard unbreakable veneer) can be an interesting space to throw up improvements. As Brene Brown says, being vulnerable is about courage – to allow ourselves to be seen as fragile human beings.  And understanding vulnerability can be the birthplace of innovation, creativity and change.

So – our outer protective shell – the canvas of our tent.  This layer – call it RESILIENCE – protects us from the elements. rather than being rigid and inflexible, it is soft…deformable…yet affords wonderful protection even under significant pressure.  Resilience is something that can be cultivated.

Of course we need supports – much like guy lines of a tent, we will need to cultivate and anchor ourselves to supports around us – our family, our friends, our colleagues.  Maybe outside interests – whether sport, a hobby, religion…whatever.  These anchors add to our resilience.

“Have a look at what’s happening in YOUR typical work day.

How well looked after are your wheelbarrow? Your battery? Your tent?”

 

 

Some other important factors for long term clinician self care

As well as thinking about your wheelbarrow, your batteries and your tent, have a think about other protective approaches to long-term clinician resilience – to keep thriving and surviving…

Have a health check : senior executives in corporations have annual health checks. How many intensivists do this? How many surgeons? How many GPs?

Get good independent advice : do NOT fall into the trap of self-diagnosing or ‘corridor consults’ with colleagues – see your GP!  But as well as seeking expert independent advice for your health, make sure you have appropriate advise for finances, for mental health (seeing a counsellor 6 monthly can be a powerful ‘future proofing’ technique).  Seek out mentors (SoMe and FOAMed helps). And if a specific area of your life is struggling (relationship, career, spiritual) then seek appropriate expert advice.

Get fit : shift work and busy days take their toll. Make time to exercise. Get your 10,000 steps in each day. The healthier you are, the easier your work will be.

Rediscover your passion : think about what you’ve given up to be where you are today.  Medical training is gruelling. University and postgraduate training eats into the time from school through to late 20s as a minimum.  Whilst those in non-medical jobs may enter into the labour market early, contributing to house purchase and superannuation, clinicians-in-training work long hours for little reward for the first decade.  Financial security comes late and may be compounded if working in private practice (no leave, superannuation, significant practice costs).  think what you’ve given up to do medicine – friendships, sports, holidays, time with family. Is it worth it?  Make time to rekindle the passions you’ve given up.

Mobilise endorphins : the best sources of endorphin are NOT the Doctors Bag or Drug Cupboard (although this is also a common trap for some!).  Natural highs are found through seven sources – laughter, sex, exercise, crying, singing, music, & meditation.

Value relationships : with spouse, with family, with colleagues, with friends…and with patients!

Have roles and fulfil them : not just our role as a clinician (indeed, one should try not to define worth through ‘doctoring’) Instead anchor yourself to other roles – as parent, as partner, as colleague, as coach etc.

Fulfil existential needs : much as we should acknoledge our vulnerabilities, we shoudl also ensure our existential needs are met. As humans we crave love, hope and meaning in our lives. Teaching is a common strategy to ensure our work has meaning (remember the origins of the term ‘doctor’? Docere, to teach). Control is also important in life; lack of control over one’s destiny (common when working as a salaried junior) can be a big contributing factor to dissatisfaction and burnout.

Recognise WARNING SIGNS and HAVE A PLAN : evaluate your wheelbarrow, your batteries and your tent on a regular basis. If something is failing, do something about it!
DoctorsHealthSA is running workshops (the next is September 2016).  Many conferences include speakers on self care and resilience nowadays. At the very least, make sure YOU have a GP and ensure you have regular health checks.

LINKS

Bren Brown on vulnerability ‘ https://www.ted.com/talks/brene_brown_on_vulnerability

Thinkwell – Hugh Kearns and Maria Gardener on clinician self care http://iThinkwell.com.au

Doctors Health SA – doctors for doctors (and medical students) – http://www.doctorshealthsa.com.au

Jellybean with Paramedic Rusty – http://lifeinthefastlane.com/jellybean-040-paramedic-named-rusty/

Unpacking the New GP Registrar

Just back from a two day GP Supervisors conference in Adelaide.  Attendance at these events is mandatory for GP supervisors.  Training primary care providers for the future in Australia has seen some changes over the years – responsibility for training was removed from the College (RACGP) in 2002 and devolved to ‘regional training providers’ or RTPs, of which there were many across Australia.  A criticism of this was duplicaiton of processes and resources for a system which, like other specialty training programmes, could and should be under the control of the College!

A shakeup occurred in 2015, with the culling of many RTPs in an attempt to avoid duplication and the establishment of a streamlined network of ‘regional training organisations’ or RTOs. Needless to say some winners and losers across the nation.  They sit under the auspices of the Dept of Health Australian General Practice Training.  Again the DOH control the training, although RACGP and ACRRM now determine entry to the programme.

GPex
won the contract for South Australia and are now responsible for funding training and ensuring access to training materials, with registrars following either FRACGP or FACRRM pathways.

I will keep my thoughts about the content of the conference to myself as it’s inevitable to compare content with that delivered by other RTOs.  Needless to say a good conference combines necessary updates in training requirements with innovative content to help supervisors be more effective in their supervision.  Of course other organisations, not least GP Supervisors Australia can help refine supervisor skills….

I see supervision as an apprenticeship – of course it’s necessary to ensure mandatory competencies across the breadth of general practice are met. To their credit, GPex have introduced the ‘GP365’ model of critical case analysis, backed up by development of a personalised learning plan.  Of course those registrars on the rural pathway need to bolt on additional skills in emergency medicine as a minimum and perhaps one of anaesthetics, obstetrics or surgery.

Content from GPex Supervisors Manual 2016
Content from GPex Supervisors Manual 2016

Whilst acquisition of either FRACGP or FACRRM is the focus of most trainees, I consider it my duty to inculcate tools for lifelong learning.  No surprise that this leads my trainees into discussions on metacognition, on heutagogy, on FOAMed and so on.

Many of my supervisor colleagues will invariably be keen to develop skills on how to give feedback, on dealing with difficult consultations (prescribing drugs-of-dependence is a common issue) and of course dealing with risk and uncertainty…along with the myriad of complexities around Medicare billing!  Much of medical training at undergraduate and postgraduate training is hospital-based…as a consequence new GP trainees are ill-equipped to deal with uncertainty, to made decisions based on limited information with no immediate access to investigations and to practice as “one doctor-one patient-one room”

“Sadly the skill is HARD to do well – but all too easy to do poorly”

I would maintain that delivery of GOOD primary care is an exhilarating blend of risk, uncertainty and good medicine – across the breadth of practice, not the narrow lens of partialist practice.

"GPs Down Under" - a closed Facebook group
“GPs Down Under” – a closed Facebook group

Of course our colleagues and our patients judge the specialty of primary care according to the lowest common denominator – hence my enthusiasm for initiatives such as FOAMed to broaden corridor conversations and narrow the knowledge translation gap.  SoMe platforms such as the closed ‘GPs Down Under’ Facebook group can also help normalise practice amongst disparate practitioners, as well as unite on issues such as the Medicare freeze etc.

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GPex does provide a rather excellent ‘GP Supervisors Manual‘ through their online resource package (amusingly called ELMO).  Despite this, some new supervisors seem uncertain on how to start off with a new GP reg. A couple of us came up with the idea of a short ‘how to’ guide for ‘unpacking the new GP registrar’.

I based this together in the airport on the way back to KI post conference  – whilst the content is specific to GPex, it may be of interest to others. It’s tongue-in-cheek and a bit rough and ready…your feedback is appreciated.

 

Links

Australian College of Rural & Remote Medicine (ACRRM) – http://acrrm.org.au

Australian General Practice Training (AGPT) http://www.agpt.com.au

Common Primary Care Presentations – racgp.org.au/…/common-general-practice-presentations

GPex http://www.gpex.com.au

GP Supervisors Australia http://gpsupervisorsaustralia.org.au

Royal Australian College of General Practitioners (RACGP) – http://www.racgp.org.au/home

Slideset

As PDF file
As Powerpoint file (converted from Mac)
As Keynote (original)
As Video file (narrated slideshow version)

Refinements on SALAD Sim

Along with many others, am playing around with various combinations of airway trainer, simulated vomit, pump and suction to develop a self-contained portable SALAD sim (SALAD – suction assisted laryngoscopic airway decontamination)

SALAD is of course the brainchild of James DuCanto, Milwaukee airway fanatic and well known to the FOAMed world. Instructions on the SALAD set up are here and training videos here

I’ve had the privilege of assisting Jim in airway workshops in Chicago and Dublin as part of the smacc conference series most recently assisted by UK anaesthetists Ben Shippey @rallydoc and Barbara Stanley (@theneurosim).  We’ve managed to train several hundred people in the nuances of airway decontamination, under both ‘static’ (simple deposit of simulated airway contaminant) and ‘dynamic’ tests (an ongoing tsunami of vomit which threatens to overwhelm the intubator unless master the art of continuous suction whilst intubating – not as easy as it sounds!)

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SALAD sim shenanigans in Dublin
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Barbara Stanley (@TheNeuroSim) ready to serve up some SALAD in Dublin
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Even experienced airway operators feel the pressure under the SALAD Sim (smacc Chicago 2015)

 

The future challenge will be to create a SALAD sim set up that is both compact & self-contained

Present SALAD setups rely upon an open container of ‘simulated airway contaminant’ (a heinous mix of xanthem gum, white vinegar and food colouring) which is then pumped to the oropharynx using variously

  • a drill-powered inline siphon pump
  • a submersible bilge or pond pump
  • a dirty water sump pump

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Flow rates can be adjusted by either use of inline valves or a variable rheostat speed-controller to reduce pump speed and hence flow of vomitus.

The contaminated airway is then suctioned out, using a medical grade suction device. I struggled with this in Dublin, as the two loan units rapidly became overwhelmed…I didn’t realise that the bags within suction cannister are designed as single use and the inlet valve soon became clogged.

In contrast Jim DuCanto’s units (from SSCOR) functioned brilliantly despite multiple rounds (200 litres each I reckon) of vomit passing through.

The SSCOR Medical Grade Suction Pump performs brilliantly - but this, submersible pump & head consume a lot of space!
The SSCOR Suction Pump performs brilliantly – but suction, submersible pump & head consume a lot of space!

Problem is, lugging around suction pumps, submersible pumps and the containers for vomit is quite bulky.

The purist in me wants to design a closed system, namely

  • bladder which can be removed, filled with vomit and then emptied at end of session
  • both submersible pump and suction pumps small enough to sit within Pelican case and be self-contained
  • suctioned contents to be automatically returned to the bladder, for further pumping to airway head
  • controls for pumps to be available on outside of case, once closed
  • variable controller built in

So the challenge will be to create something that can be carried in a Pelican case (Storm IM2500, on wheels).

It might look something like this:

Screen Shot 2016-07-10 at 1.24.28 PM

 

I’d envisage the whole unit being self-contained, the “simulated airway contaminant” (vomit) being cycled from bladder to oropharynx and back via the two pumps.

Bladder needs to be removable for filling/emptying at start/finish of session and able to tolerate periods where inflow < outflow (suction out < pump in to oropharynx).

Ideally the whole unit should function with lid of Pelican case closed, with control switches for pumps accessible on outside.  Marine rocker switches are ideal, as would a variable control rheostat panel control, flush with case.

Marine rocker switch
Marine rocker switch

A simple mains socket could be mounted in the Pelican case, such that the SALAD Pelican case can be plugged into mains power.

Really interested to hear from anyone with ideas on how to make this happen…preferably on a budget!

 

2017 #DASsmacc – Critical Care, Everywhere?

A few weeks after the madness that was #smaccDUB and it’s good to see various blogs summarising what the event meant for them (search for #smaccDUB to read the many reports of smacc in Dublin 2016).

Rest assured, the smaccTALKS will soon be coming out via smacc.net.au, intensivecarenetwork.com and the smacc-affiliated websites, of which KIDocs.org is proud to be one.

Next year smacc continues in the Northern Hemisphere – the Teutonic DASsmacc will be held over four days in Berlin from 26-29 June 2017.

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This will be the fifth smacc event…and as other conferences slowly begin to adopt the smacc-format of engaging TEDx style talks, powerful presentations and engaging speakers, it’s anticipated that DASsmacc will again break the mould.

In part I reckon the venue will force some changes; the Tempodrom is really designed as a concert venue – one stage, surrounded by seating. Which means, I think, that there will be scant place for concurrent sessions – rather the WHOLE of the smacc content is potentially going to be played out in the one arena.

tempodrom_vollbestuhlung_totale

A challenge? Perhaps – but in many ways the single stage may make it easier.  This opens up opportunities – wouldn’t it be fantastic if, instead of having several thousand critical care afficianados come together to hear a select few speak, the conference concept was ‘flipped’ such that every attendee was also a participant?

Attendees as Particpants?

How? Well of course there will be the usual finely-crafted talks across a range of topics (more on that later)…but there’s opportunity to mix it up.  Have panel discussions, have real-time simulation, have competitions and challenges.  The 2016 smaccDUB showcased wrist bracelets that attendees wore as part of the opening ceremony light show and gala dinner; how easy would it be to use the same technology to select audience members – perhaps select attendees to participate as the ‘on call team’ for a sim session?  Or to use colour bracelets to indicate audience polling on a controversial subject?

Creating immersive audience participation, such that all attendees contribute to the smacc content is one thing….how about the content itself?

One of my beefs with much FOAMed content is that we often emphasise critical care from a tertiary perspective, more often than not as practiced in a developed critical care system.  As such, the talks may be focussed on the 1% of the 1% – on prehospital REBOA, on ECMO etc.

Let’s step back and consider critical illness as a spectrum

As a rural primary care practitioner, I am privileged to be involved in all aspects of my patient’s journey. On occasions I am called to the roadside to assist the (mostly volunteer) ambulance crews for a vehicle trauma.  It’s easy to talk about the immediate care – the technical challenges of extrication facilitated by placement of an IO and an aliquot of ketamine…the roadside RSI followed by bilateral finger thoracostomies…the use of prehospital blood products….the use of POCUS in flight to confirm free fluid in abdomen and fast-track straight to OT in the haemodynamically unstable.

Many weeks after that same patient returns to their home, their pelvic and spinal fractures healed, their lung empyema drained….then the HARD work in primary care starts…managing their chonic pain, sorting out the skin grafts from their decubitus ulcers picked up in ICU, dealing with their depression, their weight gain and loss of function that impact in lost QALYs etc.  This is the grind of primary care..dealing with downstream consequences and is important to understand how this enmeshes with the work in resus.

As well as the role of clinicians in prevention and rehablitation, we also don’t talk about prevention – the mundane stuff of seat belts, of crash helmets, of driver education, of designing out human error by use of crash barriers, airbags and so on. But this is important. And that’s just for trauma. Where is our preventative care for other aspects of critical illness?

So for DASsmacc I think there are two angles to consider.

First, that is we are serious about making a difference in critical illness, then we need to consider other aspects of the critical care journey.  I recall Karim Brohi speaking in Melbourne at the ATS Trauma 2007 conference, reminding us that it is “more important to be the fence at the top of the cliff than the ambulance at the bottom

We need to talk about other aspects – preventative care…organ donation…the longterm morbidity, whether it be physical or psychological. Primary care…

It would be awesome to explore these aspects for a variety of patients in a system….whether it be the trauma patient (prevention, rehabilitation), the unsalvageable (advanced care directives in primary care, the nitty-gritty of organ donation).  I would love to hear more from those experts in prevention, in rehabilitation, in primary care….in how we can make a difference to critical illness.  I’d also like to hear more from the administrators – the people who manage the systems within which we work…how do they see incremental improvement in this arena?

Critical Care – Everywhere!

Second up, we need to acknowledge that critical illness is a global phenomenon for which many do not have the same resources as the typical audience at smacc.  As such, we can make an awful lot of difference by both understanding the dynamics of global critical illness and also contributing to effective knowledge translation. prehospital REBOA is for a very few…access to contextually-relevant knowledge and skills is likely to give more bag for buck.

A conversation with BAD-EM’s Ross Hofmeyer after the airway workshop brought this home; I had no idea that access to bougies in South Africa is problematic. Ross told me that bougies tend to be re-used for up to two years in Cape Town.  I shudder to think how many bougies I’ve used, whether in theatre or ED..or on airway courses.  I;d love to start a scheme whereby used bougies can be collected and sent on to Ross and colleagues at BAD-EM….

…and if Cape Town needs this sort of stuff, then how about clinicians in South America, sub-Saharan Africa, Pakistan etc?  I have no idea….but the potential for the critical care community to make a difference to global care is huge.

On that note, smacc was held during Ramadan. Does that impact on the ability of some clinicians to attend? Perhaps, I honestly don’t know. But where are the talks on the burden of trauma & critical care from the Middle East, South Asia etc?

Whatever #DASsmacc holds, I do hope that it has an appreciation of the global burden of critical illness and helps advocate for effective knowledge translation back from the conference to those places that are currently not part of the smacc community.

Expert Panels – TEDx talks – BLAST Updates – Cage Fights – Rants – Sim Team Challenges

So, what could DASsmacc look like?

  • 100% conference audience involvement, attendees as participants
  • longitudinal progress of a variety of patients through a system of critical care (from prevention, resus and critical care through to rehabilitation, with inout from primary care, psychology, health admin and systems engineers)
  • the usual format of engaging speakers, panel discussions intermixed with short ‘blast’ talks, rants (as at #smaccFORCE) and audience participation through polls, challenges, sim etc
  • appreciation of the context of critical illness, with discussion of applicability on a global scale, ensuring effective knowledge translation..not just of the ‘sexy’ minutiae, but through ensuring broad-brush applicability to humanity.

Because if we are serious about making a difference in critical care, we need to think outside the confines of Western tertiary care…let’s make #DASsmacc be all about ‘critical care, everywhere’

 

 

Building Community Resilience with Careflight

Rural trauma – a high-speed vehicle roll over, a farming accident with a chainsaw, a gas BBQ explosion at the family picnic.  These are all scenarios that may affect individuals & families…and the rural community.  Occasionally a multi-agency event such as a bushfire, extreme weather event or other natural disaster will cause traumatic injuries and impact on not just community but State resources.

Whilst it is true that each State has well-developed retrieval services, whether land, fixed or rotary-wing, the reality is that the help they can offer is usually distant to rural folk; response times are measured in hours, not in minutes or seconds.

For all practical purposes these services might as well be on the moon in the face of truly urgent care (catastrophic haemorrhage, impact brain apnoea, compromised airway, delivery of effective analgesia etc).

The first link in the trauma chain of survival is invariably the first responder – he or she may be a rural volunteer in a service such as ambulance, fire, SES , coastguard…or may respond as part of their job role (eg: Parks officer, tour guide)…or may be a lay member of the public who comes across an incident and is thrust into the maw of trauma care..is  This impromtu response what Christina Hernon defined as the ‘immediate responder’ in her excellent talk on ‘the disaster gap’ at smaccDUB.

The Disaster Gap is the time between the moment an incident occurs, through the first call for help, and until the first of the clearheaded First Responders arrives. In this definable time gap, the only available rescuers are people who are on scene when the event happens, who may be traumatized by their experience themselves, and who, regardless of tools or training, take immediate action to help another person or make the situation better.

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Of course many organisations insist on their members having an advanced first aid qualification; whilst these are useful, their proscribed content often lags behind current trauma care delivery. First responders are the initial link in the ‘trauma chain’ and there is no reason not to equip them with appropriate skills, knowledge and equipment – regardless of agency!

Whilst most interagency training is focussed on ‘mass incident’ exercises as a learning exercise, the reality is that these rarely, if ever, happen. Most of the work is in the usual business – a vehicle rollover or crash, an injured bushwalker, a farm accident, a patient needing medical care but unable to use the stairs, requiring SES and Ambulance teams etc – and yet do we ever train as a team for such circumstances?

Careflight MediSim – Delivering Necessary Trauma Education

This week we were privileged to have a visit from the Careflight MediSim team, to deliver the Trauma Care Workshop on Kangaroo Island, SA.

Launched in 2011, this innovative program from the Careflight organisation (mostly charity funded) delivers a world class trauma education system designed for rural first responders.

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MediSim training 2011-2015

Despite the session having to be rescheduled, willing first responders from Parks, CFS and SA Ambulance were able to come together for an interactive day of lectures, task-training and sim sessions under the credible instruction of the approachable MediSim facilitators.
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I’ve been banging on about the need for effective interagency training in rural communities for some time now.  My involvement in trauma nowadays is mostly limited to involvement via the SA RERN system (a doctor responding only when needed by volunteer ambulance officers, with the goal of value-adding by performing certain interventions), in the hospital when oncall for emergency or anaesthesia and of course in trauma education through ETMcourse and EMST etc.

Whilst RERN, SAAS and of course RFDS and SAAS-MedSTAR Retrieval have a role to play, the initial care is invariably provided by a first responder.  If lucky he or she may be a part of an emergency system…or they may be in another capacity (CFS, SES, Police, Parks etc). Most prehospital incidents will require input from several agencies.

At a typical vehicle crash, there will be representatives from Road Crash Rescue (CFS or SES), Ambulance – typically these are unpaid volunteers in rural. Add to that Police, then RERN, and Retrieval…it can be hard to both know ‘who is who in the zoo‘ and more importantly what they can do!

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A typical rural road crash (source ABC)

 

Training together has clear advantages – it emphasises the need for simple interventions to make a difference and that such interventions can be performed by appropriately trained and equipped individuals regardless of agency. It also allows discussion of current protocols and equipment (such as the value of first responders, whether ambulance, fire or SES having access to tourniquets, and a suitable haemorrhage control device).

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Simple kit to deal with haemorrhage control – in my opinion this should be in every rural ambulance, SES or CFS truck, police car, parks vehicle and tour bus. Is it?

Understanding and sharing of each other’s treatment priorities (scene control & safety, patient extrication and medical needs) can be practiced by scenario training, allowing effective communication, a shared mental model and planning for ‘the real thing’

It’s time to ditch the notion of each agency training in silos and instead practice regular ‘real life’ multiagency scenarios

The MediSim team provided local Kangaroo Island first responders with a solid foundation to develop further local community resilience.  Lectures covered the concept of a ‘zero survey’, triage. effective handover and of course the nuts & bolts of trauma care.

 

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The Emergency Bandage (formerly known as the Israeli Bandage) – cheap and essential kit for any first responder

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Checking out the MediSim ‘crash car’ designed to be used for practice extrication – it would be a simple project to make one of these for local use on KI, potentially in partnership with TAFE & Crash Repairs

The day involved practical, hands on task-training sessions on triage, on helmet removal and immobilisation, on haemorrhage control and basic airway management.

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Helmet removal – can be done safely; either let patient do it themselves or perform if trained – but get the helmet off early, not late!

Skills learned in the workshop were reinforced by scenario-based training on managing a casualty, involving scene awareness, leadership, role allocation and the delivery of basic care in an effective manner (simultaneous extrication, treatment and packaging of the patient) underpinned by clear communication both on-scene and with central comms.

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Challenges of leadership and teamwork, under stress, with limited resources in an unfamiliar environment – one which KI local volunteer teams coped with exceptionally well

All in all, a wonderful effort by the CareFlight MediSIm team and by the local Kangaroo Island volunteers who gave up their own time to attend this trauma workshop.

I am hopeful that we can run similar exercises in the future using local expertise.  To my mind the benefits of team members who are aware of each other’s roles and operational capabilities, who have trained together and share a common goal offer immediate tangible benefits to victims of trauma.

Moreover we live in a small community – the more first responders who are trained and equipped, the more resilient our response can be – whether for an accident at home, at the roadside or in the case of a community-wide catastrophe.

 

A Kangaroo Island Resilience Model, akin to those overseas, is achievable if we work together.

Thanks again Careflight for visiting Kangaroo Island – come again next year!

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COI – I received a bottle of wine from the MediSim team as a reminder of my time in Orange NSW back in 2011 (anaesthesia training and trauma care). I am not influenced in my report by this gift…although there MAY be a subliminal message they want to convey…

 

Recommended Reading

Read more about Careflight MediSim HERE

Careflight are also active in sharing their knowledge through social media; check out the Careflight Collective blog here

Learn about how the Isle of Arran (Scotland) has developed a local resilience model for multi-agency training and trauma care

Principles of trauma care are taught on many courses; I recommend

Emergency Trauma Management (ETM) course – etmcourse.com (COI I instruct on ETM)

Anaesthesia, Trauma & Critical Care (ATACC) course – atacc.co.uk (COI am trying to persuade Mark Forrest to bring this course ‘down under’)

The Holmatro Rescue Experience (COI have facilitated with Holmatro extrication guru, Ian Dunbar on this in Australia, mostly teaching SES and CFS volunteers)

Many clinicians worldwide share knowledge and skills – regardless of whether background in emergency, anaesthesia, rural medicine, critical care or whether involved as doctor, nurse, paramedic or volunteer. By sharing such knowledge we can all become better.