CPD points for #FOAMed & SoMe?

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.

BziofqsCMAA5MHI.jpg-large
Dr Ewen McPhee, Dr Tim Senior. Dr Tim Leeuwenburg. Ms Helen Barry (RACGP) & Dr Karen Price [photo by Dr Marlene Pearce]
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.

What do YOU think?

 

 

 

Is the IO really dead?

I was unable to attend the annual Australian Trauma Society meeting this year (truth be told, my membership lapsed and I’ve been busy with other projects recently). But in these days of FOAMed and use of social media to connect, I was able to follow vicariously via the twitter feed from #Austrauma. One tweet, admittedly not direct from the Austrauma feed, but from one of it’s speakers – caught my eye.

Screen Shot 2014-10-05 at 1.31.42 pm

Now it’s hard to argue with Karim Brohi – if you’ve not met him, he’s the chap who kicked off perhaps one of the earliest ever FOAMed sites – the thoroughly excellent trauma.org site (which turns 20 years old in 2015!). He’s well-regarded as a trauma expert, international speaker and leading trauma researcher. He’s also a nice chap and interacts with others through the twittersphere – whether trauma guru, student, rural doc or paramedic. I reckon he’s a chap who believes in striving for quality improvement across the board – his words from smaccGOLD still resonate re : use of audit to improve systems and lead to innovation, such as implementation of REBOA “you have to sweep the floor, everyday

So I was surprised by this statement from Brohi regarding the demise of the IO. Use of IO has taken some time to percolate down; I remember as a junior reg (so maybe 10 years ago) being admonished for placing an IO in a shut down 14 year old s they were “only to be used in children 9 years and under”. Nowadays there is no age limit – and we’ve moved from the old fashioned Cooks IO device to alternative device, the use which is taught in APLS, ATLS and other entry-level courses. Heck, we’ve even (finally) got them into small rural hospitals here in Oz!

I think Karim was purely referring to the utility of IO in a tertiary level resus bay, where rapid administration of blood is needed – the need to use pressure to infuse can cause to cell lysis, negating any advantage.

So is the IO route really dead?

I think not. Imagine a patient entrapped. Access through the window allows access to the humeral head and placement of an IO to facilitate extrication via administration of agents such as ketamine. In a resus bay, placement of an IO allows early administration of fluid and drugs, for both analgesia & procedures such as RSI.

photo

Sure there are other routes – intranasal, intramuscular, rectal….and I’ve even placed an IV in the corpora cavernosa once (well, it communicates with the vascular space – just don;t run an adrenaline infusion through a line placed in the willy)

Placement of a subclavian swan sheath or peripheral rapid infuser catheter is ideal if rapid administration of warmed fluids is needed. Indeed I think RICs should be available not just in resus, but anywhere where people bleed – theatre, labour ward and prehospital.

Here’s the infamous ‘AC/DC & Barry White rapid infuser mashup’, which Scott Weingart chose for inclusion in Roberts & Hedges Emergency Procedures in Emegrency Medicine  as a video demo of how to place a RIC…

http://vimeo.com/59608480

We still teach venous cutdown on ATLS in the animal lab – although the last cutdown I saw was over a decade a go in a difficult ED resus, requiring attempts at both saphenous and brachiocephalic veins.

Options for IO devices?

There are a few devices out there. Access points include humeral head, proximal & distal tibia, ischial crest and sternum (the latter is for FAST-1 only, not EZ-IO or BIG).

IOs such as the EZ-IO reportedly allow rates of 125ml/min, with the intrasternal device (mostly used in military) quicker still. remember to WARM FLUIDS so as not to contribute to the lethal triad.

Lethal triad

YouTube always seem to have some videos of these devices being put in – I admit that I’ve had an EZ-IO put in, which I didn’t find at all painful (and I am a bit of a needlephobe). However having 10ml of saline pushed through the device hurt big time! Some recommend administration of 1-2 ml of lignocaine prior to running in fluid (remember to use a pressure bag or dedicated person using three-way tap). Still hurts like a MoFo though!

Old fashioned Cook IO needle – these are now mostly gathering dust in the corner of EDs or have been removed completely. They were the device that we trained with on APLS a decade ago. Sadly it was relatively easy to push through the bone – and into the palm of your hand if supportng the childs lower limb.

The Bone Injection Gun – a spring-loaded IO device, which is designed for ease of use. Our hospital purchased these (no consultation with clinicians) and I can report that the experience has been disappointing. despite training, we have had nurses sustain sharps injuries by deploying the wrong way around. Locums unfamiliar with the device have struggled. One of the major problems is that the recoil of the spring can be taken up by the hand-forearm unless wrist is “cocked and locked”. Of course there is no tactile feedback either.

Although much cheaper than the EZ-IO device, the fact that failure rate is both means that 2-3 may be used per insertion attempt (anecdotal data from local experience), I would avoid the BIG, and instead recommend…

The EZ-IO device – this is simple to use. Sadly the drills are crazy expensive, as are the needles – however they allow easy insertion, give tactile feedback and are the device with which most clinicians train, making them the sensible choice. I ended up doing a deal with the health department, whereby purchased my own drill for prehospital and ED use, with needles being supplied by the Health Department.

And lastly, the FAST-1 device – this is an intra-sternal device favoured by the military (which kind of makes sense in combat as victims limbs may be blown off)

You can read a review of these devices HERE

Intraosseous Devices for Intravascular Access in Adult Trauma Patients Day M.W. (2011) Crit Care Nursing 2011 31 : 76-90 doi: 10.4037/ccn2011615 

“It’s blood they bleed, so it’s blood they need”

 

For now, I will be keeping my EZ-IO handy – I appreciate it’s not brilliant for rapid administration of fluids inc blood, but the ease of use and ability to rapidly administer analgesia or sedation/RSI drugs makes it a useful tool in the armamentarium…

…and if all else fails, there’s always a 14G needle and a strong arm to gain IO access!

 

 

 

 

 

Is the IO really dead?

I was unable to attend the annual Australian Trauma Society meeting this year (truth be told, my membership lapsed and I’ve been busy with other projects recently). But in these days of FOAMed and use of social media to connect, I was able to follow vicariously via the twitter feed from #Austrauma. One tweet, admittedly not direct from the Austrauma feed, but from one of it’s speakers – caught my eye.

Screen Shot 2014-10-05 at 1.31.42 pm

Now it’s hard to argue with Karim Brohi – if you’ve not met him, he’s the chap who kicked off perhaps one of the earliest ever FOAMed sites – the thoroughly excellent trauma.org site (which turns 20 years old in 2015!). He’s well-regarded as a trauma expert, international speaker and leading trauma researcher. He’s also a nice chap and interacts with others through the twittersphere – whether trauma guru, student, rural doc or paramedic. I reckon he’s a chap who believes in striving for quality improvement across the board – his words from smaccGOLD still resonate re : use of audit to improve systems and lead to innovation, such as implementation of REBOA “you have to sweep the floor, everyday

So I was surprised by this statement from Brohi regarding the demise of the IO. Use of IO has taken some time to percolate down; I remember as a junior reg (so maybe 10 years ago) being admonished for placing an IO in a shut down 14 year old s they were “only to be used in children 9 years and under”. Nowadays there is no age limit – and we’ve moved from the old fashioned Cooks IO device to alternative device, the use which is taught in APLS, ATLS and other entry-level courses. Heck, we’ve even (finally) got them into small rural hospitals here in Oz!

I think Karim was purely referring to the utility of IO in a tertiary level resus bay, where rapid administration of blood is needed – the need to use pressure to infuse can cause to cell lysis, negating any advantage.

So is the IO route really dead?

I think not. Imagine a patient entrapped. Access through the window allows access to the humeral head and placement of an IO to facilitate extrication via administration of agents such as ketamine. In a resus bay, placement of an IO allows early administration of fluid and drugs, for both analgesia & procedures such as RSI.

photo

Sure there are other routes – intranasal, intramuscular, rectal….and I’ve even placed an IV in the corpora cavernosa once (well, it communicates with the vascular space – just don;t run an adrenaline infusion through a line placed in the willy)

Placement of a subclavian swan sheath or peripheral rapid infuser catheter is ideal if rapid administration of warmed fluids is needed. Indeed I think RICs should be available not just in resus, but anywhere where people bleed – theatre, labour ward and prehospital.

Here’s the infamous ‘AC/DC & Barry White rapid infuser mashup’, which Scott Weingart chose for inclusion in Roberts & Hedges Emergency Procedures in Emegrency Medicine  as a video demo of how to place a RIC…

http://vimeo.com/59608480

We still teach venous cutdown on ATLS in the animal lab – although the last cutdown I saw was over a decade a go in a difficult ED resus, requiring attempts at both saphenous and brachiocephalic veins.

Options for IO devices?

There are a few devices out there. Access points include humeral head, proximal & distal tibia, ischial crest and sternum (the latter is for FAST-1 only, not EZ-IO or BIG).

IOs such as the EZ-IO reportedly allow rates of 125ml/min, with the intrasternal device (mostly used in military) quicker still. remember to WARM FLUIDS so as not to contribute to the lethal triad.

Lethal triad

YouTube always seem to have some videos of these devices being put in – I admit that I’ve had an EZ-IO put in, which I didn’t find at all painful (and I am a bit of a needlephobe). However having 10ml of saline pushed through the device hurt big time! Some recommend administration of 1-2 ml of lignocaine prior to running in fluid (remember to use a pressure bag or dedicated person using three-way tap). Still hurts like a MoFo though!

Old fashioned Cook IO needle – these are now mostly gathering dust in the corner of EDs or have been removed completely. They were the device that we trained with on APLS a decade ago. Sadly it was relatively easy to push through the bone – and into the palm of your hand if supportng the childs lower limb.

The Bone Injection Gun – a spring-loaded IO device, which is designed for ease of use. Our hospital purchased these (no consultation with clinicians) and I can report that the experience has been disappointing. despite training, we have had nurses sustain sharps injuries by deploying the wrong way around. Locums unfamiliar with the device have struggled. One of the major problems is that the recoil of the spring can be taken up by the hand-forearm unless wrist is “cocked and locked”. Of course there is no tactile feedback either.

Although much cheaper than the EZ-IO device, the fact that failure rate is both means that 2-3 may be used per insertion attempt (anecdotal data from local experience), I would avoid the BIG, and instead recommend…

The EZ-IO device – this is simple to use. Sadly the drills are crazy expensive, as are the needles – however they allow easy insertion, give tactile feedback and are the device with which most clinicians train, making them the sensible choice. I ended up doing a deal with the health department, whereby purchased my own drill for prehospital and ED use, with needles being supplied by the Health Department.

And lastly, the FAST-1 device – this is an intra-sternal device favoured by the military (which kind of makes sense in combat as victims limbs may be blown off)

You can read a review of these devices HERE

Intraosseous Devices for Intravascular Access in Adult Trauma Patients Day M.W. (2011) Crit Care Nursing 2011 31 : 76-90 doi: 10.4037/ccn2011615 

“It’s blood they bleed, so it’s blood they need”

 

For now, I will be keeping my EZ-IO handy – I appreciate it’s not brilliant for rapid administration of fluids inc blood, but the ease of use and ability to rapidly administer analgesia or sedation/RSI drugs makes it a useful tool in the armamentarium…

…and if all else fails, there’s always a 14G needle and a strong arm to gain IO access!

 

 

 

 

 

Graduate Paramedics – In Safe Hands

I never used to have much to do with paramedics as a junior doctor. It was only when working in the ED as a registrar that I was exposed to them…probably a good 3-4 years into my postgraduate medical career. Even then, I had little idea of the challenges they faced, despite being in the same business of managing trauma, critical illness. But of course with the usual pressures in ED (access block, running at 120% capacity, begging for appropriate consults and dealing with all the usual stresses of staffing and supervision) it was easy to just bemoan the fact that patients were dropped off covered in gravel from the roadside and possibly some time after the incident.

In short, as an ED reg starting off, I had little idea of the challenges posed by the prehospital paramedics. And it was easy to criticise. If that was my mindset, just think of that of the rest of the hospital!  Nothing could be further from the truth. Fastwind forward a decade. I’ve spent a lot of time in medical education, instructing (and directing) on the international ‘advanced trauma life support’ aka ATLS (EMST in Australasia). In fact the full name of this course is “ATLS Course for Doctors” – it remains medico-centric and is a product of the College of Surgeons it is no secret that I am a critic of this course- it fulfils a need for entry-level, but doesn’t really deliver modern trauma care, hence the proliferation of other course such as ATACC and ETMcourse.

The usual stereotypes of (shudder) just ambulance drivers no doubt predominate in some medics mind when I trained … and I suspect this attitude still exists, as some of my paramedic mates refer to themselves (self-deprecatingly) as ‘just an ambulance driver’. So along my postgraduate career and in time as a medical educator, I have tried really hard to do the following :

  • to understand and explain to doctors who I train about the valuable skills of paramedics/prehospital
  • to seek to break down traditional silos between different providers, such as paramedics and medics
  • to use simulation training to improve delivery of care in resus

My mission continues – part of the reason I am rotating through medSTAR is to pick up pearls from prehospital care, simulation and standardisation of training, as well as case audit and governance. Even as a seasoned doctor, I make an effort to go on other courses relevant to resus – some of which are geared specifically towards the prehospital environment (eg; STAR). But it is still rare for medics to cross train with paramedics and see how they do it.

Enter the Sim Environment…,

Restricted area

So I was delighted to be offered the chance to attend some of the sim training for graduate paramedics commencing their internship. This program is an intense three week course of lectures and scenario testing for the intern intake, designed to help equip term before “hitting the road”.

I was only able to make it for one day – but can report that I was blown away with both the quality of simulation delivered AND the clinical skills of the paramedic interns. My host was former nurse and current paramedic educator, Michael Borrowdale.

OLYMPUS DIGITAL CAMERA

Michael proudly showed me around the SA ambulance training facility (refurbished office spaces) which were cleverly kitted out on a shoestring budget to mimic indoor environments including patient homes, nursing home, resus room and crew room/stock cupboard. Furniture was sourced from donations and clever use of curtains to change wall appearance allowed the same room to function as a bedroom or a resus, bay, a bathroom or a lounge room. Cheap video cameras from DickSmithElectronics allowed recording of the scenarios to linked PC, for under $100

 

BEDROOM
Pre-painted furniture on the back wall can be concealed by a curtain printed with resus room paraphrenalia, rapidly converting the room format

RESUS ROOM

Attention to the little details adds to the fidelity of simulation – having webster packs, ID cards and the like adds valuable clinical information (organ donor, medications). And for immersive sim, use of sight, sounds, and even smell contributes hugely.

Photo ID

 

OLYMPUS DIGITAL CAMERA
Live actor, realistic faeces, overpowering smell from ‘liquid ass’ spray creates realistic immersive sim … in a cramped bathroom space

I watched four different sims, each run in ‘real time’, requiring the candidates to manage the condition from arrival to disposition, with varying levels of complexity. Use of a mix of live patients and mannikins, along with students role-playing relatives, nursing staff or police officers added to the realism and encouraged skills in scene management and situational awareness.

I was impressed that candidates had to manage the scenario from arrival and initial assessment, maintaining communications with HQ, instituting immediate management, calling for backup, dealing with distressed relatives, environmental concerns, extricating the patient, dealing with unexpected crises (sudden desaturation), loading patient, transporting via ambulance and handover to ED.

SHARP
Debriefing – I am not a fan of Pendelton’s ‘shit sandwich’ approach, preferring instead the Plus/delta approach (what went well?, what would you change?).The SHARP tool seems reasonable too…although candidates tend to focus on what went badly when asked “How did it go?”

Each scenario ran for about 30-45 minutes and was expertly debriefed by experienced facilitators with plenty of roadcraft experience. Crews were split and sim continued even after patient departed, with remaining crew having to clean up, deal with relatives/media/police and both teams write up case cards.

 

"Commotio cordis" paediatric VF arrest - unfortunate incident with a cricket ball
“Commotio cordis” paediatric VF arrest – unfortunate incident with a cricket ball
Standard ACLS in the park ...
Standard ACLS in the park …
#NOF, hypothermia and melena on the bathroom floor
#NOF, hypothermia and melena on the bathroom floor
Paediatric suicide attempt - deliberate jump from 10m, have to deal with distraught mother before can begin to assess patient
Paediatric suicide attempt – deliberate jump from 10m, have to deal with distraught mother before can begin to assess patient

The realistic prehospital scenarios, carrying a significant cognitive load  in not just clinical management but scene awareness lead to a degree of stress inoculation.

SAPOL rellatives
Involvement of patient relatives and outside agencies such as police, mean that prehospital workers have to develop excellent situational awareness and scene management, on top of clinical management priorities

Despite being involved in running trauma sims via ATLS/EMST, running my own ‘guerilla sim’ and attending other courses in resus/prehospital care here in SA and interstate, I can say that I have NEVER seen such a high level of immersive simulation. Sight, smell, sound and sheer cognitive overload from various players (distraught relatives, police, press, carers and assorted players created a level of sim I’ve never experienced before)

Throughout this, the paramedic interns displayed effective clinical skills and excellent crisis resource management.

“To put it bluntly, I have never seen this level of immersive simulation in ANY of my medical career, despite running and attending sessions focussing on resus training. Nor have I been privileged to witness the level of clinical skill displayed by the paramedic interns at such a junior level”

 

After witnessing this sim training, I am fully confident in the skills of the paramedic interns – as they progress through the ranks, skills will be further fine-honed. I hope that other prehospital workers, whether career crews in metro or volunteer crews in rural, will be able to undertake the same exposure of sim training.

I could not help but reflect that I wish that doctors had access to the same level of immersive sim – in fact, one could argue that even established senior doctors would benefit from participating in such well-organised, immersive and stressful simulations – rather than the usual token ‘stop-start’ sim. This applies whether preparing for prehospital work or for ongoing training in hospital-based work.

Recommendations for the future?

People may not be aware, but the number of graduate paramedics churning out of university each year vastly exceeds the number of available spaces. Unemployment is a real possibility for these graduates. Even the interns who do get a spot are only secure for a year – they are not guaranteed a longterm position and many seek work interstate, overseas or in other industries (mining, oil rigs etc). Meanwhile rural areas are mostly dependent on (unpaid) volunteers, trained to a Cert IV level but lacking skills such as cannulation etc. Not an easy balance between affordability, case load and number of graduates to positions.

I don;t have an answer for this!

But if we are serious about clinical training, I think we need to get away from tokenistic, task-trainer focussed sim or ‘tick box’ annual ACLS updates, moving instead towards highly immersive sim delivered in real time, using realistic scenarios backed up by actors, and use usual equipment. An ideal training facility would be co-located with emergency services, allow cross-training with other agencies (paramedics, medics, retrieval, fire service, SES etc). Ability to deliver sim to outlying sites would be useful.

But ultimately, Michael Borrowdale and colleagues prove that one can run highly effective, fully immersive simulation on a shoestring budget, with fully realistic sound, smell, touch and the cognitive stressors of scene management including dealing with highly distressed relatives, environmental concerns (rain, cold, sun) and from scene arrival to patient delivery.

 

 

 

Review – Auckland HEMS app

My friends over at Auckland HEMS have just released an app for both iOS and Android (see link at “test pilots wanted - HEMS app goes live“). I was lucky enough to score a pre-release download and play with it over the past week. It’s now been released live and available to all for feedback.

I’ve been a bit of a fan of the Auckland HEMS site – along with a few other retrieval services, they’ve made a commitment to having a web-presence (good for promotion, recruitment and also promoting information sharing via feedback). Their sim resource section is one I am watching closely, as there is great scope to share sim scenarios using the in-built function of the online community functionality of the iSimulate package

Other services, notably the collective UK HEMS, Sydney HEMS, RFDS have lead the way in sharing some of their resources in open-access format, to help others to learn and develop own procedures, as below :

Putting procedures and information up on the web is one thing…but the ultimate functionality for a retrievalist would be to have all of this information available even without immediate web access. Given the space constraints of a flight suit, and the ubiquity (and of course practicality) of a smartphone, it makes sense to develop retrieval apps that can be used on the primary communication device (iOS or Android phone).

Having a smartphone allows access to not just phone calls, but messaging, web access (if in range), ability to view documents, access apps etc. Smart app developers may also take advanatage of in-built functions such as torch/vibrate/sounds to enable visual, haptic & audio prompts. Inter-app integration for access to weather and map/GPS functions is achieveable. And the new iPhone reportedly has a barometer…opening the possibility of a retrieval app that helps flight planning and working out O2 requirements.

It’s probably worth reflecting on what the ideal retrieval app would allow a user to do. My opinion is that the ultimate app would allow

  • cross-platform functionality (iOS, Android) and usable on both phone and tablet screens
  • ease of use in sunlight and at night, with clear easy to navigate buttons
  • large buttons/tab/checkboxes, so that can be used even when wearing gloves
  • capability to record day-to-day activities within a service, eg: daily kit checks, viewing of approved rosters, navigation to useful contact numbers. Daily checklists should be exportable for audit purposes.
  • ability to record case details including case times (from activation through arrival/depart scene, dropoff at destination and return-to0base for audit purposes), record mode of transport, locations, patient demographics and coding of disease, with ability to easily export such data to databases such as Air Maestro or common office-based spreadsheets (Excel, Numbers), thus avoiding the duplication of data entry across multiple sources (ie case notes-apps-database). Naturally such recording should be password protected and HIPAA compliant.
  • ability to record scene photos or videos, protected as above, to communicate scene situation (useful particularly in a major incident) as well as to facilitate audit and training
  • integration with maps functionality, with ability to record GPS points and drop pins on location
  • access to marine & weather info
  • use of barometer function on newer smartphones for use in-flight
  • access to service-based standard operating procedures (SOPs), preferably with documents in an interactive iBook-type format to optimise viewability, rather than the difficulties of navigating PDFs on a small smartphone screen
  • access to service-approved short videos demonstrating procedures for training
  • access to relevant FOAMed links inc available podcasts/vodcasts (on the outward leg, especially via fixed wing in rural Australia, it would be hard to go wrong with the audio & video content from intensivecarenetwork.com, smacc.net.au, emcrit.org, prehopsitalmed.com etc)
  • ability to log any issues eg: equipment failure or hot debrief for the team
  • ability to record all data and export as appropriate to both service audit and governance needs, as well as record cases/procedures for clinicians requiring for logbook purposes
  • app available for moderate fee, and sharing of content between services where appropriate ie : where benefits of open-access information offer advantages (the obvious example being developing standardisation of SOPs, equipment between a retrieval service and the rural hospitals it services eg: infusion regimens etc)

So far no such app exists…but there have been some rapid developments in this area in recent times. The Auckland HEMS app is interesting, in that the authors (Robert Gooch, Chris Denny under IT tutelage of Scott Orman) have used the iBuildapp web-based service to create the content, thus saving a huge investment of $$$ on an app developer. As they say “if you can create a powerpoint presentation, you can create an app”. What I like is the commitment to evolve the app and update in real time.

The app starts with a simple splashscreen, then once loaded moves to a very easy to navigate interface, reminiscent of the UKHEMS SOP database web-interface.

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Auckland HEMS app is loading…

The initial screen has large, friendly coloured buttons that are easy to select even when wearing gloves, allowing access to each of :

  • emergency checklists
  • normal operations checklists
  • shift duties
  • major incident prompts (METHANE, NATO phonetic alphabet etc)
  • resources (including web links to FOAMed)
  • calendar
  • SOPs (standard operating procedures)
  • comms
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Easy navigation to selected content

Drilling down, the content is easily displayed and large – this is a plus, as small text is both hard to read and hard to select (especially in gloves). However I was disappointed to see that checklists did not actually allow ‘checking’. This is a shame – for a daily kit check, ability to select actions completed and then archive the actions (eg: CSV export via email) would be useful.

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Ventilated patient – accidental disconnect checklist

For a crisis checklist, the ability to check items or even build in audio-haptic-visual alerts using smartphone alarm-vibrate-torch functions can be very useful in a crisis, especially when time critical. The obvious example is that of RSI – and for a masterclass in how a checklist can be made part of workflow, see the excellent iRSI app, reviewed elsewhere.

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The ‘hot debrief’ function accessed from the bottom navigation file was useful – easy to access wherever you are in the app, this allows quick notation of mission details such as nature of mission, team members, timings and also commentary on any issues with kit, at the hospital or in transport. Again, ability to capture this data and export it to a spreadsheet for audit or training purposes would be invaluable.

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I was pleased to see the inclusion of some FOAMed material, including Scott’s cric-con concept for emergency surgical airway. I couldn’t find mention of the Vortex approach, but as time goes on I think this and other resources will be incorporated both into the app and into common practice. Links to relevant sites are included…

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Integration of marine and weather bulletins was a nice touch…

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…along with calendar and contact info for operational purposes

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Ultimately it is hard to demonstrate all functions with screenshots. My advice – get in quick, download the app and give your feedback. It is available from http://aucklandhems.com/2014/09/21/test-pilots-wanted-auckland-hems-app-goes-live/

I am fully confident of rapid improvements with subsequent iterations. To my mind, the scope for making an open-access app with broad-brush functionality according to the list above is achievable. The question, of course, is how much content should remain in-house (mindful of the considerable investment in time, money and intellectual copyright of content) and how much can usefully be shared.

Whether making one’s SOPs and resources open access is worth it remains unanswered. For blokes like me, trying to do best for rural patients, there are clear advantages in keeping up-to-date with current practice and especially in aiming to use the same kit and infusion regimens as the retrieval service. I appreciate however that there may be concerns in making one’s protocols available for all to share.

For the present, I am grateful for the availability of online resources such as those from Emergency Medical Retrieval Scotland, SydneyHEMS and UKHEMS

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EMRS includes a ‘meet the team’ with bios of registrars and regular staff as well s access to clinical, equipment & organisational SOPs
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Sydney HEMS website is a rich repository of procedures, sim, clinical governance, review articles, videos and FOAMed links. These guys know how to make connectivity work for them!
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UKHEMS.co.uk site offers access to SOPs, Emergency Drills and downloadable crash cards (useful in ED, ICU too)

 

 

FOAMed – a Primer for Physicians

So this week I am giving a talk to a bunch of physicians at the Internal Medicine Society of Australia & New Zealand. In true FOAMed spirit, I’m making the talk available online prior to the session (as a nod to the concept of a ‘flipped classroom’) and putting up some useful links for those who decide to explore the FOAMed world a little closer.

Big thanks to Chris Nickson for the inspiration of using Star Wars stormtroopers as a metaphor for ‘taking the world by storm’…and of course to Joe Lex for both the oft-quoted phrase “if you want to know how we practiced medicine…” as well as introducing me to the terms of pedagogy, andragogy and heutagogy.

They say that an audience will only take away THREE things from any talk. The concepts I wanted to get across were :

  • half of what we learn is wrong; FOAMed is a tool to help narrow the knowledge translation gap and keep up-to-date
  • we live in an age of information overload, likened to ‘drinking from a firehose’. Social Media tools allow filters to help drill down to the information that is relevant to your needs
  • using the tools of FOAMed and social media, we can make a commitment to lifelong learning much easier. Moreover, with such accelerated learning comes the potential for metacognition – specifically to understand HOW we learn and make decisions as clinicians. This is important as our diagnostic acumen is subject to bias and may fool us, regardless of our knowledge base.

So, here’s the talk as a narrated slideshow hosted on vimeo :

http://vimeo.com/105729442

The slides can be downloaded by clicking HERE

The introductory video (FOAMed – taking the world by storm) is below :

http://vimeo.com/105093904

What is FOAMed and why should I use it?

I like to think of FOAMed as a global sharing of information. We are all involved in clinical educators  we get up at journal clubs, grand rounds or conferences and deliver talks. But the reach of those talks is confined to those who attend…unless you take the bold step of creating online content – basically, putting up your ideas, talks, slides etc online in a form where ANYONE can access them. This might be in the form of a blog (reading commentary or analysis), a podcast (eg : listening to a discussion on a contentious topic) or a video (watching how to perform a procedure).

Good FOAMed sites collate information, curate it and disseminate it – with information made available for free (although attribution is expected).

It is hard to go beyond the summary of FOAMed origins and uses from the lifeinthefastlane.com crew

Chris Nickson talks about “Why FOAMed – facts fallacies and foibles”

Andy Neill’s pecha kucha talk is here “Effective Use of Social Media to Keep Up-to-Date

Richard Body talks on why FOAMed is essential for emergency clinicians (from #CEMExeter14 conference)

https://www.youtube.com/watch?v=WyAfkbcISDQ

David Marcus has a great set of slides here : FOAMed primer and other talks at EM IM blog

 

Some great examples of collated & curated FOAMed sites include :

gmep.org

lifeinthefastlane.com

emcrit.org

prehospitalmed.com

resus.me

scancrit.org

stemlynsblog.org

dontforgetthebubbles.com

ruraldoctors.net

BroomeDocs.com & KIDocs.org

and so on…

There are MANY MANY more – mostly emergency and critical care, but increasingly other specialties are coming on line – urologists (eg uroJC twitter journal club), general practitioners (FOAM4GP.com) etc.

The best medical conference – ever!

For a good example of how an excellent medical conference should be run, it’s hard to top smacc. Cadogan commented that whilst FOAMed was conceived in a Dublin bar in 2012, FOAMed was conceived at smacc2013 in Sydney. A year later smaccGOLD built on that success, with many different ‘tribes’ involved in critical care and emergency medicine coming together to share stories and learn from each other. Next year we are off to Chicago for smaccUS…check it out & register at smacc.net.au

There is also an iTunes feed for downloadable podcasts - https://itunes.apple.com/au/podcast/smacc/id648203376?mt=2

Of course the collated videos of smacc talks are available on Vimeo via vimeo.com/smacc

Here’s some feedback on smacc from assorted bloggers

“Lessons learned from smacc – bye bye dogma, – hello best practice”

“You’ve gotta have love”

“Social media & critical care”

“smaccGOLD – it hurts”

“Where do you start with something like smacc?”

 

How to use tools of Social Media to help filter and signpost FOAMed

Social media (SoMe) is useful to disseminate and discuss clinical topics. By now you will be aware that there is a vast repository of useful educational resources “out there” on the net – blogs, podcast, videos etc. But how to filter them?

The easiest thing to do is just to read blogs on topics you are interested in or authored by people who you feel have something to offer. One of the nice things about the FOAMed community is that people share good content willingly and will signpost links to interesting content. Good sites collate quality FOAMed material, curate it and disseminate it. They may have a ‘search’ function on the site…failing that, there is always GoogleFOAM.com to search for good stuff.

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RSS feeds are ideal – if you see this symbol on a website, click it to ensure that new content is delivered to your email, RSS aggregator or iTunes download queue. This makes it much easier to target FOAMed content that you are interested in – rather than have to trawl through blogs looking for updates, new content is streamed to you. By only clicking on feeds that are of interest to you, one can filter the FOAMed content, to a degree.

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I am a big fan of using RSS aggregators to collate input from twitter, blogs, google+ etc into an app – I use one called Feedly, which displays my content in a magazine style format

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Twitter. Really?

I was a sceptic initially, but now find that twitter is a great way to keep in touch, ask questions of colleagues, discuss concepts and also signpost relevant journal articles or FOAMed resources.

Twitter is essentially a microblogging platform – once you’ve registered, set up a user ID and a brief description of self/interests, then you are free to either follow like-minded people or start opening up your own conversations. Tweets are limited to 140 characters, so it is very difficult to have a nuanced conversation, Hashtags are common for conferences eg #IMSANZ14 and can also be used to collate information eg : #FOAMed #resus would delineate tweets with these items as search terms.

The Twitter app is free for download on mobile and PC/OS platforms. Afficiandos may decide to use an app like TweetDeck or TweetBot to allow collation of different content and even schedule tweets (I was involved in an on stage debate at #smaccGOLD on the use of checklists in airway management, and managed to wow the audience by talking and having simultaneous twitter feed broadcast to the audience both in the hall and worldwide, to broaden the reach of my delivery)

Learn how to get started with Twitter from these excellent videos from Rob Rogers and co at theteachingcourse.com - expect more from them

and

 

Life Long Learning & Metacognition

More than anything else, FOAMed makes one think about HOW we learn in medicine. Osler nailed this “medicine is a science of uncertainty and an art of probability”. We like to think that we are astute diagnosticians – but we are constrained by our inherent cognitive bias.

Understanding HOW we make decisions is particularly important in critical care medicine – making decisions based on limited information, under pressure.

I recommend :

Simon Carley talks on ‘Guess or Gestalt’ regarding decision-making in EM (from #CEMExeter14 conference)

https://www.youtube.com/watch?v=VQBbXIBBQp4

Chris Nickson on why ‘All Doctors are Jackasses’ (from #smacc2013 conference)

https://vimeo.com/75271893

Joe Lex on why FOAMed is essential to medical education (includes discussion of pedagogy, andragogy and heutagogy)

as well as Lex on ‘from Hippcrates to Osler to FOAM’

…and Chris Edwards’ excellent talk on ‘May the FOAMed Be With You’

There are a few more videos on decision-making & education here :

Damian Roland on ‘Evaluating Education’

Victoria Brazil on ‘Evidence based education’

Cliff Reid on ‘Resuscitation Dogmalysis’

Simon Carley (again) on ‘Do Risk Factors Factor?’

…and yet again, Carley delivers ‘Wrestling with Risk’

…and again on ‘educational Leadership & Subversion’

 

Where to from here?

If you are inspired to create some GOOD medical education content and host as FOAMed, we’d love to hear from you

This post on blogging and blog basics is useful