Being Expert Enough….

I reckon that I am lucky to be a rural doctor.  It wasn’t an area of medicine to which I was exposed as a student or trainee, and it was only good fortune that lead to my career evolving the way it has. Rural medicine offers all of the “best bits” of medicine without the tedium of being confined to one area as a “partialist”. Whilst much of the work of a rural generalist involves office-based primary care, we also have responsibility for emergency medicine via the local hospital and some of us will participate in elective and emergency procedural skills, such as anaesthesia, obstetrics and surgery.

Swiss Amry Knife

It’s no secret that my interests revolve around trauma, prehospital care and anaesthesia, particularly in the rural context. But I am also interested in palliative care, paediatrics, chronic pain, depression, internal medicine and chronic disease management. As my colleague Casey Parker at BroomeDocs put it, the generalist rural doctor is the “swiss army knife” compared to the partialists “scalpel”. Each has their uses. In the bush, you need the multitool!

And therein is the dilemma for the generalist – how to maintain skills and clinical knowledge across such a  broad array of clinical arenas? Particularly in fast-moving areas such as emergency medicine and critical care, where evidence-base may be rapidly evolving?

The answer, of course, is to use FOAMed – Free Open Access Medical Education – the rapid dissemination of ideas and learning resources, via the tools of Web2.0, to allow distributed, non-hierarchical, asynchronous learning “anywhere – anytime – anyone”.  To my mind, FOAMed is particularly useful for those seeking to develop mastery, rather than teach the basics (for that, it remains textbooks and standard alphabet courses).  The use of Web2.0 (blogs, podcasts, social media such as twitter, Google+, even Facebook) affords rapid sharing of ideas amongst peers – and extends the reach from local colleagues to allow exchange with a global community of like-minded peers and experts….all of whom willing to share ideas and content for free.

This is not a new concept in medicine – as Joe Lex points out, it dates back to Hippocrates “and to teach them this art – if they desire to learn it – without fee and covenant” – this is from the Hippocratic Oath and sharing of knowledge is part of being a clinician.  But for some, the technology and terminology in social media and FOAMed can be a barrier.

This is a shame. FOAMed has been a revelation for my practice.  A few years ago I was “comportable” in my practice. I met the required needs of credentialling (attendance at an entry-level emergency course every triennium), easily accrued my CPD points with my College and felt pretty happy in my practice. But I was not challenged. My interest in trauma and airway management lead to some online resources, at about the same time that Chris Nickson and Mike Cadogan were launching the “lifeinthefastlane” website for emergency physicians and the concept of FOAMed.

Since then I’ve been swept up in a rich learning environment, that has forced me to be challenged, to engage in discussion of concepts in my areas of interest which I would never have been able to do before. It’s made me submit papers for publication, to abandon traditionally safe roles (such as directing on EMST) and join the faculty of more modern courses, to speak at conferences, lead simulation training with paramedic and nursing colleagues and to run airway workshops. I feel connected to a rich information flow, of which I was previously oblivious. And trather than drown in a sea of information overload, apropriate use of filters allows me to receive and engage only in content which interests me.

It’s well worth exploring.

And so leads to the topic of this post – “Being Expert Enough”. I am helping out at the inaugural “Critically Ill Airway” workshop at The Alfred in May – the brainchild of Chris Nickson and anaesthetic/intensive care/emergency medicine colleagues. It should be a good course – Scott Weingart is an external consultant, there will be the likes of Andy Buck from ETMcourse and many others as Faculty.

“This is the challenge and discipline of rural medicine – our specialty is providing care across a broad range without immediate backup”

I will be speaking to a topic dear to my heart – that of the “occasional intubator” – this is pretty much is the default setting for much of the work we do as rural doctors, and requires us to have sufficient expertise to be safe and competent without backup across a large range of competencies.

https://vimeo.com/122820309

To that end, Chris is ‘flipping the classroom’ and including some content prior to the airway course itself. Above is a “teaser” of my lecture and skills station for the CIA course. It should be fun…

Even if airway management in the critically unwell is not your “thing”, do consider exploring FOAMed – I reckon it’s the best paradigm for post-Fellowship learning.  I am glad that both RAGP and ACRRM are allowing such online learning to be counted for CPD, not so much for the need for points – but because with increasing interaction amongst clinicians comes acceleration in learning and knowledge translation…which flows to us being better clinicians and patient benefit.

For us rural generalists, separated by distance and needing to maintain knowledge across a broad array of domains, FOAMed means that deficits in knowledge are no longer an excuse as the weak link in patient care.

LINK – REGISTER HERE for CRITICALLY ILL AIRWAY COURSE, May 7-8 The Alfred, Melbourne

 

 

 

 

 

 

Lessons for management of acute agitation in rural EDs

The South Australian Coroner has just released a report into the sad death of Mr Simos, who died whilst awaiting transfer from a rural ED back to a tertiary centre where he was under a current detention order.

The Coroners report can be accessed here. As with all Coroner’s reports, it makes for salutary reading and in due course I shall add it to the other list of Coroners cases of relevance for rural doctors, over at ruraldoctors.net.

Case summary

The full report can be read online. In essence though, this as a patient whose medical history involved :

  • florid psychosis, being treated as a “detained” patient (level 3 treatment order)
  • obesity
  • COPD
  • obstructive sleep apnoea
  • poorly controlled diabetes
  • hypercholesterolaemia

The patient absconded from an open ward, where he was under psychiatric care in the city. He was subsequently apprehended by police and taken to a rural hospital under existing treatment orders, with a view to being returned to the city psychiatric unit. During the course of this admission he required sedation with olanzapine and lorazepam, and an RFDS transfer was requested. Further episodes of agitation resulted in the administration of midazolam, then respiratory depression requiring assisted ventilation and reversal with flumazenil. Anaesthetic consultation was sought in regard to the pros and cons of intubation; this was deferred as patient was maintaining own airway.  Some 12 hours after admission, transfer had still not eventuated. On advice of liaison psychiatrist, haloperidol and promethazine were administered for further agitation.  A short while afterwards the patient suffered a cardiorespiratory arrest.  The cause of death was undetermined – respiratory depression, agitated delerium and QTc abnormalities were considered and dismissed.

Expert analysis and Coroner’s recommendations

The Coroner made comment of the need for timely transfer of such detained patients from rural facilities to tertiary centres, mindful of the limitations of managing such patients in rural SA.  Existing guidelines were acknowledged.

Expert opinion from the CountryHealthSA lead for emergency medicine was not critical of any particular management decisions. There was opinion given that management of such cases should involve

  • a structured response (rural doctors, hospital, retrieval service, psychiatric expertise
  • a “team leader” responsible for management decisions
  • a “flow chart” to guide delivery of care, including assessment, drug use, physical restraint, transport type and final destination

No criticism was made regarding decision to intubate/not intubate, nor use of medications.

Why does this matter?

Such cases are not uncommon in rural Australia. This sad case highlights several teaching points that I would encourage ALL rural doctors to consider, namely :

  • familiarity with initial “go to” drugs for managing acute agitation
  • assessment of risk of sedation vs exacerbating medical issues (this patient was obese, with OSA and COPD, probable underlying IHD)
  • appropriate monitoring
  • options for transfer or retrieval
  • demands of such acutely unwell patients on clinical staff in rural hospitals and ability to deliver care over a potentially prolonged period of time

The Coroner’s report doesn’t really cover these in much detail – of course in this case appropriate decisions were made and cause of death remains unclear. However I believe that the Coroner’s report could have done more to illustrate appropriate standards of care and to inform other rural clinicians. Tat it has not done so has prompted this post.

Typically such patients are unfasted. They require large doses of drugs for initial control of agitation and meticulous monitoring. My approach to these patients has been guided by knowledge gleaned from the FOAMed world, in particular an excellent discussion from the BroomeDocs blog a few years ago, as well as the ongoing work from Dr Minh le Cong and others on psych sedation in rural Australia.

A safe and structured approach to such patients might involve :

  • early telepsych consultation and teleconference with retrieval service re: transport urgency and available options
  • an agreed plan for both immediate and ongoing restraint
  • if using chemical restraint, to carefully consider risks of these agents in regard to unfasted airway, body habitus, cardiorespiratory effects and underlying concomitant medical conditions (anaesthetic risk)

risks of harm to self/others if agitation not adequately controlled

I like to think of such patients as medical emergencies (akin to a combative or resp depressed head injured patient), requiring full monitoring, including

  • 1:1 nursing by an acute care nurse
  • pulse, BP, ECG, RR, SpO2
  • waveform capnography
  • use of the Richmond-Agitation Sedation Score (RASS)
  • immediate access to O2, suction, airway equipment and difficult airway trolley
  • immediate access to skilled anaesthetic assistance
  • at least two IVs
  • consideration of safety for transport including maintenance of own airway vs ETT, and use of safety harness if not intubated

In particular, I would encourage rural doctors to be aware of the PSYCH RISK ASSESSMENT MATRIX (Casey Parker) and the use of KETAMINE for SEDATION and TRANSFER (Minh le Cong et al)

The Consensus Statement can be downloaded from the RFDS website here and I believe should be mandatory across rural SA hospitals.

If you are a rural doctor or nurse or paramedic with responsibility for these patients, please read the Consensus Statement and ensure follow the bulletpoints above. Not all rural doctors use RASS or ETCO2 monitoring, and often such patients are nursed in a dark environment without immediate access to airway kit, O2, suction.

THINK OF MANAGEMENT OF SUCH PATIENTS AS SIMILAR TO MANAGEMENT OF PROCEDURAL SEDATION

That it was not explicity referenced in the Coroner’s report is a missed opportunity – hence this post.

Consensus Statement – The Acutely Agitated Patient in a remote location at http://healthprofessionals.flyingdoctor.org.au/clinical-resources/?q=cat103%7Cref%7Cformat

 

 

 

 

smaccUS

A reminder that smaccUS is rapidly approaching – from the orginal smacc2013 held in Sydney, then smaccGOLD on the Gold Coast, in 2015 the world’s most exciting and innocative critical care conference will be held in Chicago.

Screen Shot 2015-03-11 at 6.37.11 pm

Wondering what all the fuss is about?  Have a read of the reviews from previous smacc conferences here

I am putting the final touches to my talk “All alone on Kangaroo Island” – the program looks fantastic….so hurry up and get your registration in, places are limited!

smacc.net.au

Critically Ill Airway

I am just putting final touches to the “Being Expert Enough” session for the forthcoming Critical Ill Airway Course to be held at The Alfred Hospital in Melbourne, May 7-8th 2015.

The course is being convened by that powerhouse of energy, Dr Chris Nickson of LITFLsmacc & RAGE podcast fame. Co-conspirators include external collaborators like Scott Weingart of EMCrit.org, Rick Levitan of airwaycam.com as well as local talent such as Andy Buck of ETMcourse, trauma and prehospital anaesthetist Dr Brent May and the combined brilliance of The Alfred ICU and Anaesthetic faculty.

This promises to be a well-run and fun course, with small group instruction and heaps of scenario-based training and hands on workshops. There are still some places left, so have a look over at the CIA website for more details.

CIA

Importantly this course is open to ANYONE who manages the airway of critically ill patients (doctors and paramedics). Of course I am interested – as a rural clinician I am no stranger to the concept that “critical illness doesn’t respect geography” and want to make sure we are all on the path to expertise, regardless of location. So expect a distillation of FOAMed goodness for occasional intubators whether in ED, ICU, rural or prehospital locations.

Register at the CIA website – first in, best dressed!

CIA Course will Grill Your Corn
Critically Ill Airway Course will Grill Your Corn

And remember – if all else fails in airway management, remember to fall back to a two-handed technique, squeezing the bag gently…

TwoHandTechnique

See you there!

 

Updated RERN Action Cards

I’ve been playing around with cognitive aids such as checklists and action cards for a couple of years (some are available via the RESOURCES section of this site or RURALDOCTORS.NET. Most of these were designed for handing off to nursing staff in the rural ED, partly to mitigate against the phenomenon of people disappearing off to the ‘big book of infusions’ to look up compatibilities during infrequent care of critical patients. I certainly have no problem with cognitive offloading and use of such aids in a crisis – pilots do it, and I think use of action cards is an under-utilised phenomenon in the emergency medicine.

These checklists and action cards were designed to be used both in printed format or electronically as PDFs (ipads are great for this). However working in the prehospital environment soon teaches that reliance on technology (particularly iPad or iPhone) is not without problems – mobile coverage is dismal in country (and can be at altitude)…and power failures, inadvertent water splashes or hard knocks can trash iShiny devices too easily. Recognising this, MedSTAR issue their staff with a “Vuey Tuey” – basically a 20 page clear pocket folder that fits easily in a flight suit pocket. It contains useful phone numbers, flight times to rural hospitals and other useful information.

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This is the Vuey Tuey issued to MedSTAR doctors to carry in flight suit – it contains useful information for “on the job” and doesnt require batteries
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Extra pages can be added and content modified to preference. So good, I decided to make my own for RERN…

I’ve snaffled a few of these “Vuey Tueys” from eBay (they’re also available from Army Surplus stores online). The 40 page one is not overly thick (about 1cm) and accommodates 80 sheets of paper. The aim was to create a series of action cards useful for rural doctors, particularly members of the South Australian Rural Emergency Responder Network (doctors who respond to prehospital incidents to back up local volunteer crews where no ICP available).

So here’s a series of RERN ACTION CARDS – designed with members of the South Australian rural doctor RERN team in mind  – but the content may be useful for any rural doctor who is looking for a quick pocket reference that can be easily adapted to local use.

The original was created in Pages on OSX, then converted to indivdiual PDFs and merged into one document. I am more than happy to share original files if anyone wants them to modify, or can download the entire PDF here.

One quirk of the “Vuey Tuey” is the page size – 95 x 135mm! So I generally print out two sheets onto A4 and trim up with a paper cutter.

Contents include:

  • principles of prehospital care
  • airway
  • breathing
  • circulation
  • crisis algorithms
  • drug doses

I am a big fan of making content available for all to share – and am happy to add extra sections or modify content if needed.

I should also emphasise that this content is NOT from MedSTAR, but a collation of various tips and FOAMed that I’ve found useful. Interestingly some retrieval services make their content available to share – I remain impressed with the efforts of SydneyHEMS, AucklandHEMS and UK-HEMS in this regard. Indeed, Karel Habig and colleagues gave some useful lectures at the 2014 Rural Medicine Australia conference – it’s refreshing to see such content from prehospital care creeping into rural arenas – and the PROTECTAustralia paradigm is very worthwhile.

Certainly with approx 2/3rds of trauma coming from rural areas, it makes sense to engage with rural clinicians and strive to drive “quality care, out there”. I am no expert, but seems to me that much of critical care is about doing the basics, well – and that whilst some rural doctors embrace the challenge of managing these patients, others are understandably nervous or feel under-prepared. I think this is where FOAMed, delivering asynchronous content, robust clinical governance and standardisation of protocols such as infusions etc can make a difference.

Anyhow, here are the cards. It’s work in progress. Enjoy!

RERN ACTION CARDS – click to download (NB RERN = Rural Emergency Responder Network)

 

They’re not accidents, are they?

It was back in 2001 that I read a piece in the British Medical Journal entitled “BMJ bans accidents” – hardly a new idea (it dates back to at least 1993) – yet we still hear reference to “road traffic accidents” (RTAs) or “motor vehicle accidents” (MVAs).

Words are important; I have been convinced of the BMJ argument for the past decade. I am not alone – others say “if you care, use the term crash“. The premise is simple – use of the term “accident” implies a sense that bad outcomes are due to fate and luck, rather than factors within our control. Indeed use of the term “accident” almost absolves anyone of culpability.

I am currently working in the prehospital environment. Like colleagues, I do not judge my patients – they are invariably critically unwell and my job is simple – to ensure they receive the best possible care with the minimum of delay, working within a well-governed organisation of trained clinical professionals.

However Christmas and New Year are fast approaching, and there is a sense of inevitability; namely that this holiday season will again be marred by tragedy on our roads, often due to drink- or drug-driving.

What would be the best Christmas gift for colleagues and myself this year? That we did not have to respond to roadside primaries, nor for community members to experience personal tragedy.

With this in mind, I’d recommend the following video – a montage of road safety videos from the TAC in Victoria, Australia (ironically, this stands for Transport Accident Commission)

It is sobering stuff. I remember hearing trauma surgeon Karim Brohi talk at the Australian Trauma Society conference in Melbourne, 2006 – he commented that “it’s better to be the fence at the top of the cliff, ratehr than the ambulance at the bottom”. In trauma medicine we tend to get very excited about the sexy things – prehospital REBOA, clamshell thoracotomy, helicopters etc and debate is always heated on chestnuts such as subclavian vs IO access, fluid resuscitation, skill mix of retrieval teams etc.

There is no doubt that the downstream consequences of trauma are horrific.

Instead I wonder if the greatest gains in trauma medicine remain with the unsexy – with primary prevention (um, that’s the GPs) and with rehabilitation (thats rehab physicians, physiotherapists and other allied health). we don’t often consider the contributions from primary care and rehabilitation in trauma care – perhaps we should.

Prevention is indeed better than cure. Please, this Christmas – don’t drink or drug-drive.