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A quick catch up with Dr David Hogg, one of the Directors of BASICS Scotland, tentative user of FOAMEd (send him your recommendations for FOAMed sites via twitter @DavidRHogg – I’ll kick off with lifeinthefastlane.com dontforgetthebubbles.com, foam4GP.com and of course resus.me)
You can read more bio on David via last months podcast (Podcast No #24 – Rural Connectivity & Scottish Prehospital Care)
As well as being a top chap, rural GP and significant involvement in rural prehospital care, Dav id is part of the Arran Resilience project to help facilitate interagency cooperation on the Isle of Arran – with a budget of hot tea and choccie biscuits!
Have a listen to the podcast or click HERE to download mp3
…then check out the ArranResilience website & watch the ArranResilience video below
In this podcast, I am joined by another Island doc – Dr David Hogg is based on the Isle of Arran, Scotland. He edits the very slick ruralgp.com website and is one of the Directors of BASICS Scotland.
David is based on the Isle of Arran, Scotland – with 5000 off locals and a huge tourist influx, his work encompasses not just primary care but also prehospital care.
Unlike Australia, where there is NO formalised involvement of rural doctors in PHEC nationally(*), Scotland (and indeed the rest of UK) recognise the value of having additional expertise on the scene, even before retrieval services arrive (Scottish EMRS are a slick unit).
* South Australia has the RERN system (rural emergency responder network) with rural doctors who can value add to prehospital responses, mostly by volunteer ambulance crews, before expert retrieval services arrive on scene.
In this podcast we discuss
– rural practice, similarities of Scotland and Australia
– the work of BASICS and the Sandpiper trust
– use of smartphones to enable GPS-localisation of BASICS assets
– need for connectivity, both at local level (mobile/net access) and for FOAMed
or right-click HERE TO DOWNLOAD
Check out more details via
EMRS (Emergency Medical Retrieval Scotland)
This case is inspired by listening to the RAGE podcast #2 – if you haven’t already listened, do so ASAP (download from iTunes) or click here.
RAGE = Resuscitationists Awesome Guide to Everything and is a nice 60 min or so podcast full of clinical pearls. Rural doctors may be wondering what relevance this has for them? Experienced rural docs know that ‘critical illness does not respect geography’ and it pays to be aware of useful tips and pearls.
So here’s today’s case, one which I’m also working though with the PRCC students attached to Kangaroo Island in 2014 in sim and theory. Then listen to RAGE podcast #2
The setting, as always, is a small rural ED in Australia. Transfer times are 60 mins by rotary wing, 2 hours by fixed wing (airstrip is remote from clinic and requires ambulance transfer by volunteer crews).
Facilities include small resus bay with point-of-care INR, proBNP and Chem 4/Chem 8 iStat, CXR (but you have to take the radiograph yourself), and the usual resus drugs, 2 lead ECG, telemetry, adrenaline as sole inotrope etc. There’s an old Oxylog 2000 plus transport ventilator. There is also an old SonoSite Titan ultrasound unit with linear and curvilinear transducers. Nearest CT scanner is 300 km away.
A 54 yo obese patient presents complaining of acute shortness of breath, approx 2 hours duration. She complains of pain on inspiration and feels unwell. She denies prodromal symptoms such as fever, chills, sputum. She is a smoker, on HRT and tells you that she flew in from London 5 days ago.
Q1 : What are possible causes of her acute dyspnoea? What key features on history and examination will help you decide?
Q2 : What are appropriate & available tests that may guide your management?
Q3 : Her ECG is as below. What does it show and what are your options?
Q4 : 30 mins later her SBP drops to 88/50 and remains so despite 2 x 250ml fluid load. HR 123 a/fib. Spo2 94% 15l via NRB. Apyrexic.
Results (iStat) show : Hb 145, pO2 63 mmHg, pCO2 33 mmHg, Aa gradient 24 mmHg, lactate 2.9, glu 6.2
Sadly the retrieval service are tied up with other urgent tasks in the State. They reckon they can get a physician-paramedic crew to you in 90 minutes via fixed wing at the earliest. Meanwhile she remains hypoxic, hypotensive and tachycardic. She looks grey and unwell and about to die…
Would you consider thrombolysis?
If so, what criteria or other tests would guide you?
Over to you…
PLEASE COMMENT BELOW
I have just got back from Melbourne, where I attended the new EMERGENCY TRAUMA MANAGEMENT course. I was deadset keen to attend this, as I intuitively feel that organisers Dr Amit Maini (EDTCC.com) & Dr Andy Buck (EDexam.com.au) are seeking to bring the same level of FOAMed goodness to Emergency medicine as I am via the RURAL MEDICINE MASTERCLASS. Over and above that, the new ETM Course takes attendees to places that aren;t covered on the usual ‘merit badge’ courses. I am a Course Director for EMST-ATLS and have become increasingly frustrated that the College of Surgeons content does not meet the needs of modern trauma teams.
A full report will be forthcoming shortly via Dr Jeram Hyde (@CriticalHabits), but for me highlights included :
- a credible and experienced Faculty who facilitated short lectures and hands on skill sessions
- use of high rep, low fidelity simulation involving team work
- coverage of relevant FOAMed topics inc NODESAT apnoeic diffusion oxygenation, Vortex cognitive aid, airway planning & checklists, controversies around C spine management, ED thoracotomy. Heck, we even touched on REBOA…
- excellent location and catering, plus a chance to have drinks on the first night.
Bottomline? This is an excellent course for registrars in EM, ICU & anaesthesia who have to manage trauma. It will also be highly relevant to experienced rural doctors and emergency physicians looking for a refresher. The use of early involvement in sim and graded layering of escalating scenarios from simple to complex was a welcome change to the EMST-ATLS courses on which I instruct.
I was delighted to be invited to the instructors dinner and be invited to instruct on ETM in the future.
There’s lots more to tell and I am sure Jeram will cover this in due course. But for the meanwhile have a listen to a quick 25 min podcast between Andy Buck and myself on the genesis of ETM and future plans. Sadly Amit was too shy to join us – I hope to tempt the little fella to Kangaroo Island, but have learned that my idle mention of the KI tiger snake was not well received …
On to the podcast :
Just caught up with Rob Simpson, author of the excellent AMBOFOAM blog and all round nice chap. We last met at smacc2013 and Robbie was kind enough to pick me up from Tullamarine Airport after I flew into Melbourne for the forthcoming ETM course.
The trade off was war stories exchanged over a fine meal at a fancy French restaurant. Nice how FOAMed brings relative strangers together (or, as Robbie stated ‘internet dating really works’). What happens in Melbourne, stays in Melbourne…
Rob is a MICA paramedic with Ambulance Victoria and has a wealth of experience both as solo rapid responder in the Western Suburbs of Melbourne, and as tasking coordinator in comms. His podcasts on matters such as cardiac arrest, handover and prehospital care are well worth a listen…bringing insightful and thoughtful commentary from our paramedic colleagues. Much to learn from these guys who do a tough job…
We talk here about paramedic RSI, the introduction of ketamine to the service, prehospital CPAP and shared reservations about PALM (pharmacologically-assisted laryngeal mask). The latter has been coined FACE-PALM by Cliff Reid ‘For Airway Challenged Enthusiasts – Pharmacologically Assisted Laryngeal Mask’)
Just caught up with former KIDoc, Dr Jamie Doube – Jamie is special for doing his GP registrar years in part on Macquarie Island with the Australian Antarctica Division as both Station Doctor but also as a major player in the program there to eradicate rabbits from this pristine environment.
He is way to humble to mention that he got the Antarctica Medal in 2011 for this work. He is also a useful doctor – trained as both rural & remote doctor, plus GP-surgeon and GP-anaesthetist. Not sure if I can convince him to get the trifecta of GP-obstetrics…
Jamie was with me on KI when he got the call to be part of Team Alpha as part of the Australian Medical Assistance Team (AusMAT) response to the ‘super-typhoon’ that decimated the Philipines in November.
AusMAT is one of a number of agencies, both Govt and NGO, who respond to disasters. Ironically AusMAT training had occurred on Kangaroo Island the week prior, but this exercise was no comparison to the Philipines disaster response.
I spoke to Jamie last week after he got back – and he sounded buggered after some extraordinary work in Tacloban treating victims.
But since then he’s been off on another adventure, as part of the Australian Antarctica Division response to a helicopter crash on the ice with three seriously injured expeditioners. The sheer logistics of retrieving survivors from a crevasse-laden ice field, using a variety of aircraft, to the nearest AAD Base and then transfer to an airstrip is phenomenal – a five day retrieval of over 5000km. By all reports the expeditioners are doing well, a credit to the expertise of the AAD. No doubt an ATSB report will be released in due course – but to survive a crash on a remote ice field is impressive.
Have a listen to Jamie talk about his experiences
Click HERE to download
It was a pleasure to catch up with Icelander-turned Londoner Dr Helgi Johannsson regarding the ‘Wrongfooted‘ case.
Helgi is a prolific blogger – using Social Media to disseminate both useful nuggets of clinical information under the #TGDed hashtag (trauma gas education) and also occasional trash tweets on the weekend. Follow him at @TraumaGasDoc.
I was intrigued by the ‘Wrongfooted‘ case posted by Helgi – a classic case of the WHO checklist not being used properly. Several important lessons from this case, not least the need to use checklists appropriately … and the power of Social Media to disseminate important safety messages. Contrast this with the failure to disseminate safety lessons from a nearly identical case, as articulated subsequently by medical director Dr Dermot O’Riordan – the frustration being that the lessons learned from Dermot’s case weren’t made available to a wider audience.
Clearly ‘Wrongfooted‘ has penetrated deeply – over 10,000 views to date – awesome! Helgi even goes so far as to suggest that SoMe will be the preferred way of disseminating info on critical incidents in the future.
Helgi also raises the issue of online identities – the UK’s General Medical Council insists that doctors blog under their own names – which may cause difficulty if highlighting contentious issues or “whistleblowing”. Food for thought in any SoMe policy.
Listen to the podcast by clicking HERE
One thing puzzled me – despite the lessons of ‘Wrongfooted‘, Helgi reckons he’s never used a checklist for eg: RSI. Instead there is institutional resilience through ensuring that the environment is suitable – using same kit in the resus room as in theatre, and mandating that any RSI ‘on the floor’ utilises a trained ODP from theatre [note to non-UK readers – ODP is a trained operating department practitioner].
Whilst I am all in favour of minimising error through appropriate kit and staff, it strikes me that during an anaesthetic crisis or whilst performing a technically complex procedure such as RSI (where consequences of error are severe) is exactly the time a checklist SHOULD be used! Under pressure, perhaps distracted by other factors, relying on expertise may be enough – until a simple mistake (omitting to connect O2, forgetting suction, wrong dose induction agent) causes catastrophe. We’ve got 3-4 minutes to preoxygenate in RSI – a 60 s challenge response checklist should be used. Similarly in a crisis, use checklists. Moreover, using a checklist ensures a shared mental model of what is about to happen – and sets us up perfectly for dealing if an unexpected crisis occurs (CICO).
Come along and see the debate…