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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
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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…
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It’s been a pleasure having former KI Doc, Dr James Doube back on Kangaroo Island for a short locum stint, but also a chance to catch up and talk about various schemes.
Jamie is a rare breed – a former career as paramedic and wildlife conservationist, he’s also a GP-surgeon, recent JCCA-graduate GP-anaesthetist and has carved out a niche career in truly remote & austere medicine with the Australian Antarctic Division & other organisations.
Dr Doube is also a wonderful experimental test subject.
He is WAY to modest to mention his award of the 2012 Australian Antarctica Medal for his services as both expedition medical officer but also conservationist – read more about his exploits here. He’s been involved in eradicating rabbits from Macquarie Island & with TEAM RAT on South Georgia.
In this brief podcast we discuss his work with AAD and particularly the potential for FOAMed to disseminate information to remote clinicians.
Jamie highlights the pitfalls of difficult internet access and the need to keep FOAMed resources small and accessible by low bandwidth. The idea of a ‘just a minute‘ series of procedural videos is warmly embraced.
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Critical illness is part of the remit of rural doctors, albeit encountered relatively infrequently – which of course makes it all the more challenging! Moreover rural doctors have to deal with such cases with limited staff, no backup and paucity of lab tests and definitive care.
Perhaps one of the most commonly encountered true emergencies in the bush is dealing with major haemorrhage. Our patients work on farms, in heavy industry, or are involved in road crashes.
Let’s consider a hypothetical case and see how FOAMed could help.
It’s Tuesday morning and you are busy working through a routine Primary Care Clinic in anticipation of the afternoon off. The local Rotary are hosting a BBQ at the nearby football oval and you’ve been invited as a guest speaker on the pros & cons of prostate cancer testing.
Clinic is rudely interrupted by a loud “BANG” from the direction of the footy pitch – looking out the window you see a pyre of smoke and decide to abandon Clinic to investigate.
On arrival you see the local bank manager, a proud Rotarian, lying on his back. Community members tell you that the gas BBQ exploded, igniting other gas cylinders. He was thrown some 8m backwards through a window, impacting a goalpost in his rotund abdomen & is now flailing around on the footy pitch with an obvious source of bleeding…
A – Crying in pain, hoarse voice, obvious facial burns
B – RR 26 bilateral BS, PN symmetrical, trachea central
C – obvious traumatic amputation. P 120 BP 80. Cap refill 3 secs. Tender in LUQ.
D – localises pain, groaning only, eyes open spontaneously
E – clothing tattered. Numerous glass shards embedded in zone 2 of neck and across the shoulder girdle.
Q1 : What are your priorities in managing this patient?
Yes, we’ve all done EMST/ATLS courses. But does this approach really work?
Q2 : What equipment is available in YOUR hospital (or prehospital pack) to help manage his bleeding?
Circumstances will differ – I’m interested in your answers!
Q3 : The patient has a history of non-valvular atrial fibrillation. Some bright spark (not you) decided to start him on dabigatran 3 months ago. What next?
Like it or not, there’s a whole gamut of new blood thinners out there – which affect trauma management.
Q4 : Retrieval services are flat out elsewhere in the State and will take at least 2 hours to arrive. Is there anything else that can be done locally?
Again circumstances will differ – some rural hospitals will have theatre capability and access to blood – some not. Interested in your responses
I am putting this one up more to invite contributions from the community. It’s a case that has been included for our PRCC students – the guys who spend the entire third year of their four year graduate entry medical degree attached to a rural community (the so-called parallel rural community curriculum).
Time will tell whether this initiative translates to a career in rural medicine. However one thing is clear, the PRCC students are far more likely to get hands-on experience, whether it be doing minor gynae procedures, assisting at a LSCS, basics of airway management, assessment of undifferentiated patients in the ED or having own consulting sessions.
This week’s problem-based learning session is on a neonate with breathing and feeding difficulties. As an experiment, I am putting the case up and hoping that #FOAMed enthusiasts will be able to comment – because I’d love to demonstrate the power of #FOAMed to these rural students. So come on, don’t disappoint me…
Here’s the case
Hamish is 6 days old. He was born at 38 weeks as the second child to his 29 yo married mother. Antenatal course was reportedly unremarkable. Birth weight was 3 kg. He was discharged on day two after delivery, formula-fed and with an unremarkable ‘baby check’ by the obstetric RMO.
He presents to the hospital with parental concern that “there’s something wrong with my baby”. Mum reports difficulty in breathing and feeding (60ml of formula 5 x per day).
In terms of other history, birth parents and Hamish’s elder 4 yo brother are well with no medical problems. A paternal uncle died at 2 weeks of age from ‘hole in the heart’
On examination, Hamish looks ‘crook’ – he is pale, peripherally shut down. He is NOT cyanosed and appears afebrile. He is lethargic and sweaty. RR is 100 with intercostal recession HR is 150 with palpable upper limb pulses but the attending doctor reports difficulty with lower limb pulses. BP 63/40 arm, 45/30 leg. Heart sounds are dual with S3 gallop. There’s a ejection systolic murmur at the LSE grade 1-2/6. There is palpable firm hepatomegaly 4cm below costal margin.
I am interested in how the #FOAMed community would
(i) assess this child and come to a differential?
(ii) investigate and manage, from small rural hospital through to specialist centre?
(iii) what resources could be helpful along the way…
Over to you…
PLEASE COMMENT BELOW
Dr Ed Valentine is a dual-trained EM & ICU doc in the Old Dart, currently spending a year as a retrieval Fellow with London HEMS and responding as a BASICS volunteer in his home county of Wiltshire, UK
We talk about the role of BASICS in the UK to “value add” to the scene despite existing paramedic services and the relative proximity of tertiary hospitals in the UK compared with Australia.
Ed promises to come ‘down under’ to SMACC GOLD in March 2014, so we’ll set aside a cold one for him in the SMACC lounge
Geoff is a former airman turned doctor and rural GP-anaesthetist. He’s worked in many interesting places and sounds like he’ll continue to search for future challenges.
Today we caught up during an EMST/ATLS course to discuss life as a rural GP locum, difficult airway kit and shared passion for trauma.
Have a listen to the podcast and see what you reckon ….