Is the medical conference dead?

Just got back from Fremantle and the #RMA2012 Rural Medicine Australia conference hosted by ACRRM and RDAA. To be honest I was disappointed. Some pearls amongst the three day academic programme. But perhaps recent exposure to high-quality asynchronous #FOAMed learning has raised my expectations.

That said attendance was high at over 450 delegates and it was great to hear fellow South Australian doctors Martin & Fiona Altman of Murray Bridge, SA get the ‘rural doctor of the year’ award.

 

Enjoying PubMed in Fremantle

 

However a conference shouldn’t be just about the venue or the quantity of attendees – for my money I want quality medical education and networking.

So in no particular order, here are some thoughts…

1/ not enough hands on skills sessions for frontline rural doctors, too much on training pathways and RTPs etc

A real bugbear of mine. As isolated rural docs we may struggle to engage in high quality education events. It makes sense to host them at the annual Rural Medicine conference.

On offer before the academic conference were the two-day REST course and one day sessions on burns, obstetrics and ultrasound (the latter hosted by Broome Docs author and blog-o-sphere #FOAMed guru Dr Casey Parker). Casey has posted his thoughts on ‘courses for horses’ this week – have a read of his thoughts and the comments.  Add your own, please…

Whether the College will pick up on this is anyone’s guess.

There was also a hands on demo in mucosal atomisation techniques from Tim Wolfe, ED doc and innovator, who was also over for the Australian Trauma Society do in Perth. A really useful technique for rural docs (as well as retrievalists and EM docs) – but old hat to those of us swimming in the soup of #FOAMed. Better than nowt though. More info at http://www.intranasal.net

2/ turgid education sessions, mostly delivered to large lecture theatres

A conference should be about dynamism and rapid turnover of ideas, preferably in small groups – which in turn engenders breakout discussion in breaks, over meals & outside the confines of the lecture hall.

Maybe I signed up to the wrong events, but a whole day session on telehealth? C’mon, it’s not that complicated – an iPad, Skype and a robust referral pathway is all that is needed. OK, perhaps that’s oversimplification, but this session would have benefitted from more hands on, not repeated talks of existing telehealth examples and pilot studies. I lasted about an hour then drifted in/out. Similar reports from other attendees.

Shame as telehealth and social media will revolutionise medicine, especially for the rural doc. Better to offer small group sessions repeatedly throughout the event to maximise coverage. Same for other sessions, which seemed more weighted to the medical educationalista than the frontline rural doctor.

There were a few more sessions on dermatology, parallel consulting with medical students, Nextplanon and Mirena insertion etc…but sadly all held on the last day when most delegates had to check out and catch flights back to East Coast fairly early, thus cutting short these potentially valuable sessions. Bah!

I was of course excited to present my data on difficult airways and rural docs – although to be honest this would be far better and more valuable as hands on workshop aimed at anyone who is an ‘occasional intubator’. Thankfully there’s a wealth of resources out there, including Minh le Cong’s excellent online airway training at www.prehospitalmed.com. I did run an impromtu airway workshop for interested docs over a PubMed session in the hotel bar…you can download more from the ‘resources’ and ‘videos’ sections on this site.

I have reflected that using FOAMed I could’ve presented this data back in March…getting the paper published in October and presenting two weeks later was just by chance. But next time I;ll get message out sooner using #FOAMed.

Unfortunately the paper presentations were run in 4 separate venues, with erratic timekeeping making it difficult to move between concurrent sessions. I was a bit gutted to miss Dave Townsend’s talk on SoMe in medicine, but true to form he’s bunged his slides up on the interweb for all to see at http://www.davidtownsend.com.au/blog/articles/rma2012-social-media-resources/

3/ Failure to embrace #FOAMed and the power of the interweb

Well, Joe Lex put’s this better than I ever will :

If you want to know how we practiced medicine 5 years ago – read a textbook
If you want to know how we practiced medicine 2 years ago – read a journal
If you want to know how we practice medicine now – go to a (good) conference
If you want to know how we will practice medicine in the future – use FOAM

FOAM of course being Free Open Access Medical education as exemplified by medical bloggers such as http://www.lifeinthefastlane.com, www.BroomeDocs.com and ww.prehospitalmed.com etc

Gerry Considine @ruralflyingdoc summed it all up in a cheeky manner, just in a single Tweet

“if you want to know how we practiced medicine last century, ask a rural doctor”

Perhaps a that was a little harsh – rural docs aren’t deliberately obtuse. But the systems we work in are slow to adapt.

Examples abound – my airway survey showed that few rural docs have access to the same up-to-date kit as their city specialist colleagues. Of course cost and caseload constraints factor in this, but to hear rural docs having to practice without a minimum standard of equipment is of concern.

Similarly access to bedside ultrasound is constrained – resources like the newly launched iBook (Introduction to Bedside Ultrasound) will help improve training. The cost of a decent USS machine may seem prohibitive, it will pay for itself if it means avoiding a costly transfer out of Dingo Creek to tertiary centre.

Finally, sitting in the medicopolitics session, one of the founding fathers of RDAA commented to me that ‘nothing has changed’ in 25 years of such debates. Sobering stuff, more so when the politicians are talking about linking pay to performance – despite the clear concerns elsewhere about such systems.

If you haven’t already read it, see Dr Clare Gerada’s address to the GPs at RACGP conference last week – key points about problems inherent in the overzealous measuring, medicalisation and marketisation which have destroyed UK medicine.  This does not bode well for us in Australia – read Dr Gerada’s thoughts at http://tinyurl.com/GeradaSpeech

SoMe has the potential to link doctors concerned with such events – we’re seeing this with the #interncrisis campaign which has snowballed in past few days to maximise media exposure.

As isolated rural doctors, using these resources could help us do two main things

(i) speak with a common voice on medico-political matters

and

(ii) vastly raise the bar in ongoing medical education and the delivery of ‘quality care, out there’ – not through the turgid medium of conferences, papers and ALS courses, but through evolving, dynamic, cutting-edge media bringing evidence-based practice to rural docs and their patients.

So, what for the future?

Despite my gripes about medical conferences, I am going to attend #SMACC2013 www.smacc.net.au next year. Although a critical care conference, there are valuable lessons applicable to my workplace in rural emergency medicine. Besides, casey Parker @BroomeDocs owes me a beer.

I’m also going to focus more on the maxim of delivering ‘quality care, out there’.

From 2013 I’ll move try and focus http://www.ki-docs.com towards more hypothetical case discussions – not so much though on ins/outs of EBM (www.broomedocs.com does that well) – but explore concepts such as situational awareness, logistics over strategy, audit and other topics to help “get things done” to aid the rural doctor improve his/her practice.

“Quality care, out there” – the future is #FOAMed

Difficult Airway Equipment and Rural GP Anaesthetists in Australia

Well, it’s been almost just over 9 months since I put out a survey to rural GP-Anaesthetists (GPAs) in Australia….was surely tempted to put the results up on this blog back in April/May once the data had been crunched, but I stood on academic convention and deferred discussion until the paper came out – which was this week….click here to download a printable PDF version.

Another argument for the power of #FOAMed over traditional textbook-journal-conference methods of disseminating information, perhaps?

 

 

So, what was this all about? Well, it was only last year that I spent 12 months upskilling in anaesthetics before returning home to Kangaroo Island, SA. Whilst the training I received was invaluable, and to the standard required of the ‘Joint Consultative Committee in Anaesthesia” (JCCA), I think there is a gap between the reality of rural practice and that in the city. Don’t get me wrong. Rural GPAs do a great job. They provide elective anaesthesia to appropriately screened and case-selected patients…as well as manage emergency airways in challenging circumstances.

But I found two things that troubled me in my year of upskilling and attendance at rural anaesthetic conferences in NSW and SA

(i) many specialist anaesthetists did not ‘get’ the realities of rural anaesthesia. Some were dead against the notion of GPAs full stop (yeah right fellas – I’ll stop giving anaesthetics once you guys commit to providing specialist services in the bush).

Others accepted the idea of appropriately-trained GPAs delivering services – but expected us to have access to all the gizmos and resources of a tertiary centre, not understanding the limitations of rural practice and that the work of a rural GPA encompasses not just elective anaesthesia, but also emergency airway management in the absence of immediate backup.

(ii) There is a plethora of new airway devices and algorithms to manage difficult airways – but this equipment may not be available in cash-strapped rural hospitals. This is despite guidelines from ANZCA on difficult airway equipment availability.

So I decided in Jan 2012 to conduct a survey of rural GPAs in my home State of South Australia. Once I’d worked out my questionnaire, it seemed not too difficult to extend the questionnaire to rural GPAs in other States. Sadly no one seems to have a clear idea of how many GPAs there are ‘out there’ – there is no central database, and conflicting data from RACGP and ACRRM on humber of GPs registered under the procedural grant program for anaesthesia (Medicare of course declined to release data). A National Minimum Dataset from 2010 suggested 448 rural GPAs in Oz and so I targetted these through invitations to complete survey via ACRRM/RACGP/RDAA and State-based rural doctor workforce agencies.

Apparently a 65% response rate is good for an internet-based survey; respondents were broadly representative in terms of RA 2-5 distribution, demographics and experience in anaesthesia. Open and closed-question responses were interesting – only 58% of rural GPAs had access to dedicated difficult airway equipment. Many were frustrated with their access to such equipment. Importantly, many did not have access to the appropriate equipment to manage each of the stages of recognised Difficult Airway Algorithms.

This is surprising – there are published Standards for difficult airway equipment in locations where elective anaesthesia is performed, as well as guidelines on difficult airway algorithms. Yet many respondents indicated non-compliance. Moreover, there are AFFORDABLE and ROBUST solutions out there – I’ll post some suggestions on an affordable rural GP-Anaesthetist toolkit in a few weeks or so. Suffice it to say, affordable & robust equipment is out there for less than $5K and there is really no excuse no to have this kit in your OT or ED.

My survey also looked at the involvement of rural doctors in prehospital emergencies – I reckon this is bread n butter for rural docs, but it was interesting that although over 50% of rural GPAs reported their involvement in such work, the majority had had no training in this arena, did not have concordance of protocols with RFDS/retrieval services and furthermore such responses were often ad hoc, not a formal arrangement. Overseas modes such as the UK’s BASICS suggest better models that perhaps Australia (with it’s tyranny of distance) could and should emulate….

By all means have a look at the paper – it’s in Rural & Remote Health online or come and hear me talk at the Rural Medicine Australia conference in Fremantle later this month (#RMA2012). More importantly, examine your own difficult airway equipment and have a look at some of the suggestions on sites like Broomedocs.com and Prehospitalmedicine.com, from whom I am grateful to have drawn inspiration.

For an overview see the VIMEO video here or have a look at the paper here.

As always, comments or criticisms are invited.

Affordable Difficult Airway Kit

Well, this week I’ve been playing with some AirQ II blocker intubating LMAs (iLMAs) sent to me from a rep.

For those of you not familiar with an iLMA, the device is designed to allow ‘blind’ intubation of the airway, using the laryngeal mask airway (LMA) as a conduit.

The progenitor, with which most rural doctors and anaesthetists will be aware of, is the FastTrach LMA. It’s reported to allow up to 73% ‘first pass’ successful intubation rates, increasing to 90% overall success with repeated attempts and the ‘Chandy manoeuvre’. It’s not a bad piece of kit and we’ve got one on our airway trolley.

However, the FastTrach requires some practice to get used to. I made a point of using it at least once a month during my anaesthetic year, just to get used to the kit. Using equipment in training is quite different to using ‘in anger’, especially when there’s an evolving airway crisis. Problems that I found were

• not always easy to pass the endotracheal tube into trachea
• removing the LMA whilst leaving the ETT in situ is fiddly and risks losing both
• overall success rate is 90% – so 1:10 will fail.

The C-Trach is an advancement on the FastTrach, improving rates for first pass and overall sucess to 96% and 98% respectively – basically this device is just a FastTrach with a video screen attached. Clearly then, addition of video allows visualisation of the cords and improves success rates.

However, neither FastTrach or CTrach allow you to place a nasogastric tube..unless you obturate the ETT and remove the LMA over the top, which is potentially fraght with difficulty.

Cue the AirQ iLMA.

This ‘new improved’ iLMA gets around the problems of FastTrach and CTrach – it’s similar in appearance to the FastTrach iLMA, albeit with a less acute angle. It also has a nifty side-port to allow passage of a nasogastric tube without having to remove the iLMA

Moreover, the device comes with dedicated nasogastric ‘blockers’ – an NG tube with an oesophageal balloon which can be inflated in the oesophagus to minimise aspiration risk and yet allow decompression of the stomach.

I tried it the other day in theatre and found it easy to use. As an LMA it functioned perfectly well, although I have heard some anecdotal evidence of increased supraglottic trauma with this device.

How then to improve success rates for passage of an ETT? Minh le Cong has described this elsewhere – use of a malleable intubating stylet such as the Levitan FPS allows visually-aided intubation through the iLMA conduit.

So we now have a staged procedure for the nightmare difficult airway where intubation has failed or priority is to oxygenate

• drop in an AirQ II and ventilate
• pass the oesophageal blocker to decompress the tummy
• use a fibreoptic device to intubate through the iLMA, improving intubation rate

This strategy (fibreoptic intubation through an iLMA) is Plan B of the UK’s Difficult Airway Society algorithm. Yet how many of us are really prepared to do this and have practiced on kit? Most rural docs have access to a FastTrach…so ventilation and blind intubation are possible – yet the addition of an NG tube port and allowance of fibreoptic intubation seems to offer a higher standard of care. Of course, for many small hospitals fibreoptic devices have traditionally been out of range – high cost and difficulty acquiring and maintaining skills.

But for under $3K you can pick up a Levitan scope (malleable fibreoptic intubating stylet) or the Ambu Ascope II (five disposable flexible fibreoptic scopes). They may not be as good as the fibreoptic towers that people use for an awake fibreoptic intubation…but they are bloody good gadgets to use with the above technique.

So, what would be my preferred kit for a ‘difficult airway’? Well, I’d use the Difficult Airway Society (UK) and ANZCA T04 guidelines as a starting point…and in addition to the AirQ and some sort of fibreoptic device, I’d add in a videolaryngoscope. Sounds expensive? Well my suggestions for purchase are in square brackets below – for under $4K should be affordable for small rural hospitals…

Plan A – Initial Intubation Strategy

Standard laryngoscopy – if fail, change position, blade, operator. Consider use of a videolaryngoscope in case of difficult airway. If fail, move to…

[KingVision Videolaryngoscope ~ A$1000 inc. blades]

Plan B – Alternative Intubation Strategy

iLMA to maintain oxygenation and ventilation, then secure airway using fibreoptic intubation through iLMA. If fail, move to…

[AirQ II iLMAs A$30 each]

[either Levitan FPS or AmbuAscope II fibreoptic devices to intubate through iLMA]

Plan C – Maintain Oxygenation & Ventilation, Abandon Procedure and Wake Up

Bag-mask ventilation and reverse non-depolarising neuromuscular blocker (suggamadex for rocuronium) or wait for suxamethonium to wear off. If fail, move to…

[Rocuronium for RSI – prolong time to desat]

[Suggamadex to reverse rocuronium]

Plan D – Rescue Techniques for Failed Oxygenation & Ventilation

Bag 1 – Paediatric or Easy Anatomy
Needle Cricothyroidotomy technique

Bag 2 – Adult or Easy Anatomy
Scalpel-Bougie-ETT technique

Bag 3 – Impossible Anatomy
Scalpel-Finger-Needle technique

[Melker Kit]

I wouldn’t bother with the pre-packaged kits like QuickTrach or Seldinger kits as first line for CICV – in the heat of the moment, faffing around with wires etc can be a disaster. Better to have three equipment bags set up as above using standard equipment – oxygenate first – then move on to seldinger or formal tracheostomy. Some have commented that doing the above is sufficient to ‘save the day’ then either wake up the patient or proceed to successful laryngoscopy.