What’s In Your Bag?

The subject of doctors bag contents has come up recently, with comments from a respected Emergency Physician that several of the drugs supplied for use in doctors bags are outdated. 

I was a little perplexed by the RACGP’s insistence on keeping diazepam and their pitch for oral vitamin K as essential for the doctors bag, but then again I am a FACRRM member and much of what the RACGP does perplexes me.


My preference would be to use midazolam to terminate seizures (intranasal or IV). As for the RACGP’s insistence that oral vit K be given intravenously for warfarin overdosage by rural doctors – well, I am not sure I follow their logic – someone who is bleeding and on warfarin – sure, they may need some Vit K (but they may also need more care than I can give in their living room) – I’d rather be doing this in my local hospital, with a point-of-care INR to guide me…and access to blood products if haemorrhage continues.


Don’t get me wrong – anyone who remembers the BBC’s ‘Cardiac Arrest’ series will remember the shocking episode of the haemophiliac guy with epistaxis and the immortal line from Dr Claire Maitland – “Yes your daddy’s going to stop bleeding very soon indeed“. 


If there was ever an argument for rural doctors possessing skills in emergency medicine and access to blood products for major transfusion, this sort of emergency is it. Interestingly those of us who trained in the UK prior to 2000 will remember ‘Cardiac Arrest’ as the most realistic portrayal of the utter shit that being an NHS junior doctor was. In fact I thought it was a documentary! But I digress…


So my feelings on doctor’s bags vary. 


I think there is a very real limit to what can be carried, and the contents of a day-to-day doctors bag will vary considerably from the contents of a prehospital pack for emergency use. I reckon that for doing home visits in an emergency the most useful device a doctor can carry is his/her phone – to summon help from an ambulance or retrieval service…


Doctors who do house visits are probably better off with a phone, script pad, BP cuff, stethoscope and a huge folder of Medicare forms…on the basis that the days of giving patients a shot of pethidine for ‘migraine’ are thankfully over and such patients are better served by IV fluids, high dose aspirin, chlorpromazine…ditto the renal colics – they need an indocid suppository stat and may even need parenteral opiates – again, in a hospital setting.


However doctors in the bush may be called to attend prehospital emergencies such as car crashes (I won’t call them accidents) or other incidents. Besides calling for help with a phone, the prudent rural doctor will carry an extensive prehospital pack – either stocked from local hospital, through a scheme such as RERN, or cobbled together from bits n pieces over the years. Considering that such emergencies may call for interventions up to prehospital anaesthesia, the contents need to be extensive and are bulky.


For what it is worth, here are the contents of my RERN packs…bear in mind that such callouts are to back up local volunteer ambulance officers, so monitoring equipment, extra pairs of hands, stretcher and a warm/dry/well-lit ambulance are taken as already present. RERN members are supplied with the excellent Neann bags via SA Ambulance.


BAG ONE (GREEN) – FIRST RESPONDER

C SPINE/OXYGEN/BASIC AIRWAY inc. BASIC DRUGS
Cervical Collars (adjustable) – adult and paediatric
Oxygen Cylinder C type (490 litres) & O2 tubing
Hudson Mask – 3:1 mask – Nebuliser reservoir
Guedel Airways 0/1/2/3/4
Ambu Bag, Mask & PEEP Valve
12G DwellCath cannula
Sphygnomanometer and Stethoscope
Gauze, Saline, Pads
Glucometer and test strips
LED headlight
Multitool

Drugs

Midazolam (2 x 5mg)
Naloxone (1 x 400mcg)
Glucagon (1 x 1mg)
Adrenaline 1/1000 (1mg)
GTN spray
Ventolin nebs (5 x 5mg)
Penthrox inhaler


BAG TWO (BLUE) – ADVANCED AIRWAY inc. INTUBATION DRUGS
Pouch 1 : Foot-operated Suction
Pouch 2: Chest Drains and Heimlich Valves
Pouch 3 : KingVision Videolaryngoscope & Blades, AirQ II iLMAs x 3


Intubation Pack

ETT/LMA/Surgical Airway Kit

Laryngoscopes with Mac and Miller blades, batteries AA and C
Size #3 and #4 LMA Supreme’s
Tapes, Gauze, Ties, Syringes
Ventolin inhaler connector
EzyCap and PediCap ETCO2 (“gold is good”)
Cophenylcaine spray and atomiser
Pulse oximeter
RSI checklist and kit dump mat

Drugs

Propofol 2mg/kg
Ketamine 1.5 mg/kg
Suxamethonium 2mg/kg
Rocuronium 0.6 -1.2 mg/kg
Fentanyl 100mcg x 3
Morphine 10mg x 2


BAG THREE (RED) – CIRCULATION inc. FLUIDS and EMERGENCY DRUGS


Sharps Bin
Pouch 1 : Dressing pack – Gauze – Bandages
Pouch 2 : Waste Bag – Vomit Bag – Gloves – Mask – Glasses – Aqium Gel
Pouch 3 : Pens, MedSTAR handbook, Stethoscope – Reflective Vest (DOCTOR)


Internal side pockets


Combat Application Tourniquet
Trauma Shears
Rapid Infuser catheters (RIC) 7 and 8.5 Fr


Main compartment

IV cannulae 2 x 14G – 16G – 18G – 20G – 22G – 24G & bungs
Intraosseous Needles (Bone Injection Gun, adult and paed)
500ml N/saline x 2
Giving sets
Splints
Spare dressing pack
Suture Material and Local Anaesthetic


Drugs

Adenosine

Adrenaline
Amiodarone

Aspirin
Atropine
Benzyl Penicillin
Cefazolin

Glucagon

Hydrocortisone

Lignocaine

Metaraminol

Metoclopramide

Metoprolol

Midazolam
Naloxone

I’d prefer the EZ-IO but locally we’ve been supplied with the B.I.G IO device instead.

I reckon that spending some recent time in anaesthetics has made be a bit ‘OCD’ – I tend to check my bags weekly and am constantly looking for ways to improve the set up. 

Any suggestions for improvements? What’s in YOUR bag?

Country Driving

I’ve recently driven back from Orange (NSW) to Kangaroo Island (SA) – one of those long, two-day road trips that is characteristic of driving in Australia. I counted less than 200 vehicles between Orange and Tailem Bend – over 1200km of road over two days…and of course whilst driving you tend to think about stuff. Some things struck me…

• Australia is vast
• rural areas are sparsely populated

Hence If you have a crash out here, you are likely to face a long time before help arrives. And even then :

• the major cities are a LONG way away (>500km)
• there are smaller rural hospitals; some are little more than first-aid posts & some have capabilities for surgery (which implies the presence of a doctor with anesthetic skills)

Add to this :

• the prehospital response may be initially composed of volunteer paramedics/first responders, with more more advanced practitioners few-and-far between

All together it is no surprise that the outcomes from a motor vehicle crash are worse than in the city, with one Australian study demonstrating a four-fold mortality for rural vs metropolitan areas. Not surprisingly, mortality increases the longer the time to care…and concepts like the “platinum ten minutes” and “golden hour” of trauma become academic when crash victims may not be discovered or receive help for a considerable time.

As rural doctors, it behoves us to examine best practices to try and improve survival. Certainly we need to have to skills and equipment to provide appropriate medical care in our hospitals..and some may provide an extended role at the roadside. I’ve blogged before about the concept of training and equipping rural docs to provide a coordinated prehospital response…and the more doctors I speak to, the more seem to think this is a ‘good idea’. Implementation however may take longer, and there will be hurdles to overcome (not least the oft cited response that such work is best left to experts, not enthusiastic amateurs).

Of course, the best ‘bang for buck’ is not necessarily in the delivery of expert medical care. I remember Karim Brohi making this point at one of the Australian Trauma Society annual conferences a few years back – “it’s better to build a fence at the top of the cliff, rather than provide an ambulance at the bottom to pick up the injured“. 

Locally we’ve had some small success with the ‘Roadkill Recipes‘ project – recognising that many rural traffic injuries on Kangaroo Island were caused by wildlife-vehicle collisions, a satirical cookbook of local wildlife served as a medium to convey a road safety message to locals and tourists.  Places like Kangaroo Island (and Tasmania) are interesting in that roadkill (and hence wildlife-vehicle collisions) is abundant. But for most rural areas the notorious “fatal five” of speed, inattention, drink/drug-driving, driver fatigue and lack of seatbelts are the culprits in many road crashes. 

Which is why I was heartened to see new signage as I crossed the border into South Australia (below). The Motor Accident Commission’s “matemorphosis” country roads programme aims to target country drivers, particularly male drivers who may respond to mateship peers.

The MAC campaign includes references to wankers, cocks, knobs and tossers.

I wonder if as rural doctors we need to be more proactive in injury prevention – especially when our work comprises mostly primary care as well as the ‘fun stuff’ like airways, trauma and emergency medicine. Driving change can be hard, but if we’re serious about injury prevention we need to be active in local road safety groups, at sporting events, with families and spreading the road safety message. But concomitantly we need to ensure our training and local resources are fit for purpose.

So in 2012 my projects will be:

– actively engage the local community in primary prevention health strategies,

– work with colleagues around the country to develop a ‘rural doctor masterclass’ course, showcasing latest concepts, equipment and techniques relevant to rural proceduralists,

– try and establish a more formal framework for rural doctors attending prehospital incidents (as a minimum, appropriate training, equipment and maintenance of standards) – existing retrievalist courses like RFDS STAR (RFDS Qld) and the medSTAR short course seem to be appropriate building blocks, bolstered by some online case discussion and commonality on procedures/protocols,

– work on developing a bespoke airway skills course for rural docs in South Australia, with concomitant development of minimum standards for difficult airway equipment in our rural hospitals.

What are your News Year resolutions?

Back to BASICS

South Australia is huge & not surprisingly this poses problems providing a response to serious trauma in the country. Thankfully rural doctors are mostly well-trained and thrive on the challenge of delivering excellent emergency care in their local hospitals…and if needed, can call upon the retrieval service to transfer critically unwell patients. The Statewide retrieval service has been re-invented in recent years, with MedSTAR now offering a world class service rivalling other States. Certainly the improvement in service delivery has been noticed from where I stand, as a rural doctor in country SA.


However, I wonder if there’s scope to improve things even further? In the UK, an entity called BASICS (British Association Immediate Care Scheme) enlists the skills of doctors with an interest in prehospital medicine & trauma to provide medical expertise at the roadside. BASICS personnel don’t replace paramedics or retrieval services – rather they “value add” to a situation – particularly when paramedic skills are exhausted and retrieval services have yet to arrive (see the BASICS DOC blog for more details). In Australia, the failure to call local doctors (many with critical care/anaesthetic skills) has been slammed in the response to the Kerang train crash disaster in 2007.


If the UK, with it’s small landmass, huge population and plethora of aeromedical and land-based retrieval services has a need for a service like BASICS, surely there’s more of a need in rural Australia where distances are greater and retrieval may take hours, not minutes? I posted on this recently on RRMEO, the excellent educational resource from ACRRM.


Currently, most trauma cases are dealt with by paramedics (and in the bush, these are often volunteers, not paid personnel) and a decision made to either retrieve direct from the scene (primary retrieval) or else transfer the victim to a rural hospital (where they may require secondary retrieval to definitive care). On occasions, local rural doctors may be called to assist at the roadside. Or not, as in Kerang. It’s an informal process which invites problems.


There’s a potential problem with relying on the local doctor. Emergency Medicine training in rural Australia is not formalised. Some doctors have a wealth of EM experience – some have barely any. Calling the local doctor may be a good thing…or it may not add much. Dr Peter Arvier in Tasmania has championed the need for EM training in rural Australia (demonstration of training is needed for rural docs practicing obstetrics, anaesthetics and surgery). Improving EM training is probably a good thing for the bush, although I hope old farts like me can be grandfathered if they bring in a rural EM diploma!


On top of this, a doctor attending an incident as the ‘oncall’ is still responsible for patients presenting to the local hospital. I’ve been called out to incidents 60km away from the hospital…and whilst happy to attend, I’ve had to ensure that someone else can cover in my absence.


In South Australia there has been an embryonic scheme developed by Dr Peter Joyner, known as RERN (Rural Emergency Responder Network) drawn from the ranks of rural doctors. These guys make themselves available to be called by SA Ambulance at the roadside, in addition to their usual oncall responsibilities. It’s a good idea, but I think doesn’t go far enough…the rural doctor workforce represents a hugh asset which is underused. Sure there are ad hoc arrangements (‘Help! We need a doc’) but without formalised training and equipment appropriate for the prehospital environment, doctors risk becoming ‘enthusiastic amateurs’ (I’m one!).

KI DOC is ready and waiting for your trauma call!

Whilst many rural doctors keep up-to-date by attending courses such as EMST, APLS, MOET, RESP etc, it has to be acknowledged that the prehospital environment is quite different to operating in the safety of a resus bay in the hospital. Prehospital doctors need to be familiar with rapid response driving, radio use, scene safety, extrication and working in austere environments etc. The UK BASICS scheme recognises this, encouraging training such as the UK’s DipIMC (although having read what’s involved, I reckon this could be more of a disincentive to us rural docs…better to just ensure they’ve got the right kit, understand the prehospital environment, then get them out there making a difference!)


I’ve alluded to the need for more crossover in training & equipment between various services (ambulance-retrieval-rural workforce) elsewhere on this blog (see “Keeping It Simple“). On RRMEO this topic was discussed with John Mac, who felt that it would be resisted by State ambulance services. I think this then begs the question – how much is the rural workforce integrated with State/National resources when a disaster strikes? As Dr Chris Swan recently opined in Australian Doctor :

“GPs form a vital, invaluable component of the emergency response resource in a disaster. Yet they too often are an afterthought, considered somewhere beyond the police, fire services, SES, hospital response and the military. Their clinical skills are broad, and they may well have facilities and staff at their disposal, but they are not as easily marshalled and they may be spread out”

I am particularly interested in how this sort of scheme would be received in rural Australia. What do others think? Has this idea got legs?


Bottom line – rural doctors are not infrequently called to attend to backup the ambos. Better that the doctors attending are well-trained, well-equipped and enthusiastic…not the present ‘we don’t need you…oh hang on, yes we do‘ approach which relies on the oncall A&E doctor. 


That’s just not good planning.