Advances in Trauma?

Well I’ve just got back from an EMST Refresher course in Adelaide.  This is the first time I’ve taught on a refresher course and it was nice to meet other experienced faculty as well as (mostly) rural doctors doing this refresher course. The Provider courses that I usually teach on are not usually so filled with rural doctors – more junior RMOs doing EMSt as a requirement for surgical training ANZCA no longer has EMST as a requirement for their trainees).


EMST is very much an entry-level course, but is well suited to the needs of rural doctors who often have to manage trauma as a solo doctor with limited resources. It should be borne in mind that over 40% of major trauma originates in rural Australia, so there is real bang for buck in getting effective trauma care delivered to these patients, whether y rural GPs or aeromedical services.

On this Refresher course, the hands on scenario-based skills stations seemed well received. I also had an hour after the MCQ to talk about ‘Trauma Teams and Advances in Trauma’ – a golden opportunity to chat about things like human factors in trauma team dynamics, as well as to draw on experiences from the group about well-run and not-so-well run traumas.

But what about ‘advances in trauma’ that are not covered in the EMST Provider course? Well, I reckon they can be broken down by category and it was this approach I used to guide discussion in the 30 minutes or so available to me for each group:

AIRWAY

Videolaryngoscopy as an adjunct for difficult intubation

Ketamine for trauma intubation

Difficult Airway Society algorithms

Andy Heard’s excellent youtube videos on CICV

Cliff Reid’s notorious ‘propofol assassins’ rant

Weingart/Levitan’s paper on preoxygenation

BREATHING

Finger thoracostomy

Ultrasound for evaluation of pneumothorax

CIRCULATION

Minimal volume resuscitation

C-ABC and tourniquets for catastrophic compressible haemorrhage

Tranexamic acid, CRASH II trial & applicability to rural Australia

Managing major traumatic bleeding in rural hospitals (big shout out to Casey Parker’s excellent blog on this at Broome Docs)

We didn’t get as far as DISABILITY but I daresay that discussion of hypertonic saline in head injury would have come up…

The discussion really made me think just how knowledge-hungry the rural doctors I met were, but how hard it was for information to be disseminated to these guys.   It cemented my belief that a  rural masterclass course would have a willing audience. There’s lots of new stuff to discuss in trauma alone, but add in other (non-trauma) areas of interest to the rural proceduralist and you’d have a gutsy, useful, evolving course with enough content for 2-3 days. I could rant about this for ages…

All I could do was relate my own experience in past year or so, and the value of internet-based learning and discussion which has re-vitalised my own enthusiasm for learning. Big shout outs to the rural docs for the education resources below :

Minh le Cong’s retrieval resources for ACRRM members at www.rrmeo.com and his new PreHospital And Rural Medicine (PHARM) blog at www.prehospitalmed.com

Cliff Reid’s excellent blog at www.resus.me

Casey Parker’s excellent Broome Docs, the central repository for all things relevant to the rural proceduralist

Those UCEM rascals over at Life In The Fast Lane

Scott Weingart’s EM-crit blog

Common themes amongst the rural proceduralists I spoke to remained

• difficulty accessing medical equipment (videolaryngoscopy, infusion pumps and fluid warmers were common ‘wish lists’)
• difficulty with triage and training for nursing staff in rural hospitals
• desire for cross-training with RFDS/Retrieval service in terms of infusion regiments, SOPs and equipment

In Country Health SA, there are nominated rural doctors as ‘consultants’ in each of the areas of emergency medicine, anaesthetics, obstetrics & surgery. According to CHSA, their role is to :

• be responsible for providing clinical system advice and broad support to rural resident medical practitioners in country South Australia, in their identified area of expertise
• act as a point of contact for clinicians in country regarding system issues, as related to their specialty area, and participate in problem resolution
• participate in the development of policy and procedures that guide clinical practice in country. In addition, the Chief Consultants will work with the Chief Medical Adviser, Country Health SA and other country health staff related to decision making and policy setting as related to their speciality area 

With the exception of obstetrics, for which there seems to be a proactive rural proceduralist, it is hard to point the finger firmly at any positive attempt to address the above issues by present incumbents. In fact the rural doctors I spoke to (those with EM or anaes skills) were not aware of any initiatives in past year or so by the CHSA EM or Anaes consultants.

Which is a shame, as it seems these rural docs were struggling with similar issues in their own institutions, but lacking a top-down approach to streamline equipment, protocols & training. Rather they were having to push for equipment/training by dealing with local DONs of the hospital, usually being rebuffed as ‘no money’ in CHSA. It seems that my problems on Kangaroo Island with equipment/training are the same as those in Port Lincoln, the Riverland, the South East etc…and we are all trying to fix in our own manner, which mostly comes down to enthusiasm for a particular issue at any one time. No wonder things are fragmented.

Meanwhile not a week goes by without another meaningless diktat arriving in rural doctors email from CHSA detailing the latest policy. Useful stuff…for example I’ve learned that dabigatran can cause bleeding (well, duh!)…and that I probably should not inject chlorhexidine down an epidural catheter. I only wish the same regard for safety was applied to trauma management and crisis management in theatre or the ED of rural hospitals…

Phil Tideman of iCCNet has revolutionised how cardiac patients are cared for in rural South Australia, with an initiative over past decade to place point-of-care troponin, proBNP and iStat machines into all rural EDs, as well as standardised protocols for management of ACS/STEMI & heart failure patients relevant to rural practitioners. Whilst I am not a huge fan of centralisation of services, such standardisation in equipment and protocols has had demonstrable benefits for these patients…similar with obstetrics under Steve Holmes’ wise guidance. Why not extend the same to trauma, emergency and theatre patients by assessing needs of rural doctors and addressing their common issues?


A simple issue, like availability of difficult airway equipment or new advances like tranexamic acid could and should be addressed by these consultants.


Perhaps it’s time for some new blood in CHSA to represent the rural proceduralists in SA?

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?

Exciting news

Well, those who know me are aware that (apart from roadkill recipes), two of my current interests are to try and develop a national network of prehospital doctors drawn from the rural workforce and also to improve training in skills and equipment for rural doctors.


I’m grateful for recent email exchanges with Drs Minh Le Cong (RFDS Qld) and Dr Ray Gadd (on an EM secondment in the wilder parts of Tasmania). Minh has gained a reputation as a ‘promiscuous blogger’ and his pearls of wisdom crop up on websites such as LifeInTheFastLane, EM-crit, Resus.me and Broome Docs. he’s also been the main driving force behind the excellent retrieval medicine module on RRMEO (the ACRRM online portal). He’s a rural doctor now working as a retrieval specialist and clearly ‘gets’ the issues facing rural communities. Ray’s down in Tasmania doing some EM upskilling and has made me awestruck with his knowledge of obscure cardiac arrhythmias, ready-grasp of ultrasound and sheer passion for rural medicine.


I’ve been buoyed recently by Minh’s tacit support for some sort of organisation akin to the UK BASICS, but he correctly points out that this has to be driven from the rural doc workforce. My opinions on this are laid out elsewhere on this site. Meanwhile Ray and I have chatted about perhaps creating a new upskilling course for rural doctors – a sort of ‘masterclass’ building on the best bits of courses such as APLS, ELS, RESP, EMST, ALSO, MOET, PHTLS etc but with constantly evolving content (such as that on the abovementioned blogs) of relevance to the rural workforce (apnoeic preoxygenation, USS for PTX, RUSH, etc etc). 


Ideally such a course (or clinical update) could be delivered in regional areas, with small groups and immersive scenario-training and hands on with lots of equipment (ultrasound, videolaryngoscopes, airway adjuncts, emergency kit etc and an opportunity for cross-training with local ambulance/retrieval/emergency services for the trauma component).


Anyhow, there has been some more good news this week from my home State of South Australia – a new programme for creating ‘home grown’ procedural GPs in SA has been endorsed by Country Health SA and looks set to deliver both training posts and a sustainable workforce for the future. Called ‘Road to Rural General Practice‘ this model is well overdue. Currently SA procedural doctors may have to travel interstate to upskill (I did my obs in Tasmania, my anaesthetics in NSW) and indeed opportunities for procedural doctors can be tempting interstate…if this system trains and retains doctors in SA, that’d be great.

Launch of Careflight’s mobile MedSIm at Orange Hospital, rural NSW

Meanwhile, back in Orange, NSW where I am upskilling in anaesthetics, I was asked to give a lecture on massive transfusion to candidates on the TART course (delivered by the NSW ITM, a course I’d not heard of previously). CareFlight were involved (hi to Zoe Rodgers and co. if you’re reading)…and later in the hospital carpark I spotted Careflight’s excellent MedSim mobile sim-lab and their dedicated car wreck trainer.


Seeing this has got me all enthused again – so projects for 2012 will be to try and get an Australian ‘BASICs‘ up and running…and to try and sell the idea of a course aimed squarely at the rural doctor, preferably badged under ACRRM and offering immersive, hands-on, up-to-date education at a level above existing courses but perhaps spending half a day on each of EM, Obs, Anaes, Trauma and Paeds/Psych, with guest speaker, equipment demos and scenario-based small-group learning.


I’m excited. I hope others will want to join in…