Rural GP Anaesthetists – a ‘special needs’ mob?

As a rural doc I’m very lucky to have a job that is varied. I tell students and junior doctors that rural medicine offers all the stimulation and challenges of all the ‘best bits’ of medicine.

Currently I practice primary healthcare, emergency medicine and anaesthetics (I gave up obstetrics last year).

So this weekend just gone was a highlight – a chance to attend an annual GP-anaesthetics conference at one of the mainland tertiary hospitals. I’ve had this date ruled off in my diary for 12 months now…so you can imagine my disappointment when the ferry to/from Kangaroo Island sustained damage in the recent storms and the replacement therapy had to be hurriedly re-surveyed, launched and pressed into service. Needless to say all Rex flights were booked out days ahead and despite lots of people needing to get to/from KI, Rex declined to put on extra flights.

Noone can control the weather, but the lack of a contingency plan was disappointing. Not that Rex have a strong history of customer service…

Anyway, I missed the first day of the two day conference. But although I made it to the second, I was somewhat underwhelmed by what I did attend, cementing further my belief that there needs to be content tailored to the rural GPA delivered by people who ‘get’ rural medicine.

To backtrack, I went to my first rural GP-anaesthetist in NSW last year. It was really good, a day and a half of lectures, plus a half day in the sim lab doing emergency scenarios. But what struck me there was the disparity in equipment and resources available between city and rural anaesthetists…as well as between rural GPAs in different parts of the State. Lectures by some of the FANZCAs were all very interesting…but often they did not realise the conditions in which rural GPAs work (isolated, minimal equipment, no backup, cash-starved). At the same time I was getting increasingly inspired by blogs such as Resus.me, BroomeDocs.com, Prehospitalmed.com and LifeInTheFastLane – all of which seemed highly relevant to my practice.

So I resolved to look at some quality improvement in my own practice on my return to SA, mindful of the fact that it made sense to have commonalities in equipment and protocols available to rural anaesthetic providers. Setting up a GoogleDocs survey was relatively easy, and I was gratified to get a 2/3 response rate from rural GP-anaesthetists around Australia on my topic of difficult airway equipment availability. I’ll be talking about this at the Fremantle Rural Medicine Australia conference and my paper should be out in the Oct-Dec volume of Rural & Remote Health. Stay tuned…

So, a year down the track I had really high hopes of further upskilling in SA. Whilst most of the content was good, there was an alarming propensity of some lectures to cover topics like cell salvage, lab-markers in major transfusion and the like – all very interesting, but not translatable to the rural practice environment where such resources aren’t available. Questions on topics such as delayed sequence intubation and whole blood live donor panels were unfamiliar ground for the FANZCA experts, although very pertinent to many of the rural doctors.

Small group sessions made up for it, with hands on experience and chances for case discussion.

But a common theme amongst the people I spoke to was that city anaesthetists task with lecturing had very little idea of the resource limitations in country areas. The vast majority of us don’t have remifentanil..or desflurane..or BIS…or access to FFP/cryo/platelets…or labs..or $15K videolaryngoscopes. The FANZCAs who visit rural hospitals, whether for elective lists or retrieval, did at least have an idea of our circumstances Yand ‘special needs’

So, what does the rural GPA really need?

– lectures from experienced anaesthetists? Hell yes.
– small group sessions and case discussions? Even better.
– topics targetted to the audience and suggestions for improvement. Absolutely!

…and to top it off, perhaps consideration be given to sharing the knowledge base by holding two sessions per year (allows more docs to attend…as if one doc is at the conference, the other needs to be oncall)

…and even better, consider delivering content in rural areas by taking some of the ideas on the road.

The other thing that concerns me is the lack of communication between rural docs. Locally the RDASA has a ‘rural anaesthetists’ email group, but it has been inactive for a few years. It seems that many of us have the same issues with respect to equipment procurement, training and upskilling – yet operate in silos. Moreover there is little ‘top-down’ direction – certainly I have no sense of direction from the ‘Country Health SA Anaesthetic Consultant’ and it would be nice to see some more dynamism.

Maybe next year will be better…I’m going to keep pushing the barrel for local delivery of leading edge concepts in EM/anaesthesia that are rurally relevant for myself and other doctors.

Email me if you have any thoughts on this.

iSimulate

Well, finally my wife’s iPad3 with the spanking retina display has arrived. I’m a tad jealous, but more importantly it now means I have two iPads to play with…


…and that has been vital for running a groovy piece of software called iSimulate.


I dunno about the rest of you medicos, but I’ve been to a fair few simulation training sessions, mostly as a junior doctor doing basic and advanced life support. More recently I’ve been through the simulation lab at the Royal North Shore, doing the thoroughly excellent ’emergency management of anaesthetic crisis’ or EMAC course.


These sims are high fidelity and rely on life-like mannikins, realistic environments with monitors, emergency room or operating theatre equipment etc. Moreover, such training tends to only happen as part of a dedicated training session – which may be only a few days every few years.


So I was intrigued when I saw a pre-launch version of iSimulate a few months ago at an EMST course – in fact, there were a bunch of senior EMST instructors there (intensivists, emergency physicians, surgeons and self) who all agreed that the concept was brilliant. 


iSimulate is an app for the iPad – using two iPads and a wireless netowrk connection, one iPad serves as a monitor and the other is driven by the instructor.


The beauty is that the iPad screen has been set up to look just like a standard monitor, with displays for ECG, SpO2, invasive BP, ETCO2, RR and manual BP. The iPad also has realistic alarms, just like standard monitoring equipment. Pressing the ‘BP’ button even causes a realistic ‘cuff inflation’ sound which will be familiar to anyone who’s worked in resus or theatre.

So now one can run a realistic simulation ‘on the run’ – at anytime, in any place.


No more reliance on a simulation lab, purpose-built mannikin or dedicated time off to run turgid BLS/ALS courses – with this app one can run a mock resus every shift, or at the end of a theatre list in the standard work environment, in the clinic, at the roadside.


I think it’s a game changer potentially. And my baby roo (Boo) thinks it’s a wonderful device…

What’s that Skip? He’s in haemorrhagic shock? Instructor iPad on left, Student iPad on right

There is however one drawback – it’s $2000 initially then $500 per annum thereafter…and you’ll need to buy two iPads and a wireless connection (would be mayhem if ran over 3G).


There is a version for $4900 which gives ‘lifetime’ support and licensing. You can see more and a video using a teddy bear (Hugh Grantham’s idea) of the app in action at iSimulate.com.au


However, I think this price still puts the app out of reach of small country hospitals and individuals. The big organisations will be able to afford this easily…but no doubt organisational issues will mean that simulation training continues to be rolled out in the usual ‘once a year compulsory training session’ covering just ALS and BLS.


Which is a shame, because the portability and flexibility of this app mean that meaningful sim could be delivered whenever and wherever needed


I’m in theatre next week, and I reckon we’ll use the demo version to run a mock malignant hyperthermia or anaphylaxis under anaesthesia scenario, just for a giggle.


That would be brilliant. But $4900 to educate the hospital staff at my own expense? Probably not…

Boo the Roo explores the possibilities of iSimulate …but baulks at the price tag

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…