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?