Interesting weekend, spent with Dr Pete Gilchrist and family who were visiting Kangaroo Island...Pete is a fellow SA GP who, like me, had to move interstate to NSW in order to upskill in anaesthetics due to the dearth of training positions locally. Six months down the track we were able to catch up and compare notes on experiences both whilst training and also now in independent anaesthetic practice without the immediate backup of a FANZCA.
At the same time, I read an interesting comment from Dr Minh le Cong (aka the internet’s “most promiscuous medical blogger”) of RFDS Queensland who commented on his own anaesthetic training and relevance to prehospital medicine...particularly the need to learn key skills early and focus on the basics - securing the airway, maintaining ventilation over-and-above fancy or advanced techniques....but also to be well versed in crisis management and dealing with the unexpected’ - as there is noone to back you up in the bush. Minh comments:
“During anaesthetic rotation I got taught RSI a certain way and was told get good at this and you will be fine. Only occasionally I would get an anaesthetic supervisor who would really put you through your paces and test what you thought were adequate routines. Doing a whole anaesthetic using mask ventilation alone, or giving only half the usual dose of propofol for intubation..or tubing from the side position. In prehospital and retrieval medicine, nothing is standard and trying to make anaesthetic skills fit into that environment is challenging when you have learnt them in a controlled setting. The only way to manage this is deliberate practice of non routine. Practice your routine but throw in an uncommon problem and troubleshoot. Practice the permutations. Airway management in the critically ill and injured , in the prehospital setting , is like a street fight. If all you ever learnt in unarmed combat was how to deal with punches and kicks and then you get into a situation where someone pulls a knife on you, what good is your training? Its generally true that most of the time, you dont need RSA , DSI or bougie via SGA. But the challenge is when you do need those skills, are you prepared?”
I’m grateful for the 12 months experience I had in NSW...and the Joint Consultative Committee on Anaesthesia seem to have a fairly robust curriculum laid out. Of course, one of the difficulties for both budding anaesthetic trainees and their supervisors is the need to impart key knowledge that is relevant.
A common criticism is the mismatch between anaesthesia as practiced in the elective, fasted non-urgent theatre case vs management of the emergency airway in a critically-unwell patient...Cliff Reid’s excellent rant ‘the propofol assassins’ makes this distinction very well indeed. So, what then are the key components for the rural GP anaesthetist (or indeed the rural GP on the A&E roster who is a de facto ‘occasional intubator’?).
- competence in airway assessment, use of adjuncts and effective bag-mask ventilation
- ability to safely deliver an anaesthetic via laryngeal mask or endotracheal tube
- critical decision-making in airway management
- ability to manage the emergency airway (typically unfasted, soiled with blood/vomitus and hypotensive)
- anaesthetic crisis management
- a smattering of ICU and prehospital care
In the past year I have been fanatically looking at difficult airway management - not because I particularly want to manage anticipated difficult airways (these are the cases I will be referring to my specialist colleagues)...but more because I recognise that occasionally an unanticipated difficult airway arises and needs to be managed - so I want to have both the tools and the training to safely manage on my own. Thankfully this is a shared passion, and the past year has seen a wealth of information coming through the blog-o-sphere, much of it not taught by old school anaesthetists. Paul Baker of ANZCA has given me some great advice, as has Minh and a few other medicos ‘out there’. So added to my thereapeutic armanentarium are tips and techniques such as:
- Delayed Sequence Intubation
- preoxygenation with nasal cannulae adjuncts & apnoeic oxygenation
- LMA as a conduit for intubation, utilising affordable videolaryngoscopy
- DAS algorithms
Hopefully some of these will be alluded to as my paper on 'difficult airway equipment for rural GP procedralists' draws closer to publication - reviewers comments gratefully received last week and corrections duly made, so hopefully it will get final approval shortly...
On the whole I was fortunate enough to be exposed to supportive anaesthetists who ‘got’ what Pete and I needed to learn in our limited period of anaesthetic training. Recognising that we had particular needs and a strong practical focus to deliver safe anaesthesia for both elective and emergency cases, they taught us the basics in a reliable manner to ensure our safety and that of our patients. But of course, there’s always the odd one out. Some specialists struggle with the concept of rural doctors delivering non-primary care services such as emergency medicine, obstetrics and anaesthetics. They feel, and I can understand this, that the criteria to safely practice in a specialty are the appropriate period of specialty College training and demonstrated competence by primary and exit examinations. The problem of course is that there are no specialist emergency physicians, obstetricians or anaesthetists in much of rural Australia. By necessity, rural doctors undertake training beyond that of an office-based general practitioner in order to safely deliver these services in the absence of specialist care.
So there is a potential tension between some specialists and the concept of “Macygvers-of-medicine” rural doctors. At a personal level, this manifested last year in one specialist behaving as a bully to the GP-anaesthetic trainees under his care. There was a report about bullying in medicine in the media last week, and it reminded me just how awful it was to be a forty-something doctor, going ‘back to school’ in the tertiary hospital and occasionally treated as something that the cat dragged in by one specialist who clearly held GPs in low esteem. Thankfully I have insight enough to see that this says more about that individual than myself..indeed, it has reinforced my belief to ‘act like a professional, even when others around you are not’. I won't name this individual...complaints were made last year, but AFAIK nothing came of them. Ultimately neither Pete or I will have to work with this individual again...however specialist colleagues will and they may wish to not rock the boat to make working life tolerable.
Whilst this bullying behaviour casted a blight upon an otherwise enjoyable year, by golly it made it good to get back to private practice and get away from the hierarchy of a teaching hospital. I have reaffirmed to treat my registrars and students as I would expect to be treated myself...
|The 2011 GP Anaesthetist Trainees from NSW|
The identical T shirts are an unlikely coincidence - no reference
is implied to any specialist anaesthetist alive or dead
Dismissal of the value of rural doctors is not just confined to a few individuals. On a system level, there is an increasing move towards centralisation of services. In SA many health-decisions are metrocentric, with opinions from city specialists often driving such changes. My fear is such an approach leads to ongoing deskilling of rural doctors, of downsizing of rural hospitals in terms of capabilities and staffing, and increased movement towards centralisation of services...
And so the house of cards collapses - a rural hospital loses obstetric services due to a metro-based health edict...and within a year or two theatre services are also lost...nursing staff begin to look to the city to do lucrative agency shifts rather than work locally...rural doctors with procedural skills have no opportunity to use them...and so move elsewhere (often interstate)...and within a very short period the local community is bereft of both doctors and nurses, and their local hospital is further downgraded to a first aid station...and any patient with a problem more urgent than needing a band aid is sipped off to the city, usually by the hardworking RFDS and put more strain on the already-stretched metro public hospitals.
One other thing struck me talking to Pete - the similarities with the hassles he has faced with his regional training provider (my training finished in 2005, but seems not much has changed) and the fact that the issues he faces in his rural practice are much the same as mine - yet there is no common method of talking about things like practice management, dealing with health bureaucracy. We are all operating in silos, rather than in unison. Now clearly there may be ACCC issues if rural doctors collude on price fixing etc...but one wonders if there is scope for sharing of knowledge on practical problems - ensuring adequate numbers and skills of future doctors, equipment & training for emergencies etc etc - surely such collaboration is for the betterment of patient care, not to detract from it? The internet is a powerful medium...the UK's www.doctors.net.uk has been effective in coordinating over 180,000 UK doctors...shame we don't have a similar network for rural docs in Australia to problem-solve and advocate for our communities.