Are Anaesthetists Propellor Heads?

I was just reading pearls of wisdom from those Norse Gods of retrieval medicine over at Scancrit.com...a nicely laid out blog with snippets and updates of interest to not just the prehospital doctor but anyone who is involved in anaesthesia and EM, whether in the tertiary centre or out in rural Australia.

In fact, this crisp blog is perhaps what this blog should be - a useful repository of medical information for use in an emergency at 3am. I reckon I'm quite a long way off target, but time will tell.

Anyway, this week’s snippet concerned the ‘Kepler’ robotic intubation system. Now I do think that robots are kind of cool...and it seems I am not alone in this, with the urology surgeons taking up the idea of robotic surgery with enthusiasm.

I am still not convinced that a robot is needed to intubate the trachea...but the ScanCrit docs tell me that they will soon be taking over my work on Kangaroo Island and ‘tele-tubing’ my patients for me from the remoteness of Norway.

More like teletubbies I reckon, but that’s another story...

But it is fair to say that anaesthetists, as a bunch, are ‘propellor heads’. They are the most likely to have an interest in gadgets. Maybe it comes from a training programme that seems to delve uncomfortably deep into concepts such as vaporiser design, laminar flow, Hufners constant and whether or not you can give halothane intravenously (turns out you can, perhaps)

Whatever, walk into any theatre and it will be the anaesthetist who has established a personal wi-fi hotspot so that his/her MacBook, iPhone and iPad can integrate seamlessly. As a rule anaesthetists worship at the altar of all things Apple and are as au fait with the ins-and-outs of Siri as they are with describing multicompartmental pharmacokinetic models of anaesthesia.

I managed to wind up one of the FANZCAs in NSW last year by convincing him that Steve Job’s last bequest to the world before he died was the imminently due iGas workstation, allowing anaesthetists to not only monitor their patient from the tea room using an iPad and wi-fi connection to the iGas anaesthetic machine, but also to have optional remifentanil module. I swear he came in his pants at the thought. Good thing I didn't mention the ultrasound connectivity...

In the spirit of keeping the anaesthetists happy, I have just stumbled across the following range of theatre caps - ideal for the tech-savvy anaesthetist who doesn't mind flaunting his or her knowledge. I wonder if they will catch on?

Of course, we all know it’s the orthopods who are really the smart ones.  The paper in the Christmas BMJ last year (‘As strong as an ox and amost twice as clever?’) caused some howls of anguish from the gas board who feared loss of the intellectual high ground. It’s not for nothing we refer to the blood-brain barrier.

Not me. Now whenever the orthopod growls about ‘too much/little blood pressure’ I have carte blanche to say “Well, you’re the clever one - you fix it” and go back to racking up high-scores on Angry Birds.

"ICU is full and this patient is in asystole. And you want to fix their fracture?"

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?

Emergencies & GP after hours

Well there's an interesting article this week from Emergency Medicine Australia (Nagree et al 2012 'Telephone triage is not the answer to ED overcrowding' EMA 24 123-126) as well as a media release from the Australasian College of Emergency Medicine regarding triage.

Before rural medicine I was an EM trainee. I'm pretty passionate about emergency medicine - sadly one of the reasons I got out of the specialty was frustration with things I could not control, not least the phenomenon of 'access block' - too many people in the ED, waiting for beds on the ward. I must admit that as a junior doctor I would bemoan 'GP-type' patients clogging up the ED...but as time went on and I matured clinically, I realised that:

(a) these low acuity problems were quick and easy to fix
(b) they were not a burden on time or resources
and
(c) often even the low acuity patients had complex health needs that required admission to a hospital for sorting out.

As a rural doctor I do my utmost to avoid turfing patients unnecessarily to my overworked colleagues in the ED, trying to smooth my patients' admission to the appropriate unit without them having to be stuck on a trolley in the ED awaiting review.

Whilst it is tempting to imaging the ED clogged up with non-urgent problems, the reality is that such presentations are easily dealt with (even the most junior of resident medical officers can treat a UTI or reassure parents of a child with otitis media). What clogs up the ED are complex patients requiring investigation and admission, as well as the labour and resource-intensive presentations such as critical illness.

It's also relevant to the ongoing issue of what is and what isn't an emergency - with a blatant cost-shift between State and Federal funds trying to classify many ED attendees as 'inappropriate GP-type attendances'.

But there is a problem.

Politicians need to be seen to 'do something'. They have latched onto the concept of the idea of triage 4 and 5 patients as being GP-type attendees and in a non-evidence based approach have poured hundreds of millions into schemes such as GP after hours, co-located clinics and the disastrous healthdirect phone line.

Phone triage sounds good. But it doesn't work - experience from overseas (not least the ill-fated NHS-direct in the UK proves this). Put simply, a nurse or a GP following a protocol will not be able to diagnose over the phone 100% reliably. It may be a sop to the worried well, but my grandmother can do this job just as well and won't cost the estimated $200 million that healthdirect costs the taxpayer.

The Health Minister has stated that healthdirect has deterred 30,000 patients from a million calls from visiting the ED. Sounds good...but that's only 3% of calls...surely better to spend that money on beds and more clinical staff...not a phone service.

We don't do phone triage in the ED, instead advising patients to present to the ED for a face-to-face assessment - because it is a safe approach - history and examination cannot be done reliably over a phone. In fact, the more medicine I do the more I realise how medicine doesn't fall into neat protocols or boxes. The skill of a good Emergency Physician or GP is to spot the severely abnormal amongst the morass of mostly normal. A protocol (or my grandmother) will get things right most of the time - but will miss the more unusual or atypical presentations. The UK's NHS-direct has learnt this, with several lawsuits after missed diagnosis - the headache that was a subarachnoid, the febrile child with meningitis etc.

So Prof Nagree's paper neatly debunks the idea that phone triage alleviates pressure on Emergency Departments. What then of triage as a measure of ED vs GP-type attendances?

Triage is a score of urgency of treatment - not complexity. Many triage 4 or 5 patients have been sent to the ED by GPs. To then proclaim that they are 'GP-type' attendances misses the point that such patients are complex, require extensive investigation (usually using facilities not present in a GP surgery, such as X-ray, bloods etc) and often require admission.

This may not sound like a big deal - but it is an issue in the country where patients who are not admitted are charged a fee for attending the ED, on the spurious basis that they represent routine General Practice.

Which then raises the issue of GP After Hours services - what is the appropriate level of service needed after hours and will pumping money into GPAH alleviate pressure on EDs?

The Government clearly thinks so and is throwing around money like a drunken sailor. We met with the Medicare Locals mob last month on Kangaroo Island (formerly they were the Southern Division of General Practice in Adelaide, then GP-Network South, and now the unwieldy Southern Adelaide-Fleurieu-Kangaroo Island Medicare Local). They were canvassing opinion on GPAH services but seemed to have no grasp of the issues locally nor how to address them.

I always think of GPs like plumbers - you need us during working hours for scheduled things like routine maintenance...but we might have to deal with the occasional urgent job like a dripping tap. However you don't really need these things fixing at 3am. On the other hand, if the hot water service blows up or a water main bursts, this needs to be dealt with. These are the medical equivalent of an emergency medicine service and as rural GPs we provide this too. However is this routine GP or is this an emergency?

I'm a simple chap - I think that primary care generally deals with most things...but if it cannot wait 12 hours or needs the services of a hospital then the problem is ipso facto an emergency.

Nagree's paper establishes that phone triage does not alleviate pressure on EDs - the issue is access block, not inappropriate attendees. The corollary is that most patients are in ED because they belong there - throwing money at afterhours services by GPs doesn't really address their complex health needs requiring hospital services (imaging, same day bloods etc)

However the issue of non-admitted emergency patients remains unaddressed. I can cite numerous examples (not least from the current busy Easter weekend oncall as I type) of people presenting appropriately to the ED - but being forced to pay for their attendance because they are not admitted (State Govt cost shifts to Medicare)

Examples include

- fall from a roof, 25 cm incisional wound requiring formal debridement under local anaesthesia and repair taking 90 minutes

- fall from a horse with possible cervical spine injury

- four tourists in a medium speed (60kph) rollover on unsealed road, presenting to hospital for forensic blood alchohol, assessment of injuries

- 13 year old fall from skateboard with angulated Colles fracture requiring manipulation and casting

- mental health patient brought in by Police for assessment

- 45 yo with ?fracture-dislocation shoulder requiring analgesia, X-ray and reduction

All of these patients chew up a few hours of time. I think they were appropriately seen within the ED and not deferred for a routine 15 min GP appointment in the week.

However the false reliance on triage as a marker of GP vs ED attendance will continue to encourage misguided strategies to reduce ED overcrowding that are doomed to fail. It also allows cost-shifting from State (emergency) to Medicare (GP) budgets.

As ACEM say "it is in the political interest of State governments to ensure that any definition of general practice patients seen in EDs yields high numbers. This helps perpetuate the myth that EDs have too many GP patients'

Quite.

What do others think?

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