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?

Essential Equipment

I've long struggled with the ideal contents of my prehospital pack. Time was that I carried enough gear in the back of the ute to perform an emergency laparotomy at the roadside...as time goes on I've slimmed things down...even more so on kayaking expeditions where weight and space are at a premium. Indeed, my minimalist approach to medical kit caused a small stir in the Australian sea-kayaking community, not least for the reliance on duct tape, superglue and suggesting the rectal route for treatment of dehydration and/or hypoglycaemia.


I've touched on thoughts for minimal standards for prehospital kit and a move towards similar standards in equipment and infusion protocols between small rural hospitals and retrieval services elsewhere in this blog. However, I was surprised to see the inclusion of a rubber chicken in Minh le Cong's essential prehospital kit. You can read more over at Cliff Reid's Resus.me site. But this of course raises the issue of what other 'unique' piece of kit that you feel you cannot function without.

Choking the chicken - an essential prerequisite for retrievalists?

For me, it's always been a six-pack of Dr Tim Cooper's Pale Ale (or Dr Tim's) - I usually slip a six pack in the vac-mat for the retrieval team when they take away a sick patient - in thanks for their efforts and as a reward to enjoy back at base.

What weird extra kit do you carry in your prehospital or emergency bag?

Keeping it Simple

One of the enjoyable challenges of rural & remote medicine is delivering high-quality care within the constraints of a health system that is cash-strapped, and where rural doctors often work between private clinic (own business) and public (State-run hospital) domains.


Sadly there exists a health-gap between rural and metropolitan Australians. For many services, health outcomes are worse in the country than in the city. This is in part to the tyranny of distance - the nearest specialist unit may be hundreds or even thousands of kilometres away. It's also about limited resources.


Conversely some things are done very well in the country - birthing services for selected (low risk) mothers are excellent when delivered by local midwives and GP-obstetricians, as are local surgical services which can offer an almost bespoke service rather than the 'sausage-factory' of a major tertiary hospital.


My particular interest is in emergency medicine and the particular problem of how to deliver high-quality emergency care in the bush. The 'gold standard' for delivery of emergency medicine in Australia is Fellowship of the Australasian College of Emergency Medicine (FACEM). But FACEMs, like other specialists, tend to congregate in the city hospitals where they can share workload with colleagues and also deal with the stuff they are trained to do on a daily basis.


Meanwhile staffing of the 'accident and emergency' department of a rural hospital can be variable - usually there is no on-site doctor, but a service is provided by one of the local doctors in primary care. He or she may have lots of EM experience....or very little. Which can be a challenge for medical and nursing staff who may only see this sort of emergency infrequently.


Well-trained rural doctors take this sort of thing in their stride. Ideally rural doctors have spent a year or so gaining experience in each of obstetrics, anaesthetics and emergency medicine. Excellent courses like EMST, APLS, ALSO, RESP and MOET help to keep rural doctors in touch with current practice.


More important is anticipation of the likely caseload, with planning & training for the worst.   This is not a new thing - recently guidelines for a minimum prehospital equipment setup have been suggested and such standardisation has many advantages. The lack of agreed standards is one of my bug bears.


Perhaps one of the hardest emergencies to deal with is the difficult airway. Training helps, but most of the training on anaesthetic rotations is in elective anaesthesia - I'd argue that the emergent airway is a very different beast!


In South Australia there is no agreed standard on 'difficult airway' equipment between the 30 or so rural hospitals. It seems bizarre to insist on appropriate credentialling for doctor's working in these areas, but not to insist on an agreed standard for the equipment they use.


Perhaps that is a bit harsh. ANZCA has outlined a technical guide on 'equipment to manage a difficult airway' and it is suggested that individual hospitals determine what is best for them.


Recent discussion on a hypothetical case from Minh Le Cong in FNQ made me think about this. Often experts in tertiary centres will ask why adjuncts such as non-invasive ventilation, heliox or fibreoptic intubation were not employed. Simple - we may not have them in the bush.


Hospitals often don't decide on what equipment is needed until it's too late i.e. after a critical incident, usually through the lens of a Coronial investigation (the case of blood product availability in the Riverland is a case in point). More problematic, the equipment often costs tens of thousands of dollars, which means local CEOs having to plead a case for their hospital, for a piece of equipment that may only be used once in a blue moon - but when needed, is indispensable. Such is the nature of emergencies.


Rather than the local CWA having to sell a few thousand scones and woolly teddy-bears in their annual fundraiser for the local cash-strapped hospital, I wonder if it might be better to invest in economies of scale. Agree a minimum standard between health units, train medical staff in how to use it, and allow recycling of stock that is infrequently used to the major tertiary centres. In South Australia, integration with the Statewide retrieval service (MedSTAR) would seem logical, with common protocols for low-volume infusions, difficult airway and other emergencies shared across the State.


Thankfully there is light at the end-of-the tunnel. New products on the market offer potential to turn a difficult airway (Cormack-Lehane Grade III/IV into a CL I or II). I am of course talking about videolaryngoscopes and the new disposable fibre optic devices. There's good discussion here, here and here on these, which I won't repeat....check them out for yourself!


I think it is now at a stage where it is indefensible for rural hospitals not to have good quality, easily set-up and maintained equipment for managing the difficult airway, to a standard similar to that of a metropolitan ED.


Costs are coming down, and it would seem logical for health units to agree on a standard (which should be locally-driven) and purchase devices in bulk. Equipment which is used infrequently could be rotated through higher-use centres, much as we currently cycle expensive thrombolytic drugs before expiry dates.


Moreover, medical staff rotating between sites (whether GP-anaesthetist locums or retrieval staff) would be familiar with the equipment used, allowing easier setup and use - often the main problem when in a difficult airway scenario.


What would I recommend? Well, the KingVision VL is cheap and easy to use. The video screen affords good views which can be watched by others in the room. It is going to be my default device if failed direct laryngoscopy.


I'll also lobby for the Ambu Ascope - a relatively cheap disposable fibreoptic scope than could be an asset for awake nasal or oral intubation...or as a bailout tool to pass an ETT via intubating LMA.


Having the kit is one thing - using it is another. The annual rural doctors conferences (whether State or National) are a chance for both GP-anaesthetists and GPs providing emergency care to meet and discuss equipment, with opportunity for hands-on workshops.


But there's no substitute for using the gear on a routine elective theatre ist, which again means an investment in training with the kit with a view to ensuring that it's usable when needed.


What do others think?