I was fortunate enough to be able to attend the recent Rural Doctors Masterclass on Kangaroo Island at the end of my locum placement. This was the brainchild of Tim from ruraldoctors.net and KIdocs.org with the intention of bringing cutting edge FOAM concepts to practicing rural doctors with the assistance of small group learning and hands-on skills station.
I really enjoyed the workshop and learned a lot of new concepts and skills out of it. The impression I got from talking to the other participants was that it was generally well received and that people liked the format. I suspect there is a way to go before this crowd would be convinced about the benefits of using FOAM in their day-to-day practice but at least the awareness is gradually getting out there.
Tim’s put a comprehensive run-down of the masterclass and associated “mass casualty” training exercise over on KIdocs, so I wont go into too much of the fine detail. But, for those who missed out on attending the course, allow me to share some of my main take-home learning points as well as some supporting resources that I’ve found for reinforcement:
Evidence update for rural resuscitationists
- In the emergency scenario it’s all about “paying attention to detail” and “aggregating marginal gains”, which is to say that all team members performing just a smidge better can make a big difference to the overall outcome for patients.
- The cricoid pressure debate was summarised very nicely: On balance of evidence, there is no need to use cricoid pressure for intubation. However, if you are used to doing it, you can keep doing it, but have a low threshold to request “cricoid pressure off” if the intubation is difficult or the cords are not easily visible.
- In the debate of sux vs roc for neuromuscular blocker for intubation, the point was made that rocuronium has a lower risk of complications and the longer offset time is inconsequential in the emergency situation if there is no option to “wake the patient up” if it goes pear shaped.
Tips and tricks for resource limited areas
- You don’t need all the machines that go “beep” in order to get useful clinical information! A knowledge of physiology can help, eg:
- Use JVP as a marker of preload and if it’s low, the patient is hypovolaemic and will tolerate a fluid bolus.
- CVP can be estimated clinically by the hand lift test – ie – the level at which the hand veins empty when lifted above the right atrium ≈ CVP in cm H20. Urine output is also a useful indicator.
- A pulse oximeter on the toe can help determine if there is peripheral perfusion (and contrary to popular belief – nail polish makes no difference to the readings).
- Deep rapid inspiration in a systemically unwell patient may be a sign of metabolic acidosis with respiratory compensation.
- Spray a sweaty chest with deodorant to get ECG dots to stick better.
- Think about using readily available medications in unusual ways, eg glucagon can be used for oesophageal foreign body obstruction or for overcoming B-blocker overdose (see this interesting blog post for more).
- Using the time while awaiting the retrieval team to package the patient as well as possible. This will allow the patient to be transported as quickly and efficiently as possible which gets them to their definitive care as sooner.
- Use a checklist such as this one from ARV in Victoria (MedSTAR in SA has a very similar one just being rolled out). Here’s one that the RFDS uses.
Acute psychiatric emergencies
- Physical restraints have significant risk of harm due to increased psychological distress and have been associated with sudden death.
- Ketamine is the drug of choice for chemical restraint as the patient maintains airway protection.
- 5mg/kg IM or 1-2 mg/kg IV
- Keep monitored including end-tidal CO2
- Keep topped up with 1-1.5mg/kg/hour via bolus or infusion
- There are some great apps available for calculating drug doses and equipment sizes for kids, eg Pedi STAT or Pedi Safe.
- Here are a couple of useful resources: The paediatric emergency drug formulary and anaesthetic dilution chart.
Trauma & surgery
- Tension pneumothorax:
- Needle thoracostomy has a significant failure rate – I never knew that! It’s always been taught as the definitive procedure…
- Alternative is finger thoracostomy – If the patient is intubated & ventilated you can leave it open, but a chest drain must be inserted in a spontaneously breathing patient to avoid open pneumonthorax. You can see a couple of articles and videos on the technique here and here.
- Penetrating wounds
- Bleeding in the abdomen, root of neck or other hard to access areas can be controlled by inserting a foley catheter into the cavity, inflating the balloon and pulling it back until it tamponades the vessel.
- All penetrating abdominal or gunshot wounds should be referred for exploration in theatre.
- Emergency surgical airway
- Emergency thoracotomy
- Is indicated for witnessed cardiac arrest after penetrating chest injury.
- It’s necessity in blunt trauma is less clear.
- See this detailed blog post for more info on indications, contraindications and technique.
I’m afraid this was the one presentation which missed the mark a bit with the audience. It was presented by a city based, specialist obstetrician who didn’t really understand the context of the isolated rural proceduralist. For example, the advice that GP obstetricians should transfer all retained / adherent placentas to tertiary centres for removal just in case of unanticipated placenta accreta was not particularly realistic. Perhaps for next time an obstetrician or GP obstetrician with appropriate rural and remote experience would be a better choice for this context.
For the first Rural Doctors Masterclass I think it was a great success. The well presented, relevant, up-to-date clinical content and the opportunity to discuss practice points with other experienced rural doctors from all over Australia was very valuable.
A huge thanks must go to Tim for having the vision and doing so much of the organisation as well as SAPMEA and all of the fantastic presenters. I would certainly recommend the experience to others, and would love to go again if it were repeated in the future.