So in episode 324, I gave my take on the initial resuscitation of patients in Rural EDs. I promised I was going to have some actual rural practitioners on to critique and expand the discussion.
Our Guests
Vanessa Cardy
Dr. Vanessa Cardy is currently a staff physician at Chisasibi Hospital in northern Quebec. She is a deputy editor for the emergency medicine education podcast, EM:RAP as well as associate managing editor of Right On Prime, a family medicine education podcast. She is a fellow of the Canadian college of family physicians as well as a fellow of rural and remote medicine. She wishes to encourage future physicians to take on careers in rural medicine and works to showcase the joys and challenges of clinical work in underserved and remote regions of the world.
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. I am also employed as a clinical teacher for the Rural Clinical School of UWA / Notre Dame. I have been teaching Paediatrics to Med Students for the past 7 years. I consider myself to be a generalist – I work in a place where there are no departments and we have to be able to manage all comers. This creates the problem of being a “jack of all trades and master of none”. The motivation behind this site is to try and keep myself (and maybe you) up to date with best clinical practice in the remote and rural parts of the country. I do not see why our patients should receive inferior medical care as a function of geography… at least my knowledge and training should not be the cause of inferior care.
I hope to update this blog as often as I can to keep my own neurons firing and keep my student’s busy!
Also on the web as @broomedocs
Kavi Singh
Some additional thoughts from our guests
Kavi:
Rural Resus Explosion: A. Challenges & B. Solutions
A. Challenges faced by rural practitioners
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Effecting change in a public vs private system is different.
Goals of subgroups may be aligned differently in each system
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Underlying background system resource paucity –
administrative; support – eg archives,cleaning, lab; lack of staff
Covid has magnified staff shortages x 100000
All the background stuff that is usually taken for granted is mixed in with the medical work
-
Ambulatory care workload
Emergency care is one part of the puzzle that is done in between other care or after a full day of the other stuff.
Each of these items requires its own optimization and has its own Cognitive Load:
-Dialysis, Obstetrics follow ups, Pediatrics
-High rate of chronic disease with complications
eg Diabetes (–>renal failure, chronic wounds, high risk pregnancies)
-Cleaning – eg after a triple stabbing one New Years Eve where I wasnt on call at 2am – I spent a few hours with a nurse mopping the blood off the floors, then restocking the room for all equipment, and then was on call a few hours later.
Admin tasks fall to you – Faxing papers, Meds, stocking, equipment readiness, Sterilization – is it happening?
Phone Calls – the time and attention killer in rural areas
Need to call for transfer acceptance, Then medevac dispatch and arguing
And the list can go on and on
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Issues in the actual Emergency
Staffing, knowledge, resources
First 10 min of resusc take longer -up to 30min.
Cutting of a skidoo suit alone takes 10min
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Lack of Tools and lack of awareness that a paradigm shift would be useful
-MDs don't know there can be another way. Not their fault – they've not seen anything else. May lack the time/ability/knowledge to be able to consolidate/prune and streamline resus protocols and decisions.
-Turn to ATLS and other courses that are excellent, but not optimized for austerity.
-Competency achieved but, proficiency difficult to obtain
B. Solutions
System Wide solutions
Governmental level – regional and local
Medevac equity
Resource availability (CT Scanners),
Staffing mechanisms
Training modalities
Rural training as a separate thing vs
Incorporating it into all training
Optimization
Those who have more experience can play a role, through collaboration, in creating and sharing:
-That there are strategies that exist
-Show What can be done and HOW it can be done
-80/20 – go for the big stuff that makes an immediate difference.
Foundational Resusc
-Developing this type of learning system requires a certain amount of experience in managing resus + experience in austere areas. Best done as a collaboration between austere and urban providers. Will better equip All providers at all stages of their training.
-Objective Based
-Streamlining and Design based on work/task flow (ABCD) + operational hierarchies
-Identifying critical skills – eg Anesthesia oriented skills that
Casey
Hey Scott,
More thoughts from Casey
Additional New Information
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Thanks to everyone! I work in what (or so I’ve been told- my OCD is still investigating to verify it’s validity) is one of the most if not the most rural CAH in the lower 48, based on all of the parameters the measure these things on, and it was priceless to have everyone’s input and perspective. Great learning
Thank you all so much for this amazing podcast! Thank you for starting an important and necessary discussion on EM training…I have been listening to your podcasts for a while Scott, and I have to admit that I have often felt like an impostor at work because I feel I cannot give the care you give your patients in my small rural community hospital ER (also you are way smarter then me but that is not the point 😉 ). This conversation has helped me see things from a different perspective, and has made me feel NOT alone! It also… Read more »
I’m trying to reach Dr Kavi Singh, since our group in Western Canada has been labouring on a similar “rural resuscitation” niche training program over the past 8 years. Perhaps we can mutually support each other’s efforts to close this gaping hole in rural medical education. Please pass on my contact info.
When I first got my MD there was always a scramble to get a moonlighting job. My general surgery internship paid 2$ 17 cents an hour given the time I spent in the hospital. I got a job in the boondocks. It was me and 2 nurses, that’s IT. I saw everything I did at a Level 1 Trauma center. Due to the success of malpractice suits in a nearby city all the OBGYNs an Neurosurgeons left the area. I was routinely denied transport of patients to a Level 1 in Houston or Galveston. I soon leaned , at least… Read more »
Thank you for covering an often left-out topic. I work in rural hospitals/critical access hospitals. I am a PA working (solo provider) in these ER’s with two RN’s and maybe a paramedic. I definitely picked up some useful items that I will utilize. Also, I have been listening to EM-CRIT for many years. This helps me stay up to date. Also, I meet Dr. Weingart in Berlin (DAS- SMAC). I took and Dr. Levitan’s Airway Course. Thank you, again!