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

Emergency doc splitting his time between rural and urban EM. Director, Emergency Medicine Preparedness & Risk Management, Faculty of Medicine McGill University. Creator Emergency Medicine Performance Under Pressure

Some additional thoughts from our guests

Kavi:

Rural Resus Explosion: A. Challenges & B. Solutions

A. Challenges faced by rural practitioners

  1. Effecting change in a public vs private system is different.

Goals of subgroups may be aligned differently in each system

  1. 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

  1. 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

  1. 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

  1. 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,

Thanks for doing this Rural Resus episode – it is something that is rarely mentioned in ED / Crit Care circles and I reckon there are some key differences.
As you know I have worked in a remote / rural ED for nearly 20 years, in the last few years have been doing shifts in a quaternary ED part time – so I have had the chance to see the differences and had to constantly recalibrate my “resuscitationist mindset” depending on where I am!
A LOT of what I have learned is in line with your excellent “Logistics over Strategy” podcast from 10 years ago.  But I will try to give my take on this.  A bit of a rant sorry
LOGISTICS:
In a rural ED knowing the kit / processes / drugs / machines etc is crucial.  We are often working in a “flash team” who have never worked together before and often with high turnover of staff – this means that you may not rely on anyone in the team to know where the  infuser pump button is or how to set the vent…
This “FLASH TEAM” requires a very different style of team leadership.  You cannot just rely on each team member to be awesome at their task.
Constant closed loop feedback and adjustment is key
Often I am teaching as I lead… the new Grad Nurse is capable of titrating pressors or adjusting the vent settings if I give very clear and specific instructions.  eg.  “If the ETCO2 goes above 35 I want you to increase the RR by 2 /min and let me know”  or   “Whilst I am intubating you need to watch the arterial line – if the BP goes low we will give 1 ml of metaraminol, if it goes high we will add 1 ml of propofol”
Giving very specific, focused tasks allows me to offload and focus on what I need to do
Luckily, most ED Resus Doc in rural Australia are dual GP / Anaesthesia trained – so we are self-sufficient with our Theatre work –  which translates well into running the logistics / pharmacology/ practicalities of a resus.  So I think that having the “Anaesthesia attitude” in rural Resus is very important.
Often the team is SMALL – sometimes 1 doc and 2 or 3 nurses.  We use our orderlies and volunteer Ambos to do chest compressions!
This means that the Doc should not be the team leader – at least not in the first phase of Resus where A, B, C and critical procedures need to be sorted ASAP…  it is hubris to imagine one can team lead and intubate  – trust me I have cocked this up many times.
I like the most senior nurse to be the TEAM lead + Scribe  – they stand at a pulpit stand at the foot of the room and watch / time everything.
When I am focused on the airways or placing the femoral lines they are the one watching the BP or Vent etc…
Once the initial phase is finished and we have control then I retake the Team LEad position.  Rural Resus has phases and we change roles as they progress from ABC => Optimising  => setting up for Retrieval…
I love Cliff Reid's Cognitive Simulation – every new cohort of trainees we get in Broome gets the same orientation from me – we stand in the Resus Bay and imagine all the “worst case scenarios” which require that ‘FIRST10EM' logistics..  Where is the pelvic binder?  Where is the IO kit, how do you use it?  How do you access the protocols for all the resus drugs?  Where is the kit for finger thoracostomy? …  We spend as long as it takes to go through mentally and open all the drawers / boxes and mentally plan for the common early life threats.
Mental rehearsal of procedures and Grim Fantasy internal simulations are very important if you only do that procedure once or twice a year.  It is impossible to be competent (aiming for excellent!) at a task if it rarely happens (by virtue of a small population) – therefore frequent mental rehearsal is especially beneficial for rural docs.
Simulation is really important – however access to good Sim in the bush is usually impossible – so mental rehearsal is key.
Rural ED Resus  bays need to be set up to make the processes idiot proof. (yes, I know rural docs are not idiots) This is true in big city EDs however the benefits in small places are much bigger I think.  Rural EDs tend to be very idiosyncratic with often very antiquated equipment.  Often local strong personalities drive the set up (which is usually not great!)
For me  – Standardisation is key
Having PREPLANNED processes such as
– team configuration
– RSI protocols / checklists
– procedure -specific boxes (we have CVC, Art line, Surgical airways, chest tube / thoracostomy / torniquets) all ready to go on the wall
– easy access to information such as pharmacy / blood products availability
I spent a year working with Rippey on a website to guide simple processes and protocols / training for Rural Docs… you can see it at  https://emergencywa.org/
The other “Logistics” concept that makes Rural Resus different is what I call  “Destiny Driven Decisions”  – this is a key difference in the dynamics of Rural resus.
– if you work in a town with no CT or Surgeon or ICU then you need to make early decisions about the Resus based on the problem / disease and available resources … Where does the patient need to go?  Our rural people deserve exactly the same level of care as city folk – our job is to make that happen!
For example, if the head-injured GCS 10 patient is needing a CT or ICU then the decision to intubate becomes easy – there is no gain from sitting on the airway.  Retrieval often demands taking control – I have seen a lot of errors made where folk think like big hospital docs and imagine that they can hold off on interventions such as intubation – ultimately costing time and leaving the patient at risk…
Rural Resus means you need to know what resources you have and when you need to “get out quick” – early decision-making is key.  Usually this is clear from the clinical scenario, before any imaging or labs are back… occasionally we get a surprise.
It should be mentioned that intubation is 99% a one-way street that mandates transfer to an ICU in a far away hospital…  so we also need to consider when this is not in the patient's interest .  Classic example being SCAPE / APO – where we can usually turn a patient who looks like crap into a ward admit with 2 hours of intensive CPAP and GTN.  This takes a bit of balls  as a Rural Resus doc – knowing when to say “no, we are going to stay and play” vs “get the hell out” is a tougher call.
The reality of Rural Practice is that a lot of Docs that end up in rural places are not “resuscitationists” as you describe – they are often locum Family docs or trainees who are having a bit of an adventure (or sometimes semi-retired docs out for a last hurrah!)…  this means that often their Resus skills are either developing, fading or never existed!  and then we get the scenario where “if you cannot do X, then you will not consider X as an option”….
X may be starting pressors for sepsis… so they get 5 L of saline instead…  or not starting NIV as you never have and using more and more O2 for COPD or APO.
ULTRASOUND (my biggest bias!) is invaluable in Rural Resus – however it is poorly taught and misused in practice ( current life mission is to fix this in Rural Australia).
Simple things like
– checking bilateral sliding post intubation – because it is often hours until you get a CXR that is embarrassing if in the R main!
–  never miss an IV or arterial line again if you just learn how to drive a needle under US -guidance.  The benefits for the occasional Resus doc are huge.
– nerve blocks get me out of trouble a lot – avoid having to give a GA in a crumbly dialysis patient who needs their source of sepsis controlled ASAP
FAST EXAMS – are essentially pointless in most medium to large hospitals with CT and Surgeons..  however, they remain very useful in the bush.  Unfortunately we still see a lot of “NEGATIVE FAST – therefore fine” thinking.
The FAST should probably only change your course of action if positive – then you know where you need to go.  Understanding the implications of what you can see with a probe and what that means for your resources is key.  That is use it to rule in, not rule out, then move faster
There are also a lot of considerations to think about when you are going to be putting the patient onto a small, noisy, cramped plane for 6 – 12 hours…eg.
– placing lines in practical places where they won't occlude or be impossible to access
– lower threshold for CVC (often femoral) to allow the retrieval team 3 or 4 robust ports to use)
– double / triple checking tube position, cuff pressure
– DOING all the FAST HUGS (Nicksons ICU checks) stuff before they get on the plane – you often find stuff awry here!
– Communication with the receiving team  – Time in Rural Resus / retrieval is often wasted where we can usually initiate therapy  en route if we talk to the team at the other end.
– Family is really important.  Often there are big decisions to be made about Resus / Surgery / palliation etc.  As a Rural Resus doc you are the one on the ground with the family who typically cannot travel with their loved one … so it falls to us to guide and counsel this process

More thoughts from Casey

A few thoughts in prep for the chat next week.
“Pruning the decision trees”. Examples of simple  / heuristic based decision making :
– Respiratory failure:  in the first instance I don’t get too worried about diagnosis – this can take time… so I break it down to Type 1 or 2 (what is the CO2 trajectory? Pick CPAP or BiPAP)
– then there are 2 groups of patients: those who get a good improvement with NIV and those who do not
– I give them an hour or two on NIV + whatever specific care I reckon they need and then make a call – is this going to get better?
– if the trajectory  / diagnosis / prognosis is towards a tube / ICU then it is better to do that early and transfer
– if palliation is the goal – then you have time to get family etc involved and avoid wasted TF
– burning 24 – 48 hours on failing NIV etc with intense nursing etc is a wasted resource
Trauma – a few thoughts.
– Usually there is a “destination determining injury”… this may not actually be the most severe injury.  For example, in Broome we do not have Ortho but we do have basic trauma Surgeons.  There fore a spleen injury I can handle locally where a tib/fib fracture needs to go out.   So knowing your resources and such drives decision-making.  Early recognition of the patient’s DESTINY guides decision making.   I call these  DESTINY DRIVEN DECISIONS
-If the destiny is ICU for ongoing Resus and management then an early ETT is key.  Having an awake, dunk /  agitated, line-pulling patient in a small ED burns a lot of resources and creates chaos.  If the patient needs a tube then do it early… you don’t need to rush in with a crash RSI, but you do want to get all your infusions etc ready and then proceed as soon as the team is prepared.  Do it early, do it safely and save your team a lot of trouble.
I call this the low-decibel Resus – take control of the situation and keep the patient and team calm.  Then we have time and analgesia onboard to do all the procedures / logistics and such without the noise and chaos.
PROTECT THE BRAIN
In tertiary hospital we differentiate between head-injured and “non head-injured” folk….  Usually with the benefit of an early CT.  However, in rural / remote hospitals CT is usually not available at all or not early.  We seem to be very paranoid about “protecting the C-spine” as the old EMST courses drilled that into us all!  However, there is almost no thought given to the brain in the initial or transfer phases of Resus for multiple-area trauma unless they have obvious low GCS etc….
…. my mantra here is to “treat them all as head injury” until proven otherwise.  So do the simple things well.  Elevate the head as safe with other injuries.  Avoid any thing that raises ICP.  Maintain a decent MAP.
I have seen too many cases where young folk are treated for their chest injury and eventually get a CT 6 hours later only to find a significant brain injury and ONLY THEN get neuroprotective measures.
Most of these manaiuvres are simple and don’t cost much
Sepsis:
Treating septic folk in rural / remote places is tricky.  Fluids, IV ABs, pressors are all easy -( I wrote our peripheral Norad protocol a few years ago)
– there is really no reason why any small hospital cannot do these components of the bundle of care exactly the same as any big hospital in the first few hours – all you need is 2 good IV drips.
– the big issue, the one that is overlooked is SOURCE CONTROL –  every protocol I have ever seen seems to miss this point!
– If you are hours / days away from definitive source control then the diagnostic workup becomes focused on identifying / excluding these diagnoses early.
Egs.
-Urosepsis ; you can’t just give ceftriaxone and pray – you need to ensure the kidneys are not obstructed – that is a very different scenario
-Belly source – do they need to go to the OR early?  Look at the GB – if it is obstructed that needs a tube in it – move them quick cos the Tazocin isn’t gonna work
– skin – we see a lot of diabetic feet.  AlthoughI can’t do a BKA in ED… I can place a regional block and open the pus early – the surgeons can sort it out later!
– Pneumonia is common  – and I am showing my US bias here – but if you work in a remote place… don’t just throw them on the ward if they look septic.  CXR sucks for missing empyema / effusion.  So I scan them all early if they look sick before settling for IVABs and Resus.  Diagnosing these SOURCES early will save a lot more lives than measuring IVCs on echo!!
ULTRASOUND STUFF
I am currently setting up Ultrasound Training for our states rural hospitals…. I get asked a lot about which skills I recommend that folk learn:  Here is my hierarchy:
 1. Learn how to guide a needle into a vessel (artery or vein) safely & reliably (including Seldinger techniques) – this is the cornerstone of Rural Resus.  You can be the smartest Doc on the planet but it doesn’t help if you have no access!
2. Lungs – learning how to interpret lungs is a game changer.  We usually work without Xray (at least after hours) – IF you can do a lung scan then you are golden.
– it is really the only utile part of the FAST scan for 99% of trauma cases
– you can pick pneumothorax, pneumonia, heart failure, effusion , check tube position, guide fluid Mx (with more accuracy) early before the Xray tech arrives
3. Early pregnancy – another game changer – you don’t need to be amazing, you just need to be able to identify an IUP…. And know when to worry.  This is really just about discipline.. Be rigorous and use US to exclude badness then you can relax a bit… but there are a lot of traps in early pregnancy so you need to have a robust, conservative  decision-tree
4.  RUSH or similar – basically being able to say : is the problem the pump, the tank or an obstruction….  Traditionally we have just given volume in Rural Eds and hoped… and that works 80% of the time…. But I think we can do better and find the patients who need either early transfer / inotropes or maybe thrombolysis etc
5.  FAST is what everybody wants to learn.  That is fine… it is a “gateway scan” as it gives you skills to look at other stuff. But it I a problematic scan in its interpretation… In any place with a CT or with a Surgeon it has almost ZERO utility… in my experience it tends to provide false reassurance which is a BIG problem if you are 1000 km form help!  So I Teach FAST as a screening tool…. Use it to identify patient who need to get out NOW, and can’t wait for the next plane tomorrow…. Don’t see a FAST as a happy negative  – it shouldn't change ones thoughts in that direction …
AGITATED / AGGRESSIVE PATIENTS 
This is not sexy stuff but in my 20+ years in Rural the most stressful and dangerous situations I have dealt with are around SAFE, EFFECTIVE management of these patients.
Small rural Eds don’t have a swat team of security or Police to restrain patients.  This is a huge risk to staff and if done badly – to patients too.
Simple heuristic approach below:
The single biggest error here is leaving these folk waiting- they usually get down triaged or avoided / left in a room… don’t do this.  See them early and decide on 3 things:
1. DIAGNOSIS – is this Tox / drugs / a temporary phenomenon  OR a chronic mental illness that has gone off the rails. OR  something MEDICAL – eg encephalitis
2. DUTY. – what is our DUTY OF CARE?  Is this a drunk who punched someone and needs to go to lock-up or somebody who needs protecting / medical intervention / investigation
3. DISPOSITION – are we going to keep them if they try to walk out?  Are they going to be admitted for mental illness?
I think of these in 3 groups:
Chronic mental illness that I cannot fix today – these are easy as I can usually give appropriate antipsychotic / sedation and get them to definitive care / admission – they don’t need to be dropped usually.
The Tox (eg. Amphetamine) or really aggressive MH patient – they need to be contained and treated / investigated / get care – so here we do PROACEDURAL SEDATION with the procedure being  – whatever they need.  Usually this means prolonged sedation – a long slow dive that keeps them safe.
The 3rd group are more the forensic folk – if they need arresting, them get them out of the ED ASAP – don’t put staff at risk if this is a POLICE issue (often the Police are not to clear on which group is which)
I will probably come up with more Ideas  as I am stuck in isolation alone all week and need to keep myself distracted!
IS this stuff what you are after?
Cheers
Casey

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