Mindset
The Goals are Different
Get them out alive and we can't even hold to that as a marker of good care
Play a System I Game for the First 10
Need cognitive bandwidth
Checklists
Ruthlessly eliminate Task Steps, Staff Necessity, and Equipment
Rural docs are just as smart–they just don't have the same resources
The solution is not to do identical care worse
The solution is to have a different paradigm
Foundational Stabilization
Prune the Decision Tree
NRB >> NC + BVM c PEEP >> Intubation
Bilat finger thoracost / pelvic binder / blood products
Kavi gives the example of ACLS
train compressions, and shock
Tachy–shock
Brady–epi & pace
Chest Tubes
Finger thoracostomy >> ETT
Self-Sufficiency
Any ancillary service that manages mission critical tasks but are not available within 5 minutes, 24 hours a day should spend their time training the ED/ICU staff on these tasks rather than performing them primarily
Ruthless cross-training
Use Cognitive Aides and Friends for 10 min to 24 hrs whenever needed
Equipment
Resus Room Readiness
EMCrit Intubation Bag
EMCrit Med Bag
BVM set-up with ETCO2 and PEEP Valve Hooked up to Oxygen
Choose Idiot-Resistant Equipment Whenever Possible
You Don't Need Many Resources, but the ones you do need are Mission Critical
- Ultrasound
- Buy your own VL
Additional New Information
- Should have put in the ‘cast–aggressive expansion of the role of Nurse as co-leader of all resus to allow doc to vacillate between focused and overview roles
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Enjoyed this perspective – was a camp nurse in the Rocky Mountains for many summers with little resources and long times for advanced care for serious medical and trauma (horses can do some serious damage to pediatric bodies!). Then a Flight nurse with OK resources but often in extreme and/or austere circumstances. Taught a NRP class today and went through with the resident as required all of the “perfect room with all of the best stuff” scenario – she did great. I ended the class with giving her a scenario with a police car in the parking lot with an… Read more »
For rural docs have challenged to find training, check out your nearest HEMS program and they may be delighted to invite you to their trainings. The training is top notch, designed for providers “out there all alone,” and includes most of the skills mentioned by Scott as critical for rural EDMDs. As a flight paramedic in a rural area for many years, and now working part time between Caribbean islands with low resources and a little rural ED in upstate NY, I can attest to the sensible suggestions here.
Many thanks for putting this out there. I split my time between resource limited rural EDs and a tertiary ED in the University of Vermont Health Network, with a little time in very remote arctic Alaska on the side. Absolutely loved the emphasis on self sufficiency in the first 10 minutes — you need to be able to register the patient, place their IV, override emergency meds from the pixis, push meds, intubate, work your own vent, set up your own chest tube, apply tourniquets, mix K centra, and call for transport. You will not need to do each of… Read more »
As a rural generalist I mostly agree with this. Indeed the goals are, and should be different. I do however disagree with the mentality/mindset of ‘good enough’. Perhaps this is just a semantics thing. We will never deliver the complex interventions of tertiary/quaternity ED’s but the goals of our care should not be ‘good enough’ compared to big institutions. We should strive to deliver excellent care given our context. This means understanding what is gold standard in a big institution, but not bench marking on this (which I think is your point). It means prioritising meaningful interventions, plus all the… Read more »
Jonathon—
thanks so much for writing
not sure where the mentality of good enough was stated in the piece.
i believe the line I repeated constantly was, “the goal is the best possible care within the context”
which i believe by your last line is your exact goal as well.
s
Loved this piece! Please do more. Heck it would lend itself well to a stand alone course of sorts like they do at emrap.
I am so glad you’ve done a Rural focused podcast!! I work as an ED Clinical Educator in a very rural, northern Alberta hospital and have tried for years to adapt a lot of your podcasts to our clinical setting (Your early Vent topics were a lifesaver during Covid). Would love to hear more! 🙂
just wait till the explosion episode coming in the next couple of weeks with legit rural resus docs as opposed to armchair opiners like me