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PHARM Podcast 003 – Interview with Dr. Karel Habig

Minh interviews Dr. Karel Habig, Medical Director, Greater Sydney Area HEMS, New South Wales, Australia

Hi folks

Tonight I interview Dr Karel Habig, Emergency Physician and Retrieval Specialist , in Sydney. He is a brother in arms with Dr Cliff Reid, of Resus.Me podcast and blog site. They both work for the Greater Sydney Area HEMS , a prehospital and retrieval medicine service doing up to 3000 missions per annum. This blogsite gives some useful information about their work and training.

http://nswhems.wordpress.com/

They also have an awesome YouTube channel!

http://www.youtube.com/user/GSAHEMS/feed

On the interview we discuss a recent annual training trip that Karel, Cliff and other retrieval consultants from their service do and this year they went to South Africa to learn from emergency doctors and trauma surgeons at some of the busiest units in the world! Tune in and hear some great tips described like balloon tamponade using a Foley catheter for vascular injuries.

I also pose a retrieval case to Karel on a patient with acute STEMI and prehospital thrombolysis, requiring aeromedical retrieval but with a low haemoglobin of 8g/dL.

Check out this useful reference article on aeromedical considerations of critically ill patients!

http://medind.nic.in/maa/t10/i1/maat10i1p63.pdf

Enjoy the podcast, send in your feedback, post your ratings on iTunes and stay safe!

Dr Minh Le Cong

 

Now on to the Podcast

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39 Comments Post a comment
  1. Minh and Karel,

    Great stuff. Thank you. Minh, if you shoot me a pdf of a brochure for the ASA / FNA 2012 Conference in August you mentioned, I’ll get it out to the approximately 400 members of AMPA, the Air Medical Physician Association (william.hinckley@uc.edu). I found the website; very nice. Would love to join you there one of these years.

    Regarding the foley catheter discussion for hemorrhage control: are your services in Australia carrying Combat Gauze or any other hemostatic agents for this purpose? At Air Care in Cincinnati we started carrying Combat Gauze about 9 months ago. We’ve only needed it on a couple of cases so far; worked great.

    April 18, 2012
    • Hi Bill,
      I agree that topical haemostatic dressings are the 1st world answer to this question of penetrating trauma. We recently reviewed a range of the new generation of haemostatic dressings and felt that Combat gauze had the most suitability to our environment. It will be going into our packs along with foleys in the very near future!

      April 19, 2012
  2. minh le cong #

    Hey Bill
    thanks, will dig up brochure and send your way!
    My service started carrying QuikClot gauze this year after a nasty trauma case last year. Have not used it yet so good to hear your positive experience. Is it something a lot of American HEMS or EMS are carrying?

    April 19, 2012
  3. My sense at this point is that, no, not many American teams, ground or air, are yet carrying any hemostatic agents. I know of <5. The topic's been discussed at the last three CCTMC conferences, and should soon start to gain some traction.

    Your thoughts on the JAMA article released Tuesday regarding HEMS efficacy for mortality reduction in trauma?

    April 19, 2012
    • Minh Le Cong #

      I have posted some comments Cliff Reid’s Resus.Me blog.
      I like the article. It suffers though from any retrospective study, even with large numbers. We are yet to be able to answer the crucial questions like if there is benefit then what makes the difference, the aircraft or the prehospital care…and what prehospital care is helpful?
      It is a fundamental set of questions partic over in USA where costs, competition and accidents have fueled a heady mix of debate. I just did an interview with Dr Brian Burns of GSA HEMS, the same crew that Cliff and Karel belong to, on two prehospital papers, in regard to potential harms that prehospital intubation and ventilation may incur. I am sure you are familiar with the latest Prehospital Emerg Care article on abnormal carbon dioxide readings and EMS intubation. Injury journal this month had an opposing article to the JAMA study in Netherlands , retrospective stuff again, showing that a doctor led HEMS team, seemed to make TBI outcomes worst!
      it would be fantastic to interview you on that JAMA paper!

      April 19, 2012
  4. Hi Minh & Karel,

    Interesting podcast, particularly hearing about Sth African conditions. They certainly have an awesome ED reputation.

    I just wondered what either of you might have done for your Anterior STEMI patient if she had put up her STs or become symptomatic again, mid flight. More O2, lower altitude and fly faster? How would you have handled a mid flight BP drop?

    Thanks

    April 19, 2012
  5. Minh Le Cong #

    thats an excellent question. Most complications post MI in the aeromedical setting will occur within the first 24hrs ..its a high risk time but leaving patients like these out in a remote nurse run clinic is not the way to go either. I am sure Karel has done this but I have flown a few patients who have clearly failed thrombolysis, are symptomatic or indeed in cardiogenic shock and need to get to a higher level care facility. What do I do for them?
    If their Hb was low, yes it would be a good idea to transfuse them prior to flight. No evidence base for that at all but experience and some applied physiology talking. If Sa02 low inflight then reasonable to increase FiO2 but that does not fix the STEMI only the symptoms maybe! Flight is stressful so I give some fentanyl for the cardiac pain, try some nitrates if BP acceptable. The IMMEDIATE trial looked at a long standing intervention of metabolic manipulation of MI pathophysiology. The STEMI group who received prehospital GIK protocol infusion actually had better reduction in in hospital arrest. So I would actually consider that intervention as we all should be able to do it with current EMS drug packs.
    Flying lower does not actually increase your aircraft speed so would not ask my pilot to do that. Our aircraft can be pressurised to sea level cabin but that does restrict the altitude profile of flight plan. Pilots dont like to do that as it wastes fuel I am told.But will do it if clinically necessary. The STEMI patient with failed lysis is a retrieval challenge. Karel and I have moved patients on balloon pumps aeromedically and that can help stabilise the STEMI patient in cardiogenic shock…but thats usually a interhospitl transfer rather than a pickup from a small nursing clinic!
    For hypotension post STEMI, that is bad! It usually means developing cardiogenic shock in the setting of anterior STEMI territory. I would ring Karel and see what he would do…Karel?

    April 19, 2012
    • Great question/s.
      In regards to the patient discussed – if their ST segments or chest pain worsened en-route I would do very similar things to Minh – Increase FIO2, Fentanyl for analgesia and anxiolysis, nitrates (BP permitting). I would transfuse RCC if available. Our service carries prepacked blood to all prehospital missions on the helo and road vehicles but this wouldn’t help if this anaemia was identified post departure on an interhospital mission.
      If the patient became significantly hypotensive I would assess for signs of hypoperfusion, and then I do a quick review for reversible causes – ? nitrate infusion running, quick echo for tamponade, consider RV involvement etc. I would treat with cautious fluid loading using small titrated boluses and consider peripheral adrenaline infusion using 1mg in 1000mL giving 1mcg/mL.

      My MAIN intervention in either scenario (Failed thrombolysis or Cardiogenic shock) would be logistical – I would ensure that on our arrival at the receiving hospital there was a Cath lab activated and team present to receive the patient with the updated information. This can normally be done by utilising the resources of our coordination centre so I could get on with managing the patient.

      April 20, 2012
      • Minh Le Cong #

        thanks Karel! Absolutely look for reversible causes of hypotensive STEMI patient..a quick bedside Echo may reveal something you did not expect like tamponade or valve rupture. The literature indicates that most acute coronary syndrome patients tolerate aeromedical retrieval surprisingly well! This is a good review article of the literature
        http://chestjournal.chestpubs.org/content/124/5/1937.full

        April 20, 2012
  6. Ben Hoffman #

    An interesting discussion gents thanks for that.

    Re prehospital helicopters.

    Despite being a probably one of the biggest proponents for HEMS and aeromedical retrieval (coming from both an aviation and a medical background) I can say helicopters are overrated and overused. There is and always will be a need and a justified use for them as a “tool of best fit” to retrieve patients from extremely remote locations (Careflight in Queensland as an example) or to get specialist skills to the patient quickly where ground transport is impractical (London’s Air Ambulance or GSA-HEMS) and such programs likely have a huge positive impact on morbidity and mortality (again look at HEMS London’s statistics for trauma survival) but beyond the multiply injured major trauma or severely ill pt if we look at the everyday response taskings partic in USA there is an incredible hype and sort of rockstar allure attached to them that really boils down to a whole lot of nothing based on shonky evidence.

    We’ve been sold on the idea that helicopter transport is “better” for nearly forty years because of the military trauma experiences in Vietnam and the biologic and epidemiologically plausible theory that “faster is better” as well as concept of the “golden hour” which does not exist. Let me say that again because it’s quite important: the golden hour does not exist, it never did and it never will, there is a finite time period for all multiply injured patients during which resuscitation and appropriate treatment is necessary to avoid irreversible physiologic decompensation but that period can be minutes to hours to days. The data that the golden hour was based on came from the battlefield of World War I in 1917 which said patients do better if they are treated within (forgive me I do not know the exact figure) something like four or six hours and was slickly packaged up by Dr Cowley and ta-da golden hour, not four or six as the evidence said, but ONE. Hmm sounds a bit shonky. I am not denying the helicopter saved thousands of lives in Korea and Vietnam but the circumstances were quite different than civilian trauma. What is again about trying to control or exclude possibly confounding variables such as environment and patient population that you must do to ensure your data is as reputable as possible for extrapolation into a different environment with different patients? Gosh I never was very good at biostatistics!

    There are lots of medical helicopters out there that cost money to sit around and do nothing which earn no money unless they are in the air. This does not help. There is a superstar allure attached to HEMS as being the great saviour of anybody with trauma or who is a bit crook because they can fly them to the hospital and beat the golden hour. This does not help. The superstar allure was based on shonky evidence that never really was appropriate evidence in the first place gathered from totally different environments with different presentations of patients that was sort of twisted around and spread around to fit the situation at hand.

    Well enough from a rambling Kiwi …. best nick off, looks like some bloke with a sprained ankle

    Ambulance, Medevac airborne

    April 20, 2012
  7. Minh Le Cong #

    thanks Ben. Love your ramblings. Keep it coming! Funding wise its interesting for HEMS around the world. Here in Oz, the majority are state government funded with exceptions like RACQ and NRMA rescue fleet which are funded through commercial insurance companies
    NZ as you know mostly are funded through community schemes based around farming co-ops. UK mostly hAve charity funded schemes with exception of London HEMS. Different ball game in mainland Europe with government sponsored HEMS everywhere. US as you point out has a large private commercial fleet of HEMS operations run by multiple companies.
    The origin of HEMS is military and this will continue into present day and beyond. When the battlefield has no roads, you need a way to evacuate your wounded. There is no other vehicle that comes close to the helicopter in achieving that.
    Civvie street, as you say is different, USUALLY. There are roads and a hospital system and hopefully an organised trauma system. Its the distances of transport that seem to be crucial in determining WHICH transport platform is best. This study from rural Australia http://www.mendeley.com/research/helicopter-use-in-rural-trauma/lia defined a threshold of over one hundred km.
    And then there is the safety of HEMS ..the transport may pose a risk to the patient! But thats another can of worms to open up if you like Ben?

    April 20, 2012
    • Ben Hoffman #

      Minh, you’re words are too kind for me, I’m just an up-and-coming Retrievalologist Superstar … if I can figure out the difference between proton and neutron, bloody hell!

      We both agree a need for helicopter evacuation will exist until time immemorial no two ways about it there’s always going to be people who fall down cliffs or get crook 3,000km from medical aid or nunnger themselves in a road traffic accident and so on and so on … it’s identifying those who are most-in-need of quick evacuation and/or higher skills (if your helicopter only carries an Intensive Care Paramedic who is no more equipped than a standard road ambulance it becomes arguably less important than if your service uses Flight Nurses or Doctors who have higher scope of intervention).

      Re HEMS funding yes it is absolutely bloody appalling that some of them exist because they beat the charity drum. Same with the BASIC Doctors in the UK but that is another topic for itself. The US is where I have the most experience and as you say the funding situation is often by insurance, private operators or hospital systems of which a good number are run by various Universities which their teaching hospital is associated with. Insurance usually pays the “fee-for-service” model (not unlike ACC funding of HEMS here for e.g. farm accidents or RTAs) whereas those run by hospitals or university hospital systems often get block funding and a “return on investment” is expected and that is predominantly through agian, the “fee-for-service” model given the high degree of privatisation of the US health care system be it insurance companies or Medicare. So there is a highly perverse incentive toward over-response and it’s been engrained in the culture of the Ambulance Service for so long that “helicopters are better” or “faster is better” +/- “golden hour” so the two create a situation of massive over response.

      Re HEMS safety it is very fascinating for somebody who comes from an aviation systems/safety management perspective to see how different operators run around the world both in terms of what they deem acceptable and what the regulators deem acceptable. Some operate dual pilot VFR/IFR and others are single pilot VFR only, some have extensive safety management systems and very strict weather minimums and then there is the other end of the spectrum. Look at HEMS London they are dual pilot day-time only VFR operations in what in my professional experience is an operating environment second only in risk to the battlefield of the Ia Drang Valley or the mountains of Afghanistan and in over 20 years and 25,000 missions have only had ONE incident (a chipped rotor blade). Unfortunately standards in the US are lacking and there has been a push from the NTSB for years for things to improve. The public operators e.g. Maryland State Police are held to differing FAA standards as “commercial” operators and helicopter standards are different than the standards applied to fixed wing commercial operators in terms of training, certification and equipment. Traffic and terrain avoidance systems and night vision goggles are not mandated and there are operators who do not use them whereas elsewhere in the world they are either required or considered “best practice” and are routinely used because it’s just how it’s done, sort of analogous to “standards of care” on the medical side (nb which does not include longboards, headblocks, supra physiological amounts of oxygen or in cardiac arrest in-discriminatory administration of adrenaline, intubation and possibly positive pressure ventilation!).

      Recent advice within the Ambulance Service here has stated that a helicopter is only beneficial if the patient is more than one hour by road (so ~100km) from hospital. It is often faster to take the patient by road than wait for a helicopter unless the helicopter can bring higher skills than the road ambulance capability e.g. RSI, chest tubes, thoracotomy, whole blood or blood products etc.

      Speaking of such, it is quite uncommon in the US for a helicopter to carry a Doctor, most carry a Paramedic or a Nurse but many cannot intubate (RSI) or insert chest tubes or administer blood or inotrope, antibiotics or thrombolyse etc. My answer to that then is what’s the bloody point? Note massive conflict of interest right here in an extreme bias towards Doctor led HEMS.

      April 20, 2012
      • Minh Le Cong #

        Hey Ben. Love the rant! I thought of bringing up Lady Diana’s trauma case but did not want to set you off again…perhaps I just did?! interesting reference to the Ia Drang valley!

        April 21, 2012
  8. Ambulance Victoria presented a paper at the SWAN conference in Sydney a few years ago that suggested that total transport times for trauma patients which were about twice their KPI standard (can’t remember the exact numbers) were associated with a couple of extra days in ICU and /or hospital but no difference in mortality or morbidity. I don’t remember the study population size and it was generated from a practice audit, but it suggested that, context dependant, we may have more time than we think to get to a designated trauma centre.

    April 21, 2012
  9. Minh Le Cong #

    Mathew Mac Partlin, I agree. The Queensland Trauma registry seems to indicate the same thing with up to eight hour transfer times not seeming to play a role in overall trauma outcomes. This study from Western Australia says the same thing. If you survive to get into an organised trauma system that involves well run prehospital care services, then no matter how remote you are, you do the same as metropolitan trauma patients.
    http://www.flyingdoctor.org.au/IgnitionSuite/uploads/docs/Fatovich%20et%20al%20Resuscitation%20(2011)%20Metro_vs_Rural%20Major%20Trauma%20in%20WA.pdf

    I am not for or against doctor led prehospital services or HEMS. About seventy percent of my services flights are managed by a flight nurse alone with phone support from a doctor. I think if you are prepared well for the prehospital setting, have rigorous clinical governance and clinical quality assurance systems , train in specific techniques and equipment for the prehospital and retrieval setting then it does not matter what professional background you come from.

    April 21, 2012
  10. Ben Hoffman #

    Thanks for the studies gents they are quite interesting.

    Minh, I have no specific rants about Princess Diana except to say that the French EMS system called SMUR literally translates to “mobile urgent reanimation service” and that is a totally awesome name right there!

    I do not think a Doctor is necessary in the ground based pre-hospital system routinely if one has appropriately educated Paramedics who have adequate skill exposure. The Australasian model is a good example of this where the education and scope of the Paramedic (old Ambulance Officer) level has been increasing to allow the Intensive Care Paramedic to be kept free so they are using their specific knowledge and skills regularly enough to remain proficient in things like RSI, thrombolysis, arterial lines, advanced combination analgesia, sedation etc. Certainly it does not hurt to have an appropriately trained Doctor (such as an Emergency Physician or Intensivest) available to respond on behalf of the Ambulance Service as their knowledge, experience and interventions will be greater than that of the Intensive Care Paramedic. In saying that I envisage such a response to be infrequent and limited to things like field amputation or thoracotomy; in fact during the Christchurch earthquakes there were several field amputations performed in the field.

    Now, I strongly feel that helicopter responses should include a Doctor because they are travelling further, to arguably sicker or more traumatically injured patients and they will (again arguably) benefit from the knowledge, experience and intervention that a Doctor is able to bring. Certainly a very experienced Flight Nurse who has an acute care background (ED/ICU) can also be very valuable and they are used in many parts of the world as you point out the RFDS for example. While some of the acute-care Nurses are extremely experienced with a broad knowledge base and they are expert professionals in their own right I strongly feel that the complex clinical decision making experience combined with extensive foundation and vocational medical education of an Emergency Physician, Anaesthetist or Intensivest makes them a more agile resource for aeromedical retrieval.

    But take that with a grain of salt as y’know if they stop putting Doctors on the helicopter shucks I might have to become a cardiologist or something! lol

    April 21, 2012
  11. Minh Le Cong #

    thanks Ben
    Being a doctor does not make you immune to the limitations and threats of the prehospital environment. Medical School and Hospital training does not prepare you for that at all. Just ask Cliff Reid or Karel Habig and watch their training videos of new doctors to their service, Those doctors come from anaesthesia, EM and ICU. They need to learn to think like a paramedic and that takes time to teach this. Does all your ICU hospital training teach you how to deliver a premature baby and manage a retained placenta in the back of a helicopter or ambulance? No but I know several paramedics who have delivered more babies than intensive care consultants. But its not a competition is it? The aim is to have well prepared prehospital providers who are resilient and can succeed in varying conditions.
    Agitated patients with acute mental health condition normally in a hospital setting get placed in a seclusion room and monitored by security and nursing staff with some sedation as needed. How does that translate into knowing what to do in the back of an aircraft for three hours with the psychotic morbidly obese patient with sleep apnoea and difficult looking airway? You dont get taught these things in hospital training and certainly there are no textbooks on the subject! My point is that doctors indeed potentially bring a wider skill set and better assessment to the prehospital setting but they still need to be taught to think like a paramedic and be mindful of modifying what is done in hospital with the realities of the prehospital setting, Both professions have much to benefit from each other in terms of improving patient care in an unforgiving environment,

    April 21, 2012
  12. I agree with Minh. Doctors work well in their own environments (like anyone) and need additional training to work in unfamiliar ones, as practices do not automatically translate. I work in motorsports a lot, which presents similar pre-hospital issues (though thankfully rarely psychotic ones) and often see docs coming from critical care backgrounds and assuming their knowledge and abilities supercede the paramedics, who have much greater pre-hospital trauma experience. Like Minh says, it’s not about who is better at what, but more about matching the skill set to the context and needs and making sure all players are well prepared.

    Matthew

    April 21, 2012
  13. Ben Hoffman #

    Thanks gents for your thoughts

    I am well aware of the environmental differences that exist between the in hospital and pre hospital environments and often have this debate whenever the subject of the Pre hospital Doctor is raised, particularly when speaking of systems such the BASICS in the UK or the European EMS model. Medical education does not prepare you for the specific environment of pre hospital care but it does give you a solid base of knowledge and experience that can be translated out of the hospital doors, turned upside down and put into a ditch at one o’clock in the morning or whatever. My point is that yes you have to adapt to the specific operational challenges of pre hospital or retrieval but that is like me going to Italy and trying to speak Italian with no practice!

    A Doctor is not limited by “protocol” and will probably be involved in the management of more multiply traumatically injured or critically unwell patients in a week or month than the civilian Paramedic will see in a year. Around the world you will find many examples of where Paramedics are not putting in chest tubes, performing RSI or ultrasound or initiating therapies such as inotrope, thrombolysis or antibiotics (and one or two that are) yet all of these things are standard pieces of the puzzle that an appropriately trained Doctor will bring (+/- ultrasound).

    Certainly I am not intending to place any other professional group that is involved in retrieval below the Doctor (e.g. RN, Paramedic, RT or PA) but there are multiple examples of the Doctor being involved in retrieval worldwide for their depth and breadth of experience and knowledge in dealing with critically unwell patients and the freedom they have to perform interventions which may otherwise not be available.

    Again I must declare a significant bias towards the belief that an appropriately trained Doctor should be involved in retrieval and where appropriate, pre hospital care.

    April 21, 2012
  14. Minh Le Cong #

    Thanks Ben. My aeromedical shift work yesterday supports your contention. I flew out to a quad bike accident victim and administered a femoral nerve block for transport analgesia/anaesthesia. I also had someone in a remote nursing post with a metal corneal foreign body that the nurse was not willing to try removing. So it seems like overkill but my plan was to fly in and remove it myself and patch the eye and let my GP colleague review it in 3 days time. It did not seem reasonable to let it wait for 3 days till he/she arrived in that remote post.
    I do not regard myself as being above any other professional group working in the prehospital and retrieval setting. I believe that its a team effort and what I bring to the field is helpful in certain cases but whats more important is how the team helps the patient in a bloody difficult setting. This is the crew resource management skills that are more important that individual skill sets. the human factors to it all.
    I might have more experience and obsession with emergency airway management than my typical flight nurse or paramedic but I would rather they manage the airway and I can get on and do other things during a prehospital critical care case, as long as they are happy to do so and can manage.I could easily stay at the airway and spend a lot of time up there whilst the nurse or paramedic try to get vascular access or what not but that to me is not an efficient use of team skills and performance.
    Motorsport teams are an excellent example of this . The pit crew needs to be able to work and trust each other to do a number of tasks at once. The driver cant get involved and try to direct everything or do it themself. There has to be an element of trust in the team and each member that, if someone is failing their task, someone else will be able to immediately back them up. If I am having trouble with an airway, I would want the paramedic to tell me to stop, reoxygenate and insert a LMA..or do it themself! As Cliff Reid says, my penis length will remain the same!

    April 21, 2012
    • Ben Hoffman #

      Excellent points Minh esp regarding the CRM perspective!

      Certainty the involvement of the Doctor in pre hospital care is a contentious issue and this is very true in the US, I’ve had numerous discussions with Paramedics who say things like “I can do everything they can” or “they can’t bring a CT machine so what good are they?”. Gareth Davies of HEMS London has even said he’d now and again get comments about being an “[orange] cowboy swanning out the air” from the LAS in the early 1990s. With the greatest professional respect to the Paramedics who makes such comments, I think that shows a little bit of ignorance which is unfortunate because we’re all trying to work with the patient in mind.

      It’s not about one group being better or “above” another in some sort of locker room penis measuring contest it is about as you say working together as a team for the best patient management.

      In the vast majority of pre-hospital patient care and management a Doctor is not required and is a wasted resource because very little value to the patient is added by their presence but there will be times when the knowledge and experience in complex management of critical patients that is not limited by “protocol” the Doctor can bring will be invaluable.

      But in saying all of that as I’ve always said, I am very heavily biased towards Doctor-led HEMS.

      April 21, 2012
  15. I;ve refrained from wading in so far, mainly because my background is not HEMS. And the only really useful comment I could make initially was “Karel? Carol? Ain’t that a girl’s name?”

    But Ben, Matt and Minh have been discussing the Australian situation, including the ‘tyranny of distance’. Ben mentions the intensive care paramedic model – which although well established in some States, in other rural areas we are relying more and more on volunteer ambulance officers – farmers, shopkeepers etc who put their hand up to assist.

    They are bloody marvellous in remote areas. But they ain’t ICPs.

    So we tend to rely heavily on the retrieval services, and I must say that they are bloody good (at least in my State of South Australia. I;m 100% sure Minh and Cliff are flying the flag for quality in their services in Qld and NSW respectively)

    But they take time to arrive. So I reckon the local rural doctor (GPs, but often with procedural skills in anaes/surgery/EM or obstetrics) are ideally placed to fill the gap.

    The UK has the BASCIS scheme and robust training for prehospital/immediate care. This is not an arena for ‘enthusiastic amateurs’ (like me). But in places where the ambos are volunteers, and retrieval services are hours away, it would seem sensible to utilise the local doctor, provided he/she is appropriately trained. Many of them do weekly theatre lists…and are oncall for A&E anyway.

    Again, it doesn’t really matter WHO is doing the work – just so long as they are incorporated into a trauma service, appropriately trained and a commitment to ongoing audit etc.

    Just my tuppence worth.

    April 22, 2012
    • Ben Hoffman #

      Tim, thank you for an all important rural perspective but what in the bloody hell is a tuppence? I reckon you’ve gone kookoo bananas in the brainbox mate, get the local woodwork teacher on the blower we’re gonna have a fossick around up there with the Black and Decker while the flying machine comes from Adelaide. Now, draw up this ketamine while I find some sterile water to reconstitute the vecuronium …

      You are right that way out in the boon docks the local GP or Nurse Practitioner is an invaluable resource not to be overlooked. Many systems exist around the world where the local GP or Nurse (or NP) is sent out to crook people on behalf of the Ambulance Service. In Victoria the Emergency Guidelines for Remote Area Nurses are an example of this. I think a similar program exists in NSW. Here in NZ we have a program called PRIME which exists in areas where an Intensive Care Paramedic is more than thirty minutes by road and the local GP/Nurse/NP is willing to participate (some are not owing to an already extremely heavy workload). The practitioners are equipped with a standard ICP kit (minus a couple of drugs) and activated to appropriately triaged high priority calls. It may surprise you to learn that in the UK (partic in Scotland and Wales) not all BASIC Doctors are Emergency Physicians, Anaesthetists or the like; in rural areas quite a few are the local GP but they will not be performing interventions such as RSI or chest tubes because they simply lack the adequate ongoing exposure to maintain proficiency; there may also be legalities preventing a GP being in possession of RSI drugs (the UK medicines legislation is quite difficult to make sense of and appears quite restrictive from discussions with UK based contacts).

      As for the volunteer ambos they do a bloody fantastic job and sometimes 300x more enthusiastic and motivated than some of their career colleagues! I can appreciate in some areas of AU partic NT/WA/SA the volunteer crews are really on their own for up to several hours before HEMS/RFDS arrive and I would not like to be in that position as a Physician let alone a volly ambo. However in saying that, a volunteer sitting on the end of an LMA and a bag mask ensuring good ventilation of somebody whos had a whack on the noggin (and thus preventing hypoxia and hypercapnea) for an hour is far more likely to improve the outcome of that patient than a Doctor swanning out the sky in his orange suit and tubing the patient an hour later when immense secondary brain injury has already occurred.

      It doesn’t matter WHO is turning up to provide help as long as they’ve got the right tools and the nouse to use them. Having said that I’ll argue until I am blue in the face that retrieval/HEMS should include an appropriately trained Doctor.

      April 22, 2012
  16. Minh Le Cong #

    Hi Tim and Ben
    No need for facial cyanosis, Ben. I think your point is well made. A well trained retrieval doctor is a good thing. Where that is not possible , a well trained non doctor provider is also a good thing. its all good.

    April 22, 2012
    • Ben Hoffman #

      I was being rhetorical mate I’m not trying to argue-up my point as that would be a bit arrogant of me and as we’ve said before, everybody is working in the best interest of the patient regardless of what background they have.

      April 22, 2012
  17. Spot on Ben – it really comes down to who is on the scene and equipping them to do the right thing.

    If you’ve got HEMS available and close by (I’m thinking London particularly) then this is the way to go

    Over 30 mins (most of rural Oz) – then ideally trained ICPs

    Where no ICPs, then get the GP-anaesthetist involved (I’m sure the volunteer ambos would appreciate it!)

    PRIME sounds good. BASICS works.

    But I reckon we need a similar model here in Oz, the current set up is very ad hoc (rural docs may be called to attend prehospital incidents – but in the absence of formal training, equipment and audit). We can and should do better than that…

    Noone’s mentioned my penis size, which is a good thing.

    April 22, 2012
    • Ben Hoffman #

      The idea behind PRIME is to get a higher level of knowledge and skill to critically unwell rural patients who would otherwise not have access to the treatment a PRIME Practitioner can bring be it a GP or a Nurse/Nurse Practitioner.

      As generalists they carry most of the Intensive Care Paramedic drugs (but not all) and are not expected to perform interventions such as rapid sequence intubation or inserting chest tubes as their HEMS counterparts do. There may be some PRIME Doctors who are comfortable putting in a chest drain because they are Rural Hospital Specialists and have adequate exposure to performing this. This is the same as the BASICS Doctors in the UK who are GPs in rural areas and can provide a higher level of medical intervention than an Ambulance Technician but not the full compliment of critical care interventions of their BASICS counterparts who are from a more appropriate speciality such as Anaesthesia, EM or ICM.

      In saying that just because one is a Generalist does not mean an inability to do the higher level stuff but they may not feel confident in their ability to do so; Minh is a GP Retrievalist (a new speciality I’ve made up) so it just goes to show, contrary to some comments I hear banted around, that with education and exposure to maintain competence you can teach anybody to become proficient at anything … heck even me! (now where did I put that suxamethonium?). We have to remember even a GP has five or six years of basic medical education on which to build specific competencies and they might not have put a drip in anybody since their Intern (House Officer) days or dealt with a very sick patient for longer than it takes for the Ambulance to nick around and pick them up but that does not mean they are not useful and it absolutely pains me to death when I hear these ignorant bloody people say “oh a GP is useless because they are not an Emergency Physician!”

      The idea of a GP-Anaesthetist is very interesting and I am off to have a look to see what I can find on such a person. I wonder what ANZCA has to say …. hmm I see they’ve denied my training request, poo, cardiology is it then, wait no thats not what I was looking for I was looking up GP-Anaesthetist; it’s so easy to get side tracked! (removes tongue from cheek).

      April 22, 2012
  18. Actually, just to clarify

    I’m not suggesting either unwilling conscription of rural GPs, nor ‘enthusiastic amateurs’ having a go

    The reality is that in rural Oz, many rural docs ARE called to attend prehospital events (probably less so in NSW/Vic/Tas where robust paramedic services) prior to arrival of the retrieval services

    So…the rural docs are already been asked to attend.

    But they do so in an ad hoc manner, with no formal training, equipment or audit

    How much use is this really? Probably not much. I’d rather that the attending doctor was trained and maintained competence – the BASICS model is good at this.

    The rural doc may be able to value-add to the scene – not just in prehospital anaesthesia, but more in terms of optimising haemodynamics, ventilation and avoiding ‘therapeutic inertia’ (a particular pet subject of mine, after hearing an inspiring talk by Dave Cooksley a few years ago on a MedSTAR refreshed in South Australia)

    So – we know that rural docs are already being called to attend in certain circumstances, prior to retrieval team arrival

    But we have to realise that the prehospital environment is very different to the well-lit ED. Doing an EMST refresher doesn’t really help us with scene safety, finger thoracostomy, difficult airway management etc

    My wishlist?

    - utilise the rural GP cadre and train them appropriately akin to UK’s BASICS

    - work on a masterclass with streams for prehospital and anaes/obs/EM components for the established rural docs who are out there ‘doing it’

    Basically this would give a model of trauma care which encompasses not just retrivalists, but also ambulance and rural doctors…

    Cliff, Minh, thoughts?
    Ho hum.

    April 22, 2012
    • Ben Hoffman #

      Tim, I applaud your well written and very logical comments to an area I am extremely passionate about. I was bought up in the rural back blocks and think that just because you choose to live out in the country should not mean you receives less expert pre hospital care than those who live in the Metro areas especially when rural patients are often “sicker” or more time critical – think high speed RTA, people who nunnger themselves on tractor PTOs or have the tractor fall on them, or they fall off a barn roof or Little Billy is crook so Mum puts him to bed, next minute meningococcial septicaemia sort of thing.

      I was not suggesting the only role for the Pre hospital Doctor was anaesthesia and intubation but this is also an area I am extremely passionate about; I think there is a massive potential to improve outcomes of patients with poor airway and/or breathing and in particular traumatic brain injury by pre hospital RSI. There is a small number of extremely well conducted Australian studies which support this position and it is one adopted by the Australasian Ambulance Services. Unfortunately the American studies used ill educated practitioners with poor technique and probably some over saturation thrown in for good measure so of course they got shit results!

      Cliff may be able to speak for BASICS more than I can (despite my near-perfect piss-taking English accent ability) however you are correct in saying they must all pass specific standards of education in pre hospital care and many have obtained the DipIMC from the Royal College of Surgeons of Edinburgh; I’m keen to give this a crack once I get my specialist training going (so you know, in a few years!) and it looks bloody difficult. Unfortunately the downside of the BASIC model is that is relies on charitable donations and the good will of the Doctors to respond.

      If we’re dealing with an area served by volunteer Ambulance Officers then the GP is I imagine going to be used more for things like adrenaline, morphine, midazolam or some antibiotics than cracking some bloke’s chest or something towards that end of the scale. I don’t know the scope of practice of your volunteers (and I imagine it varies in each state who still use them) but they’re probably quite similar to our Technician level ambos (LMA, GTN, salbutamol, glucagon etc) so things like flogging somebodies ticker along with an adrenaline infusion, IV fluid, antibiotics for meningococcial septicaemia, midazolam for a fitting child or parenteral analgesia are well outside their scope and depth of education/experience so a bit of help from the GP would be greatly appreciated!

      I am surprised that if rural GP’s in AU are being tasked on behalf of the Ambulance Service they are not required to undertake some level of ALS specific education or such like as they are here and in UK. I’d think they’d have said something if they feel their competence is not adequate but they may not I am not sure.

      This idea of the GP Anaesthetist still interests me greatly and I’m going to do some more reading of the ANZCA and RACGP JCCA documents about them – after I complain that they denied my training application I mean I’d love to be a cardiologist but I can’t made heads or tails of bundle branch blocks and forgot which coronary arteries supply where .. I reckon ANZCA have found out about my lowly 80% intubation success rate and decided I’m not good enough to be an Anaesthetist; what makes it worse is the one esophageal tube I’ve had was with a bloody bougie and the successful ones only a stylet! again note the tounge-in-cheekness right here.

      You may find this article about PRIME from the NZMJ interesting; it was published in 2003 so there have been some structural changes since then but it’s still a worthwhile read: http://journal.nzma.org.nz/journal/116-1173/420/content.pdf

      April 22, 2012
  19. Minh Le Cong #

    Thanks Ben for that PRIME article. very interesting and Tim has talked to me about a similar scheme in Oz. Our home state of SA has something like PRIME but certainly there is no national scheme like BASICS. I totally agree with you that in a modern health system, just because you live in a rural area should not determine your ability to receive timely and appropriate emergency care. This is in fact the reason why RFDS was created over eighty years ago now. I particularly like how the PRIME article mentions that its not only doctors who are considered eligible but also nurse practitioners. Lets face it , its not easy getting doctors to live and work in rural areas so its appropriate to train and support nurses to provide emergency care as well.
    Supporting rural doctors like Tim to provide emergency care before arrival of retrieval teams just makes sense if you subscribe to the notion that the earlier you enter an organised trauma system the better you will end up overall. Its a team effort in the war against trauma and remote emergencies and you need as many on your team as you can get. Recruiting local providers is logical because they are going to get to the patient earlier than anyone flying in.
    The PRIME article raises a good point that by providing emergency care, doctors and nurses maybe preventing the political motivation to setup professional paramedic services locally. Tim I think in Oz, we have to be careful about this!

    April 23, 2012
    • Ben Hoffman #

      I might also caution that one of the issues here in NZ has been the unwillingness of some clinicians to enter or remain in the PRIME program due to their already extremely heavy workload and relatively little break from that workload. This may have settled a bit now that the response criteria around PRIME has been tightened up; in the early days it there was a tendency to over-respond much to the frustration of some of the clinicians who had to “shut up shop” and race off into the sticks for something they weren’t of any additional value at.

      PRIME or any such system is fundamentally a sound concept for delivering a higher level of knowledge and skill than can be achieved by the local ambos and where specialist help from HEMS/RFDS is several hours away. It must be used wisely as it is making use of what is a scant resource i.e. rural GPs/NPs/RNs who already have enough pressure on them as it is without adding the responsibility of being tasked to jobs by the Ambulance Service.

      If the patient can be extricated without too much fuss (local volunteer Firefighters/CFA/SES are brilliant at getting things unstuck!) a better idea might be to take the patient to the local clinic/hospital and have the clinician stay put rather than have them go to the scene unless of course the patient has a tractor on top of them or something silly like that. I know it was never specifically mentioned that the clinician must go to the patient but I thought it was worth mentioning.

      Re the Paramedic system integration the Ambulance Service here is quite good about getting higher skills into rural areas; the paid rural crews generally include at least one Paramedic and their scope of practice has significantly increased in the last few years to align closely to what is offered in AU (adrenaline, midazolam, fentanyl, ceftriaxone etc) so rural patients now have access to a broader range of treatment; partially I believe because there has been declining access to GPs in rural areas and it has been a natural fit now that the Bachelors Degree is required for the Paramedic level so recognises the additional education. There is however still a place for a program such as PRIME provided it is implemented wisely.

      On average how far away from a retrieval helicopter is “rural Australia” that you blokes work in? (the little town that’s 3,000km away excluded). I’d say here it’s probably about thirty minutes on average.

      April 23, 2012
  20. Minh Le Cong #

    Where I work, the HEMS service covers up to 200km trips one way..roughly. I have known them to do longer trips but thats rare. When it requires a refueling stop they dont usually want to do jobs that far. Over 200km RFDS covers that territory in fixed wing B200 turboprops. Thats an excellent point about relying upon the goodwill of already overworked docs and nurses to go out and do more in the prehospital arena. For example, Bara hospital in South Africa I imagine could do with prehospital doctors and HEMS service for all the trauma they see but they have enough to cope with in the ED let alone going out to the streets to find work!

    But this is the challenge that rural Docs like TIm face. You are in your rural hospital and the local ambos call you asking for help because little Johnny on his bike has been run over by a car..what are you going to say..no?

    April 23, 2012
  21. Ray Gadd #

    That is the challenge of being a remote doctor. I have been asked by ambulance communications to assist with the ambulance crews on occasions or in some circumstances “kidnapped” from the street by the local crew.

    We do need to get betting gelling of the prehospital staff and the hopsital staff and most places this is done well. Having the training in this specific area PRIME or BASICS or would be valuable for the doctors or nurse that is involved in working with ambulance staff.

    April 24, 2012
    • Ben Hoffman #

      You really have to watch those people in bright getup that drive around in the large white van with tinted windows which has lights and plays noises attractive to children … they’ll just kidnap you right there and not even do you the courtesy of tying you down to a bright yellow stretcher and giving you some midazzle to smooth the experience out!

      I get the feeling most of the retrieval work in rural and remote AU is going out to little country hospitals/clinics to pick people up as opposed to true “pre hospital” work where you’re landing on a highway because a big rig has chewed up a little two door sedan for lunch, or some bloke is trapped under his tractor or winching down into a chasm or something like that.

      So I’m wondering if the problem is more getting the patient to an appropriate medical facility rather than getting them medical “help” at the scene per-se? (excluding of course people trapped under tractors or in a road traffic accident) I say this because in contrast on our side of the ditch the problem is getting them medical attention, most of our rural hospitals have been closed down over the years and the local Ambulance is probably better equipped than the town’s GP clinic for acute problems so it makes more sense to get the PRIME Doctor or Nurse to the patient because the hospital is just as far away.

      Now that I’ve typed this up I’m not really sure why I even did it! Certainly it will be beneficial to up skill the local GP/NP to operate in the pre hospital environment because they will invariably be needed at an RTA or person stuck under a tractor at some point in their rural tenure however I wonder if some more general “how to manage this crook person at the clinic for an hour after you’ve called for the flying contraption on your telephone machine” sort of thing?

      April 24, 2012
  22. Ben, you are right…most of the time we are involved in assessment and stabilisation of patients brought to us, them packaging for a secondary retrieval to tertiary centre. For big primaries, particulalry those remote grom GP/hospital, then retrieval will be tasked straight off to the job (and having MedSTAR presence in comms scanning jobs makes spin up and tasking that much quicker).

    Most of us are happy in our ED environs…but the reality is that we are ocasionally called (maybe once a month) to assist mostly volunteer crews with a sick patient – wherher be an extrication, an arrest, a medical sickie or a trauma.

    And we are not trained for this (I dont think EMST/ATLS counts)…but we still go.

    I reckon that there are a FEW of us who are willing to put hands up,provided we can make a difference ie: faciliate extrication with drugs, provide input/advice (which more often than not is decision to retrive early) and pform certain prcoedures like RSI/thoracocentesis etc.

    If we are going to be called, we might as well be trained to a degree in the prehopsital environment, as it is VERY different to the ED. There are systems to be paid for such work…and bottomline is, these are our patients anyway (and more likely to be frien/family than in the smoke)

    Question is, does rural Oz need this? Clearly the Uk does, hence BASICS. We have excellent rtrieval services locally…but in cases where time matters, the local doc is invariably called

    ..better that he/she is trained and/or an enthusiast.

    But how to achieve this? Its actually got to come from the docs…ACRRM could be the champion…but also need consent from the prehospital experts which are ambulance and retrievalists.

    Ray, your thoughts?

    April 27, 2012
    • Ben Hoffman #

      Excellent points Tim. BASICS exists in part as UK Paramedics are still quite limited in options for analgesia (only morphine and nubain), no sedation, no cardioversion, no pacing, no RSI etc; things that we take as standard elsewhere in the world.

      I agree that if the rural GP/Nurse is going to go prehospital then they need an appropriate amount of training; PRIME GPs/Nurses undertake a five day course.

      April 28, 2012
  23. Minh Le Cong #

    Tim, you make a compelling arguement for Oz situation.
    Ben, thanks. Five day PRIME course. Got it.

    April 28, 2012

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