Rural Emergencies Case Scenarios
Amy
Welcome, everyone. Good evening. Thank you for coming. My name is Amy and I will be hosting tonight's webinar. This instalment of the Rural Health Webinar series forms part two of the Rural Emergency's two part series on management of emergencies in a rural setting. The webinar will build on the theme of procedures, protocols and people factors with the opportunity to discuss two case studies. It follows on from part one Rural Emergencies Procedures, Protocols and People Factors.
Our presenter this evening is Dr. Antony Wong. Dr Wong is a GP anaesthetist from the West Gippsland, Victoria. In his previous career, he was a rural GP in a small town setting in the Western District, where he also provided obstetric services. Dr. Wong was one of the first graduates of the JCCA program after completing his anaesthetics training in the UK during the 1990s.
He is actively involved in simulation teaching for both undergraduate and postgraduate students, and particularly enjoys leading interdisciplinary sessions in the operating theatre and in PROMPT training. We would like to begin tonight's webinar by acknowledging the traditional owners of the lands that we are coming together from and the land on which this event is being broadcast.
I would like to pay our respects to their elders, past and present, and would also like to acknowledge any Aboriginal or Torres Strait Islander people who have joined us this evening, and just before we begin, I just have a few housekeeping things to cover.
Participants are set on mute to ensure that the webinar is not disrupted by background noise, but we do encourage you all to use the Q&A chat to ask any questions, and these questions will be addressed at the end of the webinar in the Q&A session, and finally, the webinar has been accredited for one hour educational activities CPD. To be eligible, you must be present for the whole duration of the webinar. We also kindly ask that you complete the short evaluation at the end of the webinar.
This does not take very long. It should only take a few minutes to complete, but it really helps us improve the format and the content of our future webinars. With the learning objectives for tonight, by the end of this webinar, you will be able to firstly discuss important procedural skills guided by the Australian Resuscitation Protocols in basic and advanced life support in a general setting, and two, discuss the importance of a structured approach and people factors for managing an emergency in a rural hospital setting. Thank you for listening to that housekeeping. For now, I will hand over to our presenter for this evening, Dr Antony Wong.
Dr Antony Wong
Thank you very much, Amy, for the introduction and thank you to RACGP for asking me to do this webinar for the second time. As we said, the learning outcomes is as listed with the important life saving procedural skills and a discussion on basic and advanced life support and talking around two emergency scenarios to highlight this. Just a bit about myself. I am a rural practitioner. I am not a ____, so a bit of disclosure there and that I am not a specialist emergency doctor, I am a 1991 Monash Uni graduate, and I was, as Amy said, a small town rural GP in Terang in the Western district for seven years and now I currently do full time anaesthetics in western Central Gippsland, Victoria.
I am also am instructor for ACRRM as well as teach a lot in undergraduate training with Monash Uni. What is relevant for this evening? Well, originally we started this journey with Dimitri, one of Amy's colleagues, in that he reached out to me last year and said an evaluation survey shows that rural GPs want more education on emergency medicine procedures, protocols and retrieval communication, and hence that is where we pivoted from in terms of giving this first talk last year.
The thing is, I suppose I understand where you are coming from, from your educational background and almost 30 years of transferring patients out in a rural setting, and a knowledge of the limitation of skill sets of the infrequent rural general practitioner.
The problem is these are halo events or high acuity, low occurrence events. They are the cases that I am going to present to you happen to me while I was at a small town GP in Turang, but they happen once a year and so being able to bring out the skills and remember the protocols and get your confidence up for these. I have been there, but I wanted to share with you some useful tips and tricks and some useful resources I have discovered.
Unfortunately, it is only Victoria, and to break it down and to simplify it and not make it so overwhelming and complex, so as I said, the disclaimer no conflicts of interest. I presented this last year and the feedback was overwhelmingly positive, but as you know, our mind gravitates to a negative bias, and I focused on one negative comment which was the content was a bit basic sometimes, and the participant was hoping for a higher level of difficulty.
So, of course, I reached out to Dimitri and he then offered maybe we will do a part two. I will talk about this in a bit some of the procedures, protocols and people factors in a bit more depth, but having said that, I still am very conscious of the fact that it was the majority as in 99.9% presented it as a very informative, excellent content and clear presentation, so I must have hit the mark for the majority and I do not want to take that away from the majority, but if any participants would like more detail, please do not hesitate to pause and ask or raise it in the Q&A at the end, or attend a formal emergency course which is very worthwhile, very hands on, and we will give you lots and lots of learning and that detail and that higher level of difficulty that that participant was looking for.
Let us start off with a case to warm up with. In Terang medical Clinic, Arthur collapses in the waiting room. Now, in terms of presenting zoom wise, I think a good way is for me to present a real life demonstration, and there are lots of really good resources out there in the YouTube world and the Vimeo World, but this is probably the best one that I have seen.
This is what I would hope for or what I strive for in terms of best practice management, and I would like to see this happening to my patient Arthur, who collapsed in the waiting room. What I am going to do is I am going to play and pause and discuss. A lot of protocols, procedures and people factors will be demonstrated in this excellent video.
As you know it starts off with doctors A, B, C, D, E and this is a presentation of a deteriorated patient, someone who has had a cardiac arrest. Now remember, cardiac arrest can be all different forms. The most common form being a VF, as in possibly this scenario, but there are other forms such as a hypoxic arrest or traumatic cardiac arrest, which have their own differences in management.
She checks for dangers and is checking for response and looking for particularly verbal response. After that you can categorise their conscious state or get a rough ballpark with the AVPU score, where they are whether they are alert, responding to vocal, painful or unconscious stimuli and only responding to pain or unconscious means they are in the pool or they are in a fair bit of trouble.
Okay. This is essential CPR, and you notice she has not checked for a pulse. She has not fluffed around and done anything. She has just started CPR. If the patient does not need CPR, they will push her away, but the thing is, early CPR and good effective compressions keeps the patient alive. It diffuses their brain, heart, kidneys and all the essential organs and helps you essentially buy time.
It is important to do correct CPR. In terms of the correct rate, the correct rhythm, the correct depth and the correct site, so middle of the chest lower half of the sternum, you see her technique is perfect, straight down as she is compressing that heart between the sternum and the thoracic spine. She is doing 120 beats per minute and compressing a third of the chest or at least 5 cm.
So, in this particular case because it is BLS, we are using an AED. This is the AED that you will you most likely have in your clinics, but also that is found in the wider community where you have a man or a woman talking to you and giving you clear advice, they can analyse the rhythm however we need to maintain CPR while it is applying and to minimise hands off the chest.
This is an essential component to pass in terms of safe defibrillation where you notice her verbal and her nonverbal technique in terms of making sure that we do not have any inadvertent shocks, and using clear closed loop communication.
You notice how oxygenation has been pushed right back. The theory behind this and as you know that there has been a lot of talk of only chest only compression only CPR, the giving mouth to mouth or wasting time trying to oxygenate a patient who has collapsed with a good level of oxygenation in the situation of a VF cardiac arrest, it becomes lesser of a priority.
The same time, I want you to note how they do manage the airway in terms of good technique with bag mass ventilation and then rapidly moving on to a supraglottic airway or a laryngeal mask airway. It is important to if you are going to do it, to do it properly, if you are not ventilating them correctly, all we are doing is filling up the stomach and putting them at increased risk of aspiration.
Notice the two-handed technique and the airway person is not releasing her hands to bag the mask. She is making sure she maintains an excellent seal, so as an airway person, I just see this as just a beautiful, perfect demonstration. Now, this is 2 minutes in real time.
You can see there is quite a lot of time to do things in between, those two minutes are the checkpoints to check the rhythm, and now she is preparing a laryngeal mask airway, and this will allow her basically just to free up her hands.
What they meaning in there is that it is a closed system now with the end of an advanced airway, and so rather than needing to time 30 to 2 or 15 to 1, they only need to do 10 breaths per minute. So now we are at this next checkpoint of two minutes to maintain those good quality compressions. You notice how they have swapped positions so that you have someone fresh to maintain those good quality compressions.
We are on to the second shot now.
At this point, she has a team, and the thing is another good part of this video is presenting it with two rescuers, often in a rural setting. We have a limited number of rescuers or resuscitation personnel, and we have got to use them as efficiently and optimally as possible. When she tells the helper arriving, she is able to delegate and get a little bit more information such as the history of the patient.
That is the whole challenge, I suppose, of emergency medicine in that our day-to-day office work involves a history examination, investigations in that sequence and everything suddenly is all jumbled up, not to mention the stress of the situation.
She is maintaining some calmness to it all, and she is asked to be the leader. In terms of allocating roles. Back to the history, we often use a very short-cutted quick mnemonic for a history, and that is the ample history looking for allergies, medications, past medical history, in my situation, it is a last meal and events are coming up to this situation. The whole underlying principles of being in a crisis or emergency situation is in our mind, humanly it just goes blank, and having these structured approaches and these things to hang on to helps make it a bit more smoother, I suppose.
In terms of the leadership role, you will notice how she actually stands back so that she is not hands on, and this cognitive offloading is really important for her to function effectively as well as her communication skills, closed loop feedback using names and also using cognitive aids and a checklist as you will soon see.
You can see from her isobar presentation, identification herself, situation etc. that the communication is probably one of the most important things here, and it is something that we can all do in a very structured unhurried fashion.
We are going back to the slide. I think at this point I would not mind just pausing a bit and into the chat box if people can in the next couple of minutes, just list out the relevant procedures that are important or the procedural skills, I suppose, that are important for basic life support.
Let us have a look in the chat. Anyone putting up anything procedurals, no? Any relevant protocols that people want to put up that are especially relevant to this presentation, or the paper factors? Okay. The procedures would involve a good effective CPR being able to apply the AED and use it safely similarly and basic airway management and also insertion of an agile relevant protocols would be our BLS algorithm and use of the ambulance checklist and people factors, you can see how they have good team delegation, good leadership, clear concise communication as well as decision making.
We talk about the chain of survival which is demonstrated well here in terms of early recognition and call for help, early CPR, early defibrillation and post resuscitation care. We have some chats to look at. Let us have a look at here. How to adjust the defib dose for children. Let me deal with the questions at the end of the session. Thank you.
Looking at the procedures, the CPR, defibrillation, post resuscitation care and basic airway skills, so the big question is as we progress into ALS, what would be the additional management we could include. This is moving into ALS which is advanced life support, and again there is another algorithm which is from the Resuscitation Counsel.
We really concentrated on this, and then the AED took over and assessed the rhythm as being shockable or non-shockable. It shocked and then gave CPR. but you can see from here the only additions with ALS is drugs such as adrenaline and use of an airway and waveform capnography and access to be able to administer the drugs.
The important thing to consider and correct is the reversible causes, the things that we can treat, things that we can deal with and we commonly call them the four Hs and four T's, and this is the source of the different causes of cardiac arrest, such as hypoxia or hypovolemia that can occur in conditions such as a respiratory arrest or anaphylaxis and asthma or hypovolemia such as a traumatic cardiac arrest, and these hypo and hyperkalaemia, metabolic disorders, hypothermia and hypothermic hypothermia finish off the hatches. Tension pneumothorax tamponade are particularly relevant to trauma, and toxins and thrombosis, both pulmonary and coronary.
The important people factors, just to show this diagram, you noticed how part of their doctor's ABCD, they called for help early. The first point about declaring a crisis and calling for help for the deteriorated patient is challenging because we do not often see this. We do not often see a collapse or seriously unwell patients. There is almost like a cognitive, this cannot be happening bias and that can be enough, but once it is declared, people can spring into action.
Clear communication is really important as it was demonstrated well in this video team coordination and taking on a lead role good decision making, especially if you are using a manual defibrillator and having to decide between a shockable and non-shockable rhythm and anticipation and planning, so at that two minute mark, being able to think about rotating the compressors, charging and when we are charging, the technique that we often teach is a technique called coached.
Coached makes sure that we minimise time off the chest, so that is compressions continue, oxygen away, all others away, charging, so that person that is still doing CPR continues with their CPR while we are charging, and then to evaluate the rhythm we have to do H part of coached which is hands off. Then you can see what the underlying rhythm is. You evaluate the rhythm and then you either defibrillate or disarm.
We have a second case now. In Noorat, Jim has had a hay bale accident. This has all fallen over him, so we have a case of a multi-trauma, presents with reduced consciousness, bruising to his left chest, injury to the left leg, tachypnoea, hypoxic, tachycardic, hypotensive. Lots of bad things are happening to poor old Jim. The ambulance are on their way and they summarise possible head, chest injuries and an obvious open fractured femur. What we are delving into now is a case of a deteriorating patient where again, we use our letters of the alphabet in terms of a doctor's A, B, C, D approach.
I want to demonstrate to you how we can deconstruct a very complex scenario by dealing with each of the pathophysiology one by one in a systematic and structured way. Again, trawling through, I found a really good video to highlight this. It is a bit old, it is a bit North Americanish. However, I will again pause and discuss so that we stay on the right track and focus on the main learning points.
[Video clip]
At this point, we actually have some opportunity to prepare. We have a lead. We have his team. They are focused. They are using clear communication. She is briefing them so that they all have what we call a shared mental model, and they are in the right environment. They are in their resource bay. They have all the kit there, but most importantly, it is familiar.
[Video clip]
See how he is using a technique of an internal summary. He is summarising back to the person who is taking the triage call just to make sure that it is clearer in his head. This is a technique that I use quite often, and that they have all got the same information.
[Video clip]
Again, getting an internal summary of the ambulance. I do not know about all of you, but my mind just totally goes blank, but once you are able to feedback with that communication and do an internal summary, you are starting off at a good base level.
[Video clip]
The difference with the traumatic or with a trauma is we use our doctor's A, B, C, D, E, but often there are some added things which respects the nature of the trauma. First of all, the main difference is we would start with C doctor's A, B, C, D, E. C starts with compressing any external haemorrhage. You can see on the patient's upper left leg, there is a bandage.
I would want to make sure that that is not continuing to bleed. Otherwise, we need to apply direct pressure again or indirect pressure with a knee to the groin to stop the proximal bleeding vessels or using a tourniquet which is about 5 cm above the wound that is tightened up and reducing that external haemorrhage.
Also, looking for any other red spots all around the body. Then we will move on to airway, and airway always comes with cervical spine control because we cannot assume that he has not got a cervical spine injury. The best way is for someone to apply manual in-line stabilisation while he is assessing the airway and then about to manage the airway, as you will soon see.
The other thing that we would use now is with the laryngoscope, not just a direct and indirect laryngoscope, which is what he has, what we have now is what we call a video rigid laryngoscope. Basically this is a screen so that everyone can see what is actually happening rather than just the airway person.
[Video clip]
The indication for intubating is that this person's GCS or AVPU score is in the pool. His GCS is less than 8. He is not responding to pain. He is actually unconscious. The fact that he is not actually responsive, he is not actually making his airway patent and definitely not protected. Similarly, he is also severely hypoxic. All this equals to solving all these problems by putting an endotracheal tube.
Now, putting an endotracheal tube is not going to be fairly easy with this chap. He is going to have possible blood and secretions in his mouth. He is also unable to fully extend his neck because we are worried about a cervical spine injury. The anatomical position of his larynx will be abnormal.
We have got a few tips and tricks for this, including using what I mentioned before, a video rigid laryngoscope, but we would also use other intubating equipment that might help us with that anterior larynx. The thing is these would be advanced procedures that would need to be trained for, but if you did not have that training, the most important thing is oxygenating this patient.
With the current availability of laryngeal mask airways and third generation laryngeal mask airways, this could get you out of trouble in terms of oxygen and maintaining oxygenation of the patient and draining their stomach.
[Video clip]
At this stage, we need to make sure that the tube is in the right spot. The only way to confirm correct tube placement is to see carbon dioxide. They are using what they call a colour change capnography, so that is using a colour change and gold is good where it changes from purple to yellow.
The ideal form is what we call a waveform capnography. That is an attachment with a lead going through a gas sensor that is on the screen. The other ways are seeing the chest rise and fall, auscultating both chest, seeing misting of the tube. There are secondary techniques of confirming tube placement. They are definitely not the gold standard.
[Video clip]
C-spine collars have gone out of vogue. There have been quite a few studies looking at the dangers of C-spine collars in terms of raised intracranial pressure, pressure sores. The gold standard here would be maintaining manual in-line stabilisation using sandbags and possibly taping as well.
[Video clip]
In the community, if someone has a potential C-spine injury and they are conscious, we would put a soft collar on and a lot of ambulances would say C-spine not cleared radiologically. We are we are trusting in the fact that a patient who has a cervical spine injury will not move their neck, but then at moments of risk such as if you needed to transfer them, do their airway, they needed to go to the toilet, imaging, so forth, then we would maintain manual in-line stabilisation.
[Video clip]
Before we leave breathing, we want to make sure that the killers are not present. I think of the killers from an airway breathing point of view is airway obstruction. I also think of other killers, such as tension pneumothorax, an open pneumothorax, a haemopneumothorax, a flail chest, and cardiac tamponade.
[Video clip]
Remember the principle behind your cannulas, two is better than one. We talk about a large bore and with a reduced length, not the really, really long ones. Remember Postel's law in terms of flow rate inversely proportional to the radius and the length.
[Video clip]
With trauma, blood loss is best replaced with blood. Sure, we can use crystalloid as a bridge, but blood is best replaced with blood. If you need it immediately and do not have time for a group specific or group crossmatch, then using O negative blood in women of childbearing age but O positive blood in postmenopausal and males is just as good.
[Video clip]
A massive transfusion protocol may or may not exist just purely because of logistics and the availability in rural areas, but what that actually means is pulling or asking for a pack and a pack implies that the massive blood loss and hence replacement will inevitably lead to a coagulopathy.
Mobilising blood resources in terms of packed red blood cells as well as coagulation factors are really important and logistically very challenging and try to be bypassed with a massive transfusion protocol.
The other thing that we often give is tranexamic acid and that can be given in two bolus doses; 1 g immediately and then 1 g over eight hourly. The other principle with circulatory management is permissive hypotension. Just raising their blood pressure enough say 90 to 100 systolic for perfusion of vital organs rather than overdoing it and potentially disrupting any clots except in the cases of head injury.
[Video clip]
I think I might stop there.
The people factors, I wanted to talk about again, is those crisis resource management important principles. I have already discussed, but what I wanted to move on to here was how this demonstrated nicely a concept called the Zero Point Survey. The Zero Point Survey is a really nice description described by Cliff Reid et al in 2018 for the preparatory phase that is the STE or pre-resuscitative phase prior to commencing patient management via the doctor's A, B, C,D, E. The B part, as we can see from the middle part, is the primary survey where we launch into it.
You could see from this video demonstration how it is important to have got this, which is basically how we talk about position setting ourselves up for success. Self-check, and that is really important, that is another talk in itself in terms of mental readiness and physical readiness.
These are well-oiled team who have obviously trained together, but also they might have just quickly gone to the toilet, had something to eat, made sure they had a good sleep before the shift, but then using their own personal techniques to settle themselves down to lower their heart rate, become a bit more clear-headed and ready for this resuscitation.
The team, as you could see, had a clear leader, had role clarity and a very extensive pre-brief with internal summary. Getting the environment right is really important in terms of light equipment, reduction of noise. It was a very measured, tempered sound volume throughout all and then launching into the patient.
During the resuscitation phase, we need to update where we are at. Once they got through A and intubated the patient, then he moved on to circulation where he said that that was the most urgent priority that needed it and started to change the team trajectory and the mission trajectory.
We have a clear lead team and role allocation cemented by good communication, decision making, and the flow is assisted by anticipation and planning and prior preparation. so step up. Also, this is a nice document, a nice pictorial representation of knowing the plan, sharing of the plan and reviewing the risks. In other words, having a shared mental model, everyone has a good baseline knowledge.
Note please that the leader does not have to be an expert in their field. They do not have to be a face, and they just need to have basic knowledge, basic skills, most importantly a really good attitude and peak performance. All this is linked in with maintaining situational awareness, not ending up going down into tunnel vision, clear decision making, good communication and teamwork and good leadership.
Procedures. I just wanted to show you some really handy links. There is an app called Emergency Procedures, funny enough, that you can click on, airway, breathing, circulation. Here is one on an LMA and outlining how to insert an LMA. Obviously, face to face is important, but this could be a good a good pre-reading tool. I will just click on that with this. That is the site, emergencyprocedures.org, and then you can download the app as we can see from there. Going back to the slideshow.
Again, see doctors A, B, C, D, E, and before we leave circulation, always think about where the areas of big blood loss are, the legs into the abdomen and the chest and the long bones. With him, you noticed how the guy already had a splint on, but he was still hypotensive, and there was a possibility of a pelvic fracture, so putting on a pelvic binder would be part of the resuscitation and control of haemorrhage.
Then, of course, to finish off his disability d not ever forget the glucose and drugs and exposure. Exposure is really important because exposure links into temperature and temperature links into hypothermia. There is the classic triad of badness or death that I call it, where enzymes and intracellular disruptions occur with hypothermia, acidosis and hypovolemia, which are all the challenges that this patient faces.
The other protocol that we can look at is a really good useful site on the vic.gov trauma site. I will just show you this. Here we have the Victorian state trauma system. We can see how you can click on something like thoracic trauma. You get a quick rundown and then you can click on rapid reference guidelines.
You can see how this will just take you through everything that we looked at just now and key points. Finally, is the clinical practice guidelines from ambulance.vic.gov.au. This is a really easy to use site. Clinical practice guidelines, tap anywhere to begin, and then you can see Adult, Paediatric, Maternity, Newborn, and you can flick through that. Finally, safety and quality. They recommend a nice bar presentation. That may be one of our most useful contributions to any critical care scenario is the clear communication.
In summary, tonight via two rural emergency cases, we have explored the protocols that help guide us in their management from the ALS guidelines to Victoria trauma guidelines and communication of their transfer via an ISOBAR framework. The procedural elements required to manage these cases, ranging from the deteriorated patient and immediate CPR to the deteriorating multi-trauma patient and potential for A, B or C intervention.
Finally, the people or human factor elements that underpin and cement all of this ranging from calling for help, coordination, communication and team management and good decision making, anticipation and planning. I hope I have highlighted this in these two videos.
Let us have a look at the Q's and A's. How to adjust the dose for children, babies? Usually first of all, Romani, the defibrillation is uncommon but can occur. Often, children and babies have a hypoxic arrest, so there is more emphasis on airway and oxygenation. However, we would use smaller pads that would fit on their chest wall and use a joule per kilogram as in 4 J/kg.
Does the patient need to be given muscle relaxant and midazolam when the patient is intubated? Excellent question, Clement. We do, we give two different drugs. One is what we call hypnotic to make them unconscious and one is to paralyse them because if we need to insert an endotracheal tube, the muscles around the larynx are too tight.
If you have practiced on intubating on a mannequin that is essentially a patient that is not paralysed plus or minus the gag. We want to optimise our first attempt and that is by giving muscle relaxants and having everything floppy. One of the important points here is that when we are giving a hypnotic which could be midazolam, but often ketamine is used, we give a reduced dose.
Some people talk about up to a tenth of the normal dose because remember we have got a sick patient who is potentially hypovolemic and has got a reduced total body compartment. They do not need that much. Plus, also, these drugs rob them of their sympathetic drive but also reduces their systemic vascular resistance, so it can drop their blood pressure. You need to go low on hypnotics and high on muscle relaxants. Thank you, Tom. Fun fact, TXA dose, and that is really good. Any other questions?
Amy
I think that is all. Thank you so much. I just wanted to say we really appreciate your time tonight. That was a really interesting and really informative webinar. To everyone that has attended, I just want to remind you to please complete the evaluation that will pop up in a moment when the webinar session closes. It really takes no more than a minute to complete.
For those that attended, certificates of attendance will become available on your CPD statements within the next few days. For any non-RACGP members, who would like a certificate of attendance, please just email our rural team at rural@racgp.org.au.
Lastly, I would like to invite you all to join us for part 2 of our Rural Health Webinar series, and I am just going to post this in the chat for you. Michael and Alex will be with us on Thursday, 3 April, to explore current best practices in diagnosing and managing common chronic causes of vision loss such as glaucoma, diabetic retinopathy, cataract and age-related macular degeneration. If you have not registered yet for this free webinar, please do so by clicking the registration link in the chat.
That concludes our time this evening. Thank you everyone for attending and I hope you all have a really good rest of your evening. Thanks everyone.