18th July 2015

Sonar beams deflecting cognitive error

https://badem.co.za/wp-content/uploads/2015/07/Osler.jpg 723 641 Kirsten Kingma Kirsten Kingma https://secure.gravatar.com/avatar/9717d9c9075efd22b5bd5009bca83292?s=96&d=monsterid&r=g 18th July 2015 28th December 2015

Sonar beams deflecting cognitive error

Written by guest author: Victoria Stephen

In the midst of treating a critically ill patient, whether it is pre-hospital, in the ED or ICU, time is not on your side. Multiple processes are taking place concurrently, as you take in the history, the patient’s appearance and vital signs. Your mind is rapidly assimilating the information, attempting to piece together the underlying condition and how to treat it. The pressure is on to recognise the problem and to treat it effectively while preventing harm, a situation which is fraught with the potential for cognitive error.

Cognitive error and diagnostic reasoning came up time and time again at the recent amazing #smaccUS conference in Chicago. Simon Carley spoke of clinical gestalt, that gut feeling we get when treating a patient, how often are we correct? Louise Cullen and Ric Body discussed gestalt in the diagnosis of chest pain, and showed us that gestalt (gut feeling) is as good as flipping a coin, being correct only about 50% of the time. Tim Leeuwenberg gave a powerful talk on diagnostic error and its effects on our emotional well-being. Pat Crosskerry, known for his ground breaking work on cognitive processing and error in Emergency Medicine, reminded us of how fallible our thinking is, and though system 1 thinking is useful in our time-limited high risk speciality, it is fraught with potential for error. Scott Weingart gave an interesting talk on OODA loops, a form of system 1 thinking that can be used by experts to rapidly adapt to the dynamic time critical nature of resuscitation. Make sure that you get to listen to all these fantastic talks through the smacc podcasts that will be available later in the year.

It’s all very well to be aware of diagnostic reasoning and cognitive error as we treat critically ill patients. How do we translate theory into practice? Scott Weingart’s talk on OODA loops was fantastic, but how does a trainee gradually negotiate these loops? How do we reduce our risk cognitive error and its potential effect of harm on our patients when time for decision making is limited?

There are many strategies, but one will be the focus of this post – the use of point-of-care ultrasound.

A case in point:

I was on duty on one particular busy winter’s night a year or two ago. It was 4 am; I was exhausted, having been in resus for 8 hours already. The patients had been critically ill and challenging. Just as the ED had appeared to slow down, a 35 year old female was wheeled in. She was exceptionally breathless and couldn’t complete sentences. To make the situation more difficult, she spoke Shangaan, a language which neither the nurses nor I could speak. All that could be gleaned from her was that she was HIV positive but did not know her CD4 count. She had been sick for a few days with haemoptysis and dyspnoea. That was it.

She was diaphoretic, tachypnoeic at 48 breaths per min and her sats were 61% on a non-rebreather mask. Her initial BP was 130/90, pulse 110 BPM. She was coughing up pink sputum.

A quick exam was done while monitors were placed and an IV inserted. She looked like many of the patients I had already treated that evening: wasted, pale, oral thrush – stigmata of HIV. Chest: coarse crackles bilaterally. CVS: loud P2. I couldn’t hear a murmur, the chest was roaring with crackles around the background din of the ED.

I assumed the diagnosis with little further consideration, neurons only capable of firing away in bullet points: HIV, low CD4 count, likely multi-lobar pneumonia with ARDS, possible PCP, right, let me get this patient resuscitated and intubated…opening up her fluids while preoxygenating her.

Miraculously, the radiographers were in resus at the time and a CXR was done:

Quick glance at the XR – right, as I suspected – bad pneumonia, ARDS, but I was really just thinking of how I was going to safely intubate such a physiologically difficult patient. Once she was intubated and on the ventilator, I took a look at her heart. This ED only has an old ultrasound machine with an abdominal probe, but it was enough to deliver the diagnosis:

Parasternal Long Axis view: Doming of the AMVL can be seen with restricted opening of the mitral valve. The MV is thickened particularly at the leaflet tips. The LA is large.

Parasternal Short axis at the level of the MV: The valve is thickened with commissural fusion. This is severe Rheumatic mitral stenosis, confirmed later by a formal echo.

Lung ultrasound was done, showing B lines bilaterally, indicating pulmonary oedema. “By the way doctor, the urine pregnancy test is positive” Ultrasound of the abdomen was done next, showing a bulky uterus, no intra-uterine pregnancy noted and no pelvic free fluid.

Based on this basic echo, fluids were limited and the patient was diuresed. Cardiology was consulted, confirmed the diagnosis of MS. Balloon valvuloplasty was done and two days later she was extubated and was discharged home a while later. Her septic markers were negative. Later on it was discovered she had had a miscarriage a few days before presentation. The tachycardia induced by the haemorrhage had reduced ventricular filling, raised her left atrial pressures abruptly and pushed her into pulmonary oedema, unmasking her mitral stenosis.

Ultrasound can unmask a diagnosis not detected on physical exam. Mitral stenosis is a notoriously difficult murmur to detect. The doyen of Clinical medicine, Sir William Osler once said: Mitral stenosis may be concealed under a quarter of a dollar. It is the most difficult of heart diseases to diagnose.” This is Sir Osler, mind you. What hope is there for us with our pithy physical exam skills?

This is what this case taught me:

My initial diagnosis was wrong. The echo was basic; it did not yield great images but helped me reach the right diagnosis.

Bedside ultrasound can lead to more rapid diagnosis, and earlier appropriate management. The medical registrar who saw her didn’t believe she had MS, because he couldn’t hear it. Her diagnosis and management could have been delayed for days.

Patients can have more than one diagnosis or co-morbidity. The presence of HIV and heart disease, HIV and diabetes is common.

Elia et al published a case series in the American Journal of Emergency Medicine called “ultrasound to reduce cognitive errors in the ED” The link is here: Ultrasound to reduce cognitive errors in the ED

The paper describes cases where the use of point of care ultrasound altered the patient’s diagnosis and management. Each case demonstrated cognitive pitfalls and assumptions that the use of ultrasound helped to avoid. In the critically ill where decisions need to be made rapidly, ultrasound is an effective tool to check your reasoning and improve your management.

Be careful with interpreting poor quality images however; always get formal imaging, and ensure that you are properly qualified to interpret images before you incorporate them into your decision making on critically ill patients.

Kirsten Kingma

3rd July 2015

SMACC, the FOAMed Highlight of the Year

https://badem.co.za/wp-content/uploads/2015/06/IMG_2232.jpg 3264 2448 Kirsten Kingma Kirsten Kingma https://secure.gravatar.com/avatar/9717d9c9075efd22b5bd5009bca83292?s=96&d=monsterid&r=g 3rd July 2015 28th December 2015

It has been of interest to note that the vast majority of the traffic on #badEM has been via Facebook sharing rather than twitter. This may mean that many of you guys haven’t discovered the full potential of the FOAM (Free Open Access Medicine) community. The SMACC (Social Media And Critical Care) conference is in its third year now as was held in June in Chicago, USA. SMACC is one of the big highlights on most FOAMers calendar; it is essentially the heart and soul of FOAM. SMACC over the past 2 years has had such a big impact on my medical education and mind-set that I decided that I was going to attend this year even if it meant sleeping on the streets. The next few posts will summarise the key points that I took away from the conference. This post aims to give an overview of what it is all about and how medical education is in my mind, is evolving.

In the simplest of terms, SMACC is a medical conference with an emphasis on critical care; the talks are all done in a Ted talk style. The audience is encouraged to participate in the talks through use of twitter; this is used as a platform to ask the speaker’s questions as well as share key points to others not present in the session. The speakers are chosen based on both their academic backgrounds as well as on their ability to present to an audience. The talks are informative but in a non traditional way; slides consists predominantly of pictures with minimal or no text, graphs and complicated slides are discouraged, speakers are talking on topics that they are passionate about and there are no intimidating suits and ties. It creates an environment where the audience can sit back, listen and engage with the topic at hand. Some of the talks I attended went to all new levels of extremes to engage with their audience; there was beer drinking during sessions, mechanical bulls, Milo given to the audience, passionate slips of profanity, and even some nudity. None of this distracts from the main topic at hand, it becomes clear that the speakers put months of thought and effort into how they can convey their message in the best possible way. The speakers are a heterogeneous mix of professions, cultures, genders and opinions. Debate and conflicting ideas is encouraged, often the talk carries on for many days through the Twitter platform. As a medical student, the best analogy would be to imagine one had been eating rice their entire life and now they had been exposed to the finest cuisine around, it becomes impossible to satisfy ones cravings and all you want to do is over indulge.

In addition to the presentations there were multiple pre-conference workshops. This is where the magic happened. The workshops covered a variety of topics both clinical and non-clinical. The value in the workshops is that is creates an environment to interact with the varying experts on topics that interest you. The smaller groups allow for networking and socialising while simultaneously learning. I was involved with the emergency airway, emergency ultrasound and cadaver skills workshop. Pre-reading and video content were sent to attendees to encourage a flipped classroom scenario and post workshop surveys were sent out for future improvement. The stations were designed to give off core knowledge and skills in a practical hands-on manner with faculty members giving assistance and advice.

The conference really distinguishes itself from any other through the emphasis on networking and socialising. Faculty, attendees, volunteers and students were all mingling constantly. Months before the conference #smaccRUN was created where everyone was welcomed to join in on a 5/10km run around Chicago. A constant buzz of open invitations to dinner circulated twitter daily. The gala dinner to which everyone attended was nothing short of a rocking music concert. A massive venue situated on Navy Pier housed many of the attendees till the early hours of the morning.

While FOAM tends to create “super stars” of the industry, it was refreshing to see how approachable and “normal” everyone is. It is often frowned upon to socialise within the work environment, especially with ones mentors. I left Chicago with my mentors now as some of my close friends. The level of discussion and open communication drastically improves when people are able to connect with each other. The removal of hierarchy and constricting boundaries creates an interesting situation where the real things that we often hide from honestly discussing can be approached. While many may argue that it is essential to keep “professional boundaries” between mentors and mentees, I now tend to disagree. My opinion has changed more to the need for mutual respect for ones roles rather than restrictive boundaries.

I would like to thank the organisers Roger Harris, Oliver Flower and Chris Nickson for giving me the opportunity to attend this one of a kind conference. If you haven’t seen any of the SMACC podcasts, check out:

smacc.net.au
To hear my all time favourite: How To Be a Hero by Cliff Reid
For non-medical professionals I would recommend: Stress Management: Swearing Your Way Out of a Crisis by Liz Crowe
This year’s podcast will be released for free on iTunes over the year, so SUBSCRIBE to hear them as they roll out!
- iTunes SMACC link: iTunes SMACC podcast

Next year is #smaccDUB, I would highly recommend it to everyone! This has really been a paradigm shifting, mind-altering experience that I would recommend to every healthcare professional.

#smaccDUB: Dublin Convention Centre; 13 – 16 June 2016. Limited to 2000 attendees so if you’re keen be sure to register early (Registration should open around November but follow @smaccteam on Twitter to find out more)

If you are not on Twitter: then I recommend you join today! A post will be out soon on “How to Get Your FOAM On” (and Twitter).

Kirsten Kingma

2nd July 2015

No electrodes, no problem

https://badem.co.za/wp-content/uploads/2015/05/Innovation-1-image-1.jpg 1224 1632 badEM badEM https://secure.gravatar.com/avatar/1b6b54debb689e667f4bf9ea6dd5df43?s=96&d=monsterid&r=g 2nd July 2015 28th December 2015

In the preparation for the 19th World Congress on Disaster & Emergency Medicine held in Cape Town – AfJEM asked African Emergency Medicine lovers something interesting –

“Can you hack, concoct, devise or contrive a wanted resource using only locally available materials? You can..? Really..? Now you can show it off & win some amazing prizes”

The rules of engagement we were given were:

You can only use materials that are locally available
Your end-product should have comparable functionality to the product it aims to replace
It should be simple to hack, concoct, devise or contrive
It should be novel (not have been described before)

#badEM authors & friends quickly went hard at work to submit our “tricks of the trade” & were excited to hear about the entries at the conference. After numerous entries Dr Stevan Bruijns & the AfJEM team voted for a Top 5; described below.

1st Place – Emmanuel Acheampong – ED Nurse – Ghana @achiegh

No electrodes, no problem

This is what Emmanuel had to say about his innovation: “There are times in the emergency department (ED) when there are no electrodes available to place patient on a monitor. In resource limited settings like Ghana, it is very expensive to replenish disposable electrodes and it is quite common to run out of electrodes in the ED. Improvisation in medicine has become a solution to daily problems encountered in resource limited settings. You can use cotton swab as a replacement for your electrodes.
1. Get three moderate sized cotton swabs and make it slightly moist.
2. Place the cotton swabs in position as you would electrodes for monitors.
3. Attach the probes of the monitor to the swabs and tape over the probe and swab as shown in pictures.
4. Turn on the monitor and inspect the ECG tracings”

badEM

27th June 2015

A resourceful shoulder to lean on

https://badem.co.za/wp-content/uploads/2015/04/AfJEM-competition-logo.png 1100 612 Kat Evans Kat Evans https://secure.gravatar.com/avatar/b8a10892c5764923b0131dc35daead18?s=96&d=monsterid&r=g 27th June 2015 28th December 2015

In the preparation for the 19th World Congress on Disaster & Emergency Medicine held in Cape Town – AfJEM asked African Emergency Medicine lovers something interesting –

“Can you hack, concoct, devise or contrive a wanted resource using only locally available materials? You can..? Really..? Now you can show it off & win some amazing prizes”

The rules of engagement we were given were:

You can only use materials that are locally available
Your end-product should have comparable functionality to the product it aims to replace
It should be simple to hack, concoct, devise or contrive
It should be novel (not have been described before)

#badEM authors & friends quickly went hard at work to submit our “tricks of the trade” & were excited to hear about the entries at the conference. After numerous entries Dr Stevan Bruijns & the AfJEM team voted for a Top 5; described below.

2nd Place – Lauren Lai King

A resourceful shoulder to lean on…

Shoulder dislocations are a common acute orthopedic complaint presenting to emergency centres throughout South Africa. Post reduction immobilisation is essential in the recovery and rehabilitation period. This core management step is not always implemented as a result of resource limitations, most commonly the unavailability of shoulder braces.

I propose the innovation of makeshift shoulder braces utilising easily accessible resources.

1. Improvised “polysling with shoulder stabiliser” from collar and cuff – Foam bandage is folded around the neck from which the sling can be suspended. Cable ties are used to secure the foam bandage into a support sling for the arm. Free edges of the sling are tied around the trunk to provide stabilisation and ensures that the upper limb is securely adducted to the torso. The sling can be untied with the free, uninjured hand to release the injured limb as necessary. Assistance is required during the initial fitment process and during each application of the sling.

2. Even more low resourced T-shirt shoulder stabiliser: In more resource limited settings, a shoulder sling can be created with the free edge of a t-shirt and 2 safety pins. The free edge of the t-shirt is folded up until the injured arm is supported in the shirt crease. The free edge is secured in place with a minimum of two safety pins. This creates an effective and user friendly solution. All aspects of the design can be completed by the injured individual with the uninjured hand.

Kat Evans

20th June 2015

EC Nurse from Malawi Lucia’s trick of the trade for O2 administration

https://badem.co.za/wp-content/uploads/2015/05/WP_20150316_006.jpg 916 1632 Kat Evans Kat Evans https://secure.gravatar.com/avatar/b8a10892c5764923b0131dc35daead18?s=96&d=monsterid&r=g 20th June 2015 28th December 2015

In the preparation for the 19th World Congress on Disaster & Emergency Medicine held in Cape Town – AfJEM asked African Emergency Medicine lovers something interesting –

“Can you hack, concoct, devise or contrive a wanted resource using only locally available materials? You can..? Really..? Now you can show it off & win some amazing prizes”

The rules of engagement we were given were:

You can only use materials that are locally available
Your end-product should have comparable functionality to the product it aims to replace
It should be simple to hack, concoct, devise or contrive
It should be novel (not have been described before)

#badEM authors & friends quickly went hard at work to submit our “tricks of the trade” & were excited to hear about the entries at the conference. After numerous entries Dr Stevan Bruijns & the AfJEM team voted for a Top 5; described below.

3rd Place – Lucia Mbulaje – ED Nurse – Malawi

No wall/tank oxygen.. 1x oxygen concentrator.. multiple patients needing oxygen..

This is what Lucia has to say about her solution: “Working in a resource restrained situation is so devastating but not for someone who has a sharp mind and good innovative skills. Being a resuscitation nurse at the emergency department offers a quite range of excitement for workers who have sharp mind and good innovative skills. It offers some kind of fund in adventure of finding ways to achieve desired outcomes with the absence of real equipment. For one to perform a procedure, it takes knowledge and skill about the procedure and how to use the equipment. On the other hand, it’s one thing to know how to perform a procedure and another thing to understand the mechanism of the equipment. That’s where innovation lies.”

“The resuscitation room is a four bedded space with equipment like oxygen concentrators matching the number of beds. Most often, we do have over four patients who need resuscitation at once. As a result we are forced to bring in extra beds in the resuscitation room. Since we do not have extra concentrators for the extra patients, improvising is the only option to save the lives. Ideally, one oxygen concentrator can be used for more than one patient if splitters are available e.g. “Y connector”, but the case is not the same in my situation because the splitters are not available. So we use the readily available cheap resource to achieve the same outcome and the resource we use is a “GLOVE”.
“The open part of the glove that we use when donning is attached to the outlet of the oxygen humidifier outlet. Then it is well secured with tape. The finger tips of the gloves are cut and nasal cannulas are connected and secured with tape. So when the machine is switched on, oxygen flows from the humidifier outlet into the glove where it is splitted to the five fingers and from the fingers into the nasal annuals something which enables up to five patients to benefit from one concentrator.”

Kat Evans

16th June 2015

Homemade Needle Thoracentesis Simulation Vest – 4th Place – AfJEM Resource Innovation Competition 2015

https://badem.co.za/wp-content/uploads/2015/05/Innovation-2-image-3.jpg 3264 2448 Kat Evans Kat Evans https://secure.gravatar.com/avatar/b8a10892c5764923b0131dc35daead18?s=96&d=monsterid&r=g 16th June 2015 28th December 2015

In the preparation for the 19th World Congress on Disaster & Emergency Medicine held in Cape Town – AfJEM asked African Emergency Medicine lovers something interesting –

“Can you hack, concoct, devise or contrive a wanted resource using only locally available materials? You can..? Really..? Now you can show it off & win some amazing prizes”

The rules of engagement we were given were:

You can only use materials that are locally available
Your end-product should have comparable functionality to the product it aims to replace
It should be simple to hack, concoct, devise or contrive
It should be novel (not have been described before)

#badEM authors & friends quickly went hard at work to submit our “tricks of the trade” & were excited to hear about the entries at the conference. After numerous entries Dr Stevan Bruijns & the AfJEM team voted for a Top 5; described below.

4th Place – Jamie Higgins @jr_higgins

Homemade Needle Thoracentesis vest, made from old wetsuit and bladders of two old manual blood pressure cuffs.

The vest is designed to be either: worn by a classmate, applied to a CPR doll or the wetsuit can be stuffed with newspaper. It is used for students to practice the above skill in a learning environment where expensive simulation training dolls are not available.

The vest is designed with the back slit open, for easy application. The anterior left and right chest wall have pockets stitched on the inside to allow for placement of BP cuff bladders. A hard piece of plastic with horizontal cut outs simulating intercostal spaces is inserted overlying the bladder. A complete piece of plastic is inserted behind the bladder to protect the wearer. On the outside of the vest, additional pieces of wetsuit material are applied with velcro allowing for replacement when they become worn through.

Kat Evans

9th June 2015

Below elbow POP video

https://badem.co.za/wp-content/uploads/2015/06/IMG_5038.jpg 3264 2448 Kat Evans Kat Evans https://secure.gravatar.com/avatar/b8a10892c5764923b0131dc35daead18?s=96&d=monsterid&r=g 9th June 2015 28th December 2015

Below Elbow POP

This video aims to give simple steps in the procedure of paediatric below elbow plaster of paris (POP)

Equipment: ortho wool, 2x medium rolls of POP, 1x large roll of POP
Apply ortho wool: intervals covering 50% of your last throw, down the arm
Applying the first POP: start at the wrist and work down the hand, and back up the arm
Second roll of POP: apply to the midpoint and cover the whole forearm and hand
Fold the wool: giving enough room to flex at the elbow
Reinforcement: cover the length of the forearm with a wider roll of POP
Smooth the POP: paying attention to the thumb area
Finished POP: there should be room to flex the arm, and the thumb should be free to move with the pop smoothed to prevent abrasions/ pressure areas

Additional basic tips for newbies

Children don’t liked to sit still – ensure adequate analgesia (paracetamol, ibuprofen, tilidine drops aka valoron) and if needed sedation prior to procedure
When wetting the POP rolls in water ensure you maintain hold of the loose end
Wait for the majority of bubbles to cease before removing the POP (insert vertically into water). Squeeze out excess water for the POP roll prior to application
When smoothing over ensure not to apply pressure with finger tips (avoid pressure areas at all costs). Dunking hands in water prior to smoothing helps
Remember to advise family about danger signs to watch out over the next 24 hours and when to return for follow-up

Kat Evans

1st June 2015

Using condoms to avoid PPH related maternal deaths in Africa – Not what you think!

https://badem.co.za/wp-content/uploads/2015/06/iStock_000007433779XSmall.jpg 425 282 Willem Stassen Willem Stassen https://secure.gravatar.com/avatar/38c944ce032af5c17bf315a4aec94502?s=96&d=monsterid&r=g 1st June 2015 28th December 2015

Reducing maternal death is the fifth Millennium Developmental Goal as Identified by the World Health Organisation (WHO) and has been a priority in Africa for many years. In Africa, the maternal mortality rate is still unacceptably high – one woman dies every 7 minutes in Africa from birth-complications. The leading cause of maternal death is post-partum haemorrhage (PPH) accounting for up to 35% of cases. In Sub-Saharan Africa, approximately 1 in 10 mothers will suffer from post-partum haemorrhage. The WHO guidelines for the management of PPH can be found here. In addition to administering oxytocin, tranexamic acid and other conservative management strategies, a recommendation is made to place an intra-uterine tamponade balloon in cases of uncontrolled haemorrhage until specialist care may be accessed. Yet, commercial tamponade devices, such as the Bakri Balloon may not be cost-effective and feasible within the resource-limited settings of Africa. These may cost up to $250! This problem is compounded when considering the relative shortage of blood and the geographical hurdles to overcome in order to access specialist gynaecological care. These devices may be welcome temporising measures that prevent massive haemorrhage during transfer to these facilities. So, what is the #AS2AP? (African Solution to African Problems)

Who would have thought that the very device that may prevent pregnancy, may also prevent death from delivery? Above is a novel African innovation that employs low cost equipment to effect uterine tamponade.

Willem Stassen

28th May 2015

Nasal atomisation without the device – 5th place – AfJEM resource innovation competition 2015

https://badem.co.za/wp-content/uploads/2015/04/AfJEM-competition-logo.png 1100 612 Kat Evans Kat Evans https://secure.gravatar.com/avatar/b8a10892c5764923b0131dc35daead18?s=96&d=monsterid&r=g 28th May 2015 28th December 2015

In the preparation for the 19th World Congress on Disaster & Emergency Medicine held in Cape Town – AfJEM asked African Emergency Medicine lovers something interesting –

“Can you hack, concoct, devise or contrive a wanted resource using only locally available materials? You can..? Really..? Now you can show it off & win some amazing prizes”

The rules of engagement we were given were:

You can only use materials that are locally available
Your end-product should have comparable functionality to the product it aims to replace
It should be simple to hack, concoct, devise or contrive
It should be novel (not have been described before)

#badEM authors & friends quickly went hard at work to submit our “tricks of the trade” & were excited to hear about the entries at the conference. After numerous entries Dr Stevan Bruijns & the AfJEM team voted for a Top 5; described below.

5th Place – Kat Evans @kat__evans

Nasal Atomisation without the Device

There is a need for rapid administration of analgesia to certain groups of patients who present to the Emergency Centre, however frequently this is delayed whilst awaiting intravenous access. Intranasal drug administration is an alternative rapid, low tech option which requires minimal training. Commercially designed ‘Mucosal Atomisation Devices’ are not often available in Western Cape Emergency Centres which likely leads to this option not being frequently utilised.

An adapted technique of intra-nasal drug administration is demonstrated in the attached photographs utilising a 3 way stopcock, IV cannula, oxygen/air source & syringe. See images attached.

Uses of Intranasal medications:
1. Analgesia
2. Sedation / Seizure control
3. Antidotes eg Naloxone
4. Epistaxis management
5. Topical anaesthetics
6. Hypoglycaemia management eg glucagon

Check out www.intranasal.net for more information on the intranasal route of drug administration.

Kat Evans

28th May 2015

Introduction to out-of-hospital emergency systems in South Africa

https://badem.co.za/wp-content/uploads/2015/05/10527466_10155571212515387_1714241902231677470_n1-e1432411250531.jpg 710 384 Kirsten Kingma Kirsten Kingma https://secure.gravatar.com/avatar/9717d9c9075efd22b5bd5009bca83292?s=96&d=monsterid&r=g 28th May 2015 28th December 2015

Out-of-hospital Emergency System in South Africa

Craig and Minh recently did a great podcast discussing many of the above points: listen to it here on the PHARM

South Africa has a unique out-of-hospital healthcare system, it is by far one of the more developed when compared to neighbouring countries and many standards meet that of first world norms however we are by all means still a developing country and still have many steps to go. We rely on a two-tiered system of government and private medical facilities; this counts for both in and out of hospital systems. The large private organisations provide services are often comparable to first world standards whereas our government system, which is under far greater burden, excels in certain fields but also suffers from the excessive strain.

Bakkie vs Palm Tree, 1 Blue, 1 Red trapped (1)

Practitioners

Paramedics predominantly provide services out of hospital. Doctors and nurses working in the out-of-hospital environment are the exception.

Paramedics are trained at different levels
- Basic Life Support (BLS): 5 week course equipping the provider in basic life sustaining measures (basic ventilation, CPR, how to recognise varying conditions and limited treatment (glucose, activated charcoal, oxygen, nitrous oxide). They are registered by the Health Professions Council of South Africa (HPCSA) in the supervised practice category and thus usually have an ILS or ALS practitioner working with them
- Intermediate Life Support (ILS): This is a 6 month course (requires BLS and practical experience prior). The provider is equipped to manage any patient requiring basic life support, in addition they can place IV lines for fluid therapy as well as administer certain medications as indicated (aspirin, beta2 stimulants, ipratroprium bromide, dextrose, and BLS medications). They are registered as independent practitioners and can treat and make decisions at their own discretion.
- Advanced Life Support (ALS): this can be done through continuation from the ILS qualification or via a program at a tertiary institution. In South Africa ALS practitioners are referred to as paramedics. All can give varying levels of Advanced Life Support medications and perform procedures however each is limited by a specific protocol. As an example an ECP is capable of RSI & fibrinolysis while the other qualifications are restricted in this field.
  - Critical Care Assistant (CCA): Course method consists of +- 11months as well as practical experience (in addition to having previous ILS qualification).
  - Emergency Care Technician in Emergency Medical Care (ECT) – 2 year full time at a University (this includes practical rotation during the course)
  - National Diploma in Emergency Medical Care (NDip) – 3 year full time at a University (this includes practical rotation during the course)
  - Bachelors in Emergency Medical Care (B.Tech/B.EMC) also known as ECP – 4 years full time at a University (this includes practical rotation during the course)

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Methods of transport

Road ambulance transport is the most common means of transport. While the standard of equipment on ambulances varies, the national department of health is making an effort to standardise minimum requirements for ambulances. In general ambulances are regular transport vehicles that are converted to accommodate a stretcher. Most ambulances have space for two patients on stretchers. In certain areas with a heavy burden of patients its is not uncommon for multiple patients to be transported simultaneously to a health care facility.
Aeromedical transport has a presence but is often heavily burdened and reserved primarily for transportation when distances are excessive for road transport. While there are cases where ambulances travel over 800km (Springbok to Cape Town) with patients, the aeromedical services reduce the incidence of these type of cases. The aeromedical services also provide a rescue service in the form of rotor-wing retrieval. Fixed wing services are also available in certain areas.

IY Fires (5)

Additional Services

Fire service: they have predominantly ILS trained practitioners at each station and roaming ALS practitioners. They do not transport patients however they often provide assistance at motor vehicle collisions as well as giving temporary care in medical rooms based at the fire station. They play a major role in rescue operations throughout the country.
Rescue services: these are a linked to the state ambulance service in the Western Cape, they provide support for motor vehicle extrication, structural collapses, wilderness rescues as well as others incidents which require specialised equipment and resources.
Volunteer organisations provide an important resource that supplements the full time services. These include organisations such as Wilderness Search and Rescue, Sea Rescue, volunteer ambulance services as well as others.

Where the gaps hide

While we have a system that overall provides an essential service that is accessible to most, some of the biggest challenges include:

Interprovincial variation on equipment, personnel resources and standards
- Response times to primary emergency calls can take over an hour till the 1st resources arrive on scene in rural regions
- Inter-hospital transfers to a higher level of care can take hours to be processed even in urban areas (this includes critical patients)
Densely populated urban areas with good resources and under-resourced rural areas
Poor socioeconomic circumstances (lack of transportation, formal employment) putting additional strain on the road ambulance services (many individuals utilise ambulance transport for primary healthcare needs – not a problem unique to the developing world)

These restraints lead to a burdened service however provides an environment which encourages practitioners to work hard, find simple cost effective solutions for everyday problems.