Author Archive | David Hogg

Clinical Skills Unit Update

skillunit3

The tardis that is the mobile skills unit!

Clinical simulation – both for procedures and for developing non-technical skills, is an increasingly important part of medical education, and continuing professional development.

Skills labs are commonplace in Scotland’s larger hospitals, with resuscitation teams well placed to open up simulation training to all levels of healthcare worker.

However, in rural areas, access to simulation equipment can be more tricky to organise… which is why for several years the Mobile Clinical Skills Unit has been operating.

Overseen by the NES Clinical Skills Managed Educational Network the mobile skills unit provides a cutting-edge facility that can be driven to literally any part of Scotland.  The unit comes with SimMan, SimBaby and a variety of other simulation equipment, as well as a purpose-built simulation area including a SMOTS Video Analysis facility.

A typical simulation workshop inside the unit.

A typical simulation workshop inside the unit.

We had the unit over to Arran in 2011, for which you can read an evaluation report here.  Since then the unit has visited many other areas of Scotland, and the team behind the unit remain keen for rural and remote areas to request a visit for their own training.  Outreach teams from the Emergency Medical Retrieval ServicePaediatric Transfer Services and BASICS Scotland are often able to assist with training, and link in well with local resuscitation team workshops.

You can read the latest CSMEN newsletter here, or visit their website for further information.  They’re a friendly bunch, so if you have an idea about how the unit could be used in your area, give them a ring to find out more.

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Arran Resilience: supporting rural emergencies

Arran resilienceArran Resilience was set up in October 2010, as a result of a GP Rural Fellowship project.

Recently, David Hogg (GP & Arran Resilience co-ordinator) and Mark Nelson (RNLI volunteer) were invited by NHS Highland to take part in their ‘Being Here’ conference, looking at how to support rural communities and develop local resilience.

The event was recorded by HCVF Television and they’ve allowed us to reproduce the video here.  You can view all the videos from the day, at their NHS Highland TV channel.

Arran Resilience is a cost-neutral, community-led initiative which aims to bring all the emergency services together.  Meetings are held to discuss pan-island issues, multi-agency training is organised and many chocolate hobnobs are consumed in the process.

In 2013 the Emergency Planning Society named Arran Resilience the UK Resilience Team of the Year.

 

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Rural connectivity is no trivial matter

Julian_Tudor_Hart_2007-01-19The availability of good medical care tends to vary inversely with the need for the population served.  This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.  The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.

Dr Julian Tudor Hart, 1971

Tudor Hart’s analysis remains a pertinent reflection on the difference between demand and need, and the tendency to inequality when healthcare provision is left to supply/demand (market) forces.  Yet health & wellbeing inequalities have been allowed to worsen due to market forces dictating access to digital connectivity.  Access to a mobile phone network and the internet is increasingly being viewed as a ‘basic need’, and yet there is a wide variation in this access across Scotland.  We are now at a point where unless the issue is taken more seriously, this digital divide between the ‘most and least connected’ threatens to create a very real inequality within Scotland.

phoneTen years ago, it may have been assumed that those living in rural and remote areas should not be surprised to miss out on the opportunity to use their mobile phone for calls and texts, never mind email and internet video.  However, now the poverty of connectivity in rural Scotland is no longer an acceptable fact of rural life.

The threat that poor coverage now poses to rural areas, is such that this deserves to be a high priority issue at corporate and government levels.  The ‘digital divide‘ – the difference between those who have access to fast broadband, 3G/4G cellular coverage and ‘always on’ technology; and those who don’t, has become a driver of numerous subsequent inequalities – access to information, business development, freedom of speech, the right to be heard and interaction with services essential to everyday living.  It is now commonplace for certain services – from both commercial and public organisations – to offer only online ways of interacting,  with the assumption that this is universally available across Scotland.

Even on stripping the necessities for communication right down to functions commonly viewed as ‘vital’ – such as summoning and co-ordinating emergency care – there is a paucity of acceptable network coverage.  For example on the Isle of Arran, we see the following examples of the difficulties presented by poor mobile phone coverage:

  • Difficulty in contacting on-call staff including medical and midwifery staff.  Our system is as safe as we can get it – we carry radiopagers which have improved coverage, but this offers no means to respond to the one-way message that this can send, nor any confirmation that the message has been received.
  • Difficulty for our ambulance First Responder teams – both in missing calls and subsequently volunteers naturally losing interest as they are either tied to their home phone, or have to relinquish their commitment to volunteer on a regular basis
  • The great benefits offered by SMS callout of our Mountain Rescue Team (allowing rapid assessment of who is immediately available) are overshadowed by poor coverage throughout the island – and in particular for the volunteers who live in Lamlash which is a particular blackspot.  This is dependent on 2G only, in an area that includes hospital, ambulance, lifeboat, coastguard, medical, local authority and other centres, including Arran High School.
  • The Emergency Medical Retrieval Service from Glasgow have invested heavily in making the most of iPads and iPhones to achieve and maintain gold standards in critical and transfer care of patients.   However, as our community hospital in Lamlash has no mobile phone coverage, it is impossible to access these unless sticking to offline content.  In addition, this also makes it very difficult for the EMRS team to stay in touch with their base, and maintain phone availability to other rural centres who may also have critically ill patients to discuss with them.  This example is detailed more fully in the NoBars section of this website, and is replicated across rural hospital sites across Scotland.

Position-finding

targetA number of emergency teams on Arran can make use of a basic 2G signal to find the position of a phone during emergency situations.  For example, ambulance service resource tracking (including availability of BASICS GPs) is reliant on GPS-units which continue to send a GPS position over the 2G network. When a medical emergency arises, ambulance control can quickly pinpoint who is available, and where they are.  Without 2G, this function is lost, and this is the case throughout much of Arran and other rural areas in Scotland.

Another example is in the case of finding a missing person, for example lost walkers on the hills of Arran.  In certain circumstances, Police Scotland can trace the signal from a mobile call, and work out its location.  This information allows emergency teams, for example the mountain rescue team, to rapidly reach the missing person or casualty, saving vital time in preventing ongoing injury or hypothermia.

Without any mobile coverage, these functions are simply impossible.

Smartphones are smart

Smartphones are now so commonplace that they bring an almost-universal access to their other key functions.  Email, maps and key documents whilst on the move can all be facilitated by 3G access, and the vast majority of phone customers are already on 3G contracts.  In being prevented the use of 3G functions whilst away from home wifi, this simply causes an even greater void between what is now currently possible, and what is available to folk living in rural areas.

Access to social media is also increasingly important to form and maintain professional networks, as well as keep up to date with medical news and advances.  In my own experience, much of this is possible through Twitter – our colleagues in Australia have been particularly active on this front – and yet, during a typical 8am-7pm day at work it is not possible to engage with social media due to having no connection.

The situation is further exacerbated by the barring of social media sites by many employers (in my case, our NHS IT team) for fear of activating virus activity from online contacts.  With professional and social isolation being a considerable risk and concern in rural practice, this lack of appropriate phone connectivity does nothing to improve social contacts with colleagues elsewhere in the country and further afield.

What about wired broadband?

In addition, we have seen a similar divide develop with access to hard-wired internet connections.  With urban areas now seeing access to rapid fibre-optic connections, many rural areas still lumber on with fixed copper-wire, offering no more than 6Mb/s – and often the connection is as low as 2 Mb/s.  So on both accounts (mobile and fixed networking), we are seeing the digital divide widen at an exponential rate.

Hotels now rely on online bookings and customer review sites.  GP practices rely on networked access to results, records and reporting systems.  Commercial and charitable organisations rely on cloud-based document storage.  Schools rely on adequate IT access to ensure that students are IT-savvy for the wider world.

Scotland, as a forward-looking country, needs to realise the widening disparities being created by differences in digital connectivity.

The double-whammy of 4G

flagFor many of us working and living in rural Scotland, we will look to Germany with some degree of envy.  When 4G technology came along – promising broadband-speed mobile connectivity – mobile network providers were keen to bid for licences, in order to  rollout of this service to urban areas where the money was easiest to make (no problem with that in the context of business).

Germany, at this point, realised the prospect of widening inequalities in access to digital connectivity.  The German Government therefore began their 4G licensing process by prioritising rural areas for 4G licences first.  Only after providing 4G to these areas , could mobile providers then move on to obtaining licences for more urban areas.  This, I understand, has been successful in closing the digital divide, but without significant penalty to those in cities, as high-speed fibre-broadband was generally already available.

In addition, 4G could rapidly become a surrogate for hard-wired broadband access.  The increased costs in laying fibre-optic cable across rural geography is a prohibitive and costly factor for bringing faster broadband to rural communities.  There is some realisation even within the industry, that implementation of decent 4G roll-out to rural areas would improve internet connectivity – as well as the advantages in  mobile phone coverage.

Why the concern now?

If this has long been the case, why the concern now?  Until relatively recently, mobile applications were new, and most folk living in rural areas have come to expect (justifiably) that digital rollout tends to happen in more urban areas first.  That is where the larger consumer-base is likely to be found, and so it makes sense on many levels, including for profit.

However, the last five years have seen a rapid expansion of the opportunities to network at professional, personal and social levels by having access to 3G coverage or more.  Along with this we have seen it become increasingly important to have an internet connection in order to engage with systems – road tax, online shopping, news and media, and especially professional networks.  The loss of local post office services has exacerbated this dependence on online public services.  Videoconferencing is commonplace, and virtual collaboration is essential for progressing with initiatives and projects.  Poor connectivity simply stifles this productivity.

In 1971, Dr Julian Tudor Hart’s work on describing the ‘Inverse Care Law‘ raised awareness of the fact that in order to benefit those who need it most, healthcare should not blindly follow market forces, and that demand does not equal need.  Whilst the telecommunications industry is rightly a highly competitive and demand-led consumer business, it must be realised that telecommunications per se are an essential component to successful, healthy and productive communities.  Scotland needs more effective action to tackle this inequality if it is to benefit from the vibrancy, innovation and productivity available from more rural areas of the country.  It is vital to close this digital divide.

You can find out more about the NoBars project by visiting nobars.ruralgp.com

CNET story on the importance of rural connectivity

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BBC report on the rural digital divide

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Photo Credits
Tudor Hart by Wikimedia Commons, Phone by ‘Cubosh‘, Target by ‘happy via‘, Flag by ‘Wiki Commons
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Review: PHPLS Course – prehospital paediatrics

BASICSlogoPrehospital Paediatric Life Support (PHPLS) is one of the courses offered under the ALSG umbrella.  In Scotland, providers include BASICS Scotland, and I recently completed this course when it was run in January 2014 at the Kinloch Hotel, Arran.

For those already familiar with ALS, ATLS, PHECC or MIMMS, this course similar in style & approach.  There was however substantial background reading which is necessary – even for the seasoned prehospital/community hospital practitioner – in order to achieve a pass mark in the pre-test and post-test exam.  The information is comprehensive, and as with anything else in paediatrics, there is no shortage of formulae and drug ranges to accommodate the range of ages from 0-16 years.

Much of the reading reinforces generic points seen across the ALSG courses.  A systematic approach is engendered throughout, but I did find some of the content of the course handbook less relevant than other courses that I have done.  The accompanying DVDs (there are 2!) provide a wealth of audiovisual material, but if you’ve a busy clinical day-to-day workload, you might find it difficult to find the time to get through all this.  However, the requirement to sit the online multiple-choice questions 5 days prior to the course (otherwise you can only attend as an observer) results in enough motivation to get through the written material.

For most practitioners, more benefit is derived from the course itself.  The opportunity to meet fellow professionals, benchmark your progress with theirs, and get ‘hands on’ is always appealing.  On this occasion, we were treated to an expert faculty, including some of our local colleagues from Crosshouse Hospital.  Although I am biased (being involved with BASICS Scotland as a director) there was no doubt that the faculty got it just right in their approach to the range of professionals attending.  As well as our core medical, nursing and paramedic teams from Arran, we were joined by nurse practitioners who will soon set foot in Cumbrae, and so we shared the same outlooks of resource-limited island clinical environments.

It’s worth noting that – as with many of the courses on offer from BASICS Scotland – whilst these courses are branded for prehospital use, they carry much relevance for health professionals in community hospital settings, perhaps even moreso than those courses specifically aimed at hospital specialists.  Our faculty had GPs, rural practitioners, air paramedics and consultants – all with great anecdotes and real life examples to talk about on the way.  Throughout, the course was delivered professionally, and they effectively managed to tailor many of the scenarios to the environments in which we work – appreciated.

PHPLS certainly exemplifies the fact that children are not just ‘small adults’, and covering everything from challenges of infancy to adolescence is always going to risk information overload, especially when the course includes medical and trauma cases.

Course cost varies between centres, and is also dependent on the centre where the course is delivered.  Our community friends at the Kinloch provided us (as always!) with great food, great hospitality and flexible use of their facilities throughout the weekend.

The PHPLS course is certified, meaning that there are both written and practical (‘moulage’) exams at the end.  This certainly keeps participants focussed throughout, and makes for more satisfaction when the certificate comes through.  The exams are fair enough – perhaps too much focus on some numerical figures and drug doses in the written exam (I follow the rule that for the vast majority of paediatrics, it’s always better to look it up).

I would recommend PHPLS to any BASICS responder, and any community hospital practitioner especially those in a rural setting.  I understand that the course material is due for an update soon, which would be very beneficial.  For more details of the BASICS Scotland course calendar, have a look here.

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Latest guidance on concussion: take it seriously

EHow seriously do we take concussion?  It appears that there is a wide range of response to the sports player who has taken a knock to the head, and then suffers ongoing symptoms as a result.  These symptoms can be mild, and range from nausea and feeling a bit dazed, to convulsions and collapse – but all deserve appropriate assessment, and a low thresh-hold for time-out, at least until symptoms have fully resolved.

The following poignant video tells the story of Ben Robinson, a 14 year old school rugby player.  He received a number of impacts to his head during a Belfast rugby match in 2011, following which he collapsed and died.  His father highlights the importance of taking one impact and resulting symptoms seriously. Continue Reading →

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Tips for BASICS Responders

BASICS Responders provide prehospital care across Scotland, especially in rural and remote areas.

BASICS Responders provide prehospital care across Scotland, especially in rural and remote areas.

BASICS Scotland co-ordinates over 300 emergency responders in Scotland.  Ranging in background, they include paramedics, nurses, GPs and hospital doctors.  As well as providing multiple training courses in prehospital care, the organisation enables health professionals in rural Scotland to provide an essential backup to the ambulance service – for incidents where an ambulance will take some time to attend, where there are multiple casualties, or where specific skills are required.

More information can be found on the BASICS Scotland website.

If you are a new BASICS Scotland responder you may find the following tips helpful.

  • Keep some essential equipment in your protective jacket.  I carry some OP airways, stethoscope, headtorch, warm hat, nitrile gloves and a pencil/paper.  Carry some food and fluids in your car too.
  • Organise your kit how you want it.  It’s your kit so make sure you know how to get at it.
  • Ensure that your ambulance control centre (ACC) is aware of your skills and availability.  At first, you may find it helpful to contact your ACC several times a week in order to highlight your availability to all the ambulance dispatchers who task calls in your region.
  • Remember that you can always decline a call – sometimes you will be busy, tired, not willing to travel the distance or will have had alcohol.  If this is the case, say so with brevity, and allow the dispatcher to call on the next resource on their list.
  • Send your report forms forms back to BASICS Scotland – it’s important that they get a picture of what calls are attended, so that includes any that are relatively mild and “undramatic”, and also any calls for which you are subsequently stood down en route.
  • If you have any interesting cases, let the Sandpiper Trust know – they are also keen for feedback and stories about when their kit has been helpful.
  • Consider assigning a different ringtone to ACC so that these calls are easily identifiable.
  • If asked to attend a property at night, consider asking control to request that someone stands outside the property, or that all the house lights are turned on so that you can easily determine the incident locus.

Making yourself available for BASICS responding  involves commitment to training and making yourself available during less sociable hours, but it can also be a hugely rewarding and satisfying thing to do.  If you want to talk through whether this might be for you, you can contact your local regional representative from BASICS Scotland.

For more information about becoming a responder with BASICS Scotland, you can download the New Responder Factsheet (pdf, 500KB).
Photo © BASICS Scotland, used with permission.
 
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Enabling more experienced GPs to switch to rural practice

Not all experienced GPs have a cape and beard.

Not all experienced GPs have a cape and beard.

Recruitment & retention of rural GPs is a hot topic in many countries, not least Scotland and the UK.  Traditionally, much focus has been placed on encouraging and supporting newly-qualified doctors to ‘choose rural’ in the earlier parts of their career.  Attracting younger doctors to rural areas remains a vital part of maintaining sustainable rural practice, however there is increasing attention to the opportunities of attracting more experienced GPs to rural practice.

It makes sense.  Rural practice demands – arguably – the widest spectrum of generalism in medicine.  Faced with everything from emergency medicine to complex palliative care, with complicating geographical considerations.  There are times when access to secondary care is either delayed or not possible, due to the distance or mode of transport available.  Practising medicine in this regard is particularly challenging, and requires good clinical judgement.  It’s also what makes the job so stimulating as a career choice. So for GPs who want a career change, and yet stick within general practice, rural practice may well offer the change in circumstances that they want.  And their well-honed clinical judgement and experience is highly valuable to rural communities.

Making the switch

So how can we make this an easier, a more viable choice for more experienced GPs to make?  Aside from the logistical factors, it is recognised that solid provision of training and subsequent mentoring can be very effective in ensuring that GPs making this transition feel adequately supported.  Experience from programmes such as the Scottish GP Rural Fellowship Scheme is rich in helping to pinpoint what skills and competencies are important in promoting professional resilience in rural GPs.   Initiatives such as the EU/Northern Periphery Recruit & Retain project are providing networking possibilities to learn about good practice in Iceland, Scandinavia and Scotland amongst others.

First and foremost, rural GPs need to be good GPs, with a safe and competent approach to all the common/important general practice presentations – including those detailed in the RCGP Curriculum which can act as a good aide memoire to the scope of practice that GP involves.

A close second is confidence and competence in acute care.  Organisations including BASICS Scotland are well established in running courses and refresher training in acute medical and trauma care, and are frequently cited as contributing essential skill acquisition to rural healthcare professionals across Scotland.  There is continual development of the training that they offer, with effective feedback mechanisms to match course content with what’s important in practice.

Thirdly, it is recognised that professional-to-professional support, perhaps as far as ‘pastoral support’ is important.  Mentoring is increasingly cited as an effective mechanism to support new and less experienced GPs, such that the Royal College of GPs in the UK has recently set up a nation-wide match-making facility (requires RCGP login) for mentees and mentors.  It is clear that having a supportive colleague available by phone, Skype or email, can be hugely beneficial in reducing the isolation faced by many GPs working in rural practice.

So what’s the next step?

RCGP Scotland has recently set up a Rural Strategy Group, and input to this has included the RCGP (UK) Rural Forum and NHS Education for Scotland.  The Rural Forum have been active in proposing a framework that could provide an integrated, pragmatic package of training and support for more experienced GPs wishing to switch to rural practice.  The contents of this proposal are still being finalised, however this tenet of recruitment & retention in Scottish rural practice is now clearly an important one, and will likely see fruition in the next year or so.  As ever, the funding streams need to be clarified, and ensuring quality training  that is relevant to rural practice will come at a cost.  However, with Scottish rural practice already at crisis point in terms of recruitment & retention of GPs, it is an investment that is sorely needed.

What are other countries doing?

logoIt is always easy to look to Scandinavia, Australia and New Zealand, amongst others, for ideas.  In this particular field, Australia offers some very helpful models, particularly from its Remote Vocational Training Scheme.  In typically Australian innovative style, there are a number of videos available on Vimeo that explain their work further.  You can view these here and a couple of them should appear below. RuralGP.com hopes to cover future developments in this area.  You can leave comments below, or alternatively submit your own viewpoint article and we’ll publish it here.

 

[vimeo https://vimeo.com/71862734]

 

[vimeo https://vimeo.com/78503146]

 

Dumbledore image Creative Commons licence by Spielbrick Films
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Raby Radiology Survival Course

Used under creative commons licence of Herbert

Used under creative commons licence of Herbert

Looking for a relevant, concise and effective refresher course in radiology?  Nigel Raby, consultant radiologist in Glasgow, has been running his X-ray Survival Course for several years now, and provided hundreds of new A&E doctors with the specific advice required not to miss the important bits of hand, foot, ankle, knee and other common xrays found in the emergency setting.

Rural GPs who work in community hospitals will also find this course useful.  Whether it’s remembering how to interpret a 6 year old’s elbow xray (remember CRITOL?), or knowing how to detect the more subtle changes associated with tibial plateau fractures, the course provides all this instruction in one compact day – and at good value.

Full details are on the Raby X-Ray Survival Course website.  There is an associated book which is found in many A&Es across Scotland, and a new edition is due out later next year (current supplies are very limited).

I did the course as an A&E SHO 5 years ago, and returned to Glasgow to repeat the course last month.  I’m under no sponsorship or commission (!) but would highly recommend the course to anyone who needs a no-nonsense, professionally delivered, rapid-fire refresher training to keep competencies and professional confidence at a satisfactory level.

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