NOTICE BOARD BLOG


By Dr Colin Boyd, GP at Lochgilphead Medical Centre


Rural practice and risk


In a recent BMJ article (August 14) an A&E specialist worries about deskilling and loss of confidence in carrying out procedures that used to be routine, for instance in advanced airway management because anaesthetists are increasingly called in. It is accepted in The British


Resuscitation Guidelines that non- specialists should not waste vital time attempting endotracheal intubation in cardiac arrest, due to lack of practice, relying instead on simpler ways of protecting the airway. This is a great relief to GPs such as me who work in community hospitals and may only be involved in CPR once or twice a year. But there is a wider question of how to maintain competence in infrequent problems and procedures encountered in isolated parts of the country. Until four years ago I was a GP on a


Scottish island and with five colleagues looked after a population of 7,000. As well as normal GP work we had 12 beds in the community hospital and an A&E department which had to accept all blue-light emergencies. There was no


opting out of on-call and we provided 24-hour cover, often on-call alone. The nearest district general hospital was over an hour away, including 25 minutes on a ferry which stops at night and then we had to rely on helicopter transfers. It was a very enjoyable if tiring role as a GP/hospital practitioner. I was able to do practical things such as suturing, looking at X-rays and putting on plasters, but I was also occasionally faced with complex emergencies. Things that a main A&E department might deal with on a weekly basis we saw maybe once in two or three years. For instance, from memory, during the 13 years I reduced three or four dislocated shoulders and two fracture dislocations of the ankle, inserted three or four suprapubic catheters, carried out a ventouse delivery for delay in the second stage of labour with foetal distress, and put in an umbilical catheter in a baby born unexpectedly at 33 weeks to give glucose whilst waiting some hours for the neonatal retrieval team. More frequently we saw seriously ill patients and a few seriously injured. Did I have the competence to do all


this? I felt I had even without any supervised training in much of it, and apart from the shoulders they all had to be dealt with promptly and I was there.


Courses are a good way of developing and maintaining skills. The ATLS (advanced trauma and life support) course is one of the best for this type of work, and I attended two courses eight years apart. But we allowed ourselves


only one week postgraduate training a year so it was difficult to fit in all that was needed and impossible to keep refreshed in every procedure that might be faced.


In the ideal world we could arrange drills in the hospital to practice emergencies, for instance for CPR, postpartum haemorrhage, shoulder dystocia, etc. We did this for CPR but it was difficult to schedule for all practitioners, including the ENPs as well as midwives. The introduction of ERMS


(Emergency Medical Retrieval Service) has been a step-change for us. Not only does it provide dedicated telephone access to an A&E or intensive care consultant for advice, ERMS personnel are also equipped to come out to our hospitals, usually by helicopter. They prepare patients properly for transfer to mainland intensive care units, including being able to anaesthetise to give full airway control. On top of this they provide feedback on our individual cases and run case analysis sessions, as well as practical training days. In the end you have to judge your


own competence against the need of the patient. By attending appropriate courses it is possible to maintain skill and more importantly develop confidence. Working in a small place, your actions are discussed and judged – and you still have to shop in the Co-op! If you can’t cope with that then


isolated practice is unlikely to suit you.


became head of professional services, managing both medical and dental advisers as well as still advising individual members. And it is helping members in difficult times that Jim has enjoyed most about the job. “I think of medical advisers as doctors to doctors. We discuss,


reassure and support. Counselling is part of the job profile – no matter whether you’re dealing with a professor or a new medical


subscription rate, but depending on your exact circumstances, you may need to increase your membership cover to include these activities. Please contact Membership Services at MDDUS to check you have sufficient cover for this type of practice.


AUTUMN 2014


l ‘FOCUS ON SPORTS MEDICINE The latest MDDUS Risk Factor video interview addresses the topic of sports medicine with Dr Jonny Gordon, emergency medicine consultant and course director of


graduate. That’s what I’ll miss most.” Jim plans to continue with some of his RCGP and other


professional commitments but also looks forward to spending more time with his golf and his family, including the grandchildren (though not necessarily in that order). We will all miss him at MDDUS. Jim Killgore, editor, Summons


SportPromote. Members can find all our interviews in the Risk Management section - mddus.com l LESSONS FROM AVIATION Places are available at MDDUS- sponsored master class events being run Terema - who apply principles of aviation risk to


healthcare. Places are available at Heathrow on 6 and 7 of November 2014 and at the MDDUS Glasgow Office on 12 and 13 of March 2015. Costs are £470 plus VAT and delegates can earn 12 CPD points. To register interest or book a place email risk@mddus.com.


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