Trauma: Triage, Treatment and Transport

Hello, I’m Norman Swan.
Welcome to this program on trauma. It’s the call that most rural
and remote GPs and nurses dread – the accident in a difficult location needing assessment,
treatment and transport. How to respond effectively
is what this program is about. You’ll find a number of useful resources available on the Rural Health Education
Foundation’s website – rhef.com.au. Let me introduce our panel to you. Libby Bowell is the Education Manager
for the CRANAplus, First Line Emergency Care program
in South Australia. – Welcome, Libby.
– Thanks, Norman. Previously, Libby worked as
a remote area nurse and also works for the Red Cross
internationally in Disaster Response. About to go to PNG
to look after people with cholera. On Saturday. I can reassure you today that we won’t
be talking about cholera in Australia, we’ll be talking about things
more mundane. Minh Le Cong is
a Senior Medical Education Officer with the Queensland section of the
Royal Flying Doctor Service in Cairns. – Welcome, Minh.
– Thank you. Minh has been working with the RFDS
for six years and prior to that, he was in rural
general practice for five years. Mark Elcock
is the State Medical Director of Retrieval Services in Queensland.
Welcome, Mark. Mark has provided
the clinical leadership behind the establishment
of Australia’s first fully integrated adult, paediatric, neonatal and high
risk obstetric clinical coordination and retrieval system. He speaks Scottish and I’ll do
simultaneous translation for you. Ken Harrison is Anaesthetist
and Retrieval Specialist with CareFlight in New South Wales. He’s worked in Trauma
and Retrieval Medicine for 15 years and has an active interest
in education and research in Trauma. – Welcome, Ken.
– Thank you. Ken has extensive experience
in international disasters. He was part of the AusAID response
to the tsunami affecting Aceh and the Yogyakarta earthquake
on the island of Java. So, welcome to you all. But on the phone tonight
is Sabina Knight who is a remote area nurse, Associate Professor at
the Centre for Remote Health in Alice. – Welcome, Sabina.
ON PHONE: Thank you. We’ll bring you into the program later.
Welcome to you all. So, what do you think the… I mean, what are the sort of data here
on injury and how it compares across rural
and remote Australia? Yeah, if… the graphic injury deaths
in Australia in 2004, 2005 illustrates that basically,
the more remote you are, the more likely you are to die
from an injury. Predominantly, motor vehicle accidents and you can see in this graphic here on the right of the graph
is the remote areas and you can see that there’s quite
a high proportion of deaths related to injury even in the very recent statistic. If you look at motor vehicle accident
related deaths in the same period, the same pattern of the graph. So the more remote you are, the more likely you are to die
in a motor vehicle accident. And specifically,
looking at Indigenous Australians, you can see it’s a busy graph. But essentially,
the white bar on the far right shows Indigenous males. You can see that the more remote you are as an Indigenous male, the more likely you are to die
due to a road traffic accident. And so,
this is really quite a stark statistics that the more remote you are, the more likely you are if you get
injured, you’re not gonna do as well. NORMAN: The reason is, Mark? I mean, I think there’s multiple reasons
why this is so. I mean, you’ve also got to remember that this is part of the picture
we’re looking at with the deaths. You’ve got to remember
that for every death from trauma, there’s about 31 hospital admissions and another 140 ED presentations
related to trauma so that’s the tip of the iceberg. But in terms of rural and remote, I think we try our best within systems
to promote equity of access to all Australians to access
a similar level of care but we all know people who work
in rural and remote realise that… ..what we can offer there
is not the same as if it happened
in metropolitan Sydney or Brisbane. So the normal things are often
motor vehicle accidents, motorbike and agricultural accidents,
violence, alcohol-related injuries, the comorbidities
that exist in rural and remote. I think they all add to the distance
and the reality of all. NORMAN: Is that one of the reasons
for the high risk in Indigenous people? That’s a large part of it. It’s got to do with the remoteness, it’s also got to do with
individual factors amongst Indigenous, as Mark was saying, comorbidities. The fact that
there’s a lot less compliance with things like seatbelt driving,
driving safe cars, doing things like that. If you’ve had bowel surgery and you’re
on morphine, that can’t help either. – It doesn’t help.
NORMAN: Libby? Your perspective on the reason
as you’ve seen a lot of this. Yeah, I agree with what’s been said. There’s often overcrowding in vehicles, there’s no seatbelts,
they’re unroadworthy cars sometimes, the comorbidities,
the isolated roads and the distances must impact on the mortality rate. Is there much variation
in systems and responses around the country, do you know? Look, I think there’s generally,
there is variation from state to state but generally, the majority
of the states have moved towards a centralised
coordination service where you have one point of access where the provider who needs to get help
to a trauma patient can contact one point of service and start to activate
a well-structured trauma system. Sabina, what’s your perspective
on these really unacceptable statistics? Well, in very remote Australia,
the systems are regionally based but they are nationally consistent. They’re largely Royal Flying
Doctor Service coordinated in that they pass the plane and in each regional centre,
there are retrievalists to speak to, to activate the response so there is a bit of variation
in remote Australia. You see, once you get, activate that
and get to your regional hospital or en route to your regional hospital,
you then activate the state-wide system that Ken was referring to. I think that the big difference
in very remote Australia is the distances, the very poor roads, they’re unsealed,
road conditions are harsh. Poverty plays a big factor –
people can afford less quality cars, there are more people in them and people
have to travel further for anything. So the exposure to risk of motor vehicle
accidents is much, much higher. Just because they’re in a car
longer and at higher speeds. SABINA: Indeed and fatigue’s a factor. So aside from probably, we have quite
high rates of motor vehicle accidents associated with, you know,
people who work in remote areas, travelling to work,
people who are on holidays and fatigue and loss of concentration
is a major issue. It’s probably a significant issue
in relation to recruitment and retention to some of the field that people have
about dealing with this thing. Do you agree with that, Ken? Absolutely, I think that the more
education people can get, the better. And certainly,
there’s two aspects to it. One is that you feel like you can… You feel like as a doctor out there
or as a nurse practitioner out there, as a nurse out there,
you know who you can talk to and the second thing is
you need to be trained to do the things
that you need to be able to do. So, Minh, what are the essential skills
that you need? Look, I think in terms of triage, essential skills are to,
in particularly trauma, you need to be able to very quickly
assess some factors that are gonna help plan
your whole initial management and then retrieval and transport and they would be things such as, if we have the graphic
about the initial call… We’ll come to that in a minute
but I’m talking about personal skills. Personal skills, OK. Well, I think in terms of
personal skills, you need to be an excellent communicator, you need to be able to organise
and lead this team that can be often an impromptu team so putting together a bunch of strangers
to manage an accident is a skill that is particularly useful
in remote trauma. And I think communication,
leading a team, leadership, allocating roles,
they’re some critical skills. NORMAN: Just tell… I think that if you’re a city doctor
heading out there, you need to make sure you’ve got
the clinical skills that you need. You need to make sure using… and there are resources available
that we’re going to talk to you’ve actually got the clinical skills to be able to deal
with the things you need to and that’s gonna make you feel
a lot happier that you know that if you have to
put a chest drain in, well, it hasn’t been 15 years
since you did it. Tell me about this education course
you run. Well, it actually came about through
recognition by remote area nurses that whilst the principles are the same
for all emergency courses, that there’s definite needs and
definite gaps for remote practitioners. So in conjunction with CRANA
which was at that stage the Council Of Remote Awareness in
conjunction with the College Of Surgeons and the RFDS – excuse me – they extended the emergency course
to include advanced skills and take into context
remote practitioners and the fact that you work
in an isolated setting and that you might need to step up
to intervene at a fairly high level and do skill, a skill level that
mightn’t usually happen in a hospital. So how do you get the course?
Is it online or… It’s a practical course,
it’s two and a half days. But it’s now backed up with online… ..ongoing education but you can go
to the CRANA website, CRANAplus website, and enrol that way. Mark, what are the features of
an effective service, retrieval service? I think irrespective of where you are
in Australia or internationally, there are a number
of fundamental requirements. You really require that designated
single point of contact for referral communications and pathways
to go through. Irrespective of sick or injury,
you need that one place to go through. I think you have to have a level of
medical control and oversight, providing expert and timely advice, and you have to have
the capacity to task and utilise the most appropriate vehicle whether that’s a road vehicle
or a fixed wing or a rotary wing asset. And I think at the end of the day,
you have to have the available crew mix to send and retrieve these patients so you have to have appropriately
skilled and trained clinicians whether a mixture of paramedics,
nursing staff and clinicians. – And be prepared. Ken?
– Yes, yep. And be ready for what is going to happen before the patient gets sick. I’m hoping that one of the things
that everybody takes out of tonight is that you think about
what system you’re in, think about how
your particular system works. Hopefully you already know the way
that your particular system works but if you’re not sure,
make sure you know how your system works,
whom you can talk to, how that’s going to work
and do it before the patient gets sick. If you wait till the patient gets sick,
you’re already behind the eight ball. And in terms of you getting to know
a town if you’re a new doctor in town, it’d be one of the earliest things
you should do. Definitely, definitely. And also, if you’re living in, you know,
you’ve got locals coming in, make sure there is a system
where they can get to know how to get help… NORMAN: What part of your induction… Yes, it absolutely needs to be
part of your induction. And that’s… Trauma only works
within a system. You know, even… In New South Wales,
there’s no one hospital that can take care of everybody,
even the big ones in Sydney. No one hospital can take care
of absolutely everybody. And, Sabina,
anybody could be the first port of call? Well, indeed,
you will be the first port of call and in these small,
rural and very remote areas, you’re not only the first port of call
but you’re the ambulance service as well so there’s issues that you need
to consider about preparing to leave and go out
to respond to a trauma that just don’t factor into the other
systems where you can send someone else. Minh, talk to me about the initial call. The initial call, when you get contacted
by a passer-by or someone rings in and you know that, say, a motor vehicle
accident has happened, a trauma, that there are some key things
that really are gonna help you start to plan an effective response. On the graphic there, these are some of the elements that we would consider essential in the initial call. I mean, if I can just highlight a couple of them. Basically, the first thing
that I would do is establish a clear line
of communication and that’s mentioned in there. So you really don’t want someone
to hang up the phone and you don’t really have an idea
how to call them back so very early on
you need to know, how do I call
this person back? How do I maintain an open line of communication? That person might have
come to you as a passer-by so at least they’re
there in front of you but sometimes it’s a call. The next big thing would be to know where the accident’s
happened ’cause obviously that’s
very important. And then some basic
things after that like the number of people
possibly injured, the type of injuries and particularly
some safety issues that might be involved. So it could be a fire… So, you’re really gathering
critical information from the person. Yeah, you try to get
as much information as you can. NORMAN: But there may not be
a phone call, Libby? No, it might be just somebody
coming into the health centre but I think there’s also other points
leading on from what Minh said that really alarm me
as a remote area nurse. Rather than just, like, numbers, getting a bit more of a story around
the mechanism of injury, so if there’s a rollover
or if they tell you that there’s somebody deceased
at the scene then that’s gonna give me
a really high index of suspicion that there’s potentially
some major injuries out there. Number don’t always work, though,
you know. In Indigenous culture… NORMAN: By numbers, you mean what?
– Numbers of… NORMAN: People involved?
– People involved. I think you have to start to,
like Minh said, gather your story before
you actually get out to the scene and get as much information as you can. Ken, do we talk the same language
when we are assessing people? Hopefully. We should,
there is only one language – EMST which is ATLS for Australia
for those who’ve come from overseas – is the only language
that is used in trauma. And the reason is it works and if… For people who don’t know what you’re
talking about, tell them what it means. OK, ATLS is the
Advanced Trauma Life Support set up by the American College
of Surgeons in the late 1970s. It got brought into Australia in 1988 and in Australia it’s called EMST which is Emergency Management
of Severe Trauma. It is a method of dealing with trauma in a systematic step-wise fashion which is accepted around the world as the only method of doing it. It’s been translated into a TNCC
and the trauma nursing program specifically for nurses which is
the same language talked the same way. Great thing,
you can be an anaesthetist or surgeon, you can be a GP, you can be a nurse, you will know what you’re talking about. So in terms of managing trauma,
absolutely, it’s the only way to go. What it talks about is preparing first,
which is what we’re talking about, then triaging,
then doing initial assessment, resuscitation, secondary survey, etc. – And assessment on the way.
– Yeah. And, Libby, the onsite approach? Hmm, well, again, it starts from the
time that you leave your health centre so letting somebody know
especially in the remote context, it’s really important
to raise the alarm. So, either make that call to the RFDS
before you leave the site to say, ‘Hey, I’m going out
in this direction and this is the story
that I’ve got so far.’ That may prevent the plane
going somewhere else and staying on the ground
and providing you with some support when you get out there. Alerting someone in the community
before you go, seeing if you can get someone else
to come with you – ideally, a health worker
or another nurse – but even someone else from the school or the police if they’re there that someone might be able
to manage the scene for you so that you don’t become another victim. From the slide here, there’s some other points about thinking about, from the time
that you’re in the vehicle, actually starting to allocate
tasks or roles with your teammate working out
who’s got the most experience and who’s gonna triage, who’s gonna
implement some treatment, who’s gonna… NORMAN: That’s if you’ve got a teammate.
– Yes. But in an ideal world,
you’ll at least go with one other person and as soon as
that happens, that’s a team. Making the call, like I said. Thinking about the safety of you
once you arrive at the scene so, learning how to park the vehicle, having your doors open,
having adequate light. If it’s in the middle of the day,
creating shade as soon as you can. And it comes back to what
we’ve all been saying from the beginning which is,
the more preparation you can do – and that includes the initial approach – then the next part of the intervention
hopefully will flow from that. Having the doors open? The doors open, lights on,
car parked on an angle – all things that you learn
in a four-wheel-drive course before as part of… And this goes back to even learning
the primary, secondary survey and doing, you know, emergency courses.
It’s the same deal. If you’re gonna be
a remote practitioner, you need to learn to drive
in those conditions. Sabina,
what are the skills required for triage? Well, I was gonna say
you need to be able to do a quick primary survey to identify,
you know, those who are alive, those who are not and then, those who are alive,
quick overview to see if they have an airway,
if they’re breathing and then simple interventions you can do
as you go around and I’m sure as we get to ABC, that
we’ll talk about that in more detail but you could do a chin lift
to clear an airway but, really,
the first principle of triage is to work out what you’ve got and then what your resources are and then how to proceed. The triage, as Libby said, you know, remote parts
where you’re going out absolutely contains
you being safe first. So having that, being safe, making sure
that dust controls, triangles, things are put out to prevent
you being hit by oncoming traffic. There’s not a constant stream of traffic
usually and so it’s easy for someone to come up
over the road and around the bend and collect you
and it happens from time to time and that’s totally preventable. Minh, talk to me about ABCDE. So, ABCDE is one of the principles of… NORMAN: You assume that people know it
but let’s just cover it. Yeah, sure. So, it’s kind of
a resuscitation principle, a mantra, and A is the Airway, B is Breathing,
C is Circulation, D is Disability and
E is Exposure and Environmental. So, it’s just
a very nice kind of memory aid to systematically cover
key points of resuscitation. How important is the time factor, Ken? Time factor is really important. When you look at the…
Just one thing further about that ABCDE. When you look at the EMST manual, you’ll see it’s
‘Airway and cervical spine’, ‘Breathing and ventilation’,
‘Circulation and haemorrhage control’. They give you ABCDE by itself,
it’s what you do in a cardiac arrest. When you add on the rest of it,
that’s what makes it into a real trauma. You’ve all got EMST books,
have a look at them. In terms of the time factor, yes, 20 years ago we used to talk about
the golden hour and there’s been a couple of studies
that have shown, well, there’s nothing special
about an hour but there is absolutely no doubt
that the time to definitive care is one of the factors in both reducing
injuries, as Mark was saying, and in reducing deaths. And that’s one of the factors
why remote things don’t, remote accidents, remote crashes and
other remote trauma doesn’t do so well because they extend… But definitive care is a remote,
is a moveable feast. What are you talking about
when you say ‘definitive care’? We’re actually gonna do
a thoracotomy here or what? Yes and that’s… No, that is…
It’s another thing to get into your mind when you’re talking about remote care. Definitive care is where
you’re eventually going to end up. That might be
in two separate institutions or three separate institutions to do
two or three separate things. For instance, by the side of the road, Libby or Sabina might be stopping
some bleeding by putting a bandage on. That might be the official definitive
care you need for that injury. If you happen to be
in the Northern Territory, you might also need a laparotomy.
That could be done at Darwin. But if at the same time
you also have a spinal deficit, you’re going to need eventually
to leave Darwin to go down to Adelaide or somewhere. So defining definitive care
is really difficult… NORMAN: It’s what somebody needs
at the moment. It’s what somebody needs… NORMAN: Beyond whatever
a layperson can give. Yes, and it’s also…
Yeah, that’s right. That’ll do for now.
NORMAN: Mark? Definitive care at that
particular point in time might be, Sabina mentioned,
just a jaw thrust or chin lift or may be… administering
to someone who’s unconscious all the way through
to tertiary level care. Which I think goes back to the point
where we’ve all said earlier about having to, you know, make sure
that you’re adequately trained if you’re going out there so that you do
know those simple interventions in that ABCD part of the survey
that does save lives and doesn’t need a lot of equipment. Let’s go to our first case study. There’s been a car accident approximately 25km by road
from the closest Aboriginal community that has a health clinic. The incident is actually reported
to that health clinic by the driver of another vehicle. The report comes in probably
about 40 minutes after it’s occurred. The nearest airstrip is 2km
from that community. All the roads are dirt but they’re in
reasonable condition at the moment. The vehicle seems to have rolled
and collided with a tree according to the report. And the driver who reported it said it
was on the passenger side of the vehicle so when you get there,
there are five casualties. All members of the community. The driver of the vehicle
is outside the vehicle. He appears to be inebriated
but uninjured apart from some lacerations
on his arms and face. A male passenger sitting on the ground
next to the vehicle is complaining of chest pain
both front and back. When asked,
he was not wearing a seatbelt. It’s noticed that he’s a bit lethargic
and his breathing is rapid and shallow and he’s not willing to move very much,
he’s in a lot of pain. A young woman is found sitting outside the vehicle talking to the male passenger while cradling her baby. She’s actually got a deep laceration on the left side of her forehead that’s bleeding a lot and when she turns to speak to you, she’s turning her shoulders with her head. When you look at the baby, to your horror, you find the baby is dead. Another passenger, male passenger, is found sitting in the car. He is responsive but also appears lethargic. Libby, you’re first on the scene. Mm-hm. Well, there’s things
that are a worry straight up. If there’s just me
and maybe one other person, then already my capacity is stretched – I’ve got five injured people. There’s three people
that worry me straight up – there’s the quiet person
that’s sitting in the car. Why is he still in the car? NORMAN: He’s the one
who’s gonna die on you. Possibly or it may be
just alcohol talking. But certainly, he needs to be assessed. You’ve got somebody
that’s got rapid shortness of breath, that’s got chest pain, that potentially’s got
an acute chest injury, they’re sitting outside of the car. You’ve got a woman that’s got a bleeder
from a big scalp wound and potentially a cervical spine injury. You know that alcohol’s involved and you know you’ve got a dead baby so you’ve got a really big event
happening in front of you so… NORMAN: I might bring in Sabina here. Sabina, how would you approach this
after you’ve made that assessment as recounted by Libby? So, the first thing is to report in
with what you’ve got very quickly and then… other than the baby,
all people are talking. So we know they’ve got an airway. We’ve got breathing problems
with one person identified, we’ve got risk of cervical
spine injuries with all of them and we’ve got risk of significant
internal injuries with all of them. We have a deceased baby
and other injuries that suggest the mechanism of injury
was reasonably high speed. The patient that worries me most
that may deteriorate quickest is the person who’s breathing up so we need to assess them
for pneumothorax or a chest injury which is reversible. So when you examine this person, his breathing rate’s up nearly at 40, his pulse is up at about 100
and feeling thready, feeling a bit clammy. If you’re on the other end
of the phone talking to Sabina, what’s your advice here
with this one, Ken? This one certainly sounds like
he has a significant chest injury and what you’re worried about is, in that short time frame,
it’s unlikely to be contusions ’cause they’re the most common
chest injury – that takes hours to develop – what you’re worried about is either
hemothorax or pneumothorax. 90-something per cent of pneumothoraces aren’t tension pneumothoraces. There is the occasional one that is and that’s what you’re really worried
about with this patient. So, the other number that I would like
if it’s at all possible is the saturation. Those people carry
a little pulse oximeter with them, can they put a pulse oximeter on
and give me a saturation on him? What I’m really going to have
a very low index of suspicion is suggesting that she have her kit ready to do a needle decompression
of his chest. Not necessarily at the minute because once she’s committed
to that patient, there are other ones she might need
to go back to but it all needs to be ready to go so that if she needs to do it,
she’s ready to go. And she also needs to have marked out
where the second interspace is now. It’s really easy to go
in the wrong place in a hurry. So, get a marker, find the second
interspace on that sore side and mark it out now. – So you do it anteriorly.
– Yes. Yes, as a life-saving needle
decompression for a tension in the thorax in this
remote setting, that’s the way to go. Some of you might have heard people
talking about doing open thoracostomies and there is a place for that
in urban trauma where you’re close
to the major teaching hospital where you’re just doing something and 15 minutes later, you’re gonna roll
into a major trauma centre. That’s not
what we’re talking about here. – No, we don’t need the high drama.
– No. So what’s going through your head,
Sabina, about transport? SABINA: Before we put them on the plane? Yeah, but the plane’s two hours away
in this case. That’s fine.
So it doesn’t happen here, we’ve got other patients to look after. NORMAN: Tell me about transport, then. You found out that clearly
they’re gonna have to be transported. What are you gonna do with them and given that there’s no ambulance
in the area and the RFDS is two hours away. SABINA: No, well, you’re the ambulance
so you’ve got someone on stand-by back in the clinic. Before you’ve left,
you’ve told people where you’re going, what you’re doing,
you’ve activated your resources, you have someone behind and what you then do
is decide what you can do to stabilise quickly at the scene and take the ones you’ve stabilised, take the various people
back to the clinic. It’s a bit like…
You’re not so far away here so it’s a bit more like doing… If you’re much further away,
you have to stay and stabilise the lot. You’re worried about the person
who’s still sitting in the car so you got to make sure they’ve got
oxygen, they’ve got cannulas in and that somebody’s watching them. And then, either you transport them back
or you stay. Depending on the skill set of the team
you’ve got with you, begin the transport back to the clinic for steady care
in a more organised environment where you’ve got more resources
available to you – good light, good air-conditioning. This all depends on…
NORMAN: Can I just interrupt? SABINA: ..is it cold. As Ken said,
if you want a pulse oximeter, you don’t want to be out there
in the middle of winter and be relying on it
with cold extremities. What do you… I’m just gonna
read out a comment from Alam Yoosuff from
the Finley medical practice in Victoria who says, ‘We are 300km
away from Melbourne. If I happen to need a retrieval, it takes about four hours
to get the team to come in, they come in and keep doing things
for another 30 minutes, then it takes another 90 minutes
to fly to Melbourne. Most of the time, the patient could have
gone by land long before air. We don’t have a helipad,
nearest airstrip is 15 minutes away. So, I mean, what happens here if you’re the most experienced person and just back at the health clinic,
there’s just a bed? MAN: Mm-hm. I mean, that’s… You must actually say, ‘What’s the point
of moving back to the clinic?’ SABINA: Well, that does happen. What has happened in the past is that
you stay right where you are, you’re only 20 kays away from the clinic and you stay with
your stabilised patients or continue to stabilise –
reassess and stabilise – and wait for the transport
to come to you and have someone in the community
pick them up and bring them out to you. So you have to make that call depending on your resources
and the severity of the situation. So if this guy’s really sick,
and you’ve got to stay at the scene, you’d keep the really sick guy
with you at the scene, not transport him
back to the clinic. SABINA: Yes, if there’s only one of you. You might get the others who are… If you are convinced after
assessing them and reassessing them that they’re OK, or at least… You’re concerned
about potential spinal injuries here so you’re probably
gonna have to stay put and have the retrieval team come to you. So the two… Mark and Ken both squinted their eyes
and shook their heads a little bit in response to that one. So you would
actually go back to the clinic? What’s the story here? The issue is you’ve got four patients
at least you’ve got to move. And probably… It might also be from a social, caring
for the whole community point of view, you want to move the dead baby
back to the clinic as well for a short period of time. But obviously
that’s further down the priority list. But with those four patients, patients are going to be here
for a long period of time. It’s very seldom in remote Australia. You can have aircraft arrive
to take four patients away now. So, what’s going through my mind is somehow in between
the retrieval team that is coming, the person at the end of the phone, who is hopefully
giving good clinical advice, Sabina, who’s doing all the hard work
by the side of the road, that you work out are some of the patients
going back to the clinic where somebody can do more of? Are some going direct to the airport? Maybe one for the first plane
that’s coming in. And are some of them sitting back here? Each one’s gonna have to be worked out
differently, depending on how the patients progress past that initial life-saving steps
that they both mentioned. And I think what people have said there
is really important. There are some initial life-saving
things that need to be done – quickly running round. OK, now you’re talking about
more stabilisation things. Taking care of everybody’s cervical
spine is not initially life-saving. The dust has settled a bit. Now you
can get on and do those kind of things. And you also have to make a decision
in conjunction with everybody as to what order
are you moving the patients out to. And that could depend on
what resources are coming? Are they coming from different places? If you’re right
in the middle of Australia and everything’s
going back to Alice Springs, then,
they’re all going back to Alice Springs. But if it were somewhere else, it might be that one aircraft
is coming from point A and another aircraft
is coming from point B and it might be best
to send them to two different places based on the resources available in the
destinations they’re going back to, etc. It all gets really complicated
at this point. And very difficult
to make general statements about. NORMAN: Mark and Minh? For me, the fundamental principle
here is, and Sabina mentioned it, you’re recognising early that you have
essentially a mass-casualty incident. It wouldn’t be, in the middle of Sydney, but where you are just now
with one or two responders, your resources are overwhelmed. So you have
to make some difficult decisions given the complexity of the cases
and the resources you have. So, depending on how far away help is –
I agree with what you’re saying – you have to make a call –
do I take all these people back? You’re gonna have to create
a casualty cleaning station or a holding place to look after people
after your initial resuscitation. Is that at the scene?
Or is that back at the clinic? Or is it at the airport? And I think those are fluid things that
you have to make a judgement call… You might have to leave the scene
with the most critically injured person. – Yes.
– Absolutely. SABINA: Yes, you might do. Every remote ambulance
will have a stretcher and a scoop. So you’ve got the ability
potentially to take two. Because if you get help,
you get another ute or another vehicle, if it’s a short pop,
then you can begin a ferrying service. But you are gonna have to work
within your resources, communicating effectively
and continuously with those in the community, those at your retrieval centre,
the RFDS, or whatever, and maybe the neighbouring
community health service. It might only be 100 kays or 150 kays
away, so they might be within an hour,
hour and a half, to get you to provide help. So it will completely depend, time of
day, location, and distance from town – all of those things
will come into the mix. Mark, do you want to add something? I think that that initial decision – do you go from scene
to hospital or clinic? The important thing,
from my perspective, is the mechanism, whether it’s a ute, whether
it’s an old troopy, doesn’t matter, it’s the level of care
that’s provided in that transit. So you can use whatever’s there. Before you actually move out as well. You’d want to do the…
look after airway… You want to start
the real basic stuff there, and then go. You don’t wanna be stuck
in the back of a ute bumping down the road having to do
life-saving manoeuvres. Minh? I have to say, I kinda agree with Sabina that there’s certainly times
in remote trauma where, because
you don’t have enough resources, you do have to spend
a period of time at the scene. In the city everyone would think
we just pick everyone up, send 20 ambulances
and we’ll just take them all. And you obviously can’t do that
in remote practice. It’s true, like Sabina says, sometimes you have to stay and
wait for more resources to come, and do your best. You try to stabilise people
as best as you can. And it is like
a mass-casualty situation ’cause it will overwhelm a single
doctor, single provider or location. I think that… I’ve seen a lot of
resources and improvisation used in remote Australia where, you know, private vehicles are being used
as ambulances, utility vehicles and so forth, and people putting mattresses on the back of ute truck trays
and that kind of stuff, and using that as improvised ambulance. It’s not ideal, but that’s… If you must put somebody in a ute,
what are the rules? If you gotta do it,
remember it’s not covered, you drive slowly,
you don’t want to roll the vehicle over, ’cause it’s not covered. You want to protect the person
from dust, wind and debris, and you wanna protect yourself. So you wanna make sure
you sit low on the tray, up towards the cabin. You know, these are just
some practical issues, ’cause we don’t have full ambulance
services in remote Australia. So… LIBBY: I agree with everything
that’s been said, but the other big difficulty about being
out at the roadside for too long is that communication just falls down. You’re relying on a sat phone or there’s
less and less radio contact now, and I agree with everything
that everyone’s been saying. You gotta do the… you try to do the
greatest good for the greatest amount. But the reality is
you can’t get a plane in the air until communication is really clear. And often that means getting back
to the health centre to properly assess people and to be able to make that call
about exactly what you need. MARK: The distance is a big thing. The example of the person that gave you
the question there, Norman, that would be a completely
different scenario if you were 300km outside Melbourne, to the one we’ve got just now, because we all know that sometimes if a patient gets taken
to the nearest hospital, sometimes you can stay there for hours
before you can get them out. And it’s actually hard to get them
kept on scene. SABINA: You’re limited
in your resources, you know, you’ve got only so much IV
fluids, you’ve only got so much oxygen. You have to balance all of that. NORMAN: Comment here from Pete Fenton.
Cape York Health Service District. ‘As an RAN, I would prefer the vehicle
to be called a retrieval vehicle, not an ambulance. The reality is the clinic
should always be set up as the emergency primary centre between the trauma and the transport
out to a major care centre.’ So, it’s retrieval.
KEN: Yes, I think that’s a good point. I think that you… The whole way along
you have to look about where are your points of refuge. The first one’s by the side of the road
where you’re giving basic care. The clinic in this case, as we’ve all
said, is just another point of refuge. But it’s got a lot more going for it
than the side of the road. By the airstrip might be
another point of refuge. And it might be that some of these
patients, if you’ve got five patients, it might be that one of these
five patients gets driven an awful long way to another
bigger area that can deal with it because transporting four patients
back to a clinic where poor Sabina’s by herself
is not really doing anything. One of them might be say, stable enough, best care for that patient, considering
how long the aircraft’s gonna get there, is that they get moved to another clinic
as a point of refuge till they’re eventually evacuated out
by air at some stage, you know. What documentation would you expect,
Minh, particularly in this situation? Documentation, if we go to the graphic
about retrieval documentation, I think it comes from basic
to as advanced as you want. But essentially you want the key
elements of handover of a patient, whether written or verbal, should be that the documentation and
the handover should be standardised, should be systematic, so that the person has a good idea
about what the situation that patient has come from,
what treatment they’ve received, what their response to that treatment
has been, and what is required in the next phase
of their care along the trauma system. It’s a lot to ask of one person
in a remote area with five casualties. It is. It is and that’s a lot. And I think, you know, if…
if we can bring up that graphic, there’s a great example of that,
sometimes you don’t have much time, and you’re just writing things
at the back of a glove. And I think that
that might seem very basic, but, you know, that can be enough
to give the next level of care – the idea about what phase of care
that patient has moved through, you know, they’ve required this X,
Y and Z. I think it has to be systematic,
the handover, ’cause if you don’t have
a systematic handover, that’s when you put patients at risk. MARK: That’s what I was gonna say
as well. We know from all the work
that’s been done through quality and safety
of patient care that one of the biggest pitfalls
and risks is patient handover, and we’re looking at somebody here who might’ve been looked after by
a number of healthcare professionals through their journey from the side
of the road to the tertiary – bells and whistles – and you can’t lose that information
from the scene and the observations at the time. So there has to be a structured handover
and a structured way of documenting what has actually been done. KEN: And we haven’t sorted this out
yet properly, because we’ve got… we have sorted it
out in some parts of some states doing some bits, but it would be really useful to have
the same form everywhere, and it would be really useful to have
that form available in at least… Could you maybe be asked a year
or two later for…? You may well be asked a year
or two later. And, you know,
if you’re the first person on the scene, you may well end up in court. And, you know, one useful thing to do
later on that day or whenever – write down… draw a little mud map,
write down everything you can about it, because the first you’ll know about it
is when you’re doing some other job, or working somewhere else in five, six
years’ time when the subpoena arrives, and it’s never much fun. Sabina, last comment
before we let you go? Yeah, well, some of the things that
we have got on our side unfortunately is time,
because there is delay in transference. Unless you are unable to leave
the patient, you can usually put together a pretty
good summary of what’s happened, and what you’ve given, at least
to hand over to the flight crew. Then what you’ve got time to do
after they’ve gone is to sit down and write it out
a bit more comprehensively, and fax it through
to the emergency department, so that the patient’s name, IV,
comorbidities, that’s all important background
information that you… If they’re from the community,
you will know, and to be able to flag with them
so that you… And then ring up
and tell people that are coming. Unfortunately, you do have to take
those extra steps to capture the attention of the
receiving personnel – they’re busy… So that they know, it’s all too easy
for a piece of paper to get lost in the handover,
which has happened multiple times. NORMAN: Sabina, thanks for joining us. That was Sabina Knight, one of
Australia’s pioneer remote-area nurses, talking to us from Alice Springs. Once you get back to the community here,
there are issues with the community. Because you’re gonna have to
move people out, and that’s a really hot-wire issue
for many communities. You’re taking them out of their
environment where they feel comfortable. Usually if there’s a big incident in the
community, then they’re well-known. People are… you know,
they’re usually family. They’re often family
of the Aboriginal health worker that you may be working with. You may need to send an escort
with these people, so it’s about finding
the appropriate escort. And then you need to think about
the impact it has on the family that are sending their family member
off to the city – the reality that they won’t
probably be able to visit them, and the reality that
they’re gonna be away from the family for a period of time. But utilising the knowledge
and the experience of the Aboriginal health worker
is really important at that point. Let’s go to our next case study. A 52-year-old farmer is found
unconscious lying beside his quad bike. Apparently he’s been out spraying weeds, and appears to have rolled down
the embankment and thrown him off. He wasn’t wearing his helmet. His wife initially contacted 000
using a mobile phone, and an ambulance has been dispatched. It’s in a rural area rather than remote. They’ll take half an hour to reach him
and she’s been put through to you, Ken, and she reports to you he’s lying on his
stomach and his breathing seems shallow. KEN: This is unfortunately not an unusual situation. But one of the good things
that has happened recently – some states like Queensland have got
this whizz-bang video links. At least we’ve now got phone links
in New South Wales. But it is not uncommon that… It’s like using 19th-century technology. KEN: It is. It is. We invented the phone a century ago,
we can finally use it. But it is extremely useful to be able
to talk to people in these situations, and the way that I describe what you
need to do with this woman is that… First of all, you usually need to
calm them down a little bit, because they’ve just had
the shock of their life, finding her husband critically ill. The next thing is you need
to communicate to her so she becomes your hands and your eyes, so she can do those life-saving things
you mentioned before. So, you need to really slowly
and carefully talk with her about what is happening. I would like to find out from her
how unconscious he is, go through simple steps like that. Has he got an airway?
What’s his pulse like? NORMAN: She gets a St John’s Ambulance
course from you over the phone. She gets a rapid course in…
whilst keeping her calm, so that she can do a few life-saving
things that are really necessary. But that has been… it has been really,
really useful quite often. And even if it isn’t life-saving, it is really reassuring to them… ..something other
than waiting for another half an hour for an ambulance to arrive, and the truth is,
nobody out there, quite often if it’s just…
if it’s nothing as severe as this, if it’s a musculoskeletal injury, just reinforcing the RICE principles
and getting them started now just helps in getting people over it. Rest, Ice, Compression, Elevate. So, it’s the basic principles of dealing
with musculoskeletal injuries, whether it’s a fracture
or a sprained toenail. Mohan Swaminathan from
Queensland Injury Surveillance Unit asks for your comments on the need
for ongoing… ..really a response
to this case study… ..ongoing injury surveillance in rural
and remote regional areas to identify local, specific injury
problems in the community, thereby allowing the implementation of
safety factors working in partnership with community groups. For example,
quad bike injuries such as this. Community action. You’re all into saving lives,
aren’t you? Just not really interested in
preventions. Is that right? ALL: No.
NORMAN: Poor Mohan is on his own here. Sorry, Mohan. You know, I think you look at what kind
of retrieval services. There are certain places that,
one over the years picks up as having certain mechanisms
of injuries – um… you know, tropical islands,
golf buggies… ..farms, quad bikes, that sort of stuff. Anyone who’s around Sydney,
motorbike riders and the putty road, great source of business,
great source of business. So, the question here is what role do
the people who are involved in retrieval have as members of the community
in prevention? KEN: Huge role. It needs to be… Easily, the best way to take care
of trauma is to stop it happening. And the best example in Australia
is pool fencing. Pool fencing in Australia was brought in by a bunch of dedicated paediatric
trauma specialists. OK. So, that’s… that’s the…
this is the quad bike guy. Mark, when the paramedics get there,
what’s their role? Um… In this sequence,
I suppose you’ve had first aid provided by a member of the community. And then the first responders get there
in terms of paramedics, and there would be an enhanced level
of clinical skill, acumen and experience in terms of looking after
that patient there. So, they’re gonna assess them,
treat them and then again… So he’s still unconscious. How are you
gonna know if he’s got a spinal injury? Well, I think anyone who’s unconscious should be treated
as a potential spinal injury. There are some hard, clinical things
that you might see, but I think if they’re unconscious, the paramedics and any other
retrieval staff that you send would treat them
as an unstable spinal injury. NORMAN: So, if this is remote
rather than rural, then you’re doing it… you just assume
that this is spinal. Assume it’s spinal
if they’re unconscious. That’s right. Is that what you do, Libby,
in that situation? LIBBY: Yeah, absolutely. And what do you do, Minh,
when you’re worried about the airway, and you’ve got a reasonable
index of suspicion that there might be
a high spinal injury? That’s a very difficult situation
for the remote… NORMAN: That’s why I asked the question.
– Yes, I know. I think that you…
you’ve got a couple of options. Certainly simple airway manoeuvres
can hold things at bay, and maintain an airway,
but for transport generally secure… You’re not gonna sort of slip his peg
through his spinal cord by doing that? MINH: No, that’s alright. I think simple manoeuvres
like the jaw thrust are helpful, but for transport,
to get them to where they need to go, you need a secure airway. So, you know, this behoves us as remote
practitioners to have… ..make sure that we have skills
and maintain skills in advance. The airway management,
things like intubation of trachea… So, is there a way to secure the airway
without making him a quadriplegic? Yeah, there is. There’s certainly
well-practised methods to do that. Certainly EMST, the trauma course, teaches tracheal intubation
with manual stabilisation of the head. So, someone holding the neck, whilst the
other provider does tracheal intubation. – That’s one way.
NORMAN: Hard bit’s lying on his stomach. Yeah, so… so you do need to position
them with appropriate people so that you can do that procedure. Look, there’s other ways. I think it really is a difficult thing
for a remote provider. There are a couple of things
we can say are useful. Certainly the airway audits
I’ve done in traumas – the laryngeal mask airway is a very appropriate and easy device
to maintain skills, to learn, and there’s good literature
to back that up. And it can also be a reasonable airway
in trauma if you have a high-risk procedure
where you could, you know, cause further C-spine injuries. Another question’s come in,
you know, it’s all very well… you guys,
because you’re doing it all the time. You know, as… as a rural GP, you might only do this once a year
or once every 18 months. And I think that is really, really
a very, very important question, and… but it is something. There are more things… there’s more
education that is going out, but it is one area
that we still need to lift our game on, and it’s one area that we really need
to help rural GPs, and rural other practitioners about. NORMAN: So it’s not learning
in the first place, it’s maintaining… It’s maintaining the skills. If you have somebody who comes in
and you’re… One of the things that really worries
these people is not just diagnosing it, but it’s OK, I’ve diagnosed it,
now I need to do an airway, or I’ve diagnosed,
now I need to do a chest drain. And the last one I did was 15 years ago,
you know. I think that CRANA course for
remote-area nurses is fantastic, and there are…
this is slowly going out. There is slowly more education
coming out to where rural people work, and the more agitation that can be done
to get more out there, great, because these skills
that are really necessary, that make people happier once they know that
they’re on top of those skills again. Minh, what’s your expectation
when you arrive in your chopper, or your fixed-winged plane? This sounds like the dream – ‘This is
what we’ve all been waiting for, manna from heaven, literally,
our problems are all over. Minh has arrived.’ Look, what we expect for transporting
a severely traumatised patient to definitive care,
if I could sum up in one word is that you should really think about
preparing these patients, as if you would for major surgery. OK? – Essentially, if you think about it…
– So treatment occurs at sea level. Or on the ground, I should say,
not at 10,000ft. Yeah, well, there’s a caveat to that. But essentially,
before you put him on the aircraft, you want to stabilise him enough
that the airway they’re breathing, and the circulation
is appropriately sustained. There are specific things
in the aero-medical environment, and I can categorise them
into 3 of them. There’s a graphic here about
the rural aviation retrieval challenges and specifically in the aircraft, we
don’t have a lot of room to do things. So the more time you spend
doing things on the ground, so that when you put them
in the telephone box, and we can’t do the things we want, then when things go bad, we don’t have
a lot of room or space to move. Specifically when you take them to
altitude, they need more oxygen. If they need oxygen on the ground,
they’ll need more up in altitude. Gas expands, so any gas trapped
in the body is gonna expand. And particularly for trauma
to the chest, we’d be worried about the trapped gas
in the chest, in the pleural cavity. NORMAN: So you could turn into
tension pneumothorax. MINH: Absolutely, it’s happened twice
to me on retrievals where a simple pneumothorax
has become a tension pneumothorax, previously undetected,
now has become a problem. So, we have a low threshold
to recommend pleural drainage before we take these people to altitude. The other big thing is that the aviation
environment is a stressful environment. We shake people,
we submit them to vibration, noise, and it can make them vomit,
it can increase their pain, they’re gonna use up more oxygen
because they’ll be breathing faster. So, getting people well analgesed
is very important as part of transport preparation. Sorry. The fact that…
I think the communication between the rural practitioner
and the medic on site, or the team that are coming
to retrieve them, that’s very important
in that preparation phase, because there’s a lot of time
that can be saved by having, you know, simple things like IDC – indwelling
catheters – naso-gastric tubes, all those things can be done prior
to you getting there that are gonna save you time
to get them out. And that might help that poor GP who
sent a message from rural Victoria if… maybe if the systems
could be adjusted a little bit. Certainly one of the things
we’ve found useful in New South Wales is just making sure that if we’re
sending a retrieval team out there, that if they are in a place
where they can do things to the patient, everything is done
by the time you get there. Now, sometimes, that can’t be done. Sometimes, it’s only the retrieval team
that can do whatever is necessary. But if it can be done, and it is done,
it saves time. Comment from Buck from the ambulance
service of New South Wales, ‘It’s important to note that ambulance
services are an integral part of state trauma systems. The trauma system, including potential
aero-medical response, is triggered from the 000 call.’ – Is that true of all states?
KEN: No. So it’s not even true
of New South Wales? Oh, no! It is true of New South Wales.
Absolutely. Absolutely. And it is… that phone call,
I was saying before, those ones that we get involved in, as a medical retrieval consultant
for the ambulance service, that’s how I get involved
in those phone calls. But it’s definitely not true
of all states. And even within New South Wales, it’s not really true
of far-western New South Wales. It’s only true of Dubbo east. So, in each area,
you’ve got to know who you call. You gotta know who you call,
you gotta know what your system is. Tell me about teamwork on a site, ’cause this is where
angels fear to tread. You arrive…. you know… who leads?
Who defines the roles? Who’s gonna be responsible?
What happens? I think that’s a great question. I think everyone expects major
tertiary hospital with trauma team will manage a severely trauma patient. So you have surgeons, anaesthetists,
specialists, you know, a whole team. NORMAN: Until the surgeon arrives. Until the surgeon arrives
and then it’s just him, or her. And in a rural setting…
– MARK: Does he need help? In a rural setting,
that can be really hard, because, like you said, they might only experience a trauma
once a year or twice a year. So how do you maintain those skills
of a trauma team? Well, I think, one – you gotta practise. Two – you gotta know the people
that you’re working with. You got to know the equipment…
NORMAN: They’re strangers sometimes. That’s the real challenge,
is that putting a team together of a bunch of strangers
requires leadership skills. So, I think it’s really important
for providers out there, whether it be nurses, doctors, to practise and seek training
in leadership skills about dealing with acute situations
that are changing minute by minute, to being able to put together a team
and lead that team in an effective way. And I think that starts by
defining team roles quite early. So, we have a graphic here where… ..there are actually
several organisations in it. There’s a Queensland health nurse here, there’s a Queensland police officer
in this graphic, there’s RFDS team. So you’re having people
from three organisations trying to work together as a team. They’re out in the middle of nowhere,
and they have to work as a team, otherwise, you know,
it’s gonna fall apart. So, how do you define a team role
early on? I think, you know,
you do need to have a leader, and you do need to have someone
who’s gonna say, ‘You’re gonna do this, you’re gonna do
this. This is gonna happen in 5 minutes. After ten minutes,
we’re gonna be at this point.’ And have an oversight
of the whole thing. Because if you don’t have that, then essentially people start doing
things on different tangents. In the remote context, that might not always fall upon
the doctor in the initial phase either. If they haven’t got a lot of experience
as what you’re saying, and there’s a remote-area nurse there that’s got a lot of clinical
emergency experience, then it might be up to that person
to put their hand up and say, ‘Hey, I am experienced in this. I’m happy to take the lead role
until we get back to the clinic.’ It’s what you’re saying… NORMAN: You shouldn’t let
pride get in the way. Know what you can do and let the person
who knows get on with it. Certainly. I’ve been working in
aero-medical retrieval for 20 years, and I’m never the one in charge
at a scene. There’s always with me a paramedic, and they’ve all had more experience
than I’ve had at that scene control, getting along other agencies
doing things. They’re always the one that takes
that team-leader role. My skills, when I go out there, are best looking at the sickest
or the sickest couple of patients, giving them good clinical care, and letting the paramedics with me be the one that does
the overall team leadership. If not, a senior ambulance officer. Mark, just quickly tell me
about the role of support services here, behind the scenes, helping this process,
people who are not on the scene. There’s a crucial role there
to support those initial responders, and the real facilities. And, again,
we spoke about systems earlier on. I think the basic premise here is
early recognition and early notification to those support services. And again, good trauma services define
those in advance, you know who it is. In Queensland, it might be Townsville
Hospital or something, that you’re talking to. You have to know when you go
to work somewhere what your system is. So when you’re stressed, you know
the number to dial on the phone. And the person at the end of that,
from a retrieval perspective certainly, should be providing you
with clinical advice as to what’s to happen. The clinical advice is about preparation
for transport, resuscitation, and also provide for the oversight
of the retrieval team as well. You know… that support has to give
you, you know, good visible support to get on and do things, but at the same time organise stuff
behind the scenes. And that involves clinical teams
with the right skills to come and retrieve that patient, and the aircraft,
the right platform to do it. And at the end of the day, you’ve got
to sort out where they’re gonna go. If you think they’ll require a
neurosurgeon and an intensive-care unit, you want to sort that out. You’ve got quite a sophisticated
telehealth system for all this. Over the last few years, in Queensland, we’ve managed to get the funding
to have it. I think we’ve got 83 or 84 sites
in the last count that link in to our central
communication centre… coordination centre. That has allowed us, over the years,
to really get involved there and then, in the nitty-gritty of active
resuscitation and trauma in the small hospitals. And it started off… we weren’t really
sure if people would take it on board. I think the more people have used it,
the more they’ve wanted it, and it allows
almost that equity of access to come in, and you can have a critical-care
specialist assisting those staff who maybe don’t do that very often. NORMAN: Is it improving outcomes? We’ve not actually done any studies
to… outcomes. I think it does…
there’s a number of things it has done. We think it helps keep people
in rural, remote areas, because they’ve got that extra support
for the really sick… So unnecessary transports are minimised. Yes. We did one trial on Palm Island. We showed that we reduced the retrievals
by a quarter by using telehealth. But more than that, I think,
it’s about support for procedures, enhancing the triage, allowing us to
make better informed triage decisions, and resource-allocation decisions. But it supports the rural practitioner
on site. MINH: Yeah. NORMAN: Minh, what do you do…? KEN: It would be very difficult to do any kind of study to show a difference in patient care. That would be really, really difficult and really unethical to do. MARK: It’s the simple things
we find with the telehealth that make the big difference. It’s those little things that people might not be able to get
across to you on the telephone that have occurred or are occurring. Minh, we’ve had a question
from South Australia. What if your patient is 190kg? Yeah, we just talked about this
before we went on the broadcast. Look, I think that’s a very challenging
particular patient group. I think that
our aircraft have limitations. I mean, every aircraft’s got
limitations. It can’t do everything. NORMAN: Including take-off.
– Exactly. Take off,
or even get him in the aircraft. I think in that situation,
you need to have… That’s even more reason
to have early contact with your organised trauma service
and retrieval service, so that we can try…
NORMAN: Fly somewhere else. We’ll get a Hercules
or get a bigger aircraft. But… It’s possible,
it’s definitely possible. We’ve moved much bigger people than that
from remote areas. Thank you all very much indeed.
It’s been a fascinating program. I’ve reminded myself of some horrifying
experiences in my early career which I’d rather put away,
but thank you very much indeed. What are your take-home messages? Ken? From my point of view, I think, one big thing that hopefully
people have taken away, is to get to know their system, to make sure that wherever
they’re working, they know what works. NORMAN: Before it happens.
– Before anything happens. And if it doesn’t seem up to scratch,
then agitate to get it up to scratch. ‘Cause there are systems
in every state that are available where you can make those early phone
calls, you can get things sorted out. That, you know…
it’s all part of health prevention. That’s what we all need to be in. The best to manage trauma is to
prevent it happening in the first place, and part of that is to get the system
sorted out. It’s the only way we make a difference
in trauma. NORMAN: Mark?
– It’s the same. I think you have to be prepared. You have to know before you go out there what the numbers are that you’re
gonna phone, to phone a friend. And you have to get to know your team
and your environment when you get there. NORMAN: Minh?
– Be prepared. Be prepared. Know your area, know your people,
know your skills. Be prepared to maintain your skills, because, you know, rural and remote
trauma is not gonna go away. NORMAN: Libby?
– Yeah, same. Skill up before you go there. If you know that you’re gonna work
in a remote setting, then skill yourself appropriately, and that should be from the doctor
to the nurse to the Aboriginal health worker
that’s there. And what the boys said about knowing
your team, knowing your equipment. As soon as you arrive, just know
the environment you’re working in. It helps you to feel more secure
and confident in the practice that you’re doing. Hope you’ve got a lot
out of this program on trauma. Thanks to the Department
of Health and Ageing for making the program possible. Thank you for taking the time to attend and contribute your thoughts and questions. If you’re interested in obtaining more information about issues raised in the program, there are resources available on the Rural Health Education
Foundation’s website – rhef.com.au. Don’t forget to complete
and send in your evaluation forms to register for CPD points. And if you’re a metropolitan GP and
have been inspired by tonight’s program, please stay tuned
for a short five-minute video on the benefits and incentives
of working in rural Australia through the Australian government’s
rural health work force strategies. Spark up your life. Go and live in rural
Australia or even remote Australia. I’m Norman Swan. I’ll see you next time. Funded by the Australian Government
Department of Families, Housing, Community Services
and Indigenous Affairs. Captions by
Captioning & Subtitling International

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