RE: RE: MDs for field amputations/abgl-response

[Ken Lawson-Williams <Macgyver@FlightMedicMail.com>]

I agree about remote areas (and also propose mass casualty incidents and disaster scenarios). But that brings up the QA/QI and skills competency question. I practice in such an area, where the golden hour is a complete impossibility/myth, and if you can get to the patient and then to a trauma centre within 12 hours you are at the equivalent of the 10 minute mark, and within 24 happens more than we'd like - the equivalent of the golden hour.

So how, in these remote and totally underserviced areas does a local hospital provide the educational and skill maintenance opportunities? Let alone attract and retain the surgeons etc to do the teaching?. We have a hard time keeping two orthopods on-staff in a regional centre!. Sending staff out comes to mind initially, but that is a huge cost when the closest centre is a $1000 airfare away - before hotel costs/wages/ expenses/relief staff overtimne/special insurance (to keep training institution happy) etc. 

The health board only has budget for ATLS once every five years - and so MD's who come in after a course and stay (the average) of 1.8 years will never get it - despite being the ER doc for many shifts... As to frequency, probably 1 or 2 a year since we have a large number of mining operations at extremely remote sites. I have only personally come accross 1 in the past 4 (but then there are 12 crews that fly into the regional hospital).

The rest of the tools are 'easy' to obtain and maintain, even the blood issue, but how do we deal with the core question of the skill of amputation itself? Via internet? Prebooked human patient simulator or (if there is one a surgical simulator) time (have one flown up)? with animals? (limited vet-tech's and 1 vet in town but possible), with wild game (easy technically. Many staff hunt caribou for food regularly. But not sure if it is legal to deliberately cripple or wound an animal just so you can cut a leg off for practice without letting it expire, then kill it anyway - never mind that the meat likely would no longer be edible - and deliberately killing game to feed to sled dogs is currently illegal)

I look forward to suggestions!!

Ken L-W

>That being said, the other considerations have also been touched upon.
>Maintaining skills competency becomes an increasingly greater challenge the
>more rarely a skill is performed. And the judgement question of when the
>procedure is appropriate needs also to be included in training, even though
>it can be addressed via protocol and direct medical control. I certainly
>wouldn't encourage the use of the procedure unless  *all* of the tools
>needed, including adequate pain management, sedation, and amnestic, and
>probably blood are available. If you have to send somebody to the hospital
>to pick up blood and/or meds, you may as well pick up a surgeon while you're
>there. Also, remember that this is an irreversible procedure! "Ooops, let me
>just fix that for you" isn't an option.
>If you're in the wilds of
>Alaska, and on your own, or have extended response times for an
>appropriately trained physician to the scene, yes, but I would involve your
>receiving surgeons in your protocol evolution, training, followup and QA.
>
>Thanks for letting me put more than my two cents worth in.
>
>Laurie

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