SPEAKER S1: Good evening everyone. My name is Dimitri and I will be hosting tonight's webinar. In tonight's instalment of the Rural Health Webinar series, we will explore ways to upskill your practice team on how to manage common emergency presentations. The webinar will discuss the importance of a well-stocked resuscitation trolley, identify algorithms, and discuss how to facilitate regular resuscitation scenarios for your practice team. Our presenters this evening are Dr. John Addy and Ariel Lowcock Jones. Dr. John Addy is an associate professor in urgent care in the School of Health at the University of the Sunshine Coast, and John's clinical work has been as a general practitioner, a rural and remote GP urgent care physician working in general practices, urgent care clinics and emergency departments in New Zealand and Australia. He is currently the clinical director at a South Brisbane urgent care clinic. Ariel is a registered nurse with experience in paramedicine and critical care in both rural and tertiary facilities. Ariel has recently begun working in the urgent care environment in South Brisbane and is passionate about resource management, clinical education and care for those needing urgent or emergent medical attention in the pre-hospital setting.
We would like to begin tonight's webinar by acknowledging the traditional owners of the lands on which we are coming together from and the land on which this event is being broadcast. I'd like to pay our respects to the elders, past and present, and would also like to acknowledge any Aboriginal or Torres Strait Islander people who have joined us this evening. Just a few housekeeping things to cover before we jump straight into it. You will notice that you are set on mute, and this is just to ensure that the webinar is not disrupted by any background noise. But we do encourage you to use the chat function or Q&A to ask questions. When using the chat function, we do ask that you address your questions and comments to all panellists and attendees rather than just the panellists, so that way everyone can see your questions and comments. And finally, the webinar has been accredited for one hour of educational activity CPD. To be eligible, you must be present for the duration of the webinar. And we also kindly ask that you complete the short evaluation at the end of tonight's webinar. It should only take a few minutes to complete and will help us improve the format and content for future webinars. By the end of the webinar, you will be able to discuss the importance of a well-stocked resuscitation trolley, identify resources and guidelines used to manage common emergencies, and briefly discuss how to facilitate regular resuscitation scenarios with your team. But for now, I will hand it over to our presenters for the evening, Dr. John Addy and Ariel. Thank you.
SPEAKER S2: Thanks, Dimitri and thanks to RACGP for hosting Ariel and myself tonight. Thanks also to Ariel for coming along and helping us learn about emergency presentations in primary care. In a former life, I was a basketball player. That was my career before medicine and our coaches would make us practice certain types of plays, inbounds plays from half court, from the back court, from the baseline. But one of the scenarios that we would practice is if we were down by one point with 20 seconds to go and we had the ball. Could we manage to put the ball in the hole and win the game? And one season it was the end of the season. It was the last game and we needed to win this game to get to the playoff tournament, and we were down by seven points with one minute to go and then we were down by five. Then it was three, then it was one and all of a sudden we were so glad that we'd practices that particular scenario. We ended up winning the game and making the playoff tournament. So we survived that knockout and managing emergencies in primary care is a little bit like that. Sometimes you see a whole bunch of them, sometimes you do not see too many at all. But unless you are practising them, keeping up to date and thinking about it, it's kind of hard when it comes to do the best that you can do. So what we are keen to do tonight is to introduce the topic, talk about the different resources that we need in our general practice, look at the resuscitation trolley because it's important that we get touches of the resuscitation trolley, look at escalating scenarios and also handing over to our colleagues. Then we are going to look at a resuscitation scenario. So we have videoed that today because that's the sort of thing that I'd like to see you doing. And then we are going to go through some algorithms and protocols. So what we are hoping is that you will be able to look at what we are doing, reproduce it and use some of the information from the algorithms and protocols to keep up to date. One of the things that I have found through my experiences in emergency departments, general practices, urgent care centres, especially in leadership roles, is you do get a lot of complaints and things do go wrong from time to time. And I find that if you are managing scenarios like this and you are talking about them, there's a lot less chance of things going wrong. We do not hear too much about emergency management in primary care, and one of the reasons is the coding. And this is what I found in the last seven years when I was doing a PhD in urgent care. Presentations to emergency departments are coded according to the International Classification of Diseases 10, whereas presentations to primary care are basically coded with the ICPC, the International Classification of Primary Care introduced by WONCA. What I found with the PhD research was that I had to go and look at all the presentations and translate them to ICD-10, and then I could compare apples with apples and we could make some comparisons.
And what I found, and this was an article we published last year comparing ED to urgent care to Australian general practice on a Sunday over a year on the Sunshine Coast, was that in the ED you had 14% of presentations were infection, 44% injury. In general practice, it was 48% infection, 8% injury, and in urgent care, it was 55% infection, 20% injury. So once I understood that you needed to speak the same language to compare, all of a sudden it was amazing how many emergencies that we actually saw. And we did compare it to the BEACH study. So the BEACH study, as we know, is the Bettering the Evaluation and Care of Health. It was one of the most reliable studies in Australia, with nearly 2 million encounters between 1998 and 2016. I could find lots of lists of what came into general practice for day-to-day things, but I could not find much about emergency presentations. Last month, I looked at a German paper I was having to review, and basically the start of the title was 'What you do not present does not exist' and basically the thesis was the whole thing about the role of general practice and acute care is not described very well. And that's really because of this ICD-10 ICPC disconnect. And what they said was the absence of published data on the amount of acute medical cases cared for in general practice cannot be explained by their non-appearance in GP practices because once the GP is closed, the emergency departments get busy. So I think we manage a whole lot more emergencies than people give us credit for. Here's a study that I did find, it was 2001, so it's a long time ago, looking at the emergencies presenting in the last 12 months to general practice. This is what GPs managed and you will see this list. There's a lot of things that you will be familiar with. So acute asthma, we will talk a bit about that today, psychiatric presentations, convulsions, hypoglycemia, anaphylaxis, we will be talking about that today, shock, poisoning, those types of things. But there's not a lot. So I am hoping that in the years to come, that's certainly what I will be looking at when we are starting to manage emergencies in general practice or get serious about it. It's important to have reference materials. So one of the ones that we have is Tintinalli's Emergency Medicine. I like to have hard copies because if the computer goes down and I do not have access to the internet, then at least I have got a textbook and this is what we use when I was working in emergency medicine at Royal Adelaide Emergency Department. Another great reference is the Primary Care Clinical Manual. So this is a Queensland Health initiative, pretty much 800 pages. And they update this every 2 or 3 years. So there's not many Australian references like this. What we have actually done is we have printed it out and we have got the chapters. So there might be a chapter on cardiovascular emergencies, there might be a chapter on obstetric emergencies. And I find that really helpful. So we printed that out and it's in the doctor's room. Another resource that I have produced is a policy and procedure manual. And I get help with this from my team, including Ariel. So what I have done in the 12 urgent care centres I have set up around Australia is that I write something like this.
It's a good thing, but especially when you are travelling around, I might know what to do, but sometimes I do not know the local scenarios and who's the local person to refer to for different things. So I have just highlighted a few things there. The first is our surge protocol because sometimes we are working in urgent care, you might get 12 people turning up, and one time we had 12 people turning up. One was an ambulance diversion with a semi-conscious head injury from the day before and a witnessed snakebite. And things can turn to custard pretty quickly. So we have got a protocol for that. We have also got a protocol of places to refer. So we refer to the children's hospital, hospital in the home, local pathologists, radiologists. So it's a little bit of information on that and also information on specific presentations. So not that I see too much of acute presentations for meningitis, I have seen a number of times through my career, but I always forget the dose of penicillin, so I have put that in there. This is from the Queensland Primary Care Clinical Manual. And I also always forget the dose of anti-D and when I need to give it. So I have cut and pasted that. So I encourage you to do one of these for your local area so that if I ever have to do a locum there, I will not have to worry about which number to ring for certain emergencies. The next thing I wanted to talk about was the resuscitation trolley. And when I spent some years at 4Health starting urgent care there in their network of 84 clinics, they were very lucky in the sense that they let me be the medical director over a number of clinics, but they also flew me around and we ran resuscitation scenarios in different practices so that doctors could get touches of the resuscitation trolley so that when emergencies came in, it was not such a scary thing. And one of the things that I have noticed with resuscitation trolleys and also equipment on resuscitation trolleys is that we have got a whole bunch of different skill sets with doctors and nurses. So some doctors have just come out of emergency departments, some have just come from aesthetic runs, some have come from satellite hospitals, some are country GPs. And it's something that we kind of found very interesting when we set up this urgent care centre here. I was very lucky that we have Ariel and she works one day a week in ICU. So she's managing a whole bunch of these emergencies a lot more than what we are. But she's also a paramedic, so we have learned a whole bunch from her. But she was really crucial to getting the resuscitation trolley all transformed where we are. And I am going to get her to talk a little bit about the experiences with that and the experiences of the different skill sets of the doctors here, and how you have something that is safe for the patients and safe for every doctor that works in the practice.
SPEAKER S3: Thanks, John. So yeah, coming from ICU into the urgent care setting and looking at a resuscitation trolley that had minimal drugs and was absolutely chaotic was a real big shock to me because in ICU it is very structured and organised. So I started researching rural remote guidelines for how they stock their resuscitation trolleys. And I also looked at the GP's doctor's bag and what sort of stuff they recommended GPs to keep on hand. So from there and in discussion with John, we formulated a list of what sort of equipment we should have available and also what medications we want on site for urgent care.
SPEAKER S2: And here's that list. So we have got two resources there. The first is the AGPAL guidelines for basically the resuscitation trolley and also the doctor's bag medications that we are able to get each month. The second was the Rural and Remote Emergency Services Standardisation Resource Trolley. And I have put in there in red the things that Ariel and I talked about and I will get her to highlight, especially one of those things that we talked about and the solution that we came to.
SPEAKER S3: So everything in red is what we decided was not suitable for an urgent care setting. It was just way beyond our scope. The medication, however, that was an interesting discussion and is ongoing is metaraminol. I personally really love the effect of metaraminol and sometimes think that giving fluid boluses just does not quite cut it for that really hypertensive patient, especially when you are not sure how far away backup is. However, as John pointed out in the primary health care setting, most people have not touched metaraminol recently, if not at all. So there could potentially be a bit of a skills and scope misalignment with stocking that in a resuscitation trolley in this setting.
SPEAKER S2: And the great thing about running regular resuscitation scenarios, so when I was at 4Health, I was able to do this every month for our doctors' meetings. We would put the resuscitation trolley in, we'd pick some of the scenarios that I am presenting today, and we would ask a doctor to be a mock patient, a doctor to be obviously the doctor, and we'd have a nurse in there and then we would talk about the particular case. And when I look at this list, what we have done as a result of the discussions, we have metaraminol because we have got some of the doctors that have worked in and will still work in emergency departments and ICUs. We are running a postgraduate certificate of urgent care through the University of the Sunshine Coast. We have got the urgent care reps from ASIM, ACRRM, RACGP, Royal New Zealand College of Urgent Care, Australasian College of Nurse Practitioners and Paramedicine, the World Organisation of Family Doctors.
And we have got the disaster management person from the WHO. So we are preparing a course and as a result of the discussions between Ariel and I, we are having teaching on metaraminol, after which we might be putting it back on the resuscitation trolley. So it's important to have these discussions and also stuff changes. You know, when I was at 4Health, some of the stuff that previously was on the resuscitation trolley was taken off. Another thing that I find really interesting is, it does not matter, you know, if you have agreed on your list, you often have staff coming and saying, can we have this piece of equipment? Can we have this medication? And sometimes they can be quite costly. So, talking about these types of issues at the management meetings was very helpful. So what I want to do now is just show you Ariel's work. This is a pretty nice looking resuscitation trolley. And I will just get Ariel to talk through this with you.
SPEAKER S3: So this is the resus trolley that we have in the urgent care clinic here. As you can see, it's all very neat. There's minimal clutter on top and everything that you could possibly need in an emergency presentation or for the deteriorating patient is on this trolley. So you only have to go to one place. You only have to collect one piece of equipment and you are set.
SPEAKER S2: And we share this with the general practice because, you know, we do not use it too often and you will notice just at the top of the resus trolley there's a folder to record observations and notes. You will also see on the left-hand side there are some algorithms. So pretty much what we do is we have all the algorithms there. So if you are not quite sure what to do, there you go. And I have listed those algorithms there so you can print those out for yourself and put them on your resus trolley as well.
SPEAKER S3: So all of our drawers are labelled and they kind of go in order of your doctor's ABC that you would be doing anyway or your primary assessment. So top drawer being medications, these we want to keep to just primarily your first line medications or ones that you are going to need in your emergency situations. We do not need Panadol on a resus trolley, but we do need adrenaline, for instance. Moving on to the second one, we have got our basic airway management. Is that going to the next slide? There we go. Okay. So this is our medication drawer.
SPEAKER S2: And you can see we have got an anaphylaxis pack there. So a number of places that I have worked have that just makes it nice and easy because it's one of the more common ones that we have.
SPEAKER S3: So our basic airway drawer you can see we have got some nasopharyngeal airways and some OPAs as well as just some basic suctioning stuff as well. On to our advanced airways. You might notice that we do not have any ETTs, but we do have LMAs.
SPEAKER S2: So remind us of the thinking behind not having ETTs on our resus trolley.
SPEAKER S3: So the thought process on not having ETTs on our resus trolley is that it might have been a significant length of time before the doctor had previously done an ET or used that piece of equipment and there is a high risk of error in that, whereas LMAs there is a very low risk of error. And also any nurse who's ALS trained can insert an LMA as well.
SPEAKER S2: And in my Royal Adelaide Hospital emergency department days, often we would go up and spend a week with our anaesthetic consultants putting tubes down once a year. I have not intubated somebody using an ET tube for a number of years, and I'd be a little bit scared about putting it down the right main bronchus or, you know, not having the skills that I used to have.
SPEAKER S3: So on to our breathing drawer. So we have got all of our bag valve masks from neonatal up to adult. We have then also got all your forms of face mask and nasal cannulas from neonatal up to adult as well. So our circulation drawer this is where you want to get all your access, all your cannulations basic syringes as well as fluids and giving sets as well. And then the bottom drawer is a bit of a miscellaneous drawer. This is where we want to keep PPE. Things like space blankets, shears, spare sets of equipment like stethoscopes and a manual blood pressure cuff as well. On top we have a green frog defibrillator. So an AED we do not have a manual defibrillator on site at the moment.
SPEAKER S2: In New Zealand for urgent care. The standard is an AED with a manual override, and I am thinking that's probably the way it's going to go in Australia for urgent care.
SPEAKER S3: Yeah, I agree with that.
SPEAKER S2: Next thing I want to talk about is basically PACE and ISBAR. Well, I will get Ariel to talk about that. Because this is what I have found sometimes in my career and sometimes me being me sometimes there's six people, ten people in the waiting room. You are working really hard. Your mind's going a million miles an hour. You just want to finish the next case before you go into the one that you are being asked to see. But sometimes the one you have been asked to see is like a life-threatening condition. And the interesting thing about PACE is PACE is a lovely graded way where a nurse can progressively ask you in a progressively, I would not say aggressive, but basically a way to get your attention. And then the next one is about handing over to our paramedic colleagues. Because the way I see paramedics, especially working with in the paramedic school to write this postgraduate certificate of urgent care, is that paramedics have amazing skills. They intubate a whole bunch more than I have in the last sort of 5 to 10 years. And what I try and do is to treat paramedics with as much respect as I can take a chest pain, for example. I always like to put a drip in, document the medications that I have given, write a letter, do a handover, you know, and respect them as professionals. So I will just let Ariel talk about PACE and then ISBAR beautiful.
SPEAKER S3: Communication is a really important, non-technical skill that's really paramount for effective crisis resource management and patient safety. It's often been rationalised that effective communication between hospital, allied health and primary healthcare professionals improves the quality and the continuity of care for the patient. However, despite this seemingly known fact, communication in the pre-hospital setting whether it be between the GP and the practice nurse or between a paramedic and an allied health is often quite poor, with no clear set expectation or gold standard for this interprofessional communication. In my experience as a nurse and as a paramedic, I can attribute that handovers in the primary care environment are often really clunky and there's key information missing or forgotten. There's been really big movements in universities recently to now teach structured handovers and graded assertiveness to help improve this known deficit in communication, not just in the primary healthcare setting, but in healthcare in general. So just more specifically to touch on PACE, it's a tool that was first introduced in the surgical setting to help redirect or refocus surgeons who were tunnel visioned or fixated on one task and were potentially missing a really key or critical aspect of patient care. This tool is now being taught to most healthcare professionals as a way to escalate their concerns regarding patient care or patient safety as a whole. So PACE stands for Probe, Alert, Challenge and Emergency. So what you are doing is you are escalating your level of communication. If the person you are speaking to is not understanding the level of concern that you are trying to portray. So just diving into that a little bit more specifically. So P for Probe, this is where you want to seek clarification in your communication. Did you know that this is happening? Hey did you notice this vital sign is a little bit low? In Alert if they are not quite cluing on to that previous statement. You want to offer options or alternatives that will potentially resolve this situation.
So for instance hey this patient's hypotensive. Do you want me to give a fluid bolus now? You are offering the resolution. Failing that, you then move up to Challenge. So you are really expressing concern. You are asking questions. So I am really concerned that this patient is hypotensive. Can you please explain why we are not managing this right now? And then Emergency. This is where you go for the safety of the patient. You need to stop what you are doing right now. And we need to focus on this. So you are using really direct to the point language here. Graded assertiveness as a whole is a really vital communication tool that empowers healthcare professionals to address concerns and advocate for patients and promote a culture of safety by incrementally adjusting the assertiveness of their communication based on the urgency and the response of their recipient. Healthcare professionals can foster a culture of open dialogue, collaboration and accountability whilst also just mitigating errors and improving patient outcomes as a whole. I think GPs can often forget that sometimes nurses and paramedics have a whole different bunch of skills and knowledge that can be really beneficial to use in these stressful scenarios, and it's really important that any healthcare professional feels empowered to be able to ask questions and escalate their concerns and the level of confidence of healthcare professionals in the primary healthcare setting, whether it be GPs or nurses to use graded assertiveness techniques to escalate their concerns, is only going to increase with education and further acceptance that this is an okay technique to use, and it's not met with dissatisfaction or reprimand for trying to speak up, essentially. Back to you, John.
SPEAKER S2: Oh that's good. And look, just with PACE, I often tell the staff that I work with, if you are worried about something, just ring me up and say, John, get your butt in here now. And, you know, I will just do it. I just like people to just start off. If you want me, just tell me. But this is a nice thing and it just is graduated. So the whole idea is not to cause offence. The next thing we want to talk about before you get to see our line and a resus scenario, is the ISBAR. So this is when we are handing over to our paramedic colleagues, especially when we are wanting to get them to transport a patient.
SPEAKER S3: As someone who gets handed over to really regularly, not just as a paramedic but as a nurse as well in urgent care and in intensive care, there's nothing more frustrating than receiving a really clunky unfinished handover. It leads to delay in care and increases the potential for mistakes to be made, and it just makes everyone just a little off their game. I recall attending a GP practice as a paramedic to transfer a hypotensive patient, and the only bit of clinical information we got given was that the blood pressure was 100 over something. Lo and behold, when we did that first set of vital signs, the blood pressure came back with a systolic of 130. It was not really until we started probing the doctor who then started seeing another patient what the go was. It turns out they'd got an IV access and given some fluids, which is an absolutely fantastic intervention. But we have now just wasted ten minutes trying to figure out what they have actually done and how this has been resolved. So there's been a lot of research suggesting that patient safety and outcomes have improved since the introduction of standardised handover tools. Some of the most common structured handover tools used in Australia at the moment is SHARED, ISBAR or AMBO. They all achieve the same result, so I would really encourage everyone to just pick one that they like and just stick with it and keep practising with it until you know it off the top of your head. I personally prefer using ISBAR and that was the one that I was taught in university as well. So ISBAR stands for Identification, Situation, Background, Assessment and Recommendation. This can take all of five minutes to organise a systematic approach to your handover, and it makes a massive difference to the person receiving the information as well. I am not sure they can see the screen. So as you can see on your screen, this just breaks down what's expected in each category.
You do not need to tell them the patient's whole life story. You just want to keep it short, simple and to the point. So Identify you want to say your name, your role and most importantly, why do you need to talk to this person and are they the right person to talk to in the situation? You want to know the patient's age. You want to know their gender, what's their primary complaint or why are you concerned? Why have you called for help? In their background, you really want to highlight if they have any allergies or just relevant medical background to this presentation right now. So for instance, with a cardiac chest pain, I do not need to know that their second aunt twice removed is allergic to cats. But I do need to know that this person has had a previous MI two years prior. Also in background you also just want to touch on how did they get into your situation now? So have they come into urgent care themselves? Have they been driven by a friend? What is the actual situation that's led to you calling? In the assessment, you want to make a brief sort of diagnosis of what you think the problem is, and you want to tell them all of the vital signs. Any other diagnostic tests that you have done, as well as any other interventions you have done as well. So main thing being if you have given any medications, highlight that the dose and the time that you have given it. So we know where to pick up care from. In recommendations, what do you think needs to happen next? Where do they need to go? Do they need to go to the specialised tertiary centre or can they go to the local ED down the road? And most importantly, you want to give them a solid 30 seconds to a minute to process what you have told them and ask them, do you have any questions, queries or concerns? This gives them the opportunity to just revisit information and make sure they have got everything correct. That's all good. I missed AMBO. I have not used this technique in a long time, but as you can see on your screens, this is what's commonly being taught now to paramedics going through university. It highlights really how many seconds of pause that you need to give after a handover. And it's important to revisit the information being told.
SPEAKER S2: So what you are saying, Ariel, is that if I am handing over to a paramedic, they are actually kind of expecting this type of order. And sometimes if I might give it in a different order, it kind of might throw them a little bit.
SPEAKER S3: No, not necessarily so whether you use IMSED, AMBO or ISBAR or SHARED. They all deliver the same information. The main thing is that it's in a systematic way. So paramedics are really good at interpreting your handovers. They can interpret an ISBAR handover and adjust it into their own IMSED AMBO.
SPEAKER S2: Oh yeah that's what I am saying. But it's using one of these kind of handovers would be a good thing for us to do.
SPEAKER S3: Absolutely, yes. Not using a structured handover tool creates a lot of chaos, and it just leaves a lot of opportunities for mistakes or information not getting passed across to ED.
SPEAKER S2: Great. All right. So one of the things that I started doing at For Health was to run these resus scenarios every month. And what was interesting is they had 84 clinics around the country and each of the, you know, general practices was different. And what we did was we managed to get a lot of the resus trolleys around the country, the same, the protocols the same, the drugs the same. And then it was just a matter of getting people into the resus trolley to have touches and to rehearse scenarios. Um, and, you know, so that when these situations would come in, they would be able to manage them. So what we have done in the next slide here is to do a little role play. So I will just put that on for you for seven minutes and then we will get into some scenarios after that. All right.
SPEAKER S3: Hey Jane, what's brought you in today?
SPEAKER S4: I was out at lunch at a local cafe and I had some food. And now I have started coughing and complaining of itchiness. My friends brought me here.
SPEAKER S3: Okay. Are you allergic to anything at all?
SPEAKER S4: Nuts.
SPEAKER S3: Okay. Is there any chance that you have been exposed to nuts before? Maybe. Yeah. All right. Do you normally carry an EpiPen? No. Okay, let us do a set of observations on you. And I am just going to call the doctor in here because I think you might be having a bit of an allergic reaction. Hey, John, I have got a 44-year-old female in here. She has been out at lunch today and is now coughing, complaining about her throat. She does have a history of anaphylaxis to nuts but does not carry an EpiPen. Right. Her first set of observations is just coming back now.
SPEAKER S5: What do you have for the observations?
SPEAKER S3: So we have a heart rate of 115, blood pressure of 95 over 50, respiratory rate of 24, SpO2 of 96, and a temperature of 36.8. And she is currently a GCS 15.
SPEAKER S5: Are you otherwise healthy besides what we have mentioned before?
SPEAKER S4: I have hypothyroidism.
SPEAKER S5: All right. Any medicines you are on?
SPEAKER S4: No.
SPEAKER S5: No. And obviously, the nuts. I think I heard that before, that you are allergic to nuts. So I will just have a quick listen to your chest at the back there, and we will. What am I listening to here? Can I hear anything in the chest?
SPEAKER S3: You can hear bilateral wheeze.
SPEAKER S5: Okay. All right. And just, I mean, asthma or beta blockers or nothing like that that we have to worry about. So I am a little bit concerned that you might be having an anaphylactic reaction here because you have had that in the past, and you have got some cardiac symptoms and some respiratory symptoms. So what we need to do is to get some adrenaline and just inject it into your thigh, and we are going to inject it into the muscle. So we want it to work quickly. Is that okay? And what I will do in the meantime is to grab a drip and put that in. So I will just wait for the impact there.
SPEAKER S4: Beautiful.
SPEAKER S3: So I have got some adrenaline here. Can I just confirm the dose of adrenaline that you want to give?
SPEAKER S5: Yes. So 0.5 of 1 in 1000 into the thigh intramuscularly.
SPEAKER S3: Beautiful. So 500 micrograms of adrenaline, and I am going to pop that into your thigh.
SPEAKER S5: And right now, I am just going to get the circulation going. It's not that great. We have got this all set up here. So I have got the little trolley there, and we like to put it in, and that's what we are doing now. And the blood pressure was a little bit on the low side. So we are going to run a bolus of fluid through if you can do that. And I will come here and wait while we do that. And then we can go to the next five minutes.
SPEAKER S3: So that litre of fluid is running through now. Let us do our second set of observations.
SPEAKER S5: Yes. How are you feeling now?
SPEAKER S4: My throat's really itchy.
SPEAKER S5: Wow. So you are getting worse, not better.
SPEAKER S4: Yes.
SPEAKER S5: Okay. And what are the observations like now?
SPEAKER S3: So I will just come back. She is tachycardic at 120, blood pressure is 89 over 46, respiratory rate is 24, SpO2 is 93, and temperature is 36.8.
SPEAKER S5: All right, so I will just have another quick look at the chest here. We will just bring you forward a little bit. You are a bit wheezy here, aren't you? Okay. And how is the stridor going here at the moment?
SPEAKER S3: No stridor at this stage.
SPEAKER S5: That's good. So what we might do, if that's okay, is to put a nebulizer up to give the adrenaline first because that's always our most important drug. Same deal, into the thigh intramuscularly. And if we can run a nebulizer with 10 litres of oxygen and 5 milligrams of salbutamol, we have still got the fluid going.
SPEAKER S3: Yeah. So fluids are still going through. Just confirming, I have got 500 micrograms of adrenaline, and I am giving that into the thigh, and that is the second dose.
SPEAKER S5: And we will just call the ambulance because this is the second dose, and even if she settles down, it will be beautiful.
SPEAKER S3: No worries. And I am just going to start that nebulizer now.
SPEAKER S6: So we have got the nebulizer set up.
SPEAKER S4: With some salbutamol going through.
SPEAKER S3: I will just step out and call the ambulance. Great.
SPEAKER S5: Thank you. And I will just wait here while you are doing that.
SPEAKER S3: Cool. So I have called the ambulance, and they are about 15 minutes away. What, um, should we do a third set of observations?
SPEAKER S5: Yeah. So it has been five minutes, hasn't it? Yeah. Five minutes. Okay, cool.
SPEAKER S3: Beautiful. So, third set of observations. We look like we have got some improvement here. The heart rate is 115, the blood pressure is 110 over 55, SpO2 is 98% still on that 10 litres of oxygen, respiratory rate is 20, and temperature is 36.8. How are you feeling, Jane?
SPEAKER S4: Much better. My itchiness is gone.
SPEAKER S7: Oh, beautiful.
SPEAKER S5: Let us have another listen to that. Okay.
SPEAKER S6: Okay. Here we go. Good. Yeah. That's good.
SPEAKER S5: All right, so we will just.
SPEAKER S4: Lovely.
SPEAKER S3: Oh, looks like she is coming in here. Do you want to do the handover?
SPEAKER S5: Actually, you know what? Because I have heard you do this, I think it would be good for you to do that.
SPEAKER S3: Beautiful. I think I prepared something earlier. Hey, officer. Am I handing over to you? Oh, beautiful. So this is Jane here. She is a 44-year-old female with suspected anaphylaxis. She does have a history of being anaphylactic to nuts. And she was trying out a new cafe today and started complaining of an itchy throat and a bit of a cough. Her friends, being the good Samaritans that they were, brought her into the urgent care. On presentation to us, she was mildly hypotensive and tachycardic with a generalised rash and some lip swelling and a bilateral wheeze as well. We have given three doses of 500 micrograms of adrenaline, we have given one litre of fluids, and we have also started her on a nebulizer with 5 milligrams of salbutamol here. Her latest set of observations shows some improvement with a heart rate of 115 and a blood pressure now at 110 over 55. We are requesting that she goes to the nearest available emergency department just for some ongoing monitoring here. If you have any questions, queries or concerns, let me know. Here is Jane.
SPEAKER S8: Let us get her on your stretcher and see.
SPEAKER S4: All right.
SPEAKER S2: Alrighty. So that's an example of a scenario that we ran when we did a recent GP meeting. And what I have tended to do in the practices that I have been the medical director of over the years is to try and run these as frequently as possible, even up to once a month, and just alternating. And sometimes I get different doctors to even run the scenarios. So we are all getting practice. What I have not done is try to put pressure on doctors because some people do not like being put on the spot, even though that's what happens when an emergency walks in the door. Often, I will ask people beforehand, and I will give them some sort of mental preparation. Quite often, I will say, "What did we do well, and what did we not do so well?" But the next thing that I will do is I will talk about some of the latest articles or the latest guidelines. One of the things that I have used a lot is the Health Pathways. So Health Pathways was started in Canterbury during the Canterbury earthquakes, and it has become a thing in Australia and New Zealand and also in other countries around the world. What happens is there are localised guidelines for many of the emergencies that we see, and I use those a lot. Sometimes I will use local hospital guidelines, so we will talk about a few paediatric emergency presentations. So we have got the Queensland Children's Hospital three kilometres away. So we use their guidelines because we refer to them. So it's a respect thing, and sometimes we use RCGP guidelines. But the most important thing is to have a reliable, preferably Australian guideline to use. So with anaphylaxis, we are in Brisbane South. So that's the Health Pathways that I use. We always need to consider anaphylaxis even if the symptoms resolve spontaneously if there is acute onset of respiratory and cardiovascular symptoms. So the respiratory can be upper respiratory, it could be the swelling of the tongue or the throat, or it could be asthma, and cardiovascular symptoms. So a drop in blood pressure, even cardiac arrest, or acute onset of hypertension, bronchospasm, upper airway obstruction after exposure to a possible or known allergen. So that's what we had in our scenario with the peanut. It's not essential to the diagnosis, but we can also have skin symptoms. So rash, urticaria, angioedema, or even GI symptoms. So abdominal pain, vomiting, those types of things. So a few differential diagnoses to consider.
I have been caught out by a few mild to moderate allergic reactions. I remember at the Royal Adelaide Hospital having some cases of scombroid fish poisoning. About 3 or 4 people came in with sudden onset of an all-over body rash, quite hysterical one night. I also remember a number four, panic attack, where we had given a lady with cholecystitis some ceftriaxone, and then about a minute or two later, she started really getting kind of panicky and wheezy and breathless. And I was thinking, because she had a past history of anxiety and panic attacks, could this be a panic attack? Could it be an anaphylactic reaction because I have just given her IV antibiotics? If I think it's an anaphylactic reaction, I give adrenaline. Unfortunately, it was a panic attack, so it kind of went the other way. And luckily, the boss came on and picked us and gave us some midazolam to calm her down. But there are some differential diagnoses that are important to know about when we are managing anaphylaxis. There are not too many things to give. We often lie the patient flat unless they are a little bit breathless. If I am not sure, just like with meningitis, if I am not sure about meningitis, they get the dose of either penicillin or ceftriaxone, and they go to hospital. If I am not sure about if I think it might be anaphylaxis, I give the adrenaline because it's an inflammatory cascade. If I give it early, it nips it in the bud quickly. If I let the cascade start going like this and faster and faster and faster, then it's really hard to get on top of. Sometimes we give oxygen. Oftentimes we will put in an IV access, and sometimes we will have to give antihypertensives or, sorry, we will have to give fluid boluses if the patient is wheezy. We give a nebulizer. If there is upper airway obstruction, sometimes we have to give nebulized adrenaline. And the scenarios that we always worry about are people with asthma that's uncontrolled because their mortality rate is increased, but also patients on beta blockers. Sometimes we have to give glucagon too. So they settle down after a dose of adrenaline, and we watch them for four hours, and we want to discharge them. It's important to make sure the patient has an EpiPen and knows how to use that and has an action plan. If we are not sure why they had an anaphylactic reaction, it is good to refer to an immunologist. If it's a medication-related anaphylaxis, we inform the TGA. We make sure that asthma is well-controlled, and if we are not sure about the suitability of sending them home, we transfer patients to the emergency department.
In New Zealand, where I have trained, the government pays a $200 item number for patients who have given themselves an EpiPen for anaphylaxis, and if they respond within a few minutes of that, they can come to the urgent care, and we observe them for four hours, and we have to put a drip in while we are observing them. Used to be this was back in the day, and this is why it's good to review things that if someone had an anaphylactic reaction, we would send them to hospital because of biphasic reactions that happen 12 hours later. Actually, biphasic reactions can happen up to three days. So, you know, it's not just 12 hours, but most of the clinically significant ones happen within 3 hours or 4 hours. So, if certain conditions are met and the patient is stable, it's safe to send the patient home. And the five risk factors in a systematic review that were found to be associated with biphasic reactions were a long time to the first dose of adrenaline, a previous history of anaphylaxis, severe symptoms, a number of adrenaline doses. So if I need to give two adrenaline doses, I am sending the patient to hospital, and also an unknown trigger. So here is a protocol for anaphylaxis that we have given you the link to. So I am not going to go through these because it's a busy slide. But I encourage you to print that out and put that on your resus trolley just in case you need to refer to that. The second medical emergency that I want to talk about today is bronchiolitis. So I have just picked a number that come into our urgent care centre. And also I see as a country GP when I was working in the Barossa Valley. So we will see the mild bronchiolitis and be happy to send those home. The moderate ones, it's important to know what a moderate one looks like on presentation because sometimes you will have to admit that to your local hospital. So if a child has moderate bronchiolitis, often their respiratory rate is increased. And I am often concerned when the respiratory rate is more than 60 and there's increased work of breathing with nasal flaring, tracheal tug, saturations between 90 and 92 and difficulty feeding. So the big worries for me are if the kid's looking a bit blue and if the kid's not feeding, I certainly want to think about oxygen and also nasogastric tubes. This is the Queensland Children's Hospital guidelines on diagnosis and management of bronchiolitis. Again, busy slide I am just putting it up there for your reference. But just kind of honing in on the ones that we are able to manage.
SPEAKER S6: Here we go.
SPEAKER S2: So with mild bronchiolitis, it's especially important to count the respiration rate. It's important to try some normal saline nose drops because children are obligate nose breathers up until six months. And if they settle down, and they do not have risk factors for deterioration, it's quite safe to send them home. And it's usual that bronchiolitis gets worse for the first two days. It can keep being quite nasty up to day five. And sometimes with parents, I will see the kid every day if I do not really want to admit them, but I am still a little bit worried about them. The big ones that I do worry about are the ones that were born prematurely. The ones that have a low weight compared to what we would basically expect. Also kids with things like Down's syndrome. So you'd worry about those ones. So under one, often it's bronchiolitis, between 1 and 5, it's preschool wheeze. So there are different protocols for that. When I was going through my training, it was asthma after one, now it's 1 to 5 preschool wheeze and after five asthma. Different rules for that. Another busy slide. But that's just for you to cut and paste. But we are really interested in the mild to moderate bronchial, preschool wheezes because they are the ones that we can manage in our primary care and we do not necessarily have to send to hospital. So thanks to Ariel. Ariel was fantastic with setting up our resus trolley and our nurse-initiated protocols. We have got nurse-initiated protocols for salbutamol. So with salbutamol we give, if it's mild, we give a dose and a dose is six puffs and you give a lot of nib. We do not use nebulisers so much anymore but it's spacers now.
SPEAKER S3: Yeah, it's definitely been a shift in the last few years of moving from your nebuliser into your spacers, which was a big learning curve for me as well.
SPEAKER S2: So if you have a child with mild asthma, you give a dose of Ventolin. So that's six puffs via the spacer. And you will notice here coming down once they are more than one hour between doses, then you will start to space things out. But what I have noticed with the protocol here is when they are more than three hours between the Ventolin doses, then you can consider discharge. It's different advice from asthma. When we go across to moderate here, we are giving bursts. So actually that's six puffs every 20 minutes times three. So that's over an hour. And then we get it so that they are having more than an hour between doses. Pop them in short stay. And then if it's more than three hours between doses, then they can go home. We are not actually giving steroids or oxygen unless the presentation is severe, in which case they would be admitted. And this next one is childhood asthma. So we are going from preschool wheeze to next one is asthma. So we can easily manage mild asthma. But it's the moderate ones that we need to watch out for because we are getting on that slippery slope towards not really wanting to send them home, especially at night when their natural steroid levels go down so their stats, their saturations start to drop, they start to get tachycardic and tachypnoeic and they start having accessory muscle use. Another busy slide just talking about the Ventolin and also the steroids and the ipratropium bromide. So when we are dealing with children under five, we use six puffs of Ventolin. And also once they hit five we can start using the atropine, the ipratropium bromide. And we are using four puffs as a dose and a burst is four puffs times three. With prednisolone we do not use that unless it's severe. But you will notice there's a bigger dose on day one and a smaller dose on day two to day three. Next time we will talk about is asthma. So that's diagnosed after five. Another busy slide for reference. But we are basically coming down here to mild. We would give a dose of six puffs if the child is five. If the child is six and over, it goes up to 12 puffs.
If they are improving at an hour, we send them home with an action plan. You can see with moderate here you give a burst which is three doses every 20 minutes, also with some atrovent and you give steroids. If it's moderate so preschool years you do not. If it's moderate with asthma you do. And when there's more than one hour between salbutamol doses, it's safe to look at sending the patient home with action plans. I think the chemist does not like me for this, but I will write an action plan on the actual script, just like I will write a GTN action plan. I write that out so it's printed on the patient's medication so that if anything ever goes wrong, it's documented that the instructions are there for the patient. Another busy slide about the different medications for asthma but just narrowing it down to this age five. It's six puffs sometimes every 20 minutes times three if you are mild but over age six it goes up to 12 puffs times three. Sorry if it's moderate. With the asthma when it's moderate, you give the steroids, higher dose day one, lower dose day 2 to 3. And you can extend to day five. But once you hit five years old, we are giving some atropine bromide. Next one we are just going to touch on is, and we have got five minutes to go. So we will start to wrap it up soon. So every year in urgent care we do an eight-hour CPR course, which I am sure you will do quite regularly. But the reason for putting up this protocol, which hopefully you will have on your resus trolleys is that this is a nice scenario to put up there for doctors. So, you know, basically with these, we do not have to get the dummies out. We do not have to make it too true professional, but it's just coming to the resus trolley. Having a scenario, having your brain think about these protocols and then having a debrief afterwards so that if the situation presents to your rural general practice, you will be familiar with what to do. Next one we will just talk about and probably this is the last one we will talk about today is presentations for COPD. I was involved in south-east Queensland in a hospital that had one of the highest readmission rates in the country identified by Stephen Duckett.
And what they found was that if they engaged psychologists, physiotherapists, local GPs, that they decrease the readmission rate for COPD by 48%, which was an absolute amazing turnaround. What's been happening in England at the moment is patients with COPD can go into their community pharmacist who's been having extra training and get COPD packs where they start amoxil and prednisolone if they cannot get into their GP. And that's having some amazing, positive effects of keeping people out of hospital. So a few things I'd like to just highlight, just in this again busy slide, but we will just focus on the bits that are really important. So if people have COPD and they are coughing more and they are having more phlegm or thicker phlegm, it's important to start them on 4 to 8 puffs of salbutamol every 3 to 4 hours via the spacer. And it's important to teach them about that. But if things are not improving with that, it's important to commence steroids for about five days and stop. So mild to moderate COPD is something that the general practice and also the urgent care I think can do really well for. What we found in the study for the South East Queensland Hospital was there's a lot of anxiety involved and if you can sit the patient down in short stay for 3 or 4 hours and make sure they are safe and do all the things that you would do in hospital, you can keep people out of hospital. These are the conditions where I'd be worried and I'd send patients to hospital. Or if I was in the country, I'd admit under myself as there were symptoms that were obviously severe. There was swelling of the ankles. There were saturations of less than 92% if they were not on oxygen, and they are short of breath is much worse at rest. High fever, altered mental state, other comorbidities and they are not able to do their normal ADLs. Anxiety is an important one. And this is what I find, especially if I know them and I can admit them. Well, I can keep them in the rooms for several hours and encourage them to calm down and they understand what's going on. Often I do not need to send them to hospital or admit them under myself. This is the COPD guidelines, which I think will be a fantastic thing to talk about in your meetings.
And it just talks about the benefit of interventions like LAMAs, Spiriva, steroids, non-invasive ventilation, hospital in the home and also the whole thing about the multidisciplinary care plans. And often what I find is when you see patients in an urgent situation and you have got some time to spend with them, you can go through these types of interventions and just discuss what the latest trends are in treatment. Patients really appreciate that. So we have got about 3 or 4 other scenarios that I have put up there. I knew we would not get through them all today. But I put them there and the resources, because what I am hoping if I see you at a conference that you will, and you have come along tonight, that you will say, I heard what you talked about today. We went home. We looked at our resus trolley. We made sure it was kind of had all the stuff on it that the rural faculty suggested. And we started running resus scenarios, and we started using some of the documentation and protocols that you talked about. That's what I'd love to hear. So I will put a whole bunch on there so that hopefully if you have got meetings coming up, you can start that. So we started today talking about my basketball career and how we used to practise certain scenarios that were unlikely to happen, but they could happen. And one of them came up and we actually managed it and we won the game. So just like that, we practise scenarios in the resus room using the resus trolley so that when these things come in, we can manage them. So thank you all for your attendance tonight and look forward to saying hi sometime down the track. And thank you, Ariel.
SPEAKER S8: Thanks, John.
SPEAKER S1: Thank you. Thank you so much, John and Ariel. That was a very informative webinar. Before we just end, John, there are a couple of questions in the Q&A box. I am not sure if you can see those. I can read those out. Why are some medications in red? I think that was when you were showing those pictures of the resus trolleys initially. Yeah. Thank you.
SPEAKER S2: So we just wanted to highlight, you know, the tensions that we have with all the different types of doctors that work with us and some of them are more skilled than others. And as a medical director, I am kind of responsible for what's on the resus trolley. So if I have medications that some doctors do not know how to use properly and they use them and we have a bad outcome, I might be called to account. So I just put in red the things that we have chosen not to have on our urgent care resus trolley. If I was a country GP, I would have all those things because that's what's expected of me. It's a rural general practice guideline.
SPEAKER S1: Fantastic. And if some of the GPs have joined us this evening, would like more information about urgent care courses, where can they go?
SPEAKER S2: Yeah. So I would love if you would be able to give your details to Dimitri because we have got this postgraduate certificate of urgent care over the line. So we are just developing the resources right at the moment. We hope to have it done by sort of April, May next year. And, you know, sort of available to start. We have talked to the basically the chairman of the board for RACGP last year and the acting CEO. So they were keen to support this. So yeah. So if you give your details to Dimitri and as soon as we have got something concrete that you can enrol in, we would love to have you as part of that. We are also just going to mention this is, a couple of well, over the last sort of 18 months, we have travelled to different parts of the country and ran urgent care courses. We plan to continue to do that. The reason why I put mine and Ariel's email address in the front there is that we are keen to do that and to teach this type of material so you can reach out to us as well. But if you give all your details to Dimitri, we will be, you know, once we get that course up and running, we will let you know.
SPEAKER S1: Fantastic. Thank you so much. And just a quick reminder we have gone a little bit over, to please complete the evaluation that will pop up in a moment when the session ends. It really just does take no more than a minute to complete. Certificates of attendance will become available on your CPD statements within the next few days. If there are any non-RACGP members who would like a statement of attendance, please email Rashpal at rashpal.ago. And that concludes our webinar series for 2024. We do well. We do look forward to welcoming you all next year. I have also popped a web link in the chat to our webinars for next year for February, March and April. In March, there will be an Emergency Medicine case scenario webinar presented by Dr. Anthony Wong, which is part two of his webinar that he presented in August this year. We hope that you could join us for that. Thank you again, John and Ariel. For the rest of you all, have a great evening and we will see you soon.
SPEAKER S2: Bye bye. Thank you.