A ๐ฅ rural ER Code Orange (Refinery Disaster)
Shared lessons & insights from a small regional rural hospital in Clarenville, NL (pop approx. 10 000)
#RuralRocks
#RuralMatters
@SRPCanada @alandrummond2 @snewbery1 @ElaineBlau @SarahGiles10 @TheSGEM
Murphy's Law = a disaster will happen in a rural location leading into the Labour Day long weekend, in the context of a healthcare system already in crisis.
cbc.ca/news/canada/newfoundland-labrador/8-emergency-rooms-closed-across-newfoundland-on-labour-day-weekend-1.6572205
Exacerbated by the pandemic / altered CPSNL licensing, decimating the traditional IMG MD supplemental workforce supply that rural NL was always heavily dependent on.
And intransigence on applying healthy discretion during a bona fide crisis.
cbc.ca/news/canada/newfoundland-labrador/dr-paul-hart-fogo-island-1.6577101
Rural population ER fundamentals = studied to death
Resources & access / distance / time / geography / weather.
The strategic location of Cat A / Cat B ERs within NL were well designed for precisely those reasons : mess with it / degrade it at your (& systemic) peril.
Disasters = rare, but Disaster Plans / facility Code Oranges built into muscle memory, matter.
An orchestra of integration :
On scene first aid.
Fire / RCMP / volunteer S & R response.
EMS response.
Receiving facility response.
Ultimate tertiary disposition with HEMS.
8 pts, 7/8 CTAS 1 & 2, 6/7 I&V in 1st hour.
3 x generalist CCFP ER MDs / 1 x ER NP / 1 x general Surgeon / 2 x general Internists / 1 x general Anesthetist / RTs / a 16-20 dream team of cross-trained RNs / 1 x general Radiologist / X Ray techs / Lab Techs / ancillaries.
Rigorous application of fundamentals was key :
Mechanism of injury = only initial history required
Top down primary survey A-B-C-D-E paradigm, Y / N answers only (immediate intervention & not moving on if the answer was = N).
Traditional bottom up kills in 0-30 min.
Note the (deliberate) use of "general". Yes, rural Canada needs (and thrives) on *GENERALIST* MDs and specialties.
Strewth, an Internist as an asset for trauma cases / ATLS ?! Yes, they excelled ! Hat tip @JDwoodfine
CCFP (EM) & retention of a full generalist scope = a failed training paradigm for rural Canada. Multiple projects confirmed the vast majority gravitate to tertiary / urban in limited EM only scopes. Penetration into rural Canada (original intent) is dismal, but improving.
Maintain big picture systemic context throughout, know your resources (+ & -) intimately, activate early for lead in times & support. 2 x admitted to our local ICU, 5 x T/F to tertiary ICU. Big big deal immediately clearing 5 / 12 beds in a tertiary ICU already full).
Crucial to the success : No questions asked / can do culture via HEMs & tertiary, in a system already stressed to the max & in crisis.
Impeccable collegiality / professionalism, & mutual rural / urban respect.
Kudos ๐
There is nothing, I repeat nothing better knowing that the cavalry are on the way. Our facility is a 2 hour ambu trip to St. John's, i.e. a 5 hour round trip with handover included (rural can't tolerate the loss of ambus/RN escorts).
youtu.be/ZgkIqU15WO0 via @YouTube
Our local airstrip is not IFR rated / moose fenced = no FW assets in the dark. I'm a Provincial OLMC MD for Ground Ambulances / Medical Flight Team : we've never had 3 individual expert Flight Team duos delivered / heli's queued simultaneously rural. Hat tip @hfxjrcc
Patient's arrived 17h00. Resuscitated / stabilized by 18h00. Heli's arriving 20h45 for packaging & egress (Cougar x 1 pt, Cormorant 2 x 2pt trips). Clarenville ER 18h00-21h00 closed except CTAS 1, back up and running by 21h00. All local ambus and RNs retained.
The job is not over without flawless integration into tertiary : real-time progress comms comms comms throughout.
@JDwoodfine with duty HSC ICU Intensivist
Myself with duty HSC ERP @jstonemclean / Trauma Team alerts
Rural / urban expertise marriage.
Celebrate / good news story for HCWs & the public for a change / PR / rural advocacy / recruitment opportunity
CBC TV : clipchamp.com/watch/pzlEJ2qudFi
CBC Radio : cbc.ca/listen/live-radio/1-56-st-johns-morning-show/clip/15935247-code-orange-come-by-chance?fbclid=IwAR1Y7QW474FbnaBX6VbodQJaoVGL0-XJ2iQFmmn_FYQ993NraHTD0ePOIzQ
CBC Web : cbc.ca/news/canada/newfoundland-labrador/come-by-chance-refinery-explosion-emergency-teams-gb-cross-1.6573580
#RuralMatters
Vote strategically.
Dr. A. Lafontaine CMA President @AlikaMD : rural savvy
Dr. K. Smart CMA Immediate Past President @KatharineSmart : rural savvy
Dr. B. Bouchard CFPC President @bradybouchard : rural savvy
#RuralMatters
Vote strategically.
Dr. A. Drummond CAEP Public Affairs Co-Chair : rural savvy @alandrummond2
Dr. K. Johnson CAEP Immediate Past President : rural savvy
Dr. A. Kernick CAEP President elect : rural savvy
Mutually respectful #SRPC #CAEP collaboration.
Kudos @JIMcEwen & @john_soles for the initiative in 2016, leading to the repopulation of caep.ca/em-community/rural-and-small-urban-section/ with dual membership.
Tangential rant. Elect more WOMEN to key leadership : they're simply better at it, period. Men (in general) are testosterone fueled pricks with egos that get in the way.
Christia Freeland
Angela Merkel
Jacinda Ardern
Sanna Marin
I rest my case.
It doesn't help if the man is certifiably psychotic and lives in an alternate universe devoid of truth or facts.
Rural recruitment and retention of competent generalists with clinical courage matters. @MUNMed et al
The number one reason exiting graduates fear rural solo shifted ER shifts : RSI / intubation. Sorry, a 3 day rotation in Anes during CC3 is atrocious.
No feedback on WHY it worked or didn't. Biomechanics matter. No rescue training using bougies / King LTDs / Airtraqs.
Shameless plug for AIME (no conflicts) : aimeairway.ca/
And yes, have a bit of FUN self-intubating yourself awake, you never know what you may be required to do rural !
Awake Self-Intubation with edits / practice at end youtu.be/S7P5WW5n8VA via @YouTube
The breadth of required rural generalist procedural training competencies is well represented on this excellent resource @BCEmergMedNtwrk
bcemergencynetwork.ca/resource_type/procedural-video/