Archives for October 2012

PRIMEtime Keeweedoc: Part Two The Course

Before I get onto the PRIME  course a  few questions.

How would you prepare people for prehospital work? What skills would you need to respond to well anything at all and do the “Golden hour” things? How would you teach them?

Enough questions onto the course itself.

PRIME is a five day course designed to prepare both rural nurses and doctors for prehospital work. It accepts the people on the course have previous experience and teaching is based around preparation, with lots of skill stations and scenarios to teach from.

The course is run by St Johns New Zealand and tutors are Intensive care paramedics/Advanced paramedics. These guys are great, heaps of stories, an attention span that matches mine and see the lighter side of medicine. I really enjoyed chatting with them about cases. Asking what if? is a favourite trick. Take what seems simple in ED and twist it.  Things are much more complicated on the side of the road,  in a paddock or upside down.

Day 1  Airway day (bit of IV/IO Access.)

Introductions and straight into it. The course has a deemphasised intubation as the primary skill and pushes airway management. The vast majority of the PRIMEs are “occasional” or almost never intubators.  Great of talk about LMA vs ETT and as I mentioned earlier emphasis on ventilation not intubation. Then  run through the common airway compromise situations. Discussions about airway adjuncts. Into practical skills. Using few models including some difficult airway models.  

 Local butcher kindly provided some sheep necks for needle/surgical cric practice. And some chicken legs for IO practice.

Day 2 Arrest/ACLS using Lifepacks. Cardioversion and pacing.

Kicked off with whiteboard discussion around arrest in the community. Some gems “Firefighters are great they do awesome CRP and they come in a team of at least 4. thats 2 mins on 6 mins off.” Lots of scenarios so people get used to the protocols and just recognising the time pressures and being organised. (knowing your way around the PRIME bag)

Then moved onto Tachy/Brady rhythms and cardioversion/pacing. Again short discussion, ECG analysis and then onto using the machines.


Day 3 Medical +

 Day spent on common medical emergencies. Again moving quickly over certain topics we see regularly and taking time on the more rare serious conditions. Big discussion around IV adrenaline when to and not to use. (Ill get onto this in part three promise!)

Got a few people hooked on LITFL (Its the number one gateway #FOAMed drug) after showing them the ECG library.

Day 4 Trauma

Discussion around the “trauma mindset” and triage scenarios.

Their approach to patients is to use a “critical action check” which is very similar to ATLS as you would expect. Then jumping into simulation. practice getting people out of cars with boards ect. Also putting splints on people and discussing practical things like the fact a Thomas femoral splint doesn’t fit in many of the rescue helicopters. They have stopped teaching surgical chest decompression on the course and are pushing needles for tension only. But again if you do it in your own practice the PRIME handbook is all for “Further procedures felt appropriate by the practitioner”


The trauma had an excellent simulation, you arrive at a car crash with trapped passengers. Assessment. when you asked for help eg: fire they were waiting around the corner. Turned up lights an sirens and helped you extricate your patients. Really nothing prepares you better for the reality than spending time around a crash scene. Loud, sometimes difficult patients (had great actress in the car). Makes you realise the need to take control of the scene.

Day 5  Paeds/O&G/ Mental health emergencies

Good discussion around pregnancy issues, we had an O+G trained GP and midwife who took these session. Another common theme on the course was the instructors passing the education to someone in the group who does this regularly. Covered difficult deliveries and flat babies/resus.

Had a fantastic talk about capacity and mental health that even @Eleytherius would have been proud of.


The assessments on the course were usually done in the morning. Scenarios/Sim just really showing that you could do the skills which you had practiced and felt comfortable with the protocols ect. They were happy with people doing slightly off protocol things. Provided you could justify you decision and management. There was supposed to be a written test but the papers were never written so they skipped that.


I felt the course was good. It covers what needs to be covered in a short period of time. Five days seems like ages but it flew past. Having done ATLS and APLS the major difference was the practical approach on PRIME and much less PowerPoint. Obviously with the time pressures some topics are brushed over, esp topics we see regularly or that perhaps don’t need such emphasis. Hand hygiene talk was short…

As a course I would recommend to those who dont do ED work day to day. Many of the things are straightforward to those who do them regularly. For me the biggest difference is getting into the prehospital mindset and “doing it”. Not alot I would change on the course, the protocols are due a work over and few bits of their kit are disappearing see below!

 <— Had no idea what the heck this was?

So that’s PRIME ill discuss some protocols in next few weeks. Happy to answer any questions you have.

 The most important machine in the building


PRIMEtime Keeweedoc: Part One What is PRIME?

PRIME (Primary Response In Medical Emergencies) is New Zealands answer to the problem of how you should respond to accidents and medical emergencies when an ambulance with advanced paramedics is not able to be provided in a timely manner. Its a bit like BASICS in the UK.

History lesson time!

Before the 1990s if there was an MVA, asthmatic attack ect in a rural area the local response was based on goodwill and people knowing who to call ect. This lead to inconsistencies and in 1993 the government felt this needed to be addressed. After a few difficult years PRIME was set up and trialled in 1998 and rolled out NZ wide in 1999. Other than updates on the manual and a few little tweeks the PRIME setup has performed well in NZ. Funding wise medical cover is capitated to the PRIME GPs/Nurses and ACC covers accident/trauma responses.

So where do PRIMEs cover?

“The PRIME scheme utilises the skills of rural GPs and/or rural nurses (RNs) in areas where an ambulance crew (two ambulance officers, where one is a paramedic) is more than 20 minutes away (40 minutes in the South Island). There are currently 266 PRIME service providers in New Zealand (including both rural GPs and RNs). The PRIME network is activated via a pager, in most cases, by the regional communications centre (RCC) following a 111 call, where the nearest paramedic response is more than 20 minutes away” (From paper 2003)


Each star is a Prime site. As you can see they cover the length an breadth of NZ. The south island is particularly PRIME.

 And what do PRIMEs do? (other than sounding like sweet transformers)

PRIMES respond to emergencies in rural New Zealand, they will usually meet the local ambulance crew there. The crew will have BLS skills and may have some additional skills such as cannulation. It is expected that PRIMEs will assume control of the scene and when required/indicated use there more advanced skills. They will then decide on the best site for transfer and/or mode of transfer of their patients. The intention being that the PRIME service will provide a higher standard of care that was previously available.

The reality of day to day work:

If you are a PRIME provider you carry a pager and carry on with your regular practice/clinics ect. but you need to be able to drop everything and go if there is a call out. You get a sweet green flashing light for your car (which no-one recognises) So you call back to say your responding at goto the scene. Triage/treat and usually return to your normal work.

Its not perfect

Now there are a few things that most of the PRIMEs I have spoken find difficult. Often the pages are somewhat cryptic and lacking in information so you may respond to something you do not need to or would be best brought to you at your medical center. You can call the operator about the calls and attempt to get more information and decide if you need to go. St Johns NZ have introduced a new computer triage system which can be a bit hit and miss. Its very frustrating when you arrive and are not needed after driving for half and hour and closing you practice. Also as its a 365 days a year 24 hours a day call and in many cases there is only one PRIME at a site you are permanently on call. This has been improved somewhat but is still an ongoing issue.

Finally people are very positive about the training course which i will get onto in Part 2 next week.


Is the PRIME (Primary Response In Medical Emergencies) scheme acceptable to rural general practitioners in New Zealand?Todd Hore, Gregor Coster and Janne Bills Journal of the New Zealand Medical Association, 02-May-2003, Vol 116 No 1173

A quick ECG from my mummy

Got sent this ECG by my Mum who is a kickass emergency nurse and midwife.

She saw a young man who came in after a syncopal episode.  Thoughts on the ECG?

Update October 17:

So had a few comments and thoughts on twitter and here people are pretty onto it with this one.

My thoughts:looking at the ECG,

Sinus rhythm rate of 60.

V1/V2 and maybe V3 have what i would agree look like Epislon waves. T waves are not inverted.

High voltage ECG but difficult to accertain in a skinny young male.

QTC is 390 but the QRS in V1-V3 is not widened.

So we have a young mane with syncope our concern is hypertrophic/arrthmogenic cardiac disease in this case ARVD (Arrhythmogenic right ventricular dysplasia)

First a bit more on ARVD,

ARVD is a genetic defect that causes fibro/fatty change in the myocardium. It predominantly effects the right ventricle.It has an incidence of  1/1000 with a male predominance, from 1/3 to 1/2 of cases are familial. For those working in Italy apparently it has a much higher incidence possibly as high as 40/1000. It is a major cause of cardiac death/sudden death in children and young adults.

The diagnosis is made Via ECG findings, Family history, ECHO +/- endomycardial biopsy

Diagnosis of ARVD: requires 2 major criteria and one minor.

Major Criteria

Minor Criteria

Touch more about Epsilon waves apparently can be caused by other diseases of the right ventricle, including right ventricular infarction, infiltration disease, and sarcoidosis which might also produce the pathological substrate required for production of epsilon waves.

Outcome of the case:

Patient was referred to the tertiary ED who happily took the patient. They were admitted under cardiology and patient had an ECHO which showed no concerning features! Bloods were all normal. Kept on telemetry and discharged home with follow-up. I am unsure if they are planning on going to Biopsy or not at this stage.