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.

Assessment

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.

Thoughts

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

 

Comments

  1. Great insight into the course, thanks for your review. The EID syringes are going? The last I had read in the literature (a few years ago now) they were said to have a high sensitivity in confirming tracheal intubation in adult cardiac arrest patients (ie without cardiac output). Obviously in patients with cardiac output they would be redundant, with ETCO2 being a much better indicator of correct tube placement. Can you enlighten me on the recent evidence their benefit (or lack of)?

    • Cant say I know heaps about them not knowing they existed before going on the course. found a few papers and this discussion,

      http://www.cjem-online.ca/v4/n1/p41
      Pelucio M, Halligan L, Dhindsa H. Out-of-hospital experience with the syringe esophageal detector device. Acad Emerg Med 1997;4:563-8.

      Seems using them in an arrest situation is a reasonable idea. I hope some wiser #FOAMed heads can help with this one?

      • Fair enough! I thought that may have been something the instructors discussed on the course, especially if they mentioned that they were going from the kits.

        We’ll wait to see what others have to say :-)

  2. We carry these in our prehospital packs…but not in our hospital trolleys! Check out ANZCA PS56 for guidelines on this and other kit.

    Re-affirms my belief in a similar course and scheme for prehospital responses in Oz….rural docs are already being called, just need to formalise callout criteria, equipment, training and payment….

    Perhaps take elements of RFDS STAR and best bits of REST-APLS-EMST etc and make a rural docs masterclass encompassing critc care in ED and the roadside…

    Spoke to someone on recent REST course – found a bit too basic for needs of experienced rural doc

    • To be fair PRIME at least portions are pretty straight forwards, If you do rural hospital and ED a more focused course (not sure it exists) as you are suggesting seems more like whats needed. #FOAMed has started on airway course, bring components together for #PHARM course?

      • Absolutely. The traiing will come…and after chatting with @BroomeDocs at #RMA2012 yesterday, I am wondering if just rural docs embracing FOAMed is the quickest and cleanest way forward…

        Still need to explore the reasons why reluctance to have PRIME or BASICS system here in rural Australia….data suggests many rural docs are being called to prehospital events – but without the necessary skills (NB being good in OT or ED does not equate to doing eg prehospital RSI)

        Politics has been mooted as a reqson against, with powerful paramedic and prehospital lobbies arguing against the enthusiastic amateur – raises the issue then pf why same servoces DO call rural docs when distamces are large or cannot task an asset to the scene in timely manner….

  3. Stay tuned – should be some underground guerilla broadcasting from the “GET FOAMed” mob shortly

    (GET FOAMed = generalist emergency training free open access meducation)

    Online hangouts with rural docs and specialists, covering topics to help us all bring ‘quality care, out there’ to rural patients

    I am so excited…

    • Ben Hoffman says:

      Cheers for that, great reading!

      Are PRIME Doctors expected to perform all aspects of the Intensive Care Paramedic (ALS) scope of practice for example you mentioned pacing but what about things like RSI,, ketamine, vecurnoium?

      Any change of Part III; would be good to have a .

      Cheers
      Ben

      • Short answer is no.
        PRIME doctors and nurses are expected to provide further medical support to the local ambulance officers and paramedics. In many situations there will only be local vollys manning the truck and nobody who cannulates let alone intubates.
        But PRIMEs are quite varied, some are working in ED/CC settings and may be doing RSI often enough they feel confident doing so. But all should be comfortable doing airway adjuncts/LMAs ect.
        Many are the enthauastic semi-amateurs Tim often mentions but they have a system of support in place and can call for assistance if unsure provides some backup, debrief ect.
        PRIME is far from a “perfect” trauma system but it is an improvement on what there was before. In short they didnt let perfect get in the way of good.

        • Ben Hoffman says:

          Cheers for that. I think PRIME in theory works quite well, i.e. getting support to the rural Ambulance Officers who are overwhelmingly likely to be 1) volunteer (so less than ideal clinical exposure) and 2) at Emergency Medical Technician (BLS) level so unable to do things, as you say, like IV cannulation, fluid replacement, parenteral adrenaline for anaphylaxis, midazolam for seizures, ceftriaxone for sepsis/meningococial septicaemia etc and it makes sense to use an already available resource (the local GP/Nurse Practitioner) in these situations for things like this and getting somebody with higher skills to patients who are critically unwell. The GP/Nurse may indeed be comfortable doing something else like cleaning and suturing or gluing a wound up thus preventing a trip to hospital which I think is entirely appropriate.

          My only concern would be that rural practitioners often have a very high workload and being on-call for the Ambulance Service only adds to that workload, especially if you have to shut up the clinic for an hour, or two or more, to attend a job which turns out to be not so urgent or in need of your additional value; I understand the improvements made to triage in Ambulance Communications have gone a way to relieving this problem.

          Thanks again!
          Ben

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