Dealing with risk: island and remote practice

In a recent BMJ article (August 14) an A&E specialist worries about deskilling and loss of confidence in carrying out procedures that used to be routine, for instance in advanced airway management because anaesthetists are increasingly called in.

It is accepted in The British Resuscitation Guidelines that non-specialists should not waste vital time attempting endotracheal intubation in cardiac arrest, due to lack of practice, relying instead on simpler ways of protecting the airway.

This is a great relief to GPs such as me who work in community hospitals and may only be involved in CPR once or twice a year. But there is a wider question of how to maintain competence in the variety of infrequent problems and procedures encountered in isolated parts of the country.

Until four years ago I was a GP on a Scottish island and with five colleagues looked after a population of 7,000. As well as normal GP work we had 12 beds in the community hospital and an A&E department which had to accept all blue-light emergencies. There was no opting out of on-call and we provided 24-hour cover, often on-call alone. The nearest district general hospital was over an hour away, including 25 minutes on a ferry which stops at night and then we had to rely on helicopter transfers. It was a very enjoyable if tiring role as a GP/hospital practitioner. I was able to do practical things such as suturing, looking at X-rays and putting on plasters, but I was also occasionally faced with complex emergencies.

Things that a main A&E department might deal with on a weekly basis we saw maybe once in two or three years. For instance, from memory, during the 13 years I reduced three or four dislocated shoulders and two fracture dislocations of the ankle, inserted three or four suprapubic catheters, carried out a ventouse delivery for delay in the second stage of labour with foetal distress, and put in an umbilical catheter in a baby born unexpectedly at 33 weeks to give glucose whilst waiting some hours for the neonatal retrieval team to come. More frequently we saw seriously ill patients and a few seriously injured.

Did I have the competence to do all this? I felt I had, even without any supervised training in much of it, and apart from the shoulders they all had to be dealt with promptly and I was there.

Courses are a good way of developing and maintaining skills. The ATLS (advanced trauma and life support) course is one of the best for this type of work, and I attended two courses eight years apart. ALS (advanced life support) is also useful and BASICS (British association for immediate care) run many good courses in urgent care for isolated practitioners, including maternity emergencies. These courses are practical, using manikins whenever possible, and are extremely relevant and well done.

We allowed ourselves one week postgraduate training a year so it was difficult to fit in all that was needed and impossible to keep refreshed in every procedure that might be faced. In the ideal world we could arrange drills in the hospital to practice emergencies, for instance for CPR, postpartum haemorrhage, shoulder dystocia, etc. We did this for CPR but it was difficult to schedule for all practitioners, including the ENPs (emergency nurse practitioners) as well as midwives.

The introduction of ERMS (Emergency Medical Retrieval Service) has been a step-change for us. Not only does it provide dedicated telephone access to an A&E or intensive care consultant for advice, ERMS personnel are also equipped to come out to our hospitals, usually by helicopter. They prepare patients properly for transfer to mainland IT units, including being able to anaesthetize to give full airway control. On top of this they provide feedback on our individual cases and run case analysis sessions, as well as practical training days.

In the end you have to judge your own competence against the need of the patient. By attending appropriate courses it is possible to maintain skill and more importantly develop confidence. Working in a small place, your actions are discussed and judged – and you still have to shop in the Co-op! If you can’t cope with that then isolated practice is unlikely to suit you.