It is certainly true that Australia has excellent State-based ambulance services, supported by transport and retrieval services such as the RFDS and State-based services.
However Australia is a vast continent. With increasing rurality, there is often a significant delay in transport to definitive care. Moreover emergency responders in rural areas may be limited in number and in scope of practice (for example, in South Australia 2⁄3 of the Ambulance service are unpaid volunteers).
Sadly critical illness does not respect geography. As a result rural trauma victims may face significant delay in receiving effective pain relief or advanced medical interventions, whereas the same patient in a metropolitan area would receive prompt care.
Rural doctors have skills not just in primary care but also on call responsibilities for emergency medicine and in-patient hospital care. Some may have advanced skills in anaesthesia, obstetric or surgery. These Rural Generalists are trained to deliver emergency care via their local hospital but may also be called upon to respond in the prehospital environment. Such responses tend to be ad hoc, lacking consistency in tasking criteria, equipment, training and over-riding clinical governance.
A notable exception is South Australia, which has a network of established Rural Emergency responder Network (RERN) of clinicians operating under the governance of SA Health and SA Ambulance). We think that such a system could and should be applied across Australia, utilising the skillset of Rural Generalists to ‘value add’ in specified circumstances on scene.
But why would rural GPs be involved in prehospital care?
It is certainly true that prehospital care is no place for ‘enthusiastic amateurs’. The prehospital environment is challenging and requires specific skills and training, with overarching clinical governance. This expertise is appropriate concentrated in ambulance and retrieval services.
Despite the failure to include rural clinicians in State-based trauma systems, perversely a 2012 survey showed that 58% of rural GP-anaesthetists had been called to a pre-hospital incident in their community in the previous 12 months! These clinicians had been tasked by the ambulance or retrieval service in circumstances where local resources were either insufficient or expert help was delayed.
As a consequence, the rural clinicians were involved in prehospital care, despite no agreed tasking criteria, no equipment and no training.
We can do better than this.
Rural clinicians have appropriate skills and their expertise intersects with prehospital medicine. Moreover rural clinicians have a leadership role in their communities and involvement is often expected by rural communities.
What training is needed?
Appropriate task-training, reinforced by simulation, is needed to contextualise existing skills of rural clinicians to the challenging prehospital environment. Sign off on a limited suite of meaningful interventions as a form of competency sign-off is expected before taking ownership of a Sandpiper Bag.
Who is in charge of this?
With the exception of the South Australian RERN system, there has been little commitment to including rural clinicians in prehospital care from established providers.
This is disappointing given the known position statements and views of the Australian Medical Association, the Royal Australian College of General Practitioners, the Australian College of Rural and Remote Medicine and the Rural Doctors Association of Australia.
Sandpiper Australia is a not-for-profit entity that seeks to raise funds for purchase of Sandpiper Bags for rural clinicians. We envisage training ca be delivered utilising existing curriculum and competencies for advanced skills via ACRRM & RACGP, as well as cross-traniing with local ambulance protocols.
So is this compulsory for rural doctors?
Most definitely not! The work of the rural clinician intersects with multiple specialist spheres – primary care, paediatrics, general medicine, emergency care, palliative care, obstetrics, mental heath anaesthesia and so on. Involvement in rural prehospital care is just a part of this work. But when it is needed, it is needed!
We envisage interested clinicians volunteering to undergo training and take possession of a Sandpiper Bag, forming a ready-made network of clinicians able to ‘value add’ to the prehospital scene in defined circumstances.