Last month Tuckamore Monthly took us to
Africa, where Adam and his research team worked with Malawi colleagues in order
to deliver simulation-augmented health professions education. Some of the challenges
they encountered resemble those of our distributed province: like educators in
Malawi, those in rural and remote areas of NL need proper training to deliver
good simulation teaching. However, they may be lone clinical providers serving
a large population, and are therefore hard pressed to leave their communities
and attend a course.
This month our blog goes to sea. I recently worked as a ship’s doctor in remote parts of Atlantic Canada, and along the way I thought about rural and remote health professional education. Here’s the story.
Last summer aboard MV Akademik Ioffe, I accompanied 102 passengers to beautiful remote places like Sable Island (Nova Scotia) and François (Newfoundland). I was the Expedition Physician, but I was also an observer. Places like Sable Island and François pose questions: how do we deliver health care in remote areas, and how do we teach students to practice in them?
In academic centres, we teach our students
about sophisticated technology to diagnose and treat their patients. In fact we
often use sophisticated technology like computerized human mannequins, to teach
them how to use sophisticated technology! However neither option is applicable
in rural and remote areas. If somebody is injured in François where there is no
road, for instance, caring for them is a far different proposition than in an
academic emergency centre. Clinicians in remote areas must be prepared to make critical
decisions and perform critical procedures without access to technology. They must
rely solely upon their clinical judgment. How can we best teach this?
And what about practitioners in even more
isolated locations like ships and oil installations, or those who work in
the air, transporting ill patients? They too must rely on clinical judgment and
be prepared to perform critical procedures. But they also have to consider the
logistics of evacuation, particularly in harsh environments where distance, sea
conditions and weather are serious considerations. There may be times when
these factors preclude definitive care for hours or days.
Since it is impractical and even
potentially unsafe for learners to experience these extreme environments
firsthand, we can use simulation as a vehicle to provide this kind of training.
Low-tech simulation may be especially useful for teaching low-frequency
high-stakes events (like a surgical airway) that one may encounter only
occasionally in remote places. Perhaps we should transport this teaching to
learners in remote areas since they cannot easily travel to academic centres
for courses. It is logical to use locally available material for making simple
task trainers that can be left in place, and it seems ideal to use mobile
simulation or tele-simulation to augment face-to-face instruction.
Ships’ logs reveal a variety of illnesses
and injuries at sea. On this voyage, I had some suturing to do, and I evacuated
one passenger with a potentially serious condition. A fit but elderly
gentleman, he had flown many hours to join the expedition. While aboard the
ship, he suddenly became breathless. When consulting in his cabin, I noticed he
could not comfortably walk from his bed to his bathroom. It was too risky for
him to continue sailing with us. The remote regions we would visit have few
emergency resources, so I transported him to a nearby emergency department when
I had the chance. In this case, context was everything. I had to consider the likelihood of a
pulmonary embolus or a heart attack and weigh those odds against travelling
further and further from definitive care. To complicate matters, I had to
consult with the ship’s Captain to check the weather and our planned itinerary.
Finally, since the rest of us continued our voyage, I had to communicate
between the patient, his family, the shipping operators, and the emergency
physician who treated him ashore, with a cell service that was available only
when we approached land.
I had no available diagnostic tests to help
me with this case, but I did have years of rural and remote clinical experience
on my side, as well as current training in performing critical procedures. (Well,
a bit. It’s been a long time since I
did a surgical airway, even though I usually work in a tertiary care emergency
department.) The situation reminded me that we must teach our students to make
purely clinical decisions, and we must also ensure that both learners and
practitioners can confidently and competently perform occasional critical
procedures.
Simulation is one way to go about it, and
it poses many research questions: what kinds of teaching do rural and remote
practitioners feel they need? Is tele-simulation feasible in NL? How often do
we need to provide critical skills re-training? How can we teach students to
rely on clinical judgment in a society that so values technology?
I am back on shore now. But most days at
work in the academic emergency department, I take calls from rural and remote
physicians with fewer resources than mine. I hope I can serve them usefully,
and I look forward to hearing their thoughts on education!
Hope to see you at our upcoming Rural and
Remote Emergency Medicine Conference! http://www.med.mun.ca/Emergency-Medicine/Upcoming-Courses-and-Updates.aspx
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