Emergency Medicine in Reykjavik - The Robin Mitchell Fellowship

Dr Steph Mackie

I'm a CT3 Emergency Medicine trainee in the west of Scotland, and along with Zoe Smeed was incredibly lucky to have been awarded the 2014 Robin Mitchell Fellowship.  I have come to Reykjavik in Iceland for four weeks where I'm hoping to learn lessons from how they provide high-quality care for critically ill and injured patients who are remote from large urban hospitals.  Of Iceland's population of around 300,000, almost one third live far from the major hospitals in Reykjavik and Akureyri, and the country's mountainous terrain, wildly variable weather conditions, and relatively large size can make it enormously challenging to deliver emergency care quickly and effectively to these people.  Coming from another small mountainous country in the North Atlantic, I thought there would be plenty to learn here…

So far I have not been disappointed!  I arrived last week to a city still in the grip of winter.  Although much of the snow had disappeared from Reykjavik, a snow-covered Mount Esjan was still visible across the bay from the city centre, and the drive from the airport was through a starkly beautiful, almost lunar, landscape.

After a tour of the department we sat down to agree my rota and decided I might as well get stuck in straight away with a weekend of nights.  That left me with just enough time to make it to the Icelandic Medical Association's National Conference "Laeknadagar".  Although following the talks in my very basic Icelandic was hard work (I think some jokes about puffins went over my head!), it was fascinating to see so many clinicians from different specialties coming together for high-quality education.  The day that I attended focused on new challenges from infectious diseases in the morning, and use of social media in the afternoon.  As such it was relevant to a wide spread of doctors and the variety of backgrounds of audience members seemed to trigger interesting discussion and debate.

There is a strong interest in IT and electronic health record-keeping here, so my weekend started with getting to grips with that.  There is real potential for making patient's journey through the ED more efficient.  All requests for investigations are electronic, and clinical notes go immediately to the patient's GP. Medicines prescribed in the ED can be collected by the patient from any pharmacy, without need for a paper prescription, and as many pharmacies here are open from 8 until midnight there is seldom any need to discharge patients with more than the next dose of any medication.  Much of the software used here has been developed or adapted in-house and there is great commitment to continually improving it to make it fit for purpose - shop-floor clinicians' feedback is heeded and very much guides development.

And how did I fare with central Reykjavik's weekend nightshifts?  Well, the case mix was fairly similar to many Scottish city centre EDs: a mixture of elderly people with falls and/or multiple comorbidities; complications of long-term conditions; acute illness; and trauma, a significant minority related to alcohol. There was a noticeably low rate of patients presenting from road traffic collisions - in 2014 only 4 deaths occurred on Iceland's roads - and those presenting seemed anecdotally to have much less severe injuries than often seen in the UK.

One noticeable difference at the interface between prehospital services and the ED was in communication.  The ED charge nurse carries an ambulance radio, and paramedics here radio ahead for every patient they will bring.  This allows the charge nurse to plan ahead, often some time in advance, and where needed to clear cubicles or call in extra staff.

This was used to good effect at the end of 2014 when ambulance crews radioed ahead that they were en route with a man who had been stabbed in the chest.  Cardiothoracics is based at another hospital site around 2km away, but with the advance notice given by paramedics and the coordination of ED staff, the consultant cardiothoracic surgeon arrived at the same time as the (previously conscious) patient deteriorated suddenly with cardiac tamponade secondary to ventricular injury.  The patient's prompt ED thoracotomy and subsequent discharge from hospital were featured on the Icelandic news and to celebrate that good outcome and much hard work from all the ED staff over Christmas and New Year, the Clinical Director brought in a special "thoracotomy cake" complete with icing retractors and open chest!  Definitely a great way to motivate and cheer staff, though perhaps only feasible if your brother is a pro baker.

After three nights on the shop floor I feel that I'm beginning to get a good overall view of how emergency care is delivered here.  I'm looking forward to spending more of this week doing the same, as well as hopefully seeing more about the interface between prehospital systems and the ED.  Already in the first week I've gained a huge amount in terms of inspiration and insight into different ways of caring for our patients, and I'm very grateful to the Medic 1 Charitable Trust, the departments I am leaving back home for four weeks, and for the fantastic supervision and support I've had from all of my colleagues here at Landspitali.  I've lots more to learn here and will keep you posted.

Thanks for taking the time to read,