Emergency Medicine in Reykjavik - The Robin Mitchell Fellowship - Part 2

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…

A week in and I'm beginning to find my feet - always a challenge in a new department.  I have continued to work clinical shifts on the shop floor and witness the challenges posed by cold weather (lots of broken ankles!) and difficult geography.  I've also been able to get a better overview of how the Landspitali links in with prehospital services.  My travels last week took me to the country's joint emergency services centre, a shining example of what a coordinated approach to emergencies can bring.

In an otherwise ordinary-looking building close to the centre of Reykjavik sit the headquarters of 112 Emergency Despatch, Police, Fire & Ambulance services, Coastguard, and Civil Defence (who respond to major incidents and natural disasters).  There is no armed military force in Iceland.  112 despatchers receive all incoming calls, and those primarily requiring a Police response are passed over for them to deal with, but all other calls are handled by the 112 despatchers directly.  They can see the location of every land ambulance and fire appliance across Iceland, as well as landscape and man-made features close to roads to assist in locating an incident.  A GPS app allows tracking of smartphones down to a few metres in areas of 3G/4G signal.  Typically the 112 handler will triage the call using similar questions to those used in the UK and US, and despatch suitable assistance directly.  If needed, they can contact and coordinate teams and assets from other services to assist transfer.  Multi-agency working is much easier when your colleagues are just down the hallway and you can get them all together in one room!


For example, in the event of a serious accident in the mountains to the east of Iceland's centre, 3 or 4 agencies might be involved in transferring the casualty to definitive treatment.  Local Search and Rescue teams are typically staffed by highly skilled, experienced volunteers who devote huge amounts of time to training and service in addition to their other jobs.  They may be called upon to stabilise and recover a casualty to the roadside where a land ambulance can meet them.  Depending on location, it is sometimes quickest for a helicopter-based physician to meet the patient on or near the scene.  However, with such a large country to cover flying times to get on team can sometimes be so long that it is quicker to transfer the patient to the nearest airstrip where they can be transferred by a fixed wing aircraft team based in Akureyri.  The close proximity of services in the building means that decision making and planning for team activations can be done promptly and with excellent senior input - no small feat when making such complex retrievals work.

Wednesday brings the weekly equivalent of an M&M meeting, followed by teaching for EM trainees.  Cases were presented by trainees, including quite junior ones, before discussion with medical and nursing staff from the department.  There was plenty of lively debate but a supportive attitude and strong focus on lessons to learn for improvement - perhaps having your SHOs present a case makes it easier for everyone to speak up and say what they think, or perhaps admit they wouldn't have known what to do either?  A couple of hours of high-quality teaching - this week on cardiology in the ED - followed, with lots for everyone, including me, to learn.

The end of the week brought yet more interesting learning in the form of a trauma simulation exercise.  Organised and run by the ED team, the exercise was particularly notable for its scope, with involvement of ambulance, radiology, anaesthetic and surgical staff.  Our road traffic collision "casualty" arrived by ambulance covered in blood and realistically chilly from being outside on a stretcher in a Reykjavik winter.  With her arrival prompting activation of the trauma team (push the big green button!) this was a brilliant opportunity to test out hospital trauma systems; practice using relevant equipment; as well as simulate the clinical presentation of major trauma.  I think most of us have found ourselves half way to CT wishing we had remembered to bring a vital bit of kit - much better to find out in simulation and put it right then!

The ED here has weekly in-department simulation, with a monthly exercise involving other specialties.  It's a fantastic opportunity to build confidence, improve systems, and foster high quality care for some of our most challenging patients.  There are, of course, big obstacles.  Taking staff off the shop floor for 60-90 minutes at a time can make it impossible to keep the department running safely, but I was impressed by how many staff of all disciplines had come in on their time off to participate in the exercise - another reminder of how lucky we are in Emergency Medicine to be part of some of the most motivated and passionate teams in healthcare.

In the background I've been working away on some paper-based bits and pieces, hoping to help with the ongoing educational and quality improvement work here.  Not much time putting my feet up, but it's easier to stay motivated and enthusiastic when your walk home from a backshift lets you watch the aurora sparkling away above snowy mountains...