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What is a Rural Critical Care Course?

The standard "merit badge" courses such as ATLS, ACLS, ALSO, ALARM, PALS, and ANLS do not address rural issues adequately, 0rticularly the fact that rural docs often have to deal with the entire treatment of the ill patient, not just the initial assessment and stabilization. Furthermore, transport issues are not well covered in standard "LS" courses, and, as we know, transport is sometimes impossible either due to weather problems or because budgets at tertiary care ICUs are so reduced that admissions from outside are impossible.Another problem is that many hospitals and healthauthorities are beginning to require proof of certification in all sorts of "LS" courses, in the mistaken belief that this will improve quality of care. Doctors working in small towns in Canada usually work in small groups (often less than 5), making maintenance of competence by "LS" certification and re-certification in all "LS" courses for the entire small group of doctors difficult, expensive and probably futile. One solution to this maintenance of competence problem for rural doctors is the development of a multidisciplinary course on Rural Critical Care (RCC).
The first RCC course was given in Banff, in April of 1996. It had a four hour format with plenary lectures and hands on workstations. It was overbooked, busy, crowded (many people snuck in) and a CME success by the evaluations. In 1997 it was expanded to 8 hours of hands-on workshops with no plenary sessions. We continue to stick to the principle that GPs learn better from their peers, providing the lecturing GPs give good talks with interesting deliveries and subject material. The fact that none of the faculty are specialists with full knowledge of all the intricacies of their subjects is generally seen as a bonus, and certainly reflects true "field" conditions in rural Canada.
It is impossible to include all of critical care in a one day course. It is also difficult and potentially frustrating to bring out some kind of realistic hybrid "LS" course with a rural flavour. This rural critical care course takes the view that there are several obstacles to rural doctors even beginning to learn how to care for severely ill patients. The first obstacle is to know the procedures and we hope that by becoming familiar with certain ICU procedures, doctors will find it easier to know how, when and when not to use them. As rural doctors we can never have enough instruction in radiology and ECG. Pediatric crises are particularly stressful and transport issues always loom large.
By addressing in depth these subjects with long, 2-4 hour workstations staffed when possible by rural doctors who have taken a special interest in the material, we hope to give practical learning that will serve as a realistic base for further instructions, depending on the needs of the population one is serving. Since nursing care is such an important part of critical care capabilities, we have included some of our hospital protocols for a variety of procedures. Many hospitals trying to "gear up" their intensive care capabilities find that the nursing staff initially may be reluctant to take on new responsibilities. However, any reluctance quickly turns into pride and confidence once the techniques are learned. All that is needed is for an initial nucleus of four or five nurses to take a variety of ICU courses.
Rural critical care is an evolving concept, and with apologies to rural doctors (who, after all, have been caring for severely and acutely ill patients for thousands of years) it is one that needs development. This manual is a first attempt at providing doctors with material that will assist them in this task. Any suggestions and comments are welcome.

Keith MacLellan, MD
RCC Course Organizer
Society of Rural Physicians of Canada

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