A large share of emergency medicine training positions are in regional and rural departments, and the panels there ask a scenario that metropolitan candidates often underprepare: the patient who needs a tertiary centre, and the retrieval team is two hours away. This guide is about answering it, and the related regional questions, in a way that shows you understand regional emergency medicine rather than fearing it.
The scenarios
- The patient with ST elevation two or three hours from a cath lab.
- The severe head injury in a hospital without neurosurgery.
- The snake bite in a department without on site antivenom expertise.
- The child with sepsis who needs a paediatric intensive care bed.
- The obstetric haemorrhage in a town without an obstetric unit.
- The trauma patient who is stable for now but will not stay that way.
Each is a version of the same question: what do you do during the wait?
A structure that scores
- Stabilise and treat. Everything that can be done locally, done now: thrombolysis for the infarct when primary intervention is out of reach, antivenom with the state poisons line on the phone, the first line management of raised intracranial pressure, the sepsis bundle, the obstetric haemorrhage protocol with the blood bank involved early.
- Call early. The retrieval service, the receiving specialist and the state's clinical advisory lines. Say the names your state uses. The call should go out as soon as the need is recognised, not when the patient is ready, because the delay is the retrieval team's travel time.
- Use telehealth. Most states have emergency and critical care telehealth with a specialist on screen. Say how you would use it to guide treatment during the wait.
- Prepare for transfer. The patient packaged, the airway decision made before the team arrives, the documentation and imaging ready to travel, the family informed and a decision about who goes with the patient.
- Keep the department running. The retrieval patient absorbs staff; say how you would keep the rest of the department safe.
- Plan for deterioration. What you would do if the patient arrested, if the airway became threatened, or if the retrieval team were further delayed.
What the panel is listening for
FACEMs in regional departments want to know that you will treat rather than wait, that you will call early and use the advisory services, that you can make the airway decision yourself, and that you know the limits of what the department can do. They also want to hear that you see regional practice as a place where you will learn a great deal, because it is.
The other regional questions
- What attracts you to a regional department, and how long would you stay?
- How do you keep your skills current where case volume is lower?
- How would you work with the GPs and the rural generalists who refer to the department?
- What are the health challenges facing the region's rural and Aboriginal communities, and what is the department's role?
Have honest answers. A candidate who presents the regional post as a stepping stone to the city, or who cannot name a health challenge in the region, will not be chosen over one who has thought about staying.
Practising
Talk each scenario through aloud with the retrieval call included, and have someone play the receiving specialist asking what you have done so far. Then practise the deterioration follow ups, because the panel will ask what you would do if the patient crashed at the ninety minute mark.