Remote Site Healthcare – Just how important is your on-site resource?
By Peter Brink
With the oil & gas and commodity prices low, companies are forced to operate leaner and reduce both capital and operational costs. All aspects of operations are scrutinized and cost vs. benefit interrogated. This does not come without certain risks, some of which can be to on-site healthcare in a more pressurized environment.
From a workforce health perspective, companies may be forced to look for more cost effective, logistically easier solutions to satisfy their duty of care for employees and workers. This includes making use of local healthcare faculties and medical professionals, becoming more reliant on evacuation plans and having access to evacuation or medical assistance on a “call when needed” basis.
The potential risks with these approaches are that:
- a) not all healthcare professionals are created equally,
- b) where time is a critical factor, “call when needed” is sometimes too late and,
- c) an evacuation or emergency plan is nothing more than a list of things to do and numbers to call – it does not treat a patient.
Experience has shown that some decision makers are not aware of the limitations or differences between training and experience of various healthcare professionals. A lack of understanding of these two factors can lull clients into a false sense of security – feeling comfortable in the belief that having any level of healthcare professional on a remote site or a medical facility close by is adequate.
When we say that not all healthcare professionals are created equally, we think of the horses for courses concept. For example, a doctor (national or “western trained” general practitioner) may be perceived to be best suited to a remote site, however, general practitioners do not spend as much time on actual emergency medicine and do not have the focused training and experience that, say, a Paramedic would have. Generally speaking, a doctor may spend 5 or 6 years studying general medicine, but a paramedic would spend 3 or 4 years studying emergency medical care and rescue, almost exclusively. (This obviously excludes doctors who have specialized in or have a keen interest in emergency medicine)
When we look deeper into the healthcare training capabilities within Africa, the unfortunate truth is that there is no formalized Advanced Life Support (ALS) paramedic training in much of Africa outside of South Africa – with the possible exception of a developing EMT (Emergency Medical Technician) training program and some short courses in cardiac care in Kenya.
The title “Paramedic” refers to ALS providers, all other levels are Basic or Intermediate Providers – not Paramedics. The term EMT refers to a basic life support provider, and the term Paramedic refers to Advanced Life Support. Nevertheless, many EMT-Basic and EMT-Intermediate consider themselves to be Paramedics.
With the greatest respect to our colleagues, national healthcare practitioners – doctors, clinical officers, nurses and “Paramedics” are generally not specifically trained, experienced or equipped to diagnose and treat significant medical and trauma emergencies. Its not their fault, or for us to question their willingness or belief that they are trained. It is however, a reality. Some do travel abroad for specialized training, but many have neither the funds or ability to do so.
A short course in Advanced Cardiac life Support or Advanced Trauma Life Support may provide insight into emergency care but without an existing experience base or knowledge of the equipment, these courses are largely ineffective.
Sometimes decision makers don’t know the difference, a doctor is a doctor and a paramedic is a paramedic.
We place emphasis on the word “experience”. This is critical because on a remote site, thankfully medical emergencies or significant injuries are infrequent. Despite the infrequency of these events, the implications thereof are dramatic to both the patient, the operation, insurers and funders. However, when one does happen, the healthcare practitioner should be able to rely on solid training and experience, having performed enough advanced life support procedures for it to become second nature.
Technological advancements in the oil & gas, mining and exploration environments have allowed organizations to drill faster, extract better and refine more cost effectively.
The same holds true for general and emergency medicine; where technology and up to date, evidence based medicine can improve outcomes, save lives and reduce long term disability as a result of a medical emergency or injury. For example:
- A simple medication such as Aspirin could have a significant effect on the long term outcome of a heart attack,
- High flow, high concentrations of oxygen can be detrimental in certain circumstances,
- Some of the medications traditionally used for a cardiac arrest have no benefit, waste time or can even be detrimental to a successful outcome,
- Knowing when to administer a certain medication is as important and life-saving as the medication itself,
- Spine boards / backboards, neck braces and extrication devices have been shown to do more harm than good and are only used in specific circumstances.
Sending a patient off-site for primary healthcare diagnosis and treatment can be appropriate, provided that the facility is suitably equipped, staffed and resourced. This is especially relevant in a medical emergency.
When deciding on the most appropriate healthcare resource for a remote site, key points to bear in mind are:
- Risk vs. Cost vs. Benefit,
- Medical qualifications and experience levels of the healthcare practitioner,
- Availability of, training and experience of the selected healthcare practitioner on emergency equipment,
- Availability of local healthcare resources, clinics, hospitals and emergency services,
- The time it would take to activate an emergency plan, air ambulance or drive to a medical facility,
- Capability of a local resource, clinic or hospital which, for example, may have an operating theater, however, the presence and availability of a surgeon and anesthetist should be confirmed.
The following case studies are not about passing judgment on any healthcare professional or painting them as untrained, unwilling or incapable. They are to illustrate the concept of appropriateness of deployment of a resource.
Case Study 1
A local doctor was retained for on site medical care. The doctor is a general medical practitioner with a solid approach to general medicine, primary healthcare, local patient interaction and cultural awareness.
He was called to attend to a contractor experiencing chest pain with an irregular heart rhythm.
Outcome: Unfortunately, without specific training in cardiac emergencies, he was unable to provide Advanced Cardiac Life Support. Sadly, the patient demised on site. The Insurance company performed a repatriation of mortal remains.
Case Study 2
A client elected not to have medical personnel on the site, opting for an emergency plan with air ambulance evacuation available if required.
An expatriate patient experienced a life threatening medical emergency and a call was placed for air evacuation.
Outcome: Patient demised before an air ambulance could be activated.
Case Study 3
Two contractors on the same site each retained their own medical provider. contractor A engaged a western trained paramedic and contractor B retained a local healthcare professional. The local healthcare professional has good primary health diagnostic skills, an excellent understanding of Malaria, endemic diseases and a hard worker. He is able to translate, guide on cultural aspects and engage with the local workforce.
There was a vehicle rollover incident at night involving contractor B’s personnel. One patient was dead on the scene and two had multiple fractures of the lower limbs.
- Contractor B’s healthcare professional did not have formal immobilization devices or specific training in extrication of patients from a vehicle. Pain management was ineffective for long bone fractures.
- Contractor B’s healthcare professional was unable to conduct a focused assessment of the patient to identify possible head, chest or abdominal injuries.
Outcome: No additional fatalities, the national employees were taken to the local clinic, a few hours by road.
Case Study 4*
“Mismanagement of injuries may cause injury costs to skyrocket”
A rig worker employed by a large drilling company and working for a major oil company was poked through the glove by a broken wire in a steel cable that had grease, mud and other contaminants on its surface. This “wicker stick” led to a staph infection.
Delayed examination and treatment: As is often the case, the employee did not stop working, clean the wound or hands and did not report the injury until his third day off-duty and away from the rig. He then went to the emergency room with severe pain and swelling, thinking he had broken a finger.
On examination, a puncture wound was discovered under his wedding band on his left ring finger. The ring was removed, and the wound was cleaned. An infection was diagnosed, and the patient was placed on IV antibiotics. Despite the IV medical treatment, the employee experienced an increase in pain and swelling in the finger and hand in the next few days.
Eight days after the injury, the hand surgeon offered relief by surgically operating on the infected hand by opening, draining and further cleansing the wound. The surgical incision ran the length of the finger, through the palm of the hand and down to the wrist. The incision remained open and irrigated for three days. The employee’s hand healed with some stiffness. After 18 days, the employee was released to restricted duty for six weeks.
This case could have cost much less than it did for the drilling contractor, their insurance provider and the employee had it been reported and treated in a more timely manner. The direct cost to the drilling contractor was about $80,000. The indirect cost is estimated at an additional $400,000.
It should be noted that the LTI had the potential to also result in the loss of the remainder of the rig contract, valued at about $16 million in revenues.
Effective case management is critical to preventing workplace injuries from requiring hospitalization, reaching the LTI classification and containing medical costs. The utilization of safety/medics in remote operating areas is a proven benefit in ensuring timely treatment, mitigating injury severity and containing medical costs. Simply put, “An ounce of prevention is worth a pound of cure,” or “Pay now or pay more later.”
* Quoted from Drillingcontractor.org: “Numbers show: Good safety is good business”
Dry Kurt Papenfus, Medical Director for Safety Management Systems
Peter Brink is a business unit manager for Medical Support Solutions and an ALS Paramedic with 20 years experience, five of them travelling into Africa. peterb@medsupportsolutions.com
References:
- Kalisya et al; The state of emergency care in Democratic Republic of Congo, African Journal of Emergency Medicine, 2015
- WHO publication on road traffic deaths in the Democratic Republic Of Congo
- Aloyce R, Leshabari S, Brysiewicz P. Assessment of knowledge and skills of triage amongst nurses working in the emergency centres in Dar es Salaam, Tanzania. African Journal of Emergency Medicine. 2012;4(1):14-18
- House DR, Nyabera SL, Yusi K, Rusyniak DE. Descriptive study of an emergency centre in Western Kenya: Challenges and opportunities. African Journal of Emergency Medicine. 2012;4(1):19-24
- Wachira, W; Kenya: 2013 Field Report:. Emergency Physicians International, Issue 11
- Nicks et al; The state of emergency medicine in the United Republic of Tanzania, African Journal of Emergency Medicine, Volume 2, Issue 3, September 2012