This is a very good questions. The major questions that need to be addressed is starting skillset of the physician, consumables, capacity of the establishment and evacuation - all of these would determine what skills would be most suitable. I would not want to intubate and ventilate a casualty if there was a significant manpower issue. The ICRC have a number of good publications that can help answer this question.

To be very precise and exact:

- communication skills

- history taking (interviewing), and clinical skills for diagnostic and curative aspect of care while health education skills for patient education and disease prevention.

- appropriate technological and innovative skills (to overcome the resource constraints by adapting and use of local resources in a scientifically plausible manner). Resources like 'Where there is no doctor' could be thoughtful read through and desk ref for the purpose to use as such or draw an analogy from.

Hi,

I have worked in Syria/ Damascus during 2011 and 2012, in the general surgery department. I do believe that in the emergency war surgery, with the lack of materials, equipment and medicine. The life-saving or organ-saving surgery take a place and I remember once we did a splenectomy in 8 minutes. My experience revealed that its all about the mental and psychological stability, physician should be very sharp in terms of decision making, because we are all good in peace time, whereas in war time, the wrong decision usually which leads to the wrong treatment and surgery. We were shocked how much the human body can handle and tolerate a lot in terms of infection and compensation, if you give him/her a chance to live.

I think that the rural doctor should have the following at the least (in no particular order):

1) Patient assessment skills- to identify when a case is an actual emergency, or needs referral

2) A cool head, a value for life and very little ego

3) First aid skills

4) IV/IO access skills

5) Endotracheal intubation/ airway skills

6) Basic surgical & Suturing skills, immobilization techniques

7) Conducting deliveries

8) Knowledge of common adult and pediatric emergencies

9) Knowledge of commonly used medicines and action mechanisms/Side effects

10) Effective communication

All very good suggestions from everyone.

As to not overlap, here are some other good ideas to put on the list:

-Crash course in dental emergencies

-multi-lingualism

-high frustration tolerance

-salutogenesis

-optimism

-capacity to learn from others

Just to name a few.

Obviously core physician skills cannot be stressed enough

In my experience in similar situations I can divide the patients into two groups: patients who can be transferred and those that can not be transferred.

I can not transfer for the following reasons:

1) the patient is not stable (hemodynamics, airway, bleeding, tamponade, etc.)

2) I do not have an ambulance (or other transport) to transfer the patient

3) the patient or relatives do not have the economic resources to transfer

So I have to be able to stabilize the patient for transfer to, then I must be able to give a decisive solution of the problem (eg, cesarean section or chest drain, etc.)

We must not think like when we are in hospitals equipped with many specialists, we are alone, in this situation and resource scarcity is normal, it will not change, it will be the norm

Cultural awareness and sensitivity

Knowledge of endemic pathogens and tx options including local remedies.

Dear Paolo

The physician to work in a small town must be very well qualified. Need to have sufficiency in medical clinic, pediatrics, obstetrics, general surgery, traumatology and anesthesia. To the doctor has these skills he needs to do post-graduationl before going to the little city. Needs a compatible salary, and minimum local resources to make the diagnosis and possible surgical procedures (which usually does not exist, at least in the small cities of Brazil). So who usually goes to the small city is the newly graduated doctor with few qualifications !

ATLS ;-)

Did anyone mention radiological skills yet, in the suggested setting particularly conventional X-Ray.

Without a shadow of a doubt the most important would be to ensure you get good quality down time. That and a good sense of humour.

It depends on the speciality. One can not have every quality and there can not be a single doctor for every speciality. But overall the scope is limited due to scarcity of manpower (educated assistant etc.), drugs, sophisticated instrument, referral center etc. Sometimes it may not be possible to communicate with the relatives due to language barrier, low IQ status. Most important thing is to gain confidence of the patient party, keep patience, be able to make the party understand the situation. Patient party should be made updated regarding the patient condition no matter how worse. The news of sudden demise may be like a shock, so it is better to make the party rather prepare for the worst news by continuously updating the critical condition. Sometimes the scope is restrained due to scarcity of the things mentioned earlier. Even, in that condition too it is important to gain the trust of the party by showing patient party that I am doing something and I am giving my best effort. Experience is most important to deal such scenario.

If you are the only physician or even if you are the only one working at that time you need to cover all the emergencies. Since emergency medicine is a recognized specialty in most countries you can just look up the skills list for that in your own country or a similar one. IFEM also has a general list at:  http://www.ifem.cc/Resources/IFEM_Curricula_for_Emergency_Medicine.aspx

In  developing  Countries  like  India,  the  presence  of  a  qualified  MBBS doctors  is  a  boon to  the  rural  population, since  nearly  70% of Indian  population  dwell in  the  Villages.  I  as  a  medical  Teacher  always  stressed  the  importance  of  availability, accountability  and  responsibility.  Treating  Diarrhoea with  Rice  Kanji  common Salt  and  sugar  added before  IV fluids  infusion,  high  grade fever  with  tepid  sponging before  anti pyretic  drugs, organophospherous compound poisoning  with  concentrated  saline given  by  mouth  to  induce  vomiting  and  thorough  cleaning  of  the  patient  with  soap  water (  to  achieve maximum  decontamination ) scorpion  sting site  with  ice  fomentation before  local  anaesthetics, snake  bite  wound, incise just  above  the  bite  site  and  let out  the  blood  and  apply  a  tourniquet just tight  enough preventing  venous  return  and  not  jeopardising the  artery  supply,  severe  vomiting  with  tender coconut  water/ butter milk before  injecting  anti  emetics  and  so  on. But  again  not to  prevent  BLS and  even  ACLS training  and  execution  at  rural  level. But  very  sad  state  of  affairs  that  even  after  about  68 years  of  Independence in  a  biggest  democratic  country  in  the  world  the  rural area remains  poorly  developed and  we  have  no  vision  to  change  this scenario.

Dear Paolo 

I agree with Richard above

Teaching would be a useful skill to teach patients who to manage some of the minor problems themselves and understand what is a true emergency and what can wait until morning. The one benefit of being truly rural like this is a that you have a captive patient population. 

That said I am unclear what roles you will be occupying

would be important skills- if you are the only doctor then hats off you are occupying a true generalist role in this era of growing specialisms - one could never hope to have every possible skill level BUT being comfortable with common emergencies in pads/obs/psych and emergency medicine will cover most then a different level of skill and training is required for the routine medical care to be offered if you are the only doctor.

I am unclear why you are discussing some emergency orthopaedics, what is the exact clinical site, other resources available

mick