25 Oct 2011

Back to BASICS

South Australia is huge & not surprisingly this poses problems providing a response to serious trauma in the country. Thankfully rural doctors are mostly well-trained and thrive on the challenge of delivering excellent emergency care in their local hospitals...and if needed, can call upon the retrieval service to transfer critically unwell patients. The Statewide retrieval service has been re-invented in recent years, with MedSTAR now offering a world class service rivalling other States. Certainly the improvement in service delivery has been noticed from where I stand, as a rural doctor in country SA.

However, I wonder if there's scope to improve things even further? In the UK, an entity called BASICS (British Association Immediate Care Scheme) enlists the skills of doctors with an interest in prehospital medicine & trauma to provide medical expertise at the roadside. BASICS personnel don't replace paramedics or retrieval services - rather they "value add" to a situation - particularly when paramedic skills are exhausted and retrieval services have yet to arrive (see the BASICS DOC blog for more details). In Australia, the failure to call local doctors (many with critical care/anaesthetic skills) has been slammed in the response to the Kerang train crash disaster in 2007.

If the UK, with it's small landmass, huge population and plethora of aeromedical and land-based retrieval services has a need for a service like BASICS, surely there's more of a need in rural Australia where distances are greater and retrieval may take hours, not minutes? I posted on this recently on RRMEO, the excellent educational resource from ACRRM.

Currently, most trauma cases are dealt with by paramedics (and in the bush, these are often volunteers, not paid personnel) and a decision made to either retrieve direct from the scene (primary retrieval) or else transfer the victim to a rural hospital (where they may require secondary retrieval to definitive care). On occasions, local rural doctors may be called to assist at the roadside. Or not, as in Kerang. It's an informal process which invites problems.

There's a potential problem with relying on the local doctor. Emergency Medicine training in rural Australia is not formalised. Some doctors have a wealth of EM experience - some have barely any. Calling the local doctor may be a good thing...or it may not add much. Dr Peter Arvier in Tasmania has championed the need for EM training in rural Australia (demonstration of training is needed for rural docs practicing obstetrics, anaesthetics and surgery). Improving EM training is probably a good thing for the bush, although I hope old farts like me can be grandfathered if they bring in a rural EM diploma!

On top of this, a doctor attending an incident as the 'oncall' is still responsible for patients presenting to the local hospital. I've been called out to incidents 60km away from the hospital...and whilst happy to attend, I've had to ensure that someone else can cover in my absence.

In South Australia there has been an embryonic scheme developed by Dr Peter Joyner, known as RERN (Rural Emergency Responder Network) drawn from the ranks of rural doctors. These guys make themselves available to be called by SA Ambulance at the roadside, in addition to their usual oncall responsibilities. It's a good idea, but I think doesn't go far enough...the rural doctor workforce represents a hugh asset which is underused. Sure there are ad hoc arrangements ('Help! We need a doc') but without formalised training and equipment appropriate for the prehospital environment, doctors risk becoming 'enthusiastic amateurs' (I'm one!).

KI DOC is ready and waiting for your trauma call!

Whilst many rural doctors keep up-to-date by attending courses such as EMST, APLS, MOET, RESP etc, it has to be acknowledged that the prehospital environment is quite different to operating in the safety of a resus bay in the hospital. Prehospital doctors need to be familiar with rapid response driving, radio use, scene safety, extrication and working in austere environments etc. The UK BASICS scheme recognises this, encouraging training such as the UK's DipIMC (although having read what's involved, I reckon this could be more of a disincentive to us rural docs...better to just ensure they've got the right kit, understand the prehospital environment, then get them out there making a difference!)

I've alluded to the need for more crossover in training & equipment between various services (ambulance-retrieval-rural workforce) elsewhere on this blog (see "Keeping It Simple"). On RRMEO this topic was discussed with John Mac, who felt that it would be resisted by State ambulance services. I think this then begs the question - how much is the rural workforce integrated with State/National resources when a disaster strikes? As Dr Chris Swan recently opined in Australian Doctor :

"GPs form a vital, invaluable component of the emergency response resource in a disaster. Yet they too often are an afterthought, considered somewhere beyond the police, fire services, SES, hospital response and the military. Their clinical skills are broad, and they may well have facilities and staff at their disposal, but they are not as easily marshalled and they may be spread out"

I am particularly interested in how this sort of scheme would be received in rural Australia. What do others think? Has this idea got legs?

Bottom line - rural doctors are not infrequently called to attend to backup the ambos. Better that the doctors attending are well-trained, well-equipped and enthusiastic...not the present 'we don't need you...oh hang on, yes we do' approach which relies on the oncall A&E doctor. 

That's just not good planning.

24 Oct 2011

Reductio ad absurdum

Recent discussions with fellow rural doctors in South Australia have left me somewhat depressed.

I reckon that being a rural doctor is one of, if not the best job in medicine. You really get to enjoy all the 'best bits' of medicine, with a diverse workload that is continually challenging. Its also a great lifestyle (I don't miss living in the city nor being stuck in traffic when commuting to/from the tertiary hospital). And the remuneration for a rural procedural GP is relatively good.
Dr Tim - proudly South Australian

But last night I heard from colleagues that specialists now outnumber generalists (GPs) in this State...and that they find medical students are increasingly pursuing careers in lucrative 9-5 specialties rather than general practice. 

Personally, I find that some specialists are more like partialists - how many times have we seen patients discharged form the 'chest pain assessment unit' with a scrawled discharge summary "serial troponins negative, normal exercise-stress test. Diagnosis = non-cardiac." What the? That's not a diagnosis...it just means that the patient hasn't had an angina attack or infarct. They may still have a pulmonary embolus, or a pneumonia, or gallstones, even shingles - all of which can cause chest pain. Thankfully there are still a few "general physicians" around who get the big picture (mostly geriatricians) but they, like the rural doctor, are increasingly marginalised as partialists take over.

Now there is a danger here - increasing specialisation can lead to loss of the overview that is so important when treating a patient (and despite modern advances, medicine remains art as well as science). Patients seeking a 'partialist' may end up being passed from the cardiologist (not cardiac) to the gastroenterologist (not reflux) to the respiratory physician (not lung). The costs of fragmenting care in this way can be huge, particularly when there's noone taking control.

Trigger-happy GPs (you know the ones - the guys who are writing the specialist referral even as the patient enters the room to sit down) are partly to blame, as is a culture that expects a specialist to be the be-all and end-all in the medical journey.

There remains value in a good family doctor, who can see the overall picture, take a decent history and initiate management, perhaps refer for an opinion when necessary, then continue ongoing care. I'm proud to be a generalist, not a partialist. In these days where everyone wants a holistic approach, the family GP is best-placed to deliver such care.

Jack of all trades, 
master of none
But oft times better,
than master of one

Money is also an issue - medical students face increasing debts (some are coming out with debts approaching $100K) and need to pay off their training. There is a perception that general practice is poorly remunerated. The ceiling may be less than some specialties, but the non-monetary benefits of a flexible portfolio career are worth money in the bank. Rural proceduralists can command high incomes, but the cost for this can be no time off and a life cut short by long hours. As the rural workforce dwindles, this problem compounds and the attrition rate accelerates.

Why then are we struggling to recruit and retain rural doctors? It may well be lack of exposure, or a teaching hospital that denigrates generalism vs partialism. I was one of these naysayers when I was a junior doctor, but was soon converted once I was first exposed to rural medicine. And there's the rub - we need to get student doctors exposed to rural medicine early in their careers, and sell them on the lifestyle benefits and income potential that is the drawcard for many in Gen Y

The current contract between RDASA and Country Health SA is up for negotiation (contract expires Dec 2011) and of course one way to hang on to the current declining rural workforce is to improve remuneration for the most arduous part of the work ie: on call duties as outlined by RDASA. Whether the bureaucrats will see merit in this or not is moot - experiences on KI last year, when CHSA willingly spent $2000 a day on locums rather than negotiate with local doctors, leaves me to suspect that bureaucrats may well save a few bob by failing to meet RDASA demands, and instead end up paying 10x more through use of locums. But it probably comes from another budget, so that's OK?!?

On Kangaroo Island we have recently become involved in the PRCC programme, whereby third year students spend a year located in a rural environment to pick up their skills, rather than rotate through traditional 'firms' in the teaching hospital. It's an innovative idea and I hope it works (for my own succession planning and the ongoing needs of my community).

South Australia may also soon head down the pathway of encouraging a career in rural medicine through dedicated rural procedural training pathway - a sort of cadetship if you like, similar to that used in Queensland, whereby medical graduates are fast-tracked through rotations relevant to a rural career, not least obstetrics and anaesthetics (traditionally hard to come by)....with the whole deal sweetened by a guaranteed income from State coffers to work as a rural proceduralist.

We need these sort of innovations. Because one thing is for sure - if we continue down the pathway of referring everything more complicated than a hangnail to a specialist, health costs will skyrocket and the needs of the public will not be well met.

23 Oct 2011

Gear fetish

I'm in love...with my KingVision videolaryngoscope. It's somewhat of a generalism, but anaesthetists tend to be 'propellor heads' - they like to fiddle with equipment, & they are invariably seduced by things technical...you can usually tell anaesthetic doctors at a conference - they're the ones with MacBook Pros or iPads or iPhones.
But I digress. Last week was one for coincidences - the local rep sent the KingVision up for me to trial and at the same time Broome Docs posted on the issue of 'which video laryngoscope', whilst Minh Le Cong of RFDS Queensland posted a review of the device on EM-crit. Then to top it off I spent the weekend at the NSW proceduralists conference, where videolaryngoscopy was discussed and utilised both in the simulation lab and in the conference talks. I was so impressed I forked out my own cash to buy one, rather than wait for my local health unit to come to the party.
I think that VL is a game changer. Don't get me wrong, I'm diligent in developing and maintaining my direct laryngoscopy technique...but when faced with a difficult airway, the VL has potential to substantially improve the view.
We've got the C-MAC up in theatre where I am currently doing some anaesthetic upskilling. It's a great piece of kit and I think that the ability to see laryngoscopy on the screen is both reassuring for everyone, as well as accelerating the learning curve for novice intubators (they reckon that it takes at least 60 intubations to progress from 'novice').
There's also great potential to use the VL to simulate the difficult airway...given that Grade III and Grade IV Cormack-Lehane views are supposed to come along with relative infrequence (less than 1%), I reckon there's merit in using the VL to take a look at the cords, then either reposition the patient or the scope to simulate a Grade III or IV view...then utilise techniques to still intubate the trachea (BURP, bimanual manipulation, blind pass bougie, stylet etc etc). Again, this greatly advances the learning curve. 

For the 'occasional intubator' (most rural docs) the VL gives additional comfort - particularly when our decision to intubate is often forced due to imminent respiratory failure, or severe obtundation...and invariably in an un-fasted, un-optmised patient with haemodynamic instability. In a collar. Maybe at the roadside. Quite a different kettle of fish to the ASA I/II selected cases fasted for theatre on whom we practice. Of course, the big drawback is money. The C-MAC comes in at around $15K. It's not a device that is realistically affordable for Kangaroo Island or indeed other small health units in Australia.
Some doctors have opted for the AirTraq, which is not a VL as such (relies on prisms to give an optical view)...it's cheap as chips at under $90 each, but I find that peering through the viewfinder is fiddly and that one loses situational awareness. 
Hence the KingVision with it's built-in screen offers similar affordability (blades are about $30 each, the re-usable screen under $1000) and allows me to maintain situational awareness. I plan to have it to hand for anticipated difficult airways (trauma, collar, weird anatomy, failed LEMON etc)...and of course to use it now and then on routine lists to keep up skills (the technique is subtley different to DL).
Today I popped down to the local hobby store and haggled for a 12 inch TFT monitor with mounts for IV pole...then I've hooked up to the KingVision via the supplied composite-out video cable...so now I've got a system that allows big screen playback and recording, for a fraction of the cost of a C-MAC. Great for teaching. 
Bloody brilliant.
If you haven't already, take a look at the KingVision. For the price, it does exactly what is says on the box. Given that tertiary centres insist on having some sort of backup device for the difficult airway, I think that it's now indefensible for smaller hospitals not to have kit that does the same job.
[Please note that I am not affiliated with KingVision and that the model I purchased was with own cash at retail prices]

Networking and Silos

Well, just got back from the excellent GP Anaesthetists conference held in Sydney under the auspices of the NSW Rural Doctors Network. Apparently it's an event they hold every other year (alternating with an obstetric workshop) and manage to do each workshop twice in each year - delivering quality education to approx 80 of the 150 or so rural GP proceduralists in NSW. It's an extensive event that would go down well back in South Australia...although I reckon we'll have to get Dr Minh Le Cong and Dr Casey Parker along to emphasise the 'rural connection'.

What makes this event stand out was a day spent in the simulation lab at the Royal North Shore Hospital, with hands on quality simulation training in a variety of anaesthesia-relevant emergencies, then a conference dinner and the next day spent with a variety of speakers pitching content to the rural audience.

It was good for me to meet with other rural doctors, mostly from NSW and a few from Victoria. Interestingly, once they knew I was from Kangaroo Island, all were interested in the events of 2009 and our stoush with Country Health SA and the ACCC debacle (details of which I really should blog one day, as I should about upcoming contract negotiations with Rural Doctors in South Australia).

What I found interesting was that many of us rural doctors have the same problems - such as ongoing skills maintenance, lack of funding for nurse training and essential equipment, ongoing threats of hospitals being downsized and procedural services cut, remuneration for on call hospital work, as well as poor relationships with health bureaucrats. Most worryingly, many said that they were having to find own solutions to these shared problems, rather than a 'top down' approach. Basically, we're all operating in our little silos, rather than solving problems and lobbying for changes en masse.

It was particularly illuminating to hear some of the speakers (mostly metro-based anaesthetists) talk about difficult scenarios and resources to cope. In a few instances the speakers seemed aghast that many of the rural GP anaesthetists did not have access to equipment that their metro counterparts considered essential - things like suggamadex, desflurane, remifentanil, FFP, fibre optic intubation, modern anaesthetic 'workstations' etc. Sure, some of the rural docs had some of this stuff. But by no means all, in fact more like fingers of one hand. Out of 40 doctors.

Why? Cost, as always I am afraid. But that's OK. I think the key to being a good rural doctor is to "adapt-improvise-overcome". Luckily we stand on the shoulders of giants and most of the hard work is already done - providing we are well-trained, and equipment is well-maintained, it's perfectly possible to deliver a safe service using tried-and-tested agents.

So...anyone still using nitrous? I've been told that 'no ANZCA trainee uses nitrous' yet it's been around for ages and remains on the anaesthetic machines in most places.

17 Oct 2011

Keeping it Simple

One of the enjoyable challenges of rural & remote medicine is delivering high-quality care within the constraints of a health system that is cash-strapped, and where rural doctors often work between private clinic (own business) and public (State-run hospital) domains.

Sadly there exists a health-gap between rural and metropolitan Australians. For many services, health outcomes are worse in the country than in the city. This is in part to the tyranny of distance - the nearest specialist unit may be hundreds or even thousands of kilometres away. It's also about limited resources.

Conversely some things are done very well in the country - birthing services for selected (low risk) mothers are excellent when delivered by local midwives and GP-obstetricians, as are local surgical services which can offer an almost bespoke service rather than the 'sausage-factory' of a major tertiary hospital.

My particular interest is in emergency medicine and the particular problem of how to deliver high-quality emergency care in the bush. The 'gold standard' for delivery of emergency medicine in Australia is Fellowship of the Australasian College of Emergency Medicine (FACEM). But FACEMs, like other specialists, tend to congregate in the city hospitals where they can share workload with colleagues and also deal with the stuff they are trained to do on a daily basis.

Meanwhile staffing of the 'accident and emergency' department of a rural hospital can be variable - usually there is no on-site doctor, but a service is provided by one of the local doctors in primary care. He or she may have lots of EM experience....or very little. Which can be a challenge for medical and nursing staff who may only see this sort of emergency infrequently.

Well-trained rural doctors take this sort of thing in their stride. Ideally rural doctors have spent a year or so gaining experience in each of obstetrics, anaesthetics and emergency medicine. Excellent courses like EMST, APLS, ALSO, RESP and MOET help to keep rural doctors in touch with current practice.

More important is anticipation of the likely caseload, with planning & training for the worst.   This is not a new thing - recently guidelines for a minimum prehospital equipment setup have been suggested and such standardisation has many advantages. The lack of agreed standards is one of my bug bears.

Perhaps one of the hardest emergencies to deal with is the difficult airway. Training helps, but most of the training on anaesthetic rotations is in elective anaesthesia - I'd argue that the emergent airway is a very different beast!

In South Australia there is no agreed standard on 'difficult airway' equipment between the 30 or so rural hospitals. It seems bizarre to insist on appropriate credentialling for doctor's working in these areas, but not to insist on an agreed standard for the equipment they use.

Perhaps that is a bit harsh. ANZCA has outlined a technical guide on 'equipment to manage a difficult airway' and it is suggested that individual hospitals determine what is best for them.

Recent discussion on a hypothetical case from Minh Le Cong in FNQ made me think about this. Often experts in tertiary centres will ask why adjuncts such as non-invasive ventilation, heliox or fibreoptic intubation were not employed. Simple - we may not have them in the bush.

Hospitals often don't decide on what equipment is needed until it's too late i.e. after a critical incident, usually through the lens of a Coronial investigation (the case of blood product availability in the Riverland is a case in point). More problematic, the equipment often costs tens of thousands of dollars, which means local CEOs having to plead a case for their hospital, for a piece of equipment that may only be used once in a blue moon - but when needed, is indispensable. Such is the nature of emergencies.

Rather than the local CWA having to sell a few thousand scones and woolly teddy-bears in their annual fundraiser for the local cash-strapped hospital, I wonder if it might be better to invest in economies of scale. Agree a minimum standard between health units, train medical staff in how to use it, and allow recycling of stock that is infrequently used to the major tertiary centres. In South Australia, integration with the Statewide retrieval service (MedSTAR) would seem logical, with common protocols for low-volume infusions, difficult airway and other emergencies shared across the State.

Thankfully there is light at the end-of-the tunnel. New products on the market offer potential to turn a difficult airway (Cormack-Lehane Grade III/IV into a CL I or II). I am of course talking about videolaryngoscopes and the new disposable fibre optic devices. There's good discussion here, here anhere on these, which I won't repeat....check them out for yourself!

I think it is now at a stage where it is indefensible for rural hospitals not to have good quality, easily set-up and maintained equipment for managing the difficult airway, to a standard similar to that of a metropolitan ED.

Costs are coming down, and it would seem logical for health units to agree on a standard (which should be locally-driven) and purchase devices in bulk. Equipment which is used infrequently could be rotated through higher-use centres, much as we currently cycle expensive thrombolytic drugs before expiry dates.

Moreover, medical staff rotating between sites (whether GP-anaesthetist locums or retrieval staff) would be familiar with the equipment used, allowing easier setup and use - often the main problem when in a difficult airway scenario.

What would I recommend? Well, the KingVision VL is cheap and easy to use. The video screen affords good views which can be watched by others in the room. It is going to be my default device if failed direct laryngoscopy.

I'll also lobby for the Ambu Ascope - a relatively cheap disposable fibreoptic scope than could be an asset for awake nasal or oral intubation...or as a bailout tool to pass an ETT via intubating LMA.

Having the kit is one thing - using it is another. The annual rural doctors conferences (whether State or National) are a chance for both GP-anaesthetists and GPs providing emergency care to meet and discuss equipment, with opportunity for hands-on workshops.

But there's no substitute for using the gear on a routine elective theatre ist, which again means an investment in training with the kit with a view to ensuring that it's usable when needed.

What do others think?

16 Oct 2011

Welcome to KI Docs

Inspired by excellent Australian blogs such as Dr Casey Parker's (Broome Docs) and Dr Cliff Reid's (Resus.me), this website is aimed fairly and squarely at current (or aspiring) rural doctors in Australia.

Being a rural doctor is a challenging yet rewarding job, not least in a location like Kangaroo Island off the coast of South Australia.

Often lauded as the 'jack-of-all-trades, master of none', rural doctors hold their collective heads up high, proud to be true generalists...not narrow-focus partialists (or single-organ specialists). A rural doctor must be happy to be not just a primary care expert, but also to be competent in internal medicine, to perform minor surgery, to deliver a baby and to give an anaesthetic. Moreover, rural doctors often operate with minimal back-up such as easy access to blood tests, ultrasounds and CT scans.

As the emergency physicians at the excellent 'Life In the Fast Lane' emergency medicine website say :

"GP proceduralists in remote Australia are what most doctors were maybe eighty years ago — and what most of us dreamed of being when we went into medical school: having a baby? They’ll deliver it. Need an operation? They’ll gas you down (and they might even chop your leg off too). Got some bizarre disease no one’s ever heard of and you’re in the middle of nowhere? No worries, they’ll sort it out. You name it, if it has to be done, they’ll do it. These doctors are the princes of our profession."

So, in this blog the KI Docs (mostly frogs, not princes) discuss issues of relevance to rural docs Australia-wide. Whereas Broome DocsLITFL and Resus.me bring you the latest in gnarly case discussions and critical appraisal of the literature, this blog discusses some of the other factors involved in rural medicine - skills maintenance, networking, 'getting things done' and some of the common problems and solutions in rural medicine.

I'll leave the clever stuff to people like Casey and Cliff!

You can check out more via the KI Medical Clinic or our exciting project designed for rural proceduralists at Island Locums