Tracheal Trauma

When I was a young lad, one of the things that would excite me was stories of pirates and murderous 'cut-throats'. At the age of ten, the idea of a 'cut throat' was somehow synonymous with a quick death. Fast wind forward a decade or so (ahem, well maybe more) and I'm reflecting on some of the more interesting cases of 2011.


One was a young man involved in a 'glassing' in the local pub. He presented to the ED via ambulance, maintaining his own airway but with an obvious zone 1 neck injury. Now, I teach in the animal lab on EMST courses and it amazes me how difficult it can be to identify the appropriate place to perform a tracheostomy. We aim for the cricothyroid membrane, but I've seen FACEMs bugger it up completely and transect the trachea (even once the oesophagus and damn near severe the vertebral column!)


Anyhow, this chap's assailant had obviously either been on an EMST course or had performed percutaneous tracheostomies in the ICU - because with just a broken beer glass, he'd managed to make a perfect incision in the victim's trachea, between 2nd and third tracheal rings. OK, not the cricothyroid membrane, but otherwise a damn near perfect tracheostomy!


So we took him upstairs and performed an awake fibreoptic intubation with a surgeon scrubbed and ready to perform a tracheostomy. And the patient did OK (had an injury to posterior tracheal wall with oesophageal perforation confirmed on oesophagoscopy, but no mediastinitis and injury healed over time in ICU).


So I've been thinking about these sort of injuries and how best to manage them with my (limited) kit back in the bush. Although reasonably rare, both blunt and penetrating laryngotracheal injuries present difficulties for the rural GP-anaesthetist...as the airway needs to be secured ASAP.


And this is not a hypothetical - such injuries are not uncommon in the bush - the classic is 'clothes-line' injury where a quad or trail-bike rider impacts a fencing wire at speed, sustaining tracheal injury. Add to that 'robust' sports, the usual gamut of farming and motor vehicle injuries..so the rural docs needs to have some form of game plan on how to manage these. And the 'exam answer' for ANZCA may not be applicable for the rural doctor, with limited equipment/backup.


The danger of course is that attempts at direct laryngoscopy may cause complete tracheal disruption, with subsequent passing of the ETT tube down a false passage, development of subcutaneous emphysema, failed ventilation and a spiral down into demise.


Every now and then, one hears of paramedics just popping a suitably sized ETT tube through the hole made in a traumatic tracheostomy - a fine strategy for the penetrating injury, but not available for blunt injury or small penetrating wounds.


How then to approach this? There isn't a great deal in the literature and my FANZCA colleagues fall back on the 'awake fibreoptic intubation' answer...which is fine in the tertiary centre, but impractical in a small rural hospital.


So, what to do when faced with a patient with tracheal injury and needing emergent intubation (let's assume they are becoming obtunded or failing to keep SpO2 up). My thoughts?


- direct laryngoscopy. May seem controversial, but this is what I am best at and the equipment is readily to hand (ETT/bougie). However DL risks disruption of the larynx/trachea and a false passage, making further attempts at intubation impossible.


- do a formal tracheostomy under local. Sounds fine, especially if can delegate to a surgeon. If I am in luck there may be an ENT surgeon visiting for a fishing trip, otherwise it's going to be a messy scrabble with a patient who may refuse to lay flat/be combative. Nasty, but potentially do-able with equipment to hand (betadine-gloves-drape-local anaesthetic-scalpel-lots of gauze-retractors-ETT-lots of light-assistant)


- indirect laryngosocopy using videolaryngoscope. I like this idea, as intuitively seems to involve less mechanical distraction of the larynx...and the KingVision allows easy passage of a bougie, then railroad ETT over the top. Parker-tipped ETT to try and avoid any 'hang up' at the arytenoids...


- use an iLMA to maintain oxygenation - then intubate with ETT through this using either AmbuAscope or a malleable intubating stylet such as Bonfils or Levitan. To my mind the Ascope seems to offer an advantage here as could use iLMA as a conduit then follow down to carina...ensuring no false passage - then railroad ETT over the top. The shaped intubating-stylets allow one to visualise the laryngeal inlet..but not to insert down to carina, so potentially will intubate through the cords, but suffer false passage further down.


- topicalise the airway and perform an awake fibreoptic intubation. Preferred technique of my FANZCA colleagues, but it's hard to do enough AFOIs to keep 'current'. Now is not the best time for a relative novice to be trying!




What do other's think?


- any thoughts on above?


- gas induction or classic RSI?


- what kit do you have available to assist you, either now..or planned.




Bring it on...

Contract Negotiations Update 15/12/11

Well, my last post on the contract negotiations between SA Rural Doctors and the Country Health Dept was in mid-November.


By way of background, the current contract was agreed in 2010 and was due to expire on 1/12/11, in part because the Rural Doctors Association SA were unhappy with the oncall fees negotiated last round. 


There was expectation that the current round of negotiations would yield a better oncall payment, recognising the significant impost that responding to the requirements of the public hospital has on the GP's own private practice.


Sadly negotiations have dragged on; indeed, it was only on 30/11/11 (the date of expiry of the current contract) that Country Health SA wrote to GPs stating that the contract would be extended a further three months. No reason was given for this delay, which is disappointing.


In early December, the RDASA received a revised offer from CHSA - and in a news release to members on 15/12/11, the RDASA have advised that the offer falls short of what was asked for and remains unacceptable. 


However there will be a further attempt at negotiation with CHSA, with RDASA pushing for the following:


- increased payments for oncall rosters


- recognition by CHSA that many patients presenting to public hospital EDs are NOT routine general practice and should not be billed by the GP (a blatant cost-shift by CHSA onto Medicare and the patient). In some circumstances, CHSA has refused to pay the attending doctor for providing emergency services, with patients being asked to pay for a service that they would receive for free in a metro ED (eg: reduction of fracture/dislocations, forensic medical exam etc)


- RDASA rejection of the proposal by CHSA to tie admission privileges and fee-for-service payments to being on the oncall roster (a move that would discriminate against doctors on sick/maternity/paternity leave, or those who wish to continue to admit patients under their care but not to participate in an onerous oncall roster)


The new contract, if it is accepted, will be for three years. I have an opinion on this, but it is vital that rural doctors consider their position should the Health Dept fail to meet the proposals of the RDASA, and the RDASA are unable to recommend the contract to members. In such circumstances it will be for individual entities to determine whether they wish to accept the contract, or negotiate separately...or withdraw entirely.


Having worked in rural NSW for the past 12 months, it has been interesting for me to compare terms and services between this State and South Australia. Certainly there appears to be less bickering over cost-shifting, with the NSW Health Department paying the doctor if he/she is called to attend as part of his/her duties oncall for the hospital - rather than the obfuscation in SA. Of course, such differences play a factor in recruitment and retention of rural doctors. As a GP-proceduralist, I am certainly tempted by better money interstate, the chance to live in a coastal town and most importantly by a hospital that continues to provide obstetric and anaesthetic services.


To be offering a newly-announced 'rural proceduralist' pathway in SA, yet failing to nurture the relationship between rural doctors and CHSA seems tautologous. Let us hope that CHSA will recognise the value of the rural medical workforce before it is too late.


You can feedback to the President of RDASA, the Negotiation Committee, or regional reps via the RDASA website


Interesting times, indeed.

Nearly home...

Well, had my viva for the JCCA anaesthetic credentialling earlier this week - glad to report it was successful. Four more weeks to go in Orange NSW then I'm headed back to Kangaroo Island with anaesthetic credentials under my belt.


This video clip says it all really:


http://www.youtube.com/watch?v=5rJ8nCTgZ2Q&sns=fb


Now, where's my fibreoptic scope and some local anaesthetic spray? I've gotta try this at home.

Essential Equipment

I've long struggled with the ideal contents of my prehospital pack. Time was that I carried enough gear in the back of the ute to perform an emergency laparotomy at the roadside...as time goes on I've slimmed things down...even more so on kayaking expeditions where weight and space are at a premium. Indeed, my minimalist approach to medical kit caused a small stir in the Australian sea-kayaking community, not least for the reliance on duct tape, superglue and suggesting the rectal route for treatment of dehydration and/or hypoglycaemia.


I've touched on thoughts for minimal standards for prehospital kit and a move towards similar standards in equipment and infusion protocols between small rural hospitals and retrieval services elsewhere in this blog. However, I was surprised to see the inclusion of a rubber chicken in Minh le Cong's essential prehospital kit. You can read more over at Cliff Reid's Resus.me site. But this of course raises the issue of what other 'unique' piece of kit that you feel you cannot function without.

Choking the chicken - an essential prerequisite for retrievalists?

For me, it's always been a six-pack of Dr Tim Cooper's Pale Ale (or Dr Tim's) - I usually slip a six pack in the vac-mat for the retrieval team when they take away a sick patient - in thanks for their efforts and as a reward to enjoy back at base.

What weird extra kit do you carry in your prehospital or emergency bag?

Anaesthesia & Aviation

How many times have I heard people (usually other doctors) liken anaesthetics to flying a plane - 99% boredom and 1% sheer terror?

In only a few more weeks I return home to Kangaroo Island after a year spent upskilling in anaesthetics...like a pilot, I've accrued many hundreds of hours of 'flying time' and have a fairly impressive logbook. I'm flying solo (but with an experienced senior pilot readily available should I need it)...all good preparation for returning home and anaesthetising selected patients for the visiting surgeons who visit KI.

I recently attended an airway courses with Paul Baker of the ANZCA difficult airway special interest group. The Elaine Bromiley video was shown...and served as a discussion of human and technical factors in anaesthetic mishaps. Elaine Bromiley's husband is an airline pilot and he has brought the rigour of the aviation industry, particularly crew-resource management, to crisis management in medicine.

One thing that struck me was the tight adherence that the airline industry has to checklists. In addition to the human factors and difficult airway algorithms, I think that this is something that we could and indeed should incorporate into routine clinical practice, particularly in ED or resus, where clinicians may be taskloaded and team members have to complete complex tasks that they perform relatively infrequently.

It's true that in the Operating Theatre the surgical and nursing team perform a ritual known as 'time out' - a final check of patient identity, proposed surgery, consent and allergies. However I have recently been in some operating theatre scenarios where the communication between team members has been nonexistent...usually reflecting strained working relationships or one or two toxic individuals. What a shame that there is no anaesthetic-surgical team timeout - to confirm nature of proposed surgery and anaesthetic, to discuss plans in the event of mishap, and to clearly identify team member roles and responsibilities (watch the Bromiley video for an example of how copilot and pilot do this...something that I wish some surgeons and anaesthetists would do routinely). 

I found this on the web, which is an extension of the surgical time out and involves introduction of team members, discussion of critical steps and anticipated problems. It's from the WHO and I like it.

Checklists are all very well, but they are a form of strategy only...you've got to know how to implement actions in case of disaster. Scott Weingart has recently podcasted on the concept of logistics vs strategy, emphasising that knowledge of the former distinguishes a true expert from an amateur. It's all very well to trot out the medical student answer that in the case of a massive bleed we would give packed cells, FFP and cryo (strategy)...but the true expert needs to know how to activate the massive transfusion protocol, troubleshoot the level one infuser, transduce the arterial line and mix up prothrombinex etc. This distinction of theory from practice is one which can be applied in whatever field of medicine one practices.

Continuing the aviation theme, a mob of ICU trainees from the UK (www.saferintubation.com) have developed a useful 'intubation checklist' and I would commend this to people to copy and print out on their resus bay wall or on the airway cart.

However if we are going to extend the 'anaesthetics is just like flying a plane' metaphor, then Grant Hutchison's infamous 1998 essay "Biggles FRCA" from the UK's 'Today's Anaesthetist' remains the definitive text.

Airplanes, unlike Sick Patients, are designed to fly

For those who don't recall the 'Boys Own' adventures of Capt Biggles, the eponymous hero was a creation of Capt W.E. Johns and promulgated the adventures of a wartime aviation hero, who got into various scrapes and yet triumphed despite insurmountable odds.  Like Tom Cruise in 'Top Gun', one could argue that there was some homoerotic content at the bottom of all this (titles such as 'Biggles Takes It Rough' and 'Biggles Takes It In Hand' lend themselves to satire). Nevertheless, the concept of a rugged, unfazeable hero who triumphs despite the odds is one that I think could apply to anaesthetists - as they are invariably the doctors that other doctors turn to when the shit hits the fan.

Anyway, here's the Biggles FRCA story reproduced for your edification. Our hero Biggles is an anaesthetist...the Chief Engineer is a Surgeon:

[from Grant Hutchison (1998) 'Today's Anaesthetist']

If one more person tells me that giving an anaesthetic is like flying a plane, I will swing for them, I really will.

Look. The whole point of a plane is that it is designed to fly, and if it's not working properly then you don't take it off the ground. Human beings, in contrast, are not designed to be anaesthetised, and are often not working properly when the occasion arises. They are also rather poorly provided with back-up systems and spares, and frequently have long histories of inadequate servicing.

So if giving an anaesthetic is like flying a plane, then this must be what flying a plane is like:

Captain James Bigglesworth DSO stepped out into the thin sunlight, and took a deep breath of the damp air. It was good to be alive. He was taking up a new crate today, and he relished the little knot of mixed tension and anticipation that always formed at the pit of his stomach under such circumstances. He strode briskly towards the hangar.

The Junior Engineer was waiting next to the aeroplane. He handed Biggles a single sheet of paper, on which he had scrawled a haphazard note of his work on the craft. "Is this all?" asked Biggles. "Where is the service record?"


"It seems to be lost. The filing department say it's maybe still at the previous airfield."

"And the manual?" asked Biggles.



The Junior Engineer looked startled. "I don't think there is one. We thought you knew how to fly a plane."



A cloud drifted slowly across the sunny sky of Biggles' mind. He began his walk-round. "Where's this oil coming from?" The Junior Engineer frowned seriously. "I don't know."


Biggles sighed. But he too, long ago, had once been a Junior Engineer. "Where do you think it might be coming from?"

"The engine?" hazarded the youth.

"Of course. So what's the oil level in the engine?"

"I don't know."

"Have you checked the oil level?"

"No."

Biggles could feel his voice becoming a little tight, a little cold. "So could you check it now, please?"

"What? Now?"

"Now."

"But you're just going to take off. The Chief Engineer wants you to take off right away."

"Not without an oil level. And this undercarriage strut is broken. And the port aileron is jamming intermittently."

At that moment, the Chief Engineer arrived. "Biggles, old chap! Ready to take her up? Good man."

"She's not remotely airworthy. I need an oil level and some basic repairs."

The Chief Engineer sighed. "What do you want an oil level for? You know it's going to be low. We've got to get her into the air before we can control the leak. And that undercarriage and aileron aren't going to get any better while we stand here. She needs to be in flight before I can properly assess them. Come on, old chap - the tower's given us a slot in ten minutes' time. If we don't take off then, we'll be waiting all day." He eyed the plane despondently, and tapped a tyre with the toe of his boot. "And, frankly, I don't think she'll last much longer."

Biggles rippled the muscles of his square jaw. The Bigglesworths had never balked at a challenge, but this ... Well, there seemed to be no way out of it. He was going to have to take the old crate into the air, just as she stood. Deuced bad luck, of course, but no point in whining.

Twenty minutes later, they were aloft. The plane kept trying to fly in circles, and the engine temperature gauge was sitting firmly in the red. The Engineer was out on the cowling with a spanner.

"Just turn her off for a bit," he bawled over the clattering roar of the sick engine.

Biggles was astonished. "What?"

"Turn off the engine. There's nothing I can do about this leak until the engine's stopped."

Reluctantly, Biggles turned off the engine, and trimmed the aircraft for a shallow glide. The weight of the Engineer, out there on the nose, was not helping matters at all. Four minutes passed in eerie silence, as the treetops swam up to meet them. "I'm going to need power again soon." There was no response from the Engineer. Another thirty seconds passed. "I need power." No answer. "I'm turning on now." The engine roared, and the Engineer recoiled, cursing, in a cloud of black smoke.

"What's your game, Biggles, old man? I almost had the bally thing fixed, and now we'll need to start all over again!"

Biggles bit back an angry retort, and concentrated on guiding the crippled plane upwards. This time, now that he knew what was going on, they would start their glide from a lot higher.

After another protracted glide, the Engineer clambered back into the cockpit, beaming. "All fixed!"

Biggles tapped the oil pressure gauge. "Pressure's not coming up," he said. "It will, it will," said the Engineer breezily. "Don't be such a fusspot. Now let's get the aileron sorted."


He crawled out onto the wing, and began to strike the recalcitrant aileron with a hammer. A minute later, the plane rolled violently to the right. Biggles struggled momentarily for control, his lips dry. By cracky, they'd almost lost it completely, there.

"Don't do that!" he called hoarsely to the Engineer.

"Do what?"

"Whatever you did, just then."

"I wasn't doing anything, old man."

Almost at that moment the plane lurched again, more fiercely, and rolled through forty-five degrees. "That!" screamed Biggles, fighting the controls for his very life. "Don't do that!"

"Fair enough," said the Engineer, cheerily. A minute later he did it again, and the plane was inverted for ten long seconds before a sweating Biggles regained any vestige of control.

"Fixed! Undercarriage next!" called the Engineer, and clambered out of sight below the fuselage.

Ten minutes later, Biggles caught brief sight of a set of wheels dropping away earthwards. "Couldn't save 'em," said the Engineer when he regained the cockpit. "Better off without them, frankly."

"I still have very little oil pressure," said Biggles, worriedly.

The Engineer pursed his lips and tapped the pressure gauge reflectively. "Well, the leak's fixed, old man. Must be something about the way you're flying her." He reached under his seat and pulled out a parachute. "Look, I'm most frightfully sorry about this, but the nice men from Sopwith are taking me out to dinner tonight, so I've got to dash. Be a brick, Biggles old fellow, and just put her down anywhere you like. I'll cast an eye over her in the hangar tomorrow morning."

And with that, he was gone.

Biggles thought longingly of his own parachute. But he couldn't abandon the old girl now. It wasn't her fault, after all. Black, oily smoke was already billowing out of the engine cowling, however - he needed to put her down soon. He began to peer around for a flat place to land and, almost immediately, he spotted a distant grassy field. He moved the controls a little so that he could take a closer look.

He flew around the field once, and it certainly looked flat enough. Oddly, someone had painted huge white letters across the level green grass - ICU, it read. He had no idea what that meant, but it seemed vaguely comforting, for some reason. The engine coughed once, and then stopped. He could see a fitful orange glow beneath the cowling. This rummy ICU field would just have to do, it seemed.

As he swung the ailing aircraft around to make his final approach, he realised that the field was just a little too short for comfort. He licked his lips, and prayed that there would be enough room...


Sounds familiar to my anaesthetic chums? Happy landings, colleagues!

Exciting news

Well, those who know me are aware that (apart from roadkill recipes), two of my current interests are to try and develop a national network of prehospital doctors drawn from the rural workforce and also to improve training in skills and equipment for rural doctors.


I'm grateful for recent email exchanges with Drs Minh Le Cong (RFDS Qld) and Dr Ray Gadd (on an EM secondment in the wilder parts of Tasmania). Minh has gained a reputation as a 'promiscuous blogger' and his pearls of wisdom crop up on websites such as LifeInTheFastLane, EM-crit, Resus.me and Broome Docs. he's also been the main driving force behind the excellent retrieval medicine module on RRMEO (the ACRRM online portal). He's a rural doctor now working as a retrieval specialist and clearly 'gets' the issues facing rural communities. Ray's down in Tasmania doing some EM upskilling and has made me awestruck with his knowledge of obscure cardiac arrhythmias, ready-grasp of ultrasound and sheer passion for rural medicine.


I've been buoyed recently by Minh's tacit support for some sort of organisation akin to the UK BASICS, but he correctly points out that this has to be driven from the rural doc workforce. My opinions on this are laid out elsewhere on this site. Meanwhile Ray and I have chatted about perhaps creating a new upskilling course for rural doctors - a sort of 'masterclass' building on the best bits of courses such as APLS, ELS, RESP, EMST, ALSO, MOET, PHTLS etc but with constantly evolving content (such as that on the abovementioned blogs) of relevance to the rural workforce (apnoeic preoxygenation, USS for PTX, RUSH, etc etc). 


Ideally such a course (or clinical update) could be delivered in regional areas, with small groups and immersive scenario-training and hands on with lots of equipment (ultrasound, videolaryngoscopes, airway adjuncts, emergency kit etc and an opportunity for cross-training with local ambulance/retrieval/emergency services for the trauma component).


Anyhow, there has been some more good news this week from my home State of South Australia - a new programme for creating 'home grown' procedural GPs in SA has been endorsed by Country Health SA and looks set to deliver both training posts and a sustainable workforce for the future. Called 'Road to Rural General Practice' this model is well overdue. Currently SA procedural doctors may have to travel interstate to upskill (I did my obs in Tasmania, my anaesthetics in NSW) and indeed opportunities for procedural doctors can be tempting interstate...if this system trains and retains doctors in SA, that'd be great.

Launch of Careflight's mobile MedSIm at Orange Hospital, rural NSW

Meanwhile, back in Orange, NSW where I am upskilling in anaesthetics, I was asked to give a lecture on massive transfusion to candidates on the TART course (delivered by the NSW ITM, a course I'd not heard of previously). CareFlight were involved (hi to Zoe Rodgers and co. if you're reading)...and later in the hospital carpark I spotted Careflight's excellent MedSim mobile sim-lab and their dedicated car wreck trainer.


Seeing this has got me all enthused again - so projects for 2012 will be to try and get an Australian 'BASICs' up and running...and to try and sell the idea of a course aimed squarely at the rural doctor, preferably badged under ACRRM and offering immersive, hands-on, up-to-date education at a level above existing courses but perhaps spending half a day on each of EM, Obs, Anaes, Trauma and Paeds/Psych, with guest speaker, equipment demos and scenario-based small-group learning.


I'm excited. I hope others will want to join in...

Teaching old dogs new tricks

I have just got back from the Airway Skills course held in Sydney and run by Paul Baker (airwayskills.com). Unlike other courses, this was was genuine small group learning with plenty of opportunity to discuss cases, get hands on with a variety of equipment and was suitable not just for anaesthetists, but also intensivists, ED docs and rural proceduralists.

Its amazing how much one can learn even when one is doing a job on a daily basis. Paul Baker is well known as the author of numerous papers and the ANZCA 'difficult airway' equipment recommendations. As such, he brings a calm authority to discussion of airway and was a patient teacher.

I got a chance to play with a variety of equipment, including understanding the vital difference between proseal and supreme LMAs, play with combitubes, fiddle with Frova's, Aintree catheters and confirm my choice of scalpel-bougie-tube for surgical airways. Also a great session on AFOI, as well as discussion of using 15l/min O2 via nasal specs as an adjunct to preoxygention/RSI and Levitan's excellent airway book...

Only one thing was missing - a 'soiled airway' mannikin, to simulate the emergency airway that is the province of trauma and emergency docs...I know Minh le Cong has been muttering about such a simulator, but I reckon it'd be a great chance to wet test some ideas like Weingart's ETT as suction catheter.

Rural docs have a plethora of courses to choose from - EMST, APLS, ELS, RESP, MOET, ALSO etc, as well as clinical attachments for procedural upskilling. I've blogged previously about the excellent Rural Doctors NSW procedural conference (combined with a day at the sim lab for GP-anaesthetists) and how I'd love to bring a conference with similar content to South Australia. The Baker airway skills course is so good that I reckon it'll soon become oversubscribed, and the rural proceduralist cohort may miss out...wouldn't it be great to bring this paradigm to a wider audience, rather than just 3-4 courses per annum on Oz and NZ?

Contract Negotiations

Well, it's just over three weeks until the expiry of the current contract between rural doctors and Country Health SA.


Call me a cynic, but I won't be holding my breath. It's no secret that many rural doctors are less than enthralled with their working relationship with CHSA in the past. Up until 2009 we didn't even have a contract describing working rights and responsibilities between doctors and their hospitals. Moreover the existence of 'local deals' saw a huge disparity in oncall payments between doctors in different health units.


Astute readers on the web or those dialled into medical politics may be aware of the Kangaroo island doctors being caught up in a brouha in 2009 when they expressed dissatisfaction with their terms of service and threatened a boycott. Indeed, at a recent NSW rural proceduralists meeting, when I mentioned that I was from Kangaroo Island, many doctors stated they'd been following the matter from afar (news to us, as we felt isolated in more ways than one!). I guess that I am tired of explaining the issue, so here is the short story.


Back in 2009 the KI Docs were fed up with the lack of a contract and the fact that their colleagues over at Victor Harbor were paid on a totally different (and more generous) package, despite us sharing the same CEO for both hospitals. Seeing patients at the hospital is at the expense of running a practice (put simply, every hour that a doctor is called away from his/her clinic means more patients that aren't being treated...and the doctor remains responsible for his her practice costs whilst subcontracting to CHSA as the oncall doctor). Oncall work is an essential part of being a rural doctor, but in a tourist destination, the work of running A&E for the Health Department comes at the expense of doctor's private practice...with none of the benefits of long-service leave, Workcover, superannuation or adequate remuneration. The disparity between our pay and that of our 'sister' hospital was making it hard to recruit and retain doctors locally, threatening the viability of medical services on Kangaroo Island.


In frustration, we spoke to the ACCC and our hospital CEO; the former advised us that as a group practice we were allowed to collectively negotiate our terms ...and the latter suggested that if we didn't like it, we escalate our issue. With ongoing stonewalling by CHSA, we wrote to the Hospital CEO and proposed a withdrawal of our services unless a contract of our liking was instituted. Within a week the (then) CEO of CHSA had flown in to meet us, agreed a handshake promise that a new contract would be forthcoming, and we agreed to continue working and thought no more of it...until the week after, when the ACCC invited us to Adelaide to explain our actions (noone is sure who reported us to the ACCC, but I can say with some certainty that it wasn't the KI doctors!).  


The ACCC required all five of the doctors to fly up to Adelaide to be interviewed - the irony that in so doing the island would be without sufficient doctors to provide oncall services seemed lost on them. Over 2-3 days of interviews and a tense wait, we finally received a slap on the wrist over our actions and a promise not to do it again (apparently we were allowed to collectively negotiate...but not to threaten a boycott - a fact that we were unaware of). 

"Medical Observer" magazine summed it all up

All in all this was a harrowing experience that lead to the loss of one doctor from the Island and was both professionally and personally exhausting. Needless to say, this affair did little to bolster confidence in our relationship. Indeed, the following year saw the virtual collapse of our ability to deliver A&E services (doctors left, two went on maternity and paternity leave, one declined to rejoin the roster after a sabbatical etc) and CHSA flew in locums at great expense, not all of whom were up to scratch.


The current contract was negotiated in 2010 by the RDASA (the AMA rejected it) and signed by many rural docs in SA for a limited period of 12 months only, in the expectation that a better contract would be negotiated for the future. Of course, those on existing 'sweetheart' deals continued on them and will do so until their expiry...


So - the new contract is due on Dec 1st. You can see the proposal by the RDASA here. I am unaware of any response to this offer at the time of writing...and it fills me with alarm that only three weeks remain for a contract to be agreed, signed and implemented - especially one that ties rural doctors in for three years.


Not a good way to do business, I fear. To my mind, several issues remain to be answered satisfactorily by CHSA in any new contract:


- remuneration for being oncall and attending meetings etc, reflecting the cost of so doing to the doctor's private practice (we have to pay staff/utility bills/rent etc even when we are working at the hospital),


- clarification of 'who pays' for non-admitted A&E attendances (in rural SA, patients are billed by the doctor for services which they would receive for free in a metropolitan ED).  CHSA refuses to accept liability for the doctor's fees unless the patient is admitted to hospital for over four hours (so things like reducing a shoulder dislocation, rehydrating a migraine, suturing a wound, forensic medical exam etc are cost shifted from State to Medicare by CHSA, despite these services provided as the oncall doctor's duty when working for CHSA)


- safe working hours and locum relief. We are all getting older, and the idea of working a 72 hour shift for A&E is increasingly untenable. Obstetric and anaesthetic doctors may be rostered oncall for several months at a time, with scant opportunity for a locum to relieve them,


- clarification of whether admitting rights are to be tied to signing the oncall roster. Many doctors provide a valuable service to inpatients (palliative care, frail elderly etc) but, for various reasons, may not wish or be able to participate in the oncall roster. Better to keep these doctors on side, rather than 'conscript' them...as towns then risk losing valuable doctors who can participate in clinic and routine ward work, but aren't prepared to be up all night,


- status of existing 'sweetheart' deals in rural SA (eg: Victor Harbor, Naracoorte, the Riverland, Whyalla and who knows how many others). Simply, will there be a uniform contract for all rural doctors, or will their continue to be different deals according to geography/local circumstances etc? If so, how are these determined?


There are probably lots of other things that will need clarification...but in the absence of a draft contract to read and a real time pressure before the current contract expires, I am less than sanguine about CHSA's sincerity. 


To my mind, a partner who was willing to engage meaningfully would have sorted all this stuff out weeks or months ago. But I have been burned in the past...


I'll update if there's any news.

A CHSA negotiator prepares to 'negotiate' with a rural doctor
"Watch where you're putting that fist!"

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.

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.

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]