This site has moved to www.kidocs.org - check it out for FOAMed resources for rural doctors

Well, KI Docs has been up and running for a year now and hosted on the Blogger interface. Although it's been fairly easy to use, one of my major gripes has been the inability to post content for sharing with other Rural Docs - videos, podcasts, PDFs and presentations.

Discussing interesting cases, talking about aspects of emergency medicine, anaesthesia and critical care relevant to rural medicine has been a real bonus of using the blog-o-sphere. Reading existing blogs from the likes of Casey Parker, Minh le Cong, Cliff Reid, Scott Weingart and those eccentrics over at LITFL has inspired me to re-examine the way I practice medicine and try to keep abreast in my particular areas of interest (mostly rural trauma management).

The concept of FOAMed (Free Open Access Meducation) is one to be embraced. But in order to participate, I need to be able to share files with anyone who stumbles across this blog. Moreover, it's a good way to disseminate info.

Jump in and enjoy the FOAM

So I've moved over to - kidocs.org

Rural GP Anaesthetists - a 'special needs' mob?

As a rural doc I'm very lucky to have a job that is varied. I tell students and junior doctors that rural medicine offers all the stimulation and challenges of all the 'best bits' of medicine.

Currently I practice primary healthcare, emergency medicine and anaesthetics (I gave up obstetrics last year).

So this weekend just gone was a highlight - a chance to attend an annual GP-anaesthetics conference at one of the mainland tertiary hospitals. I've had this date ruled off in my diary for 12 months now...so you can imagine my disappointment when the ferry to/from Kangaroo Island sustained damage in the recent storms and the replacement therapy had to be hurriedly re-surveyed, launched and pressed into service. Needless to say all Rex flights were booked out days ahead and despite lots of people needing to get to/from KI, Rex declined to put on extra flights.

Noone can control the weather, but the lack of a contingency plan was disappointing. Not that Rex have a strong history of customer service...

Anyway, I missed the first day of the two day conference. But although I made it to the second, I was somewhat underwhelmed by what I did attend, cementing further my belief that there needs to be content tailored to the rural GPA delivered by people who 'get' rural medicine.

To backtrack, I went to my first rural GP-anaesthetist in NSW last year. It was really good, a day and a half of lectures, plus a half day in the sim lab doing emergency scenarios. But what struck me there was the disparity in equipment and resources available between city and rural anaesthetists...as well as between rural GPAs in different parts of the State. Lectures by some of the FANZCAs were all very interesting...but often they did not realise the conditions in which rural GPAs work (isolated, minimal equipment, no backup, cash-starved). At the same time I was getting increasingly inspired by blogs such as Resus.me, BroomeDocs.com, Prehospitalmed.com and LifeInTheFastLane - all of which seemed highly relevant to my practice.

So I resolved to look at some quality improvement in my own practice on my return to SA, mindful of the fact that it made sense to have commonalities in equipment and protocols available to rural anaesthetic providers. Setting up a GoogleDocs survey was relatively easy, and I was gratified to get a 2/3 response rate from rural GP-anaesthetists around Australia on my topic of difficult airway equipment availability. I'll be talking about this at the Fremantle Rural Medicine Australia conference and my paper should be out in the Oct-Dec volume of Rural & Remote Health. Stay tuned...

So, a year down the track I had really high hopes of further upskilling in SA. Whilst most of the content was good, there was an alarming propensity of some lectures to cover topics like cell salvage, lab-markers in major transfusion and the like - all very interesting, but not translatable to the rural practice environment where such resources aren't available. Questions on topics such as delayed sequence intubation and whole blood live donor panels were unfamiliar ground for the FANZCA experts, although very pertinent to many of the rural doctors.

Small group sessions made up for it, with hands on experience and chances for case discussion.

But a common theme amongst the people I spoke to was that city anaesthetists task with lecturing had very little idea of the resource limitations in country areas. The vast majority of us don't have remifentanil..or desflurane..or BIS...or access to FFP/cryo/platelets...or labs..or $15K videolaryngoscopes. The FANZCAs who visit rural hospitals, whether for elective lists or retrieval, did at least have an idea of our circumstances Yand 'special needs'

So, what does the rural GPA really need?

- lectures from experienced anaesthetists? Hell yes.
- small group sessions and case discussions? Even better.
- topics targetted to the audience and suggestions for improvement. Absolutely!

...and to top it off, perhaps consideration be given to sharing the knowledge base by holding two sessions per year (allows more docs to attend...as if one doc is at the conference, the other needs to be oncall)

...and even better, consider delivering content in rural areas by taking some of the ideas on the road.

The other thing that concerns me is the lack of communication between rural docs. Locally the RDASA has a 'rural anaesthetists' email group, but it has been inactive for a few years. It seems that many of us have the same issues with respect to equipment procurement, training and upskilling - yet operate in silos. Moreover there is little 'top-down' direction - certainly I have no sense of direction from the 'Country Health SA Anaesthetic Consultant' and it would be nice to see some more dynamism.

Maybe next year will be better...I'm going to keep pushing the barrel for local delivery of leading edge concepts in EM/anaesthesia that are rurally relevant for myself and other doctors.

Email me if you have any thoughts on this.

How I Met My Specialty

I’m a big fan of rural practice. To me it offers all of the ‘best bits’ of medicine and has been a rewarding career. But it is not everyone’s cup of tea...many junior doctors make their career decisions based on what they don;t like...and many will not be exposed to the over 70 different career options within medicine. Sadly many will be put off rural medicine through lack of exposure and the misapprehension that the work is unrewarding.

I have just been sent this piece by a colleague, spoofing the manner in which choice of specialty in medicine is made. I seem to recall a similar collection of comments posted on ‘Doctors Net UK’ - regardless, it is deserving of a wider audience.

I particularly like the concept of specialists ‘stuck in a loveless marriage of convenience’. I’m lucky to be a rural doctor, flirting with many different interests...

How I Met My Specialty

I was an impressionable yet cock-sure intern when I started a relationship with a girl called Surgery. She was really sexy and I’d had my eye on her most of my time through medical school. I finally wooed her after a lot of hard work and for a little while things went well. My friends thought she was hot and my family thought she would be good for me long term. But behind closed doors, she was either aloof or extremely demanding and I seemed to be spending all my time trying to please her. In the end she was just too high-maintenance for me and we went our separate ways. I think we both knew from the beginning it wasn’t going to work out. On the quiet, behind closed doors, she was far too much into sadomasochistic control and humiliation. She liked to inflict pain on all her new boys, for a very long time and whether they want it or not, and I've never been one to put up with that kind of abuse. Plus she was obsessed with how people are put together rather than going any deeper. Never the girl for me, although I spent a lot of time thinking I wanted her, until I got to know her.

I soon started a relationship with a lovely girl called Anaesthetics. I have to admit I had been kind of seeing her behind Surgery’s back. She was a wonderful girl. We spent ages just sitting there watching the world go by, talking about nothing. We had some really exciting times too. Well at the beginning. But those times became fewer and farther apart as I got to know her better. I was comfortable with her and she was very supportive but there was a side of me that was never going to be happy. Added to which I kept on flirting with Surgery over the green curtain. In the end, as much as I cared for her very much, I just couldn’t see myself with her for life. Besides that, a friend told me that she went to sleep with multiple partners...

Of course, it wasn’t all bad – there was a weird little ménage-a-trois going between Anaesthetics, ITU and General Medicine for a while. They both got along really well – they were quite alike in some ways but really bewitchingly different in others. ITU is like the supermodel version of medicine - a tired, broken shell of what she used to be. General Medicine, or Genny as we call her, has been too kind to too many for too long and spends all of her time overwhelmed, so there's no love and attention anymore, she's just dragged from one disaster to another, never really loved and used by so many people. It would be great if she could harden up and say no to some people now and again, but her upbringing won't allow it and her old fuddy-duddy parents accuse her of laziness, and manipulatively demean her with "in my day" stories when she points out modern problems. She's got some great new mates really trying to help her out and make some opportunities for her, but I can't be there whilst she gets sorted out - it may never work, and I'll give up too much watching her sobbing through every night to spend my life with her.

Anaesthetics was such a calm, sorted out person but sometimes when I just wanted a bit of crazy in my life she was not really up for it.  Fortunately ITU was there and was always ready for a riot – usually at 3am on a Saturday night! She could be pretty aloof sometimes, and picked and chose her moments - Genny Medicine really got upset with the way she sometimes just sauntered off and refused to get involved.

Our happy little ménage-a-trois was suiting everyone really well - Anaesthetics had her devotees who would see no-one else, and ITU had a couple (but not many) regulars - she didn't like the full commitment, too much pressure.

Unfortunately some of the more judgemental of the new-wave evangelists couldn't understand our love, and hated us for it. They said we were only dabbling in a relationship and kept trying to split us up. They said I should make a decision now and forever between the two. It was all very confusing.


So I left the girls at it and flirted with EM (she’s changed her name – she was A+E when I met her of course) and I seemed to have found the right girl. It was tricky at the start because my friends and family thought she was a bit of a nightmare and rather unconventional. My mum certainly took time to approve of her. My uncle, an orthopaedic surgeon, thought she was a bit of an easy tart. But they came around because they realised that I loved her. We were made for each other. Sure she often threw complete hissy fits and I was up all night essentially getting abused, but she calmed down eventually. She tolerated my short attention span and my own tantrums. She was always challenging me (she’s rather experimental at times!) and coming up with something new for us to do together. I look back on those times with some fondness – it was dysfunctional, chaotic, passionate, stimulating and somehow it worked.

As a mate said, EM’s always good when you are on the rebound because: 

1. EM is easy in, easy out. If you don't want a major commitment you can have an on/ off relationship with EM and it's OK.
2. There's a lot of variety. You want to try something new, pretty much anything and EM will let you get away with it.
3. You want to have a bit of a dalliance elsewhere for a few months, or bring an old flame like anaesthetics or surgery into what you do at nights with EM and that's all good...

EM liked a bit of the rough stuff, and didn't half knock me about but it was all in the heat of passion so it was ok. She certainly knew what got me going. However, I noticed that my juniors seemed to prefer a more stable nurturing relationship - with a girl like, say, Anaesthetics - where they may start off quite unsure of themselves but they can be taken in hand and gently shown all the tricks and the way to do things without fear of embarrassment or feeling neglected and unsupported.

So, although I was very happy with my tempestuous relationship with my wildcat missus EM, I was quite jealous of the number of suitors the somewhat homelier girls seem to attract. I began to think that perhaps EM needed to clean up her act a bit (actually, a lot) otherwise she faced the very real danger of ending up as a bitter lonely old spinster

So what to do? By this time I was several years out of medical school – I’d had dalliances with surgery, with anaesthetics (and a bit of ITU on the side) and a rough n tumble with EM. I needed something different...

I think it was at a party when I met Psychiatry. I'd heard about her before I met her, and to be honest she sounded a bit scary. But as soon as I met her I found her a fascinating character. There was never a dull moment in our relationship, always something wild and crazy going on, and although she's often misunderstood by others I thought she was just the most amazing girl ever. Until I realised she was a bunny boiler.

I reckon it was then that I sought solace in someone younger. I had a romance with a teenager called Paediatrics. She was a wonderful member of the family; very rewarding, fun, an excuse to have good toys and everything can be made right with a sticker. My parents loved her, although my ex-partners were very jealous of the attention that I gave her. Like EM she tended to have tantrums at night and woke me up at very inconvenient times, even if she was staying with someone else. There was also the massive problem of her birth mother, Midwife. She is an evil witch and tries her best to undermine me at every turn. One minute Midwife is being nice and asking for my help, the next she is a screaming banshee! 

Paediatrics tended to behave like the child in the nursery rhyme; when she was good, she was very very good but when she was bad she was horrid! She inflicted great joy but also great sadness. Her best friend and ally, Parents, were also trying at times. In the end I realised that she was just too young for me... I needed something more mature.

I met someone called aged care. She was profoundly unattractive, obese, smelled terribly and was into all sorts of kinky shit. She knocked me out, kept me in the basement and beat me daily, frequently anally violating me violently and forcing me to eat broken glass and drink my own piss. Gradually I came round to see that this sort of shit life was all I deserved anyway. For a solid six months it seemed normal to dress in a gimp suit daily and if was lucky, she’d occasionally let me out on a leash. I was still getting sodomised everyday though...

Then one night I met a lass called Neurology. She was sexy, and everyone was very impressed that I'd managed to woo her. It was a very cerebral relationship - she loved setting me puzzles and watching me solve them and at first we had lots of fun together. But gradually, I realised that once we'd solved the puzzle together there was nothing afterwards - she didn't know how to treat anyone well in the long term. As the puzzles kept on coming, I gradually saw that even my clever-seeming girlfriend didn't really know all the answers.

I started dating GP. She had some of the nice qualities of EM, but was a little less erratic. Plus I found that things were almost tantric, sometimes going on for months rather than the hours that EM had. I eventually married GP but I always remembered EM, though...

Recently EM and I got back together after a chance encounter in Australia. Turned out GP was a bit curious too - and so I have found myself with EM several times a week, and sometimes with GP at the same time! GP is really happy about this as she knows that when I am with her I am actually better than I used to be. EM likes it too, as sometimes GP pops up in the hospital and I'm better there too. 

As if that wasn’t enough, Anaesthetics comes to play a few times a month and we have the most fantastic times together – I’m not as young as I used to be, and there’s a chance that doing all three will kill me...but I’ll keep it up for as long as I can manage.

Who'd have thought that I'd have ended up a polygamist!

Still, I look at some of my specialist colleagues from medical school - trapped in a loveless marriage of convenience.

Nothing like a fine wine

Living on Kangaroo Island, we are blessed with not only gorgeous coastline, fine fishing and abundant wildlife...but also great food & wine.


I am indebted to one of my colleagues (you know who you are) for the following article "Wine Enema and Proctoclysis"...

This is important research. No doubt questions such as red vs white, whether cork or screw-top remain to be answered. 


This of course has got me thinking about the rectal route as a means of drug delivery. I am certainly familiar with rectal paracetamol or indomethacin for pain relief. I've also heard that the British Army favours the rectal route for rehydration in the field...and have dim memories of shipwreck survivors administering salt water enemas on life rafts to keep alive.


Anecdotally, I've also heard that the French paramedics may use a Mars Bar (or local equivalent, presumably "Le Mars Supreme") administered rectally as their first line approach to hypoglycaemia.


In which case, if making up a prehospital pack, perhaps I should make mine a Toblerone!

Splendid News!

Just heard that former Kangaroo Island doctor, Dr James Doube, has been awarded the Antarctica Medal.

Jamie is currently over in NSW doing anaesthetics upskilling. If we are going to talk about skills of rural doctors, then I reckon this chap is up the top - he’s a GP-surgeon, an excellent doctor and will soon have his anaesthetic ticket.

Moreover, he’s comfortable with tackling ropes, steering a boat in frigid Antarctic waters and even penguin or seal anaesthesia.

James came to Kangaroo Island a few years back as a GP-registrar, having already served one tour down on Macquarie Island. Inevitably he was drawn back, especially to be part of the rabbit eradication programme down there.

He is truly one of those Magyver’s of medicine and if I were ever stuck in a lifeboat I would pray that someone with the calibre of Dr Doube was with me.

You can read more at

http://www.antarctica.gov.au/media/news/2012/2012-antarctic-medal

and I copy this from the press release 21/6/12

"Dr Doube who was the Station Doctor, Search and Rescue Leader, Field Training Officer and Watercraft Operator for more than three years received the award for outstanding service to Antarctic expeditions to Macquarie Island.

“Dr Doube has an exceptional level of skill across a variety disciplines including generalist medicine, expedition medicine, public health and occupational medicine,’’ Mr Burke said.

“He has honed skills in biology and science, communications, media, search and rescue and field support and enabled the success of the various expeditions and programs and is an inspiration to other doctors practicing remote medicine.”

Jamie, bloody well done mate. You are a credit to rural doctors and the AAD.

Just get your good self back to Kangaroo Island next year, because you and I have to set up the faecal transplant clinic next door to the Hospital, as well as the planned penguin anaesthesia theatre suite.

Dr JD, back row, left with fur skin hat

Catching up with colleagues

Interesting weekend, spent with Dr Pete Gilchrist and family who were visiting Kangaroo Island...Pete is a fellow SA GP who, like me, had to move interstate to NSW in order to upskill in anaesthetics due to the dearth of training positions locally. Six months down the track we were able to catch up and compare notes on experiences both whilst training and also now in independent anaesthetic practice without the immediate backup of a FANZCA.

At the same time, I read an interesting comment from Dr Minh le Cong (aka the internet’s “most promiscuous medical blogger”) of RFDS Queensland who commented on his own anaesthetic training and relevance to prehospital medicine...particularly the need to learn key skills early and focus on the basics - securing the airway, maintaining ventilation over-and-above fancy or advanced techniques....but also to be well versed in crisis management and dealing with the unexpected’ - as there is noone to back you up in the bush. Minh comments:

“During anaesthetic rotation I got taught RSI a certain way and was told get good at this and you will be fine. Only occasionally I would get an anaesthetic supervisor who would really put you through your paces and test what you thought were adequate routines. Doing a whole anaesthetic using mask ventilation alone, or giving only half the usual dose of propofol for intubation..or tubing from the side position. In prehospital and retrieval medicine, nothing is standard and trying to make anaesthetic skills fit into that environment is challenging when you have learnt them in a controlled setting. The only way to manage this is deliberate practice of non routine. Practice your routine but throw in an uncommon problem and troubleshoot. Practice the permutations. Airway management in the critically ill and injured , in the prehospital setting , is like a street fight. If all you ever learnt in unarmed combat was how to deal with punches and kicks and then you get into a situation where someone pulls a knife on you, what good is your training? Its generally true that most of the time, you dont need RSA , DSI or bougie via SGA. But the challenge is when you do need those skills, are you prepared?”

I’m grateful for the 12 months experience I had in NSW...and the Joint Consultative Committee on Anaesthesia seem to have a fairly robust curriculum laid out. Of course, one of the difficulties for both budding anaesthetic trainees and their supervisors is the need to impart key knowledge that is relevant.

A common criticism is the mismatch between anaesthesia as practiced in the elective, fasted non-urgent theatre case vs management of the emergency airway in a critically-unwell patient...Cliff Reid’s excellent rant ‘the propofol assassins’  makes this distinction very well indeed. So, what then are the key components for the rural GP anaesthetist (or indeed the rural GP on the A&E roster who is a de facto ‘occasional intubator’?).

• competence in airway assessment, use of adjuncts and effective bag-mask ventilation
• ability to safely deliver an anaesthetic via laryngeal mask or endotracheal tube
• critical decision-making in airway management
• ability to manage the emergency airway (typically unfasted, soiled with blood/vomitus and hypotensive)
• anaesthetic crisis management
• a smattering of ICU and prehospital care

In the past year I have been fanatically looking at difficult airway management - not because I particularly want to manage anticipated difficult airways (these are the cases I will be referring to my specialist colleagues)...but more because I recognise that occasionally an unanticipated difficult airway arises and needs to be managed - so I want to have both the tools and the training to safely manage on my own. Thankfully this is a shared passion, and the past year has seen a wealth of information coming through the blog-o-sphere, much of it not taught by old school anaesthetists. Paul Baker of ANZCA has given me some great advice, as has Minh and a few other medicos ‘out there’.  So added to my thereapeutic armanentarium are tips and techniques such as:

• Delayed Sequence Intubation
• preoxygenation with nasal cannulae adjuncts & apnoeic oxygenation
• LMA as a conduit for intubation, utilising affordable videolaryngoscopy
• DAS algorithms

Hopefully some of these will be alluded to as my paper on 'difficult airway equipment for rural GP procedralists' draws closer to publication - reviewers comments gratefully received last week and corrections duly made, so hopefully it will get final approval shortly...

On the whole I was fortunate enough to be exposed to supportive anaesthetists who ‘got’ what Pete and I needed to learn in our limited period of anaesthetic training. Recognising that we had particular needs and a strong practical focus to deliver safe anaesthesia for both elective and emergency cases, they taught us the basics in a reliable manner to ensure our safety and that of our patients. But of course, there’s always the odd one out. Some specialists struggle with the concept of rural doctors delivering non-primary care services such as emergency medicine, obstetrics and anaesthetics. They feel, and I can understand this, that the criteria to safely practice in a specialty are the appropriate period of specialty College training and demonstrated competence by primary and exit examinations. The problem of course is that there are no specialist emergency physicians, obstetricians or anaesthetists in much of rural Australia. By necessity, rural doctors undertake training beyond that of an office-based general practitioner in order to safely deliver these services in the absence of specialist care.

So there is a potential tension between some specialists and the concept of “Macygvers-of-medicine” rural doctors. At a personal level, this manifested last year in one specialist behaving as a bully to the GP-anaesthetic trainees under his care. There was a report about bullying in medicine in the media last week, and it reminded me just how awful it was to be a forty-something doctor, going ‘back to school’ in the tertiary hospital and occasionally treated as something that the cat dragged in by one specialist who clearly held GPs in low esteem. Thankfully I have insight enough to see that this says more about that individual than myself..indeed, it has reinforced my belief to ‘act like a professional, even when others around you are not’. I won't name this individual...complaints were made last year, but AFAIK nothing came of them. Ultimately neither Pete or I will have to work with this individual again...however specialist colleagues will and they may wish to not rock the boat to make working life tolerable.

Whilst this bullying behaviour casted a blight upon an otherwise enjoyable year, by golly it made it good to get back to private practice and get away from the hierarchy of a teaching hospital. I have reaffirmed to treat my registrars and students as I would expect to be treated myself...

The 2011 GP Anaesthetist Trainees from NSW
The identical T shirts are an unlikely coincidence - no reference
is implied to any specialist anaesthetist alive or dead

Dismissal of the value of rural doctors is not just confined to a few individuals. On a system level, there is an increasing move towards centralisation of services. In SA many health-decisions are metrocentric, with opinions from city specialists often driving such changes. My fear is such an approach leads to ongoing deskilling of rural doctors, of downsizing of rural hospitals in terms of capabilities and staffing, and increased movement towards centralisation of services...

And so the house of cards collapses - a rural hospital loses obstetric services due to a metro-based health edict...and within a year or two theatre services are also lost...nursing staff begin to look to the city to do lucrative agency shifts rather than work locally...rural doctors with procedural skills have no opportunity to use them...and so move elsewhere (often interstate)...and within a very short period the local community is bereft of both doctors and nurses, and their local hospital is further downgraded to a first aid station...and any patient with a problem more urgent than needing a band aid is sipped off to the city, usually by the hardworking RFDS and put more strain on the already-stretched metro public hospitals.

One other thing struck me talking to Pete - the similarities with the hassles he has faced with his regional training provider (my training finished in 2005, but seems not much has changed) and the fact that the issues he faces in his rural practice are much the same as mine - yet there is no common method of talking about things like practice management, dealing with health bureaucracy. We are all operating in silos, rather than in unison. Now clearly there may be ACCC issues if rural doctors collude on price fixing etc...but one wonders if there is scope for sharing of knowledge on practical problems - ensuring adequate numbers and skills of future doctors, equipment & training for emergencies etc etc - surely such collaboration is for the betterment of patient care, not to detract from it? The internet is a powerful medium...the UK's www.doctors.net.uk has been effective in coordinating over 180,000 UK doctors...shame we don't have a similar network for rural docs in Australia to problem-solve and advocate for our communities.

Zen & the Art of ED Management

There has been a lot of discussion this week regarding pressure on the Emergency Department at Flinders Medical Centre in South Australia.

Rack 'em and stack 'em!

I have a ‘soft spot’ for Flinders. I worked there as a junior resident and then registrar in the late 90s/early naughties and like to think that I learned a bit. The Consultant staff were excellent and engaged in training. The nursing staff were fantastic. And the work was great fun - I certainly enjoyed the immediacy of emergency/critical care but was seduced away to rural medicine by the lifestyle advantages and variety that this work offered. More importantly, the one thing that affected my decision not to complete training in ED/ICU was the lack of control over factors in my work (some might say that dealing with Country Health SA is similar, and you would be right, but more of that in another post).

The big issue for the ED is ‘access block’ - the inability to efficiently deal with emergency patients because there are insufficient beds in the ED..because there are patients waiting for beds ‘upstairs’ ie: in medical and surgical wards. And why are there no beds? Because the medical and surgical wards are either run at 100% capacity leaving no room for ‘surge capacity’...and/or that medical beds may be clogged with patients awaiting discharge to home, nursing home or country hospital.

Because there is no slack in the system, the clogging of ward beds filters back to the ED causing access block. And when the ED is full, the unhappy situation arises when ambulances cannot handover their patients because the ED is full and ambulances are ‘ramped’(literally wait on the ramp outside the ED). And tying up ambulances waiting outside EDs means there are not enough ambulances to deal with emergencies in the community.

Ramping has been a common phenomenon at Flinders Medical Centre in the past few weeks. Last Friday I was at an EMST course at Flinders and heard that the Director of ED, Dr Di King had resigned after being called into the CEOs office and asked to guarantee that ramping would not occur.  Of course this is impossible - Dr King has no more control over this than anyone else - the solution lies with the CEO and Minister of Health, not the ED Director. And so Di resigned, putting more pressure on a beleaguered Health Minister.

Yesterday Dr Dave Teubner came out and said it was safer for people to remain in an ambulance than to be seen in the ED. Dave is a passionate ED doc...he is not some hopeless academic, but a chap who really gives a damn. He is of course correct - it is better for people to be at least in an ambulance with oxygen, suction and a paramedic than lost in a corridor in the ED, unobserved and awaiting assessment or treatment with access to neither.

In essence, the whole idea of a well run health service should be to ensure that care is escalated with every referral. It is frankly dangerous to have care take a step downwards from ambulance to ED, as is the case at FMC when under bed pressure.

This is a concept that is a particular hobby horse of mine - the idea of ensuring there is never a ‘therapeutic vacuum’ or ‘inertia of care’. Every single thing we do should improve patient care, not stall it or even detract from it.

Certainly people admitted to an ED should see an increase in the level of care delivered to them. And so on...every single doctor, nurse, paramedic is doing his or her utmost to make this happen.

But the system seems to conspire against us.

And of course this is not just about ramping in the ED. It also applies to rural medicine, to the operating theatre, to in-patient care and to discharge.

Like many people working in health, I get hot-under-the-collar bemoaning failures in ‘the system’ where things could (and should) be better. Particular bugbears include 

• lack of equipment to manage a difficult airway in rural EDs and theatres
• lack of ownership of equipment and emergency training for rural staff
• cost-shifting between State and Commonwealth coffers for ED patients
• lack of discharge summaries from people who have been admitted and discharged from metro hospitals

...and so on.

What can we do to improve things?

Well, political pressure is one - I would imagine that Dr Di King’s resignation has served to highlight the issue locally and perhaps prod the Health Minister into action. 

More so, we can engage and try to make things better. I’ve been revitalised in the past few months by some of the information coming through the blog-o-sphere, with concepts of relevance to my practice that one is not going to get from a textbook or clinical placement. So I’ve done a survey on difficult airway equipment for rural GP-anaesthetists. I’ve offered to run some small group scenario-based sessions for nursing staff at the end of each of my anaesthetic lists and whenever I am on call for A&E. And I’ve been developing a web-based repository of emergency training for local use...how to set up the oxylog, where to find and use the rapid rhino kit for dealing with an epistaxis, a dump mat for RSI etc.

Another new idea is borrowed from the UK - a ‘one minute wonder’ fortnightly update on topics of relevance for our multiskilled rural nursing staff - basically a single A4 poster explaining how to find/set up/use a piece of ED equipment - displayed on the wall above the iStat machine to give people something to read whilst waiting for the iStat or Troponin reader to do it’s stuff.

Small things, but they might make emergency management in the bush easier.

Of course, the astute reader would wonder why these initiatives are not flowing ‘top down’. It would seem intuitive to have a minimum standard of airway equipment in rural hospitals, to have standardised ED kit and protocols, to train staff in equipment use beyond the token annual ALS refresher.

But this doesn’t happen. Change takes time, there needs to be initiative and drive, and solutions need to be appropriate to the local situation.

Anyone else got any pointers to drive change and improve emergency management in rural areas?

Advances in Trauma?

Well I’ve just got back from an EMST Refresher course in Adelaide.  This is the first time I’ve taught on a refresher course and it was nice to meet other experienced faculty as well as (mostly) rural doctors doing this refresher course. The Provider courses that I usually teach on are not usually so filled with rural doctors - more junior RMOs doing EMSt as a requirement for surgical training ANZCA no longer has EMST as a requirement for their trainees).


EMST is very much an entry-level course, but is well suited to the needs of rural doctors who often have to manage trauma as a solo doctor with limited resources. It should be borne in mind that over 40% of major trauma originates in rural Australia, so there is real bang for buck in getting effective trauma care delivered to these patients, whether y rural GPs or aeromedical services.

On this Refresher course, the hands on scenario-based skills stations seemed well received. I also had an hour after the MCQ to talk about ‘Trauma Teams and Advances in Trauma’ - a golden opportunity to chat about things like human factors in trauma team dynamics, as well as to draw on experiences from the group about well-run and not-so-well run traumas.

But what about ‘advances in trauma’ that are not covered in the EMST Provider course? Well, I reckon they can be broken down by category and it was this approach I used to guide discussion in the 30 minutes or so available to me for each group:

AIRWAY

Videolaryngoscopy as an adjunct for difficult intubation

Ketamine for trauma intubation

Difficult Airway Society algorithms

Andy Heard’s excellent youtube videos on CICV

Cliff Reid’s notorious ‘propofol assassins’ rant

Weingart/Levitan’s paper on preoxygenation

BREATHING

Finger thoracostomy

Ultrasound for evaluation of pneumothorax

CIRCULATION

Minimal volume resuscitation

C-ABC and tourniquets for catastrophic compressible haemorrhage

Tranexamic acid, CRASH II trial & applicability to rural Australia

Managing major traumatic bleeding in rural hospitals (big shout out to Casey Parker’s excellent blog on this at Broome Docs)

We didn’t get as far as DISABILITY but I daresay that discussion of hypertonic saline in head injury would have come up...

The discussion really made me think just how knowledge-hungry the rural doctors I met were, but how hard it was for information to be disseminated to these guys.   It cemented my belief that a  rural masterclass course would have a willing audience. There’s lots of new stuff to discuss in trauma alone, but add in other (non-trauma) areas of interest to the rural proceduralist and you’d have a gutsy, useful, evolving course with enough content for 2-3 days. I could rant about this for ages...

All I could do was relate my own experience in past year or so, and the value of internet-based learning and discussion which has re-vitalised my own enthusiasm for learning. Big shout outs to the rural docs for the education resources below :

Minh le Cong’s retrieval resources for ACRRM members at www.rrmeo.com and his new PreHospital And Rural Medicine (PHARM) blog at www.prehospitalmed.com

Cliff Reid’s excellent blog at www.resus.me

Casey Parker’s excellent Broome Docs, the central repository for all things relevant to the rural proceduralist

Those UCEM rascals over at Life In The Fast Lane

Scott Weingart's EM-crit blog

Common themes amongst the rural proceduralists I spoke to remained

• difficulty accessing medical equipment (videolaryngoscopy, infusion pumps and fluid warmers were common ‘wish lists’)
• difficulty with triage and training for nursing staff in rural hospitals
• desire for cross-training with RFDS/Retrieval service in terms of infusion regiments, SOPs and equipment

In Country Health SA, there are nominated rural doctors as ‘consultants’ in each of the areas of emergency medicine, anaesthetics, obstetrics & surgery. According to CHSA, their role is to :

• be responsible for providing clinical system advice and broad support to rural resident medical practitioners in country South Australia, in their identified area of expertise
  
• act as a point of contact for clinicians in country regarding system issues, as related to their specialty area, and participate in problem resolution
  
• participate in the development of policy and procedures that guide clinical practice in country. In addition, the Chief Consultants will work with the Chief Medical Adviser, Country Health SA and other country health staff related to decision making and policy setting as related to their speciality area 

With the exception of obstetrics, for which there seems to be a proactive rural proceduralist, it is hard to point the finger firmly at any positive attempt to address the above issues by present incumbents. In fact the rural doctors I spoke to (those with EM or anaes skills) were not aware of any initiatives in past year or so by the CHSA EM or Anaes consultants.

Which is a shame, as it seems these rural docs were struggling with similar issues in their own institutions, but lacking a top-down approach to streamline equipment, protocols & training. Rather they were having to push for equipment/training by dealing with local DONs of the hospital, usually being rebuffed as 'no money' in CHSA. It seems that my problems on Kangaroo Island with equipment/training are the same as those in Port Lincoln, the Riverland, the South East etc...and we are all trying to fix in our own manner, which mostly comes down to enthusiasm for a particular issue at any one time. No wonder things are fragmented.

Meanwhile not a week goes by without another meaningless diktat arriving in rural doctors email from CHSA detailing the latest policy. Useful stuff...for example I've learned that dabigatran can cause bleeding (well, duh!)...and that I probably should not inject chlorhexidine down an epidural catheter. I only wish the same regard for safety was applied to trauma management and crisis management in theatre or the ED of rural hospitals...

Phil Tideman of iCCNet has revolutionised how cardiac patients are cared for in rural South Australia, with an initiative over past decade to place point-of-care troponin, proBNP and iStat machines into all rural EDs, as well as standardised protocols for management of ACS/STEMI & heart failure patients relevant to rural practitioners. Whilst I am not a huge fan of centralisation of services, such standardisation in equipment and protocols has had demonstrable benefits for these patients...similar with obstetrics under Steve Holmes' wise guidance. Why not extend the same to trauma, emergency and theatre patients by assessing needs of rural doctors and addressing their common issues?


A simple issue, like availability of difficult airway equipment or new advances like tranexamic acid could and should be addressed by these consultants.


Perhaps it’s time for some new blood in CHSA to represent the rural proceduralists in SA?

Obfuscation & the 'Blame Game'

Well, I was not expecting that the letter in my last post would be referred to in 'The Weekend Australian' in follow-up to a previous report. Thanks to Dr Scott Lewis of Wudinna for telling me.

Oh dear.

There seems to be confusion about the issue of ED patients being charged fees in rural SA hospitals. It's something that has been an issue locally every since I have been on Kangaroo Island, and my colleagues tell me has been going longer still. I refer to the fact that patients presenting with serious problems (examples might include assessment after a car crash, a suspected fracture/dislocation, a forensic medical exam after sexual assault, repair of a complex laceration) are forced to pay the attending doctor, whilst they would receive the same service for free in a metro ED or interstate.

This is counter to the Australian Healthcare Agreement and the letter which is referred to in the Weekend Australian support this. The practice has been longstanding in South Australia, and I reckon arises over confusion over what is an emergency and what is a GP-type service.

The Australian college of Emergency Medicine have recently issued a media release that dispels the myth of triage 4/5 patients being 'GP-type' attendances, and highlights concern for such cost-shifting between State and Federal coffers.

Me? I am just fed up having to charge people for conditions that are more serious than your usual GP attendance, more so when they have been referred to the ED by another GP or a GP after hours service like HealthDirect. Don;t get me wrong, I am happy to charge privately for my services when it is appropriate - but charging a mental health patient, a rape victim or a car crash victim several hundred dollars just seems wrong. Much better to be paid by the Health Department, after all the doctor is attending in his/her role on the on call A&E roster, not as a private arrangement.

Today I received an email from the Rural Doctors Association of South Australia, which appears to cling to paragraph G21 of the Australian Healthcare Agreement, which allows for medicare billing in the specific circumstance of "eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor" (my emphasis underlined).

The RDASA email states:

There has been a lot of email traffic and concern from you about the article appearing in the Australian over the weekend inferring that charging patients for after-hours services in publicly funded hospitals was contravening the National Health Care reform document. 

Please be assured that the RDASA Executive have taken immediate action on this issue, writing to Minister John Hill referring him to section G.19 of that Agreement and the assurances from CHSA that the current arrangements are acceptable to the Federal government. We have sought written confirmation that:

·         Doctors can bill Medicare for triage level 4 and 5 after-hours consultations that occur at public country hospital facilities

·         Doctors will not have to pay back any money to Medicare for money already collected

Maybe I am being thick, but it seems unfair to use clause G21 to then slug rural patients for services that would receive for free in a metropolitan ED or interstate.

RDASA seem curiously quiet on this issue of equity and I fear that this approach may be regarded as more about preserving doctor's incomes than in equity for their patients. Given that many of these patients are genuinely in crisis or not-medicare compensable (particularly in a tourist location like Kangaroo Island), I would much prefer to be paid by the Hospital for my services rather than bulk bill or chase bad debts. After all, the Hospital called me as the A&E doctor for the hospital, not the patient as part of a prior arrangement or agreed private service.

Anyway, here's my letter to the RDAA on this issue. It will be interesting to see what eventuates.

Comments, as always, welcome.

Paul Mara

President

Rural Doctors Association of Australia

10 May 2012

Dear RDAA

You may be aware of the recent ‘Weekend Australian’ article regarding billing of public patients attending public emergency departments in South Australia (http://www.theaustralian.com.au/national-affairs/state-politics/warning-for-states-on-hospital-charges/story-e6frgczx-1226347278031). Last month I received a letter from Minister Plibersek’s office (attached) which supported my concerns regarding the practice of charging public patients in public EDs for non-admitted services. This letter was posted on my blog site and subsequently referred to by The Weekend Australian without my knowledge. 

I have been seeking clarification on this matter since 2007 from the South Australian Health Department, as there exists significant potential for cost-shifting from State to Federal Health budgets. Specifically, patients who attend the Emergency Department are annoyed at having to pay fees for non-admitted attendances in rural areas.

I should clarify that these fees are being charged not just for GP-type attendances, but for ED attendances that require the resources of a hospital and can chew up considerable time for assessment and treatment. Many of these patients have been referred to a rural ED by GP-after hours services such as HealthDirect, and are not typical of GP attendances in metropolitan areas. Examples might include the assessment of car crash victims after a rollover, forensic medical examination after sexual assault; urgent mental health assessment of patient brought in by Police; the assessment, X-ray, manipulation under anaesthetic and plastering of fracture/dislocation; repair of complex laceration etc. These are services that Country Health SA has in the past deemed ineligible for admission and hence cost-shifted to Medicare by refusing to remunerate doctors on the A&E roster.

On questioning this in the past, South Australian doctors have been directed to clause G21 of the Healthcare Agreement which states:

"in those hospitals that rely on GPs for the provision of medical services...eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor"

The most recent (indeed, only) contract between rural doctors in SA with Country Health SA goes further, to state :

“after hours GP services and non-admitted emergency services are provided under the Medicare system (ie the patient is charged by the medical practitioner and seeks reimbursement from medicare). For the avoidance of doubt, Country Health SA shall not be liable to pay any fee for such services”

This statement in our contract neatly ties both emergency attendances and after hours GP services under the same umbrella, ie: to be charged to Medicare. This is at odds with legislation.

I understand the RDASA has recently written to the RDAA on this matter. From the email to SA members, the issue has been obfuscated by confusing triage 4/5 patients with GP-type attendances, an assertion that is not reflected in either the National Healthcare Agreements or current contracts in SA. Indeed, the Australian College of Emergency Medicine gave recently issued a media release on this very issue, dispelling the myth that “ED triage 4 or 5 patients = GP attendance” and highlighting the concern for State to Federal cost-shifting by such ploys (see http://www.acem.org.au/media/media_releases/GP_Patients_ED_attendances.pdf).

I am concerned that this issue disadvantages rural Australians In SA who may defer ED attendance for potentially serious conditions due to fear of fees. I am concerned that the SA Health Department is promulgating an interpretation of the Australian Healthcare Agreement which is at variance with other States and which both Medicare and the Federal Health Minister’s office have told me is not allowable. I am concerned that genuine GP after hours or private arrangements (where I am more than happy to charge a private fee) are being used as a cover to defray State health costs.  For the record, can I ask for your assistance to clarify with the Health Minister and RDASA:

1. that the Australian Healthcare Agreement states that eligible public patients are entitled to free emergency care in a public ED,

1. that the South Australian Department of Health is responsible for provision of emergency medical services in both metropolitan and country areas,

1. that the contract between rural doctors and Country Health SA is to participate in on-call services for Emergency Medicine (A&E), not GP-after hours services,

1. that whilst clause G21 does allow for rural doctors to charge privately (with Medicare rebate) this is only in the situation where patients “request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor”. Many patients who present to the ED have either been referred there by a GP or an after hours service (HealthDirect) or else have needs that require ED attendance. They have not requested treatment by their own GP nor is their a pre-existing prior arrangement with the doctor on call for the A&E roster for the State Health Department.

1. that in situations where a patient elects to be treated privately by their own GP then clause G21 applies and Medicare fees are allowed,

1. that the assertion that triage 4/5 patients are to be billed under Medicare is not supported in the Australian Healthcare Agreement and indeed is counter to advice from the Australian College of Emergency Medicine who dispel this myth in a recent media release and state “It is in the political interest of state governments to ensure that any definition of general practice patients seen in EDs yields high numbers. This helps perpetuate the myth that EDs have too many GP patients.”

1. that the situation as it stands in South Australia is at odds with arrangements interstate.

I would be grateful for your clarification on the above points. To my mind it is vital that rural Australians are not disadvantaged when attending the ED with a genuine need. Similarly there may be concerns from rural doctors that such Medicare-billing is not supported and there needs to be clarification that such practices are allowable in certain circumstances (eg: as part of a GP after hours service utilising the local hospital premises, ie: private arrangement, ongoing care). I am happy to charge privately for my services when it is appropriate - but charging a mental health patient, a rape victim or a car crash victim several hundred dollars just seems wrong. Much better to be paid by the Health Department, after all the doctor is attending in his/her role on the on call A&E roster, not as a private arrangement.

I am sure you would agree that it is important for rural doctors to be seen to uphold the same standards in each State and to ensure that neither patients nor doctors are disadvantaged.

Sincerely

Dr Tim Leeuwenburg

Kangaroo Island, South Australia www.ki-docs.blogspot.com