A Course..a Course! My Kingdom for a Course!

[adapted from King Richard III, Shakespeare, W 1594]

Well, this week I am up in Darwin teaching on an EMST course. The Early Management of Severe Trauma course is the Australasian version of the worldwide Advanced Trauma Life Support course from the American College of Surgeons. The history behind it is interesting, but the bottom line is that this course teaches a uniform, practical and structured approach to the management of trauma...identifying and treating immediately life-threatening injuries (hence early management of severe trauma).

I’ve been teaching on this for a few years now and I enjoy the interaction with other Faculty. Although badged under the College of Surgeons, Faculty are a hotch-potch of surgeons, anaesthetists, intensivists, retrievalists, emergency physicians and the odd rural doctor. I think they put me on the Faculty for comedy value.

But I always learn something from fellow doctors who teach...and hopefully the 16 Candidates on each course benefit from our combined experience. It’s something I am pretty passionate about...and later this year I will be taking up the mantle of Course Director which will be interesting.

EMST is just one of the many courses ‘out there’. For rural doctors like me, who need to be able to manage pretty much whatever comes through the door (at least initially until the cavalry arrive), there are many entry-level courses such as:

Advanced Paediatric Life Support (APLS)

Emergency Life Support (ELS)

Rural Emergency Skills Training (REST)

Advanced Life Support Obstetrics (ALSO)

Major Obstetric Emergencies & Trauma (MOET)

...plus a few courses run by State agencies such as rural doctor workforce groups and trauma/retrieval services. Minh le Cong’s RFDS STAR programme looks interesting and I’ve done some components of the James Cook University ‘Aeromedical Skills course’ along with colleagues at MedSTAR. But they are aimed at the prehospital/retrieval audience.

When I am teaching on EMST I often feel constrained by the limitations of the course. Don’t get me wrong, it’s a great programme, and aimed squarely at junior doctors who are developing their skills and involvement in trauma management. But there is just so much more out there...and a lot of ‘current’ thinking is not taught on these courses as it takes time to translate through course manuals, materials and instructors.

I’ve just been reading about finger thoracostomy over on the Scancrit.com blog. It’s a technique I always try to explain & demonstrate in the animal lab and on thoracic trauma skills stations, but it’s not (yet) in the standard EMST teaching.  So I reckon there’s scope for a ‘masterclass’ course, constantly evolving and reflecting some of the topics and discussions that one comes across on the net or that are used day-to-day by experienced practitioners.

After all, medicine evolves and our learning should be lifelong. Why then just have a series of entry-level courses for the rural docs - especially when access to hands-on learning for them is often difficult. Rather than repeat the course, better to advance to a new level.

Such a course would be a great addition to the entry-level courses...the knowledge of which is assumed. It’d be aimed squarely at the experienced rural doctor and could be delivered by our College, ACRRM. Of course they also deliver the REST course - so an advanced course would frighteningly be called something like ‘advanced rural & remote skills training’ or ARREST!

Regardless of the name (and I think something along the lines of ‘rural masterclass’ or ‘current topics in...’ etc work better), one can imagine a two day course covering things like:

• ECG phenomena such as Brugada etc
• use of ultrasound inc FAST/RUSH
• difficult airway gadgets and protocols
• what’s new in paeds/O&G

Content would be delivered by experienced rural or specialty docs, with content shaped by participant’s needs and reflecting current thinking. Getting along a few of the reps such as KingVision, Ambu, Laederal, iSimulate and SonoSite would seem sensible and allow hands on of equipment that your cash-strapped, time-poor rural health service would not otherwise have had access to.

Now THAT would be worth the $2K a day procedural upskilling grant that is available.

Had a gutful

Well, it's kind of ironic that over the weekend there's been a small flurry of interest in the issue of non-admitted hospital patients being charged a fee in South Australian country hospitals (see The Australian p7 24/3/12)...and yet at the same time this issue arose locally.


I understand that the Minister of Health is not a happy bunny currently - being the Health Minister must be an unforgiveable job, especially when the budget is squeezed tight. 


And I've recently been criticised for raising this issue - on the basis that it's been going on for a while and may impact on doctor's hip pockets (some rural docs are doing OK charging a $50 gap for non-admitted patients and may be reluctant to see a change in the status quo). 


It's also a fairly intense time at the moment - the contract between Country Health SA and rural doctors remains 'in negotiation' - even though a finalised deal was supposed to have been in place by 30/11/11...and we are on our second 3 month extension. There may be anxiety that politicising this issue will affect negotiations.


I agree and think this issue transcends whichever party is currently in power.


Anyhow I was on for anaesthetics this weekend and was called in by the hospital for a 'cardiac arrest'. I arrived ahead of the A&E oncall doctor and the patient, who was transported by ambulance.  


Suffice it to say that when they arrived at the hospital, the patient was very much alive and indeed combative from another cause. 


After a quick ABC assessment I was stood down and left the patient in the capable hands of my A&E colleague. I understand that the patient left the ED some time later, discharged to the care of a capable adult.


Today I emailed the head of Country Health fee-for-service, asking how this attendance should be billed.


The response? Well, as the patient was not admitted, it is apparently 'a private matter between the patient and the doctor and CHSA is not liable'


I've had a gutful of this. I really don't mind being called in, whatever the hour, whatever the reason. If the hospital feels they need my services, and I am oncall, then I am available and will come in.


But to then turn around and say they won't pay?


Now, this will no doubt be sorted out after the usual barrage of emails to-and-fro until someone (usually the CHSA medical advisor) makes a determination. I will expend many hours chasing the debt, my BP will climb...but ultimately I will get paid.


But it is all so tedious and mind-mumbingly unnecessary. I am fed up with having to chase payment from a health service that seems to apply rules inflexibly and illogically.


I sure as hell am not going to charge the patient - they arrived by ambulance with four paramedics in attendance, two doctors, extra nursing staff etc and were transported to the appropriate place - a nice shiny hospital.


My expectation is that if the hospital feels a matter is urgent, and calls a doctor, then they should pay that doctor regardless of outcome, of subsequent diagnosis or of triage score. I think most common sense people would agree. However the wording of current arrangements opens the door to cost-shifting from State funds (public hospital) to the patient (Medicare reimbursement if compensable).


I don't care, I just want to get paid without fighting every bloody time!


Is this really so unreasonable or hard to understand?

Affordable Difficult Airway Kit

Well, this week I’ve been playing with some AirQ II blocker intubating LMAs (iLMAs) sent to me from a rep.

For those of you not familiar with an iLMA, the device is designed to allow ‘blind’ intubation of the airway, using the laryngeal mask airway (LMA) as a conduit.

The progenitor, with which most rural doctors and anaesthetists will be aware of, is the FastTrach LMA. It’s reported to allow up to 73% ‘first pass’ successful intubation rates, increasing to 90% overall success with repeated attempts and the ‘Chandy manoeuvre’. It’s not a bad piece of kit and we’ve got one on our airway trolley.

However, the FastTrach requires some practice to get used to. I made a point of using it at least once a month during my anaesthetic year, just to get used to the kit. Using equipment in training is quite different to using ‘in anger’, especially when there’s an evolving airway crisis. Problems that I found were

• not always easy to pass the endotracheal tube into trachea
• removing the LMA whilst leaving the ETT in situ is fiddly and risks losing both
• overall success rate is 90% - so 1:10 will fail.

The C-Trach is an advancement on the FastTrach, improving rates for first pass and overall sucess to 96% and 98% respectively - basically this device is just a FastTrach with a video screen attached. Clearly then, addition of video allows visualisation of the cords and improves success rates.

However, neither FastTrach or CTrach allow you to place a nasogastric tube..unless you obturate the ETT and remove the LMA over the top, which is potentially fraght with difficulty.

Cue the AirQ iLMA.

This ‘new improved’ iLMA gets around the problems of FastTrach and CTrach - it’s similar in appearance to the FastTrach iLMA, albeit with a less acute angle. It also has a nifty side-port to allow passage of a nasogastric tube without having to remove the iLMA

Moreover, the device comes with dedicated nasogastric ‘blockers’ - an NG tube with an oesophageal balloon which can be inflated in the oesophagus to minimise aspiration risk and yet allow decompression of the stomach.

I tried it the other day in theatre and found it easy to use. As an LMA it functioned perfectly well, although I have heard some anecdotal evidence of increased supraglottic trauma with this device.

How then to improve success rates for passage of an ETT? Minh le Cong has described this elsewhere - use of a malleable intubating stylet such as the Levitan FPS allows visually-aided intubation through the iLMA conduit.

So we now have a staged procedure for the nightmare difficult airway where intubation has failed or priority is to oxygenate

• drop in an AirQ II and ventilate
• pass the oesophageal blocker to decompress the tummy
• use a fibreoptic device to intubate through the iLMA, improving intubation rate

This strategy (fibreoptic intubation through an iLMA) is Plan B of the UK’s Difficult Airway Society algorithm. Yet how many of us are really prepared to do this and have practiced on kit? Most rural docs have access to a FastTrach...so ventilation and blind intubation are possible - yet the addition of an NG tube port and allowance of fibreoptic intubation seems to offer a higher standard of care. Of course, for many small hospitals fibreoptic devices have traditionally been out of range - high cost and difficulty acquiring and maintaining skills.

But for under $3K you can pick up a Levitan scope (malleable fibreoptic intubating stylet) or the Ambu Ascope II (five disposable flexible fibreoptic scopes). They may not be as good as the fibreoptic towers that people use for an awake fibreoptic intubation...but they are bloody good gadgets to use with the above technique.

So, what would be my preferred kit for a ‘difficult airway’? Well, I’d use the Difficult Airway Society (UK) and ANZCA T04 guidelines as a starting point...and in addition to the AirQ and some sort of fibreoptic device, I’d add in a videolaryngoscope. Sounds expensive? Well my suggestions for purchase are in square brackets below - for under $4K should be affordable for small rural hospitals...

Plan A - Initial Intubation Strategy

Standard laryngoscopy - if fail, change position, blade, operator. Consider use of a videolaryngoscope in case of difficult airway. If fail, move to...

[KingVision Videolaryngoscope ~ A$1000 inc. blades]

Plan B - Alternative Intubation Strategy

iLMA to maintain oxygenation and ventilation, then secure airway using fibreoptic intubation through iLMA. If fail, move to...

[AirQ II iLMAs A$30 each]

[either Levitan FPS or AmbuAscope II fibreoptic devices to intubate through iLMA]

Plan C - Maintain Oxygenation & Ventilation, Abandon Procedure and Wake Up

Bag-mask ventilation and reverse non-depolarising neuromuscular blocker (suggamadex for rocuronium) or wait for suxamethonium to wear off. If fail, move to...

[Rocuronium for RSI - prolong time to desat]

[Suggamadex to reverse rocuronium]

Plan D - Rescue Techniques for Failed Oxygenation & Ventilation

Bag 1 - Paediatric or Easy Anatomy
Needle Cricothyroidotomy technique

Bag 2 - Adult or Easy Anatomy
Scalpel-Bougie-ETT technique

Bag 3 - Impossible Anatomy
Scalpel-Finger-Needle technique

[Melker Kit]

I wouldn’t bother with the pre-packaged kits like QuickTrach or Seldinger kits as first line for CICV - in the heat of the moment, faffing around with wires etc can be a disaster. Better to have three equipment bags set up as above using standard equipment - oxygenate first - then move on to seldinger or formal tracheostomy. Some have commented that doing the above is sufficient to ‘save the day’ then either wake up the patient or proceed to successful laryngoscopy.

Open Letter to the Minister

Well, it's finally happened. I've succumbed to the urge to fire off Victor Meldrew-like letters of indignant fury to the Health Minister over the recent exchange of press releases between Liberal and Labor Health Ministers regarding the issue of country patients being charged fees for A&E services.


Grumpy old doctor aside, I really believe this is an issue that is important. Rural Australians are disadvantaged enough, without having to face fees for A&E services.


I should note that this is not an issue of self interest - as a rural doctor, I derive part of my income from charging fees to attend a patient at 3am. And I am comfortable with charging a fee where it is fair. But when the same patient would get the same service for free in a metro ED, I have to question the process. And when patients are afraid to attend the A&E because they fear a fee, something is very very wrong.


It is true that a private fee can be charged as part of a continuing care episode or by prior arrangement for a patient to see a particular doctor privately. Fair enough.


But the people who attend EDs usually have urgent issues that cannot be dealt with in GP private rooms. They often require services that cannot be delivered in rooms (X-rays, anaesthetic, plaster etc). They haven't asked for a particular private doctor to see them - they have correctly self-presented to the emergency department and the hospital has in turn decided to call in the doctor.


Rural health outcomes are already bad - to charge people just makes this worse.


So - I'd be a lot happier if I was paid by the hospital for attending patients who the hospital feels need to see a doctor urgently, through my contract to provide A&E services. I may be poorer if paid by the hospital, but it would be a fairer system


I am pretty sure patients would prefer it!


Anyway, here's my latest missive.




11-03-12


Dear Minister

I read your latest Press Release re: country hospitals charging fees in response to the Press Release of Martin Hamilton-Smith. Regardless of whichever party is in power, I remain perplexed.

The fact remains, country people are charged fees for non-admitted A&E attendances in rural hospitals,  for services that are provided for free in metropolitan areas.

These are not, as you suggest, charges for routine GP services - your 2010 contract with rural doctors is very clear - non-admitted patients in the ED are considered to be private patients of the GP

Examples of non-admitted A&E attendances include

- forensic medical examination of a rape victim

- assessment including X-ray, reduction & plastering of a fractured limb

- repair of a complex laceration

- assessment of victims of a vehicle rollover

- urgent assessment of a complex mental health crisis

- administration of a neuroleptic agent for reduction of a dislocated shoulder

These are not routine GP services. These services are appropriately provided through an Emergency Department and are provided for free everyday in metro EDs.

When the Hospital calls the oncall doctor, it is through his/her contract with CHSA to provide A&E services, not as a private arrangement betwixt GP and patient. 

Many patients are rightly fed up with being charged fees for services in an emergency. Sadly some patients do not seek medical attention with urgent problems that SHOULD be seen in an ED, for fear of cost. I have recently been told of a patient who delayed seeking medical attention for fear of fees...then presented in extremis several days later and died.

Your press release intimates that the only alternatives are for either GPs not to charge patients their gap fees, or for CHSA to put in salaried medical officers and 'put rural doctors out of business'

You neglect to mention the third option - simply to pay the oncall doctor for the work he or she does, regardless of admission status. Existing fee-for-service arrangements would be more than adequate and would be in line with conditions interstate.

Surely it's not that hard to grasp? If a patient presents to a CHSA hospital with a problem that is deemed urgent, the hospital needs to call a doctor as part of the A&E roster, and the service cannot be provided in routine GP rooms....then the patient should receive the service for free and the doctor be paid by CHSA.

The matter has been needless obfuscated by lack of confusion over what is and what isn't an admitted service..and a continuing reference to provision for private patients to be treated by their own doctor when they request as part of a prior arrangement or as part of continuing care. None of these apply for the patients I am called to see when on your A&E roster.

I rang Medicare last week. They reckoned it was illegal for me to be charging patients for services provided in the A&E department and referred me to the National Healthcare Agreement which states that:

States and Territories will provide health and emergency services through the public hospital system, based on the following Medicare principles:

(a) eligible persons are to be given the choice to receive, free of charge as public patients, health and emergency services of a kind or kinds that are currently, or were historically provided by hospitals;

(b) access to such services by public patients free of charge is to be on the basis of clinical

need and within a clinically appropriate period; and

(c) arrangements are to be in place to ensure equitable access to such services for all eligible

persons, regardless of their geographic location.

As far as I am aware there is no section 19 exemption between SA and the Commonwealth.

How then can CHSA continue insist that doctors on the A&E roster charge patients for A&E services in CHSA EDs for conditions that are certainly serious but may not require admission for the requisite four hours to satisfy admission criteria?

I look forward to your response. These questions have been asked by me previously to CHSA CEO's George Beltchev and Clare Douglas without response.

I hope you can finally answer this, not with political spin, but in the interests of rural patients who deserve a better deal.

Kind regards

tim leeuwenburg (dr)
kangaroo island
south australia

Loving the Job

I reckon the work as a rural doctor is the best that medicine offers. Just heard from a colleague with whom I did anaesthetics last year in NSW.

"Mate I love this job! In the past 7 days I've thrombolysed a 44 year old with a STEMI, resuscitated a 5 year old who had a fit in the local pool, drained a 2L pleural effusion off an ol' fellas chest, gassed 5 people on a gen surg list, managed a snake bite, released two carpal tunnels, resuscitated a floppy neonate after a ventouse and seen a whole load of people in general practise. I LOVE MY JOB! Hope you're having fun mate. This job just keeps getting better!"

No, he hasn't been at the drugs cupboard. He is expressing the simple joy of being a rural doctor with the skills to do your work. As I've stated before, I reckon that being a rural doc is one of the best jobs around - especially for those with procedural skills.

Sadly skills aren't all you need - you need the equipment to do your work well and you need structures behind you to ensure that your work is sustainable in what is, ultimately, a high-pressure job. For most of us, that means adequate locum relief or being paid for the work you do.

With regard to equipment, I've just submitted my paper on the availability of difficult airway equipment for rural doctors. Of the estimated 448 rural GP-anaesthetists out there, I've got responses from 293 - a 65% response rate, which is apparently quite good for an internet-based survey. So paper has gone in for submission...

I won't give the game away (wait for the paper, if it survives the review process) - suffice it to say that there are common themes amongst the rural GP-anaesthetist cohort - lack of funding for basic and advanced airway equipment predominating amongst respondents. 

I've tried to outline in my paper some suggestions for affordable equipment to help advance the cause - for under $4K a small hospital can purchase some of the intubating LMA AirQ-II blockers, plus a fibreoptic device to allow intubation through the iLMA (something like the flexible AmbuAscope 2 or the Levitan malleable intubating stylet). There'll still be change leftover to buy a KingVision videolaryngoscope - all of this gives a fairly robust kit for the 'occasional intubator' or GP-anaesthetist.

A&E Services & Contract Negotiations

Meanwhile, the State opposition Minister for Health has finally twigged to the inequity of country patients being charged for non-admitted A&E services that their metropolitan counterparts receive for free through Emergency Departments. Minister Hill is now on record saying that the 'only solution' would involve putting in salaried medical officers which would 'send GPs in rural towns broke' (The Advertiser, p15 9/3/12). He neglects to consider the alternative option - pay the oncall rural GP for A&E under existing fee-for-service arrangements, regardless of whether patient is admitted or not.

This solution would ensure patients attending the A&E with problems deemed inappropriate for routine GP would not face fees. It would mean the doctor is paid by the Health Dept without having to chase fees. Everyone is happy...

And it would be fairer to rural patients who already face significant health inequalities due to rurality.

This issue is all the more relevant as the existing contract between rural doctors and CHSA expired on 30/11/11 and has been postponed not once, but twice. I dunno about other rural docs, but I'm a little fed up of CHSA failing to come to the negotiating table and sending missives advising of a 90 day 'contract extension' on the last day of the existing contract.

It's not a good way to do business and seems symptomatic of a relationship whereby CHSA treats rural docs and patients as a hinderance to their bureaucracy, rather than a vital component of the health service.