It’s a funny thing, working as a private practitioner but on contract to a hospital for anaesthetic and emergency services. For one, there’s a constant tension between demands of running own business and the need to be available to the Hospital when required. Effective triage is key to this. Clarity over what is and what is not an emergency is valuable not only for timekeeping, but also for billing!
But one of the hardest things is to establish effective control to help make change happen in the Hospital. Unlike some of my tertiary hospital colleagues, I don’t get paid to participate in education, nor audit. I also have no control over spending decisions – current bugbear is a Hospital that has spent $17K on a new anaesthetic monitor – that we didn’t need..and yet not purchasing an extra monitor for our ED. Such top-down decision-making without consultation is frustrating. Bottomline is that as private rural doctors, we are engaged to provide a service – but not to effect change in the institution – that is ‘not our remit’
I’d love to spend an hour or so each week doing team-training with nursing staff and have recently started running sims in Theatre at the end of each list. Rural nurses have a tough time as they are frontline for whatever comes through the door, and have to manage the patient until the doctor arrives. That said, I am making an effort this year to improve educational resources for rural clinicians (whether doctor, nurse or paramedic) via the ‘Fifty Shades of Brown’ section on KI-Docs.
Audit is one of the areas that has traditionally frustrated me. Our local ‘Principal medical Officer’ (neither local, nor a frontline rural doctor) used to hold compulsory audits every year – I gave up when I realised that all he was doing was auditing expected deaths in the adjacent nursing home, not looking at near-misses or critical incidents in ED or Theatre.
A few months ago I was in email correspondence with Dr Toby Fogg, an ED Physician & Retrievalist over at the Royal North Shore in Sydney – I was fascinated to see that he and colleagues were setting up an Australian Airway registry and wondered if collective data from rural doctors in small rural hospitals would be useful.
It’s no secret that I am mildly obsessional about airway management, particularly as pertains to availability of equipment to manage a difficult airway in an isolated rural environment. Given that critical illness does not respect geography, I don’t think it is good enough to accept a lower standard of care or a higher complication rate in the bush than in the city.
Truth be told, we don’t know if things are worse. Intuitively, I feel that well-trained rural doctors do a good job – both of elective intubations but also for emergency airway management. But we don’t really have the data one way or the other. Although I’ve approached Country Health SA to pursue the idea of a rural airway audit, there was a lack of interest – the sceptic in me says that in these cash-strapped times, Health Depts would rather ‘not know’ than be presented with data that might require them to spend on appropriate kit!
Anyhow, 2013 has started well with results from the RNSH ED airway audit becoming available. You can check results out at http://www.airwayregistry.org.au/results-of-first-18-months/ and see comments over at Cliff Reid’s http://www.resus.me site via http://resus.me/lifting-the-fogg-on-ed-intubaton/ [sic]
But I reckon it’d be interesting to get collective data from rural EDs – despite the well-worn comments from various experts that there is ‘no room for enthusiastic amateurs’, the reality is that in the bush we HAVE to be able to manage such situations…and on the whole we do a good job…