Category Archives: Emergency

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.

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:
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?