Category Archives: Training

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.

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.

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
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?