Tag Archives: Airway

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.


Back in the saddle

Well, have been a bit hectic the past few weeks since getting back to Kangaroo Island after my year away doing anaesthetics in NSW. Thankfully it’s relatively easy to slip back into the groove of rural medicine – and in fact it’s been a welcome relief after being back in the tertiary hospital system. But still had to get used to running on time, all the paperwork that seems to swamp us as well as catch up with friends and family back home.


Hence no blog posts since early January.


However today I am on call, sitting on the deck with a 12 month old kangaroo that Trish has taken on board in my absence, watching the rains over the north coast of KI.


Being on call again is actually quite refreshing – the Kangaroo Island doctors as a whole are now doing three weeks out of every four on the EM roster…the remaining (4th) week covered by a Country Health SA locum. I believe similar arrangements have been in place elsewhere in the State, where local doctors are struggling to fill the EM roster. Meanwhile between four of us we are providing full cover for anaesthetics and obstetrics, with two doctors doing each discipline.


I’ve also been getting to grips with delivering anaesthetics on KI – two lists so far which have been uneventful, although I’m still trying to work out how to make the anaesthetic machine display a minimal alveolar concentration of anaesthetic agent, and struggling with an end-tidal CO2 monitor that reads in unknown units (3.5-4.5 seems the average, not the 35-40mmHg I’m used to). One for the hospital to work out…


When not at work, I have been analysing the results from the GP-anaesthetist survey – over 370 responses so far, and a fair proportion are dedicated GP-anaesthetists as well as ‘occasional intubators’ (rural docs who are on an EM roster and may be called upon to intubate seldomly). Results have been interesting, with no surprises that rural docs don’t have access to a lot of the airway kit that would be taken fro granted in the city. More worryingly, a session at the local (mostly volunteer) ambulance station last week showed me that they’ve got some kit on the ambulance that we don’t have in our hospital! Had some helpful insights from airway giants like Paul Baker (NZ) and Minh le Cong (RFDS Qld), as well as lots of comments from the wider GP-anaesthetist cohort who seem to share similar frustrations as we do locally. But more on that later, as I polish my manuscript and hope to get published later this year. Meanwhile, will try and give a few talks during the year to interested parties.


But back to on-call….I’ve realised that it’s been almost two years since I’ve done an EM shift on Kangaroo Island – away for all of 2011 doing anaesthetics and for 2010 the docs on KI were reeling from all the nastiness over contract negotiations with Country Health SA and the ACCC. Now I am on-call for anaesthetics for half the year and doing one emergency shift a week….and wondering where we are at with contract negotiations – the last contract was due to end Nov 2011, rather than the usual three years…as rural docs were generally unhappy with the contract terms but were prepared to accept an interim contract hoping things would improve.


Back on 30/11/11 the head of Country Health, Belinda Moyes, wrote asking for a three month extension to contract negotiations. That extension is due to expire on 28/2/12 and I’ve not heard peep from Country Health over contracts. One has to wonder if they are serious about negotiating a new contract, or will just keep ‘extending’ the current contract rather than negotiate.


A big issue for me (and many other doctors) has been the sheer unfairness of Country Health insisting that people presenting to the emergency department are billed privately by the on call doctor, unless they are admitted to a hospital bed. This seems plainly unfair – whilst patients in metro areas are treated for free in the Emergency Dept of public hospitals, their country cousins are charged. 


Many of these services are for things that are not routine ‘general practice’ ie: X-raying a fracture and setting a limb in plaster, suturing an extensive laceration, pulling a dislocated shoulder back into shape, dealing with an alleged rape or victims of a motor vehicle accident. Country Health has managed to formalise this in the most recent (well, in fact the first) contract from 2010 with a clause stating that:


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, CHSA shall not be liable to pay any fee for such services”


Their rationale is that such patients are an extension of the doctors private practice. Indeed, CHSA states that:


“This funding model with MBS being paid for public patients attending state hospitals, is acceptable to the Commonwealth due to an exemption in the National Healthcare Agreement that ‘in those hospitals that rely on GPs for the provision of medical services (normally small rural hospitals), 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.’ 

As far as I know, South Australia doesn’t have an exemption under the National Healthcare Agreement but continues to obfuscate this issue. What really twists my melon, and that of the patients who I see who are charged for their attendance, is that they have neither requested treatment by their own GP, nor is there treatment part of continuing care or a prior arrangement with the doctor. Basically, it’s not a private service…it’s just Coutnry Health SA cost-shifting dollars from State to Federal expenses.

In fact, the on call doctor is called to attend patients in the ED as part of his/her role as the doctor on-call for emergencies in a contract with CHSA. There is no prior arrangement, they are not private patients and usually this is not part of continuing care.

Quite how the Health Department continues to get away with this blatant cost shift from State to Federal (Medicare) coffers amazes me. And it is cold comfort to our patients – the rural ones are already disadvantaged enough, and the metro or interstate ones are flabbergasted to be charged fees for services in ED that they would receive for free at home. And of course the overseas tourists (and we see a fair share on Kangaroo Island) are less than impressed to receive a bill and aren’t covered by Medicare.

Bottomline, the doctor on call for emergency medicine for CHSA doesn’t get paid to come and see emergency patients, unless they are admitted to hospital for over four hours…



Let’s hope this issue will be resolved in contract negotiations – although with two days to go until contracts expire, I am not optimistic.

Country Driving

I’ve recently driven back from Orange (NSW) to Kangaroo Island (SA) – one of those long, two-day road trips that is characteristic of driving in Australia. I counted less than 200 vehicles between Orange and Tailem Bend – over 1200km of road over two days…and of course whilst driving you tend to think about stuff. Some things struck me…
  • Australia is vast
  • rural areas are sparsely populated
Hence If you have a crash out here, you are likely to face a long time before help arrives. And even then :
  • the major cities are a LONG way away (>500km)
  • there are smaller rural hospitals; some are little more than first-aid posts & some have capabilities for surgery (which implies the presence of a doctor with anesthetic skills)
Add to this :
  • the prehospital response may be initially composed of volunteer paramedics/first responders, with more more advanced practitioners few-and-far between
All together it is no surprise that the outcomes from a motor vehicle crash are worse than in the city, with one Australian study demonstrating a four-fold mortality for rural vs metropolitan areas. Not surprisingly, mortality increases the longer the time to care…and concepts like the “platinum ten minutes” and “golden hour” of trauma become academic when crash victims may not be discovered or receive help for a considerable time.

As rural doctors, it behoves us to examine best practices to try and improve survival. Certainly we need to have to skills and equipment to provide appropriate medical care in our hospitals..and some may provide an extended role at the roadside. I’ve blogged before about the concept of training and equipping rural docs to provide a coordinated prehospital response…and the more doctors I speak to, the more seem to think this is a ‘good idea’. Implementation however may take longer, and there will be hurdles to overcome (not least the oft cited response that such work is best left to experts, not enthusiastic amateurs).

Of course, the best ‘bang for buck’ is not necessarily in the delivery of expert medical care. I remember Karim Brohi making this point at one of the Australian Trauma Society annual conferences a few years back – “it’s better to build a fence at the top of the cliff, rather than provide an ambulance at the bottom to pick up the injured“. 

Locally we’ve had some small success with the ‘Roadkill Recipes‘ project – recognising that many rural traffic injuries on Kangaroo Island were caused by wildlife-vehicle collisions, a satirical cookbook of local wildlife served as a medium to convey a road safety message to locals and tourists.  Places like Kangaroo Island (and Tasmania) are interesting in that roadkill (and hence wildlife-vehicle collisions) is abundant. But for most rural areas the notorious “fatal five” of speed, inattention, drink/drug-driving, driver fatigue and lack of seatbelts are the culprits in many road crashes. 

Which is why I was heartened to see new signage as I crossed the border into South Australia (below). The Motor Accident Commission’s “matemorphosis” country roads programme aims to target country drivers, particularly male drivers who may respond to mateship peers.

The MAC campaign includes references to wankers, cocks, knobs and tossers.

I wonder if as rural doctors we need to be more proactive in injury prevention – especially when our work comprises mostly primary care as well as the ‘fun stuff’ like airways, trauma and emergency medicine. Driving change can be hard, but if we’re serious about injury prevention we need to be active in local road safety groups, at sporting events, with families and spreading the road safety message. But concomitantly we need to ensure our training and local resources are fit for purpose.

So in 2012 my projects will be:

– actively engage the local community in primary prevention health strategies,

– work with colleagues around the country to develop a ‘rural doctor masterclass’ course, showcasing latest concepts, equipment and techniques relevant to rural proceduralists,

– try and establish a more formal framework for rural doctors attending prehospital incidents (as a minimum, appropriate training, equipment and maintenance of standards) – existing retrievalist courses like RFDS STAR (RFDS Qld) and the medSTAR short course seem to be appropriate building blocks, bolstered by some online case discussion and commonality on procedures/protocols,

– work on developing a bespoke airway skills course for rural docs in South Australia, with concomitant development of minimum standards for difficult airway equipment in our rural hospitals.

    What are your News Year resolutions?