Providing a lifeline for rural doctors

Rural doctors often have specific training for rural emergency medicine. What they lack for difficult cases is immediate access to onsite specialist advice. Unfortunately, telemedicine programs are often designed to meet the needs of specialists rather than rural doctors and their patients.

This editorial by the Director of CREM, Tim Baker, outlines the view of advice lines and telemedicine programs from the perspective of the rural doctor making the call, and makes a plea for a more coordinated approach.

Access article on publisher’s site

Baker T. Providing a lifeline for rural doctors. Medical Journal of Australia -1 Nov 23 2015, Oct 5;203(7):277.

Improving Rural Emergency Care

 April 2011

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Small rural emergency departments are important. They are a significant fraction of a state’s emergency medical system. Although they each see only a few thousand patients a year, as a group they are likely to treat more emergency patients than the largest city hospital. It is a myth that they only deal with minor ailments. Many isolated rural hospitals receive ambulances because ambulance services are reluctant to send their only local ambulance out of area. In addition, many patients with serious illness come directly to the emergency department without calling an ambulance.

There is little ongoing research into how these departments operate, and how their performance can be improved. Here we offer three ways to improve emergency care for communities around small rural hospitals.

Provide a simple access point for rural families, and advertise it.

We have found that country people are uncertain how to access help in a medical emergency. When we asked farming families to nominate their nearest emergency department, 10 % incorrectly nominated towns with no emergency department at all. Only some of these towns had a medical centre. Many studies have demonstrated rural families’ reluctance to call ambulance services. It is easy to imagine a scenario where people drive through the night to find the only available emergency care was in the other direction.

Improve co-operation between rural hospitals and ambulance services. Work out the number of critical care procedures required each year, and use simulation to keep a small number of clinicians competent to perform them.

It is hard for a small town to recruit enough doctors with critical care skills. It is just as hard to recruit paramedics with those skills. And there are not enough emergencies in most towns to keep a full complement of doctors, remote area nurses and paramedics from becoming rusty. Unfortunately, there are often too many to ignore. And unfortunately, a helicopter service is not always available either. Many small towns have a hospital and an ambulance base, but their rosters are not co-ordinated. One day there will be an intensive care paramedic and General practitioner Anaesthetist in town. Later in the week there will be nobody with critical care skills. An integrated system will also provide certainty for rural general practitioners who are concerned that they may have no role in rural emergency care in the future.

Add a key performance indicator for regional emergency departments that gives a minimum percentage of transfers from their surrounding small hospitals that must be accepted.

Every emergency department has an Admitting Officer to receive calls from surrounding health services. Most are helpful, but to meet the performance targets of their own department, they often become Deflecting Officers who refuse patients when they are busy. There is little downside to this for large hospitals, but a doctor at a small hospital can waste many hours looking for someone to accept his or her patient.

These three tasks – advertising a single access point, co-ordinating critical care cover, and auditing the responsiveness of regional services – will require different approaches in different jurisdictions.  They will also require research, so that the solutions can be well targeted and evidence based. The Centre for Rural Emergency Medicine is committed to assisting in this process.

Farmers with acute chest pain are uncertain how and when to seek help

April 2011

A pilot study of the prevalence of cardiac risk factors in a group of agricultural workers and of their decision-making abilities with regard to when and how they would seek help when experiencing chest pain has found that most put themselves at risk of dying.

Dr Tim Baker, from the Centre for Rural Emergency Medicine at Deakin University School of Medicine, and Scott McCombe, Cate Mercer-Grant, and Susan Brumby, from the National Centre for Farmer Health at Deakin University School of Medicine and Western District Health Service, studied almost 200 farm men and women recruited from 20 rural Victorian sites.

Their study is published as an Early View article in Emergency Medicine Australasia, the journal of the Australasian College for Emergency Medicine.

The farmers underwent health assessments for total cholesterol, blood glucose, weight, height and blood pressure, and they completed a survey to determine their knowledge of chest pain treatment, local emergency services, and likely response to chest pain.

Each year in regional Australia approximately 9000 people die of coronary artery disease, with acute myocardial infarction accounting for approximately half of these deaths.

Nine hundred of these lives would be saved if mortality rates in regional areas were the same as those in metropolitan areas.

Delays in initiating treatment for acute cardiac events in rural areas might also contribute.

Treatment in the first two hours following a myocardial infarction can decrease mortality by half. Also, one in four people who experience a myocardial infarction die from cardiac arrest within one hour of their first chest pain.

Farmers and non-town dwellers are often thought to be the slowest rural Australians to seek emergency medical treatment.

Reasons given include the poorly defined and stereotypical concept of stoicism and an apparent fatalistic acceptance of supposed outcomes.

In this study, the researchers found 61% of the farmers had cardiac risk factors, with 61% of men and 74% of women either overweight or obese.

When asked to name their nearest ED, 10% of participants nominated health services or towns where no ED exists.

And 67% of respondents believed it was safe to travel to hospital by car while potentially having a myocardial infarction.

“This group of agricultural workers were at considerable risk of experiencing acute coronary events, but many would make decisions about when and how to seek medical help for chest pain that are at odds with published community guidelines,” the researchers concluded.

The researchers said a close relationship with a general practitioner remains the cornerstone of good rural health care, but contacting or visiting a local doctor at their clinic is not recommended when a patient has chest pain.

“Despite this group’s beliefs to the contrary, acute coronary syndrome can seldom be excluded in a clinic setting, and it has been shown to delay hospital presentation by at least one hour.

“In the present study, it appears that many farmers saw being driven to hospital as an acceptable alternative to calling the ambulance. Many reasons have been suggested for the reluctance of rural people to use ambulance services.

“Most rural people can recall an anecdote, from word of mouth or the media, where the use of an ambulance service was said to result in a poor health outcome.

“ There is a widespread belief that travelling by car is quicker and thus safer.

“One participant wrote on their questionnaire that it was ‘sometimes quicker to drive to hospital rather than get an ambulance’. Although the wait at home might be shorter in this scenario, the time to care, which is the most important factor, has been shown to be longer on average.

“Calling the ambulance also provides immediate telephone advice and activates the emergency medical system.

“Paramedics also have the ability to defibrillate once on the scene. From our group, it is not difficult to foresee a tragedy when someone travels by car for 30 minues to an ED where the doctor is unavailable or, even worse, to a town without an ED.”

Improving health literacy among farm men and women is of the utmost importance as they have higher rates of clinical risk factors and appear to be lagging in emergency knowledge and services when compared with their urban and regional counterparts, the researchers maintain.

“Farmers are generally the most remotely located within a population and would achieve greater benefit from acting rapidly in response to acute myocardial events and other medical emergencies.

“Programmes addressing behavioural barriers to accessing care and improving emergency decision making within the farming cohort might be readily translatable into rural lives saved.”

FURTHER INFORMATION:

Dr Tim Baker, phone 03 55633500, 0400 902 758

Australasian College for Emergency Medicine, phone 03 9320 0444

Issued for the Australasian College for Emergency Medicine by Marilyn Bitomsky, Impact Promotions & Publications, phone 07 3371 3057 or 0412 884 114. Media please note: I am overseas for a couple of weeks so if you need assistance, please contact Kerry Reeves, 07 3882 1068, 0407 036 791, kreeves@bytesite.com.au.

Farmers with acute chest pain are uncertain how and when to seek help

A pilot study of the prevalence of cardiac risk factors in a group of agricultural workers and of their decision-making abilities with regard to when and how they would seek help when experiencing chest pain has found that most put themselves at risk of dying.

Researchers Dr Tim Baker, (Centre for Rural Emergency Medicine), and Scott McCombe, Cate Mercer-Grant, and Susan Brumby, from the National Centre for Farmer Health and Western District Health Service, studied almost 200 farm men and women recruited from 20 rural Victorian sites. The farmers underwent health assessments for total cholesterol, blood glucose, weight, height and blood pressure, and they completed a survey to determine their knowledge of chest pain treatment, local emergency services, and likely response to chest pain.

In this study, researchers found that 61% of the farmers had cardiac risk factors, with 61% of men and 74% of women either overweight or obese. When asked to name their nearest ED, 10% of participants nominated health services or towns where no ED exists. Sixty seven percent of respondents believed it was safe to travel to hospital by car while potentially having a myocardial infarction.

Improving health literacy among farm men and women is of the utmost importance as they have higher rates of clinical risk factors and appear to be lagging in emergency knowledge and services when compared with their urban and regional counterparts, the researchers maintain.

Read more: Access article on publisher’s site

Baker, T., McCoombe, S., Mercer-Grant, C. and Brumby, S. (2011), Chest pain in rural communities; balancing decisions and distance. Emergency Medicine Australasia, 23: 337–345. doi: 10.1111/j.1742-6723.2011.01412.x

Portland Hospital responds to a major challenge

April 2009

Portland District Health’s revamped emergency department has recorded a successful response to a major bus accident on Thursday night.

The hospital accepted all patients from the crash, including those with serious chest and spinal injuries.

Associate Professor Tim Baker, from the Centre for Rural Emergency Medicine (CREM), said the emergency department had successfully coped with the situation.

“On the night of the bus crash the system worked the way it was planned,” Associate Professor Baker said.

He said the department had undergone a transformation over the past 12 months, with recruitment of experienced doctors, installation of new equipment and emergency nurses gaining experience in Melbourne trauma centres.

“The terrible and unfortunate events of the Portland bus crash gave the hospital its first chance to fully demonstrate these changes,” Associate Professor Baker said.

“It succeeded because of the work done over the past few months. Months of preparation have gone into last night running smoothly,” he added.

Associate Professor Baker said the successful response showed the benefits of having rural doctors and a responsive emergency department at Portland.

The hospital has remodelled its emergency department as part of its commitment to improving services to the Portland region.

Two hospital doctors, two specialist emergency physicians, a general practitioner and many nurses trained specifically in trauma care were involved in the response on Thursday night.

Patients were stabilized and given pain relief. The most seriously injured patients had their injuries investigated by CT scan and were transferred to The Alfred and South West Healthcare in Warrnambool, where appropriate surgical units were expecting them. Stable patients were treated locally and admitted to Portland District Health or discharged.

At 2pm Friday … patients remain in PDH with minor injuries. Their conditions are stable. Nine passengers and the driver were taken to the hospital after the bus crash which claimed three lives at 6.40pm on Thursday

CREM is funded by Alcoa, Deakin University, Portland Hospital and Warrnambool hospital has also contributed. Funding from CREM provides a specialist emergency physician, Associate Professor Baker, to assist in the continuing improvement of emergency medicine in Portland.

He said two specialist emergency physicians work in the emergency department each week. “They have focused on staff training, working with local general practitioners, improving protocols, stocking of appropriate equipment and streamlining interaction with pathology and radiological services. In particular, they have worked on improving the way patients are transported from Portland hospital to city hospitals.”

Associate Professor Baker said recent media reports had highlighted the difficulties in getting country patients to the city for surgery.

“CREM has a voice on regional committees overseeing emergency transport of patients, and staff have been trained in the best way to have the system work for their patients.”