CREM Director wins 2016 Regional Achiever Award

South West Regional Achiever - Tim BakerCREM is delighted to announce that our director, Dr Timothy Baker, has been awarded the  South West Regional Achiever Award, 2016.  This award is a great honour and reflects the contribution, not only of Dr Baker personally but of many other people and organisations who contribute to rural emergency medicine in our region.  The staff of CREM research issues of importance and help spread new ideas to clinicians in small towns. Warrnambool and Portland emergency departments, and the surrounding Urgent Care Centres continue to incorporate new models of care to provide the best outcomes for their patients.

CREM appreciates the ongoing funding and commitment of Alcoa Australia, the Victorian Department of Health and Human Services, and Deakin University to the South West Region.  CREM would like to thank the sponsors of this award, South West TAFE and Deakin University, for recognising and honouring those who work for their communities in the South West Region of Victoria.  Dr Baker would like to congratulate the other finalists and nominees in this category, who have all contributed greatly to the local communities, making our region such a wonderful place to live.  Thanks to Prime 7, The Weekly Times and the Bank Of Melbourne, the major sponsors of these awards.

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.

South West Healthcare Upskilling Emergency Department Doctors Under the Emergency Medicine Programme

South West Healthcare has employed three trainee doctors undertaking their specialist emergency medicine training thanks to funding under the Emergency Medicine Programme (EMP) from the Commonwealth Government.

EMP funds Specialist Training Posts to enable trainee emergency doctors to experience the lifestyle and work environment of rural and regional settings.

Director of South West Healthcare Emergency Department and the Centre for Rural Emergency Medicine, Dr Tim Baker said ‘our aim is to help recruit rural medical students, train them locally at Deakin University and provide as much of their specialist training as possible, here in the country. This is the best way to have doctors build country lives and, therefore, stay in the country.’

In addition, the Emergency Education and Training (EMET) program provides surrounding small hospitals, including Portland, Camperdown, Terang and Hamilton with visits, assistance, and training from the emergency specialist doctors based at Warrnambool.

South West Healthcare is one of 43 EMET hubs across Australia. In the past 30 months, the EMET program has been responsible for delivering more than 3,000 training sessions to 25,000+ doctors and nurses in more than 200 regional, rural and remote hospitals.

The EMET programme seeks to improve care for patients requiring urgent and emergency medical services in rural and remote areas by providing education, training and support to the large number of doctors and nurses working in the smaller hospitals and emergency care services who are not specifically trained in emergency medical care.

Dan Tehan, Member for Wannon said “that programs such as the EMP and EMET help to encourage health professionals who are committed to rural and regional areas at the completion of their training.”


Improving Rural Emergency Care

 April 2011


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.

Out of hours radiology

March 2011



Although Rural Emergency Departments operate 24 hours a day, not all hospital resources can do the same. In order to maximize the number of daytime radiographers, a reduced service is often in place after hours. Deciding to call in a radiographer at night may reduce the number of radiographers available the next day.

Unfortunately there is little research to base out of hours radiology guidelines on. Nobody really knows which images can be safely delayed until morning. The best that can be done is to see what has worked in other rural hospitals.

These guidelines were originally written for Portland District Hospital in Western Victoria. Portland is a town of 10,000 people on the South West Victorian coast, four hours drive from the capital city and over one hour drive to the nearest regional centre. The hospital has 69 beds, and the Emergency Department sees 9000 patients annually. The radiology facilities available between nine AM and five PM on weekdays include X-rays, CT scans and ultrasound. The radiographer is on call from home after these hours and on public holidays. There is no onsite radiologist, but opinions are obtainable by telemedicine 24 hours each day.


Radiographic imaging should only be ordered at night if it will significantly change the management of a patient. Positive images that confirm a diagnosis and negative images that exclude a diagnosis can both be useful. Radiographs should be ordered if a delay in imaging could adversely affect patient outcome. This can occur when uncertain diagnosis or inability to exclude important diagnoses result in

1. Delayed critical treatment  

– Example: Confirming air under the diaphragm prior to laparotomy

2. Delayed critical investigation 

– Example: excluding asymmetrical ICP rise prior to lumbar puncture

3. Delayed transport to critical care services  

– Example: excluding pneumothorax prior to trauma transport by air

4. Delayed transport for urgent surgery  

– Example: confirming fracture type underlying open wound

5. Prolonged patient pain because treatment cannot be initiated 

– Example: confirming first dislocation of shoulder prior to reduction

6. Prolonged patient pain because treatments cannot be removed 

– Example: Many hours in cervical collar when it could be removed if imaging showed no fracture


Several options are available

1. Emergency department staff can order any image, using this protocol as a guide 

2. All image requests have to be cleared by the radiologist 

3. Requests in accordance with this protocol  can be ordered without radiologist approval. Borderline cases or cases outside the parameters of this guide have to be cleared by a radiologist. This is the option chosen by Portland District Hospital.

Weekends and public holidays

These are officially out of hours, but sometimes it is inappropriate for patients seen on Friday night to wait for two days for their imaging. This is particularly problematic on long weekends. For this reason, consider a system where  a number of patients may be brought back on a weekend afternoon who do not strictly meet the after hours parameters. An example of this would be a deformed wrist fracture: Imaging can wait until morning, but should not wait for two days.

Trauma imaging

Portland is designated as an Urgent Care Service in Victoria’s Trauma system. It is tasked with rapidly assessing and stabilizing trauma patients and then moving them quickly to definitive care. Delayed diagnosis of traumatic injury, especially head injury or occult bleeding increases the likelihood of an adverse outcome.

Urgent radiology is indicated for

• Any trauma meeting major trauma criteria

• Head injury with any of the following

– Focal neurology

– Glasgow Coma Score < 14 (even if possibly due to intoxication)

– Severe headache

– Anticoagulant use (will need rescan at 24 hours also)

• Neck injury with any of the following

– Focal neurology

– Severe neck pain

– Inability to maintain c-spine precautions due to poor patient compliance

– Significant patient discomfort due to hard collar when delay in imaging is likely to be many hours.

• Chest trauma with any of the following

– Respiratory distress

– Hypoxia

– Significant pain

– Significant chest wall or sternal tenderness

• Abdominal trauma with any of the following

– Rebound or guarding

– Hypotension or tachycardia

– Macroscopic haematuria

• Pelvic trauma with

– Pain on pelvic springing

Urgent radiology is seldom indicated for

• Mild symptoms in low impact injury

• Intoxicated patients (GCS14) tolerating the hard collar, where intoxication precludes collar removal, even with a clear CT scan

Respiratory imaging

It can be difficult to diagnose the underlying cause for a patient’s respiratory distress. As treatments can be quite different (diuretics, anticoagulants, bronchodilators), it is important to make the diagnosis as soon as possible. Certain diagnoses (such as pneumothorax or large pleural effusion) can be treated immediately if they can be confirmed.

Urgent radiology is indicated for

• Shortness of breath of uncertain diagnosis with any of the following

– Increased work of breathing

– Tachypnoea

– New hypoxia (saturation < 95%)

• Possible pneumothorax

• Possible thoracic dissection

• Possible large pleural effusion requiring urgent aspiration (and post aspiration film also)

Urgent radiology is seldom indicated for

• Shortness of breath were the patient is not in respiratory distress

– Example: Probable mild to moderate pneumonia

• Shortness of breath where the diagnosis is certain and the patient is improving

– Example: acute asthma

• Possible pulmonary embolus where the patient is stable

– Unless the patient has a high risk of bleeding, the patient can be anticoagulated and imaged the next day

Abdominal imaging

Unless the diagnosis under consideration is likely to require immediate surgery, imaging can be delayed. It is often sensible to discuss the case with surgical staff prior to imaging.

Urgent radiology is indicated for

• Acute abdomen

– Obtain surgical advice. Immediate transfer or operation may be a better option

• Possible organ rupture

• Possible volvulus

• Possible leaking aortic aneurysm

• Possible ectopic pregnancy

• Unfortunately out of hours ultrasound is not available in many rural hospitals. The patient will need to be transferred

Urgent radiology is seldom indicated for

• Abdominal pain with localised abdominal signs

Orthopaedic imaging

Most patients with limb fractures can be made comfortable with splinting and analgesia. They can return the next day for x-ray. Even moderately displaced fractures are unlikely to be operated on after hours. They should also be splinted, but the patient may need to remain in the emergency department until x-ray is available the next morning.

Urgent radiology is indicated for

• Open fractures

• Fractures with significant limb deformity or neurovascular compromise

• Possible dislocation, if immediate relocation is possible

– Patients with recurrent shoulder dislocation may sometimes be relocated without x-ray, and remain in the emergency department for a post reduction film in the morning

• Possible cauda equina syndrome

Urgent radiology is seldom indicated for

• Mild or moderately displaced fractures with little chance of neurovascular problems

• Suspected fractures

Neurological imaging

Urgent radiology is indicated for

• Cerebrovascular accident with any of the following

– Time since symptom free < 3 hours

– Possible intra-cerebral bleed

– Example: associated anticoagulation, hypertension, headache

– GCS < 14

– Deterioration

• Focal seizures

• Prior to lumbar puncture

– Discuss with consultant staff. CT is occasionally not needed

Urgent radiology is seldom indicated for

• Transient ischaemic attack, if symptoms resolved

• Post seizure, if patient is returning to normal GCS

• Syncope, without focal neurology or abnormal vital signs

Other imaging

In general, patients being transferred to intensive care should not have their imaging delayed. If a patient requires urgent transfer for surgery, but that cannot be arranged until imaging results are known, imaging may have to be performed out of hours.

Urgent radiology is indicated for

• Patients being transferred to a critical care bed or for urgent surgery

– Example: post central venous line placement

• Patients requiring anticoagulation, but require exclusion of bleeding

– Example: Possible pulmonary embolus and altered mental state – exclude intracerebral bleed

Urgent imaging is seldom required for

• Possible acute coronary syndrome, if chest is clear and the patient is not being transported

• Peripheral foreign bodies

Dr Tim Baker

Deakin researcher and paramedic hopes to improve paediatric policies

September 2010

Warrnambool paramedic and PhD student with Deakin University’s Centre for Rural Emergency Medicine Kate Cleverley hopes a study she is conducting will lead to improved procedures for transferring paediatric patients to hospitals.

Ms Cleverley said the study could lead to new guidelines that could be used across rural Victoria for the best procedures for taking paediatric patients to the most appropriate facility.

A paramedic with 10 years experience, Ms Cleverley said there were no current guidelines to direct paramedics.

“The intention of the study is to look at paramedic decision-making and to develop protocols and guidelines to make sure paediatric patients who need to go to a higher level of facility are transported there as rapidly as possible,” she said.

“It is not only about the timely nature of the transportation but determining the most appropriate facility to take patients to depending on the level of care required.”

Ms Cleverley said that anecdotally there had been some reports over time of cases where young patients had not been taken to the most appropriate facility.

“It isn’t a common problem but I think having guidelines for paramedics to follow would make the situation less likely to arise.”

She is conducting her research across the Barwon South West region and will include paramedic focus groups, interviews and information from the ambulance service databases. However, she said the planned guidelines could apply to any rural region.

Ms Cleverley completed her Master’s thesis in paediatric weight calculations used by paramedics and was keen to continue her studies in a similar field. She started her PhD studies this year and expects it will take several years to complete. “I am studying part-time at Deakin University in Warrnambool and working at the same time. It’s still in the early stages.”

Ms Cleverley has worked from Warrnambool for the past 18 months and for the six years prior to that was based at Hamilton.

Deakin’s Centre for Rural Emergency Medicine (CREM) is a joint initiative between the Department of Human Services, Portland District Health, South West Healthcare (Warrnambool), Alcoa of Australia and the Deakin Medical School.

Innovative link to medical specialists

May 2010

An innovative online program is bringing specialist medical support directly into the emergency department of Portland District Health.

The new monitor system connects patients in Portland to a network of skilled specialists around Victoria.

The new Datascope Panorama Central Monitor and Web Viewer allow doctors in Portland to consult specialists who will be able see and monitor their patients via on-screen images.

Centre for Rural Emergency Medicine Director and Portland Emergency Department Director, Dr Tim Baker, said the system would ensure patients get the very best care available.

Alcoa Australia has funded the new hardware and software through its Partnering Stronger Communities program.

Dr Baker said the equipment would collect a patient’s pulse, blood pressure, heart rhythm and breathing patterns and monitor trends such as falling blood pressure or increasing pulse rate. The web viewer makes the information available on a secure internet site.

Dr Baker said Portland hospital staff already consulted specialists from larger centres on a regular basis and transferred information such as X-rays and photographs.

“The Panorama weblink is the most important aspect of this telemedicine capability in that it provides direct access to the vital signs that are so important in assessing a critically ill patient,” he said.

Dr Baker said that doctors in rural hospitals such as Portland were often isolated from specialist support.

“Rural hospitals simple cannot employ every type of medical specialist and it is not uncommon to seek specialist support a few times per week. With the new monitor an emergency physician can now call for advice to and the specialist can see the patient and monitor their vital signs. As they say, a picture tells a thousand stories.”

“The specialist can log in and view streaming patient data remotely from virtually anywhere.”

It is expected the system will be used by the emergency physician on call for the Portland and Warrnambool hospitals, the Cardiology Unit at Geelong Hospital, the Alfred Hospital and the Adult Retrieval Service in Melbourne.

Dr Baker said it would be used for the safe care of patients with a variety of critical conditions or injuries and would be used to monitor patients waiting for transfer by air services to other hospitals.

Dr Baker said Alcoa’s support for the project was fantastic. “This equipment will save lives,” he said.

The Centre for Rural Emergency Medicine, which is based at Deakin University in Warrnambool, is also funded by Alcoa Australia in conjunction with the Department of Health.

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.”