In a few weeks, the Australian College of Rural and Remote Medicine will hold their annual conference in Cairns. Part of this gathering is an online competition involving making a quick one minute refresher video on an aspect of medical care. JAMIT or Just A Minute Instant Tutorial has the potential of reminding clinicians about the basics of a procedure if they havent performed it in a while.
My contribution is a quick update on nasogastric tube insertion. Below are some extended tips for those wanting more information. These tips can also be used by medical students and junior doctors doing terms in emergency medicine and/or surgery. Enjoy!
- Gastric decompression – SBO
- GI imaging
- Feeding – choking risk
- Removing toxic substances
- Severe mid face trauma
- Recent nasal trauma or surgery
- Base of skull fracture
- Oesophageal varices
- NG tube (put in fridge if too bendy)
- Nasal spray
- Water with straw
- Lubrication gel
- 60ml syringe, litmus paper
- Tape, pin
- Drainage bag
- Explain procedure, need good bedside manner, build rapport
- Risks/benefits (sore throat, blood nose, sinusitis, oesophageal perforation, collapsed lung), (prevention of aspiration, nausea)
- Pick the most patent nostril and spray with lignocaine
- Measure length from tip of nose to left costal margin
- Sit upright, mild flexion of neck, hold back of head gently
- Assistant/patient hold water cup
- Lubricate and advance along the floor of the nose, twist tube as advances
- 10-20cm resistance, start sipping water, swallow tube down
- Encourage as tube passes “sip, sip, sip” “keep going” “you’re doing well”
- When to stop: cough, cant speak, nasal haemorrhage
- Check placement: blow air and auscultate, pH, CXR
- Tape to nose, pin to hospital gown
- Cepacol lozenges if throat sore
A few weeks ago, I was working an after hours GP shift at a ‘country’ hospital. I say this in inverted commas as it is only about 30-40 minutes drive to the city. The shift itself present relatively few challenges with a mixture of chest pains, general GP type presentations and some virally kids. At about 9:30pm, I was asked by the ward nurses to come and help with a patient who was getting agitated. Once this was sorted, one of the other nurses asked me to check on a patient down the corridor and replace her IV line. From the notes, the lady in her late 80s had been admitted that afternoon by her regular GP from his rooms. Given the severity of the illness, the GP had requested that the ambulance service take her from the rooms straight to a major hospital in the city. However from the ambulance crew note, it was evident that they had decided to bring her to the country hospital instead stating that going to the city hospital was “too harsh for her.” According to the GP notes, she was living at home with her daughter and independent in her ADLs. Evidently, she was quite a prim and proper lady who certainly wasn’t loaded with co-morbidities. The GP had documented some agitation, chills and that the patient was uncomfortable. He had sent off urine and bloods, but no CXR. The nurses were worried that she had deterioated and was now complaining of central chest/epigastric pain.
When I stepped into the room, this lady looked sick. Her respiratory rate was 40, pulse 94 and was sweaty and writhing in pain. The little voice in my head said “Gerry, she doesn’t belong here.” Its funny how that immediate reaction comes before any rational thoughts. But I thought through the scenario sitting back at the nurses station. Here were some of those thoughts:
- going home from my GP clinic shift in just over an hour
- two nurses on overnight for 30 inpatients
- limited access to radiology
- no monitoring available
- Usually a well lady, independent
So weighing it all up and putting it through the ‘grandparent-o-scope’ (what would I want done or do if this was my grandparent), I decided that she needed transfer to the city. Granted, this was the place that her GP originally wanted her to go. Muscle memory from working 6 hours from the city in Wudinna helped me dial the number in less than a second and I asked to be put through to the ED consultant. In the back of my mind were the handover calls that I had made from Wudinna. This is how the conversation went, I have changed the names and my parts are in bold:
ED: “Hoshsjs Ropsjnskss (unintelligible)”
GC: “Sorry, who am I speaking to?”
“Trevor Jones, ED”
“G’day Trevor, I’m Gerry a GP working up at Woopty Doo tonight. I have a quite a sick 87 yo lady I’d like to transfer down to you”
“We’re really busy here tonight”
“I understand, but I’d like to send her as I’m not at the hospital for much longer and I think she needs more care than we can provide. She was admitted by her GP for a suspected infection today, bloods and urine are still being processed. I havent got a CXR to look at but her lungs sounds pretty cruddy. She is breathing up to 40/min, temp is 38.9 and her BP is 196/88. Im wondering that she has a pneumonia or pyelonephritis.”
“Well, look you have the same antibiotics as us and we are really busy.”
“So you’re saying you want her to stay here? I havent got access to a CXR at this time and Im not here over night, Im a bit worried about this patient given her vitals.”
“What does her chest sound like?”
“There are some coarse creps in the bases”
“Well she might have a pneumonia…”
“Thats what Im worried about. Also I was wondering about some advice for her pain. She is quite distressed and I thought perhaps some morphine IV”
“That might stop her breathing”
“Ok, well maybe I’ll start with something oral to see…<click>”
Hung up. Just like that. No extra advice, no ‘ok then well send her down,’ nothing. Just click and the conversation had ended. Sod it. So I sat down and wrote up a quick review/transfer note and waited for the ambulance crew to arrive as I had already asked for them prior to the call! It was an intensive care paramedic that rocked up and we talked through the case. He was suprised by the decision by the previous crew to change the destination earlier in the day and agreed that this lady did not belong in this hospital. We got and ECG off, placed a new cannula in her and got her on her way.
Two days later I was able to drop past the city hospital ward the patient was on and had a chat with the CNC about her and the ED rudeness. The patient ended up having a nasty pyelonephritis and needed a few days of IV antibiotics. The CNC said that often the ED guys don’t understand where you are calling from and what resources you do and don’t have. Working in Wudinna last year, I could understand that clearly. But even close to the city, there are times when more intensive observation and care is needed. Unfortunately, the closer you are to the city, the more blurred the distinction becomes. People assume that you have a dedicated medical team overnight and 24 hour access to radiology and pathology. Im also getting a bit tired of the line “we’re really busy tonight” or “the ambulances are ramping” like that is going to change the outcome for the sick patient. True, it might be just a cry for acknowledgement that things are going crazy in their department, but what is it supposed to make me feel? Guilty for transferring someone who needs more care? Not a great place to put a country doctor in.
“we’re really busy tonight”
For me, the most disappointing part of the interaction was the rudeness to a fellow colleague asking for help. If you are 30 mins or 6 hours away, politeness shouldn’t change. And having worked in a city ED, I completely understand how busy they can get and how you end up trying to reduce the patient load as much as possible. But we are all in this game together. Often, I found the referrals from rural GPs to ED were great as they had been worked up with pathology sent, analgesia on board and IDC and IV lines in.
It is a shame that as a future rural GP, this has been a common experience when speaking to EDs in the city. Perhaps next time I won’t give a courtsey call and just let the patient rock up on the doorstep in an ambulance. But I believe in a handover and perfer not to be yelled at or hung up on. It made me think of this interaction that Tim Leeuwenburg had recently. So ED docs out there, think of us GPs in small hospitals without the luxuries that you may enjoy. We are transferring you the patient for a reason. Not because we want to avoid work, but for the patients best care. If we are sending them to you, it is because they need care greater than the level we can provide.
Rural GPs admit to our hospitals or discharge from clinic a lot of patients that might otherwise need transfer to the city. So be nice to us, because we could send a WHOLE lot more work if we wanted to!
In the first plenary of the day, Professor Emily Banks from ANU gave an informative and engaging speech about translation of research into policy and practice. Prof Banks started the talk with an old quote from a gentleman with a most upstanding name:
“…thoughts ran into me, that words and writings were all nothing, and must die, for action is the life of all, and if thou dost not act, thou dost nothing.” – Gerrard Winstanley, 164
The quote reminded me of something that I heard at a plenary session at the Primary Health Care Conference last year. “Research without implementation, is archive” – Campbell Murdoch, 2012. Prof Banks defined policy as principles or guidelines that guide decisions and practice as what we actually do. Unfortunately there is often a disconnect between the two with research occurring into topics that won’t influence policy. The notion of research translation was raised and seemed somewhat of a dirty phrase, meaning to express an idea in another, especially simpler, form. Akin to “let me dumb this down so that you can understand it.” Banks said that while this might be appropriate for basic sciences, it shouldn’t be used for primary care research. A more useful term from our Canadian friends is “knowledge translation.”
#2013phcconf Emily Banks in the myth of the linear research -> policy -> practice process. Thoughtful, challenging, amusing!
— Lesley Russell Wolpe (@LRussellWolpe) July 10, 2013
Primary care research has the additional barrier of having a perceived lack in drama and many of the triumphs are invisible. Patient care is improved by preventing fancy diseases, much less ‘Today Tonight friendly.’ Prof Banks suggested that with persistent effort, we must advocate for increased funding for primary care research. This could be in the form of contributing research, attending conferences or supporting colleagues in the field. Good timing given the announcement of new money allocated by the Minister. She finished with the mortality benefits seen in Australia’s war on tobacco advertising and with some useful lines for general practice: Patients that smoke 10 cigarettes per day double their mortality risk or put themselves in the same category as the morbidly obese.
Smoking 10 cigarettes a day doubles your risk of death, the same as being morbidly obese. #2013phcconf
— My Health Career (@HealthCareerAus) July 10, 2013
We then heard from Dr Megan Elliot-Rudder who was awarded best paper of the conference. Dr Elliot-Rudder managed to conduct an RCT in rural NSW looking at the factors that can encourage ongoing breastfeeding. She found that collaborative motivational support was a key strategy. It was great to see an example of real world based research after Dr Bank’s address. Although I always seem to detect a hint of militarism when it comes to breastfeeding. Part of the talk was a particular story about her friend observing that breastfeeding not being dinner conversation reminded me of the Kochie debacle.
Congratulations to Megan Elliot-Rudder for #2013PHCConf best paper: Continuation of breastfeeding cluster RCTs.
— UNSW Primary Care (@UNSWPrimaryCare) July 11, 2013
Morning tea offered the opportunity to mingle amongst researchers, consumers, caffeinated beverages and assorted pastry goods. During this 30 min break, I was able to catch up with Amanda Griffiths who runs the My Health Career website. She was hoping to gather a few video interviews talking about the path to different health specialities. It was nice to talk about my journey to rural GP and reflect on what I had learnt along the way. In fact, it was a nice segue to the next session that I was keen to attend….
The rural and remote presentation session in the afternoon was very interesting and contained some research looking at longitudinal tracking of rural doctors and patient access. The CRE group in Alice Springs presented data looking at the core services that rural communities require with maternal/child health, acute services and population health services featuring. They will also work on discovering population number thresholds for different services. In other words: as towns get bigger, what health services do they need? Another presentation investigated barriers and strategies to improve cardiovascular health care in rural areas. The main points summarised below:
- Access – distance from major centres
- Funding – patients cant afford the care
- Motivation – getting patients interested
- Time – 15 min GP consults not long enough
- Workforce – nurses not well paid or motivated enough
- Reward prevention – money saved by primary care goes back to primary care
- Integration – teams of health professionals
- Health promotion – starting in schools
- Clinical strategies – identifying and tracking high risk patient
After a chance to refresh and throw on some smart clothes, delegates gathered at the Pitt St hotel entrance to await transport to dinner at the Sydney Opera House. Snaking at a snails pace down one way streets in the CBD prompted some to observe that walking there may have been a quicker, albeit colder option. Once at Bennelong point, the walk to the function area offered some breathtaking views of the ‘coathanger’ looming across the Harbour. Only one of the registrars had done the walk up the Harbour Bridge commenting, “it was great, I spat off the top.”
Dinner itself was a great chance to meet other delegates and conference organisers. The PHCRIS crew that I sat next to were battling one of the other tables on Twitter, taking photos of their anthropomorphic paper clips in compromising positions. Salmon or beef in the belly, it was time to hit the dancefloor.
Observation: researchers and policy-makers speak the same language on the dance floor #2013phcconf
— Jodie Oliver-Baxter (@jodwah) July 11, 2013
The cover band did a great job providing the soundtrack for some more hilarious dancing and moves that may not have seen light for decades. The water sprinkler during ‘Play that Funky Music’ was a high(low)light. Buses convened at 11pm for the trip back home which I happily utilised. The 6:15am flight back to Adelaide* on Friday morning was heavy on my mind.
The conference and preceding academic registrar workshop was another great experience to meet like minded GPs, researchers and consumers. It reaffirmed my love for primary health care work and that I will continue to attend such gatherings. Thanks to PHCRIS, GPET, AOGP and all the other acronyms for making it possible. Finally, a very special thanks again to Prof Michael Kidd for spending some of his valuable time to further inspire and hear about what junior GP registrars are up to.
Great meeting with young GPs and senior research leaders at Australia's primary care research conference in Sydney #2013phcconf
— Michael Kidd WONCA (@WONCApresident) July 10, 2013
*I had originally booked the flight to be back in Adelaide by 8am for my undergraduate teaching. However, I only realised last week that it was uni holidays. Whoops.
First of all, an apology to regular visitors of this site as it has been a long time between drinks. Since my last post, the inactivity on the blog has been substituted by a flurry of GP exam study, research and clinical work away from my computer. Hopefully those areas will provide some fodder for future posts when things quiet down in a month or two.
The reason I’ve been able to update the site is that I am currently in Sydney attending the 2013 Primary Health Care Research Conference. It is largely organised by the Primary Health Care Research and Information Service (PHCRIS) and brings together academics, GPs, nurses, allied health and consumers interested in ‘coal face’ practice. Over the next three days we will hear from research intended to improve health outcomes for patients and also how to work more efficiently as health professionals.
Just arrived at #2013PHCConf , looking forward to a good conference
— Dr Chris Barton, PhD (@dr_chris1) July 9, 2013
To some it may seem like all of this research and good work goes unnoticed by those who matter. Not true. The newly appointed Minister for Health (and Medical Research), Tanya Plibersek opened the conference this morning and announced an additional $13.5 million for primary medical research. The Minister also launched the National Primary Health Care Strategic Framework that is hoped to improve patient care and build on the work of Medicare Locals.
The four main strategies were outlined:
- Patient focussed
- Better access and equality
- Emphasis on health promotion and screening
- Accountability of system
Before dashing off to Hobart, she left a parting volley of shots perhaps looking to wedge the Coalition on the matter of Medicare Locals and patient care:
#2013PHCConf To stand against Medicare Locals is to stand against the evidence and what is best for patients Tanya Plibersek
— Leanne Wells (@ACTML_CEO) July 9, 2013
#2013PHCConf Minister's address"concern for patients by primary health policy of those across political divide" election battle-lines drawn!
— Matthew Day (@matthewsday) July 9, 2013
Michael West, who did well to remember all of the Indigenous names of the local Sydney area, offered a generous welcome to country. Many of us were doing well to remember those new faces we’d met over breakfast!
The first keynote speaker of the morning was Dr Mary Foley, Director General of NSW Health. She reiterated a strong commitment to primary health care and research with a focus on integration. Some of the challenges involved at a state level were differences in acute care (emergency departments and ambulances) and primary care (less institutionalised private practice). Dr Foley said that primary health care is more complex from a policy level given the diversity of patients, casemix and location. Importantly she was aware that in the rural setting, lines between emergency care and chronic care are blurred with the GP and team often managing both. One rural doctor recently explained the requirement to write a discharge summary to himself and highlighted this fact to the bemused Director General.
We were then subjected to the dulcet French-tinged English tones of Dr Martin Fortin from Canada. I commented to my neighbour that I would feel much more healthy just listening to his voice as my GP. Dr Fortin is looking at the impact of multimorbidity (MM) and strategies to better prevent and treat patients. He demonstrated that the prevalence of MM was increasing and has only just begun to have an impact of health policy and care. In Quebec, about 45% of the adult population had MM which was an increase of 15% from 2005. MM had patient effects including decreasing quality of life (QOL), causing psychological distress and increasing medical complication rates. The effects on the health system involved increased cost, higher re-admissions and more ED visits. Not surprisingly, the best strategies to combat MM involved patient centered care model starting from age 30-40.
Martin Fortin: multimorbidity is the rule in PHC & conseq are numerous & not just for elderly. #2013PHCConf
— Deb Russell (@debtherats) July 10, 2013
His research showed that their model conferred better medication use and compliance plus improved prescribing practice. Future research needs to define the patient populations at risk of MM and then looking at outcomes focusing on QOL and physical functioning. Dr Fortin admitted that although patient centered models do exist, they are not yet implemented on a large scale. In other words, they sound good – but do they work? One of the questions/statements from the audience was poignant:
New name for the Patient Centred Medical Home model suggested by group #2013PHCConf : Person centred Health Care team ? any takers
— Charlotte Hespe (@runningdoc14) July 10, 2013
I then sat in on a workshop concerning ‘Developing a Patient Safety Collaborative.’ One of their points stated that any aim or objective should be a ‘stretch’ to reach for. The example given was that 90% of patients should be able to access their doctor of choice on the day of their choice. Just a bit of a stretch! The speakers spent some time explaining that changes to a clinic system should happen one or two at a time. My question was as a junior GP how to encourage senior GPs in the practice to embrace a particular change. The response covered the need for conversation about issues and also data. The inherent competitiveness of GPs could also be harnessed with this data as most of us don’t like being outliers, but often don’t know that we are. It had been shown that when GPs access de-identified data of how colleagues are performing, their own performance is enhanced.
It was about this time that some of the delegates (including myself) who had been tweeting and typing away found that our mobile phones were getting drained. Luckily the lovely Leanne at the National Rural Health Alliance (NRHA) booth had us covered:
— NRHA (@NRHAlliance) July 10, 2013
There was no rest for the wicked as there was a lunchtime panel session held in the main room with NSW Minister for Health Jill Skinner. She commented on the challenges facing rural health care in NSW with over 25% of the population living outside the major cities of Sydney, Wollongong and Newcastle. Already NSW Health had some runs on the board with 11 new specialists in Dubbo, a renal palliative outpatient scheme and commencing a rural generalist program. The experts presented research and ideas around tackling obesity and using generalists for chronic care. The Minister fired back some great questions calling on her experience as a reporter, who covered the Vietnam War no less. In response to her question about how to get collaboration in rural areas on obesity and lifestyle, the answer was to call on a local champion to lead and give the community a sense of ownership. In rural areas that rely on sport for social gatherings, this could be easily done. In the UK, one expert reported that generalist care of chronic issues improved patient outcomes, but was a drain on the practitioner. Working in teams of nurses, doctors and health workers would help here perhaps. The role of GPs was found in the UK to be:
- Navigators – helping patient through the health system
- Special interests – covering specialist areas
- Generalists – whole person care
There were some other good ideas to better primary health care, but it was a case of “we know what to do, but not how to do it.” Some of the experts stated that although randomised controlled trials are great, often simple case studies are all that is needed. It made me think of what Dr Fleming had put together for mental health care in Tumby Bay.
In the afternoon, academic registrars were lucky enough to spend over an hour with Professor Michael Kidd to talk about research and GP work in general. Prof Kidd had recently been elected the President of WONCA and was able to tell us about the challenges facing other countries around the globe. As GPs, he said that we are flexible. We are able to work different hours, move around protocols and a good knowledge of the patient as a whole. I liked that he also shared a bugbear of mine – being called in the middle of a consultation (emergencies excepted of course!). He mentioned that for much of the time, the pressure we feel is that which we put on ourselves. Some other pearls included not getting angry or frustrated when someone gets squeezed in right at the end of the day. In fact, the phrase that stuck out for me was:
“Every patient encounter is a gift….especially while you are training.”
It will help me remember not to get flustered which can be all too easy sometimes during a long clinic. He finished by commenting on the observation that although there was a need for GPs to be generalists, many have special interests. Prof Kidd said that this would happen naturally as patients pick you to look after particular problems. In this way, it is our patients that define our special skills as they cluster around you. But this makes it hard as a junior doctor in training as you have to see everything! Every one of the 12 of us in the room left with a spring in our step and a new zest for general practice. It seems like the world community of GPs is in very good hands for the next few years!
Since starting my career in medicine, I have been asked to certify death on many occasions. The first few that I was called to see were in hospitals as part of a ward team or even after hours as the intern covering surgical or medical wards. Often, I had not known these patients for more than a few days and had sometimes been already non-interactive for this time. Therefore, I felt little sense of personal connection. When called to certify, I was merely formalising the passing of the patient. I would dutifully listen for heart sounds and breathing for one minute, check pupils and response to pain. Of course there were a few challenging cases…
In the country as an intern, I was called at 3am to see a patient. Of course I missed the nurses first few sentences as my brain spooled up on the phone in bed. All I heard was “…so he’s fallen and there’s a large laceration to his forehead.” My response was something along the lines of “ok, so I guess I’ll come in and stitch him up?” The nurse replied “didn’t you hear me, I said he’s dead.” An important reminder for those calling doctors in the middle of the night, summarise the case at the end of the call! At any rate, this inpatient had advanced metastatic cancer and got up out of his bed and fallen in a separate corridor. My junior tired doctor brain didn’t know whether the coroner needed to be called. So we called the office and they said not to worry, just take some photos and certify. This was the first time I’d had to assess and certify a death where the patient hadn’t passed away peacefully in bed.
On another occasion earlier in my career on the hospital ward, some of the patients family wanted to be present at the certification. I had to quickly think about how to inflict a painful stimulus in a non-dramatic way. Surely sternal rub or supraorbital pressure was out. I fell back to nail bed pressure with the cap of my pen. So after checking for a radial pulse, the pain response was covered discreetly. Then came the difficult part, what should I say as I leave and walk out the door? Sorry for your loss? I didn’t really know the patient, so it would be hard for it not to sound forced.
Interestingly working in a country town last year presented a solution to that problem of what to say. But it also raised a bigger issue. By living and working in a small community, you invariably get to know your patients a lot better than in a large hospital. You see them every fortnight or month in the clinic and then in the other times down the street, at the footy and supermarket. Some were even my close neighbours and friends. You learn their little nuances and build up something that draws me to general practice, rapport. You are part of the best and worst of their lives. Watching a new treatment work wonders for someone all the way through to the end of life. I saw many of my neighbours, patients and friends pass away last year. But unlike city practice, as a rural doctor you are the one to certify and see the final state of your patient that you have got to know. Many times, the last thing I remember of these people is certifying a lifeless body in front of me. I want to remember the laughs in the clinic, seeing them moving better with a frame in the community or having a beer at the pub. It is the burden that rural doctors take on when this happens. For this reason, I always ask the family if I can get a copy of the little funeral booklet that often tells the amazing life story of your patient. It helps me to replace the last image and moments with them in the hospital with a vibrant history and imagine the living patient again.
But it is not all doom and gloom in the country. Having been the patients doctor and friend for a longer time has allowed me to say more to the family when it comes time to edging out of the door. Previously an awkward moment of ‘what to say’ was now backed up by rapport and the patients story. I will often say: “I’ve known and looked after ‘John’ for the last 10 months now. It has been a privilege to be his doctor in that time and I’m going to miss him in the clinic.” So the extra emotional burden of losing your patient in fact helps to better talk to the family with compassion. It is real as often you are grieving as well. I’m looking forward to working in the country and being a part of the community, but how will I deal with the constant loss? If any GPs would like to comment, I’d be very keen to hear your thoughts.