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MBS Item Number Handy Reference

Hi all and welcome back! This is the first post that I have popped up online since October last year. Since then my fiancee, the ever prolific GreenGP, and I have moved to country South Australia to begin our careers as fully qualified rural GPs. Understandably we have been very busy settling in to a new town, getting to know three new practices, playing some local sport and also trying to enjoy some free time!

One of the jobs that I find myself scrambling to complete in the brief 5-10 seconds of a patient walking out my consulting room door to the reception counter is looking up the appropriate item number for that counsult. Of course the majority of them are 23′s (Level B), the occasional 36 (Level C) and a couple of standard procedure items. However, I’m often found at the end of a day trawling through the disatrous fees list on our computer software to bill excision and histology results. So what started as a little project in Wudinna 2012, has been completed for Mel and my (and now your) peace of mind and ease of use. Having spent most of my registrar training in rural areas, the numbers listed are somewhat aimed at country doctors. But feel free to laminate and pop on your desk next to the mountain of paperwork, insurance reports and cold coffee.

PDF link here: MBS Handy Reference

Hope to be writing a bit more frequently from now on. Cheers, Gerry

 

Nasogastric tube insertion

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!

 

 

Indications

  • Gastric decompression – SBO
  • GI imaging
  • Feeding – choking risk
  • Removing toxic substances

Contraindications

  • Severe mid face trauma
  • Recent nasal trauma or surgery
  • Base of skull fracture

Relative

  • Oesophageal varices

Equipment

  • NG tube (put in fridge if too bendy)
  • Nasal spray
  • Water with straw
  • Lubrication gel
  • 60ml syringe, litmus paper
  • Tape, pin
  • Drainage bag

Technique

  1. Explain procedure, need good bedside manner, build rapport
  2. Risks/benefits (sore throat, blood nose, sinusitis, oesophageal perforation, collapsed lung), (prevention of aspiration, nausea)
  3. Pick the most patent nostril and spray with lignocaine
  4. Measure length from tip of nose to left costal margin
  5. Sit upright, mild flexion of neck, hold back of head gently
  6. Assistant/patient hold water cup
  7. Lubricate and advance along the floor of the nose, twist tube as advances
  8. 10-20cm resistance, start sipping water, swallow tube down
  9. Encourage as tube passes “sip, sip, sip” “keep going” “you’re doing well”
  10. When to stop: cough, cant speak, nasal haemorrhage
  11. Check placement: blow air and auscultate, pH, CXR
  12. Tape to nose, pin to hospital gown
  13. Cepacol lozenges if throat sore

 

Respect, communication & understanding

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:

"DON'T SEND!"

“DON’T SEND!”

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!

Primary Health Care Research Conference 2013: Day 2

2013 PHC Research Conference - Allies for better primary health care

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.”

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.

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.

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….

photo(3)

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:

Barriers

  • 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

Strategies

  • 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.”

 photo(2)

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.

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.

*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.

Primary Health Care Research Conference 2013: Day 1

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.

2013 PHC Research Conference - Allies for better primary health care

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.

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 Minister for Health and Medical Research

The Minister for Health and Medical Research

The four main strategies were outlined:

  1. Patient focussed
  2. Better access and equality
  3. Emphasis on health promotion and screening
  4. 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:

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.

MM research on the rise

MM research on the rise

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.

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:

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:

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:

  1. Navigators – helping patient through the health system
  2. Special interests – covering specialist areas
  3. 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!

Certifying death and losing patients

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.

 

Tips FROM students!

For the past 4 months I have been tutoring medical students in both Year 1 clinical skills and Year 3 case based learning. Before this, colleagues had always said that you learn so much from students. I have found this to be very true. It has also been a great way to look my own consulting and examination skills and find areas for improvement. Here is a short list (that will hopefully grow) of things that I have taught, I have learnt and that bring a smile to my face. If you are a clinician, I highly recommend doing teaching of some sort.

  • Avoid negative leading questions “you havent been febrile have you?” It leads the patient to an answer, I’m guilty of it sometimes too!
  • If after your beautiful open question the patient says “I have a cough.” Instead of jumping in to closed questions, ask another open question like “tell me more about the cough…”
  • Explain examination procedures to patients in simple terms. So instead of saying “I’m going to percuss the lower lung fields,” you can say “Im just going to tap on your chest quickly.”
  • If you state the absence of esoteric signs (Janeway lesions), be prepared to explain what they are a sign of
  • To save you time listening to the chest say to the patient “take a big deep breath in and out through your mouth everytime you feel the stethoscope on your back
  • Its called a ‘tongue depressor’ not ‘suppressor’!
  • Avoid saying “cool” or “excellent” when asking history. It’s good that you have got the information, but it doesn’t sound great if they’ve just told you about their bowel cancer. Say “ok” or “mmhm.’
  • Don’t pronounce the ‘p’ in ptosis
  • Pt: “I havent seen a GP in 35 years.” Student: “Well its good that you came to see us today.” Great line
  • Recap your history at the end. It gives yourself some time to remember any points you might have forgotten, the patient might remember something and it shows you’ve been listening!
  • If a patient says they are not smoking, make sure you ask if they have every smoked.
  • Similarly if you ask about recreational drugs, it’s a good idea to list some common examples.
  • Be non-judgmental about any answer that comes back.
  • Don’t be afraid of silence. In fact if there is a large pause, let the patient break it.

 

To PR or not to PR…

A few weeks ago, my uni students were given a scenario similar to this one:

Mr Hugh Jass, 65 year old lawyer presents with headache, nausea and sweatiness. Cough, non productive. Muscle aches, dysuria and urinary frequency. No symptoms of meningism. 25 year pack history. No other relevant family or past history.

O/E: Temp 40C, HR 90, BP 110/90, RR 18. Crackles in right base. Abdo tender suprpubically, no loin tenderness. BS normal.

W2gwBkE7_QAiuwHz6DNDng5DMqvm-WfPC_qqs-9Q09kshat would you do from here?

In the case, Hugh is referred to a tertiary ED where he has some tests. CXR shows some COPD but no consolidation and urine grows E.coli. He is evenutally seen by a urology consultant who gets a better LUTS history and does the PR and PSA test.

The question was asked, quite fairly, should we have done a PR earlier? And if so, when? GP room, first ED work up? It made me wonder “would I have done a PR in the GP room for this man?”

I also put myself out on a limb during the case conference with the other tutors and said that I probably wouldn’t have sent this man to ED. Was almost shouted down! I thought that a reasonable action (even in the peri-urban setting) may have been to check for UTI with dipstick and commence on oral antibiotics. Given his high fever and symptoms perhaps even a shot of IV antibiotics as a stat dose? Although I understand that a UTI in a male is a concern, I thought immediate referral to ED was a tad overzealous. Of course more detailed history about urinary symptoms, DRE, PSA (if symptomatic) and a referral to urology would be on the cards, but within a week or so. It seemed from the other tutors that this would be too gung-ho….

Interested for your thoughts.

RDWA Keynote Speech

Delivered on the 24th May to the 2013 RDWA Conference. First time I had to speak for 30 mins!

“Gerry grew up for 22 years in the outer suburbs of a small Victorian town called Melbourne. So how was it that this ‘city boy’ ended up undertaking GP training and wanting to work in rural South Australia? Was it family heritage in the bush, inspiring placements, the lure of aviation or all three? Surely they will find out he barracks for Collingwood sooner or later….”

Impetigo: Rocky style

Having difficulty remembering what the lesions look like, what antibiotics to use or what else to education patients? No fear, in 3 minutes your problems will be solved. Apologies for poor singing/pitch and subliminal pro general practice messages…

 

 

 

Country GP taught me to fix my jumper

IMG_1785

Poor old jumper

I have a favourite black jumper. In fact, its helping me write this post at this moment. Everyone has an item of clothing just like it. Unfortunately, the price paid is increased wear and tear. My black jumper started to develop a large hole under the armpit area at the start of last year. The nurses in Wudinna would give me grief when I started wearing it in the winter (sometimes for the cold, other times to disguise a non-ironed shirt…)

Tools of the trade

Tools of the trade

Eventually, enough nurses, family members and people on the street convinced me to get it repaired. Some said take it to a shop and other offered to stitch it up themselves. After politely declining on a few occasions, I found the opportunity to repair my old friend on a recent trip to Melbourne. Mum provided the obligatory box of needles, thread and scissors. But I had never fixed up any sort of material damage before, the only relevant word I knew was ‘darning’ from Elenor Rigby by The Beatles.

But the truth was I had done something like this, in fact I would do it once or twice a week. Often patients would present to the clinic with large cuts and lacerations and need stitching. Surely I could use these skills here? During a medical student and intern placement in country South Australia, I learnt a number of tips and tricks for suturing. In Jamestown, a pulley type horizontal mattress and running subcuticular stitches were taught to me by the great GPs there. To finish off each run of suture, I managed to remember how to do a hand tie. Amazing what can come back to you after three years!

Concentration at the kitchen table

Concentration at the kitchen table

So away the stitches went attempting to close the large axillary dehisence in my jumper. One aspect that was different was having to thread the cotton through the needle tip. That took steady hands and a large amount of accomodation (see cross-eyed picture above). Luckily I avoided any needle stick injuries as the material edges started to oppose. It probably took me 3 times longer than stitching up skin, but I eventually finished. And I can report that there has been no further wound separation since!

Has anyone else used medical/surgical techinques for everyday tasks? Im sure there’s more out there…(looking at you Leeuwenburg)

I had to cut my own threads!

I had to cut my own threads!

 

Interview with Jim Muir from Telederm

A face not just for radio!

A face not just for radio!

Speaking with Dr Jim Muir about ACRRM‘s Telederm program. Jim is a dermatologist based in Queensland who says he has ‘a face for radio.’ He has been running Telederm for the past 10 years which provides online dermatology diagnostic and management help. I’m chatting with Jim about the service, its benefits, how it started and what the future of it might be. Unfortunately, the funding for Telederm is threatened. To learn more about the crisis and how you can help, please have a read of this post.

To add your name to the petition to #savetelederm, visit the page here.

#SaveTelederm

Arm - close up

Arm – close up

About a week or two ago I had an interesting dermatology case that I saw in the clinic. It took me a second visit to get my head around what could be going on. By then, I had tried some treatment and taken a fairly good history. But it made me think. What had I not thought about? Was there more important history? What did the rash look like to other doctors? In this grand age of #FOAMed, I wrote this post and asked the online doctor community for some help. The response and discussion was amazing. But this concept and process is nothing new. It has been the bread and butter of Telederm. The post also sparked a discussion and recent realisation for myself and some other rural GPs that the future of Telederm was at risk.

But what is this Telederm?

Dr. Jim Muir - Telederm

Dr. Jim Muir – Telederm

Telederm is an online dermatology resource faciliated by ACRRM and run by Dr. Jim Muir, a dermatologist based in Queensland. Listen to an interview with him here. The Telederm service has been operating for the past 9 years. Jim has been prolific in his posts online and education of GPs around the country. In fact, I was able to dig up an article about Jim and Telederm from 2005. Interestingly was quoted then as saying:

“the uptake of Telederm is not as high as it should be, because it is seen as time-consuming for GPs to have to take photos and upload them.”

Fast forward to 2013 and the use of Telederm has grown exponentially. Perhaps the advent of smart(er) phones and better cameras has helped with increasing uptake? I also like to think that GPs, registrars and students have realised what an amazing resource it is and have spread the word. Along with case discussion threads (that I have lurked and watched without posting on for the past 4 years!) there are quizzes, a service for a proper dermatology opinion often within 24-48 hours and instructional excision videos.

Why is it so important?

Unfortunately, there is still a wide gap in the medical services that are available to rural and remote patients. Access to specialists is still woeful in many parts of the country. Telederm not only reduces the tryanny of distance for these patients and their GPs to specialist advice, but also saves big bucks through reduced Medicare expenditure.

Some other benefits of Telederm include:

  • Free advice on diagnosis and management of tricky skin conditions
  • Saving of patient’s time and expense
  • Increased speed of diagnosis and treatment for patients
  • Up-skilling of GPs in rural and remote areas
  • Ability to provide local medical services that would not otherwise be possible

So what is all the fuss about?

Unfortunately the funding required to keep this service online is currently at risk. ACRRM, the rural GP college that keeps Telederm running has made a submission to the Department of Health and Ageing to continue funding this valuable resource. A response was due in March and has not been forthcoming. Therefore, we need your help to advocate and make some noise….

#SaveTelederm facts

How do I make a difference?

Already there has been a lot of noise coming from Twitter using the hashtag #SaveTelederm and blogs penned by rural doctors (Minh Le Cong, Tim Leeuwenburg and Jonathan Ramachenderan) that use this service and are passionate about its continuation. If you have a blog, please write something. If you teach students, tell them about it. If you are a patient in rural areas, talk to your local member. And everyone, get online and sign this petition: https://www.change.org/en-AU/petitions/keep-telederm-funded-savetelederm

Every signature sends an email to the Health Minister and the Department of Health and Ageing so that they can realise what a tragedy it would be to lose Telederm. Thanks for your time and support.

 

A tale of on-call radiology

Better than the iPhone x-ray app

Proof I can take x-rays, my own finger

Hi all, a little story (somewhat of a rant) that I’d love for you to read and comment on.

This year I have been helping with an after hours GP clinic about 30 mins drive from Adelaide. It runs out of a small ‘country’ hospital between 6:30 to 10:30pm. Attached is a private radiology department that has x-ray, CT and ultrasound capabilities. The after hours service is mainly for small emergencies that are easily treated by a GP that can’t wait until the morning. Even still, there are some who come for repeat prescriptions…but I digress.

I was at the clinic when a 9 year old boy presented one night. The poor lad had fallen off his little motorbike coming down a hill at about 20 kmh or so. On initial examination he had a few grazes and a 3 cm cut to his left forehead (was wearing a helmet!). Secondary survey revealed a very sore left elbow and sore right metacarpals that he didn’t want to move at all. Before suturing him up we called for the on-call radiographer to come in and shoot some x-rays at these sore spots. Just as the last stitch went in, he was whisked away to get irradiated. Luckily, there were no nasty breaks. We thanked the radiographer and got the boy cleaned up.

An hour later I had two more patients that I thought needed x-rays. One was an 11 year old girl who had fallen in large pothole. It sounded like she had suffered an inversion injury, was unable to weight bear and was tender over her 5th metatarsal head. BOOM! Ottawa Ankle Rules, she needs an x-ray. Just as it happened, the next patient came in 5 mins later. This time it was a 7 year old girl who had falled on her outstretched hand the day prior, non tender over her scaphoid bone, but was maximally tender over the distal radius. I thought “this could wait til tomorrow with a backslab, but if the radiographer is coming in for the first one…” The lovely casulty nurse dutifully called up and returned after I seen a few more patients and reported:

“I don’t think the radiographer is very happy with you, they want to know how qualified you are and if the x-rays really need doing. They are about 30 minutes drive away.”

There was so much in that short discussion that made my neck hairs stand up. It was something that had irked me before at a large tertiary hospital. That is someone being on call, getting paid to be on call, but then giving some resistance to coming in. To their credit, the radiographer came in and took the x-rays for me. There were no fractures in either of the young girls who in turn didn’t need a plaster on overnight. Some tubigrip bandage, RICE and home it was to follow up with their usual GP in a few days. That did make me feel a little silly for the call to be honest.

Before leaving, the radiographer and I had a chat about what was company policy was with regards to what they should be called about in the future. Apparently the motorbike injury was OK, the girls apparently not. I might have stepped over the mark by going on to say that I was not only qualified as a doctor, but also to take x-rays (even of my own finger after dislocation). Of course I wouldn’t be allowed to use the company x-ray machine in the hospital I was working, but certainly any of them 15-20 minutes towards the country. In fact up until about five years ago, the GP after hours service could use a portable x-ray machine that lived in A&E. But it was removed following pressure from her company. Now not wanting to point the finger at  company policy, the radiographer who helped me out this night, any of the patients and hopefully myself, what is the best move here?

I would be interested to hear your comments!

Was I being too cautious in asking for the last two x-rays?

Should I have just broke out the Plaster of Paris and sent them for a GP/hospital review the next day?

Should you actually have to put up a fight to get someone who is on-call to come in for a patient?

Adult Dermatology Case #1

45 yo female presents with itchy arms and some sores all over them. No regular medications. Has already seen a GP one week prior who gave her some hydrocortisone cream, but this hasn’t helped. She see is seeing you for a second opinion. Questions below:

Arm

Arm

Arm - close up

Arm – close up

 

What further history would you like?

Dr. Mel Clothier of GreenGP has listed some good points to cover on history, including some I should have asked. Here is more of the history that I gleaned on first visit:

  • Rash had been there for 3-4 days before seeing first GP, hasn’t changed since hydrocortisone. So now ~10 days in total
  • Has only tried paw paw ointment and some barrier creams
  • Never been allergic to anything in the past, no history of eczema/asthma
  • Somewhat icthy, but not driving her mad. Still sleeping well
  • Lives alone, but no other contacts with rash
  • Occupation (big point to cover): works at an animal shelter, looking after stray domestic pets and some natives.
  • No change to soaps, washing detergents etc
  • I didn’t ask about nutritional status, mental health issues, family history of skin problems or delve into past medical history.

How would you describe the lesions/skin?

These pictures are from the second visit. Initially there were more reddish vesicles with some pus and a few crusted lesions.

What would your initial management be?

My first thought was that it looked a touch like impetigo. I wondered about scabies or even possibly pruritis from some internal med issue. The story of the exposure to animals was interesting, but DermnetNZ had said that animal mites do not infect humans. I swabbed a purulent wound for bacterial MCS, started a course of oral Flucloxacillin and prescribed some Celestone (betamethasone) cream. Because of the mild itch, I didn’t say anything about anti-histamine use. At this early stage, I thought I would leave bloods and biopsy until after the antibiotics had done their thing (or not).

Twitter already has a few ideas bouncing around:

 

One week later, my patient has booked back in to see me. She says the redness is a bit better and the lesions have scabbed over mostly, but they have spread to her legs and are starting to itch some more. The swab results are also back:

micro results

She also tells me a bit more about her work. It turns out that the animal shelter uses old mattresses and blankets directly from donations (i.e. not via Op Shops). She thinks that the spots had come up after a recent batch had come through to be used, but was adamant that the sheets etc had been cold washed prior.

What are the preferred diagnoses now?

What would the next step in management be?

Is there anything to follow up or advise the patient about?

How AHPRA taught me to use social media

This picture is getting well used on this blog!

This picture is getting well used on this blog!

In September last year, I was relatively new to Twitter. I had probably been using it for about 6-8 months posting on little observations, but nothing much productive or useful. Then while waiting for a tram in Melbourne, I happened across the AHPRA draft social media policy. The tone was rather disappointing and it seemed as though the regulation body was looking to tightly regulate health professionals’ use of social media so that it would be rendered too risky to take part. The regulatory version of sticking fingers in your ears and shouting “na na na.” However online communities like #hcsmanz (health care social media Australia & NZ) and blogs like Croakey started making some noise.

At the time, I was attending the GPET conference in Melbourne. Co-incidentally, I had been attending social media workshops and seeing Twitter being used brilliantly by people like Dr George Forgan-Smith. It jolted me enough to start getting involved with #hcsmanz, using Twitter more often and blogging about the issue with this piece. It was a call to arms, ironically fueled by the group seemingly wanting to limit doctors’ online presence. I have since made many strong online bonds with those who were on the front line during those days. Via GPRA, my response called for collaboration of various stakeholders including ours  which represented many Gen Y future GPs with a large online presence. (N.B. To this day, @AHPRA on Twitter is still devoid of posts)

Cut to May 2013. Just last week AHPRA formally released this consultation paper that includes amongst other sections, a new draft social media policy, revised Code of Conduct and guidelines for advertising. Dr Edwin Kruys has dissected more about the effect of incorporating social media aspects into the Code and advertising guidelines as it pertains to his practice in Geraldton on his blog.

It looks like AHPRA have listened to what the stakeholders have said in response to the draft last year. But what questions do the new social media guidelines raise for GP registrars and fellows?

Do online as you do in person?

In essence, the social media policy appears to repeatedly refer back to the Code of Conduct which regulates health professional behaviour in the real world. While this may be good for continuity, it still my stifle progress and new online initiatives that come forward in the future. Understandably, real life and the online world are very different entities. So should there be a separate Code of Conduct for social media?

Do we need another policy or guideline(s)?

Rightly so, AHPRA has defined their place for their own social media policy. Unlike the policy produced by the AMA to protect professionals online, AHPRA’s mandate is to protect the public. I hope that the new policy is framed not only to best protect the public, but also to encourage novel use of social media which may enhance patient care.

Will my online work breach confidentiality?

The same rules will apply for online use of unauthorised use of photographs or patient information as those in the real world. However, given the vast use of clinical data for teaching may mean that those posting online will need to be very careful and use proper documentation and consent.

Do they know what we’re doing?

Yes, fortunately AHPRA recognises the ever expanding use of social media ‘user generated content’ on blogs, websites and more widely known social media sites.  They stop short of endorsing its use in this way, but again remind health professionals of their obligations to maintain standards especially with the permanent and public nature of online material.

What does AHPRA want to know from you?

As part of the call for feedback, there is also a list of questions that the regulatory body has posed:

  • Do you support the approach of including general guidance in the draft policy, the Guidelines for advertising and the Code of conduct, with appropriate cross-referencing?
  • Does the guidance in these documents reflect the National Boards’ regulatory role?
  • Do you agree with the approach of referring practitioners to other sources for guidance on social media that goes beyond the National Boards’ regulatory role?
  • Is the content of the draft Social media policy helpful?
  • Is there any content that needs to be changed, added or deleted in the draft policy?
  • Do you have any other comments on the draft policy?

 

I'm not sure if I can post this?

I’m not sure if I can post this?

Lastly, I’m not sure if this sentence (which is dreadfully too long) even responds to the concerns raised in September:

“The National Boards have responded to this feedback and are proposing an approach which addresses the regulatory issues related to social media, consistent with the Boards’ role, but which does not unnecessarily restrict the use of social media that is unrelated to a practitioner’s professional life.”

The responses last year were so impassioned because of the very opposite of this. Many practitioners are using social media AS PART of their professional life. All for the benefit of education, and interaction which in turn are for the betterment of patient care. Any attempt to restrict its use for this purpose may only create further tension. Reassuringly, AHPRA has stated that it will review the guidelines each year and they do appear to be much less stringent than what was seen last year. A wise move given the dynamism needed to keep up with changes in social media.

AHPRA is requesting feedback via guidelinesconsultation@ahpra.gov.au by close of business on 30 May 2013 to the social media policy

 

Paeds Dermatology Case #1

So this 9 year old boy came through the clinic the other day. He sat in the chair closest to the desk. Good start. I started with “G’day, what can we do for you today fella?” Response *look straight at Mum* Ah well, can’t win em all!

Thumbs up!

Thumbs up!

Anyway, he had been having trouble with a non healing scab/wound on his proximal thumb. It had started about a week or two ago when he thought that something might have bitten him. After that it swelled up and went a bit red. Mum said that it only lasted for 2-3 days and had got better so she didn’t get it checked out. After a week some yellow blisters appeared and then popped with some clear/yellowish fluid drained. Since then it hasn’t really got much better. His immunisations were up to date and there wasn’t anyone sick at home or at school. Feel free to comment below and weigh in…

Description of the lesion?

Im going to go with Penny’s description of an inflamed lesion on the proximal right thumb that has some crusted yellow sores. I wondered whether the middle reddish part of the lesion was an initial injury or bite that kicked off the infection.

Preferred diagnosis with differentials?

From the history and from the looks of the lesion, impetigo was my first thought. Not sure what the cause here might have been, usually a scratch or insect bite. Dr Penny Wilson makes the good point that it could be due to an area of prolonged irritation such as with a thumb sucker. DermnetNZ also mentions that scratched eczema could also present like this. Scabies and head lice should always be considered also.

Investigations and treatment options?

For this chappy, I took a bacterial swab and started him on oral Flucloxacilin. I suppose that given the localised nature of the infection, I probably could have got away with a topical antibacterial such as mupirocin (Bactroban). Dr Mel Clothier added that a viral swab to rule out underlying HSV may be helpful. Apart from oral antibiotics there are a few simple measures that both the Therapeutic Guidelines and DermnetNZ suggest including:

TreatedImpetigo

  • Soak moist and crusted areas with cloth containing vinegar/tepid water mixture (1 cup in a litre)
  • Antiseptic or antibiotic ointment if simple case
  • Treat carriers: full body bath with small amount of bleach and/or mupirocin per nostrils
  • Avoid close contact, cover sores, separate linen/towels
  • Non infectious once crusts dried out

 

In the end, Mum found that the lesion had reduced in size, was healing well and didn’t need further treatment. She sent me this photo which highlighted the benefit of teaching our patients and parents to take good images! The microbiology results showed Staphylococcus aureus and was sensitive to penicillins.

More images of impetigo from DermnetNZ.

Interview with Prof John Murtagh

Murtagh1

Master and (very much) apprentice

In this short podcast interview (below), Prof Murtagh talks about his own pathway to medicine and general practice in the country. Starting as a science teacher interested in maths and physics, he came to medicine after being inspired by his own GP in the country town he grew up in. Part of Monash University’s first medical cohort, John said that he “liked everything” and that the “country is the place to be.” Seems like rural general practice was an easy choice for Prof Murtagh, but not without its challenges as he explains.

He found some isolation in the country, however help was only a phone call away. We wonder whether the advent of social media and blogs may help reduce this tyranny  of distance even more. Also in the interview are some memories from the Prof, including risque interactions with octogenerians, exam preparation tips and pearls of wisdom for medical students just starting their own journey. I hope that you enjoy this chat and learn just as much as I did from a great mentor and spokesman for general practice.

photo-6

Murtagh’s GP textbook (Mk1)

Suprapubic Rainbow

I remember my first removal/re-insertion of a suprapubic catheter (SPC) very well. In fact, it will be something that will remain in my memory for a long time to come. During medical school there had been plenty of standard urinary indwelling catheter (IDC) insertion and removal rehearsals with those hard rubber models. I’m sure we all know the ones with the unrealistic non-malleable appendages and ‘bits.’ Then I had even managed to practise many real life IDCs on the hospital wards as a senior medical student (and actually longed for those practice manikins that actually held their shape!) But I had never been able to attempt or even witness a removal of a catheter that went straight into the lower abdomen. We had learnt all about suprapubic techniques in paediatric rotations, but my first foray into this area was during a country general practice intern placement (PGPPP).

My patient for the day was a 50-year-old lady who had been using suprapubics for the past year. However, she had found the whole process so painful and unbearable that each change was conducted at the hospital under analgesic cover. Unfortunately her level of pain tolerance, or lack thereof meant that these episodes were usually quite a scene. Three changes before my shot, the patient had throttled the closest nurse out of sheer desperation. Luckily the GP in this town was open to alternative techniques and enrolled the help of a hypnotist from the next major town. On previous changes the patient had been instructed to imagine everyone naked and giggled her way through the whole procedure. Then it came my turn. Fortunately the naked trick was not being used this day. As I entered the room I could hear singing. My patient had been hypnotised and was already in a trance like state singing the tune “Somewhere over the Rainbow”.

So it came to be that my first suprapubic catheter removal was performed with the patient calm and singing sweetly in my ear. Unfortunately, the Wizard of Oz has since lost some of its magic for me and consequently will never think of the Yellow Brick Road in quite the same way again! I guess Im just happy it wasn’t a double rainbow “all the way across the sky…”

What makes a good patient?

On time, everytime

On time, everytime

In the modern world of consumerism, the customer is always right. In the 21st century, this even translates to the world of medicine. Patients now have unprecedented choice in their practitioner. The internet is full of reviews and blogs stating what the health consumer likes about a certain practice or GP. Doctors are increasingly under the microscope, but what makes a good patient?

 Thats teamwork

The first overarching rule is teamwork. In general practice, most complaints and health issues can be solved with preventative care. That is, patients are now able to sit in the driving seat of their health. The newer generations of doctors are taught in university to help facilitate this.

Take an interest in your health

Some patients actively research their symptoms, conditions and ask for an explanation of their results. It is much easier to explain complex issues to patients that have some background knowledge. Some useful resources include the NPS and Better Health Channel. If you are going to use ‘Dr. Google,’ remember that information on some sites is not reviewed or accurate. Your GP should be happy to help you find the right information

Get to the clinic on time

I have heard some patients call up and ask if the doctor is running late in order to lessen the waiting room stay. Yes, your doctor may be half an hour behind on some busy days, but many times this is due to late arrivals. So do the right thing and get to the clinic 5-10 minutes before your time. Who knows? They might be running ahead!

Fasting bloods and samples

Attending the clinic in the morning? Why not fast from midnight before and tell your GP? If you are due for a blood test, then your doctor can check your sugar and cholesterol level. Also if you are attending because of a urine or bowel complaint, have a sample pot and bring it in. This saves a further appointment and can have your results back sooner.

Appointment length

If you know your reason for attending will take longer than 15 minutes, then simply ask the receptionist for a double appointment. This often happens when you need to discuss more than 2-3 problems and/or have a procedure done (e.g. pap smear, skin lesion). Similarly don’t be too annoyed if you GP can’t address all your concerns if it was only a short appointment.

Symptom diary

Often patients will present to their GP with symptoms that are not very specific. Examples include headache, stomach pain, tiredness and blurred vision. This can make it hard to pin down what the problem might be. A simple measure to address this is for the patient to keep a symptom diary. Noting down when the symptom happens, the severity, what you have tried and what other symptoms or activities it was associated with can help your doctor immensely.

Ask questions!

This comes back to the first point about teamwork. In the past, doctors had the final word on diagnosis and management. Now there is more scope for open dialogue and we expect patients to question what is happening. It can also help keep us doctors on our toes and up to date with the latest guidelines!

This piece first appeared on the NPS website on the 25th Jan 2013

AHPRA notifications: A junior doctors guide

This picture is getting well used on this blog!

In the past year, I have been subject to two notifications via AHPRA. This seems to be a trend across Australia, with numbers of complaints/notifications rising. A recent Age article demonstrated this and some of the predictive factors. For a junior doctor like myself having only practiced for three full years, it was like getting hit with a truck full of bricks. Of course I won’t to go into details, but suffice to say nothing permanent gone onto my record. However in both cases (one being from a parent in a tertiary ED and the other from another doctor), I have learnt a great deal. Yes the medical board is there to protect the public, but both times I had the feeling of having to prove my innocence, not the other way around. I’m sure that it is more the way my mind appreciated the situation rather than the intended effect of the process, but it certainly feels for want of a better word…shithouse.  The length of time taken for each issue was also appalling. It took at least 4-5 months from initial notification to final outcome. This is something that the big GP stakeholders have recognised in this article via Medical Observer. It is something that I would not wish upon anyone, but if you find yourself there…here are my tips:

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12th National Rural Health Conference Podcasts

Discussing mental health in the bush

“Live from Adelaide, its the 12th NHRC in April 2013!!”

Over the four day 12th National Rural Health Conference, I was lucky enough for sit down for a couple of minutes with some interesting delegates who told me a little about their path to the country and why they are so passionate about rural health. Listen to their stories here:

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Breathing New Life 2013 (Part 2)

Leaders Forum FTW

Continued from Part 1

The Leaders’ Forum discussing GP Workforce 2025 was one of the highlights of the conference. Chaired wonderfully by Dr Emily Farrell, it comprised a veritable who’s-who of GP leadership. Prof Murry from ACRRM (covered in the early stages by Dr Davies), Dr Hambleton from the AMA, GPRA Chair Dr Vergara, GPSN Chair Mr Townsend, Dr Baker from NGPSA, Dr Marles from RACGP, Dr Kammerman from RDAA, Sharon Flynn chair of the RTP CEOs and Prof Kidd (no introduction required!).

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Breathing New Life 2013 (Part 1)

Health Minister talking up GP

It is quite fitting that I sit down to write this summary of the Breathing New Life (BNL) conference held in Canberra recently. At the conference last year, I was so inspired by the stories of other GPs and the use of blogs and twitter, I decided to start my own blog. It is the one you are reading now. Since then I have kept updating my flying training progress, commented on social media policy in healthcare and attempted a humorous post (or two). Unfortunately, I never got around to summarising my experience at BNL 2012 and you can still see the lonely post here. But luckily, I was inspired once again…and hopefully a little more motivated and better at writing!

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Haemochromatosis

slider1

A 56 year old man presents to your GP clinic with generalised fatigue and darker skin recently. He has an uncle that needs blood drained every few months. What test results would confirm his diagnosis of haemochromatosis?

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Flying training vs. GP training

At the beginning of 2012,  I was fortunate enough to commence community based general practice training in rural South Australia with Adelaide to Outback GP Training. But before heading out into ‘GP land’ for a year, I interviewed at two practices in the country. Subsequently, I had this conversation with the second practice and GP supervisor:

GP supervisor on ground and air

GP supervisor on ground and air

Supervisor: “Just drive to Port Pirie and I’ll pick you up from there”

Gerry: “But I could just drive the whole way”

S: “No, no. I’ll fly there and pick you up”

G: “Oh, do you have a plane?”

S: “I’ve got two”

G: “Wow, flying is something I’ve always thought about doing sometime”

S: “Well we need to talk…”

And so I started my first GP placement and my flying training after generous encouragement from Dr. Scott. Following this first year of starting both country GP and flying training, I started to notice some similarities between the two. But GP training is not the first within the medical field to be compared to the aviation industry.

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Rural vs. peri-urban medicine

I first must apologise for the paucity of blogs and vodcasts on this site in the past few weeks. To explain, it has been a period of massive change and logistics. Firstly, was wrapping up my 12 month stint in Wudinna as a GP registrar. As I explained at the Australia Day breakfast, each town that I practice in from now on has it tough. I will be using Wudinna as the yardstick. During my time there, I could not have been more welcomed and well supported by the community, practice staff, hospital staff and my GP supervisor/baseball player Scott Lewis. It made for a bittersweet move. This was made especially difficult by the fact that many patients did not understand that GP registrars move on every 6-12 months asking “why are you leaving?!” Secondly, I am between residences at the moment. This means staying with some friends in the southern suburbs of Adelaide while I look for an apartment in the city proper.

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Country GP is boring

Doctor/pilot x 2

Doctor/pilot x 2

I remember a colleague in medical school commenting on my intended choice of general practice saying “oh, I couldn’t do that…how boring.” Perhaps a small part of me agreed with them. Sure, I had sat as a student in a room with an urban GP and even completed a 6-week GP term in the country with some tedious moments. But now at the end of 12 months and my first registrar placement in rural general practice, I can look back and see how wrong my classmate was. I can’t even remember the number of times that my supervisor, Dr. Scott Lewis (above), and I would see a particularly interesting case and remark (tongue in buccinator) “geee, how boring is country general practice!”

During the year we have retrieved and transferred patients via RFDS for a variety of conditions including:

  • Haematemesis with a Hb of 55
  • Three appendices in the last 2 months
  • Suspected septic knee joint in an 18 month old
  • 2 cases of severe bronchiolitis in the space of 2 weeks (Thanks RSV)
  • Numerous renal colic, some with pyelonephritis
  • Suspected spinal epidural abscess

But it’s not all about the high end critical care stuff, no matter how much the PHARM/ED/ICU/anaesthetic gurus will trumpet. The nuts and bolts of GP are there too:

  • Immunisations and baby check ups
  • Cancer screening
  • Preventative care for heart disease and diabetes
  • Family planning
  • Skin lesion removals
  • Antenatal care
  • One of my favourites, ear syringing
  • Palliative care planning, to name a few

For this reason general practice (and country in particular) has been termed “womb to tomb” or “cradle to grave” care. However, I do prefer the alternative: “crack to croak.”

Perhaps the real scope of rural general practice was demonstrated a few weeks ago. Wudinna recorded the highest temperature in the country that day, reaching 48.2C. To add further difficulty, my supervisor (the only other doctor in town) was away. Luckily I had the help of a great Flinders 4th year student. Here’s a brief summary of what happened:

End of a *hot* day

Start of a *hot* day

Woken up at 3am – Chest pain brought in by ambulance – MSK, likely thoracic spine in origin

Morning Clinic

  • Fasting bloods x2
  • 12 month immunisation
  • Funny rash on shoulders – pityriasis versicolour
  • Follow up after USS for ?DVT

Up to hospital for foreign object in eye – used slit lamp to examine

  • Follow up after ureteric stenting
  • 18 month immunization

Up to hospital again for facial laceration – 7 stitches and epiglue

  • Change in bowel habit with PR bleeding
  • Diverticulitis

Lunch

*** Cut short by a car rollover with three occupants 30 km out of town. All self extricated. Blood alcohol levels on each and C-spine XR on driver to clear neck and removal collar. ***

An ex-Ford Fairlane

An ex-Ford Fairlane

Afternoon Clinic

  • Hoarse voice in 7 month old

Up to hospital. 3-year-old not tolerating orals, vomiting – admitted for observation

  • Diabetes check-up
  • Blocked ear – eustachian tube dysfunction
  • INR check
  • 6 week post-natal check
  • Chronic leg ulcer

Would be hard pressed to call that day boring! Was it stressful? Yep. But fortunately the vast majority of our days were not this busy, but the variety was always there.

More than one SAAS crew at hospital = bad

More than one SAAS crew at hospital = bad

General practice allows the doctor to be a true jack-of-all-trades and master of some. Some have said that specialities are learning more and more about less and less, until one day they know everything about nothing. The converse might also be said about GP work. But as long as I know what to look for and ask my specialist colleagues for help at the right time, I’m happy. Not only with the management of patients, but also my choice in medical specialty. General practice is never boring, you just need to look for inspiration in right places.

@ruralflyingdoc

Applying for GP training: http://www.gpet.com.au/ApplyforAGPT/NewApplicants/

Croup (Laryngotracheobronchitis)

You’re called in to your local country hospital one cold winter night. As you walk in the front door, you can hear a toddler barking away like a seal. You see that he is a 2 year old who has a harsh stridor when sitting quietly with Mum. He looks to be working quite hard with his breathing. What are you going to do and should you discharge, admit or transfer him?

Read More»

Herpes Zoster (Shingles)

A 60 year old man presentes to your GP clinic with a very painful right chest for the past 2 days. He has recently just finished a long course of prednisolone. On examination, you see a well demarcated vesicular rash on one side of his back and side. You suspect it might be shingles, but what are you going to do?

Read More»

Paediatric Hip Pain

So you have a toddler/child/adolescent complaining of a sore hip and limping in your clinic? What are the different causes, how can you differentiate between them and what do you do from there? Watch on!

Read More»

Erectile Dysfunction

A 60 year old male comes into your practice asking about tests for prostate cancer. He has Type 2 DM and had a heart attack 3 years ago. You sense that there is something else he wants to talk about…..

Read More»

Finger dislocations and auto-irradiation

Doctors are trained to diagnose and treat conditions that patients come to them with. But what happens when the doctor themselves are unwell? Discussions with colleagues often reveal stories of self-prescription and treatment. Usually, this is limited to antibiotics and regular medication use. Recently, I was confronted with a self-treatment situation as a GP registrar in my 2-doctor country town.

Now where was that ureter?

Now where was that ureter?

However, the precedent for medical practitioners treating themselves is not a new one. In 1961, Leonid Rogozov performed surgery on himself as the only doctor on an isolated Russain Antarctic station. He recognised the symptoms of appendicitis and dutifully performed an auto-appendicectomy. Luckily he had the equivalent of surgical interns helping, a driver and meteorologist holding instruments and a mirror.

Read More»

Pityriasis Versicolour

A six minute overview of this common summer month derm presentation.

Online resources:

DermnetNZ: http://www.dermnetnz.org/

Mycology Online: http://www.mycology.adelaide.edu.au/

Choosing a baby name 101

It seems in the past few years that baby names have taken a left turn at the common sense intersection. Those of us working with children (teachers, doctors, nurses, childcare workers) would have certainly noticed this shift in name trends. Of course, popular culture has always influenced the choice of moniker for our offspring. Unfortunately (in my humble opinion), our pop culture now includes such institutions such as Glee, Big Brother and the like. Parents are now naming their children to reflect their (often misplaced) love for these TV shows and movies. In the past, this choice of strange names was limited to the rich and famous: Moon Unit, Pilot Inspektor, Fifi Trixibelle and Sage Moonblood, the list goes on. But the general populous is catching on. Just have a look at the names that are apparently growing in popularity:

Read More»

Butterflies in the stomach

Swallowed foreign objects in kids

I was called to see a poor young fella up at our country hospital the other week and the case got me thinking about the above topic. As we all know, kids are delightfully inquisitive and adventurous. Of course Freud provided us with the five psychosexual development stages. The oral stage is first and spans from birth to around 21 months of age. Unfortunately this stage coincides with the period in which children become increasingly mobile and can evade the watchful eyes of parents. It follows then that the risk of objects being swallowed also increases. (Interestingly, our ED collueges tend to see many adults stuck on the 2nd and 3rd psychosexual stages presenting with interesting radiological findings….)

However a large observational study in 1999, found that the mean age was 5.2 years (Cheng, Tam; 1999). Although many objects will pass through unobstructed, there are a few cases in which emergent care and/or watchful waiting must be undertaken. Like any medical problem a proper history, examination, investigation and treatment plan is required.

History

The primary objective is to glean what the foreign body is and when it was ingested. Sometimes this isn’t always obvious as the parent was not present at the time. An important strategy is to bring a replica of the object. Especially when dealing with lego, disc batteries or hair clip if possible. Any reports abdominal pain or blood in the stool is important. A history of developmental or intellectual delay can also be associated with major complications given a delay in presentation and vague symptomatology. This extends to adults with such disabilities and should always be considered in any case of abdominal pain in this population.

A list of commonly swallowed objects:

  • Buttons
  • Bones (chicken, fish)
  • Coins
  • Keys
  • Safety pins
  • Drawing pins
  • Lego
  • Glass
  • Soft drink lids
  • USB sticks

Special cases:

  • Large coins (ie 20 and 50 cent pieces)
  • Hair clips
  • Button/disc batteries
  • Magnets

Examination

The demeanour of the child may provide hints as to how far the object has progressed. A child with an oesophageal foreign object may be in distress, vomiting, drooling, and irritable or refusing oral intake. Those with objects in the stomach conversely, may be asymptomatic. However these presentations are not the rule and further investigations sought. Palpation of the abdomen can be normal, but signs of peritonism or localised tenderness point to perforation. Generally, examination will be unremarkable.

Investigation

Plain x-ray (XR) is indicated for any metallic foreign objects. The role of XR is to demonstrate that the foreign object has passed the oesophagus. In this case, the object will be below the diaphragm in the stomach. Mouth to anus imaging is usually required.

Nasty battery, luckily in the stomach (NB fluoro light reflection, not chest tube!)

Treatment

Disc batteries

The alkaline nature of these batteries (used in watches and hearing aides) can erode tissue when in contact with moist mucous membranes. If stuck in the oesophagus as seen on XR, these should be removed urgently or the child retrieved to a centre that can perform endoscopy. The tissue destruction can occur in a matter of hours. On the other hand, asymptomatic children with subdiaphragmatic batteries can be observed at home. The stool must be searched and a repeat XR performed after 3-4 days if it has not passed.

Coins & Hair clips

If the offending currency/clip reaches the stomach, there is usually no treatment or intervention required unless symptoms arise. If the agent is stuck in the proximal or middle oesophagus, then semi-urgent endoscopy is required. Although they lack the chemical effect of disc batteries, they can still cause pressure necrosis and perforate. Distal oesophageal objects can be observed with follow up XR. Check stool for passage.

Magnets

The most important question apart from those covered above are: what sort of magnet and how many were swallowed. Recently, there has been a growing trend of ingested strong magnets causing perforation, obstruction and even fistulae. Fatal attraction indeed. So magnets may need urgent surgical intervention even below the oesophagus.

Humorous stories

A young man that I went to college with had skolled a pint of beer at a pub night that had a dollar coin at the bottom. When he presented to ED that night, the coin was found to be subdiaphragmatic. Palpation over the stomach was performed asking “are we on the money here?” and the patient was sent home to ‘pass the buck.’

Not so shiny anymore…

I saw the poor young girl in ED in late 2011, above, who had on her birthday accidentally swallowed her shiny new hair clip and inadvertently got butterflies in her stomach. I didn’t follow up as to whether she was given a replacement.

Another comes from Dr. Scott, my affable GP supervisor had this gem on hand:

God speed, little pendant

Dear Doctor,
‘James’ was brought into A&E this afternoon after swallowing a St Christopher medallion.  We x-rayed him and confirmed that this had passed the diaphragm. We have reassured the parents that the medallion should pass with time and without complication.  We have, however, advised them to see you or represent here should St Christopher’s own travels be unduly delayed.
Sincerely,
A&E Consultant

Final pearls of wisdom:

  1. Find out what it was and when it was swallowed
  2. Foreign bodies in the stomach or intestine should pass in 99% of cases (with normal anatomy)
  3. Most complications involve foreign bodies in stuck in the oesophagus
  4. Plain x-ray can localise a metallic foreign body and stratify into oesophageal and subdiaphragmatic
  5. Caution with disc batteries!

References: 

Murtagh, J. (2008) John Murtagh’s general practice.  (4th Edition). Sydney: McGraw-Hill Australia.

Cameron P, et al. (2012) Textbook of paediatric emergency medicine. (2nd Edition). Sydney: Elsevier.

Cheng W, Tam PKH. Foreign body ingestion in children: experience with 1266 cases. J Pediatr Surg 1999;34:1472-6.

Riding in harvesters with farmers

Cultivating primary prevention: the mechanised agricultural approach.

 

All aboard the combine harvester

Just the other day I was fortunate enough to visit one of our local grain farmers on their land. All over our corner of the Eyre Peninsula, hard working farmers are driving neat patterns in their combine harvesters (headers) collecting wheat, barley and other crops. Interestingly enough, our patient numbers have fallen steadily during this time. It seems that most of the community is too busy harvesting to be sick! Subsequently one afternoon, I only had two patients right after lunch. An early day! I’d spoken earlier in the year with a patient about visiting his farm and seeing what goes on around harvest time. After half hour driving east of town, I arrived to be greeted by a gargantuan green machine. There had been plenty of them parked in an empty lot next to the medical centre over the year, but when switched on and heading towards you, they are a different beast altogether!

ALL THE WHEAT!

chomp, chomp, chomp

Obviously things have changed a lot since the humble scythe, kyphosis and a headscarf. These days, the operator sits in air-conditioned comfort with a pre determined track and auto steering. The on board computers can tell the farmer the current yield of the crop and let him calculate (with SMS prices popping up continuously) how well they have done for each field. Looking out through the huge unobstructed windshield, you are able to see everything happening. From being plucked from the ground to being stored in the back of the header, a piece of grain has an amazing journey. When the comb at the front cuts the head of wheat, it is fed into the header by some conveyer belts. Inside, the stalk and the head are agitated so that the grain can fall below and be placed in the hopper for further use. The stalk and left over husks are then spat out the back into the field.

It got me thinking. Could we apply this same principle to primary health care and prevention? Watching the header bear down on me first and then seeing the wheat collected into the machine to get sorted gave me an idea. Often general practitioners, community nurses and health promoters have difficulty encouraging the public to connect and participate in health prevention strategies. One simple reason for this reluctance to attend may be that these approaches rely on self-directed changes. Eating less sugars/salt/saturated fats, exercising more, cutting out smoking and reducing alcohol. Stopping all the things that people can enjoy. But these are also all essential elements in reducing serious preventable health issues such as diabetes and CVS disease.

*duelling banjoes*

I propose this. Rather than relying on self-presentation, family members nagging or proactive health workers, we construct a transportable health prevention vehicle. “But Gerry!” I hear you exclaim, “such schemes exist already.” Ah yes they do (Harold et al), but never before like this. The Combine Health Harvester (CHH) will function in a similar way to the headers currently out in the fields surrounding our medical practice. Gathering then triaging the wheat from the chaff. The process by which the harvester can increase health officer access to patients with poor health lifestyles and then do something about it follows:

  1. Unsuspecting patients scooped off the street by scoop
  2. Channelled into the back of the harvester
  3. There, a BMI, blood glucose, blood pressure, and SNAP history taken, nicely.
  4. If enough risk factors exist, the patient will be kept inside the harvester for delivery to the local clinic.
  5. If the patient is healthy, they will be deposited back onto the street. Then left to continue their daily business with a healthy lifestyle pamphlet in hand.

How it works

Once dropped at the clinic, the patients assessed being at high risk can be tested further and referred to specialist care if needed. The technology and policy for the harvesting and patient education are already here. We just, in the words of the machine itself, need to combine them. Now just to pacify those civil libertarians….

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DISCLAIMER: This blog post is intended to be taken entirely as parody and humour. If it has not been, then perhaps you’d better go outside and get some sun. Our capture methods in Wudinna are currently much more crude than stated and will be refined in time. Thank you for your patients (sic).

One Page Paeds – Dermatology

Way back in 2008, I was studying 3rd year medicine and decided that my study for final paediatric exams would be aided by one-page summaries. I wanted these to cover simple GP-type presentations and to cover the core of each topic. I have updated them and will continue to add and refine as management changes. In the meantime, please feel free to use for study or just a quick refresh as I still do as a GP registrar now! Comments welcome.

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Impetigo

Useful links:

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Molluscum Contagiosum

Useful links:

  • DermnetNZ: http://dermnetnz.org/viral/molluscum-contagiosum.html
  • PubMedHealth: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001829/
  • RCH fact sheet: http://www.rch.org.au/kidsinfo/fact_sheets/Molluscum/
  • Murtagh’s patient info:

#interncrisis

Scrubs Protest – Sat Oct 20th

Over the last few days you may have become tiresome of my tweets and re-tweets that contain a certain hashtag. ‘#interncrisis’ refers to the current shortage of jobs for newly qualified, first year doctors (i.e. that have just graduated). In Australia, these ‘interns’ shoulder a large responsibility in our public hospitals. They take bloods, write in notes, explain decisions with patients and compile discharge summaries (sometimes within a week of discharge!). Without them, our system fails. So why are we so interested in these P-plater doctors?

During intern allocations this year, it became apparent that close to 182 interns would have no hospital employment in 2013. This is not an unexpected or new issue. Since the mid-2000s, the number of medical student places has increased dramatically to address the shortage of doctors in the workforce. However, the downstream effect of this move wasn’t and still hasn’t been addressed. Even going back in 2009, NSW found that their hospitals were ‘buckling in tsunami of interns’.

Is there an #internsolution? 

So what then is the #internsolution you may ask? As many people already realise, there is a large imbalance in the doctor workforce. Rural communities and hospitals are often short staffed and rely on locums to fill vacant positions. For many years, governments have relied on this expensive option to plug these gaps. Often, this has meant an abuse of many international medical graduates (IMGs). But with the current oversupply of interns in our metropolitan hospitals and a need for medical services in the country, it should be a case of simple diffusion.

Already the Prevocational GP Placement Program (PGPPP) exists to enable interns and junior doctors gain experience in a general practice setting. Even for those not interested in a career in GP, it can provide all junior doctors a better understanding of how primary health care works. All of our patients have contact with GPs, so too should our junior doctors. A call for mandatory intern GP terms was made back in 2010, but has yet to be implemented.

PGPPP – GP Synergy banner

To many, it seems that PGPPP may be the answer to our intern crisis. It is therefore unfortunate that in a knee-jerk, myopic decision, the federal Health Minister has decided to pay for an extra 100 intern places by taking funding away from the PGPPP initiative. A single year stop gap measure that degrades for what many junior docs, a valuable entry point into general practice. A faceless spokesperson for Mrs Plibersek responded to Medical Observer, stating that the PGPPP has previously been undersubscribed. I find this hard to believe and will have to check with AGPT. In any case, a move to make intern GP placements mandatory would solve any under subscription issues! I would also be very wary of falling back on using private hospitals and corporations to accommodate interns. Yes they would be employed, but would the level of supervision and ongoing education meet the national curriculum framework?

For the states part, extra intern spots can be created in some of our larger regional centres. These communities have sufficiently sized hospitals so that interns cover the required ED, medical and surgical terms. In fact Broken Hill will host three interns in 2013 to help solve the crisis. Already in South Australia, the town of Mt Gambier currently hosts 6 interns and has done so for the past few years. SA has the ability to fund additional intern positions in towns like Whyalla, Port Augusta and Port Lincoln. There are plenty of other such towns in rural and remote Australia. Of course with any scheme such as this, adequate supervision and training is paramount.

So, what now?

Simple maths…

In the meantime we may well have to sit and watch the political hot potato been thrown between state and federal governments. In my view both need to come to the table. On one hand, the federal government is able to fund more PGPPP placements and help free up further hospital placements by also offering additional GP spots. Of course this will cost money, but manageable with a generous surplus handed down by Mr Swan. On the other, state governments can provide additional intern positions in some of our larger regional centres as seen in Broken Hill and Mt Gambier.

These changes need to happen now, before larger numbers of interns are without places. We are talking about 182 missing out in 2013, in 2014 it may be hundreds more. The next step will then be to increase training positions for the different specialities. As it stands, general practice is already oversubscribed with many taking multiple years to enter. If this second step is not addressed, we will be left with a generation of continuing medical officers without career progression staffing our already bursting hospital system. Our very own registrar crisis could be just around the corner.

The key to lowering health spending is in primary health care and it seems that creating more GP placements for junior docs and then increasing GP training spots will solve not one, but two problems.

What can you do to help?

  • Like this page: http://www.facebook.com/MedicalStudentActionOnTraining
  • Tweet your thoughts: #interncrisis, @Tanya_Plibersek and your local member
  • Snail mail: federal and state Health Ministers and your local member
  • Discuss: let your family, friends and patients know that this is a real problem and may only get worse if nothing is done.

Situs Inversus

A 50 year old lady presented to our tertiary hospital with abdominal pain of a non-specific origin. It was decided by the ED consultant to order an abdominal CT scan (otherwise known as a ‘grope-a-gram’). Although there was no obvious pathology detected to explain her symptoms, I was still showed the abdominal slices to look for an interesting finding:

“Who is the fairest of them all?”

I will post a short precis on this condition (and its classification) in a few hours leaving some for the Twitterverseto have a gander. I wonder how long it takes you to find it, I remember it being well over 30 seconds for me!! ===============================================================

So after my almost minute of searching through the above grey/white/black image for subtle fat stranding, flaps of aortic lining and pancreatic abscess, it hit me. “Oh s**t. The liver isn’t supposed to be on that side.” My heart sank when a medical student came up and said straight away “this CT looks weird” and without missing a beat exclaimed “everything’s on the wrong side.” A few terms of colorectal surgery and general medicine had me looking for minutia. I’d failed to see the forest for the trees, or leaves even! The more thoracic slices were easier to pick:

Put your hand on your heart….other side please

What we had was a case of situs inversus. This condition can also be known as situs transversus, situs oppositus or situs organsaroundthewrongwayus*. Their internal organs are mirrored across the sagittal plane, or more simply: things usually on the right side of the body (liver, gall bladder, caecum) are found on the left and vice versa.

*Term made up by me, just now.

So what is the first thing you should think of when you see a CT like this? No the answer shouldn’t be situs inversus. Common things happen commonly. Mislabelling or image mirroring of the CT may be to blame. Then if you are confident this is not the case, time to delve into the rarefied air of such genetic abnormalities. Rare, yes. But the classification of position of internal organs is quite simple. It is not clearly essential knowledge, however very good for impressing cerebral physicians…

Total flips of the heart

  • Situs solitus (‘normal’) - How most of us and the anatomy text books are put together/drawn
  • Situs inversus with dextrocardia (situs inversus totalis) - Most common form of inversus which has a right sided heart, in keeping with the switch
  • Situs inversus with levocardia (situs inversus incompletus) - A much more rare form of an already rare condition in which the heart remains on the left (normal) side of the thorax
  • Situs ambiguous (heterotaxy syndrome) - Any combination of the above that does not fit a pattern of complete solitus or inversus. Calling it ‘incomplete’ situs inversus probably explains it better, but sounds too much like the latter.

Basically your insides are all topsy-turvey…

Situs inversus is thought to have a prevalence of 1 in 10,000 people. It is inherited in an autosomal recessive manner and is usally associated with other congenital heart defects (most commonly transposition of great vessels, TGV). Interestingly, although Leonardo Da Vinci was the first to describe dextrocardia, it was Matthew Baillie who described situs inversus and TGV. He was a Scottish physician who in 1793 wrote the best titled text I have come across: The Morbid Anatomy of Some of the Most Important Parts of the Human Body.

Interestingly 25% of patients with situs inversus have an underlying diseased called Primary Cilia Dyskinesia (PCD). Cilia are tasked with placing organs in their appropriate positions during embryogenesis and this is where things can go wrong. If patients have the triad of chronic sinusitis, bronchiectasis and situs inversus, then this is known as Kartaneger syndrome. Perhaps its worth conducting a thorough listen to the chest (or ECG) for those patients with recurrent sinusitis and mucousy coughing?! These conditions pose interesting anomalies, but what are the practical consequences for the patient sitting across from you?

  • ECG interpretation: If you attach the leads (correctly!!) and see strange axis deviation, p-waves inversions and a decrease in QRS voltage across to V6, then there may be inversus. To confirm this, swap all of the leads across to the right chest, including limb leads. The lesson though, is always double check lead placement lest you end up diagnosing ‘technical dextrocardia’

RA lead goes on the left lower limb?

  • General surgery 101

    Pain/Tenderness: We are taught in surgical training to know that for pain or tenderness in the abdomen, think about the underlying structures to help differentiate causes. Clearly if things are mirrored it will change your thinking. LIF pain could be appendicitis, RIF pain could be sigmoid diverticulitis and LUQ pain could be gall bladder related. Bruising over the right flank might mean you are worried about a splenic rupture.

  • Organ transplantation: The vast majority of organ donors will have anatomy orientated in the usual way. However if a patient with situs inversus needs a transplant, problems arise. Not only are arteries and veins in different positions, but the physical shape of the organs will not match up. In fact, an American patient with situs inversus underwent a heart transplant in 2007. The six-hour long operation was likened to solving a “three dimensional Rubix cube” (actually not sure what other dimensions Rubix cubes come in…but here is one solved in 30 seconds)

Thanks for reading and contributing. Clearly this is not a common presentation or finding, but hopefully if you happen across an interesting CT, CXR or ECG, you will have some background knowledge of these rare and fascinating disorders.

Bow-ties in medicine

“I have an opinion about men who wear bowties. They are mavericks; truly adventurous dressers who live on the sartorial edge. They are nonconformists and often seen as threatening to the establishment. Yes, look out for the man who sports a bowtie – he probably has an attitude.” – Chris Hogan, 2008.

Revenge of the Ner..Doctors

So I’ve been busying myself this year by watching online lectures as part of the Diploma of Child Health. This is run out of the Children’s Hospital at Westmead in the outer suburbs of Sydney. Throughout these lectures, I have noticed many of the doctors sporting natty bow-ties. During my time at Flinders Medical Centre and in GP land, I could probably count the number of docs setting this trend on one hand (free from polydactyly). But it seems every second professor or head of department on these web-based lectures are wearing them! What is going on? I propose this hypothesis: As one delves deeper and deeper into the sub-speciality crevasse, silent pressures force a required dress code. The most obvious and classic of these, the humble bow-tie. The graph below summarises my findings. Unfortunately elbow patches, jumpers tied across chests, pocket protectors, grubby white coats and mad scientist hair variables have not been investigated, but pose areas for future study.

Figure 1: Bowties verses subspecialty

Neurons or shooting stars?

Additionally, my off the cuff choice of neurologists at the pinnacle of this fashion statement seems to be rather accurate. In an article published in 2010, an American medical news outlet outlined neurologists penchant for wearing bow-ties. The American Academy of Neurology’s self-appointed spokesman on neckwear, John C. Kincaid, MD states that “Bowties suggest the wearer is ‘on the precise side,’ which describes many neurologists.” Yes it also describes the majority of people diagnosed with OCD. Perhaps suggesting a slight overlap in populations? The Academy is pretty serious about this caper, so much so that they even have an official bow-tie festooned with miniature neurons. But you are a renegade infectious diseases consultant, you want something slightly more relevant adorning your small piece of tied fabric. Well never fear. This website makes and sells bow-ties featuring microscopic lovelies such as: Anthrax, E.coli, Swine flu and Rhinovirus. Just don’t get any Syphilis on your neck….

E.coli (not to scale)

But this lighthearted choice of bow-tie material brings us to an important point in medicine. Infection control. Millions of healthcare dollars are spent around the world trying to reduce the number of hospital acquired diseases. Instead of regular neck ties dangling around in purulent exudate or hospital food (equally as nauseating) ready to be transfered to the next vicitim/patient, bow-ties remain high above strangling the neck of the treating physician. Neck ties have been shown to carry nasty bugs such as Staph aureus, Klebseilla and Pseudomonas as shown by a study of New York doctors in 2004. But obviously it depends on the specialty of the wearer, as you wont see much patient/doctor interaction from a radiologist. On a recent Twitter discussion it seems that along with neurologists, gynaecology and urology have higher proportions of bow-tie wearers. Whereas neurologists may be keen to avoid a long tie tickling a patients face during cranial nerve examination (albeit a nice quick way to check CNV sensation), our friends working below the umbilicus may well be avoiding ‘bits’ on their attire. (I chose the word ‘bits’ as the alternatives have been getting too much coverage in the media of recent days and I thought it rude of me to slipper them in.)

White is the colour of purity….

I can also see the benefit of bow-ties in paediatric populations as a way of breaking the ice. Whether the use of novelty ties that spin or flash lights would entertain the children as much as the wearer remains to be seen. Another avenue of research that may be followed. Until then, myself like many rural docs are happy with rolled up sleeves and the occasional boardshort/thongs combo. US readers should note the Australian use of the word ‘thong’ unless you have a confession KI Doc?

Bogan Medical Terms

Benign – What you be, after you be eight.

Artery – The study of paintings

Bacteria – Back door to cafeteria

Barium – what doctors do when patients die

Cesarean section – a neighborhood in Rome

Cat scan – searching for kitty

Cauterize – made eye contact with her

Colic – a sheep dog

coma- a punctuation mark

D & C – Where Washington is

Dilate – to live long

Enema – Not a friend

Fester – quicker than someone else

Fibula – a small lie

Genital – a non-Jewish person

GI series – world series of military baseball

Hangnail – what you hang your coat on

Impotent – distinguished, well-known

Labor pain – getting hurt at work

medical staff – a doctor’s cane

Morbid – a higher offer

Nitrates – cheaper than day rates

Node – I knew it

Outpatient – a person who has fainted

Pap Smear – A fatherhood test

Pelvis – second cousin to Elvis

Post Operative – a letter carrier

Recovery room – place to do upholstery

Rectum – darn near killed him

Secretion – hiding something

Seizure – a Roman emperor

Tablet – a small table

Terminal Illness – getting sick at the airport

Tumor – one plus one more

Urine – opposite of you’re out

Varicose – nearby / close by

Over regulation of social media in medicine: stifiling progress?

Dr. Google will tweet you now. Like?

Over the past three days, over 600 people involved in general practice education and training converged on Melbourne for the annual GPET conference. Peppered throughout the gathering were sessions relating to the current and more excitingly, possible future use of social media in the medical field. Some areas that have already started down this track and will in the future include:

  • National e-Health Record (PCEHR)
  • Registrar and medical student training
  • Connection of doctors, nurses and allied health
  • Patient education and FAQ videos or sites
  • Medical Practice information, booking and contact details
  • Videoconferencing between rural patients, GPs and specialists

At the afore mentioned GPET2012 conference, one notable session was run by noted internet savvy practitioner Dr. George Forgan-Smith (The Healthy Bear). He highlighted to the standing room only session the different uses of internet based systems. It was inspiring to hear about the use of exciting and ever-changing web-based tools. For example:

  • YouTube: for the production of medical themed videos
  • Facebook: for your own advice site and medical practice information
  • Yahoo Answers: providing common sense answers to those too scared to ask
  • Google: Patients being able to find you and your practice

It was especially heartening to listen to this doctor who has seen lots of misinformation on the internet trying to provide his own considered (and safer) information. As a GP registrar, I am both excited and wary of the prospect of this brave new world. Already after the conference and session run by Dr. Forgan-Smith, I am newly motivated to explore the role of producing amongst others: online teaching videos, patient consent videos and education snippets.

“why don’t they just get another cup?”

Recently, the national board AHPRA has released a consultation paper to help “to clarify…the expected standards relating to social media use.” Some blogs have already highlighted the lack of clarity offered by this statement. They have punctuated the areas (below) with related examples. I won’t delve into these myself, but please visit Impacted NurseCroakey and Phillip Darbyshire as all have summarised this very nicely.

  • Professional boundaries
  • Professional behaviour
  • Confidentiality and privacy

Interestingly, Impacted Nurse has observed that already their social media activity (along with mine and many others!) would already be in breach of the proposed policy. The whole tone of the AHPRA statement is restrictive and casts a dim view of social media in medicine. In fact it highlights a lack of knowledge and experience in the very area that they look to place boundaries around.

But AHPRA is not the first group to try to address professionalism relating to social media.  The Royal College of Nurses have already released useful and supportive guidelines. Medical peak representation bodies have also been proactive and drafted guidelines addressing these issues. The AMA DiT, NZMA DiT, NZMSA and AMSA released a joint initiative way back in 2010. They identified that there was the potential for legal and professional risks. As such, many medical defence organisations have drafted and published case studies, guidelines and recommendations for their members. In the age of an increasingly connected society and the further blurring of professional and social boundaries, an increase in medico legal cases with a social media focus is inevitable. Although I agree that there is a need for nationally regulated guidelines or policy regarding online conduct and behaviour, they need to be permissive enough to allow innovation and progress while maintaining professional standards. We must not let a nanny-state approach stifle this form of interaction that has to potential to do so much for a great number of patients in an increasingly fast paced online world.

Given that AHPRA is calling for feedback on the issue of social media in medicine, the lack of Twitter/Facebook*/YouTube presence is notable. Therefore, AHPRA is asking for feedback by regular old email (socialmediaconsult@ahpra.gov.au) by COB on 14 September 2012.

*The only AHPRA site to be found on Facebook is “Asociación Hondureña Protectora de los Animales y su Ambiente”

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A copy of the letter that I help GPRA co-author as a submission to AHPRA, sent on Friday 14th September 2012:

AHPRA SM Policy Response

 

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The story is picked up by Medical Observer on the 17th September 2012:

 

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Response from AHPRA on Wednesday 19th September 2012:

“Thank you for your submission to the preliminary consultation process on the National Boards’ draft Social Media Policy.

Your feedback will be considered by National Boards but as this was a preliminary consultation process, your feedback will not be published.

There will also be a public consultation process in which you are also welcome to participate, and information will be available on the Board’s website about this soon.

Thank you again for your interest in this issue.”

Tales from the Wudinna Radiology Department

In Soviet Russia, x-rays take you!

Ok, so I’d better make it clear. The “Radiology Department” in Wudinna consists of four radiographers. That’s a GP, GP registrar (me), the Director of Nursing and the CNC. The radiographs are taken in the A&E and then developed in an old broom cupboard with a fan. I thought that I would reflect back after taking my 20th x-ray tonight. It has been almost 3 months since completing the course that enabled us rural registrars to fire off energized photons into the atmosphere. My first x-ray (below) was of an old bloke who’d fallen onto his hand. I know now that I should have asked about any previous damage/operations to that wrist….”sorry, where exactly did your scaphoid bone go?!?”

Complete with adamantium rods and screws

This blog will document some of the good, bad and ugly radiographs that I have taken for educational purposes. It may also prove to be a repository of settings and views to call back on in the future.

Would hate for Mr. T to need a CXR

So first up some tips I have learnt/gathered over this time (updated as required):

  • Only a brave radiographer packs away the x-ray machine prior to developing the film.
  • Take off all jewellery from the patient. Think also about watches, phones, metal zips and buckles, forgot for my first CXR (right)
  • Always load fresh film into the cassette as soon as the exposed film is removed, nothing worse than taking an x-ray with a filmless cassette.
  • With 15 room changes of air per minute, the developing room is the best place to fart.
  • Don’t take the developing room/film cupboard key home with you.
  • Label your film with patient name, DOB, body part and put L/R markers on.
  • Check for pregnancy, always use gonad shielding for patient and lead apron/lead shield for yourself (don’t want children looking any more strange than they already will).
  • Make sure the collecting hopper is clear of previous x-rays
  • DON’T TAKE THE KEY HOME, GERRY!!

Today one of the films came out completely black. Stunned at the first x-ray that hadn’t worked out, I tried to remember the five reasons for such an occurrence (but had to look them up again):

  1. Film overexposed
  2. Processing times too long
  3. Ambient temperature too warm
  4. Film exposed to another light source
  5. Red safelight in developing room cracked

Checklist: the right settings were used, the machine was set up the same, the day wasn’t super hot and the film hadn’t been opened or exposed to white light. What had happened? So like any good doctor or engineer, or possibly any male, I took the x-ray again without changing anything! This time when putting the second film through the machine, I realised the first one had only just come out. The black film I’d pick up initially was a test film that had been run the day before by someone else and left in the hopper for an unsuspecting registrar. Another tip!

At least these guys got my name right!

When it comes to evaluating a film there is a helpful acronym (PACEMAN) that radiographers often use for quality control. Note that this is not to do with interpreting an x-ray for diagnostic purposes, its more about working out how to improve the actual picture.

  • P – Position
  • A – Area covered
  • C – Collimation
  • E – Exposure
  • M – Marker
  • A – Aesthetics
  • N – Name and DOB

So an evaluation of an x-ray make sound like “this is an AP view of a tib/fib. The ankle through to the knee is visible and collimated to the skin edges. The film is possibly a little over exposed, but good bony detail seen and the film is otherwise diagnostic. There is a left marker in place. The leg is lined up well on the film and the name/DOB have been removed for confidentiality.” It is important to think about the exposure especially as you may need to repeat the film and change the settings accordingly.

Fingers usually don’t bend between knuckles…

At the moment, Wudinna like many other towns around SA, use x-ray film and an automatic developing machine to produce images. Crystal Brook still has the old, old, old school method of manually dunking the film in each step of the process with a timer to help. Computed Radiology (CR) is a method of producing x-ray images straight to computer without film. This technology has been used at the major hospitals in the city for a few years now. Soon CR will be available at most small country hospitals in South Australia (already available at Jamestown, Ceduna and others?). This will certainly improve the quality of film, speed of referral and even the accuracy of reporting. Although there is a high initial cost for the system, running costs are vastly reduced as there is no need for ongoing purchase and disposal of hazardous chemicals or film. It will also mean that I can stop using the hospital camera or my iPhone for taking pictures for this blog and/or my friendly orthopaedic surgeon in Whyalla.

If you have any further pearls/gems/basic tenets of rural radiography…please comment!

Copyright © Dr Gerry Considine. All Rights Reserved 2013