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Be a ZERO, Not a HERO

DISCLAIMER : This post is about how medics interact within the various tribes. It is NOT about primary care vs teaching hospital, ED vs medics, surgeons vs anaesthetists. I’ve had some people comment on twitter that this is ‘about being a GP undermined by colleagues’. It’s not. It’s about clinicians, of whatever ilk, either undermining each other OR failing to work effectively within a team as too busy showing off how good they are. It’s a piece inspired by astronaut Chris Hadfield’s book and the concept of new team members being either a’plus one’, a ‘zero’ or a ‘minus one’. Now read on…

Medicine attracts bright people. I am constantly amazed at the smartness of some of my colleagues…and the ongoing exposure to brilliance via the FOAMed community. Not that you have to be smart to be a medic. Before medicine I trained as a research scientist, with undergraduate, Masters and PhD in an arcane area of immunology. But a life at the bench wasn’t for me – I enjoy interacting with people too much – hence the drift into medicine as a mature-age graduate. At medical school it struck me that medics were NOT particularly smart – the ability to absorb, memorise and regurgitate several phone books worth of information seemed to be the prerequisite, rather than original thinking. But insistence on high grades and academic excellence are just a cut-off to limit intake into the over-subscribed medical schools…and this encourages competition at a very early stage.

“Doctors are ingrained to compete – there is competition to get into medical school, competition for intern posts, competition for residency programmes, competition in Fellowship exams, competition for the desired consultant post…plus the inevitable competition between specialties”

Don’t get me wrong. I am all in favour of clinicians who are high-achievers and keen to move themselves to the right of the Gaussian distribution curve (mindful of the fact that 50% of all doctors are, by definition, below average). FOAMed helps us achieve that goal and strive to be better. For guys like myself in rural practice, than means to aim to bring “quality care, out there”.

But there is an ugly side to this competition. We all have tales of colleagues who have fallen by the wayside – whether through alcohol or drug addiction, failure of relationships, mental illness (including suicide). I am pretty sure that most of us have engaged in badmouthing colleagues, whether in the same discipline or in other specialties. Some of this is good-natured banter (think anaesthetists vs surgeons)…but it can become ugly, particularly when detracts from patient care or is a result of stressors perceived as being outside our control (bed pressure, busy workload etc). Both Dr Gerry Considine and myself have blogged about this from the perspective of rural practitioners – but it works both ways – primary care vs tertiary & vice versa as well as between in-hospital disciplines.

It never ceases to amaze me that medical training fails to expose junior doctors to primary care, given that this is where most patient encounters occur. And of course the bullshit perception of ‘just a GP’ continues to be promulgated within the tertiary centres leading to the comment ‘just a GP, not a specialist‘. Dr Penny Wilson blogs nicely on this. From my perspective, the more savvy tertiary colleagues turn pale when I suggest they sit in my shoes – they understand the skills needed to spot illness in undifferentiated primary care patients and would rather the security of preselected narrow-focus work.

“before you criticize a man, walk a mile in his shoes…then you will be a mile away from them & have their shoes”

I have certainly been guilty of critiquing colleagues without understanding their work. Before making the move to rural medicine I was a dual-trainee in EM & ICU. It was VERY easy to sit back and criticise the perceived failings of other doctors, especially as EM & ICU generally see a narrow selection of cases that have not been caught in primary care – blissfully ignorant of the wonderful “saves” out there. Add to this a complete lack of awareness of what different specialties actually do, and the system creates perfect conditions for disharmony. One of my shorthands as an ED reg over 10 years ago was ‘GPFI’ – GP is a ****ing idiot. My how we laughed. Now I am older and wiser.

A recent article in the NY Times captures this problem well, describing a paper in the Journal of Internal Medicine “Physicians Criticising Physicians to Patients” which has been re-tweeted by myself and others. The NY Times article on doctors badmouthing other doctors is worth a read.

“doctors will throw each other under the bus”

As a more grownup clinician in rural practice, a salutary experience for me was managing a patient presenting with acute-on-chronic back pain. I admitted him for analgesia..then 24 hrs later his BP dropped suddenly and the underlying sepsis from his epidural abscess declared itself – the source from an infection picked up a week or so prior whilst gardening. His retrieval & intensive care stay was prolonged and complicated, with devastating sequelae.

A single comment from an ICU nurse “you should sue your doctor for missing this” drove a three-year wedge between myself, the patient and family – very difficult in a small rural community, but eventually healed once the time course and decision-making had been explained. Systems failings (no ‘early warning’ notification, failure to appreciate significance of raised respiratory rate and falling urinary output so deterioration not communicated to doctor) all had their part to play, as did cognitive bias ‘just a flare of usual back pain’. But that chance comment from an ICU nurse undermined the therapeutic relationship.

That’s one example. I am sure you will all have similar stories. The ‘barndoor’ appendicitis referred to the medics as gastro by an ‘idiot ED reg’. The flail chest mismanaged as an infective exacerbation of COPD on the Care of the Elderly ward after a patient has fallen against bed rails. Mistakes happen, diagnoses are revised. But we are often quick to hang our colleagues out to dry with the benefit of the retrospectoscope.

Beware critique of others - but NEVER be afraid to apologise for an error
Beware critique of others – but NEVER be afraid to apologise for an error

The more medicine I do, the less certain I am. As a senior doctor I have more appreciation of the myriad presentations of disease, the understanding that patients don’t always ‘follow the textbook’. Contrast this to the cocksure certainty of a relatively junior doctor. The old adage rings true – “How do I avoid making mistakes? By getting experience! How to get that experience? By making mistakes!

FOAMed helps broaden that experience, sharing experiences and clinical discussions with colleagues worldwide. “Doing the simple things, well” is the essence of not just critical care, but all branches of medicine – particulalry in resource-limited rural Australia. Meticulous attention to obs (especially RR), use of bedside testing such as point-of-care lactate, having a heightened sense of “what if?” all contribute to better outcomes.


To be a ‘plus one’ a ‘zero’ or a ‘minus one’? Your choice…

All of which brings us full circle and (finally) to the purpose of this post. As ultra-competitive clinicians, trained to be better than our colleagues in order to progress in a system that seeks to limit entry at every waypoint, it is all to easy to fall into the trap of self-aggrandisement and for want of a better word “pissing on perceived competitors”. But does this REALLY help anyone? Of course not. we are all players in the healthcare team, yet it is almost de rigeur to criticise the perceived failings in other specialties without any understanding of what they do.

How then does a team function well when all the members are highly competitive? I’ve just finished reading Chris Hadfield’s book “An Astronaut’s Guide to Life on Earth“. It’s not a bad read, although I suspect is a springboard for former International Space Station Commander Hadfield’s retirement from the space programme into motivational speaking.

Hadfield talks about initial assessment of team members as ‘plus ones’, ‘zeroes’ and ‘minus ones’

Astronauts are all ‘plus ones’ – highly competitive, incredibly skilled across disciplines (he describes a typical day as performing ocular & cardiac ultrasound on fellow astronauts, fixing a malfunctioning toilet, playing Bowie’s ‘Space Oddity’ on guitar and Commanding the ISS). ‘Plus ones’ add value to the situation – they are leaders. Everyone wants to be the ‘plus one’ in a situation, in order to demonstrate their value to the team. That’s only natural when you are used to competing.

It should go without saying that there is no room in space (or in healthcare teams) for ‘minus ones’ – people who detract from the team plan. They cause problems, whether through laziness, inefficiency or lack of awareness.

But Hadfield outlines the BEST astronauts as the ‘zeroes’ – people whose input is neutral and doesn’t tip the balance one way or the other. Typically they quietly get on with the business of ‘making things happen’ – helping colleagues not for personal gain but because it helps the team overall. Reflective before acting. Competent information sponges.

In medicine we all strive to be ‘plus ones’, often by being the first to answer in a small group session, the first to critique patient management until the patient came under your brilliant care, or to blame ‘the GP’ or ‘those clowns in ED’ for dumping a patient on the already busy acute medical take. But declaring yourself as a ‘plus one’ in a situation almost guarantees that you will be perceived as a ‘minus one’ regardless of the skills you have. we see this when selecting instructors for EMST – we don’t want the flashy know-it-all, we are looking for the quiet, reflective achiever (the ‘zero’) who helps others become ‘plus ones’.

The take home message? I paraphrase from Commander Hadfield’s book :

When you have some skills but don’t fully understand your environment, there is no way you can be a ‘plus one’. At best, your can be a ‘zero’. But being a ‘zero’ is not a bad thing to be. You are competent enough not to create problems or make more work for everyone else. And you have to be competent, and prove to others that you are….

…even later, when you do understand the environment and can make an outstanding contribution, there’s considerable wisdom in practicing humility. If you really are a ‘plus one’, people will notice – and they’re more likely to give credit when you’re not trying to rub their noses in your greatness

Our environment as clinicians is the entire health care system. We occupy different ecological niches (with some amazing psychopathology between us) – primary care – emergency – surgery – medicine etc. yet we often have little understanding of what happens in other disciplines and are quick to critique. Even more so when all we see is other people’s mistakes (ED, ICU).

But unless you understand the nuances of another discipline, be slow to critique and quick to praise.

Be a ‘zero’ not a ‘hero’. Wise clinicians know this.

 

 

COMMENTS FROM TWITTER  – keep ’em coming or (better still) add a comment below :

@KangarooBeach Great stuff, spot on! The consultants I respect most: play zeroes, step up to heroes if need. Love the vid, @Cmdr_Hadfield !

Brilliant article from @KangarooBeach about badmouthing colleagues: Be a ZERO, Not a HERO

“Be a Zero, Not a Hero” Great stuff by the inimitable @KangarooBeach MT @emcrit: great read feedly.com/k/1euyYLb

Brilliant post from @KangarooBeach: Be a Zero, not a Hero. kidocs.org/2013/12/zero-h… #FOAMed

Such an excellent post Tim!!! Ironically a ‘plus one’ précis about some pervasive concepts 🙂 @KangarooBeach

Simon Carley @EMManchester

@AndyNeill @KangarooBeach Thanks for this piece – time to reset to 0

@KangarooBeach “Be a ZERO not a HERO” is a brilliantly written article, thank you. (def going to check out @Cmdr_Hadfield‘s book) #FOAMed

@KangarooBeach hey nice article on zero vs hero! maybe we can get @Cmdr_Hadfield to do a podcast about it?

@johnboy237: Follow this link ‘Be a ZERO not a HERO’ wonderful & truthful insight @KangarooBeach kidocs.org

@KangarooBeach @Cmdr_Hadfield Absolutely Tim! You enjoying the book too?

Andrew wrote: “Good one Tim, but would love to use GPFI on triage screen.”

So much hot gas – ETCO2 for non-anaesthetists

End-tidal CO2 is increasingly becoming used outside of the Operating Theatre and it is prudent for the rural doctor to have an appreciation of what it is, how to measure it, when to measure it and it’s utility in common scenarios.

“you get A, B & C in a single squiggly line” 

Casey Parker, BroomeDocs.com

It is my belief that ETCO2 should be used not just in intubated patients, but as a valuable adjunct for procedural sedation, for monitoring patients ‘at risk’ and to help guide resuscitation.

timthumb.php

 

What is end-tidal CO2?

Unlike plants, we breath in oxygen and exhale carbon dioxide – we can measure this as ‘end-tidal CO2’ (ETCO2). ETCO2 represents the partial pressure or maximal concentration of CO2 at the end of exhalation. The principle determinants of ETCO2 are:

(1) alveolar ventilation,

(2) pulmonary perfusion (cardiac output)

(3) CO2 production (and elimination)

How can I measure it?

We can measure ETCO2 in several ways

(i) colorimetric

Devices such as the Easy-Cap or Pedi-Cap are designed to confirm the presence or absence of expired CO2 – a pH detector (metacresol purple on filter paper) detects pH shifts and changes to the colour yellow in the presence of expired CO2.

Colorimetric ETCO2 device connect to endotracheal tube
Colorimetric ETCO2 device connect to endotracheal tube
GOLD IS GOOD
“GOLD IS GOOD”
colour change from purple to yellow indicates presence of CO2 > 2%

 

(ii) waveform capnography – during BMV or mechanical ventilation

A sample line is placed as a sidestream to the breathing circuit (usually via the HME filter at intersection of endotracheal tube and breathing circuit). Exhaled gas is sampled by a dedicated analyser (anaesthetic monitor or some defibrillators).

Typically such methods generate both a waveform (capnograph) and a number (ETCO2).

 

wave-2
The ETCO2 capnograph – consider the baseline, height, shape, frequency, rhythm

 

The normal capnograph trace can be divided into distinct phases

I – the end of inspiration & the beginning of expiration, when the Co2-free gas occupying dead space in airway is exhaled. Hence in theis phase the ETCO2 = 0 mmHg

II – there is a rapid rise in measured CO2 as alveolar gas appears

III – expiration continues but CO2 doesn’t rise much further – a plateau in normal lungs. ETCO2 total is derived from the maximum on this plateau

IV – a sharp drop in CO2 to zero, representing inspiration

 

tmp2A92_thumb221
Propellor heads can get excited about different phases. Be aware of them.

 

 

The capnograph gives us lots of information in addition to the absolute number of ETCO2 (aim 35-45 mmHg). It is easiest to consider the waveform baseline, height, frequency, rhythm & shape.

You can correlate changes in patient or equipment as being reflected in the ETCO2 trace eg:

baseline – non-return to zero caused by re-breathing

height – increasing ETCO2 due to excess production eg: malignant hyperthermia

frequency – decrease or increase in ETCO2 peaks in hypo- and hyperventilation respectively

rhythm – patient breathing vs mechanical ventilation as neuromuscular blockade wears off

shape – obstructive ventilation pattern causes a slow phase II upstroke

 

There are some must know waveforms in the ‘rogues gallery’ later below. The ones I worry about most are the absent or rapidly disappearing ETCO2 rtace seen in inadvertent oesophageal intubation…and the falling ETCO2 waveform with loss of cardiac output.

 

(iii) waveform capnography – during spontaneous ventilation

As an alternative to sampling expired gas directly from the anaesthetic circuit or HME filter attached to an endotracheal tube, it may be useful to monitor ETCO2 for spontaneously ventilating patients, whether on room air, nasal specs or oxygen mask.

I use this routinely during endoscopy, colonoscopy in the operating theatre, as well as when performing procedural sedation in the ED. I am increasingly using ETCO2 monitoring to confirm ventilation in other situations – particularly to confirm ongoing ventilation of the agitated psychiatric patient who has been effectively sedated with agents such as benzodiazepines, haloperidol or ketamine – mindful that hypoventilation or apnoea may be missed.

Remember that relying on SpO2 to confirm ventilation is inadequate – measured oxygen saturation may remain elevated for some time after cessation of breathing-  and once a fall in SpO2 has been detected, your patient is already hurtling down the oxy-haemo-coaster.

Beware the falsely reassuring statement “He must be breathing – the sats are OK” – use ETCO2 to gauge ventilation

In ED ot theatre, there are different gizmos. Most ETCO2 sampling equipment is dedicated to sit in-line as either an adaptor between ETT and circuit, or as a filter line to attach to HME filter. There are also sampling devices designed to sit under nares like nasal specs.

I tend to just take the sampling line from the HME filter, attach to a microfilter and then attach to either blunt cannula or plastic tube of an IV – this can be pushed through the holes in a Hudson mask to detect ETCo2 for patients receiving sedation NB: the ETCo2 will be LOW as diluted by oxygen.

Ubiquitous Dr Minh le Cong offers some hints on MacGyvering ETCO2 setups below :

Prehospitalmed.com “Capnography with LifePak 15” – Dr Minh le Cong

Noninvasive Capnography Setup (PK talk) – Dr Minh le Cong

as do the mob from the EM resource ‘Standing on the corner minding own business’ (SOCMOB)

how to make your own end-tidal CO2 detector

When should I measure ETCO2?

End-tidal CO2 is classically considered as the standard of care when performing intubation. Either colorimetric or waveform capnography can be used to confirm the presence of exhaled CO2 and hence confirm desired tracheal vs inadvertent oesophageal intubation.

The waveform also gives clues to alveolar ventilation (hypo- or hyperventilation), airway resistance, cardiac output, CO2 production & elimination, as well as the obvious confirmation of tube placement within the trachea – both initial & ongoing.

Other uses include :

  • confirmation of tube placement & efficiency of compressions during CPR
  • sudden increase in ETCO2 during CPR may indicate ROSC
  • during sedation to confirm ventilation when direct observation of the patient may be difficult (eg: under drapes/blankets/on side)
  • in psychiatric sedation to achieve effective sedation & avoid apnoea
  • during transfer to confirm presence of cardiac output & adequate ventilation
  • as a numeric target to aim for eg: in treating the head-injured patient where normocarbia, normotension and avoidance of hypoxia are key goals to avoiding rises in ICP.

 

Thus we can summarise ETCO2 measurement as :

  • to confirm tube placement
  • to confirm ventilation & perfusion of patients during mechanical ventilation
  • to confirm ventilation of patients who SHOULD be self-ventilating (but at risk of hypopnoea or apnoea)

 

The clinical bottomline?

End-tidal CO2 monitoring is mandatory not just for the intubated patient, but should be used whenever using a neurolept eg: sedation in ED, monitoring of psychiatric patient etc.

Even if you are not performing anaesthesia, know how to hook up ETCO2 monitoring for your spontaneously ventilating patients at risk of hypopnoea or apnoea.

Dedicated ETCO2 monitors exist, but most capnographs will hook up to existing monitors in OT, ED and ward defibs.

Insist on the use of ETCO2 monitoring in your shop.

 

ETCO2 waveform capnography is now available in handheld monitors - along with SpO2, HR, RR etc
ETCO2 waveform capnography is now available in handheld monitors – along with SpO2, HR, RR etc

 

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ETCO2 monitoring is available for the Phillips Heartstart MRX used in most rural EDs and with SA Ambulance

M3536A-2T

Where can I find out more?

Life in the Fast Lane posts on capnography and interpreting waveforms

Check out Prof Kodali’s website capnography.com & read his excellent paper entitled “Capnography outside operating rooms” (download here)

You may also be interested to read those Norse Gods of resus (ScanCrit) on capnography in cardiac arrest & Cliff Reid’s post on ‘even the dead exhale CO2’ – explaining why you MUST use waveform capnography in resus

 

 

ROGUES GALLERY OF ‘MUST KNOW’ ETCO2 WAVEFORMS

 

NB: these images downloaded from Google. I haven’t been able to find the author to attribute, so apologies if unattributed. I reckon an American source (who else omits the diphthong in oesophagus?)

 

OESOPHAGEAL INTUBATION

HYPOVENTILATION

HYPERVENTILATION

 

REBREATHINGONSTRUCTION CUFF LEAK

FAULTY VALVE

INADEQUATE NEUROMUSCULAR BLOCK

 

SUMMARY OF CAUSES & ETCO2 CHANGES

 

FLAT ETCO2 TRACE

  • Capnograph not connected
  • Oesophageal intubation
  • Airway (ETT) misplaced
  • Respiratory or cardiac arrest
  • Capnograph sampling tube kinked or blocked
  • No ventilation – either forgot to bag the patient or there is a ventilator malfunction

SUDDEN DROP IN ETCO2 TO ZERO

  • Kinked ET tube
  • CO2 analyzer defective
  • Total disconnection
  • Ventilator defective

SUDDEN CHANGE IN BASELINE (NOT TO ZERO)

  • Calibration error
  • CO2 absorber saturated (check capnograph with room air)
  • Water drops in analyser or condensation in airway adapter

SUDDEN INCREASE IN ETCO2

  • ROSC during cardiac arrest
  • Correction of ET tube obstruction

ELEVATED INSPIRATORY BASELINE

  • CO2 rebreathing (e.g. soda lime exhaustion)
  • Contamination of CO2 monitor (sudden elevation of base line and top line)
  • Inspiratory valve malfunction

INCREASED ETCO2

CO2 production

  • Fever
  • Sodium bicarbonate
  • Tourniquet release
  • Venous CO2 embolism
  • Overfeeding

Pulmonary perfusion

  • Increased cardiac output
  • Increased blood pressure

Alveolar ventilation

  • Hypoventilation
  • Bronchial intubation
  • Partial airway obstruction
  • Rebreathing

Apparatus malfunction

  • Exhausted CO2 absorber
  • Inadequate fresh gas flows
  • Leaks in ventilator tubing
  • Ventilator malfunctioning

DECREASED ETCO2

CO2 production

  • Hypothermia

Pulmonary perfusion

  • Hypotension
  • Hypovolemia
  • Pulmonary embolism
  • Reduced cardiac output
  • Cardiac arrest

Alveolar ventilation

  • Hyperventilation
  • Apnea
  • Total airway obstruction (high airway pressures)
  • Extubation

Apparatus malfunction

  • Circuit disconnection (low airway pressures)
  • Leaks in sampling tube
  • Ventilator malfunctioning

 

Rural GP Anaesthetists – a ‘special needs’ mob?

As a rural doc I’m very lucky to have a job that is varied. I tell students and junior doctors that rural medicine offers all the stimulation and challenges of all the ‘best bits’ of medicine.

Currently I practice primary healthcare, emergency medicine and anaesthetics (I gave up obstetrics last year).

So this weekend just gone was a highlight – a chance to attend an annual GP-anaesthetics conference at one of the mainland tertiary hospitals. I’ve had this date ruled off in my diary for 12 months now…so you can imagine my disappointment when the ferry to/from Kangaroo Island sustained damage in the recent storms and the replacement therapy had to be hurriedly re-surveyed, launched and pressed into service. Needless to say all Rex flights were booked out days ahead and despite lots of people needing to get to/from KI, Rex declined to put on extra flights.

Noone can control the weather, but the lack of a contingency plan was disappointing. Not that Rex have a strong history of customer service…

Anyway, I missed the first day of the two day conference. But although I made it to the second, I was somewhat underwhelmed by what I did attend, cementing further my belief that there needs to be content tailored to the rural GPA delivered by people who ‘get’ rural medicine.

To backtrack, I went to my first rural GP-anaesthetist in NSW last year. It was really good, a day and a half of lectures, plus a half day in the sim lab doing emergency scenarios. But what struck me there was the disparity in equipment and resources available between city and rural anaesthetists…as well as between rural GPAs in different parts of the State. Lectures by some of the FANZCAs were all very interesting…but often they did not realise the conditions in which rural GPAs work (isolated, minimal equipment, no backup, cash-starved). At the same time I was getting increasingly inspired by blogs such as Resus.me, BroomeDocs.com, Prehospitalmed.com and LifeInTheFastLane – all of which seemed highly relevant to my practice.

So I resolved to look at some quality improvement in my own practice on my return to SA, mindful of the fact that it made sense to have commonalities in equipment and protocols available to rural anaesthetic providers. Setting up a GoogleDocs survey was relatively easy, and I was gratified to get a 2/3 response rate from rural GP-anaesthetists around Australia on my topic of difficult airway equipment availability. I’ll be talking about this at the Fremantle Rural Medicine Australia conference and my paper should be out in the Oct-Dec volume of Rural & Remote Health. Stay tuned…

So, a year down the track I had really high hopes of further upskilling in SA. Whilst most of the content was good, there was an alarming propensity of some lectures to cover topics like cell salvage, lab-markers in major transfusion and the like – all very interesting, but not translatable to the rural practice environment where such resources aren’t available. Questions on topics such as delayed sequence intubation and whole blood live donor panels were unfamiliar ground for the FANZCA experts, although very pertinent to many of the rural doctors.

Small group sessions made up for it, with hands on experience and chances for case discussion.

But a common theme amongst the people I spoke to was that city anaesthetists task with lecturing had very little idea of the resource limitations in country areas. The vast majority of us don’t have remifentanil..or desflurane..or BIS…or access to FFP/cryo/platelets…or labs..or $15K videolaryngoscopes. The FANZCAs who visit rural hospitals, whether for elective lists or retrieval, did at least have an idea of our circumstances Yand ‘special needs’

So, what does the rural GPA really need?

– lectures from experienced anaesthetists? Hell yes.
– small group sessions and case discussions? Even better.
– topics targetted to the audience and suggestions for improvement. Absolutely!

…and to top it off, perhaps consideration be given to sharing the knowledge base by holding two sessions per year (allows more docs to attend…as if one doc is at the conference, the other needs to be oncall)

…and even better, consider delivering content in rural areas by taking some of the ideas on the road.

The other thing that concerns me is the lack of communication between rural docs. Locally the RDASA has a ‘rural anaesthetists’ email group, but it has been inactive for a few years. It seems that many of us have the same issues with respect to equipment procurement, training and upskilling – yet operate in silos. Moreover there is little ‘top-down’ direction – certainly I have no sense of direction from the ‘Country Health SA Anaesthetic Consultant’ and it would be nice to see some more dynamism.

Maybe next year will be better…I’m going to keep pushing the barrel for local delivery of leading edge concepts in EM/anaesthesia that are rurally relevant for myself and other doctors.

Email me if you have any thoughts on this.

Obfuscation & the ‘Blame Game’

Well, I was not expecting that the letter in my last post would be referred to in ‘The Weekend Australian‘ in follow-up to a previous report. Thanks to Dr Scott Lewis of Wudinna for telling me.

Oh dear.

There seems to be confusion about the issue of ED patients being charged fees in rural SA hospitals. It’s something that has been an issue locally every since I have been on Kangaroo Island, and my colleagues tell me has been going longer still. I refer to the fact that patients presenting with serious problems (examples might include assessment after a car crash, a suspected fracture/dislocation, a forensic medical exam after sexual assault, repair of a complex laceration) are forced to pay the attending doctor, whilst they would receive the same service for free in a metro ED or interstate.

This is counter to the Australian Healthcare Agreement and the letter which is referred to in the Weekend Australian support this. The practice has been longstanding in South Australia, and I reckon arises over confusion over what is an emergency and what is a GP-type service.

The Australian college of Emergency Medicine have recently issued a media release that dispels the myth of triage 4/5 patients being ‘GP-type’ attendances, and highlights concern for such cost-shifting between State and Federal coffers.

Me? I am just fed up having to charge people for conditions that are more serious than your usual GP attendance, more so when they have been referred to the ED by another GP or a GP after hours service like HealthDirect. Don;t get me wrong, I am happy to charge privately for my services when it is appropriate – but charging a mental health patient, a rape victim or a car crash victim several hundred dollars just seems wrong. Much better to be paid by the Health Department, after all the doctor is attending in his/her role on the on call A&E roster, not as a private arrangement.

Today I received an email from the Rural Doctors Association of South Australia, which appears to cling to paragraph G21 of the Australian Healthcare Agreement, which allows for medicare billing in the specific circumstance of “eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor” (my emphasis underlined).

The RDASA email states:

 
There has been a lot of email traffic and concern from you about the article appearing in the Australian over the weekend inferring that charging patients for after-hours services in publicly funded hospitals was contravening the National Health Care reform document. 
 
Please be assured that the RDASA Executive have taken immediate action on this issue, writing to Minister John Hill referring him to section G.19 of that Agreement and the assurances from CHSA that the current arrangements are acceptable to the Federal government. We have sought written confirmation that:
 
·         Doctors can bill Medicare for triage level 4 and 5 after-hours consultations that occur at public country hospital facilities
·         Doctors will not have to pay back any money to Medicare for money already collected

Maybe I am being thick, but it seems unfair to use clause G21 to then slug rural patients for services that would receive for free in a metropolitan ED or interstate.

RDASA seem curiously quiet on this issue of equity and I fear that this approach may be regarded as more about preserving doctor’s incomes than in equity for their patients. Given that many of these patients are genuinely in crisis or not-medicare compensable (particularly in a tourist location like Kangaroo Island), I would much prefer to be paid by the Hospital for my services rather than bulk bill or chase bad debts. After all, the Hospital called me as the A&E doctor for the hospital, not the patient as part of a prior arrangement or agreed private service.

Anyway, here’s my letter to the RDAA on this issue. It will be interesting to see what eventuates.

Comments, as always, welcome.






Paul Mara
President
Rural Doctors Association of Australia
10 May 2012
Dear RDAA
You may be aware of the recent ‘Weekend Australian’ article regarding billing of public patients attending public emergency departments in South Australia (http://www.theaustralian.com.au/national-affairs/state-politics/warning-for-states-on-hospital-charges/story-e6frgczx-1226347278031). Last month I received a letter from Minister Plibersek’s office (attached) which supported my concerns regarding the practice of charging public patients in public EDs for non-admitted services. This letter was posted on my blog site and subsequently referred to by The Weekend Australian without my knowledge. 
I have been seeking clarification on this matter since 2007 from the South Australian Health Department, as there exists significant potential for cost-shifting from State to Federal Health budgets. Specifically, patients who attend the Emergency Department are annoyed at having to pay fees for non-admitted attendances in rural areas.
I should clarify that these fees are being charged not just for GP-type attendances, but for ED attendances that require the resources of a hospital and can chew up considerable time for assessment and treatment. Many of these patients have been referred to a rural ED by GP-after hours services such as HealthDirect, and are not typical of GP attendances in metropolitan areas. Examples might include the assessment of car crash victims after a rollover, forensic medical examination after sexual assault; urgent mental health assessment of patient brought in by Police; the assessment, X-ray, manipulation under anaesthetic and plastering of fracture/dislocation; repair of complex laceration etc. These are services that Country Health SA has in the past deemed ineligible for admission and hence cost-shifted to Medicare by refusing to remunerate doctors on the A&E roster.
On questioning this in the past, South Australian doctors have been directed to clause G21 of the Healthcare Agreement which states:
in those hospitals that rely on GPs for the provision of medical services…eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor”
The most recent (indeed, only) contract between rural doctors in SA with Country Health SA goes further, to state :
“after hours GP services and non-admitted emergency services are provided under the Medicare system (ie the patient is charged by the medical practitioner and seeks reimbursement from medicare). For the avoidance of doubt, Country Health SA shall not be liable to pay any fee for such services
This statement in our contract neatly ties both emergency attendances and after hours GP services under the same umbrella, ie: to be charged to Medicare. This is at odds with legislation.
I understand the RDASA has recently written to the RDAA on this matter. From the email to SA members, the issue has been obfuscated by confusing triage 4/5 patients with GP-type attendances, an assertion that is not reflected in either the National Healthcare Agreements or current contracts in SA. Indeed, the Australian College of Emergency Medicine gave recently issued a media release on this very issue, dispelling the myth that “ED triage 4 or 5 patients = GP attendance” and highlighting the concern for State to Federal cost-shifting by such ploys (see http://www.acem.org.au/media/media_releases/GP_Patients_ED_attendances.pdf).
I am concerned that this issue disadvantages rural Australians In SA who may defer ED attendance for potentially serious conditions due to fear of fees. I am concerned that the SA Health Department is promulgating an interpretation of the Australian Healthcare Agreement which is at variance with other States and which both Medicare and the Federal Health Minister’s office have told me is not allowable. I am concerned that genuine GP after hours or private arrangements (where I am more than happy to charge a private fee) are being used as a cover to defray State health costs.  For the record, can I ask for your assistance to clarify with the Health Minister and RDASA:
  1. that the Australian Healthcare Agreement states that eligible public patients are entitled to free emergency care in a public ED,
  1. that the South Australian Department of Health is responsible for provision of emergency medical services in both metropolitan and country areas,
  1. that the contract between rural doctors and Country Health SA is to participate in on-call services for Emergency Medicine (A&E), not GP-after hours services,
  1. that whilst clause G21 does allow for rural doctors to charge privately (with Medicare rebate) this is only in the situation where patients “request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor”. Many patients who present to the ED have either been referred there by a GP or an after hours service (HealthDirect) or else have needs that require ED attendance. They have not requested treatment by their own GP nor is their a pre-existing prior arrangement with the doctor on call for the A&E roster for the State Health Department.
  1. that in situations where a patient elects to be treated privately by their own GP then clause G21 applies and Medicare fees are allowed,
  1. that the assertion that triage 4/5 patients are to be billed under Medicare is not supported in the Australian Healthcare Agreement and indeed is counter to advice from the Australian College of Emergency Medicine who dispel this myth in a recent media release and state “It is in the political interest of state governments to ensure that any definition of general practice patients seen in EDs yields high numbers. This helps perpetuate the myth that EDs have too many GP patients.”
  1. that the situation as it stands in South Australia is at odds with arrangements interstate.
I would be grateful for your clarification on the above points. To my mind it is vital that rural Australians are not disadvantaged when attending the ED with a genuine need. Similarly there may be concerns from rural doctors that such Medicare-billing is not supported and there needs to be clarification that such practices are allowable in certain circumstances (eg: as part of a GP after hours service utilising the local hospital premises, ie: private arrangement, ongoing care). I am happy to charge privately for my services when it is appropriate – but charging a mental health patient, a rape victim or a car crash victim several hundred dollars just seems wrong. Much better to be paid by the Health Department, after all the doctor is attending in his/her role on the on call A&E roster, not as a private arrangement.
I am sure you would agree that it is important for rural doctors to be seen to uphold the same standards in each State and to ensure that neither patients nor doctors are disadvantaged.
Sincerely
Dr Tim Leeuwenburg
Kangaroo Island, South Australiawww.ki-docs.blogspot.com

Affordable Difficult Airway Kit

Well, this week I’ve been playing with some AirQ II blocker intubating LMAs (iLMAs) sent to me from a rep.
For those of you not familiar with an iLMA, the device is designed to allow ‘blind’ intubation of the airway, using the laryngeal mask airway (LMA) as a conduit.
The progenitor, with which most rural doctors and anaesthetists will be aware of, is the FastTrach LMA. It’s reported to allow up to 73% ‘first pass’ successful intubation rates, increasing to 90% overall success with repeated attempts and the ‘Chandy manoeuvre’. It’s not a bad piece of kit and we’ve got one on our airway trolley.
However, the FastTrach requires some practice to get used to. I made a point of using it at least once a month during my anaesthetic year, just to get used to the kit. Using equipment in training is quite different to using ‘in anger’, especially when there’s an evolving airway crisis. Problems that I found were
  • not always easy to pass the endotracheal tube into trachea
  • removing the LMA whilst leaving the ETT in situ is fiddly and risks losing both
  • overall success rate is 90% – so 1:10 will fail.
The C-Trach is an advancement on the FastTrach, improving rates for first pass and overall sucess to 96% and 98% respectively – basically this device is just a FastTrach with a video screen attached. Clearly then, addition of video allows visualisation of the cords and improves success rates.
However, neither FastTrach or CTrach allow you to place a nasogastric tube..unless you obturate the ETT and remove the LMA over the top, which is potentially fraght with difficulty.
Cue the AirQ iLMA.
This ‘new improved’ iLMA gets around the problems of FastTrach and CTrach – it’s similar in appearance to the FastTrach iLMA, albeit with a less acute angle. It also has a nifty side-port to allow passage of a nasogastric tube without having to remove the iLMA
Moreover, the device comes with dedicated nasogastric ‘blockers’ – an NG tube with an oesophageal balloon which can be inflated in the oesophagus to minimise aspiration risk and yet allow decompression of the stomach.
I tried it the other day in theatre and found it easy to use. As an LMA it functioned perfectly well, although I have heard some anecdotal evidence of increased supraglottic trauma with this device.
How then to improve success rates for passage of an ETT? Minh le Cong has described this elsewhere – use of a malleable intubating stylet such as the Levitan FPS allows visually-aided intubation through the iLMA conduit.
So we now have a staged procedure for the nightmare difficult airway where intubation has failed or priority is to oxygenate
  • drop in an AirQ II and ventilate
  • pass the oesophageal blocker to decompress the tummy
  • use a fibreoptic device to intubate through the iLMA, improving intubation rate
This strategy (fibreoptic intubation through an iLMA) is Plan B of the UK’s Difficult Airway Society algorithm. Yet how many of us are really prepared to do this and have practiced on kit? Most rural docs have access to a FastTrach…so ventilation and blind intubation are possible – yet the addition of an NG tube port and allowance of fibreoptic intubation seems to offer a higher standard of care. Of course, for many small hospitals fibreoptic devices have traditionally been out of range – high cost and difficulty acquiring and maintaining skills.
But for under $3K you can pick up a Levitan scope (malleable fibreoptic intubating stylet) or the Ambu Ascope II (five disposable flexible fibreoptic scopes). They may not be as good as the fibreoptic towers that people use for an awake fibreoptic intubation…but they are bloody good gadgets to use with the above technique.
So, what would be my preferred kit for a ‘difficult airway’? Well, I’d use the Difficult Airway Society (UK) and ANZCA T04 guidelines as a starting point…and in addition to the AirQ and some sort of fibreoptic device, I’d add in a videolaryngoscope. Sounds expensive? Well my suggestions for purchase are in square brackets below – for under $4K should be affordable for small rural hospitals…
Plan A – Initial Intubation Strategy
Standard laryngoscopy – if fail, change position, blade, operator. Consider use of a videolaryngoscope in case of difficult airway. If fail, move to…
[KingVision Videolaryngoscope ~ A$1000 inc. blades]
Plan B – Alternative Intubation Strategy
iLMA to maintain oxygenation and ventilation, then secure airway using fibreoptic intubation through iLMA. If fail, move to…
[AirQ II iLMAs A$30 each]
[either Levitan FPS or AmbuAscope II fibreoptic devices to intubate through iLMA]
Plan C – Maintain Oxygenation & Ventilation, Abandon Procedure and Wake Up
Bag-mask ventilation and reverse non-depolarising neuromuscular blocker (suggamadex for rocuronium) or wait for suxamethonium to wear off. If fail, move to…
[Rocuronium for RSI – prolong time to desat]
[Suggamadex to reverse rocuronium]
Plan D – Rescue Techniques for Failed Oxygenation & Ventilation
Bag 1 – Paediatric or Easy Anatomy
Needle Cricothyroidotomy technique


Bag 2 – Adult or Easy Anatomy
Scalpel-Bougie-ETT technique


Bag 3 – Impossible Anatomy
Scalpel-Finger-Needle technique
[Melker Kit]
I wouldn’t bother with the pre-packaged kits like QuickTrach or Seldinger kits as first line for CICV – in the heat of the moment, faffing around with wires etc can be a disaster. Better to have three equipment bags set up as above using standard equipment – oxygenate first – then move on to seldinger or formal tracheostomy. Some have commented that doing the above is sufficient to ‘save the day’ then either wake up the patient or proceed to successful laryngoscopy.

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