The concept of a “GP anaesthetist” or “GP obstetrician” can be a vexed one.
Colleagues with the appropriate specialist ticket (FANZCA & FRANZCOG respectively in Australia) may question why the heck a general practitioner is meddling in their arena of expertise. We may hear similar from FACEMs in regard to emergency care.
I have no doubt in my mind that appropriate specialty training is the Gold standard and to be aspired to. But there is a reality in rural Australia – the immense size of the continent and the relatively low population density mean that there is neither the workload to sustain a specialist presence in smaller rural towns…nor the income potential.
So – rather than the ‘precision scalpel’ of a specialist in anaes, obs or EM, rural Australia is reliant upon the ‘swiss army knife’ of the rural generalist. I am indebted to colleagues in rural medicine who are devoted to shifting the bell-curve of expertise of rural generalists to the right – in particular FOAMed inspirations Casey Parker of BroomeDocs and Minh le Cong of Prehospital & Retrieval Medicine blogs.
My own KIDoc and RuralDoctors.Net sites are devoted to the concept of delivering “quality care, out there”, drawing on the collective experience and tacit knowledge of both specialists and generalists worldwide.
So to the topic of rural anaesthesia and the rural “GP anaesthetist”. I gave a talk at the ANCZA scientific conference in SA last November – the theme was ‘anaesthesia allsorts’ and encompassed speakers from military, austere, retrieval and rural backgrounds, self included.
My title slide on “GP Anaesthesia 2020 an byeond” caused a small furore (the infamous ‘use two hands, squeeze bag gently’ picture); the talk can be downloaded here
The fact remains that, despite the increase in FANZCAs looking for work, there is little chance of them moving to isolated rural Australia – nor would there be the workload to keep them in employ. For the meanwhile, training exists to ensure rural GPAs are able to safely deliver elective and emergency anaesthesia in their communities, recognising limitations of both skill and equipment…
The training is run under the auspices of the Joint Consultative Committee on Anaesthesia (JCCA), a tripartite body with representatives of ACRRM, ANZCA and RACGP. The curriculum is designed to ensure that the GP-Anaes can safely deliver anaesthesia to selected elective cases, as well as deal with the common emergencies.
I’ve been keen to ensure that my needs have been met beyond the JCCA curriculum as delivered – with the wealth of FOAMed information out there, there’s no excuse not to ensure that GP-Anaes have the following additional considerations covered :
- – a bombproof difficult airway plan, appropriate to available equipment (AFOI kit not usually available in rural)
- – robust plans for ‘unusual’ situations where no immediate backup exists (the bariatric patient needing DSI; the ‘fish-in-airway’ scenario; the fencewire vs larynx etc)
- – familiarity with ketamine for both analgesia, dissociation and induction
- – robust failed spinal and failed epidural plans
- – use of ApOx, DSI, second generation iLMAs, scalpel-finger-bougie techniques etc
- – a good repertoire of nerve blocks for use in OT and in ED
Most importantly, I think ongoing audit via peer review and regular case discussion is essential, facilitated by experts (whether metro FANZCAs or rural docs). I spent the second half of 2015 with MedSTAR, South Australia’s retrieval service – this was a good opportunity for me to experience the heterogeneity in skills “out there” in rural SA, as well as to reinforce my belief that lessons from prehospital care are highly relevant to rural practice, not least:
- regular case audit
- standardisation of equipment and SOPs
- team training
It makes me wonder what should be the expected skillset of GP-obstetricians on graduation before heading bush? Ability to perform a partial hysterectomy in case of catastrophic PPH? Not just Ventouse and low-/mid-outlet forceps, but also Kjiellands rotational forceps? Advanced obstetric USS skills?
Meanwhile, I think the future of GP anaesthesia is safe, in rural areas at least.