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.

Welcome to Wudinna

Welcome to Wudinna

Since leaving the Eyre Peninsula, I’ve started part-time registrar work in the Adelaide Hills, with the other half split between a research project and teaching undergraduate medical students at the University of Adelaide. It has been a great mix of academic work, medical clinics and some on-call rosters. During the year I hope to dedicate some blog-space to my research and some gems that I glean from teaching med students clinical skills and case based learning. In the past, there has been so much to learn from fresh student eyes. The move has meant that my commute has stretched from the not-car-worthy 1.2 km to 34 kms in peak hour traffic. The landscape in the Hills is vastly different too, with plenty of rolling hills, green trees and rows of vineyards criss-crossing the valleys.

Welcome to Hahndorf

Welcome to Hahndorf

Even already, there has been a notable difference in the casemix and behaviours between a remote country town and outer (or peri-urban) medical practice:

  • Patients know when their time is up: In the country, many patients are up for a long chat. This is fine for a simple repeat script, but not so much as the clock ticks closer to 20 mins in a 15 min appointment. I have found that patients in the peri-urban setting realise that there are plenty of other people to be seen and usually are out the door by 10 mins without subtle prompting! It could also be that they are busy themselves and are rushing off for a meeting in town.
  • Calling back about ANY results: In the peri-urban setting, there have been many more phone calls or emails to the practice about pathology results. Even 1-2 days after collection! Perhaps these patients are more interested in their health (or more health literate)? It seemed that in the country, patients were happy to be called only if something was worth discussing. I’m sure the previous AOGP academic registrar Annabelle would have something to add here. Her research in 2012 looked at some of the predictors of this phenomenon, with rural patients not knowing as much about their health.
  • More children with viral illness: I have seen more children with parents saying “I think they’re ok, but just wanted them checked” in the past month than I did in the whole year in the country. Not sure about this one? Perhaps more doctors available for this sort of check up closer to the city? Or just tough country parents “I’m only taking you to the doctor if you arm is hanging off…”
  • Medical certificates: Many more patients in the peri-urban areas coming in just for medical certificates. Again, either tough country patients “Can’t come in to work today, Ive coughed up a kidney” or rural companies/businesses not being as strict with the medical reason for not coming in.
  • Less happy about waiting: Even after spending time with emergency presentations, *some* patients seem less happy to wait compared to the country. I’m guessing that rural patients are used to having the only one or two doctors busy at the local hospital with other sick patients. Perhaps even because they have been that sick person themselves?

I’m sure there will be plenty to add as the year marches on. In the meantime, hope to hear any other thoughts on the reasons for some of these simple observations.

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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/

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Filed under Emergency Medicine, General Practice, GPRA, Rural GP

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?

However, not all is as it seems. When that pathognomonic cough doesn’t behave like croup (from Casey at BroomeDocs): http://broomedocs.com/2011/07/clinical-case-19-if-it-barks-like-a-seal-is-it-a-seal/

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January 22, 2013 · 9:39 am

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?

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January 17, 2013 · 1:01 pm

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!

Online resources:

Acutely Swollen Joint Flow-chart

RCH guidelines for Acute Hip Pain

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January 14, 2013 · 11:37 am

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…..

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January 13, 2013 · 8:17 am

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.

Alas, my story is not as hardcore.

"just some tape will do"

“just some tape will do”

It was the fourth round of Mid West football in country SA and I was lining up on the wing for the Wudinna United B grade team. Even though the two teams playing were bitter rivals, first quarter went by without incident. However, halfway through the second quarter, I went to punch the ball coming down into a pack of players. As my 2nd finger hit the Sherrin, there was a pop then numbness. Looking down at my right hand it was obvious that I had dislocated the proximal interphalangeal joint. Luckily, I was able to easily reduce the finger as soon as it happened. There was surprisingly little pain, perhaps the adrenaline was covering that? A trainer had seen me holding my fingers and came over. “What do you want to do doc?” And I thought they were the experts! I had seen enough jarred fingers in the city emergency departments to get something started. Some tape did the trick in buddy strapping to my middle finger and I grabbed a couple of ibuprofen. At half time one of the other trainers sidled over and looking at my two fingers strapped together said, “hope you’re not offended if I cancel my rectal exam this week mate.”

Still getting a touch while crippled...

Still getting a touch while crippled…

Better than the iPhone x-ray app

Better than the iPhone x-ray app

Back at the hospital, I took my own x-ray and interpreted the film. No big or intra-articular fractures….that I could see anyway. Perhaps just a slight little chip off the volar aspect of the base of the middle phalanx (left, happy for radiology comment!!). Certainly not enough to warrant anything to drastic as far as surgery went. So I decided that the management should be continued continued as RICE and NSAID-based analgesia. But it made me wonder, if in my post game haze, I had followed proper treatment of finger dislocations for this injury? Certainly I had seen cases in ED where you could always ask for a ortho/plastics opinion. But in the country this isn’t as easy. So what would have been the indications to get my x-rays and finger looked at properly. Next week, I will discuss the equipment and alcohol necessary to take out your own appendix*

Lead shield in place?

Lead shield in place?

Searching around, I found some quick points regarding proximal interphalangeal joint (PIPJ) dislocations:

  • Vast majority are dorsally dislocated
  • Caused by direct blow (usually a ball) to the tip of the finger (axial load)
  • Put in ring block if reducing in ED, but patient can try to self reduce easily as soon as it happens
  • Reduced by slight traction and pressing on the distal end of middle phalanx
  • Murtagh suggests holding onto the distal finger and asking the patient to lean backwards
  • Ortho/plastics referral may be required if
    • Lateral instability
    • Fractures involving base of middle phalanx
    • Extensor mechanism rupture – buttonhole or mallet finger deformity
  • If no worrying signs: buddy strap to adjacent finger for 3-6 weeks to avoid hyperextension

*Fortunately, prospective Antarctic doctors now have a prophylactic appendicectomy.

Ouchy

Ouchy, but not my finger. Same injury

References:

  1. Murtagh’s General Practice
  2. Roberts and Hedges, Clinical Procedures in Emergency Medicine

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Filed under #FOAMed, Emergency Medicine, General Practice, Radiology, Rural GP, xrays