Are we using the correct first aid for jellyfish?

The answer is predicated on our knowing what the correct treatment is — and we don’t

In this issue of the MJA, Isbister and colleagues report that hot water immersion was no more effective than ice packs for treating the pain of stings by the box jellyfish (Chironex fleckeri).1 This finding is surprising, as jellyfish venoms are heat-labile,2 but unsurprising, given that heat treatment for some patients did not begin until 4 hours after the patient was stung.

Managing jellyfish stings is generally subject to confusion, and official advice needs revising to make it clear, consistent and effective. The current Australian Resuscitation Council (ARC) guidelines for treating jellyfish envenoming3 encourage this confusion by suggesting that people stung while swimming in temperate waters (south of Bundaberg) should use heat immersion to reduce pain (based on a randomised controlled trial of treatment for bluebottle stings4), but those envenomed in tropical waters (north of Bundaberg) should be treated with ice. The guidelines also advise that vinegar should be used to minimise envenoming only in tropical areas — unless it is clear that the patient has been stung by a bluebottle, in which case vinegar should never be used. Which treatment should you use if you are stung while swimming at Bundaberg? The answer is, at present, uncertain, and urgently requires investigation.

Interestingly, the practice of applying vinegar is based on a single study that found that it deactivated undischarged stinging organelles of the box jellyfish (C. fleckeri).5 No direct evidence contradicting this finding has been published, but a recent study found that treating the discharged stinging organelles of C. fleckeri with vinegar could increase venom release by nearly 70%.6 Data indicating that applying vinegar saves lives has not been reported, nor any that it increases mortality or morbidity. There is, however, retrospective data suggesting it may increase both the level of analgesia required and the length of hospital stay for people presenting with Irukandji syndrome (caused by several species of small box jellyfish).7 Vinegar nevertheless remains the treatment of choice for these stings.

Non-evidence-based treatments dominate first aid for jellyfish stings. Once any of these treatments is entrenched, substantially more evidence is needed to abandon it than was required to establish it. For example, urinating on a jellyfish sting has been shown to aggravate jellyfish envenoming,5 but is still thought by many to be acceptable first aid.

Applying pressure immobilisation bandages (PIBs) to treat jellyfish envenoming is a further example. PIBs were first introduced as first aid for jellyfish stings because of their role in treating snake bites. Two published studies finding that applying them increases venom expression from jellyfish stinging organelles8,9 and several years’ lobbying were needed before this approach was removed from ARC guidelines.

The treatment of Irukandji syndrome with intravenous magnesium is yet another example, introduced on the basis of a single case report.10 Despite many subsequent published studies finding this procedure ineffective, including one randomised controlled trial,11 it is still standard practice for many medical professionals. Magnesium may be helpful in some situations, but may not be as effective as first thought, perhaps because of differences in the venoms involved.

There are significant differences between the venoms of jellyfish: differences between jellyfish from different geographic locations,12 between different species,13 between jellyfish at various ages, and between different parts of the jellyfish (tentacles and body).14 It is not unlikely that these variations lead to very different effects in people stung by jellyfish.

How should we proceed? As it is estimated that there are more than 150 million envenomings by jellyfish each year,15 we need to know our enemy. A more complete understanding of the ecology of these animals and their venoms would make the answer much clearer, but in the meantime treatments may be unsystematically selected in the hope that they might work. At the same time, we need to temper the determination by practitioners to persist with treatments that lack evidence of their effectiveness.

There is still much to learn about jellyfish venoms. We need a simple, consistent first aid approach that works, and this will require well designed investigations of the complexities of these venoms, how they operate, and how their effects can be mitigated. “Are we using the correct first aid for jellyfish stings?” is the wrong question; we should be asking, “What is the correct first aid for jellyfish stings?” The challenge is to design and conduct experiments that are sufficiently comprehensive to answer it!

News briefs

Ice use adds up to 150 000 emergency room visits a year

Methamphetamine use adds between 29 700 and 151 800 additional emergency department visits in 1 year, according to researchers from Curtin University, the University of New South Wales, the University of Newcastle and Monash University. The study, published in Drug and Alcohol Review, estimated past year rates of health service utilisation (number of attendances for general hospitals, psychiatric hospitals, emergency departments, general practitioners, psychiatrists, counsellors or psychologists, and dentists) for three levels of methamphetamine use (no use, < weekly, ≥ weekly) using panel data from a longitudinal cohort of 484 dependent methamphetamine users from Sydney and Brisbane. “We estimate methamphetamine use accounted for between 28 400 and 80 900 additional psychiatric hospital admissions and 29 700 and 151 800 additional emergency department presentations in 2013,” the researchers wrote. “More frequent presentations to these services were also associated with alcohol and opioid use, comorbid mental health disorders, unemployment, unstable housing, attending drug treatment, low income and lower education.” They concluded that: “Better provision of non-acute health care services to address the multiple health and social needs of dependent methamphetamine users may reduce the burden on these acute care services.”

Mapping malaria drug opens new possibilities

International research led by the Walter and Eliza Hall Institute of Medical Research (WEHI) has for the first time mapped how one of the longest-serving malaria drugs works, opening the possibility of altering its structure to make it more effective and combat increasing malaria drug resistance. The study, published in Nature Microbiology, produced a precise atomic map of the frontline antimalarial drug mefloquine, showing how its structure could be tweaked to make it more effective in killing malaria parasites. The team used cryo-electron microscopy, which produces images of biological molecules in their natural state in unprecedented detail, to see exactly how and where the drug binds the malaria parasite. Mefloquine has been associated with some serious side effects, including neurological symptoms. Dr Wilson Wong, from WEHI, said that the detailed atomic map would enable future drug improvements. “We now know mefloquine binds to a hotspot of activity on the ribosome surface,” he said. “However, our map of the ribosome and drug-binding site showed the fit is not perfect. We were able to mimic this interaction with compounds that were able to block the protein machinery and kill the parasite more effectively.”

Doctor as patient

DR RICHRAD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

In the week that the AMA released its 2017 Public Hospital Report Card, a dose of salmonella saw me experience first-hand the pressures that public hospitals are under, and appreciate the value of a GP home visit for urgent care in circumstances when you can’t access your usual GP.

I had flown into Canberra for a weekend meeting of the AMA Council of General Practice, already feeling unwell with established symptoms of food poisoning. I was becoming sicker and more dehydrated. With abdominal pain and rebound tenderness, I found myself at the local emergency department at 10pm on the night of my arrival.

During the next eight hours I got to see my hospital colleagues dealing with the pressures of managing multiple patients in varying states of illness and distress, with limited resources and a bed capacity unable to keep up with demand.

Here it seems the world revolves around assessing and prioritising the steady stream through the door, although things can quickly change when a major incident happens. While I was there, the deluge of more than 80 patients affected by a local bushfire appeared to almost overwhelm available resources. The doctors, nurses and other staff worked diligently to ensure that patients were seen as soon as possible but, on a night like this, benchmark targets seemed to have very little relevance.

Sometime around 5am, with blood cultures taken and intravenous rehydration commenced, a long awaited physical examination revealed that my earlier rebound tenderness had resolved although there was still significant point tenderness. With no acute abdomen I was discharged around 6am Saturday.

During the morning I deteriorated, with worsening diarrhoea, vomiting and abdominal pain. I desperately needed a doctor and did not want a return visit to the ED. It was time to call one of the after-hours GP services, which sent a GP to see me in my hotel room. Following a comprehensive examination, which revealed marked lower abdominal tenderness and a positive Murphy’s sign, I had a script for ciprofloxacin. Armed with this, some ondansetron and gastro-stop I tried to make my flight home only to be bumped because I was too sick. Following a visit to the after-hours chemist and after commencing my ciprofloxacin I finally turned the corner, improving enough to fly home Monday morning.

I understand the health system better than most and know how daunting it can be to navigate – particularly at times when your usual GP is not there to guide. This experience was a timely reminder of the challenges our patients experience when seeking care, and why the AMA’s advocacy for our profession and our patients is so important.

Besides getting a taste of what my patients experience when seeking care outside of surgery hours, this episode has also highlighted the importance of looking after our own health. I did try and soldier on for too long, not wanting to let my colleagues down.

We are not super human and we do get sick. When we are, perhaps we should consider what advice we would give a patient in the same situation. We need to be kind to ourselves and recognise when we need another’s medical expertise.

The new normal

DR JOHN ZORBAS, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING

Something strange happened to me recently that reminded me of how badly calibrated our frames of reference can be. I’m a dual trainee, and with the new training year upon us, I was migrating from the calm and collected ivory tower of the intensive care unit, back down to the chaos and madness in the pit of the emergency department. It’s clear that I like really sick people; I just can’t seem to decide on the speed of sickness that I prefer. Fast or slow? I relished the change of pace. It was frenetic. We were getting things done. I was happy.

And then we had a teaching session. One of those beautifully peaceful moments when you leave the emergency floor and you enter the tranquillity of education. We discussed stroke management. I spoke about ultrasound. So far, so good. All normal. Our director of training asked us how we were going and he made specific mention of just how busy we’d been lately. I took note and thought “OK, so we’ve had a busy few days. Nothing new here”. He kept probing and then the other trainees started talking about the pace. It then became abundantly clear to me that the last few weeks were not normal. They were chaos. The cubicle pressure, the acuity of the presentations, the backlog in the hospital… none of this was normal. Not by a long shot.

It might not sound much, but I was quite shocked by just how incorrect my frame of reference was. If you don’t have a good frame of reference, you start to misjudge things that happen. What you explained away as a quirk of the system could quite easily become a serious medical error. And so, with this new calibration I started to re-hash the events of the past few weeks. What had I missed? If this pace wasn’t normal, had I expected too much of my juniors at any point? Had I been too hasty with investigations, or documentation? What pressures had I placed on my nursing staff? Looking back with this new frame, I made my peace. Yes, things were fast. No, they hadn’t been unsafe. But I remained shocked with this error of calibration. The compass was off, and a bad compass leads you to icebergs.

I’ve been a doctor for eight years now, and in that time, I’ve had to recalibrate on several occasions. I’m no expert and I’m certainly no source of truth, but here are some common “normalities” I’ve encountered along the way:

It’s not normal to excel at every assessment along the way, and it’s normal to fail. We’ve created this system of training in which hypercompetitive medical students vie for the “best” internship (whatever that is supposed to mean) and endlessly buff their CVs to achieve immortal greatness in the specialty of their choice, to the exclusion of all others. This type of system demands that doctors perform at 100 per cent of their operating capacity, at all times, which just isn’t reasonable. I’ve spoken before about the green and red lights of assessment, and the dire lack of orange lights along the way. This isn’t normal outside of medicine and it shouldn’t be normal within it. We need systems of assessment that don’t demand shiny whitewashed walls of achievement. The odd coffee stain isn’t just acceptable, it should be encouraged. It should be a badge of honour, because stains draw attention, and they allow you to focus on how to improve yourself rather than improving at assessment. Use your frame of reference to improve, not to impress.

It’s not normal to not see your loved ones for days at a time. My partner works shift work as well, and our training has meant that while I rode the escalator down into the pit of mayhem, she’s taken the elevator to the top of the afore-mentioned tower. She relishes the opportunity to have a good laugh when I call from ED for ICU to please come and join the party. We’re less jovial about our jobs when we’re passing ships in the night, only seeing each other at the start and finish of shifts for a quick chat and a kiss goodnight. Now don’t get me wrong, we’ve chosen this life and these rosters. However, no matter how you paint it, it isn’t normal. We have had to take these runs as a sign to slow down and be sure to spend quality time with each other. If you’re going to roster work, make sure you roster life.

It’s not normal to be so close to death all the time. I’ve chosen two particularly bloody specialties, and death (often horrific death) is not uncommon. And yes, your temperament for death will be part of what guides you to your specialty. But death like this shouldn’t ever be normalised. We need to remember to debrief with those around us, especially for new staff who might not be used to the abnormality of death on invasive organ support. To extend this further, I’d like to also point out that death of our colleagues is never, ever normal. It should be treated with the utmost of seriousness and should always result in an organisational response. We should never expect doctors to just get back to business as usual when they lose a peer.

It should be normal to enjoy your job. It should be normal to be proud of your profession. It should be normal to have a healthy workplace culture. Sometimes we hit these points of normality and at other times we don’t. For my part I’m going to keep checking that compass. Pick up the deviations before we get lost, lest we run into icebergs.

Public hospitals – funding needed, not competition

ASSOCIATE PROFESSOR SUSAN NEUHAUS, CHAIR, AMA HEALTH FINANCING AND ECONOMICS COMMITTEE

Under its terms of reference, public hospital funding is a key focus for Health Financing and Economics’ work. How funding arrangements affect the operation of public hospitals and their broader implications for the health system has always been an important consideration for HFE, and for Federal Council and the AMA overall.

The AMA Public Hospital Report Card is one of the most important and visible products for AMA advocacy in relation to public hospitals.

The 2017 Report Card was released by the AMA President on 17 February 2017. The launch and the Report Card received extensive media coverage.

The Report Card shows that, against key measures relating to bed numbers, and to emergency department and elective surgery waiting times and treatment times, the performance of our public hospitals is virtually stagnant, or even declining.

Inadequate and uncertain Commonwealth funding is choking public hospitals and their capacity to provide essential services.

The Commonwealth announced additional funding for public hospitals at the Council of Australian Governments (COAG) meeting in in April 2016. The additional funding of $2.9 billion over three years is welcome, but inadequate.

As the Report Card and the AMA President made very clear, public hospitals require sufficient and certain funding to deliver essential services.

“Sufficient and certain” funding is also the key point in the AMA’s submission to the Productivity Commission’s inquiry into Reforms to Human Services, in relation to public hospitals. The Commission is expected to report in October 2017.

As part of this inquiry, the Productivity Commission published an Issues Paper seeking views on how outcomes could be improved through greater competition, contestability and informed user choice.

While the AMA believes there is clearly potential to improve outcomes of public hospital services, its submission highlighted that there are significant characteristics of Australia’s public hospitals that must be taken into account.

Health care is not simply a “product” in the same sense as some other goods and services. Public hospitals are not the same as a business entity that has full or even substantial autonomy over their customers and other inputs, processes, outputs, quality attributes, and outcomes.

Public hospitals work on a waiting list basis, usually defined by acuity of need, to manage demand for public hospital services. Private hospital services typically use price signals. There is limited scope to apply mechanisms for patient choice (such as choice of treating doctor) to access arrangements in public hospitals that are governed by waiting lists.

Public hospitals also operate within a highly developed framework of industrial entitlements for medical practitioners and other staff that are tightly integrated with State/Territory employment awards. These measures are intended to encourage recruitment and retention of medical practitioners to the public sector, offering stable employment conditions, continuity of service and portability of entitlements. They support teaching, training and research in the public sector as well as service delivery.

The freedom to choose between public and private hospital care, and the degree of choice available to patients in public hospitals as distinct from private patients, is an integral part of maintaining Australia’s balanced health care system. The broad distinction between public and private health care is generally understood by the community as a basic feature of the health system and part of Medicare arrangements, even though detailed understanding of how this operates, including what they are actually covered for in specific situations, is often lacking for many people.

Introducing private choice and competition elements into public hospital care will tend to blur the distinction between public and private health care, and reduce the perceived value of choice as a key part of the incentive framework for people choosing private health care.

The Commission’s Issues Paper proposes that increased competition will address equitable access for groups including in remote areas, benchmarking and matching of best practice, and greater accountability for performance. These are all worthwhile and important objectives in their own right. As such, they are already the focus of a range of initiatives.

Public hospitals are already subject to policies and requirements that address the same ends of improved efficiency, effectiveness and patient outcomes, including:

Hospital pricing, now supported by a comprehensive, rigorous framework of activity based funding and the National Efficient Price;
Safety and quality, supported by continuously developing standards, guidelines and reporting, including current initiatives to incorporate into pricing mechanisms;
Improved data collection and feedback on performance including support for peer-based comparison.

The single biggest factor that will increase the returns from such initiatives is the provision of sufficient and certain funding. Increased competition, contestability and user choice will not address this need.

The AMA Public Hospital Report Card 2017 is at ama-public-hospital-report-card-2017

Holistic medicine provision in the outback

Overcoming the barriers to chronic disease management in rural areas

The Royal Flying Doctor Service (RFDS) has been providing essential medical services to rural and remote Australia since its inception in 1927. The service, founded by Reverend John Flynn, started as a single base at Cloncurry in Queensland1 and now operates out of 21 bases, providing both primary care clinics and emergency retrieval services. RFDS has been servicing clinics from its Broken Hill base since the 1940s; by 1970, there were three full-time doctors conducting the clinics and running the on-call service via the radio network. In 2016, Broken Hill doctors treated patients in 17 different clinic locations each month. On most weekdays, there are general practitioners at three clinic sites, along with dentists, nurses and mental health practitioners.

RFDS is well recognised within Australia and internationally as the only provider of emergency care to large swathes of the outback. Television shows, such as The Flying Doctors and Outback ER, make acute care and cutting-edge medicine familiar to the public. What is less well known, however, is the organisation’s extensive involvement in delivering primary care services to people living in remote locations.

Chronic disease management (CDM) is a key component of the primary care services offered, and the appointment of a practice nurse in 2011 was the first step taken to focus on CDM. The nurse’s initial task was to create and manage the chronic disease register. This formalised the disease database and enabled the setting up of recalls to ensure that patients received regular follow-ups, and it also required doctors to comply with the full functionality of the MedicalDirector system. In addition, the opening of the Clive Bishop Medical Centre (CBMC) at the airport base, in August 2014, allows patients from remote locations to see an RFDS doctor when they are in town in between remote clinic days. Thus, in recent years, the RFDS has redefined its role from bush clinics and emergency evacuations to include a more comprehensive primary care approach in an effort to improve chronic disease outcomes.2 However, due to a number of factors, RFDS is still limited in its ability to deliver high quality primary care.

This model of care in remote New South Wales requires significant investment in medical staff. In an area of 640 000 km² and with about 6000 patients who live outside Broken Hill,3 eight whole-time-equivalent (WTE) GPs are needed to provide appropriate primary care and emergency services — an increase from four WTEs in 2000. Staff fatigue management and CDM considerations have driven the increase in staff numbers. Clinical, pilot and engineering staff salaries, along with aviation fuel, are all required to enable aircraft-serviced clinics and incur a high cost per patient.

In a metropolitan setting, a patient may need an emergency ambulance ride to hospital at a cost of $364 plus $3.29 per km travelled.4 However, in remote locations an $8 million dollar aircraft will need to be sent out at a cost of about $3000 per hour flown. Although the secondary care costs may be expected to be comparable, the approximate tenfold transport cost impacts significantly on health budgets, and demands optimised local CDM and patient concordance.5,6

Western countries have resourced primary care significantly in the past decade, with GPs incentivised to improve CDM. For example, the United Kingdom Qualities and Outcomes Framework rewards GP practices for the overall control of diabetes, chronic obstructive pulmonary disease and cardiovascular disease.7 In Australia, GP management plans (GPMPs) can be charged at a significant premium ($144.25) compared with a standard long Medicare consultation ($71.70).When done well, this should have the effect of more reliable monitoring and control of chronic conditions.8

The Commonwealth contract for the RFDS South Eastern Section, however, does not place a premium on these services. Standard RFDS consultations outside Broken Hill are funded based on historical data; CBMC consultations are Medicare bulk billed under a separate arrangement. When GPMPs are used in remote settings, they do not enable patients to access allied health services — such as diabetes educators, podiatry or physiotherapy — under the Medicare-funded scheme. Patients must either finance it themselves, or book an appointment in a Medicare billed location to access Team Care Arrangements funding.

By involving its in-house multidisciplinary team (funded by a variety of income streams), including practice nurses, women’s and children’s nurses, mental health practitioners and substance misuse workers, RFDS has sought to develop services in line with current best practice. Additional integrated team-based care with medical (generalist and specialist), nursing and allied health staff is known to be associated with improved health outcomes in patients with chronic illnesses.9 Rural and remote primary care centres, such as clinics in far west NSW, are less likely to have a team approach because of limited access to allied health workers.9,10

Recruitment and retention of doctors

RFDS doctors at Broken Hill are required to have a fellowship of the Royal Australian College of General Practitioners or a fellowship of the Australian College of Rural and Remote Medicine. Attainment of these qualifications ensures the standard of knowledge and training of the GPs responsible for treating patients in remote settings. However, the reality is that a full-time doctor may only conduct 2–3 clinics per week (spending the rest of their time on call). With travel time to clinics of up to 2 hours each way, and the attendance varying from 8 to 16 patients per day, clinical skills are used less often and confidence may diminish. Some doctors find this frustrating; others are happy to have time out of private general practice.

The maintenance of clinical skills in emergency care is more challenging. Practitioners need to complete a regular cycle of courses — including Advanced Paediatric Life Support, Advanced Life Support in Obstetrics, Early Management of Severe Trauma and airway skills updates — but there may be months between course completion and the need to use the skills. The gap between competence and confidence may be too much for some doctors to bear, and for those who prefer the emergency to the routine, there is not enough excitement.

Therefore, there are two competing challenges to address: where to find GPs who are experienced enough in their field to be able to manage well the uncertainty in remote places — whether face to face or over the phone — and enough emergency cases to keep this self-selecting group interested. Then of course, there is the remoteness of the place; 1200 km from Sydney and 500 km from Adelaide is too much for most Australian GPs. At present, the full-time practitioners are UK or Irish graduates, and the longest serving of them has been employed for 3 years.

Continuity of care

If a high staff turnover is not controlled, continuity of care in each clinic site will be adversely affected. Even when fully staffed, manning 17 clinic sites and rostering night shifts means that doctors have to be rotated. However, it has been shown that both patients and doctors prefer to know each other as part of an effective therapeutic relationship.11,12 This is an important factor in the effectiveness of CDM and patient engagement.

In addition to the RFDS doctors, health services in Wilcannia, Ivanhoe and Menindee are simultaneously provided by GPs from Maari Ma Health, which is the Indigenous community controlled health organisation. Five Local Health District (LHD) facilities, which include these three, also provide nursing staff at these sites. With the rotating system of both RFDS and Maari Ma Health rosters, along with significant use of agency nursing in remote sites, it is easy to recognise the fragmentation of what should ideally be integrated care. The responsibility for CDM of certain groups falls between the gaps sometimes, and it is not always clear who should be keeping track of follow-up and recall systems. There is, therefore, room for further system development and collaboration here.

Medical records

GP and hospital records are now multi-user friendly and most sites enable multidisciplinary teams to make entries within the same system. However, Maari Ma Health has a separate MedicalDirector system from RFDS, and LHD has recently upgraded to NSW Health’s latest hospital electronic medical record system. Thus, the usual norms of primary care, in which a GP is confident that the electronic record is complete, have not been possible to achieve in recent years. RFDS doctors are fully oriented to the need of keeping updated records for emergency and primary care consults, so that colleagues may be apprised of their decision making.

Social considerations

In remote NSW, there are many circumstances that may impact the clinical follow-up of medical conditions. It is widely believed that logistical, economic and cultural factors affect the low attendance rates for CDM in remote settings.13,14 The reasons for low RFDS clinic attendance rates include socio-economic conditions, the lower likelihood that males in rural communities will use preventive health services than urban males, and a higher proportion of Indigenous people.14 Logistical dimensions of proximity, affordability, accommodation, timeliness and psychosocial attitudes and beliefs are well known to hinder continued primary care in remote regions.13–15 Identifying infrequent users of primary health care who have chronic disease, with consideration of culturally appropriate preventive care, will assist in targeting those patients who require medical services.

There are still many barriers to the high quality management of chronic conditions. Efforts to improve this situation should focus on enhancing continuity of care, follow-up systems and planning of a team care approach. The increased use of telehealth technologies will be an important part of remote consultations, and current initiatives to improve CDM are of the utmost importance.

[Perspectives] Deborah L Birx: on a mission to end the HIV/AIDS epidemic

Ambassador Deborah Birx is the US Global AIDS Coordinator and in charge of the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the US Government’s engagement with the Global Fund. She is also the US Special Representative for Global Health Diplomacy and aligns the government’s diplomacy with foreign assistance programmes on global health issues. Speaking to her on the day after the US elections, she was upbeat about PEPFAR’s future. “We are very lucky to have an incredible programme that has bipartisan support now and from the beginning.

Health Care Homes must be tailored to Indigenous needs

I am continuing the important tradition of chairing the Taskforce on Indigenous Health as AMA President. The taskforce acts to identify and recommend Indigenous health policy strategies for the AMA.

On 8 October 2016, it was my privilege to chair my first meeting of the Taskforce. A number of important issues were discussed, including the AMA’s election priorities relating to Aboriginal and Torres Strait Islander health, the AMA’s support for the establishment of an Academic Health Science Centre in Central Australia, as proposed by Baker IDI Heart and Diabetes Institute and its partners, and the Indigenous health focus of the Medicare Benefits Schedule (MBS) Review.

One issue that was raised as being of particular concern was how the proposed Health Care Homes initiative will affect health care for Aboriginal and Torres Strait Islander peoples. The AMA supports the concept of Health Care Homes – a policy announcement made by the Coalition prior to the 2016 election, and we are pleased that the Australian Government has committed to an extended trial of the concept.

The AMA has concerns about the Health Care Homes model in relation to Indigenous health, and we assert that the specific health needs of Aboriginal and Torres Strait Islander people must be addressed through the scheme.

The concept of the medical home is not new in Australia. For many Australians, their local general practice is already their Health Care Home, and their GP, their primary carer. Patients whose care is well managed and co-ordinated by their GP are likely to have a better quality of life and to make a positive contribution to the economy through improved workforce participation. Health Care Homes should mean more expensive downstream costs can be avoided. Chronic conditions, if treated early and effectively managed, are less likely to result in the patient requiring hospital care for the condition or any complications.

The Health Care Home model has worked overseas and the evidence is of significant reductions in avoidable hospital admissions, emergency department use, and overall costs.

The AMA sees Health Care Homes as potentially one of the biggest reforms to Medicare in decades.

However, we know that, for the Health Care Home model to succeed, the Government needs to engage with and win the support of general practice. We also need to see greater detail about how the Health Care Home model will operate in remote and Indigenous communities.

Indigenous communities face a range of unique health problems and chronic diseases uncommon in our cities. A high turnover of medical practitioners and support services in these areas means continuity of care and follow up treatment can be difficult to maintain.

Trust is a vital component of health care, especially for Aboriginal and Torres Strait Islander peoples, and knowing and trusting a GP is critical in the management of chronic conditions. How the Health Care Home model will deliver consistent, ongoing GP care and management of chronic health conditions is not known, and the AMA has been urging the Government to provide greater details about funding and operation.

There is a degree of anxiety among the Aboriginal Community Controlled Health Organisation (ACCHO) sector that any announcements made by the current Government will result in cuts to Indigenous health. There is a strong view that building up the ACCHO sector is the best model of care for Aboriginal and Torres Strait Islander peoples, particularly as ACCHOs are the preferred provider of Indigenous health services.

ACCHOs, like Health Care Homes, need to be built on existing relationships and investment in models that work. The Government must not rush the Health Care Homes trial and, if it is to be successful, it must be adequately funded.

As a model, it has the potential to help close the gaps in health outcomes between Aboriginal and Torres Strait Islanders and non-indigenous Australians. The AMA’s position will be to closely monitor what works and what does not work, and work constructively with Government to ensure the necessary changes are made.

Central visual loss following a motor vehicle accident: traumatic airbag maculopathy

Clinical record

A 62-year-old woman was the driver of a car travelling at 60 km per hour when it collided with a stationary truck with subsequent airbag deployment. She wore no spectacles and her seatbelt was fastened at the time of the accident. She was initially assessed in the emergency department (ED) and subsequently discharged. Four days after the incident, she was referred by her general practitioner to the ED as she had persistent blurred central vision. The patient did not report any neurological symptoms. Her past ocular history included blunt trauma to the right eye from a snowball as a teenager.

Her best corrected visual acuity was 6/15 in the right eye and 6/24 in the left eye. No acute anterior segment pathology was present. Dilated fundus examination revealed several small intraretinal haemorrhages, but no retinal tears were found. A spectral domain optical coherence tomography (SD-OCT) scan showed subretinal fluid as well as hyper-reflective material at the fovea bilaterally (right more so than left).

Subsequent macular SD-OCT scans demonstrated bilateral resolution of the subretinal fluid over a period of 3 months with associated improvement of her vision to 6/12 in each eye (Box).

Our literature review on the PubMed database using the keywords airbag, trauma, macular and maculopathy yielded 12 similar cases, but none from Australia. We therefore believe this to be the first report of an Australian case of central visual loss from traumatic airbag maculopathy (TAM) without apparent external injuries. Despite saving lives, airbags have been associated with a range of ocular trauma specific to their deployment, including corneal injuries, hyphaema, intraocular haemorrhages, retinal tears and detachments.1 Other modifiable risk factors that affect the severity of the eye injuries include unfastened seatbelt, wearing spectacles and close proximity to the steering wheel.1 Newer airbags have reduced inflation force, which decreases overt manifestations of direct blunt ocular trauma; however, as our report shows, they may cause a separate pattern of occult ocular injury.

The postulated cause of the specific injury of TAM relates to the acceleration–deceleration forces resulting in retinal dehiscence.2,3 The forces involved may cause blunt trauma to the ocular tissue, due to the airbag inflating in one direction and the head moving in the opposite direction at high velocity. The traumatic mechanism causes a disruption of the connecting cilia of cones and rods in the outer segment.4

One reported case of TAM described immediate unilateral blurred central vision with no other ocular injuries, and an SD-OCT scan demonstrated foveal detachment.5 Another report described two cases of post-traumatic unilateral maculopathy with serous retinopathy on SD-OCT imaging.2,5 All three cases showed resolution of foveal subretinal fluid over 4 weeks, consistent with the pattern of resolution seen in this case; however, full retinal architecture was restored within 12 weeks. Despite substantial visual improvement and return to a normal anatomical appearance, patients can report ongoing paracentral scotomas, which are detectable only on electrophysiology testing and suggest a persisting disruption to retinal function.5 The time frame for the resolution of the subretinal fluid is important as it may coincide with the resolution of ocular injuries, such as hyphaemas or vitreous haemorrhages, which may obscure the diagnosis of the macular pathology. Therefore, clinicians need to consider TAM in patients with persisting scotomas and obtain an electrophysiology study in the context of normal clinical and SD-OCT scan findings.

In summary, significant sight-threatening ocular injuries related to airbags can occur despite the lack of apparent external trauma to the eye. The visual symptoms and visual acuity should be specifically assessed in these patients. A prompt referral to an ophthalmology service is paramount to allow detailed ocular assessment and detection of subtle maculopathy that may have long term visual consequences.

Lessons from practice

New airbag technology has resulted in reduced external ocular injuries.
Subtle maculopathy resulting from dehiscence forces is a newly identified clinical entity that has unknown long term consequences.
Ophthalmology referral may be required even when there is no apparent external ocular injury.
Assessment for sight-threatening conditions, including traumatic airbag maculopathy, is required in symptomatic patients with blurred vision following airbag deployment.

Box –

A and B: SD-OCT scan of the maculae through the fovea at presentation, 4 days after a motor vehicle accident. OD: foveal subretinal fluid with a choroidal scar nasally from a previous injury. OS: foveal subretinal and intraretinal fluid. C and D: SD-OCT scan of the maculae 2 weeks after presentation. OD: residual subretinal fluid. OS: scan 2 weeks after presentation showed residual subretinal fluid. E and F: SD-OCT scan of the maculae 4 weeks after presentation. OD: the retinal architecture is largely restored. OS: residual abnormalities are noted in the inner and outer retinal structure. G and H: SD-OCT scan of the maculae 3 months after presentation. OD: retinal atrophy nasal to the fovea is noted and consistent with a previous choroidal rupture. OS: the inner and outer retina is structurally restored.

Emergency department care 2015–16: Australian hospital statistics

In 2015–16: – There were about 7.5 million presentations to public hospital emergency departments; – 74% of patients received treatment within an appropriate time for their urgency (triage) category; – 73% of patients spent 4 hours or less in the emergency department; – 2.2 million patients were admitted to hospital from the emergency department, and 49% of these were admitted within 4 hours.