Teledermatologists’ management of emergency skin conditions

Traditionally, when patients present to emergency departments or rural hospitals with a complex skin condition, the on-call dermatology registrar will be consulted by telephone. More recently, clinicians have begun using store-and-forward technology to send images directly to the specialist, significantly improving their capacity to accurately diagnose and manage patients remotely. Such teledermatology services also provide valuable teaching opportunities for rural doctors and registrars. While there are numerous benefits, including improved timely access to specialist advice for rural patients and clinicians, and reduced unnecessary investigations and outpatient referrals,1 the issues related to patient privacy and confidentiality must be addressed.

Following a successful pilot study in Queensland in 2008–2009,2 the Skin Emergency Telemedicine Service was implemented at the Princess Alexandra Hospital (PAH) in Brisbane. Despite no active promotion of the service, referrals have almost doubled from 167 cases in 20123 to 318 in 2014. The disease spectrum of referred cases in 2014 was similar to 2012, with 30% diagnosed with dermatitis, 21% with infection of the skin and 15% with drug eruption. Referral sites continue to be dispersed across the state, from Brisbane to Innisfail, 1600 km away. After the cessation of outreach services to Qld towns such as Mt Isa in 2013 and closure of the Dermatology Department at Cairns Hospital in 2014, the PAH Skin Emergency Telemedicine Service has been an essential part of ensuring timely access to a dermatologist (average response time = 4 hours) for patients with acute skin conditions across Qld.

The increased use of smartphones by clinicians to capture images for telemedicine services has raised concerns about patient privacy and consent. The study by Kunde and colleagues of dermatology registrars’ (n = 11) use of digital and smartphone technology for clinical imaging reported widespread use of the technology.4 The vast majority of clinicians had stored over 100 clinical images of patients on their personal phones, and 10 of 11 surveyed clinicians reported they had texted or emailed images to colleagues. Although patient consent was obtained verbally by 10 of the responding clinicians, few reported recording consent in the patient’s medical record (n = 2).

In 2014, the Medical Indemnity Industry Association of Australia and Australian Medical Association developed the Clinical images and the use of personal mobile devices guide for medical students and doctors.5 The guide makes recommendations for the collection, use and disclosure of clinical images as well as storage and security. Clinicians using teledermatology services must familiarise themselves with the relevant guidelines, hospital policies and privacy legislation, and ensure that images and evidence of obtained consent are documented in patients’ medical records.

The addition of store-and-forward technology to the traditional referral system has enabled clinicians to access specialist advice in an efficient and timely manner, potentially improving patient care. Strategies to improve access to specialist advice should be supported, but the relevant ethical and legal issues must also be considered.

Providing a lifeline for rural doctors

Telemedicine programs are often designed to meet the needs of specialists rather than rural doctors

Australia has almost twice as many small rural hospital-based emergency facilities as designated emergency departments.1 They see 16% of Australia’s emergency patient presentations, or almost 1.3 million presentations each year.1 Although small rural facilities are tasked with managing mainly minor injury and illness, they also treat patients with complex and time critical problems.2 These facilities are staffed by nurses alone, or by junior doctors, general practitioners or rural generalists. Rural doctors often have specific training for rural emergency medicine, and they usually have more years of experience than junior doctors who treat most patients in urban emergency departments. What they lack is immediate access to onsite specialist advice.

Tertiary specialty units that receive patients from rural areas are often aware of this deficit. Concerned about the poor outcomes for their rural patients (although rural–urban outcome research is often confounded by hard-to-control-for factors3), some have created systems to provide a lifeline for early advice and support. A recent systematic review4 described tele-emergency programs that provide support for stroke thrombolysis, trauma management, burns care, eye conditions and several other specific problems.

Direct access to specialists with a passion to help rural doctors is incredibly valuable. Rural doctors feel more supported, and may be more likely to stay in rural practice.5 It is easier, and likely to be safer, than the usual process of speaking to a registrar at a suitable hospital, although robust evidence is lacking.4

However, telemedicine projects that are driven by specialty units create problems. When each program chooses a separate technology that is ideal for their condition of interest, rural doctors can struggle to maintain familiarity with each system. Of more concern is that advice can only be obtained if the patient is critically ill or has a condition that interests one of the specialty telemedicine programs. Advice is difficult to obtain if the patient presents with an undifferentiated illness that is probably self-limiting but in which life-threatening conditions have not been excluded. Telemedicine advice providers with limited resources have complained they are there to “consult with sick patients … Not [to deal with] every other thing”.6

But undifferentiated problems, such as dyspnoea, chest pain, abdominal pain, collapse and headache, are among the most common emergency presentations at both large and small facilities.2 No rural ambulance service has the capacity to transfer all such patients to a larger centre just to make sure that the small number of serious diagnoses are detected. These decisions can be difficult. An expert opinion in borderline cases can make a difference, sometimes avoiding unnecessary and expensive transport and keeping patients where they would rather be. It can also save lives. The South Australian Integrated Cardiology Clinical Network provides advice to rural clinicians for any patient with chest pain. As a result, within a decade, they have removed the gap between rural and urban mortality from myocardial infarction.7

The alternative approach is to create a centralised telemedicine system staffed by emergency medicine specialists.8 This replicates the practice in many regions where emergency physicians provide telephone support to surrounding small hospitals. This system has several advantages. Emergency specialists become more familiar with the small hospital environment by seeing it regularly during consultations. It provides a single access point for rural clinicians. No type of presentation should be out of their scope of practice, even if the patient has vague symptoms or is drug affected.

There is a disadvantage too. In emergency departments, emergency specialists rely on inpatient unit specialists directly reviewing some cases. Unless this is explicitly built into a centralised telemedicine system, emergency specialists must use an ad-hoc system of calling specialists or their registrars at surrounding hospitals who may have no access to the video-links and may feel that offering such advice is not part of their employment.

How do we combine a centralised system with a system of specialty units on call? A centralised telemedicine system may have to be located at an actual hospital with a full complement of speciality units resourced to help rural doctors. There is a system like this in Australia, or actually over Australia. For more than a decade, the Good Samaritan Hospital in Phoenix, Arizona, in the United States, has been providing advice for medical situations on Qantas, and many other airlines’, flights. A doctor on shift in the emergency department is called to provide advice, with all the specialist and subspecialist resources of a large tertiary hospital available for backup.9 Can we provide the same service, or something similar, for rural hospitals on the ground?

Patients face potentially lethal delays as hospitals struggle

Emergency physicians have warned the public hospital system is at “breaking point”, with thousands of patients being forced to wait hours for a hospital bed, clogging emergency departments and preventing ambulances from unloading.

A survey by the Australasian College of Emergency Medicine of all the nation’s 121 accredited emergency departments has found that 70 per cent of emergency department patients are being delayed more than eight hours as they wait for beds in other parts of the hospital to become available, adding to evidence of enormous strain in the system.

The survey’s author, Associate Professor Drew Richardson, said the result highlighted the extent of the “access block” problem, when a dearth of free beds in the main body of a hospital prevents patients moving out of emergency. The knock-on effect is to clog the emergency department, which in turn means ambulances cannot unload patients.

“These figures…show that too many patients are waiting too long to receive the proper care,” A/Professor Richardson said. “They reflect a hospital system that is critically overburdened and that is putting patients into the firing line.”

More than half the hospitals in the survey reported that at least one patient had to wait for more than 12 hours for a bed, an outcome A/Professor Richardson said was “completely unacceptable”, and should be ringing alarm bells for health authorities across the country.

Evidence indicates that the longer patients are forced to wait in emergency, the worse their health outcome is likely to be. A Canberra Hospital study found that older patients forced to wait more than four hours for a ward bed were 51 per cent more likely to die than those who suffered shorter delays.

The survey’s results underline AMA warnings of an impending crisis in the public hospital system as a result of the Federal Government’s decision to rip $57 billion from its funding over the next 10 years.

The Federal Government has walked away from the National Health Reform Agreement with the states, cut incentive payments, dump activity-based funding and reduce indexation of its public hospital funding to inflation plus population growth.

AMA President Professor Brian Owler has warned the cuts will have a profound effect on the hospital system, warning that “public hospitals and their staff will be placed under enormous stress and pressure, and patients will be forced to wait longer for their treatment and care”.

“Rather than funding the necessary hospital capacity, the Commonwealth has withdrawn from its commitment to sustainable public hospital funding and its responsibility to meet an equal share of growth in public hospital costs,” Professor Owler said earlier this year. “Funding is clearly inadequate to achieve the capacity needed to meet the demands being placed on public hospitals.”

The AMA’s annual Public Hospital Report Card, released in April, showed that although there had been marginal improvement in public hospital performance against Government benchmarks, no State or Territory met the target to see 80 per cent of emergency department Category 3 urgent patients within clinically recommended triage times.

Professor Owler said access block was a particularly concerning issue.

He said that emergency departments were able to meet performance targets for patients who did not require admission to hospital.

“But when they have to be admitted, that is where performance suffers. That is an issue of the capacity of our public hospital system,” he said.

Professor Owler warned the system would be hit by “a perfect storm” when lower indexation funding arrangements kick in in 2017-18.

“This will lock in a totally inadequate base from which to index future funding for public hospitals,” he said. “State and Territory governments, many of which are already under enormous economic pressures, will be left with much greater responsibility for funding public hospital services. Performance against benchmarks will worsen and patients will suffer. Waiting lists will blow out.”

Adrian Rollins

AMA in the News – 21 September 2015

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

Annual budget for each patient under GP plan, Adelaide Advertiser, 5 August 2015
The Primary Health Care Advisory Group published a discussion paper, outlining radical changes to GP care and inviting comment by September 3. AMA President Professor Brian Owler said the discussion paper challenged the profession to consider new payment models, and this is something that will require an ongoing discussion.

Happy little home brew puts Vegemite in the firing line, Sunday Times, 9 August 2015
Australia’s iconic Vegemite could be ripped from supermarket shelves in remote communities because it is being brewed into booze. Professor Owler said the impact home brew could be devastating, with alcohol abuse still one of the greatest issues facing Australia.

State of bad health, The Herald Sun, 13 August 2015
Stress, poor role models and beliefs that bullying is character building are blamed for the culture of intimidation and harassment in Australia’s surgical ranks. Professor Owler called for gender balance in senior roles to help promote more inclusive workplaces. Saying quotas were one of the most effective tools available.

Women also harass men: senior doctors, Sydney Morning Herald, 13 August 2015
Sexual harassment goes both ways in the surgical room, according to senior doctors, who say that female doctors and nurses do not hesitate to use their sexuality to get ahead. Professor Owler said now was not the time for senior doctors to try to justify their actions, rather they should encourage a behavioural change in medicine.

Safety advocates call to put brakes on road toll, Northern Territory News, 15 August 2015
Autonomous emergency braking is the new focus for cutting the death toll on Australian roads. ANCAP and the AMA have launched a joint campaign on AEB, claiming the technology could be as important as seatbelts in cutting the road toll.

Doctors ordered, The Saturday Paper, 15 August 2015
Professor Owler planned to visit Nauru to see for himself whether healthcare in the Australian-run detention centre was up to scratch, but attempts were delayed.

Medibank insurance strategy under fire, Australian Financial Review, 20 August 2015
Doctors and other medical professionals are turning up the heat over an increasingly bitter dispute with Medibank Private over hospital insurance cover. Professor Owler said the idea that the Government does not have a role in this dispute is ludicrous.

Detention boycott debated by doctors, Sydney Morning Herald, 20 August 2015
Responsibility for the health care of asylum seekers in detention should be stripped from the Department of Immigration and Border Protection to steer off the prospect of a doctor boycott. Professor Owler said he did not support a boycott.

Medibank row: Feds urged to intervene, Canberra Times, 20 August 2015
Professor Owler has ramped up calls for the Government to intervene in Medibank Private’s bitter dispute with Calvary hospitals. Professor Owler said they can continue to stay out of the game, or they can get involved and start to fix up some of the mess they created.

Doctor Pot holds clinic, Canberra Times, 29 August 2015
Doctors are facing increasing pressure from patients demanding answers on whether cannabis might ameliorate their pain, and if so, where can they find it. Dr Stephen Parnis said we accept there is a legitimate place for treating some problems with cannabis.

Medirank, The Daily Telegraph, 28 August 2015
Medibank wants hospitals to sign a contract where it would refuse to pay for more than 165 preventable and sentinel events. AMA Professor Owler is concerned the new contracts are heading towards a US-style managed care system.

$220m bill for dodgy GP visit, The Sunday Telegraph, 30 August 2015
GPs have raised concerns about a home doctor service providing free bulk billed home visits after 4pm that is costing taxpayers $220 million a year. AMA Chair of General Practice Dr Morton said it is not free. It is paid for by all taxpayers and should be respected for that.

‘Secret’ deal on hospital care, Adelaide Advertiser, 31 August 2015
The public must be told the terms of a controversial contract deal between Medibank and Calvary hospitals so patients know if the fund will not pay for certain events. Professor Owler criticised as unacceptable the secrecy surrounding the 11^th-hour agreement.

A king hit on games boxing, Courier Mail, 4 September 2015
The AMA wants boxing banned from the Olympic and Commonwealth Games, but Australia’s top boxers claim it would send the game underground. Professor Owler said the aim of boxing is inherently dangerous, and sometimes fatal.

Ley cops Medicare blast, West Australian, 4 September 2015
Doctors have accused the Abbott Government of softening the ground for cuts to health after it released alarmist figures on rising Medicare costs. Professor Owler said Ms Ley was treating the one million-a-day claims figure as if they were separate visits to the doctor.

Doctors want protection from ice rage, The Canberra Times, 4 September 2015
The AMA has warned crystal methamphetamine is making the work of doctors more dangerous, and called for additional security in hospitals. Professor Owler said doctors nationwide had noticed a significant rise in the number of people using ice, and associated symptoms such as aggression and psychosis.

Radio

Dr Stephen Parnis, 612 ABC Brisbane, 13 August 2014
Dr Stephen Parnis talked about the risks of travelling overseas for treatment. Dr Parnis said cosmetic surgery and dental surgery are the main reasons people travel for medical treatments.

Professor Brian Owler, 2UE Sydney, 20 August 2015
Professor Owler talked about allocating medical resources to ailing patients. He said most health resources are used to prolong people’s lives, in the last few months of life, and sometimes when patients are unable to indicate whether they would like the action taken.

Professor Brian Owler, 6PR, 4 September 2015
The AMA is calling for combat sports which encourage violence to be banned. Professor Owler said, while these sports continue the AMA wants to ensure there are trained medical personnel who can look after the participants.

Dr Stephen Parnis, 612 ABC Brisbane, 4 September 2015
Dr Stephen Parnis talked about a ban on combat sports. Dr Parnis said they are opposed to sports where the primary goal, is interpersonal violence, to stop the opponent continuing.

Television

Professor Brian Owler, Ten Eyewitness News, 12 August 2015
A new report has revealed half of Australians have a chronic disease, and one in five have multiple illnesses. Professor Owler is calling for an investment in health care. Health Minister Sussan Ley says throwing money at the problem isn’t the answer.

Professor Brian Owler, The Today Show, 13 August 2015
Professor Owler speaks to the Today Show about the emergency breaking system available in Europe and America that the AMA would like to see become standard in all new cars sold in Australia.

Professor Brian Owler, Channel 7, 25 August 2015
Doctors have hit out at a suggested extension of the GST to health care, not long after the controversial GP co-payment was dumped. Federal Treasurer Joe Hockey said such a measure could help fund tax cuts. Professor Owler said it would impact those with chronic and complex disease.

Professor Brian Owler, Channel 10, 3 September 2015
Australia’s Medicare bill has doubled in the past decade and the Federal Government says we can’t afford such an increase. Professor Owler said the Health Minister is using the figures to develop a narrative around how she needs to cut costs in health.

Crush injury by an elephant: life-saving prehospital care resulting in a good recovery

We present the first case of severe injuries caused by an elephant in an Australian zoo. Although the patient sustained potentially life-threatening injuries, excellent prehospital care allowed her to make a full recovery without any long-term complications.

Clinical record

A 41-year-old female zookeeper was urgently transferred to the Royal North Shore Hospital Emergency Department (ED) by ambulance after a severe crush injury to the chest caused by a 2-year-old male elephant.

The 1200 kg male Asian elephant was born in captivity and was well known to the keeper. On the day of the incident, they were involved in a training session when the elephant challenged an instruction. The keeper recognised this change in his behaviour and tried to leave the training area, but the elephant used his trunk to pin her by the chest against a bollard in the barn, resulting in immediate dyspnoea and brief loss of consciousness for 20–30 seconds. Her colleagues arrived and moved her to safety.

When the ambulance arrived, the woman was alert and oriented, and complaining of dyspnoea and severe right-sided chest pain. Initial observations were pulse rate of 110 beats/min, systolic blood pressure (SBP) of 100 mmHg, and a respiratory rate of 36 breaths per minute. She rapidly developed increasing respiratory distress and was found to have absent breath sounds on the right side of her chest and reduced air entry on the left. She had subcutaneous emphysema involving the head, neck, torso and upper limbs. Intensive care paramedic backup was requested; when they arrived, she was unconscious with agonal respirations and no palpable pulse. High-flow oxygen was applied at 15 L/min through a mask and cardiopulmonary resuscitation was commenced. A provisional diagnosis of bilateral tension pneumothoraces (PTx) was made. The ambulance officers performed bilateral needle chest thoracostomies with 12G × 9 cm Dwellcath cannulas at the level of the second intercostal spaces in the mid-clavicular line. Although there was no immediate rush of air following either procedure, after about 10 minutes there was a return of cardiac output (pulse rate, 76 beats/min; SBP, 160 mmHg), return of spontaneous respiration (32/min) and improved conscious state (Glasgow coma scale, 10).

On arrival in the ED, she had a heart rate of 115 beats/min, SBP of 90 mmHg, respiratory rate of 38/min and SaO₂ of 74% on 14 L oxygen. Physical examination was difficult because of extensive subcutaneous emphysema over the torso. There was significant bruising over the right breast and upper abdomen. No other injuries were identified. A Focused Assessment by Sonography for Trauma (FAST) examination of the abdomen was performed, but it was difficult to interpret because of the extensive subcutaneous emphysema over the chest and abdominal walls.

She was intubated and bilateral 32 Fr intercostal catheters were inserted, which improved ventilation and haemodynamic stability; the bilateral decompression needle catheters were removed. Chest x-rays (Box 1) showed extensive subcutaneous emphysema, multiple rib fractures and a persistent small right apical PTx.

Computed tomography of the cervical spine, chest (Box 2) and abdomen showed injuries involving the spine, ribs, sternum, lungs and liver (Box 3).

The woman was admitted to the intensive care unit with ventilation support for 4 days. Subsequent recovery was uneventful and she was discharged home on Day 11 without further complications.

Discussion

In the past 15 years, there have been at least 18 fatal incidents involving elephants in zoos around the world.1,2 To date, no cases of injury or death caused by an elephant in Australia have been reported in the literature.

This case of elephant-related trauma shows the importance of clinical acumen and good prehospital management in the management of serious chest trauma. Tension PTx is a rare and potentially fatal medical emergency. It is a reversible cause of traumatic shock and cardiac arrest.3

Tension PTx can occur after significant blunt chest injury.4 Symptoms and signs include severe respiratory distress, decreased oxygen saturation, hyperexpansion and hyperresonance on percussion, and reduced air entry on auscultation.5 Tension PTx can cause acute cardiovascular collapse and shock because of decreased venous return that results from sudden positive intrapleural pressure.5 The diagnosis is usually made clinically (as in this case). A chest x-ray is not usually seen, but, if taken, will show marked midline shift, hyperexpansion of the affected side and lung collapse in a unilateral tension PTx. In bilateral tension PTx, there is bilateral hyperexpansion of the pleural cavities and bilateral lung collapse.

Trauma consensus guidelines recommend that tension PTx be diagnosed clinically, because urgent chest decompression is required.4

Unilateral or bilateral tension PTx caused by blunt injury may be associated with significant subcutaneous emphysema6 that makes auscultation of the chest difficult.

The immediate management of tension PTx requires urgent needle decompression in the second intercostal space mid-clavicular line, followed by definitive management with insertion of an intercostal catheter (tube thoracostomy), usually in the fourth or fifth intercostal space anterior to the mid-axillary line.

In Australia, needle decompression of the chest can be performed by appropriately skilled paramedics (level 4 and above). Indications for prehospital chest decompression after serious injury include traumatic cardiorespiratory arrest, significant (refractory) hypoxia or hypotension, multiple concomitant injuries, long transport time, need for positive pressure ventilation, and helicopter transport. Retrieval medical specialists may also perform tube thoracentesis or open thoracostomy in the prehospital environment.6

1
Initial chest x-ray showing bilateral rib fractures, extensive subcutaneous emphysema and bilateral intercostal catheters

2
Coronal computed tomography of the chest showing residual right-side pneumothorax, pneumomediastinum, extensive bilateral subcutaneous emphysema and bilateral intercostal catheters

3
Injuries sustained by the woman and identified by trauma computed tomography

Fractures

Left C1 transverse process
Sternum (undisplaced)
Left ribs: 1, 2–5 (flail segment), 6–8
Right ribs: 1–2
Right sternochondral joint angulation: ribs 3–5

Other

Left haemopneumothorax
Right pneumothorax and pneumomediastinum
Bilateral pulmonary contusions
Extensive bilateral lower lobe collapse
Periportal oedema of the liver
Extensive subcutaneous emphysema

News briefs

Severe head trauma mortality drops at Royal Darwin

Mortality rates for severe head trauma at the Royal Darwin Hospital are down 40% from the 79% rate reported in a study 10 years ago, according to the ANZ Journal of Surgery. The study reviewed clinical service between 2008 and 2013, highlighting the continuing challenge of remoteness to the delivery of emergency medicine and surgery in the Top End. Alcohol remains a major player in hospitalisation, with 57% of patients having evidence of alcohol involvement and 39% of patients with traumatic brain injury having alcohol as a factor in their presentations. Indigenous persons were also overrepresented, accounting for 39% of all procedures as well as being considerably younger by a median of 15 years than their non-Indigenous counterparts. Resident generalist surgeons are reliant upon interstate neurosurgeons, who provide ongoing education, training and support, both by way of outreach visits and by 24-hour telephone and teleradiology consultation over 2600 km away.

Maternal, neonatal tetanus eliminated in India

Maternal and neonatal tetanus has been reduced to less than one case per 1000 live births in India, according to a WHO report. Until a few decades ago, India reported 150 000 to 200 000 neonatal tetanus cases annually. According to Dr Poonam Khetrapal Singh, WHO Regional Director for South-East Asia, the Indian government used a mix of existing and new programs to make elimination possible. “India’s re-energized national immunization program and the special immunization weeks and the most recent ‘Mission Indradhanush’, helped ensure that children and pregnant women are reached with vaccines”, he said. “The ‘National Rural Health Mission’ promoted institutional deliveries with a focus on the poor. The ‘Janani Suraksha Yojana’ encouraged women to give birth in a health facility.” Maternal and neonatal tetanus in South-East Asia now exists in just a few districts of Indonesia.

Hazard alert for hip replacement component

The Therapeutic Goods Administration has issued a hazard alert for one model of the Profemur cobalt-chrome femoral neck (part number PHAC1254 – “long 8-degree varus”) due to the potential for the component to fracture. The manufacturer, Surgical Specialities, is also undertaking a recall of unimplanted stock. Component fractures are extremely rare; however, the manufacturer reported that there had been 27 reports of fracture of the PHAC1254 component in the approximately 9800 units sold worldwide over the previous 5 years. Only 32 units have been sold in Australia. “If you are treating patients who have had a hip replacement and are concerned about the above issue, advise them to be alert to the potential symptoms of a femoral neck component fracture (the sudden onset of symptoms such as pain, instability and difficulty walking or performing common tasks).”

Elevated lead levels in 30 NT children

The Northern Territory Health Department has confirmed that 30 children have been found with elevated blood lead levels in three separate locations across remote areas of the territory, the ABC reports. Children in Palumpa and Peppimenarti, in the West Daly region, and the Emu Point outstation, had higher than expected lead levels, probably due to contact with lead shot, used for shooting magpie geese, according to NT Health Minister John Elferink. NT Chief Health Officer Professor Dinesh Arya said that the children and their families were being interviewed to determine the cause, and all the children were receiving treatment from “specialist paediatricians”.

Ebola vaccination trial extended to Sierra Leone

The WHO reports that a new case of Ebola virus in Sierra Leone, after the country had marked almost 3 weeks of zero cases, has set in motion the first “ring vaccination” use of the experimental Ebola vaccine in the country. A swab taken from a woman who died aged around 60, in late August in the Kambia district, tested positive for Ebola virus. “The Guinea ring vaccination trial is a Phase III efficacy trial of the VSV-EBOV vaccine. Interim results published last July show that this vaccine is highly effective against Ebola. The ‘ring vaccination’ strategy involves vaccinating all contacts — the people known to have come into contact with a person confirmed to have been infected with Ebola (a ‘case’) — and contacts of contacts.”

Paramedics and scope of practice

Highly-trained paramedics can initiate the pathway of care that will achieve optimal outcomes for patients

The question, posed to me by the Journal’s editorial staff, “Are paramedics exceeding the evidence?”, is a very global one that implies a dichotomous response. However, nothing in our complex health system can be so simply evaluated, so the question gets an equally global (if vague and unhelpful) answer: “Yes, probably, but no more or less than the rest of health care”.

My professional obsession with objective analysis must necessarily be tempered in this instance by my experience in contributing to the professional transformation of the ambulance service, particularly in the 1990s. This transformation resulted in considerable expansion of the scope of practice, underpinned by improved education and training — from in-house unstructured training, through the vocational training sector to university degrees.

The transformation in prehospital care was largely driven, not by evidence, but by the enthusiasm of proponents (mostly doctors) and by emerging international experience. The intellectual foundation was not usually evidence, but rather a defensible and logical rationale. Innovation is often so, because we cannot test system-wide effectiveness without introducing system-wide changes. However, sometimes that rationale is flawed when we make the “conclusional” jump that if anything is worth doing, then doing it earlier will always be better. However the logistical, training, equipment and safety impediments of working in an uncontrolled environment must necessarily influence the clinical cost–benefit analysis.

The problem we confront is both a lack of evidence and the influence of individual, professional, social and economic factors that then influence the scope of clinical practice. These may act contrary to science and its application. Traditionally, paramedics were poorly paid and relied on special allowances and penalty rates to reach incomes that could sustain them. As the scope of practice expanded, the industrial drive was for additional skills to be recognised financially, thus creating an incentive to undertake training and to value competence. There was thus some reluctance in certain quarters to rely on evidence or even a defensible rationale. In 2008, the then Queensland Minister for Emergency Services responded to pressure from staff and ordered the scrapping of a National Health and Medical Research Council-funded randomised controlled trial that aimed to test adrenaline against placebo in managing asystolic cardiac arrest.

Relating evidence to practice in uncontrolled environments

Next, while we recognise the capacity of evidence-based care to reduce costs and improve outcomes,1 the real challenge is to find evidence that can inform practice. A study in 2007 of almost 20 000 candidate articles found only 400 that were relevant to prehospital care, and that there were only 13 reviews.2 The Cochrane Library also demonstrates the limited utility of the evidence to inform practice. A review of the use of aminophylline for cardiac arrest found five trials with no survivors.3 A report on prehospital thrombolysis showed a reduction in time to thrombolysis, but limited evidence of its safety or on its long-term outcomes.4 Finally, a report on the use of oxygen for patients with chronic obstructive pulmonary disease noted that, of 741 abstracts reviewed, only two were of randomised controlled trials, both of which were ongoing and lacking outcome data.5 Much of the literature lacks an understanding of how its findings apply in the uncontrolled environment that characterises prehospital care. There are interventions for which the evidence is more clear-cut. Prehospital defibrillation improves survival (patients walk out of hospital).

The real value of highly-skilled paramedics

I am reminded of the international debate about prehospital management of trauma, which critics reduced to a simplified dichotomy — scoop and run, or stay and play. I wish I could draw, for I would design ambulances as modified garbage trucks or casinos to demonstrate the absurdity of either proposition. Surely what we expect is safe extrication, stabilisation, initiation of care and then securing appropriate ongoing care for the patient.

It is this last aspect which, to me, represents most value for the massive investments in professional development of paramedics. They are at the sharp end of the patient journey, and best placed to initiate a pathway of care most likely to achieve optimal outcomes. Paramedics’ judgement is necessary to bypass to trauma centres, take patients directly to catheter laboratories, or reduce the burden on emergency departments by treating patients in situ or directing them to more appropriate and cost-effective care options.6

For relatively smart people, we seem to struggle with complexity, and we try to reduce complex issues into binary thinking — on or off. The reality is always more complicated. The opinion of patients is clear: paramedics remain one of the most trusted health care professions. However, to retain that trust there is a professional imperative for research into prehospital care to seek the evidence or, at least, a defensible rationale so that the patient’s best interest retains its primacy.

Cars that save lives

Ninety per cent of road crashes involve some form of human error, so not paying attention when behind the wheel, even for a second, can result in devastating injury or death.

The AMA and the Australasian New Car Assessment Program (ANCAP) last month came together to launch the ‘Avoid the crash, Avoid the trauma’ campaign to call for automatic brakes to be installed in all new vehicles sold in Australia.

Autonomous Emergency Braking (AEB) systems use camera and sensor technology to detect the speed and distance of objects in a vehicle’s path, and automatically brake if the driver does not respond.

80,000 Australian lives have been saved due to improvements in road safety since the 1970s, but modern daily lives are full of spur-of-the-moment choices and potentially deadly interruptions.

Juggling work and family commitments is never easy and being contactable every moment of the day on our mobile phones has, arguably, added another layer of complexity and distraction.

AMA President Professor Brian Owler said systems like AEB could be as effective as seatbelts in saving lives.

Speaking at the campaign launch at Parliament House in Canberra, Professor Owler called on politicians, the car industry, and all road users to join the push for adoption of new technologies such as AEB to make cars safer and save lives.

Professor Owler, who is a leading Sydney neurosurgeon and the face of the successful NSW Government ‘Don’t Rush’ road safety campaign, said road trauma was avoidable.

“The key is making cars safer, and educating drivers about the risks of speeding and careless driving,” Professor Owler said.

“Too often, I see the horrific injuries and loss of life caused by road crashes when drivers get it wrong.”

ANCAP Chief Executive Officer Nicholas Clarke said fitting new cars with AEB is standard practice overseas, but in Australia it is either a costly option or not offered.

“AEB is a technology that will reduce the number of deaths and injuries from road crashes,” Mr Clarke said.

“While the number of people killed on Australia’s roads is declining, road crashes are still unnecessarily killing around 1200 people every year.”

Odette Visser

Substandard medication-related processes in primary care costing millions

Poor medication-related processes in the primary care setting is resulting in hospital admissions that could be costing hundreds of millions of dollars, a study has found.

Researchers Dr Gillian Caughey and colleagues from the University of South Australia and the BUPA Health Foundation analysed the hospital admissions of 83 430 older patients between July 2007 and June 2012.

They used data from the Department of Veterans’ Affairs and found that a quarter of admissions were due to substandard medication related processes.

The results have been published in the Medical Journal of Australia.

They found that for those who were hospitalised for fractures after a fall, 85.4% of those patients aged 65 or over had been prescribed a falls-risk medicine before admission.

For patients hospitalised for chronic heart failure, 17% hadn’t been dispensed an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) in the previous 3 months prior.

Similarly, “about one in 10 admissions for renal failure occurred in patients with a history of diabetes who had not received a renal function test in the year before admission and were not dispensed an ACEI or ARB,” the authors wrote.

The authors say the study highlights conditions where there are gaps in medication management in the older population.

“The results could be used to inform and focus the development of interventions and efforts to improve the quality of health care delivery, potentially reducing morbidity and health care costs,” they write.

To read the full study, visit the Medical Journal of Australia website.

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