more_vertA 53-year-old man presented to the emergency department of our hospital in January, 2014, after a syncopal episode. He was a regular smoker and recreational drug user, and had taken heroin, cannabis, and benzodiazepine during that week. He had a history of glucose-6-phosphate dehydrogenase (G6PD) deficiency. On examination he had grey pallor and was dyspnoeic at rest (respiratory rate 23 breaths per minute). His oxygen saturation was 70% on 100% inspired oxygen and his blood sample, which showed anaemia (haemoglobin 54 g/L; normal 130–180 g/L), was chocolate brown (figure).
Preference: Emergency Medicine
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GP pay up for grabs in primary health overhaul
Set fees and performance payments are among changes to GP remuneration being considered as part of efforts to remodel the primary health system to improve the care of patients with chronic and complex conditions.
The Federal Government’s Primary Health Care Advisory Group, led by immediate-past AMA President Dr Steve Hambleton, has canvassed a number of GP payment options in a discussion paper outlining potential reforms to address the rising chronic care challenge.
While the current fee-for-service model worked well in the majority of instances, the Better Outcomes for People with Chronic and Complex Health Conditions through Primary Health Care Discussion Paper said it did not provide incentives for the efficient management of patients who required ongoing care.
Instead, it suggested alternatives included capitated payments, where GPs, health teams, practices or a Primary Health Network receive a set amount to provide specified services over a given period of time; or pay-for-performance, where remuneration is tied to the achievement of particular care outcomes; or some combination of all three.
The discussion paper also suggests ideas about how care is organised and managed, including the creation of medical homes, GP-led team-based care, improved use of technology and upgrading techniques to monitor and evaluate care.
AMA President Professor Brian Owler welcomed the release of the discussion paper, but warned the Government that reform would not succeed without significant investment in general practice.
Professor Owler said several of the options for reform canvassed by Dr Hambleton’s Group had long been supported by the AMA, including GP-led team-based care, the improved use of technology, care coordinators, and an expanded role for private health insurers.
He said the new payment models outlined were a challenge for the medical profession, and would need ongoing discussion.
But he warned that the Government needed to support general practice if it was genuine in seeking to improve care.
“What is missing from the discussion paper is an explicit statement that we need to better fund and resource general practice if we are to meet the health challenges of the future,” Professor Owler said. “The final outcome from this Review must be more than simply re-allocating existing funding.”
Dr Hambleton emphasised that the paper had been developed to encourage discussion, but warned that things needed to change.
He said increasing life expectancy meant more patients were presenting with multiple chronic and complex health complaints, and current arrangements were increasingly struggling to meet their care needs.
More than a third of Australians have a chronic health condition and the discussion paper said that because the system was not set up to effectively manage long-term complaints, many were turning up unnecessarily in hospital and emergency departments, adding millions of dollars to the nation’s health bill.
Health Minister Sussan Ley said it was “essential” to review the provision of chronic care, because Medicare benefits for chronic care were soaring – up almost 17 per cent to $587 million in 2013-14 alone.
“We are committed to finding better ways to care for people with chronic and complex conditions and ensure they receive the right care, in the right place, at the right time,” Ms Ley said. “This discussion is a real opportunity to cater for the increase in chronic and complex conditions, and this approach ensures that health professionals and patients continue to be central to this process.”
But Professor Owler said the reality was that primary health review was being undertaken at a time when general practice was under sustained attack from the Government, and a “more positive” attitude was urgently needed.
“General practice has been the target of regular Budget cuts that undermine the viability of practices, and threaten the long term sustainability and quality of GP services,” he said. “The freeze on Medicare patient rebates is the prize example. It is causing great harm to GPs, their practices, and their patients.
“If the Government is genuine about improving how we care for patients with chronic and complex disease in primary care, greater investment and genuine commitment to positive reform is needed,” Professor Owler said.
As part of its consultation process, the Primary Health Care Advisory Group is conducting an online survey that will be open until 3 September. To access the survey and discussion paper, visit www.health.gov.au
In addition, the Group is holding a series of public meetings in major cities and regional centres around the country, and will host a nationwide webcast on 21 August.
It is due to present its final report to the Government by the end of the year.
Adrian Rollins
Emergency: real stories from Australia’s emergency department doctors
Edited by Dr Simon Judkins, 2015, Penguin Random House, RRP $32.99, 260 pages
Review by Adrian Rollins, editor, Australian Medicine
It’s not surprising so many television dramas are set in hospital emergency departments, where life is portrayed at being lived at an intensity well beyond the norm.
In this celluloid world, every day is filled with raw human emotions, adrenaline-pumping action, wrenching life-and-death decisions, and a heady mix of tragedy and triumph against the odds.
This may be one of the rare instances where reality matches – and in some cases, exceeds – the imagination of the dramatists.
In Emergency, 26 physicians give outsiders an intriguing glimpse into what it really means to be on the medical frontline.
In well-crafted and frequently moving accounts, they relay both the what of the job – retrieving everyone from toddlers to octogenarians from the brink of death – and its consequences: the lasting emotional effects of these experiences, which are often pushed to one side in the heat of the moment, but resonate loudly in the all-too rare moments for quiet reflection.
Take the story of the emergency doctor dangling over the edge of a conveyor belt to comfort a trapped worker whose legs have been crushed and amputated in a garbage compactor.
Or the physician who finds himself wading through puddles of blood to treat a stream of bullet-riddled gang members brought to hospital from the badlands of Cape Town.
Or the gut-wrenching realisation for a resuscitation team that, despite their herculean efforts, they have been unable to revive a two-year-old who strangled herself playing with a cord dangling from the blinds above her bed.
The stories in the collection traverse the breadth and depth of emergency medicine practice.
Readers are transported from major Australian city hospitals to the PNG highlands, to Uluru, Sydney Harbour and bleak industrial estates.
They witness the exhilaration that comes from saving a life, and the trauma that can accompany losing one.
They also get a glimpse into the challenges of practising this exacting craft – the marathon hours, the high levels of stress, the frustrations caused by inadequate resources, the seemingly endless demand for help, and the lack of time and space to reflect.
But what shines through, and what television scriptwriters tend to overlook, is the commitment to patients that overwhelms all else.
It is what drove Dr Mark Little to try just one more time after 75 minutes of failed attempts to revive a 60-year-old builder who had suffered a cardiac arrest – this time to succeed.
It is apparent in the tortured reaction of staff to the death of a toddler, despite their valiant attempts.
“This is fucked,” Dr Judkins recalls one nurse saying. “Why does this happen? This is not right.”
“This is why we do the job,” he responds, articulating his philosophy that, while they were unable to save this particular life, they had the skill to save others, “and that’s incredible”.
AMA Vice President Dr Stephen Parnis, an emergency physician in Melbourne, says it is not just about saving lives.
Relating the experience of advising and supporting a favourite uncle during a four-year battle with bile duct cancer, Parnis reflects that some of the most rewarding aspects of the job come from caring for the dying: “To ease their anxiety and pain, to calm their fears, to share that time with them, is a privilege”.
Practising emergency medicine is not for everyone, and the risk of burnout can be high.
The hours are long and often unsociable – after all, medical emergencies can happen any time – and the demands can be relentless.
But it is clear that for those who shared their experiences in Emergency, the connection with patients, the chance to save lives – or, on occasion, to ease death – and the satisfaction that comes from working as part of a well-drilled team, more than make up for these inconveniences.
[Series] Nuclear disasters and health: lessons learned, challenges, and proposals
Past nuclear disasters, such as the atomic bombings in 1945 and major accidents at nuclear power plants, have highlighted similarities in potential public health effects of radiation in both circumstances, including health issues unrelated to radiation exposure. Although the rarity of nuclear disasters limits opportunities to undertake rigorous research of evidence-based interventions and strategies, identification of lessons learned and development of an effective plan to protect the public, minimise negative effects, and protect emergency workers from exposure to high-dose radiation is important.
[Perspectives] Koichi Tanigawa: a passionate voice in radiation disaster medicine
On March 11, 2011, when a force 9 earthquake and subsequent tsunami hit the Japanese east coast near Fukushima, Koichi Tanigawa was 900 km away in Hiroshima. But not for long. As the then Chairman of Hiroshima University’s Department of Emergency and Critical Care Medicine, and also Deputy Director of its Radiation Medicine Centre, he found himself with a key part to play in subsequent events. His institution had been designated a tertiary centre for dealing with major disasters, and within 2 days Tanigawa had been flown to Fukushima as leader of the radiation emergency medical team.
AMA in the News – 4 August 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
Patients set to pay in Medicare impasse, Courier Mail, 21 July 2015
AMA President Professor Brian Owler warned there would be a sharp rise in the number of visits in which patients would be hit with out-of-pocket fees unless the Government lifted its freeze on Medicare rebates.
AMA calls for no GST on GP visit, Courier Mail, 22 July 2015
Patients face paying GST on doctors’ visits if the tax is broadened. AMA President Professor Brian Owler called on the Government and the states to rule out broadening the GST to include health care.
Medibank blasted for cost-cutting, The Age, 23 July 2015
AMA President Professor Brian Owler warned Australia was heading toward a US-style health care system, saying the cost-cutting behaviour of private insurance giant Medibank was offensive.
Medibank’s offensive stand lacks insight: AMA head, Australian Financial Review, 23 July 2015
AMA President Professor Brian Owler said Medibank Private’s hardball negotiating demands are offensive and misunderstand the motivations of health professionals. Professor Owler said one of the highly preventable adverse events that Medibank has said it would not pay for was maternal death associated with childbirth.
GPs could have seen to hospital visits: survey, The Australian, 24 July 2015
Almost a fifth of emergency department visits by the elderly are for problems that could have been managed by their GPs. AMA Vice President Dr Stephen Parnis said it was hard to differentiate when the best care should be provided by a primary care physician or an emergency department.
AMA President’s wrong diagnosis on budgets, The Australian, 28 July 2015
AMA President Professor Brian Owler is calling for an urgent recognition of the costs of providing high quality care. Professor Owler told the National Press Club it was not the AMA’s job to say where the funding should come from.
Medibank Private ready for scrap with hospitals, Weekend Australian, 25 July 2015
Medibank Private is ready for a long battle with private hospitals. AMA President Professor Brian Owler said negotiations between hospitals and private insurers had become increasingly aggressive and he warned that Medibank’s patients would no longer be fully covered for treatment in a Calvary hospital.
Radio
Professor Brian Owler, 2UE Sydney, 21 July 2015
AMA President Professor Brian Owler talked about health funding. Professor Owler said that, when it comes to public hospital funding, the states and territories are the ones that have the responsibility to get the job done, but they rely on Commonwealth funding.
Professor Brian Owler, 2GB Sydney, 22 July 2014
AMA President Professor Brian Owler talked about the dispute between the AMA and Medibank Private. Professor Owler said that Medibank Privates decision to list 165 conditions for it will not provide insurance cover was not common practice.
Professor Brian Owler, 2UE Sydney, 23 July 2014
AMA President Professor Brian Owler discussed Medibank wanting to change its maternity coverage so that if the mother dies during child birth they don’t have to pay. Professor Owler said it was “offensive” that anyone could think that a financial penalty was needed to motivate hospital staff to prevent deaths during child birth.
Dr Stephen Parnis, 5AA Adelaide, 27 July 2015
AMA Vice President Dr Stephen Parnis discussed alcohol advertisements. Dr Parnis said foetal alcohol syndrome was a serious problem in Australia and that sometimes warning labels on packaging were used as an excuse for not taking more significant action.
Television
Professor Brian Owler, ABC, 22 July 2015
Acknowledging the political and economic realities that confront governments, AMA President Professor Brian Owler outlined the practical, affordable, and achievable policies and actions that the AMA believes will best serve the health needs of the Australian population.
Foreign aid cuts a health disaster for many
As a final-year medical student, I am the first person to admit that I’ve been very fortunate so far in life.
Most of these blessings are facets of our rich, first-world society – free, high-quality health care and cheap tertiary education, not to mention the basics that I take for granted every day like somewhere to live, food and clean water.
Sometimes, though, it can become easy to forget two things. Firstly, I did nothing to deserve these blessings. Secondly, billions of people around the world are less privileged than I am. For these reasons, I am thoroughly disappointed in the $1 billion cuts to foreign aid announced in the recent Federal Budget.
Under the previous Labor government, Australia had a bipartisan commitment to contribute 0.5 per cent of its Gross National Income (GNI) to foreign aid, though this was delayed several times.
Little did we know at the time that the 0.38 per cent of GNI level reached at the time Labor left office would be the peak.
Since then, a succession of major Budget cuts by the Coalition Government have driven to our foreign aid contribution down to the point where we are now only giving 0.22 per cent of our GNI.
These cuts fly in the face of the 0.7 per cent of GNI commitment Australia agreed to at the UN in 1970, and which has been repeatedly reaffirmed ever since.
Meanwhile, our counterparts in the UK have recently passed a Bill legally ensuring that they will continue to give at least 0.7 per cent of GNI as aid.
Doctors and medical students alike should be unequivocally outraged.
Our profession is one in which we are privileged to have the opportunity to help people each and every day.
In medical school, we are taught that it is essential to be an advocate for our patients, especially those who have no voice. We must apply this principle to the people of the developing world and fight for effective altruism.
The recipients of Australia’s development assistance have no real means by which to communicate their needs with our government, but doctors can take up this mantle. Of course, various advocacy groups are already doing this. However, it is clear that current efforts are inadequate.
We need to face the facts – these aid cuts will equate to lives lost. Real people with families will die. Australia’s foreign aid provides vital health services in developing countries, as well as emergency assistance to other countries when disasters strike, such as the recent earthquakes in Nepal.
If Australia, one of the most economically developed countries in the world, refuses to provide these funds to countries in our region, who will?
We tend to forget it, but giving aid also benefits us.
Along with the obvious advantages of diplomatic relations associated with generous aid, Australia should leverage its expertise as a leader in tropical diseases to fight the epidemic of tuberculosis in Papua New Guinea, or else the consequences might spread to our shores. Instead of diverting our aid money to offshore detention programmes for refugees, we should invest in developing countries to alleviate poverty and assist displaced people whose lives have been torn apart.
It is the responsibility of doctors to advocate for not only the health outcomes of Australian citizens, but those individuals without the good fortune to be born within our sunny borders. Foreign aid is an essential component of Australia’s contribution to global health and wellbeing, and must be consolidated rather than compromised.
Nicky Betts is a final year medical student at the University of Western Sydney, and Vice-Chair External of AMSA Global Health.[1] [2] [3] [4] [5]
News briefs
Inhaled Ebola vaccine stops virus in monkeys
The New York Times reports that a single dose of a new, inhalable Ebola vaccine has neutralised the virus in monkeys. The study, conducted by University of Texas researchers, was published first in the Journal of Clinical Investigation. Four rhesus macaques were given one aerosol dose, four were given two aerosol doses and two were given the vaccine in liquid form. Two were not vaccinated, serving as controls. Four weeks after treatment, all the monkeys were given a dose of Ebola, 1000 times the fatal dose. A week later, the two unvaccinated monkeys died but the vaccinated animals remained healthy. The survivors were euthanised and their blood and tissues showed no sign of Ebola. The next step is for the National Institutes of Health to perform clinical trials on humans.
New CEO for Medical Deans is Carmel Tebbutt
Former New South Wales cabinet minister Carmel Tebbutt has been announced as the new chief executive officer of the Medical Deans Australia and New Zealand. She will replace incumbent Professor Judy Searle, who is retiring from the role after 2.5 years. Ms Tebbutt starts in the position on 19 October. She spent 11 years as a minister and senior member of the Cabinet in the NSW Parliament, with portfolio responsibilities across a number of areas including education and training, health, community services and the environment. “There are many challenges confronting medical education and research. I am looking forward to using my skills to forward the objectives of the Medical Deans”, Ms Tebbutt said. “One of my first tasks will be to meet with members and stakeholders to hear first-hand about the key issues for the sector.”
Tax on soft drinks: it’s working in Mexico
Health economists at the University of North Carolina in the US have studied Mexico’s 18-month-old “soda tax” and found that it is reducing consumption of sugar-heavy drinks in the country where annual consumption tops out at 163 litres per person, Wired reports. The one-peso-per-litre tax has caused a drop in consumption of an average of 6%, according to the researchers. “The decline accelerated as the year went on, reaching 12 percent by December [2014].” With plans to increase the tax to two pesos per litre, the results show that it was the poorest Mexicans who cut back on soda the most, averaging a 9% decline and peaking at 17%. Consumption of bottled water increased by 4% in the same time period. “A soda tax alone is not going to solve the entire obesity and diabetes epidemic”, the researchers concluded. Still, it might help “shift people’s mindset about these beverages. They’re not innocent”.
http://www.wired.com/2015/07/mexicos-soda-tax-working-us-learn
Non-invasive device could end finger pricking for people with diabetes
Science Daily reports on a new low-powered laser sensor that monitors blood glucose levels without penetrating the skin. Developed by a team at the University of Leeds in the UK, the device “has continuous monitoring capabilities making it ideal for development as a wearable device”. It could also be a simpler and cheaper alternative to the two current methods — finger pricking, using disposable sample strips, or invasive continuous monitors using implanted sensors that need regular replacement. “This technology opens up the potential for people with diabetes to receive continuous readings, meaning they are instantly alerted when intervention is needed. This will allow people to self-regulate and minimise emergency hospital treatment,” the researchers said.
http://www.sciencedaily.com/releases/2015/07/150714200110.htm
Retracted papers cited years after withdrawal
Retraction Watch reports that disgraced American anaesthetist Scott Reuben’s retracted papers are still being cited 5 years after retraction, and only 25% of those citations correctly acknowledge the retraction, according to a new study, published in Science and Engineering Ethics. Reuben, who fabricated data, spent 6 months in prison in 2009, and has now accumulated 25 retractions. In the new paper, the authors counted 274 citations of 20 of Reuben’s papers between 2009 and 2014, 45% of them more than once. “Our paper shows that perpetuation of retracted publications is still an ongoing problem in our scientific community… In addition, we could demonstrate that, despite the overall number of citations of retracted publications decreasing over the years, the percentage of correctly labeled citations dropped even more.”
[Correspondence] Legal preparedness and Ebola vaccines
On Dec 9, 2014, US Secretary of Health and Human Services Sylvia Burwell issued a declaration1 under the US Public Readiness and Emergency Preparedness Act to provide immunity from legal claims in the USA related to manufacturing, testing, development, distribution, and administration of three candidate Ebola vaccines except in instances of wilful misconduct. Although progress in combating Ebola in west Africa has shifted public attention away from vaccine development and deployment, we should not forget that the management of legal liabilities related to vaccines has been an important subject of discussion between national governments, international organisations, vaccine manufacturers, and other parties who have been engaged in the worldwide response to the Ebola outbreak during the past year.
AMA in the News – 21 July
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
Doctors, teachers face gags under immigration laws, Sydney Morning Herald, 4 June 2015
Doctors and teachers working in immigration detention facilities could face up to two years in prison if they speak out against conditions in the centres or provide information to journalists. AMA President Professor Brian Owler said this was the first time doctors had been threatened with jail for revealing inadequate conditions.
Medical research fund could be ‘slush’ fund: Labor, The Age, 5 June 2015
The Abbott Government could raid its Medical Research Future Fund to pay for election promises and “pet projects” under proposals before federal Parliament, Labor has claimed. AMA President Professor Brian Owler said decisions about which research projects would be funded needed to be made at arm’s length from the minister.
Help for violence victims, Northern Territory News, 5 June 2015
A new resource to assist doctors in providing better support for victims of family violence was launched by the AMA at the AMA National Conference. AMA President Professor Brian Owler said the medical profession had a key role to play in the early detection, intervention and treatment of patients who has experience family violence.
Experts fear flu season shaping as the worst on record, The Saturday Age, 6 June 2015
The first five months of 2015 have been the worst on record for influenza, with experts warning Australia could be in for a rotten flu season. AMA Chair of General Practice Dr Brian Morton said Australia tended to follow the northern hemisphere’s flu season, which had been severe due to the emergence of new flu strains.
Banned flu drug still being given to children, Sunday Mail Brisbane, 7 June 2015
A disturbing number of doctors have ignored multiple warnings against administering the flu vaccine Fluvax to children younger than five years, even though there are safe alternatives. AMA President Professor Brian Owler said this risked undermining an otherwise safe vaccine schedule.
Leaked trade deal terms prompt fears for Pharmaceutical Benefits Scheme, The Guardian, 11 June 2015
The leak of new information on the Trans-Pacific Partnership agreement (TPP) shows the mega-trade deal could provide more ways for multinational corporations to influence Australia’s control of its pharmaceutical regulations. AMA president Professor Brian Owler said while doctors were very concerned at the possible effects on Australia’s health care system, their fears were routinely dismissed by Trade Minister Andrew Robb.
Save the planet for better health, The Canberra Times, 24 June 2015
The biggest boost to public health this century could come from action to tackle climate change, such as shutting down coal-fired power plants and designing better cities, according to a Lancet Commission report. AMA President Professor Brian Owler said the Australian health system was not prepared for climate change.
‘Whistleblowers’ challenge Australia’s law on reporting refugee conditions, CNN, 2 July 2015
More than 40 doctors, nurses, teachers, and other humanitarian workers have signed an open letter to the Australian government, challenging a new bill that could put whistleblowers in jail for disclosing the conditions of Australian detention centres. AMA President Professor Brian Owler said the act puts doctors in a dilemma when treating detainees and asylum seekers if they have concerns about the provision of their health care.
Medibank dust-up sparks care debate, The Saturday Age, 11 July 2015
AMA President Professor Brian Owler said the contract clauses being pushed by Medibank Private that put financial risk for unplanned patient readmissions and preventable falls back on private hospitals are evidence the newly listed market leader has shifted its priority to shareholders.
Radio
Professor Brian Owler, 666 ABC Canberra, 28 May 2015
AMA President Professor Brian Owler talked about the issues surrounding the bulk billing of GPs. Professor Owler said a doctor can bulk bill and this means they can accept the amounts from Medicare.
Dr Brian Morton, 5AA, 3 June 2015
AMA Chair of General Practice Dr Brian Morton discussed medicines on the drug subsidy scheme will rise in price on July 1. Dr Morton said that any medicine that currently costs consumers less than $36 will be hit by the rise.
Professor Brian Owler, 702 ABC Sydney, 4 June 2014
AMA President Professor Brian Owler talked about Medicare. Professor Owler said there have been a number of reviews but, these have never really been dealt with the schedule as a whole.
Professor Brian Owler, ABC Classic FM, 11 June 2014
AMA President Professor Brian Owler discussed health issues including the “Don’t Rush” road safety campaign, neurosurgery, and vaccinations.
Dr Brian Morton, 3AW, 29 June 2015
AMA Chair of General Practice Dr Brian Morton talked about issues with Dr Google. Dr Morton said it could be beneficial when trying to understand a treatment a patient is undergoing.
Professor Brian Owler, 612, 13 July 2015
AMA President Professor Brian Owler discussed diabetes in Australia. Professor Owler said the majority of type 2 diabetes cases were preventable and encouraged people to eat healthier food and get regular exercise.
Television
Prof Brian Owler, ABC Brisbane, 29 May 2015
The AMA has warned that doctors’ fees could go up if the freeze on Medicare rebates for GP visits continues, and that even patients with private health insurance could end up paying more
Prof Brian Owler, Channel 9, 31 May 2015
A new online tool to help doctors identify and respond to family violence has been rolled out. The resource launched by the AMA allows doctors to provide information on support services.
Dr Stephen Parnis, Channel 7, 13 June 2015
AMA Vice President Dr Stephen Parnis discussed warnings Victoria was on the verge of a whooping cough epidemic. Dr Parnis said deaths from whooping cough were not common but were entirely avoidable.
Dr Brian Morton, Channel 10, 20 June 2015
AMA Chair of General Practice Dr Brian Morton warned of a spike in emergency department admissions, with the price of some of the most common Pharmaceutical Benefits Scheme prescription medications set to rise.