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Preference: Emergency Medicine

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US doctors want to ban assault weapons

American doctors have called for a ban on the sale and ownership of all assault-type weapons.

The American Medical Association voted in June to amend its policy on firearms, resulting in the United States’ biggest doctors group taking a stance against gun violence.

The AMA declared it to be a public health emergency.

The Association also raised the issue of bump stocks, which basically turn semi-automatic firearms into automatic ones, saying sale of them should be prohibited.

And it called for an end to the sale and ownership of high-capacity magazines and armour-piercing bullets. 

The AMA also supports laws to require all firearms to be registered, to ban sales of guns to people under the age of 21, to make it illegal for anyone found of guilty of domestic violence to be in possession of a gun, and to keep schools gun-free zones.

Debate on all of the issues was reported to be contentious, with delegates who were gun owners wanting more time to review the language used in the resolution. 

But the delegation voted overwhelmingly in favor of the ban on assault weapons resolution, 446 to 99.
In America this year alone, more than 6,300 people have died from gun violence.

CHRIS JOHNSON 

 

[Comment] Troponin assays: developing indications

Cardiac troponin assays were introduced into clinical practice in 1995 for the diagnosis of acute myocardial infarction. Originally, this assay could not help to reliably rule out myocardial infarction until about 12 h after symptom onset. Consequently, there has been a drive to develop more sensitive and reliable troponin assays that would facilitate an earlier exclusion of myocardial infarction, ideally in the emergency department.1–3

Mr Hunt, are we there yet?  Continuing the public hospital funding journey

BY DR RODERICK MCRAE, CHAIR, AMA FEDERAL COUNCIL OF PUBLIC HOSPITAL DOCTORS 

By the time of this column’s publication, we may have had some further information from the Federal Minister for Health Greg Hunt, at the AMA’s National Conference, although the Budget is pretty fresh. We know public hospitals are fundamental to Australia’s overall health system, dealing with greater than six million admitted patient care episodes and around 92 per cent of emergency admissions in any one year. Nonetheless, we experience chronic under-funding partially because of near stagnant growth in financial support. This has been going on for just too long; we all feel the pressure day in, day out.  We know under-funding is building to crunch point.

AMA’s 2018 Public Hospital Report Card shows bed numbers per 1000 population are static; performance, basically, is plateauing at best; waiting lists, you know the sorry truth about that and our patients are suffering!  My December 2017 Australian Medicine column criticised the Council of Australian Government’s (COAG) savage imposed financial penalties where avoidable re-admissions or hospital-acquired complications are deemed to have occurred. The AMA’s 2016 Safe Hours Audit shows that in public hospitals, 53 per cent of doctors are at “significant risk” of fatigue with dangerous fatigue levels being reported across a raft of specialty groups.

So, the effect of underfunding is cumulatively adding up to seriously affecting our, and the system’s, ability to perform optimally for our patients, and our own health and wellbeing is at stake. That’s why the 2018 Budget decisions matter; it’s about what the future holds for public hospital medicine. Without vital new investment, required infrastructure, and human resource capacity, an appropriate standard of result cannot happen.

Reflecting on AMA’s pre-budget submission, what we have said is that the Budget must fully fund, for the medium to long term, internal capacity building and expansion of their integrated care responsibility.  Not to penalise an already underfunded sector via that sneaky COAG device that will redirect otherwise committed funds.  The AMA also says States and Territories must be fully compensated for any loss in private patient revenue and any funding decisions must not dilute support for patients electing private treatment. Mr Hunt has said he intends to look at these private patient issues so we don’t yet know where Government is headed.

Despite the known pressure on public hospitals the new 2020-25 Hospital Funding Agreement ratchets up this financial pressure on hospitals even further. Within existing levels of Federal funding, the Agreement will require public hospitals to implement new measures to cut waste, increase productivity and extend their responsibilities to engage in the care of chronically ill-patients post discharge to reduce overall admissions.

I agree integrated care is essential – but this work requires new Federal funding to pay for the hospital and primary sector resources required to deliver it. The public hospital funding in the 2018 Federal Budget was nothing more than the amount forecast over the forward estimates to maintain funding at current levels. 

There are many laudable new funding initiatives out of this Budget, to name some: a rural doctor workforce/training package, increased support for aged care in the home, and mental health/suicide prevention services, new research investment and (perhaps laughable!) the “unfreezing” of Medicare indexation. However, the Budget lacks consideration of how any savings from the Government’s yet to be finished MBS reviews will be re-invested into public health, and we still wait on needed big structural reform. There must also be funds to urgently begin development of a national medical workforce strategy.  On that, your Council of Public Hospital Doctors is working through the AMA to encourage all jurisdictions to cooperate more closely in their planning and coordinating of our future medical workforce to meet Australia’s future healthcare needs.

There’s an election coming; maybe this year; and Labor has promised an additional $2.8 billion ‘better hospitals’ fund to target reducing elective surgery waiting times and increasing emergency department bed numbers. Your CPHD will be looking to score both major parties as they release more health policy and keep a watching on eye on any moves to change public hospital private practice arrangements. We must push for the government to match Labor’s pledge and make Government fund for growth, not just, as it has been, keeping pace with activity. It’s matching funding with growth and having a workforce plan that really matters!

Seriously (and hilariously) scarred for life

THEATRE

BY DR SUE BELPERIO

When our perennially accident-prone son was 21, he fell off his pushbike while riding to an important musical workshop at the Adelaide Festival Theatre. He had not a scratch on his body, and his vital signs were entirely stable, so it was not immediately obvious to either parents, both anaesthetists, that anything was seriously wrong.

His only complaint was a slightly sore left shoulder. After a few hours with a painless soft abdomen and totally normal observations, he suddenly became acutely pale, and peripherally shutdown. With outward calm and inward terror, I dialled 000 and was placed on hold.

Despite the assistance of his brother and partner, he collapsed while we attempted to get him into the car. It wasn’t until we had laid him out supine in the back of my car that I was taken off hold from 000. Knowing what a life and death situation this was, I decided to make the five-minute dash for the nearest hospital, St Andrew’s, rather than explain my probable diagnosis to the ambulance and then wait for an uncertain period of time for one to materialise.

Upon arrival, his blood pressure was still normal and the accident and emergency specialist told me that he suspected a vasovagal. Holding up his pale cold fingers, I implored them to consider a ruptured spleen, and as such, was granted an abdominal CT scan just to ‘reassure’ me. The rest is history.

Our son had behaved like a child with shock, which obscured the gravity of his situation to the adult emergency physicians. He was then retrieved to the trauma centre at the Royal Adelaide Hospital, where additional resuscitation occurred. On the brink of total cardiovascular collapse, with a rapidly rising pulse rate, he finally made it into theatre about five hours after the accident. He underwent a three-hour laparotomy followed by a splenic embolisation to stop the ongoing bleeding. This was not the type of theatre he was supposed to be in that day!

Devastated that he had missed his festival theatre event, and being a consummate composer with a degree in Composition, he did the only sensible thing he could: From his ICU bed, he asked for a notebook and pencil, and he started jotting down ramblings and documenting his journey throughout the entire hospital experience and beyond.

The result was a cabaret show, Scarred For Life, which premiered at the 2017 Adelaide Cabaret Fringe, receiving three five star reviews. The show then returned to the 2018 Adelaide Fringe Festival where several more five star reviews were garnered, followed by the Adelaide Fringe Best Cabaret Award for Week Three. Josh’s show even earned the attention of Andrew Bolt, who summed it up with “Man Falls Off Bike, Becomes Star”.

However, the real as yet untapped audience for this show lies with the medical and nursing professions, who need to hear about this patient experience. Josh’s physical and psychological scars are laid bare along with his soul in an hour of original music and lyrics “that is equal parts Minchin and Mozart” (Scenestr).

Now, Scarred For Life is travelling to Melbourne, for two shows only on August 4 at Chapel Off Chapel. Here, Josh’s show becomes act one, and he teams up with talented local Melbourne performers Damon Smith and Adam Coad who present their original show Mental As Everything as the second half of the evening’s complementary entertainment. Both showcase physical and mental health, and both are funny and poignant. “Inspiring, heartwarming and exactly what a night at the theatre should be!” (Glam Adelaide).

Don’t miss this one-off opportunity, a must-see for the medical and nursing professions: bookings via Chapel Off Chapel live link:

https://chapeloffchapel.com.au/show/mental-as-everything-scarred-for-life-double-bill/ or phone 03 8290 7000.

Produced by Under The Microscope Theatre, further enquiries to matthew@underthemicroscopetheatre.com

 

Pic: Wilson and Lewis Photography

 

 

 

 

[Comment] Emergency deployment of oral cholera vaccine for the Rohingya in Bangladesh

Cholera is a threat to vulnerable populations caught in humanitarian emergencies.1 WHO has recommended that inactivated oral cholera vaccines (OCVs), in conjunction with provision of appropriate rehydration therapy, clean water, and sanitation, be considered for use in humanitarian and emergency settings at high risk for cholera.2 Since 2013, inactivated vibrio whole cell OCVs have been made available for deployment from a global OCV stockpile, funded by Gavi, the Vaccine Alliance, which is intended for cholera control in outbreaks, humanitarian crises, and settings with endemic cholera.

Candidate profile – Dr Gino Pecoraro  MBBS FRANZCOG

Nominating for the position of AMA President

My name is Dr Gino Pecoraro and I’m asking for your vote in the AMA National Presidential election.

Australia’s stressed healthcare system needs an upgrade. The ideal time for change is now, with Government reviewing the MBS and private health insurance value and affordability.

Our largely State-funded public health facilities are struggling to meet increasing demand and need ongoing additional funding. Private sector access is increasingly more expensive with non-indexed Medicare and PHI rebates causing greater out of pocket costs. 

Some form of indexation (ideally one supported by the AMA) must be embedded in legislation. In this way, rebates can start to reflect the true cost of accessing services and keep medical care affordable.

Ensuring our GPs are adequately paid will help them give patients the time needed to deliver quality care and disease prevention. Ultimately, this will keep patients out of already crowded hospitals and save the health system money.  

Similarly, PHI providers need to understand that their moves towards managed care models will not be tolerated and that patient choice of doctor and hospital must be protected in all policies.

Decreased demand for public hospital outpatient and inpatient services means money can be redirected to other areas e.g. emergency department waiting times and chronically underfunded mental health services.

Medical student numbers have radically increased without an increase in the number of postgraduate training positions. No more medical schools are needed. What students and doctors-in-training really need are an increase in the number of fully-funded postgraduate training positions. These positions need to be in the disciplines and locations where shortages exist. Relocation support needs to be provided for these doctors and their families. 

The AMA President is expected to be the public face of the organisation and deliver our members’ policies to parliamentarians, the medical profession and the general public. 

My extensive experience in medical politics is what makes me the best candidate, and includes:

  • Senior roles with RANZCOG (Council, Board and Examinations);
  • Ongoing association with the University of Queensland;
  • 2010 Queensland AMA President and Board Member; and
  • Current Federal Council representative for Obstetrics and Gynaecology.

I have been instrumental in the Federal Council’s formation of the Council of Private Specialist Practice, developed to serve a previously underrepresented part of our membership. I have acted on the AMA’s behalf to put a stop to the National Maternity Services Framework, which had been formed without a single doctor on the committee. I continue to represent the AMA on multiple Government committees.

An AMA President must be an effective communicator. I’m a seasoned media performer with 25 years’ experience encompassing print, radio, television and online platforms.

I continue to write columns for newspapers and magazines as well as having produced and presented State and national television shows. I have experience in live breakfast, drive and talkback radio.

My eight years’ experience on Federal Council means I fully understand the workings of both our organisation and the Government departments we seek to influence.

* See other candidate profiles on this site. 

 

 

Health Budget steady as she goes

The AMA has labelled the 2018-19 Health Budget as “safe and steady”, but adds that it is notable as much for what is not to be found in it as it is for what is included.

Treasurer Scott Morrison has delivered a Federal Budget with an eye on the next federal election, promising tax relief for middle Australia, significant infrastructure investment and more funding for aged care.

On the health front, the establishment of a new 21st century medical industry plan to create more jobs and support more medical research projects is a major commitment.

This Budget includes an extra $1.4 billion for listings on the PBS, including medicines to treat spinal muscular atrophy, breast cancer, refractory multiple myeloma, and relapsing-remitting multiple sclerosis, as well as a new medicine to prevent HIV.

The Government will also provide $154 million to promote active and healthy living, including $83 million to improve existing community sport facilities, and to expand support for the Sporting Schools and Local Sporting Champions programs.

It has dismissed a proposal for a single and separate Murray Darling Medical School, in favour of a network, in what AMA President Dr Michael Gannon has described as a better approach. 

Mr Morrison said the plan was to get more doctors to where they are needed through a new workforce incentive program.

“This plan includes the establishment of a new network of five regional medical schools within the broader Murray Darling Region,” Mr Morrison said when delivering his Budget Address to Parliament on May 8.

Dr Gannon said many of the rural health initiatives outlined in the Budget are a direct response to AMA rural health policies and the AMA Budget Submission.

“We welcome the Government’s strong focus in this Budget on improving access to doctors in underserviced communities, particularly rural Australia,” Dr Gannon said.

“The decision to reject the proposal for a stand-alone Murray Darling Medical School, in favour of a network, is a better approach with the Government instead pursuing a policy that builds on existing infrastructure to create end-to-end medical school programs.

“However, while the Government has made a welcome commitment not to increase Commonwealth-supported medical school places, it has taken the unnecessary step of compensating medical schools with additional overseas full-fee paying places.

“This will not address community need, and instead simply waste precious resources.”

Dr Gannon said overall, the Government had delivered a safe and steady Health Budget, which outlines a broad range of initiatives across the health portfolio.

Necessary funding to aged care, mental health, rural health, the PBS, and medical research, were all welcome commitments.

“But some of the bigger reforms and the biggest challenges are yet to come,” he said.

“Due to a number of ongoing major reviews, this Budget is notable as much for what is not in it as for what is in it.

“The major reviews of the Medicare Benefits Schedule (MBS) and private health are not yet finalised, and the ensuing policies will be significant.

“We are pleased that indexation has been restored to general practice and other specialty consultations, but new and considerable investment in general practice is missing.

“Also, the signature primary care reform – Health Care Homes – did not rate a mention.”

Health Minister Greg Hunt described the Budget as a “record investment in health” and pointed to a previously announced commitment from the Federal Government to public hospitals.

“The Government will deliver more than $30 billion in additional public hospital funding under a five-year National Health Agreement, with funding increasing for every State and Territory, every year,” Mr Hunt said.

But Shadow Health Minister Catherine King said the Budget failed the health test.

The Government was persisting with a plan to cut $715 million from hospitals over the next two years, she said.

“Their hospital cuts are putting doctors, nurses and hospital staff under increasing pressure; forcing delays in surgeries; and making emergency department waiting times even worse,” Ms King said.

CHRIS JOHNSON

 

 

 

 

 

 

 

 

Excerpts from Treasurer Scott Morrison’s Budget Speech 2018-19

Our national economy is strengthening, but it is also true that the benefits are yet to reach everyone. This will take more time. That is why it is important to stick to our plan. There is more to do. We cannot take a stronger economy for granted. We live in a very competitive world. If we make the wrong calls, other countries will ‘cut our lunch’. There is a lot to gain and much to lose. We can’t ease off.

***

In this year’s Budget there are five things we must to do to further strengthen our economy to guarantee the essentials Australians rely on.

  1. Provide tax relief to encourage and reward working Australians and reduce cost pressures on households, including lowering electricity prices,
  2. Keep backing business to invest and create more jobs, especially small and medium sized businesses,
  3. Guarantee the essential services that Australians rely on, like Medicare, hospitals, schools and caring for older Australians,
  4. Keep Australians safe, with new investments to secure our borders, and, as always,
  5. Ensure that the Government lives within its means, keeping spending and taxes under control.

That’s our plan.

***

Tonight we announce a new 21st century medical industry plan to create more jobs in this fast growing sector of our economy. The health sector represents 7 per cent of our economy and 14 per cent of jobs. Our plan will provide more support for medical research projects, new diagnostic tools, clinical trials of new drugs, scientific collaboration, and development of new medical technologies that can be sold overseas. In particular we will back in Australian medical scientists through the largest single investment of the Medical Research Future Fund to date of $500 million over ten years for Australia to become a world leader in genomic research. This is about building another strong and competitive industry in Australia that will generate income and jobs, from the white coats in the labs to the workers making new medical devices on the shop floor.

***

In rural and regional areas we have funded a plan to get more doctors to where they are needed through a new workforce incentive program. This plan includes the establishment of a new network of five regional medical schools within the broader Murray Darling Region. And we have moved to guarantee rural and remote access to dental, mental health and emergency medical services through increased financial support for the Royal Flying Doctor Service. Indigenous Australians also benefit from our $550 million commitment to address remote housing needs in the Northern Territory and $1.7 billion through our primary health care model. Our veteran centric reform package will continue with a planned additional $112 million in this Budget, as will our support for ongoing veterans’ mental health and employment initiatives. Finally, every dollar and every cent committed to delivering the National Disability Insurance Scheme remains in place and always will.

***

Our new five year hospitals agreement, which is being signed onto by the States and Territories, will deliver $30 billion in additional funding, a one third increase over the previous five years. And following last year’s Budget, funding for Medicare and the Pharmaceutical Benefits Scheme or PBS has been guaranteed in legislation. This Budget includes an extra $1.4 billion for listings on the PBS, including medicines to treat spinal muscular atrophy, breast cancer, refractory multiple myeloma, and relapsing-remitting multiple sclerosis, as well as a new medicine to prevent HIV. Lifeline Australia will receive additional support as will funding for Mental Health Research, with $125 million over 10 years from the Medical Research Future Fund.

The Government will also provide $20.9 million to support parents and infants by funding tests for new conditions and ensure that debilitating conditions are picked up at the earliest opportunity. The Government will provide $154 million to promote active and healthy living, including $83 million to improve existing community sport facilities, and to expand support for the Sporting Schools and Local Sporting Champions programs.

***

Just because you are getting older does not mean you should have to surrender your dignity or your choices. We’re living longer. It’s a good thing. We want to preserve and increase the choices of older Australians. To support the choice of older Australians who wish to stay at home and avoid going into residential aged care the Government will be increasing the number of home care places by 14,000 over 4 years at a cost of $1.6 billion. By 2021-22, over 74,000 high level home care places will be available, an increase of 86 per cent on 2017-18. We will also be providing $146 million to improve access to aged care services in rural, regional and remote Australia. We will also provide $83 million for increased support for mental health services in residential aged care facilities, especially to combat depression and loneliness.

 

[Editorial] Austerity in Spain: time to loosen the grip

Calculating the health impact of a financial crisis and subsequent austerity measures is an inexact science. A new UN report, published on April 25, 2018, illuminates the repercussions on health care of the 2008 monetary crisis, state retrenchment, and the implementation of a royal decree in Spain, echoing findings of an earlier European Commission 2017 Country Health Profile. The consequences and patient perceptions of Spain’s emergency rescue package in the wake of the financial crash were also analysed in an Amnesty International document, published April 24, 2018.