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This weeks postcard comes from Rawene in the far north. Clare Ward ( FRNZCGP dist.; FDRHMNZ) been based in Hokianga, at Hokianga health, for almost 3 decades working across the primary secondary interface.
The end is where we start from
In Hokianga cultural memory is long and buried deep in the grain of its people. One hundred and two years ago there were mass graves and no ceremony as the flu epidemic reached and brought mortal sickness to our communities. Today there are memorial stones to mark these places.
Today we expect that one hole will hold the one who has succumbed to this new virus. We know that there will not be time for traditional tangihanga. We know that only one or two home people will be there to say farewell on behalf of the whole whanau community. We know that tears will fall in a hundred homes and there will be a sense of something incomplete.
Already in our hospital we have had one such farewell- not a victim of the infection itself but a casualty of the shadow it has cast over all of us.
Cultural memory has brought up the past and so it is not difficult to pass by a friend and know that the physical distance between us is a mark of the respect and manaakitanga we have for each other.
The past is always with us in the faces of this generation and this generation looks back and calls back to its ancestors and walks forward in the knowledge that it is possible to learn from that time in 1918 when what we knew and the ways in which we could respond were so much less.
As always we acknowledge that which is greater than we are
Noho ora mai I roto I nga ringa o Te Atua.
We are bringing you a ‘Postcards from the Edge’ series: short reflections from rural/remote settings around NZ and the region, which will make up the LOFP blog leader during the Covid pandemic. Our hope is that these will keep the rural remote voices loud and all of us connected and uplifted.
Instructions for those wanting to submit
Please send your reflections +/-photo for our Postcards from the edge series to firstname.lastname@example.org
We are looking for geographical and creative diversity to cover a broad swath of rural and remote health care in NZ and the pacific.
Maximum word count 400 , wll be strictly adhered to.
Please attach a photograph and/or artwork with your submission (or it might be your piece).
NB: it is unlikley that all submissions will be able to be published: please don’t be offended if it doesn’t make it.
The birds are louder this week
Ending the first week of the COVID–19 proper, although still feels like a prelude. We have done a lot of talking. So many emails. Not many patients.
At least two cases of COVID–19 confirmed pneumonia have been admitted to a rural hospital. A DHB freaked out. Interesting. Sanity prevailed after several hours. The patient stayed for a few days. The patient deteriorated and was transferred. This went smoothly. Suprising.
People have stopped coming to hospital. Seemingly unnecessary investigations have stopped – this seems to have been accepted by patients. Interesting.
Some DHBs have become more helpful and communicative. Some are visiting rural health services, some are building negative pressure rooms. Most are talking to us and some are listening. Others…
The birds are louder this week
The kids are at home. Our bubble is huge. It still hasn’t rained.
The city seems to have come to the beach for a ‘holiday’. Anxiety over how we will cope if they get sick. DHBs didn’t make a statement. Mayoral pleas didn’t make the mainstream media. Road blocks and dynamite?
The are birds are louder this week
Maybe it will rain tomorrow…. I hope we stayed home early enough.
Associate Professor Garry Nixon, Department of General Practice and Rural Health, University of Otago, comments:
“Rural communities will be more vulnerable to the impact of Covid–19. This is because the residents of rural towns are on average older, have a lower socioeconomic status, are more likely to be Māori, have poorer health status, and less access to health services, than urban dwellers.
“Rural indigenous communities may be particularly at risk around the world. We know for example the swine flu epidemic hit rural aboriginal communities very hard, and rural Māori communities suffered considerably in the 1918 ‘Spanish flu’ pandemic.
“Only a handful of patients have so far needed hospital admission in New Zealand but at least two of these have been admitted to small rural hospitals. This is potentially a significant problem for three reasons:
- Rural hospitals lack ‘surge capacity’. They are largely driven by acute need and are often at capacity in the winter months and they do not have outpatient clinics or elective surgery that can be cancelled in order to create urgent additional capacity.
- The majority of rural health services are chronically understaffed and are often heavily reliant on locums.
- Because of the infection risk, very unwell Covid–19 patients are difficult to safely transfer from a rural to a base hospital.
“The isolation and low population density of rural towns may help but the large numbers of tourists will increase spread. The Coromandel Mayor has urged people not to use their bach for isolation – with the Rural GP Network saying their health services won’t cope. In Norway, urban dwellers have been banned from using their vacation homes for isolation. It will be important to limit movement into rural communities to the absolute minimum.”
Send through comments, experiences, thoughts and any COVID-19 related links to email@example.com so can be included in next weeks entry.
Recording from the latest Rural CME webinar in case you missed it or want to watch it again. Below are some additional resources including Dan’s Pneumonic device for delirium (I CLAP in time).
There are some really good printable self help guides here; https://web.ntw.nhs.uk/selfhelp/
I often recommend people have a look at https://www.headspace.com/ which is a smart phone app that teaches / guides people through relaxation exercises.
http://www.mhaids.health.nz/your-health/help-for-mild-to-moderate-mental-health-issues/ is a page with a lot of links to other support resources and there are a whole load of other information and support agencies out there.
I CLAP (in time)
I Inattention (most sensitive sign)
C Cognitive Impairment (Think of the domains on the MoCA)
L Level of Consciousness (usually decreased but can be increased arousal)
A Affective changes (usually depression)
P Perceptual disturbance (visual hallucinations)
These are the classic symptoms of delirium.
They occur ACUTELY and TEND TO FLUCTUATE (that’s the ‘time’ bit).
“We don’t have enough staff or resources, and our remoteness means that help can’t easily be brought in. And who would want to come anyway?”
Conway JC, Friedman BW. Medical Expulsive Therapy (Alpha Blockers) for Urological Stone Disease. Academic Emergency Medicine. 2020 Feb 7. EZ Proxy link
A systematic review that updates the Cochrane review from 2014. Table summarising findings below: Alpha blockers appear safe and effective, especially if stone >5mm, for expelling stone and reducing need for hospital admissions.
Urinary tract stones are common and usually painful. Lifetime prevalence is approximately 10%.1 Direct health care costs are estimated to be over $10 billion dollars annually.2 First‐line treatment is typically analgesia with nonsteroidal anti‐inflammatory drugs until the stone passes. If the stone does not pass spontaneously, urologic intervention may be necessary.3 Spontaneous passage rates for small stones less than 5 mm is 68% and for stones between 5 and 10 mm is 47%.4 Certain medications such as alpha blockers are sometimes used to hasten passage of stones and decrease the need for urologic intervention or hospitalization. Alpha blockers act on ureteral alpha‐1 receptors and decrease the basal tone and peristalsis, thereby facilitating stone passage.5 However, conflicting results from randomized controlled trials (RCTs) have limited their use. The systematic review discussed here is an update of a 2014 Cochrane review.6 It includes several new, large, RCTs.
The purpose of this systematic review was to determine the effectiveness of alpha blockers for adult patients with symptomatic ureteral stones measuring less than 1 cm and confirmed by imaging. The systematic review included 67 trials with 10,509 patients. The included studies compared alpha blockers with placebo or medical therapy with non-steroidal anti‐inflammatory drugs, corticosteroids, or antispasmodics. The primary outcomes were stone clearance (defined as stone free imaging, symptomatic relief, or stone collection by the last day of the trial) and major adverse events (defined as orthostatic hypotension, collapse, syncope, palpitations, or tachycardia). Secondary outcomes included hospitalization and the need for surgical intervention. Subgroup analysis compared stone clearance rates for stones 5 mm or smaller versus stones greater than 5 mm. Further analyses examined only high‐quality studies, excluding studies at high risk of bias.6
Overall, the use of alpha blockers was associated with increased stone passage (relative risk [RR] = 1.45, 95% confidence interval [CI] = 1.36 to 1.55, absolute risk difference [ARD] = 28%, number needed to treat [NNT] = 4, low‐quality evidence) without increasing the risk of major adverse events. Alpha blockers were also associated with a lower risk of hospitalization (RR = 0.51, 95% CI = 0.34 to 0.77, ARD = 14%, NNT = 7, moderate‐quality evidence) and no difference in the risk of surgical intervention (low‐quality evidence). The subgroup analysis based on the size of the stone revealed that alpha blockers did not impact passing of stones ≤ 5 mm but did improve passing of stones > 5 mm (RR = 1.45, 95% CI = 1.22 to 1.72, ARD = 30%, NNT = 3, moderate‐quality evidence).6 When the analysis was performed using high‐quality trials only, alpha blockers increased stone passing (RR = 1.09, 95% CI = 1.06 to 1.13; ARD = 7%, NNT = 15, high‐quality evidence, five studies, 4,133 participants) while having no effect on major adverse events, hospitalization, or surgical intervention.6
This review is limited in several ways. Most importantly, the quality of evidence for most outcomes was low due to several methodologic limitations of the included studies, inconsistency in study results, publication bias, a lack of prospectively stratified subgroups, and clinically important heterogeneity.
The findings of this meta‐analysis are consistent with other recently published meta‐analyses.7 However, some included RCTs, such as the SUSPEND trial, did not demonstrate a benefit for MET.8–10 The findings of individual RCTs may have been skewed toward no benefit because of limited sample size, a high percentage of smaller stones, and insufficient power to detect group differences between small and large stones. Additionally, a recent, large RCT, the STONE trial, was not included in this meta‐analysis. The STONE trial, which included 512 patients found no significant differences in outcomes.11 These findings are unsurprising as this trial has the same limitations as other individual RCTs. Because of the lack support for MET by several well‐designed RCTs, it is important to counsel patients on the potential limitations of the evidence that is being used to recommend MET.
In summary, using alpha blockers appears to be beneficial in increasing ureteral stone passage (especially if stones are >5 mm) and reducing hospitalization. They appear to be safe as they do not increase the risk of major adverse events when compared to placebo, non-steroidal anti‐inflammatory drugs, corticosteroids, or antispasmodics. Because benefit is likely (particularly for stones larger than 5 mm) and there is no apparent harm, we have assigned a color recommendation of green (benefits > harm) to this treatment.
Things were/are pretty tough across the Tasman. Lots of coverage on this but one from our rural health colleagues that was sent across. John came and presented at the rural health conference a couple of years ago.
Prominent rural health academic Professor John Wakerman and his family were among those evacuated from the devastating fires on the south coast of NSW earlier this month.
Wakerman writes below about the angry and frustrated letter he has since sent to the Prime Minister, as well as some key lessons from the current disaster, including the importance of telecommunications security for rural and remote residents.
(1) join the local volunteer fire service;
(2) do all I can to advocate for sensible policies to mitigate the impact of global warming;
(3) minimise my own impact on the environment through sensible and frugal consumption – food, fossil fuels and the many oil derivatives on our lives; and
(4) continue to acknowledge and reciprocate the kindness and generosity of my family, neighbours, friends and complete strangers at a time of need.
A good list of things that we can all aspire to.
See the below programme for the International Commission for Alpine Rescue medical commission and Land SAR mountain medicine conference to be held at The Commodore Hotel 449 Memorial Ave Christchurch on Friday 17th April
To register see the ICAR-MED website
|1||0830||Welcome: NZ & Antarctica||Dick Price & John Apps||NZ|
|2||0845||Volcanic Eruption on Japanese Mountain||Kaz Oshiro||Japan|
|3||0925||White Island Eruption||Craig Ellis||NZ|
|4||0945||Penthrox: the NZ experience||Craig Ellis|
|5||1000||Analgesia in the field||Panel||International|
|7||1100||Hypothermia & HOPE score||M athieu Pasqqier||Switzerland|
|8||1140||ECMO & Mechanical CPR NZ||Sara Gordon||NZ|
|9||1200||CPAP type device||Geoff Shaw||NZ|
|11||1330||Equipment in the Cold||Steve Roy||Canada|
|12||1410||Determination of Death||Corrina Schon||Switzerland|
|14||1530||Emotional Rescue||Alison Sheets||USA|
|16||1630||6 trips by sea to Antarctica||Jenny Visser||NZ|
|17||1715||Social function: meet & greet|
This useful document provides a pathway that those that are interested can follow to up-skill in simulation and debriefing.
Look forward to more simulation resources being made available – and perhaps a repository of NZ rural cases and scenarios that we can contribute to and access.
The Rural Simulation Faculty vision is of a pool of inter-professional faculty with expertise around simulation-based education (SBE) and debriefing who can all contribute to all rural simulation courses as needed. The group of rural courses should be strategically planned each year by the whole group to maximise value and demand. Each course will have designated course directors or leaders but can expect assistance from all faculty group members as available.
- Establish a broad interprofessional rural group of SBE faculty across NZ.
- Describe a common pathway for rural faculty to be credentialled as course providers through a shared understanding and experience of SBE
- Maintenance and development of simulation expertise through feedback, mentoring and sharing of learning resources
- Develop opportunities for learning, developing and collaborating using simulation-based education.
- Design interprofessional educational courses for rural health care workers.
- Research and evaluation of rural SBE
Rural simulation faculty development stream:
- Open for all doctors, GP’s, nurses, paramedics, allied health and midwives involved in rural health care at all levels of training.
- Faculty development stream comprises 7 components within three tiers, with stepwise progression through.
- Participation is purely voluntary and is expected to be self directed
A team of supervisors from Auckland and Otago Universities is currently looking for Masters and/or PhD students to work with the MSOD project.
About half of doctors make career decisions in the early postgraduate years, rather than during medical school. But we are aware from the international literature and our own research on Otago and UoA MBChB graduates that there are multiple factors that influence decision making starting with who is selected to become a medical student. Currently there is a mismatch between what doctors might decide as a career and the health workforce needs of Aotearoa New Zealand.
The Medical Schools Outcomes Database (MSOD) is a national longitudinal project collecting information on intended career choices and locations. Medical students are surveyed at entry to and exit from medical school and graduates are surveyed 1, 3, 5 and 8 years after graduation. Included in the surveys, are 24 questions that ask about influences on career choices – respondents are asked to rate these in importance.
To better understand what factors influence the career decisions recently graduated doctors make. (using the database).
If you might be interested I can provide further information and contacts. firstname.lastname@example.org