The 4 hour rule , urgent and out of hour care in Geraldton

The 4 hour rule , which has been called the greatest health reform in 20 years has arrived in Geraldton form April 2010. The WA Health services has set a target of 98 % of patients arriving at an Emergency Department ,have to be seen , treated , transferred for further care, admitted or discharged within 4 hours. But the 4 hour rule is more . The 2 years Geraldton Hospital has to reach the target, involve a phase of measurement , monitoring patient flows from ED and in the Hospital , a phase of review and options for improvement, followed by a phase of implantation of changes and re measurement. The large Perth Hospitals have started working with the 4 hour rule process since April 2009 and have already shown great improvement in reduced patient waiting times , better flows and less ambulance blockades of ED entries. Geraldton Hospital has to look at it specific difficulties like growing population, permanent doctor and nurse shortages, distance to tertiary specialist hospitals and services, partial reliance on RFDS and transport issues for transfers to Perth. It’s ever hard working staff in all departments and managerial levels is required to come up with specific solutions for Geraldton rural circumstances and specific conditions as the solutions from success in larger city hospitals or the UK, where the 4 hour rule is worked for some years now cannot be blindly copied due to our specifics of thin population, large distances , low density of nursing and doctor staff. Speaking for the 4 hour rule is that it will commit health service , WA government and commonwealth to make available funds, it involves all hospital staff and consumer (patient) advisors , it is easy understood by clients and patient, it seems a good process to review and improve flows in existing setups, and it has already lead to improvements in the city hospitals of WA and that it is always better to envisage change than to sit it out. Against it might speak the initial increased work load for already stretched hospital staff, the temptation for managers to design targets around existing inadequacies as a senates committee review highlighted in Canberra this year , the lack of staff , and resources which is especially gross in rural Hospitals the increased workload it might present to rural GP’s in already busy surgeries, when patients are earlier discharged as the Rural Doctors Association says. What options have Geraldtonians got to seek urgent or unplanned as well as out of hour care? It is always advisable to ring your practice or dentist Ist thing in the morning and to make clear that you need to see a doctor or nurse urgently that day. Most practices will accommodate you, as they keep slots or even run nurse clinics or doctor on call clinics for that purpose. One practice runs Saturday morning clinics , and plans to extend this to 5pm-9pm weekdays, funding and interest provided. Other practices might follow suit. SJOG operates an out of hour clinic weekdays 6 pm to 10 pm and 9 – 10 pm on Weekend days. You can phone for advice on self limiting illnesses or directions where to attend by ringing health direct on 1800 022 222 or got to www.healthdirect.org.au. Your trusted pharmacist will also able to advice you, further Fountains and Sunset Pharmacy are open 8am – 8pm every day. And you could go to ED or be taken there by an ambulance, but please only use them for non walking and absolute emergencies. Some patients have to wait longer than others as the ED staff applies clinical Triage ( sorting ) criteria to determine the urgency and timely need of care, this being the reason why a cough or toothache, waits longer than a chest pain or road trauma , which might require immediate attention. Please keep in mind that all hospital staff always works hard within given resources and set frameworks and is aiming to provide best possible care. Finally consider to enrol at Durack’s for nursing training or become a mature medical student in Perth to bolster staff numbers for the future in truly rewarding and guaranteed never out of job careers.

Helko Schenk
28 6 2010
Sources :
www.health.wa.gov.au/fourhourrule
http://www.healthdirect.org.au

South African Travel Fever

"Veels geluk maatjies!" (best of luck friends/mates)

The Soccer fever has gripped the world and thousands of Australians will flock with the rest of the world to the “Cradle of Mandkind" to cheer their teams. Thousands more will just travel to experience this beautiful land, not to mention the large South African originated workforce and their families in WA, who might return for a visit to their home country this year , often falsely presuming their immunity against African grown illnesses. South Africa is one of the leading economies in Africa with Ist world facilities in all cities of the worldcup. The risk of contracting illness if restricting itinerary to major centres will therefore be low. However the consideration of a minimum prevention programme like the Seasonal and pandemic Flu vaccine , Tetanus Booster , Hepatitis A , Typhoid, oral Travel diarrhoea vaccine (Dukoral) as well as carrying of Diarrhoea medication and oral rehydration treatments would be highly commendable. Drinking of tap or even fresh water is generally not recommended if for the risk of contracting a travel diarrhoea which is your highest health risk travelling to SA, but there is also danger of contracting Hep A , in north eastern provinces even Schistosomiasis. There was a measles outbreak with 6000 cases 2009 alone in all SA provinces and the country still has one of the highest world wide incidences of TB and drugresistant TB. Rabies is common in all provinces and bites scratches by dogs , foxes , mongoose, jackals in fact all animals should be taken serious and post bite prophylaxis within 24 hours should be sought from medical centres. 18% of the countries population and 50% of sexworkers are HIV positive so safe sex practices are always adviced. Travel to northern provinces of Limpopo, Mpumalanga , North Eastern Kwa Zulu and the Kruger Park makes mosquito bite precautions ( spray , nets , long sleeve / leg shirts trousers) as well as malaria prophylaxis paramount. Have a travel health insurance in place as care in outside areas can be substandard and transport and care in centres or evacuation back to Australia might be necessary and expensive in case of acute illness or accident.
Crime rates are of the highest level in South Africa, have good personal security strategies in place and use good common sense. Avoid travel on commuter trains and Bus taxis, lock your car if travelling at all times especially in cities, (leave valuables (handbags,mobiles) locked in the trunk of your car), and (do not stop on highways to sitesee) Don’t visit townships uninvited and unaccompanied. Check out the government website http://www.smarttraveller.gov.au/ with good Travel and Health advice for SA.
Indirect Travel via other countries might make Yellow Fever vaccine for entry into SA as well as re-entry into Australia compulsory. In summary have a great time this year in South Africa and good luck to the Socceroos, but seek a health and vaccination check from your GP or Travel Clinic before you go and see your GP or ED doctor, if you develop anything more than a minor illness on your Return.

"Hamba Gashle Umgani!" (go well our friends)

http://drhelkoschenk.blogspot.com/
Geraldton 12 6 2010

Sources.:
http://www.travax.com/
http://www.istm.org/
http://www.smarttraveller.gov.au/
http://drhelkoschenk.blogspot.com/
Southafrican friends and colleagues

When Acid strikes

The feeling of fire rising behind the chest also called heartburn caused by the upwards flow of stomach acid into he gullet (oesophagus) in medical terms called “reflux disease” seems to be incredibly common in western society . Some rate it’s occurrence up to 20 % of adult population. 1:10 adults suffer heartburn daily.
The stomach produces acid to help digest food. The bottom of the gullet is protected by a sphincter or valve muscle, which keeps acid out of the food pipe and let’s food through into the stomach. Stomach cells are especially protected from the acid , but oesophagus cells are less so . If there is a mismatch between acid production , stomach pressure ( pregnancy , overweight) and sphincter function, acid can flow back ( reflux) and lead to irritation of the gullet, causing heartburn , bad oral smell, rotten teeth, but even chronic cough and if severe chest pain. If this is a rare occasion, you can treat your self with antacids like Mylanta or Gaviscon. You should see your doctor if symptoms are severe or frequent , not settling but especially if you loose weight, without wanting to, feel excessively tired, feel that food is getting stuck in your gullet.
The doctor will take a history and either advice on lifestyle , diet changes and or treat you with effective medication to suppress acid production ( Proton pump inhibitors , Histamine 2 receptor blockers). Sometimes if there are other risk factors or the story is not typical refer you for a an endoscopy ( camera test ) to check on your gullet. Treatment and testing might be required to prevent and exclude scarring of oesophagus or ulcers of the same and even rare cancerous changes due to chronic heartburn ( acid irritation). The camera test can show oesophagitis( inflammation ) or sometimes no changes (endoscopy negative reflux disease) which doesn’t mean you imagine your symptoms. Surgeons recognize ,that some gullets are very sensitive to even smallest amounts of acid and therfore causing symptoms even without surface changes of the gullet.
You can help , by stopping to smoke , avoiding excess meals or alcohol intake, identifying triggering foods (caffeine, spices, chocolate). It sometimes helps to avoid eating in the hours before sleep or even lifting the head end of the bed with the aid of bricks or books under the bedposts.

Helko SchenkGeraldton 1 3 2010

Insomnia , Sleep problems

Insomnia , difficulty to fall asleep, maintain sleep, or early waking seem to be incredibly common , in fact repeated studies have shown that up to 30 % of the Australian population suffer or perceive to suffer from poor sleep. Sleep deprivation is used as psychological torture but yet few people have died in the natural world of lack of sleep. Sleep , length and needs are often overrated and lead to anxiety and worry which in turn reinforce sleep disturbance – a very vicious cycle to break. Sleep need vary hugely between people and generally fall from 17 hours in babies to 8 hours to 30y-somethings and less than 6 hours in the elderly. Important is a fresh and regular awakening.
A number of reasons for sleeplessness are accepted, age might be a normal cause, medical reasons like the need to pass water more often overnight, pain , breathing problems , medicines taken for other conditions , smoking before bed time, excess and late use of alcohol and drugs, stress , bereavement, anxiety , depression can all cause poor sleep. Have a chat with your doctor , or get some information to explore sleep hygiene and causes you can correct yourself like room temperature , comfortable bedding , darkness of room and reduced noise exposure. Good leaflets are available at
www.patient.co.uk “Insomnia”, “Sleep problems”
www.abc.net.au/health pulse series “INsomnia” ,”Do natural Sleep Pills work?”
Australian Sleep association “Insomnia & Sleep health”
Advice on good Sleep hygiene can be found there or in discussion with your Doctor/psychologist. Simple things to remember is not to worry about sleep, to stay active , not to take naps, have a bedtime routine, No to coffee , nicotine, tea , chocolate and other stimulants. If not able to sleep get up read a boring book or watch a boring programme , drink a hot malty or milky drink and return when tired.
Medications while effective in the short term (sedating antihistamines , benzos…) have side effects , quickly become useless and some can lead to rapid addiction and dependence. Modern ones especially if used with alcohol (Zopilone/ Zolpidem) can have bizarre side effects but might still be safer to use. (Night walking)

Beware natural therapies of unproven effect and composition, While prescription Melatonin (Sleephormone) might have a place in treatment of severe jet lag or psychiatric illness , over the counter melatonin is severely diluted and propably not effective. Some Antidepressants are sedating and might be a safe option but should be reserved for underlying emotional issues , which if improved can better sleep dramatically. Try to self diagnose , better sleep routine and hygiene but see your doctor if you suspect underlying medical , emotional issues as discussed above .

Geraldton 9 2 2010

Pregnancy and Travel

Giving the right advice to the pregnant woman keen to travel requires appropriate mix of caution and bravery, simply as this is a phase of great risk and there is a lack of controlled studies on the effects of travel , vaccinations … on pregnant women.

It is clearly sensible to discuss travel plans well in advance (6 weeks) with your GP / Obstetrician/ Travel Medicine Doctor.


Some Contraindications to travel especially abroad are:
Obstetric Factors
- complicated present or past pregnancy
- preterm labour
- retarded intrauterine growth
- twin pregnancy
General Medical Factors
- High Blood Pressure
- Diabetes
- Cardiac Arrhythmias
- High risk of blood clots (Vein thrombosis)
Hazardous Destinations
- a good travel doctor has access to information regarding general warnings
- www.cdc.gov/travel
- www.smarttraveller.gov.au
General and pre-travel information
- Geraldton travel clinic: www.gmgn.com.au/travelclinic.html




Most international Airlines carry pregnant women up to 32-35 weeks, but require a letter stating your fitness to travel and confirming date of delivery. It is also wise to carry all pregnancy documentation, Blood group, medical history , antenatal record .
The Oxygen pressure in air plane cabins is reduced , which is generally not a problem but might become if you pregnant and also anaemic or have sickle cell disease. To prevent blood from clotting in veins hydrate well, do regular in travel exercises of legs, wear below knee compression stockings.

Vaccinations should bare some exceptions - were risk of catching the true illness outweighs the harms of vaccine - be generally avoided in pregnancy. Advice on vaccination has to be based on a thorough medical and vaccination history, up to date knowledge of destination health risks. Vaccination for Diphteria Tetanus, seasonal and pandemic Flu, Hepatitis A + B, Pneumococcus , Typhoid could be considered in pregnancy.
BCG(tuberculosis), Mumps Measles Rubella, Chickenpox – vaccines are contraindicated. Tricky is the decision on Yellow fever vaccination.
The most popular travel souvenirs are common viral infections and particularly diarrhoea and vomiting in pregnancy. Persistence with oral rehydration are important to avoid particular risk of shock , metabolic illness , preterm labour in pregnancy. (Buy oral rehydration packs from your travelclinic or pharmacy!) It is not clear if anti diarrhoea medicines like immodium are safe , but they have been used in pregnancy. Only certain antibiotics can be used in pregnancy.

Malaria is a significant risk to mother and baby, avoid travel to malaria areas if possible! Mosquitos seem to be attracted to the pregnant due to increased skin temperature and higher CO2 production. Screens , Bed-nets sensible clothing , staying indoors at night and the sparingly use of insect repellents seems advisable. DEET (the commonest repellent) particularly if applied thick to large areas of skin get’s absorbed , and even travels the placenta into the babies blood. Discuss oral antimalarials with your doctor.
Other travel issues are common ailments and discomforts of pregnancy, ready access to medical facilities, safety of national blood supplies, availability of anti D for rhesus negative mothers.


Helko Schenk
Geraldton 26 1 2010

Stomach pain in children

”My belly hurts” is an all to common complaint in children, and a puzzle to parents and medical professionals alike. Causes reach from surgical and medical to anxiety and school avoidance. Careful listening and detailed attention to history and presenting symptoms by parents and doctors can help to sieve the serious from the not so serious. If there is an obvious mild self-limiting illness like an upper airway infection or gastro bug and things can be managed with simplified diet , hydration , warm water bottles and mild pain killers in a not so unwell child, there is not so much worry. Note that only 1 in 15 children with acute (new onset ) of abdominal pain require surgical admission and only 60 % of these require specific therapy including surgery. Yet 1% of children, most commonly in the 10-12 year olds will develop acute appendicitis ( inflammation of the appendix) Warning signs for acute surgical or medical tummy ache are:
- persistent vomiting especially if bile stained ( yellow / watery)
- sudden onset of severe pain
- pain in one location
- pain away from the central abdomen (the belly button area)
- significant and persistent Weight loss
- child prefers to be still
- fever especially prolonged and not controllable
- fluid refusal
- obvious swelling / lumps of the abdominal wall (Hernia)
- bloody stools
- chronic ( over days ) diarrhoea ( frequent soft – watery stools)
Lack of an obvious simple explanation and any or more of above red flag presentations should lead to a visit of GP or after hour service. The Physician will familiarize himself with the parents and child , ask a lot of questions , do a simple physical examination, including some basic tests like Urine bedside testing , stool testing to help him differentiate between simple self limiting causes and the ones like Appendicitis , urinary infections , diabetes , gastroenteritis , abdominal and genital trauma (especially in boys), even chest infection which require treatment or admission to hospital.
Even trickier is the recurrent abdominal pain of childhood , intermittent quiet severe tummy pain or cramps for hours or days between long periods of no symptoms at all. Only 8% of these more chronic presentations eventually reveal some organic (medical, surgical ) pathology. These chronic pains are often over investigated , when attention to detail and history could safe the child from unnecessary sometimes in itself stressful tests. Most chronic pains are better managed with simple medications , dietary modifications, as well as reassurance. Conditions include stomach migraine of childhood , Irritable bowel, constipation , and mesenteric adenitis ( abdominal lymphnode swelling of childhood), anxiety , bullying. Similar red flags as for acute pain apply though, others are:
- age less than 5
- mouth ulcerations
- skin disease around the rectum

It seems to be even harder to keep the good from the bad in chronic pain but studies show that significant time of school and no significant weight loss suggest a non organic cause.
Good communication between parents , GP, specialists, child and family is essential for a good outcome.

Helko Schenk
11 1 2010

Spiders- , dog- and other bites

The November edition of the Australian Family Physician was dedicated to bites. Australia is home to 10000 spider species , including the world’s most poisonous one the funnel web , luckily only of touristic interest for us smiling West Australians but an absolute medical emergency and should be treated like a snake bite if attacked by one over east. Our most commonest cause for help sought is the red back spider bite. Easily diagnosed if bite witnessed, but sometimes missed in kids who might just present with irritability sweating and localized pain as fang marks are missing. Red back spider antivenom is reserved for bites causing severe pain or general illness . There have not been any deaths since 1950ies . Recent studies have not been able to show a link between white tail spiders and ulcerated wounds, it seems that it is more likely in Australia to suffer ulcer due to trauma , infection or poor perfusion . But who knows what spiders are still out there. A much bigger problem seem to be dog bites , 35-42 of Ozzie house holds own dogs and 2 % of the population are annually bitten , almost 100000 patients require treatment for dog bite and 13000 in hospital. Biggest risk factors for dogbites seem to be :
- male gender of victim
- children less than 5 years
- household’s own dog
- male unsterilized dogs
The worst offenders by far are doberman’s , german shepherds , Rottweilers and pit bull terriers responsible for 31% of all bites. Lesson clearly has to be never to leave children alone with dogs under any circumstance. Educate your kids to approach dogs with caution, and strictly under adults supervision, leave feeding dogs and puppy rearing bitches alone, avoid territorial dogs. Watch for signs of infection ( redness, inflammation, pus collection or discharge) Get a tetanus shot ! Cat bites are particularly nasty as sharp teeth can penetrate deeper structures lead to joint infection , tendon and vascular injuries even they appear as minor puncture marks on the surface only. The worst by far ar human bites ( attack and love bites) which almost always become infected and also need a chat to the ED DR or GP as there could be concerns re Hepatitis B / C and HIV , which might need prophylactic treatment. Remember rabies and seek immediate medical attention , if you are bitten or scratched by animals when abroad , however lovely they might look. Did you know that Australian bats can transmit a lyssa virus a near identical and as deadly as the rabies virus. Now sleep tight and don’t let the bed bugs bite and if they do (which they do more often even in 4 star hotels again) get the professional pest controllers in and don’t try to treat them yourself as they apparently have grown resistant to a number of pesticides .


Helko Schenk
Geraldton Medical Group
4 12 2009