Irish Institute of Rural Health Ltd

Rural Satellite Conference
Talks & Papers

June 1998

Westport, Co Mayo, Ireland

Immediate Care in Rural Practice

Professor Andrew Murphy, University College, Galway

This talk will provide an overview of Immediate Care in Rural General Practice. Discussion in detail of the management of suspected cases of myocardial infarction by urban and rural Irish General Practitioners will then follow. Description of the Immediate Care courses organised by the ICGP and Departments of General Practice at UCD and NUI,(G) and their evaluation, will also be provided.

Follow-up of the use of defibrillators and basic life support kits by a sub-group of participants on these courses will be shown. Finally results of a qualitative study reviewing the effects, on general practitioners and their spouses, of providing an out-of hours immediate care service will also be presented.

St Brendan's Village, Mulranny, Co. Mayo - A Healthy Model of Care for Elderly & Handicapped.

Dr. Jerry Cowley, GP and Barrister, Mulranny, Co. Mayo.

Having practised as a family doctor in Mulranny, a west Mayo seaside village of 300 people with a very scattered sparsely populated hinterland of thousands with higher than average numbers of elderly people, I feel that a model of care of the elderly and handicapped has emerged in this area which is very much in accord with the wishes and good health of the elderly and handicapped of our community. This has struck a chord with many other rural communities who are engaged in community care to varying degrees.

What exists here is a progression or continuum of care giving the support to the person as it is needed, so that he/she is always living to the maximum amount of independence possible at every stage of well-being. In this way personal dignity is preserved, allowing 'own' space (we all like to be able to close our door to the world when it suits us), and personal autonomy is retained. This I feel is an ideal model of care of the elderly for now and the future.

St. Brendan's Village offers people the opportunity to stay locally. The alternative is the sad silent emigration of the elderly to old folks homes in distant towns when they are most helpless and vulnerable and need our help most. The Model of Care starts with supporting our people in their own homes with visits to our day centre and meals on wheels as necessary.

The next step is low support sheltered housing. But even with this low support sheltered housing some of our residents become more feeble and now they are not fit to live alone so St. Brendan's (called after the great adventurer) is for those who are liable to forget ' to turn on the heat' or forget ' to turn off the cooker'. This development has helped the revitalisation of our rural village and the residents have enriched us with their presence. However there needs to be some genuine long term State commitment to help ensure the survival of these rural initiatives.

General Practitionars Confidence in Performing Minor Surgical Procedures before and after Skills Course Attendance: Implications for the Provision of Quality Care. Dr. Nick Breen - GP and ICGP Skills Fellow

INTRODUCTION: Increasing numbers of GP's who are providing surgical services for their patients. The ICGP established a Fellowship in Minor Surgery in 1996, to promote the provision of quality care in this field.


METHODS; A one-day skills course in minor surgery, covering theoretical principles and practical techniques, is offered to GP's in Republic of Ireland on a regional basis. To date, ten courses have been run for 165 GP's. All participants complete a course assessment form rating confidence levels for various procedures (ellipse excisions, lipoma removal, sebaceous cystectomy, cryotherapy, curettage, electrocautery) before and after course attendance, on a scale of 1 to 10. Satisfaction ratings for the sessions were also requested. Comments and suggestions are also solicited. The response rate was 82%.


1) The participants had been in general practice for an average of 12 years.

2) The mean confidence level for all demonstrated procedures prior to the course was 3.88; range of means for individual procedures: 2.8 to 6.1. This had risen to a mean of 7.11; range of means: 6.6 to 7.8 after the course.

3) The means of the mean satisfaction ratings for all aspects of course delivery was 7.98 (range of means: 7.1 to 8.

CONCLUSION: GP's confidence in performing minor surgical techniques is improved by a one-day course attendance. This does not give any indication of competence. Audit of individual practitioners service provision will be necessary for this. Further research is required to assess the long term impact of such courses.


Cryosurgery in General Practice

Dr. David Buckley, GP and Dermatologist, The Ash Street Clinic, Tralee, Co. Kerry.

Cryosurgery is a method of using sub-zero temperatures for the selective destruction of unwanted benign, pre-malignant and malignant tissue in many different parts of the body. Success in cryosurgery depends on the following four factors:-

1. Cryogen 2. Equipment 3. Technique 4. Patient selection

Best results are achieved by using liquid nitrogen via a cryogun. To achieve high cure rates and good cosmetic results, technique and patient selection are probably even more important than the choice of cryogen and equipment. Good technique will only be achieved by proper training and experience.

There is only one important safety rule in cryosurgery. Never treat any lesion using cryosurgery unless you are sure of the diagnosis. If there is any doubt as to the diagnosis on the clinical assessment, then don't freeze. Take biopsy, or refer the patient to a colleague for a second opinion.


Health Problems and needs of Rural People in Developing Countries

Dr. M. Tariq Aziz (General Secretary Pakistan Society of family Physicians)

INTRODUCTION: Health problems of rural people are slightly different from urban people and become more pronounced due to distant or non-availability of health facilities. Health Problems: - In rural areas main problems are infections, Skin infections, Worm infestations, Malnutrition and Agricultural Accidents, Goitres, Anaemias, Hepatic disorders, Amoebiasis and Allergies are also found. The ' needs' of rural population can be split into two main categories - non medical e.g. basic amenities like clear water, sanitation, education (+health, education) means of communication, medical facilities can be preventive e.g. vaccinations and dietary care regarding hygiene and balanced diets meeting infestations. Deficiency diseases, surgical facilities, especially for trauma etc. Inference. There is nonavailability of basic needs of health care in rural areas. Reasons mainly are lack of health education and infrastructure- both have direct needs of FUNDS and social support.

CONCLUSION: Health problems and needs of rural population is not fulfilled because of financial constraints besides lack of infrastructure.


Enteric Fever-Rural/Urban Differences in Central Rural Punjab Pakistan

Dr. M. Iftikhar Rana. M.B.b.s.(ph) F.R.S.H. (London) Sina Clinic Pattoki Distt. Kasur (Pakistan).

INTRODUCTION: Typhoid Fever is still one of the commonest infections in Pakistan like other third world countries but its prevalence differs in different areas and communities because of disparity in their living conditions.

OBJECTIVE: Aim of this study is to differentiate the frequency of enteric fever between rural and urban population so that adequate preventative and curative measures could be suggested to concerned personnel.

DESIGN: perspective study,

SETTING; General community in private practice in sian clinic, a private hospital in a big town in rural punjab, Pakistan.

TIME PERIOD; 6 months (from first May 1995 to 31st October 1995)

METHOD : 250 patients with enteric fever 140 (56%) found to be from rural areas and 110 (44%) from urban communities.

CONCLUSION AND COMMENTS: Unlike the general impression that enteric fever is more common in rural areas this study reveals that the big towns have almost the same frequency of involvement by enteric fever as in villages. The possible reasons are poor hygienic conditions and consumption of improperly covered vegetables in the town markets.


Traumatic Injuries in Rural Areas of Pakistan

Dr. Noor Ahmed Akhter - Chapter President. Pakistan Society of Family Physicians, Noor Hospital, Kot Radha Kishen Kasur Pakistan

INTRODUCTION: The pattern of musculoskeletal injuries in rural areas are mixed in nature. These include fractures open, simple and polytraumatic. These also include a large number of nerve, vessel and tendon injuries.

METHOD; - in this study during the year 1997, 2806 patients were enrolled in the out door of this hospital, out of which 1939 patients were registered as indoor; 435 patients were of traumatic nature; 272 having siimple injuries; 76 patients had simple multiple fractures; 37 patients were of nerve muscle injuries; 45 patients wer e suffering from osteomyelitis. Out of these 75 patients were operated (internal fixation etc).

INFERENCE:- In rural areas trauma is different from urban areas due to mechanization of farm machinery and implements. Most cases are mismanaged due to lack of facilities.

CONCLUSION: There is almost no facility for trauma in rural areas. Rural Health centres are grossly ill equipped. Private sector has provided some facilities but Government has no incentives at all. Support from WHO & UNICEF should be provided to N.G.O.s to meet the requirements.


Factors which Influence Sustainable Rural Practice

An International Workshop Workshop Convenors: Prof Roger Strasser, Dr. Criag Veitch

JUSTIFICATION: Recruitment and retention of health professionals in rural and remote areas is a problem worldwide. Retention in particular, is dependent upon the presence of factors which contribute to sustainable practice. Without these factors in place, retention is likely to be impaired. The convenors have recently been involved in a national investigation of models of sustainable general practice in Australia.

PURPOSE: The purpose of the workshop is to provide an opportunity for participants from across the world to share knowledge and experiences of factors which impinge on sustainability and models of sustainable rural practice in their country.

ORGANISATION: The workshop will consist of three stages: Stages 1 and 3 will be full group sessions, while Stage 2 will be a small group session.

Stage 1 will be an introduction and focusing session in which participants will identify issues pertaining to sustainable rural practice. These issues will be grouped into broad topic areas (eg. community characteristics) which will be examined in detail in Stage 2.

In Stage 2 participants will break into small groups. Each group will work on one of the topics identified in Stage 1. Their tasks will include identifying the key issues relating to the topic and models or strategies for improving sustainability.;

Stage 3 will be a Plenary session in which a representative from each group will outline the group's thoughts on their topic. Proposed Outcomes - a better understanding of the factors which impinge upon the sustainability of rural practice, particularly generic factors. - An opportunity to share knowledge and experiences of sustainable rural practice with international peers.


When the Balance Tips

A Tool for Self Appraisal in Rural Practice Presented by Dr Martin London, Centre for Rural Health, Christchurch, NZ

There is an understandable preoccupation with the difficulties faced by rural practitioners and their families. While this focus is entirely justified when seeking solutions or campaigning politically, it is also useful to focus on the positive reasons why people choose to go into rural practice and remain there for reasons other than entrapment.

This paper presents a tool which has been developed for looking at the balance between the positive reasons which lead us to choose and remain in rural practice, set against the price we pay for this choice of life and work. The tool is intended to be used in the context of support visits to rural practitioners and their families as a way of helping them to identify their current level of comfort in rural practice, areas of concern which could be worked with to improve their level of comfort and as a preparation for recognising "when the balance tips" to indicate a well planned and orderly departure from rural practice as a positive life style choice.

The intention is to put some positive energy back into rural practice and to help communication between practitioners and their spouses to help family decisionmaking.

The tool can be used either on an individual basis in the context of a practice visit or for use in a workshop context for groups of rural practitioners and their spouses.

Doctor Heal Thyself

Dr Greg Down, Director, West Australian Centre for Remote and Rural Medicine.

Are doctors their own best physicians? Our health outcomes include a high suicide rate and high anxiety levels. The causes for this are many but perhaps the real question is how to to prevent this and what early

Royal Flying Doctor Service in Australia

Dr. G.K. King Medical Superintendent (Q'ld)

1998 marks the 70th anniversary of the Royal Flying Doctor Service in Australia. It began in 1928 in Cloncurry in Queensland in response to the needs of rural and remote areas. Today the Queensland section of the RFDS looks after a populationof 3 million people and sees as its customers people living, working and travelling in rural and remote areas and the health professionals who look after them.

The Republic of Ireland has a similar population to the State of Queensland and currently the concept of an integrated Helicopter Emergency Medical Service network is being mooted by rural health professionals.

This paper discusses the RFDS model and what elements or concepts may be transferable to the Irish situation.

HEMS - The Case for Ireland

Dr. Ronan Fenton, Senior Registrar in Anaesthetics, Royal London Hospital

The main advantage of helicopters is their ability to rapidly deliver skilled personnel and equipment to the patient. They can often access locations with greater ease than land based vehicles who may have to contend with geographical obstructions or sheer traffic volume in the urban setting. Once treatment has started the patient can then be rapidly transferred to the centre with the appropriate facilities for their condition, accompanied by a team that is skilled in this type of work.

The Government Review of the Ambulance Service in 1993 and the Irish Intensive Care Society in 1994 both indicated that improvements were needed in pre-hospital care and transport of the critically ill in Ireland. Both documents indicated that special transport teams need to be available and that the question of rapid patient transport needs to be addressed. Given the rural nature of the Irish community and variable quality of the road system the use of helicopters was suggested as an option worth investigating. The concept of a system capable of reaching all areas of the country within a 30 minute period after activation is appealing.

It is fortunate that there are many such systems currently operational internationally. Lessons can be learnt from them and the systems adapted to suit Irish needs. With careful planning we have the opportunity to do it well and our patients deserve no less. Robert H Hall, Senior Lecturer, Monash University Centre for Rural Health

We would like to conduct a focussed participatory discussion, with the doctors at the Westport meeting, for 3/4 - 1 hour, to test our ideas against the "Wisdom of the tribe" gathered there.

We would specify the QUESTIONS for discussion, (from the perspective of rural general practitioners) based on the objectives of the project, which are:

1. To clarify the urgent care needs of people in rural towns:

1.1 - without local hospital support;
1.2 - without a general practitioner;
1,3 - without an ambulance;

2. To clarify the needs for and propose support and training, for GP's in towns without hospitals, and for the supporting extended practice nurses and emergency transport personnel.

3 To recommend processes for training and maintaining urgent care skills for rural GP's and other personnel who lack opportunities for routine application of those skills;

4. To specify well defined models to guide support for urgent care services in rural towns (of different sizes) without hospitals;

5. To identify a range of models to support GPs with infrastructure and teamwork in this situation, in towns of <1,000; 1-2,000; 2-7,000; and those of 7 - 25,000

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Rural Satellite Conference, Talks and Papers, Westport, Mayo, Ireland