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%.
RESULTS:
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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