Rural and Indigenous emergencies

Published on 14/03/2015 by admin

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Chapter 44 Rural and Indigenous emergencies

Mark Byrne, Bonita Byrne

RURAL AND REMOTE AUSTRALIA

A doctor providing medical services in a rural or remote area requires a broad skill set with the ability to work independently in a setting with limited or no immediate access to specialist care.

The rural practitioner provides holistic care within a setting that often has unique socio-cultural issues.

Every community is different and local knowledge is essential. What works in location A may not work in location B, so working closely with the community is important.

Australia is a vast country with a relatively small population of 21 million. One-third of Australians live outside urban areas, many in remote, isolated locations. There are recognised differences in health status among rural Australians, compared to their urban counterparts. Despite efforts to bridge these inequalities, access to health services and health professionals for rural Australians is generally poorer.

APPROACH TO THE RURAL PATIENT

The initial approach to the undifferentiated rural patient is the same as if the patient presented to a major tertiary centre. For example, the principle of ‘airway, breathing, circulation’ is fundamental. The provision of services may require adaptation as resources may be limited.

Modern technology does provide many rural sites with video conference facilities which link the rural practitioner with a tertiary hospital and can provide real time, interactive specialist assistance. Ringing for advice and utilising the Internet to gain opinion on ECGs etc is worthwhile.

PATIENT TRAVEL, TRANSPORT AND RETRIEVAL

This has been covered in detail in Chapter 21, ‘Patient transport and retrieval’.

Developing an understanding of who is responsible for the transport and retrieval of patients is essential. Area health services will have a local protocol.

Early planning for patients is important and, if unsure, it is better to discuss the patient early if there are any doubts or perceived management dilemmas.

Each state has provision for financial assistance for people who need to travel long distances to obtain specialist medical or dental treatment that is not available locally. Medical staff have a responsibility to complete documentation associated with travel assistance.

INDIGENOUS PATIENTS

Epidemiology

Indigenous Australians are the most disadvantaged across all socio-economic denominators. These disadvantages stem from colonisation and land dispossession.

Aboriginal health not only includes physical health but also encompasses social, emotional and cultural wellbeing.

Aboriginal and Torres Strait Islanders comprise 2.4% of the total Australian population. Most (69%) live outside the major urban centres, with one in four Indigenous Australians living in remote areas compared with only one in fifty non-Indigenous Australians.

Over 50% of Indigenous Australians live in New South Wales (29%) and Queensland (27%). Although only 12% of all Indigenous Australians live in the Northern Territory (NT), they represent 29% of the total population of the NT.

Health status

Aboriginal history has continued implications for health care, and the health status of Indigenous Australians is worse than that of other Australians. Life expectancy is worse than in many underdeveloped nations: 53% of men and 41% of women die before the age of 50.

Aboriginal patients may have chronic conditions at a younger age and, therefore, age-based risk stratification is often not applicable among Indigenous Australians.

Cardiovascular disease is the leading cause of death for Indigenous Australians, with respiratory, endocrine and external causes the other major causes.

Indigenous Australians also have higher rates of mortality from all major causes of death. Mortality rates for Indigenous males and females for endocrine, nutritional and metabolic diseases are around 7-fold and 11-fold higher than those for non-Indigenous males and females.

Cultural issues

Providing affordable, culturally appropriate facilities and transport will improve access and attendance.

Mandatory training should be available so that all health staff can be educated in Aboriginal culture, with emphasis on the local community.

Treating Indigenous patients as individuals and avoiding cultural stereotyping is essential.

Cultural and communication barriers can affect the patient–doctor interaction. Finding a balance between medical priorities and social needs is essential.

ABORIGINAL HEALTH WORKERS

An Aboriginal health worker or Aboriginal liaison officer is an invaluable resource and should be consulted when appropriate.

There are over 130 Aboriginal community-controlled health services and Aboriginal medical services throughout Australia that are also excellent local resources.

COMMUNICATION

Many Indigenous Australians have difficulty in understanding and/or being understood by a heath provider. Therefore, culturally appropriate communication is essential for effective patient management.

For example, in the Northern Territory, 70% of the Aboriginal population speaks a language other than English at home. This has implications in relation to providing information on appropriate care, obtaining informed consent, explaining diagnosis and treatment and reinforcing compliance.

Eye contact is often avoided and should be understood within its cultural context.

Aboriginal people have strong family ties and kinships, and the inclusion of the extended family in decisions is appropriate.

Many Aboriginal people have a fear of hospitals, which they may associate with death. Be patient, and make allowances if compliance is to be achieved. Further, consider alternatives to admission such as daily reviews and ambulatory IV antibiotics.

Where possible, a doctor of the same gender should see an Indigenous patient, as there is men’s business and women’s business. This includes not placing men and women in the same room.

Provide written information and instructions each and every time, prior to discharging. Use everyday language, without jargon, and take the time to make sure the patient understands the information. Arrange prompt follow-up and provide written information to the referral service.

Allow time and space for the extended family during grieving and when a death has occurred.

ALCOHOL AND SUBSTANCE ABUSE

Indigenous Australians are less likely to drink alcohol than other Australian people. However, there is a higher prevalence of dangerous drinking levels among Aboriginal people.

Alcohol and substance abuse is a major contributing factor to the poor health and wellbeing status of many Aboriginal people. It has a causal and a non-causal relationship with domestic violence, mental health, suicide, road deaths, imprisonment, sexually transmitted infections and sexual abuse.

Alcohol abuse has a major impact on Indigenous communities. The immediate management of alcohol-related emergency department presentations is no different than in the wider community.

Illicit drug use, including marijuana, amphetamines, heroin and inhalants such as glues, aerosols and petrol, is also a major problem in many communities.

Proactive and opportunistic provision of culturally appropriate intervention is the role of all primary care medical staff, as even small reductions in alcohol consumption have benefits for both the individual and the wider community.

Despite widespread alcohol and substance abuse, a non-judgmental, non-stereotypical attitude is essential. Individual assessment is paramount, and making assumptions based on Aboriginality is inappropriate.

EDITOR’S COMMENT

Especially for those emergency doctors working in the many city or rural hospitals that see and treat these groups, it is important and rewarding to actively become familiar with and good at caring for these patients (e.g. while doing courses, rural rotations, locum work).

RECOMMENDED READING

Australian Bureau of Statistics website. Available: http://www.ABS.gov.au

Couzos S., Murray R., editors. Aboriginal primary health care: an evidence-based approach, 3rd edn, Melbourne: Oxford University Press, 2008.

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