Dr Elissa Hatherly  00:02

Welcome to The Round Up, a North Queensland based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician, and head of JCU's Clinical School here in Mackay. This collaborative podcasting project between North Queensland Regional Training hubs, JCU, and our local, regional, Hospital and Health Services, will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. In today's episode, I'm joined by Dr. Kaylene Girgenti who is a rural generalist with a specialty in women's health, having trained in O&G, who enjoys some practice in private general practice and some public work in the Townsville region, across at Magnetic Island, in Currumbin, all kinds of exciting places. Welcome, Kaylene.

 

Kaylene Girgenti  01:05

Thank you so much for having me. It's a pleasure.

 

Elissa Hatherly  01:07

We really wanted to talk about contraception, and I know this is something you spend a lot of time working in and have a particular passion for. What led you to women's health in the first place, do you think?

 

Kaylene Girgenti  01:19

Well, I think being a woman, it's always really important to be seeing someone that you have confidence in, they know what they're talking about, and that they've seen some things and that they have some experience, and so I really wanted to be that person for the women that I was seeing. I've worked in a lot of rural areas and I know sometimes there aren't many options for the practitioners that you see but I just really wanted to be confident, comfortable and experienced in women's health. So I've really sought out as much as I can to try to make that a possibility for patients.

 

Elissa Hatherly  01:51

You're right, we have so many more opportunities these days in terms of contraception prescribing. Should we talk through a case then because sometimes people don't recognize the breadth of contraception options that are available to young women today. For example, a young woman who's 23, who comes into the practice, who is asking for a repeat prescription of her contraceptive pill, what would be the sorts of things you'd talk to her about?

 

Kaylene Girgenti  02:21

So, and that is a scenario that plays out so often, and you might not have met the woman before, and you know, they often expect to just come in, get their script and be gone five minutes later, if that but I think it's really important to make sure that it's the right option for that woman to be on. So I like to know a little bit about her, you know, like to know, Is she in a relationship or not at the moment? Is she just solely using her pill for contraception? Or was it perhaps commenced for other reasons? Was she having menstrual difficulties? Was she having issues with acne? I then want to make sure, obviously, that if I'm prescribing something, I'm not giving her a medication that could cause harm and that's where those medical eligibility criteria can be really important to be aware about and perhaps I've looked at before. You know, if this is a young woman who suffers from migraines with aura, then perhaps a combined contraceptive pill isn't the best option for her and it might be important to talk about other things and contraception isn't necessarily the be all and end all. You know, do we need to talk about sexually transmitted infections and how to prevent those. There are so many other things that come into it.

 

Dr Elissa Hatherly  03:29

Right. So if she has no contraindications to the contraceptive pill, then it might be something that you continue with.

 

Elissa Hatherly  03:36

What if she did have migraine with aura, as you mentioned, and we look at the medical eligibility criteria and recognize that the combined oral contraceptive pill is contraindicated?

 

Kaylene Girgenti  03:36

Yep. Yeah. So, it's one of my most dreaded conversations, to be honest, because a lot of women are very attached to their pill. They might have used it for years and be really comfortable with it, and happy with it, and everything is going well but you know, it really doesn't sit well with me if I know that there are contraindications to women using it. And so, you know, I've had to have this difficult conversation a number of times over the years and just say, look, there's good evidence that this could be risky for you to be using, and there are so many other options out there that may still offer you the same benefits or even more. You know, I'm not comfortable necessarily prescribing you that, but can we try to talk about why and maybe work out something that might be better suited for you, and it's one of those difficult conversations to have.

 

Dr Elissa Hatherly  04:31

And it's that or that's so important with migraine, isn't it? We don't want to write off the combined oral contraceptive pill as an option without good reason.

 

Kaylene Girgenti  04:40

That's right, and, you know, some women who have other types of headaches are definitely fine to keep using it., but yeah, that migraine with aura especially is something to really be on the lookout for.

 

Dr Elissa Hatherly  04:51

So what other pill options would we have for this particular woman Kaylene?

 

Kaylene Girgenti  04:54

So if she's really happy with taking an oral contraceptive pill than, obviously, you've got your progesterone only options. So the traditional ones might have been Microlut or Micronor, or one of those two options. These days, there's a new progesterone only pill on the market as well by the name of Slinda and I've been finding that it's quite useful for women. So it's the pill, which has drospirenon in it. I've been using that a little bit more frequently these days as well. What are some of the benefits of using that new drospirenone pill, Slinda. I believe it has some antiandrogenic effects as well. Sometimes it might be helpful in terms of avoiding like fluid retention or weight issues. I believe that it can also help with acne issues and those sorts of things as well. So it might have some other spin off benefits that might be attractive for women.

 

Dr Elissa Hatherly  05:46

And of course, the 24 active pills and the 4 sugar pills means that the period or that withdrawal bleed is more predictable for women using the drospirenone pill rather than levonorgestrel or norethisterone progesterone only pill, right?

 

Kaylene Girgenti  06:02

That's right, exactly right. I think that's one of the main issues sometimes with many pills is that you may get some unpredictable spotting here and there, which can be one of the reasons why women might not like it so much.

 

Dr Elissa Hatherly  06:13

 If she doesn't really like taking a pill every day. What else should we be talking to her about?

 

Kaylene Girgenti  06:19

Again, I think at this point, it's really important to assess what are you wanting out of your contraceptive? Is it just solely contraception, in which case, the long acting reversible contraceptives or LARCs are really important to talk to women about. You know, do they want it to be the most reliable option out there. In which case, things like Implanon and Mirena might be worth talking about with about a 99.9% efficacy rate at preventing pregnancy. It's really hard to go past them in terms of preventing pregnancy, not to mention the fact that you're not needing to remember to take something every day and so convenience can be really useful. The spin off to that is that it might sometimes involve a medical procedure, which a lot of people might not be overly excited about but I think if it's going to be something that works for you, and it's something that you don't need to think about for three or five years, and again, that can be really attractive for young women. 

 

Elissa Hatherly  07:13

Of course, and in the private sector, there would be a bit of an outlay financially to commence one of those LARCs might there be but if for an extended period of time, as you say, three to five years. So, that might actually make it more cost effective in the long term.

 

Kaylene Girgenti  07:29

Yeah, that's right. Obviously, the devices aren't overly expensive these days, if you've got a healthcare card, then they're going to be the same low price that you would pay for one of your pill packets. It's more, I guess, the procedural cost depending on which GPs, you see or clinics you see, and again, there may be some public options, they often have a bit of a wait time. So yeah, I guess the initial financial outlay of the consult and the procedure cost might be a bit of a concern to some people but certainly over the course of three to five years, it's probably going to be able to work out as a more cost effective option.

 

Dr Elissa Hatherly  08:01

So Kaylene, what would be the reasons for going with an Implanon or a Mirena, one over the other?

 

Kaylene Girgenti  08:08

When I'm talking to women, I suppose I like to assess, have they tried other hormonal contraceptive methods before? and did they ever notice any particular hormonal side effects that they might have been down to the hormones themselves? A lot of times women might find mood issues or emotional issues can be a bit of a problem with contraceptives and so I guess if you're talking to them about Implanon versus Mirena, you might talk about how there's quite a low circulating hormonal level with Mirena. So that might make that option a little bit more attractive for women. You might talk to them a little bit about bleeding. For girls or women who are having menorrhagia or abnormal bleeding, then Mirena can often offer quite good control of bleeding patterns, and if women don't stop having a period completely, then oftentimes their periods will at least become lighter. So that again can be another great option with the Mirena. Implanon, I suppose, I don't find to be quite as good as Mirena at controlling bleeding patterns, but can still be worth giving a try.

 

Dr Elissa Hatherly  09:10

So for our hypothetical, 23 year old woman who's currently on the combined oral contraceptive pill. Would there be a reason not to start a Mirena? If she has not had a pregnancy, for example, would that be a deterrent?

 

Kaylene Girgenti  09:19

Not for me. I know that some inserters might feel uncomfortable about the idea of putting in a Mirena in a nulliparous woman, but I do it regularly and I often find that these young women are quite motivated when they've made that choice to try the Mirena, and I can't say that I have had any more difficulty inserting Mirenas in nulliparous women than I have in any other woman and I find often it's really straightforward and they're quite well informed as well.

 

Dr Elissa Hatherly  09:53

I would have to agree Kaylene I think that's been my experience as well. So for women who are keen, what would be a contraindication then to using the Mirena?

 

Kaylene Girgenti  10:02

So, I guess with any type of contraception, they will always caution us about abnormal uterine bleeding, you know, has that been looked into? Are we satisfied that there's really nothing suspect going on that could be causing that. Women with a fibroid uterus can sometimes have difficulty with Mirenas. It may be worthwhile, if there's anything unusual in the history, just maybe looking into that a little bit further. Otherwise, I guess there are very few contraindications to using the Mirena because it's working so locally, you don't really need to worry about medication interactions, like you might do with some of the other contraceptive options. It's a really great option for a lot of different women for a lot of different reasons, even those women around the time of menopause, and I guess the one thing that I do often suggest is that we do an STI screen before we insert them and I kind of make that a bit of a routine practice regardless, and obviously excluding pregnancy is a massive thing whenever we're starting contraceptives, but other than, I guess, undiagnosed abnormal uterine bleeding, or a particularly troublesome fibroid uterus, I don't think there are very many contraindications.

 

Dr Elissa Hatherly  11:10

Fantastic. Would you use the Depo-Provera, or Depo-Ralovera injectable contraceptive very often these days then Kaylene?

 

Kaylene Girgenti  11:18

Not really. There are still some women who like using depo but I suppose it doesn't tend to be, and maybe this is because of my practice, maybe because it's not one of the first things that I talk about or suggest to women, I find that it's been getting used less frequently but you know, there are some women who've been on it for some years and they're quite happy with it and they want to continue, but I guess yeah, just because of the way I practice, it's not one of the ones I'll often talk about first.

 

Elissa Hatherly  11:46

What are some of the downsides, then of using the Depo injection, because it does seem like such an easy decision for young women to make and then when you come in, and you're having that conversation with them, and present some of the potential downsides, it becomes a much less appealing option, right?

 

Kaylene Girgenti  12:03

So I guess fertility is a big one. Depo-Provera is one of the main forms of contraception that may delay a woman's return to fertility, and so when I'm talking to a woman about depo, I really make certain that they have no imminent pregnancy plans, and I often make the suggestion that if they're going to use that for their form of contraception that they think about stopping it at least 18 months ahead. Because for some women, there really may be a delay in their return to periods and ovulation and all of that sort of stuff. So I guess that would be the biggie that I'd be counselling them about. Obviously, it's something that they need to have done every 12 weeks, or there abouts, and coming back to the doctors for that might become a bit of a hassle. The fact that they need to be keeping regular appointments up with doctors and I suppose one of the other issues, I sometimes find that Depo may be more inclined to cause weight gain in women and obviously once it's in, we can't really take it out. So that's the other thing. If Mirena or Implanon are causing issues we take it out, whereas Depo you're kind of stuck with it until it wears off in its own time.

 

Elissa Hatherly  13:01

Yeah, that's a great deterrent, isn't it? That you can't get it out if you do experience and nasty side effects and you're right, that 12 weekly injection does come around really quickly, and often takes women by surprise. There's also that chance of osteoporosis with prolonged use of Depo, too, right?

 

Kaylene Girgenti  13:19

Yeah. So they used to talk about that, especially in, like, adolescent girls, and I think they've looked into it further, and please correct me if you've had more recent reading that's changed that thought. I think it wasn't such a big issue as they originally thought and and they think that bone density kind of does return to baseline after a couple of years, but yeah, that's always something that lingers in the back of your mind as well.

 

Elissa Hatherly  13:40

Yeah, you don't want someone to miss out on reaching their peak bone density when there's another option in terms of contraception that would be just as effective or maybe even more useful for them.

 

Kaylene Girgenti  13:52

Yeah.

 

Elissa Hatherly  13:53

So, when we're thinking about a 23 year old nulliparous woman who's been on the combined oral contraceptive pill, turns out she's having migraine with aura. So we've looked at a few other options, including an intrauterine contraceptive device, because even though she's nulliparous, you and I are both quite happy popping an IUD into her as long as she's not going to pick up an STD as you were saying. What about a copper IUD? Do you use those very often these days?

 

Kaylene Girgenti  14:20

Not often. You do get the occasional woman who is so convinced that the Mirena is causing hormonal side effects and you do certainly meet a small group of women who may notice hormonal issues with the Mirena or just, I guess, be hesitant to put any type of hormones into their bodies, quote, unquote, and so they will often look more towards the copper IUDs. I guess when I'm counseling women about copper IUDs we discussed the fact that potentially periods might become heavier or more painful. So it's not common, but as a matter of fact, recently I've had a woman who had had a Mirena put in postpartum, mustn't be liking it currently, so she's requested a script for a copper IUD and I expect to see her in the near future to change that over.

 

Elissa Hatherly  15:02

The big drawback I think is that women don't realize that the copper IUDs aren't stocked routinely and a lot of pharmacies we have to get them ordered in, but of course, that increase in the amount of blood loss that a woman has with that copper IUD might only be the first couple of months mighten it? Their period might settle down and be acceptable and if it's not, then we could always swap it out for one containing a hormone.

 

Kaylene Girgenti  15:25

Correct.

 

Elissa Hatherly  15:25

The outlays for those copper IUDs, though is a little bit more, isn't it?

 

Kaylene Girgenti  15:29

Yeah, I believe they're not on the PBS and because I don't use it so frequently. I'm not exactly sure on the price. I have to ask my lady when she does come back. Yes, I do understand that they're more expensive.

 

Elissa Hatherly  15:40

Yeah, I think they can be in the order of $100 or so which is a bit more than Mirena or an Implanon which you'd get for $30. For those women who are really trying to avoid hormonal contraceptives, as you mentioned, some women might find a copper IUD a great option, what other alternatives do we have?

 

Kaylene Girgenti  15:59

Obviously, condoms and quite often when we're talking about sexually transmitted infection, we'll also throw in condoms as well, because our other hormonal contraceptive options probably aren't going to give us much or any protection against sexually transmitted infection. So condoms. diaphragms, I guess, don't tend to be used too much these days, but it's something that women who are quite informed might look into. Again, some women want to discuss the rhythm method or the Billings method and I guess I can't tell them about the fact that it's not perfect. But if you're really motivated, then, you know, having an awareness about that method is better, I suppose, and not using anything at all, or having complete unawareness about when your most fertile times are, but I guess those would be the main non-hormonal options, condoms, diaphragms, and natural family planning methods.

 

Elissa Hatherly  16:48

Of course with natural family planning those really, as you say motivated patients, they can go through training programs to make sure they've got as much information about using that as possible, which might work for them really well.

 

Kaylene Girgenti  17:01

Yes.

 

Elissa Hatherly  17:02

In terms of a diaphragm. We used to measure women up to get a perfect fit diaphragm for them but we don't do that anymore, do we?

 

Kaylene Girgenti  17:09

No, and to be honest, I have to say that in my however many years of practice since graduating,  I graduated in 2005, I have never once had a woman who has wished for a diaphragm. I've never had to provide them one or size them up, which I don't know how many times you've had to do it, but it's just so uncommon. I would really have to go away and research and look into that myself.

 

Elissa Hatherly  17:31

I think I've done three over 20 years Kaylene. So there you go. But interestingly, I don't recall having seen any of those women come back to actually talk about how successful those diaphragms are.

 

Kaylene Girgenti  17:43

As long as they come back pregnant. I would take that as a good line as well, I think.

 

Dr Elissa Hatherly  17:46

Oh my gosh! Of course these days, you can buy the Caya why a diaphragm online?

 

Kaylene Girgenti  17:53

Yep.

 

Elissa Hatherly  17:54

You can't even get it from your local pharmacy.

 

Kaylene Girgenti  17:57

So people order it over the internet these days. There you go.

 

Elissa Hatherly  18:00

Yeah.

 

Kaylene Girgenti  18:00

Might be why I don't do many consultations. It's all self help and sort yourself out. 

 

Elissa Hatherly  18:05

Which isfantastic, isn't it? We want to make contraception as accessible as possible, particularly for women in North Queensland in rural and remote areas, or in the islands. We don't want women to have to miss out on the best contraceptive of choice for them. One thing we haven't talked about Kaylene is the Kyleena, the new, slightly smaller hormone containing an IUD.

 

Kaylene Girgenti  18:27

Yes.

 

Elissa Hatherly  18:28

Have you inserted a few of those?

 

Kaylene Girgenti  18:30

I haven't, and I guess to be honest, I suppose, I would, I would really need a patient who I felt the actual dose of the hormone was the biggest issue for, because I'm not sure about your practice when you're inserting them but I need to insert a sound first anyway, which I believe is as big or the same size at least as a Mirena. So the drug reps are kind of marketing this as a smaller option and more petite option but the practicalities of insertion for me mean that the sound that I'm putting in first is probably bigger than the Kyleena itself. So, you know, I'm not really seeing necessarily what the point is, but that's just my personal opinion. That is not anything based on evidence or education. What are your thoughts?

 

Elissa Hatherly  19:13

Yeah, it certainly is much the same size as a Mirena. You're right. I suppose it's been useful for me in women for whom the dose in the Mirena has been too much for them to manage, you know, those women who might get recurrent ovarian cysts, for example, won't experience that with the Kyleena, but they're still going to get a period with Kyleena. They are going to miss out on that potential amenorrhea that the Mirena offers.

 

Kaylene Girgenti  19:40

So yeah, I haven't really used a lot of Kyleena as yet, but there will be those women where it will be a decent option. I think the women who have tried Mirena and didn't like it will often then opt for a copper IUD if they're still thinking along the IUD lines and I might have a little bit of a battle trying to talk them into trying and Kyleena or if they didn't like the Mirena. But yeah, but perhaps I need to mention that as a first option for those women with ovarian cyst history that we're really concerned about.

 

Elissa Hatherly  20:07

Yeah, I do think it's a little bit less uncomfortable for those really young women. So girls who are 16-17-18, who are quite small in stature themselves. You know, those really petite framed women who don't have a heavy period, who are looking for that long acting reversible contraceptives. Then I might try the Kyleena. But of course, we do see so many really young women who have an ridiculously heavy period who really need that menstrual management to be maximized for whom the Mirena is actually going to provide the greatest benefit.

 

Kaylene Girgenti  20:39

Yep.

 

Elissa Hatherly  20:39

We could always pop the Kyleena in and then upgrade them down the track to a Mirena, if they don't get good enough period control. What are your top tips then, Kaeleen, for prescribers in terms of contraceptive options.

 

Kaylene Girgenti  20:52

So, I think, number one is know your patient. What are they looking for? Is it just solely pregnancy prevention? Or do they have those other issues with acne or menstrual difficulties, or all of those other sorts of things? So know your patient. Find out a little bit more about their life? What's going to be most convenient for them? What can they afford? Those considerations can be really important as well. Give them all of the options and let them make an informed choice. I often find the little handouts, the patient information handouts from the old family planning website, which is now called true.org.au, and we'll attach links below this podcast to the websites that I find useful. Helping women to make an informed decision is really important. If they feel like they've been part of that decision making process, and it's not that we've forced something upon them that they weren't really interested in using. I think there's much more success of women using it well, and having confidence in that type of contraception, and I guess just keep communication lines open. Encourage them to come back if they're having any issues. Sometimes you need to do a little bit of troubleshooting if women are having problems with breakthrough bleeding or any of those sorts of things. So just make sure that you've left those lines of communication open after you've had that consult and decided on your first option.

 

Elissa Hatherly  22:05

I think that's fantastic advice, Kaylene. Think there's nothing more difficult than the patient who comes in and says I want the best contraceptive. What are you going to give me? I want the best one, and I say there's no best.

 

Kaylene Girgenti  22:17

Best for what?

 

Elissa Hatherly  22:18

That's right. We need to find the contraception that's right for you. That's fantastic advice. Dr Kaylene Girgenti, from the Townsville region, thank you so much for talking about contraception today.

 

Kaylene Girgenti  22:30

I could talk all day about it. Thank you very much for having me.

 

Elissa Hatherly  22:35

For more information about the round up, please share your feedback and ideas. For future episodes, visit nqrth.edu.au/news/roundup-podcast/, or contact us at NQRTH.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's Integrated Rural Training Pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

• True Relationships & Reproductive Health
• Therapeutic Guidelines - Contraception
• Faculty of Sexual and Reproductive Healthcare

Elissa Hatherly  00:02

Welcome to the roundup a North Queensland based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician and head of JCU's Clinical School here in Mackay, this collaborative podcasting project between North Queensland Regional Training Hubs, JCU, and our local, regional Hospital and Health Services will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. In today's episode, I'm joined by nephrologist from the Cairns region, Dr. Tahira Scott. Hi, Tahira.

 

Tahira Scott  00:48

Hi Alyssa, how are you today?

 

Elissa Hatherly  00:50

I'm well and so excited to be able to chat to you I understand your work as a kidney specialist is mainly in Torres and Cape regions. I can't think of anyone more well qualified to talk about renal disease today.

 

Tahira Scott  01:04

Well, thank you for having me. Yeah, that's right. So I am very privileged, I get to go and travel to the communities in the Torres and Cape and see the patients out there. So I'm excited to talk to you about kidney disease today. Thank you for having me, again.

 

Elissa Hatherly  01:17

I'm sure it's something you're super passionate about or you wouldn't have trained in it, can you start by giving us a definition of chronic kidney disease or CKD.

 

01:26

Absolutely, always a good place to start. So the definition of CKD really is centered around abnormalities in the pathology that needs to be present for three months, and that it's present on several tests that you've ordered. So the first criteria that you can meet the definition of CKD is if you have an eGFR (estimated glomerular filtration rate) less than 60 mgs per minute per 1.73 metre square, and that's on the CKD-EPI formula, which all Australian laboratories use. However, it's important to remember that creatinine can be quite fluctuate, and it can vary with hydration, and so it's always important to check if this is the first time you've seen your patient with this kind of result with an eGFR less than 60, that it is truly persistent. So we always recommend to check the kidney function again within one to two weeks to confirm that. The second criteria that meets the definition of CKD is if you have a normal eGFR, but evidence of kidney damage, and the way we define evidence of kidney damage. The first example is albuminuria, which you would confirm on a urine albumin-creatinine ratio (uACR), and we always recommend to repeat this test more than once, and the recommendation is to try and do it for the first void in the morning. Which I know can be quite challenging logistically to get your patients to do that, but the reason why is that albuminuria has a diurnal variation. So after you've been up and about during the day in ambulatory, you will have a higher albuminuria result at the end of the day. Another example of detecting kidney damage as haematuria, and so you'll see dysmorphic red cells once the pathologist spins down that urine, and if you do see haematuria, and it doesn't have the comment that it's dysmorphic, it's still worth just working up because unfortunately, the morphology on urine MSUs (midstream specimen of urine) are not always very accurate. So it's important to exclude urological causes of that haematuria and I would recommend doing an ultrasound to exclude any stones, any lesions, and of course, the three urine cytologies, which I'm sure most of the listeners are familiar with. And then the last evidence of kidney disease that you may find is when you do an ultrasound, KUB, you may see cysts on the kidney, and they may actually qualify for polycystic kidney disease, all dependent on the age and their family history.

 

Elissa Hatherly  03:46

Right. So, that's a lot of things to be considering in our day-to-day practice, thanks Tahira. When we consider all those different ways to define CKD, what then is the burden of CKD in Queensland's population, and particularly the Aboriginal and Torres Strait Islander population?

 

04:04

So the burden of CKD is a very topical issue at this point of time, and this is because the kidney health Australia Organization released a report this year outlining the burden of CKD at the national level and also the cost to the taxpayer. And just to let the listeners know, in 2021, there was over 2 million Australians with evidence of CKD and it was costing the Australian taxpayer $9.9 billion and that's because kidney disease is expensive. Patients with kidney disease have higher rates of hospital admissions because they're comorbid. They also have an increased risk of cardiovascular disease, and just as a side note, the new Aus. CVD risk calculator actually classifies patients as high risk for cardiovascular disease if they have an eGFR less than 45 or a severely increased albuminuria. So that's uACR greater than 30, meaning that they're at a greater than 10% risk it within five years of having a cardiovascular event. So at the local level, well within Queensland one in 10 patients have evidence of CKD or one in 10 Queenslanders, sorry, and one in five Aboriginal and Torres Strait Islanders will have biochemical signs of CKD. And just to make the issue even more concerning, from a metabolic point of view, two thirds of Queensland is currently overweight and obese, which is predicted to lead to a diabesity epidemic and really encouraging us as clinicians that we need to start thinking about screening more widely, because if we do not change our current screening practices and screen more widely, it's forecasted by 2030, that the number of patients that have kidney failure will increase by 42%. So it's very concerning Elissa.

 

05:41

Two million Australians, one in five Aboriginal and Torres Strait Islanders. That's just massive! Talking about increasing our screening capacity Tahira, who should we be screening for kidney disease? So not just people with a lower GFR, it sounds like anyone who is overweight or obese we should be doing a urine ACR perhaps?

 

Tahira Scott  06:01

Yeah, so that right Elissa. So, at the moment the Kidney Health Australia specifies screening all high risk individuals every 12 months, and so they define high risk individuals as patients that have diabetes mellitus, hypertension, a family history of kidney disease, if they're an active smoker, or if they've had a history of AKI (Acute Kidney Injury) because AKI will lead to nephron loss and therefore risk of CKD. As well as patients that have vascular disease or if they've had a heart attack before, or they have peripheral vascular disease, and patients that are greater than 60 years of age. And then the last factor which is really relevant given I just told you two thirds of Queenslanders are overweight and obese is that they recommend screening severely overweight and obese individuals, and I mean severely overweight is a little bit hard to define, but as a clinician, if you just suspect that you should be screening your patient for kidney disease, I would just encourage you to go ahead and do it because the tests are relatively inexpensive and the impact of detecting kidney disease and managing it is quite profound. There's actually different recommendations for screening in our first nation populations. So for First Nation people, it's recommended to start doing a kidney health check as soon as they turn 18 years of age as part of their adult health check that they do, and that's with annual screening once again. But I just want to share some additional factors if that's okay, Elissa just about First Nation kidney disease.

 

Elissa Hatherly  07:22

Sure.

 

Tahira Scott  07:23

Last year, the caring for Australian and New Zealand's with kidney impairment guideline was released, and they've recommended removing indigenous status as a risk factor for chronic kidney disease because the increased risk is explained by adverse social determinants of health, which leads to a greater burden and progression of CKD. So these additional risk factors when you're seeing your First Nation patients should be considered. So one of the additional risk factors is having a low birth weight. So if they were born at less than 2.5 kilos, and the pathophysiological reason for that is when infants are born with lower birth weight, they're born with less nephrons, and they get a phenomenon called hyperfiltration in the kidney, which actually leads to insu glomerular hypertension, and because of that, you get scarring of that nephron, and we call that secondary focal segmental glomerulosclerosis (FSGS), which eventually will be completely sclerosed and they'll lose that nephron, and therefore, they're at a higher, high risk of CKD. Other risk factors include acute post-streptococcal glomerulonephritis, and the social disadvantages that we know that exist, especially in our rural and remote communities, like lower socioeconomic status, lower education, and insecure housing. And why it's so important to find kidney disease in our First Nation population is that we have evidence from the eGFR study, led by Jackie Hughes, that once a First Nation person has severely increased albuminuria. so that's a uACR greater than 30, they're more likely to have a rapid decline in their eGFR by more than 6mLs per year, which is very, very rapid considering the normal accepted eGFR decline is around 1 to 2 mgs, which is accepted as a normal age-related decline in a non-diabetic patient.

 

09:09

This is shocking to hear Tahira. Even in a workplace, like we have, where we know the social determinants of disease are so impactful. In a region where we know equitable access to health care is diabolical. It's a massive, massive problem and only, as you say, expected to get significantly worse over the next few years. When we're doing our screening., you've mentioned uACR a few times, is that just one tool should we be doing the GFR and the uACR annually?

 

09:40

So the standard kidney health check involves a blood pressure, which most listeners would do, a urine albumin creatinine ratio, and an eGFR, as you mentioned. I think it's worth just exploring and really explaining why we're doing a urine albumin creatinine ratio rather than a urine protein creatinine ratio to the listeners because we kind of just made that switch a couple of decades ago, and a lot of people don't quite understand why. The reason why is that albumin is the most common protein within our blood, and it's very indicative of glomerular damage. When you do an albumin creatinine ratio. It's a standardized ratio, meaning that if you had a uACR done at Sullivan Nicolaides, and then you got it done at Queensland pathology, you can compare those two results and they would be very similar, where the urine protein creatinine ratio, however, it detects other proteins such as light chains, globulins, Tamm-Horsfall protein (THP), and some of those are different assays, depending on which laboratory can detect more proteins and others can. So they're not really directly comparable, as well as the fact is I mentioned before, it depends on what time of the day you're testing it. The other reason we do a urine albumin creatinine ratio, rather than a urine protein creatinine  ratio is that we've been using uACRs in our research now for some time, and we can directly correlate an albuminuria level to the risk of cardiovascular disease, and also progression to kidney failure. That's the standard test that you do, Kidney health check, and if you find a signal on those tests that there's evidence of kidney disease, then it's recommended to start investigating further. To think "Hey, hang on a minute, what's causing this kidney disease", and so the test that we recommend would be starting off with the full blood count, doing some inflammatory markers, like an ESR (erythrocyte sedientation rate) and CRP, and that's simply just to screen and make sure that there's nothing else going on like a multiple myeloma or another autoimmune condition. Of course, a urine MSU is very important, especially looking for dysmorphic red cells, which could represent a glomerular disease. Other important things are an ultrasound KUB really to define the anatomy, and I have been asked by clinicians in the past, do I need to do an ultrasound KUB if they have a normal eGFR? Well, if you're investigating albuminurea, I would highly recommend doing it because some patients are born with one kidney, so they have a solitary kidney, and that kidney because they have less nephrons is once again undergoing that hyper filtration process, working extra hard, having scarring, and it will manifest as increasing albuminuria. And then lastly, really, when you detect kidney disease, you need to screen for chronic diseases that may actually be causing the kidney disease, and so doing a HBA1c, if you don't know if they have diabetes yet and a lipid profile.

 

Elissa Hatherly  12:22

That's a great and comprehensive list of what we can do and something that all of us can manage in our day-to-day practice, for sure. So, once we've detected the kidney disease then, after having performed our kidney health check in any of those follow on investigations, what's our next step in terms of our management? Because a lot of us will be able to initiate those lipid lowering medications and diabetes medications to improve GFR straightaway, or do we need to get in contact with the nephrologist sooner rather than later?

 

12:54

So what I recommend is Kidney Help Australia have an excellent app that you can download to a smartphone called the CKD Go app, and essentially, this app allows you to enter the patient's eGFR and the albuminuria status, and it essentially lets you know straightaway, should you, or should you not refer to nephrology and gives you some suggested management plans. And it really all depends on what you think is causing the kidney disease, really. The Kidney Health Australia guidelines recommend an immediate referral to nephrology if their eGFR is less than 30 mgs per minute, or, if they have persistent severely increased albuminuria, which we used to call macroalbuminuria, where the uACR is greater than 30 milligrams per millimole. There's two other criterias where you can refer and that's if you have a sustained decrease in eGFR, 15 mg within one year, so within a 12 month period. So as a practical example, say your patient had an eGFR above 60, say 75 the year prior, you see them, it's dipped below 60, I would still suggest once again, to just check it and if it's persistently below 60, then a referral to nephrology is warranted, because there's probably a rapid progressive kidney disorder that needs to be investigated by nephrologist at that point of time. But it's very useful if you could do those other tests that I mentioned to explore why they... why they might potentially have kidney disease. And then the last criteria that Kidney Australia list include a patient that has CKD. So meaning that definition we went through at the start of the podcast, and they have really challenging or difficult hypertension to control. So they have the definition of resistant hypertension where they're on three antihypertensives, with one of them being a diuretic, and their blood pressure is still greater than 130 on 80 on a standard office measurement. Of course, if you find some other peculiar situation where you think someone might have glomerular disease and they don't fit within those criterias, you can always refer or you can always ring your local hospital and ask to speak to the renal register or the consultant on call and they can help guide you from there.

 

14:58

Oh, that's fantastic Tahira. So we'll do our kidney health check, which is starting off with our urine albumin creatinine ratio looking for a number less than 30, an eGFR, and a blood pressure, and we can then refer if the eGFR is less than 30, or the uACR is greater than 30 straightaway, or, we can look for some assistance from the CKD Go app or from our local nephrology reg or kidney specialist who will be able to give us a little bit more guidance with our patients. Tahia, can we talk about diabetes, please? I'm a little bit scared.

 

Tahira Scott  15:35

Of course, we have to talk about diabetic kidney disease. It's a very important condition that we're all seeing in our practice, especially in North Queensland and Far North Queensland. So, yes, let's talk about diabetic kidney disease. Really, when it comes to diabetic kidney disease, we can expect that 30 to 40% of patients that have diabetes mellitus will develop diabetic kidney disease, and historically, we used to call it diabetic nephropathy, and that really was defined by a patient having retinopathy and type one diabetes and albuminurea. Now we're using the term diabetic kidney disease, which I personally like because it's more patient friendly, and essentially all that term means is that they've got diabetes and they've got signs of kidney disease, as we mentioned in our definition of CKD. So when it comes to diabetic kidney disease, really the hallmark is albuminuria, but it's important to remember that not everybody that has diabetic kidney disease will have albuminuria.

 

16:39

Right, so not everyone who has diabetic kidney disease has albuminuria. How are we going to tease out which of our diabetic patients need the help of a kidney specialist?

 

16:51

It would be exactly the same as the criteria that we mentioned before, Elissa, with referral, but today I want to talk to you a little bit about how primary care can manage diabetic kidney disease because we have now, in the literature, the four pillars of diabetic kidney disease management, which kind of target the different pathophysiological pathways that are leading to the damage within the kidney. So I might just briefly go through the pathophysiology, just to remind the listeners about why diabetes is causing kidney disease, and then go through the different four pillars of diabetic kidney disease management.

 

Elissa Hatherly  17:25

Fantastic.

 

17:26

So the reason why patients get kidney damage from diabetes really is because of three pathways. So the first thing is we have the hyperglycaemia, which leads to advanced glycation end products (AGEs), reactive oxygen species (ROS), and inflammation in the kidney, and so this inflammation can lead to fibrosis, and once you have fibrosis in the kidney, of course, you're going to get progressive nephron loss. You also get the haemodynamic dysregulation, which leads to insu glomerular hypotension simply because you have endothelial dysfunction just because of that hypoglycaemic environment amongst other things. So overall, if we were to biopsy patients with diabetic kidney disease, which we often don't, you would see on a biopsy, what we call mesangial expansion and nodules. Probably the most important thing that kind of may help the listeners understand why the patients get albuminuria, though, is that you see endothelial damage, basement membrane thickening, and podacyte loss. So, across the board in most kidney conditions, if you have podacyte loss, then you will get albuminurea because the podacytes and their foot processes are the last barrier between the glomeruli and the filtrate, and so if those podacytes aren't working protein will get into the urine where it shouldn't be, and we will see that manifest as albuminurea proteinuria. Now with diabetic kidney disease, once the damage is there, it's irreversible, and we really need to mitigate the progression. So how do we as nephrologist diagnose diabetic kidney disease? If we are not, byopsing patients? The first thing is that they have to have signs of CKD, which we've gone through that definition. It is very suggestive that they're going to have diabetic kidney disease if they have retinopathy, because let's face it, hyperglycemia doesn't select what small arterioles it's going to affect. If it's affecting the eyes, it's going to be affecting the kidneys, and also it helps when someone's had a duration of diabetes for more than five years. It's more suggested they're going to be having diabetic kidney disease. The other criteria is that we as clinicians need to assess and ensure that we don't think there's any other alternative diagnoses going on. So we're pretty confident it's going to be the diabetes. They've had it for 10 years, they've had some historic poor control,  and they've got albuminuria. Nephrologist rarely do kidney biopsies for diabetic kidney disease unless they're suspicious that there may be another aetiology that's the primary driver, or, if someone has very stable albuminuria for some time, and they suddenly have a rapid increase in the amount of albuminuria that can suggest that potentially the site anything else going on? Sorry, the four pillars of diabetic kidney disease management, are you ready to talk about them, Elissa?

 

Tahira Scott  20:05

Let's this is... there's quite a lot to go through here. There is a lot to go through, but I think it's important to talk about these pillars because it's forecasted within the next five to ten years that three of the four pillars will be the causes of CKD. As you know, now with SGLT2 inhibitors, we have the indication for CKD with albuminurea. So there's a lot of these drugs that we'll be using across the board in most CKD, and this will be conditions that are not glomerular disease that require high doses of immunosuppression or conditions like PKD (polycystic kidney disease). Now, when I'm talking about these four pillars of diabetic kidney disease, these can all be started by primary care, and it's mostly really discussing type two diabetes that's causing diabetic kidney disease, and I would admit, you have to be quite creative with how you use your PBS codes to try and get your patients on these drugs. So let's dive in. So the first pillar is ACE inhibitors, and ARVs and most listeners will be very comfortable with using these drugs. We use them in CKD. We've got large international RCTs, which show that they're effective, and they work on that pathophysiological pathway of the haemodynamic dysregulation by dilating the Eforan Arterial, and we know by trying to get patients on the highest tolerable dose of an ACE or ARV, the main limitation being hyperkalaemia that we can potentially see a 15 to 20% relative risk reduction in CKD progression. Everyone's pretty comfortable with ACEs and ARVs right.

 

Elissa Hatherly  21:36

Yep.

 

Tahira Scott  21:36

So the second pillar is SGLT2 inhibitors, which I'm sure most primary care doctors are getting very comfortable with too,  now.

 

Elissa Hatherly  21:45

Yeah.

 

Tahira Scott  21:46

So, we have three large international trials now in the kidney space for these drugs. So, Credence, DAPA-CKD, and EMPA-Kidney, and SGLT2 inhibitors work in the kidney by several pathways. The first one is they also work by resolving that haemodynamic dysregulation, so it does that by the Eforan Arterial constricts, essentially by restoring the tubular glomerular feedback loop and reducing intra glomerular hypertension, and then SGLT2 inhibitors also reduce inflammation in the kidney. I'm not going to get into the nitty gritty of why, but they do, and the benefit of this is that we've seen across those three large trials and pooling all that data in a large meta analysis, that we can see a reduction in progression to basically requiring dialysis by greater than 40%. So it's quite significant.

 

Elissa Hatherly  22:39

And of course, working together with the ACE inhibitors, and the ARVs that's going to be an even greater benefit, isn't it?

 

Tahira Scott  22:45

That's correct. That's right, and so at the moment, the PBS does restrict prescribing it to patients that have albuminuria, but it's actually recommended in our KDIGO international guidelines that we should try and start all of our patients with diabetic kidney disease on SGLT2 inhibitors regardless of the stages of albuminuria. So we've seen in the studies that there is benefits, even at you know, microalbuminuria levels, however, the most beneficial or more notable benefit is when you have severely increased albuminuria.  So, Tahira, how are we going to get around the PBS guidelines for dispensing the SGLT2 inhibitors?  Great. So I guess you could either use it for the diabetic indication or you can use it for the CKD with albuminuria indication. So the other newer indication, as mentioned, the uACR, actually it's a funny number, is 22.6, so greater than 22.6, or an eGFR greater than 25, but I'll just reassure the listeners that the EMPA-Kidney study went right down to an eGFR of 20. So it's quite safe to use it even at a low eGFR, and that you would stop the SGLT2 inhibitor once they're on dialysis or they get a transplant, but there is actually a large RCT occurring right now looking at using SGLT2 inhibitors and transplant and dialysis patients for the cardiac benefits. The important thing to know though, is that they need to be on the 10 milligram dose for it to be effective, because I have seen some patients that are on the combination Dapa-Metformin dose, and they're just on the five milligram. Whatever the Metformin dose is just once a day. The pharmacodynamic studies that they did before DAPA-CKD showed that the most effective dose is 10 milligrams, so I'd encourage the listeners to ensure they're on the 10 milligram dose. The other thing, just to be cautious of is that SGLT2 inhibitors do change the haemodynamics of the kidney initially, and so we advise, if you can avoid checking the bloods for the first four weeks, I would avoid it because you might panic because you might see that eGFR has dropped more than 30%. If you have to check it for another reason and it has, a recommendation is just to do a fluid assessment and make sure they're not intravascular dry, and if you're starting on a patient that's on a loop diuretic and the euvolaemic, we recommend reducing that loop diuretic by 50%, when you start an SGLT2 inhibitor.

 

Elissa Hatherly  25:06

Okay. Yeah, that makes sense.

 

Tahira Scott  25:08

There is one other caveat to starting an SGLT2 inhibitor which I find is very common in the neighborhood where I work. If someone has a double digit HBA1c, I would wait until the HBA1c is closer to a single digit to avoid the genital urinary fungal infections.

 

Elissa Hatherly  25:25

Yeah, they can be so difficult to manage, can't they?

 

Tahira Scott  25:28

Yes, and it's very difficult to encourage the patient to try it again. Once their glycaemic controls a bit better.

 

Elissa Hatherly  25:34

Yeah. Okay, so pillar number three Tahira.

 

Tahira Scott  25:37

Pillar number three. All right, so we've got two more to go. So Finerenone. So it's, it's a new drug. It's only just been on the PBS in the last couple of months. What is Finerenone, you ask? So, it's a novel selective non-steroidal mineral corticoid receptor antagonist that basically is like an anti inflammatory for the kidney. It's different to the steroidal mineralocorticoid receptor antagonist (MRA) like Spironolactone. It's a cleaner drug, so you're less likely to get side effects like, well, you don't get the side effects of gynecomastia. The pathway we're targeting with Finerenone is the inflammation and fibrosis, and there's two trials that have been done with Finerenone, the FIDELIO and FIGARO trial, and they enrolled patients with eGFR greater than 25, or uACR, greater than 22.6. They were already on an ACE and ARV, and it showed that it reduced the progression of CKD by 23%. Once again, we can start getting these patients on all these organ protective drugs that are targeting the different pathophysiological pathways, hopefully, we can delay dialysis.

 

Elissa Hatherly  26:40

An anti-inflammatory for the kidney. That is brilliant. I love it.

 

Tahira Scott  26:44

The cool thing about Finerenone is there's really minimal side effects. In fact, in the in the studies that are the major side effect they saw was hyperkalaemia, but the problem was when they were running these trials SGLT2 inhibitors weren't used as widely as they are being used now. In fact, only 7% of the cohort were on SGLT2 inhibitors and why that's relevant is now to prescribe Finerenone, which primary care can, the patient has to be on a SGLT2 inhibitor, and SGLT2 inhibitors stimulate kaliuresis, so potassium excretion. So if you have them on the combination, you're less likely to see hyperkalaemia. That's what we think, but there is a trial underway at the moment with an SGLT2 inhibitor and Finerenone, which will probably change the following recommendations about what to do once you start Finerenone with regards to hyperkalaemia.

 

Elissa Hatherly  27:32

Tahira, what is the PBS criteria then for commencing Finerenone?

 

Tahira Scott  27:36

It's essentially identical to who they enrolled in the trial. So just anyone with type two diabetes, the uACR has to be greater than 22, eGFR greater than 25. They have to be on an ACE and ARV, and an SGLT2 inhibitor unless any of those drugs are contraindicated, and they can't be on Spironolactone as well. So they can't be on the steroidal mineral corticoid receptor antagonists, and then PBS also asked if you have heart failure, reduced ejection fraction, and you're likely to require a steroidal MRA that you don't prescribe Finerenone.

 

Elissa Hatherly  28:07

Yeah, okay, that makes sense.

 

Tahira Scott  28:09

So if you start someone on Finerenone, there's three different doses. So if they're eGFR is greater than 60, you start them on 20 milligrams, and if it's less than 60, 10 milligrams, but it's recommended only to start them on that if their potassium is less than 5.5, or closer to five would be ideal. And the recommendation is to check their electrolytes after a month, and if it's stable, then just four monthly onwards, which is essentially when you do that routine diabetics cycle of care.

 

Elissa Hatherly  28:36

Yeah, fantastic. So then, the fourth pillar Tahira, what's that?

 

Tahira Scott  28:41

The final pillar is GLP-1 agonists, which we know are in hot demand across the country. So drugs like Ozempic have shown in international trials that there's potentially promising nephroprotective benefits, and they're currently doing a study right now with Semaglutide called the Flow trial, where they have patients on ACEs and ARVs already and some SGLT2 inhibitors to see whether or not there's a further additive benefit to reduction of CKD progression, and obviously, the GLP-1s also have the benefit of the improve hyperglycemia and also the weight loss, which is beneficial because obesity can lead to focal segmental glomerulosclerosis. Now obviously the biggest trickiest thing about GLP-1s is navigating the PBS with prescribing that.

 

Elissa Hatherly  29:27

Yeah, everybody wants to know which pharmacy has Ozempic. I need Ozempic. What is the tips and tricks to prescribing the GLP-1s from your point of view, Tahira?

 

Tahira Scott  29:37

Well, I guess availability is key. Look, I don't really have any tricks. Obviously, Ozempic is really the only one that's available at the moment. There's still major supply issues with Trulicity. I think most people just follow the routine suggestion where you start at 0.25 milligrams weekly. And then after a month of tolerating that going up to 0.5 And then under one milligram after they've tolerated the lower dose prior to that, really, if they're on high doses of insulin, they suggest having a 20 to 30% reduction as well, unless their glycemic control is extremely poor.

 

Elissa Hatherly  30:14

It's an awfully big undertaking for patients with diabetes, isn't it to make sure they don't develop the diabetic kidney disease, and then go on to need all of these medications. Tahira, how are we better able to manage our patients to help avoid diabetic kidney disease? I suppose it just comes back to really good general comprehensive care of our cohort of patients.

 

Tahira Scott  30:38

Yeah, that's right. So unfortunately, you know, sometimes when we diagnose patients with type two diabetes, they may already have had hyperglycaemia for some time, and the damage to their kidney has already started, and so there's not much prevention, there's only really mitigation to prevent it getting worse. So the recommendation is just like the standard comprehensive care, as you said, you know, encouraging those lifestyle changes, ensuring that they have optimal glycemic control as close to the beginning of their diagnosis. So once you've diagnosed them, and then also addressing their cardiovascular risk factors, as well as good blood pressure control.

 

Elissa Hatherly  31:15

It's a good reminder to all of us to be more encouraging of our diabetic patients to keep that really good glycemic control isn't it? Tahira, we've talked about a lot of stuff today. So the kidney health check looking at the uACR, the eGFR and the blood pressure. Investigating further if we have any concerns about kidney health in any of our patients. Remembering that one in ten Queenslanders are affected by chronic kidney disease, and one in five people from Aboriginal and Torres Strait island backgrounds, and remembering that overweight and obesity is a major risk factor for kidney disease, and screening our patients early if we suspect they might develop a kidney concern. Really excited to learn about Finerenon. Excited to learn about the CKD Go app. I'm going to be downloading that and having a look shortly. Tahira, is there anything else that we need to know in our community about chronic kidney disease or nephrology generally that you think we should be sharing with our listeners today?

 

Tahira Scott  32:16

I guess I just like to encourage the clinicians that are seeing patients with diabetes to not be afraid to start these medications that are targeting the four pillars of diabetic kidney disease, rather than waiting for them to see a nephrologist because as soon as we get the patients on these organ protective medications, we are preventing ongoing damage. That's essentially it Elissa.

 

Elissa Hatherly  32:38

That's fantastic.

 

Tahira Scott  32:39

Time is kidney!

 

Elissa Hatherly  32:41

Time is kidney. I like that. I think we can get a whole advertising campaign around that slogan - 'Time his kidney'. Dr Tahira Scott from the Cairns region looking after our Torres and Cape patients. Thank you so much for your time today talking about kidney disease and diabetic kidney diseas. Got a lot of things to take home and put into our own practices. Thanks so much.

 

Tahira Scott  33:03

Thank you.

 

Elissa Hatherly  33:08

For more information about the roundup to share your feedback and ideas. For future episodes, visit nqth.edu.au forward slash round up hyphen podcast, or contact us at nqth.mci@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

• Cari Guidelines | Recommendations for Culturally Safe Kidney Care in First Nations Australians

• Kidney Health Australia | CDK-Go App

Dr Elissa Hatherly  00:02

Welcome to the Round Up a North Queensland based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician and head of JCU's Clinical School here in Mackay, this collaborative podcasting project between North Queensland Regional Training Hubs, JCU, and our local, regional, Hospital and Health Services will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. In today's episode, I'm joined by Dr. Jason Yates, a paediatric endocrinologist at Townsville Hospital and Health Service, who is Medical Director of Women's and Children's Services. Hello, Jason, thank you for joining us.

 

Dr Jason Yates  00:54

My pleasure. Good morning.

 

Dr Elissa Hatherly  00:56

Jason, you really wanted to talk about diabetic ketoacidosis (DKA), one of your passion projects. I think that's an incredibly important thing to talk about with the rising incidence of diabetes in our communities. Are the numbers really going up that much?

 

Dr Jason Yates  01:11

Yes I think if you think about diabetes, as a general disease process across all ages, it's going up dramatically and has been for the last few years. Obviously, my role is paediatrics for which type one diabetes makes up the majority. And we have seen an incidence rise over the last five years as well, and actually, we've seen a jump in the last 12 to 24 months, which post COVID has a lot of people wondering about how much linkages there are there?

 

Dr Elissa Hatherly  01:41

Oh, wow, that's terrifying, I must admit though, I've been a GP for nearly 20 years, and I've only seen one paediatric case of diabetic ketoacidosis. I think the young boy was maybe 15 or 16, brought in by his mom, and he looked like a zombie when he was walking through the door within ridiculous blood sugar. Should we be looking more carefully for the earliest signs of diabetes, then, in our patients in the community?

 

Dr Jason Yates  02:07

100%, and look, you know, we have done a bit of work on this, and we plan to do some more work, hopefully in the next twelve months, and so we got some funding through Clinical Excellence Queensland to develop an intervention for want of a better term where we looked at trying to improve the awareness of the signs of hypoglycaemia in the community. Part of the planning for that project, we got out and about and tried to look at the evidence base, as well as look at what people have done in the past, and one of the big things that comes out in that is from a primary care perspective, the the incidence of type one diabetes in the average practice is very low. So most families that have type one diabetes, sort of whisked up into the specialty clinics, and I can say this with insight is we're not very good at sharing, and that's probably to the detriment of what we're trying to achieve, but I remember doing a survey, about ten years ago now in Brisbane. It was an after hours function for GPs through the Mater and we... just out of interest did a brief survey of the 30-35 GPs that were there - all very experienced, and I think only about 60 to 70% of them had never actually seen type one diabetes in their careers. So never diagnosed, it never seen it. The ones that had it only done at once. So while small numbers, it really did highlight the fact that this is just not something that's commonly seen in primary care, and so the chances of being able to go 'well hang on this could be type one diabetes' is much lower, because the vast majority of diabetes seen in primary care is a completely different phenotype and type two.

 

Dr Elissa Hatherly  03:46

Yeah, right. So I'm not alone, then that's reassuring. Jason, what are those signs and symptoms of hyperglycaemia that we might need to be more wary of in our paediatric patients that we're seeing in the community?

 

Dr Jason Yates  04:01

The four common ones that we talk about - we call them the 4Ts, and this actually, so this concept originated in the UK, but Diabetes Australia, coined the term 20 years ago and brought it across as being something catchy that would highlight what the symptoms are, and lots of research has shown that those symptoms remain the same. So it hasn't changed with any changes in incidence or disease. So the 4Ts stand for toilet, thirsty, thinner and tired; and what that translates to is polyurea and polydipsia, which are drinking too much and peeing too much, weight loss and lethargy. With polyurea and polydipsia being the two most common symptoms. So we call them the 4Ts to keep them catchy. As part of the little intervention that we did a couple of years ago, we even came up with some pretty pictures to go with each of them and to really just try and get a really simple message out to the community that if you've got any of these four symptoms fingerprick blood glucose is all you need to do. There's no fancy testing. It's just a fingerprick. Using a glucometer, we've got some cut off blood glucoses that if it's above, then need to consider diabetes and send them to a place where they can get difinitive care.

 

Dr Elissa Hatherly  05:10

I suppose for those patients who have those symptoms, there is the odd chance that their finger prick glucose might be normal at that particular point in time. I don't know how often patients say I had these symptoms yesterday, but today, they've resolved. What else should we be doing then if the finger prick is normal at that moment, but we have a high clinical suspicion?

 

Dr Jason Yates  05:30

So, I guess it depends a little bit on how long they've had the symptoms. If you think about the physiology behind why they've got polyurea and polydipsia. If it's diabetes, then by definition, their blood glucose should be high. So the polyurea is driven by a osmotic diuresis, from hyperglycaemia. So the increased glucose in the blood causes water to move from the intracellular space into the intravascular space, which then causes you to pee because your kidneys are working fine but you keep pain and pain and pain until eventually your body's like, well, I need some water now, and so you start drinking, and usually once the glucose is sort of hitting above 11, that's when you start getting glucose loss in the urine, which increases the polyurea. So if they've had, if they've had the symptoms for 1,2,3,4 weeks, then if it's caused by diabetes, then their blood glucose will almost certainly be high. We've got three bands of concern that we use. So the first one is, and the most common, is the random blood glucose, which is usually when you're going to do it. So if that's greater than 11, regardless of whether they're sick or whatever, then there needs to be a really hard thought about whether this is diabetes. If by chance they come in and they don't haven't had breakfast, and they're fasting, then if it's above seven, then that's abnormal, and then the other thing that we say is if they've got a blood glucose between 7 and 11, but it's random, there needs to be a consideration about whether they do have an abnormal glucose pathway, which might be the early stages of diabetes. Those sorts of kids that we do, we do HbA1c screening, we do antibody testing. So I guess, I mean, that was a very long winded answer to say that usually they will have a high blood glucose but if if you've got a high clinical suspicion that they've got diabetes, but you don't have the cut off blood glucose levels that I've just said. One, you can pick up the phone and speak to your local diabetes service and and just talk through the case, the other thing you can do is you can send them off for HbA1c and antibody testing. Now, I always am a little bit worried about saying this, because what we commonly see is someone thinks that this could potentially be diabetes, and instead of doing the glucometer test, they send them off for blood tests, and I've certainly had a fair share of diabetes diagnosed by a phone call from Sullivan Nicolaides telling a family that the blood glucose is 30, and you should go to the hospital. Really, that can be the difference between them presenting with diabetes and not in DKA, and presenting in DKA. So glucometer is still the best, I guess the glucometer test is normal and your suspicion's high then you can do antibodies and HbA1c but I would do that in conjunction with a diabetes service.

 

Dr Elissa Hatherly  08:05

Fantastic, and we do have such a great service across all of North Queensland looking after diabetic patients, I know. Jason, are there are particular cohort of kids who we need to be more mindful of developing type one diabetes and then a risk of DKA, than others?

 

Dr Jason Yates  08:21

Yeah, so the peak incidence of type one diabetes in childhood is twofold. So there's two areas that this happens. So the first is that early school age. So usually from the ages of five, six through to eight. And then again, another incidence peak at... in adolescence usually around puberty. So they're definitely the peak ages that we see. Although that being said, we've got age ranges from nine months through to a lot older, and there's 30 and 40 year olds that have been diagnosed with type one diabetes. So it's not only these ages get it but certainly the that's the highest incidence. We find the younger kids are the hardest in regards to DKA. So no intervention that I've seen across the world has been able to influence the less than two year olds, because I think they're just so tricky to pick those 4Ts, and so the DKA rate in that age group is usually very high. What we do know though is that in those older age groups in the places that have done interventions, they've been able to reduce their DKA rates from unacceptably high rates to less than 15%. And actually, when I started training, 20% was supposed to be the number. So one in five kids present in DKA, four infive don't, whereas we did a peer review of all diabetes services a few years ago and it was sitting at 50% or 45% as a statewide average and in some pockets 100% were presenting in DKA.

 

Dr Elissa Hatherly  09:47

So that was 45%, up to 100% in some cohorts, in Queensland Jason?

 

Dr Jason Yates  09:52

In Queensland. That's seen pretty globally across all of the states in Australia. We're getting to that sort of 40 to 50% We looked at QCH's data, which is the Children's Hospital in Brisbane, and they were sitting usually around 50%. Our own data's been a bit interesting. We originally, in Townsville, had a DKA rate that was between 50 and 75%. I did a bit of a death by PowerPoint presentations to a bunch of GPS across Townsville, particularly the trainees, but also some GPs, and basically the message that I've already told you about the 4Ts, and please do a finger prick, and we actually dropped our DKA rate down to 25% for a period of time, and that was just purely through some awareness of what to do. We haven't quite been able to sustain that but we do have one of the better DKA rates in the state because I think there's been some lingering, but as of the COVID period, we found that tricky again, just because people were finding it more and more difficult to access all forms of care, and then there was some other things that people were worried about, not necessarily the 4Ts.

 

Dr Elissa Hatherly  10:56

Right. So Jason, we've talked about the increasing incidence of type one diabetes across Australia, across the world, I imagine, particularly over the last 12 to 24 months, and maybe linked to COVID. Particularly about the need to increase awareness of the signs of hyperglycaemia. Those 4Ts - toilet, thirsty, thinner and tired; and how important awareness is to reduce the number of patients presenting with DKA. Just doing that finger prick is so incredibly important. When we do have those patients come in with elevated blood sugar, they've got those symptoms, we can get on the phone to the local diabetes service. For those patients who have DKA they need to go straight into a hospital, we can't manage them in the community safely at all, can we?

 

Dr Jason Yates  11:44

No, and look to be to be fair, I think anyone that's got a diagnosis of type one diabetes should be referred in, usually to the hospital because that's where most of the either the paediatricians or the paediatric endocrinologist or diabetes specialists are going to be, because it's not just about making the diagnosis. It's also about commencement of insulin, which is the therapy but also the education. It's a huge change to the way families do business, and it's, you know, you're sweeping the rug out of a lot of families feet with this diagnosis. They think their kids just got a flu or might have a urinary tract infection, and now they've got this lifelong chronic disease. But DKA in itself, and I guess that's probably the next part of this is, you know, you'll hear lots of specialists come and talk to you about their pet project and why it's important, and everyone needs to listen, but DKA has such a significant impact on kids and adults with type one diabetes, both in the short, but also in the long term, which is why preventing it is so important. So short term DKA is if you're going to die from type one diabetes, DKA is the leading cause of death. Its mortality rate is still only about 0.9 of a percent, which is great, it's low, but it's still the highest cause of death of type one diabetes and childhood, and there's a particular complication of diabetic ketoacidosis known as cerebral oedema, which is where your brain swells, and that's the thing that generally is the cause of death in DKA, and the problem with cerebral oedema is not only if you get cerebral oedema, about 30 to 40% of kids will die. So cerebral edoema is really bad if you get that and DKA. But the ones that survive, about half of them will have neurological disability, which is you know, an added layer to a chronic disease diagnosis that they weren't expecting. So DKA is is quite dangerous as an emergency as essentially. The other thing is, is that most of these kids need some sort of high level of care whether it be an ICU or high dependency type area of a ward, sometimes they need more invasive testing or lines, which can increase other morbidities such as venous thrombosis where the lines are. They all get a degree of trauma, and not just the kid but the family particularly you know, there'll be families out there that have had a child in the ICU environment for a whole range of reasons, and it's scary time. They always associate the time that they got diagnosed with diabetes with that scary time. It delays the ability for our team to teach them about diabetes, and it certainly increases the length of stay that they spend in hospital. So in the short term DKA is such a bad start to what's already a really traumatic new diagnosis. But this just makes it far worse. And families talk about it for years later about how they are still impacted by that initial diagnosis and that DKA diagnosis in particular.

 

Dr Elissa Hatherly  14:29

Oh, wow. So Jason, for those of us keeping our eyes open for the young people with the 4Ts so that we can avoid DKA. If we do find a patient with diabetic ketoacidosis what can we do as their first line of medical contact to help reduce the impact of this traumatic diagnosis?

 

Dr Jason Yates  14:50

This is where prevention is so important, right? The treatment of DKA is very protocolised. So I think from a primary care perspective, keep the kiddy safe they might need some oxygen, and call an ambulance. If you get them somewhere pretty quickly, because even just the treatment with fluids needs to be done in a certain way to avoid making cerebral oedema worse. So, from a management point of view, we've protocolised it so heavily now just to avoid some of the event variance and practice that we used to see. To me, the biggest thing that we can do is prevent this, and it's so preventable. I did a brief study at the same time that I did that piece with the GPs, where I interviewed everyone that had been diagnosed with type one diabetes over a 12 month period and in Brisbane, at the Mater Childrens, as you know, decent numbers, and what I found was that when you looked at the two groups, so those kids that had DKA, and those who didn't, they all had the same symptoms. So there was no difference there, they all had the same duration of the symptoms. So there was no difference. The only difference between the two groups was that those that presented in DKA, had seen someone in health care at least twice to get the diagnosis. So it's and that's that's just what I found, but certainly when you look at some of the international literature, that is a recurring theme, which is they're not diagnosed with type one diabetes, when they first seek help, and you know, we're talking the delay might be a couple of days, but that might be all that it requires for them to progress into diabetic ketoacidosis. So prevention is the cure, like we hear that a lot. But this is certainly something where if we prevent DKA, we actually set them up for a whole bunch of long term benefits. There was a study that's come out of the Royal Children's in Melbourne that they're continuing to look at and this has been repeated in some other sites that showed that those kids that presented in DKA, were cognitively worse off six months after the diagnosis, and that's when they compared them to people not in DKA of the same age. Their insulin therapy was the same, their control was the same for the six months post the diagnosis. The only difference was that they presented in DKA and they were cognitively worse off. So that's just in the short term, short to medium term, and then in the long term, there's really lots of evidence starting to show that DKA is a risk factor for complications. So even before you're diagnosed, you could be setting yourself up for diabetes related complications, just because we didn't do a finger prick in time. It's so important.

 

Dr Elissa Hatherly  17:16

So a higher incidence of diabetic retinopathy, renal disease, peripheral neuropathy, all of those sorts of things. And the cognitive impairment, Jason, is that one of those neurological complications of DKA, that you mentioned earlier? What are some of the things we need to be thinking about?

 

Dr Jason Yates  17:31

I think when we look at the cognitive impacts that are emerging in the evidence, and we don't know, if these are temporary or permanent cognitive changes. What we do know is that the pH diagnosis for DKA is quite significant. So you need to reach a certain threshold from an acid base disturbance, and even for mild DKA, your pH needs to be 7.2 to 7.3, which is actually reasonably abnormal, and that's mild DKA; and for severe decay, it needs to be less than 7.1, with a less... a bicarb less than five. So we're talking about a significant metabolic compromise, and there are some emerging studies that have shown that even any DKA can lead to some form of cerebral oedema. It may not be clinically evident, however, on MRI, they were able to show some evidence of it, and so that may be the causative factor for why some of these kids have cognitive impairment in the six months proceeding a diagnosis. You know, I think what this says and you put all of this together to just show that DKA is not a benign thing. The kids all get better, they usually get better within 24 to 48 hours, the treatment processes that we have work, and we do it in a way that usually tries to keep them as safe as possible. They do walk out of hospital with a life changing diagnosis, but they do it feeling better. But actually, we may have already set them up for a life that's more tricky than it needed to be, and I think that's the important point to get across.

 

Dr Elissa Hatherly  18:57

Right. So Jason, our take home message is keep our eyes peeled for the 4Ts in our young people - toilet, thirsty, tired and...[pause]

 

Dr Jason Yates  19:08

Thinner.

 

Dr Elissa Hatherly  19:09

Thinner! How could I forget thinner? Anyone who has DKA needs high level care immediately, and fortunately, that's done by the protocol to keep these young people as safe as possible, but the trauma for the child and the family is so much greater when there's diabetic ketoacidosis as the diagnosis. Plus the increased incidence of those end stage diabetic markers with damage to their eyes, their kidneys, the peripheries, which we can avoid by just being more aware as that first port of call in the community or in our emergency departments when we see these young people. Jason, is there anything else we need to be mindful of when we're thinking about diabetic ketoacidosis?

 

Dr Jason Yates  19:52

No, I think probably the other important point is for practice managers and admin staff in GP practices. They'll get families that call with some of these symptoms, and what we were able to show which we published a couple of years ago is families don't see the 4Ts as anything to worry about, particularly the polyurea and polydipsia ones. They actually don't consider that to be a reason to go see your GP same day. So usually, I think most reception triage admin areas of most GP practices will ask about what the urgency is, and parents won't say this is urgent, and so that's one thing that we need to think about. Because I mean, we'll be living under a rock to know that access to primary care has been challenging over the last couple of years and a lot of practices, particularly popular practices, do have reasonably long waiting lists and they all have emergent slots that families need to know how to activate those emergent slots so that they can be seen. So there is a community piece in this about if your child suddenly starts wetting the bed of a nighttime and they've always been dry or they're drinking ridiculous amounts of water even for North Queensland weather, that's an emergency reason to go and see a GP.

 

Dr Elissa Hatherly  20:58

Dr Jason Yates, paediatric endocrinologist in Townsville, thank you so much for your time today and shedding a bit more light on diabetic ketoacidosis. It would be great to see the incidence of DKA down from the 45 odd percent down to that 20% goal and even lower, that would be perfect. We look forward to seeing what happens with your research into the increasing incidence of type one diabetes over the last couple of years. Thank you so much for your time today.

 

Dr Jason Yates  21:28

It's my pleasure.

 

Dr Elissa Hatherly  21:32

For more information about the Roundup, or to plase share your feedback and ideas for future episodes, visit nqrth.edu.au/news/roundup-podcast or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's Integrated Rural Training Pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organisations and general practice clinics.

• Diabetic Ketoacidosis | Clinical Excellence Queensland | Queensland Health

Dr Elissa Hatherly 00:02
Welcome to the Round Up, a North Queensland based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician and head of JCU's Clinical School here in Mackay. This collaborative podcasting project between North Queensland Regional Training Hubs, JCU, and our local, regional, Hospital and Health Services will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. In today's episode, I'm joined with Dr. Denise Craig, a psychologist from the Cairns region, who has recently completed her PhD with James Cook University in the practical application of advanced care plans. Welcome, Denise.

Dr Denise Craig 00:57
Thank you, Elissa. Lovely to join you. Thank you for the opportunity.

Dr Elissa Hatherly 01:00
I'm really keen to talk about advanced care planning today. As I mentioned, this has been part of your PhD project and it's something close to your heart, isn't it, Denise? What brought you to advanced care planning?

Dr Denise Craig 01:14
Oh look, it really is close to my heart. I've been a psychologist working with people with dementia for the last 14 years and I came to that position through a personal link when my mother was diagnosed with dementia. What I realised, as a daughter, is that sometimes clinicians are not really across the law and there can be some difficulty understanding consent and shared decision-making. But of course, people who have a diagnosis of dementia who complete an advanced care plan are doing so to take advantage of their right to put down in writing what it is that's really important to them.

Dr Elissa Hatherly 01:52
Of course, advanced care planning is not just for those patients who have a diagnosis of dementia is it? It can be with other degenerative conditions like multiple sclerosis or motor neuron disease, or even conditions like Parkinson's for which dementia can sometimes be part of the disease process?

Dr Denise Craig 02:10
That's absolutely correct. It's really for anybody who would like to put down in writing what it is that really matters to them later. So they may have no diagnosis at all. I always think that a diagnosis might make decision making easier, because you're probably able to get in touch with what your later life might look like. Otherwise, I mean, imagine if you were 21 and had never had a day ill in your life and somebody suggested that you might think about doing an advanced care plan. I just don't know how well that would work. Unless, of course, you really did have clear ideas and some people do. In my study, I narrowed it to people with a neurodegenerative disorder really to wrap some parameters around it. So all of those conditions that you just mentioned, were a part of my study, specifically, but a person may not have any of, any of the above.

Dr Elissa Hatherly 03:01
Now, in Queensland, we started doing advanced health directives... was around 2000, I think, wasn't it Denise? And the legislation's changed a little bit recently. As you mentioned, clinicians are not always over the latest updates in the legislation. Can you give us a bit of an idea about what clinicians need to know now?

03:22
Look, I think what clinicians are doing is they're busy trying to assess what is what is going on for a person and help to make, often typically, medical decisions around how best to support the person and so advanced care planning, certainly in Queensland to my understanding has never had mandatory education wrapped around it. And the laws in Queensland are complex and our medical education intends to keep the end-of-life law substitute decision-making type education a little bit generic so that it will apply across Australia. So we know from research that was conducted by Ben White and Lindy Willmott over the years, and there was a really amazing study done in 2014, where they looked at the knowledge of specialist doctors across three states and they found that this was really a substitute decision making an advanced care planning "end of life law", actually, as they called it, was really not well understood at all and it's partly because of the complexity with it. Really, for doctors to get into a deep dive and understand that it's going to be self-directed, rather than mandatory.

Dr Elissa Hatherly 04:27
Right, and of course, doctors would find it really challenging to talk about reducing treatment or withdrawing treatment when often doctors are desperate to offer everything they can to a patient. In your research, Denise, what was it that you found?

Dr Denise Craig 04:44
I found that doctors were consistently agreeable that advanced care plans are designed to give people a voice and they encourage people to complete an advanced care plan to have a voice but in essence in reality, decision-making is really very complicated and that voice tends to hang in the balance when a person doesn't have the capacity to make the decision in the moment. So the doctors were saying, we really want to know what matters to this person, and how are we going to get to that information. They didn't always have faith in the advanced care plan to be able to give them the information that they needed. So there was general consensus that the doctors would be reluctant to leave families out of the mix. Families, in theory, will know what the person had intended when they completed their advanced care plan, and families will be the people who will live on after a person has died.

Dr Elissa Hatherly 05:40
Of course, the family doesn't have to be involved in that advanced care planning, do they? But it would certainly be easier for the patient and the clinicians and other family members, if as many members of that patient's family could be involved as early as possible, I imagine. That's right. Generally families, a person completing a plan is strongly advised and encouraged to include their family but that was one of the things that I have had concerns about because a person might conceivably complete a plan to cut their family out. Perhaps they want to alleviate the family of responsibility. In some cases, they may not trust the decisions of the family and I've certainly also seen it occur where family can be really troubled by becoming involved in these decisions, because they can then feel responsible for perhaps the death of somebody that they love very much. So it's quite challenging and I understand the need for the generosity and compassion, I think of doctors to say, we really do want everybody to be okay with this, it's just a little bit tricky, especially in those cases where perhaps family were not aware, perhaps the person completed a form to maintain that control, and we must remember that we do have to respect what we know about the person and if that's been written in an advanced care plan, it really needs to be respected and included in conversations and serious consideration. Okay. So there's some of the human factors contributing to advanced care planning. What are some of the systemic issues at play, found in your research, Denise?

Dr Denise Craig 07:19
Well, the law was a really big one. Complexity with the law, and also interesting issues with trying to access the advanced care plan. So it's one thing for a person to complete it but it's a multi-step process. Of course, as you would know, especially when it's the health directive, they have not only been to see their, usually GP, but also typically either a JP in the community, or a lawyer to have it witnessed as well, and then they tend to put it in their file. So, if a person is to be admitted to hospital, and the treating team ask to see the advanced care plan, chances are, it's not in the medical records. So, we do have a portal in Queensland that people are encouraged to upload it to, but remember, the patient owns the document, and it's up to them what they do with it. If they choose to keep it in the filing cabinet at home, that's their right, but if the treating team asks for it, and the family bring it in two days later, it's possible that the patient is by now being treated by a different team and an acute resuscitation plan has been completed in the meantime. And so sometimes doctors feel as though the acute resuscitation plan is addressing the hospital needs and so there seems to be less priority then about necessarily reading the advanced care plan, which the person completed out in the community.

Dr Elissa Hatherly 08:36
Okay, so that advance care plan portal. Can you tell us a little bit more about that, please, Denise?

Dr Denise Craig 08:42
That's been an initiative that was set up to try to help get around this problem, because forms are not registered. If you complete even an enduring document, they're not registered anywhere and so how do we get our hands on them when they're needed. There was an office set up in Brisbane, and it's the Office of Advanced Care Planning and in the latest forms, the Enduring Power of Attorney (EPOA), and the Advanced Health Directive (AHD) form, and the Statement of Choices form, the address and details for submitting it to that office are there and what that office does is peruse the document to make sure it's been completed and that it's valid. So that means it's been appropriately witnessed, etc., and they will then upload it into the portal. So that's incredibly handy. That also gives the Queensland Ambulance access to the documents. So if the document is stored in the portal QAS will probably be across it by the time they arrive at their destination, and they will be familiar with the contents and the gist of what the person has said there. So that's really helpful, but of course, it's back to the patient to have submitted that for upload. I did find that sometimes clinicians don't... they don't always know how to use the portal because generally, certainly in the far north Queensland region, there hasn't been a critical mass yet of the documents build up in the portal. So if a clinician was to have a look in it, it might be nothing there. So there might be that sense of not having areward for effort but it's a magnificent option. People can case note in there to say I saw Mr. Smith today, and we had a chat about the decisions that he made a year ago in the community and his health directive, and he had a new diagnosis since then, but he feels even more strongly about his decision now. That type of case noting can help the future decision-maker doctors to have confidence about the decisions that have been made, whereas, typically, another systemic issue is that document, there's no legal requirement for it to be reviewed. So it could be aeons old, and nobody's looked at it again. So it's tricky to ask a hospital-based doctor to have faith in a document. They don't know what the patient understood when they recorded their decisions and the old forms used to be mostly tick boxes, yeses, and noes, which didn't really satisfy the need of the treating doctor to say, well, did they really understand this. So, if a form has never been reviewed again, and meanwhile, a person has, perhaps, even their situation has changed, and it's not been reviewed, then it's going to be trickier to get that across the line. Whereas I maintain if we took a village approach to this, and we all took every opportunity to review documents with people to say, just checking, is this still what you would like? And then document that, that Mr. Smith stands by his decision? Or sometimes people say no, actually, I did that straight after a diagnosis and I expected a pretty bleak outcome, and there were issues going on with the family and I don't feel that way anymore, and we're then sending them back to the GP to say, please review to have a really good chat and change the document. If they still have capacity to make a new document, they might like to take advantage of the... for the new forms, which I think are much better. They'd give much more nuance, yes, there's 'Yeses' and there's 'Noes', but there's also 'unsure' and 'textboxes'. So you might say, well, I'm really not sure about this particular decision and maybe this is one for my attorneys to make with the treating team at the time. And that again, would probably give treating doctors the faith that you really understood some of the complexity in this. Whereas if all of the yeses, or all of the noes are ticked with no context added, I think it increases doctors anxiety,

Dr Elissa Hatherly 12:17
With the portal, Denise, do other states have similar options? If we have visitors from interstate? Do we have the opportunity to look for these documents or similar documents from other states around Australia?

Dr Denise Craig 12:31
That's a really good question. Certainly, we have My Health Record and so that's Australia wide. Doctors might very well find somebody else's, and other states advanced care plan in there. If a person moves to Queensland, they're going to stay here, then the treatment of their advanced care plan would be a little bit different, it wouldn't actually be uploaded by the Office of Advanced Care Planning at this point. They could hand it to whichever hospital was providing their care, and of course, their new GP and they could make sure that it's in the My Health Record, but it is treated a tiny bit differently. And there's some little issues with following advanced care plans from other states as well. My understanding, at least, that it's only the elements which match Queensland law, which can be expected to be applied here. Where there is not a match in the law, then obviously, that leaves a gap in Queensland.

Dr Elissa Hatherly 13:25
So Denise, in terms of the advance care planning, you've talked about the importance of involving as many family members as possible into the preparation of the Advance Care Plan; and of using the text boxes or the unsure category in the new format paperwork to help give doctors and other health care professionals as much information about the context and the background of this particular patient's wishes. You've talked about the fact that we need to be uploading all of this paperwork to the portal wherever possible, and reviewing paperwork in case patients circumstances have changed and their wishes have evolved over time. How else can advanced care planning be done better than?

Dr Denise Craig 14:11
In my perfect world, we'd be taking a multidisciplinary approach to this and that might even be in relation to the setup of the document in the first place. So rather than thinking of it as being important to complete it in one sitting, depending on what is going on for a person, it may be that they could benefit from the input of another discipline. Even the allied health disciplines; Speech Pathologists often have a role here, Dietitians often have a role here. So it's about being as all-encompassing as possible. The more richly informed the document is, or the decisions are, probably the more confidence it will give to treating doctors but there's one little caveat here, and that is that by law, the patient's under no obligation whatsoever to accept advice. This is something that they must not be coerced to do. It's a matter of inviting them, and helping them to understand why this might help. So I think we also need this iterative approach and taking that whole village approach that we're all in this together. I do hope that people complete a plan, and remember that this is probably going to be read by somebody who's never met them before and that person could be under a degree of pressure, and is really trying to get a clear sense of the person's values and wishes or directions. So I love that the new forms provide more opportunity for nuance, the forms came in after my data collection. So I'm actually not sure, yet, what difference the nuanced information might be making, but the other thing I say to people is that by all means, if you can fill these out on a computer, because you can fit much more in the text boxes, and the new forms are allow to add sheets as well, which the old form didn't. So if you choose to write "War and Peace", you are allowed now, and that can get added to the back of the document. So we've switched a bit in the changes to a more human rights lens, to really, truly authentically trying to get at enabling the person, giving them all of the information that they need to make the best decisions for themselves that will help them to express their autonomy. I think that's really, really important is bring in all of the advice and if you if need to contact somebody else, or you need to refer the patient to perhaps some guidance from another organisation, I mean, Advanced Care Planning Australia offers telephone consults to help people who might need some more guidance. So take advantage of that and then if you have a flag in your system, saying it's been whatever, one year, two years, new diagnosis, or whatever you think appropriate, and you raise the topic again, with your patients, then I think we're more likely to see more faith in the documents, and when there's more faith in the documents, I think they're more likely to do what they were designed to do for a patient.

Dr Elissa Hatherly 16:57
Sure. You make the really good point there too, Denise, that the people preparing the document are not going to be the same people actioning the document at that pinch point for the patients. When we are preparing these documents, it's a really valuable opportunity to give a little bit of guidance about potential consequences for that patient's decision, the various decisions that patient's making. We need to be really clear that patients understand what artificial nutrition means, what artificial hydration means, without offering coercion, as you say, inviting patients to make a decision that they're comfortable with.

Dr Denise Craig 17:34
Well, I think that's a really good point Elissa. If I could pick up on that, certainly, socially, I did speak to a lady once, who was a very, very intelligent, highly accomplished lady and she said, I've done my health directive and I have ticked the box that I do want artificial nutrition and hydration. I do not wish to die hungry or thirsty. So I said, "Can you, can you explain what that might look like? Tell me what that might mean" and she didn't know, and so it seemed to me that it probably wasn't explained to her what artificial nutrition and hydration might possibly entail. When this type of thing happens. They're the types of decisions that can erode the hospital doctor's faith that the person had given informed consent through their advanced care plan. Now in today's new world, he might have been able to support her choice with a comment. The day that I spoke to her she had no further information because she appeared not to know what that meant but she had this clear notion that dying, hungry or thirsty would not be pleasant. We can also remind people that there is the statement that... we've got two forms in Queensland, and the Health Directive is the legal heavyweight that was born in about 2000, but since then, there's a Statement of Choices form, which it's not providing consent, but it gives people an opportunity to provide some really rich, qualifying, guiding information, and if sometimes if a person's, let's say a person with dementia, is... does not meet capacity requirements to complete an Advanced Care Plan, but their spouse may choose to complete the Statement of Choices for them, then that's an option. Whereas a second party can't complete a Health Directive. It has to be the person who has capacity to do that. So the Statement of Choices does provide a really good option. In fact, for people who are concerned about the legal route and feeling as though they may make a decision that they might possibly not standby in 10 years time, whatever reason people may have for not liking the legal option. Then the Statement of Choices simply provides useful information that can help guide decision makers. So that it's nice that that's there.

Dr Elissa Hatherly 17:39
Denise, what else do we need our patients to be aware of? As you say they need to think about the Advanced Health Directive, they've got the Statement of Choices as an option, and it's great for patients to have other family members on board when they're making those decisions, although it's not a legal obligation, what else do we need to keep front of mind in our patients when they're doing this documentation and making these decisions.

Dr Denise Craig 20:13
I think, if they have strong feelings, it's about trying to articulate where they're coming from, so that a perfect stranger will get a sense of where they're coming from and this comes back to, although they're under no legal obligation to discuss their plans with significant others, doing so might help everyone. The doctors that I interviewed in the study, were a bit reluctant to strictly apply an Advanced Care Plan, because they really wanted to make sure that everybody was on board with whatever was the current decision, and doctors did think that families would likely be aware of the decisions that the person had made. So having those conversations as families, and sometimes families can care so much, they might shut down a person who might say, look, I want to talk about this, and you'll hear family members say "Oh, no. Don't be silly. You'll live for another 10 years, we're... let's not go there." I say, well, actually, death is the ultimate endpoint for all of us but advanced care planning is not only about preparation for death, either. It's really about incapacity, and any of us could lose capacity at any point for any reason, and it might be temporary, and the purpose of the Advanced Care Plan is to still provide that voice when you are unable to give that voice in the moment. Doctors, in my study, made very clear that what mattered the most to them was knowing what mattered the most to their patients. That's a nice message, I think, to communicate to patients is 'bottom line as a village, we want as a society to do our very best to provide you with what it is that you would choose for yourself if you were able to do so in the moment, can you be onboard and help with that by communicating clearly and reviewing decisions', and an Advanced Care Plan that's done very well is very much appreciated by hospital teams and families because it can just help everybody to be okay. and are real... well more okay, shall we say, at a really tricky time.

Dr Elissa Hatherly 22:10
And of course, a more difficult decision and discussion for families can be around Voluntary Assisted Dying can't it Denise, which has just become legal in Queensland and is legal in many other Australian states or soon will be. How can the Advanced Care Planning help inform that voluntary assisted dying decision?

Dr Denise Craig 22:32
They actually don't sit together by legislation. That's because an Advanced Care Plan, the Statement of Choices / Advanced Health Directive take effect on the loss of capacity of the patient. So they have expressed their wishes to be read when they do not have capacity, but Voluntary Assisted Dying requires that a person maintains capacity. So, the person cannot include Voluntary Assisted Dying in their Advanced Care Plan in a way that it could then be actioned. So that can't happen, but people can put whatever information they like in their Advanced Care Plans. So they may choose to say, 'You know what, if I got to make a decision myself, I'd be all in favour of Voluntary Assisted Dying', or whatever they might say, and that information might help a treating doctor in future to say, well, this is where the person was coming from, I now know this tiny little bit more, but it will not by legislation mean that a person has qualified for Voluntary Assisted Dying, no matter what they've written in there, simply because as I said, at the issue of capacity versus no capacity,

Dr Elissa Hatherly 23:37
And that Voluntary Assisted Dying question is so polarising, isn't it? Some people are very for, and some people are very against. When a lot of the community probably need more education around the Advanced Health Directive, and that Statement of Choices that you mentioned, which actually might serve their needs better, and making sure that people's wishes are adequately communicated can be really reassuring, can't it?

Dr Denise Craig 24:02
Yes, and it's, of course, it's really tricky to get to everybody, and trust me I'm trying, but it is... I think we need a top-down, bottom-up, and side-to-side approach to all of the advanced care planning. And by that I mean top-down - so support from the highest of authorities, and bottom-up - getting to consumers and helping to educate them and, empower them to make whatever decision is right for them including, perhaps not participating in advanced care planning. Some people do not wish to engage in this, as is absolutely their right. Sometimes culturally, people have got other practices around this. So we must be very careful that we are advising people of options and never crossing the line into coercion, coercing. And side to side how do we help each other? How do we support each other and have good communication to remove some barriers and increase enablers to all of us supporting our patients and clients because, I think, that's why we're all in healthcare. We all want the same outcome, and that is the best possible life and death for our patients and clients.

Dr Elissa Hatherly 25:09
What a fantastic point to finish on Denise. We need to support enablers and reduce barriers to the very best health care including end-of-life planning and planning for when patients' capacity is limited or taken away entirely. Dr Denise Craig, Psychologist in Cairns, thank you so much for your time today.

Dr Denise Craig 25:31
My absolute pleasure. Thanks for having me on board. Elissa, I appreciate the opportunity.

Dr Elissa Hatherly 25:38
For more information about The Round Up, or to share your feedback and ideas for future episodes, visit nqrth.edu.au/news/roundup-podcast or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training Hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice, and is for educational and entertainment purposes only. Northern Queensland Regional Training Hubs is an initiative of the Australian Government's Integrated Rural Training Pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organisations and general practice clinics.

• Advance Care Planning Australia

• Queensland Government | Advance care planning | Health and wellbeing

Dr Elissa Hatherly  00:02

Welcome to the Round Up, a North Queensland based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician and head of JCU's Clinical School here in Mackay. This collaborative podcasting project between North Queensland Regional Training Hubs, JCU, and our local regional Hospital and Health Services will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. In today's episode on the Roundup, we're talking with Dr Max Ryder, who we spoke with last year about the changes to voluntary assisted dying here in Queensland. Good morning, Max.

 

Dr Max Ryder  00:52

Hey, thanks for having me back, again.

 

Dr Elissa Hatherly  00:54

It's a great opportunity to catch up and see where Queensland is at with voluntary assisted dying. You have a particular interest in helping people at end of life with both palliative care and then voluntary assisted dying, and have been really instrumental in getting this new legislation off the ground in our region. Tell me how are things going?

 

01:16

Look, they've been fantastic. It's been such a learning curve over the last six months coming into the new program, and it's only been positive experiences, so far. My team have been blown away by the support of our health service, and we've really been enjoying helping people who are in a very vulnerable part of their life, and I think that we've learned so many things, and we're definitely building on our experiences and our services only only getting better each month that we progress into the year.

 

Dr Elissa Hatherly  01:51

By team I'm sure you mean yourself, other clinicians who have undertaken the training with Queensland Health, and your support staff in terms of nurses and admin staff. How many other doctors do you have contributing to voluntary assisted dying here across North Queensland?

 

Dr Max Ryder  02:10

Look, we're definitely a small team in the Mackay Health Service. Queensland Health formally employs myself and Melissa Harris, who's one of our CNCs who's instrumental in helping people navigate their voluntary assisted dying journey, and outside of our Queensland Health team, we have voluntary assisted dying practitioners of which we we estimate there is about six others in our region, but it is hard to gauge because not all practitioners do wish to share their their information with us. We are probably one of the smallest teams in the state, but we're actually the second busiest team in the state. So it's quite an interesting relationship, that statistic. Let's talk about that a little bit. I imagine for people in regional and rural Queensland, often their diagnosis of a terminal condition comes a little bit late, later in the piece than it was someone in a metropolitan region, and access to palliative care is limited, and people might think voluntary assisted dying is their only opportunity.

 

03:15

It's interesting, our numbers for rural areas. The top three areas in our state are actually outside of Brisbane area local, and it's hard to say what the reason for that is. It could be the burden of disease is higher, the access to diagnosis is a bit harder, and access to treatment is a bit harder. So, people may be are a bit sicker in rural areas. Also, our access to palliative care is, is quite difficult in our health service, although that has definitely been improving in the past twelve month. And so we know that most people who go on a VAD pathway or some assessment process or completion, most of those people will get access to palliative care. The numbers are a bit small for us to say for sure, but we do think that our health service is probably having lower interactions with palliative care than other districts. So, our practitioners are obviously thinking about people symptom management as well, and whilst we're not palliative specialists, we're definitely always taking into account their symptom management and making sure that we, we offer palliative support for each of our patients, irrespective of their specialist input.

 

Dr Elissa Hatherly  04:23

That sounds fantastic. People's needs are just individual, aren't they? And we need to individualise our care for them. So with Voluntary Assisted Dying (VAD) then in our region, and the small number of clinicians, do we need to ask our colleagues to look at undertaking some of those education modules that are offered by Queensland Health, if not to become a voluntary assisted dying practitioner but even just to broaden their education around the topic because we really just want to normalise Voluntary Assisted Dying for those patients in whom it is needed, don't we?

 

04:56

Yeah, I've spoken to ten practices in our region and I've presented at Grand Rounds, and the feedback that I get from people who aren't practitioners, or haven't engaged in any Voluntary Assisted Dying training yet, the feedback is, is that it's not that they're not willing, it's just that they're very busy, and finding the time to undertake the training is, is challenging. The other component is, is that the current situation with no Medicare item numbers for Voluntary Assisted Dying does make it challenging for general practitioners to engage for long consults. These patients require many hours of a doctor's time over the course of a couple of visits, and that can be a barrier to practitioners looking to sign up to be a practitioner. And so, there's two things that I'd like people to take away is that that we do have a 45 minute module that's available through Queensland Health that GP practitioners are welcome to use as well, and that's what's happening in the VAD space, and how does the VAD process work legally and clinically, and that module really will give people an insight into the program and what's happening. The practitioner module to become a VAD practitioner is a bit longer, it takes approximately six hours, but it can be completed over a determinate period of time, and it's a deeper look into the process, the pathway, and how to implement VAD services. And, I suppose what my request is, is that as a health service, that we share the burden to share the workload. If we all were doing our little part, we just would make our process a lot smoother for our patients and make their experience a lot smoother getting through what is a difficult, difficult assessment process. For a lot of these people, it's quite confronting talking about this process given it's quite new, and most people aren't familiar with it.

 

Dr Elissa Hatherly  06:42

Max, it is such an enormous undertaking as the clinician, you've talked about some of the benefits and being able to help patients navigate through such a difficult time, and then offering symptomatic treatment, and that little bit of basic palliative care support where you can. What are some of the other positives and negatives that you've experienced as a clinician in this area?

 

Dr Max Ryder  07:04

Well, I'm a GP obstetrician as my base trade, and I consider delivering babies to be quite a rewarding job but these patients that we see for our VAD consults are probably the most rewarding clinical experiences I've ever had professionally. The patients and their families have had such a struggle for a long time, with often cancers or neurodegenerative conditions, and they're searching for relief. And, when we're able to provide that for a small group of people who are requesting that service and the appreciation, the thoughtfulness, and the support that we receive from them during this process is just amazing. And, I think that's what all of my VAD practitioner colleagues have found that whilst it seems to be a burdensome job, it's actually very, very clinically rewarding, and the paperwork is the only thing that is the real downside but I think we have to respect that with such a sensitive new project that there has to be adequate scrutiny and paperwork is an essential part of that, unfortunately.

 

Dr Elissa Hatherly  08:02

Sure. Max, what are the most common neurodegenerative conditions that you're seeing in your voluntary assisted dying work at the moment?

 

Dr Max Ryder  08:10

Look, it makes up a small percentage of our cases but to be honest with you, there are some conditions that I had never even heard of through medical school or my medical training, but generally speaking, they're motor neuron type clinical presentations, where people are having loss of function of motor functions, swallow, but we've actually had quite an array of different syndromes that present with quite severe debilitating burden of disease. And, those patients are typically the most keen to get support from us because their symptoms are nearly impossible to manage with excellent palliative care and their suffering is very great and often occurring at younger ages, 40, 50, 60 years of age, and so those conditions are challenging. But we have found that there hasn't been too much of a concern with loss of capacity with regards to damage with dementia only had a few cases that have had to be rejected due to loss of capacity due to dementia, so, which has been quite reassuring. Most of our assessments that we conduct are successful and most are not found ineligible during the assessment process.

 

Dr Elissa Hatherly  09:15

Can you just talk us through, Max please, the referral pathways for those of us working in the hospital or in primary care? How do we start the process for our patients?

 

Dr Max Ryder  09:25

The internal referral processes is via the E-Blueslip process, which most people are pretty familiar with, and the key questions that we need to get from clinicians is, what the diagnosis is and what their estimated prognosis is, as well as their other associated comorbidities, because as you can appreciate, formulating a prognosis to make sure that they meet the criteria is is a very delicate thing and very difficult for us to arrange, sometimes. The external process from the general practitioners is through a smart referrals page. It can be also faxed as well, and there's a healthpathways link now for Voluntary Assisted Dying referrals. I think it's just really important that when people are referring into us, they give us as much information as they can, because the determination that we're making is quite serious, and depending on the severity of the patient's illness can be challenging. Particularly for people who have a prognosis between six to twelve months, it's harder to delineate, if they do meet the criteria or not, and if there's ever any questions, we're always contactable through the Mackay switchboard because our VAD CNC is contactable business hours to help support people in the community with questions that they might have.

 

Dr Elissa Hatherly  10:33

That's really great to know, Max, isn't it? And I suppose to then for clinicians who are interested in signing up to become a VAD practitioner, knowing that you have a community of other clinicians you can phone to bounce ideas off or ask questions of, would be really reassuring to be reminded that you're not the only person dealing with some of these challenging topics, isn't it?

 

Dr Max Ryder  10:53

And that's right, and that's what my position with the team was designed for. Was to help support the community, support the hospital,  and make sure that clinicians are able to provide a high quality service and to make sure that it's not burdensome on them. That they're actually able to smoothly process their patients through the pathway, and that they're not doing so many cases that it's burning them out. At the moment we're operating in a default mode, is what I would refer to it as, where the hospital service is doing 95% of the cases and almost all of them have been coordinated by myself, which is unfortunately, not sustainable going forward. We need to share the workload across the health service in general practice and the hospital service.

 

Dr Elissa Hatherly  11:34

Max. Just to recap on what we've talked about. Voluntary Assisted Dying legislation has been enacted since the beginning of the year, and the rollout has been going really well in the Mackay region with lots of patients receiving the referrals that they need either through E-Blueslips internally or through the smart referrals pathway externally. You have a team of very few clinicians but great nursing support to help make sure the process goes as smoothly for our patients as it possibly can. The education modules through Queensland Health website might only take 45 minutes just to upskill Doctors give them the opportunity to think about maybe becoming a voluntary assisted dying practitioner themselves, and that the whole process is as positive as it can be for our patients locally who don't have access to diagnostic or palliative care services that our neighbours in metropolitan regions do. They're all really important points for us to think about Max for our lay people who are listening to the conversation today. It sounds like now that VAD is part of our new normal, that we really need to be advocating for improved palliative care services in our region. Would that be fair to say?

 

Dr Max Ryder  12:50

Yeah, that's right, and I think that there has been an injection of funding to our health service, it'll come down to recruitment of staff ultimately at the end of the day, and I think that I can't emphasise enough, that early palliative care referral is absolutely essential. A lot of these patients are being referred quite late for their palliative care and we're finding and often people think that palliative care is it and the line referral but actually if you've got an illness that cannot be cured and you're receiving even palliative treatment with chemotherapy or radiation, I would strongly encourage that people consider referring to our palliative teams through SPaRTa (Specialist Palliative Rural Telehealth) in Townsville, and internally we have a new palliative consultant inpatient consults early just so that way they can maximise their symptom control before they get too unwell.

 

Dr Elissa Hatherly  13:37

That is fantastic news. Dr. Max Ryder, are there any other tips or tricks we need to be taking home from today's podcast?

 

Dr Max Ryder  13:44

No, I think. Thank you for engaging with Voluntary Assisted Dying and it's something that we want to keep talking about it. It's the new normal. It's a new offering for people. It's an end of life option and some people will choose to take it and we want to make, what is a very difficult decision for our patients, to be as simple as it can be and to support them through it. And, myself and Mel Harris at the hospital are here to support the community and the hospital as well. So please, do give us a call, give us an email. We're happy to help.

 

Dr Elissa Hatherly  14:12

Dr. Max Ryder GP obstetrician in the Proserpine region, Voluntary Assisted Dying clinician as well for our community here in North Queensland, seeing people at the beginning of life, caring for them at the end of life. Thank you so much for your time today.

 

Dr Max Ryder  14:26

Thanks for the time.

 

Dr Elissa Hatherly  14:27

For more information about the roundup or to share your feedback and ideas for future episodes, visit www.nqrth.edu.au/roundup-podcast/ or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training Hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice, and is for educational and entertainment purposes only. Northern Queensland Regional Training Hubs is an initiative of the Australian Government's Integrated Rural Training Pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander Health Council, Health Services, Aboriginal Community Controlled Health Organisations and General Practice clinics.

• Voluntary Assisted Dying: A Clinical Update by Dr Max Ryder and Mel Harris

 Dr Elissa Hatherly  00:02

Welcome to the Round Up, a North Queensland based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician and head of JCU's Clinical School here in Mackay, this collaborative podcasting project between North Queensland Regional Training Hubs, JCU, and our local, regional, Hospital and Health Services will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. In today's episode, I'm joined by Dr Anna Kermond, who's one of the advanced trainees in rheumatology, currently in Cairns. Welcome, Anna.

 

Dr Anna Kermond  00:50

Thank you for having me, Elissa, it's been a long time coming. Excited to be here!

 

Dr Elissa Hatherly  00:55

It's amazing that you wanted to talk to us today about fibromyalgia. It's something that comes up often in general practice, and is always there in the back of our minds as a differential diagnosis when patients come in with pain. So it's a great opportunity to talk a little bit more about fibromyalgia. Wonder if we wanted to start with diagnosing the condition because we have lots of criteria that the patients need to meet, don't we?

 

Dr Anna Kermond  01:25

Yeah, that's right. I mean, fibromyalgia, I guess in general, is not everyone's favourite topic. And I know certainly with some rheumatologist, if you mention the word, they just look nauseated and want to lock their office door. So I feel like it's a condition that if you can handle the emotional turmoil that comes with it, sometimes it can be really rewarding. And I just found personally in terms of my journey fibromyalgia patients that I found it so rewarding if I managed to implement some treatment strategies that help them. But to kind of get back to the diagnosis side of things, I think the tricky part with fibromyalgia is it actually isn't any individual patient diagnostic criteria that are validated. When I speak with a lot of I guess, people from the general practitioner community, the main thing that they look at is that 2020 ACR criteria. And that's the one that's like the blue PDF document, we can send it in the notes, post this that kind of has widespread pain index score, associated symptoms, that kind of thing. And I don't know about your experience with it personally, but I actually find that criteria a little bit wild with some of the things that's classified as other symptoms of fibromyalgia, I don't know, do you use it? Or do you ever look at it yourself?

 

Dr Elissa Hatherly  02:40

It's a really hard criterion to follow. And as you say, there's so much emotional turmoil associated with diagnosis, people come in really clutching on to the idea of giving a name to their particular set of symptoms. And because there's no one diagnostic test, trying to work through whether or not a patient may or may not have fibromyalgia is really hard.

 

Dr Anna Kermond  03:02

So difficult! And if you go in the the diagnostic criteria with the ACR guidelines is, you know, to aid diagnosis, but not validate it. And I think that, in essence is the biggest difficulty with fibromyalgia, there is no one test, there's no one way to go about it. But if you look in that criteria, one of the things that it kind of mentions is other the symptoms, including easy bruising and frequent urination and bladder spasms and itching and wheezing and just things that I personally would never attribute to fibromyalgia without quite extensive investigation. So I personally don't like or use most of that criteria. I just got off sort of different flow, which I kind of run you through. Now. I think knowing that there's no criteria is probably the most helpful thing. There's no tick box like this many things. Yep. That's it. To start with, when I'm meeting the patients in clinic to diagnose them I ask really open ended questions and say, 'tell me everything about your pain'. Realistically, we often have a sense of it with the referral before they come into clinic because there'll be things GPS will mention; pain everywhere, inflammatory markers persistently normal can't figure it out. Is there anything you can do to kind of help it or to be honest, in the waiting room and you look for the one with the fluorescent pink hair that can also help when you're trying to figure out how to diagnose it. It's a lot about the history of fibromyalgia pain is an unpredictable pain. And obviously, it's very different for each individual patient. But the most consistent things that we tend to see is the migratory nature to the pain and the generalised soft tissue tenderness when you're first asking about their pain and trying to differentiate whether or not it's inflammatory arthritis versus not I asked them when they're telling me I have pain everywhere. I say can you point or kind of point to forearm the shoulder, their thigh? I say do you get ever pain recurrently in one specific area and almost 100% of time they'll say no, you know, it'll be this shoulder, that leg, this foot, my head, whereas if you're thinking about inflammatory arthritis or some other cause of the pain, it tends to be reproducible recurrent, symmetrical the same areas. Getting a good idea of their unpredictable pain that migrates and isn't consistently over one joint, one muscle, one area, I think sort of starts that process and that idea that's probably Fibromyalgia one of the questions I asked when trying to get an idea of their pain is I was like, 'Do you ever just wake up and feel like you've been hit by a truck because it hurts in so many areas?' And I would say 99.9% hit rate of fibromyalgia patients feel like 'yes, everything hurts'. And you can never tease it down to just one isolated area. It's never going to be the MCPs, PRPs it's going to move it's going to be sore at all random times of the day. And when we talk about inflammatory pathologies, which is ultimately what we're trying to differentiate when they come into clinic, their symptoms are always tend to be more worse in the morning better, the more you move them really significant stiffness, whereas with fibromyalgia, they will more consistently say it hurts any time of the day, it's tends to be worse when I'm active, worse when I do things, worse when I move. The history of the pain alone often is almost all you need in that it's the complete opposite of an inflammatory arthritis.

 

Dr Elissa Hatherly  06:14

How do we then decide that yes, this is Fibromyalgia is it just that clinical pain picture? Or would you prefer that we have no inflammatory markers being elevated? No other...you've excluded a lot of other conditions, then.

 

Dr Anna Kermond  06:28

Yes, the first part is the history. So I spend a lot of time asking about the type of pain, associated symptoms, and in that initial history, I also try and get a flavour of previous traumatic events, their social setup, reasons why they might be particularly high risk of fibromyalgia, you know, like grief, childhood trauma, eating disorders, that sort of thing. Then next part of my diagnosis, obviously examining which you just look; they're sore pretty much wherever you touch, and that's what we say is that generalised soft tissue tenderness or widespread pain index. Step one histor; step two exam. I think we're really getting towards more diagnosing things, it's ultimately of exclusion, which is a frustrating thing for anyone to be told as like a physician, but they can and often do have dual pathology, you know, obviously, I haven't been training for very long, only a year and a half. But I have seen a lot of fibromyalgia and also, in my general medical times, I've seen cases that have been labelled Fibromyalgia that very much aren't. The basic investigations that I would do as things of exclusion to then work towards the diagnosis would at least be a CK, I find that that gets missed a lot, making sure because they often complain of myalgia, I would say inflammatory markers, which yes, ideally, would be normal taking into account, obviously, with ESRs. The older the patients become, especially with obesity and ESR is not our favourite test, but it's always still helpful. So I'd still recommend it. ESR, a CRP, a CK and thyroid function are the bigger ones that I like to do as the basics. Obviously, an ANA opens up Canada worm and that if it's positive, I'll get patients will come to clinic with the ANA printed out and like highlighted with pins and stickers on it being like they go, here's my lupus, and I'm like 'who gave you that?'. Having a negative ama can be very useful for us. Because if the ANA is negative, you know, they don't have lupus, and that way, you don't have to pay as much attention to them answering yes to a lot of questions like fatigue, mouth ulcers, alopecia, they'll often say rashes and the nuances with fibromyalgia history is they will often answer yes to everything, because it's sort of like a psychosomatic kind of conversion of what they feel and what they think they're exhibiting on clinical exam. I think an ANA, in addition to the above is useful. And if it's positive, I would follow it with an ENA and C3 and C4, because by the time they hit clinic, that way, you can say, Yep, the ANA is positive, but the compliments are normal, that a nice negative, this isn't going to be lupus, I don't have to explore it. Whereas if the ANA is not negative, you know, it's not lupus, you're good, you don't have to go down that road. So that would be out. And the other investigation I always do is iron B12, vitamin D, just some fatigue related investigations, because they're almost always fatigued. And the thing about it being of exclusion is if they have terribly low iron and low B12, and low vitamin D, of course, they're going to be tired, and it doesn't matter how much I tell them to exercise, they are going to have to overcome those legitimate barriers as well. So that would be my initial bloods that I would do for a fibromyalgia patient that I see in clinic for the first time.

 

Dr Elissa Hatherly  09:32

Okay, so we've talked about the fact that Fibromyalgia will have that really classic pain history that is poorly defined pain everywhere, waking up in the morning feeling like you've been hit by a truck, not reproducible, it's not symmetrical, it's not feeling any of those other pain kind of conditions, and that often those markers will be normal. You've also raised the issue of some of those Fibromyalgia mimics or the things we don't want to diagnose quite by accident like lupus or hypothyroidism. What are some of the other things that we need to be mindful of when we're thinking Fibromyalgia in the back of our mind? Those are the things not to miss.

 

Dr Anna Kermond  10:11

Yeah, so the ones that I would definitely not miss, as you said, so hyperthyroidism, you know, any haematinics kind of deficiencies, lupus, but lupus is tends to be a bit more like obvious, but the other ones that I've seen over time is obviously myositis. So having that see, obviously, looking that it's not elevated, because I have had a few patients who've had myositis, you know, that's sort of been rumbling along treated as fibromyalgia. Other big ones I think not to miss is multiple sclerosis (MS), and obviously, that's a hard diagnosis. So I say that knowing that's probably really irritating, but if they are complaining of paresthesia that's very common in fibromyalgia, and so what I do when I'm trying to tease that out in clinic is asking about that hot / cold insensitivity. So, we're thinking about in a hot shower, does it feel hot? And when you touch ice, does it feel cold? Have you noticed any weird temperature sensations in your body, and I also try and ask if the paraesthesia migrate. So, if they feel tingling on one hand one day, one leg another day, that tends to not be as consistent with MS. Whereas, if they give you a history to say that they've had tingling that started in their hands six months ago, and that's still tingling, but now it's also their left foot or something like that, then I tend to go down that road a little bit more, ask a few more questions about the temperature related things, family history, have a look at the demographics, and ultimately, sometimes I do order an MRI brain or C-spine, I have found probably two MS cases since I started, though, I think knowing a little bit of the questions, ask around MS would be helpful. And the other ones is probably, I guess, what would be the other big mimic? I think, always making sure that the age appropriate malignancy related things up-to-date, just because it feels terrible, or it would feel terrible to miss it, and so if they're complaining of abdominal pain and bloating and GI upset, which again, happens in a lot of fibromyalgia, making sure that you know, their pap smear's okay, there's no blood in their poo, and that they've had their skin checks and just things that if it's all found to be nothing, and they're all good, then excellent. But you know, if they've had an ovarian mass, and that's why they're so bloated. Obviously, you don't want to miss those things.

 

Dr Elissa Hatherly  12:28

You touched on some of those other social things that increase the risk of fibromyalgia. Can you just talk through that a bit, please Anna?

 

Dr Elissa Hatherly  12:37

Right.

 

Dr Anna Kermond  12:37

Yeah, of course. So, I think one of the things I like to tell other doctors, when I'm talking about fibromyalgia being real, is, you know, because there are still people out there who genuinely don't believe it's a diagnosis, and I think that's wrong, obviously, being on this podcast. But when I was first trying to... I think I was a resident at the time, just doing some time in rheumatology, I had a patient who was this very stoic woman in her 80s, who had just lost her husband, and then she had been referred in by her GP for query rheumatoid arthritis. And she had this beautiful classic story of fibromyalgia. And that was my first experience to say not all of the fibromyalgia patients are, unpopular opinion, but like young women, more so Caucasian like vibrant coloured hair, all sorts of piercings, eating disorder, histories, that sort of thing. It can happen to anyone, but the most consistent thing that I see is that they've had either profound grief, and whether that's from loss or you know, sexual abuse as a child, or physical trauma or emotional trauma, there tends to be like an element of grief or prolonged stress in most of these patients that I see. So, when I'm meeting them in clinic, and I'm trying to get that open ended question, I just say, so tell me about your life, and where are you up to blah, blah, blah. Just kind of get the conversation going, and then, more so when I've got a bit of a rapport established, I say, you know, it sounds like you're dealing with a lot in life, you know, how are you coping with that? Is that anyone helping you? What's stressing you out? And normally, in that conversation, you tend to find that someone's either had a lot of abuse as a child, or neglected as a child, or had been in a car accident and since then has had chronic pain. So, there tends to be psychological, physical trauma or grief in most of the patients that I would see.

 

Dr Anna Kermond  12:38

So, I think that that fits with it, you know, with the pathophysiology of fibromyalgia.

 

Dr Elissa Hatherly  14:30

Can you talk to us a bit about the potential pathophysiology of fibromyalgia?

 

Dr Anna Kermond  14:35

Yeah, so there's obviously a lot of people internationally looking into this because clinic around the world and general practices around the world are dealing with fibromyalgia. So there's a few sort of theorised mechanisms if we're talking in the pathophysiology, bio-chemical way, and it's sort of thought to be a combination of genetic influences environmental triggers and stresses, ultimately resulting this abnormal autonomic and neuro endocrine function in your body. In terms of trying to study exactly what physically happens within them. So big cohort studies of fibromyalgia patients have shown associations between higher cortisol levels and pain ratings. There's thought to be maybe some abnormalities in the serotonin transporter gene via HTT. I think it is, but I'm not sure. Fibromyalgia patients tend to have a larger postural drop, lower heart rate variability, and this COMT enzyme, which has something to do with catecholamines, I think. So there's, there are some consistent and emerging biochemical abnormalities in patients, but for me the most, that pathophysiological mechanism is, how do I say it? When I'm talking to the patients, I say if you imagine that your brain is a destination of somewhere, there are two roads that lead to this destination, only two, no other way to get there. When you have a thought, or an impulse. Think of it as something negative, like I'm worried about money, I miss my grandma, I look ugly today. Whatever we go through, that thought, imagine it is like a car driving along one road. And those thoughts just keep coming. So by the time you're, you know, twenty, thirty, fourty, that's traffic jam, so there's no room left there. So then you go to the other road, which is meant to be for pain. But if your brain is getting to traffic jammed, any impulse or any thought we'll go down the other road and just be turned into pain, because your brain can't receive an impulse and do nothing with it. It's just not how it works, and we know that. Otherwise, we'd all be the most relaxed people in the world. So, once the negative path is kind of clogged up with all those nasty thoughts, then you're left with every thought and sensation and touch, your brain just starts rewiring it and sending it down the alternative road and saying pain, pain, pain, rather than anxiety, stress, fatigue, worry, blah. I think it helps when I'm trying to explain something as complicated as 'you waking up feeling...', I also feel like I don't know why I say that to patients, because I feel like we all do it. We all sometimes wake up be like, I look like crap. But when you wake up and you have a bad thought it can't go anywhere if you can't, or not processing your thoughts and your feelings and emotions, but your brain can't do nothing with it. So it's going to relabel it. It's going to call it pain.

 

Dr Elissa Hatherly  17:04

Yeah, right. Anna, you've talked about the difficulty or the caution that we need to have with interpreting inflammatory markers,

 

Dr Anna Kermond  17:11

Yes

 

Dr Elissa Hatherly  17:12

And the need for that rheumatology review. Some of us don't have rheumatologists close by or it might take a long time before we get our patients in to see someone with a particular interest in fibromyalgia like yourself.

 

Dr Elissa Hatherly  17:26

Yeah.

 

Dr Elissa Hatherly  17:26

How can we better help our patients whilst they're waiting for that formal diagnosis, or even if we are suspecting fibromyalgia and are unlikely to get a formal diagnosis, what's going to be our best treatment strategies to start with for these patients.

 

Dr Anna Kermond  17:41

Firstly, just to touch on the abnormal..., that interpreting inflammatory markers. So, the biggest thing I would say is that inflammatory markers are inflammation from anywheres. It's helpful to know on referrals and things as well if it's happening at a time that they've had a chest infection or something else like that, but interpreting with age and obesity are probably the two biggest things. So say someone's 140 kilos and they have a CRP [C-reactive protein] of 6 or 7. That's just not going to be significant clinically. But the thing I do see in that realm is when we're talking about ANAs [Antinulear antibodies], you would have seen the DFS70 pattern, we get referred that a lot being like a in a positive DFS70, that's actually an antibody pattern that's negatively associated with autoimmune disease, so you are less likely to have autoimmune disease in the general population, if you have DFS70 pattern. I think that's a really helpful tip for people to know, to be like right, you're less likely to have lupus, I don't need to worry about this one. So that would be the two things about interpreting. In terms of treatment strategies. So say you've gone through all the bloods we've spoken about - CK [creatine kinase] is normal, inflammatory markers are normal, they have a history that's consistent general pain, hit by truck, nothing helps, happens all the time. The things that I find, is any investigations you haven't done, like that we've spoken about, having those underway so that you yourself can reassure your patient and say, your muscle enzymes good and your thyroids, good, and I'm making sure that we've excluded some of the nasties. So doing that kind of process, finding something to image is great. Even if you look at it, you don't think there's anything that I do find a big treatment strategy with fibromyalgia patients is having objective evidence to show them that there's nothing damaging them in their body. So I don't necessarily mean a top to toe MRI, you do see patients who have had that done, but I normally pick I would ask and find it helpful if you pick an area ask the patient where their worst pain is, you know it will probably move and just Xray, or ultrasound, or whatever you, yourself, think might be the best area to image that, because being able to show patients, to say "I've done these tests, and I've done this imaging and nothing's being damaged, nothing's being destroyed, there's no deformities happening in your joints. It's okay while we wait for the rheumatologist." That sort of verbal reassurance with objective science to show some patients can be really helpful but obviously selected based on what you think would be the most relevant thing to show, but I do find at least one image of one area and reassuring them about that's good. In terms of the other, like treatments type stuff, like initiating treatment. Three main things, and they're all difficult to implement. A big part is explaining it to the patients about what it is why it works, you know, the highway theory, that sort of mechanism, reassuring them, nothing is being destroyed. The first one is obviously exercise. I explain it to them, to my patients, as saying when you exercise, it is a good stress, not a bad stress, and you're starting to teach that abnormal pathway and that abnormal wiring in your brain that you can feel stressed, but after it's over, you're going to feel better, not worse. And it's those sorts of repeated signals to the brain that teach it how to undo that traffic jam and undo that abnormal kind of wiring. So I try and really encourage exercise by explain it as and when it's done, you get this wash of dopamine and serotonin and you're going to feel better, and you do that again and again and again. And you're going to trick your brain that it doesn't need to interpret everything as pain anymore. There's some caveats to it. I do say to the patients, it will be very hard, and you just have to stick at it. So don't sugarcoat it and say, "Oh, you go for one jog a week, you can be feeling amazing". They won't, they'll feel terrible for the first couple of months, and saying to them if you can commit to 5 to 10 minutes of sweaty exercise a day. So, whatever that looks like for you, walking up and down a steep hill near your house, pedalling on the exercise bike in front of your TV, going for like 10 laps of your pool. Whatever it is, start by just initiating 5 to 10 minutes of getting your heart rate up, and that's what your brain needs to kind of make those changes, and then go up from there. But you will be tired, you will feel wrecked, that's normal, that means it's working, keep going. I try and really motivate them to know that it will be worse before it gets better. Like a plane coming up in turbulence. So, when you take off the plane, it's gonna be really rocky and you get to feel terrible and nauseous and tired, but when you're up high over the clouds, you'll really feel good. So, kind of try and initiate that therapy is really helpful.

 

Dr Elissa Hatherly  22:00

Okay, so we've explained fibromyalgia to our patients, and we've encouraged them to get on to the exercise bandwagon. What else can we do for them?

 

Dr Anna Ker  22:10

The next step I'd address is some sleep hygiene strategy, and I can definitely send the fibromyalgia treatment sheet that I give my patients in clinic. Addressing the depth of their sleep and trying to change some of their sleep habit, it can be very, very helpful. And again, it's explaining to say "If you can't have good sleep, you're not going to be able to benefit from all of this exercise you've been doing", and so just simple things. I talk about the Headspace app or the Calm app before bed and avoiding caffeine, smoking, stimulants right before sleep. Obviously avoiding blue light, just reading books in bed or magazines, because a lot of them don't read books but yeah, read in bed instead of watching stuff, and another big thing is, you know, try and avoid your larger meals within, you know, two hours before sleep. Try not to nap in the afternoon when you're feeling that way and just very simple sleep hygiene strategies. To say "Complete oil change. You're gonna be working out and sleeping eight hours that a few months." So sleep strategies is a big one. And then within that you can start to touch on that pharmacological aids. I'm not a big fan of, you know, just jumping right in for certain medications, but in the sleep element, and a lot of the fibromyalgia patients have terrible sleep, I think it's very reasonable to do low dose amitriptyline, pregabalin, those sorts of things, just to make them kind of sleepy and gooey right before bed if they need that extra addition, but I do try the non-pharmacological stuff for at least six months before I add that in.

 

Dr Elissa Hatherly  23:36

Right.

 

Dr Anna Kermond  23:36

That's, obviously, taking into account their other comorbidities. And the reason I mentioned amitriptyline, pregabalin is out of all of the things that we've been studying and looking at for medications. The medications that tend to have the best evidence is those amitriptyline, pregabalin, low dose naltrexone, low dose Tramadol, duloxetine, and venlafaxine are the ones that have been proven to have potential modest benefit, is how they summarise it. Which is not very reassuring, but those are the only medications we know have had positive info within the fibromyalgia rounds of medications.

 

Dr Elissa Hatherly  24:08

And, so, some of those will actually help with the pain itself too, won't they? Like the amitriptyline and the duloxetine?

 

Dr Anna Ker  24:14

Yeah, well, I guess the way I say it to them is that "Those medications are mostly helpful because they're treating either some of your insomnia so you can get a restful sleep, or they're potentially helping the underlying mood disorders like anxiety or depression", but I actually kind of lean away from saying it treats your pain itself because the pain it's sort of a central nervous system creation rather than a peripheral stimulus. So obviously, we love pregabalin, amitriptyline for peripheral neuropathies, but I try and explain, if I give it to them, I say "this is to help you sleep and this is to help your mood, but as we discussed, there's nothing physically wrong in your body that we can see. So this is more about your head space and your sleep rather than a damaged nerve". Because they tend to really lock on and conceptualise that, something's actually wrong. So I try and say "This is just how helping you sleep and helping your moods, da-da-da,  rather than your pain". If that makes sense?

 

Dr Elissa Hatherly  25:05

Sure. When would we consider a pain medication for some of these patients? You know, sometimes they'll come in and they're already having regular Panadol osteo, three times a day, or they've added in ibuprofen, and they're really holding onto those pain medications. Do we try and stop those straightaway? Or should we try and initiate some of those other non-pharmacological strategies first?

 

Dr Anna Ker  25:27

Yeah. I just wouldn't use analgesic agents for treatment of fibromyalgia because it's not a nociception issue. Like it's not a peripheral pain stimulus that's binding onto something. It's very centrally mediated. So, I wouldn't give any analgesic options. Obviously, if they're low risk, and you're just trying to pick your battle that day, if they come to you on some Tramadol and regular Panadol, things like that, I say "We'll look at that later. Let's focus on the non-pharmacological things", but outside of those medications I mentioned, I wouldn't give them any analgesic kind of agents because they don't work, and what you do find when people report benefit is actually they're just getting some sedation or some transient euphoria from the analgesic options rather than, you know, generally treating the underlying problem, which is the perception of stimuli.

 

Dr Elissa Hatherly  26:15

That's right, and placebo effect is so incredibly common, isn't it with almost all of our medications.

 

Dr Anna Ker  26:21

Yep. So, so big and, you know, what you end up in those situations are sometimes patients who are on buprenorphine patches with sublingual boop, and they're basically riding high on an opioid kind of dependency. It becomes just so much harder to motivate for the exercise, the psychology and the sleep strategies, because you've started that pathway of, almost addiction, really. So, I don't touch any pain relief stuff, and I only go around sedation at night, only ever at night, or antidepressants, anti-anxiolytics, if sort of thought appropriate for their mental state.

 

Dr Elissa Hatherly  26:53

Anna, is there anything else that we need to know about our fibromyalgia patients before we finish up today?

 

Dr Anna Ker  26:59

I think education is a big thing. Two more points, I'll send you a whole list of some of the websites that are used and some of the other things I show to my patients. But I do think that first impressions really matter, and for me, the most success I've had with my fibromyalgia patients has been when, no matter how difficult it could be, I just bring it back to validation, compassion, listening, and very open ended questions. And my success story, that I like to tell people, is that I have had a patient once, who in my initial appointment had mentioned that she had survived being decapitated, which as we know, is typically not a survivable injury, but we spoke about exercise treatment, strategy treatments, didn't say "No, that's wrong, that didn't happen. That's not real." Just let it all kind of wash over me, and I think being really conscious of not being judgmental, even if the story sounds insane, really helps the patients think that you didn't just fob it off, know that it's fibromyalgia in the first five minutes, and then start telling them to work out. You have to hear the story before you can make these recommendations, otherwise, it's really hard to get them on board, would be my, my closing thing.

 

Dr Elissa Hatherly  28:08

So fibromyalgia is a journey for the patient, but it's also a journey for the clinician, but the success, the reward at the end of that journey is massive for both of us.

 

Dr Anna Ker  28:19

Definitely, and I think we sort of didn't really get a chance to speak about the psychology element in there as well, with between the sleep and the exercise, but obviously, if there's any identified anxiety, depression, even when I meet any of my fibromyalgia patients, I recommend at least a few psychology sessions and say, "If you can teach your brain how to deal with the stresses of just being alive, then you're going to reduce the pain that you feel." So, that's the only thing I forgot to mention earlier psychology. Get it in there. It's good for everyone. We should all be seeing a psychologist.

 

Dr Elissa Hatherly  28:50

What an excellent point to finish on Dr. Anna Kermond, that's trainee rheumatology currently in Cairns talking about fibromyalgia today. Thank you so much for your insight, we are so much more aware and better prepared for those patients who come in with that weird pain story. Thank you so much for all of your expertise.

 

Dr Anna Ker  29:10

You're so welcome. Thank you so much for inviting me. It's really great to be a part of something that was trying to improve the quality of life with all of these patients. I really feel passionate about it. So thanks so much.

 

Dr Elissa Hatherly  29:23

For more information about 'The Roundup' or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at NQRTH.mackay@jcu.edu.au We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training Hubs or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training Hubs is an initiative of the Australian Government's Integrated Rural Training Pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander Health Council, Health Services, Aboriginal community controlled health organisations and General Practice clinics.

Resources and recommended websites

• Fibromyalgia Self Management Program (fibroguide.com)
• Arthritis Australia (www. arthritisaustralia.com.au)
• Fibromyalgia Network (US) (www.fmnetnews.com)
• Arthritis Foundation (US) (www.arthritis.org)
• American College of Rheumatology (www.rheumatology.org)
• Arthritis Research UK (www.arthritisresearchuk.org)
• The FibroGuy(http://www.thefibroguy.com/)
• Australian Pain Society (apsoc.org.au)
• New Zealand Pain Society (nzps.org.nz)
• Painaustralia (painaustralia.org.au)
• US National Institutes of Health Fibromyalgia site (http://www.niams.nih.gov/health_info/fibromyalgia/)
• Arthritis Australia Fibromyalgia Information Sheet (http://www.arthritisaustralia.com.au/images/stories/documents/info_sheets/2012/Fibromyalgia.pdf)
• American Chronic Pain Association - Fibromyalgia Information Handbook (https://www.theacpa.org/uploads/FibroHandbook.pdf)
• American Chronic Pain Association(theacpa.org) 
• American Pain Foundation (painfoundation.org)
• National Pain Foundation (nationalpainfoundation.org) 

Pain Self-Management Sites

•  https://www.aci.health.nsw.gov.au/chronic-pain/chronic-pain
• https://www.tamethebeast.org
• https://www.theacpa.org
• https://www.liveplanbe.ca

 Dr Elissa Hatherly  00:02

Welcome to the Round Up an North Queensland based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician and head of JCU's Clinical School here in Mackay, this collaborative podcasting project between North Queensland Regional Training hubs, JCU, and our local, regional, Hospital and Health Services will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. In this episode, I'm talking about migraine with Dr Kimberly Forrest, a general neurologist from the Cannes hospital, who works in the public sector. Good morning, Kim.

 

Dr Kimberley Forrest  00:51

Morning, Elissa, how are you?

 

Dr Elissa Hatherly  00:53

I'm really well and very excited to be talking about headaches and migraine specifically, which is such an incredibly common presenting complaint. I know you deal a lot with this. Should we start by talking about how we define migraine?

 

Dr Kimberley Forrest  01:09

Yeah, absolutely. So I guess before even doing that, and thinking about migraine in a primary care setting, there's there is a there is a key, there are key diagnostic criteria for migraine, which I'll go into in a moment, but the key is to really suspect it in the first place. So and that requires a lot less specific. So for any patient who's coming in reporting, frequent headaches, and perhaps if there's some features that increase the likelihood that this headache can be, could be migraine, things like an associated visual aura, or if they have a family history of migraine, then already that should be raising the suspicion of migraine in your mind. Now as to the the actual definition of migraine. That's, so what we refer to as the ICHD-3 diagnostic criteria, so it's a primary headache disorder, and we divided into migraine with aura and migraine without aura, so migraine without aura being the most common. And so strictly speaking, you have to have at least five attacks that fall fulfils certain criteria, which I will list in a moment. And that the headache, the headache attacks after lasts for about anywhere between four and 72 hours, and that timeframe is important. The headache has to have at least two of the following four characteristics. So it has to have a unilateral location. All these are with caveats though, some people experience bilateral migraine. But generally a side lot pain, pulsating quality, moderate or severe pain intensity, and aggravation by/or causing avoidance of routine physical activities, say for example, walking or climbing up the stairs. And so during the headache as well, this is the key, that differentiates, one of the key features that differentiates it from just a nasty tension headache, for instance, is that you also need to have at least one of the following during the headache, you need to have nausea and/or vomiting, and photophobia and/or phonophobia, so that, that aversion to sounds and as all of our criteria go, that it's not better accounted for by any other headache diagnosis. So it's that and it's basically the same for migraine with aura as well. But in addition to the the key headache features, it's typically preceded by one or more of the following fully reversible aura symptoms, or either a visual aura, which is by far and away the most common, that scintillating scotoma, or fortification spectrum that people get. You can get sensory symptoms, they can be positive or negative, so a sense of tingling or an absence of sensation. Some people, it's very rare, but you can get difficulty speaking, and then there's the weird and wonderful is motor and brainstem, which I haven't, it really is so common that I haven't seen it. So uncommon rather.

 

Dr Elissa Hatherly  04:22

Yeah.

 

Dr Kimberley Forrest  04:23

So that's, that's the definition of migraine in a nutshell. But again, the key is in the first place, I mean that can be looked up, you know. I deal with migraine every day. I have a general idea of the diagnostic criteria, but of course I was reading that straight from the from the criteria*. (*ICHD-3 - The International Classification of Headache Disorders). I guess what I wanted to emphasise is that in primary care, just have a general idea about what you're thinking. Just suspect in the first place and know that it's both the headache plus these additional features of the photophobia, phonophobia, and aggravation with daily activities, and nausea and vomiting?

 

Dr Elissa Hatherly  05:01

Sure. That definition is complicated, but as you say, it's probably not the most important thing when we're thinking about that recurrent headache, but to just suspect it, as you say. But you know, as a primary care physician myself, I know that headache is ridiculously common, and as you said, as the general neurologist, headache makes up an enormous part of your daily work. How prevalent is migraine in our community?

 

Dr Kimberley Forrest  05:28

Yeah, so quite. Let's have a look. So, again, it was really great, looking into this, looking into some extra details for this podcast. So these were numbers that you sort of intuitively know, but it's staggering when you look them up. So I got this data from the headache Australia website, and it affects apparently 4.9 million people in Australia. And of course, that's just the people who suffer from the headaches. That, that's not mentioning the families of those people with headaches, you know, they're the employers, they the government, you know, such a big knock-on effect. And apparently it costs about $35.7 billion to Australia per year in terms of price.

 

Dr Elissa Hatherly  06:17

Wow!

 

Dr Kimberley Forrest  06:18

Yeah, so it's not a, it's not a small thing. It's not just a headache, I think is the point.

 

Dr Elissa Hatherly  06:26

No, that's, that's an incredible point to make, isn't it? Because we know it's common, but that lost productivity is massive. I suppose you know, in primary care, often people are coming in with headache, and when I was a junior doctor, a little while ago, we were always suspicious of people come in looking for narcotics to manage their headache. "Oh no, my headache only goes away with an injection of Pethidine or what have you." You know, in primary care, I just don't see that, I see people who are genuinely suffering, and as you say, it's their families and their employers who are also impacted. Are there some risk factors that we need to be mindful of, to talk through with our patients?

 

Dr Kimberley Forrest  07:11

Risk factors for migraine in the first place?

 

Dr Elissa Hatherly  07:15

Yeah.

 

Dr Kimberley Forrest  07:16

So generally, it's just, so it's quite genetic. So that's the main risk factor is, is unmodifiable. But then, maybe what perhaps you're alluding to is, are you thinking along lines of triggers, or things that people can do to increase their likelihood of having a migraine?

 

Dr Elissa Hatherly  07:42

Yeah.

 

Dr Kimberley Forrest  07:43

Yeah. So, that's actually that's a really interesting point, that's an important thing to bring up because, traditionally, so we talk about, there's a lot of emphasis put on triggers. So people will say, you know, if they have a long migraine, if they have migraine history, they'll be able to say I avoid chocolate, I avoid red wine, oh, I know that if the wind is blowing this way, then I'm going to get a migraine. So in fact, studies haven't really borne that out at all. So in terms of triggers, the traditional triggers that people talk a lot about, they're probably not as important as we had previously put weight on, and in fact, there's some evidence to suggest that, that, that it's more about correlation, not causality. So, people will naturally try to find causes for things, especially things that cause them pain and, and difficulty in participating in everyday life. So, for example, the, some people will say, 'Ah, chocolate brings it on', whereas the current way of thinking is, in fact that the craving for chocolate may very well be a part of the prodrome of migraine, even before the headache comes on, and a lot of migraine sufferers will tell you this, too, that they just don't feel right in the day leading up to their headache day. And so, some, and so, in that natural human way of trying to figure out a cause to therefore avoid it for the next time. People, people will often associate, you know, that food that they have craved as the cause rather than the effect of them.

 

Dr Elissa Hatherly  09:20

Right.

 

Dr Kimberley Forrest  09:21

Yeah, so that's, and I think it's important to point that out. Really, because I think that the, the relentless search for triggers can actually be counterproductive and lead to a very restrictive lifestyle, and diminished quality of life. I know I'd be pretty sad if I was told I could never have chocolate or red wine ever again. And in fact, there's so much more bang for your buck that you can get through other treatments and modifications. So, so that's, yeah, that's as far as that goes. What can you do though? So, I guess we're, what you need to do in order to decrease the risk of triggering a migraine. So people with migraine are just more predisposed, everyone can, if you tried really hard, everyone could get a migraine, but just some have a lower threshold for developing it. So when people who have migraine, there's some non pharmacological measures that we suggest, and it's really quite boring, and what we've been, what all doctors in every specialty have been yammering on about for years. And it's just basic lifestyle measures, good sleep, well rounded diet, exercise, and weight loss is debatable, whether, as to whether or not it decreases the chances of, of tipping into a migraine.

 

Dr Elissa Hatherly  10:54

Oh now let's not advertise that point, because it's a motivator that I use frequently. [Laughter]

 

Dr Kimberley Forrest  11:02

Yes, I totally agree I wanted not to put that in there. But the way, the way I rationalised it is that if you, if you're getting a well rounded diet, exercise and sleep, then you know, generally the weight loss hopefully follows. Or maybe, or maybe we should put it that you know, you shouldn't, you shouldn't aim for weight loss at, ah, single mindedly, and forget about all the other things, you know. So don't go and get a, don't go and get a, a gastric sleeve.

 

Dr Elissa Hatherly  11:41

1. So, you've talked about the fact that the biggest risk factor for migraine is genetics, which is unmodifiable. And that some of those other triggers that are often talked about in the literature like chocolate, red wine, and changes in the weather, are really a correlation not necessarily causal. And that lifestyle factors like adequate sleep, good diet, and exercise are really important. What are some of the other first line treatments that we should be looking at before we send our patients in to see yourself? Is a headache diary a useful tool do you think?

 

Dr Kimberley Forrest  12:20

Yeah, so that, that forms one, one part of the process. And I might even take us back one step even, and say that the process, or the decision to treat, or to refer, really comes back to what they told us in med school as well. It comes down to the history. It's really about trying to define in the first place, whether or not someone has migraine. And you can do that via the definition, obviously, but you, in order to get to that, to see if someone fits that definition, you need to take a good history in the first place. So focused, you know, not a not a general physician long case necessarily because of time pressures, but a focused history, plus/minus examination, to rule where you thinking really about ruling in the migraine. Like if you have a strong focus, if you have a strong suspicion, you try to think is this actually migraine? If it is migraine, is it migraine with aura, standard episodic migraine, or is it chronic migraine, and it becomes chronic migraine if it's over 15 days per month of headaches. And then the other important thing you're doing when you're trying to figure out if this is, when you're taking this history and trying to diagnose the headache disorder, is number one, it's important to differentiate migraine from other primary headache disorders. So thinking tension headache, a cluster headache, for instance. And that's important, because the treatments differ. So if you want treatment success, you've got to define the headache disorder in the first place. And then the other thing is to make sure that you're not, is to look at, look for the red flags as well, to make sure that you're not missing any particularly secondary migraine or headache disorders, you know, things that we don't want to miss - subarachnoid haemorrhage, space occupying tumour, giant cell arteritis. So, before going into the treatments, it's important, it might sound like stating the obvious, but it's very important to just invest in that initial history taking to make sure that what you've got is highly likely to be migraine. Therefore, in subsequent reviews, when perhaps there's not as much time and the patient comes back and says the treatments not working. You can at least rely on the fact that although, you know, the confidence you have, be really relatively confident that the treatments not working not because it's the wrong condition that you're treating, that because maybe that treatment didn't work for that person. So, with that [laughter], going into it, you're always gonna get a lecture about taking histories from a neurologist [laughter]. So, here we go, can't get out of that one. Don't get me started on examination [laughter]. But luckily for you a lot less important with this. So here we go. So in terms of treatments, yes. So, when you, when you are treating migraine, a couple of considerations be, once you're sure it's migraine is, is this, is, is it episodic migraine? Or is it chronic? Because the treatments may differ ever so slightly. I guess, and then you think about acute versus preventative treatments. And then we can talk a little bit about non-pharmacological treatments in a moment. So as far as, so if someone has episodic migraine, so that's, that's, by definition, less than 15 Headache days per month, you want you may think about just giving them acute treatment, and everyone should be offered acute treatment and counselling around this. And generally, you get the you know, the if you look at guidelines and criteria, they say that you know, only offer acute treatment for anyone who's got less than two headache days per month, and maybe think about preventative treatment for anything above that. In reality is you know, a list of like it comes down to how much it's impacting that person. While one person might be able to stoically manage four headache days per month, someone else may absolutely not, and even one day a month is unacceptable for their lifestyle. So, it really comes down to judgement. Acute treatments, so, these are the treatments that people, you know, it's the pill in the pocket. People administer these to themselves, when they feel the pain of the migraine coming on. And I say pain because there's no evidence for, unfortunately, for taking these acute treatments during the aura phase, it's just when the headache comes on. So, and, as with all pain treatments, they need to be taken the earlier the better, basically. Hit it hard and fast. There's the stepped wise approach is the way to go. With the, sort of, with the least, least potentially harmful, the less, the least expensive medications being first line, so our old pal aspirin and ibuprofen, two of the best ones for acute migraine treatment. So, I think one thing that I have to counsel people on often is that it's not just one Aspro clear, it's three. And if you're in the US even four but three is usually the trick. And then the same with ibuprofen 400 to 600 milligrams, as soon as possible, as acute treatment. If that works for people for their migraines, then that's their treatment from there on in. Keeping in mind, the frequency with which they're taking these medications, and the and the well known side effects of NSAIDs* (*nonsteroidal anti-inflammatory drugs). The next line, so if that doesn't work for people, then the next line, typically, is bumping it up to the triptans. So these are tried true and tested, you know, Sumatriptan, Rizatriptan, Eletriptan, and these come in a variety of formulations, the same principles of pain management apply, the sooner the better. And the AMH* (*Australian Medicines Handbook) has very good guidelines on on how to give these, but it's usually one, sometimes up to two in a 24 to 48 hour period if the headache returns after it's been abolished, and depending on and depending on what works for that person. So I guess an important key point is a lack of response to these treatments. The triptans isn't a class effect necessarily. So if someone tries Sumatriptan for instance, and it doesn't work, then maybe try Rizatriptan. If Rizatriptan doesn't work, have you tried Eletriptan? Yes, and the same goes for mode of delivery. So, some people just, you know, some people will do very well just with the tablet, some people need the oral disintegrating wafer, some people's headaches come on so quickly that you need the injection or the nasal spray. So again, there's a whole lot to be done in that second line space before bumping it up. So that's that and we've got, perhaps on the horizon as well, there's, there's the newer medications called the gepants, which, the, a variation on the CGRP* (*calcitonin gene-related peptide) antagonism theme, and I'll go into the CGRP antagonists a bit later. But yeah, these are oral, small medic molecule CGRP receptor antagonists. TGA has approved them but they're awaiting PBS review later on in this year. And if they work anything anywhere near as well as the preventative CGRP antagonists, then, hopefully, we'll be on onto something good with them too. But at this point in time, not available in Australia.

 

Dr Elissa Hatherly  20:47

Okay, so for the people who suffer with migraine, which is enormously expensive to our community, our acute treatment is aspirin. So three Aspro clear, or ibuprofen, whichever one works for the patient, keep going with that into the future. The second line treatment is the triptans, it's not a class effect, try them all if you need to, and keep an eye out for the CGRP antagonists in the future. So, what is the future of migraine treatment then, Kim? Do we have the CGRP potentially coming? Is there any other magic bullet out there for our patients?

 

Dr Kimberley Forrest  21:26

For the acute treatments?

 

Dr Elissa Hatherly  21:28

Yeah.

 

Dr Kimberley Forrest  21:29

Not necessarily, but the exciting stuff, the future is now, with the with the preventatives?

 

Dr Elissa Hatherly  21:35

Great. Let's talk about preventative treatment then. How do we manage those people who need something a bit more than that episodic acute management?

 

Dr Kimberley Forrest  21:47

Okay. Sorry, before I go on, I just failed to mention two key points with the acute treatments. Number one, for those who have significant nausea, add in a prokinetic, so usually Metoclopramide as soon as possible. And then the other key point is that paracetamol, surprisingly, has very little evidence for it. So you can basically throw that out. However, if someone says they respond to it, then that's fine. But generally less less evidence and the other medications. Now, preventers, let's talk about it.

 

Dr Elissa Hatherly  22:18

Let's talk preventatives.

 

Dr Kimberley Forrest  22:22

So, you think about preventers, again, strict criteria, or recommendations from the headache societies is, so anyone who's having more than two headaches per month, and you start to think about preventers, you'd call that episodic migraine. But if someone's having greater than 15, headache days per month than that's chronic headache. I've thought about this, because I don't actually, the only thing I think about is if someone's really suffering from their migraines, taking lots of time off their daily duties, and the acute treatments aren't effective to curtail that. Then it just opens you up to a whole variety of medications. So, the way that we choose, which ones, really comes down to patient characteristics, I'll come back to that, the ease of use of the medication, and, because we, and of course, PBS criteria, because not all medications are equally funded. So when it comes to patient characteristics, I think most GPs would be very familiar with the, with the usual first line, so we're thinking about Propranolol, Topiramate, Candesartan, Amitriptyline, Valproate, etc., Pizotifen. And we'd all know these are very commonly used medications not just in migraine, but in a in other, in other systems. So, when I say apparent patient characteristics, what I mean is just thinking about how you can fit those medications to that person's needs. Thinking about contraindications, so unfortunately, pregnancy is a big contraindication for most, for all, medications, the preventers. You can think about whether someone's got hyper- or hypotension. So you'll be, you know, not thinking about Propranolol, if they have got hypertension. Think Propranolol if they're quite hypotensive and bradycardic, like a young woman, for instance.  You probably not going to be thinking about Propranolol or Candesartan, reactive airways disease, if they're overweight or underweight, if they have insomnia. So we can use the side effects of some of these medications to our advantage. So, for instance, that's you know what Amitriptyline is wonderful for as well. If someone's not sleeping all that well, then a little bit of Amitriptyline at night time can certainly help with that too. There's, as GPs you'd probably be able to do, you'd be more conversant in all the quirks of PBS prescribing. I guess the the key things to know are that there's no authority required for Propranolol or Pizotifen. So, you can try those. If you want to bump up to something like Topiramate, which is good for both episodic and chronic migraine, then, you can either go off label, and it's not very much to do to do that. But if you go by PBS criteria, the person has to have failed or not be in a position to use his or Pizotifen or Propranolol. So that's that I guess. The, the key points with those as well, I can't say the percentage off the top of my head, but this will work for a reasonable portion of people, but for a great proportion of people, these first line medications don't work. And then we think about the next line assuming that all other variables have been ironed out, such as adherence to medication, what education on migraine, and goals of care have already been discussed. So assuming that all that's been done, then you can think about going up to the next line of treatment. So, this is the future is now, well, in fact, the future is yesterday, because we've had Botox for quite a while now [laughter]. So there's that. So there's Botox. The current toolbox, we have are Botox and the monoclonal antibodies against CGRP receptor. And so we just, I guess, we just call those the CGRP antagonists. And in Australia, we have four of those, and they all have extremely difficult names to pronounce, and annoyingly, their brand names are no easier to pronounce. I don't know what they are trying to do to us. But there's erenumab, which is Aimovig. There's fremanezumab, which is Ajovy; galcanezumab - Emgality; eptinezumab - Vyepti.  A, so these are, these are the options now. So we think about those and people who've failed three first line medications. So, and that's the PBS criteria. Again, you can use any of these off label, but they're very expensive. You know, I think a vial goes for about 1000 bucks, and we use two vials every three months for Botox. So that's what we look at. Is there anything in particular you would like to know about these before I could, before I talk all day about how wonderful they are?

 

Dr Elissa Hatherly  27:44

Well, intensive monoclonal antibodies, of course, I don't imagine that's something the GP can initiate. How do we get our patients on to the monoclonal antibodies?

 

Dr Kimberley Forrest  27:55

Yeah, so, they, so you'd have to, for the first prescription, it has to be to, a referral to a neurologist. So, that's the PBS criteria, they have to, the first prescription needs to have been done by a neurologist and with confirmation of the diagnosis, and confirmation that three first line treatments have been failed, or are contraindicated.

 

Dr Elissa Hatherly  28:24

Right. And so for Botox? Is that useful for all types of migraine, or only in a particular subset of our patients?

 

Dr Kimberley Forrest  28:34

Oh, it's, so certainly anecdotally, and, yeah-no, anecdotally it's suitable for all of my all the patients that have seen migraine with aura or migraine without aura. It can be used for episodic and it could be used for chronic, but by PBS criteria, it has to be chronic, so greater than 15 headache days per month...With the monoclonal or with the CGRP antagonists, they neurologists can write the first script, we generally that's I'll do that. I'll bring them back after three months, which is what the first script allows you. Once monthly injections for three months. Bring them back, see if it's if it's been effective, and if it has I write the next script, which is for six months. And from there on in, as long as it continues to be effective for the patient, and that's, by effective, the definition is reduction of headaches by 50%, then a GP can continue to write those groups.

 

Dr Elissa Hatherly  29:46

Fantastic. So, Kim, where to from here?

 

Dr Kimberley Forrest  29:52

Where to from here? Oh my gosh. Well, I would think, where to from here? Hopefully, I think these, these CGRP inhibitors have been, antagonists rather, have been absolutely revolutionary. They're the first. So, hopefully, where to from here, is that with increasing recognition of migraine, and treatment, and now treatment with medications that have, that are, what I've seen in clinic, is that these medications, you tend to know earlier whether or not people respond to them. Generally most, a lot of people, do respond to them, remembering though, that I see people who are, have been referred by people like yourself in the first place where they've failed three firstline medications. So generally, these, we get a very good response to these medications, they have very little side effects, people can take the treatment into their own hands. It's a once monthly injection, fabulous, it's not having to remember to take a tablet every single day. The, I would hope that, so there's a there's a push for them to be, to be first line. So, to have people not have to do the trial and error of the oral medications. Because I mean, it's absolutely in terms of health care costs, absolutely make sense. These are expensive medications, and, and if we can get away with treating migraine with a less expensive medication that it benefits, you know, the entire healthcare system. But when you think about how that works on the ground, that's a lot of time invested by people who are already suffering, you know. You need to give each oral medication at least three months, ideally, six months to see if they work. So that's, you know, three, three to six months times three medications using up almost a whole year. Not to mention the costs of coming and, you know, coming and going from GP visits as well, and lost productivity in the meantime. So, I would think that in the right, in the right circumstances, it would be great to see CGRP antagonists pushed a bit further up in the, in the PBS, but, so that's in an ideal world where things don't cost anything. I guess the, the, in terms of what else the future holds it, it'd be very nice to, one huge gap in the market is for pregnant women and breastfeeding women. At this point in time, maybe you know, there's people, women who are pregnant have to go off their preventers. In certain circumstances, and with ,you know, with good, with thorough discussion of the pros and cons, there are a couple of preventers you can use, for example, propranolol, but generally we avoid it. It would be, but there's generally no preventers, and no acute treatments that can safely and broadly be applied to pregnancy. Even with the newer medications, even Botox, which is not systemically absorbed, just because of lack of studies into it, we still can't safely recommend Botox during pregnancy and certainly monoclonal antibodies. For CGRP, being relatively new medications, we definitely can't recommend either, but that'll just be a matter of time, as with all new medications, you know, after a while in use, then the data will gather and we'll be able to provide women with much better advice on the safety profile of these medications. So, that's my thought. 

 

Dr Elissa Hatherly  34:03

Right. Kim, it sounds like a research project is waiting for you. So, just to summarise then, our take home messages, I suppose are that migraine is common, and to always suspect it. Be careful with that diagnosis of migraine making sure we're excluding other types of headache, and the more sinister causes like space occupying lesions, subarachnoid haemorrhage, giant cell Arteritis. Start with our simple antiinflammatories, try all the triptans, and those second line medications like the propranolol, amitriptyline, topiramate. How good is amitriptyline? And then we've got the Botox and CGRP antagonists monoclonals for those people who need something a little bit more. And of course, the reminder that pregnancy is dangerous, particularly for migraine sufferers, and mindful of the factors you said earlier that paracetamol is pointless, one of the few medications you can take during pregnancy. Is there anything else we need to take away from today's talk to change our practice, do you think?

 

Dr Kimberley Forrest  35:17

I think we've covered most of it. I think we've covered definitely the key points, it really just comes down to suspecting it, diagnosing it to the best of one's abilities, going through that stepwise process of acute then preventative management and referring on. I guess that's maybe that's the next point to point out is. Once you get to that point where you're a bit stuck, please do talk with us. There's, I think this podcast was for GPs in Far North Queensland and North Queensland, is it? So I could, you know, put in, put in a plug happily [laughter], please call your local neurologist and, you know, we're very happy to take calls at the hospital. If you're unsure, or you know, if it's less urgent than just a referral through the hospital, that's absolutely fine. If there's any diagnostic uncertainty, or treatment uncertainty, or then, then do refer on, and this is what, that's what we do, we manage migraines that, that aren't behaving how they should in primary care. So, do discuss with us we're very happy to discuss the, and then in terms of other take home points or points to realise, oh, that's it. It is weaning the medication so people don't need to be on preventative medications forever, and you can think about stopping preventative medications, including CGRPs and Botox. After, you know, anywhere between, sort of, one to two years of headache freedom, which is some what some people do like to try. So that's absolutely a thing. You're not necessarily committed to being on preventative migraine treatment forever.

 

Dr Elissa Hatherly  37:12

Fantastic. Dr. Kim Forrest, Neurologist in Cairns, working in the public hospital there. Thank you so much for your time talking about headache today.

 

Dr Kimberley Forrest  37:21

My pleasure. Thank you so much for inviting me.

 

Dr Elissa Hatherly  37:23

For more information about the roundup, or to share your feedback and ideas for future episodes, visit https://www.nqrth.edu.au/news/roundup-podcast/, or contact us at nqrth.mackay@jcu.edu.au We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training Hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander Health Council, Health Services, Aboriginal community controlled health organisations and General Practice clinics.

1. Ashina M, Buse DC, Ashina H, Pozo-Rosich P, Peres MFP, Lee MJ, Terwindt GM, Halker Singh R, Tassorelli C, Do TP, Mitsikostas DD, Dodick DW. Migraine: integrated approaches to clinical management and emerging treatments. Lancet. 2021 Apr 17;397(10283):1505-1518. 
2. Eigenbrodt, A.K., Ashina, H., Khan, S. et al. Diagnosis and management of migraine in ten steps. Nat Rev Neurol 17, 501–514 (2021). pages501–514 (2021)volume 17, pages501–514 (2021)

Dr Elissa Hatherly  00:02

Welcome to the Roundup, a  North Queensland based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician and head of JCU's Clinical School here in Mackay. This collaborative podcasting project between North Queensland Regional Training hubs,  JCU, and our local, regional, Hospital and Health Services will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. In this episode, I'm joined by Dr. Ben Reeves, a paediatric cardiologist in Cairns hospital who is dedicated to rheumatic heart disease in North Queensland. Good morning, Ben.

 

Dr Ben Reeves  00:52

Good morning.

 

Dr Elissa Hatherly  01:06

Thanks so much for being involved in our podcast, we know rheumatic heart disease is a massive problem across North Queensland and is something that we can all be better acquinted with and understand more fully. Can we start by asking you to remind us what is Rheumatic Fever?

 

Dr Ben Reeves  01:11

So rheumatic fever is an immune response to streptococcal a infection. So it happens most commonly in childhood, and begins typically as a group A strep throat infection, and pharyngitis. But more recent research has shown that it also happens as a result of skin infection with group A strep. So regardless of the, the portal of entry, it's a streptococcal infection that then sensitises the immune system. And it seems to take a number of infections for the immune system to be sensitised and then react against the infection and cause acute rheumatic fever. So that's a constellation of symptoms, including fever and joint pains. It causes cardiac valve damage, which is rheumatic heart disease and, and repeated episodes of acute rheumatic fever appear to cause cumulative damage to the heart and, and that's what we worry about as cardiologists. It causes valve dysfunction and very severe rheumatic heart disease can lead to death.

 

Dr Elissa Hatherly  02:30

Yeah, right. We've got to be on top of this in the community and in our emergency departments. So with strep throat and strep skin infections being so common, what are the other risk factors that we know about for developing rheumatic fever?

 

Dr Ben Reeves  02:47

So it's really all about that streptococcal exposure. So we know that in Australia, rheumatic fever happens much, much more often in First Nations communities,  in Aboriginal and Torres Strait Island communities. And they are much more disproportionately affected compared to, to urban affluent Australia. So it's a disease of social disadvantage. And it's at its root, it's caused by overcrowding of houses, and poor access to hygiene and health services. It's a disease really, that was eradicated from most of Australia in the 50s and 60s. But despite this in indigenous communities, we have some of the highest rates of rheumatic fever and rheumatic heart disease in the world. So it's really those primordial factors of social disadvantage that are that are causing this problem.

 

Dr Elissa Hatherly  03:58

Right, so short of completely overhauling our social services system in Australia how can we prevent rheumatic fever happening for those most disadvantaged in our community at from a medical point of view, at least?

 

Dr Ben Reeves  04:16

Well, you say short of overhauling our social services, I think that's where we should be leading as a, as a community. I think we should be addressing those primary drivers of social inequity and disadvantage, and I think we can do a lot more in improving housing and hygiene services in in remote communities. As health professionals, obviously, that's not always up to us, but we can certainly advocate for that social change. The main way that we can intervene is with is with primary and secondary prophylaxis against infection with strep and rheumatic fever. So, for the people encountering skin infections and sore throats then timely treatment with penicillin can avoid that progression to acute rheumatic fever. For those people like me in the hospital system, then identifying cases of rheumatic fever and rheumatic heart disease means that we can enrol children and adults into regular penicillin prophylaxis, and we use intramuscular benzathine penicillin, which gives coverage and prevents infection with group A strep for up to 28 days. So that treatment of sore throat and skin sores and then preventing recurrence of rheumatic fever by treating with benzathine penicillin is really the mainstay of hospital treatment and primary care responses to avoid that end stage rheumatic heart disease.

 

Dr Elissa Hatherly  06:01

So talking about rheumatic heart disease, then Ben, what is the effect of that group A strep on the heart? You mentioned valvular damage.

 

Dr Ben Reeves  06:10

Yeah, so when we look at the hearts of people affected by rheumatic fever, it causes damage at many different levels. So so we see endocarditis, we see valve dysfunction on the endocardial surface of the heart, we can see effects on the myocardium as well effects the conducting system, and it can cause myocardium, weakness and reduced function. And we see pericardial problems as well. In severe rheumatic fever, it can cause pericardial effusion and pericarditis. But really, in children, what I see mostly is is valve dysfunction, and particularly regurgitation of valves, primarily affecting mitral and aortic valves. And that's the acute inflammatory process of rheumatic fever. It causes valve leakage and heart failure as a result, if it's severe.  In its chronic form, we see a change in that inflammatory process to become scarring and contraction of valve leaflets. So then you see stenosis of valves, and restriction of mitral valve inflow and aortic valve outflow primarily. So it mostly affects valves on the left side of the heart, and initially causes regurgitation and then causes scarring and stenosis.

 

Dr Elissa Hatherly  07:43

So then the whole of life impact of rheumatic heart disease is enormous, isn't it?

 

Dr Ben Reeves  07:49

Oh, absolutely. And it can start very early in childhood. So we, we do see children as young as three and four years of age, present with rheumatic fever. And if it's not prevented from recurring, then yes, you get progressive valve dysfunction with each episode. And you get worsening symptoms of heart problems, commonly rheumatic fever in it's early, sorry rheumatic heart disease in its early stage, is frequently asymptomatic and it takes a while and progressive valve damage for them, for them, to patients to present to, to health services, with symptoms. So it it's largely a hidden disease. And as I said earlier, it occurs in in disadvantaged and often remote populations that find it hard to seek health care.

 

Dr Elissa Hatherly  08:48

Right, so just to summarise them, Ben, we've talked about rheumatic fever being an immune response to group A strep from often a pharyngitis or a skin infection, and it's that repeated infection that tends to create that immune response with whole of body problems like the fever, the joint pain, but particularly the valvular damage as one aspect of the heart impact of rheumatic fever. That primary prophylaxis with penicillin first up is incredibly important, but then that regular benzathine penicillin, for that secondary prophylaxis is incredibly important then for these members of our community. So, Ben, you're just talking about really young children who are experiencing heart disease already, when you're seeing them at three or four years old, and that it's a hidden disease. How can we go about making sure we find those affected children? Do you have a screening programme that you've been able to successfully implement?

 

Dr Ben Reeves  09:52

We have and traditionally, screening efforts were really targeted at auscultation of the heart. So we have existing school screening programmes in Queensland, carried out by child health nurses. And they look at hearing and vision testing for children, they auscultate the heart, they check haemoglobin levels and so on. We know that listening to the heart is neither sensitive nor specific for rheumatic heart disease, however. So there is a large body of evidence in the literature showing that echocardiogram screening for rheumatic heart disease picks up more than 10 times the number of cases that auscultation does, we now have very clear guidelines based on echo characteristics of what rheumatic heart disease looks like. And over the last 15 years or so, I've been involved in a number of projects in Australia and overseas, trying to measure the prevalence of rheumatic heart disease using these echo screening studies. And so in the last four or five years, we've been doing this regularly in northern and western Queensland, travelling to remote communities, performing echo screening on school children, in schools themselves, so we can access a large number of children. And this helps us to identify the burden of rheumatic heart disease, but also most importantly, enrol these children in preventive treatment programmes and regular cardiac follow up so that hopefully, where we're finding this hidden burden of disease and, and avoiding that, those bad outcomes I mentioned earlier,

 

Dr Elissa Hatherly  11:55

That's incredible. What an exciting project to be part of but Ben, an echo is a really impressive skill for any of our staff to undertake, and you know, yourself from your own training, it's a really specialised area, how were you delivering an echocardiogram to so many children in such remote areas?

 

Dr Ben Reeves  12:20

So, I mean, the technology has come a long way. So we're using portable echocardiogram machines that are approximately the size of a laptop, and they're increasingly accurate devices that that fit in the palm of your hand to deliver point of care testing. So one aspect of this is the technology that's becoming more accessible, less expensive and more portable. The other aspect of this is training of people to perform brief echocardiograms by non expert operators, and there is an emerging amount of evidence that these sorts of interventions can be effective, I think, there's still a long way to go. With this, obviously, there, there's a lot of training required to become really good at this. And we're trying to find the balance between providing expert operators like a cardiologist or, or a cardiac sonographer to go out to these remote communities and, and whether this scope of these exercises can be improved by by training other interested operators to do this sort of work. So it is exciting. There's still a lot to work out as to how these sorts of projects should be done. But yes, I think it does contribute to improving outcomes. And hopefully, you know, saving lives in the future.

 

Dr Elissa Hatherly  14:02

And ideally, no longer holding top position as the country with the greatest number of young people affected by rheumatic heart disease. That's a frightening statistic. Ben when you're talking about the group A strep, pharyngitis and impetigo, we do see that so often in general practice or presenting to emergency departments in our smaller centres. We're often looking at people who have a lot of viral symptoms as well. Who should we be offering antibiotics to when we're suspecting it's a viral infection? Should we be more enthusiastic about offering penicillin to those First Nations children just in case it is a group A strep infection?

 

Dr Ben Reeves  14:47

I mean, this is a really good question and it's something that people are struggling with in Australia and overseas as well. In our setting, probably between about 10 and 40% of pharyngitis that presents will be due to group A strep. So, inevitably, if we treat every pharyngitis, we'll be over treating with antibiotics. And obviously, we need to balance this with the risk of with the concerns of antimicrobial stewardship and emerging resistance. So there's a lot of decision making to be done about this. The Australian guidelines for rheumatic fever mention, or have a whole chapter devoted to this essentially, but split these patients into high risk patients, and low risk patients and your high risk patient would be a Aboriginal or Torres Strait Islander person living in an area of high prevalence or living in a socially disadvantaged setting or living in overcrowded households. And for those high risk settings, then you apply a clinical decision tool for the pharyngitis as it presents. So for example, a child with a sore throat and enlarged lymph nodes and an appearance of a purulent discharge and absent of absence of cough is much more likely to have group A strep and therefore should receive treatment. I hesitate to give your audience too much advice about this because I'm not a primary care doctor and my days of seeing children with sore throats are long behind me, but there's a good reference in that rheumatic fever guidelines that can help with that decision making process and, and allocating people to high risk groups. Also, I think it depends on the setting, you're seeing people in obviously, up in Cairns, and in the Cape and Torres, the risk of rheumatic disease is much higher, and therefore your threshold for antibiotic treatment would be lower. And I think that's important for the audience to realise that when they're travelling to remote places, the threshold for treatment should be lower for those those people.

 

Dr Elissa Hatherly  17:30

Sure. So Ben, it is a bit of a minefield, those sore throats and skin infections. So can you tell us how well your research is going at the moment? When are we likely to see some outcomes? And what are the numbers that we're going to need to be looking at to make a big impact on our communities, health services Ben?

 

Dr Ben Reeves  17:54

So the the Echo screening projects that we're doing, are targeted really more at clinical outcomes, than research, we do have a number of other projects that we're collaborating between multiple other sites, looking to improve outcomes in this area. One of the ones we've started recently is looking at MRI diagnosis of acute rheumatic fever, which can, which is likely to be much more sensitive than echocardiograms. And we're collaborating with a team in Melbourne to do that, and started recruiting patients who already were involved in a number of other trials in very early phase at the moment, looking at biomarkers for acute rheumatic fever, with a team in at Griffith University and New England University. And we're also looking at contributing to a multicentre trial of steroid therapy for Sydenham Chorea, which is another feature of acute rheumatic fever. So we've got a number of things that we're we're waiting for, to emerge that should hopefully make a difference for the future,

 

Dr Elissa Hatherly  19:08

Ben that's an enormous undertaking. I wish you well in all of your projects. Just thinking about all the things that we've talked about today. Ben, what would be your top take home tips for people thinking about rheumatic fever and rheumatic heart disease in their patients?

 

Dr Ben Reeves  19:27

I think the just the awareness that this disease is common, and can have very significant later effects. And I think your threshold for treating skin sores and sore throats should be lower. And recognising the potential for rheumatic fever and investigating appropriately is really important. And in that, you know, thinking about rheumatic fever, we need a number of tests to be performed before we can then make a confident diagnosis, including blood tests looking for the inflammatory markers and streptococcal serology, we need an ECG at diagnosis to detect prolonged PR interval, which is a minor criteria for acute rheumatic fever. If all of these tests are done in a timely fashion, then it certainly helps me who may come along a month later and try and look in retrospect to make a diagnosis to potentially put someone on to long term by Bicillin treatment. And we want to make this diagnosis as accurate as possible because the stakes are quite high. Looking back at our example of a four or five year old child, they'll be on by Bicillin phrophylaxis, receiving painful injections every 13 times a year for 15 or 16 years. So it's really important that we get as much information as we can to make an accurate diagnosis and avoid over treatment, but also provide that life saving treatment that will make a difference in the long term.

 

Dr Elissa Hatherly  21:15

Dr. Ben Reeves, thank you so much for your time today. It's great to have a bit more of an in depth understanding about the potential minefield that rheumatic fever and rheumatic heart disease can be for some of our patients, and the research that you're undertaking that should make following up those patients a little bit easier, and making sure that we can reduce those health inequities in our community. Dr Ben Reeves, paediatric cardiologist in Cairns thank you so much for your time.

 

Dr Ben Reeves  21:43

Thanks very much.

 

Dr Elissa Hatherly  21:47

For more information about the Roundup, or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice, and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organisations and general practice clinics.

• ARF RHD Guidelines 3rd Edition

Dr Elissa Hatherly 00:02
Welcome to the Roundup, a North Queensland-based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician and head of JCU's Clinical School here in Mackay. This collaborative podcasting project between North Queensland Regional Training hubs, JCU, and our local, regional, Hospital and Health Services will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. On today's episode, we're talking about rural generalism with one of the superstars of rural generalism Dr. Sarah Chalmers, welcome, Sarah.

Dr Sarah Chalmers 00:50
Thanks for having me Elissa.

Dr Elissa Hatherly 00:53
Sarah is the immediate past President of the Australian College of Rural and Remote Medicine or ACRRM. She is the medical superintendent on Palm Island and has had years of experience in rural and remote Australia, including a long stint in Arnhem Land and some time in Tennant Creek. You probably Sarah are the best-placed person in Queensland to talk about rural generalism today. What was it about rural generalism that really drew you in, that made it so enticing for you?

Dr Sarah Chalmers 01:30
That's a really good question to start with. I, when I went to medical school, I actually had an idea in my head that I wanted to be a rural doctor. I, we didn't talk about rural generalists back then. It wasn't. You know, it wasn't a well-used term. It was probably really just in its infancy. Both my mom and dad are rural generalists, or what we now call rural generalists and actually, so was my grandfather back in rural New Zealand. And I, you know, I think when those lines about, you know, if you can't see it, you can't be it. If you do see it, you can be it. I think so there was that. My other big driver was that having grown up in small places, so when we moved to Australia when I was five, we lived in Gove, in Nhulunbuy in East Arnhem Land. And then in Darwin, which back then was quite a small country town and I really did not want to live in a big city. And so rural medicine was an obvious career choice for me.

Dr Elissa Hatherly 02:45
Fantastic. And so you turned that into reality. How did you actually go about getting into rural generalism, then once that idea had really formed in your head?

Dr Sarah Chalmers 02:54
So it was, I mean, without sounding super old, which, of course, I'm not. There, the opportunities that exist, certainly for medical students, but also for rural generalist registrars didn't really exist back then. And so you kind of had to make your own way. One of the things that I knew that I wanted to do was to work back in the Northern Territory, it would be good to, you know, did the idea of returning home or back to a community that, you know, very much appealed to me. And I guess I had a chat to a few people along the way. So not my mum and dad, because you never ask your Mum and Dad for sensible advice. And they would have just given me some big long, boring lecture. So instead, I went out looking for real doctors, which is how I thought of it at the time and just said, you know, what sort of things should I try and do before I go to my rural community? And so, and again, we didn't really talk about ASTs. I didn't want to do obstetrics and anaesthetics, which were, you know, skills that lots of rural doctors had at the time. So I decided that I was going to do emergency medicine. That was a recommendation that somebody suggested when I said I didn't want to do obstetrics and anaesthetics, so I spent much of my junior doctor years doing as much emergency medicine as I could. And yeah, and then when I started my GP training, which was actually rural generalist training, the, you know, I was already out in my remote community, and I did my training there. And so when it came to thinking about what I wanted to do, as a grown-up as a fellow doctor, I was already doing it. So yeah, that's kind of how it all happened.

Dr Elissa Hatherly 04:58
Right. So you mentioned that you had gone through RACGP training in a rural generalist kind of location. Of course, these days, we have the Australian College of Rural and Remote Medicine, which is another pathway, right?

Dr Sarah Chalmers 05:12
That's correct. And so at the time ACRRM was, so when I started my GP training ACRRM existed and I was a member, it's just that they didn't actually have a fully accredited AGPT training programme at the time. And so the advice was to get an RACGP fellowship, but when I'm doing it in a remote place, to look at, you know, the, what they were proposing for ASTs, to look at the education modules and things that they already had up and running. And that they would help me, you know, transition from my RACGP fellowship to my ACRRM fellowship. So, yeah, I was, both my mum and dad were foundation members of ACRRM and in fact, my mum, I'm pretty sure was on the foundation ACRRM board, and my dad was one of the original educators. So I knew it was coming. I just wanted to get my fellowship. You know, I mean, that's what we want to do right? We don't want to be registrar's for too long, because you get paid better, you get more opportunities once you've got your fellowship. So, yeah, I went ahead and got an RACGP fellowship and then when ACRRM was accredited, I completed some of the other parts of the assessment so that I had my FACRRM. So I've got both fellowships.

Dr Elissa Hatherly 06:41
Wow. So for anyone these days who's interested in rural and remote medicine, they could still go through either pathway, but the ACRRM fellowship would usually be the one to go through. It is an acronym dense industry that we're in. You did mention ASTs, you mean advanced skills training, don't you Sarah.Did you want to talk us through how that works for ACRRM, please?

Dr Sarah Chalmers 07:05
So Advanced Skills Training is part of an ACRRM fellowship. And it's not, you know, lots of people think of it as you know, you do GP training and you add something else on that is not what rural generalist training with ACRRM is. Every single person who has an ACRRM fellowship has completed their core module. So that's your core generalist training, which of course, is you're working in a rural and remote community in primary care predominantly. But it also recognises that you can be doing your primary care in places other than a bricks and mortar general practice. So you might be doing it in a remote clinic, you might be doing it on a school veranda, which is where I did some of my core generalist training. But you can also do it in a hospital, because in places where there aren't enough general practices and things, you know, we do a lot of primary care in our emergency departments. To answer your direct question, an AST is your advanced specialist skill. And it is something that all as I said, that all FACRRMs have, and it is the extra part of your rural generalist training that makes you the part of the just trying to think of the right word. Part of the efficiency, I think that rural generalists offer. So it is, I mean, ACRRM has 11. And there's always lots of talk about what other ASTs we would have. And so it's things like obstetrics, so you can have get an Advanced Diploma in obstetrics, and you can perform, you know, complex, more complex births, including emergency caesarean sections in rural and remote communities. You can do anaesthetics, and there's now recently started a rural diploma, sorry, a Diploma of rural generalist anaesthetics. And then there's other ASTs in mental health, Aboriginal and Torres Strait Islander health, paediatrics, internal medicine, I'm not going to try and rattle them all off here. But essentially, we go and do specialist training. So with non-GP specialists, often in the hospital setting to have those extra skills we can deliver more than just primary care in our in our rural and remote communities.

Dr Elissa Hatherly 09:41
That's an incredible breadth of medicine that rural and remote specialists are offering then, isn't it? So an incredibly important part of our workforce, to those most underserved communities across Australia. What is it that we need to know before embarking on a career in rural and remote Australia?

Dr Sarah Chalmers 10:11
I think, so, one of the things that's very apparent to me right now, is that you actually have to practice a very different type of medicine to what you do in town. And what I mean by that is, you know, I mean, obviously, we still follow the diabetes guidelines, we follow, you know, emergency protocols, and, you know, medicine is medicine. But actually, a lot of things that are just assumed as a normal part of medicine in towns and bigger, and certainly in bigger cities, is access to resources. And so one of the things that we get good at, and in fact have to include as part of our special skills, is the ability to work without machines that go ping, the, the most obvious one of those, for example, is a CT scanner. So, you know, I recently worked in a big city emergency department. And when someone comes in with, you know, almost any concern, you know, of a, you know, intracranial pathology, they have, they get a head CT. And, whereas when you're in a more remote area, you you don't necessarily, you know, you can't go straight into a CT. Before you can get to a CT, you need, you know, a 2 hour ambulance ride or a helicopter trip, or, you know, a boat ride. And it may not happen as an emergency. And so it makes you think a little more about do do we actually need this when you're taking someone out of their community, for example, so they might not want to leave the community, in which case, how are you going to manage this person without, for example, a CT scanner. So we work in low resource environments and, and we work in smaller teams. So we don't have you know, people like to make jokes about, you know, a left knee surgeon or a big toe surgeon. So as we are true generalists, we don't just deal with primary care, we deal with anything that presents to us and a lot of what would otherwise be managed by an emergency department or an orthopaedic surgeon. So we, because of where we are, because of who we are, and who we have to work with, we do actually have a massive breadth of clinical requirements. And so the other thing that we need, as well as, you know, understanding that that's the environment that we work in, and that it is different. There's a group of rural and remote rural generalist academics who've come up with a, an extra skill, it's a bit like the force that rural generalists have. And they call it clinical courage. And, and I really like the term, the more I think about it, the more I like it. And it is that extra sense of maybe risk taking, but also, you know, using clinical skills, interpreting them thinking about the whole person, and what they, you know, what they are presenting with, where they come from what they need, and being able to do things that are a little, maybe just bending the rules slightly or going outside of the scope, or, you know, it's all of those things kind of built in, and it means that we are probably slightly bigger risk takers. But actually, we do a whole lot of risk mitigation, so that to ensure that we're actually still working safely.

Dr Elissa Hatherly 14:11
I love that. So rural generalists work with the force, they have that clinical courage. I think it's about becoming comfortable with that diagnostic uncertainty, isn't it Sarah, which we don't feel comfortable with as junior doctors and I think we become more courageous as clinicians with the experience to try and learn that as a more junior doctor in a rural or regional setting is incredibly difficult, I imagine but I do love the term. So we can train through RACGP or ACRRM and through ACRRM rural generalists have up to 11 different advanced specialist training skills that they can acquire. Usually it would be one or two of those advanced specialties that they can then take out to their rural or remote location and performing a different type of medicine with limited resources, as you say. But Sarah, out when you're practising in Arnhem land or on Palm Island, are you still truly alone? Like you would have been 20 years ago, when you were first starting out? Surely there are some IT solutions that are helping to bridge the gap in those smaller communities?

Dr Sarah Chalmers 15:28
So it still depends where you are actually. So there are still, you know, large pockets of, for example, Arnhem Land that don't have, you know, full mobile phone reception services, and definitely have fairly sketchy internet connection. So they might be working on a portable satellite. So, yes, you're right, in lots of places, you are less alone than you used to be. Before I talk about it, though, you know, we talk about single doctor posts, but whenever we're we're very rarely completely on our own. You know, one of the other things that's really important about rural and especially remote medicine, is the teamwork, the multidisciplinary teamwork. And we have, you know, rural generalist, nursing and allied health colleagues who work alongside us in our slightly crazy, you know, work situations. And so I think it's really important to recognise that, you know, when you say, you're not alone. We were never alone, we were always working very, very closely with our colleagues. And, and I know that, you know, GPs and actually, hospital doctors often talk about the teams based approach. But when we talk about that in rural and remote medicine, you know, we're often talking about so we're talking about doctors working outside of a normal scope of practice. So we're not GPs we're GPs that do a whole bunch of other things. But many of our nursing and allied health colleagues, our pharmacists, our OTs and physios and social workers, and Aboriginal health practitioners are all working to a really broad scope, and we cross over and support each other a lot. So going back to the IT stuff, yes, you're right, we do use, you know, we, we've been using digital health and telemedicine for way longer than everybody else has. So we had access, for example, to some Medicare rebates, and I can't remember when they started, particularly around mental health, and have been, you know, case conferencing with psychiatrists in remote, you know, from our remote location. We had Medicare rebates for that, for, I think, going back sort of 10 years or so. We also, you know, sorry, we also do things like, you know, when I was a young DMO in Arnhem Land, just starting my GP training, one of our roles, when we were on call was to work with the nurse, the remote area nurses and Aboriginal health practitioners out in remote communities, so they would ring us and describe to us what they could see. And we would interpret that and come up with a management plan. So you know, we've been doing that stuff for ages.

Dr Elissa Hatherly 18:41
Right, so the rest of the primary care community is a bit late to the party. But finally, we're on board thanks to COVID and the necessary changes to the Medicare item numbers that have eventuated from that, hopefully, we keep those for a long time. So, Sarah, the message that I'm hearing from you is that as a rural generalist, advocacy for our remote communities is incredibly important to make sure that the resources are adequately applied across the broad scope of our land, where some of those communities are going to be incredibly limited. And that might not be providing a CT scanner, in remote Arnhem Land, but it might be just about making sure there's adequate phone coverage. How do you today, advocate for your communities through the huge bureaucracy that is managing health in our country?

Dr Sarah Chalmers 19:46
That's a really, that's a really hard question. So advocacy is, you know, it's, again, a very broad term and it can be as simple as writing, you know, a letter to Telstra to say, just in case you weren't aware, you know, half of or three quarters of houses in Palm Island don't have, you know, adequate mobile phone reception. And as a matter of urgency, from a healthcare perspective, this should be, you know, looked into and rectified right up to, you know, talking to the federal health minister, to explain to them just exactly why we need, you know, a funded rural generalist pathway to ensure that, you know, we've got a we have a career pathway that our junior doctors and medical students, for example, who might be listening to this and thinking, how am I going to do that, that sounds really hard. So, you know, telling the health minister, these are the things that you have to do, so that any junior doctor, you know, who hears about the potential for a career in rural generalist medicine, can walk up to, you know, their director of training and say, I want to be a rural generalist, how can you help me? So, you know, it's, it's an enormous body of work to advocate for our communities. And there are days when, you know, so I was the ACRRM president, and did a lot of work, for example, to get access for our rural and remote medical nursing and allied health colleagues to be vaccinated, for example, against COVID-19. And on the days where you get told that the first box is actually making it, the first box of vaccines is actually making its way out to a remote community, specifically for the medical and health team. That's amazing. And it feels great, you feel like you've really managed something. A lot of the time, it feels like I just have a giant bruise on my forehead, from banging my head against a brick wall. Because the you know, what we are? What, you know, what we've, you know, we're almost, we're such outliers, I think, in medicine, you know, certainly in medicine in Australia, and in much of the developed world, people are becoming more and more and more specialised. And, you know, so much of our graduating medical school work, you know, graduates are going looking at that they see that as part of their training. And they think, yep, that's what I want to be because I see that and that looks fun and interesting. And I can see how that is a very valuable, you know, career to have. We don't have enough of our medical students seeing rural generalists in action. We don't have enough training going on in rural and remote Australia, for our medical students and junior doctors to actually see it, they don't you know, that many of them don't even know that such a career exists. And they hear the stories from inside the hospital, where, you know, a rural doctor may have made a referral. And, you know, the consultant gets off the phone and says, you know, that guy is an idiot. He doesn't really know what he's talking about. You know, I suppose we'll have to rescue their patient kind of thing. Really, there's really bad messaging, I think, in in the big institutions in Sydney and Melbourne.

Dr Elissa Hatherly 23:51
Yeah. Sarah- What are the top tips for those aspiring rural generalists in our communities? What are the take home messages from today's talk? Do you think?

Dr Sarah Chalmers 24:06
So the most important one is that a career as a rural generalist is, you know, an incredible career, it can be extremely rewarding. It's varied. And, you know, it gives you an opportunity to, you know, provide a service to a community, who will, you know, where you can make a really, really significant difference to lots of people. So, I would encourage anyone who's had any thoughts about it to, to go and talk to somebody who, who does this kind of work and find out, you know, all of the good things about it. That's the most important bit. It's a really, really great thing to do. Secondly, would be, you know, for medical students and junior doctors, you know, getting rotations in rural and remote communities and working with rural generalists and understanding what they do, and, you know, finding out how they got there. And what are the good bits and the not so good bits, getting tips and tricks from people, you know, who are already doing that work, I guess have having a look at the training pathways and, you know, particularly the rural generalist pathways that are popping up all over the country now. And the, the opportunities, I think, looking for opportunities to to experience what it's like, so that you really understand just exactly what it is that you're that you're getting into. Does that help?

Dr Elissa Hatherly 25:50
I think it is. And I think the first opportunity that those students and junior doctors should be taking up is listening to this story about how fantastically rewarding rural generalism is, from your first hand experience of how interesting and streamline training has become recently, how you get to truly work within a team who are working to their full scope of their capacity in their location. And how you're practising a different type of medicine, with using the force as well, I mean, who's going to knock back that as an opportunity? Sarah Chalmers thank you so much for your time today. We really appreciate learning about rural generalism.

Dr Sarah Chalmers 26:40
Thank you, Elissa. And thank you very much for the opportunity to talk about rural generalism because I think the more we talk about it, the more normalised it will become.

Dr Elissa Hatherly 26:51
Absolutely. Thanks, Sarah. For more information about the Roundup, or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice, and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organisations and general practice clinics.

• The Australian College of Rural and Remote Medicine (ACRRM) website.

Dr Elissa Hatherly  00:02

Welcome to the Roundup, a North Queensland based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician and head of JCU's Clinical School here in Mackay. This collaborative podcasting project between North Queensland Regional Training hubs, JCU, and our local, regional, Hospital and Health Services will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. In today's episode, Dr. John Wood staff specialist from Cairns hospital who is a rheumatologist and one of the senior lecturers with James Cook University is going to talk with us about Gout. Welcome, John.

 

Dr John Wood  00:55

Thanks so much for having me Elissa.

 

Dr Elissa Hatherly  00:58

John, I know you're super passionate about education and we really appreciate you talking to us about gout, which is so incredibly common. Why do we need to talk about Gout today?

 

Dr John Wood  01:10

Well, I think you've really hit the nail on the head in terms of, we need to know the common things really well and gouts the most common inflammatory arthritis in society and most patients with gout will present to their primary health care providers, their GP's for advice and management. And as doctors, we want what's best for our patients. And it's really important that we understand how to educate our patients about gout so that we don't have the effects of untreated Gout which is loss of quality of life, potential damage to joints, erosions to joints and also the economic burden of untreated Gout when patients come into hospitals, so you know, when I was a med student I, I learned, you've got to know the common things really well. And Gout is the most common inflammatory arthritis that I treat and the treatments often the simplest. So that's the reason I want to talk about it today. Thanks.

 

Dr Elissa Hatherly  02:06

Okay, so just remind us. What exactly is Gout? And how are we going to best diagnose it?

 

Dr John Wood  02:13

So Gout's an inflammatory arthritis. So a bit like rheumatoid arthritis, psoriatic arthritis, pseudo gout. And by definition, that means that if you aspirate a joint, there'll be more than 2000 by 10 to the six white cells. So Gout is an inflammatory arthritis caused by deposition of monosodium urate crystals in the joint. And if you can imagine having splinters in your joint, the immune response is to try and mop that up. So Gout is caused by the presence of crystals in the joint. And the subsequent inflammatory response leads to what we see when our patients come in. And so a red hot, tender, swollen joint or possibly a couple of joints. And Gout is a spectrum like a lot of our diseases that can present as a one off, or it can become chronic and chronic, you know, untreated Gout can lead to Tophaceous Gout, and it can also have effects on the kidneys, as well as urate nephropathy.

 

Dr Elissa Hatherly  03:18

Right, so we're diagnosing it clinically, then with that red hot, swollen joint. Do we need to aspirate the joint to be confirming the diagnosis, John?

 

Dr John Wood  03:28

So that's a really good question Elissa, thanks for asking. The diagnosis actually tricky. The gold standard is to aspirate a joint and demonstrate the negatively birefringent needle shaped crystals. But in reality that can be difficult, particularly in primary practice when patients may not have the swollen joint when they present to their GP. So there's a few ways to diagnose Gout. The best way is with an aspirant. So if someone comes into emergency they have a swollen knee, aspirating the joint can both confirm the presence of crystals, but also exclude mimickers that you don't want to miss like infection which requires an orthopaedic washout. So where possible obtain the gold standard, which is an aspirate. In primary practice, you might even consider an ultrasound guided aspirate with one of your friendly radiologists. But where possible, try and secure the diagnosis because treatment with urate lowering therapy is lifelong. And it's important to to not over treat so. So a clinical diagnosis is the other way to diagnose it. So as you've alluded to a patient who is at risk of Gout so that's anyone who's hyperuricemic who describes intermittent discrete attacks of joint swelling in in appropriate joint and classically that's a great toe or an ankle or a knee, who has an episode of swelling that might last for five to 10 days, settles with a nonsteroidal, you know, that's good enough for clinical diagnosis of Gout. The other thing that more recently, we have been using to try and help us quench that diagnosis is imaging modalities. So a dual energy CT scan is a type of CT, that has a sensitivity and specificity so they're not perfect, but they can demonstrate the uric acid crystals that show up this bright green. And that can be quite useful if you suspect Gout based on your history and the pretest probability. So dual energy CT can be useful, but it's more sensitive in patients who have had long standing Gout with quite a high Gout burden. The other thing is an ultrasound can be useful. And our radiologists are so good that if they can aspirate a small amount of fluid and demonstrate the crystals, then then that's another way to do it. So in summary, either the gold standard aspirate with clinical history or clinical diagnosis, and imaging can also be complementary to these things if your pretest probability is reasonably high.

 

Dr Elissa Hatherly  06:06

Okay, so when we're thinking about Gout in our patients, am I right to say that we're thinking about the late middle aged men who eat lots of crabs, and drink lots of beer, or should we be thinking more broadly than that?

 

Dr John Wood  06:22

Another really good question. Thanks Elissa. So typically, Gout, you've described the phenotype really classically. And the prevalence of Gout increases with each decade. So the older you are, the more likely you are to get Gout. The main risk factor for Gout is hyperuricemia, and hyperuricemia is caused by a number of factors, but most of them is genetic. So it's decreased renal clearance of uric acid. And you've hit on a really good point here, because hyperuricemia is not just limited to elderly males, although it's more common. We see people with Gout in their 20s in their 30s and their 40s. And it's important to intervene early. So common things being common, it's important to suspect Gout in someone with intimate and discreet episodes of joint swelling, whose hyperuricemic. The other point I'd like to make is that when I asked students and also patients what they think the main risk factor for Gout is a lot of them say diet. And we know that a pure enriched diet can be important. But the problem with people thinking that diet is the main cause of hyperuricemia is that they immediately think that the treatment long term is dietary change. And one of the key messages today is that if you want to beat Gout, you do not have to talk about diet at all. That's that's basically a myth. And we've shown that many times through randomised controlled trials, that changing your diet is not how you beat Gout in the long term. So in answer to your question, it's more common as we get older, it's more common in certain ethnic groups, so Maori Pacific Islanders have one of the highest prevalences of Gout in the world, it's about 25%. In in Maori patients in their 80s, in New Zealand, and the world experts in Gout are in fact from New Zealand. And just to reiterate the point, they often don't talk about diet in the long term management of their Gout patients. The other thing to be aware of is that it's less common to see Gout in pre menopausal women. And that's because oestrogen is, in fact, Elissa, a uricosuric agent, so it helps to decrease the uric acid.

 

Dr Elissa Hatherly  08:42

Okay, so for those patients with chronic Gout, so more than say two attacks per year, what would be the best management for them? It sounds like it needs to be urate lowering treatments.

 

Dr John Wood  08:57

That's exactly right Elissa Gout management is, is easy. The goals of Gout management is to get the uric acid below a certain level. And that's generally less than 0.36, or if you have tau phi less than 0.3 So the way to do that is with urate lowering therapy, and that's generally Allopurinol, which is first line. But there's a few tricks that it's important to know about when you're starting these medications. So I'm really grateful that you were talking about the chronic management of Gout today, because I think about Gout management, a bit like asthma management. When someone has an acute flare, it's really easy to treat them because they're in front of you. But the chronic management, you know, time and time again, we've shown that where we're not doing as good a job as we potentially can for our patients. So the chronic management of Gout, I think a bit like asthma management, a preventer and Allopurinol is the preventer. What you do with Allopurinol is you start low at 100 milligrams a month, as per therapeutic guidelines, and you build the dose up every month by 100 milligrams until you get to a uric acid level less than 0.36. And I explained to patients, and it's really important to do this, that Allopurinol is the one medication that can make the condition worse initially, and that's through mobilisation of uric acid. So if you don't explain to patients that Allopurinol can potentially worsen your Gout initially in the first six to 12 months, then they go home, they take Allopurinol, they have a horrendous attack, and they don't they lose that therapeutic relationship with their GP. So you've got to explain that at the start that it might be a rocky road for six months, but we'll get you to target uric acid, and then your quality of life will be much better and you can work and not have these attacks. So I explain that firstly, and then I give them a Gout action plan a bit like an asthma action plan. And I tell them, I actually write it out for them. And I tell them that we're going to increase the Allopurinol, we're going to check your uric acid every month so that the patient is invested at getting to the target uric acid, and to decrease the chance of any flare ups during that initial stormy period, we introduce Colchicine, which has both, which treats acute attacks of Gout, we introduced Colchicine for six months, 500 micrograms a day, just to minimise that rocky period as we introduce Allopurinol. Now, the other thing that's really important Elissa during this process, is that if patients do have a flare, we give them the right information. So if you have a flare on Allopurinol at 100 milligrams for instance, after a month, you should continue on 100 milligrams don't stop it, a lot of patients start, stop, start, stop, and then this continues for 20 years, just continue on 100 milligrams of Allopurinol, but treat the acute attack, and often you'll treat the acute attack with a short course of say prednisolone, 25 milligrams for five days, and then you increase the Allopurinol again to 200, 300 and some patients will need to be on 600 milligrams a day of Allopurinol, sometimes 900, whatever it takes to get them to target uric acid. You do need a patient who, who's on board with that, who's on board with saying, yes, I want to beat Gout and I'm happy to take Allopurinol lifelong, so if you've got a patient who's willing, then you can work with your GP to get you to target uric acid and beat Gout.

 

Dr Elissa Hatherly  12:37

Yeah, it's very different to what I learned at medical school to just use Allopurinol when the Gout flares have settled and then use Colchicine for the flare up. So we're using Allopurinol just to double check John 100 milligrams per day for the first month, then increasing to 200 milligrams once a day for the next month, and then continuing to increase every month until we get to the dose of Allopurinol that achieves our target uric acid level of less than 0.36.

 

Dr John Wood  13:12

That's perfect. And the key thing is to use that Colchicine, just because as you up titrate, you're more likely to have have flare attacks. That's exactly right.

 

Dr Elissa Hatherly  13:21

Okay, so for those flares, we can use the Colchicine 500 micrograms a day, or as you mentioned, the prednisolone 25 milligrams once a day for five days, we can use a standard NSAID as well can't we John?

 

Dr John Wood  13:37

That's exactly right. There's three options for the acute management, either Colchicine, nonsteroidals, or prednisolone. And I really choose which one, depending on the patient in front of me, if they're a patient with poorly controlled diabetes, I might avoid prednisolone. If they're a patient above 65, who has CKD, stage three, or they're at risk of complications from nonsteroidals I'll avoid nonsteroidals. So the acute management you can kind of choose from the options you've mentioned Elissa, and just tailor it to the to the patient, you've hit on a good point there as well, because one of the other the other myths about Gout management is that you can't start Allopurinol during an acute attack of Gout, you have to wait till the Gout attack finishes. In reality, some people have chronic Gout and they're constantly in a state of flare. And there is evidence that you can start Allopurinol when the patients in hospital or they're having an attack. And in some ways that makes more sense because they're all already on prednisolone. And that's probably the ideal time to start when they're actually on treatment because the risk of a mobilisation flares' going to be less.

 

Dr Elissa Hatherly  14:49

Okay, I suppose the other thing we need to talk about John is the other metabolic conditions that can go along with Gout because often these patients are overweight. They have high lipids, their blood pressure is not ideal. We need to be thinking about Gout as part of metabolic syndrome, I suppose, don't we?

 

Dr John Wood  15:08

That's a wonderful point we know that hyperuricemia is associated with the metabolic syndrome. And just before I touch on that, if a patient has hyperuricemia, you don't necessarily or you shouldn't start urate lowering therapy, it's only if they have two attacks a year. But hyperuricemia has been shown in multiple studies to be part of this Metabolic Syndrome and therefore GPs are really well placed to optimise those other factors such as dyslipidemia, diabetes, hypertension, that all contribute to ischemic heart disease. So there's no evidence to treat asymptomatic hyperuricemia. But part of Gout management long term is very much holistic, as you've alluded to, and that we should be managing their comorbidities.

 

Dr Elissa Hatherly  15:54

So even though we're not no longer suggesting a change in diet to prevent attacks of Gout, we probably still need to be talking about a change in diet to address those other metabolic syndrome features, don't we?

 

Dr John Wood  16:08

I think you've absolutely nailed it there.  I think that diet is extremely important to discuss with every patient in terms of lifestyle. But the way to evaluate an intervention, be it Metformin in diabetes, or Perindopril in patients with proteinurea, or diet in Gout is to put that intervention diet into a randomised control trial, and see whether it makes a difference for the outcome, which is decreasing Gout flares, and diet doesn't change your Gout flare management. So although patients want to talk about diet, I don't discourage that. But if your main focus of beating Gout is with diet, you're simply not going to win. And that is the key message to really take home today, I think.

 

Dr Elissa Hatherly  17:02

Right. So you have mentioned kidney disease a couple of times for those patients whose renal function is poor. Do we need to adjust our doses of Allopurinol then John?

 

Dr John Wood  17:15

yeah, the the AMH has a really good guide on this Elissa, and patients with CKD are more prone to hyperuricemia, and therefore to Gout. And so the key message, depending on the GFR is to still treat to target uric acid less than 0.36 or 0.3, but to start low and go slow. So if the GFR is, you know, between 15 to say, 30 or 45 Sorry, sometimes I'll start at 50 milligrams a day, and I will up titrate by 50 milligrams a month. The key thing in that initial Allopurinol up titration period, is just to make sure the patient doesn't develop a rash. If you're going to develop a rash, it will happen in the first three months. And the reason we start low and go slow, is to decrease the chance of a rare, but potentially serious condition called Allopurinol hypersensitivity. So at the lower levels of GFR, CKD, four and five, we're more than happy to be consulted for advice. But these are the patients who are more prone to Gout. And, in fact, the nephrologist will often say, for their patients on dialysis, if they're having Gout attacks, it's because they're not dialysing enough, because dialysis actually removes the uric acid. But the AMH has a pretty good guideline on this. And indeed, a lot of the things I'm talking about today are very much guideline driven.

 

Dr Elissa Hatherly  18:47

Okay, now, now that we are thinking about Gout a little bit more clearly, we are not advising our patients to change their diet, we are treating with Allopurinol more aggressively to reach that target uric acid level. We are not stopping our Allopurinol during a flare but adding in an anti inflammatory like Colchicine or prednisolone, or an NSAID. We are hopefully making a big difference to the lives of our patients that have been enormously impacted by the pain and disability caused by Gout. What else do we need to be thinking about with our patients who are affected by Gout?

 

Dr John Wood  19:33

Yeah  I think you've summarised that really nicely. And I just want to be clear, I mean, lifestyle is important, but one of the barriers to treating Gout is that I think, as health providers, there are knowledge gaps in how we treat Gout, and I certainly think diets important but it's not important in the management of Gout long term. So that's the key thing. The other sort of quick message I want to sort of convey is, be aware that during an acute attack of Gout, the patient's uric acid level is often normal. So it often drops during an acute attack. So if someone comes in with a swollen joint, you I will often look at their historical uric acid levels through a pathology provider to see whether they they were hyperuricemic because it often drops during an acute attack. The things that I always mention to patients because as doctors, the first rule is do no harm, Allopurinol is a very safe medication, but like anything, you have to be aware of potential interactions and side effects. So the one drug interaction that I teach people, you need to be aware of is azathioprine, which some of our, you know, patients with inflammatory bowel disease are on as a maintenance therapy. So there is an important interaction between allopurinol and azathioprine. And you have to be aware of that because if you use the same dose of azathioprine, when a patient's on allopurinol, you can potentially cause toxicity and pancytopenia, as azathioprine's not metabolised as it should be. So that's one thing I mentioned before starting allopurinol, check your patients not on azathioprine. Once in every three years, we see someone coming in quite unwell because that interaction is not recognised. And the other thing is that patients who are more at risk of having a rash or a severe Allopurinol hypersensitivity, are potentially patients of Asian ethnicity, so the Han Chinese and people of Asian extraction, you should be thinking about a HLA association called HLA B 5801. And warning your patients as I do every patient, if you have a rash, which is more likely to happen in the first three months of being allopurinol, you should stop the medication. And the good news Elissa is that there's now an alternative xanthine oxidase inhibitor to allopurinol, that's PBS subsidised called Febuxostat and that's for patients who have an intolerance to the Allopurinol.

 

Dr Elissa Hatherly  22:02

That's fantastic to know that there's an alternative that's affordable for those patients with a rash due to the allopurinol, I think, particularly for myself, John, the fantastic take home message is the idea of the Gout management plan. I think that's a fantastic strategy that we can use with a lot of our patients, it helps to clear it up. And as you say, the education for our patients affected by Gout is so incredibly important. We need to make sure we take them on the treatment journey with us.

 

Dr John Wood  22:40

I'm so grateful for your taking an interest in it. And the management of Gout is just so easy Elissa, and, you know, we have a privilege as doctors to be able to help our patients. So it's so important that we're educating them with the right information. And I think historically, we kind of think yeah, it's, you know, one of these things that doesn't really affect us. But on a regular basis, I see patients who've had it for 20 years, that's really affected their life. And so I'm really grateful for your interest and the simple message of treat to target uric acid. And really involve your patients in that treatment paradigm as we do with every patient interaction and get them checking the uric acid themselves every month and watching watching it come down. And when they're invested in that treatment paradigm, they feel involved and, and they're part of that decision making process. And that's ultimately the goal of what we do, but it's also the goal and the benefits of getting them to beat their Gout long term.

 

Dr Elissa Hatherly  23:39

Thanks so much John Wood, staff specialist at Cairns Hospital, super rheumatologist with a guide to Gout that we can all follow. Thank you again for your time.

 

Dr John Wood  23:49

Thanks so much for having me, Elissa.

 

Dr Elissa Hatherly  23:53

For more information about the Roundup or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled Health Organisations and general practice clinics.

• Gout: The pivotal role of primary care

Dr Elissa Hatherly  00:02

Welcome to the Roundup, a North Queensland based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician, and head of JCU Clinical School here in Mackay. This collaborative podcasting project between North Queensland Regional Training hubs, JCU, and our local, regional, Hospital and Health Services will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. Today I have Dr. Michael Clements with me. Michael is a local Townsville GP, who also has experience with RACGP in their rural faculty, and is a veteran himself. Welcome, Michael.

 

Dr Michael Clements  00:56

Nice to talk to you, Elissa.

 

Dr Elissa Hatherly  00:58

Thank you so much for being here for this episode on DVA patients, the Department of Veterans Affairs can be a little bit difficult for doctors to navigate. Can you please start by giving us a little bit of your story and why you are particularly interested in veterans health?

 

Dr Michael Clements  01:16

Well, it breaks my heart when I hear some of my veteran friends and colleagues talk about using a GP and the GP telling them that they don't know about DVA, or they don't understand about DVA, and therefore don't help them or don't help them with the paperwork. And so it sort of dawned on me very early on that not only did I need to do my best to support other veterans in my own general practice work, and I've got three practices in Townsville. And we do have a focus on providing veterans support and veterans care. But actually, I needed to invest what time I could to help support and educate other GPS to provide a really high standard of care to our veteran patients to actually help our doctors navigate the paperwork, but also help the veterans navigate the transition to civilian life. And so I was very privileged to work closely with Kerrie Summerscales, a veteran herself, and developed some education packages, looking at supporting our GPS in providing great care to our veterans.

 

Dr Elissa Hatherly  02:26

 Oh, fantastic.

 

Dr Elissa Hatherly  02:26

So you've got a lot of experience from a personal perspective, both as a veteran and as a GP. What, what is a veteran then, how do we define veterans?

 

Dr Michael Clements  02:38

It's really important to understand that the wording has changed over the years, I think people often used to think of a veteran as being Vietnam War, or first or second World War, there was often the mistaken belief that you're only a veteran if you went to a place with bombs and bullets. My own career was largely based in Australia with the Air Force as a doctor working in Northern Territory in Townsville, of course, but I did my deployment overseas and one of the operations supporting Afghanistan operations, I went on exchange in the UK. So for me, being a veteran does include the fact that I did do some war like service. I did do some humanitarian work but I also spent time overseas on exchange with other militaries. And I spent time in Australia on exercises, working on base supporting local people doing their work, local troops and getting them ready. So the definition of veteran is a lot broader now and it essentially includes anybody who's done at least one day in uniform. So if there's a reservist that's been to initial training, if there's a junior soldier who's been to the first few weeks of recruits, but then decided to leave or had an injury and left, they are still counted as a veteran. So for the purposes of DVA and for the purposes of how we talk about veterans, we're talking about anybody who has signed up to defence, who was essentially signed up to say that they are going to support the Australian community, the Australian people in the Australian Government, they're going to do the training that's asked of them and go, go wherever they're asked to go to support the Australian community. So they're a very valued commodity. And while every veteran like myself has a different backstory, every single one of them signed the dotted line to say that they wanted to serve their country.

 

Dr Elissa Hatherly  04:30

Sure. So for those very deserving members of our community, who have been part of the Defence Force, we often hear about white cards and gold cards. I'm not 100% sure of the difference between the two. Can you run us through those please, Michael?

 

Dr Michael Clements  04:46

It's a little bit messy. So we'll start off with the white card. So it used to be that you only got a card if you had an injury. And then, thankfully, DVA was able to get through legislation that means that every person that's ever done a day in uniform is now entitled to a white card. So I've got a white card, and anybody from whether you served in the Navy 30 years ago, and have never talked to DVA since then their still entitled to a white card, and a white card is a card that means that the government DVA are happy to contribute to the health care of any issues that they have accepted responsibility for. And for all white card holders, that means that they accept responsibility for mental health coverage. So you don't have to have had depression or anxiety diagnosed in defence or afterwards. But for the rest of my life, for example, I am entitled to show my white card and seek reimbursement from DVA for things like GP care relating to my mental health, psychologists and mental health medications, psychiatrists or even admission to a psychiatric hospital, and psychiatric medications. So, white cards will come with a list of conditions where the DVA have said that they're going to support the care for. So as I said, mental health is automatic for everybody. But commonly, people will have things like lower back pain, or they call it lumbar spondylosis, or shin splints, or upper back pain, or thoracic spondylosis, they might have chondromalacia patellae and knee injuries. But the white card can have as little as one condition of mental health or it could have a very wide range of conditions that are covered on there. And a veteran will be able to get a printout or a copy of the conditions that are covered on the white card when they log into my gov. Now the gold card is something that we often associated with our Vietnam veterans or older people. So traditionally, people used to think of the gold card as meaning somebody who was a lot older, or somebody that have received war like injuries or very serious injuries. And there's actually a number of different qualifying conditions to get a gold card. So yes, it's true to say that many of our Vietnam veterans will have a gold card by now. But I if for example, because I did war like service, I'll automatically be given a gold card when I turn 70 years old. Other people will be given a gold card because the sum of all of their conditions has reached a threshold at which the DVA has approved for them to receive a gold card. So I've even had 25 year olds with a gold card and somebody whose injuries sustained during initial training was so bad that they essentially crossed the threshold and have been given a gold card as a person in their early 20s. And so that gold card means that all health care or at least all medically required health care, will be covered under the gold card or subsidised by DVA. I say medically required, because it doesn't cover things like cosmetic procedures unless it's medically indicated. So the gold card, which many people be familiar with means that the veteran will get subsidised medications, generally, in the order of $7 for their scripts, that they will get subsidised GP visits or most practices like mine accept the gold card as full payment, subsidised specialty appointments, or in most cases, many cases people do accept the full rebate from DVA and equivalent to private hospital coverage as well.

 

Dr Elissa Hatherly  08:27

Sure, so for our veterans to access services, like things like Allied Health referrals, I will often complete the D 904. And I must admit that's the only DVA paperwork that I'm really familiar with, is that our bread and butter paperwork, the D 904?

 

Dr Michael Clements  08:45

Well, it's interesting, we like tradition in medicine. So D 904 was the name of the form that we had to use. So this was a very, it was a coded form. It came in in a template, it said D 904 at the top and it was the form that a GP would sign and complete that says that this particular veteran requires allied health support. So a D 904 might say, please can this physiotherapist see my veteran. If they're on a white card it would say for their accepted condition of bilateral knee osteoarthritis, and then they would get up to 12 visits using that referral, paid for by DVA. And then with a gold card, you don't need the specified condition because the gold code covers all allied health. Everything from chiropractors and osteopaths, through to podiatrists, speech pathologists and OTs. Now, in its wisdom, the DVA did change the rules so it doesn't actually have to be a D 904 form anymore. It doesn't it doesn't need to say D 904. On it. DVA legislation says the standard referral was suffice. But because we like our traditions, I still have my referrals rejected from the occasional allied health person that says it wasn't on a D 904 form Dr. Clements and I say, well, I could either argue with them and say, well, it doesn't need to be under the new rules or just give them a D 904. So sometimes you choose the path of least resistance.

 

Dr Elissa Hatherly  10:06

We're often doing that arent' we but that's important to know. So we don't have to use the D 904 these days. Okay, so what is a claim really? And how are we helping our patients make a claim to see if DVA will actually cover the injury or impairment that the veteran is experiencing.

 

Dr Michael Clements  10:27

So I think most of our doctors and GPs are quite comfortable with managing our veterans in terms of using the white card and gold card to access services. But where we see most of them come unstuck is when we're talking about new claims, or impairment assessments. So a new claim is where the veteran has recognised that they've got an injury or condition or illness that they think is related to their military service. Now, if that veteran can prove that the military service lead to their bilateral knee osteoarthritis, or lead to their lumbar spondylosis, or lead to surgery, or even irritable bowel syndrome and ulcerative colitis, for example, if the veteran can prove that they've number one got the condition, and then number two defence caused it, then that condition will be added onto their white card or gold card if need be. And they will often receive some form of compensation or recognition for that, in terms of accruing points towards getting things like pensions and as part of their impairment assessments. So we often we are seeing defence do better at trying to encourage our veterans to put in their claims before they're discharged. But we you will always still see, and I've got veterans of the Vietnam War that still come to me for new claims, where people recognise that their dodgy back or their dodgy knee actually occurred during military service, but then they've putin a claim, and they'll come to you and ask you to help with a claim form. So the general process is that the veteran recognises that they've got an injury or illness that they want to submit a claim for. Sometimes the veteran will use a advocate to help them in this process. And I do recommend all of my veterans get themselves an advocate who's more skilled at this than the veteran themselves, to help them figure out how to build a case. And the veteran will come to you with a form where they're asking for you to confirm a diagnosis of let's say, knee osteoarthritis, and then certify that they've got that condition. And they ask you to sign a form that says, yes, this veteran has this condition, the evidence of the knee osteoarthritis is the plain film, the X rays that are attached here. And then the veteran will submit that claim through to DVA. And then in time, whether that's six months or two years, we'll get a response back from DVA as to whether or not they accept that claim. So you will see more and more veterans try and complete that paperwork while they're in defence. But if you've got a veteran that comes to you after discharge, and has a new condition that they want claimed, I would normally encourage them to use the the services of an advocate which are often free. And then what they'll be coming and asking you to do is confirm the diagnosis, which you might need to order X rays for or a DVA may give approval for MRIs or, you know may need to refer them to a non GP specialist. But once you've confirmed that diagnosis, then you fill out the second page of the form and then they submit it.

 

Dr Elissa Hatherly  13:27

Right. So is that when we start to do an impairment assessment, Michael, because that's an enormous amount of paperwork. Can you talk us through that process, please?

 

Dr Michael Clements  13:35

Well as GPS, we're quite used to seeing patients walk in with a wad of paperwork asking us to fill out and say, Oh, don't worry, Doc, I'll just leave that here on your desk, you can do it in your spare time and I'll come and pick it up next week, and we shudder and scream and run away. So yes, and so sadly, many of my veterans come to me and say, Oh, I showed this paperwork to my normal GP and they said that they don't do it. And that really breaks my heart because an impairment assessment is a piece of paperwork designed for the GP (you) to reflect on the medical condition and how it's affecting your patient, your veteran, and it's always best done by the patient's own GP that knows them, and that's been with them. So I much prefer to support GPS do their own impairment assessments with their veteran in front of them than by sending them off somewhere else. So let's say we've got the knee osteoarthritis example. Well, they will come back to you eventually with paperwork for the impairment assessment, where DVA are asking you to reflect on the impairment caused by that those that knee osteoarthritis, and it asks you questions like well, how often do they get pain? How bad is the pain? Is it severe? Is it mild? Is it persistent? What does it stop them from doing? How does it affect them? Does it cause them embarrassment? And it might be 20 pages of questions about sore knees which can be quite confronting for us. This is a real opportunity for you as a GP to support your patient, the DVA know that you're the patient advocate, DVA know that you are not an orthopaedic surgeon, and that you're not an independent person. And so they're not expecting you to provide an occupational physicians assessment or an orthopaedic assessment of somebody's degree of disability with a certain knee condition. They're asking for you to fill out questions that ask the patient, how do they feel, how is the knee condition affecting them. So it's not done to the standard of an orthopaedic surgeons assessment or an occupational physician assessment, so you don't need to use them. But you can, you can refer them on to an orthopaedic surgeon to do it. Having said that many orthopaedic surgeons don't like to do it. But what I normally do, my normal process is that I'll get the patient, I'll have a look at the forms and it might be 20 pages, it might be 50 pages, and then I'll schedule enough time to manage it. So I might say listen, I will do this paperwork with you, it's probably going to take me an hour to sit with you and do that. And then you schedule the time and you sit down and go with a patient. And you'll go through and ask them all the questions. You'll ask them to answer, honestly. And you'll see in the impairment assessment, it's not really it's not actually asking you for an independent, it's not often asking you for an independent assessment about function, it's actually just asking you to ask the patient questions, which is pretty straightforward. Now, if you've got an impairment assessment, and you're not comfortable, or you're not happy with the type of questions or the patient's answers, then you can of course, refer them elsewhere and say that they need to find somebody else. But I'd prefer that you didn't do that it's normally better if the GP does it. In terms of payment, the impairment assessments pay well, I actually tell my veterans don't feel sorry for me, I get paid per page. DVA will pay the GP per page plus for the time. So if you spend an hour with the patient, and you're doing 50 pages, you're getting hundreds of dollars for that assessment. So please remember, when you're doing an impairment assessment, take your time, bill for your time using the normal DVA items. Take a good history and examination as part of it and document that. But then when you submit the paperwork DVA pay you I think it's about $11 per page, even if there's only one question on the page. So, again, I think if people don't recognise that DVA do actually pay us quite well, they might turn these patients away to somewhere else. But that hour of work that I do, for the doing the impairment assessment, is really valuable for the patient, because it's me, who knows them that's helping them answer the questions, and they trust me. But it also funds the practice appropriately as well, we are actually quite well paid for that paperwork. So impairment assessments are a really important part of our role as GPs and as advocates, it's not done to the standard of a surgeon or, or a physician, a occupational physician. It's deliberately designed for GPs to answer. So please do actually take them on, take the time with the patient and don't forget to bill appropriately.

 

Dr Elissa Hatherly  18:00

Right, so in terms of billing for other consultations with our DVA  patients, does that work differently to our usual Medicare patients as well?

 

Dr Michael Clements  18:11

Yeah, really, I'm glad you asked. So our DVA patients even under the gold card, where they get unlimited and free access to allied health, you are still welcome to use the GP management plans and team care arrangement paperwork, you do not need to do a GP, MP and TCA to trigger access to the allied health but if you meet the Medicare criteria, so as in if you take your time to sit with a patient, understand all of their complex chronic conditions, summarise their goals, come up with smart goals, and a plan of how you're going to help them meet that. And if you get corroboration and collaboration with at least two other care providers, then you will still meet the Medicare criteria for GP NP and you can still bill DVA for those items. So if you're taking on a veteran, you will find that you will be doing GP management plans and team care arrangements for many of them. You will also be able to do mental health care plans. Now mental health care plan is a trigger for accessing mentor the better access to mental health care consults. And your veteran doesn't need that because the veteran will automatically get unlimited psychotherapy using their white card. But if you're taking the time to assess your patient, develop a diagnosis and a plan and you're communicating that plan to other psychologists, then it's absolutely appropriate for you to do a normal GP management plan, remembering that DVA rates for GP management plan are higher than Medicare rates and the same for the mental health care plans and all of the others. And there's one final care plan that many practices aren't aware of and they're missing out. Coordinated veterans care programme CVC. And if you don't know what I'm talking about, you need to pause write down CVC and make sure that you schedule time to discuss it with your practice manager. cvcs are where DVA has said listen, we recognise that our veterans have complex health needs and need extra time, that doesn't always mean face to face time with you, and that they cost your practice time and energy and effort. The CVC programme is an additional payment on top of GP care plans and TCAS and mental health care plans for the coordination of the veterans care. And it's their eligibility criteria. And gold card holders have to have a chronic condition and be at risk of hospitalisation, which to be honest, is most senior Gold Card holders that I have. And its a  nurse driven item. So the nurse spends a lot of time with them drawing up documents that are very similar to a GP care plan, but different. And you can go to the DVA website to find out about cvcs and get some templates. But when you draw up those templates in that paperwork, and when you follow the bouncing ball for CVC items, and the nurse checks in with them and spends time with them at least once every three months, which includes by phone, then you're getting over $2,000 a year as an additional payment on top of all of the other benefits and in the government. In the wisdom of the DVA, which I'm very pleased with I didn't mean that sarcastically. DVA have also said that if there is a patient on a white card, who has got a mental health condition that defence has caused. So that's an accepted mental health condition, where they accept that they've got, they cause depression, that's different from people that get automatic mental health care like me. This is people where defence accept they cause PTSD, then they're entitled to the CVC programme as well. And I've personally done the maths on comparing how much we get billing a standard patient for AMA, private rates for every time we see them and compare that to what we get for looking after a veteran using the CVC and care plan items. And we're definitely ahead with the DVA patients and CVC. So if you don't aren't doing the cvcs, then you really need to be talking to your practice managers and nurses about how to start doing them.

 

Dr Elissa Hatherly  22:03

Right. Okay. So Michael, we've talked about white cards for everyone who has ever signed up for any defence position at all. We've talked about Gold cards, which are mainly for older people, or for people whose sum of all of their injuries or impairments meet the threshold. We've talked about the D 904, has now been superseded by any standard referral, even though sometimes people still ask for a D 904. And you've mentioned the importance of the advocate for patients needing to navigate the DVA system, which I think is a fantastic system, and the brilliance of the CVC, the coordinated veterans care programme. So thinking about all of the mechanics about navigating the bureaucracy, then putting that aside, what is it in your experience as a GP in Townsville, has really stood out for you about the health journey for most of your defence force patients, once they leave the military, what are the common things, the common conditions, the common issues that they're facing, that we should be looking out for, for our patients?

 

Dr Michael Clements  23:20

Well, thank you. And I'm glad you helped us separate, I guess the technical aspects of caring from the veteran, to the actual, joyful and rewarding aspects of looking after our veterans. You know, veterans come in all shapes and sizes, we've got first nations veterans, plenty, plenty of female veterans, male veterans,and lots of different cultures. Every veteran's got their own story about the military service. They've got their own stories about why they joined and what they did, why they were in. And the 15 year service of a veteran that spent their whole time in Townsville and Queensland is just as important to the military effort and just as important to the country as a veteran that spent half that time overseas. So I really enjoy looking after these people as part of my daily work. They're often salt of the earth kind of people that put up their hands to say I want to serve my country. And even though they may have left the job, and they're out now, there's still a bit of that still inside them. And so they can be some of the most rewarding and joyful patients to look after. Now, most veterans actually have a positive military experience. Most veterans leave the Air Force voluntarily. Most veterans reflect on the time in the military in a positive way and think about the benefits and what they enjoyed. And I absolutely loved my time I'd do it again in a heartbeat. But with my family now, it's probably a bit too taxing. But most of us will reflect on the positives of our role, but there are certainly many who may be medically discharged. And so these are people that may have a knee condition or a back condition brought on by work, but it has become so severe that they can no longer fulfil the requirements of the job. And remember, in the military, you're in uniform. Only if they can put you on a plane or a ship, and send you overseas at short notice, they need to know that you can carry your weapons, fight the good fight, run away, perhaps, provide care in a battle zone, if you're not fit enough to do all of those things, then you're not fit enough to be in the military. And so that's why it doesn't take much, it doesn't take much of a back injury, or much of a shoulder injury or much of a knee injury for some of our military people to be discharged. And if you can imagine, for some of our young for some of our young diggers, you know, somebody that's joined in 1820, with all the ideals served, done 10 years in done wonderful things overseas, worked in humanitarian disaster relief, they get a knee injury at the gym one day, and then all of a sudden, the military's kicking them out because they say, well, you can't be an effective soldier anymore. That's really heartbreaking. I once looked after a soldier that was shot in the ankle while he was overseas in Afghanistan. And again, the military said, listen, we want to keep you're a great soldier, you've done great things, but we just can't have you in the military with a bung ankle. So they had to discharge him. And so you can imagine that these people, men and women, who really gave their lives to the service of their country actually can leave defence under a medical discharge quite broken in their minds and broken in their souls, because they've been told that they're not good enough to do the jobs that they wanted to. Of course, and then there's those that have been exposed to psychological trauma, whether that's in a war zone or humanitarian zone, or even whether that's just in terms of bullying and harassment, which sadly occurs in many workplaces, but certainly occurs in defence. I just remember one patient in particular, who was a wonderful soldier who was excellent at their job, she was sent to the tsunami zone in the first crew, and her job was to go and move the bodies off the roads. Now, you can't train for that. You can't prepare people for that. And so it's no wonder that we are now helping her manage in civilian life, looking after herself in the real world. And when this person drives past dead animals on the side of the road, that takes her straight back to where she was in the tsunami zone. So you can imagine that, that we do have some that need our intensive care. So the first thing I'd say is not everybody's broken, but some are. For those that are broken, we often find that the first thing that we're trying to manage is their loss of self identity, their loss of life purpose that they had put their heart and soul into, is now gone. And many people quite clearly identified themselves as a soldier and their unit and their team, Army, Navy, Air Force, as Army, Navy, Air Force, we always poke fun at each other, but we're always very proud of the service that we're in. But all of a sudden, they're out. And they're often given quite good compensation to be frank, they're off in the first year after medical discharge, they're normally given almost a full income for that first year. So they don't have to work. But what I find is that if we don't help them find their self identity and sense of purpose, if we don't help them retrain in their mind, that they can actually do something else, they might be still useful, they're still useful as a civilian, the world still needs them. Whether that be in mining roles, customer service, roles, administration roles. The biggest challenge I have is taking people from that first day after medical discharge, rebuilding their sense of confidence and helping them find their place in society and finding a role that gives them that sense of purpose. Because remember, what often drove them into the military in the first place, was doing a job that gave them a sense of value and purpose. And as soon as the military takes that off them, they can feel quite lost. So I've got some veterans that struggle in that first year, that struggle with that loss. And they stay in their four walls, and they play their computer games and they are too afraid to go out. They get more agoraphobic, they start chewing painkillers, they start using alcohol or they stop exercising, so they put on 20 kilos. And so that first year is really a time that we as the GPs need to be holding their hands and supporting them. Because that first 12 months of being out is often where they need us the most. Just to help them find themselves, get that sense of value. And I know that as soon as I've helped them find the job that they feel they can do or got them into university and retraining. It's only when I've done that that I actually see the rest of their medical conditions, the aches and pains, their sore knees, that chronic back pain, or shoulder pain actually start to get better.

 

Dr Elissa Hatherly  29:54

All right, Dr. Michael Clements, thank you so much for your insights I can't imagine having a better more positive advocate in your corner than yourself as a DVA specialist, I certainly feel that I have more tools and a greater insight into how to better support my DVA patients. And I'm sure that's the same for many doctors across our region. Dr. Michael Clements, thank you so much for your help today.

 

Dr Michael Clements  30:20

Thanks, Elissa.

 

Dr Elissa Hatherly  30:24

For more information about the Roundup, or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice, and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled Health Organization's and general practice clinics.

• Information for General Practitioners, Practice Nurses and other primary healthcare providers

Dr Elissa Hatherly  00:02

Welcome to the Roundup, a North Queensland based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician and head of JCU Clinical School here in Mackay. This collaborative podcasting project between North Queensland Regional Training hubs,  JCU, and our local, regional, Hospital and Health Services will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. In this episode, I'm talking with Dr. Deb Lee's from Cairns about disc prolapses and when we might think that surgery is the best option, Debbie is an incredibly experienced orthopod, who is working in the public service in Cairns. Deb is originally a chiropractor from South Africa and has a background in helicopter paramedic work, and has worked also as a commercial diver and as a chiropractor in the UK, for professional athletes. She comes to us here in Cairns with a fellowship in spine, particularly in trauma and experience in paeds as well. Welcome, Deb.

 

Dr Deborah Lees  01:21

Hey, how you doing?

 

Dr Elissa Hatherly  01:22

Thank you so much for joining us, we've got so many interesting things to talk about in terms of disc prolapses, maybe we should just drive straight in then. As a doctor how am I going to know clinically that a person has a disc prolapse on their examination findings or do I need to go straight to imaging?

 

Dr Deborah Lees  01:42

So the imaging is actually one of the last things that we like to do. And most of the time, we can actually tell, you know the nature of the person's problem by the way that they walk in the door, and also the story that they give us. So I often tell a lot of our juniors that, you know, really, we should be able to get the diagnosis from a good history and then your examination just really ticks the box that you're on the right story with the history. And then you know, the imaging is just really to confirm your diagnosis and really should be the last thing. So in terms of signs, people often give a story that they were bending over, that they've picked up something heavy, they did an awkward manoeuvre, or they've sneezed or they've coughed, is you know, the classic acute way and people often describe that this is initially back pain, and then it develops leg pain and they can normally give you a very, very accurate description of where down the leg that goes. There's another group of people who have got more degenerative disc prolapses and they kind of provide a story that you know, it's been sore for a while, you know, but then again, there's normally an aggravating or a culprit factor that comes along with that. So it's generally the leg pain, that's the giveaway that we're dealing with the disc, which differentiates it from mechanical back pain. And then particularly, it's that they can't straighten the leg out in front of them. Or that it shoots down to the foot. So typically below the knee, and typically into the ankle, and then sometimes into the foot. So it's that leg pain, that's really, really key.

 

Dr Elissa Hatherly  03:21

Right. So, when Deb, are we thinking that this disc prolapse might in fact be an emergency?

 

Dr Deborah Lees  03:29

So the things that we take note of the most is that I always ask people is about the bowel and bladder dysfunction, because that constitutes a cord recliner and a cord recliner or compression of the cord recliner, which is the group of nerves, the horse's tail of nerves that comes down the low back. And those are the nerves that control the bowel and bladder. So if there's any threat to those in terms of compression, space occupying lesions, we always worry about the bowel and bladder because these are life changing injuries and we need to operate within 24 to 48 hours at the very least, if we are to have a good result. So there's very specific questions you have to ask someone to determine this. A lot of people are embarrassed to ask someone or they don't know if it's, you know, a long standing urinary issue with women is it to do with childbirth, you know, pelvic floor weakness? So specifically, I ask, are you having any trouble with your bowel and bladder, and specifically, can you start and stop with good control? is the key word that I use. And the other thing that I ask is can you feel your bladder filling up? Because if we've got problems with a cord recliner, the definition of a bowel or bladder dysfunction is that you end up with a painless urinary retention and then an overflow. So what happens people aren't aware of the bladder filling up because they've lost the sensory inputs to the bladder. And then when the bladder reaches approximately a litre, the urethral sphincter then becomes incompetent and then they have a sudden incontinence. So it's not that little stress incontinence, oh, I've coughed or sneezed that I've got a little bit of wetness. Often it's you know, it's a frank incontinence from the water side of things. Now, the, the faecal side of things is different, because this is where you get loss of anal tone. So this is where people describe smearing, they describe, you know, passing motions and not being aware of it. And then also, because they've lost saddle sensation, they're not aware of having soiled themselves. And it's normally you know, other things that alert them to the problem. So that would be that the main thing in terms of painless urinary retention then with an overflow incontinence, and then a loss of anal tone with subsequent incontinence there, but generally, by the time we were on to the faecal side of things, that comes after the urinary side of things, we're normally you know, into unsalvageable sort of territory. And then the other things that we look out for is any form of neurological deficit. So is there a loss of sensation? Is there a loss of power? Has there been any change in their reflex status? So you know, are they losing reflexes, that kind of stuff?

 

Dr Elissa Hatherly  06:12

Right. So, with lower back pain and leg pain being so incredibly common, and disc degeneration, or a disc bulge being one of those potential causes, what is the criteria for deciding that a person might need surgery?

 

Dr Deborah Lees  06:29

So first of all, if they've got any signs of cord recliner threat, that's an emergency, we want to see them quickly and that's because we want to take them to theatre ASAP. If they've got any kind of neurological deficits, such as a foot drop, we normally want to try and get them to theatre within two to four weeks. Unfortunately, some people don't go to the doctor quickly enough so may miss that particular window, and then if someone's just really not coping with the pain, you know, despite throwing everything we've got at it analgesia wise, and they are just not coping, we then talk about doing something early. So normally, we would want to try and get the person over the acute episode, if it's not cord recliner or not associated with neurological deficit, we'd want to try and get them over that acute episode with non operative measures, physiotherapy, painkillers, icepacks, positioning, and then normally, people tend to turn a corner, and things start to settle down. But if things are persisting after six weeks, particularly if we're getting to sort of, you know, the two month, three month mark, then it's less and less likely, as time goes on that things are going to settle.

 

Dr Elissa Hatherly  07:44

Right. So for someone who does need surgery, as you've just described, what will that actually entail for the patient? And, you know, do you take out the whole disc? Or do you just reduce the pressure in the space? What do you actually do?

 

Dr Deborah Lees  07:58

Okay, so we take them to theatre. We've got a very glamorous table, we put you face down on and we localise the area with X ray, to make sure we've got the right level, we normally come down the side where the disc bulges. So normally, disc, side or the other, we come down that side, we may have to take a bit of bone to access that disc more easily, we sweep all the nerves to the side, we do it under direct vision and then that disc bulge normally declares itself. And once we show we can see it, we then remove any disc material that is loose. So saying that it's normally a question of a lot of the disc material, just you know, mobilises on it on its own once we're down there, and we actually incise the posterior longitudinal ligaments, it normally just pops out of its own. It's a bit like Dr. Pimple Popper, if you've seen any of that, and then we take out as much that is loose, but I try to leave any disc material that is solidly adhered, I try to leave that because we still have, you know, a function for that disc to serve. If we can not remove everything, that would be my preference. So I do normally counsel people that there is a small risk postoperatively because we've not removed the entire disc, that if they do do something a little rash, or they pick up something or have another trauma, there is a risk that another disc fragment then mobilises in which case we may have to go down and do a revision surgery.

 

Dr Elissa Hatherly  09:35

Right. So the disc really can prolapse a second time can't it?

 

Dr Deborah Lees  09:38

It can. So I normally tell people, you know, if they've had one disc prolapse, the chances of them having a recurrent prolapse at that same level is higher, that they're more at risk of that happening, particularly if they engage in risky activities such as manual labour jobs, heavy lifting, that kind of stuff. But we'd normally offer a second discectomy or revision discectomy. But by the time we've done two discectomies there isn't really much disc material left and then if they have ongoing problems, then we're really talking about some kind of fusion procedure.

 

Dr Elissa Hatherly  10:12

Right, so even before we get to surgery, Deb, often these discs will settle with time, won't they? Can we use an injection in those circumstances too?

 

Dr Deborah Lees  10:24

So yes and no. So a lot of them will settle and a lot of them we do manage non operatively and there's actually quite a big proportion of people who come to us with, you know, big disc protrusions on MRI, who then say, I really don't want surgery, that route, and all of that's fine, you know, provided there's no threat to their neurological status. Now, injections we use slightly differently in the hospital compared to general practice and that is because we're kind of coming at this problem from different sides. So the two ways we use the injection is one thought from my side on a surgical side is to prove that we have the correct culprit in terms of what is causing the pain. So if I've got a big disc bulge, and it maps to a certain dermatomal level, I'll do a nerve root block at that level, and then follow up with the patient to see if they had any pain relief. And if the person says, Look, that was lovely, took the pain away, even if it just lasts for a couple of hours, I can then confirm that definitely got the right level, it is definitely that disc that's causing the pain and the pain isn't coming from the hip isn't coming from, you know something else that we then need to investigate further. And that if we do do surgery, we could expect a good outcome is what I tend to use the injection score. The other aspect of that is if we have someone who's an extremist, in a lot of pain, we're really struggling to control that and give them a bit of a quality of life. We can then offer an injection from a pain management point of view but it's not really a good prolonged strategy in terms of pain management. And I normally say to people that you know, I do these injections as a test. And as a side effect, some people have a prolonged relief, because there's a steroid as part of that injection. It's a combination of local anaesthetic and steroid, the initial flush of pain relief is actually the local anaesthetic that works and then the steroid takes a couple of days to kick in to have an effect, and then has hopefully a prolonged relief, but not everyone has that prolonged relief. So it's not always a guarantee. It's not always a foolproof strategy and it certainly doesn't work long term. But if someone's desperate, and you know, we can't get them to surgery or they're not a surgical candidate, for whatever reason, then that becomes one of the tools that we use. But personally, I use it more for confirmation of diagnostic level rather than pain management.

 

Dr Elissa Hatherly  13:04

Sure. So Deb, you've talked about the patients who really need surgery quite urgently, those with cord recliner symptoms, or any neurological deficit. You've talked about the patients who are suitable for surgery when their analgesia needs are just not being met with our medications that we have on offer. And you've talked about those patients who are just dead against back surgery regardless, and I can appreciate that, that's for sure. Yeah, who are those patients who would be better off with physio, or persisting with analgesic medications?

 

Dr Deborah Lees  13:42

So those are people who often have back pain. So one of the issues with disc surgery is that the discectomy is very good for relieving the leg pain, but isn't very good for relieving the back pain because the back pain comes from the facet joints, and comes from mechanical issues; facet joint osteoarthritis, facet joint irritation, of which a discectomy is not going to address and sometimes in order to access the disk, I actually have to undercut that facet, we call that a facetectomy procedure. And that can sometimes again stir up inflammatory changes around that facet and sometimes it can actually worsen the back pain so that is something I counsel people about. Other people who have good results from non operative management are people who actually have a bit of a sequestrated fragment because once it's sequestrated, which means it's moved out from behind the posterior longitudinal ligament into the canal and is kind of a free floating kind of segment, the body is then able to reabsorb that but if you have a protrusion, a disc protrusion or a disc extrusion that's still contained behind the posterior longitudinal ligaments, it's very unlikely that that then gets absorbed because it doesn't set off that same inflammatory process. So a sequestrated segment is worth riding out a little bit longer to see if that resolves. They don't always resolve but there's a much better chance of that resolving, than, you know, something that's still contained behind that posterior longitudinal ligament.

 

Dr Elissa Hatherly  15:20

Right. So physio can be a great option there. What about chiropractic? Is that useful at all?

 

Dr Deborah Lees  15:27

It is actually, and I'm a great supporter of chiropractic and I know it's a bit of a contentious issue, because not everyone is supportive of it. And generally, I find that really, because a lot of people don't understand what chiropractic is, and a lot of people make the assumption they do and that it's spinal manipulation. And a lot of people are particularly worried about spinal manipulation, particularly of the neck, they've all heard horror stories of people having their neck adjusted, and then potentially having a stroke. If you look at the statistics of that, it's incredibly rare that that happens. A lot of the incidences that have been reported were chiropractic techniques being used by people who were not chiropractors. And, you know, when you look at the profile of chiropractic, the safety compared to some of the stuff I do, you know, I can create a lot more problems with surgery, there's a lot of complications, a lot of risks, compared to something like chiropractic, osteopathy, which is very hands on, is very, very effective. Often, the evidence doesn't necessarily reflect tha but a lot of that is just we don't have the evidence, not that it's not effective. You know, there just hasn't been funding into it, there hasn't been a lot of operation of that. But, you know, certainly, anecdotally, we have a lot of patients come in who have, you know, gone down the dark art of some of these options, and are quite actually embarrassed to admit it, because they feel that they'll be judged, or that it will be viewed, you know, in a bad light that they've sought out this kind of help. But a lot of people say, you know, I actually, you know, have had a great experience, I had really good, good results, but because it's not supported by mainstream medicine, they feel incredibly guilty, you know, having gone down that route, and are very reluctant to admit it, very reluctant to discuss it again, worried that they'd be judged, you know, against that. So my recommendations is that if you are going to see someone who is a chiropractor, who is an osteopath, you know, make sure that they are suitably qualified, make sure that they are suitably registered and insured, ask around to get some of their reputation. Because there's lots of people who will know who they are and what they do. And then you know, sort of work with that person and see that you get on well with them that, you know, you can have a good therapeutic relationship with that person. And then, you know, I think you, you're on to a good, a good option there, you know, provided you you go in and make sure that it's not someone who's just got a sign outside, but you know, doesn't have all the qualifications around the back.

 

Dr Elissa Hatherly  18:06

Right. So now, for those of us who don't have disc prolapses, what are the sorts of things that we can do to make sure we keep our backs as healthy as possible and avoid a disc prolapse?

 

Dr Deborah Lees  18:19

That's the million dollar question, if I had, that, if I had the answer to that, I think I wouldn't be working here I'd be sitting on a really nice boat somewhere in the Mediterranean. So I think there's a couple of practical things that people can do. And one of the most effective things is to try and keep your weight within a healthy range. Essentially, your back, particularly your lower back, which is where you get a lot of the disc bulges, you know, carries a lot of that, that weight, it's the support structure for your pelvis. So by keeping your weight down, you just reduce the strain that those joints have to put up with. It's a bit like calluses under your feet, you know, so the less irritation to the area, the less degenerative changes you get there. Having a good core so you know, making sure that you've got good strong stomach muscles, that those are balanced with your spinal muscles that you do some good exercise, that you have a good healthy diet that encompasses a good protein option. That, you know, the body then has the amino acids for the repair particularly for your collagen based structures. And then also, you know, just keeping moving, you know, make sure that you're not doing stuff where you've got a repetitive activity that you're not taking a break from, you know, driving for prolonged periods without stopping for a break and stretching your legs, doing repetitive gardening, doing repetitive construction work, that kind of thing. You know, make sure you take regular breaks, make sure you stretch, you know, and then the other thing is that a lot of people go straight for the heat packs. You know, using an ice pack can be very effective as well. So, yep, things like that hydration is the other thing I put down, particularly in far north Queensland, you know, we get some crazy hot days and then when I speak to people, they just don't drink enough. And one of the issues we see on the disc is dehydration. Now whether drinking a lot is going to change the hydration of the disc, I couldn't guarantee, but certainly, you know, the more circulating water that you've got, the more options your body has for using it and distributing it.

 

Dr Elissa Hatherly  20:40

Sure. Okay. So for those patients who do suffer a disc injury, Deb, when is referring them to the hospital, the right choice as their clinician?

 

Dr Deborah Lees  20:53

So if we have people who have, you know, possibly a threat to their cord recliner, people who've got a foot drop, people where we're worried about the neurological deficits, then those are people we really want to see urgently. And we can assess them, we may not have to do anything urgently, but certainly, if we can see them and assess them, we at least have the luxury of, you know, safet netting them, and also appropriately triaging them. The second group are the, you know, this has been an ongoing issue for a long time and they're struggling with employment, they're struggling with activities, they're, they're struggling with relationships. And these are people that we then want to see, but we don't necessarily need to see them urgently. And we'd like to be sure that these people have, you know, exhausted all the other options before they get to us. So preferably, they've had a good bit of time with the physio, that they've had a really good analgesia regime. You know, what is very frustrating is if we see people who've had these ongoing chronic issues, who want to discuss what the surgical options are, and then you ask them well, what have you tried for analgesic and they say I don't like taking tablets,  I don't take them. And, you know, the discussion there as the risks of surgery can be huge, you know, compared to the risks of some of the medication and sort of putting that into perspective, is sometimes needed. So it's a bit frustrating when people come wanting to have those discussions, not having tried the other stuff that might actually be very effective.

 

Dr Elissa Hatherly  22:28

Yes and that's certainly a battle that we all face with our patients, isn't it to get them to try something that they're a little bit reluctant to do? I must admit, I would be more reluctant to have my back operated on and it's sounds like that's not an unreasonable point to take, as you say, the disc surgery has much greater risk than some of the other options we have as therapies around.

 

Dr Deborah Lees  22:49

Yeah. And, you know, by all means, surgery may very well be necessary. But you know, I always say to people, if we consider the things that can go wrong, if we're in a situation where, you know, unfortunately, something does happen, you know, if we've made the decision to do a procedure very lightly, and we've not tried the other options, and then you're sitting there thinking, I'm now having to live with the consequences of an unfortunate complication. You know, would I have been better off taking the medication? Or would I have been better off seeing the physio?, but not knowing that because you jumped straight to surgery is often a regret, you know, people can live with and it's a hard one to live with.

 

Dr Elissa Hatherly  23:34

Dr. Deb Lees from Cairns, thank you so much for your time today and your expertise in backs. I really appreciate particularly being reminded of the old adage that we all learned at medical school that the diagnosis is of course made on the history and confirmed with the examination. I think often times we go too quickly to investigating. But thank you so much for your expertise. And we look forward to speaking to you again next time.

 

Dr Deborah Lees  24:02

No problem. Thank you for having me. It's been a great afternoon.

Dr Elissa Hatherly  24:07

For more information about the Round up, or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander Health Council, health services, Aboriginal Community Controlled health organisations and general practice clinics.

• Spine Society of Australia Facebook Page
• The role of spinal surgery in the treatment of low back pain: The Medical Journal of Australia
• Spinal Disc Problems - treatment, symptoms, causes and types: HealthDirect
• Making Sense of MRI of the lumbar spine: RACGP
• Australian Chiropractors Association

Dr Elissa Hatherly  00:02

Welcome to the Roundup, a North Queensland based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician and head of JCU Clinical School here in Mackay. This collaborative podcasting project between North Queensland Regional Training hubs, JCU, and our local, regional, Hospital and Health Services, will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. In today's episode, I'm talking about residential aged care facilities or RACFs with Dr. Chris Stelmaschuk, who is a GP practice owner in Townsville, and who has held lots of other positions in Medical Education, General Practice Support, and those sorts of positions over the last few years. Welcome, Chris.

 

Dr Chris Stelmaschuk  01:03

Thank you very much Elissa,  appreciate you inviting me on to the podcast to chat about RACFs.

 

Dr Elissa Hatherly  01:09

I know you have a particular passion for aged care, can you give us an idea of where that started from?

 

Dr Chris Stelmaschuk  01:15

It's so I guess it's a very odd background, in that I never thought I'd end up in aged care. You know, when I first started, as a GP, I started in a big practice with some other doctors who had residents in RACFs and I sort of had to take over that role when one or two of them slipped away. And it was the usual story: scattered patients, very hard to maintain those patients to get to see them on a regular basis and I really didn't like it. What happened was about five years ago, a RACF opened up, basically two blocks away from our practice, they asked us as a practice to take it on. So 5 of us sort of put up our hands and we created a little, like a system that made RACF work a lot easier, a lot more enjoyable. And I've been trying to figure out how we can take our little system we have here at North Shore and Townsville, and I guess, expand it, you know, within the region or help other people into this space in the future. So yeah, it was something I'd never intended on doing but one of those things that I sort of just fell into.

 

Dr Elissa Hatherly  02:29

It's an incredibly important part of our work as general practitioners in North Queensland, isn't it? So for a group of people in our community who are generally underserved or poorly served by medical practitioners, and it can be super daunting when you're first starting in general practice because you don't really know what you're doing. We have a few tips and tricks for troubleshooting RACF work. Can you take us through some of the things you've learned about prescribing, please, Chris?

 

Dr Chris Stelmaschuk  02:58

Yeah, I guess, prescribing is listed as one of the biggest issues with an RACF. It's a quite a messy scenario, the way it's routinely done and that you have to chart on a medication chart at the RACF, which that's then gets translated into their software for dispensing gets sent to the pharmacy for for them to to dispense it back to the RACF, and then we have to chart it in our own medical software. So it's quite messy. And there's a huge range of areas that you can make mistakes, you know, from a prescriber standpoint, from a dispensing standpoint. So I think the way it's currently set up is quite difficult. I have had some more recent experience with the electronic national residential medication charting system. So this is relatively new being rolled out in the last one or two years where basically it's an online medication charting, which acts as the prescription and the dispensing software. So it basically gets entered once the nurses get notified straightaway, they can dispense from the software and the pharmacy gets notified straightaway so they can send the medications to the RACF. So this is taking basically the biggest bugbear of GPs within the RACF space and creating a really excellent solution. Unfortunately, it's not the solution that the RACF that we mainly support uses, they still use the old system. And we're still running into a lot of problems there but I've got a few patients elsewhere that use this system and it's been been a godsend. It's been amazing being able to treat these patients both on site and you know, remotely. If I go into a RACF and want to chart something for a patient down the road, you know, I've got to find a nurse to find the medication chart to get this done and then you know, all the other issues I mentioned previously come into play. Whereas I'll be sitting with a patient at one of these RACFs with the electronic charting, and I'll be able to log on to my phone and chart the medication and you know, a minute later, a nurse will pop her head in saying, I see you're changing the medications, like it's, it's amazing.

 

Dr Elissa Hatherly  05:25

That sounds brilliant. So making a really, or finding a really simple solution to a really big problem that we've all faced with RACFs. So that brings me on to my next thought about information gathering where a lot of our practice based records are electronic, but then in the RACF, that tends to be paper based, what are some of the solutions that you found to that information, collecting that chart and record keeping?

 

Dr Chris Stelmaschuk  05:53

Yes. Again, I think you know, different RACFs do a lot of things differently and thankfully, there's only a handful of RACFs that are really continuing with the paper based charting. So most of them have their own electronic charts now, which makes a big difference, particularly if you can get remote access to them. So our system is set up so that we've got remote access to both medical software at work, and also the RACF medication charting. So basically, it's one, it's a one entry, and then copy and paste process into the opposite chart, which makes it a lot easier. Also, again, when you're looking at after hours, it's quite easy to gather information when you've got easy access, and basically two different places, I can see what the GPs have done recently on our medication charting and alternatively, I can see what sort of care, we're gonna have a look at the obs and whatnot that the nursing home staff have done, remotely logging into their software. So instead of having to chase someone down for the right information, you can easily access it from from a laptop or computer in the nursing home.

 

Dr Elissa Hatherly  07:07

That's incredible, isn't it just to improve that access, really reducing the barriers to communication that we've all experienced. So you can really from your consulting room and your practice, monitor how a patient might be going and in real time make some changes to their medication or their cares.

 

Dr Chris Stelmaschuk  07:28

Absolutely. And look, this still relies on the RACF staff and getting that information into the software. So it's not always still an easy process. And you know, there's still a lot of limitations within the RACFs themselves with staffing, and agency staffing, that type of thing. So not there's not always information there, but certainly a lot better than flying blind.

 

Dr Elissa Hatherly  07:50

Sure. So what are the other things that you found have worked well, in terms of improving that communication between your GPs, the patient's family and the staff in the RACFs?

 

Dr Chris Stelmaschuk  08:03

Yeah, so I guess communication is key in any relationship. And that's one thing that's that's obviously been very pronounced with what we've been doing. A lot of it is setting the expectations on the delivery of the information. So you know, different doctors or GPs prefer different lines of communication. So we find that a lot of the older GPs prefer that phone call, no matter what time an audit is, whereas newer GPs prefer an electronic method of communication that might be emailing, and you know, like it's the younger GPs that are much more likely to be checking their emails pretty regularly than the older GPs, so I think it's it's almost individualising the process based on the GPs you've got, and making sure that the nursing staff that the RACF know how to contact. Now, again, that's not always easy with with the turnover of staff and the agency staff because they might not always know how to access a GP. But you know, you try and let the clinical clinical managers now you try and put signs up around the RACFs about the best forms of contact, to allow that to happen.

 

Dr Elissa Hatherly  09:10

Great. So all of those streamlining processes with your electronic medical record, getting that information shared between yourself and your practice easily in a timely fashion with remote access to the software and those better communication processes that all helps to make it a much more efficient clinical consultation with the RACF. So that's certainly going to improve the bang for the buck, isn't it? How have you found the integration with the RACF?  I know the item numbers changed a couple of years ago. Are you finding it cost effective now, is it worth your while because that money is really a deterrent to a lot of doctors, isn't it?

 

Dr Chris Stelmaschuk  09:56

Absolutely. I know from some of the research that I've been doing you know, the money is a big detractor, we find that a lot of GPs who aren't in the RACF space aren't aware of the earning power they have within RACFs. And we also find that the ones that are in the RACF space don't utilise the item numbers that actually make it beneficial for their remuneration. So the use of care plans, CMAs, care plan reviews, medication reviews, mental health care plans, they don't often get utilised, like it's estimated that less than 50% of those item numbers are utilised. So if you if you set up, like you're doing a GP practice, where you might have a nurse that helps you formulate the care plans and spend a bit of time with the collection of data and whatnot, you can actually streamline that as well. So you can make use of those item numbers and obviously, you need someone keeping an eye on when these item numbers are due, and the care plans are due and the medication reviews are due. So this is all things that can help. Now the other, I guess benefit as well is the PIP money, which can be up to $10,000. Now our GPs hit that the patient requirement which is up to 180 visits by the end of December, so in less than six months, we get our full $10,000 extra and I think a lot of people forget about that there is some extra incentive to do this work. So look, I've worked it out that you know, you can earn close to probably 75 to 100% of your regular GP clinic billings by doing the RACF work but making the most of the item numbers that are available to you. So it's about again, streamlining that process and setting it up to make it easy so you're not having to think too hard, you're not having to rush around after rounds, acute needs rounds and trying to get some extra paperwork done so that you can access these item numbers. When you when you've got it streamlined, you've got people helping you out it makes it a lot easier.

 

Dr Elissa Hatherly  12:03

Right so being organised, being well set up and making the most of those Item Numbers, PIPS and SIPS that are available to us will mean that we could even make it our full time job I suppose and not see patients in our clinics.

 

Dr Chris Stelmaschuk  12:17

Look, there are people out there that do do this, like the there's a couple of organisations, that do purely RACF the telehealth stuff and they've got it set up and streamlined so that they can do it.

 

Dr Elissa Hatherly  12:29

Sure. So mentioning telehealth the Chris, time management has been made so much easier with the availability of telehealth billing now. How do you use telehealth in your practice? And what other strategies do you have to improve your time management?

 

Dr Chris Stelmaschuk  12:46

Look, to be honest, we don't utilise telehealth much in our practice because of our set up prior to COVID. We just continued that so having regular visits to the RACF there's usually a GP there, at least three days of the week so we don't really need to use digital health, although it is something I'd like to explore a bit more and maybe do you know fortnightly face to face visits and fortnightly telehealth for acute needs. I think that's there's definitely merit in having a setup like that and there are other organisations that are more purely towards telehealth. So I think there's a big space to improve efficiency there. I think the limitation so far with this type of setup is basically within the RACF, again having the staff there to be able to deliver telehealth to patients, and also the digital infrastructure, just having, you know, a Wi Fi or adequate connectivity for things to function to do the telehealth. So, so those are the limiting factors at the moment but I know that there's a lot of background work being done to help improve those things in the near future.

 

Dr Elissa Hatherly  14:01

Okay, so then understanding some of those limitations that we've talked about with connectivity, with accessing the electronic medical record or electronic prescribing record, and that communication with staffing within practices. How do you and your colleagues manage your on call and after hours sort of work to make it fit within your practice, with your families and with all of your other commitments?

 

Dr Chris Stelmaschuk  14:30

Yeah, I guess after hours is another one of the biggest stresses for GPs in the space. I think with our setup, it does limit the amount of after hours. So the nursing staff are aware there is going to be a GP on site at least three days a week. They're less likely to call for the minor things and really only call if there's a major issue if there's a question about going to hospital. And in Townsville, again that's helped by having a frailty team, so the team based out of the hospital, who can, you know, provide that pre hospital care or hospital avoidance care? So, so we're sort of backed up by that as well. I mean, we do get the occasional after hours call but I can't think of many times in the last five years where I've been called at an inhospitable time, like between the hours of 10 and 6 are probably, you know, maybe once or twice in the past five years with their setup the way it's been. Again, I think there needs to be more done in the area to help GPs particularly in other centres as well. And again, that's something that's being looked at in the background is, you know, how do we convert, I guess the deputising services that GPs use now in their normal day to day work into something that can assist the RACFs as well, because it isn't something that's really been streamlined. But I do know that a lot of doctors still prefer to do their after hours as well, particularly the older generation, but I think for the younger generations coming through, there needs to be some sort of deputising service that hopefully can link in with the GPs that provide the care to the RACFs so that there is a bit of a flow of information, you don't really want to fragment the key, you want to connect the key. So that's, that's the sort of thing you need to try and work on going forward.

 

Dr Elissa Hatherly  16:18

Fantastic, Chris, look, thanks so much for talking to us. It's been really interesting to hear how you and your colleagues in your practice manage your local RACF. I just wonder, we've talked about how you guys make your RACF work more appropriate for you guys but what about the flip side? What are the patients, what are the residents of the RACF think, what did the management and nursing staff of the RACF think? I imagine that you've been keeping in close contact with them to make sure their needs are being met as well.

 

Dr Chris Stelmaschuk  16:54

That's right. I mean, we're very patient focused care practice to start with, and that sort of spills over into our RACF work, the feedback we get is very good from from the patients, and I think they really appreciate the care that they receive, you know, they've got access to a GP more than just about anyone else in the towns or region really. But, you know, getting in contact with the families is always difficult. Often, they're working families that don't have a lot of time to designate during the day when we're there to be around. So there is a little bit of contact sort of after hours or not, with the patients around that that needs to be done. The relationship with the RACF is good, we've always had a good relationship with the managers. But it's a real struggle from their end trying to get the support they need, trying to get the staff they need. In the end, they rely a lot on us to deliver the medical care. There's one, I guess, worry about the way we do things that might be over servicing and, you know, not empowering the nursing staff at the nursing home to to make those key decisions on their own. Ultimately, we'd like to have a working relationship where you know, we're confident in the decisions being made and, you know, we can empower the nurses there to do what they need to do without needing our input, and that's something we'd like to work on. But again, the limitations there have been within the huge turnover of nursing staff and having agency staff. So we tend to develop these relationships with management there and then, you know, within a few months or a year, you know, it's different management again, so we've got to start from scratch. So it's less than ideal on that regard. But, you know, like I said, overall, the relationships good, we just need to be able to work on on what they can do on their end, really, and give the accountability and the empowerment like we were talking about to the staff there.

 

Dr Elissa Hatherly  18:59

Right. Oh, look, Dr. Chris Stelmaschuk, thank you so much for spending time talking about  RACFS today and troubleshooting all of those issues that we come home with from our visits around prescribing, keeping our information and charts up to date, how we are communicating with the staff, with the residents, with our colleagues. How to better remunerate ourselves for our time, making best use of that time, and then how we're managing that after hours space. Thank you again.

 

Dr Chris Stelmaschuk  19:30

You're welcome. I just want to say I know it sounds very scary, but like I said, my own personal situation, I went from something I never think I'd do to something I really love so I think there's hope for people out there. They just got to, you know, dip their toes in and get the right experience, not the bad experience. There's lots of good experience out there. So if anyone wants to ever get in contact with me, I'm happy to have a chat to them about how they can set things up.

 

Dr Elissa Hatherly  19:54

What a great message to finish with. Thanks so much, Chris.

 

Dr Chris Stelmaschuk  19:58

No problem. Thanks for having me Elissa.

 

Dr Elissa Hatherly  19:59

For more information about the Roundup or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only, and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice, and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander Health Council, health services, Aboriginal Community Controlled Health organisations and general practice clinics.

• Doctors in Aged Care (DiAC) - Financial Models

Dr Elissa Hatherly 00:02
Welcome to the Round Up, a North Queensland-based podcast with regional content for regional clinicians. I'm Elissa Hatherly, a GP and family planning clinician and Head of JCU's Clinical School here in Mackay. This collaborative podcasting project between Northern Queensland Regional Training Hubs, JCU, and our local, regional, Hospital and Health Services will bring you a different regionally relevant podcast each fortnight. Before we begin, I'd like to acknowledge the traditional owners of the lands where we meet today, who were the original providers of health care in this region. In today's episode, we're talking about rapid access bowel screening with Associate Professor Guy Hingston, a surgeon in Mackay working both privately and publicly. Welcome, Guy! Thanks for joining us to talk about bowel cancer screening. I know it's something you're incredibly passionate about. Did you want to kick off by talking about bowel cancer in Australia generally?

Associate Professor Guy Hingston 01:03
Absolutely. Bowel cancer is the second leading cause of cancer death in Australia, behind lung cancer. So it's a very common disease, it affects a lot of people and the surprising thing about bowel cancer is it's very preventable. There are now some studies showing a 50 to 66% reduction in the death rate from bowel cancer with adequate screening, so across Australia today, if we can roll out screening programmes and screening, faecal occult blood testing, screening, colonoscopy, and all these things that are shown to reduce the death rate, then we can make a significant difference. 4000 Australians die each year from bowel cancer. So imagine the percentage reduction in that if we could get enough screening across the entire eligible population.

Dr Elissa Hatherly 02:03
And in Australia, we're quite good at screening aren't we certainly cervical screening has almost eliminated deaths from cervical cancer and mammograms have really revolutionised early intervention into breast cancer. I understand bowel cancer hasn't been as enthusiastically adopted over the last few years, though, as those other interventions.

Associate Professor Guy Hingston 02:26
So I think that's a fair comment. Cervical cancer has definitely played a huge role. 20 years ago, 400 women were dying each year from cervical cancer and now it's a lot less than 200. So we've made a really good dent in cervical cancer mortality with screening. Breast cancer screening, yes, great uptake. Now, we'd still want more, of course, but we're looking at about I think it's about 65% across the board when you include both public and private breast screening modalities. Bowel cancer, though, as the newbie on the bench here, really, still lagging way behind at about 40% participation across Australia. Some states do better, some are up at about 45 - 46% and some are down and 35 - 36%. But on average, around 40% of eligible Australians are participating in bowel cancer screening programmes, which means around 60% of eligible Australians, when they received the kits in the mail, then they're not doing it. Now, this has been been a work in progress, obviously across Australia. In 2006, the Australian government agreed to fund bowel cancer screening. And then 2009 It started with two ages 55 and 65. Progressively over the last 12, 13 years, 14 years, they've ramped up to now for the last couple of years they're offering, or they're sending FOB faecal occult blood testing kits every two years from the age of 50 to 74 when an Australian has an even birthday, as per their Medicare card medical registration. So that's, that's been quite a ramp up over the last 15 or so years. But still, even though now that it's fully ramped up at that, at two yearly from 50 to 74. We're still only seeing a 40% uptake. So yes, it's sort of lagging behind Elissa and I hope that during this podcast we can discuss some of the reasons why that is the case.

Dr Elissa Hatherly 04:55
Right so at the moment screening is every two years from ages 50 to 74 by a faecal occult blood test that arrives in the post, and only 40% of eligible Australians are participating. That's a really disappointing number. Why do you think that is?

Associate Professor Guy Hingston 05:12
Well, I think there are a number of reasons. I think the most, the most common reason is this non-acceptability of the test. The fact that a middle-aged adult has to, after passing a bowel motion, take a small plastic spoon essentially, take some of the poo and put it in a container is just just a bit abhorrent to a lot of people. So I think a lot of people don't want to do that you can do it quite easily without touching the poo as it were. But I think that's the most common reason people just don't want to do it. But there are other reasons as well. I think the second reason that middle-aged Australians aren't keen to do bowel cancer screening is a lack of understanding of the benefits of the test. So we now know through several large, randomised prospective controlled studies across the globe, that we can achieve around about 20% reduction in death rate, just by faecal occult blood testing. The initial study in 1993 actually showed a 30% reduction in the death rate from bowel cancer but around but some of the latest studies have less than that number to around 20%. And so I think a lot of people haven't really got it in their head that by doing these bowel cancer screening tests, they can actually reduce their individual chances of dying of cancer significantly. And I think that the third most common reason that people don't want to do faecal occult blood testing, is that they actually fear that actually, the test might come back positive, and they might have bowel cancer and they don't know it. And of course, a lot of people just don't want to know, the main reason bowel cancer is so successful as a killer in Australian society is it's truly occult, it's hidden. And, and a lot of people don't know they've got bowel cancer until it's well advanced. But the benefit of bowel cancer screening is here for every radio, so for people who present with a positive faecal occult blood test, only one of them actually has bowel cancer. So if you participate in the screening programme, and you return a positive test, well, you've still only got a one in 20 chance of actually having bowel cancer. So I don't think people should be afraid that by participating in the testing programme that they fear that they might have bowel cancer, although as I say, I think it's a significant reason. So, so just the unacceptability of testing one's own poo, a lack of understanding about mortality reduction. And the genuine fear that actually they could have bowel cancer. I think they're the three main reasons that people don't take up bowel cancer. So I think, I think working in Mackay, it's, again shown to me, the problem with regional and rural Australia and the lack of access to testing and, and I think that's another factor up here outside of Metropolitan Australia. It's just logistically harder. I've just travelled around and read a lot of different GPs as we promote this rapid-access bowel cancer screening clinic. And, again, just the sheer distances involved make, if you return a positive test, even though it's all sent in the mail, and the results return, you've still got to drive 2, 3, 4 or 5 hours to actually access a colonoscopy. And then there's, there's all of the pallava surrounding that. So yeah, I think there are lots of reasons why people genuinely don't want to do it. But of course, 40% are doing it and we hope those numbers will go up. In America in some parts of the USA achieve an 80% community participation and bowel cancer screening. Of course, the Scandinavians achieve about 70% screening participation. So yes, we're a bit behind the eight ball but I remain optimistic that we'll get there with time.

Dr Elissa Hatherly 09:47
Fantastic. So a lot of good reasons why we should be undergoing bowel cancer screening. A few myths busted about why we should not undergo bowel cancer screening. It sounds like education is really what's needed in this area over the next few years to improve screening rates. So, Guy, can you talk us through this new rapid-access bowel cancer screening place?

Associate Professor Guy Hingston 10:12
Absolutely. So one of the one of the factors that prevent or limit bowel cancer screening is just the access issue. You have to get a GP referral, you have to go see a specialist. They have to agree to the procedure, you have to have bowel preparation, you have to go and have the tests, you've got to go and get the results. There's a whole lot of steps in the way and then there's the cost factor, public versus private, logistics, what's available in the area. So I've been in Mackay a year now and I've identified a real problem with accessing bowel cancer screening or screening colonoscopy for the wider regional, rural and remote areas that that we serve from Mackay. So the Mackay Specialist Day Hospital approached me several months ago and said, Well, look, could we could we do something together? And I said, Yep, if we can set up a rapid access clinic, then let's go. And we're underway this week is our first list with some patients on it. And it's been an exciting journey to set up, Elissa, the buzzword here set up the system that we hope will serve a lot of people in a positive way. So with this new rapid access pathway, we ask patients to see their GPs in the normal fashion and GPs to refer in the normal fashion either via medical objects, email, fax, telephone, or whatever. I'll then vet the referrals, and then one of the team from the Mackay Specialist Day Hospital will then contact the patient and organise their bowel preparation via a local chemist close to where they live at home and organise a date and then they can come in having their bowel completely prepared, which is one of the limiting factors for this procedure is you do need to have diarrhoea for 12 hours to clean out your colon. So that can now be organised remotely as it were, and then they can come in on the day, have their procedure, and be given the colour printout of everything we find. And we also on the same day email the GPs with the same operation report, including the colour photos as of anything that we've seen. The big benefit of bowel cancer screening is as I started off by saying is the ability to prevent death by bowel cancer. And, the main way we achieve that is by removing precancerous polyps. Now, if you imagine a small five-millimetre polyp that's growing on the tip of your nose, most people would go and see their GP and arrange to have that removed because they can see it. The problem was bowel cancer is when you have that five-millimetre or one-centimetre or two or even four-centimetre size polyp, you often don't know it's there. In fact, you don't know until someone looks in with a colonoscope or someone has a faecal occult blood test result that comes back positive and you then have a colonoscopy to see these polyps so by removing these polyps, we can prevent them from turning into cancer and prevent people dying from bowel cancer. So there's a big misconception out there Elissa that the way that bowel cancer screening works is by picking up early cancer, like early invasive cancer. So actually, as I said before, only one in 20 people who have a positive faecal occult blood test have an actual cancer, but up to 10 of 20 people will have pre-malignant polyps and if we can remove those polyps as we do, then those people don't go on to develop that bowel cancer and don't go on to die from bowel cancer. Hence, we have these amazing statistics. One from a 17-year follow-up study of 200,000 people in the UK that's the famous flexible sigmoidoscopy study which showed a 66% reduction in death rate from left-sided bowel cancer, truly phenomenal findings. And now in the UK, everyone is offered a flexible sigmoidoscopy at the age of 55 as well as faecal occult blood testing from 60 onwards. So that's the UK's solution. But just six weeks ago, the Nordic, four European countries, they published their long-term colonoscopy versus faecal occult blood test bowel cancer screening. And in those people who had a colonoscopy, again, they showed a 50% reduction in the death rate from bowel cancer at the end of the trial. And of course, the benefit is ongoing. So there will be an even higher percentage over time. So the key thing for rapid access is, is to get in there with the colonoscope, for eligible people and remove the polyps so they don't turn into cancer. And one on 20 times, yes we'll see an early bowel cancer and we can treat it with modern surgery, chemotherapy if required, radiotherapy if required, immunotherapy if required. And the actual death rate, even though 4000 Australians are dying a year from bowel cancer still, you'll be aware that the Australian population continues to increase. And so the actual death rate for per capita from bowel cancer has actually halved over the last 20-30 years with all of these improvements, with early detection, surgical medical and other oncological care. So rapid access being able to break down the barriers and enable greater community participation, I think is really key to access these important health care benefits.

Dr Elissa Hatherly 16:56
So the rapid access system will preclude a faecal occult blood test, we're not needing to do that pretest initially and wait for positive, we're going to be going straight to screening with the flexible sigmoidoscopy or the colonoscopy, which you can then use as your therapeutic and diagnostic procedure as well as your screening procedure. Do I have that right?

17:18
Great question Alyssa. So to get a significant reduction in death rates from bowel cancer, we need a multi-modal approach. So my strong message to everyone in the community is to participate in the bowel cancer screening program. At the age of 50 off they go every two years to do the test and if it's positive, come along for a full colonoscopy. But there are other people that might not work for so Medicare understand this and they've introduced an item number in the last couple of years, 32227 if listeners want to look at it, where people can have a one-off colonoscopy. If they're concerned they might have underlying polyps or cancer. So this is only for people who have never had a colonoscopy. So they're now able to access colonoscopy that way and yes, you're right, Alyssa with your question. They can come to it through their GP for a one-off screening colonoscopy which Medicare will fund a proportion of that cost. Of course, there are lots of other indications for colonoscopy which Medicare funds, positive family history, faecal occult blood testing, rectal bleeding, previous polyps, and previous significant large polyps, because there are different polyp surveillance programs; one year, three years, five years, 10 years are the four main groups of surveillance that we provide under Medicare. And of course, then there are the genetic syndromes, familial adenomatous polyposis, MetS syndrome, and others who need more regular colonoscopies. They're all Medicare funded, and all of those patients can access their care through a rapid access endoscopy clinic as we've now started to provide.

Dr Elissa Hatherly 19:18
Right, so bowel screening is vital. We've made that very clear. Early Intervention through polypectomy is vital. We've made that really clear. What do we need to do to actually get our patients to present or to participate in their faecal occult blood test and then to participate in that one-off colonoscopy or regular scopes depending on the category in which they fall?

Associate Professor Guy Hingston 19:49
That's a great question Elissa. I wish there was a magic wand that someone could wave and the whole community would just sort of go and say 'right, we need to have testing'. But what we're seeing is a societal change here. So 1993 was the first time a medical publication confirmed the mortality reduction of bowel cancer screening. So up until then, this didn't occur. So since 1993, we've had an increase in the number of people having bowel cancer screening. And that increase should continue on. My own personal view is as it's becoming more and more accepted, that we should be teaching teenagers in preventive health, or PDHPE, Health and Physical Education at high school, the benefits of cervical cancer screening, breast cancer screening, bowel cancer screening, blood pressure testing, etc, etc, as per what the college of GPs recommend in their Red Book. So if we can start teaching teenagers, then by the time they become middle age, there'll be much greater acceptability. But if you look at it from my perspective, literally when I started colonoscopy 30 years ago, I looked down the colonoscope. We didn't have video colonoscopes in those days, and as technology improves, education improves, as community awareness improves, we'll keep getting there. And yes, the recent Medicare change is helpful. I think that the change in general practice over the last generation or two to have age-based screening registers that are publicly funded and the PIP payments from the government. You know, these all help as well. But I think the biggest driver from my perspective is educating the community getting them to present to the GP, rather than having the GP chase the patient, I think it's much better to educate the community and say, Look, you know, we can halve your chances of dying from bowel cancer now with a one-off colonoscopy. It's such a good news story. I look at it like this, Elissa, you have two brothers and a family; one decides to have a colonoscopy and has precancerous polyps removed, dies at 90, 40 years later from something else. The other brother decides not to have bowel cancer screening, the pre-malignant polyp that there then turns into a cancer spread throughout the body and could take that person out three or four years later. Now if you stand back and look at those two over, you know, 34-year period, and think that's a massive difference. It really is a massive difference.

Dr Elissa Hatherly 22:56
We know cervical screening, as you said, the numbers of cervical cancer have come right down and the teaching is that the only women who experience cervical cancer now are those who were under-screened. Not been screened with a pap smear or cervical screening test as often as they should be, or they have never been screened. And it sounds like we could hopefully get to that place with bowel cancer screening as well. I just can't imagine a time when 80% of our community would participate in bowel cancer screening like you've mentioned happens in some parts of America. Certainly, as a GP, I'm always asking people how much alcohol they drink, whether they smoke, is their mammogram up to date. Is their cervical screen up to date? Is their bowel cancer screening up to date? And people will say to me, 'Oh, yes, I received a kit in the mail. I wonder where I've put it. It's somewhere I'll have to find it'. Yes, I say, 'Why don't you do that? Let's do that tomorrow morning. Pop it in the bathroom so it's ready to go'. But those simple reminders and regular reminders can start to affect some change in our community. So Associate Professor Guy Hingston, what would be the take-home message about rapid access screening that all of our listeners should be really mindful of?

Associate Professor Guy Hingston 24:18
Well, I think the take-home message is there's a genuine shift in the community to try and break down the barriers to try and make it easier for people to get a colonoscopy. And I'm hopeful that by visiting all the GPs in our community and providing the service, people will find it easier that there would be fewer barriers. And, you know, at the end of the day, I'm just one person and operating theatre, doing what I do. But if it's through rapid access, we can break down community barriers and get more and more people through screening through colonoscopy, then I think that's a positive community message. Of course, Elissa, you must understand that I feel guilty as a specialist. I feel guilty because I know all of this information, I keep my finger on the pulse on the latest data. And I know that 50 to 66% reduction in death rate from bowel cancer, so of course, when I turned 50, I asked one of my colleagues to do a screening colonoscopy. So listen, my big problem now is if it's good enough for Guy, why shouldn't it be good enough for the rest of the community? You know, what is Guy Hingston doing to help the rest of the community when he's looking after himself in this way. So that's where I'm coming from with a rapid access program, trying to get trying to break down the barriers to facilitate this to make it as cheap as possible, as affordable as possible and with the least logistic problems as possible. So that people can go through it and receive the really significant life-long benefits from either polypectomy or picking up bowel cancer early.

Dr Elissa Hatherly 26:10
Yeah, it's not a difficult message to sell, is it? Hopefully, with this podcast with your rapid access program, with improved education across all of our communities, starting with young people, as you mentioned, we can actually start to effect some change and reduce some of those health inequities. Associate Professor Guy Hingston, thank you so much for joining me today to talk about the rapid access bowel screening program.

Associate Professor Guy Hingston 26:34
My pleasure Elissa, all the best.

Dr Elissa Hatherly 26:40
For more information about the Round Up, or to share your feedback and ideas for future episodes, visit nqth.edu.au/roundup-podcast or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training Hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training Hubs is an initiative of the Australian Government's Integrated Rural Training Pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander Health Council, health services, Aboriginal Community Controlled Health Organisations and general practice clinics.

• Healthcare Provider Portal: National Cancer Screening Register
• Queensland Government: Bowel cancer screening and prevention
• Community HealthPathways Mackay: Bowel Cancer
• 2018 Bowel Cancer Screening
• 2022 The Lancet Controversy over Colonoscopy Screening
• Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death

Episode 1 IUD The Roundup

Thu, 9/8 10:45AM • 33:55

SPEAKERS

Dr Elissa Hatherly, Dr Stephen Lambert

Dr Elissa Hatherly  00:02

Welcome to the roundup, a North Queensland based medical podcast offering local content for local clinicians. I'm your host Elissa hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the lands on which we practice. In this episode, Dr. Steven Lambert talks to me Elissa Hatherly about some common pitfalls with intrauterine devices and answering some common questions.

Dr Stephen Lambert  00:52

Good morning, Elissa. Just in general, in terms of women's health, I know as a male GP, it's probably an area where I'm probably giving okay care, maybe a standard of care but good quality health care, what's been your experience of, of good quality health care, particularly when it comes to sexual health, contraception, womens health?

Dr Elissa Hatherly  01:16

Yeah, we are really behind the eight ball. Unfortunately, we don't have quality sex education in the schools. We don't have good, respectful relationships, counseling, a lot of schools don't have any respectful relationships, counseling, or a lot of sex education at all, maybe as part of a health class. So the general health literacy in the area is poor. And when I talk to young people, particularly they are getting poor advice from their parents, even if they are bold enough to ask their mums and dads, because the mums and dads didn't have good quality advice. So if we can do better, that would be great for the community. Sex Education, contraception, counseling, emergency contraception, counseling, all of those things are not rocket science. But I certainly don't expect every GP to be as good at every aspect of medicine as every other. And certainly for the junior doctors who might be seeing women in emergency with an unplanned pregnancy or threatened miscarriage, or who I've just popped an IUD in, having a good idea about some of those skills that are needed with those patients is really important. It makes it easier for the doctor, and much nicer for the patient.

Dr Stephen Lambert  02:28

I think today we're going to be talking about contraception. I'm imagining contraception is an area where, you know, we're talking about the public in Mackay probably feel like they've got a lot of information about you know, you would have talked to your mom, you would have got stuff in schools, that kind of thing. What I'm hearing you sort of say is there's there's an opportunity for doctors across the board, you may not be practicing this type of medicine every day, in the same way that you are, but there's a role for all health practitioners, doctors, you know, GPS, interns, Junior Doc's to be where the opportunity presents itself to be increasing the literacy, health literacy. Yeah, that's

Dr Elissa Hatherly  03:14

right. So for example, I just saw a young woman for an intrauterine device insertion on Friday, she had a six week old baby. The last time I saw this young woman, I inserted an IUD, and I said to her what happened to the IUD that I put in and she said, my GP took it out because I have endometriosis and PCOS and the GP reassured me that I wouldn't fall pregnant. And that GP I'm sure, wasn't doing what they thought was wrong but it has made an enormous impact on this young woman's life that can't be underestimated. And

Dr Stephen Lambert  03:49

maybe that'd be helpful for today's conversation is exploring some scenarios and common scenarios, particularly in the general practice environment, probably the patients I'm seeing where I'm not doing Woman's Health everyday or providing contraceptive advice, but I guess there is a body of knowledge that I would need to deliver a high standard of safe quality care. Certainly when I was in medical school, oral contraceptive pool was what we focus most of the time on. Copper IUDs were around. It was kind of like oh yeah, there's this thing. That that there was a little bit of knowledge. And then I think, you know, long acting reversible contraceptives (our LARCS) have probably come to the fore in the last sort of 5-10 years

 

Dr Elissa Hatherly  04:34

or so women doctors  like me have been banging on about LARCS for a long time. So hopefully that message is really starting to filter out into the medical community. A long acting reversible contraceptive is our focus for all women of all age groups because they are much more effective at preventing a pregnancy. The contraceptive pill is an easy one for any doctor to prescribe, but it is not an easy one for women to use and use reliably. And even if it is being used reliably, we can only expect it to prevent a pregnancy in 98 times out of 100. And if you don't want a pregnancy 98 times out of 100 is not good enough. We want a LARC where we are getting contraceptive efficacy, almost 100% of the time. So we use the numbers of about 99.9% effective, statistically a LARC is a more reliable contraceptive method than sterilization.

Dr Stephen Lambert  05:33

With that sort of context, do you want to give us just a bit of an understanding of particularly in terms of intrauterine devices, so in terms of LARCS, yeah, different products there and then I guess even within the class of intrauterine devices, the various products with their pros and cons, so it'd be great to just get your thinking about when you would use which of those.

Dr Elissa Hatherly  05:57

So in terms of LARCS, we have the implanon etonogestrel rod that sits in the upper arm that lasts for three years and provides really good contraception. It can give some unpredictable bleeding in a small number of women, but it's a great starting point, particularly for young women and women who maybe are not sexually active. That's an easy one to learn to insert and to do regularly in your practice, and is a great starting point. They cost about $30 for anyone, which is great. Financially effective, economically viable contraception for young women. When we look at  uterine devices, we have two types. We have those containing a progesterone likely Levonorgestrel, so we have the Mirena which lasts for five years, and delivers a higher dose of progesterone and now we have the Kyleena, which is a fractionally smaller device, again, lasting five years delivering a smaller dose of progesterone every day. And then we have the copper IUDs which irritate the lining of the uterus and are equally effective at contraception. We have the Multiload, the T 375 and the TT 380, that last one will last for 10 years. The smaller IUDs containing 375 millimeters of copper will last for five years for contraception. The copper IUDs can also be used for emergency contraception if inserted within five days of unprotected sexual intercourse. So they are fantastic. For women who don't want any hormone they can go for a copper IUD. For women who don't want any hormone, they might actually benefit from an intrauterine device containing progesterone. Because the progesterone is really only being delivered into the uterus, it's not going into the rest of the bloodstream, it is unlikely to impact on their mood or their weight. The fantastic thing with those progesterone delivering IUDs is that they are quickly reversible, like the copper IUD. So if you try a progesterone containing IUD and don't like it, we can take it out and you go back to normal almost immediately.

Dr Stephen Lambert  08:09

So in terms of IUDs, we've got the those impregnated with Levonorgestrel and the copper IUDs. And in terms of choosing one or the other, am I hearing you say that's kind of patient choice? Or is there? How would you go about selecting?

Dr Elissa Hatherly  08:30

So the progesterone containing IUD's cost about $42 each, which is very different to the copper IUDs, which we can access for around $100, which is still really cost effective when they're used for five to 10 years. Unfortunately, a lot of pharmacies in our region don't stock the copper IUD. And so the women who want a copper IUD might have to ask for it to be ordered in so access is a little bit slower, but not inaccessible at all. The copper IUD as I said, irritates the lining of the uterus, so it does increase the heaviness and the crampiness of a period. That might just be for the first few months it might be for the lifetime of the copper IUD, but you wouldn't know unless you tried it. A lot of women who use copper IUDs are super happy with them. For the progesterone containing the Levonorgestrel containing IUDs, they thin the lining of the uterus, which tends to give women a much lighter, shorter, less crampy period than they might experience any day of the week. So they are a fantastic option for women who need contraception. They are also a fantastic option for women who have an unmanageable period or a period that's interfering with their lives, which can be really variable. I have women all the time who tell me that changing two pads a day is unacceptable for them and that's fine. I have women who are changing two pads every hour, which I think we can all agree is unacceptable. But it's down to the woman whichever way she wants to manage her period and IUD can be there to help.

Dr Stephen Lambert  10:09

So in terms of the progesterone containing IUD, it seems like there are two basic clinical indications that that you could use this for. So ones contraception, the other related to menorrhagia. Yes. We may as well start with sort of contraception and then maybe move to sort of menorrhagia. So I've got a 27 year old, so the lady who's come to get a prescription for the pill, shes got two children doesn't want any children anytime soon. Part of my usual practice, with a request for the oral contraceptive would be to do sexual health screen, obviously, rule out contraindications, but I've been trying to get better at going have you explored other alternatives for sort of contraception? Have you had that conversation in terms of making people aware of IUDs, the benefits, and then helping them weigh up the pros and cons?

Dr Elissa Hatherly  11:07

Yep. So for anyone who comes in, regardless of their age, or where they are in their family planning, I would talk about long acting reversible contraceptives, we know that intrauterine devices, for example, are perfectly acceptable for nulliparous women, so women who have not yet had a baby. And even I will insert them in women who have not become sexually active, if that's the right contraceptive for them. So if someone comes in for contraceptive advice, I will actually just hand write a list of all of the different classes of contraceptives available to them. Also talking about the cost, because that's important, talking about patient input, because that's important. If you can't remember to brush your teeth every day, then you probably shouldn't be remembering to take a contraceptive pill every day, we talk about whether or not people do shift work, whether or not they have multiple sexual partners, and then maybe shouldn't have an intrauterine device. We talk about other things that might be bothering them, like their weight, or their mood, and help walk through the different options to work out what is going to be most acceptable for that woman.

Dr Stephen Lambert  12:15

And so what I'm hearing you sort of say is as part of the counseling, particularly, you know, not just for the LARCS, but particularly with the IUDs, a good set of sexual health history would be sort of really sort of important as part of that consult. It's

Dr Elissa Hatherly  12:35

tricky, isn't it? It's hard to do that in a sensitive fashion without being too interested in the nitty gritty of someone's sex life. But we do recognize that women who are not looking after their sexual health are at higher risk of contracting chlamydia and gonorrhea, which are both really prevalent in our community at the moment. If you pick up chlamydia or gonorrhea, and you have no symptoms, then you might end up with tubal occlusion, and primary infertility or secondary infertility. And that is devastating for those women. So in women who I'm talking about intrauterine devices with,  I say to them, you know, it's incredibly important that we screen you for chlamydia, make sure you don't have an undiagnosed infection. And of course, use condoms with new partners. And that's a conversation I have with everybody, when talking about contraception, regardless of their marital history, or their occupation, or however many children they have, that reminder that condoms are always important with new partners cannot be overstated.

Dr Stephen Lambert  13:35

So in terms of, I guess, myself, I wouldn't be inserting sort of IUDs. Just I haven't had the training to do that. But I've got a young lady in front of me, and we're talking about contraception. I'd like your input, I guess, into I guess, a potential approach for others listening, who may not be in the position where they've had the training to insert IUDs. So I guess the one thing in the back of my mind, if I'm going to refer someone for an IUD, this is the right form of contraception for them, there's a potential of a gap where they might not be covered with contraception before from my consult to seeing you, and some, you know, some patients or a lot of patients just need time to sort of think through the pros and cons I've given them information I've printed information. So my practice would be to give them the pill, so they keep going, give them the referral, I'll often give them a script as well, to perhaps collect that and then come sort of see you knowing that they won't have it inserted on the first consult. Do you have some things or just in your experience? Just nuancing that approach a little bit what would be the best way in approaching that sort of consult where there is potentially a gap in contraceptive cover?

Dr Elissa Hatherly  14:56

so we don't ever want a gap in contraceptive cover, even if women promise that they'll use condoms, I'm always a little bit nervous because condoms require two dedicated partners to use condoms correctly. So we often prescribe what we call bridging contraception. So that might be using the contraceptive pill for a short time, you would want to start it on an active pill, so that it's into their system as soon as possible. Or you could use a depo provera injection, for example, or you could use a nova ring if that was most appropriate or a progesterone only contraceptive pill. We always encourage people to use condoms, as I said, but that bridging contraception is incredibly important. If someone is already using something like the contraceptive pill and has been using it for a long time, don't ask them to stop their pill, I would always want them to continue with that contraceptive pill for seven days after the insertion of the IUD. Because a levonorgestrel progesterone containing IUD will take seven days to become effective. We know that those those IUDs are effective straightaway as contraception if they are inserted at the time of the period as long as it's a true menstrual period. If someone's had a medical termination of pregnancy, for example, we're not 100% sure what recent bleeding might mean whether they have had a true period and whether that IUD insertion is going to be effective straightaway. And of course, if you send someone in for insertion of an IUD and something pops up in that history that we need to investigate a little bit further, or we think a different form of contraception might be nice for that woman, then we don't proceed with that IUD insertion, we might further delay that contraceptive commencement and have a need for further bridging contraception. So if someone's coming from outside, I would ideally like them to still be on active contraception. So when women are coming into family planning clinic, for example, they don't need a referral because we are GPs who run that clinic women can self refer and they don't need a paper referral from the hospital. And we will ask them to have a little bit of pain relief about half an hour before that appointment time to bring the device with them on the day, to bring a pad and maybe, particularly if they're young women who haven't had a pregnancy, we'd suggest they have a driver to take them home afterwards, because they can be super crampy and maybe even feel a little bit faint. But for the vast majority of women, even women who've only had caeserian section births, the difficulty or the discomfort with insertion is really short lived. And I don't think people appreciate that adequately, you might be really uncomfortable for a minute or two but women leave our rooms with some mild period pain and can happily go back to work or go about their business. It's not perhaps as big a deal as some people might consider.

Dr Stephen Lambert  17:59

That's awesome. That's good to understand, I guess the process from the family planning side so that, you know, I guess we can adequately plan.  Would you what would your approach be? So that let's assume this young lady's had her IUD, she comes back five, six months later. She's concerned that she's put on a little bit of weight. She's concerned that her moods have changed, and it may be related to the progesterone. I'm assuming this is not  infrequent.

Dr Elissa Hatherly  18:36

Everyone blames their contraception.

Dr Stephen Lambert  18:39

How do you approach that consult in the sense that I think a lot of us or hopefully know that that's fairly sort of rare, and that this is working locally. But at the same time, you know, patients do come with, it's in their mind that there was an event and this is cause and effect relationship. How do you approach that? Yeah.

Dr Elissa Hatherly  19:04

So we actually see all of our patients six weeks after insertion to make sure that the bleedings settling down that there's no evidence of infection or expulsion of the IUD, and that the unpredictable bleeding that you would normally get at the initiation of the progesterone containing IUD has pretty much settled down. We know that for the first three months or so with a progesterone containing IUD, you might get a higher dose of progesterone released, which might actually get into the systemic circulation so could potentially make women feel a little bit bloated. They might complain of headache mastalgia, their mood or they might be a bit more tearful than usual. Some of those PMT symptoms might be there in a mild in a mild they you know some of those symptoms might be mild. But, you know, I reassure people that if it is related to the IUD, but that that effect would be gone by the three month mark. If we're at six months and women are concerned that their bodies are substantially changing, then an important thing to do is look at what contraception they have used previously. So if people have used a contraceptive pill, for example, that has really suppressed ovulation, when they have their IUD, they might notice more cyclical mood changes as their ovary kicks back into gear, they might notice more ovulation pain at mid cycle, they may not know where they are in their cycle, because the Mirena has suppressed their period, but they might notice cyclical ovulation pain, they might notice that they have gained a little bit of weight or their mood is a little bit poor, because they've actually benefited from the contraceptive pill. Whereas now all we've done is not necessarily to introduce a mirena. But we have removed a contraceptive pill that they had a lot of benefit from, aside from the contraceptive effect. We call those the beneficial side effects of the pill, they are substantial.

Dr Stephen Lambert  21:08

That's really helpful for me in the sense that thinking through what a patient's presenting with, you know, we lump these contraceptives under contraceptive, without thinking that the different modes of action, there's there's actually substantial differences in physiology and how you're getting the contraceptive effect. But there are also other beneficial side effects  to these different forms. Once again, this comes down to the counseling side of

Dr Elissa Hatherly  21:36

Yeah, but keeping our patients engaged is incredibly important. So we need to acknowledge that that patient has those symptoms that they're experiencing, they may not be the side effect of the mirena they not may not be because we've withdrawn the contraceptive pill. But it's also important to ask about other things that are going on in their life have they recently had a baby have they recently returned to work, have they commenced some other medications like an SSRI. So as I said, we can always remove the IUD and give them a period of time without their IUD to see if their symptoms improve. More often than not, I will also give them a prescription for another IUD at that same consult and say look, I'll take out your IUD, if you find that things don't magically change without your IUD, then we can always pop another one in and you can with your GP explore causes for your other symptoms down the track.

Dr Stephen Lambert  22:30

So what I'm hearing is the key point here is the patients come in thinking, you know, they're focused on the IUD. Really important to take a biopsychosocial approach, not have that anchoring bias, where the patients come in this is the problem but rather to zoom out and do a thorough history examination for for other biological causes or their symptoms, all while acknowledging that what they're experiencing is valid and reliable. I think sometimes the message we give is not your IUD keep the IUD in sort of.

Dr Elissa Hatherly  23:02

That's the message I'm going through inside my head, but out of my mouth comes a much more compassionate approach. And of course, it's going to depend on how much sleep I've had the night before how many patients I have waiting in the waiting room, how hungry I am, did I bother to eat lunch today? Probably not. So you're only as good at counselling your patients as you are at managing all of those other things in your workplace from day to day as well.

 

Dr Stephen Lambert  23:31

We might sort of finish off with just one more scenario around IUDs, and then to  summarize some of the key points. So I guess the second scenario is a 45 year old lady who still requires sort of contraception, but in terms of your history, you've uncovered that their periods getting heavier and longer and it's actually impacting sort of life. What would your approach be to that sort of scenario?

Dr Elissa Hatherly  24:01

So it's incredibly important that we offer women at midlife contraception up until we are sure that they have passed through menopause. So women who have their last period before the age of 50, we need to provide them with contraception for two years, just in case they have an unexpected ovulation in that time. For women over the age of 50, we want to provide them with contraception for at least 12 months after their final period. So if someone is using a contraceptive, like the pill, for example, then they are going to be having a reliable withdrawal bleed every month. And we may not know when they are going to go through their last period. We might need to stop their contraception and ask them just to use condoms for a period of time so we can assess what's going on with menopause. So for most women at the age of 45, the average age of menopause being 51 in this country, so women at 45 will not infrequently have a heavier period, that doesn't necessarily mean there's anything nasty going on. And we often use the nice criteria to just establish whether or not we need to investigate that heavier bleeding more enthusiastically or not. For those women who have no concerning pathology on the radar at all the ones who are not making the hairs on your back of the back of your neck stand up, we would look at a contraceptive that's going to provide reliable contraception, but also help to make their life a little bit easier with a lighter, less crampy and maybe even shorter period and that's really where the progesterone containing IUDs come into their home. So when we are over the age of 45, we can provide women with a progesterone containing contraception for what we use extended what we term extended use, so we don't leave that IUD for five years. We actually leave it for seven years, as long as we've removed it by the age of 55. So anyone over the age of 45 would get their last IUD their last progesterone containing IUD and that would be removed 12 months after we are sure they've passed through menopause. With a mirena or a Kyleena, we can be sure they've gone through menopause just by measuring the FSH because that is not interfered with by that contraception. So if you have an elevated FSH in a patient, you would wait another 12 months before removing her IUD. If that FSH is particularly high, like 80, then you don't need to repeat the level. If the FSH is only marginally elevated, you would repeat it six to 12 weeks later to be sure that it was still elevated, and that that woman was in menopause. But it's important that we leave that contraception for 12 months after we suspect their last period so that we capture those women who might have an extra ovulation down the track.

Dr Stephen Lambert  27:02

So in terms of our history, we're suspecting a fibroid uterus in this particular patient and we're able to sort of confirm that with further investigation. Do you want to talk a little bit about the role of IUDs and managing.

Dr Elissa Hatherly  27:18

So when IUDs first became more popular in Australia, it was a common misconception that women who'd only had caesarians were inappropriate for an IUD, that women who had a fibroid uterus were inappropriate for an IUD, that women who were nulliparous were inappropriate for an IUD and we just know that that is not the case. So many women will have fibroids in the uterus. Many women will have small fibroids. A large fibroid might increase the risk of spontaneous expulsion of that IUD, but I will always suggest it to women as an option to try or women who have an IUD would be encouraged to examine themselves for the string of the IUD to be sure that their IUD is in the correct place. If you or your partner can feel the string, then you are reassured that your IUD is in the right place providing contraception. If that IUD improves that woman's period substantially, or insubstantially even, it's up to the woman to know whether that IUD is affecting her period adequately or not. So if we try an IUD for six months, and that woman finds her period is much improved, then we would leave that IUD. If we use that IUD and the woman's period isn't very much changed, or they are crampy, or the IUD is pushed a bit low in the uterus, then we might say, Okay, we've tried the mirena, it's not going to work for you for your period and look at other options for that woman. I'll always give Mirena a go.

Dr Stephen Lambert  28:55

So just to summarize the discussion today, some of the take home points that I've taken and feel free to add any in terms of your long acting reversible contraceptives. I've heard you say that they're more effective than sterilization. So very effective form of contraception. Yeah. Second thing is they're appropriate for any woman basically of any age or previous obstetrical gynecological history. There are some contraindications obviously to it. But in terms of when they initially were introduced, there were ladies excluded, that would no longer be excluded. So the IUD can be considered for anyone wishing to use it as a form of contraception, definitely. In terms of your copper IUDs versus your progesterone impregnated IUDs the mirena and Kyleena are the most available and accessible to ladies here in Mackay.

Dr Elissa Hatherly  29:56

That's right. They're the ones that we have in Australia and all pharmacies stock them, they are a similar cost, they are really cost effective for women of all ages, and really have made an enormous impact on women's quality of life.

Dr Stephen Lambert  30:10

In terms of good medical care around advice around contraception, or providing sort of options, like my takeaway from this is always to take a good biopsychosocial approach to these conversations, there are lots of factors that come into determining an appropriate form of sort of contraception or beneficial side effects from different forms of contraception. And once again, just I guess, good communication skills when counseling prior to, you know, insertion of an IUD, but also the follow up down the track where a patient may come in and go I think it might be my IUD causing these symptoms, just taking a really sort of thorough history and examination and balancing the science at the back of your head going unlikey, but let's let's explore this a bit further.

Dr Elissa Hatherly  31:07

That's right. So of course, the pelvis is a complex anatomical area, it's easy to write off a woman's pelvic discomfort or symptoms as related to an IUD. Often women are also constipated, or might have an appendix that's playing out or suffer with irritable bowel syndrome. There are lots of other things going on. Whilst you might have an IUD in place, that is not the axis of evil. There are other things at play always.

Dr Stephen Lambert  31:35

So once again, thorough history examination, investigation, don't, don't don't let your anchoring bias necessarily get in the way.

Dr Elissa Hatherly  31:45

That's right. And at the end of the day, we just need to do what is best for that particular patient.

Dr Stephen Lambert  31:50

Any final thoughts? If there was one take home that the listeners today needed to take home from this, what would it be?

Dr Elissa Hatherly  31:58

Use condoms. And remember, an IUD for all of your female patients, they can be really helpful, we're so lucky in Mackay to have an easy access pathway for women. But of course, they can always see one of the gynecologists either publicly or privately. And there are lots of GPS in town who are trained to do IUDs you need to be doing them frequently to be proficient, and I would encourage every doctor to consider IUDs in their counseling of their patients.

Dr Stephen Lambert  32:30

Fantastic. Thank you. Thanks for your time, and hope to catch up with the next topic sometime soon

Dr Elissa Hatherly  32:36

Thanks Steven. For more information about the round up or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice, and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Burnout: In yourself and your colleagues podcast resources

The Burnout Scale (theburnoutproject.com.au)

Self report scale that can provide some guidance on whether you are burning out and if so how severely it is affecting you.

Burnout: A guide to identifying burnout and pathways to recovery by Gordon Parker | Goodreads

An excellent book on Burn out by teg Australian Psychiatrist who was one of the founders of the black dog institute.

TEN – The Essential Network for Health Professionals - Black Dog Institute

The online TEN Navigating Burnout program has been developed specifically for health professionals to reduce the impact of burnout in a way that is sensitive to the unique challenges they face.

The Thriving Doctor: How to be more balanced and fulfilled, working in medicine by Sharee Johnson | Goodreads

This is a book written by an Australian Psychologist who specialises in treating Doctors. It concentrates on the psychological aspects of self care and complements Gordon Parkers book. It isn’t a replacement for it as it doesn’t cover the really important aspect of how to approach your workplace to discuss a position that is burning you out.

Crucial Conversations: Tools for Talking When Stakes Are High by Kerry Patterson | Goodreads

This is a great book that can help guide you in how to maximise the likelihood that any negotiations with your managers/supervisors result in appropriate adaptations to a role that is burning you out.

The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth by Amy C. Edmondson | Goodreads

Psychological safety is a really important aspect of organisational culture that can protect against burn out. This book is by one of the pre eminent researchers in the field.

Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework - Kathryn Turner, Nicolas JC Stapelberg, Jerneja Sveticic, Sidney WA Dekker, 2020 (sagepub.com)

Restorative just culture and its relation to critical incident analysis is another approach that can protect clinicians in an organisation against burn out. This paper describes its implementation specifically in relation to suicide but if you exchange suicide for any critical incident you will see it actually provides a generic template that is applicable across the board.

Clinician health - Caring for Colleagues

Burnout in yourself and your colleagues

Thu, 9/8 10:32AM • 12:29

SPEAKERS

Dr Elissa Hatherly, Dr Paul Henderson

 

Dr Elissa Hatherly  00:02

Welcome to the roundup and North Queensland based medical podcast offering local content for local clinicians. I'm your host, Alisa hatherly. I'm a local GP and family planning clinician and head of James Cook University is Clinical School here in Mackay on Nui country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the lands on which we practice. Welcome to today's episode on burnout in clinicians with Dr. Paul Henderson. Paul, thanks so much for joining us, you are so experienced in this area as a local psychiatrist here in Mackay. And burnout in doctors is something you're really passionate about. When we think about burnout from trauma. Of course, the type one trauma where there's a particular event or type two where there's repeated long term exposure to a traumatic event, or vicarious trauma. Burnout is something that is incredibly prevalent, isn't it? I think

 

Dr Paul Henderson  01:17

yes, absolutely. Because of vicarious trauma. You know, in ourselves in first responders, we not only witness a great deal of direct trauma, so to speak, but we also bear witness to a great deal of trauma in other people's lives, we, unfortunately are in the position of having to give a lot of bad news, which is very traumatic. We're also in the position of treating people with conditions that we we can't find a treatment for that works, which is which is also very traumatic. So So yes, so you know, everything that applies for PTSD, and our patients apply to PTSD and us. But I think if I suppose I would, I would open it up to something which in my mind is much more prevalent, and in many ways, much more significant, which is burnout. And this is something close to my heart. Because I've written myself like twice in my career. So far, you didn't get to learn after the first time. And you think as a psychiatrist, I would have learned to learn to recognize the signs growing in me. But the last time was only about 18 months ago, and it was what it was what triggered my transition from public health into into private health to be honest. So you know, when you look at surveys that look at prevalence rates, it's it can be absolutely enormous and really astoundingly enormous, you know, usually the lowest figure that is reported is 30%. And the highest figure that I've seen is up to 70% in surgical residents in America. And that, you know, that is enormous because it is it can be such a devastating experience to be burnt out. And I suppose the things to be aware of is that, you know, the core symptom is fatigue, absolute exhaustion, and I suppose that's generally what we don't recognize, because we all work so hard, that we just expect to be fatigued. But when that fatigue stops lifting over the weekend, and becomes a permanent part of our day to day working life, you know, that's a sign that you're starting to creep into burnout, distance, you know, having a sense of distance from your job, or cynicism about your job, or distance from your patients. So compassion, fatigue, those are all common parts of burnout. And also having a having an increasing self doubt about your effectiveness as a doctor is a common part of burnout. And, you know, sleep disturbance is a really common potent part of burnout. Because of the exhaustion, distance feeling from your family and friends is a really common part of burnout, anxiety, you know, particularly anticipatory anxiety going into work, having really low mood and work. And unfortunately, it becomes a self perpetuating cycle, because you're so exhausted. And you know, it's hard to say, but you start to lose the ability to care about what you're doing, that really starts to constantly promote that self doubt.

 

Dr Paul Henderson  03:57

And, you know, I'm no longer practicing with my value set. Because when I came into medicine, I was highly conscientious, I was highly compassionate, I was trying my best for my patients. And now I just don't seem to care anymore. And that is such a source of shame. For doctors, that is a massive barrier for us seeking any help, because you have a sense that I can't reveal to anybody that I don't feel like I'm the doctor that I should be. And I know I experienced that. And you know, and I find it hard to reach out for help as well. But I think, you know, once you recognize that yourself, there's many different ways that you can go about trying to address it. But if you don't recognize it in yourself, it can continue to build and it's, you know, once you have enough doctors in the system or enough professionals in a system where burnout is common, then the whole system starts to burn out. And you know, once you understand the the impacts and symptoms of burnout, you know, you start to recognize that the you know, the person that you work with who just doesn't seem to care anymore. It's not because they're a bad person. It's because they're burnt out but you We'll also see that when there's a number of people that are sort of affected by that, and they're starting to engage in what would commonly be termed as presenteeism, so they're present in work, but nonetheless, they're still absent from work, because they're just doing the bare minimum, because they don't have the mental reserves to go any further, then it means works get shifted to other people, that that increases the chance that they will burnt out, or burn out, that increases the risk of their risk of resentment, it causes tension with in teams. And so it really, you know, it really sort of spreads across teams, unfortunately. So I think, you know, for our own well being, it's really important to recognize, but also for our patients, because, you know, sadly, the research shows that a burnt out doctor is not a doctor, that's that is that is working at their highest level of productivity, or efficiency, or compassion, or conscientiousness. And that, you know, we all want to be that doctor that is functioning in that way. But sadly, the system and it's not a reflection of us on the whole, it's a reflection of the system that we work in is massively overloaded, constant time pressure. And I think, you know, something that's really become apparent in COVID is moral injury and moral injury can be a significant cause of burnout, it can be a significant cause of PTSD as well, actually. And moral injury is when you are behaving away in a way or that when you witness behaviour, that is inconsistent with your value set. And, you know, you'll probably recognize and what I just described about burnout, that you start to experience increasing motor and injury, about your own behaviour, or potentially start to have increasing moral injury about your own behaviour as you burn out. Because you, you just simply can no longer practice in a way that is consistent with your value set, because you're so absolutely exhausted and emotionally numb.

 

Dr Elissa Hatherly  06:43

Gosh, okay, so we need to be a lot more aware of burnout in our colleagues and in ourselves, study percent of our colleagues up to 70% is a massive number. And as you say, in the light of COVID, that moral injury is enormous.

 

Dr Paul Henderson  07:01

Absolutely. And in the show notes, I've included a really fantastic book by a is an Australian psychiatrist called Gordon Parker, literally called burnout. And he is one of the psychiatrists was one of the founders of the Black Dog Institute. And that is a really fantastic exploration of how burnout affects people, particularly within the medical profession. I've also actually included a link to a self reported burnout scale, if anybody is concerned that there may be burning out and just want to have a sense of if that is the case. And it's a spectrum, you know, from subtle symptoms of feeling exhausted, but nonetheless, really recovering over the weekend, to absolute exhaustion, all the other symptoms, and simply not being able to turn up to work. And at the extreme end of this spectrum, because burnout, there's a lot of similarities to depression, but it's not depression. But at the extreme end of the expected spectrum, up to 30%, of people with burnout would go on to develop depression as well.

 

Dr Elissa Hatherly  07:55

Okay, so for doctors who are experiencing burnout, or other mental health concerns, like depression, they can always access the doctors for doctors, peers, or the peer support work through the hand in hand Foundation, can't they?

 

Dr Paul Henderson  08:12

Absolutely. And the black dog Institute also has something called 10, the essential network for professionals. And that is for any medical professional, who is concerned, they may have burnout or other mental health conditions. And it's, I suppose, a professional group that can signpost them or provide support. There's lots of sort of psycho educational material on in that part of the website, and more generally, in the Black Dog Institute website, and I'll put a link in the show notes to that aspect for them as well. And there's also a good book by an a, an Australian psychologist whose name escapes me now but who, who now solely devoted time to coaching doctors, particularly with burnout. And her book is, I think, called the thriving doctor, which I've put in the show notes as well. And that's a really in depth, sort of self help book for how you can concentrate on the psychological aspects of self care, I suppose, you know, to you know, self care work life balance is really important to try and limit the impacts of burnout. But there's two other aspects and these are really well documented in the book called burnout is you really have to, and this is really hard, you really have to think, hard and deep about the role that you're in. Because even with all the self care in the world, if you're in an unworkable role, and sadly, there are many other workable roles in health at the moment, the chances of you being able to stave off burnout, even with all the best self care in the world, are quite low. So you need to you need to think long and hard about the role you're in. And that doesn't necessarily mean that I'm going to change role. But at the very least, it means you have to understand why the role is having such an effect on you, and be able to hopefully talk to a manager that will listen to you and that isn't always the case or a supervisor that will listen to you about the impact of the role on you And what can be done to change the world. And the last thing is a personality characteristic that is that is highly correlated with burnout. And it's related to conscientiousness, which is perfectionism. So when we come into medicine, the more conscientious we are, the more we get praised, essentially. And that can for people that aren't already perfectionist, that can provoke perfectionism. And even in a role that is actually genuinely doable. If you're a perfectionist, you can simply drive yourself into burnout. So you know, sort of the three areas you know, when you're thinking about burnout, self care, thinking about the role you're in what can be done to change it, but also specifically thinking about if you have perfectionist qualities to yourself, and what can be done to address those as well.

 

Dr Elissa Hatherly  10:42

Oh, Dr. Paul Henderson, thank you so much for your time today. Burnout is something that we all need to be thinking about. In the lead up to are you a K day in September, recognizing in ourselves and in our colleagues that we are not okay is incredibly important. Dr. Henderson, thank you so much for your time, we really appreciate it and look forward to seeing the great work that you're doing in our community. Thanks, Paul. For more information about the Roundup, or to share your feedback and ideas for future episodes, visit nqth.edu.au forward slash roundup hyphen podcast, or contact us at nqth.mci@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Table 1. The differential diagnosis for neonatal jaundice1,2
Early jaundice (Within 48hours of life) Pathological	Intermediate jaundice (Day 3-10 of life) Common and mostly benign	Prolonged jaundice (Beyond Day 14 of life)
●       Haemolysis -          Rhesus/ABO incompatibility -          G6PD deficiency -          Hereditary spherocytosis -          Alpha thalassemia   ●     Intrauterine Infection   ●     Sepsis	●   Physiological jaundice which may be exacerbated by/associated with: -          Prematurity -          Bruising -          Cephalohematoma -          Polycythemia -          Delayed passage of meconium -          Breastfeeding -          Dehydration -          Asian ethnicity -          Infant of diabetic mother   ●    Haemolytic causes	●     Breast milk jaundice   ●       Sepsis   ●       Hypothyroidism   ●     Inherited deficiencies of glucuronyl transferase enzymes - very rare   ●     Conjugated jaundice  Biliary atresia, neonatal hepatitis

Guideline: Neonatal jaundice (health.qld.gov.au)

 

 

Table 2. Pertinent questions on the history of a jaundiced neonate2
History	Risk factors for jaundice
Day of onset of jaundice	-    Always pathological if <24 hours of life
Antenatal  factors	-    TORCH infections (Toxoplasmosis; Other(Syphilis, Hepatitis B); Rubella; Cytomegalovirus; Herpesviridae) -    Maternal diabetes
Maternal blood group	-    Blood group O and baby group A or B (ABO incompatibility); -    RhD negative for rhesus related haemolytic jaundice
Birth history	-    Prematurity -    Traumatic delivery: cephalohematoma, bruising
Neonatal feeding	-    Exclusive breastfeeding -    Dehydration
Family history	-    Siblings with neonatal jaundice -    Gastrointestinal disorders -    Haemolysis
Stool and urine colour	-    Acholic stool and dark urine are concerning features of conjugated jaundice

RACGP - Prolonged hyperbilirubinaemia in a neonate

SPEAKERS

Dr Elissa Hatherly, Dr Gopakumar Hariharan

 

Dr Elissa Hatherly  00:02

Welcome to the roundup a North Queensland based medical podcast offering local content for local clinicians. I'm your host Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the land on which we practice. Hi, and welcome to our podcast today with Dr. Gopan Hariharan. He's one of the neonatologist's at Mackay Base Hospital. We wanted to talk about neonatal jaundice today one of the most common conditions that requires medical attention in newborn babies, super common in general practice and we need to be confident managing these babies. Gopans also a senior lecturer with me at James Cook University here in Mackay. Welcome Gopan.

 

Dr Gopakumar Hariharan  01:09

Thank you for having me today.

 

Dr Elissa Hatherly  01:10

Oh, well, thanks for coming along. Let's start off with a really common case that GPs may encounter. I see these babies all the time. We had a little baby who was one week old, a little girl presenting for her routine seven day baby check. Her birth was pretty uneventful at term and uncomplicated vaginal delivery and the antenatal period was pretty unremarkable. Everything during the pregnancy had been fine. She had a normal morphology scan and maternal serology was all negative, there was nothing concerning there and her clinical examination from the paeds department prior to discharge was also normal. From memory, she was about 3.6 kilos when she was born, so that makes her a nice big baby. But on examination at day seven, she was quite jaundiced. She was otherwise fine, but the jaundice was quite remarkable. So I wanted to ask you today Gopan, just how common is jaundice?

 

Dr Gopakumar Hariharan  02:09

So approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life. So it's very common for babies to have jaundice. The question is, whether that requires treatment or not. Around 3% to 9% of total neonatal population, may need phototherapy as a treatment. There are a couple of reasons why babies are predisposed to jaundice. Firstly, the neonates have a larger red cell mass and a shorter lifespan. And we know that the bilirubin is a breakdown product of haem, and with a larger red cell mass, and a shorter red cell lifespan, a greater release of bilirubin occurs into the circulation. Therefore, predisposing to hyperbilirubinemia. Neonates also tend to have an immature liver function, and that can lead to slower metabolism of bilirubin. Another factor is delayed passage of meconium. Thereby there is increased reabsorption of bilirubin from the intestines. So these are the reasons why jaundice is relatively common in babies.

 

Dr Elissa Hatherly  03:30

Right that meconium isn't a factor I often think about So are there any groups of babies who are at higher risk of jaundice?

 

Dr Gopakumar Hariharan  03:38

Apart from the babies being predisposed to jaundice by their nature itself, there are some maternal and neonatal risk factors that predispose some babies for exaggerated jaundice. The maternal risk factors would include blood group incompatibility related to ABO or rhesus blood types. There are occasions when we come across minor red cell antibodies in a mother and that can also result in exaggerated jaundice but they would be predominantly pathologic jaundice which appear generally within first 24 hours of life. Babies born to families from particular ethnicity, for example, East Asian or Mediterranean tend to have a greater degree of jaundice. In a family if there is a previous jaundiced baby who required phototherapy, then the subsequent siblings are at higher risk. And it's very important to note this when taking a history, maternal gestational diabetes is a very important risk factor and that is attributed to the polycythemia that these babies have. A larger degree of red cell mass can result in a greater release of bilirubin into the circulation, thereby predisposing to hyperbilirubinemia. From a neonatal perspective, feeding is probably the most common condition that we see. Breast feeding itself puts babies at risk of increased jaundice and we refer to them as breast milk jaundice. Reduced intake can predispose babies to jaundice because of dehydration and increased enterohepatic circulation. If the baby have hematoma or bruising, probably from birth trauma, these sites can release bilirubin resulting in exaggerated jaundice. As you already mentioned, the polycythemia in an infant of diabetic mother is a significant risk factor. Then there are factors causing haemolysis example this expediate efficiency. Again that can lead on to the pathologic jaundice. They could present in first 24 hours of life, or they could present with prolonged jaundice. Bowel obstruction, infection, and prematurity are all other risk factors for jaundice. So it's an exhaustive list of causes and predisposing factors. It is important to recognize that late preterm babies are at particularly elevated risk of jaundice, and we have several admissions to the paediatric ward. The late preterm babies are found to have difficulties with feeding and related dehydration can cause them to have severe jaundice and getting re admitted. So it is important that we shouldn't be reassured that these babies are born closer to term. They are at risk. And it's important to remember that these babies are at risk of high jaundice levels.

 

Dr Elissa Hatherly  04:03

Right. And of course, those late preterm babies that would be at around 36, 37 weeks gestation when they're born. Is that right Gopan?

 

Dr Gopakumar Hariharan  07:17

Yeah, absolutely. So 35 to 37 weeks those will be the late preterm babies,

 

Dr Elissa Hatherly  07:24

okay. So, when would jaundice be considered pathological then from your point of view?

 

Dr Gopakumar Hariharan  07:30

the jaundice is considered pathological if it's onset is less than 24 hours. And as I already mentioned, conditions which can cause hemolysis, such as ABO or rhesus incompatibility can result in pathologic jaundice. Pathologic jaundice can also occur if it persists more than two weeks of life when we refer to them as prolonged jaundice. The other factors which raises possibility of pathologic jaundice include, if the baby is unwell raising the suspicion of sepsis or has an elevated conjugated bilirubin component or has pale colored stools. These require prompt investigation and management.

 

Dr Elissa Hatherly  08:15

Right. So what would those key components of the assessment of that jaundiced neonate be then Gopan?

 

Dr Gopakumar Hariharan  08:22

When we encounter a baby who appears jaundiced the relevant factors that needs to be taken into consideration are the age of onset, if the jaundice has manifested less than 24 hours, or if the jaundice has persisted more than two weeks, then they are considered pathological and needs further evaluation. Antenatal course is important, the presence of maternal antibodies, or intra uterine infections can predispose to babies having jaundice, presence of birth trauma from instrumental delivery, these babies could have cephalohematoma, or significant bruising and these could be sites where bilirubin is released into the circulation. Feeding is very important to look for. Breastfed babies have an increased risk of jaundice and referred to as breast milk jaundice. And if the feeding is inadequate, then it can lead on to dehydration and increased enterohepatic circulation leading on to significant jaundice. It's important to ask parents whether the baby has been passing dark urine that stains nappies or history of pale colored stools and that could suggest significant pathologies like biliary obstruction, which needs urgent attention. Presence of a setting for ABO rhesus or any other hemolytic condition also needs prompt attention. If the baby is unwell or febrile child then that could suggest a septic child, septic baby and needs further evaluation along those lines and urgent treatment.

 

Dr Elissa Hatherly  10:17

Yeah, okay. So we've assessed the baby now and so, as part of the examination, what particular things will we be looking at in the jaundiced neonate then Gopan?

 

Dr Gopakumar Hariharan  10:29

The key components important in evaluating a baby with jaundice would include a general examination, a general examination, looking at general tone and neurological examination. The idea is to detect whether the jaundice is highly elevated resulting in complications like kernicterus. So, that will be very important and if the baby has a shrill cry or abnormal tone, then that needs immediate attention and treatment. Hydration status will be very important, looking at capillary refill time, and also looking at mucous membranes. And that will give us an idea whether the breast milk is sufficient in the first place. Plethora from polycytemia would be an indicator that the baby has allowed the red cell mass, releasing greater bilirubin into the circulation. Looking for bruising and cephalohematoma would be important and hepatosplenomegaly in the abdominal examination would allow us to think differential diagnosis pertaining to primary liver conditions.

 

Dr Elissa Hatherly  11:43

Sure, so what's been the initial approach when we're investigating the baby with jaundice?

 

Dr Gopakumar Hariharan  11:50

Any baby who visibly looks jaundiced needs a serum bilirubin done. And what we're looking for is both the unconjugated fraction and the conjugated fraction of bilirubin. If there is high bilirubin, or once we once we get the serum bilirubin done, it's important to plot it on the gestation based specific nomogram that's freely available from the Queensland or statewide guidelines. And this is to determine whether a baby crosses the threshold for treatment with phototherapy or exchange transfusion. If the condition warrants, then further testing, like full blown examination and Coombs test, would be necessary if there is a suspicion of hemolysis.

 

Dr Elissa Hatherly  12:46

Right so, of course, it's really the GP then who's most likely to come across these babies between 24 hours of life and 14 days of life when they're most likely to get jaundice, what would be the most common causes, and then the relevant investigations needed for this group of normal jaundice in the neonates?

 

Dr Gopakumar Hariharan  13:08

Jaundice that occurs between 24 hours and 14 days of life is probably the most common presentation to the general practitioners, as you rightly say, because if it was pathologic jaundice, generally it gets managed within the hospital itself within the first 24 hours. The common differential diagnosis considered will include physiologic jaundice, which is the most common, breastfeeding jaundice, sepsis, hemolysis, breast milk jaundice or bruising from birth trauma. So the investigations will be targeted to rule out these possibilities. For example, if dehydration is a possibility from breastfeeding jaundice, then a serum sodium would be very important, because it will be quite elevated in case of dehydration. A blood sugar would be useful in order to detect hypoglycemia if the feeding has been grossly inadequate. CRP blood culture, urine culture, lumbar puncture as per sepsis protocol may be necessary for a baby who looks unwell and the suspicion is sepsis. In case of probable hemolysis then a full blood examination blood film, reticulocytes, neonatal blood group and typing, direct Coombs test would be important. A G6PD screen may be undertaken in certain high risk group for example, those coming from Asian ethnicity and further workup for hemolysis may be necessary depending on the clinical situation. If we are confident that it is physiological jaundice, then no further testing is necessary. No testing is necessary if we are confident that it is breast milk jaundice, or jaundice secondary to bruising.

 

Dr Elissa Hatherly  15:07

Good. Okay, so then for those babies in whom we think it is simply that physiological jaundice that you mentioned, what's the treatment then?

 

Dr Gopakumar Hariharan  15:18

The initial step in the treatment of hyperbilirubinemia is to establish that we are dealing with an unconjugated hyperbilirubinemia or are we dealing with a conjugated hyperbilirubinemia. In order to determine this, it's important to look at the conjugated fraction of the bilirubin and that should be less than 20 micromoles per liter, and the conjugated fraction is less than 20% of the total bilirubin. As I already mentioned, once we get the serum bilirubin, it is plotted into the bilirubin chart available from the statewide jaundice guidelines and if the baby's bilirubin level is above a threshold for phototherapy, then baby may require admission for that. It's also important to treat underlying condition if we can find anything. For example, if the baby is breastfeeding, and has lost weight, dehydration is a possibility and that might be contributing to exaggerated jaundice. In these situations, we generally involve maternal and child health lactation consultant, and sometimes speech pathologist to help mother with breastfeeding. Speech pathologist is particularly useful in late preterm babies where sucking and swallowing may not be entirely mature. And it's useful for speech pathologists to get involved in these cases. So also, if there is a consideration of significant tongue tie affecting breastfeeding, in these situations we also sometimes suggest formula feeds while the mother is having breastfeeding supported. That's that's not uncommon that sometimes we do recommend formula feeding if the mother is struggling with breastfeeding. If sepsis is a possibility, then we follow the statewide sepsis guidelines, investigate accordingly and treat with antibiotics. If hemolysis is a possible, possible underlying cause, then we get full blood examination G6PD, Coombs test, reticulocyte count, osmotic fragility, if hereditary spherocytosis is a possible possibility. And in some cases, we do seek hematology opinion in managing these babies. We also review maternal blood group for ABO and rhesus incompatibility. Probably that's the most common thing that we look in the first instance as I already mentioned, breast milk itself can cause significant jaundice, and that is due to factors which are transferred across breast milk, and which can inhibit the metabolism of bilirubin by the liver. It can also lead on to break down of conjugated bilirubin in the intestine and handle releasing excess and conjugated bilirubin into the circulation. These babies are generally well looking with adequate weight gain. If we find that the conjugated fraction is high, alongside having pale stools and dark urine that stains nappies then biliary atresia should be considered and urgent gastroenterology opinion should be sought.

 

Dr Elissa Hatherly  18:55

Right? Gopan can I just ask you to go back to the breastfeeding jaundice? If you could just clarify for me please the difference between the breastfeeding jaundice and the breast milk jaundice. What's the difference?

 

Dr Gopakumar Hariharan  19:11

So breastfeeding jaundice generally occurs in the first week of life when breastfeeding is just being established. Inadequate feeding can result in dehydration and increased reabsorption of bilirubin from the intestines resulting in hyperbilirubinemia. Inadequate intake sometimes also result in delay in passage of meconium which contains large quantities of bilirubin that is then reabsorbed into the infants circulation. Treatment is through supporting breastfeeding by involving lactation consultants, and child health nurse as needed. And at times, as I already mentioned, sometimes we do suggest formula feeding if the parents wish while breastfeeding is being established. This is a temporary measure. We are advocates for breastfeeding, but this is just to tide over that that phase when breastfeeding is being established. Some babies could have tongue tie which needs assessment by speech pathologist and lactation consultant and we facilitate that in the hospital. In addition to our clinical review, breast milk jaundice on the other hand, generally occurs in the second or later weeks of life and continues for several weeks. It's postulated that factors such as beta glucuronidase in breast milk, increases the breakdown of conjugated bilirubin in the intestines to unconjugated bilirubin. There are other factors such as lack of protein lipase and non esterified fatty acids in breast milk, which inhibit normal bilirubin metabolism. And these can predispose to breast milk jaundice. The only way to establish the diagnosis is by temporary cessation of breastfeeding for 12 to 48 hours. And if we can establish that there is a dramatic decrease in serum bilirubin with stopping breastfeeding, then the breast milk jaundice can be diagnosed. It is also important to remember that we have to investigate thoroughly and make sure that we are not missing any substantial diagnosis before coming to the diagnosis of breast milk jaundice. And these babies continue to be a bit jaundiced to around six weeks and and that is acceptable.

 

Dr Elissa Hatherly  21:49

Okay, so there's a lot of information here Gopan, I might just try and summarize that if I can. Our approach to jaundice between 24 hours of life and two weeks of life starts with that detailed history and clinical examination, particularly checking for the dark urine and pale stools of biliary obstruction. And the other things that we're looking at would be checking the total serum bilirubin and looking at the fraction of the conjugated bilirubin, which should be less than 20%. We need to check the maternal blood group for ABO and rhesus type, and any other minor blood group abnormalities that might pop up plus the full blood count, the direct Coombs test, the reticulocytes and the blood film in suspected hemolysis. And then the other things will depend on that clinical picture like the urea and electrolytes and liver function test, other things that might contribute to a high rate of hemolysis like G6PD deficiency and hereditary spherocytosis, there was a sepsis workup as well, looking for congenital infections. So that would be the torch screen, of course, and screening for inborn errors of metabolism, and things like that we will probably leave to the pediatricians as well as the thyroid function test, and other inborn errors of metabolism, like urine reducing substances and things like that. There's a lot to be thinking about Gopan. Are there any groups of babies who we should be particularly monitoring and really keeping under close surveillance when they're first discharged?

 

Dr Gopakumar Hariharan  23:39

There are a subset of babies that we do close surveillance, especially those babies who had pathologic jaundice, for example, from ABO incompatibility or rhesus incompatibility. They are at risk of continuing to have hemolysis and continue to be jaundiced. So they require very close surveillance. The other group would be those who had cephalohematoma. They are at risk of jaundice, and so are some babies who have bruising from the birthing process itself. So in a nutshell, babies who have predisposing factors for exaggerated jaundice, we do a very close surveillance and it's important to have a very close follow up.

 

Dr Elissa Hatherly  24:29

Okay, so the follow up required for babies who have received phototherapy. What should we be looking out for in those babies?

 

Dr Gopakumar Hariharan  24:38

So babies coming off phototherapy should have a repeat bilirubin after 18 to 24 hours to ensure that there is no rebound hyperbilirubinemia. A safe limit for stopping phototherapy is when the serum bilirubin has fallen less than 50 micromoles per liter from the threshold line for further therapy. In order to happen in order for this to happen, the baby necessarily doesn't have to stay in the hospital. Once the babies are discharged from the hospital, we have child health nurses who visit the family and make clinical assessments and decide on further testing. Those from private facilities may have their own processes. And in many of these cases, we find that the general practitioner will be very closely involved in following up these babies. At the time of discharge, we give a detailed verbal and written information on neonatal jaundice so that they are aware of what to look for. The statewide neonatal jaundice guideline is a great resource to refer while managing these cases.

 

Dr Elissa Hatherly  25:50

Yes, of course. So, what's the risk Gopan if babies are not identified promptly, who in fact need treatment?

 

Dr Gopakumar Hariharan  25:59

babies with the exceedingly high unconjugated bilirubin heart rate or increased risk of kernicterus and the kernicterus is a condition where excess unconjugated fraction of bilirubin crosses the blood brain barrier and get deposited in various areas of the brain, especially the basal ganglia. In significant cases, this could result in dystonic cerebral palsy and other morbidities could be hearing deficits and neurodevelopmental delays. And that is the risk posed by significant jaundice and if there is delay in treatment, and that risk is caused by any of the pathologic causes that can result in jaundice, for example, ABO incompatibility. A rapid rise in bilirubin example, more than 8.5 micromoles per liter per hour also puts a baby at particular risk. So it's it's not only the absolute bilirubin value, it's also the rate of rise, which is important to look at in case of evaluating a baby with jaundice.

 

Dr Elissa Hatherly  27:12

Okay, so now Gopan, let's go back to the baby that I was talking about at the beginning of this chat. You know, this baby too. When we looked at this baby born at term who was jaundiced at one week of age, when I examined her she was clinically well, but we sent her off to have her serum bilirubin check. And when you looked at it, and I suppose you would have plotted it on the age specific bilirubin chart, you found that the level was high enough for the baby to warrant phototherapy. What happened next?

 

Dr Gopakumar Hariharan  27:48

this baby got admitted to the pediatric ward because as you just mentioned, the the levels were quite high, above the threshold for phototherapy. We also noted that baby has had lost more than 10% of birth weight. And at that point in time, we did a serum sodium which was 148, which was elevated and that suggested dehydration. So in addition to the phototherapy, we involved the lactation consultant in the hospital to help the mother with breastfeeding. And the parents were open to trial some formula feeds at that point in time while the mother was establishing breastfeeding. We talked about other possibilities as well. At that point in time, there was no setting for hemolysis as mother's blood group was A positive and baby didn't have any particular features of sepsis. Baby was active otherwise, therefore no further blood tests were needed. With adequate feeding established, the bilirubin steadily dropped to safe limits, and we discharged the baby from the hospital after 72 hours. We ensured that the baby and the family was linked with a child health service in the community and a repeat bilirubin, which was done in 24 hours after discharge was in safe limit and baby had demonstrated good weight gain.

 

Dr Elissa Hatherly  29:21

That's a really reassuring end to the story, isn't it Gopan. So yeah, what would be your key take home messages from this story on neonatal jaundice?

 

Dr Gopakumar Hariharan  29:33

So the key points would be to ensure taking a thorough history, performing a physical examination to rule out any significant underlying pathologies and relevant investigations as necessary to treat a jaundiced neonate. It's important to pay particular attention to late preterm babies because of the risks that I already mentioned. It's also important to consider a wide range of differential diagnosis in babies presenting with jaundice even though physiologic jaundice is the most common cause. Pediatric referral is indicated for cases of early jaundice, that's jaundice appearing within 24 hours of life, conjugated hyperbilirubinemia, babies with pale colored stools, prolonged jaundice, or any other additional concerns.

 

Dr Elissa Hatherly  30:30

Oh look thank you so much for your time Gopan, we really appreciate you sitting down to talk through neonatal jaundice. I think next time we'll have to talk about prolonged hyperbilirubinemia where it's a little bit different, but thank you so much for your time. Thank you. For more information about the round up or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Since the COVID-19 pandemic there were concerns that asthma patients could be at increased risk for SARS-CoV-2 infection and disease severity, it appears that asthma is not an independent risk factor for both. Asthma is not over-represented in hospitalised patients with severe pneumonia due to SARS-CoV-2 infection and there has been no increased risk of asthma exacerbations triggered by SARS-CoV-2 in that setting.  

There is accumulating evidence that asthma phenotypes are important factors in evaluating the risk for SARS-CoV-2 infection and disease severity, as findings suggest that Th2-high inflammation may reduce the risk of SARS-Cov-2 infection and disease severity in contrast to increased risk in patients with Th2-low asthma.

Regarding asthma medications, the use of ICS, despite early concern about immunosuppression, is safe. Furthermore, ICS do not increase infectivity or disease severity. In contrast, chronic or recurrent use of SCS before SARS-CoV-2 infection is a major risk factor for poor outcomes and worst survival. Biological therapy for severe allergic and eosinophilic asthma does not increase the risk of being infected with SARS-CoV-2 or having worse COVID-19 severity. These data emphasise the need for optimised management of asthma patients in order to achieve asthma control and avoid whenever possible the need for chronic or recurrent use of SCS. However, further studies are needed to answer still unresolved questions such as the relation between different asthma phenotypes and SARS-CoV-2 infection.

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Branco ACCC, Sato MN, Alberca RW. The possible dual role of the ACE2 receptor in asthma and coronavirus (SARS-CoV2) infection. Front Cell Infect Microbiol 2020; 10: 550571

Zhu Z, Hasegawa K, Ma B, et al. Association of asthma and its genetic predisposition with the risk of severe COVID-19. J Allergy Clin Immunol 2020; 146: 327–329.e4

Yamaya M, Nishimura H, Deng X. Inhibitory effects of glycopyrronium, formoterol, and budesonide on coronavirus HCoV-229E replication and cytokine production by primary cultures of human nasal and tracheal epithelial cells. Respir Investig 2020; 58: 155–168

Yu LM, Bafadhel M, Dorward J, et al. Inhaled budesonide for COVID-19 in people at high risk of complications in the community in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. Lancet 2021; 398: 843–855

RECOVERY Collaborative Group, Horby P, Lim WS, et al. Dexamethasone in hospitalized patients with COVID-19. N Engl J Med. 2021; 384: 693–704

SPEAKERS

Dr Elissa Hatherly, Dr Pranav Kumar

 

Dr Elissa Hatherly  00:02

Welcome to the roundup, a North Queensland based medical podcast offering local content for local clinicians. I'm your host, Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the land on which we practice. Welcome to today's episode where I'm joined by Dr. Pranav Kumar, one of our respiratory physicians at the base hospital. Pranav has qualifications in respiratory medicine from not only Australia, but India, America and the UK. Thank you so much for joining us today.

 

Dr Pranav Kumar  01:00

Thanks, Dr. Hatherly. It's really nice. I'm really excited to sort of come to join this podcast.

 

Dr Elissa Hatherly  01:07

We wanted to talk a bit about asthma today and I suppose it's a particularly important topic in light of COVID. How big a problem has asthma been in the COVID era?.

 

Dr Pranav Kumar  01:19

 So, basically, we see that as is never been sort of a lesser problem. Prior to the COVID era, if you see, really, if we estimate the percentage of cases throughout Australia, so nearly 10% of the population which sort of diagnosed or sort of latent or cough variant the asthma is present, it is one of the top 10 diagnoses presenting to our emergency department. And overall, if we compare the whole degree of severe asthma in the post COVID era, it normally consumed about three to 5% of the total cases of asthma. So if you look at the whole, this whole data is Lex there got quite a mammoth problem at this moment. And what actually, we see is with the COVID-19, although there was a misconception that normally, as after COVID, we get more cases of asthma or exacerbation. It is partly true and partly untrue, which I'm going to explain you in a later discussion of the time. What I really want to put in here is it has intensified the stigma we had around the asthma cough. And we see that there was a very interesting survey which said that nearly 43% of Australians who  saw someone coughing and they, they, they thought it to be contagious, though they are, you know, just a mild cough, small cough-variant asthma. So overall, if you look at the whole data, I think the problem has gone and there has been more unmasking of the silent or cough-variant asthma to sort of become very persistent and see their form of asthma post COVID era.

 

Dr Elissa Hatherly  03:31

Right. So COVID is helping to unmask those patients who have silent asthma. Getting that reactive airways as a response to that inflammatory process. And yeah, that stigma around cough is really prevalent in our community. We've certainly noticed that in general practice, but three to 5% of the community is a big number. With asthma, then what increases the risk with COVID-19 in our patients, what are the sorts of things we need to be mindful of?

 

Dr Pranav Kumar  04:06

Well, you know, that doctor Hatherly we had this notion that was you know, the major drivers for all our, you know, asthma exacerbations, are the respiratory viruses and that holds true for time immemorial like every asthma exacerbation, if you look at the most of the data as we see nearly 80% or more of the cases from the all the respiratory viruses. And since after the COVID it was thought that look, this is one of the Coronavirus is going to be no different and then we're going to more and more number of increased severity or increased number of cases or exacerbations through the years. What normally we have seen that you know how the COVID they viruses they basically uses more angiotensin converting enzyme 2 expression. And that has also been contributed that, that they will be more severity of infection, there will be more infectivity, as is one of the viruses. But all the epidemiological data or studies, which we have so far has said that the incidence of these cases are pretty low, that there is no asthma doesn't sort of, you know, in these people cases hasn't gone up. And it has shown that the incidence of COVID 19, in people with asthma was pretty low. And the current evidence also supports that the notion that asthma does not increase the risk of COVID 19 was also true. But it all saying this, you know, the other aspect of it was severe COVID, which, which normally, we seen the people who had asthma, and has got an old age, or they had different comorbidities in form of cardiovascular disease, or diabetes, or obesity, they are the ones who are the most sufferers. And I also think that the there are two, or the two data, which I like to sort of mention here is one from the Belgian asthma registry or Sani which has got, they did a severe asthma network in Italy. They, they they said that and they found out through their you know, course of the disease, that severe asthma is not an independent risk factor for COVID-19. So, if you look at the whole picture, I think, what we thought initially, that, you know, we are going to have more and more, because it's one of the respiratory viruses, and then we're going to get more ACE2 inhibitor expression and increased infection and increased severity, which wasn't the case, but only the people who had severe COVID and asthma were the people who belong to the old age group or the people who had comorbidities in the form of obesity, cardiovascular and diabetes, who were the worst sufferers.

 

Dr Elissa Hatherly  07:32

Yeah, certainly, we learnt a lot in that first twelve months about COVID and respiratory disease. So with some asthma, I wonder if you could take us through some of the different phenotypes and relate that to disease severity, then please.

 

Dr Pranav Kumar  07:48

Yeah, that's a very interesting question and Dr. Hatherly, I recently had the European respiratory Congress, where they had a long debate about these phenotypes and the treatment part and that was really interesting. And they know the what we know till date is we got type two or Th2. So, there are two types Th2 high or Th2 low these are the two phenotypes, which normally we use and the difference between them is Th2 high is mostly the 50% of the formal asthma diagnostic diagnosis patients will have it and type two, before I sort of go further, I just say that they have this interleukin manifestation like IL4, IL5, 13 eosinophils pheno epithelioid barrier dysfunction, all these can cause a protective effect on the size of COVID-19 infectivity and severity Yes. So, this was very interesting that despite of the you know, there is expression of these they have poor risk, protective effect. And mostly if you see there was also some studies which has shown if you've got more eosinophils, they are more protective for this COVID 19 infection and severity, in comparison with Th2 type or more they will call Th2 low they have more neutrophilic infiltration and they are more mostly pauci-granulocytic inflammation where this is mostly non allergic type and they had common association with people who had obesity related or smoking related or other comorbidities related in there. The you know, as we know there was more severity there was more infectivity and much more mortality. Compared to IL 4, 5 they have if you see the biomarker, there were IL6 which was predominant. And as is noted in one of the studies, these obese people will have increased leptins, and the increased leptin will cause more Th1 pathway, and they will cause more severity and more infectivity.

 

Dr Elissa Hatherly  10:24

Right. So the higher the eosinophils, the more protective toward COVID. That's fantastic. And of course, would include a lot of our patients that we have here in our region. In terms of asthma medications, then do we need to be tailoring those a little bit more to those different phenotypes to better address that risk of COVID-19 and the disease severity?

 

Dr Pranav Kumar  10:51

That's a really interesting question. And that's really sort of generating a lot of interest in I think there will be a lot of a lot of studies has still to be carried out. But when we talk about the predominant as we know that inhaled corticosteroid (ICS) is one of the which, which is mainly used for the prevention and our protection as a as a preventer in asthma medication. If we think ICS per se, it says that it confirms some of the protections against the COVID. So there was initial when we had COVID, when we started to have COVID. And there was concerns that using people on a high dose corticosteroid or inhaled corticosteroid will give them instead of more mortality and more chances of severity of infection didn't come through on this study, we say that they causes a decreased expression of ACE2 although you know the where these, these viruses are binding. So they will be less a less than of their, you know, binding and less severity of infection. They also had some sort of biochemically protein seronase in the lung, they were also reduced and they helped in overall modify the risk or confers a kind of protection against the COVID. As we also know, Dr. Hatherly that all these ICS causes decrease inflammation. That's the main main job and, and in some studies, if you see there's very interesting that some of the anti inhaled corticosteroid in form of ciclesonide or Mometasone, they, they sort of suppress this virus per se as well. So there's still study going on. So but that was very interesting finding that some of these inhaled corticosteroid also suppress the SAR school or COVID-19 infections. And as you know, in our at the moment, when we're treating we're treating a lot of people with, with the when we say some sort of severity of the COVID, we do use, inhale budesonide drugs, which is a very common to give them like at least, you know, 12- to 16-hundred micrograms of budesonide. And that was based on a trial, which was the principal trial, and we say that the more inhale Budesonide you use, and they will decrease the symptom burden, and also helps us in the time of recovery, and also reducing the total hospital admission. So that was a really, really, very good trial. And that has prompted us to help us to sort of designed this, putting this budesonide as a routine kind of management for this COVID, which is not that severe, to decrease their symptom burden, as well as recover and reducing in the hospital admissions.

 

Dr Elissa Hatherly  14:13

Right. So those ACE inhibitors have that anti inflammatory effect as do the inhaled corticosteroids, which we've known for many, many years. Now. That's, that's interesting.

 

Dr Pranav Kumar  14:24

Yeah. There's another one, which was really sort of, we always thought that if you use systemic steroid in this group of patients, like if you use, they will have more severity of the disease, isn't it that will cause more while to sort of replicate. And there was a recent recovery trial, which did say that, if you've used the dexamethasone of like nearly six milligram per day, for nearly 10 days in those group of patients, it was found that 28 day mortality was very less, and also the rate of the decrease like rate of intubation in those group of patients. So that was really interesting finding and sort of still sort of worked out for all the severity cases in the what we get in the ICU.

 

Dr Elissa Hatherly  15:20

Yes, certainly important information for you to have before the COVID patients started to appear in our part of the world. Dr. Kumar can we ask about the biologics then too, so we know the ACE inhibitors, the inhaled steroids and the oral steroids are really effective. What about some of those newer biologics that we've been prescribing in the last few years?

 

Dr Pranav Kumar  15:41

Yeah, and that's very, very, I mean I'm really particularly very interested in like, biologics. Since we have biologics, it is really sort of I have patients here who, on a lot of them, like at least I know, five of them, who are my patients and on non-biologics, they most of the time, they presented to the hospital, got intubated and went to the ICU. And since they've been on biologics, they've been doing pretty well and sort of out of the hospital for most of the time. So that really sort of made me very interested. And I post COVID I've seen that we did have sort of a lot number of cases which has come up with increased severity and there was a sort of they being labeled as a long COVID. But in fact, they were the COVID, they were the asthma with a sort of gone into a severe kind of asthma which was not responding to any treatment. And in a couple of them, I recently put them on biologics, and they they are recovered on their, on the pathway of them. And so, if you see the types of biologics, we have, like anti-IGE, IL5 and IL5  receptor antagonist, we are mainly using here anti IL5 and anti IL5 receptor. And they normally they do is they blocked the type two, inflammation and confers a degree of protection against COVID as well, only thing, which was sort of contradictory that in one stage, we know that eosinophils are protective. These drugs basically they got, they have concerns of decreasing the tissue and the blood eosinophils. So, we thought that we will get more disease severity or increased severity in these cases. And there was a study which all eyes I think have done this in our talk earlier, that eosinophils are kind of more than 150 they normally give you a decrease mortality. But you said this was a contradictory finding at one at one stage, we were saying that if you've got a more eosinophils they are protective to overall confirms that I have you know less risk from the COVID. At the same time that we are using biologics, we say that they are providing a protection, though they are decreasing your eosinophil counts to a very significant level or even to the normal and there has been clinically evidence with so that this use of biologics are pretty safe. It is it has found that during the course of the follow up that they are not associated with increased severity or mortality. So, so since when this study has come up, I think we have instead of as soon as the patients are diagnosed and they are being they're being put on the biologics without any much of you know, risk of that, you know, you're using biologics in this group of patients. We don't we previously thought it to be very, very cautious and nowadays these study coming up, even though they have found out that they treat the severity cases and more morbidity and mortality are less though, it is quite safe to use the biologics

 

Dr Elissa Hatherly  19:17

Right. So particularly as you said, for some of those patients who might be experiencing what we thought was a long COVID symptom like persistent breathlessness. You think sometimes it can be undertreated breathlessness and the patient's need to be more fully worked up and more comprehensively treated then.

 

Dr Pranav Kumar  19:39

Yeah, and that's that's very important point as you said, in the post COVID They will have more like an array of symptoms in the form of shortness of breath, to chest pain to palpitation, and all so many kinds of symptoms. And most of the time if the people had COVID, and it persisted for nearly four weeks or more, we just term it as a long COVID. But if we sort of sticks seriously, because you know, if you see this group of patients, in some of them, if you do a lung function, if they got a very serious sort of airflow limitation in people who got a persistent sort of shadowing versus a perioheral area of consolidation, like organizing kind of pneumonia on the CT scan, they need to be treated, rather than labelling. So it's basically if the symptoms persist, there is nothing harm in doing some tests to confirm that we are not dealing with something which has been unmasked by the COVID, or is still the COVID long effect, because in there was recently a case with us, who has been labeled as a long COVID has a lung fibrosis that that chap, I think he left, he was in Indonesia. And then he when he came in and half of the lung was fibrosed, so he's finally getting lung transplant done. But it was initially labeled as a long as long COVID. So that does a few of the things which really sort of makes you wonder that you know, that of course, the long COVID will present with lots of issues and lots of somatic problems and health problems. But doing some investigation, before we label them will be a perfect way to deal with deal with this situation.

 

Dr Elissa Hatherly  21:41

Right. Okay, so for patients with persistent symptoms after COVID or worsening symptoms, it might be long COVID. But we need to be carefully ruling out other comorbidities like lung fibrosis, as you said, Is there anything else we should be looking for? Do you think?

 

Dr Pranav Kumar  21:59

I think it's, you know, if the patient has got, like, you know, the long COVID will have a array of symptoms. For the lung point of view, I would say that doing the chest X ray and doing a CT scan or lung function test, wont harm us, but actually help us to rule out the other causes which can sort of mimic and as a long COVID.

 

Dr Elissa Hatherly  22:27

Right, look Dr. Kumar, thank you so much for your time and your expertise today talking about asthma and the post COVID world I had no idea it was so incredibly prevalent, as you said, usually in the top 10 of our Emergency Department presentations and with severe asthma. Of course, in primary practice we can we can cope with that a little bit more enthusiastically, I suppose by making sure those patients are having their inhaled corticosteroids at maximum dose. And as you said, just ruling out other conditions with a chest X ray, a lung function test and maybe even a CT chest. Dr. Kumar, thank you so much for your time. We really appreciate it.

 

Dr Pranav Kumar  23:11

Thank you so much. I really do indeed a pleasure for me. Thank you so much.

 

Dr Elissa Hatherly  23:18

For more information about the Roundup, or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Trauma, PTSD and burnout in our patients and ourselves podcast resources

Australian PTSD Guidelines - Phoenix Australia

Phoenix Australia is a not-for-profit public company, affiliated with the Department of Psychiatry at the University of Melbourne. As well as having Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder and Complex PTSD it also has a lot of easy to read psychoeducation material for people who have ben traumatised. The only negative, in my opinion, is they take an overly narrow view of the definition of trauma (limiting it to the DSM V definition)

A Practical Guide for the Provision of Behavioral Health Services - Trauma-Informed Care in Behavioral Health Services - NCBI Bookshelf (nih.gov)

Free and excellent online book on all aspects of trauma informed care. It takes a broader view of trauma than Phoenix and includes a lot of practical guidance on how you go about asking trauma related questions.

Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) - PTSD: National Center for PTSD (va.gov)

5 question screen for PTSD

Life events checklist – self report

Self report trauma screening checklists have been shown to have higher rates or true positive responses than clinician interviews.

Life events checklist clinician interview

This interview adds some important questions about the quality of parental/carer relationships in childhood. Not only does this allow access to the potential trauma of emotional abuse or neglect but it also adds important information about the increased vulnerability people can have before an adult trauma occurs which is likely to have some prognostic value when thinking about the potential and times scales of recovery from later life trauma.

Dissociative experiences scale

Although it is unlikely that most GP’s or none mental health specialists would administer this scale it none the less gives a very helpful overview of the many different ways in which dissociation can impact people.

Dissociation FAQs - ISSTD (isst-d.org)

This web page has more detailed information about the different ways dissociation can impact someone.

Recovery orientated language guide

This is a guide produced by the Mental Health Coordinating Council and although at first glace it could be seen as overly PC its actually a really helpful resource to reflect on. People who are traumatised can be extremely sensitive to have they perceive they are being treated so a thoughtless use of words could be mean the difference between someone engaging enough to enter into treatment or not.

Blue Knot Foundation

BNF are the National Centre of Excellence for Complex Trauma. Their website includes resources and support materials for people who have experiences of complex trauma, and those who support them, personally and professionally. They have a support line and a referral service than can link people with therapists specially trained in providing trauma informed therapy.

Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults - American Journal of Preventive Medicine (ajpmonline.org)

A good summary of the data from the seminal study of the impact of childhood adverse experiences on adult physical and mental health outcomes.

Grounding Techniques: Exercises for Anxiety, PTSD, & More (healthline.com)

This provides straight forward instructions on how people can engage in a number of different grounding exercises.

The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk | Goodreads

This a fantastic book the details our understanding of how trauma impact our neurobiology and physiology in general and clearly links these impacts to how we see trauma affecting patients in theire day to day lives.

 

Elissa Hatherly  00:02

Welcome to the Roundup, a North Queensland based medical podcast offering local content for local clinicians. I'm your host, Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the lands on which we practice. In today's episode, we're talking about PTSD and trauma with local psychiatrist Dr. Paul Henderson. Paul, thanks for meeting with us today.

 

Paul Henderson  00:50

It's a pleasure. Thanks for inviting me Elissa.

 

Elissa Hatherly  00:53

We understand that trauma is something you're particularly interested in. What do we need to know about trauma in general terms as doctors in the community?

 

Dr Paul Henderson  01:04

I think sort of overarching is the concept of trauma informed care. And I suppose I hope by the end of this discussion, your listeners will have more of a sense of what that is, and how they can improve and enhance that aspect of their own practice. And I suppose most importantly, feel more confident when they are confronted by a person that has had trauma in their own life and also be more confident about how to address trauma in their lives as well.

 

Elissa Hatherly  01:35

So when you talk about trauma, it might be different to what I think of as trauma. What's the traumas that we need to be asking our patients about or more alert to in our practice?

 

Dr Paul Henderson  01:48

I think the most sort of general definition of trauma in my mind is any event that overwhelms a person's coping mechanisms, and has a lasting adverse effect upon them. Because to me, that that encompasses all aspects of trauma. And I suppose importantly, it distinguishes the quite narrow types of trauma that are part of the diagnostic criteria for PTSD. And I think in general, day to day practice, if you just think about the diagnostic criteria for PTSD, you'll actually be overlooking a lot of traumas that people experience. So if we, if we sort of drill down a little bit further in that definition, there's a number of different ways you can categorize trauma. But possibly the most helpful is thinking about type one, trauma type two, trauma and vicarious trauma. The type one trauma is what we would probably all classically recognize as trauma, as distinct individual events, whether that's a car crash, or an injury, or a near death experience. A one off event that is that is in keeping with the diagnostic criteria for PTSD. Type Two trauma is repeated and chronic trauma, it's it can be repeated type one trauma, so they're not entirely distinct. And it's more commonly occurs in younger people, although it can occur in older people. And more commonly, it's much more interpersonal in nature. So something that is done by someone to you and would tend to be of higher rates of psychopathology following it. And then there's vicarious trauma. So witnessing other people's trauma, hearing about other people's trauma, and that's something that is obviously particularly relevant to us as doctors.

 

Elissa Hatherly  03:32

Ok so what are the sorts of things you mentioned with type one, a distinct event might be a car crash? What are the things that might fit into the type two category?

 

Dr Paul Henderson  03:44

So things that would fit into type two are childhood sexual abuse, domestic violence, war, genocide, you know, anything that refugees, asylum seekers often go through people in domestic violence, violent relationships, severe and chronic racism would also fit into type two traumas. So anything that is ongoing and traumatic, and as I say, generally done by one person to another,

 

Elissa Hatherly  04:13

Right. So with trauma being an overwhelming experience impacting or overwhelming a person's coping mechanisms and affecting their function. What are the first steps that we as clinicians should take with patients who we feel have experienced trauma type one or two or vicarious?

 

Dr Paul Henderson  04:35

I suppose the first step is understanding potentially how prevalent it is and understanding that it may not be the first thought in mind that this person has experienced trauma, but nonetheless, there's a high chance that a lot of people that are walking through your doors, whether you're in primary care, or within hospital setting, have experienced trauma, and that may be impacting their presentation with you at that moment in time. So if we think about prevalence, you know, the type one traumas estimates are up to about 50% of people in their life will experience a significant one off incident of trauma. And when it comes to type two traumas, possibly up to about 25%, of which the rates of childhood sexual abuse are, unfortunately, very high, up to one to one, sorry, one or two out of every 10 girls will have experienced childhood sexual abuse of some form or another, and potentially up to one in 20 boys will have experienced it. And that's, as I say, just one type of sort of type two trauma that that is prevalent. So it's, the prevalence rates are very high. And though we were going to go on to talk about PTSD, trauma can present in a multitude of ways. So after a type one event, probably only about 15% of people will continue to have PTSD symptoms after about 12 months after the event. So actually, for most people, the outcome is resilience. Though we're talking about the negative effects of trauma, actually, we should understand that for most people, the outcome is resilience, and they will process it and they will get through it.

 

Elissa Hatherly  06:09

Wow, I had no idea that type one traumas were so prevalent about 50% of our community, that's incredible. Of course, we all know that sexual abuse is much more prevalent than we've ever really understood before. But those statistics are still really frightening.

 

Dr Paul Henderson  06:24

Right. So if we were meeting a patient for the first time, or even someone who we knew quite well, and we suspected trauma might be at the heart of their presenting complaint, is it appropriate for us in general practice, for example, or seeing a patient in the emergency department to flag whether or not trauma might be behind some of their presenting complaint? Or is it better to refer them on to a psychiatrist or a psychologist so that they can explore that potential in a safe space?

 

Dr Paul Henderson  06:24

Yeah, and if we if we think about other aspects of PTSD, maybe 15% of people would develop it, but with with thinking mental health outcomes, depression, anxiety disorders, substance use disorders, psychotic disorders, adjustment disorders, somatization disorders, abnormal grief reactions, and even at times OCD. Those are these are all mental health disorders that can be triggered by a traumatic experience. And as well, also, we need to think about physical health disorders. There's a seminal study called the Adverse Childhood Experiences Study, which was done in the late 90s in the States, and it recruited about 17,000 people in two cohorts. And they looked at 10 different adverse childhood experiences, all the way from parental divorce, to somebody in the household having mental health problems, through to poverty, domestic violence, childhood sexual abuse. And really, when you look across almost all physical health outcomes, cardiovascular disease, cancer, autoimmune disease, the more of those events that you've had in your childhood, the more chance that you have of experiencing that sort of negative physical health outcome in the future. And once you get over four, four events, the rates of all those physical health problems significantly increase. So somebody, somebody doesn't even have to be presenting to you with a mental health problem. If somebody is chronically physically unwell at an early age, it's also just worthwhile having in the back of your mind has this stemmed in some form of childhood trauma,

 

Dr Paul Henderson  08:36

I think it's absolutely appropriate to screen for trauma, in primary care or in ED. Because, you know, in a step care model, there's a number of things that can be done in those settings, before onward, ongoing referral, that can really help a person at the time of presentation. And just simply the question of, you know, and which, depending on how you state the question, but most simply, have you been traumatized in your life that on its own can be massively important because actually much of the time that aspect of a person's care is avoided for for many reasons that we can come on to talk about both within our system but also within the person themselves. And so just indicating that you're interested to understand if somebody has had a traumatic event in their life can actually really open the doors to them wanting to engage and access treatment with you. There are certainly you know, challenges in doing it in primary care or within the ED or within general hospital settings. That you know, the first of which is we are constantly time pressured, and constantly overloaded. And actually when somebody discloses trauma, what you need to do is to be able to give them some time to be able to say whatever it is they need to say about it. But yeah, the way that you can you can, you know, start the conversation is you know, you're telling me this, you know, when whatever this presenting complaint is and a number of people that I've seen that have similar problems have also experienced some trauma in their life. I'm just wondering, you know, have you ever experienced any traumatic events that you think are continuing to, you know, have an impact on you just now.

 

Elissa Hatherly  10:14

Right. So then for patients who self-declare that they have experienced traumatic events, or in whom your suspecting what would be our next steps, once we have started to uncover some of those concerns?

 

Dr Paul Henderson  10:28

Well, I suppose if we start with people who you're suspecting and maybe with that open question, they haven't felt confident enough to say something. But nonetheless, if you still have a sense that the there's something that they're ashamed about that they're a little bit reluctant to talk about, then a different way of going about it and actually, the evidence shows that going about it this way is probably gives more reports more elicits more reports of trauma than just asking questions, is to provide a screening questionnaire to them that they can do on their own. And there's a number of screening questionnaire that's out there. But I've in the show notes, I've included a one called the life experience questionnaire, which is a simple page of A4, I think it covers somewhere between 10 and 50, different types of trauma. And it's something that somebody can go away, and sort of in their own time and dispassionately just tick a box as you go as they go down the list. And the next time that you see them in whatever setting that is, that may then allow you to start exploring it more fully.

 

Elissa Hatherly  11:26

So Paul, if someone discloses trauma to me as a clinician, how do I go about discussing it with them? And what are those next steps?

 

Dr Paul Henderson  11:35

Yeah, I think this is, you know, this is a really important part, because I think this is the part that, understandably, a lot of people, clinicians don't feel confident about. And that's what can lead to, you know, avoidance of asking questions, you know, the fear that they will not be able to handle this discussion in a sensitive way, you know, the fear that they may be may re traumatize the person, which actually, if you just have time to listen, you're non-judgmental, and you're compassionate, the chances of re traumatizing somebody is very small. And it's also not mistaking the fact that yes, people may be getting distressed when talking about their trauma, but that doesn't equate to being re traumatized. And actually, you know, you would often expect people to get distressed by talking about their trauma, but that's fine, as long as you have the confidence to be able to contain that with them, and continue the discussion with them. So I suppose, you know, just in situations where we're unsure, I think it's always good just to go back to basics. So what are the outcomes that you wanted from the discussion? So really, you know, at its most basic, you want to know how the trauma is affecting somebody, it's not important to really know the details of the trauma and anyway, so you know, have confidence that you're not going to be exploring the trauma in a detailed way. And actually, that is something that you probably do want to avoid, to some extent, because doing that, within an unskilled way, can be where, where people get really traumatized. And then also, you know, so understanding how it's affecting the person, and then by the end of the discussion, how can we start the process of maximizing the chance of recovery? So within that, you know, you're, you know, it's about understanding the barriers to the conversations, yeah, the person's own shame, the person's previous negative experience of, of trauma, your own experiences of trauma. So these are sort of things that you may want to reflect on beforehand, when you're thinking just impacting a trauma informed condition, understanding what the person's expectations are for treatment, understanding what can be done in the immediate term, you know, what you can do in that discussion with them that from that point on which you can be helping them. And also, then we'll be talking about what can be done in the longer term from a formal treatment point of view. And so if we're thinking about the structure of the conversation, again, it's back to basics. So it's the presenting complaint. And in that, you know, you're really starting up front by reassuring them that, you know, I don't need you to tell me everything about the trauma that you've been through, what's most important for this discussion is that I understand how the trauma is affecting you. So please feel free to tell me as much or as little as you want about the trauma. So already, that you're starting to overcome a barrier there about the person's fear about what they're going to say. You'd probably also want to be talking about confidentiality, because another barrier is what's going to happen with this information. And that's particularly relevant if somebody is still in a traumatizing situation. So in a domestic violence relationship, you know, if they think you're going to take the information and report it to the police immediately, and that's going to actually mean more trauma for them, then the chances of them talking to you are pretty slim. But you also do need to sort of caveat the confidential discussions, you know, along the lines of well, but, you know, although what we say is confidential, I have to say if you do tell me something that makes me fear that anyone is still significantly at risk it may be that we that I can't keep what you told me confidential and that allows that you know, that's honesty but it also allows the person to couch the conversation in a way that they can still have it. But if there's things that they want to hold back, because of that, and they can, and that's not ideal, but it still allows the conversation to be had in a way that can then lead into further conversations. You may also want to ask, you know, have you told anybody before, because often people will previously have disclosed and had a negative response. So classically, particularly with a childhood, childhood sexual abuse, children will have disclosed, and their disclosure will be minimized, or they'll be told you're lying, or you're imagining things. And you can imagine that, if that's been their experience, the chances of them wanting to explore things, again, is much, much lower. So if you understand they've already had a bad experience, you know, say so what was it that was difficult about that? And then that can understand how, you know, let you understand how you can specifically couch your conversation to try and be the opposite of what their previous negative experience was. And also, you know, if they said, if they say that they haven't told anybody before, you know, thank them, I really appreciate that you put enough trust in me, that you've been able to tell me this today. And I hope that by the end of the discussion, that we can start understanding how we can help you move forward from this. I suppose the one sort of special case within the presenting complaint is children disclosing trauma, because that's something that, you know, essentially has to be reported to child safety. So if we think you're moving on to the history, because then the complaint is, then how is it you know, how is this affecting you? And, you know, just as with any history, you're starting with open questions. So, you know, how do you think what happened is affecting you now? So just nice and open. And then, you know, slightly drilling down into slightly more closed questions: has it made you think differently about yourself?, because a lot of trauma really affects a person's self-worth their sense of their self, that causes them develop to develop a lot of shame. And you can start getting that sense with that open question. Has it affected your, your beliefs about other people has it affected your trust in other people? Now, you know, if it's a natural disaster, or a car crash, or something like that, it's not an interpersonal trauma, probably not. But if it isn't interpersonal trauma, and they're massively distrusting, then you need to understand that that's going to be a significant barrier to doing a lot of self-care things, but also accessing more formalized sort of treatment going forward. Thinking about shame, a lot of people will believe that, that what has happened, has happened because they deserve it to happen. And that is a massively corrosive self-belief. So you know, if you're feeling confident enough in the area, this area, you may actually want to ask that question, do you think you deserve it, because you really want to right from the outset, be countering, and gently challenging those beliefs, you know, there's nothing that you've told me so far, that would suggest that you deserve this. And really, for me, it sounds like this, this, the responsibility lies with the person that did this to you. Because if you believe you deserved it, then you there's also a good chance that you don't, you don't deserve to access treatment, and you don't deserve to feel better. So you know, trying to expose that belief early on, will be quite important as well. And then drilling down into more sort of closed and symptom specific questions. So, you know, are you feeling more anxious since this happened? Is it affecting your mood? Is it affecting your sleep? Are you feeling more irritable? Are you feeling emotionally numb, and people can have this horrible situation in which they go between anxiety and anger and numbness. So they don't feel any positive emotions and the only emotions they do feel are really horrible. And that's, that's not an uncommon in people that have been traumatized. Is it impacting any of the important relationships in your life, particularly if people are feeling emotionally numb, they will also feel quite distant in their relationships. And also, quite importantly, are you avoiding anything? Are you avoiding doing anything because of the way you feel at the moment, because it's important to understand that are there, have they started to avoid all the positive things in life or many of the positive things in life, that could actually be helping them get through this in the short to medium term, then you sort of move on just very briefly into drug and alcohol history, you know, since this has happened, have, you know, you know, there might be drinking has that changed, have you know, the amount of cannabis you're using has that changed? Because, you know, it's a very common coping mechanism to use drugs or alcohol to, to numb the negative emotions you're feeling or numb the shame that you're feeling. And clearly, if that's the case, you're giving yourself a much higher chance of not processing the trauma. So again, that will give you an idea if that's an area that you're going to need to work on when you're thinking about treatment plan. Obviously, with this sort of thing, it's thinking about the immediate treatment, it's important to then move on to think about risk. You know, since this has happened to you, have you ever felt that it's not worth living anymore? Or have you ever felt that you know, you've ever thought about harming yourself? Have you thought about suicide? So because obviously, if that is the case, you may need to be thinking about sort of safety plans in the short term and immediate ongoing referral. If somebody's telling you yeah I really don't know how I can cope with this anymore, then, you know, referral to the acute care team is something that you may have to do there. And then lastly, sort of, you know, once you've sort of concentrated on the more pathological side of things, you know, starting to think about what are the more positive things, what are the things that you can draw on? So what are your social circumstances at the moment? Who's important in your life? Who can you rely on? Who can you connect with? And even if you've withdrawn from the moment who is potentially there that could help you through this? And then we can moving on to think about more specifics, specifically about immediate treating plan, it's really important to ask the person, so how do you want this to go? You know, they may say, yeah actually say, to you actually, I'm just really happy, I've told somebody, and I don't want anything else at the moment, I'm not prepared, I don't feel like I'm in the right place to deal with this in the moment and that's absolutely fine. If trauma is ongoing, or if the symptoms of trauma are ongoing, the person really needs to be in the right place in their own minds to start addressing them. Because if you start addressing them too early, or you try to start sort of forcing somebody to address them too early, they're just going to withdraw and avoid and actually, you're going to get the opposite outcome to what you want. And in that case, you know, for you know, for a general practitioner, it's a sort of holding pattern, you know, you're talking, you're going to be giving them advice that will go on to talk about the generally healthy things in life, and then bring them back and just see how they're going, you know, are you ready to start addressing it or, you know, as we mentioned before, the a lot of people have these traumas, symptoms will naturally start to improve anyway. And so you get an understanding that we don't have to do anything more formal. So once you once you know, what the person's expectations are, you know, all the,you know, thinking about all the generic things you do. So psychoeducation is enormous, you know, explaining, well, you know, because the links between trauma, and all the different ways it can affect us, there not a lot of common, you know, anxiety, obviously sleep to some extent, but a lot of them are not sort of common sense. And so it's going to sit down with the person and say look these are all the common ways that that trauma affects you. But also what's really common that after a matter of weeks, or a matter of months, these will gradually lift if you just do the right things for yourself in life. And you shouldn't, you know, even though it feels absolutely horrific now, you know, for most people, you shouldn't have to worry that it's going to continue feeling like this, you're going to continue feeling like this. And if you do continue feeling like this, then there's a number of things, different things that we can do at that point. But at the moment, these are probably the, you know, the basic things you need to be doing for yourself. And before gets sort of necessarily going on to the generic basic things, you can also, you know, take a strength based approach by asking the person so you've been through this really tough event, you know, it's common for tough events to happen in life, how have you coped with in the past? You know, what have you done that's been really helpful for you in the past? And actually, they may say, well, I haven't been through any hard events. And you can say, well, what do you think, you know, what do you think of what do you think are your strengths? What do you think are the aspects about you, that you might be able to bring into play here that you can help yourself so so that, you know, allows you to obviously talk about the generic stuff, the person said, look, I really love playing my guitar, I haven't picked it up since this happened, you know, you may start encouraging, Well, Julie, you could start doing that again because if that's something that gives you a bit of pleasure, a bit of joy, a bit of meaning, then doing that, again, something like that, that's just a wonderful natural counter to the effects that the trauma is having on you. So when we're thinking about the more generic stuff, you know, as you know, sleep is so important. Maintaining social contact is really important, but often a real challenge for many of the people we see, and often they haven't really had much social contact before the trauma anyway, minimizing avoidance is enormously important. You know, because that becomes a self-compounding situation and your anxiety about going into the situations that you're avoiding, would just keep building and building over time, minimizing your drug and alcohol use, if that's a particular issue, maximizing your nutrition, maximizing your exercise, and, you know, potentially doing something like breathing exercises, that's a lot, and you're not going to throw all that at somebody at once. So, you know, if somebody just isn't sleeping well, you know, maybe concentrating on their sleep, concentrating on trying to maintain social contact, concentrating on minimizing drug and alcohol use, and concentrating on trying to minimize avoidance and, you know, employing any of the strengths that that that a person has already reported to you and sort of sort of bringing them into action. And I suppose, then, that sort of can be where the conversation concludes. So, you know, I've understood how this has impacted you. I've had a discussion with you, to help you understand more fully about how it's impacting you. We understand what strengths that you could be bringing into the situation at the moment, we understand what are the things you probably shouldn't be doing that could make things worse, and we understand things that you ideally you could be doing to help you process and recover more quickly. So I suppose the last thing that comes to mind is what happens in the situation that we fear the most, and somebody just gets really, really emotionally distressed during the discussion. And I suppose for somebody that is traumatized, that probably means they're being in their mind, they've been taken back into the traumatic situation. And they are either sort of having a flashback potentially, or just lots of, you know, the memories which are just flooding through their mind, or they're experiencing all the emotions that that were there at the time of the trauma. And if that's the case, you know, you would you would be explicit about that. You know, I can see you know, the discussion, you know, understandably, is, really upsetting you. So let's stop talking about it now and we can maybe come back to it the next time we meet. But I think at the moment, let's try and just help you feel a little bit less distressed at the moment, and just changing the topic may be enough for somebody else. So if you know somebody reasonably well, and you know, that they have a really positive relationship in their life, so you know, you know, whether that's their husband, their wife, their child, their grandchild, you could just ask them to talk about that person, because naturally that will bring them their mind away from the trauma or, often will. And it will. And because that person is associated with a lot of positive emotion, hopefully, that that will allow the positive emotion associated with them to replace the negative emotion that is associated with the trauma. So I know you have a really good relationship with your grandson Johnny, tell me about, you know, tell me more about what he's up to at the moment. And that can be enough of a change of direction to, you know, to minimize the distress and just take the person out of the mindset that they've got into. If that's not enough, then you can just be a little bit more sort of start to sort of introduce some basic psychological first aid. And so what you can say, there's a number of different ways you can go about it. But you know, if they're breathing very quickly, you could say ok, you know, it looks like you're probably reading a bit too fast and that's making you a bit more anxious so why don't we just sit and do some slow breaths for a minute, and you will do that with them. And the important thing, when with any breathing exercise, is that the out breath is longer than the in breath, because that's how the, that's where the parasympathetic nervous system is stimulated. So you could sit down and go, Okay, we're going to breathe in through our nose for four, take a little pause, and then we're going to breathe out through our nose for six. And you can just do that with them. And you're counting in for four, and counting out for six. And if you do that for a minute, a lot of people will start to be able to calm down or feel less emotionally distressed. And lastly, you know, if somebody is really sort of stuck in a flashback, or the memories, it's about grounding them in the moment, and the breathing can be enough because you can get them to actually concentrate, concentrate on the sensations of the breath, not just slowing the breath, but say to them, okay, well, why don't you feel actually how that breath is when as it goes in and out of your nostrils? Or can you feel your breath in your belly, and that is taking their focus away from the trauma and into the here and now. Or you could say, how about we just do a little bit of grounding exercise, and I've put some grounding exercises on the show notes. And what this is about is just bringing your focus to the here and now. So why don't you tell me five different things that you can see in the room? Because grounding exercises, use any of your senses. So that's obviously a visual one. Or you're sitting in the chair at the moment, why don't you put the hand your hands on the arms of the chair, and just tell me what the arms of the chair feel like. So anything that really activates any of your senses, and classically, actually smell is the best one. But often, we don't have anything that's really strongly smelling about. But if you're if you happen to be sitting with a woman, and you might say, tell me, have you got any perfume in your bag? Do you want to bring it out, and do you want to smell the perfume and tell me what it smells like? Because classically speaking, those, those can be the strongest and most profound, grounding exercises that can really bring somebody out of a lot of emotional distress quite quickly, if done well.

 

Elissa Hatherly  28:15

So if they do score highly in terms of trauma, do they, are they best served by seeing a trauma specialist? Or would any psychologist have the skills then to help those patients work through those traumatic events?

 

Dr Paul Henderson  28:30

I suppose I hope in this day and age where trauma informed care has been much more prevalent, particularly within psychological circles for you know, probably the last 10, 15, 20 years that any psychologist should be in a position to be able to provide trauma informed care, now there’s lots of different psychological approaches to trauma informed care. And, and in particular, psychologists may be more skilled in one approach compared to another. But equally, having said that, you know, the research base, which suggests that whatever trauma informed approach you use, will generally be as beneficial as another, although for individual people, you know, no doubt one particular approach may be more beneficial than another. So yeah, so you shouldn't necessarily have to refer to somebody who specializes in trauma informed care, but if you know if somebody is very highly traumatized and very complex, the Blue Knots Foundation, which is the sort of peak body, in non sort of non-governmental organization within Australia, for people that have experienced complex trauma, so that type 2 trauma, they do have a referral service where they can identify, they can they can provide information on on psychologists around the country that can provide very high levels of trauma informed care, and that's also a link that I will include in the in the show notes for you.

 

Elissa Hatherly  29:50

Fantastic.

 

Elissa Hatherly  29:51

So you did mention that resilience is incredibly important in recovery from trauma and what are some of those factors, those protective factors in our patients that make them more likely to experience that resilience and have a less negative outcome from their trauma.

 

Dr Paul Henderson  30:13

That's an interesting one, because a number of them are not having a number of negative experiences already in life. So you know, less experience of trauma, less experience of social isolation, less substance use less preexisting mental health problems. I suppose when you flick around, all those other things give you a higher chance of having a negative outcome with trauma. If you're if you're thinking more sort of from positive basis, I suppose, having enough emotional intelligence to some extent, to recognize the impacts of trauma on you to be able to reach out to your natural friends and family and support systems to be able to discuss and process it within the relationships that are closest to you, without necessarily having to rely on professional relationships to help process it, doing the all the sort of self-care, things that we know are generally helpful for mental well-being you know, whether that be nutrition exercise, sleep is a massive one, if you're not getting enough sleep right from the outside, from the outset, whatever you're doing, everything else is going to be so much harder. So yes, there's a number of sort of different factors. And I suppose, you know, going back to childhood, the quality of your relationship with your parents is a really important one, the better, the more supportive, the more nurturing, the more loving a relationship you have with your parents, the more likely you will be able to, you'll have developed the skills of emotional regulation yourself of emotional intelligence, that will set you up to be more resilient if you experience trauma later. And conversely, you know, unloving, critical, cold, judgmental parents or relationships will leave you at much higher vulnerability for having negative impact on your mental health if you experience trauma in life. And to be honest, you know, having a negative or cold or critical relationship with your parents is traumatic in and of itself. And that's a really good example of a type of trauma that can have massive consequences in later life. But nonetheless, it's completely missed when we think about purely the very type definitions around PTSD.

 

Elissa Hatherly  32:18

Right. So moving on to PTSD, then Paul, how do we diagnose it you mentioned earlier, it has really narrow criteria for the definition as a as it appears in the DSM.

 

Dr Paul Henderson  32:32

Yeah, so in DSM, they have what is called criterion A, which is the criterion that you must satisfy before considering all the rest of the criteria to have a diagnosis of PTSD. And their wording is exposure to actual or threatened death, serious injury or sexual violence in one of them or one or more of the following ways. And that's including direct experience within yourself, witnessing it in another person, or learning about it from another person. And that's that latter bit is where vicarious trauma comes in, into play.

 

Elissa Hatherly  33:02

Right. And so then the current best management, that's with psychological therapies, isn't it?

 

Dr Paul Henderson  33:09

So it usually would be with the probably with a combination of psychologically psychologic therapy and pharmacological therapy. And which is not to say that everybody has to have pharmacological therapy or psychological therapy, you know, a lot of it will come down to personal choice, because if you put no stock in pharmacology, then in pharmacological or psychological therapy, the chances of it, you know, really being helpful for you are fairly small. So if we think about sort of psychological therapies, just a general trauma informed approach is important. Trauma focused CBT is a well recognized approach. Narrative exposure therapy would be a well recognized approach. EMDR would be a well recognized approach, cognitive processing therapy would be well recognized approach. But there's probably another 10 or 15 therapies that other psychologists could engage in. If we think about sort of more complex trauma, things like EMT, sorry not EMT, DBT, would be a really appropriate way to sort of start approaching that with the person as well.

 

Elissa Hatherly  34:15

So that's a lot of options for management in terms of psychological therapies. That's reassuring, but as you say, you really have to have buy in from your patient to engage in either the psychological or pharmacological therapies. So developing that sound and positive therapeutic relationship is the key to all management for all conditions across the vast variety that we see, isn't it?

 

Dr Paul Henderson  34:39

Absolutely. And actually, the evidence base in psychology shows that probably 80 to 85% of the benefits of a psychological approach is nothing to do with the type of psychological approaches that has been taken and everything to do with the nature and the quality of the relationship you have with your psychologist. And I think that would expand to the nature and you know, you know, outside psychological approaches You know, the nature of relationship you have with your treating doctor as well, whatever, whether it's primary care or within a specialty. So what I always sort of coach patients is that, you know, you've got your mental health care plan, you've been referred to a psychologist, if in the first couple of sessions, you're sitting down with them, and you don't feel that you gel with them, you have a sense of, they don't quite understand where you're coming from, or even if they do the treatment approach that they're taking, you know, doesn't necessarily gel with you, you know, if you feel assertive enough, have that conversation with them. But otherwise, just understand that you need to gel with your, with your psychologist or psychiatrist. And if it's not working, then have the confidence to say, Okay, I think I'm going to go and try and meet somebody else that that I do gel with. And that's really hard, because it goes against sort of general kind of social rules of not wanting to upset people not wanting to disappoint people, but it's also really hard, because the chances are that you'll have waited on a waiting list for 2,3,4 months and then if you get there and all of a sudden, it doesn't seem to be what you need you think oh really I have to go through this again, maybe I'll just stick with this. But to be honest, going somewhere else, if you know, because just sticking with it. If you're not gelling with a person, it's probably not going to get you very far, unfortunately.

 

Elissa Hatherly  36:06

Okay, so troubleshooting with the patients, if they're not achieving a really good therapeutic alliance with their treating psychologist or psychiatrist, have the confidence to make a change. And we say that to our general practice patients too all the time, don't we, not all GPs are right for all patients. What are the best pharmacological therapies? You mentioned there are a few. Can you talk about those in broad classes, please?

 

Dr Paul Henderson  36:35

Yeah, so really, the place to start is with an SSRI. And the also in the show notes, there's the Phoenix, Phoenix, Australia, PTSD guidelines. And that really, you know, details everything to do with the treatment of PTSD and the most up to date, evidence base, and they refer to Sertraline, Fluoxetine or Paroxetine as a good starting point. And I suppose I would have, although Paroxetine can be a wonderful antidepressant, I would have a little bit of caution about it with anybody that you fear won't be really consistently compliant, because it has really significant rates of withdrawal, even after just missing one dose for some people can actually be a pretty aversive reaction for somebody who is not able to take it day in day out. Fluoxetine, on the other hand, is absolutely the opposite. You know, if you take it for two weeks, and you stop, it'll still be in your system for 10 days. So that's a medication that can actually be pretty good for people that are struggling with compliance, obviously, you know, the less compliant you are, the less chance it's going to be beneficial, but at least you won't be getting withdrawal effects. Sometimes it can be a bit stimulating. And so for people that are very agitated as part of the trauma response, you may want to think twice about Fluoxetine, and then something like Sertraline can be pretty, pretty helpful from that point of view, because it tends to be better tolerated than almost any other antidepressant.

 

Elissa Hatherly  38:02

Okay, so any other tips and tricks or troubleshooting go to's for us please?

 

Dr Paul Henderson  38:11

I think, as I mentioned before, sleep is really important as a foundational foundation stone of any form of recovery. And so trying to get sleep right is really a necessity in whatever you're doing. And, you know, and that starts from just all the basic sleep hygiene stuff, you know, how much caffeine your having in the day, you know, what are the distractions or noises or light levels within your, within your bedroom? How much screen time just running up to bed, you know, are you working late and your brains really busy before going to bed. So just, you know, all the general sort of sleep hygiene rules apply. And but I suppose in my mind that if there, if there's a trauma response that is causing sleep problems, the sleep hygiene stuff will stop it getting worse, probably you will stop, it'll stop you doing things that make it worse, but whether it will then actually help it improve that's, I suppose a different thing. And then, you know, so then you're thinking, well, if somebody is having a lot of nightmares, Prazosin can be really good as a direct treatment for trauma related nightmares. And in that case, I would usually start at somewhere between 0.5 and two milligrams depending on the person. So you know, a reasonable size adult, reasonably aged adult that doesn't have any problems with low blood pressure, I'd be happy to start them at two milligrams. But somebody who's frail and elderly possibly has problems with low blood pressure I'd start them with 0.5. And you can work up in a stepwise manner to potentially up to 10 milligrams. And my experience is you often see a gradual stepwise improvement as you do work up the dose. And I would give somebody you know, probably a couple of weeks on a single dose before deciding whether to take the next step up or not. If nightmares are not a particular concern then some augmenting with something like Mirtazapine to whatever other antidepressant you may choose, or, you know, simply using Mirtazapine on its own, though, it's actually interesting it's not in the guidelines, but nonetheless, you know, starting Mirtazapine at 15 milligram grams at night can be very helpful for sleep. A lot of people, you know, respond well to Phenergan between 10 and 75 milligrams, and remembering with whatever you're doing with a sort of sedative medication, that for people that are experiencing hangovers in the morning, that can be really off putting, as long as it doesn't knock them out as soon as they're taking it then you can bring it early and earlier in the evening, and some people will even just take these medications after dinner, they will you know, will not be sedated enough that it makes them go to bed at half by seven. But it does relax them enough that they can get off to sleep reasonably without having too much of a hangover in the morning.

 

Elissa Hatherly  40:46

Thanks so much for joining us today Paul to talk about trauma and PTSD. Of course with PTSD, there's more than one criterion for the diagnosis. We've only really touched on criterion A today, but we'll add the additional diagnostic criteria to our podcast notes. So we've talked about so many things. Particularly I think, for me the importance to remember that the outcome of trauma for the vast majority of patients and friends and coworkers is of course resilience, and that we shouldn't be shy when we're starting a conversation about trauma with our patients, or with anyone else for that matter and the importance of good social supports and self-care as part of that resilience piece, and part of recovery from traumatic events. Thank you so much for your time. For more information about the roundup or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

QLD Health Voluntary Assisted Dying in Queensland

https://www.health.qld.gov.au/system-governance/legislation/voluntary-assisted-dying-act

Link to register to join the QLD Voluntary Assisted Dying Implementation Conference

https://www.health.qld.gov.au/news-events/events/qh-events/queensland-voluntary-assisted-dying-conference

SPEAKERS

Dr Elissa Hatherly, Dr Max Ryder

 

Dr Elissa Hatherly  00:02

Welcome to the roundup, a North Queensland based medical podcast offering local content for local clinicians. I'm your host, Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the land on which we practice. Welcome to this podcast on voluntary assisted dying. I'm joined by Dr. Max Ryder, who's a doctor in Proserpine and working in the community in palliative care. Is that right Max?

 

Dr Max Ryder  00:52

Yes, somewhat correct. I'm employed by Queensland Health through Proserpine as a rural generalist obstetrician. And I've started working privately through a GP practice here locally, to provide end of life, palliative care for people in their home.

 

Dr Elissa Hatherly  01:07

So you must have been really excited when the voluntary assisted dying legislation first passed at the end of 2021 to give your patients some more options.

 

Dr Max Ryder  01:18

Yeah, it's been a big landmark release from the Queensland Government, we're catching up with Victoria, and WA at the moment. And we're now developing our own pathway to support people who inevitably suffering with a terminal illness and they're wanting to exercise their right and the option to request medical assistance for the end of their lives.

 

Dr Elissa Hatherly  01:44

Okay, so with that new legislation introduced at the end of last year, I imagine 2022 has been a really busy year, for everyone involved with voluntary assisted dying to engage with the stakeholders and develop those pathways. Is that what you've been involved with?

 

Dr Max Ryder  02:00

Yeah, so I've come about halfway through that development process. It all started with setting up the voluntary assisted dying unit, the VAD unit down in Brisbane, and there are a group of people that have been working on developing a lot of the policy structure, protocols, navigating all of the all of the issues that they've they've found from Victoria and WA, and trying to put a package together that could be presented to the health care services. And so I've joined as a representative for our Mackay health service alongside Melissa Harris, who is a palliative care support CN in Mackay Base Hospital. And we're now taking it forward to try and implement that locally to make sure it meets the the very demands of very diverse, geographically spread out healthcare service, such as our region here.

 

Dr Elissa Hatherly  02:56

Yeah, you're right, diverse is an understatement for our HHS, that's for sure. So for the patients who are coming to end of life, I imagine there are quite strict eligibility criteria that they would have to meet before they can go down the voluntary assisted dying path. Can you talk us through that, please?

 

Dr Max Ryder  03:14

Yeah, that's right. So there's, I suppose two ways to look at it. There's eligibility criteria for the patients, but also eligibility criteria that clinicians and that includes doctors and nurses need to have in order to assess, discuss and help implement the process of voluntary assisted dying. So for patients, our criteria are a little bit different to Victoria and WA ,they have somewhat been refined. And they've done that in a way to try and ensure that a very general level of medical training is required, and not relying upon specialties to help get people through this process. So people need to have an advanced progressive illness that will cause death, and is expected to cause death within 12 months to the best of the clinicians understanding and it must be causing suffering that the person considers to be intolerable. And I guess that's a really important part because we need to make sure that people are having a full assessment in terms of their current symptoms, and if they can be better managed. And that includes ensuring good palliative care, which is a different chapter to voluntary assisted dying. And this is, this is an end of life option, as opposed to a management of symptoms potentially, like palliative care is. They need to have decision making capacity and acting voluntarily without coercion and they need to be at least 18 years of age and fulfill residency requirements. So that's the five point checklist of eligibility that gets assessed by two different clinicians on two separate occasions. And we'll put a flowchart up for people to see hopefully that the title for these clinicians is either a coordinating practitioner so someone who is the is the key person responsible for helping to support someone through the process. And then a consulting practitioner, which is a doctor that double checks the eligibility criteria to make sure they're met. And then, together with those two people signing off, then they are supported with the voluntary assisted dying unit in Brisbane to make sure that all the checks and balances have been met before an administration decision can be made. And then a plan can be enacted to support that person should they wish to go through with the voluntary assisted dying administration.

 

Dr Elissa Hatherly  05:40

All right. So that's a really important point, isn't it about the difference between voluntary assisted dying and palliative care. I think a lot of people in the community think of voluntary assisted dying as a requirement. Where as from a clinical point of view, it's really palliative care that the vast majority of our patients really need assistance with, and that voluntary assisted dying is only for a very small subset of those patients. Would that be your experience?

 

Dr Max Ryder  06:04

Yeah, that's exactly right. And and when we talk about voluntary assisted dying, there's two, two categories, I suppose we've found in the other states that there's a large percentage of people that will go through an eligibility assessment through this rigorous process and get their authorization to be eligible and be able to undertake a voluntary assisted dying administration, however, they don't actually go through with with that administration. And what we've found is that people find that comfort knowing that they have an alternative option. And a lot of these people who are still having decision making capacity, and still potentially 12 months away from death, just like to have the option available, should their symptoms become intolerable and deteriorate quickly. Because obviously, this process is going to take a matter of weeks to potentially a month or so depending on how streamlined that process can be for that patient.

 

Dr Elissa Hatherly  07:00

Sure. And of course, locking in their option before they potentially lose that decision making capacity would be incredibly important for those patients.

 

Dr Max Ryder  07:07

Yeah, that's, that's correct. It's all part of good, good medical counseling about their condition, their symptoms and their progression at a very early stage rather than people coming in necessarily just to talk about voluntary assisted dying, I think.

 

Dr Elissa Hatherly  07:20

Right. And you mentioned also in the eligibility criteria, the importance of fulfilling residency requirements. So to the voluntary assisted dying, patients in Queensland need to have been Queensland residents for a certain period of time?

 

Dr Max Ryder  07:35

Look, I'm not quite sure on the exact details of the residency requirements, I would suspect that that they would need to be Queensland residents and have a Queensland address would be my assumption is what that does refer to,

 

Dr Elissa Hatherly  07:49

Certainly by the end of this consultation period before those final plans and processes come into place, I imagine the government will make a decision about that for sure. So we've talked a bit about the eligibility for the patient. Can you talk to us a bit more about the eligibility for the clinicians? And you were saying there are two clinicians that need to be involved?

 

Dr Max Ryder  08:14

Yeah, so I think the first thing over arching is the clinician, whether it be doctor or nurse being involved or any any practitioner for that matter whether it's speech therapist, social worker, they have a right to conscientious objection as an individual practitioner, it's important that if they do object to discuss, be involved in in that process, so they do inform the patients early, and they do offer them support to access the service, either through the Central Support Service or an actual clinician they're aware of. The important thing to make note of is that entities have been protected in this legislation. That means that all Queensland health facilities will be required to ensure people have access and entities won't have the right to withhold or deny people access to these this process, which is a little bit different to what has been experienced particularly in our health service with regards to medical and surgical termination of pregnancy, which has been in our health service been objected to, since my involvement in the HHS, but when we talk about the role of the medical practitioner, there's a few criteria the the most general term is that a general registration must be held for at least five years. So that's looking at roughly a PGY 6 trainee who's not on a specialty, has not had reached a specialty level or they may hold a specialty registration for at least one year. And that could be general practice. You know, physician training, whatever it may be. There's no specific requirement to have a field of expertise. You must have an expected level of medical training and then go on to conduct the appropriate online training to make sure that you, you are able to be one of these practitioners involved in the voluntary assisted dying process.

 

Dr Elissa Hatherly  10:08

Right. So you need to have gone through the process as a patient looking to achieve the voluntary assisted dying requirements, you need to go through a process with two different people, one of whom must be a medical practitioner of at least five or six years standing who has completed the training, which is an online training option. And then the second person who has to give an okay, that could be a nurse or a social worker or speech pathologist, is that correct? Max?

 

Dr Max Ryder  10:39

No, in fact, it's two medical clinicians that do need to sign off on this, the role of the nurse is delineated similarly, so they do differentiate between registered nurse and nurse practitioner. And the role of a registered nurse is that they can act as the administrating practitioner should the patient choose to have the intravenous formulation, they are able to discuss conversations about voluntary assisted dying, but not to initiate and nurse practitioners the main differentiation there is that they can initiate conversations about voluntary assisted dying whilst being able to administer as well. And they must meet the same requirements of online training and also have a level of seniority as well.

 

Dr Elissa Hatherly  11:28

Okay, so we've got two medical practitioners who are signing off both of whom who have conducted the appropriate training and then the administering person could be a nurse or a nurse practitioner who has also undergone the appropriate training.

 

Dr Max Ryder  11:43

Correct.

 

Dr Elissa Hatherly  11:44

When we look at the history of voluntary assisted dying in both Victoria and Western Australia that you mentioned, I imagine there are a lot of really great learnings that the Queensland team will be able to take from those groups. I understand that in Queensland, being able to fulfill the requirements for voluntary assisted dying, if you are expected to pass away within about 12 months is a little bit more generous than in Victoria. Can you talk us through that timeline?

 

Dr Max Ryder  12:16

Yeah, so there's there's two things there. There's one about the the eligibility criteria, which you refer to as ours is 12 months, there's is a lot shorter. And also in Victoria, they actually need to get involvement from their direct specialty, depending on their illness. So if it's a cancer, an oncologist, and a neurological condition a neurologist, which can be a bit of a burden for people in a geographically spread out area. And so that's why we've gone from a very general level of training, but made sure that there have been a level of experience. The second thing that differs from the states is the actual route of administration. So both states have the option for intravenous and oral. However, Victoria does state that they would like people to have the oral version unless there is a medical reason that they can, they cannot and that might be swallowing related absorption related concerns. So when when we're coming to our model, we work similar to the WA model where people get the option to choose between either or and that's a personal preference rather than a requirement. And what we're expecting is that when people do get the option, it seems that intravenous has been a more favored option from patients based on the WA data. And so I guess that's something that's worth noting, because it requires there for a nurse or a doctor to be involved in the administration as opposed to that patient taking home the medication and having someone observe them at home, who may be a family member or a friend to observe the process. So it will require substantial health care manpower to make sure we have enough people who are comfortable, administrating, administering the medications, which we know is going to be more potentially more confrontational for people to be involved in when you compare it to checking against the eligibility criteria and filling out the necessary paperwork.

 

Dr Elissa Hatherly  14:17

Sure. Okay. So in Victoria, I'm not sure about in Western Australia, but I know in Victoria, there have been quite a lot of people from regional and rural communities who have taken up the voluntary assisted dying option. The ability to have practitioners with more general registration involved in signing off those patients in the first place will make an enormous difference in our community, as you say, being so dispersed across our enormous state. Has the experience been similar in Western Australia? Do you know or have the patience being mainly those In the centres?

 

Dr Max Ryder  15:02

Well, I'm not too sure about the exact geography of WA, I know you are right in Victoria. General practitioners were responsible for a large percentage of almost all the percentage of regional and rural, voluntary assisted dying patients. I expect that that would be not dissimilar to our our snapshot as well. But it will be interesting to see the distribution. Obviously, large density populations will have inevitably more voluntary assisted dying episodes. However, as telehealth and especially the services are able to be given in regional rural areas, we find that there are lots of patients that remain in their rural and regional areas to receive their health care. And inevitably, that leads them to, to want to pass away at home through this process.

 

Dr Elissa Hatherly  15:52

So Max, how are we going to proceed from here? What happens next with voluntary assisted dying in Queensland?

 

Dr Max Ryder  16:00

Well, we're we're working on it at the moment, at our local level, we've developed a working group in this region, and that includes people from the hospital and also the community sectors, medical nursing, pharmacy, social work, indigenous liaisons, and we're working on our terms of reference to make sure that we're set up to help facilitate this rollout from the health care, HHS level trainings going to start coming online towards the back half of the year. And we'll start enlisting people to undertake the training and be prepared for the beginning of next year, January 1. And were working on building up our workforce to ensure that we have appropriate levels and staffing to support this rollout. So we're in the process of making budget requests to get access to medical nursing, and, and other allied health input to make sure we have appropriate staffing, because we are going to be predominantly holding on to this through the health service network. But also having a heavy involvement with the community as well as they step into our network to gain access to provide service, begin access to get training, and also to get involved with getting access to the drugs as well that are required.

 

Dr Elissa Hatherly  17:16

Right. So there's a lot of work to do, I imagine too Max, practitioners are probably looking at the skill set they already have around delivering quality palliative care to their patients in the community and in the HHS, what are some of the trainings that you undertook? Where have your supports been? How can people, medical practitioners in our region upskill so that they are more well prepared for patients at end of life?

 

Dr Max Ryder  17:45

Yeah, it's a great question. I mean, I guess we all we all do it innately. In any case, we deal with people who have these terminal conditions, you know, from the beginning of our careers and early in our training. And I think that this is a conversation that had been brushed aside when when people inevitably bring it up, asking for that relief that, could you help me end my life earlier. And now I think it's time that we, we relaxed our conversation, we explore by asking patients what what they mean by that and unpacking what their concerns and queries are. I think that we have the skills I don't think it takes a specialist of any particular kind to have these discussions about what end of life looks like for people if they were to have their, their their say in the matter. And I think that, yes, good palliative care is essential for these people because they have less than 12 months prognosis inevitably, will have symptoms that need managing. And yes, that does require more focused training. And I think in our health service, we rely heavily on telehealth services through Sparta and through one through PallConsult, and, and they're referral, they're referral networks that inevitably allow people to engage with palliative specialists and and learn from their experiences and learn from the way that they treat their patients. And so I think that it just takes a curious mind to ask more questions and, and make those referrals earlier. So that way people can learn, learn alongside their patients to see what what good palliative care can look like, in order to support people to make sure that this is the right decision for them. And that they have reached a place where their symptoms are well controlled or, or they feel that they've explored all the options to get to the point of having well controlled symptoms to satisfy a curious mind I think.

 

Dr Elissa Hatherly  19:36

Yeah, and for those of us in general practice, just talking to our colleagues can be incredibly beneficial too can't it. When I first started in Mackay, palliative care was delivered by senior experienced GPs and some of those GPs are still working in our practices, who have the experience in palliative care and are happy to take us on the journey with them.

 

Dr Max Ryder  19:57

That's right, and that goes to my point we've been doing it for a long time, we've been caring for people in their last 12 months and then their last moments of life, no matter if you're a GP or a medical oncologist for that matter. So I think this is just going to give us more more flexibility to have deeper conversations with our patients and really make sure we're meeting their needs. And you know, this isn't, this isn't something that everyone particularly signs up for and gets excited about. I think this is part of our job that isn't the most obviously pleasant thing. But you have to appreciate that, that we're here to serve our patients and our patients have been asking for this. And obviously the government has listened and that's why this is happening. It's something that is in demand from our communit and we should respect that and make sure we we do the right thing to support them.

 

Dr Elissa Hatherly  20:45

Thank you so much, Dr. Max. So we'll have training coming in an online capacity towards the end of the year, ready to roll out voluntary assisted dying for the patients who need it from the first of January next year. What are the other take home messages for today?

 

Dr Max Ryder  21:02

I think it's good to start talking to your patients and exploring the the idea about for these people who are in the last 12 months of their life. We're not waiting for January 1 for this to happen. We we want to start the conversations early so people open up and feel free to talk about their wishes and make sure that if there's something that's underlined, that needs to be addressed, it gets addressed to make sure that people are getting the best in their terminal illness and making sure they do achieve quality of life which is ultimately everyone's goal.

 

Dr Elissa Hatherly  21:37

Dr. Max Ryder, thank you so much for joining us today. We appreciate your time and your insights.

 

Dr Max Ryder  21:42

No worries. Thanks for having me.

 

Dr Elissa Hatherly  21:46

For more information about the Roundup, or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Dr Elissa Hatherly  00:02

Welcome to the Round Up, a North Queensland based medical podcast offering local content for local clinicians. I'm your host Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the lands on which we practice. In today's episode, we wanted to explore how we might manage patients experiencing insomnia using the wide variety of medications available today. Our first presenter is Karalyn Huxhagan, one of our local pharmacists who works particularly in rural communities. Hi, Karalyn.

 

Karalyn Huxhagan  01:01

Hi, how are you going today, Elissa?

 

Dr Elissa Hatherly  01:03

I'm very well. Thank you so much for joining us today to talk a little bit about the medications that we use in insomnia. I wonder if you could just start with talking about the different classes and when they might be useful.

 

Karalyn Huxhagan  01:16

Okay, so there are several classes. So benzodiazepines, which have been around for a long time, and the one that's most often used for sleep is Temazepam so it has a action of about six hours. So it increases your total sleep time. It has less sedation the next day, as long as the patient takes it at a reasonable time. And so I always say to my patients, you should take this after tea, normal bedtime, you can't take it at midnight or two o'clock in the morning, expect to get up and be good for the next day. The next class is what we call the Z drugs. So the Z drugs work definitely in the GABA area of the brain, they potentiate GABA, they're very good for people who are like, reps or traveling and that to improve sleep when in a short for a short period of time. But they do have a lot of issues and they shouldn't be used definitely with alcohol. That's that's a definite no. Their use is very much for a short term use to improve sleep.

 

Karalyn Huxhagan  02:34

Okay, so we can't use the Z drugs with alcohol, that would be because of that GABA activity. The same with the Benzodiazepines. Is that right?

 

Karalyn Huxhagan  02:44

Yeah, but the Benzodiazepines the effect is more the sedation and the increased effect on on the sedating effect with alcohol. But with the Z drugs, they have a particular way that they, the alcohol then causes them to go into that real GABA area and you get the hallucinations, you get the the really poor side effects. So patients have been found to go out of their house and get in the car or on a motorcycle and go for a drive with no awareness that they're doing it. I've had patients who get up in the middle of the night and do things like, you know, heap of baking, or they'll clean the house furiously. The the interesting area of when they discovered this was a problem was actually identified in England. In the first part where security personnel in hotels were finding that certain patients, certain guests were getting up in the middle of the night and going off and doing things and they had no clothes on. So they'd left their bedrooms, and we're wandering around the hotel with nothing on and doing weird things. And it got linked back to the use of the Z drugs and, and having alcohol with their meal or you know, a couple of beers after dinner or whatever. And it's, it's a very significant issue. So anybody that's using any of the Z drugs so Zolpidem or Zopiclone definitely should have no alcohol within their system within 12 hours. And this is a problem and it's well documented now with some very good research by people like Dr. Geraldine Moses, from Mater in Brisbane about the effects of, of what that Z drugs plus alcohol can do. It's a it's far more of a It's not truly hallucinogenic, but it's a total lack of awareness. And you know, it's been quite severe because people do some really bizarre things when they combine the two.

 

Dr Elissa Hatherly  04:49

Yeah, although I think cleaning the house without any awareness, I wouldn't mind I must admit. So then melatonin probably wouldn't have that same interaction with alcohol, is that right?

 

Karalyn Huxhagan  05:03

Correct. So, the melatonin is very much there to improve the circadian rhythm. So to get you back into a good sleep cycle, it doesn't have any potential to interact with alcohol. In Australia, the dose of melatonin is normally two milligram. Overseas countries do use higher doses. But Australia, it's registered at two milligrams. And it's registered for a use of up to 13 weeks to reset the circadian rhythm. It does have its place, it's certainly well tolerated. It doesn't make the person sedated and groggy the next day, it's been used in aged care a little bit because it doesn't have the same risk of falling as some of the hypnotics. So the benzos can increase the risk of falls so melatonin certainly being used, the downside of melatonin is its price not covered on the Pharmaceutical Benefits Scheme. So the affordability is one area for that drug, particularly in aged care.

 

Dr Elissa Hatherly  06:15

Right. So then the benzos, the Z drugs and the melatonin, they're a more short term use medication, it sounds like. Then looking at the orexin receptor antagonists, that's for people with longer term concerns, isn't it?

 

Karalyn Huxhagan  06:34

It is. And it's very much for a very small subset of patients who you really have to make sure you've done your homework in looking at all the other medications they're on and everything else that they do. It has a it's a got a tiny area of practice. But it's definitely for only for chronic insomnia. And it's a drug that when you start it, you must monitor that patient. I've had some severe adverse reactions with Suvorexant, but not in all patients. So it's just one that does have some other potential side effects. So you do have to monitor them, and they really, truly have to have chronic insomnia that the diagnosis is important for the use of that drug.

 

Dr Elissa Hatherly  07:24

Okay, so can you just remind me, Karalyn orexin is the protein, orexin protein B, the neuro peptides that help promote wakefulness? Is that right?

 

Karalyn Huxhagan  07:37

Yes. That's how it works. Yeah, it has the blocking in that pathway. Yeah, it's, it's a tricky pathway. So you do need to, to watch it, but that's how it works. It does blocking that neuropeptide pathway to B.

 

Dr Elissa Hatherly  07:58

Okay. So what about more old school medications like those more sedating antihistamines? I think, certainly, they were very popular when I started in general practice 20 years ago, is there still a place for those do you think?

 

Karalyn Huxhagan  08:13

There is, but doxylamine is the one that's used the most, and there's probably at least 20 brands of doxylamine. You know, sleep assist, restavit, you know, they've all got sleep or rest or tiredness or something in their brand naming. It's it's short term, the ones the patient that we see that uses them probably the most are your shift worker type patient. So the miner, the nurse, those who, when they flip over from daytime work to night time work and are trying hard to get their sleep cycle back. The ones that we see use it. The problem with using the sedating h2 receptor antagonists is that if you use them every day, for a long period of time, the sedation effect disappears. These are an anticholinergic medication, but, and then, because of their structure, they do cause sedation. But with time that sedation effect will wear away

 

Dr Elissa Hatherly  09:20

with the anticholinergic effects, which aren't so pleasant,

 

Karalyn Huxhagan  09:23

that's right. So you've got to be careful with them. And because they can buy them over the counter, it's, you know, one of the hardest tasks is to explain to them you, you really should only use this two to three times a week on your swing week, when you're a shift worker to get your back into cycle. It's not something you should use all the time. And you've got to watch out for the anti cholinergic effect because you don't want to be using it, you don't want them using a lot of that if they've got other things happening like you know, prostate issues, urinary retention, or dry eye glaucoma and things like that, that you do don't want to add an anti cholinergic into as well. That's a hard drug to persuade people that it's not the easy sleep tablet that they will think it is. But yeah, which brings you back to, if they've been taking it forever, and they still find it, it makes them sleep, how much placebo effect they're getting from the medication is probably another discussion to have.

 

Dr Elissa Hatherly  10:23

We love a placebo effect. Okay, so when we're looking at those hypnotics, and we talked about the benzodiazepines, the Z drugs, and you mentioned temazepan is the best one because it's short acting, and it's quick onset too I think, isn't it?

 

Karalyn Huxhagan  10:40

Yeah about 20 minutes.

 

Dr Elissa Hatherly  10:43

Right. Okay. So,of course, with the sedating drugs, there's a concern with impaired performance and coordination, cognitive function, and there's also a concern about maybe less good quality sleep, is that right?

 

Karalyn Huxhagan  11:03

Yes. So if they're trying to achieve to get into the deep sleep for when memories lay down and audit the, the function, re coordination happens in the brain, you you've got to, if they don't get into that, the right layer of sleep for all of the that healing and all of the function late work to happen, then they're just lying in that very light sleep area. That's not, in the long term that's not good, because that's why then you end up with this cognitive function issues. So with sleep, it's important that there's enough time down into the proper, deepest sleep phases. If you've got a patient that's just tripping up and down very quickly, they're not getting the restorative sleep that they need.

 

Dr Elissa Hatherly  12:01

Right. So then if patients are using have been using those for quite a long time, I imagine we need to wean them off that quite slowly too. Would that be correct?

 

Karalyn Huxhagan  12:11

Yeah, it's it's not as hard to wean them off Temazepam, as it was back in the days, or Nitrazepam, or Mogadon which was much longer acting. But if you can start to wean them back to, you know, three times a week then twice a week, and then you know, when needed, it certainly is, you shouldn't just take them away, you know, stop and that's it all over rover.

 

Dr Elissa Hatherly  12:41

Cold turkey would be unkind it sounds like.

 

Karalyn Huxhagan  12:44

Yeah, that would be not good for them. Because they'll get a whole rebound activity happening. But you just taper down and do it slowly. So you know, as I say, three days a week, we always suggest and then we say you pick your pick your two days and then bring them back to when needed. But the flip side of it is to really delve into what's causing that patient not to sleep, and my primary area of work is in aged care. So yeah, I'm forever saying well, do they truly need to temazepam? Is it the noise of the facility? Are they in pain? what else? What else is happening? Are they fearful? Do they have anxiety? I think when we say we're going to taper off, we have to offer another a flip to it. Or let's explore why you don't sleep. What wakes you up,are you going to the toilet four times a night? you know, are you fearful in your environment? It does need to be a deep and considered conversation which may then bring in you know, the use of someone more like a counselor or a psychologist. You know, as a practitioner, you can't just take away one thing without offering a better solution.

 

Dr Elissa Hatherly  14:06

Yeah, you're so right there. So talking about mood then Karalyn, in the past we might have used tricyclic antidepressants to help with sleep too, because sometimes they'll have that sedating effect. And with any luck, the patients will sleep through any anticholinergic concern with their dry mouth or dry eyes. Do you think there's still a place for the tricyclic antidepressants?

 

Karalyn Huxhagan  14:31

There is, the patient who struggles to sleep due to their pain and discomfort. If we look at some of the tricyclics' like Amitriptyline and Nortriptyline, you can use low doses of that type of medication for both the sleep part of their ability and their pain relieving ability. So those patients who say they can't sleep because they need that, you know, by three hours that they're very in a lot of pain and, and you know, they have to get up and walk around and that. They definitely can benefit from using something like a tricyclic. Those patients who have terribly irritable bladders that, you know, just no matter what won't stabilize and won't hold, it's worth a try of something like Nortriptyline to see if just using the actual anticholinergic side effect helps to stabilize the bladder longer for them to get maybe two, three hours before they have to get up to go to the toilet. They do have a role, you know, some adverse reactions are a side effect to one patient and a benefit to another. So you do need to consider that with the drug.

 

Dr Elissa Hatherly  15:54

Okay, so looking for those beneficial side effects then and making it quite case specific.

 

Karalyn Huxhagan  16:00

Yes

 

Dr Elissa Hatherly  16:00

So we've talked about the benzos, we've talked about the Z drugs, we've mentioned melatonin and Suvorexant, the tri cyclic antidepressants, and then we also have Quetiapine that we use a little bit these days to help with that severe anxiety in a proportion of our patients. It can be really helpful for initiating sleep in those patients, is there any thing we need to be on the lookout for when using Quetiapine?

 

Karalyn Huxhagan  16:31

Yeah, Quetiapine certainly, if the patient has an anxiety or that kind of classification, Quetiapine is certainly used. And in aged care, there was a lot of work done saying Quetiapine was good to settle patients to sleep, who did have you know, fear of, of the dark, fear of their new environment and things like that, and doses of 50 to 100 milligrams were like the recommendation. You've got to be careful, it's different to in aged care to a patient in the community because now with the aged care guidelines from the Senate, and the Royal Commission, the use of things like Quetiapine, for sleep is considered a chemical restraint. So you, you can't use it in that kind of patient without putting yourself into a whole area of regulation. So, but out in the community, for patients who are fearful of whatever, you know, there certainly is a role for Quetiapine. It doesn't have to be high doses, but I sadly see some shockingly high doses of Quetiapine for sleep. To reduce the anxiety for sleep, it should be more into that 50 to 100 milligram area of practice. But Quetiapine is a drug that has a an ability to become addictive's probably not the correct word. But it does have a certain type of patient will become very use, you know, like the feeling that the Quetiapine gives them and then tend to want to grow the dose and go on from there. So Quetiapine is a drug to be used in caution, bit like the benzos in the valium days. So you do need to watch your patient. The other medication that you would see most prescribers use before Quetiapine would probably, in the anxiety patient, would be Mirtazapine.

 

Dr Elissa Hatherly  18:44

Yeah, let's talk about Mirtazapine a little because it's a class all on its own, essentially, isn't it?

 

Karalyn Huxhagan  18:51

Yeah, it's a very individual little drug all by himself. So Mirtazapine is a wonderful little drug in its right place. But it has different dosing schedules for whatever you're using it for. So if you're using it for sleep, to reduce anxiety for sleep, 7.5 to 15 milligrams is is usually adequate. You certainly don't need the 45 milligrams that we see people getting placed on though but you do also need to be careful about his weight adding ability. So at the low doses, it's used for sleep, but it does have we use it very much in our anorexia patients to try to reduce their anxiety and to improve their appetite. So you know, just be careful a very obese patient may not like you putting them on Quetiapine and then they're going to eat a bit. So yeah, but it's a good drug. And I find it good in practice, using it low dose, getting them back into a sleep cycle, getting the anxiety under control by also using a psychologist or a counselor to sort out the cause of the anxiety, getting that sleep pattern happening so that then they cope and they more restorative in looking at the bigger picture of what's causing the anxiety by onboard counseling. And then you can usually take it away to a PRN stage. And they just use it for those bad days, you know, the cat got run over or whatever. It's a drug that can be used PRN. And but it's, you know, it should be used in a multidisciplinary team format, you know, what's causing the anxiety and use the drug plus the counselor.

 

Dr Elissa Hatherly  20:55

Right. So that's probably our take home message today, isn't it, Karalyn, that sleep will often have other associated issues that need to be addressed, like mood or sleep apnea or any other medical condition and make sure we're tailoring the medication for that person so that we're using something that's an appropriate medication for the duration that the patient needs it for and an appropriate dose.

 

Karalyn Huxhagan  21:24

It's absolutely correct. I think we should approach sleep like we do with opioids. You set up a plan with the patient to get them back on track. And then the plan says then you evaluate the long term parts of the plan to reduce the drug away once they're coping and have got their sleep patterns back on track.

 

Dr Elissa Hatherly  21:49

Or Excellent. Thank you so much, Karalyn Huxhagan. I really appreciate you going through sleep medication with me today. Thanks again.

 

Karalyn Huxhagan  21:56

Thank you. Bye.

 

Dr Elissa Hatherly  21:59

Our second presentation is by Glen Clark, another local community pharmacist who has a particular interest in melatonin metabolism. Welcome Glen.

 

Glen Clark  22:09

Hi, how's it going today?

 

Dr Elissa Hatherly  22:11

Thanks so much for joining us. Sleep is such a difficult thing to manage with some of our patients. Could you help us understand a little bit more about melatonin metabolism, please?

 

Glen Clark  22:23

Yeah, sure. So melatonin is a derivative from serotonin. It's through the pathway chain that we also need serotonin to make melatonin and it's a it's kind of a negative feedback with that, that serotonin factor. So throughout the day, when you're having your cortisol levels dip, to the end of the day, our melatonin is actually rising. And that's why when we go into bed, we have that increase in melatonin and get us that nice sleep throughout the night.

 

Dr Elissa Hatherly  22:52

Okay, so that might help to explain why I have difficulty with sleep with some of my patients, when I use an SSRI. I do have one patient, I think you might have seen her. She's about 16. She started on venlafaxine, which she's taking in the morning. But then since commencing that medication, she's waking at about two o'clock every morning. Can you help explain what's going on there, please.

 

Glen Clark  23:21

So like I mentioned with the negative feedback side, so with with the SSRIs, what they're trying to do is obviously allow that more serotonin to hit that interstitial space acting on those 5HT 1, 5HT 2 and 5HT 3 receptors. As we all know, insomnia is a common side effect of that because of its action on 5HT 1. But with melatonin, what we're trying to do is obviously we can supplement that into the patient and give them a little bit of assistance again, the sleep. The problem is, is if we give them too much, we actually cause the melatonin to negatively feedback into serotonin so remake itself into serotonin. And that's why they wake up about four to five hours after the fact that they've taken the medication.

 

Dr Elissa Hatherly  24:08

Right? Yes, of course. I often use the melatonin the two milligram extended release formulation in those super anxious girls. So I've probably created that insomnia, haven't I?

 

Glen Clark  24:18

It could be a number of factors, but it is always best even trial, just drop it drop the dose don't actually increase the dose because sometimes more doesn't always mean a better outcome for the patient and actually if you drop the dose, we might find that that will actually give the patient a full night's sleep.

 

Dr Elissa Hatherly  24:35

Okay, so maybe instead of a two milligram extended release formulation, get a compounding pharmacist to make me up a one milligram tablet and have that just an hour or so before bedtime would that be the best way to manage that?

 

Glen Clark  24:47

We always when we were when compounding is available. It's actually quite a good start to trial the patient's on liquid formation. The reason why that is is that we can adjust the dose to work out how they operate really well, so that that liquid formation can be in, you know, one milligram changes, or even half a milligram changes. The advantage with compounding is that once we have that strength and we know what works best for the patient, we can actually formulate that into a capsule formulation, which can be any, any value what we want it. So even if it's 2.56 milligrams, they can make it that way. So it makes it easier.

 

Dr Elissa Hatherly  25:25

Yeah, I suppose that capsule formulations then a bit more stable, it doesn't need to be refrigerated. So it's convenient with traveling and things like that, isn't it?

 

Glen Clark  25:33

And obviously, capsules are a little bit more easy than tablets for patients.

 

Dr Elissa Hatherly  25:37

Yeah, for sure. Okay, so the other thing I suppose to do would be to reduce the dose of the venlafaxine in this particular patient, isn't it? What else could we try?

 

Glen Clark  25:48

We could look at actual less than pharmacological factors if there is other factors that are causing so non pharmacological factors would come into play. So simple things of working out how they are getting to sleep, whether, you know what, what are they doing before they go to sleep, whether they are using their phone or their iPad, right before they go to bed, because we know that that blue light can really affect that retinol pattern on the back there, and making them stay awake. Even simple things, looking at their medication, what else they're taking might also influence them. So what vitamins and minerals they're taking even magnesium is really helpful for their sleep.

 

Dr Elissa Hatherly  26:29

Okay, all right. Any other tips and tricks for using melatonin in our patients, Glen?

 

Glen Clark  26:36

one of the best things is to try and assist the patient with the melatonin side. In terms of giving us the best kind of reaction to them is to record what you're doing every night and seeing how each night they go with it. It will take about two weeks for you to get a full valuation of what's going on. But even if you can just write down the diary, how well your sleep was and how well they go the next day after, whether they're sleepy or if they you know, having too much coffee throughout the day. That's really helpful for, I'm assuming for the GP side, but also from the pharmacological side of how we can help them treat their medication.

 

Dr Elissa Hatherly  27:18

Fantastic. Okay, so Glen, thanks so much for your time, we need to think about keeping a diary in terms of sleep symptoms with our patients, be mindful of sleep hygiene, and all of those tips and tricks that we know to be so important. And then think about the serotonin surge that our patients might be experiencing in the early hours of the morning and adding back a little bit of melatonin. Look Glen thank you so much for your time and your expertise. We really appreciate it.

 

Glen Clark  27:47

Thank you very much Elissa.

 Dr Elissa Hatherly  27:51

For more information about the Round Up to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

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Dr Elissa Hatherly  00:02

Welcome to the Roundup, a North Queensland based medical podcast offering local content for local clinicians. I'm your host Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the lands on which we practice. In today's episode, I'm joined by Dr. Jasmine Davis, a GP in Mackay, who also works in the sexual health clinic here in Mackay. Jasmine is particularly interested in improving access to women in regional and remote areas for womens' health concerns, particularly for medical termination of pregnancy or MTOP. Welcome, Jasmine.

 

Dr Jasmine Davis  01:06

Thanks Elissa, thanks for having me.

 

Dr Elissa Hatherly  01:08

What is it that we as clinicians in the community really need to know about unplanned pregnancy options to best help our patients when they come and see us?

 

Dr Jasmine Davis  01:18

Yeah, I think you're right, I think we need to focus on what's important for the patient. So when someone presents with an unplanned pregnancy, we need to have the skills and knowledge to be able to counsel the patient as to what their options are, and then to be able to refer and guide them to the most appropriate option for them. You know, sometimes people find that it's quite a difficult situation to be in, quite an emotional decision to be making. So I think we need to do our best to support our patients, and help them through the process.

 

Dr Elissa Hatherly  01:52

I think that's great advice. And I would know, from my experience, it's not unusual for a woman or a couple to come in with an unplanned pregnancy, who has until that moment had really fixed ideas about how to manage an unplanned pregnancy. But once they've experienced their own unplanned pregnancy, those previous beliefs or particular persuasions kind of go out the window, people start to look at other options as may be the right option for them.

 

Dr Jasmine Davis  02:20

Yeah, absolutely. And I think until you're in the reality of a situation where there could be a new baby in your life, bringing a child into the world is a pretty big decision. And you know, when it's a hypothetical situation, it's easy to say, I would never do this, or I would always do that. But when the reality comes in, then I think people often need to think a bit harder about what their decision is, whether that be continuing with the pregnancy, or going ahead with a termination.

 

Dr Elissa Hatherly  02:53

Okay, so medical termination of pregnancy. We haven't been doing it in Australia all that long. But it's a really important option for women, particularly in rural, regional and remote Australia, isn't it?

 

Dr Jasmine Davis  03:05

Yeah, absolutely. Well, I think particularly for the women in our area in Mackay, it's quite difficult to access a surgical termination of pregnancy, unless someone's got private health cover, and a bit of money to pay excess in gap fees, or to pay for flights down to Brisbane since the closure of the regional surgical termination clinics. So in understanding that, then we've got to know you know, there are people that can't travel or don't want to travel away from their home to access surgical termination. So then we've got the option of doing a medical termination where they can undertake that in their own home. And, you know, they're probably out of action for about a day, but then can continue to work and provide care for other children if that's what they need to do.

 

Dr Elissa Hatherly  04:04

So, in terms of medical termination of pregnancy, how do we walk our patients through those options?

 

Dr Jasmine Davis  04:12

Yeah, so, I think um, the first thing to figure out is the gestation of the pregnancy, because depending on gestation under the PBS, we can only prescribe the medical, the medical termination up till nine weeks and zero days, whereas the surgical termination can be done for any reason, up till 22 weeks. Obviously, as the gestation increases, the costs increase and also does the medical risks to the patient. So, you know, if they can get it done within that first trimester, that's ideal, but sometimes, we've got patients that are finding out or have a change of circumstances at a later date. When I'm helping someone to make that decision first I'm looking at what's their past medical history? And do they have any contraindications to a medical termination of pregnancy, like a bleeding disorder or being on anticoagulants, any chronic adrenal failure or dependence on oral corticosteroids for another problem, because that would immediately make me lean towards the surgical option. Other times, we've got to have caution with a medical termination, if any conditions where excessive bleeding would be a problem for the person so a cardiac condition anyone with anemia or a severe kidney or liver disease. Other than that, it would be mostly talking to the person about, you know, what are their preferences? Would they prefer to go to the clinic, have an anaesthetic and wake up and have it all be finished? Or would they prefer to be able to be in the comfort of their own home and go through that cramping and bleeding process, you know, with their support people nearby, rather than having to travel, you know, get on a plane, take time off work, potentially be away from their other kids. And then of course, the cost. So the cost of a surgical termination, that do outweigh the medical termination.

 

Dr Elissa Hatherly  06:17

Right. So what would be the expected process then for our patients when they're coming to see you to commence a medical termination of pregnancy?

 

Dr Jasmine Davis  06:26

Yeah, so it really depends on whether or not they've seen their regular doctor and had some initial investigations done. You know, ideally, someone could see their usual doctor, have an ultrasound to confirm the pregnancy is intrauterine and to get the dating of that pregnancy. And ideally, I'd want to see a blood test haemoglobin and beta hCG for a baseline reading for them, and sexually transmitted infection testing if they need that. At that stage, then people will send a referral to one of the private providers. In Mackay, you know, we've got quite a few GPs who are now providing medical termination of pregnancy. And then for our financially or socially disadvantaged people, there is a service at the sexual health clinic. When they come to that appointment, we would check through their investigations and their past history and make sure it is appropriate to proceed with the medical termination. Of course, we'd be checking that they do have the capacity to consent, and that they're making the decision of their own free will with no coercion from maybe a partner or anyone else. And then going through with the patient what to expect and what can go wrong and go through the consent process, just like any other medical procedure,

 

Dr Elissa Hatherly  07:50

Really all patients need to know is that they need that quantitative beta hCG and a haemoglobin and that ultrasound to confirm that the pregnancies intrauterine when they come for that initial consultation.

 

Dr Jasmine Davis  08:04

Absolutely. We also need to start that conversation about future contraception, just so that the person has the opportunity to have a think around what they want to do after the termination. particularly encouraging the long acting reversible contraceptives, but give them their personal options, so that they can think about it and we can get that happening straight after the termination.

 

Dr Elissa Hatherly  08:31

Great. Okay, so for women who are pregnant, often we'll do a blood group and antibodies screen. We're not really doing that for the women who were looking for a medical termination these days are we?

 

Dr Jasmine Davis  08:44

So certainly knowing if a patient is rhesus negative is really important if they are going to have a surgical termination. So if they were undecided. I would order that but if we knew that we're going ahead with a medical termination of pregnancy, if it is within that time, we can prescribe up till nine weeks, there's no requirements now for the anti-D injection.

 

Dr Elissa Hatherly  09:07

Okay, so it's pretty straightforward then for women who do find themselves needing a medical termination of pregnancy. You have mentioned some of the risks around severe kidney and liver disease and adrenal insufficiency. What are some of the other things that we need to be mindful of with our patients?

 

Dr Jasmine Davis  09:25

Oh, look, I usually like to make sure that someone lives within an hour or so of a hospital where they can provide emergency support, just in the case of excessive bleeding. I like someone to have a support person available. So that if things do go wrong, that they have transport to get to a hospital. You know, in terms of the major risks, the risks are that we could have excessive heavy bleeding. Now that is uncommon, but that does happen. So I ask the woman to monitor her bleeding, monitor her blood loss. And if she does find it excessive, so soaking, saturating through more than two pads in an hour, then she should be monitoring that closely. And if she's experiencing dizziness, lightheadedness, or fainting, then seeking out emergency medical attention. In terms of other complications, you know, we do have the odd occasion where it's not, it doesn't work. So a continued pregnancy. And in that situation, we certainly would recommend that they continue the process, either through a repeat of the medical termination or by going through a surgical procedure, mainly because the Misoprostol is teratogenic. So, you know, it's not ideal for someone to change their mind and continue the pregnancy. And if they were to do that, then they would need to have some tertiary scans, some monitoring of the baby.

 

Dr Elissa Hatherly  10:53

Right, so, sorry, you mentioned the Misoprostol. Can you just talk us through the medication that we give to the patients and the timing of that?

 

Dr Jasmine Davis  11:04

Yeah, absolutely. So the medication that we use is called MS-2 step and it's a packet including Mifepristone, which is 200 milligrammes and Misoprostol, which is 800 micrograms. So, how I usually work it is I ask the woman what day it would be to be most convenient for them to have that bleeding day when they're probably going to be stuck at home with a support person with a hot water bottle and pad. So you know, if that if that falls, they would prefer that to fall on the weekend, then we can work backwards to figure out what day to take the Mifepristone, the Mifepristone has to be dosed 36 to 48 hours before the Misoprostol. So I work that out for the patient and give some written information as to how to take the medication. Mifepristone is taken orally, and the Misoprostol is taken in the cheek where it absorbs so that if they do have any nausea or anything following that medication is already absorbed into their system. It's really important that we make sure that the person has adequate pain relief, and antiemetics available again so that they can manage their own symptoms at home and avoid ending up in the hospital and this is absolutely necessary.

 

Dr Elissa Hatherly  12:32

Okay, so the complications of the procedure then you've talked about the excessive bleeding and the nausea and the heat pack with them before the significant pelvic cramping. What are some of the other complications we might expect? And how are we best managing those?

 

Dr Jasmine Davis  12:50

Yeah, so probably the most common complication would be retained products, similar to after a miscarriage. There can be some membranes or products left behind and when a person experiences prolonged ongoing bleeding, I would usually expect the bleeding to last about two weeks but if it was lasting longer, say three, four weeks, or got suddenly heavier after it was getting lighter, then I'd be wanting to investigate, usually with an ultrasound and involving our gynaecology colleagues at that point for management of ongoing retained products. I suppose from a medical perspective, managing retained products after termination is very similar to after a miscarriage. So I would expect that, you know, the majority of GPs' would be well within their comfort zone of being able to manage complications like that. The complication again similar to after miscarriage is that they can get an infection, so endometritis. So we ask them not to use anything inside the vagina, so no sex or tampons, those menstrual cups until we're happy that the product has passed. And if their discharge becomes smelly or malodorous, or they do get the temperature, then we need to treat with antibiotics. Again, that's that complications, quite uncommon. But it does happen. And in that case, we need to ensure the patients have access to prompt medical care so that we can manage those complications.

 

Dr Elissa Hatherly  14:32

Right. So we've given the MS-2 step medication having counselled the patients about their options, what to expect with the process and obtained written consent. The patients have had the progesterone blocker 36 to 48 hours before having the prostaglandin and then we'll start to pass the products of conception, hopefully and there'll be getting some bleeding. We've talked about the risks and the complications, how do we then follow up those patients after they've had their medical termination?

 

Dr Jasmine Davis  15:10

That's really important that we follow them up to make sure we find out nice and early, whether there's been a complication. So my personal practice is to give people a phone call a few days after that bleeding day, just to make sure that they did bleed, that they did pass products, and that everything went according to plan. You know, with telehealth over COVID, it has made things a lot more convenient for the patients that they don't have to keep coming in for these appointments. So people find that pretty convenient. The other thing that we need to do is do a follow up  beta hCG, usually about seven days after the Misoprostol. That's when I arrange it, and making sure that the beta hCG has dropped by 80%, at least, if there's an ongoing increase in beta hCG, or if it hasn't dropped significantly,that makes me think that, you know, things haven't really gone according to plan. And that we need to investigate further to determine, you know, is there an ongoing pregnancy? Or is there significant retained products that that could keep that beta hCG up high?

 

Dr Elissa Hatherly  16:24

Right, so I imagine that history then from those patients about whether or not they've had significant bleeding in the first instance is super important too. Now I understand there's a 1300 number that we can register our patients to provided by the Marie Stopes organisation to help provide that after hours care for our patients after they've commenced, their MS-2 step. Can you talk us through that, please?

 

Dr Jasmine Davis  16:51

Yeah, so the manufacturer of the medication provides a 24/7 support line. And that's staffed by a nurse. So it's really helpful for the patient to be able to make a phone call and get some immediate advice by someone who's got that expertise in the area, particularly when our clinics may not be open. I think that would probably save a few people a trip up to the emergency department for sure because they get that immediate feedback as to whether the bleeding they're experiencing is okay, or is it too much, or what to do next. So that we can put a link to that phone number, I don't know it off the top of my head, to be honest. But you know, often providing that in the written information for the patient so they've got something to refer to.

 

Dr Elissa Hatherly  17:44

Yeah, having that reassurance is incredibly important when you're embarking on this kind of medication for sure. Now, you mentioned contraception earlier, Jasmine, you mentioned larcs, in particular, those long acting reversible contraceptives, and starting that conversation about contraception early in the process for these women. What do you talk about with your patients in terms of contraception?

 

Dr Jasmine Davis  18:11

Well, look, I find that most people are quite receptive to contraception in these consults, because they've seen, you know, the immediate consequences of either their contraception not working, or that they haven't been on anything. So, you know, I'd like to encourage them to use something that's reliable. So you know, if they had been taking the contraceptive pill, and they've been missing a few doses, and that's why they've had a failure of the contraception, well, then, you know we need to find something that works a bit better for them and doesn't rely on them, you know, being able to take it every day. So, you know, something like the hormonal implant, the implanon or the IUD the Mirena or the Kyleena, are all really appropriate choices. It does have to be a bit of a delay in inserting the IUD after having the medical termination just to make sure that all the products have passed and the uterus is empty. So there is that little window there where the person could get pregnant in that time. So I do always offer that we could bridge that gap with the Depo Provera which can be given on the day of the termination. The implanon can also be inserted on the day of the termination and the combined contraceptive pill can be started on the day after the Misoprostol.

 

Dr Elissa Hatherly  19:37

So, Jasmine, yeah, once the products of conception have passed, it'll only be about eight days before fertility returns for that woman. So starting that contraception early and that bridging contraception as you mentioned before they continue with a long acting reversible contraceptive of their choice would be ideal.

 

Dr Jasmine Davis  19:58

Absolutely. And look, I mean, at the end of the day, we have to remember that it's people's choice, whether they want to be on contraception or not. So it's all about facilitating them, providing them with the facts and encouraging them to make a choice that that works well. But, you know, all of our contraceptives do come with the risk of side effects. So I can appreciate that some people want to avoid the hormonal option. In that case, the copper IUD is certainly a good choice and is highly effective. Or if they if they are choosing to use barrier contraception, like condoms, then, you know, they just need to remember that condoms only work when. So if they break or if they forget, you know, then they just need to think about emergency contraception like the morning after pill.

 

Dr Elissa Hatherly  20:53

Okay, so you've given us a lot to think about Jasmine, I understand MS-2 step prescribing, you need a particular qualification for. Can you talk us through how we might become a prescriber?

 

Dr Jasmine Davis  21:08

Yeah, absolutely. So it's quite straightforward to become a prescriber, but you do have to do initial additional training. And you can access that via the MS-2 step website, the trainings all online. And once you receive your certificate, then you can start the process of of becoming a prescriber. I also found that there was a really useful module via the RACGP, which talked through non directive pregnancy counselling. And if you go through that planning process, then you do have access to the additional item number for that non directive pregnancy counselling. And another excellent resource is the therapeutic guidelines they've got really comprehensive advice on there now. So that's a great place to go if you do become a prescriber and need to troubleshoot any complications.

 

Dr Elissa Hatherly  22:05

That's fantastic information. And of course, for those clinicians who are not keen on becoming a prescriber themselves, or might even be conscientious objectors, of course, that's their choice. But it's important that they don't create barriers for women's access to those services with another clinician in their practice or at a neighbouring practice. How do we go about managing that difficulty with some of our peers?

 

Dr Jasmine Davis  22:30

Yeah, so I mean, look, the the law recognises that a doctor can have personal values or beliefs that mean they can't provide care for someone for termination of pregnancy. So in that case, they can invoke conscientious objection. But there is that legal obligation that they do need to advise the patient and refer to someone that can provide that care in a timely fashion. And, you know, we've talked about time being of the essence with, with the gestation, being able to provide the medical termination up to nine weeks, any delay in referral would be very inappropriate. You know, from an ethical point of view, the AMA Code of Conduct really outlines that doctors should continue to treat their patients with dignity and respect, and really refrain from expressing their own beliefs in a way that causes a patient any distress. So I think, you know, we've all got to be really aware of our own personal values and judgments. And sometimes it's a matter of keeping them to ourselves, and providing the care that the patient needs.

 

Dr Elissa Hatherly  23:34

Oh look Dr Jasmine Davis, thank you so much for your time today. This has been a really important conversation to have around medical termination of pregnancy. You've given us all a lot to think about. And we look forward to talking to you another time about another hot topic. Thanks so much.

 

Dr Jasmine Davis  23:52

Thanks goodbye Elissa. Talk to you next time.

 

Dr Elissa Hatherly  23:54

For more information about the Roundup or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health Council Health services, Aboriginal Community Controlled Health Organizations and general practice clinics.