Pension on fast track to 70

The Weekend Australian headlines suggest that by 2029 the government will have crept the retirement age to 70 years. I read that both Liberal and Labor treasurers believe pushing the retirement age will improve the sustainability of the Australian pension system in the face of improvements in life expectancy.

That’s fair enough for me, because as long as I am not shuffling around a nursing home, eating mash everything, wearing a nappy and painting the walls my poo. I intend to meaningfully continue to contribute to society with gainful employment

A few weeks ago, I went for a bike ride and had to push myself to keep up with the pack leader, who is just one year short of the current retirement age. I expect he will be going strong at 70, 80 and maybe 90.

Then I thought about some of the older than me people I have seen in clinic in the last week, some will probably reached the end of their telomeres by 65 let alone 70.

But how does Treasury’s theory account for those more weathered by the morbidity of aging?

I fear that in years to come I will be filling in even more TDRs to support disability pension claims for those whose health failure predates 70.

Just another symptoms of a society arbitrarily demarcated by chronology and gender rather more selective criteria. Like start school at 5, driving at 17…….

I wonder what would happen if I were to suggest  that women should retire latter?

 

life chartlife expectancy

 

PS

You may have read in the same article the Joe Hockey quote that one in every three children born today will live to 100. I’m not sure where he gets his statistics from but from looking at ABS data it is closer t 1% rather than 33%

 

 

Triple 000 here, will that be paramedic or taxi?

This news items sounds like a victory for common sense.

Paramedics given power to send patients to GPs in NSW crackdown trial

People on the New South Wales central coast calling an ambulance for trivial matters such as tooth aches will be taken to their local doctor instead of hospital in a new trial.  The trial will give paramedics the power to decide whether a case warrants a hospital visit or a trip to a general practitioner (GP). The move has come out of recommendations from an Auditor-General’s report and is designed to relieve pressure on emergency departments.

Ambulance Service deputy commissioner Mike Willis says it will mean less time wasted on more trivial ailments.

“Sadly sometimes people call paramedics to their home for trivial things such as sore teeth, or in fact they’ve run out of their medication. That’s not what paramedics are for, that’s what taxis are for. This trial is designed to take those patients who are not life threatening and have low acuity illnesses direct to their GP where they can be assessed.”

http://www.abc.net.au/news/2014-03-09/paramedics-given-power-to-decide-destination/5308548

It seems to me that the trial is still going to have paramedic crews acting as taxis. Instead of taking someone to an ED they are being taken to a GP. Maybe the ambulance service could just hand out taxi vouchers which can just be used to attend a health practitioner? Be it doctor, dentist or pharmacist…… iridologist, nutritionist, chiropracter??

I do see a problem for the paramedic crew as to which GP the patient may be taken to. I’m certain AHPRA would take a very dim view of any GP-paramedic collusion.

There seems to be a difference in what is an ambulance from state to state. A 2010 paper by Eburn and Bendall (The provision of Ambulance Services in Australia: a legal argument for the national registration of paramedics. Australasian Journal of Paramedicine, 2010; 8(4)) gives some background on the situation. Another example of how the laws of each Australian state differ (for no good reason) and can create confusion!

A sense of entitlement?

Recently I has a conversation with a patient who had asked me to redo a Centrelink Certificate.  According to the copy he brought in he has chronic back pain and depression that prevent both gainful employment and him actively looking for work.  Horatio (not his real name) tells gets a sore back, sometimes feels a little sad and spends most days in a variety of non-productive pursuits.

I see in his record from a few years ago a psychiatrist letter that deferred making an Axis I diagnosis until he stopped multiple substance abuse. He tells me he has quietened down a little in the last few years.

He tells me he hs given up on beer because it gives him diarrhoea! He has substituted spirits. He was  bit vague on the actually quantity in standard drinks. So I asked how much would he spend on alcohol?

Depends he said on whether he goes to the pub or just visits a mate. Finally after much umming he settled on around $100 a week.  Then add in cost of the tobacco! He hints that it is criminal that the price has risen so much recently. At least he says he doesn’t have to pay for his cannabis as he grow his own.

That would be fine (well not really) if he was gainfully employed. Except he isn’t.

He thought that it was quite alright to use his Centrelink benefits to support his non-nutritional intake and lifestyle choice. I consider whether it would actually achieve anything to challenge his view or should I just copy the previous form and move onto the next patient…….

Government bails out 20,000 tonnes of chocolate……but no fruit

Employment Minister Eric Abetz has defended the Coalition’s decision to provide chocolate company Cadbury with $16 million of taxpayer’s money in the wake of its rejection of SPC Ardmona’s bid for government assistance, arguing the Cadbury funds will be good for regional tourism in Tasmania. Read more

To quote the Minister

“There is no doubt that the Cadbury tours were very popular. People of my age [he is 56 years of age] remember them and talk about them. And it’s great if they can be reinstituted and will add to the total tourism experience for Tasmania, beside, might I add, this expansion of Cadbury’s in Tasmania will see the dairy herd grow by 6,000 head of cattle. So that is a substantial boost in Tasmanian terms. And, of course, we will be exporting an extra 20,000 tonnes of block chocolate from Tasmania.”  ABC Insiders 2/2/14

Both are foreign-owned companies but both provide an employment opportunity to local families. Both have been operating in Australia for a long time., having started in the early 1920′s.

Political machinations aside I wonder what kind of public health message this recent bail out sends to the community.

May I offer my opinion….

It is fine to underwrite 20,000 tonnes of obesity-inducing chocolate confectionery on the pretext of encouraging a tourist-driven factory visit revitalisation  for Tasmania. But it is not okay to use tax payer dollars to assist the fruit & vegetable processor, a much healthy option in this obesity ravaged country!

Now I am not saying that SPC Ardmona products are all healthy but I would rather have my kids eat a Goulburn Valley fruit salad rather than a Caramello koala, or a serve of baked beans than a block of Dream.

May I suggest if SPC Ardmona introduce a tour to its Shepparton factory!

FVMPageImage

For the health message go Crunch and Sip

No conflict of interest. I offer no bias as I have eaten both company’s products. And I even visited a Cadbury factory albiet in Dunedin, New Zealand.

No blood no stones…..challenge dogma

From a previous Post…..

A 60-year old man leaves home with the hint of an impending UTI. Pre-emptively he started a course of antibiotics from a repeat left over from a previous successfully treated UTI. He travels across Australia gradually getting worse. He stops for advise at a mainland country hospital. There he is given the diagnosis of pyelonephritis treated with oral antibiotics and analgesia. Shortly after arriving on KI he presented to quite unwell, febrile, tachycardic and dehydrated with marked left abdominal pain. My working diagnosis was diverticulitis and I admitted him, hoping that he would settle with IV antibiotics and not require a journey with the flying doctor to Adelaide. Two days latter with CRP risen from 60 to 220, rising creatinine, still requiring morphine for his pain, bowels not open, with no blood in his urine, he is transferred to the care of a friendly surgical registrar at a big teaching hospital. A CT scan revealed a large mid-uretric stone, hydronephrosis and perinephric stranding. He was stented 2 days latter by urology registrar who happily told me 30% of patient with stones don’t have blood in their urine!!

Okay so what can I learn.

Oxford Handbook of Clinical Medicine suggests that a mid-uretetic renal stone may mimic diverticulitis.

Through the mists of time I had accepted that if you don’t have blood in the urine then you can’t have a kidney stone.

Maybe I have been prejudiced by the ED mantra

“moaning & groaning drug seeker, no blood in the urine, cant be renal colic, no opiates for you, just a paracetamol & indomethacin suppository….. oh, your leaving are you?”

So is my friendly urology registrar right?

To quote Up To Date (add the American accent)

“On the other hand, the absence of hematuria in the setting of acute  flank pain does not exclude the presence of nephrolithiasis. Hematuria is not detected in approximately 10 to 30 percent of patients with documented nephrolithiasis.  One factor that may undermine the sensitivity of hematuria is the  interval from the onset of acute pain to the time of urine examination.  In a retrospective study of over 450 patients with CT-documented acute  ureterolithiasis, hematuria was present in 95 percent on day one and 65  to 68 percent on days three and four.”

Press and Smith reviewed 140 patients who presented with flank pain to their emergency department from January 1, 1992, through December 31, 1992, and underwent intravenous urogram. No haematuria was found in 14.5% of patient proven to have stones. They also found that by considering a negative combination (urinalysis plus urine dipstick test) as a new definition of negative hematuria, the incidence of negative hematuria in patients with acute stones was only 5.5% (P < 0.031). Press SM, Smith AD. Incidence of negative hematuria in patients with acute nephrolithiasis presenting to the emergency room with flank pain. Urology. 1995;45(5):753.

Bove et al reviewed the medical records of 267 consecutive patients with acute flank pain referred for unenhanced helical CT. Microscopic and dipstick urinalysis data were obtained in 195 patients. Using helical CT as the gold standard, we calculated the sensitivity, specificity, predictive value and accuracy of hematuria for diagnosing ureterolithiasis. Of the patients with ureterolithiasis 33% had 5 or less, 19% had 1 or less and 11% had no red blood cells per high power field. Bove P, Kaplan D, Dalrymple N, Rosenfield AT, Verga M, Anderson K, Smith RC. Reexamining the value of hematuria testing in patients with acute flank pain.  J Urol. 1999;162(3 Pt 1):685.

 So, maybe the off the cuff remark was a little overstated. Regardless I had succumbed to my own personal dogma that no blood no stone. Lesson learnt.

Trial of labour or elective section….what to choose?

I help to provide a low risk obstetric service in a remote area. I work in private practice and provide my services to the local hospital on a fee for service basis.

Imagine a 36-year-old woman who has had four babies by vaginal delivery in another location without any complications.  Her last was an elective section for a breech presentation in a teaching hospital. It was a routine delivery.

Now she comes and asks me where she could have her next baby. If she wants a repeat section would be prepared to do it at our local hospital.

Significant obstetric risks for her include;

  • 1:4 to 1:10 risk of placenta accreta if she has placenta previa
  • 3:100 risk of placenta accreta if there is even if there no placenta previa
  • 3:100 that the next baby also being breech at term

In choosing the mode of delivery the NIH Consensus Development Conference Statement on Vaginal Birth After Cesarean: New Insights published in 2010 provides some guidance in making this decision. In a hypothetical group of 100,000 women of any gestational age who undergo either procedure the table below shows the complication risks

Trial of labour after a Caesarean section

Elective repeat Caesarean section,

Maternal deaths

4

13

Uterine rupture at term

778

22

Hysterectomy

157

280

Blood transfusion

1200

900

Deep vein thrombosis

40

100

Perinatal deaths

130

50

Neonatal birth trauma

180

30

Neonatal hypoxic ischemic encephalopathy

46

0

The rates of maternal hysterectomy, haemorrhage, and transfusions did not differ significantly between trial of labour and elective repeat Caesarean delivery. I wonder how many GP obstetricians are able to manage the 0.28% of women who will need a hysterectomy?

Currently our hospital only provides elective repeat Cesarean section. This was a decision which predates my arrival and primarily it was a decision based upon the concern that a uterine rupture may overwhelm local resources. Thus the decision becomes complicated by whether the woman wants to go to town or stay home. Generally, the journey to town to await the onset of labour is recommended at around 37 weeks. This is a long time to be potentially apart from support networks and can be a financial drain on families.

Now, something to stir a conversation.

In private practice you can often make a decision not to look after a patient. After all, they may well be seeing you by a quirk of the appointment system. You skill set may not be appropriate to the patients needs. Obviously if the patient has anaemia and melena they need someone who can do an gastroscopy and sort out the bleeding. If they have paranoid schizophrenia they need the help of a psychiatrist.

What if you feel like you have failed engaged with this theoretical pregnant patient and not been able to establish a therapeutic relationship. You can, I believe, suggest that they would be better served by seeing a colleague. But what do you do in a remote setting were the alternative to you providing care may involve a distant journey?

Or do you suck up your reservations and continue to treat her despite your feelings.

When not to travel….

This Christmas break has highlighted to what extent some people will go to fulfill the need to travel.

Examples of note

A 60-year old man leaves home with the hint of an impending UTI. Pre-emptively he started a course of antibiotics from a repeat left over from a previous successfully treated UTI. He travels across Australia gradually getting worse such that he stops for advise at a mainland country hospital. There he is given the diagnosis of pyelonephritis treated with oral antibiotics and analgesia. I am not certain what my colleague was thinking but the man continued on his way to KI. Vomiting can be expected on the ferry but not fever and vomiting along the highway even before Cape Jervois. Shortly after arriving on KI he presented to the local hospital quite unwell, febrile, tachycardic and dehydrated with marked left abdominal pain. My working diagnosis was diverticulitis and I admitted him, hoping that he would settle with IV antibiotics and not requiring a journey with the flying doctor to Adelaide.

A 50 something year old man arrives to check his warfarin dose. Two days earlier his implanted defibrillator has fired off, not once, twice but three times. Felt like a horse kicked me in the chest her explained. Oh he went to hospital and got cleared to continue travel. He was restarted on amiodarone and ask to check his INR given the interaction. The local doctor did have a conversation with his cardiologist. Good and did he think it was a good idea to continue to travel to a remote (but stunningly beautiful :- ) part of Australia? Sure he said. The look on his wife’s face suggested maybe subtly different advise.

A family of four had booked a Christmas holiday on KI to spend time with his cousins including a new born baby. A two year who developed a red rash, fever and stopped eating was not enough to deter the holiday. Thankfully a viral exanthem rather than meningitis. A few days latter the local family brought in one of the children with something similar. Thanks for the Christmas present.

I wont tell you how many times I have had to write prescriptions for people who travel with their medication still in the bathroom cupboard back at home.

No we don’t have a CT, MRI or half reasonable ultrasound machine here.

Apart from an istat, bloods and other pathology get sent to Adelaide once  day and we get the results the next day.

Oh and we drive on the left…….