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Biggest test of all

Cate Swannell
Med J Aust
Published online: 18 May 2015

The combination of emergency medicine and a rural, remote setting provides the ultimate challenge, according to Dr David Rimmer

DR David Rimmer is an emergency physician with a preference for working in rural and remote areas.

These days he is the executive director of medical services for Central West Health in Queensland, for which Longreach is the main hospital and town centre.

In his days as a fly-in fly-out emergency doctor with the Royal Flying Doctor Service (RFDS), Dr Rimmer learned the realities of remote emergency situations.

But ask him about the worst situation he’s ever flown into and his answer may surprise. Rather than telling of huge motor vehicle accidents or other large events, it is one woman’s tragedy which sticks in his mind.

“We were called in to do a small hospital retrieval of a patient with a very severe head injury”, Dr Rimmer tells the MJA.

“The patient was very drug affected and had fallen backwards off a balcony.”

The woman was morbidly obese and intubation had failed. Her lung pressures were very high. In the end, the head injury proved to be unsurvivable.

“It was a huge knock to my self-confidence”, Dr Rimmer says.

“It’s the reason I continued to push for as much training as I could, to maintain the highest standards.

“The review of the process found that we’d handled it well, that we’d done everything we could, but it’s a very bad feeling to walk away from that situation without [saving the patient].”

Family history

It was almost inevitable that Dr Rimmer would become a doctor of one kind or another. Both his parents, Betty and Bill, were general practitioners in a rural setting — St George in southern Queensland.

“My father did the surgery and caesareans, and my mother ran the birthing suite and did the anaesthetics and anything else my father didn’t want to do”, Dr Rimmer says.

After training in Queensland, Dr Rimmer spent 5 years in hospitals before deciding to “go rural” and acquiring the extra skills needed in surgery, obstetrics and adult medicine he felt he needed to be a successful country GP.

“I had planned to go back to St George and work with my parents, but my brother, who was also a doctor, had settled in Toowoomba and wanted me to go into practice with him. My wife said yes”, he laughs.

Dr Rimmer spent 17 years in Toowoomba. As more specialists came to town, he diversified, becoming involved in the division movement, and running an adolescent health program in eight secondary schools, using drama classes as a way to demystify doctors, and giving teens the skills to talk with their doctors and better access health services.

Along with Dr Denis Lennox, now director of Rural and Remote Medical Support (for Queensland), operating as Queensland Country Practice, Dr Rimmer set up the first rural training program in an Australian hospital, attracting “really good doctors who wanted to go bush”.

“I’d always said that when they stopped me doing obstetrics I’m leaving town”, Dr Rimmer says.

“Eventually every other GP in Toowoomba gave it up and we got caught in the middle of the midwives versus specialists argument.”

So Dr Rimmer moved to Brisbane where he set up private emergency practice at the Mater Hospital and “did all the courses I could”.

In 1998 he began working locums for the RFDS, work he continued until 2012. It meant 6 weeks a year, spread across the 12 months, working in every RFDS base across Queensland.

That time included a 3-year stint flying into Kowanyama — an Indigenous community on the west coast of Cape York Peninsula — on a 2-week-in, 2-week-out basis.

So how does it feel to be flown into an emergency situation, in the middle of nowhere, with only yourself to rely on?

Self-reliant

“I always quote my mother”, Dr Rimmer says.

“You have to step back and think. There’s nobody else better qualified than you around and the patient has a significant problem.

“All you can do is your best, so get over yourself and get on with it.”

His life has had its dangerous moments.

“We were flying a patient who was on a ventilator into Brisbane when the plane hit an eagle and cracked the windscreen”, Dr Rimmer says.

“There was no visibility but the pilot said that wasn’t a problem because they could do an instrument landing, but it did cross my mind to wonder what would happen if the window fell out.

“In the end I took a fatalistic approach and made a joke of it with the nurse, saying if the cabin depressurised we’d take it in turns with the patient on the ventilator.”

In the end, the RFDS plane was given priority to land and made it safely to ground.

The differences between emergency medicine in the city and that in the country are stark, Dr Rimmer says.

“If there’s a major motor vehicle accident in the city, then the emergency would be dealt with by teams of 14 or 15 people really organised in a ballet, with one person whose only job is to direct traffic.

“In a rural setting you’re the one who has to do the thinking while intubating, organising retrieval — multitasking.

“In the city, if you’re in private practice you’re seeing captains of industry, famous figures and the like.

“If you’re in the public sector your patients tend to come from the lower socioeconomic demographic.

“But in the bush you get it all. You have to deal with a broader spectrum of patients.”

In his role as executive director of medical services for Central West Health, Dr Rimmer is responsible for health care across a vast area.

Central West Health covers the health care needs of 0.3% of the Queensland population spread across nearly a quarter of the land mass of the state. The region has major health inequalities, such as understaffing, limited resources and geographically isolated service access.

Dr Rimmer is now a graduate of and advocate for Emergency Life Support (ELS) — a comprehensive, not-for-profit course that teaches pivotal skills and knowledge to doctors to help manage medical emergencies safely and effectively.

Lifelong learning

The first ELS course was held in Tamworth, New South Wales, in 1997, according to a spokesperson for the company.

“By the end of 2014, 234 courses have been held in various locations through Australia and New Zealand and over 4500 medical practitioners have participated in the course.

“The ELS course became an incorporated association in 1999 and, as such, operates as a non-profit organisation, is self-funding, and continues to operate on the strength of its instructors who donate their time and expertise for free.”

Dr Rimmer has attended the ELS course over the past few years and strongly believes that it “supplies an innovative toolkit for doctors and nurses in rural areas”.

As a result, the 14 doctors and seven nurses from the Central West Hospital and Health Service, together with colleagues from surrounding areas such as Emerald, will attend an ELS course held for the first time in an isolated outback town.

Dr Rimmer is delighted that the course is being held in Longreach as it “allows the instructors to experience the towns whose doctors they teach”.

“Usually, our doctors would have to travel over 1000 km to access training.”

Before he took the ELS course, Dr Rimmer says he would get “very quiet” during an emergency.

“Now I talk everything out methodically”, he says. “It instils calm in the people around you — who are usually more junior doctors.

“Learning to talk in moments of stress has been very important for me.”

Emergency medicine, he would tell medical students, is challenging.

“You have to be realistic, well organised, you have to be careful of yourself, and you must be well rounded.”

Working in rural and remote Australia adds another level of challenge, he says.

“The more you want to test yourself, the further you need to go from the mother hospital.

“You can’t beat the community and the sense of belonging in the bush, and being accepted as a person.

“[Emergency rural medicine] is one of the last bastions of real medicine.”

  • Cate Swannell


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