Author:  Stephanie Pommerel

Editor:  Antonia Clarke

 

Dr Rolf Gomes and his work with the Heart of Australia was one of the reasons I chose the remote town of St George in rural Queensland as the location for one of my third year placements.  I’d previously seen Australian Story feature his vision and unshakeable drive to bring cardiology services to the bush.  With considerable determination along with substantial industry and philanthropic support, Dr Gomes has redefined outback specialist service delivery to provide a comprehensive mobile service articulating with, yet independent of, the public sector.  A custom-built truck with a team of staff delivers a compact suite of cardiology, medical and diagnostic services to the outback towns of Queensland.  I was curious to meet the man behind this initiative, and to see how this contributed to the nexus of local health service provision.

When I arrived at St George Medical Centre to begin my ‘Medicine in Society’ placement as part of the University of Queensland’s inaugural Doctor of Medicine program, I was offered a list of contacts to make the most of my time there.  I was delighted to note Dr Rolf Gomes’ details on that two-page document, and immediately set about getting in touch.  Shortly after, I arranged to join the Heart of Australia team for the next weekend they would be in town.  

The Heart of Australia truck runs two circuits throughout Queensland and arrives in St George for a weekend almost every fortnight.  It is an incredible service, meticulously designed to provide a mobile cardiology consultation suite, with capacity for exercise stress ECG and echocardiography, including resuscitation – if required, of course.  I was impressed by the execution of this vision as I stepped onto the truck directly into a reception area, complete with staffed desk, cushioned seats and magazines.  At the front of the truck, between the reception and driving cabin, there is a kitchenette for staff to make tea and where meals are prepared on the road, and adjacent, the on-board toilet.  Towards the back of the truck a second consultation space has recently welcomed Dr Merryn Thomae, dual qualified General Physician and Endocrinologist.  Dr Gomes provides the bulk of cardiology services in collaboration with several colleagues.  The group’s services on offer are expanding rapidly.  Psychiatry and Gastroenterology have been added this year alone, along with Nephrology. 

Dr Gomes is an affable, unassuming man, whose laidback approach belies a fierce passion to bridge the gap of health inequality for people living in rural regions compared to their urban counterparts.  The relaxed yet professional tone is set from the moment you step onto the truck.  There is no sense of time pressure – despite the fact the team necessarily keep an ultra-tight schedule. 

It’s an approach that speaks volumes to the local farmers, bushies, and Indigenous community alike.  Sure, he’s in a suit, but Dr Gomes is not some city slicker without appreciation of the harsh realities of living remotely.  He is fully aware of the distances involved for folk to travel to the city for specialist consultation.

St George is a picturesque spot, located along the banks of the Balonne River.  It’s a 500km drive west of Brisbane, along the Moonie Highway.  A place rich in history and full of natural beauty, the Balonne shire has a population of around 5000, with the local economy sustained by agriculture.  For most people in St George, attending specialist appointments in the city would mean three days off work:  a day of travel there and back on either side of a day in town.  There’d be a trip for an initial appointment, a second for tests if they hadn’t been arranged prior, and if intervention such as angioplasty or coronary artery bypass grafting were needed, there would be further time off work, not to mention the time required for recovery. 

Adding to the travel time, there are increased costs of travel and accommodation, and the safety risks of long distance driving.  The Heart of Australia takes the initial appointment and screening investigations into outback communities.  Plenty of local people, who would otherwise have difficulty taking time away from their livelihood, can now choose to access this local health service for screening, prevention and treatment, rather than pushing on, prioritising their livelihood over their health.

Rural and remote Australians suffer worse health outcomes than do people living in metropolitan areas [1].  A recent systematic review into the burden of ischaemic heart disease in Australia showed that while Australia’s rural and remote populations are far from homogeneous, they consistently suffer poorer outcomes with regards to premature mortality and increased death rates [1].  Life expectancy decreases with increasing remoteness, although prevalence appears to be equivalent [1].  Indigenous Australians, although most live in urban centres, comprise a greater proportion of the remote population [6].  There is an urgent need for comprehensive and sustainable delivery of dedicated cardiac care to these areas, with a particular focus on preventative health and risk factor modification [6].

Although St George Hospital provides acute medical treatment in its 28-bed facility, specialist services including cardiology are limited to outreach clinics provided on a monthly basis.  For one local farmer, further investigation of unstable angina could not be performed locally or expedited in Brisbane.  He presented with increasing frequency but despite positive ECG findings, serial cardiac markers remained negative.  Together with a significant personal and family history of heart disease (his father and all three brothers died from heart attacks), a 70 pack-year smoking history and dyslipidaemia, the patient’s condition was precarious.  He understands that aeromedical evacuation would only be warranted if myocardial infarction could be confirmed; given his history, such an event would likely be fatal. 

While cardiology is a discipline that lends itself to telemedicine [3] with ECG findings transmitted for tertiary consultation, there is no denying that the presence of a cardiologist, with tools available for local diagnostic testing, streamlines the treatment pathway.  Given that population density and location influence the provision of and access to services, rural settings lend themselves to the development of new models of healthcare delivery [4].  Local ventures must not only be economically feasible, but must also have adequate staffing for their operation.  Because each stream of health service relies on people to deliver them, there’s a built-in fragility to the provision of services.  Despite the commitment of a core group of medical practitioners in St George, like all country towns, services are limited because of difficulties attracting and retaining qualified staff [7; 8; 5; 4]. 

With evidence-based practice at the forefront of developing policy and its outcomes of practical resource provision, rural research is needed urgently to complete the picture [1].  Local involvement in this process improves acceptability of practice, leading to sustainable implementation of verified practice [2].  However, practitioners must have protected time and space to collaborate in research. 

Recognising these issues, I developed a particular interest in addressing the rural workforce shortage and poorer health outcomes for people outside the metropolitan area.  Dr Gomes works closely with a team of people to bring about this service; their efforts are ambitious and commendable.  Further proof of its success is required to attract long term, sustainable support for the Heart of Australia model.

I felt honoured to spend the day sitting in on consultations with Dr Gomes, as he saw his booked patients.  It is clear that they appreciate not just his returning presence but also his matter of fact approach.  New patients are greeted with a casual yet incisive initiation to the consultation.  “Tell me a bit about yourself so that I can get to know you.  Where did you grow up, do you have any brothers and sisters?”.  For nervous outback patients seeing a specialist doctor from the city, it immediately puts them at ease and allows the interview to begin without fuss and a focus on facts ensues, allowing the process to move seamlessly from history into examination. 

One of my most memorable experiences of patient examination during my time at Heart of Australia was when I was asked to take a patient’s blood pressure.  The first time this occurred painfully slowly – having just come off my mental health rotation, I was a little rusty.  Unsure of my answer, Dr Gomes repeated the reading in just a fraction of the time.  Thankfully, he did not comment when the blood pressure cuff went on the wrong way around – he simply corrected my error and allowed me to continue.  This no fuss approach was replicated with ECG stress testing, which was performed efficiently and successfully in such a close space!

For the farmer with unstable angina, following referral by St George Medical Centre Practice Principal, Dr Karen Benn, to Heart of Australia and subsequent consultation with Dr Gomes, echocardiography revealed critical four-vessel restenosis, and urgent coronary artery bypass grafting was arranged.  He is a living testament to the success of Dr Gomes’ Heart of Australia mission.  His story is just one of many, with every successful intervention producing local survivors, each poised to become an advocate for health within their own family and broader community.  When one person connects to a broader purpose and brings others together to combine focus and expertise, transformative change can result.  The Heart of Australia delivers a core service that goes not just to the heart of the country, but to the heart of the people who live there.

 

References

  1. Alston L et al. Rural Inequalities in the Australian Burden of Ischaemic Heart Disease: A Systematic Review. Heart, Lung and Circulation. 2017. February; 26(2):122-33. Full article available from ScienceDirect: http://www.sciencedirect.com/science/article/pii/S144395061631530X?via%3Dihub
  2. Brooke F. Rural and remote research: Supporting the heart and soul of Australia. Australian Journal of Rural Health. 2016. December; 24(6):424. Abstract available from PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27981685
  3. Molinari G et al. Telecardiology and its settings of application: An update. Journal of Telemedicine and Telecare. 2017. January. Abstract available from PubMed: https://www.ncbi.nlm.nih.gov/pubmed/28084886 
  4. Smith T, Brown L, Cooper R. A multidisciplinary model of rural allied health clinical-academic practice: a case study. Journal of Allied Health. 2009; December; 38(4):236-41. Abstract available from: ResearchGate https://www.researchgate.net/publication/40689284_A_Multidisciplinary_Model_of_Rural_Allied_Health_Clinical-Academic_Practice_A_Case_Study
  5. Spiers MC, Harris M. Challenges to student transition in allied health undergraduate education in the Australian rural and remote context: a synthesis of barriers and enablers. Rural and remote health. 2015. June; 15(2):1-17. Full article available from: http://www.rrh.org.au/publishedarticles/article_print_3069.pdf
  6. Walsh WF, Kangaharan N. Cardiac care for Indigenous Australians: practical considerations from a clinical perspective. The Medical Journal of Australia. 2017. July; 207(1):40-5. Full article available from: https://www.mja.com.au/system/files/issues/207_01/10.5694mja17.00250.pdf
  7. Wilson, NW et al. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural and remote health. 2008. August; 9(1060):1-21. Full article available from: http://www.rrh.org.au/publishedarticles/article_print_1060.pdf
  8. Young, SH. Outsourcing and benchmarking in a rural public hospital: does economic theory provide the complete answer? Rural and remote health. 2003. March; 3(124):1-14. Full article available from: http://www.rrh.org.au/publishedarticles/article_print_124.pdf

 

Useful resources

Blog – The heart of Australia by Rolf Gomes

 

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