Transcription: Talila Milroy
Editor: Emily Nash
On Tuesday 6 December 2016, Dr James Edwards who is based in Sydney interviewed Dr Rolf Gomes, a Cardiologist, about his innovative program ‘Heart of Australia’ which is based in Queensland. The following article is based on this phone interview which has been transcribed and edited.
Cardiologist Dr Rolf Gomes has revolutionised the way specialist medical care is delivered to Australians living in regional and remote areas of Queensland. He established the Heart of Australia program, also known as the Heart Bus, which delivers specialist cardiology, respiratory, general medicine and endocrinology consultations and diagnostic testing to patients in the bush. He also has plans to deliver gastroenterology and renal services in the near future and hopes the program can spread across the rest of Queensland and across the country.
The Heart Bus is a 25m long clinic-on-wheels, comprising a waiting room, two consulting rooms and a testing room in which stress tests, cardiac echocardiograms, holter monitors, sleep studies and respiratory function tests are performed. The truck travels about 8000km per month, which is close to 100,000km per year. It runs seven days per week. “It cost about $1.5 million to build…it’s been used very efficiently and with a lot of effort from a very small team” says Dr Gomes.
“Years ago when I thought about bringing cardiovascular medicine to the bush I couldn’t see any point for a cardiologist to fly a thousand kilometres just to see someone and say you’ve had pain in the chest so I think you need to travel a thousand kilometres back to run on a treadmill for nine minutes.”
Motivated by his first hand experience of lack of health infrastructure as a child growing up in India and working as a junior doctor in remote areas of Australia, Dr Gomes is passionate about improving health outcomes for future generations of Aussies living in the bush. “In 2011, the Bureau of Statistics released data that showed if you live out in the bush you’re 40% more likely to drop dead of a heart attack, 70% more likely to die from heart failure and 32% more likely to have a stroke. What we’re trying to do is bridge the gap in outcomes by addressing these kinds of issues of accessibility to basic diagnostic infrastructure” states Dr Gomes.
As a cardiology trainee with a background in engineering in the petrochemical industry, Dr Gomes dreamt up the idea of a bus to mobilise more services, particularly cardiac services, to different regions. After his three children went to bed one night in 2010, he drew up the initial plans for a mobile truck. The truck first rolled into town in October 2014, after three and a half years of hard work, many pavements pounded, a few doors slammed in his face and remortgaging his own house in order to fund the project.
“I realised there were four main things we had to achieve. The first was finding the money, secondly finding the workforce, the specialists and the staff to run the program, thirdly being able to when the time came to deliver the service efficiently and fourthly getting the community and the GPs on side. And if we could do all of those four things successfully, the program would be a success.”
Growing up in India and experiencing the death of his brother as a child, Dr Gomes was touched personally by the consequences of a lack of healthcare. As the son of Indian immigrants, Dr Gomes explains he had a desire to give back to the Australian community in exchange for the chance to “grow up in this country and receive such a good education and all the opportunities I’ve had”.
Dr Gomes recalls the difficulties he experienced working as a junior doctor with limited specialist support and limited equipment in remote areas such as Palm Island, “I remember one occasion when I was really struggling with a neonate on Palm Island who I thought was going to die and thankfully the helicopter came and evacuated the baby to Townsville neonatal intensive care. And then on another occasion there was a gentleman who came in with severe pain in the neck and I was almost certain he had an unstable cervical spine fracture. Trying to convince him to go somewhere that had a basic x-ray imaging service was almost impossible and I had this sense of anxiety about how we need to bring more services out to regional areas.”
These formative experiences had a lasting impact on Dr Gomes and were some of the driving forces behind establishing the Heart Bus. A love of the country and of country people also helped. “Being able to see the horizon without traffic lights and buildings, it allows my mind to stretch. It allows me to be a little bit more visionary and I find it very therapeutic. I love the country people, they are very stoic, they are very grateful for what they’ve got and they’re fairly straight shooting people”, claims Dr Gomes.
Dr Gomes believes that the mobilisation of health care is more possible now than it was ten years ago due to the miniaturisation of technology occurring in parallel. “When I was a cardiology registrar ten years ago you would push around a machine the size of a washing machine, which was your cardiac ultrasound, whereas now they are the size of laptop computers. And internet bandwidth capacities have improved so every night the truck transmits ten to fifteen gigabytes of data and imaging. There are online patient records, so you log in and load up and you have access to the entire patient records so you’re not relying on filing cabinets and cream coloured charts”, says Dr Gomes.
“It is very stressful for a GP if they have a gentleman sitting in front of them who says ‘I was out there harvesting hay and I got a niggle in the chest but don’t ask me to go anywhere because we’re right in the middle of a harvest or I just can’t afford it’. So bringing the services right to the doorstep – the stress test, the ultrasound, the holter monitoring, the sleep studies, the respiratory function tests – it really provides the GPs and cardiologists the tools they need to help their practice.”
An independent cost benefit analysis funded by the Queensland Government in 2016 found that the program was cost effective. “So that every dollar the government was to invest they would get $2.70 back. It also showed that having the equipment on site means we find 25% more major cardiac pathology and 50% more minor cardiac pathology and that from an intuitive sense is expected because if you have the tools to diagnose the problems you’ll find more significant cardiac pathologies” reports Dr Gomes.
“The truck itself services thirteen towns a fortnight. It never stops and it stays in each town roughly overnight. There are hub towns where we fly a specialist and a sonographer in. So for me on a Thursday morning, someone picks me up with a sonographer and we go out to a town called Dalby where we see patients from 10am ‘til 6pm and then we go to the pub and have dinner. The next day we see a few more patients in Dalby, then the truck packs up and travels to the next town. Within an hour of arriving we quickly see a few patients again that evening and the next morning and then it travels to the next town. So I leave on a Thursday and I fly out on a Sunday and in that time I see roughly 30-40 patients. I fly back to Brisbane with the sonographer and the truck drives onto Charleville and on Monday we fly another team in, including a cardiologist and a sonographer. They then fly back on a Wednesday and then we fly in another team.”
The program has been warmly welcomed and widely accepted by GPs and patients in the bush, and the outcomes look promising. “Last year, the Heart of Australia saw more patients than the entirety of the Queensland Health Outreach service, so it is now the dominant service provider in Queensland for cardiovascular health in the bush which was what the original aim of the program was – to find those people that had been neglected and hopefully save some lives in the process…We think that we’ve kept in excess of two hundred patients out of hospital by picking up things early. We’ve had numerous Indigenous patients who have gone on to have bypass surgery with critical coronary disease and valve replacements for rheumatic heart failure. So in terms of Indigenous health outcomes, I’m really hopeful we can show a difference there as well and try and bridge some of those terrible gaps in outcomes. It’s also quite opportunistic because when we’ve got them there, if we need to do any further testing we can offer to do them the same day. So rather than give the patient the referral and say ‘ring up and make an appointment to go into town’ which might be 1000km away and three or four days away from family, we can go from symptoms to diagnosis to treatment potentially within the one visit” states Dr Gomes.
Dr Gomes hopes to inspire the next generation of junior doctors to find more innovative ways to deliver more medicine, to more people, for less money. He offers the following take home messages for junior doctors: