The rural physician and myocardial infarction: part 1: pre-hospital management.

The majority of patients who succumb to myocardial infarction die before they reach a hospital. Three types of services have been developed to reach and treat patients immediately: the mobile coronary team (Belfast model), the coronary ambulance (American model) and family doctor services. Of the three types, only the family doctor service is practical in most rural communities. Evidence in the literature suggests that it is possible for rural physicians to reduce the mortality from MI in the community by visiting the patient with a suspected attack in the home as quickly as possible. The alternative of bringing the patient to hospital by ambulance before he has received any treatment is probably much less desirable.

The rural physician and myocardial infarction: part 2: the hospital phase of treatment.

A critical review of the literature reveals several facts which are important in helping the rural physician decide where and how patients with myocardial infarction should be treated. The effectiveness of coronary care units has not been well established, even for patients admitted during the early phase of the disease; they do not benefit the majority of patients admitted five or more hours after the onset of symptoms. Transporting patients over relatively long distances during the early phase results in increased mortality. The survival rates for patients treated in small hospitals is quite comparable to that of patients treated in coronary care units. The majority of rural patients with myocardial infarction are therefore more appropriately treated in a small local hospital than by being transferred to a coronary care unit. Those coronary care units which have been established in small hospitals do not appear to have reduced mortality. Patients with myocardial infarction who are being treated in small hospitals should be observed carefully, but electronic monitoring should be used only when there is a specific indication.

Medical education in a rural health centre.

A health centre located in an isolated community on the northeast coast of Newfoundland has taken medical students since 1965. Currently students in their first year, in their clinical clerkship, and in the second year of the family practice residency, visit the centre. Responses from students at all levels have been very positive. To assess if this rotation had an effect on their subsequent choice of practice, questionnaires were sent to the former students three to nine years after their clerkship rotation. Almost all of the students subsequently went into family practice and there was a tendency for them to select small towns. A rotation of this type has real benefits for the supervising physicians and the rural community. It is helping to correct the maldistribution of physicians by specialty and location of practice. It is still viewed by the former students as a very valuable learning experience.

General practice in northern norway.

A study was made of general practice in northern Norway where conditions are similar to parts of rural Canada. The Norwegian general practitioner has developed expertise in the preventive and psychosocial aspects of practice and the team concept is highly developed. Since the general practitioner is separated from the hospital, his facilities for procedures and diagnostic workups are primitive. Involvement of general practitioners in medical education is not yet well developed although all new graduates spend a compulsory period in rural practice.

Training physicians to practice in remote canadian communities.

Of 31 hospital administrators from small northern Ontario hospitals, 20 indicated in a survey that their areas need more doctors. Of the 183 doctors practicing in these areas, 47% do not have local bacteriology services, 34% do not have blood gas analysis available, and 23% do not have a local physiotherapist. Of the 24 hospitals where surgery is done, only 16 have specialist surgeons on staff. Twenty-nine of the hospitals treat obstetrical cases, but only two have obstetricians; similarly, 29 of the hospitals treat myocardial infarction but only two have internists on staff. More younger general physicians are tending to have extra training in anesthesia. Only one hospital has a pediatrician. If general physicians are to care for patients in the absence of consultant back-up, they will need extra training. The University of Western Ontario is beginning a third year family medicine fellowship in an attempt to meet this need.

Medical service for isolated areas.

The important factors in providing medical care to isolated areas are discussed. These are the attracting of suitable staff through the provision of good working conditions, living conditions and remuneration. A type of organization which has proven successful in providing these conditions is described. An added advantage of this type of clinic is the provision of circumstances well suited to the experimentation in new forms of health care delivery and to medical education.

Management of myocardial infarction in a rural area.

In an attempt to determine the most appropriate type of facility for the treatment of myocardial infarction in a rural community, the five-year experience of a practice serving 10,000 people is reviewed. This population is found to have a low incidence of myocardial infarction, a low death rate from the condition both in hospitalized patients and in the general population, and a low incidence of complications in the survivors. None of the deaths either in or out of hospital would likely have been prevented through the use of specialized facilities. It is concluded that no such facilities are necessary in this community and that other areas considering their acquisition should justify the need on the basis of their own experience and not on accounts in the literature.

The safety of obstetric services in small communities in northern Ontario.

The safety of the obstetric care system in the small hospitals of northern Ontario was assessed by analysing the outcomes of all obstetric cases over a 2-year period. Information was retrieved by place of residence rather than hospital of delivery so that the overall perinatal system, including the referral patterns, would be assessed. There was little difference in perinatal loss rate (stillbirths and neonatal deaths up to 28 days per 1000 births) for residents of areas served by different levels of obstetric care. Areas served by units where cesarean sections are done regularly but which do not have specialists in obstetrics or pediatrics had a perinatal loss rate of 10.43, whereas areas served by units staffed with two or more specialists in both obstetrics and pediatrics and handling more than 1000 deliveries per year had a perinatal loss rate of 12.13. Although many of the smaller hospitals did not have the minimum capabilities suggested for obstetric units relatively safe care was being provided. These results do not support the need for further centralization of obstetric services in northern Ontario.

Videotapes as continuing medical education for physicians in isolated communities.

The lack of available and appropriate continuing medical education is a major problem for physicians practicing in isolated communities. This paper describes a pilot project in the use of videotapes as one method of meeting this need. The tapes were well received by the physicians who participated in the project and highly rated as being an effective learning method, appropriate to their practices. Videotapes provide an educational opportunity for physicians working in isolated communities at a relatively low cost and with little disruption of practice or personal life.

Management of obstetric complications at a small rural hospital.

To determine if there is a way of identifying obstetric patients in whom complications will develop, the experience of one small hospital was reviewed. It was found that there is no satisfactory method presently available that allows a hospital to select such patients so that they can be referred to a large centre. While the scoring system designed by Goodwin, Dunne and Thomas for assessing antepartum fetal risk is fairly effective in selecting fetuses at risk, its results do not correlate well with the frequency of obstetric complications. Since in a significant proportion of obstetric patients complications develop that require emergency intervention, it is important that hospital staff maintain their ability to do safe cesarean sections and to obtain blood for transfusion quickly. Hospitals in which there are fewer than 100 deliveries per year probably do not have a sufficient caseload to maintain the ability to do safe cesarean sections; it is therefore suggested that they discontinue obstetric practice. At hospitals with a larger caseload elective cesarean sections should be done so that the ability to do emergency procedures can be maintained.

A controlled trial of the impact of the family practice nurse on volume, quality, and cost of rural health services.

Rural Newfoundland communities with and without expanded role nurses were compared on a before and after basis. The rural communities are located in a geographically isolated area served by a 40-bed hospital staffed by salaried physicians. Primary care visits within the community increased by 186 per cent after establishment of the family practice nurse community clinic and attendance at the hospital decreased by 35 per cent. Acute care days in hospital decreased 5 per cent in the experimental group and increased by 39 per cent in the control group. A major portion of the community based visits provided to the experimental group were classed as preventive. The total annual health service cost per 1,000 persons in the experimental group increased slightly more than in the control group (26 versus 21 per cent). Adequate management of certain indicator conditions and drugs was maintained by the family practice nurse when compared to the adequacy rating for the physician during the same time period.