David McDonald. Away from ivory towers, Don't Forget the Bubbles, 2017. Available at:
It can be a challenging and fairly unsettling experience commencing work in a regional hospital if most of your prior exposure has been in a stand alone tertiary children’s hospital. The majority (80%) of urgent recalls to regional hospitals are neonatal, and at times you will be the only person present in the entire hospital with that skill set, so make sure you have done a decent length stint in NICU at registrar level before your rotation.
Some challenges registrars may need to adapt to are:
- Being On call
It is quite different to be “on call” if you are accustomed to the traditional frantically busy 10 -12 hour shifts that are a feature of working in tertiary units. The minute to minute work load is generally quieter. The challenge is not immediate workload and time pressure, but the prolonged commitment required to be available at short notice around the clock. One or two sick or unstable kids can make a big difference. The on call duration can be 72 hours continuously if covering over a weekend. It can be a long time between drinks!
The priority is to first ensure that your availability is absolutely rock solid – mobile phone batteries are charged, “dead areas” for reception are identified (mobile reception is patchy in regional areas), and a backup phone number ( e.g. mobile first/land line second) is available. The roster should be unequivocally clear about who is first and second on call and who the backup will be (typically registrar/then consultant) if communication fails.
It is good advice to continue after hours life as close to normal as possible while you are “on call”. This includes going to the gym, getting some exercise, eating and drinking sensibly (you cannot consume any alcohol when on call), getting adequate rest and sleep. It is unhelpful to sit at home watching the mobile phone waiting for it to ring. It can easily look like a ticking time bomb.
Ensure your offsite login for CIAP or the Clinicians Health Channel is working. This is a great resource for checking guidelines, drug doses and “Up To Date” when giving advice over the phone.
- Working in “mixed hospitals” can be challenging
The age range of patients attending the average Level 4 mixed ED will vary from 2 weeks to 102 years. This does mean that approaches that may be standard practice in a Children’s Hospital ED (e.g. septic work up/LP in a febrile 3 week old infant) is outside the skill set of many ED staff, including consultants. It is absolutely unhelpful to be critical of the situation. Productively engage with the department and assist them with areas of challenging paediatric care, particularly neonates. The quid pro quo of gaining their respect and affection will make your life much easier.
- You have less support.
In tertiary hospitals you can often get help straightaway e.g. from PICU. Out here you are the help, so it can be challenging. Familiarise yourself with available local resources – for example, the local anaesthetist will normally have enough paediatric experience to expertly secure an airway. Your consultant will be a great resource when things get sticky!
- Different policies
Different hospitals have different policies and there is no ‘just one way’ to do things. This is particularly true if your origin is from a stand-alone children’s hospital who tend to have policies that work well in that environment, but which, at times, encourage rigid and site-specific thinking. There can be many different ways to manage the same condition and local resources vary, therefore ensuring the same solution may require a fresh approach.
Most regional units adhere to commonly used guidelines such as NSW state health guidelines or the excellent RCH clinical practice guidelines.
An example of different policies that affect clinical management is the decision in timings of admission of a child with asthma to a ward. Some children’s teaching hospitals have a ‘you can’t go to the ward until you are on hourly salbutamol’ rule which is quite different from the “4 hour rule out of my ED” used outside the children’s hospitals. Insisting on adherence to policies that are not localised will mean that patients with asthma are stretched too early and under-treated in an attempt to ‘move them on’. Another example is nebulisers vs puffer/spacer in regional ED – nebulisers are familiar to ED general nursing/medical staff and require less direct supervision, so are at times used more readily than in children’s hospitals. Remember, it’s all salbutamol!
- Telephone communication
The nature of rural geography means that it is common to receive phone calls from distant units that are less well-resourced than yours requesting transfer or advice. This is challenging as you may not have visited the unit, or be aware of local resources, or have met with the person asking your advice. Doctors who have poor English skills in particular can easily be underestimated in terms of capability. Be helpful. Never be critical or disparaging.
Adherence to an established communication system like ISBAR is valuable. Taking time to listen can be challenging (particularly at 2am). Objective data is always helpful. The use of NETS cameras to assist management is increasing and is valuable. Best not to use your own mobile for this purpose.
In addition to the above, the geography of your unit means that clinical decisions should factor in the tyranny of distance. It is crucial that ambulance transfer is not undertaken for an unstable patient as even fairly short distances can be hazardous. If when talking to a remote hospital it becomes clear that the ultimate destination will be a PICU avoiding a ‘double jump’ transfer is important. Don’t forget to explore what local resources are available. Many country towns have GP anaesthetists who are skilled and resourceful. Maximising and optimising the use of local resources is essential.
- Working with pathology and radiology
The quality and child friendliness of these resources are quite different in regional hospitals. The finger prick micro collection techniques common in stand alone tertiary hospitals are generally not available, so that even a FBC needs venepuncture and can be a trauma for all involved, especially the child. The paediatric registrar will be called upon to undertake difficult collection. It is a valuable reminder to always make sure that the test you are ordering is really necessary and that the results will influence management or improve patient care.
Radiology is also usually different. After hours 24/7 ultrasound may not be readily available and the variability of operator expertise is a consideration. It is a potential mistake to be told that ‘the abdominal ultrasound is normal’ whereas critically important clinical questions such as ‘was the appendix visualised’ were overlooked because the sonographer undertaking the ultrasound after hours was not told what was the potential diagnosis or did not have a lot of paediatric experience.
Sedation for brain MRIs is challenging. Chloral hydrate sedation has a significant failure rate (20%). It is rare that general anaesthesia for MRIs is available in regional centres.
The delay in availability of pathology/imaging results does influence management and should be factored into clinical decisions.
- Relationships with the nursing staff
In regional centres the nursing staff are a stable workforce that have often been there for 20 years or so and will have established close personal relationships in most cases with the resident consultant paediatric staff. This can feel intimidating. The nurses will frequently have a much more autonomous role than in teaching hospitals, and after hours self-determine a great deal of the hour to hour management such as deciding to stretch salbutamol for asthma, modifying IV fluid rates, assessing analgesic requirements etc. If you can engage in a constructive friendly manner with the nursing staff you will deliver much better-quality patient care, as paediatric and SCN nurses are a great source of local knowledge and expertise. Never forget that everyone wants the same outcome (the child’s condition to improve, adequate comfort and pain relief administered), and everyone to be happy upon discharge. Harmonious team relationships are important.
If you encounter difficulties in this area never ever become involved in heated confrontation on the wards. You should raise any concerns directly with your supervising consultant.
All accredited units have a term supervisor, who is selected because of their experience and functionality. Make sure to have frequent discussions with your term supervisor and raise any concerns early. Concerns that cannot be resolved locally should be communicated to the Director Of Clinical Training at your origin hospital sooner rather than later. Any concerns raised should be communicated in an explicit and specific manner.
Rural rotations offer exposure to an interesting area of general paediatrics. You will get the opportunity to use all of your skills. 80% of recalls are neonatal, including attendance at urgent caesarean sections, unexpectedly flat babies, challenging obstetrics and recalls to nursery. The hours are long and potentially antisocial, it is difficult at times but also extremely rewarding.
The College of Physicians mandates six months of rural training as recognition that rural areas are where general paediatrics is the most closely practiced, as there is not the same drain to tertiary clinics for paediatric conditions such as type 1 diabetes/cystic fibrosis/epilepsy/cardiology. Rural training represents an opportunity to practice widely and autonomously. The mandated training is definitely not a policy to encourage aspiring paediatricians to move to rural locations.
Living rurally is after all just wonderful. Clean air/friendly communities/no commuting/affordable real estate/opportunity to become part of your community is a superb lifestyle. Plan to enjoy your time in the country!
If you want to hear more about life away from the ivory towers then come and listen to David at DFTB17