One needs to look at how theatre efficiencies can be increased.

I would propose that one small step to the solution could be to look if an additional case can be done in each public hospital theatre each day. This would help reduce the numbers on the waiting lists. This would require flexibility on the part of the booking office, day ward, patients, medical staff, nursing staff and admin. But this can be done. There is usually enough spare time during a day’s operating list where the theatre is used to fit in a short case – eg carpal tunnel, skin cancer, gastroscopy, colonoscopy and even a simple hernia repair. All that is needed is a common desire to reduce the waiting lists as much as possible. Without fear that this will mean the budget to the hospital will be cut the next year etc

For private hospitals, the risks are much lower
14 out of 220 327 for same day
19 out of 12641 for multiple day.

http://www.theage.com.au/victoria/hospitals-behind-in-national-rating-20111129-1o571.html#ixzz1f6CHlkpb

This means that there were additional 25000 patients being added to the waiting list last financial year in Victoria alone…how will this waiting list be reduced?
The capacity is there – eg if one increases the hours theatres are utilized – extending lists to 6-8pm on weekdays, Saturday lists but the costs are prohibitive…esp with a cash-strapped Victorian government

What is Medicare?
“Medicare ensures that all Australians have access to free or low-cost medical, optometrical and hospital care while being free to choose private health services and in special circumstances allied health services”. You can read more about this including eligibility from the Medicare website. Basically Medicare sets up a list of fees for various medical items. Eg Consult with GP, consult with specialist, excision of skin lesion, blood tests. Each item has a specific item number. (You can find that online if you search for the Medicare Benefits Schedule)

What is Bulk-billing?
Medicare pays only 85% of the Medicare Benefit Schedule for most outpatient services and 75% for inpatient services done privately. This Schedule is determined by the Australian government and has not kept pace with inflation over the years. Clinics that bulk bill would get their patients to sign the Medicare slip and claim the fee directly from Medicare. Hence patients would not need to pay anything out of pocket.

What is a Gap?
Most doctors would charge fee higher than the 85% of the Medicare Benefit Schedule – the difference in the fees is the gap.

Why is a Referral needed to see a Specialist?
Specialists can only claim their specialist consulting fees only if the patients have a referral. The standard referral from a general practitioner(GP) is valid for 12 months unless otherwise stated. A referral from another specialist is only valid for 3 months.

Why is it important to have a family doctor?
There is a lot more preventative medicine practiced here in Australia. Having a GP would ensure that you are that you have adequate screening for common medical conditions and that you have had the appropriate vaccinations. Also it is a lot easier to see a GP when one is really ill if one already is a patient of a particular clinic.
For routine consults, there can be a waiting time to see a popular GP – eg It can take 1-3 weeks to get an appointment to see some of the GPs I know(of course if one is really ill, the GP will try to fit you in or the clinic will try to fit you in to see another GP at the same practice)

Why are there waiting times here in Australia?
That is the culture here… eg there can be even a few weeks wait to book dinner here in some popular restaurants
Also not as many doctors work long into the night or as many weekends like say the GPs in Malaysia – there is a good work life balance here in Australia. Hence you can be assured that the doctor you see is fresh and not fatigued!

If the public system is free , why should I get private insurance?
There is a waiting list in the public system. While the public system is all right for cancers and other life threatening illness – for other medical conditions, the public system is too overburdened to meet the demands in time.
There is an online website where you can actually check the waiting times for surgery for common medical conditions eg hernia repair
Lets say a 35year old patient has bleeding in the toilet bowl from haemorrhoids. The patient first sees his GP. The GP first treats this with haemorrhoid ointment and advise a high fibre diet. The patient then returns for review with ongoing intermittent bleeding after 2 weeks. The GP then refers the patient to a surgeon at the public hospital. The patient would usually have to wait for a few weeks and sometimes months to get an appointment at the surgical outpatient clinic. Once the patient is seen in the outpatient clinic, if the haemorrhoids require banding or the bleeding needs to be investigated further to rule out bowel cancer with a colonoscopy, the patient is then put on a surgical waiting list. This can be either Category 2(up to 90 days) or Category 3(up to 365 days). Hence it will be a few more months before one has the procedure.
If one goes privately or tells the GP that one has private insurance and wishes to see a surgeon privately, then the GP would refer directly to see the surgeon(usually around 1-2 week wait) and then from there the patient will be booked in to have the procedure in 1-2 weeks.

Also after a certain age, the cost of private health insurance increases for each year later that one takes it up.
So if one were to need a knee or hip replacement one day – one has either pay much more to take up the private insurance later in life or wait 1-2 years in the public health system.

Furthermore, if one’s income is above a certain level, one has to pay an additional 1.5% Medicare Levy Surcharge(additional tax) if one does not have private insurance.
“Currently, you have to pay the surcharge if you are:
a single person with an annual taxable income for MLS purposes greater than $80,000 in the 2011-12 financial year; or
a family or couple with a combined taxable income for MLS purposes greater than $160,000 in the 2011-12 financial year. The family income threshold increases by $1,500 for each dependent child after the first;
and do not have an approved hospital cover with a registered health fund.”

1. Terminology: Depending on location – they are more likely epidermal/epidermoid cysts or pilar cysts.

2. A cyst can certainly get infected – I have seen green pus amongst the cheesy white keratinous material (and it can certainly smell!). If there is a lot of induration – it may be best to just drain the pus and keratin material first.

3. If the cyst has recurred because part of the wall has been left behind, then the cyst may not feel as tense as a normal cyst. It will feel boggy and soft.

4. The cyst can be easily excised with the wall intact – local anaesthesia is used to hydrodissect around the cyst as well as for anaesthesia. Care must be taken not to let the fluid squirt out through the punctum! (no problem for the patient – but more for the surgeon and the assistant) A small incision is made right down to the wall of the cyst – care must be taken not to cut into the wall. Then a fine artery forceps can be used to dissect the cyst off the surrrounding tissue. The cyst can then be squeezed out throught the narrow incision …usually intact.

5. If a cyst has been been knocked or inflammed, then it may not be as easy to remove the cyst. Sometimes, the wall has be be excised with a scalpel.

These are relatively common in surgical practice. Despite having done lots of these, I still find the occasional challenging ones which are hard to excise. And it is not always possible to remove the wall intact.

A grooved director is used to protect the median nerve as the transverse carpal ligaments is cut

One cannot see the benefit from doing it endoscopically from making two cuts instead of one

He will be having a list on Saturday August 27th at John Fawkner Private Hospital.

Dr Cheah normally prefers to see all his patients beforehand so that full informed consent can be obtained. Dr Cheah will be consulting at:

The Clinic Footscray (Wednesday) – Aug 17th and 24th
1st Floor, 91 Paisley Street, Footscray 3011 Tel: 9687 2271 Fax: 9689 6008

John Fawkner Private Hospital Consulting Rooms(Monday – Aug 22nd)
267 Moreland Road, Coburg 3058 Tel: 9385 2285

Caroline Springs Specialist Centre Suite 3-5, 224-226 Caroline Springs Blvd, Caroline Springs 3023 Tel: 8361 7655

(Please inform the reception that this is consult is for endoscopy on Sat Aug 27 if there is no appointment times available)

Please bring along a referral from the general practitioner. (If you have seen Dr LP Cheah before, you would need a new referral if the last referral letter from your GP was more than 12 months old)

If it is not possible to come for a consult before hand or it is an urgent referral(ie acute bleeding from haemorrhoids) – please contact Dr LP Cheah directly through the rooms.

For more information about the procedures and the bowel preparation please see www.melbournesurgery.com

Examination findings:
Patient lying still in bed, sore to move around
Vital signs – may have fever and tachycardia
Abdominal examination : Tender in right iliac fossa, rebound tenderness , crossed tenderness
(note: the tenderness can only be mild if the inflammed appendix is sitting behind the caecum – ie retrocaecal appendicitits)

Ix:
Imaging – an increasingly used modality, helps reduce incidence of negative appendicectomy; Ultrasound can show a swollen appendix(but may not pick up an early appendicitis, also dependent on sonographer and body habitus) CT abdomen – can be helpful but the disadvantage is the radiation exposure
Blood test – elevated white cell count in particular neutrophilia with left shift, elevated C-reactive protein(an inflammatory marker)..but there are cases of appendicitis where the blood test is normal early on

Treatment:
Nil by mouth
Intravenous antibiotics as soon as diagnosis is suspected(why wait?)
Surgery – Appendicectomy : through short incision if diagnosis is confirmed on CT/US, Laparoscopy if uncertain eg in females ?ovarian pathology ?endometriosis or other pathology

Differentials – other diseases that can mimic appendicitis:
1. Diverticulitis – ie if long redundant sigmoid colon, esp in elderly
2. Cancer of caecum
3. Inflammatory bowel disease involving the caecum or terminal ileum
4. Meckel’s diverticulitis
5. Gynaecological – ovarian cyst rupture, Mittelschmerz, torsion of ovary, ectopic pregnancy
6. Worms – eg pin worm
7. Torsion of fat around right colon
8. Low lying inflammed gallbladder

Problems we face:
1. Increasing population
2. Increasing percentage of patients from elderly age group…people do get sick eventually even with the best of care – such is life…
3. Budget pressures on hospitals leading to inefficient use of theatre times eg some hospitals do not allow cases after 11am or 4pm on morning or afternoon lists in case of theatre overruns; prolonged theatre closures over Easter and Xmas(to reduce hospital costs)
4. Lack of surgical beds….more and more presssure on beds for medical patients, more patients in hospital waiting for nursing home beds

Overall, I am not optimistic… although there are steps that may help.

I was just referring a patient to surgical outpatients at a tertiary hospital in Melbourne(too high risk to be operated on in the country) – was asked to tick the urgency for the outpatient consultation…Cat 1 (within 30 days) Cat 2(30-90 days) Cat 3….
Once the patient gets the appointment and sees the specialist there(or the registrar or intern) – they will then be put on another waiting list for their surgery ..again Category 1 , 2 and 3
(and the patient’s wait did not just begin when the patient saw me…he had been waiting for a few weeks for an appointment to see me, prior to that he had to have some investigations..and also wait 1-2 weeks to see his GP…and again 1-2 weeks to see his GP again for the referral to me)

Sometimes, I find it incredible that there is so much waiting in the health system despite the amount of money the government pours in (perhaps a lot is wasted on various levels of bureaucracy/administration) … This seems to be one big weakness of our health system.