A night in the life of a National Home Doctor

By Dr Umberto Russo MBBS, FRACGP

I have practised as an after hours Doctor for 26 years now. I still enjoy the variety of cases, and the challenge of assessing and providing care for acute conditions. It is amazing how grateful patients are when you visit them in the after hours. It proves to me time and time again that we are meeting a real need in the community.  We are also relieving pressure on hospital EDs, and supporting the family GP in the after hours.

On a personal level, a great deal of my love for the job stems from the privileged position I hold, to enter the home of a patient and administer care in a time of need. Most of the patients I see are elderly or at the opposite end of the spectrum, small children with a very concerned parent by their side.

I have been fortunate to see the remarkable progress of after hours services over almost three decades. From the early days when there was very little triaging of calls, and the use of information technology was limited, times have changed.  Today  our innovative  technological systems used for receiving calls, triaging and information management have led to the delivery of safe, quality care for patients in need of acute care during the after hours period.

I often get asked what sort of cases I see in the after hours, and truthfully I can say that no two cases are ever the same. Some of the characteristics of patients on a typical night might be as follows:

7.50pm. Call from young mother

The request from a mum to see her young child with a known history of asthma, presenting with cold symptoms of 2 days’ duration. After consultation, a diagnosis of Exacerbation of Asthma/Viral URTI is made and the treatment includes the addition of prednisolone liquid. We do not always know the nature of the problem until a face to face consultation is conducted. 

8.20pm. Elderly man in confusion

Next – a request from an aged care facility for an elderly man who has been confused for the day. Attempts to get his GP to visit had been unsuccessful, and the GP requested that the care facility call the after hours service. The consultation is conducted with the patient’s concerned daughter present. Further enquiry and examination confirms a diagnosis of UTI - most likely - and antibiotics are commenced. The patient’s daughter comments about how wonderful it is to have a back-up doctor when her father’s GP is unavailable. The availability of primary care for acute episodic illness in the absence of the patient’s GP should never be underestimated – day or night.

9.05pm. Suspected influenza

A middle-aged man calls with muscular aches and pains, minor cold symptoms, high temperature and headache of 2 days’ duration.  He has been progressively getting worse and calls 13SICK. After further history and examination, I diagnose influenza. He is mildly dehydrated and treatment includes advice about fluid intake to improve his hydration status. This intervention is important to minimize the risk of dehydration and the need for an ED visit for IV fluids. 

10.30pm. Unexplained vomiting

Next I visit an elderly woman in an aged care facility who has been vomiting. After further enquiry and examination there are no signs to establish a definite diagnosis. A urinalysis is normal. Further management includes IM Maxolon and instruction to try and increase fluid intake. Instructions are provided on the recommended follow up, with instructions for the GP to review the next day. My clinical notes are completed electronically and sent by fax to the care facility immediately, and to the GP next day, to ensure effective hand-over.

11.25pm. Crying in pain

I visit a four-and-a-half-year-old boy with an earache. Mum expresses concern that her son has had a cold for several days but the earache has only come on since late afternoon, and her son has been crying because of the pain. Panadol has not helped the pain and the child is unable to sleep. After further history and examination, I decide to provide a stat dose of Painstop and, due to the toxic nature of the presentation, commence Amoxycillin liquid. It is extremely stressful for parents to have children suffering during the night and feel helpless about the situation. Availability of after hours urgent care provides comfort to parents and ensures the matter does not result in a trip to ED.

1.00am. Acute back pain

Next I see a 45-year-old man with acute lower back and lower leg pain after bending to pick up his 7-year-old son. He has a past history of lower back pain, but it has never been as bad as this and usually settled within several days. He is agitated with the pain and his mobility is quite restricted. The pain is particularly burning down his lateral hip and he has pain around his anterior shin consistent with L4 nerve compression. Examination confirms L4 nerve root compression with a positive femoral nerve stretch test. He has had minimal relief from Panadol.  I decide to treat him with regular Ibuprofen in addition to regular Panadol and provide other symptomatic advice with instructions to be reviewed by his GP when he is able to get into his car to drive. The option of using Tramal as a PRN (as needed) medication was discussed if pain was unresponsive to the Panadol/ibuprofen. Access to after hours home visits for patients with acute mobility issues is important. 

1.30am. Teenager with high temperature

A call where mum explains her 14-year-old daughter has had increasing sore throat for 2 days but her temperature now is 39 degrees and she was not eating. Mum called her General Practice at 3pm but there were no appointments available. An appointment was made for the next day and she was advised to call the Practice’s after hours service for a visit that night if the mum felt a consultation could not wait until the next day. Mum becomes increasingly concerned about the symptoms and decides to call 13SICK later that night as her daughter was experiencing considerable pain. After history and examination, I diagnose acute tonsillitis and prescribe phenoxymethylpenicillin, in addition to giving other symptomatic advice. The patient was provided with a starter pack of medication until a prescription could be filled the next day. 

3.05am. Diabetic with flu symptoms 

I receive a call for a 60 year old non-insulin-dependent diabetic complaining of headache, fever, rhinitis and generalised aches and pains of only 4 hours duration. Upon further history and examination, I diagnose influenza. Notwithstanding the controversies surrounding Tamiflu, the timing is right for early commencement and I proceed with the Therapeutic Guidelines recommendation of commencing Tamiflu. I provide him with 2 tablets as samples to cover the next 24 hours until he can fill a prescription.  Timely access to primary care in this instance will provide the best opportunity for the patient to benefit from early intervention and prevent complications.

5.00 am Home

My chaperone drives me home while I finish my clinical notes.

Clinical notes

I take care in completing my clinical notes, knowing that these are provided to the patient's GP to ensure continuity of care. I have always valued the feedback I have received from GP colleagues who have contacted me to discuss my management of their patients - whether positive or negative.

Routine requests

It is uncommon for me to receive requests for obvious non-urgent matters, as our Operations centre will triage all non-urgent requests, and direct patients back to their usual GP. Our service is for the treatment of acute, episodic medical conditions.  We do not accept calls for routine management of diabetes, hypertension, requests for immunisations, etc. Of course there will be times when, after the completion of the consultation, it is clear the condition did not require urgent treatment. In these cases the consultation attracts a non-urgent MBS item number. Such an obvious case is a call out to see a child with diarrhoea, only to find out during the consultation that mum or dad’s motive was the need for a clearance certificate for child care. Urgency can be sometimes be very difficult to assess over the phone, but it becomes more obvious during the consultation. As a guide, consultations attracting non-urgent MBS Items happen approximately 20-25% of the time. 

Inappropriate calls

National Home Doctor Service has stringent protocols in place for screening inappropriate callers or problem patients, so I rarely get these calls, except for the first presentation. I know that when I flag such a patient with the call centre, it prompts further action via our comprehensive Problem Patient Policy and Procedure process. This may result in severe restrictions for further visits or a management plan in collaboration with the patient’s GP. This policy is important to the safety of other Doctors and the safe delivery of care for these types of patients. 

Dr Umberto Russo MBBS (Adelaide) FRACGP is the Chief Medical Officer at 13SICK, National Home Doctor Service. He has more than 26 years’ experience both as a GP and a visiting home doctor, with a special interest in after hours medical care.