Thirty Miles at Sea — Providing Consistent Care in an Inconsistent Environment

Margot Hartmann, M.D., Ph.D., and Jason Graziadei, B.A. N Engl J Med 2017; 376:1306-1307April 6, 2017DOI: 10.1056/NEJMp1701449 Share:Article References Metrics
Audio Interview

Interview with Dr. Heather Kovich on the challenges facing patients and physicians in rural areas of the United States.

Interview with Dr. Heather Kovich on the challenges facing patients and physicians in rural areas of the United States. (10:07)

Small community hospitals throughout the United States are facing threats including low volume, declining reimbursements, and staffing challenges.1,2 Nantucket Cottage Hospital, a 19-bed facility and one of the smallest hospitals in Massachusetts, must also navigate the complexity of operating on an island 30 miles offshore, where the year-round population of 15,000 swells to more than 60,000 during the summer months.

There is no off-the-shelf staffing model that works in the clinical environment of our emergency department (ED). The ED provides care to more than 10,000 patients every year, but the majority of them present between Memorial Day and Columbus Day. Our ED team sees everything you would expect at a community hospital, plus more than our share of tickborne illnesses (ranging from routine to catastrophic), whose incidence is far higher on Nantucket than in many other places in Massachusetts.3

The evolution of emergency services on the island has been dictated by the potential risk of high-acuity, low-frequency events for a small hospital with limited human resources. For us, a mass casualty incident is a van rollover with 16 elderly victims or a carbon monoxide leak in an overcrowded basement apartment. Nantucket’s location means that medical transfers to a tertiary care hospital on the mainland aren’t always possible. Inclement weather or fog can prevent Boston MedFlight from making it to the island, and in the post-9/11 world, the Coast Guard isn’t always available. The tricky equation of appropriate and efficient ED staffing4 is made more complex by Nantucket’s geography and seasonality. So despite our low clinical volume, we need emergency physicians with high skill levels.

For “the season” on Nantucket, when our population explodes and the demands on our ED surge, our answer for many years was to put together a varied team of board-certified physicians that tended to come back year after year with their families, but with no guarantee on either side. We were hiring 30 to 32 people from Memorial Day to Columbus Day in 2-week shifts in order to have 24/7 coverage. Though we were certainly fortunate that a stint on Nantucket was attractive to some physicians and their families, we had to house them, find ways to accommodate them with their dogs and their grandmothers, and organize everything for their stay, in addition to coordinating travel on the ferries to and from the island. A big part of the challenge was juggling these teams amid the island’s ongoing housing crunch.

We also had to manage physicians’ expectations of work versus vacation — discouraging the perception that the assignment would entail sitting on the beach with a pager. Whereas urban and suburban institutions may have teams from cardiology, pulmonology, psychiatry, and other specialties on call to support the ED, our rotating ED team and the few year-round island doctors were our total resources. Some people saw that limitation as a wonderful opportunity to exercise their problem-solving skills in a low-resource environment, but not everyone found it so thrilling.

So we ended up with a mix of summer providers that we had to reinvent every year, always under pressure to get it right. Before each summer, we would launch a process involving recruiting, licensing and credentialing, and managing various logistic challenges. It was not a way to create a cohesive team; some visiting physicians didn’t have a real stake in this place after they left.

In recruiting this team, it was difficult to convey the types of judgment calls that needed to be made in a place like Nantucket to physicians who would be here for a very short time but were being entrusted to provide care during our highest-volume period. It was anxiety-provoking to recognize that we might not have the best match between resources and patient needs or that a visiting doctor might be on service with a visiting nurse, neither of whom was schooled in our particular practice environment. These visiting providers had to constantly keep track of factors that might be unfamiliar to them: What staff members are on island and on call? Is orthopedics here? What’s the current volume? Will the weather prevent MedFlight from getting here?

Assembling the summer ED team became increasingly difficult. The usual cadre was aging, and some clinicians chose not to return. Seeing that the model that had evolved wasn’t serving us and couldn’t be sustained, we began to think about an alternative. Our chief medical officer identified an emergency staffing group — MEP Health, now called U.S. Acute Care Solutions — that, far from being daunted by a new problem, was intrigued by Nantucket and its unusual circumstances. Aiming to balance delivery of high-quality medicine — an ever-evolving goal — with continuity provided by a core team that understands the puzzle we face, we negotiated a trial agreement. MEP Health became the employer of the existing year-round providers, including physicians and physician assistants, as well as some longtime summer team members, and supplemented them with rotating clinicians from its higher-volume hospitals. It took on responsibility for scheduling, peer review, and quality metrics, while building awareness of Nantucket-specific aspects of clinical judgment, so that we no longer have to constantly reorient personnel. This model forces a careful comparison between the cost of subcontracting ED staffing and the cost of directly hiring six or more ED physician and PAs, even if we could recruit them to the island and figure out how to enable them to buy into the housing market. Most of all, it takes advantage of the continuity and stability of our year-round ED base, while allowing us to stay current as medicine evolves.

Now we don’t have to worry about filling our schedule for next summer or about depending on a locum agency for physicians whose quality we have no way of judging in advance. Instead, we can focus on becoming fluent in the type of medicine that best serves our island.

Disclosure forms provided by the authors are available at

Source Information

From Nantucket Cottage Hospital, Nantucket, MA.


The Maternal Health Compact

Susan Mann, M.D., Kimberlee McKay, M.D., and Haywood Brown, M.D.
N Engl J Med 2017; 376:1304-1305April 6, 2017DOI: 10.1056/NEJMp1700485
Audio Interview

Interview with Dr. Heather Kovich on the challenges facing patients and physicians in rural areas of the United States.

Interview with Dr. Heather Kovich on the challenges facing patients and physicians in rural areas of the United States. (10:07)

In a rural Minnesota town with fewer than 5000 residents, an 18-year-old woman with a term pregnancy goes into labor in a hospital that performs about 75 deliveries per year. Her pregnancy has been uncomplicated, but chorioamnionitis develops during labor and she undergoes a primary cesarean delivery for arrest of descent during the second stage of labor. Her low-risk pregnancy has become high risk — a common story for intrapartum obstetrical care in any hospital, but one that can have deadly consequences in a hospital with fewer resources, including a small staff and limited blood-bank capacity. The woman has a severe postpartum hemorrhage and loses more than 2 liters of blood. She is given the usual uterotonic medications and surgical intervention with B-Lynch suture placement, but they prove ineffective.

The lone obstetrician in the hospital is about to perform a hysterectomy when she recalls a conversation she had 2 weeks earlier with the obstetrical medical director of her hospital system about a program for team training and simulation for obstetrical emergencies that was being offered at her hospital. The director encouraged the obstetrician to reach out regarding safety concerns and left a card with her cell-phone number. Running low on options, the obstetrician contacts the director, who recommends giving the patient a transfusion from the hospital’s very limited blood supply. The director then facilitates consultation with Avera eCARE, a telehealth service that provides real-time specialty expertise to lower-resource care settings.

The teams at Avera arrange transport by helicopter to a tertiary care hospital in Sioux Falls, South Dakota, a 20-minute flight. The patient arrives 2 hours after the initial call was placed, and the telehealth specialists support both the transporting-hospital care team in stabilizing the patient for transport and the receiving care teams in intensive care and interventional radiology. The patient, who was about to have a life-altering and possibly life-threatening hysterectomy, instead undergoes a uterine artery embolization and further stabilization in the intensive care unit (ICU) and is discharged 3 days later.

More than 60% of U.S. hospitals that provide obstetrical care perform fewer than 1000 deliveries per year, or fewer than 3 a day. A review of obstetrical outcomes in 600 rural U.S. hospitals and low-volume, nonteaching hospitals — lower-resource hospitals — revealed that they had higher maternal morbidity than teaching hospitals. The possible issues identified in the lower-resource settings included maintenance of competencies and recruitment of staff.1

In the United States from 1998 to 2008, delivery and postpartum hospitalizations that resulted in maternal mortality and severe maternal morbidity increased by 66% and 75%, respectively.2 The Centers for Disease Control and Prevention and state departments of health have recognized the difficulty of obtaining accurate data pertaining to severe maternal complications and pregnancy-related deaths owing to varied definitions and reporting requirements. Even less information is available regarding the setting in which these cases occurred — urban versus rural and academic centers versus community hospitals. Rural health care centers have been essential for patients, but many of these smaller hospitals have shut down their maternity services.3 For a patient in a rural setting, frequent severe weather and long distances may impede access to a larger hospital. Is it reasonable for these women to drive for hours to get to a larger medical center, or can we do more to support obstetrical practitioners in remote settings?

We believe that Avera’s approach can provide a model for other parts of the country, where a Maternal Health Compact could be created linking lower-resource hospitals with tertiary care hospitals, with the goal of transporting patients to the appropriate facility when possible and making care as safe as possible locally when transport is not an option. Telehealth services in obstetrics can help to bridge the gap in three ways: facilitating transport of patients, supporting care provided remotely, and assisting in local quality-improvement activities.

Under a Maternal Health Compact, a tertiary care hospital provides services to its referring lower-resource hospitals for high-risk patients. Smaller hospitals also benefit from increased collaborations in which, for instance, the tertiary care hospital runs simulations of obstetrical emergencies and assists with quality-improvement activities such as implementation of hemorrhage-treatment algorithms. Such collaborative work can be done in person or through telemedicine connections.

National efforts at improving obstetrical care have stopped short of addressing rare emergencies that can occur in a lower-resource hospital. In 2015, for example, the American Congress of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine released the Obstetric Care Consensus on Levels of Maternal Care, which delineates criteria for identifying women at considerable health risk (such as those with placenta previa, placenta accreta, or preeclampsia with severe features) who should be cared for at a hospital with appropriate staffing and resources to avert obstetrical complications and related deaths.4 Unfortunately, the consensus statement does not address the situation of an 18-year-old with an unexpected severe hemorrhage. Yet with better preparation and planning through a Maternal Health Compact, hospitals could be ready for these crises.

Telehealth is already used in many disciplines in which there is a mismatch between patient needs and specialty expertise, such as dermatology, geriatrics, and mental health, but to our knowledge, there has been no telehealth model for obstetrical care for an acutely high-risk pregnant woman in a lower-resource hospital. In the case of the Minnesota patient, a coordinated telehealth team intervened quickly and effectively; they worked with the rural hospital to stabilize the patient, arranged transport, and prepared the tertiary care hospital.

Through a Maternal Health Compact, physicians and nurses made available to lower-resource hospitals through a video link can help manage on-site obstetrical emergencies. Physicians make recommendations regarding care, while nurses support the nurse in the field by documenting the patient’s course and care in the medical record and facilitating communication with the local pharmacy to obtain necessary medications. The telehealth program developed at Avera, for example, houses under one roof a variety of medical departments — ICU, pharmacy, emergency, and others — to provide continual specialty care to partner care facilities. This kind of coordination is invaluable to patients.

The development and implementation of national standards supports the consistency of obstetrical care. The National Partnership for Maternal Safety, an initiative aimed at reducing maternal morbidity and mortality, released a Consensus Bundle on Obstetric Hemorrhage, in conjunction with the Alliance for Innovation in Maternal Heath (AIM), which recommended that all hospitals that provide obstetrical care develop a standard treatment protocol for postpartum hemorrhage.5 The challenge for the smaller, often rural, hospital has been to determine what the protocol should be for a massive transfusion when their blood bank carries only a fraction of the blood products considered essential for most hemorrhage-treatment protocols. Lower-resource hospitals need site-specific protocols for managing the care of patients with massive hemorrhage. The tertiary care physicians who accept transfers of such patients should help identify resources available at the referring hospitals and partner with them to create such site-specific algorithms, including use of emergency-release blood, fresh frozen plasma, shock garments, and tranexamic acid. The workflow for patients requiring transport should be as efficient and seamless as possible.

Pregnant woman in rural communities cannot afford to lose access to local hospitals; rather, we need to make the care they receive as safe as possible. Team training and simulation of emergencies are common tools of the patient-safety movement, and electronic connectivity and broad implementation of a Maternal Health Compact are the next logical steps for improving patient care, retaining rural care facilities, and recruiting and supporting practitioners in the field.

Disclosure forms provided by the authors are available at

This article was updated on April 6, 2017, at

Source Information

From the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston (S.M.); the Obstetric Service Line, Avera Health, Sioux Falls, SD (K.M.); the American College of Obstetrics and Gynecology, Washington, DC (H.B.); and the Duke University School of Medicine, Durham, NC (H.B.).

The 14th World Rural Health Conference

The Australian College of Rural and Remote Medicine (ACRRM), in recognition of its leadership and success in championing rural practice, is proud to have been invited by the WONCA Working Party on Rural Practice to host the 14th World Rural Health Conference to be held in Cairns from 29 April – 2 May 2017. This important conference will be held in collaboration with the 14th National Rural Health Conference from 26 – 29 April 2017, as part of A World of Rural Health.

The WONCA 14th World Rural Health Conference is an international event that will see delegates from around the world exchange information on the latest developments and challenges in rural family practice and rural and remote health generally.

The World Organisation of Family Doctors (WONCA) is a not-for-profit organisation with 118 member organisations in 131 countries and territories. The WONCA Working Party on Rural Practice consists of up to 20 members with representatives from each of the world’s regions: Europe, Asia, Africa, North America, South America, Australasia / Pacific.

The WONCA Working Party on Rural Practice vision is health for all rural people around the world.

The conference expects 900+ national and international delegates to attend. These will include rural doctors, researchers and academics, teachers, doctors-in-training, medical students, policy makers and administrators from both the public and private sectors.

The program will feature streams based on themes most relevant to all rural and remote health practitioners. These include Social and environmental determinants of health; Leadership, Education and Workforce; Social Accountability and Social Capital, and Rural Clinical Practices: people and services.

The extensive program will include a wide range of plenary sessions and workshops, and a number of excellent keynote speakers have already been confirmed. It also includes clinical sessions to provide skills development and ongoing professional development opportunities.

The World Summit on Rural Generalist Medicine is to be held as a pre-conference event, and potential delegates are welcome to participate in this important optional event.

Please email for any detailed information required relevant to the WONCA 14th World Rural Health Conference in 2017 in Cairns.



A bursary fund exists for medical students, young doctors (in GP training program/Registrars/Resident – in first 5 years of GP practice) and doctors from developing countries, to assist with costs of attendance at the conference.



Supported by

Susur Sungai Kahayan

Palangkaraya, Indonesia

Susur Sungai Kahayan


Salah satu objek wisata yang menjadi andalan di Palangkaraya adalah Sungai Kahayan. Sungai ini adalah salah satu sungai terbesar yang ada di Pulau Borneo. Panjangnya sekitar 250 km dan banyak penduduk yang tinggal di sepanjang sungai ini. Salah satu wisata unik yang tergolong baru khas Palangkaraya yang sedang di gemari saat ini yaitu susur Sungai Kahayan. Anda bisa berwisata susur Sungai Kahayan ini berombongan.

Selama menyusuri sungai, Anda akan disuguhi dengan pemandangan khas hutan-hutan Kalimantan. Di sepanjang perjalanan Anda bisa melihat fauna khas Kalimantan yang tidak bisa ditemukan di tempat lain diantaranya orang utan, uwa-uwa, kera abu-abu dan bekantan. Selain itu, Anda juga bisa mampir ke tempat pemancingan atau situs sejarah dan habitat orang utan di Pulau Kaja. Rute wisata bisa dipilih sendiri sesuai dengan keinginan Anda.


Untuk menikmati wisata eksotis ini, Anda tidak perlu merogoh kocek dalam karena biayanya sangat terjangkau. Satu paket wisata untuk minimal 10 orang dibrandol dengan harga mulai dari Rp 750.000. Harga tersebut sudah termasuk makanan ringan dan fasilitas kapal wisata yang digunakan untuk menyusuri sungai. Kapal ini terbuat dari kayu besi, memiliki kamar tidur, AC, live music dan tempat bersantai.

Akses transport

Bagi Anda wisatawan jauh yang ingin menikmati alam khas Kalimantan ini tidak perlu bingung karena Pemerintah Palangkaraya telah berinisiatif membuat buku panduan wisata untuk para wisatawan.

Anda bisa menghubungi Dinas Pariwisata setempat untuk konfirmasi wisata susur Sungai Kahayan. Untuk menuju dermaga tempat perahu milik Dinas Pariwisata saat Anda sudah tiba di Palangkaraya, Anda bisa naik bis umum atau mobil sewa menuju Kantor DPRD Provinsi Kalteng, letaknya tak jauh dari situ.

Prof Amanda Howe

About the President of Wonca

Amanda Howe took office as WONCA president in Rio, in November 2016.

Amanda has been deeply involved with WONCA since 2000, when she facilitated a workshop for their Working Party on Women and Family Medicine. She is on their Executive, chaired the group from 2007-2009, and hosted an international meeting at UEA in 2009. Professor Amanda Howe was elected RCGP Honorary Secretary in 2009. She practises at the Bowthorpe Medical Centre in Norwich, England and has been Professor of Primary Care at the University of East Anglia since 2001. “I wanted to be a GP when I was a medical student, despite influences from tutors to do otherwise”, says Professor Howe. “I’m fascinated by the role that the GP consultation can play in helping patients make sense of their lives, and overcome physical and mental adversity.”

She remains “in awe” of how resilient patients can be. “It’s a privilege to work with people faced by adversity and illness. People are often very courageous and extremely strong, they really do inspire me, that’s why general practice is such a great place to learn”

New research quantifies genetic mutations caused by smoking

8 November, 2016


Smoking one pack of cigarettes a day could cause 150 extra genetic mutations in lung cells every year, according to new research.

The study, published in the journal Science, analysed the DNA sequence of cells from more than 5,000 cancers from both smokers and non-smokers.

Overall, the study found cancer cells from smokers tended to have a greater number of mutations within certain mutational signatures than non-smokers.

For example, most lung and throat cancers from smokers had many mutations in signature 4. The researchers went on to describe the other individual mutational signatures where they found differences for smokers versus non-smokers, including signatures 2, 5, 13 and 16. The researchers were able to estimate the number of mutations that would be caused in different types of cells.

The results support the theory that smoking causes cancer by increasing the number of mutations found in the cellular DNA, though the exact mechanism by which this happens isn’t completely clear.

Professor Sir Mike Stratton, joint lead author, said: “This study of smoking tells us that looking in the DNA of cancers can provide provocative new clues to how cancers develop and thus, potentially, how they can be prevented.”