What does emergency medicine have to do with good health?*

*If you have gone to the Rick Bukata school of medicine you would automatically conclude the answer is no based purely on the title, but maybe there’s room for debate

I’m returning to Australia from a holiday in Scandinavia and Germany. As my return flight loomed closer, insecurities were growing about my abilities as an emergency physician. Had I spent the previous six months living up to the standards of clinical credibility that I hold myself to? Had I tried to foster a culture of kindness and caring towards my colleagues whilst trying to nudge for small improvements (usually less radiation, more ultrasound and history+exam)?  

When travelling, I love the privileges afforded by walking almost everywhere. There is usually a beer:exercise mismatch which needs managing, and lots of thinking to be done about life. When thinking gets tiresome whilst walking, podcasts offer an alternative form of simulation.  In the depths of my introspection tonight whilst walking home from a museum, my self-admonishment was interrupted and dissipated by an ABC Radio National Big Ideas podcast on refugees – specifically on the systematic and codified methods of physical and psychological abuse of fellow human beings meted out by my own national government, who are nominally the democratic instrument of the Australian population.  Having spent most of my day at the Deutsches Technikmuseum Berlin and seen railway wagons which transported Jewish people to their deaths, perhaps I was already primed to react strongly against state-enacted human rights abuses. Feeling somewhat impotent to meaningfully deal with this issue, I started to reflect on the social determinants of health (since the refugees on Manus Island are completely screwed in this respect). What does it means to have “good” health?  Can emergency medicine influence this in anyway?  My holiday experiences suggested some answers.

I spent seven days in Norway and did not see anyone who was obese.  This is in contradistinction to the town I live in, where some days it seems like I do not see a single person who is non-obese.  I spent five days in Sweden and I did not see anyone who was drunk and disorderly or drug affected.  To contextualise – I specifically went to Sweden to attend several electronic music concerts which went on well into the early hours – I think I had a fair crack at trying to find drug or alcohol related problems.  On the whole, the people in Scandinavia seemed to be far more healthy. Why could this be so? I’ve tried to identify some possible determinants of the perceived differences

Attitude towards the environment
In Norway, I observed a pervasive respect for natural beauty, and a desire to preserve, improve, and be a part of the physical environment.  Perhaps it’s related to colonial heritage, but when the scrubby forest surrounding my town was first surveyed, settlers concluded that the trees were not good for anything except for chopping down to make handles for stock-whips – hence The Whipstick.  54% of Swedish energy is renewable. The current Prime Minister of Australia jokes that coal won’t hurt anyone. Could Australian poverty in environmental values translate into poverty of health? 

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The physical environment itself
There is no denying that the Lofoten Islands are stunningly beautiful, as is the Swedish archipelago. It could be argued that the natural beauty draws people out of their homes, thereby keeping them more fit and active. Beautiful it might be, but if you do want to go outside in winter you have to contend with temperatures of -10.C or less, with wind chill factors more again.  It clearly didn’t stop the numerous nanas I saw from getting out and about on their 3-runner push sleds which appeared to be the equivalent of our 4-wheel frames.  With the snow and ice, “#NOF central?” as one of my colleagues suggested. I don’t think so. The older adults I saw looked pretty darn robust.  I couldn’t find any nursing homes either. A different attitude to supporting elderly people as well perhaps? Thinking about the Australian relationship with nature, for many I suspect “The Great Outdoors” is a TV show.

 

Treatment of marginalised people
For a small town in the arctic circle, I was astounded to find a host of resettled refugees in Svolvaer. Taking a straw poll from various locals, they all spoke warmly about the refugees who had come to their town, and acknowledged with compassion that when other people are suffering, you have a morale duty to try to help them.  How reasonable! In Australia, meanwhile, there are concerns that marginalised people will take our jobs, erode white Christian values, or terrorise us.

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Poster of a healthy nation?

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Short memory?

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The Norwegian perspective

Attitude towards alcohol
In Sweden, outside of bars/clubs/restaurants, the only place you can buy alcohol is the state-owned monopoly of stores: Systembolaget. The trading hours are restricted compared to Australia, but if you plann your alcohol purchases in advance it’s easy. Interestingly, the cost of alcohol in Sweden seemed notably less than in Australia. The drinking culture seemed to be sensible. This had not always been the case – as readers of Per Anders Fogelström’s “City of my dreams” could well attest to, so somewhere along the line alcohol use in Sweden alcohol attitudes changed for the better.

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No need for refrigeration in winter

Relationship with animals
In Scandinavia it is very natural for dogs to go everywhere – trains, buses, bottle shops. The dogs seemed happy, as did the owners. I’m sure that this happiness translates into health. If 25 million people can do it in the northern hemisphere, why do 25 million people in the southern hemisphere have conniptions at the mere thought of a dog riding a VLine service?

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Social connectedness and harmony
The places I’ve recently visited seemed disinterested in identity politics. A person is a person is a person, and that is good enough.  Gender neutral toilets everywhere in Sweden were just one example of the population getting on with focusing on togetherness rather than divisiveness.  

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Relationship with work
In Norway people are heavily taxed if they work too much (financial disincentive for not looking after yourself?).  In Australia, despite hollow gestures from employers and regulators, people in health care are routinely punished by being worked got the point of severe health problems. This is tacitly culturally accepted by the powerful as being “what you have to do”.

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The response so far…

Sense of humour
The Scandinavians didn’t seem to mind taking the piss. Seriously, when your national language is Swedish, why not give your train an English name to stick it to the poms? (The poms couldn’t bare the thought of not being taken seriously and despite popular vote chose not to go with Boaty McBoatface; I fear the colonial apple doesn’t rot far from the tree).   I feel that being too serious is bad for your health – look at the NHS.

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Express Stockholm to Gothenburg

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What happened to the ministry of silly walks?

Can do attitude
In 2016 the Norwegian airforce used a fast jet to deliver an ECMO circuit to Bødo (a remote but incredibly beautiful town, I can recommend) for a time-critical emergency.  Meanwhile if you have a STEMI complicated by cardiogenic shock on a weekend in Bendigo, the cardiologist can be at your bedside but the Cath lab won’t open because “it can’t”.

 

Putting it all together, people in Scandinavia are almost certainly not more healthy than Australians because they have better access to statins, ECMO circuits, or a tax on sugar (they don’t, as the number of cinnamon buns I have consumed attests to). I wonder if it’s because they have better relationships with their fellow citizens, their neighbours, their planet, and their own individual inner moods and emotions on their journey in life to obtain meaning and happiness.

So can emergency medicine help influence good health? Sometimes it really feels like it is pushing shit up hill. But I guess it depends. The fabulous work done by people such as Diana Egerton-Warburton have clearly had a profound positive impact on health at a population level.

At present, I disappointingly don’t think I’ve got the staying power to take the path Diana has. To start with, I might aim to nudge good health into my immediate surroundings by trying to set an example of the Scandinavian values I’m so admiring of. Maybe in another 10 years I’ll be frustrated and take the public health route, but then again emergency medicine is just so much fun…

Où Allons Nous

I’m on the cusp of the ACEM fellowship clinical exam, surrounded by practice OSCE stems, motivating phrases on a white board, and self-critical thoughts about neglected relationships. This milieu is a psychologically provocative one and I find myself reflecting on a particular piece of art by the synthetist painter Paul Gaugin:

D’où Venons Nous / Que Sommes Nous / Où Allons Nous
(Where do we come from / Who are we / Where are we going)

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Where from?

I stumbled into medicine by chance.  Despite coming from a medical family, medicine in general had never been part of my life agenda. My father, a rural generalist solo practitioner, discouraged me from medicine for the first two decades of life.  After following a crowd into law school post- high-school, I dropped out after one day to begin a stillborn apprenticeship as a chef.  The cooking business lasted a year: by chance I read a book by Russian journalist Anna Politkovskaya on the Russian invasion of Chechnya, which was catalytic in reorienting my career aspirations. Medicine became a craft with a tangible, portable skillset that could be exercised in the spirit of social justice. I was able to piggyback off my high-school grades into medical school and muddle my way though, collecting a handful of mentors along the way. A tragic aside – Politokovskaya was murdered in my second year of medicine – the murder motivated by her social justice advocacy through journalism.

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Anna Politkovskaya, 1958 – 2006 – an unfinished life

Who?

Patients often ask me if I am married. I usually make some nonchalant self-assured remark about having a couple of children and a mistress – two kelpies and the emergency department. Beneath the glib attempt to put patients at ease, there is a troublesome reality – without imposing boundaries on medicine, it could easily come to define my life. I am thankfully able to rein it in by fostering a broader perspective on life, society, the environment and the cosmos.

Truth be told, I am far from self-assured. I generally feel like a confused albeit cultured ape. I take pride in honing my clinical credibility and delivering care to vulnerable, anxious and wounded fellow primates. At the same time, I feel ashamed by waste, pollution and potential harm I do to the planet and to patients, as a cog in the enormous wheel of the medical industrial complex. I feel uncomfortable that this technology driven-wheel tends to grind for the haves at the expense of the have-nots. I feel no satisfaction spending public money on exercise stress tests (up to 24 false positives for every 1 true positive in women), or other no-value investigations, therapies or procedures. At the same time, I feel immense satisfaction when I connect with patients and provide explanation, reassurance or comfort. These dilemmas pervade the rest of my life as well. Should I respond to climate change by not having children? Or should I not worry about the planet since we’re just a pale blue dot anyway? Accepting the uncertainty of existence makes accepting uncertainty in medicine much easier.

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The blueish-white speck of Earth with 6 billion kilometres of perspective. Voyager 1, 1990

Where to?

Training in emergency medicine has been a wonderful journey. The cobbles are now more familiar than when I was a truant medical student, however I’m not sure familiarity is where my future lies. I’ve no doubt emergency medicine could be harmonized within the context of the cosmos, but the model of health care in the industrially developed world seems to stray farther and farther from the reasons why I took up the stethoscope in the first place (ultrasound actually; I don’t own a stethoscope).

Paul Gaugin gave up a career as a stockbroker to learn art and paint his way around the world. Perhaps I too may choose a path less worn. Thus far, emergency medicine has gifted me with instruments necessary to manage complexity, uncertainty, stress, conflict and high emotion. Ultimately, I know that wherever I chose to navigate my future, be it in EM or art, I’m well equipped to sail around the shoals and find safe harbour.

Thomas Brough, May 2018

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Rosie and Jade already know how navigate the tricky waters of life
without losing sleep over exams, missed diagnoses or stroke thrombolysis.

The Procedures Course

This week we got 9 of our consultants through The Procedures Course. Added to the one who had already done it, that is half of our senior staff having done the course now.

There are a lot of useful courses around these days, with higher and higher expectations of acute health care and fewer opportunities to maintain skills in the workplace due to specialization, safer working hours and the expectation that clinicians will not learn something new on a critically ill person without having some sort of qualification or experience in it first.

This course is a bit different from most. While the wonderful world of simulation has brought us the chance to practice many critical cognitive and technical skills in safe environments, the use of cadavers in medical training has really dropped off. In Australia, more than the US, we have a squeamishness about cadaver training. As a medical student I spent several hours a week for the first year and a half on cadaver based anatomy workshops but that is largely gone from modern medical training. Clinical training with cadavers remains quite uncommon here.

Thanks to the enormous generosity of the people who asked to donate their bodies to medical training before they died, and the hard work of the team from the Alfred Emergency and Trauma Centre and Trauma Unit, supported by expert faculty including neurosurgeons, ophthalmologists, obstetricians, orthopods and others, we were able to learn and practice a raft of life, limb and sight saving skills this week. It is hard to describe how much more capable I feel as an emergency physician having done this course, and I’ve been one for a while now!

Check out the course website, not that they need the publicity, they have sold out their next course already.

Hog Fat… Is there anything it cannot do?

I’m showing my age clearly because when I searched for that quote online to get the youtube clip of Homer Simpson uttering the words in wistful admiration of a power station powered by hog fat, it was nowhere to be seen. Now that I think of it, that episode probably predates youtube.

Anyway, down to business.

Khiem Ngo has just joined the Bendigo ED Education team as Co-DEMT. I have him to thank for bringing us this innovation.

When you have eaten all the crispy pork belly you can possibly eat (impossible?) use the left overs to create a peripheral IVC ultrasound phantom that is more realistic than any you will buy commercially.

 

Ingredients

  • Pork belly or waste pig skin (ask your butcher as they will often have some that is destined to be tossed out)
  • Long skinny balloons used for making balloon animals
  • Water

Method

  • Fill balloon with water but don’t distend it. Tie it off.
  • Cut pig skin into strips 4-5 cm wide and 15 cm long (2 inch x 6 inch)
  • Blunt dissect a tract through one of the fascial planes. We used a dilator from an expired pigtail catheter set but you could probably use a biro or pencil
  • Use a pair of long artery forceps to feed your balloon through the tract
  • Massage out any air bubbles along the tract

How much does that scan cost?

When I started out as an EM trainee, having dated a radiographer I was very cognisant of the radiation penalties from medical imaging as well as the associated risks of developing a new malignancy.  Over time my conscientiousness in requesting radiology has waned.

My individual threshold for imaging remains relatively high, especially in circumstances where validated clinical decision instruments determine further work-up to be unnecessary.  Nevertheless, arguing the toss over imaging vs not imaging with other teams (who will likely ultimately be responsible for the patient’s care) becomes intellectually frustrating. It is usually easier to facilitate care by ordering a scan and saving one’s energy for something else. Like stroke care. No wait…. forget that one too.

In equivocal cases, appealing to the attendant radiation penalty of a study may encourage deferment in favour of clinical observation.  I put together this infographic to help facilitate such a conversation, and to help me quantify radiation dose and risk of malignancy in preparation for my fellowship exam.

Another way to look at it: if you’ve spent a metaphorical $20,000 worth of medical radiation you’ve probably given someone cancer. And made a radiologist wealthy. Let’s budget our radiation wisely.

P.S. If you’re prepared to pay with personal time to study and scan, ultrasound is free 🙂

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Promises from #ACEMVIC16

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If you enjoyed my talk in Torquay and you want to know more about #FOAMed and how you could benefit from using Twitter here are some resources that you will find interesting

Enjoy your journey on Twitter and I hope that you find it as fascinating as I have! Feel free to message me if you have any queries about this

@cianmcdermott