Dear doctors, be kind to each other.

Bishan:

Kindness is Key!

This blog post by Dharmaraj Karthikesan is like pure gold – laden with courageous statements that ooze of wisdom! (like the one quoted below) thanks Dharmaraj :)

The health profession needs more docs like you!

“We often excuse doctors who are bullies because they are ‘great with patients’ and are ‘brilliant clinicians’ or ‘gifted surgeons’. This hurts the profession more than you can imagine.”

read on ….

Originally posted on Dharmaraj Karthikesan's Blog:

I met a young doctor who used to work under me recently. I had just completed my night rounds in the hospital and I was leaving for home.

And then I saw him. He was unkempt, exhausted and appeared famished. Worst of all, he looked like a man who has totally given up on being a doctor. He appeared hesitant when I asked him what was wrong, but I could not just leave him there.

After much persuasion and insistence on my part he agreed to join me for a late supper. While he ravaged through his first proper meal of the day, he finally opened up. He has started working for the past week in a new speciality. Though the hours are longer, it was not an issue. He was well aware of the sacrifices he was expected to make.

However, the degradation, humiliation and constant harassment have finally taken…

View original 1,731 more words

Emergency medicine, and the loophole of love!

the loophole of love

With love we rise above,
Like the angel to the dove,
That flies high in the sky,

Above the the question of “why?”,
This should happen, or that should happen,
Instead taking “acceptance” as the key,

For only then will we be free,
From the visitudes of life,
For these are the ones that give it the spice,

Like a curry to its rice,
Remembering that there is no price,
In dreaming away,

So forget what “they” might say,
Because inside we can continue to pray,
For the gift of smiling yet another day,

And loving the present moment,

For in the end,
It’s all we have.

9-5-15

I recently started a new rotation of Emergency Medicine training, and before long have found myself immersed in all it’s beauty and simultaneous horror. Our speciality is full of energy, love and frustration. There are good days and challenging days, magic moments and equally frustrating ones, often intertwined into the same 10 hour shift, if not the same hour.

Most days are heavily mixed with both energies which makes it hard to have a frame of reference for an answer when someone from outside this world asks, “so how was your shift?”. For me, it is perhaps most truthful to answer this question with a guitar in hand. An example of this is provided with the the song titled “in the night drift”, that I have included at the end of this post.

Often the pressures within a single shift are high, but when compounded within a persons training period, or across sections of their career span, it is understandable that a soul searching doubt can easily set in, to the point where the question of “why am I doing this again?” is asked.

I am sure that this question gets asked by many in the field, perhaps with haunting frequency, regardless of whether one is a nurse, doctor or any of the multitude of other health “carers”.

Doctors, nurses, and the many other important ones

Whilst most would argue that “doctors and nurses” are at the core of health care provision, there is an array of other people, who occupy either named professions or unnamed roles. These people often contribute under the radar of recognition, but are making a huge difference in the field of emergency medicine everyday.

The list, in no particular order, includes but is not limited to;- physiotherapists, radiographers, clerical staff, nurse aids, cleaners, porters, special care assistants, pharmacists, translators, administrators, radiographers, laboratory staff, parking attendants, building engineers, ambulance and police staff, public health workers, aged care workers, counsellors and social workers, and not least the patients themselves and their families. We are all one, interacting together, in the common milieu of a single shift on the emergency medicine shop floor (a term that is often used to encompass the Emergency Department by Emergency Physicians in Australasia).

Why we practice emergency medicine?

Regardless of whether one is a doctor or has one of the many other important roles in this arena, perhaps Mel Helbert puts forward one of the best expositions of why someone would consider undertaking a career in emergency medicine in his recent talk titled from the EM essentials conference titled “why we practice emergency medicine”.

Mel, is the creator/founder of the EM Rap education channel, is a champion in emergency medicine education. When I use this term I mean it both literally, but I also mean to use it as a term from the field of “knowledge translation“, used to describe those who are proponents of change, in the evolving culture of crossing the “know-do” gap.

Whilst everyone’s story is interesting in their own unique way, Mel seems to have captured with his unashamedly honest exposition something that reaches out and inspires his audience, no matter if you love it or hate it, are within or outside the profession, or are simply curious about why anyone would want to do this job.

It was a really interesting 15 mins so I thought I’d share it here – thanks Mel!

The night shift

 
As promised, this is a song called “in the night drift” that I recorded directly after surviving busy nightshift, when I crawled back to my hospital accommodation and had a much needed sleep (albeit after a date with my guitar!). Enjoy :)

A PhD thesis in knowledge translation: Improving medical management through research and training

When I tell people that I have been doing clinical research for the better part of my last decade of life I usually get a few or more of the standard questions that are asked of higher degree research students like, “what did you do your PhD on?”, “what did you find?”, “was it hard?”, “why did you do it?”, and “what’s next?”.

These questions can be asked in a matter of seconds, but to answer them even briefly can take from 15 minutes to hours, depending on the level of interest. Now that the PhD is finally wrapped up, I feel inspired to write down some of the answers to these questions. I write in the spirit of what my thesis was all about “knowledge translation”, in other words, getting research off the shelves and into practice.

What was your PhD thesis on?

The title was “Improving the medical management of organophosphorus poisoning (OP) throught health services research and training”. Self harm is a big problem worldwide, and anyone working in an emergency department will be no stranger to this problem whether it is from people cutting themselves or taking overdoses. In many parts of rural Asia people drink pestices as a means of self harm resulting in over 300,000 deaths annually.

The vast majority of these pesticides are a particular form called organophosphate agents. This is much more toxic that the common weed killers used in Australia, such as round-up which is a glyphosate, and organophosphorus agents result in high case fatality rates, in the order of 15-30%, despite best practice.

The research collaboration that I worked with to conduct my research, the South Asian Clinical Toxicology Research Collaboration (www.sactrc.com), was a project that aimed to address many aspect of the public health problem of pesticide self-poisoning.

My work focussed specificially on two areas;

1) Improved medical management through the use of point-of-care tests that could provide information (acetylcholinesterase, ACHE, levels) that was thought to be useful in guiding antidote therapy
2) The evaluation of a train-the-trainer system of education to address training deficits in resuscitation education in the rural Sri Lankan setting

Both of these streams of study were different vehicles on the same journey of aiming to close the knowledge practice gap surrounding the management of OP poisoning. Thus the overall theme of my thesis was to do with this process of “knowledge translation”. The studies have been liked together using this conceptual framework.

They say a picture says a 1000 words so perhaps a figure from the introduction section of the thesis of the conceptual frame work , and two figures from the conclusions sections would aid to this strategy (ie 3000 words!?)

fig1

fig2

fig 3

Was it hard? Why did you do it?

These two questions are perhaps best answered together.

Yes it was hard.

I did it for multiple reasons, but most of all, it was the journey of trying to make a difference in the world. I have always wanted to do this, and when I started doing educational research I realised that there is an immense potential to improve the world by creating, and then assessing different systems of education.

The following video/slideshow shows how this happened in a poetic format.

The course of the PhD offered many challenges for my Emergency Medicine training that I was doing concurrently, as well as the ups and downs of life.

However, despite the knocks and triumphs, I strengthened my resolved to follow the dream I initially had with making a difference through training in Emergency Medicine training and International Research, and so far it has paid off in ways that I cound’t have imagined.

What’s next?

The first step was to stop, appreciated, and then reflect upon lessons learned, and wisdom gained that will hopefully help myself and other in the future. The next step is to become an Emergency Medicine consultant by finishing off the training, through training and sitting a fellowshop exam next year in 2016.

As for the future, I have some dreams and visions. I would like to continue as a clinical academic, teaching medical students and junior doctors. The vision I have is to help address many challenges in health care training, by fostering better “systems of training and education”. Perhaps one way this could be done is through research that also takes into account the important human factors of communcation and compassion, but who knows – tomorrow is still a mystery?

References:
(6) Arnold LK, Alomran H, Anantharaman V, Halpern P, Hauswald M, Malmquist P, et al. Knowledge translation in international emergency medical care. Acad Emerg Med. 2007 Nov;14(11):1047-51.

(8) Lang ES, Wyer PC, Haynes RB. Knowledge translation: closing the evidence- to-practice gap. Ann Emerg Med. 2007 Mar;49(3):355-63.

The Golden Day – PhD submission

Oh the joy of finally submitting the bound, accepted thesis. Thank you! ‪#‎love‬ ‪#‎gratitude‬ ‪#‎PhD #ANU #perseverance

CDqe4lsUsAAZzdt

“Improving the medical management of organophosphorus pesticide poisoning through health services research and training” – Bishan N. Rajapakse, PhD , Australian National University, February 2015.

Abstract

Organophosphorus (OP) self-poisoning is a major global public health problem resulting in over 200,000 deaths each year with a case fatality of 15-30%. Early medical management consists of effective resuscitation and targeted antidote therapy.

This thesis argued that health services research and rural doctor training could be used to improve the medical management of OP poisoning in a resource limited rural Sri Lankan setting, where the delivery of critical care is limited by a lack of diagnostic tests and resuscitation skills. Research investigating the use of AChE in guiding clinical management, and research that measured the effectiveness of rural resuscitation training, were the two streams of research that were the founding pillars of the thesis. These two elements were linked together through a conceptual framework of knowledge translation, each operating at different points in the continuum of evidence being translated into practice.

An AChE point-of-care test (Test-mate ChE) was demonstrated to provide accurate and reliable results in acute OP poisoning when compared with a reference laboratory. A survey based analysis of clinician’s knowledge, attitudes and practices found that most doctors valued the test, but also surprisingly found that doctors who were more experienced with AChE valued the test less. Low proportions valued the test in guidance of acute poisoning management (e.g. to direct oxime therapy and early discharge).

A systematic review highlighted a lack of supporting primary evidence for the use of AChE in relation to oxime use and discharge decisions. Advice on interpretation of AChE and caution about pitfalls in measurement were also lacking. These areas need to be addressed to optimise provision of AChE POC devices.

A train-the-trainer (TTT) model of resuscitation education was effective in improving resuscitation knowledge and skills in rural peripheral hospital doctors, and improvements in most components were sustained for 12 weeks. This demonstrated the effectiveness of using non-specialist doctors to conduct peer-led advanced life support (ALS) training in a low resource peripheral hospital setting, using objective knowledge and skills endpoints according to standardized metrics.

A systematic review of resuscitation of OP poisoning found no texts solely focused on acute initial management. An ‘OP specific’ ALS guideline was proposed based on consistent literature recommendations highlighting the importance of rapid atropinisation (doubling dose regimen) to be delivered simultaneous with immediate airway, breathing and circulation management. Other antidotes such as oximes should not be in the ALS guidelines.

A participatory action research approach was used to address practical problems through close engagement with health services and local training systems. The experience from both streams of research showed that such strategies were integral to the completion of the studies employed in the low resource rural setting. The thesis demonstrated health services research and training could be used to close the evidence-practice gap, and may have a role in the improvement of the medical management of OP poisoning. Future research should investigate clinical endpoints associated with the use of AChE in guiding OP poisoning management, the development of decision rules offering practical guidance in measurement and interpretation of AChE, the evaluation of OP specific ALS guidelines, and the sustainability rural resuscitation training programs.

Reflections of the Boxing Day Tsunami in 2004

Bishan:

In light of the tragedies occuring after the recent Earthquakes in Nepal Arjuna Mohottala shares his memories of lessons learned from his first hand experience of another devastating disaster, in Sri Lanka, with vote of hope the best possible recovery for the Nepalese society.

Originally posted on Arjuna Mohottala:

A little over 48 hours ago, close to noon on Saturday April 25, 2015, the peaceful country of Nepal was rocked by a magnitude 7.8 earthquake and subsequent aftershocks. Many of you would have seen the effect of this earthquake, the aftermath and the ensuing agony of those who were affected by this natural disaster on media and through friends.

A decade ago, I too had a front-row seat to witness one of the greatest natural disasters in modern history; the Boxing Day tsunami of 2004. I still recall it as yesterday. My father being a meteorologist all his life and the Director of the Meteorological Department of Sri Lanka for over 12 years, I would have been one of a handful of Sri Lankans who knew the true meaning of the word tsunami prior to the unfolding of events on that fateful Sunday.  The first indication was when I felt…

View original 664 more words

Awaken the genius within

Awaken the genius within,

Start to sing,

The songs that have no meaning,

 

 

Brush aside your heart-strings,

And begin the journey of your soul,

Don’t put it on hold,

 

 

Keep your mind on this gold,

For you never know what will unfold.

 

Yesterday I met a poet at the hospital registrar orientation and it was a very inspiring encounter indeed.

So often it is easy to feel lost in one’s workplace, which is a conglomeration of people who have gathered to work in similar roles, from varying disciplines. On the surface they have a common goal, perhaps even holding the same “job title”. However, their backgrounds, hopes and aspirations all differ quite dramatically – if only we take the time, and perhaps have the courage to enquire what inspires them in life.

One person I met was an avid kite-surfer, who also happened to know people from Canada who were my research mentors. For example, Eddy Lang is a guru in the research on “knowledge translation”. Knowledge Translation is a field that involves strategies of translating evidence into practice (which is outlined in this hallmark paper published, http://www.annemergmed.com/article/S0196-0644(06)02142-1/pdf , The principles outlined in this article had a strong influence on the theme of my PhD thesis, and i’m very grateful for this).

Later on in the day I spoke with a poet who had a passion for many things that brought meaning to her life including a fascination with animal kingdom. Perhaps the reflection from this encounter was that I would have never learned about so many interesting things, had I not asked the initial questions about what it was she was passionate about. The other side of the same coin is that we can easily shy away from “sharing” what makes us tick because of the fear of not being valued through what has become a narrow focus in our modern fast-paced world, and I have often found myself falling into this trap.

I find it ironic that in a caring profession like medicine, which is based upon uncovering the stories of our patients, we have a culture that is often misses the richness of the experiences of those with whom we work.

I am very passionate about music, and wisdom, and I would like to share an early rendition of a song I wrote years ago now.

The song is called “Peaceful Revolution”, and the song is also about how I discovered wisdom in the simplicity of the villagers of rural Sri Lanka, compared with the hustle bustle of my western urban background. Here is an earlier version in all its raw simplicity…

Illawara folk festival 2015

Festival of truth,

Festival of love,

 

With music for the soul,

We all rise above,

 

Beyond the dirt and mirth,

The extension of our girth,

 

Is a ‘being’ waiting to be born.

 

Beyond a critics scorn,

Our passion is forlorn,

Within the realm of “creativity”,

 

So let the energy of dance flow,

And with the night stars they glow,

Eating food for all cultures,

No longer are we a vulture,

But rather “creators” of the best,

Forgetting all the rest,

 

By simply enjoying the energy of FUN.

 

18-1-15

Today we were entertained and enthralled by the Illawara’s premier music festival that was oozing with local and international talent. There was dance, food, world music, folk, rock, blues, open mic, story telling, funk, and much, much more.

We had heard good things about this festival and awaited it’s arrival, but upon spending 8 hours in this magical setting, located at the Bulli showgrounds, with camping on the race tracks, we were both blown away with how the afternoon, and evening panned out.

There were many highlight amongst the multiple acts, performed on multiple stages, that were viewed by us today. The line up of what we saw or partook in included; Debasis Chakroborty and the Kriti, Kristina Olsen, Micahel Fix, Michael-John Azzopardi, the Scottish Ceilidh with the fiddle club, Guerilla Zingari, Afenginn, Sea Shanties, Swing Booty, and Big Erle.