Two Poems for champions of my heart

Equality

 

We are all equal,

There is no sequel,

For we have only this one life.

 

Heaven or strife,

This is our choice,

 

So use your voice,

And your heart,

To rise above the dirt.

 

Make use of your mirth,

That heals up the scars and the pain,

 

Let it flow, let it rain,

 

For perhaps solace lies in the “insane”,

Who can feel the beauty of the life that we live,

Giving of ourselves without a seconds thought.

 

 

16-6-16

 

At the moment my world is inundated with study, work and exams.

As I am progressing through the arduous and challenging joruney of completing specialist training in Emergency medicine, most aspects of my life outside medicine have taken a back seat, to dedicate focus to wards the path of learning the matrix of what is is to be a specialist. I am doing what I feel is effective, and and have learned to possibly be helpful, such as reading widely in books, attending practice exams, studying alone and in groups. I have sometimes been sharing the highs and lows with others on the path, but mostly experiencing them alone, in a solitude that will never be known to the world at large (apart from in daring writings such at this).

Today I learned of the exam results being released for the OSCE (objective, skills and clinical examination), and it is with great joy and simultaneous sadnesss that I heard of the success and failure of friend who are dear and near to me in both my heart, but in terms of the journey that all fellowship candidates are on, past and future.

In the joy of one particular friend I breathed a breath of relief, and for others I shared in a gasp of despair. It seems unfair that some individuals who have such a heart, such skill, and such potential for this profession, have not made it through (this time) final gate of a greater than 10 year training. Whilst this exam processess is well intentioned, and designed to empower these very qualities, it can arguabley, on occasions, be seen to perhaps fall short of what it set out to achieve.

As a researcher in education systems, and someone who has been observing their own progression through various stages of a very diverse journey of education in the arts, sciences, surgery, research and now emergency medicine, I am acutely aware that “assement” and “qualification” are but a prediction tools of relative certaintainty, but are simultanously not gold standards in this objective. In my own endeavours to help improve education and assesment systems, I’ve realised that training, sitting exams, and passing are but steps on a much greater journey, in which the destination can perhaps never fully be realised, for it is ever-evolving.

So then how do we evaluate the concepts of failure, or success?

Is it not an imaginary line (albeit, calculated through a process and mechanism), on a continuum of life-long learning?

Perhaps in specialist training, and many other forms of education for that matter, this line forms a both an psychological, and actual barrier to progression. I wonder how well the impact of examinations correlate to the end product of achieving skilled, well rounded individuals?

These may seem like esoteric questions, but to an educational researcher they questions that could potentially form a life’s work.

 

Coping with Success and Failure – through the relationships we make along the way

As a friend who was studying for his own specialist exam in another field, Anaesthetics, once reminded me “failure is an event, not a person” (taken from a line provided by personal development legend Zig Ziglar). This advice came in incredibly handy when I sat, and failed, my own big exam, the fellowship “written” exam. I have now been studying for a whole year since then, whilst working, getting over the loss of esteem, and building an entirley new strategy. If I pass this time around in August, I have the opportunity and privelidge to sit the same exam, the OSCE, that I am celebrating and mourning the results of with my friends, who are at this next stage.

It seems like a very long and uncertain journey, and perhaps this is why the final result will be so very special.

However, in the meantime there is so much pain, and equivalent joy. The joy partly lies in the hope of achieving what I set out to do, partly in feeling the success of others, but perahps the most guaranteed joy of all, is the wonderful relationships that are forged along the way – irrespective of outcome.

When studying for this exam we are in positions of vulnerability and humilty that most would not actively choose to occupy. Some, perhaps, will quickly forget how uncomfortable it feels to not definitely know if one can make it “there”, whilst others will never forget, no matter how well they perform, for it is in their nature to help others on the path.

Two of these such people, who are always there to help others, ironically did not pass the the OSCE this time around (and I’m sure there will be more good candidates to come, who also didn’t pass, for the OSCE has a pass rate often hovers around the 50%, or less, mark).

Perhaps you also know someone like this, someone who is clearly capable and desrving of such a pass? Perhaps it is even you, the reader.

Whatever the case, the following poem wholeheartedly dedicated to all of you, and all of “us”, life-long learners, who courageously endeavour to live, learn and love.

 

Wisdom, compassion and humility

 

Champions of wisdom, compassion and humility,

Using a pathway to divinity,

That has guided us thus far,

 

Whether we drive a sailboat or in a car,

The vehicle is of no consequence,

If we are not guided by light.

 

Use your sight to look within,

And feel the unity of “Humanity”,

As we once knew and later forgot,

 

We only have this shot,

To get it right,

To live without fright,

For there is really no fight,

 

When we use our energies together at large,

Voyaging in natures communal barge,

That can only be experienced as “Love”.

The whale inside

The whale is inside,
Please don’t let it hide,

For you are destined for the ocean,
This magic potion that keeps us alive,

Energy is why we thrive.

So do not waste time on what matters least.
Instead have a feast,

On what you know to be true.

Endure the pain,

For soon will come the rain,
Washing you to shore,

And once more you will rise,
When we finally realise,

That love is the only prize.

8-7-16.

Last night I had a dream about whales playing in the ocean.

I have a special connection with whales ever since a close encounter that I had with them 3 years back.

I met someone randomly at the gym a few days ago. As I entered the room he came up to me and asked me about my experience on that fateful Sunday when I was knocked out by one of the most majestic marine mammals to roam the planet.

This person went on to tell me about his own amazing encounter with whales whilst surfing only a week back. He was just surfing by Stanwell Park, in the Illawarra when he was surrounded by a whole heard of whales, curious and interactive.

My new found friend and I seemed to connect on many levels. It was refreshing to meet someone like this, who was incidentally a masters student in Medical Philosophy, doing some fascinating research, because we seemed to be invigorated by a discussion about the bigger picture that often seems to be lost on so many who are caught up on the rat race of life.

Perhaps only those who are truly open to the great majesty and force of nature will be even close to expressing how beautiful it is to behold. This is something we both could relate to, and it wasn’t just about an experiment with whales, it was more about recognizing the gift of nature that is there every moment we are aware.

“In the stillness of a single moment of nature doth the power lie”

I never really know what the purpose of the whale’s message was, but perhaps if we love ourselves enough, we can find a part of their wisdom within us.

 

#SmaccDUB – critical care and beyond…

I recently returned from a 4 day convention titled “smaccDUB”, the conference otherwise known as “social media in critical care”, this year held in Dublin, Ireland. The conference stayed true to its founding virtues of learning, education and innovation in pursuit of excellence within critical care. Smacc is also the ideological meeting place for all those passionate about promoting “free open access meducation” (a.k.a. #FOAMed) as a means of disseminating and translating knowledge to improve the world of medicine. However, for me this years conference had something a little extra within it, something rather special. The opening laser ceremony touted the themes of exploration, connection, and inspiration and by the end of the conference I couldn’t help but feel this was exactly where we had journeyed. I hope to share some of the reasons why I felt this way through the musings of this blog post.

 

Diversity and creativity

SmaccDUB pushed boundaries, moving beyond the diverse range of resuscitation and education themes that I’ve grown enjoy at the 2 previous Smacc conferences I’ve attended. The talks expand further than ever before on the spectrum of leadership, communication, teamwork, and ethics in the critical care.

Many of the talks showed a progression from pure science to the humanities, and even the philosophy of modern health care and science as we know it was repeatedly challenged during the course of the 4 day convention. To this end the use of the current journal system as a means of knowledge creation and dissemination was questioned in an interesting debate. The panel included former BMJ editor, Richard Smith, and the current editor in chief of the New England Journal of medicine, Jeff Drazen, who argued their differing perspectives on the benefits, or shortcomings, of the current peer review system.

Perhaps exploration of this nature, challenging entire paradigms, is called for at this point in history. For anyone who has witnessed the rapid technological advances that health care has seen over the last 20 years, will be forgiven for wondering just where we are going in the future. With the increasing focus on protocol driven investigations and treatments, it was refreshing to note that the conversation amongst the Smacc speakers seemed to continually  bring the focus of conversation back to the “human aspects” of care.

On the other hand, creativity was an equally important theme embraced by the conference, which itself was a highlight for me. It seemed as if fun and creativity, branded by the use of music, lights and live performance, were like the vessels through which the content was delivered. It was as if “science” and “art” seemed to be inextricably linked at every stage. This was particularly evident for me in the pre-conference sessions which included a workshop on creative writing, design and fine art in order to help make educational content more interesting. But it persisted every step of the way, from the rock-concert style opening ceremony, with laser lights display, right up until the final act of the grand finale.

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The additional daily antics that included choreographed ultrasound displays and competitions, and finally interactive debates, making use of rap and rhyme to argue out positions on issues like thrombolysis in submissive PE, was all part of the mix.

 

Mindfulness, leadership and communication

The conference opened with the “John Hinds” plenary, named as such in honour of the individual whose career long contribution will continue to inspire, as much as his loss will be felt amongst this community of critical care workers, following his relatively recent tragic death. In this section, Victoria Brazil (@SocraticEM) kicked off by entertaining us with a high quality role play. She cleverly illustrated to a captive live audience, the potential negative and positive impacts that our everyday communication can have on the quality of education, trainee self-esteem and ones motivation to learn.

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Scott Weingart (@emcrit), of the EM Crit blog, similarly pushed the boundaries of a traditional talk by discussing Vipassana meditation and the role of this practice in his life. He opened minds and hearts by delivering a plenary session on a topic that perhaps has never before been delivered in a conference of this nature. Speaking from direct experience, his talk endorsed the personal and professional values of meditation when looked at entirely from a scientific perspective. Scott likened this practice to a structured “training”, or exercise for the mind – coining the phrase “kettle bells for the brain” to describe what meditation was analogous to in his mind.

To me this was a groundbreaking talk because here was a leader in our field highlighting a practice that is still relatively unfamiliar amongst our medical community, despite its great potential to improve self-awareness, communication and decrease stress. It was also encouraging to see Scott maintain a completely scientific approach, and alerting the audience of the growing  evidence base for mental health and performance benefits following a meditative practice. The benefits of mindfulness is something that I have experienced in my own life, and I thus my encourage whenever I get the opportunity. The talk even included a short demonstration of the practice meditation, and provided a motivating discussion of how the philosophy of mindfulness could potentially help in stressful settings such those that are commonly encountered in emergency medicine and intensive care.

Multiple talks furthered the leadership theme, including those by TEDMed speakers such as Resa Lewiss (@ultrasoundREL), and visionary talks about the future of medicine, by senior clinics such as Simon Carly (@EMManchester) who blogs at St Emlyn’s virtual hospital. Simon provided an insightful back track into the journey that modern medicine has taken over the last 20, and providing an insight into where it is headed. He also provided a live demonstration of an iPhone ECG trace being delivered through a $100 gadget that is easily accessible already – indeed it appears to be brave new world of health care which we are heading towards at great speed!

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War, fear, and love

Building on the theme of mindfulness and self-awareness the conference also included a talk on “fear”, and heart-felt presentations about working in emergency situations of terrorism and war. A wake up call was delivered to our small room audience when Kass Thomas (@KassThomas4) presented recent real life experience of falling victim to US led gunship attacks on the Kunduz Trauma hospital where she was working during her first MSF mission in Afganistan. Her courageous and chilling talk detailed how she survived the ordeal of seeing so many friends, colleagues and patients die in front of eyes on that frightful October night. Her talk in particular highlighted an urgency to address the plight of hospital aid workers across the globe as there continues to be increasing numbers of hospitals suffering the same fate by being targeted under the hospices of war.

The theme of critical care workers experiencing trauma beyond the realms of normal experience was continued in other talks such as that by Christina Hernon (@emedtox)  who was an immediate responder in the Boston Marathon bombing, and Ashley Liebig (@ashleyliebig), who is a flight nurse who recounts a story fo a heart wrenching paediatric field resuscitation. In a similar vein both these speakers courageously revealed the human behind the professional veil.

Through their captivating stories they took us, the audience, into that vulnerable space of humanity, that nobody voluntarily enjoys.  These talks generated a magnitude of interesting discussion both on the twittersphere and in-person discussions amongst other delegates. Perhaps the common theme that was uncovered was a respectful appreciation of the vulnerability that goes with the human side of the critical care, a side that rarely discussed in fast pace of daily business, and I am grateful to these speakers for creating that space.

In keeping with this gloves off approach, nothing was more “on the mark” than the unplugged presentation by Ross Fisher (@ffolliet), a TEDx speaker and Paediatric surgeons who discussed the inward reaching topic of “what scares me”, “what scares you”. In his day 2 plenary session, he challenged the audience, and guided them through recounts of salient challenges in his own professional career, towards taking a long and hard introspective view at our own personal fears.

One of the most memorable experiences for me in that talk was Ross’s request for the audience to join him in a journey of exploring one’s own worst fear. Despite the vast majority of the audience coming from a critical care background where perhaps the intense nature of the job lends itself to forge patterns of adopting a fearless stride we walk, on this occasion, when asked by Ross, whether we could identify our fear and its debilitating nature, I can’t recall a single person who was left seated. “That was fear”, acknowledge by all, and together we stood.

Many other talks that also provided a compelling discourse about other human factors that are often given secondary importance, were covered with vigor and passion, such as the importance of palliative care, bedside teaching and team training, and the topic of physician and trainee burnout.

However, perhaps one other memorable talk that pushed the boundaries, again,was that by the experienced and entertaining social worker, wellbeing specialist, researcher Liz Crowe (@LizCrowe2) who gave the first talk I’ve heard in a critical care conference whose title and focus centred on “LOVE”. With great passion and enthusiasm, and a large dose of wit, Liz delivered a very serious and important message that “love can revolutionise the way we deliver critical care”.

Liz advocated that there is science that supports what mechanistically makes sense, humans have an improved ability of to make good decisions when they work in an environment where they feel supported and cared for, as opposite to when they feel intimidated and stressed. This talk was laden with culture changing gold and I can’t wait it to come out on the smacc video cast so that we can “share the Love” that Liz speaks of!

Dublin, its surroundings and the Socials

Dublin was a wonderful city, that could provide no better a venue that offered history and culture, as well as fun and frivolity that only a Smacc participatory audience could dream of. Daily #smaccPUB, with rotating venues along the old temple bar, along with the grand finale party at the 5 story Guinness storehouse complex, fully equipped with live bands and DJs ranging from house, to rock to Irish folk – not to mention the highly acclaimed FOAMeoke, and few cats who decided to so some street jamming as part of the after party– who could ask for more?!

From physical reality, back to the twittersphere…

So I will end this post with a handful of crafted tweets by the arguably the biggest component of the conference itself, the delegates, speakers and followers both locally and afar. After all perhaps half the magic of this conference is to do with the emphasis that has been placed on audience participation and interact, that arguably no medium does better than 160 summary of words/photo/or link which the average “tweet” offers as a communication tool.

So congratulations if you made it this far in the entry that I started writing on the plane home, as part of the #smaccdown process. I tried to cut it down but there really was so much happened in such a short period of time, a fact that I’m sure those who also attended will attest. There were many other innovative talks that I attended on resuscitation, hospital systems and medical education that unfortunately couldn’t make it into this post, but hopefully some of them can be covered in the tweets below.

It is clear to see that I thoroughly enjoyed this conference, leaving energised and inspired, but as always I’m keen to hear from you, if you attended or simply were intrigued by what I have shared in these words, and images, so please leave your comments below.

Thank you to the smaccDUB organising team who did a great job, in particular Chris, Roger and Oli, and their team! Also farewell to the other delegates who are part of this friendly ever-growing social media driven med-ed community.

Hope to see you all next year at #DASsmacc!

 

Related posts; 

Scott Weingart: on Vipassana meditation

Andrew Tagg: Don’t forget the bubbles-  smaccDUB summary 

Richard Carden: St Emlyns – A trainee perspective 

Suzie Edge: Primary survey – Speaking out: teams, juniors, leaders and what smaccDUB taught me

 

 

 

A Proposal and Engagement: with imagination, hope and love!

A poem, flower and a ring,
Holding this within our heart,
Even the peasant becomes a king,
Through the land of enchanted love,
Rising above cloud and rain,
Moving beyond the insane,
This is where dreams are made,
Where dues are paid,
In exchange for the hope of “imagination”.

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26-7-15

A few days ago I asked the woman that I love to marry me. She said yes and now we are engaged. We don’t even know what this fully entails. Apparently in Swedish culture, upon discussing this with some Sanna’s family here in Sweden, it is more traditional for both the bride and groom to exchange rings at the time of engagement, and it is only the bride who gets a wedding ring (Hang on a sec! That means we’ve done this backwards as I’ve just given a Sanna a ring, and I figured we would exchange rings at some point in the future when we get married?).

I had no idea of the particulars of how one should propose to a Swede, many questions crossed my mind, like whether I should ask her father beforehand, or even what would be a good thing to say? In fact the only ones who really knew on my side were my two brothers back in Australia and New Zealand, whom I told of my intention at the beginning of the year. However, in terms of this proposal I needed some specific help. Lucky for me, I happened to sit next to a man who looks about my age on the plane from Brussels to Stockholm, who also originated from outside Sweden (ie in Portugal) and married a Swede. I learned from him the Swedish words for “will you marry me?” which gave me much needed confidence in the secret mission that I was about to embark upon, however, this lesson was followed by a subtle warning that if I was not careful with my pronunciation I could easily be stating that I wanted to be poisoned! I thought about telling him that this was a bit ironic as I had recently been awarded a PhD in the field of Toxicology (poisoning) – but perhaps this was going sound a little strange, so I just made a mental note “say “Vill du gifta dig med mig?” (pronounced Vil-du yifta-day-med-may)

The actually proposal was like magic, I had to keep it all secret as I figure I didn’t want to tell anyone. The perfect spot on top of the lookout at Trysunda island where Sanna visited regularly growing up, which was also one of my favourite places on the planet. But still there was so much doubt, with the ring in my backpack, the words in my head. My mind was riddled with a series of “what if” type questions, as it easily can be when taking important decisions about my life. These worries are all to do with the future and completely ignore the wisdom of the present.

Lucky for me the skill of meditation and the craft of writing are two things that came to my rescue in a time of need. A short sit, and a little bit of journal time in the boathouse on Trysunda Island created the space to connect with my heart. It was clear to me in that moment that there really was no right time, So on this occasions, as with almost all the most significant decisions that I have made in my life, the answers have come from within, only if I dare to ask.

On Facebook it looked like a fairytale proposal, and it really was looking back, but what is not shown on these made-over social communications channels like Facebook are ally the not so shiny bits. In addition to the normal fear and trepidation that had to first be overcome, which of course included the fear of her saying “no thanks”, the morning rain had set in. However, I was determined to go for a walk, rain or shine and share a morning moment with Sanna. For some reason in that moment the Angels were showering there blessings upon us and the rain cleared. The was just enough time to pass on a blue-bell flower, and read the romantic poem that I had written the night before, followed by a ring and my line in Swedish (quickly followed by the English translation to avoid any incorrect assumptions). Well let’s just say that she said “yes”, we were elated, and I was very relieved and, well, the rest is history as they say. It seems now, even after a few days that it was so the right thing to do, and all the doubts and fears seemed to quickly disappear into the Trysunda mist.

Leaving Sweden! “Tack” for the wonderful time 🙂

It is with great gratitude and joy that I now look back on the wonderful week that we have both experienced in Sweden. However, now we have to drive to the airport and say goodbye to those we love and care about. Whilst I know we are not alone in this all too common problem where families are scattered around the country and globe – it still doesn’t make the separation any easier to take.

When I reflect upon the trials and tribulations of even the most happy occasions in life, such as getting engaged – perhaps the real magic lies not in the sun streaming down from the skies when a ring is held out in front of the one you love, but in the ability to see “beyond the clouds” and focus on gold that is always looking at you straight in the eye.

To all our family and friends who have sent such warm congratulatory wishes in phone calls, emails, and in notes on social media. Thank you from the bottom of our hearts.

We don’t know much about when, where or how the wedding will be, but all will become clearer in the months to come. Let’s just say that we both strongly believe that “life is an adventure”, (albeit with plenty of ups and downs), so at some point in the future we really hope to be riding that wave called marriage!

Lots of love from us both!

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 🙂

The Golden Day – PhD submission

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

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“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.