The Hidden Curriculum – Funambulism

As supervisor for the newly qualified clutch of interns swimming through our emergency department I get to nurture them straight out of medical school, before the cynicism of the ward service sets in. It’s never the medicine that is a challenge, but the hidden curriculum that they are not taught in medical school. This is a companion piece to the one I wrote on getting more time for online activities.

As a thought exercise I decided to log my week and figure out just where the minutes disappear.  Now, understand that I am in the privileged position of having made it through my training and out the other side into the land of the consultant so my weekly roster is lighter than those of you still undergoing training. To compensate for that I work two jobs.

There are some things that I have to do every day – eating, drinking, sleeping, and what my father would call the 4S’s (sh!t, shower, shave and shampoo). I sleep roughly six to seven hours a night depending on what the children are up to. Once those vital activities are dealt with, and I take out work, I have about 69  hours for myself and all of my other needs.

Most of us have heard of Maslow’s hierarchy of needs*. Even if you didn’t know the name you would have seen his pyramid. He’s also got a really interesting Wikipedia entry that is worth taking a gander at. His basic premise was that human beings want to realize their full potential, that we want to become better people. Rather than Freud and Jung’s more pathological approach to personal psychology, Maslow epitomized the burgeoning positive psychology movement. To me this sounds a lot like the premise of the #FOAMed movement. He felt that once people surmounted their ‘deficiency needs‘ they were able to move on to ‘growth‘ or ‘being needs‘. They would then journey towards a state of self-actualization, in which people are fulfilled and have achieved everything they are capable of. The cynics out there will think this is an impossible ask. That does not mean that one shouldn’t strive for it. And that is where the doctor becomes a funambulist – a tight-rope walker – trying to achieve balance whilst moving forward.

I am not just a doctor, or a father, or a husband, though. I am a combination of all three. And each aspect of my life has it’s own competing hierarchy. Is it truly possible to achieve a state of balance or am I just going to lurch, lopsidedly and flat-footedly from peak to peak to peak? Let’s break down the steps of Maslow’s pyramid and look at how they may differ in my different roles…

 

Physiological

You might think that these basic pre-requisites are easy to achieve but how often do we go through a shift at work having made it through a shift surviving on the life sustaining calories of a charity box Freddo Frog? How many times have you gone to the toilet at the end of a busy work day and absentmindedly wondered to yourself what your renal function was like? I know I am not the only one. Doctors and nurses are notoriously bad at looking after themselves at work. It would be impossible to reach that state of self-actualization nirvana if we don’t do the basics right.

Bottom line: It’s hard to have good judgment if you are ‘hangry‘ – take something (healthy) to nibble on during your shift. I’ve normally got an apple in my bag and some almonds in my pocket. My wife also knows that if I am not making sense or being downright unreasonable she should forcibly shove food into my face.

 

Safety

It is easy for me to feel safe at work – I am a six foot three white male. But anyone can be a victim of bullying. The Australasian College for Emergency Medicine have set up a working party to look into discrimination, bullying and sexual harassment in the workplace and a number of other colleges have set up similar initiatives.  If you feel as if you are being bullied, or witness such improper behaviour then please speak out.

Work safety also encompasses work stability, free from worries of where you are going to work.

Bottom line: Look out for each other, not just yourself.

 

Belonging

Having dealt with the biological necessities it is time to move to the more challenging stage of the climb towards self-actualization, where competing, and often contrasting, interests are at play. It is great to feel a part of the team – not just the small team looking after one patient but the larger team of the department as a whole.  How can one achieve that? I think (and it is only personal opinion, not backed by rigorous scientific evidence) that you can start by learning and using peoples names. I might get my three children’s names muddled up at times but I know the names of the orderlies, the cleaners, the radiographers and clerks. The department I work in is like a family. When things have been at their worst they have rallied around, providing meals and emotional support.

But does this mean my real family misses out? Though I may only spend 40 hours a week at work I am sure that I spend a lot more additional time thinking about it and other work related projects.  It is easy to be distracted by constant push notifications so every day I try to be more mindful of how I come across. Every time I feel the fear that I am not getting stuff done I think about what is truly important at that exact moment in time.  I’ve done my weekly audit, I know I have so much more free time than I think, and that being present, baking Anzac biscuits or watching Frozen for the fiftieth time is much more important than answering an e-mail or reading a journal article.

It is one thing to be a part of a family but to maintain a loving relationship with a spouse despite the pressures of work can be really tough. I’ve chosen a speciality that will rely on me working shifts until the day I retire and so it is vital that myself and my partner communicate around our needs. We share Google calendars so we each know what is going on at a glance. I used to pride myself in keeping my work and home lives separate but over time have come to realise that is more harmful than helpful.  An honest answer to “How was your day?” is much better than trotting out a clichéd reply.

Bottom line:  Be truly present, whether that is at work or at home.

 

Self-esteem

What exactly is it? Maslow would have it that self esteem is an external construct based on recognition and respect. If you believe this then you are setting yourself up for failure. Any psychologist would suggest the importance of developing an internal, rather than external, locus of control. You cannot control what people think, or how they behave towards you but you can control how you respond to them. That gap between stimulus and response is increased by self-esteem.  Sure, we all like to be rewarded for a job well done. But I’m not going to be an obedient Labrador, gazing up at my master, waiting for a ‘Good boy!” and a ruffle behind my ears if I’ve done a good job, got that cannula in the chubby 2 year old.

Something I’ve struggled with for years is that my own sense of identity is intrinsically linked with what I do.  It is, to some, ‘just a job’ after all.

Bottom line: You cannot control how other people feel but you can develop control over how you feel.

 

Self-actualization

And so it would come to this, the summit of Mount Maslow, where only the most experienced climbers and their sherpas may tread. Here one may plant the flag of #FOAMed and nurture others. Fulfilment and self-actualization comes, not just from helping yourself be better (whatever that means), but also from helping others become better. People who have reached a stage of self-actualization do so through exposure to what Maslow would call ‘peak experiences‘ – a perfect date, that bacon sandwich after a heavy night out, a state of flow in a once chaotic resus bay.

Towards the end of his career Maslow tried to determine how self-actualized individuals behave differently from the rest of us, by examining the lives of a number of key figures. He selected twelve particular characteristics :-

  1. They embrace the unknown
  2. They accept themselves, complete with all their own flaws
  3. They enjoy the journey, not just the destination
  4. They may be unconventional but they don’t set out to shock
  5. They are motivated by growth not satisfying needs
  6. They have purpose
  7. They don’t sweat the small stuff but focus on the bigger picture
  8. They are grateful
  9. They share deep relationships with a few
  10. They are humble
  11. They make up their own minds
  12. They are not perfect

Does any of this sound like someone you know?

Bottom line: It is not just about you

 

I began writing this post as an exercise in dealing with work-life balance. As I have explored some of the challenges involved I have realised that, rather than walking the tightrope between the peaks of family and work, that to achieve true balance those pyramids need to become more closely aligned

 

It’s also worth exploring Nikki Abela’s take on Maslow in the workplace over on the RCEM FOAMed network.

 

* There is a lot to criticise about the simplicity of the this mountain with many modern psychologists arguing that there is fluidity at the higher altitudes.

References

Maslow AH. A theory of human motivation. Psychological review. 1943 Jul;50(4):370.
Solomon AW, Kirwan CJ, Alexander ND, Nimako K, Jurukov A, Forth RJ, Rahman TM. Urine output on an intensive care unit: case-control study. BMJ. 2010 Dec 14;341:c6761.

Hair tourniquets

If you are coming up with a list of causes of the unconsolabale infant, the presence of a hair tourniquet falls very close to the bottom, along with corneal abrasions and hernias. As usual, one of my children* kindly volunteered her own experience as a way to spread the knowledge.

What is a hair tourniquet?

You can find the first documented case report of hair tourniquet syndrome hidden amongst the latest evidence for the treatment and prevention of cholera in an 1832 edition of the Lancet. Dr G. reported a case of a strand of hair forming a constricting band around the penis leading to ischaemia. In the same way surgeons use an elastic band to create a bloodless field, a thin piece of thread or a long hair may wrap around a digit leading to necrosis.

Cases have been mainly been reported in young infants and incidence probably increases by about 3 months of age as maternal post-partum hair loss kicks in.

Telogen effluvium is not just the name of prog rock band form the 1970’s but also the term for post partum related hair loss. Many pregnant mothers are complimented on the fullness of their hair, little knowing that it will fall out around three months after birth. According to DermNet NZ around 85% of hairs follicles are in the growth, or anagen, phase of development and 15% are in the resting, or telogen, phase. These telogen hairs have a club bulb at the base and are pushed out as the result of new hair growth. Sp, paradoxically, the increase in hair fall post partum is actually a sign of regrowth.

As they cut through skin and are buried in the surrounding oedematous tissue they can be hard to find and so may be missed. If present for some time they can be covered by a layer of new skin growth making them even tougher to diagnose and remove.

 

Where might they be found?

Case reports abound of digital auto-strangulation (predominantly toes) as well as reports of hairs around the labia, clitoris and penis. Indeed, hair has been used as a means of female genital mutilation since time began.  Exceedingly rare cases involving hair tourniquets around the uvula and circumvallate papillae have also been recorded in the literature.

An extensive literature search by Mat Saad et al. found 210 case reports in the literature – 44.2% involved the penis, 40.4% involved the toes, 8.57% involved the fingers with all other sites accounting for 6.83% of cases.

 

What are the risks of leaving them alone?

Prolonged ischaemia and tissue necrosis leading to auto-amputation has been widely reported.

 

How can you get rid of them?

In order to restore circulation to the encircled appendage the tourniquet needs to be completely removed. Sometimes this can be done in the emergency department but if there is any doubt as to whether any remains then the child should be taken to theatre. Here the surgeon usually makes a longitudinal incision down to bone ( at 3, 6 or 9 o’clock) to ensure complete removal. In the case of penile strangulation then the specialist will have to (carefully) cut down between corpus spongiosum and cavernosum. Take look a this Trick of the Trade from Academic Life in Emergency Medicine that suggests using a cutting needle rather than scalpel.

Rather than unwind, or incise, there is another option – depilatory cream.

They work by breaking down the keratin in hair, and thus will not work if the tourniquet is caused by a thread. Applying a small amount to the groove cut by hair for around ten minutes is followed by a gentle wash in warm water followed by almost immediate resolution of symptoms.  Of course those cases in the literature are victims of positive reporting (who is going to submit a case report to a journal when the technique hasn’t worked?) but it is a painless methods to try. Finding depilatory cream in the emergency department is another matter. Toothed forceps are often just sharp enough to slide under the hair tourniquet and strong enough to break the offending strand. Once circumferential skin breakdown has occurred though these things really can become difficult to be confident you have removed completely, especially if the tourniquet is blonde.

 

What was the outcome?

Fortunately these hairs and threads were pretty easy to untangle, leaving little Rosie with the full complement of toes.

* No children were actually harmed in the writing of this post.

References

Dr. G (1832) Ligature of the penis. Lancet II: 136

Golshevsky J, Chuen J, Tung PH. Hair‐thread tourniquet syndrome. Journal of paediatrics and child health. 2005 Mar 1;41(3):154-5.

Thomas AJ, Timmons JW, Perlmutter AD. Progressive penile amputation: tourniquet injury secondary to hair. Urology. 1977 Jan 1;9(1):42-4.

Saad AZ, Purcell EM, McCann JJ. Hair-thread tourniquet syndrome in an infant with bony erosion: a case report, literature review, and meta-analysis. Annals of plastic surgery. 2006 Oct 1;57(4):447-52.

O’Gorman A, Ratnapalan S. Hair tourniquet management. Pediatric emergency care. 2011 Mar 1;27(3):203-4.

Strahlman RS. Toe tourniquet syndrome in association with maternal hair loss. Pediatrics. 2003 Mar 1;111(3):685-7.

Kurup HV, Gnanapavan M, McSweeney L. Hair‐tourniquet syndrome: Unwind or incise?. Emergency Medicine Australasia. 2006 Aug 1;18(4):415-.

Alruwaili N, Alshehri HA, Halimeh B. Hair tourniquet syndrome: Successful management with a painless technique. International Journal of Pediatrics and Adolescent Medicine. 2015 Mar 31;2(1):34-7.

DFTB17 – Frequently Asked Questions

We are very excited to be putting on our very first conference this year in Brisbane, August 28th to 30th 2017. We’ve worked hard to put together a diverse group of speakers from a variety of backgrounds with the hope that there is something for everyone.  Every now and then we get an e-mail or two from would be delegates so we thought we would put together a brief FAQ for you all…

Who is the conference aimed at?

Simply put, DFT17 is aimed after anyone that looks after children. You could work in primary care, pre-hospital or hospital based medicine and we can guarantee you’ll find something to interest you.  Take a look at the fantastic program we have put together.

The allied health/registrar tickets are sold out. Does that mean I can’t go?

We managed to secure a limited number of reduced price tickets and these have now sold out. That does not mean you can’t come but unfortunately you will have to pay full price. That works out as less than 350$ a day for world class education.

I can’t make it to DFTB17? Are you going to record the talks?

Absolutely. DFTB was founded on the principles of FOAMed and we aim to keep it that way. We aim to release the talks as audio podcasts after the event.

Are you doing poster/abstract presentations?

We did think long and hard about this. We understand that for some of you it is easier to secure funding to go to a conference if you are presenting a poster or abstract. There was little initial interest and we though it might be a little weird just having a couple of posters up for perusal. We are happy to revisit this in the future.

Are you running any workshops?

It’s our very first conference so we wanted to get the basics right.  It’s certainly something we a re considering in the future. If any of you have any bright ideas of workshops you would like to see then please let us know.

What about social events?

After the first day we are going to have an informal meet and greet cocktail party where the drinks are on us. It will gave you a chance to catch up with fellow delegates and speakers and a chance to share your passion for paediatrics. After the second day we going to host an amazing party. More details will follow. We’ve also got some other surprise events planned but you’ll have to watch this space.

I’ve got this great idea for a talk…

We are more than happy to hear form you if you have a great idea for the future.

Is this a one off event or is there going to be a DFTB18?

We want this venture to be a big success and, of course, the future of a DFTB18 or DFTB19 really depends on you, our audience.

 

If you’ve no yet registered for DFTB17 then head over to www.dontforgettheconference.com and sign up. What are you waiting for?

Speakers Corner – Ross Fisher

As it gets closer to our inaugural Don’t Forget The Bubbles conference in Brisbane later this year we thought it about time we showcased some of the amazing and inspiring speakers we have lined up for you.  Coming from a wide range of backgrounds and life experiences we hope that they will help us all become better at looking after unwell children and better at looking after each other.

Ross is a consultant paediatric surgeon at Sheffield Children’s Hospital, Sheffield, UK. Heis the Lead for Oncological Surgery and Trauma Management. He is also Chairman of TARNlet, the national paediatric trauma research database. His alter ego @ffolliet is much more famous than that though, maintaining a website at ffolliet.com on presentation skills and travelling anywhere folks will ask him to share ideas on improving #presentationskills.

He is NOT a professional golfer.

You can find Ross on Twitter here.

Ross has a website devoted to improving presentation skills which you can check out here. If you are interested in hearing talk about presentation skills then think about coming to the Teaching Course Australia in Melbourne, 31st August to 3rd September.

And for a preview of the man, himself, watch his TEDx talk

 

 

The 5th Bubble Wrap

With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from the world of paediatrics to point out something that has caught their eye.

Both the PERUKI and DFTB teams agreed that there was only one paper that HAS to be read this month.  And whilst some of you might be interested in the role of the vitamin C cocktail in sepsis, I think you will all agree that this is a paper that will truly change practice.

The Article – Television is a force for good

Oleg Puhl, Jo Konuu, Guhl Abel, Current knowledge of children’s television programmes by doctors predicts safe discharge of children from Emergency Departments. Pediatr. Miscellany. 2017 Apr;1(1):1-5. doi: 11.3340/hta18880.

What’s it about?

You’ve never heard of Peppa Pig? Are you serious?” There are some fundamental attributes that are needed by health care professionals who work with children. You need to have patience, empathy and good clinical skills. You also need to know what children relate to. In this innovative study Oleg Puhl and colleagues demonstrate that a working knowledge of popular kids’ television programmes may well impact on clinical care.

Why does it matter?

The premise of this work was that doctors who are able to engage more effectively with infants because they can discuss cartoon characters/TV shows etc. are more likely to make a correct diagnosis. They hypothesised rates of children discharged from an Emergency Department who returned to be admitted would be less in those with a greater working knowledge of the most popular programmes. Obviously some children sent home appropriately may return to be re-admitted but this risk should be the same across all groups. It was a shame they didn’t undertake a power calculation in advance (as the incidence of return to be re-admitted would have been known) but they did pilot and create a valid tool to assess knowledge (Cohens Kappa 0.83). The biggest limitation of the study, acknowledged by the authors, was that confounders couldn’t be accounted for. Doctors weren’t stratified by years of experience, specialty or interest in paediatrics. However this makes the study in someways more pragmatic and applicable. For a given emergency department there appears to be a direct relationship between how much children’s TV you watch, or are aware of, and your ability to discharge appropriately. So at the next handover what TV character will you be telling your staff about?

The bottom line:

Watching cartoons is good for you.

Reviewed by: Damian Roland

We asked our panel what their favourite children’s show is…

 

That’s it for this month.  Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.  If you think they have missed something amazing then let us know.