Speakers Corner – Andy Tagg

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.

 

Today we are interviewing Andy Tagg, one of our the key creators of DFTB and an emergency physician. When he isn’t working in ED, retrieving patients or playing with his children, he spends his time writing thoughtful blog posts about Clowns and Clinical guidelines, championing  our monthly Bubble Wrap and organising the conference!

1) How did you first become involved with Don’t Forget The Bubbles?
I was doing a PEM job whilst studying for my fellowship and was tweeting out the occasional paediatric pearl when I got a DM from Tessa asking I wanted to get involved in an exciting new project. I had been looking for some sort of creative outlet and rather than start my own blog, with all the hassles of having to create regular content on my own, I thought it better to team up.
2) What does Don’t Forget the Bubbles mean to you?
It means an outlet for my enquiring mind and a chance to ask and answer the questions that I don’t know the answers to. It also means the chance to change a little bit of the hospital culture as I’m trying to with my series on the hidden curriculum.
I’m the supervisor for interns in my department and I want them to have the best careers possible, whilst enjoying their lives at work. Being involved in DFTB  means being part of the wider FOAMed community and chatting to people from around the world who are as excited about life in medicine as I am.
3) What is a “career defining” moment that you can recall?
I was working in a large trauma centre in Melbourne when the alarm rang from the waiting room. A backpacker had unexpectedly delivered a baby in the toilets.  This was a hospital that does not do kids and I gave mouth to nose rescue breaths as I carried the newborn to resus.  I had spent so much time reading about neonatal resus after the death of my first daughter that all I could think about was this keeping this little one alive. My heart was racing, my mouth was dry and I was in that tunnel vision state until I stopped, slowed my breathing right down and then the  doctor in me took over. It made me realise that even if you don’t look after children you need to know how to look after them in times of need. It was my last shift, a night shift, at that trauma hospital and it will be talked about for a long time.
4) Who inspires you in your clinical practice and why?
I’m a strong believer in setting my own standards rather than comparing myself to other people. Often, via the Twitter-verse, we hear of outstanding diagnoses and amazing saves but I’m inspired by the humanity in medicine.  I’m inspired by doctors and nurses that take their time to talk to patients like people rather than diseases. I’m inspired by residents sitting with dying old ladies and  busy consultants making a patient a cup of tea without grumbling.
5) What is a little known fact about you?
I was once shortlisted for a job as an agony uncle on Radio 1 (A popular radio station in the UK)
6) What is your proudest achievement or most memorable encounter with a patient?
I have had so many memorable patient encounters, especially during my time working as a doctor on cruise ships that it is hard to narrow them down. But of course I’m most proud of my wife and lovely girls that have supported and encouraged me through all of my endeavours.
You can find Andy on here on twitter or check out his other DFTB posts here

If you haven’t yet checked it out, you can find the programme for DFTB17 here.

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.

Speakers Corner – Fiona Reilly

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.

An irrepressible traveler with an infinite appetite, Fiona Reilly has spent her life traveling the world, eating her way across more than fifty countries. After moving to China in 2009, and unable to work in her usual job as an emergency physician, Fiona discovered a deep love of writing and storytelling.

She now divides her time between Australia and China, and between her two jobs – as a senior paediatric emergency physician at Brisbane’s Lady Cilento Children’s Hospital, and as a novelist and food and travel writer for international publications. Fiona believes that medicine and a creative life are mutually enhancing, rather than mutually exclusive.

You can check out some of Fiona’s fantastic photographic adventures and writing here.

Fiona gave a brilliant TED talk on A Life Without Boundaries which you can check out here:

If you haven’t yet checked it out, you can find the programme for DFTB17 here.

Giving feedback

Yesterday, you heard one of your junior doctors, Jessica, berating at a colleague at work. It was a busy shift, and she was very stressed and under a lot of pressure. A 7 month old baby presented with bronchiolitis and her mother was struggling to manage at home. Jessica wanted to admit the patient to the ward, but the paediatric registrar on call did not feel admission was required. This interaction escalated and Jessica ended up being aggressive during the referral.

As a consultant, you will like have mentees to supervise. As registrars, we work closely with other, more junior, doctors. Whilst rocking the resus room is part of being a good doctor, actually being able to give feedback constructively and sensitively to our juniors is also a crucial part of being great at our jobs.

The aim of the feedback is to improve the mentee’s performance, not to decimate their confidence. They should go away feeling like they have a plan and are motivated to move forward. Here are our top ten tips for delivering your feedback well.

 

1: Introduce the conversation

“Jessica, do you have a few minutes, I’d like to have a chat to you”

That part seems easy enough. Jessica’s heart may be sinking as she wracks her brain for what might be coming. But you have made her aware that feedback is on the cards.

 

2: Be timely

We learn best through recency, and so feedback is better received closer to the incident. Getting feedback four months later isn’t that helpful. The exception to this is if it is highly emotional or highly charged. In that case it may be best to wait until you cool down.

In Jessica’s case, the incident happened yesterday, so the timing is good.

 

3: Do it in private…

Make sure you have a safe place and won’t be interrupted (particularly when sharing an office). It is humiliating to be criticised in front of your coworkers.

Bring Jessica into your office and make sure your colleagues know not to interrupt. Do not deliver the feedback to her in front of the rest of the department.

 

4: ….Or do it in public

Not all feedback is negative, although the most difficult types usually are. When praise is due, it should be heaped on people in public. Show your employees that you value their achievements. See Adrian Plunkett’s Excellence Reporting as a great example of this (which we have recently implemented in my own hospital ED).

 

5: Be specific

Stick to facts and give examples, and try not to exaggerate “all” or “never”.

Rather than ‘you tend to be rude to your colleagues in other departments” you could say “I have received feedback from an incident yesterday where you spoke aggressively and inappropriately to the paediatric registrar on call.”

State the impact of that behaviour “When you are referring patients, I want the receiving team to realise what a compassionate and competent doctor you are, and not to be distracted by you being aggressive during the conversation”.

 

6: Ask for their reaction

“Jessica, what are your thoughts on this?”

You need to give them a right to reply – is this a fair representation of what happened?

Expect defensiveness! Any normal person will feel affronted when given negative feedback by someone senior to them. They may deny, cry, or simply become enraged. Any of these is a completely normal response. And importantly, remember that there is no right time to give negative feedback. If Jessica gets angry, that is not because you didn’t pick the appropriate moment, it’s because it’s a shameful, embarrassing, awkward experience for her. It’s fine for her to get upset or defensive.

 

7: Provide suggestions

Consider SMART or GROW as frameworks for providing improvement suggestions. Focus on behaviours that can be changed, not personality traits.

“Jessica, can I make a suggestion? Next time you are a referring a patient, try to push all the other stressors going on in the department out of your mind. Focus on the fact that both you, and the receiving doctor have the patient’s best interest at heart. And try to see where they are coming from. Let’s meet again in two weeks to see how things are going.”

 

8: Be sensitive

Don’t be mean-spirited. You can be tough, but do not be mean. Telling someone they are “stupid”, “rude”, or “unprofessional” is not helpful.

The feedback isn’t about you making your mentee feel rubbish, it’s supposed to be for their benefit. If they feel hugely awkward or are made to feel stupid, then they are not going to be able to move constructively forward.

The feedback is for the recipient, not for you, so be sensitive to how your message comes across.

“Thanks for having this conversation with me, I know it was awkward for both of us”.

 

9: Keep it short

It does not take 20 minutes to provide negative feedback. The whole conversation can be tied up in 4-5 minutes. The truth is, Jessica just wants to get out of there and spend some time thinking about what you said/sticking pins in your voodoo doll. You need to let her do this without holding her hostage in your office.

 

10: Reflect afterwards

Although the focus of this feedback was for Jessica, you should take time to reflect on your feedback performance. Did it go as planned? Consider what would you do differently next time.

 

Jessica leaves your office with a flushed face. She is embarrassed, but she knew at the time that she had let the pressures of the department get the better of her. She can do better and will make sure her next referral is dealt with more appropriately so that at your next feedback meeting, things will be more positive.