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Hello and welcome to Sustainability in Progress, a podcast focused on exploring the most topical themes in sustainability. In this series, we will be inviting guest speakers and industry experts to discuss the most challenging issues facing our world today. But more importantly, the opportunities to address these challenges and make tangible changes. The sustainability space is constantly evolving, so we've decided to call this podcast Sustainability in Progress, or SIP. There is no one-size-fits-all formula to solve the environmental crisis, implement social justice, and install systems focused on equity. We invite you to join us on the journey where we will explore topics from sustainable food and agriculture, law and policy, economics, to the science at the very heart of our challenges and opportunities. Are you ready for your morning sip? In this episode, we look at how corporate sustainability has evolved and influenced the rise of environmental, social, and governance investing, and where the future of the ESG industry is headed. We're joined by Jo Giesler-Weiss, who is the former head of global citizenship at White & Case, where she created and led one of the first comprehensive ESG responsible business initiatives at a large global law firm. As you may already know, ESG and ESG investing is a framework that's getting a lot of attention these days. But in case you're not familiar with the terms, ESG stands for environmental, social and governance. And it's widely used by investors, businesses and financial institutions to evaluate how sustainable and ethically responsible an organization's operations and practices are. So bringing it down a bit further, the E in ESG represents the environmental aspect. For example, looking at energy efficiency. The S is for social, which includes labor standards and human rights. And the G stands for governance, looking at things like board composition and executive compensation. By considering these factors, investors and stakeholders aim to identify companies that prioritize sustainability, ethical practices, and long-term value creation. That being said, critiques of ESG investing raise some concerns. One major issue they cite is the lack of standardization. As there isn't a universally accepted framework for measuring ESG performance, this can sometimes make it challenging to compare companies effectively. And while we don't agree with this sentiment, another concern is that companies that prioritize social or environmental objectives may do so at the expense of financial returns, potentially sacrificing profitability. Critiques also argue that without clear guidelines and oversight, companies might engage in something called greenwashing refers to the practice of making false or misleading claims about environmental or sustainability benefits without actually taking substantial actions to support those claims. Essentially presenting a misleading image of being eco-friendly or socially responsible without truly walking the talk. And to tackle greenwashing and ensure transparency, global regulatory schemes are cracking down on misleading claims. They're pushing for labeling and disclosure requirements that communicate the sustainability of products, including financial ones. In the US, we're awaiting an upcoming proposed rule from the SEC, which would require publicly traded companies to disclose material climate-related risks in their financial filings. Meanwhile, in the European Union, they're already a few steps ahead and have implemented a disclosure regime for sustainable investing known as the SFDR or the EU taxonomy. So with all that as background for our listeners, let's dive right in. Jo, thanks so much for joining us today. We're really excited to have you on. Could you start off by giving us a little bit of your background, particularly on how it relates to the ESG space? Well, thank you, Laura. I'm delighted to join you today. I appreciate being invited. I think I'm one of the people whose careers evolved along with the growth of ESG. I have a background in business and consulting and then switched to the nonprofit sector for a while, was involved in the early days of diversity consulting at a great organization called Catalyst, which is still very active today. And then wanted to move back into the private sector. And the opportunity that came up to me was in corporate philanthropy, which then when I joined White & Case, as you mentioned, it was creating a global pro bono practice. And that position of kind of being a person with a business background in a large global law firm 15 years ago and looking at the issues that we were doing in the pro bono practice, we used to say in the firm we were kind of the canary in the coal mine of seeing the connection, especially between business and human rights going, starting to come together early on. I joined White in Case in 2009. The UN guiding principles were adopted in 2011. And the whole field of business and human rights sort of has greatly expanded since then and gotten linked to, of course, the environmental sustainability issues and together this sort of basket of ESG, which as we'll talk about, why is it ESG? Why are those three things together? Because at the top of the house of a big company, they really want to look at it across these issues when they're looking at strategic decisions. So when you need a lot of different expertise in each vertical, you need to be able to put them together in a strategy decision-making process, which is what we're going to talk about today. So I had a good seat at a great table to be part of bringing this together and it was my privilege really to work in this area and to continue to try to think through these issues and say, how can we accelerate these changes? So your background, you know, the intersection of business, human rights, and the environment is part of why we're so excited to have you on today. So first, I want to start off as you know, the ESG space has been getting a bit of a bad rep. And I think it's important to start this conversation by reminding ourselves of the positive outcomes of genuine ESG investing. For me, one of the best examples is the Japanese pension fund's GPIF, Embrace of ESG, led by its CIO, Hiromichi Mizuno. I probably said his name wrong, but that was one of the cases we tackled in your class, which really shed light on the industry for me. And so when Mizuno found himself in charge of GPIF strategy in 2015, he effectively had a say on how 1.6 trillion in assets should be invested, representing 10% of the Japanese stock market and 1% of the global stock market, arguably at the time, the largest pool of capital in the world. Could you talk to us a little bit about his strategy, its outcomes, and what it meant for the industry as a whole? Well, I'm glad you found the case valuable. I think HBS did a great service by writing up the path that Mizuno went down with GPIF. Pension funds have been leaders. GPIF is not the only one of those. And it's because the long-term timeframe of a pension fund aligns with ESG concerns. Also, they're very aware of their ultimate investor in a way that, you know, retail asset management is more diverse in terms of its customer base. So that's not surprising. But Mizuno's, he's really singular, certainly at the time, is an inspiring champion who accomplished a lot and was a very early leader. It's interesting that he himself talks about a dinner conversation he had with Kofi Annan, the Secretary General of the United Nations at the time, where Kofi, showing the soft power of the UN and people in leadership there, which I think is perhaps underestimated sometimes. Mr. Anand asked, Secretary General asked him at a dinner, you know, do you know what ESG is? And Mazzucco wasn't sure. And at the end of that dinner, he, you know, decided to take it on as a package, not just the S or the G or the E, to separate them out as one or the other other or even subsets of the S, say, for instance, board diversity, which was more common in Japan at the time. So I think an interesting link with a very big picture thinker there who I think pounced at that dinner. So Mizuno did sort of three things I would highlight. They launched five ESG indices, which drove company behavior to be included, as opposed to a divestiture strategy to exclude, which as a universal investor as huge as the Japanese pension fund, that wasn't really an option for them anyway. Second, he moved active managers to multi-year compensation contracts. And third, he instructed both active and passive managers to actively engage with the companies in which they invested. Subsequent surveys showed that the behavior of asset managers did change, though not without the need for adjustments as they went along to clarify what was expected and get the compensation formulas right. So he did these very tactical things that are replicable for other companies, were sort of groundbreaking at the time. And on top of that, he used a great deal of communications and convening leadership modeling in the field to promote this direction of play. And Mizuno himself is still very active and today as a UN special envoy for responsible investing. |
So you just talked about active engagement within the case. And I think a big question that often comes up in sustainable investing more generally is whether divesting is a solution. If a company, for example, is exposed to coal, should portfolio managers divest or is an active engagement strategy preferable to push companies to make measurable change and impact? Divesting is certainly a choice, but I'd say it depends. If a portfolio manager has the resources and the expertise to pursue an active engagement strategy, certainly I think that's a powerful tool, but not all do. We'll talk in a bit about the credibility of ESG ratings, but if they aren't credible or comparable or both, and they really aren't right now, then certainly retail investors may have no option but to divest if they want to be sure their money is not funding certain activities. Now, this is easier to do with the E, and coal is probably the most obvious case right now, but much harder to do with the S. I think divesting, personally, I think divesting over social performance is a last resort for truly awful performance with no credible effort to address it. This will change as disclosure improves, as companies get their hands around their actual social performance. So would you say that if you're a larger asset manager and you're able to yield influence, would an engagement strategy potentially be preferable to divesting? Yes, and I think we're saying that, right? I mean, the very large asset managers are in the lead with hiring a lot of wonderful grads from the Columbia program to work on stewardship teams, right? To work with the companies, to explain what this is, to help them just build the capacity to both get their hands around the data and understand their risk. What is the data telling them, and then take steps to mitigate those risks? So there's, we've seen a recent example where engagement could potentially be beneficial versus divestment with the case of ExxonMobil, which supported the nomination of climate-friendly directors onto its board. And whether or not this has worked in practice remains to be seen. But could you maybe talk about how the investment community was able to pull this off at an oil major and whether this opens up the possibility of more board-related activity across other high-emitting sectors? This was a very interesting case, and it was driven by the investor group Engine No. 1. board members backed by engine number one, two elected in June and one subsequently in July are now on the ExxonMobil board. Really unprecedented in the history of sort of board elections, certainly around ESG. But it is unclear what effect this will have on ExxonMobil's strategy or speed of transition. But certainly the conversation in the boardroom is expected to be different with a different mix of board members, which was what engine number one was going after to pursue. The folks from engine number one have been speaking about the situation, and they're saying they aren't sure what happens next, but we need to wait and see. And it seems preferable to the status quo from an ESG perspective. Interestingly, the founder of Engine No. 1, Christopher Jones, is now saying they want to work with companies rather than take an activist role. There was a Wall Street Journal article in the summer subsequent to the ExxonMobil elections. And as an example, engine number one reportedly played a role in getting three U.S. oil and gas companies, ConocoPhillips, Pioneer, and Devon, to join a U.N a UN backed working group called the Oil and Gas Methane Partnership. Now, we talked before Laura in class about how the civil society has become much stronger and much more likely to build consulting arms to partner with the private sector to move them on environmental and social issues. And I think it's interesting to see engine number one, which is not a nonprofit, but sort of taking that same kind of an approach. And I do think it's powerful. So I don't know what's behind that. And I'm not an insider to this, but I think it's an interesting development. And, you know, I think changing board composition and working with companies to help them engage on these issues and turn the ships around are both important tools at this stage. Absolutely. I think, you know, sort of this shift to collaboration and also more broadly within the sustainability space, you know, pre-competitive, we're seeing more and more pre-competitive solutions, which I think is really interesting. So turning back a little bit to the role of a board of directors at a company, what would you say, you know, in your opinion and your experience, how can or what role can the board play in executing environmentally friendly strategies at portfolio companies and how can they make the most impact? Well, first, I think we should look at the situation facing companies now. There's a lot of forces, different forces on companies moving them in the direction of the growing importance of ESG. There's macro forces, climate change, technology, globalization, the pandemic, conflicts make everything worse. There's legal and governance changes, a lot of changes to regulation and legislation related to due diligence and disclosure and addressing ESG issues popping up all around the world. There's corporate governance issues, complications, case law, stock exchange rules starting to change, and stakeholder pressures from clients and customers, from employees, affected communities, media, investor concerns and advocacy groups. So there's a lot of forces pushing business right now to say, hey, pay attention to this stuff, right? And there's the three ways that businesses can respond. There's the ostrich approach, which is really don't do anything. And then that's really called crisis management because you're risking a crisis, in which case you're going to have to deal with it. So that's not a good option. And certainly the board in the C-suite should be leading the charge to say, let's avoid that. Let's avoid that. Then there's risk management, which is important and critical and must be done. And maybe enough in and of itself, depending on the industry you're in. But for many, many companies, there's also many opportunities presented by what adoption through good communication around what you're doing to green your operations. And that's an option. But also new products, new services that are popping up because of the growth of ESG. So, you know, there really is an opportunity here. It's not just risk avoidance. So let's, I thought it might be useful to say what exactly is this? Can we define our terms here just a little bit? What kind of risks are we talking about? So the top environmental and human rights issues for businesses are, first of all, the environmental impact on operations, employees, communities, and climate and habitat. So that's environment in a nutshell. In terms of human rights, there's high-risk labor issues like modern-day slavery, which is relevant for certain large global companies working in high-risk industries, land and property rights, but also security and civil rights issues, discrimination, gender, race, central orientation, the whole basket of diversity, inclusion, and equity issues. Digital rights and privacy are increasingly being considered as part of the ESG concerns. Anti-corruption and bribery long concern are being recognized as being part of responsible business, right? So those are the issues that, you know, boards and the senior executives, the C-suite, chief executive and his or her direct reports are thinking of when they say ESG, right? But there's a fear in the boardroom of how far they can go because of what is the purpose of a corporation, right? And typically that's described as profit. Shareholder primacy is sometimes the language used. So that can be confusing. Well, am I supposed to earn less profit if I, you know, make sure that my operations switch over from fossil fuels to renewables? That might be really expensive for a few years and the payback is going to be a while. And I don't know, I'm leaving profit on the table. Am I open to a lawsuit from an activist shareholder? Am I open to the market beating up my share price because I'm underperforming my competitors, right? So a key thing that is sometimes overlooked, a lot of times overlooked, is not that the boards and the C-suite don't want to do this, although sometimes it is, it's that they think perhaps they can't or they don't see how they can because of this confusion about corporate governance law. And it's different in different countries around the world. There are an increasing number of stakeholder codes, stewardship codes that are being adopted in different countries that give more leeway. Japan is an example. The UK is an example. But Delaware corporate law, which governs most of the companies registered or incorporated in the United States, is viewed typically as being more stringent than that. Now, this remains a problem, and it isn't solved. |
And certainly as these forces reach a tipping point and environmental pressures become, the environmental crisis becomes so critical as we're seeing. But even if the company is in a field where the human rights issues are so germane, those things are going to be clearly rationally related. If you're in a crisis management situation, that is rationally related to your financial performance. So you want to avoid that. But how far can you go? When does it become that you're going too far? That line is remaining to be seen. And it's important to remember that that might be a thing that is in the minds of boards, right? It is in the minds of board members. So first of all, thank you so much for defining ESG, because I think, you know, we talk about it sort of so comfortably, but it's really important to actually define the three different, what, you know, environmental, social governance really looks like for boards and for companies. And I completely agree with you, you know, it's just going beyond just having a risk framework. If you take a long-term view, companies can really increase their bottom line and profitability. We've looked at the opportunity and potential for incorporating environmental criteria. Could you speak to what companies and specifically what boards at companies can do on a social and governance front? Yes. So it's important to distinguish the role of the board and the executive, right? The executive runs the company and the board advises and oversees and hires and fires the CEO. So within the board itself, today, typically, ESG is treated as neither a board specialty nor a core competency. It's not the clear responsibility of any committee. Sometimes it's audit, sometimes risk, if at all. So boards need to develop their ability to identify and implement a rationally related ESG governance strategy. But of course, what boards do is they lead by asking questions. So I think boards need to ask these kind of questions. Is ESG part of our long-term strategy? When you present your strategy to us each year, we want to see the ESG connections there. Do we as a board, they should ask themselves, have the info we need to oversee our ESG strategies and risk? What should we be asking the executive to share with us? And is that a new meeting? What's the format for that? How are we going to get that information? What kind of framework are we using? Boards should be aware of the reporting frameworks and the changing climate on that. And how can we improve the transparency of our disclosures to meet investors' expectations better? And are we effectively telling our story to investors? So I think those are the kind of questions and the kind of role that boards can effectively play here. So you kind of told us what the boards can do. Could we switch a little bit to the consumer view and talk about, first of all, this is very topical, what greenwashing is and maybe explain that to the listeners, but also how can consumers effectively avoid investing in strategies that may be exposed to greenwashing? Yeah, greenwashing is corporate communications designed to make your ESG efforts seem better than they are. Contrast this to authentic communication, which is trying to communicate what you actually are doing accurately. Companies need to tell their story, and they should. They should be allowed to tell their story. We should not be overly cynical when we see a company saying, here's what we're doing on ESG. And they're not going to tell it in the worst light, of course not. But storytelling and disclosure are different. So often the storytelling can be directed to the consumer market. And so we see the slick ads, and that's something that the retail consumer has to sort of judge, you know, to what extent do I buy this? Whereas the institutional market relies more on disclosure. And in the end, required disclosure and ultimately enforcement of key practices, as well as provision of remedies, are really needed to unearth the truth of what a given company is doing. Regulators, journalists, third-party watchdogs, market ratings, even lawsuits can keep the greenwashing in line. But I would say that awards for the best player should not be discounted either. No company is or is going to be perfect, so it's all relative, subject to a threshold of reasonably decent performance. I mentioned ads, and there's an interesting one I just saw on CNN International with the Suntory CEO and I saw another one recently on a podcast with the Pacific Gas and Electric Company CEO, both of which talking about important steps that their companies were taking to reduce their environmental impact. Should we take this as authentic communication or greenwashing? Certainly they're not slick commercials. The CEO's spokespeople and slick commercials usually don't go together know, I think that it will be interesting to see if the market can provide valid ratings that consumers can look at to validate what they're seeing in the PR and the corporate communications of the companies that they buy from. And the two can work together, hopefully, in the long run. Yeah, thank you so much for that. I think it was maybe in one of our previous discussions, there was actually a New York Times article that sort of had a, you know, controversial but interesting standpoint where it talked about how, you know, obviously greenwashing is not good, but it actually shows that the industry as a whole is moving in a positive direction. So I know we're going to look in a few questions, we're going to talk about how consumers can actually try to avoid investing in greenwashing funds. But first, I wanted to talk a little bit about what has been happening on that front. The ESG investment world is still largely unregulated, but we are seeing a shift in the industry with the EU taxonomy's sustainable finance disclosure regulation, which has also influenced the SEC's recently proposed climate disclosure rules. In Europe, we saw the first event of a police raid of Deutsche Bank's asset management and subsidiary DWS just earlier this year, and that was for overstating ESG claims. In the U.S., the SEC fined BNY Mellon for misleading claims about ESG funds. So do you think this recent increased scrutiny might lead to more authentic sustainable investing? I do, Laura. There's two pressures on getting more credible data. The pressure on companies to know and show, and the pressure on asset managers to be accurate and not inflate their claims, which is a longstanding legal duty. That's not new for asset managers. It's application to ESG assessment is what's new. And it's complicated, right? So it's hard. Asset managers really need good data so that they can know they are accurate and also to remove the temptation to push the limits of their claims because there's just too much ambiguity about ESG data and therefore it's linked to financial performance. I think poor data is the root of the problem. We need standardization. And so the regulations that you cite are a very welcome development, I think, by all involved and critical. Absolutely. And I also think that technology will definitely play a role to help us get there. And do you think requirements should be the same for smaller firms who might not have the means or might be overstretched and understaffed versus larger corporations? I think it's sometimes harder for smaller companies to have the same level of rigor for data assessments, for example, which can then lead to greenwashing. Do you think regulators are considering that? Yes, I do. Most of the regulations and the laws passed so far define the scale of the companies impacted or drawn at the right levels. But regulators are aware of this. Really, I think it's the supply chain pressure from big companies that can catch a lot of the smallest companies. And I think that the market is aware of this. The players are aware of this. It's pain for big companies to actively engage with their supply chain, and they're going to have a scale and certainly materiality assessments as well for who they can engage with. But because the responsibility for ESG impacts extends to the supply chain of large companies, they really have to understand what's going on in their supply chain. And this is a way to catch the education and evolution of smaller companies. That's a really interesting way to talk about it. Yeah, absolutely. I think the pressure on supply chain will, from larger companies, will influence smaller companies. So I think, you know, we've touched on this sort of throughout the last few questions on this episode, but we try to tie these concepts into the consumer's approach. In this case, we can think of the consumer as the investor of financial products. So, you know, what do retail and institutional investors need to be aware of in light of shifting regulatory regimes around greenwashing and disclosures, and how can they make the most informed decisions? The market needs to serve retail investors with credible, comparable ESG ratings or data dashboards, some digestible assessment of ESG performance. This is not in place today. |
Hello and welcome to Sustainability in Progress, a podcast focused on exploring the most topical themes in sustainability. In this series, we will be inviting guest speakers and industry experts to discuss the most challenging issues facing our world today. But more importantly, the opportunities to address these challenges and make tangible changes. The sustainability space is constantly evolving, so we've decided to call this podcast Sustainability in Progress, or SIP. There is no one-size-fits-all formula to solve the environmental crisis, implement social justice, and install systems focused on equity. We invite you to join us on the journey where we will explore topics from sustainable food and agriculture, law and policy, economics, to the science at the very heart of our challenges and opportunities. Are you ready for your morning sip? Hi, my name is Loha Neg, your host for this episode of Sustainability in Progress. Today we're recording this episode virtually from London, and we'll be discussing one of the fastest growing areas within sustainability. This particular segment of the market seeks to address one of the most significant sources of greenhouse gas emissions, the emissions stemming from how we get around. The transportation sector accounts for approximately 15% of global greenhouse gas emissions, Thank you. problem and transition our global economies to a low-carbon system, we must address the emissions caused by the transportation sector. Today, one of the most impactful methods being used is the electrification of vehicles. EVs have seen incredible growth in production and demand. Sales of electric cars doubled in 2021 to a new record of 6.6 million, with more now sold each week than in the whole of the year 2012. In fact, even here in the UK, the government intends for all new cars and vans to be fully zero emission at the tailpipe by 2035. So we have reason to be optimistic that one of the largest sources of GHGs will be addressed and potentially eliminated if we continue on this trajectory, right? Well, yes and no. The answer is a much more nuanced one and requires a deeper and more thoughtful analysis of the calculation of emissions created during the production and life of an EV. To answer some of these questions, today I'm joined by Christoph Meinranken, who is an Associate Research Scientist at Columbia University's Earth Institute. Christoph has researched these exact issues and conducted something we refer to as Life Cycle Analysis, or LCA, to determine the true emissions of electric vehicles versus hybrids and internal combustion engines. Hi, Professor. We're really excited to have you join SIP today. Since we have a lot of ground to cover, if you're ready, we'll jump right into it. Sure. Hello, Laura and everyone else, and thank you for having me. It's an interesting and exciting topic that I happen to care a lot about. So fire away. So there's a lot of debate around what carries a heavier GHG impact between modern internal combustion engines, hybrid vehicles, and EV vehicles, and what should be considered. From a lifecycle analysis perspective, can you shed some light on what the different considerations should be? Yeah, I think in the research field, and once people get more into it and turn into like a fixer-naggers about it, there's a lot of comparisons between different drive trains, so-called, and that would be the three classes are usually the traditional internal combustion engine that you mentioned. And then there's different types and subtypes of hybrid, as you mentioned. And then there's EVs, and sometimes people emphasize the pure all-electric vehicle. And that can get quite technical pretty quickly, that discussion, the different pros and cons from a greenhouse gas perspective of the different drivetrains. But I think what sometimes people are forgetting is that there's a lot of other factors that impact the fuel efficiency of all three drivetrain types the same way. So if you, for example, picture two different cars, one is a very heavy SUV with a very strong engine, four-wheel drive, all the works, and the other is a much smaller, elegant, if you will, electric vehicle, then I think what some people understand right away is that, well, yeah, of course, the heavier car with a more powerful engine will have a disadvantage in terms of fuel efficiency and, therefore, a disadvantage in terms of greenhouse gas emissions. But almost the biggest influencer is also the size of the car as it drives on the highway, just pushing air out of the way. And that's sometimes something that I still cannot believe that people are not really aware of this, that they might think, oh, I want the big car because I want to sit high up on the road and I want a heavy car for safety reasons and I want a strong engine to be sporty. But actually, what they're also getting is the kind of car that at high, fast highway speeds just uses most of their gasoline to push air out of the way. And the same is true for the electric vehicle. If you buy an electric vehicle that is large and has a big cross-section and it's not very aerodynamic, you spend a lot of the electricity that you put into the battery just by pushing air out of the way. So just sort of as an introduction, I think sometimes it's nice to take a step back and also think about from a buyer's perspective, what kind of car do I really need? Because there's some basic choices that were always around, even when there were just ICE cars around, that affect greenhouse gas emissions from cars a lot. And they're not fringes, fringe effects such as, you know, I think one of our former presidents got himself into hot water when he mentioned that people should make sure that the tire pressure is correct so that they save a little bit on gasoline, which is true, but the effect about the size and the wind resistance and all that are much more pronounced. So that's really interesting. Now that we have some of the considerations in mind, such as size and the effect of wind and weight, some advocates of EVs just argue that it's the obvious cleaner choice since they do not emit GHGs when you compare that to ICEs or hybrid vehicles. But a common mistake is the lack of an apples-to-apples comparison, which I think you alluded to just now. Can you talk to us a bit more about comparable scenarios and their outcomes? Yes. So now let's try to make an apples to apples comparison. So for example, what you might do is, I did this study a few years ago, but it mostly probably still valid if you take a Toyota Corolla sorry if I use specific brands but just for people to picture it the ICE version against Nissan LEED for example one of the early available all electric vehicles it's pretty apples apples. They both have the same number of people in them. They have both similar acceleration behavior, similar wind resistance, etc. One thing that's not exactly a fair comparison is that Nissan Leaf, because it has a reasonable battery size rather than a super big battery, it just doesn't get quite the range that an ICE would get. After 100 miles or so, you have to recharge your battery, whereas the gasoline car takes you much further before you have to fill up. But otherwise, pretty fair comparison. So with that, it then comes down squarely to the carbon grid intensity of the grid. So in other words, for every kilowatt hour of electricity that you put into the Nissan Leaf, how many greenhouse gas emissions were already emitted to get the electricity into the battery? And those greenhouse gas emissions, of course, as we know, they're not local. They're not point emissions at the point where the vehicle itself is. They do not come out of the tailpipe, but they're somewhere else, right, at the power stations and in the incidence of coal and natural gas also in some of the mining of those fossil fuels in the first place. And what we find there is because you asked this very important question about the apples to apples, is that for the average grid intensity in the US, so that would be two, two and a half pounds of carbon dioxide per kilowatt hour. The all-electric vehicle, yes, has a much better greenhouse gas footprint than an ICE. But ironically, the all-electric vehicle has more or less the same greenhouse gas footprint as a hybrid car. And by that, I mean a hybrid that actually drives on gasoline, like a traditional Toyota Prius, for example. So it gets very interesting for buyers because all of a sudden they stand, if they want to have a similar size and performance cars, that would be the apples to apples. They don't actually have to say goodbye to gasoline, if you will, because a hybrid vehicle would do the same, would give you the same greenhouse gas emission savings in comparison to the ICE as an all-electric vehicle would do. Yeah, that's really interesting. That was a big wake-up call. I also think it's important, though, to highlight that that might be different for somewhere with a really low carbon grid. |
Definitely. And that's why I emphasized before I used that word average a lot, right? The average carbon grid intensity in the US. So Norway, Switzerland, France, also because of nuclear power, which is unproblematic, at least from a greenhouse gas perspective. New York State, too, interestingly, has quite a low grid carbon intensity because of all the hydropower we get from Canada. So even in the U.S., state to state, there have been very interesting studies that show that in some states, the all-electric vehicle wins, quote unquote, and in other states, the hybrid gasoline vehicle wins. And that, of course, changes over time as technology changes a little bit, as drive train technology improves, as even the grid carbon intensity in some of those states changes, as, for example, more renewables come online. But broadly speaking, it's still the U.S. average, and then state by state, it can be quite different. Definitely. So you've addressed the issues around higher carbon grids and the average carbon grid in the US. Is it also important to take into account the hours or timing needed for the recharging of the batteries in order to avoid charging at peak hours? Wow. I love that question. Why are you asking that? I guess, you know, first of all, it's so different everywhere to avoid peak hours. And, you know, is it consideration when there's really hot weather in the summer or is it at night and whether there's actually policy that can be built around it. But to even think about that, I think it's interesting to understand if it's an important requirement within the SCA analysis. Yeah, it definitely is. But it's one of the more intractable ones, both from a research methodology point of view and also for consumers to figure out. The basic effect that you're correctly stating is that let's take two extreme examples. One is in the summer in a state where there's quite a bit of solar energy on the grid. It might be a warm but not super hot summer day, so there's not much air conditioning load on the grid. So if I then plugged in my car, I would probably get just a little bit more electricity from solar because it's available. So that means that specific electricity, if you will, it's referred to as the marginal grid carbon intensity that I get at that very moment is actually very low carbon. So then it would make sense. Whereas in other situations, let's say it's the middle of winter, people use a lot of electricity for heating, it's dark, there's no solar, maybe there's not a lot of wind, so there's no wind power, and additional coal-fired power plants have to go online on the grid to even support the basic need of electricity, not even thinking about electric cars. If you then plug in your car, you get very high carbon electricity. So in that particular incident, you would be much better off just taking the gasoline car or renting one if you don't have one and leaving the electric car parked where it is. The reason I mentioned it's tricky is from a methodology point of view, it's difficult to, over the course of one year, figure exactly out in what region of the country, at what times of day, what marginal grid carbon intensity is at play, but it's possible. But from a consumer point of view, it's even more so. How would you know locally at any given time of day the current real-time grid carbon intensity? The peak hours that you mentioned, I think, in your question, if I heard you right, is an attempt to get there. So there's very advanced tariffs that basically change, for example, the price of electricity in real time, often in an attempt to signal to the user how high currently the grid carbon intensity is or, also in other words, how precious is electricity at that point in time. But it doesn't always work one-to-one with regards to that the price really is directly reflective of the grid carbon intensity. So it's a great question. I love it because it gets to the more complicated things that are also unfortunately at the moment still quite intractable for consumers. That's a really helpful answer. I think it tells us and the listeners that there's a lot of complexities with the assumptions that need to be made. And so now if we could turn to the battery component, starting with the required mining inputs at the earlier stage of the LCA, and importantly at the final stages of landfill and disposal, and what might be potential barriers to recyclability? Yeah. So before I answer that, I'll just put it back into context with one of your earlier questions. I like how your questions flow and build on each other. I mentioned earlier that, oh, you know, sort of almost by the way, for average U.S. grid electricity, an EV vehicle and a hybrid vehicle, hybrid gasoline vehicle is essentially a toss-up. And I just want to emphasize here that my understanding is that this podcast is mostly or exclusively about greenhouse gas emissions, right? Because everyone knows there's other environmental considerations around EV vehicles where they always win hands down, right? And for those listeners who were kind of surprised by that Nosh or Not, it's a toss-up, they were surprised, rightly so, because they may have wondered, but I just don't understand. If I put gasoline into this ICE engine that's in a car, it's a small engine, How could it ever burn gasoline so efficiently and turn it into mechanical energy that it could win against a very large, optimized economies of scale power plant that also uses fossil fuel to turn it into electricity? And the reason is largely like you say, Laura, that for the battery electric vehicle, an additional greenhouse gas contribution that has to be taken into account. And that additional is quite substantial comes from the battery. So someone has to source the raw materials for the battery. And I'm just now again talking about greenhouse gases associated with lithium mining, for example, not even talking about other social problems and other ecosystems. So someone has to build that battery. Someone has to use energy to manufacture, put it together. Then it's sitting in the car. So every mile that that car drives, all of a sudden the car is heavier because the battery is so heavy. So it's like having several extra passengers in the car, which adds to the fuel consumption. I mean, electricity consumption as a form of fuel. And recyclability also, important aspect that you mentioned, if batteries were fully recyclable yet, it's not always the case, then the greenhouse gas footprint of batteries would also be a little bit smaller. You would still need the energy when you recycle it. Anyway, so all of those effects together in total get you to a point where, for example, in that Nissan LEAF example I mentioned earlier, just the battery alone is easily 10, 15, 20, 25% of the greenhouse gas footprint from driving such an electric vehicle. So it seems that even with a low carbon grid, long range vehicles, including trucks, are heavily penalized by the number of batteries and you just mentioned the reasons why. So how well is technology advancing to reduce the weight and improve performance? And in your opinion, is this still the key technology which will lead to universal adoption of EVs? Yes. I'm not a battery technology expert. I'm following sometimes the amazing improvements in battery technology. And they are very much like you say. They try to improve the amount of electricity that can be stored per weight. Cost is also an issue, but we're not talking about that here. Also, other issues a little bit less important than weight or maybe less of the focus of research is how much electricity you just simply lose by charging the battery and then taking it back out of the battery before that electricity even arrives at the motor, right? So that also sometimes puts you down 5% to 10% to the comparison of a pure gasoline vehicle. So that's why I think, rightly so, Department of Energy, et cetera, put a lot of research, money, and effort behind better battery technology. But the second part of your question was interesting. With that battery technology, is that actually going to be the thing that's going to get us over the hump to all-electric transport? And I think there we just have to keep in mind that even if the battery weight goes to zero, let's just think in the extreme, in terms of the overall footprint, it's still just an incremental improvement to the overall footprint of the BEV. So unless there's massive improvements to the amount of renewable generation on the grid, it could still happen in 5, 10, 15 years that all of a sudden there's a carbon neutral fuel or much more carbon neutral fuel than even electricity that's partly generated with renewables. That would then just change the entire equation. Incrementally, yes, important, big advantage. |
Hello and welcome to Sustainability in Progress, a podcast focused on exploring the most topical themes in sustainability. In this series, we will be inviting guest speakers and industry experts to discuss the most challenging issues facing our world today. But more importantly, the opportunities to address these challenges and make tangible changes. The sustainability space is constantly evolving, so we've decided to call this podcast Sustainability in Progress, or SIP. There is no one-size-fits-all formula to solve the environmental crisis, implement social justice, and install systems focused on equity. We invite you to join us on the journey where we will explore topics from sustainable food and agriculture, law and policy, economics, to the science at the very heart of our challenges and opportunities. Are you ready for your morning sip? Hi, SIP listeners. Welcome back. We are so happy to have you back for another episode. This one's a little bit harder to pin down to one topic, but it broadly relates to one of our most precious bodies of water, the ocean. Our guest today, Andy Cross, she has spent years exploring the ocean and we think this episode is definitely going to transport you there. But first, before we kick that off, like we do on every episode, Laura, what is your guilty pleasure for this episode? So I'm trying to think of one that relates to travel or the ocean. And what I'm thinking doesn't really, I think, qualify as a guilty pleasure. It's just more about me being historically negligent. So for the longest time, I wasn't particularly attentive to what sunscreen I used, as long as it did the job. But more recently, I found that chemical sunscreens are particularly bad for the ocean. They can damage reefs and marine life. And honestly, they also have claims that they carry carcinogens. So probably safer to stay away from them in general. So now I try to stick to mineral sunscreens and avoid any that carry like really nasty chemicals. And there's like a whole list, but I'm not going to go through that because I will mispronounce all of them. But I think one that comes up a lot is oxybenzone. So avoid that. And not to make this a mineral sunscreen ad, but they do feel a lot better on your skin. They don't have that like sticky feeling. Okay, so this didn't really count as a guilty pleasure. But let's hear yours, John. Okay, this is highly relevant. And I used a bunch of sunscreen based off of the vacation that I just took. But it's a little bit related to the vacations that sometimes occur during peak season, because it is the summer. And usually that lines up with my downtime from work, and I get to travel a little bit. That also means all the finance bros are out and about at these destinations and the crowds tend to lead to over tourism and often irresponsible tourism. So working on that and Andy, by the way, is going to share some tips on how to be more conscious when we travel and finding those opportunities to be a little bit more conscious with our travels going forward. So that's mine. Yeah, John, you're just going to have to settle for colder plunges in April and May instead of July. Yeah, that's going to be a little bit difficult for me. But yeah, I think I might have to resolve to that and have to get the surfing bodysuit and just go to the beach that early. Yeah. So I think for this intro, we're going to keep it pretty short because there aren't too many technical terms that need defining, but mostly we believe this episode is going to interest anyone who's ever been interested in a change of career or rethought their way of life, has hit that crisis and said, what do I do? Should I do something drastic? I think it's really exciting that our guest, Andy Cross, is a former corporate strategist turned professional scuba diver, explorer, and consultant. Yeah, so Andy splits her time between exploring, and she's a member of the Explorers Club in New York. And anyone familiar with it will find that pretty cool, so I had to mention that. So the Explorers Club started in 1904 and served as a meeting point for explorers and scientists worldwide. And they're famous for accomplishing the five firsts. So their members were the first to go to the North and South Pole, to the highest summit of Mount Everest, to the deepest point of the Mariana Trench, and obviously to top it all off, to land on the moon in 1969. So that's just to give you an idea of the type of members that are at the Explorers Club. But as part of her exploration, Andy is leading a self-funded two-year global expedition, sharing stories of ocean progress and connecting with those on the front lines of the climate crisis. And when she's not exploring, she's helping impact-driven businesses grow through her consultancy. And she's going to talk about that on the episode today. So without further ado, let's jump right in. Hi, Andy. We're so excited to have you on SIP today. And I know how hard it is for you to make this happen, you know, traveling between different locations. So I know you've just come off the ferry and I was curious to know where you were headed from and where you're headed, well, where you've arrived to now. Thank you so much for having me. This is really exciting and long awaited. So I'm very glad we're getting the chance to chat. I was just with the team in a place called Chetamal, Mexico. And Chetamal is where the world's deepest blue hole was recently discovered and announced. So we had the chance to be some of the first people in the world to dive this incredible site and help the team document what's down there at 45.5 meters, although the hole goes to about 450 meters, if not deeper, which they're trying to figure out. And then we have since this morning at 5am drove up the coast of Mexico and the Yucatan Peninsula. And we've just made our way over on the ferry to Cozumel, which is one of the more popular dive destinations on the planet where we're getting the chance to meet with Escuba Schools International Dive Center to learn all about their conservation work. Amazing. Well, I'm sure we're going to get into more of that in this episode. I'm curious to know, was the previous deepest blue hole, was that in the Bahamas? No, the previous deepest blue hole was in China. And they, I don't know the exact depth. I want to say it was 200, 300 meters or something, 300 meters, I believe. And yeah, the team in Chetamal at ECOSOR, which is a university in the area who's working on all of the research and discovery, they're pretty excited about taking first place. Yeah, that's so interesting. I mean, we could do like a whole other episode on this, so I won't pry too much on this topic, but it's fascinating. So to get us started, could you tell us a little bit about your background? We know it's a really interesting one that takes a lot of twists and turns, and I think it might inspire our audience to get out of their comfort zone. Oh, absolutely. I guess I can start with the very beginning and then make a few big leaps. The beginning started in Philadelphia where I grew up. Although we're close to the ocean in New Jersey and Maryland, Pennsylvania is not known for its ocean experiences, but at a young age was quite fascinated with the ocean and its animals and species. So I really had a passion for it. I did not pursue that dream at all as I started my career. I went to school in Washington, D.C. at the George Washington University, and I graduated with a major in marketing and advertising and then went on to move to New York and pursue my dream as a new business executive, which meant that I was winning clients for our agency that I was working for at the time. I started off at an agency called Ogilvy, which is one of the largest worldwide. It has 365 offices at the time I was working there and 2000 people in the New York office. And I came in a bright eyed, bushy tailed, entry level individual, really excited about building a career. And I spent three years there. And then I moved over to a startup agency after to work in the luxury sector. So I was working with brands like Rolls-Royce Motorcars, Atom R.P.G., Groff Diamonds, Timbers Resorts, all of these really incredibly niche luxury brands, understanding how those businesses work. While meanwhile, at Ogilvy, I was working more on enterprise mainstream clients like Coca-Cola or Begrim's Ale or IKEA, for example. |
So I started working with a venture capital firm called Hatsume Most Libby. They're based out of New York and I still work with them today. So going on about seven years, which is really crazy to have such an incredible partnership. And they opened my eyes to the world of impact investing and impact growth strategy, which meant we were helping high growth startups figure out how to scale at their earliest stages, all the way through to multiple series, all with a focus on contributing to the planet, supporting people who don't necessarily have the same access, and just really, really majorly important projects, at least in my eyes, that have the ability to upend the way we look at things on a societal level or on a planetary level. And they actually introduced me to my first ever ocean nonprofit that I started working with, which at the time was called Blue Sphere Foundation. And I started to realize that there was this world where I could apply my skills and my passion for the ocean and actually do something with this professionally. While I was working with Hatsumimos and Libby in a freelance capacity, I took on a role at a company called Huge, which is a digital and design firm that's quite notable for some of the products and platforms that they've built and i got a crash course in digital marketing and digital design and development which was something definitely needed coming from a proper advertising background um so i worked there for a couple years and then took my first ever trip to the eastern hemisphere and never came back so i was living in new york for 11 years and it was amazing and I got such incredible training. But then my first taste of the other side of the world was definitely something that piqued interest and made me decide I wanted to upend this career that I had been building over all this time in New York to try to do something different and really get closer to the natural world. So that prompted a move to Australia. And I lived there from 2019 all the way till recently when the team and I have decided to go on this multi-year expedition all around the world to go one step further with applying our expertise to organizations, people, places that are really on the front lines of conservation and climate change. So yeah, it's been a little bit of a crazy journey going in lots of different directions, but all with the same North Star of how do we really figure out, how do we figure out how to apply our skills to something that is really important and meaningful to us and tapping back into that childhood passion. So without getting too much into your current work, I'm just curious, my first question. So is Australia still currently home? Or would you say that there's no home at the moment? Oh, there's no home at the moment. We do not have a house or a home address. If we ever have to say a home address, it's our family's houses. So we don't have a permanent residence right now. However, if I were to classify home, it's Philadelphia with my family. It's Los Angeles with my brother. It's New York with my friends. And it's Australia with my career and my heart. So it's definitely all over the place. That's amazing. I mean, you have such an interesting career path. You've had your hands in so many different baskets, starting off in what sounds like really cutthroat corporate world of marketing and then going into venture capital and impact investing and growth strategy, which is also, you know, really intense, but sort of really applying your passions to that. And I was wondering if you'd be able to share some advice to listeners and entrepreneurs out there who are looking to make this kind of, you know, existential big switch to their careers. Sure. So this is what I tell everybody. Getting trained as a growth strategist in the most traditional sense, so going to work for a mega agency like Ogilvy, was probably one of the best decisions I personally ever made, although it has very little to do with what I'm doing right now. But it was the foundation for how to work hard and what effort really means in putting into your career. And also just learning from people who really are quite seasoned and getting to soak in that knowledge from experts who have come before you. So I took a lot away from watching in my early stage and listening instead of being the one to be at the decision maker table or being in the front of the room. It was really just a chance to absorb everything that was happening around me. And through that absorption process, I started to realize the things I liked in the business and the things that I didn't like. The other thing is when our execs would say, work hard and stay longest and be in the office. I really took that quite seriously. So there were times I was working 100-hour weeks. And that's what I knew. That's what I grew up with. That's what hard work meant. And that's how you moved ahead. Today, that's not how I feel. But at the time, that was the cultural norm. And that was the norm within the organizations I was working at. And I realized that you just simply don't have to work that way to be the most productive or to be the most effective. And then throughout my career, I started to really think about how can I work as smart as possible, not as hard. So that was definitely something that today I don't have it all figured out, but I've definitely come a long way from those early days working a hundred hour weeks where I look back and I don't necessarily think I optimized my time as well as I could have. But today that's been such an incredible lesson because it's been something that I've been able to carry throughout every single role. And it's enabled me to do the things that I've really wanted to do with my career. And then the last thing for me, the best advice I can give is if there's opportunities that might feel really uncomfortable or where you're in over your head, or the stakes are incredibly high, or there's so much to lose if you don't deliver in this way. Putting yourself into those environments will allow you to start gaining confidence when you do succeed in them, but it does require you to listen and learn and take advice from others and seek out information that you might not necessarily have and push yourself to do things that don't really fit within the norm. And that's been really the defining theme throughout every step in my career. And I really have seen a lot of benefit from that, even though it's scary and terrifying and hard when you're first getting started with it. It definitely builds confidence in your ability to say, hey, I can take on these types of challenges. I've done it before. I'll do it again. I'll do it again and again and again, and constantly learning from that. That's so interesting. I think also what your career now really embodies is, you know, you said, oh, you know, I don't believe in just working all the time, or I sort of believe in smarter working. But I think also, you enjoy, it sounds like, you know, you're so passionate, and you're enjoying the work that you do sometimes, that maybe sometimes it doesn't feel like work, but you're probably putting in similar hours to what you used to do? Yeah, well, I have to say, I actually, to your point, really do enjoy working. And I always have. I like contributing to something. But when I was working at the mega firms, and I was young, sometimes I didn't understand why I had to do the things I was doing. It didn't feel like it was meaningful. But once I started to understand that these are all stepping stones to eventually do the thing you really want to do, it made working a lot easier. So yes, maybe the research reports I was pulling together on the brands that we were pitching at Ogilvy wasn't the most exciting project of my entire life, but it was the stepping stone to enable me to understand how critical research is. And I apply that skill all the time in my present role. So it's kind of appreciating the journey a bit and realizing we have to work. That's a big part of us being able to survive, but also being able to contribute to society. And then also really understanding that the stepping stones are critical and you can't just race to the finish line. The journey is the best part. So that's definitely been something that I always keep in mind, even today when I'm doing things that I really don't want to do. I have to do those things because they're going to enable me to do the thing I really want. And it's all part of the process. And the process is really fun. And it's a really inspiring journey. Definitely like reading about, you know, what you've accomplished is extremely exciting. And I'd like to hear a little bit more about your most recent initiative, which is Edges of the Earth. |
And like sort And what was the catalyst for it? Sure. So when I moved to Australia in 2019, I wanted to get closer to the ocean because I didn't have the chance to really do that when I was living in New York. New York was very much about working in the city and being part of the city experiences, which occasionally we'd get to the ocean, but it wasn't really to explore it. It was a vacation. It was a moment in time. It was brief. So I wanted to move to Australia where I could really get stuck in and learn the art of scuba diving. As someone who did not have a lot of experience in the ocean, that meant even learning how to swim properly, which was a journey in itself. But I really wanted to try. And I knew if I went to Australia, the training would be quite rigorous. I'd be around people who grew up by the ocean. I would be surrounded by experts and people willing to help. And I'd have the comforts of an ocean within a few minutes of me at all times, pretty much up and down the coast, anywhere I was going, because I moved to Western Australia. So I could really maximize my time. So when I moved over, I started working at an agency to help me get into the country for once. So I got on a working visa. And with time, I started to realize, especially when the pandemic hit, that it was time to break off on my own and do my own thing and not work within an organization that was already stood up. I wanted to create something. And so Marla Tamarag, who's on our expedition team, she and I built a company called Wild Palm and it's an impact consulting business that focuses on high growth startups, scale ups and enterprise businesses, as well as agencies who are looking to plug into the world of impact, whether they have their impact business themselves and we're helping them grow or they're an agency working with impact businesses. The focus has been very much on how do we enable organizations that are going to do well for people and planet to excel. So in creating that, we started also working with quite a few nonprofits in the ocean sector that we're looking to grow, mainly digitally online. And we noticed that there was a gap. The storytelling was constantly this doom and gloom and fear and the ocean is in decline and what are we going to do about it? We're running out of time and there's so much urgency and this very intense, really emotive narrative around the sea. And for us, we just kind of felt like that had been done. We've heard it all all before the doom and gloom fatigue was becoming super real for us and this was back in around 2020 2021 so we wanted to figure out what organizations were thinking about a new narrative or if we could not find that how could we create a new narrative and that's what prompted our desire to go around the world to as many locations as we possibly could to figure out who was on the front lines of conservation, nonprofits, scientists, researchers, academics, divers, photographers, activists, conservationists, you name it, who was really pushing a positive message because they had something positive to share. We know what the challenges are. We've heard them all before. We wanted to understand who was taking that challenge and coming forward with a solution and actually have results of something working or we're in the process of coming out with those results of positive news and positive progress. So that's what prompted what we call the Edges of Earth Expedition. And today we're a year in, almost a year in, as of June 8th, it will be a full year, going to some of the most remote, interesting, unusual, exciting places on the planet, some of the most unexpected places on the planet where there's really incredible positivity happening around ocean conservation, science, restoration, and discovery. So that's what prompted it. We didn't actually have a lot of expectation when we first began. We didn't know what would happen here. And we didn't know how many positive stories we'd actually find. But the good news is there's so much. There's so many places. There's so many people doing amazing things for the planet, whether on the tiniest, smallest scale, all the way through to some of the bigger projects that we've had the chance to see. There really is a lot of incredible work happening. And we're just so thankful that we get to be alongside these amazing teams, people, communities, helping to tell their stories. So I really want to get into the storytelling piece of Edges of the Earth, and we're going to do that. But first, I know from chatting with you a few weeks ago, well, and you also just said, you know, that you were not an experienced swimmer, but I don't think you were, you had been doing diving before. And so I was curious to hear a little bit about how you got started scuba diving and then where were like, where did you do your early expeditions? And were there any places that really stood out to you that you visited from maybe like an environmental perspective or social perspective? Sure. Yes. So the diving, it all started because I was complaining to my friends quite regularly that I wanted to apply my skills towards the ocean and I didn't know how. And a lot of my friends were saying like, oh, you'll figure it out. It will be okay. Like just, you know, you just work for a nonprofit or something and then you'll feel better. Like keep working your day job at huge. That's where I was working at the time, but go work for a nonprofit or like go volunteer your time. I was like, okay, sure. So I started doing that and that was great, but I felt a little inauthentic because I was talking about the ocean all the time and I was working with these great nonprofits and I was volunteering my time in certain capacity, but I had no idea what I was trying to save or why it was so special. I understood it from a theory perspective. And obviously I had gone to aquariums and I had read books about the ocean, but I actually had not explored it ever. So one of my friends one day, she said to me, have you ever tried scuba diving? I think you'd really like it and it would solve a lot of your problems that you won't stop complaining about. I was like, scuba diving? I never even considered that even in a second for someone like me. And she really got me onto it. And so I started researching quite a bit and I started to understand this whole other world where you could see our planet in a completely different way. And I was obsessed. Yet there were some pretty significant hurdles because to pass your open water test, you're meant to be able to swim quite a few laps in a pool of which I simply could not do. So I got some assistance down in the Bahamas. I went down there by myself. I went to a resort in Nassau and I asked the lifeguards on duty if they could help me prepare for my training, which was quite embarrassing as a 30-something, an early 30-something, kind of realizing I actually didn't know how to put on a mask properly, didn't know how to fin properly, like all of these really basic things for a scuba diver to know. But somehow I miraculously passed. Although my instructor did tell me I'd have a long road ahead before I was good at this, which was quite honest and true. And then after that, I started diving. My next dives were in Bali. So I learned in the Bahamas. I took all of my online coursework. I did all my online coursework in New York, did my open water exams and ocean experiences in the Bahamas, did a few dives in Bahamas, and then immediately ended up going over to the Eastern Hemisphere to Bali where I did quite a bit more. And that's where I really got the sea legs. I ended up actually going back to back in my training from advanced to rescue into some of the specialty courses when I moved to Australia, which was by design. And then I went during the pandemic, I actually got stuck in the USA for nine months and was not able to get back to Australia due to border restrictions and the flight cancellations to and from. So I did most of my serious diving at the time in California up and down the coast. And that's temperate water. So it's much different than diving in the tropics like the Bahamas. So that definitely helped me gain quite a bit of confidence in the water. And then I did all of my dive master training back in Australia where things really changed after that training experience. I had such an amazing instructor. We worked together one on one for weeks and weeks every day, just getting in the water, practicing, practicing, training, training. |
And then now today, since completing Divemaster, while we're on this expedition, we're working quite a bit on other specialty courses like altitude diving and ice diving, cave and cavern diving, hopefully soon. But to answer the question of where are some of my favorite places to dive, it really is so hard to answer that because everywhere we've been is special in its own unique way. And it just depends on what type of diving you're really into. When I first started, I was very into the big marine species. So whales and dolphins and sharks and manta rays. And obviously I love seeing those animals. They're so exciting and so beautiful. And there's a lot of places you can go today to see those animals and their natural habitat in just such an exciting and interesting manner. However, my personal favorite dives are the ones that are extremely niche and very weird. So for example, the blue hole that we just dove in Chattamal, which is not a recreational dive site, it's a science, it's a research site at the moment. And I'm not sure it should ever be a recreational site. Things like that are what excite me most where it's some natural, natural wonder that was created and you have no idea what's down there, what, what really is happening beneath the waves. And it's just, it's so exciting to go on dives like that. Blackwater diving is some of my favorite, which can be found in all over the world, but very notably in Anilau, the Philippines, in Kona, in Hawaii, off the coast of Florida, in some places in Indonesia as well. It really is so exciting to watch the vertical migration that happens two times a day in completely dark water in 200 meters, sorry, 2 meters, 3000 meters of water with only your torch to guide your way. That is some of my all-time favorite diving. And I'm very much looking forward to the ice diving. We're going to be doing that in the Arctic coming up in the near future. So I'm really looking forward to that. So yeah, niche diving is definitely my favorite kind. That sounds incredible. I mean, first off, can we just say that, talk about proving your teacher wrong, that it was going to be. Oh, it was. It was a journey. Going from open water to rescue in a short amount of time is no small feat. I mean, I dive myself and by no means a rescue, but it's a lot. It's a lot to go through. And I have to say the swim test at the very beginning, I still remember that. And I could swim okay, but they do make you stay in there without holding onto anything for a while. So it is a little, it's on the tougher side. And then I also want to say, yeah, for me, one of the best tests was the Beyonce one. I feel like that really does help you feel stable underwater. Definitely, definitely. The Divemaster swim test is the worst. So that was the one that I was really sweating because even though I had managed to make it through open water advanced rescue, you don't really need a lot of unaided swimming in that because you're always wearing your fins and your mask and you have quite a bit of support. But for dive master, you really do need to know how to swim properly. So bless my mother-in-law's heart for spending many, many hours with me teaching me how to properly swim because it was, I would say there were a lot of tears and it was certainly a journey, but we have since completed the task and it's definitely critical to understand and have those skills as you advance in your diving career. Andy, this all sounds so exciting. And I think the part that I really wanted to expand a little bit further was on the part where you said those really exciting dives, the ones that take you to remote, very niche areas, the unexplored parts, I have to imagine that you're probably encountering a lot of coastal communities, a lot of marine communities and people that rely upon marine ecosystems for socioeconomic benefits, but also the environmental benefits of nature and things like that. So can you give us and our listeners a little bit of background on the importance of the health and resilience of the coastal ecosystems that you visited and why it's so important that we need to prioritize protecting those? Absolutely. I think this is probably one of the most important things we've learned from living on the edge of the earth for the last year. So I'm really glad you're asking me about this because we have encountered so many communities that rely on the sea in a completely different way than that of a New Yorker, right? So there are, the ocean is such a resource and so valuable to so many people. And that varies depending on where you are. But for example, when we visited small island developing nations or, or sorry, small island, island developing states, it's very critical to understand and be respectful to the cultures and the communities that are there. They are living off of the sea, literally. It's their source of food. They are leveraging tourism dollars to run tours out to see some special features. They are protected by some of these coastal regions, like the mangroves, for example. There are so many benefits for these communities with the ocean. And when we go and visit certain places, the first thing that we do is better understand who exactly we need to meet with, who are on the front lines of conservation. We say that all the time because these are the people who are living off of the sea. They rely on the sea. They're seeing the changes of climate change, the impacts of climate change every single day. And we want to listen and learn from them. So we want to hear their perspectives. We want to hear the things that they're going through. We want to experience their world in the way um that they've allowed us and they've granted us access to and every single place we have gone has a community or communities that are relying on the ocean in this way and a lot of the a lot of the places that we've explored especially when it comes to mangroves and there are these or coral reefs there are these amazing barriers barriers that help mitigate some of the impacts of our changing world. And if we're seeing these incredible ecosystems being depleted time and time again, these communities are up against some really harsh realities as our planet changes. So for example, we were just in Belize and we were working with one of the leads of Great Barrier Reef Foundation's Resilient Reef Initiative. And she took us on a journey to show us how badly Belize has been impacted by climate change and the impacts that are being had on the community because of that. And how these communities rely so heavily on tourism, so heavily on fishing. When the stocks are depleted, when there's no coral reefs to be explored, there's such a hit to these communities. It's quite indescribable. Belize is an amazing example, though, because they have so much support from government, from big businesses, from nonprofits, from community to all rally together to protect their natural resources. But when we went to Cambodia, for example, the teams that we were working with there have no support. They have no funding. They have no big business leverage. They do not have government help. They're just starting to work with local government to support them. But it's just night and day, the conservation, restoration, and science work that can be done in places depending on the level of support that they have. And that really plays into when you're a traveler or a tourist and you're exploring some of these places, really knowing where your tourism dollars are going because helping these communities who are on the front lines, it really does go such a long way versus putting your money into big mega corp chains or enterprise level businesses. If you make even that slight switch, it really does help these coastal communities. But I could go on and on about some of the challenges these coastal communities are facing from ocean acidification, sea level rising, things of that nature. And I'm happy to dig in deeper. But what I'll conclude on for this question is a lot of people rely on the sea and it's not just a playground. It's a place that people are actually leveraging to sustain their life. And we need to understand that, be respectful of it and try to learn as much as we can from people who are on the front lines. So Andy, you mentioned that a lot of these coastal communities rely heavily on tourism. They live off of the sector and they rely heavily upon tourism dollars. That's obviously an important economic lever for them. But as we've seen before, we've seen a ton of headlines how tourism and unresponsible tourism is often a driver of ecosystem destruction, pollution, biodiversity loss. |
So this is the rock and the hard place because to your point, on one hand hand tourism is so helpful to some of these coastal communities and just communities in general that we visited but on the other hand getting there traveling to these certain destinations especially when they're quite remote what that experience looks like in total from start to finish has its downside, certainly. And then if you go to a place that's overrun with tourism, there's lots of challenges that present themselves. So it's kind of a rock and a hard place. You want to see these incredible places. You want to learn from these unique cultures. You want to contribute in some way to support them. But at the same time, a lot of the things we're doing are quite damaging. Even going scuba diving is damaging because there's the inevitable fin kick that just knocks a piece of coral or scrapes that sandy bottom. There's no avoiding it at times. And no matter how skilled of a diver you are you certainly will do it and it's so bad and so i'll give you a perfect example we were just in rowaton we were working with the rowaton marine park and they're running a reverse marketing campaign to get people out of the water because there's too many people scuba diving in rowaton so and that's quite counterintuitive you would think for a community that relies very heavily on scuba diving, but we're getting to that point. We're getting to the point where our natural resources are being depleted. There's a lot of people who are traveling and exploring. There's a lot of people who, regardless of how skilled they are at certain things like scuba, are causing damages to our natural world. And so what we have to remember when we travel, and this is something that Marla, Adam, and I on the expedition team talk about all the time is how can we just do better? If we're going to go to these places, if we're going to meet these people, if we're going to explore these unique and raw and exciting ecosystems, what do we have to do to mitigate the problems as best we can? And for us, this is where we started really leaning into something called conscious exploration. That means leaving a place better than you found it. It doesn't mean leaving a place as you found it, it's better than you found it. So when we go to any of these locations, we are living with the communities, we're learning their cultures and ways, we're supporting them by giving them our expertise free of charge. We do not ask any community to pay for our services the way we would in our consulting work. And we try to leverage our expertise to support them in ways that they just don't necessarily have access to. And that's something all of us can do. We each bring something unique to the table. We can go to these places and not only have an incredible experience interacting with the natural world, but then also provide some sort of value in exchange, as well as the money in which we are giving from our tourism pockets. So a lot of these coastal communities, a lot of these projects and initiatives that we visit, the number one thing that they need, yes, is cash to continue to run their programs and continue to keep working in this capacity. But the other thing that they need is support across a wide variety of things, whether that's helping to build infrastructure or whether that's helping to clean up polluted beaches or whether that's helping with their marketing and their communications or helping them with their fundraising. There's so many ways that we can get involved in support. And then also just making really good choices as we travel, using local currency, staying at local properties, eating local foods, trying to keep things as local as possible and going with organizations, teams, people who really do understand what ecotourism means, which is quite challenging in a world where we're being greenwashed every single day. It's hard to navigate through these complexities, but there's a lot of resources out there and a lot of sustainable travel guides that really do help point you in the right direction to the people, places, teams, experiences that really are contributing to help and clean up the planet, helping restore the planet, also helping to conserve the planet. So to answer this really succinctly, it's on us as travelers, explorers, tourists to do our research before we get to a certain place. It's on us to reach out to local communities and understand how we can support them just as much as they're supporting us. And then it's on us once we get there to really do our part to contribute. Now, this doesn't mean every single place we go for the rest of our lives, we have to be consciously exploring per se. We can go places on vacation. There's definitely a space and a place for that. But going to places that are completely overrun with tourism, going during peak season, going when things are a little full on might not be the best option. Maybe going at off season or shoulder season or going to places that don't necessarily have an over tourism problem. Or if there is over tourism happening in a place that we want to go, figuring out a time when we can go where your tourism dollars actually will matter because it's a low point in time. So there's just so many ways of thinking about how to explore, how to travel. Also, the flight patterns. If you're flying from Australia to New York, it's an incredibly long-haul flight. There's obviously a lot of issue with the long-haul traveling. So perhaps looking at routes that enable you to take shorter flights or enable you to just drive or enable you even better to just ride a bike. So there's so many ways of thinking about how to contribute consciously. It doesn't have to be an always on action because that's not realistic for a lot of people. But it's really important for us to start thinking like that and making tiny little tweaks every step of the way to ultimately start living. And that has a whole host of impact for the people that live there with the ultimate hope of giving the natural ecosystems a chance to breathe and to recover a little bit. You kind of described this a little bit, but in terms of living with the communities, speaking to key decision makers, people who've been in those communities for a long time, learning and listening, a lot of this conservation work and a lot of this research is done behind the scenes. And that doesn't often come up to the surface. But it's really important to bring that forward, right? Because you're saying now, if you want this to have a big impact and a pretty outsized impact, speaking to the people that have the local ecologic knowledge is important. And that helps showcase the success of these programs. So could you talk a little bit to some of the stories that have inspired you, some of the things that you've come across that make you think a little bit more positive and less of that doom and gloom that you mentioned earlier about how we do have a potential at restoring those ecosystems that are at risk. Sure. So the doom and gloom is everywhere. There's no avoiding it. And it's very true. There's a lot of destruction that's happening. But I will say that literally every single stop and every single place that we have been, there's some good news coming out of it. So we've been to 28 locations since the start of our expedition. We've worked with probably over 100 individuals total. And we have about 35 plus more to go in the next year. And where there is doom and gloom, there is also hope and light, which is really, really exciting. One of the best examples that I can give total is California. California was an amazing story of communities rallying together to really push conservation, science, restoration. The difference with California is there's a lot of funding going into that. So that's one example where when cash is put to the test and put into the mix, things can get done. Another example is in Vanuatu. That was one of our first stops that we went to where we were living with local communities who don't necessarily have that funding and they are working so hard to push ecotourism, to push sustainable practices, to bring people to their country to really show some incredible underwater experiences and ecosystems, but are trying to do it as sustainably as possible and fighting tirelessly to make that happen. But I would say probably my favorite story of them all, the one that I was anticipating and hoping that we'd get the chance to experience and work alongside this team was what we saw in Thailand. We worked with a company, a nonprofit and a for-profit entity called Andaman Discoveries. And Andaman Discoveries is run by only a few people and they focus on tried and true community development, which means helping to build up community so that they can take on tourism in a way that's very authentic and true to their cultures and to their way of life. |
And these sea nomads, the Moken people have historically for 4,000 years traversed up and down Thailand and Myanmar water living off of the sea on houseboats. And there was a tsunami that hit Thailand and that tsunami then forced the Moken people to become land-based by government order. And so they were no longer allowed to live on their sea boats, on their houseboats, and they had to live on land. And their way of life was just getting taken away from them step by step by step. And the Moken people don't understand property. They don't understand government, they don't, those aren't things that are part of their culture. Instead, they share their communal, their family-based, everyone's, everyone is part of the same system and they live off of the sea and that's how they've survived for all of these years. And so when they were sequestered to land, they were no longer able to spearfish or hunt for their food or do the things that are very innate to their livelihood. And Enderman Discoveries saw this happening and came in to support, to help them figure out how they were going to adapt to their new normal and fit their culture within modern society. And so getting the chance to live among the Moken and really see community development at its truest core was probably one of the most profound experiences we had because we saw this incredible culture, these amazing people just really trying to figure out how they're going to survive in this new way and how much had been taken away from them, but how much positivity, hope, optimism this group of people have and are really working to make ecotourism, community development, a possibility for them to show off their culture and to give people the opportunity to see what they're all about and to also earn from that as well, given that they're not able to do the things that were inherently true of their way of life. So that story is sad, incredibly sad. But there's always this silver lining that this team is constantly pushing forward. We're still here. We're still on this planet. We're still alive. We still are, you know, looking at this ocean that we once called home and we're going to do whatever it takes to survive. And that to me was one of just the most heavy hitting experiences. Hey, we just can't, we can't give up even in the face of adversity. And when these horrible things are happening, we have to keep pushing forward no matter what and find new ways and adapt and change and evolve. And that is true of every place we've been. We just finished working with the team in Belize for 11 days and their whole narrative to us was we need to adapt, we need to change, we need to evolve in order to survive our changing world. And we need to start thinking about how we can do better because these challenges and these problems are real. They're sitting on our doorstep. We're staring them straight in the face. This is so, so problematic, but we can't give up and we need to find solutions. So the Moken people, it's just such a sad, sad story. And you can look at it through that lens, or you can look at it through the lens of there's a lot of people out there trying to figure out these solutions and try to right these wrongs. And if a lot more of us contributed to some of these things, we would be in a much different place. So it really is a call to arms to say the solutions are out there. People need our help. Coastal communities communities need our help if you have a skill or an expertise to lend now's the time and let's propel some of these solutions forward that's incredibly inspiring and i think it also reinforces the idea that with the government forcing them to to to move to a land base to land base i think that's incredibly reinforcing the idea that the local knowledge and understanding what the true needs of the people are is going to be crucial for this next phase where we start to look for solutions, etc. And without that input, without that understanding, without the stakeholder engagement, the listening and learning that you mentioned, there's just bad solutions out there and it could definitely have outsized negative impacts for a lot of communities. Exactly. And the listening and learning bit, although I had fully embraced that in my younger years, learning in corporate, I didn't realize how important it was until recently to truly just listen to what other people have to say, look to those experts, look to those communities who really do have such a deep perspective and deep knowledge of their home and the ocean and the natural resources around us, and just hear all of these different perspectives. And in listening this much and spending so much time asking the questions and hearing what others have to say, we're starting to see patterns in what people are saying. And those patterns are very unavoidable of what we need to do and what the solutions really are. It's now just about how do we make all of that happen? And I think a big difference for you is that you're directly seeing those changes. You're hearing directly from those Indigenous peoples or local communities of what we really need to do to adapt to, you know, nature collapse, climate change, not to bring back the doom and gloom. But yeah, I hope this turns into a story that could be inspiring versus, you know, what it sounds like that it is now. I was curious to know if any of the communities were able to go back to their way of life or if that's still something that the Andaman Discovery Organization is working towards. Andaman Discoveries is still working towards this. They are piloting programs that we got to experience where the Moken community gets to showcase their livelihood or their way. And it really was so incredible. We got to experience the houseboat with them. We got to experience their wood carving, their music, their arts, and the way they leverage ocean resources to create things. But it's certainly not complete. There's a lot of work that needs to be done. And it's a real push to figure out what is the right balance. This thing has happened. It's real. It's sitting at our front door. But how do we just make this work? That's the big question that they're always pushing towards. The solutions that have been accomplished so far are amazing. So, for example, bringing education to the island to support Moken in furthering their knowledge, other livelihood pathways where the Moken people receive grant funding for projects and initiatives that they want to get off the ground. They've done a lot of amazing things, but there's certainly still work to be done. Yeah, that's, I mean, it sounds really moving. I can't imagine living through that experience. I was interested to know, so for the Edges of the Earth initiative, when you choose the sites that you're going to explore, do you want to make sure there's both an environmental and social impact component? And how did the process of picking sites evolve over time? Sure. So when we first started planning, everything was revolving around marine aggregation. So large marine aggregations that we were interested in learning more about. We looked all over the world, looked at seasons, looked at the over tourism destinations or places that are overruns. And we looked at places that didn't necessarily have that, that had big marine aggregations, but also didn't have high traffic in tourism. So those were the two, those were the two big lenses. Then seasons became the big one because we obviously were planning a two-year expedition and we needed to get from point A to B. How do we map all of this according to the right seasons? And like I mentioned before, we don't like to visit during peak season. We like to visit during off-season or shoulder season for the over-tourism reason. We also wanted to make sure that if we were going to certain locations, we could meet with the right teams. And so that's what started it. What it's evolved into is when we reach out, we want to make sure that the partner that we're working with on the ground actually wants us to come. Because if we go to a place and we force ourselves there and we're living among communities that don't necessarily need or want our help, that's certainly something we don't want to do. We want this to be as mutually beneficial as possible where we get to learn from these great experiences while we also get to really help the communities in which we're visiting. If our support is not needed, we don't go. So when we reach out, it's very much to teams that we believe could leverage our expertise or have actually asked for our expertise. So nowadays we're getting requested to go certain places, which is so amazing. And I really didn't think that would happen. And we're so honored when people reach out to us in this capacity. It's amazing. |
So we do not write in the same capacity as a journalist would. We are very much on growth strategy, content creation, design. And the reason why we put that forward is we work with the local communities and the teams that we meet to tell their story from their lens. So we are not coming in and reporting from a journalistic view. We're coming in and reporting from really how these communities are experiencing things and their point of view. So we also want to make sure that where we're going, that's of interest and possible. And now when we are looking at locations, we're doing a bit of rerouting for 2024 and into 2025. And that's also due to life happenings. We've had a lot of things happen to our team that have caused us to need to reroute in certain ways from personal loss to injury to environmental problems that have happened on some of our team's home bases, that that has caused us to look at schedules and where we're going and what we're doing with some flexibility. But through and through now, today, we are very much looking at who we're meeting, who we're supporting, how we're helping, and trying to form really close personal relationships with the people that we meet along the way, especially when we're living on site for weeks at a time. Is there good synergy? Is this the right fit? Not everyone is a perfect fit for the Edges of Earth team and vice versa. So we definitely want to make sure that there's that type of relationship that we can build. We haven't gotten it right every single time, but I would say 98% of the time, after spending so much time talking to these individuals, teams, groups over Zoom or over the phone or over WhatsApp leading up to the moment we're on site, we really do form these incredible bonds and we're able to come on site and work together to figure out how can we support, help, and elevate the amazing work that's happening on the ground. So what once started as a chase for marine aggregations has now landed us firmly in a chase for human connection. So Andy, so I want to take a little bit further back to your time when you discussed growth strategy and being a brand expert and what you just mentioned about finding the right fit and working with the right people that can communicate this message, it's incredibly important, right? Even if you're not a journalist, writing and communicating what's happening on the ground is incredibly important because that helps other people see the stories of success. But we also see on the flip side how difficult it is in communicating in this day and age with the very saturated message, the need for conservation, the need for funding, the need for policy support from global governments. We can even look to, you know, every year we have a conference of the party, and there's so many different signals coming out of each different thing about what's needed from global governments and corporations, etc. But going back to your days as a growth strategist and brand expert, let's just say the ocean was your client. How would you approach the ocean's brand and growth strategy in the hopes of saving it? I love this question so much. Thanks for asking. So many years ago, I would have branded the ocean as a place of recreation, a place of fun. Come in and see the ocean wonders and everything's amazing and you're going to have these incredible experiences. Why not get in? That is not how I would talk about the ocean today. The way I have talked about the ocean regularly in our communication and just in general after seeing so many places and living on the front lines this way, is that the ocean is a resource and a source of livelihood. It's people's direct source of survival in some cases. And so if you understand how critically important the ocean is for us as human beings and everything on earth to survive, then you start to look at the world a little bit differently and you start to look at the ocean a lot differently. When I think about branding the ocean and how I communicate it, it is literally our source of survival. So it's trying to find ways, I was thinking about a growth campaign of how to really enable people to get involved. It's thinking of ways of linking people's livelihoods directly with the ocean who livelihoods are not visibly linked today. So for example, it's really easy to show how a fisherman survives off the ocean because that fisherman is catching fish out of the ocean, bringing that fish to local markets and earning money for it. But if we can create more job opportunity that directly links to ocean, and that is happening around the world where there really are a lot of jobs opening up that connect you back to sustainability, ocean, climate, then we can start getting people to care a lot more because they are seeing that their survival depends on this resource. And that is how I would brand it and market it today. The more people that can understand that we need to survive off the ocean is the source of survival that's going to go a very long way. The more people we can connect to the ocean who might not have ever had access to it, who live in landlocked regions or don't know how to swim, or even if they're on the coast and they're just afraid to get in, but they do realize the value and the necessity of the ocean. That is so critical. And especially in the rise of impact startups and impact investing, where a lot of money is going into solutions for our planet and very, very exciting ocean solutions that are popping up left and right. We can create more jobs that way as well. Within big enterprises, if we can create sustainability teams, or if there already are sustainability teams, but we can double the workforce and really get people thinking about this across all different types of skills, knowledge, expertise, experiences. That would be the campaign that I would run to really push people to understand that you can contribute directly to restoring, conserving, protecting our ocean, and that will directly benefit you in these ways. So it's a little bit more, it's not as light and fluffy as it once was it's definitely more of a harder and more um sophisticated cell i'd say but i don't think we understand to a certain degree how vital the ocean is when you're landlocked um or even in a place like new york where i was living for all those years i didn't realize how important the ocean was to my survival. And not just because I love scuba diving and I enjoy learning to surf or things like that. So all of that recreation becomes secondary. We get to do those things because we have an ocean that's protected, restored, is healthy. We don't get to surf anymore if we don't have coral reefs or if we don't have healthy ecosystems or we don't have some of the marine species. We don't stand a chance if sea levels start to rise even further or ocean acidification really becomes genuine and the ability to not actually be able to get in the water because of it. And we really don't survive if biodiversity is truly lost. So when we're able to link livelihood and prove that livelihood and all of this positive progress directly increases our ability to enjoy the ocean and to survive, I think it would go a really long way. Not to say that this has to be a doom and gloom message by any means. This is a hopeful, optimistic, and positive one where our skills and expertise really can be a driving force in restoring our planet. Yeah, for sure. I completely agree. It's definitely a positive one. And I think it's linking the positive aspects to being more informed to ensure that it continues to be a positive impact on these communities. And you mentioned things like accessing coasts for a lot of people. Earlier in the episode, you said you're in Philadelphia and the closest coast to you is New Jersey, things like that. So obviously, the three of us here and a lot of our listeners, we're all travelers and tourists, and whether, whether that's Philadelphia to New Jersey's coast, or even as far as Vanuatu. So oftentimes it takes us to the very communities you've described today. Like you said, the edges of the earth. And there's a lot of opportunities to get exposure to these communities and see how they live off of these things. And you mentioned linking the critical importance of livelihoods to oceans, to coastal ecosystems. And you also gave us a couple of tips earlier about being incredibly informed, doing research beforehand and engaging with local communities. But beyond that, how can we ensure we are being more conscious travelers, making sure we're minimizing our footprint and giving ourselves the largest opportunity to learn more from the cultures that we're embedding ourselves in and the ecosystems in which we are operating and traveling to. And we'll close on this. Yeah, for sure. So if we're going to travel and we are, it's not going anywhere. I definitely have seen and heard the opinions of stop traveling. It's the number one contributor to our planet in decline. We've been told that ourselves. |
Hello and welcome to Sustainability in Progress, a podcast focused on exploring the most topical themes in sustainability. In this series, we will be inviting guest speakers and industry experts to discuss the most challenging issues facing our world today. But more importantly, the opportunities to address these challenges and make tangible changes. The sustainability space is constantly evolving, so we've decided to call this podcast Sustainability in Progress, Thank you. invite you to join us on the journey where we will explore topics from sustainable food and agriculture, law and policy, economics, we're zooming out a bit and debating what sustainability really means. But we're also going to focus on the importance of transitioning to a circular economy. We're going to look at how sustainability can really be a driver of business value and profitable growth, and also how corporations, governments, and consumers can influence change and rethink capitalism at every step of the value chain. So today, our guests are really well positioned to discuss this topic, given their incredibly exciting backgrounds. But first, Laura, guilty pleasures. What is your guilty pleasure? So my uncircular guilty pleasure is that, you know, living in New York City, it's sometimes hard not to be tempted by the variety of options for takeout. And I do typically indulge every Sunday. And the issue here is that unfortunately, there's so much single use packaging that comes with just a single order of takeout. And all of that packaging ends up in the landfill. And it's typically the worst kind of packaging. And you can do small things like, say, you know, no utensils, but it really doesn't move the needle much. Okay, so I have to ask, what is your go-to Sunday night takeout meal? It's usually Thai or Chinese food because I can't make that myself. Okay. Yeah, I totally get that. On that single use utensils and packaging piece for delivery and takeout, have you come across when you've ordered and stuff, do you know if there's anyone working in that space to disrupt it? Have you come across any names? Yeah, I think there are a few companies working on solutions um i think there's one called deliver zero and they're looking to replace packaging with reusable containers but i'm not really sure like how far along they are if they still scale if they scale that all and like you can actually like order and with certain restaurants that use them um and then there's restaurants that provide incentives for reusable packaging. Like I think just salad does that if you bring your own utensils. But turning to you now, what is your unsustainable guilty pleasure? That's a good question. So I'll have to say, you know, I do have a car. And I'm not going to it's a combustion engine car. It's not an electric vehicle. I'm not going to dive into the whole life cycle analysis of electric vehicles versus combustion engines. But for our listeners, we do have an episode on that. So shameless plug for SIP episode early in the days. But I do know that I could probably use public transportation more often. That is totally fair instead of my car. But there's just that added convenience value when you can leave whenever and arrive whenever and not have to worry about NJ Transit delaying you by an hour on a regular basis. And I know for all our New York, New Jersey listeners, they can relate to that as well. I will say, I will caveat though, my car is not a Hummer, which gets like five miles per gallon. It does get pretty decent gas mileage. I think I'm closer to 30 miles per gallon or something. So it's not the worst thing in the world. Yeah, and we're just going to say that you're trying to get as much reuse as possible out of that car before you make the switch to electric. And hey, maybe when you make the switch to electric, the batteries will have longer life and it'll be just more sustainable all around. Exactly. That's exactly what I'm telling myself. So some of you listening may be familiar with a circular economy, but since there are a few technical terms that come up, we thought it might help to shed some light on those before we dive deeper into the topic. So, John, maybe you can kick us off by explaining what a linear economy is, which is, you know, what we mostly experience versus a circular economy. Yeah, of course. And this episode, that's really important because we're going to hear both linear and circular economy mentioned a few times. So first off, like Laura said, a linear economy is what we have right now. That uses a take-make-waste model. And essentially, that refers to the way that we use resources, make products, and then throw them out once they've been used. Obviously, as you can imagine, this approach is highly unsustainable and contributes to things like resource depletion and a lot of pollution. But on the opposite side, you have something called a circular economy. And this approach is looking to eliminate waste and pollution, circulate products as much as possible, as well as materials, and regenerate nature. Now, this helps keep valuable resources in circulation through reuse, recycling, and composting, which we can get into a little bit later. And this also helps us keep within our planetary boundaries and ensure we don't breach those thresholds or tipping points that if crossed could lead to irreversible changes in our planet's systems affecting the life as we know it. So there are nine planetary boundaries including climate change, land system change, freshwater change, ocean acidification, and biosphere integrity. I'm not going to name all of them, but those are like the sort of ones that are, you know, most familiar. And each planetary boundary defines a critical threshold beyond which there is a risk of pushing Earth's systems into a new state that may not support human civilization in the same way. And this is something we really want listeners to take away, is that the planet, you know, is not going anywhere, but our civilization is severely at risk. So thanks a lot for that. So this conversation is going to take a walk through a lot of these concepts. And that's why we're particularly thrilled to be joined by Danielle Azoulay, who has spent the majority of her career in senior sustainability roles at Fortune 500 companies and recently launched her own sustainability consultancy. Danielle is also going to be joined today by Lindsay Coffey, who is a World Wildlife Fund ambassador, a Remake Fellow, and a model who amazingly became the first U.S. representative to win Miss Earth. Lindsay also lobbies on Capitol Hill, and two of her recent advocacy initiatives, which she will talk about later, relate to Bottle Bill, which incentivizes the redemption of glass, metal, and plastic containers, again, a circular concept, and the Fabric Act, which seeks to establish workplace protections and manufacturing incentives to promote the United States as a global leader in responsible apparel production. And you will hear this throughout the conversation. The concept of circularity does not only relate to consumer packaged goods and recycling and things like that. It cuts across several different sectors. Both of our guests bring a wealth of experience and very diverse backgrounds. So we are thrilled to hear how that has shaped their thinking and their efforts today to push for climate action. Hi, Lindsay and Danielle. We're thrilled to have you both on today. This is a really exciting day for SIP as we haven't had two guests on before. Daniela, I hope you've had a second to rest from your RV tour across the country. And I think you're back on the East Coast now. Yes, that's right. I'm doing this podcast from sunny Florida. Well, that's great. I'm glad you didn't have to experience the mini earthquake this morning over here. Lindsay, if I can get started with hearing more about you and your really interesting career path into the sustainability space, could you tell us a little bit about Miss Earth, how it's different from other pageant competitions, you know, winning on behalf of the US against so many other nations? I'm curious to know if this propelled your path forward to work on sustainability solutions. Yes, of course. And thank you, Lauren John, for having us, Danielle. So great to be on this podcast with you. So, yes, a little bit about Miss Earth, especially for those who haven't heard of it. Miss Earth is completely different from any other system. And you see that immediately through their message, which is advocating for environmentalism. And they've had the same platform from its inception in 2001. Now, personally, I don't consider them a pageant. It is an environmental competition. I don't even like to use the P word. That's not even a term for me. And they simply use their entertainment to advance their mission. And it's really strategic if you think about it, using the entertainment platform to further your cause. Now, on the international level, you prepare presentations. |
And you are interviewed extensively on environmental topics, whether it be from policy to disasters to green solutions. And let me tell you, if you don't know what you're talking about, the entire world will know. So you have to be well-read and really be able to project that confidence within your presentations as well. And despite being what I like to call a closeted environmentalist growing up, Miss Earth did give me that confidence to pursue environmental activism because I did struggle with feeling underqualified because I didn't have a degree in environmentalism, completely far off of environmentalism, and nor did I even work in an environmental field. But I learned, you know, your degree doesn't define you. Neither does your job nor your background. And education occurs inside and outside of the classroom. And sometimes you don't see what you have to offer until you test yourself. And by showing the world I knew what I was talking about, I was able to prove it to myself. Thank goodness, because if that wasn't enough, I don't know where I would be. So that's a little bit about it. That's so great. Thank you. You know, you really conveyed the message that there are so many different avenues for us to make an impact, so many ways to enter the industry. So it's really inspiring for everyone involved. Danielle, if I could turn to you now, you know, you have such a wealth of experience across consumer brands. And more recently, you founded the CSO Shop, your own consulting group. And obviously, you know, you're an incredible professor at Columbia University. So just hearing more and, you know, about your experiences and how, you know, you've come to where you are today. Yeah, thanks for having me, Laura and John. It's a pleasure to be on a podcast with two of my star students, ex-students. So happy to reconvene with you guys in this capacity. But that's right. I've been a sustainability practitioner in some of the largest Fortune 500 consumer product companies in the world for the past over 15 years. And after I left my most recent in-house job, I did some real deep thinking about sort of how I could continue to make my own personal impact greater. And I became familiar with a model that a lot of startups use. It's called a fractional model, and I'm sure a lot of your listeners are familiar with it, but it was a little bit new to me where startups would need sort of the strategic guidance of C-suite level executives in, you know, it's very common in marketing and in finance and sometimes even CEO where they bring in fractional executives to sort of provide that strategic guidance and develop a pathway forward for the company. But they do it for many companies. And I felt like that was the right approach for me at that point in my life and where I was craving a little bit of flexibility as well with my, you know, I don't, I'm, I find it a lot of people love going into the office and, you know, sitting at a desk and being with their colleagues. You know, for me, I like to, I find I'm most creative when I'm surrounding myself, you know, with my own personal space. And it gives me the opportunity to think really big and broadly about these really big issues. And, you know, now I'm able to work with many companies at once who are trying to solve or at some point in their, you know, sustainability or social impact transformation and really want to understand how this can go from a nice to have to like a really, you know, a driver of growth for their company. And so that's what I work with companies now to do. I am working with, you know, small to medium sized enterprises. These are well-funded startups, maybe like B or C round or pre-IPO, and trying to figure out how we can make this part of the customer value proposition rather than it sort of sitting siloed in its own corporate function. How do we really make this a cross-enterprise pursuit so it can be part of all business leaders' decision-making day in and day out? And so it's been gratifying in a completely different way. That's really interesting, Danielle. And I think especially as we've seen the sustainability space evolve, even just over the last five years or so, this as a function is becoming increasingly embedded into more and more roles across corporations. So keeping with that same theme of experiences shaping thinking, Lindsay, I'm going to turn to you. And in your case, being an influencer with a sustainable mindset, how do you decide what to promote? Yes, so I do. I like to team up with those who are sincere. They're passionate. They're making a real impact. And I also look for crossovers, whether I am motivated through my own personal interest or if it's motivation by my career and wanting to make a difference within that industry. So as far as long-term partnerships that I really have been advocating for quite some time now, I am currently a World Wildlife Fund ambassador, which focuses on wildlife and environmental preservation in many different aspects. And I'm also a Remake Fellow, where we address the fashion industry's contribution to the climate crisis, as well as its harmful treatment to garment workers and communities. And currently, I also work with EcoBranders, which crosses over into the fashion and textile manufacturing industry. And for those of you who are unfamiliar, EcoBranders is one of the first eco-conscious branded merchandise retailers in the United States. And it is completely revolutionizing the business and marketing sectors through mindful consumption, supply chain transparency, accountability. And it's completely reshaping consumer culture, which is what we really need to be doing today. And that is why I was so driven towards them because of also of my career and having that crossover where I can help be part of the fundamental building blocks to change, which has to start with our own culture. Lindsay, I have a question for you. Do you get to travel anywhere cool with WWF to like see wildlife or interact with some of these big issues or what's the nature of that engagement? Sounds so amazing. So with WWF specifically, they actually do offer mission trips that you can travel to multiple different countries and explore the environment there, explore the animals, interact and interact in a safely, cautious manner where you can learn and educate yourself about these ecosystems and the biodiversity within them. But I haven't done it personally with WWF yet, but for my own personal interests, I've traveled. I've been on all six. Well, there's seven continents, but it's very difficult to get to Antarctica, which I'm trying to do, but you need a permit. So I'm trying to go on like an Antarctic. You need a heavy coat. You need a heavy coat. And a very heavy coat. That is most important. So I really want to do an authentic Antarctic, Antarctica expedition, as well as one in the Amazon as well. So but currently I've traveled extensively where I've personally just created these trips where I can immerse myself within that environment. And with my work as well, I travel. And unfortunately, I've even witnessed a lot of devastation that I wasn't even expecting. And so I've lived through multiple natural disasters, one even being in Cape Town, South Africa, where, which Africa is, oh my goodness, by far one of my favorite continents. Just everything about that continent is gorgeous. And the wildlife there, of course, is so just expressive and beautiful and unique. And not a lot of people get to experience that type of atmosphere. And I ended up living through one of the worst water crisis in history and within Cape Town, South Africa. And just being able to, through my work and through my own personal trips, seeing the devastation as well as the beauty across this planet, it is really eye-opening and it creates such a new perspective where I try to encourage so many people to just get outside of their own backyard because being able to witness from your own perspective these changes and what other communities and ecosystems are battling and going through, it's revolutionary. And that's what I feel like we all have to do is be involved with companies or organizations like WWF or just kind of create trips on your own so you can understand what is actually happening outside of your own world. Yeah. And you don't even have to travel to Cape Town. I mean, there's so many communities, even in the United States, who are going through major transformations as a result of climate. Yeah. And you would definitely know because you're a cross-country RV trip that you're just stuck. Exactly. Well, I actually learned a lot on this trip and sort of like the ecological, you know, the precarious position that we are in across America, whether it's like the lack of water infrastructure in Southern California or the dryness of the deserts or, you know, I mean, environmental justice issues. |
And the closer you can get to the community is the more crystal clear it becomes, you know. Yeah, I completely agree with you. And yeah, even within our own backyard, there is a lot of suffering going on. And yeah, especially within California too, the droughts are heavy. And it was even shocking that rainwater harvesting, which is amazing. You see even be illegal until, you know, a few years ago for Californians to harvest their own rainwater. It's wild. Oh yeah. So wild. Really helpful context. And especially, I think it's, it's, it's a good segue into the next question because we talked a little bit about different areas and how diverse this issue is entirely. And Lindsay, I'm going to keep on with you, but Danielle, we want to get your thoughts on this too. So to both of you, do you have a particular sector or theme that you choose to focus on? And if so, what was that one moment that propelled you to make that a focus of your own? Or was it more of a gradual sort of recognition throughout your career and your lived experiences that brought you to that point? And then maybe, Lindsay, since we're starting with you, specific for you, we can start with this question, but how do you decide what areas to focus your lobbying, your advocacy activities on, and what are you currently focused and excited on? Yes. Okay. So as a theme, going back to the first question, I tend to emphasize the power within our choices as consumers, as constituents, referring to lobbying, simply as citizens, basically. And I like to focus on legislation, whether it is encouraging people to vote through those lobbying efforts, speaking directly to our representatives. And even in terms of that aha moment pertaining to a specific sector, it was definitely the fashion industry for me, as opposed to advocating for nature, which was always on my heart, advocating for the fashion industry felt like an obligation due to my role within it. And I felt a bit hypocritical as a model working in such a destructive industry. Even though I'm not involved in designing or manufacturing, sourcing, none of that, but I'm still part of the industry. And I wanted to do what I could within the position that I held. And so when it comes to lobbying, I've also, excuse me, I've also been able to act on behalf of just the fashion industry when it comes to implementing more policies and regulations. But each time I am on Capitol Hill, I do represent an organization. So I do lobby on behalf of two, which is WWF and Remake. And this year with World Wildlife, we were garnering support related to plastic pollution. And there were a couple policies related to EPR programs, which stands for Extended Producer Responsibility, as well as deposit return systems, which is also known as the bottle bill. And we also advocated for two additional bills. One was called the Recycling and Composting Accountability Act, which instructs the EPA Environmental Protection Agency to gather extra data on recycling and formulate a national composting strategy, which is something we really need. And the other is the Recycling Infrastructure and Accessibility Act. And that establishes an EPA pilot initiative to develop recycling infrastructure projects in rural and underserved areas, kind of like what Danielle and I had briefly mentioned with her cross-country and seeing the lack of infrastructure that we do have. And I do have good news. On March 15th, we did find out that the Senate passed both bills. And so now it is off to the House. So that was really, really exciting to hear. And it happened so quickly. And now with Remake, back to fashion, I've been working for a few months now on the Fabric Act, which is a bill that will completely redesign the American garment manufacturing industry, proposing new workplace protections and manufacturing incentives, allowing us, the US, to become a global leader in responsible apparel production. Now, this has been ongoing for quite some time. And, you know, we're going, we have a lot of back and forth with our representatives trying to garner more endorsements from companies and other organizations. So it's not as quick and brief as the results from WWF that we saw in March, but we're still pushing. We're going strong. And this is what you kind of have whenever you do, you have a lobbying experience. You really don't know how it's going to go, but you have to be ready for pushback because you're going to find a lot of pushback in our legislative branch, which is just something that exists. And it's just learning how to overcome these pushbacks and doing everything you can to the best of your ability. But yeah, it's one of my favorite activities that I do do. And I feel the truest solution to any crisis is within the legislative branch. So that's why I do really like to focus my efforts speaking directly with our representatives, as well as encouraging others, such as the consumer, to be able to become a voice for their planet as well. Thanks, Lindsay. 100% agree that the solutions are in the legislative branch. And it's also really interesting how your background in fashion and being an insider for years enables you to bring a unique perspective, which I'm sure is extremely valuable when you're in the room with those on Capitol Hill. So Danielle, we're going to turn it over to you to share what areas you the largest awareness and also, you know, lead people to become part of a movement? And, you know, how do we envision the world in which we want to live and make the decisions that get us closer to that, right? And so, you know, and also I will say, like, I grew up loving fashion, loving beauty. And so I found myself really working in the consumer product sector for two reasons. One, as an enthusiast of those two industries, I wanted the products that I bought and wore and, you know, and the brands that I supported. I just thought that it shouldn't be up to me to like do the research and make sure that things are sustainable. It just felt like things, it shouldn't be a choice. Everything that we purchase should be inherently sustainable. And that really only comes, you know, with the work Lindsay's doing on the policy side. Right. But ultimately I thought there was an opportunity to really start building that momentum, working within these large global consumer products companies to, you know, lead their transformations to more sustainability and social impact, but also understanding consumer behavior. And, you know, that's sort of the niche I ended up carving out for myself. I love working with brands established and new. You know, it's fascinating to see sort of how 100-year-old heritage brands reinvent themselves around this value proposition of sustainability and social impact. And it's also amazing to see new brands launch with this really at the core of their mission and vision and values, you know, and how does that come to life with the products, with the supply chain, with the materials that they choose or ingredients that they choose, with their marketing to consumers, you know, and all of these things in between. And ultimately, that's really where I was interested and what I wanted to pursue for my career. So, yeah, that's how I got to sort of really focusing on this expertise. Danielle, I have to say, I completely agree with you. And there's so much unfair responsibility that falls on the consumer, making them have to handle and deal with the consequences of the company's actions. So I completely, I love everything that you said. And I just wanted to just thank you for knowing that there are so many other people like yourself out there that just believe and see things in that manner. And that's what we need to be doing is showing that there is that unfair responsibility and these manufacturers need to take, hold themselves accountable for their actions. Totally. Thank you. policy driven and driven by the business so that the consumer, you know, doesn't have time or capacity to figure out what they should be buying. It's just, it should be on the shelves. You know, I heard a business leader who works in the space say that, who used to work in policy say that, you know, policy is about 30 years behind like an identified need, right? And if you think about that through the lens of this issue, it's kind of interesting, right? Dial back 30 years, where were we? We were really starting, just starting to talk about climate change as a culture, like, you know, at the level of cultural awareness, right, versus like a niche issue. And understanding that within our system, getting the buy-in from the private sector as a critical stakeholder, right, in policy. You know, it's one of the things that makes me hopeful about where this is going is it does feel like, to me, we are at an inflection point. |
But ultimately, with the advent, and also we're on the precipice of one of the largest wealth transfer in the history of humanity with values driven as it relates to their purchasing power. So I think these couple of sort of shifts are positive indicators when it comes to sustainability and social impact or, you know, hopefully anyway. And those two things do give me a lot of hope. So you all touched upon it a bit, and I want to dig a little bit deeper. I think it's really quite interesting that we have this group together because there's so many different backgrounds and so many different perspectives. So from being on the legislative side, at the corporate side, working with brands, from your experience in all those different areas, can you give us an idea of number one, what sustainability should look like? And number two, what sustainability actually looks like? And for the latter, why is there such a disconnect between some of the efforts that large brands are undertaking and why progress on their initiatives have been so slow? And we'll kick it off with Danielle and then Lindsay, really welcome your thoughts as well. You know, I think sustainability by nature is aspirational and should remain aspirational. So even as policies are passed to make some of these aspects compliance-driven, I still think there's room to push forward on many different things. So while the focus right now is on decarbonization from a policy perspective, you know, that doesn't mean that we should take our eye off the ballization or sorry, just the planetary boundaries in general, where we've surpassed the recommended boundaries for safety, the safety of humanity, right? The safety of humanity and the future of humanity thriving. And I think we have to think about sustainability as a momentum builder and a mechanism to continually push society forward on these critical issues. There is no end to this work. It's not like we will get there and be like, okay, high five, everyone. Like, moving on, let's go figure out what else we're going to do. It's when we've accomplished one goal, we need to shift our momentum and perspective to another goal and continue to push that forward. Why is the work challenging within organizations or why does it look different within organizations? You know, I think also I would be careful in assuming that organizations aren't getting to where they thought they were or where they wanted to get to. We still have six years left of this decade of action, right? And I think with science-based targets, a lot of the first major milestone being around 2030 commitments. Companies had to be committed externally, and there's organizations that will hold them accountable. And I think if they miss their goals, that will have a real negative effect on the valuation of the companies, on the perception of them as employers, of the leadership capabilities, and on and on. So I think that as we get closer to 2030, the more resources, the more budget is going to be allocated to these things because it needs to be, right? And so, you know, hopefully, even though we'll have to get there quicker and it would have been nicer to like do this work in a more incremental fashion, you know, that's not necessarily how things work internally, right? We're working, the internal conversation is really about driving growth and meeting our investor and shareholder expectations and ensuring that quarterly, annually, you know, we're meeting the goals that we're getting to. Does, you know, five years, 10 years, that feels like a long time when you're working so rapidly inside a company to meet those short-term targets that sometimes perhaps these things get deprioritized in what is important today. But eventually, you know, those things will be what's important today and need to be addressed immediately, you know. So it's going to be the next five years is going to be really interesting to see how this all unfolds for sure. Thanks, Danielle. I like your take. And it's quite important to stay hopeful that companies will be ready to meet their commitments in 2030. And there's definitely a lot of progress to be monitored. Lindsay, I want to turn over to you for the same exact question. Welcome your thoughts. Yes, Danielle. I totally agree with everything that you said, especially when you mentioned accountability. And for example, even eco-branders. So eco-branders encourages brands to incorporate the three R's, reduce, reuse, recycle into their programs by buying less products, but better ones. And if they're for promotional purposes, you only give them to those who truly want it. And when it does come to reusing, you design your product for reusability. And in regards to recycling, buy products made from recycled materials or make them from recyclable materials. You can offer take-back programs. You can donate your excess and unusable merchandise and materials. And these are ways that we can really implement those practices into each type of business model. And there's also other options where I mentioned we can implement more EPR programs. You can also enforce responsible waste disposal practices as that's a significant issue, especially in manufacturing. And switching to renewable energy or investing in carbon offsets, as Daniel mentioned, decarbonizing the economy is a focus at the moment as well. And even back to the businesses, we need to create more transparency within our supply chains and also implement education programs that are directed towards consumers. So they can even know what to do if they receive a recycled product, they know how to recycle it properly or what they can or cannot do. And so today, a lot of companies appear to look sustainable by slapping a leaf on one of their products saying it's green, or they emphasize a certain positive impact that they make while they're overshadowing or hiding all these other negative packs that they are creating, which is also known as greenwashing. And progress to transition is slow because it does require a significant change in processes within their infrastructure and especially within their mindset, which is also that perceived disconnect because there are so many people that have a formula of sustainability versus profitability when in terms we can actually have both. And it's also really, we lack the policy and regulation that we need. We lack economic incentives, certain infrastructure and technology. And even within the supply chains, they are very difficult to have that transparency within them because they are complex and it's difficult to coordinate across multiple regions and countries. And there are also challenges related just to the overall cost and design and the functionality requirements of certain products. There's just so many different factors at play as to why we have such a great significant challenge. And even within just the consumer mindset, we have a challenge there because supply and demand also plays a massive role as consumers control the market trends. And if there's still a demand, there will be a company to create it. And even if you place full responsibility on the companies and they only produce ethical and plant-based products, They're regulated. There's policies that have been implemented into place. But if there's still a demand for the opposite, a new company will pop up the next day to satisfy that demand. And so that's why we need a collective effort from our government, our companies, from our consumers in order to really reach our sustainability goals and to implement these practices within legislation, within business models, and within our own daily lives. Thanks, Lindsay. That is exactly where I wanted to go next. I'm really glad you brought up some of the key components of the circular economy, creating value where there was no previous value and thinking about rethink, reuse and recycle. Danielle, I still have that ingrained from your class, the three R's when we're thinking about a circular economy. And it's also, you know, important to say that it's in that order of importance. So today I really want to focus on the rethink component. And I was hoping you could tell us a little bit about how businesses you've worked with are approaching that component. You know, I think as sustainability advances, when we say it can't be just business as usual, it doesn't just mean that the context, the environmental context in which we're operating in is changing, so we must change, right? It means that the way we make decisions inside companies, the processes, the governance, all of these pieces have to be reconsidered and rethought. And because there's a reason why we got to this place where we're in today, where all of these externalities are not being accounted for to the detriment of society and humanity, right? And so I think ultimately the most successful organizations are the ones who understand that fundamentally every aspect of their organization has to change. And it's not just about designing better products. And like you said, Laura, I think like slapping a certification on it, it's a fundamental shift in how we think of that enterprise in society, going from a single stakeholder approach to a multi-stakeholder approach, rethinking capitalism to be more inclusive and account for the because this is, we can't continue, right? |
You know, when I first started this work, that's the day of the year where we've used up all of Earth's resources in a sustainable manner, right? And every year it gets earlier and earlier in the calendar year because we're not evolving rapidly enough to really use our resources in a mindful way that's sustainable for the long-term health of the planet and civilization. And I think also just want to clarify, I think one of the fundamental shortcomings of the environmental movement of the 70s of save the planet was really misguided, right? Because it's really not about saving the planet. It's about saving ourselves. Like we really need to understand how closely linked and interdependent we are, our survival is to a healthy and stable planet. And, you know, ultimately that's going to require a mindset shift for every decision that's made within businesses day to day. So it's not just about putting out better products or better design products. It's about rethinking. And that's also, by the way, Laura, why I love circular economy, right? It forces us to rethink every aspect of the value chain and our relationship to the things around us and challenge ownership models and challenge our ability to like, do we have to own everything? Like, is that, do we want all this crap in our house? Like, is that really what we want? I don't think that's what people want. You know, and I think we're getting to a point where people want to be more nimble, they want to, especially after COVID, I feel like we all got a glimpse into what life was like with a major sort of shock to the way we do, you know, the way we live life day to day. I think we're still processing what that meant for us in our lives and in the lives of our loved ones and in our communities. And I'm hoping that people are drawing parallels between that and what life could be in a climate unstable environment. So, you know, there's a fundamental shift that needs to take place. And it's not just about putting out better products. It's about challenging every existing norm that we have and figuring out how do we look at it through the lens of equity and environmentalism. I couldn't agree more. I love that you brought up the sort of language that was used in the seventies and that's sometimes used now and in like the environmental backlash of like, you know, going against the greens or against the earth. And really what we're trying to do is allow humanity to continue and allow our species to survive. So I really like that point. And Lindsay, did I hear you? Did you want to chime in? Oh, yes. I was just going to say, I love that you use one of the R's is rethink. And that is something that we need to be doing more of within sustainability is just thinking, especially from the business side and crafting a new business model. And like what I mentioned before, there is that argument of sustainability versus profitability that still exists where so many businesses have that mindset and to be able to shift that mindset, just, you know, think, and they can save so much money by, you know, switching to energy efficient manufacturing and, you know, optimizing the resource consumption. All of that does save them money. And it also mitigates future environmental risks that they might have to clean up. And so everyone's thinking in this, excuse me, everyone is thinking in this short-term mindset rather than the long-term. And okay, even if things have an upfront cost in the short-term, you're going to be saving that money in the long-term. And also if you are, as you mentioned, even certifications, and it's not even just certifications, it's verifiable certifications. And having verifiable certifications and creating transparency, partnering with ethical and sustainable suppliers, all of that even increases your brand reputation. It attracts new customers, loyal customers. And that's even what EcoBranders does, which is how they also act in reshaping the culture within business and within consumers is by providing all of these things where they even show the organizations that your purchases interact with that show a positive global impact that they're creating just from your purchase. And it gives a competitive advantage where you are attracting those customers that are willing to pay even maybe a bit of a premium at times just to be associated with a purposeful business. And something I also found fascinating, and it's just a theory, but there's a theory that in the long term, businesses that prioritize ESG strategies will actually outperform those who do not. And yeah, again, it's just a theory at the moment. So we don't know for sure, but there are supporting factors included with what I had mentioned, where it is that risk mitigation, they have those cost savings, they're opening up new market opportunities and attracting those new customers. They have that increased brand reputation and customer loyalty. And most of all, they have access to more capital, which we've already seen trending because companies now with strong ESG performance are seen as less risky and resilient. And you can just check this out on so many companies also have such a budget for environmental initiatives. And I mean, just look at Wall Street and like check out the stocks performing. There are a lot of investors focusing on ESG performance because it is safe. So there's just so much there's so much to to consider and all you have to do is just think about it. So I think it's so easy just to add the rethink as one of yours. You've both made an incredible case for why businesses should start rethinking their business models. But I also want to ask, what are you seeing as the most common barriers for companies to not want to do that work? Just even following up with what I had said, so many people just have such a short-term mindset. I think so. Again, I'm kind of outside of the businesses, just outside looking in. And from what I've seen and spoken to just within the fashion industry, it's all, I mean, to me, I just want to call it greed if I can just be blunt about it. And again, they're just thinking about profitability rather than having sustainability as well, because you can have both. You can still have that revenue and still be an ethical and purposely driven business. And there is, of course, even as I mentioned, so many issues involving just having to completely transform your business model where it does take a lot of time to transition. But we also have so many options now that you can find suitable for the business that you want to run. So you don't have to completely switch to renewable energy, maybe to reduce your carbon footprint, but maybe you can invest in carbon offsets. So there's always, that actually doesn't change your business model at all. So there are just so many different options that we have that you can find what is suitable for your business needs and how you want to run your business. And that's why I really just want to come down at the end of the day, just saying it's greed and a lack of motivation. I have a slightly different perspective, although I do appreciate Lindsay's point of view as someone on the outside looking in. And I have, as when I can sort of like compartmentalize myself as an outsider looking in, I have the same sort of frustration of like, why isn't this happening faster? This is so stupid. Don't these people understand, you know, that we're, that we're literally running off of a cliff here, you know, And then I turn to my like other person who's been on the inside, right? And I know how challenging it is to transform an organization with a lot of external competing priorities, right? And how legally public companies have to continue to demonstrate profitability. Otherwise, they can be challenged. And I've been inside organizations that have been challenged by investors who didn't feel like the leadership was maximizing the potential for growth, who were ousted and who can't focus on anything but keeping their head above water. And that's the reality of this sort of quote unquote game, right, that we're in. And it's really hard to hit pause. I mean, you can't hit pause. You have to rebuild the plane as you're flying it, right? And it's like unbelievably challenging. And I think the people who do this work internally don't get enough credit for how hard it is, you know, but, and they're going to work every day and like taking, frankly, a lot of shit from a lot of different directions. And it's really hard. And it does get you down after a while. But if anybody needs a pep talk, give me a call. But also, the other reality is that companies can only make changes at the pace that there are solutions out there for them to implement. |
That companies made by 2025, they would be recyclable, compostable, refillable. All packaging would be da-da-da. Well, guess what? There's not a lot of suppliers out there. When they made those commitments, there weren't a ton of suppliers out there that could help them achieve those goals. And so we do, it does take time for these companies to start to get funded, to develop their infrastructure, to educate consumers on behavior change, etc., etc., so that it can be taken up and scaled to a regional, countrywide, or global level as these big corporations need to do. And, you know, it is very challenging. So I would say that a lot of times, yeah, sure, our resources internally lacking, for sure. These teams operating really lean and small. Yeah, and that totally sucks. And it leads to like high level of burnout and all of these like, you know, things. But I will say there are new, there's a new generation of CEOs who are coming to lead these organizations. There's new generations of board members who are sitting on boards and they're having challenging conversations with the folks who have been in those seats for a long time, like an old school, new school dynamic. And it is happening, even if you don't see it on the outside or feel that, it is happening within these organizations. And it is not happening at the pace that we need it to. And that's what's so frustrating is there is an external urgency that is our reality. And we need people to act fast. And also, these organizations and enterprises are not used to acting fast, right, in these kinds of situations. So there is a both and here. And I think it's important to, yes, keep the pressure on and always challenge, you know, our values and in society and like what we think is important. And also recognize that the kind of transformations that we're making are really big and really hard. And they might be happening in a way that feels super incremental and that sucks, right? But also recognize that there has been a lot of progress made in the past 10 or so years on sustainability and social impact. So I think both of these things can be true at the same time. I appreciate having more of an inside look to that to answer that question. And I totally agree, like the difficulties within that transition, whether it is, you know, due to certain infrastructure and technology that doesn't really exist yet, that is too difficult to implement. Totally understand that that is one of the challenges that they face. And even whenever you mentioned sustainable packaging, that alone is so difficult to do. And even also related to cost, the material that is available to produce these sustainable packages, and even the design and the functionality of that package, because sometimes it does require specific, like protective packaging that doesn't exist in a sustainable way. So I know there are so many little tiny things that are so difficult that a lot of the general public don't understand and are kind of just like, just do it, which is also my mindset in some of the ways, because yeah, I still don't know much about it, but that's more on the implementing that infrastructure and technology side of it. But going back to what you had mentioned, just with the stakeholders applying pressure, and wouldn't you say though, I understand you still have to maintain a profit, especially if you want to continue being sustainable, because that's the only way you can do it. So I understand that, but I also truly believe, especially a lot of these big companies out there that exceed like their revenue goals yearly and yet they still choose not to do anything about it. And wouldn't you still say that that's greed driven? Sure. I would say it's probably not that black and white though, right? Like I think, I think that a corporate executives today are measured on their success, uh, on being able to drive giant, you know, drive growth for their organization. Right. And until we start to evaluate and measure them based on their ability to lead an organization through a transformation towards sustainability, you know, it's not going to necessarily be prioritized. Right. And so that's, I think, one of the challenges is we have to make sure that our expectations of these leaders is crystal clear that it's not just profitability. It's also sustainability, social impact, human rights. You know, I'm yet to work with a CEO that doesn't care about human rights. Like if they, they're like, they may not have traceability and transparency up the chain of their supply chain, but once they do, I mean, no CEO wants to put their head down on their pillow at the end of the night and think about forced labor or child labor in their supply chains, right? And know that the organization that they're leading is contributing to that. That blatant kind of exploitation, in my mind, doesn't exist in the way that we would perceive it from the outside looking in. I will say, barring a small subset of corporations that I think are responsible for the largest amount of emissions and impact, who do know, you know, their, the role that they're playing in these sort of horrible supply chains, mostly in like fossil fuel and oil and gas, right. But I will say like day in and day out, a typical brand like fashion CEO is really conscious about wanting to make sure that they're not contributing to the negative, you know, perpetrating negative things on people within their value chain. And I think that when they know about it, they take action, you know, but it's ultimately it's, it's, I will say it's like not as black and white as we would like it to be. And I will say that also, I get the, you know, wanting to like name something and then go for it, because that's human nature, right? We like want to fix things. We want to identify one problem that we can attribute to something and, and go for it and fix it. And, but I think we in sustainability and social impact live in the shades of gray and like every day is shades of gray and like, how can we do things they're incrementally better and then when we get there how can we continue to push the boundaries and really build on that over and over over time versus like you know ripping a band-aid off and getting getting us to where we want to go overnight people don't like change change. That is human nature. And even asking people to do their jobs even slightly differently is challenging. So it's not just the CEOs. It's like everyone from leadership, from the board to the bottom and everywhere in between trying to help people understand that every job is a climate job and that everyone has something to contribute. And I understand you might be retiring in five years and you just want to focus on like your pension and getting across that finish line. And you've been at this company doing your job one way for the past 25 years. And I'm annoying, asking you to change everything now. But, you know, being able to navigate that conversation takes time, being able to build that trust takes time, you know, and that's just the reality of it. And usually there's like, one to five people doing that work within an organization where really you need like a whole army of people, you know, to make the transformation happen quickly. And perhaps where that's where like, you know, the greed or, you know, the lack of leadership might be able to help more is to staff these departments properly, resource them properly, and help the people internally succeed. Because today, really, they're set up for failure. And that is challenging. That is one of the biggest challenges, I think. Yeah, I will say, I feel like, especially with how society runs today, a lot of businesses and even individuals are set up for failure. But it is really nice to hear that you do think, you know, when your back's against the wall and you know that there are a lot of humanitarian rights, human rights being violated, that they would want to act more so than not, which is great. So I would like to think that as well. But then you also see that not happening because even on behalf of Remake, we performed a demonstration in Times Square in front of Levi's and we've been trying to get them to sign the Pakistan Accord, which really focuses on protecting worker rights and paying them a livable wage, especially after this one catastrophe in Bangladesh that one of the factories burnt down and took the lives of many garment workers. And that wouldn't have happened if they actually had, they weren't violating their worker safety rights. And then yet Levi still would not sign onto the accord. Now, a few, a couple months ago though, they did sign onto another accord and the name is escaping me. |
Hello and welcome to Sustainability in Progress, a podcast focused on exploring the most topical themes in sustainability. In this series, we will be inviting guest speakers and industry experts to discuss the most challenging issues facing our world today. But more importantly, the opportunities to address these challenges and make tangible changes. The sustainability space is constantly evolving, so we've decided to call this podcast Sustainability in Progress, Thank you. We invite you to join us on the journey where we will explore topics from sustainable food and agriculture, law and policy, economics, to the science at the very heart of our challenges and opportunities. Are you ready for your morning sip? We're back with Yannick Radin for part two of our Russia-Ukraine discussion. In this episode, we're looking at the linkages of the Russia-Ukraine war and the ongoing global food crisis. The region is incredibly important for the world's food supply. Russia and Ukraine export nearly a third of the world's wheat and barley, more than 70% of sunflower oil supply, and are major suppliers of corn. In addition to the region's importance on food production itself, shipping these food products has become considerably more difficult as a result of the war. 90% of wheat and other grain from Ukraine's fields are shipped to world markets by sea, but have been held up by Russian blockades of the Black Sea coast. Some grain is being rerouted through Europe by rail, road and river, but the amount is a drop in the bucket compared with sea routes. As expected, when food production and shipping is disrupted, prices increase. As mentioned in part one, energy prices have risen as a result of the war, and natural gas prices have led to a rise in the price of fertilizer, making it difficult for farmers to remain profitable. Today, we are joined by Professor Radin to discuss the impacts of food supply, shipping disruptions, and rising fertilizer prices on different parts of the world, particularly the most vulnerable nations facing the direct effects of a food crisis and what we can do to rethink our existing food systems and habits. So in the first part of this episode, we talked about the energy crisis as a result of the Russia-Ukraine war. And now I want to turn to the war's role in fertilizer exports and the impact on food security. So Russia and Belarus account for approximately 20% of the global fertilizer supply and 40% of potash is found there. Last year, fertilizer prices were around 200% less than current prices. So fertilizers that cost $300 an acre are now priced as high as $800 an acre for certain farms in the U.S. This can mean hundreds of thousands in budget impacts. Some farmers have even stopped planting altogether because of this price volatility. Can you talk to us about how the war in Ukraine is affecting the supply of fertilizer? Remember I said there's either glass half full or half empty. One of the things I think that we've made a mistake on as a structural element in the past is we've forgotten some of the things that nature taught our civilizations for thousands, if not hundreds of years. What I'm getting at is that fertilizer is good. It's made possible more food on the table, but it's also made us neglect basically know-how. And I just saw, I think it was on Kenya, where women farmers were going back to traditional farming without the fertilizer. So what I'm getting, and we don't also fully appreciate what fertilizer has done to many agricultural areas of the world, because after a while, the fertilizer seeps into the ground. So yes, it's impacted it, but maybe it also has a silver lining of a wake-up call, wondering whether fertilizer is always good to the degree that we've been using it. But in the meantime, it comes back to something else that I said in the earlier part of the broadcast. And that is the potential bridge building that we need to do for the future. Belarus, Ukraine also, as well as Russia, have these natural ingredients that we need for the food supply. That's one way of rebuilding step by step a relationship that's now been decimated to a great extent for obvious reasons and for valid reasons because of the war. So I think that and the developing world in particular needs it because they've had their own population explosions. But maybe it's also time to rethink whether all the products that are done by fertilizer are the best healthy ones. Let me switch for a second to Mexico. We're standardizing the tortillas and everything. Variety is good. And the reason is because we want one, can we put five different or 500 different types of products on the shelf in the supermarket? Maybe this will give us the time to reflect and to rethink that diversity in food products is actually the way to go as opposed to one massive standardization of food products. I couldn't agree more. I'm really hopeful by what you just said. I hope that we can transition to more regenerative agriculture and increase education around food solutions. But as you said, for emerging countries that will likely need fertilizer, at least in the short term. Do you see potential alternative suppliers? I've interrupted because my reaction is no, not in the short term. That's the problem. It takes time to grow to get the ingredients. So the short term, we're between a rock and a hard place. I do not see any short term provisions that can now be affected. It may mean, as I saw in this one broadcast, that we eat something maybe differently, etc. So different food supplies that we've put out. And coming back to something else I said in the earlier podcast is the following. The amount of waste, look at the water, as I said, seeps through the pipelines. How much food are we actually wasting? So maybe it's time to rethink and to refocus a little bit. But in the short term, I'm sorry for jumping when you were asking the question, but I don't see any short-term solutions right now except to economize a little bit on the waste that we've had to value the food that we have as opposed to the amount that we let just spoil. And what does this mean for the industry and what does this mean for future food prices, recognizing that there might be a significant time lag before the effects are fully felt? What is your view there? Well, I do think prices will go up. Developing nations can probably cope with that. It's a matter of saying food is more important than the latest fashion shirt that I want to buy. But developing nations will have suffering, and I don't see any solution to that other than that the world community steps up, although I'm not optimistic on that. On the other hand, it also might get a force for reflection of developing nations that you always have to save for a rainy day. And I come back to what I said before about Namibia, which dedicates a third of its budget for education. Botswana, when it had obviously HIV problems, it had enough money to take care of its sick people. So I think the only silver lining I do see is a time for reflection. And so you just mentioned how emerging countries will likely be harder hit. Can you talk a little bit about how different parts of the world are more or less affected by a decrease in fertilizer supply? I think that to a great degree, and here I'm not an expert, so I will have to excuse myself as far as being knowledgeable on the facts of it but Africa much of Africa has for example I know in South Sudan where they actually didn't want to use fertilizer in many respects because they wanted to further their local production traditional ways and not just rely on massive fertilizer. So again, I come through a concept of differentiation. I think Latin America can probably cope more easily, one, because a lot of the products that they need are locally produced. They still have diversification, but I do feel that Africa will suffer more because they've relied more on the fertilizer from the Belarus, Ukraine, and Russian space, and so they will be more adversely impacted, and they've also are affected by a drought period. So I think we will have a massive problem in particularly the continent of Africa. Asia, I think, is also a little bit more diversified. So again, we need to look at case by case. But as a group, I think Africa seems to have the biggest challenges for the foreseeable future. Beyond the obvious factors like malnutrition and poverty and starvation, do you see further issues being exacerbated in regions like Africa? I think those are obviously the ones. The other ones is, like I said, I see a silver lining that maybe there's a rethink coming and saying that we have to produce and further our local production because for example much of Africa such as Nigeria which is naturally resource rich in the country with oil less so with gas basically were self-sufficient in food for many years until they relied completely on the export of oil and priced out its local agricultural production. |
Hello and welcome to Sustainability in Progress, a podcast focused on exploring the most topical themes in sustainability. In this series, we will be inviting guest speakers and industry experts to discuss the most challenging issues facing our world today. But more importantly, the opportunities to address these challenges and make tangible changes. The sustainability space is constantly evolving, so we've decided to call this podcast Sustainability in Progress, or SIP. There is no one-size-fits-all formula to solve the environmental crisis, implement social justice, and install systems focused on equity. We invite you to join us on the journey where we will explore topics from sustainable food and agriculture, law and policy, economics, to the science at the very heart of our challenges and opportunities. Are you ready for your morning sip? Welcome back to our listeners. We've got an exciting two-part episode coming up to discuss a very pressing topic that probably wouldn't be viewed as a sustainability issue at first glance. But when we peel back the layers a bit, we see how profound and lasting of an impact it will have across the world and for generations to come. We're of course referring to the Russia-Ukraine war. For the first part of this episode, I'll be chatting with Yannick Radin, an international affairs expert who has a wealth of experience and some amazing stories to tell. We'll be covering the impact on energy pricing and policy, and then my co-host Laura Negri will be speaking with Yannick about the war's impact on fertilizer and food pricing. Fun fact, in 1990, when the Republic of Estonia was striving for independence from the Soviet Union, he accompanied Estonia's Minister of Foreign Affairs to the office of President Ronald Reagan to secure support for Estonia's independence. He also co-founded the Afghanistan Relief Committee to restore Afghan independence after the Soviet invasion, co-authored investment, privatization, and corporate laws for Poland, Estonia, and Georgia, and drafted the Interim Peace Constitution of Nepal. So naturally, we jumped at the chance to talk to him about the current crisis in Ukraine from both an international affairs lens and a sustainable development perspective. Today we're joined by Professor Yannick Radin, Adjunct International and Public Affairs Professor. First, Professor Radin, can you give us a bit of your background and talk about how you got started in international affairs? A bit. That will narrow it considerably. I've always been into international affairs. It started way back when, actually, when I was 10 years old and saw the Hungarian Revolution on TV and wondered why they had to leave their country. And when I went to Columbia College, I was very much focused on international data, field trip to Brazil on anthropology, and that opened up the entire world and Just continued in that path. So I'm very lucky. I knew what direction I wanted and the direction was international global Although the word global was not used in those days But it's very very much that it's been the path that I started and I I will say one of the assets that I have, and maybe a number of you also might have it. I was born overseas. I was born in Berlin. I came as a kid. So anyone who is bicultural, by definition, offers a lot to contribute to the international space because they can bridge what they knew from home to what they're learning in school, etc. So I think it was a natural for me and there are many more like me. Great, thank you. We want to delve a little bit into the conversation related to Russia's invasion of Ukraine and we're now almost nine months into the crisis. So can you give us an update on the current state of affairs and how you see this issue playing out into the new year and beyond? Well, obviously, that's a question that can't be answered in a minute or two. But right now, we see the Ukrainians really energized, although they're suffering tremendously. I mean, the country has been decimated, and it will, as many people have predicted, be the largest reconstruction since World War II that the world has known. The real question is, where does it go? And I think, one, we need to stop the killings, stop the atrocities, etc. But then we have not just a question of reconstruction and building the lives of those who have lost it, the families, etc., the children. And I know from a fact that children will suffer throughout their entire lives because they will be mentally scarred from what they've seen. And that's a sad commentary. So what I'm getting at, it's a long-term process. In addition to that, how do you rebuild? And that will not happen in my lifetime. And I underscore my lifetime, although I expect to be here until at least 100, it will be in your lifetime on how do you rebuild the relationship with Russia, given the atrocities that have been playing out on TV and blogs, etc. So basically, we have a real problem of how to not just rebuild a country or rebuild, which is Ukraine, but rebuild a relationship with Russia because Russia is not going anywhere. It's there. It has natural resources, whether energy or even agricultural resources. In addition to that, one of the things that also has to be rebuilt, and that's really difficult given what happened, is trust. One of the things that has happened, and it goes to your basic question of the status, the Budapest Memorandum, which gave security to Ukraine if they would give up their nuclear weapons, which they had because they were part of the Soviet Union, that has now been decimated as a concept. So you have to ask yourself what country in the world would ever give up anything nuclear in light of the fact that this particular agreement has been violated. So that's one of the legacies that we're going to have to live with. Great and I'm glad you brought up the agricultural resources because we're going to get into that in a little bit. But in the immediate term, the crisis seems to have set back many nations' climate and environmental goals, especially as they've had to ramp up their production of fossil energy sources to bypass Russia's gas supply. But in the process, they've also shifted their policy focus to diplomacy and defense and energy damage control versus meeting those net zero emissions targets that they set over the last several years. So the question for you is how much of a lasting impact will the conflict have on the environmental and climate initiatives that were taking shape before the conflict emerged? In that sense, there are only two types of people in the world, those who see the glass as half full and those that see it half empty. On that, I see it as half full. I think it's a blimp that we have, that we have to resolve, get over, but I don't think it will have a lasting impact because I think the interest in the world is there to worry about climate change. It's not going as fast as we want, the worries and the implementation. But I think this is a problem that we have right now that we have to resolve, which is technically a temporary one, but it may last a few years. But I don't think long term it will have a lasting impact. It will have a short term impact, but it will also have an impact that we have to resolve. Let's say the decimation that's occurred, that's impacted climate change. So in one respect, I'm optimistic, although the short term will not be very good, it will set everything back. Can you elaborate a little bit on the decimation from a climate perspective? Well, as you said, for example, the use of the fossil fuels, people are going to freeze, so they want gas, they need oil. And when you need that, you're focusing your energies on how do you resupply that, as opposed to anything that might be putting your funds into the transition. So in other words, it's a distraction which takes energies, personal energies, governmental energies. And therefore, if you need to have warm homes, you'll pay whatever it is. That means you're encouraging more production in the areas that can send you the gas and the oil, because obviously the Russian ones are under an embargo, etc., sanctions. So basically what I'm saying is that the need for the fossil fuels to heat and to electrify is going to remain with us for at least the near future. Great, and I'm glad you brought that last point up. And towards the end of our podcast, we typically try to tie these issues of global sustainability concerns, risks and opportunities into the consumer focus. So we'll touch upon that right before we close. But you mentioned glass half full. So let's keep that same thought process going. We have to ask you on the flip side, the optimistic view suggests that the energy crisis will naturally force Europe and other market participants to be less dependent on foreign energy and in their stead push for a faster energy transition, as you mentioned. |
But could there be a light at the end of the tunnel? And what's your thought process on when we would likely see that? Obviously, with the caveat that there's pretty minimal visibility as we stand now. Let me rephrase your question in some respect through my answer. While transition, we have not yet the world has agreed that nuclear is the way to go. We can agree that solar works wherever it can work with the sun. We can say that hydro works wherever it doesn't do environmental damage and redoing the rivers, etc. But nuclear, we should also keep in mind that we are worried about a nuclear explosion in Ukraine because of the fighting. So nuclear plants around the world have their own negatives. Look at what happened in Japan, which was just a natural disaster. But if we now have to worry that nuclear plants, nuclear facilities are subject for armed targets, we got a problem. So what I'm getting at is while Germany has discontinued it and is resurrecting it interim, it may not be the answer for the future unless we also figure out how to handle them from a security point of view, which I think no one really focused on up to now. But I think Ukraine is a wake-up call that nuclear may be good from an environmental point of view, although I think the judgment is somewhat out, but it's better than fossil fuels. It is not necessarily good from a security. And if security overrides everything else, we got a real problem for the future. So I think that the transition is not as clear. And the other thing is one of the things that we keep forgetting in the transition is solar works wherever it is, but wind does not if there's no wind. Hydro doesn't if there's no water. Look at what's happening in the Himalayas. Less water is coming down. So we will, unfortunately, the truth is still need fossil fuels at the minimum as a backup. So there will be no complete, and that includes whether oil or gas, there will be no complete transition. It's a question of how to manage and what the proportions are going to be. So, and maybe technology can help us get the fossil fuels to be cleaner, but I'm not optimistic for what I know. Okay, that's super helpful context. So, I know we've spoken before in the past, and I wanted our listeners to get a little bit more context about your career and your work in the Eastern European region. In the context of what the diplomacy pathway looks like, you mentioned earlier, building that relationship back up with Russia. What does that look like? And based on your time in Eastern Europe, what are our possible options here? Well, let's say, one, we're in a crisis, obviously. And during a crisis, people look at resolving the crisis, or right now, many people are rightly, underscored, upset with what's going on. So therefore, no one is really focusing on how do we get out of it in a real way. For example, right now, we got a wheat deal, so to speak, a grain deal with Russia to permit the export from Ukraine. That's small steps, but a significant step in bridge building. That rebuilds it. So agreeing on what you can agree on while you fight on the things that you cannot agree on. So I think diplomacy requires a lot of bridge building at this point, small steps in the right direction. For example, it could be COVID inoculations. They need the pharmaceutical products. So it's going to be a step-by-step as opposed to a massive policy, one that we can just solve all problems at once. And the other thing is, and here I know that I might be of difference, is do we really want to restrict Russian citizens from, let's say, traveling to the West? Most people don't fight. Most people sit on the sidelines. Sadly, they're not activists. But if they see that there's a better life somewhere else, they come back home and say, I want that. So you also have to figure out how do you persuade those who are just sitting in, watching and doing anything but they can make their demands more subtly so I think diplomacy is back channels is bridge building and also opening up the eyes whether through tourism of that of those people who are not activists by nature it's hard to be an it really is. And I have a bunch more questions on the energy side, but given that you have such a rich background in the region, one more question for you on the policy side. How has diplomacy and international affairs and the international community, how has the approach to conflicts in the region changed as you've seen it since you began your career in this field? Can you give us a little bit of context there? Well, I think there's a lot that has changed. I mean, until 91, we viewed the Soviet Union, and understandably so, as the enemy, existential threat, etc. Then I think to a great degree the world fell asleep. We didn't worry about security, we worried about climate change, rightly so. But we forgot the other aspect of it. And the other thing which is, for example, we focus too much on economy in some respects. In other words, the G7 is basically an economic rich countries grouping. But did we have the voices of those who are aspirational or did we have the voices of, for example, a country like Estonia where I'm very well acquainted, the small country dynamic that's built up a successful society and a good transition. In other words, from my point of view, if you only have the voices of those who are economics, you don't have the philosophical, the moral, the human, which is the world we want. The world we want is what do we want out of the economics, a better world. So we need a greater span of that one. So it has changed dramatically that we focus more almost exclusively sometimes on economics. But should we have only done that? I don't think so. We should have also built up why do we have economics? So you can educate your people, so you can get better health, so you can get better infrastructure, so you can communicate worldwide. We have to give an outlook, a positive outlook. We've missed the psychology since 91. And in the same context of the economics, so the Ukraine war has shown Europe's broad dependency on Russian energy. Do you see Russia being able to maintain its position as a critical energy provider of gas by diversifying and exporting to China and India as their economies continue to grow? Or do you think with the loss of Europe, its best days are over? Let me put it in a different way before I answer directly your question. There are countries like Singapore, a small country, which, what's the biggest assets of Singapore? It's actually its people. It does have a pivotal location, but other places do too. Japan has basically no natural resources. What's its asset? Its people. So what I'm getting at is that we've focused a lot on developing people, which is right. Education, to me, is the mainstay. But we have not focused a lot, for example, on Russia. When we did buy their gas, we became dependent on their gas. But on the other hand, what else did they have to sell, for example, other than natural resources? But we didn't focus or try to say, how are you developing your own country? So in other words, it was a narrow focus. We buy, they sell, we buy. But we should have also said what are you doing with what we buy other than buying mansions in London, for example, other than buying teams in the UK, for example. So in other words, we can't just focus on natural resource-rich countries and say we buy your resources and we pay you for it, which they have to, but we also have to make sure that they invested in their people. That's a hard one to do, but we've never focused directly on that. So in other words, Russian development also was handicapped by the fact that there was not sufficient internal investment, whether in its people or in diversification of its economy. No, I do not think that Russia has seen the end with its natural resources. Other countries that you have pointed out, like China and India, China being more natural, it's easier. It borders on Russia. It will have a market. The products have a need. So just because it won't send it to Europe or will ultimately send less of it to Europe. By the way, the pipeline to Hungary is still working through Ukraine. It's not been cut off. So, no, its best days are not over. But its best days are over if it doesn't ultimately develop its economy, its people to diversify. You can't just be natural resource rich because you've got to do something with it. |
Hello and welcome to Sustainability in Progress, a podcast focused on exploring the most topical themes in sustainability. In this series, we will be inviting guest speakers and industry experts to discuss the most challenging issues facing our world today. But more importantly, the opportunities to address these challenges and make tangible changes. The sustainability space is constantly evolving, so we've decided to call this podcast Sustainability in Progress, Thank you. invite you to join us on the journey where we will explore topics from sustainable food and agriculture, law and policy, economics, to the science at the very heart of our challenges and opportunities. Are you ready for your morning sip? Hi SIP listeners, welcome back to the second season of Sustainability in Progress. We're so excited to have you all back with us. For this season, we wanted to keep it real. And so although we do try to do our best in terms of our carbon footprints and our social impact, we're still mere mortals living in a consumption-driven society. So to kick things off, here are some of our unsustainable guilty pleasures. John, I'll let you go first. Yeah, so Laura, you know me, you know my wardrobe. It essentially consists of sweaters and scarves, and that's exactly why I've been waiting for this fall and winter season. I never miss a chance to stock up on my sweater collection. And the one I'm wearing right now, I'll probably have to get a lot more wears out of it to make it even remotely sustainable. How about you? It is a good sweater though, so I get it. I definitely have a few tabs open for online shopping as we speak. It's pretty hard not to at this time of year. And I've definitely committed some Black Friday and Cyber Monday crimes. But so maybe you've picked up on the theme of this episode, which will cover the problematic side of sourcing in retail supply chains. Some of you may be familiar with the environmental impacts of the fashion industry, thinking about carbon from polyester, the energy used for nylon, industrial water pollution for finishing and dyeing textiles, pesticide use for growing cotton, and just the sheer amount of discarded clothes sent for either incineration or to landfills. But today's episode is focusing on the social components of the fashion industry's supply chain. There are a few key challenges in the industry that make it difficult to progress on human rights and social issues. For example, factory workforces often operate under horrible conditions. The auditors that examine factories have a ton of inspections to carry out in a narrow turnaround, and we don't have all the information we need to determine the social impacts of the supply chain, especially as we move further up the supply chain and begin to ask questions about our suppliers, suppliers, suppliers. Oh, so that sounds like we're getting to the third tier of suppliers, but we know it doesn't even stop there. That last point you made is really interesting. It begs the question of how we actually get this info and also introduces the concept of traceability. For example, we've all seen the Made in China label thousands of times, and the. alone imports over $50 billion in apparel and textile products from China, which makes up about one-third of our total textile product imports. So how do we actually trace that product back to where it comes from within China and ensure that human rights are preserved? Well, unfortunately, there is more forced labor attached to these everyday items than we realize. For example, there are a lot of textiles, threads, and yarn sourced from the Xinjiang region in China, where the government has targeted over 1 million Muslim Uyghurs who have been detained in re-education camps and essentially become free labor for much of the world's cotton sourcing. Yeah, and even though there are regulatory efforts like the Uyghur Forced Labor Prevention Act, which you'll hear on this episode referred to as the USPLA, which looks to ensure that products entering the US market are not a byproduct of forced labor from this region, there are still loopholes that remain and products manufactured using forced labor still flood global markets. And so for today's conversation, we're thrilled to be joined by David Uricoli, who spent 32 years at Ralph Lauren working to ensure the company's supply chain took into consideration human rights and labor issues. David is also heavily involved in the YES initiative, which seeks to drive modern slavery out of cotton production. So welcome, David. We're really excited to have you on SIPP. Well, thanks for having me, Laura and John. I really appreciate that. And so I'm going to go back a little bit. I graduated from FIT in the early 80s with menswear with a degree in menswear and marketing, and it was pretty exciting back then. So I started with, believe it or not, after my degree in menswear as an assistant designer in a very busy ladies' private label company in downtown Patterson, New Jersey, which was quite historic at the time. And we made, historically, the Halston 3 line for JCPenney's, which at the time was really radical. And now, if anyone's familiar with Halston's work, and I know there were a couple of movies made last year about him, that was really relevant to his downfall and also to a new wave in the industry as far as licensing is concerned to sort of lower priced retailers. So that was quite a major thing. And we thought about who we were working on that line back then. And then I joined Ralph Lauren in 1988 in product development and sourcing. And for us, one of the first things I learned while I was there, besides all about the company and all that great stuff, was about factory analysis as a major component for doing things, bringing new factories on board at Ralph Lauren. A good factory analysis was all about all aspects of the business operations that we were visiting, from factory rules to workers' rights to factory efficiencies and capabilities and their operation itself. A well-run and efficient factory generally meant to us fair employment, safe environment, and first quality products, not really understanding the base that we had created at the time. So I worked on quite a few exciting moments at Ralph Lauren, the beginning of the purple label line, sourcing all over Europe, and then Double RL, which is a denim line. So I learned all about the denim industry, which really brought me to one of my consulting commitments today. RLX and Polo Sport, learning all about the activewear industry and how relevant that was, and introducing Ralph Lauren to something as simple as Polar Fleece because it was so new. So traveling around the world, visiting factories, sourcing, developing new suppliers, we recognized toward the late 90s that we needed to do more than just our initial assessments and evaluation. And I can say right about that time, 97, 98, the Global Human Rights Compliance Department was born at Ralph Lauren. And then by the time I left Ralph Lauren, which was in 2020, we had a fully functioning policy-driven program making real improvements and worker life improvement programs. And the department has since been named Global Citizenship, which is much more apropos, and they're so much more involved in the workers' lives and the factory environment. It's really great to see, after creating that base, how they're really soaring right now. So I'm quite proud of them and the work that they're doing. And which has obviously, after that, led me to consulting work. And this has been quite a journey. It's been two years now since I ventured out on my own. And I could finally say that things are really picking up. That sounds great, David. So you've been in the CSR space for quite a long time. Have you seen it change drastically during your career? And if so, what are some of the biggest challenges you face and how do you get around some of the skepticism or pushback you may face from counterparts? Right. Well, I can tell you that, you know, I have been around a long time to the point where I remember some of the episodes actually happening, you know, back in the 90s, the mid 90s, everything from a Nike audit report being published in the New York Times to a daytime TV celebrity, Kathy Lee Gifford, who was actually was Kathy Lee. And we just filmed a show, which is now Kelly Ripa and Ryan Seacrest. But that show was live. And the reason why I mentioned that it was really important because one of the first activists, Charles Kernighan and the National Labor Committee called out Kathy Lee because she had a license lined by Walmart and there were workers in Honduras underage making her blouses. And then Charles Kernighan found workers in New York City that were getting paid making her blouses. So he called her out on national TV and she sort of became what not to do. So by Kathy Lee Gifford becoming that face of how not to handle these situations, we all learned a lot of lessons. And that was really my first awareness. |
We started actually sewing home products and working on all different types of programs in different countries where we'd never been. Sri Lanka, I mentioned India, and then also Malaysia. So it was really amazing. It was an amazing time in the company, but it was also an amazing time in the industry because back in 1997, President Clinton teamed up with some major companies such as Liz Claiborne, Reebok, Nike, Adidas, and invited a bunch of us, and Ralph Lauren, and invited a bunch of us down to Washington, D.C. for what was called the Apparel Industry Partnership. And we had our first major meeting with the Department of Labor back then. I didn't say much, but I can tell you that some of the pioneers that were at that meeting are still involved in the industry today doing some really great things, such as Doug Kahn and Marcia Dixon, Professor Marcia Dixon, I should say. But there was a lot of skepticism on the brand and manufacturing level. All the fingers were actually being pointed at all the manufacturers. It wasn't our fault. It was our manufacturer's fault. So that was a real heavy shift because all of a sudden we did everything we could to try and control what was happening in the factories, you know, attending courses and seminars on how to write a code of conduct, how to develop a social audit. And social audits became the main tool that was being used to understand what was going on in our factories. Now, as I mentioned to you before, Ralph Lauren had already been evaluating our factories, what we called our on-site evaluation, which was really part of our onboarding. So it became a standard part of onboarding through the sourcing department. And we developed standards for bringing suppliers on board. And a lot of it had to do, again, with us really understanding what the factory was about, which was a little different than some other companies were handling. So we had really tried to form a partnership with factories. There's also this concept of audit fatigue, whereby auditors are very overworked. Essentially, social audits at facilities are a one or two day process where two auditors alone have to sort through sometimes up to 1,000 workers and cover 13 or 14 topics. And these can include everything from payroll reviews to worker and management team interviews, full health and safety tours, and even an inspection of the premises. As if that wasn't enough, the auditors are also required to write up a preliminary report before leaving the site so that the factories can review the findings from the audit. That process really hasn't changed over two decades, and auditors aren't really getting paid much better either. So now there are a lot of other processes. When you even look at the streams program with Verite and Responsible Sourcing Network and Elevate, which is LRQ, I think they're called, I can't remember the name of Elevate auditing company now, but we should have realized back then what a burden we were putting on auditors. So that burden is still there. And it's being mitigated in many different ways, including time training of auditors through an auditor association. I think there's a couple of auditor associations out there. So it really has progressed. And I think there are organizations and companies that understand they need to do more so that the partnership word process, which then brings you into worker programs, not just about reducing risk because of findings you found in the factory, but being more proactive and giving the workers opportunities to advance both in their personal life and their professional life by providing professional training, working training, but also self-help skills, banking skills. There's a huge push, especially in Asia, about digital working, digital payments. So it's not just about paying workers into a bank account, but it's teaching workers how to manage that bank account and even how to manage their money. Okay, that's really helpful context. And in the same vein of factories, we're seeing even today that businesses haven't mapped their suppliers to at least the fourth tier. And as a result, they aren't agile enough to deal with some of the challenges that have become pervasive in the wake of the COVID-19 pandemic. We've seen so many headlines related to supply shortages, congested ports, transport delays. And as a result of these supply issues, we've seen incredible inflation through almost every sector of the economy. So how in that regard can you ensure traceability beyond tier one suppliers and be sure that your tier two, three, and four suppliers can provide accurate data and that can lead to more actionable insights to avoid these things such as supply shortages and transport delays? So working at a company like Ralph Lauren, most of the fabric, most of the trim and notions that we used were either signature or developed by Ralph Lauren. When I say developed by Ralph Lauren, you know, tremendous and incredibly talented staff that did everything from developing yarns to fabrics to finishes to functions, as well as everything in between. So we knew what mills we were working with. We knew where our trim was from. And then the rest of it was nominated by the factory itself. But yet we still knew who they were and we still approved it. So going into tier one, which is the finished goods factory and any, and I mentioned before about subcontractors and assists such as printers and embroidery houses, those are all part of tier one. Tier two gets into the fabric suppliers. And that was an area that we had penetrated while I was still there on several different levels, including the projects in India looking at the hand woven or hand fabrics, or I should say indigenous fabrics, because they were made by hand with hand looms and then they were mechanized after that. So I digress. Tier three is actually going into the manufacturing of these fabrics from finishing to finishing fabrics to dyeing yarns. So tier three is actually the yarn tier where everything starts to happen. And then you get down to tier four, which was really where the raw commodities are. So looking at tier three and tier four, those are the most difficult to penetrate, particularly if you're a company that doesn't nominate your products. So you may buy a product from a factory that they offer to you or whatever the case, however it was developed. But I'm going to assume that you didn't have to do too much product development because the factory already makes the product you wanted them to. And they also have fabric that they showed you and they took care of the entire package and you paid one price and they gave you a final garment. Well, you really need to rely on the factory to do that type of supply chain documentation. But more than that, you really need to teach that tier one factory how to trace all those items. So number one, they could at least understand where they're all from and have that documentation as part of their normal operating procedure. But then beyond that, that's where you start to really look at what they're doing, how they're doing it, and even on tier two, tier three, who their suppliers are. So there are suppliers of suppliers of suppliers. When you think about maybe in a waistband and what goes into that waistband, there's three, four different components that make up a waistband. And one of them may be a piece of non-woven, what they call fusible, that contains glue and it sticks the fusible, which gives the fabric more body, such as what's needed in a waistband. And it's glued to the fabric through heat, the heat process, which is sometimes eyes with it with an iron with a hot iron or going through a machine but the point is is that somebody has to supply that glue that goes on the fusible that's supplied by one company and the other company that supplies maybe the waistband or maybe it's the same company but there's three or four components in that waistband that have to be traced and then those are made in a factory. What kind of chemicals? It's as if you're looking at tier one all over again and inspecting, except now you're on tier three and the suppliers start to multiply and they start to do less. It could be one operation and one supplier. You really need to understand the entire supply chain And you can only do that with your tier one and tier two suppliers. You can never investigate fabric unless you do it with a tier two supplier. Thanks for walking us through the supply chain tiers, because I think a lot of people are not necessarily familiar with the different levels and the challenges for traceability, particularly with tier 3 and 4, and the importance of controls on purchase orders. And you talked a lot about responsible sourcing. And I know that you're part of the implementation working group for YES, which is carrying out such important work. I'd love for you to give us a brief overview of YES and what the goals are for the initiative. Mainly, it's a spinner certification for yarn spinners to ensure that any of the yarn they're bringing into their facilities to mix and spin were made without forced labor. |
The combing and cleaning process is part of the spinning process. So the raw bales of cotton get shipped to the spinner along with the paperwork that represents where that cotton is actually from. There is a global cotton bale numbering system, but I'm not sure how effective it is. YES was working on training cotton spinners to recognize and document, as I mentioned before, every level needs to be trained and understand what they're doing. So the YES program is really concentrating on the spinners themselves and training the spinners to understand the requirements of the certification, as well as a reliable resource to ensure resources to ensure that the information they do have is accurate and verifiable so that when they sell their yarn, their finished yarn, they know that it's still one traceable so that, you know, it comes with the paperwork from what farm it's from. And from there, like as in blockchain, every transaction is recorded. So that spun yarn is certified by the yes team. And I didn't get to that part. It was a temporary contract basis. So I'm not exactly sure where it is at right now. But intimately, I do believe that it's working and they have some pilot programs that they've completed. So yes, his work, you know, addressing forced labor and human trafficking at the spending level is really impressive. But I also think an area that needs more attention. For example, if we think about the crisis in Xinjiang, what can you recommend retail companies do? China supplies a fifth of the world's cotton. So how realistic is it for a company to stop its supply from China? And that can also sometimes mean losing Chinese customers who are core to a company's business model. So any ideas you have to diversify the supply chain would be really interesting to hear. It could be done. It's not an easy thing to do. The reliance on China alone, let's just put cotton aside, has been tremendous. China was very clever because the easier they made it for their customers, the better off they were. As I mentioned, there are some brands that really don't specify anything and their suppliers do everything for them. And I think that was one of the things that a lot of the suppliers in China got so good at, making it so easy for their buyers. So, you know, I think that's one of the reasons why China was so popular, because, you know, it was quickly realized after the, I'm going to say the first 10 years of China being such a hub of manufacturing that they weren't the cheapest. The race to the bottom had other places to go. But sticking with China, you could still work in China but not use Chinese cotton, which is not necessarily an easy thing to do, hence the traceability work that needs to happen. And there are companies working in China using even American cotton. A lot of American, most of American cotton, if I'm not mistaken, gets shipped to China. So what the problem with that is, is that, you know, the whole Uyghur issue, which is, I believe, Muslim Turks, I think, in the northern part of China. And what's important about that is that after they were trained, they all didn't stay in northern China. So there's Uyghur labor all over China. And it's really up to you and vetting through your suppliers to understand who the workers are and where they're from. I mean, that's essential. Pulling out of China or moving your production to other areas is not such an easy thing to do, even if it doesn't have Chinese cotton. And I know a lot of buyers are doing just that. I know a lot of buyers are struggling to do just that. And I know there's some buyers that are still trying to figure out what to do about it. You know, for every brand that is so well aware of what these challenges are and are working on them, there's another one or two that really are not part of that process. And they're small private companies that are kind of flying under the radar screen. Not that there's, I think, you know, everybody needs to take responsibility for what they're doing. So if you're one of those small little companies flying under the radar screen, these new forced labor laws, the USUFLPA, is a huge challenge. And that will vet out the companies that aren't doing anything or aren't doing as much as they should to impressing upon them even through a withhold release order, meaning a customs holding your shipment because they believe it was made with forced labor, will really bring you into the reality of having to inspect your entire supply chain. Sourcing from China using Chinese cotton is a challenge. A lot of companies are doing it. And a lot of companies are still working in China without using Chinese cotton for their orders and proving that the cotton that they are using is not from forced labor. However, it's a challenge because one of the things about China and I think one of the reasons why they are so big and why they are so popular, is one price was the main thing, but they made it awfully easy for buyers to buy from them, basically doing everything. What I mentioned before about companies that aren't really aware of where a lot of their raw material supplies are from is because the factories they're working with made it awfully easy for them to just pick a style, pick some fabrics, and they did the rest. And that particular way of working really is not a transparent way of working, but yet it puts companies that work as a sort of one-stop shopping in a very difficult position to try and now figure out where, in fact, all of these raw materials are from. So the reason why it's so important to work with your tier one suppliers as part of your traceability journey and being diligent about where all this stuff is from. So you mentioned the UFPLA, which is the Uyghur Forced Labor Prevention Act. But even with that in place, it can still be tough to verify sourcing. You know, there have been instances where Chinese companies simply redirect volumes internally so that, you know, traceability is harder. Or you also see auditors being turned back at checkpoints or questioned and followed. So how can companies actually go about enabling genuine transparency within their supply chain when all these roadblocks are present? First, that was a great question, Laura. And it's obvious you did your homework, even with that question, because it's a really good and complicated one. So yes, the Uyghur Forced Labor Prevention Act has created a lot of challenges for a lot of companies and has created challenges for auditing companies. So I did some audits in China in the very beginning of the Uyghur Forced Labor Act, and we still didn't get to the bottom. Factories were not being transparent, And factories that did have suspected forced labor or weaker labor simply denied it. And that was back in 2020. So once the problem was identified and given an acronym, UFLPA, it's really difficult now to have auditors go into a factory in China and come out with reliable data. It's almost impossible now so that if you are working in China, you have to come up with alternatives instead of relying on sending two people into the facility to inspect it and think that they're going to get information that would be useful to help you identify any forced labor. China came up with their own program about anti-forced labor. And so I have to say there's a bit of denial in the process. But even still, U.S. Customs, as much as people are confused by a lot of these regulations, there is also programs they came out with and best practices, you know, between, you know, really developing a good due diligence program, as I mentioned, that we did at Ralph Lauren from the very beginning, is going to be very helpful to you because you can't send auditors into China. Because if you do have a good due diligence program, which is compliance, social responsibility, traceability, and remediation, if you do have a good program, chances are you already know your suppliers and what they're doing. Whether you could get in there and look and see what they're doing at the moment might be challenging. But nonetheless, if you have a good relationship with your suppliers, hopefully you were able to continue to cultivate that and be reassured that what you think is happening or what you've found is happening in your supply chain is accurate. So it relies on your previous relationship. It relies on transparency and also verification, trust but verify. If you can't do any of those things, that may be a strong indication that it would be time to move your production somewhere else. Thanks, David. If you haven't noticed already, we love our acronyms. So I have one more for you. Under the new CSRD, which for our listeners, that's the Corporate Sustainability Reporting Directive, as many as 50,000 EU companies will be obliged to disclose transactions across their value chains. |
Hello and welcome to Sustainability in Progress, a podcast focused on exploring the most topical themes in sustainability. In this series, we will be inviting guest speakers and industry experts to discuss the most challenging issues facing our world today. But more importantly, the opportunities to address these challenges and make tangible changes. The sustainability space is constantly evolving, so we've decided to call this podcast Sustainability in Progress, or SIP. There is no one-size-fits-all formula to solve the environmental crisis, implement social justice, and install systems focused on equity. We invite you to join us on the journey where we will explore topics from sustainable food and agriculture, law and policy, economics, to the science at the very labeling system in the United States. Polypropylene is now considered widely recyclable. So when you hear us discussing that material, keep that in the back of your mind. This update shows the incredible impact of collaborative action and we're excited to discuss the topic in this episode and in upcoming shows. Hi, my name is Lohan Agha and I'm your host for this episode of Sustainability in Progress. Today we are going to cover one of the most challenging problems affecting our environment and why almost every effort to solve this problem always seems to fall short. We're talking about plastic pollution and the recycling problem, and more specifically, consumer confidence or the lack thereof. According to National Geographic, of the 8.3 billion metric tons of plastic that have been produced, 6.3 billion metric tons have become plastic waste. The production and disposal of plastic generates excessive amounts of greenhouse gases and hazardous waste, causing a buildup of toxic chemicals in oceans and the air, which then leads to health issues and harmful impacts on Earth's natural ecosystems. To help us talk through how we got to this point and what actions consumers, companies, and governments can take to halt and reverse these impacts, I'm joined by Anne Beddorf, who works at Colgate-Palmolive as a sustainability manager within the global design and packaging group. Anne and I met through Columbia University's Women and Sustainability Mentorship Program, and she brings a wealth of experience through her work with brands, retailers, packaging suppliers, governments, and nonprofits. Anne, thank you so much for joining us. So I think to start us off, it's important to clarify some of the nuances around different terms. For our listeners, could you clarify the difference between an item being biodegradable, compostable, or recyclable? Thank you for that question. It is a key question and one that is very confusing because the concepts are similar and they've been perhaps misused by some in the past. So those three terms are really referring to end of use. What happens? What should we do with this product or package? So recyclable, you would think that would be pretty straightforward. The technical ability to be reprocessed into a new product or package is the simplest way to think about that. Some of the nonprofits, collaboratives, regulators, and others we work with have more specific definition of recyclable layered onto that. Is it practically recyclable? Something might be technically recyclable, but is it actually something that gets collected and reprocessed, what we say, at scale? And that's important to have something reach a scale for actual recycling rates. Then there's biodegradable slash compostable. Biodegradable is really meant for those types of things like an ingredient in a body wash that goes into the water. And clearly you want that to, you know, break down in the liquid type of system or the wastewater. However, it's not really an appropriate term for solid materials, packaging and other products, mainly because there isn't a timeframe associated with it. And the most common way to dispose of something in a landfill is meant to hold materials so that they don't degrade. Because if they do, methane is released, which is a greenhouse gas. So we prefer to focus on an end of life or end of use of compostable, which has a timeframe, which has an industrial compostability requirement, and there's infrastructure around that. It's not widespread, but it is growing. And so when we say, you know, we want something to be able to break down, it's really can something be collected and sent to a compost facility effectively? Otherwise, something like a biodegradable plastic really could be misleading if it ends up in a landfill. Sometimes, like with certain paper products, they could be both recyclable and compostable. And so there's a number of different options that are not mutually exclusive. Everything is ultimately biodegradable. And the truly interesting question is how quickly items are able to biologically degrade and how. So now that we have an idea what these terms mean, let's turn to one of the biggest challenges facing the consumer. I think it's fair to say that recycling is quite onerous on the consumer. There are those consumers who discard a dirty plastic soda bottle in the recycling bin and hope for the best, not realizing the contamination impact that might have on recycling streams. But even for more thoughtful consumers, recycling is challenging. For example, states accept different numbered plastics, and the numbers I'm referring to are found in a triangle at the bottom of the container, which are identification codes for the type of resin used. New York State recycles numbers one, two, four, and five, while New Jersey next door recycles one, two, and five. And then there are so many materials that do not contain a number code. How do we bridge the education gap so that consumers can increase their recycling rates and minimize the amount of contamination in the process? That's a great question. And I think we're reaching a point where, you know, industry is working with government and the nonprofit world to try to get some national harmonization, or at least state level, you know, harmonization. So there is consistency there. And obviously, you know, a consumer, we're all consumers, people have to play a role. And I would say there's two pieces to this. One is avoid wish cycling and do get to know your local list, at least on a top level basis. So I can't tell you how many times I've gone to a sorting facility and seen a bowling ball or a hose, right, or a tangler as they call other tanglers like wires. So clearly, you know, it went in doubt, leave it out. But absolutely, there's so much that can be done, both in terms of how communities communicate to residents, but also on PAC. And those numbers are called resin codes. They were never actually meant to be recycling instructions. They were meant for the reprocessors to have an idea about what resins they're getting into the system. So that's why you've seen a move away from chasing arrows towards triangles to kind of get away from those. And they're not always required. They're only required in certain states for rigids over a certain amount. And so the movement is to, number one, have consistency in what's accepted. Bottles with caps on, containers with lids on, and then other types of things like tubes as communities are able to accept them and as they are more and more designed to be recyclable. So that's, you know, and moving away from the numbers. And that's where I think we'll see a lot of movement in the next few years, both because industry is trying to do this. You know, I know Colgate is very thoughtful when we think about our recycling instructions, but also because we've seen state level legislation requiring it, which is actually a really good thing. So, you know, you can't say a plastic is biodegradable or you can't use the number code. You have to, you know, specify this is a bottle, you know, with the cap on and it's recyclable. So I think we'll see a lot of improvement in that area. And I think the other thing that the localities realize is it's not a one and done. There's a constant education process. And we have to include the on-pack labeling, bin signage, you know, at your local park and then instructions at home and really get to a harmonized system to make it less confusing. But we're still going to need, you know, people to attempt to put things in a bin. We will never, you know, give up that need. And hopefully there can be not only easier instructions, but more and more incentives. And that's one other thing I want to say is there's been a lot of negative press about recycling. Recycling is not going to solve the plastic pollution problem, but it is key to creating a circular economy. It gets materials back in the system. It creates jobs. It saves carbon. And the numbers that you see about low recycling, that's partially because they're global numbers and it includes places in Southeast Asia where, you know, we have less infrastructure, for example. |
Thanks so much. And we're definitely going to jump back into the idea of global plastic waste. But I wanted to just reiterate some of the things you said for the consumers. So number one, get acquainted with the state, local state recycling regulation. I think you said when in doubt, leave it out. And not to focus too much on the numbers, but more, you know, what is actually regulated in that state. I did read that number one, two, and five are usually the most easily recycled plastics. So, you know, and then sort of avoid soft plastics that can jam sorting machines. Would you agree that consumers could look to one, two, and five, or is that maybe not the way to go? Yeah, I would say partially, yes. So ones and twos, it's a PET bottle, like a beverage bottle, and HDPE is a number two. So that's like your laundry detergent bottle. So absolutely, the recycling rates in the US for those hover just under 30%. Industry wants more, you know, that our friends in the beverage industry, you know, they have committed to, you know, get as much of that material back into their beverage bottles. Most companies have 25% post-consumer recycled resin or PCR goals. And so there's a lot of demand for that material right now. And so absolutely with caps on attached so that they can get through the system. Number five is polypropylene and that's used for containers, but also things like deodorant sticks, for example. And that is hovering right on the edge of being considered widely recyclable in the US. It's really fluctuated. But I actually was on a meeting yesterday, it looks like, you know, we're getting close to meeting that minimum of what's considered widespread access to recycling, which is the number five polypropylene. So keep an eye out for that. But more and more communities are going to be either adding back in or adding for the first time polypropylene because of the efforts that are out there to get it back into the system. Thanks. Thank you, Anne. So I think now it will be interesting to switch to industry. And I was wondering, you know, what are some of the best practices you see that are being undertaken to reduce the amount of waste being sent to landfills and increase the amount that gets recycled and reused? Yeah, my first thought, and this relates to the previous question as well, is the use of the How to Recycle label. So that's a US-Canada labeling system that's meant to bring clarity to recycling, not just what can be recycled, but the how, literally how number two recycle. And it includes things like the replacing the cap. An interesting thing is pumps. Some pumps are recyclable because they don't have a metal spring. Others are not. And so for example, the label might, for the how to recycle might say empty. So emptying the bottle is important. You don't need it to be squeaky clean, actually, but empty and replace pump or empty and discard pump, right, depending on how that pump is designed. So I think it's, that's a really good best practice, something to keep an eye on and look for, even though sometimes the writing is very small, there are good instructions there, you know, which labels need to be removed. Most don't, but some of the full body shrink sleeves now have zippers, for example, on them in order to easily remove those labels where they haven't, you know, been able to make them compatible with recycling yet. So I think that's a best practice to be, you know, transparent, using how to recycle label. And in some cases, like some, for example, chip bag, it just says, you know, do not recycle this, there's a chasing arrow with a slash through it. And one other example, I think, refers to the soft or flexible plastics that have a label that says store drop off. So this conflicts with say a number two or a number four, say on a plastic bag, you don't want to put those in your curbside and those resin codes are misleading for that. But if you see the label and it's on, for example, lots of Amazon mailers, it says store drop off. That means don't put it in the curbside, but put it, take it back to your store, your Target, your Walmart, your ShopRite, your Whole Foods, you know, the local stores, even some of the like Home Depot type stores will take those back. And so I think having that type of transparent communication is really one of the best practices that companies and then also hopefully localities can build off of. And then the second is, I think of it as putting it out as a market signal. These goals of, you know, we want to by 2025, which is coming up quick, have, you know, go from, in our case of Colgate, 14%, you know, on average recycled content for plastics to 25%. So we want to say that this material is wanted. Why can't the bottle recycling rate be 90% instead of 30%? You know, let's keep working on, you know, getting additional bins out there and collection opportunities. And we have a membership in an organization that many brands, retailers, governments are part of, and it's called the Recycling Partnership. And what they've been doing is giving grants out to help communities streamline their education, to provide rolling carts so that more material can be collected, and to help get the word out. And again, to make that education consistent. So we just discussed what the role of the consumer is and touched on industry best practices. I'd like to pivot to the role of corporations. According to the Plastic Wastemakers Index, 100 companies are responsible for more than 90% of all global plastic waste. There's a feeling that no matter how well consumers recycle, corporations still produce the overwhelming majority of waste. And without clear regulations, the problem will continue. How do we address that? Yeah, again, I think nothing is one simple answer or a silver bullet, but a multifaceted approach is needed. And I think, you know, the reason that there exists the waste is because there's a product being delivered, right? So there's this idea of product delivery, we still have to deliver products, right? And again, we think about Colgate, bringing good oral health to people is pretty essential. And that's been the focus for so long. And so how do we do that while not only reducing plastic? I think that's part of the answer, but also, you know, creating this circular economy and circular system. So reduction, how do we reduce? So there's material switching. You know, that's one thing we can do. Go to glass, go to aluminum. The challenge there, higher carbon impact usually. So that's always a big trade-off that, you know, companies are considering. Believe it or not, not always embraced by a consumer, you know, to have a switch there. But sometimes it is, and I think more and more so. And then reuse refill system, you know, how can we make those more common? And this is where I think the power of collaboration is just so key, because one company cannot change wholesale wholesale like consumer habits. And so this is the nut we're trying to crack now in, you know, our meetings with the Ellen MacArthur Foundation, you know, the Global Plastics Commitment Signatories, which is most major companies, or the plastics packs that they have started, which includes, like in the US, for example, it's run by WWF and the Recycling Partnership, but there's now, I think, over 20 of them in the world that help bring this to a reality. And reuse refill systems is one of the work streams. Because sometimes there is this gap between what people say they want and then what they're actually actually willing or able to do and reuse refill, it's not always a simple thing. Nobody wants to, you know, bring 20 jars back to the store, I don't think. And so trying to get really innovative. And, you know, maybe it's like, for example, we have the soft soap tab, that is a foaming soap that you put in a refillable aluminum container that has, you know, reusable pump. I think more and more, we're going to see more acceptance of those types of things. And hopefully people realizing this is a little bit of an investment, but in the end, you know, there's a return on that investment for everyone. It's a win, win, win. And so that's, I would say the biggest challenge right now is to think about how can we reuse and refill more and have our retail partners really embrace that. |
Then there's also using recycled content, as I already mentioned. I think that's, again, going to continue to be key. And hopefully we can move all of these things together in parallel. What's been a very interesting transition that I've seen happen, you know, being in this field now for over 20 years is companies are embracing that responsibility of, you know, yes, we make products that we want to be beneficial to people. But we also want to take a leading role in the reclaiming of whatever waste is created in that process. So we've seen now, especially in the U.S., this rise in what's called EPR, our extended producer responsibility types of systems, where there's fees based on the material that, you know, a company puts in in the marketplace and that becomes, you're considered a producer. And then how can, again, we work together with governments to collect that material. And with these EPR systems, we now have it, as of the time of this recording, in four states in the U.S., about half the provinces in Canada. It's much more widespread in Europe. How can we do those and do them right so that they lead to more recycling being put back into the system in a circular way? So I've been really encouraged by the willingness of industry to say, yes, we want to be part of the solution. Here's what we think an optimal system would look like. We would like that material going back into our packaging and products and we're willing to, you know, be the first movers or the first group that takes that material and brings it back. But we also need to better design things so that there aren't, you know, the wrong kinds of labels and adhesives going into the system, which makes the plastic more yellow when you try to make it clear, for example. So it's really also not only, you know, through those fees, systems and working with governments to make a difference, but also being responsible and understanding what the best design choices are in order to enable maximum circularity of really everything, but in particular for plastic. That's really interesting. And I think it's so important to think about sustainability as a holistic system where using recycled plastics might be more beneficial for some industries than others. And I think we've touched on this together, Anne, in the past. It would be interesting to hear from you how you see the EPR system working and maybe a from plastics being used in the textile industry? Yeah, it's very widespread. Most carpets these days are, if you look at them, they are made from some type of synthetic material. And so how do we ensure there's enough material for industries to reuse and recycle? But how do we get as much of it as we can? We'd like to see, you know, our recyclable tube, which is made of mostly HDPE, and I say ours, Colgate's, but many companies are now moving towards that. How do we get it back into our detergent bottles, for example, to keep that circularity? I think one of the challenges is having, so I mentioned those four states, it's Maine, Oregon, Colorado, and now California, all of the systems are different. And that's a real, we would rather not spend time trying to figure out how to report four different ways and build four different systems, which is kind of a false system anyway, because systems don't exist solely within a state. We'd really like to see a national system. We've been saying this for a long time. I think we need that state leadership, you know, to get us going. And I think there's a lot of great ideas and thinking that have gone into developing those systems. I think we need to see how that plays out in the next few years and then widen that to create a national system that also leads to that harmonized education. You know, I know in Europe, a lot of the, what's called the PROs, the producer responsibility organizations, not only take on that role of infrastructure, so collection and sorting and reprocessing, but also connect it to that streamlined, holistic type of education. So that's one thing we're going to keep working towards with our partners. Colgate actually is interesting. We don't have lobbyists, so we really rely on some of our partners in order to best represent, you know, how industry can be part of the solution. So I think that's really interesting. And you sort of answered one of my questions, which was, you know, how do we rethink the entire system to incorporate more circular economy principles and and structurally shift the way we approach production and consumption and um as you've mentioned i think this epr system that exists in maine and oregon california and colorado i think yes might be so a promising way forward. Absolutely. And what's really great is the discussion now, and this isn't true of all four of those states, but it also is taking food waste and compostables into consideration, which is so needed. You know, when you look at waste characterization, both on a local level and nationally, food waste and other compostables, that can be up to a third of what goes into landfills and other waste systems. Now, we need to reduce food waste, right? There's lots of things that are being done by other groups in that area. There's a great group called ReFed. So maybe another topic for another day that are looking at things like changing date labels. So people don't, you know, throw stuff away that isn't really bad, right? It might just be a best by date or something like that. But I know, you know, so they've looked at the reduction, but then when you have the food waste, how can we get that into an effective composting systems? And the EPR really also needs to incentivize or and fund the composting side of the equation so that we like truly have a holistic approach to the waste that's being creative both created both on this the commercial side right so say you know a food company that has waste product from their operations all the way down to that, you know, consumer level of yard waste and food waste, you know, the organics and the other things that can be composted in that system. Would you say that from your industry expertise, you're seeing maybe a shift to work in flexible packaging? Yes, for sure. So there's a couple of things there. I think policy-wise, we're seeing goals and regulations towards both waste diversion and composting. Like Austin, Texas, for example, they have a timeline for getting businesses that generate food waste are going to be required or already are in some cases required to compost and more and more included as the, as the years go by. Right. So it starts with the biggest generators and then, you know, gets slower and slower, smaller and smaller ones to require composting. There's a bit of a challenge there. From a composter's perspective, they're not there to deal with people's waste. They're there to create a beneficial product that helps the soil and goes back into the soil. And so not everything is appropriate to be made compostable. And because of lookalikes as well. So think about like a light green vegetable bag, which is made of polyethylene or produce bag and a light green compostable bag. And how would a consumer know or how would the composter know once they see it in their pile, which is which? So I think we need to take note of the things composters have to deal with, make policy and voluntary agreements so lookalikes are eliminated so that they feel more comfortable taking compostable packaging and then only having things be, you know, designed to be compostable, whether it's a product or a package when it's appropriate and otherwise can't be recycled. So I think we're kind of looking at all of these things in parallel. And there's a lot of interest in the packaging community, but it's a little bit of the chicken or the egg while we kind of wait for policies or agreements to reflect the different ways that are needed in order to, again, appropriately communicate to people, but also to address the problem of lookalikes, which is a big problem. I feel like we could do a whole new episode just on this topic. Absolutely. So I know we started off by introducing the idea of sustainability and progress. In that regard, can we touch on some of the positive impacts and efforts taking place? For example, in the private sector, are you seeing any really exciting innovations? And will that positively impact consumers and as well as the industry? Yeah, I think across the board, there is innovation happening. There is so much focus. So an example might be, you know, typically when you use recycled content, you have to use more of it because it's weaker. |
Hello and welcome to Sustainability in Progress, a podcast focused on exploring the most topical themes in sustainability. In this series, we will be inviting guest speakers and industry experts to discuss the most challenging issues facing our world today. But more importantly, the opportunities to address these challenges and make tangible changes. The sustainability space is constantly evolving, so we've decided to call this podcast Sustainability in Progress, or SIP. There is no one-size-fits-all formula to solve the environmental crisis, implement social justice, and install systems focused on equity. We invite you to join us on the journey where we will explore topics from sustainable food and agriculture, law and policy, economics, to the science at the very heart of our challenges and opportunities. Are you ready for your morning sip? Hi SIP listeners, we are so happy to have you back for another episode. This one is about coffee, so it should go hand in hand with your morning SIPP. Our guests today are really well positioned to discuss this topic, given their incredibly exciting backgrounds. But first, like we always do, guilty pleasures. So Laura, over to you. What's your guilty pleasure for today? So I'll keep this one close to coffee. I bought one of those reusable cups a few years ago, but I have to be honest, I definitely haven't used it enough to make it competitive from a carbon footprint perspective in terms of like comparing it to like the disposable takeout usage that I currently mostly do. But it's just really tricky to remember to bring it with me. So that's my sort of, I don't know if it's a guilty pleasure, but it's definitely an unsustainable thing that I do. What about your unsustainable guilty pleasure? So mine also happens in coffee shops. I tend to grab a lot of those napkins, stack them up inside the car or in my drawer at the office. And the reason why is because I spilled coffee on myself either in my car or all over my keyboard and desk. It happened twice today, but generally over the last several months, it's happened five or six times. So I'll be honest, I need those handy, but I think I might just need to invest in spill proofing my devices and surfaces, get one of those rubber covers for my keyboard. That's, I think, the way forward now at this point. Yeah, I mean, I think that's definitely one of mine, too. My personal solution is just, you know, extra laundry, which I don't think that works too well either from a sustainable standpoint. That's a fair point um so back to the intro so we're going to keep this intro pretty short uh because we have an extra segment which is a bit of a blooper segment today no coffee spills but it does include a coffee taste test between 100 arabica coffee and an alternative coffee that is consisted of 50 alternative uh made out of date pits and andory root, and then 50% Arabica as well in the blend. Laura, I know you already tried it in the past. So what do you think the outcome will look like among our taste testers? So I'm not sure because I previously tasted the 100% alternative. But even that, I thought tasted way better than the real Starbucks coffee. Then again, I'm not a fan of Starbucks coffee, so maybe I'm a little bit of a biased taster. But yeah, it'll be interesting to see what the outcome is. What about you? I completely agree on all the points, especially the part about Starbucks. The 100% alternative I tasted a few months ago, the original product was quite good. I remember that there was a very noticeable chocolate flavor, which I liked. But it seems like this new product formulation has added that 50% Arabica, so not 100% chicory root and date pits. But like with any alternative, we know that exists out there with dairy or meat. I'd have to imagine it's pretty hard for it to taste like a traditional brew, but we'll see once we get the results. But before we get to that, a few definitions we thought we would clarify for our listeners that come out a lot in this episode related to smallholder farmers and shade-grown cultivation. So first off, smallholder farmers are individuals or families who own or manage small plots of land. And they grow crops or raise livestock primarily for their own consumption, though they also sell a portion of their produce often in local markets. And the size of these small farms can vary by region and country, but they're generally characterized by limited resources like capital, labor, and technology And this is particularly relevant to the coffee sector, as most of the coffee is grown on smallholder farms. And there's a huge livelihood impact. And we'll get to that throughout the conversation today. We're also going to talk a lot about shade grown cultivation. And to keep that simple, essentially, that is an agricultural practice where the crops are grown under a canopy of trees or in a partially shaded environment. This is particularly common in the cultivation of coffee, cocoa, and certain types of tea. And it's generally accepted to yield a number of sustainability benefits. Yeah, thanks for that, John. I think we also touched on agroforestry in the episode, which is an integrated land management system that combines trees and shrubs with crops or sometimes livestock. So shade-grown cultivation can also be a type of agroforestry. And this approach aims to create a more diverse, productive, profitable, healthy and sustainable land use system. There are lots of different types of agroforestry, but for the purposes of this coffee episode, we're going to spare you. Something else that comes up in the episode is that our guest Yvette also mentions her work in Chiapas. And for those of you who aren't familiar, that's a place in the southern part of Mexico, which borders with Belize and Guatemala. And speaking of our guests, for today's conversation, as Laura mentioned, we are thrilled to be joined by Dr. Yvette Perfecto and Dr. Amanda Caudill. Both of them are experts in the field of coffee, especially the coffee sector's impact on biodiversity, ecosystems, and the climate. Dr. Perfecto is an interdisciplinary scholar, and she works in agroecology with a focus on the intersection between biodiversity, agriculture, and food sovereignty. Currently, she is conducting research in Mexico and Puerto Rico, and she is a co-author of four books, Breakfast of Biodiversity, Nature's Matrix, Linking Agriculture, Conservation, and Food Sovereignty, Coffee Agroecology, and Ecological Complexity and Agroecology. And second, we have Dr. Mandy Cowdill. Mandy is an ecologist and research scientist who has worked in the coffee industry for over a decade. She's led research studies in coffee growing regions of India, Costa Rica and Mexico. Mandy completed her postdoctoral research with the Bird Friendly Coffee Program at the Smithsonian Institute and taught classes in coffee, agroecology and food systems at Columbia University. She leads the Knowledge Transfer Project, which is a collaboration between the University of Brighton and Falcon Coffees to identify and implement methodologies for measuring and mitigating carbon emissions in the coffee supply chain. And with that, we can meet our guests and jump right in. Good morning, Yvette, and good afternoon, Mandy. Thank you for joining us today. We're thrilled to have you on SIP. You both have such a wealth of experience across the food and agricultural space, so we'd like to kick off with you giving our listeners a bit of your background and how your career began in this area. Yeah, I'll start. My name is Yvette Perfecto. I'm a faculty member at the School for Environment and Sustainability, the University of Michigan. And I teach courses in agriculture and biodiversity conservation primarily. I am Amanda Cuddle. I am the carbon project manager currently at Falcon Coffees in the UK. And I previously taught at Columbia in agroecology and food systems and then did my PhD at the University of Rhode Island in wildlife conservation and coffee. And then did my postdoc with the Smithsonian looking at mammal biodiversity and coffee farms, then also a little bit of pollinator studies. Mandy, it's so good to have you on. And our listeners have probably picked up through our intro, but we're talking about coffee today and all things related to coffee sustainability. But before we get into the really serious questions, we have to ask you both, how many cups of coffee do you consume per day? Mandy, I'll turn it over to you first. I really only have one nice cup of coffee a day, sometimes two. I know a lot of people in the industry will drink coffee all day long, but I really just stick with one or two. Yeah, and I drink about two, maybe three some days, but mostly two cups of coffee a day. Laura, how does that stack up against your consumption? |
And if it's a good day, if it's a bad day, it can be like closer to four. Okay, awesome. I'm sipping on one right now and this will be probably one of three. So we're kind of around the same range, but that's a perfect segue into our first set of real questions. We're going to dive into some of the work that you're currently doing. And Yvette, we'll start with you. We see your broader agroecology expertise, as you mentioned, with your intro, but you've also written quite a few pieces specific to the coffee sector. So what drove that initial interest in researching that specific area, if you can give us some context? Yeah, well, a long time ago, I would say in the early 1980s, I was teaching a course, an ecology, field ecology course in Costa Rica for the Organization of Tropical Studies. And this was the time when a lot of the coffee farms were being transformed in Costa Rica. So I was witnessing this transformation from very diverse coffee farms with a lot of shade trees to coffee monocultures. And as part of the course, we did a little study on comparing basically farms that were intensified. That means farms where the shade had been cut and the density of trees was higher and they were applying more chemicals, agrochemicals, et cetera, with the more traditional, diverse shaded coffee systems. And I have been studying ants for a long time. So we basically did a comparison of the ant species richness or ant diversity between these different farms and found a dramatic reduction of biodiversity. And that led to that little study with a group of students led to basically a career. I'm still working in coffee. I'm still working on biodiversity issues in coffee. But it got initiated at that time in Costa Rica about 40 years ago. Brilliant. Thanks, Yvette. Mandy, how about you? First of all, I just want to say that I've followed your work since the beginning of my career, so just hearing how you got started is amazing. When I first started doing research, I was reading all of your articles, and I did my postdoc with Robert Rice at the Smithsonian that I know you guys worked together as well. Yeah, so it's very cool to hear how you got started with things. For me, I started off also in Costa Rica. I was looking at, I was doing like an informal population count of capuchin monkeys in the rainforest. And then I went to a Spanish school in Oroci, which is one of the coffee growing regions, and noticed that there was such a huge disparity between the wildlife and the type of habitat that I was seeing in the rainforest compared to what I was seeing in the coffee farms. And so then I was interested to understand if we're paying more money for coffee that's certified or that has some sort of biodiversity certification attached to it, so that actually make its way down to the coffee farms and make any sort of difference. And that's where I started looking for a PhD program. And that's when I found the University of Rhode Island and worked with Professor Tom Husband there. But my current role is looking at carbon emissions in coffee farms. So I started asking questions about shade-grown coffee to a lot of the roasters in Brooklyn where I was living and asking them, are they sourcing shade-grown coffee? Do they know where to find it? And not a lot of people did, but one of the coffee shops called Sweetleaf in Brooklyn led me to reach out to Falcon Coffees because they were an importer that they worked with and they knew that they had a lot of data on their coffee farms. So I reached out to Falcon Coffees and was in touch with them for probably a few years before a job opened up, which is a project that I'm working on now. It's a UK government funded project. That's a collaboration between the University of Brighton, which is here in the UK and then Falcon coffees, which is the coffee importer or trader really. And the whole project is to figure out how we measure carbon emissions for coffee production. So how do we do that on the farm level? And it's easier to think about when you're thinking about it as a research project where you're just going into one farm and devoting all of your time and resources to coming up with that method. But one of the main challenges has been when you're working in the industry, how do you come up with a method that works over, I think we source from hundreds of thousands of different farms and 26 different regions or origins. And everybody farms coffee just a little bit differently. So that's been the project that I've been working on. So I think in terms of if you can dive in a little bit further on some of the challenges that you work with on a day-to-day basis, Mandy, beyond GHG emissions, can you frame the issue of nature and biodiversity loss and some of the other adverse impacts stemming from coffee production? Yeah, that's an interesting question. So I actually look at it the other way around. I kind of flip that where I look at the benefit that coffee farming can have on biodiversity and nature because there's, as Yvette was mentioning, you can grow coffee in a monoculture that's technified, that has a lot more agrochemicals and not a lot of resources for habitat and biodiversity. Or you can grow it in rustic shade or in farms that have a lot of different types of shade trees, a lot of different vegetation strata, a lot of different resources and habitat for wildlife. So coffee is grown in the tropics that overlaps with areas of high biodiversity. And it can be that win-win situation where you're conserving biodiversity and growing a crop for economic value. There are definitely adverse effects as well if you're talking about full sun coffee, if you're talking about deforestation. There's also adverse effects if you're looking at land conversion. So if you have a coffee farm and then it's converted to pasture, which has very little habitat value and biodiversity, or what we're seeing in a lot of areas as well is there's pressure for development. So if you're taking that coffee farm and then converting it to houses or residential areas or highways. So I kind of look at it a little bit the other way around where how can we support the producers that are growing coffee in a way that can support biodiversity in nature. Yeah, Mandy, and that's precisely the way I've been looking at coffee for all these years, because it's not just the diversity that is maintained within the coffee farms per se, but also how these landscapes that have shaded coffee contribute to the conservation of biodiversity at the landscape level, no? So sometimes we think that what you're doing in the farm doesn't affect that much the patches of forest that are surrounding the coffee growing regions, but you need to have migration. You need to have movement between those patches of forest, no? For the species, the forest species that cannot live in the coffee farm, for them to be able to sustain in the long term. Because otherwise you're going to have extinctions in those patches. And if you have a very intensive coffee farm or for that matter, something else like soybean plantation or something like that, that restrict the movement of organisms between the patches of forest, no? And eventually those organisms are going to become extinct in the patches of forest. So having an agroecological, diverse, shaded coffee landscape contribute or matrix, let's say, contribute to the real socioeconomic issues at play as well. How is the climate crisis making this sector that is already very subject to price volatility and slim profits worse for farmers, and especially if we're looking 10 to 15 years into the future? What does the industry look like and what can we expect? Yeah, well, obviously climate change is exacerbating a lot of the problems that farmers already have, coffee farmers already have, no? Coffee has a very, very narrow window of temperatures where it performs the best. And so increasing in temperatures is going to affect the yields. Also, you know, changes in precipitation. The region where I work, for example, in Chiapas, has been experiencing a lot of droughts and a lot of variability. It's not just, you know, a particular direction in which climate is changing, but it's a very high variability. So it's very hard for the farmers to be able to plan ahead of time. One important component that I think is important to consider is the way that you produce coffee. When you produce coffee in a monoculture, that coffee plant is more vulnerable to microclimatic conditions. So extremes in microclimate also are going to affect the yield and the performance of the plant. When you have shade, the trees that are above the coffee plants basically buffer those microclimatic conditions. And other studies have shown also that areas that have shaded coffee have lower incidence of landslides when you have hurricanes, for example. |
There are a lot of potential benefits. In addition to that, the farmers benefit as well from a diversity of crops that they can grow within the coffee farms. I work in Puerto Rico as well. And in Puerto Rico, a lot of the farms, the coffee farms are shaded, but a lot of the shade consists of fruit trees and trees that have other values, no other purposes. And so the farmers basically have this kind of economic buffer as well, because they're not only producing coffee. They're not completely dependent on the production of coffee and the volatility of the price of coffee, which is an internationally traded commodity. But they also produce other crops that they can sell locally, and that buffers them as well economically. So Mandy, I think that tees up really nicely for you to answer the same question as well. From your perspective being consumer facing, how do you view the climate crisis as playing a role with farmers and further upstream and profits? I am so glad that Yvette had that question first because she explained it very well. It's a tough one for me because I think that the climate is so unpredictable and what we're seeing are changes in weather patterns. So sometimes there's more intense rainfalls, but sometimes there's more droughts. And my project now is in the northern part of Peru in Haiyan. And we spoke with producers there about a year ago about what they're seeing in terms of the impact of climate change. And we heard from them that there are more pests and diseases than before, that they're seeing new pests that they had never seen in their farms. They have more intense rains, there's more extreme weathers, and they're starting to see shifting in seasons with the timing of the rain. So I think sometimes when we talk about climate change, we're talking about it as something that would happen in the future, but I think that it's important for us to acknowledge that all of this is happening right now. I think there's one other point that I would add to Yvette's about the agroforestry and shade coffee, how that can help with climate change. With the outbreak of pests and diseases, there's been a lot of studies that have shown that if you have habitat for birds, then they're able to provide some pest management for the coffee farms. Like the coffee berry borer, the broca beetle is one example that there was a study that showed that if you have diverse habitat for birds, then you can reduce the infestation by up to like 50% of something astronomical. So there's different attributes of having climate-smart agriculture with coffee as well. Thank you both for that. So, you know, to summarize, there's, you know, extreme changing weather patterns, warming temperatures, which I think we also touched on, but it's been linked to deforestation, particularly in Brazil, because farmers are starting to go to higher elevations to grow their coffee, which is also a big challenge. And on the social side too, one of the statistics that really shocked me when I was starting to research this commodity is how little ends up going back to smallholder farmers. I think it was something like 4 cents per $4 cup of coffee. And to add to those socioeconomic concerns, which we talked about, we're really starting to witness both the risks to its dependencies. So as you mentioned, the weather, less arable land that's available and impacts like deforestation. So we started to talk about this, but I'm wondering if we can dive into it a little bit more. What needs to be done in the short term and longer term to enable sustainable coffee production? And I think, Yvette, you started to mention, you know, farmers are diversifying their crop. A way to basically counteract this vulnerability is for farmers to add more value to their crop by basically forming cooperatives. And this has been shown to be very effective in places like Mexico and Costa Rica as well, where, you know, a single farmer, a single family farmer farm cannot have or is very difficult for them to process the coffee themselves, no? Because there's machinery involved and there's certain investment that they have to make. But if you have a cooperative, then that cooperative can actually buy or purchase the machinery that's required, not only for processing the coffee, but also for roasting the coffee. And now what we're seeing in some places are cooperatives that basically take the coffee from the ground, from the seat, all the way to the coffee cup. Not only do they process their own coffee, they roast their own coffee, they have their own brands, and they even have coffee shops. And so that's where most of the value added is. And so the farmers, and these are small-scale family farmers, the farmers that are in this type of cooperatives, they basically end up acquiring or receiving a much larger percentage of what you pay for your cup of coffee in a coffee shop. So I see that as a way for the farmers to basically counteract this price volatility. And I think that it's important for small-scale coffee farmers to get organized and start forming cooperatives like that. And it's also better for acquiring certification because the certifiers usually don't certify coffee on a single small scale farm. No, you have to be part of a cooperative because they can't go to thousands of visit thousands of coffee farms, no, but they can certify a cooperative with thousands of coffee farmers that belong to that cooperative. So that's, that's, I think in my, in my view, that's one of the main ways that the farmers can turn around, you know, this system that is very unfair if you're on your own, basically trying to survive as a coffee producer. Yeah, that's a great point. That's, you know, the coffee supply chain is long. There's a lot of players in it and everybody takes a little cut. So by the time that you get to the end, the amount that you pay for coffee in a coffee shop doesn't make its way back down to the producer. So having a coffee shop or, you know, having demand for coffee and coffee growing regions is one way that you keep all of that value in the same place. I think one thing too that I think a lot about coming from the type of work that I do is how do we support producers who are already farming coffee in a sustainable way? And then how do we provide incentives for other producers to do the same? And one way that I think that is kind of a value added would be things like I'm doing with the carbon accounting. So providing metrics and assessments to the producers about their farm that they're able to share and they're able to market. So I think that that gives the farmers more data and it gives their practices more visibility. Carbon accounting is one piece of a much bigger picture, but it's something that I think has, it's a common currency that we understand in business and then also on the farms themselves. And I also feel like we're moving away from storytelling a little bit about coffee farms and farmers more to science-based metrics, which as a scientist is really exciting. It's a really cool space to be in right now. And I think that if we're able to provide more quantitative information to the producers, that they're able to show what their farm is doing and have a way to prove what sustainability metrics their farm has and I think that that's powerful for them as well. Thank you both. I have a few quick follow-up questions. So Yvette, you mentioned the concept of cooperatives. Is that synonymous to direct trade or do they work together? Well, it depends on the type of cooperative. There are some cooperatives that only provide the processing of the coffee and then they sell the coffee to a roaster. So they're not the coffee directly that way. Yeah, that's really good to hear and probably something to look out for when you're buying coffee to, if that, you know, gives more support to smallholder farmers. So we talked a little bit about the financial side and the supply chain constraints of the coffee sector. And Mandy, you touched on science-based metrics for the environmental side, which sounds really exciting. And I was curious to know if we're starting to see practices like regenerative agriculture or shade-grown cultivation being linked to higher yields or more secure yields that are less susceptible to risk of disease, for example. Yeah, that's where things get a little tricky. So there is a balance point between the amount of shade and then the impacts on the coffee production, on the coffee yield. So you can't have too much shade or else you're going to decrease your yield. Ideally, if you're looking just for wildlife conservation and for biodiversity, you know you'd have a forest. But we're talking about a working farm that is the source of someone's income. |
There's been more and more talk about regenerative agriculture. I'm a little confused about what it means. I think there's a lot of different definitions out there right now, kind of like sustainability. So I think in the coffee industry, it seems like we're trying to define that a little bit better. But I do think that regenerative agriculture is something we'll see more of. I don't know about the certifications or how we'll recognize what constitutes regenerative ag at the moment, but it is something that more and more people are talking about. Mandy, one quick follow-up for you. You mentioned a few things and just to frame how much effort goes into on the producer side, what is the process to determine what the optimal structure is, how much shade is used in that process, what sort of techniques are used? Is it trial and error or is it a lot of capacity building from suppliers further down that share knowledge upstream working with farms in the area? Like, what does that process typically look like? That is a great question. I think it's pretty complicated. So there's different definitions of agroforestry. So it can be having the shade trees intercropped within the coffee, which to me is ideal. There's also different configurations where you can have something called a live fence, which are trees, shade trees, planted around the perimeter of the coffee. There's plantings in buffer areas, such as near water sources or near forest, as Yvette was mentioning. And there's, you know, coffee is grown in 50, 70 different countries throughout the world. So what that looks like is different in different places. It's different regionally. It's different for different elevations. There's a lot of different variables that go into it. So I think a lot of times it's looking at what's been done before, what works. You want to keep with native species as much as possible. A lot of times people will want to plant fruit trees so you can diversify income or timber trees to diversify income. Inga species are good for nitrogen fixing. So there's a lot of different attributes that you have to look at and research to plan out what your agroforestry system should look like. I hope that answered it somewhat. Yeah, of course. Thank you. Okay. And I will add to that, that the integration of the trees with the coffee, like Mandy was saying, is the ideal because in that way, it contributes more to the conservation of biodiversity and the benefits that are provided by the trees are, you know, like we have been mentioning before, there are many functions, which is always a question that emerged when you're talking about shade coffee and the benefits of shade coffee. And there's a tendency to think that there is a trade-off, a very sharp trade-off, no? The more shade you have, the less yield you have in the coffee farm or the less coffee you can produce. And although there is some negative relationship, I would say based on the studies that we have conducted, mostly in Mexico, but also a review of the literature, what you have is more like a humpshake curve. That is that, you know, at very low levels of shade, you have low yields. At very high levels of shade, you also have low yields. And at intermediate levels of shade, you have, and we're talking about between 40 and 60 percent of shade cover, you have the highest yield. And I should emphasize that this is with small-scale farmers that have very little cash to invest in agrochemicals, no? Because if you are a very large-scale farmer with a lot of capital, you can substitute, you know, the nitrogen that the trees are supplying with synthetic fertilizer, and you can apply pesticides and all that, and you can have very high yields at low levels of shade. But you have to basically invest a lot of money on that. If you're a resource-poor farmer that don't have a lot of capital, or you're conscious about the environment, you don't want to contaminate the environment, et cetera, then at very low shade levels, you actually have lower yields. And so that's what we have found empirically, based on studies that have been conducted in mid-elevation tropical regions. So that's something to consider, that you don't want to have too much shade because then the yields go down dramatically. They can go down dramatically, but you can still have a fair amount of shade and be able to produce a fair amount of coffee. That's one thing. The other thing that I want to mention is that one of the main problems, and this might sound a bit controversial, especially now that people are talking about the negative impact of climate change and the production of coffee worldwide and all that. But basically, one of the main problems that farmers face with regard to coffee is the price of coffee in the international market. The more coffee is out there produced, the more coffee is produced, the lower the price. And so it makes, and this, if you look at coffee production throughout, let's say, a 50, 60 year period, you see these cycles, no? Sometimes the price of coffee is very high because there's not a lot of coffee in the market, it makes more sense to produce worldwide, to produce less coffee in a more sustainable way, rather than have increased production at the maximum and flood the market and then farmers don't get a fair price for their coffee. That's really helpful context. I think it reinforces how delicate that balance is and the tightrope that a lot of smallholder farmers work in order to maintain their livelihoods. So thank you for that context. So we've talked about the challenges. We've touched on some of the changes that need to happen. And as well as solutions, you know, as Yvette mentioned, for smallholder farmers, which make up about 80% of coffee producers, 40 to 60% shade, if you do 40 to 60% shade grown cultivation, that can really give you those higher yields, you know, if you don't have access to things like agrochemicals. So this is also a little bit more of a controversial question. And turning to innovation, in terms of alternative coffees, so if you started to see this trend of, you know, beanless coffee, where they use things like date seeds or chicory root to make the coffee. Do you think that that could have the potential to disrupt the market a little bit like what we've witnessed with alternative dairy? Well, that's a great question. I actually just heard about beanless coffee not that long ago. I have not tried it, but I'm very skeptical. People that drink coffee, well, especially when we're talking about specialty coffees, people care a lot about the taste of the coffee. I doubt very much that these coffees, these so-called coffees, can taste like real coffee. I might be wrong, and I don't know, maybe some of you have tried this coffee and you think it does taste like coffee, but I think that it's going to take a very strong kind of publicity effort to get people convinced to drink a bin less coffee. So I'm not that worried about that right now. But I might be wrong. I don't have a crystal ball. I think I completely agree with you, but I haven't heard about it at all either until you guys mentioned it, Laura and John. I don't know if I understand the purpose, though. I get dairy alternatives because of allergies or dietary restrictions or animal welfare, for example, but that doesn't really apply to coffee. And then as Yvette was saying, like roasting and brewing coffee is such a culinary art with so many different complex taste profiles. I don't know how you'd be able to replicate that by having lab-grown coffee or beanless coffee? So I had the same initial skepticism. I have tried some of the alternative coffees. Well, just one, actually. And I was surprised by the likeness of real coffee. It won't ever compete, in my opinion, with speciality coffee, but i think it does compete with the likes of a starbucks for example um i wasn't able to tell the difference between that and starbucks when i did a blind test taste for it really yeah interesting that's cool and and their premise sort of you know is because you were asking why what's the need for it since you know it's not like cattle that it's so obviously you know has a huge impact on the environment they were sort of taking the angle that they had seen a lot of deforestation happen in South America and that there will be increased population increased demand for coffee. And so they were sort of seeing it as an alternative solution to meet that extra demand. So yeah, it's a big conversation. We could have like an episode just on that because obviously there's so many like social concerns. It's sort of just transition concerns. |
It'll be interesting to see what happens. Yeah, I think there could be a lot of negative impacts on, I mean, if something like that picks up and it displays, let's say, some of the coffee that is being produced, I think it's going to have potentially a negative impact on farmers in the global south. But like you say, I mean, it's a whole area of research, of investigation that needs to be done in terms of the potential negative or positive, although I don't see much on the positive side, but I think, making sure that it's people-centered and farmer-centered and ensuring that the benefits that are shared do touch the upstream smallholder farmers, and in a way, we can transition the sector to be more sustainable without leaving them behind. So with that, what do we need to know when we're at the store, when we're buying coffee grounds, when we're buying our coffees every morning before that morning sip? And yes, I know that's a fully intended pun. How can we all be more sustainable in our coffee consumption? So what can we watch for as those key indicators of responsible and fairly produced coffee? Mandy, we'll start with you. I think the first is to be educated about where your coffee comes from and how it's grown. Support shade-grown coffee. I think we should be asking a lot of questions. You know, asking questions of your barista, if you're in a coffee shop or coffee businesses, they might not have answers for you necessarily, but it will prompt them to seek out those answers. I also want to point out that if you're looking at carbon emissions, that the highest is in import countries with brewing coffee. So I think we also want to look at ourselves when we're talking about sustainability and bring your own cup to the coffee shop. Don't use disposable cups. Compost your grounds. So there's different things that we can do as consumers as well as where we're sourcing our coffee from. Yeah, I agree with that. And also I would add to that Fair fair trade coffee. I think that that's one of the certifications that at least attempt to provide a fair price for the farmers. And it would be easier to find out because those are certified. So you can see that it's fair trade coffee and you can, like Mandy was saying, you know, when you go to your coffee shop, ask the barista where the coffee comes from. Is it certified? Is it shea grown? So that even if they don't know, it will plant that seed of, you know, curiosity on the minds of the barista. I think a lot of them actually know because they're very interested in the whole, you know, in coffee in general. So I think that they can also bring it to their managers. I think that us as consumers have that responsibility, whether it's coffee or anything else that you're eating, that you're buying to consume, no? So I think that it's important to see or try to figure out what are the environmental, social impacts of the products that you're consuming. And coffee is something that you, most of us, drink on a daily basis. And so we have a certain responsibility, you know, to try to make sure that this coffee is produced in a sustainable and in a socially just way as well. So, yeah, I will go first for, you know, fair trade coffee, but also ask a lot of questions to your your barista yeah just to add to what Yvette and Mandy just said fair trade is great from like the um giving back to the smallholder farmers because it sets this uh price level um but there's also a few other certifications like the Rainforest Alliance. So you can look out for that. There's also the Bird Friendly Alliance that I think enforces specific shade grown cultivation practices. So yeah, just looking out for certifications, getting educated, bringing your cup to the coffee shop, as mentioned. I think there's also some companies now piloting that. I think maybe even Starbucks has started doing that. So lots of opportunity. But thank you so much to both of you for being on. It's been a lot of coffee for thought today. Thank you. Thank you both. Thank you. Hi, SIP listeners. As we mentioned earlier in the intro, today we have a blind taste test of real versus alternative coffee. So stay on for a couple more minutes and you'll hear the results. We are here with my co-host, John, his wife, and my boyfriend Javier, and we are... Fiance. Okay. Yes, fiance. As of very recently. We are here to try or taste test some real coffee versus some alternative coffee. And we all told you about how the alternative coffee is made in the episode. So we're gonna just get into it. Yeah. Which one are we trying first? So we're gonna take a sip, both of us, out of one of them. Okay, so I think it's one by one, so... But should we do smells first? Okay, we'll do smells first. Okay. Daisy, you're down to go down to go first yeah okay so eyes closed and i'll hand it to you okay so you can smell that one smells really good it's a little sweet it has like a little darkish finish. Kind of oaky. Just kidding. When in doubt, just call it oaky. It's really good. Can I try it? No, not yet. Okay. Okay. I'll take this. Thank you very much. And then now smell this one. Sorry. Here you go. This smells like the coffee you would smell when you walk into a coffee shop. It smells really good. It's like a pot of coffee. Okay, if you had to give a guess, which one do you think is the real coffee? I think the real coffee is the last one. All right. John, your turn. Okay. I'm just smelling it, right? Yeah. Okay, this is like, it's not as strong a coffee smell, but it is there. And a little bit like, kind of chocolatey, I think. I could be way off. Okay. But it smells a little chocolatey. I'll give you the next one. Here you go. Okay, this actually smells a little bit lighter. The second one smells a little bit lighter. Okay, so if you have to guess. I think I would say the second one is the alternative coffee okay yeah all right javier your turn eyes closed okay just want a coffee for the listeners javier claims to have incredible smell no i don't know we might have to invite Alfie, because... Yeah, I think the first one. Is what? Is their real coffee. Okay. Okay, so my turn. Oh. This is kind of flowery. It's tough. Can I have the first one again? I'm really confusing myself. Okay. Ginger for a palate cleanser? Okay, so I have one in my right hand. Okay, I think the left one is the real one. So the left one is the first the first one this one you smelled okay okay okay so Javier and I got it wrong right yeah I think so yeah yeah I don't know if I got it right you did get it right you both got it right okay I think so okay okay now moving to the to the tasting Daisy you ready? It's really nice. It's a little strong at the end. That's number one. Oh, that has a smoother kind of flavor throughout. I like this one a lot. You like that one more? You like the second one? Yeah. Over the first one? Yeah, and I think this was the alternative one. Alright. So you like the alternative than the original? Yeah. You did pick the alternative. Interesting. Okay. All right. My eyes are closed. This has to be the regular. I think it's a little bit stronger. Hold on. They actually taste quite similar. Can I try the first one again? Here you go. I think this is the real one. The first one that I tried, I think that is the real one. Okay, what's your favorite then? They taste very similar. I think I would prefer the first one. Okay. Okay. This one tastes a little light. And that tastes quite similar. I would say this is the second one is the real. Okay. Which one do you prefer though? It tastes quite similar to be honest. I think there's more light too. Which one did you put more in? We did the same scoops. |
Welcome to On The Wards. It's Chris Elliott here. And today we're talking about patient design thinking with Rebecca James, who's a paediatric rheumatologist. This podcast is produced in collaboration with Avant, who's a proud partner of On The Wards. I'm really excited to tell you about Rebecca today and introduce you to her insights and her way of thinking. Dr Rebecca James is a paediatric rheumatologist and a healthcare improvement fellow at Queensland Children's Hospital. She's going to tell us in her own words about her journey to date, but just so you know, she completed her paediatric training at the Royal Children's Hospital in Melbourne, then moved to the UK for extended fellowships in a bunch of different London hospitals, and later worked as a consultant at St Thomas', and then returned to Australia in 2018 and completed a Healthcare Improvement Fellowship to the Clinical Excellence Queensland in 2021. She has a range of relevant interests for our discussion today, including in healthcare quality and safety, how health services engage with patients and service design and provision, and as well as issues around access to care, access to medications, both at home and globally. Rebecca, it's a real privilege to talk to you about this really important part of medicine and something that we perhaps don't talk as much about in our junior years as we might. Thank you. I want to start with you and then talk a little bit about your work. Oh, sorry, go on. I was just going to say thanks very much for the invitation to be part of the podcast, Chris. Yeah, no, delighted. This is something that I've only learned about in the last few years and I'm really excited to bring this to our audience. So I want to talk a little bit about you and your journey through medicine and then your work and, you know what we really want clinicians to take away and incorporate into their practice now and probably into the future. So you're now a pediatric rheumatologist you obviously trained here and overseas what got you into medicine what was your what were your early years like? It's a really good question actually actually. I was drawn to medicine, I think, because of the human stories. And that is interesting because it ties in so neatly with what I've ended up doing. So I like science, but I don't love science. I'm not a scientist. I don't have a PhD. I like people. I like people's stories. I like the narratives of people's lives and medicine and particularly the type of medicine that I'm in, paediatrics and rheumatology. So chronic illness, children development is such a privileged window into how people's, the longitudinality of people's lives and the rhythms of people's lives and being there with them. So that's what drew me into medicine. And I guess on reflection on your question, that's kind of how my medical career has played out too. I've always been really interested in what happens to healthcare and medicine when there's no cure or there's no, you know, fix, you know, what's the role of medicine? And a little bit that probably ties into what you're talking about, about people's journeys and their experiences. So I think that's fantastic. You know, do you remember being a junior doctor the first three or four years of your training? Has that been suppressed or is that still quite live for you? No, I remember it very vividly. And in fact, I had a really formative experience, I suppose, in that I graduated and very early in my internship, maybe six weeks into my internship, my father was diagnosed with a terminal illness. And I had this parallel experience, I suppose, of cutting my teeth as a doctor and simultaneously for the first time really in my life having to engage with healthcare, not as the patient, but as with somebody that was very dear to me. And that was a really, I think, really profoundly shaped the kind of doctor that I became. But my recollection of those, I interned at the Royal Melbourne and I have these kind of very vivid memories of walking back home in the autumn sort of Easter time after I started my internship in sort of January, February, and the leaves were falling off the trees and being completely knackered and having this real sense of that I was part of the machine now and that I was on the roster. And when I was on the roster, I had to show up for work. And this quite profound burden, I suppose, of responsibility that you really don't have when you're a medical student or when you're pulling beers or, you know, a checkout chick or whatever other job you do in uni. But, of course, with that comes great privilege. And I think one of the things that you learn as you move through medicine and the training gears of medicine is that, yes, the responsibility increases, but also so does the, you kind of put your head above the clouds and you get this whole extra level of privilege and of not just gratitude from patients, but you get the longitudinal follow-up of patients. You get the satisfaction of seeing how the decisions that you make have really positive outcomes on people's lives. You get the affirmation that you know what you're talking about and that you've seen this stuff before. And I guess my field's pretty niche, pediatric rheumatology, and often people have been on a pretty convoluted path by the time they get to me when their kid's lupus or arthritis, whatever. It's very satisfying to be able to say, I know you've seen, you know, six or eight or 10 clinicians before me, but I know what this is and I've seen it a thousand times before and I know how to help you. So I do have that sense of being overwhelmed and exhausted and of being on this vertical learning curve early on in the piece. And certainly the responsibility has increased since then, but I think so has the job satisfaction. I often say to people, trainees, you know, the thing about being a consultant is that your job stops changing every three months and you just get to really learn to be good at your job finally, instead of just constantly being uprooted and placed somewhere else. And, you know, that insight you shared, which we all feel, we somehow get trained to elevate the roster above all other considerations and we become totally subservient to our space on that roster. And so finding stories and narratives and through lines and satisfaction in there is quite difficult sometimes. And there's, of course, satisfaction to be had in a successful procedure or a good conversation. But yes, we're talking now about deeply engaging with families over a long period of time and then what you can learn from them. And so I guess that comes to your role, you know, in this fellowship. So I think Avant has sponsored some of your work and there's some mixed funding. Can you tell us a little bit about how the fellowship came about, what it is, what you do? Yeah, so I had a, I guess to give a little bit of background, I did my PEADS training in Melbourne, went overseas for what I thought would be a 12-month fellowship and ended up staying in London for a number of years and working at several different hospitals and really opening my eyes to the world, opening my eyes to clinical medicine, opening my eyes to just a really bigger pond than I'd ever been part of before. And right from the time I was in Melbourne, I'd had an interest in quality and safety and that the NHS in the UK has quite a machinery, I suppose, around quality and safety. And so that opened my eyes a bit more. And then when I came back to Queensland, or when I moved to Queensland, I worked for a couple of years and then an opportunity arose through Clinical Excellence Queensland, which is kind of Queensland health headquarters, where they sponsor four doctors, four nurses and four allied health every year for a 12-month healthcare improvement fellowship. So essentially it's a master's level study in a whole breadth of change implementation and quality improvement in healthcare. Everything from complexity science to design thinking to human factors to change implementation models, human safety models, a real breadth of literature. And the thing that kind of really stood out to me in that year of immersing myself in learning about quality is that whether you look at healthcare models or industry models or any model of successful change implementation, fundamental is a stakeholder engagement. You've got to talk to the people who are on the front line. You've got to talk to the people that the change impacts on because if you don't, it just doesn't work. And you might have change, but you won't have sustainable change and you won't have successful change. And it was this lightbulb moment that we in healthcare almost never talk to patients about what their experiences are, talk to patients about what they want, what they need, what we're doing well, what we're not doing well. |
And we're really, all of us, we're trying our best. It's not for want of goodwill. It's not for want of effort. It's not for want of energy. But change in healthcare, sustainable and change in healthcare is extremely difficult. And it just seems a no-brainer to me that, of course, if we're not talking to patients about what they want and what they need and what their experiences are, then we're going to be kneecapping ourselves every time. So I became really interested in this idea of how health services talk to patients and consumers and families about their experiences of healthcare. And then we entered this module where we looked at design thinking. And that's particularly taking the academic discipline of design and applying it to healthcare. So these are people who are not healthcare workers at all, not clinicians, but have experience and expertise in design, which is really problem solving, academic problem solving, and learn a bit about that. And then kind of stumbled or evolved or matured this project, which is called the First 100 Days of Juvenile Arthritis, First 100 Days of JIA. And essentially juvenile arthritis is a prototype for any chronic illness or any chronic interaction with health care but what we're looking at is how the early experiences of health care for a child that's diagnosed with a lifelong chronic illness shape their whole of life health outcomes and their whole of life health care narrative really coming back to that idea of narrative and storytelling and how those early words and moments and experiences and touch points with a healthcare system really shape the child's narrative about their own illness, about ability and disability, about empowerment and disempowerment, about confidence and lack of confidence, and also that of their family and what we can do in that real sort of first 100 days of care that has ramifications and reverberations and echoes for the next 80 years, potentially for some of these kids. And so I've been working with the sponsorship of Avant, which has been absolutely formative and incredibly generous and really heartening and affirming of Avant to sponsor a project like this, because fundamentally this is a quality improvement project and Avant do sponsor not just research, but also quality improvement. Myself and an academic designer called Jessica Cheers, who's got expertise in experience design and in co-design, and then a project officer called Sue Pager and I have all been working on this project, talking to families, engaging with them in different ways, workshops, what we call patient probes, which are things that patients have been filling in for us, interviews, of course, all different ways of talking to families and facilitating families feeding back to each other and learning about what matters to them and how we can improve care. And it's not, families have just been so generous and so reasonable and so understanding. And it's been incredibly affirming that this is such an important step for all of us as clinicians, not just, I mean, engagement in healthcare has tended to occur at a very macro level and institutional level that they have patient satisfaction surveys. And occasionally they'll have a consumer advisory group or a consumer representative on a senior committee. But it really has to be happening at the front line between clinicians and patients and the people who really design services and make the change. So it's been great. That is such a great summary of so many ideas. I want to see if we can just pull on a couple of those threads because it's such a rich overview of design thinking and the why and the macro and health systems and families and the experience of doing the work. So thank you for that. I guess the thing that I pull out of that, which is often missed, because, you know, you've used a lot of words and phrases that are not part of our healthcare curriculum and not even part of our daily nomenclature, you know, handover, blood pressures, bloods, whatever, you know, you're talking about design thinking and patient activation and narratives and stuff. And, you know, there's a risk that it's a bit wishy-washy. And I say this as a true believer. And of course it's not. And I wonder what I often say to people is, you know, wouldn't you like to be more confident that your hard-earned time was making a real difference to people? Like, wouldn't that be amazing if when you're working your 16-hour shifts or you're staying back later, you know, that you were really delivering highly effective healthcare? And I guess that's kind of how I think about the whole point of everything you've just said. How does that sit with you? Yeah, I guess that's one of the things that I've learned from the project because it has been fairly innovative. This is not something that there's certainly a movement towards co-design. In fact, hospitals in Australia are mandated to co-design with patients by the national standards. But I guess the things that I would encourage junior doctors to think about is how, well, there's a quote from Maya Angelou, people will forget what you said, people will forget what you did, but they'll never forget how you made them feel. I think that's really true. When you think about any kind of interaction, particularly when you're breaking bad news, but any type of clinical interaction for you, it's probably one of 50 in the day. It's something you've probably done before and it's something that you probably won't remember. But for that particular family, particularly when I'm making a diagnosis of juvenile arthritis, which I've done a thousand times, but for that particular family, it's a really formative moment. And I became really interested in what I say and do in that moment that they remember 10 years down the track, because it's whatever, 45, 50 minute interaction. And what is the two or three or four seconds or words that they remember down the track that have really hit home at an emotional level, these emotional touch points that they have with healthcare? And how can we tweak those things to really impact the patient journey? And I'll give you an example that has really, it's such a simple thing, but it's really changed me as a doctor, and that's the word fail. So in rheumatology, in medicine, we talk all the time about people failing. Kids fail, hearing tests, people fail, whatever kind of test investigation. Failed chemotherapy, failed treatment, failed to attend. Failed to attend, failed to thrive. Failed to comply. In rheumatology we talk about, historically you talk about failing methotrexate or failing a treatment. She failed methotrexate so I put her on Humira, she failed Hum, so I put her on tozolizumab, whatever. And family said to us, telling them that their child has failed a treatment is really dispiriting and quite pejorative as well. Their child didn't fail methotrexate. Methotrexate failed their child. And it's something so simple to take the word fail out of your lexicon, your professional lexicon, which I've now done to the best of my ability, which has cost no money at all. It's taken no time. It's taken no training. And yet that's one of those emotional touch points where the family probably don't remember the 15 side effects of methotrexate that I've talked about, but they do remember me saying that their child failed the treatment. And so these are the kind of really profound emotional touch points that patients have with the healthcare sector that stick in their mind and that shape not just whether they come to appointments, whether they have trust in their healthcare professionals, but also their whole narrative about their own illness, their sense of whether they're disabled or whether they have a disability or not, their sense of whether they're empowered in their illness, whether they have any control over their illness and their health. These are the moments that shapeshift those really long-felt echoes of those early appointments. And so these are the kind of things that we're learning from patients. These low-hanging fruit fruit of stuff that you can do or that I can do as a pediatric rheumatologist, you can do as a pediatrician, that we can do as healthcare providers that really have an impact on healthcare consumers. And you mentioned two of my favorite things, things that improve care that are free and don't require extra training, you know, and to come back to one of your other threads about the system. So I don't think it's unduly cynical to say that any well-intentioned program, if implemented in the wrong way, can be tokenistic or disruptive or fail to achieve its aims. And patient-centered design can be the same way if you just do a whole bunch of like it scales and then move on with your day. But what you found is an insight and then that's so incredibly meaningful and that can be then applied in a context that's so respectful of the healthcare professionals, so our junior doctors or nurses or whoever. |
It's a substitution at a really achievable level that produces a materially better outcome. And to me, I think that's one of the most exciting things about the work that you're doing and the whole field is that this doesn't have to be yet another time sink, mandatory orientation, drain on your resources. And again, not a presenter to us and our colleagues as a way in that we have failed. There's an opportunity to easily improve your practice at no cost to yourself. I mean, and I'd be curious to know, because, you know, if I was, what word do you use instead of fail? Tell me now that methotrexate has been unsuccessful and you're going to have to try a monoclonal antibody. How do you say that now? I guess. To only put you completely on the spot. I'd say that the patient hasn't responded to methotrexate and so we've got to try something else or that the arthritis hasn't responded to methotrexate. And I don't get it right all the time and none of us get it right all the time. But the other thing that patients have told us is that we get it right a hell of a lot. And we didn't receive this barrage of negative feedback. Of course, there's stuff that we can do better. But the beauty of engaging with consumers is that you also, as a clinician, hear about the stuff that you're doing well and you so rarely, I mean, you get occasional cards or perhaps, you know, small gifts or whatever, but you so rarely get really genuine feedback from families and they were so generous to, so enthusiastic to give it and to have a mouthpiece to give feedback, both positive and negative. Yeah, it's been really humbling, actually. You touched on something that I've only learned about recently, positive organisational scholarship in healthcare, which is really focusing on the things we do well and not ignoring the things that we could improve on because that's essential, but to seek out those things we do well and then spread them widely, which is a really alien, in fact, quite uncomfortable concept for a lot of clinicians who are much more used to complaints and sentinel events and so on. But, you know, I think that's what you're sort of talking about is that, you know, when you ask people, they can tell you a dozen things that they really appreciate and that you can implement right away. I think that it feels, it sounds to me like it felt quite vulnerable to you to go to patients and ask them what they thought. I have also had that experience, but done in a safe way, it sounds like it's actually been very enriching and positive. Yeah, deeply positive, much more so than I ever anticipated. I should say one of the things that we've learned is that particularly for doctors engaging with patients, we do, of course, have to be cogent of things like conflict of interest and unintentional but nonetheless present power imbalances. And so it's not as, although it can be simple, it's not as simple necessarily as a doctor asking a patient what they think without any structure perhaps or any psychological safety around that. Because if I'm looking after a kid for the next 16 years and I off the cuff ask a family what they think of the service I provide, it's very difficult for them to provide meaningful feedback. And so there's paths to navigate in that territory. But I do think it's really important that frontline clinicians, that there's an interface between frontline clinicians and patients, families and carers giving feedback to each other. Because fundamentally, even though's strategic policies and you know these really macro decisions that are made at around budget and strategy and organizational direction fundamentally the care is provided the services are designed the services are evolve at the level of the frontline clinician and we are the ones who are the subject matter experts, not just in our area of specialisation, but also in the care that we provide, in the physical environment that we provide it with the limitations, budgetary and otherwise that we have around us. So that there's certainly a symbiosis, I guess, between us learning from patients, patients learning from us, but overall it's been a deeply humbling experience. And I think the power of, we've talked a lot about narrative, but there's a quote from a poet, Muriel Rukama, I think is her name, but she says the universe is made of stories, not atoms. And that has really, I think, nails this idea that human beings are fundamentally storytellers and that we fundamentally, our memories are formed as stories, our interactions happen as stories, the opinions we make of other professionals or otherwise, it's all about stories, our sense of our own abilities and disabilities are stories and narratives. And I think really seeing patients with that lens, that very human lens, rather than a scientific in the classical sense, I guess, physiologic lens, I think is really powerful and important. And if we don't do that as clinicians, then we're really fundamentally overlooking who human beings are more than, you know, a couple of ventricles and an aorta and two kidneys and a bladder. No disrespect to the liver or the lungs. So, Rebecca, you know, for those who don't know, I'm also a paediatrician. So this is two paediatricians waxing lyrical about journeys and narratives. Let's see, let's extend ourselves a little bit and talk directly to our colleagues who are passionate about interventional surgery, intensive care, you know, these much more, these groups that also have highly qualitative components. So we know the connection between mind and body substantially relates to your ability to improve from post-operative complications and so on and so forth. But help me understand someone whose greatest joy in life is learning technical skills, of which medicine is built on technical skills. We're almost rediscovering narrative medicine after 100 years of being distracted by improving, you know, the technical quality of our care. Just help me, let's make it real for those people. Why should patient activation thinking, patient design thinking, you know, is there economic benefits? What has that got to offer those technical spheres? I would say, and you see it much more as a consultant, I think, than as a junior doctor, no matter what field you get into medicine, whether it's neurosurgery or paediatric rheumatology or gastroenterology, whatever it is, you will have a cohort of patients who present with functional and som symptoms and whether that's functional abdominal pain or that's pseudo seizures or that's um widespread whole body pains whatever it is you will see a bunch of patients um who either have functional somatic symptoms or have symptoms that you just can't explain it's not to say that they're necessarily functional somatic, but medicine accounts for, when you're in med school, I think you have this sense that medicine can account for and can deal with and can diagnose the vast majority of patients you see. And then when you're a consultant, you realize there's a whole chunk of them for whom you either don't know the answer or the answer is much more complex than biologic and physiology. And it is, you know, that biopsychosocial functional kind of model. And so you will encounter these patients, you know, whether it's you're a neurosurgeon, you're seeing patients with back pain or you're a gastroenterologist, you're seeing patients with abdominal pain, a gyne, and you're seeing patients with pelvic pain, whatever. You're going to be seeing patients throughout your career for whom you don't know the answer, for whom there is no clear physiologic, biologic answer. And you have to still be able to respond to those patients in a way that is sensitive and helpful and empathetic. And for those patients in particular, I think it's all about the narrative. It's all about the story, taking time to listen to the story, to respond to the story, because not everything in medicine is appendicitis where you chop it out and get rid of it. And to be honest, even some of those patients end up with chronic abdominal pain too. So part of all of our maturing as a consultant is not being able to deal with the easy stuff. It's being able to deal with the complex stuff. And you can't deal with complex human beings by breaking them down into organ systems. You have to see them within their family context, within their social context, within their psychological context. And perhaps we do a bit more of that in paediatrics than some adult specialties. But there is no escaping patients for whom you don't know the answer. And yet, hopefully, you can still help them, even if you can't provide direct physiologic, pathologic explanations of their symptoms. |
Welcome to Key Lime. This is a special down under edition of Key Lime, and it's also a conjoint podcast with the On The Wards podcast, which we highly recommend to you. It's Jason Frank speaking. I'm here in beautiful Sydney in a very small closet-like room, very cozy with two of my MedEd guru colleagues. I'd like to introduce you to Antony Llewellyn first. So Antony, you are the MedEd director of HETI. What is HETI? Thanks, Jason. HETI is the Health Education and Training Institute of New South Wales. So our role is to help all the public health services in New South Wales with their education and training needs. And I look after the MedEd. It's good to be collaborating today with Key Lime from the On the Wards podcast. Fantastic. So this recording today will be used for multiple podcasts, both Key Lime and it's called On the Wards. We're here in Sydney this week in particular for the Hedy conference that they're hosting. So thank you for inviting us down here and allowing us to be part of these meta discussions. And now the paper we're doing today is chosen by my friend, Mary Louise. Do you want to introduce yourself, Mary Louise? Yeah, sure. Hi, Jason. Yes, it's Mary Louise Stokes, and I'm the Director of Education for the Royal Australasian College of Physicians. And we have a responsibility for the training of specialist physicians and pediatricians in Australia and New Zealand. Fantastic. And so what's the scope of your job? What kinds of things do you do on a daily basis? Well, in my role, we're looking at the program design, which is a curriculum and everything that builds around that, the assessment, the teaching and learning that supports it, the accreditation of the settings in which the training occurs, and the delivery of examinations for our trainees. Fantastic. And on your route to becoming a clinician educator, I understand the two of you actually at one point held the same job. Is that right? Over the course of your careers? Yes. Mary Louise was my predecessor at Hedy, although it was called something else in those days. I believe it was called IMET at that time. So, yeah. So, we have a strong tradition at IMET and Hedy of producing great mediators. Great. Fantastic. So, no pressure at all. So, Mary Louise has chosen the first paper we're going to review today. It is a pediatric milestones paper. So this is very much in the vein of competency-based medical education. And if you've listened to our podcast over our past episodes, you know we've touched on this quite a bit. We've talked about milestones. And now we have the first generation of papers coming out that have validity evidence. So take it away, Mary Louise. Thanks, Jason. Yes, the paper I've chosen is called Competent for Unsupervised Practice, Use of Pediatric Residency Training Milestones to Assess Readiness. And this is a paper published in Academic Medicine, and it's from a bunch of authors, Su Ting Lee, Daniel Tancredi, and colleagues. They are all part of the Association of Pediatric Program Directors and part of actually a really coolly named group, the Longitudinal Educational Assessment Research Network, or the LEARN Network. And they have collaborated to produce this paper. So isn't that one of the lessons of being a great researcher, that you have to have great research acronyms? It's like a branding thing or something. Can't get into the New England Journal without a good research brand. That's right. So the reason I chose this paper, it caught my eye, was because in Australia and New Zealand, we are looking to implement competency-based medical education for our specialist training. And articles that talk about the practicalities of implementing this new paradigm in medical education are really attractive. And one of the most important things to think about is what are going to be the rules of progression in competency-based system when you're moving away from the time-based plus sitting an exam to actually incorporating assessment of competence at different stages of training and particularly that graduating transition from when you're no longer a trainee, you're being from a trainee to a consultant. So that's why I was particularly attracted to this paper. I think it's probably useful for, particularly for our Australian audience, a little bit of background. This is a paper from the United States and in the US since July 2013, the Accreditation Council for Graduate Medical Education, or the ACGME, requires evaluation of trainees or residents, as they're called in the US, using educational milestones, and the milestones being observable developmental levels of behaviour, mapped to their six competency domains, which are patient care, medical knowledge, interpersonal and communication skills, practice-based learning and improvement, professionalism, and systems-based practice. The ACGME are then working with the different specialty groups to build their framework for milestones and the progression of milestones through what is typically a three-year postgraduate training program, and that's the case for paediatric training in the US. So the paediatric group define their milestones using a five-level framework recommended by the ACGME, which is influenced by that Dreyfus model of expertise development. And they worked to come up with a continuum of milestones from level one, which is novice, set at the early medical student level, through to level two, advanced beginner, level three, competent, level four, proficient, and level 5, master, which they benchmarked at the seasoned expert practitioner level. So in paediatrics, they span the whole continuum. So the question is, what level or what is the target for achievement at that transition from trainee to independent practice? The ACGME have set a target, but not a requirement, a target of a level four achievement. So the paediatric group said, well, okay, we'll have a look at that and validate it and see will that target level work in our group, in our specialty, given that framework that we've set up that I just described. So what the group did was have a look at the milestones that are described for 21 sub-competencies mapped against those six domains and have a look and see what happens to those across the three years of the training in the participating programs. So essentially the purpose, describe the clinical skills progression during paediatric residency by analysing the distribution of milestone assessments by sub-competency and year of training, which is PGY1, 2 and 3, to determine what would be reasonable milestone expectations at time of graduation. It's a multi-institutional prospective cohort study. 45 of the 199 US paediatric programs participated, covering 2,030 paediatric residents. So they've got a lot of data there to work with. And they did the usual things that you'd expect, you know, look at the sample of programs compared to the non-participating programs and also the residents compared to those residents in the non-participating programs and showed that they were comparable. And they developed a bunch of descriptive statistics which are reported in the paper. I might just stop there. Fantastic. So maybe I'll just pick it up there and start, Anthony, and throw to you. So just by way of context, I think we all know a debt of gratitude to the ACGME and the Dutch who are a few years ahead of most of us in trying to actually implement a CBME program. Many of us have been talking about the principles of CBME and competency-based systems and how we want to move in that direction. Our group's been talking about it for 20 years. These guys have actually moved to a nationwide system where they've tried to ask every discipline to independently define five stages of milestones, as they're called in the U.S. And now we're seeing the first generation of these validity evidence papers. So we're all kind of holding our breath to see what happened. Anthony, what do you think of the sort of context of this kind of paper? Yeah, I think it's a really important paper, and I think it's entirely relevant to our Australian audience, as Mary Louise has said, Jason. For our On The Wards listeners, we are moving to an environment postgraduate where these sort of competency-based medical education programs are going to be more prevalent, even in the intern space. It's going to move away from that time-based experience and form-filling in exercise that most people are used to to learning goals and constant feedback, a little bit less exams. Many of the colleges in Australia have already adopted similar frameworks and are implementing them in their first stage. So get used to it if you're a trainee in Australia. OK. Marie-Louise, do I have any comments about the methodology that you saw that they used? Are you pleased? Do you have any hesitations? |
It was simply, I think, presenting in a descriptive way what the milestone ratings were across PTY 1, 2, and 3. And I think to the goal of their paper, which was to see actually what level do people achieve at the point of graduation. And so I think to that extent that it was fine. Appropriate design. What do you think, Anthony? Are you happy with the design? Yeah, overall I thought the design was great. I mean, they've got an impressive number of centres participating. They've done a lot of work to describe how their study sample replicates the more overarching sample in the States. You know, I too was relieved by the simplicity of statistics. I must say, as a visual learner, I liked the spider graph, which was figure one, which showed the sort of outcomes. I was somewhat distracted by the table that if you stare at it out of focus slightly, you get a 3D elephant popping up at you. But I thought they, in a variety of ways, managed to present their data quite eloquently and make it accessible. So we're about to transition to the results. I think the things that you've highlighted already, I would also endorse for positivities. This is that first generation getting it out in the literature so all of us can improve and build on it. These guys did a very large multi-site design, which in medical education, we need to do more good on them for making a nice clear paper. Now, I'm going to hold back my concerns about the validity of the evidence until after the results. So I'm going to throw to you then, Mary Louise. Tell us what happened. The key outcomes. What they found that was actually fewer than 21% of residents achieved a 4, which is the proficient level, or higher in all 21 sub-competencies, remembering that the ACGME have set a target of 4. So there is already a point of discussion. What they did find was that most residents, about 79%, achieved a three or higher in all 21 sub-competencies. So the three being set at the competent level in the paediatric framework. They also found that overall the study group of residents combined progressed in their milestone ratings across the three years of training, which is reassuring. It's certainly consistent with what you would expect, but it is nice to see that progression from the data as opposed to what you observe day to day, to see it combined in that way. Interestingly, they found that variation in milestone rating was greater at the beginning of training in PGY1 than in PGY3, and that was in fact one of their hypotheses, that people enter a program with variable skills and background, but when the training takes effect by the time they get to PGY3, that variability reduces. That was a finding. Another finding was that there appeared to be some sub-competencies that were harder to achieve, the Level 4 in, and the one was quality improvement seemed to be harder to achieve. And there's probably good reasons for that, that it may be difficult for residents to demonstrate their competence in that area as opposed to the patient care professionalism domains. I agree with Marie-Louise. Jason, the results weren't really that unsurprising. I wasn't surprised that going into the program there was more variability and less at the end. I guess that would suggest that in this training program learning is social, that the trainees are not just learning according to the program but learning from each other and calibrating against each other. I wasn't quite clear from the results about dropouts and trainees being held back, but I understand that's quite rare in the States in programs that you get held back in this program. So both from a contextual point of view as an Australian reader, it would have been helpful to sort of have an explanation around that. The most interesting finding for me was that the top 25% in any cohort were on a par with the bottom 5% in the year above. And again, that kind of replicates what we see in the real world. I guess the concern is, are they setting a standard and then people are moving towards the standard? Are they holding people back here? And it was a concern that they were suggesting the results showed that setting the target of four was a little bit unachievable in this program. And they were leaving the next phase of medical training a problem, which is transitioning people from trainee to independent practitioner. I'll just add a few comments into the context of these results. First of all, I want to declare a couple of things. One is the ACGME folks are not only people that I have a great deal of medical education respect for, but they're also friends of mine. So a shout out to the ACGME leadership. So this is Zara Combo and Stan Hamstra and Ingrid Filibertson. And so this is, you know, definitely a PEDS paper, but the ACGME folks are the ones that set this in motion. They're, like I say, they're collaborators and friends. I do have some concerns about how much us as a medical education community can take from this first generation of papers. The other thing I'll say is very positive up front. This is a giant relief. You know, we just designed a system over the last five years, and now we've just peeked under the hood at the data, and thank goodness it has face validity. Wow, fantastic. Everybody doesn't achieve level five immediately, and people do have stepwise progress. It actually is a positive that there seems to be less variability near the end. It suggests perhaps that this is a great way of promoting constructivism, learner-centeredness. People don't all travel in straight lines. Some people take a little longer and then they catch up at the end. That's fantastic. However, here's a couple of my concerns. This has the potential for workup bias. So if you take that sort of concept from clinical epidemiology and diagnostic medicine, this concept of I a priori define something that looks like my outcome. And so when the, in the ACGME process, as I understand it from my colleagues, when they asked the each American board to define the milestones, they coached them to anchor it more or less like what you'd see in a good PGY1, PGY2, PGY3, and so on. So they were written so that the anchors for these ACGME milestone scales are really reflective of people's experience with PGY year. So the fact that the results show a growth across PGY years is on one hand, thank goodness, and on the other hand, yeah, because that's what we designed it to do. So that just makes us hesitate because the whole goal of this stage of the Milestones Project, as I understand it, is to move away from this norm reference, purely time-based stuff, present with a pulse, and move towards kind of a criterion reference. Did you meet the criteria to be labeled at this level? So I think we're making progress, and I do think the world owes a debt of gratitude for this first generation of paper, but I think all of us need to be a little bit critical about what is actually in the data. To go further a little bit, there's no standardized assessments across these programs, as I understand it. There's quite a bit of variability about how they're completed, and these decisions about what level someone is at, what milestone they've achieved in each domain, those are made by competence committees based on the data available. So you have to be careful about garbage in, garbage out, a bit of social desirability bias and workup bias. All of us in all of our programs around the world need to be conscious of that. I do think this is progress, so good on them. But I'm not sure this is all the way that we want it to go for CBME, those of us involved in the movement. I don't know if you both agree, Mary Louise and Anthony. Yeah, I agree. There's some ways they could have strengthened the results, perhaps if they had collected some data from the individual programs about the type of information they looked at when making this decision and were able to demonstrate there was a multitude of different data sources that might have provided a bit more validity for the outcome. And I guess, yeah, there is a danger. I mean, as I understand it, one of the ideas of competency-based medicine is to allow people that are able to accelerate a bit faster to do that. So we have to be careful that if we set criteria based on time still, that there really isn't competency-based outcome. That's still about experience. So there's, you know, as I understand it, the five level is really about mastery. And it's suggesting that you need to have had a lot of experience, i.e. time doing the job before you can meet that criteria. |
Welcome to On The Wards, it's James Edwards here today. We're talking about some common emergency medicine orthopaedic presentations and we'd like to welcome back Dr to welcome back Dr. Nick Maluga. Welcome back, Nick. Thank you very much. Nick is currently an orthopaedic registrar working in Sydney and we've gone through a big trauma orthopaedic and now we want to touch on some of the probably the more common presentations that junior doctors will see. And we'll start with one that nearly anyone who's done more than a day in emergency medicine would have seen. A 64 year old female presents to the med department with a deformed left wrist following a fall. You rightly suspect a fracture, maybe a bit of numbness when the triage nurse spoke to them. What are your initial thoughts and concerns when you see this patient? Look, this is a bread and butter presentation for both the emergency junior and the orthopedic registrar. So with the history of numbness and tingling in the first three fingers, which are the thumb, index finger and the middle finger, my concerns would be whether the fracture is compromising the nerve or the median nerve specifically as it's the most common cause but also it's not unusual to develop acute carpal tunnel syndrome in this kind of presentations and you know for bonus points and this is so further elucidated with an x-ray is whether the patients got the deformity not because of the fracture but rather because of the dislocation so scaffolding that dislocation can potentially appear as a fractured wrist and also give you the median nerve compromise from the lunate pressing on the median nerve. Okay, you described your initial concerns about median nerve involvement. What are the key features on history exam you're taking somebody who presents with a presumed distal radius fracture? Yeah, of course. So I guess it's a combination from history, imaging, and examination. You try to identify the, sorry, elucidate the mechanism of injury, and that will give you an idea of the energies involved. So a simple fall unlikely to result in a scapholina dislocation but a fall from a motorbike might. X-ray very early on it will give you a lot of information and guide your management from that point onwards also. It will allow you to target your examinations but a thorough neurovascular examination will help you identify the level at which there might be a compromise. Ensuring that there's blood supply to the distal hand is very important. Radial pulse, ulnar pulse, capillary refill of the fingers are essential, cannot be missed. Sometimes it can be difficult because of the swelling or because of the surrounding bruising, but do take your time. Failing that, apply a pulse oximeter to the finger. If you can get a good, steady reading, then your hand's probably well perfused. And neurologically wise, whether the palm's affected from the palmar cutaneous branch, that will suggest a higher involvement of the median nerve, or whether it's the fingers that are more affected, or both, that will give you an idea at which level the nerve might be compromised. Are there other nerves involved? You know, the superficial radial nerve in the first web space? Is there a ulnar nerve in the other two fingers? So, whether it's an isolated injury or not. And do you test motor function as well? How would you do that? I know it's a little difficult when they've got a pain in the wrist. Correct. So sensation is probably your easiest go-to. Water function can be useful but very difficult to elicit sometimes, particularly in the paediatric population. But movement of fingers, you know, with the median nerve, you're looking for pinch grips. so opposition of the thumb to any other fingers. And regarding you go to order an x-ray if you're not sure whether it's a wrist fracture or probably a scaphoid fracture does that influence what sort of x-ray you order? Absolutely so they're completely different views so for if you're concerned for a wrist fracture, you ask for a wrist X-ray. But the scaphoid views are very specific. They require wrist to be positioned at a totally different angle. So if you're concerned or want to rule out or rule in, depending on your findings, scaphoid injury, then you have to ask for a scaphoid view as well. So in regard to imaging, sometimes we get asked to order a CT scan after a plain x-ray. Correct, yes. What are the indications for ordering a CT scan? In the wrist, generally, it's anything that's comminuted. There's a lot of very small bones in the wrist and comminution further makes it harder to evaluate the extent of the damage. X-ray is a two-dimensional representation of a three-dimensional structure. You get a lot of shadow and a lot of overlaying. So reducing the break is a first stage to try to realign the fragments and then further ordering a CT after that to evaluate the extent of the damage to the joint and also to see if there's any other fractures that you suspect might be there but not visible on the x-ray such as an undisplaced scaphoid waist fracture might be, well, usually are extremely helpful. They guide your treatment long term as they can predict the likelihood of the closed reduction being successful or not. They also help the surgical team to determine which equipment might require to be ordered. Every hospital will carry a standard distal radius plate, but in a very comminuted fracture, you may require fragment specific plates, which not everyone will carry and may need to be ordered in. What other injuries are often missed after a fall onto an outstretched hand? So, we've described a couple of them. Scaphoid disassociationation is very commonly missed as the wrist can appear normal in both clinically and on an x-ray. And it requires a very keen eye to notice that the lunate is not quite sitting where it's supposed to be. Or the rest of the carpus is not sitting where it's supposed to be. But also the scaphoid fractures, which we touched on previously. Anything that's proximal to the fracture, elbow injuries, shoulder injuries, clavicle injuries, are very commonly missed for several reasons. One, they're rare. And two, they are so far away from the site of injury that any discomfort there can be attributed to the mechanism of injury in the first place. So don't get sort of blindsided by the second fracture. When do fractures need to be reduced urgently within the immersive department or when is it more appropriate to get the fracture reduced within an operating theatre? So pediatric fractures involving growth plates should always be done in operating theatre with the use of the I.I. Remanipulation of those fractures confers a poorer outcome and you want to ensure a perfect reduction for those and the use of I.I. allows you to do that. All other fractures and dislocations should at least at the first attempt be performed in the emergency department for the reasons we previously touched based on it improves pain, reduces the damage to the surrounding tissues and allows you to formulate a plan, gives you time to formulate a further plan. That's pretty much it. It's part of reducing fractures and dislocations as part of emergency management. What are the essential elements of doing a good wrist plaster? Good question. Very hard to explain in a podcast. It's more of an experience-based kind of procedure. And the more you do, the better you're going to get at them. But there are a couple of points which can be highlighted. The best way to plaster a wrist is to either use a dorsal and volar slabs, like a sandwich plaster, or use a gutter slab. Whichever one you prefer is really up to you. And it depends on the amount of available hands. But plaster needs to be approximately allow the elbow to flex without pinching at the crease. Otherwise you get pressure areas and people get stiff joints because they don't move their elbow because of the pain. Distally you don't want to plaster past the palmar crease. Palmar crease is where the metacarpophalangeal joints articulate, and anything distal to that will reduce the movement in the fingers and reduce the function of the hand. Same as cutting out a segment of the plaster to allow for free thumb movement. Especially in an elderly patient who's likely to have a degree of arthritis, immobilizing the thumb can potentially lead to significant complications down the track with stiffness and arthrodesis of that very osteoarthritic joint. And so potentially they can get more comorbidity from a poorly applied plaster than they can from an injury in the first place. And how many kind of layers of the plaster of Paris on either side? Also difficult to quantify. Minimum of eight layers. But big arms and legs require more layers. Little arms and legs require less layers. |
If the hand is going purple, probably wrapped too tight. Molding is very important. It's probably the most skill-based part of the plaster application, knowing where and how to mold, but also the one that makes the biggest difference long-term in terms of outcomes. So essentially, you want to mold in the direction opposite to fracture disposition. So if the fracture is going dorsal, you want to mold volar. If it's going volar, you want to mold dorsal. Essentially the plaster is there to prevent the displacement of the fracture back to where it wants to be. And where it wants to be is where it was before you reduced it. This patient's going home with a, they had a successful treatment of their wrist fracture. They were being referred home, either from the med department or from the ward. Do they require a referral for bone mineral density testing given they're 64 years old? So according to Medicare, no. So if she was 70 years old, then she would get an automatic referral for a bone mineral density scan. So anyone over 70 with a fracture gets a referral for DEXA scan. Now up until then, you have to have a certain amount of clinical suspicion. So somebody who comes in with recurrent fractures or from simple injuries, falling, knocking yourself on the corner of a table. Somebody who's got conditions which can lead to severe bone loss early, such as early menopause. Severe and prolonged vitamin D deficiency from institutilized patients. Overactive thyroid, hypoactive pituitary, they all can cause washing out of calcium, so to speak. it's a good idea to to refer those patients for DEXA scans. We might move on to another case. This is another common one an 80 year old female has been referred to the emergency department from a hostel with some hip pain following eye witness fall and x-ray shows a subcapital neck or femur fracture. Can you describe some of the emergency department management of hip fractures? Absolutely. Thousands of these patients present to emergency departments every year. Knowing how to manage these is very important. Luckily, most hospitals will have a NOF protocol in place. It's come down from NICE guidelines, which have come out of England a good four or five years ago now, but it's all very strategized. So every patient, apart from their usual history and neurovascular assessment and assessment of other comorbidities, trying to elucidate the cause for the fall, will receive an x-ray of the affected area. Blood tests, full blood count, UCs, CMPs, co-ex, liver function tests, and group and hold as a baseline. ECG and chest x-ray, fascia iliac block for pain management, and a catheter with urinalysis. So this has a two-prong approach. One, it prepares the patient for surgery and ensures that they are comfortable, but also allows you to investigate for most common causes of the falls in the elderly, such as undiagnosed urinary tract infection, arrhythmia, or pneumonia. And how early should they be operated on with someone with a neck or femur fracture? So according to the NICE guidelines, all the nicothemal fractures should be operated within the first 24 hours. That has been shown to have the best outcomes unless there is a condition that is preventing surgery that can be optimized, such as severe pneumonia. What other teams need to be involved in the management of an older patient with a fracture? It's a common presentation. Sounds straightforward enough, but actually requires quite a significant multidisciplinary approach, starting from the emergency physicians who see the patient and carrying on to the surgeons, the anaesthetists, the geriatric team, and then all the allied health staff that are involved in rehabilitation requires a lot of input from many different specialties. There's been a specialty that's essentially been developed around these kind of elderly patient presentations, and they're known as orthogeriatrics. And they specifically work with elderly patients who get admitted into hospital with orthopedic injuries, predominantly neck or femur fractures, but not exclusively so. And they are particularly useful in managing and optimizing these patients before the surgery as they know what can be improved and what can't be in the setting of this patient going to surgery. So they know what's going to happen. They know the stress this patient's going to go through. And they potentially can preempt some of the complications down the track, whether transfusing early or optimizing their electrolytes, that sort of stuff. When is a hip fracture considered pathological and how would that change your management? Well, neck or femur fractures in elderly are just an indication of overall decline. So musculoskeletal system is just another system that's failing. A lot of them will have other comorbidities, whether they're cardiac or respiratory or renal, which are the most common ones. But any patient's got a past history of osteoporosis. Osteoporotic fractures are, in definition, pathological fractures. Any patient's got a past history of cancer is suspected to have a pathological fracture until proven otherwise. And any patient that's got an evident lesion in the neck or femur will have a pathological fracture, which will require slightly different approach to the management of this patient. And this will usually involve getting additional scans, and also the fixation will alter a little bit in preparation for potential ongoing management of that lesion. Having said that, normally know, normally a subcapillair neck or femur fracture would be managed with hemiarthroplasty, whether it's cemented or press-fit would kind of depend on surgeon preference, equipment that's available, and patient bone quality. However, if you're suspecting a pathological fracture, one, you must send samples from during the surgery to try to elucidate what kind of cancer it is. And two, every time you do a cemented replacement. This is because there's likelihood that this patient will receive radiotherapy and then you will need to have the bone implant interface which is cemented as it can, the radiotherapy affects healing. And how about things like DVT prophylaxis, which is something that most June doctors will need to decide for someone who's got a neck and femur fracture. What's your suggestions? Look, there's a lot of debate in the literature about what's optimal. However, the easiest way to go about it and to think about preoperative and postoperative DVT prophylaxis. And the most common medications which are used and which you see are aspirin, you see claxane or low molecular weight heparin, and oral anticoagulants such as factor Xa inhibitors and the warfarin, which are more commonly used in the community. Now, preoperatively, you want to try to give patients something that's reversible in preparation for something that acts short-term and reversible in preparation for going for surgery. So, Clexane or low molecular weight heparin are probably the best options. Postoperatively, well, you very much should be guided by the decision of the department. However, something that's easy for the patient to take as well, that will improve compliance, is advisable. So in my facility, we use Rivaroxaban, which has been, as in the hospital, anticoagulant when the patient is minimally mobile, and on discharge when the patient is more mobile, we switch them over to aspirin, as they've been shown to have slightly less complications. Okay, well thank you. That's case number two. One more case to go. No worries. Let's get cracking. Now you've moved down to the paediatric area. Seven year old boy has been to some monkey bars and fell onto his left forearm. He's got now a swollen and painful elbow. Able to move it a bit, but it doesn't look right. Just give me some tips on examination of children with possible elbow fractures or maybe a dislocation? Well, this is a classic history. I think the monkey bars were invented by orthopaedic surgeons. Kids require an entirely different approach. Additionally, you're not only managing the child, you're also managing the parents. So a lot of it is play-based, joke-based with the child, but very informative with the parent and explaining what you're doing, why, where are we going from that. You've got the distressed child, the distressed parent. It's a very charged environment, and so being able to manage the environment is very important. If you can make the child happy, you can generally make the parent happy. So creating the environment, setting up the examination room is very important. But when you're going to examine the child, essentially you're trying to achieve the same things you would with an adult. You want to try to identify the area of injury, try to identify if there's been any additional injury such as neurovascular injury, and also try to formulate your investigatory plan, your differential diagnosis and your investigatory plan. |
Welcome to On The Wallwards, it's James Edwards and today we're going to be talking about something that I know very little about, although I think I've seen many of these patients, and it is medically unexplained symptoms, or MUPS. And we have back Dr. Joanne Ferguson. Dr. Ferguson is a psychiatrist and addiction medicine specialist at Corning Community Health. She's previously spoken to all listeners on the wards on depression and psychosis. And today, we're going to talk about MUPS or MUS. Tell me, tell me a bit about this, Joanne, because it is something that I'm unsure about. So what is medically unexplained symptoms and how common are they? It will actually be quite a common experience in general medical practice for a patient to have medically unexplained symptoms. It will be a common experience on the wards and also when people are in practice. It can be quite frustrating as a doctor and can also lead to significant conflict between the patient and the doctor. Some people in general are more somatic. They're more physical in their expressions of distress and they tend perhaps to present psychological syndromes or general distress in a physical manner. And a classic example is abdominal pain in children, which is a common scenario in emergency departments. Some people are more fearful or anxious about normal bodily functions and don't quite know where a normal function and the level of discomfort associated with that might sit and they might interpret it more seriously than other people might. Sometimes people who are more stressed at a particular time in their lives become more focused on physical symptoms, whereas normally they'd be able to cope without bringing them to a doctor. But on the wards, so as junior doctors, you will come across patients with medically unexplained physical symptoms, which are defined as symptoms for which the treating physician or other health care providers have found no medical cause or whose cause remains contested. There's usually some functional impact from the symptoms, and this can be quite severe. This has caused someone to come looking for help, and so it's had some impact on their life. It's quite common and more common in some areas of medicine than others. It occurs in all subspecialties and including surgery. Particularly say for example areas of high distress presentations in ED, for example chest pain. Sometimes there are symptoms that can't be accounted for despite a clear diagnosis, so symptoms perhaps are in excess of expected symptoms. And this can also be quite distressing for the patient, quite difficult to explain. So it's estimated that about 15% to 30% of all primary care consultations are for medically unexplained symptoms. There was a large Canadian community survey, a bit old now, but it revealed that the most common medically unexplained symptoms are musculoskeletal pain, ear, nose and throat symptoms, abdominal pain and gastrointestinal symptoms, fatigue and dizziness. The term MUPS, medically unexplained physical symptoms, can also be used to describe syndromes where the etiology is sometimes still contested, including chronic fatigue syndrome, fibromyalgia and multiple chemical sensitivity syndromes. There are some associated psychiatric syndromes which are different but have some similarities. A common one is called conversion disorder which involves primarily symptoms of altered voluntary or sensory function inconsistent with recognised neurological or medical syndromes. So this is quite different. People are presenting symptom profiles which are inconsistent with known syndromes. And there's an illness anxiety disorder, which is different. This is a preoccupation with having or acquiring an illness where there may or may not actually be somatic symptoms. And this is quite a different illness to, say, having medically unexplained symptoms. What are some of the etiology or underlying risk factors for developing medically unexplained physical symptoms? This is a bit contested I suspect that little is known about the mechanisms that cause MUPS and it's important to approach this carefully. The symptoms that brought the patient to the doctor are real, even when the cause is not known. And no cause may be found. There are many illnesses where the diagnosis may be delayed. Multiple sclerosis, the time from first symptom to diagnosis can be years. Even in psychiatry, the first symptoms may have an onset years before the syndrome-defining symptoms emerge. It's not uncommon in schizophrenia for early symptoms to be five to ten years before the primary positive psychotic symptoms emerge. Bipolar disorder, the time from first symptom to diagnosis, is often seen as five years. The discovery of helicobacter pylori associated with gastric pain and peptic ulcers revolutionised our approach to upper gastric pain, even though no cause is actually found still for the majority of gastric pain. And I'm sure everybody can think of examples in their own practice where there's been a significant delay between the patient's presenting symptoms and being able to put a definitive diagnosis on it. Often researchers focus in their area of interest, of course, and so immunologists tend to emphasise that side of the syndrome. Some psychiatrists have emphasised the psychological sort of factors. But it's important to remember that anxiety, unhappy, dysphoric mood and distress are common when patients have physical symptoms, whether they have physical symptoms for which there's a diagnosis or they have medically unexplained symptoms. So you'd expect that a lot of people with medically unexplained symptoms might actually also have some anxiety and or depression. There's been a number of theories put forward over the years and most have assumed a psychological cause and previous theories have emphasised histories of trauma or personality but it's sort of more of a consensus now moving towards seeing a person as having a conceptualisation of their illness experience and expression as an interaction between their background, their culture, their personality, their previous illness experience, their previous experience of treatment. And it occurs in a context in which the person finds themselves at the time. So symptoms that have brought the patient to the doctor are real, even if the cause is not known. And the physical symptoms are associated with adverse psychosocial and functional outcome across culture, irrespective of ideology, explained or unexplained. How does MUPS commonly present? fatigue or muscle ache are harder to specifically ascribe to a cause and can overlap as a symptom with many general medical problems, with general distress or the feeling of being physically overwhelmed and exhausted. This can lead to a lot of conflict between patients and healthcare providers, conflict over diagnosis, illnesses, ascription and treatment. Many patients feel that their concerns are being rejected if there's an implication that the problems are all in their head. And that can be a bit of a challenge because as doctors, we all like to be seen to treat illness. We all like it to get better. And it gives us a strong feeling of meaning and satisfaction and achievement. And we can even get sort of angry at the patient or be dismissive of them. And even to the point that sometimes they're making disparaging remarks. And this can be quite problematic, of course. We may go to a case just to put MUPS into some context. You work as an intern and you're with a registrar in a busy rheumatology clinic. You're asked to see a patient who's presented for review with generalised muscle pain, fatigue and pain sensitivity. What would be your approach to this patient? I guess within the context of being a psychiatrist, but maybe an assistant for that intern who's seeing that patient. Apart from a general comprehensive medical history and examination, including the timeframe on set of symptoms and associated life stresses, you'd have to consider the need to take a comprehensive personal developmental history, a social history, a drug use history, looking for symptoms of psychological distress and defining how significant or severe those symptoms might be. And it would be important to think with the patient about how these symptoms were impacting on the patient's life, what the functional impact and how they'd come to be with you at the time seeking some assistance. So you've mentioned anything else on history and examination you think would be helpful? Apart from those things, I think you've covered it. And what investigations are appropriate in this patient? Well, I suspect the full range of medically appropriate investigations needs to be performed at least once and well documented. Somebody coming to a clinic will have had some investigations done by their GP. It's important to know what they are and what the results were and also the context in which they were taken. Were they taken 18 months ago and so might be quite different now? Were they taken when the person's symptoms were particularly mild or particularly strong and they might be quite different. It's important to actually look comprehensively at the investigations so that you can see where they fit into making a diagnosis for the patient. You go through the history and examination investigations and speak to your registrar and no obvious cause is found for the patient's symptoms. What's your approach now to the management of mucks both in the short and the long term? So yes, as you say, you have to discuss this with your registrar or your consultant and they would help you make a determination about the need for referral to another specialist, a psychiatrist or another specialty for investigation. |
Welcome to On The Ward, it's James Edwards and today we're talking about acute limb ischemia and I have Dr. Shannon Thomas with me. Welcome Shannon. Thanks for having me James. Shannon Thomas is a trained vascular, endovascular and renal transplant surgeon who works at Prince of Wales Hospital in Sydney and today we're going to go through a case of acute limb ischemia with Shannon and I mean acute limb ischemia is a reasonably common vascular emergency that I guess junior doctors may see in the ED or sometimes on the wards. And I will go through a case of a junior doctor covering the vascular ward on a night shift, always fun on a night shift, and been asked to review a patient who's got type 2 diabetes, who's got an infected foot, and they're on some IV tazazine, but the nurses called them due to concerns about the left foot looking a bit blue. What is your, I guess, your initial approach and what kind of questions may you ask over the phone? So, look, this is a common situation and it's intimidating if you haven't had a lot of experience in vascular surgery. Obviously, with the foot being blue, the diagnosis of most concern is that the foot is acutely ischemic and threatened. And the worry is that if you don't do something quickly, that the patient will end up losing their leg. That can be quite intimidating to go into that scenario, especially when it's after hours, and then having to make an assessment and call for senior help. I think there's different types of ischemia. This is one thing you've got to keep in mind when approaching this type of patient. You can have chronic ischemia, and that's where a limb for a long period of time, we usually say greater than two to four weeks, has a lack of blood flow to the foot. And therefore, they will get ulcerationation rather than and they'll get rest pain as well but they won't get acute pain and the limb is certainly not acutely threatened however you can also get acute on chronic ischemia and that's where you have lots of plaques in the arteries that are causing a chronic lack of blood flow into the foot. And then one of those plaques ruptures or a clot forms somewhere in that system and it becomes acute ischemia. And so you get an escalation in the pain or an escalation in the clinical findings. And it can be extremely confusing, even for us as vascular specialists, it can be confusing to work out whether the patient has chronic ischemia or acute on chronic ischemia or whether it's all just acute ischemia. And so there is a couple of things we use to approach this situation and try and clarify just how desperate the situation is. So you will remember the six Ps, and this is what I always think about. Pain, pulselessness, paresthesia, perishingly cold or poikilothermia, paralysis, and pallor. And so we can use those signs to gauge how desperately ischemic the limb is. So when the nurse calls, you want to find out, is there any pain? Why is the patient in hospital? Are they known to have vascular disease? Have they got vascular stents or bypasses in the legs? And what is the surgical plan? Have they had imaging? Are they waiting for imaging? And then you also want to try and work out a timeline for the deterioration. So has the foot been blue since admission or is it something that's been gradual over a couple of weeks? So that's certainly my initial approach. And then you obviously have to go and see the patient and then try and work out which one of the six Ps the patient has. Do they have all of them or just one or two of them and you then need to basically call for for senior help now that the summary of it is that if someone if a patient has got a lack of sensation or a lack of motor movement in that limb or the foot then that is proper acute limb ischemia where the leg is about to die or the arm is about to die. And it's very important when you call the vascular surgeon to, if you see those findings, if you have a lack of sensation or if you notice the patient's got no movement, that you convey that because that will ultimately lead to urgent revascularization and the saving of that limb. So Shannon, in regard to, I guess, the timing, which one of the P's would likely to occur first and which one is, I guess, a later stage? So pulselessness occurs first and then you get the pallor and then you get it being perishingly cold. And obviously the pain tends to come quite quickly as well. But the paralysis and the paresthesias tend to be late signs. You can get a situation, for instance, and not in this clinical situation, but for instance, if someone's got atrial fibrillation and they shoot a clot down into their SFA, they will report some paresthesias initially. But as the collateral circulation opens up, those paresthesias should diminish. So we generally, by the time someone gets to hospital, most patients won't have the parasthesia and the paralysis. If they do, that's a bad sign. And that's when we take someone urgently to theater. And if they've got both, we will, that is, you know, you've got minutes to save that leg or limb. And so we will stop any other operations that are going on, get the patient into theater straight away for urgent revascularization because that limb is about to die. So definitely the focus needs to be on the neurological signs in the vascular examination. Any other kind of hints on examination for the kind of, I guess, a vascular exam for a limb? So looking for scars, I mean, as I think some of the listeners will appreciate, patients who've got vascular disease aren't often the best historians. So when you're examining, looking for scars of, you know, a fem pop wound, groin scars or scars on the thigh. Also looking at the feet to see if there's been any digits that have been amputated before. From a vascular ischemic point of view, you want to look at a Berger's sign elevating the leg. Is the foot cold? Is it warm? Are there pulses? Pulses is a very, very subjective and notoriously unreliable exam in that people can get really stressed if they can't feel pulses because they automatically think that means the leg is acutely ischemic. But you can have a limb where there are no pulses and that doesn't mean the leg is acutely ischemic. And that's very important to keep in mind. So feel for pulses, but don't put too much weight on their presence. Doing an ABI is part of the examination. And that's where you take the systolic blood pressure in the upper limb, and you put a blood pressure cuff around the ankle and you use a Doppler probe to measure the blood pressure in the feet. It's good when it's done in experienced hands. And if people have experience with doing it, then sure, they should do an ABI and that will provide some confidence about what the diagnosis is. But after hours, it can be hard to find a Doppler probe, etc. The other thing that's very important on the examination then is looking for the signs of infection, which in this case scenario, the patient has. And you really want to look at, is there pus in the leg? Is there a fluctuant mass in the foot? Is there erythema that is extending up the ankle, up the leg? Certainly patients with diabetes are relatively immunosuppressed and can develop a florid infection with lymphangitis very quickly and therefore become very unwell. So, you know, certainly if you're being called to see a blue foot, it might actually be that the forefoot is unable to perfuse itself because there is a tense abscess in there that needs to be glanced. So certainly looking for signs of inflammation is important. You mentioned diabetics. Often they also have peripheral neuropathy. Does that make one of the P's, I guess, less reliable in your examination and history? Yes. So it makes the examination or trying to figure out clinically what's going on, even more difficult. Diabetes is now increasingly the leading vascular risk factor that our patients have, especially as smoking becomes less prevalent. And the fortunate thing with diabetes is that you get neuropathy. And so when patients do get vascular disease, they don't get the severe pain. They're sort of protected by the neuropathy. But on the flip side, it makes it a bit of a diagnostic dilemma trying to work out how ischemic the patient is. So you're totally right there, James. So we mentioned some of the red flags in regard to trying to work out this is an acute limb ischemia that is threatening and needs and is hopefully salvageable. |
Okay welcome to On The Wards, it's James Edwards and today we're talking about clinical pathways. These clinical pathways are a bit different to what junior doctors may be used to and we're going to talk about clinical pathways in the community. And I'd like to welcome today Dr Kate George and Kate is a general practitioner at Leichhardt in Sydney and Dr Angus Ritchie who's a staff specialist in nephrology at Concord Hospital. Welcome Kate and Angus. Thank you James. Thank you. So as we we've talked about clinical pathways, I guess it's part of trying to collaborate with general practice and hospitals. Maybe I'll start with you, Angus. What is a clinical pathway? Clinical pathways are a healthcare tool that's really come to vogue in the last couple of years, although they've been around for a long time. In the hospital context, we often think of a clinical pathway as from the point at which the patient enters the hospital, their journey through the hospital. You come with community-acquired pneumonia, you're going to get evidence-based care through that admission to discharge. But what we're talking about today is more broadly, how do we extend that concept to a patient journey from the community in and out of the secondary care system and then back to primary care? Both Kate and I work on a program called Health Pathways Sydney, which is a large clinical pathways project in this area. And it's about generating locally agreed best practice clinical pathways for patients across a range of chronic and acute diseases. These pathways, they're different to guidelines. Guidelines tend to be summaries of evidence, whereas the pathway is the nuts and bolts. How do you assess someone with a particular problem? How do you manage that problem in primary care? What are the indications to refer them on to a secondary care service? And then how do you actually make that referral? Who are the people in the local area that see those conditions? How do they prioritise them? And if you just want advice, who do you call for that advice? How do you access those resources like the clinical nurse consultants and the other members who are parts of the team but a bit harder to get to? That's what a clinical pathway is. I mean, why do we need clinical pathways between secondary and primary care? It's very hard when you're working in a health system where you have different funding bodies, different groups, different employers, and how do you bring everyone together to work as a team to treat a patient? So locally we've got a range of primary care services which are funded by Medicare, not just the general practitioner but some of the nursing services provided in primary care. We've got community health programs, we've got hospital-based specialist programs. How do we bring them all together into a coherent journey for the patient so that the right patient gets to where they need to go at the right time and the right kind of services that they need? So we've got some health pathways in our local area in Sydney. Are there health pathways for those working outside of Sydney? Yeah, it's an idea that's really seems to have been adopted quite widely. We have a local instance of health pathways here. It's one of nine in New South Wales. Most health districts and primary health networks are doing some sort of clinical pathways work. And that's one of 25 sites in Australia and New Zealand, all of whom are sharing this content and trying to refine those pathways over time. It's quite a large community. But even amidst that community, it's still locally relevant. It's always focused on what's happening in your local environment and how do the bits of the puzzle fit together there. Well, maybe, Kate, we can get maybe some of your experience using the clinical pathways and how have you found them of value? Yeah, I've found them really, really helpful, particularly when you come up against something you don't see all the time where either for the junior doctors it's completely unfamiliar or for the more experienced doctors they mightn't have seen it for a while and can't yes uh i'm quite sure what current practice is um being able to go to a pathway check that we've done the appropriate stuff in terms of assessment check that we've gone through or get guidance on the appropriate things to do in management. And then the next part of it, which people absolutely love in practice, is there's very clear information about how to get people to where you want to get them. So phone numbers, names, times of clinics, addresses of clinics, different resources within both the community, non-government sector and within the hospital sector. So, yeah, I think general practice is embracing these sorts of pathways very enthusiastically and very happy to be involved in it. I mean, I think junior doctors would probably see some similarities. They do learn after a number of years how to navigate hospitals and really this is navigating from a general practitioner's things that are sometimes common and sometimes uncommon. You only obviously have any experience to learn how to do those and there's so many hidden rules and ways of doing things you may not get to know until it's actually happening so it's great that they're out there. Have you got an example maybe you can provide to our listeners about where a pathway has been helpful? Yeah, we had a case in our practice which was fairly unusual in our practice demographic where a registrar had done a routine STI check and it came back positive for syphilis. And having not managed syphilis in general practice or indeed anywhere, the registrar looked up the health pathway and had a look at that and worked out what to do. So there was local information, local advice and management details, including contact details for the local public health unit. And what the registrar found particularly valuable was that it was localised. So it had local information. They could ring up the local service, get detailed advice from the specialist as to what to do next, and the patient was seen promptly by their team the following week. So again, as Angus said before, it got the patient with the right information, the right assessment, to the right place in the right time. And it saved a lot of time hunting for that information in all the different places that it might reside. Yeah, and trying to find national guidelines on syphilis management, et cetera. Angus, you've got any examples from, I guess, a hospital perspective? Yes. The one that comes to mind is about heart failure. We have all these wonderful community health programs now where we're trying to deliver more and more care in the community, but we still have a problem about how we link those patients into those programs. So the example was from one of the GPs working on the Health Pathways program. She had a 90-year-old patient who'd been in hospital five times over two months with heart failure, was known to be not very compliant with her medications. She lived on the second floor of a housing commission block, had trouble getting up and down the stairs and a few falls, regularly stopping and starting her medications, she says, according to women's magazines, neighbours, costs involved, and had really poor health literacy and an anxiety disorder. So that really complex milieu in this patient is driving her representations. But despite being in hospital five times, she never got linked into the heart failure program. But the GP, knowing about health pathways, looked up the details and was able to successfully connect that patient to the program. The patient was getting weekly visits at home, had stayed out of hospital for the subsequent two months. So it's about, we have these wonderful programs, but people often don't know about them, don't know how to access them. And we need to make sure that all the people involved in the care of that patient can access that information. And if you can bring that together into one place, it makes it much easier for GPs and any other clinicians in the system to know where to find that information. So maybe I'll ask you, can the junior doctors find this information available now? Certainly for the Health Pathways Sydney program and all the Health Pathways programs, these are web accessible. They're designed primarily for a general practice audience but increasingly we see the educational value and also clinical value for people working inside the health system about how they can better collaborate with primary care. So you don't need passwords to get in? There is at least for our system a username and password but we grant them to anyone clinical who asks for access to the program. That layers there just because this information is not generally available to the public. We publish information around direct phone numbers, say for emergency departments, to really help the clinicians. And we just want to make sure that they don't get misused. Yes, thank you for that, for the message. So when he holds that phone in emergency departments. That said, there's some really good patient information within the pathways which is linked to as resources at the bottom of each pathway. Maybe what are some of the really popular pathways that, you know, general practitioners are using frequently? |
Welcome to On The Wards, it's James Edwards and today we're talking about improving cardiovascular health in remote central Australia through new technologies with Associate Professor Chris Wong. Welcome Chris. This podcast is produced in collaboration with Avant, a proud partner of On The Wards. Chris is an academic cardiologist with a broad clinical and research interest in cardiovascular medicine. Chris was recently awarded a Fulbright scholarship to undertake further study and training in the United States at Harvard University and also at the University of California. He's also currently a cardiologist at the Cardiovascular Centre in Norwood and also an lecturer of physiology in pacing for Waterloo Adelaide Hospital. And we'll get a chance to read Chris's CV, but it is one of the more outstanding CVs I think I've ever read. And I'm so glad that you come and speak to us today. And we're going to really concentrate on, we could talk on so many different things, but I was really interested in about the research project you did. So maybe you can tell us a bit more detail about that research project and how it kind of set up the foundation or helped you progress to where you are today. Thanks, James. And again, thanks for inviting me to be part of this podcast. The research project is more a research theme, so to speak, and it really started when I was based in Alice Springs as a basic physician trainee. So I was fortunate to spend three months in Alice Springs, which is in remote central Australia. And then later returned a few years later where I spent six months as part of my advanced cardiology training at Alice Springs. And so I was fortunate to spend almost a year in this remote part of the country. And if anyone who's had the opportunity to work in these areas, it's an eye-opening and fascinating experience and very different to city medical care. And obviously the disparity in outcomes experienced by a lot of the community there, mostly by the Indigenous community, is quite stark. And it was really when I was there that I started thinking about what I could do to make some small contribution. And at that point in time, I had an interest in atrial fibrillation or AF for short. And doing a little quick PubMed, I realised that no one had ever studied AF in Indigenous Australians before. And so that's where this theme of research started. And the grant was very generous in supporting me. It continues this theme. So I suppose one theme of work has been exploring the burden of AF in Indigenous Australians and how it affects this population and how we can better treat it. A second theme has been looking at various investigations and particularly the new investigations with regards to how we can better detect and investigate cardiovascular disease particularly in a remote community like central australia and and then finally how we can integrate that with city-based care to try and i guess overcome some of the difficulties with Alice Springs being a relatively small centre, obviously, and not necessarily having the benefit of tertiary level care and specialists just around the corner. Okay, so you've outlined some of those themes, which are obviously very important, but also somewhat surprising they haven't been touched on before. Yeah, I guess it just goes to show that despite us thinking we know a lot about medicine, there's still so many questions and areas that are deserving of further exploration. And so it was, you know, quite pleasing to know that, you know, we were the first to study in Indigenous Australians and we confirmed what we thought anecdotally was happening, that Indigenous Australians appear to get AF at a much younger age. They have it much more commonly than non-Indigenous patients. And often they're not receiving basic guideline medical therapy, such as anticoagulation of those who are high risk of stroke. And so I really think, you know, there are areas which are relatively low hanging fruit that we could target to try and improve outcomes in these disadvantaged populations. And so how did you go about finding that? It was surprisingly straightforward, to be honest. Using routine databases, it was actually fairly easy to identify which patients had been already diagnosed with AF in this case. And in some regards, Central Australia is an easy population to study because Alice Springs Hospital is the only secondary centre where everyone received inpatient and outpatient care. And so rather than having databases in many different areas that you have to combine, the databases were relatively centralised in Alice Springs. And so it was possible to be able to calculate a fairly accurate estimate of the burden of disease in this area. Okay. And so what kind of period did you do this over? So we collected data over 10 years to try and increase the numbers of people we had. And that provided sufficient numbers to be able to show these findings. Okay. Were there any people who kind of linked into Alice Springs Hospital? Or were you able to link in with general practices within Alice? Yeah. So it was mostly patients who were managed at Alice Springs Hospital. So I suppose there could be some patients who were managed only in general practices that were missed. And I suppose that's the nature of research and that there are pros and cons to different approaches. But we're fairly confident that most patients who, particularly who were developing AF at a young age, would be referred on for a cardiac opinion at the hospital, and so we think we would probably be capturing most of these patients. So when you say young age, can you give us an example of, I guess, a common, maybe in the city, in Adelaide, versus in the indigenous population, Alice Springs, what I guess the age difference is? Yeah, it's a good question. I mean, I suppose in clinical practice in our label, Sydney, I'd consider someone with AF under 50 would be unusual and young age and would certainly be thinking about familial contributions to that sort of development at a young age. But AF in 30s or 40s in Indigenous individuals in Central Australia were not uncommon at all. And we went one step further to try and investigate why that was occurring. And the strikingly high prevalence of AF risk factors like high blood pressure, diabetes, rheumatic heart disease, obesity, were all contributors to that AF risk. And when we included all that data in a multivariable model, once you adjusted for the very high rates of these comorbidities and AF risk factors, the association between ethnicity and AF became null, which strongly supports that it's the high burden of these other diseases, which is leading to AF developing, which I guess just reinforces the importance of prevention in trying to better treat these conditions, as well as addressing the broader societal and environmental contributors to these risk factors. So how do you see the findings that you found in this study or this research you've done plan to what you're going to do in the future? Yeah, I think it's highlighted that there are definitely areas of low-hanging fruit. And I mentioned the anticoagulation example earlier. For example, we found that a lot of Indigenous patients who are at high stroke risk are not receiving blood thinners. And that's an easy thing that can hopefully be instituted by some form of practice change, whether by electronic decision-making supports or otherwise. But similarly speaking, there were a lot of patients who were at low risk of having strokes. So they had, you know, Chasvast scores of zero who were already getting blood thinners. And so there's, they were also getting exposed to the risk of blood thinners, but not necessarily being at high enough risk to derive any benefit. And so it worked both ways, I think. And the other sort of theme of work, which sort of ties in is that I think and the other sort of theme of work which sort of ties in is that I think better investigation of underlying risk factors may also be helpful and so I did mention things like high blood pressure and diabetes but I think we haven't appreciated in the past that people with AF often have coronary artery disease and that's one other theme of work that I've been able to investigate in Central Australia with support of this grant and so for example basic testing like stress tests and CT coronary angiography haven't been previously validated in Indigenous populations and so another theme of work that we're able to do and show that these tests were just as good in this population. And the so-called warranty period is similar in a sense that one common scenario when facing patients presenting with chest pain over and over again was how long is negative stress test valid for? Just because they had a stress test last year, should we be still worried about that patient? And so it was reassuring to see that the so-called warranty period of these stress tests was just as valid in indigenous populations as well as non-indigenous populations where they were originally validated in. Okay. Okay. So, I mean, it sounds like it's created lots of different, I guess, as most research does, lots of other questions as well as kind of solutions. So it'll be exciting to, I guess, see where that work goes. |
Welcome to On The Wards, it's Dr. Alison Hempinstall and today we're talking about a career in rural and remote medicine with Dr. Rebecca Lettingham. Welcome, Rebecca. Rebecca is a rural generalist at Broome Hospital in Western Australia and also a senior lecturer at the University of Western Australia. Bec, thanks so much for joining me today. This podcast is all about learning about different career types, including careers in primary care and, in particular, rural and remote practice. I'd like to firstly ask you why you decided to become a rural GP. So before I did med school, I was a nurse and I went to Alice Springs in my grad year and then I went out to a remote community called Papunya as a remote area nurse, which I really loved. So I think that experience really made me want to do more of more remote medicine in particular. And then when I was in medicine, I just liked everything. So with a couple of exceptions, I liked every rotation a lot and found it really interesting. And that really kind of lends you to rural generalism, I think, when you find yourself liking everything. So I couldn't really rule any specialties out. And I was left with, apart from surgery, and I was left with the obvious choice, I think, to be rural. I really like being part of a community as well. So the rural and remote part is quite important to me in terms of the other life outside of work. For junior doctors out there who are interested in pursuing a career in primary care, what kind of training did you go through to get to where you are now? I had babies in my junior doctor years, so they were kind of interrupted and a bit of part-time and a bit of cobbling it together, which I think is totally fine in your pre-vocational years to do a bit of everything. And I would encourage a bit of whatever you're interested in, really. It's kind of the time in your life where you're getting paid and you can feel the freedom of being paid. But before you get on a training program, you might as well have a taste of everything, I think. So I did my intern year in rural South Australia and then I came back to Perth. And I then in my residency year did quite a few PGPPP rotations, which are no longer unfortunately a thing, but all the community-based stuff, which I found really useful. So I did some community-based palliative care. I did quite a lot of ED because I think that's in mixed EDs as well, so mixed adult paediatric EDs, and some general practice rotations as well in my pre-vocational years just to get a full kind of taste of everything. And it's probably good to do a fair bit of internal medicine and get some acute skills just so you've got a bit in your armoury. You don't need all of it though because you do work in teams. So I did six months of PEDS and six months of ONG because that was my particular interest. But I think it's a bit of a choose your own adventure when you're going into remote primary care because you can be across everything and that's important, but you can also choose a special interest as well so that you can build a team with people who have different special interests to you. Definitely. Bec, you're in Broome and you've been in Broome for a while. What do you enjoy about your job at the moment? So it's an interesting time to do a podcast on my job because we're in amidst this pandemic, which has just changed life as we know it remarkably. But the things that I really like about my job here is the variety and that no day is the same as another day. I think that when you go rural and remote, you're much more likely to have a few different hats as well. So obviously, clinician is a big part of your hat stand, but you also get involved in policy and advocacy and planning, particularly now with the COVID pandemic, the planning is ramped right up. And I think it's probably different to the city where that's happening removed from the frontline workers. I think in the rural areas, we are really all in it together and you work alongside your specialist colleagues. So, you know, we're all kind of one team. So I count my obstetrician, paediatrician, general surgical, physician colleagues, psychiatry. We all kind of work very closely together to look after our patients, which I really like. And just, you know, the cradle to grave, you can see a brand new baby for a baby check and kind of, you know, be involved in palliative care in the home all in one day, which I really enjoy. Bec, are you based in both the hospital and in the community? Yes. So over the time, I think the other thing about medicine in general, but particularly rural generalism, is that you can move across sectors because the skills are very needed everywhere. And so over time in Broome, I have done private general practice, Aboriginal medical service work, and also DMO work in the hospitals and teaching. So all the sectors, I've got an academic position as well. And so, I've kind of moved fluidly between those depending on the needs of one or the other. So, I've kind of stepped a little bit back from my academic position this year and I've gone more clinical. And unfortunately, currently, I've got a vulnerability. So, I have had to step back from the frontline in the pandemic and I'm now doing again some more kind of management planning, you know, admin type roles and telehealth will be a big part of the future, I think, for all of us. So I'm going to get involved in some of the role out of more telehealth. Definitely, it's a big role already incorporated into the healthcare that we provide here in the Torres Straits. Yep. Bec, you said that at the moment you are involved in the preparation and planning for COVID-19 response with this global pandemic. What are the unique challenges that you see for rural and remote communities in Australia? I think it's really interesting because there's some great challenges that we are facing and they include distance and geography and timely transfer of sick people and also how an infectious disease can really get through a small community quite ferociously. But there's also the upside of that, which is unlike the cities in Australia, I think rural and remote communities in particular have a chance to actually, so the phases, I guess, of the pandemic are prevention, containment, and that's kind of where we're at at the moment, trying to contain, but they could probably prevent. And so some of those really big measures that have been put in place in the Kimberley where I am, remote communities have been closed to travel. And just yesterday, the Kimberley was closed. So we are not letting anyone in without quarantining before they come into the Kimberley. And so I think while there's some very big challenges and it's quite scary to think of what would happen if a community had lots of cases. We also have a natural protection in the geography and the distance. So hopefully we will use that to our great advantage for communities. And I guess the other challenge is that all of the comorbidities and health conditions that make someone more vulnerable to a disease like COVID are very prevalent in the communities. And that's probably the challenge for people working in remote Australia ongoing is to see those chronic diseases lessen over time. Definitely. I think we're not going to be able to fully appreciate the sequelae of this for some time to come, but hopefully we're prepared for what's going to come. Putting the pandemic aside, what do you find is most challenging in your day-to-day job as a rural general practitioner? I think some of the challenges are, again, just like that answer, some of the challenges are also some of the wonderful things. So one of the challenges when you're working in a small community, in a tight-knit community, is that you often know and care about the people that you're treating, not just as their doctor, but as the parent of their children that they teach, or you've got these multiple connections to people. So I think it makes everything quite meaningful, but it also makes it a challenge when you're walking next to somebody and caring for them going through particularly tough times, that you're often connected to them in other ways. So that's one of the challenges. And distance and communications are often a challenge in remote because we're often calling our tertiary colleagues or people in bigger hospitals down south trying to convey the situation to the best of our ability that we're in. And sometimes there's such contextual differences that it's quite difficult for the people to appreciate where we're coming from. It really helps you to hone your communication skills to be in this role. Definitely. |
Yes, definitely. I think that some of the changes that come out of this pandemic will be definitely for the better. There's a lot of unnecessary travel because we're stuck in the 1980s in terms of the way we do things. So I think, you know, if somebody's considering, say, having an operation in a tertiary centre, their first visit should be telehealth because they still get to make the decision if they're going to have the operation and often we're flying them. You know, there's some places in the Kimberley that take three days to get to Perth and they're only going there for the consult to see if they want to go ahead with the intervention. So I think this will prove to the medical fraternity what's possible and I think it will help to break down some of that distance barrier because you know some of the stats and things out of particularly areas like cancer treatment and survival for people in remote areas is terrible and a lot of that is about the decision not to go for treatment because it's too far away from family and I think that's really sad for people to have to make decisions like that. I'm currently actually writing a book, a fictional book, which is something that I've always wanted to do. And the protagonist in the book is a 13-year-old girl and her mum gets breast cancer and it's based in Broome and she has to travel every two weeks for chemotherapy. And I've walked the walk with patients that had to do that and I've understood on an intellectual level how difficult that is. But when I had to write this character and she's a single parent of this child having to go down south every two weeks to get chemotherapy and coming back feeling crook, I realised just how difficult, even to imagine a character doing that and to imagine how her life would work has given me a different level of understanding of how difficult that must be for people. And Broome's got three flights a day, you know, and with some of our communities, it's a whole day to get to even just to Broome. So I'm hoping that some of those distance barriers after the pandemic will be lessened by telehealth. That book sounds so interesting. You're going to have to share with us the link when you have it published. Absolutely. I'm about a third of the way through at the moment. So it's my first attempt at writing a book. So hopefully I will get it published. I think that's what's really fabulous about a lot of primary care doctors and in particular rural journalists is they have these amazing hobbies and interests outside of medicine. Besides writing fictional books or your first attempt at one, what else do you do outside of your clinical work? I think what's very nice in remote practice and with our colleagues, I know you're remote as well, is sometimes I feel like I don't really belong with doctors, but when you get remote, you kind of find your tribe a little bit. And we're all a little bit of a misfit in the traditional medical world. And we find each other out here in the remote areas. Some of the things that I really love to do is really nature, you know, to do with nature. So camping, which is right on our doorstep. We've got the best the best camping in the world. Just hitting the beach and getting involved in community events. So we have a festival here every year called the Shinju Festival, which is a multicultural festival celebrating the multicultural history of Broome. And my children and I have been the legs of Sammy the Dragon that leads the festival a couple of years in a row. you know just getting involved in all that kind of local cultural stuff which is really special we had a an amazing performance about shorebirds and their migration that was giant puppets on the mudflats and the I'm in the adult choir and my children's school choir was in it and these really fantastic local musicians were in it one of my medical students was a professional violinist in her past life and she played violin and we put on this big performance as the tide was coming in. So there was really big time restraints around it because the tide would be here and we had to stick to time and it was phenomenal. So, you know, I think small remote towns often punch above their weight in the arts and it's really nice to be able to get involved in the arts sector as a doctor. Absolutely. For people who haven't been to Broome, Bec, do you mind sharing a little bit about the Indigenous culture and community that is around Broome? Yeah, there's a lot of different communities around Broome. So Broome itself has been a place of people coming and going for a long, long time. So we've got the pearling industry that has kind of Japanese and Indonesian kind of history in that and Singapore. And so there's a Chinese connection in Broome as well. And I think that almost like an island culture, it feels that there's that broom in its history has always welcomed visitors. So there's a lot of feeling of being welcome. I was born in New Zealand. So traditional kind of all the cultural feeling and broom is very similar to that in New Zealand, which is obviously an island nation. And then what's really fascinating, as I said before, I spent some time in Central Australia, which was in my formative years, in my early 20s. And I've now done some work in Fitzroy Crossing, which is much more desert inland culture and more similar to that in the Central Australian communities, which is just very different. It's private, I guess. I can't explain it, but just beautiful, you know, really very traditional. I think Broome is a lot more of a meeting place of all different people. So a lot of joint cultures. So, you know, there's lots of people who speak Indonesian in Broome and lots of people with different Asian backgrounds. So probably similar to Darwin, I think, in that way for people who know Darwin. So it's really hard to pin it down. I think it's got its own unique kind of background and lots of people who are willing to share it. So we have a cultural kind of event called A Taste of Broome, which has a musical picture show of all the history and people who dance and sing and share the history of Broome through music and pictures, which is really beautiful. But I would struggle to capture that in words. I think the best thing for people to do is to come here and check it out for themselves. Absolutely. It actually sounds like a really multicultural place. Yeah. Yeah. Everyone's kind of got multiple stories that have fed into their story, which is a really beautiful thing. Absolutely. Would you, Bec, recommend for people, sorry, medical students and junior doctors to branch out in their early years and try and go on a rural or remote rotation, even if it means that they don't go on to become a primary care doctor or a rural GP? Yeah, I think it's probably one of the, you know, the hospitals in the tertiary centres are becoming more and more subspecialties. So I think that going rural, sorry, that's my lab who's getting a bit old and slightly demented. Going rural is kind of a great way of just that generalist specialists, if that makes sense. So you can do general medicine and general surgery, which is a little bit harder to come by these days in tertiary hospitals. You know, there's a leg orthopedic surgeon and an arm orthopedic surgeon. But if you come rural, you get to kind of look after the whole person in whichever specialty that you want rotations in. So definitely junior doctor years. And I think, you know, the increasing number of medical students is making it harder to come by remote rotations because we've got increasing numbers of students that are coming here for longitudinal placements, which is fabulous. But if you get the opportunity in your medical student years, I wouldn't pass it up, that's for sure. I think that's a very sound advice, Bec. If you could look back and give yourself as a medical student some advice, what would it be? So as I said earlier, I had a baby. I was 39 weeks pregnant with my first baby at graduation and I spent a lot of my medical student years worrying and wondering when the right time to do that was and wondering about how it would affect my progression through training. And, you know, I think we get hung up on the details. And I think as soon as you finish your intern year and you've got general registration, you're a doctor and nobody's going to take that away from you. And I think you should just enjoy the ride. And if we're learning anything from our complete change of life in the last few weeks from the COVID pandemic, it is that actually that planning might be for now. |
Welcome to On The Wards, it's James Edwards and today we're talking about health but not the health of doctors but health of bones and to talk about bone health we have Dr. Curtin Gander. Welcome Curtin. Thank you. Who's an endocrinologist based in Concord here in Sydney. So bone health it's an interesting topic one we haven't discussed before and I think if we go back to a case and this is the case that I probably see infrequently, not infrequently as an ED physician, a 65 year old female has a trip and falls on her wrists and you do an x-ray and it shows that they're minimally displaced, just a radius fracture and you speak to the orthopaedic team and they go yeah that's great just put her in a back slab, we'll see her in a couple of weeks and you think great, the back slab, job's done, I start to see the next patient. But in your opinion, is your job done? Is there something more we could be doing for these patients? Yes, so Andrew, certainly this is a, you know, a really good place to start in terms of addressing bone health in individuals who've sustained a fracture. Of course the first step where we need to determine, the first thing we need to determine would be what are the mechanism, what was the mechanism of the fracture? And if it was a traumatic fracture, you'd probably, you know, you're less likely to investigate them further for underlying causes of poor bone health. However, most people who sustain a wrist fracture do so after a stand from a falling height, which is also known as a minimal trauma or fragility fracture. And fragility fractures imply, by their very mechanism, imply that the patient has poor bone health, which is usually due to osteoporosis. So it does open up a can of worms after that because it's certainly not a matter of only fixing the fracture, but in fact that's the best time in which to evaluate the patient's bone health because it's a sentinel event, patient's in a lot of pain, and otherwise people wouldn't know they have osteoporosis because it's a painless condition. So once they have the fracture, the best time to act is within the first few weeks even, first few days to weeks, in terms of trying to investigate them for osteoporosis, and this will in, hopefully help with adherence to therapy later on if they do require it. So in some ways, we're looking, could they have osteoporosis? I mean, is there a role of screening for osteoporosis more generally within the hospital group of patients, some of those ED patients, or even within the community? Yeah, so the stage at which one would investigate patients for osteoporosis varies with the individual. So if you have a patient, a community dwelling patient who's 65 years of age, such as this lady, who sustains a fracture, usually the ED is probably not the right place to do all the investigations at the time because, you know, you want to meet your four-hour rules, et cetera. Yes, targets. So there wouldn't be time for DEXA scans and further investigation at that time. However, a simple thing to do initially would be just to check their renal function and serum calcium and a vitamin D level. That can be done initially or on follow-up. So we already know that less than 20% of people who sustain a fracture due to minimal trauma are investigated or treated for osteoporosis and therefore any point in time after the initial fracture would be good. Ideally, the patient should come back to something like a fracture liaison service after their fracture, which RPA and Concord both have. And it is during that time, which might be three or four weeks after the fracture, that the investigations can be done. Or as a general practitioner, they would also be in a good position to do the DEXA scan and some blood tests to look for secondary causes for poor bone health. The other group of patients are, for example, hip fracture patients. And those are the people who stay in hospital for a long time. And that's an ideal opportunity to evaluate bone health with DEXA scans. Basic set of blood tests to rule out secondary causes. That includes, you know, UCs, renal function, calcium and phosphate levels, vitamin D level, thyroid function. Those are very easy to do, cheap tests that will tell you which way to go in terms of therapy. Once you have the DEXA scan, you know if someone's had a hip fracture from after a fall from a standing height, that indicates they have significant osteoporosis anyway. And you would probably, there's an argument for even not doing a DEXA scan because then you know you have osteoporosis already and therefore initiation of therapy would be critical at that point. However, one finds that those people with hip fractures tend to have a very low vitamin D. And that then plays into what therapy can you use in hospital. And if the vitamin D is below 50, the risk of hypocalcemia is quite high after therapy, parenteral therapy, such as denosumab or zoledronic acid, the latter of which is a bisphosphonate. So, you know, I would generally recommend that people have their vitamin D tested when they come in. After a hip fracture, if the vitamin D is low, replace the vitamin D. However, that will take at least four weeks for the patient to become vitamin D replete. And once the patient's vitamin D replete, i.e. a vitamin D above 50, they could then undergo the infusion. By then they may be in the rehab ward at which stage they could start treatment for osteoporosis. But one has to remember that the critical point is that once you have a fracture you need that investigation and treatment because you can reduce the risk of further fractures by up to 70%. So, I mean, that was really going, I mean, why do this screening? What are you trying to achieve? Trying to get reduced osteoporosis, get better DEXA scans or reduce fractures. Yes. So, ultimately, the major outcome we're looking at is reducing further fractures, which causes a significant morbidity and mortality. In fact, there have been some studies to indicate a reduction in mortality after treatment with anti-osteoporosis agents. So certainly, there's very good data to support individuals, particularly with hip and vertebral fractures, but also with wrist fractures. And you have to remember that people who have come in with a hip fracture, more than 50% of them warned us that they were going to get the hip fracture by developing a wrist fracture maybe five or ten years prior to that. So, yeah, so that's the point with this patient, where they're 65 and have a hip fracture, that would be the ideal time to intervene. And I guess from a bone health perspective, what kind of features are important on history? And I guess also looking at maybe some risk factors for osteoporosis. Yes. So if you have a patient who you're seeing who's just had their fracture, of course the mechanism, first of all, the questions are targeted at falls on the one hand and osteoporosis on the other. So the first question I often ask is, have you had any other fractures? Have you had it in the last, since you were 50 years of age? And that tends to, if you have had, then your risk of further fractures certainly at least doubles. And any particular fractures that make you worried that they've got osteoporosis? Yeah, the big two are vertebral and or hip fractures. So if you've had a vertebral fracture before, whether it's symptomatic or asymptomatic, that puts you at very high risk, up to five to seven times higher risk of further fractures. And similarly, hip fractures are very high risk ones. So they would ring alarm bells. for risk of falls is have you had any falls in the last 12 months? And, you know, if they've had one or two, that sort of, again, you try and think about what are the causes of that? Are there any sedatives? What's their vision like? What's the balance like? Do they have neuropathy? Are they diabetic? Or, you know, so you'd go down that path in terms of evaluating falls risk factors and preventing them. But in terms of the bone health specifically, things one would ask about are history of hypothyroidism, any malabsorptive disorders such as inflammatory bowel disease, celiac disease, corticosteroid exposure is very important. And then there are also things like rheumatoid arthritis, which is a very major risk factor for osteoporosis. In men, hypogonadism is a risk factor, strong risk factor for osteoporosis. And the questions I would specifically ask in that scenario would be, has your shaving frequency decreased? So has beard growth reduced? |
So sex drive is a very sensitive indicator of low testosterone. So certainly those would be, and in females, menopause age is important. Premature menopause, menopause less than 45 years of age, and a history of oligomenorrhea, that history needs to be listed. Then we have non-modifiable factors, particularly family history of osteoporosis that needs to be inquired about, particularly a paternal or maternal history of hip fractures, and lifestyle risk factors including poor dietary calcium intake, poor sunlight exposure which increases the risk of vitamin D deficiency as well as what the exercise regime is like. So and the final thing that's also very important is to determine whether or not there has been a height loss of more than 2.5 centimeters since they were younger. So if you've had significant height loss of more than 2.5 centimeters, that may be an indication of a vertebral fracture, and therefore a spine x-ray would be warranted. So I guess maybe we'll go to making a diagnosis of osteoporosis. Yes. Can you do it on a blood test or a plain X-ray? The blood tests are not the best way. We can't detect osteoporosis on a blood test. We can mainly look for secondary causes for the blood tests. X-rays can tell you if someone has osteoporosis, depending on the type of fracture. You may see osteopenia on the X-ray itself, but the major, the gold standard for diagnosing osteoporosis is a DEXA scan. And, you know, once one does a DEXA scan, that's like an X-ray that images usually two or three sites in the body, the hip, the spine, and the wrist. Usually we do the lumbar spine and the hips to determine how dense the bone is, and what we get is a T-score. A T-score is a measurement that compares your bone density to someone of the same gender when they were around 20 or 30 years of age. So a young, a matched, a younger person, you're comparing your bone density with a person that is 20 years of age. That just seems unfair. Yeah. It just seems unfair. It is. But if the T-score, by definition, is less than 2.5 standard deviations, that indicates osteoporosis. But a point that I really want to make is that even if you have osteopenia on bone density and you've had a minimal trauma fracture in the past, that still indicates you have osteoporosis. You don't have to have a T-score less than minus 2.5 to make a diagnosis. All you need is a minimal trauma fracture in reality. Okay, so it can be both ways. Yes, yes. And does a DEXA scan, I guess, help predict who will get fractures in the future? Yeah, it has a strong ability to determine fracture risk. And there is a concept that certainly DEXA scanning, the bone density is critical in evaluating fracture risk, and it has a strong predictive capacity to say, oh, you're going to have X percentage chance of developing a fracture in the next 10 years. However, one has to also take into account other risk factors to determine your absolute fracture risk. So in the end, it's not really the bone density that's really important. it's a combination of the bone density, age, whether they've had falls or fractures in the last, you know, couple of years and that will help determine your absolute fracture risk and based on that, that's what you would use to determine whether someone would benefit from therapy. You've outlined a number of blood tests that we could do looking for this second-in-course osteoporosis. Are there any other investigations you think are important? Yeah, there are further blood tests that I do tend to perform in patients with osteoporosis and one of them is a celiac screen which is again, I tend to use the tissue transglutaminase antibodies and an IgA level, and that's often useful as a nice, simple blood test, a screening test to exclude celiac disease. Besides that, one may want to do a PTH, but I generally reserve that for people who have been found to be hypercalcemic. If you're hypercalcemic, then the PTH is very useful to determine the cause. Other investigations include a spine x-ray. And I often do perform that in someone who has had a recent fracture because that will help me to determine what the actual fracture risk is. So if that person has a vertebral fracture as well as the wrist fracture, that puts them at much higher risk of having further fractures. And therefore, I guess the treatment would be more urgent. Maybe we'll go to some of the, I guess, some management strategies for treating osteoporosis. Maybe we'll start on a medication that a lot of people are on, a kind of calcium or vitamin D supplementation. Is that indicated? And is it indicated irrespective of the vitamin D level that you may have already tested? So, yeah, so there's two different components. One is calcium and the other one's vitamin D. The current recommendations for calcium intake in a postmenopausal female is up to 1,300 milligrams of calcium per day. Now, it's preferable to obtain that calcium from the diet rather than supplements. However, most people, so just to illustrate what I mean by that, one serve of dairy is equal to 300 milligrams of calcium. So if you have one serve is like a 250 mil glass of milk or two slices of cheese or a 200 ml tub of yogurt, each of those is one serve, which equals 300 milligrams. So to get to 1,300, you need four serves a day, which most people would not get. And therefore, most people end up having two serves of dairy, that's 600 milligrams, and then you add in a supplement of, say, a calcium carbonate supplement, which usually has 600 milligrams in it, and that would make your, that would mean, if you do stick to that regime, you would then have an adequate dietary calcium intake. That's for someone with osteoporosis. Now, there has been controversy as to how much calcium should be given because there have been conflicting data with regard to cardiovascular events and calcium. And the current approach is for us to supplement up to the 1,300 a day and not any more, and preferably, as I said, through diet rather than supplementation. With regard to vitamin D, and also your question regarding serum levels of calcium and whether that represents adequate intake, there's no correlation between serum calcium and dietary calcium intake because if your dietary calcium intake is zero, your calcium will still be normal. And the reason for that is your PTH rises if you don't have much dietary calcium and the PTH resolves bone and then the calcium leaches out from the bone into the serum, and that in turn normalizes serum calcium, but it's not a reflection of dietary calcium intake. Vitamin D. We recommend a vitamin D of above 50 nanomoles per liter. I prefer in my patients to have a vitamin D closer to 70 or 75 nanomoles per liter amongst those with osteoporosis. And vitamin D levels in the blood are a very good reflection of whether someone has adequate levels or not. And so currently sunlight, of course, converts, helps produce vitamin D in the skin and the current recommended for fair skin people it would be about five or ten minutes, 15% of your body area exposed during a safe time of the day that is before 10 a.m. and after 3 p.m. in the summer months. But, you know, it's often a lot easier to take one or two thousand units of vitamin D to maintain your vitamin D levels, especially in people who don't see a lot of sunlight. So I hope that answers the question. But overall, the role of calcium and vitamin D in fracture prevention, there is limited data that calcium and vitamin D does help reduce the risk of fractures amongst those with osteoporosis, but the data is quite weak and the risk reductions are very, very small. So you're not getting a lot of benefit, but a lot of the trials that have been of bisphosphonates or anti-osteoporosis medications have used calcium and vitamin D in the placebo arm anyway as a sort of a, I guess, standard of care in a way at the time. But we don't really know how strong that effect is, and it seems to be weak in terms of anti-fracture efficacy. So calcium and vitamin D alone are recommended, and it's good because they essentially provide the building blocks and adequate calcium for the skeletal mineralization, but on its own it doesn't seem to be adequate and you need the other specific osteoporosis medications. Tell us about those agents and which ones are commonly used. I guess what are the indications and also maybe some of the side effects. Yeah. |
The indications, I'll talk about PBS more than anything because that's sort of a more practical aspect of it. So if you sustain a minimal trauma fracture, that means you have osteoporosis, and the PBS recognizes that, in that if you've had a minimal trauma fracture, you can get PBS subsidized therapy. It's a matter of the clinician determining what their fracture risk is, and if it's moderate or high, then we tend to initiate the specific therapy to prevent further fractures. So the other PBS indication, there's another two PBS indications for anti-osteoporosis therapy. The second one is if you're 70 or above and have a T-score of minus 2.5 or below on DEXA, then yes, you have PBS subsidy. And the third category, if you're on a long-term supraphysiological dose of corticosteroids like prednisone, 7.5 milligrams or more for more than three months, then you would qualify for osteoporosis pharmacotherapy. So those are the main categories under the PBS. But, you know, there's always sort of leeway there in terms of who would benefit from therapy. So some people may benefit without qualifying under PBS criteria. So the actual medications, I often explain it in a way, there's oral and there's parenteral therapy. So with the oral agents, which have been around for many years now, around 2000 or even earlier, the main category are the bisphosphonates, loxafine, sorry, residronate and alendronate are the main ones available in Australia. So Elendronate's the brand name Fosamax and generally Actonel Residronate. And they are generally given as a weekly dose, so once a week oral medication. That's a bisphosphonate agent. And a bisphosphonate is like two phosphate molecules joined together. And essentially what it does is once you swallow it, a small amount of it gets absorbed into the system, goes to the bone, and coats the bone. The bisphosphonates coat the bone, and then the osteoclasts come along and eat away at the bone, and essentially paralyzes those osteoclasts, so they don't work that well, and therefore you have a reduction in bone resorption, and that's the mechanism by which they work. So there's a relative reduction in bone resorption. There's also a slowing down of bone formation as well, however, but I suppose the resorption is the... If you suppress resorption, to some effect, there's also the slightly more bone formation, and therefore there's some degree of increase in bone mineral density or stabilization of bone mineral density. So those are the bisphosphonate clots. So that's oral bisphosphonates. And then the other form is an IV, intravenous bisphosphonate. The main one that we have available now is zoledronic acid, which is an annual infusion. The next broad class of agents is denosumab, which is a fully human monoclonal antibody against a molecule called rank ligand. Rank ligand is a molecule produced by osteoblasts, the cells that make bone. So generally, Rank Ligand, it's spit out by the osteoblast and it goes onto the osteoclast, the premature osteoclast, and stimulates formation of osteoclasts. And basically, the Rank Ligand inhibitor inhibits that molecule and therefore you inhibit the maturation of the osteoclast. So basically, you wipe out the osteoclast, so you don't get bone resorption anymore. So that's a six-monthly injection, denosumab, rank ligand inhibitor, which is another very good therapeutic option. And then, of course, there's weaker anti-osteoporosis agents, including the selective estrogen receptor modulators, which an example of that is raloxifene. And that's in the same class of drugs as the medication used in breast cancer, which is tamoxifen, and hormone replacement therapy. But that's generally reserved for the younger people, females in their 50s and 60s. Of course, then we've got another agent, which is teriparatide, which is a PTH analog. And teriparatide is the only anabolic agent available on the market. All the other agents stop bone resorption, but this agent stimulates bone formation and that does have very specific indications under the PBS because it's quite expensive. You have to have had anti-resorptive therapy for at least 12 months prior to the initiation of teriparatide and you have had at least two fractures in the past. If you've had two fractures, you've had past at least 12 months of antiresorptive therapy with a bisphosphonate or a prolia, and you have to have a T-score of minus three or below, then you can qualify for 18 months of teriparatide, which is a daily subcutaneous injection. Now, which one do you choose for which patient? These days, I tend to use the parenteral agents over the oral agents. The oral agents tend to give the main side effect is nausea and gastroesophageal reflux. And we find that adherence after 12 months is quite poor, down to 50%. Persistence with therapy after 12 months with the orals. So they don't really, they're not really that effective because, due to those reasons. So we tend to use the IV zoledronic acid, which is a yearly infusion. And the other one is the six-month injection, which is the denosumab injections. Those are the two main agents. The zoledronic acid, the main side effect is that 20% of people can get flu-like symptoms from it, which lasts for a few days. But that's probably the most severe reaction that you'd get with zoledronic acid. And you have to be cautious amongst those with renal impairment. One of the side effects of bisphosphonate therapy is osteonecrosis of the jaw. Yes. Is that common, and how would it typically present? Osteonecrosis of the jaw, I tend to... It's a very rare complication associated with bisphosphonate or anti-resorptive therapy, including the rank ligand inhibitor denosumab. Now, the incidence rate is quoted as between 1 in 10,000 to 1 in 100,000 person years, which is a very, very low rate. And I guess, and it's a long-term side effect. The longer you're on a bisphosphonate, the higher the risk of this event happening. But generally, even if after 10 years, in a patient at high risk of an osteoporotic fracture, the risk of an osteoporotic fracture far outweighs the risk of osteonecrosis of the jaw. Now, osteonecrosis of the jaw is a condition in which basically you have, if for example you had a tooth extracted, generally you find that the gum heals over within six weeks over the extraction site. However, with osteonecrosis of the jaw, people tend to get pain at the socket and the gum doesn't heal over the bone. And that's referred to as osteoporosis of the jaw. And it's a painful condition that's difficult to treat. So of course, you'd want to prevent it. And on a practical level, I tend to recommend if anyone has any sign of dental cavities or painful teeth, then I would say before we start therapy, let's just go in to see the dentist. If you need extractions or any dental work, have that done first and then come back. Once it's all healed up, we can start it. Okay. Maybe just follow up with the last couple of questions. Just in follow-up, I presume you don't want every patient with osteoporosis to come to your clinics. Where should they be followed up? In hospitals, in the community? Is it something most general practitioners are comfortable managing? Yeah, so in terms of follow-up, I think that most people who have... I think it's often useful to have initial specialist input at the initiation of therapy, and then follow-up can generally be done very well through the general practitioners. And for example, if I saw this 65-year-old lady with a wrist fracture, she had clear osteoporotic lumbar spine T-scores, for example. We start her on a denosumab, for instance. The next point at which this patient would probably continue on the denosumab every six months with their GP who would administer it. And I would generally recommend in the first year, I would check the bone density because there'd been a change in the therapy just to see if the bone density is improving. |
Okay, welcome to On The Wards, it's James Edwards and I'm speaking to Dr. Ed Aberdeer, a haematology registrar at RPA and Concord Hospital, in part three of our session on anal coagulation. Welcome, Ed. Thank you. We've spoken about warfarin, we've spoken about the heparins. Now I want to speak about the NOACs or DOACs. What is a NOAC or a DOAC? So the accepted term these days is DOACs, so direct oral anticoagulant. So they're all oral medications that have a direct inhibitory effect somewhere upon the coagulation cascade. So in what circumstance or situation do you think JMOs may come across these and what are the common ones I probably see? So the common indications currently in Australia are for atrial fibrillation, for venothromboembolism, which includes DVT and PE, and for DVT prophylaxis post-orthopedic surgery. And I think more and more people come across them as they become a more important role and people have more familiarity and use them more often in the setting of thrombotic disease. The three currently listed on the PBS in Australia are, there's two factor 10a inhibitors and that's apixaban and rivaroxaban and there's one direct thrombin inhibitor and that's dabigatran. Apixaban and rivaroxaban and dabigatran, all three of them are licensed for use in atrial fibrillation as well as use in DBT prophylaxis post-orthopedic surgery while rivaroxaban is the only one that's licensed to use in venothromboembolic disease. And maybe can you compare and contrast the three different agents? Yeah. They are generally, I guess, a fairly easy way to think of it. They're all fairly similar in their clinical use and their contraindications, but there's some subtle differences. So in terms of mechanism, dabigatran inhibits as a direct thrombin inhibitor, inhibiting factor 2, while rivaroxaban and apixaban are inhibitors of factor 10. They all are impaired and can accumulate with renal function, which is probably the most important thing to understand, and they're all contraindicated with an EGFR of less than 30. And they will all have longer half-lives with less EGFR. Their half-lives vary differently, but generally, and especially vary depending upon renal function, but those with normal renal function, encompassing all of them is about 8 to 15 hours as a standard half-life. Apixaban and Dabigatran are administered twice a day for therapeutic anticoagulation, so for atrial fibrillation treatment, while Rivaroxaban is administered initially twice a day for venothrombomboic anticoagulation, but then it becomes once daily and is once daily for an AF treatment. So the administrations are slightly different in that effect. Aside from renal impairment, there are certain inhibitors. The inhibitors of the glycoprotein system will affect the bigotrin and to a lesser extent the other two. And rivaroxaban and pixaban can be affected by inhibitors of the glycoprotein system, but also the cytochrome B450 system and the common medications that do that are azole antifungals can increase the relative dosing of those two. And I guess what's the advantages of these agents over Warfarin? Yes, so the advantages are that they do not need stringent monitoring like Warfarin does, in fact, in all the trial evidence presented that there is no monitoring required, so no monitoring is generally done with these agents, that they, since they are effective relatively immediately and have short half-lives, they work at a quicker onset than warfarin, and when you discontinue them, their effect is discontinued quicker than warfarin would be when you ceased it. The advantage of the heparin family is that they are an oral administration. We talked about warfarin at some time reading bridging therapy. Do you need bridging therapy with the new ones? So if you're taking a direct oral anticoagulant at a therapeutic dose, you need no other anticoagulation on board at that time. Okay so fantastic for things like outpatient management of atrial fibrillation and maybe in the future more people with pulmonary emboli going home on oral medication. I think so certainly. One of the concerns has been about the kind of new direct oral anticoagulations is what happens if a patient bleeds. We know how to manage warfarin, we know how to manage heparin, but this is a group that I know within the emergency department we are concerned that they could be bleeding on one of these agents. So this is, it is harder than heparin and warfarin. It's harder because there's no readily available reversal agents and it's harder because it's hard to judge the amount of anticoagulation a person has on board at any one time. So to assess how much anticoagulation a patient has on board, to assess the degree in a kind of rigorous quantitative manner is impossible, so not like warfarin where you get an INR result or heparin where you get an APTT result you can perform some tests that will tell you whether they are likely to have any form or significant amount of anticoagulation or if they're unlikely to have that so dabigatran promotes the thrombin time sorry the thrombin clotting time and the APTT. And the APTT is a common test that we have available. So patients on Dabigatran who have an elevation of APTT, you'd be confident in saying there is likely to be some effect. Though what that effect is, it's hard to judge, but it's likely they have some form of anticoagulation. In terms of rivaroxaban, rivaroxaban increases the prothrombin time of the PT, so any patient who has a prolonged PT there, you're likely to say that there is some form of anticoagulation on board. Apixaban is more difficult and needs a modified anti-10A level to determine with any reasonable sensitivity whether you have any of the drug available. So it is more difficult to monitor. But tests that our lab has available and most other metropolitan hospitals will have access to are specific drug levels. And the specific drug levels, again, don't correlate well with the amount of anticoagulation you have. But if they have an undetectable drug level or below the thresholds provided, then you are more confident in saying they do not have a significant anticoagulation effect on board. So we'll often look at those things to determine whether we think they may or may not have a significant anticoagulation effect. In terms of reversal, aside from experimental agents which are in trials now specifically to reverse them, of all the standard agents we use for other medications, including warfarin and heparin, including blood products, there are no great trials in reversing them. All the data comes from animal studies or healthy volunteers. And if a patient has a life-threatening bleed on any of these medications, you have to take your standard steps. Any patient with a life-threatening bleed, try to control the source, resuscitate as required, volume replace, correct other possible coagulopathies caused by the bleeding, consumption of platelets, etc. But there are some therapies such as prothrombin X or prothrombin concentrate activated factor 7A or FEBO, which is a factor 8 inhibitor bypass bypassing agent, that have been studied and may have some effect, and those can be used in a life-threatening bleeding consultation with a hematologist. I think for a junior doctor, ring for help. Yeah, safe bet. Having a significant bleed, I'd ring for help early. Yeah, good, perfect. Okay, is there any other take-home messages in regard to the new emerging field of doax yeah so doax um work much better if things are planned ahead so planned procedures planned surgeries you have to keep in mind when do i have to stop them um and when we're happy to restart them so it's much better to think of these things ahead of time because if you come to the day of the surgery and it's not been stopped, it's very hard to determine then how long you have to stop it for. It will disrupt all the plans. So if you know you have a procedure coming up which you're concerned that anticoagulation may not be appropriate at the same time and you have a patient on a DOAC, discuss it with the proceduralist, get their views. And if it does require stopping, then there's many local guidelines about when to stop them, and it depends upon the type of DOAC and the patient's renal function and if they're elderly or not, about how many days to be stopped beforehand. |
Okay, welcome to On The Wards, it's James Edwards and today we're talking about a sore ear and we have the pleasure of having Dr. Joel Hardman. Welcome Joel. Thank you. Joel is currently in TSMO here at Royal Prince Edward Hospital. We're going to be talking about the sore ear in general but especially trying to work out is it otitis media, is it otitis externa and trying to work out I guess some simple tips in regard to history examination also treatment. So maybe we just start as a pretty brief overview. I mean, what are some of the causes of a sore ear, Joel? Well, there are many things that can cause a sore ear. I think the important thing is to differentiate exactly where it's coming from. So breaking it down into sort of anatomical structures, looking at the external ear, or whether it's within the external canal or within the middle ear itself. It's also important to remember that you can have local causes that give you pain as well as the ear can represent a manifestation of a systemic process and it can also be secondary otalgia so you can get pain from other structures in the head and neck, and so it's important to consider these as well. We commonly hear terms otitis media and otitis externa. Can you kind of define those and give them more detail about what they actually mean? Yeah, so otitis media is basically infection or inflammation of the middle ear. So we define that as acute onset of symptoms with pain and on examination there is a bulging or erythematous tympanic membrane. For otitis externa, that's infection of the external ear canal. And again, that's usually acute, so it's defined as pain with an inflamed or erythematous skin of the external canal. Now I think generally most junior doctors will see people with painful ears predominantly in the emergency department rather than the ward. So we'll start with a case from the emergency department. It's a 50-year-old female who walks in, two days history of worsening right ear pain. What is your general approach to a scenario such as this? I think a fairly sort of standard approach, taking a good history and examination. But as I was mentioning before, it's important to identify exactly where her ear pain is arising from. And just from the introduction, you would generally see more otitis externa in the adult population rather than otitis media. So that would be where you kind of start thinking. And what are some of the key symptoms we should be asking on history? So it's important to ask about duration and previous treatments, as well as the exact nature of the pain, whether she's had discharge from the ear, whether there's been any sort of trauma, whether that be obvious sort of blunt force trauma or whether they're using cotton buds or instrumentation in the ear in an attempt to clean, and whether she's had any sort of previous episodes of a similar presentation. And any other kind of relevant comorbidities or background information we should ask you about? Yeah, the important ones are immunosuppressive conditions. So the big one is diabetes, but also other conditions that require patients to take immunosuppressing medications. Previous radiation to the head and neck can affect the ear canal as well and predispose to otitis externa. It's also important to ask about hearing aids. Patients with hearing aids often do get recurrent infection, but will often present without them in because of the pain. And things on a history, things like hearing loss, are they important? Yeah, so that's the main thing we obviously worry about in the ear. You want to get both a subjective and objective sort of assessment of their hearing. So patients will often complain of the sensation of a blocked ear. And then there are some basic sort of examination techniques, tuning forks and whisper tests and things like that that you can kind of more objectify their hearing. Okay, so maybe we'll look at the examination. So when you're doing examination, just maybe outline your general approach to someone who's got a painful ear. Yeah, so I would always inspect the ear before I touch it. So you're looking for signs of erythema or swelling around the ear or of the pinna itself. Patients with otitis externa will often feel pain as soon as you put your fingers on their ear, so it's important to be careful of that. And then you want to have a look with the otoscope within the ear itself. So you're looking at the lining of the external canal and trying to visualize the tympanic membrane. And then as we were just talking about, in terms of assessing their hearing loss, doing Renee and Weaver's test with the tuning forks and getting a sense of what their hearing is like. Now, maybe we'll go through otoscopy. Just some tips on how to do it. Yep. Okay. So the important thing to remember in patients that have otitis externa is that it will be exquisitely painful for them. So you have to proceed very carefully. Using the standard sort of otoscopes that are attached on the walls in the ED department are fine. And the older ones are actually good because they often have a working port through them. The newer ones have the macro vision, have the big heads. So you want to carefully advance the otoscope into the external canal. If a patient has severe otitis externa, you probably won't be able to advance very far, and that's a good time to stop there. If the patient has something else, or otitis media, then you want to try and visualize the extent of the canal, and then looking at the membrane. And particularly, you want to assess colour, whether there's fluid behind the ear or air bubbles, whether there's any sort of evidence of scarring. It comes up as sort of white patches on the tympanic membrane. And then you also want to try and get the patient to Valsalva if they're able to, or old enough, to see the movement of the tympanic membrane. You can also use the pneumatic otoscope with negative and positive pressure to get the same effect. Okay, so you'd be expecting normally, in a normal ear, they do the VASALVA, the membrane should move. Yeah. In otitis externa, the tympanic membrane is usually unaffected. So if you can see the tympanic membrane and it moves, then that is consistent with otitis externa. But if you have a look in otitis media, generally the eardrum doesn't move. Okay. Do you have any landmarks you look for when you look in the ear? The ear canal naturally curves up and down away from you. So you want to make sure that you're in an appropriate position with the otoscope to visualise the whole of the tympanic membrane. And often visualising the anterior portion is the hardest. Okay. I think that's the important thing, just trying to make sure that you can visualise as much as possible. And when you said fluid fluid behind the ear what does fluid behind the ear look like you can often see an air fluid level and there may also be air bubbles within it which would be suggestive of fluid behind the ear often it can be difficult to discern especially if the membrane is particularly inflamed but it does sometimes bulge out towards you and has a sort of concave appearance, which is suggestive of fluid as well. Okay. I mean, other thing, I mean, I know when I see people with otitis externa, you know, I often pull on their earlobe on the tragus. Yep. Usually they get really ouch. Yep. I think it's otitis externa. Is that a valid test? Yeah, well, that's one of the sort of signs, I guess you would say, like pressure on the tragus. Yep. It's suggestive of otitis externa, definitely. And often one of the things we do kind of come to thinking, or the questions that come up, you know, you can see maybe some parcel exudate in the ear canal, and're wondering could that come from a perforation of an otitis media or from an otitis externa? How would you kind of differentiate between those? In otitis externa, you often get infective debris in the ear and it can be a white waxy sort of appearance. If you have discharge from a perforated otitis media, then it typically looks more pus-like, more fluid-like. And if you do the kind of our salmonella with them, you know, sometimes the pus seems to bubble through. Yeah. That's what I've done. Yep. Any other tips on differentiating between otitis externa and otitis media? It really is a clinical diagnosis except for perhaps the typical patients that we usually see otitis media more commonly in children. And then as they get older, it's less frequent. |
Now, I guess we see otitis externa is often called swimmer's ear. It seems really benign. Are there any risk factors for having a more significant or malignant otitis externa? Yeah, so untreated otitis externa can extend, and you can get periorricular spread of the infection. And the most serious sort of complication that we look out for is malignant otitis externa, which is effectively osteomyelitis of the temporal bone around the ear canal. And typically those patients are middle to elderly patients with poorly controlled diabetes. We'd also worry about patients that are getting recurring infections that aren't responding to the standard treatment. So when they say malignant, it's nothing to do with cancer? No, it's not. It's just a severe case of osteomyelitis? Yeah, it's basically osteomyelitis rather than, it's not a tumour or cancer. Okay. Is that usually like a pseudomonal type infection or is it usually polymicrobial? It can be either. So the most common bacterial infection, infective agent is pseudomonas. But you can also get staph species that cause otitis externa as well. And fungal infection is also important to be aware of. It's also quite common for otitis externa. Okay. Do you ever get bilateral otitis externa? You can, but it is uncommon. Generally, we see unilateral disease. Now, we've kind of described some of the complications of otitis externa. What are some of the complications of otitis media? I think the most serious one is mastoiditis. So if you have untreated acute otitis media, it can spread to the mastoid air cells which sit behind the ear canal and that can become an emergency because it can then spread into the posterior cranial fossa and cause sort of intracranial complications. Fortunately with the treatment these days it's very uncommon, especially in developed countries. Although I think people would say probably within Australia, within indigenous communities. Exactly. Yeah, there are still some at-risk populations here in Australia, so it is something you need to be aware of. Yeah, but again, it's something that I think it calls a consultant. Could this be mastoiditis? And usually my answer is no. It's uncommonly seen, but it definitely does occur. So I guess we could say about at-risk populations, what other sorts of things would make us concerned it could be mastoiditis? So mastoiditis is largely a clinical diagnosis. So we're looking for a patient that has acute otitis media, particularly if it's a prolonged episode. And then on clinical examination, we're looking for inflammation behind the ear over the mastoid tip. So it can be erythematous and it's usually tender and usually the ear is pushed forward so when you look at the patient front on the ears are asymmetrical in regard to doing investigations I mean you've kind of really emphasized to me that these are clinical diagnoses our investigations important in either a tire externa or otitis media? For mild to moderate cases of both, not really. You would treat empirically and monitor for response. For severe cases, especially with otitis externa, taking a swab of the ear canal is sometimes useful and help into direct therapy. Again, if you're concerned about systemic sort of complications, then checking inflammatory markers is a good way to assess sort of effectiveness of treatment over time. And for serious complications, we would also look at doing some radiological studies. So we would normally organize for a CT scan if we're concerned about mastoiditis. And what are your CT of the kind of mastoid? Yeah, you can ask for CT of the temporal bones and that'll be a focused CT. Sometimes in kids, obviously, we would prefer to avoid the radiation so they can also have an MRI, but that also depends on resources available at the institution that they're in. We may just go on to management. Maybe we'll start with otitis externa. What's your kind of approach to managing otitis externa? So I think the important thing to remember is that it's empiric therapy first. So if you diagnose someone, then you should convince them on topical antibiotic treatment. So we typically use siloxan or sofradex, especially for mild to moderate. If we were seeing someone with severe otitis externa where the ear has essentially closed over due to the edema, it's very helpful to insert a wick. It allows for the drops to penetrate through the length of the canal and also helps to stent open the canal. Okay. Now, Sulfuridex, is that a combination? Yeah, so it's an antimicrobial with a steroid. Okay, so it kind of treats the infection also, maybe some of the inflammation. Exactly. And how often do you prescribe it? Is it kind of once every couple of days or is it kind of, you know, for how long and how many times a day? It depends on the extent. So for a lot of the drops, we usually use a regime of long lines of three drops three times a day and then review. So for the severe cases, we generally like to follow them up in our clinic and then we can make an assessment based on how they're progressing. Is it worth trying to clear some of that debris away from the ear? In otitis externa, I think it's very important. It's often not easy because it's exquisitely tender for patients. So it's something that I think helps to facilitate antimicrobials. If you're clearing out the debris, then your treatment is reaching as much of the skin and the canal as possible. And how do you go about doing that? So there's two sort of techniques. We generally use micro suckers, so they can connect to the wall suction, but they're a fine ball sucker. You do it very gently. And are they soft? No, they're metal. Okay. So you do have to be very careful. I think that if there was any concern for residents and registrars in an emergency, then we're always happy to come and clean out an otitis externa ear. Or they can be referred to clinic and we can do it there for them. And is there, topical seems to be first-line therapy, is there a role for oral antibiotics as well? So topical for everybody with otitis externa and then orals as a supplement if you were concerned that there was some spread outside the ear canal or you thought were sufficiently severe, or they were potentially a high-risk patient, like someone that was immunosuppressed or a poorly controlled diabetic. Would they get oral antibiotics, or would they come in for intravenous antibiotics, I guess, that latter group? Yeah, it depends on the severity of their disease. But, yeah, if they had bad perichondritis associated with it, then yes, they'll come in for some intravenous antibiotics. Now, you suggested about inserting an earwig. Sounds easy. Any tips on inserting them? Because they are painful from my experience with inserting them. Yeah, well, they're typically very painful for the patient. Yeah, actually, they're not that painful for me at all. I should have re-questioned that. They are painful for the patient. So the earwigs are quite small. They look like a tiny brick. You use a crocodile forcep holding onto one end, and you basically insert it for its entire length into the ear canal. It will be painful for the patient. You do need to warn them. To help, you can also put a bit of antibacterial ointment on top of the wick, a Bactroban or Closet. It can help sort of lubricate the insertion. You've just got to make sure they hold their head still and be reasonably quick in putting it in. Okay. Okay. And when you put it in and when you put the ear drops, do you kind of drop it onto the ear wick or will it just kind of you drop it near the ears? Ideally, you want the patient on their side and you place the drops on top of the wick because that then expands the wick. It's best if they can lie on their side for a couple of minutes. For patients that don't have too much external sort of involvement, some gentle pressing on the tragus can help deliver it down the ear canal. But some people will be too tender for that. Okay. People often ask, well, what will happen to that ear wick? It basically expands like a sponge in the ear, so it becomes much bigger than it looks like when it goes in, and it just sits in the canal. |
Welcome to On The Wards, it's Jules Wilcox here. Today we're continuing the theme of financial wellness and we're talking about investing with Jeremy Kalman. Welcome, Jeremy. G'day, Jules. It's great to be here. Yeah. So just an introduction to Jeremy. Jeremy's worked in the financial markets and traded and invested for himself since the early 90s, and he was first licensed to provide financial advice in 2000, and he established his own financial advice business in 2001. He's got extensive capital markets experience, spanning research, strategy, structuring portfolios, asset allocation, risk management, across a whole load of different asset classes. And together with his business partner, Ian Flack, they established Cowan & Flack in 2013. And he's a member of the Cowan & Flack Investment Committee, and he holds the responsibility of being the investment portfolio manager for the Cowan and Flack model portfolios. He's got a unique take on the economic world and investing that's underpinned by his understanding of economic history and cycles and events that define it. And he's a bit of an innovator in challenging the accepted investment landscape. He's a very knowledgeable presenter. I've met him several times at trading conferences that he runs. He authors the Counterflak blogs. He hosts a podcast called Properly Australia's Favoured Obsession and the Counterflak Insight Series and presents at a lot of other seminars and events, as I've said. He lives in Adelaide with his wife, Alice, and spends his spare time watching his sons playing AFL or just relaxing with family and friends. So Jeremy and I have known each other for a few years now, Jeremy. I can't quite think how long it is. Yeah, it'd be a number now, Jules. We've done pretty well, crossed paths numerous times, had a whiskey or two. One or two, yeah, absolutely. And I guess the thing for our listeners, this is sort of financial stuff is pretty much out there for doctors. Generally, we get no education on that normally and we have to do our own thing. And so for people who are listening to this, I've got a couple of rules that I tend to go by. And the first one is don't take a financial advice from somebody with less assets than you, because if they're any good at what they do, they should have more. And I would suggest that, Jeremy, you're probably doing all right for yourself and probably tick that box. Life's pretty comfortable, let's say, Jules. Okay. All right. The other reason I've asked Jeremy to come on is because I think doctors are massively overrepresented in scans. And there are a number of people in the financial, not all by any means, but there are a number of people who are interested in collecting their fees and so forth. And it's very hard to get good financial advice. And sometimes you can be seeing somebody who's very well-meaning, very honest about things, but actually they don't have a good theoretical knowledge. And I use Jeremy to base my investing decisions on things. I trust Jeremy over the years. We've got to know each other. And so that's why I've asked him to come on here because when you find somebody that you can trust in sort of financial world, it's really useful. And I think that's probably one of the best things that we can do here is to introduce you to people or at least you can hear ideas from people who I believe that I know what they're talking about and have a really good track record and trust. So that's why I've asked Jeremy to come and talk to you or talk to me. And so Jeremy, let's kick off then, I guess, with that. Why is investing so hard, do you think? It's a really interesting question that, Jules, because in a lot of ways, it just shouldn't be. It's a lot of it is just not that hard at all, but in the other ways, it's really very difficult. I think probably the biggest, I think the hardest thing you've got to kick over is your own personal psychology. I think that's probably the first thing that, that, that you need to really think about. And that sounds maybe a little bit, I don't know, you know, a little bit flippant or whatever, but the problem is you've got a lot of competing, there's a lot of competing thoughts that go through your mind. There's a lot of competing ways in which you can spend your money. Investing itself can really be quite challenging in a lot of ways, you know, mentally when things do or don't go well, when things do or don't live up to expectation. And unfortunately, as humans, we have almost a need for, you know, we need to progress, you know, we need to do things, you know, we need action. And often people or investors have trouble settling their own thoughts down and taking a long-term view, you know, that deferred gratification, you know, investing for a long term, that sometimes things take a little while to actually play out. So, and the other thing too, I think that's really, there's a number of, I think reasons that, but another one that's really important too, is that we like to think of the world in a linear manner. We get presented with financial research and, you know, cash flows and the like that look very linear, but the world just doesn't work in a linear fashion. And so when we challenge with that in the real world and things don't live up, as I said, to expectations, it can be very difficult to hold the line and continue down the same process. And because there's so many different, unlike most fields or certainly something like medicine where there's a very clear process for an outcome. The thing with investing is that you can have a process and you can create the outcome, but a lot of the decisions that you make along the way, like in medicine are, I guess I could say maybe semi-informed that you don't have a full account of information in front of you. You're making a lot of judgments and you're making expectations about the future, et cetera. And sometimes those judgments are correct. Sometimes they're not. Sometimes you can make mistakes and it can be, as I said, it's psychologically very challenging. The other side to it too that I think makes investing so difficult is that there's a lot of vested interests when it comes to investing. There's a lot of different ways to skin the cat and there's a lot of different vested interests. And that means that you're always getting competing views, challenging you about what you're doing. It means that there's always different forms of advice. Often I'll put in brackets or in inverted commas for sale. People are pitching their wares because there's a lot of vested interest. There's a lot of money to be made. And, you know, unfortunately in our industry, there's times when, you know, it can be questionable as to whose retirement plan is actually being worked on. And that's unfortunately just a function of the industry. And I'm not saying that everyone in the industry is. There's great people, et cetera, but there are a lot of competing vested interests and a lot of different ways in which you can approach investing. Yeah. Okay. So what basic principles do you think people should follow when it comes to investing to make it easier? I mean, you talked about goals and I did a segment on, I think you've listened to that one on sort of investing about the personal psychology and the goals. Because as you say, it's so important. It's absolutely important, correct. If you don't have a goal, if you don't know where you're going, you can't really get there. And it's amazing how many people they come with the thought that they want to invest, they want to do better for themselves, but they don't really understand why or what they're trying to achieve. And when you don't know, as you said, when you don't know where you're going, it's very difficult to work out how to actually get there. And consequently, you know, you constantly see people who, to use a bit of analogy, you know, they'll plant a tree or a seedling, they'll water it, they'll nurture it for a little while and it doesn't grow quick enough. So they'll pull it out and they'll plant another one and they'll nurture that and they'll water that and that won't grow quick enough. So they'll pull it out and they'll plant another one. And in the end, you end up with all these little small dead seedlings rather than actually having a decent tree in your backyard. Right. Yeah. Yeah. Okay. |
So there's a couple of things that we definitely base all our thoughts and processes and approach around. The first thing I think that is probably really important is people to understand the idea of what we would term the effortless advantage. Typical economics calls it the economic rent, but it's not rent as in a landlord, renter sort of situation. The economic rent is essentially the free uplift that you get with investments and hence our term, the effortless advantage. And when I talk about that, Jules, I'm talking about, you know, where your great aunt has purchased a house in Bondi 40 years ago for $15,000 and it's now worth, you know, three or four million bucks, where it's the same piece of land. You know, she might have paid a few rates and taxes, et cetera, and had it painted once or twice. But essentially that uplift in price, she hasn't had to work for. So the important thing about that is that it is effortless. It's not about the effort that one could put into re-landscaping their backyard or putting in a pool or an extension or anything like that, or actually physically painting the property. It's not to do with the physical exertion and hence the reward for that exertion. It's got to do with the uplift in values that occurs without any effort. And that occurs across financial assets, whether it's shares, the rise in shares and the dividend stream that you receive. Again, there's nothing that you as an investor have to actually do to receive that uplift or all those dividends, et cetera. And so understanding how that effortless advantage works means that you can start to realize that in the financial markets or in investing, unlike when you go to work as a doctor, you don't get reward for effort as such. You can get reward for little to no effort. And once you can understand that concept and understand that that's the way in which finances or certainly investments work, then that's certainly a big step forward. And then once you can understand that concept, then it's a matter of understanding, well, why does that effortless advantage occur? Why does that uplift occur? And the way in which we would explain that is that at the end of the day, there's essentially five drivers of our economy. And they've all got to do with productivity, that the more productive we become, Jules, the more profitable we become. And the more profitable we become, then of course, the more valuable we become or our assets become. And so for us, our drivers are technology, infrastructure, population, government-granted licenses, and, of course, the ever-important credit. And when you understand how those five drivers continually manifest throughout history to create productive gains, then you can start to understand how investment markets work. And when I say against history, you can go back, credit sometimes becomes a little bit dubious when you go back, you know, historically a very, very long time, but you can see all those productive drivers in play throughout history as far back as you want to look into, you know, ancient history texts. Yeah. And I think perhaps should just um talk about this aspect of it a little bit more so one of the things that jim this is how i know jeremy and things uh as we um i initially started following a guy called phil anderson who's done a heap amount of work on cycles and property cycles initially based out of the u.s but he's tracked that historical data back for a couple of hundred years looking at the price of land and its relationship to stock markets and so forth and cycles. And this has been written out of the economic textbooks now, hasn't it, Jeremy? It's quite amazing how that actually has come about, Jules. So again, without trying to bore you too much, I might find this exceptionally interesting, but I accept that maybe not everyone listening does, but it is, you know, hang in with us because it is so crucial. It's absolutely crucial for understanding everything. I mean, what we're going through now with the pandemic and the mid cycle slowdown and Phil called this called this, what, 10 years ago, 15 years ago, and said, oh, look, something's going to happen around 2020, 21. But don't worry, property's not going to fall particularly. In fact, if it's going to be really big, we're going to come out of that, it's going to be a big boom. And he's totally right, because he gets this understanding, which you get, and which I now understand, having spoken to you a lot about these things. And when you see the world in these terms, it dramatically changes how you then restructure what you're doing and how you see stuff. So I think it's really important that we spend a little bit of time just digging into this with those five drivers and with, you know, credit and so forth, if you don't mind, because I think it's something that's really unfamiliar to most people. And that includes most mainstream economic commentators, the people you read in the press. And now I usually read the press and do the opposite. Yeah. And look, I was going to say, just to take a back a step too, Jules, that like it is, some of it sounds really quite complex. And your first question is, you know, why is it so hard? And I'll sort of said, it's it is really hard, but it's not hard. If you actually just take your time and stop and think about things logically, there actually is quite a logical progression to our investment markets and our economy. The problem is that we get caught up in the short-term news cycle. We get our emotions start to override us and we lose, you know, the forest for the trees in a lot of examples. That noise comes through. Absolutely. That there is actually a procession that our economy has to go through. And to me, like you said, that the idea of the effortless advantage and our drivers was a little bit like us discovering the x-ray that you know you could see through the body you could see actually what's happening underneath and things start to make a lot more sense once you get that and and for us it becomes a framework of thinking to ensure that we can make just like you would in medicine know, you're making non-emotional decisions with incomplete information. And that's essentially what we're doing when it comes to investing, that we're making, you know, the best decisions we can at a time. But unlike most in our industry who, you know, make very emotive decisions, we get to actually put that within a framework to help our thinking and our understanding of, you know, what our expectations are and where we are. Yeah. Okay. Yeah. And I mean, I think in terms of resources, which we can, I can attach them a reading list or something to this podcast, but I think, you know, reading some of the background around this, obviously Phil Anderson's book, The Secret Life of Real Estate and Banking, you know, is a classic text and the power of the land, Fred Harrison and things. And going way back to 18, something with Poverty in Progress by Henry George. Yeah. Just detailing how the land captures all the gains. And so this is, again, a really interesting concept, Jules, because when you think about it in our, so from a historical economic perspective, we would say that we would talk about three factors of production, that land, labour and capital. To produce anything, you can only use land, you can only use labour and you can use capital. And they're the three factors of production. What has happened is because we've moved away from an agrarian-styled society where we lived off the land, that we no longer see land as being an important function. And so now when we talk about the facts of the production, we talk about labour and capital, and land just kind of gets bumped under the balance sheet under capital and it doesn't have its own heading. I mean, the Fed, I think, but I believe don't even take it into account at all in their calculations, which may be why they never predicted a recession in their entire existence. Well, you can't, unless you look at the three factors, Jules. You're not looking at, you know, it's like saying, you know, I'll listen to the patient, I'll look at the x-rays, but I'll ignore the blood work. I mean, it's just ridiculous. You know, how are you going to get to the end conclusion? And the thing is that land is a very, very different style of asset to everything else because, you know, you have to have land in everything that you do. You know, where we're recording this podcast, you know, we're sitting on our chairs. We're taking up space. You know, in your hospitals, you've got hospital beds. |
You can't have a hospital without land. You can't go surfing without land. You can't go for a swim without access to, you know, land. You know, the pool's going to take up a certain amount of space, et cetera. And so land, whether we like it or not, you know, we might not live in an agrarian society where, you know the pool's going to take up a you know a certain amount of space etc and so land whether we like it or not you know we might not live in an agrarian society where um you know 90 of us are out farming the fields as such but land still has as much of an impact on our life today as what it ever has we just don't see it in those terms anymore yeah and that's unfortunately that makes you know, really quite blind to the way in which our economy actually works. Yeah. And I think that's the thing I realised now, having now looked at this, and I guess to sort of encapsulate it in, if you look at, you know, say in Sydney, around Western Sydney, where they're building the airport, they're putting a train line through or something, you know, now I look at it and go, well, those house prices are going to go up big time. That's exactly right. If you're near, if you're in a Western suburb of Sydney, and now there's a light train station built, you know, 500 metres from your house, and you can now get into the city in, you know, half an hour regularly, that's going to do, and we know that from London, that happened in the cross rail links there, the house prices doubled. And that's that effort, that'sless advantage you're talking about, isn't it? It's a great example, Jules. It's a great, great example because that idea of just taking that one train line around the airport, I mean, there's a whole lot of drivers that that invokes there. I mean, you're talking about infrastructure for a start, obviously the infrastructure line. You're talking about the government granted licence of who gets to actually run the trains. You're talking about the government granted license of who gets to actually run the trains you're talking about the government granted license with regards to the change in potential change in zoning of the land around that station to be able to infill and create smaller dwellings so and then of course there's the credit as a driver obviously credit has a huge impact on the way in which our economy works and where asset prices get bid up because the more available credit or the more credit that's available to investors and speculators, then the more they will bid up the price of assets. And that's exactly what's happened. And from a population point of view, we said population was another one of our drivers. For those people that are living near that train station, the owners of those houses, obviously that makes life much easier, much more desirable location pre the train station for that population. And that's going to going to obviously feed into, you know, restaurants, cafes, shops, amenities, sporting facilities, et cetera, et cetera. And all of that just makes us more productive. It makes our economy more vibrant and the more money we have, the more we will price up the value of land or the value of a house that That you as a doctor, you know, as the more money that you have and the more credit you can get from the bank or the more you can borrow from the bank, then the more you will pay up for a house in a more desirable location. Yeah. And I think really crucially as well, and a lot of people, a lot of listeners may not realise that the, although the recommendations from the, the Hain report of just with COVID to help kickstart the economy, they've just all been got rid of, haven't they? And that's going to loosen up credit. So in terms of an investment plan over the next few years, I mean, all the billions of dollars that the government has been chucking into the economy and governments around the world and infrastructure spending around the world, it's got to go somewhere. And so you'd expect it's going to go into property and stocks in the next few years. That's exactly correct. That there's, again, there's a couple of things there to pick up on. And number one, as you said, the Haynes, the Royal Commission, the Banking Royal Commission and the legislation that was put on the banks with regards to the responsible lending requirements, et cetera, that are being removed, it's really important to understand that that's how the cycle actually works. That's the process that actually the cycle needs to go through, that in the troughs, in the lulls, after you've had a massive bust, then there's going to be a whole lot of finger pointing. There's going to be legislative change because those who are in charge are going to take that stance never again on my watch. You know, I will do something to make sure that this happens. But then as the cycle starts to move on and, you know, the economies get back to normal and investment markets start to move, you know, more freely and more normally, et cetera, then those concerns about the bust start to fade. And that psychology that I spoke of at the start, the investor memory, it's very, very important. It's very strong, the way in which our investor memory actually works. And the further we move away from that bust, the less we are concerned about having a repeat. Whereas when you're having the bus, everyone's concern is that there's going to be another one. We, we as human beings, yeah, we love to extrapolate yesterday into tomorrow. And that's that whole thing about seeing the world in a linear fashion that, that what we see yesterday, we, we see for tomorrow. And it's really important that, you know, that's not how the world works, that it does actually work in a cyclical manner. Absolutely. And I think, you know, going back, I mean, for starters, this happened in the last cycle and it happened in the cycle before and it happened in the cycle before. And Phil goes through that for about 200 years and says, you know, each time the banks go bust and, you know, all this happens and then there's regulations and they all get swept away and off it goes again. And it happens, you know, every roughly 20 odd years. So it's not new, but people forget. And it happens in different ways, which makes it not quite so obvious. But if you know- We always say, Jules, we always say, sorry to interrupt, that every cycle, it's same, same, but different. And the reason that we say that over and over again is because the underlying drivers are the same. We're always going to have those drivers of infrastructure, technology, population, credits, and government-granted licenses, but it can't be the same because they must manifest differently each time because you've got investor memory, you've got different legislation, you've got different technology, you've got different financial products. There's different infrastructure that's being built and being able to be used and leveraged, et cetera. So no cycle can ever be the same. That's ridiculous to think that. But the drivers, the underlying drivers will always be there and they will manifest to the same outcome. But I think what is the same, because we haven't evolved that much in the last few hundred years, is the investor psychology is a groupthink type thing. And that's why you see those big booms and those big busts. And going back to what you were saying earlier about how people with the reasons to buy, so when they've just had a crash, they're most worried about a crash. That's when you want to be buying. Correct. That's when you want to buy a house a couple of years after when the things are right at the bottom and everyone's really scared, you can't have a bust when everyone's really scared because now everyone's in cash. And you can only have a crash too, Jules, when nobody's expecting a crash. Yes. If people are expecting a crash, then of course they're going to take, you know, they're going to change their behavior to protect themselves so that when the crash occurs, they don't get hurt. And then by doing that, they'll ensure that a crash doesn't happen. When a crash does happen is when nobody's expecting it and nobody's prepared. And that's when everyone's saying at this time, it's different. And you know, oh, this is going to be, the economy is the best it's ever been. We've solved the problem of having boobs and busts. And yeah, when that starts coming out, then you know, you've got to watch out. |
Okay, welcome to On The Wards, it's James Edwards and today we're talking about delirium and I'd like to welcome back Dr. Scott Murray. Welcome, Scott. Thank you, James. Scott is a geriatrician at RPA and is also the Director of Pre-Vacational Education and Training and has previously spoken on this topic. So it's a really update, isn't it, Scott? It is. Nothing dramatic has changed in this area, but it's worth going over a very common clinical syndrome. Yes, and it is very common because I think every junior doctor who's covered the wards would have seen someone who's had some acute confusion or delirium. And it may be a go to a case of Joan, a 78-year-old female who was admitted three days prior with a community-acquired pneumonia and has been very worrying the nurses this evening because she's crying out, moaning, trying to get out of bed, has also had a fall. The nurses are a bit worried. They want you to come and see them and try to hint at you that maybe a prescription of a tranquiliser may be helpful and maybe really prevent future falls. So maybe we'll go through, I guess, a general description description what delirium is and I guess how common is delirium in hospitalized patients? Well one of the key concepts which I'll repeat when we get to the end of our talk is to think delirium. A lot of delirium in hospital is very much under-recognised, yet we know from lots of studies that an older patient like Joan, 20 to 30% of older patients on a medical ward will experience delirium. And for those people working in orthogeriatrics, the risk of delirium in fact increases to about 50%. If you're then even working in an intensive care environment, the rate of delirium may be as high as 85%. The other thing to identify with someone like Joan is that it can take two very distinct forms. One, like this case, is similar to what we'd describe as hyperactive del delirium where there's restlessness, agitation, increased motor activity, but a different older patient like Joan may actually present with delirium with hypoactive delirium and in fact have reduced motor activity, sedation, less interaction with staff. And in both cases, it's very important to identify that delirium may be occurring early in the hospital stay. So we may go, but it seems very common. I mean, can we prevent delirium? Or is it something that just we need to recognise and treat? What's very key in that question is that there was a landmark study which is now 20 years old in the New England Journal of Medicine by Professor Inouye from Yale, who identified in almost a thousand older patients that early intervention in a hospital stay could in fact prevent delirium occurring. In that big study, she was able to reduce the incidence of delirium from 15% down to 9%, and in fact reduce days of delirium from 160 down to 100. What was also key was even with intervention, those patients who then developed delirium in fact had the same severity and the same duration. So there's a lot to be said for preventing delirium in the first instance because our therapies for then treating delirium thereafter are much more difficult. Okay, so what sort of complications are associated with the development of delirium? I mean, why would you worry about it? I suppose the key one is we know patients with delirium actually have a higher mortality. Mortality? Mortality. And we know the risk of mortality can be as high as 10% or 20%. But there's also very key complications of delirium, including a longer length of stay, very common sequelae of delirium such as pressure ulcers, pneumonia and also your risk of needing to go to residential care after hospital is again much more increased. One thing that does come up a tiny bit is trying to compare delirium with, I guess, some other common pathologies seen in the age population, such as dementia or maybe underlying psychosis or depression. Can you maybe just briefly compare and contrast the different groups to try and work out what's delirium and what is not delirium? One of the simple assessments we have in the hospital, which in fact nurses on a geriatric ward can perform on a daily basis, is a simple test called the confusion assessment method. And it has four simple aspects that you can look at, including inattention, altered consciousness, what we would more easily recognise as confused thinking or speech, but also that key concept of acute onset and fluctuation. And of those, differentiating between dementia or an acute psychosis and delirium, inattention and fluctuation during a normal clinical day are probably the two key aspects of that assessment. So maybe we'll go back to the case about Joan. You get this call over the phone. What sort of brief questions do you ask the nursing staff over the phone? Within the hospital, I think it's important for the junior doctor to recognise that our expertise that we particularly bring to this case is from a medical perspective. It's important that the nurses recognise that Joan's in a distressed state and she needs to be seen by someone but the specialist knowledge that we bring is in fact in the first, helping sort out whether there's a medical or surgical condition that may be leading to Joan being very distressed. Some of the questions over the phone would be that first important question as to how sick the nurse feels Joan is, as there can be many causes for the delirium, some of could be very acute such as myocardial infarction hypotension hypoglycemia hypoxia so a some simple questions to gauge the acuity of the request is important and certainly asking for some of those important vital signs so that you can prioritise how quickly you need to come and see Joan. We've asked a few questions over the phone and we've decided now to go and actually get to go see Joan. You're there at the bedside. Can you just give, I guess, a brief outline of your approach to Joan and really assessing and managing her delirium? First thing before you go and see Joan is to have a quick risk assessment, both for Joan herself, that she's not in imminent danger of hurting herself. We've already heard that she's climbed out of bed and fallen on the floor. I think it's also important to assess the risk to yourself with a confused older person in hospital and to the staff they're looking after, including the nurses. Having assessed that your own safety is okay, then a comprehensive clinical medical assessment is very much what's required of the junior medical staff or the registrar who may then come and see the patient. It's comprehensive in the sense of a brief cognitive assessment, some simple questions, not too much information for Joan, simple questions, a non-threatening approach that doesn't invade her space initially, and then focusing on the different systems that may be important. Certainly want to identify any abnormalities in her cardiorespiratory system, any acute neurological change. It can be very satisfying in a sense to identify unrecognised urinary retention and medical conditions that can be easily modifiable once they've been identified. In regard to taking your history, what are the particular risk factors you should look at or when you see someone that you're concerned about they may develop a delirium? Some of the groups that we know are very high risk for delirium that should start to ring some warning bells are, as Joan is, age over 65 and many of our older patients are now much more elderly than that. Previous cognitive impairment and that part of the history may be already identified in their clinical notes. Certainly the severity of the illness at any age and that also reflects intensive care patients becoming very confused and very much identifying a very high risk group such as orthopaedic patients or elderly patients that have had major surgery because we know as I said before that almost one in two of that patient group will become confused in hospital. You gave a few tips in regard to examination, what are some other key features that you should look for on a comprehensive examination when you're looking at a patient on the wards after hours? Certainly go for those homeostatic abnormalities which are very easy to identify, hypoxia and in a high-risk group, hypercapnia, certainly looking for dehydration which we know is a key promoter of delirium and that may be reflected in hypotension or poor urine output, may be reflected in previous blood tests that they've had and simple bedside tests such as hypoglycemia or even hyperglycemia in the right patient. In regard to doing a neurological exam or using other cognitive degrees, you mentioned Camerady, is there any particular focus when you do a neurological exam? |
You can certainly initiate a simple conversation. Most people who are not delirious or confused should be able to identify where they are. Simple orientation questions. Certainly be able to respond to simple questions such as strength and command type questions and then a very focused neurological examination looking for tone, strength, possibly reflex performance. But in this situation, particularly in the evening or late at night, having identified that there has not been a new major neurological change such as a stroke or a seizure, the examination is still kept on a global scale and more targeted examinations or in fact investigations can often be done once the acute situation is under better control. We may go on to investigations. You mentioned measuring a blood sugar level which can be done at the bedside. Any other investigations you think are routine? I don't like using routine or should be indicating someone who presents with delirium? Some of the simple things that can be done do involve taking a blood test and they would certainly be a full blood count and a biochemical profile for the patient, particularly looking for acute infection or anemia, looking for metabolic disturbances such as hypercalcemia, hyponatremia or hepatic encephalopathy. Some other simple things that can be done if they haven't been done more recently is a urinalysis to look for a urinary tract infection. And I'd certainly include a chest X-ray and an ECG in that initial battery of tests. Again, many myocardial infarcts in elderly people may present with delirium rather than chest pain. And certainly a chest X-ray will give good information as to whether there may be pulmonary edema or an acute infection having a role in the delirium. Interesting about the role of a urine test. Many patients age group have asymptomatic bacteria and often we put down every delirium, maybe in the men's department, to a urinary tract infection. I don't know if that happens on the ward too. What is the answer to that? Have you got any tips in regard to interpreting a urine test in someone who presents with delirium? A positive urinalysis in the right clinical scenario, such as an elderly confused person with a fever, may warrant at the end of your assessment and investigations antibiotic therapy, certainly as a empiric first treatment. Whether urinalysis is particularly helpful is if the urinalysis is negative because we know if there's no indication of pyuria in particular, the negative predictive value of that test is about 95 to 97%. And that simple test, which may involve an in-out catheter in most hospitals performed by the nursing staff, an important potential source of sepsis is not eliminated completely but can to a large extent be excluded. We've almost outlined in regard to why we're doing some of our investigations about the underlying etiologies but can you maybe just outline some of the potential etiologies of delirium and what some of the common ones are? Well, the case of Joan highlights quite a few, including her recent community-acquired pneumonia and, in fact, many causes of sepsis will cause delirium. Sticking with infection for a moment, it's also a very important concept as to what is causing delirium in an older person. And I quite like to think of delirium as an acute brain syndrome. We don't know the etiology, but there's lots of theories about cholinergic deprivation, dopaminergic excess, but also the role of cytokines in a sick elderly person, in fact leading to a disordered brain function. The important concept of acute brain toxicity, similar to the heart and other systems in the body is early treatment is most likely going to lead to earlier resolution and hopefully less sequelae in the future. In Joan when you come to see her late at night certainly simple things to exclude would be urinary retention, checking for constipation would also be a simple thing to exclude, checking her recent electrolytes or full blood count and repeating them as required, a bedside glucose test and particularly in Joan's case we had that extra component that in fact she's fallen out of bed. A fall can take many forms, witnessed or unwitnessed, but if there's any concern in Joan that she may have hit her head, then in this day of easier access to CT scanning particularly in the larger hospitals it would be important in Joan even in the middle of the night to consider and exclude if warranted an interest intracranial event. How about the role of medications or you know we start lots of early people on lots of medications in hospital and obviously out of hospital what role do they have in I guess precipitating delirium in hospitalized patients? One of our medical roles when we come to see a confused patient is to undertake a medication review. Many of our medications have an anticholinergic effect and many medications that we're not aware of. The closer we look at all of our medications, many of them do reduce acetylcholine within our body systems. But common ones that we identify or are more well known would be digoxin toxicity, the antidepressant medications, and certainly the anti-seizure medications can also be implicated. Within the concept of medication review, it's also important to recognise that some withdrawal states, particularly for benzodiazepines and alcohol, may lead to someone having a quite impressive delirium once they've been admitted to hospital. In regard to our initial management of this patient, I guess from what you've described, obviously treating the underlying cause is important, but then we look at, I guess, more general management of delirium. Maybe we start with non-pharmacological methods. What are some that you'd suggest? And that's an important concept, James, that the treatment of delirium is multifactorial. It's not simply the junior doctor coming and providing a fix for the elderly person in hospital. Some of the non-pharmacological treatments include providing a well-lit environment in a quiet space if possible, sometimes very difficult in hospital and in emergency, talking to the person calmly, using simple language in a very non-threatening way, helping them to reorientate as to where they are, that they're no longer in hospital, that they're no longer at home, I should say, that they are in fact in hospital, giving them some simple messages as to what's happening to them in hospital. Often that might be the time to investigate whether there's family or friends who can be involved in the old person's care. So having a familiar face, having someone who's able to be with the patient in hospital and although it's not pharmacological, a medical invention would be maintaining someone's adequate oral or even intravenous or subcutaneous hydration so that you can correct any dehydration that may be contributing. Sometimes simply for older people it's re-establishing a regular meal regime for people who may in fact be undernourished or living on their own at home and those simple strategies just to maintain good bowel care. We also know that getting an older person up on their feet and mobilising them early in their admission, very important on an orthopaedic ward but also very important on other wards in the hospital. And some of those simple things, one, are able to help prevent delirium but also are part of the armaments, the non-pharmacological armaments that we have for delirium. When it comes to pharmacology, though, about giving drugs, which ones, when, how much? Good question. And still, even five years on from my last presentation and certainly after review of BMJ best practice, having a look at the NICE guidelines from the UK, this is an area that is not guided by a lot of evidence. There's no big new multicenter study that is available to help us with these decisions. But there are guidelines that have been developed over time, both local hospital, state, but also national guidelines, at least to give us a clue as to what might be useful in the first instance. Peridol, which allows us also to administer the medication intramuscularly or intravenously as a second-line agent. Haloperidol is still part of the pharmacology because it's been used for a long time and there are some historical studies that have proven its efficacy in delirium. Like many other medications in older people, it's very much the same rules of starting low, going slow, and the frequency of administration may be further apart than you would use for a younger person. But people want to know how much and for both risperidone and haloperidol, as the first two agents I talked about, the dose range for initial treatment is 0.5 to 1 milligram. Reassessing how an older person may have responded to this initial treatment at 30 minutes or one hour and consideration of another small dose if the delirium is still distressing or impacting on an older person's care. And roughly in both cases, having maximum doses around 5 mg for a 24-hour period gives a rough guideline as to what a junior doctor might start with. |
So it's my great pleasure to introduce an exceptional panel today to talk about you know navigating this career and and getting through it. So here we've got, starting from the far, we've got Dr Belinda Gray, General Practitioner with an interest in women's health working in rural New South Wales. Dr Claire Richman, who is currently considering a career in lots of things, neonatology, geriatrics, intensive care, anaesthetics, she's not quite sure yet. Dr Bridget Johnson, who's General and Community Paediatrician working in Sydney. Dr. Ria Liang who is also a general practitioner and Dr. Ken Lu who's a staff specialist. General surgeon. We'll get to that because this is what the panel told me they wanted to be when they were your age. It's very important that we know that because these accomplished individuals are so well packaged and their story makes so much sense that it can be difficult to know, difficult to imagine that was anything other than inevitable that they would become who they are and of course it was not inevitable at all. So thank you for the correction, sorry. Why don't we go back and you can just quickly introduce yourself as you are now. So Belinda, I introduced you as a general practitioner with interest in women's health and you are currently? I'm a cardiologist with a particular interest in sudden cardiac death in the young and I also have a high academic load with an NHMRC early career fellowship at the University of Sydney. And you recently returned from London four days ago to speak to you specifically with her. That's right. Just for this meeting. Claire, you told me you wanted to do a million things, neonatology, geriatrics, intensive care and anaesthetics, and you currently... Do a million things. So I'm an emergency physician and I primarily work in pre-hospital and retrieval medicine with New South Wales Ambulance. And so therefore I get to do all of those things I thought I wanted to do. I've just found a way to package it together and I do a lot of education and training in both of those roles. Claire worked a night shift last night. Thank you for being here, Claire. Bridget, I introduced you as a paediatrician, but you're actually... Totally on the other end of the spectrum. I am a palliative care physician. I'm an adult palliative care physician and I work as a staff specialist at Greenwich Hospital and also the director of physician's education there. And she had to get up to our daughter last night, so thank you for being here, Bridget. Thank you. Ria, I have to tell you what Ria said she wanted to be. So Ria told me she wanted to be a GP because she loves chatting to people, is fascinated by diversity of human life, that's all good, hates early starts and late finishes, has a tiny stomach and gets hungry easily, gets tired standing for long periods, is physically tiny, wants to have a decent family life and is well, basically unsuited to a career in surgery in every way except that she likes using her hands. Ria, what do you do now? I know everyone else knows already, but just to... So I'm a general and breast surgeon on the Gold Coast and I'm also a surgical educator and I'm the chair of the Operating with Respect Committee for the College of Surgeons. Ria's an epic mega superstar who you all know. Ken, you told me you wanted to be a staff specialist in liver transplant at a major tertiary centre. No, that's where I am now. But you did also say that that's what you had always wanted to be from your final year of med school. Well, gastroenterology, not necessarily liver transplant. Okay, but that's important, right? Because some people do know what they want to be and then they go all the way through and I think that's really interesting to tease out. Now, given that our audience is in that hopeful, dreaming, planning phase and given that you were all there now but in a very very different places I really wanted to help our audience understand what that felt like so Bridget you're gonna be a G you're gonna be a pediatrician tell me about the first step you took off that path and then I'll ask everybody else what What was the first time you moved away from that? I was pretty confident going through university that I wanted to be a paediatrician and I did a paediatrics term in fourth year uni and then fifth year and thought it was great. And then I did a term as a resident at John Hunter and my job as the female resident was to be present when there were forensic photographs taken for abuse cases and I thought this is horrific I can't do this for the rest of my life I know that people like that exist but I don't want to do this for the rest of my life because actually I just find this too heartbreaking and then I suddenly was like well what am I going to do instead and I think it took me frankly years to work out what that was I then decided that instead of paediatrics actually I'd like to do adult medicine and then gradually ruled out terms as I went along until I did a palliative care term and it was like someone turned up the colour I was like wow this is really it I love this this is what I could do for the rest of my life. But I was already in physician's training by then. Like I'd already started on a pathway and I certainly didn't know at that stage where the pathway would end. Okay. So it was an experience of doing the thing that you thought you wanted to do that realised it was not the thing you wanted to do. Yes. What about other panel? Belinda, you were going to start as a GP. What was the first step off that? Yes, so I grew up in the country, in country New South Wales, and went to medical school with full intentions of returning to country New South Wales. And much to my parents' disappointment, I first did a cardiology term in fourth year medical school and really enjoyed it. And I thought, oh, I quite like this, but I thought I would be a paediatric cardiologist and so I continued along that kind of thought thinking maybe not GP maybe maybe paediatric cardiology was for me and then when I was a resident at RPA with Claire I actually found myself every time I was in emergency picking up the patients with chest pain and avoiding everything else. And I thought, oh, hang on, you don't like psychiatry and you don't like obstetrics and gynaecology. And whenever I saw the children, I found it really heartbreaking that they just hated the doctor doing anything to them. And they had always had three patients, the parents and the child, and I found that a bit much for me. And then I'd just go and see another chest pain. And I started to think, okay, and everybody else hated the chest pain. And I thought, oh, I don't mind chest pain. I quite like it. And so that's how I ended up in cardiology. And then at a conference similar to this, I heard my mentor, Professor Chris Samsarian, speak on sudden cardiac death in the young. And I realised that that was the area of cardiology that was for me. And I pursued that by doing a PhD with him after my training. And that's how I ended up more in the academic path. Okay, so before we move on, Ria, I want to ask you about non-tertiary experiences because this is people stumbling into their pathway in tertiary hospitals. But that's fascinating. So you've got a conference just like this. Yes. So just like these people here. And just tell me what happened. How did you know what happened? So Chris, Professor Chris Hemsarion is a prolific researcher in sudden cardiac death and he talked about the particular research that he does with some videos of athletes dying suddenly, which you can find on YouTube. So showing them dying. Yeah, some of them were successfully resuscitated, some not. And I found it's such an interesting area and obviously a massive area of research in cardiology. And although I didn't mind seeing chest pain, some of those patients were a bit old and crumbly and I guess for me also having had that interest in paediatric cardiology, the sudden cardiac death and the young thing kind of crosses over with still seeing younger patients but adult younger patients. Okay, so last question then we'll move on. At the end of that talk, what did you do to then end up doing a PhD with this guy? So I emailed Chris, I found his email address on Sydney University website and I emailed him through the Sydney University portal and he ignored me and thought I was spam and he openly admits this. |
And then a few, maybe like a year later, he admitted that he had ignored my email. He actually at the time told me that he had not seen it. But he thought I was spam. He didn't really remember you from the email. No, he just remembered that he'd received an email from an eager physician trainee through the portal. Who just inherited a large amount of money but needed a bank account as well. So basically just approaching them, finding their email address online and approaching them and putting myself out there slightly. So that's two really important things about following up and being rejected but it still being the thing that maybe got you there in the end. Ria, so this is highfalutin tertiary medicine but you are quite passionate about non-tertiary experiences, and Claire, maybe you talk about that as well, about getting out of the tertiary bubble, which is where we're all very familiar. Why is that important? How does it happen? And what might that offer people who don't see their mentors in tertiary institutions? Yeah, so I hadn't realised when I was a medical student and a young doctor that what you train with is actually only a subset of medicine. So these are the high-end tertiary specialists who work primarily in public practice. That's what you see. And it wasn't until I was a junior doctor out in a little hospital called Rotorua in New Zealand, which at that time had no advanced trainees and was run with eight junior staff, that I was exposed to the full range of, like, all the specialties. And, you know, when you get something that's a bit out of your box, you actually have to solve the problem rather than passing it off to the relevant subspecialty team, because there isn't a subspecialty team. And that's where I first started to get my hands dirty and to operate and everything. And, you know, when you realise that you've got the good tachycardia, you know, you're going into theatre and it's like your heart is racing, but in a good way, because you're like, what's going to happen when we open this belly? What's inside? I know, it's so exciting. You know, but even then I was conflicted. So it took me until PGY3, and actually I shouldn't use the word bullied, but I was slightly coerced into it when my boss said, you know, you've got fantastic hands and you've got all the competencies and you are going to apply to surgical training or I'm not going to pass you on this rotation, was the sort of way it was phrased. Because even until then I thought, oh no, I'll still be a GP, I'll be a GP with a procedural practice and, you know, take skin lesions off and have, keep the operating side of myself happy while still having the GP practice that I'd imagined myself with. And right up until, because then I did everything around the wrong way. I went backpacking for a year. I had two kids, you know, and so each time I was like, no, that's me. I'm off. I'm back to GP land. But each time I'd come back to it and kind of find myself, you know, you'd find your mojo again. You'd find yourself with your hands, you know, up to your elbows and inside someone going, oh, it's too much fun. But I wouldn't have got that experience if I'd stayed in the main centres because I would have kind of done my three months surgical, which everyone knows in the big centres is like glorified secretary work, you know, and never actually gotten to do what the actual practice is. And were you like the unlucky recipient of a ballot that ended up putting you in Rotorua or did you choose to go there? We chose to go there. My husband has connections, has family there. Your husband has connections, everybody. Okay, so you made a choice to step out and just before we move on and talk to Ken about why, about how you got onto your pathway, what did it feel like to leave the tertiary centres at that time? Was that something that people warned you against or that you felt was a risk or was it easy because your husband had connections? Yeah. So when I say connections, his aunt and uncle ran the only Chinese takeaway in town. So we were fed well. So you had free food. That is strong and motivating, isn't it? Yes, very important for a young doctor with a big student life. But in terms of your career, did it feel like a risk? Yes. The prevailing wisdom is that you should stay in the main centres because it exposes you to the big bosses and you'll get the good references. Now, the way it's set up at the moment, and Ian and Cole could probably speak to this as well, is that your references count exactly the same whether they're from the big bosses or from someone out in the rural centres. Ian's confirming that is correct. That's interesting. I had always assumed that it mattered what their title was. No. They all matter exactly the same. And because you have more of that personal connection, you work much more closely with them, then in those systems where you have to get very high reference scores to be offered an interview, in the country places I think there's that personal connection. They don't see you as just yet another one of their junior doctors. In Rotorua we were literally one of the eight junior doctors that ran that place back then. And they would have leaned on you heavily, not just for paperwork. They needed to know who you were. Yeah. Ken, so you knew what you wanted to do, gastroenterology, so you walked the path, which is fine, but tell me, amazing of course, tell me about, you know, Belinda emailed some random guy and was ignored, Ria took a chance on Rotorua, what was the bravest thing you did to follow your dream? What was the big thing? The risk that you took that got you where you are? Well, I'd like to think my path has been pretty stock standard in the sense that I... No such thing. I completed my training, then I did the terms in gastroenterology I got on well with my supervisors and then I went overseas for a fellowship and then did a PhD so that's for physicians anyway a well trodden path. To be fair though you are a super super sub specialist in a super super tertiary hospital so there's not many of you around this might be well trodden but it's hard to get um you were a student at rpa then uh no i was in sort of liverpool bankstown okay how'd you get to rpa it just was the closest hospital to where i lived so i put it at the end of um med school yeah okay and then you were allocated then you never left except to go overseas for a bit. Yeah. Okay. And going overseas, and Belinda's just come back from overseas, we're going to talk about it a bit later on, but let's follow that. So what did going overseas feel like? Because now you're leaving the mothership for the first time in a decade. Yeah, I guess even before then I went to do two years at Concord because in gastro training you can't do all three years anywhere else. After you pass the basic physician's exam? That's right. And everyone knows your highest chance of getting onto advanced training is in your own hospital. But I could only do the liver transplant fellow year in my third year. So I knew if I wanted to do that and try out liver transplant, I had leave And do my first two years somewhere else like I guess that that's really my bravest moment. Okay, okay? I had to sit down with the head of the department like hey I don't want to come here for first and second years, is that alright? Bless. So you had a conversation and planned it out. So that sounds very strategic to me, which is important Because we're always told be strategic, be strategic, but I don't actually even know what that means anymore. Claire, what does being strategic mean if you've got so many passions? So what did you do to plan from all this energy to get to where you're going? So I think the idea of being strategic is actually, for me, was actually in many ways having a bit of a scattergun approach to start with. I did a lot of different things during my intern year, resident year, but started to focus down knowing by the end of that that I'd actually wanted to do emergency medicine. But by focusing down, that didn't mean I spent all my time working in emergency medicine. |
It meant that I spent lots of time in ICU doing the things that I thought would make me a better emergency physician and I spent time learning other skills that I thought would apply knowing that when I started going down the training pathway I would start to specialise more and more in those particular areas. So I wanted to gain lots of other skills that eventually would hold me in good stead. When I knew I wanted to do retrieval medicine as well, combined with that, again, it was what other skills are going to hold me in good stead to be able to be a retrievalist before I was even able to get there. So to be a retrieval physician, you need to get to your final year of critical care training, so either anaesthetics, ED or ICU training. And you can only do it in your final year, despite the fact that I wanted to do it from a retrieval from a fairly early on in my ED training. I spent lots of time chomping at the bit to want to go, but actually was advised by my mentors, Sam Bendall, who I work with at RPA, and a number of other retrieval physicians, to actually wait and do it properly, and actually instead of jumping off and doing it as a second year registrar, which was a possibility at the time, it's not really anymore, but actually to go and do it when I was fully prepared to take those risks, because as a retrievalist, actually out there as a registrar by yourself and that was actually where I had my very first grade four airway and I'm so grateful I took that advice of my mentors to do that. It also meant that I went have worked in rural and remote environments as well. I think I completely agree with Rhea is to go elsewhere and put yourself in positions where you get to in a more supported environment and some of those rural and remote environments will give you a more supported environment than the retrieval world will. Once you're out alone on the side of a cliff intubating somebody you really need to know that those skills are there but you want to practice those in an emergency department and tertiary versus a smaller hospital versus smaller again are things that you can try. So being strategic about gaining the skills that you need I think is really important but I think with that I also want to make sure that I've reflected on am I going to be good at this? Is my inherent nature to be good at this? And I think that's something to think of. Not will my parents think I'm good at it, not will my boss think I'm good at it, but actually deep down will I know that I'm good at it. So can I throw back to you then, Ria? Your boss knew you'd be good at surgery, but did you know you would be good at it? That's a really interesting point. I knew I would be good at it, but I didn't want to invest into the lifestyle of the training. I had spent years kind of going, I can't do it. My husband's going to be a specialist. He was already a declared psychiatric trainee. I wanted to have kids. I didn't want to sacrifice all those years of training. And the narrative about how long it is and how hard it is and how difficult it is with kids, that's very much ingrained. So it really took my bosses to kind of shove me into it. And just picking up on something that Claire had touched on, and others actually, part of being strategic is actually finding those mentors. The people who know you better than you think you know yourself. Who can see something in you that you can't see. And because they've been in that area or professors or leading that area, they can see where they can put you. Yeah, to take that advice and to just trust them. OK, so mentors. Because two things... A few things strike me here. So Belinda bludgeoned her mentor into accepting her. Ria... No, that's not quite true. But you actively pursued a mentor. Ria, you stumbled into mentorship. So what makes a good mentor? How would you know that someone's a good mentor? Bridget, what's a good mentor to you? I think it's one of those things, you know it when you see them. I mean, in terms of the people who still are my mentors today, they're usually people who I worked with along the way and our personalities gelled. They're people who literally, I can call them having not spoken to them in five years and say, actually, I've got this issue or I'm not quite sure where to take my career yet. And they're like, no problems. I've got three hours. Let's sit down and nut this out. But that's something that actually is very hard to sort of pin down and find out. I think it needs to be someone who is interested in investing in you, who spends enough time working with you that they know your style and therefore can give you proper advice. And I think it's just the X factor, which is that your personalities are either similar enough or gel well enough that you can have a good mentor-mentee relationship. Anyone else? I appreciate that. So this is that, you know, we're one of the bosses that we sort of click with. What else is important? I think for me one of the most important things about the mentors that I've had over the years is actually not that they tell me what to do but that they're asking me questions or proposing situations to ask me to reflect and that's probably the number one thing that I found really helpful from a mentor is not that they're sitting there telling me I must do this, but actually to put out the idea as a suggestion or to ask the question in a way, a bit of Ria's advocacy and inquiry type question along the way is helpful to allow me to kind of come to that decision myself. So there's different mentors for different types of people. Did you push Belinda? Yeah, I was going to agree because although Chris is definitely a true mentor of mine academically, I have a number of other mentors, particularly female cardiologists because although now it's about 50-50 in cardiology, cardiology has typically been quite gender unequal. And when I was in AT, I had a couple of female cardiologist mentors who really helped in terms of helping to direct me as to how it was going to be able to work in cardiology with a work-life balance. And some of these female cardiologists, I had coffee with one on Wednesday, the day after I arrived back from London, to talk about the next steps and also to reflect on what I've been doing. And these are people that you can, as I really echo what Bridget said, where you can call them after two or three years and it's like you spoke to them yesterday and they really have your own interests at heart. And particularly reflecting on what they did and what didn't necessarily work for them and what they think maybe they would have done differently themselves if they had their time over and I find that really useful because when you're just starting out as a consultant, you're setting everything up and you're thinking, okay, a bit of research here, a bit of private practice there, a bit of public work. Oh, how many days are there in the week? So I think that that's something that you need to have a few mentors, actually. OK, so a few mentors. There's this... You've all got mentors. It almost feels like relationships. It almost feels like dating. So for our audience who are still on mentorship Tinder or whatever, really very cool. So there was that email, but now you're having coffee, you haven't phoned for five years, someone you've operated with. Depends what time of the day it is. Yeah, definitely. So these are benchmarks, high benchmarks to meet. Ken, or anyone, but it's really about that first step from someone you click with to then how do they become your mentor? So what happens? Do you have mentors that you can, yeah. And how did you sort of start dating your mentor in a way? I came out completely wrong, I apologise. Actually, one thing I would add is you should probably have mentors outside your specialty as well. and the bit Bridget said about you just see your mentor it's for me It's a particular attribute about them that I want in my own practice. So for example, I might have a mentor On work-life balance because I you know this rheumatologist I admire really has that down pat I might have have another mentor on academia, because they've got a good research track record, and that's their non-gastroenterologist slash hepatologist. So, yeah, that's something I would like to add. And the other thing is, how do you start that conversation? |
And usually if you just ask, do you have a minute or a spare moment to have coffee or have wine or whatever, and the rest really takes care of itself if you've picked the right person. So everyone on the panel would mentor your own people, is that fair to say? I think this is something very opaque to junior staff, the benefits, the joy of mentoring. So if you are mentoring people now yourselves, tell me what it's like to be approached, to be asked to mentor someone, when it works well, but also what would you do if someone, well, just when it works well, so how do you like to be approached and how does it make you feel? It's a little bit like Tinder in that you get out what you put in. So there's this idea of predatory menteeship. Right, tell me about that. So I get a lot of people who approach but they want something of you. I want to, you know, and it's almost like they don't want to put the effort into it. So it's like, can I write a paper with you? Can I clip myself onto one of your research projects? Can I, you know, that sort of thing. And it's like, I think all of us here probably get approached by a lot of people, but the ones that you really want to mentor, it's almost like no effort to mentor them. Because you delight so much in what they bring to each meeting and you love seeing them progress and everything, whereas the ones who are kind of predatory are just hard work. And I think that's what happened to me, actually. Like, I don't think that Chris was being malignant. I think that he honestly probably gets 10 of those emails a week. And so, you know, but when we actually met and worked together and we instantly gelled, and I think that that's a very good point. OK, so, you know, and that's important. So it's joyous in a way to mentor the right person and if you ask someone to mentor you and then it feels right then, because my recollection is calling a mentor in that early stage is very daunting. You don't want to annoy them or irritate them or bug them or whatever. So knowing that it's quite a positive experience in both ways. What still though you gel in a clinic or in a helicopter? I'm not sure. But then what next? So it feels natural. Of course, you're rotating out in six weeks, two weeks, tomorrow. How do you follow up? One of the things I think has been really fascinating for me over the years in terms of being a mentor to other people is actually it's not always just medical staff. So I actually have mentors myself that are paramedics and nurses as well as doctors and, to be honest, people from other fields, non-medical people in my life that will actually I think of as mentors. And I mentor other people from different areas as well and I think to carry on with that is actually to think there is a little bit of the what can they do to help me but actually to have people that are specific for those different areas where I know that that's what I bounce back backwards and forwards with and simply a text message sometimes is enough for me to check in with my mentees and sometimes that text message to ask a particular question is something else that can be really helpful. It doesn't have to be big and deep. If you keep in mind that mentors are humans and if you want to make them feel that they're enjoying mentorship then occasionally you would write them an email saying, hey I've progressed to here now got onto cardiology training or whatever thanks for your help with that so then they would feel like i've you know i've contributed somewhat to that and they would want to keep mentoring you so i think giving regular updates on how your you know career is going to your current and previous mentors is really useful to keep that relationship going i I think it's important because what we're hearing from Ian, from everybody, is I heard a lot of confidence. So Claire and others talk about getting the skills you need for the job you want, which I think is a very confident, authentic pathway to your career. I think a lot of junior staff, when I see them, are very worried about the scores and the hurdles. So it's not really about what do I want to do, it's how do I rise to the top of a very competitive battle and I guess mentors can help with that. They can help encourage you to do other things or perhaps guide you through some of the things so you can play the game right but also get the skills that you need and want. I want to talk about going overseas. We talked about sort of leaving the mothership a little bit but going overseas is a particularly onerous investment. Why do it? What do you get? And what's that about? Glenda, you've just... So I thought a lot about overseas fellowship when I was coming towards the end of my PhD. I had two kids at that point and a husband with a very big non-medical career. But really the opportunities that are provided in an overseas setting, purely because I think two reasons. One is size, so much bigger centres with just higher volume, which we just can't have in a country of our size. You know, the population of London is essentially the population of Australia. So high-volume centres, and then also because of that, therefore, the volume of consultants. So the hospital that I worked at in London had more than 40 cardiologists on staff. So you can imagine that each of those people had their particular niche, which may not be something that you want to do for the rest of your life, but if there's something that you're particularly interested in, to just really immerse yourself in that for, I was there for two years, but really any period beyond, I think, six months. I think under six months, it's a big move and you've really got to think about whether you really want to do that for such a short period of time. But six months or beyond, it's an amazing experience to broaden your career in terms of your skill set for procedural based specialties. Obviously, you'll just get a huge volume through which you can then put onto your CV. And that's something to bear in mind, which I think I never got pointed out to me when I was a junior doctor, that you do need to keep a record of your numbers for all of these procedures. And it comes up in consultant interviews. And then you kind of think you've kept your logbook when you were an advanced trainee because you had to in the colleges checking your logbook. But once you kind of check out of that advanced training, no one kind of asks you again for your logbook until you rock up to a consultant interview and they ask you how many angiograms you've performed. And you think, oh, how many have I done since, you know, for the last five years? But luckily that had again been pointed out to be by my mentor, but it was not something that was raised much. So returning to the overseas thing, I think the other thing that you simply cannot have because of our location is the networking and collaboration that you achieve by an overseas fellowship. And I now have extensive research and personal contacts all around the world, in the UK, of course, but actually also all across Europe and North America because of research and clinical work that I've done over there so that's going to set up me for life with my area of interest and for me I work in a rare area of cardiology, rare disease so obviously having collaborations and contacts is critical to progressing our field. And a quick question before we move on about coming back. So you've got a great job, but you would have had to leave it. How did that work? How did you come back to this? So I guess that's a really interesting point, Chris, because I had a consultant position as a kind of what's called an honoree BMO. Which means you don't get paid anything. Correct. Before I left. And I'm back now and in the process of organising an appointment, but actually I don't have an appointment at a public hospital currently. I'm still an honoree, but I'm funded by the NHMRC currently, which is a research grant, basically. So when you come back, it's a challenging time, actually, because you have this amazing CV, and that's when you really have to start putting yourself out there, and it doesn't come naturally to a lot of us, and it's a challenge of returning from fellowship. But again, mentors are key in that regard in terms of putting you in touch with the right people. |
Starting being a consultant is really the beginning of the next part. I really want to come back to that. That's how we're going to end about where you are now. Ken, what about coming back? What was your experience of coming back? So the other way to approach fellowship is often you would have talked to your mentor who suggested that you go in the first place and hence when you come back they already have a plan for you. So I just settled straight into a PhD when I came back and that was always the plan. Who are you? That's amazing. Feel like Kim, that's great. Yeah, I guess I was fortunate in that my PhD supervisor was the head of department in the liver transplant unit and he sort of had this strategy of, okay, who he's going to bring in next and what this person needs to fulfill in terms of a mold and then he just said oh look I think you should go here to get these skills you should do this type of PhD to get this knowledge and then there should be a job for you at the end. So this is you're obviously a good fit for the job but to be fair you kind of offered you like I will do the things I will jump the things. I will jump through the hoops. I'll offer my pound of flesh, even if it's willing, and then I'll get something in return. It's different to carving your own career by searching out different skills, Claire or Belinda, and following your heart in that way. That was much more clear. Bridget, you went overseas not as a fellow and then came back. So you went over as? As an SRMO. PG correct okay and then what what where'd you go what'd you do it was madness and my boyfriend at the time told me it would be a really good idea um smart man smart man um so yes so Chris and I are married but um we it was it was at the end of residency neither of us had quite decided what we were going to do. And then we thought, you know what, we've both thought, let's do some work in a lesser developed country. Let's see what comes up. And actually, as residency progressed, like middle of the year, we hadn't taken a job. And it wasn't until December until the right job came up. And it was actually the most amazing thing, working in rural northeastern Thailand, doing cryptococcal meningitis research in an HIV population and doing someone's maternity leave essentially for research that was being done through Oxford University and it was mind-blowing and amazing and and also a massive gamble that really paid off and actually when I came back everyone in job interviews was just so interested that I'd done something that was off the path that frankly it dominated all of my physician training discussions because I'd been a junior in John Hunter but wanted to move to Sydney and all of a sudden everyone was like tell us what you did as an SRMO so actually as being a gamble it was a gamble that paid off in so many ways. So that's interesting. So, you know, I think one of the things I wanted to, the reason I introduced people with clearly their wrong, you know, titles was to just highlight the variation and the power of drifting from the norm. Because I remember before you went overseas, we went overseas, people warned us very strongly not to go. It was a terrible decision, career ruining, getting out of the social centres. You know, a lot of people have had that advice too. And yet a lot of people on the panel have had a lot of success doing things that are a bit different or out of the norm. Can I just say one thing on that point, though? I do still think that physicians training, and it sounds like it's quite different to other trainings, is very in-house. So whilst I think that going overseas opened doors for me because it meant that actually I could jump from another hospital to RPA, I think that there are some subspecialties where a mentor can guide you to this where actually you do want to be in the tertiary centres. But I think that's when you need a mentor just to be able to say to you, if this is the path you want to go on, then this is the route you need to follow. So I had a similar experience, actually, different to Ken. So I was in JMO at RPA and had applied for physician's training at RPA. And then, unfortunately, in the year that I was going to be a BPT, for some peculiar reason, lots of people wanted to do cardiology and they allocated the terms and in fact I was the one who drew the short straw and of the two years of the eight terms I didn't get a cardiology term I didn't get one at all and so I was kind of the ninth person they just said they drew it out of a hat and I had this kind of moment where I thought can I really sign myself up for advanced training in something that I've never worked at as a BPT? And I talked to a few of my consultant mentors at RPA and they kind of said to me, you'll be fine, you really were liked, we'll still give you a job as an AT. But it was more for myself. Did I really want to sign up for this apparently terrible lifestyle if I hadn't even tried it as an advanced trainee? So I took a real gamble and I took a job at a different hospital at the 11th hour where they promised me a cardiology term and I moved to the St Vincent's Network in the December before starting my AT in January. I got told that it was a terrible decision by a number of the consultants that I worked with at RPA and I just had to do what was right for me. I knew that I couldn't sign up for advanced training without having done this and in fact it was a great decision because although I really enjoyed my cardiology term at St Vincent's and I confirmed that I wanted to do cardiology training, for me I also confirmed where I wanted to do advanced training and luckily for me the head of department who was the one person who said to me, it's not a bad decision, if you need to do this you should go, we still want you back as an AT and luckily he stood by that and I went back as an AT and I actually really enjoyed having gone somewhere else. So this is your final year of BPT or when did you No, that was when I was a resident applying to get onto BPT and they allocated the terms. They'd accepted you to RPA I had the job for six months, yeah I'd done the allocations in July I guess it is and then it was in the terms. They'd accepted you to RPA. I had the job for six months. Yeah, I'd done the allocations in July, I guess it is, and then it was in the December. I pulled out. I changed networks at the last minute because I didn't get allocated the term that I needed for my career. Yeah, I think that's a very powerful story. I'm sure everyone has stories of doing things like that and worth reflecting on the risks that we take and that they can turn out for good even if they don't turn out where you thought they would go. So to finish up then, and we'll take one or two questions, this idea of getting there and then now having it all and being there, and like I said, this is an extremely accomplished panel with a strong sense of inevitability and purpose, but there's still, would would be right to say there are still things to go still jobs to find or PhDs to start Ria you're thinking about a PhD is that right I started it eight weeks ago so that is not to get a job clearly this is not so you can become a subspecialist why tell me a little bit about the journey continuing after getting it lost. Yeah. So, Edna, I had a really productive discussion over lunchtime with, you know, one of you with it about this. So, from where you sit, I know it is crafted as though it's some mad rat race to consultancy. But I'm saying to you, you know, the average lifespan in Australia for men and women exceeds 80. You know, if you expect that you're going to get to consultancy in sort of typically mid-30s or something like that, what are you going to do for the next 50 years? You know, and so to say this is not, you know, when you say how do I get from where I am to the goal, you're like that is not the goal. The goal is this ever-changing, ever, you've got to expect, I think, in these days, and it's reflected in the wider society too, you know, no one these days works the same job from one end of their life to the other throughout adulthood anymore, which is what maybe our parents' or grandparents' generation did. You've got to expect that you're going to have two or three different careers. |
Welcome to On The Wards. My name's Steph. I'm one of the junior doctors working at RPA and I'd like to welcome Dr Paul Hamer, our RPA-D pet and sleep physician, to today podcast. Thanks for having me, glad to be here. So our scenario for today would be that you're a junior doctor starting a relief term in a busy tertiary hospital and you're rostered to work your first week of nights in three days time. So our first question would be how would you prepare for this week of nights, particularly focusing on your sleep cycle? I think it's actually a good question because a lot of junior doctors face the daunting task of moving on to night shifts after being on days for quite a while. I just want to clarify a bit about the scope of the talk and I suppose what you and I know. A lot of people who do nights, say in the States or in South America or Canada, do a whole day of working and then will do night shift overnight. And they're trying to catch sleep here and there and also manage the wards. And managing that sort of sleep is a lot more difficult. Whereas what we do in Australia, just in case we have international listeners, is often have a block of three to seven nights in a row. And then you're given a block of days off to catch up on your sleep which I think is much more healthy so I think we'll sort of just focus on that and trying to stay healthy through that. So if we talk about sleep and managing your sleep I think from a sleep physician's point of view I think it's useful to think about the physiology of sleep and And there are two big drivers of sleep. The first is sleep debt. And the second is your circadian rhythm. So sleep debt is a bit like hunger or thirst, it builds up over time if you haven't had any. So you know that if you haven't slept for, you know, several hours, you start to become more tired and tired and tired. Sorry, more sleepy, sleepy, sleepy. And if you have a small nap, you quench that thirst for sleep. You repay some of your sleep debt. And you'd probably know that if you have restricted sleep for several nights in a row, you may need to catch up. So that's sleep debt. So that is one big driver of getting people to sleep and consequently trying to stay awake as well. The second thing is circadian rhythm. So circadian rhythm is something that's built into all living beings. So from the smallest single-celled organisms all the way to multicellular organisms like us, they all have a circadian rhythm. And it's based on the fact that the Earth moves around, has a 24-hour cycle. In fact, and interestingly, human circadian rhythm varies from person to person. We have clock genes which help regulate our time. So most people actually have a 25-hour circadian rhythm. And it gets brought back into alignment with our 24-hour day by several things. But the most useful one is light. And so light stimulation helps suppress melatonin and keep you awake. And as light tends to fade away, melatonin starts to rise and that induces sleepiness and starts the physiological process of sleep initiation. So knowing how your circadian rhythm works is very important as well. And knowing which, whether you're a person that works with sleep debt or circadian rhythm also helps. Knowing these two things, we can use knowledge of those to try adapt our sleep for night better. So how do we do that? So first things you need to think about is are you a night or a morning person? If you're a night person, it's usually more likely that your circadian clock is 25 hour a day clock rather 23-hour. Because you find it easier to stay awake a little bit later each night, and that might help you prepare. If you're someone who wakes up like that in the morning at 7 o'clock every morning without an alarm clock, and you just jump out of bed and go, I just can't sleep, you might not feel refreshed, but at seven o'clock you wake up, then you clearly have a very strong circadian drive to wake you up as a stimulus to waking. And so sleep debt might be harder for you to push on and sleep because those sorts of people, doesn't matter how tired they are, they could go to bed at three, four o'clock in the morning, like on a big night out Saturday night, they'll still wake up at seven and find it very difficult to use their sleep debt to push through. So knowing what sort of person you are helps adjust your sleep cycle. So what does all this mean for someone who's preparing for night shift? The majority of people have a stronger sleep debt drive and have a 25-hour circadian clock. So this would be my advice for them. In preparing for your night shift, most people don't work for the day or two before their night shift. It's good to try to stay up just that little bit later each night, the nights before your night shift. So say you're starting on a Monday, on the Saturday night, stay up till 12 or one o'clock. And on the Sunday, stay up till one, two o'clock in the morning. And that gets your sleep debt building up just a little bit. If you can, try sleeping as much as you can in the morning and make sure that you don't start off the night shifts in sleep debt, because you're going to accumulate sleep debt on night shifts absolutely because it's difficult to shift but if you already go in to night shifts with sleep debt then you're going to be in trouble. Then in the afternoon just before your night shift take a nap even if you can't sleep put yourself to bed and close all the blinds get your room room dark and try and have a nap. And what that does is quench your thirst for sleep, reduces your sleep debt down a little bit and makes you more resilient to work the night shift that will be coming ahead. At the same time, in that afternoon, what I used to do is I'd prep my room. So I'd put aluminium foil on all the windows because I had very bad curtains. So you can get some curtains which are very good. You're laughing, but it's true. So if you don't have block-out curtains, which you can get from Spotlight and other fabric stores, very thick curtains, if that doesn't work, aluminium foil works great. It's completely impenetrable to light. And because you want your room to be as dark as it can be when you get home the next morning, even if it's sort of a mild light, for some people who are very light sensitive, that means that it'll put their circadian clock out of whack. Their circadian rhythm will be confused. Is it day or is it night? Should I be sleeping or should I be awake? So trying to get your room as dark as possible in a sleep-like environment is very important. Buy yourself some earplugs so that you're in a nice quiet environment and let your housemates or your family know that you're going to sleep and that you will need some time to go sleep. So that's how I sort of prepare for night shifts in the leading up to it. So in summary, it's paying off your sleep debt, trying to build up some resilience in the nights beforehand, preparing your room by making it black and telling your environment, your friends and family and your neighbours that you'll be on night shift. Thank you very much, Dr Hamer. I guess another question would be some people go home and they go straight to bed. Other people tend to stay up for a couple of hours, go to bed around lunchtime and then sleep later. Would either of those? I think you've got to do what your body tells you to do. So some people will have, after the first night shift, will be so sleepy that they just need to go home and sleep. And I think you just have to play your body that way. Other people feel okay. Maybe they've been drinking coffee through the day. So I think you have to play it by ear. I do think, say you're doing seven nights in a row, what I used to do is after the first night I'd go to bed straight away, but each day I'd go to bed an hour later. And it makes the transition back to days a whole lot easier at the end of it. And you mentioned that some people like to drink a lot of coffee. Is that coffee and other caffeine forms something? Yeah, so coffee and eating, I suppose, is useful to talk about. So I think you need to do what you would normally do when you're awake in normal day shifts. So if you drink a cup of coffee before you go to work anyway, then you're definitely not going to survive a night shift without a cup of coffee. |
But caffeine is useful when used appropriately. It's not useful if you're drinking super energy drinks the whole night and then you can't sleep at the end of your shift. I think that's wrong. And sometimes too much caffeine will actually interfere with the quality of your sleep at the end of a shift. So it is important to balance that out. I suppose we can talk about meals at the same time. So the advice from a sleep physician point of view would be to try realign your meals to your night phase. So when you wake up, you have a breakfast type meal. And before you go to bed, you have a dinner type meal. Because eating and social activities, again, helps realign your circadian clock. But having a bowl of cereal at dinnertime when your family is having a lamb roast or something doesn't make sense for a lot of people. So I used to go out with friends and eat a proper dinner for my breakfast meal. But look, you sort of just need to play it by ear and get to know what your body does. If you're finding it difficult to swap your body over, maybe try aligning your meals as well. I suppose the other thing is often on night shifts, there's a lot of sugary sweets around. The nurses have got bowls of lollies and it's easy to go from ward to ward and just have a little bit here, a little bit there. I find that it makes you sleepier and more tired. That energy rush you get from the sugar lasts for 10, 15 minutes and then you get that big dip post the sugar. And you add that in combination to your natural tiredness and sleepiness from your sleep debt that you've built up because you've been awake most of the day is not helpful. So I try to avoid sugary stuff, have a lot of low carb type energy. So fruits, vegetables, things like that is better. And do you have any comments about exercising during night shift? Yeah, look, exercise, again, you need to know your body. Exercise is usually an awake promoting exercise, which, you know, it's funny that you say, but generally if you exercise in the hour before sleep, you'll find that the sleep quality is less and quantity is less. So I think exercise is useful when you wake up. So maybe do it before you start your night shift. But I don't think it's particularly useful to do a night shift, go home, go for a run, and then go to sleep. And that's for two reasons. One is you're stimulating your body to say it's wakefulness time when really you should be saying I need to go to sleep. But the second thing is most people do exercise outside and you're stimulating or you're exposing yourself to a lot of light which will suppress your melatonin and not allow your body clock to shift over and not allow you to initiate sleep. If you don't have melatonin rising, you're not going to fall asleep. So you want to avoid light like you're a vampire on your way home from night shift. Wear big, dark sunglasses. Don't go outside if you can. And definitely, the longer you stay out and the brighter the sun gets, the harder it will be for your body to initiate a good, decent sleep. Something that we'd all hope for would be that you would clear all the jobs off your board and the wards are particularly quiet. At about 2am, would you suggest having a power nap? Power naps. Well, I think that's an interesting question. Again, you need to know your own body. So say you have cleared all the jobs off the board and there's nothing to do. My general rule was I didn't. The first reason for that was as soon as I fell asleep, I'd get a page about something going wrong and I would just jinx myself if I tried to do it. But the second reason is that because of that sleep debt, when I went home, I used my sleep debt to power my sleep and push my sleep and keep my sleep continued when I actually got home. If you pay off a bit of that sleep debt, it depends on your body. Some people can do it. But for me, I knew that if I did that, I'd find it less able to fall asleep when I got home. I do think it's useful on your first night if you're falling asleep doing your work, you know, you're writing up medication charts and your eyes are heavy and you just feel exhausted. I do think a power nap is useful because you need to recharge your batteries somehow. So a true power nap is only 20 to 30 minutes long. If you stay longer than that, you actually go into stage three sleep, deep sleep, and it's extremely hard to wake yourself from deep sleep without waking up feeling totally confused and not knowing what's going on. So 20 to 30 minutes, I wouldn't hop on into bed. I would find a couch that was quasi not comfortable, you know, but comfortable enough for you to fall asleep and then have a power nap on that. So I find couch napping much better than a bed sleep because in a bed sleep, you're totally comfortable. You're telling your body and your brain things, oh, it's sleep time. But a couch generally doesn't tell your body it's sleep time. They just say it's nap time. So all those little cues you think are kind of funny, but the brain does register them as cues that it's bedtime or nap time or awake time. So my advice would be 20 minute nap on the couch, set yourself an alarm, and when it goes off, you get up. Our next question would be safety considerations when doing after night shifts, for example, driving home after night shift. So this is one of the more difficult questions to answer. So there is a higher risk of car accidents for those who do night shifts. The evidence is there, it's documented. I suppose what we need to try to do is mitigate those risks. So one of the ways you can do it is, like we mentioned, if you're very, very sleepy, take a power nap at the hospital before you go home. So have a small nap. The second is stimuli do keep you awake. So making sure that you're driving during the light hours, then that will help stimulate for you to stay awake. The most riskiest driving you can do is highway driving, where it's boring, straight roads, and you combine tiredness with that and that definitely isn't good. So, and driving for longer than 20 minutes is also a risk factor. So my advice would be if you live more than 20 minutes away and it's on a highway, you really should consider how tired you are and have an awareness of it. And if you are sleepy, perhaps stay in the JMO accommodation overnight, well, to sleep, but during the day, to catch up on sleep before you go home. If you do find yourself falling asleep at the wheel, you need to pull over. You can't have micro-sleeps. So if you feel yourself with the heavy eyes and the really long blinks, you just have to pull over and stop and have a nap, wake yourself up in 20 minutes and see if you can keep on driving because it is a risk factor and you have to just be very aware of yourself and your own body. Very important points. Do you have any other take-home messages for us, just as some last comments? Well, look, maybe we'll just talk a little about medications that people might use to help them sleep or keep themselves awake. My personal opinion is that they do more harm than good. Sleeping tablets generally will have a bit of a hangover effect. So they're not particularly good for, so they're okay for sleep initiation, but the quality of sleep you get isn't great. They're not particularly good for sleep maintenance. So you might still wake up in two, three hours time. And when you do wake up, some of them have a bit of a hangover effect. You can feel a bit groggy. So my general rule is avoid them. But if you have to use them, be aware that they could make you groggy. And you can't use them in isolation. You have to use them with these other tricks that we talked about, about adapting your circadian clock. Because if you try, for example, say you can't get to sleep, you go home from a night shift, it's 8am, but your room is still quite bright, and you take a sleeping tablet, the sleeping tablet will put you to sleep to all intents and purposes, but it won't be a deep sleep or an effective sleep, and half your brain will be saying it's time to wake up because it's quite bright in the room. |
Welcome to Underwards, it's Jay and Deb, and today we're talking about an underappreciated complication of invasive procedures, chronic post-surgical pain. I'd like to welcome back Dr. Jane Stanton. Welcome Jane. Thank you for having me. Jane's a consultant anaesthetist and also an interventional pain specialist and we're going to talk about chronic post-surgical pain. It's something I might say maybe as an ED physician I should be more aware of but maybe can we start with a definition. I mean what is chronic post-surgical pain? So by definition chronic post-surgical pain is new pain post-surgery that persists outside the time of normal wound healing but in actual fact the definition is currently changing according to the International Classification for Disease, ICD-11. Chronic post-surgical pain, by definition now, will be persistent pain continuing at three months post-surgery or significant tissue trauma. I mean, we can give a case example of a male who's waiting for pleurodesis for recurrent pneumothoraces with a background in depression and very apprehensive about getting this procedure done and the nurses ask you to come see the patient who's got some six out of ten pain and the patient is distressed and really wants his surgery done now and doesn't want to delay that surgery because he's dying of pain. Maybe just as a general comment, what's your approach or how would you say a junior doctor approaches or tries to disarm this patient who's a bit verbally aggressive? So that's always very challenging for a junior medical officer and actually I think it's one of the most challenging situations for someone who is just fresh out of medical school. I always encourage junior medical staff to not engage in a patient's distress. That's very important to remain calm in the face of difficulty and to seek senior moral support in a situation such as this quite quickly if the junior medical officer feels that the situation might escalate. A patient like this, so you've used some catastrophic descriptors, the patient saying he might die of pain. So that to me indicates a significant amount of distress, but scoring his pain at six out of 10 obviously has some moderate to severe pain as well. So it can be quite challenging to separate out how much of a situation like this relates to pain generators and how much of it relates to a patient's personality type, their approach to pain and how distressed they are in relation to this. So it's quite complex for a junior medical officer. I would always err on the side of caution if a patient says that they have a lot of pain and waiting for surgery then I think the most sensible thing would be to provide analgesia at this stage to the patient and that would be appropriate for the type of pain that the patient is describing. If the patient indicates that he's apprehensive about certain aspects of management such as the general anaesthetic for the operation then it might be appropriate to engage the Department of Anaesthesia and ask possibly for an anaesthetic registrar to come and talk to the patient about what particular concerns that patient has in regard to the anaesthetic. So I think generally overall as a sort of a as a general rule it's always appropriate to take an empathetic approach to patients like this. I think that's probably the easiest way to engage them not to get distressed because the patient is distressed and to take their issues seriously and to validate them for the patient as well. Yeah, so you've given some advice on how to, I guess, establish an empathic relation with your patient. Any other suggestions or advice? I think if a patient is depressed or anxious, that probably needs to be explored preoperatively as well. There's not a lot of details in this case but if the patient has a significant history of a mental health problem then that certainly needs to be optimized before the patient goes ahead and has surgery and that might be clarifying whether they take generally take any psychotic medication or antidepressants, is there any suicidality risk in this patient and does a mental health liaison officer need to be involved at this stage. In regard to chronic post-surgical pain, how can we minimise the risk of this occurring and look, I mean, why does it matter? Okay, so why does it matter? Well, it matters because persistent pain can significantly interfere on a patient's ability to function, and that has both societal and vocational considerations. What can we do to minimise a patient's risk of developing chronic post-surgical pain? Well, we tend to split into preoperative risk assessment, intraoperative factors and then postoperative minimization of potentially mitigating factors. So preoperatively we assess the patient, it's quite clear in the literature now that psychometric scoring and levels of anxiety, depression, and preoperative catastrophization equate to a higher incidence of chronic post-surgical pain post-operatively. And how these factors can be modified preoperatively can be quite difficult, particularly if the patient is in hospital and is having surgery within 24 hours. Other factors preoperatively more generalized are younger patients, female patients, patients who have a history of chronic pain are all in the higher risk arena of developing chronic post-surgical pain. Intraoperative factors pertain to the type of operation that the patient's having. So again, the figures are much higher for certain procedures such as thoracotomies, mastectomies, inguinal hernia repairs, and then so forth down the list to joint replacement surgery. And there's strong indications now that surgical minimization of intraoperative nerve lesioning would probably pertain to reduction in chronic post-surgical pain so essentially the expectation is that surgeons be careful to not cut nerves. But obviously for an example, an operation like a thoracotomy or a mastectomy, a large number of very fine anterior cutaneous nerves are cut when a lateral or breast incision is made. And so that can be quite difficult to alter. Then post-operative factors are essentially good pain management. So the less severe a patient has in terms of post-operative pain, the less likely they are to develop chronic post-surgical pain. And there's a number of ways that we can provide analgesia to patients, both intraoperatively and postoperatively, to minimise pain and to minimise the risk of chronic post-surgical pain. Specific techniques now that have been encouraged are thoracic epidurals for thoracotomotomies with good support in the literature that this reduces the incidence. And paravertebral blocks for mastectomies is another specific provision of analgesia to reduce the incidence of chronic post-surgical pain. There's a large multicenter randomized controlled trial being undertaken at the moment, and it's run by by ADSCA clinical trials called the ROCKET trial, R-O-C-K-E-T. And there's a protocol for a ketamine infusion. A bolus dose is given intraoperatively and a post-operative infusion is run for 72 hours with the understanding that to date the literature supports perioperative ketamine again as reducing the incidence of chronic post-surgical pain. So the outcome of this trial is not yet available but it will be interesting to determine whether or not there is a significant statistical difference because that may well alter the way we currently give anaesthetics and provide analgesia postoperatively. We'll be awaiting the outcome of that study. And look, unfortunately the operation goes pretty smoothly and three days later the patient's due for discharge and sent home with some oxycodone and instruction to take some regular paracetamol and see his local doctor for follow-up. Should patients with acute surgical pain be discharged with opioids such as oxycodone? Well, it is common practice to provide patients with a definitive amount of a short-acting opioid because the patient has had major surgery. I would always encourage provision of a non-pure mu agonist such as Tramadol, immediate release Tramadol or immediate release Dependadol rather than a pure mu agonist such as Oxycodone. Both medications, that's Tramadol and terpentadol, are associated with lower rates of abuse in the community, and it's probably less misuse and diversion associated with these medications as well. Any medication in the opioid family should be limited, so provision of analgesia should be limited and certainly follow-up with the GP within three days is recommended. Any history of opioid misuse and certainly any suggestion of opioid diversion, then the patient should not be given opioids for discharge and that alternative regime should be made. Ten weeks later the patient books himself into the carotid acid clinic, no further pneumothoraces which is great but still got ongoing pain and ever since the operation complains of a deep burning sensation across the chest and is unable to go back to work because of this pain. What else would you go back through, I guess, within your pain history? So in order to make a diagnosis of chronic post-surgical pain, it's important to exclude two things. One, whether or not there's any contributing factor to ongoing pain. These would include things like infection after a surgery, intercurrent medical problems such as malignancy or other significant issues that could be contributing to this pain. |
Welcome to On The Wards. perhaps contribute. So I might send this to them or I might delete it forever. Sounds good. I am sort of wondering how I got the courage to ask you to do this at the end. I'll start by introducing myself for anyone who's listening. My name's Emily Buckley. I'm a first year medical student at ANU. I feel like I'm doing a history right now and that's a little ironic because Dr. Michelle Barrett, who I'm interviewing, is kind of the one responsible for us learning to take histories, so no pressure. And over the past couple of years, Dr. Barrett has done 13 of these interviews where she's interviewed people who teach us here at the medical school about their medical lives and their careers and where they went to school and their experiences in medicine. And while we've heard some of these over the past year, throughout Dr. Barrett's stories, we've also heard hints at her amazing life. And so I thought, particularly at this time when we're worried about exams, it's good to get some perspective, particularly from someone we know so well over this year. And I'd also like to thank you because as you've given so many of these interviews, you're practically interviewing yourself because it's all of Dr Barrett's questions pretty much. So hopefully it'll be all right. I guess we should start at the beginning. Where did you do medicine? I did medicine at Flinders in Adelaide between 1986 and 1991. That was when it was still an undergraduate degree. And what prompted you to study medicine? I've thought about this a lot over the years. I think one of the things probably was that my grandmother was a midwife. She used to tell quite amazing stories about her midwifery. And when I was a school child, for work experience as a 15-year-old, I got to go to the little local hospital in Adelaide where she had been a midwife and where, fact I was born. And during that three days of work experience, I got to see a caesarean section, which literally had me sort of back against the wall like this, in terror. But it was so incredible that it was really quite a life-changing experience for me. And also about the same time, about 15 or 16, good friends of my family had a premature baby. And the mother had had to be evacuated from Darwin down to Adelaide. And the baby was only 25 weeks old. And I went to visit him in hospital, in the NICU, at Flinders, by chance. And he was literally only as big as my hand. And I clearly remember looking at him through the incubator and just thinking it was the most amazing thing and the most amazing place I'd ever been. He only weighed 500 grams, so that's like a tub of margarine. Anyway, he grew up to be a big strapping man of six foot something or other. He's got some high-powered job. He's a father himself. It was incredible what medicine was doing all the way back then. And so they were very pivotal moments in my young life. So then I decided to try and see if I could get in. Wow. Which was always a bit of a challenge. Was the process of getting in similar to what they do now? Did you have to do a test and interviews? No, no, no. It was a lot easier. It was a lot easier than what you guys have had to go through. A lot easier. Much, much, much, much. And I'm wondering, after having such amazing experiences, what was it like then to go back and to do as we're doing now, the sort of intense introduction to medicine, when you'd seen these amazing things, and then you'd get into the lecture theatres? That's an interesting question. Yes, I wasn't very good at the beginning because I had worked very hard at school to get the marks to get in and then I got to university and nobody was checking on me so I didn't go. I hung out with my boyfriend. I'd gone to a private school, so I started walking around with no shoes on and jeans with holes in them, thinking I was terribly groovy. So then I started to fail. Yeah, which was a bit ironic because my best friend and I had got in together. We'd sat in the maths classes at school together, planning and hoping to get in. And then we went to the open day and found out at university you needed 75% to get a high distinction. Well... LAUGHTER Who's ever got 75% to get a high distinction. Anyway. Who's ever got 75%? So when I failed a couple of exams, I realised I was playing with different kids. Was there a point when that turned round when, at some point in medical school, just asking for a friend? These questions weren't on our list. Sorry. Yes, when it got more clinical. Okay. Well, because the next question is on our list, which was, what did you do next? So, in sixth year, we had an elective, and that was basically a great excuse to go travelling all around the world, which I did. And in the process of that travelling I met my now husband in Scotland and he came over to Adelaide and we decided together to strike out, to go somewhere else for my internship rather than stay in Adelaide. So we came to Canberra thinking we were passing through 26 years ago. So clearly we've had a very good experience and Canberra's been very good to us and it's a good town to live in. And you were also in the army around this time? I was. So I'm from a military family and there was what still exists now, a thing called the undergraduate scheme, where the Army would effectively give you a scholarship for your last couple of years of the degree. You had to have got through the first three. They weren't going to give it to you when you were mucking around with no shoes on. And so that seemed like a good idea because they were going to pay me. I remember how much they paid me because I thought it was so much money and it was $12,500. And I said to my uncle, who was a fancy partner in a big accounting firm, what am I going to do with all this money? And he said, I expect you're going to spend it, Michelle. Which I did. I thought I was going to invest in shares and things like that. Throughout your time in the Army, I know you went to a few different places. Yeah. So my husband and I came over here to Canberra and I did my internship and residency here at this hospital. But then I had to start my return of service with the army. So they had supported me through half of fourth year and fifth year and sixth year. So you have to then pay them back whatever they've supported you, plus one year. So I basically had about three and a half to four years that I was contracted to pay them back in time. So I then, but you have, of course you have to do your intern and residency. So then I started to work for the army in the first field hospital, which used to be in Ingleburn in Sydney. And then Rwanda came along. And so that was in 1994. And Rwanda is a very small country in the middle of Africa where there was a horrific civil war where two tribes went to war and one of them had a very good go at committing genocide. And about a million people were killed in the course of a few weeks. So the Australian Army with the UN, in response to the UN, said that they would send a medical contingent and so I, you know, being one of the young doctors sent to the military hospital was one of the sort of first cabs off the rank of people to go. And I did, and it was a matter of putting my hand up. I remember the commanding officer talking to me and you could tell that he was checking out whether or not I was prepared to do this. And I had spoken to my husband about it and he said, well, you know, you'll have to, you can't sort of, you can't have that opportunity, and it was an opportunity, and not take it up. So I went to Rwanda for six and a half months as a PGY3, and that was really something. You listed Rwanda under the best things that you've ever done, but also under the worst thing. Yeah. And that's why I take your time. I was wondering whether perhaps we could do the worst thing first and then move on to some positive things. Okay. What do you feel like? That's a good idea. Yeah. Yeah. So it was... |
So there was me and another doctor and 90 other people who included medics who are... Graham is in the audience somewhere, he's been a medic in the army, who are people who are basically trained like ambos, they're very sophisticated first responders. And there are nurses, there were only a couple of nurses there with us, with the advance party. And there was me and this other doctor, and he was about five years older than me. And otherwise there was infantry and engineers and support people and all the people that make up an army contingent. And when we first got to this bombed out little hospital, it was... There was... None of the roofs were closed because they'd had bombs come through them. And there was no electricity and there was no running water and all of the ground was undulating everywhere you walked because it was full of shallow graves. And there was blood on the walls and things like IV poles just hanging where people had ripped the IV out and run away. And we went, so Lindsay and I, the other doctor, went looking around this place and we found this little operating theatre. And in that operating theatre were some NGOs, an organisation called Emergency, which is an Italian aid organisation that still operates. And there was a fellow there called Gino, who was a surgeon, and he'd been the only surgeon in town for a month. So we sort of blithely walked up and said, you know, hi, we're doctors from Australia. And he went, right, you're surgeons now. And so we watched him do one amputation on somebody who'd set up a farm. And then he said, all right, Michelle, you do the next one. I said, okay, I don't know if they do things differently in Italy, but I've maybe held a retractor a few times for one or two amputations. I certainly haven't done one. He said, no, see one, do one, teach one. Off you go. So this woman was a 26-year-old woman who had her leg macheted, but it had been macheted about six weeks beforehand, and it was just flailing around and was gangrenous. So I amputated her leg and that was sort of the beginning of what it continued to be like the whole time. The worst experience that I had there was, It was still a very, very unstable country. Even though the main massacre was over, everything was very unstable. And one Sunday morning, we were radioed in that there'd been a massacre in a village and that we were going to get a number of casualties choppered into us by the UN. So that was all, you know, it's not very nice to admit it, but it's all quite exciting when you've got, when you're dealing with major casualties, when you're dealing with a major emergency. So the whole contingent had to rally and we were there, numerous of us having to conduct recesses. And I was conducting a recess on a young girl of about 10 or 11. And she had this wound in her abdomen that we didn't know if it was a gunshot wound or if it was a stabbing wound. But it was about this big and it was messy looking. So I did the recess and you know so that includes all the standard things that you'll learn over the years and by this stage of the game we had we did have specialists with us so reservist specialists from Australia had come over so So by this stage of the game, I was being more, acting more appropriately for my level of training in that this girl was then going to be going on to see a real surgeon. But I had to do the recess first. And so I knew that when you have these kinds of injuries, you have to look for entry and exit wounds. And the medics know that, and there's an arrangement where you say one, two, three, and they lift the patient up, and you look at their back for entry or exit wounds. Because an entry wound, say from a bullet, is in fact much smaller than the exit wound because it comes in sharp and then rolls around inside your body and explodes out. So I knew to look for that and we did look for that but I didn't see anything. So we got her stable enough to go to surgery and then the surgeons did an open laparotomy to explore the big, the wound from the front and they debrided things and cut off and sewed up bleeders and that sort of thing and she seemed quite stable. And she went back to the ward and she was being monitored for her vital signs every 15 minutes and then she just died. And so I was pretty devastated that it was my fault that she'd died. And I went and had another look at her, and I could see an entry wound on her back. It was about a centimetre long, and it was linear, so it had closed over, which is why I didn't see it in the first place. So I was pretty beside myself about that. But the way that I tried to deal with that is I went and spoke to the surgeons and said, look, I think, you know, look, come and have a look at this. Here's the entry wound. And they said, yeah, well, Michelle, it wouldn't have made any difference because we still had to do the open laparotomy and explore from the front anyway. It didn't actually change what we then had to do. And she had a chest X-ray and she had a very enlarged heart, so she probably had some congenital heart abnormality and then just had an arrhythmia and died. Of course I couldn't, I had a lot of trouble getting that out of my head that she died and there was something that I missed even if it wasn't actually related. And what was really terrible is that then her father showed up. And he had been walking for three days. So she'd been choppered out of the village where this massacre had happened. He'd been walking for three days to find her. And I had to take him to the morgue. And up to that time, there was a fair bit of thinking. You know, we were developing hard skins. And we were just starting to think, okay, well, you know, this is happening to these people who are these Rwandans who have been involved in this incredible war. This isn't actually anything to do with me. I'm just here being a technician. But when I had to show the father, and of course neither of us spoke each other's language, his daughter, and he fell to his knees in the morgue. It really brought it home to me that your child is your child. It doesn't matter where you are. And that was all pretty bad and pretty hard to deal with. And that was my worst story. Thank you for telling us that story. I know that's a tricky one to tell. I then wanted to ask you, going through that relentless experience, because I'm guessing there's a lot of other stories like that one. Yeah, it was pretty relentless. You're quite right. Why do you say it was one of the best things that you did as well? Because, oh well, because it was an incredible experience for a PGY3, you know, a 26-year-old girl from middle-class Australia to end up in the centre of Africa in a war zone. It was an incredible eye-opener to me from the point of view of what people are capable of, what humans are capable of, in terms of the war that had gone on, but also an incredible eye- eye opener from the point of view of how people cope. So for instance how I coped, how all the soldiers around me coped. I almost took up smoking. I really wanted to because a lot of the soldiers would smoke and I'd think, I need that. I didn't. Which was a good idea. But I really remember thinking, I've got to do something like that. But from the point of view of managing, of developing resilience and trying to cope with horrific experiences, that was a big eye-opener for me. The other thing you said was the best thing you ever did was to do with your practice. Yes, yes. I'm wondering how did you get from 26 in Rwanda to having your own clinical practice? Yeah, that's an interesting question. Mostly because the Army kept putting me in these positions of responsibility that was way above my experience. And so after I'd had my second child and the army said oh why don't you go to East Timor and manage the medical company there and my baby was six weeks old I thought maybe that's the end of the army so but the thing was they kept putting me in positions of seniority. |
Welcome to On The Wards, it's James Edwards, the host of our podcast series. Today we're speaking about bleeding in early pregnancy with Dr Neil Campbell, an obstetrician and gynaecologist here at RPA. Yeah matey thanks for asking me to come along. So again we'll start with a case and we I think most junior doctors would more likely to see PV bleeding early pregnancy whilst they're doing emergency terms so we have an emergency medicine case a 30 year old female presents to ED six weeks pregnant with some PV bleeding. What's your immediate kind of approach or risk assessment if you're a junior doctor asked to see the patient? Yeah, I think the most important thing is just to follow the things that you would normally do in terms of your stabilising and resuscitating the patient as necessary. Most of these patients are actually very stable, but I think making sure that you sort out the very sick patients first, so stabilization with IV access, full blood count, checking a group and hold, potentially doing a cross match if the patient's very unwell and maybe moving to a more resuscitation friendly environment in the emergency department and doing a beta HCG which will then, as time progresses and the scenario develops, enable you to have more information. I think once you know that you've got a stable patient where you've got time to evaluate and you're not rushing off to theatre, then I think the history is very important. So I think looking at the severity of the pain, if it's present, the amount and duration of the bleeding, and then you can kind of move backwards from there looking at is there some kind of history here that is going to enable you to differentiate or increase the likelihood of this patient having an ectopic pregnancy. For example, a previous ectopic, previous pelvic inflammatory disease or significant history of endometriosis. So what are the kind of things in the back of your mind, what's the differential diagnosis for PV bleeding in early pregnancy? You mentioned ectopic. Well, I think the most important thing is differentiating an ectopic pregnancy from some kind of early miscarriage. And as you know, there's a wide variety of miscarriages from a threatened miscarriage, which would be somebody who would turn up with a small amount of bleeding but no pain, all the way through to an incomplete miscarriage where the patient might be bleeding quite heavily and have significant cramping type pain. And then you go through all of the other different scenarios of the missed miscarriage or what used to be called a blighted ovum and an inevitable miscarriage which is not a particularly useful term because it's somewhere between a threatened miscarriage and an incomplete miscarriage. And then I think most of the patients you're going to be in a situation where you can very easily distinguish that they're either having an early miscarriage or a threatened miscarriage or they have an ectopic pregnancy. And then you're left with a small number of patients where there's a kind of diagnostic conundrum. And they're the people that need your kind of work up and more effort. Okay, so you've mentioned a few things on history. Yeah. Anything on examination that may help difference between an early miscarriage and ectopic? So I think, again, it's important to take your history and then move on to your clinical examination before rushing ahead to investigation. So I think a general clinical examination, so looking at your pulse, your blood pressure, temperature, looking at a general cardiovascular and respiratory examination to see whether your patient is actually compromised. Then moving steadily downwards, so you're doing an abdominal palpation, looking for signs of peritonism. I mean, that's probably the clear thing is that most ectopic pregnancies, when the patient is unwell and when there's been significant bleeding intraperitoneally will have a unilateral abdominal tenderness and they may have some guarding. That might then clinically correlate with your history where they might have some shoulder tip pain showing some diaphragmatic irritation from bleeding. And then once you've done your abdominal examination then you need to do a thorough pelvic examination and that involves a clinical inspection of the vulva and vagina looking for the amount of bleeding and whether there's blood clots or products of conception there at the time and then moving on to your speculum examination. And really the speculum examination is giving you an idea of the quantity of bleeding, whether or not there are products of conception at the top of the vagina or within the cervical os, and whether the cervical os is open or closed. Because this will then make your differentiation of either your type of miscarriage to say this is an incomplete miscarriage or whether the cervix is shut tight and there's not much bleeding but they have a lot of abdominal pain which might suggest that they've got an ectopic pregnancy. And then a bimanual examination can give you some more information as to the size of the uterus, the location of any tenderness in either the right or the left vaginal faunuses. And often, I think particularly with more inexperienced people, it's easier to actually feel the cervical os and whether it's open or closed than it is to see it on a speculum examination, which might be more difficult. Often comes up in emergency departments the question of someone's bleeding settled down, they're not too much pain, but have got some bleeding, whether the junior doctor should do an exam in ED when it's probably going to be repeated by maybe the gynaecology registrar or they should say look I'm not going to do the exam, gynaecology will do it. What are your thoughts on that? My thoughts are that if you take that to its logical conclusion, given the fact that in the environment that we work in at the moment where a lot of people get a lot of their experience in all of their kind of presentations through their emergency department experience, if you say to everybody you shouldn't do a speculum examination unless because the gynaecologist is going to do it, then you never actually get any good at it. There are some good registrars and more senior clinicians in the A&E department that are very capable of doing speculum examinations. I think if a clinician is not, you know, if a very junior clinician is not confident in doing a speculum examination, then they should be still doing the speculum examination, but they should have somebody to supervise them. Whether that's somebody more senior in the A&E department or whether that's one of the gynecology registrars depends a little bit on the scenario. Okay, so we've done a history exam. We mentioned some investigations, I think a full blood count. A group and hold. A group and hold. Possibly a cross match, yeah. Yeah, cross match and beta HCG. Yeah, also a progesterone level can help. So if you're in a scenario where the clinical examination has left you very unsure, the pain is not very significant, the bleeding is not particularly heavy, and you're looking to move on to an ultrasound to help you with the diagnosis, then a progesterone level can help you a little bit when you correlate it with the beta HCG and the transvaginal ultrasound findings. For example, if you have a history that is suggestive of a miscarriage, the ultrasound scan shows that the uterus is empty, the HCG is low, and the progesterone is less than 10, then you can be fairly sure that's a complete miscarriage. And so you could be quite confident in discharging that patient and then bringing them back for follow-up in a few days' time. And conversely, if you have somebody who has an ultrasound where the HCG may be around 1,000 or 800, so you're not sure whether you would always see an intrauterine pregnancy on transvaginal scan, and your clinical history is making you concerned that they might have an ectopic, if the progesterone comes back between 20 and 60, then that would push you more in that direction, which might help you work out whether that patient then gets seen by one of the specialist teams, or whether you discharge them and then you follow them up in the early pregnancy clinic in one or two days' time. So why is rhesus blood group important for females to present with PV bleeding? So rhesus blood group, in our population 70 to 80 percent of all people are rhesus positive. If a woman is rhesus negative it's therefore likely that the baby would be rhesus positive. So in any kind of scenario where there's vaginal bleeding or trauma to the placental site, then there's the possibility of some of those rhesus positive blood cells going through into the maternal circulation and then the mother developing an antibody response, which then might affect a future pregnancy. We have an abundance of anti-D, which can be given. I think at the moment we're using it routinely in pregnancy as a prophylaxis to reduce the number of sensitized women. And therefore, we almost see no cases of rhesus disease anymore, which is great. |
And what's the dose? Because there's a lower dose in early pregnancy. So we usually, so under 12 weeks, I think we use 250 units intramuscularly, and then we use 625 if they're over 12 weeks. Okay, and so look, usually we've done some blood tests, and usually it's the ultrasound, the next test. I just want to chat about when the ultrasound should get done, trans-abdominal versus trans-vaginal. Yeah, I mean I think if you have, it depends on the scenario. So if you have a patient who's had a previous ultrasound that shows that they've got an intrauterine pregnancy, then that makes you much less concerned. You know that this is some kind of a miscarriage and then the diagnosis is fairly easy. If they're bleeding very heavily and the cervix is open, then they need to go to theatre for a DNC for an incomplete miscarriage. And if they don't have, if they have minimal symptoms, it's likely that they would be able to wait until the next day to have an ultrasound to either confirm or refute the diagnosis of miscarriage. The key things are the patients who are symptomatic where you're concerned that there might be an ectopic pregnancy. And that's where really the correlation of the HCG and the transvaginal ultrasound really help you. Because if you have an HCG that's over a thousand thousand it would be very rare for us not to be able to see a gestational sac on a transvaginal ultrasound. Transabdominal ultrasound is generally done initially as a kind of screening tool so if you do a transabdominal ultrasound you see that there's an eight-week gestation you see a fetal heartbeat then there's no need to progress on to the transvaginal scan. But in most cases, women will be having a transvaginal scan, because you're mostly dealing with pregnancies where you're looking for a gestational sac. And a transvaginal scan will pick up a gestational sac around a week before a transabdominal scan, and give you much more accurate information. So sometimes you get the ultrasound comes back, no gestational sac, they've got a positive beta HCG, what are the clinical possibilities? Well at that point the clinical possibilities are either they've had a complete miscarriage or they have an early pregnancy of uncertain viability or they have an ectopic pregnancy that's yet to be determined. If those patients are very stable and if the HCG is below a thousand and they have minimal symptoms then I think it's quite reasonable for those patients to come back and see us in the early pregnancy clinic. But if you have a patient where you have an HCG that's more than a thousand, you have some symptoms, so maybe a unilateral pelvic pain, some, and something in the history that alerts you to this might be an ectopic pregnancy, then obviously you need to take that much more seriously. They need to be reviewed by the gynecology team, and they may actually go to theatre for management of a possible ectopic pregnancy at that point. The problem is always when there's been a fair bit of vaginal bleeding before the presentation and you have an HCG that's over 1,000 and an empty uterus, is this a complete miscarriage and the HCG will be falling when you do the HCG in 24 to 48 hours time? Or is this an ectopic pregnancy? And that's where the whole clinical picture comes in and unfortunately that does come with experience. Okay, so we've gone through some of the use of ultrasound for the blood tests. It sounds like you have described some of the criteria for which ones can go home and which ones need a gynae review. Any other clinical cases? I mean, I must always say if anyone's got unilateral pain, I tend to get a gynae review. Yeah, I mean, there are other scenarios. So I think the other thing to remember at all times with this is that a number of people in early pregnancy present with other problems that are not necessarily directly related to the pregnancy. So we see quite a lot of ovarian pathology, so either cyst accidents, cyst rupture, or potential torted ovaries. And we also see patients who just happen to be in early pregnancy but also have an appendicitis. So I think it's important just to remember that you can have other presentations while you're in early pregnancy. But the take-home message really is not to miss the ectopic pregnancies because it's very, very rare for someone to bleed very heavily from an early miscarriage. And it's usually fairly easy to make that decision if they are bleeding heavily because the cervical loss will be open and you'll often see pregnancy tissue at the cervix. Whereas with the ectopics they often come in and they can become very unwell quite quickly without too many overt signs. So I think that's probably the most important thing. And if you stick to most of those rules what you find is that you have a number of patients that are very sick that need to go to the operating theatre, and you have a small number of patients where the diagnosis is a little bit uncertain. And most of those patients, if they've had an HCG and a detailed clinical examination and a significant assessment of their past history and symptoms, will actually be able to go home and then follow up with our very well evolved early pregnancy service. If someone you do think maybe ultrasound has shown a complete miscarriage or maybe incomplete miscarriage, what are the kind of treatment options available? So for a complete miscarriage we usually follow those patients up particularly if there's been no identified products of conception because I think it's very important to make sure that their HCGs fall down to zero and just to make sure that empty uterus wasn't because the pregnancy was in the fallopian tube. I think the other, let me just go back a minute, I think the other managements when you're looking at either a missed miscarriage or an incomplete miscarriage, then there are two main options. We can take them to theatre and do a traditional dilatation and curatage, but that may have some complications associated with it. We have a new policy here, and it's moving through Australia fairly slowly, where we're using mefipristone 48 hours before starting oral or buccal misoprostol. So we're using a prostaglandin related approach to try and improve the spontaneous miscarriage rate. And obviously there's also the option for a patient with a miscarriage of just waiting and seeing. They get very carefully followed up in the early pregnancy clinic. We usually see them at weekly intervals and we make sure that the uterus is empty and then we're counselling them on a weekly basis about their various options. And if you do find what may be speculums and products of conception, what should we do with those products of conception? So I think any tissue that comes out of the body in the hospital really needs to go off to the laboratory. One of the more rare concerns would be a molar pregnancy and either a partial mole or a complete mole. So any tissue that gets taken out of the cervix should go into a pot with formalin in it and be sent off to histopathology and then they'll make a decision as to whether that's a partial mole or a complete mole. And then we have a register for those patients and we follow their HCGs on a monthly basis. Well, on a weekly basis until it goes back to zero and then on a monthly basis for six months before those patients are then advised that it's safe for them to get pregnant again. Okay, is there any other kind of issues or take-home points you want to talk to us about leading an early pregnancy? I think the only other thing would be to say that if there is a significant amount of uncertainty, this is a very sensitive group of patients. We have an increasing presence at Prince Alfred Hospital with our early pregnancy clinic with a midwife being present who is very experienced in early pregnancy issues over the weekend. And there are very small amounts of time that are not covered by somebody who has a significant amount of experience. So if you're not sure then I think it's very important to escalate that and get some more senior advice. Because if you do make the wrong decision with somebody in early pregnancy and you're not completely sure that they fit into the criteria to be discharged, the potential for harm with a ruptured ectopic is still there, even though we don't see deaths anywhere near as often as we used to from a ruptured ectopic pregnancy because people are much more aware of their services. The emergency department has improved its care of the very sick patients and the triaging of patients in early pregnancy tends to be very quick. But I think if there is any uncertainty, then there needs to be some escalation to more senior. I think it is difficult. |
Welcome everyone to On The Wards. Today we've got Dr. Rob Heslop back. Many remember Rob's podcast on oligour. Currently our highest rating podcast. Welcome, Rob. Hi, James. Good to hear it. Look, Rob's an intensivist at RPA and head of the department of the Mater Hospital. The clinical lecturer at the University of Sydney. And the way you've described yourself is sometimes you like to challenge conventional wisdom. So surely we're talking today about altered level of consciousness. It's a fairly dry topic. Yes. But, Rob, will you be challenging any conventional wisdom in how to manage a patient with altered level of consciousness today? Yeah, I think so. Perhaps a little less so than my oliguria talk, but maybe a little bit, yes. Okay. Look, we'll start with a case. You're the junior on the ward in the evening. You're asked to see a patient who's 70 years old who's become agitated and confused, and they're about day one post-operative hip replacement. What sort of things would you ask over the phone when the nursing staff give you a call? Well, look, I think this is the kind of problem that you shouldn't really be managing over the phone. I think probably some good things to know are how dangerous is the situation, how agitated, how elevated is the patient? Are they swinging punches at nurses? Are they pulling lines out? Are they trying to climb out of bed? And if that's so you may need to prescribe some sedative over the phone but really you need to get yourself to the bedside as soon as possible and have a look at the patient. These sorts of situations can be particularly dangerous, and a lot of this comes down to judgement. So there are all sorts of different ways that patients can behave when they're delirious. Some have hypoactive delirium and lie in bed relatively still and compliant, but having no idea what day it is or what's going on or where they are. And other patients can have extreme levels of agitation and elevation and can pose an immediate great danger to themselves and those looking after them. And if that's the case, then this is really a medical emergency. So you have a quick discussion with the nurses over the phone. They said, you know, they're trying to climb out of bed. So you head down and see the patient. When you arrive to see the patient, describe your approach. Again, quickly just take in as much as you can. How alert and awake is the patient? What are their vital signs? Are there any signs of airway compromise, hypoxia, hypotension? So like any critical situation, I guess start with your ABCs and just make sure they're attended to. And if they're all reasonably adequate, then I guess you need to start attending to trying to manage the situation as well as trying to figure out why the patient's like this. In terms of managing the situation I think quite often what you need is several people, hopefully relatively strong folk, who can help to physically restrain the patient if they're extremely agitated and elevated and unable to obey commands or comply with orders or requests, whilst you can establish intravenous access if there is none, and administering some sedative agents intravenously to control the situation pharmacologically. So I think it's very cultural in Australia, probably more so than in other parts of the world, to use physical restraints in patients who have agitated delirium and are non-compliant with therapy. And I think that's perfectly reasonable, but I think that should be a starting point to enable us to get pharmacological control and we should not be aiming to use physical restraints as our means of making these patients safe and making the work environment safe. So you feel they're safe from an agitation point of view currently and their vital signs are something overly abnormal. What else would you be looking for in the history and exam to try and work out, I guess, the cause of their delirium? Well, I guess, you know, the causes are myriad and there are long lists of things that can make patients go loopy post-operatively or in the middle of the night or whenever. These include infections, sepsis, inflammation, metabolic causes, endocrine causes, electrolyte abnormalities, drug withdrawal, drug intoxication, and the list goes on and on. And I guess really you need to go through this in a relatively thorough fashion. Sometimes things will jump out at you. And quite commonly, patients will either have an inflammatory or an infective problem. And I think it's underappreciated just how common it is that inflammation is the cause of delirium in patients in hospital. So just having had a big operation in itself is probably enough to make patients delirious. They may not have sepsis, although they may, and if they have sepsis, that's a very common cause of delirium. But quite often patients can be post-operative. They can be in a relatively high inflammatory state from the surgery. They've had drugs, they've had anaesthetic agents, their sleep might have been disturbed for a night or two, their sodium might be deranged and they can be very delirious and agitated. Another marked cause of delirium really is sleep deprivation in hospital. And I think another thing that we have some idea about is what you might call brain reserve. So what sort of function did the patient have out in the community before they came into hospital? Are they an elderly patient who's really been suffering some slow decline in their cognitive and mental capacities and now they've been tipped over the edge with the insults of what's happened in hospital? Of course, alcohol is an important thing to consider. So alcohol withdrawal, withdrawal of other depressive agents in particular. But I would just caution everyone against jumping to the conclusion that someone who has some kind of alcohol intake history who becomes delirious and agitated, I would caution against jumping to the conclusion that therefore this must be alcohol withdrawal syndrome. Although there's a lot of drinking out there in the community and a lot of heavy drinkers can suffer from alcohol withdrawal symptoms when they stop drinking, delirium in hospitals is also exceedingly common and it's not necessarily as simple as someone drinks, someone's been a day or two without their alcohol and now they're delirious. It's not just that simple that it's alcohol withdrawal. So you do need to look for other causes, be aware of other causes and manage those as well as managing the behaviour of the patient. So I guess the other thing that's worth remembering is that when we sedate patients with agitated delirium, we're not treating the delirium as such, we're treating the symptoms. We're making the patient safer, hopefully, although depending on the level of sedation we provide, we may be actually exposing the patient to the risk of that sedation in terms of cardiorespiratory depression. But hopefully we're making the patient safer and we're making the environment safer for those working with the patient. And I think that's something we underappreciate as doctors as well. If we're managing these patients with delirium, particularly the patients with very agitated, elevated deliriums, we have a duty of care not just to the patient but also to the staff looking after them. And one of my strong feelings is that culturally medical professionals are a little bit hesitant, reticent to treat these problems aggressively enough. So I guess this is where I'm a little bit different to some of the pervading culture out there in terms of treatment of agitated delirium. I think that quite often we undermanage it and we leave patients in ongoing elevated states with almost homeopathic doses of sedative agents or antipsychotic agents, which leaves the patient in their elevated, violent, agitated state, leaves them exposed to the risk of pulling their lines out, falling out of bed, tripping over, and leaves the staff looking after them at risk of being assaulted and hurt and injured. So, Rick, you're talking of agents, you're talking things like haloperidol, which most geriatricians would say start very low, 0.5 milligrams orally, maybe only escalate up. And their concern is if they get a big dose of something like haloperidol, then they tend to sleep for the next kind of 24 hours. And they have a point. And yes, I am talking about drugs like haloperidol. So I'm talking about drugs like haloperidol, perhaps olanzapine, possibly chlorpromazine, and sometimes oral agents as well. So I'm quite a big advocate of using intravenous agents. I'm an advocate in using them and titrating them to effect and standing at the bedside and continuing to administer the drug at intervals, observing the patient's response. |
And so I guess taking from that what I'm advocating is in patients who are particularly elevated and particularly delirious and particularly difficult to manage and violent, I don't think it's unreasonable for such patients to be reviewed by intensive care doctors with a view to admitting them to intensive care to provide the sedation that they need in a safe environment that can manage the unwanted side effects of cardiorespiratory depression or airway compromise. So I agree with the geriatricians that there can be problems with providing these sedative agents. In my experience, I find that patients who are exceedingly elevated, it can be very difficult to titrate them to that Goldilocks zone we want, where they're now calm and obeying and alert, reasonably alert and interactive, but no longer pulling their lines out or climbing out of bed or swinging punches. And the reality of the situation, at least in my hands, is that I'm not always able to titrate my sedative agents to that end point. And I've seen many patients who I've been providing sedation to and they're almost semi-conscious now but they're still swinging feeble punches and they're still pulling at their lines. And I think in the real world, some of these patients, you cannot titrate your therapy to a spot where you like the way they are. They're either still agitated and elevated and still dangerous to themselves and others, they're quite deeply asleep. So for that reason I think it's not unreasonable to get attention from critical care doctors, intensivists or their registrars with a view to admitting the patients to that unit so they can provide that sedation and make the patient safe. Okay, so it's great to have I guess an intensivist perspective of delirium. I guess you see ICU-type delirium, which you often get when patients have been there for a while, especially after they've been sedated for a long period of time. I guess for the junior doctors out there, it's probably worth having a listen to our podcast on delirium, which was done by Scott Murray, one of the geriatricians, and he has a slightly different perspective, but along the same lines as trying to find the underlying cause and really just using those kind of agents to make everyone safe. We'll maybe go to another case. It's very similar. Night shift, somebody's 70-year-olds and they're day one post-op, but this time they're difficult to rile. So they're not, they're kind of agitated. They're just, you know, the nurse tried to wake them up and they didn't seem, they seemed a bit sleepy or a bit concerned. How would you price this one? So I guess we're talking about a patient really with an altered level of consciousness. So again, as an intensivist in this sort of situation, I would start by assessing the patient's ABCs, making sure their airway is patent and if it's not, supporting it, making sure they're breathing adequately. if they're not, support it, provide some oxygen, make sure their pulse and blood pressure are adequate, if they're not, support them, institute some monitoring, and then assess just how difficult they are to arouse. So I'll do that by GCS examination, so looking at their eyes, looking at their verbal response and their motor response. And then I can make an assessment of how drowsy they are. Are they in a deep coma? Are they just moderately drowsy and slightly difficult to rouse or what? And from that I can get an idea of how dangerous the situation is and what I might need to do next. When you say deep coma, moderately drowsy, I mean where are they on the new kind of GCS? Most of us would say if your GCS was 8 or below that was a reasonably deep level of consciousness impairment or relatively deep level of coma and if you scored something between 9 and 12 that would be sort of moderately deep and 13 to 15 would not be so bad. One of the problems though with the GCS is that not every element of the GCS is as important as the others and the score that's particularly important is the motor score. So if you imagine a patient who's had a dominant hemispheric stroke, is completely alert but totally dysphasic, they might score relatively poorly on their GCS but actually, actual fact their conscious state is not impaired at all they just have they have dysphasia so and you can also imagine patients who are deeply comatose but whose eyes are open so the GCS the score of the GCS is not perfect and what is much more meaningful is the motor score. Can the patient obey commands? Can the patient at least localise to pain or not? Or are they doing something really nasty like abnormal posturing, extensive posturing to pain, something like that. So that's where we really place most of the credences in the motor score when we're assessing the GCS. And what's your differential diagnosis of someone who's got a little bit of a conscious problem that's kind of drowsy rather than agitated? Well, I guess I'd probably go back a step and say if I'm assessing someone with an altered level of consciousness like this, I'd first try and assess whether the patient, which group, which one of three groups does this patient fit into? Are they a patient who has an altered level of consciousness with focal neurological signs? Or do they have an absence of focal signs, but there's meningism present? Or is there an absence of focal signs and no meningism? So if you start with those three categories, that can help to take you down a diagnostic and also investigation and management algorithm. So in examining such a patient as this, if I find focal signs like a fixed and dilated pupil on one side or abnormal posturing on one side or an extensive plantar on one side or something like that, then to me that's really highly suggestive of a structural lesion in the brain and that really mandates urgent imaging. So I guess that's the first thing to say. If this was a patient who didn't have focal signs like that and was just reasonably difficult to rouse and there was no meningism present, then again the causes are relatively myriad, but things that would spring to mind would be drug intoxication, postictal states, organ failures, encephalopathies, hepatic encephalopathy, uremic encephalopathy, electrolyte disorders, endocrine disorders, things like that. It's interesting because the way you approach the exam because a lot of junior doctors will see someone unconscious and kind of go, well, they're unconscious, they can't do an examination on them. Maybe what's the intensivist approach to examining an unconscious patient? It is interesting because we get taught at medical school how to examine patients and we nearly always get taught how to examine conscious and cooperative patients. I guess because that's the bulk of the patients that we see, particularly when we're in tutorials and stuff like that. But there's actually a remarkable amount you can do even on a patient with a GCS of 3. So we can obviously assess their GCS and then we can examine their cranial nerves. So you actually can get a lot of information about cranial nerves 2 through 10, even in a comatose patient. So you can examine their pupillary response to light. You can examine their corneal reflexes, which will tell you about the sensory nerve of 5 and the motor output of 7. You can do their oculocephalic reflex, which will examine quite a lot of the brainstem and tell you about the connections in the brainstem between the nerves supplying the ocular muscles and the vestibular nerves. So there's a lot you can do. From then you can go on and examine for focal neurological signs around the place, look for posturing, examine the upper limbs and lower limbs, examine for meningism, look for toxidromes, which is very important. So there are certain drug intoxications that have classical pictures. So we all know about patients who've overdosed on opiates who have pinpoint pupils and have slow respiratory rate, bradycardia and hypotension. And many of us might have seen patients with serotonin syndrome who have dilated pupils and clonus in the lower limbs well out of proportion to their upper limbs and stuff like that. So toxidromes are very helpful. A lot of these toxidromes also have antidotes that can be very effective or particular types of care that can help to keep the patients safer. So there's a lot of neurological examination that can be done. I think I mentioned meningism. So despite the fact that there might be a patient lying in front of you who can't comply with your examination, there's still a lot you can do and a lot of information you can glean which can help you to know what tests to do next and also how to start managing the patient beyond the ABCs and basic resuscitation and supportive care. |
I guess that leads in some ways, one of the big questions for junior doctors, which one of these needs a CAT scan? Absolutely. And this is something we see very commonly in intensive care is that patients get scanned all the time for altered level of consciousness. And, I mean, it's not unreasonable, but a better way to start would be have a proper look at your patient examine them thoroughly looking for signs of focal neurology signs of focal pathology and if you find that absolutely that mandates imaging if it's a new pathology that is I mean I guess if you have a patient with a known old hemispheric stroke and there are signs consistent with that, that doesn't necessarily mandate imaging. But if you find new focal neurological signs, that mandates imaging. If there's a complete absence of that and there's an absence of meningism, then really the yield on CT scanning these patients is very low. Now I have to admit that occasionally I have scanned such patients. If I've been looking after someone in the intensive care unit who's not waking up and has been quite some time and I'm expecting they should, sometimes I lose my bottle and scan them. Most of the time I still find nothing. Very occasionally I get surprised. So I wouldn't say hard and fast never scan these people, but I would say it's reasonably justifiable in the absence of focal neurological signs not to do a CT scan. And if you're scanning someone with meningism, you're really doing that for two things, I guess. One is to see is there evidence of a subarachnoid hemorrhage, and the other is to make sure it's safe for you to do a lumbar puncture if part of your differential is an ingoic kephalitis. Any other investigations you'd routinely order? So we've got the CAT scan for those with focal signs. So obviously if there's meningism and you've done your CT scan and if you think the patient might have meningitis, then obviously you will have administered the appropriate antibiotics and you'll have sent off blood cultures before you've done that. But if we're talking about a patient with no focal neuroscience, without meningism, and let's say they might have presented to the ED or something, then I guess your battery of tests should include urea and electrolytes, particularly looking for sodium. Calcium is important, as is magnesium. Bedside glucose. Bedside glucose, absolutely. Don't ever forget glucose. I always forget glucose. And if you're administering glucose, you want to think about thiamine because you don't want to precipitate Wernicke's. What else? It would be worth doing a paracetamol level, salicylate level. But some screens that can help you a lot is an arterial blood gas and you can look for a metabolic acidosis. Together with a blood gas it'd be worth measuring a serum osmolality and if you find that there's a difference between the osmolality that's measured on the blood and what we would calculate or what we'd expect the osmolality to be by looking at the sodium and the urea and the glucose, if you find a discrepancy between the expected and the actual osmolality, then you need to think about an exogenous osmol, usually an alcohol, which might just be ethanol or it might be a toxic alcohol like methanol. Okay, so there's the investigation. I guess the most difficult part is management, trying to work out which ones require usually protection of their airway. And I guess management will really depend on what you think the underlying cause is. But what are some of the common sort of management strategies and how do you approach the one working out who requires intubation airway protection? I guess, too, the other thing I keep forgetting to mention is seizures, seizure disorders. So these patients also should probably get an EEG at some stage and if you think seizures is part of the differential you should consider managing it. So just repeat the question for me. Airway or decision about airway management, which ones require intubation and then just common maybe, you know, is there a role for naloxone, is there a role for other medications if somebody's drowsy? Very good. So in terms of intubating, this is something that I wouldn't recommend all and sundry to be doing. I'd recommend them to be referring the right doctors with the right skills, so emergency doctors or anaesthetists, intensivists. As a general rule of thumb, many of us use the throwaway line, GCS less than 8, intubate. And that's not a bad rule of thumb, but there are some exceptions to that. And certainly the main thing we really want to be doing is intubating someone if there's any risk at all that they're not likely to protect their airway. Now, that doesn mean if they're breathing okay they don't need to be intubated and some people do tend to equate breathing okay with protecting your airway. Protecting your airway is a different thing. It really means if this patient was to vomit are we confident that they wouldn't aspirate? So the only way really to make that assessment is to assess their gag. And if any doubt, we should consider intubating them. So GCS less than 8 as a rough rule of thumb, but again, the motor score is the most important thing. And the other thing we would look at is if someone's level of consciousness may be better than that, but if it's falling reasonably rapidly and the situation looks poorly controlled, then we'd be much more likely to control their airway earlier and get definitive access early. So there's that. In terms of naloxone, if you consider that the patient could be suffering from an opiate intoxication, there is a decision to be made about whether you should or shouldn't administer naloxone. Now you can get yourself in trouble by administering naloxone. So I've seen this in emergency departments where people have come in overdosed on heroin, they get some intramuscular naloxone, wake up, pull everything out, tell everyone to rack off, walk out of the department and lose consciousness again. So that's a dangerous situation. And perhaps in that situation it might have been safer just to intubate the patient, move them to a safe area of the hospital like the intensive care unit and support them while the drug wears off. But I guess that's a judgement call but it's always worth remembering that's the kind of trouble you can get yourself into. And we see this on the wards as well, we see patients in post-operative states who have had maybe a bit more opiate than really they could tolerate. Maybe they've got some renal dysfunction or something like that and they end up narcotized. Now, going and administering a bolus of naloxone to them might help you diagnostically because they might wake up very quickly. But it can create problems. So these patients can wake up and suddenly experience extreme pain because they no longer have any opiates acting. So that can be one problem and the other problem is that it might wake them up, it might make them safe for a little while but quite often that naloxone again will wear off much more quickly than the opiate that's on board and then the patient's back in a dangerous situation in a half an hour or an hour's time and really we've achieved nothing. So I think if there are patients who are sick enough or dangerous enough to require some naloxone to provide some reversal of their opiate, it's not a bad idea again to consider admitting them to intensive care for a naloxone infusion. And that enables us to titrate a very low dose of naloxone just to antagonise the opiate effect enough to help them to breathe more safely or support their airway, yet perhaps not precipitate extreme pain and discomfort. So I guess I think intermittent naloxone is a very bad plan for opiate intoxication. Similarly, I don't think reversing benzodiazepines is a great plan either, usually. Benzodiazepines, reasonably safe overdose in inverted commas as long as we provide the appropriate supportive care of airway and breathing and circulation. I mean, it's probably difficult to describe too much management because it's really dependent on what the underlying cause is. But maybe in regard to escalation of care, someone who's got a reduced LOC, I mean, is that something a junior doctor should be speaking to the medical or surgical registrar about pretty much every patient? Yeah, I would have thought so. And again, it depends on exactly what their GCS is. If someone has a GCS of 14 or 13 and they've been like that for two days and everyone knows why, that may not be such a bad thing. But certainly if it's much lower than that, I'd expect junior doctors to be escalating that upwards, especially in the absence of a diagnosis and especially in the absence of ongoing deterioration. |
Welcome to On The Wards, it's James Edwards and today we're talking about preventing and resolving trainee disputes and I have the pleasure of welcoming Penny Brown. Welcome, Penny. Thank you. Penny is a general practitioner and work extensively with general practice education and is currently a senior staff specialist in general practice at Hornsby and is also the senior medical officer at Avant. So maybe we'll start, within your role at Avant, why have you become concerned about training program disputes? Yeah, thanks, James. This is a really interesting area. Clearly it piqued my interest because of my medical education background. But in my role of senior medical officer, I go around and talk to people, to colleges, and obviously I've had lots of contacts with doctors that have contacted Avant over the years and I'm seeing increasing numbers of this and increasing angst and then there was some noise and some chatter from the colleges that perhaps the medical defence organisations were part of the problem because they were facilitating junior doctors to lawyer up and escalate so I thought it was hoped on us to try and unpack what the issues were. Shall I just prattle on? Prattle on. Okay. So I thought I really wanted to try and understand what were the various elements and try and help people to look at it from a range of perspectives because often we get locked into our own paradigm. So as the supervisor, I can see all the issues as a supervisor and how difficult it is and how my life is getting more busy and I don't have time for teaching and the organisation that I deal with becomes increasingly bureaucratic for me as the supervisor. My trainees are struggling with the same thing. And then people look at it, the college looks at it, they've got increasing numbers and there's people trying to bend and twist rules. So what they do is they add more and more rules on and become increasingly bureaucratic and they go down their tunnel. And as the MDO, we actually get to see all of that because we're seeing both sides. So we actually do look after the supervisors as well as the trainees. And I went, this is a bit bit crazy so I started talking to people and talking to the colleges and realising not only were they looking at a very tunnel vision but also they were actually looking for their own various solutions and some of the solutions were really reasonably constructive some of them were saying oh actually you can't really be a supervisor without training so we're going to make the supervisors do some training and some of that has actually been quite effective but none of them were talking to each other. So I decided in my infinite wisdom wearing my sort of medical education hat that I should throw all these people together in a room so we held a big workshop last year and had people from pretty much all of the major colleges and certainly a number of the minor ones we had people from from AMA, we had doctors in training, we had various supervisors. And then what we did for the day, it was actually a really interesting day, you know, wearing an education hat. I found it a great process because what we did was we picked a, we made up a scenario which was a compilation of a whole lot of things and just walked it through and got everybody to look at it. We started with the registrar registrar or sorry playing with my mic registrar perspective and then went through and looked at it from the supervisor perspective then the college and then the hospital administration who also has a perspective in this and everybody and everyone was good it was sort of a bit of an aha moment yes um and i found it a very useful day and certainly everybody that was there found it very useful so we did with that, we produced a report and then we produced that discussion paper which is available on our website. And we'll provide a link to it. Yeah, and a lot of people, and we've presented that and we've had quite a lot of feedback from that. And really that wasn't trying to provide the answers because the answers exist in a range of spaces. It's not actually sitting with us. All I was really doing was trying to facilitate it. But it did raise the issues and it tried to encapsulate some of the key problems and concerns. I mean, is it because you're seeing a lot more of these cases or? Yeah, look, the numbers remain small. Yes. That are actually claims. We have a funny thing in insurance that a thing is not a claim until you've made a trigger on the policy. So the numbers of claims are reasonably small, albeit growing, but we are getting increasing numbers of calls. A lot of doctors call our medical legal advisory service or our hotline and we're getting more and more calls there. And actually that's probably the right place for it to happen because often that means they're coming in early and we can provide a listening voice and some sensible reflection. I mean the numbers also don't totally tell the story because the angst associated with this for everybody that's involved is phenomenal. I mean you and I don't have to be very few steps away to realise how difficult it is for a trainee that's involved in a dispute or thinks they're going to be involved in a dispute and they catastrophise and see their career on the line. And it often is quite difficult to move from career A to career B in medicine. As we know, the colleges are getting tighter and more competitive. So they do catastrophise, they do get extremely anxious and it adds to all the terrible stuff that's going on with sort of doctors' health. I mean, people that have contacted us actually have all... We do see the pointy end, obviously, in a range of spheres, not just in training disputes. And doctors' health is a huge issue that we're exposed to because people are usually... They're most stressed when they have contact with their MDO about a claim or a dispute. And for the doctors in training, often they feel like they've got nowhere else to go. Yes. Yeah, I mean, I presume you're only really seeing the tip of the iceberg. There must be so many of these or having these ongoing stresses, but maybe at a lower level and really only escalate. That's right. And I guess there was a takeaway message for me is to actually say to the doctors in training out there that they aren't alone. And in fact, often it's really helpful if they go and seek some help early. It actually doesn't mean you're lawyering up. And in fact, this is a reassurance I've given to the colleges as well who actually have put that to us, that actually if we can get involved early, we can often help the trainee unpack what are the issues and provide some sensible avenues for trying to resolve it long before it becomes actually a dispute in the true sense. So why do you think this is becoming more common and what are some of the, I guess, key factors around this? Yeah, why is it becoming more common? Look, there's a... Why is it happening? There's a range of issues which we've unpacked in that paper. I think one of the key... Well, there's two or three, four, really. I could go into details, tell me when to stop prattling on. One of them is process issues. And again, as the system gets bigger and more complex, what a lot of organisations and colleges are no exception do is add in more rules. And so the rules are layering up and with that the rigidity of the process becomes more extreme. And so then if somebody deviates, they're less likely to be flexible in an approach. So that often leads to it. Can I give you an illustration? So we had a doctor that was trying to get onto a training program. We often get the disputes right before they arrive and this particular program needed them to put up five referee reports as part of their entrance process. But it was actually the responsibility of the college to chase down those referees. So they would put in the names and contact details and so on. And the college in this instance, one of the referees was overseas, couldn't reach them, got four out of the five, I can't remember exactly the number, and because they didn't get the fifth, they said, no, your application was not successful, even though actually it was their doing. And the trainee hadn't, or the potential trainee hadn't been contacted to say, we can't get this person, could you put up somebody else? And they came to us going, should this and we said well here's your options this is you know this actually yes you have a case and in the end and this is often the case the trainee said I don't want to take my you know block the copy book I don't want to be noted as somebody who's a troublemaker back down and waited a year but that's the sort of rigidity and difficulty of the processes. Many times, so the processes are difficult. The other one is the supervision stuff. |
There's supervisors who are working in a stressed, busy system, often under-trained, often the junior person, and you probably know from your own department, often the junior person is the last person to put their hand up who may have very little skills or aptitude or interest. And depending on the college, they get variable amounts of training before they start the role. And then they have this funny thing, and it depends on what college you're involved in, is that the supervisor often wears many hats. So they're a mentor, they're an educator, they're also an assessor. And so swapping those hats is not always clear to everybody, including the supervisor. So there are problems with, there's problems for the trainees. So the trainees as a cohort are different, I think, to the generation ago. There's more competition. I think they're more stressed as a generation. They've got more financial pressures. They're often a bit older. So they often may have children and other things that add to the complexity and the rigidity of processes become more difficult. They're more culturally diverse. So we've got different trainees. And as I was talking to a trainee about this yesterday, she said, and one of the other things which hadn't even occurred to me is not in the paper was that actually the trainees are under huge pressure as well at the other end to get jobs and so for that reason any slight negative step in their training even if it's not at the level of dispute even if it's just negative feedback they considered they catastrophize and believe they won't get the next job so we've got all those those pressures on the supervisors, the trainees, the hospitals, as we all know, are busier, higher turnover, more complex, you know, chronic and complex care. So that makes a more difficult training environment that's happening in a hospital. And same in general practice, if it's a general practice setting, the turnover just to make a buck is actually high. So there's a range of pressures in the supervising. And what happens sometimes in the supervising and trainee relationship, and it's the big problem, is that sort of failure to fail. Everyone just avoids it. And then sometimes it pops up right at the end. And that's when people get surprised and there's a real problem because somebody's invested a huge amount of time and effort, believe they're almost at the last hurdle, and then someone goes, oh my goodness, this person's about to complete their training. They're really not up to being a specialist in A, B or C, you know, so and then they pull the plug. So that's a real problem. There's some discrimination, there's the workplace issues, the sort of the bullying and harassment, there's often a part of any complaint or claim. And it's really hard to unpack. and it's sort of difficult to tell whether somebody who's not able to receive feedback well perceives it as bullying. The supervisors are often frightened to give feedback because they're worried about being accused of bullying. So the whole sort of bullying and harassment, no one kind of works, can work out where that plays into this and discrimination, I mean obvious discrimination, but there's often subtle discrimination like all of the I don't know for example and I say all of the lectures or the training program the tutorials are held before childcare opens early in the morning so someone who's got a child will have difficulty getting there and so they may be perceived to be less interested because they can't make those tutorials or whatever. So there's that sort of subtle discrimination that I think often comes in. There's an assumption that you will be like me and you will have the availability that I've got. I mean, if you had to give some advice to supervisors, what kind of advice would you give to supervisors to try and prevent these issues? To supervisors? Okay. One of the things for supervisors is if you are detecting a problem with a trainee is that it's really important to actually give those feedback away from patients, away from other people and be specific, close to the event and actually give them a chance to correct it and give them a chance to come back and show how they've corrected it so that you can actually almost close off the loop. If that's not enough and it's escalating, I think by the time you're getting a second or a third time where you're sitting down for the cup of coffee chat, I actually think it's really worthwhile to have another person with you. One, so you don't get into that sort of bullying type perception or reality, whichever one that would be. But secondly, sometimes somebody else in the room, and that's where I find if I'm having the difficult conversations with a trainee, it's quite good to have another person. They can bring another person they want. But just to help a different perspective or you find yourself getting down a bit of a tunnel approach to it and someone can come out from the side and rescue and it actually can be a bit gentler actually and a bit softer but again it needs to be labeled as to what it is you need to be quite clear and what quite clear what will happen as a result of that conversation so you know there's been a problem I've had some feedback about X I'm sure that's just a you know do you want to explain it give the retraining a chance to explain what's going on here their side of it here that there's something terrible happening for them at home or there was an emergency elsewhere and they took their eye off the ball whatever the reason for them and give them an opportunity to redress it I'm gonna think what a lot of the trainees will say the supervisors their feedback is is so much just focused in one area, like the mid-term, end-of-term. They don't get any feedback for like six weeks and then suddenly they get all this feedback and it may not be positive. And it's hard to try and turn that around in a short period of time. Yeah, look, I mean, if there's a message to both trainees and supervisors, whoever might be listening, is to actually do it as often as you can. Often, and as I say, close to the incidents. And it's important that the trainees have a role in this. They need to actually be a bit active. Don't avoid the feedback. Go and seek it. It's really critical that they learn to be able to not only give but to receive feedback and seek it. And if the feedback is vague and willing, help the supervisor get to the, so what actually are you getting at here? Help them to be more specific and actually pin them down. So what would you like me to do to correct this? So that you can actually, as the trainee, gently lead the supervisor who may or may not have the skills to do it or who may be feeling uncomfortable because they really like you as a trainee but don't like to be able to give that negative message. Yes, yeah and I think all trainees say they want more feedback but sometimes when you give feedback that seems negative they go well I don't want that feedback I just want the positive feedback. But I think in fact giving ongoing feedback is so important for trainees to improve because really that pat on the back, you're doing well, doesn't really improve trainees' performance much and unfortunately that's what I think a lot of the feedback they get. Yeah, that's right and that's because it's easier. Yes. And one of the ways to help that is a bit of the S sandwich as they would call it. But I think that's reasonably important so that you're not destroying someone's confidence and one of the things I'm really mindful as I go into the new registrar term that you need to actually help build up their confidence. They're often very highly anxious in a new clinical setting and they're usually doing a lot of things well but there may be one or two things that are driving you crazy that you want to stop early and you want to address those early so you give them the the good and as well as the not so good and in regard to trainees one thing that I think supervisors sometimes is maybe trainees lack insight or ability to self-reflect how can we get trainees to be better at self-reflection? Yeah, I guess one of the things that I do is actually, this is me jumping into my supervisor hat here, but I've been doing it for a long time. One of the things I do is actually try and get them to tell me what the issues are rather than the other way around. |
You know, Mrs Jones didn't go so well what do you think happened what do you think went wrong what would if you could rewind the clock what would you do differently and often they'll tell me in which case my a my jobs done for me so be it's helping them because even if they get halfway there and I can help them go the rest of the way what that's doing is not only helping them with the feedback but also helping them to understand the sorts of things because they've actually had to commit to the process does that make sense so that's a particularly helpful one and I think it's good the other thing I do in my clinical setting which I'm quite lucky is actually we do video consultations so we video their consultations and the most powerful part of that is actually nobody saying anything and just looking at it and there's no way better than actually developing an insight in fact if you've ever done it yourself it's quite confronting so just looking at yourself and actually really looking having that opportunity to be on the outside looking in at your own consultations is very powerful so that's another way I mean your general kind of working working discussion paper, what did you kind of look at and regress to the process of the adversarial dispute resolution process? I mean does that work well or are there issues around how that does work? Obviously we would really like to try and do something to make it much less adversarial and there are some tricks and clues and there's more that could be done in this area. If there's any work that I'm going to continue doing it'll be in this area. One of the best ways to actually try and avoid it being an adversarial process is again is to nip it in the bud. So get in early and I would, one of my takeaway messages to trainees out there would be to actually go and seek some help and particularly from your MDO. We get, as I say, calls all the time and often can unpack the problem early. So that will prevent it escalating in many instances to a dispute. The other thing then is also to have some support to make sure that we keep the college, and it's often the college but it may also be the hospital, make them stick to their own rules and follow their own processes and make sure that it's a fair and just process so that we don't have the same person being on the assessment committee as who provided the report, for example. You know, things like that. There needs to be a fair and equitable process for the trainee. And often by just doing that and just keeping them honest, the problem will resolve. We have very, very few that go right through to the pointy end. I think most junior doctors which we've encouraged before on our website is to have a mentor if possible. And that's another person they can go to outside of those who are actually doing the actual training. I guess the assessment. And it's often the directors of clinical training or directors of training are often good people to go to initially if there are concerns. Because often what those supervisors will identify is that I didn't know there was an issue or problem until maybe the MDO comes to them and goes, I didn't know. If you told me, I may have done something. So it's just trying to make sure. Keep everyone in the loop early, I think. Look, I think that's right. So even before you go outside to the MDO, go and try the internal resources if you're in a hospital setting to find. And I think that concept of a mentor, I mean, there's a lot of places that have tried to put that in place. It was a difficult one because really in the end all the evidence tells us that the best mentor is is the one you find for yourself so the um and some people are better at doing that you know it's a degree you need a degree of assertiveness and confidence and some people do struggle there are certainly a number of people who call us who say they feel like they have nowhere else to go now i don't know whether that's actually but to them that perception is very real i mean we've identified some of these issues how they're increasing but I guess the trainee what are some of the warning signs that maybe they're about to get a poor assessment or about to develop into a dispute about their training? Yeah look we hear the story many times over that they say they had no idea and it came left of field and suddenly it was sprung upon them that they're about to do a remedial term or they were getting an appalling or they're about to fail this rotation or whatever. But actually, if you look back, the signs are often there. And there are some clues and the sort of clues is that negative comments coming around the place or the body language of their supervisor or the slightly negative comments that perhaps haven't been followed through into an effective feedback. Sometimes worse than that is the supervisor ain't there at all. And with certainly in your role with the junior doctor training, you'll hear that many times over once they get to the more senior to the registrar level they usually know their supervisor because they're there for longer and there's a little bit more direct engagement but even still in those terms there are times when the people really have little interest and little availability or maybe they're just absent they're overseas and then what happens if they They don't get to know you, to know the good you. They may only turn up when there's a problem. So then that colours the judgement. So that's another one. Sometimes I think there's lots of people making small complaints is a bit of a clue. And the other one that I think is important is when the service itself is under major strain. So maybe the bosses, there's a big battle happening between the bosses or it's the emergency department in the middle of winter and everyone's just absolutely under the pump and no one's got time to breathe, let alone teach. So those sort of things are clues that you actually need to go out and seek that. The other final clue is an important one, and it's to be honest to yourself, is when you're under your own strain. So something else is happening in your life, something's happening outside of work that's not going completely well. Perhaps you've got your own mental health issues. In those sort of situations, there is a reasonable chance that you aren't performing to your best and that you need to think about how you're going to address that and I mean that's another whole taping session for another day but it does come into the performance and that's why it's so important to address some of those issues. And telling your supervisor early about those issues, most supervisors are understanding when they know that you're going through something outside of work, relationship difficulty or something else, they're understanding but when they don't know and performance starts to impact that they tend to forget about it. I agree, and it's better to do it before the supervisor comes to you, preempt it, but also talk to them in an adult way. Look, I know this is a problem. I know this is going to impact, but these are the things I'm doing. Putting in place to minimise that. Please let me know if that's not enough. You know, that sort of a comment comes in as adult to adults rather than oh I've got problems at home so I'm gonna have to leave early every day or whatever that's going to set off tensions so it's the way you do that is also important yeah I mean that's always that balance between the as an employee employee and also a trainee doing those dual roles is always difficult that's right And there's all those hats that we talked about for the supervisor that make it quite difficult because you have those multiple responsibilities. So as either trainee is struggling, you mentioned some of these before, what would you do for that trainee? What would you suggest for that trainee to do if they saw these issues arising? Yeah, look, one is to stop and think and actually try and develop your own reflective things and say what is going well, what's not really, you know, am I happy in this term, you know, what is it maybe I don't feel comfortable with the superpowers and actually do your own analysis first because I think that's actually really helpful because then you've done your pre-thinking before you launch into the conversation. And then I think it's really important to go and try and find the time, not in the corridor, not in the middle of the ward round, but a cup of coffee time with the supervisor. Can we please have a chat? And then actually have that adult-to-adult conversation about how do you think I'm going? I've noticed some things. And try and actually unpack what the problem is. I'm really keen to do well, I'm really enjoying the term or I'm not or whatever the situation is and try and actually adult to adult unpack the problem early. And often the supervisor's very relieved. |
Hello and welcome to On The Wards. I'm Sarah Dalton and today we're talking to Angelina Chakwajira about malignant spinal cord compression. Welcome, Angelina. Thank you very much, Sarah. It's lovely to be here. Angelina is currently a medical oncology clinical trials fellow at St George Hospital in Sydney. And today we're talking about spinal cord compression. Spinal cord compression is a common complication of cancer and occurs in up to 10% of patients. It can cause pain and potentially irreversible neurological deficits. A junior doctor can encounter cord compression in ED, during an after-hours shift on the haematology or oncology wards, or during a rotation in the haematology, oncology or palliative care areas. And the most important thing is that early recognition is absolutely vital for better outcomes. So I have to say, Angelina, this is going to be a very important topic for our JMOs. We all worry about this. Maybe you could start by telling us, what are the patient groups who are at particular risk for cord compression? Sure. Thanks, Sarah. So as you've mentioned, it's without a doubt that JMOs would encounter cord compression, and it's not uncommon in cancer patients. So in terms of the patients at risk for cord compression, you'd have to think about the malignancies which have a predilection for bone metastases. And in solid malignancies, these cancers would be breast cancer, prostate cancer, lung cancer, renal cancer. And in the hematological field, you do see cord compression with multiple myeloma, non-Hodgkin lymphomas, and some leukemias. So these would be patients at risk of cord compression. So that's quite a lot of our patients then who are at risk of cord compression. Yes, that's right. And I guess the only other thing to mention is that we do get on occasion patients presenting with back pain undifferentiated with no prior diagnosis of cancer. And they do present with cord compression. That's how we diagnose the cancer. So how does cord compression generally present? Sure. So essentially, as you've mentioned, early recognition is crucial. So as a JMO, you need to know how cord compression generally presents. So the most common first symptom that patients usually report is of pain. And this can be in the neck or back, wherever the vertebral met is in the spine. And this pain can be localized, referred, or radicular. And you're looking for red flag symptoms. So pain that is worse lying down, pain that wakes a patient up at night. Following from pain, you then get to see the neurological deficits and more the motor than the sensory. So you'd see more of a progressive bilateral weakness. And in terms of sensory deficits, numbness or paresthesia. Lastly, a late feature would be of autonomic dysfunction, so bladder or bowel dysfunction, with the caveat that cord compression that affects the conus medullaris, which is just above the cord or equina, can present with back pain and only bladder or bowel symptoms. So these are generally how patients present. So there's quite a wide range of possible presentations. Yeah, that's right. So essentially, I think it's important for any cancer patient that presents with a new back pain, you need to consider cord compression and try to rule that out. So I'm guessing then that a really thorough physical examination is important. Can you talk through what that would look like and some tips? Yeah, of course. So essentially, whether you're a JMO on the ward or an ED, a thorough physical is important. So I think as with any physical examination, take a step back. Is patient in pain from from their vertebral mets and if so give them some analgesia it'll make your examination easier for yourself and for the patient have a look around are they having any mobility aids next to them do they have a bottle which means they can't get to the toilet in time and then do a thorough neurological. So this is a chance to make sure your neuro skills that you've done for final year OSCEs are not going rusty. Do the cranial nerves, upper limbs, lower limbs. Check for tone, power, reflexes, sensation. Do a PR. Check for perianal sensation and anal tone in the case of corda equina and walk with the patient, see if they need any assistance transferring or walking. In terms of the neurological examination, what you're looking for is bilateral weakness in the legs. You're looking at hyperreflexia below the level of the cord compression. And essentially with cordquina I mean the reflexes are depressed in the lower limbs and then following the neuroexamination you can then palpate the vertebral column just to see where the tenderness is and that can give you a clue to which levels are affected so I think from a general point of view if you do that examination I'd be quite happy with that. And I guess it's all trying to work out a likely location for the lesion as well as the severity of the lesion. Yeah, definitely. Which I'm guessing helps guide your diagnostic imaging. Yes. So what is it you'd recommend when it comes to gold standards around diagnostic imaging? Sure. So, you know, if you do have a clinical suspicion of cord compression what you definitely need is an urgent MRI whole spine and this should occur within 24 hours and so as a JMO you talk to the radiology registrar and present your case and express the urgency. Sometimes MRI slots are hard to come by so you might need to talk to the neurology registrar or the neurosurgical registrar to explain your case and the urgency in terms of getting a slot for your patient. So MRI whole spine, it doesn't need to have gadolinium contrast. If it does have contrast, that's great as well. It can enhance the tumor better, but the radiologist generally can diagnose cord compression in a non-con whole spine MRI as well. Okay, so let's take it to a case now. Let's say you're a junior doctor on an after-hours shift on the medical oncology ward, and the nurse asks you to review a 70-year-old patient who has decreased mobility. Of course, you've got lots of other jobs to do, including talking to a patient's family on the ward, reviewing a patient with a potassium of 3.2, reciting cannulas. What other information do you need to ask for to help you work out how to prioritise this? Sure. So, I mean, you know, as a JMO on the ward, you've got other things on your mind. So when the nurse calls you up with a patient with decreased mobility on the cancer ward, I think you ought to try and get information to help you triage how urgent it is you need to review the patient. So things you'd like to ask is, you know, when did the patient get admitted? Why did the patient get admitted? What type of cancer does the patient have? They're on the oncology ward. Do we know if it's a metastatic cancer and is it involving the bone? Has a nurse looked after the patient before and noticed there has been a deterioration in their mobility? And does the nurse know what the baseline function of the patient is? So those are some of the questions you might want to ask the nurse while you get the phone call as a GMO. And presuming that you eventually hear that this person does have some metastatic cancer in the bones and then you're concerned about spinal cord compression, what are the differential diagnoses that you would be considering for the decreased mobility? Sure. So essentially knowing the patient's got advanced cancer with bone lesions, then obviously the top of your differential for an urgent review would be to exclude a cord compression. Other things that are urgent could be whether this patient's got a stroke, new brain mets, and less urgent things could be drug-related reasons, are they on a statin, statin myopathy, general malign or lethargy, but certainly you'd want to review the patient as a matter of urgency, knowing that they've got advanced cancer of the bone and they're complaining of decreased mobility. So let's say then you've reviewed the patient, you've done a really thorough physical examination, what are your next steps in assessing this patient? Sure. So, I mean, as a JMO, I think the next step would be to communicate with the treating team, call them up and say, look, I've been looking after this patient and I'm worried about cord compression. These are my findings. |
Welcome to On The Wards, it's James Edwards, I'm here again speaking to the junior doctors out there. Today we're talking about something that most junior doctors do get a tiny bit concerned about and it's inter-reporting and RCA's or root cause analyses and speak with me today I've got Andrew Baker. Andrew is the Director of Pre-Vacation Education and Training at Westmead Hospital here in New South Wales. He's also a medical administrator and has had a long interest in clinical governance, so a perfect person to speak to today. We're going to start with a case, a bit of context for a junior doctor who's working on the ward and asked to see a 50-year-old female who's an inpatient with fever and you notice there's some cellulitis at a cannula site in her arm. You treat the cellulalic attacks and blood cultures and you consider whether you need to lodge an incident report. Maybe we'll start, Andrew. Why is it important to report incidents? Well, reporting incidents hopefully allows other people to look into what's been happening, what's gone wrong and hopefully to try and improve things for the future. Communication is another aspect of this. Hospitals are complex organisations and junior staff may think that just letting the team know is fine, but sometimes the message is going to go further in the organisation. So incident reporting is one way of trying to get that message broader through the organisation. This one's a cannulocyte infection, but what are some of the other common errors and mistakes that occur within hospitals? All manner of problems. Those common infections you've mentioned, falls, medication errors. But when you look at the classification system that's built into the reporting system, you'll see they anticipate things to do with aggression, occ health and safety, accidents, equipment failure. It goes on and on. The things that the medicos tend to get more excited about are clinical decision making and when we've done the wrong thing and we've done the right thing, mistakes, errors and near misses. I mean, you kind of mentioned this in your first answer, but what's the benefit to patients and staff of reporting incidents? Well, the benefits to patients hopefully are that we look into what happened, we have a mechanism for responding to them in the short term, reassuring them about the thing that might have gone wrong, and then trying to do right by them, trying to fix the problem both in the short term and looking at the system's issues to try and fix those in the longer term. So maybe I'll start with whose responsibility it is to report incidents on the ward? Is it something a junior doctor can do or do you think that's something for the nursing staff? Sure, I mean the short answer is it's everybody's responsibility. There's no doubt that before we had a computerised reporting system there was a strong culture of reporting among the nursing staff and it's probably fair to say they've embraced that quicker than the doctors but it's very wrong to see this as purely a nursing activity. I think all doctors should be aware of the system and all doctors should be capable of putting something into the system. Well maybe we'll kind of go to what type of incidents should be reported. This can be difficult for junior staff because typically they don't interact with it an awful lot. My short answer is that if they think that something's gone wrong or something happened that shouldn't have happened then that's the basis for putting something into IMSS. I mentioned before some of the types of categories that are anticipated that we will be reporting into IMSS but it's really if you feel something happened that you're uncomfortable with. You mentioned IMSS, what is IMSS? Well that's the Statewide Computerised Incident Reporting System. I think it stands for Incident Information Management System. It's been in place for about a decade and you can put information into it from virtually any computer in any hospital and all staff members can interact with it. It's a potentially anonymous reporting system, although you can identify yourself if you so desire. And it would be likely that most states in Australia have a similar reporting system? Yes, something along the same sort of lines as a general rule. New South Wales has had that for, as I said, a decade. Started off in South Australia, actually. Now, in regard to the type of evidence you've described, do you only report incidents that cause harm or do you also report near misses? Near misses are important. I mean we're looking for things that have gone wrong and how to fix them and things can go wrong and yet still not cause any problems for patients. We can get away with it by sheer blind luck from time to time but they're still worth looking into. Are there any type of incidents that maybe shouldn't be entered on IMS or something you should, I guess, look at a different pathway? Yeah, it's always difficult to know what the threshold for putting something into IMS is, but the things that I'd comment that don't belong in IMS are when people are using it purely to try and score political points or to complain about their colleagues. There are better ways of dealing with your problems than that. But otherwise, as I said before, if you feel that something happened that shouldn't have happened, that's the sort of thing that a junior medical officer would be putting into IMS. So, yeah. I mean, if you're involved in an incident and something goes wrong, I mean, is there a kind of risk that you may want to avoid telling anyone about it because if you do enter it in IMSS that your supervisor will find out and maybe affect your assessment? Yeah, listen, I'd be silly to say that that's not something junior staff might be worrying about. To be honest, we're talking about things that are going wrong with patients or things that are a bit odd, and I'd like to think that our senior staff were aware enough of their own patients to be well across those sorts of things before they read about it in IMSS. So that's the first thing to make note of. IMSS is intended to be a non-blame incident reporting system, which means that we're looking, trying to fix problems rather than identify who's at fault. For that reason, in my hospital, the system administrators will de-identify particular reports if they specify the individual clinicians involved. But more so than that, senior staff, in my experience, actually respond well to people that are self-aware and self-reflective. If you can show that you think about the quality of the care that you provide, both as an individual or at an organisational level, that's something that I think the senior staff admire. And this is a lesson that I'm always trying to tell the juniors at the time of recruitment because these sorts of questions about how you respond to error, which is going to happen to all of us at some stage, commonly come up in interviews. And the person that demonstrates that they've thought this sort of thing through and how to engage with the system as well as know how to improve themselves personally, they come across as quite impressive. So putting something into IMS is just as likely to impress your bosses as it is to tip off that you did something wrong. So maybe we'll go through that process of entering something into a management such as IMS. I guess what's the process maybe within New South Wales? Yeah, it's fairly straightforward. You'll find IMS in some guys on your hospital internet somewhere. I obviously can't tell you the precise details, but if you don't know the nursing staff will point you to it. When you click on the appropriate icons you end up with effectively an electronic form where you get to fill in the boxes. The boxes are all fairly self-explanatory and it's just a matter of working your way through them. They want to know things about the patient details, where it happened, what sort of thing happened and any suggestions you might have for how things could have gone better. As part of that entry information on that system, you're often asked to determine the severity of an incident. How do you do that and what's a SAC1? Severity Assessment Code is just a rough and ready guide to the severity of an incident. SAC1 are the most severe, SAC4 are the least. My rough rule of thumb is a SAC1 is usually when the patient has died or got some sort of serious disability. SAC2 is something serious going wrong or increased level of care required, SAC3 something minor has happened, it's had an impact on the patient but not too bad and SAC4 very little happened. So that's roughly how it works. You can also look at it from the point of view of the response required. So the SAC 1 incidents also require the most serious responses, which involve writing a report and providing that to the Department of Health. SAC 4, on the other hand, we tend to just monitor the trends over a period of time. So SAC 1, how is that investigated and how are incidents investigated in general? |
Hi, it's James Edwards, welcome to On The Voice. It's February 2015 and today we're talking about assessment. So assessment's not one of our usual clinical topics but there's a lot of interest in assessment of junior doctors at the moment with some changes in Australia with our national intern assessment. And rather than me interviewing someone I'm going to ask Paul Hamer who's the current Director of Pre-Vacation Education and Training at Royal Prince Edward Hospital to speak to me. Thanks James. So I'd better introduce you as well. So James is the current Chair of the Prevocational Training Council for the Health Education and Training Institute in New South Wales, and he's also a member of the Australian Medical Council's National Intern Assessment Evaluation Group. There's some big words there. There are. I think I said Director of Prevocational Education and Training very quickly. That's on the roll off the tongue. No, I just say DPET. DPET, sounds better. So today we're talking about assessment of junior doctors. So they've just brought out this new form, James, which everyone's talking about. Maybe we can take a bit back to basics. Why are junior doctors assessed in the first place? Look, I think there are a number of reasons, Paul. I think firstly, it's probably back to patient safety. We need to make sure that our patients are safe, and that's why supervisors need to assess interns. They need to be supervising them and making sure that they're appropriate level to be working on the wards. Because if there are concerns that the intern is not performing and it becomes a patient safety issue, then something needs to be done straight away. I also think it's important for the junior doctor. You need to get feedback about your performance if you're going to improve. And what I'll be saying throughout this podcast is the importance of feedback. The assessment and feedback go together. But lastly, it's probably in regard to the public because the public expects that junior doctors have reached a certain standard and competency before they're generally registered. And in New South Wales and Australia, that requires general registration. So that provides a nice segue to my next question. How does registration with the AMC relate to internship? So when you finish medical school in Australia, you're granted provisional registration and you need to complete an internship, which is 47 weeks. You need to do usually five turns, but at least 10 weeks of medicine, 10 weeks of surgery and eight weeks of emergency care. And you need to have reached a level that your supervisors think is an appropriate standard and meets what we'll speak about later, the National Intern Outcome Statements. And then they can recommend that you receive general registration to the Medical Board of Australia. And what does general registration allow you to do that provisional registration doesn't? That's a good question, Paul. Look, it does allow you in prescribing. What used to happen is when you're at general registration, you go out and start practising a GP really the next year. That doesn't happen so much now. So between general registration, it gets an extra link before you become registered with a vocational college, because really vocational colleges is GP training as well as specialist training. So it probably hasn't quite the imports it may have done 20 years ago, and it's one of the reasons there's a current review into internship within Australia. Okay. So what's the current assessment process that junior doctors might go through? So the current assessment process in each term, you get a midterm and end-of-term assessment. And over that five terms, you are either deemed to have passed your internship or that information about your internship is passed on the Medical Board of Australia and they make a recommendation whether you receive general registration. I think it's important to recognise from the Medical Board of Australia's point of view that they look at the whole year. So if you happen to fail one term at the start of the year but remediate and improve and end up meeting the outcomes at the end of the intern year, you can go on to general registration. Okay. And so I suppose thinking about assessment and there are these new forms, I get a lot of junior doctors come to me and say, oh, look, I just have to complete this form at the end of the term and, you know, that's it. How does assessment and the forms relate? So, I mean, I think there is one of the concerns that when you have a form, it just becomes a tick box exercise. Just tick the boxes, move it on, I'll get registration at the end. But we really want assessment to be more than that. We want the assessment form, which includes the national intern outcome statements, and that was part of the whole improving our current intern process within Australia. It was a national process. Previously, each different postgraduate medical council had their own assessment forms, so it's trying to bring everything together. It also aligns with the graduate medical outcome statements for the medical schools. They kind of link, and that's great to see that education assessment are on continuum. So I think the important part of the form is not ticking the box. It is trying to address performance of a junior doctor against the intern outcome statements. And the intern outcome statements are kind of divided into four different domains, and within those domains there are subsections, and each of those has a score from five to one, and they provide descriptors or behavioural anchors that describe the performance of that intern within that term. Okay. So I suppose when you're looking at the new form, you've pointed out some of those features of the new form. What's my role or what is a junior doctor's role in looking at that form and assessing that form? I think especially at the start of a term, you should really grab the form and have a look at the actual form and probably at the start of the year as well. But when you meet up with your supervisor at the start of your term as part of your orientation, you should have a think about what your goals are, but also what the expectations of your consultant and your team within that term. It's nice to have an understanding of how you're going to be assessed, what the supervisor's going to do to get that assessment, who they're going to ask or what's going to be based on. You can start to organise a mid and end of term assessment then and how that's going to run. So whether you're the one who'll be contacting the supervisor, the supervisor will contact you. So it's important you take charge of the assessment. It's your responsibility as well as the responsibility of the supervisor. I think it's also important when you do come to the different domains, there are some of the domains, especially in regard to health and advocacy, or the domain three, that think it's difficult for sometimes supervisors to assess. And it's worth you trying to help out. You can bring examples how you've met those expectations or met those outcomes. And this could include things like cases that you've been involved in or some online learning. I think assessment, it shouldn't be a passive process. It shouldn't just be someone, a supervisor that tells you about your performance. I think it really should be promoting a discussion and trying to evaluate where you're doing well, where you're not doing so well and where you need to improve and what areas you need to work on. Because fundamentally assessment is about feedback and improving your performance. So if you look at some of the domains, I mean, they're quite pertinent to junior doctors like communication, documentation, and planning, prescribing. These are all important qualities of junior doctors. They are. So, I mean, and that's why that in some ways is the essence of the form. We've tried to address what the intern needs to be performing so that at the end of your intern year, if you've met all those different outcomes, then everyone can be reasonably confident that you have the necessary skills and attitudes to go to general registration. Okay. Now, in New South Wales, we've brought in a form and it's got a self-rating section there as well. Why have we got that and how should I be thinking about that? Yeah, I think as a junior doctor, I think the self-rating can be challenging. What the reason behind having self-rating, we want junior doctors to reflect on their performance in the term for them to identify what they do well and what they don't do so well so they can continue to work on those areas. And it does help the supervisor to see if a junior doctor has some insight into areas they are particularly good at or, more importantly, if they've got weaknesses in. Because if someone has self-rated them quite high but the supervisor thinks there's particular issues, then that requires a much bigger discussion. |
So they'll often under-mark themselves. Some junior doctors will kind of try and game things by marking themselves up in an attempt to get a better score from the supervisor. But I think the self-rating section should be a means for reflecting on your performance, and it's not so much about the number that you give yourself as long as you think about how you perform in that term. I mean, I agree with everything you said. One of the things I really like about the self-rating section is it very much goes to the principles of adult learning. I think it's really important that junior doctors have the ability to assess what they're good at, honestly, and what they're not so good at, because that will give them lifelong skills so that they can work on areas that they can improve or not. So for me, I think it's a really important part of the assessment form, but something that's only in New South Wales at the moment, but certainly could be thought about by interns in other states. And I think self-reflection, whether it's part of the form or not, it should become, as you said, part of your lifelong learning practice. As you move through your different training, there will always tend to be an element of self-assessment. We have it as consultants, you have it as a registrar, so it is an integral part of your learning assessment. So I'm meeting with my supervisor and we're going through this assessment form. What sort of information does he use to assess me? Yeah, so he or she could use different things and it'd be nice to know that at the start of your term. The typical things I tell supervisors is to get feedback from multiple different people. I think if you just have your own views on an intern, they may be correct, but I think everyone's seen junior doctors who are very nice to the consultant, but then when the consultant's out of the room, maybe a bit rude to the nursing staff or Adelaide Health. So I think you need to not only look at other consultants, yourself as a supervisor, find out from the registrars and I think nursing staff are extremely valuable to get feedback from. So I think you should be expecting that your supervisor will ask lots of different people within the team on your ward. Other areas they could look at is your documentation. They'll be likely to read what you write in the notes after ward rounds. They should be reviewing your discharge summaries, reviewing medication charts. There may be some other more formal work-based assessments such as case-based discussions. There may be something procedural where they watch you suture in theatre or watch you perform procedures on the ward. They could all form a basis for your assessment. Okay. So at the end, they piece all these sources together and they'll come up with a final rating. This is on the final term assessment form. And there's a box there that says satisfactory, borderline or unsatisfactory. So what happens if a junior doctor receives an unsatisfactory or borderline assessment? I think the important thing to consider is that doesn't mean that they're going to fail the year. You can, as I said, get an unsatisfactory assessment during a term, but if you, throughout the year, we can view the totality of your performance and that meets the intern outcome standards, then you'll be looking like you'll get general registration. However, obviously, it's a wake-up call for junior doctors because junior doctors, most of them do pass all their terms. So there is a term that you didn't pass or didn't perform as well as you should. I think you need to go back and self-reflect whether it's something about your performance. Sometimes it's actually more to do with the term. Sometimes it is a difficult term, something like the supervision wasn't there within appropriate orientation. But I want to try and avoid trying to blame it all on the term. Because usually there will be maybe a combination, but really your performance will only get better if you accept that there may be some areas where you need to improve on and then you need to carry it on to the next term. So I think it definitely provides an opportunity for remediation. What the supervisors should do then is get an Improving Performance Action Plan form, and that's available as part of the new National Intern Assessment Forms, and they can complete, your supervisor supervisor should complete that and they'll usually complete that with the Director of Clinical Training or Director of Pre-Vacation or Education and Training and create a plan for how you can improve. Identify the particular domains that you haven't performed well in and then have an area where a way of improving it may be some further discussion, some extra tutorials or extra discussion with somebody senior, some help on the ward with a mentor. There's different ways we can try and improve an intern's performance. But at least it gives a formal document that allows you and the supervisor knowing of where you're going to go and where you're going to prove and it actually has a kind of time frame behind it. So it's a really valuable part for a junior doctor and it's something that many juniors won't get but some will and you shouldn't see it as a negative. It usually means that you'll get a lot more feedback and a lot more resources in regard to trying to improve your performance because I think every supervisor and every DCT, DEPET is really keen for all our interns to get to that next level and get regional registration. But we've got a responsibility to make sure that if someone isn't performing, they don't kind of slip through the cracks. And I think at the end of the day, having that list of tasks that you can improve on is really positive. And I think if junior doctors take a mature approach to the suggestions that are given, they'll be able to improve as doctors as a whole. And I think that's the aim of the game, really, to make junior doctors be the best doctor that they can be. And I think nearly every junior doctor who comes to an assessment usually complains they don't get enough feedback. They all would like more feedback, especially those are the ones who are doing well. You know, just because you're doing well, you want to know how to get to the next level, and that's why I think it's important that all junior doctors do get feedback because that really helps in regard to making them better doctors. Okay. So after I've completed this form, what happens to the information? What do I do with it? Yeah, well, that information is usually kept within your hospital. And I think it's important to recognise here that information should not be released to anyone else. It says as part of the forms that these forms should not be used for employment purposes. So the reason we're saying that is because as part of that self-rating or self-reflection, we want you to identify if you do have problems and you aren't performing well, we want you to identify that. And we don't want people to not write comments that are potentially negative or are needing in terms of improvement because they don't want to own your record. Sometimes GP colleges have asked me for assessment forms and asked you not to send in all their assessment forms. If you want to, you can, but you don't need to. All the college needs is a letter from your DCT DPET outlining which terms you've done and whether those terms have been passed satisfactorily. They do not need to take any comments or anything further. So you shouldn't feel that this form is somehow going to live in your file and your future vocational training providers will see it. It's something just for the junior medical workforce unit and it's for the DPET and DCT to determine how you've gone in that term. What has changed in the intern assessment process is there's now an intern assessment group. So for some of those who have struggled a bit during the year, there will be a group and it will have independent people from within the hospital to look at your performance and they can sometimes make that final decision. So don't feel that you can't go to your DCT or DPET with concerns about your performance or how you can improve because they're going to be the ones making that final decision about registration. There should be another group around that person to provide some guidance so that you can reflect and you can be honest about your performance. Okay. So we've talked a lot about interns. Does this apply to residents, PGY2s and PGY3s? It's a good question, Paul, because a lot of PGY2s think that assessment's over, I don't need that. I'm now generally registered, I don't need assessment anymore. But that's not true. PGY2s still need assessment. Our form in New South Wales is called a junior doctor assessment form so the same form for an intern we have it for a junior doctor PGY2 or PGY3. |
Welcome to On The Wards, Jules Wilcox here, and today we're talking about peer mentoring with Rob Perlman and Sonia Chanchalani. This podcast is produced in collaboration with MedApps, a proud sponsor of On The Wards. So welcome Rob and Sonia. I'll give you a quick background. Rob taught himself to code whilst he was an intern because he wasn't busy enough and he built MedApp. His response to the inefficiencies that a junior doctor experiences whilst rotating through different hospitals and terms. And since launching in 2015, the platform is now deployed in 50 public and private hospitals across Australia, New Zealand, the UK, and Canada, with over 20,000 clinicians using it to access site-specific hospital information. He's passionate about health tech and improving doctor mental health. And outside of MedApps, continues to regularly assist in theatres and enjoys cycling, swimming and sci-fi. Sonia has been balancing clinical forensic medicine and training with the Royal College of Medical Administrators across WA, New South Wales and Queensland. She completed a dual master's in health management and public health alongside research and interventions to promote clinician wellbeing. Advocating for junior doctors and enabling a safe working environment led her to being appointed as director of clinical training at the Royal Brisbane Women's Hospital prior to her current role as a chief medical officer at MedApps, working closely with organisations to ensure governance, clinician engagement and wellbeing are prioritised. So guys, thanks for coming along to this and joining us today. So I think we should probably start up. I mean, mentoring has become quite popular recently with well-being through, I think, colleges as well as individual hospitals. And there are different types, and we can go into that in a minute, but what does peer mentoring mean to you, Sonia? I think if we go back to basics, the definition of peer mentoring is a relationship between people who are around the same career stage or age, whereby one person has more experience than the other in a particular area and then can provide support and knowledge. And I think in the world of medicine, informal and formal variations of this concept have been adopted by clinicians, like you said, at all stages, colleges, medical schools, but, the programs are dependent on their needs at their differing career stages. But back to the formal definition, I think the common thread, regardless of the type of program, is the recognized need for support and knowledge sharing in our world, where clinicians are constantly moving between units, hospitals, states, and even countries throughout all levels of our training. Yeah, I think that's, yeah, I think there's multiple different ways to do mentoring, isn't there? And it depends. We've trialed a number at Gosford. So we started off with consultants mentoring interns. But then I saw some evidence saying that actually, although there can be a lot of value to that increased experience, sometimes the consultants are a little bit removed from the intern days and don't quite get the thing. And also interns feel quite threatened, you know, talking to consultants. And so we've now changed it to a near peer. So the PGY2s now mentor the PGY1s, the interns, which has seemed to be quite well received. And both can be successful and both have got advantages and disadvantages. So I think there are some key fundamentals for mentoring. And I think in terms of junior doctors, where do you see the main benefits for near-peer mentoring? I think that's exactly the purpose and the area of my research that my team undertook in 2014 to really explore the benefits of peer mentoring programs. To date, we know that there are a lot of problems, organizational environmental problems in the world of medicine. And peer mentoring has always kind of been bandied around as an initiative that's regularly promoted to tackle these issues. But I guess when we looked into it, there hadn't been any real depth research around the benefit to specific interns in the Australian setting surrounded by the issues that we were facing. And so the qualitative research that I led included interviews and focus groups of a randomized control of interns who did receive mentors and who did not receive mentors. And I guess the benefits that we noted and concluded were that the participants received a positive impact on stress levels, morale, sense of support, job satisfaction, and kind of overall psychosocial well-being to those that were matched with a mentor. And our conclusions led to, our conclusions were that a well-designed peer-led mentoring program can improve the mental health and job satisfaction of junior doctors by providing additional support, building a sense of community and helping them navigate their new professional environment. And so we were like really satisfied with what we set out to explore. So Sonia, what do you think some of the key components of a successful mentoring program are? Because there's multiple ways of doing this, isn't there? Yeah, I think primarily willing and eager participants, mentors and mentees willing to sign up. I think one of the most important aspects is good leadership and governance. So the right people overseeing the program structure, managing the match program, and then ensuring that there is formal kind of framework of structure to everything. Most importantly, clear support and escalation strategies. So who to go to for what. And I think for the last key component that's usually forgotten or overlooked is the evaluation and improvement element. So to ensure sustainability, it's important to have clear measure outcomes regarding participant satisfaction with the program, the framework, the escalation strategies. And I think a combination of all of these components would lead to success. Yeah, it's interesting that, isn't it? I think it's hard sometimes getting that evaluation in the sense that you're looking at qualitative data rather than quantitative, and that can be quite hard. And what, what may be, because we looked at this when we, when we set it up at Gosford and we were trying to work out because you may have a problem as an intern during the year that gets resolved because of the mentoring, or you get a lot of support with it, which is really good, but it might be a completely different problem with a completely different outcome to somebody else's problem and so to match up those two things and get comparisons or between the control is quite hard but um but the overall sort of satisfaction and support i think that those are easier easier managed um the the willing and eager participants we've battled with that a little bit and i been interested to hear your thoughts on that, whether you make it an opt-in or an opt-out, because I've had episodes where mentees, and we've made it an opt-out. So, you know, initially you had to come and see me and tell me why you didn't want to do it. If you, if you wanted to opt out, which is fine, I wasn't, you know, going to browbeat them into it. But what we found was, and we had some feedback from some people saying that, you know, I wasn't going to do it, but I decided, oh, you know, whatever, because it was an opt out one. And in fact, it was one of the best parts of the year. And it really solved a lot of problems for me. And I felt there was such good support. And I it was just it was so good. And I would have missed that if it had been an opt-in one and you know and they wouldn't have seen the benefits so I have a little um I don't want to force people into things but I think sometimes people don't know what the benefits are what do you feel about that how do you do yours do you yeah so my experiences have always been with opt-in because they were new programs to organizations. In fact, my journey in this space actually started when I was a first year medical administration trainee at the Royal Perth Hospital in 2014. And the juniors approached me and requested me to help them to start a mentoring program. So with back in 2014, 15, and all of the issues around junior doctor wellbeing and bullying, suicides was quite prominent in the media. And so the junior doctors decided to take it into their own hands to implement strategies and solutions. And so together we worked towards creating this mentoring framework that we now promote. It started out opt-in. We did a pilot program with a few where we developed the match criteria based on career aspirations as well as gender preferences. And we found that the majority of juniors did opt in to the program. And exactly like what you noticed, when they participated in the program and left it, most of the intern participants became mentors because of the benefits that they saw in the program. And then in fact, the resident participants turned around and said, well, where's our mentoring programs when we become registrars? And then the consultants came and said, well, where's our mentoring program? So I think the opt-in approach worked well for successful kind of sustainability. But I can see the benefits of an opt-out program and I foresee them turning into opt-outs in the future. Yeah. |
It doesn't matter what your level of seniority is. Mentoring is still good. And I think a lot of us as seniors often have our sort of informal mentoring groups and things. But I think that second point that you were saying about the leadership and the governance and having a structure to it is just so important, you know, in terms of, you know, having regular meetings and collecting the data on that so that people say, well, that was rubbish. And you say, well, you only have one meeting in the year, you know, what do you expect? And things and trying to get funding and so forth. It's so important. So I think with that and having the escalation strategies and the training of mentors as well in terms of how to have conversations and some of the rules around the systems, if people are listening to this and thinking, hey, you know what? I'd like a mentoring program at my place or I've been thinking of setting one up? How could they go about that? Because it is a bit complicated, isn't it? Initially, until you've done it once or twice, and then it becomes a lot easier. Yeah, Rob, do you want to answer that one in terms of sort of the MedApps aspect of this? Yeah, well, I think it's something that we've been working increasingly on is how to provide that sort of engagement and that opportunity for people to be able to connect. It's always important, you know, I think that there's some sort of centrality to it and that it's being run by the organisation. And since Sonia's joined us a year ago, we've been increasingly trying to use, you know, put together the information that stems out of her research and the work that she's done in the past to be able to kick off starter kits for organizations that want to get going in that space. Some resources that people can access. Yeah, that's right. Okay. Yeah. Yeah. Okay. I've got some, you can have as well if you want. That would be great Jules. Yeah. Yeah. Okay. Yeah. No, because it is, I mean, I'm at the first time I tried to start, so it took me six months to a year to get it all together and get it up and running. And then once it's happened a few times, it's like, Oh, now I've got all those resources. I just, you know, click, cut and paste done, you know, and it just takes it, you know, a couple of weeks to get it, pull it together. So, which is, it's, you know, it's so much easier. So I think that's like, oh, now I've got all those resources. I just click, cut and paste, done. And it just takes a couple of weeks to pull it together, which is so much easier. So I think it's a bit daunting otherwise if you've not done it before. So I think that'll be a really, really good resource. What was I going to say next? Is COVID impacted on this, do you think? So I think that, well, I'm sure that it's been a big topic of conversation, not just in this podcast previously, but also in, you know, medical administration training get togethers and all of those different areas. I think, well, beyond speaking outside of just mentoring at the moment, obviously it's been an incredibly disruptive year. I know specifically with regard to my sister who did her BPT exam last year and then had short and long cases delayed until December and then finally had a short case earlier this year where she's now in a Brisbane hospital, had to go to the Sunshine Coast during their lockdown and walk past signs saying no one from Brisbane allowed after it had been cancelled, rescheduled, cancelled, and then told that it was on all in the space of three weeks. And the disruption to that for these people, such an enormous part of the medical cohort and obviously focusing just on the physician trainees, and I know that it's affected everyone else as well is I think terrible and the you know I think that there's a lot of uncertainty that COVID has created around the mentoring side of things I think absolutely there was a definite need for people to be able to talk to not just each other, but also those that are further up in the decision-making hierarchy or the physicians or other senior doctors who have gone through it to get some reassurance, get some support, and also try and get some answers as to what's going to happen next, because I think the uncertainty has been the worst of it. And Jules, I'm sure that you've probably seen that as well up on the Central Coast. Yeah, absolutely. I think uncertainty is always bad. Once you know what you're dealing with, you can deal with it. But it's the uncertainty that's the trouble, and people don't necessarily deal so well with uncertainty. I think the only other thing I think for the COVID aspect, which I think has been a positive has been the sort of introduction of telehealth and Zoom and being able to access Zoom at work and things like that now. And that's been one small mercy where it's sort of facilitated that a little bit. But yeah, I fully get that there's been a lot of extra stress this year or in the past year that could be helped with mentoring. Sonia, one of the other things, obviously your medical administration thing, I mean, one of the issues that I sometimes see with mentoring is it's sort of, oh, there's all these problems and junior doctor well-being and stuff. And therefore we'll put a mentoring program in and that'll fix it all. We're not gonna actually bother trying to change the system. And I think that's a bit of an issue sometimes, isn't it? Mentoring isn't a be all and end all thing. It's just one part of a support network and one part of a way of dealing with things. But have you found in any of your things with the sort of increased communication across different levels that that helps to fix the systems and stuff at some point? So people will start to realize that there's, you know, issues which perhaps they didn't realize were affecting things. Have you come across any of that in your research? Yeah, and in fact, that's exactly why we turned it into a research study, because when we first, when the junior doctors approached me and suggested the mentoring intervention, and we approached the administration, the feedback was, well, what is the value of this? What's the benefit? What's the value? Why is this the right intervention to tackle the issues that are happening within medicine? And so that was really kind of the initiator of the research around the benefits. But I think the outcomes were that it provided an avenue for a discussion about what's happening at an organization. It provided a safe space. It provided an opportunity for people who are going through the same issues to debrief, to talk through strategies. And then that's where the framework comes in, the escalation of those issues. They can't just stagnate in that one mentoring conversation. There's a responsibility of the mentor to then bring it to administration, escalate it up the food chain. And so that's where the trust and the formal structures of leadership come into play. And unless the administration act on it, the purpose of the program actually becomes redundant in terms of being a safe space to identify and escalate issues. Around that time, like I said, in the media, there were the issues around bullying and harassment. And one of the specific questions we asked in our research was, if you were bullied or harassed, what would you do? And the majority of the participants said they would escalate it to their mentor. And then the mentor was clear that they would escalate it to the director of clinical training, who was kind of the lead of the program. And so that's where, like, that's where the safe space comes in. Yeah, I think, and that's, I mean, for anybody thinking of setting up a mentoring program, that's one of the sort of cast iron rules that we have is that you cannot be a mentor if you're also their supervisor. Because it's such a huge conflict because, you know, somebody's, your supervisor or training, and then they try and mentor you and you've got some psychological issues, mental health issues, or anything that you can't, you can't air those, or you possibly can, but you're going to be so worried about whether it's going to be non-judgmentally received or not, that we'd say, so it's a cast time thing. |
What would you say if you had people wanting to uh set it up or or thinking of i was divided into two um people who wanting to be mentored maybe there isn't a formal program in their hospital as a way that they can start to access or that to set it up at an individual basis, do you think? Or it's quite hard for people sometimes. It takes, you know, people listen to this. If there isn't a thing in their place, it's going to take probably six months to a year to get it sorted, by which time they may well be in a different hospital. So in the meantime, what can people do to try and sort of move this forward if they felt they wanted mentoring and so forth? You got any tips for that sort of scenario? Yeah, I think so. If there's a junior doctor who wants a mentor, I would suggest that they just ask someone to be their mentor. I don't think you need a formal program to initiate the process of finding someone to debrief with, get support, understand the new organization or environment that you're a part of. I know that throughout all of our training, we have been encouraged to just approach someone that you're comfortable with and ask them, would you be my mentor and set some parameters around what to expect and what you both hope to achieve out of that relationship. But if, if you want to start a formal mentoring program at your hospital, whereby there's proper structure, there's a match system. There are formal escalation strategies. Like you said, it is a little bit more challenging, but that's where like med apps can come in. That's where we can come in. So after I published the paper in the MJA a few years ago, my contact details and my off, you know, the offer that I put forward of forwarding a starter pack actually did initiate a number of organizations to contact me and ask for the pack, which includes basic guidelines, the matching process and templates, escalation strategy examples. And I have helped organizations across Australia and the UK start mentoring programs quickly and more streamlined than it would be for you and me when we were starting from scratch. From a MedApp point of view, if you download MedApp, the open access free version has the information and my contact details. And we have starter packs that we can forward to organizations and junior doctors to approach their director of clinical training and say, look, here is all of the information you need. Let's get this going in the next six months. And I think I would just encourage junior doctors to get involved. Yeah. And approach. Yeah. Okay. Yeah. I think certainly from, from my point of view, the DPAC or DCT should be a go-to person. If you were, if anybody listening to this was thinking if they wanted to try and set up a more formal process into their medical workforce. And I have a load of resources that I've given out to a number of DPETs to help them with that, which came from ASIM originally, but ASIM is also happy for those to be utilised as long as they're acknowledged. Things like confidentiality protocols and things like that, or agreements, which are so important so that there is that trust in the relationship and so forth. So, yeah. And I think the rapport thing you touched on there very briefly is really important as well. I know from sort of my coaching days that about 30% of the benefit that you get out of those conversations is actually related to the rapport. So if you're thinking about who do you pick, pick somebody you feel comfortable talking to. Don't necessarily pick somebody who, you know, I'm thinking of going into radiology, therefore I'm going to pick a radiologist. You know, it's not necessary. It doesn't have to be in the same field. Sometimes it's even better not being in the same field or something. But that rapport is absolutely crucial, I think, for that, which is why we struggle with the matching because when we have interns, we don't know them. So it's really tricky to try and match interns because we have absolutely no prior knowledge of them. So. Joel, do you mind if I follow up on one of the questions or one of the comments you made earlier about the training. What's your experience or opinion about mentors requiring training to participate in this? Yeah, I think it's really important. And I usually run sessions for mentors. A, going over the expectations and guidelines of the program. I think that's really important so that everybody is on the same page and you do that as well with the people coming in. But also actually going through, I usually do a session on coaching skills and, you know, sort of asking open-ended questions and some of the sort of theory behind executive coaching as well. You know, we're not talking sports coaching here. We're talking more about, you know, how to have those conversations which allow personal growth. And one of the things is really, I think, as a mentor is to often try not to give advice because, and sort of the example that I'll often use is if I have a mentee, you know, I'm a 50-something-year-old white bloke, and my mentee or the person I might be talking to might be, for instance, a 25-year-old female Asian person. Well, what's right for me and what I think is correct may be completely inappropriate for them, you know. But the idea behind it being that they know what's best for them. You just need to be able to ask the right questions so they can figure it out for themselves. And I think that that's a real skill. And it's really hard to do because we are always so good at giving advice and saying what we think, particularly as doctors. And so I think some training around that is really, really useful, really useful. And I would recommend anybody anybody who's thinking of being a mentor and it doesn't matter what level you are um doing a sort of something like an executive coach training uh course or something is invaluable absolutely invaluable in that sense yeah sometimes i find um the the training requirements uh barrier for organizations to then commence mentoring programs It sounds like an element of your training is actually orientation to the program, setting the ground rules, expectations, confidentiality, and kind of advice. And then I guess access to formal coaching or executive skills training is kind of a secondary element. That's easier for consultants and people with access to study leave because they can use that study leave for those courses and particularly now with covid and you can't go overseas well you can do them in sydney and brisbane and canberra and all those places so that that's if you're a junior doctor it's not it's not as easy um but then again you know people spend thirty thousand dollars on a masters of critical care um now you could do 10 coaching courses for that, that thing and have a proper certificate. I mean, that would make a CV look a little bit different. So you get a lot of value from that. You know, Jules, I think it's quite interesting, I guess, what we're talking about now. It was my view that I formed, I guess, soon after shifting over to most of my time in MedApps from sort of clinical medicine, that one of the things that we do worst as a, I guess, medical community is understanding that, I guess, the informal side of the mentoring and also, I guess, what I've now come to call that managerial relationship. And there's this process in medicine where you go from being an intern to a resident. And even as an intern, you might be looking after and providing guidance to medical students. And as a resident, you've got an intern and registrar, you've got a couple of residents. And there are very few points during the process where someone says, okay, you're now responsible or you have a leadership role or, you know, some duty of care to the people who are underneath you. And I think this is particularly interesting talking to a friend of mine who used to be a chief technology officer for quite a large company in the United States. And when he came into this organization that had a couple of thousand developers, they didn't have training career pathways. So the career pathway in technology was, in this organization was, as you develop more seniority, in order to go up a rung, you need to become a manager and the reality of people who are in you know playing around with code is that there are some people who only want to bang code together and if you're good at that and only want to do that then that shouldn't necessarily be a restriction on you shifting up the payment ladder and then there are those who want to go into the management side. And so what was happening was people were being forced to take on management roles or some degree of management roles, even though that they were completely unsuited for them and had no interest in them. And the harm that that does, I think, is quite severe. |
Welcome to On The Wards. It's James Edwards and today we're speaking about a topic very close to my heart, headache in the emergency department and we have with us Dr. Catherine Spira. Welcome Catherine. Thanks very much. Catherine's a close friend of On The Ward and is a neurologist who works privately also at Prince of Wales Hospital and we're going to do a few topics. The first one's about headache in the emergency department which as an emergency patient I know is very common. What we may do is start with a bit of a case, and it's a bit of a long, complex case that will make, I guess, the listeners start thinking, and also we can start thinking about what some of the issues are. The case is an 82-year-old male who presents with two weeks of right-sided headache and feeling unwell. At the beginning of the headache he saw some rainbow lights in his right visual field and these have been coming and going throughout the episode. The headache is there almost all the time and varies between a dull ache and severe throbbing pain and part of his head is very sensitive to touch. It's always on the right side, as is the visual disturbance. There's no photo, photo, osmophobia, and no nausea and vomiting. In high school, he remembers having two migraine headaches with visual disturbances, nausea and photophobia, but he's not had a headache since. It's not a headache sufferer. What are some of the questions we may ask is, when you listen to this, what's your initial response to this patient presentation? Okay, so there are a few things that stand out about it that make me concerned. First of all, this is a man who hasn't had a headache for about 70 years who's got a headache now. So a new onset headache is always concerning in anyone over 50. So that would be the first thing that I would be concerned about. So looking at the other components of the presentation, there's talking about rainbow lights in his vision. So in a migraine, you can get visual disturbances that are like this. However, these have been coming and going over a period of two weeks. So the classic migraine visual aura lasts about 12 minutes and then it abates and then the sufferer may get nausea, vomiting and headache coming on after that. And the headache, the visual aura classically, the most classic visual aura will gradually spread in the visual field and then recede and abate. So this is not that kind of visual aura, this is something else I would say. And then the headache is there all the time, so any new persistent headache in anyone of any age would concern me. And the other things that are in here that it's always on the same side of the head, which also does not sound like migraine, which tends to be, can be on one side during an attack, but will usually shift between sides during an attack and between attacks. So those things are concerning. And he's got some sensitivity to touch on his scalp, which is a feature that is often seen in giant cell arteritis also talked about as polymyalgia rheumatica and also can be a sign of nerve damage if it's occurring elsewhere like in a trigeminal distribution it's sometimes associated with a trigeminal neuropathy you can get allodynia and touch sensitivity and migraine but again some of this is not looking like migraine to me. The other thing is there are no features often associated with migraine like light sensitivity, sound sensitivity or increased sense of smell and the history of him having had migraine before, considering it hasn't happened for seven years, is not that significant in my opinion. It is possible for older people to, for the first time in their life, get visual aura. And often it doesn't proceed to headache. And it's a strange thing where it comes in as a query stroke type of presentation. But, yeah, the features of this do not sound like that typical spreading visual change, recedes within 12 minutes, goes on to headache or not. So I'm feeling uncomfortable with this. And there are suggestions, both the patient's age, the fact that he's feeling systemically unwell, and also the scalp sensitivity that this may be something that's taking on a giant psilocybin flavor and the main problem with that is threat to vision so that's the main reason that this needs to be picked up straight away and treated as an emergency threat in vision. So you mentioned some of the key history but I mean when you're taking you through somewhere headache what are some I guess the key questions you think are really important to ask? Okay so really important especially in ED is onset so particularly trying to pick up a thunderclap onset type picture so what I like to know in my head is I like to have a picture of the pain so I sort of treat anything that goes from zero to a hundred within 10 seconds is very concerning for a thunderclap onset headache. This sounds like it's got an indolent gradual onset. So onset's important. And then I like to think about what the pain is doing. Sorry, I like to think about the character of the pain. So is the pain throbbing versus a dull ache versus sensitivity to touch? And what are those sorts of character features? So the next thing you want to know is the severity of the pain as well. So is this a dull ache versus something that's extremely debilitating? And usually just looking at the patient from the end of the bed, you get a pretty good idea of that. And then, I mean, the other things we've already really elicited is the demographics of the patient. Has this ever happened to them before? And in a patient, the trickiest part is in a patient who has headaches, why is this headache different? And is this a dramatic change from their usual presentation of headache? Those are the sort of main things I think in the ED are really important and of course anything systemic that's going on, so does the patient have a fever, are there neurological signs associated or is the patient weak down one side and how did this come on and at what point did those neurological systemic features come on? So those are the sort of main things. So regarding the key history, is there any particular things, I guess, in past medical history or what medications they have been taking or are taking? Well, with past medical history, I guess malignancy is the first one to think about. There are lots of persistent ongoing headaches from space-occupying lesions. So that's definitely something to think about. And then there are some systemic syndromes that put you at more risk of vascular events, like antiphospholipid syndrome, vasculitides, and things like that. And then with medications, there's a lot of exacerbation of headache due to misuse of analgesic compounds and actually headache management drugs. So you get a migraineur who's got a history of ramping up medication use and ramping up headache, particularly opioid analgesics and triptans, that's something that goes into your mind definitely. But I think in anyone with migraine where there's been a big change in the pattern, you sort of have to take it seriously in emergency irrespective of whether they're overusing medications or not. It's more something you get to after you've cleared the air and you're not scared about that anymore. You can move on. Okay, so these are good things based on history. What are particular things on examination that you think we should routinely look for, and especially, I guess, the ones that we may not always immediately think about, especially when it's all about the headache? Sure. So in this this particular patient I think examination of their vision is probably the most important thing. So they're describing positive visual symptoms which always makes everyone think of migraine but actually when someone that age develops visual loss often the brain will fill in the blanks and give them positive visual symptoms so So it's called Charles Bonnet syndrome and basically we think it's some kind of cortical filling in the gaps kind of mechanism to this. So lights in the vision is one thing that can describe. People sometimes have fully formed visual hallucinations and you can sometimes get a history of this being only on one side of the vision or in one part of the vision and it sometimes corresponds to the region of visual loss. So one of my favorite patients with giant cell arteritis saw a queue of people just in front of them but stopping at the midline and she wasn't sure what they were queuing up for but they disappeared once they shifted in a queue so you can see really bizarre things like that but this this light in the vision is more much more typical so I'd really want to closely examine that the optic nerve I think that that's a key part of the examination and of of course, in all headache, looking for papilledema is so important. Papilledema and headache needs imaging, needs to be taken very seriously in the ED. So that's one of the most important things. |
So vital signs are important and also neck stiffness goes along with that and potential infective signs. You need to do a full neurological examination on anyone with headache because you do not want to miss problems with the neurology plus headache is actually also very concerning for a secondary headache. So those are the main things that you look for in examination. You mentioned a few along the history and exam. Are there particular, I guess, red flags or something we need to particularly worry about when we see a headache in the advanced department? Absolutely. So my favourite red flags mnemonic is by David Doddick, who's a neurologist and one of the great teachers of headache from the United States. And he published a paper about his favourite mnemonic, which is SNOOP. So S is for systemic, so any derangement of vital signs or signs on systemic examination, so things that we were talking before, fever, neck stiffness, that kind of picture, that needs imaging, that needs further investigation. N is for neurologic, so focal neurological signs on the patient. The first O is for sudden onset, so 0 to 100 in less than 10 seconds, very concerning, thunderclap headache. The next one applies to this case so it's onset after the age of 50 so no one starts getting headaches after the age of 50 usually unless there's a problem and you need to be very confident before you say that it's just a primary headache and there's no underlying cause. And then there he's got a number of P's and I've put in a couple more. So one P is pattern change. Progressive headache is the other one. So this is also a story of ongoing progressive headache. Precipitated by Valsalva. So there are a number of issues including vascular malformations and other things that can give you a headache exacerbated by valsalva. Postural aggravation. So is it worse when the patient sits up? That could be a spontaneous low pressure headache, or in the setting of someone who's had a recent lung puncture, it could be related to that. And then papilledema, which we've talked about. And I also like to put in pregnancy or postpartum because that's a prothrombotic state that someone can be in. And there's also a general risk of vascular events in pregnancy, but especially affecting cerebral vasculature. So to have a systemic, that's usually going down an infective or inflammatory route. Neurologic is things like stroke with headache, which can particularly happen with posterior circulation strokes, but also with infarcts elsewhere, and also with space-occupying lesions. So anything that's inside your head and gives you a neurological deficit can give you a headache as well and that's probably what you should be focusing on. We talked about thunderclap onset so things like subarachnoid hemorrhage is what everything with a thunderclap onset is until proven otherwise. Then you can have things like reversible cerebral vascular constriction syndrome, aneurysms that haven't actually ruptured can give you a headache without a subarachnoid bleed and dissections, meningitis and there are common headache types that can do it too but we're not going to assume that it's just another one of those that person's migraines before we investigate further so that kind of headache ideally needs ct scan which within six hours is actually fairly accurate in diagnosing subarachnoid hemorrhage a lumbar puncture especially if it's presenting anyone after six hours but everyone should really have one because missing a subarachnoid is not a wonderful thing to do. And a CT angiogram is actually, I know it's controversial in some hospitals, but I think it's very important for looking for unruptured aneurysms and reversible cerebral vascular constriction syndrome and dissection. So I would always progress to that, especially if the non-contrast CT didn't have anything to find on it. And also don't do a contrast CT just because it sounds good. Non-contrast CTs are much better for seeing haemorrhage. And this is for a query subarachnoid bleed or head exogen? Anything with the thunderclap onset, I think, should have those tests done. Onset after age 50, we're sort of discussing a key case of one of the more common causes of that. But these are all things that you should be thinking about imaging and investigating further and taking seriously. So I think, I mean, imaging does come up and the sub-rater of imaging is, you know, controversial in regard to the role of a CTA and also the role of a number partnership. But I think one of the challenges we find is there are lots of choosy-wisely campaigns that are saying we shouldn't be CTing headaches. But then we don't want to miss a potential life-threatening disease. So can you give us any guide on some of the imaging guidelines around headache and what other tests that you may consider such as blood tests? Okay. So I know that in ED there are systems for making those decisions like Canadian CT rule and all these other things. What I actually use is a bit different, and it might be because I do lots of headache all day long. But for me, anything that's atypical gets imaged. So if someone comes to me and they're 40 and they've had migraines since they got their period when they were a teenager and their headaches have been going through phases where sometimes they're very frequent, sometimes they're infrequent. They have syndrome that sounds very similar to their normal headache, but it's been increasing in frequency. They've been increasing their use of opioid analgesics alongside it and now they're coming to see me because they're desperate. I wouldn't necessarily image that person because they've had a change in their pattern, but essentially the headache's the same and they're just getting them more frequently. And there's also a possible cause in the history. If I see someone with migraine, but they're getting aura with every single migraine, that's something that I actually, that's not normal. So people that get it, you know, with their migraines about 20% of the time or 50% of the time, that's sort of normal. But if they have a very stereotyped aura that's happening every time, I'll image them. So things that sound a little bit atypical, I would actually image. In ED, it's more difficult because I guess you need to know, is this going to cause a serious harm to the patient in the next 24 hours, in the next two hours. So, you know, the tools that are out there are very helpful. But I do think if you get someone coming into the emergency department with worst headache of my life, non-headache sufferer, that's very straightforward. But I do think there is a real gray area. And I think I would personally use those red flags to guide me. And anyone who satisfies them gets image. But also anyone with an atypical sort of sounding migraine who has normal migraine or something that sounds very classical usually. Also, there are lots of out there with tension type headache but if they come to you with a headache that's sufficiently different in character so really that the complicated patients are really the ones that already have headache and actually you know P for pattern change in the snoop mnemonic suits them. That's my opinion. The one way you probably have some of the challenges with is someone has a migraine but often the migraine you know this is my worst headache in the city of migraine and one of the neurologist colleagues just said yeah he kind of described it's like the same radio channel but louder or like a completely different new channel and it's kind of one of those things that yeah yeah no it is like my normal pattern but it's worse than that and that's usually just they've come to it because they've had a terrible migraine versus no i've had migraines this is yeah a different pattern that makes you a couple of change now in regard to blood tests we've done a bit about imaging and so it sounds like a non-contrast ct brain for query sub-britanoid you're worried about meditancy would you or-occupying lesion, should they get contrast, or would they be okay with a non-contrast? So I would actually, it depends what the story is. So you can really have space-occupying lesions presenting in a patient with, sorry, you can really have things like a thunderclap headache in someone with a history of malignancy. In that case, if you have reason to suspect hemorrhage, like a thunderclap headache in someone with a history of malignancy. In that case, you know, if you have reason to suspect hemorrhage like a thunderclap onset headache, then I would do a non-con followed by a contrast CT. I still think non-contrast scans are very useful and I'd probably do both in most patients where you were suspecting a space-occupying lesion. |
Welcome to On The Wards, it's James Jensen and I'm here today speaking to Jo Ringleton who's a Senior Pharmacist for Education and training in the South East Sydney Local Health District. Welcome, Jo. Hi, how are you going? We're going to talk about opioids today, which is a really big topic. So we probably would like to get your perspective as a senior pharmacist on opioid prescribing that junior doctors do. So maybe we just start fairly general. What are some of your thoughts on the prescription opioids generally within hospitals? Okay, well, how long is a piece of string? It is a big topic and there's a lot of things that you have to consider. Obviously pain is pretty subjective, so every patient is going to be different. Obviously you've got to look at the type of pain that you're trying to treat, make sure that opioids are in fact an appropriate choice. You've got to look at what other analgesics have already been tried, because obviously you try and use a combination to reduce the dose of opioids that you need to give in certain situations anyway. When you mentioned about the type of pain what type of pain does opioids particularly effective for oh you know it's the nociceptive pain in reality um i suppose what i'm saying is that we need to look at if you had a patient who was presenting with neuropathic pain you know would an opioid actually be an appropriate choice first line probably not okay. So, yeah, you've got to approach everything on a case-by-case basis. There's not a one-size-fits-all rule for opioids. You've got to make sure that you know your drugs and you need to know the risks associated with those drugs. I suppose the first thing we need to look at is the age of the patient. Okay, there are different, I suppose, dosing guidelines. They're usually based on age. So children, I'm not even going to go into children at the moment, but certainly elderly patients, you would use a much smaller dose in a frail 80-year-old than you would in a fit and healthy 100 kilo rugby player. Okay, so when you look at age versus weight, they're more related to age than weight or it's a combination of both? I think it's a bit of a combination of both. The guidelines say it's age-related. However, you know, if you've got a guy who's, you know, 60 kilos and a guy who's 120 kilos who comes in with an acute pain, you're probably going to use a slightly bigger dose in the bigger fella. So, yeah, you've got to think about that. Certainly elderly patients, though, you start way, way low down the dosing scale, usually about 25% to 50% of the normal adult dose. And is that because they're more likely to get side effects? They are. They are much more likely to get side effects. They're much more sensitive to opioids as well. there's probably um renal implications with elderly patients as well so you've got to take that into consideration too um yeah um i suppose one of the other things you need to think about is is the patient who's presented to you are they nilblometh or can they take oral medications that's one way you've got to think about which drug you're going to use as well. Oral route is preferable, if possible, but sometimes it's not. So if you do present with someone who's got an acute abdomen oophorma thing, then obviously the oral route's not going to be something that you can use. You certainly need to know whether they can swallow tablets whole as well. In an acute situation, it's not such a big deal because you wouldn't usually use a slow-release medication in an acute situation. It takes too long for it to work. You can't titrate the dose as well. You'd use an immediate-release preparation. We'll talk about post-op in a little while, though, which is a slightly different scenario sometimes. But if they can't take things orally you need to be careful you don't end up crushing slow release medications because then you'll don't stop okay um you can cause a lot of problems with opioid toxicity if you do it that way um you also need to think about what else is wrong with them i suppose because there are certain situations where you would need to be much more careful with opioids. So, you know, anything that might increase the risk of respiratory depression, so if you've got somebody with severe COPD or something like that, you'd need to be much more careful with using an opioid because it'd be at a greater risk. Or if you've got somebody who potentially has a head injury as well that sort of restricts the opioids that you can use. Yes. And also you can get issues with confusing, deteriorating neurological conditions with sedation as well. Okay. So that's something else to think about. You certainly need to think about what their renal and liver function's like because there are restrictions on what drugs you can use in certain situations as well because in renal dysfunction you can get accumulation of some active metabolites and they can cause a lot of problems. Obviously, what other medications they're taking. We'll talk about drug interactions, I think, in a little while. But in general,, in general, if you've got an old lady who's taking, you know, some CNS-depressive medications like sedatives or benzodiazepines, you would need to be pretty careful that you don't increase the side effects linked in with those. And obviously then if you think about whether patients are pregnant or breastfeeding, that's an implication if they're female. OK, so they're breastfeeding. Some of the metabolites or some of the drugs can... Some of the drugs aren't really that appropriate in patients who are pregnant and breastfeeding. And if you do have any questions about opioid use, you can always, in those particular sort of cohort patients, there are a couple of good resources that patients can use as well. MotherSafe would be one of them. Or also you can talk to your acute pain team. And there's guidelines on CF as well about drugs in breastfeeding and pregnancy. Okay. As I said, if you're looking at using oral medications, you need to think about what formulations are available. There are immediate release formulations of certain medications and slow release formulations of certain medications. And there has been a lot of problems with doctors not specifying which one needs to be given. Can you give an example? Probably the one that's caused most issues is hydromorphone. There's been a lot of incidents with that medication being given incorrectly. It's got its own special place in the high-risk medicine policy now from New South Wales Health, hydromorphone. So the mix-up between the immediate release, Dilaudid, and Genista, which is the slow release can be quite an issue so it's really important when you are prescribing that you do specify exactly what you actually want the nurse to give okay um way you know like i said it's important to know what drugs are around and when you can and can't use them. You've got your weak opioids, so codeine, which you would usually give in combination with paracetamol. How effective is it? You know, there's all sorts of issues with codeine and, you know, people's ability to metabolise it. You know, some people can't metabolise it. It's a pro-drug. So some people can't actually metabolise it to its active form. So there's no analgesic effect there anyway. Whereas some people, you know, there are issues with it being over-metabolised. So codeine, very commonly used. Probably oxycodone would be the one that most people are familiar with in an acute pain situation. Again, there's an immediate release and a slow release version of that, so just be very careful. There's also the formulation that has the naloxone linked in with it that helps minimise the GI side effects of constipation, but we can talk about that a little bit later too. There's obviously morphine. Morphine is used orally, but it tends to be used in its slow-release form rather than in its immediate-release form because it's quite unpredictable, the absorption of immediate-release morphine, and it's quite hard to titrate the dose in an acute pain situation, So you probably tend to see it more used in chronic pain, I would say. Hydromorphone, as I said, there is an immediate relief and a slow-release form available. So be very clear about which one you want. It is a very strong opioid and is, unfortunately, commonly mixed up with morphine. They are different drugs. Hydromorphone is five times more potent than morphine, so just bear that in mind. |
50 milligrams of morphine. It's pretty much, yeah. So just remember that, you know, that they aren't the same. It's really important. It's been linked to lots of incidents, hydromorphone, as I said. Tramadol probably isn't used so much nowadays unless it's pretty much for minor procedures. Tramadol is a pretty weak opioid and it does have some issues. It is a serotonin and noradrenaline reuptake inhibitor. So you have issues with those kinds of side effects rather than the opioid side effects, the immolality. So, you know, sweating, nausea, those kinds of things. I could go on for hours for this. So there are so many different types. There are. Lots and lots and lots of different types. Different routes, different doses. Yeah. I mean, as a junior doctor, what kind of resources are available to try and make sensible prescribing decisions in regard to opioids? There are lots of resources available on SIAC that are useful. Obviously, you have the AMH, which is the Australian Medicines Handbook. It gives you some good guidelines some good dosing guidelines as well, tells you all about the side effects of the drugs. You've also got the therapeutic guidelines, the ETGs for analgesics. I think they probably need to be updated soonish, but, you know, they're still relevant. There's a couple of drugs or a couple of formulations that aren't mentioned in there, but they give really good guidelines as to when and what to use in different situations. You've also got up-to-date, which is very, very thorough about, you know, what to use when and the side effects and risks associated with them. The World Health Organisation produced an analgesic ladder a long time ago. I think it was 1986. That was initially aimed at cancer pain, but I think that's now generally being sort of expanded to other kinds of pain as well. So, you know, that sort of recommends, you know, the whole thing about oral dosing regularly. It individualises the dose. So that's a good thing to have a look at. Don't forget that most hospitals have a pain team, an acute pain team or a chronic pain team as well, that you can always ask for advice if you, you know, you get a complex patient. So say you get someone who comes in who's opioid dependent already and needs treatment for acute pain. That can be very complex. So don't forget you've got those for advice. Of course, ask your pharmacist. We can help. So what are some of the situations you think involving the ward pharmacist will be useful? Useful. Certainly if you've got people who have um renal problems hepatic problems we can provide advice there as to what you can and can't use and when um if you do have somebody who you know is already opioid dependent um we can have a look at that certainly advice on when people can't take things orally, what we can do, how we can manipulate dose forms to help you safely. We can certainly help with that. And elderly recommendations on dosing. Making sure that we're following appropriate guidelines, I suppose, on surgical wards as well. We do see a few weird and wonderful things happening out there um you know as I said that you know with acute pain that you wouldn't normally see um a slow release preparation being used to treat it when you're looking at surgery particularly sort of surgery like orthopedic surgery where you're expecting that they might have a bit of a prolonged episodes of pain or instances of pain, it's quite common practice now to use the modified release drugs like oxycodone. So you might see oxyquantin or you might see targin, which is the one that's linked in with naloxone, post-op. And basically what they're doing is they're sort of almost hitting it quite hard and then stepping down the dose so that when the patients go home they can tailor it off by the GP but again it's really important that you give direction to the GP exactly what you want to happen so that you don't end up with somebody who's being maintained on a slow release opioid for no reason. You mentioned one of the roles of the pharmacist is to help you, I guess, calculating some of the equivalent dose of opioids. They do have different potencies. Some oral and intravenous would have different doses. So any tips on doing that? Yep. Well, again, there's a number of resources that can help. If you have access to the pharmacist, we obviously will help you. The pharmacist isn't there, there's a couple of tables. One's in the AMH, Australian Medicines Handbook. And there's one in the ETGs as well, which shows you the equianalgesic doses. They're all compared to morphine. Yes. So it's either compared to oral morphine of 30 milligrams or parenteral morphine of 10 milligrams. Basically, what you can do is look across. So if you look at, say, the 10 milligrams of parenteral morphine, it's about 150 to 200 micrograms of fentanyl. And like I said, 1.5 to 2 milligrams of hydromorphone is the equivalent. So you can see the fentanyl is much more potent than the morphine. So that's fine. But what you've also got to remember is when you are swapping over to a different opioid, as you know, patients get tolerant to opioids pretty quickly. That doesn't necessarily translate to cross-tolerance. Okay. So just because you've got quite tolerant to morphine doesn't mean you're going to be as tolerant to oxycodone. So the best approach is to actually reduce the dose by half when you're swapping over. So, yep, okay, if you've got 30 milligrams of morphine, that's what they're on. Well, that's 20 milligrams of oxycodone. In fact, what you'd want to do is give them 10. Okay. Okay, so that you would start with that 50% of the dose and then retry trade it up because, as I said, there's not complete cross-tolerance between the opioids. Okay? And then what you would do is use a breakthrough dose of an immediate release, of the immediate release form of that. And usually when you're working out a breakthrough dose, you use one-th to 1 12th of the total opioid dose for the day. Okay. Also remember that if you're changing the route of a drug, that the doses aren't always the same. Okay. So again, I harp on about hydromorphone quite a lot, but it is a drug that you do need to be very careful with. And we do see sub-cort oral doses written that are the same, when in fact they're not. So the dose of hydromorphone orally is very different than the dose of hydromorphone. So it's really good practice not to put the same route, different routes on the same order. Okay, because the doses are always equivalent um with the so you know the advent of emeds or you know electronic prescribing you can't do that anymore anyway but um you know it's taking quite a long time to get around yes and we've got a national audience here i don't know everyone's yeah we're up to with um electronic medication ordering um but yeah hopefully we Use separate orders. Yeah, use separate orders for different routes. You mentioned in your initial approach to your thoughts on opioids about drug interactions. What are some of the really, I guess, really common drug interactions with opioids that junior doctors may see on the wards? Okay. There are a lot that you just need to keep in mind, I suppose. Probably the most important one to think about is, is a patient already taking a CNS-depressant drug? So if you think about sedatives, hypnotics, benzodiazepines, particularly if they're elderly, but anybody, in fact, you know, that will potentially increase the effects of the opioids and also increase the risk of respiratory depression. So just be very careful with that if you're using both drugs. Okay. As I mentioned earlier, some of the drugs don't just affect opioid receptors. They can affect serotonin and noradrenaline. They are, sorry, serotonin and noradrenaline reuptake inhibitors. Such as tramadol. So tramadol would probably be the one that you would associate with it. But also fentanyl as well can have this problem. And pethidine, although we don't use pethidine anymore, really, there are too many issues with pethidine. You'll find it's been taken off the formula in a lot of places. It seems maternity. |
I don't even know if they use it in maternity anymore, to tell you the truth. I don't work in maternity. So, yeah, there's too many issues with it. So it's very, very rarely used now. But, yeah, you do need to be careful if you're combining, say, one of those drugs with something like an SSRI or you would have to be very careful that you don't get serotonin toxicity. And if they're actually on an MAOI, which is another kind of probably an older type of antidepressant, you actually can't use them together. There are methadone, which you don't tend to see used unless it's from a chronic specialised pain team. But that can have issues with QT prolongation. And it does have a lot of drug interactions. I think we need to remember that most of the opioids are metabolised in the liver by the cytochrome P450 system. So a lot of things that will affect that system can affect the amount of opioids that are being metabolized, so you can get toxicity. So if you think about, say, fentanyl, which is already a very potent opioid, it is metabolized by the CYP3A4. So anything that will affect that or inhibits that, so if you look at drugs like, I suppose, fluconazole or voriconazole, you can get a huge increase in the amount of fentanyl that's floating around. Conversely, if you've got an inducer, you might end up losing your analgesic effect. I think what I did want to sort of mention, I don't know if I did mention before about fentanyl patches and buprenorphine patches that really aren't suitable for opioid-naive patients at all. There's a much greater risk of hypertension and death. In fact, if you use those in opioid-naive patients, and they shouldn't be used for acute pain. The problem with those as well, if you have got someone who is on them, is that because they're slow release and they leach the drug out over a long period of time, their effects can actually last longer with drug interactions as well. So it can be like 24 hours, 48 hours before the drug's actually gone. So just bear that in mind as well. And the other thing that doctors may not realise is that if you put heat onto patches, so opioid patches like fentanyl and buprenorphine, you actually increase the rate of release of the drug. So if you've got a patient who's got a sore back, they put a hot water bottle on them, you can actually increase the rate of release and that can be really dangerous. I've never heard of that. Oh, no, no, no. That's common or they're in front of a fire. Or if they've got a fever as well, they're actually much more susceptible to the amount of opioid that's coming out because the rate of release does increase. So just bear that in mind too, that if you do ever prescribe a patch, that they're told that. Yeah. I think that's probably covered about most of the drug interventions. There are lots. There's a lot to think of. There is, there is. You've given a very good overview of some of the issues in regard to prescribing opioids. We may go to a case, and a lot of this has already been highlighted already, but you're a junior doctor and you're asked to review a 65-year-old female patient who is day two post-elective hip replacement. She has a history of some renal impairment and been on some regular oxycodone for two days. And you're thinking about prescribing some initial ongoing analgesia but also discharge analgesia. What other information do you think is important to assess or evaluate? Okay, well, when we go to see this lady, there's a few things that we sort of need to know, I suppose. We don't know anything about her at the moment, so I'd want to know what allergies that she has. Obviously, it's pretty important. Is she taking any other analgesics? The best way to approach perioperative pain is to actually use a multimodal approach, not just opioids. So what do you mean by that? So looking at drugs from different classes, so things like regular paracetamol, maybe an NZ depending on whether it's appropriate or not, and then looking at an opioid as well. So you've got a bit of a couple of pronged approach to treating the pain. Obviously, just mentioned there's a whole heap of drug interactions that we might need to be worried about, so we've got to look at what she's on. I'd want to know what dose of oxycodone she's already been given, and I'd certainly want to look at how sedated she is with that and whether her pain is controlled. Obviously, that's important too. And whether she's showing any signs of other side effects. You know, is she constipated? Any urinary retention? Or is she vomiting? So yeah, we've got to make sure she's got appropriate pain relief. I did mention before about them using the slow-release oxycodone after surgery at the moment. It's certainly common practice. And as I said, it's very, very important that are clear with the gp as to what is meant to be happening with that pain relief when they leave hospital it is a problem that you know people are continued on things when they don't need to be um so yeah that's what i'd be looking at initially what's her baseline renal function you know what's happening with her renal function okay so you have looked at the renal function, you know, what's happening with her renal function. Okay, so you have looked at the renal function, you have looked at the liver function. Are there any particular precautions you need to consider when using opioids in patients with renal or hepatic dysfunction? Yep, yep. So if I went to look at this lady, I'd have a look at her, as I said, her sedation scores, look at her respiratory rate, I'd look at her urea and creatinine, work it all out. Basically, in renal dysfunction, some of the drugs are contraindicated or should be used in caution because they've got active metabolites that can accumulate. Such as? Morphine would be one. So morphine's not so great in patients with renal dysfunction. It's not the drug of choice. Certainly, if you had someone who's got a more severe renal impairment, you'd look more closely at fentanyl or hydromorphone. Okay. And when you say severe, what kind of... Do you use creatinine, creatinine clearance, or what are your... Well, we tend to use creatinine clearance as pharmacists, and we've worked it out with Cogroff. The EGFR that's currently on C-APM you can use is a little bit more accurate than it used to be. If you're looking at it from a critical dosing point of view, I'd probably still personally err on the side of Covcroft Gold at the moment. Once you are getting into that less than 10 millimiters per minute, then you start getting into trouble with the drugs that you can use. Like I said, fentanyl is probably... There's no active metabolites with fentanyl, so it is probably preferred. You can use oxycodone if they've got moderately impaired renal function, but you've got to start thinking about reducing the dose. Hydromorphine is used quite regularly on renal units as well. It doesn't seem to have the same issues that morphine has. If they're on dialysis, that's a different story again. And that's something where you really need to start looking it up. I'm pretty sure that morphine or oxycodone aren't really appropriate in dialysis. So with liver failure, you know, most of the opioids are biotransformed in the liver, they're metabolised in the liver, so you've got to be very careful. So it would be really sort of slow incremental doses and just be very wary of precipitating somebody, you know, if they've got cirrhosis or something, you know, the end stage liver failure, be very careful of precipitating them into a coma. Basically, codeine, I'm pretty sure, wouldn't work because it wouldn't get metabolised. So there would be no point. And I think, again, fentanyl might be the one that would be more appropriate. But when you get into those stages, it's best to use your references and check in an individual drug. Yeah. So, can you take fentanyl orally? Look, there is an oral form of fentanyl that's sort of just, there's always been the lozenges. |
They're pretty much only licensed for use in cancer pain at the moment. People do use intranasal fentanyl, and I know in the US there is a formulation of intranasal fentanyl. I'm not quite sure how they use it here. But it's an off-label use. It's not an indicated use. So often those patients with renal failure, really, if they're getting on oral medication, they'll probably... Probably be hydromorphone. Yeah. But again, very low doses. Hepatic failure is a little bit different. Yeah. So again, you'd have to look at it on a case-by-case basis. I don't think there's a general rule. Certainly with dialysis, there's a renal drug handbook. The other thing as well with liver disease, though, is it's best not to use low-release preparations. You're better off with the immediate release. Yeah, liver disease is quite hard. You just have to be very careful. And paracetamolol sometimes. Well, that's right. You want to make sure you don't have too high doses. Yeah. I mean, look, you think oxycodone is appropriate to continue in this patient? Look, it is, as long as the renal function's not, you know, drastically compromised. If it's, you know, moderate renal failure, that's fine. You just need to reduce doses. That's all. And, you know, I check how she's going, like I said, with her sedation and stuff. I make sure that she probably is prescribed a paracetamol as well. So what are some of the common low-risk side effects associated with opioids? And maybe then also should we be prescribing other medications such as Perian with opioids? Yep. Well, all opioids pretty much have GI side effects, as I'm sure you're aware. So nausea and vomiting are a few hypothetical reasons why it does this. So you just kind of make sure that the patients are prescribed suitable anti-emetic. I think they get quite tolerant to the nausea so it should lessen as time goes on. Constipation is a big problem and it's quite sometimes a limiting problem for people who are on chronic opioids and can limit the amount they have almost it's very common and they get very little tolerance to constipation as well so it is really important that they watch their fluid intake and their diet that they mobilize if, but you should always, always use a laxative for people who are on chronic opioids. And even if they're beginning acute opioids, you'll find that most people will charge them for usually a stimulant laxative and a stool softener. So coloxal and thinner would be sort of your gold standard drug that you would use. But you can use the osmotic laxatives as well. So things like Movicol or even even sorbitol but coloxanthin I think is probably a gold standard one that they use just be a bit careful with bulk forming laxatives because it actually might make it worse and as I mentioned there is targin which is the oxycodone naloxone. So the naloxone, as you know, is an opioid antagonist. When you give it orally, it's not got a great bioavailability. And it's got extensive first-pass metabolism. So what it does is actually just works on the opioid resets for the symptom gut. And so it stops the drug, causing that local effect of constipation. and so it doesn't actually affect the analgesia at all. The other problems that you might get from opioids are itching. So pruritus can be a problem. Urinary retention sometimes. Obviously it can get a bit sloopy anyway. You might find in older people that you have some cognitive issues. They get a little bit knocked delirium. They get a little bit knocked off in a delirium, yeah. And sometimes you can get a problem with postural hypertension. And in an old person, that can be a bit of an issue if they're potentially falling over. So yeah, and obviously, you've got the tolerance to opioids as you go on. So yeah, there's a few things you just need to watch out for. So there's some of the low-risk side effects. Are there anything more serious, anything more serious life threatening that gene drugs should be aware of? Look, I think the one that you probably need to be most aware of is respiratory depression. Look, it's more likely to be an issue if your doses are increased too quickly or you start with too high a dose or if you've got somebody who's predisposed to having lung problems. So somebody who's got COPD sleep apnea so you're worried about co2 retention yeah um pretty much yep any condition where you've got that compromised lung function i suppose you would be an issue and as i mentioned earlier if they're on something that causes you know sedation so something like a benzodiazepine that's also going to increase your risk however if you start low go slow take it easy you know you're much more likely to minimize your risk of that happening you should always check their sedation scores to make sure you know if you've got somebody I don't know how much tonamose are away of the sedation cause I assume they are but if you looking at, there's usually a scale you can use. So, you know, zero would be wide awake, one would be easy to arouse, two is, you know, easy to arouse, but they can't really stay awake. If you're looking at that sort of sedation score, then you might start to have a problem. Yes. And so basically what they're doing is they're measuring how awake the patient is and their ability to respond to verbal commands. So be familiar with that. Basically, those sedation scores are more likely to be predictive of respiratory depression than actually a reduction in the respiratory rate, although it will also be important to look at that. Your sedation scores are the ones that really you should be focused on because they're an early predictor. An early predictor. That's right. The respiratory depression will likely happen later. Yeah's right. That's right. So you're looking to keep a sedation score, obviously, less than two. Okay. And if you do increase doses of opioids, make sure you increase your frequency observations as well. Okay. That's an excellent point. Just to keep an eye on it. The only other issue, really, or more serious, well, I mean, there's always going to be serious issues with opioids, but I suppose just be careful with IV. Opioids, if you give it too quickly, you can actually drop that blood pressure quite a lot and you can get bradycardia vasodilation and so you can cause a few problems there as well. So I look at the rates that you give things to. Okay, I mean, we've had an excellent overview of some of the issues with opioid prescribing. Have you any take-home messages, I guess from the aspect of a pharmacist working on the wards? Yeah, okay. So just make sure you treat everyone on a case-by-case basis. As I said, there's no hard-and-fast rule that fits everyone. Your approach to dosing a frail 80-year-old should be very different than a big, strong, rugby-playing 25-year-old. Just make sure you start cautiously. Start with small doses and just increase regularly until the patient's pain-free or you're limited by the side effects, usually sedation. Respiratory depression is an issue with opioids, but it shouldn't preclude anyone being treated with opioids. You just have to be very careful and make sure you look at their sedation scores because that's a better indicator of respiratory depression than respiratory rate, as we said. Know your drugs, know their risks, and remember that hydromorphone is five times more important than morphine they are not the same be aware of the different doses for the different routes make sure you're prescribing things on separate orders make sure you're equi analgesic doses and that you actually do reduce the dose before you re-prescribe a new opioid you know that cross tolerance doesn't occurolerance doesn't occur. I'll say it again, transdermal patches are not for opioid-naive patients and they shouldn't really be used in acute pain, OK? And make sure there's a discontinuation plan for opioids post-op, OK? Make sure you're very, very clear about what you want to happen. And, look, be careful. Start with low doses, and if you don't know, ask. You know, they're not a drug that you mess around with. They're a high-risk drug for a reason. Because if there are errors with them, the consequences of those errors are greater than with other drugs. |
Welcome to On The Wards. It's James Edwards today. I'm speaking to Associate Professor Amanda Walker in regard to the National Safety and Quality Health Services Standards and what it means for you as a junior doctor. We've asked Amanda to speak to us today because of her important role as a Senior Clinical Advisor at the Australian Commission on Safety and Quality in Healthcare. Welcome Amanda. Thank you. Look I suppose the first thing I say is it's an awful mouthful, so I'm just going to refer to them as national standards. Good. Usually they kind of, you know, like some acronym for me, but National Safety and Quality Health Services Standards. Let's call them national standards. Absolutely. So what are the national standards? Look, basically they're the framework for safety and quality for health services across the whole country. So wherever you go, the level of care should be similar. It's about consistency of services. So wherever patients go, they access a service that has an incident management system, a compliance landing system, where people use aseptic technique and hand hygiene, where there's blood safety programs in place, antimicrobial stewardship, that kind of thing. So it's basically ensuring that all of the health services that we put money into in this country are up to standard. So how were the standards developed and decided upon? So there was an enormous consultation process about eight years ago and they looked at a number of criteria. So they looked at areas where there are lots of patients affected, where there are known gaps between the current situation and the best practice outcomes, so someone is doing it better. And they looked at existing improvement strategies that are evidence-based and achievable. So what they did was they gathered clinicians and consumers from all the states and territories together and they identified the areas that they felt were most important and it was an extensive consultation process to bring it together to the current 10 national standards. Now they've been in place for about five years and they're now moving towards the second version which will actually drop to eight national standards. So the focus again is on what are the most important issues, what affects the greatest number of patients, and where is there evidence that we could be doing it better? So how do we all get to best practice? So you may have almost answered it, but why are they important, the national standards? Because they're all about patient safety and they're all about improving patient care. So often in clinical practice you get really frustrated that there's only a focus on ED wait times and surgical wait lists and that kind of thing but this is actually about ensuring that wherever you go you'll get care of a certain standard and I think that's important as a clinician but also as a taxpayer it's about accountability like here in New South Wales we spend a quarter of our budget that's 20 billion dollars on health and as taxpayer, we have a right to know that if we're going to spend that much, are we actually getting reasonable outcomes? And is good care being delivered across the system? And if I go to a hospital in Upper Kumbukta West or on the main street of Sydney, will the care be vastly different? And so as a community member, I need to know that where I go and where my parents and my husband and the people I love go will be of a good standard and that they'll get care of a certain level. And we know that no clinician comes to work wanting to harm patients, but one in ten patients are harmed in our health system. And so these are all strategies to try and minimise that harm to our community. So what's the relevance to junior doctors? Well junior doctors are at the forefront of patient care and so they're ideally placed to identify what's working and what isn't and they meet patients, they assess them, they document the histories, they chart their medications, they document the plan. So wherever you work in health, safety and quality is your responsibility. But junior doctors are at the front line of that. They are delivering the service. So they're also accountable to ensure that it's the best it can be and to continue to make it better. So are there, maybe before we go into the junior doctor's role, there is an accreditation process for hospitals. Can you outline how that accreditation process works? Look, the accreditation process is a bit like at university you have a curriculum, but you have to sit an exam to show that you've met the requirements of the curriculum. So the standards themselves are the framework for safe and high-quality care, but we actually need an external validation process just to make sure that people are actually doing it. So the actual accreditation process is a group, a facility or a group of facilities assess themselves against the standard and they work out what evidence they think they have to meet their standard and to demonstrate that they meet it. But then every few years a group of independent assessors come and they actually audit whether you're doing what you say you're doing. And sometimes it can become a great big drama and a whole bunch of paperwork gets done and a hive of activity, but that's not what it should be. If we're actually doing it well and we're doing it right, the standards are about how we do business every day and how we work at getting better at the business we do every day. Does that make sense? I mean, there really should be a kind of quality safety cycle ongoing. Absolutely. It doesn't just start or end when there's accreditation. Absolutely. I think sometimes we all see accreditation process because we do a lot in different roles within the hospital, sometimes ticking a box. Yeah. But it shouldn't be seen that way. It should be a way of identifying where we're doing well, but also not so well so we can improve. Absolutely. And I don't have a problem with us being accountable for the way we deliver care. So even if there are times when it feels like it's a tick box, we are demonstrating to the world that we provide high quality care. And that's not a bad thing for your organisation to be able to look at itself and say, looking at all the different ways we deliver care, we're actually doing well. You know, it's quite a nice thing after accreditation to look back and go, wow, look at how much we've achieved in the last two years. Look at how we've improved patient care here. And that's a good thing. Do you think the accreditation standard look at delivery of care or outcomes? In fact, we're moving to both. And in fact, one of the things that may happen in the future is that if you can demonstrate your outcomes are at or above benchmark, then accreditation processes would be much less frequent or may not even need to happen. Because if you can demonstrate you're delivering the outcomes, you know, if you're not having healthcare-associated infections, then clearly you're doing your aseptic technique right, you're doing your hand hygiene, all of that kind of thing. So you don't have to show your audits because you're showing your results. So there's a lot of talk about how we can move to that more with version two of the national standards. But at the moment, we still have to demonstrate that we're meeting it. But some of that is what are our outcomes and how are we working to improve our outcomes? So are there opportunities for junior doctors to engage with the national standards and I guess how? Okay, look, absolutely there are lots. As a group, you can talk about them in your general clinical training committee or in your JMO patient safety committee or whatever kind of group JMO forum you have. But as an individual, you can talk to your boss, you can talk to your NUM, your CNC about how you might be involved. Find out what kind of audits there are, or just think about what are the things that piss you off? What are the things that don't work that you would like to see work better? Or what's something that you saw work really well in one rotation in another facility that's not working so well in this rotation? And if you know that they've got a better tool or something that might be really helpful then look at adapting it to your local environment because the beautiful thing about the standards I think is they say what needs to be done but they don't say how it needs to be done. We have the freedom to work out locally what is the best way to do this for our patients and what do our patients need for us to do this well. So you have the freedom to take a tool from somewhere else and adapt it locally so that it works in your situation or it works on this kind of ward that's, you know, a surgical ward is clearly different to an ICU which is different to a palliative care unit. But there are certain things that you can adapt and make work. So, you know, a lot of doctors are only kind of starting to come to the party now, realising that this isn't just about an imposition. It's not on top of our work. |
And it is how we do it and how we continue to get better at doing it. So all you have to do is pick something. Pick something that's important to you and then start. So measure how you're going and then have a look at how you might do better. And there's a whole lot of information about clinical practice improvement. There's a fantastic tool called the Clinician's Toolkit, a great resource that's downloadable from the New South Wales Clinical Excellence Commission. It shows you how to do clinical practice improvement, but it can be something as simple as what worked well in one rotation isn't working well here. How can we adapt it here and try and use that here and measure it, you know, and then write it up and talk to the quality manager, talk to the NUM, talk to the CNC. You'll be surprised how happy they will be to hear from you. Yeah, look, at many hospitals, they have almost a committee for each of the standards. Yeah. And they're always looking for junior doctors to be involved. Absolutely. For all the reasons you say. Yeah. So if you put your hand up... You will be welcomed with incredible warmth. You'll be noticed. And it's not a bad thing for your CV. You know, from a self-interested point of view, to have a few quality audits under your belt is not a bad thing when you're going for jobs. And I often say that in regard to comparison to research, which often has a very long lag time and a long time to get something published, it's difficult if you have not started that to get that done in a short period. Sometimes a quality safety project can be the turnaround, can be three months from start to finish and you have something in your CV even though it may not have been at the start of the year. Absolutely. It's something that you can get through quite quickly. Do you have any examples of how junior doctors have meaningfully contributed to the national standards? Oh look there's heaps of them. So we were talking about a young lady May Wong who was working in a hospital and realised that you know at times of distress when the rapid response call went out the recess trolleys were all different and they had different bits of equipment and you couldn't reach in the second drawer and find the thing you were looking for. And the time you most want things standardised is when you're under the most pressure. So she audited all the trolleys and then held a little group and the working group kind of came up with what needed to be in a standard recess trolley and they standardised them and set up a little checklist to make sure the right things were there and they were in the right place. So in the middle of the night when you're under pressure, you can always get the right ET tube and you can always get the adrenaline and that kind of thing. And I think that's such a perfect example of a really simple thing to do that is very easily within a JMO's control. But even things like streamlining referral processes to allied health, working on comprehensive discharge processes, getting involved in medication reconciliation or antibiotic use, auditing antibiotic use in your clinical unit, reviewing your own cannula insertions, honing your diagnostic skills and looking up the final diagnoses of the patients you saw on ED. There's a whole bunch of things that you can do that are very much within your control, but just think about the things that drive you nuts and then could they be done better? And then start working on it. What skills do junior doctors require if they wish to contribute to such projects? Look, the basic skill set is how to do what's called a PDSA cycle, which is Plan, Do, Study, Act. And that's part of the clinician's toolkit, but it's basically the art of clinical practice improvement. But you just have to work out what's the issue you want to address, explain why it doesn't work, and then try and work out ways that might fix it, and then try them out in real life and keep trying to improve. And all the while you're measuring so you can prove that what you're doing now is better than the way you tried to do it before. Often we tend to jump to the solution. So we often think, oh, we know what needs to happen to fix this without exploring why is it not actually working. And I think one of the big lessons from people who've done Plan, Do, Study, Act cycles is that the thing you thought would fix it isn't always the grand solution. Often there are a whole series of other simple, creative, cost-free solutions that you just need to explore why it's not working in a bit more depth to move forward without jumping straight away. And you can download that document, the Clinician's Toolkit, from the New South Wales Clinical Excellence Commission website. Any other further advice to junior doctors on how they can, I guess, achieve a good outcome in regard to their project or some of the strategies for success? I think talking to people who've done it before is really helpful. So identify someone who can be a mentor or colleague or just a confidant, someone to run things past. I think connecting with the right people in your organisation can make a really big difference. So the clinical nurse consultants, the quality manager or quality support unit, whatever you have in your local service, and not being scared to even approach the DMS or the Director of Clinical Training, sorry, the DPET, because often they'll be able to connect you to people who can really help out. Then the most important thing is measure. And I would always say try not to make it too big. Oh, absolutely. Start with something small. Because I see so many junior doctors see an issue or problem, but it is a very large problem and it will be difficult to solve within a short period of time. You'd be surprised how much even something small does take time, does take all the effort, and is a really good way to start. So are you familiar with the Pareto Principle? Yes. That 20% causes all, 80% of the drama. And so if you bite the small project that you can chew, you'll actually make a really big difference. So trying to solve the Middle East peace crisis is probably not your best first choice, but working on something simple can actually make a really big difference to patients and you'd be surprised how much of an impact you can have. Some hospitals around Australia support junior doctors through rotations in quality safety units at the hospital. What are your thoughts on this concept? I love it. I absolutely love it. I'm a fan of A.A. Milne and Christopher Robin. There's a beautiful image of here comes Edward Bear, bump, bump, bump on the stairs down behind Christopher Robin. And Christopher Robin's dragging him down and his head is landing on each step as he goes down. And he says, sometimes he thinks that there might be a better way of coming downstairs. If only he could stop bumping for a moment and think about it. And I think time and equality and safety unit is a fantastic way to stop bumping and think about how you deliver the care that you provide to patients and getting your head around these clinical practice improvement principles so about how you can work to make it better in a scientifically appropriate way. So applying some scientific rigour to trying to get better at what you do and while you're mastering your clinical skills and while you're making the transition from being a medical student to being a doctor, being able to step away from that for a moment, take a breath and think about, okay, what does my service do really well? What can my service do better? What can I as a clinician do better? What are the things that I want to focus on for me? I think to learn these principles early on shapes how you look at the world and it makes you an improver for life. And we talk about being lifelong learners and I think we also need to talk about being lifelong improvers, that we continue to work at getting better at what we do. And I'd highly recommend people, even if they can't do a rotation, to take up other quality and safety opportunities. So to ask the quality safety manager to join a root cause analysis team, to be part of an independent review, to review a clinical incident, anything like that, to start to understand a slightly different perspective at looking at patient care. I think there's some fantastic suggestions for how gene doctors can be more involved in the standards and they can understand the standards better. So please don't be scared of them. They're not scary, they're not an imposition. It's actually about doing the best thing for patients and making sure that we all provide the best care and we continue to get better at providing the best care. Thank you Amanda for speaking to us today and the information you provided. Pleasure. Thanks for listening to On The Wards. |
Welcome to On The Wards, it's James Edwards and today we're talking about upper GI bleeding, one of my favourite topics. Now we've got Dr Anastasia Volovets who's a gastroenterologist and hepatologist from Royal Prince Alfred Hospital. Welcome Anastasia. Thanks James. Upper GI bleeding is one of my favourite topics too. It's a critical care gastro, it's one of the parts I really enjoy and that's a fairly sad thing to say I presume because upper GI bleeding can be lethal. Absolutely. And it's fairly common and a junior doctor most times will either see the emergency department or on the wards and this case will come from on the wards because they're working after hours and they call from nursing staff concerned that a patient who's in there for alcohol withdrawal medical management has just vomited up and what they describe as coffee granth vomitus. You get the phone call, what questions do you ask that nurse over the phone? I guess the number one most important thing you need to figure out is the patient's stability. Because as a junior doctor on after hours you're always triaging your thousands of competing priorities and job lists and you really need to figure out how sick this patient is. And so the first thing I would always ask as a junior doctor and then as a gastro registrar is what their ops are and if there's any indication that the patient is having a bleed that's causing them to become unstable, so if they're tachycardic or they're struggling to drop their blood pressure, then you need to escalate that quickly. And, you know, occasionally you need to tell the nursing staff that the patient needs to have, you know, a med call called or a PACE call called, whatever it's called in your local hospital. Definitely, if there's any frank hematemesis, bright red blood, that a patient is vomiting, before I would run to see the patient, I would activate an emergency call because that is just not something you want to be dealing as a junior doctor on your own having said that if it's a small amount of coffee ground staff no red things and you know their bloods are very stable that I would still see that patient promptly in the next 15 to 20 minutes and assess them prior to calling the gastro ridge okay so I mean's some really good stuff about, I think whenever I ask that question to every consultant about any patient that they're worried about and they ask questions over the phone, the first thing is get some vital signs, have a assessment of prioritising that patient. So we think this person, they've got coffee-grade vomit, which we know sometimes can be associated with an upper GI bleed. What are some of the most common causes or how do you classify the causes of upper GI bleeding? Yeah, look, I divide upper GI bleeds into two categories and one is variceal bleeding and one is non-variceal bleeding. And variceal bleeding is pretty obvious. So patients with chronic liver disease has big varices, big dilated chunky veins full of blood either in their gullet or in their stomach that pop and it's really important to identify those patients because variceal bleeding kills people very very quickly and those patients need to be treated in a different way to the non-variceal bleeders. The causes for non-variceal upper GI bleeding are actually quite varied so the most common one of those would be peptic ulcer disease either gastric or duodenal. Occasionally it can be a presenting sign for a malignancy, either an esophageal or a gastric or again an upper duodenal. Occasionally, you know, this is more rare things that we see as gastro-registrars. People have aberrant blood vessels called Julafoy lesions. And even more rarely, you know, small bowel tumours such as a gist or a carcinoid or lymphoma I've once seen a melanoma in the small bowel those things tend to more present like melina rather than actual hematemesis or coffee ground vomiting. I think we just really quickly need to talk about coffee ground vomiting because I think that gets passed around a lot and people assume that coffee ground vomiting equals upper GI bleed and that's not the case. So quite a lot of the time I see patients who have some sort of gastric stasis, you know, maybe they have a bowel obstruction, then they'll vomit up kind of dark, grotty looking fluid with a little bit of clot in it. But without dropping their haemoglobin or raising their urea count, that's not the same as an upper GI bleed. So an upper GI bleed, in my mind, is either frank hematemesis or definite melina, and occasionally a low-grade upper GI bleed can present with coffee ground vomiting, but in the absence of hemodynamic instability, I wouldn't necessarily equate the two. Okay So, and you think in regard to maybe some of the symptoms that you may present with an upper GI bleed, maybe we'll talk on those. Yeah. So, typically, you know, upper GI, I mean, typically an upper GI bleed most commonly will present with melina. If the lesion is in the stomach, then hematemesis is more common and that's really easy. If someone vomits up blood, that's an apogee. I believe probably a gastric ulcer, you know what you're doing. Melina can sometimes be quite difficult actually to determine. So if, again, if it's a small volume and it's been sitting in your gut for more than 16 hours, then it will come out just black or, you know, the words people use would be tarry. It has quite a characteristic smell. Most gastro-urgers can identify, you know, as soon as they get onto the ward where they're running to. Walk in the department. That's right. But what can be sometimes tricky with Melina is if it's rapid volume, rapid transit, sorry, of blood because the patient's bleeding quite a lot, then the blood will come out. The bottom is actually looking dark red. And so occasionally I've been asked to see a patient who's presented with quote-unquote PR bleeding who's quite unstable, but the blood is quite dark and actually the urea is through the roof. And you say to yourself, this may be upper GI and they've had a huge duodenal ulcer and they've just bled quite a lot the important thing to note is that Maria is dire sorry is that Molina is diarrhea genic so what I mean by that is if someone's actively bleeding Molina will go through them okay so patients presenting with solid black stools are not having an upper GI bleed okay they may have just been started on some iron which turns your poop black or they may have had a very small you know swallowed a tiny amount of blood that's come out through but if a patient's not having liquid stuff pour out of them they're probably not actively bleeding they certainly may have had a bleed and they still need an endoscopy to you know see what's going to happen to that bleeding risk from now on. But it's rare that patients are having active blood with no blood externalised, if you know what I mean. Any other ways they could present with MISH? Yeah, so look, occasionally I have seen patients present with a syncope first and then a large bowel motion afterwards. And we always have to be wary about patients who are elderly or visually impaired who may be aware of the sensation that they're having a lot of diarrhea, but they don't actually check the ball or they can't see and they're not aware that it's full of black melina. So really important to have low index of suspicion for a patient who's had a syncopal attack and they have a low hemoglobin or a raised urea, do a PR exam. Yep. And in regard to your differential diagnosis or important management, where's your initial focus? Yeah. So the most critical thing in managing an upper GI bleed is time to endoscopy. Okay. Because until we get the patient into the endoscopy suite, we don't know where they're bleeding from and how likely they are to bleed again. So the JMO's job here is really to stabilize the patient to facilitate a timely and safe endoscopy. You know, upper GI bleeding that's not catastrophic is rarely continuous and it's usually intermittent. So the endoscopy is done for two reasons. The first is to diagnose why the patient's bleeding and two, to assess and decrease their risk of bleeding. So patients that are having a variceal bleed, they may have had a vomit of blood at home and presented to hospital. If this is variceal, they will certainly re-bleed and they will probably do it in the next couple of hours. So those patients who have had a variceal bleed need to be gotten to the endoscopy unit and scoped or to theatres, usually within four hours. |
Whereas patients who have had maybe one small episode of melina, they've dropped their hemoglobin a little bit, but it's not terrible. They've responded to fluids and their ops have stabilised. They're patients that can be scoped within the next 24 hours. You really emphasise the importance of knowing where they've got variceal bleed, but unless you've had a scope before, how are you going to know who's got a variceal bleed or not? What are some of the risk factors? Yeah, that's a great question. Absolutely. So essentially, do they have liver disease, I guess, is the really important thing, or do they have any risk factors for liver disease? So our opening case was a patient who's an alcohol withdrawal, so there's a good idea there that this patient is someone who's been a chronic alcoholic for a long time. But anyone who's been a heavy alcoholic, who's had longstanding hepatitis C, who's got overt features of chronic liver disease or maybe a previous diagnosis of chronic liver disease, anyone who's jaundiced, anyone who's got ascites, anyone whose blood tests are showing an INR that's elevated and platelets that are down and the liver tests are off, all those sorts of patients, that should be pointing you towards this is variceal or at least there's a risk for being variceal. Occasionally, and this is rare, patients have had very complex pancreatic surgery or severe pancreatitis can develop local varices and gastric varices. But I wouldn't really expect an intern to make that diagnosis for me. But it is really important for you to know your patient's medical history. And if, and if they're someone who has had, you know, a prolonged kind of admission in intensive care unit and lots of pancreatic drains and all that sort of stuff, I need to know about that because that actually includes, increases their chances of non-sorotic portal hypertension. What are those kind of risk factors or something you'd want to get for the history of someone with an upper GI bleed? Yeah, so look, anyone who comes in with an upper GI bleed, once they're stable, you should ask them, you know, have you had an endoscopy before? Or have you had ulcer disease before? And a lot of patients will tell you that they have. And again, it's something that's really good to dig up and have available for you. It's really important to get their medication history. So anyone who's on a regular PPI that they've been taking consistently for the last month and they're coming in with hematemesis, they're probably not going to have peptic ulcer disease as a cause of their hematemesis. Patients who have recently been on NSAIDs or aspirin, however, are very likely to have peptic ulcer disease as a cause of their haematomesis. So a medication history is really important. And as we've already talked about, it's really important to get their recent clinical history and hospitalisations. And another special case I'll just mention is actually an aortic abdominal aneurysm that has been treated with an endostent. That's probably the one time that I would not rush a patient to theatre but actually perform an endoscopy after having done a CT angiogram because you're really worried about an aortic fistula and that's something that's really catastrophic. So it's a really important bit of history to get. So we've got a bit of that kind of stuff on history, but in regard to the initial treatment and management, what are your initial priorities? Yeah, patient stability. So if you've got someone who's got, you've got concern that they've had an upper GI bleed, you need to get IV access as a junior doctor. And, you know, sometimes that's really difficult, and if you're struggling and, you know, all you manage to get is a tiny blue cannula, then you need to call for help. So IV access is really important, and you want at least two large-bore IVCs. Three may be necessary, and sometimes in our patients, especially cirrhotics and those that have had previous intravenous drug use, that can be impossible for an intern to do. And sometimes these patients just need an urgent central line. So if you're struggling and you're not getting access after 20, 30 minutes of trying, actually probably even less than that, if you're not getting any access after five minutes of trying, call for help. As soon as you get some access, get some bloods off. I always do a gas at the same time as do routine bloods because that way I can have a hemoglobin back in 10 minutes rather than waiting the hour for a formal hemoglobin and on your formal bloods you're looking for a hemoglobin as we've mentioned as well as the urea which we've mentioned goes up disproportionately to the creatinine also their platelets and iron and deranged lfts suggesting liver disease and i always send a group and hold and then i set up some IV fluids and again you know I'm not going to pour litres and litres and litres of IV fluid into the patient if they're actively bleeding at some point I'm going to need to switch to blood but while you're trying to figure out what's going on a bag of IV fluids is a good idea. And I must say getting intravenous access in these patients is often very difficult and I know within the emergency department we often use idrosis as an interim measure until we can get some access. That's probably something that will be less done on the wards. Yes, I don't and certainly hopefully not by a JMO loan outside of a setting of a cardiac arrest call. No. Look, they're actually very easy to do but that's... In regard of further treatments, we've done some initial resuscitation and you're trying to do stability and one of the things about stability is the color questions I forget asked with you may so the batting turns is should I do a possible blood pressure on the patient and do I need to always do a PR you know answer those questions if we go to treatment yes the answer is II I think the answer to both of them is yes, to be honest. If you've got a perfectly, you know, if you've got a patient who's come in, who's had what seems to be a low volume, you know, episode of Melina a couple of hours ago, and they look reasonably well, I would do a postural blood pressure just to give me an idea as to how hypervolemic they are and to help me guide my fluid management. Obviously, if you have a patient in front of you that's old, that's frail, that can't stand up properly and is already feeling dizzy and is already hypotensive, then doing postural blood pressures is not going to add anything else. So, no, I wouldn't get that patient up. Should you always do a PR? Look, I think in the emergency department, if you're trying to make the diagnosis, yes, of course, you should do a PR. Otherwise, if you know that the gastro register, you know, if you're very convinced that it's an upper GI bleed, or if you see melina on the blood sheets, then no, that's not going to add anything. So, you know, I will almost always do a PR exam as the gastro registrar. But if the intern's done it first, and I'm, you know, and I know what they're, and I trust the intern, then no, I wouldn't repeat it. But definitely a patient who you're not sure of whether they're having an upper jaw bleed or not, but you're concerned, they need a PR as part of your diagnostic tool. But if there's melina all over the bed, no, you don't. It's pretty clear then. In regard to further treatment? Yep. Okay, so as we've already talked about, adequate resource is key. Okay, so you've given a litre of fluid and patients are still unstable. You need to start asking for blood. And, you know, the transfusion targets are always kind of talked about and we've always sort of been told in the past to get everyone's haemoglobin up above 100 because that's a good round number. But really, the most recent literature is not supportive of that, especially in serotics. You know, you should have your target for resuscitation in serotic patients should be about 70 because anything more than that will actually elevate their portal pressures and contribute to bleeding paradoxically. |
I sometimes get asked, although rarely these days, about whether we should put in a nasogastric tube if someone's, you know, have active hematemesis because we're concerned about aspiration. The answer is categorically no. If you're really concerned the patient's vomiting up so much blood that they're going to aspirate, they really need a code red, urgent endoscopy and intubation. Interesting, I mean the US are very big on putting nasogastric tubes into diagnosed upper GI bleeds, but it's not a practice that's done in Australia. No, we don't do that. And I find that, I don't find that that makes sense to me because if you've got a giant ulcer or a varix or something in the gullet and you're poking a tube and the patient's gagging, I don't think that's the right thing to do. Apologies to any of my American colleagues who are listening to this. Okay, so anyway, so then we've stabilised the patient a little bit and then, of course, the question you're about to ask me, James, is should this junior doctor give them a bolus of a PPI? And that's something that's been debated in the literature. And there have been some studies that are showing that a pre-endoscopy administration of a PPI bolus or infusion doesn't change patient survival outcomes. And look, I think that's a pretty controversial topic. And you can argue about the validity of those studies studies and the issue really here becomes is how confident you are that what you're treating is a peptic ulcer and how quickly can you get this patient to the endoscopy suite. A lot of those studies were done in Japan where patients were periodically would go you know they'd come into the emergency department and from there they'd go straight to the endoscopy suite and have an endoscopy within the first four hours, which, you know, is not always possible for us. So I personally usually err on the side of caution and if I'm going to delay the endoscopy by another day, so, you know, it's seven o'clock in the evening, the patient's stable, we're going to do an endoscopy the next morning, I probably would give a bolus of a PPI and or infusion. However, if I've got an unstable patient in front of me and I'm trying to rush them to the theater to do an endoscopy, then spending another hour putting in a cannula just for a PPI infusion is not the right thing to do. And then the other thing we need to look at is the patient's coagulation parameters. So if their platelets are low and they're thrombocytopenic, especially haematology patients, they'll probably need a bag of platelets. And when I say low, I mean really anything less than 50 for me is properly low. But we also have to remember that patients who are cardiac patients who are on antiplatelets such as clopidogrel, ticagrelol, less so aspirin, who are having a large volume bleed may have normal platelets, but those platelets will be dysfunctional. So occasionally I give those patients a bag of platelets as well. And again, if this is a complex patient who's recently had coronary artery stenting, you know, and has a stent that's only two weeks old, I'm probably going to call the cardiology reg before I start giving all sorts of reversal agents and make their blood thicker because, you know, I can stop the bleeding most of the time, but if then they clot off their bare middle stent in their left main, then they'll die. So it is really important in patients that are stable and you're giving them reversal of anticoagulants or giving them extra platelets, you have to think about why they're on anticoagulants to begin with. And similar with vitamin K, the vitamin K will help in our malnourished patients and will make the numbers a little bit better in liver disease. Vitamin K will not correct the INR in advanced liver disease because that's due to synthetic dysfunction. So in those patients who are actively bleeding, we have to give them FFP or prothrombin X. In patients that are on warfarin, however, it's not always necessary to completely reverse their anticoagulation. If someone's come in with clearly a super therapeutic INR, for some reason they've been, I don't know, started on antibiotics and their INR shot up to 10 and they've had a low volume bleed, I would give them some vitamin K and provided they were stable, bring their INR down to a normal limit of two to three and then do an endoscopy. But I wouldn't necessarily be giving them high doses of IV vitamin K because it's not that they're bleeding just because of the warfarin. They're bleeding because their warfarin is super therapeutic. And if you completely eliminate all the warfarin from their system, it might actually hold them in hospital for another week trying to re-warfarinize them. It can be a bit complex. So really, I guess what I'm trying to say is if you've got a patient in front of you that's pretty stable and looks good, you know, I wouldn't necessarily be reversing all of their anticoagulation, all of their antiplatelets, giving them platelets, doing all these things if they're stable and well. I would chat to gastro first because you might actually paradoxically do more harm than good. If you have a cirrhotic patient in front of you who you're convinced is having an upper GI bleed, and that's any kind of upper GI bleed, either variceal or they've also got an ulcer on top of everything else, give them some antibiotics. There's good evidence that that would prevent them getting spontaneous bacterial peritonitis and dying of sepsis. And the most common antibiotics we would use would be Tazosin. And again, if you have a patient who's cirrhotic, who is catastrophically bleeding in front of you, the idea is to get them to endoscopy as quickly as possible. If you have a little bit of time, then giving them something that will decrease their portal pressure. So in the past, we used to set up octreotide infusions. These days, we've switched over to turlipressin boluses because there's actual survival improvement with that based on the data. However, turlipressin does have more significant complications and can sometimes precipitate things like pulmonary edema. So again, I would chat to the gastro reg. If you've got time, a stable patient, everything's okay, before I would be throwing the kitchen sink, I would chat to the gastro reg and talk that through. Okay. I mean, one other question is, is it upper GI bleed or lower GI bleed? Any kind of advice on how to differentiate those two? Yeah, you need to do an endoscopy. No, look, I think it can be really tricky sometimes, you know, and identifying where it's coming from. I mean, I really use the patient's blood to guide me. If the patient's got large volume of dark blood coming through their gut and their urea's quite high and they're pretty unstable, I think the right thing to do is always to do an endoscopy first because that's quick and takes five minutes. And if it's normal, that's fine. And then from there on in, I would send the patient to have a CT angiogram. You know, the only time you can be pretty confident that it's lower GI bleeding is if the blood is bright, bright red and the patients are stable and, you know, occasionally you'd go for a CT CT angio then and it's just important not to be really didactic with the process what you need here is the gastro registrar and the colorectal or the general surgical registrar depending on the hospital you're working in working together and communicating and it's okay to do one test and to find that you're wrong and go on and do another test as long as there's always things being reviewed and communicated for the benefit of the patient. You've mentioned a couple of times the raised urea. Why do you get a raised urea and someone's upper GI bleed? It's because as the extra blood travels through your gut and gets broken down, extra urea is released and reabsorbed. So the urea is usually disproportionately elevated to the creatinine. So what you would see in a good-going GI bleed is a... And the creatinine will go up a little bit because patients are dehydrated unwell, but you can see a creatinine that's gone from 60 to 100, but urea that's gone from 7 to 28. There's not many things that will cause that apart from an upper GI bleed. |
Welcome to On The Wards. As James said today, we're part two of our discussion with Dr. Sean Lau in the assessment and management of heart failure. Just going back into one of my original thoughts is from a clinical, before you have an echo, can you tell the difference between heart failure with reduced ejection fraction for a preserved ejection fraction? Do they present in some ways in a different way? Before you have the echo, they're pretty much the same. Yeah, i think it's actually very difficult to tease out because if you look from the outpatient point of view and if you're taking the the history of the patient at the bedside pre-admission uh they'll both describe breathlessness on exertion a diastolic heart failure will give you breathlessness on exertion because as you need to increase your heart rate you need the heart to feel more efficiently, and it can't do that because the left ventricle is stiff. So I think it can be difficult. I think you have to look at just the whole issue of the risk factors. I think if you've got the patient who's, again, we see it also in women. So the classic example would be the elderly woman who's overweight, who has diabetes and hypertension, and they're telling you they've been at increasing breathlessness on exertion and they've come in with pneumonia and maybe their heart rate's gone a bit fast, they've got some pulmonary congestion. If you were betting, you'd say that's going to be diastolic dysfunction. So we've gone through, I guess, their history and exam. What kind of initial investigation would you do for a patient who's on the ward? Look, on the ward, depending on what their oxygen saturations are and how that's changed, blood gases can be useful there. If they're actually okay and maintaining okay on nasal prongs, I don't see any need. But if there's been some clear change and they're now needing high-flow oxygen, you'd want to do that and get that result quickly. The other would be an ECG if there's a tachycardia and you want to look at what the rhythm is or if you're worried about ischemia, so they're complaining about chest pain with their shortness of breath, an ECG is important. Look at the ST segments. Is there ST elevation or depression there? So doing those things at the bedside straight away taking bloods at the same time to look really at precipitance of the shortness of breath has the hemoglobin dropped has their kidney function gone off because it's low output heart failure. Liver is now more congested because of right heart failure. So looking at those things. Thyroid function is important in somebody who's got a tachycardia, but often that would have been done in the emergency department. A troponin may have been done in the emergency department, but if there's any hint that it might be ischemia, then a troponin will be useful as well. And then, of course, ordering a chest X-ray at that same time, that's going to be the thing that will tell you if there's a change from the remission. Just in the troponin, obviously most of you see high-sensitive troponin. Can you have a raised troponin with heart failure in the absence of probably having, I guess, ischemia. Yes, and this is what I say. What's great about high sensitivity troponin is its rule-out value. So when it's negative, you can be sure, and we tell patients this who've come through the ED and have been discharged. The issue then becomes if it's slightly positive, what does that mean? Two aspects there. One is the actual trend of the troponin. So how fast is it increasing? Is it continuing to rise? And then the other aspect is what is its absolute value? So to put it in context, a troponin that might be 20 or 30, then it goes to 40 or 50 and it's under 100 and then you've got somebody who's a bit elderly who's got some renal impairment, stiff heart, they've gone tachycardic. That is what we call a trop leak. But a troponin that starts high, continues to go high, or a troponin that's initially normal but then really jumps 200, 300, 400 and keeps going, then you're worried about a separate acute coronary syndrome. It's not quite clear why you can have a small leak as opposed to the more classic troponin rise with infarction. One theory has to do with there being troponin in the cytoplasm of the cardiomyocytes and that you can get a little bit of disruption to the membrane of the cardiomyocytes and then there's a little leak as opposed to actually cardiomyocyte death that results in the classic troponin rise. I mean, I think they're trying to work out whether they just call it myocardial injury. Exactly. Versus, you know. Exactly. And I think that's a really, it's a dynamic field even from a research point of view. In regard to, so you were going to say doing a chest x-ray, but in regard to blood tests, some hospitals use BMP. What's your experience using BMP and how can that help you in, like, your diagnosis of heart failure? Look, I think it's, we tend not to use, as cardiologists, a lot of BMP in the acute setting because I think if you've got all the signs, the symptoms and signs and radiographic evidence of heart failure, you've made your diagnosis. So where it's useful in diagnostic terms is for actually telling you about is the shortness of breath presentation heart failure or not. But I think in the setting of an emergency presentation or somebody at the bedside is acutely short of breath, you would go on all those clinical signs and symptoms. Where it is actually useful is where it's unclear as to the diagnosis. So somebody might have no history of heart failure at all and they're presenting with shortness of breath, but they've got a history of lung disease. The BNP can be useful if you're significantly elevated as being quite specific then for heart failure because it's about stretch of the atria and then that release. So it is specific in that respect. I would just caution about different values and laboratory values for BNP. It's important you look when you've ordered it what for your hospital the values are. It also changes with age, the cut-offs. It also is affected by obesity and pregnancy. And so you need to put it in context. Where it is actually very useful is out in the community, is the outpatient where you're tracking somebody who's got known heart failure and you're looking at their congestion and are they having an exacerbation of their underlying heart failure and are you doing all right with diuretics and trying to maintain it whilst balancing that with kidney function and other side effects and things like that? So it's useful for tracking is what I find. But I think if the diagnosis is in doubt, somebody with no cardiac history who's short of breath in hospital, then it's a useful test to do. Have you any tips in interpreting a chest X-ray to make the diagnosis of probably venous congestion? Yes, I think always the first thing to do is compare the chest X-ray that you're doing to a previous one. And in the case of being on the wards as a junior doctor, you're going to look at the emergency chest X-ray, particularly if there's a change in symptoms. So in this case of this patient, presumably there might have been a pneumonia that was diagnosed on the chest x-ray and the ED. So if you're now seeing new changes, so new signs of congestion, so there might be upper lobe diversion or perihilo congestion or actually frank new pleural effusions or where you're just looking at alveoli infiltrates, that suggests straight away that the pneumonia has set off heart failure, I think. So I really look for those sort of those changes. It can be a bit difficult going back to the diastolic heart failure patient. They may have a baseline level of some mild upper lobe diversion, perihilic congestion, that's just part of the raised feeling pressures and, you know, congestion with the diastolic dysfunction. So that can be difficult when they come into the emergency department and you look at that, you know, so you then have to really go back to your clinical context to look at it. But the pleural effusion is also, you know, an important sign as well. I think the cardiac silhouette itself. So, again, somebody who says, no, I have no history of any heart problems, and then you look in the chest X-ray, that cardiac silhouette's big. It's not specific. |
But I think in this context, absolutely, if you see that, then you're thinking about, is this heart failure? When you send a patient, it's kind of 7.30 p.m. on a Friday, a roll of an echo. Yes. You know, when does an echo need to be, I guess, done that night, done as an inpatient, done as an outpatient? Yeah, absolutely. So I think what you're really looking at there is, as a junior doctor, do I need to call the cardiology registrar on call here to come in? It probably warrants a call if you've made a new diagnosis of heart failure, but it's that call really of, is this urgent? You need to come in and do a bedside echo. And I think that goes back to your very first thoughts when you approach the patient, and that was their hemodynamics. So I think somebody whose blood pressure is tracking down, whose heart rate is tracking up, who has signs of a low output state, reduced urine output, creatinine going up, signs perhaps that their perfusion is not good, you want help right away. That would include getting help probably from your colleagues inside the hospital, so your registrar or an ICU registrar, as well as notifying cardiology, because almost certainly that's going to be a new diagnosis of heart failure, and that will warrant a bedside echo. There's the cardiac tamponade aspect as well, not really related here, I think, to the patient with pneumonia, but can have similar signs. So I think if you go by those vital signs, those first signs that you elicit at the bedside, that's where you're making your decision about calling for help and calling cardiology in. And as part of that, they would do an echo. Otherwise, if it's a case of things are quite stable, but perhaps this is a new diagnosis of heart failure or an exacerbation of some underlying heart failure, whether it be diastolic or systolic, you would notify cardiology to get some idea about management, I think, which might include diuretics or if they're really hypertensive, trying to bring down their blood pressure, if they're tachycardic but have no normal function, left ventricular function, bringing down that rate, et cetera. And that's where you would notify cardiology. And as part of that, I'm sure they would say, well, yes, here's some advice about what to do now. I'll come and see the patient tomorrow and we'll organize, or can you please put in a request for an echo to be done? I think that's very appropriate. Where it would be a case of you say, look, they don't even need it as an inpatient, I'll do it as an outpatient. I think that's where somebody has very well known heart failure, whether it be diastolic or systolic. Perhaps they've been seen recently by their cardiologist. They're in hospital, likely to be discharged soon because of the pneumonia's result. And you've just noted they've got a bit more congestion and that might be handled by upping their their lasix their furosemide dose and in which case it's a well you know they can just have a it's far better they have been an outpatient echocardiogram that can be compared to previous echocardiograms with their usual cardiologist that makes sense in regard to management now you mentioned some of them just briefly let me just go. Yeah, look, I think as we've spoken about in the past, James, I think one thing to make clear about is the use of the patient who's tachycardic, you know, who's classically atrial fibrillation, who your instinct is naturally to give them beta blockers. I think that is nine times out of ten appropriate. I think we just have to bear in mind the patient with the new diagnosis of systolic heart failure whose raised heart rate is actually driving their cardiac output. And if you blunt that, that can result in a cardiogenic shock. So that is a rare event and would be rare also in somebody who's already been admitted and is on the ward because they would have had the investigations in the emergency department. It's probably more relevant for the junior doctor in the emergency department. So I think... Or the senior doctor. Or the senior doctor, exactly right. So I think the blood pressure is the key there. When somebody's got a normal blood pressure 120 130 or they're actually more commonly hypertensive and then they've got a tachycardia more and they've got some pulmonary congestion so you're diagnosing heart failure more than likely what that is is it's the classic diastolic dysfunction hypertensive and then tachycardia reduced filling time pulmonary congestion can also be with systolic heart failure, but it's mild systolic heart failure. That's why their blood pressure is good. And so it's really the tachycardia that's the problem that's giving them the pulmonary congestion. And particularly if it's atrial fibrillation, you're having some sort of bit of dyssynchrony there. So that's where you actually need to lower their heart rate. Otherwise, you won't get them out of the pulmonary congestion. So I think just bearing that in mind and obviously getting help from a senior doctor is important. Looking at the chest X-ray is very important because, you know, if a patient with new heart failure has got this gross cardiomegaly on the chest X-ray, then you're worried about a new dilated cardiomyopathy and you don't want to be doing too much to their atrial fibrillation there. But otherwise, if it's a case of, look, this looks like pulmonary congestion, good blood pressure or high blood pressure, and they're tachycardic, it is appropriate maybe with beta blockers to, like with some metoprolol, small doses to try and bring down that heart rate. That increases diastolic filling time, so then it leads to less less congestion you obviously want to relieve the congestion and improve the patient symptoms and the shortness of breath so that's where uh frizomide uh is very useful it's also a vino you know has some vino dilatation too so it can actually result in some um pulmonary vino dilatations and actually help with some shortness of breath intravenous is going the fastest in the case of, you know, you're called after hours to see the patient who's short of breath. I wouldn't sort of give oral unless it's something mild. So intravenous, 40 milligrams, 20 to 40 milligrams. And just a bit of trial and error. See what response they get. Actually look at what urine output comes out. Ask the nurse, can you please measure their urine output to see what their response to diuretics are. And that will help you gauge, do I need to give them another dose? I think we were discussing before about, so the patient who's hypertensive, then you want to bring down that blood pressure. You want to cause some venodilatation to reduce preload, and that's where your GTN infusion is useful. But if you're doing that, then you've got to be talking to cardiology. They should be moved to the cardiology ward if they're going to need GTN. So in low doses, GTN is a venodilator, and that's why it's very useful in a heart failure exacerbation because it reduces preload, reduces filling. Once you start going at higher doses, as you've probably seen, you can then start reducing someone's systolic blood pressure. And for the patient who's got ischemia as well as a potential driver for their heart failure or vice versa, GTN is useful then for actually causing dilatation of those smaller arteries, the coronary arteries, and relieving that as well. In regard to why they've gone into heart failure, I think some of you might have diagnosed as exacerbation of heart failure, but we don't actually think about what the reason is. Absolutely. What are some of the common precipitants of heart failure? Are they coming through the immune department, what you may see on the wall? Oh, look, absolutely. So, you know, infection is going to be right up there. And so, you know, pneumonia, as in this case example, would be a classic example of precipitating heart failure. A tachycardia as well, as mentioned, the reduction, so the diastolic filling time will lead to pulmonary congestion. Not missing the basics, sort of, you know, the thyroid function that's gone off or the hemoglobin that's dropped and that's relevant for the junior doctor seeing somebody on the surgical ward who's post-op who's gone, who's now short of breath. So having a look at that as well. |
Welcome to On The Wards, it's James Edwards and today we're continuing on our focus on domestic violence and injury. In our first podcast, we talked about recognising and responding to domestic violence with Dr Rosemary Isaacs and today we're continuing the theme and looking at the more severe end of strangulation and also the importance of documentation and domestic violence and injury. Welcome back, Ros. Hello James, good to be back. As we discussed before, Rosemary is a forensic physician and also a general practitioner. She was previously head of the Sexual Assault Service at Rupert Salford Hospital where we both work together. We're going to continue on with the case of a 33-year-old female teacher who presented the immense apartment with her concerns about having a broken nose after a report of tripping at home. When you delve more deeply you identify as a junior doctor that she had been pushed and struck by her partner during argument and as we described it's really important to have a delve in further into a history and examine the patient in more detail, not just on the potential broken nose. And in this case, you notice that the patient's voice is a bit raspy and hoarse and didn't actually go to work today because of the sore throat in addition to the broken nose. What are some of the possible causes of sore throat and what would be your concern in your role? Well James I'm sure your listeners are aware of the causes of sore throat but the one I wanted to highlight is strangulation because I don't think we're aware how serious and common it can be. So that would be strangulation in this case causing soft tissue injury, swelling of the larynx and either pain in the neck or a raspy voice and sore throat. So what are the symptoms of strangulation? Well it's probably helpful just to think of a bit of an overview here of strangulation. The vital structures in the neck are, of course, the arterial supply, which can be obstructed, the venous supply, and the larynx. Now, it is possible in strangulation to injure the cervical spine or to cause an arrhythmia, but those are pretty rare. It's fairly easy to obstruct the carotid arteries and it can be done with a single hand and in fact unfortunately there are YouTube videos demonstrating how to do a choke hold which is to obstruct the neck with the elbow. That can be done without leaving any bruising or signs. So we might think of strangulation with a ligature such as a belt or or something around the neck. That will probably lead to external signs. But strangulation with an elbow, which is covered by soft tissue, often won't. Your listeners like to think, how long do they think it would take to strangle someone to unconsciousness by obstructing the carotid arteries? Amazingly, this research was done on healthy volunteers in American jails in the Second World War. And these young healthy men in their 20s, it's done quite scientifically, it's eight seconds if you can obstruct both carotids to unconsciousness. Most triangulation cases probably instruct the vena cava, which of course will take a lot longer, or the respiratory. And those are the ones with the classic venous obstruction signs, which are going to give you the petechiae, the hemorrhages, the swelling. But if you get both carotids, that's all the oxygen to the brain. So the symptoms of strangulation... So you can get soft tissue symptoms. You can get symptoms from the venous obstruction. You can get respiratory symptoms. So what sort of symptoms would you get from venous obstruction? Okay. Actually, probably there, I'm talking about signs. So I'll just go back to the symptoms. You can get respiratory symptoms, shortness of breath and get sore throat neck pain coughing hoarse voice that sort of thing and you can get neurological symptoms now the first neurological symptom is unconsciousness but the person may not be aware that they became unconscious if it was an actual arterial rather than being the subtraction They just become unconscious and they wake up a few seconds later. If the assailant continues to put pressure on the neck when they're unconscious, they may wet themselves. They may be incontinent of bladder or bowels. And of course, they may have grand mal or other seizure symptoms, but they won't be able to observe that. But they may wake up kind of confused, unaware of what's happening, visual or auditory disturbances. On the other hand, someone who's just very traumatised because their partner has assaulted them may have all those symptoms from sort of psychological trauma. So it's easy for us to put it down to that and not think has there been an assault on the brain causing acute brain injury either by head injury or by strangulation. So it sounds like the symptoms of strangulation can be fairly subtle. Yeah, they can be. So if we want to particularly look for examination findings, what kind of signs would be suggestive of strangulation? Okay, so if we look first of all at the signs from the vena cava obstruction, petechiae are the classic sign that you can find and that could be a scleral hemorrhage, which is really the same thing, a little burst blood vessel, patches of petechiae. It's worth looking in the ear. That can be in the external auditory canal. You can see the petechiae, under the hairline. A lot of women have long hair. Pick up the hair, look at the neck and look actually under the hairline. And when you are looking in the ears, don't forget to look at the tympanic membrane because in the case of a direct blow to the head, you can actually get rupture or a blow to the ear. You can get bruising behind the ear and rupture of the tympanic membrane. You can get petechiae in the back of the throat and you can just get swelling of the face and the neck either by direct pressure or by venous obstruction, which can give you that hoarse voice. Yeah, I mean, we do see often petechiae can be lots of different causes of petechiae, but I sometimes you always need to think of petechiae just in the I guess the face only or the rather than generalized petechiae which have a I guess a differential diagnosis it would be much more broad. Oh that's right and you could get that by coughing, extreme coughing or vomiting in the face and head alone. So we've got the petechiae I mentioned, occasions of swelling. I mean, what around, in regards to around the neck? Do you always see bruising? No. Probably a good 50% of cases you don't, but you might. Or you might be seeing the patient quite early on and just see swelling and erythema, that sort of thing. Again, it's a matter of looking carefully and not just accepting the first explanation from the patient, oh, I was scratching myself or whatever it is. Our disadvantage is we haven't seen the patient before. So the swollen lips and the swollen neck and the slightly breathy voice we might think is their normal appearance. And of course, when someone's been crying for a long time, that may affect their throat too. so it's not an easy diagnosis to make and you need history as well. Okay so what would you document now in the medical record based on this history, the sore throat, the signs and symptoms you see? Well I'd document it but the key thing is to ask the patient. This lady was worried she might have a broken nose and she may think that's more important than strangulation. It's quite common that somebody comes with a particular symptom that's bothering them and they don't realise how serious strangulation is. It's happened before and they manage to go to work the next day. So they think they kind of minimise the importance of it. In fact, epidemiological evidence from domestic violence shows the single factor that's most likely to predict future death in another assault is whether strangulation occurred, because it's actually very easy to kill someone by strangulation. So let's talk more generally about domestic violence documentation in the medical record. Can you give some advice on documenting domestic violence or possible history in the medical record? Yeah. I encourage you to document both things. If you have a suspicion of domestic violence, a strong suspicion, but the patient denies it, to say there were these and these bruises I asked about this she she denied that it happened because it's going to help a future practitioner would it carefully there's the second thing and this is the particularly important thing is when the patient tells you something's happened so he strangled her is not really very helpful or you put his hands on her neck. We actually want to know what happened. Was it a hand? Was it an elbow? Difficulty breathing could have been a pillow on their face. That's not uncommon, especially in a sexual assault situation. |
Because did he strangle you? The patient might think, oh, I'd be dead if he strangled me and say no. But did you have difficulty breathing? Oh, his hands were on my neck and I was struggling to breathe is a really relevant thing. So if you can find out what happened and actually write that down in two or three sentences, ideally in quote marks, in inverted commas, in the patient's own words, what she or he says happened to them. That's very helpful. Then any symptoms, go through a bit of a symptom review and write down any symptoms they had, either immediately afterwards or when you're seeing them. So she may say, I was dizzy, I was confused, I'm feeling a lot better today. We still want to know the symptoms that happened at the time because it helps validate this which is both a legal and a social as well as a medical problem. So I would take a past history and find out if this has happened before or if there's been any other violent assault on them before. Unfortunately, people may have had a previous violent relationship as well, which is very important for their general care. But in this particular medical care, we're probably looking at what's happened in this relationship. And then you want to document your findings on examination both positive and negative. Can you give any tips on how we can do that? Yeah so if we just talk more generally about documenting injuries and the sort of injuries you see are probably soft tissue injuries from a blunt force or from a sharp injury. Now, sharp injuries are not as common in domestic violence and they're quite serious when they occur. And you're looking there at a knife or scissors, someone's been stabbed or cut. In other forms of violence, at a fight at a pub, there may be a broken bottle involved. And a broken bottle, one end will give you a blunt injury and the other end will give you a sharp injury and it's really helpful especially forensically if you can document which sort of injury you're seeing so sharp injuries are cuts or stab wounds and tears of the tissue which we call lacerationsations, a forensic doctor would call a cut an incision, as in a surgeon makes an incision, and they would not use the word laceration for that because a laceration is a tear. So if you think about it, if there's a blow over a bony prominence, such as over the tibia, the tissue may often tear. And you will, instead of getting a clean cut, you get a more raggedy cut. You might see tissue bridges across it. And there's often bruising or abrasion around it. So you can see the tissues have either been by direct force torn or overly stretched. If the tissue's been very stretched, it will also tear. And that gives a blunt force injury. The other common blunt force injuries are bruising and abrasions, abrasions being grazes or scratches. So when we see something like that, what we want to document is its location on the body, its size. So I look at medical notes and it says three large bruises on the abdomen. I don't know if a large bruise is 2 centimetres or 20 centimetres. But if someone can give me a size, it doesn't really matter if it's 9 or 10, which it is, but it doesn't have to be obsessively measured, but we want the size of the injuries and where they are. Another problem that happens is people might write there's a fingertip bruise. Now I don't know what they saw if they write that and in fact you can't really diagnose one fingertip bruise. Fingertip bruising is a pattern where you see four or five bruises together in the pattern of a hand. Really important in detecting child abuse. But what they're really saying is I can see four bruises in a line or three bruises in the line each approximately one centimetre diameter and perhaps there was a bruise on the opposing side of the arm which is from the thumb, again about a centimetre diameter. Now it's helpful if you can write them down, what you saw and the anatomical position. It's more helpful if you can do it on a body diagram. It's quicker, it's easier and it gives a better picture. And it's even more helpful if you can get clinical photography. And I'm hoping we're moving to the stage where our emergency departments will have that. Not only is it important in domestic violence, it's vital in child abuse to get photos of the injuries. I mean, what you've described, photos and writing them on a body, I guess, map, I guess it's sometimes very hard with electronic medical record. It was previously a bit easier. Now with a electronic medical record, I never know how to quite draw something I can describe it. And clinical photography I guess is a challenge in regard to things like consent and who takes that photograph and using your own bring your own device or you have a specialised camera. I still think we have a long way to go in that area. It's something so important. We. We do. And if we're going to use clinical photography, we want to use it to supplement our written notes. The photograph's not great, you've still got your written notes. Where it really makes a difference is when you're getting alternative explanations for an injury. For example, the parents bring a child in, they say, this is what happened, do you accept that? And then the police say, oh that's not what happened. It's very hard to give a second opinion on somebody's written notes of an injury, whereas a photo can be matched up with what, did that slippery slide, what did that toy, what did that look like, it can be matched up. The other thing with regard to documentation is often these documentation may go to the gym practitioner in a referral letter like we usually do when we send someone home what can you write in a discharge letter from the medicine department given that it's maybe likely that the partner may read that letter. Okay so are you handing the letter to the patient to take home? Yes, that's what we normally do. Often they do get faxed as, well, credit fax and now most EMRs will have a system where they go with EMR as well. So that's, you know, I'm just trying to work out what can you write down or whether it's something that you'd prefer, maybe a phone call to the general practitioner rather than having documented those concerns within a written document? Well, given the fact it takes most people a long time to leave a domestic violence situation, it's vital to get that information to the general practitioner. You're really in a difficult situation if the patient is asking you not to document something in the medical records that's relevant to their health and it needs to be documented even if it's documented after the patient's left so that it's not in the discharge letter. The problem I would think your only way out of this situation is not to hand the discharge letter to the patient if the the person's asked the patient, is it safe for you to take the discharge letter? I'm required to record this in the notes, but I don't want to get you into any more danger. The patient says, no, it's not safe. Don't give them the discharge letter. Hand write something in an envelope and give it to them and send the discharge letter to the general practitioner. Because the assailant is not going to see the GP's notes or the hospital's notes. It's the discharge, it's the documentation the patient walks out with that's dangerous. I always tell my junior doctors that the expectation is everyone reads the letter. It's usually the first thing people do is they walk out the door and they read the GP's letter and I guess in this circumstance you'd assume that the partner of the patient would also probably read the letter so don't put anything in that letter that you would not like them to read. I think it's really important to either write an abbreviated version that is fine about the broken nose but maybe either have a separate discussion with the GP., and I think that's vital because the GP is there and when the patient comes in with other injuries, you've alerted them to ask questions. Most injuries don't make it to the hospital. In regard to documenting the referral and the information you offered, how would you normally write that down? Or how is that important? Oh, the referral to other health services that can help. Okay. The idea in domestic violence is to empower the person who's suffering the domestic violence, I say the patient, to be able to make decisions and to plan to be able to get herself to safety or himself. This takes time. They've got a lot of stuff to process. There's the feeling of shame from having experienced domestic violence. There's I can't believe it's happening to me. |
Welcome to On The Wards. It's James Edmonds today. I have the pleasure of speaking to Dr. Alice Gray, who's an immunology and allergy advanced trainee. Welcome, Alice. Thanks, James. Now, Alice, you were once my intern. That's correct. But now I'm asking you the hard questions. Ask about antibiotic allergy. Now, this is obviously something we see a lot of, and I can give my personal story. I've got an antibiotic allergy to penicillin because I got a rash when I was seven. Ah, that's a very common story that we hear, James. Classic, classic, classic. So I always wonder. Welcome in our clinic any day. Yes, okay, thank you. So let's go to a case. You're working after hours on the medical ward. Somebody who's in their 50s has been admitted with a cellulitis. Background of diabetes and hypertension, and has been charted for some intravenous fluoxicillin. But he missed his first dose in ED because the nurses noted that there's a penicillin allergy document on his medical chart and paged you what should we do. So maybe you can just grab your general approach to somebody who's got a documented reported antibiotic allergy. Yeah, so antibiotic allergies or reported antibiotic allergies are obviously really common and they're something that JMOs have to deal with all the time, often in the after hours setting when they may feel a little bit less supported as to how to kind of make those decisions. And penicillin allergies are the most common of all the reported antibiotic allergies. So this is something that JMOs have to deal with all the time. And the reality is that even though we have some tests to help us stratify whether someone may or may not be allergic to penicillin, particularly in the after hours sort of acute setting, you're not really going to be able to make use of any of those tests. And so it's going to come down to a sort of risks benefits analysis, just like anything in medicine, I guess. So the key thing that the JMO can do in that kind of situation is take a really good history. And I guess the thing that I say if a JMO calls me about this kind of situation is it's just like seeing a patient with chest pain. If you're going to risk stratify, you know, how likely it is that that chest pain is something sinister, you're going to ask a really good detailed history. And I liked your example about your penicillin allergy age seven, because I think that points to some of the huge difficulties JMOs have in taking a history, which is often the patient is really vague. Often it happened decades ago and the patient might not have a very good idea. And that's fine. I guess my only tip would be, be a little bit persistent in history taking. Often if you ask some directed questions, the patient can give you a bit more information than they originally thought. And have in mind what you're trying to get out of the history. So what you're trying to decide in your head is, number one, is this really an allergy or is it more likely to be, you know, an adverse drug reaction, something that's not really an allergy? And number two, if it is an allergy, is it an immediate hypersensitivity type reaction, so something where you don't want to give them a penicillin and you don't want to give them a related antibiotic, or is it more in the nature of a delayed reaction where you've got a bit more room to play with? So some of the questions I like to ask patients are, do you remember your face swelling up like a balloon? Do you remember that you needed medical treatment to help you manage the allergic reaction that you had? Do you remember what form the medication came in? Was it an injection that you'd been given? Was it a tablet? Go to the collateral history as well. So it's really great now that a lot of hospitals have electronic prescribing. I mean, the number of times I get told, oh, I'm allergic to penicillin, and then you look back at two admissions ago and they've been given a course of Augmentin with no problems. It happens all the time. In daytime hours, you can ask the family, you can ask the GP, you can ask the pharmacist, all those things that are sort of the basics of taking history that can sort of help you to build up a case for what kind of reaction the patient had. You mentioned immediate versus delayed hypersensory reaction. What features help you on history to differentiate between those two? So it can be tricky, particularly when people mention rashes, because often it's hard to distinguish whether it was an immediate type rash or a delayed rash, particularly if the patient's a bit vague. I guess, and I'm not going to go into the sort of immunological pathophysiology because that would be incredibly boring, but it is helpful to sort of think about conceptually what's the difference between the two reactions. So an immediate hypersensitivity reaction is one that's usually caused by preformed IgE antibodies to the particular drug or its metabolites. They tend to happen quickly. So if it's an IV medication, they often happen straight away as soon as the medication is injected or if it's a tablet within an hour. Some of the features that I would specifically ask about that are very suggestive of an immediate reaction are angioedema, so swelling of the lips or eyes particularly, any systemic symptoms, so whether the person had shortness of breath, collapse, and an urticarial rash as well. And this is something that, again, I think I certainly wasn't that familiar with what an urticarial rash looks like before I did immunology and saw them all the time. If you're not sure what it is, then Google it. Basically, it looks like sort of mosquito bites on steroids, so people get large wheels all over the body. It tends to be a migratory rash, so if the patient says, oh, I had a lump over here and it disappeared and then came up five minutes later in another area, that's very suggestive of an urticarial rash. And all of those features are quite suggestive of an immediate hypersensitivity reaction. A delayed hypersensitivity reaction, they tend to be T-cell mediated, so they take a bit longer to occur. Often they occur a couple of days after a patient's been started on an antibiotic. And interestingly, they can even occur up to a couple of days after the patient has finished the course of antibiotics, so that's something to bear in mind. And the rash tends to be a bit more nonspecific. It might be a sort of macular papular rash, a bit of a vague kind of rash with no specific features. So they're some of the things that I'd use to help me distinguish between the two types of reaction. Are there any other types of reactions that we should be worried about? Yeah, so I think the two kinds of reactions that you need to keep in mind are the severe cutaneous reactions like Stephen Johnson syndrome and the severe systemic reactions, so dress syndrome or drug reaction with eosinophilia and systemic symptoms. You can see why they call it dress because it's a very long description. And the reason why you want to keep those in mind is because they're really serious reactions. They can be organ threatening and they can be life threatening. And none of our testing actually looks for those kinds of reactions. So we have no way of testing for them. And if a patient has one of those, then they should never be given that medication or related medications again. So, and to be honest with you, usually if a patient has had a dress reaction or a Stephen Johnson's, they remember because they're pretty memorable types of reactions. But I usually like to ask the patient, do you remember any involvement of mucous membranes? so eyes, lips, genitals? Do you remember that you were in hospital and had problems with your liver or your kidneys? Do you remember having to go to ICU? So they're the sorts of things that point to those kind of reactions. If we go back to our story with a patient with senilitis, reports about 10 years ago, had a tablet for his chest infection, bit of rash over his arms, which we remember was a red and blotchy, but he thinks it went away without treatment. What do you think now with that story? Should they get the flu clocks or should they think about giving another antibiotic? Yeah, so I guess in the case of a penicillin allergy, we know that if a patient's allergic to penicillin, then there is a small but a real chance that they can have a reaction to related medications. So those medications would be the keflosporins or the carbapenem, so medications like Keflex, Keftriaxone or Meropenem, for example. |
Because if they do, then you're probably not going to want to give them related medications. So in this situation, look, the history is not particularly sort of suggestive of either an immediate reaction or a severe reaction. So I would say that it would probably be reasonable to administer a keflosporin because you risk of cross-reactivity is low and it didn't sound like a particularly serious reaction to begin with. If, on the other hand, you got a history of a reaction that was either serious, so the patient mentioned systemic features like shortness of breath or collapse, they mentioned angioedema, then you would want to avoid both penicillins but also carbapenems and kephalosporins. And in that case, you can use something like astrinanam, which is considered safe for people with a penicillin allergy. So in this case, would you consider doing any particular tests or investigations to try and work out whether they are allergic to penicillin? Yep. So there are some diagnostic tests available. I guess the main thing to note is that most of those will be helpful down the track because we're immunologists, we don't tend to work quickly. We will take, you know, a while to come up with an answer. So there definitely are, and I'll give you a sense of what those are. But for the JMO that's on the ward after hours, the most important thing is going to be that history and trying to make that risk assessment say it's the next day you've you know you've given the patient kefazolin and they've tolerated it fine but you still want to know you know are they allergic to penicillin because we would ideally like to give them flu clocks then there are two types of tests that we can do so the first one is called specific ige which is a blood test I think the old terminology for it was RAST or R-A-S-T. What that looks for is the presence of IgE antibodies to a particular drug or its metabolites in the blood. So you write on your blood form, you know, specific IgE to penicillin or to kefir claw or amoxil or ampicillin, send it off to the laboratory. Now, if it comes back positive, that's very helpful because it suggests that there's a high likelihood that the patient had a true allergic reaction because they've got the antibodies that cause that kind of reaction. The problem is that these tests are almost always negative, and that can be the case even in patients who really do have an allergy. So if the test comes back negative, it's not good enough to say on the basis of that test alone that the person's not allergic. If it comes back negative, what we then do is go on to skin testing. So that's when the patient comes to immunology clinic or on the wards, depending on how urgent the situation is. And we do some skin testing where we inject a tiny amount of the drug underneath the patient's skin and we see if they develop a wheel. If the skin testing is negative, then we go on to do a little challenge, which is where we give the person sort of greater dose of usually amoxicillin under supervision to see if they tolerate it. And if they tolerate it, then we say pretty unlikely that you're allergic to penicillins. You can go on and receive them in future. If the skin testing is positive, then at that point we'd say it's pretty likely that you're going to be allergic and we'd say that you should avoid penicillins and related antibiotics in the future. In what group of patients would you do this in? I mean, you've just had one episode of cellulitis, you've been cast on for five days, who cares if you're allergic to anybody? Does it matter? Look, it really depends. I guess on a bigger scale, it kind of matters because we know that there are downsides to people being labelled with the penicillin allergy. So there are downsides for the individual. You know, they could come in, you never know, 10 years in the future with endocarditis, for example, and, you know, you might not be able to give them the best treatment for that infection because they have this supposed penicillin allergy. There was a big study that came out late last year, I think, that showed that patients who have reported penicillin allergies have a higher rate of post-operative skin infections because they tend to get antibiotics that aren't as good as prophylaxing as the penicillin-based antibiotics. But then you've got to weigh that up against the hassle of having to go and skin test the patient, which is annoying. The waiting clinics for immunology testing are often quite long. So in general, I guess we would prioritise those patients who have a real clinical need for that antibiotic. But most immunology clinics are happy to see anyone because you never know when it may be useful for that patient in future. If patient really required the appropriate antibody, which is a penicillin-based one, would there be anything you could do or you just need to look for another option? No, so if there's a definite indication for that antibiotic or for another drug, then we can do something called a desensitisation. And so we usually do that either where we know that the person definitely has an immediate hypersensitivity or we suspect that there's a high chance they do. And what you do in a desensitisation is you have a protocol and basically you start out administering a tiny, tiny, tiny amount of the drug and you give it in steadily increasing doses up to a sort of normal standard dose. And that's done under very close sort of medical and immunological supervision. There are very strict protocols for the amount of drug that you give at each particular point in time. And depending on how severe the original reaction was, you may even do that in the intensive care, for example, to make sure that any reaction can be handled. Usually desensitizations do work, but the important thing to note is that if you desensitize someone they're only considered desensitized while they're receiving that antibiotic so if they miss a couple of doses or once they've completed that course then they have to be considered allergic again and if you want them to be to receive the antibiotic again you've got to go through the whole protocol. I guess the other thing to note is you can't desensitise to some of those severe reactions that we were talking about before, like Stephen Johnson's or dress syndrome. So if a patient's had those, then usually it just means they can't get the antibiotic at all in future. And are you only desensitised for that one drug? Yes, exactly. Does it cover a couple of drugs at once? Usually you'd only be happy enough to say you desensitise for the drug that you want to give them. And we spoke at another podcast recently with Roger Garcia in regard to anaphylaxis and the importance of having EpiPens. Is there a role for EpiPens in people who've got antibiotic allergies? So generally we would say not. The main reason that we give people an EpiPen is basically so that they can manage anaphylaxis if they're inadvertently exposed to something. So the usual situation is food allergy because you know you may know that you're allergic to peanuts but you know go out and eat a takeaway meal and accidentally eat some peanuts and so it's important that you're able to manage that. The thing that is helpful for drug allergies is a medical alert bracelet, particularly for things like commonly used antibiotics or for contrast allergy, because a person, you know, may be in a car accident, they may get septic, be brought into the ED unconscious. And in that situation, you want to make sure that they're not administered a medication that they're allergic to inadvertently if they can't speak up and say that they're allergic to it. Random question. What about a seafood allergy and intravenous contrast? Yep. So that's a great question. And it's one that comes up all the time. It's quite an interesting one. So a lot of patients and quite a lot of clinicians as well believe that seafood allergy is caused by allergy to iodine, which is contained within seafood. And for that reason, there tends to be this belief that, oh, if you're allergic to crustaceans, for example, you shouldn't have contrast media that contain iodine. And that's a total myth. So seafood allergy is not usually, well, it's not caused by allergy to iodine. It's caused by allergy to some of the proteins that are contained within the seafood. And in fact, contrast allergy is not caused by allergy to iodine either. So there's no reason why someone who's allergic to seafood should not be able to be administered iodine-based contrast media. |
Welcome to On The Warts, it's Tom Aitman. Today we're talking about corneal foreign body removal. The presentation of a patient with a corneal foreign body is not uncommon in the emergency department. Junior doctors should attempt to become competent in removing an uncomplicated corneal foreign body by the end of their term. When attempting for the first time, or if you are not confident, perform the procedure under supervision with someone more experienced. Using the salute lamp, as well as the correct instrument to remove the object can be a little daunting. Today we speak with Elisa Cornish. Welcome Elisa. Thank you. Elisa is a consultant ophthalmologist at Sydney Eye Hospital and she specialises in inflammatory, retinal and inherited diseases of the eye and will be talking to us about some tips and techniques on making this procedure a little easier for you. So we'll go into a case now and so imagine we're in the emergency department and you're seeing a 22 year old construction worker who was presented to the emergency department with an acutely painful and red eye. They also complain of some blurry vision and the patient mentions to you that they have been grinding with some metal earlier in the day. So over to you, Elisa. How common is this type of presentation to the emergency department? Oh, thank you, Tom. Actually, it is one of the most common presentations to the general emergency department, first being corneal abrasions and corneal foreign bodies coming in a close second. So at a large tertiary referral teaching hospital, you're bound to see at least one or two of these a day and sometimes more. Okay, great. And so now going back to the case, what information would you like to have immediately? Eye registrars or eye doctors always want to know about the visual acuity and in particular the other eye as well because you would like to know whether or not you're dealing with an only eye. I'd also like to know about the intraocular pressure and what the pupil's doing. What's the shape, its reactivity and whether there's an apparent papillary defect seen. Okay, great. And so what are some of the important questions you want to ask when taking your history? It's pretty important to know when it occurred. I mean, not always do the patients know when it happened, but in this case, we knew it was earlier in the day because it sounded like a probable mechanism. However, sometimes patients present a couple of days after they've been welding, thinking that the pain is from a flash burn and that it would get better, but it doesn't. So a foreign body that's there for too long can actually result in white cell recruitment, a rusting and infective keratitis. So knowing the timeline is very useful. It's also important to find out what kind of material are you looking for in the eye or on the eye. Were they hammering a nail onto the wood or were they using hammers on a cement or grinding through a metal sheet? Because you need to understand the velocity at which the foreign body possibly hits the cornea. In my history, I also ask them about eye protection because usually they're sitting there next to their partner and I don't really need to know whether they were wearing it or not, but I use it as my educational bit to say, look, you should be wearing it because most of the time they've taken their goggles off and popped it on their head just to measure something else up. But it's more about educational purposes to prevent future potential blinding injuries. Okay and how would you examine a patient when you're looking for a corneal foreign body? Well the patient won't let you near them unless you do something about their pain so usually I some topical anaesthetic in and kids might not even let you close enough to do that straight up. So they might need some systemic Nurofen or something given by mum and then you'll be able to get a bit closer to get the drops in. Once the patient allows you to have a look at them, it's best done on the slit lamp. Okay, and so we'll get on to that. What tips have you got for the novice in using the slit lamp? Well we don't get a lot of slit lamp education in our medical degrees so the first thing I would say is always watch the opto reg when they come into the eye department or into the emergency department because you can learn hands-on experience there. But first of all, when you set them up, before you even bring in the patient to the slit lamp, make sure that the eyepieces are set to zero and that you're not looking through an eyepiece that's dialed to a myopic refraction. And then adjust the eyepieces so that they fit to your papillary distance, your interpapillary distance. And you do that by looking through the eyepieces and then moving them towards each other horizontally so that you get only one image rather than two. Then work out turning on the slit lamp. Make sure it's on the white light and swing the light to about 45 degrees from the direction that you're looking at the patient. And this is great because you can make a slit and then that will help you work out with the beam of light at that angle what depth the foreign body is in the cornea. And then it's about that point when you know that you're going to see something when you look through the eyepieces, you ask the patient to place their chin on the chin rest and adjust the chin rest so that their lateral canthus, the side part of the eye, is adjusted to the black line or the mark on the slit lamp. And this way, you know, when you come in with your light, you'll actually be getting a view of their eye. And then also they've got to push their forehead forward so that their head actually sits on the forehead rest as well. Before I look through the eye pieces and focus my beam, I actually look at the beam on their nasal bridge. They tolerate that better than going straight to the eye. And I get it in focus while looking at it from the side and then when I've got a sharp image on the nasal bridge then I look through the eyepieces and move the light to get the eye in focus and by pushing the hand piece towards the patient you're going further deeper into the eye and putting other posterior oculus structures into focus and then then that way you can work out. So if you're in focus on the cornea and you push forward, you'll then go into getting the iris in focus and then the lens in focus. And then the best thing to do is ask them to look at your ear. So if I'm looking at someone's right eye, I ask them to look at my right ear. And that's a much easier way to keep them on the slit lamp and in the right position. And you might often need to use a cotton tip to lift the upper lid just so that you can get a view of what you're looking at on the cornea. Okay, great. And from my experience, I think just getting in there and practicing, even though you might not have the theory completely down pat, certainly just practicing and practicing, and eventually you intuitively pick up some of these things that you are talking about. Exactly. And that's why I say jump in there when the iRedge comes in, because you watch what they do, then ask if you can jump in and have a look at what they're looking at because that's the way you learn. They're usually pretty friendly fellows. Yeah. We want people to learn. That way we understand what you're saying on the phone. Okay. And so going back to the case, are there any flags that may indicate that this is more than just an uncomplicated foreign body? Yeah, so basically anything that's abnormal in regards to their vision or their pressure, like if it's really bad or their pressure, a good pressure I'd be happy with between 10 and 23, 24. If it's like 5 or if it's 30, then you start to think that something else is going on. As I mentioned earlier, it's really important to comment on the pupil or look at the pupil and see whether it's irregular. If it's peaking, that makes you suspicious that maybe it's peaking towards the cornea or it's actually going through a perforation of the cornea. So the pupil shape is really important. And of course, you need to look to see that the anterior chamber is not flat. Check that it looks filled and that there's no hemorrhage inside the eye because sometimes your foreign bodies come with a bit of force and you could get a blunt trauma as well. And another red flag that I often get concerned about is if I put in topical anaesthetic and five minutes after they're not feeling any better. |
Okay. And what equipment do you need to remove the object? So clearly it's easier with a slit lamp, anesthesia, and then of course the fluorothene. We use the 2% fluorothene, and I'll explain the reason for that in a minute. I always, removing a foreign body is kind of a stepwise process, and you should only ever remove a body, remove a body, remove a foreign body is kind of a stepwise process and you know you should only ever move remove a body or remove a body remove a foreign body um when you're comfortable in what you're doing so stop when you get to a point where you go i'm not comfortable i've not experienced enough in doing this um and then pass over to somebody that can help you so i first start with a wet cotton tip and brush gently on the foreign body. Sometimes you need to hold the upper lid open either with another cotton tip or your finger. But if that doesn't work, you can then move on to a needle bevel. And what I do with a needle bevel, you can either use it just as a straight edge or you can bend it into kind of an ice cream scoop shape and brush gently down over the foreign body to see if you can dislodge it. You've probably noticed that some emergency departments have a dental burr but I definitely wouldn't be using that unless you have the experience and that you've been taught and you're confident in that. Okay. And what are some of the important steps to remember when removing their body? Well, one thing is if you've taken one out, always look for more. It could be some dislodged in the cornea or in the conjunctiva or sitting under the eyelids or sometimes down in the fornices. And also remember that, you know, some foreign bodies are hard to remove, even for trained ophthalmologists, so don't be shy to refer them on. And in the emergency department, I think I always tell the person on the end of the phone, if it's peripheral and you feel comfortable to take it out, that's fine, but if it's central, it should be left for an eye specialist to remove. Okay. And these patients are obviously in a lot of agony and they're quite hesitant when you're coming towards them with a needle, for example. How can you gain their cooperation? Well, anaesthesia really helps. Once you've got them a bit more comfortable, they're more willing to sit still. And with kids, the other thing is a cooperative parent, bribery, whatever you can, so that you can get a look because it's really important to see what's going on in the eye. And sometimes you need the help of the emergency department team to give you a little bit of sedation to help look at little kids to see what's going on on their cornea. And when you do have an adult and you've got them on the slit lamp, it's good to give them something to look at, such as a poster on a wall behind you. That way they look at something, they're being distracted and that helps them cooperate so that their eye position is correct on the slit lamp. And what would happen if the foreign body was not removed? So if it was sustained for a number of days or weeks, seven? Well, if you leave a foreign body, the eye and the body wants to fight it. So you get a good corneal reaction with white cells and you can possibly get a bacterial infection or other infection so it's really important because pain continues and the eye will continue to tell you that there's something there so you need to make sure that if you if you leave it they're followed up with the ophthalmologist or an eye specialist because an infection can occur or you can develop a rustering around the metal object and all this can cause scarring and is also very vision threatening. Okay, and that brings me on to my next question. So any considerations after removing a metal object, say, from the cornea with that rustering? Do we need to get all of that out? Oh, no, definitely. What you really need to do is remove the foreign body, and if you do that, that's a win. If there's a residual rust ring, which is around where the object was, you don't have to remove it on day one, and it's totally appropriate to put some glossy ointment on and pad the eye and get them to follow up with the ophthalmologist the next day. And they can do the more detailed removal of the rust ring. And you've also got to remember to tell them that if the pain, it's going to be painful that day that you take it out. But if the pain is there the next day, just as intense, you need to come back to the emergency department and always refer them to see an ophthalmologist as follow-up. Right. Are there any investigations you'd like to perform in this particular case? Well, in this case, in any case where I take out a corneal foreign body, I want to check that they're SEDEL negative. Now, if you remember, that's where you put in some fluorescein, the 2%, and makes everything yellow on the cornea. And what you're doing is to check that there's no leak of aqueous coming through the hole from where you took the foreign body. And if you were looking at the yellow cornea and you saw a waterfall effect, which would be the aqueous coming through, the aqueous wouldn't be stained and it'd be washing the fluorescein away. And that's obviously an urgent eye review. So that would need them to come in and have a look then. And also depending on the mechanism, the action of the injury, you might wanna do further imaging, say a facial X-ray or a CT looking for deeper or other metallic foreign bodies, depending on the mechanism, if it was an explosion or something more diverse, then that's what I would be suggesting. Okay, great. And what are some of the complications that can occur with this procedure? So as I mentioned earlier, a foreign body that's in the cornea could be too deep that when you pull it out, it's a full thickness or a penetrating eye injury. Also, removing a foreign body in itself could require us to actually dig too deep. So that's a risk at any point of using a needle near the cornea. But also when you're holding a needle near the eye through a microscope, you can cause an iatrogenic laceration to the lid or the eye or the nose because it is quite a difficult skill to pick up. When should you ask for help? Well, as you mentioned earlier, Tom, if you're an intern or a junior medical officer in an emergency department, always ask for supervision from your seniors. That's what they're there for. And if you're a senior emergency physician and you're struggling, ask for help. There's no reason why you should continue digging if you're not winning. So ask for help from another person in the department or the ophthalmology registrar. And we've partly already answered this question, but when do you think a junior doctor should refer to the ophthalmology registrar? Look, to be honest, you should always talk it through with your senior. But if the foreign body is central, you shouldn't be going near it. If there's a residual rust ring, then that needs to be removed by the ophthalmology registrar. And again, if you're struggling to get the foreign body out, refer on. And if the eye is an only eye, and when I mean only eye, that means the vision in the other eye is severely reduced, then the only eye they've got is the one with a foreign body. You should refer that on to the eye registrar as well. And then again, if anybody that you see is just not what you expect or is out of range or the vision's out of range or the IOP, just give us a call and talk it through and we're happy to see the patient at a follow-up appointment. Okay, great. And so we've now removed the foreign body. Everything's gone according to plan. The patient is cytosine negative. What is the management after from this point onwards? So the patient is going to need some analgesia. Usually I recommend Nurofen or an ENSI because that's good for corneal pain. Cycloplegia, so if you've got some cyclo drops or some atropine to keep the patient dilated gives good pain relief. And they always need an antibacterial drop or ointment. So usually what I do is I fill the eye with antibacterial ointments and then I double pad the eye shut. |
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