A gentle nudge…

Cite this article as:
Tessa Davis. A gentle nudge…, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11516

Children have a right to receive healthcare regardless of the decisions made by their parents. This week, the RACP released a further statement citing refusal to treat patients for non-vaccination as ‘unethical coercion’. Whilst the majority of paediatricians are clear on the benefits of vaccinations, parents can choose not to vaccinate their children. Under the No Jab No Pay policy, this choice can lose them their right to Child Care Rebate. However, it should not lose them their right to receive healthcare. A poll by the Royal Children’s Hospital in Melbourne found that 17% of children who were not fully vaccinated had been refused healthcare by a provider. But what does ‘refused’ actually mean? And does the RACP’s statement leave us confused rather than providing clarity?

 

What was the poll?

The Australian Child Health Poll team at RCH is led by Dr Andrea Rhodes. It runs a quarterly poll on contemporary child health issues by conducting national surveys across Australia. The latest poll, released earlier this week, looked at vaccination perspectives of Australia families.

Data was collected from 1945 parents (with 3492 children). They were asked questions relating to the vaccination status of their children and attitudes to vaccinations.

 

What were the key findings on refusal of care?

  • 95% of the children were fully up to date with their vaccinations
  • 30% of parents had some concerns about vaccination
  • 9% of parents did not agree that “…it was important to vaccinate their child to protect the community (herd immunity)”
  • Of those not up-to-date, 17% had been refused healthcare (29 children)

 

Why are children not up-to-date with their vaccinations?

24% had delayed some vaccinations due to to minor illnesses, and there were misconceptions about when to delay.  36% thought that vaccines should be delayed in child with a runny nose but no temperature, and 47% thought they should be delayed if the child was on antibiotics. 22% thought vaccines should be postponed due to a local reaction from a previous vaccination.

18% had a preference against vaccinations, and perhaps worryingly 10% thought that vaccinations were linked to autism and a further 30% felt unsure about the link.

22% had delayed because of barriers to education and access. Half of these struggled to attend for vaccination and the other half had questions about vaccinations that they were unable to get answered. This emphasises the importance of our role. This sizeable group needs our input as paediatricians – to offer information, be open to discussion and assist with making vaccinations accessible.

 

What can we take from this?

This is the first poll in Australia providing information about refusal to provide healthcare.

Our role as paediatricians is to provide healthcare for each child regardless of their circumstances and certainly regardless of any actions of their parents. This poll makes it clear that there is a sizeable group of parents with uncertainty about vaccination who are interested in engaging and accessing services. We would be doing them a disservice by refusing to treat their children. And even where parents have made a specific decision not to vaccinate, we still have a duty to provide healthcare for their children. It is only by keeping the channels open that we can support, educate, and engage.

The RACP has released a clear statement on this which reinforces their Immunisation Position statement.

It is inappropriate to refuse to treat unvaccinated children, firstly because it represents unethical coercion and secondly because the children will be further disadvantaged.

Yes, we know that vaccinations are beneficial. And yes, we want to increase vaccination rates and ensure our patients are vaccinated. However, by denying unvaccinated children healthcare we are disadvantaging them even further. The RACP goes as far as to call this ‘unethical coercion’. We need to provide healthcare and not use it as bargaining chip.

However, the concept of refusal may not be clear cut. This poll did not collect data on the circumstances of refusal so we do not know which provider has refused treatment or how that refusal has occurred. It is possible that parents perceive that healthcare professionals are not happy to treat them and classify this as outright refusal.

Research in the US has shown that providers worry that unvaccinated children will pose a risk to young babies in their waiting rooms, or that the unvaccinated child themselves is at risk of catching a serious infection. These are reasonable concerns and therefore steps may need to be taken to minimise these risks. If unvaccinated children need to sit separately, could this constitute refusal in the eyes of parents? If the parents have to engage in an awkward 10 minutes of discussion with the paediatrician about the benefits of vaccination, could this constitute refusal in the eyes of the parents?

So the answer is not as clear cut as the RACP’s statement makes it seem. Of course we should not refuse to treat a child because their parents didn’t vaccinate them. But it is also our role to encourage vaccinations and to engage in discussion about the benefits of vaccination. This engagement may make vaccine-refusers feel uncomfortable and affect their perception of our willingness to provide healthcare. This is not the same as refusal to treat.

 

Phone a Friend

Cite this article as:
Andrew Tagg. Phone a Friend, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11413

As supervisor for the latest batch of interns that come through our emergency department I get to nurture them straight out of medical school, before the cynicism of the ward service sets in. It’s never the medicine that is a challenge, but the hidden curriculum that they are not taught in medical school. This time I’m going to focus on a piece of technology that I use every day at work but have never once been taught how to use – the telephone.

Coping with errors

Cite this article as:
Tessa Davis. Coping with errors, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11227

When you lie in bed at night and have moments of reflection about your work, what do you think about? The patient whose abnormal blood result you didn’t spot? The time you prescribed the wrong drug dose for a patient? The child who died unexpectedly and you wonder what you should have done differently?

That’s Entertainment

Cite this article as:
Andrew Tagg. That’s Entertainment, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.10997

As a birthday treat (mine not hers) my five year old daughter took me to see Operation Ouch Live! It’s one of the few television shows we watch as a family in our house so I thought I’d share you some (non-clinical) lessons I have learnt from Dr Chris and Dr Xand.

The good old days

Cite this article as:
Andrew Tagg. The good old days, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11095

As I introduced the latest batch of interns to the department I thought back to my first few days as a doctor and how I have changed. I qualified in 1997 and I still remember lots of things about my first year. I remember the fear of being on-call, the physical and mental exhaustion that would result in me falling asleep on the toilet, and I remember the colleagues that helped me through it.

Never enough hours in the day

Cite this article as:
Andrew Tagg. Never enough hours in the day, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10228

How do you do it? How do you keep up with all this blogging, tweeting and writing whilst holding a job and keeping your family happy?” It’s a question I invariably get asked when I speak about the use of social media in medical education.  I can talk about podcasts, and keeping up to date with the literature and there will always be a voice of dissention that wants to know “How?

Ring-xiety and how to unplug

Cite this article as:
Henry Goldstein. Ring-xiety and how to unplug, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10236

Ever felt your phone buzz in your pocket, only to find it hadn’t? Do you have #FOMO when it comes to the latest @ketaminh tweet, an @EMTogether podcast, or even the latest DFTB post in your inbox (yep, you can subscribe)?

I bought my first smart-phone two days before I graduated Med School (and certainly my patients are almost exclusively younger than the iPod (15 years!)), and the device has been omniscient throughout my clinical practice. Unsurprisingly, I have at times become overly attached to my ‘screens’, be they phone, tablet, laptop or desktop. (I ditched my pager long ago.)

This post confronts some of the challenges of how to ameliorate or obliterate your technophilia and how to combat the distraction of hyper-connectivity. It offers some pragmatic ways to reduce the influence of the devices, social media and the internet intruding into your thought space.

Firstly, I challenge you to think about the relationship you have with your device. Where is it now? Are you using it to read this?  Perhaps as you stroll down one of Antwerp’s mobile phone lanes ? (Perhaps you’re doing an ‘internet poo’!)  Is it your pocket? Out in your eyeline? Chances are if you’re not using it, it’s within reach.

I would speculate that in the medical profession, we succumb to the idea of keeping our phones close as part of the ‘emergency delusion’. In truth, MET buzzers, Cat 1 Caesarian pages, Bat-phone calls and their ilk are NOT coming through on our mobile. And, unless you are on call for a resus area, or retrieval service, it is entirely possible to discount the notion that the buzz in your pocket is a life-threatening medical emergency.

Other reasons we are so attached to our phones might include ringxiety, FOMO or as a nervous habit, perhaps it’s just something to do with your hands. We might even postulate that many people use their phones as what our psychiatric colleagues call a “transitional object”; much like a toddler’s thumb, teddy or blanket. Consider Winnicott’s seminal 1953 summary of the special relationship of the “transitional object” 

Summary of Special Qualities in the Relationship

  • The infant assumes rights over the object, and we agree to this assumption. Nevertheless some abrogation of omnipotence is a feature from the start.
  • The object is affectionately cuddled as well as excitedly loved and mutilated.
  • It must never change, unless changed by the infant.
  • It must survive instinctual loving, and also hating, and, if it be a feature, pure aggression.
  • Yet it must seem to the infant to give warmth, or to move, or to have texture, or to do something that seems to show it has vitality or reality of its own.
  • Its fate is to be gradually allowed to be decathected, so that in the course of years it becomes not so much forgotten as relegated to limbo. By this I mean that in health the transitional object does not ‘go inside’ nor does the feeling about it necessarily undergo repression. It is not forgotten and it is not mourned. It loses meaning, and this is because the transitional phenomena have become diffused, have become spread out over the whole intermediate territory between ‘inner psychic reality’ and ‘the external world as perceived by two persons in common’, that is to say, over the whole cultural field.

If you’ve made it this far, I suspect you’re somewhere at or beyond the contemplation phase of behaviour change (turns out it’s not just for quitting cigarettes!)

stages-of-change

At work,

Mobiles can really muck with our work; they divert our attention from the patient in front of us with a mere (and often phantom) vibration, they cause awkward pauses as we “just finish the text” before talking to a colleague and occupy our wandering minds in a packed clinical handover room. Not to mention distracting us on the drive home or during another death by powerpoint teaching session.

A common rebuttal to the use of smartphones in the medical setting is that they have a wealth of information at your fingertips. I have no dispute with this fact; but other than a calculator, a stopwatch and Shann’s Drug dosing, I’m yet to come across an app that has genuinely, in the moment, augmented my clinical practice.

If you do the kind of work which involves serious conversations or giving bad news to people on what could be the worst day of their life, practice turning your phone off or giving it to a colleague.

Mobile phones are sometimes prohibited in the NICU environment for their hypothesised risk as a bacterial vector, however, a 2014 study by Mark et al identified no pathogenic bacteria in swabs from 50 phones from the members of a surgical unit in Belfast. 

What about away from work? It’s important to consider the influence of shift work and the sleep-wake cycle; we live on a 25-hour planet when you consider New Zealand (GMT -11) vs American Samoa (GMT+13)!

As the sun rises and sets in different parts of the world, different sectors of the social media landscape ebb and hum. When it comes to devices, and mobiles phones in particular, consider the negative aspects of device usage at particular times of the day.

During the daytime, our phones can distract us from the task at hand, including real-time person to person communication and being present in the world around us. At night, devices can stop us from sleeping.

On the run,

Exercising without your device can sometimes be a challenge, particularly if you like music or run/ride/?ski more than five minutes from home. The tradeoff can be listening to birdsong, traffic noises or the gym’s choice of playlist. Besides, would you answer your mobile phone on a bicycle? Listening to a plain-old music player allows space from the threatened buzz of the cell phone whilst working out.

At night,

Sleep hygiene is essential in the medical profession. There are many components of this including having a dark room, minimal caffeine in the six hours before bedtime, a sleep routine et cetera. Some of the device related parts of this are to keep (charge) your phone away from the bedside, preferably out of the bedroom. This distance also slows the instinctive email-check as a soon as your eyes open. Remember, you can always buy an alarm clock!

Many of the tips offered to teenagers can help too, such as no phones at the dinner table. Some households have a Wifi bed time and a mobile phone bowl. That means there’s no chance of pottering around on Reddit after the appointed “electronic lights out”.

Productivity,

Use the right screen for the right task, and get rid of the others; if you’re trying to dictate a letter, write a paper or plan a talk, your mobile phone probably isn’t the ideal instrument for this. Make the most of ‘clean screen’ apps, such as good-old word processors, Grammarly, or Drafts, and if you’re really trying to unplug, you can always use pen and paper!

 

The overall message for this part is to eliminate the unnecessary & non-beneficial intrusions of your mobile into your life. In particular, I’d say this applies to holidays and night time. In his book “The 4-hour Work Week”, Tim Ferris dedicates a large component to the ‘elimination phase’ of information overload. Sometimes, one of the best things we can do is take an actual, wifi-less, internet-free holiday without any phone service.

Device tips

 If you must have your device in your pocket or nearby, try some of the following;

Do Not Disturb – most smartphones can be set to “Do not disturb” mode, which automatically silences all calls, messages & notifications between the prescribed hours. If you’re worried about emergencies, two calls from the same number within a few minutes will override the silence function. I only turn this off when I’m on call.

Night Mode – is another form of blue-blocker, which reportedly helps you regulate your circadian rhythms; this can be set as automatic on the iPhone. Kristin Boyle via Life in the Fast Lane reviews some other methods for this in the shift work environment here.

Notifications can be turned off on an individual app basis. From a stimulus – response point of view, less is likely more. That is, only calls and messages elicit any sounds. You can also reduce banner-style interruptions to zero both locked and unlocked, as well as stopping individual apps from showing the number of badges/notifications awaiting your limited attention.

The challenge here is to make the phone a thoroughly uninteresting proposition for procrastination / distraction. Consequently, if one gets to the stage of dragging the phone out of the pocket, it’s on your chosen schedule, not exclusively as a reaction to ongoing noises or buzzing.

Next, aim for no banners/notifications on your lock screen (these can be turned off, as above), so once you look, you know the time, date and perhaps glance at that photo of your loved ones or favourite motivational quote, before returning the phone to pocket, bag or table.

img_5213

After an accidental but compulsive unlocking of the phone in a weaker moment, aim to see no badges ( “Ooh, shiny!”) or things to attend to. Continue to open your particular app of choice, until…

img_6915

Freedom is an app that blocks part or all of the internet. You can set particular periods, and with a subscription, you can schedule repeating blocks. Currently, I have the first four hours of my work day set to block “all social media” and a few sites I visit out of habit (think ABC news, sports apps and Notemaker.com.au) to waste brain space. When the block is on, they just won’t load. Thwarted, I return to the present!

Forest is another app, more the carrot than the stick kind. Forest allows you to set a timer, during which time a digital tree or bush grows. When the timer finishes, the plant is added to your forest. But, if you change apps or switch to the home screen, your plant dies immediately, and the dead tree sullies the landscape.

One last app that can be an interesting and objective way to become aware of excessive phone usage is to us the IFTTT ‘Do Button’ feature. You can create a ‘recipe’ which collects a time stamp every time you press the button. Leave the app open and each time you unlock the phone, the button says “Unnecessary phone use.”; you are are obliged to press it before continuing; usage is collected in a google sheet for you read at a later time.

Both Forest & Freedom are about “blocking” the internet or phone usage. But what about positive internet time? I mean, it’s good to have some connection to the hive mind. Ferris describes setting time aside to screen emails and respond. Pragmatically, rather than withdrawing entirely, you can set aside an hour or two a day of dedicated social media time to “get your fix” whilst fostering connections and even schedule tweets.

Another way to make the most of short periods of connected time is to set emails to ‘snooze’; Google’s inbox offers this feature, as does the Boomerang app. This kind of technique also works well with the philosophies of David Allen’s Getting Things Done.

The Apple ecosystem has a habit of installing apps on all your devices. Critically and selectively deleting apps that you don’t want on a particular device allows you to discriminate what will buzz when. For example, I have twitter on my iPad but not my mobile phone.

To help with this ‘feature creep’, some folks use particular private message apps for set groups. For example, family on viber, work on WhatsApp, sports team on FB messenger and so on. In concert with the use of selective notifications, you can filter the distractions to a manageable amount.

If you’re really struggling to unplug from social media, but can’t be rid of your phone, you can just uninstall it all. Sounds dramatic? Try limiting your device to a set number of social media apps. Which five do you want the most? Which three? Which one? The same goes for all kinds of network; which of twitter, Instagram, snapchat, facebook, Reddit, LinkedIn and the rest can you divest yourself from without feeling isolated or lonely?

Password managers can also be useful; sometimes the temptation to “just to see what’s happening” on a particular social network leads to the actual website (in lieu of the app). If you can’t remember the inordinately long password, it’s another cognitive block to log in.

Lastly, consider do you need a smartphone? In the USA, about 1 in 7 people still use a “feature” or dumbphone . The phones can send messages and make phone calls; what else do you need? A handful of my colleagues have tried the two-phone option – one number for work calls, one for the rest of the world. It allows discrimination between the two and, I’m told, helps people to stop hating & fearing their phone.

In summary, mobile phones and devices are omnipotent in clinical and personal life for most people. Many people feel that their devices intrude into their lives. Although a bit preachy, this post has considered some of the challenges attendant with being constantly connected, as well as some pragmatic ways to free our minds from our screens. We’d love to hear your suggestions in the comments below!

Disclosure:

I’ve tried almost everything mentioned in this post, some successfully. I paid for any of the apps or actions in this post by myself. I also killed at least 4 trees in the Forest app, glanced at my phone six times whilst driving home, browsed twitter for thirty-nine minutes, read extraneous PubMed (and DSM-V) material for twenty-eight minutes, glanced at my iPhone (it’s in reach) at least twelve times and looked at expensive fountain pens whilst researching & compiling this post. Uploading was also delayed because I stayed up too late at night and thus my internet was blocked.

Or Not…

Cite this article as:
Andrew Tagg. Or Not…, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10499

With an impending new arrival I was excited about the educational opportunities that would arise.  I’d read up my fetal physiology and was eagerly awaiting the chance to write a series of posts on what normal babies do.  I had planned to take pictures of meconium filled nappies and film normal neonatal reflexes. I’d made a little list of the things I really wanted to capture. But things don’t always turn out the way you expect them to.

Big Picture Paediatrics : Adverse Childhood Experiences

Cite this article as:
Henry Goldstein. Big Picture Paediatrics : Adverse Childhood Experiences, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10082

So much of paediatrics, and medicine in general, is focussed on small experimental or observational studies. This series of posts takes the wider view; we’re talking here about some of the biggest and longest running studies that help us frame, measure and understand childhood through time and across the world.

Who & what was studied?

Kaiser Permanente is a large Medical Insurer in the USA; they collected data in two waves in the primary care setting with a view to describing the long-term relationship of childhood experiences to important medical and public health problems. The study initially rolled out in 1996 & 1997.

Felitti, VJ, Anda RF, Nordenberg D et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults : The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998:14, 245–258.

The study aimed to assess – both retrospectively and prospectively – the long-term impact of abuse and household dysfunction during childhood on disease risk factors and incidence, quality of life, health care utilization, and mortality for adults.

Here is the actual questionnaire:

Answer yes or no; all ACE questions refer to the respondent’s first 18 years of life.

Abuse

  • Emotional abuse: A parent, stepparent, or adult living in your home swore at you, insulted you, put you down, or acted in a way that made you afraid that you might be physically hurt.
  • Physical abuse: A parent, stepparent, or adult living in your home pushed, grabbed, slapped, threw something at you, or hit you so hard that you had marks or were injured.
  • Sexual abuse: An adult, relative, family friend, or stranger who was at least 5 years older than you ever touched or fondled your body in a sexual way, made you touch his/her body in a sexual way, attempted to have any type of sexual intercourse with you.

Household Challenges

  • Mother treated violently: Your mother or stepmother was pushed, grabbed, slapped, had something thrown at her, kicked, bitten, hit with a fist, hit with something hard, repeatedly hit for over at least a few minutes, or ever threatened or hurt by a knife or gun by your father (or stepfather) or mother’s boyfriend.
  • Household substance abuse: A household member was a problem drinker or alcoholic or a household member used street drugs.
  • Mental illness in household: A household member was depressed or mentally ill or a household member attempted suicide.
  • Parental separation or divorce: Your parents were ever separated or divorced.
  • Criminal household member: A household member went to prison.

Neglect

  • Emotional neglect: Someone in your family helped you feel important or special, you felt loved, people in your family looked out for each other and felt close to each other, and your family was a source of strength and support.
  • Physical neglect: There was someone to take care of you, protect you, and take you to the doctor if you needed it, you didn’t have enough to eat, your parents were too drunk or too high to take care of you, and you had to wear dirty clothes.

What does this mean?

The ACEs questionnaire accumulates a score from zero to seven based on yes/no responses to the above questions. These results in conjunction with a “Health Appraisal Clinic’s questionnaire” allowed correlation with risk factors such as smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, any drug abuse, sexually transmitted diseases, parental drug abuse and a high lifetime number of sexual partners (>50), as well as the big swingers; mortality and overall morbidity.

The ACE score has been utilised to demonstrate a graded dose-response with more than 40 outcomes. You can see the entire list of publications here.

How good is this dataset?

Although there are almost all of the expected threats to validity from a questionnaire administered to people obtaining health insurance in the USA in the 1990s, the dataset is very good.

Of the 13,494 surveys, there was a 70.5% (9508) response rate, sent a week after standardised medical review. Respondents who did not respond to all questions were excluded from the final analysis. After non-responders and exclusions, a total dataset of 8056 responders was analysed. Alarmingly, more than half of the exclusions were for not answering the question about childhood sexual abuse. This certainly raises some concern for a risk of underreporting, particularly if this was the only question omitted! 

What meaning can be drawn from the results (so far)?

The dataset has lent itself to the associations between adverse childhood experiences and a veritable laundry list of medical, psychiatric pathology as well as social and public health problems.

This is data reports that 1 in 5 were sexually abused, nearly 1 in 4 lived with a “problem drinker or alcoholic” and that around 1 in 6 had a household member who was depressed or mentally ill.

It’s worth remembering that this study paints a picture of the adverse childhood experiences of the older generations in the USA – the mean age of respondents was 56.1 (19-92) years – in a study undertaken just over 20 years ago.

Rather than provide a snapshot of what childhood is like today, this data informs us about the childhood of parents of our patients. This gives us some understanding and frameworks by which to consider expectations of childhood from the parental & societal viewpoint – that most parents hope for a rosier childhood with fewer adverse experiences than their own.

With this in mind, and with a critical eye to some of the correlating outcomes, behaviours such as alcohol & drug abuse, smoking, over-eating, and sexual behaviours might alternatively be viewed as both coping strategies and symptoms of the anxiety, anger and depression that is likely co-morbid with high levels of adverse childhood experiences.

Primary prevention of adverse childhood experiences necessitates change at the societal level; with a focus on improving the quality of family and household environments through the childhood years.

Funding for the original study was combined between Kaiser Permanente (San Diego) and the US Center for Disease Control.

Where next?

The Centre for Disease in Childhood has taken over the study and, since 2009, transformed it into a national program across 32 states of the USA, called “Behavioral Risk Factor Surveillance System” (BRFSS). Data from the 2010 BRFSS has been published and includes more than 50,000 respondents. You can see more about the participating states, future timeline and previous data via the CDC website, here.

References:
Felitti, VJ, Anda RF, Nordenberg D et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults : The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998:14, 245–258. 

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention Adverse Childhood Experiences (ACEs)”.U.S. Department of Health & Human Services, Atlanta, USA. Accessed 27 September 2016. https://www.cdc.gov/violenceprevention/acestudy

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. “About Behavioral Risk Factor Surveillance System ACE Data”.U.S. Department of Health & Human Services, Atlanta, USA. Accessed 5 October 2016. https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html

Are you okay?

Cite this article as:
Andrew Tagg. Are you okay?, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9785

Today (8th September) in Australia is RUOK? day. It’s a time for people to come together and think about more than themselves and meaningfully connect with others. I wrote recently about the prevalence of bullying in medical society and some of it’s consequences. The 2013 Beyond Blue survey on depression in the medical workforce showed that one in five doctors suffer from depression and that a quarter  had thoughts of self-harm or suicidal ideation.

But today, I’d like you to remember that mental health concerns only remain hidden because of stigma.  By talking out loud we can help smash the stigma. It’s a topic I’m going to expand on at next year’s DFTB17 conference. If one in five Australian doctors suffer from depression and (if it’s not you then) there is a good chance that one of your friends or team members does.  Don’t be afraid to ask the question – and listen to the answer without judgement.

For more information on RUOK? day then take a look at their official website.

If you need help then contact:-

BeyondBlue

Trethewie on death in the acute setting

Cite this article as:
Davis, T. Trethewie on death in the acute setting, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/pac-trethewie/

We have teamed up with APLS to share the videos from their Paediatric Acute Care Conferences. These videos have never been open access before, so if you weren’t able to attend the conferences, then now’s your chance to catch up.

The PAC Conference is run each year by APLS and consists of presentations on a range of topics relevant to paediatric acute and critical care.