DFTB in Dublin – A reflection

Cite this article as:
Tagg, A. DFTB in Dublin – A reflection, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-a-reflection/

I have a confession to make. I hate people.  I hate lots of people. Not in the obscenity-spitting, swilling distilled hatred from a brown bag sort of way but in a way that is just as disruptive to my life. You see, I am an introvert. There, I have stood up from my chair at Introverts Anonymous and made my pledge.

At work, the scrubs I wear are my uniform, my cape and cowl. My embroidered name becomes the symbol on my chest. When I change from my (now) not so secret identity as mild-mannered Clark Kent wannabe I become immune to the fear of it all, of exposing myself. I know my stuff. I am a good doctor. When I walk into the resus bay to see a still fitting child and a look of indecision on the face of the team I take control of the situation. But it is not with loud words or an overbearing attitude, but with a sense of calm. You see, you can be an introvert and have a commanding presence too. Those of you who have read Susan Cain’s book, Quiet, will have discovered that we are taking over the world. My heart is not racing along at 140 beats per minute thrusting me into Condition Black, it is pumping at 80 affording me fine motor control. When I talk to the parents about what is happening I don’t spout thoughtless platitudes and interrupt their questions. I remain calm and quiet and I listen. That is what an introvert does. We listen.

But what do you do when you fly 17,208 kilometres to attend one of the world’s foremost medical experiences whose very name implies talking to people – not at work, not in my protective uniform – the Social Media And Critical Care conference?

I had been there at the start, in Sydney, but had my family with me. They were an easy excuse to duck out of functions and head to Darling Harbour and have a rainbow gelato. At that time I was barely on Twitter and Don’t Forget The Bubbles was merely a glimmer in Tessa Davis’ eye. I knew a couple of people from work and so enjoyed the talks for what they were and left, feeling energised and enthusiastic about my job.

But now I am in Dublin, a long way from home.  I could have done the same but I saw it as a wasted opportunity. Over the three years since Sydney, Don’t Forget The Bubbles has been growing in content and readership and has become a large part of my non-work life. I have had more late night conversations on Twitter and Slack with my colleagues Tessa, Ben and Henry than nearly anyone I know. I have taken part in virtual journal clubs and discussions with doctors and nurses and paramedics and pharmacists from all around the word.  But all that was behind the pseudo-anonymity of a 400 by 400 pixel image. You cannot do that at a conference – especially if the wifi doesn’t work as planned.

Then I had a revelation, that lightbulb moment. The people at the conference were not strangers at all, they were friends – good friends. When I saw Jesse Spurr in Dubai airport I went up to him and put my hand out and said ‘Hello’. We had never spoken in real life but because of social media we knew each other and any awkwardness was lost. He greeted me with a huge smile (despite having been on a plane for 14 hours) and we chatted before boarding for Dublin. When I met Casey Parker, the man that started me blogging, I didn’t even need to pluck up the courage to put out my hand as he beat me too it, with a warm grin and we talked of our families and holidays and our hopes for the conference. When I met Henry, who (despite having written and edited with for almost four years) I had never met, we exchanged a manly hug and it was like greeting an old, old friend.

Sure, going up to people you have never met can be a terrifying experience. You worry that you may say the wrong thing or stop them doing something important (sorry, Cliff) but it doesn’t matter. Nobody is out to make you feel small or stupid. There was an overwhelming spirit of kindness and compassion at the conference that was reflected by a number of the speakers but I think Ash Liebig put it best when she spoke about the golden rule. If you treat others how you would like to be treated then that little bit of courage will be rewarded ten-fold. And once you start, the positive feedback loop becomes a wonderful form of Skinnerian reinforcement.

So, as I became more confident putting myself out there I spoke to some of my idols – to Simon Carley (who is just as nice in real life), to Haney Mallemet (who is as charming as he is intelligent) and to Ross Fisher (who is as antithetical to the surgical stereotype as you could imagine). And you know what? None of them brushed me aside, asked me why I was talking to them, told me to go away.

To all of you introverts out there, I urge you just to start. Take the risk and take one step forward, put out your hand and say hello. Connect, share stories, ask questions. That is the ethos of the FOAMed community and that is why we all came to SMACC. And now the banners have been taken down and nothing but the creamy dregs of Guinness remain in the glass we head home to take stock and reflect. How can you bring this feeling of compassion and kindness back to your workplace? Is it taking time to let the nervous medical student stutter out the wrong answer to a question and not berating them? Is it not questioning why the paramedic has brought in the 85 year old granny with a sore knee? Is it spotting a resident having a hard time and making them a cup of tea or buying them a soda?

It’s time, now, for me to pack up my laptop and make my way through multiple timezones and security checks, back home to my family. I’ve had a wonderful time – in part due to Oli, Chris and Roger – but mainly because of the friends I have made. Conversations on Twitter will now be with real people, not just static avatars. Plans are already being made to catch up again in Berlin for Das SMACC (if I can get a ticket) but if not I know where I can find them all. I don’t have to hand in my membership card for Introverts Anonymous just yet though as I have learned to face some of my fears and reach out.

For me, this conference was about connection and it delivered it in spades.

 

DFTB in Dublin – the Final Day

Cite this article as:
Tagg, A. DFTB in Dublin – the Final Day, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-the-final-day/

By means of performance enhancing substances (caffeine) we made it to the final sessions of #SMACCdub – voices somewhat subdued by trying to converse at the gala dinner, held in the historical Guinness Storehouse. The pains of struggling bandwidth were ameliorated  by a drop in attendance.

An all female panel took to the stage for the first plenary of the morning on moving ‘Beyond the Ivory Towers’.

Emergency interventions in African children:What next?

The internationally renowned author of the FEAST trial, Kathryn Maitland, began the morning reminding us of the enormous burden of disease in sub-Saharan Africa. With up to 70% of pneumonia related deaths occurring in SE Asia and Sub-Saharan Africa there is a clear need for simple, pragmatic guidelines to improve mortality.  Resources that we take for granted such as monitoring and oxygen therapy are in low supply. With clinical signs a poor indicator for the need for ongoing oxygen supplementation a number of inappropriate children receive supplemental oxygen.  Initiatives like Lifebox may help.

Whilst there is a state of equipoise in the use of oxygen therapy in such a population it is an area ripe for study. But oxygen is expensive and can take up to a half of Professor Maitland’s drug budget and so nurses have to become resourceful. It must also be pointed out that oxygen alone cannot fix ventilatory failure.

Critical care in difficult contexts

Nikki Blackwell of Brisbane and ALIMA then came on stage to tell us what it is really like working in a resource poor setting. Working in environments ravaged by war, disease and hunger emergencies (there is food but not in the right places) she has seen a rise in ‘humanitarian action as a response to political failure’.

“The key is bringing up healthy, well adjusted people that care about justice and social equity”                                                                                                          Nikki Blackwell

With fewer resources available there are less problems with iatrogenically introduced disease and children can have remarkable recoveries once attention is paid to the basics such as hygiene and nutrition. By making their own hand gel sanitizer they were able to drop infection rates and also increase buy in – a problem that we all face. She also described how African mothers were able to assess their own children for malnutrition and that by using locally made products such as PlumpyNut – a combination of peanut butter and milk powder – huge gains could be seen for a few cents.

Ethiopia: Treating Malnourished Children With Therapeutic Plumpy Nut USAID?s Office of U.S. Foreign Disaster Assistance has provided $5.8 million to the U.N. Children?s Fund for 640 metric tons of ready-to-use therapeutic Plumpy Nut, which will treat an estimated 64,000 severely acutely malnourished children. If a child has no appetite for the thick peanut paste, she/he is moved to a stabilization center for more intense treatment. File information Filename: Ethiopia_3_plumpy_nut2.JPG Album name: padams / Humanitarian Assistance Keywords: Ethiopia Famine Hunger Feeding Centers Young Children Therapeutic Feeding Photographer: Kimberly Flowers Photographer's Organization: USAID/Ethiopia Location of Photograph (City, Country): Ethiopia Date Photograph Taken (MM/DD/YYYY): 2008

We need palliative care everywhere

Ashley Shreves, an emergency physician with a passion for palliative care told us her origin story and spoke about how the ever revolving cast of players can derail one person’s perfectly constructed end of life plan. Having reinforced the concept of having a good death it is worthwhile reflecting on Greg Kelly’s superb talk from SMACC Gold.

The Golden Fleece, The Golden Hour and The Golden Rule

Following on from last years talk on looking after ourselves Ashley Liebig bravely described how he completely went against her own advice after dealing with a heartbreaking paediatric trauma.  We are all consummate professionals but sometimes a misjudged word can throw our our world into a tailspin.  We need to be kind to our colleagues, and ourselves.  Often those that work in Ivory Towers have no concept what like is like ‘out there’ – be it in a small country hospital or at the roadside.  So the next time you think to yourself, “Why didn’t they do….?” just stop. They may not have the resources or the skills available to do the things you almost take for granted. Put yourself in their shoes for once and…

“Treat others how you would like to be treated yourself”

After catching up with friends both old and new Henry and I took the stairs to the paediatric session, chaired by Nat May.

Should we transfuse the sick child in Africa?

After her earlier talk on oxygen therapy, Kath Maitland, moved from breathing to circulation and the role of blood transfusion in Africa. As well as pneumonia profound anaemia (Hb <6g/dl) is another high cause of mortality in sub-Saharan Africa with up to 10% of children dying in hospital as a result and a further 12% dying in the six months after admission. This anaemia is multifactorial with sickle cell disease, infection and nutritional deficiencies all playing their part.

The ongoing TRACT trial looks to see what volume, if any, of blood makes a difference. With current WHO guidelines suggesting transfusion at haemoglobins less than 4g/dl (or 6g/dl in the presence of comorbidities) there is little relevance to patients in the developed world but this is still very important work indeed. We expect to hear some answers in the next few years.

Spotting the sick child

As we discussed at the pre-conference paediatric workshops it can be near impossible to spot the sick child. We are all scared by what we may miss and Simon Judkins recounts one such event in Real ED stories.  Sure we could rely on tests and biomarkers but in end speaker Ffion Davies urges to go back to basics and think of the physiology of the child.  It is easy to try and rationalize abnormal results but tachypnoea is the most sensitive sign of badness.   Doctors often just look at the admission observations but we remember “Observation is an intervention”and get them checked more than once and be very wary of sending home a child with abnormal vital signs.

Whilst biological parameters such as pulse, blood pressure or oxygen saturations are almost fixed with little room for interpretation what is more problematic is how we think when dealing with children. The majority of the kids we see in the emergency department are well so our immediate cognitive disposition to respond assumes that every child we see is well rather than considering the worst possible outcomes.  Remember that children are just little adults (though babies are another species entirely) and are incredibly resilient.  If a child appears well they probably are and if they appear sick they certainly are but it is those children in the grey zone that Ffion focussed on.

Iconoclasm: Breaking the myths without breaking your patient

The only man on in the session (minus Casey Parker moderating), Tim Horezcko, took the stage to bust some paediatric myths – or pediatric myths as he spells them. He really elucidated what all of us really felt inside:-

The myths of paediatric medicine

His talk will be up online shortly.

Small Packages, Big Lessons: Neonatal and paediatric retrieval

The final talk of the morning was by EMBRACE consultant, Hazel Talbot (Ed. note COI to declare Hazel was two years below me at the best medical school ever – CXWMS). She told us that babies are not small children but an entirely different species that tries to survive no matter what we do.  She explained the concept of the evil fairy that sneaks into the back of every helicopter or ambulance when we go on a retrieval mission with the sole intention of creating chaos where once there was calm.  She is not so powerful when the team have rehearsed together practicing accidental intubation drills in the back of an ambulance but she is always ready to sprinkle some fairy dust on the child and muck things up. But remember sometimes it is not the equipment that is wrong but the child.

Both Henry and I met some wonderful people over out four days in Dublin. We finally met people we have been chatting with online for years and would happily call out friends. We met people we have never met before but who inspired us both. And we finally said hello in person.

So if you missed out on SMACC this year and think it is the sort of conference you would like to go to but are concerned that there is not enough paediatrics then check out www.dontforgettheconference.com. The Don’t Forget The Bubbles team have listened to you all and are hosting a conference in Brisbane at the end of August 2017. Book your leave now!

DFTB in Dublin – the Second Day

Cite this article as:
Tagg, A. DFTB in Dublin – the Second Day, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-the-second-day/

Small children prevented Henry and I spending too much time out on the town enjoying what Dublin has to offer. One advantage of this was that we were both able to enjoy the mornings sessions without the hangovers that so many of our friends and colleagues had.

The theme for the morning plenary session was “Slaying Sacred Cows”. Four excellent speakers took the time to challenge long held beliefs and make us question some of our ingrained ideas.

Leadership: not (just) for men

Resa Lewiss began by talking about leadership. To some of us the word ‘leader’ conjures up images of old white men with power ties and masculine poses.  Res reminded us that over half the medical population are women and it is time for us to realise this. Just as we have seen #Ilooklikeasurgeon trend worldwide she wanted to trend #IIlooklikealeader. With many strong leaders in the world of paediatrics this is something that we at Don’t Forget The Bubbles support wholeheartedly.  SMACC has tried hard this year to ensure gender equity with the speaker panel and this is one of our core aims for #DFTB17.

Resa had the following tips for those that want to inspire and lead:-

Praise in public, criticise in private

Make decisions – don’t be indecisive

Concentrate on your strengths and let others cover your weaknesses

Make people feel good about themselves

If you don’t ask you don’t get

As someone who is an extreme introvert it was this final point that really made me reflect. Nat May has already written a superb post on impostor syndrome but it is worth remembering that there is power in breaking free of the self-imposed shackles of quietitude and putting yourself out there and just asking for help. 


Things that scare me

Paediatric surgeon and presentation skills guru Ross Fisher showed why he is so well respected as a speaker. Eschewing supportive media he took to the stage to speak about fear.  Over the course of twenty minutes he spoke about some of the times in his life in which he had been truly scared.  Not the sort of fear you get riding on an out of control roller-coaster but the sort of deep, visceral fear that makes your mouth dry up, your head pound and your legs shake. By the end of his talk there was barely a dry eye in the house (or on the stage).  This is a must watch talk when it comes out and is the one that really made me just stop and think.

Emergency management of the agitated patient

Reuben Strayer concentrated on something that we don’t see very often in the emergency department. We do occasionally have to deal with agitated teens and it’s worthwhile looking at this alternative take.

What's love got to do with it?

The morning was topped off by the fabulous Liz Crowe.  She reminded us that we obviously all love our jobs – most of us seem to spend over a third of our lives there – but like any relationship we can have good times and not-so good times.  Just as any marriage takes effort to make it work the same is true for our relationship with our job.  We need the support of our work husbands and wives when times are tough and to remind of us of those times when we basked in the afterglow of our first successful resuscitation.

And whilst we love our jobs Liz reminded us that we must also love our patients. We must treat them all with kindness and compassion. They did not, would never, choose to be in hospital.  We must always, always remember that.  A kind word, a cup of tea, a warm blanket go a long way.

Later that same day...

After coffee we broke for concurrent sessions. I went to the session entitled “Time to gas, time to cut”. Karim Brohi spoke about Zen and the Art of Trauma, again reinforcing the need for the leader to be the centre of calm.  That calmness is infectious. We’ve heard about tools we can use in the moment to help use regain calm but Karim reminded us that calmness is a learned behaviour. It is paying attention to the minor details, reducing errors and variance in the system. It is understanding when less is more, that some patients do not need every conceivable test but only the necessary tests to get them to theatre. And it is mentally rehearsing for every possible outcome.

And whilst some of the talks may seem heavy, the morning session was completed by the (not safe for work) Suman Biswas.  I’ll leave this here…

But the question on everyones mind was where would SMACC be in 2017?

DAS SMACC

So start asking for annual leave now if you want to travel to Berlin.

DFTB in Dublin – the First Day

Cite this article as:
Goldstein, H. DFTB in Dublin – the First Day, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-the-first-day/

Andy and I had flown halfway across the world to meet up in person at the Social Media And Critical Care conference in Dublin. Although touted initially as a critical care conference it is much more than that. Health care workers (not just doctors) from such interwoven disciplines as anaesthesia, intensive care, emergency medicine and paediatrics came together to learn, connect and be inspired.

Smaccdub opening ceremony

Here’s our take on Day 1.

Opening session

The opening ceremony began with the pizazz and style to which SMACC delegates have been accustomed, including a Coldplay-style light show with lasers and flashing wrist bands. This was followed by the John Hinds Plenary session featuring;

Victoria Brazil‘s talk ‘So, you think you’re a resuscitationist…’ dissected the art and science of improving. In particular, she espoused the importance of giving and eliciting feedback, doing so often, and doing it with compassion and honesty. She wanted us to be the mirror and elicit perceptions.

Scott Weingart podcasted live from the SMACC auditorium about the ‘Kettlebells for the Brain’ that are meditation. He introduced the SMACC auditorium to the concepts of mindful meditation and negative visualisation in a powerful presentation and moving talk.

Exercise is work to make you live longer; meditation is work to make you live better.

Gareth Davies of London HEMS proposed the ‘Case for Helicopter Emergency Medical Services’, reinforcing the importance of clinical excellence accompanying the inherent ‘sexiness’ that helicopters bring to pre-hospital care. He encouraged us all to practice medicine ‘full bore’ – not going off half cocked but providing maximum quality care to all.

The session was brought to a close with a fitting and beautiful tribute to Dr John Hinds, SMACC-alumnus, pre-hospitalist, anaesthetist and motorcycle doctor extraordinaire who tragically died last year.

Morning concurrent

My choice of concurrent for the morning was ‘Emergency!’, opened by the astute Simon Carley  presenting the future of Emergency medicine with a focus on the people, the politics and the possibilities of rapid technological progress. He made some big calls about the future of bioinformatics and personal health.

Subsequently, the ever elegant Michelle Johnston juxtaposed Carley’s utopia with an equally possible dystopian future, potentially attributable to the small decisions we make each day. Journeying through Philip K. Dick’s world of replicants and Voight-Kampff tests, Winston Smiths image of the future as a ‘boot stamping on the human face, forever’ and Terry Gilliam’s bureaucratic fever dream, Brazil we saw what life could be like. Multiple small, seemingly insignificant decisions, when combined could lead us down an irreversible path of excessive tests, unstable economics, physical and bureaucratic waste. Choose wisely.

Suzanne Mason gave a talk about frailty and geriatrics, and for me the take home message as it pertains to paediatrics is that we need to learn to love and understand our most frail patients, particularly kids with transplants, GMFCS4+ cerebral palsy or refractory seizure disorders with or without profound disability. They don’t present for nothing; they already spend too much time in hospital. Frail patients generally cope less well with admission and so it pays to think hard before admitting these kids “just in case”.

In the always challenging ‘last presentation before lunch’ spot Anand Swaminatham  discussed the notion of thin slicing in the ED – specifically knowing and understanding the spectrum and severity of disease. That is, that we should call a disease for what it is, every time. This includes a modifier including severity. By this construct we are encouraged not to minimise severity and hence escalate the management to match.

One of the other themes echoing throughout the conference has been  Daniel Kahneman’s seminal work “Thinking, Fast and Slow”; which introduces the idea of System 1 (rough, ready, intuitive, heuristic) and System 2 (contemplative, analytical, reflective, questioning) thinking.

Afternoon Concurrent and Panel Discussion

The afternoon focussed on research and publication.

Firstly, I attended the concurrent including Richard Smith the ex-editor of the BMJ, and Jeff Drazen current editor of the @NEJM included a spirited discussion on the role of the big journals in medicine. This session also included an eloquent explanation of the merits of the (in)famous p-value as well as introducing the concept of the fragility index – a full explanation is beyond the remit of this post, but if you read one bio stats piece of analysis this year, I’d make it on this.

After the tea break, the last session of the day continued the editors’ spirited discussion to a ten person panel, answering such questions as;

  • What conventional publishing, as opposed to social media, offers to medicine and research?
  • What works for trainees (there was one on the panel.)
  • A discussion about the pressure of publication and impact factors.
  • The panellists were asked about the role of major journals and equality of representation within author and editor groups.
  • Finally, there was a continuation of the previous session’s robust and forthright discussion on the merits of conventional literature and the role of peer review.

The main message of the session, as emphasised by Drs Carley & Myburgh, is that research is about improving patient outcomes, not careers, not impact factors, not about egos. With each item of information, we must continue to seek better care for our patients.

DFTB logo tattoo

In the meantime, Andy had bumped into Doug Lynch of @TheTopEnd and JellyBean podcast fame; keep an ear out for it in the next few days.

The day wrapped with a bumptious Welcome Dinner in the exhibition hall. So until tomorrow…

CCD by night

 

Jet lag and children

Cite this article as:
Andrew Tagg. Jet lag and children, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8446

We recently covered some of the issues around sedation for transport, both within and outside the hospital. Whilst all of us are afraid of being stuck in front of an irate and agitated toddler for the duration of a long-haul flight, the trouble is not over for the parents when they land on the ground. Many of us have known the pain of having their children wide awake at 3am when all you want to do is sleep.  So is there anything we can do about jet lag in children?

Take a #SMACCselfie

Cite this article as:
Andrew Tagg. Take a #SMACCselfie, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8777

Team DFTB are heading to Dublin for SMACC.  Please feel free to say hello to Andy or Henry.

If you want to win an exclusive* Don’t Forget The Bubbles t-shirt then take a #SMACCselfie displaying your DFTB badges, stickers or tattoos (yes, we have those too!) and tag #DFTB.  Each day one lucky winner, drawn at random, will win a t-shirt.

*Actually the team all have one too, so not truly exclusive.