Annet Alenyo Ngabirano.

(That's Annet on the right in the photo with Kat Evans on the left and Mulinda Nyirenda in the middle.)

Emergency Medicine in the Uganda, the pearl of Africa.

Annet presented at dasSMACC and has become a huge personality in the the developing community of emergency medicine in the continent of Africa. While we associate Annet with Uganda she is really an Adventurer, on an adventure that goes beyond the borders of any country.

This is a wonderful insight into the curious journey of one special person. It stretches from Mbarara to Berlin, from South Africa to Sydney. There is much to learn and at every step there are surprises.

Annet found out so much about her own system through her normal training (normal for Mbarara) but also through personal tragedies. Her journey has turned her mind to things that she hadn’t thought of, she learned new practical skills and she even learned to ride a bike.

Dr Alenyo Ngabirano is interested in research but she is interested in research that asks the right questions. We all are but I cannot tell you what the right questions are for any sub-specialty and you cannot tell Annet what the right questions are for Ugandan Emergency Medicine.

Uganda is a country in which emergency medicine is only emerging. What exactly do we need to build? What exactly do we have? How do we even find that out?

There seems to be an increased effort by the FOAM / FOAMed community to spread the useful stuff around, spread the love, spread it beyond the big FOAMed three; USA, Australia and UK. That is not as simple as it sounds. We have to try to avoid all the mistakes that have been made in the past, this is not an opportunity to feel good about ourselves and the good thing we do. What we should do is listen to the people on the ground. Listen to the locals. Do the appropriate research. Support the people that are there and that will stay there. Figure out what we know and what we need to find out. Annet realises that even she needs to know more about the system in Uganda and she knows more about it than you ever could.

CODAchange wants to step into this space. It won’t be easy. There will be many opportunities to mess things up. To start with maybe we just need to talk to our colleagues in other places. It is about relationships. Take an interest. Find out more. Maybe even go and see for yourself but go there to learn stuff rather going there with some idea that you can tell people what to do.

Annet and I talk a about AFEM, the African Federation for Emergency Medicine ( aka Fedération Africaine de Médicine d’Urgence ) which is a fast growing pan-African organisation that works to ensure the development of collaborative, comprehensive, and cross-cutting emergency care systems in Africa. Check out their projects. Have look at their Handbook, available from Oxford University Press and everywhere. The second edition is out recently. The first edition had the same look as the legendary Oxford Handbook of Clinical Medicine. (I still have my first copy of that book, feeling a little bit nostalgic just considering that.)

https://afem.africa/what-we-do/

https://afem.africa/project/afem-handbook-of-acute-and-emergency-care/

Their next conference, the African Conference on Emergency Medicine (AfCEM) is in Mombasa, Kenya in November 2020. Why not go there? Why not show these guys respect and contribute to the growth of their conference and federation simply by attending as a delegate? Why not go one step further and Support a Delegate at the same time? The Support a Delegate appeal at dasSMACC was very successful. But it was not a one off. There are still conferences, there are still under-funded delegates. Please do not forget this practical and ultra-tangible way of lending a helping hand.

The little audio clips at the beginning and the end are topical. The actor and singer Seu Jorge is a Brazilian legend. Having shot to international recognition in the 2002 movie "City of God/Cidade de Deus" he has become a huge figure in Samba. This track is a cover of the Bowie classic "Oh! You pretty things" as performed for the Wes Anderson masterpiece "The Life Aquatic". Both movies are recommended as is the associated album "The Life Aquatic, The studio sessions featuring Seu Jorge".

At the last SMACC event in Sydney the Brazilians turned up in force. It was impressive. They came to learn but quickly it became apparent that we should be learning from them too. I won’t pretend to be a SoMe expert but I have never come across such sophisticated use of Instagram as a #FOAMed tool. Instagram is pretty huge and it may well be the number one SoMe platform for the generation that is entering medicine now. So if you are interested in things like teaching young nurses, doctors, paramedics then you might learn something really useful from an unusual source. Instagram is not a fringe #FOAMed platform when Nursing Educators have nearly 200000 followers on Instagram.

First let’s quickly talk about the weird thing that just happened to you if you listened to the podcast first. Yes the podcast is 80% Português. It starts with that annoying Irish guy and then the Português starts at 6:20 when Henrique Herpich takes over. The English starts again at 24:20, cue laughs and we are done. We immediately went out for drinks and there is a reason that the Irish and the Brazilians get on very well. (My brother in law is Brazilian. He is extremely cool. Olá Gustavo!)

But why? Why would I try to alienate the listeners to this podcast by hitting them with a podcast in another language? The Lusophone Commonwealth is why. Brazil, Angola, Mozambique, Portugal, Guinea-Bissau, East Timor, Equatorial Guinea, Macau, Cape Verde and São Tomé and Príncipe. 207 million Portuguese speakers in Brazil alone. Most Portuguese speakers are in countries where medicine is either developing very fast or in need of developing very fast! So they could do with some Português FOAMed. So we need FOAM other than English; #FOAMOTE

The hope is that everyone involved with #FOAM and #FOAMed will look to their language-other-than-English colleagues and see opportunities and not barriers. These people want to work together and the fact that YOU don’t speak their language does NOT mean that you cannot work together. (That and the fact that @Sandnsurf speaks Portugueś and wanted to hear more Portugueś podcasts.)


This PodcastThese are the #FOAMedBRA people that were in the room:

Ian, Henrique, Lucas, Jule, Niciole and Daniel.

@breakem www.breakem.org Go there and click on “Quem seguimos” (Who we Follow).

(Nearly Dr) Henrique Herpich Twitter @H_Herpich

Dr Lucas Oliveira J. e Silva @Lucasojesilva12 isaem.net

Dr Jule Santos emergenciarules.com Twitter; @julesantosER Instagram; Emergencia Rules and a podcast! https://podcasts.apple.com/au/podcast/emerg%C3%AAncia-rules/id1387183276

Dr Nicole Pinheiro @nicolepin

Dr Daniel Schubert Twitter @ducschub

So what I want all #FOAMedBRA people to do is spread this around all the nurses, doctors, paramedics in the Portugueś speaking world and get them to visit this post, listen to this podcast because this is a felicitation. This is people like me and people like you saying “HelloMyNameIsXXXX, nice to meet you, how can I help?” to the entire Lusophonic world. There is more that unites us than divides us.


FOAMbra Links are all on LITFL.com and TheTopEnd.org

Abnormal Treatment Behaviour.

The stress and trauma associated with what you do is real and it affects how you perform.

Jannie Geertsema is a child and adolescent psychiatrist working at the Hospital Formerly Known as Lady Cilento Children’s Hospital. He was at the last wonderful Don’t Forget The Bubbles Conference in Melbourne.

The “doctor patient relationship”. You may work in a ‘gnarly’ emergency room, or an over run ICU but the sort of damage we are talking about can be severe in almost any care-givers role. Jannie is a care giver that works with children/adolescents and their parents and regularly finds himself in the unfortunate space in between parent and child. Think about that sort of dynamic. It’s a dangerous space as Leonardo can tell you.

Jannie has become increasingly interested in this and started to dive into the stress and trauma associated with his role. Increasingly he has found that many of his colleagues (psychatrists and others) have similar problems.

There is one half of that relationship that we almost certainly have not given the appropriate attention. My half. The providers half, The therapists half. Your half. You!

Jannie throws himself on the psychiatrists couch and blows open a rarely considered trap; The Abnormal Therapeutic relationship. This exists for all clinicians in a “therapeutic” relationships with their patients/clients/consumers.

Call them “variably autonomous, mostly humanoid, largely organic carbon based therapy consuming units” if you want. (Usually referred to as VAMHLOCBTCU’s). I usually still call them patients but I am not a psychiatrist or a midwife or one of the various other disciplines that have their own good reasons not to call them patients.

We talk a lot about the “Doctor-Patient Relationship” in this podcast. But we are not just talking about doctors when we talk about “Abnormal Treatment Behaviour”. There are a few reasons that the “Doctor-Patient” phrase is used; the crucial paper that Jannie refers to is written by an Australian Psychiatrist qualified in the 1960’s; Prof Bruce S Singh. (I mistakenly refer to his paper as being written in the 1960's but it was actually published in 1981.) And both Jannie and I identify as doctors. Jannie expands on this further when you listen to the linked talk from DFTB and is asked a question about it at the end. (There is a link below.)

There is not a lot more written, at least not that Jannie has found. That we have only one paper written by a psychiatrist does not dismiss the other variations on this theme. In fact, each variation, be it Nurse-Patient, Psychologist-Patient, Social Worker-Patient…., would surely merit it’s own analysis. I am willing to bet that there is more written about this by experts from the other caring professions than by the physicians.

If there is one thing to take away from this it is that I do not exist as an inert perfect practitioner. I do not perform in a perfect space. I am flawed. I have feelings. I barely know what my own feelings are. But if I can just keep in mind that I do have thoughts and feelings, that they do affect my interactions with others, then I am at least cogniscent of the fact that roughly half of the people in the “Doctor-Patient Relationship” are Me. Or You. Or Us. I do not need to have read, or agree with, Freud to benefit from that sort of insight.

As Jannie puts it if you can keep in mind that you are anything less than perfect then you are getting somewhere.

If you can get to the next DFTB then you are getting somewhere special.

If you cannot then you can stream the entire conference for a small fee or for FREE if you are in a lower/middle income country. That is fantastic. Has anyone else done that?

LINKS

All the Links are available over on TheTopEnd.org

Vaccine hesitancy and vaccine refusal. New York is in crisis. Who is hesitant, who is refusing, what should you do? We asked Dr Margie Danchin. She knows.

New York Measles Crisis. This is not a paediatric issue. This affects us all. Margie Danchin has been thinking about vaccines and the related controversy for many years. She is a paediatrician that has researched and worked clinically in this area at the highest level. She shared her knowledge with the lucky punters that came to DontForgetTheBubbles in Melbourne last year. DFTB 2018. If you can go the next DFTB, in London in June, you really should.

THE BLURB

New York City is in a health emergency. Mayor Di Blasio has taken the radical step of making vaccination mandatory and has threatened fines of $1000 for non-compliance. How did we get to this? What are exemptions, who asks for them, who gets them, who gives them and who makes up the rules?

You might have an opinion about vaccination and anti-vaccination. You may have read a bit about it. You have not read as much or thought as much as this woman. Margie Danchin is a researcher and clinician practicing in this area. She was willing to speak to the room at DFTB2018. She was willing to come and talk to the podcast. Margie gives a fantastic insight into the Australian version of this problem and her insights are really valuable in times like this not just for Australian listeners, for us all. A crisis like this is potentially coming to your town, your city and your hospital soon. I strongly recommend you listen to this and check out the wonderful DFTB page which has a bunch of great links and her talk on stage and a great illustrated note (#doodlemed ) by @gracie_leo and more good stuff. You have to be impressed by what Drs Davis, Lawton, Goldstein and Tagg are doing over there. I am. @TessaRDavis @paedsem @henrygoldstein and @andrewjtagg

Go to the conference in London. If you cannot go you should follow the DFTB Podcast and those little Educational Nuggets will literally find their own way to you. Then go to the next conference in 2020. Have you got something better to do?

Margie is a compassionate doctor that reads the hardcore medical research and sits with the real world vaccine refusers and vaccine hesitant people. She spends hours of each week with real people that care for their children in her specialist clinic in Melbourne. Listen to her wonderfully balanced and open-minded words.

The MumBubVax resource is here.

http://www.ncirs.org.au/ncirs-seminarwebinar-series/20319-2019-influenza-program-and-mumbubvax-new-tool-support-midwife

LINKS are good.

@DanchinMargie

http://www.ncirs.org.au/our-work/sharing-knowledge-about-immunisation

https://www.skaiproject.org/about-the-projecthttps://itunes.apple.com/au/podcast/dont-forget-the-bubbles/id1281356948?mt=2

https://dontforgetthebubbles.com/margie_danchin/

The Jellybean Podcast is a funny little thing. We advocate and collaborate. In the coming months there will be a load of new interviews. A very mixed bag of different subjects and different voices from different events and different backgrounds. We kind of need people to subscribe to be able to keep going.

https://thetopend.org/subscribe-to-the-podcast/

Mwiche Chiluba

TITLE

Emergency Medicine in Zambia

At the moment there is only one public emergency department in Zambia that actually has a trained emergency physician. It only has one. That’s the boss. It’s Mwiche Chiluba. (@mwichiluba) A few years back she literally quit her old job, packed her bags and set off to South Africa to learn how they are practicing emergency medicine. Four years later she completed her training and packed her bags again.

This is not a one woman show but it is pretty close. Across the world, in every continent, there are women and men like Dr Chiluba that are in the vanguard at the front line of the expansion of critical care. This is not an African thing, this is not a lower middle income countries thing, this is everywhere. Emergency medicine is still relatively new. We are still developing EM. We have more in common than many appreciate. We can help each other and learn from each other.

Zambia, landlocked nation in southern part of the continent of Africa with a population of approx 17 million people. Health care parameters are improving very fast. Huge recent improvements in maternal mortality and childhood mortality are a great indication of how fast things are developing. Emergency is a new discipline.

One of the nicest things about how Mwiche sees it all is that, with not one single emergency physician to help her, if you ask Mwiche what she is doing to train more doctors, she is immediately careful to emphasise that you cannot deliver a good emergency medical system with emergency physicians alone. She has solid nursing and primary health support but she wants triage systems, paramedics, specialist support. Triage is a developing art in Zambia, in Mwiche’s hospital even with her

Every hospital EP

A great insight into one nations emergency medicine and the huge role that nursing professionals play in healthcare delivery. Nurses carry the weight. Lest we forget.

At the SMACC event in Sydney in 2019 the organising committee invited emergency medicine ambassadors from around the world. The Jellybean Podcast was lucky to be able to catch up with a number of these amazing people. Thank you to Mwiche for coming on the podcast and thank you to the SMACC people for having the foresight to see that we need to hear voices like Mwiches. We have a lot to learn.

Links are good;

Twitter

Dr Chiluba @mwichiluba

SMACCreach people @aalenyo @mgabin5 @Mulinda_EMalawi @ulovegeorge

Societies etc @RECA_RWANDA @EMAT_info

BADEM people @bad_EM @craigwylie @Kat__Evans

African Journal of Emergency Medicine @AfJEM

Developing EM @developingEM

FOAMed is just not for English speakers. We love a bit of FOAMote (FOAM other than English)

At SMACC I set out to meet the international visitors to find out about their version of Critical Care. And let me tell you, the Chilean version is pretty impressive.

Chile is special. The longest country in the world with the driest desert, the highest lakes, the highest volcano, a huge mountain range making it strangely isolated and then they have Patagonia.

The health system is highly developed. Emergency medicine has been growing for 25 years and there are conspicuous local and imported protagonists to thank.

https://developingem.com/2014/08/14/presenter-profile-billy-mallon/

If you only read one article to accompany this podcast let it be this one:

https://www.sciencedirect.com/science/article/pii/S0716864017300299

These days the home grown talent is taking up the reins and I was lucky to meet 4 of them at SMACC. Chile probably has the most high functioning health system in South and Central America. Based on a solid economy and a long history of professional advocacy the discipline of Emergency Medicine is now formally recognised by the Ministry of Health and by the rest of the world. Chile could become a power house of critical and emergency care in the Spanish speaking world. Do not underestimate these people.

Cesar, Loreto, Manuela and Josefina came to SMACC in Sydney where I was waiting to meet them. Have a listen to what this group have to say.

Challenges do, of course, remain. Chile has long since made the “epidemiological transition” to 1st world pathologies. The delivery of care still varies depending on location. Santiago is very well served but the regional and rural areas less so. They have robust public health and vaccination programs, but there is a resurgence of some infectious diseases in part related to population movement. Their economy is strong and their government has been increasingly willing to take on the responsibilities that go with being a regional power. Their borders are long and they have had a huge increase in asylums seekers, refugees and other immigration in recent years. Not insignificant numbers of French Creole speakers have come from Haiti, perhaps related to the presence of Chilean peace keepers. Mass immigration is new. The challenges it brings are huge.

It’s a steep learning curve. But, let’s face it, we like steep learning curves!

Some links, links are good;

The App Josefina Larraín spoke about is Reanimapp ( @reanimapp )

The city with the large indigenous population is Temuco. The indigenous language spoken in the hospital is Mapudungun.

“Do not underestimate the South American countries.” So said a wise woman from Santiago.

Chilean Spanish Language #FOAMed resources;

Mueve www.mue.cl Twitter @MUE_14

Sociedad de Chilena Medicina Urgencias www.socihmu.cl Twitter @Sochimu

MonKeyEM www.MonkeyEM.com Twitter @MonKey__EM

MCU Universidad de Chile www.mdu.cl Twitter @UChileEM

Conferences

Sochimu has its first Congreso Medicina de urgency 21-22 Nov. 2019

https://www.sochimu.cl/noticias/1%C2%BA-congreso-medicina-de-urgencia

The conceptos conference is in 11-14 September 2019

http://www.urgencia.uc.cl/conceptos/

These are not small events; Chris Nickson, Cliff Reid, Amal Mattu and Vic Brazil have spoken there. They know a bit about this sort of thing.

Chile is amazing. But don’t take my word for it.

Butchery and Ethics.

@mededgene is a flight paramedic from Vancouver with a soft spot for that soft spot on the front of your neck. You know the one. It has the cricothyroid membrane behind it.

Once upon a time there was a nice man called Gene. I didn’t call him Gene though. I called him a Butcher. The rest is history.

Gene Benoit @mededgene is a flight paramedic rom Vancouver. He does have a bit of the Val Kilmer about him and despite the nick-name of Iceman, he is not very icy.

Gene and colleagues have been trying to create an affordable, realistic, cruelty free surgical airway training device. I’m all up for most things that are “affordable, realistic and cruelty free” .

Gene tells the story of his interaction with the drama that surrounds the surgical airway. It really does seem to get people a little bit wound up. It got him wound up. So he set about unwinding that. And the next thing you know he is making 3D trainers that replicate human tissue without requiring the sale of your own human tissue (kidneys etc) to be able to buy one!

I claim no credit at all for inspiring this but I will suggest that one should never under-estimate the power of what you say.

Gene can teach me how to wield a scalpel and get past a troublesome voice-box but I shall have to teach myself how to control myown troublesome voice.

Have a listen and hear about fear & loathing on the airway education trail, how an ethicist might conceivably arrive by helicopter to save your life and where Peter Singer fits into critical care education.

Links:

Twitteriness; @mededgene

https://advancedparamedicine.ca/about/

http://3dcrictrainer.com/

The Jellybean with Prof Julian Savulescu is, in fact, number 49.

https://soundcloud.com/thetopend/jellybean-49-oxford-professor-of-practical-ethics-julian-savulescu

Welcome to SMACC.

This is Dr Pendo George.

This is the possibly the best thing about SMACC this year.

The SMACC organising committee have run an excellent program this year bringing leaders from countries around the world. These people are creating entirely new specialties in their home countries. These people are heros. Their task is HUGE.

Have a listen and learn about.

Check this out; http://emat.or.tz

And maybe go to TACEM this in October of this year.

www.tacem.or.tz

Have you been to Tanzania?

Think about it.

CICMxJellybean 8 (Jellybean 100)

Recorded at CICM ASM 2018 Hobart

Peta Alexander is a Queenslander. A Queenslander mixing it up with the best in the world at the Boston Children’s Hospital. She is a cardiologist and paediatric intensivist working with some of the worlds best surgeons and caring for some of the sickest kids on the planet.

We caught up with Peta towards the end of the ASM in Hobart and despite her efforts she was still up for a chat. We get stuck into the odd subjects of changing cultures and cultural change.

Peta trained in Australia before heading off to the states and has a very interesting perspective on the ways of the critical care world.

You can find Peta’s talks from the ASM on IntensiveCareNetwork.com;

https://intensivecarenetwork.com/congenital-heart-disease-repair-or-palliate/

https://intensivecarenetwork.com/principles-of-management-of-acute-heart-failure/

https://intensivecarenetwork.com/debate-who-should-care-for-guch/

And she was generous enough to talk before the conference at the Trainee Symposium. Legend!

https://intensivecarenetwork.com/paediatric-icu-for-the-adult-intensivist-by-dr-peta-alexander/