You will (eventually) not be terrified every time your pager goes off
I can vividly remember the first time my pager went off on day 1 of internship. I was sitting in our haematology multidisciplinary meeting and the intrusive beeping just about made me jump out of my skin. I called back, timidly introducing myself as “Kate, the new intern… someone paged me?” When the nurse on the other end of the phone asked me to review a patient who had chest pain, my immediate thought was ‘oh I better let one of the doctors know…’ - it took another minute to realise I was one of the doctors. I walked down the corridor towards the ward, internally panicking that I was about to walk into the room to see a patient half-dying in front of me. Thankfully I soon found out that not only was the patient alive and well, but they also had a history of reflux and had currently had similar symptoms, which were beginning to ease after taking their usual medications. Crisis averted. After an uncoordinated and stressful examination on my part (terrified I would miss something crucial despite a perfectly well-looking patient in front of me), I returned to the meeting and my heart rate gradually returned to normal.
Whilst in reality 90% of times I was paged over the year were for non-urgent problems or paperwork issues, it took at least 6 months to stop my heart from racing when my pager beeped, and to stop having dreams about work that mainly revolved around being paged repeatedly or my pager going off but not being able to find it. Had I realised at the start of the year that in a real emergency situation I’d never be alone for long, and that most pages would be a nurse asking me to rechart a medication or pharmacy needing me to sign something, I’d have saved myself so much stress and pager-related anxiety.
You know more than you realise
The initial weeks and months of internship provide many opportunities for the new intern to feel useless, be talked down to by rude colleagues, fumble through poorly-planned consults and not have answers to any questions patients or nurses ask you. For every thing you realise you don’t know, there are another three things that you do know and you don’t even realise.
The first few rapid response calls (MET / PACE / whichever system your hospital uses) that you are called to, you’ll feel stupid, helpless and need to ask multiple questions of your seniors to convince yourself that your fluid bolus or your stat analgesia order won’t kill the patient. Fast forward a few months, and you’ll start initiating management of deteriorating patients before senior help arrives, and running your initial plan past them rather than waiting for them to turn up and decide on the plan themselves.
Every single patient you see is adding to your subconscious ongoing learning and it isn’t until you sit back and remember how much of a bumbling idiot you felt like in the first weeks of doctor-hood that you can really see how much you are learning without even trying. Four to six years of medical school is only the tip of the iceberg in terms of a career’s worth of ongoing learning, but don’t discount how much you have learnt already. As long as you know your scope and when to ask for help, you will be a safe and competent intern.
…but it’s a steep learning curve
Having said all of the above, be warned that despite having senior help often close at hand, you will have to put in effort and reflect on your own practice to truly progress in your knowledge and clinical skills. It would be easy to coast through the year without so much as peeking at Up To Date, but to capitalise on the rich clinical exposure and breadth of patients you will look after, a little reading around some of what you are seeing on ward rounds or in clinic will do wonders to consolidate your knowledge.
After being thrown in the deep end with a highly sub-specialised first rotation, it took me a while to feel like I had the time and energy to do anything work-related outside of the hospital. But when I did take the time to jot down patient cases that were interesting or unusual, or just common things I didn’t feel confident in managing, and then spent 5 minutes having a quick read on eTG/Up to Date etc, it made it so much easier to learn having that patient in my head. If you treat every patient as a learning opportunity and do a little bit of study here and there, it will really help to solidify your skills for the next time a similar case comes along.
The year will be overwhelming at times, as well as frustrating and exhausting, and you’ll feel physically and mentally drained if you don’t step back and take care of yourself. Recognise when you are getting exhausted and speak to someone (GP, friends, supervisor etc) if you need help. It’s a massive change from being a medical student - remember that no one is expecting you to be an expert.
There’s no way to sugar-coat it - after-hours shifts can be awful
My first after-hours ward call shift was terrifying - a 14.5 hour shift on a public holiday and absolutely non-stop the entire day. I finally paused to eat something at 5pm (after getting to work at 7:30 in the morning) and was running between wards until I finally handed over to night shift. The day was a constant stream of rapid response calls, patients needing new cannulas, clinical reviews for fever/rash/headache/hypertension and endless medication charts to be redone. I needed the rest of the weekend just to recover from the onslaught.
There are no two ways about it, these shifts are long and tiring. Ward call / after-hours shifts involve skeleton staffing and lots of patients per doctor. You just have to get stuck in, prioritise what needs to be seen early and keep a list of things that can be done later. Get into the habit of finding out as much info about each patient you are asked to review when you are called, and get the management started over the phone before you get to the bedside:
- what are the patient’s obs, and what is the trend?
- what is their relevant history?
- when were their medications given?
- do they need an ECG?
- do they have a cannula?
- can I give a phone order for a medication or arrange anything else in the interim?
Think about what you need to know that will help you manage the patient when you get to see them, especially if there are other more urgent reviews and this patient might be waiting a while to be seen by you.
On the plus side, you will learn lots, get more confident at managing common problems (chest pain, shortness of breath, fever etc), and overtime penalty rates are always well-deserved and welcomed come pay day.
Being an intern is actually an enjoyable and privileged job
There’s been a lot in the media this year about doctor wellbeing, bullying amongst the medical profession and work-related distress. These are real and troubling problems. Luckily on the whole, I have found internship to be highly enjoyable and rewarding, and has cemented that I have made the right career decision in pursing medicine. We are in the privileged position of looking after patients who are vulnerable and suffering through the worst times in their lives. Though being amongst it everyday normalises the whole situation, we have the potential to make such a huge difference in the lives of others. Finally being able to do procedures independently, make clinical decisions and formulate management plans for common problems, be part of discussions about patient care and contribute to the medical team are all incredibly satisfying.
Over the course of my intern year, I have seen patients die despite intensive medical care, those who were on the brink of death recover and walk out of hospital and others walk in with a simple problem end up with a life-changing diagnosis. I have seen the routine illnesses and injuries benefit from our world-class public health system and bounce back to their normal lives. It is easy to get caught up in the mountains of paperwork, discharge summaries and medication charts that interns are lumped with, but when you finally get to work in the field you’ve spent years studying towards, it doesn’t matter. I have worked alongside some fantastic doctors who I now count as fantastic friends.
The year has flown by and I’m only a few weeks away from launching into residency and training as a GP registrar. There have been some extremely challenging days and weeks this year, but finally being able to step up to the plate and begin my medical career has made it all worthwhile.
One of the first things I was ever taught as a student nurse was that people will forget what you said, they will forget what you did, but they will never forget how you made them feel. It is a sentiment that I have carried with me in the decade spent caring for patients since then.
It was a busy Wednesday evening when I looked after an elderly man (let’s call him Jim) who had been brought to the emergency department by his wife (we’ll call her Anne). Jim had mild dementia and his wife had noticed that he was losing weight, had lost his appetite and was becoming more lethargic. “He’s normally so healthy” Anne told me, “he hates coming to hospital, but I was worried he might have pneumonia”. After taking a thorough history, examining Jim, checking some blood tests, getting a chest x-ray and reviewing notes from his GP, the cause of his symptoms became clear. Anne had brought with her some paperwork from a recent colonoscopy, along with a series of scans and blood tests done by the GP. Jim had bowel cancer which had spread throughout his body, however he and his family didn’t seem to know.
How do I, as someone who only met Jim an hour ago, deliver the heart-breaking news that he has cancer which has spread throughout his body and is slowly killing him? How do I break it to this man’s wife of 70 years that her husband will only continue to deteriorate further into a shell of the man she married? How do I tell Jim’s two children, who have now also arrived, that their Dad is dying?
No matter how many lectures or role plays you sit through on breaking bad news, giving patients a heartbreaking test result or diagnosis just isn’t a skill that can be taught, it has to be shaped and crafted through first-hand experience.
I pulled the blue curtains around Jim’s bed and sat down with his family, who all smiled at me eagerly as though I would be able to give them the answer they had brought Jim here for, and crack on with fixing him.
“Did your doctor ever give you the results of your recent colonoscopy?”
I began tentatively, however I couldn’t delay the news much longer.
“The growth that they removed at the time was cancer, and the other tests that your GP sent you for afterwards showed that the cancer has spread to your lungs and liver.”
“I’m so sorry Jim, but I think you are feeling unwell because the cancer is continuing to spread.”
Usually a diagnosis of this magnitude is delivered by a specialist at the time of its discovery, and I wondered whether there had been a decision made, either by a family member or Jim himself, to not find out the test results. But when he came to ED with clear symptoms of his cancer, it was in the patient’s best interest to know that there was a cause for the way he was feeling. Due to his age and other health issues he did not want to pursue any active treatment. I spent quite a long time talking to Jim and his family, explaining what palliative care was, and the services that community palliative care nurses could provide to enable him to stay at home and comfortable.
For those moments, the blue curtains that separated the patient’s bed from the rest of the department felt like they had separated us into our own timezone, where I didn’t notice the beeping of IV pumps or cardiac monitors, the PA system announcing the arrival of another patient with chest pain or the constant hum of activity in the background.
I finished getting Jim organised to be discharged home, with plans for him to be seen by the community palliative nurses. I encouraged his family to keep taking Jim out to his favourite coffee shop, let him eat as many Iced Vovo's as he liked and spend as much time together as they were able. The most important thing was not the number of days or months Jim had left, but the time he was able to spend with his wife and family and doing the things he loved.
As a doctor, it can be very hard to take a step back from the history-examination-investigation-diagnosis-treatment mentality to refocus on simply allowing a person to have a dignified end of life with management of symptoms and allowing death to happen without furiously holding it at bay. Having previously worked in an area of nursing where I was heavily involved in end-of-life care for patients, I felt slightly more at ease sending Jim home without a definitive treatment for his condition and instead allowing him to be kept comfortable.
Jim was ready to head home after a visit to hospital which I’m sure will be replayed in the minds of his wife and children for a long time to come. I walked over to him with his discharge paperwork and wished him and his family all the best. Anne took my hand in both of hers, with tears in her eyes and thanked me so genuinely for being patient, understanding and helpful; as if I’d been able to fix her husband after all. Jim and his children were also so kind and thankful, echoing Anne’s thanks and reminding me that it’s not what anyone says or does that we remember, it’s how they make us feel.
I won’t remember the exact words used by Jim or his family, but I will always recall that they made me feel like I had done my job well and been the type of doctor I will always aspire to be - kind, caring and my patient’s number one advocate.
I had an hour left of my ten hour shift when a patient had a sudden and unexpected cardiac arrest in the emergency department. I took over CPR on the third cycle (doctors and nurses rotate giving CPR every 2 minutes to minimise fatigue and maintain strong compressions). By the time my hands were on the man’s chest, there was already a tube down his throat allowing another doctor to provide artificial breaths, multiple lines into his veins delivering adrenaline to try and encourage his heart to restart, and he had been shocked with a defibrillator twice. It was a very odd sensation to finally be delivering cardiac compressions to a real human after so many simulations on dummies. In other resuscitations I’ve been involved in, it was my job to get another drip in, or to get the latest blood test results or send more blood off. My own pulse was skyrocketing as I climbed on top of the hospital bed and started pressing down on the unconscious man’s chest. Several of the man’s ribs were already broken, and his sternum was freely depressible deep into his chest. Try pressing inwards on your own chest - it doesn’t feel like one of those CPR dummies… but I can tell you that once the ribs are broken by the initial compressions, the dummy is a fairly realistic simulation.
I did several cycles of CPR throughout the resuscitation effort on this man. While my hands worked to try and squeeze his heart to deliver vital blood to his brain, a flicker on the defibrillation monitor and a hand over his carotid artery showed that he had regained a pulse. For a split second it seemed things were looking up and my own pulse again was racing. Unfortunately a swift ultrasound of the heart and another glance at the monitor painted a more dire picture. After close to an hour of CPR, defibrillation, drug therapies and ventilating by a team of doctors and nurses, further efforts were deemed futile. The entire team stepped back in silence as the head doctor solemnly announced “time of death, 10.48pm. May he rest in peace”.
I have witnessed the final moments in the lives of many patients. Whilst working as a nurse, I held the hand of an elderly lady as she gasped for her last breath. I have examined recently deceased patients to certify their life extinct. I have made the awful call to family members to give them the heart-breaking news that their loved one won’t live to see another sunrise. But this death was different.
This was first patient whose chest my hands had worked on to try and bring back life. This was the first patient who I witnessed complete the transition from life to death whilst working as a doctor.
It says a lot about us as doctors and nurses that after a brief pause to debrief and regroup, we all dove right back in to the rest of the department, where every other patient is unaware of what we have just witnessed. We all become a bit desensitised to just how profound it is to witness another person’s final breath, and this is necessary to some degree or we just wouldn't be able to function. It is easy to forget that we really are in a privileged position to be on the frontline to be involved in other people’s lives beginning, ending and all the most difficult moments in between.
Great news for women who hate Pap smears…
I have been at the business end of enough pap smears to know that no woman turns up for their second-yearly cervical cancer screening appointment for fun. From the embarrassment of baring your bottom half to the discomfort of the examination itself, as much as we may all dread the experience, it is generally over in a couple of minutes and is infinitely less horrible than having cervical cancer. Since the introduction of national cervical screening in 1991, the number of cases of cervical cancer diagnosed, and the number of women who have died of cervical cancer, has HALVED. That is a huge amount of pain, suffering and heartache that has been prevented by a couple of minutes of minor discomfort per test.
It has been a long time coming, but as of December 1st this year, the current second-yearly cervical screening test will be replaced by five-yearly HPV testing. But what will that involve exactly, and how will the changeover work? And why do you still need screening if you’ve had the ‘cervical cancer vaccine’?
Currently, the process of screening for cervical cancer involves insertion of a speculum (the plastic duck-bill shaped tool) to allow visualisation of the cervix and collection of cells with a small plastic brush or wooden spatula. The cells are then either put onto a slide or into a liquid medium, and sent to a lab. The samples are then stained and viewed under a microscope where pre-cancerous changes can be detected. This allows women to be treated when changes in the cervix have not yet progressed to become cancer, but are at risk of doing so, therefore preventing cancer before it actually occurs.
Once December rolls around, the process at the GP will be basically the same for women presenting for screening. It will still involve a speculum insertion and use of a small plastic brush to collect cells from the cervix, but the tests done in the lab will be completely different. Instead of looking for pre-cancerous changes, the new tests will be detecting the human papilloma virus (HPV), which is the cause of 99.7% of all cases of cervical cancer, and is the virus at which the cervical cancer vaccine (which is actually an HPV vaccine) is directed. This test is more accurate than the current testing which means you will only need to have screening once every five years!
HPV is a very common virus, spread by genital skin to skin contact, and most people will contract it at some time in their lives and be none the wiser. It is usually harmless and most of the time your body clears the infection without causing you any symptoms at all. BUT, when it isn’t cleared, there is a risk that the infection will cause pre-cancerous changes to cells in the cervix and then progress into cervical cancer. So detecting this process at the stage of initial HPV infection means that changes in the cervix can be found earlier, and potentially treated earlier, with the aim that less woman actually end up developing cervical cancer at all.
“But I’ve had the HPV vaccine! Surely that will do the trick?!” I hear you say… well there are actually 100 different types of HPV, and the vaccine only protects against type 16 and 18 which are high risk types that cause 70% of all cervical cancers. One of the HPV vaccines that is available in Australia also protects against two other HPV types which cause genital warts. Bonus! Moral of the story is, whether or not you’ve been vaccinated, you will still need ongoing screening to detect the pesky HPV infections not covered by the vaccine and ensure any abnormalities can be picked up early.
Another change beginning in December is that the age of first testing will be pushed back from 18 to 25 years old, or once a woman becomes sexually active, whichever is later. The evidence shows that screening hasn’t changed the number of cases of cervical cancer in women under 25, or the number of deaths from cervical cancers in this age group, despite halving the overall number of cervical cancer deaths in the 26 years since national screening started. In young women under 25, there is also a higher risk of ‘over-treating’, where abnormalities are treated even though they might not actually be problematic. Treatment of cervical abnormalities can include removal of tissue and laser to the cervix, which later increases the risk of pregnancy complications like cervical incompetence and premature delivery. The widespread vaccination of both girls and boys has reduced spread of virus within the community, so young women and all the immunised generations that follow will be at lower risk to begin with. So it’s a balancing of risks and benefits, and in this case the evidence points towards 25 years of age as the time where HPV testing should begin.
In the changeover period, women will be invited to attend screening two years from their last test, and then every 5 years after that. As the new test is more accurate than previously, it is safe to have a longer interval between screening. If you are due for a pap smear before December 1st, continue as normal and have the current test when it is due, then your next one in another two years time will be the new HPV test.
When all these changes were announced, there was mass panic amongst some women who were concerned that the new testing was merely an exercise in cost savings and would put women at risk with longer time between testing. However, since more information has become available and the concerns regarding risks and efficacy of the new tests have been addressed, the vast majority of women, as well as doctors and the public health sector are welcoming the changes. Not only will it bring more accurate testing but it means the number of speculums a woman will have to encounter in her lifetime has more than halved.
Despite all of the above, if you have any abnormal bleeding, pain, discharge or other worrying symptoms, do not wait for your next test to come up, see your GP straight away.
Do you have questions or concerns about the changes? Leave a comment below, I’d love to hear your thoughts!
Before I launch into a semi-rant/semi-informative blog post about healthy eating, let me get a couple of things straight. Firstly, I am not a dietitian and am in no way about to provide the definitive works on nutrition and diet. Secondly, as I am writing this I just bit the ears off a delicious Cadbury chocolate bunny and may well continue devouring it as I write the following paragraphs so I’m not about to shame you for doing the same every now and then.
It is no secret that Australians on average weigh too much, exercise too little and suffer the consequences when it comes to lifestyle-related chronic diseases. At the moment there is a huge movement bordering on obsession with ‘clean’ eating, religiously following quasi-experts who champion fad diets and tracking all our food intake and activity. And yet as a nation we still keep getting more type 2 diabetes, more heart disease, more fatty livers and more lifestyle-related cancers. There is so much conflicting information out there about whether we should eat high protein, low carb, low fat, gluten-free, low-GI, low-GL, Mediterranean, DASH, paleo or sugar-free etc etc that it all becomes too much to think about and so most of us continue on without changing anything we eat at all, or worse decide to calm down from the diet madness with a nice slab of chocolate cake.
Of course, what you eat is going to be based on your health goals, whether that be weight loss or gain, training for an event or avoiding foods that don’t agree with you. But when it comes to eating well for life, and to preventing lifestyle-related diseases that will creep up on us if we aren’t careful, what should we actually be eating?
For every research study that is published showing that low carb is better than low fat, or that sugar is the root of all evil, another is published showing that in a nutshell, all diets have the same outcome: if you can’t stick to it long term then don’t bother. Numerous large studies have recently examined long term outcomes of various diets and all groups pretty much lose the same amount of weight and have similar health effects down the track. Maybe instead of focusing on specific nutrients or specific diets, we need to take a step back and just eat REAL FOOD? Ground-breaking, I know.
So with that in mind, and without even entering the ‘which is worse: fat or sugar’ debate, here are my official ‘Dr Kate’s Guidelines for Healthy & Happy Eating’…
Fill 90% of your trolley with raw/unprocessed/real whole foods
I’m not talking about eating raw cacao beans with a hint of quinoa, I mean make the majority of the food you buy each week be as close to the natural form as possible. 90% of the ingredients you need to create delicious and healthy meals can be found in the wondrous fruit & veg, deli/butcher and fridge sections of the supermarket. It might sound extreme but if you stock your kitchen with healthy ingredients, then the meals you create will in turn be nutritious and delicious. Of the 10% that comes from the grocery aisles, aim to buy foods with as few ingredients as possible… and if you don’t know what any of the ingredients are, then maybe you shouldn’t be eating whatever that chemically-sounding thing is. On that note, the more you can learn about reading nutrition panels on foods, the better choices you will be able to make.
Everything in moderation, with a few exceptions
When it comes to food-related mottos, ‘everything in moderation’ is my number 1, closely followed by ‘treat yourself’. However, in the interests of eating for health and eating well for life, things like lollies, ice cream and biscuits need to be eaten in the way they were initially designed - as treats. Not as something to be bought regularly with the weekly groceries or chucked in school lunch boxes. When kids are eating packets of chips, chocolate bars and pies on the reg, it’s little wonder that what we consider as ‘treat’ foods have gone from a chocolate bar to a donut stuffed with 3 chocolate bars coated in more chocolate and covered in sprinkles.
Your body is constantly renewing the cells that make up all of its tissues and organs, and the only fuel it has is whatever you consume. Think about it… if you want to build a lean, healthy and happy body, you need to fill up on top quality fuel because you actually are made up of what you eat. So it goes without saying that consuming any amount of cigarette smoke (I’m looking at you Mr ‘I only smoke when I’m drinking’ and Ms ‘but if I stop smoking I’ll eat more’), excessive alcohol or just rubbish food will hinder any health goals you set for yourself.
Divide and conquer
Aim to divide your plate into 50% salad/veggies/fruit, 30% lean protein and 20% wholegrain carbohydrates… or whichever similar ratio works for your eating goals, with the emphasis on making the majority of your meal fresh produce. You can adapt any of your favourite recipes to fit, like adding more veggies to homemade pizzas or pasta, or supplementing a juicy steak with a generous serving of salad. You can gradually increase the amount of veggies you include in meals by finely grating carrot/zucchini/broccoli/any veg really into pasta sauces or hamburger patties to add ‘hidden’ veggies to meals you already like eating. Minimal effort for a maximal nutrient boost! By also buying groceries in a similar ratio, it is easier to eat a varied and enjoyable array of healthy meals.
Fuel your lifestyle
No matter how healthy your diet is, if you spend all your time sitting down and don’t do any exercise, chances are that over time you will still gain weight and develop lifestyle-related chronic health issues. Being physically active in and of itself is a protective factor against heart disease, osteoporosis, depression, some cancers and all-cause early death. Most Australian adults are sedentary at work and in their leisure time, so we have to put in more effort to be active than our grandparents, who likely walked around and exerted more energy in their everyday lives without even trying. Following current guidelines, we all need to aim for daily activity of 60 mins, and that’s vigorous exercise that increases your heart rate enough to make you breathless and break a sweat. Find an activity you love and it won’t even feel like a chore - trampolining, kayaking, hiking, yoga, boxing, jogging or good old aerobics classes - all workouts are better than none.
If the healthy ingredients aren’t in your kitchen, chances are you won’t be eating them. There is a wealth of meal prep inspiration out there for the taking (just open Pinterest for starters), and especially getting lunches organised for the week ahead of time makes it much less tempting to buy a less healthy option. Also on that note - when doing the groceries, write a shopping list and don’t go near a supermarket on an empty stomach (otherwise you will definitely leave with a chocolate mudcake, Tim Tams and none of the veggies you actually needed… not talking from experience or anything I swear…) Double wins for your wallet and your waistline! What we do every day is much more important than what we do every now and then, so getting the staples sorted in advance sets you up for a solid food foundation.
Focus on the end-game
If you have made it this far down the page you must have some interest in your health, so if you want to do something positive and health-promoting, what exactly is your goal? If you can tangibly measure whatever health outcome it is you want to achieve, then sticking to eating healthily and exercising regularly becomes a whole lot easier.
If we start viewing the food we eat as fuel for our body, rather than a reward or a currency to bargain with, we can shift the focus from short term dieting to long term eating for health and happiness. There is no point restricting yourself to only eating organic steamed kale all week if you are then compelled to binge on 5 blocks of chocolate on the weekend. By creating a balanced, delicious and nutritious way of eating that is sustainable, eating becomes an experience to be savoured and not a source of stress. The less we obsess over fads and instead embrace eating real foods, the more we will be able to establish sustainably nourishing eating patterns. On that note, time to put down the Easter chocolate and cook up some fresh and tasty lunches for the (extra short) week ahead!
So you’ve enrolled at uni, bought your stethoscope and tried to decipher a packed semester 1 timetable. The first weeks and months of med school can feel a bit being repeatedly slapped in the face or rolling down a hill covered in bindis, so here are my tips on how to survive and thrive the trials and tribulations of medical school!
‘The days are long but the years are short’ is an apt way to describe studying medicine, and before long you’ll be out in the hospital or in the clinic treating real patients who put their trust in your knowledge and judgement; so study hard, look after yourself and enjoy all the wonderful opportunities that lie before you!
I don’t know her name, and I’ll probably never know what eventually happened to her. But I do know that I’ll never forget the day our paths crossed in the most dire of circumstances.
Just a warning in advance that this blog post contains some fairly graphic depictions of a real-life emergency scenario which may be disturbing to some readers.
During a recent holiday, my husband and I took a day trip to snorkel off a small and fairly remote island. After a 30 minute drive then a 1 hour boat trip, we arrived on the tiny 0.5 square kilometre island where the only facilities were some tables and chairs and long drop toilets - not even running water.
While we took a break from snorkelling and sat down at the far end of the beach, we noticed a group of people gathering up the other end of the beach as a person was dragged from the ocean. Despite both knowing first aid and being confident around the water, we still hesitated before making the decision to go and help. Firstly (as I’m sure many other junior health professionals will relate to) there is the feeling of self-doubt - ‘yes, I’m a doctor but I’m not that experienced, I would probably just be getting in the way’, and secondly there were at least 30-40 people now standing around a person on the sand. We assumed that surely someone was performing some immediate first aid.
In the few minutes it took us to walk over to the scene, we weren’t able to get a view of the person due to the surrounding crowd, however the atmosphere was noticeably void of panic or hysteria. Subsequently, we assumed everything must have been under control. It was only when my husband stood on top of a table to try and see what was happening that he noticed that despite the amount of bystanders, no first aid was actually being administered. He yelled out to me and indicated that I would need to offer my help. While the surrounding onlookers didn’t seem to understand the severity of the victim’s condition, my stomach dropped as the seriousness of the situation became clear and I realised that I would need to manage it.
I pushed through the surrounding onlookers and my own pulse quickened when I finally was able to lay eyes on the limp, grey and clearly unconscious young woman who lay on the sand, not moving and quite obviously not being attended to by anyone who knew first aid. What had looked from a distance like a person who had been placed in the recovery position was actually a person who had been dragged from the water and left on the sand haphazardly, with her face laying in a puddle of her own regurgitated sea-water on the sand. I still feel queasy thinking about what lay before me in that moment.
As I approached the victim, a staff member from one of the snorkel boat companies also came over and I asked if they needed help. He said yes, before going back to his boat to arrange for transport to hospital, so for what felt like much longer than the 5-10 minutes it probably was, I was a lone first responder.
Prior to that moment, the only out-of-hospital first aid events I’ve had to assist in have involved minor sporting injuries, insect bites or cuts and scrapes… nothing where I had the potential to actually be the sole difference between life and death, or at the very least between life and terrible morbidity. The realisation that these potential consequences depend on your actions, on an island more than an hour from the nearest hospital or basic first aid resources is absolutely terrifying.
As soon as I reached the victim I started the familiar DRS ABCD of basic life support that to many of us with basic first-aid awareness is second nature, and perhaps we take for granted that the average lay person doesn’t immediately think of these things. In a perfect world I would have cleared away non-useful bystanders, donned a pair of gloves and called for an ambulance but unfortunately on a remote island without fresh water, soap or mobile phone signal, sometimes the best available option is far from best practice. I immediately called to the woman, squeezed her hand and yelled in her ear without a response. At the same time, I lifted the woman’s head out of the sand and had some assistance to roll her properly over onto her side as she had clearly been vomiting or regurgitating water. She began bringing up large amounts of sea water and as I continued to apply head tilt keep the airway open, she started taking regular breaths.
I’m not sure if she was breathing at all up to this point, owing to her position and the fact her mouth and nose were directly in sand and water; but I don't think I have ever felt as relieved as when those first spluttery breaths occurred. She continued breathing, at first with short rapid breaths with increased effort, but her colour changed from the terrifying blue-grey to pale but with some pink returning. I knew this woman was by no means out of the woods, this was a sign things were heading in the right direction.
The woman kept breathing but remained unresponsive and unconscious during the eternity it seemed to take to arrange the boat to transfer her to hospital. When a stretcher finally arrived on the beach and the woman was moved onto it, I felt so helpless as I tried to communicate with the boat staff who were to take her. There was no “1, 2, 3, roll” or careful consideration of possible spinal injuries. The woman was placed onto her back despite that if she stayed lying supine for any length of time it was likely she would choke on the sea water she continued to bring up. As much as I tried to signal, instruct and move her myself, it took me yelling repeatedly before another person understood and helped me to roll her over. At the time I didn’t even think about the fact those people probably didn’t speak very much English, I was just determined to try and do what I knew was best.
I felt even more helpless as the boat staff carried the young woman onto the waiting boat, almost dropping the stretcher and the woman in the process. It made me feel sick to my stomach. It seemed to take so long for them to get her back on her side and leave the beach to get her to a hospital. Just as shockingly, many tourists in the water seemed to ignore my husband and others who were trying to clear them from the water so the boat would be able to load the woman on and transport her away. It felt so frustrating not being able to do more, or to know that I had done enough. After the woman was on the getaway boat, I turned around and burst into tears. I don’t know whether it was the confronting nature of what I’d been involved in, the inaction of the dozens of other bystanders before we arrived or the frustration of it taking so long to get this woman to proper medical assistance, but the whole situation was just incredibly overwhelming and quite traumatic.
It was shocking that of the 8-10 boats who had brought tourists to the island that day, only one staff member came to assist. Especially considering we were in a country where many tourists don’t swim regularly at home, and aren’t confident in the water, I would have thought that all tour companies would have to train their staff in first aid at the very least. I would like to think that if a similar thing was to happen in Australia then there would be plenty of bystanders who would at least have some knowledge of what to do if someone is pulled from the water and sufficient resources to appropriately respond. However, on arriving home from our holiday and hearing news of a huge number of drownings in NSW over the Christmas period, maybe we all need a refresher on water safety and what to do when something goes wrong.
I held my bronze medallion and lifeguarding certification for a number of years before I completed my medical training, so somewhere in the depths of my memory I had plenty of knowledge about assisting in drownings, even if I hadn’t yet had to put it into practice. These potentially life-saving courses don't take very long to complete but could prevent one or your children, one of your friends or even a stranger from suffering terribly. Royal Lifesaving Australia runs courses in basic first aid & CPR, lifesaving techniques in the Bronze Medallion, and a swim and survive program for school-aged children and even have a course in water safety for older people. I would highly recommend checking out the Royal Lifesaving website (http://www.royallifesaving.com.au) for details of these courses. As Australians we spend much of the warmer months around the water and you never know when you will witness a person in distress.
According to Royal Lifesaving, 280 people drowned in Australian waterways last year, a 5% increase on the year before. Here are their top tips to keep yourself and your family and friends safe when enjoying our beautiful waterways:
The following advice DOES NOT replace completing a first aid or lifesaving course (which I would strongly suggest everyone considers booking in for and regularly re-doing), but if tomorrow you came across a drowning person, what should you do?
(Adapted from the Australian Resuscitation Council Guidelines: http://www.resus.org.au/policy/guidelines).
When looking back over my experience in assisting with a drowning victim, I am left with many questions, to most of which I’ll never have an answer. Was there something more I could have done to have given the woman a better chance at a full recovery? Did she make it to hospital ok, and did she in fact recover? What caused her to drown in calm and fairly shallow water? Did all those bystanders have no idea what to do, or was there a cultural reason for not jumping straight in to help?
Regular searches of the local news have not turned up any reported drowning deaths at the island where the incident occurred, but other drownings were reported in the months prior - so I have to maintain hope that this means the small actions I took on that beach might have enabled that woman to not be another statistic. We can all learn from this, especially my fellow junior health professionals, not to doubt yourself in a stressful situation; and to always offer your help in an emergency, even if it looks to be under water-tight control. Finally it is a harsh reminder that our beloved oceans (and pools, lakes, rivers!) can be dangerous places, and if we all made an effort to gain skills and knowledge to keep ourselves and each other safe, then many tragic drowning deaths could be prevented.
Royal Lifesaving Australia: http://www.royallifesaving.com.au
Australian Resus Council guidelines: http://www.resus.org.au/policy/guidelines
The effectiveness of Fitbit and other fitness trackers has recently been under fire as a study in The Lancet Diabetes & Endocrinology did the rounds last month, claiming that fitness trackers did not improve health outcomes. Fitbit addicts everywhere were defending their step challenges and meticulous meeting of daily goals as news outlets jumped on the revelation that maybe these fitness trackers are simply a waste of time.
As a self-confessed Fitbit junkie, I was interested to look a bit further into the evidence and find out whether I am just wasting my tracking stats for nothing. I found a whirlwind of conflicting evidence and a range of small studies looking at the use of trackers in different demographics and overwhelmingly a few things stood out.
Wearing a fitness tracker increased the amount of activity in most studies
Even in the study that has been splashed through the Sydney Morning Herald (http://www.smh.com.au/national/health/fitbit-fails-the-selfimprovement-test-study-finds-20161004-grudh9.html) and other news sites recently, the group that wore Fitbits did do more exercise than those who didn’t, but at the end of the study there was no difference in weight, blood pressure or other health outcomes compared to those who didn’t wear a Fitbit. Interactive trackers also have been shown to get people moving more than standard old-school pedometers. However - across multiple studies, it seems that while people wearing trackers are taking more steps and doing more leisurely activity, the amount of moderate-vigourous exercise (i.e. the kind that is needed for fitness gains) is not increased.
Fitness trackers are reasonably accurate for counting steps, less so for calculating calories burnt and assessing sleep
There have been a bunch of studies done to determine how accurate the various monitors are, and it seems they are generally quite good at counting steps but much less accurate when it comes to determining energy expenditure (a.k.a. calories burnt) and sleep. However, a few studies comparing trackers directly to traditional sleep monitors used in medical settings determined that for tracking sleep cycles over multiple days, commercial fitness trackers are reliable enough for this purpose - just don’t expect minute to minute analysis of sleep quality to be completely accurate.
Weight loss generally isn’t drastically increased by wearing a fitness tracker
There are small studies where a weight loss benefit is seen, but most of the research shows no significant weight loss benefit from wearing a tracker alone. Most of these trials have given a group of participants all the same diet and exercise advice and then given half of them a tracker to use for a designated timeframe and it seems that the tracker doesn’t provide any significant weight loss benefit over and above traditional diet and exercise advice alone.
The social networking associated with the wearable monitor is a significant contributor to increasing activity levels
The apps and social aspects of wearable trackers allow for goal setting, accountability, self-monitoring and feedback and social recognition and support; all of which are known to be beneficial in health behaviour change. Perhaps these are the aspects of the devices that need to be promoted or used more effectively to help people meet their health and fitness goals.
Deciding to stop using your tracker isn’t going to ruin your fitness goals
A recent American study followed up people who had decided to stop using their trackers to see whether their fitness levels and amount of exercise changed. It turns out overall people still did the same amount of exercise, but they feel guilty about not monitoring and tracking it. So stopping the vigilant monitoring might make you feel like you’ve fallen off the wagon but in most cases it doesn’t actually make you do less exercise.
Fitbit, Jawbone, Garmin or Apple Watch - none of them will be a magic fitness cure-all
Looking over all the recent studies, it is pretty obvious that none of these devices will magically improve your health and fitness and cause you to lose weight any more than tried and true exercise and diet changes. The psychological impacts of these devices needs further study as they appear to have a motivational benefit in improving activity levels but not vigorous (and even more beneficial) exercise, so maybe the knowledge around types of exercise needs to be better dispersed amongst device users.
So if you are a dedicated tracker of exercise, step counts, sleep and water intake; or if you are considering investing in a wearable tracker, are you wasting your time? Well it depends on what your goals are - not everyone who wears a Fitbit or Jawbone is wanting to lose weight and I think a lot of the research data seems to ignore that. By understanding the various reasons people use the devices and what they hope to achieve by wearing them, only then is it possible to say whether that Fitbit is effective or not. If you want to lose weight and plan on getting a tracker but don’t make significant changes to your diet and exercise then don’t expect to see the kilos come off. If you want to keep tabs on your steps and beat your friends in step challenges then chances are that wearing a tracker will make you walk more. If you want to log your workouts and monitor progress in a handy app then the goal-setting and accountability functions could be of great use.
Looking over the research and pondering the ways people use these devices in their lives, here are a few ways you can maximise the benefits and avoid the pitfalls.
Customise your goals and continually update them
The standard 10k step goals, calorie burn goals and others that come programmed on fitness tracking apps are not necessarily going to fit with the goals that you are wanting to achieve for yourself. If you want to lose weight, you need to increase your activity above whatever you are currently doing as well as reducing calorie intake, so if you are doing 9000 steps in an average day before trying to lose weight then just aiming to do 10k probably isn’t enough to make much of a difference. Instead try upping the goal to 15000 and give yourself something to strive for. If your goal is to improve fitness, focusing on running distances, weights lifted, resting heart rate and other stats are going to be of more use than the basic step count which many of the apps place front and centre.
Involving friends in your activities is a great way of being accountable and introducing a bit of friendly competition - as long as you don’t skip out on the swimming/weights training/other activity because it will earn less steps than going for a walk - leisurely walks aren’t a bad thing, but if your goal is to improve fitness then there are more effective exercises to do. Instead of just focusing on your weekly step contest, involve friends in your healthy lifestyle in other ways like doing high intensity aerobics classes together, getting active with a bike ride on the weekend or have a fortnightly afternoon of healthy meal prep.
Remember that the step goal might not always be the most important
See above. Mentioning this twice because it’s the biggest take-home point. As satisfying as it is to have that magical 10000 steps be reached, have a think about what that actually means and whether there is a better goal you can set yourself.
Take a break
It seems that taking off your tracker won’t send your exercise routine down the drain but it might make you feel guilty. You might want to take a week or two breather from wearing your tracker and see how you feel - if you still feel motivated to be active every day and eat healthily, chances are you will still do these things, you just won’t have your phone flashing at you to celebrate your daily successes. Instead you can celebrate the simple joy of going for a run or a swim or spin class and soak in how good you feel afterwards and not feel compelled to jump straight on your phone to see what your heart rate was doing. In a world where people spend most of the day staring at their phones, maybe this is the bit of reprieve that some of us need!
Are you addicted to your fitness tracker? Has it helped or hindered your healthy lifestyle? I’d love to hear from you!
Daniel A. Epstein, Monica Caraway, Chuck Johnston, An Ping, James Fogarty, Sean A. Munson
Beyond Abandonment to Next Steps: Understanding and Designing for Life after Personal Informatics Tool Use
University of Washington
Lyons EJ; Lewis ZH; Mayrsohn BG; Rowland JL
Behavior change techniques implemented in electronic lifestyle activity monitors: a systematic content analysis
Journal of Medical Internet Research. 16(8):e192, 2014
Cadmus-Bertram LA; Marcus BH; Patterson RE; Parker BA; Morey BL.
Randomized Trial of a Fitbit-Based Physical Activity Intervention for Women
American Journal of Preventive Medicine. 49(3):414-8, 2015 Sep
Greene J; Sacks R; Piniewski B; Kil D; Hahn JS
The impact of an online social network with wireless monitoring devices on physical activity and weight loss.
Journal of Primary Care & Community Health. 4(3):189-94, 2013 Jul 1
Finkelstein, Eric A et al.
Effectiveness of activity trackers with and without incentives to increase physical activity (TRIPPA): a randomised controlled trial
The Lancet Diabetes & Endocrinology
Evenson KR; Goto MM; Furberg RD
Systematic review of the validity and reliability of consumer-wearable activity trackers
International Journal of Behavioral Nutrition & Physical Activity. 12:159, 2015
de Zambotti M; Claudatos S; Inkelis S; Colrain IM; Baker FC
Evaluation of a consumer fitness-tracking device to assess sleep in adults
Chronobiology International. 32(7):1024-8, 2015
As I write this inaugural blog post for the brand-spanking new Dr Kate website, I am sitting in a jet-lagged haze where I can’t decide whether the next few hours should be spent sleeping, or spent making the most of daytime, knowing that when I get to work tonight I’ll still feel tired regardless of how long or how little I slept for today. Ahh yes, the wonderful world of night shift. If you are a nurse, doctor, hospitality or transport worker or someone else lucky enough to be in a 24/7 career, you will know this feeling precisely. But did you know just how hazardous shift work can be to your health?
Shift workers are more likely to be obese, have heart disease, metabolic syndrome (a cluster of pre-diabetes, high blood pressure, high cholesterol and abdominal obesity), suffer mood disturbances, have accidents both at work and on the journey to/from work, and may even have higher risks of some cancers though the evidence isn’t quite as clear.
How can simply being awake and working at night do all this damage? Mostly it is thought to be due to the body’s internal clock which controls hormones, digestion, body temperature, heart rate and of course the sleep-wake cycle. Also known as circadian rhythms, they rely on exposure to light during the day (and lack thereof at night) to keep everything running as planned. It seems that confusing our natural sleep-wake cycle changes the release of hormones that influence digestion and metabolism, and may cause higher blood pressure (especially when shift work is prolonged), and has pretty marked impacts on mood, alertness and cognitive function in the short term.
As well as stuffing up the hormones that control how we feel, our digestion, weight and most basic bodily functions; shift work quite simply means that many workers just don’t get enough sleep. Even someone who has never worked a night shift in their life knows how much easier it is to order take away, be tempted to eat that last row of chocolate and skip the gym when you are tired, and if this goes on for months or years the consequent damage to your health is pretty obvious.
So now all that grim part is out of the way, what can you do as a shift worker to counteract these risks as much as possible and to just feel better when you are working the graveyard shift? Here are my personal insiders’ tips…
1. Get as much good quality sleep as possible
Throw away the 8 hour rule, stop tracking it on your FitBit and stop watching the clock. Just make your bedroom as dark, cool and comfy as possible and don’t overthink it. Simple things like an eye mask, ear plugs, blackout blinds or window shades or even a fan can make your sleep haven just that little bit more inviting and help you stay asleep longer. If you aren’t tired or sleep isn't happening, get up and do something else until you do feel tired enough. One of the hardest things when sleeping in the day is to actually stay asleep for more than a couple of hours at a time - your body likes sleeping at night when your body temp is lower (yes that’s why around at 2am at work you are reaching for a jumper as well as a coffee) so sleeping at midday in summer is like fighting your own physiology. Power naps can be effective in reducing fatigue and I like to have an hour nap ending about half an hour before I need to leave for work to help me feel refreshed and ready to start my work day.
2. Avoid caffeine hangovers
If you are going to have anything containing caffeine, keep it to the first few hours of your shift and not within 6 hours of the time you’ll be trying to sleep. Steer clear of energy drinks and stimulant medications which have a whole host of other problems associated with them (and where energy drinks are concerned, are not worth the filthy amount of sugar in each can).
3. Mentally switch off the second you sign out of work
Meditate, listen to music on the drive home, watch 20 mins of trashy TV or take the dog for a walk - whatever you need to do to clear your mind before you hit the hay. Keep a to do list next to your bed and offload anything to it that is floating around your mind as you are trying to sleep.
4. Get into a routine
Figure out which part of the day is the best sleeping time for you - it might be the second you walk in the door after work, or might not be until the afternoon, but try and stick to somewhat of a day to day routine. It not only helps your body get into the zone of sleeping when your head hits the pillow but also helps you feel more human and get more done with the time you aren’t at work.
5. Eat sensibly
If you are on a rotating roster and know you have nights coming up, prepare snacks and meals for before and at work in advance. I like to have a stack of meals in the freezer that I’ve made in bulk so I can sleep until just before work starts and have a healthy dinner (/breakfast) ready in no time. If you have a healthy snack to eat overnight it also makes resisting those staff room chocolates and vending machine chips much easier. Have your kitchen fully stocked before your run of nights begins so you have decent food at your fingertips and don’t have to do grocery shopping on 2 hours sleep - this always ends in buying multiple blocks of chocolate and cakes that weren't on the list.
6. Stay active
You don’t need to run 10k every day to keep your health and fitness on track while you throw your body through the night shift ringer, but you do need to do something active every day to help counter-act those aforementioned risks. As with any exercise, find something you like doing that gets your heart rate up and makes you sweat and do it regularly. My active pursuit for today was hitting up my old friend the trampoline park for an hour and I can tell you that not only are my legs sore now but I know I’lI have a solid pre-work power nap because of it!
7. Stay safe
DON’T DRIVE HOME FROM WORK IF YOU ARE OVER-TIRED. In capitals because it is so so so important for those finishing work as everyone else is starting their day. All too often there are fatal car accidents involving nurses and others who have been at work all night and don’t want to trouble someone else for a lift home when they are really too fatigued to safely drive themselves. It’s not worth it - check yourself before you get behind the wheel and keep an eye out for your colleagues. Pump the air conditioning, blast some music and drive with a full bladder if you must but don’t risk your life and everyone else’s on the road - check the RMS tool “Test Your Tired Self” for more info (http://www.testyourtiredself.com.au).
8. Soak up some sunshine
It’s much easier in summer with longer days to find time to catch some rays, but no matter what time of the year, it’s especially important for those who might spend most daylight hours under the covers to get out and make some vitamin D! It does wonders for your mood and alertness to feel some sunlight on your skin after working under fluorescent lights all night.
9. Look out for your colleagues
There is a sense of camaraderie in my workplace after hours - everyone works really well as a team and it makes stressful moments much more tolerable. Be there for your colleagues and they will be there for you - keep an eye out for anyone who isn’t coping and remember that lack of sleep can wreak havoc on a person’s mood so lend an ear where one is needed. Just be a nice human - this goes for all working hours!
10. Look on the bright side
This all sounds like a long list of cons about working nights but remember there are some positives!! Think of the extra money, the ability to be flexible around your other commitments and the fact your workplace may be quieter at night - whatever the highlights may be. Focus on these and you’ll be out the other side of your night shifts in no time!
What are your night shift hacks that make being awake all night easier, or improve your sleep in the day? Do you have any other insiders tips on how to survive and thrive as a shift worker? Let me know below!