Thursday, August 14, 2014

An apple a day can have surprising health benefits!

The Australian CHOICE consumer magazine publishes a great deal of useful health information, both in the main magazine and in the separate Choice Health Reader.

This small article about the health benefits of an apple a day appeared in the February 2014 issue of CHOICE:

Friday, August 8, 2014

St Francis' Choir, Melbourne sings at the Holy Trinity Festival on Saturday 16 August

Members of St Francis' Choir are looking forward to performing at the "Sounds of Joy" concert as part of the Holy Trinity Festival on Saturday 16 August 2014. For further details see: holytrinitymelbourne.org.au.


Tuesday, July 22, 2014

Opposing the Australian Federal Budget proposed $7 GP co-payment

My own view (and that of many others) is that the introduction of this proposed impost would be a public and preventative health disaster and an administrative nightmare for GPs and other direct service providers.

A website has been set up to collect signatures for a petition opposing the co-payment (which still has a chance of being defeated in the Senate) and to share people's stories as to why they disagree with this measure.

Sign and/or share your story at http://www.copaystories.com.au/sign/.

Wednesday, June 18, 2014

Australian Federal Budget: Medical co-payment belongs on the scrap heap

There is a terrific article on page 20 of "The Age" (Melbourne) today from Professor Brian Owler, President of the AMA which includes many of the reasons I had thought of as to why the medical co-payment proposed in the Federal Budget is a bad idea if we are advocating for our patients.

http://www.smh.com.au/comment/medical-copayment-belongs-on-scrap-heap-20140618-zsbb3.html

Saturday, June 7, 2014

Bouquets and Brickbats: When is "travel insurance" not travel insurance?

Caveat emptor - beware of travel insurance which is underwritten by Allianz. This includes CHI and Aussietravelcover.

My iPod Touch was stolen during a trip on 'The Ghan'. Not only did Allianz first try to deny liability (alleging that the iPod had been "left behind" (no cover if you leave anything behind anywhere during your travels) but then after getting a supporting letter from the Terminal Manager they agreed to pay, but only wanted to pay a pittance for an iPod that was in 'as new' condition (applying a savage level of depreciation). As this would not come anywhere near the replacement cost for the iPod I argued with them, and they increased it a bit, but still nowhere near enough to buy a new one. At this point I was exhausted and gave up and had to settle for a second-hand one with a tiny bit of marginal screen damage (sourced through EB Games https://ebgames.com.au/).

As a result I would never ever insure anything with Allianz. Never, ever!

This is also a lesson for people purchasing travel insurance to read the terms and conditions carefully to make sure you are covered for accidental loss. To my mind, so-called travel insurance that does not cover you for accidental loss or leaving things behind is not travel insurance at all and does not deserve your business. Also, if you have an expensive piece of technology in good condition, you will want replacement value, not just their arbitrary depreciated value.

For terrific value and more generous terms and conditions try this one instead provided by ACE Insurance (and available in three levels of cover):
https://fairfax.aceinsurance.com.au/FairfaxAU/TA
(The medium level of cover is also available through www.seniors.com.au/age with a 10% discount for an online quote, but it is cheaper through the Fairfax website.)

Thursday, May 29, 2014

Medical Book Review: Talley and O'Connor - Clinical Examination (Seventh Edition 2014)


Medical Book Review – Clinical Examination. A systematic  guide to physical diagnosis. Seventh Edition.Nicholas J Talley and Simon O’Connor
Churchill Livingstone/Elsevier
ISBN: 9780729541473 Publication Date: 2014 RRP: $125.96 (free delivery in Australia/NZ).
(Bonus online resources (videos, ECGs and images) are available to purchasers of this book through the Student Consult portal.)

The book is also available in two other formats: a standard eBook containing the content from the print edition plus four additional chapters covering the history and examination of gynaecology, obstetrics, neonatology and paediatrics, and an interactive enhanced eBook which contains the four additional chapters together with OSCE videos, ECG case studies, an imaging library and MCQs.

I purchased the fourth edition of this book (together with the pocket guide) when I was a medical student. This paperback edition comes in at around 600 pages, and is physically larger than its predecessor, and, unlike my earlier edition, contains an impressive number of colour photographs and other illustrations and tables. I was literally ‘blown away’ by the quality of the book (and its contents) as an educational resource, and it is a book in which even a highly experienced practitioner can find learn something from.

The Contents section follows straight on from the Foreword, and is well set out with bolded headings which make it easy to identify the topic of interest at a glance.

The book is divided into several key sections:
1.            The general principles of history taking and physical examination;
2.            The cardiovascular system;
3.            The respiratory system;
4.            The gastrointestinal system;
5.            The genitourinary system;
6.            The haematological system;
7.            The rheumatological system;
8.            The endocrine system;
9.            The nervous system; and
10.          Specialty examinations.

The ‘specialty examinations’ have been considerably expanded from my earlier edition, with seven topics covered as opposed to the earlier three. These now include:
Chapter 38: The eyes, ears, nose and throat;
Chapter 39: The breasts;
Chapter 40: The skin, nails and lumps;
Chapter 41: A system for infectious disease examination;
Chapter 42: Assessment of the geriatric patient;
Chapter 43: Assessment of the acutely ill patient; and
Chapter 44: Assessment of death.

There are three appendices which were also present in my earlier edition (‘Writing and presenting the history and physical examination’,’ A suggested method for a rapid screening physical examination’ and ‘The pre-anaesthetic medical evaluation (PAME)’. The book concludes with an extensive Index.

Most chapters conclude with two useful and practical components, ‘T&O’C essentials’ and ‘OSCE revision topics’, and a list of references.

The Preface (written by the two authors) summarises their approach to this new edition:
“… we cover the core clinical skills from the basics to an advanced level. We have taken an approach that is patient-centric and evidence-based; the patient must always come first. The edition has been brought right up to date with the latest clinical data, including new research specially commissioned for this edition. Learning should also be fun and the book is deliberately laced with humour and historical anecdotes that generations of students have told us enhance the learning experience.”

Further information concerning the evidence-based approach which has been taken in this edition appears in the Acknowledgments section, together with a list of the highly credentialed reviewers who have also contributed to the manuscript.

I particularly enjoyed the next two sections: ‘Clinical methods: an historical perspective’ and ‘The Hippocratic Oath’. In keeping with the evidence-based approach, these are followed by a section detailing ‘Credits: figures, boxes and tables’.

Section 1 (general principles of history taking and physical examination) provides a structured approach to both these elements together with abundant resources in terms of photographs, tables and practical advice (including about OSCEs). There is a specific section on evidence-based clinical examination.

In my work as a medical educator, the clinical history and examination topic that we have most recently covered with our students was the gastrointestinal system, so I have elected to look at this chapter in some more detail as an example of the system-based chapters.

As is customary, this chapter begins with a pertinent quotation, this time from Shakespeare. A short section on ‘examination anatomy’ follows, containing a detailed colour illustration and descriptions of the major areas in the abdomen of anatomical interest. The correct positioning for examination is then described, and a systematic approach to examination follows. This begins with jaundice and weight and wasting, and a very thorough section on skin follows, together with several photographs and a very detailed table setting out relevant diseases with skin and gut associations. The general introductory section concludes with ‘mental state’. The next section covers the examination of the upper limbs, beginning with the hands (nails and palms) and a discussion of the most common relevant findings, proceeding to an explanation of hepatic flap and then possible findings on the arms. Several illustrative photographs and a table for assessing malnutrition are included in this section.  The next topic looks at the face and head, and includes discussions around the eyes, salivary glands and mouth. Several photographs and tables are included. After a brief section on ‘Neck and chest’, the chapter moves on to examination of the abdomen. This section begins with detailed information on inspection and then a systematic approach to palpation of the abdomen, including assessment of the major abdominal organs and possible causes of other abdominal masses. Once again several helpful illustrations and tables are included. Sections follow on percussion, ascites and auscultation. These are also well supported by additional resources. A section follows on hernias (including how to examine for these) with useful illustrations. Next is a detailed section on rectal examination, including proctosigmoidoscopy. There is a brief section on other areas of the body which may be relevant to examine, and then the chapter concludes with a section on ‘Examination of the gastrointestinal contents’ (including faeces, vomitus and urine. There is a helpful illustration of the bilirubin pathway and a table listing the changes in urine and faeces with jaundice.  The final three elements are the ‘T&O’C essentials (nine key points from the chapter), ‘OSCE revision topics’ (five points) and the references.

There is also a complementary chapter immediately following on ‘Correlation of physical signs and gastrointestinal disease’. This covers examination of the acute abdomen, signs commonly associated with chronic liver disease and portal hypertension, hepatic encephalopathy and dysphagia, an approach to assessment and diagnosis of gastrointestinal bleeding, a discussion of inflammatory bowel disease and finally, malabsorption and nutritional status (signs, causes and classification).

Both these chapters are very thorough but well-organised and laid out and are as a result easy to follow. The plentiful illustrations and tables support the written text and enable the reader to gain a better understanding of the subject matter. These additional resources essentially make the book a ‘one stop shop’ so that in general it is not necessary to look elsewhere for supporting materials to aid comprehension.

This is a magnificent book, which is one of those references which will well and truly ‘stand the test of time’ and the authors are to be congratulated on their efforts. Whilst the amount of detail is probably in excess of that required for junior medical students, for those undertaking their clinical training, and indeed for junior clinicians in training it would provide an invaluable resource. It is also a well-loved resource for medical educators. This is a book which has ‘something for everyone’ and it is not hard to imagine that even highly experienced medical practitioners would find it useful to turn to from time to time.


Verdict: Highly recommended!

Wednesday, May 21, 2014

Book review: 'Hypothermia' by Arnaldur Indridason

This is one of a series of crime novels concerning Icelandic detective Erlendur. At 314 pages I managed to read it during a two-hour 'plane flight. Published in 2009, it came into my hands from a colleague who thought that I might be interested to read it. Having been to Iceland in 2006, its haunting landscape was familiar to me, and had visited Thingvellir national park and seen the view over the lake Thingvallavatn, where much of the action takes place.

Like any detective story, there are a number of threads which initially appear to be unrelated, but are drawn together in the last few pages of the book. Erlendur fits the Scandinavian mould of the somewhat tortured middle-age male detective who is divorced and has a fractured relationship with his family. The story is almost a morality play about the negative consequences of infidelity and how both anger and the desire to be free can drive murderous intent and a fabric of lies and deception. It is also a story about an innocent love story that ends in tragedy, the impact of tragedy and loss over a lifetime, the ghosts that live on, the question of life after death and its intersection with medical madness. It is somewhat poignant that tragedy and loss also enveloped Erlendur's own family in his childhood.

The book is clever in terms of its twists and turns and the way in which the various clues are gradually revealed, and 'putting it all together' really does come down to the last few pages when our suspicions that an apparent suicide was really a murder are confirmed. There is of course a certain element of 'willing suspension of disbelief' as the elements of the plot are spun together, and we are left wondering whether the murderers will in fact 'get away with it'. I was left feeling very sorry that the victim, who was on the verge of getting her life back together again, was so cruelly robbed of this opportunity, and did wonder about things like why would the police not check the plastic rope in the noose for fingerprints, and why would someone who was so afraid of the dark and hated being left alone voluntarily go to stay in an isolated cottage on the edge of Thingvallavatn without the author making more of this inconsistency?

Since I love Iceland, and this is a reasonably good yarn that allowed me to have a few stabs at where it was all heading towards the end, which is always fun, I am going to recommend it! There are apparently several other novels in the series by the same author if you are interested in reading more.

Friday, May 9, 2014

Outstanding Fish and Chips - St Georges Fish & Chips (Melbourne)

In my exacting search for the best local fish and chips, there is a new leading contender.

St Georges Fish and Chips
350 St Georges Road
North Fitzroy
Melbourne
Open 6 days (Wed to Mon) 11am to 9pm

The pieces of blue grenadier were large, sweet and succulent, with a crispy outer coating. Both the potato cakes and the calamari rings were very generously sized (the calamari actually being the biggest i have ever seen) with the same crispy coating. 'Minimum chips' is $3.00, but this also erred on the generous side, with a crispy golden outer coating and a light and fluffy interior.

The Friday night traffic was a bit of a challenge, but it was worth it!

Highly recommended!

There are also a number of special deal packs on the menu, and they also serve hamburgers, steaks and souvlaki.


Sunday, April 27, 2014

Movie Review: Captain America - The Winter Soldier

This second instalment in the Captain America franchise and the Marvel universe is, in short, a 'kick-arse' movie. It is so action-packed that at times it borders on sensory overload, and you wonder if, in their desire to please, the creators have perhaps tried a little too hard.

The plot is complex, in the "who can you truly trust?" genre. The Captain is having trouble integrating into modern times and embracing modern values. He makes a new friend, who turns out to be 'The Falcon'. His somewhat unlikely working partner is Natasha Romanoff, 'The Black Widow', whom he does not initially trust. They rescue some hostages from a SHIELD ship that has been taken over by pirates, and Romanoff downloads some Shield data onto a flash drive, which then plays a key role in the remainder of the plot.

The Captain challenges Nick Fury, head of Shield, about openness and honesty, and Fury reveals a secret project called 'Insight', which is building three airbone massive troop carriers with impressive firepower and the capacity to wipe out threats before they occur. the Captain is not impressed, and after their discussion Fury requests his associate, Alexander Pierce, to request the world security council (of which he is secretary) to delay the initiation of the project.

Shortly afterwards, thre is a spectacular car chase and assassination attempt on the life of Nick Fury, head of Shield. He barely escapes with his life and winds up in the Captain's apartment, telling him "to trust no-one". He is promptly shot by an unknown assailant, who we presume is the 'Winter Soldier'. Fury is transported to hospital, where he dies (the doctor in me was wondering, does he?).

After Pierce comsiders that the Captain is being evasive about why Fury was in his apartment, Rogers becomes a wanted man on the run. He goes underground with Romanoff to try to find out from whence the evil stems. In shades of the new movie 'Transendence', they discover that a mad (and evil) German scientist has embedded his consciousness into some remarkably old computer equipment in a bunker and has developed an algorithm that identifies people who will be a threat before they a actually become a threat. His goal (and that of Hydra, the many-headed serpent embedded within Shield) is that humanity will at last give up its freedom to avoid living in fear (Project Insight).

The Captain and Romanoff manage to avoid become barbeque by-products when missiles predictably strike the bunker, and when Rogers comes face to face with the Winter Soldier, he realises that this is his best friend Bucky, who was presumed to have died in the 1940s, but has also survived in an enhanced form courtesy of the mad scientist.

In the central part of the movie Rogers also has a poignant reunion with his now-aged former 'best girl' Peggy, who is still alive in a nursing home.

The Captain and Romanofff enlist the help of The Falcon, and work with a small band of trustworthy allies to try to save the day. My medic's gut feeling is proved correct when Fury emerges alive from the shadows.

Now unhindered by Fury, Pierce presses ahead with the initiation of Project Insight, and our small band of intrepid heroes must board each troop carrier in time to replace one of the data chips with an inert one which sever the connection with orbiting satellites and prevent millions of hapless people from being exterminated.

We are treated to some superbly choreographed chase scenes and fight scenes, in a variety of locations, including in the air, and it all comes down to the final chip and a 'Wild West' style showdown between the Captain and the Winter Soldier. The chip nearly falls to Earth at least twice, but somewhat miraculously Rogers manages to avoid being smashed to smithereens and replaces the final chip as the Earth-bound controllers are about to fire on their 20 million unsuspecting targets. The Winter Soldier, now trapped under a girder, is rescued by Rogers, who reminds him of the brotherly bond between them. Both survive the troop carrier crashing out of the skies.

The Captain's demand, prior to the final assault, of both Hydra and Shield being dissolved, "as something is rotten in the state of Denmark", is duly met, and new career paths are needed all-round. Fury stays officially dead, but continues his work behind the scenes, Romanoff feels a need to invent a new cover (but has won the respect and trust of Rogers), and The Captain and The Falcon make it their next mission to find the Winter Soldier.

In the now traditional 'teasers' at the end, we see one of the remaining offshoots of Hydra with an advanced weapon, which has at its core the eerie blue glow of the Frost Giants (first intalment of 'Thor'), and twin mutants kept in separate rooms with very different powers, who appear to be intended as future challenges for our protagonists.

More poignantly, we see a glimpse of the incognito Winter Soldier at the Smithsonian reading about Captain America's best friend, Bucky.

This really was a terrific movie, much better than I expected, and because of the pace and intensity you would probably need to watch it at least a couple of times to pick up all the finer points.

Highly recommended!

I am totally "over" the 'Spiderman' franchise, as there can be too much of a good thing, but I look forward to both a new 'X-Men' movie, which goes back to their roots, and forthcoming next installment of 'The Avengers'. Also look out for a fabulous documentary which was on TV recently about the origins of the relatively new Marvel Studios and their vision of the Marvel universe.

Saturday, April 26, 2014

A bouquet for Virgin Australia (Melbourne to Perth)

I recently flew to Perth and back within twenty four hours (for work purposes) with Virgin Australia.

Travelling economy on this occasion was more pleasant than most. Although the flight was about two hours late in leaving Melbourne (allegedly due to bad weather over the past couple of days) and the in-flight entertainment system was not working, it was a pleasant surprise to be offered complimentary beverages and then a hot evening meal (which was reasonably nice). I commented on this and was told that it is standard practice on transcontinental flights. The flight attendants were polite, friendly and helpful.

It was also nice that an announcement asking people to raise teir seats to an upright position was made when the meal was about to be served.

The return flight the next day left on time (and arrived early), the (free) entertainment system was working, and we had the same crew and same food and beverage service. It was nice to be remembered by the friendly flight attendant from the previous day!

Well done to Virgin for making our long trip as pleasant as possible.

Coffee Review - Lavazza Torino Qualita Oro

Lavazza Torino Qualita Oro, 100% Arabica coffee beans.
Medium roasting, strength: 4

"Qualita Oro has an intense taste with the rich flavour and aroma expected from a true Italian espresso."

I have been grinding the beans at home (on a fine setting) and then brewing the coffee in a standard large coffee plunger.

When drunk black, this coffee has a full-bodied, nutty flavour with a hint of sweetness. It is smooth on the tongue rather than being noticeably bitter, but there is an underlying sense of that warm and rich bitterness that you get with a good dark chocolate. The aftertaste decays gradually.

Adding milk dampens down the sense of bitterness and enhances the smoothness, and it would be quite easy to drink a lot in one sitting!

Verdict: a pleasant, smooth and sophisticated cup of coffee.

Wednesday, April 16, 2014

Steig Larsson: The Girl who kicked the Hornet's Nest (A brief review!)

Having bought all three books in the Millenium trilogy a few years back, I had previously had an abortive attempt at reading this final massive volume of 602 pages.

On a recent long trip I started again from the beginning and succeeded in getting to the end.

For the most part, it is tightly and cleverly written, and reveals the attention to detail in the underlying research. Of course it helps to know the back-story, and the legendary sexual prowess of protagonist Mikael Blomkvist is a little tedious at times, but all the threads of the story are woven together in a masterful and largely satisfying way.

One gets the feeling that it could have been edited a little more tightly, but it is what it is. It portrays strong women, resourceful hackers who it seems can do anything, and a group of elderly men who seemingly have been puppeteers for the Swedish State over many decades.

Given Larsson's untimely demise, it is fitting that it concludes with a raprochement between Blomkvist and Salander.

If you can stay the distance, a worthwhile read!

Music for Easter, St Francis' Choir, Melbourne

If you live in Melbourne and would like to experience some fabulous music in conjunction with the traditional Easter church services, then look no further than St Francis' Choir, Melbourne. Yours truly is back on the Music Repertoire Sub-Committee this year (a one year on, one year off policy) and was especially excited to get some wonderful English and continental polyphony on the program:

http://www.stfrancischoir.org.au/program/program.htm

All welcome!

Red Rooster Fish and Chips "rip-off"

Red Rooster recently started advertising what appeared to be thick chunky succulent and generously sized fillets of flathead with a correspondingly generous service of golden thick cut chips.

The family pack of ten fillets with chips costs $25.00 and I foolishly thought that this would do for a couple of meals. Nothing could have been further from the truth.

The fish fillets were tiny and looked nothing like the picture, also several being a brownish colour on the verge of being burnt, and the chips were soggy and anaemic and definitely not a family serve.

As a result ,this package is literally a "rip off" and much better value can be found by purchasing directly from your local fish and chips shop. Do not be seduced by the misleading advertising! This would definitely be one for the 'pack comparison' segment on The Checkout on the ABC.

Shame on you Red Rooster!

Friday, January 24, 2014

Medical Book Review - Emergency Medicine. The Principles of Practice. Sixth Edition. Authors: G and S Fulde.

Medical Book Review – Emergency Medicine. The Principles of Practice. Sixth Edition.
Gordian Fulde and Sascha Fulde.

Churchill Livingstone/Elsevier Health Sciences
ISBN: 9780729541466 Publication Date: 27-09-2013 RRP: $109.93 (free delivery in Australia/NZ).
For further information see: http://www.elsevierhealth.com.au/emergency-medicine/emergency-medicine-paperbound/9780729541466

I have a previous fourth edition of this book by the highly credentialed Professor Fulde, which I was given whilst at medical school and has done good yeoman service over the years, but this new edition is an impressive replacement. It is also nice to see that Sascha Fulde is carrying on the family tradition. Professor Fulde recently appeared on the news bemoaning the prevalence of alcohol-fuelled violence, and is obviously still very much a ‘hands-on’ clinician as well as an academic writer. This bodes well for the practicality of the contents.

The new edition is considerably heavier, coming in at around 1,030 thin pages, but does have an in-built protective plastic cover which can be wiped clean, which is a definite advantage in terms of infection control. The old book was monochromatic and contained some tables and diagrams, but no photographs. The new edition has a blue, white and black colour scheme, and includes a number of black and white photographs as well as tables and diagrams.

Being a Basic and Advanced Life Support instructor, as soon as I opened the book I loved the fact that it has both the BLS and Adult ALS algorithms inside the front cover, and if you flip it over and look inside the back cover both the Choking and Infants and Children ALS algorithms can be found there. How easy is that!

Turn over another page and you find the “Quick Reference”, compiled by Fiona Chow. This section of 115 pages (with a list of Abbreviations at the end) is a handy little guide. An index is provided on the first page, but with white text on a blue background it is a little difficult to read in less than optimal lighting conditions. The two ALS algorithms are followed by that for newborns and a summary of suggested drug usage in adult and paediatric cardiac arrest. Sections follow on miscellaneous drugs used in adults and children. As well as recommended dosages and route of administration, some indications are also given. There are helpful sections on cardiology and ECGs, respiratory medicine, trauma, metabolic equations and electrolytes, thromboembolism and coagulopathy, neurology, important procedures, toxicology, drug infusions, paediatrics, orthopaedics, obstetrics and gynaecology, dental, common conversions, antibiotic prescribing and normal values. There is potentially some overlap with the discussion of antibiotics as common antibiotics are also listed in the earlier drugs section.

The book proper commences after the Quick Reference section.  The Contents sets out a  summary of what is in the following forty-eight chapters. These have been written by an impressive list of contributors, and the book has been reviewed by a shorter but equally impressive list of personnel.

As you would hope with an emergency medicine textbook, the chapters have a strong practical orientation and provide a lot of ‘how to’ guidance as well as enough of the ‘why’. Chapter 2: Securing the airway, ventilation and procedural sedation, is very comprehensive and detailed, and would provide a lot of comfort to the inexperienced practitioner. Chapter 3: Resuscitation and emergency procedures, provides a very helpful step-by-step guide to several common procedures such as IV cannula insertion. Chapter 4: Diagnostic imaging in emergency patients would probably have benefitted from some illustrations to go with the descriptions provided. The same might apply to the following chapter on ultrasound. A number of chapters dealing with cardiac and respiratory emergencies follows, including a thorough effort to explain the nemesis of many a student and doctor, the ECG.

It is nice to see a separate chapter on pain management in the ED, which is appropriately followed by a chapter on trauma. The chapters then jump around a bit. For instance, neurosurgical emergencies are some distance away from neurological emergencies. In the interim, the book travels through aortic and vascular emergencies, orthopaedics, hand injuries, urological emergencies, burns, patient transport and retrieval , mass casualty incidents and a handy chapter on ‘The seriously ill patient – tips and traps’. As someone who works in the pre-hospital setting and has trained in disaster medicine, I thought it was great to see both the retrieval and mass casualty chapters in this book as coverage of disaster medicine is certainly very common in American emergency medicine textbooks. (Upon checking, they were in the earlier edition also.) Following neurology, the book moves on to chapters on gastrointestinal  and endocrine emergencies and then acid-base and electrolyte disorders (another subject which strikes fear into many hearts but is comprehensively and clearly covered here). The very pertinent topic of poisoning, overdosage, drugs and alcohol follows. This is very detailed and provides advice and information for a number of commonly abused substances.

The final third of the book also jumps around quite a bit in terms of topics and ordering. Common orphans drowning and Envenomation follow next, then electrical injuries, hypothermia and hyperthermia, childhood emergencies, geriatric care, gynaecological emergencies, ophthalmic emergencies, ENT, dental, psychiatric presentations, dermatology, infectious diseases, the immunosuppressed patient and ED haematology.

The book concludes with a collection of six practical and interesting chapters which contain “something for everyone”. These are rural and indigenous emergencies, advanced nursing roles (which should enhance understanding  of what nurses actually do and thus team work), the general practitioner; working with IT (which deals with the vexed issue of interactions between GPs and EDs and provides a template for that essential discharge letter), administration, legal matters, governance and quality care in the ED (a catch-all chapter which contains some important advice on legal issues, including “How do you avoid a law suit?”), and two final chapters of immeasurable worth to residents and medical students: a guide for interns working in emergency medicine, and a student’s guide to the emergency department. It is nice to see that Sasha and Tiffany Fulde and Richard Sullivan, all doctors-in-training, have between them contributed to the pearls of wisdom in these chapters.

Whilst writing this review in the late afternoon and the transition to artificial light, I did find the pale blue headings in the chapters a bit difficult to read as they do not stand out well against the bright white of the pages. Paragraphs of pale blue text fortunately do not occur frequently in the book, but they are even harder to read in artificial light, especially as the pages are a bit shiny and the light source reflects off the surface of the page.

Another small criticism that I would have from recently ‘road-testing’ the book out on location is that the Index at the back could be better. For instance, I went to look up “penetrating eye injury” under E for eyes but it wasn’t there (not there under ‘penetrating’ either). I knew it would have to be in a book about emergency medicine, so went to the Contents and found the chapter on Ophthalmic Emergencies and of course it was there. There was one other similar example that I came across during testing.

My only other comments about things that ideally I might have liked to see is more intuitive chapter groupings and perhaps a few more diagrams and pictures where these could contribute to better understanding. Even if that is not possible, are there online resources that people could be referred to, such as YouTube? For instance, knowing how to reduce a shoulder dislocation is much easier if you can see it done properly first. (Apparently there is a separate eBook available for purchase which contains enhanced content, but this does not assist the purchaser of the print edition.)

As a review of the section on penetrating eye injuries demonstrates, this is a book grounded in emergency department practice rather than a first aid manual. It assumes that the first aid has been done and that the patient has come into the department and that you are getting on with history, examination and management. It is an enormously impressive resource, even though it did not always have quite as much detail as I would have liked on a particular topic. I guess everyone’s needs will vary in this regard, depending on your pre-existing knowledge and level of training and inquiry, but the authors have done a very good and solid job in covering the basics. Some chapters do drill down into a lot of detail.

The authors are also to be commended for including cutting-edge and imaginative topics amongst the chapters that are really going to provide practical value for doctors at the front line.

I feel this is a “must have” book for any Australian doctors interested in or involved in practising emergency medicine. It is written for local conditions by local authors from a variety of clinical backgrounds.

It is probably a bit thick and heavy to carry around in your pocket, but indispensible to keep in your bag for ready reference. For those with smartphones and tablets, the back cover of the book refers to standard and enhanced eBook versions and a PocketED app.

Verdict: Highly recommended!

Sunday, November 17, 2013

Movie Review: Gravity (3D)

This is an amazing movie and an absolutely vivid experience in 3D. I have no idea how the movie makers so convincingly created the impression of the actors being in outer space floating above the Earth (the movie was filmed at Shepparton Studios in England). The special effects are incredible, including several space walks, debris hurtling around the Earth, the space shuttle Endeavour, the International Space Station, a Chinese space station, a Soyuz capsule and its Chinese equivalent.

It is even more remarkable for the whole story being carried by only two actors (George Clooney and Sandra Bullock) and for a time the disembodied voice of Mission Control (Ed Harris - a neat tribute to his previous roles). Clooney plays a convincing role as jocular seasoned astronaut Matt Kowalski acting as mentor to nervous newbie Dr Ryan Stone.

This is a disaster movie, but a very personalised one. There is the customary large-scale destruction, with debris resulting from the Russians accidentally shooting their own satellite creating havoc and tearing at high speed through the space shuttle, the ISSS and the Chinese station and many other satellites, blacking out communication with Mission Control.

In the opening scene, Kowlaski, Stone and one other astronaut are outside the space shuttle conducting some repairs to the Hubble Space Telescope. Initially it seems that the debris will miss them, but due to a chain reaction it is suddenly heading their way. The three astronauts do not have time to get back inside the shuttle and end up floating in space. Stone is suitably panicked by the situation and starts hyperventilating and uttering lots of disconsolate grunts. Kowalski has a jet pack and manages to rescue her and clip them together, but their other colleagues are not so lucky. Ever calm, he hatches a plan to travel across a large expanse of space to the ISSS, from whence they will take a Soyuz capsule back to Earth. During their journey he manages to engage with Stone on a personal level and finds out that she tragically lost her only child, a daughter, at the age of four. As they approach the ISSS, it is clear that the station is deserted, with one Soyuz gone and the other is damaged, with the parachute deployed. Kowalski determines that it is still serviceable enough to hitch a ride across to the Chinese space station Tiangong, from whence they can take the Soyuz-equivalent capsule back to Earth.

By the time they near the ISSS, all of Stone's oxygen is gone apart from the air in her suit. By a combination of circumstances, they overshoot the station and are about to drift off into space. Miraculously Stone's foot is caught by the strands of the parachute. However, the pull of Kowalski's weight being tethered to her causes the grip to loosen. Kowalski can see that her only chance of survival lies with him unclipping their connection, and with a remark about breaking the spacewalking record, he lets go. Stone is distraught and insists that she will come and get him.

Drowsy from the lack of oxygen, Stone barely manages to get inside the ISSS. She recompresses the airlock, takes off her spacesuit and floats blissfully in a foetal position for what seems like an eternity. A journey through the station to Soyuz results in further disaster as a loose panel sparks when slammed shut but she does not realise this as she floats past. She tries to raise Kowalski and applies the same positive psychology techniques that he earlier used on her. Before too long the fire has taken hold and spread, and Stone once again barely manages to get into Soyuz and as a last-minute thought takes the fire extinguisher with her. At the time it seemed to be a bit of a strange thing to do, as surely there would be one inside the capsule, but like Gollum in The Lord of the Rings, this device has a future role to play for good or for ill.

Stone gets ready to propel the capsule off towards the Chinese station but the parachute anchors are holding tight. She sets off on another spacewalk to unscrew them just as the debris arrives on its second orbit, effectively destroying the ISSS as she struggles to set the restraining wires free. Having succeeded, she gets away from the mayhem only to discover that she is drifting in space with no fuel left.

Desperately trying to make communication with anyone, she issues a 'Mayday'. To her surprise, she picks up an earthbound signal which is coupled with interference. It is a language she does not understand (an Inuit from Greenland) and there is a dog and a baby in the background. Stone talks about realising that today is the day she is going to die, and turns down the lights and turns off the oxygen pressurisation dial in the capsule and lies back in her seat.

Suddenly the hatch opens and in climbs Kowlaski. In good humour, he says it is "quite a story" as to how he managed to be there. He immediately turns on the lights and the oxygen and pulls out a bottle of vodka from under the dashboard, having previously indicated that he knows where the Russians hide it, and takes a swig after offering it to Stone, who declines. Stone is agitated, as she explains that she is out of options as the fuel tanks are empty. Kowalski jovially retorts that there are always options, and the landing thrusters can still be used to propel them towards the Chinese station Tiangong from whence they can travel home as the Chinese capsule is exactly the same as Soyuz. Stone has been concerned about flying the capsule as she always crashed it in the simulator.

Equally suddenly, Kowalski is gone and Stone sits up with a jolt. She thanks Kowlaski for the insight and decides to go home. She asks him to remember her to her daughter. With the lights and oxygen restored, Stone determines how to separate the landing module from the other components of Soyuz and engage the thrusters. This successfully done, she heads off towards the Chinese station. As she nears the station, she has another moment of insight, dons her spacesuit and exits with the fire extinguisher. In scenes reminiscent of the Wild West, she tumbles and turns through space using the extinguisher as her jet pack. Once again she nearly overshoots, but manages to grab onto a railing at the last possible moment.

Once inside she heads for the Soyuz equivalent just as the storm of debris arrives again. This time all the lettering is in Chinese so there is an excruciating game of "eenie meenie miney moe" as Stone works how to disengage the capsule and head home. She is accompanied by a fiery band of debris from the now-destroyed space station heading alongside towards Earth.

Somewhat miraculously, the capsule lands in a lake not far from shore. When Stone opens the door, the capsule starts to flood and sink to the bottom. She eventually manages to swim out, but the weight of her spacesuit prevents her from rising to the surface. She discards it and swims upward towards the light and surfaces. In an echo of her foetal position on the ISSS, she floats blissfully on the surface and drifts towards the shore. Stone drags herself out of the water and grabs a handful of the red earth, savouring the feeling of being back on terra firma. Like a newborn foal, she struggles to rise to her feet, the effects of having been weightless for an extended period evident, and then triumphally succeeds. The film ends with the camera behind Stone, who is facing the wilderness in the knowledge that a rescue mission is on the way.

Sandra Bullock's extraordinary performance carries this film. It is unusual for a film to feature only two actors and even more unusual for the weight of the film to fall on only one actor. Apart from Clooney's brief cameo as a hallucination and the foreign language triumvirate of man, dog and child, Bullock's character is entirely alone in space.

At the start of the film, we are reminded that space is a completely inhospitable environment, where not only can no-one hear you scream, but unaided survival is impossible.

This is a classic story of salvation and survival against the odds. In the first act we discover the unsure and tortured rookie who finds a kindly mentor only to lose him again in tragic circumstances. He sacrifices himself and implores her to live. In the second act she finds her courage as a sole survivor in a truly remarkable way, but then seems out of options and decides to die in a controlled and dignified way ("pray for me"). At the start of the third act, after a delirious deus ex machina moment, she realises that she wants to live and finds the courage and the means to achieve this. It is a story worthy of any saga or heroic poem.

For a single actor to achieve in a convincing way such a depth of characterisation and range of emotion in terrifying circumstances where the odds are never good is nothing short of remarkable. Both terror and tension are palpable for much of the film, and it is all plausable enough for the willing suspension of disbelief. I did find Bullock's fearful grunts and vocalisations a bit wearing, but perhaps it was felt necessary to have some sound to interject into the silence. At other times the music score is quite powerful.

I would not be surprised if this film is the recipient of a number of Academy Award nominations. Does Bullock deserve an Oscar - yes, absolutely!

(P.S. A nice touch from the Australian perspective that astronaut Andrew (“Andy”) Thomas was an advisor to the project.)

Verdict: Highly recommended!

Getting a quote from an arborist – Simpson’s Tree Service, Melbourne

The rather large tree overhanging the back of several body corporate units needs a trim in order to preserve neighbourhood equanimity so it was time to get some quotes from qualified arborists. Three is always a good number, and the final quote was obtained from Simpson’s Tree Service as it had contributed to a feature article in the local newspaper not long ago and came off sounding as if it is an experienced and reputable company.

The first two gentlemen who came to quote (from other companies) had been personable and engaged in social niceties such as introducing themselves and shaking hands. In contrast, the representative from Simpson’s Tree Service (whom I will call "Mr STS") was taciturn and world-weary and did not offer his hand. However, he was thorough in assessing the tree and cited his lengthy experience and provided a well-considered quotation. I bade him farewell with a non-committal remark about being in touch later and some time went by without further contact.

Late last week I happened to be working at home and had the doorbell turned off as is customary unless someone is expected. There was a knock on the front window and as I approached the front door there was a strong stench of cigarette smoke. I opened the door and went outside and was surprised to see several men in work clothes standing around. The apparent leader made a scarcastic remark about the bees flying in and out of a gap in the masonry between units: "just admiring your bees' nest" and then said "can we get this car out of the way", referring to my car which was parked in the carport. I appeared puzzled and this man (wearing sunglasses and ear muffs) said "we're here to do the tree". I then realised that this was Mr STS. I indicated that I had not made a booking and I did not believe that any other owners had done so either. He seemed unconvinced and appeared annoyed, so I indicated that I would make a telephone call to check this. He also remarked "aren't we getting the job?", to which I indicated that it was my belief that a decision had not yet been made. I made the 'phone call and confirmed that no booking had been made and that confirmation of the chosen arborist was subject to Body Corporate ratification. I conveyed this information to Mr STS, who once again seemed unconvinced and attempted to persuade me to go ahead on the spot. I politely declined and reiterated that I was sorry, but no booking had been made. Mr STS appeared aggrieved but retreated. At no time did Mr STS remove his sunglasses whilst talking to me. As I turned to return inside I noticed that the offending cigarette butt had been thrown onto the front lawn just next to my car.

As there is no rear exit, the tree branches would have to be brought through one of the units and considerable preparation would be involved in rearranging furniture to provide clear access so it was simply not practicable to accede to his request to allow them to commence work "on the spot".

However, as a result of this episode, they will not be getting the job. I was not impressed with the attitude and behaviour of Mr STS and his crew, which I felt was unprofessional. I felt that I was not treated with respect and common niceties were dispensed with. I came away feeling that this had been an unsavoury experience and had the perception of having being stood-over by an unpleasant man in sunglasses who seemed unwilling to acknowledge that the problem had originated at their end.

WARNING - Do not buy from Megabuy.com.au!

This is a bit of a belated review, but I had such a bad experience with megabuy.com.au I would like to warn others about this. In my experience this company engages in bait advertising and snowballing tactics and then fails to provide any customer service and delays providing a refund, using your money for working capital. This is the worst online ordering scam that I have encountered.

On Wednesday 8 May I received an email from Megabuy advertising the latest Apple iPod Touch 5th Generation 64Gb in yellow for $299.00 ($323.03 incuding courier and credit card charges). Since my iPod had been stolen at New Year and I had limited insurance money to replace it, this was the best price I had seen so I ordered one late in the evening. The next day I received another email advertising the same model in pink for the same price, so I rang up to change my order. I was assured that stock was available and that one would be put aside for me.

My credit card was debited on 8 May and I expected to receive my new iPod within a couple of days as per the delivery advice. I waited and waited and nothing arrived. A few days later I received an email saying that, as a new customer, I had to verify my identity in order to avoid fraud. I had to provide an alternative email address and/or a work telephone number and someone who could vouch for me being who I said I was. This appeared to be a scam to obtain personal information, and as the credit card payment had already been processed, it was a suspicious and inexplicable breach of privacy for a minor purchase.

After complaining about this and referring Megabuy to my public web presences that verified my identity, I received another email advising me that stock had run out and that my order could not be satisfied.

I complained about this and Megabuy claimed that, despite a unit having been put aside for me, they had "completely run out of stock" and offered me either a refund or a 32Gb model for the same price (half the capacity of the one that I ordered). Despite threats to report them to Fair Trading and the ACCC (which unfortunately I have not had time to do), there was no response to my complaints and insistence that the item be supplied as ordered and paid for, and I simply received an email on 31 May saying that my order status had been changed to "refund" and a refund would be provided within 24-48 hours. A refund was not received until 6 June 2013. Megabuy had my money for nearly a month.

In summary, Megabuy:

  • engaged in bait advertising;
  • confirmed that stock was available and set aside for me but later failed to honour this;
  • debited my credit card at the time of placing the order (rather than after confirming stock availability);
  • 'snowballed' on delivery through making a very suspicious demand for further personal employment and contact details;
  • subsequently claimed that all stock had run out;
  • offered an item of lesser value and capacity for the same price;
  • did not respond to my consumer complaints and threats to report them to consumer affairs authorities; and
  • took a month to refund my money utilising it for working capital in the meanwhile.

As a result, I strongly recommend against dealing with them no matter how good their prices sound - if it is too good to be true, it probably is, and no-one should have to go through this sort of experience if you are dealing with a reputable company.

Why are we waiting? - mixed experiences with Virgin Australia

I have recently made two day trips to Sydney to take workshops at some Advanced Life Support courses. Both times I flew with Virgin Australia and then took the airport train and a suburban train to within walking distance of my destination.

The first round trip was on a Friday in late October, and turned out to be a bit of a horror story from a flight perspective. I left home at 06:50 and then finally returned home at 22:30 for a very late dinner.

I drove myself to the airport and arrived in plenty of time as I did not have any luggage other than my carry-on backpack. I checked the departures screen on arrival, and was dismayed to see that my 08:30 flight had been cancelled. My blood pressure was already rising, as I had to be at my destination in Sydney no later than 12:30 to set up for the afternoon workshops. I wasn't sure what to do, as the check-in area was crammed with people and I knew from experience that it would take about 45 minutes to get to the front. I rang my colleague in Sydney and he suggested going to the barely populated Priority Check-In desk. I did this, only to be told off as I am a mere Velocity Red member as opposed to a Gold or Platinum member or Business Class flyer who would actually qualify to use this desk. However, fortunately they helped me anyway.

First of all I was told that I had been re-booked on a flight to Cairns at 09:00. Cairns???? It took some time to sort this out as of course I was going to Sydney. I was eventually re-booked on an 09:00 flight to Sydney, but there was further consternation and discussion as the fare class was more expensive than my original fare. Close to 30 minutes later I finally walked away with a new boarding pass in hand. At that stage I noticed that there was a Service Desk nearby, but its existence had been completely obscured by the crowd of people queued up around it and there were no overhead signs to assist in locating it. I went through Security and headed for the Gate Lounge.

Alas my new flight was not running on time either, and in the end was delayed by a further 55 minutes. By this stage it was a long time since I had eaten or drunk anything substantial and I started feeling both mildly hypoglycaemic and caffeine-deprived. By the time the complimentary coffee arrived on the aircraft I had quite a headache. However, I was pleasantly surprised to be given some yoghurt and a muffin as this was included with my new and improved fare class. I scoffed the yoghurt and saved the muffin for later, as I had a feeling that I would be needing it during the afternoon (which proved to be the case).

When I arrived at Sydney Airport the Visitor Help Desk was not manned, and the person I waited to speak to at the city bus counter had not heard of the private hospital that I had to travel to, but helpfully looked it up on his iPhone and made a suggestion as to the nearest train station. I went down to buy an Airport Train ticket, and the service person wasn't sure where I had to get off either, but sold me a ticket to what he thought would be the nearest station. I had to change at Central, and as I still wasn't clear where I was going, I asked the lady in the control booth. Miraculously she was familiar with the hospital and the area and was able to suggest both the nearest train station and how to walk to the hospital from there.

Sydney has marvellous double-decker suburban trains, and it was a bit of a thrill to travel across the Sydney Harbour Bridge by train. Eventually I arrived at St Leonards, but the girl in the ticket office had no idea where the Mercy Hospital was, and time was marching on, so I went out the front and took a taxi for the final leg. The hospital was more or less straight down the road, but it was certainly quicker by taxi. I arrived at 12:25, but there was no time for lunch and half a sandwich later it was on with set-up. The workshops were fairly full-on and then we had to pack up all the equipment afterwards. My colleague drove me back to the airport, arriving at 17:20.

This was a day when lightning did indeed strike twice. The flight home was delayed and the gate was also changed without telling anyone until I noticed that my flight had disappeared from the lounge display screen and made an enquiry. I was missing my afternoon coffee and was getting increasingly hungry and headachey, so after consuming the banana muffin I decided to self-medicate with a large cappuccino from the airport McDonalds, this being the best value. After an extremely long wait, the coffee was finally mine. It was actually very nice. It was a dark but smooth roast with depth of flavour. My strength renewed, I approached the gate lounge staff to ask whether it might be possible to change to an earlier flight, but unfortunately it was completely full, so I went back to waiting.

I think that my frustration was made worse as my work colleague had been telling me how nice it was to spend time in the Qantas and Virgin lounges whilst waiting for a flight. These provide a quiet and comfortable environment with free internet access, food and drink. As he travels frequently there is no problem with maintaining enough "status points" to get into the lounges. However, whilst I have a massive number of Velocity points I have nowhere near enough "status points" to gain access to the lounge.

On the fight back complimentary tea, coffee and alcohol were offered, but no food. I felt this was very inappropriate as the flight had been badly delayed and most people would be ravenous and it is never a good idea to drink alcohol on an empty stomach.

My flight departed 65 minutes late and I eventually landed in Melbourne at 21:30. After catching the bus back to the Long Term Car Park I drove home to enjoy my now very soggy fish and ships at about 11pm.

In total I spent 5 hours and 50 minutes waiting around at the airports waiting for delayed flights. It really was a physically draining ordeal on top of all the other travelling time. At the end of it I was actually hesitant at the thought of ever flying Virgin again.

However, as I am trying to accumulate enough Velocity points to get a "reward" flight to travel to an overseas conference next year, I bravely agreed to take another Virgin return trip the following time that I had to go to Sydney for work.

Fortunately the second time went more smoothly. The morning flight ran to time, but as it was a Sunday there were multiple delays due to the infrequency of trains. I took the Airport Train to Central and then travelled to Westmead and walked to the Private Hospital. Amazingly the major road I had to turn down did not have a signpost so for some distance I was not sure that I was actually on the right road! This time I arrived at 12:15 and had a little time to eat before we had to set up for the workshops. The workshops went well, and my colleague dropped me back at Westmead station shortly after 16:30. I had to wait for a train to Central and then wait at Central for the Airport Train. I actually found the stop to get off at a little confusing, as I recalled Mascot being the name of the airport "in the olden days". Wrong! I alighted in confusion at Mascot station and it turned out that this is now a suburban station and the domestic airport was one stop further along. After another fifteen minutes' wait I finally arrived at the airport.

According to the Departures board my 19:00 flight was now scheduled for 19:40. Dismayed I approached the check-in desk shortly before 18:00 and asked if it was possible to take an earlier flight. The lady at the desk very kindly helped me and transferred me to the 18:30 flight. I was in a hurry to get to the gate lounge, but there were delays at the security screening and just as I started to run for the gate I was grabbed by the man with the explosives screening wand and forced to submit to my bag and my shoes being checked, and during this process I was further distressed that my computer was knocked off the small shelf that my bag was on and fell onto the floor. Fortunately it does not appear to be damaged.

Food-wise this time I had planned ahead and had brought a thermos of coffee and a muesli bar. I ate this together with the last few mouthfuls of cold coffee whilst I was waiting at Mascot.

The return flight was mercifully running more or less on time and I arrived home for another late dinner just after 21:00.

Virgin did much better the second time around but both times it was a very long and tiring day. It would have no doubt been a lot easier and more pleasant if it was possible to pop into the Lounge whilst waiting, and I can't imagine doing a regular commute of this nature on any other basis.

Vale Fatso the Warfarin-resistant mouse

Over the past few months it was not unusual whilst sitting at the kitchen table and working to catch a glimpse out of the corner of your eye of a daredevil dark brown shape darting across the floor. This 'Scarlet Pimpernel' of the mouse world could be seen at any hour of the day or night and seemed to have a voracious appetite for Ratsac pellets (which contain a Warfarin equivalent). This little mouse appeared to be plump and prosperous, with a sleek and shiny chestnut coat. As a result he was dubbed 'Fatso' and almost was around for so long that he almost became a household pet!

Some days after a small and considerably skinnier grey mouse succumbed to the pellets, I came downstairs one morning with a migraine and noticed a dark shape stationary on the floor near the pantry. Once fortified by analgesia I returned to the spot to investigate. There sat an unwell-looking plump brown mouse. Alas Fatso had consumed one pellet too many.

I pondered what to do. It was a lovely warm and sunny day, and in the end I decided the most humane thing to do was to scoop Fatso up in a small container and take him outside to enjoy the sunshine before he too finally succumbed. You could tell that the spirit was willing but the flesh was weak and he was unable to put up much of a struggle. I deposited him on top of the rich mulch at the base of a huge Desert Ash tree and left him in peace.

His chestnut coat glistened and looked positively beautiful in the sunlight and his perfectly formed little feet were gorgeous. Even though he qualifies as vermin, it was still a sad moment as I knew that he was not long for this world. I also paused to think how ironic it is that mice and rats have done so much to help humans through medical research whilst simultaneously causing so much havoc and disease, the most famous case of which being the transmission (by rats) of Yersinia pestis ("the Black Plague").

Fatso was certainly a survivor, and perhaps even a genetic mutant - he also had a curiously bent tail. However, it is possible that he acquired this via the thrillseeker run through the refrigerator fan, which was a cause of mortality for at least one of his colleagues.

Vale Fatso - a memorable character!