"Surgery: The Ultimate Placebo" by Professor Ian Harris (New South Books, Australian RRP $24.99).
Showing posts with label Healthcare. Show all posts
Showing posts with label Healthcare. Show all posts
Thursday, May 5, 2016
Book Review - "Surgery: The Ultimate Placebo" by Professor Ian Harris
This is a "must read" book - it has a great explanation of how evidence-based science works (or doesn't) and challenges us to question whether doing things "because that is the way we have always done it" is in fact the best way to do things or whether it should be done at all, for instance treating appendicitis at first instance with surgery rather than a trial of IV antibiotics.
"Surgery: The Ultimate Placebo" by Professor Ian Harris (New South Books, Australian RRP $24.99).
"Surgery: The Ultimate Placebo" by Professor Ian Harris (New South Books, Australian RRP $24.99).
Saturday, April 16, 2016
The Southern Hemisphere 'Flu Season is underway - get your 'flu shot!
The Southern Hemisphere 'flu season is upon us. I had my 'flu shot a couple of days ago, and would recommend it for all adults (baring contraindications).
Available from your friendly GP or from many chemists. For instance, Chemist Warehouse is offering the trivalent for $8.99 and quadrivalent (what I had) for $11.99. A small investment potentially to prevent an extended period of illness and absence from work/study etc.
Available from your friendly GP or from many chemists. For instance, Chemist Warehouse is offering the trivalent for $8.99 and quadrivalent (what I had) for $11.99. A small investment potentially to prevent an extended period of illness and absence from work/study etc.
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:
For further interesting health news and research articles, see the following board on Pinterest:
http://www.pinterest.com/rowenachristian/health-news/
This small article about the health benefits of an apple a day appeared in the February 2014 issue of CHOICE:
For further interesting health news and research articles, see the following board on Pinterest:
http://www.pinterest.com/rowenachristian/health-news/
Monday, August 5, 2013
How much water should you drink? A scientific assessment.
Water: Mysterious and marvellous
Water needs to be
consumed according to need, not rules, so knowing when and how often to drink
it involves staying once step ahead of thirst.
Author: Professor David Cameron Smith
(Originally published in CHOICE Health Reader, June 2013, page 3.)
Water is essential for life. The right to clean water,
along with food, are basic human rights endorsed by the General Assembly of the
United Nations. Many people, however, continue to live in areas where the
scarcity or pollution of water makes daily life a struggle.
Water makes up between 30-70% of total body mass,
depending upon levels of body fat. Of the parts of the body that are not
comprised of fat, including the muscle, brain and internal organs, water is on
average 73.2% of the total weight. Within each of these tissues the level of
water is carefully managed to ensure optimal cellular function.
Managing water levels in cells is an ongoing process
where electrolytes (salts) are continually pumped in or out of cells to control
the osmotic pressure. Water moves from areas of low electrolytes (and hence
high water concentration) to areas of high electrolytes (and lower water
concentration).
Managing water in the body is even more complex
because it is continually lost through a variety of ways. Everyday water is
lost in respiration (expired breath), urine, faeces and sweat. Balancing this
loss is water that is consumed in liquids or as part of foods, like some fruits
and vegetables.
The desire for fluids is driven by changes in blood
volume and the concentrations of electrolytes. Both mechanisms are not
activated by subtle changes in hydrated status, so thirst is often felt well
after considerable amounts of water are lost from the body.
Consumption guidelines
The wide variation in physical activity, climate and body
size make prescribing required water each day extremely difficult. Given the
widespread (and sometimes inaccurate) reporting that inadequate hydration
impairs mental and sporting performance, it has become commonplace to accept
the dogma that humans need ‘at least eight glasses of water a day’. There is no
scientific basis to this statement.
Fluid intake, preferably water, needs to be adaptable
and increase when water loss is likely to be greater. Continuous swigging of
water from an ever-present water bottle has no advantages, particularly in the
absence of exertion in an ambient environment. In fact, there is some evidence
that athletes perform slightly better by running themselves ‘a little dry’.
Daily fluid needs remain difficult to determine and
fluid intake should be dynamic and not rigid. Water has few health risks,
although there is a small risk of hyponatraemia (when the amount of water in
the body dilutes the electrolytes enough to affect heart rhythms). Only
dangerous in extremes and found mainly in endurance athletes, hyponatraemia is
unlikely in the general population. The other side effect of excessive drinking
is frequent urination. Exactly what constitutes enough water depends on your
day, so drink responsibly and according to your body’s needs.
For reference: Rush EC et al. Water:
neglected, unappreciated and under researched. European Journal of Clinical Nutrition 2013; Jan 30. doi
10.1038/ejcn.2013.11. [Epub ahead of print].
Thursday, April 4, 2013
When the doctor becomes a patient - reflections on a constrained public health system.
Sometimes when you have a health issue it can take a long time to tease out exactly what is responsible for your presenting symptoms. In my own case this applies to the debilitating post-viral fatigue that I developed after a trek in Nepal in late 2011.
The jury is still out, but I have already been assessed by three departments of one of our major teaching hospitals, including Infectious Diseases, Haematology and Neurology.
Many of my appointments have involved the customary long wait in the Outpatients Department along with a herd of other people. I think at worst this has been about three hours. On this occasion one saintly staff member started bringing around cups of water to the waiting crowd.
We are lucky to have a fine public hospital system in Australia that gives people access to the specialist care that they could not otherwise afford, but it is a pity that there does not seem to be any antidote to either the lengthy delay in scheduling of appointments or the crowded and slow-moving waiting rooms. Despite these trying circumstances, people are generally still very resigned, patient and polite and remain grateful for the attention they receive. We are conditioned to accept that it "is what it is" in terms of waiting for healthcare, whether it is at the GP or in the Emergency Department or Outpatients.
However, I digress. For my neurological symptoms I was fortunate to see an experienced consultant whom I knew of by reputation. In addition to blood tests I was scheduled for a Neurophysiology nerve conduction study and two MRI scans (brain and lumbar spine). There was a little bit of a wait on the day of the nerve conduction study and I was a little concerned whether I would get back to my car within the two-hour parking limit but fortunately I got back with about five minutes to spare. The study itself was an interesting experience. I had used a nerve stimulator on other people during anaesthetics training and had tried a TENS machine on myself, so initially it was quite similar to this, with electrodes being attached to my skin and conduction being measured with electrical stimulation, both before and after "exercise". As my muscles were getting fatigued with exertion, I had assumed this aspect would involve at least moderate exertion of a reasonable duration, but this was a faulty assumption. This component involved only a small number of repetitions of almost minimal movement e.g., opening and closing your thumb. The second aspect involved the insertion of fine needles under the skin, identifying pairs of nerves and measuring conduction. This caused a little bit of bleeding in my forehead so pressure had to be applied to prevent a haematoma and bruising. I was quite surprised that this area was exquisitely tender for about ten days afterwards.
My first MRI (brain) was in the public section of the hospital. Once again I did not have to wait too long to be called through. After changing into a hospital gown there was a little bit more of a wait before one of the nurses inserted an IV cannula in my arm (for administration of contrast) and went through the safety checklist. The cannula took two attempts but we had a nice conversation, and I was asked several times if I was warm enough. I was given some headphones to listen to music during the MRI scan (rather loud and bombastic classical music unfortunately) and was again asked several times during the scan if everything was OK. There were lots of loud noises, clicks, whirring and even some vibrating from the scanner, but time passed quickly enough. I can see why some people might feel claustrophobic in the small narrow tunnel, but I just closed my eyes and tried to assume as meditative a state as possible, and all was fine.
The second MRI (lumbar spine) was in the private section of the same hospital one evening. This time it was a long wait for the scan and in the holding bay before the scan, but the staff was attentive and caring. I had a 7pm appointment and left at 9pm.
My outpatients appointment was on 22 March, but the day before the second MRI I received an unexpected letter advising me of an appointment for a third MRI on 9th April. I queried this at my second appointment, and was advised that there had in fact been three MRIs requested (brain, lumbar spine and cervical spine), but this had only just been realized so a third scan had been booked. I was concerned that this booking took place after my outpatients appointment (for which I had already been waiting several months) had been scheduled. In the end I was just told “sorry, we can’t make it any earlier”. I then contacted Outpatients, and asked for an early appointment after my third MRI scan. It was a case of “sorry, the earliest is 10th May”. A few weeks later I received a letter advising me (without explanation) that the appointment had been moved to the 25th of May, which was two months after my previous appointment.
I will now be having the review of my blood tests and investigations six months after my initial appointment with the neurologist. It will then be over eighteen months since I first attended the hospital seeking a diagnosis for my post-viral fatigue.
I have gone through this process to date the same as any other person, without any special favours due to my vocation. This first-hand view of a compartmentalized and overstretched system is not reassuring in terms of the health care of the average person without the benefit of medical training to assuage their fears. On an individual level, everyone is doing their job and doing it well (with the exception of failing to book a third scan around the same time as the other two) and as is so often the case it is perhaps systemic issues that need to be addressed. Surely we can do better. It would be interesting to know how often logisticians and systems analysts have been included in review teams focusing on how to make our health services function more efficiently.
The jury is still out, but I have already been assessed by three departments of one of our major teaching hospitals, including Infectious Diseases, Haematology and Neurology.
Many of my appointments have involved the customary long wait in the Outpatients Department along with a herd of other people. I think at worst this has been about three hours. On this occasion one saintly staff member started bringing around cups of water to the waiting crowd.
We are lucky to have a fine public hospital system in Australia that gives people access to the specialist care that they could not otherwise afford, but it is a pity that there does not seem to be any antidote to either the lengthy delay in scheduling of appointments or the crowded and slow-moving waiting rooms. Despite these trying circumstances, people are generally still very resigned, patient and polite and remain grateful for the attention they receive. We are conditioned to accept that it "is what it is" in terms of waiting for healthcare, whether it is at the GP or in the Emergency Department or Outpatients.
However, I digress. For my neurological symptoms I was fortunate to see an experienced consultant whom I knew of by reputation. In addition to blood tests I was scheduled for a Neurophysiology nerve conduction study and two MRI scans (brain and lumbar spine). There was a little bit of a wait on the day of the nerve conduction study and I was a little concerned whether I would get back to my car within the two-hour parking limit but fortunately I got back with about five minutes to spare. The study itself was an interesting experience. I had used a nerve stimulator on other people during anaesthetics training and had tried a TENS machine on myself, so initially it was quite similar to this, with electrodes being attached to my skin and conduction being measured with electrical stimulation, both before and after "exercise". As my muscles were getting fatigued with exertion, I had assumed this aspect would involve at least moderate exertion of a reasonable duration, but this was a faulty assumption. This component involved only a small number of repetitions of almost minimal movement e.g., opening and closing your thumb. The second aspect involved the insertion of fine needles under the skin, identifying pairs of nerves and measuring conduction. This caused a little bit of bleeding in my forehead so pressure had to be applied to prevent a haematoma and bruising. I was quite surprised that this area was exquisitely tender for about ten days afterwards.
My first MRI (brain) was in the public section of the hospital. Once again I did not have to wait too long to be called through. After changing into a hospital gown there was a little bit more of a wait before one of the nurses inserted an IV cannula in my arm (for administration of contrast) and went through the safety checklist. The cannula took two attempts but we had a nice conversation, and I was asked several times if I was warm enough. I was given some headphones to listen to music during the MRI scan (rather loud and bombastic classical music unfortunately) and was again asked several times during the scan if everything was OK. There were lots of loud noises, clicks, whirring and even some vibrating from the scanner, but time passed quickly enough. I can see why some people might feel claustrophobic in the small narrow tunnel, but I just closed my eyes and tried to assume as meditative a state as possible, and all was fine.
The second MRI (lumbar spine) was in the private section of the same hospital one evening. This time it was a long wait for the scan and in the holding bay before the scan, but the staff was attentive and caring. I had a 7pm appointment and left at 9pm.
My outpatients appointment was on 22 March, but the day before the second MRI I received an unexpected letter advising me of an appointment for a third MRI on 9th April. I queried this at my second appointment, and was advised that there had in fact been three MRIs requested (brain, lumbar spine and cervical spine), but this had only just been realized so a third scan had been booked. I was concerned that this booking took place after my outpatients appointment (for which I had already been waiting several months) had been scheduled. In the end I was just told “sorry, we can’t make it any earlier”. I then contacted Outpatients, and asked for an early appointment after my third MRI scan. It was a case of “sorry, the earliest is 10th May”. A few weeks later I received a letter advising me (without explanation) that the appointment had been moved to the 25th of May, which was two months after my previous appointment.
I will now be having the review of my blood tests and investigations six months after my initial appointment with the neurologist. It will then be over eighteen months since I first attended the hospital seeking a diagnosis for my post-viral fatigue.
I have gone through this process to date the same as any other person, without any special favours due to my vocation. This first-hand view of a compartmentalized and overstretched system is not reassuring in terms of the health care of the average person without the benefit of medical training to assuage their fears. On an individual level, everyone is doing their job and doing it well (with the exception of failing to book a third scan around the same time as the other two) and as is so often the case it is perhaps systemic issues that need to be addressed. Surely we can do better. It would be interesting to know how often logisticians and systems analysts have been included in review teams focusing on how to make our health services function more efficiently.
Migraine Attack - How are the mighty fallen!
After successfully enduring the rigors of standing and singing for the four major Easter services on Holy Thursday, Good Friday x 2, Easter Vigil and Easter Sunday, I was laid low on Easter Monday with a massive migraine. I felt a few 'niggles' of a headache before going to bed tired on Sunday evening, but took some simple analgesia and thought nothing more of it. The migraine crept upon me in the early hours of Monday morning, and I tried all the usual simple remedies - a hot pack to the neck, simple analgesia, anti-emetics and caffeine, but to no avail. The waves of nausea sweeping over me became more and more insistent, and in the end I had no choice but to succumb. I was amazed at the amount of liquid that issued forth, and had to conclude that the migraine had brought on a case of gastric stasis and that everything I had drunk during the morning had gone no further than my stomach. As usual, I felt much better after vomiting and was able eventually to go on and retain an anti-emetic and a prescribed migraine tablet (usually kept as a "last resort" due to the cost per tablet). Although I was now feeling a bit better, I was quite listless. I had no energy to do anything, could not read due to blurry central vision and kept wanting to doze off whilst watching an otherwise interesting documentary on the "Curiosity" Mars Rover. In the end I just continued resting in bed. Fortunately I was able to eat a light evening meal and went to bed early, sleeping for over nine hours. In the morning the headache was thankfully virtually gone, with just residual muscle stiffness and soreness remaining. As I was still somewhat bereft of energy it was lucky that there is a break from teaching this week and I can just work at home.
Migraines run in the family, so I was perhaps doomed from the start, but I still remember the first migraine I ever had at age 13 - I woke up in the middle of the night and felt as if someone was digging an ice-pick into the side of my head. Sometimes I get auras (kaleidoscopic geometric patterns moving across my visual field in an expanding crescent shape) or blurry central vision with or without a headache, and sometimes I don't. Whatever the story, it is always enervating and leaves you feeling guilty about lost time.
It is worth noting that the Skins compression garments certainly helped me to stand up for lengthy periods and reduced the stiffness in my legs but I wonder if the top section, although helpful for my back, was counter-productive for my neck and shoulders and in retrospect it was perhaps a mistake to keep wearing it overnight.
Migraines run in the family, so I was perhaps doomed from the start, but I still remember the first migraine I ever had at age 13 - I woke up in the middle of the night and felt as if someone was digging an ice-pick into the side of my head. Sometimes I get auras (kaleidoscopic geometric patterns moving across my visual field in an expanding crescent shape) or blurry central vision with or without a headache, and sometimes I don't. Whatever the story, it is always enervating and leaves you feeling guilty about lost time.
It is worth noting that the Skins compression garments certainly helped me to stand up for lengthy periods and reduced the stiffness in my legs but I wonder if the top section, although helpful for my back, was counter-productive for my neck and shoulders and in retrospect it was perhaps a mistake to keep wearing it overnight.
Friday, February 8, 2013
Calling all introverts ...
"The Sunday Age" - 30 December 2012
It is nice to see that the term 'introvert' is increasingly being used less as a pejorative term and recognised more as an equally valid part of the spectrum of 'being human'. It was also good to see in this article a recognition that people are allowed to have different and equally valid learning styles rather than the 'one size fits all' extrovert model.
Someone who was close to me at the time once said (intended as a meaningful insult) that I was "the most introverted person" he had "ever met", and there have been plenty of other occasions where a cautious, thoughtful and reflective approach to learning and new people and situations has been regarded as defective and demonstrative of a form of mental deficiency. This is never good for the self-confidence and self-belief of an introvert and demonstrates the difficulty of making a good first impression and winning friends and influencing people in a world where extroversion is prized.
As mentioned in this article, I am familiar with the concept of 'stepping outside yourself' to deliver what the world requires, and equally familiar with the necessity of having 'quiet time' to recharge and rejuvenate. I always find it wryly amusing how some people abhor spending time alone, whereas to me a shot of time 'home alone' can be just blissful, and I do my best thinking when I can quietly focus on the task at hand.
Considering that (according to a 'Psychology Today' article – “Revenge of the Introvert” http://www.psychologytoday.com/articles/201008/revenge-the-introvert) introverts are the quiet 50% of the population, credible sources such as this that encourage introverts to be proud of who they are rather than being apologetic are to be encouraged!
It is nice to see that the term 'introvert' is increasingly being used less as a pejorative term and recognised more as an equally valid part of the spectrum of 'being human'. It was also good to see in this article a recognition that people are allowed to have different and equally valid learning styles rather than the 'one size fits all' extrovert model.
Someone who was close to me at the time once said (intended as a meaningful insult) that I was "the most introverted person" he had "ever met", and there have been plenty of other occasions where a cautious, thoughtful and reflective approach to learning and new people and situations has been regarded as defective and demonstrative of a form of mental deficiency. This is never good for the self-confidence and self-belief of an introvert and demonstrates the difficulty of making a good first impression and winning friends and influencing people in a world where extroversion is prized.
As mentioned in this article, I am familiar with the concept of 'stepping outside yourself' to deliver what the world requires, and equally familiar with the necessity of having 'quiet time' to recharge and rejuvenate. I always find it wryly amusing how some people abhor spending time alone, whereas to me a shot of time 'home alone' can be just blissful, and I do my best thinking when I can quietly focus on the task at hand.
Considering that (according to a 'Psychology Today' article – “Revenge of the Introvert” http://www.psychologytoday.com/articles/201008/revenge-the-introvert) introverts are the quiet 50% of the population, credible sources such as this that encourage introverts to be proud of who they are rather than being apologetic are to be encouraged!
Advocating for good communication skills in healthcare
Sunday Age articles - 30 December 2012
- Patient advocates
- Health consumers looking out for themselves
These two articles make interesting reading for anyone involved with the medical profession, dealing as they do with communication skills and standards of care.
In modern medical courses, students are trained in the art of communication skills, but there is always going to be a "Bell curve" in terms of implementation, ranging from lack of bedside manner to superlative skills. Most people will be in the middle, making an effort to communicate effectively with their patients. However, simply by working in the medical profession, one becomes 'medicalised', and it becomes a challenge to remember what it was like to be an ordinary patient or a medical student or a junior doctor and to "stand in another's shoes" and communicate or behave appropriately. These challenges are compounded when you are facing time pressures or dealing with patients suffering from an impediment, whether that be age, infirmity, level of education or English language capacity. In these circumstances, it is easy to appreciate why a patient advocate service might appear to be useful, but the very fact of its existence shows that overall health professionals still need to work harder in terms of tailoring communication to patient needs.
The second article concerned with avoiding mishaps and receiving appropriate care clearly conveys the challenges for patient care inherent in a cash-strapped and resource-stretched health system. Even within my own family over recent years we have experienced less than optimal care of an elderly relative and a tendency to ignore the requests and instructions of carers. It can be very difficult to have issues addressed and problems solved in a positive way. Stepping into the role of patient yourself is always an interesting experience. Over the past twelve months I have personally experienced doctors ignoring or trivialising presenting symptoms, failing to follow up on blood tests, not following through with referrals and not bothering to read the medical history and test results that I brought to the appointment. I have also experienced waiting months to get an outpatients appointment and then waiting hours to be seen and subsequently waiting months more for investigation bookings and a further appointment. I understand how patients have to live with their symptoms and uncertainty for an extended period in the hope that someone will eventually work out what is causing the symptoms and offer a positive solution. In the end, when we are patients we are all living on faith that the health system will 'do the right thing' by us and that we will receive appropriate and timely care. If it is hard for those of use who are part of the system to get that care for ourselves and our own families, imagine how hard it is for others who lack that context. There is certainly a role for empowerment and respectful assertiveness, but to mirror this we need systems to promote acceptance of constructive feedback and continuous improvement of practices. We can learn a lot from human factors theory and research, but responsibility for and openness to continuous improvement and doing the best that we can by our patients must occur at both an organisational and individual level. This includes overcoming the notions that either someone else is the problem (including the patient/relatives) or that it is someone else's problem.
In modern medical courses, students are trained in the art of communication skills, but there is always going to be a "Bell curve" in terms of implementation, ranging from lack of bedside manner to superlative skills. Most people will be in the middle, making an effort to communicate effectively with their patients. However, simply by working in the medical profession, one becomes 'medicalised', and it becomes a challenge to remember what it was like to be an ordinary patient or a medical student or a junior doctor and to "stand in another's shoes" and communicate or behave appropriately. These challenges are compounded when you are facing time pressures or dealing with patients suffering from an impediment, whether that be age, infirmity, level of education or English language capacity. In these circumstances, it is easy to appreciate why a patient advocate service might appear to be useful, but the very fact of its existence shows that overall health professionals still need to work harder in terms of tailoring communication to patient needs.
The second article concerned with avoiding mishaps and receiving appropriate care clearly conveys the challenges for patient care inherent in a cash-strapped and resource-stretched health system. Even within my own family over recent years we have experienced less than optimal care of an elderly relative and a tendency to ignore the requests and instructions of carers. It can be very difficult to have issues addressed and problems solved in a positive way. Stepping into the role of patient yourself is always an interesting experience. Over the past twelve months I have personally experienced doctors ignoring or trivialising presenting symptoms, failing to follow up on blood tests, not following through with referrals and not bothering to read the medical history and test results that I brought to the appointment. I have also experienced waiting months to get an outpatients appointment and then waiting hours to be seen and subsequently waiting months more for investigation bookings and a further appointment. I understand how patients have to live with their symptoms and uncertainty for an extended period in the hope that someone will eventually work out what is causing the symptoms and offer a positive solution. In the end, when we are patients we are all living on faith that the health system will 'do the right thing' by us and that we will receive appropriate and timely care. If it is hard for those of use who are part of the system to get that care for ourselves and our own families, imagine how hard it is for others who lack that context. There is certainly a role for empowerment and respectful assertiveness, but to mirror this we need systems to promote acceptance of constructive feedback and continuous improvement of practices. We can learn a lot from human factors theory and research, but responsibility for and openness to continuous improvement and doing the best that we can by our patients must occur at both an organisational and individual level. This includes overcoming the notions that either someone else is the problem (including the patient/relatives) or that it is someone else's problem.
Monday, February 4, 2013
"The Ghan" Flight and Accommodation Package offered by Great Southern Rail - Bouquets and Brickbats
Even though the standard of service on The Ghan was terrific, overall the concept of a "luxury package" was let down by the things that were left out. People normally expect that a package will include things like transfers and "Bed and Breakfast", without having to pay extra for these or find your own breakfast and transfers.
As mentioned variously below, it would be helpful to receive some additional information in advance of the trip. It cannot be assumed that people (especially the elderly or international visitors) have extensive access to the internet to look up the GSR website or are able to read a lot of information in English on-screen. It would be good to send out a package with the booking confirmation and include a copy of the timetable and information on the stopover destinations and the optional side-tours available during the train trip so that people can be prepared financially and with the right sort of clothing etc. as applicable.
1. Credit Card Surcharge
It was very disappointing to be told about a credit card surcharge late in the booking process. This does not appear in the Terms and Conditions or the advertising information about the packages. It provides a disincentive to complete the booking, and having to pay through the alternative method of EFT delays confirmation and requires additional time and inconvenience on the part of both the customer and Great Southern Rail (GSR). In terms of the GSR staff time for processing these payments individually, how does this cost compare to absorbing the credit card bank fees? These fees are a cost of doing business that is tax-deductible, and by not levying this surcharge GSR would generate a lot more customer goodwill than the reverse.
2. Virgin Australia economy class flight from Melbourne to Adelaide. There were no issues with this (reviewed separately).
3. Adelaide Ground Transfers (separate cost).
The transfers were an additional cost at the time of booking (if paying on-the-spot $13 each way).
No vouchers were provided, which was not helpful for either the guest or the driver. These could easily be supplied in PDF format so that the guest could hand these to the driver. In addition, the drivers could be provided with a list of people who had pre-paid and pick-up points, so that they could just 'tick people off' rather than telling everyone that they have to pay.
No information was provided on what to do when you arrived at the airport. Guests had to figure it out for themselves and walk over to the bus area.
No information was provided on what would happen in terms of getting the shuttle bus to the rail terminal. Rydges don't deal with this, so it was necessary to make a personal phone call to the Skylink company to find out what the arrangements were. It would also have been helpful to know that it would be a very long shuttle bus trip to the terminal (around 45 minutes) and that the terminal is so close to Rydges. People (with very little luggage) might choose to walk or else get a taxi, which might well cost less than the bus and would be a lot quicker. One couple staying at Mercure indicated that the taxi from the airport cost about $23 and another group mentioned that the taxi from the hotel to the rail terminal was $8. For two or more people that works out cheaper than taking the Skylink shuttle at $13 per head. (The travel documentation incorrectly stated that this was a transfer from the rail terminal to the hotel.)
On the trip to the rail terminal the driver became very agitated (almost aggressive at times) telling people that they had to pay (even though nearly everyone who got on had already pre-paid). There was also a safety issue with the shuttle bus. At one stop it began rolling forwards while stationary, and the bus driver stated that whilst it had a handbrake, this didn't work. If so, the vehicle is not roadworthy and should not be used for carrying members of the public.
4. Overnight accommodation at Rydges South Park, Adelaide was provided as part of the Ghan package.
Positives:
An easy-to-operate safe in room, comfortable beds and pillows, TV with a wide range of channels and free WiFi.
Negatives:
After being booked to arrive from Melbourne just after 11am, check-in was not until 2pm. This necessitated several hours of wandering around in the heat (carrying all our valuables) to try to find something to eat and drink in the city area, which was some considerable distance away, and for someone such as myself suffering from a physical impediment, this was an exhausting and painful exercise. I ended up with a painful back strain as a result which impacted on enjoyment of the rest of the trip and lasted well beyond the end of the journey.
Possible improvements:
* Either a later flight or an earlier check-in would have been preferable. Ideally people should be informed of the late check-in time at the time of booking and given the option of arriving later in Adelaide.
As mentioned variously below, it would be helpful to receive some additional information in advance of the trip. It cannot be assumed that people (especially the elderly or international visitors) have extensive access to the internet to look up the GSR website or are able to read a lot of information in English on-screen. It would be good to send out a package with the booking confirmation and include a copy of the timetable and information on the stopover destinations and the optional side-tours available during the train trip so that people can be prepared financially and with the right sort of clothing etc. as applicable.
1. Credit Card Surcharge
It was very disappointing to be told about a credit card surcharge late in the booking process. This does not appear in the Terms and Conditions or the advertising information about the packages. It provides a disincentive to complete the booking, and having to pay through the alternative method of EFT delays confirmation and requires additional time and inconvenience on the part of both the customer and Great Southern Rail (GSR). In terms of the GSR staff time for processing these payments individually, how does this cost compare to absorbing the credit card bank fees? These fees are a cost of doing business that is tax-deductible, and by not levying this surcharge GSR would generate a lot more customer goodwill than the reverse.
2. Virgin Australia economy class flight from Melbourne to Adelaide. There were no issues with this (reviewed separately).
3. Adelaide Ground Transfers (separate cost).
The transfers were an additional cost at the time of booking (if paying on-the-spot $13 each way).
No vouchers were provided, which was not helpful for either the guest or the driver. These could easily be supplied in PDF format so that the guest could hand these to the driver. In addition, the drivers could be provided with a list of people who had pre-paid and pick-up points, so that they could just 'tick people off' rather than telling everyone that they have to pay.
No information was provided on what to do when you arrived at the airport. Guests had to figure it out for themselves and walk over to the bus area.
No information was provided on what would happen in terms of getting the shuttle bus to the rail terminal. Rydges don't deal with this, so it was necessary to make a personal phone call to the Skylink company to find out what the arrangements were. It would also have been helpful to know that it would be a very long shuttle bus trip to the terminal (around 45 minutes) and that the terminal is so close to Rydges. People (with very little luggage) might choose to walk or else get a taxi, which might well cost less than the bus and would be a lot quicker. One couple staying at Mercure indicated that the taxi from the airport cost about $23 and another group mentioned that the taxi from the hotel to the rail terminal was $8. For two or more people that works out cheaper than taking the Skylink shuttle at $13 per head. (The travel documentation incorrectly stated that this was a transfer from the rail terminal to the hotel.)
On the trip to the rail terminal the driver became very agitated (almost aggressive at times) telling people that they had to pay (even though nearly everyone who got on had already pre-paid). There was also a safety issue with the shuttle bus. At one stop it began rolling forwards while stationary, and the bus driver stated that whilst it had a handbrake, this didn't work. If so, the vehicle is not roadworthy and should not be used for carrying members of the public.
4. Overnight accommodation at Rydges South Park, Adelaide was provided as part of the Ghan package.
Positives:
An easy-to-operate safe in room, comfortable beds and pillows, TV with a wide range of channels and free WiFi.
Negatives:
After being booked to arrive from Melbourne just after 11am, check-in was not until 2pm. This necessitated several hours of wandering around in the heat (carrying all our valuables) to try to find something to eat and drink in the city area, which was some considerable distance away, and for someone such as myself suffering from a physical impediment, this was an exhausting and painful exercise. I ended up with a painful back strain as a result which impacted on enjoyment of the rest of the trip and lasted well beyond the end of the journey.
Possible improvements:
* Either a later flight or an earlier check-in would have been preferable. Ideally people should be informed of the late check-in time at the time of booking and given the option of arriving later in Adelaide.
* It would also be very helpful to have some information provided by GSR on each destination in advance e.g., where to find food, that the tram is free in the centre of Adelaide, etc.
Room 116 at Rydges is probably best avoided. The room had a dank musty smell, which improved with airing, but then recurred when the room was shut up again. The room also opened out onto a balcony which had no less than five airconditioning units right outside the door, with water run off trails and bird droppings nearby. This made me worry about air and water-borne infections. (Perhaps this less-desirable room was a 'budget selection' as part of the Ghan package.)
Both the swimming pool and the spa on the sixth floor were unpleasantly cold. However, the views were great ...
No breakfast was provided as part of the package and the non-inclusion of breakfast (both Adelaide and Darwin) was not made clear when booking.
In Adelaide in particular this was a problem due to the high additional cost of the hotel breakfast ($25 Continental, $28 Cooked), the long distance to both alternative eateries and the nearest supermarket, and the shuttle pick-up about 10am.
It would be nice if Great Southern Rail provided more information about this exclusion "up front". It would be even better if, as people will mistakenly think it is an "all in luxury package", consideration was given to providing "Bed and Breakfast" as part of the package in both Adelaide and Darwin.
In Adelaide a hotel closer to the city centre would be preferable to facilitate guests sourcing their own dinner and breakfast. At the very least, information should be provided to package-holders on feasible alternatives in terms of sourcing your own breakfast nearby.
5. Side trips when The Ghan stops in Alice Springs and Katherine.
The audio announcement dealing with the "Whistle-Stop Tours" which is made during the afternoon after boarding the train refers to this information being in the "Platform" magazine, but is is in fact in a separate brochure. It would be good if the Hospitality Managers mentioned these side trips when they are giving their initial individual briefings shortly after boarding the train so that people are aware of them and what they need to do to book. (Ideally it would also be good to provide information on these trips as part of a package received after booking.)
6. Cabin Orientation
Especially for those who are keen photographers, it would be good to be offered a choice of which way the cabin faces during travel when checking in. Travelling 'backwards' means that you lose the ability to prepare and only see things as they are disappearing behind you. When discussing our disappointment with facing backwards, the cabin manager mentioned that it was possible to request facing in a preferred direction at the time of booking. Perhaps people could be asked if they have a preference as part of the booking process.
7. Transfers: Darwin
When checking about this in a telephone enquiry I was told that a "complimentary transfer" is provided from the rail terminal to the hotel. No information was provided as part of the travel documents regarding how and with whom this would occur. Fortunately this information was made clear through audio announcements on the train as it was pulling into Darwin.
Guests are left to their own devices to arrange an airport transfer. Luckily this was able to be arranged through the hotel reception. The cost was $15 per person (with a small discount for 2 or more persons).
8. Stopover in Darwin
Sadly the option to stay in Darwin longer than overnight was not offered at the time of booking. This means that in effect only half a day was available for sightseeing before the late afternoon return flight to Melbourne. The NT Tourism Authority lady at the Adelaide rail terminal was enormously frustrated (as were the guests) that without a full day in Darwin, people could not take advantage of afternoon sight-seeing options nor take a trip to Kakadu (a full day).
The Holiday Inn Esplanade in Darwin was terrific. However, there was massive confusion on the shuttle bus as to which hotel (Holiday Inn Darwin on the Esplanade vs Holiday Inn Esplanade) people should be getting off at. Perhaps this could be alleviated by a staff member checking people's travel documents upon boarding the bus and giving them a colour-coded voucher and then announcing at the destination - everyone with a green voucher (Holiday Inn Darwin) get off here, etc.
The hotel room was great, and there was a choice of firm or soft feather pillows, which was brilliant as I had left my feather pillow at home in the interests of light packing. The hotel is very close to Mitchell Street in the centre of Darwin, where there are lots of restaurants, bars, pubs, take-away food outlets etc. and also Coles supermarket (Woolworths is a bit further away). The hotel also has a large outdoor pool which is open late into the evening.
9. Miscellaneous Matters
Regarding pillows on the train - some softer/more malleable pillows would be good for people used to sleeping on thinner pillows or feather pillows.
It would be good to be provided with an emergency number that people can call after-hours on the evening or next morning following their arrival at the final destination if they suddenly realise they have lost something or left something on the train. The GSR office is closed and by the time it opens the next morning it may be too late to get out to the rail terminal to chase up lost property. Sadly I accidentally left my beloved iPod on the train and despite extensive searches and enquiries it has not been recovered.
(For those interested in reading more, there are a variety of other blog postings on "The Ghan" travel experience and meals.)
Room 116 at Rydges is probably best avoided. The room had a dank musty smell, which improved with airing, but then recurred when the room was shut up again. The room also opened out onto a balcony which had no less than five airconditioning units right outside the door, with water run off trails and bird droppings nearby. This made me worry about air and water-borne infections. (Perhaps this less-desirable room was a 'budget selection' as part of the Ghan package.)
Both the swimming pool and the spa on the sixth floor were unpleasantly cold. However, the views were great ...
No breakfast was provided as part of the package and the non-inclusion of breakfast (both Adelaide and Darwin) was not made clear when booking.
In Adelaide in particular this was a problem due to the high additional cost of the hotel breakfast ($25 Continental, $28 Cooked), the long distance to both alternative eateries and the nearest supermarket, and the shuttle pick-up about 10am.
It would be nice if Great Southern Rail provided more information about this exclusion "up front". It would be even better if, as people will mistakenly think it is an "all in luxury package", consideration was given to providing "Bed and Breakfast" as part of the package in both Adelaide and Darwin.
In Adelaide a hotel closer to the city centre would be preferable to facilitate guests sourcing their own dinner and breakfast. At the very least, information should be provided to package-holders on feasible alternatives in terms of sourcing your own breakfast nearby.
5. Side trips when The Ghan stops in Alice Springs and Katherine.
The audio announcement dealing with the "Whistle-Stop Tours" which is made during the afternoon after boarding the train refers to this information being in the "Platform" magazine, but is is in fact in a separate brochure. It would be good if the Hospitality Managers mentioned these side trips when they are giving their initial individual briefings shortly after boarding the train so that people are aware of them and what they need to do to book. (Ideally it would also be good to provide information on these trips as part of a package received after booking.)
6. Cabin Orientation
Especially for those who are keen photographers, it would be good to be offered a choice of which way the cabin faces during travel when checking in. Travelling 'backwards' means that you lose the ability to prepare and only see things as they are disappearing behind you. When discussing our disappointment with facing backwards, the cabin manager mentioned that it was possible to request facing in a preferred direction at the time of booking. Perhaps people could be asked if they have a preference as part of the booking process.
7. Transfers: Darwin
When checking about this in a telephone enquiry I was told that a "complimentary transfer" is provided from the rail terminal to the hotel. No information was provided as part of the travel documents regarding how and with whom this would occur. Fortunately this information was made clear through audio announcements on the train as it was pulling into Darwin.
Guests are left to their own devices to arrange an airport transfer. Luckily this was able to be arranged through the hotel reception. The cost was $15 per person (with a small discount for 2 or more persons).
8. Stopover in Darwin
Sadly the option to stay in Darwin longer than overnight was not offered at the time of booking. This means that in effect only half a day was available for sightseeing before the late afternoon return flight to Melbourne. The NT Tourism Authority lady at the Adelaide rail terminal was enormously frustrated (as were the guests) that without a full day in Darwin, people could not take advantage of afternoon sight-seeing options nor take a trip to Kakadu (a full day).
The Holiday Inn Esplanade in Darwin was terrific. However, there was massive confusion on the shuttle bus as to which hotel (Holiday Inn Darwin on the Esplanade vs Holiday Inn Esplanade) people should be getting off at. Perhaps this could be alleviated by a staff member checking people's travel documents upon boarding the bus and giving them a colour-coded voucher and then announcing at the destination - everyone with a green voucher (Holiday Inn Darwin) get off here, etc.
The hotel room was great, and there was a choice of firm or soft feather pillows, which was brilliant as I had left my feather pillow at home in the interests of light packing. The hotel is very close to Mitchell Street in the centre of Darwin, where there are lots of restaurants, bars, pubs, take-away food outlets etc. and also Coles supermarket (Woolworths is a bit further away). The hotel also has a large outdoor pool which is open late into the evening.
9. Miscellaneous Matters
Regarding pillows on the train - some softer/more malleable pillows would be good for people used to sleeping on thinner pillows or feather pillows.
It would be good to be provided with an emergency number that people can call after-hours on the evening or next morning following their arrival at the final destination if they suddenly realise they have lost something or left something on the train. The GSR office is closed and by the time it opens the next morning it may be too late to get out to the rail terminal to chase up lost property. Sadly I accidentally left my beloved iPod on the train and despite extensive searches and enquiries it has not been recovered.
(For those interested in reading more, there are a variety of other blog postings on "The Ghan" travel experience and meals.)
Travelling on "The Ghan" - "Whistle-Stop Tours" - From Katherine - the Nitmiluk Gorge Cafe Cruise
From Katherine - the Nitmiluk Gorge Cafe Cruise
Approximately 3 hours including transfers. $89 adult, $76 child.
This tour includes a cruise through the First Gorge (with a commentary explaining significant aspects of local indigenous culture) and a short walk to some ancient indigenous rock paintings at the top of the First Gorge). Morning tea is also included.
The tour passed through the centre of Katherine and then its outskirts on the way to the Gorge. It was interesting to find out that, in addition to Darwin, Katherine had also been bombed by the Japanese during the Second World War.
The boat had a capacity of around 40 people seated at semi-circular tables so that everyone had a good view. As we travelled slowly up the Gorge our guide provided commentary on the landscape, plant and animal life and the legends of the local Jawoyn indigenous people. We saw one small freshwater crocodile just poking his snout above the water.
It was a beautiful vista, but the real highlight was being able to see some ancient indigenous rock paintings at the end of the first part of the Gorge (where the boat could travel no further due to natural rock barriers). There were recognisable animal shapes and handprints, and our guide explained that some of the artwork was clearly interpretative of the legends of the Dreamtime.
It was fearfully hot and humid whilst on the boat and standing around looking at the rock art and the greater percentage of my clothing was soaked through with perspiration by the end of it. Our guide on the boat warned everyone at the start about heat exhaustion, and there was a bottomless supply of cool drinking water available during the cruise (in addition to hot drinks and scones with jam and cream). It was nice to have a shower and a change of clothes when we got back to the train.
Approximately 3 hours including transfers. $89 adult, $76 child.
This tour includes a cruise through the First Gorge (with a commentary explaining significant aspects of local indigenous culture) and a short walk to some ancient indigenous rock paintings at the top of the First Gorge). Morning tea is also included.
The tour passed through the centre of Katherine and then its outskirts on the way to the Gorge. It was interesting to find out that, in addition to Darwin, Katherine had also been bombed by the Japanese during the Second World War.
The boat had a capacity of around 40 people seated at semi-circular tables so that everyone had a good view. As we travelled slowly up the Gorge our guide provided commentary on the landscape, plant and animal life and the legends of the local Jawoyn indigenous people. We saw one small freshwater crocodile just poking his snout above the water.
It was a beautiful vista, but the real highlight was being able to see some ancient indigenous rock paintings at the end of the first part of the Gorge (where the boat could travel no further due to natural rock barriers). There were recognisable animal shapes and handprints, and our guide explained that some of the artwork was clearly interpretative of the legends of the Dreamtime.
It was fearfully hot and humid whilst on the boat and standing around looking at the rock art and the greater percentage of my clothing was soaked through with perspiration by the end of it. Our guide on the boat warned everyone at the start about heat exhaustion, and there was a bottomless supply of cool drinking water available during the cruise (in addition to hot drinks and scones with jam and cream). It was nice to have a shower and a change of clothes when we got back to the train.
Travelling on "The Ghan" Day 3: "How green is my country!"
The landscape had changed once again, with lots of lush green grass and trees (mainly eucalypts) and quite a few pools of water just 'lying around'. At times the train passed through quite dense eucalypt forests. Termite mounds were also plentiful - no wonder they had problems with termites eating the railway sleepers before changing over to concrete sleepers! Many mounds were the characteristic ochre red, but there were also some paler brown ones. The height and breadth of some of the obviously older ones was quite impressive. Around the town of Katherine there was a definite tropical feel in terms of the vegetation. It was also quite hot and humid. The outlook varied from overcast to cloudy over the course of the day. As we drew close to Darwin, quite a few palms started popping up in-between the eucalypts.
The tour and cruise along the first part of the Katherine Gorge (Nitmiluk) was very worthwhile, and it was a definite highlight seeing some indigenous rock art which is thousands of years old. (This tour is reviewed separately in another posting.)
Whilst in the Northern Territory we experienced the paradox that is indigenous life and culture in Australia. In Alice Springs and Katherine, many indigenous people appeared to be spending the day just sitting under trees in parks (some obviously drinking alcohol), whilst at Nitmiluk we saw the other end of the spectrum - educated, articulate indigenous people who were proud of their heritage and culture and were making a living from sharing aspects of it with visitors to the region.
The Darwin Rail Terminal is 15km from the city, and situated close to thick stands of mangroves (not unlike Cairns Airport!). Darwin is very flat, and the drive in to town takes you through a number of industrial suburbs with low squat buildings and past a Department of Defence establishment. The absence of tall buildings in the centre of town is quite striking, and those that exist seem outwardly to be hotels and apartment buildings. Perhaps this is a legacy of Cyclone Tracy, which devastated Darwin on Christmas Eve 1974. My family and I experienced Cyclone Althea in Townsville in ..., but Tracey was far worse. Even in our experience, the most difficult time was after the storm, when all essential services were cut and there was "water, water everywhere".
The passengers from The Ghan seemed to be distributed over a number of the hotels in town, but many of us were either at the Holiday Inn Darwin or the fabulous Holiday Inn Esplanade (both on the Esplanade). In contrast to Rydges in Adelaide, I was hugely impressed with both the room and the facilities at the Holiday Inn. Even a choice of feather pillows was made available on the beds - soft vs firm! It was also extremely nice that when the TV was turned on, there was a message welcoming you by name.
We arrived in the late afternoon to the now familiar sight of indigenous people lying on the ground in the park across the road, and later on one of the young women in our group was approached by an obviously drunk Aboriginal man. Whilst out foraging for food there was safety in numbers, with indigenous people soliciting donations and loitering around the entrance to shops and eateries. A number of places appeared to have security guards patrolling the front entrance, and shops which were closed due to it being New Year's Day appeared heavily fortified to avoid vandalism.
The sense that we non-indigenous people were being 'eyed off' made me feel uneasy in a way that I have not felt since I was in Nepal and tried to go for a walk around central Kathmandu, but was accosted with every step I took. Within metres of the front door of the hotel I had come to the inescapable conclusion that westerners were seen as walking cash machines to be exploited at every opportunity, being bombarded with demands to buy this or that or the other thing or to avail yourself of some service. It was so unpleasant and "in your face" that I became discombobulated and lost my normal impeccable sense of direction in the rabbit warren of haphazard street layouts and had to ask for directions back to the hotel. It was also clear that there was one price for locals and another highly inflated version for visitors (and no fixed prices displayed). I abandoned my plans for gift shopping and solemnly emailed my family to explain the situation and covey my apologies in advance. I was very glad that we did not have to dally long in Kathmandu before heading off for Lukla and our Expedition Medicine course and trek.
However, I digress! Following all that gourmet food on the train I had a hankering for something simple, such as good old-fashioned fish and chips, and fortunately we found an outlet (Chip 'n' Fish - reviewed separately) that was open in the 'foodie' district in Mitchell Street nearby. Since breakfast was not included as part of the package, we also descended on the adjacent Coles supermarket and found some more bargains - yoghurt for $2.99, two cans of mango slices for $2.50, a litre of juice for $1.00, and a packet of scones for $2.70 and mince pies for $0.90. However, I have to say that the Coles self-checkout system was rather user unfriendly and frustrating.
The next morning it was stormy with thunder and lightning and moderately heavy tropical rain. Despite this we enjoyed a swim after breakfast in the excellent outdoor pool at the hotel. It is probably about 30 metres long and reasonably wide and 2 metres deep at one end so it is great for lap swimming.
After that it was off to the local Police Station to report the theft of my iPod Touch on The Ghan. I had accidentally left it in a small alcove above my bunk bed on the morning of the last day and did not realise it was missing until a few hours after disembarkation. The Terminal Manager was very helpful and the cabin was checked thoroughly and various staff avenues followed up, but without success. I was very sorry to lose it as it has been a wonderful and versatile tool, and often helped me to meditate and get to sleep. The Terminal Manager (and the carriage manager on the train) mentioned that it was extremely unusual for anything valuable to go missing, so I guess I was just unlucky. Fortunately I had travel insurance and still have my original purchase receipts so should be able to make a claim. (Moral of the story: make sure your valuables are locked in the safe when you are out of the cabin!)
The rain had stopped and there were a few hours spare before departing for the airport, so after another relatively healthy Subway lunch the gang headed off for a foot tour of some of the historical buildings close to the city and the waterfront. From the ruins of the old town hall to Christ Church Cathedral incorporating elements of the old and the new to the renovated Administrator's Building and the timber Government House, there were many stories of courage and resilience in the face of the devastating destruction of Cyclone Tracy.
The new and modern waterfront precinct is very attractive, with a number of multi-storey apartment buildings ringed around a small beach with a protected swimming area and a very reasonably priced wave pool nearby (adults $5 half-day/$8 full day). The Entertainment Centre and the sea wall and wharf are also accessible from this area.
It was extremely hot and humid and, as in Katherine, our clothes were pretty well soaked through by the time we had been out for a few hours. We walked back to the hotel along the Esplanade for a bit and then visited Coles again to pick up some juice and ice-cream to rehydrate and cool off. As well as a lounge off the downstairs foyer, Holiday Inn Esplanade has a large and comfortable lounge on the first floor, to which we retreated to recover from the heat. They were also happy to store our bags after we had checked out and were wiling away the time waiting for the airport shuttle. Just after we arrived back at the hotel there were more heavy showers, so we had timed things well!
The airport shuttle is $15 per person (discounts for two or more) and was an efficient and stress-free way of getting to the airport. Check-in was uneventful, but yet again I was targeted for the explosives residue scanning test just after the security scanning. It seems to happen nearly every time I fly - perhaps I am just unlucky!
Things were looking up - seats in row 6 and access to the window seat for takeoff. Then it all went pear-shaped very rapidly. There was someone with a loud hacking cough in the seat behind and a family of five settled into row 5, including mother, father, girl aged about 8, boy aged about 6 and a screaming toddler of approximately 2. He wrestled and squirmed like an anaconda and screamed like a banshee when his mother tried to strap him into a harness prior to takeoff. His efforts were so impressive that the cabin attendant came and suggested that she wait until the aircraft was actually ready for takeoff. He did not appear to like being restrained in any way and the ear-splitting screams continued for around 3.5 hours of the four hour flight. Apart from being physically unpleasant and exhausting, it was so intrusive as to render my planned work activities impossible as I could not "hear myself think". The cabin attendant was obviously sympathetic to those who were suffering, and towards the end of the fight was kind enough to offer us a complimentary snack as a gesture of solidarity. Eventually we landed just before midnight and nary an apology was offered at any stage by the parents.
It is not the first time that my flight experience has been completely destroyed by disruptive screaming children (even worse when on an international flight and people are trying to sleep), and of course these families have a right to fly, but perhaps there are ways of being more considerate to their fellow passengers. Aside from the vexed question of parenting style, perhaps things like more playful distractions, travelling at a time that is not past a toddler's bedtime, and seating the family down the back of the aircraft (where there were quite a few vacant seats and fewer people would be disturbed (no-one behind them) and it would be easier for the parents to get up and move around with the toddler) might be helpful.
During the flight there was a quite spectacular sunset visible from the other side of the aircraft (but alas no chance to get to a window to capture it) and then as we neared Melbourne I could see a blood-red half-moon rising over the horizon. This gradually became orange and then gold, floating above the city lights as we came in to land.
The Busy Beaver Airport Parking bus was fortunately waiting outside the terminal so I was able to collect my car fairly promptly and was home just after 0100. I was very pleased with the service that they offer and would use them again.
The tour and cruise along the first part of the Katherine Gorge (Nitmiluk) was very worthwhile, and it was a definite highlight seeing some indigenous rock art which is thousands of years old. (This tour is reviewed separately in another posting.)
Whilst in the Northern Territory we experienced the paradox that is indigenous life and culture in Australia. In Alice Springs and Katherine, many indigenous people appeared to be spending the day just sitting under trees in parks (some obviously drinking alcohol), whilst at Nitmiluk we saw the other end of the spectrum - educated, articulate indigenous people who were proud of their heritage and culture and were making a living from sharing aspects of it with visitors to the region.
The Darwin Rail Terminal is 15km from the city, and situated close to thick stands of mangroves (not unlike Cairns Airport!). Darwin is very flat, and the drive in to town takes you through a number of industrial suburbs with low squat buildings and past a Department of Defence establishment. The absence of tall buildings in the centre of town is quite striking, and those that exist seem outwardly to be hotels and apartment buildings. Perhaps this is a legacy of Cyclone Tracy, which devastated Darwin on Christmas Eve 1974. My family and I experienced Cyclone Althea in Townsville in ..., but Tracey was far worse. Even in our experience, the most difficult time was after the storm, when all essential services were cut and there was "water, water everywhere".
The passengers from The Ghan seemed to be distributed over a number of the hotels in town, but many of us were either at the Holiday Inn Darwin or the fabulous Holiday Inn Esplanade (both on the Esplanade). In contrast to Rydges in Adelaide, I was hugely impressed with both the room and the facilities at the Holiday Inn. Even a choice of feather pillows was made available on the beds - soft vs firm! It was also extremely nice that when the TV was turned on, there was a message welcoming you by name.
We arrived in the late afternoon to the now familiar sight of indigenous people lying on the ground in the park across the road, and later on one of the young women in our group was approached by an obviously drunk Aboriginal man. Whilst out foraging for food there was safety in numbers, with indigenous people soliciting donations and loitering around the entrance to shops and eateries. A number of places appeared to have security guards patrolling the front entrance, and shops which were closed due to it being New Year's Day appeared heavily fortified to avoid vandalism.
The sense that we non-indigenous people were being 'eyed off' made me feel uneasy in a way that I have not felt since I was in Nepal and tried to go for a walk around central Kathmandu, but was accosted with every step I took. Within metres of the front door of the hotel I had come to the inescapable conclusion that westerners were seen as walking cash machines to be exploited at every opportunity, being bombarded with demands to buy this or that or the other thing or to avail yourself of some service. It was so unpleasant and "in your face" that I became discombobulated and lost my normal impeccable sense of direction in the rabbit warren of haphazard street layouts and had to ask for directions back to the hotel. It was also clear that there was one price for locals and another highly inflated version for visitors (and no fixed prices displayed). I abandoned my plans for gift shopping and solemnly emailed my family to explain the situation and covey my apologies in advance. I was very glad that we did not have to dally long in Kathmandu before heading off for Lukla and our Expedition Medicine course and trek.
However, I digress! Following all that gourmet food on the train I had a hankering for something simple, such as good old-fashioned fish and chips, and fortunately we found an outlet (Chip 'n' Fish - reviewed separately) that was open in the 'foodie' district in Mitchell Street nearby. Since breakfast was not included as part of the package, we also descended on the adjacent Coles supermarket and found some more bargains - yoghurt for $2.99, two cans of mango slices for $2.50, a litre of juice for $1.00, and a packet of scones for $2.70 and mince pies for $0.90. However, I have to say that the Coles self-checkout system was rather user unfriendly and frustrating.
The next morning it was stormy with thunder and lightning and moderately heavy tropical rain. Despite this we enjoyed a swim after breakfast in the excellent outdoor pool at the hotel. It is probably about 30 metres long and reasonably wide and 2 metres deep at one end so it is great for lap swimming.
After that it was off to the local Police Station to report the theft of my iPod Touch on The Ghan. I had accidentally left it in a small alcove above my bunk bed on the morning of the last day and did not realise it was missing until a few hours after disembarkation. The Terminal Manager was very helpful and the cabin was checked thoroughly and various staff avenues followed up, but without success. I was very sorry to lose it as it has been a wonderful and versatile tool, and often helped me to meditate and get to sleep. The Terminal Manager (and the carriage manager on the train) mentioned that it was extremely unusual for anything valuable to go missing, so I guess I was just unlucky. Fortunately I had travel insurance and still have my original purchase receipts so should be able to make a claim. (Moral of the story: make sure your valuables are locked in the safe when you are out of the cabin!)
The rain had stopped and there were a few hours spare before departing for the airport, so after another relatively healthy Subway lunch the gang headed off for a foot tour of some of the historical buildings close to the city and the waterfront. From the ruins of the old town hall to Christ Church Cathedral incorporating elements of the old and the new to the renovated Administrator's Building and the timber Government House, there were many stories of courage and resilience in the face of the devastating destruction of Cyclone Tracy.
The new and modern waterfront precinct is very attractive, with a number of multi-storey apartment buildings ringed around a small beach with a protected swimming area and a very reasonably priced wave pool nearby (adults $5 half-day/$8 full day). The Entertainment Centre and the sea wall and wharf are also accessible from this area.
It was extremely hot and humid and, as in Katherine, our clothes were pretty well soaked through by the time we had been out for a few hours. We walked back to the hotel along the Esplanade for a bit and then visited Coles again to pick up some juice and ice-cream to rehydrate and cool off. As well as a lounge off the downstairs foyer, Holiday Inn Esplanade has a large and comfortable lounge on the first floor, to which we retreated to recover from the heat. They were also happy to store our bags after we had checked out and were wiling away the time waiting for the airport shuttle. Just after we arrived back at the hotel there were more heavy showers, so we had timed things well!
The airport shuttle is $15 per person (discounts for two or more) and was an efficient and stress-free way of getting to the airport. Check-in was uneventful, but yet again I was targeted for the explosives residue scanning test just after the security scanning. It seems to happen nearly every time I fly - perhaps I am just unlucky!
Things were looking up - seats in row 6 and access to the window seat for takeoff. Then it all went pear-shaped very rapidly. There was someone with a loud hacking cough in the seat behind and a family of five settled into row 5, including mother, father, girl aged about 8, boy aged about 6 and a screaming toddler of approximately 2. He wrestled and squirmed like an anaconda and screamed like a banshee when his mother tried to strap him into a harness prior to takeoff. His efforts were so impressive that the cabin attendant came and suggested that she wait until the aircraft was actually ready for takeoff. He did not appear to like being restrained in any way and the ear-splitting screams continued for around 3.5 hours of the four hour flight. Apart from being physically unpleasant and exhausting, it was so intrusive as to render my planned work activities impossible as I could not "hear myself think". The cabin attendant was obviously sympathetic to those who were suffering, and towards the end of the fight was kind enough to offer us a complimentary snack as a gesture of solidarity. Eventually we landed just before midnight and nary an apology was offered at any stage by the parents.
It is not the first time that my flight experience has been completely destroyed by disruptive screaming children (even worse when on an international flight and people are trying to sleep), and of course these families have a right to fly, but perhaps there are ways of being more considerate to their fellow passengers. Aside from the vexed question of parenting style, perhaps things like more playful distractions, travelling at a time that is not past a toddler's bedtime, and seating the family down the back of the aircraft (where there were quite a few vacant seats and fewer people would be disturbed (no-one behind them) and it would be easier for the parents to get up and move around with the toddler) might be helpful.
During the flight there was a quite spectacular sunset visible from the other side of the aircraft (but alas no chance to get to a window to capture it) and then as we neared Melbourne I could see a blood-red half-moon rising over the horizon. This gradually became orange and then gold, floating above the city lights as we came in to land.
The Busy Beaver Airport Parking bus was fortunately waiting outside the terminal so I was able to collect my car fairly promptly and was home just after 0100. I was very pleased with the service that they offer and would use them again.
Travelling on "The Ghan" Day 2: "A Town like Alice"
The day was overcast and at least in the early part of the morning travel was through more heavily vegetated areas than late yesterday. There was a plentiful cover of grass tussocks, many small shrubs and occasional forest-like sections with trees and large shrubs. I am no expert on what these might be, but I did recognise some eucalypts and what looked like silky oak. Apparently the large shrubs are saltbushes. Later on in addition to the silky oaks there were some tall pine-like trees with cones. The red earth seemed a little duller, but perhaps this was just due to the overcast sky. There were occasional signs of civilisation, such as dirt tracks, windmills and water and communication towers. At one stage on the western side of the train line there were extensive areas where it looked as if a grass fire had gone through not too long ago, but had not 'jumped the track'. From time to time a number of cattle were spotted lingering under trees and a couple of eagles soared overhead.
As the train will be stopping in Alice Springs in the early afternoon, there is a curious arrangement catering-wise of a "rolling brunch" between 0700 and 1200 rather than breakfast and lunch. Having a bit of a propensity towards hypoglycaemia with lack of food, I decided to start the day with a muesli bar and a cup of tea and then attend 'brunch' later in the morning to improve the chances of lasting through to dinner time without 'fading' too much. I also hatched a cunning plan to take the aforesaid trusty thermos on the Alice Springs 'whistle-stop tour' (but alas did not have time to use it due to the tight timeline). (The tour is reviewed separately in another posting.)
Travelling north from Alice Springs the vegetation was generally denser and greener, and there were a few waterholes along the side of the track. At one stage there were also many tall red termite mounds amongst the bushes. The day remained overcast and by late afternoon it had completely clouded over.
Being New Year's Eve, GSR kindly provided nibbles and a complimentary drink in the lounge close to midnight as well as party decorations and balloons. A relatively small group saw in the New Year and several (quite brief) firework displays in Tennant Creek (the train stopped here for a couple of hours).
It is somewhat amusing that every time you are seated with a new group of people in the dining car that you always end up having some elements of conversation that are exactly the same - where are you from, what do you do, have you done any other train trips like this, what made you decide to travel on The Ghan, etc.
As the train will be stopping in Alice Springs in the early afternoon, there is a curious arrangement catering-wise of a "rolling brunch" between 0700 and 1200 rather than breakfast and lunch. Having a bit of a propensity towards hypoglycaemia with lack of food, I decided to start the day with a muesli bar and a cup of tea and then attend 'brunch' later in the morning to improve the chances of lasting through to dinner time without 'fading' too much. I also hatched a cunning plan to take the aforesaid trusty thermos on the Alice Springs 'whistle-stop tour' (but alas did not have time to use it due to the tight timeline). (The tour is reviewed separately in another posting.)
Travelling north from Alice Springs the vegetation was generally denser and greener, and there were a few waterholes along the side of the track. At one stage there were also many tall red termite mounds amongst the bushes. The day remained overcast and by late afternoon it had completely clouded over.
Being New Year's Eve, GSR kindly provided nibbles and a complimentary drink in the lounge close to midnight as well as party decorations and balloons. A relatively small group saw in the New Year and several (quite brief) firework displays in Tennant Creek (the train stopped here for a couple of hours).
It is somewhat amusing that every time you are seated with a new group of people in the dining car that you always end up having some elements of conversation that are exactly the same - where are you from, what do you do, have you done any other train trips like this, what made you decide to travel on The Ghan, etc.
Travelling on "The Ghan" Day 1: "I love a sunburnt country, a land of sweeping plains ..."
After surviving the ordeal of being in the shuttle bus in Adelaide for around 45 minutes (long enough to start getting a headache as it was not possible to open the windows), we finally arrived at the Parklands Rail Terminal.
The impressively long Ghan was standing at the platform, with its trademark red engine at the front, and a long line of silver carriages. The large entrance hall contains a check-in area, a NT Tourism desk, a shop and a cafe. Boarding commenced at 11:30 and the train left Adelaide at around 12:20.
The Gold Service cabins are small and old-fashioned, but functional, with a long bench seat, a window, an en-suite (with complimentary toiletry packs) and two fold-down bunk beds. Sitting on the benches, one travels backwards. According to my extensive observations on Melbourne trams and trains, this is not the natural preference for most of the human race, who, given a choice, will normally sit facing the direction of travel. (I later found out that half the cabins face in the direction of travel - as a keen photographer it would have been nice to have been offered a choice.) The cabin was a bit stuffy to start with but quickly cooled off once the train got underway. Free tea and coffee is available in a small kitchenette at the end of the carriage. A selection of music is available in the cabin, and the classical content is certainly of good quality. (Unfortunately for classical music lovers who "know their stuff", the selection is repeated.) Apparently WiFi is in the process of being installed, but I am not sure whether I actually like the idea as it is rather nice to be liberated by being free of email and the Internet for just a few days. At some stage during the first evening we also passed out of mobile phone network coverage and this felt strangely blissful. I expect connectivity will be resumed again when we pass through major towns during the rest of the journey, but in the interim the feeling of freedom from modern technology is rather pleasant! All part of the enchanting romance of train travel - sometimes less is more!
The customer service was excellent, both in terms of management of the cabin area, the lounge and the dining car. Announcements of relevance were made from time to time. A complimentary drink was provided in the lounge prior to lunch. Lunch and dinner times are booked and staggered in order to allow everyone to be served in the small Queen Adelaide dining car. (Meals have been reviewed separately.)
The Ghan initially follows the same route as the Indian Pacific (to Perth) but turns north at Tarcoola. Once we passed out of Adelaide we quickly encountered great expanses of farmland, red earth and golden stubble under a cloudless postcard blue sky. As well as catching glimpses of the Spencer Gulf on our journey to Port Augusta, we also saw vast white salt flats and acre upon acre of olive-green saltbush contrasting with the orchre earth. The impressive Flinders Ranges seemed to stretch from here to infinity, and we were told that we were looking at a very old remnant of ancient history that was once connected to Antarctica. Having travelled extensively in alpine and arctic regions, seeing a vast treeless landscape gave me the (false) sensation of being at altitude or high latitude. In the late afternoon we saw grey kangaroos, emus and sheep grazing amongst the saltbushes, unperturbed by the passing train. It was not difficult to spare a thought for the early explorers and the people who did the hard work of constructing the railway in such a hostile and unforgiving environment.
The bunk beds (and pillows) were reasonably comfortable. Coming from Melbourne, it was a case of going backwards in time twice - half an hour for South Australian time, and then an additional hour for Central time (as the NT does not have daylight saving). I have never had any trouble sleeping on trains - I find the motion quite soothing (if a bit noisy) and if it works for recalcitrant babies, why should it not work for adults? My last experience of a sleeper car was on the overnight train from Stockholm to Malmö, where there was a dizzying number of bunks stacked up to the ceiling, and a disconcertingly early arrival in Malmö. Taxi prices there are unregulated, so I was lucky there was a bus service which stopped close to the youth hostel in central Malmö. Even luckier that the driver took pity on a poor foreigner and did not charge me for the short journey!
Ah the irony of "mozzing" oneself! It turned out to be quite an eventful evening. Upon first retiring the train was "going like the clappers" with every imaginable vibration and groan. Despite being in the middle of nowhere with the blinds down, it was surprisingly bright with 'lights off', so I opened the blinds and peeked out and there was a full moon in a cloudy sky. Accustomed as I am to sleeping with a beautiful malleable feather pillow, the pillows provided were too 'lumpy' (fixed shape synthetic) and gave me no joy. Not long after midnight we stopped abruptly and remained stationary for about two hours. Perhaps this was to give way to another train. Once travel resumed it seemed to be at a more sedate pace (or else on a newer section of track) as the rattles and vibration were less than previously. I drifted in and out of sleep, wrestling with the pillow and trying to find a comfortable position, and was then fully awake by 0600 Central time, waiting for the knock on the door with the promised 'wake-up' coffee. This failed to materialise, but no matter. With the airconditioning going all night my mouth became a little dry so it was good to have a water bottle handy.
The impressively long Ghan was standing at the platform, with its trademark red engine at the front, and a long line of silver carriages. The large entrance hall contains a check-in area, a NT Tourism desk, a shop and a cafe. Boarding commenced at 11:30 and the train left Adelaide at around 12:20.
The Gold Service cabins are small and old-fashioned, but functional, with a long bench seat, a window, an en-suite (with complimentary toiletry packs) and two fold-down bunk beds. Sitting on the benches, one travels backwards. According to my extensive observations on Melbourne trams and trains, this is not the natural preference for most of the human race, who, given a choice, will normally sit facing the direction of travel. (I later found out that half the cabins face in the direction of travel - as a keen photographer it would have been nice to have been offered a choice.) The cabin was a bit stuffy to start with but quickly cooled off once the train got underway. Free tea and coffee is available in a small kitchenette at the end of the carriage. A selection of music is available in the cabin, and the classical content is certainly of good quality. (Unfortunately for classical music lovers who "know their stuff", the selection is repeated.) Apparently WiFi is in the process of being installed, but I am not sure whether I actually like the idea as it is rather nice to be liberated by being free of email and the Internet for just a few days. At some stage during the first evening we also passed out of mobile phone network coverage and this felt strangely blissful. I expect connectivity will be resumed again when we pass through major towns during the rest of the journey, but in the interim the feeling of freedom from modern technology is rather pleasant! All part of the enchanting romance of train travel - sometimes less is more!
The customer service was excellent, both in terms of management of the cabin area, the lounge and the dining car. Announcements of relevance were made from time to time. A complimentary drink was provided in the lounge prior to lunch. Lunch and dinner times are booked and staggered in order to allow everyone to be served in the small Queen Adelaide dining car. (Meals have been reviewed separately.)
The Ghan initially follows the same route as the Indian Pacific (to Perth) but turns north at Tarcoola. Once we passed out of Adelaide we quickly encountered great expanses of farmland, red earth and golden stubble under a cloudless postcard blue sky. As well as catching glimpses of the Spencer Gulf on our journey to Port Augusta, we also saw vast white salt flats and acre upon acre of olive-green saltbush contrasting with the orchre earth. The impressive Flinders Ranges seemed to stretch from here to infinity, and we were told that we were looking at a very old remnant of ancient history that was once connected to Antarctica. Having travelled extensively in alpine and arctic regions, seeing a vast treeless landscape gave me the (false) sensation of being at altitude or high latitude. In the late afternoon we saw grey kangaroos, emus and sheep grazing amongst the saltbushes, unperturbed by the passing train. It was not difficult to spare a thought for the early explorers and the people who did the hard work of constructing the railway in such a hostile and unforgiving environment.
The bunk beds (and pillows) were reasonably comfortable. Coming from Melbourne, it was a case of going backwards in time twice - half an hour for South Australian time, and then an additional hour for Central time (as the NT does not have daylight saving). I have never had any trouble sleeping on trains - I find the motion quite soothing (if a bit noisy) and if it works for recalcitrant babies, why should it not work for adults? My last experience of a sleeper car was on the overnight train from Stockholm to Malmö, where there was a dizzying number of bunks stacked up to the ceiling, and a disconcertingly early arrival in Malmö. Taxi prices there are unregulated, so I was lucky there was a bus service which stopped close to the youth hostel in central Malmö. Even luckier that the driver took pity on a poor foreigner and did not charge me for the short journey!
Ah the irony of "mozzing" oneself! It turned out to be quite an eventful evening. Upon first retiring the train was "going like the clappers" with every imaginable vibration and groan. Despite being in the middle of nowhere with the blinds down, it was surprisingly bright with 'lights off', so I opened the blinds and peeked out and there was a full moon in a cloudy sky. Accustomed as I am to sleeping with a beautiful malleable feather pillow, the pillows provided were too 'lumpy' (fixed shape synthetic) and gave me no joy. Not long after midnight we stopped abruptly and remained stationary for about two hours. Perhaps this was to give way to another train. Once travel resumed it seemed to be at a more sedate pace (or else on a newer section of track) as the rattles and vibration were less than previously. I drifted in and out of sleep, wrestling with the pillow and trying to find a comfortable position, and was then fully awake by 0600 Central time, waiting for the knock on the door with the promised 'wake-up' coffee. This failed to materialise, but no matter. With the airconditioning going all night my mouth became a little dry so it was good to have a water bottle handy.
Saturday, January 26, 2013
Travelling on "The Ghan" - Overnight stopover in Adelaide
Adelaide - City of Churches and Cricket
Adelaide was but an overnight stopover en-route to "The Ghan" train service. This city is famous for its churches and a love of cricket and for many years was home to its adopted favourite son, Australia's legendary Sir Don Bradman, a cricketer of whom the whole world still speaks in deferential hushed tones.
The new airport is simply gorgeous. Clean, open and spacious with a definite Scandinavian feel to it, there is ample use of panoramic glass windows and warm wood panelling. It is also only a stone's throw from a large IKEA store!
It was a beautiful warm summer's day when we arrived - a cobalt blue cloudless sky and the sun beating down on a parched dry land. There is something quintessentially 'Australian' about this. We respond to the dry air in our nostrils, the muted and pastel green, gold, brown, ochre, blue and purple of the landscape, the way the brightness of the sun almost stings our eyes and makes us squint, and the stillness and expanse of the 'Great Southern Land' in which our heartbeat is just a tiny portion of the pulsating liveliness which underpins everything in and upon it. It is as if once the sun touches the land, the spirit of the land is magnified and radiates back outwards, illuminating us all.
I have not been to Adelaide for many years, and my first impression of it is that it is a bit like a large country town. It still possesses many of its 'Colonial era' buildings, and wide open boulevards. It made me think of other cities with quaint charm, such as Hobart and Christchurch in New Zealand. The centre of the city is laid out in a grid, so it is impossible to get lost, surrounded by the unimaginatively named "North", "South", "East" and "West" Terraces.
I recall from the distant past that the iconic Rundle Mall was quiet and gentrified, with many small cafes and eateries. Now it is busy, noisy and commercialised, not unlike any other major shopping centre/strip anywhere else in Australia. One curious thing was that a movie theatre was nowhere to be seen.
The beautiful St Francis Xavier Church is in the centre of the city, with a sculpture memorial to Australia's only Saint, Mary McKillop, out the front. Inside it is cool, dimly lit and contemplative, with a beautiful rose window above the back gallery. With ceiling fans creating a gentle breeze, it was a welcome respite from the heat.
What to do about food? With an annoyingly delayed 2pm check-in at the hotel (Rydges on South Terrace) our group trudged what turned out to be a very long way in the heat into the city searching for something as simple as a sandwich and fruit drink for lunch. Eventually we stumbled across Gouger Street, heart of Adelaide's 'foodie precinct' and found a Subway. As one of the healthiest of fast food choices, the turkey, ham and salad roll ($8.95 for a 12 inch Sub for sharing) and 500mL Goulburn Valley orange juice with pulp ($3.70) was like manna from heaven and supplied some much-needed energy. On our way back to the hotel, we also stumbled across an intriguing-sounding restaurant called "British India", near the corner of Gouger and Morphett Streets. The original plan was to return here for dinner, but exhaustion got in the way! However, upon researching this restaurant on Urbanspoon, the reviews were almost universally good, so it sounds like one worth trying if you are looking for somewhere to eat in central Adelaide.
Since there was no breakfast included with our package, taking care of this was also another obstacle to overcome. It was too far to walk back to Gouger Street with a shuttle pick-up shortly after 10am, and the hotel breakfast was way too expensive - $25 Continental, $28 Cooked, so another plan had to be hatched. According to the hotel information brochure, there was an IGA in nearby Gilbert Street (they neglected to mention that this was a looong way along the street back towards the city!) so we trudged off again and eventually found it. The airconditioning was a welcome relief and spent a whole $8.47 on breakfast for the group - milk, yoghurt and canned fruit. On reviewing the invoice later, we also discovered that we had been charged $0.10 for a plastic bag. The cashier did not advise that there was a charge for bags. As a strong proponent of recycleable bags at home, I would not have willingly purchased a plastic bag in this instance. Whether this is a South Australian or IGA initiative, they have a duty to inform customers prior to charging them.
On our way back from the supermarket, we decided to check out the bistro in the nearby pub on the corner of Gilbert Street and West Terrace - the Elephant and Castle (reviewed separately) and enjoyed a tasty and cost-effective meal.
Adelaide was but an overnight stopover en-route to "The Ghan" train service. This city is famous for its churches and a love of cricket and for many years was home to its adopted favourite son, Australia's legendary Sir Don Bradman, a cricketer of whom the whole world still speaks in deferential hushed tones.
The new airport is simply gorgeous. Clean, open and spacious with a definite Scandinavian feel to it, there is ample use of panoramic glass windows and warm wood panelling. It is also only a stone's throw from a large IKEA store!
It was a beautiful warm summer's day when we arrived - a cobalt blue cloudless sky and the sun beating down on a parched dry land. There is something quintessentially 'Australian' about this. We respond to the dry air in our nostrils, the muted and pastel green, gold, brown, ochre, blue and purple of the landscape, the way the brightness of the sun almost stings our eyes and makes us squint, and the stillness and expanse of the 'Great Southern Land' in which our heartbeat is just a tiny portion of the pulsating liveliness which underpins everything in and upon it. It is as if once the sun touches the land, the spirit of the land is magnified and radiates back outwards, illuminating us all.
I have not been to Adelaide for many years, and my first impression of it is that it is a bit like a large country town. It still possesses many of its 'Colonial era' buildings, and wide open boulevards. It made me think of other cities with quaint charm, such as Hobart and Christchurch in New Zealand. The centre of the city is laid out in a grid, so it is impossible to get lost, surrounded by the unimaginatively named "North", "South", "East" and "West" Terraces.
I recall from the distant past that the iconic Rundle Mall was quiet and gentrified, with many small cafes and eateries. Now it is busy, noisy and commercialised, not unlike any other major shopping centre/strip anywhere else in Australia. One curious thing was that a movie theatre was nowhere to be seen.
The beautiful St Francis Xavier Church is in the centre of the city, with a sculpture memorial to Australia's only Saint, Mary McKillop, out the front. Inside it is cool, dimly lit and contemplative, with a beautiful rose window above the back gallery. With ceiling fans creating a gentle breeze, it was a welcome respite from the heat.
What to do about food? With an annoyingly delayed 2pm check-in at the hotel (Rydges on South Terrace) our group trudged what turned out to be a very long way in the heat into the city searching for something as simple as a sandwich and fruit drink for lunch. Eventually we stumbled across Gouger Street, heart of Adelaide's 'foodie precinct' and found a Subway. As one of the healthiest of fast food choices, the turkey, ham and salad roll ($8.95 for a 12 inch Sub for sharing) and 500mL Goulburn Valley orange juice with pulp ($3.70) was like manna from heaven and supplied some much-needed energy. On our way back to the hotel, we also stumbled across an intriguing-sounding restaurant called "British India", near the corner of Gouger and Morphett Streets. The original plan was to return here for dinner, but exhaustion got in the way! However, upon researching this restaurant on Urbanspoon, the reviews were almost universally good, so it sounds like one worth trying if you are looking for somewhere to eat in central Adelaide.
Since there was no breakfast included with our package, taking care of this was also another obstacle to overcome. It was too far to walk back to Gouger Street with a shuttle pick-up shortly after 10am, and the hotel breakfast was way too expensive - $25 Continental, $28 Cooked, so another plan had to be hatched. According to the hotel information brochure, there was an IGA in nearby Gilbert Street (they neglected to mention that this was a looong way along the street back towards the city!) so we trudged off again and eventually found it. The airconditioning was a welcome relief and spent a whole $8.47 on breakfast for the group - milk, yoghurt and canned fruit. On reviewing the invoice later, we also discovered that we had been charged $0.10 for a plastic bag. The cashier did not advise that there was a charge for bags. As a strong proponent of recycleable bags at home, I would not have willingly purchased a plastic bag in this instance. Whether this is a South Australian or IGA initiative, they have a duty to inform customers prior to charging them.
On our way back from the supermarket, we decided to check out the bistro in the nearby pub on the corner of Gilbert Street and West Terrace - the Elephant and Castle (reviewed separately) and enjoyed a tasty and cost-effective meal.
Medical Book Review - Practical Management of Head and Neck Injury
Practical Management of Head and Neck Injury
Edited by Professor Jeffrey V Rosenfeld
Churchill Livingstone/Elsevier 2012
Paperback edition 500 pages
http://www.elsevierhealth.com.au/emergency-medicine/practical-management-of-head-and-neck-injury-paperback/9780729539562/
Put simply, this book is a fabulous resource which holds value for everyone from pre-hospital first responders in a remote location through medical to students, junior doctors and trainees to specialists. "The book adopts an evidence-based approach to the management of traumatic head and neck injury, supported by the latest research." It "captures the essence of the day-to-day management of head and neck injury by following all aspects of care through the patient's journey ..."
Its special features highlighted on the back cover are:
The layout of the book comprises:
Edited by Professor Jeffrey V Rosenfeld
Churchill Livingstone/Elsevier 2012
Paperback edition 500 pages
http://www.elsevierhealth.com.au/emergency-medicine/practical-management-of-head-and-neck-injury-paperback/9780729539562/
Put simply, this book is a fabulous resource which holds value for everyone from pre-hospital first responders in a remote location through medical to students, junior doctors and trainees to specialists. "The book adopts an evidence-based approach to the management of traumatic head and neck injury, supported by the latest research." It "captures the essence of the day-to-day management of head and neck injury by following all aspects of care through the patient's journey ..."
Its special features highlighted on the back cover are:
- The complete management of patients with head and neck trauma, from the accident scene through to rehabilitation;
- Safe, practical tips to assist the non-neurosurgoen in managing head injuries and preventing secondary brain injury - a major concern for emergency and pre-hospital medical personnel;
- All aspects of neck trauma covered, including the management of cervical spine injury;
- Detailed discussion of topics such as the classification of brain injury, concussion in sport, head injuries in children and the elderly, penetrating head injuries and the prognosis of head injury;
- The operative surgery of head and neck trauma outlined for the non-surgeon;
- Contributions from a wide range of specialists, both from Australia and overseas;
- Integration of neurosurgery with ear, nose and throat (ENT) surgery, maxillofacial surgery, ophthalmology and spinal orthopaedics; and
- Basic principles of relevant anatomy and pathophysiology, each covered in a separate chapter.
The layout of the book comprises:
- Contents
- Foreword
- Preface
- Acknowledgments
- Contributors and reviewers
- 1. Epidemiology
- 2. Anatomy of the head and neck
- 3. Pathophysiology of traumatic brain injury
- 4. Pre-hospital management
- 5. Emergency department management
- 6. Injury to the spine and spinal cord
- 7. Vascular injury
- 8. Operative surgery
- 9. Intensive care management of head injury
- 10. Ward care of the head-injured patient
- 11. Rehabilitation
- 12. Head injury in children
- 14. Head injury in sport
- 15. Penetrating head injury
- 16. Bleeding diathesis and anticoagulants
- 17. Neurotrauma in pregnancy
- 18. Brain death
- 19. Persistent vegetative and minimally responsive states following head injury
- 20. Prediction of outcome and the prognosis of head injury
- 21. Prevention of head injury and the role of trauma systems.
- Index
The illustrations are an excellent aid to understanding, and include tables, graphs, stylised and line drawings, anatomical drawings, CT and MRI scans, angiograms, pathology specimens, real-life 'action shots' including surgical instruments and processes, and reproductions of various guidelines and protocols. The authors have obviously gone to some effort to make this book a practical rather than theoretical resource.
As someone who has worked with Ski Patrol in remote locations as both a volunteer patroller and a medic and in small town rural emergency practice, I thought I would try approaching my review of this book from this perspective and look at its utility from the point of view of both a first responder and a remote emergency practitioner. Accordingly, the three chapters that I will specifically examine here are:
Chapter 4 opens with an explanation of the goals of pre-hospital emergency medical service (EMS) treatment for severe traumatic brain injury (TBI) and then proceeds with sound advice for bystanders immediately to call the EMS and to place an unconscious casualty in the left lateral position. However, things become a bit more murky thereafter. If respirations cease, the bystander is advised to give some expired air resuscitation in the supine position and cardiac arrest should be assumed and chest compressions commenced. However, this is at odds with the current Australian Resuscitation Council (ARC) Guidelines which are taught in first-aid courses that if someone is unconscious and not breathing normally, chest compressions should be commenced first, followed by breaths in the ratio of 30:2.
With reference to removing a motorcycle helmet, the importance of stabilising the cervical spine during this procedure could have been stressed, and perhaps even instructions provided (for instance, the American College of Surgeons has a nice PDF diagram with explanatory notes).
Under the "Paramedic Initial Assessment" the mnemonic "DRABC" is used. However, this has now been superseded in Basic Life Support by "DRSABC", where the "S" stands for "send for help". Even though some might argue that the paramedics "are the help", even for trained first responders, the "S" serves to remind them to reflect on whether they can manage the situation or need to call for further reinforcements.
There is a good discussion of potential dangers, but the text disappointingly then goes on to refer to the "AVPU" scale for assessing conscious state rather than the 'gold standard Glasgow Coma Scale (GCS). The GCS is taught to ski patrollers and certainly appears in the Ambulance Victoria CPGs (as part of the "Vital Signs Survey" which immediately follows the Primary Survey) and is of course used in Emergency Departments and can form a vital component of handover. Perhaps AVPU is appropriate as an instant assessment prior to completion of the Primary Survey, but most practitioners would probably prefer an accurate assessment of the GCS prior to determining whether to proceed with a Rapid Sequence Induction (RSI) and intubation as discussed in the next section. The GCS score forms part of the assessment in the Ambulance Victoria "Trauma Time Critical Guidelines". A pre-hospital GCS score is actually referred to later in the airway/breathing section and in the section on circulation, so it is a pity that its place in pre-hospital EMS management was not consistently considered in this chapter.
The advice about inserting an oropharygeal airway is confusing, and one would hope that clearing the airway of any debris that is present would occur prior to attempting to insert any type of airway. It is not mentioned that caution is indicated in inserting a nasopharyngeal airway in TBI where there is any suspicion of a base-of-skull fracture. There is also no reference to positioning of the head for optimal ventilation; nor to the possible modalities of mouth -to-mouth or mouth-to-mask in pre-hospital practice. My own feeling is that this section is rather clumsy and does not echo the clear and methodical approach that is used in Ski Patrol BLS training. Airway - inspect and clear if necessary. Breathing - look, listen and feel. Patrollers are permitted to make a short pulse check, but if the patient if not breathing normally, commence compressions and assisted ventilations after first favourably positioning the head. Only if ventilation is inadequate (even with a two-person technique) is the use of an airway adjunct then considered. Especially with a TBI, caution is required as triggering the gag reflex may contribute to vomiting and aspiration and an increase in intracranial pressure. With regard to ventilating the patient, if there is a significant mechanism of injury and spinal injury is suspected, special care must be taken with positioning of the head and neck and minimising movement. This is not mentioned at all.
The reference to the insertion of chest drains for decompressing a tension pneumothorax is somewhat alarming, as the Ambulance Victoria guidelines only refer to needle decompression, and specialist skills and equipment would be required for a drain.
Only at this point is fitting a cervical collar mentioned. Once again, instructions might be useful in terms of how to approach this and stabilisation of the head and neck during the procedure.
There is an extensive theoretical discussion about RSI in the field and whether this is of long-term benefit to the patient. (MICA paramedics in Victoria can intubate patients.) However, it was good to see discussed at the end of this section the issue of whether intubation should be undertaken without supplemental drugs. At this point airway stimulation possibly leading to vomiting and a rise in ICP is actually mentioned!
The section on circulation primarily discusses hypotension and fluids. It might have been useful to include some of the basics, such as expanding on the unreliability of the pulse check and whether standard first-aid measures such as elevating the feet are appropriate in TBI. In a remote or wilderness setting access to IV fluids may not be initially available. It was good to mention the points about control of haemorrhage.
I find it surprising that the author has not referred to the ARC Guidelines at all in this chapter, as they contain a wealth of information relating to management of a patient in the pre-hospital setting. They are the 'Bible' which forms the basis for the Ski Patrol Advanced Emergency Care Manual.
The "Additional initial procedures" and "Secondary Survey" contents are certainly not consistent with the Ambulance Victoria approach, which follows the Primary Survey with the "Vital Signs Survey" - GCS and assessment of perfusion state and respiratory state and pattern/mechanism of injury/medical condition - the purpose of which is to determine the time criticality to manage appropriately. The "Secondary Survey" covers a head to toe assessment (inspection, palpation, auscultation), pulse oximetry, monitor/ECG, temperature, EtCO2, blood glucose level and more detailed history. The combination of these three surveys allows the clinical problems to be identified. It is disappointing that a GCS assessment is only mentioned as part of the Secondary Survey here. Blood sugar is mentioned under a separate heading.
The author discusses the role of therapeutic hypothermia and concludes that it is not recommended in TBI patients outside the setting of a clinical trial. It might have been useful to provide some advice about the optimal management of hypothermic TBI patients in terms of preventing further heat loss and warming them as they make their way to definitive care.
The final section about transport discusses the role of specialised trauma centres and the efficacy of helicopter transport. One issue it does not raise is the possibility of transport delays in remote areas (not uncommon whilst awaiting evacuation from alpine locations) and monitoring and care of the patient (who may possibly deteriorate) whilst awaiting transport (or even arrival of the EMS). A short Summary and references are provided at the end of the chapter.
In summary, I found this chapter disappointing. It was disorganised and large chunks were more theoretical than practical, and the inconsistencies with Australian practices would be confusing for some people. However some of the discussion aspects were both interesting and useful. (It is noted that there is extensive information provided on both RSI and GCS in Chapter 5, "Emergency Department Management".)
Chapter 14 "Head injury in sport" is a much larger chapter and well laid-out and practical in emphasis. The chapter begins with a discussion about concussion and provides a useful 2001 consensus definition. The incidence section covers both American and Australian sports and helpfully mentions the factors that may affect the incidence of concussion in sports. The authors subsequently introduce the "Concussion in Sport Group" (CISG) and its consensus statements and assessment tools. This leads into an extensive section on "On-field assessment and game-day management", which is written in such a way as to be comprehensible by people outside the health professions (although it might be difficult to follow in places without having had any first-aid training), and it is stressed that such people have a vital role to play in the assessment and management of concussion. A copy of a 'pocket assessment card' (also available as an "app") and a long list of the symptoms of concussion are provided. Game-day management follows. There are a couple of references back to Chapter 4 "Pre-Hospital Management' regarding the "general rules of emergency management of head injury" (more succinctly summarised here than there) and the "general head-injury pathway" (which I could not find mentioned in Chapter 4, and there is certainly no flow diagram for a 'pathway'). This section suggests a number of relevant assessment tools and emphasises continued monitoring and follow-up. A note on impact seizures follows.
The section on "Post-game day concussion management" highlights the need for a complete brain recovery before return to play and provides a graduated return-to-play protocol. A couple of pages follow on different modalities of "Ancillary testing". At the conclusion of the chapter several assessment tools are reproduced together with some advice sheets.
Expanding on the "if in doubt, sit them out" them, the section on "Return to sport" includes a discussion on 'Modifiers' - factors which complicate recovery, and protective equipment and evidence for benefit. (This theme is taken up again at the end of the chapter in respect of "Return to sport, return to school, return to work".) There are three "Special situations" discussed in the following section - children, diffuse cerebral swelling and second-impact syndrome, and boxing. Although these discussions are more academic, they are still quite accessible. The paragraphs on boxing are particularly sobering and provide good background information concerning the consequences.
The penultimate section (before the succinct and pragmatic Summary) on "Prevention and education" provides some very useful information and practical advice. Two case studies (with discussion) are also included, the second one raising the issue of where does a GP go for advice on managing a patient whilst that person is waiting for an Outpatients appointment? Answer: continue monitoring and arrange a more timely assessment by someone experienced in concussion management. The corollary of this is that it is useful for GPs to have some idea of "who ya gonna call?" in the local area. (References are provided at the end of the chapter.)
I felt this was a terrific chapter, and it certainly has potential to be useful to all levels of health professionals.
Lest I exhaust the reader, I will not go into so much detail concerning Chapter 21, "Prevention of head injury and the role of trauma systems". It is a relatively short chapter (with Key Points and references at the end). The introduction concerning the categorisation of prevention activities as primary, secondary or tertiary and the use of Haddon's Matrix as a conceptual framework for "understanding the origins of injury problems and for identifying ways to address these problems" is interesting. A worked example of the Matrix is provided in Table 21.1. A section is devoted to each level of prevention - "Primary prevention: various measures", "Secondary prevention: trauma systems" and "Tertiary prevention: rehabilitation". This final section reminds the reader of the 'hidden costs' of TBI: "For every two patients who die of traumatic brain injuries, there are ten survivors with severe permanent disabilities".
The section on primary prevention concentrates on road traffic injuries, discussing the minimisation of exposure to high-risk scenarios, restraints, airbags and helmets (motorcycle and bicycle). Harking back to the two chapters examined above, I would have liked to see a wider discussion of the role of helmets including in sporting activities. Although their use is becoming more prevalent in the snowsports setting, some people still remain to be persuaded, and a textbook like this could play a powerful role in this struggle. The discussion on trauma systems, including the historical background, is really interesting. It also emphasises the importance of assessing the level of consciousness using the GCS as a modality of deciding the disposition of the patient. "Getting it right" in terms of where the patient is sent at first instance for definitive care is important, and this may be an issue in rural and remote areas with long waits for transport or accessibility issues e.g., bad weather. Sometimes ambulance dispatch may have a different view about time criticality to the people on the ground. Together with my colleagues at a Victorian alpine resort, I have experienced such a situation, where we told dispatch that we had a patient with a serious orthopaedic injury who needed to go by helicopter to Melbourne. A road crew was sent instead after several hours' delay. When they arrived and saw the patient they immediately concurred with our assessment and a helicopter was called for. By now it was night-time and the weather conditions had become difficult, but fortunately the road crew was able to drive the patient to a landing site lower down the mountain and met the helicopter there. I mention this story because of the issue of communication - for the trauma system to work effectively there must be good communication and trust in the assessment of the people in the field (as well as objective criteria such as vital signs and GCS). Perhaps as 'icing on the cake' it would have been appropriate to mention the importance of good communication and teamwork between different types of health professionals in the trauma setting. An emergency consultant once said to me that “trauma is a team sport”, and my own experience has shown this to be a truism. (This subject is addressed briefly in Chapter 5.)
In a book like this where different chapters are written by different people, there is bound to be some variation in style, and this is acknowledged by the editor in his Preface. Even to someone just flicking through the pages, it is immediately obvious the book contains a wealth of high-quality information and great care in its preparation. There is no doubt that many medical students and doctors find neuroscience a forbidding and inaccessible topic, and overall the editor and the authors are to be congratulated on producing a very practical and useful book which explains concepts which might otherwise be daunting in an accessible way.
Verdict: Recommended!
As someone who has worked with Ski Patrol in remote locations as both a volunteer patroller and a medic and in small town rural emergency practice, I thought I would try approaching my review of this book from this perspective and look at its utility from the point of view of both a first responder and a remote emergency practitioner. Accordingly, the three chapters that I will specifically examine here are:
- Chapter 4 - Pre-hospital management;
- Chapter 14 - Head injury in sport; and
- Chapter 21 - Prevention of head injury and the role of trauma systems.
With reference to removing a motorcycle helmet, the importance of stabilising the cervical spine during this procedure could have been stressed, and perhaps even instructions provided (for instance, the American College of Surgeons has a nice PDF diagram with explanatory notes).
Under the "Paramedic Initial Assessment" the mnemonic "DRABC" is used. However, this has now been superseded in Basic Life Support by "DRSABC", where the "S" stands for "send for help". Even though some might argue that the paramedics "are the help", even for trained first responders, the "S" serves to remind them to reflect on whether they can manage the situation or need to call for further reinforcements.
There is a good discussion of potential dangers, but the text disappointingly then goes on to refer to the "AVPU" scale for assessing conscious state rather than the 'gold standard Glasgow Coma Scale (GCS). The GCS is taught to ski patrollers and certainly appears in the Ambulance Victoria CPGs (as part of the "Vital Signs Survey" which immediately follows the Primary Survey) and is of course used in Emergency Departments and can form a vital component of handover. Perhaps AVPU is appropriate as an instant assessment prior to completion of the Primary Survey, but most practitioners would probably prefer an accurate assessment of the GCS prior to determining whether to proceed with a Rapid Sequence Induction (RSI) and intubation as discussed in the next section. The GCS score forms part of the assessment in the Ambulance Victoria "Trauma Time Critical Guidelines". A pre-hospital GCS score is actually referred to later in the airway/breathing section and in the section on circulation, so it is a pity that its place in pre-hospital EMS management was not consistently considered in this chapter.
The advice about inserting an oropharygeal airway is confusing, and one would hope that clearing the airway of any debris that is present would occur prior to attempting to insert any type of airway. It is not mentioned that caution is indicated in inserting a nasopharyngeal airway in TBI where there is any suspicion of a base-of-skull fracture. There is also no reference to positioning of the head for optimal ventilation; nor to the possible modalities of mouth -to-mouth or mouth-to-mask in pre-hospital practice. My own feeling is that this section is rather clumsy and does not echo the clear and methodical approach that is used in Ski Patrol BLS training. Airway - inspect and clear if necessary. Breathing - look, listen and feel. Patrollers are permitted to make a short pulse check, but if the patient if not breathing normally, commence compressions and assisted ventilations after first favourably positioning the head. Only if ventilation is inadequate (even with a two-person technique) is the use of an airway adjunct then considered. Especially with a TBI, caution is required as triggering the gag reflex may contribute to vomiting and aspiration and an increase in intracranial pressure. With regard to ventilating the patient, if there is a significant mechanism of injury and spinal injury is suspected, special care must be taken with positioning of the head and neck and minimising movement. This is not mentioned at all.
The reference to the insertion of chest drains for decompressing a tension pneumothorax is somewhat alarming, as the Ambulance Victoria guidelines only refer to needle decompression, and specialist skills and equipment would be required for a drain.
Only at this point is fitting a cervical collar mentioned. Once again, instructions might be useful in terms of how to approach this and stabilisation of the head and neck during the procedure.
There is an extensive theoretical discussion about RSI in the field and whether this is of long-term benefit to the patient. (MICA paramedics in Victoria can intubate patients.) However, it was good to see discussed at the end of this section the issue of whether intubation should be undertaken without supplemental drugs. At this point airway stimulation possibly leading to vomiting and a rise in ICP is actually mentioned!
The section on circulation primarily discusses hypotension and fluids. It might have been useful to include some of the basics, such as expanding on the unreliability of the pulse check and whether standard first-aid measures such as elevating the feet are appropriate in TBI. In a remote or wilderness setting access to IV fluids may not be initially available. It was good to mention the points about control of haemorrhage.
I find it surprising that the author has not referred to the ARC Guidelines at all in this chapter, as they contain a wealth of information relating to management of a patient in the pre-hospital setting. They are the 'Bible' which forms the basis for the Ski Patrol Advanced Emergency Care Manual.
The "Additional initial procedures" and "Secondary Survey" contents are certainly not consistent with the Ambulance Victoria approach, which follows the Primary Survey with the "Vital Signs Survey" - GCS and assessment of perfusion state and respiratory state and pattern/mechanism of injury/medical condition - the purpose of which is to determine the time criticality to manage appropriately. The "Secondary Survey" covers a head to toe assessment (inspection, palpation, auscultation), pulse oximetry, monitor/ECG, temperature, EtCO2, blood glucose level and more detailed history. The combination of these three surveys allows the clinical problems to be identified. It is disappointing that a GCS assessment is only mentioned as part of the Secondary Survey here. Blood sugar is mentioned under a separate heading.
The author discusses the role of therapeutic hypothermia and concludes that it is not recommended in TBI patients outside the setting of a clinical trial. It might have been useful to provide some advice about the optimal management of hypothermic TBI patients in terms of preventing further heat loss and warming them as they make their way to definitive care.
The final section about transport discusses the role of specialised trauma centres and the efficacy of helicopter transport. One issue it does not raise is the possibility of transport delays in remote areas (not uncommon whilst awaiting evacuation from alpine locations) and monitoring and care of the patient (who may possibly deteriorate) whilst awaiting transport (or even arrival of the EMS). A short Summary and references are provided at the end of the chapter.
In summary, I found this chapter disappointing. It was disorganised and large chunks were more theoretical than practical, and the inconsistencies with Australian practices would be confusing for some people. However some of the discussion aspects were both interesting and useful. (It is noted that there is extensive information provided on both RSI and GCS in Chapter 5, "Emergency Department Management".)
Chapter 14 "Head injury in sport" is a much larger chapter and well laid-out and practical in emphasis. The chapter begins with a discussion about concussion and provides a useful 2001 consensus definition. The incidence section covers both American and Australian sports and helpfully mentions the factors that may affect the incidence of concussion in sports. The authors subsequently introduce the "Concussion in Sport Group" (CISG) and its consensus statements and assessment tools. This leads into an extensive section on "On-field assessment and game-day management", which is written in such a way as to be comprehensible by people outside the health professions (although it might be difficult to follow in places without having had any first-aid training), and it is stressed that such people have a vital role to play in the assessment and management of concussion. A copy of a 'pocket assessment card' (also available as an "app") and a long list of the symptoms of concussion are provided. Game-day management follows. There are a couple of references back to Chapter 4 "Pre-Hospital Management' regarding the "general rules of emergency management of head injury" (more succinctly summarised here than there) and the "general head-injury pathway" (which I could not find mentioned in Chapter 4, and there is certainly no flow diagram for a 'pathway'). This section suggests a number of relevant assessment tools and emphasises continued monitoring and follow-up. A note on impact seizures follows.
The section on "Post-game day concussion management" highlights the need for a complete brain recovery before return to play and provides a graduated return-to-play protocol. A couple of pages follow on different modalities of "Ancillary testing". At the conclusion of the chapter several assessment tools are reproduced together with some advice sheets.
Expanding on the "if in doubt, sit them out" them, the section on "Return to sport" includes a discussion on 'Modifiers' - factors which complicate recovery, and protective equipment and evidence for benefit. (This theme is taken up again at the end of the chapter in respect of "Return to sport, return to school, return to work".) There are three "Special situations" discussed in the following section - children, diffuse cerebral swelling and second-impact syndrome, and boxing. Although these discussions are more academic, they are still quite accessible. The paragraphs on boxing are particularly sobering and provide good background information concerning the consequences.
The penultimate section (before the succinct and pragmatic Summary) on "Prevention and education" provides some very useful information and practical advice. Two case studies (with discussion) are also included, the second one raising the issue of where does a GP go for advice on managing a patient whilst that person is waiting for an Outpatients appointment? Answer: continue monitoring and arrange a more timely assessment by someone experienced in concussion management. The corollary of this is that it is useful for GPs to have some idea of "who ya gonna call?" in the local area. (References are provided at the end of the chapter.)
I felt this was a terrific chapter, and it certainly has potential to be useful to all levels of health professionals.
Lest I exhaust the reader, I will not go into so much detail concerning Chapter 21, "Prevention of head injury and the role of trauma systems". It is a relatively short chapter (with Key Points and references at the end). The introduction concerning the categorisation of prevention activities as primary, secondary or tertiary and the use of Haddon's Matrix as a conceptual framework for "understanding the origins of injury problems and for identifying ways to address these problems" is interesting. A worked example of the Matrix is provided in Table 21.1. A section is devoted to each level of prevention - "Primary prevention: various measures", "Secondary prevention: trauma systems" and "Tertiary prevention: rehabilitation". This final section reminds the reader of the 'hidden costs' of TBI: "For every two patients who die of traumatic brain injuries, there are ten survivors with severe permanent disabilities".
The section on primary prevention concentrates on road traffic injuries, discussing the minimisation of exposure to high-risk scenarios, restraints, airbags and helmets (motorcycle and bicycle). Harking back to the two chapters examined above, I would have liked to see a wider discussion of the role of helmets including in sporting activities. Although their use is becoming more prevalent in the snowsports setting, some people still remain to be persuaded, and a textbook like this could play a powerful role in this struggle. The discussion on trauma systems, including the historical background, is really interesting. It also emphasises the importance of assessing the level of consciousness using the GCS as a modality of deciding the disposition of the patient. "Getting it right" in terms of where the patient is sent at first instance for definitive care is important, and this may be an issue in rural and remote areas with long waits for transport or accessibility issues e.g., bad weather. Sometimes ambulance dispatch may have a different view about time criticality to the people on the ground. Together with my colleagues at a Victorian alpine resort, I have experienced such a situation, where we told dispatch that we had a patient with a serious orthopaedic injury who needed to go by helicopter to Melbourne. A road crew was sent instead after several hours' delay. When they arrived and saw the patient they immediately concurred with our assessment and a helicopter was called for. By now it was night-time and the weather conditions had become difficult, but fortunately the road crew was able to drive the patient to a landing site lower down the mountain and met the helicopter there. I mention this story because of the issue of communication - for the trauma system to work effectively there must be good communication and trust in the assessment of the people in the field (as well as objective criteria such as vital signs and GCS). Perhaps as 'icing on the cake' it would have been appropriate to mention the importance of good communication and teamwork between different types of health professionals in the trauma setting. An emergency consultant once said to me that “trauma is a team sport”, and my own experience has shown this to be a truism. (This subject is addressed briefly in Chapter 5.)
In a book like this where different chapters are written by different people, there is bound to be some variation in style, and this is acknowledged by the editor in his Preface. Even to someone just flicking through the pages, it is immediately obvious the book contains a wealth of high-quality information and great care in its preparation. There is no doubt that many medical students and doctors find neuroscience a forbidding and inaccessible topic, and overall the editor and the authors are to be congratulated on producing a very practical and useful book which explains concepts which might otherwise be daunting in an accessible way.
Verdict: Recommended!
Medical Book Review - Emergency Medicine MCQs
Emergency Medicine MCQs
by Waruna De Alwis and Yolande Weiner
Publisher: Churchill Livingstone/Elsevier
Paperback edition 2012 (440 pages)
http://www.elsevierhealth.com.au/clinical-general-medicine/emergency-medicine-mcqs-paperback/9780729541046/
Layout:
Part of the very great appeal of this book is that it is written for Australian conditions (by two FACEMs working at Logan Hospital in Queensland), and should be very helpful to those studying for the ACEM Fellowship exam as well as those working regularly in the area who wish to expand and consolidate their knowledge of emergency medicine.
by Waruna De Alwis and Yolande Weiner
Publisher: Churchill Livingstone/Elsevier
Paperback edition 2012 (440 pages)
http://www.elsevierhealth.com.au/clinical-general-medicine/emergency-medicine-mcqs-paperback/9780729541046/
Layout:
- Contents
- List of Authors and Contributors
- List of Reviewers
- Dedication
- Preface
- Acknowledgements
- Questions: Chapters 1-24
- Answers: Chapters 1-24
- Index
Part of the very great appeal of this book is that it is written for Australian conditions (by two FACEMs working at Logan Hospital in Queensland), and should be very helpful to those studying for the ACEM Fellowship exam as well as those working regularly in the area who wish to expand and consolidate their knowledge of emergency medicine.
The book "is structured to reflect the topics covered in the core curriculum of the Australasian College for emergency Medicine fellowship program" and "contains evidence-based, clinically relevant and practical multiple choice questions in adult and paediatric emergency medicine". The contents have drawn upon the knowledge and experience of expert authors in addition to textbooks and peer-reviewed journals. It is aimed not only at exam candidates but also at being a useful resource for everyday clinical practice and improving both knowledge and critical thinking skills.
Additional timed exam papers and quizzes are available in "Practice Exams in Emergency Medicine" for iOS devices and Android.
The topics covered in the Chapters are very comprehensive (as per the ACEM curriculum) and include:
Starting to look through the book was a bit like "being a kid in a candy store" as there were many areas I was interested in exploring to see how my existing knowledge 'stacks up'.
It is obviously not possible to review every single question and answer, so I will just look at a selection to try to give a flavour of the level of difficulty and the depth of the information provided in the answers.
In Chapter 1 on "Resuscitation", there are thirty-two questions relating to adult resuscitation and eighteen relating to paediatric resuscitation. These are fairly wide-ranging, (in adults) covering topics like CPR protocols, ventilatory support, defibrillation and pacing, hypothermia, lactic acidosis and septic shock, vasoactive substances, fluids, thoracotomy and echocardiography. I have to admit that I found some of these questions challenging (I'm not going to say how many I got right on the first pass!) and some of them I simply didn't have detailed enough knowledge even to make an 'educated guess'. However, the beauty of the answers is that they not only explain which is the correct answer (and why) but also why the other answers are incorrect.
I commend the authors on their use of terminology in the questions. It is very clear which alternative the reader is being asked to indentify e.g., "which ONE of the following statements is TRUE/INCORRECT" or "which ONE of the following is NOT ...". I think all medical students hate questions like "Choose the MOST CORRECT/LEAST CORRECT answer from the alternatives below". Some of the questions stray a little in this direction, such as "Which ONE of the following patients will MOST likely benefit ..." or "which ONE of the following is the MOST appropriate answer?" but it seems that the intention here is to tease out critical thinking rather than present a gradation of fiendishly difficult alternatives.
I have chosen one (shorter) example of a questions and answer from this chapter (which incidentally I did get right!):
27. Regarding the use of hypertonic saline in traumatic brain injury (TBI), which ONE of the following statements is true?
A. It reliably decreases intracranial pressure and significantly improves cerebral blood flow.
B. It is as effective as mannitol when osmotherapy is indicated.
C. There is good evidence showing an outcome benefit in TBI.
D. It is the preferred crystalloid if severe TBI occurs with hypotension.
27. Answer: B
Hypertonic saline as been shown to reliably decrease ICP in patients with TBI (LOE II) and it is at least as effective as mannitol. However, no studies so far have demonstrated improved cerebral blood flow; neither is there good evidence showing an outcome benefit. Despite the potential benefits in reducing ICP in patients with TBI, there is currently no evidence to recommend hypertonic saline over isotonic saline for fluid resuscitation and restoration of the intravascular volume (footnote 40).
References are supplied at the end of each chapter of Answers, and it is good to see that the authors are also supplying the Level of Evidence for propositions were relevant.
Next I thought I would move on to Chapter 12 "Emergency Anaesthesia and Pain Management", which I also hoped I would know something about already! There are twenty questions, relating to RSI, medications, local anaesthetics, nerve blocks, opiods, procedural sedation and pain management (these cover both adults and children).
These questions require quite a bit of detailed knowledge, so I think people who are not regularly dealing with the content on a regular basis will find them quite challenging. However, the answers are very educative.
Here is an example from this chapter.
4. The laryngeal mask airway (LMA) is a successful rescue device in emergency airway management. Which ONE of the following statements is TRUE regarding the LMA?
A. Positioning of the patient into the 'sniffing' position is essential.
B. It is a useful alternative to an ETT for establishing a definitive airway.
C. Cricoid pressure almost always impedes insertion of an LMA.
D. The device should be held firmly in place during inflation to allow the LMA to seat properly.
4. Answer: C
The LMA is a useful alternative to endotracheal intubation when an advanced airway is required but it is not a definitive airway and doesn't protect the patient from aspiration. Positioning of the patient into the 'sniffing' position is not essential but it is preferable. The LMA should not be held while the cuff is being inflated to allow the LMA to seat properly. The LMA tube on average will move out of the mouth approximately 0.7% during inflation. The LMA can potentially be placed too deeply if the tube is held in place during inflation and not allowed to rise slightly. (Footnotes 10-12.)
This answer demonstrates nicely how the authors have in many answers highlighted particularly salient points.
Additional timed exam papers and quizzes are available in "Practice Exams in Emergency Medicine" for iOS devices and Android.
The topics covered in the Chapters are very comprehensive (as per the ACEM curriculum) and include:
- Resuscitation
- Cardiovascular emergencies
- Respiratory emergencies
- Neurological and neurospinal emergencies
- Endocrine emergencies
- Gastrointestinal emergencies
- Renal emergencies
- Haematological and oncological emergencies
- Infectious diseases
- Dermatological emergencies
- Electrolyte and acid-base disorders
- Emergency anaesthesia and pain management
- Trauma and burns
- Orthopaedic emergencies
- Surgical emergencies
- Eye, ENT and dental emergencies
- Urological emergencies
- Obstetric and gynaecological emergencies
- Toxicology and toxinology
- Environmental emergencies
- Psychiatric emergencies
- Paediatric emergencies
- Disaster management
- ED management and medicolegal issues.
Starting to look through the book was a bit like "being a kid in a candy store" as there were many areas I was interested in exploring to see how my existing knowledge 'stacks up'.
It is obviously not possible to review every single question and answer, so I will just look at a selection to try to give a flavour of the level of difficulty and the depth of the information provided in the answers.
In Chapter 1 on "Resuscitation", there are thirty-two questions relating to adult resuscitation and eighteen relating to paediatric resuscitation. These are fairly wide-ranging, (in adults) covering topics like CPR protocols, ventilatory support, defibrillation and pacing, hypothermia, lactic acidosis and septic shock, vasoactive substances, fluids, thoracotomy and echocardiography. I have to admit that I found some of these questions challenging (I'm not going to say how many I got right on the first pass!) and some of them I simply didn't have detailed enough knowledge even to make an 'educated guess'. However, the beauty of the answers is that they not only explain which is the correct answer (and why) but also why the other answers are incorrect.
I commend the authors on their use of terminology in the questions. It is very clear which alternative the reader is being asked to indentify e.g., "which ONE of the following statements is TRUE/INCORRECT" or "which ONE of the following is NOT ...". I think all medical students hate questions like "Choose the MOST CORRECT/LEAST CORRECT answer from the alternatives below". Some of the questions stray a little in this direction, such as "Which ONE of the following patients will MOST likely benefit ..." or "which ONE of the following is the MOST appropriate answer?" but it seems that the intention here is to tease out critical thinking rather than present a gradation of fiendishly difficult alternatives.
I have chosen one (shorter) example of a questions and answer from this chapter (which incidentally I did get right!):
27. Regarding the use of hypertonic saline in traumatic brain injury (TBI), which ONE of the following statements is true?
A. It reliably decreases intracranial pressure and significantly improves cerebral blood flow.
B. It is as effective as mannitol when osmotherapy is indicated.
C. There is good evidence showing an outcome benefit in TBI.
D. It is the preferred crystalloid if severe TBI occurs with hypotension.
27. Answer: B
Hypertonic saline as been shown to reliably decrease ICP in patients with TBI (LOE II) and it is at least as effective as mannitol. However, no studies so far have demonstrated improved cerebral blood flow; neither is there good evidence showing an outcome benefit. Despite the potential benefits in reducing ICP in patients with TBI, there is currently no evidence to recommend hypertonic saline over isotonic saline for fluid resuscitation and restoration of the intravascular volume (footnote 40).
References are supplied at the end of each chapter of Answers, and it is good to see that the authors are also supplying the Level of Evidence for propositions were relevant.
Next I thought I would move on to Chapter 12 "Emergency Anaesthesia and Pain Management", which I also hoped I would know something about already! There are twenty questions, relating to RSI, medications, local anaesthetics, nerve blocks, opiods, procedural sedation and pain management (these cover both adults and children).
These questions require quite a bit of detailed knowledge, so I think people who are not regularly dealing with the content on a regular basis will find them quite challenging. However, the answers are very educative.
Here is an example from this chapter.
4. The laryngeal mask airway (LMA) is a successful rescue device in emergency airway management. Which ONE of the following statements is TRUE regarding the LMA?
A. Positioning of the patient into the 'sniffing' position is essential.
B. It is a useful alternative to an ETT for establishing a definitive airway.
C. Cricoid pressure almost always impedes insertion of an LMA.
D. The device should be held firmly in place during inflation to allow the LMA to seat properly.
4. Answer: C
The LMA is a useful alternative to endotracheal intubation when an advanced airway is required but it is not a definitive airway and doesn't protect the patient from aspiration. Positioning of the patient into the 'sniffing' position is not essential but it is preferable. The LMA should not be held while the cuff is being inflated to allow the LMA to seat properly. The LMA tube on average will move out of the mouth approximately 0.7% during inflation. The LMA can potentially be placed too deeply if the tube is held in place during inflation and not allowed to rise slightly. (Footnotes 10-12.)
This answer demonstrates nicely how the authors have in many answers highlighted particularly salient points.
By now I was realising that perhaps there is one small criticism in that there is no colour-coding of the chapters, and if you are just flicking through the book you have to look at the small print at the bottom of the pages to locate the chapter that you are looking for.
For my last example, I decided to have a look at a chapter that perhaps a lot of people might gloss over, but having done a post-graduate degree in this area I was interested to test my knowledge. Chapter 23 deals with "Disaster Management". In the relevant literature, it is recommended that all health professionals should know something about this area, but this rarely occurs in practice. All the American emergency medicine textbooks I have seen have splendid chapters on this topic. All credit to the authors for incuding it in their book and bringing this topic to the attention of a wider audience.
There are only ten questions. Once again, fairly detailed knowledge is required in order to answer them correctly.
9. Regarding a patient experiencing a significant radiation exposure, which ONE of the following statements is TRUE?
A. Patients developing symptoms secondary to gamma irradiation pose an ongoing risk to healthcare staff.
B. Bone marrow suppression following a serious exposure develops over 3-5 days.
C. Patients developing gastrointestinal symptoms can be expected to recover over 6-8 weeks.
D. Potassium iodide blocks the uptake of radioactive material if ingested in the first few hours following exposure.
9. Answer: D
In the event of a nuclear accident, radioactive iodine might be released into the environment. Potassium iodate tablets block the uptake of radioactive iodine by the thyroid gland, therefore reducing the risk of developing thyroid cancer. Irradiated patients are not radioactive, and so do not pose a risk to staff. Patients exposed to particulate radioactive material - such as following an explosion - may still have radioactive material on their person, and so should be considered as requiring decontamination until declared clear by a radiation safety officer. Haemopoetic syndrome - due to bone marrow suppression - displays developing symptoms of bleeding, depressed white cell count (WCC) resulting in impaired immune response and fatigue by 3 weeks post exposure. Treatment is supportive. Gastrointestinal symptoms of vomiting, bloody diarrhoea and ileus denote an exposure of >2-10 Gy, and result in 50% mortality due to renal, hepatic and pulmonary injuries. (Footnote 5.)
There is a small inconsistency between the question and answer - the question refers to "potassium iodide" whilst the answer refers to "potassium iodate".
The answers in this chapter are a good example of how the authors provide helpful mnemonics to assist memory and recall.
For FACEM candidates this book will no doubt be very useful in testing out the limits of knowledge and identifying weaknesses whilst also providing the means to remedy these theoretical gaps.
If you are not a FACEM candidate, this book is probably best approached with humility and an open mind and willingness to learn. If you look at it in those terms, it is a terrific resource that will help you to take your practice of emergency medicine to a higher level. It is a salient reminder that in the practice of medicine you should never be too cocky or complacent about your level of knowledge and the capacity for improvement.
Verdict: Recommended!
For my last example, I decided to have a look at a chapter that perhaps a lot of people might gloss over, but having done a post-graduate degree in this area I was interested to test my knowledge. Chapter 23 deals with "Disaster Management". In the relevant literature, it is recommended that all health professionals should know something about this area, but this rarely occurs in practice. All the American emergency medicine textbooks I have seen have splendid chapters on this topic. All credit to the authors for incuding it in their book and bringing this topic to the attention of a wider audience.
There are only ten questions. Once again, fairly detailed knowledge is required in order to answer them correctly.
9. Regarding a patient experiencing a significant radiation exposure, which ONE of the following statements is TRUE?
A. Patients developing symptoms secondary to gamma irradiation pose an ongoing risk to healthcare staff.
B. Bone marrow suppression following a serious exposure develops over 3-5 days.
C. Patients developing gastrointestinal symptoms can be expected to recover over 6-8 weeks.
D. Potassium iodide blocks the uptake of radioactive material if ingested in the first few hours following exposure.
9. Answer: D
In the event of a nuclear accident, radioactive iodine might be released into the environment. Potassium iodate tablets block the uptake of radioactive iodine by the thyroid gland, therefore reducing the risk of developing thyroid cancer. Irradiated patients are not radioactive, and so do not pose a risk to staff. Patients exposed to particulate radioactive material - such as following an explosion - may still have radioactive material on their person, and so should be considered as requiring decontamination until declared clear by a radiation safety officer. Haemopoetic syndrome - due to bone marrow suppression - displays developing symptoms of bleeding, depressed white cell count (WCC) resulting in impaired immune response and fatigue by 3 weeks post exposure. Treatment is supportive. Gastrointestinal symptoms of vomiting, bloody diarrhoea and ileus denote an exposure of >2-10 Gy, and result in 50% mortality due to renal, hepatic and pulmonary injuries. (Footnote 5.)
There is a small inconsistency between the question and answer - the question refers to "potassium iodide" whilst the answer refers to "potassium iodate".
The answers in this chapter are a good example of how the authors provide helpful mnemonics to assist memory and recall.
For FACEM candidates this book will no doubt be very useful in testing out the limits of knowledge and identifying weaknesses whilst also providing the means to remedy these theoretical gaps.
If you are not a FACEM candidate, this book is probably best approached with humility and an open mind and willingness to learn. If you look at it in those terms, it is a terrific resource that will help you to take your practice of emergency medicine to a higher level. It is a salient reminder that in the practice of medicine you should never be too cocky or complacent about your level of knowledge and the capacity for improvement.
Verdict: Recommended!
Wednesday, November 21, 2012
CPD for Doctors (and Medical Students) - the next chapter!
Looking back over the year, it has certainly been a busy one in terms of continuing professional development in addition to my teaching duties at the University and working as an occasional BLS/ALS trainer. You certainly never stop learning as a doctor!
The Cool Topics in Neonatology conference and the Supporting Neonatal Transition workshop presented by the Royal Women's Hospital were excellent. There is so much interesting research going on, much of it here in Melbourne.
The Royal Children's Hospital deserves to be commended for its CPD program - weekly Grand Rounds, special Practical Paediatrics events for GPs and the recent Campus Research and Education Week, which was simply outstanding.
Also deserving of credit are the RVEEH (Royal Victorian Eye and Ear Hospital) for its series of updates for GPs, and MIPS, a medical indemnity organisation which runs risk management workshops for its members.
The RACGP runs several workshops and seminars over the course of the year, as does Australian Doctor, and the ones that I attended were both interesting and worthwhile.
Over the past couple of years I have attended both of the Anaesthetics symposia run by St Vincent's Hospital and the Alfred, and these are normally of a very high standard.
The Monash University Disaster Resilience initiative continued its series of periodic symposia in 2012, and these appear set to continue in 2013.
The International Congress of Aviation and Space Medicine hosted some interesting presentations, and it was a good opportunity to meet fellow practitioners from around the world. Perhaps the highlight was the visit on the last day to the Air Ambulance facility at Essendon Airport and the Trauma Centre at the Alfred Hospital. Some photos appear at the bottom of this page.
Photos from ICASM visit to the Air Ambulance base and the Alfred Hospital Trauma Centre, Helipad and Hyperbaric Chamber (20 September 2012).
The Cool Topics in Neonatology conference and the Supporting Neonatal Transition workshop presented by the Royal Women's Hospital were excellent. There is so much interesting research going on, much of it here in Melbourne.
The Royal Children's Hospital deserves to be commended for its CPD program - weekly Grand Rounds, special Practical Paediatrics events for GPs and the recent Campus Research and Education Week, which was simply outstanding.
Also deserving of credit are the RVEEH (Royal Victorian Eye and Ear Hospital) for its series of updates for GPs, and MIPS, a medical indemnity organisation which runs risk management workshops for its members.
The RACGP runs several workshops and seminars over the course of the year, as does Australian Doctor, and the ones that I attended were both interesting and worthwhile.
Over the past couple of years I have attended both of the Anaesthetics symposia run by St Vincent's Hospital and the Alfred, and these are normally of a very high standard.
The Monash University Disaster Resilience initiative continued its series of periodic symposia in 2012, and these appear set to continue in 2013.
The International Congress of Aviation and Space Medicine hosted some interesting presentations, and it was a good opportunity to meet fellow practitioners from around the world. Perhaps the highlight was the visit on the last day to the Air Ambulance facility at Essendon Airport and the Trauma Centre at the Alfred Hospital. Some photos appear at the bottom of this page.
November 2012
November 2012
November 2012
Oct/November
2012
October 2012
October 2012
October 2012
September 2012
September 2012
September 2012
September 2012
September 2012
September 2012
August 2012
August 2012
July 2012
June 2012
June 2012
June 2012
May/June 2012
May 2012
May 2012
May 2012
May 2012
April 2012
April 2012
March 2012
March 2012
March 2012
March 2012
March 2012
March 2012
March 2012
March 2012
February 2012
February 2012
February 2012
February 2012
January 2012
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RWH – Cool Topics
in Neonatology 2012 2.0*
RWH –
Supporting Neonatal Transition 2012 1.0*
Social Media,
eHealth and Telehealth (MIPS Education) 0.5*
RCH Campus
Research and Education Week 3.0* (Events attended: Optimising the
use of modern learning environments; Qualitative Research; Clinical Update:
Sleep and Allergy; Research Higher Degree Workshop (Authorship and
Plagiarism); Grand Round: Paediatric Fracture Guidelines; Epidemiology of
trauma at RCH; Designing education to address learners’ needs; Statistics:
the basics (CEBU); Basic principles of coding qualitative data; Contemporary
evaluation of injury severity scoring; MESS: amputation vs conservation; The
Primary Trauma Care Course – Trauma education in less affluent countries;
Non-operative management of occiputo-cervical dissociation in children;
Tactical Medicine: Medical care in the modern combat environment; Selling our
message to patients in the new millennium; The Big Idea; The rise of the
‘ePatient’: how it is affecting our clinical practice and research; Telemedicine;
But I thought the Internet would provide the interaction; The Great Debate:
“Social media is a vital tool in healthcare research and education”.)
Dealing with
Difficult Patients (MIPS Education) 0.5*
RVEEH -
Dizziness, Vertigo and Common Eyelid Disorders 0.5*
Mastering
Patient Expectations Workshop (Cognitive Institute) 0.5*
60th International Congress of Aviation and Space Medicine, Melbourne 4.0*
Faculty of
Medicine, Dentistry and Health Sciences Values Symposium 1.0*
Short Course
in Perioperative Medicine Intensive Weekend 2.0*
The Alfred
Anaesthetics Symposium: Goal Directed Therapy 1.0*
RCH Practical Paediatrics Program: Paediatric
Orthopaedics Part 3 0.5*
Australian Doctor Paediatrics Seminar 0.5*
RACGP Psychodynamic Approaches to Focused
Psychological Strategies 1.0*
Peter MacCallum Cancer Centre – Lymphoma,
Leukaemia and other Haematological Cancers, Late Effects of Cancer Treatment
– What GPs Need to Know 0.5*
University of Melbourne MD Student Conference 3*
RVEEH - Cataract and Pterygium, Rhinitis and
Polyps 0.5*
Ambulance Victoria Remote Area Nurses (Victoria)
Emergency Care Update Program – Workstations observer 1*
Australian Resuscitation Council (Victorian
Branch) 5th State Conference. Resuscitation 2012: Translating Evidence into
Practice. 1*
Monash Disaster Resilience Forum – Managing
internally displaced people 1*
RCH Grand Round – Chronic Fatigue Syndrome: Tired
but never boring. New opportunities for a common illness.
Acute
Life-Threatening Emergencies, Recognition and Treatment (ALERT) 2*
MIPS Seminar - Healing at the end of life 0.5*
AMA - Working Overseas in Crisis Areas Seminar
0.5*
Rogaining Training Day, Victorian Rogaining
Association 1*
Faculty of Medicine, Dentistry and Health Sciences
Equity and Staff Development Forum: Working together to support work-life
balance 0.5*
Dealing with Difficult Patients 0.5*
Australian Doctor Mental Health Seminar 1*
RVEEH – Hoarse Voice & the Inflammatory Red
Eye 0.5*
Melbourne Med. School – Integrating
Communication Skills in Clinical Rotations 0.5*
Melbourne Medical School – Providing Feedback to
Students 0.5*
Monash Disaster Resilience Forum – Learning
lessons:recent disaster reviews 1*
RCH Grand Round - Does general anaesthesia damage
the developing brain?
SVH Department of Anaesthesia Workshop: ‘Avoiding
Disasters – Minimising Risk and Maximising Safety’ 1*
Paediatric Advanced Life Support (PALS) Course 1*
Medical
Education Unit, Melbourne University Medical School – Principles of Clinical
Practice Tutor Training Workshop 0.5*
Orientation Tour, new Royal Children’s Hospital,
Melbourne 0.5*
Medical
Education Unit, Melbourne University Medical School – Case-Supported Learning
Tutor Training Workshop 1*
ACCET Choral Conductors 19th Summer
School 4*
|
Photos from ICASM visit to the Air Ambulance base and the Alfred Hospital Trauma Centre, Helipad and Hyperbaric Chamber (20 September 2012).
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