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Preference: Education

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News briefs

Inhaled Ebola vaccine stops virus in monkeys

The New York Times reports that a single dose of a new, inhalable Ebola vaccine has neutralised the virus in monkeys. The study, conducted by University of Texas researchers, was published first in the Journal of Clinical Investigation. Four rhesus macaques were given one aerosol dose, four were given two aerosol doses and two were given the vaccine in liquid form. Two were not vaccinated, serving as controls. Four weeks after treatment, all the monkeys were given a dose of Ebola, 1000 times the fatal dose. A week later, the two unvaccinated monkeys died but the vaccinated animals remained healthy. The survivors were euthanised and their blood and tissues showed no sign of Ebola. The next step is for the National Institutes of Health to perform clinical trials on humans.

http://www.nytimes.com/2015/07/14/health/inhaled-ebola-vaccine-stops-virus-in-monkeys-study-finds.html

New CEO for Medical Deans is Carmel Tebbutt

Former New South Wales cabinet minister Carmel Tebbutt has been announced as the new chief executive officer of the Medical Deans Australia and New Zealand. She will replace incumbent Professor Judy Searle, who is retiring from the role after 2.5 years. Ms Tebbutt starts in the position on 19 October. She spent 11 years as a minister and senior member of the Cabinet in the NSW Parliament, with portfolio responsibilities across a number of areas including education and training, health, community services and the environment. “There are many challenges confronting medical education and research. I am looking forward to using my skills to forward the objectives of the Medical Deans”, Ms Tebbutt said. “One of my first tasks will be to meet with members and stakeholders to hear first-hand about the key issues for the sector.”

Tax on soft drinks: it’s working in Mexico

Health economists at the University of North Carolina in the US have studied Mexico’s 18-month-old “soda tax” and found that it is reducing consumption of sugar-heavy drinks in the country where annual consumption tops out at 163 litres per person, Wired reports. The one-peso-per-litre tax has caused a drop in consumption of an average of 6%, according to the researchers. “The decline accelerated as the year went on, reaching 12 percent by December [2014].” With plans to increase the tax to two pesos per litre, the results show that it was the poorest Mexicans who cut back on soda the most, averaging a 9% decline and peaking at 17%. Consumption of bottled water increased by 4% in the same time period. “A soda tax alone is not going to solve the entire obesity and diabetes epidemic”, the researchers concluded. Still, it might help “shift people’s mindset about these beverages. They’re not innocent”.

http://www.wired.com/2015/07/mexicos-soda-tax-working-us-learn

Non-invasive device could end finger pricking for people with diabetes

Science Daily reports on a new low-powered laser sensor that monitors blood glucose levels without penetrating the skin. Developed by a team at the University of Leeds in the UK, the device “has continuous monitoring capabilities making it ideal for development as a wearable device”. It could also be a simpler and cheaper alternative to the two current methods — finger pricking, using disposable sample strips, or invasive continuous monitors using implanted sensors that need regular replacement. “This technology opens up the potential for people with diabetes to receive continuous readings, meaning they are instantly alerted when intervention is needed. This will allow people to self-regulate and minimise emergency hospital treatment,” the researchers said.

http://www.sciencedaily.com/releases/2015/07/150714200110.htm

Retracted papers cited years after withdrawal

Retraction Watch reports that disgraced American anaesthetist Scott Reuben’s retracted papers are still being cited 5 years after retraction, and only 25% of those citations correctly acknowledge the retraction, according to a new study, published in Science and Engineering Ethics. Reuben, who fabricated data, spent 6 months in prison in 2009, and has now accumulated 25 retractions. In the new paper, the authors counted 274 citations of 20 of Reuben’s papers between 2009 and 2014, 45% of them more than once. “Our paper shows that perpetuation of retracted publications is still an ongoing problem in our scientific community… In addition, we could demonstrate that, despite the overall number of citations of retracted publications decreasing over the years, the percentage of correctly labeled citations dropped even more.”

http://retractionwatch.com/2015/07/14/half-of-anesthesiology-fraudsters-papers-continue-to-be-cited-years-after-retractions

Vale Dr David Game, distinguished GP and medicSA editor

Dr David Aylward Game was born in Adelaide on 31 March 1926, the fourth son of a bank manager and a nurse. On 14 May, in his 90th year and having played bridge at the Adelaide Club that morning, he died suddenly at his desk while attending to computer tasks. The table was, as usual, meticulously set for dinner.

David was educated at St Peter’s College, Adelaide, and the University of Adelaide, where on his first day he met fellow medical student Patricia Jean Hamilton. They married immediately after graduation and were the first married couple to receive their MBBS degrees on the same day. In 1953, David commenced general practice from their first home on Payneham Road, but as the family grew to include their four children – Ann, Philip, Timothy and Ruth, they moved to Rokeby in Royston Park.

From his early years as a family doctor, David became an advocate for general practice as a specialty in its own right, a cause which became an abiding passion and the source of great achievement. He was a founding member of the Royal Australian College of General Practice, in which he held a number of key roles, including that of President from 1974 to 1976.

In 1980, he received the college’s highest accolade, the Rose Hunt Award. He represented the College at a number of international meetings, and in 1970 became involved in the formation of the World Organisation of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians, with its somewhat peculiar acronym WONCA, and was its President from 1983 to 1986.

Among the many anecdotes about David’s experiences in these roles with various dignitaries, there is a wonderful story about Prince Philip confusing WONCA with wombat, leading to the establishment of the Honorary Wombat Award for retiring presidents, David’s having pride of place in his office.

David was a pioneer for the involvement of GPs in public and teaching hospital work, holding positions at the Adelaide Children’s, Modbury and Royal Adelaide hospitals. He is the only GP to have been granted an emeritus appointment at the RAH.

Early in his career, he involved students and family medicine program graduates in his private practice, and between 1991 and 1998 was medical director of the South Australian Postgraduate Medical Education Association. In 1983, he was appointed an Officer in the Order of Australia for service to general practice.

He was a Fellow and Life Member of AMA South Australia, filled many important roles for the SA Branch, and was editor of medicSA from 2004 to 2012, during which time it won the award for best State publication twice. His significant contributions saw him awarded the AMA(SA) President’s Award in 2006.

This exceptionally generous and caring man is greatly missed, not only by his four children, six grandchildren and four great-grandchildren, but by his colleagues and many friends.

In the weeks since his death, tributes have arrived from around the world and, in particular, from his WONCA colleagues in countries including the United States, UK, Singapore, South Africa, Holland, Nepal, India, Jordan and Ireland.

The AMA honours the work of this distinguished South Australian general practitioner.

* This article was supplied by medicSA, where it was first published last month.

Your AMA Federal Council at work

What AMA Federal Councillors and other AMA members have been doing to advance your interests in the past month:

Name

Position on Council

Activity/Meeting

Date

Dr Stephen Parnis

AMA Vice President

National Medical Training Advisory Network

19/05/2015

Dr Danika Thiemt

Chair AMA Council of Doctors in Training

National Medical Training Advisory Network

19/05/2015

Dr Roderick McRae

AMA Federal Councillor

ACHS Council meeting

25/05/2015

A/Prof Robyn Langham

AMA Federal Councillor – Victoria nominee and Chair of AMA Medical Practice Committee

Australian Health Practitioner Regulation Agency’s (AHPRA) Prescribing Working Group (PWG)

7/5/2015

Dr Omar Khorshid

AMA Federal Council Representative for Orthropaedic Surgeons

MSAC (Medical Services Advisory Committee) Review Working Group on Arthroscopic Hip Procedures

29/5/2015

Dr Tracey Soh

AMA Federal Councillor

Australian Medical Council Inter-Professional education workshop

9/6/2015

Dr Chris Moy

AMA Federal Councillor

Australian Medical Council Inter-Professional education workshop

9/6/2015

 

Dr Richard Kidd

AMA Federal Councillor

GP Roundtable telco – MERS briefing

17/6/2015

DVA Stakeholder Engagement Design Workshop

16/6/2015

Aged Care Gateway Advisory Group meeting

12/6/2015

Aged Care Gateway meeting

4/5/2015

 

Dr Gino Pecoraro

AMA Federal Council Representative for Obstetricians and Gynaecologists

Diagnostic Imaging Advisory Committee

19/6/2015

 

 

Fostering creativity and innovation in the health system: the role of doctors-in-training in biomedical innovation and entrepreneurship

Doctors-in-training are well positioned to continue Australia’s strong history of biomedical innovation and entrepreneurship

In Australia and overseas, there is growing interest in the development of biomedical innovation and entrepreneurship relating to improvement of diagnostics, treatments and health services.1,2 Innovation follows from the efforts of biotechnology and pharmaceutical organisations, academia and the health services sector. Entrepreneurship is then required to market innovations.

A lack of talented biomedical innovators and entrepreneurs limits positive change in health care. The Department of Health and Ageing’s McKeon review: strategic review of health and medical research — better health through research proposed ways to enhance research capacity and commercial and non-commercial pathways to innovation.1 The review strongly supported junior health professionals engaging in innovation research. These proposals were endorsed by the Australian Medical Association’s position statement on clinical academic pathways.3

Doctors-in-training (DITs) — medical students, interns, residents and specialty trainees — are well placed to develop their innovation and entrepreneurship skills, given their traditional medical skills and knowledge. They have skills in basic, clinical and public health science. DITs train at the coal face of the health care system, and are therefore exposed to the practical outcomes of policies, procedures and systems. They have well developed skills that are empirically associated with entrepreneurial success,4 such as team work, communication, productivity, accountability, responsibility, problem solving and data analysis.

Biomedicine in Australia has many innovators and entrepreneurs (eg, CSL, Cochlear and the inventors of the human papillomavirus vaccine), and Australia has a strong biotechnology sector. According to the Scientific American Worldview scorecard for 2013, Australia ranked seventh in the world for biotechnology (across health and non-health industries), up from tenth in the previous year, first for “best growth in public markets”, second for “greatest public company revenues” and second for “most public companies”.5 The 88 biotechnology companies listed on the Australian Securities Exchange are valued at more than $51 billion. However, there is room to further support innovation and entrepreneurship training systems for our DITs to further strengthen the Australian outlook, particularly when considering the plethora of international training programs that are offered.2

Engagement with biotechnology and pharmaceutical industries can generate benefits for academic research, including funding, in-kind resources (eg, high-throughput facilities), commercial exploitation of technology or intellectual property, and cross-fertilisation of knowledge and skills.

In this article, we explore the role of DITs as biomedical innovators and entrepreneurs.

International experience with training in biomedical innovation and entrepreneurship

The US-based Society of Physician Entrepreneurs (SoPE) recently launched their Innovation Scholar Program, which offers doctors hands-on bioentrepreneurship experience through practicums with biomedical companies.6 The program comprises a 1-year apprenticeship, in which the junior physician is linked to a biomedical company, a mentor and a project. Companies provide the scholar with a broad array of knowledge, skills and experiences in product development and commercialisation. The scholar may also engage in an innovation-related university curriculum, depending on the geographical and workplace situation.

A Society for International Bioentrepreneurship Education and Research was recently proposed, with a mission to advance international bioentrepreneurship education and research.

A new course titled Medical device design and innovation from Yale University offers students opportunities to develop innovative solutions to problems posed by physicians.7 This course pairs physician mentors with students from medicine, engineering, physics, chemistry and management. Also, massive open online courses (MOOCs) on innovation are freely available online and are gaining popularity among junior doctors; for example, Coursera — an education platform that partners with top universities and organisations worldwide to offer free online courses — has a course titled Healthcare innovation and entrepreneurship.8

Other pathways exist for doctors to engage in specific innovation and entrepreneurship training. For example, in the United Kingdom, Industrial CASE (Collaborative Awards in Science and Engineering) Studentships9 are offered to bioscience PhD students in a collaborative environment; partnerships are established between academic institutions and organisations in the private, public and civil society sectors, with a PhD supervisor supplied by each branch. This program is administered by the Biotechnology and Biological Sciences Research Council and, in 2015, 125 of these 4-year studentships were made available. This program is funded by academic and non-academic partners, but financial obligations of non-academic partners depend on the size of the company.

Drivers of increased training in biomedical innovation and entrepreneurship

The development of innovation and entrepreneurship-related skills is emphasised in physician competency framework of the Royal College of Physicians and Surgeons of Canada (the CanMEDS Framework),10 and is supported by the Australian Medical Council’s graduate outcome statements,11 the Australian curriculum framework for junior doctors12 and the Committee of Presidents of Medical Colleges’ position statement on the role of the medical specialist.13 Through exposure to the health system, practitioners develop an understanding of the complex systems in which innovation will be applied.

It has been shown that device manufacturers gain more premarket approvals from the patents of physician-founded firms than from those of non-physician-founded firms.14

National experience with training in biomedical innovation and entrepreneurship

The role of DITs in Australian biomedical innovation and entrepreneurship has received little attention from researchers, and not much is known about current levels of activity.

Quality and safety improvement projects for junior doctors are now offered, albeit in selected hospitals in Victoria and Western Australia. These seek to develop skills and leadership in medical service safety and quality improvement.15,16 The Medical Service Improvement Program in WA includes 3 months’ work on a quality improvement project.15 Throughout the program, junior doctors are offered supervision and mentorship, attend lectures, and visit non-health industry locations.

A recent review found that junior doctors entering the health care system are ideally placed to cultivate their interest and expertise in improving the health system.17 Collaborating with junior doctors rather than with their senior colleagues builds a strong quality culture. In the United States, quality improvement skills are now a core competency for accreditation of residents (ie, the vocational equivalent of DITs in the US) and this has stimulated quality improvement training in medical curricula.

The crisis in clinical academia and need for integrated pathways and structures for development of clinical academic careers has been widely discussed in Australia and overseas.18 There is a clear need for more medical practitioners to incorporate research, education and leadership dimensions into their clinical duties.1 Interest in clinical academia is high among medical graduates — up to 56% of Australian medical students express interest in including research in their careers.19 Several universities in Australia now offer dual MB BS/PhD degrees, with the aim of strengthening clinical academic training.

Benefits of increased training in biomedical innovation and entrepreneurship

Trainees, health services that employ trainees, the Australian community, research institutions and biotechnology companies all stand to benefit from greater development of innovation skills and knowledge. A number of academic articles explore the effectiveness of residents’ and trainees’ participation in curriculum redesign, clinical guideline implementation and quality improvement teams.20 Intuitively, health services are more likely to attract and retain a higher-quality workforce if they provide innovation-friendly positions.

Risks of increased training in biomedical innovation and entrepreneurship

Time away from clinical positions (part-time or full-time) means longer training, but evidence for compromised clinical learning as a result is slight.21 Greater non-clinical activities may draw medical practitioners out of clinical practice, but the effects of this remain to be empirically explored. The impact of a potential reduction in full-time equivalent DITs in clinical care owing to non-clinical activities (eg, research and innovation) should be tracked carefully. Population-based studies such as the Medicine in Australia: Balancing Employment and Life (MABEL) study enable such tracking.

Recommendations

To enhance innovation and entrepreneurship training for DITs, we recommend the following strategies.

Explore interest and engagement: Studies are required to better understand motivations for, perceived benefits of and detriments of engagement in innovation activities.

Encourage interest: A cultural change to enhance the focus on innovation in health care is needed. This could be be brought about by advocacy, mentorship, education programs and grant funding schemes. Interest in innovation should be encouraged throughout the medical career continuum. Coordinated and strong agency-led leadership is important. The Australian Academy of Health and Medical Sciences may be a suitable leadership organisation.

Develop structured education, mentorship and coaching programs: These would enable freer interchange between researchers and the biotechnology, pharmaceutical and investment industries, and would embed a greater commercialisation culture in research.

Enhance flexibility of training pathways: This would include opportunities for breaks in training and allocation of protected time for innovation-focused occupations, which could be counted towards training requirements.

Develop funding incentives to drive research and innovation: Universities, health and hospital systems need to be effectively incentivised to promote innovation.

Australia has a strong biotechnology sector, within which a stronger innovation-skilled medical workforce could be developed. In developing such a workforce, it is important to focus on training DITs as they are our future workforce.

[Comment] Diabetes, obesity, and the metabolic syndrome: a call for papers for EASD and the World Diabetes Congress

Diabetes, obesity, and the metabolic syndrome are starting to overtake communicable diseases as major threats to health worldwide. The prevalence rates of diabetes and obesity are rising sharply, and while some of the causes are clear—for example, adverse changes in physical activity and diet, led in some populations by demographic change—better strategies for prevention and treatment are still needed. Research into treatment, public health and education interventions, and epidemiology is urgently required to address this epidemic.

Muslim doctors in the mainstream

The challenge of multiculturalism is for the community to recognise, appreciate and accommodate cultural differences

I anticipate that this article will be published halfway through the month of Ramadan.

My experience of the Muslim world was limited until about a decade ago, when, in the Spanish city of Córdoba, I stumbled upon a symposium about Maimonides, the medieval Sephardic Jewish scholar and doctor who had a profound influence on both Islamic and Christian thinking and philosophy. At the time, I had just wandered through the Great Mosque of Córdoba, now the Cathedral of Our Lady of the Assumption. Built in the 8th century, the mosque was taken over four centuries later by Christians, who then constructed the cathedral within it.

The fate of Jews, Muslims and Christians has long been intertwined, but often the interaction has been one of conflict rather than an expression of shared cultural values.

In his book What went wrong?, about the relative decline of Islam in the 20th century, especially in the Middle East, Bernard Lewis asks:

If Islam is an obstacle to freedom, to science, to economic development, how is it that Muslim society in the past was a pioneer in all three, and this when Muslims were much closer in time to the sources and inspiration of their faith than they are now?1

This is a complex question that requires deep exploration of culture and history to answer.

Multiculturalism in Australian medicine

In the prevailing culture of my boyhood, opportunities for mutual understanding, if not cultural affinity, among Muslim and other people in our community were few. My closest friend, who attended the same private Anglican single-sex school that I did, admitted to a strong Jewish heritage. There were other Jews at school and then at university, and I was fortunate to sustain friendship and collegiality with them during my professional life. So, in the critical developmental period of my life, I was socialised alongside Jews. By contrast, my social contact with Muslims was minimal, and the Muslim world remained on the periphery of my early professional life.

However, over the past 20 years, the number of Muslim doctors in Australia has grown, among both local and international medical graduates. As I became more involved in the delivery of rural health services over the past decade, through my role as director of medical services of several small contiguous health services, my contact with Muslim doctors increased substantially. I quickly came to realise that in some Muslim communities, there is a culture of male doctors treating male patients, and female doctors treating female patients. Such patterns were reflected in many of the Muslim doctors’ attitudes, leading to tensions. When there is no easy familiarity with cultural differences, the community tiptoes around them, fearful of accusations of racism.

At the same time, the term “multiculturalism” is bandied around as though it were an instant anodyne. However, multiculturalism must flow deep in the nation’s heritage — a tradition in the mainstream — to truly exist.

Improving cultural understanding

The challenge of multiculturalism is for the community to recognise, appreciate and accommodate cultural differences. These differences are often manifest or enshrined in religious observances. In the case of Islam, the most obvious is the month of Ramadan, with its fasting between sunrise and sunset. I know young Muslim doctors who were asked by non-Muslim colleagues why they were not eating on a particular day: were they sick?

To improve cultural understanding among their colleagues, I invited two female Muslim interns to prepare a presentation on Ramadan before it commenced in 2013. This presentation was refined by one of them last year and presented again just before Ramadan, then repeated this year. On each occasion, the presentation invoked considerable interest among a predominantly non-Muslim audience. The meaning underlying ritual is central to community tolerance, just as Lent and Easter require Christian explanation.

In another instance earlier in my role as the director of medical services for these health services, a Muslim doctor with paediatric training brought to my notice the issue of circumcision and its proscription in public hospitals by the Victorian Department of Health. This policy seemed not to have taken account of Muslim sensibilities, resulting in the extreme situation of one family taking their child overseas for the procedure. Male circumcision was once common and, although less popular now, remains legal. To draw attention to this Muslim concern, I arranged for the Muslim doctor to present a Grand Round on the matter, with a senior Christian paediatrician acting as discussant. There was a diverse audience of non-Muslims, and the discussion was balanced.

The growing number of Muslim doctors in the Australian community brings mutual obligations, and it is through open communication and education that misunderstandings are resolved, particularly regarding the relationships between women and men. I have seen value in encouraging Muslim doctors to share their experiences, as occurred with the Ramadan presentation. Ramadan finishes in the Eid al-Fitr fast-breaking celebrations, which in a truly multicultural society could be marked by a public holiday.

The Ramadan presentation could be used to good effect elsewhere in the health system, and controversial areas such as male circumcision should be openly discussed. For me, the complexity of multiculturalism was brought home forcefully that day in Córdoba, on the banks of the Guadalquivir River. Gazing into the river, I could reflect that here, for a time, notwithstanding the periodic eddies, a mainstream of Muslim, Jewish and Christian cultures did coexist.

Penetrating neck injury in an isolated medical setting

Clinical record

A 34-year-old man presented to a small rural emergency department at 21:45, arriving by private car from a bush campsite some 45 minutes’ drive away. An empty “stubbie” beer bottle had been recapped and thrown on the fire. It subsequently exploded, showering glass fragments onto surrounding people, one of whom sustained a small penetrating neck injury (PNI) with a piece of glass lodging in his anterior neck.

On arrival at the hospital, the patient had removed the glass and was clutching his neck with paper towels, describing a feeling of blood in the back of his throat, with associated haemoptysis.

He had a Glasgow Coma Scale score of 15, with normal vital signs, and was found to have a 1 cm wound just above his cricoid cartilage slightly to the right of midline. There was minimal active bleeding externally, but air occasionally bubbled from the wound and surgical emphysema was palpable on the right side of his neck. He was most comfortable slightly head down on his right side, and was maintaining O2 saturation of 99% in room air, with no clinical evidence of pneumothorax.

In consultation with Adult Retrieval Victoria, the attending anaesthetic-trained rural general practitioner decided to proceed to rapid sequence intubation (RSI) with an oral endotracheal tube (ETT) before evacuation to a tertiary centre.

With assistance from the nursing staff and a second anaesthetic-trained rural GP, the patient was pre-oxygenated with deep spontaneous breaths and a successful RSI under direct laryngoscopy was performed. For easier insertion, a size 7.5 cuffed ETT was placed. Blood was present on the vocal cords, but the oropharynx was clear.

Mechanical ventilation was carried out initially with a portable unit (Weinmann Medumat Standard-a), on minute volume cycle with a minimum available pressure of 20 cm H2O. Subsequent chest x-ray showed extensive surgical emphysema (Figure) and air mediastinum, at which point he was moved to the operating theatre to allow lower pressure ventilation using an anaesthetic ventilator. The ETT was shifted further down the trachea to tamponade the site of traumatic injury, and reduce bleeding and tissue emphysema.

Assisted ventilation at the hospital continued until 01:38, when the retrieval team arrived by road ambulance some 4 hours later.

He was transferred by road ambulance to the tertiary hospital, arriving at 04:22, where investigation with computed tomography (CT) angiography excluded any vascular injury. A surgical tracheostomy and tracheal repair was undertaken at 12:40 later that day. He spent over 24 hours in the intensive care unit on mechanical ventilation before making a full recovery.

Penetrating neck injury is commonly related to violence in countries such as the United States and South Africa,1 but it is rarer in Australia. This case report highlights the challenges and importance of initial management of a PNI in an isolated medical service, and the importance of health education around campfire safety.

The initial management of a PNI in a patient with a patent airway and who is haemodynamically stable with no signs of vascular injury is generally now considered to involve CT vascular imaging and selective surgical management.2,3 In an isolated medical facility without access to these services, management options are more limited. Initial treatment involves management of actual and potential airway complications together with stabilisation of vascular injury and resultant haemorrhage, with a plan for early evacuation to an appropriate tertiary facility for definitive care.

Our patient was haemodynamically stable and clinically had no obvious evidence of a significant vascular injury. The penetrating glass fragment was described as small, although not seen by the medical staff as the patient had removed it before arrival. The ongoing haemoptysis and palpable surgical emphysema suggested airway injury, and potential risks associated with haematoma formation and airway obstruction during transport led to the decision to perform rapid sequence endotracheal intubation. This is thought to be the safest initial airway management when anatomical structures are preserved,2,4 although definitive surgical airway management would be required at the tertiary centre.

Incorrect ETT placement, inadequate seal, or excessive ventilator pressure, may lead to acute deterioration where tracheal injury exists. This is particularly important in a remote medical setting, where considerable delay can occur before transport to an appropriate tertiary care facility, which could have become a critical issue in our case had the patient not been haemodynamically stable.

Despite standard transport immobilisation protocols, the literature recommends that cervical spine immobilisation is not required unless focal neurological deficits are present.2 Penetrating neck injuries (particularly stabbing) rarely cause spinal cord injury,5 and cervical collars can impede airway visualisation or evidence of other injuries. Our patient had no clinical evidence of spinal cord injury and no mechanism of injury to suggest one, so a cervical collar was not applied, making it easier to intubate as well as to monitor and assess the injury site.

Many outdoor recreation activities involving campfires occur in isolated environments, with limited access to medical and emergency services. In such situations, burns are an increasing concern,6 either from falls or exploding containers.7 This case demonstrates the additional risk of projectiles from exploding containers irresponsibly placed into fires. Although common sense dictates that it is risky to throw sealed containers into open fires, anecdotally it is often done when alcohol consumption is combined with open fires in a relaxed bush environment.

This case suggests that appropriate initial management of PNIs in an isolated rural setting can include careful endotracheal intubation until later surgical management with a definitive surgical airway. In addition, it reinforces the public health message that responsible behaviour reduces risk — particularly when setting an example and providing health education messages to the next generation. This case was unusual, but the clinical and public health lessons it provides are perhaps generalisable.

Lessons from practice

  • Management of penetrating neck injury in an isolated setting involves stabilisation and endotracheal intubation.
  • Cervical spine immobilisation is not required with penetrating neck injury unless focal neurological deficits are present.
  • Rapid sequence intubation is a useful skill for general practitioners to have when working in a rural setting.

X-ray of the patient’s neck and upper chest after initial intubation

Red arrow: surgical emphysema. Black arrow: tip of endotracheal tube.

Celebrating 10 years of collaboration: the Australian Indigenous Doctors’ Association and Medical Deans Australia and New Zealand

Closing the gap by growing the Aboriginal and Torres Strait Islander medical workforce

This year marks the 10th anniversary of the collaboration between the Australian Indigenous Doctors’ Association (AIDA), the professional association for Aboriginal and Torres Strait Islander doctors and medical students,1 and Medical Deans Australia and New Zealand (Medical Deans), the peak body representing professional entry-level medical education, training and research in Australia and New Zealand.2 In October 2005, AIDA and Medical Deans established an inaugural collaboration agreement formalising our shared commitment to achieving health equality for Aboriginal and Torres Strait Islander people, with a focus on growing the Indigenous medical workforce.

Over the past 10 years, AIDA and Medical Deans have reaffirmed this strong and sustained commitment to achieving our shared objectives through three successive collaboration agreements. Notable milestones have been achieved since 2005, including:

  • a growth in the Aboriginal and Torres Strait Islander medical student cohort;
  • co-auspicing of the biennial Leaders in Indigenous Medical Education (LIME) Connection, which brings together a range of key health and medical education stakeholders to share innovative approaches in Indigenous medical education;3
  • implementation of the Capacity Building for Indigenous Medical Academic Leadership Project to support more Aboriginal and Torres Strait Islander people becoming medical academic leaders;4 and
  • the National Medical Education Review,5 which highlighted best practice for Australian medical schools in implementing the Indigenous Health Curriculum Framework.6

While all our achievements are significant, we are particularly pleased with the marked growth in the number of Aboriginal and Torres Strait Islander medical students. In 2005, Aboriginal and Torres Strait Islander medical students represented just 0.8% of first-year domestic enrolments. In 2011, this increased substantially to 2.5%, reaching population parity for the first time. In 2014, a record number of about 30 Indigenous medical students completed their degrees, and three universities celebrated their first Aboriginal and Torres Strait Islander medical graduates. These achievements reflect the importance of partnership in supporting Aboriginal and Torres Strait Islander medical students along the education and training pathway, to contribute to a growth in the Indigenous medical workforce.

Although there has been real progress in growing Aboriginal and Torres Strait Islander doctor and medical student numbers, there is still much work to be done in this area, particularly in regards to strengthening recruitment and retention. We envision a future where Aboriginal and Torres Strait Islander doctors and medical students reach a critical mass in the Australian medical workforce; and one in which all doctors are trained to deliver equitable, accessible, high-quality and culturally safe services to Aboriginal and Torres Strait Islander people.

The success of the AIDA and Medical Deans partnership has provided the impetus for similar arrangements to be developed across the medical education and training continuum, such as AIDA’s collaboration agreements with the Committee of Presidents of Medical Colleges and the Confederation of Postgraduate Medical Education Councils. Our achievements have been recognised in Australia and internationally, through presentations on our successes at forums such as the Pacific Region Indigenous Doctors’ Congress (PRIDoC) Conference. PRIDoC provides a culturally safe environment for health and medical professionals of the Pacific region to share and promote culturally safe research and clinical practices for Indigenous peoples.7

The current AIDA–Medical Deans collaboration agreement is due to expire at the end of 2015.8 To ensure that our partnership continues, AIDA and Medical Deans are in the process of developing a new collaboration agreement for 2016–2018. We anticipate launching the new collaboration agreement around the time of the 6th biennial LIME Connection, which will be held in Townsville on 11–13 August 2015. The development of the new AIDA–Medical Deans collaboration agreement is timely, as it coincides with the theme of AIDA’s 2015 conference — “Collaborate, communicate and celebrate” — which will be held in Adelaide on 16–19 September 2015.

We look forward to extending our partnership to continue our work in growing the Indigenous medical workforce and improving health and life outcomes for Aboriginal and Torres Strait Islander people.

The link between health and wellbeing and constitutional recognition

The Lowitja Institute is Australia’s national institute for Aboriginal and Torres Strait Islander health research. It is an Aboriginal and Torres Strait Islander organisation, named in honour of its patron Dr Lowitja O’Donoghue, AC, CBE, DSG. The Institute was established in 2010, emerging from a 14-year history of cooperative research centres.

The Lowitja Institute has led an initiative called Recognise Health, which promotes understanding of the important link between health and wellbeing and constitutional recognition of Aboriginal and Torres Strait Islander people. The initiative has brought together a coalition of 125 leading non-government organisations across the Australian health system in support of constitutional recognition. These organisations have signed the following statement (https://www.lowitja.org.au/recognisehealth/statement).

We call on all Australians to support recognition of Aboriginal and Torres Strait Islander peoples in the Australian Constitution.

We look forward to a time when all Aboriginal & Torres Strait Islander people can fully participate in all that Australia has to offer, enjoying respect for our country’s first cultures and leadership, and the dignity and benefits of long healthy lives.

Australia’s First Peoples continue to die far earlier and experience a higher burden of disease and disability than other Australians. This is a result of long term economic disadvantage and social exclusion, among other factors. Constitutional recognition would provide a strong foundation for working together towards better health and social wellbeing in the hearts, minds and lives of all Australians.

Recognise Health was launched at Parliament House in Canberra on 5 March 2015, with parliamentarians, medical and health leaders and community representatives present, in a strong show of commitment to the initiative.

The Australian Constitution, the main law that guides the operation of the Commonwealth of Australia, took effect in 1901. At that point in time, Aboriginal and Torres Strait Islander people had lived on this land for thousands of generations, keeping alive the world’s oldest living continuous cultures. However, Australia’s founding document does not recognise this first chapter of our national story.

Following the 2012 report of the Expert Panel on Constitutional Recognition of Indigenous Australians, all major political parties declared their support for recognition. Subsequently, the Prime Minister announced that the government intends to work towards a referendum. For the referendum to pass, the people of Australia need to understand and support the case for change, and there needs to be strong leadership from across the political spectrum, business and community sectors, and, of course, by Aboriginal and Torres Strait Islander leaders. Part of the work required for a successful referendum is to engage key community organisations — such as health organisations — in the national dialogue, thereby engaging their membership and the broader public to support the referendum.

Recognition of Aboriginal and Torres Strait Islander people would acknowledge their powerful sense of identity, pride, history and belonging to this land. It would promote opportunities for full participation in all that Australia has to offer and would be a significant step towards equity between Indigenous and non-Indigenous Australia.

Recognition, participation and equity would, in turn, have profound positive consequences for wellbeing, and therefore health. There is significant evidence from health research to indicate that being connected to the wider community, having a strong identity and feeling socially supported all have significant positive impacts on health.

The role of social and economic factors in determining health status is well understood; health does not exist within a vacuum. It is intricately connected to education, employment, housing, and more. Cultural factors also have a profound impact. Having a strong sense of identity and pride — individually and communally — has a supportive, protective and healing influence. Unfortunately, how we experience the great benefits of modern medical science has become disconnected from cultural, community, social and economic contexts.

As Aboriginal singer and performer Archie Roach stated at the launch of Recognise Health: “I really believe that being recognised within the Constitution has a lot to do with how we feel about ourselves, that we are worthy and we can be proud of my people” (http://www.recognise.org.au/blogs/ourstory).

The Institute has worked closely with Recognise (http://www.recognise.org.au), the people’s movement to recognise Aboriginal and Torres Strait Islander people in the Australian Constitution, on this initiative. More information, including a short film featuring five health leaders, is available at https://www.lowitja.org.au/recognisehealth.