The Auricle 2022 - Edition 3

THE AURICLE Volume 5 Edition 3

May - June 2022

IN THIS EDITION...

Editors' Letter ............................................................................................................ 1 Humans of Medicine: The Nexus Quartet ............................................................... 2 "Shield", by Samantha Yee ...................................................................................... 4 Spotlight: "The Ambulance Ramping Crisis", by MECCSIG ................................. 6 Book Review: "Heart - A History", by Dinali Panagodage ..................................... 10 Community and Wellbeing: "Please Listen", by Andy Li ....................................... 12 THE 10 LAWS OF THE HOUSE OF MONASH, by Anonymous ........................... 13 The MIPS x Auricle Creative Writing and Visual Art Competition ..................... 14

EDITORS' LETTER Dear readers, Welcome to Edition 3, May-June, of The Auricle for 2022! We hope you enjoy this Edition, which features even more amazing work from Monash medical students.

Once again, Samantha Yee wowed us with her writing in her piece "Shield". We have published Andy Li's artwork "Please Listen" again, which initially featured on our online Wellbeing Wednesdays series.

There's also a new Humans of Medicine profile on the Nexus Quartet the first time a group has been featured in this segment!

Lachlan Coman is currently completing a Master of Public Health.

Our Spotlight in this edition has been brought to you by MECCSIG, on ambulance ramping and access blocks.

Find also some informative and entertaining reads - we have a book review by Dinali Panagodage and a satirical piece, "The 10 Laws of the House of Monash".

Please also don't forget The Auricle x MIPS Creative Writing and Visual Art Competition. Submissions are now open (until 31 July) and cash prizes are on offer. Get your submissions in ASAP!

Jordi Shahab is undertaking a BMedSc (Hons) year.

Happy reading :)

Lachlan Coman and Jordi Shahab

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HUMANS OF MEDICINE: The Nexus Quartet

Our newest Humans of Medicine series profiles The Nexus Quartet, consisting of four talented Monash Medical Students on the strings.

Can you introduce yourselves to us?

Hi, we’re the Nexus Quartet, composed of 4 very keen and passionate medical musos. Our members include Xenia (violin), Brendan (violin), Matt (viola) and Steph (cello).

What prompted you to form a quartet, and What kind of music do you play? why do you enjoy playing together? Everything! We’re currently building up on our Steph famously once said that if she doesn’t play the cello, med can feel a bit crazy, and that’s something we can all relate to! Getting together and discovering amazing musical works with your friends brings such pure enjoyment and is the best stress release anyone could ask for. We also play at a decent level, so nothing feels impossible and the musical world is our oyster!

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classical repertoire, and tackling some challenging quartets including Shostakovich, Ravel, Beethoven, Borodin, Grieg and many more to come (the list of quartets we want to play grows on a daily basis). Some of the most beautiful melodies were written for string quartets, there is a never-ending amount to explore, and is the perfect medium to truly delve into different styles and eras. We also play gigs (weddings and other functions), so we don’t shy away from contemporary works either!

Is there a favourite composer for your group, or does everyone have a different preference?

We all have our individual favourites, but our love for Shostakovich is definitely a binding force! His music is very intense (any words we write about how intense his music is will be an understatement, it can only be experienced by listening) and he really pushed the boundaries of classical music, and for that reason he’s not everyone’s cup of tea. If you’re the type to say classical music is boring, go check out Shostakovich, his music has an untamed ferocity but is also shrouded in grief and melancholy.

I understand you recently had success in a competition - can you tell us about that?

We recently placed 1st at the Music Society Victoria’s Chamber Music Award. We weren’t intending on placing at all, we just wanted a motive to truly perfect the Shostakovich 8 and Ravel quartets, and really push our musicianship to a higher level. Particularly with the Ravel quartet, there are so many beautiful textures and intertwining melodies to play around with, and it’s difficult to make it sound good without it just ending up as “a wall of noise”. Thus it was quite a shock to win! In the past all of us have competed in various competitions, at the time intending for music to be our career (and thus a single mistake suddenly becomes a huge deal when you consider your whole career is on the line!). So, it was such a pleasant experience to participate just for fun, as it was solely driven by our desire to share our love for what we do.

What are the challenges of playing in a group as opposed to being a solo performer?

From a technical perspective, balance of sound and dynamics is really important, and more complex with 4 players, as opposed to just a soloist and accompanying piano. However there's probably a more profound challenge: as individuals, we all have our own personal styles, but even though being in a quartet allows your own personality to peek through, there still needs to be a sense of cohesiveness and clear direction in the music. As with any group, at the start it was challenging to speak up and give each other feedback or to gather confidence to try and sway the direction of the music we were playing, but over time we grew more comfortable with each other and now make decisions as a group without fear.

What’s next for the Nexus quartet?

We have recently formed a website (https://nexusstring4tet.wixsite.com/my-site), if you ever need to hire a professional quartet for a wedding or gig. We’re also planning on doing heaps more competitions so watch this space!

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Shield

Words by Samantha Yee

I’ve always thought honesty my shield – that if I have nothing to hide, then there is nothing they can use to hurt me… I know my truth. I stand proud on the challenges I have faced and conquered and revel in the triumphs in my life. Though I am simply traversing the plains of life, equally uncertain and unknowing of the path that lies ahead, my experience might be one others may vicariously extract wisdom from, and I too through theirs.

This is not to say I am to shout out to the world my savings, my social security number: my identity but have I inevitably through the life story I have so willingly shared upon a single question, shared upon curiosity, given up my individuality?

My grandma says getting to know a person is analogous to a flower blooming on a spring day. Its beauty so ephemeral that a rush to bloom will simply hasten the wither. We are but simple creatures: beauty enraptures us, reflections and refractions of light captures our gaze and threatens to never let go – but only for as long as it exists. In our desire to be acknowledged, we forget the evanescence of it all, only questioning thereafter where it all went wrong and how we are left with nothing except the remnants of another’s fleeting attention.

Where do we draw the line between honesty and deceit; self-preservation and cunningness? Why must answers that are given be half-truths? Why should

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we omit our story for fear that it might be turned upon us and taken advantage of? Why do others seize upon vulnerability and raw emotions and experiences only to mould them into weapons of destruction of the worst kind – the self?

Am I to fear that one day, a misplaced trust in another might shatter my shield, leave me defenceless and alone against the prowling wolves of life?

They say I will learn – like a wide-eyed puppy freshly birthed from a mother’s womb, a blank canvas – my elders will be my guide and I shall soon soak up their wisdom to navigate life. But what a paradox that is… because amongst all the lessons they imparted upon me, they say veiled honesty should also extend to those near and dear – that no one should know me better than myself; that there are secrets of the self that I should take to the grave. What a lonely journey that will be… To be unable to place unconditional trust in the physical is to place unconditional trust in the intangible – life’s most venerated but at times, most unforgiving guide: mistakes.

At this point in time, I am fortunate to still be in the warm embrace of mother life. She is tender and nurturing. Alas, this too is ephemeral. Mistakes of today are tolerated but less certain is this patience for the mistakes of tomorrow and of a few years to come. As we begin to lift from her embrace and onto her shoulders, a fall from this height can be devastating. The gift of recovery is limited and she may only extend it to a privileged select few who she has ascertained has the means to rebound and prosper… I may not be one of them and the ripples of my fall may indirectly hurt those still in her tender embrace.

I may be making a mountain out of a molehill but truth be told, I am fearful. I am questioning the integrity of my shield that took 20 years of life to forge and how difficult it may be to reinforce it and imbue it with newfound mystery. I only ask for the strength and dexterity of an experienced blacksmith to craft my shield to accompany me to the end of this plain.

Samantha Yee is a Year 2A medical student.

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SPOTLIGHT:

THE AMBULANCE RAMPING CRISIS

Words brought to you by Katie Mazzochi, James Liang and Jordi Shahab on behalf of

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OUR HEALTH SYSTEM is in distress. Images of idle ambulances are broadcasted in news coverage daily. Far too often, we hear of tragic cases whereby a person has died waiting for an ambulance or whilst on an ambulance stretcher, waiting for a bed in an Emergency Department (ED). Healthcare workers are turning to social media to expose the gaping cracks in the system and its effect on workplace stress.

‘But we are still amidst the aftermath of a once-in-alifetime pandemic’, you may say. COVID-19 has certainly exacerbated ED overcrowding, ambulance ramping and access block, however these issues predate the pandemic.

In fact, literature in this field dates back to over twenty years ago. Dr Omar Khorshid, the current President of the Australian Medical Association (AMA), says “Well before the pandemic, Australian hospitals were in crisis.

The pandemic has shown there is no spare capacity in our hospitals.” (1) The factors underlying this crisis are complex, intertwined and deep-seated.

It is important to clarify the terminology used in regard to this topic. ‘Access block’ is defined by the Australian College of Emergency Medicine as the circumstance where patients who have been assessed in the ED as requiring admission, are delayed in receiving an inpatient bed for greater than eight hours (2). A lack of inpatient bed capacity has a flow on effect to not only the patient and ED, but the ambulance service as well. Therein lies the issue of ‘ramping’ whereby paramedics are delayed in transferring the patient from the ambulance into an ED bed. Whilst ramped, paramedics provide care to patients in the back of an ambulance or the hospital corridor. In the meantime, paramedics are unable to respond to subsequent callouts, including the most urgent of calls such as those for a suspected cardiac arrest. With this vicious cycle in full swing, the healthcare system becomes overloaded and less efficient with the already limited resources it has available.

CONTRIBUTING FACTORS AND IMPLICATIONS Why are these problems worse now, when hospitals have dealt with staffing and capacity issues for their entire existence? The factors contributing to access block and ambulance ramping are numerous, and partially attributable to the COVID-19 pandemic. Not just the direct impact of acute COVID-19 illness, but indirectly as well. There are many chronic conditions for which comprehensive medical care has been neglected.

Typically,

MYTHBUSTERS Receiving transport to the hospital via ambulance does not preclude patients from sitting in the waiting room. Irrespective of how a patient arrives at an ED, they are triaged using the same criteria. If a patient is brought in by ambulance but does not require emergent intervention or monitoring (e.g. cardiac telemetry) they can be offloaded to the waiting room.

The causes of overcrowding, and therefore the solutions, are not confined to the ED. To have enough inpatient beds available for acutely unwell patients, solutions may be found in improving patient flow and systemic capacity.

Typically, it is the most vulnerable of patients who have evaded essential care due to fears of COVID-19 exposure.

The issue of ambulance ramping is not a new one. A study published in 2009 investigated access block and ambulance ramping in Australia, finding significant increases in access block in hospital systems from 2004 to 2008 (3). It is possible that these problems were inevitable with time. Ramped patients also experience a longer time to triage compared to non-ramped patients (4). In ideal circumstances, regardless of ambulance ramping, all patients should be triaged upon arrival at hospital in order to determine their emergent requirements. A delay to triage is dangerous.

The adverse effects of ambulance ramping are not well studied but have certainly been hypothesised. It is logical that a delay in care prolongs the time until definitive treatment can be given. Research has indicated that ramped patients are more likely to stay in ED for greater than eight hours, compared to non-ramped patients (4).

Whilst this study did not demonstrate a mortality difference, further data is needed to determine the mortality effect of ramping. Nonetheless there have been numerous patient deaths while ramped (5, 6). It is indisputable however that ED overcrowding is associated with preventable mortality and morbidity (7).

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Unfortunately, the repercussions of ambulance ramping also extend to our frontline workers. Paramedic morale is suffering and disillusionment and burnout are on the rise (8). Paramedic and Secretary of the Victorian Ambulance Union, Danny Hill, has spoken out about the challenging work conditions saying, “They work without meals, without breaks and a lot of overtime at the end of a shift.”

(9) According to a survey conducted by ACEM in 2019, ED physicians attribute the greatest proportion of workplace stress to ED overcrowding and access block (10). With no end in sight, paramedics and ED staff are understandably at a breaking point.

prudent to increase the capacity of residential aged care and disability care facilities (13). Currently, some elderly patients and patients with disabilities wait for residential care bed assessments for weeks after being deemed suitable for discharge, leading to unnecessary congestion of finite hospital resources. By enhancing the acute and palliative care potential of residential care facilities, presentations to hospitals could be reduced, as could the length of hospital admissions.

Patients with prolonged wait times are more likely to experience dissatisfaction and be perpetrators of physical violence towards healthcare workers. Being on the receiving end of such violence has been associated with increased symptoms of depression, anxiety, stress and post-traumatic stress disorder among Australian paramedics (11).

A variety of structural solutions have been suggested to address systemic failures contributing to access block and ramping. These include:

Structural Solutions - Data, Funding and Patient Identifiers

Improved interoperability and funding integration across different levels of healthcare to improve data collection on workforce utilisation and resource allocation; 50/50 funding of hospitals between State and Federal governments to inject more funding into the public hospital system; and Patient identifiers across health systems to improve understanding of hospital admissions data to design data-driven prevention measures (14).

Although these structural solutions are more abstract and difficult to implement, each step taken to improve the system will reduce the hospital logjam crisis.

Freeing Up ED Beds

FUTURE DIRECTIONS Having understood the problem of ambulance ramping and access block, naturally we want to understand what can be done about it. Urgent action is pertinent, as the AMA projects average daily ED admissions to exceed bed capacity by 20% before 2031. This will inevitably lead to further unmet demands for healthcare (12).

Improving Patient Flow Streamlining admission and discharge processes to improve patient flow throughout the hospital system will likely free up inpatient hospital beds and therefore reduce access block. Given our ageing population, it is 8 The Auricle May-June 2022

Although ‘GP-suitable’ patients are not the primary cause of ambulance ramping or hospital access block, solutions have been introduced to reduce lower acuity presentations to EDs. These include the establishment of bulk-billing urgent care centres with extended hours to treat simple fractures, wounds and minor burns (15).

Virtual EDs have also been introduced with great success, allowing for online triage by a nurse to determine whether a patient is suitable for a telehealth consult with an ED physician (16). Ultimately, these measures free up ED resources to treat patients with higher acuity presentations.

Although many solutions have been proposed, piloted and delivered to address the hospital logjam, no single solution in isolation can be a panacea to the systemic and structural challenges faced by hospitals and EDs. As medical students, sometimes it may feel as if we are a small cog in an enormous machine. However, with appreciation of the challenges within the healthcare system, we are able to more effectively advocate for what needs to be changed. Check out the Hospital logjam finder (https://www.ama.com.au/clear-the-hospital-logjam) to draft an email to your local MP if you want to speak out about hospital logjams!

REFERENCES 1. https://www.ama.com.au/clear-the-hospital-logjam 2. https://acem.org.au/Content-Sources/Advancing-EmergencyMedicine/Better-Outcomes-for-Patients/Access-Block 3. Australian College for Emergency Medicine. ACEM Snapshot 2008.

Available at http://www.acem.org.au/.

4. Hitchcock M, Crilly J, Gillespie B, Chaboyer W, Tippett V, Lind J. The effects of ambulance Ramping on emergency department length of stay and in-patient mortality. Australasian Emergency Nursing Journal. 2010 May 1;13(1-2):17-24.

5. https://www.abc.net.au/news/2021-07-02/inquest-into-mans-death-in2019-examines-ambulance-delays/100263032 6. https://www.theage.com.au/national/man-dies-in-emergencydepartment-after-waiting-hours-at-rural-hospital-20220412-p5acst.html 7. Sprivulis PC, Da Silva JA, Jacobs IG, Jelinek GA, Frazer ARL. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Medical Journal of Australia.

2006;184(5):208-12.

8. https://theconversation.com/bad-for-patients-bad-for-paramedicsambulance-ramping-is-a-symptom-of-a-health-system-in-distress-169528 9. https://www.news.com.au/national/overworked-paramedics-takingambulances-home-make-desperate-plea-to-the-public/newsstory/63200aed8a1d72e6acd2d829728a8e70 10. https://acem.org.au/getmedia/451cd2ba-f4d9-405f-90f92fbc414e3969/2019-Sustainable-Workforce-Survey-Report-R3 11. Phillips WJ, Cocks BF, Manthey C. Ambulance ramping predicts poor mental health of paramedics. Psychological Trauma: Theory, Research, Practice, and Policy. 2022 May 12.

12. https://www.ama.com.au/sites/default/files/202203/Public%20hospitals%20-%20cycle%20of%20crisis.pdf - Page 34 13. https://www.publish.csiro.au/ah/pdf/AH09821 14. https://acem.org.au/Content-Sources/Advancing-EmergencyMedicine/Better-Outcomes-for-Patients/Access-Block-(1)/Hospital-AccessTargets 15. https://theconversation.com/labors-urgent-care-centres-are-a-step-in-theright-direction-but-not-a-panacea-181237 16. Sher L, Semciw A, Jessup RL, Carrodus A, Boyd J. Structured evaluation of a virtual emergency department triage model of care: A study protocol.

Emergency Medicine Australasia. 2022 May 15.

Dear MP, I’m writing to you to express my real concern about my local hospital.

My local hospital is in logjam, and so are other hospitals right across the country.

Ambulances ramping, overcrowded emergency departments, growing surgery waitlists - these are all signs of a public hospital system in crisis.

I’m concerned about what will happen if I, or one of my loved ones, needs access to the hospital system.

I’m also concerned about my broader local community and the lives that are at risk.

Australia’s doctors and other medical workers are world-class. But in order to keep us safe and healthy, they need an adequately funded, world-class hospital system. At the moment, that’s not the case.

This isn’t about COVID-19. COVID-19 has obviously exacerbated the problem, but my hospital was in logjam well before COVID-19 hit our communities and it will continue to remain this way unless your government delivers adequate funding for the future.

Please, help clear the logjam in my local hospital before it’s too late. Commit to future funding for our public hospitals.

Thank you.

Katie Mazzochi (Year 5D), James Liang (Year 2A) and Jordi Shahab (BMedSc) are members of MECCSIG. MECCSIG is the Monash Emergency and Critical Care Special Interest Group. Check out the MECCSIG Facebook page (https://www.facebook.com/MonitorMECCSIG) for informative and engaging academic and career-informing content regarding critical care.

MECCSIG also runs clinical and pre-clinical workshops and career nights.

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BOOK REVIEW. "Heart: A History" Review written by Dinali Panagodage

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I’m not entirely sure whether this is something that happens to every medical student, but I personally find that as I am reaching the end of my degree, I’m looking everywhere for assurance that a lifelong career in medicine is indeed something to look forward to.

Medical autobiographies are therefore very enlightening. They provide the opportunity for physicians and healthcare workers to share their incredible stories and bring light to the sacrifices this field requires. These autobiographies are certainly holding a strong position on the bookshelves these days, and deservedly so.

Dr Sandeep Jauhar’s Heart: A History opens with Jauhar’s own health scare, the story of which he is all too familiar with: a middle aged man presents with increasing shortness of breath on exertion, who finds out he has significant coronary arterial calcification. Dr Jauhar is a cardiologist and opinion writer for the New York Times, a 9/11 first responder, and the author of three memoirs detailing his experiences throughout his medical career.

This is no ordinary memoir, however. Scattered in-between Dr Jauhar’s stories and own personal experiences, we slowly learn not only about the heart itself, but of the risks and sacrifices that were required to discover the cardiovascular technological advancements that we take for granted today.

Jauhar writes in a way where we can see that he’s aware of the delicacy of the subject matter; too much med-ification and the heart becomes nothing more than a glorified pump.

Dr Jauhar takes us through how every discovery and every intervention required someone to ask a difficult clinical question (and sometimes also slightly unhinged: see Werner Forssmann, who developed cardiac catheterisation by doing it to himself). Each chapter begins with a riveting medical story that feels like an action-packed cold opening of a tv show.

"we slowly learn not only about the heart itself, but of the risks and sacrifices that were required to discover ... advancements that we take for granted today" For example, we join Dr Jauhar on Christmas Eve, emergently operating on a patient with infective endocarditis in a quiet but purposeful theatre. It’s in this theatre that we meet the heart-lung machine, and Dr Jauhar takes us on the journey of its invention spanning across decades. Taken back to the 1930s, we learn that the heart-lung machine began with the insane concept of linking one person’s blood supply to another’s (much like a mother and a foetus), and ends with a full-fledged machine that allows surgeons to operate on an arrested heart.

Heart: A History is the kind of memoir that legitimises the journey through medical school, makes you excited to see the discoveries to come, and the possibility to be part of something new. I recommend Dr Sandeep Jauhar’s memoir to anyone fascinated by medical history, and I hope that it captures your heart as much as it did mine.

Dinali Panagodage is a Year 5D medical student and aspiring anaesthetist.

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Please Listen Artwork by Andy Li

It’s easy to forget what it’s like to know nothing; to be in the dark about your own body. https://www.abc.net.au/news/2022-05-11/amrita-lanka-monash-childrens-hospital-death/101054286

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THE TEN RULES OF THE HOUSE OF MONASH

By Anonymous

Ed: Enjoy this Monash-themed take on the 10 Laws of the House God, from the satirical 1978 novel House of God by Samuel Shem.

I. PLACEMENT IS KING. II. MATURING IS REALISING GEN MED IS A BETTER FINAL YEAR ROTATION THAN NEUROSURG. III. IF YOU'RE INTO MASOCHISM, LOOK NO FURTHER THAN PEBBLEPAD. IV. A SOCIAL WORKER IS WORTH 10 INTERNS, 20 FINAL YEARS, AND AN INFINITE NUMBER OF 3RD YEAR STUDENTS. V. THE ONLY GOOD LECTURE IS A LECTURE CANCELLED. VI. EVERY IMMIGRANT WITH A COUGH HAS TB. VII. MINDFULNESS IS BETTER THAN A CURE. VIII. THERE IS NO MENTALLY-ILL YOUNG WOMAN WHO CANNOT BE TREATED WITH ESCITALOPRAM + CBT. IX. APPLYING THE ESSENCE MODEL OF CARE WITH A STRAIGHT FACE IS AN ASSESSABLE SKILL. X. A FEVER IN A RETURNED TRAVELLER IS COVID UNTIL PROVEN OTHERWISE, UNLESS IT'S MALARIA, IN WHICH CASE YOU CAN EXPECT A VERY EXPENSIVE MEDICAL NEGLIGENCE LAWSUIT.

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Creative Writing and Visual Art Competition 2022 6 June - 31 July 2022 See the Facebook Event or www.theauricle.org for more!

Proudly sponsored by:

https://www.mips.com.au/I-am-a/student