Author: Blair Bigham

Twas the night before Christmas; all through the North Pole
Every creature was talking ‘bout Donald’s new role.
The President-Elect came out from left field,
And in a just a few weeks, great power he’ll wield.
 
The elves were all anxious, awake in their beds;
Fears of being deported bounced ‘round in their heads.
Jeff Sessions as AG would be a big smack,
Foreign elves deemed illegal could all be sent back.
 
And the Arctic toy shop in Canadaland,
Might get caught up in a Wilbur Ross plan.
With him leading Commerce, NAFTA’s future’s uncertain,
This year’s hottest supply of toys could be hurtin’
 
But a wage freeze provides a small silver lining,
Andrew Puzder thinks that those elves should stop whining.
Minimum wage will likely stay very low,
And Santa’s narrow profit margin is bound to grow.
 
He’ll need every penny, chubby, plump and of age,
Health insurance fees will dig into his wage.
If Obamacare goes, as Tom Price wants to do,
Spending less time with partner: – person who spend less time in making love and more time staring at your deeprootsmag.org cialis prescription online screen. Would it be worthwhile to use the services of viagra soft 50mg one of them? Being a counselor and consultant myself, I would say a definite “yes”, as people who have a chance of “talking off” their problems often feel better and more relieved emotionally and find their depression reduced or gone. There are various concerns those simply say, sitting is not the relevant style of detoxification. viagra 100 mg deeprootsmag.org Lot of the times continue reading for info buy generic cialis erectile dysfunction acts as a precursor to a major cardiovascular event. Self-employed Santa will pay for health too.
 
But Santa’s resilient; he will overcome,
The challenges mounting since Mr. Trump won.
He’ll load up his sleigh, the presents packed high,
And command his reindeer up into the sky.
 
But Rudolph’s red nose might not be so bright,
Given the upcoming smog warnings in sight.
Scott Pruitt has been tagged new EPA head,
Climate science is out; it’s ideology instead.
 
But a greater risk to Santa’s sleigh is of worry;
Rex Tillerson’s sympathetic to Russia’s war fury.
Putin’s jets might mistake the sleigh full of toys,
For a Syria-bound United Nations convoy.
 
Santa sits by his fire, contemplating what’s next,
His brow is concerted, his expression seems vexed.
He lets out a sigh, his tone not so fun:
“Happy Christmas to all, it might be my last one!”
 

Most paramedics had never heard of “carfentanil” before it showed up on the streets of Ohio in July. That’s because it’s not a human medicine—it’s an elephant tranquilizer used by veterinarians.

It is 10,000 times more potent than morphine, and a grain of it—20 micrograms—can kill a human.

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Click here for my latest story: The 5 things you need to know about Carfentanil.

This post is intended for an emergency / paramedic audience.

Paramedics and physicians outraged by CTV’s investigative broadcast W5 episode “911 Roulette” took to social media last night to display their disappointment and shock in what one paramedic called “irresponsible journalism.”  The episode, which questioned primary care paramedicine in Ontario, was hosted by experienced journalist Kevin Newman in the second episode of the show’s 51st season.  As both a paramedic and a journalist, I offer my analysis of 911 Roulette and attempt to answer the question: How could W5 get it so wrong?

Before we get into the journalism, I’d like to express my condolences to Karen Calberry.  In the broadcast, Karen discusses the death of her husband David, a 54 year old firefighter, in the back of an ambulance while being transported to a hospital after suffering a heart attack.  Her contributions to the episode offer insight into public perceptions of a technically challenging dilemma facing paramedicine: what is the right level of care?

The Goal of Journalism

I believe that a free press is required for a free society.  The goals of journalism are two:
1) to protect democracy by holding those in power accountable
2) to deepen an honest understanding of the world around us

The role of a journalist is to answer questions that achieve one, or both, of those goals using accurate and balanced reporting.

If you were to call me right now and say “Blair, that piece you wrote for VICE.com last week (plug!) was full of shit” I would say to you:
1) Were there factual inaccuracies?
2) Was it balanced?
The goals of journalism essentially involve tension.  They involve questions and answers that some people may not like.  There will always be criticism, more detail that could have been added, more jargon that could have been said.

And, yes, those goals involve communicating those questions and answers to an audience.  It is HERE that paramedics must stop and reflect; journalists and their editors know their audience.  We must put ourselves in their shoes: how do we communicate a complex issue to an audience? This was the greatest struggle for me in J-school.  “World Peace!” is not a story, and neither is “Dopamine causes more arrhythmia than norepinephrine in the treatment of septic shock.”  Too broad.  Too specific.  Journalism requires laser focus and the ability to communicate complexity to people who don’t possess technical expertise, without being condescending or boring.  It’s actually quite hard to do well!

The Question Wasn’t Wrong

Journalists start with a question.  At the beginning of the broadcast, Mr. Newman ponders if people are playing “roulette” when they call 911; he observes “in Canada, calling 911 doesn’t always guarantee the paramedic who arrives can do everything in their power to save your life – in fact in most provinces, some of them are prevented from doing that.”

Put more technically, Mr. Newman asks what harms a person might experience if a primary care paramedic – rather than an advanced care paramedic – arrives on scene, noting that it seems to, at least at times, be chance.

This question is not unreasonable.  Health human resource questions like this have been prominent in public discourse for decades.  As governments fight to contain costs, we have seen RN positions replaced by RPN positions, we have seen physician services transfer to pharmacists and nurse practitioners, and we have seen family doctor home visits replaced by community paramedics.  It is not unreasonable to ask “what impact does this have on patients, systems and the economics of health care?”

Let’s Just Admit One Thing…

Allow me a brief anecdote.  Many years ago I suffered a kidney stone.  When I say suffered, I am of course exercising restraint.  It was fucking awful.  A paramedic, I called 911, begging for morphine.  When two PCPs arrived at my door, my heart sank.  Not because I didn’t trust or respect the PCPs – but because, in that moment, I really wanted a narcotic!  Years later, when a colleague was involved in a car accident, I was relieved when I heard it was an ACP crew that transported her to a trauma centre.  There is little rationale in this comfort, but I nonetheless felt that way.  I’m sure many of you can relate.  We want the very best caregiver in our personal circumstances – everyone does – evidence and economics be damned.

So, to begin, I say “bravo!” to W5 for asking a reasonable question.

Then, I wonder how the hell a well respected group of journalists could get the answer to that question wrong.

What Makes A Good Story?

Tension – there must be some component of debate.
Important or Counterintuitive – the story that makes me say “I want to read that.”
Underreported – if I have already heard about it, I’m unlikely to pay any attention.
Timely – it must be something that is happening now (or soon).
Substance – while cat videos defy this criteria, a good story has meat to it.

Let’s apply these criteria to 911 Roulette
Tension: emergency patients are critically ill, but not all paramedics are equally trained.
Important or counterintuitive: when you call 911, you might not get the help you need.
Underreported: while we all know about level of care intimately, the public, it seems, does not.
Timely: not particularly, but we all might need an ambulance tomorrow.
Substance: Ahhhhhh…. more on this later.
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So, we have a reasonable question that makes a good story.  Sounds like it’s worth answering!

How Do Journalists Answer Questions?

Start by turning a given truth upside down.  Some of the best journalism comes by asking questions we thought we actually knew the answers to, but didn’t.  Then, use human sources, data, documents and field work to  answer the question.

Step 1: Question everything you think you know.
Step 2: Pick up the phone and talk to people.  Lots and lots of people.  Ask those people questions.  Question everything they think they know.  “How you know that?”  “Who might disagree with you?”  “When might that not be the case?”
Step 3: Research the data.  Policies.  Legislation.  Reports.  Manuscripts.  Graphs.  Charts.  Look at the data: does it reflect what people are saying?
Step 4: Get the documents.  Court files, government registrations, computer records.  Find hard evidence of what is happening.

Communicating A Story: it’s ugly, but it works.

Now the tricky part: communicate the answer.  This is where you sell a little bit of your soul to communicate your message in a way that someone will hear it.  Attention spans are short, and demand for attention high.  This makes the art of journalism critical, if not a bit ugly.  A radio clip might be limited to 75 seconds; an article to 600 words; a broadcast to 23 minutes.  Here, clarity and brevity are required, leading to one cutting, slashing and burning their story from a beautiful thesis to a reported story.  In this process, granularity is lost, details are left out, and jargon is replaced with terms my grandmother would understand.

For example, a needle thoracostomy and a tube thoracostomy are two very different things.  Colloquially, we might call one a “chest needle” and the other a “chest tube”.  But in a brief broadcast, it really doesn’t matter to my grandmother; ACPs can stick a thing in her chest to make her better, and a PCP cannot.  If I tried to explain the difference to her (she’s dead, so this is metaphorical) she would roll over in her grave.  So, paramedics, get over it: no jargon, no details, just clear facts.  (Yes, some of the facts were wrong… keep reading!)

What W5 Got Right

The electronic record of the defibrillator is a document that raises legitimate concerns about delays to defibrillation.  Out of context, it is hard to fully interpret… for example, a patient may be in V Tach with a pulse, receive an alarm, but not require a shock.  Still, it’s worth reporting.  They also gave the context that the paramedics were investigated and received additional training.  While they missed that “STEMI – pads on!” is a new standard, they raise a fair point in asking if a different crew might have done something different.

The controversy of making paramedicine self-regulated isn’t new, but it’s worth having in the public eye.  W5 correctly raised the issue.

Three Things W5 Got Wrong

I will not list every factual inaccuracy in the piece, aside from noting the following, and cautioning that a simplification is not necessarily an inaccuracy.
The Medicine: Nitroglycerine does not save lives.  Chest needles do not fix pulmonary arteries.  To say that the difference between life and death was an ACP intervention is dubious.
The Evidence: there is a large base of scientific evidence to draw from to make decisions about how best to model an emergency medical system.  W5 didn’t report any of it.
The Balance.  There was no interventional cardiologist to explain that STEMI bypass is preferred to closest hospital.  There was no base hospital physician or Paramedic chief explaining why different levels of care exist.  There was no PCP to offer perspective.  The paramedics in question were not featured.  The system in Saskatchewan was selectively reported, and the Ontario-Saskatchewan comparison, framed as like-like, is apples-and-oranges.  It’s hard, in a 23 minute broadcast, to present all points of views, and first person accounts are important.  But in this case, they swayed away from balanced reporting.

My Analysis:

Objectively, the episode in question accomplished the goal of journalism: to deepen an honest understanding of an issue that is relevant to the audience.  The issue of “why doesn’t everyone get an advanced care paramedic” is controversial and not settled.  It is debated throughout North America.

The idea of self-regulation and the public benefit of such is also hotly debated, and many in Ontario have been advocating for this for years.  Further, it is fair to question why certain features of scopes of practice are the way they are: the current model is a bit archaic, and perhaps not fully patient-oriented despite the best intentions of those involved.  The model is, in fact, the reason I left paramedicine and went into a self-regulated profession.

Yet, as a paramedic, scientist, physician and journalist (I think I need to stop going to school!) I was saddened by how this story was told.  I will focus on the following critiques of the story:

1)Some of the facts were wrong, and that led the story in the wrong direction.

2) The balance was way off.  The closing statement of Ms. Calberry in particular required a counterstatement to offer a different point of view; surely it is not smart to drag loved ones into your car and rush them to hospital when they are dying of a heart attack.  Emotion should be balanced with reason, and that was missing from the episode.  W5 has since responded to this criticism online.

This story hits close to home; not only does it offend me as a paramedic, it challenges me as a journalist.  As I strive to achieve the goals of journalism, I must always challenge my own biases, question everything, and seek proof over hyperbole, no matter how sexy the headline may be.

“It’s no use going back to yesterday, because I was a different person then.”
― Lewis Carroll, Alice in Wonderland

Want to read more about my foray into journalism? Click here!

Need some lighter reading? Click here to read how you cram more into a day.

What the hell have I gotten myself into?
That’s what I questioned, exasperated and confused, when one of my mentors picked up the phone. Even on the opposite end of the continent, he could tell I was panicked and responded with the slow, confident voice I needed to hear. “Tell me about another time you felt uncertain on day one” he asked wisely. Examples abounded. “Has your gut ever been wrong?” he asked. No, not on matters like this. “Tell me why you signed up for this; why journalism?” I paused.  

The industry of medicine is engrained in dogma, fixed in many of its beliefs, and takes a conservative approach to change. For those who work in, and depend on, modern healthcare delivery, challenging perceived truths and brining public light to the untold stories of those with soft voices is daunting if not impossible.  

Equipped with training in communications and journalism, I hope to develop a sharp ability to ask important questions, to report on issues that are counterintuitive, and to prompt people to think differently.  

Easier said than done. We continued to flush out my discontent, acknowledging that while “Man Bites Dog!” is an interesting story, it doesn’t tell us anything about dog bites. But there are other stories, deeper stories, about problems that affect us all. Or maybe they don’t, but they could. Or maybe they couldn’t, but you really want to know about them. Or maybe you don’t, but I want you to. Maybe that’s enough. To walk away in April knowing how to spot the important stories, how to build an emotional connection with those I report on and express those emotions those I report to, so that what seems important to me seems important to you.

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I guess we all have mentors for a reason.

So I now realize why I came home deeply dissatisfied with my day. I was worried about writing about things that were fleeting and inconsequential, like so many of the news articles I read this morning while sipping a tea on the GO train. But there are important stories, stories that matter, happening all around me. Our constant need for order forces us, as individuals, organizations and societies to apply preconceived and convenient truths to aggregate populations. Whole populations fall through the cracks of conventional discussion. By digging deep, voices can rise up, trees lost in the forrest. 

“Why journalism” he asked me again.

“Because… I trust my gut.”

Yep.  Why not? After my bid in 2008 failed to secure me a job with the Canadian Space Agency, the next recruitment for the Canadian Astronaut Corps closes next week and my application is ready to go.  Below is my (draft) cover letter.  I’ve decided to crowd-source editors (you!) to help me shine!  Have at ‘er in the comment section below 🙂

To The Canadian Space Agency:

The last time I applied to be an astronaut, I did so because I thought space exploration was an exciting and noble avenue. Since then, my commitment to being an astronaut has strengthened and my motivation has matured. As a physician and flight paramedic, I am uniquely suited to provide health care in adverse environments and stay calm and resilient in stressful operational situations. As a scientist, I am intellectually positioned to contribute to our understanding of the physical and biological world we live in, and ethically bound to the highest standards of integrity. As a traveller, public speaker and writer, I am well positioned to communicate the virtues of space exploration to a global audience; and as an accomplished collaborator, I have the temperament and disposition to represent Canada in the global space industry. Most importantly, my motivation and industrious nature, combined with my dogged determination, should assure you that I will succeed as a Canadian astronaut.

Since I was a child, I have been an explorer. I have a fascination with Earth, indeed having tried to visit every corner of the globe, from SCUBA diving the depths of the Pacific to hiking in the heights of the Himalayas. On every trip I take, I can’t help but lay out in the open air in the middle of the night, staring at the sky, noticing which constellations I can spot from different points on the earth. In these star-gazing moments, my mind wanders to what I assume are the borders of the universe, and knocks on what is beyond even my wildest imagination. The moon, particularly, makes me feel united and whole wherever I am on Earth; I reach for it, feeling both small and big all at once. So many worldly problems can be solved if we advance our understanding of the planet we live on. To do that best, we must sometimes leave it.

Allow me to articulate why I am a formidable candidate for the Canadian Astronaut Corps. You will find supporting evidence demonstrating these qualities and abilities in my CV.

Integrity. My mantra has always been “integrity above all else.” Success in both my personal and professional lives has been facilitated by my commitment to honesty, sincerity and effort. I have developed a reputation for being dependable, determined and trustworthy. As a scientist, the validity of my findings are judged first on my personal reputation, and then, on the methods of the research. In medicine, the bonds I have developed with other health care providers determines if my clinical opinion is respected and acted upon. I am invited to collaborate on international, national and local committees based on my past performance and ability to not only build but maintain relationships. This is only achievable when one places their personal integrity above all other considerations.

Judgment. Throughout my career, excellent judgment has lead to excellent results. As a flight paramedic, I was faced with critically ill patients, incomplete information, a small, loud environment where traditional stethoscopes and interviews were useless, and time was of the essence. Here I developed skills to make important clinical and operational decisions based on “best available” information, adapting plans as new information arose or clinical changes dictated an alternate course of action. In this mobile, dangerous and stressful environment, I developed the ability to control my own responses to stimuli, demonstrate resiliency, and maintain situational awareness. As a scientist, there are many “easy ways” forward but few “right ways”. Good judgment is required to ask the right question, develop a rigorous and ethical approach to answering it, and develop the systems and collaborations required to execute a research project. Further judgment is required to navigate the political and technical aspects of academia, grant mechanisms and publishing. As a physician in the emergency department, I have continued to develop outstanding judgment skills. While not as chaotic as the field, I have evolved in my ability to multitask: some days there are over 100 people in the emergency department at any given time. Lastly, my travels have taken me to 76 countries, many of which required cultural, environmental and security considerations. Whether scuba diving, mountain climbing or exploring an urban core, I have a commitment to absorbing all available information, processing it without undue emotional noise, and acting accordingly.

Reasoning. I have a demonstrated ability to take large amounts of information and make sense of it. And when I do, I’m trained to check my assumptions against possible biases, challenging my mind and my gut to ensure I am on the right track. I believe in analytic, evidence-based reasoning so long as it passes the “gut check.” I am trained to intuitively and quickly make split second decisions, all while checking my instincts against tried-and-tested tests. Be it in medicine, flight paramedicine, scientific study, or the board room, I bring a questioning mind that formulates accurate answers.

Resourcefulness. Whether treating patients in Ontario’s North or remote Uganda, I am often working in an underresourced setting. Just recently, I was the night physician for a music festival where 50,000 people camped out on a farmer’s field. Providing medicine in austere environments forces one to think outside the box, adapt previous habits, and solve problems with available resources. This includes managing physical as well as human resources to maximize operational effectiveness. I believe a key factor in one’s success in resource-limited settings is to know the resources available; when a preferred medication is not available, another might be appropriate for substitution; when a piece of equipment is broken and can’t be repaired, duct tape, suture string, or laceration glue may be sufficient to return the tool to service temporarily. In Uganda, I remember mixing salt and boiled water to make a sodium chloride infusion; a strong understanding of the solution allowed me to create what was lacking, rather than stare helplessly at the empty stock cupboard. Preparation and knowledge, when combined with experience and creativity, have allowed me to be resourceful in difficult situations.
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Ability to synthesize plans. As one of my mentors used to say, “a vision without execution is a hallucination.” I try to keep this in mind when coming up with plans to execute ideas. Knowing the destination is a start, but the real work often occurs in mapping a route to success. In my efforts as a scientist in medical science, I worked in a very challenging field; out of hospital cardiac arrest. This involved huge data coordination and provider training efforts. The randomized clinical trials I was involved with involved over 200 ambulance operators employing over 10,000 paramedics, 100 receiving hospitals, dozens of dispatch centres and covered a population of 20 million people. Planning was key to the success of our trials, and a skilled interdisciplinary teams of stakeholders, computer programmers, data abstractors, statisticians, field providers and scientists worked painstakingly to execute trials across the network, landing several high profile publications that have influenced how cardiac arrest is treated worldwide. From this decade-long work to a day-to-day view, treating critically ill patients requires rapid synthesis of treatment plans that must be fluid and able to adapt to changes in patient condition, new information, and department demands. Whether planning for a long-term project or caring for a patient in front of me, I have developed strong skills in creating and executing plans to achieve the desired outcomes. 

Communicating and Public Speaking. I am an experienced writer. Whether scientific manuscripts, trade industry editorials, or public blogs that break down complex topics into understandable puzzles, I am able to clearly communicate complicated topics. I am also an accomplished and sought-after public speaker. I am frequently invited to speak locally, nationally and internationally on controversial and emerging topics in the area of emergency medical services. My audiences have included international scientists trying to grapple the challenges of just culture and patient safety (delivered using a live translator) to local groups of students eager to learn more about working on a medical helicopter. My written and oral communication skills are about to expand further; I am starting an intensive, 8-month fellowship in Global Journalism at the University of Toronto Munk Centre for Global Affairs. This mentored journalism program will teach me the skills needed to communicate with the public via traditional, online, broadcast and social media platforms and further develop my strong abilities as a communicator.

Teamwork and Leadership. In both medicine and emergency operations, it is impossible to tease out leadership and teamwork; without one, the other cannot be. A strong leader motivates and directs teams to perform exceptionally. Strong leaders can transition into the role of a follower, contributing to the functionality of a group as needs change and roles evolve.   Perhaps this is most true in two of the environments I thrive best; the scene of an emergency and the resuscitation bay of an emergency department. In both these settings, up to a dozen or more people may be working under stressful and under-resourced conditions to save a life. Necessary steps must be prioritized and needs anticipated. It is in this environment that I have honed my leadership, teamwork and crisis communication skills to become a respected and valued resuscitator. Teamwork is also required in my research and governance activities. On the Board of Directors for the MedicAlert Foundation of Canada, I have led the transformation of a dying industry focused on bracelets to a healthy, mission-focused organization embracing wearable technology, satellite communications and e-commerce. In my roles with Resident Doctors of Canada and the Professional Association of Residents of Ontario, I work hard to represent the needs to residents and improve wellness and resiliency amongst my colleagues across Canada.

Motivation. If the tone of this letter has not already conveyed the excitement and motivation I feel towards the possibility of joining the Canadian Astronaut Corps, be assured that serving in space is a serious endeavor for me. I work hard to be physically and mentally fit. I have sought advice of past Canadian physician-astronauts, particularly Dave Williams, as well as past physician candidates, one of whom I have worked with in the past. I have sat down with my “board of directors” – mentors and advisors from all walks of life – who have supported my decision to apply and challenged my motivations, biases and preconceptions of what this could mean for my life. I am beyond motivated; I am determined.

Living and serving in space is beyond unique and challenging,; my extensive preparation means I’m ready to serve in the Canadian Astronaut Corps.

Submitted respectfully,

Blair Bigham

*Disclosure: I’m a rich, white man.  

This week, race-related issues have made headlines. From the BLM protest at Pride, to the seemingly senseless shootings of black men by police, to the horrific killings of officers in Dallas, we are reminded that racial conflict is pervasive in North America. I have read many posts by very intelligent people who are on seeming “sides” of whats going on. But the matter of black vs white is anything but black and white.  When stressed by emotions, it is our nature to dichotomize.  But while a coin has two sides, society and it’s challenges does not.

For all the criticisms of BLM staging a sit-in at the Toronto Pride Parade and demanding that police floats be banned in 2017, I would remind us all that the very birth of Pride was political and necessitated by injustice of a marginalized population. The message of BLM must be separated from its tactics; to combine the two is to lose the forrest but for a tree.  Speaking of losing perspective, it appears that BLM leaders are not favouring the historically-proven benefits of reconciliation.  Groups of people that have murdered each other now live in relative harmony after undergoing heartbreaking reconciliation processes, letting go of historical injustices in favour of connecting through shared humanness.  Their message, that black LGBTQ people continue to face discrimination, is valid and real and political and deserved attention through peaceful protest.  Their demand to exclude police members from a parade that at its core represents human value is, in my mind, clouded by the very hate they hope to dissipate.

Viral videos are telling.  They shed light in places once left dark, where officer testimony offered a deceptively bright moonshine on events where memory can hardly be considered reliable.  Yet, they are only telling part of a story.  I have worked in the field alongside police officers.  They have, on at least one occasion, saved my life while risking their own.  I thank police officers for their service; they have a tremendously shitty job more often than most people would care to know.  With that shitty job comes shitty, but often reasonable, tactics.  But it would seem police are still often too quick to pull the trigger.  Stressful circumstances demand resiliency and bravery, and at times constables suffer from human failings that lead to bad decisions.  Being caught in the fog of crisis is not an acceptable excuse.  This problem, it appears, is systemic.  It amounts to two things, training and culture, and both of those can be addressed.  Shaky videos demand answers – even if those answers are more nuanced and granular than those who don’t make shoot-to-kill decisions can process.  The symbol of justice is a scale that is meant to be level.  Both police and civilians should be treated with due process, and penalties brought against those who break the law.

Line of duty deaths are horrifying for those who serve in dangerous roles.  Our families and friends fret for our safety.  An underlying stress digs into our dispositions, modifying our personalities and narrowing our viewpoints.  No one should go to work in the service of others and be killed.  What happened in Dallas is unspeakable.  It is separate, so separate, from what happened in Louisiana and Minnesota (and on a Toronto streetcar).  Motivated by these events, probably.  But oh so separate.  We can be outraged about a white officer killing a black motorist in Minnesota, and we can also be outraged about a black man killing a white officer in Dallas.  We don’t need to choose because there is no choice unless we subscribe to a construct that is as outdated as it is insane.
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I choose to be outraged by human lives cut short. The test for outrage is simple when you apply equality to all human life, an application easier to write than to truly believe.  I struggle with this daily, and check my privilege at the door when trying to understand how it must feel to be a cop or a black person or a black cop in times like these.  But, if I try, and I do try, to understand, I think back to the morning of June 12 when I read about 49 gay people being gunned down.  I can’t list the myriad emotions that are rising to the surface even now as I write this post.  I can’t understand but I can try to understand.

These issues are not black and white.  They are more complex than a tweet or a sound byte or a blog post could capture.  By coming together as human beings, we can try to understand better, and when we can’t, to know that it’s ok not to know, not to be understood, but just to hold value, and be valued, for being.

Thanks for reading.  If you agree, or disagree, let’s have a discussion in the comment section.  I”m eager to hear more views about these difficult topics.

“If I waited till I felt like writing, I would never write anything at all” – Anne Tyler

A dear friend called me today lamenting about a particularly bad case of writers block. If my factitious epidemiological data is to be believed, 10/10 writers will experience writers block in their lifetime. While writers block is usually self-limiting, resolving in hours-to-days, severe cases can persist for weeks and require the intervention of a specialist.

Signs of Writers Block are sometimes hard to talk about and include:

-avoidance of writing tasks

-frustration when staring at blank pieces of paper or computer screens

-demoralisation and loss of sense of self-worth

-sudden desire to quit

-googling new careers

The Prescription:

Stage 1 Writers Block

• 

  Plan your writing day. Schedule it. Sleep well the night before. Eat breakfast.

• Have a reward in mind for after the task. Pizza? Yoga? You name it.
• Make a list of things you want to write.
• Change locations. A different room, a coffee shop, a library… find a spot where you can be alone without distractions.
• Walk away. You have to be in a mood to write. If now isn’t the time, go do something else and come back later.

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Stage 2 Writers Block

• Draw out a skeleton of what you need to write. See if a particular component speaks to you, and start writing about that. If none of the components seem interesting, try writing just one sentence for each one. Sometimes one sentence will turn into two, or three, or a book.
• Post-it notes with paragraph or section titles stuck on a wall allow you to move things around and use visualization to frame what you are trying to write.
• Write the end. The end is always the best part, and by writing it, you may feel inspired to tell the whole story. Of course, you’ll edit the end later… maybe.
• Write something else. Rather than write what you are trying to write, write about something you want to write about. Maybe a poem about cats, or a rant about your toaster. Be silly, be tangential, and write like a lunatic. Once you start to have fun writing, you may start to gravitate back to the work at hand.  The saying is “the worst thing you write is better than the best thing you did not write.”

Stage 3 Writers Block

• Stop writing; read.  Go read a book.  A book you want to read.  Reading will sometimes encourage creativity and you just might get inspired to run back to that writing task.
• Consult a friend. Gain perspective. Get inspired. Be told you need to forgive yourself for your writers block, which isn’t your fault at all.
• Ask for deadlines. Speak to your editor, supervisor, or mentor. Ask them for a due date. Commit to it.
• Go back in time. What originally inspired you to end up having to write? Remember those emotions. Allow them to carry you through the difficult task of putting pen to paper.

If none of these ideas work, it’s ok. Consult this:

Do you have tips and tricks to write well?  Share them in the comments!

(This relates directly to medicine; give me a minute to get there…)

I’ve come to learn a thing or two about how to make the flying experience a little less painful. The year before I quit my job to attend medical school, I spent 91 nights in a hotel, 11 nights on an airplane, visited 32 countries, and flew 304,542 miles. That’s nearly 1 in 3 nights away from home and just a few miles short of flying to the moon. I’m not bragging – trust me, flying that often isn’t all giggles.  But when airplanes, airports and hotels become your home away from home, you start to notice the little things.

Most people fly once or twice a year, and they often find their skyward travels infuriating. Can you imagine waiting in check-in queues every day? Sitting cramped in the back of a jet for 72 hours a week? Eating chicken (or was it beef…) that tastes oddly like paper mache? You would feel unloved.

But the airlines love people like me and they have us in their sights; see, my company spent over $100 000 to fly me almost-to-the-moon that year. That’s money they airlines want, and they want it badly. Badly enough to go the extra airmile and improve my flying experience so I choose Airline A over Airline B. And you know what? It works. Over the years I have developed my loyalty, sometimes based on rationale and other times based on irrational emotions.

These perks I get – from hotels, airlines and travel companies – make for exceptional travel experiences. Flying to Australia for a week makes sense when your trip over is in Lufthansa First Class and your ticket cost nothing more than points in some bank you’ve accumulated over time, and you bypass every line an airport can throw in your face.

One of the smartest tools the airlines and hotels use is to give me an honorary title. I’ll never forget the day
Air Canada declared me “Super Elite”, or the day Hilton upped my status from Gold to Platinum. With those titles come perks that start with customer service and end at every possible detail the discerning traveller could care about. These perks have one massive effect: they make me happy.

I’m often told I have great bedside manner. My patients seem to like me, and I think that means they listen to what I tell them about improving their health. By providing a great experience in what are universally shitty circumstances, I am able to build credibility and exert influence that, I hope, leads to behaviours that are conducive to good health.

This bedside manner isn’t innate; it’s learned. My experiences travelling in gifted luxury have rubbed off on me in a good way (and also bad ways, as my close friends remind me every time I get pretentious).

Here are my Top 6 Tips to make your patient feel SuperElite.

• Make people feel welcome by connecting with them. Know your patient’s name, and use it while making eye contact. Do this at least twice; once at the start of the interaction, and once at the end. I repeat: and once at the end. We are great at starting off strong, but often we end by dashing off in mid-sentence. Close the conversation in a genuine fashion.  Did you know that hotel maids are taught to say “Hi” to guests that they pass in the elevator or meet in the hallway and hotel check-in clerks are trained to discuss the city you’re from? These are ways of making you feel like you belong.
• Acknowledge screw-ups. The wait, the delay, the miscommunication, the odd paucity of pillows in hospitals, the terrible food. Acknowledge that we could, we should, do better. It’s not offering excuses, but it’s not hiding our limitations under the rug either.  Have you noticed how irritated people get when their plane is late but they don’t know why? A good airline will announce the reason for the delay and update passengers on when the flight might board.
• Patients are my guests. The hospital is my home, and I am a host. Patients are not a pain in the ass, they are not intruding, and they are not a bother. Use phrases like “I’m really glad you came to see us for this” to validate their presence. Use phrases that demonstrate that you are there to help them. Small word swaps can make huge differences. When a patient asks for a glass of water, “sure” or “yep” can be swapped for my favourite phrase, “My pleasure.” Make eye contact to add non-verbal language that you actually want to get them a glass of water, because you don’t want your guests to be thirsty. I’m not suggesting we do anything unreasonable or burdensome, but small tokens go a long way.  Hilton Hotels has noted my preference for a high floor (I love skylines).  Each time I check in, the clerk says something along the lines of “And Mr. Bigham, I’ve found a room right at the top floor.  You’ll have an incredible view.”
• Offer “perks.” It really doesn’t take much time, and it makes all the difference. A glass of water, a warm blanket, an adjustment in the recline of the bed… it’s a small signal to say “I want you to be comfortable here.” Many hotels will give frequent travellers suite upgrades, while airlines will upgrade SuperElite fliers to First Class or provide complimentary lounge access.  Lufthansa goes the extra mile: on my recent flight to Singapore, they picked me up at the lounge in a Mercedes and drove me down the tarmac directly to my A380! 
• Watch your non-verbal language. Nothing is worse than words that don’t match their delivery. This makes people feel abused and disrespected.  Many companies will have specially-trained staff take care of their elite guests; these staff are trained in the fine points of communication.
• Set expectations. Let people know why they are waiting and what is going to happen next. Evidence strongly shows that people who are dissatisfied simply wanted to know what was going on. “I’m going to do some bloodwork, and it should take about 2 hours to get the results. In the meantime, please don’t eat or drink anything in case you need surgery. If your bloodwork is normal, we’ll get you a sandwich.”   Part of this is to promise a little and deliver a lot. If you say 2 hours for blood work and it only takes 90 minutes, you’ll exceed expectations.

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Does this resonate?

Think about your last trip on a plane, or stay in a hotel. What made your experience particularly special? Can you be specific? Was it the tone of the gate agent, the upgrade to more leg room, the art in the foyer? It was probably a small detail… a “nice little touch” that made you feel particularly well-served. It only takes an inch to go the extra mile and make your patient feel SuperElite.

If I still haven’t convinced you, there is strong evidence that nice doctors don’t get sued as often as mean doctors, so re-read this post with that in mind. 🙂

A summary of tips to make your patient feel SuperElite:

Welcome people. Connect with them.

Apologize for screw-ups.

Patients are our guests. It’s “our pleasure” to care for them.

Offer “perks”.

Be aware of non-verbal communication.

Promise a little, deliver a lot. Set expectations.

“Hi Elaine, I’m Blair, one of the resident doctors working tonight. I love the author you’re reading! I’m so sorry for the wait. I heard about your chest pain from Julie, and I’m so glad you’ve come to get it checked out. I’d like to do some bloodwork, which will take about 2 hours to run. Can I grab you a warm blanket while you wait?”

//

How do you go the extra mile to make patient’s feel welcome?  Comment below!

Millennia ago, before cannons and flintlocks, sabre-toothed tigers stalked our ancestors. Like most creatures of prey, Darwinian evolution led us to adapt to threats like tigers. We learned to run from danger or, when running wasn’t an option, to defend ourselves to the end. This was not only a mindset innate to humans, but a complex biochemical response: when faced with danger, hormones flood the body, blood delivery to muscles is prioritized, senses are heightened. This response, the Flight or Fight response, is triggered in a small part of our brain termed the amygdala.

Fortunately, sabre-toothed tigers don’t roam modern-day streets. Our bodies, however, haven’t caught up to this reality; the amygdala is standing ready to superhumanize our bodies should our survival be in question. The amygdala works at lightening speed: it bypasses the frontal cortex, where options are considered and debated based on reason and fact, in favour of instinct. Located deep in the part of the brain we share with prehistoric reptiles, the amygdala causes us to react to stress. Sometimes, that stress can be maladaptive, harming us more than it helps. In that sense, our amygdala hijacks our brain, sending our heartrate through the roof and filling our stomach with butterflies.

If you work in a high-stress environment that demands high performance, the amygdala hijack can be deadly. SWAT team snipers, Navy SEALs, 911 operators and emergency workers all face high-stress situations yet must remain level-headed. The conundrum? We are trained to listen to the amygdala! Pattern recognition allows for fast reactions to new information. Secret service agents scan crowds for suspicious patterns just as emergency physicians can spot a heart attack patient from the other side of the room. This allows our mind to pick out problem patterns that are dangerous – to the president, to the patient, to us – and put us on an instinctive reactive pathway.

And this is where the system falls apart; once the hairs on the back of our necks go up and we have been alerted to a threat, we have to quickly overcome the amygdala and analyze the situation. See, the amygdala overcalls threats. A car backfires, and you startle. A plane has some turbulence, and you grip the armrests. We react a little too often to stimuli that the amygdala interprets as threats, but actually aren’t.

The trick, then, is to know how to control the physiologic response set off by the peptides coursing through your veins once the amygdala sounds the alarm. Rather than react immediately, we must suppress that crocodile-brain of ours and activate our frontal cortex, the part of the brain that makes us smarter than every other species on the planet. Except maybe dolphins, I hear they are pretty smart, and they’ve never voted to leave the EU… but I digress.

Whenever I feel my amygdala taking over, I repeat a calming mantra to myself:

Pause, Reflect, Respond.

The amygdala short-circuits the frontal cortex in favour of immediate, instinctive action. My job is to take that intuitive signal and check it against the facts. I pause. I regain control of my brain, quite deliberately, by switching off the hormonal response. A slow, deep breath in pushes the diaphragm downwards, activating the vagus nerve. The vagus nerve activates the parasympathetic nervous system, reversing the effects of the amygdala hijack. Holding the breath stimulates baroreceptors, sending calming signals to the brain. Nodes in the heart are stimulated to slow, epinephrine is moped up and cleared out, and the fog of fear clears from the mind, restoring the analytic abilities of the frontal cortex.

Alerted to danger and ready to think, the next step after pausing is to reflect. Are the facts that I am seeing congruent with the emotions triggered by the amygdala? Is the threat real? Can I obtain more data to confirm my intuition? Some of this will seem very familiar to work done on the psychology of clinical decision making championed by Nova Scotian Pat Crosskerry, and it is! You can check out some of his work if you are more curious on how health care workers think.
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Now that I have considered the information, I can respond to the situation. Note the word “respond” rather than “react”. A reaction is quick, instinctive; a response is slow, considered. That’s not entirely true… skilled and experienced health care workers can experience an amygdala alert, pause, reflect, and respond, in milliseconds – but only because they have trained their brain to do so.

Pause, Reflect, Respond is of course oversimplistic. Pausing, I find, is incredibly challenging when the stakes are high and a room full of people are looking to you for leadership and direction. Reflecting involves teasing out reality from my own perception of reality, where cognitive and social biases are deeply rooted. Responding requires confidence and ability, something I am still developing as a junior doctor, and negative self-talk, self-doubt and “impostor syndrome” frequently scare me away from a plan of action in favour of deferring to others, a feeling that I don’t (anymore) have when I work on the helicopter (and one of the key reasons I continue to do so). I am practiced at Pause-Reflect-Respond to nearly any situation I come across on the helicopter, but in the emergency department, it’s a different ball game.

Lastly, while clinical analysis is our core job, emotional intelligence is what really gets the job done. Being able to lead a team to achieve the goals required to treat a heart attack patient is as essential as knowing how to identify and treat a heart attack. Pause-Reflect-Respond applies to this realm of medicine also; understanding the state of your team, and being able to modify it to achieve higher performance, is the hallmark of an effective emergency physician.

The amygdala hijack causes smart people to do dumb things. By pausing, reflecting and responding to stressful situations, we get the best of both worlds; accessing our past experiences while analyzing new ones helps us utilize our entire mind to best lead teams to perform at their very best. High performance teams freed of the amygdala hijack –be it on the battlefield, in the cockpit, or in a resuscitation bay – save lives.

Are you good at controlling the Amygdala Hijack?

Do you have the tendency to:

-be deliberate and apt to survey a situation before responding?

-control your emotions?

-resist impulse under times of stress?

-describe yourself as emotionally neutral?

-not allow emotions to colour reality?

Have tricks to overcoming your fight-or-flight response? Comment below!