G’day, should you chuck a shrimp on the Barbie?

An OOPE in Sydney, Australia.

Dr Thomas Cromarty

I have just returned from an OOPE and wanted to share my experience of living and working in Australia. After embarking on the best training scheme of them all (Paediatrics) in 2012, I worked around South Wales from ST1-5. The Welsh Paediatric Training Programme Director is keen to produce well rounded paediatricians and encouraged me take the opportunity in Westmead Children’s Emergency Department, Sydney.​

I could tell you about all the trips we went on: Visiting my dad in Canberra, Campervanning around Tasmania, watching the tennis in Melbourne, taking selfies with the quokkas on Rottnest island (Perth), surfing in Margaret River, watching the Commonwealth Games in the Gold Coast, swimming with turtles on the Great Barrier Reef and night treks in the Daintree rainforest. But that will just make you jealous and me sad, so I’ll try and give you unbiased view of my reflections on a year working there instead.

“Big surf” in the Australian Life Saving Ironman @ Queenscliff Life Saving Club

Nat and I with the Rottnest star of the show aka “The Quokka”

​​It would make a mockery of a blog if I didn’t start by mentioning the Work:Life balance situation! My partner and I lived 500m the beach in a place called Queenscliff near Manly. Our end of the beach was quiet, had waves most of the time and was pretty much perfect. We lived on the top floor of an apartment block which included a roof top terrace aka skin cancer zone. As an “outdoorsy type” I was in heaven. There were running, cycling and triathlon clubs, surfing beaches, SUP, yoga studios, open water swimming and even Dragon Boat racing! You name it, it was expensive, but it was available.
 
Unfortunately, I worked 40km away in the west of the city which meant that I had my old friend, traffic, to contend with on a regular basis. I worked 4 x 10 hour shifts per week in the Paeds ED, with most shifts mirroring the peak attendance times of 14:00-00:00. Despite the commute, there was no chance of me moving to other side of the world and not living by the Ocean!

The Work: Positives

• Remuneration was fantastic, I received about double my UK salary, and although cost of living was more expensive, there was still plenty to go around.
  
• Westmead Kids is a single point of entry system, meaning that the ED and CAU are combined and all referrals from the whole region come through the same door and are triaged the same way.
• The ED is the Major Trauma Centre (MTC) for the whole of New South Wales and that was one of the main reasons I initially chose this placement. Paediatric major trauma is thankfully not a common event in many places in the world, however when it occurs it needs to be managed well. There were slick procedures in place, excellent staffing of the acute areas with capable nurses and consultants on the shop floor for most hours of the day. It was a perfect environment to learn in.
• Online systems for the whole hospital; ordering imaging, bloods, “consults” and other investigations was easy. Prescribing medications appeared to be safer as the process was all electronic (as long as the weight was checked correctly). Notes are easier to read and backgrounds easier to copy and paste. It does highlight the importance of touch-type skills in the future.
• Observations recorded online allowed easy recognition of abnormal and normal vital signs (“Between the Flags”). The objective numbers empowered nurses to call for help early, and if there was no improvement to the numbers, a “Rapid” assessment was required and the on-call team to review. This system picked up acutely unwell children and alerted them to senior staff quickly before they deteriorated further. Senior clinicians were able to alter alarm criteria if appropriate, for example regular salbutamol and sinus tachycardia.
• Procedure nurses on shift from 15:00 till 23:00 enabled doctors to continue to see and make plans for patients. Of course, this came with the caveat that it was only the difficult cannulas/bloods that doctors were then asked to perform, with fewer potential veins and less practice.
• An Emergency Medical Unit (EMU), allows extra time for patients that need more observation but don’t need to be admitted, using vital ward beds. Ideal for stretching wheezers, small babies with feeding issues or minor head injuries for neurobs etc.
• Paediatric trainees rotated through the department for 3 or 6 months at a time, with many completing multiple placements at Westmead or as part of the “relief rota”. This built trusting relationships between individuals and enabled much better inter-team working. These relationships are key to providing superb multidisciplinary healthcare.
• Specific work mobile phones (1 for the acute and 1 for the non-acute sides of the department) allowed messages and pictures (with consent) to be sent to fellows and consultants both day and night. Sharing of information was therefore easy, which reduced waiting times for families and enabled faster and more accurate communication between teams.
• Regular education sessions: “PET” / Acute Care Round / Simulation / Fast Sims
  
  • Ward rounds from 08:00 were followed by some form of teaching every weekday at 08:30 – 09:00 allowing the nights team to attend if they could manage.
    
  • Daily 14:00 – 15:00 teaching - afternoon starters could also attend some sessions.
    
  • Anaesthetic days where trainees could practise managing airways and intubations.
    
• There was a 2 strike rule for cannulas for everyone at every level, with Anaesthetics generally happy to come down to assist with their USS guided skills if required.
• Clowns – Dr Smarty Pants and Dr Quack. Loved them! They visited the ED relatively frequently, keeping patients, relatives and medical staff entertained.

 

Dr Smarty Pants, hard at work… at Westmead Children’s Hospital

The Work: Negatives

• Working during times of peak attendance means getting flogged most shifts. The late finish meant that I often didn’t get home or to bed until 02:00, which meant missing quality time with my partner/family/friends for the 4 days of the week I was working.
  
• Work pressures meant that the volume of patients often exceeded the infrastructure available, seeing patients in the corridor was a regular occurrence. It highlights the need for marked changes in the way we organise the structure of ED departments as if we keep doing what we are doing, we are going to keep getting the same result.
• One of the main ways in which we all learn is to be challenged and have to think, reflect and educate ourselves. As a tertiary centre there was always plenty of “pathology”, however with the close proximity of super specialists came an easy way out that is just not available in DGH environments. Ophthalmology, ENT, Plastics and even the Surgeons were happy to be involved. When time pressure was added in, lots of these skills were best delegated to the specialist departments, resulting in a loss of skills for the original practitioner.
• Unfortunately, children on the other side of the world suffer from the same diseases and issues as the UK. The inevitable emotional nature of human beings means that it can be difficult for patients and families as well as the healthcare workers when disasters happen. Team debriefs after such devastating events were strongly encouraged, and when facilitated by versed practitioners, were particularly effective in enabling positive and necessary reflections.
• Although the year out of programme allowed me a temporary reprieve from the  ARCP and curricular requirements, I still found it very useful to relate back to. I also found myself searching for feedback from consultants as a chance to develop my clinical and non-clinical skills even when they weren’t mandatory. I strongly believe that we need to create environments where all colleagues are encouraged and expected to give compassionate feedback to their co-workers.

I produced a PDP of goals to achieve throughout the year, these included upgrading my USS skills as well as confidence managing paediatric trauma and minor injuries. I found this particularly useful and would encourage everyone to take some time to establish some short, medium, and long term goals for life both in and outside of work.
 
I think it is essential for all medical staff to experience working in a number of different settings. This enables them to be exposed to a number of working environments and behaviours, choosing which to adopt into their personal style, facilitating their journey to becoming a more effective clinician and leader. My year working abroad will undoubtedly be different to yours and you need to decide if it is right for you (and your significant others!) What I would say though is if you don’t try it, you’ll never know… What’s the worst that could happen?!

The start of “Hells Bells” 24 hour adventure race in Noosa, Queensland

Helicopter trip over Sydney CBD

Fair Dinkum, I had a ripper of a year out and am looking to continue that growth of skills this year as a Clinical Leadership Fellow in Cardiff and Vale, engaging junior doctors in leadership and QI development. If you want to get involved with this project, have any questions about taking a year out or just want to see some more photos please don’t hesitate to contact me at Thomas.cromarty@wales.nhs.uk.

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Favourite phrases:
 
Patient’s parent: She’s been crook for days mate?
Doctor: Nah no worries mate, she’ll be right!