Australia. A Primer for US Emergency Physicians

It’s possible you know a little about Australia. You may even have met a few of its inhabitants. Odd bunch, sure, but what can you expect from the toddler of Gondwanaland? But an Australian contributor to EMN? Where will this madness end? We know, however, that Emergency Physicians are an insatiably curious bunch, so my role, slotting between your marvellous, regular writers, is to rummage around some of emergency medicine’s quirkier parts; construct a little international emergency medicine corner and throw in a few literary highlights while we’re at it. Exactly. A column about all the things you didn’t realise you wanted to know.

First off, Australia. What’s your opinion? You may be in the camp of chucking us and our rustic cuteness on the cheek, Bari Weiss style (1) (more on that NYT article in a minute), or, alternatively, you are convinced the country is a parched, snarling pit, heaving with vipers, surrounded by unpleasant oceans thick with marine velociraptors and creatures with ungodly tentacles – a lethal landmass fringed by a clawful of boozy, brawling cities. In other words, wondrously appealing to the Emergency Physician. Both, I’m afraid, are clichés, and we all know what they say about those. The multitude of serpents though, that is true.

One of the things Australia is exceptionally good at, is reinvention. We can rebrand anything quicker than unseating a Prime Minister.  Our country’s ophidian swarms lend us ample opportunity to prove it. Think you know how to treat snake bites? Blink. Wrong! That was last week. Nothing changes more rapidly than the evidence around managing snake envenomation. The long running ASP (Australian Snakebite Project) (2) is to thank for the nest of evidence we have. During the last few decades we have revamped our recommendations with unprecedented ferocity. Even our toxicologists have vertigo. We have twirled about and asked the same questions less than a year apart, coming up with dizzyingly opposite answers. We have:

• Given two units of antivenom, then up to ten, then down to one (no more than a single snake could hawk), and now we are edging up to two again, depending on the likely perpetrator
• Gone from believing that antivenom was the reason that nobody with access to health care dies from an Aussie snakebite anymore, to thinking it effectively binds all circulating venom, to realising it has no effect on VICC (venom induced consumptive coagulopathy), to working out it does not stop the progression of serious neurotoxicity, to wondering whether the hell it works at all (note – probably not)
• Loved the Venom Detection Kit, and then decided the best place for it is the bin – biochemical and geographical profiling proving far superior for identification
• Poured FFP fuel into the consumptive fire of VICC, struck down by the fear of watching someone completely defibrinate in front of us (surely! Products must be the answer), only to discover we were making the conflagration worse, and we now wait for the liver and other bits to regenerate the necessary coagulative ingredients (while tucking the patients up in cotton wool and asking them not to sneeze).

What has barely changed, unsurprisingly, is the basic first aid. Yes, we used to talk about tourniquets and the ceremonial taste and spit, but for the most part, a good pressure immobilisation bandage will probably save more lives than any fancy pharmaceutical. Doing the basics well. Sound familiar?

It is fascinating to gaze upon this Medusa head of evidence and subsequent recommendations, giving us sobering pause when considering how their evolution informs our critical care practice. Best practice is constantly changing; it is a kaleidoscope of clinical care (and true patient centred outcomes), evidence based medicine, and biologic leaps in understanding. We should not condemn these reversals, but welcome them as exciting new knowledge.

But enough emergency medicine philosophy! Australia. How to summarise it? Perhaps a nation of paradox. Where we strive forwards in some ways, we sit languishing in others. The NYT article, as lovely as it is, got something wrong. We have serious cultural issues. James Baldwin said it best, and his words could apply to Australia just as comfortably as to America. To paraphrase (3), our racial problems are perhaps a symptom of white lovelessness. We are a nation of immigrants and invaders, and we are often slow to extend our good fortune. The cute nation of barbecuers does not sit well with our current national identity crisis. We have a long way to go to reach federal decency and truth, a little like the perfect management of a snake bite.

And, if you ever wanted to be deeply moved by a literary snakebite, read Barbara Kingsolver’s The Poisonwood Bible. “Two dots an inch apart, as small and tidy as punctuation marks at the end of a sentence none of us could read. The sentence would have started somewhere just above her heart.” What a book.

1. https://www.nytimes.com/2019/01/08/opinion/australians-have-more-fun.html
2. https://www.mja.com.au/journal/2017/207/3/australian-snakebite-project-2005-2015-asp-20
3. https://www.theatlantic.com/entertainment/archive/2019/01/james-baldwin-idea-of-love-fire-next-time-if-beale-street-could-talk/579829/?utm_source=feed