Review Articles

Acute blood loss in children

Hypovolaemia is the leading cause of circulatory failure in children. Effective fluid resuscitation is a mainstay of patient management and is dependent on accurate detection of blood loss or volume depletion. Calculation of blood volume in children is based on age, weight and clinical physiology and the estimation of the volume of blood lost requires interpretation of the history and orthostatic vital signs, especially heart rates. Administration of fluids following these calculations will also be discussed.

Feature Articles

Is mandatory pre-procedure ultrasound viewing before termination of pregnancy ethical?

Sally is a pregnant nineteen year old woman at eight weeks gestation. Sally is currently serving time in gaol and has arrived at the hospital gynaecology clinic with several members of Justice Health.

Sally is informed that the hospital can offer surgical termination of pregnancy and she is advised about the possible complications and risks of the procedure. Upon hearing these, Sally becomes tearful. The doctor advises Sally that she should not terminate the pregnancy if she has any uncertainties. Sally explains that she is concerned about the risks of the procedure, but still wants to go ahead with the termination.

As part of her initial assessment, the doctor performs an ultrasound. The consultant points out the fetal poles and heartbeat stating, “Here is the baby’s heart beating.” Upon hearing this, Sally begins crying and becomes withdrawn, not responding to any questions. The doctor concludes that Sally should be given more time to contemplate whether she wants to terminate this pregnancy and does not book her in for the procedure.

The above clinical example raises a number of ethical issues in regards to abortion. Can the woman make an informed choice without coercion when she is shown the ultrasound in this manner? Is the autonomy of the patient compromised when she is forced to listen or view information that is not necessary to her medical care? Is it in the patient’s best interest to show her the ultrasound without first asking her preference? In this article I will focus on the medical ethical values of autonomy, informed consent and beneficence in regards to the use of pre-procedure ultrasound for abortion…


Secret Diary of an Arts Graduate

“So, what did you do before you did medicine?”
Me? Oh, I did a Bachelor of Arts.
“Do you mean Science/Arts?”
No, no, I mean Arts. Just plain Arts.
“A minor in psychology or biology perhaps?”
[Pause] “But how did you get here?”

Same as you, buddy. I read some chemistry books and wrote some essays and sat an interview and someone, somewhere, whom I’ll never meet, let me in to this crazy profession and it has been one of the greatest things I’ve ever done.


National standards in medical education

Since 1999, the number of Australian medical schools has doubled.

While this has brought about diversity, it has arguably also created a worrying lack of standardisation in the skills of graduates. National curricula are currently a hot topic, with the development of a standardised Australian curriculum for Kindergarten to Year 12 well underway. Is it time to rekindle a similar debate within Australia’s medical education sector?

Presently, the only force acting to maintain a degree of standardisation between Australian medical curricula is the Australian Medical Council (AMC) and its accreditation processes. The AMC accreditation standards guide, while laudable, does not direct the specific structure or content of curricula, leaving the door open for the veritable potpourri of programs that we now have across the country. For example, the guideline for curriculum content of the basic biomedical sciences, which occupies one line of the document, does not even mention the names of the various biomedical disciplines: “[t]he course provides a comprehensive coverage of … basic biomedical sciences, sufficient to underpin clinical studies.” [1] Either the AMC is not prepared to put more specific guidelines in the public domain, or little guidance exists to direct curriculum development. The open-ended regulatory framework has seemingly acted for more than a decade to feed a process of medical schools constantly reinventing the wheel with ‘revolutionary’ medical programs.

Of all the medical science disciplines, the teaching of anatomy has been the most criticised in recent times. Anatomy provides a case study in teaching disparities between universities. In a recent national survey, striking differences were demonstrated between medical schools in several areas, including the amount of hours dedicated to formalised anatomy teaching, the delivery of lessons, the use of cadavers, and the manner of assessment of anatomy knowledge. [2] For example, eleven of the nineteen medical schools surveyed have no specific requirement that student demonstrate sufficient anatomical knowledge at examination. Most medical schools pool anatomy questions with those of other disciplines, and calculate an overall passing grade. Thus, a student could be considered competent in basic clinical sciences without passing anatomy. These and other findings have prompted recent calls for a national curriculum for anatomy. [3] However, despite being extremely topical of late, anatomy is but one example of the heterogeneity in teaching across Australia. It would be difficult to make a strong case for having a standard curriculum for one subject and not others.

The suggestion…

Feature Articles

A very good iDEA: The inaugural gathering of the student division of Doctors for the Environment Australia

The result of one attendee’s bright iDEA.

In early December 2009, just prior to the much-hyped COP15 round of United Nations climate negotiations in Copenhagen, 40 medical students, representing six states and eleven medical schools, descended upon Melbourne for iDEA, the inaugural gathering for the student division of Doctors for the Environment (DEA). Attendees were encouraged to be mindful of their carbon footprints whilst travelling to the conference, with many students opting for train or coach rather than air travel. Most impressively, three Tasmanians cycled for three days from Hobart to Melbourne University (with the assistance of the Bass Strait ferry).

Education and networking were the focus of this three day gathering at Newman College within the University of Melbourne, where a plethora of distinguished speakers presented talks and interactive workshops to enlighten the receptive minds in attendance: academics, environmental activists, clinicians and all combinations of the three.

All present agreed that it was long overdue that medical students gathered to discuss environmental issues relevant to health; issues that for various reasons have been sidelined by the medical fraternity. These issues often traverse traditional subject boundaries, implying a perceived or real lack of academic expertise. Additionally, the lack of confidence in using one’s ‘authority’ as a medical professional plays a part. Climate change, for instance, is often seen as a political or economic concern rather than a threat to health. Being too busy, self-preservation, fear over allegations of hypocrisy, ignorance, inertia and ‘donor fatigue’ all contribute to the reluctance of doctors to speak up.

According to Costello et al., climate change “is the biggest global health threat of the 21st century” and the repercussions to health will be global in reach, but with a disproportionately large impact falling on the developing world. [1] Matthew Wright, co-founder of Beyond Zero Emissions, a Melbourne-based organisation promoting the rapid transition to a zero carbon future, raised the interesting point that planning for a zero-carbon future is different to planning for a low emissions future, which, in turn, is different to planning for a doubtful emission reduction trading scheme in which concessions are made to big polluters. Although it seems paradoxical, government inaction in the short term could thus be preferable to legislating a hurried, binding scheme, that is in fact ineffectual in preventing an unsafe average global warming of two or more degrees.

Richard Di Natale, a former GP and Public Health physician, provided insight into how one might make the transition from clinician to environmental activist and politician. His non-linear career trajectory has seen him transition through positions in primary care, HIV programme development, Government Health Department bureaucracy and community-building. Most recently, he is persuading Victorian voters to give him the job of a Greens Senator at the next Federal election…

Review Articles

Complementary and alternative medicine use among children with asthma in Australia


Aim: To explore current complementary and alternative medicine (CAM) use by children with asthma in Australia. Methods: The results of an audit of CAM use by one of the authors (AMD) in 212 parents of children with a history of asthma, recruited from three different settings (outpatient clinic at a tertiary paediatric hospital, metropolitan and rural practices) were compared to three published studies of CAM use in children with asthma in Australia, as identified by literature review. Results: The prevalence of CAM use amongst children with asthma in Australia is 45-61%. Common CAM modalities used include chiropractic methods, vitamins and minerals, homeopathy/naturopathy, spiritual/psychological modalities and diet therapy. CAM was used more commonly in female children and those with persistent asthma, poor control of symptoms or using high doses of medication. Importantly, only a small number of parents report their child’s CAM use to their doctors. Conclusion: Recent surveys of CAM use among children with asthma in Australia demonstrate a high prevalence which has important implications for those managing paediatric asthma.