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What Lies Beneath

What Lies Beneath

Australia, Wondrously Appealing to the Emergency Physician

Johnston, Michelle MBBS

doi: 10.1097/01.EEM.0000554851.10788.86
    Australia, snakes
    Australia, snakes:
    Australia, snakes

    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 marvelous, 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 realize 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, as Bari Weiss did in the New York Times article, “Australians Have More Fun.” (Jan. 9, 2019; Or alternatively, you are convinced the country is a parched, snarling pit heaving with vipers and 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) is to thank for the nest of evidence we have. (Med J Aust 2017;207 [3]:119; We have revamped our recommendations with unprecedented ferocity over the past few decades. 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 10, 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.
    • We have 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 realizing it has no effect on venom-induced consumptive coagulopathy (VICC) to working out it does not stop the progression of serious neurotoxicity to wondering whether it works at all (note: probably not).
    • We have loved the Snake Venom Detection Kit and then decided the best place for it is the bin. Biochemical and geographical profiling is proving far superior for identification.
    • We have poured FFP fuel into the consumptive fire of VICC and been 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 him not to sneeze).

    What has barely changed, unsurprisingly, is basic first aid. Yes, we used to talk about tourniquets and the ceremonial taste-and-spit, but for the most part, a good pressure immobilization 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, which give 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-centered 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 summarize it? Perhaps a nation of paradox. Where we strive forward in some ways, we languish in others. The New York Times article, as lovely as it was, got something wrong: We have serious cultural issues. James Baldwin said it best, and his words could apply to Australia just as comfortably as they do to America. To paraphrase, our racial problems are perhaps a symptom of white lovelessness. (The Atlantic Jan. 9, 2019; 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.

    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.

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    Dr. Johnstonis a board-certified emergency physician, thus the same as you but with a weird accent. She works in a trauma center situated down the unfashionable end of Perth, Western Australia. She is the author of the novel Dustfall, available on her website, She also contributes regularly to the blog, Life in the Fast Lane, Follow her on Twitter@Eleytherius.

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