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Written by Liz Baugh, from PRAXES Medical Group’s partner Red Square Medical 

Click here to read the article on LinkedIn

I recently asked the question to my Linked In connections; What would you like to read about with reference to First Aid and medical care at sea. One of the comments suggested some scene management with casualty bracing/positioning in adverse weather. So, rather than just write a generic article about that, I asked the person that made the suggestion to give me a scenario to work with and here it is:

“Offshore installation man overboard (25m fall, some contact with structure). Emergency Response Rescue Vessel (standby vessel) in close standby launches Fast Rescue Craft. FRC alongside casualty and recovered in 9 minutes and FRC recovered onboard in 14. Casualty suffering from cold and deep laceration to forearm. Sea state 3m, force 4 wind, 12 degrees sea temp, 10 degrees air temp. Casualty to be transferred from FRC to boat deck. Possibility to use hospital. All standards ERRV equipment available. FRC crew have only applied direct pressure to wound. As ship is maneuvering out of the platform exclusion zone there is a lot of rolling. Open steel deck.”

On further investigation we have some additional information about what the crew member was wearing and an update on his condition. Lets summarize the main points that will affect the medical response:

• We have a casualty with a deep laceration to his forearm that is currently having direct pressure applied to it by one of the rescue crew.
• He spent 9 minutes in the water which was 12 degrees Celsius and he was wearing a boiler suit. Air temperature was 10 degrees with a force 4 wind (13-18mph)
• He had a lifejacket on and it was deployed, but because of his injured arm he couldn’t get the spray hood in position.
• The casualty needs transferring from the FRC to the boat deck of the ERRV which is an open steel deck but there is a possibility the casualty can be transferred to the hospital.
• The casualty appears to be deteriorating as he is now drifting in and out of consciousness.

Ouch! I hear you say, a tricky situation to be in and becoming more critical by the minute. Where do our priorities lie? How can we do all this in rough weather as safely as possible?

Lets put our list above into priority order:

• The casualty needs transferring from the FRC to the boat deck of the ERRV which is an open steel deck but there is a possibility the casualty can be transferred to the hospital.
• The casualty has a deep laceration to his forearm that is currently having direct pressure applied to it by one of the rescue crew. However, the casualty is deteriorating and is drifting in and out of consciousness.
• He spent 9 minutes in the water which was 12 degrees Celsius and he was wearing a boiler suit. Air temperature was 10 degrees with a force 4 wind (13-18mph)
• He had a lifejacket on and it was deployed, but because of his injured arm he couldn’t get the spray hood in position.

OK, so to break down each part of the dilemma.

The casualty needs transferring from the FRC to the boat deck of the ERRV which is an open steel deck but there is a possibility the casualty can be transferred to the hospital.

Many ERRV’s have a basket style stretcher available which is a useful way of transferring a casualty from the FRC via the boat deck of the ERRV and then onwards to the hospital. They have a strap system that will allow you to keep the casualty safe during a transfer when the adverse weather makes it hard. This will require a team effort and all team members should be familiar with the use of the stretchers on board.

The casualty has a deep laceration to his forearm that is currently having direct pressure applied to it by one of the rescue crew. However, the casualty is deteriorating and is drifting in and out of consciousness.

How long should you apply direct pressure the wound? What will affect the bloods ability to clot? So, we normally expect 10 minutes of direct pressure to control most bleeds of this nature but the casualty has been in the water and it was pretty cold! Hypothermia can affect the bloods ability to form a clot so the pressure may need to be held for an extended period of time with thought being given to clotting agents if they are available.

Based on the fact that the casualty is deteriorating, and their conscious level is dropping then we must go back to the beginning of our primary survey and start again. Do you remember what DRS ABC stand for? If you don’t then you need some refresher training ASAP!!

Danger – they have been removed to a place of safety but the ERRV is rolling heavily. Lets make sure that they are well secured in the stretcher and that we have plenty of people to help us manage the manual handling element of the rescue and get them into the hospital.

Response – they are drifting in and out of consciousness. What is our concern with this? If you answered protecting the airway, then you are on the right path. With decreasing levels of consciousness, the risk of the airway becoming blocked becomes much higher. So, what should we do about this? We could use the recovery position, but we have equipment available to maintain the airway such as suction for fluids and oropharyngeal airways to keep the tongue clear of the airway.

Shout for help – well, you are the help so good luck with that!

Airway – As mentioned above this is at risk, so basic measures must be taken to maintain the airway as tolerated by the casualty. We could also consider the possibility of Cervical Spine injury at this point, this is based on the mechanism of injury – a whole other articles worth of info needed for that one!

Breathing – well we know that they are breathing but how effectively are they breathing? A basic look, listen and feel along with pulse oximetry will give us a better idea of the casualties breathing efforts. So, lets say that they have a breathing rate of 15, both sides of the chest are rising and falling evenly but the Pulse oximeter is reading 92%. What next? Do we put them on Oxygen? If so, how much? There are various systems available for delivering oxygen to a casualty. We always try and titrate to need so would start off low using a venturi 24% mask set at 2 litres per minute and up it if necessary until we can achieve oxygen saturation levels above 95%. However, there is an important factor in the information that we have been given. Any idea what it might be? Yes! He was in the water and couldn’t deploy his splash hood. That increases his risk factor for secondary drowning. That will need close monitoring to ensure that his breathing does not deteriorate.

Circulation – So, this person has a deep laceration. Direct pressure is being applied but is that the only source of his bleeding? We know that there was some impact with the vessel when he fell overboard. What assessments should we be doing to work out how hard his heart is having to work? The best place to start is with a pulse. This can be taken at the neck or wrist and should be felt for 30 seconds. Times the result by 2 to get the beats per minute. So, our chap has a pulse of 96. A little high. We should also have assessed the strength and regularity and made a note of any abnormalities. We can do a capillary refill check on all 4 extremities. This will tell us if there is any compromise in the supply of blood to the furthest points in the body. If you are able then you can also do a blood pressure but this is not essential so please don’t worry if you don’t know how to do it.

The casualty is losing blood through his deep laceration but as he was a man overboard, he may well have injured other parts of his body and could even be bleeding internally. The organs of the abdomen, the pelvis and the femurs (thigh bones) are all places that blood can be lost in significant quantities so ensure that you check those thoroughly.

Next…..

I am going to throw in a couple of extra letters for your DRSABC algorithm. Just to keep you on your toes. DE. Arghhhhh….but that is just following the alphabet I hear you say! Well yes, us medics are a simple bunch really and need things to be easy to remember in an emergency. ABCDE is learnt as a child so what better way to remember how to assess our casualty?? So….

Disability – our casualty is drifting in and out of consciousness. He could possibly have a head injury so we ought to check that out. Remember how to check the pupils and what they are supposed to do? Right, well lets do that. His pupils are equal and reacting to light. Is that a good sign? Yes, it is…..for now. We need to check that regularly along with the ABC to make sure we don’t miss a significant change.

He spent 9 minutes in the water which was 12 degrees Celsius and he was wearing a boiler suit. Air temperature was 10 degrees with a force 4 wind (13-18mph)

He had a lifejacket on and it was deployed, but because of his injured arm he couldn’t get the spray hood in position.

This leads us onto the final letter in our now extended primary survey. E.

Exposure – The body is designed to operate at between 36 – 37 degrees Celsius. Check out the temperature of the water, air and the wind speed. Combine that with what he was wearing and we are looking at many potential problems. But guess what? Cold shock would’ve got to him way before hypothermia sets in. Familiar with the effects of cold shock? I hope so because that is a whole other article!!

So, let’s take a temperature. Want an accurate one? Go rectal. Not concerned about hypothermia then oral or aural will suffice.

What about these wet clothes? He will continue to lose heat if left in them so lets cut them off and wrap layers of blankets around him. Whilst doing that check his whole body from top to toe for any further deformities, obvious injuries, tender areas or swelling and skin rashes.

Phew! Now what? You are not going to like me for this but…..

Start all over again and recheck your DRABCDE’s. Write notes, communicate significant information, recheck all vital signs and most importantly? Keep talking to the casualty. Be reassuring and calm (even if you don’t feel it), don’t discuss your fears in front of them, save that for out of earshot and mostly take comfort in knowing that you are doing your best in a pretty tough environment.

Published Jun 20, 2019 – Written by Dr. John Ross, PRAXES Medical Director

Full article can be viewed on the Chronicle Herald website. 

Last week, I walked by the former Common Roots Urban Farm site, beside the Halifax Infirmary, that is usually in full bloom by now. It is just brown/grey and empty. The garden was moved to the concrete and asphalt jungle at the intersection of a multi-lane highway, Bayers Road and a mall. It was moved from its Commons location to make room for the QEII Health Sciences Centre redevelopment. The highly visible care-for-your-health, locally grown, fresh, no-long-distance-transport-required produce from the garden will be replaced by the voracious demands of the reactive disease care system. Hospitals do not provide “health care.” They are there for disease and injury.

I worked as an emergency physician at the VG and HI for almost 30 years, unquestioningly responding to the emergent needs of sick and injured patients. Near the end of my clinical career, I realized that the social determinants of health — factors mostly related to society values and political policies — are causing a lot of what ends up in the disease care system. While we like to blame people’s personal choices, that is a small fraction of the problem. Working more or longer shifts and hiring more staff is not the solution. Demand will continue to grow and supply, well, we read and hear about that every day — more doctors and nurses will not miraculously appear.

The new Canada Food Guide and exploding research… are challenging the status quo. But the status quo of making money from sick people and marketing low-quality food does not like to be challenged.

How does the local, organic, plant-based healthy produce of Common Roots compete with the trillion-dollar medical, industrial and agricultural industrial complexes? While a few lucky people have garden plots at Common Roots, and a few more get their produce from local farmers, the vast majority get food that is overpackaged, processed and trucked in. “Food as entertainment” — taste, smoothness, sweetness, smell, brain dopamine release — is more important than actual nutritional value. They tend to be low nutrient, full of chemicals and create a lot of garbage — but taste oh-so-good. And it is affordable, for most. For some fellow Nova Scotians, however, the social determinants are highlighted by the Halifax Food Policy Alliance (www.halifaxfoodpolicy.ca): 73.5 per cent of Nova Scotia households on income assistance experience food insecurity; the average distance food travels to HRM is 4,000 km; 17,000 people, one-third of them children, were supported by food banks in Nova Scotia.

The new Canada Food Guide and exploding research on the critical importance of our gut bacteria, nutrition and health are challenging the status quo. But the status quo of making money from sick people and marketing low-quality food does not like to be challenged. The sad irony is that we are all complicit in a complex system that is making us sick. We want the lowest price, convenience, taste, and to be told it is healthy by fake marketing and packaging. Examples — labels such as “all natural,” “organic,” “fortified with essential vitamins” and multi-billion-dollar gluten-free fad diets are examples. Many of those products take original whole foods, process and reconstitute them, losing most or all of the natural nutrients, then reassemble all the parts into “Frankenstein food,” so it can sit in a bottle, box or freezer pack for months, or years. Did our bodies evolve over millions of years, constantly moving, gathering mostly plants and occasional meat, to all of a sudden, in the last 50-plus years, be eating frozen pizza? Why are we sick? Really?

I have mostly withdrawn from the rampage of the local disease care “crisis.” It is not solvable until we start reducing the supply of sick people.

“But the label says it’s good, and it’s cheap, so I will buy it.”

I have mostly withdrawn from the rampage of the local disease care “crisis.” It is not solvable until we start reducing the supply of sick people. While that depends in part on personal choices, the majority depends on public policy, strong visionary leadership, support for local agriculture, addressing food insecurity and confronting the fact that our loosely regulated free market economy directly competing with a fair, more equitable and broadly productive society cannot co-exist.

Fellow humans are labelled as consumers. We sadly call ourselves consumers. If we do not ask a lot of questions, demand profound policy change and push back corporate control of everything we do, including what we put in our bodies, then we are what I saw at Dartmouth Crossing the other day — consumer zombies.

An urban farm, with many small plots, provides outside physical activity, social engagement, purpose, carbon capture and low-cost healthy foods. That is HEALTH CARE. What happens inside hospitals is not.

Written by Dr. John Ross, PRAXES Medical Director

Original article found here 

Most people, including those of us who are health-care providers, think of health care as made up of doctors, nurses, hospitals, CT scans and pills – all the people and things that try to make us well when we get sick.

But there is a difference between what we now call health care and what health care could be. Most of us don’t seek out the things and people that try to make us well until after a health problem such as a disease or injury occurs and we want our health back. This is actually “disease care” – reacting to a problem – not health care.

Health care should imply caring for one’s health – staying healthy. After all, repairing broken things rarely results in something as good as the original. Car owners do not wait for the engine to seize up and catch fire to tell them it is time for an oil change – they change the oil proactively based on how far they drive.

So, where does self-care fit in?

We believe our public health-care system will be there for us no matter what health difficulties we may face. But here in Nova Scotia, we still find ourselves struggling with getting timely access to primary care providers and we experience long waits for diagnostic imaging, specialists and elective surgery. There are more inconsistencies: we enjoy living in Nova Scotia, yet our province has one of the highest rates of people using anti-anxiety and anti-depressant medications. When Nova Scotians are asked to report on their own health they say it is “good” or “very good,” but general population health studies always report our low ranking in heart, lung and joint diseases.

It seems to me that Nova Scotians have a problem. We seem unaware of the need for self-care.

Let’s look at the data:

The 2013 Canadian Tobacco, Alcohol and Drugs Survey reported:

• 19.4 per cent of Nova Scotians smoke tobacco
• Less than 50 per cent of Nova Scotians get regular physical activity
• 37.5 per cent of people in the province are overweight (compared to 33.6 per cent in Canada) and 25.1 per cent are obese (that is, with a body mass index greater than 29) – almost seven per cent higher than the Canadian population as a whole

We can directly influence all of these behaviours and habits that affect our health. We can prevent, or at least modify, the negative effects. But there are other big society-wide challenges that can interfere with caring for one’s own health, and these challenges cannot be ignored.

The social determinants of health (SDOH) dwarf the too-little-too-late effects of showing up at a hospital when sick. Income and income distribution, education, unemployment and job security, working conditions, early childhood development, food security, housing, social isolation, health services (we spend over 40 per cent of our taxes on health services), aboriginal status, gender, race and disability all influence our personal health outcomes.

For people living in poverty, self-care for a healthy future may be impossible to achieve. For example, for a person who works from 6 a.m. until midnight every day and has to raise a family on a poorly paying job, finding time for self-care is nearly impossible. This is an all too common situation in Nova Scotia.

In the 2015 Report Card on Child and Family Poverty in Nova Scotia, the provincial rate for children living below the poverty line was 22 per cent. The rates increased for Cape Breton: 32 per cent of all children in Cape Breton are living in poverty, with 42.7 per cent of children aged newborn to six years old living below the poverty line. Simply put, one in five children in Nova Scotia and one in three children in Cape Breton lives in poverty.

Children who spend their early years in poverty are at a disadvantage from the start, and their personal health may never recover. Our increasingly expensive “disease-treatment system” is forced to deal with our failure to understand the long term impacts of the SDOH. Nova Scotia could be the first province to redefine ‘health care’ far more broadly than doctors, hospitals, and pills by accepting that a truly healthy, economically-productive population is only possible by directing some health-care dollars to education, housing, affordable good food, employment and other social determinants.

Why not start with dramatically reducing child poverty rates in Nova Scotia and focus on giving all kids a good start in life? This would give them the chance to build healthy habits from an early age.

What if more people were encouraged and enabled to be more active – at school, at work, at home? We know that physical activity results in less obesity, lower rates of diabetes, fewer heart and blood vessel diseases, and is also a natural anti-depressant.

What if we redirected more of our tax dollars to programs and services that support communities as a whole? One such program is Nova Scotia’s Community Health Centres, where communities identify their own needs, gather their own resources, work together to practise disease prevention and health care, and innovate locally.

To move our province from “disease care” toward true health-care and self-care, we need to see significant reform. It’s time to make progressive changes to public policy that support individuals in taking responsibility for their own health, encourage us to demand more of each other and demand more of system managers.

Self-care is the future of health care, but it takes more than just going to the gym three times a week and avoiding fast food. Fixing the social determinants of health is complicated, but it can be done. Everyone deserves a fair chance at good health. Everyone deserves a fair opportunity to care for their own health.

Over to you: What are some of your ideas for how Nova Scotians can practice better self-care? Leave your thoughts in the comments section below.

Dr. John Ross is an emergency physician, professor at Dalhousie University, and medical director of a telemedicine provider. He continues to advocate for profound personal behaviour and public policy changes despite the stifling powers of the status quo.

Dr. John Ross, PRAXES Medical Director, and Liz Baugh, Red Square Medical, have recently created some race fit tip videos. They include helpful information that you should know and be aware of before going on a marine race, like the Clipper Round the World Yacht Race. You can also find these videos published on PRAXES social media channels.

Race Fit Tip #5 – Sleep

What do new parents and the Clipper Round the World Yacht Race crew have in common?

Less sleep. Lack of sleep. Interrupted sleep. As. Dr. Ross and trainer, Liz Baugh share in Race Fit Tip #5: this is not a cruise 🙂

Race Fit Tip #4 – Your Diet

We encourage race crew to be mindful about how we fuel our bodies as we prepare them for the adventure ahead. In short: less sugar, unhealthy carbs and alcohol; more veggies, fruit and lean protein. You know the drill, now is the time.

Race Fit Tip #3 – Medications

This video contains one of our top tips for any remote-based client regarding medications and your supply in advance of your voyage.

Race Fit Tip #2 – Upper body strength

A sailing enthusiast himself, here’s Medical Director, Dr. John Ross from his own sailboat, where he’s constantly reminded of the importance of upper body strength!

Race Fit Tip #1 – Physical fitness & stamina

Dr. John Ross is sharing our first tip from Halifax, Nova Scotia – and that is to start working on and improving your overall physical fitness and stamina.

If you are not an overly physical or active person right now, start by aiming to be out of breath several times throughout the day. Don’t just walk upstairs, run. Try taking a brisk walk for 15-20 minutes. If you can start with small daily steps, you will be amazed at how much of a difference you will see after just a few weeks.

If you are already quite physical and active, consider mixing up your routine and adding a little extra each day. If you tend to lift weights, start cross training and adding in aerobic activity – things like swimming, rowing, running, cycling. Something that will build your overall endurance.

Strength and muscle tone will develop naturally over the course of the race but if you arrive with a decent level of stamina then you will find working the deck a lot less tiring and help to prevent injury.

Are you interested in PRAXES telemedicine service for your vessel or location?

Reach out to us and get a free quote for the services you require.

As an installation nurse, Jonathan Christopher, has the integral role of primary health care provider for an onboard crew working in remote locations offshore. Originally from St. John’s, Newfoundland, Christopher completed a medical assistant course in HMCS Quadra, BC, and became a staff cadet at only 17 years-old teaching First Aid courses in Cornwallis, Nova Scotia. He completed his Paramedic Level I certificate in 1999, Paramedic Level II in 2000 and went on to work on a road ambulance for over four years. In 2008, Christopher completed his nursing degree at Memorial University and began working as an emergency room nurse at St. Clare’s Mercy Hospital. After developing an interest in occupational health and the offshore life, he applied for a position with PRAXES and was hired as an installation nurse in 2015 onboard the Stena IceMAX. Christopher spoke with us about his career path and what it takes to work offshore.

Can you describe what your position entails as an installation nurse?

Onboard the Stena IceMAX, I am the primary health care provider for the crew of the platform in the event of an illness or injury and I maintain all medical emergency equipment onboard including stretchers, First Aid boxes, eye wash stations, AEDS, a register of dangerous drugs and emergency hospitals. I also maintain medical stocks, records and a confidential medical log. Identifying occupational health problems to be referred to the occupational health doctor is also a part of the position and I provide health surveillance of all personnel exposed to hazardous substances during their period of work onboard the offshore installation. Additionally, I conduct training exercises with members of the medical emergency teams.

Another important element is to provide clinical care for personnel and refer cases to company doctors when necessary. I monitor the general health of the crew including respiratory and skin screening that must be reported as an occupational health matter. I will also assist administration in the movement of personnel arriving and departing the installation, assist with helicopter briefings and baggage weights. There are so many exciting elements to my position including promoting general well-being through health promotion activities with provisions of handouts and activities onboard.

What types of medical incidents occur onboard?

Nowadays, there has been a change in the pattern of medical emergencies that occur on offshore installations. In recent years, we have reverted from a pattern of “more injuries than illnesses” to a culture based on increased safety management. As medics working remotely, we must be able to cope with a range of medical emergencies in addition to minor ailments. The majority of injuries that can happen range from minor muscular/ soft tissue injuries sprains/strains and fractures, to severe injuries, falls, and major lacerations and amputations. Gastrointestinal problems, skin issues, respiratory and dental issues make up approximately 65 percent of visits seen in the rig clinic.

Routine or emergency cardiovascular/respiratory cases make up a very little percentage of visits in the offshore industry. Although, these types of medical emergencies are low we must be able to recognize these life threatening presentations immediately, provide prompt treatment based on complaint and undertake specific procedures and administer specific drugs quickly and provide proper care autonomously or under remote supervision.

What characteristics are required to be effective in your job?

I feel that we are often the “front liners” and need to be compassionate and respectful. Honest and straight-forward communication is the best tool to gain respect. It’s also important to diversify and keep abreast of the latest technological advances in both offshore and medical areas. The best advice I can give to anyone looking to pursue this medical field is to be a clear communicator and to listen to the needs of the patient and their concerns. Offshore life is not for everyone but there is no denying that it can be a truly rewarding career.

What do you bring with you for a stretch of time offshore?

Beside my necessities, I bring pictures! My family are my life and I have pictures of them everywhere in my cabin and workspace. My wife, Danielle, made me a picture book that tells the story the story of our milestones together including the birth of our daughter, Ava-Grace, followed by my son, Jon-Thomas. It is my most prized possession and I do not leave for work offshore without it.

Was there a defining moment that inspired you to pursue this career?

My sister really inspired me and helped launch my career path by encouraging me to take my medical assistant course which led me to secure a staff cadet position teaching First Aid when I was only 17 years old. At that time, I had one young student who wasn’t grasping some of the concepts and was in danger of getting sent home. I advised him to come back early from lunch so we could have a teaching session. We did and in the end he successfully completed his course. A year later, a more mature male approached me and let me know that he was the kid I had taken aside. He was so thankful for the life saving skills I had taught him and told me that his uncle had suffered a sudden cardiac arrest several months after summer camp. He performed CPR and was able to keep him alive until the paramedics arrived and revived him. Essentially, he had kept his uncle’s blood circulating and saved his life. To this day, I remember looking at that freckled faced kid and deciding that I knew what I wanted to do with my life – help people.

PRAXES Installation Nurse, Jonathan Christopher, knows first-hand what it’s like to work for long stretches of time away from home and the importance of prioritizing physical and mental health. He gave us three tips for offshore workers striving for wellness in their lives.

Live a life of balance

“Take time to prioritize the things that you enjoy and make time for both work and play. Pick acceptable work hours, prioritize making time to talk to family and friends back home but most importantly – take time for yourself. Make room in your life for hobbies, past-times and interests. The difficulty with working offshore is that these elements are usually absent and maintaining a normal state of mind is critical.” – Jonathan Christopher

Keep active

“Exercise regularly and set clear goals for yourself. This really helps to manage energy levels and release stress. Keeping active helps build stamina and allows you to maximize your health, energy and performance while away in a harsh working environment.” – JC

Maintain a calm perspective

“Offshore plans can change in the blink of an eye and you need to expect the unexpected and be ready, flexible and self-aware. You must be able to react to stressful situations in a calm manner and make quick decisions. Keeping your cool is vital.” – JC

On April 17, 2016, Martin Frey became the first person in the world to climb the Seven Summits and sail the Seven Seas. He began his challenges in the mid 2000s and proceeded to scale the summits one by one. Once the trekking was completed, he turned his attention to the ocean and proceeded to sail halfway around the world with his wife, Kym, and daughter, Lily. In January 2015, Frey joined the EUROPA and Aventura III expeditions to cross the Southern and Arctic Oceans. Next up, he participated in the Clipper 2015 – 2016 Round the World Yacht Race aboard the Visit Seattle yacht to sail across the North Pacific to complete his remarkable achievement of sailing all the Seven Seas. As a vastly experienced mountain trekker and sailor, he firmly believes in the need for telemedicine in remote situations.

Yachtsman, Martin Frey, sailing aboard the Visit Seattle yacht

Over the course of his 11 year journey, he faced many perils and challenges and realized the immense value of telemedicine especially in remote locations. Frey answered a few questions for us on his recent experience using PRAXES’ service during the Clipper Race and why he thinks it’s a must-have for remote adventurers.

The Clipper Race has been full of dramatic and unpredictable moments. Can you describe what happened when you needed assistance from PRAXES?

We were thousands of miles from land and I started to get red welts and spots all over the back of my hands and we couldn’t figure out why and where they were coming from. Having PRAXES there to call was fabulous. Our skipper, Huw Fernie, was the one to call and I think he was nervous that I was going to have a disease that might take me down. The doctor on the line helped work us through exactly what it was and diagnosed it as trench foot – something that the WWI soldiers had in the trenches in France. We sent a picture through and the fact that she was able to look at it was a big help. We were on the phone for about 30 minutes and she asked subtle questions like – ‘Is it more red around the edges?’. She asked specific questions, things that we wouldn’t have thought to check, and this really made a big difference in finding out what the root cause was. I have sailed through the South Pacific and visited some clinics on tiny islands with very questionable medical practices so knowing that we had a world-class team of physicians to support us through PRAXES was very reassuring.

In your opinion, was PRAXES’ service effective?

Absolutely, I think whenever you have a team race like this or these kinds of situations where you are out in the middle of nowhere, remote medical support is definitely the way to go. I would recommend PRAXES to anyone and I think it was a big help during the race.

What was the outcome of this situation and do you feel it would have been different without PRAXES’ support?

She recommended drying out and staying warm, which we had a good laugh about because those are two things that don’t happen in the Pacific! It’s healed now and I’m doing fine. However, I think we would’ve been quite nervous if it wasn’t properly diagnosed because these red blotches were continuing to spread and it turned out to be because of the wet gloves I was wearing and the conditions we were dealing with.

From your perspective, what are the advantages of having 24 – 7 remote medical support on-call for the duration of the Clipper Race?

Simply having expert advice on-call and to advise on whatever medical situation the crew might be dealing with at any time is a big advantage. Another crew member on our yacht burned herself and we also had more serious incidents to deal with. Just knowing that they were there to support us gave us as race participants a huge sense of confidence going forth on such a dangerous adventure. During my Everest expedition, we had a doctor at base camp on our team and on other expeditions we’ve used a remote medical service and it’s incredibly reassuring. I’m a big believer in it.

PRAXES Medical Director, Dr. John Ross, recalls a case of remote telemedicine in which a serious medical incident took place at sea and how the team at PRAXES was able to provide world-class telemedicine support.

At approximately 2 pm, a crewman on a factory fishing ship, located 250 nautical miles offshore on the Grand Banks of Canada’s East Coast, developed chest pain while he was working in the fish processing area. Several minutes later he collapsed and co-workers found him unresponsive with a very slow pulse and laboured breathing. The captain, who had the most advanced medical training on board – advanced first aid, was summoned. At this point, the crewman was responsive but confused, sweaty and complaining of severe crushing chest pain. The captain obtained a heart rate of 40 beats per minute but was unable to get a blood pressure reading. He asked the bridge and ask for someone to contact the Coast Guard and request medical assistance. The bridge crew instead called a medical clinic and spoke with a doctor who recommended giving several sprays of nitroglycerine for the chest pain. Unfortunately, the contact was then lost. The captain arrived back on the bridge, followed proper protocol and contacted St. John Coast Guard Radio, part of Canada’s Joint Rescue Coordination Center (JRCC). They were quickly put in contact with the on-call PRAXES Emergency Specialists physician.

The captain briefed the physician on the the condition of his crewman and said he believed his patient was having a heart attack. The captain had experienced a heart attack himself, and believed the crewman may have been experiencing similar pain. He told the Praxes physician that a clinic doctor had recommended giving nitroglycerine. However, the on-line doctor was concerned about the slow heart rate and very low blood pressure. Nitroglycerine in that setting could kill the patient. The PRAXES physician explained that it may or may not help with pain symptoms but that it is not an important part of managing a heart attack.

The PRAXES physician and captain decided to administer ASA, a simple but critical treatment in breaking clots in coronary arteries (it is used by all critical care units in the world) that cause heart attacks as well as treatment for the man’s nausea and pain. The captain was next asked to repeat the vital signs regularly. At the same time, the PRAXES physician decided that an emergency medevac was warranted to get the man off the ship and to definitive care as soon as possible. The JRCC began working through the logistics of the medevac. The Canadian Navy’s Search and Rescue (SAR) team was contacted and the captain started heading for shore as the vessel was outside the range for a rescue helicopter.

Further calls between the captain and the PRAXES physician carefully followed the man’s progress. He was moved from the factory floor to the ship’s medical room and the medications began to have some effect. While the chest pain was still present it was now less severe. Fortunately, his vital signs had improved and the vomiting had stopped. During the wait for the helicopter, the PRAXES doctor calmly reassured the captain that he was doing everything possible within the constraints of that austere, remote setting.

Three hours after the initial call, a Search and Rescue (SAR) helicopter arrived, and a SAR Technician was lowered to the deck from the hovering aircraft. The patient was reassessed, loaded onto the stretcher and hoisted onto the aircraft. Two hours later, at the tertiary care hospital, the acute myocardial infarction was confirmed and the patient was taken to the coronary catheterization suite where the partially blocked artery was opened and two stents placed. He made an uneventful recovery and eight months later was back at work – no longer smoking and 20 pounds lighter.

The key components of this successful out come are:

1. Having a medical kit on board to treat serious medical events – the more sophisticated, the more that can be done.
2. Having crew members with a minimum of Advanced First Aid training.
3. Having immediate access to an on-call emergency physician who understands the constraints and challenges of providing care in a marine environment, far from shore, and who is willing to provide decisive advice to an unknown person with basic medical training.
4. Having highly trained and skilled search and rescue and/or medevac personnel available when emergency medical transport is required.

Doctor Samuel Campbell talks about the complexities of providing the best telemedicine support possible to clients in remote locations.

Dr. Samuel Campbell has been with PRAXES since 1997 and has seen the growth of the telemedicine industry firsthand. He trained in South Africa and worked there for three years before moving to Canada to practice in the far north around the British Columbia and Alaska border for five years. After specializing in emergency medicine in Vancouver, Campbell moved to Halifax where he still resides. In addition to working with PRAXES, he is Professor of Emergency Medicine at Dalhousie University and Chief of the Department of Emergency Medicine at the Charles V Keating Emergency and Trauma Centre at the Queen Elizabeth II Health Services Centre. Campbell also works as a provincial trauma team leader and on-line medical control physician for Nova Scotia Ground Ambulance, LifeFlight, the Community Emergency Care Centre program and the extended paramedic program and the Nova Scotia Regional Poison Centre. He answered a few questions for us on the complex challenges of providing the best telemedicine support possible.

You have such a diverse background and extensive experience in medicine. How do you apply your specialties and knowledge to your work providing telemedicine care with PRAXES?

I am extremely fortunate in working with some of the best minds in emergency medicine and critical thinking in the world, including my colleagues at PRAXES. Our association with the Academic Centre allows us, in addition to being the generalists required of us by emergency medicine, to have special areas of interest, and each of us is able to learn from the special knowledge of our colleagues. If time permits, modern communication systems allow us to consult with each other in really complicated or unusual cases to make the best and most patient-centred decision. My own research interests include medical support of remote healthcare providers, the emergency management of infectious and respiratory disease, continuous quality improvement and emergency airway management.

Telemedicine has evolved to become a viable option for healthcare. What are some of the challenges you face when providing telemedicine support?

The concept of remote support of people with emergencies extends many of the complexities that exist in contemporary emergency medical care. In John Ross’ earlier blog about being an emergency physician, he mentions the ‘undifferentiated’ nature of the emergency medicine patient. While TV shows might suggest that patients who present for emergency care are actively seizing, have blood squirting out of a wound or are profoundly unconscious after a drug overdose, these cases represent a very small proportion of what we do. Far more cases present a puzzle both from a diagnostic and a treatment perspective, and the ability to avoid being seduced by what seems an easy diagnosis, but is actually an atypical presentation of something worse – is very important. Perhaps only in primary care, is the cause of the patient’s concern, or any potential solution to their problem, as ill-defined. In emergency medicine, the need to decide what to do in a short frame of time is added to this complexity. In many cases, decisions will need to be made without all of the information that would be ideal to inform what is actually going on. Depending on how sick the patient is, a diagnosis might be less important than a specific action, referred to as ‘empiric therapy’ (therapy based on experience and on the basis of a clinical educated guess), which estimates what is most likely to kill the patient and treating it as if it is that, while you wait for the situation to become more clear.

There are many factors involved when making a medical decision from a distance such as the environment and the other individuals working with your patient. How do these elements affect your work?

After 20 years of delivering remote emergency advice in many different settings, to providers from lay patients alone at sea to emergency specialists in modern hospitals, I continue to receive calls that are very different from any I have had before, with new and unusual circumstances and challenges. I continue to make decisions I have never made before, adapting knowledge from a hundred other scenarios, usually in partnership with the caller, who, as the person on scene, really knows the most about what can and can’t be done. It is a thrilling, exciting and very rewarding job, and as our ability to communicate remotely continues to expand, the possible options for managing each case expand with it. Whenever I have been away for a holiday, I am excited to get back to work and receive my first call.

Part Two

In the second of a two-part post, PRAXES Dr. Samuel Campbell further examines the challenging variables of delivering high-quality telemedicine and the complex differences between treating a patient in person versus remotely.

What are some of the overall challenges the medical industry faces when treating a patient in an emergency situation?

In this era of resource limitations and long waits for emergency care, any decision regarding how you manage one patient has to take into account the impact that the action will have on other patients or on the system trying to carry the load. Furthermore, medical intervention and testing is not always benign and unnecessary tests can lead to false results that further muddy the situation, delaying diagnosis and correct treatment while leading to unnecessary treatment and/or more invasive testing. It has been estimated that over a third of the money spent on healthcare in North America adds no value to patient care, and the emergency department is as guilty as the rest of the system in this regard.

Are there specific variables you must give special consideration when treating a patient remotely?

When it comes to supporting the emergency care of someone remotely, via telephone, videoconference or even by text, so many more variables complicate decision making. When the patient is away from organized care, there are the usual emergency medicine questions regarding diagnoses but contextual elements specific to the case also need to be considered, such as:

•    Where is the patient and how far are they from a better health care location?
•    How much more likely are the most dangerous possible diagnoses than the more benign ones?
•    Who is there to take care of the patient and what is their training?
•    What facilities and medications do they have available?
•    Are there other people nearby with medications that we can borrow while waiting for transport to arrive?
•    What are the medical risks of moving them/or of leaving them where they are?
•    Would others be endangered if we had to get them out of there? If so, by how much?
•    What is the risk of misdiagnosis in this particular patient? For example, is a ‘wait and see’ strategy made more risky by sacrificing transport time just waiting?
•    What are the risks of empiric therapy and is it available?
•    Am I about to spend a huge amount of money transporting a patient for the wrong reason?

What are some of the key differences between treating a patient in a hospital setting versus treating a patient remotely via telemedicine?

A decision made while working with a patient remotely may appropriately differ significantly from one which would be made if the patient was in front of you in a hospital setting. You might over-treat with antibiotics in a patient with only a small probability of a bacterial infection, or you may leave a patient with chest pain out at sea, even if you are worried he might be having a heart attack, if the risk to him and his rescuers are clearly higher than the risk of poor outcome from his heart.

To complicate things further is the need to address cognitive biases that all of us are prone to, and which can be amplified in the uncertainty illustrated above. For example, we tend to believe what we want to believe which might be the most convenient diagnosis. We persist with our first impressions, noticing things that support them as a conclusion less than things that refute them. We might inherit the impressions of others, and make different decisions if scenarios are presented to us in different ways. We make different decisions if we are tired, angry, impatient or depressed, and may attribute clinical findings to certain personal characteristics that have nothing to do with the question at hand. An example of how we might address a bias is asking ourselves if we are ordering a medevac only because we don’t have the cognitive energy to really evaluate the risks of leaving the patient where he is. Or are we considering a recent case experience that was totally unlike the current one but which went badly because you decided to delay a medevac. There is also possibility of making a decision because we feel more comfortable with just doing something (potential errors of commission) than with doing nothing (potential error of omission). Providing remote medical direction is both challenging and stimulating. The sense that we are providing some comfort and help to those to whom the ‘usual’ medical system cannot reach is a significant factor that keeps us engaged.

The dynamic partnership between Halifax-based PRAXES Medical Group and UK-based Clipper Ventures Plc has been steadily growing for several years now. PRAXES VP of Marketing, John Hockin, discusses how an ambitious vision has evolved into an exciting and powerful international partnership.

Over the years, PRAXES has had a diverse group of clients in industrial markets such as the marine sector and offshore oil and gas, among others. What inspired the company to reach out to the Clipper Round the World Yacht Race?

PRAXES is Canada’s premier supplier of telemedicine to industries active in remote and dangerous environments. We help clients deal immediately with medical emergencies, while simultaneously reducing their medical costs. We try to help clients avoid medevacs and diversions – situations which can cost them over $100,000 an incident.

We are now leveraging 18 years of industrial experience and moving into consumer markets as well. Most people don’t really understand the potential power of telemedicine.  They live in urban locations where 911 services are available. Few realize that perhaps 95% of the earth’s surface has no such service. We wanted to increase awareness of PRAXES services to a broad global audience and we needed an example that an average person would connect with – they could see themselves as potential users.

I knew that working with an around the world yacht race would illustrate the reach of our services. How much further can you get from medical support than the middle of an ocean?

How was the relationship with the Clipper Round the World Yacht Race first established?

Clipper Round the World Yacht Race Founder, Sir Robin Knox-Johnston, was a boyhood hero of mine. I was fascinated with his adventures and his ability to do things that no one else had ever done. In 2011, I was looking for a way to showcase the PRAXES service to a global audience but we are a small business with limited marketing resources.

The intent at the outset was to offer our service to the race and prove its value in front of a huge global audience. We did not know what would happen from a business perspective, but hoped that increased awareness would lead to business opportunities that were not yet in view. Our Clipper Race partners also told us that most of the biggest successes had come from opportunities that were not visible at the outset of the relationship. Remarkably, this had been our exact experience!

I began communicating with Clipper Race Manager Gillian Russell back in 2011. We exchanged messages over many months as we got acquainted with each other. The race didn’t have telemedicine support at the time. Coincidentally, the Clipper Race finished the 2011/2012 race and experienced a very high level of insurance claims, so future insurance costs were an issue for them. All of this was happening at the same time that I was reaching out to Gillian.

Luckily for us, the race was in Halifax in June 2012, so our CEO Susan Helliwell and I were able to meet the race team personally. We explained how our service had assisted the marine industry in the past. We explained that we believed many medical situations could be handled on-board. Our physicians felt that 35% of past incidents could have been successfully resolved on board. This face-to-face meeting made a huge difference. Our teams liked each other and over the course of many meetings we built confidence in each other, and realized we had common goals. Neither of us wanted to start a partnership for promotional reasons only – we both wanted to make a difference and prove medically and financially, that we could improve medical support for crews.

PRAXES then became the Global Emergency Medical Support Partner for the Clipper Race 2013 – 14 and has become a Fleet Sponsor for the 2015/16 race. What were the results of PRAXES support in the last race?

Our goals were to handle more medical incidents on board and thus reduce the number of on-shore hospital visits, claims and cost for the race. We also wanted to achieve a high level of satisfaction with our service among skippers, crew, staff and even families. The results were gratifying and support our claim that telemedicine has a role to play in improving remote health care delivery:

• Insurance claims were down by 50%
• Financial pay-outs were down by 57%
• Satisfaction of the service has come to us via the ringing endorsements of the skippers and crew
• Clipper Ventures was so satisfied they set up a joint venture company with us to market the PRAXES service globally 

Today, PRAXES and Clipper Ventures Plc are launching a global joint venture business called ClipperTelemed+™. Can you describe how this business venture came to fruition?

From the outset we at PRAXES had two big dreams – that we might someday be able to partner with Clipper Ventures to jointly launch a business and that a future yacht would have our name on it – both have already been achieved!

We wanted to prove from the beginning that an international company like Clipper Ventures could experience extraordinary results using the PRAXES telemedicine service. After the 2013-14 Clipper Race, crews and staff gave us a strong endorsement. Canadian winner Eric Holden has subsequently asked PRAXES to support his personal ocean racing activities. Surprisingly Sir Robin identified a benefit that we missed. He said that the service reduced worry for the family of crew members who remained at home.

Based on these race results we decided to approach Clipper Ventures about a joint venture. At a race-end reception in July 2014, I had an opportunity to speak to CEO William Ward. William was perhaps the busiest man in the world on that day!  But I introduced myself and pitched the idea of turning the PRAXES service into a global Clipper product. I asked him what he thought. In less than a minute he looked at me and said “Yes, email me next week.” This was the beginning of ClipperTelemed+™!

Since July we’ve been working with Clipper Ventures COO Jeremy Knight and have developed the business plan, scoped the service, fleshed out administrative responsibilities, hired a Business Development Manager and jointly entered a yacht in the upcoming race!

ClipperTelemed+™ is a telemedicine service that will be available to commercial shipping, private yacht and super-yacht owners. With the launch scheduled for this spring, it sounds like 2015 will be a busy year for PRAXES. Can you share some of the news regarding your plans?

So much has happened in the last six months! The Clipper Ventures team moves quickly and our ClipperTelemed+™ branded yacht is already in the water. We will be at the UK vessel launch event on April 17. The crew and skipper will be assigned on April 25 and the service will officially begin taking customers on May 1. Our ClipperTelemed+™ crew will be offering corporate sailing days in the UK during June and July, in the run up to the race start on Aug 30.

For the 2015-16 Clipper Race, PRAXES has become a fleet sponsor, which means we supply all medical support services including medical kits. Our joint venture will have a yacht named ClipperTelemed+™ in the race and for 11 months it will provide lots of marketing horsepower. Our Business Development Manager, Tom Bettle will be working to promote it. We are expecting to get a lot of international interest in both PRAXES and ClipperTelemed+™. We also hope to significantly raise the profile of PRAXES here at home in Canada, using the race as a promotion vehicle.

We’re thrilled about working with one of the world’s premiere sports events. The Clipper Race is followed by over one billion people, many of whom are potential customers for our telemedicine service.

I’ve been working with various marketing partnerships for many decades but I’ve never had a better marketing partner than Clipper Ventures. Whenever I’ve had a request or an idea, their answer is always “yes”. Their “yes” attitude shows they will go to any possible lengths to support a partner.

Seven recommended sources of Medical Information on the Internet

by Dr. Donald Haigh, PRAXES Occupational Health physician

Finding accurate medical and scientific data on the Internet can be a daunting task. In addition, the results of incorrect information can be serious (missed consultations, missed diagnoses, missed treatment, etc.). These are the Internet sites that I recommend as better than most in terms of scientific validity:

• The National Library of Medicine sub-site MEDLINEPlus.http://www.nlm.nih.gov/medlineplus/ This is an American list in plain English and plain Spanish of over 18 million peer-reviewed medical citations plus the advice from many of the Specialist Groups in the USA (called Academies)
• For Occupational Medicine/Industrial Hygiene/Safety information. I recommend 2 sites; one American and 1 Canadian
  • The National Institute of Occupational Safety and Health (NIOSH) in the USAhttp://www.cdc.gov/niosh/ This organisation is a section of Centers for Disease Control and Prevention {CDC} of the American Government. Many freebies are offered including the unsurpassed NIOSH Pocket Guide to Chemical Hazards. The language can be somewhat technical
  • The Canadian Center for Occupational Safety and Health in Canadahttp://www.ccohs.ca/ This group is a combined Management, Labour, Academic administered website developed to inform Canadian workers of health and safety risks in the workplace as well as prevention. It provides the different regulatory rules in each province of Canada. The language is simple and straight forward.
• Environmental Health
  • Canada www.ec.gc.ca A gateway to all pertinent information concerning Canada’s Environment
  • USA  www.epa.gov Web site for the US Environmental Protection Agency (EPA) with lots of research results etc.
• Preventive Medicine. There are 2 major sites which give the best information on the most useful medical screening examinations
  • Canada http://canadiantaskforce.ca/ Slightly more conservative than the US version
  • USA  http://www.uspreventiveservicestaskforce.org/

Ignorance is the curse of God; knowledge is the wing wherewith we fly to heaven.

-William Shakespeare

Donald Haigh M.Sc, MDCM, FCBOM, CIME

Life as an Emergency Physician

PRAXES Medical Director, Doctor John Ross, shares insights on his fast-paced, dynamic career:

The role of a PRAXES emergency telemedicine physician can be unpredictable, challenging and often exciting. PRAXES Medical Director, Doctor John Ross, is dedicated to global health and wellness and takes pride in providing the most efficient and accurate telemedicine support possible. In addition to his career with PRAXES, Ross is a trauma team leader at Capital Health, a professor at the Royal College emergency training program at Dalhousie University, a published author and much more. Ross took some time out of his busy schedule to discuss what it takes to be a PRAXES emergency telemedicine physician and what makes him so passionate about what he does.

When you’re on-call with PRAXES, what would be an example of the type of call you might respond to?  What steps do you follow?

Currently all calls come through on cell phone. We are on call from 0800-0800. When the phone rings, call identifier shows it is coming from the Praxes Communications Centre. The call taker tells me who is calling and where they are, generally something about the problem such as age, complaint, and often basic vital signs. We have asked callers to obtain some basic information to make the call most efficient. Calls from offshore fishing, container ships, cruise ships go through the Joint Rescue Coordination Centre (JRCC). In those cases, the next person I talk to will be their radio controller, who then connects the ship at sea. As you might imagine, the quality of the call depends on radio/phone quality, satellite transmission, caller accent and many other factors. For land based calls, they can come directly from a land phone or via satellite in the far north.

Call types are a broad spectrum. They can come from really experienced medically trained people who have a good sense of what the problem is and what to do next such as calls from the Burnside Jail from paramedics, most of whom we already know. They often call because in order to do certain things they require a physician’s approval and oversight. Other callers are skippers of boats who have very limited first aid training and little equipment – so the conversations can be dramatically different.

Once the chat is over, a plan of some sort is agreed to. It might be anywhere from ‘give two ibuprofen and see how it goes’ to ‘this person needs to be helicopter medevac-ed immediately – we’ll help get that arranged.’ Callers have different levels of medical knowledge and supplies on hand. Some can treat quite a lot – captains on Clearwater vessels and the skippers on Clipper yachts have a number of antibiotics and pain meds, other have less. Some cases will be ‘start this and that, but divert to the nearest port or other vessel or medevac.’ The decision to get someone off is made by the skipper who can guesstimate their time to port or to get within a safe helicopter to and from range. For example, if they are 300 nautical miles off the coast and the helicopter can only go 200 nautical miles including hover time for extrication, we need to consider these factors. We need to consider who is there coordinating the medevac. It might be the Coast Guard or military search and rescue technicians (SARTechs.) Sometimes that involves getting their authorizing doctor on the line to further discuss the risks and benefits. Flying out to get someone comes with lots of risks and costs.

What is your top priority when assisting a client through a medical situation from a distance?

Patient safety while considering everyone else who is at the site is a top priority. One has to remember that although I might be fairly comfortable treating a problem on board a vessel or mining site, the people there may not be. Also, weather and many factors may influence whether to medevac or transport someone. For example, they don’t sound too bad right now, but in eight hours, the weather is going to make transport impossible, so they should go just in case it becomes necessary later. It is all done as collaboratively as possible. I have the medical knowledge, but logistics and caller comfort are all part of the mix. One needs to keep an open mind and be as flexible as possible.

In your opinion, what are some of the most valuable characteristics an emergency physician with PRAXES must possess?

They need experience in caring for potentially sick, undifferentiated patients. Our emergency physicians are excellent at seeing a high volume of sick and relatively well people and being able to differentiate them. They are up-to-date in terms of managing a broad range of problems. They are good communicators. They are good team players as the ED requires seamless working with patients, families, RNs, paramedics, RTs, social workers, administrative staff, housekeeping, security and others. ‘Undiff’ means that they do not have a known diagnosis, and under the circumstances, are not going to get a definitive one with limited resources. Our PRAXES emergency physicians really like what they do.

Is there a particular PRAXES incident that you can share that stands out as being quite dramatic and memorable?

Honestly, there are so many. Just recently I had a call at 0300 from a cruise ship. The captain of the ship was the first person I spoke with after being connected by JRCC who explained their current location. The ship’s doctor was with the patient and the captain gave me some basic information. Then the doctor came on and he sounded very worried. He had done what he could and I thought he was considering the right possibilities for the elderly passenger with increasingly severe shortness of breath (SOB). SOB, chest pain, abdominal pain each have a long list of possible causes. It is impossible to know in such a setting what is the cause. It might be a combination of things. Sometimes, even at specialist hospitals the cause is not definitively found. So, he was starting several treatments at the same time for some of the possible causes and we agreed the passenger had to come off immediately. The ship could divert to the nearest appropriate port in approximately seven hours or he could be lifted off in two to three hours. It was dark and the weather was good. Time was of the essence. So, I authorized a medevac. JRCC contacted the SARTechs. I got a call 30 minutes later from someone asking about the best destination. He could go to a regional hospital in Nova Scotia and be there in 15-20 minutes after extrication, or fly longer to a tertiary care hospital. I felt he would do fine in a regional hospital. I called that hospital hours later and he was safely in the ICU and they were still trying to figure out the complexity of his problem.

You wear many hats such as trauma team leader, emergency physician, professor and author. Clearly, you are very passionate about health and wellness on a global scale. When you find some time away from work, what do you like to do?

I am still very interested in global health and building capacity in developing countries for emergency care – Tanzania for several years and now trying to establish a program in Nicaragua. I’m also interested in Canada’s far north for the same reasons. So travel and learning about the world, its networks and interdependencies and complexities are passions of mine. I try to exercise regularly to preserve my mental health. I enjoy biking, kayaking, racquet sports, and even just jumping up and down being flogged by a relentless person on a DVD when traveling! I’m always reading eclectic stuff, and trying to think outside the box while working on a bunch of weird projects. But best of all, I love hanging out with my wife and two boys whenever we have the opportunity.