Reflections

Navigating parenthood and pandemics: uncertainty is the new normal

Jacqueline Fleetwood

The psittacosis epidemic of 1929–1930, spread by the Australian budgie, provides lessons for the COVID- 19 pandemic

Robert M Kaplan

It was mid-morning, halfway through ward round

Jillian Chau

In health care, we now need to be curators and disseminators of accurate and timely information, not solely producers, this includes digital sources

Rebecca A Szabo

Medicine in the pre‐antibiotic era offers lessons still relevant today, particularly regarding the prudent use of valuable medications The handwritten line on an archived envelope stored in a safe in The Children's Hospital at Westmead undercroft — “The first child in Australia to have ‘Penicillin’ therapy” (Box 1) — understates the remarkable story of how an experimental drug was requested, approved and delivered in secrecy during the Second World War for one child. The “Penicillin Papers”, rediscovered in 2018 by the Heritage Committee of The Children's Hospital at Westmead, highlight important questions of ongoing relevance. The story of the fortuitous discovery of penicillin by Alexander Fleming in 1928 has entered popular consciousness. What is less well known is how penicillin, which dramatically changed the course of medicine, came to be given to patients. The patient: a small boy in wartime Sydney On 17 June 1943, Peter, almost 7 years old, was admitted to the Royal Alexandra Hospital for Children with fever and increasing drowsiness. During the following 24 hours he reported headache, and a lumbar puncture found turbid cerebrospinal fluid (CSF) with an “uncountable number of leucocytes”, and Streptococcus pneumoniae “type 18” was cultured, a serotype that frequently caused meningitis.1 Sulfonamide drugs were manufactured in Australia in the 1940s, but between 1942 and 1945 stocks were strictly controlled, being reserved almost exclusively for military campaigns in New Guinea.2 Peter, diagnosed with pneumococcal meningitis, was treated with intravenous sulfapyridine for four days, and his fever resolved (Box 2); daily lumbar punctures showed CSF clearing. Treatment switched to oral sulfapyridine, but his fever and vomiting returned. Further intravenous sulfapyridine for one day was followed by extremely painful subcutaneous sulfadiazine infusions for 18 days, then by oral sulfathiazole for four days. Sulfadiazine was obtained from the 118th General Hospital of the United States Army, based in Herne Bay (now Riverwood) and staffed by health professionals from the Johns Hopkins University Hospital in Baltimore. Access to the restricted sulfa drugs was granted by Major McPherson Brown (1906–1989), a professor at the Johns Hopkins, suggesting early involvement of the US Army. By 10 July, however, Peter's CSF was again culture‐positive for S. pneumoniae and the outlook was “grave”. In 1943, penicillin was a highly experimental drug; clinical trials in US troops in Sicily were underway, and only two scientific articles on its clinical use had been published.3,4 In the US, the unenviable task of rationing the small supply for civilian use fell to Chester Keefer, professor of medicine at Boston University Hospital and chairman of the National Research Council Committee on Chemotherapy. Keefer personally vetted each penicillin request, restricting its use to cases in which all other treatments had failed.5 To better understand its potential and limitations, he collected detailed information on all patients given penicillin. Fortunately for Peter, his father was Lieutenant Commander Leo Harrison, a Navy surgeon working as a base medical officer in Sydney in 1943. It is likely that his father's connections with US Army doctors helped secure access to the treatment that ultimately saved his life. On the morning of Saturday, 10 July, Sir Alan Newton, chairman of the Medical Equipment Control Committee, cabled Washington to request urgent supply of penicillin for Peter. At 4:30 pm, one million units (600 mg) were despatched from Washington to San Francisco, together with documents stipulating that the penicillin was for research purposes only, and on the understanding that clinical notes would be provided to the National Research Council following treatment. The penicillin was transported by Liberator bomber from San Francisco to Hawaii, and from there via Brisbane to Sydney, arriving at the Royal Alexandra Hospital at midnight on Thursday, 15 July. The first dose was administered to Peter intramuscularly at 12:18 am on 16 July. Over ten days he received 15 000 units (9 mg) penicillin intramuscularly every four hours, and 10 000 units (6 mg) intrathecally. Today, 5 million units intravenous benzylpenicillin per day would be recommended for a boy of Peter's weight (almost 22 kg). Although Peter's condition improved dramatically, waking from “a stupor” to eat a full breakfast within 48 hours, the dose and treatment duration were inadequate. By 21 July, Peter was again febrile and CSF cultures were positive. Regretting that type‐specific pneumococcal antiserum had not also been requested, Newton had sent a second cable to Washington on 16 July. Rabbit anti‐pneumococcal (type 18) serum arrived and 100 000 units were administered intramuscularly each day from 23 July to 1 August, and oral sulfadiazine from 26 July to 8 August. On 18 September 1943, Peter was discharged home “cured”. Seventy‐five years later, he and his family (Box 3) were interviewed by ABC News reporter Tracy Bowden,6 after his case had been re‐discovered by The Children's Hospital at Westmead Heritage Committee. Research secrecy There are three references in the medical literature regarding this incredible case. The first was a report published in the Medical Journal of Australia in June 1944 by the treating physicians Donald Vickery and Lindsay Dey.7 The second, a short mention by Newton in a speech to the British Medical Association, was published in July 1944;2 the third, a letter by Dey's son in the MJA in August 1981,8 described his father's recounting of events that “would have made an excellent basis for a film”. The initial publication7 was delayed by the condition that details of the case be released only to the US National Research Council, effectively a non‐disclosure agreement. Discussions about research secrecy are as old as science itself.9 Proponents of openness argue that it promotes innovation and enhances productivity and efficiency of research. Openness is essential for testing hypotheses and fostering collaboration. Sharing information with the public fulfils moral obligations to provide evidence for shaping policy and to be accountable for the use of public funds. Conversely, research secrecy is often justified as protecting credit and intellectual property, shielding scientists and human research participants from stigmatisation or harassment, and minimising threats to national or international security. The financial interests of biotechnology and pharmaceutical companies further complicate the discussion. In 1943, arguments for secrecy about experimental penicillin treatments were compounded by the need to protect the limited supplies of the drug. It is pertinent here that the reverse of the envelope containing the Penicillin Papers was marked “Silence saves soldiers” (Box 1). Under the direction of Keefer, the Committee on Chemotherapy charged “accredited investigators” with assessing thousands of requests for penicillin.5 A strict allocation policy was adopted to ensure that decisions were made on clinical grounds. Only patients with severe infections caused by sulfonamide‐resistant, penicillin‐susceptible streptococci, gonococci and staphylococci, should receive penicillin, and only then if a cure could be expected. Access, compassionate and otherwise Equitable allocation of limited medical resources is a problem that often confronts clinicians and public authorities, particularly in resource‐constrained environments and during wartime, natural disasters,10 or epidemics.11 In 1943, Vickery and Dey did all they could to obtain the experimental drug penicillin for their patient. Wartime priorities in Australia did not include active control of therapeutic substances, although the National Health and Medical Research Council dealt with some medication access questions.12 In the US, the Food and Drug Administration (FDA) first addressed access to investigational drugs for therapeutic purposes in January 1963,13 three months after President Kennedy had approved the amendment of the Food, Drug, and Cosmetic Act that strengthened the FDA mandate to approve medications.14 The process of “expanded access”, the preferred FDA term for compassionate use — that is, of an unlicensed drug or device outside clinical trials — was formalised in 1987 in response to requests for access to investigational anti‐retroviral agents.13 In Australia, the Therapeutic Goods Administration (TGA) was established in 1989 as the national regulatory body; its Special Access Scheme, introduced in response to the 1991 Baume report,15 is the mechanism by which doctors can secure access to unlicensed drugs for selected patients. The 1962 American drug law amendments, passed in the wake of the thalidomide catastrophe, had the potential to make children “therapeutic orphans”, as many drugs have been tested only in adults.16 Paediatricians today regularly use medications off‐label, but the use of unlicensed drugs is less common and usually restricted to neonatal intensive care.17 Fortunately, the importance of including children in clinical trials is increasingly recognised internationally by research institutions and funding and regulatory agencies.18 Further, the FDA was empowered to provide financial incentives for including children in clinical trials and licensing applications by the 2007 Best Pharmaceuticals for Children and Pediatric Research Equity Acts.19 Lessons for the post‐antibiotic era from the pre‐antibiotic era Sulfonamides, the first effective antimicrobial agents, were available from the mid‐1930s, but drug resistance was widespread by the 1940s. One initial control on penicillin use was the requirement for demonstrated penicillin susceptibility and sulfonamide resistance: an early form of antimicrobial stewardship. As we approach the post‐antibiotic era because of rapidly increasing antimicrobial resistance, institutional, national and international antimicrobial stewardship programs are being implemented to protect the limited therapeutic options available for many infections. Multimodal programs incorporate pharmacokinetic and pharmacodynamic principles to avoid treatment failure through undertreatment, as experienced by Peter in 1943.20 In the future, strengthening these antimicrobial stewardship programs by integrating molecular technologies and high throughput screening methods will be critical. We also need to rediscover non‐antibiotic approaches to treating infections, including serotherapy21 and bacteriophage therapy.22 Both were widely and successfully employed in the early 20th century, and Peter's ultimate recovery in August 1943 appeared to require type‐specific anti‐pneumococcal serum treatment. However, our reliance on antibiotics over the past century has led to clinical and research neglect of alternative treatment modalities, although interest has revived in recent years, particularly in bacteriophage therapy.22 Greater investment in alternative treatment options is needed, as well as investigation of novel therapeutic and infection prevention strategies. Box 1 – The “Penicillin Papers”, retrieved from a safe in the basement of The Children's Hospital at Westmead in 2018, include letters and telegrams about the acquisition of penicillin from the United States and its use for treating Peter Harrison Source: The Penicillin Papers; courtesy of The Children's Hospital at Westmead. Box 2 – Details from transcribed observation charts for the first patient in Australia to be treated with penicillin, 1943 Source: The Penicillin Papers; courtesy of The Children's Hospital at Westmead. Box 3 – Peter Harrison (right), the first person in Australia to be treated with penicillin, pictured with his family in 2018, together with Bethany Robinson (second from right), the University of Sydney student who rediscovered the “Penicillin Papers”

Ameneh Khatami · Philip N Britton · Glendon Farrow · Megan Phelps · Alyson Kakakios

The institute that has investigated the “common diseases of mankind” for 100 years was established by an unlikely partnership During the First World War, two young men served with distinction on opposite sides of the battlefields in France. One, William Wilson Ingram (1888–1982) was wounded in action, “mentioned in despatches”, and awarded the Military Cross by the British government. The other, Max Rudolf Lemberg (1896–1975), was awarded the Iron Cross after being wounded in the Somme offensive of March 1918. Despite being on opposing sides of this appalling conflict, they later formed a partnership in Sydney, together laying the foundations for the Kolling Institute of Medical Research at the Royal North Shore Hospital. The Kolling, which traces its origin to the Institute of Pathological Research in 1920, is the oldest medical research organisation in NSW. In this, its centenary year, it is an opportune time to explore the contributions of its two remarkable pioneers. William Wilson Ingram (1888–1982) MC, MB, ChB, MD (Aberdeen), FRACP William Wilson Ingram graduated from the University of Aberdeen in 1912. On the declaration of war, he enlisted in the Royal Medical Corps. He served in France, where he received the Military Medal in 1915; wounded, he returned to England. In 1916, Captain Ingram resumed active service, and ultimately took command of the Pathology Services at the headquarters of the British Expeditionary Force in France.1 After the War, Ingram completed a medical degree at Aberdeen. He then accepted the post of lecturer in physiology at the University of Sydney, and also established a general medical practice. In 1921, Ingram was appointed Honorary Pathologist at the Royal North Shore Hospital (RNSH), where, in addition to supervising the routine pathology service, he founded the Institute of Pathological Research. The Institute of Pathological Research of New South Wales In 1920, a group of influential NSW citizens proposed a research institute for investigating the “common diseases of mankind”, inspired by the Lister Institute of Preventive Medicine in London. They launched an appeal for establishing the Institute of Pathological Research of New South Wales (under the Royal North Shore Hospital of Sydney Act of Incorporation, 1910).2 Initial donations were disappointingly few, but after Mr Thomas Rofe (1869–1945), member of the Hospital Board, donated £5000, the Institute was ready to proceed in 1923. These funds facilitated the appointment of G. Vincent Rudd MSc, senior biochemist, as its first fulltime research scientist in 1925. Later that year, Ingram returned to London for postgraduate study, during which he observed the clinical effects of the newly discovered insulin. On his return to RNSH, he established one of the first specialist diabetes clinics in Australia. He later collaborated with Rudd on the significant and popular text, The diagnosis and treatment of diabetes, published in 1933.3 By 1928, space at the Institute was at a premium, and as it expanded in scope and personnel, more commodious, fully equipped laboratories were urgently required.4 Ingram invited Eva Kolling, the widow of American‐born merchant, Charles Kolling (1858–1926), to tour the original hospital cottage that now served as a laboratory. Mrs Kolling was suitably impressed by the standard of clinical research carried out in extremely cramped conditions. With the opportunity to commit funds to commemorate her husband — but also because “many lives will be spared and Humanity assisted generally”5 — she donated £5000, a sum matched by the NSW government. Ingram drew up plans for the “Charles Kolling Memorial Laboratory” shortly before his departure as medical officer with Douglas Mawson and the British, Australian and New Zealand Antarctic Research Expedition (BANZARE) (Box 1). Eva Kolling laid the foundation stone for the new laboratory in 1930 (Box 2) and, after Ingram returned from his second BANZARE expedition (1931), she officially opened the new facility on 12 September 1931. After the move into the new building, which provided much needed laboratory space and a library, and to re‐emphasise its focus on research into common medical conditions, the institute was renamed the Institute of Medical Research. Ingram was appointed honorary director, a position he held until his retirement in 1974. When Rudd resigned in 1934, Ingram was unable to recruit a suitably qualified Australian‐based scientist, and extended his search overseas. Max Rudolf Lemberg (1896–1975), with a 14‐year background in biochemical research and working in Cambridge after fleeing Hitler's Germany, applied for the position. Max Rudolf Lemberg (1896–1975) Max Rudolf (Rudi) Lemberg was born in Breslau (Silesia; now Wrocław, Poland), where he graduated in science in 1916. In mid‐1917, he enlisted in the German army as a private, a gunner in the field artillery. Lemberg was wounded in action during the Somme offensive of March 1918, his bravery recognised with the Iron Cross. These experiences had a profound effect on Lemberg, who became a convinced pacifist; he later (1952) joined the Society of Friends in Sydney. In 1922, he completed a doctorate in Breslau under Heinrich Blitz, an organic chemist. Blitz strongly advised him against an academic career, citing the poor prospects for a scientist of Jewish descent in any German university.6 After a period as an industrial chemist with Boehringer in Mannheim, he returned to academic life in Heidelberg in 1926. Equipped with a Rockefeller Foundation scholarship, he moved to Cambridge to study with Sir Frederick Gowland Hopkins (1861–1947) in the Institute of Biochemistry.7 He then returned to Heidelberg, but Lemberg later recalled that “the Nazi shadows began rapidly to gather”, and in 1933 his academic career came to an abrupt halt. He realised that, despite his war service and Iron Cross, he was unlikely to escape ending in a concentration camp.6 He fled Germany and returned to Cambridge, which at the time was full of highly qualified refugees from Germany, and not all could stay. Lemberg successfully applied for the position of director of the biochemical laboratories at the RNSH, going “into the wilderness, for I did not expect inspiration from my Australian colleagues at that time.”6 After a final (and risky) visit to his ageing parents in Breslau, Lemberg and his wife arrived in Sydney on 1 October 1936. Australia must have seemed remote from his academic life in Heidelberg and Cambridge, especially as “there was little space for research and hardly any equipment”.6 Nevertheless, Ingram and Lemberg established a good partnership, Ingram as the director of the Institute of Medical Research and Lemberg later as assistant director until his retirement in 1972 (Box 3). Ingram managed the administration and provided the clinical input, while Lemberg undertook fundamental scientific research, primarily into porphyrins and tetrapyrrole metabolism, research with which the Institute developed its scientific reputation. The Institute during the Second World War During the Second World War, Ingram enlisted in the Australian Army Medical Corps and served as Lieutenant‐Colonel until 1944.8 Lemberg remained in his laboratory, contributing to the war effort with research into the metabolism of trinitrotoluene (TNT) in animals, the role of sulphonamides in bacterial metabolism, and the preparation of X‐ray contrast media, among other topics.7 Eva Kolling, who remained one of the most significant supporters of the Institute, died in 1941, and left an extraordinary bequest of £25 000 to support and expand the work of the Institute and the Charles Kolling Memorial Laboratory. The Institute of Medical Research, 1945–1974 In 1948, the RNSH became a teaching hospital of the University of Sydney; in 1950, Ingram created a Unit of Clinical Investigation within the Institute of Medical Research, under the direction of Frank Rundle (1910–1993), later founding Dean and Professor of Surgery of the University of New South Wales. A new teaching block in 1963 provided additional facilities for the Institute, and a closer relationship with the clinical school developed. In 1964, routine hospital pathology moved from the Kolling laboratories into stage I of the new hospital complex, so that the Institute of Medical Research was free, for the first time, to concentrate solely on research. Lemberg continued his basic biochemical research. In 1949 he published his monograph on Hematin compounds and bile pigments, which became a standard text in the field of tetrapyrroles and confirmed his international scientific reputation.9 In 1952, he was elected a Fellow of the Royal Society and a Foundation Fellow of the Australian Academy of Science, and in 1955 was elected the first president of the Australian Biochemical Society. His scientific output was prodigious, encompassing more than 200 scientific publications.7 After Ingram and Lemberg: the Kolling Institute of Medical Research Following the retirements of Ingram and Lemberg, David Nelson (1935–1989), clinician and researcher, was appointed the first fulltime director (1974–1989). From 1971, the Institute was commonly known as the Kolling Institute of Medical Research, and, under Nelson's direction, concentrated on the emerging discipline of clinical immunology.10 Under its third director (1994–2011), Robert Baxter, the Kolling focused on endocrinology and cell biology. In 2008, the various research laboratories were all relocated to a new purpose‐built facility on the RNSH campus. With the appointment of Jonathan Morris as its fourth director in 2012, the academic research focus of the Kolling broadened to ensure that medical research findings informed clinical practice. Carolyn Sue was appointed the fifth director in 2019. The Institute now hosts numerous research teams investigating an extensive range of medical conditions. The Kolling Institute of 2020 has thereby remained true to the original charter of the Institute of Pathological Research in 1920, investigating the “common diseases of mankind”. Box 1 – William Wilson Ingram, 1929 Source: Archive and Heritage Collection, Royal North Shore Hospital, Sydney; with kind permission. Box 2 – Eva Kolling lays the foundation stone for the new laboratory of the Institute of Medical Research, 1930 Source: Archive and Heritage Collection, Royal North Shore Hospital, Sydney; with kind permission. Box 3 – Max Rudolf Lemberg and William Wilson Ingram, 1970 Source: Archive and Heritage Collection, Royal North Shore Hospital, Sydney; with kind permission.

Catherine E Storey

Beached by COVID‐19, orthopaedic surgeons have cooked up some new techniques to enhance skills There is a hidden danger in the enforced “shutdown” caused by COVID‐19. Bored certified orthopaedic surgeons who now have a lot of time on their hands, with very few patients to see and even less surgery to do, are stranded at home. This is a recipe for disaster. This communique outlines a superb technique designed to eliminate boredom and to enhance surgical skills. Marooned at home by the COVID‐19 isolation and because necessity is the mother of invention, rather than doing nothing, I travelled to the local store and bought a box of a Better known, do‐it‐yourself cake mix (Moist Vanilla 540 g). I had seen my mother make cakes in the past; it did not look that hard. Indeed, even the instructions were on the back of the box. This was as simple as Chemistry 101; they even specified the weights (and I had scales). So imbued with the unbridled hubris of a surgeon, I proceeded to make my first ever Moist Vanilla cake, with icing. Cake number one was perfect. I followed the instructions per the pack; added “A” to “B”, mixed, put it in a pan and cooked it for 55 minutes at 160°C. It turned out just like my mother used to bake; it was perfect. Buoyed by this success and bathed with arrogance, I became more adventuresome. I purchased another packet of the same stuff, and this time decided to make “Whisky Cake”, a self‐creation (Box 1). At a critical point of the mixing of the components, I added a very specific quantity of whisky (“specific” means a quantity greater than 25 cm3 but less than 100 cm3 or maybe a bit more). (Note spelling of “whisky” is without an “e” because it was Scotch. As my Scottish mother taught me, if the country has an “e” in it then so does the spelling of whisky. Irish whiskey can be substituted.) This creation went through the same cooking process and, once again, the “Whisky Cake” turned out to be beautifully moist and friends and acquaintances all enjoyed their sample, and even after consumption they were able to maintain verticality and appropriate social distancing measures. Praise was heaped upon me. Now, if the “Whisky Cake” was good, then, logically, a “Double Whisky Cake” must be better (please refer above for required quantity of whisky for the “Double Whisky Cake”). Sadly, the inescapable logic of arithmetic progression does not appear to have made it to the Annals of Cookery, in fact, what emerged at the end of 50 minutes of baking is what could be best described as “sludge”. Surgery training teaches you that complications occur … and physicians often joke that surgeons bury their complications. Emotionally crestfallen, the mutant, little less than successful “cake” was judiciously hidden from my friends and acquaintances and, loathing waste, the “Double Whisky Cake” sludge was offered to my four rescue dogs. They loved it and promptly slept all afternoon. However, physicians have no understanding of the logical approach that orthopaedic surgeons apply to problem solving (eg, problem: the square peg won't go into the round hole; solution: get a bigger hammer). But it takes much more than a bigger hammer, it takes sheer bloody‐mindedness and a certain strength of ego to soldier on when crestfallen. My inbred surgical fearlessness emerged, and knowing that failure is an important part of learning, I became emboldened by this “lesson”. The next experiment was a “Lemon Orange Single Whisky Cake” with added zest from the rinds of lemons and oranges. “Double Whisky” was thought to be the demon. (It emerged later that “Double Whisky Cake” was actually a Type II research error. A Type II error, as Wikipedia explains, means “the true fact is that the item is a weapon but the system keeps silent at this time”.2). The zest was boiled up together and added to the mix. Cake number four was very satisfactory. Current “scorebored”: good, good, disaster, and another good. Further emboldened by my newly discovered talent, I then went to the freezer where I had some mulberries (given to me by a patient many months ago, destalked and frozen). This time, I decided to make “Mulberry‐Apple‐Cointreau‐Single Whisky Roller Pie with Flaky Pastry”, another new creation — Cointreau was selected because (a) the whisky was nearly empty and (b) Cointreau was “on special”. The “Whisky Roller Pie” component is mentioned only because I did not have a roller and because I used the nearly empty whisky bottle to roll out the pastry. The flaky pastry was prepared exactly per selected internet recipe. About one hours’ worth of rolling, folding adding butter and folding again, all the time believing the words from the internet recipe when it wrote that, “You'll never go back to buying flaky pastry in the supermarket ever again”. One has now learnt not to believe everything one reads on the internet. Everything seemed to be going well. A specific amount of Cointreau was added per previous formula. Pie was baked and, at the end of one hour, it was removed, allowed to cool and then … it exploded. In many regards, the explosion was an epiphany, reminiscent of a major polytrauma. Mulberries are ferociously red … the smallest quantity of fluid stained everything and not only do the stains remain, the dispersed fluid clots like blood! It was just like being at work again. For the mulberry clot, see Box 2. It took me about a humbling hour and a half to clean it up. The four rescue dogs were very grateful to have this “Mulberry‐Apple‐Cointreau‐Single Whisky Roller Pie with (not so) Flaky Pastry” pie. Conclusions The COVID‐19 “shutdown” conveys hidden dangers. This research has unearthed some important facts and highlighted a number of issues: One should never underestimate the skill of your mother and her cooking ability. If this is a glimpse of what retirement might be like, then it is not going to be pretty. I recommend using the Better known brands of cake mix as they include the pre‐made icing. Pre‐made icing is important. Other brands of cake mix provide the icing sugar and “easy instructions” how to “make it yourself”. This is clearly a new definition of the word “easy”. My self‐made icing gracefully floated off the top of the cake on to the table then on to the floor. Rescue dogs to the rescue … again! Cooking and baking should be assigned CME points and should be included as an essential part of basic surgical training. Consideration should be given to creating a new specialist Royal Australasian College. Orthopaedic surgeons, who are often the butt of medical jokes, have demonstrated that we are the leading researchers into psychological support for the self‐isolated surgeon. Addition of flammable ingredients to cake mix should only be attempted by seasoned professionals who have sampled the agent in equal parts. “Double Whisky Cake” is a misnomer. The internet does not always tell the truth. Mulberries should be declared a Level 4 biohazard. This research suggests that further investigation needs to be done into “The Triple Whisky Cake”. Ethics approval from the RSPCA will be needed. Finally, this research illustrates the hidden danger that unoccupied orthopaedic surgeons pose not only to themselves but also to the wider community. This is obviously a specific concern during this COVID‐19 crisis and the MJA owes it to the general readership of this esteemed Journal to publish this article as a warning. Disclaimers The author did not receive any funds from any do‐it‐yourself cake mix company. No animals were harmed in the manufacturing and testing process. Besides the fact that the alcohol component is boiled off … any issues mentioned herein, which some might consider “controversial”, should be taken with a pinch of salt. No recipes will be available from the MJA. Box 1 – Irish whiskey cake1 Greenwood recently published “The Irish Whiskey Cake” in The Irish Times and reported, “Normally, I avoid adding alcohol to bakes that my children eat, but so far, this [Irish Whiskey Cake] doesn't seem to have resulted in any adverse effects”. My self‐created “Whisky Cake” (no “e”) appears to be a synchronous creation. Box 2 – Mulberry clot

John S Fox

Removing students from clinical placements may have significant implications for future workforce planning Clinical placements for medical students are central to teaching and learning in any medical program, with students in the later years generally undertaking rotations in disciplines, such as general practice, general medicine, paediatrics, psychiatry, surgery, anaesthesia, obstetrics and gynaecology. In our medical program, there are close to 300 students currently enrolled in the 2 final years. Despite the current coronavirus disease 2019 (COVID‐19) pandemic, Flinders University has remained committed to providing medical students with clinical placements, a stance that aligns with the Medical Deans of Australia and New Zealand,1 all state and territory health authorities, and the Australian Health Protection Principal Committee. The local consensus between stakeholders is that we have an obligation to treat all patients with appropriate safeguards in place. Given that the longer term response to COVID‐19 is unknown, removing students from clinical placements may not only affect their medical training but may also have significant implications for future workforce planning.1 However, there are extraordinary challenges in the clinical and university environments. While COVID‐19 represents a unique situation in terms of world involvement, there are other examples of large‐scale disruption to medical education, including the severe acute respiratory syndrome (SARS) outbreak of 2003. In Canada, the local transmission of SARS in Toronto caused a significant interruption to usual teaching, particularly affecting the teaching of clinical methods skills and causing the cessation of third and fourth clerkships. This had an impact on all final year medical students and first year residency positions in Canada,2 an experience that was reflected in Hong Kong with the cancellation of ward teaching and delays in examinations.3 While we may wish to avoid this outcome, maintaining all medical students in their clinical placements can be challenging. There is heightened anxiety among the existing workforce, who are understandably concerned about the rapidly changing impact of COVID‐19, and this can lead to differing opinions among clinical supervisors as to the merits of continuing clinical placements. At our university, in partnership with medical students and health care providers, we have addressed this concern by writing and widely distributing clear guidelines for clinical placements. In some high risk placements, such as endoscopy and other aerosol generating procedures, we have encouraged clinical supervisors and students to negotiate appropriate activities that do not increase the risk of COVID‐19 exposure to the student, other staff or the patients, while still allowing the student to learn in the clinical environment. The SARS experience in Canada highlighted the variability in standard precautions and infection control practices and teaching.2 In our medical program, training on the use of personal protective equipment was previously embedded within clinical rotations. In response to COVID‐19, we have instigated refresher training for students on handwashing, N95 (or P2) mask fitting, and donning and doffing of protective clothing, with formal certification on completion. To date, students have chosen to remain on clinical placements. While they have concerns about their personal safety, they remain committed to both patient care and their own learning. This was also the case in Canada, where students took pride in their role as part of the health care team and understood that providing health care is not without risk.2 Furthermore, real‐life learning in the current situation may be invaluable. Students have seen health system governance operationalised, have witnessed senior clinicians act thoughtfully and with intent despite their own anxiety, and have watched professional practice in the provision of good communication and a sense of humanity and compassion for sick patients. COVID‐19 presents significant challenges to medical schools that embed teaching and learning within the clinical environment. Our final year students are the future medical workforce and it is our job to ensure they are competent, undifferentiated, work‐ready practitioners. Furthermore, the wider community has reasonable expectations that the newly graduated workforce will be prepared for pandemics in addition to the provision of routine care. This situation reinforces the case for competency‐based teaching and learning. Education that is discipline‐focused is likely to be significantly disadvantaged by the cancellation of risky placements or by placements that have undergone substantial modifications as a result of health care resource reallocation. However, it is important to remember that considerable clinical work unrelated to COVID‐19 still needs to continue. Ongoing evaluation of the actual educational experience that students are receiving will assist us in the provision of additional learning if deficits arise, and, in the worst case scenario, help us identify if clinical placements are no longer tenable.

Julie A Halbert · Alison Jones · Liam P Ramsey

Reducing smoking during pregnancy among Aboriginal and Torres Strait Islander women is a national priority, but there has been little exploration of their experiences and desired support

Michelle Bovill

If I am allowed to anaesthetise again, I'll share a few quiet reassuring words with my patients I had spent the past 25 years working in hospitals, intensive care units (ICUs) and theatres. So many thousands of operations on so many patients, and yet here I was, fearful and frankly embarrassed. I lay motionless, face fixed in an unconvincing grin for the benefit of former colleagues as I floated past them, a single off‐white sheet covering my goosebumps. Just another patient this time. Paraded down the corridor; relatives and staff trying to guess whether you were haemorrhoids or a vasectomy. I was no longer the operating room DJ, “gasman” and “wannabe comedian”. Rather than choosing a playlist and sipping the first of many espressos that morning, I had stiffly, illegibly signed a consent form and wet my parched lips from a plastic cup. The last time consent for surgery had been requested, it had been during an emergency helicopter flight, given by my shell‐shocked wife, thousands of miles away. She had tearfully agreed to the trauma team's plans to stabilise my broken neck and jaw, sew my ear back on and drain my exploded right chest, ruptured lung and kidney. The good news was that the pulverised hands and multiple lumbar fractures could wait for another day. It hadn't been clear at that stage if walking was going to be an option, nor whether the brutal deceleration would take a longer term toll upon my brain. It would be a week in the ICU, ventilated and restrained, plus many months of interminable rehabilitation before anyone would know for certain. I remembered accelerating down that long steep hill into Apollo Bay, tucking low on the frame, not even having to pedal to gain speed rapidly, looking ahead for the group I had lost contact with. I flew past other riders, cautiously feathering their brakes on the descent. My eyes watered in the chill jet stream and the bike's carbon wheels chattered on the gleaming tarmac. Then darkness. Silence. Darkness. A large, calloused hand gently, insistently squeezed mine. Like waking from a deep restful sleep, I realised that I had been aware of the pressure on my palm for some time before I understood to try to respond. Slowly, hesitantly, I opened my eyes. The voice was deep, resonant and strangely familiar. It was my son. The brain damage that I sustained on that cold morning in Melbourne, head on into a street pole at 65 km/h tossed me onto the other side of life's road. Each of us doctors spends our training and junior years formulating our own personal and crucially professional identity. Born from repetitive, regular crises of confidence through patient deaths, personal errors and sometimes just promotion to the next terrifying level of responsibility. It wasn't so much learning what to do to be a competent doctor; it was more learning what it was to be a doctor, how we saw ourselves and how society regarded us. I realised that I could no longer muster that theatre blues’ confidence, that surgical squad strut. Laying on a theatre trolley, in a queue for the lifts, I was just another tremulous punter, nervous about the loss of control. I was most afraid of the drug‐induced, return to the darkness. The maxillofacial surgeon had asked me, many weeks after the plates and metalwork had been screwed in, between loosening yanks on the wires holding my face together, if I remembered the accident. I gargled denial noises, my mouth jammed open. “That's a good job,” she laughed. “What a mess!” Operating lists had been my working day and I missed them and my colleagues too, diligent and quirky, good‐hearted and generous. I watched them quietly busy around me, hushed and focused as they made their last detailed preparations. Part of me was ashamed that I knew so little about each of them individually, especially since so many had spontaneously sought me out, given me support and warmth during my months in rehabilitation. Perhaps there was more to medicine than just caring for people. Health teams build something together. Trust, empathy, a united resolve to do the best we can. It looked simple enough when you saw staff doing the same operation a thousand times, but it was the commitment to excellence and good outcomes that defined these humble, generous people. Many of the staff knew me that day as I arrived in the cool clinical space, air conditioner humming, the last stop before the deep dive. A familiar face checked me in for the final time. Knowing her well as I did, I was fleetingly relieved that it was my arm, and not some more delicate area that had been crushed as I was catapulted from the bike. I lay there quietly and felt the emotions rise again, tears welling up. The crash trauma and the rehabilitation had made me afraid of the absence, the journey into that anaesthetic void. I could picture the theatre scene on the day of the accident. Probably not much different to today really. Relaxed, professional and all quite routine. Shredded Lycra, chest drains, ruptured organs and the rest. Sometimes, when I had been the boss, patients would get worried when I told them that things were routine. That wasn't to say we weren't concentrating, it's just that we had done it many times before. I would deliberately avoid the patient's back story just to keep my own anxiety at bay, ignore the injustice and bypass the random cruelty of their situation. Just put an airway into them and keep them asleep while the damaged bits got sorted. No doubt, when they lay my broken body onto a theatre table after the crash, it was much the same. Maybe some passing banter about the weekend's footy results, the crappy Melbourne weather and “middle‐aged men in Lycra” who really should know better. How ironic it would have been had I not hit the pole with my chin, but with my forehead and pithed my brain. Imagine the plaudits for the State Medical Director for DonateLife who felt so impassioned about saving other people's lives through organ donation, that he selflessly became a donor himself. Surely at least an Order of Australia for me? It could have been one of my team informing my family, hands held tight, that their husband and father was not going to make it but that he could save other people's lives. Drugs now flowed into a vein. I often tried to excel at the flippant and the ridiculous in the face of the worst of emergency situations, but not today, not on the other side, a scared patient. “Another one bites the dust” had always got a giggle if I played it from my Spotify favourites, just before sleep time. I used to jokingly tell patients before I put them under that being worried was quite understandable and that if anything bad happened, they would never know because they'd be dead. Strangely, that didn't seem funny anymore. Perhaps if I am allowed to anaesthetise again, once my brain is straight, I'll just share a few quiet reassuring words with my patients, tell them that it's okay to be frightened, that they're safe and that I won't leave their side until they awake. I used to pat myself on the back when a patient left my ICU. Now I have seen that leaving the ICU is not the end of the journey but the start of a new journey. I tried to explain through the mist of my confusion to the nurse caring for me that without her company and support, I wouldn't have survived. She started to cry. I hadn't meant to upset her but I wanted her to know that I was grateful. The outpatients’ clinic since then has been shocking and revelatory. I was the only one not in a wheelchair and for that I felt terrible guilt. Proper patients with proper injuries, courage and optimism by the bucketload have been a sombre reminder of what might have been. I have no memory of those first few steps, my wife's tears or the cheers from my hemiplegic room‐mate as I edged back onto my bed for a well earned rest. Because of the brain injuries, the thought of anaesthetising someone now fills me with an unfamiliar fear. It took me all my waking hours to craft this cast‐iron professional identity of mine and an instant to fatally fracture it. I even had the Rod of Asclepius tattooed on my biceps on my 50th birthday just to affirm a life's commitment to medicine. The supreme irony that I may never practise again and the loss of that coveted persona have been the most traumatic part. Who am I now? I used to be a doctor until that day on the Great Ocean Road. Not anymore. Perhaps one day I will accept the crash and its consequences; move on with my life. Not quite yet.

Bruce Powell

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