#badEMfest18 Day 1. St Emlyn’s

Last week the St Emlyn’s team in the form of Janos Baombe, Natalie May, Ross Fisher and myself travelled to Greyton for the very first #badEMfest18. This is a conference with a real difference. Set out on a farm about 2 hours out of Cape Town and convened by the badEM crew, it has brought clinicians together from across Africa (and some from further afield) to learn, meet and share. We will bring you blogs from each of the four days over the next few weeks, but if you want a sneak preview on what we thought it’s this.

You should also read Penny Wilson’s blog and this from Dan Roberts, perspectives of the conference as a whole which really sum up how important it was in bringing together practitioners from such diverse backgrounds in a wonderful setting.The focus here is very much of an African conference; a meeting of people who want to improve care here from a local perspective, with clinicians working together to find local solutions to local problems.

A brief intro by the incredible #badEM team set the tone for the whole conference and introduced the first session, which was around equality. I think this is the first time I’ve seen equality given such a prime spot at an emergency medicine conference. This conference kicked off by tackling real issues about the people, the challenges and the diversity that we all experience, and which is especiallly relevant here. This recognition of E&D issues right at the start of the conferencce was both encouraging and thought-provoking for me.

You can watch Heike’s talk here.

Afternoon Talks

Do they know it’s EM?

Heike Geduld did a fantastic job of starting the conference talks with a call to arms for emergency medicine and emergency physicians across Africa. Heike spoke passionately and candidly about how African EM must find its own solutions to managing emergency care in Africa. There are arguably far too many people “parachuting” into Africa armed with solutions that are either inappropriate, unachievable or unsustainable for care here. It takes up a huge amount of energy and funds and it’s just not the right thing to do. That does not mean that African EM is ignoring help, but rather that external agencies need to work in true partnership with local services.

Heike talked to us about how Africa is often perceived as weak and desperate. The idea of ‘relief porn’ as epitomised by songs such as Do They Know It’s Christmas struck a chord with the audience. It is complex but also clear that Africa should not be perceived as a failure deserving of nothing but aid and sympathy. It’s so much more than that.

Heike also talked to us about the health inequalities that exist here in South Africa where the life opportunities and health outcomes differ so much depending on an individual’s location and social grouping. As someone coming from a nationalised health service it was difficult to hear just how different life is depending on where you are, who you are and how much you have.

Lastly, Heike called us to support more diversity in the EM workforce. There are just 7 black EM consutlants in South Africa. Why is this? Well, the answer is complex but cannot improve unless we talk about it, think about it and do something about it. Interestingly, there was some weird feedback on twitter from people not actually at the conference, speculating that there were not enough black people on stage based on a single photo. In the photo, every person is African and are also advocates for equality and diversity progress in African Emergency Medicine. Perhaps it just reflects the way many outside Africa confuse what being African means. It is not a single region, culture, religion, ethnicity or anything else, and to pigeon hole Africa or Africans into a single western-defined entity is simply wrong.

To close, Heike ended with the repost to Do They Know It’s Christmas with this amazing and very funny song in aid of Norway. It’s intended to be humorous, but it makes a real point about Africa and the way the rest of the world sees it.

Advocacy in EM.

Nat Thurtle challenged us to think about our wider roles in EM, in particular how we can advocate for out patients beyond simply clinical care. She used some amazingly difficult examples from her work in the UK and Australia, and also with her time with Medecins sans Frontiers. The disasters at the Berm in Syria, lead poisoning in Zamfara and the war in Mosul are all examples where we as clinicians need to do so much more than simply treat patients. We need to advocate for their needs and their humanity. That may sound obvious and it’s certainly easy to say, but Nat talked about how hard it can be to stand up for our patients and how hard it can be to challenge the politics, systems and cultures we need to challenge in order to do so. You can find a version of her talk from #DFTB17 here.

For me this was a bit of a light bulb moment in highlighting how we can advocate for some of the most vulnerable patients we see. That might be as a clinician working internationally with an organisation like MSF, but it’s just as likely that you can play the advocacy role in your department, in your hospital and maybe you will need to do so on your next shift. Nat talked about advocating for a vulnerable and difficult to manage drug user in a London hospital with the same passion as when talking about populations in far-flung lands. The bottom line is that this is something we can all do, but that at times it will be tough. To stand up and do what’s right is not always easy, comfortable or even welcomed, but it is vital.

Stop and think about what you can do for your vulnerable patients beyond simply delivering clinical care.

Muti Mayhem

Vidya Lalloo spoke on the use of traditional medicines in South African society. She started with an emotive and personal story that challenged us all to reflect on how we might think differently about non-allopathic techniques if we get to a point where allopathic medicine has no solution for us.

Muti is simply a term related to traditional medicine based on traditional beliefs about how the actions and beliefs of the individual affect their health. Muti takes that belief and uses herbs, plants and other substances to correct the problem. It is prescribed, not based on disease as we understand it, but based on disease as caused actions such as the breaking of taboos, non-performance of rituals and being bewitched by others. Traditional healers, known as sangomas, use muti in the form of herbs, plants, and other substances to correct the perceived problem.


Some of those treatments are dangerous and many clinicians in the room have had experience of patients being harmed or even killed as a result of traditional medicine, but that has to be taken in context. Epidemiologically it’s almost certainly less dangerous than the drugs you prescribe in hospital (food for thought).

There is great confusion about how much Muti is really used and also in the overlap between traditional and allopathic methods. Two members of the staff in Vidya’s department are Sangomas and so the links and overlap are never far away in the ED. The point that African EM docs need to understand the practice is well-made, not just from the pharmacological perspective but also as a way of understanding the culture of the patients. In a wider conversation outside of this particular lecture, it was clear that the medical workforce in many hospitals does not closely reflect the patient population. That’s an issue in many parts of the world, but seems to be particularly an issue for some docs at the conference (nurses are much more likely to be integrated with the local population). I was really impressed with how Vidya and her colleague Prof Dries Engelbrecht have worked to understand their populations and not just ignore their beliefs and practices.

For me, this was a really interesting insight into how we need to not simply dismiss non-traditional health care interventions, but instead need to understand them in context and as a greater overlap into our own healthcare.

As a side note, Vidya is a real star. I met her in 2012 at IFEM and she continues to shine. She not only taught beatifully on tox issues here, but also encouraged us all to practice Yoga from a wellness perspective. It was a real epiphany and something I’m already booked to continue back home in Manchester.

Unicorns and Rainbows.

I’ve known Kal for some time now and they are fantastic. As a paramedic in South Africa they have worked in some of the toughest areas in the country, but this talk was not about Kal as a paramedic and clinician, but Kal as a person.

So who is Kal? Well, this talk was really about how that question has been answered over a personal life with a whole variety of unplanned experiences, perceptions and identities.

Kal was declared to be a girl at birth but rapidly realised that this label did not feel right. Forced into dresses as a child (Kal showed a great photo of the most unhappy looking child at the age of 8  wearing a dress), it was clear that the fit was not right, but who was the real Kal?

Coming out is a real challenge for anyone who does not sit on the traditional gender model, it’s tough and challenging and so Kal decided to do it twice! Coming out as gay at the age of 24 and then as transgender at 30. For the record they do not recommend doing this twice, but that’s just how life works.

Gender is far more complex than many people think – the bottom line is that you cannot determine gender by what is between your legs. It’s far more complex than that and it’s best explained by the gender unicorn or genderbread person diagrams.

What did we learn about what we need to know as EM clinicians? There was a lot, and I’ve listed a few things that we should be aware of below (please add more in the comments).

  • Use the pronouns that they choose and not that you choose. If you are unsure use ‘they’, it can feel a bit weird at first but just go with it – or use the person’s name!
  • Unless there is a clinical reason to ask about surgery such as gender reassignment, don’t. What’s between your legs really has nothing to do with a sprained ankle, for example.
  • Understand that gender is not binary in any of its forms and that although it’s quite useful to pigeonhole people into categories there are lots of people that simply don’t fit.
  • There are problems with admin issues such as clinical and electronic notes that may not have anything but binary categories. If you are designing, redesigning or implementing new systems, take this into consideration.
  • Transgender can be expressed and/or changed through social, medical and surgical means. Those interventions don’t exist on a spectrum, they are just different ways with different people on different journeys. The concept of judging ‘how’ transgender someone is regarding where they are on that spectrum is, quite frankly, bonkers.
  • Transgender people are at really high risk of social/familial isolation, abuse and mental illness and have alarming rates of self harm and suicide. The stats are frightening and illustrate the challenges and vulnerabilities that transgender people face through what, for most, is a really difficult lived experience.

I’ve been to a few talks on Equality & Diversity issues in the past and sometimes they can come across as a bit negative – you know the ones, where someone stands up and tells us what we are doing wrong. I do understand those talks as I need to hear what we can do better, but I also want to hear what we can do in terms of positivity too. That really came across in this talk. The power of friends, the tremendous impact that can be felt when trans people are accepted for who they are without judgement, malice or fear. I’m proud to say that Kal inspires us all on this, they have an amazing group of friends and I’m proud to be one of them.

The Big 5 Echo Findings Not To Miss

Jacques Malan is a force of nature, a real presence in any room and with an enthusiasm for echo to match. He articulated why we need echo as a point of care test in emergency medicine and especially so in South African EM where access to CT and MRI may be limited. We did not get as far as all 5 of his diagnoses not to miss (so I think we missed something 😉 ) but it was clear that point-of-care ultrasound can really make a difference in differentiating some very important local pathologies. As a UK practitioner, the likelihood of me finding a TB pericardial effusion is much lower, and the chance that I would then aspirate it remotely by telling my junior doc how to do it is even more remote (!), but that’s the reality of EM here – challenging medicine with brave and wise clinicians.

Paediatric Myocarditis

Andrew Redfern similarly introduced us to the world of paediatric myocarditis in South Africa. It’s not a common diagnosis here, but the principles of patient assessment and treatment were relevant to us too. Again, the use of point-of-care echo was advocated although it’s clear that the burden of disease here with effusions, myocarditis and valvular problems are much more prevalent. We don’t do a lot of paeds echo in my department (though I did pick up one life-saving diagnosis a few years back), but this did make me wonder whether we could translate some of our adult echo practice for some of our paeds patients.

Andrew also reminded us that if we get to the PICU stage and we are thinking about intubating these kids, we should be really, really careful; get lots of help and canvas some expert wisdom before you rush in with a tube as post intubation collapse is both common and terrifying.

Cardiac care in Africa

The presentations finished first with a debate about the use of thrombolytics in South Africa. Take note that PCI is not available in any (maybe one) public hospitals and not in very many private ones here. The vast majority of patients will never have the opportunity for PCI and for those with STEMI the drug of ‘choice’ (as in, it’s the only one available) is streptokinase. Think about that if you’re working in Europe, North America or Australia. I’ve not seen Strep in years, yet it is the standard of care here. It’s a resource and access issue mostly, but it did remind me of those rather challenging times of deciding about thrombolysis and the complications that arose as a result. The debate was around the care of a patient with relative contraindications to thrombolysis (e.g. recent surgery) and it was interesting to see how the panelists noted the importance of patient and family engagement in decision-making. My only thought was that there was a general feeling that thrombolysis was more effective than it really is. An NNT of 4 for thrombolysis was suggested, but in reality it’s way, way, way higher than that, and that should influence our decision making in practice. Check out the NNTs here.

We then moved onto a really difficult talk by David Stanton on whether CPR is worth it. The natural reaction to that question is ‘of course it is,’ but stop and think; without the chain of survival in place for sudden cardiac events there is pretty much no chance of your patient surviving. This, once again, brought the inequity of healthcare access to the fore. David is an influentiual clinician with regard to cardiac arrest care and was involved in setting the ALS guidelines internationally; he asks us all to think about what matters in healthcare. It’s a real challenge to stop to consider what does work, what can work and what might be more worthwhile investing in when you consider something like CPR in a resource-challenged environment. He also challenged us about the crazy and disproportionate costs of some international life-support courses. It simply cannot be right for African clinicians to fund foreign organisations through excessively high course costs. It really brought to mind the idea that as educators and clinicians we must be mindful of the ethics of advocating advanced interventions in a resource challenged health economy.


The 24/7 conference.

Final thoughts on day one can be summed up by the ever positive Ross Hofmeyr and friends as we reflected, ran, swam, talked, reviewed and asked each other questions around the camp fire. This conference had everyone staying in the same place for several days. We all camped under the most incredible stars and woke to inspiring views and nature. That really brought people together. The WiFi was largely rubbish but no-one cared, there was just enough to keep in touch with home but the rest of the time we talked and shared. We did not do questions at the end of each session because you knew that you would be having a beer and a chat with the presenters later with time to really discuss things in depth and without the pressure and awkwardness of the conference question. I think this made a real difference and resulted in the group coming together far quicker and more effectively than I’ve seen at any conference since SMACC Gold.



Don’t forget to read this great blog from Penny and then from Dan


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