Kia ora tātou
E ngā maungā korero
E ngā wai tapu o te motu
E ngā hau e whā
Tēnā koutou (x3) tatau katoa
Greetings everyone
To those assembled from various parts of the country
To the speaking mountains, waterways & four winds of this land
Greetings, salutation, acknowledgements to you all.
Acknowledgment of Country
I would like to acknowledge the Wurundjeri people of the Kulin nation as the Traditional Custodians of the lands upon which this annual scientific meeting is hosted this week. I also acknowledge the Traditional Custodians of the lands upon which Australian emergency departments are located and which conference delegates are based. I pay my respects to Elders past, present and future; for they hold the memories, traditions, culture and hopes of Aboriginal and Torres Strait Islander peoples of Australia.
In recognition that we are a bi-national College, I take this opportunity to acknowledge Māori as tangata whenua and Treaty of Waitangi partners in Aotearoa New Zealand.
Introduction
Welcome to you all and thank you for joining me for the inaugural virtual President’s Half Hour at this virtual Annual Scientific Meeting of the Australasian College for Emergency Medicine in what has been a truly extraordinary 2020.
As we convene virtually from any number of locations across our two nations, and further afield, I wanted to reflect on what has arguably become a mantra for this year – “No going back - An Opportunity to Redefine the Role of Emergency Medicine.”
But as we do this, it is important to first look back at where we have come from and how we have travelled in 2020, and what has defined us this year.
Over the 37 years of our College’s existence, our members and trainees have advanced an incredible amount of work. Clearly, way too much to do justice to in 30 minutes.
I’m talking about vital work that has enhanced the scope, maturity, esteem and indeed sophistication of our chosen field of Emergency Medicine and enabled us to continue to better support the communities we serve.
The commitment, perseverance and sacrifices of so many before us are why we find ourselves in the position we are in today – well established leaders of our medical profession and a well-run, agile, mature specialist College, trusted in our chosen field of Emergency Medicine, public health, and global health. Agile because we have had to be.
While there is much excellent work that can be reflected on over many years, I wanted, however, to focus on a slightly shorter time period – namely the past 12 months, even if it seems to have been longer than a year.
This is in no way to diminish the tremendous contributions of so many, over many years. Rather, it is acknowledgment that we have all just experienced a truly extraordinary year.
A year in which our world changed, and changed very rapidly.
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We have been through a lot since we gathered – in person – some 12 months ago in Hobart for our 36th ASM, when I was honoured to become the first ACEM President from Aotearoa New Zealand in a ceremony with tikanga (or protocol) overseen by Tainui Kaumātua and Kuia (or elders).
Then, in the context of a looming, tinder-dry Australian summer, on the 21st of November 2019, in a first for our College (or perhaps any College), ASM delegates joined together to march through the streets of the Tasmanian capital as we raised our voices and concerns about the terrible health impacts of climate change, to demand action on the unfolding climate crisis.
As a College we declared a climate emergency. It proved to be grimly prescient.
We all now know of the long, hot and deadly summer that followed.
Devastating bushfires raged across much of Australia through December and well into January.
Sydney’s skies turned orange, and smoke haze clouded eastern Australia, reaching as far as New Zealand, even South America.
Thirty-four people ultimately lost their lives in the fires over summer (with an estimated 445 deaths indirectly attributed to smoke related illness), 18.5 million hectares were burnt, countless animals annihilated and 3500 homes incinerated. Some lives, and many livelihoods were destroyed, with an estimated cost of over $100 billion.
Emergency Physicians, as always, stepped forward, leading the emergency and public health response.
This leadership extended beyond treating ED patients in the aftermath.
This was leadership in advocating for genuine climate action and for measures to mitigate the devastating public health impacts of the climate emergency.
We know an emergency when we see one, and it was, and remains, our obligation to speak up and speak out. I feel proud that we are redefining our lane, or lanes, in the broader aspects of public health, the health of our people, and the health of the planet.
There is, though, still much to do.
And while the distractions and challenges of recent times have been immense, we cannot lose focus of this important issue of addressing our climate crisis.
Punctuating Australia’s black summer of infernos, came a separate tragedy in Aotearoa New Zealand.
On the 9th of December 2019, the afternoon calm at a popular tourist attraction was shattered when Whakaari/White Island volcano erupted, ultimately claiming more than 20 lives and gravely injuring many more.
In the ensuing chaos it was once again our emergency people who came to the fore across New Zealand.
Our ED staff found order in the chaos of these dramatic scenes, treating the seriously injured, and critical patients streamed firstly into the small rural ED in Whakatane, to be resuscitated, some compassionately palliated and, those still alive, redistributed to other larger hospitals for definitive care.
The teams at Whakatane and beyond did what was possible, both in terms of saving lives, as well as easing the suffering of those for whom no amount of treatment was going to be sufficient to save them.
By any measure it was a distressing and traumatic end to 2019, but once again we showed our mettle and showed we were up to the challenge.
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Then came the severe acute respiratory syndrome coronavirus, SARSCoV2, the novel coronavirus, or COVID-19 – a slow-moving disaster, causing massive covruption, a tsunami on a global scale.
It has been often observed how rapidly this pandemic took hold and unfolded, and if we are brutally honest, in February, I don’t think many of us truly understood the enormity of what was about to happen to 2020.
An abridged timeline of events provides some indication.
31st of December 2019; a patient with pneumonia of unknown cause was reported to the WHO China Office.
10th January 2020; WHO issued its first guidance on the novel coronavirus, ultimately calling a PHIEC – public health emergency of international concern, on 31st January.
13th January; the first case of novel coronavirus outside China was confirmed in Thailand.
25th January; the first case in Australia was recorded.
28th February; the first case in New Zealand was recorded, both in return travelers.
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Then came a long March.
1st March; the first death was reported in Australia.
11th March; the WHO declared a global pandemic.
From here, things began change even more rapidly and dramatically.
My own firsthand taste came when, on the 13th March, I left ACEM’s Jeffcott Street HQ for what would prove to be my last visit to Australia for the foreseeable future. We finished running our last Fellowship OSCE on that day, everyone on tenterhooks that none of the hundreds of ACEM participants would be the index case of an outbreak.
On returning home to New Zealand, I was met with tough new border measures that came into effect that night.
The result, as I had arrived at half past midnight - the cut-off – was two weeks of quarantine at home, and the start of our new normal, including our lives on Zoom.
It was over this period, as the enormity of the situation took hold, that the College had to rapidly plan in the face of uncertainty how to run our College operations, including, in particular exams – taking the difficult decision to postpone or cancel some examinations scheduled for May.
This marked the beginning of a titanic juggling act and logistical exercise, led by our College Board, Council of Education and College staff, which has continued to this day.
An exercise not so much in adjusting to goal posts that had moved to a new position, but rather, trying to keep playing when the goal posts were caught in a relentless tornado.
19th March, New Zealand closed its borders and within a week was in level 4 lockdown nationwide.
24th March; ACEM transitioned all staff (approximately 110) from working at Jeffcott Street to working from home, where they have remained ever since.
29th March; there were a few shy of 5000 cases in Australia (with 16 deaths), and 514 confirmed and probable cases in New Zealand. New Zealand reported its first death on this day.
In the context of Australian jurisdictions also imposing lockdown and movement restrictions, it was around this time we also began to see seismic shifts in the way we worked as Emergency Physicians.
With one eye on unfolding devastation and the overwhelming of health systems being witnessed in other parts of the world – most notably Europe, and specifically Italy – our own systems swung into overdrive.
Our EDs were divided into COVID and non-COVID zones, and the focus on PPE, and the protection of our emergency medicine workforce became ever more pronounced.
We repeatedly told all who we engaged with – governments, politicians, chief health and medical officers, the media – that ‘there is no patient emergency more important than the safety of our healthcare workforce’.
In a show of co-operation and collaboration, the whole of our health systems prepared and braced for the expected tsunami of critically unwell patients that, at that time, did not ultimately materialise.
Amid the disruption, the College too swung into gear, with a team of FACEMs offering their expertise, in collaboration with College Staff, to produce our COVID-19 clinical guidelines.
This is but one example of what has been achieved and produced by working together through this far from ordinary year.
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Next came April.
In Tasmania, we gained an insight into what an impact this virus could have when EDs in the northwest were closed for deep cleaning following infections and exposure in staff.
As our curves flattened, discussions moved from managing the acute phase to planning for a more chronic phase, and workforce issues came starkly onto the radar as movement restrictions, particularly around international, but also interstate borders, remained in place.
Strong levels of collaboration blossomed at the inter-College level as we collaborated with the four other critical care specialist colleges/societies, the 5Cs, as well as primary care providers, and many other specialists navigating the new and changing landscape of pandemic healthcare.
Internationally, as a College, we met fortnightly with colleagues at the Royal College of Emergency Medicine in the United Kingdom, seeking to share lessons learned and avoid some of the dire scenes being experienced internationally.
By the 30th of April, there had been 3.2 million cases recorded worldwide and more than 227,000 deaths. It seemed a lot at the time.
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By the 1st of May, Australia had recorded 6,753 cases (with 91 deaths) and New Zealand had 1,479 confirmed and probable cases (with 19 deaths).
This was a fraction of the cases and deaths recorded in places like the United States, Italy, United Kingdom, Spain and France, which at this time had all recorded well in excess of 20,000 fatalities per nation.
Our curves were indeed being squashed.
New Zealand eased back to level two restrictions and as Professor Brendan Murphy put it - We’d got ourselves on a life raft, bobbing around in the South Pacific, just uncertain which way to paddle it, whilst our colleagues in UK and US were still floundering in the water. They are still floundering.
There were, though, some worrying signs. As many Emergency Physicians observed at the height of lockdowns, there was a significant yet temporary downturn in ED presentations.
This in itself was cause for some worry, as we publicly raised concerns that some people with serious illness may be delaying seeking much needed medical attention, in particular those who were already socially and economically marginalised.
Then, as some lockdown restrictions eased, many hospitals rapidly went back to access block and ambulance ramping.
In the media we raised concerns about ‘unethical’ ED crowding, spreading infection in the COVID era.
This in the context of the tragic death of a patient who had waited in a ramped ambulance outside a metropolitan Melbourne hospital.
It was a stark reminder to all that we cannot go back to chronic ED overcrowding, access block and ambulance ramping.
Then, by the end of June, Victoria’s second wave had erupted.
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Amid surging case numbers, already vulnerable populations – residents of aged care facilities and public housing towers – were disproportionately affected.
Far too many healthcare workers, including College Fellows and trainees were infected, impacting their colleagues and families, and stretching the ability of parts of healthcare systems to maintain services.
Our ED colleagues acutely felt the impact, with Melbourne hospitals like the Northern, St Vincent’s, Royal Melbourne, Sunshine and Frankston all severely affected at various points.
Five to 10 per cent of the ED workforce furloughed (a word I thought belonged in horse racing), taken out with COVID or quarantine.
It was a traumatic time, with many lessons to learn.
With Victorian case numbers reaching what we now hope to be their unprecedented peak of more than 700 cases per day by early August, Metropolitan Melbourne and the Mitchell Shire moved to stage four restrictions.
These were to remain in place for nearly three months.
And just as we might have been getting complacent on this side of the Tasman, after 102 days with no community spread in New Zealand on the 11th of August, four cases of community transmission were discovered in Auckland, prompting lesser lockdowns in the city and restrictions in other parts of the country.
And now we are confronted with a critical dilemma with this wicked virus: the realization that elimination cannot be a long-term strategy for the virus that is now endemic in the world, and the question of when/how can we progress to strategies of suppression and mitigation of its impact on the healthcare workers and vulnerable populations?
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By late September, with the cases in Melbourne continuing to fall, some restrictions finally started to be eased.
0n the 28th of September, the global COVID death toll passed one million, with the unofficial number undoubtedly significantly higher than this.
By mid-October, a one-way trans-Tasman travel bubble went into effect, where travelers from New Zealand were able to visit some Australian states, although they would require two weeks quarantine if they desired to return. I still accept my fate of not being able to fly over.
On the 26th of October, Victoria recorded zero new cases and zero deaths statewide for the first time since June. Their first double doughnut.
I am sure you will all join with me in expressing gratitude to our truly excellent Emergency Medicine workforce in that state for their incredible efforts, sacrifices and hard work under so much pressure.
All of this has been achieved at a time when much of the rest of the world was experiencing a surge in case numbers with the virus running rampant in the USA, and much of Europe looking to re-impose lockdowns, many have now done so, in a bid to regain control of the situation.
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In a moment of self-indulgence I would like to reflect that I personally really miss being in the same room as people, friends, colleagues, and there have been challenges in communication as a result of missing those personal chats and living on relentless Zoom, a necessary but challenging unidimensional communication tool.
Emails with their inherent challenges in discussing complex and controversial issues, even phone-calls, are also not a substitute. This inability to do the most human of things, communicate directly in person, has unfortunately contributed to a few immoderate emails and reactions.
I cancelled over 20 planned flights across the Tasman to Australia in 2020 and half a dozen to further afield, including South America and Europe. Great for my carbon footprint, but a little frustrating as I work with a new way of trying to connect and support our team of 6000 members, trainees and staff members.
On the 9th of November, the ‘Ring of Steel’ separating metropolitan Melbourne from regional Victoria was relaxed and Victoria could consider itself one again. By the 18th of November the state had recorded 19 days of double doughnuts with no new cases and no deaths, and this has, so far, continued.
In yet another demonstration of the many twists and turns the fight against this virus continues to take, just the week before last we saw a worrying outbreak in South Australia.
And with one of the patients linked to that new outbreak having spent time awaiting treatment in an Adelaide hospital emergency department, we were presented with yet another example of why dangerous ED crowding and hospital access block must be addressed as a matter of renewed urgency.
In a COVID world, it is unethical to allow these issues to persist, and every attention must be given to addressing them.
The US records a death every minute of the day and US, India, Brazil streak ahead with 12.5 million, 9 million, 6 million cases, nearly 50 per cent of the global total. Over 50 per cent if you include Russia’s 2 million.
And heading into Christmas we look to be in a relatively strong position compared to so much of the rest of the world. They are still floundering. We are indeed lucky countries.
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If all of that seems like a lot, that’s because it is. But it brings us to where we are today.
As the world hit 60 million cumulative cases on Tuesday, as we began out conference, and 1.4 million deaths on Monday – the official record – and we move forward towards a new year, will a vaccine save our countries that have no herd immunity?
Will the pandemic virus become endemic? Can we suppress the impact to avoid a Melbourne-esque wave of harm and lockdowns? Can we mitigate the effects on vulnerable populations? Indigenous people? The elderly The co-morbid?
We should in no way understate how trying this year has been:
- The trauma, the strain and the distress that has affected almost every aspect of our work and life.
- The real impact of the illness, those who got sick, in particular HCW, and the devastation of those who have lost loved ones.
- The workload pressures for healthcare workers at the front line, contending with a whole raft of new and complex challenges.
- The trainees contending with exam disruptions and interruption to their career progression as well as the clinical pressure of work.
- The social isolation and real economic impact for many in community lockdowns.
These are all very real impacts resting on the shoulders of many.
It has been incredibly hard.
But if we look to so much of the rest of the world, relatively speaking we are incredibly lucky to be in this beautiful corner of the world in the paradise that our countries are, in as good a position as we could expect. And for this we should be thankful.
Luck has played a part, but by no means is it all luck. Our College members, trainees and staff have been amazingly agile in responding to the pandemic.
Rapid and firm public health responses have done their job, once again showing the value of strong and well-functioning public health systems.
And, once again, Emergency Physicians have been at the forefront. I am firmly of the belief that in a disaster there are opportunities, and to use an old cliché, when the going gets tough, the tough get going.
I have always thought that Emergency Physicians are in their element making decisions under duress, with a paucity of information, decisions that have real impact on people’s lives. Whilst society might reward proceduralists in medicine, our major weapon is our minds, our experience, our decision-making, and our compassion.
It has been scary at times. But we train for this.
In a year full of emergencies – or one giant emergency if you choose to look at it that way – we have been in our element, and up for the challenge.
It’s in our name – ‘Emergency Physicians’.
We deal with emergencies everyday – humbly, capably, kindly and professionally, dealing with what’s in front of us, serving our communities.
As much as we wish we were not amid a global pandemic, we are – and this is our time. Our time to lead.
We have risen to the challenges time and time again, and it is something every one of us should be proud off.
There is evidence of it everywhere.
Across our countries, Emergency Physicians have been elevated into senior roles and involved in significant frontline government efforts.
Emergency Physicians have been recognised, at home and internationally, with honours and accolades. Donald Campbell, Diana Egerton-Warburton, Tony Joseph and Jennie Martin, all receiving Order of Australia Honours. Many other Fellows were honoured with other awards.
Emergency Physicians have been thanked and recognised by their communities for all that they have done, and continue to do. I would like to add my voice to that.
In supporting all of these efforts, our College, our agile College has stood by you – continuing its business as usual – and then some – in far-from-usual circumstances. Our 110 staff in Melbourne have been working from home since March and I would like to thank each and every one of them for their efforts, led by a skilled executive leadership team in turn under the experience and leadership of our CEO, Dr Peter White.
I have mentioned the COVID-19 guidelines and I have mentioned the extraordinary efforts made around examinations, but there is more than that.
At the College level, ongoing work has continued, and new work has been carried out. Our other Council - the Council of Advocacy Practice and Partnerships, or CAPP – backed by the capable Policy and Strategic Partnerships team, and individual Faculties, have been hard at work, advocating for important issues that affect what we do every day.
Our mental health advocacy has advanced, our work on ED metrics, including access measures and time-based targets, has progressed, and our focus on workforce is borne out by the significant discussion paper now out for member consultation.
We have remained focused: on issues of wellbeing and limiting burn-out, on promoting healthcare equity; on seeking a greater share for rural and regional healthcare settings; on responsible resource stewardship and Choosing Wisely; on addressing our climate emergency – on any number of issues and initiatives that impact our work, our colleagues and the communities we serve.
There has never been a time more important to Choose Wisely and allocate the rare and precious resource that is healthcare rationally and equitably to our people who need it.
Our work has also extended beyond the borders of our two countries. With a view to assisting our nearest neighbours in the battle against COVID-19, our global Emergency Care Desk and Committee have provided support and leadership in convening fortnightly Zoom meeting with staff on the ground and health system leaders in the Pacific region.
It is testament to the regard and value of the College’s Global Emergency Care work that they have also successfully won a large DFAT contract to commission a new ED in Lae, Papua New Guinea.
With this commissioning work to be done remotely, this is yet another example of our achievements as we seek to improve the standards of emergency care provided, not just in our nations, but internationally.
So, thank you to the College staff for all that has been contributed this year, largely from your homes.
Thank you also to our members and trainees. Without you there is no ACEM, and what you have given this year is something special.
Amid this tumultuous year, our College continued its growth, reaching the landmark of 3000 Fellows in June, with over 2600 FACEM trainees and many others enrolled in our Certificate and Diploma programs.
And to all of our member, trainees and staff, never have our core values of Respect, Integrity, Collaboration and Equity been more important.
Never have we lived them more.
Speaking of equity, I am immensely proud of the fact that earlier this year our College Fellows voted overwhelming in favour of including an object in the College constitution that affirms we will:
Strive for excellence and equity in emergency care for Aboriginal, Torres Strait Islander and Māori communities in Australia and Aotearoa New Zealand, through a commitment to the principles of Te Tiriti o Waitangi in Aotearoa New Zealand, the process of Reconciliation in Australia and the intent of the United Nations Declaration on the Rights of Indigenous Peoples.
From an all-male Board of 2018, following this year’s College Annual General Meeting, we now have a 60 per cent female Board.
And whilst diversity is by no means just about gender, nor solely race or ethnicity, this year’s developments are an exciting sign of the progress we continue to make. It is about cognitive diversity, different world views and different ways of thinking about things. And we must do better.
Looking to the Board, I would like to congratulate the College’s new President-Elect Dr Clare Skinner, who has taken up her position following the recent AGM.
Clare has stepped into the vacancy left by College Immediate Past President Dr Simon Judkins, who stepped down at the AGM following the conclusion of his term.
I know you will all agree that Simon’s contribution to our College has been utterly immense and continues.
I would also like to congratulate and welcome the other new members of our College Board, Trainee Member Dr Shannon Townsend from Orange in NSW, as well as Non-FACEM Members Ms Libby Pallot and Mr Craig Hodges. And whilst not on the Board, I welcome the new Deputy Censor-in-Chief, Dr Kate Field from Tasmania. I am sure that they will all make significant contributions through their roles.
Speaking of contributions, I cannot finish today without acknowledging the passing, in August this year, of Dr Tom Hamilton, the inaugural ACEM president, a giant of the College, on whose shoulders we continue to stand.
I hope you will all join with me in offering our thanks to Tom and the many others who have come before us, who have helped build the modern and robust College that we are all a part of today.
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My first year as President has certainly not been what I expected but I have (at least virtually) visited each and every state and territory and I commend each and every member and trainee on your tireless work at the front line of acute healthcare provision, potentially putting your health and the health of your families at risk, as you do what you do so well; care for sick and injured patients.
As we continue to confront this global pandemic, and stare down the barrel of another year, we must ask, ‘What is next?’
Having fought our way through a truly epic year, how do we continue building on this ever more solid foundation?
Our College is a strong, mature and agile organisation and we will endure. We will continue our tireless work, looking at some stage in 2021 to return to a new normal. We will continue our work, supporting each other and the communities we serve.
How do we seize upon the seismic shifts, the openness to solutions, the new ways of doing things and the unprecedented sector-wide co-operation that we have witnessed at different stages of this pandemic?
How do we implement the solutions which may finally help address issues of access block, of dangerously long waits for mental healthcare patients, of rural healthcare workforce maldistribution, of healthcare inequity, of addressing burnout and many other wicked problems?
We do it by supporting each other, by watching each other’s backs, by reaching out when it’s needed, and by celebrating all we have achieved; all the while showing compassion to our patients, and showing compassion to ourselves.
Because in a year of emergencies, we have come into our own.
And as we look forward into 2021, we must also acknowledge that there can be no going back.
Kia hora te marino May peace be widespread
Kia whakapapa pounamu te moana May the sea be smooth like greenstone
Hei huarahi mā tātou I te rangi nei A pathway for us all this day
Aroha atu aroha mai Give love, receive love
Tātou i a tātou i ngā wā kātoa Let us show respect for each other.
Hui e, tāiki e.