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Why I Do ICU - Dr Mary Pinder

Updated: Jan 24


Dr Mary Pinder is an Intensivist in Perth and the Immediate Past President of CICM


 

Why did you choose to do intensive care?


When I was a medical student, I actually wanted to do paediatrics. I thought I'd do some jobs that would be good for going into paediatrics. So I did six months of anaesthesia, six months of emergency medicine, some O&G. And then I applied for a paediatric rotation, and I actually didn't get it. One thing they recommended was that I did a bit more adult medicine.


So, I applied for adult medicine rotation. And then I thought, well, the bits I really enjoyed was the best bits of medicine and the best bits of anaesthesia. You had the immediacy of everything happening like you do in anaesthesia, but you were more in control over your workload and the patients that you saw. Whereas in anaesthetics, you were dependent on the surgeon. And continuity. We had that opportunity to talk with families and have those sorts of conversations, see people through the journey of their illness. And that was kind of encapsulated in intensive care.


And I suppose that they're the things I still love about it now.



How did you get to where you are today?


My aim was to come to Australia at some point. Australia has this reputation for the best sort of training program. I did my fellowship in anaesthesia and I did the MRCP exam. I also wanted to go overseas and work somewhere in a low middle income country in a sort of low resource situation.


I ended up getting a job with the Overseas Development Administration, which was part of the foreign office in the UK, involved in the delivery of foreign aid. So I worked in Fiji for a year, and essentially was kind of running their ICU. This sounds really cheesy, but I ended up in Perth because when I was in Fiji, I met a French guy who was based in Perth. So I rang a couple of hospitals and Charles Gairdner had a job. After I'd been in Perth for 18 months, I then went and worked with Jeff Lipman in South Africa, which was amazing experience.


While I was working there, Richard Lee came over to do a sabbatical for three months. And he must have talked to people back here because out of the blue, I got a call from the Alfred saying, do you want to come and do a registrar job with us?


I worked at the Alfred for a year to start with, got the exam and at that time, the training program was pretty straightforward. And then was a fellow very shortly after that.


So, then I contacted the people I knew back in Perth, and they had a local consultant job.



What have you seen as the most significant changes in the way we practice intensive care medicine?


Obviously, a lot has changed in terms of science and evidence-based medicine. What we know now compared with what we knew 10 or 20 years ago, treatments that we did, we don't do now.


When I first qualified and had exposure to ICU, patients were ventilated, to a normal pCO2, and O2 was slammed in. Ventilators were very unforgiving. Obviously over time, we've learned a lot more about sort of ventilator related lung injury and ventilators have become a lot more sophisticated.


There've been huge changes in technology. When I first started in anaesthesia, pulse oximeters were kind of a new fandangle thing that had come in. I remember talking to one consultant who was near retirement, who was telling me when he started as a junior anaesthetist, it was an unusual thing to have a drip up for an operation. He said wow, if you did that, the surgeons would say do you think I'm going to cause a lot of bleeding? What do you do?


From a broader perspective, we are more patient centred and inclusive of families. More than we used to throughout medicine.


In terms of training and education, the see one, do one, teach one kind of model is a thing of the past. There is more structure to teaching and training, and nurturing the next generation.


Two or three years ago, I went home to my husband and said “I've had this miserable day at work.” I’d probably, been struggling with the ultrasound or something. “All my young colleagues, they're all so much better at echo.”


And he just looked at me and said, “Hmm, it would be a sad day for your specialty if the people coming after you weren’t smarter or better.” And it was so right. It's progress. It's evolution. I can't stand in the way of evolution and I just felt so much better about it.


And, that's how things should be. We should get better at what we do. Things shouldn't stagnate and stay as they are.



What are the changes that you've made for ICU trainees and consultants that you were most proud of?


When I was coming up to be president, the one thing I wanted to see that happen was that we were able to continue the exam through COVID. I really wanted to drive an online exam. I think we were really lucky in that we started planning early and we started looking at “If all of this happens, what would we have to do differently?” Or “What would be the problem with this?” I said, we need to do mock exams so that trainees can get used to doing it on online and the examiners can get used to doing it.


I think what was good for us was that we had enough trainees to make it worth doing but not so many that the logistics were awful. We also had enough examiners to train, to be able to run it all. We had people like Frieda Keough – her attention to detail is just phenomenal. She had thought through everything.


We made sure that everybody had that online exposure beforehand. We were lucky that the technology held out and it worked.



What do you think are the next steps for ICU as a specialty?


I think the future for what has been a bit of a metro-centric specialty is supporting rural intensive care more. The likelihood is that's where there will be more jobs as well. I think we need to find ways to support what the regions are doing already and to make the jobs attractive to people to go and work there. The more we can get people to do permanent jobs in those areas rather than just locum or fly in and fly out will be a sort of win-win that certainly will improve the richness of our specialty.


We have been taking steps towards improving cultural safety and cultural awareness but we still have a long way to go. I think that improving the culture and wellbeing of our staff so everybody enjoys their job and their working day – I think there will be many developments so that when we look back at things that we do now, in ten years’ time we might think “Did we really do that?”


Online education is really important as well, and better feedback. I think that's something that we need to do a lot better.



Have you had a hit to your confidence at work and if so, how have you moved on from this as an Intensivist?


I don't think there is anybody who hasn't had a problem. I can remember one instance at a small private hospital. I decided to do a tracheostomy on a Sunday afternoon. It wasn’t recorded in the history, but she'd had a partial thyroidectomy in the past. And there was a thyroid remnant; I caused torrential bleeding. And again, in those days it wasn't practice to use bronchoscopy or have a second person. So, I was actually there with a resident and I had to call an ENT surgeon and it was Sunday afternoon. He was at a footy game and he had to battle his way through the pretty heavy traffic to get to the hospital and was cursing me.


I remember going home and again, saying to my husband, “Oh, this has happened. And it's all awful.” And he just looked at me and he said, “You work in a high-risk profession. Shit's gonna happen, deal with it, move on.” -- glass of red. And that was all he said. And I thought, yeah, he's right.


No one goes to work thinking, “Oh, I'm, I'm going to make a complete hash of this tracheostomy”, or “I'm going to go and cause some horrible adverse event”, but in retrospect you think all the holes in the pieces of cheese were there and to do a procedure like that on a Sunday afternoon, with just a junior resident, yada yada yada. I think there needs to be acceptance that, it's a cliche, but we're human and we make mistakes.


I think it would be a tragedy if those meant nothing and they didn't stay with us.



What was a career defining moment for you?


I remember we had two patients who'd both had gunshot abdomen injuries, AK-47. At the time the management was multiple relook laparotomies and I think they both had something ridiculous, like 18 relook laparotomies they were maxed out 100% oxygen ventilated, maximum doses of vasopressors, renal replacement therapy.


All the knobs would turn to the far right. And there was, nothing else, you know? No room to go anywhere. And as you do you talk to the patients separately and I said to them, look, we are doing everything we can. The rest is up to you. I spoke to one of the other doctors and she said, she'd had the same conversation with both of them as well. And one got better and one died, but it was just amazing to see the guy who got better leave the unit eating.


And then when I started as a consultant in Charlie's, we had a patient who was an 18-year-old girl who was in a car accident and her boyfriend was driving. I think he was killed. And she had multi trauma and a really bad head injury. She got abdominal compartment syndrome, which wasn't really recognised that much in those days. I persuaded one of the surgeons to do a laparotomy, just to open up the peritoneum, which she did to the ridicule of all her surgical colleagues, but it made such a huge difference.


We were able to control the ICP and ventilation got easier and she left the unit, although not looking great. She was making sort of semi purposeful movements and kind of looking at the ceiling. And six months later, she walked into the unit, with a bit of a limp, but she walked in, and was gonna go back to uni.


So that, that was pretty special. She was a standout.



And are there things that you learned over in South Africa that you still use in your practice today?


There were things you learned, like, how to, how to ventilate someone with severe ARDS, and to some extent how to manage with finite resources as well.


I think also just learning humility as well, how many things we take for granted, in our world. I remember I went to Fiji, and if you need a pair of rubber sterile gloves, they would've been re-sterilised and repackaged and everything. And you'd be lucky if you got two that were the same size in the same packet. And when I went to work and they said, what size gloves do you want? I was like, well, anything between a six and an eight? They'd kind of look at me like, um, okay, so I said “Well, I'll take a six and a half if you've got them.”


I think, we always grumble about resources in Australia and there are huge resource issues, but it's so much worse than so many other places. I think having gratitude for what we have is important, and perspective as well.



As an Intensivist, what do you think is the hardest part of the job?


I think it’s keeping up to date with new stuff as it evolves and comes through. As a trainee, you get exposure as part of your training. As new stuff comes in, new techniques , you have to learn it as a consultant.


I remember the first time I saw an echo machine used by Intensivists in the ICU. Yeah, that was different. Just having that integrated so casually into our practice over the years, has been really interesting. Now I'm finding the junior registrars can operate them better than me! It's like, oh my goodness. I'm just amazed at that learning.


I heard one of our senior registrars once teaching the juniors and, using ultrasound and vascular access and he said, it's like the difference between getting dressed in a dark or with the light on you. I was thinking, but there are times where it's useful to know how to get dressed in the dark. Because there might be a power cut or you're somewhere with no electricity or you don't want to wake everybody else up by putting lights on. In a house with a mass murderer and you don't want them to know where you are, it's actually a useful technique to have.



What would you say to women who are thinking of doing intensive care?


I would say follow your passion.


There's no reason to stop you. And do it how you want to do it. Don't feel there's one way. If that's your passion, that's your interest, do it.



Who inspires you and why?


I suppose if I did think about it, in my immediate circle, I would probably like to combine the characteristics of the other female board members. So I'd like to be a combination of Felicity Hawker, a bit of Penny Stewart, a bit of Nhi Nguyen and a bit of Priya Nair all in one. Oh, and a bit of Martina Zib.


I almost said our dog! There are a lot of features of dog's personalities that we can all aspire to.


I think looking back on the last two years, I just feel I've been so lucky to have been president with such an amazing group of people on the board. They're all altruistic, supportive, smart, passionate. They've just all been phenomenal.


It's been wonderful. And I think, probably the sort of wider college community isn't aware of that, but they are individually amazing and collectively just phenomenal. I've been very, very lucky in it.



Interview conducted by Dr Kerrianne Huynh and Dr Georgina Jenkins




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