dr-bruce-powell

Speak to Me

Tue, 05 May 2026 07:19:38 GMT

Same moment. Different understanding.

Annabel lies alone in her side room, cot sides up.

She can’t speak.

Who has a massive stroke at 48?

I’m not sure what to do.

I’m resigned to another bollocking.

The bow-tied neurology professor spelt out what he expected of me.

‘S-P-E-A-K to her.’

’She can’t speak, Sir’, I plead. ‘I feel like I’m annoying her.’

‘That makes two of us.’

I shuffle out of his carpeted office, back onto the wipe-clean 8th Floor, knock rhetorically, and re-enter the side-room.

The slow steady beeping of her heart monitor punctuates the sterile silence.

‘Do you mind if I call you Annabel?’

Perhaps she’s deaf and blind?

I take a gamble.

'NEVER SIT ON THE BED.' The nurses would say.

Her face flickers. Progress?

Her right arm unfolds from the lifeless left and straightens out towards me, ramrod straight, palm up, fist clenched.

Now we’re getting somewhere.

Her long, middle-finger unfurls itself from the fist and straightens beneath my chin. She eyeballs me for twenty two heartbeats.

We connect.

F-U-C-K-O-F-F she mouths.

I hang the “DO NOT DISTURB” sign on her door as I leave.

We’re trained to measure communication in words.

She managed without them.

The professor was right.

I need to learn how to listen.

The Problem with Knowing

Tue, 05 May 2026 06:12:51 GMT

There's a Price to Pay for Insight

This piece is inspired by Dr Fergus Gracey’s excellent Headway UK webinar, “Identity Change after Brain Injury”.

https://www.headway.org.uk/about-brain-injury/professionals/headway-webinars/webinar-recordings/

Without lived experience, brain injury is often seen as a problem of movement and speech. Yet for some, the real challenge is behavioural.
Aggression. Disinhibition. Apathy. Poor judgment. These are the visible, front-of-house problems. Observable. Measurable. Manageable. At least in theory.
But behaviour is only the surface. Beneath it sits something more complex.

Awareness.

Awareness first appears to be an advantage, a useful vantage point during recovery.
It isn’t that simple.
Recognising the fault line does not stabilise it.
It makes you aware of how close you are to falling.

From my experience on Both Sides of the Bed, I recognise two distinct clinical presentations that appear similar from a distance but diverge on contact.
On one side lies the patient with limited insight; disinhibited, impulsive, inappropriate. They upset people. They breach social rules seemingly without conscience or concern. Families describe them as changed, different, sometimes dramatically so.
Medical professionals label this as a personality change and focus on containment: behavioural strategies, risk management, supervision.
For their own good.
Messy but pragmatic.
On the other side lies the patient with insight. Someone like me.
They notice their disinhibition, emotional volatility, cognitive slips, hesitation, delay, and the void where confidence and identity once were.
Crucially, they remember who they were.

To observers, insight looks like preserved function, a foothold that suggests rehabilitation will be easier.
It’s not as simple as that.
From the inside, insight feels corrosive. A cursed mirror held up to the face.
Reflections do not restore function; they only serve to sharpen the contrast with the past, an enduring comparison between two portraits of self and what has been lost.
The person becomes a voyeur of their own decline.

I am plagued by the troubling misconception that insight is an advantage, a head start on a new life.
On the one hand, the system values insight because it aligns with cooperation, but on the other hand, that same insight generates distress. A sustained awareness of loss without resolution.
A new normal, clinicians call it.
The thing is, fuck off with your new normal. I don’t want it. I don’t want a lived experience, I want my old me back.
And yeah, I shouldn’t swear, and I know that you are trying to be positive.
Unhelpful helpfulness Kate and Nadine would call it*.
I experience your generosity as pain and distress.

There is a point where the language of change stops working, clumsy and unrealistic.
From the inside, the awareness of this new identity feels like discontinuity.
Not a change in personality, but the traumatic termination of one life, reincarnated as another.
Memories of my prior self feel complete but inaccessible. Those recollections fade, replaced by something unfamiliar, unstable, and misunderstood.
I know who I was, but I do not feel like him anymore.
I know the new person is me, but I do not know who I am.

At times, insight makes life intolerable.
Without it, there is at least the possibility of settling into the new version.
With insight, the comparison between past and present is relentless. The person with limited insight can adapt to new circumstances, while the person with insight constantly measures the distance from their former self.
One stable but gone. One present but unreliable.

As my life carries on and I seek a new identity and direction, the challenges of insight extend beyond clinic appointments and home life.
I access committees, advisory groups, and advocacy roles using my old identity card. The one that looks like me, but isn’t.
Insight amplifies that dishonesty.
Every contribution comes with self-monitoring.
Was I too blunt? Too slow? Too much energy?
Sometimes this spills over: a committee meeting where I push too hard. The logic is sound, intention good, but the delivery isn't. Too sharp, too direct, poorly timed. The Zoom players shift uneasily in their video-cubes. Not dramatically, but enough that I notice.
A few days later, the chair emails me.
Let’s have a chat. Perhaps this group is not the right fit for you.
That moment lands differently with insight. A painful reminder of my youthful, cantankerous self.
I might have dismissed it. Pretended to be misunderstood.
But that moment becomes evidence for the prosecution, pushing for a guilty verdict in the trial of Brain Damaged Bruce.
Worse than that, it might easily happen again.
The issue is not the chair’s comments; it is the perceived unreliability behind them.

Should I apologise and keep going, or retreat to solitary safety?
Neither holds my fragile self-worth.
Habitual apologies reframe me, but retreat shrinks my ambitions and my value.
Maybe there is a less binary, durable approach in the middle of this mess.
A way to manage my expectations rather than apologise for my errors.

Here’s how.

I shall anticipate my flakey fallibility; replace apology with correction; allow my imperfections to be visible without telling stories about them. Accept my limitations.
From the outside, insight still looks like an advantage. Just needs a tweak or two.
But from the inside, control is a draining effort, continuous and invisible.
The question is not how to eliminate that cost, but how best to spend my limited resources.

Fuck it. I’ll figure it out.
For now, I just need to rest.

*Thanks again to the PBS+PLUS APPROACH team from Monash University and the leadership of Kate Gould and Nadine Holgate for helping me with the discomfort of insight.

https://www.monash.edu/medicine/pbsplus

Man Behaving Badly

Mon, 27 Apr 2026 05:28:33 GMT

Bad Behaviour

We like to think behaviour reflects character. It’s a useful shortcut. It lets us decide, quickly, who is thoughtful and who is difficult. The problem is that it only works when capacity is stable.

When someone is abrupt or aggressive, we assume intent. But behaviour isn’t always a choice. Often, it’s a failure of execution under load.

Challenging Behaviour

In medicine, this is called “challenging behaviour.” Outside of medicine, it’s just called being a pain in the arse. Either way, the judgment is similar. But behaviour isn’t always something we choose.

After a brain injury, that idea starts to break down. You might want to stay calm and measured but still not manage it. It’s not that your values have changed, but your ability has.

Before and After

Before my injury, I worked as an intensive care doctor. My behaviour felt steady. If I was sharp or impatient, there was usually a reason. After the injury, that changed. Some days I could control myself, but other days I couldn’t. Sometimes conversations shifted halfway through, or a sentence came out wrong, and it was too late to fix it.

The difference wasn’t about character. It was about mental bandwidth.

Self-control depends on cognitive capacity: attention, working memory, and emotional regulation. Damage or overload those systems, and behaviour slips. The intention may still be there, but the execution isn’t.That’s the part other people don’t see. They see impact. A tone that feels off. A comment that lands badly. You don’t get judged on the intention behind it. You get judged on the effect it has and the effects build.

Friendship and Trust

Friendships fade. Professional trust weakens. Invitations stop coming. It doesn’t happen all at once, but through repeated small moments, little cracks, over and over.

It’s easy to see this as a question of responsibility. Maybe the injury explains it, or maybe you just lost control. But neither explanation really works for long.

The injury clearly changes what you can handle. But the consequences are still social. People still react, and the world doesn’t change much to accommodate you.

So you end up in the middle. Your behaviour isn’t completely reliable, but it still matters.

Something to Fix

Rehabilitation tends to treat this as something to fix. Techniques, strategies, therapies. Sometimes they help. Often, they only work under the right conditions. Control turns out to be conditional.

I can manage my behaviour if I’m prepared, rested, and not overloaded. Take any of that away, and the system degrades. Under pressure, the gap between intention and action widens.

This isn’t unique to brain injury. Most people recognise the edge of it. Under stress or fatigue, patience shortens, judgment slips, and behaviour changes. The difference here is scale and frequency.

But we still judge others as if their capacity never changes.

Expectations and Reality

When behaviour doesn’t match expectations, we reach for simple explanations: rudeness, lack of effort, attitude. They’re convenient. They let us blame the person and move on.

But there’s a cost to thinking this way.

When behaviour is mistaken for intention, people get judged for things they can’t control. In healthcare, this can mean people stop engaging with rehabilitation services. Outside of healthcare, it can lead to isolation, shame, and fewer opportunities.

None of this takes away the impact. Words still matter. Actions still have consequences. Understanding someone’s capacity doesn’t change that. But it does change how we think about it. Instead of asking why someone acted that way, it might help to ask what made it likely. Rather than expecting people to be consistent, expect some ups and downs. Instead of just correcting behaviour, consider what’s happening around it.

It may be less satisfying, but it’s closer to the truth.

My behaviour doesn’t always show who I am. It shows what I can handle at that moment. Sometimes those match up, and sometimes they don’t.

But only one of those is visible to others.

Thanks to https://www.monash.edu/medicine/pbsplus , Dr Kate Gould and Nadine Holgate for their fabulous course and insights into the challenges of positive behaviour support.

Dr Bruce Powell MBBS MRCP FRCA FANZCA

The NDIS Trap

Sat, 25 Apr 2026 07:53:40 GMT

The Executive Function Trap at the Heart of the NDIS

My friend Dan is dead.

He could not manage the complicated world he woke in after his brain injury.

Insurance and legal paperwork left him confused. He was overwhelmed by endless surgical, rehab, and administrative appointments. Deadlines passed, and Dan’s future was decided by the kind of paperwork most of us dislike but manage. For Dan, it was simply too much. The system became a blur, and people called him 'difficult.'

Ironically, he could not navigate the disability support system that was supposed to help him.

Dan lived in his car, fished for food and drifted to the margins of a society full of services he technically qualified for, but could not meaningfully access.

Dan’s story is extreme and tragic, but it is not unusual.

One of the strange things about the NDIS is that many people have to use the very thinking skills their disability has affected just to get help.

To get into the scheme, people have to collect reports from different doctors, figure out complex rules, set up appointments, fill out long forms, show how their disability affects them, upload documents, keep track of deadlines, answer follow-up questions, and sometimes argue decisions.

In short, they need to show they can stay organised, remember things, plan ahead, read and write well, keep going, and manage their emotions. The NDIS expects people to have strong thinking and organising skills, even when those are the very skills they struggle with.

This is a major flaw in the system, not just a small problem. The people who need help the most are often the least able to deal with all the paperwork and rules needed to get it.

Many have to depend on family, unpaid carers, costly advocates, or just luck.

Those without this kind of help often miss out without anyone noticing.

We act like this is just a matter of things being complicated. But really, it’s an extra mental burden placed on people with disabilities. It’s an extra mental cost for people with disabilities.

How good an NDIS application is, often depends less on how severe someone’s disability is and more on how skilled their helper is. Two people with almost the same disability can get very different results, just because one has an organised partner, a paid advocate, or a doctor who will stand up for them.

That’s not a fair way to judge people.

It’s a kind of bias built into the system.

Some people say the system needs to be strict. They argue public money must be protected, fraud must be stopped, and eligibility must be checked carefully.

That’s fair.

No one seriously disagrees with that.

But being thorough doesn’t have to mean making things hard to access.

A process can be strong and fair without being mentally overwhelming.

When the support system punishes people for having trouble with thinking and organising, it stops measuring real disability. Instead, it just tests if people can deal with paperwork, which goes against what the NDIS is supposed to do.

This problem is especially clear for people with brain injuries.

Many people with brain injuries seem to speak well to others, but they struggle a lot with memory, organising, thinking quickly, tiredness, planning, and managing emotions. They might be able to talk about their symptoms in a clinic but still can’t handle all the paperwork needed to prove their disability.

Families often say that applying for help feels like going through another injury. Every report has to be tracked down. Every phone call has to be made again and again. Every deadline adds more pressure to families who are already stretched thin.

This is important for both moral and financial reasons.

When people can’t get the disability support they need, the need doesn’t go away. Instead, the costs show up elsewhere, in hospitals, mental health problems, lost jobs, carer exhaustion, family problems, and more serious help needed later.

A support system that is difficult to access is not necessarily efficient.

It might just cost more in ways that don’t show up right away on a budget. We have accepted ramps for those with impaired mobility. Interpreters for those with impaired hearing. Assistive technology for those with impaired vision.

But when someone has trouble with thinking and organising, we still give them a pile of forms and call it fair. This doesn’t make sense.

If getting help for thinking and organising problems requires you to have those very skills, then the NDIS has missed the point.

Technology might help. Tools like AI writing assistants, guided evidence checklists, and better admin support could make things easier. But technology isn’t the main issue. The deeper issue is that we need to stop acting like dealing with paperwork is fair for everyone. is neutral.

It is not.

It helps some people and leaves others out.

A disability support system should focus on the disability itself. It shouldn’t judge people by how well they handle paperwork. The NDIS needs to change so that getting support doesn’t depend on showing skills that people have lost. Policymakers and administrators should redesign the process to fit the needs of people with thinking and organising problems.

And many will fail, simply because they are exhausted.

NDIS Cuts: Cost Control or Design Failure?

Wed, 22 Apr 2026 22:08:40 GMT

Cost Control or Design Failure?

“Up to 160,000 people to be removed from the NDIS.”

People’s reactions are easy to guess.
One side calls it an attack on the vulnerable.
The other calls it overdue fiscal discipline.

But both views miss the complexity of the issue.

The Wrong Argument

The NDIS was never meant to be cheap.
It was meant to be effective.

Framing the NDIS as just a cost or just an investment misses the real issue. It is both. The real question is whether the money actually leads to better outcomes.

Good disability support can lower long-term costs, but if it is managed badly, those costs can grow even larger.

What Clinicians See

For people with acquired brain injuries, support is essential. It can change the course of their lives.

Having enough support versus losing it can mean the difference between:

Returning to work or long-term welfare
Independence or repeated hospital admissions
A stable family or carer burnout

If support is taken away without a real alternative, the costs do not go away.

They just move somewhere else.

Often, these costs end up in emergency rooms, hospital beds, or with families who are already overwhelmed.

That is not real reform.
It is just shifting the burden.

What People Don’t Want to Admit

It is hard to defend the NDIS exactly as it is now.

Growth has outpaced expectations
Eligibility decisions can be inconsistent
Outcomes vary widely
Some funded supports show little measurable impact

Any system this large will have some inefficiency.

So, two things can be true at once:

The NDIS is essential
The NDIS is flawed

Ignoring this only makes the case for the NDIS weaker.

The Real Policy Failure

The real problem is not the cost.
It is the lack of precision.

Cutting large numbers of people might help the budget, but it dodges the tougher question:

Do we actually know which supports deliver long-term value?

Value is not just a matter of opinion. It can be measured:

Does it reduce hospital use?
Does it improve participation?
Does it sustain employment?
Does it reduce carer strain?

Too often, these important questions take a back seat to what is easiest for administrators.

Why Brain Injury Challenges the System

Acquired brain injuries do not follow a simple pattern.

Needs fluctuate
Recovery is uneven
A person’s abilities do not always match what is written in reports.

Someone might look stable on paper but still struggle day to day. Another person might make big improvements if they get the right support.

Rigid systems do not handle this well.

Making rough decisions about who qualifies can mean taking support away from people who need it most.

Three Key Questions

If many people are cut from the NDIS, we need to focus on a few simple things:

On what basis are decisions being made?
What evidence supports those criteria?
What replaces the support for those excluded?

Without clear answers, this is not real reform.

It is simply a step backwards.

Let’s Move Past the Labels

Arguing about whether it is a “cost” or an “investment” misses the point.

A well-designed system should do both:

Improve lives
Reduce downstreamA poorly designed system does neither of these things. neither.

Right now, the debate skips over the harder job of actually designing a better system.

What a Real Solution Looks Like

The NDIS does not need to be defended at all costs or cut without thought.

What it really needs is precision:

Identify high-impact supports and protect them
Remove or redesign low-value interventions
Recognize that complex situations need flexible solutions, not strict rules.

This is especially true for conditions like brain injury, where nuance is essential.

The Takeaway

If the NDIS cannot keep going as it is, the answer is not to cut people out.

The answer is to make better decisions.

Anything else just balances the budget by pushing the problem somewhere else.

Usually, it ends up in parts of the system that are already struggling.

Time for a Coup?

Mon, 20 Apr 2026 03:33:50 GMT

Rehabilitation's Awkward Position

Emergency departments overflow.
Ambulances queue.
Governments talk about fixing the “front door.”

That framing is wrong.

Hospitals rarely fail at the point of entry. They fail at the point of exit. Patients cannot leave. The system stalls. The blockage is not triage. It is rehabilitation.

This is where the contradiction begins.

Rehabilitation medicine is responsible for what happens after survival. It determines whether patients return to work, regain independence, or drift into long-term dependency. Yet despite this central role, it remains structurally peripheral in the very system that depends on it.

If that sounds exaggerated, it is not.

The Quiet Phase Everyone Ignores

Acute care attracts attention. It is visible, dramatic, and politically useful. Trauma teams mobilise. Surgeons operate. Intensive care units sustain life.

Then the patient survives.

What follows is slower, less visible, and far more consequential. Recovery. Function. Reintegration.

This is where outcomes are decided.

Rehabilitation is not an optional extra. It is the phase that determines whether survival has meaning beyond discharge. Yet culturally, it is still treated as the afterthought. The place patients go once the “real medicine” is done.

That hierarchy is not just symbolic. It has operational consequences.

The Beds That Did Not Come Back

During the pandemic, hospitals expanded acute capacity rapidly. They had no choice.

Rehabilitation beds were among the first to be repurposed.

The assumption was simple: they would return later.

Many did not.

The result is now visible across the system. Medically stable patients wait for rehabilitation that is not available. Acute beds remain occupied. Emergency departments cannot move patients through. Ambulance ramping becomes a symptom of a downstream failure.

We continue to treat it as a front-end problem because that is where it is easiest to see.

The Exit Problem

Modern medicine is increasingly effective at keeping people alive. That is not controversial.

What is less well addressed is what happens next.

An ageing population, rising rates of neurological injury, and improved survival from major illness all point in the same direction. The future workload of healthcare is not acute rescue. It is recovery.

Rehabilitation sits at the centre of that problem.

Remove or constrain it, and the system does not bend. It stops.

Influence Without Authority

Given that reality, you might expect rehabilitation medicine to hold meaningful influence within the structures that shape healthcare.

It does not.

Within Australia, the Australasian Faculty of Rehabilitation Medicine sits inside the Royal Australasian College of Physicians. Yet despite the scope and importance of the specialty, its presence at the central decision-making level remains limited.

That is not a theoretical concern. Governance structures signal priorities. If a specialty is not consistently represented where policy is formed, its influence is, by definition, constrained.

At the same time, a second gap persists. A field dedicated to restoring participation for people living with disability still struggles to consistently embed those voices within its own governance.

That tension is difficult to ignore.

A Familiar Pattern

There is precedent here.

Intensive care medicine once sat within another specialty structure. Over time, its clinical scope expanded, its identity sharpened, and its importance became unavoidable. Eventually, it separated and established its own college.

That process took decades.

Few would now argue it should reverse.

Rehabilitation medicine is not identical, but the trajectory is recognisable. Expanding responsibility. Limited influence. Increasing mismatch between what the specialty does and the authority it holds.

Not A Revolution, But A Question

I am being deliberately provocative. That’s the advantage of observing from outside health systems and Royal Colleges.

I am not proposing institutional theatrics, but the underlying question is legitimate.

If rehabilitation medicine is responsible for recovery pathways, discharge flow, and long-term functional outcomes, should it continue to operate with limited structural influence? Or does it need to redefine its position within the system?

There are less dramatic options. Stronger representation within existing governance. Restoration of lost capacity. Genuine inclusion of lived experience in decision-making.

All are achievable but the issue is whether they can and will happen.

The Uncomfortable Reality

Healthcare still behaves as though saving a life is the endpoint.

It is not.

It is the beginning of a different, more complex problem.

Rehabilitation medicine sits at that junction. It determines whether survival translates into something sustainable, both for the individual and for the system.

At present, it carries that responsibility without equivalent authority.

That imbalance manifests in delayed discharges, blocked beds, and patients waiting for a phase of care that never arrives on time.

Patients living with brain injury, chronic illness and ageing already carry enough. Recovery is complex without also having to compete for resources and attention.

Acute specialties dominate the system, and for good reason. They deal in immediacy and survival.

But survival is only the first step.

Whether those specialties are prepared to advocate for recovery, or whether rehabilitation medicine will need to assert its position independently, remains an open question.

Step Out of the Moment

Wed, 08 Apr 2026 00:15:43 GMT

Step Out of the Moment

My day starts with two emails.

One is from the Australian Taxation Office. It's kinda formal, measured. Not an obvious threat. A large PAYG instalment overdue, stated calmly, as if already agreed. The email doesn't ask me to act immediately; it does not include a login link and reads with a certain convincing gravitas. The kind of thing that exists whether I engage with it or not.

The other claims to be from Origin Energy . Lighter tone. I have overpaid. There’s a small refund. A neat, specific amount with a link that expires in 24 hours. The email invites action. Click. Claim. Resolve. Move on. An opportunity rather than an obligation.

Different tone. Different stakes. Same problem.

Both emails ask me to do something.

The ATO email is more subtle. It doesn't push me directly, but positions itself as legitimate and procedural. The amount is large enough to matter and the language is plausible. The message creates a quiet pressure to check, to confirm, to resolve. Not urgent, but persistent.

The Origin email is more suspicious come to think about it. Reward paired with urgency. Not addressed to me by name, just like the ATO mail. There's a link that becomes the centre of my attention. One click and a small administrative correction. Something in my favour. Something easy.

Both emails rely on the same human reflex: clear the task in front of you.

Go and put the kettle on.

It sounds trivial, almost absurd as a response to a financial prompt. But it does something that advice rarely achieves. It interrupts behaviour at the point of action. Not after analysis. Not after suspicion. Before.

The kettle is not about thinking better. It is about not thinking at all. Making a brew creates a gap between stimulus and response. A small, physical ritual that breaks the flow.

Without it, the sequence is predictable. See email. Assess quickly. Act. Even when we believe we are being careful, we are still operating within the email’s frame. We are still reacting to its cues. Its urgency, its tone, its implicit authority.

The kettle allows me to step out of the moment.

Time passes. The emotional charge fades. The need to resolve the issue immediately diminishes. What remains is easier to question.

Why would the ATO communicate something important by email and not through MyGov? Why would a refund require a separate claim at all? Why the deadline? Why the link?

These are not complex questions. They do not require technical knowledge. They require distance and time.

The kettle creates that space.

It also enforces a second step, which matters more than the first. Change the channel. If something is real, it will exist independently of the email. Inside a secure account. Through a known contact. Via a route I initiate, not one presented to me.

This is where most advice fails. It tells people to inspect the email more carefully. Check the sender. Hover over links. Look for inconsistencies. That assumes time, attention, and a level of technical confidence that is often absent, particularly under cognitive load.

The kettle bypasses that entirely.

It does not ask me to become an expert in phishing detection. It asks me to follow a rule. Pause. Ignore the email. Verify elsewhere or not at all.

In the ATO example, that means logging into my account independently and checking whether the instalment exists. If it does, the email becomes redundant. If it does not, it becomes irrelevant.

In the Origin example, the same process applies. No link. No form. Either the refund is already visible in my account, or it does not exist. The email adds nothing.

What is striking is how little effort this requires. The complexity sits with the attacker, not the recipient. The kettle shifts the burden back where it belongs.

There is also a deeper point. These emails succeed not because people are careless, but because they are efficient. We are conditioned to process small tasks quickly. To trust familiar brands. To resolve minor issues without friction. The system relies on that behaviour. Scams exploit it.

The kettle introduces friction deliberately.

It is a small, repeatable act that changes the default response. Not engage. Not analyse. Pause. Then choose a safer path.

In both cases, the content of the email becomes secondary. The decision is made before the details are considered. That is the strength of the approach. It removes the need to judge each email on its merits.

The emails look different. The mechanism is the same.

Break the momentum, and the email loses its power.

Go put the kettle on.

Rehabilitation: Underfunded and Under-estimated

Sun, 22 Mar 2026 05:28:50 GMT

Underfunded and Underestimated

Rehabilitation underfunded and underestimated — Medical Journal of Australia Insight+

�� https://insightplus.mja.com.au/2022/18/rehabilitation-underfunded-and-underestimated/

Brain Injury Community Needs Action Not Words

Sun, 22 Mar 2026 05:23:02 GMT

Time for Action is Overdue

Brain injury community seeks action on Royal Commission findings

InSight+ | 11 December 2023

This InSight+ article features my work in brain injury advocacy and the ongoing need for real action following the Royal Commission findings. Brain injury is often poorly understood, badly measured, and too easily overlooked in public discussion, despite its enormous personal and social impact.

The article speaks to a simple point: people with brain injury and their families need more than sympathy. They need recognition, better systems, and a stronger public voice.

Read the full article:

https://insightplus.mja.com.au/2023/48/brain-injury-community-seeks-action-on-royal-commission-findings/

Organ Donation and the Quiet Work of Trust

Tue, 17 Mar 2026 05:00:11 GMT

WA Parliament’s Standing Committee on Public Administration, May 2023

There is something slightly surreal about sitting in front of a parliamentary committee and explaining something that, for most of your career, felt almost routine. Not routine in the sense of easy or casual, but routine in the sense that it was simply part of the work. Another difficult conversation with a family. Another clinical decision at the edge of life and death. Another moment when tragedy might, very occasionally, allow someone else to live.

Organ and tissue donation occupies a strange space in medicine. It sits at the intersection of hope and loss. For every transplant recipient who receives a second chance, there is a family somewhere whose worst day has just unfolded. That tension is never far away for those of us who have worked in the system.

When I spoke to the Western Australian Parliament’s Standing Committee on Public Administration on the 23rd May 2023 about organ donation, my first instinct was to remind them of something very simple. None of us own this system. Not the clinicians, not the administrators, not the politicians. We are merely custodians of a process that ultimately belongs to the community. That distinction matters because organ donation is built on trust. Without trust, the entire structure collapses.

For the public to support organ donation, they must believe that the healthcare system acts first and always in the interests of the patient. Families must feel confident that doctors are trying to save lives, not looking for opportunities to retrieve organs. If that confidence were ever compromised, even slightly, the willingness of people to donate would disappear overnight.

This is why the clinical separation between patient care and organ donation is so important. In the intensive care unit, the first and only priority is the patient. Treatment decisions are made based on what is best for that individual, not on whether they might become a donor. Only when the medical situation is clear, and when death has been determined according to strict criteria, can the conversation about donation even begin.That sequence is not a bureaucratic technicality. It is the ethical foundation of the entire system.

People often imagine organ donation as a policy problem. Governments discuss legislation, registries, consent systems, and awareness campaigns. These things matter, of course, but the reality of donation happens somewhere much quieter. It happens in intensive care units, often late at night, when a clinician sits down with a family whose world has just been turned upside down.

The family is grieving, exhausted, confused, and trying to understand what has happened to someone they love. In those moments, conversations about organ donation require enormous sensitivity. The decision cannot feel like pressure. It cannot feel like an administrative process. It has to feel like a genuine opportunity for the family to honour the wishes of the person they have lost. Sometimes families say yes. Sometimes they say no. Both responses deserve respect.

One of the misconceptions about organ donation is that increasing donor registrations will automatically increase the number of transplants. In reality, the medical circumstances that allow donation are quite rare. Only a small proportion of deaths occur in conditions compatible with organ donation, usually involving catastrophic brain injury in intensive care. Even then, medical suitability and timing can affect whether donation is possible.

This means that improving donation rates is not simply a matter of public awareness. It also requires strong hospital systems that recognise potential donors and support clinicians through the complex process that follows. Training, communication, and coordination all matter. Yet even the most sophisticated systems depend on something more human: relationships.

Donation programmes rely on cooperation between many different groups. Intensive care clinicians care for the patient. Donation coordinators guide the process with families. Transplant surgeons prepare to receive organs. Administrators and policymakers create the frameworks that support the system. When these groups trust each other and communicate well, donation programmes function smoothly. When relationships break down, opportunities can be missed.

Working in this field also reminds you that healthcare professionals carry emotional burdens that are not always visible. ICU staff regularly confront situations that most people do only once or twice in their lives. Death is not an abstraction in intensive care; it is a daily presence. Supporting families through those moments is part of the job, but it takes a toll. Clinicians learn to balance empathy with professionalism, compassion with the need to continue functioning in a high-pressure environment.

Organ donation conversations occur within that emotional landscape.

What makes donation remarkable is the generosity that families sometimes show despite their grief. Agreeing to donate organs in the hours following a loved one’s death is an extraordinary act of altruism. It is not something that can be demanded or expected. It is something that must be received with humility.

This is why maintaining public trust is so important. Organ donation programmes succeed only when the community believes the system deserves their confidence. Transparency, ethical clarity, and respectful communication are essential.

There is also a tendency in policy discussions to assume that structural reform can dramatically increase donation numbers. While improvements are always possible, we must also recognise the natural limits of the process. The goal should not be unrealistic targets but rather a commitment to ensuring that when donation is possible, it is handled well.

Handled well means respecting patients, supporting families, and ensuring that the clinical process is conducted with integrity.

Looking back on years spent working in intensive care and organ donation, what strikes me most is not the complexity of the medical procedures or the policy frameworks that surround them. It is the quiet dignity of the people involved.

Families who choose generosity in the midst of grief. Clinicians who navigate the hardest conversations with compassion. Recipients who carry the knowledge that their second chance came from someone else’s loss.

Organ donation is sometimes discussed as a healthcare system or a public policy issue. In truth, it is something much more human. It is a moment when a community expresses its values.

Our responsibility, whether as clinicians, administrators, or policymakers, is simply to look after that trust.

If we do that well, the system will continue to work.

And if we forget it, no amount of policy reform will save it.

The Kettle Rule: Why Scammers Hate Tea

Tue, 10 Mar 2026 04:13:29 GMT

The Kettle Rule

I have a simple rule when something urgent or suspicious happens.

I call it The Kettle Rule.

When someone tries to rush you, slow everything down.

Put the kettle on.

Why Brain Injury Makes Me a Target

Let’s be honest. Living with a brain injury makes me the perfect target for a scam.

Reactive, desperate to avoid overload, easily fatigued, forced into binary choices.

But it’s not just me who is vulnerable to this kind of sophisticated deception.

Let’s admit something uncomfortable. We cannot eliminate scams or the criminals who create these cruel frauds. In a world designed to exploit urgency and cognitive overload, being fooled occasionally is not stupidity.

It is the cost of being human.

Talking About It Matters

The first step is to talk about it.

Share the humiliation, the anger, the depression.

Shame and isolation dissolve when spoken aloud.

Secondly, we recruit allies. Partners in the struggle.

Could Artificial Intelligence Help?

Might artificial intelligence help defend us?

Perhaps.

AI can certainly interrogate suspicious emails and messages and flag worrying patterns. But its real value may be something simpler and more human.

Opening the app forces us to pause and think.

Imagine the moment.

What was the fella on the telephone saying?

He just rang, out of the blue. Number withheld.

Grab your smartphone, laptop, iPad, whatever.

Open an AI App.

Simply doing that moves your attention away from the scam. The urgency dissipates. The moment slows. Thinking widens.

AI becomes a place to externalise the thinking. A place to cool the emotional heat and ask better questions.

In other words, it restores a little margin. A firebreak.

Other Ways to Pause

Come to think of it, there are other ways to pause.

I could walk around the garden.

Call a friend.

Or just put the kettle on.

And that is often exactly what I do.

The Phone Call

“Thank you for calling. Sounds important. I’m just going to put the kettle on and make a brew.”

“Yes but…”

“Back in ten.”

The kettle takes five minutes to boil and my caffeine-free teabags take an age to mash.

Settle down and pick up the phone.

The caller has hung up.

Of course they have.

The bastard is a scammer.

Thinking Returns

Come to think about it…

It is Sunday night.

The bank would block my account before they called me.

The caller didn’t know my name.

I’m going to take another ten minutes and drink my tea.

Then I might call my bank.

Or my friend.

Or my daughter.

I am not going to be rushed.

The kettle takes its time.

So will I.

The Kettle Rule

That is the kettle rule.

When something feels urgent, make it slow.

Put the kettle on.

If the problem is real, it will still be there when the tea is ready.

If it is a scammer, they will already be gone.

Screw AI, you got this.

Still not convinced?

Put the kettle on and have another brew.

(The beautiful illustration is provided, without permission, by my wonderfully talented and patient wife.)

Can I Trust AI? Scams and Trust in the Age of Artificial Intelligence

Thu, 05 Mar 2026 03:45:44 GMT

How could you be so stupid?

For years, scams were clumsy. Bad grammar. Odd phrasing. Suspicious formatting. They relied on volume and probability. Someone, somewhere, would offer help to the Nigerian billionaire who wanted to share their lottery winnings.

Today, scamming is an international, trillion-dollar industry powered by artificial intelligence (AI). Criminal networks share tactics and refine their methods across global online communities.

Generative AI tools like ChatGPT now refine scammers’ scripts the way marketers refine advertising campaigns, measuring responses and adjusting their patter. AI lowers costs and raises the quality of scams, seamlessly imitating authority while creating urgency with a perfect tone.

Deception on a grand economic and immoral scale.

Vulnerable people cannot adopt defensive tools at the same speed.

Why Brain Injury Increases Vulnerability

Scams work not because people are stupid, but because people are reactive.

Those living with brain injury are especially vulnerable.

When cognitive bandwidth narrows, we default to shortcuts. We yield to authority, respond to urgency and search for familiar logos.

These reactions are human. They are how our brains conserve energy.

But scammers understand these shortcuts very well and AI exploits them with extraordinary precision.

The Hidden Cost of Being Scammed

The damage caused by scams is often discussed in financial terms, but the emotional cost can is far greater.

The shame of being scammed is a corrosive burden. For people living with brain injury, whose competence may already be quietly under scrutiny, a single mistake can feel like compelling evidence.

For some, the risk is not just monetary loss, it is the potential loss of independence.

A scam can quietly become evidence in a case nobody intended to open: the case against someone’s competence.

Trust Is Becoming Procedural

For generations, trust was something we felt.

We looked for clues. Tone of voice. Familiar language. Subtle warning signals that something was not right.

AI is eroding those signals.

Messages can now perfectly imitate banks, government agencies, family members and colleagues.

Trust is no longer something we simply feel.

It is becoming procedural.

We check email addresses; verify phone numbers; interrogate callers; sometimes we stop answering the phone altogether.

The Real Question About AI

The real question is not whether AI can be trusted. AI has no conscience, no loyalty and no instinct for truth.

The question is whether humans can adapt to a world where deception is automated.

For many people, especially the vulnerable, trust once functioned as a safe place.

But trust is no longer something we feel. It is something we must corroborate.

Losing that sense of safety may be the most unsettling change of all.

High Performance Communication

Thu, 26 Feb 2026 04:56:11 GMT

Sometimes the hands hold stories that the mind can not carry.

I met a young woman the other day who interprets for the Deaf.

I expected Auslan to be something functional and efficient, translating every word.

Kind of like manual subtitling.

But it isn’t.

It’s artistic. Emotional. Contextual. Personal.

“Signs are not just words shifted onto the hands,” Lily explained. “They are social and often faintly autobiographical.”

Lily showed me.

The sign for a librarian is a gesture that mimics a hair clip. Not a definition. A recognition. A stereotype. How librarians are seen, remembered, caricatured into something instantly legible.

I watched Lily colour her ideas with instinctive, minimalist hand gestures of place and time.

“How do your friends who are Deaf sign your name, Lily?” I asked. “Do they have a secret Auslan name for you?”

Lily smiled, a favourite image forming.

“I had a severe bob haircut once, so ‘Lily’ became an L-shaped hand moving down my hair, followed by a chopping motion at the shoulder.”

When a Name Becomes a Story

A shared, affectionate observation. Funny and intimate.

A name turned into a story.

A story turned into a gesture.

Something you only understand if you know her well enough.

I found myself tearing up.

Names are a slippery struggle for me. An embarrassing weakness. Words too, sometimes, hovering and dissolving as I reach for them. It creates a quiet reluctance to socialise, to test myself, exhausted by the effort of seeming normal.

Our children can sign hunger and thirst long before they can speak. The comprehension is more fundamental than words.

I have built my own improvised system to sidestep the shame of forgetting.

Michelle, my OT, is a marathon runner. I wiggle my fingers like running legs, triggering the memory of the double “l” in her name.

Auslan and High Performance Communication

Auslan is not a crutch to lean on.

It is high performance communication.

Signs are dense and economical, loaded with imagery, history, and shared understanding. They do not politely queue like spoken words. They arrive whole. Visual. Spatial. Embodied.

Speech now seems oddly fragile by comparison. Linear. Sequential. Dependent on flawless retrieval. One missing word and the entire sentence stumbles.

Auslan reminds me of how I write: determined to create an impression, to evoke emotion rather than punctuate perfectly.

Like speech for the Deaf, enunciation is irrelevant. Meaning and context are everything.

Rethinking Communication After Brain Injury

The abrupt, traumatic changes in my life have opened unexpected ways of seeing.

I have learned that in Deaf culture:

Pointing is not rude.

Banging a table is not aggression.

Attention is negotiated physically, visibly, collectively.

Meaning lives in the body as much as the mind.

Lily introduced me to the phrase Deaf Gain, a provocative reframing suggesting deafness is not simply a loss of hearing, but a different sensory orientation bringing its own richness: visual acuity, spatial awareness, expressive nuance.

I watched the film CODA last night.

The finale.

The daughter sings while signing.

Voice and gesture layered together.

Music audible. Emotion visible.

Communication interpreted rather than merely translated.

Auslan feels strangely familiar. Less about correct vocabulary. More about conveying an idea.

Memory, Identity, and Visual Language

A feeling. A recognition. Memorably human.

I left the conversation knowing Lily not as a sequence of letters, but as a playful chopping motion at the neck.

How else would I remember a haircut I have never seen?

An abbreviated biography.

A visual shorthand.

A name less likely to drift away when my attention does.

Speech still matters. Of course it does.

But there is something quietly beautiful in discovering that meaning does not belong exclusively to the voice.

Sometimes the hands hold stories that the mind cannot carry.

When Thinking Saves Lives

Fri, 06 Feb 2026 05:47:47 GMT

High Performance and Cognitive Load

A young family is drifting away from shore.

At first it barely registers. The beach still looks close enough to swim to. The children are still laughing. Then the distance widens. The sand stops getting closer. Panic arrives quietly, then all at once.

The mother does what parents do. She scans the water. Counts heads. Gauges distance. Wind. Current. Time. Three children. Her mind races, pulling in every possible threat. This is not calm reasoning. It is instinct. Fight or flight has already begun.

This moment isn’t about courage. It’s about what happens to thinking under pressure.

All of us face moments where accuracy matters and the stakes are high. A crisis at work. A medical emergency. A sudden decision that cannot be delayed. When we fail to manage the moving parts, the consequences can be serious.

For fast-jet pilots, astronauts and medical first responders, these moments are routine. They train for them. For most of us, they are rare, which makes them harder to handle.

When too many things demand attention at once, thinking degrades. We simplify. We rush. We latch onto decisive actions, not always good ones. Psychologists call this cognitive load. You don’t need the term to recognise the feeling.

Think of a phone with too many apps open. It slows. It freezes. Sometimes it crashes. Human brains do something similar under stress.

Back in the water, the mother is carrying everything at once. The sea state. The children’s abilities. The distance to shore. The fear of what might happen if she gets this wrong. Time pressure makes it worse. Fatigue makes it worse. Under that load, options narrow.

In that narrowed space, she makes a decision. The strongest child should swim for help.

This isn’t foolish. It isn’t neglect. It’s a decision shaped by overload. When thinking space shrinks, people divide problems, offload risk, and choose actions that feel decisive. The aim is to reduce pressure now, even if it creates danger later.

High-performance training for medical first responders and fast-jet pilots isn’t about heroics. It exists to stop the brain from betraying you when it matters most.

Under threat, pessimism is dangerous. When the mind decides a situation is overwhelming or doomed, it stops problem-solving and shifts to damage control. Thinking collapses. The outcome often follows.

The boy’s experience in the water is different.

Alone, he decides the task is hard, but possible. That judgement matters more than strength. He doesn’t sprint. He doesn’t thrash. He floats on his back to rest. He paces himself. He removes his life jacket when it becomes a hindrance rather than a help.

These are not heroic choices. They are thinking choices.

The boy not an elite swimmer. He had previously failed a swimming test. What saves him isn’t fitness or bravery. It’s the ability to keep thinking under pressure.

Eventually, he reaches shore. Help follows. The family survives.

The remarkable part of this story isn’t that a child swam to safety. It’s that two people, facing the same threat, experienced two very different mental states. One was overloaded. One kept just enough space to think.

Humans aren’t the strongest swimmers. But when conditions allow, we are very good thinkers. Survival often depends less on courage than on whether thinking stays online.

In moments like these, that difference is everything.

Dr Bruce Powell

High Performance and Brain Injury

Tue, 20 Jan 2026 05:50:21 GMT

System Overload

High Performance after Brain Injury

When we think about high performance, we picture fast-jet pilots, trauma surgeons, special forces operators performing complex tasks under pressure, lives on the line, alarms sounding, and time fading away. We rarely associate high performance with standing in a supermarket aisle, pondering whether to buy Crunchy Nut Cornflakes or Coco Pops. For many of those living with a brain injury, everyday life is an endlessly demanding, exhausting and even distressing environment, with no applause or medals.

High-performance management is not about brain brilliance; it is about managing cognitive load, preserving bandwidth, and creating systems that reduce our brain’s workload and prevent meltdown. That insight matters in cockpits, frontline operating theatres, and supermarkets alike.

Cognitive Load is the Enemy

Let us start with a straightforward fact that applies to us all. The human brain has a limited working capacity and when that capacity is exceeded, just like a computer running too many programs simultaneously, performance degrades, errors increase, and in the worst case, the system collapses. In addition, with humans, cognitive overload causes fatigue to accelerate, and decision-making processes to become unreliable.

In elite environments, this is treated as a design problem, not a personal failing. High performers do not rely on talent; they engineer simplicity; pilots do not memorise every checklist because they are forgetful; they use checklists because even the elite have working memories that are fragile under stress; trauma teams do not improvise roles during a resuscitation, they assign tasks in advance because ambiguity and uncertainty consume cognition.

Now consider the cognitive reality of someone with a brain injury. Simple conversations are exquisitely complex if you are unable to filter and manage the inputs and outputs. Language, tone, intonation, facial expressions, hand gestures, and body position are complex before we even try to understand what is said, and why. We have not even got to planning a day, filtering noise, remembering instructions, managing fatigue, and regulating emotion. Ask an AI specialist how enormous those tasks would be if they had to write lines of code for each step.

None of these is a subconscious operation anymore. They are front-and-centre with the brain working closer to its limits, more often, with fewer reserves. That is not low performance. That is high load and elite performance, to survive.

Deficit and Disability

Society frames brain injury as a deficit problem.

What can’t you do? What did you forget? Why are you angry? Are you stupid?

If we assume competence, we will ask different questions.

How do we protect high-performance cognition? How might we excel for longer?

This altered perspective matters because a person with a brain injury is not failing to cope with life; they are operating in a permanently narrowed bandwidth environment, like an experienced high-level pilot working amid harsh environments with multiple targets and hunted by aggressive adversaries.

How might we share strategies across the spectrum of cognitive bandwidth?

Reduce the Load Before You Increase the Effort

In high-risk professions, the first response to overload is not to try harder. Fighter pilots reduce tasks during key moments of flight; surgeons standardise procedures to avoid unnecessary variation; emergency services use protocols. All adopt the same strategies, not because they lack intelligence, but because intelligence must not be focused on unavoidable, crucial decisions.

For brain-injured individuals, this principle is transformative. If the day is overwhelming, the solution is not motivation; it is to re-design for fewer decisions, fewer transitions, fewer environments, fewer inputs, fixed routines, binary choices, and predictable schedules.

This is not giving up; this is skilled, elite, load management.

Automaticity is the Goal

Automaticity, executing a task without conscious effort, is the hallmark of elite performance under pressure. Automaticity expends little cognitive energy and is reliable under stress. Elite performers do not perform better because they think more; they perform better because they think less. This principle applies directly to brain injury recovery.

Automaticity is a trained skill; not once, not twice, but repeatedly. Morning routines, medication, transport, communication scripts, and energy management all help reduce the load of a person living with brain injury. If a task requires active thinking, it will eventually fail under fatigue. It is commonplace for rehabilitation to emphasise task completion rather than task efficiency.

The question should not be 'Can you do it?' but 'Can you do it without thinking?'

Externalise Cognition Without Shame

We are reassured when we see a pilot or a doctor working through checklists, recognising that these strategies allow for complex planning and issue resolution. High performers aggressively, obsessively, habitually offload their cognitive burden, routinely employing checklists, whiteboards, stopwatches, standardised language, and call-and-response communication.

External memory aides for routines and checklists are safer than internal memory, yet people living with brain injuries are told to improve their memory. This is the wrong target. The target should be to remember less and thus, calendars, alarms, notes, visual and surrounding prompts are not aids, but cognitive prosthetics. By associating such strategies as those of elite individuals, we remove the social stigma around such survival tactics for those living with brain injury.

Fatigue is not a Sign of Weakness

In elite settings, fatigue is relentlessly monitored because it is dangerous to exceed accepted parameters. Tired people underestimate the impact of cognitive fatigue. Ironically, those with limited cognitive bandwidth become much more aware of their own fallibility and frailty. Ignoring this fact in either group, is not resilience; it is malpractice. Flight hours are regulated , shifts are limited , and mandatory rest is enforced . For those living with a brain injury, lack of self-awareness, reckless behaviour and disinhibition make fatigue a familiar and challenging proposition.

Thus, high-performance and brain injury behaviour means planning rest, scheduling challenging tasks early, protecting recovery time, stopping BEFORE collapse, pacing as good practice, and always being load-aware.

Language Matters

Language is an essential part of rehabilitation for those living with a brain injury. While cognitive loss can be problematic, loss of identity is most common and potentially devastating. When we frame a person living with brain injury as impaired, dependent, or fragile, we strip them of agency. The language of high-performance psychology does the opposite and treats individuals as remarkable operators constantly under demanding conditions. A simple reframing of the language restores dignity, confidence, and further boosts performance.

'You are working at your maximum bandwidth', rather than 'you aren’t coping'.

'You are remarkable' rather than 'you are damaged'.

What This Means for Rehabilitation

Rehabilitation must move beyond skills training and become performance engineering, designing environments that reduce load, training automaticity instead of insight, building routines that survive fatigue, normalising external supports, and respecting limits without judgement. This is not lowering expectations; it is understanding the hurdles of the brain-injury environment, just as we do with our elite performers.

What This Means for Society

If we understood brain injury as a high-performance challenge, we would design work differently. We would design public spaces differently. We would stop equating independence with isolation. We would stop asking people to overcome biology with willpower.

High performance does not work that way.

Conclusion

Dr Stephen Hearns (Peak Performance Under Pressure) writes about excellence under pressure in extreme environments. Still, the most extreme environment many people will ever face is ordinary life with a brain that no longer filters, prioritises, or recovers the way it used to. These individuals are not low performers; they are operating at the edge of capacity every day. The question is not whether they can rise to the challenge; the question is whether we will finally give them the tools that elite performers have learned to use. If we do, something remarkable will happen; performance returns, confidence stabilises, identity rebuilds.

Let us stop pushing harder and work smarter; create resources that respect the limits revealed by high pressure and cognitive load.

Coping with the limiting bandwidth of a brain injury IS high performance.

Christmas Shopping

Mon, 15 Dec 2025 04:16:31 GMT

Cognitive Overload: When Familiar Skills Suddenly Collapse

My friend was visiting the UK, driving in Cumbria. He is an experienced, sensible Aussie driver but had never driven this hire car before and never been on narrow icy roads populated with homicidal, tractor-driving locals. It was 3:30 pm and the last watery rays of the winter sun dropped below towering hedgerows. The driver starts to feel a strange pressure in his chest, a sense of panic and impending doom. He is close to shutting down, stopping the car, and getting out into the freezing gloom.

What is going on? He knows how to drive. There is no accident, no obvious single reason to falter.

Same man. Same brain. Different car, different roads, different light, different weather, different speed, different rules, different instincts. Suddenly something he had done effortlessly for decades becomes frightening. Overwhelming. Exhausting. His brain is flooded with unfamiliar inputs and his bandwidth collapses. Not because he is incapable, but because the context changed faster than his automatic systems could adapt.

That is cognitive overload in its purest form.

Brain Injury and Invisible Overload

I met a man yesterday, a PhD, a consultant with a chemical engineering degree from Cambridge. He suffered a brain injury a few months ago. Now he is struggling. He looks fine, no drooling or limping; he went back to work; he runs every morning; he answers his emails; he goes to the scheduled meetings in his calendar. He even went to a charity party for survivors of brain injury. Suddenly the music was too loud, the voices too demanding, the faces too complex to understand.

He ran out. Ran home. Safe.

High Performance, Bandwidth, and Automaticity

I spent the last few days listening to jet pilots, NASA astronauts, and trauma clinicians talk about this exact phenomenon. How to manage bandwidth. How to filter noise. Elite people learning how to protect decision making under stress. How to preserve automaticity. The thing is, the PhD chap was elite, is elite, but he was overcome.

Most of us do not realise that our cognitive automaticity normally lets us ignore most faces, most voices, most expressions, most background sound, most emotional signals. We do not consciously choose this. Our brain simply filters it. That filtering is what makes life feel manageable.

Take that filter away, and the world becomes Cumbria in the dark, charity disco, space shuttle engine failure or poisonous gases, shootings, and multiple burns.

Why Brain Injury Care Lags Behind What We Already Know

This phenomenon is familiar to brain injury communities and yet support groups and health professionals still struggle to understand the experience.

The irony is that we understand how to manage cognitive overload. High performance communities train for it relentlessly. Yet we do not translate those same principles to brain injury care. We do not teach filtering. We do not teach prioritisation. We do not teach cognitive load management as a survival skill.

We should.

Excellence Is Not Optional

NASA pilots and trauma specialists must excel when they are working.

Those living with a brain injury will have to excel just to shop for Christmas.

PTSD in Trauma and ICU

Sun, 07 Dec 2025 04:37:27 GMT

Me and the Space Shuttle Pilot

WTF am I doing on the stage?

I promised myself that I wouldn’t, but as usual I defaulted to humour. Joking about me and Pam, the extraordinary space shuttle pilot who spoke before me.

It is a coping strategy.

The trauma and critical care audience understood the trick. Make people laugh and you do not have to let them see what lies underneath. Six years on, it is time to stop pitching my experiences of brain injury and rebirth as a comedy set and start framing it in a way that actually serves people.

Trauma Is Not a Normal Workplace

Trauma and ICU are not normal environments.

They bend people.

Patients.

Families.

Clinicians.

Everyone absorbs something from the blast radius, whether they admit it or not. Even those of us who escape the obvious concussive effects of repeated psychological violence carry something quieter and more corrosive.

As leaders, we must be prepared to act when our colleagues are brave enough to raise their hands.

I now live on the other side of the bed. I do not like it. But it has given me a perspective I never wanted and can no longer ignore.

I do not have stories of volcanoes or space flight. I can only stand up and admit weakness and fear.

When Humour Becomes a Shield

There is a risk of me becoming a novelty act.

The ex-clinician with the brain injury.

The dark mouth.

The black jokes.

The touching photos of a life now past.

That is not why I speak.

Given the cognitive toll this takes on my brain, the anxiety and the tears, I owe it to myself to refine my message and focus my language.

If humour gets me in the room, fine.

But once I am there, I have a responsibility to say something real.

PTSD in ICU and Trauma Medicine Is Common and Poorly Managed

The simple truth is this.

PTSD in our profession is common.

It is under recognised.

It is poorly managed.

We push through.

We hide it.

We pretend we are fine.

I did all of that.

None of it worked. This is not resilience. This is survival mode dressed up as strength.

There Is No Simple Fix for PTSD

I do not have a blueprint.

I am not offering a treatment plan.

The only thing I know with certainty is this.

The first step is admitting that something is wrong.

Not in a dramatic way.

Not in a career ending way.

Just in an honest one.

From Clinician to Patient

That is the talk I owe people.

And that is the one I will give next time.

Brain Injury and Western Australia's Prisons

Sat, 29 Nov 2025 00:38:28 GMT

Brain Injury in WA Prisons: An Overlooked Majority

I attended a meeting on Wednesday evening about the health of WA's prison population and drove home with a familiar feeling of anger, disbelief, and helplessness. I thought I’d learned to manage it, but some truths still shake me. As many as 70 per cent of people in Western Australian prisons have a brain injury, and the moment they enter custody, they lose access to Medicare, their GP, their regular medication, and even the right to be represented by the Australian Human Rights Commission.

How Brain Injury and PTSD Intersect Behind Bars

Brain injury is disorientating. The gaps in memory and reason. The fear. The struggle to explain to others what is happening inside your head while looking normal on the outside; your identity melts away, leaving you in a fog of instinct, habit, and reflex. Now imagine living through that in a prison cell with no advocate, no GP, no continuity of care, no human rights framework, and no way to articulate your own needs.

That’s what shook me.

This isn’t an abstract policy failure but an identity crisis happening at scale.

When my own brain injury tore through my life, I had the privilege of people around me who wanted me alive, wanted me whole, wanted me back. Even then, the PTSD that surfaced later was destabilising. Identity reconstruction is like rebuilding a house using only the rubble and whatever memory your body still carries.

The Hidden Cost of Removing GP and Medication Access

Most prisoners don’t get that chance. Not because they’re undeserving, but because the system isn’t built to see them as human in the first place. Inside WA prisons, healthcare becomes a closed loop: under-resourced, opaque, and disconnected from the national healthcare structure. Prisoners with brain injury, who already struggle with memory, impulse control, emotional regulation, communication, and planning, are expected to navigate a complex, convoluted system.

Brain-Injured Prisoners Lose Access to Medicare

Prison’s denial of freedom is its punishment, a place for reform and rehabilitation yet in WA, prisoners are punished for symptoms and ignored for their disabilities; no Medicare, no GP, no psychologist, no oversight, and no one keeping track of what is happening to their minds. PTSD becomes a silent, ever-present accomplice.

PTSD and the Silence That Protects Injustice

PTSD teaches you to avoid what hurts and step away from the truths that destabilise your sense of who you are and how the world works; turn away from the things that feel too big, too bleak, too loaded with shame or helplessness.

But trauma also teaches you something else: if you don’t speak the truth, it corrodes you. That’s why I write, why I speak. Why am I saying this now?

My own recovery taught me that silence is never neutral. Silence protects the status quo. Silence is the oxygen of injustice. And silence is the one thing people with brain injuries in prison cannot afford from the rest of us.

Why We Cannot Stay Silent About Brain Injury in Custody

The people in WA prisons with brain injuries are not a minor subgroup. They are the majority. They are people whose neurological injuries preceded their offences, shaped their vulnerabilities, distorted their decision-making, and now determine their ability to survive incarceration. Yet they are denied the very healthcare safety net designed to prevent harm.

It is hard to describe the anger that rises when you realise this, harder still to describe the helplessness that follows. Speaking and writing such uncomfortable truths is the only act of agency I have left.

A Human Rights Gap No One Talks About

WA’s treatment of brain-injured prisoners is not a bureaucratic oversight; it is a human rights failure. A failure we have normalised for far too long.

Building a Home and Rebuilding a Life

Mon, 24 Nov 2025 05:23:16 GMT

Feeling Lucky After All

I’ve watched Grand Designs and Location, Location, Location for years, usually with a cup of tea and a raised eyebrow. You know the scenes: people crying over window frames, falling out over roof angles, melting down over tiling delays. I always used to think, “Why are these people getting their knickers in such a knot? It’s just a house. Calm down.”

What I didn’t realise then was that I’d never really had a home in the way they were fighting for.

For me, home was simply where I crashed between work shifts. A roof, a bed, somewhere to drop my bag before running back into the world. Our boys had their shared bedroom, filled with toys and books and games; Anita had shelves of photos and drawers of clothes from a range of era, family photos and jewelry; I had none of that. I didn’t invest much meaning into possessions, bricks or mortar because my identity lived entirely in my work. I never even hung my professional certificates in the toilet as was the norm. Home was an efficient, speedy pit stop between patients.

And then life changed. Catastrophically.

I will never call what happened six years ago “lucky” — it wasn’t. It was brutal and disorienting, and it took away parts of me I’ll never get back. But it also forced me to slow down in ways I didn’t know were possible. And in that slowing, I learned to care about my surroundings and my family in a way I never had before.

So when we decided to build a home — our first real home — something shifted. It wasn’t a design project. It wasn’t an investment. It became part of my recovery.

We have built an old workers’ cottage from the ground up, restoring the quirks and crooked charm that once belonged to another era, shaped gardens filled with native Australian plants, the kind of garden that will hum with life even when no one is watching. And we did it all in full view of the community. Every passer-by has an opinion. Every neighbour has a memory of what the cottage used to be.

And surprisingly, instead of shying away from it, I found myself wanting to explain what we were creating. I felt proud of my wife’s creative vision. Protective. Connected.

Somewhere in the digging, planning, repainting and replanting, something in me rebuilt too.

A home is a declaration: “This is where I belong. This is who I am now.”

For the first time in my life, that sentence doesn’t feel borrowed or temporary.

It’s not just about the structure. It’s about identity, stability, hope. When you’re rebuilding your life from the inside out, the external world starts to matter in a different way. You want it to reflect the care you’re learning to give yourself.

My home is now the place I spend most of my time. It’s where I write, where I rest, where I feel grounded. The cottage has become a physical expression of the life I nearly lost and the life I’m still building — slowly, deliberately, imperfectly.

I used to think recovery was only about the big internal battles: memory, trauma, identity. But sometimes it’s also about choosing a kitchen tile that makes you smile. Planting a tree that will outlive you. Creating a space that feels safe enough to imagine a future.

I’m not grateful for the injury. But I am grateful for the perspective that followed and the time I am afforded to appreciate all that I have.

I’m grateful for the house that now holds my days.

And I’m grateful that somewhere along the way, I realised I’m allowed to build a life that feels like mine.

In a strange, unexpected way, I feel really lucky.

Fishing Without a Hook

Tue, 21 Oct 2025 08:37:37 GMT

Fishing Without a Hook

During my recent UK visit, I found myself walking along a towpath one damp, still morning. A man stood on the bank ahead of me, holding a fishing rod over the reeds, beside the waterfowl and swans, into the dark green waters.

“Any luck yet?” I asked him.

“What do you mean?” he replied, smiling at me.

“Fish? Trout? Pike? I dunno I’m not a fisherman.”

“Neither am I.” The man laughed.

“Sorry, I’m confused. Aren’t you fishing?”

“I used to, but not anymore. My line doesn’t actually have a hook on it. I’m just catching a few moments of peace.”

The Quiet Rebellion

It’s one of the most quietly subversive things I’ve ever heard — an act of rebellion against the modern world’s obsession with results. We count everything now: steps, calories, achievements, followers, hours, output. Even rest has become competitive. We monitor our sleep to see how well we’ve relaxed.I used to live that way too.

As an intensive care doctor, I measured everything — heart rates, blood pressures, oxygen levels, lives saved, hours lost. Life was data, and success came in decimals. Then, after a cycling accident, I woke up on the other side of the hospital bed, this time as the patient.

My body was broken, my memory erased, my old self gone. Suddenly, there was nothing left to measure.

Learning to Let the River Flow

Now, I understand what that gentle fellow had been doing all along. Fishing without a hook isn’t pointless. It’s trust. It’s the radical act of allowing something to happen — or not happen. without interference.

After the crash, I couldn’t run, couldn’t work, couldn’t remember, couldn’t strive. The only thing I could do was be. For someone who’d spent a lifetime chasing goals, that felt like defeat. But over time, it became peace.

When we stop striving, the noise quietens. The river keeps flowing whether we catch a fish or not. The sky doesn’t care about our progress. The act of standing there, fully present, without agenda, becomes enough.

Writing

That’s what writing became for me. Not a job, not therapy, not a way back — just a way of standing in the river of thought and watching what floats past.

Some days, I catch something beautiful. Other days, nothing. But the point isn’t the catch. The point is the standing, the breathing, and the being.

We’ve been taught that meaning comes from doing, from building, from achieving. But meaning also hides in stillness — in walking without a destination, cooking without photographing the result, reading half a terrible book and putting it down without guilt.

These are small rebellions against a world that measures worth by productivity.

Catching Breath, Not Fish

That fisherman wasn’t talking about mindfulness. He didn’t quote philosophers or post pictures of sunsets with hashtags. He just stood there, watching the river.

He’s not catching fish, he’s catching his breath.And maybe that’s what peace looks like: not the absence of noise, but the absence of need.

“Wouldn’t you like to catch something?” I asked.

“Not at all,” he said. “A bite would spoil this moment, the only time that feels real.”

That line stayed with me. Because after my accident, the world felt unreal, a blur of effort and recovery and trying to become “me” again. Peace came only when I stopped trying. When I allowed myself to exist without a hook in the water.

“I’m sorry to have disturbed you.”

“Not at all,” the fisherman replied. “Where are you walking to?”

“Nowhere really, just walking.”

"Maybe you are further along your journey than you realise?"

Stand in the River

Sometimes the most meaningful thing you can do is nothing. Stand still. Watch the current. Listen to the water’s peace. Let the river run past you.

The world doesn’t need more people catching fish. It needs more people learning how to stand quietly in the water.

Fishing without a hook.

Is Rehabilitation Really Valued?

Tue, 02 Sep 2025 06:47:45 GMT

Brain Injury Rehabilitation, Funding Challenges, and the Hidden Value for Patients, -Carers, and Society

During the COVID-19 crisis, rehabilitation services were among the hardest hit. According to the Australasian Rehabilitation Outcomes Centre (AROC):

43% of inpatient rehabilitation services were closed or repurposed.
46% of outpatient rehab services shut down.
Half of all Allied Health outpatient staff were redeployed to other areas.

This disruption exposed a long-standing truth: rehabilitation is still undervalued, underfunded, and under-recognised. Yet the science is clear — for every $1 invested in rehabilitation, $92 is returned in long-term savings (BMJ). No other sector of healthcare offers a higher return. So why does rehabilitation remain an afterthought?

Carers: The Hidden Sacrifice Behind Rehabilitation

Families of people with a brain injury understand rehabilitation better than anyone. They know it is life changing, but they also know it is all-consuming. Without structured neuro-rehabilitation, patients rarely achieve independence. Without carers, even the best rehabilitation cannot succeed.

Too often, carers sacrifice their own futures because systems do not provide enough support. They step back from careers, education, and personal ambitions to fill the gaps. But must carers carry this heavy burden forever? Or should governments properly fund rehabilitation so carers have a real choice — free from guilt, exhaustion, and impossible sacrifice?

Why Is Rehabilitation Funding So Difficult?

The challenge is political and financial. Rehabilitation costs are immediate, visible, and fall squarely within health budgets. The benefits, however, are spread across society:

Reduced welfare dependency.
Increased workforce participation.
Stronger family resilience.
Lower long-term medical and aged-care costs.

Yet Medicare and insurance rarely cover the full rehabilitation journey. Critical elements like physiotherapy, occupational therapy, speech therapy, psychology, glasses, hearing aids, home nursing, and even ambulance services often fall outside the system. Families and patients are left to fill these gaps themselves, often at great personal cost.

What’s Wrong With the Current Rehabilitation System?

Rehabilitation is not broken, but it is consistently neglected.

The challenges include:

Slow and invisible: No TV dramas, no viral headlines, no protest marches.
Chronic underfunding: ICU and surgery attract investment; rehabilitation receives the leftovers.
Hidden burnout: Dedicated staff cover shortages with unpaid overtime, masking systemic cracks.
Cultural neglect: Rehabilitation is still treated as the “poor cousin” of acute medicine.

The result? Patients wait longer, staff burn out faster, and carers shoulder more than they should.

Do We Really Value Rehabilitation Outcomes?

Traditional cost-effectiveness measures consistently undervalue rehabilitation:

High-dependency patients often make huge functional gains, but these improvements are not captured by blunt disability scales.
Cognition and behavioural changes — which can mean the difference between dependence and employment — are rarely measured, despite their immense economic value.
Inpatient rehabilitation shortens total hospital stays, saving up to 150% in costs compared with acute wards.

The numbers prove it: intensive inpatient rehabilitation, combined with structured outpatient support, is one of the best investments a healthcare system can make.

The Challenge for Politicians

Governments tend to count the costs of rehabilitation in the short term but struggle to measure the benefits that flow across decades. Ministers see budgets, not people; deficits, not carers’ sacrifices; line items, not lives regained.

But rehabilitation is not a dumping ground for the chronically ill. It is the foundation of independence, recovery, and reintegration into society. If we valued outcomes honestly, we would reframe rehabilitation not as an expense, but as one of the smartest, highest-return investments in modern healthcare.

Rehabilitation is not about extending costs — it’s about reducing them while restoring dignity and giving patients, carers, and communities the chance to thrive.

The Brain Game: Rehabilitation After Brain Injury

Sat, 30 Aug 2025 05:05:55 GMT

No One Chooses to Play The Brain Game

No one chooses to play The Brain Game.

One day you wake up, alone on the tee, holding unfamiliar clubs, staring down a course you’ve never seen before.

You’ve played games before, life itself is one long game, but suddenly none of the old rules apply. Your grip is off. Your balance is shaky. Even your swing feels wrong.

This is what rehabilitation after brain injury feels like.

The Course No One Chooses

On this strange golf course, you notice other players. Some look confident, with caddies and high-tech clubs. Others walk alone, carrying their own gear. Everyone is nervous. Everyone is learning.

When it’s your turn, all you can do is swing. Sometimes you miss. Sometimes the ball disappears into the rough. You get a couple of mulligans, but you must keep moving.

Wherever your ball goes, you must find it and play on. Fairway, bush, impossible lie, it doesn’t matter. Rehabilitation works the same way. However many setbacks you face, you must keep trying.

Strange Victories

Welcome to The Brain Game.

At first, your progress is painfully slow. Each shot only inches forward. Victories feel strange and small:

· remembering your bank PIN,

· tying your shoelaces,

· recognising your friend in a crowd.

Every mistake hurts. Every forgotten word stings. Sometimes you cry behind a tree. Sometimes you scream at the sky. No one minds. Everyone playing this game understands the frustration.

Playing Beside Others

You’re not alone. Some people speed ahead, adapting quickly. Others vanish before reaching the green. Some walk beside you, sharing stories while hacking through their own rough.

Everyone plays the same game. No two scorecards look alike.

This is the truth of brain injury recovery: each journey is unique, but every player knows how much effort it takes to keep swinging.

Reaching the Green

Eventually, you reach the green.

Not because you mastered the course, but because you refused to give up. You swap stories with others who’ve made it this far. You share tips, laugh at the absurdity, and realise persistence is the only rule that matters.

Then it’s on to the next hole. Maybe longer. Maybe shorter. Maybe trickier. That’s rehabilitation, always another challenge, another round.

Playing Your Own Shot

Rehabilitation gives you therapists, carers, doctors, and loved ones. But eventually, everyone steps back. It’s just you and the ball. Wherever your shot lands, it’s yours to play. You are in control, however bad your golf might be.

And that’s what makes neuro-rehabilitation so hard, and so human.

There are no winners here. No podium. No trophy. Just players walking the course together.

All you can do is keep swinging.

Welcome to The Brain Game .

Why do I forget? Understanding Memory, Brain Injury, and the Gift of Remembering

Mon, 25 Aug 2025 05:22:03 GMT

Why do I forget?

Memory, Brain Injury, and the Power of Remembering

We spend far more time worrying about why we forget than asking why we remember. Yet forgetting isn't failure, it's a key feature of our remarkable brains. Without it, our brains would be drowning in details that don't matter. Forgetting clears the clutter so that memory can prioritise what's essential: the choices we've made, the relationships we value, and the stories that shape who we are. Memory is not a static archive. It's a prism, refracting our experiences into coloured light, bending our view of the world, shaping our relationships, and even defining who we might become.

Why Do I Forget? The Function of Forgetting in Memory

We tend to treat forgetting as a flaw, but in truth, it allows us to focus. By letting go of the mundane, memory gives us space for meaning. This is why happiness comes not from what we experience but from what we remember. Our remembering self, not the experiencing self, decides whether life feels good.

The Brain and Memory: How Injury Changes What We Remember

The brain is a vast network of specialised regions, each performing unique tasks. The prefrontal cortex acts like the CEO, coordinating all the divisions. But this area is fragile: the last to mature in childhood, the first to decline with age, and easily affected by trauma or infection. After a brain injury, memory can change dramatically — sometimes fading, overgeneralising, sometimes distorting.

Episodic vs Semantic Memory: Two Ways of Knowing

Neuroscientist Endel Tulving distinguished between two kinds of memory.

Episodic memory lets us mentally travel back to relive experiences: a wedding, a childhood adventure, a loved one's death.
Semantic memory stores knowledge outside of time and place: who won the World Cup in 1966, or the square root of 144.

Both are essential. Episodic grounds us in lived experience, while semantic equips us with transferable knowledge.

The Role of the Hippocampus in Forgetting and Remembering

The hippocampus is like a time machine, linking fragments of sensory and emotional experience stored across the brain. It indexes them by time and place, so recalling one fragment can bring others tumbling out. Slice an orange at a picnic, and suddenly you're remembering the football game that followed. Most everyday forgetting happens not because memories are gone but because the path back is blocked. Provide the right cue, and even long-buried experiences return.

Why Context Matters in Memory Recall

Context is everything. When a conversation shifts or a surprise occurs, we hit an event boundary. This mental fence makes it harder to recall what came before. Forgetting in these moments is not a loss but the brain reorganising, preparing for the next challenge.

Is Memory Reliable? Forgetting, Imagination, and Distortion

We like to think of memory as a photograph. It's more like an impressionist painting: part faithful, part imagined, stitched together by motives and emotions. That flexibility makes us creative, but also vulnerable to distortion.

Brain Injury, Trauma, and Remembering Too Much

For people living with PTSD or brain injury, the challenge is often not forgetting but remembering too much. Traumatic events are stored vividly, sometimes triggered by cues only loosely connected to the original trauma. The brain overgeneralises, producing flashbacks and disorientation. Yet memory is plastic. Psychotherapy, storytelling, and even writing can help us reframe painful memories. The goal is not to erase but to update and thereby place the past in a new perspective.

How Memory Shapes Identity and Collective Stories

Memory is also social. Families, communities, and nations build collective memories that shape identity. Retelling our stories constantly reshapes them, sometimes reinforcing bias, sometimes creating space for healing. Forgetting the trivial and remembering the essential keeps us grounded, connected, and imaginative.

Forget the Burden, Remember the Gift

So why do we forget? Because it allows us to remember what matters. Memory is imperfect, but that imperfection is a gift. It keeps us adaptable, creative, and deeply human. For anyone living with a brain injury or trauma, memory may feel like an unreliable partner. Forgetting aspects of our earlier life, details of our injury, or who we were, feels like failure.

We are not alone in forgetting. It’s a gift not a burden. Our memory’s unconscious flaws provide the opportunity to grow, to imagine, and to redefine who we are.

To explore more about the journey of recovery, see Rehabilitation after Brain Injury article.

Shift Happens

Thu, 21 Aug 2025 04:48:31 GMT

In this new series of podcasts, Bruce chats to some of the interesting, funny and resilient people he has met since his accident 6 years ago.

Medicine can be a very limiting and intensely personal career. Bruce now has the opportunity to listen and learn from other’s experiences.

Episode 1:

In this first episode, we hear from Bruce himself.

Episode 2:

In this episode of Shift Happens, we meet Cam, a remarkably brave and generous man.

Episode 3:

Alex is one of Fremantle Dockers doctors, looking after the well-being and fitness of the players both on and off the pitch. Engaging and modest, Alex shares some of his journey and his leadership skills.

Episode 4:

Will is a highly regarded senior arts, travel and music journalist as well as a warm generous fellow. We chat about music, writing and a host of other topics.

Episode 2:

In this episode of Shift Happens, we meet Cam, a remarkably brave and generous man.

Episode 3:

Episode 4:

Will Yeoman joins Bruce to discuss creativity, art, journalism and quantum physics in a wide-ranging and engaging conversation with one of Western Australia’s most respected journalist and presenter.

Episode 5:

Geoff chats about his long career at the ABC and his new book. Insightful, funny and thought-provoking conversation.

Episode 6:

In this episode, Bruce is joined by Christie , an AI expert who breaks down what artificial intelligence really means for our lives today – and tomorrow.

Organ donation Special

Wed, 20 Aug 2025 07:55:20 GMT

Bruce reflects upon the powerful impact of organ donation upon his personal and professional career.

Related Resources:

Psychology is Hard (Editing is Harder)

Fri, 08 Aug 2025 04:42:24 GMT

More editors than psychologists.

I’ve had three psychologists and five editors in the past five years. I’m either difficult to work with, or writing is more complicated than brain injury.

I’ve stuck with Jay* (*not Jarred’s real name), my psychologist for the past four years. PTSD, anxiety, cognitive fatigue; Jay treats them all with patience and honesty. I’ve tried to stop seeing him more than once, gone six months without his counsel, but each time I’ve had to admit I need a consulting room. Sadly, he doesn’t have a leather couch to lie back on, but his office is a formal place, somewhere to say things out loud, admit my struggles are real.

Writing is like that for me. I read my words in my head and think, Yes, that’s it. But when I hear Microsoft’s gentle Irish voice read them back, it doesn’t sound right. I chose the forgiving accent deliberately, but the phrases and syllables are still clumsy. One editor told me writing was like creating lyrics to a tune only she could hear. I should read each sentence like a line of a song, let the consonants and verbs tap out the rhythm.

Writing is hard. Proper writing, that is. Writing with verbs and prepositions, active and passive forms, a narrative arc. Medicine’s anatomy and biochemistry are black or white, right or wrong, dead or alive, so much easier. Writing isn’t binary. It’s a blitzkrieg of styles and opinions, a bewildering subjective moshpit.

“I like Hemingway and Claire Keegan,” I argue. Only because there are fewer words to blend in my head. Hemingway reckoned ninety-nine of every hundred words he wrote were rubbish, which means The Old Man and the Sea took him 2.7 million words to create. Depressing.

Editors are like psychologists for me. They keep me honest. They make me listen to my words, confront my amateurish styling, and commit to be better.

My first editor got me writing, became my friend, and is still a wise, patient guru. For her, I could just write for fun. Editors don’t read for fun.

“Bruce, this isn’t what we agreed you would write about.”

My second editor was more professorial and clinical, butchering my work with red slashes of biro; PASSIVE AGAIN scrawled across each sheet.

My third editor was a great writer and turned my waffling into a prize-winning essay.

“Who wrote this?” my wife Anita asked. “It doesn’t sound like you. Way too flouncy and funny.”

“This is really good,” the fourth often said. My medical career has made me suspicious of those who are gentle and supportive.

My fifth editor I found on a website. I sent him my first whole book, Only a Doctor .

“Your stories make you sound like a sociopath. Your readers may not know you’re joking.”

Who said I was joking?

“ Only a Doctor ?” said Anita. “You don’t think that at all. You doctors all think you’re great.”

Finally, a wonderful writer who refused to have me at her retreat asked, “Why are you trying to write about things that are still confused and traumatic?”

“Because they are important to me.”

“All the more reason to wait. Accept your experiences, process them until you can relate them without struggling for the words and choking back the tears.”

So that’s what I have been doing. Writing stories about my neurodiverse childhood, medical school trials, and my naval journeys.

I haven’t shown anyone yet.

I’m debating whether to choose a new editor or pick one from the old crew. I wonder if Jarred can edit as well as counsel. Save me the trouble of finding a seventh.

Bruce

FUBARBUNDY: Waking Up on the Other Side

Wed, 16 Jul 2025 00:19:01 GMT

Episode 1

FUBARBUNDY

Waking up in Intensive Care, “F**ked Up Beyond All Recognition But Not Dead Yet”, Dr Bruce Powell tries to make sense of what has happened.

Episode 2

All Change

Becoming an optimist, starting to make some sense of the traumatic events of that September day.

Episode 3

Christmas Day in Intensive Care

Despite being an experienced Intensive Care doctor, it is hard to understand what has happened. Paranoia, confusion and euphoria make a complex cocktail.

Episode 4

Trauma Unit and the Great Escape

Despite being an experienced Intensive Care doctor, it is hard to understand what has happened. Paranoia, confusion and euphoria make a complex cocktail.

Episode 5

Making Friends at the Rehab Hospital

When you’re a patient as well as a doctor, it can be tricky to tell which one you are supposed to be. Especially when life remains familiar and also deeply strange.

Episode 6

Back to Life – Back to Reality

Trauma is different for everyone. If you don’t really understand what happened, it isn’t especially distressing. Loved ones suffer in silence, back at the BnB.

Episode 7

Back Home

However confusing hospital can be, getting home and coming to terms with the time that has passed, is a new troubling challenge.

Episode 8

Insight can be a painful thing

Time passes slowly and the increasing realisation what has happened, is confronting and enlightening.

Episode 9

So What?

What does any of that mean? The end of the first season, and the start of something new. Coming to terms with our own realities.

FUBARBUNDY

Wed, 28 May 2025 05:15:02 GMT

Voted the Best Poster at the World Congress on Brain Injury in Montreal.

What a journey, halfway across the world to offer my poster to the World Congress and what a pleasure to be voted the winner.

The conference itself was worth the trip and I look forward to maybe contributing more when the next event occurs in Valencia, Spain 2027.

A massive thanks to the organising committee and all the fascianting, driven, passionate clinicians I met there.

Bruce.

Who are you?

Wed, 14 May 2025 04:02:55 GMT

Who are you? You’re not just your name? That’s not all you are.

What about your school, your family, your footy club, your nationality, your job, your age, your hobbies?

Do you ever think what makes you, you?

—-

6 years ago, I had to think very hard about who I was. I had a terrible accident and when I woke up, I had forgotten. Loads of things changed that day.

The nurse who found me became a life-saver.

The helicopter crew from the RFDS proved how amazingly skilled they are.

My wife, Anita became the bravest, kindest person anyone could ever be.

I became an Intensive Care patient and someone with brain damage.

—

The thing is, that being a ‘doctor’ isn’t who I am. That’s just a thing I used to do for work.

I’m not a patient anymore either, although I will always be brain damaged.

Look at those photos. I am not a navy officer, or a cowboy either ………and BTW that’s not the real Elvis.

During my recovery, I was told that I was neurodivergent.

OK, I am not arguing, but that’s not WHO I am, either.

—-

Bruce likes sport and hates bananas.

Bruce loves TV and hates spiders.

Bruce loves the beach and hates studying.

Bruce is hard-working and lazy.

I am all of these things.

It’s OK to be lots of different things.

That’s who I am.

—

Sometimes we must be who others want us to be; a good son or a hard-working pupil.

That can be hard sometimes. I have done lots of things I love and I have done things I hated too.

That’s how I managed to become a doctor, a husband and a Dad.

The better you know who you are, the better you know when things will be easy and also when you’ll have to try hard and do things that you don’t like.

Just so long as you figure out who you are, you will succeed and be proud of yourself.

Just make sure you know who YOU are.

—

So if I asked you again now, who are you? What would you say? Think about it tonite.

Maybe ask your loved ones who they are.

See what they say.

Thank you for reading this.

I am Bruce. That’s me.

Brad’s Circadian Rhythm

Mon, 31 Mar 2025 05:18:01 GMT

Hundreds of boys file into the school hall. Lines of plastic chairs are filled neatly, without gaps, not like a church or a footy stadium. This community sits shoulder to shoulder. Sure, they’re told to, but it looks natural. No one sits alone. No one is isolated by skin colour or footy allegiance. They wear uniforms and neat hair, sing their songs, and reply to prayers with one voice.

I march in behind the shrill song of the bagpipes with other members of the assembly team. I can feel emotions bubbling in my chest. Ritalin and coffee will do that, but the low hum of bagpipes and a sea of young faces would be enough to break the most stoic of observers. I stare at the floor, steadying myself. I’ve got to stand up and speak soon.

Today’s assembly is about neurodivergence and tolerance for all kinds of humans, every taste and vision. I hope none of these kids have read my grumblings about ADHD labels. I’m pretty sure they’ve got better things to do.

Earlier, I met the assembly team at the Inclusive Education Centre and was introduced to Brad (not his name). He’s tall and charming. Fifteen years old, curly-topped, and smart.

“I’m tired,” he says, straight off.

I offer him my usual brand of sarcasm, aiming for a laugh. Big mistake.

“It’s because of my circadian rhythm,” he explains. “I row. At 4:45. Every morning.”

Plonker. Too busy trying to be funny instead of listening. Now I see him. My teacher friend, an expert in all things neurodivergent, shuffles closer, looking worried. My brand of humor doesn’t always read as empathy.

“Your steroid levels go up and down,” I say, the nerdy schoolie in me resurfacing. “That’s why you’re cold early in the mornings.”

Brad looks curious. “Really?”

“Yep. When Australian athletes compete overseas, they adjust their body clocks to perform better.”

“How?”

“They train at night and sleep during the day.”

“Maybe I should try that.”

“I doubt school, or your Mum would go for it.”

He grins. “I’ll ask.”

My teacher friend relaxes. Me and Brad have found common ground in sciencey trivia.

“I owe you an interesting fact,” he says.

“I’ll be waiting.”

Little does he know I’ve got a trunkful of Guinness World Records facts ready to go — Robert Wadlow, the SR-71 Blackbird. You name it.

We shake hands. I look at him carefully, and I see him. A beautiful, vulnerable young man.

Then my name is called. A pupil leader says generous things about my bravery and resilience as I walk to the podium, grabbing it like I’m riding a runaway racehorse.

I wave to my teacher friend at the back. “Tell me when to stop, will you?” She smiles. I smile back. This is okay.

Behind me, photos flash on the screen — a boy, a naval officer, a married man, a doctor, a critically ill patient. The boys laugh. Some look worried when they see me unconscious on a ventilator.

I tell a few stories. No foreign ports, no rugby club drinking games. I manage not to blaspheme, except for a “flippin’,” which I figure is fair game. The headmaster, in his flowing Hogwarts gown, doesn’t object.

I explain how I never plan things and how sometimes that works out, and sometimes it doesn’t. Marriages and careers, accidents and injuries; take your pick.

“I’m not a patient, or a doctor. I’m just a dad and a husband now. That’s enough.”

That’s the only white lie I tell that morning.

I want to say I’m a writer too. But ten minutes isn’t enough time to explain the uncertain, uber-competitive nature of publishing, and the future.

The headmaster chokes back a tear as he thanks me, visibly moved. Then the bagpipes start, and I stagger off stage, trying to find the stage stairs through blurry eyes.

We march down the hall, the drums guiding our steps. I smile at the boys when I dare to look up.

“I need to hide for a while,” I whisper to my teacher friend, and she squeezes my hand.

I’m still waiting for Brad’s interesting fact. I bet it’ll be a good one.

Bruce Powell

Fun and Games in Osage County

Mon, 10 Mar 2025 01:53:18 GMT

I am flying to Canada on Friday. It’s the World Congress on Brain Injury. I’m presenting a poster. That’s not what wakes me up this morning. Science meetings and presentations don’t faze me but they do remind me of the old days, when I was a medic.

The thing is, Friday is a long flight—via Dubai to Montreal, a chilly and unfamiliar city. At the conference, there will be hordes of new people to engage with, hours of lectures about topics that matter to me, and long evenings trying to be sociable before finding my way back to my hotel alone.

I think I’m scared.

Yesterday, Sunday reminds me of my frailty. It’s intense.

I spend the day wrestling with building issues and budgets. I’m going to the theatre in the evening, but that will be fine. I’ll relax once the lights go down.

Brain fatigue doesn’t work like that.

My friend Ann picks me up at 4 pm. She is a good person. She tells others that I am her “cultural partner”—which sounds dodgy, I know. No hanky-panky, she’s 82. I regularly accompany her to theatre and musical events when she can’t find a more broadly educated escort.

I know I’m in trouble as we drive into town.

“Oh yes, Dexy’s Midnight Runners! Turn it up, Ann! Drive faster, let’s go!”

“Bruce, please.”

“Come on, grandad, get out the way! Fuck sake.”

Scary for Ann. She won’t understand what’s happening. Control, for me, is a delicate illusion that shatters under pressure. How would Ann know? She’s never seen this before.

There’s a scrummage in the theatre car park, cars crawling in all directions, no one giving space, everyone staring straight ahead, muscling in and out of spots. Ann’s window is down. Big mistake.

“IS THERE A FIRE?” I shout across Ann at the lady in the Porsche Cayman that’s an inch from our wing mirror.

The lady’s window winds down. “What did you say?” Porsche-woman wants a fight. And in this state, I’m hungry for conflict—emboldened, invigorated. The adrenaline rush of confrontation is the only thing keeping me upright.

“BRUCE, stop it.” Ann is mortified.

I laugh and for a moment, I get a grip. But not really.

“I’m being overcome by the stink of piss,” I yell as we take the stairwell down to the ground floor.

“Bruce, please.”

Next, the euphoria leaves and my anxiety grows.

ALCOHOL. That’s the answer. Not really, though.

The bar queue is long, and my mouth is unhinged. I moan to my fellow queuers about staffing levels. I even tell them I’m brain injured. I have never done that before. When the tannoy announces that the play is about to start, I lose it.

“Sir, you must go in now, otherwise we will lock you out.”

The drinks line disappears empty-handed into the dark.

I can’t bear my own internal turmoil. I’m not leaving without my therapy.

“Three beers, please. NOW.”

The bar lady looks worried. I just stare straight ahead. She tries to apologise.

“I’m not interested,” I snap.

I’m rude to the usher too, but she lets me passed as the lights dim.

Auto-pilot. Sit down. Drink. Drink.

Two bottles straight down. Takes the edge off my terror but I’m in free fall.

Ann has made sandwiches that she slips to me in the gloom. I eat eight quarters of chicken and mayo in the dark. One greedy mouthful each time; fairly sure I eat some of the clingfilm too.

The usher catches Ann take a nibble of her ham and mustard and comes over to tell her off. God only knows what I would have done if the usher had shone the torch in my stuffed face.

There’s a voice that only appears in my head when I am truly unhinged.

Unpeel the sandwich and slap her cheeks with the mayonnaise.

That’s him—that’s my inner voice. Now I’m really worried.

“I’m not OK,” I tell Ann in the first interval.

“Why don’t you catch a cab home?”

“I don’t think I know how. Will you look after me if I stay?”

I did and she does.

I was planning to review the play.

Osage something it’s called.

Feuding families. Jealous daughters. Fighting.

But I cannot. I don’t know what happened. I can’t remember. I lost the time.

One minute, the family gathers for a funeral—Dad’s suicide, I think.

The next, there is a woman in a dressing gown lying on the floor at the front of the stage, bawling something unintelligible as the lights dim.

The lights go down, then up.

I applaud but I cannot stand up. Not yet. The cast will have to forgive me for sitting with my head in my hands.

I am already afraid for the exit. The stairs are steep, and the crowds will be eager to get back to the killing fields of the car park. I might fall. I might take Ann with me. Crush her skull and her ham sandwiches.

This is how fatigue is for me. I should have planned the day better. It’s not fair on others.

I am my own responsibility. Montreal mustn’t go this way. I’m on my own there.

No “F**k Trump” T-shirt or risqué banter with immigration staff or police officers.

Stay in control. Rest well. Listen to my brain.

I’m going back to bed now

Born Voyage.

Bruce's Personal Journey Through Grief, Resilience, and Recovery

Fri, 14 Feb 2025 01:55:38 GMT

“Life is like a box of chocolates, you never know what you gonna get.”

Dear Mom,

I watched Forrest Gump today. Not all of it, just my favourite bits; the bit when Lieutenant Dan appears on the dockside and him and Forrest fish for shrimp together; the bit when a storm hits them and Dan sits in the rigging and screams at God for taking his legs; the bit when Forrest’s beloved Jenny comes back and tells Forrest that he has a son and that his son isn’t stupid; the bit when Forrest starts to run because of his grief at losing Jenny to AIDS; I especially like the bit when, after 3 ½ years, Forrest stops running because all that grief that he doesn’t really understand is behind him.

‘I’m tired’ he says.

I don’t know why I cry a lot. I think it might be because I’m tired. I dread these days and wonder if I will cope. But I do cope. I take one of my Ritalin and I lie down for a bit. Nala, my dog, she lies with me in a dark room.

When I’m ready I’ll get up again. That’s how it is sometimes having a brain injury. Pain and sadness and falling over and crying.

That’s OK. It’s fish and chip Friday tonight, just me and Anita.

I’ll have another go at the other stuff tomorrow.

Lots of Love,

Forrest ‘Bruce’ Gump.

Living with PTSD: A Doctor’s Journey Through Trauma and Healing

Thu, 06 Feb 2025 02:01:30 GMT

I have PTSD. There, I said it.

Am I better off with the label?

It feels like we’ve started slapping labels on everything—grief is now depression; pre-exam nerves are anxiety. Are we just medicalising the normal ups and downs of a life that is, by nature, uncertain and often cruel? Do labels help people understand and manage their struggles, or do they just invite stereotypes and stigma?

But here’s the catch: you don’t get to diagnose yourself. You can’t just print off a PTSD certificate and start wearing the t-shirt. Without a professional’s approval, there is no official label. And without the label, there is no funded therapy, no medication, no ‘approved’ way forward.

PTSD is not just stress or sadness. It comes from real trauma—something witnessed or experienced directly—that rewires the brain. It brings nightmares, intrusive memories, avoidance strategies, emotional numbness, shame, a detachment from life and relationships. And it sticks around. PTSD isn’t a bad week or a rough month. It lingers, shaping how you see yourself and the world.

So, what if I don’t have PTSD?

I absolutely do not want to be labeled, but PTSD is a strange beast. It thrives on avoidance—pushing memories away while still letting them fester beneath the surface. It makes emotional connection very hard, even with the people you love most. But here’s the thing that really messes with my head: I don’t even remember my accident. How can I have PTSD if I don’t recall the trauma itself?

Turns out, explicit memory is not a requirement. The brain does not need crisp, detailed recollections to store trauma. The body remembers the experiences, deep inside. The mind holds onto fear and pain in ways we do not fully understand. I tried waiting it out, hoping time would be the great healer. Instead, I found myself caught in a loop of anger, depression, and denial.

Given my brain injury, my PTSD is a mix of physical and psychological wounds—meaning both therapy and medication might help, but there’s no one-size-fits-all treatment.

PTSD recovery is trial and error. Brains are messy, exquisitely complex and our understanding of brain science is still rudimentary. The most well-supported treatments rely on exposure therapy—forcing the brain to reprocess trauma instead of running from it. The idea goes back to Pavlov and his drooling dogs. He rang a bell when feeding them, and eventually, they learned to salivate at the sound alone. PTSD works in reverse—the brain pairs certain triggers with fear, long after the danger has passed. Exposure therapy aims to unlearn those responses.

Writing is my version of Pavlov’s experiment. It’s a way to revisit my trauma without tearing at every fragile scar. Structured writing therapy has an evidence-base, but even outside of formal treatment, storytelling can be powerful. Writing offers a safe space where trauma can be confronted, made sense of, rewritten such that regret and fear become acceptance and optimism.

I still cry when I try to find words that encapsulate the waking moment in the Intensive Care Unit after 6 days unconscious; hearing my son’s voice, feeling his hand in mine. Maybe I’m just slower than Pavlov’s dogs, or maybe waking from the coma—the real, psychological one—takes longer than I expected.

But writing helps.

Admitting that PTSD was a problem for me, prompted me to do some research and seek help. I don’t have a t-shirt, I don’t wear a label, nor am I seeking sympathy, but with the gentle, patient aid from family and healthcare professionals, I have created a file with advice and contact details for those who can help me when I am struggling.

I’ll get over the crash. I’ll work my way out. I’ll move on.

I’ll start by writing about my past as a doctor—who I was before that day on the Great Ocean Road. Not the pain, not the fear. I don’t have the words for that yet, and I don’t want anyone else finding them for me. It’s my story.

Once I’ve written about the past, I’ll stop looking backward.

And one day—when I’m ready—I’ll write about the crash, about losing myself somewhere on that descent. And once I’ve done that, I’ll be able to write about the future.

Just not yet.

ADHD-Man

Thu, 16 Jan 2025 02:06:09 GMT

Somewhere in suburbia he’s goldfishing, tornado mode, chronic score creep, happy feet.

He does the front door Macarena.

Keys, phone, wallet, plan?

Why so chaotic?

He forgot the Kiddy Coke, the Speed, Uppers, Vitamin R, R-ball, Skippy, Smarties, Kibbles & Amp Bits, Diet Coke, R Pop, Coke Junior, Jif, his Study buddy?

Opening credits role.

Music starts: ‘Dinna dinna dinna dinna dinna dinna dinna dinna

A Deep Voice rumbles “He is vengeance. He is the night. He is ADHD-man.

Defending the ‘lazy’, the ‘stupid’ and the ‘sloppy’, avenging those who feel guilty, ashamed and confused about their special powers.

Unleashed on him by his own cruel fate, ADHD-man wages war against the slow thinkers, the narrow-minded and the evil multi-taskers.

ADHD-man thinks outside of the box. He can’t remember where he put the box.

Spontaneous, going with the flow, distractible and hyperfocused.

Get tasks done and lose track of time.

Can he reach the glamorous bikini-clad lady inexplicably tied to the railway line?

Can he divert the onrushing freight train?

Well he could have done, but he got distracted by the lizard sunning itself on the grassy embankment.

He overcomes the tallest problems with a single idea and doesn’t know where he left the keys to the Scat-Mobile.

He’s not a playboy. That would require socialisation.

He is no billionaire either, although many of his ideas will make others rich.

Either way, he doesn’t worry, just moves on.

Queue Title Music

Dinna dinna dinna ADHD-MAN.

The Range Project

Mon, 18 Nov 2024 03:05:21 GMT

Tune in as Dr Powell and our hosts Sam and Steve reflect on the challenges facing neurodiverse students in our education system, pivoting careers, seeking fulfilment and embracing uncertainty.

Headway: Brain Injury and Me

Wed, 25 Sep 2024 00:08:21 GMT

A short bio for the upcoming Headway Golf Day.

Special 3 – Bruce and Janco Return

Tue, 16 Jul 2024 00:58:57 GMT

One more chat before Janco returns to his proper career, working in “sustainability”, whatever that means.

1:05 Med Student mentoring. Brain Melt.

3:15 Golf

5:49 Beards at school

7:45 ADHD labels

10:40 Brain Injury Unit

14:10 Qantas pyjamas

15:30 Transition from patient to independent person again

17:00 Naked podcasting and nudism

27:15 Escape Plan

28:10 Base jumping and nudity

28:50 Cognitive collapse and Ritalin.

34:45 Hard to be in medicine if you don’t fit in

36:30 ADD vs ADHD

37:45 MAFFS? Isn’t that married at first sight?

38:50 Let Janco talk more

Special 2 – Bruce and Janco Chat About Their Experiences Living with ADHD.

Tue, 16 Jul 2024 00:50:04 GMT

01:08 – Episode Start

01:48 – Education and Studies

02:50 – Studying Music and a Bachelor of Audio

05:36 – ADHD and Labeling

09:20 – Writing music for ADHD people

11:14 – Being a Junior Doctor

13:22 – ADHD and Social Anxiety

19:57 – Music and the Creative Process

24:59 – Is ADHD a superpower

32:01 – What does school teach you?

39:46 – Being a Doctor and Societies Views

59:21 – Choice, Having options is much more difficult

01:04:02 – Building strong foundations

Millsy at Midday: Talking Organ Donation: Stories That Inspire

Mon, 27 May 2024 06:17:58 GMT

Chatting to the team about being an advocate for organ donation.

A touching, personal conversation about the aftermath of the accident and the interviewer’s tragic, personal connection to organ donation.

Related Resources:

The Bank of Me: When Your Reserves Run Low

Sun, 21 Apr 2024 06:30:35 GMT

I am mentally frail, fragile and emotionally labile. I have learned through personal trauma about the sort of cognitive fatigue and emotional exhaustion that affects so many of us. This is all so new to me. I never needed to check the balance in my “ Bank of Me ” account. The personal account, opened by my parents when I was young was filled to the brim for me by my family and my career. I never realised how lucky I was.

What do you do when your balance gets low?

How do you manage when your creditors come calling?

Life Stories Australia

Fri, 19 Apr 2024 06:34:00 GMT

Moving Onwards and Upwards

What a pleasure to chat with, and join “Life Stories Australia”. Trying to recount the past has opened a whole new life for me in the future and I am very excited to join Deborah and others crafting Life Stories.

“First up, in a Life Stories Australia first, we have a guest speaker who has become a member. Dr Bruce Powell, who had us all enthralled about his life story journey after a horrific cycling accident has joined our group as an Associate emerging life story teller. Along with writing his memoir, he has assisted Rhu Griffiths with workshops. We welcome him aboard. If you missed his forum or would like to revisit it, you can watch it here .”

Writing WA Podcast: Dr Bruce Powell on the (new) writing life

Fri, 08 Mar 2024 06:19:42 GMT

Writing, creativity, life change, brain injury, writing as a therapy.

https://writingwa.substack.com/p/dr-bruce-powell-on-the-new-writing

“The Year That Made Me.”

Tue, 06 Feb 2024 06:36:43 GMT

ABC National Radio

It seems obvious that the ‘Year That Made Me’, is the year that I crashed.

But it isn’t.

The year that made me was the year that I became a medical student.

The rest is just detail.

Synapse: Bruce's Journey BIAW22

Thu, 10 Aug 2023 06:26:02 GMT

Recovery from brain injury, the struggles, identity, direction, misunderstood, guilt, fighting.

Special 1 – My Friend Pierre

Sun, 16 Jul 2023 00:37:13 GMT

Pierre and I shared a room for a few weeks. His is the only face that I remember from that difficult time in hospital after the crash. He was a wonderful man and this is a tribute to him.

Rest In Peace.

Back in the Day

Tue, 07 Mar 2023 07:12:03 GMT

It’s hard not to dwell on the past, however much it shaped who you are or how you feel about yourself. I found this video in my archives and figured I would share it. If only to reveal how the hairstyles and shorts have changed with time.

Organ Donation with Me and Geoff Hutchison on ABC

Mon, 20 Feb 2023 07:37:47 GMT

The Politics of Organ Donation on ABC Radio

Mon, 20 Feb 2023 07:30:00 GMT

Multiple views on organ donation. How to improve it. Engagement is key. Passionate views from all sides.

Related Resources:

Do You See?

Wed, 14 Dec 2022 07:39:39 GMT

Investment in rehabilitation saves money. Dan died without support. Alone. Isolated. Brain injury does that. NDIS is difficult. Isolation. Tragic loss.

Thanks to the West for publishing this opinion piece.

2022 ASSBI Conference

Mon, 28 Nov 2022 05:37:35 GMT

An honour to be invited to speak at the Australian Society for the Study of Brain Impairment.

Two of us: Bruce & Anita Powell

Fri, 04 Nov 2022 06:35:29 GMT

‘I catapulted into the sign head-first’: How a brain injury redefined a marriage

Professor Bruce Powell, 56, a retired anaesthetist and former director of Western Australia’s organ-donation program, proposed to his wife Anita, 55, on a dance floor 28 years ago. A serious brain injury in 2018 redefined their relationship.

Flying Solo

Tue, 12 Jul 2022 05:42:23 GMT

“Waaaahhhhhhaaaaaayyyyyyyy”

A joyous cry erupts from business class.

Yep that’s me in 2 C.

I’m one of those people who cheers when a waiter in a posh restaurant drops a whole tray of glasses. One who laughs out loud when their wife walks into the closed glass patio door.

I’m not saying that’s an admirable or desirable trait, I’m just saying that’s who I am.

I’m sat at the front of the plane, journeying East at the behest of The Organ and Tissue Authority. Unbeknownst to most, Government policy states that I am eligible to relax at the posh end of the 737, annoying the the politicians and the diplomats.

I often raged about wasteful federal policies, but not this one. Funny eh?

I always wore my seatbelt too. Proudly unconventional, but not stupid.

I had a G, T and lime in my right hand, that’s how you know that you’re in business on an Australian domestic flight. The proletariat get a slab of lemon, a plastic cup and a can. I had vowed not to drink, as it was going to be a long 48 hours of endless meetings.

Just the one eh?

One instant, the ice cubes the Gordon’s and the Angostura bitter stained tonic are mixing amicably in the cut glass tumbler and the next, they are hovering above the glass, an 80-proof crystal chandelier.

The stomach-churning leap into the void lasts a few seconds. Next, a shattering crash back into the waves of turbulence that we had launched from.

There was a brief silence in the cabin, a jangle of falling cutlery and the tumult of escaping hand luggage from overhead lockers, and then the murmurings of fright and laughter. Clearly I wasn’t the only one whose frontal lobes thrived in that moment of energy and uncertainty.

“My fucking leg is broken,” screamed a voice from behind me.

Oh bollox!

The gin, tonic, fruit and ice reunite with such velocity that the glass tumbler is cracked, or had I reflexly grippled my tipple as we flew earthwards.

I know what happens next and mouth the countdown.

“5,4,3,2……….”

“Ladies and Gentlemen, is there a doctor onboard?”

“There we go.”

Perhaps there’s another one? My daytime job provides quite enough excitement and ego-massaging. I have no desire to perform for the assembled Qantas crowd.

The screaming was constant now, distinct in its agony.

“Ladies and Gentlemen…….”

“Excuse me, Dr Powell,” Jackie the front seat’s charming air stewardess knelt suppliantly at my feet.

“There’s a problem down the back?”

No shit Sherlock! I can hear the wailing distress through my earphone-dampened ‘80s anthems.

I unbuckle and my ego lifts me to my feet. I turn and walk slowly downwards through a dark sea of faces, illuminated only by flickering film screens. More faces lift up as the voice cries desperately from the galley at the rear.

“Ladies and gentlemen, if you could please stay in your seats while the doctor makes his way down the cabin.”

There’s always a brief, necessary period of excitement and adrenaline, psyching myself up for the battle to come. I would have happily remained anonymous, ordered another drink, but since I am summoned to perform, it’s time to get my game face on.

I resist the urge to high five others passengers, confining myself to a few winks and raised eyebrows as I catch aisle-seat eyes on my journey south.

I’ll admit it, I’m always happy to be lauded, fêted if asked, but I have grown out of the need to smear myself in medical drama. I pay an emotional price for each intervention. Images of shattered limbs and nylon nighties melted onto faces haunt me when I dream.

The screamer wasn’t in a seat.

There was a body lying ahead of me on the rubberised galley floor, head hidden by the bulkhead and occupied toilet that whooshed a triumphant fanfare as I approached.

Now I’m no surgeon, but even anaesthetists know that whether you are lying on your back or front, your feet are supposed to face in the same direction. In this case, one foot was balanced on its big toe, facing downwards and the other foot was resting on the heel pointing at the ceiling.

In medicine, we call that a “bad sign”.

I assumed it was a lady. Moderately high patent heels, tights and a blue pencil skirt was all I could see.

It was a Qantas stewardess.

First things first……a bit of traction and turn one leg round so that her feet face the same way. There’s not much point introducing yourself and seeking consent while someone is screaming in agony.

Reminded me of inserting epidurals for labouring Mums.

“Just get it in and stop asking stupid questions,” one shouted.

Suited me! I wasn’t much of a small-talker.

Now that I had straightened out her tights, twisted as they had been by her shin being snapped in half and turned round 180 degrees, I took a deep breath. Good instincts and a certain degree of spontaneity that bordered on recklessness would only get you so far. Now I needed a plan.

I said hello and made some inappropriate quip about hands up Qantas staff’s skirts. I was a very funny doctor and she smiled between winces. Her leg was more comfortable without the tightened tights and facing in the right direction.

I shoved an iv into her arm. A familiar sense of calm and control arrived.

“The pilot is circling the airport while you stabilise her doctor.”

Stabilise her in what sense I wondered? Straighten her knickers and reapply mascara.

“We need to get on the ground right now please.”

Senior doctors say “please” when they mean “Read my lips. Do this right now.”

“You’ll have to go back to your seat. Regulations I’m afraid.”

Given that she had just had the full 20 mg of morphine and my career was thus in peril, I did my best not to be rude. We were now in shared responsibility territory and I had to at least acknowledge her instructions. No need to draw pictures of blocked airways and dead colleagues. Surgeons were the same. Smile and wave boys, smile and wave.

“Tell the pilot I’ll strap in as he lands.”

Yeah right! I wasn’t going to leave her lying half conscious on the galley floor. There was no proper resus gear if things went wrong.

I was flying solo.

So what? What happened? No dramas?

Nope. Nothing really. On my day, I was amazing.

We did OK. She did OK. Ketamine sorted her out until the surgeons could nail her leg back together.

Her name was Lauren. She’s a paramedic now. She gave up being a stewardess after meeting a doctor on a flight to Canberra. She said he was lovely, gentle, kind and funny.

She found him inspiring.

I reckon that was the Special K, not my bedside manner.

Funny how you do what you do and people decide for themselves if you’re an arrogant prat, or a good ‘un.

“The Ultimate Altruism”

Tue, 28 Jun 2022 05:44:35 GMT

The Life Project: Raising Awareness in WA

“Being an organ donor is not about what it does for you, but what it says about you.”

Michael O’Reilly.

7 years ago, I started at DonateLife in Western Australia.

The job of State Medical Director was a much maligned, thankless task that clinicians didn’t really fancy. It was a highly regulated, politically sensitive area of health with considerable practical challenges for a state the size of Western Europe.

As a newbie, the chance to lead a statewide, high profile service was a unique privilege. Nothing so important, or complex would ever come my way in the United Kingdom.

The DonateLife teams across Australia are remarkable organisations. Such tireless professional commitment to donors and their families was humbling to be a part of. Thanks to their graft and attention to detail, I was able to work on innovative ideas and projects, trying to connect our community upon whom we relied for our life-saving organs and tissues.

The Life Project at City Beach was the culmination of 4 years work. Collaboration with Town of Cambridge Council, WA Health, our donor family community and Simon Youngelson the sculptor, led to the beautiful installation that graces the foreshore to this day.

I’d like to think that all those people and all those organisations across Australia, have led to the remarkable increase in donor registrations that we have seen over the last 2 years.

Organ donation is the ultimate act of altruism and it speaks volumes of the Australian spirit that despite COVID, we remain willing to offer the gift of life to others.

Sure, we have a way to go to match the best, but each step is a crucial one in the right direction.

Thank you!

Bruce

https://www.lifeproject.com.au/register/

http://www.donatelife.gov.au

https://www.simonyoungleson.com

“We Know it Hurts”

Sat, 21 May 2022 05:48:51 GMT

Personal privacy and public health: "I've had to delete my SafeWA app and burn my AstraZeneca t-shirt"

Fri, 18 Jun 2021 06:20:56 GMT

ABC Mornings News Panel guests criminal barrister Linda Black and doctor and writer Bruce Powell, discuss whether the WA Police use of data from the SafeWA app was a breach of privacy.

"I've had to delete my Safe WA app and I have had to burn my AstraZeneca t-shirt," Dr Bruce Powell said.

"What am I supposed to do when the goal posts around SafeWA privacy and the vaccination go around so fast, I don't even know which way to kick."

Linda Black described the actions by police as "deplorable".

"I think it is absolutely deplorable behaviour by the Police Commissioner, to take advantage of what he described as a loophole in the terms and conditions in circumstances where he knew that people had been prepared to give up their essential privacy in order for the protection of the greater public good, and the protection of all of our health," she said.

Listen to the full conversation on Mornings with Nadia Mitsopoulos.

ABC Perth Drive: Dr Bruce Powell on his life changing accident

Mon, 03 Aug 2020 06:17:09 GMT

Geoff Hutchison and me chat about life after brain injury. Early days. Loss of memory. Dark humour. Resilience. Charisma. Fight on. New start. New normal.

https://www.abc.net.au/listen/programs/perth-drive/dr-bruce-powell/12520266?utm_content=link&utm_medium=content_shared

Back from the brink. Podcast Special with The Medical Journal of Australia

Thu, 16 Jul 2020 00:31:47 GMT

Anaesthetist Dr Bruce Powell was competing in a charity bike ride when he slammed into a telegraph pole at 65km/h, almost killing him and ending his clinical career. He talks about medicine, living with a brain injury and sharing what he’s learned about being a better doctor.

The Other Side

Thu, 14 May 2020 05:50:52 GMT

ON 16 SEPTEMBER 2018 my medical career ended. It wasn’t that I made a terrible mistake with a patient’s care or falsified my tax return. I hadn’t suffered an epiphany of self-doubt in the face of the tragedy and sadness that so often colours our lives as doctors. I wouldn’t even say that I had found the working pressures and expectations too onerous to bear any more, growing accustomed as we all must, to a professional life of clinical crises and administrative torment. In fact, I’d probably come to take my charmed life in Western Australia for granted having largely figured out how the patients, the people and the politics stuff really worked.

I think that I felt that I was at the peak of my powers, widely qualified across medicine, critical care and anaesthesia, working both publicly and privately. As the state’s leader of Donate Life, donor numbers had almost tripled in six years and no one was more surprised than me that I was the longest-ever serving medical director. Unfortunately it turns out that pride really does comes before a fall. To be precise, on a damp chilly morning, descending the steep and slippery road into the Victorian coastal town of Apollo Bay, I cycled head-on into a street sign at 65 km h.

I don’t remember any of the bad stuff, the broken neck and shattered jaw, the partial scalping and the torn off ear, the crushed chest and multiple lumbar fractures. I missed the worst of the anxiety and pain, ventilated and restrained for a week while my family held a vigil at my bedside. I also missed the fear and the distress, the sleepless nights and the over-the-phone consents for stabilising trauma surgery that I inflicted upon them. Once I finally awoke in the intensive care unit many days later, my wonderfully gentle wife Anita repeatedly had to explain to me that I was a patient and not the on-call consultant.

Even after I had escaped the critical care and trauma wards, my befuddled brain still defaulted to familiar behaviours, wandering around the rehab hospital TV room in my pyjamas, examining other’s wounds and drip sites on my daily “ward round”. Afterwards, mentally exhausted, I would then fall asleep watching another Netflix series that I wouldn’t remember.

In time honoured medical tradition, I even tried to cheat on my cognitive assessments by plotting with my dear brain-tumor roommate to memorise the questions that he was asked. Sadly I couldn’t remember any of his prepared answers and failed miserably. It’s a long journey back to medical expertise when you can only recite two of a list of 15 words that you’re meant to remember. Having returned from Melbourne six weeks after the crash, rehabilitation at Fiona Stanley Hospital in Perth was confronting and upsetting. The fight to recover drove a bewildering mix of emotions.

I seemed to be the only one in clinic not in a wheelchair and for that I felt terrible guilt and perverse regret. I was ashamed because I even had to make up stories foreach of my amazing carers, just to allow me to recall their names. Michelle (“two-little-legs-runner”) the occupational therapist cared for me with such patience and kindness. (“Whiffy”) Miffy at the state head injury unit was all optimism and empathy in the face of my stream of tangential consciousness and bitter rage. Times had now changed. I was suddenly afraid of uncertainty, wary of my explosive, irrational anger and reckless nature. The diffuse axonal injuries had left my personality peppered with multiple micro-haemorrhagic holes and through them the irrationality could uncontrollably flow out. I would cry repeatedly during our hours together and each would sit quietly and wait for the emotional squalls to pass. In between showers of tears I would rage and laugh, wandering without embarrassment or insight across a whole range of unrelated personal topics. My rehab consultant told me bluntly, when we first met unscheduled in a corridor, that she didn’t know if I would ever work again. I was so angry and upset, having fought irrationally hard with only that single outcome in mind, that it wasn’t until the rush hour train journey home that I calmed down enough to blub embarrassingly once mor e.

How could any of the rehab team know whether I was fit to practice? Who even knew what us gassers did?

“Exhaustive knowledge of human physiology?”

“Precise dosing of dangerous and complicated drugs?”

“Hours of intense concentration?

”All that sounded very challenging but nothing like what I did as a senior clinician.

It was only as the time came closer to reboot my expertly crafted 80s operating theatre playlists that the reality began to dawn. Physically, my “Jeff Bridges” beard now hid the metalwork in my chin and only the subtle neck and hand scars betrayed the plates and screws holding my head and hands on.

I looked pretty normal, long hair and all. As D-day of my return to work approached, through repeated sleepless nights, I was forced to admit to myself that I was afraid of the huge responsibility that us anaesthetists bear and realised how often I would have to hide my own anxieties to facilitate others doing their jobs. An anaesthetist’s lot is not to take centre stage but to quietly keep everything in order. Early on in our relationship, I tried to tell my brilliant private surgical partner of my concerns for a particular patient. “Sorry Bruce” he interrupted “I don’t want you to take this the wrong way but I’m not really interested. You know what you’re doing. I’ll just wait until you’re ready.

”His dismissal of my concerns had me livid for a moment and then just as quickly very flattered and emboldened by his trust in me. We were a great team for that very reason, that and a shared love of beer and oysters. Naturally it can be daunting to be a leader and us anaesthetists often have to step up. We are relied upon, trusted with command of the ship when the storm breaks, deliberately calm and precise. For all the time that I had fought to return to work, I had sub consciously belittled my role. I had focused upon the ease that 25 years of experience and hard graft had afforded me. “I’m only an anaesthetist” I used to dismissively say. On reflection that was true, in the same way that Donate Life’s extraordinary donor co-ordinators are “only” administrators, mere facilitators. Of course the reality is that both groups are only noticed when things go wrong, when fault needs to be attributed. That is when we have to stand up and lead. Otherwise we just sit quietly, “drinking coffee”, “playing sudoku”, crediting others with the successes and the lives saved.

"The greatest ally of the physician is time” my first medical consultant used to recite before each ward round. I remind myself of that incantation when the black dog tries to interrupt my morning ocean swim. I won’t ever anaesthetise again and that is hard to accept. I am acutely conscious that I am much luckier than other trauma victims and for that I quietly rejoice. I think that I’m finally done trying to remember what happened yesterday. I’m certain that today and tomorrow are much more important.

“Is it OK to Cry?”

Thu, 07 May 2020 05:52:29 GMT

“I was better after I had cried than before – more sorry, more aware of my own ingratitude, more gentle.”

Charles Dickens. Great Expectations.

I cried quite frequently when I was working, although not in front of colleagues or patients if I could help it. Tears were a release, not an omen of imminent meltdown. I could just as easily make some uncomfortably dark joke and move on. Also, my outbursts didn’t have to specifically be caused by one of our patients. Sometimes a combination of personal life pressures and work responsibilities had me sitting in the consultant’s car park sobbing. It never occurred to me that I might be depressed or need help, since open expressions of emotion were a family trait that I never grew out of. I only recognised the ‘tear-taboo‘ that I was breaking when I casually mentioned my occasional outburst at a senior management, leadership course. My casual revelation during a group discussion, precipitated a wave of quiet, concerned looks and corridor hugs.

Sensitive men had all the fun it seemed.

I believe that most doctors cry, male and female, the reserved and the pathological, although we would all prefer not to. It’s a painful business, unwittingly connecting with the anguish and the suffering that we witness. The public, whom we serve, might expect us to be moved by their experiences, empathetic and understanding, and also remain placid and calculating. The discomfort of seeing your medical professional crying over your loss, or your impending demise, was not really what anyone wanted. Warmth and empathy were rarely expressed and on ICU, regarded with suspicion.

I once spontaneously kissed a brave, paralysed, spinal-injury patient who returned unannounced to the unit to deliver a box of chocolates. Not a Trumpesque smooch on the the lips, just a peck on the cheek. Even so, the nursing staff appeared distinctly uncomfortable with my genuine delight at seeing her. I hadn’t planned to react thus, but I was so surprised and moved to see her cheerful face, so full of vigour and life that it seemed only natural. The more conventional show of joy, the hug, was not that easy to accomplish with someone in a wheelchair. If you were not careful, you could find yourself shoving their face into your groin as you semi-bend over and hug their head. Even I had limits to my interactions.

I’d known the lady for three months, from her near-death-admission, to her triumphant, admittedly wheeled, departure. When I think of her fortitude and her injuries now, having broken my own neck and back and walked out of hospital seven weeks later, it is hard to contemplate such human spirit. I don’t think that I would ever have spoken civilly to anyone ever again if I’d have been paralysed. I’d have gone for the Lieutenant Dan, Forrest Gump version, raging against life and smoking huge amounts of weed. Of course “Lootenant Dan” becomes wealthy, regains his will to live and even walks again on his “magic titanium legs”. Back in the real world, my legs hadn’t been blown off by a land-mine and worked only a week after the crash, so I wasn’t exactly Stephen Hawking either.

Shedding tears, connecting with other’s pain, doesn’t necessarily make you a better doctor. It might actually render you ineffective in a crisis or break you in the longer-term. A brain surgeon, an ED physician, an executive nursing officer, as leaders, may not have the luxury to be so self-indulgent. It’s not cold-hearted to become accustomed to death and suffering, if that is your normal daily routine. For me, there might be 20 patients on the Intensive Care Unit. If bed one was the helmet-less motorcyclist who had left his testicles on the handlebars of his Harley as he crashed and broke the world long jump record, there was still 19 other patients to care for, so we moved on. One of my bosses used to reverse the order in which we saw the patients, start at no. 20 instead of one, each alternate day. I could only ever remember about half the patients by name, so that worked well for me. Whichever end you started, after two hours of concentration, everyone was drained. You most certainly couldn’t emotionally care for everyone, solve their complex, life-threatening medical condition and recall who asked for the “Berry Hibiscus Refresher” on the day’s coffee order.

Despite all that training and those learned professional strategies, you could still be caught out. There would be a sudden, unexpected lump in the throat and a strange hiccup instead of a steady intake of breath, like suddenly realising you are going to be sick. There would always be a patient that triggered the gut-reaction but not in isolation. Such a dramatic reversal of mood could be precipitated by up-all-night-fatigue, or a patient’s extraordinarily tragic plight, but often a combination of both. The more experienced I became, the less likely it was that I would be shocked or surprised, but the rare times I was truly moved, the experience was even more intense and draining.

I read that each different area of medicine tugs upon their own unique heart-string. In the emergency department, if tragedy is to strike, patients normally die within the first two hours of their arrival. Thus the principal emotion is shock, often made worse by the tendency for patients to be younger and previously well. On the contrary, patients who die after weeks in hospital, have fostered relationships with staff. There is more sadness and a sense of loss for doctors and nurses alike, often shared with relatives whom they have come to know. In Intensive Care Units, patients have about a 20 percent overall chance of dying, or much higher depending on what is wrong with them. Hence it is not a shock when people die, but it is often after a long, courageous struggle and a period of shared relations and friendship.

I used to smile knowingly to myself when chatting to relatives who would optimistically say, “They’re a real fighter, you know Doc.” That phrase invariably condemned the patient to a drawn out and painful death. “They’ll just give up and die, Doc.” That would have been much easier to witness and less traumatic, but it never happened. The human spirit and a bloody-minded refusal to let this sweet life go, just didn’t allow it.

Increasing Donor Numbers Through Trust and Community

Wed, 06 May 2020 05:54:24 GMT

Trust. Engagement. Donor register. Community. Life-saving. Courage. Increasing donor numbers.

Breaking Down the Barriers – Medical Forum
— Read on mforum.com.au/breaking-down-the-barriers/

“Threw Him Away”

Sat, 02 May 2020 05:55:55 GMT

Starting a new job is confronting and disconcerting. The day before, you knew what you were doing, you were an ‘expert’. Now that you have been promoted or recruited, ironically, you’re clueless. You will definitely figure it all out, but the first few days constitute a crisis. Medicine is especially prone to that phenomenon and the accompanying anxiety that comes with moving one-step closer to the absolute responsibility for each patient’s well-being.

The State Medical Director for Organ and Tissue Donation was a very large step indeed. High profile and politically tricky, the unique part about donation was that without our community’s engagement, belief and trust in us, there was no donation. It wasn’t ‘my’ service, nor anyone else’s at DonateLife. We were merely the facilitators of a life-saving process that had no ceiling to its budget, no limit to the number of retrievals we could potentially do, except those set by the public’s willingness to donate part of themselves, to someone that they would never meet.

I witnessed my first organ retrieval as a houseman, looked after kidney transplant patients as a nephrology registrar, anaesthetised for organ retrieval and implantations and finally cared for donors and their relatives on intensive care unit. With increasing experience and fewer chance of surprises, comes a vague whiff of arrogance, even for the humblest of us. I was already an ICU Head of Department and now a whole Australian State’s solo representative on the national ‘Organ and Tissue Authority’.

I was practically a God and divinity can make social engagements particularly enjoyable, since our community holds a special place of mystery and intrigue for organ donation and transplantation.

“Do they take your organs before you’re dead?” took a bottle of Corona to dispel.

“Has anyone ever woken up after their heart was removed” took only a mouthful of nuts to deny.

Whereas “how come my relatives can overrule my decision to be a donor” could take a half bottle of wine to cover the legalities and the rationale. In fact the questioner needed the other half of the Sav Blanc to stay enthused.

It had only been a few weeks but I had it pretty much covered already. Our community knew so little about donation that even the range of questions was predictable and limited.

“Are you in charge of organ donation?” a lady asked as she approached me and my newly acquired sausage from the BBQ. I instinctively hoped this was the second “has ever anyone ever woken up…..” question. If it was, the sausage would outlast my answer.

“They threw my husband away.”

That was a first, as an opening gambit at a BBQ. The novelty of the introduction was in itself, disconcerting, irrespective of the images it conjured.

“He had a brain tumour. So they just threw him away.”

I gazed thoughtfully down into the heart of my sausage/bap/onion combo and wished it was a bottle of Gin.

“They never told us that he could have been a donor. Never asked us. Just dumped him in a hospice and waited for him to die.”

I tried to formulate an opening line through the beer, wine and nuts, still staring at my onions but missed my slot in the discussion.

“Me and my kids don’t get to go to any services of thanksgiving. Have him remembered for saving someone’s life.”

“Just threw him away.”

“Why didn’t they ask me?”

I sort of knew the medical answer to that conundrum, but from the other side, that reasoning didn’t stand up to scrutiny.

I would have to find answers for us both.

Me and Geoff Hutchison Chatting about Organs

Fri, 01 May 2020 05:57:09 GMT

More of Geoff and me chatting about organ donation. Sign up. Engage. Take the time to sign up. Gift of Life. Improving .

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Life After the Fall: The Anaesthetist Who Faced the Unexpected

Sun, 26 Apr 2020 06:01:30 GMT

On September 16th 2018 my medical career ended. It wasn’t that I made a terrible mistake with a patient’s care or falsified my tax return. I hadn’t suffered an epiphany of self-doubt in the face of the tragedy and sadness that so often colours our lives as doctors. I wouldn’t even say that I had found the working pressures and expectations too onerous to bear any more, growing accustomed as we all must, to a professional life of clinical crises and administrative torment.

In fact I’d probably come to take my charmed life in Western Australia for granted having largely figured out how the patients, the people and the politics stuff really worked. I think that I felt that I was at the peak of my powers, widely qualified across medicine, critical care and anaesthesia, working both publicly and privately. As the State’s leader of DonateLife, donor numbers had almost tripled in 6 years and no-one was more surprised than me that I was the longest-ever serving Medical Director. Unfortunately it turns out that pride really does comes before a fall.

To be precise, on a damp chilly morning, descending the steep and slippery road into Apollo Bay, I cycled head-on into a street sign at 65 kmh. I don’t remember any of the bad stuff, the broken neck and shattered jaw, the partial scalping and the torn off ear, the crushed chest and multiple lumbar fractures. I missed the worst of the anxiety and pain, ventilated and restrained for a week whilst my family held a vigil at my bedside. I also missed the fear and the distress, the sleepless nights and the over-the-phone consents for stabilising trauma surgery that I inflicted upon them.

Once I finally awoke in ICU many days later, my wonderfully gentle wife repeatedly had to explain to me that I was a patient and not the on-call consultant. Even after I had escaped the critical care and trauma wards, my befuddled brain still defaulted to familiar behaviours, wandering around the rehab hospital TV room in my pyjamas, examining other’s wounds and drip sites on my daily “ward round”.

Afterwards, mentally exhausted, I would then fall asleep watching another Netflix series that I wouldn’t remember. In time honoured medical tradition, I even tried to cheat on my cognitive assessments by plotting with my dear brain-tumour roommate to memorise the questions that he was asked. Sadly I couldn’t remember any of his prepared answers and failed miserably. It’s a long journey back to medical expertise when you can only recite 2 of a list of 15 words that you’re meant to remember.

Having returned from Melbourne 6 weeks after the crash, rehabilitation at Fiona Stanley was confronting and upsetting. Learn more about the Rehabilitation after Brain Injury process here. The fight to recover drove a bewildering mix of emotions. I seemed to be the only one in clinic not in a wheelchair and for that I felt terrible guilt and perverse regret.

I was ashamed because I even had to make up stories for each of my amazing carers, just to allow me to recall their names. Michelle (‘two-little-legs-runner’) the OT cared for me with such patience and kindness. (‘Whiffy’) Miffy at the state head injury unit was all optimism and empathy in the face of my stream of tangential consciousness and bitter rage.

Times had now changed. I was suddenly afraid of uncertainty, wary of my explosive, irrational anger and reckless nature. The diffuse axonal injuries had left my personality peppered with multiple micro-haemorrhagic holes and through them the irrationality could uncontrollably flow out. I would cry repeatedly during our hours together and each would sit quietly and wait for the emotional squalls to pass. In between tear-showers, I would rage and laugh, wandering without embarrassment or insight across a whole range of unrelated personal topics.

My rehab consultant told me bluntly, when we first met unscheduled in a corridor, that she didn’t know if I would ever work again. I was so angry and upset, having fought irrationally hard with only that single outcome in mind, that it wasn’t until the rush-hour train journey home that I calmed down enough to blub embarrassingly once more.

How could any of the rehab team know whether I was fit to practice? Who even knew what us gassers did?

“Exhaustive knowledge of human physiology?”

“Precise dosing of dangerous and complicated drugs?”

“Hours of intense concentration?”

All that sounded very challenging but nothing like what I did as a senior clinician.

It was only as the time came closer to reboot my expertly crafted 80’s operating theatre playlists that the reality began to dawn. Physically, my ‘Jeff Bridges’ beard now hid the metalwork in my chin and only the subtle neck and hand scars betrayed the plates and screws holding my head and hands on. I looked pretty normal, long hair and all.

As D-day approached, through repeated sleepless nights, I was forced to admit to myself that I was afraid of the huge responsibility that us anaesthetists bear and realised how often I would have to hide my own anxieties to facilitate others doing their jobs. Anaesthetists lot is not to take centre stage but to quietly keep everything in order.

Early on in our relationship, I tried to tell my brilliant private surgical partner of my concerns for a particular patient.

“Sorry Bruce” he interrupted “I don’t want you to take this the wrong way but I’m not really interested. You know what you’re doing. I’ll just wait until you’re ready.”

His dismissal of my concerns had me livid for a moment and then just as quickly very flattered and emboldened by his trust in me. We were a great team for that very reason, that and a shared love of beer and oysters. Naturally it can be daunting to be a leader and us anaesthetists often have to step up. We are relied upon, trusted with command of the ship when the storm breaks, deliberately calm and precise. For all the time that I had fought to return to work, I had subconsciously belittled my role. I had focused upon the ease that 25 years of experience and hard graft had afforded me.

“I’m only an Anaesthetist” I used to dismissively say.

On reflection that was true, in the same way that DonateLife’s extraordinary donor co-ordinators are “only” administrators, mere facilitators. Of course the reality is that both groups are only noticed when things go wrong, when fault needs to be attributed. That is when we have to stand up and lead. Otherwise we just sit quietly, “drinking coffee”, “playing sudoku”, crediting others with the successes and the lives saved.

“The greatest ally of the physician is time” my first medical consultant used to recite before each ward round. I remind myself of that incantation when the black dog tries to interrupt my morning ocean swim. I won’t ever anaesthetise again and that is hard to accept. I am acutely conscious that I am much luckier than other trauma victims and for that I quietly rejoice.

I think that I’m finally done trying to remember what happened yesterday. I’m certain that today and tomorrow are much more important.

Dr Bruce Powell
MBBS MRCP FRCA FANZCA

Organ Donation; A Wicked problem?

Sun, 26 Apr 2020 06:00:06 GMT

Summary

– Since the creation of the Organ and Tissue Authority (OTA) in 2009, whilst organ and tissue donor numbers in Australia have increased, they have come nowhere near the outcomes that the world’s leaders such as Spain achieve.

– Despite more than $300 million of government investment, OTA’s aspirational target of 25 donors per million population (dpmp), remains seemingly unattainable and nowhere near the 48+ per million that Spain achieves.

– Achieving world-class performance in the donation sector represents a “wicked problem”. Such a problem is nigh impossible to solve because of contradictory and ever-shifting requirements and competing interests.

– The current mix of authoritative and competitive strategies in donation are limited in their potential to improve donation outcomes in Australia.

– The nature of wicked problems necessitates broad collaboration and big picture thinking to succeed.

– A Collaborative or Collective Impact Strategy has the potential for sustainable world-class outcomes in Australia.

– The large scale, broad-reaching social change required to effect real change across the donation sector demands that all parties desist from their focus upon isolated activities.

– The likely gut reaction to talk of collaboration and cooperation is that no one has the time or the resources to do “more”.

– Collective Impact, were it to be taken seriously as a potential vehicle to improve outcomes for donation, could not succeed without the funding to provide a specific backbone organisation.

Introduction

Let’s be honest, the Australian community, along with the Organ and Tissue Authority (OTA) has not delivered the ‘world-class’ results that we all hoped; not yet anyway. In its 2019 annual national report, the Organ and Tissue Authority (OTA) announced that there had been 1% fewer donors and 6% fewer recipients than the previous year. Even the relatively modest “aspirational” national target of 25 donors per million population (dpmp), compared to Spain’s 48+ dpmp, appears to be unattainable. Sure, Australia’s dpmp has more than doubled since 2009, but considering the investment from the Commonwealth, the States and Territories, the results are not as many had hoped. The perceived failure of the Howard Government’s 2006 National Clinical Taskforce on Organ and Tissue Donation initiative for a ‘world-class’ service, threatens to undermine public confidence.

In order to find some answers to this recalcitrant riddle, firstly let us consider what the nature of the “problem” is. In 1967 C West Churchman, an American philosopher and systems scientist wrote an editorial in which he created the phrase “wicked problems” and defined them as a “class of social problem that are ill-formulated, where the information is confusing and where there are many clients and decision-makers with conflicting values”. In 2007, the Australian Public Services Commissioner, Lynelle Briggs published a report entitled “Tackling Wicked Problems”. She noted the highly resistant nature of wicked problems and the need for novel and innovative solutions. The report reflected upon the nature of wicked problems that challenge the very fabric of government’s function, skills base and organisational capacity. Briggs concluded that the management of wicked problems was “an evolving art”, necessitating broad collaboration and big picture thinking.

Question: Is organ and tissue donation a wicked problem?

One need only read a selection of social media to get a sense of the first defining characteristic of a wicked problem; that they are difficult to clearly define. Is Australia’s relatively poor performance in organ and tissue donation a cultural thing, a medical thing, a community thing, a financial thing, or an educational thing? Browse through a few NGO websites, Health Department press releases and David Koch outbursts and you will be none the wiser. The complexity lies in the fact that there are elements of truth in many versions of the donation problem. Each of the passionately held opinions is a valid and different view of the same challenge.

Wicked problems have many interdependencies and are often multi-causal. Donation is remarkable for its propensity to generate passion and commitment, yet it is that very passion that encourages an adversarial, isolationist approach. The language used in the donation sector often focuses on being an “Australian Leader” or “the best State” or the “key contributor”. If we accept the proposition that donation is a wicked problem, then Churchman’s stated view was that, “whoever attempts to tame a part of a wicked problem, but not the whole, is morally wrong”. A modern take upon that would be that it is wilfully misleading for any group to claim to have the “key”, since the very nature of the problem tells us that there isn’t one.

It is the multi-causal, interdependent nature of donation that means that efforts to address the wicked problem lead to unforseen consequences. Adopting international strategies, such as those employed in the “Spanish Model” in an isolated and piecemeal fashion is no guarantee of success. As Edward Lorenz, famous for coining the phrase “the butterfly effect” stated, “small differences in the initial conditions can lead to vast differences in outcome”. Given the complexity of a nation’s sociological, financial and political context, it is bold and naïve to contend that the application of a previous strategy or international policy will “solve” the problem. Indeed, in the context of a wicked problem, to claim that one had the “answer” would in itself be dishonest.

Wicked problems are by definition unstable in that they are often constrained by evolving science, finances, legislation and of course political allegiances. The organ and tissue sector has seen many changes in the decade that it has been in existence and each of those can have profound effects upon the problem itself, never mind the solutions. Just as the answers to a wicked problem are elusive, the problems themselves are volatile and unpredictable.

Wicked problems do not have clear solutions or definitive answers. Hence the problem and the strategies applied are often resource limited, rather than limited by the end of the problem. Approaches to wicked problems that are pursued based on a “solution” have the potential to act upon false assumptions and create unrealistic expectations. By claiming to know the “secret” one obscures the complexity and denies the opportunity to truly make progress.

A key challenge in donation, is to manage the social complexity. Whilst the technical aspects of any solution might be manageable and even transplantable between health systems and nations, the co-ordination between agencies, communities, advocates and financiers is unique. Social complexity is an inherent and powerful reason why wicked problems are not solved by placing the responsibility within one organisation. Wicked problems demand action at all levels, with coordination and collaboration being crucial for all partners.

Finally and crucially, wicked problems involve behavioural change. It is fundamental to change that all parties involved acknowledge that their efforts, however committed and passionate, cannot solve a wicked problem like organ and tissue donation. Indeed it is that frustrated, adversarial energy which can often preclude the necessary collaboration and co-operation. There are no “answers”, no “keys”, and no “solutions”. What there could be is a commitment from all to collaborate. We could refuse all opportunities to undermine or blame since therein lies the erosion of the public’s faith in any of us to create a world-class service.

Wicked Problems in Organ and Tissue Donation

It would be churlish to claim to have answers, having extolled the virtues of declaring that no one does! Were the problem a “tame” or management issue, well-established processes could be instigated, as they would have been before. Indeed there are many in the donation sector that would seek to apply a set of trusted formulae to solve the problem. Governments and their employees are highly efficient at applying previous ‘solutions’. Whether that ‘solution’, that ‘key’, that ‘secret’ might be legislative, financial, strategic, community-based, hospital-based, all may have their place and their validity. Unfortunately, the wicked problem’s complexity precludes any such simple management solution and demands a leadership strategy. That fact in itself may render the problem unsuited to government’s timescales and personnel retention.

Roberts’ 2006 paper ‘Coping With Wicked Problems’ outlines the strategic options based on the sharing of the power and influence. In an ‘authoritative strategy’, one that is most closely akin to the creation of OTA in 2009, a group is designated as leading the process of decision-making and direction. In this case, OTA arose from a combination of power, knowledge and organisational position. The fatal flaw with this, as the basis of tackling the wicked problem of donation, was that at OTA’s inception, divisions were created with other interested, influential parties. Crucially there was no agreement as to the validity of the appointment, or if there was, it was grudging and resentful. Hence there has persisted a sense of injustice and illegitimacy around OTA’s role. In the early stages of the ‘donation revolution’, during a time of ‘crisis’, such authoritative approaches were effective. The poor donation rates were portrayed as a self-evident crisis, hence there was no time for discussion or dissention. In this situation, the authoritative approach provided a timely, decision-making structure and also mandated a certain degree of compliance. However, the disadvantages to such a strategy of solving wicked problems are that there is a certain legitimised coercion, with obedience encouraged through reward. Be that through funding or through offers of influence and power, disenfranchised parties are controlled for a time. The longer-term consequences for partners such as Non-Government Organisations, is that their commitment to any proposed solutions is likely to be weak and transient. This authoritative strategy, over time, has generated unrealistic expectations and thereby distrust and resentment since it has misguidedly promised to provide the “answer”.

‘Competitive strategies’ are also woven into the current situation in organ and tissue donation in Australia. Such strategies create a competition for influence and investment. Thus, States; Hospitals within States; Departments within Hospitals within States; ultimately Clinicians within Departments within Hospitals within States; all compete for the prizes on offer. Whilst such competition has the propensity to drive innovation and ideas, it also has the tendency to create silos, secrecy and generate distrust and conflict. As Roberts concludes, such competition can actually consume resources that might have been used to problem-solve for the good of all. Competitive strategies abound within the donation sector in Australia, numerous groups competing in a win-lose mentality for ever-shrinking budgets and receding community trust.

Collective Impact as a Strategic Plan

Possibly the most effective way to deal with a ‘wicked problem’ is to employ a collaborative strategy. ‘Collective impact’ offers just such a strategy. As a concept it grew out of the necessity for a new kind of collaborative strategy to deal with ever more complex social problems. The paper by Kania and Kramer from the Stanford Social Innovation Review in 2011 stated, “large scale social change requires broad cross-sector coordination, yet the social sector remains focused on the isolated intervention of individual organisations”. A large number of the early collective impact projects centred around education. The ‘Strive Project‘ in Cincinnati brought together more than 300 leaders of local organisations who agreed to participate in a collaboration to arrest the slide in high school results. Those leaders took the courageous and innovative step of abandoning their individual agenda in favour of a broad-reaching, collective commitment to improving students’ achievements. There was a collective realisation that fixing any single point along the whole process of a child’s education would not produce the desired long-term, sustainable results. Hence Strive did not change any of the individual programs that were being run already. Rather, they focused their collective efforts on an agreed set of outcomes, measured in the same way. Hence this disparate group, formerly isolated in their efforts, worked collectively, developed shared performance indicators, discussed their progress and aligned their efforts to support each other.

Why was a collective impact strategy not considered in the donation sector?

In defence of policy-makers at the time, collective impact was in its early years and the complexity of the donation problem was underestimated. There was also not such a widely dispersed power-base as there exists now. In that time of perceived “crisis” in the donation arena, with very low donor numbers and fractured state-based organisation, a more authoritative strategy was indeed appropriate. The initiative came from government and thereby was controlled centrally. However with the relative failure of the OTA’s policies in achieving results akin to the Spanish, the power and influence of OTA is threatened. Lobby groups and naysayers from many clinical and non-clinical groups now abound and their influence with communities and government grows. So whilst a collaborative strategy might have been too new and perhaps not appropriate then, it most certainly is now. There is a large number of stakeholders with considerable influence and power with a wide variety of key issues and aspirations. Having been sidelined in the early years of OTA, excluded from the sphere of influence, these groups have gathered support and resources from outside of government and health. With the failure to deliver the ambitious targets, those same groups, disenfranchised by the initial, authoritative strategy are now back for their piece of the game. In this dispersed power model, collaboration may hold some solutions. At its core, a collaborative strategy demands partnership, collaboration, common goals, agreed outcomes and shared measurables.

Conclusion

The current structure of organ and donation services in Australia can not deliver the world class outcomes it aspires to because at its heart, the structure is not designed to tackle wicked problems. There exists expertise outside of government, in creating and managing ‘Collective Impact Models’. Perhaps we should seek out that expertise for help. All interested parties must each be acknowledged as vital cogs in the donation-machine and they in turn must recognise that no single agency has the answers, not even OTA. Through the creation of a collective impact framework, perhaps the next decade will see the emergence of the “Australian Model” as a sustainable, collaborative and indeed wonderful success story for organ and tissue donation and transplantation.

Finally, Lawrence J Peter, the famous Canadian Educator and inventor of the “Peter Principle” of hierarchy, once commented, “some problems are so complex that you have to be highly intelligent and well informed just to be undecided about them.” I believe that there are just such people within our government, donation and transplant communities and they need to stand up and collaborate for all our sakes and for the sake, crucially of donor families and waiting recipients.

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