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? You’re not just your name? That’s not all you are.
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
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.
“Life is like a box of chocolates, you never know what you gonna get.”
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.
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.
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 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.
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?
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.
“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 Life Project: Raising Awareness in WA
“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.
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.
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. 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
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.
