Godbye Tassie, Hello Tropics

We appear to have left Tassie just in time and Tassie appears to be largely closed for the present by the volcanic ash from the Peruvian vocano - no flights in or out for nearly a week. That might well have resulted in my doing serious bodily harm. To myself or others.

But, we made it out successfully just ahead of the cloud and off to the tropical wonderland of Cairns, Queensland - well inside the tropics. A small version of Cancun in many ways: large high rise hotels and plenty of stuff for the rich and super-rich. Gotta travel a way for the beaches, though. And, if rumor is correct, about half the hotel rooms are "backpacker" hotels.

The backpacker label appears to be a rather specific lifestyle in OZ - even in Launceston, there were lots of backpacker hotels. Cairns is full of them - with many subspecialties: women only, hostels, cheap hotels, etc. They're mostly back from the beach a bit and in a district of cheap restaurants (though some were quite good), and plenty of alternate lifestyle shops. The backpackers apparently live the lifestyle long enough that many of them drift from job to job - and right now, Queensland is short on temporary jobs such as banana picking (trashed by the cyclone), cane cutting (mechanized), and tourism (down by the global economy, and by the extraordinarily strong Aussie dollar).

We spent 4 days on a small cruise boat (18 folks on a boat that normally holds 50, 1 Kiwi, 2 brits, and us 2 Yanks) out on the Great Barrier Reef. Loafing, and getting in a couple hours of snorkeling each day. Pretty stuff and enjoyable. The highlight seemed to be the giant clams, which are not only large, but quite colorful. Disappointed to not see any Octopus. But, the super highlight was having a whale (not very big - maybe 20 feet, Minke) swim by while snorkeling. I've seen (and petted) whales close up from my kayak, but seeing one under water was quite special.

As much fun as anything for me, was hanging out on the bridge (open bridge policy). Got to know the captain a bit and learned a bit about the navigation and weather issues. Quite fun was watching the "trainee", and the first mate, and the captain - and other sailing staff - interacting over the trainee issues of the boat: very much akin to medical residency training. The trainee is filling out logs of stuff that he's done - and the mate's evaluation forms of his performance, and picking the brains of the mate, and practicing tying knots and having the mate tear them apart (the knots, not the trainees), while the mate did all the formal calculations of the navigation and filled out the paperwork, and the captain sat somewhat aloof and shmoozed with the passengers (me, mostly), and occasionally critiqued, corrected, and taught the underlings. Cool electronics with depth meters, radars, GPS, and lots of different ways of displaying the data on a bunch of different screens. Great fun. I think I could sail it now.

Got a chance to get out mountain biking a couple days, including one day riding the system of trails used for the 1996 world championships. The hardest bit we just walked to and looked at (and when I later looked at a video from the world champs, nobody successfully rode it - though I heard that one guy made it down successfully on 1 of the 6 laps). A number of other sections that I didn't ride, though I think with some work I might get down them.

Spent one day hiking, and one day on a guided tour in the rain forest - got to see a cassowary on our unguided hike - quite a treat and rather rare. The guided hike was kinda a quirky guy that has his own private nature preserve and feeds the animals and birds a lot, so they get quite close (actually one bird tried to grab some food from inside my mouth - I think that's pretty close). Pretty knowledgeable and entertaining.

Now we're in Sydney doing city stuff - including a symphony orchestra concert. More later if anything interesting happens.

What happened?

Should I cancel my flights? Stop in Utah and wait for Colorado to re-open?

(Colorado is (was) a large clothing retailer in OZ)

University of Tasmania Medical School

Today was my last shift - and I didn't do too much work: many of the students, interns, residents, and registrar grabbed me for performance evaluations. Not my favorite thing - i'm not good at evaluating folks' strengths and weaknesses and I'm terrible at being critical.

But, I talked with some of the students and learned a bit about the med school: 5 year school, straight out of secondary education for most. 1st 3 years are all preclinical and in Hobart at the main University Campus. Then 2 years of clinical rotations spread out to Burnie (small hospital in a city of under 30,000), Launceston, and Hobart. By reputation: Burnie has good teaching programs but a small hospital with limited patients. Living is cheap, so those on low budgets like going there. Hobart - good to stay near family, big hospital with all the specialties and lots of patient material, but poor teaching. YOYO approach - not even much in the line of lectures, supposedly. And here's the shocker: Launceston is the place to go for good teaching: plenty of lectures and programs, and REgistrars and consultants who are willing to sit down and go through patient presentations. Hmmmm!

Got home from work, and suddenly my phone rang with the ER number on it! AAAGHHHH - did I forget that I was on call? Was there a disaster and they needed more help? Turns out that some of the nurses didn't realize that I had just finished my last shift - and called - at midnight, to say goodby. Good on ya, mates.

Talked a bit with one of the Reg's about medical care in India - his home. Public hospitals and care is apparently abysmal, crowded, overworked, poor quality. And, an impenetrable barrier between private and public. The big companies all provide insurance for the employees, and the private hospitals are by his account, comparable to the more developed world - big, clean, well equipped with all the latest - and partly supported by medical tourism including from the US. His mother had a syncopal episode (fainted) last month and got a CT, MRI, and echocardiogram for $600 and got her permanent pacemaker for $6000. I believe that I could see a syncope patient at the University and the cost of cab fair to DIA, plus round trip flights, plus all that stuff would be about 1/3 of the cost to get it done at the U.

OK, probably no more medical stuff. Off to the Great Barrier Reef and mountain biking in Queensland.

A Snog in the Fog for the Blog

Jean & I took a drive up to Ben Lomond - Tasmania's ski area. It was thick fog (thus the Snog in the Fog last picture). We hiked up the ski hill - measured it at nearly 600 feet of vertical. Beautiful tundra - though we could only see a few feet of it at a time. Wallabies all over the place - interesting animal to have on a ski slope.

Ben Lomond's Terrain Park. Really, this was the only feature that we could find.

Hard to tell in the picture, but the tuft in the middle of the moss is about 10 feet across.
The Snog in the Fog. One of the finest self portraits to date.

Finally some time off

Jean's been here a few weeks now. We've gotten in a little riding. Nobody in Tassie rents road bikes, so she's been renting mountain bikes and cruisers and when we ride together I use the cruiser and she uses the 'cross bike with road tires - we end up about the same speed.

We've been to nature parks to see wallabies and 'roos, and wombats. Onto the beach at night to see the "little penguins" - cute little guys about a foot high. Rode out along the Tamar River - quite a beautiful rolling ride. Stopped on one ride to watch a little "footy" - may be one of the great games in the world: you can run, kick, throw, tackle, dribble - all on a field the size of Rhode Island.

Post dental bleeding

Despite the overloads, this place does have interesting stuff to do.

Yesterday a local dentist pulled an upper wisdom tooth and somehow managed to get into major arterial bleeding and brought the guy to the ER. We could temporarily control it with direct pressure, but any time the guy opened his mouth it was a major gusher. And, the guy was a "gagger" with a big tongue and limited mouth opening.Max/Fax was planning on taking him to surgery to ligate his greater palatine artery - but they were tied up for many hours in a big radical neck. So, what the hell, why not inject a little epinephrine into the palatine foramen like we "try" to do in palatine nerve blocks. So, with horrible visibility between the anatomy and blood all over the place, I used a needle like a harpoon in the general direction of the back end of the hard palate and squirted in a bunch of marcaine with epinephrine. (Not sure, might have missed and squirted it into the carotid or brainstem or something, for all I could tell.) Much to my surprise it either worked, or was performed just at about the time that the bleeding stopped spontaneously.

And to round out the day a posterior shoulder dislocation (the only one I can remember seeing that wasn't due to a seizure), a grapefruit size fungating cancer on a guy's hand (his GP had been trying various ointments on it for a ear), etc. I've cardioverted more folks in the last 3 months than I have in the last 5 years at University, and probably about 2 years worth at Boulder. And more profound bradycardias than I've ever seen.

Couple days a ago had a distal radius reduction in fastrack, so ketofol - no monitoring, no suction, etc, etc. Thankfully that went well and had been done by the Registrar before I heard about it.

Crushing workloads

It's been a while.

One of the great difficulties of an ER like Lonnie is that with the vast majority of the staffing being provided by fly-in-fly out Docs, when something happens to affect staffing there is no slack in the system. So, an illness in either a consultant or a Registrar leaves one with no backup (the administrative doctors seem to have no interest in helping with clinical coverage. It's quite entertaining to see the medical director wandering through the department with a bunch of "suits" chatting, bulshitting, and checking the dust in the air ducts - while we're short one consultant and two registrars and there are twenty in the waiting room.) 3 evenings ago, the charge nurse came to me in near tears - just didn't know what to do. We had no beds, no place to put another patient, and were at a complete standstill - about 20 waiting , with a few ill (unwell in Australian) but mostly minor complaints. Our only hope was that many would give up and go home - which was what ultimately happened.

As best I can tell, the underlying problem is one of this pattern (apparently widespread throughout Australia, except in the largest cities - all 7 of them) of fly-in-fly-out. The Docs apparently like it (the guys tell me that they make much more in their locum jobs than they do in their permanent jobs). But, it leaves most hospitals with nobody to keep pushing to get the system to work, and of course, no way to take up slack in case of an emergency - whether a crunch situation, or a staff illness.

Anyway, because of all that I've been working far too many hours and under far too much pressure. And, have had no time nor energy to keep up the blog.

Ozzie training

Learned something about Registrars that I hadn't known before:

For each specialty, a hospital may be "certified" or not certified as a training center. They may still have Registrars in the field, even if not certified. So there are "service" registrars and "training" registrars. And, even at the certified hospitals, there can be both types of registrars. The "service" registrars do the work - as an orthopedist, for instance - but aren't getting any credit towards eventual certification as a consultant orthopedist. They end up doing a lot of the routine stuff, and a lot of the consultations. While the "training" registrars are in the operating theatre doing the surgery.

Many of the guys do one or more years as a service reg while waiting for a chance to enter a training program. And, may move from hospital to hospital during that time. Some hospitals have only partial training certification, so that you can do some training but not the entire program (ER can get only 6 months credit for their time at Lonnie).

High prestige (plastics and max-facieal and dermatology) can take many years as a service reg before getting a training position. Low prestige (internal medicine and emergency medicine) "all you have to do is raise your hand, and you've got a job." (That from one of my EM Reg's). It's all very disjointed compared to the US.

I've got a bit more sense of why the ACEM board exams have to be so tough - I don't see that there is the day-to-day program of training and supervision and evaluation that we're used to, so instead there is a very tight orifice to squeeze through at the end of the tunnel.

One of my Registrars did his very first chest tube 3 days ago, and his second yesterday - and it appeared that having some supervision and guidance was an unexpected bonus for him (it was nice for me to identify the subcutaneously placed tube by palpation rather than having the embarrassment of finding it on the post placement XRay).

Later, Mates.

more crowding & chaos

Another of those days with the ER jammed to the gills. One field STEMI (heart attack) notification that I wasn't taking care of, but the cardiology registrar arrived shortly after the patient and couldn't find the patient!!! I helped him look and we eventually found him sitting in a chair down the back hallway - fortunately with his pain resolved. At least he could lay down in the cath lab when he got there (I'm not actually sure, but I hope that he didn't have to walk over).

Had a guy still "ramped" - on the ambulance stretcher, waiting in line, not yet physically into or registered into the ER - but hauled the shitty little old, beat up ultrasound out to where he was and identified the hemo/pneumothorax (from having a big tree fall on him when he cut it down).

Dragged someone else out of the "theatre" (such a cool name for the little room where they don't do anything that anyone would actually like to view for entertainment - actually did have one "viewing" Dad of a patient hit the floor yesterday) so that we could get his chest tube in. XRay appeared to be at lunch or on break, so we never did see them - but CT showed up quickly and we got our "pan scan" done very efficiently (after the 1st 700 ml of blood was already in the Pleurovac). Trauma surgery showed up sometime or other and decided that we were under control and left some admitting orders and went off elsewhere.

The place is at times so understaffed that it is astounding that more people don't get hurt, but we run from place to place doing what we can and it all feels a bit third-worldish and mostly stuff gets done.

There are a few of our specialty Registrars (and consultants) who are distinctly unhelpful - perhaps assholes would be an appropriately descriptive term - but they stand out amongst a bunch who plunge in to the chaos and try to help keep the ass-deep alligators at bay.

It falls down with stuff like the previously healthy older guy who had had 5 syncopal episodes before arriving, including several that were long enough without pulses to get CPR. He had a normal ECG that would abruptly slow (sinus still) into the 40-30-20 and full stop for 20-30 or more seconds. There are no pacer wires available in the ER, so we ran him on boluses of atropine and an isoproteronol infusion (I don't recall using that since the 1970's) and external pacer. Cardiology wasn't interested in helping since it was later than afternoon tea. WTF! I hope the guy (cards) breaks an arm sometime so that I can flop it around a few times. And then let him wait for 6-8 hours to give him 10 mics of fentanyl. Medicine was stuck managing the guy overnight.

More later.

Critical care and Emergency Medicine

One interesting aspect of the practice here: The EM registrars tend to call (or the nurses call for them) the ICU Registrar (and consultant) for every significant resuscitation. Unfortunately, those guys tend to arrive and take over - reinforcing my impression that EM here is 10-15 years behind the US in that EM is distinctly a second class specialty - a step removed from the GP's, and often treated as just overpaid interns (remember those days?). I've tried to discourage those early calls, unless we really need the help, and push the EM guys to do the resuscitation - both the diagnostic and cognitive parts of it, and the procedural stuff. Interesting how few procedures many of the guys have done, despite the large number of resuscitations we do (using the broad term resuscitation of trauma, sepsis, etc - not CPR stuff). There seem to be 2-5 folks per day needing serious attention to volume, airway management, arrhythmia treatment, etc.

On the other hand, it is fun to work with and/or watch these guys from ICU. Guess what - treating critically ill is all they do (we winnow out the chaff for them) and they are more practiced, experienced, and slick at it.

It makes me think that we really need to get one or more EM/Critical Care trained and (soon) boarded guys at DHEM/UCHSC. Someone of that ilk would be able to spend time in ICU working that end of the skill set, and share it with our residents - to the betterment of the training. Just a thought.

Mount Wellington

Jean and I (yeah, Jean's here now!) spent a few days in Hobart - the capital of Tassie, and a city of 200,000 with its suburbs. Faces south at the end of a long bay - so very well protected, but last stopping place before Antarctica. Did some mellow rides in the neighborhood and some touristy kinds of things.

Today, I took off alone to ride up Mt Wellington. Start right at the harbor, at sea level and climb to nearly 1300 meters (over 4,000 ft) in 23 km. Mellow low down, but lots of 10-12% grades up higher - through city, then suburbs and yuppie homes, up into eucalyptus forests and then above treeline tundra. Quite a dramatic ride. Cloud deck was below the summit, so intermittently in clouds but bright sunshine between. Cold winds made one of the long switchbacks brutal, but the final 3 km was a screamer uphill tailwind.

Great rock formations up high.

Huge radio transmitters at the summit. Signs all over the parking lot explaining how to get into your car if the transmitters disabled your remote key/keyless entry system and then to get your car started if the transmitters had scrambled your car's ignition system. Must be a powerful transmitter - nice to think of all those radio waves cooking my brain and other assorted body parts. Hope it didn't damage the carbon fiber bike frame.

Cycling

Finally a chance to do lots of riding. Already posted about the ride up to the ski area (BTW, looking from a distance - looks like snow down beyond treeline up there today.) 2 days of riding along the Northwest coast - faces onto the Bass Strait which separates Tas from the Big Island - 200 km wide. Pretty cold, but little wind and no big waves. Very pretty riding. 2 towns of about 20,000 each. Devenport is the terminal from the Ferry from the mainland - lots of trucks on board, and tourists. Some bring the cars over (expensive). Others travel as foot passengers, and rent a car when they get to Tassie. About 600 feet and the trip takes 11 hours.

The other port is Burnie and is where all the container traffic comes in.

Rode up onto a flat topped bluff on the edge of the ocean - turns out it's an old basalt core from a lava vent (think of the basic geology of Tassie as a lot of sedimentary limestone layers, with younger lava that pushed up through the sediments and laid down layers of igneous dolorite on top of the limestone. Lots of exposures of the dolorite, and limited exposures of the limestone. This was an area with lots of limestone and this one basaltic core pushing through it. The core was about 2 km in diameter and stuck up about 200 meters.) The top was apparently very fertile, and rolling farmland and entirely occupied by tulip fields - the largest patch of tulips in the southern hemisphere. Only one small field of purple tulips were still in bloom, but the pictures of spring when they are all in multicolored bloom look pretty spectacular.

Along the coast was a lot of sedimentary rock with large glacial erratics from hundreds of kilometers away, dumped here in the last ice age. Pretty neat.

Today rode near Lonnie and found a hill that was over 20% for 400 meters. That's a really long way to be that steep - had to do a few zig zags and stopped in a driveway for a break before finishing it off. Felt like a wimp, but I was afraid that if I blew up and couldn't turn the crank one more time, I'd never get unclipped and could roll backwards to the bottom of the hill - or something. It was really pretty insane. The rest of the ride was rolling open farmland.

Aussie politics, etc.

Yesterday was a big day - a week of breathless buildup on TV with commentary, predictions, preparations for..............Budget Day!

The Government presented its budget last night - kept secret until the presentation in parliament, and with enough hoopla leading up to it that it could be the Super Bowl.

Aussie politics is really nasty. It appears that no matter how trivial the matter, the two sides call each other uninformed, idiots, make nasty comments, etc. It's pretty bizarre. And they do it while facing each other across the middle pit of parliament - and it's always associated with a personal attack on intelligence or integrity, not just a disagreement with the policy.

Current hot topics: Australia television is currently transitioning to all digital and the government has proposed providing free installation and set top boxes to convert digital input to analog signals for old TV's of "pensioners" - retirees. Given a recent fiasco with government sponsored installation of home insulation - that in a few cases was improperly installed and caught fire and burned the house down, there is a good target for the opposition. Apparently Tony Abbott (who might really be stupid) doesn't believe that old people need to watch TV. He might be right.

Then, there's a major uproar about a deal with Malaysia: Australia will send back to Malaysia about 800 refugees who sailed here without permission ("Illegal immigrants" in US - speak), in return for 4000 who have achieved legal status as qualifying for amnesty status (I think mostly from places like Afghanistan). Aussies have a strange mix of needing highly trained immigrants to keep the economy going, and not wanting to be the dumping ground for all of South and Southeast Asia's unwanted.

On TV: Netball. Never heard of it before. It seems to get more live coverage than any other single sport (though nobody seems to discuss it). Women play it. There's a basketball style net, with no backboard - seems nearly impossible to get the ball through the hoop unless you're within about 3 feet of the net. And, when you have the ball, you can't move your feet and the person guarding you appears to not be able to move either. And, you can't jump if you have the ball. It's really fast action with lots of passing and running by everyone not having the ball, until finally you throw it to someone standing a foot from the net. Then, everything stops and she hold the ball straight over her head and throws it upwards and it occasionally goes through the hoop. Seems very popular, though I'm not aware that anyone actually watches the numerous TV broadcasts.

Footy (Aussie Football) is great for my business. 18 per side on a field that's 200-250 meters long (I counted 10 referees at one point, but could only see part of the field). You can punch the ball (but not throw it), or kick it, or run carrying it - basketball-style dribbling it once every 10 or so strides (imagine dribbling an oversized football on turf). And, you can have large numbers of people converging at high speed on a long, high kick - imagine a punt that everybody can and does try to catch - or punch the ball away from somebody else trying to catch it. Lots of concussions, lacerations, and dislocated shoulders. Saw a guy dislocate a finger, and the trainer just ran out on the field and popped it back into joint while the guy was running along - slowed down, then kept on going.

And, lots of rugby - still don't understand why they dive over the line, even while completely alone, and slide on the ground holding the ball. May relate to the amount of Foster's ingested at half time.

Interesting days, boring days

Talk about contrasting days.

Friday was challenging day: facial fractures with significant orbital hematoma and only light perception - John, one of my registrars got to do his first lateral canthotomy - after watching the YouTube video. Went very nicely, and got good decompression and quickly improving vision.

Simultaneously, had a relatively young and healthy dominant hemisphere proximal MCA stroke (visible vessel sign on non contrast CT). Aphasic, hemiplegia, field cut, - the whole dominant MCA bag. Thrombolytics would have been stretching the limits a bit - because of the size of the clot, the high NIH stroke score, and the vascular territory at risk , but I recommended that we do it (would have been in at about 2.5 hr from onset). But, there was a visiting neurologist in town for his once monthly neuro clinic, and the stroke registrar (an internal medicine reg running the stroke ward for a month) consulted him - he turned out to be a no thrombolysis is good thrombolysis kinda guy, so we didn't lyse this guy.

Incidently 3 days earlier, we had lysed an identical guy with a dominant visible vessel proximal MCA stroke with a very high stroke score. He was even sketchier to do because we didn't have a definite time of onset - and it was between 3 hrs and 4 hr 15 minutes when we started the TPA. He did well. At 3 days he was talking - not well, but talking, and using his arm and leg.

Later on Friday, we had a 3rd - almost identical dominant MCA stroke. But, he came in after 5 PM and we didn't get a CT for over 2 hours, and he was being managed by an unenthusiastic Reg (I didn't even hear about it until quite late on - after the CT). So, lysis was nowhere in the works.

Then, throw into the mix a car crash with seat belt chest injury including multiple rib fractures, sternum fractures and hemothorax. Chris, another resident got to do his first ever chest tube - went well. (I talked to the surgical Reg, and learned that the surgical Reg's here get very few chest tubes because there is no thoracic surgery - so their only chance is in the ER. So, there's a bit of a lack of teaching material for that particular procedure, and a bit of challenge to get enough balance between the 2 services. I think that not all the attendings are particularly aggressive at being sure that the EM Reg's get the experience they need. I can be reasonably confident that John wouldn't have gotten to do the lateral canthotomy with most of the attendings. Chris also got his first ever LP on Friday.)

For a grand finale, the same MVA guy had a line in his aortic arch that I'm suspicious was artifact, but we couldn't be certain wasn't an intimal tear. I later learned that in fact we might have been able to get a TEE which would have been the ideal to confirm the finding or lack of, but wasn't aware that anyone did TEE at LGH. So, we cranked up to medically manage pusle and BP and transfer to Melbourne - about 250 air miles, plus ground transfers at each end. Labetalol isn't available, and Esmolol isn't stocked in the ER. So, we started with metoprolol plus NTG (GTN when you're upside down on the bottom of the world) for rate and BP control. Then gradually collected esmolol until we had the entire hospital supply which we calculated would just about last long enough for the transfer, and then transitioned him to the esmolol.

Somewhere in there was the sickest Henoch-Schorlein Purpura I'd ever seen - lots of confluent purpura, and enough GI symptoms that we CT'd him - demonstrated total bowel edema, lots of ascites, and some pneumatosis. Not febrile, but until we got it all sorted out, consider Ricketsia and meningococcemia so did the big antibiotics for starters (no IV doxy here, but azithro apparently works fine for most rickettsia. Very nice to not have any internet sites blocked, so quick online lit searches are easy - including YouTube videos of procedures.)

So, Friday was a busy and challenging day. Then Saturday was weak and failing 80 year old day. And terrible performance on my part day. Made big deals out of stuff that the superficial and obvious first answer was the right answer, but way too much testing before I got back to the obvious.

I got reminded of one of the great drawbacks of paper medical records: the record that has disappeared into purgatory after discharge. One of the guys had been discharged a day earlier after a long hospital stay. His record was no longer on the ward, but hadn't yet gotten filed in med records. So, I didn't even have correct information as to how long he had been admitted. Only after a few hours did I stumble into one of the reg's that knew him and got the whole story - which would have clarified the issue with no testing. So, next time I complain about EMR's, I'll try to remember this.

Finally, for new onset Atrial Fibrillation, there is an Amiodarone infusion protocol which appears to never work (I recall that the literature is about a 50% conversion rate) but takes 12 hours or so. So, I've cardioverted 3 guys this week that had been in the ER for 12-24 hours, failed amio and then I buzz them and send them home. So, I've learned a bit about that whole deal. Nobody here seems to have heard about propafenone and I don't know if procainamide is available. Procainamide at least is only an hour infusion.

Local practice is that amiodarone is good for almost anything. They may put it in the water on the cardiology ward. I've not previously had a chance to see the pretty blue color that you develop if you've been on it for a while. Makes me want to give them a little oxygen. Mama, don't let your daughters go to a cardiologist that uses amiodarone a lot!

Enough for now.

Ride to the Ski Area (sorta)

I drove out of town to the beginning of the road up to the Ben Lomond ski area - Tassie's only ski area: 4 Poma's and 2 T-Bars. Looks like maybe 200 feet of vertical.

It's a gravel road - 18 km with about 1100 meter elevation gain, so use the 'cross tires on the bike. There are 3 separate climbing sections separated by long false flats. The first 2 climbs are 9-12% gradients, and then the Jacob's ladder is a switchback climbing about 200 meters gained at 13-14% the first 3 switchbanks, then 16% and 20% for the last 2. On a cross bike with cross tires, and a double crankset, that kind of gradient on gravel is touchy - a little mistake and you're off. I was cooked by the top.

The top is a long plateau false flat up to the ski area itself.

A ski lodge, a small bar/bistro, and rental lodges, duplexes and motel units that look like the've got maybe 100 rooms. Parking lot might hold 200 cars if you pack them in tight. Quaint.

Top was at 1500 meters. Last night was predicted to rain - but with snow down to 900 meters, but there wasn't any snow up there and just damp ground. Bitterly cold wind.

The switchback road section was 1 lane - I guess they expect all the skiers to go up in the morning, and all to come back in the afternoon - no passing expect a pull out at each switchback corner.

I had 2 cars pass me all day. 5 cars in the parking lot, but the restaurant was open.

Coffee shops & cafe's here don't serve brewed coffee - you have to order a "long black" for about $3 - kinda like an Americano except they put the water in the cup first and the Espresso on top so that you get a little foam. Talking to Aussies that have visited the US, they think we have awful coffeee - that horrid brewed stuff.

Ben Lomond is a plateau that is an igneous dolorite block lifted up above huge surrounding dolorite flats. About 5 by 20 km size. The dolorite has all fractured into vertical columns much like basalt, so the cliffs are quite striking. And, even at only 1500 meter (5000 feet) elevation the gently rolling summit is above treeline. Very pretty muted colors this time of year. Supposedly lots of wombats up there, but I didn't see any today.

Fog

Life in the rural medical world: guy with known CAD develops acute pulmonary edema, presents at 11 PM to a tiny hospital. They immediately decide to ship him - as they should, but fog has closed down the Launceston airport where the air ambulance is based - and it's a 5 hour drive to Lonnie, so they go for the 3 hour drive to Burnie - which is a bit better equipped than the really small place. There he's got a little troponin bump to .09 (no acute changes on ECG), and he gets nitroglycerin and Lasix. So, when the fog finally clears, EMS flights (the retrieval service) goes and gets him. By the time he gets to me - 12 hours after the 1st hospital arrival, he's no longer short of breath (never had chest pain), his chest x-ray has now cleared, his troponin has risen further to 2.24, he's already had his Plavix and enoxaparin at the second hospital, and in an hour he's off to the cath lab. Not bad considering all the travel time involved. The fog was gone and it was a beautiful sunny afternoon.

Even though we're about 3 hours from the East Coast beaches, we get stuff from out there - today was a body boarder that face planted into the sand off a large wave. Paralyzed and had to pulled out of the water by friends to keep from drowning. Largely recovered except for a little paresthesias and hand clumsiness by the time she arrived at ER. That was Saturday - they only did a plain film: normal. (Oooops.) Sunday, back to ER - CT:" normal (Ooops.) Back today - MRI showed minimal amount of cord signal, but no ligamentous injury: presumably a central cord syndrome. Treatment: nothing. OK - so the plain films, and even CT were not terribly sophisticated, but eventually all the tests we had led to the same spot: wait it out - you'll probably get back to normal or near normal.

A few other goodies: superior mesenteric venous thrombosis without clinical or imaging evidence of bowel necrosis - admitted for anticoagulation. More A Fib for cardioversion. And, lots of chaos - same as most days.

Muddy mountain bike racing

Mountain bike racing - a fund raiser to support efforts to save the Tasmanian Devils (estimates are that 90% have died in the last 10 years from an unusual viral caused and transmitted facial cancer) by setting up preserves that separate uninfected animals from those carrying the disease.

75 racers in 3 man teams riding a 4 Km course - about 15-18 minutes per lap for the faster riders.

We started in drizzle with wet slippery rocks and roots, the rain ramped up to torrential downpour with insanely slippery mud as well as the rocks and roots. About half single track, a number of short punchy climbs that were middle ring if you made it to the top, granny gear if you didn't get to the top before having to throttle back. Quite a lot of fun, and most people coated with mud and totally unrecognizable by the end.

I rode with a couple younger guys who were about a minute per lap faster than me and we got 4th. Couple bottles of wine and a dinner voucher at a fancy restaurant (for the team) - they took the wine, I took the voucher - use it with Jean in a couple weeks.

One of my teammates was a CT tech from the hospital - interesting to hear his side of the CT story (radiology thinks - but appears the thought has not been passed on to the guys in the ER trenches - that we order too few MRI's, and are ordering CT's when we should do MR's. That seemed clear to us in the ER, but wherever the communication fails, the message in the trenches is different: don't do so much imaging. Hmmmmm - wonder what's up.)

Ouch! that hurts

Fairly routine guy with new A Fib. Checked things over, nothing unusual, little propofol, push the button, zap. Back in sinus rhythm. Feeling fine.

20 minutes later I'm in the nursing station, doing paperwork and from his bed comes this funny nose and he bounces up off the bed - spent about 3 seconds figuring that he's joking with the nurses. But, noooooooo - the nurse had decided to clean things up getting him ready to go home, and got so efficient that she even ran the "test strip" on the defibrillator. Unfortunately, the patient (wide awake) was still attached! Apparently, the "smart" defibrillator isn't smart enough to note that it's still attached to a very awake patient.

The guy thought it was way funnier than either the nurse or I did. He apparently works as a technician doing physics labs for the high school and one of his recurring jobs is to be the guy that gets zapped by the Van de Graff generator. And, once while setting up with no one else around grabbed the electrodes on a rheostat demonstration - but had bypassed the rheostat and got the full voltage and couldn't let go until finally he had sufficient seizure activity that he got ripped free. So, he thought that being accidentally defibrillated when wide awake was pretty small potatoes compared to previous experiences and thought it was pretty funny. To quote Queen Victoria: "We are not amused."

Press Ganey, where are you when we need you?

Realllly Full

Recall we've got 19 official beds, plus 3 add-on beds and 2 "chairs", plus 2 fast track rooms, a family room and a fast track office.

Stopped by to borrow a bicycle this morning and we had: 20 inpatient boarders and a total of 40 patients as boarders, ER patients, and patients "ramped" (still on EMS stretchers) and in the waiting room. 4 of the boarders were in the fastrack rooms, office, and family room so Fastrack was out of action except for the waiting room and hallway chairs.

So the hospital had finally gone onto "Capacity Emergency" status. No other hospitals in Lonnie, so no local EMS divert. But, no patients accepted as referrals from the little outside hospitals or from GP offices. Some of the really small hospitals might be able to get help from a bigger small hospital (i.e. one with no lab or x-ray might send to a small but better resourced small hospital), but most would mean flights to Hobart or to Melbourne.

More importantly, the status puts pressure on inpatient teams to discharge, and to inpatient floors to accept inpatients to hallway bed status on the inpatient floors.

It's remarkable to me that despite the very different structural patterns and financing patterns of medicine in the US, UK, Canada, and Australia - the overcrowding issue is the same everywhere.

Keeps being interesting

We're back into stacking 'em like cordwood mode: head injuries examined and CT's and discharged without ever leaving the waiting room. The guy with typhoid from last night is still in the ER, and doing fine - no longer has that attractive gray color.

Guy with acute pulmonary edema from going into A Fib at 200. A little propofol, a little electricity, and he's fine. Biggest tongue I've seen from angioedema (probably from Augmentin, not on an ACE inhibitor) - fortunately sucked in an awake blind nasotracheal tube nicely.

All this with no space to work. Challenging. Fun.

Still working on the language

Discovered a few days ago, that when a patient is described as "average" - where not talking about the arithmetic mean. "Average" in Aussie seems to me right at the bottom of the barrel. OK, so that explains why the patient always seemed to look a bit worse than me.

Walking home tonight, beautiful clear night and I realized that the sky still has no constellations that I recognize. Where did that big dipper go?

There's a mountain bike race this Sunday - 3 man teams to do as many laps as possible in 3 hours. One of our nurses is the president of the Mtn Bike Club putting it on, and came rushing back from the triage desk today with the great news that she had found me a mountain bike to use and a team to ride on! One of her friends, just about my size, was out in triage with a broken clavicle - so his bike and spot on a team was mine. Should be fun.

Continue to get interesting cases: guy went to Fiji for a diving holiday, came back with abdominal pain, constipation, and fever. Pretty sure that it's typhoid - don't recall diagnosing that before.

As I get to know the system better (and, the system and more importantly, the people in the system, get to know me) it works a bit better. No place for nursing orders, but post-its work really well. Have to call radiologist to get approval for CT, etc after hours - but, as long as you're half-way reasonable they always try to help - even though the available resources don't allow exactly what you want. Today, I even asked for a CT (Easter Tuesday is a holiday in Tassie - so we're on part staffing) and was told that an MR would be better (which I knew) and he'd just do that instead (the MR and CT techs are cross trained, so once a tech is in, both studies are fine).

Getting to know the other specialty Registrars better, also. And that smooths interactions quite a bit.

I've had the distinct impression that Emergency Med is a second class citizen/overpaid intern sort of attitude here. But, part of the problem, I suspect is that there is so much turnover in EM, that nobody gets to know the capabilities in the ED and it isn't to unreasonable to assume the worst. Until they get the resources, and permanent staff, I expect it won't much change.

Medicine with limited imaging

Yesterday was appendicitis day: 3 of them. One was classic, straight to theatre without imaging. One had classic localized peritonitis, but a 3 day course and the localized tenderness was in the anterior axillary line rather than McBurney's point - surgery poo-pooed a bit, so we got a CT and as predicted by the ER, a retrocecal appendix wrapped around and up against the lateral abdominal wall where the tenderness was. The third had diffuse tenderness of the entire abdomen with no area that was clearly worse - until we gave him some fentanyl and he then localized nicely to the right lower quadrant - straight to theatre without imaging where he had a perfed appy with generalized peritonits - as predicted.

We've had a couple of big trauma resuscitations this week: 3 year old with isolated head injury (clipped in the head by the projecting bed of a flatbed truck), and an ultralight plane crash. We get the ICU critical care team (anethesiologists) as well as surgeons. It works remarkably smoothly (especially with the number of temporary folks here), is relatively low key - with lower ambient noise than I'm used to, and based on only 2 cases seems to work well. The drawback is that - the EM Registrars get treated as very much second class citizens in the resuscitation (not unlike the general flavor of everything here).

Inpatient beds were readily available (I presume no elective stuff over the 4 day Easter holiday, so lots of inpatient space). So, we had no boarders in the ER and it became remarkably efficient to move through fairly high volumes (it seemed to be crash your dirt bike motorcycle weekend - tons of fractures).

Politically incorrect?

Sushant had one of our computers live streaming an IPL (cricket - Indian Professional League) game last night at work. I had some paperwork to do, so sat down and watched for a little while doing the paperwork - they flashed the score of one of the teams: Mumbai Indians. I thought gee, thats funny (and very incorrect) that a team from Mumbai would choose a name from American Natives. It took a couple seconds (after the words were already out of my mouth) to realize that the team was actually "Indian" - Sushant gave me a bit of a reminder lesson on how American Indians actually got their name.

Ramped

Today's Tasmania new headlines was again about the LGH ER: Monday afternoon (glad I wasn't there) we had 48 patients in our 23 bed ER. Plus 4 more "ramped" - still in ambulances with no where to go.

No bypass here - just stack em up.

Should I visit Tassie??

I'm sure some folks wonder whether a trip to Tassie would be worth it:

Tassie's pretty interesting - small towns, bush walking, sea kayaking, cycling, beaches, surf. There's a few things that you can't see anywhere else in the world - Devils mostly. And a few things that you'll see only in Australia: kangaroos and wallabies, eucalyptus (except southern California), white bellied sea eagles, kookaburras, wombats, etc.

But, everything I did, there was always something I'd done someplace else that was a little better and that I'd recommend ahead of coming to Tassie:

Birds: try the Chitwan in Nepal

Bushwalking: try Colorado, or Utah canyon country, or Nepal

Walking on the beach and watching waves: Oregon coast, or better yet - Tofino on Vancouver Island

Southern Hemisphere rain forest: South Island of New Zealand

Cycling by the ocean: New Zealand, Western Isles of Scotland, central coast of California, northern California and Oregon, and best of all: Newfoundland - pack ice, icebergs, whales, caribou, moose - all visible from the bike.

Mountain cycling: Colorado, Canadian Rockies, Morocco

Exotic cycling: Vietnam (don't do Saigon to Hanoi like we did. Stay 4-5 days in a few different towns and ride the back roads around the towns - fat tires on a cross bike.) Morocco.

History while cycling: Great Britain - do the End-to-End or shorter rides.

Sea Kayaking: Sea of Cortez, California Channel Islands, Vancouver Island, San Juan Islands, and again best of all: Newfoundland - icebergs and whales!

All of these are trips I've done - and there are lots more I'd like to do. All of these that I've done, I'd do again in a minute. But, Tassie is fine and interesting and if you're here, there's enough to do. But, I'd never make the trip back again - there's so much more and better closer to home.

Queenstown burned down

I stayed in a little town called Queenstown my last long weekend (and took care of a lady from there that I think had carbon monoxide poisoning - but couldn't prove it).

Yesterday, something caught fire in the central block of town - either started in or spread to a machine shop with acetylene torch cylinders which exploded. Apparently most of the downtown is gone, and what is left - including my hotel - has no windows from the explosion. Glad I missed that excitement.

I haven't heard of any injuries (happened at 2 am). Presume the hotel was empty - I was the only guest the night I stayed there.

Aussie humor hits back

"How does a New Zealander find a sheep in the bush?"

"Quite delightful, thank you."

I recall being in New Zealand years ago and noting that about half of all Kiwi humor was at the expense of Aussies - that's the first Kiwi joke I've heard here.

BTW, I was walking on a beach today in Freycinet (Fry - sin -eh?) National park and a couple of sea kayakers pulled up - from Boulder of all things. NOAA researcher currently working on American Samoa and over here for a couple weeks off.

GoodNewsWeek (sort of like Wait, Wait but spoken in Australian, much more rowdy, and on TV) made quite a lot of fun of the American poll that found that 1/3 of native-born Americans would not be able to pass the US citizenship test (even those real applicants who spoke no English are reported to have done better than Sarah Palin). About 1/4 of all the jokes tonight were about Palin.

"What's the One Thing Americans don't know about America?"

"That there are places other than America."

What would you like to give William & Kate for a wedding present?"

"A job."

Lionel Richie was the American of the 8 guest/contestants- pretty funny. Didn't know he did funny.

Global warming may just give Tasmanias a chance to see what it feels like to wear shorts.

After hours CT

You've heard me talk about the necessity to call a tech in to do CT's or anything else after hours (after 5 PM or anytime on weekends in the case of CT). Part of the need to "batch" the cases grows from the radiologists have no way to read from home, and there's no contract for off-site "nighthawk" readings. So, the radiologist comes in from home and reads a few then goes home. The most organized of the the radiologists then walks over to the ER with 4 or 5 readings on a single 2x2 post-it note and runs through it with one of the consultants! That's efficiency - 5 readings, one post-it! The others just wander through and mumble a perhaps comprehensible verbal report. Better be sure you're really confident of your own ability to read before you come here.

BTW, there's a limited number of places where you can access the PACS system to look at images. Yesterday I saw the orthopedics system: Aaron, the registrar, has an iPad. He takes it up to the PACS, and takes pictures (must be an iPad 2) of the image on the PACS screen. Then, goes off to clinic or theater where the consultant is - and shows him the pictures on the iPad. Human ingenuity fills in the technology gaps!!!

Circadian rhythms

I'm not sure what computer program is used for writing schedules here, but please, Yaron, don't ever use it! If you really want to mess up somebody's circadian rhythms, you couldn't do it better than the scheduling here - routinely late evenings are followed by early evening followed by days. Thank goodness there are no nights for the consultants.

And, who cares what the coverage actually is? Supposed to be double and triple consultant coverage during the afternoon and evening with the last consultant (we'd call him and attending) leaving at midnight. But, if it's a bit inconvenient, single coverage is fine. Or, the last consultant can leave at 10 and the registrars can just suck it up for 10 hours instead of 8 hours. And, if there are some meetings for the consultant to go to (because he's the only permanent guy on staff) he can just wander off for a few hours, and the registrar can deal with whatever.

80 year old lady found in her home (after a few days of worsening headaches) obtunded, complaining of headache, vomiting, and at the rural hospital found to have bit of an elevated troponin. She woke up and the headache went away at the hospital, and some hours later she arrived at our place. Felt fine. Trop 0.8. Gotta be carbon monoxide. But, heat pump, electric water heater, no wood stove. (Forgot to ask about paint strippers.) I didn't hear about her until 8 or more hours after she was removed from her house, and the intern didn't understand how to order a carboxyhemoglogin, so we still didn't have a level reported when I left for the night and it's likely to be back to normal by then anyway. But, since they seem to use Non-Rebreather Masks for everything here - rather than nasal prongs - she'd been on high flow oxygen for a long time anyway - so had been treated. So, the medical team will probably muck about for a while and send her home with no diagnosis, and she'll strip some more paint off old furniture, or the neighbor will leave the truck running next to her window, or whatever the unidentified source is and her GP will treat her for migraines. Khe Garne. (For Drew: that case is from Strahan - really, do you pronounce it"strawn"? - no wonder people looked at me funny when I was there 2 weeks ago and pronounced it: "Stray-han".)

Gee, maybe electronic medical records are a good idea

12 year old girl with vomiting and abdominal pain. Transaminases up in the 200's, and biliribin around 4 in US numbers (that's liver problems for you nonmedical types). 2 years ago similar thing - neg viral studies, saw GI guy who worked her up for autoimmune hepatitis (and for Wilson's disease that can act just like autoimmune but is way worse and caused by copper accumulation in the liver). She had normal ceruloplasmin, and slightly elevated serum copper. Liver biopsy did not show any sign of autoimmune hepatitis, but he treated her with steroids for a couple months anyway. Couple more similar episodes of symptoms, but without the transaminase rise in the intervening 2 years.

So, I'm scrounging through her old charts trying to figure out what is going on and find misfiled among the "correspondence" a pathology report - labeled as "amended" - of a copper concentration from the liver biopsy that is 8 times the upper limit of normal, and twice the level considered diagnostic of Wilson's in UpToDate. UpToDate notes that ceruloplasmin and serum copper are imperfectly sensitive for diagnosing Wilson's, and the definitive test is the biopsy. Talked to several folks, including 2nd hand to the original gastroenterologist, and we don't know if there was an original erroneous report that got amended, or if he never saw the report since it was misfiled, or what. But, everyone seems to agree that , OH SHIT!, she does have Wilson's.

Since Wilson's can abruptly transform into fatal fulminant liver failure, good thing that the kid didn't do something too bad in the interim. Probably a good thing that this time she was seen by an anal-retentive attending rather than by a house officer who might have paid no attention to the misfiled report. (And, yes, Wilson's was on my mind and I was specifically looking for the copper studies going through the chart.)

Yesterday's Launceston newspaper had 2 editorials: one was the lead editorial talking about the failure to fund the biggest local nursing home, so that they have refused new patients - leaving a number of people at LGH for months to over a year because there is no nursing home to transfer them to. Of course, that backs up into the ER - yesterday had 16 boarders at beginning of day, down to 11 by late afternoon. That's of 19 real beds - expanded to 25 including the hall, "pit", and doubled up room beds and not counting the times when beds are just parked everywhere side to side, end to end, and chairs are elbow to elbow with really sick folks sitting in chairs.

The other was a letter to the editor saying how nice the doctors and nurses were during her 48 hours in the ER with no chance to sleep, lights on, noise, etc. But, she asked, couldn't it be made just a wee bit better. (Hold on lady, the new facility might open in less than a year. Better than the bigger ER will be the additional 10 acute medical beds.)

Last night's LP of the night: intern chickened out, Registrar chickened out, fools rush in........ so fat that I had to indent the skin by about 2 cm with the hub of the needle - actually had no idea where the spine actually was, but after the first time that I hit bone I figured that I must be in the area. 1 RBC! I was going to make the intern by me champagne, but 1 RBC foiled me. All this because some stupid neurologist in Melbourne told a GP that a lady needed an LP - when she had a straightforward post-concussion syndrome.

Keeping warm in the ER!

Here's a really cool concept (actually warm concept):

The hospital gowns at Lonnie are thick, warm, flannel. What a concept: patients are warm and comfortable (to say nothing of the convivial atmosphere of having beds spaced about 2 feet apart). They remind me of the terry robes that I hear are provided at nice hotels - I wouldn't know for sure. I bet the simple change from thin, chilly cotton gowns to thick, warm, flannel would be worth about 1.75 Press-Gainey point (Hearken well, Bruce).

Here's a weird one: for some reason that totally escapes everyone that I've asked, there is a governmental restriction on parenteral thiamine. A page of multiple blanks to fill in and sign - with no apparent reason, if you'd like to use IM or IV thiamine instead of oral. WTF???? Took a while to get the paperwork done and sent off to pharmacy so that one gentleman with unfortunate social habits, and with a wee bit of Wernicke's could get treated.

I had a guy with pneumonia sent down from a hospital at St Mary's (because of rising creatinine - although, since they had no imaging, they didn't know that he had the pneumonia as a cause for his fever and vomiting) - on the East Coast, about 2 hours away. I sorted out a few things and got him fluffed up a bit and appeared that he could be managed at a small hospital - and we were experiencing 48+ hour delays in getting people admitted from the ER (one guy spent about 4 days). I talked with the Doc at the little hospital, and at some length with the patient's wife - who happened to be the nursing supervisor of the hospital. 2 reasons for not sending him back: more flooding was going on and the road had been closed. More interestingly: the hospital is 8 beds. 1 is the ER. There is no imaging, and no lab. Each of the last 4 years they've requested an I-stat machine so that they could do simple stuff. So, since the issue that had prompted the transfer was worsening renal status (they do a blood draw, and send it to Lonnie and get the results a day later) it seemed unwise to send him back even though I was confident that his renal status was just inadequate volume replacement.

18 year old girl sent in from another little rural place. 12 weeks since last menses, had 1 home and 1 clinic positive urine pregnancy test about 8 weeks ago. Presented to little hospital with 12 hrs severe abdominal pain, one episode of heavy bleeding, and BP's in the 80's but with pulse only 90. They gave her some fluids and shipped her. We took a quick look on arrival with our 1950's era ultrasound (2 of the 3 better machines in the hospital were out for repair, and one was in use) - she had a normal uterus and a 5.5 cm complex cyst and no free fluid. But, then when she gave us urine had a negative urine pregnancy test, and 90 minutes later we had our Quant which confirmed zero. Since we have no doppler on our Ultrasound there was no way to look at flow in the cyst to make any guess as to whether the pain was torsion, or was due to what appear to be a hemorrhagic cysts (wavy little curlyQ's within the cyst). And, no hope of getting a formal US for another 12 hours. Sooooo, hopefully just a hemorrhagic cyst. Any theoryies out there in listener land as to what the scenario was? 12 weeks by dates, with positive UPT early on, but not now? Pure false positive? Early fetal demise? Of an IUP? Of an ectopic? Beats me. Somebody must know something. Hellllllp!

Observations on Tas

Walking & driving: the driving around town is pretty aggressive - diving into the roundabouts rather briskly - enough that if another guy were to make a mistake it's be tough to adjust. I'm still getting used to looking to the right - and having to look 3 entries away into the circle, because I'd still have to "give way" to a guy coming fast and aggressive from 3/4 of the way around the roundabout. Especially challenging to keep that in mind on bicycle when I've got to look to my left for a guy that will eventually catch me from the right!

And, as a walker - there is no thought of pedestrians have the right of way. Pedestrians definitely yield to the cars. Once every couple of days I'll see a car slow, or even stop to let a pedestrian across and it really messes things up because the other cars don't expect it to happen so there's sometimes a squeal of tires from behind the slowing car of the nice guy. Just stay on the sidewalk, mate!

Real estate:

The house across the street went up for sale last week. It's the most expensive listing in Harcourts' large Launceston catalogue - but with no price listed. In 2008 it was the "House of the Year" for Lonnie. From the road it's a very unassuming nicely kept up old house (1840 to be exact (with a flagpole that gets a different flag each day). Turns out that what I see is just "the cottage" - and connects via a glass passageway to "the house" which is a modern, glass-walled multilevel with great views. Totals about 3000 sq feet. The listing is for "expressions of interest" which will close at 5 PM on May 2nd. I gather that's sort of like a silent auction - our eBay in miniature. Love to see what it goes for. The pictures of the interior and the views are pretty spectacular. If your interested, got to: Harcourts.com.au and look for TLA 3001 or just rank the Launceston listing from most expensive and it's the first one.

I ate in a restaurant this afternoon, and realized that it was my first real "meal" in 6 days: up to now it's been a combination of cereal (wheat bix mostly), apples (I did buy a couple of expensive Florida grapefruits and a couple bananas - that are currently about $2.25 per banana! because 80% of the banana crop was wiped out by the Queensland floods), milk and cookies, peanut butter and jelly, and (real treat) exceedingly delicious submarine sandwiches that I buy on the way into the ER from the coffee shop/bistro right next to the hospital - very similar to Amante in Boulder, but more expensive.

Working 5 days straight, I only got in a couple of 15 - 30 minute short hard workouts, so today felt good to get out for 3 hours through the countryside/farms/eucalyptus forests and up into the hills - cold, overcast, a little rain but absolutely beautiful, relaxing, enjoyable ride with a few hard efforts during the last half. Had planned a little longer, but the road that I was on turned to dirt/mud so I turned back.

More flooding in the Northeast of Tas - hampered some of the medical transfers yesterday.

Teaching patterns

I talked with another of the Australian locum doctors yesterday. He tells me that the fly-in fly-out locums pattern of ER staffing is pretty common throughout Australia (especially at smaller hospitals).

Here at LGH, the locums appear to be considered as the "turn the crank" guys - see a lot of patients and move the meat (though that is in much smaller numbers than what we're used to. Rarely do you see anyone juggling more than 3 or 4 patients at a time. I haven't had a chance to go through the logbook to see just how many are being seen per shift, per senior doctor. But, if we see about 100-120 per day and rotate through 5 registrars and 3 consultants - that's about what it feels like - 10-15 per shift max - with some of those being seen by interns and junior residents with limited if any input from the senior staff.)

Often, the sicker patients are handled solely by a consultant or Registrar while the interns continue to plod through the less acute and serious stuff. Fortunately, the whole program is loose enough (gross understatement - loose, in the sense of totally without pattern) that I'm able to pick up a sick patient and then grab an intern to "take over" from me - and the intern gets to be primarily responsible with close oversight. They seem to like the chance to see a sick patient, get close supervision and teaching, and maybe some procedures. And, since documentation is loose - but onerous, it saves me a lot of paperwork time. Seems like a good tradeoff.

A little different style than some of the attendings, I gather.

Another sidelight: we get really annoyed at home about the "safety" stuff: Pyxis, double and triple checking, etc. Apparently, there is some virtue to all that. I started an order sheet (on a hyperkalemic guy with a cardiomyopathy who had a baseline wide QRS that was even wider) and a nurse stuck a sticker on it for me - but for the guy 1 bed over. Fortunately the guy in the next bed over had a high normal K+, though he didn't much like the taste of the Kayexelate (and, perhaps fortunately, there's a recent article that suggests that Kayexelate doesn't actually work). Anyway, all the good stuff - calcium, bicarb, albuterol, insulin - got to the correct patient, and he eventually got some Kayexelate also.

Nurses had not apparently given Calcium Gluconate "neat" before - another new Aussie term, apparently brought to the hospital from the Pub.

Gotta figure out the surgical consult pattern: resident called surg registrar to see a lady pretty sick with clinically perforated diverticulitis (fever to 39.6, tachycardia, and pretty extensive LIF (Left Iliac Fossa - our LLQ) peritoneal findings. Surg didn't want to see it - medicine should handle it. Medicine didn't know if they should do a CT. But, the ED staff gets their ass kicked if they order the CT and find something surgical and then call surgery with the (now) clearly surgical diagnosis. It's a real catch-22 deal. I've gotten to know most of the surgical registrars well enough that it's less of an issue for me, but I see it continue happening to the more junior folks.

Off to work. My best to all in the states.

I still love that bedside blood gas machine. So much information, so quickly - as long as the nursing staff notices the order for it.

Oh, that reminds me - there is no "flagging" system for orders - you just stick med orders and lab orders in with all the other paperwork and hope that someone sees them, or wander around the wilderness until you find a nurse to tell verbally that orders are ready. There is no ordering system for non-medication nursing tasks or ECG's - all verbal (give some Kayexelate to one of the guys in obs - any one will do). Hand written imaging requests - you personally walk over to radiology and find a tech to hand the paperwork to!!! 10 patients per shift - it's about right.

A few notes on ER staff

Non-medical staff in the ER works a bit differently. No techs: we have some support staff that are called just that: ER support. They function rather as traditional orderlies: stocking, patient transport, physical tasks, but nothing like our techs with wound care, IV's etc. I really miss our paramedics who are so good at all those technical patient care things like splints, IV's, wound prep, etc.

Nursing roles are much more limited also. Ranging from being less forward in requesting/reminding the docs of patient needs (Doc, the guy in 12 needs pain meds, etc.). No ability to pre-order x-rays, labs - best that seems accepted, is to hand you the order slips with a sticky label on it already.

IV starts require certification for nurses, and some seem to choose not to do so - so some RN's don't start IV's. RN's don't start nurses on little kids - gotta be a Doc, don't do male urinary catheters, or little kid urinary catheters, etc.

RN staffing faces the same sorts of shortages as the Docs: including no sick-call backup. Last night we were overloaded with patients - especially borders, and short on nurses so poor Matt had 13 patients stacked 2 to a room and in the hallway. He looked pretty downtrodden until I met him outside on my way home where he was smoking a cigarette - can't say I blamed him a little nicotine before going back in to face that mob.

Weird case of the day was the 8 year old boy with urinary retention (821 ml with the bladder scan) from a fecal impaction. When we get this with old men, I like to put in a foley catheter first (since the over-distended bladder is the most painful issue), then work on the underlying constipation/impaction. Couldn't get even a 5 French feeding tube into the kids' bladder, so decide to work the impaction next (and save a suprapubic drain as last option). So, with a finger up the kids butt, digging away, he was able to pee ('wee' in Australian) as soon as I got the first couple grams out - firing all 821 ml against the far wall - much to the relief of all. I think the interns should have gotten that case, but all the fun was over by the time one of them was free.

MRSA

We had a young guy (avid Aussie Rules Football player - promised to teach me a bit about the sport if I show up for one of his games) with a "spider bite." Of course, hadn't seen the spider. In Denver it would have been a no-brainer diagnosis: patch of black necrotic skin overlying a palpable abscess and some surrounding cellulitis. But, MRSA hasn't yet arrived in Tassie in a big way, so there were a lot of house officers scratching their heads in confusion when I first saw the guy. (BTW, I suspect that the largest source of importation of MRSA is colonized locum tenens ER Docs from the US.)

So, a quick talk about characteristics of MRSA and antibiotic choice or non-choice, and on to the I&D. Some things are the same around the world: After the first 13 swipes of the scalpel, the intern had finally made it through the epidermis and was ready to start on the dermis and eventually had a full 5 mm incision and started to work downwards into the gloom with a hemostat. When I finally "helped him a little" and extended the incision to a reasonable size and buried the hemostat the hilt, his eyes got a little big, but was reassured when only pus and not arterial blood gushed forth.

The Beach, the Southern Ocean

Not having done much running or hiking recently (a side effect of having an old dog) - and what hiking I did was on skis, so no downhill steps - yesterday's roughly 3300 feet up and (more importantly, I think) back down has generated massively painful quads today. Walking down steps is an ordeal.

So, I drove down to Strahan (I can't pretend to come close to the local pronunciation - something close to "strain" or maybe "strayin' ") and went for a walk on the beach. The beach is 33 km long - one of the longest in the world. I didn't quite make it to the end. I had read about it in a Sea Kayaking magazine article sometime back - there are no landing sites, and with the usual wave conditions of the Southern Ocean (no longer in the Indian Ocean down here - it's the Southern, or Antarctic, Ocean) - it's impossible to ever get a kayak on and off the beach, so you have to paddle the whole 33 km in one go, often in tough conditions.

Today was as good as it ever gets - very little wind, only small local waves, and a swell of only 3 meters with occasional 4 meter sets. But, the surf zone looked to be 3 or 4 hundred meters wide so would take 5 or minutes to get through. The break is typically 50% higher than the swell so you're looking at having repeatedly to try to get through surf that's well over 10 feet. Never happen - not with the strongest paddlers. 33 km to go to the next landing!

Strahan is a nice little seaport town on a quiet harbor. They've got a bunch of cruises around the (very long) harbor and up the local river, but all had left for the day and were long enough that I didn't want to stay for tomorrow's cruises. And the evening cruises only run during summer.

So, drove on to Queenstown - big Copper Mine that has torn up a very large area of the mountainside above the town. Currently shut down and a major restoration effort going on. Pretty old town, not very prosperous, but has a Wilderness Railway somewhat like the Durango narrow gauge.

Staying here in an old hotel with a grand stairway listed in the National Historical Register. They cut the wood locally, shipped it to England to be carved, then shipped the completed stairway back in 1904 to be installed.

I've got some pictures, but my camera battery ran out and I don't have my charger - so won't be able to download them until tomorrow.

One note from yesterday: the high boggy areas above treeline all have elevated boardwalks for hiking (Bushwalking) - looks like a major advantage for preservation of the environment. A step ahead of Colorado.

The hot news in Tassie is a proposed detention center for refugees. A bit of a fight between the NIMBY group, and those who want it for the jobs and income it will provide. Refugees seem to be a big deal here - with not an excessively welcoming attitude. In 2007 they came from China, Malaysia, East Timor in Indonesia, India, Pakistan, Sri Lanka, North Korea, and Lebanon. I've heard that Afghanistan is now heavily represented. Oh, and a big brouhaha about a Tassie government minister who let slip that a shadow minister had applied for a job and was only ranked 4th among the applicants - should've been confidential. Remember that Tassie is only 500,000 people - half the size of Denver. So, State Government is drawing from a small pool of competent people and well, it's small townish.

Cradle Mountain

Plateaus & Canyons from summit
Wet Tundra
Summit ridge, dolorite blocks
Raven
Fresh water fjord - Dove Lake
Cradle Mountain

Quite a drive to Cradle Mountain - it'd be a fantastic killer bike ride, with steep long climbs, and swooping descents with snaky roads - all on the wrong side.

The hike up Cradle Mountain is a net 2600 foot climb, with some up and down so the total climbing is about 3300 feet. A lot of the final 1/2 hour section is scrambling over big blocks of igneous (dolorite) rocks so is pretty slow going. Today was beautiful weather - blue skies with scattered clouds, little wind, and t-shirt the whole way. Very unlike Tasmania. I talked to a guy yesterday who had been up Cradle 3 days ago with snow and ice still all over the summit from last week's storms.

It's actually not that impressive - it'd certainly be a minor peak at home - comparable to Bear Peak from Boulder, but with more rock scrambling along the ridge to get to the summit, and looking down on more lakes.

The geology is interesting with lots of the igneous stuff on top of a limestone layer - which weathers more rapidly, and then the whole thing cut up with glacial formations. It leaves large plateaus with glaciated valleys between them, and Cradle Mountain itself is an old nunatuk on top of a glaciated plateau.

At first glance, the tundra above tree line looks very similar to that at home. On closer inspection, the plants are quite different and much more lush. And, below treeline the forest is a temperate rain forest - very thick, and with lots of stuff that is quite unrecognizable. Eucalypts in many forms, beeches - unlike American or European beeches ( I seem to recall completely unrelated), tree ferns, and giant fern-like things that I couldn't categorize. And moss.

Only saw one mammal - a rather plump wombat, standing in the trail and very uninterested in me. I had to step over him to continue on my way. It didn't seem like alpine tundra with no marmots or conies to divert one.

The Ravens here are a bit different: white tips to the flight feathers and tail feathers. Bright colored eyes (yellow and red). They had a recognizable raven croak, but some vocalizations that continued on in varying pitch and volume for at least 6 seconds. Haven't heard that before.

Tonights accommodations are a bit different. The Tullah Lake Lodge is a very pretty site on a lake. It's an old dormitory for local mine operations that is gradually being upgraded, but is still 90 % occupied by miners and contractors (including some who arrive by helicopter). The only remaining rooms when I got here were in the economy wing - pretty basic, but adequate and 1/3 last nights price. There appear to be 2 tourist couples and about 50 minors. I believe the bar may be busy.

I tried "scallop pie" - think chicken pot pie but with scallops. Shoulda gone for the hamburg.

Overall the peak (the "iconic" Tassie view) was anticlimactic to someone who has been to Colorado, or the California Sierra, or the Canadian Rockies, or Alaska.

So rather than spending more time here, I'm going on to the West Coast - home to full on exposure to the Southern Ocean. It'll add driving time, but should be interesting.

Australian News

Listening to ABC news on the radio is a bit different: one news station for the whole country (not unlike NPR), but because the population is so spotty, it can also do a lot of local news too. There's really only 5 major cities (Perth, Brisbane, Adelaide, Melbourne, and Sydney). So in about a minute, you can cover traffic for the whole nation. Since there's only 6 states and one territory, you can add 2 more small cities (Darwin and Hobart), and include all the state capitol weather reports in another minute. Neat.

The Aussie news seems to be about 1/3 - 1/3 - 1/3: Oz, US, and the World. With US news being financial, political and a few horror stories thrown in to make you glad that you live in Oz and not that horrible place the other side of the Pacific. Easy to keep up on what's happening at home.

Back to the place where I stayed last night and enjoyed the pumpkin strudel. Talked to the woman of the couple that owns the place and she explained that in Australia, pumpkin is usually thought of as part of the main meal - rather than considering it a "sweet" or dessert (as in pie) as in the US.

There were 3 guests at the hotel last night. Me, and two women (not traveling together). One was quite silent and spoke only 3-4 words that I heard - I think in American. The other was quite a chatty Aussie and went on quite a political discussion with the proprietors at breakfast this morning. After apologizing for going on about politics (Oh my, It's too early for politics), you then plunged back in on "That despicable Tony Abbott - you do think he's despicable, don't you?". I actually learned a bit by listening in.

The proprietor also introduced me to "Shazam" an app on his Android that he used to "listen" to something that was playing on the radio, that then somehow in about 15 seconds was able to "think" with its mother website and identify the song and the artist. How cool is that? Wonder if it works with Classical? If you can do that, they've gotta be able to do it with "dog". This bark means "I'm hungry", that means "It's mine," and the ever-popular"Squirrel!!!!!".