No worries, Mate!

No worries is used here for all kinds of stuff: "May I have a glass of water? - No worries, mate! I'll bring right over." "Thanks for the help. No worries, mate." Etc, etc.

I take coumadin and fell down and hit my head and now I have a subdural: No worries, Mate! In Tasmania we have Prothrombinex - a Prothrombin Complex Concentrate (that includes factor VII), and in 15 minutes, we've got you're INR back to normal. Comparable to the Octoplex in our study at UCH, but routine here, and has been for a long time. Sure makes this case much more efficient and less hazardous than it would be in the US. (Then again, if she had come in a couple of hours later, a tech would have to be called from home to do the INR in the lab, and another one to do the CT. Interesting mix of real retro care and real advanced care. Oh, we kept her at Lonnie - but with everything geared up to fly her to Hobart if the subdural got bigger and neurosurg would be needed.)

Lots of flying around, and phone calls to handle: "Hi, I'm ..........a GP on Flinder's island (somewhere between Tasmania and Hawaii I think - OK, just a 30minute flight) with a guy with hyertrophic cardiomyopathy and new ischemic sounding chest pain and a bizarre ECG. Can I give him his Plavix load and enoxaparin and GTN (NTG - they reverse the letters since we're upside down on planet earth here) and fly him to you?" Sure, no worries mate. We'll be ready for him.

About 8 PM last night I realized that I hadn't seen another ER consultant for a while and looked around and, it was true it was just me, a couple registrars (one had called in sick) 2 interns and a resident. Turns out that on Thursday the overlap consultant does teaching in the morning and then leaves at 6 PM (for the evening flight back to Melbourne) rather than at 10 PM. So, the evening consultant (me) is responsible for a lot of beds (we've got 17 numbered beds plus paeds, plaster, "theatre", eye, 3 fast track, 2"pit" - kinda in the nursing station, 3 or 4 "chairs", often another bed parked in the middle of the observation area (originally 4 beds but now always 6, and sometimes 7 or 8 if you put a few trolleys in the middle). Somewhere up in the 28 or so beds. Clearly, I don't get a grasp on all that - and don't need to since the more senior of the Registrars function completely independently. The above noted anticoagulated subdural I didn't hear about until about 6 hours later when it was mentioned in passing. No worries, mate.

Then there was the guy with a known 5.5 cm AAA awaiting surgery on it who developed severe back and abdominal pain, looked ghastly, but with a good BP. While arranging a flight to Hobart - which got cancelled after talking with him, his wife, and his son and deciding on comfort care only without surgical care - we did manage to get a timely CT (the CT tech had already been called from home), and sorted out that the AAA wasn't leaking, but one of his gallstones was now in his CBD and his pancreatitis was sitting right on his AAA.

The photos are of two of our interns, and one of our registrars (Kim (pronounced Keeeem) is Australian, Natasha from Singapore, Sushant is our cricket fanatic Indian registrar). Note the working attire - no green scrubs required here, and note the candy bars for sale on the counter behind Sushant.

I always wonder when surgery is taking someone to "theatre" if they will be seeing an opera - Don Giovanni perhaps, or having their gallbladder out.

Pelvic exams are done without stirrups here, works just fine as long as you can find a light (privacy is a bit iffy - especially in the very crowded 6 bed observation area with just curtains and little space between beds). I found some plastic speculums (apparently reused although designed as disposable), but without the plastic light source. Some rooms, the wall light sources on an arm are fine, but in the curtained cubicles, they are at the head of the bed so not helpful. So, I've taken to using the "spotlight" app on my cell phone - actually works quite well - very bright and maneuverable. Thus far it has not rung while in use for this purpose.

Quite a high density of severe pathology here: sick mesenteric ischemia with lactate of 8, severe pulmonary hemorrhage from a lung cancer, lots of central lines, arterial lines, resuscitations, cardioversions - more commonly done than my initial impression, dislocated total hips. Displaced fractures are often done by the ED residents and registrars under supervision of the ortho reg (BTW the fractures needing fixation are admitted for "theatre" within 24 hours - no consideration of insurance status. I don't know the literature, but the ortho reg tells me that there is support for debridement and irrigation of open fractures within a 24 hour time frame rather than the traditional 6 hours, so open fractures are admitted to go to theatre sometime in the next 24 hours).

The bedside blood gas machine is great for stuff like the DKA with venous pH of 6.92 and K+ of only 2.7 where we repleted K and could follow levels every 30 minutes, and delay starting the insulin until we were happy with the serum K level.

No Pyxis machines so it's pretty quick and easy to pull the drugs you need in a hurry and I've quickly learned to use push-dose pressors (metaraminol and phenylephrine) as advocated by Scot Weingart on the EMCRIT website (great site and podcasts on emergency medicine and critical care if you haven't used it).

I didn't know that you could get anaphylaxis from leech bites (as well as Jack Jumper ants). I've seen more anaphylaxis here in a week than I've seen in a couple years.

How about "Oriental cholangiohepatitis" - haven't seen it before, but they get repeat bouts of ascending cholangitis and get quite ill.

Enough.

A little on politics

One interesting sidelight of government in Oz is that parliament is not in near-perpetual session as in the US. So, during there periodic sessions (this may not seem so unusual if you consider that the population of the country is smaller than Texas and California, and a wee bit bigger than New York) there is extensive live coverage on radio & TV of the debates and other proceedings of parliament - rather like CSPAN, but with the speeches actually given to a chamber with people in attendance. Yesterday there was a vote on broadband coverage that called for a "division" - a formal vote count rather than just a audible "The Ayes have it." So, the first line from the speaker was "Lock the Doors." Then the ayes line up and walk by on one side of the speakers chair, and the no's on the other side of the chair and are count by 4 "tellers" - 2 from each party.

The current hot topics are a proposed carbon tax, and a proposal for regulation and encouragement of broadband internet service to the country.

In the news, these follow just behind the news that Ricky Ponting resigned as captain of the national cricket team.

One other interesting little tidbit: I can't recall having heard or seen anyone referred to as a wife, husband, or spouse. Partner - both in casual conversation and in news reports. I've been introduced to people's partners, heard of their partners. And, in the news, the businessmen and politicians have partners (including the front page picture of a politician with his hand casually planted on the bum of a young lady who appeared to be about half his age - his "partner").

Off to work.

Medicine

For a physically small ER, we do get a variety of stuff: complete heart block with a ventricular escape rate of 37. Kept his BP reasonable, and his mentation good. Turns out we've got external pacing capabilities, but no pacer wire & box for transvenous. Would have been interesting if he'd been a little sicker and had to be urgently paced.

A flutter at 150 walked in to his GP's office asymptomatic - so no clue how long he'd been in it. But, he was already anticoagulated with a therapeutic INR, so we just cardioverted him. I didn't watch closely enough as the 1st year registrar gave the propofol, and he was "generous" with the dosage - the electrical cardioversion went smoothly, and respiratory status was OK, but took 12 minutes for him to wake up and for his BP to get above 60.

Great deal of interest in this: not sure that cardioversions had been done in the ER in recent memory, and no one had ever used a gloved hand to assure firm contact of the pad to skin.

Ortho was getting slammed, so for his Smith's distal radius fracture that he wanted just a reasonable reduction before admitting him for surgery in the AM, it was quicker to just put that guy down with propofol than to do a hematoma block. We do a lot of sedations here - all with no paperwork! He let our intern have a go at the reduction first, then, in disgust said "You pull like a girl" and then pulled like an ortho (I think they're all rugby players here), and away we went.

Quite a sick DKA with pH 6.93 but a K+ of only 2.7. So wanted lots of K+ on board before we started insulin. But, her precipitant was a submandibular and neck cellulitis and abscess, so put in a femoral line. Then opened the abscess - very little pus, but unusually awful swelling - wonder what the bug will be - presumably an anaerobe. Turned into quite a discussion/negotiation between medicine and ICU registrar as to who would take the patient. ICU/critical care is all done by anesthesia - no medical or pulmonary critical care here - so if the patient doesn't need a vent, ICU typically doesn't want them - treat them in the ER long enough to get them stable enough to go to the floor. Finally did go to ICU (well, sort of, there weren't any beds in ICU or on the floor, so she was staying in the ER for the foreseeable future).

Getting a bit of a feel for the practice styles of the various short term locums consultants - many or most come down and "turn the crank" - so see patients primarily, don't do much teaching, review cases with the junior residents, and on to the next. So, a bit more teaching, supervision, etc style that I'm used to, seems a distinct change and appears welcome.

Saw a "Jack Jumper" ant bite: Jack Jumpers are medium sized ants that grab you with their pincers, then curl their body in a half circle and sting. The sting is reportedly somewhat more painful than a bee sting and much more prone to anaphylaxis than a bee sting. So, there's lots of anaphylaxis from stings here.

The highlight of technology here is the POC (point of care) blood gas machine. Gives pH, pCO2, pO2, K+, glucose, Ca++, lactate, and Hemoglobin - all in a minute or so and gets used regularly. Fantastic when you're taking care of of a really sick patient (4 rounds of these numbers in the first 2 hours with the sick DKA - that let me see that our K and lactate were coming around and heading in the right direction). Further, It's a bit of overkill, but if you need any one of those numbers to get someone out the door - done in a minute instead of waiting an hour, to see if for example, the Hemoglobin is stable. I plan to unbolt it from the shelf and bring it home with me!

Anytime anyone gets near a patient, they put on a disposable plastic apron. Looks like cooking school!

Snakes, food, open water

Recovery ride today, so drove an hour to near the mouth of the river and then took a 50 km ride up to the Bass Strait - 240 km over the water is Melbourne. Trees unlike those at home - and some that are similar. Norfolk pines and eucalyptus remind me of southern California, Huon pines have long needles and massive trunks, then there's stuff that's unrecognizable to me, and rather surprisingly some palm trees.

I got a picture of an Eagle myself for those who were disappointed that I had to steal from Google Images - not very good, but just to prove my point, whatever it might be.

One large snake (probably a Copperhead) wriggling across the road. It was about a meter as it wriggled, so would probably be over 1.5 meters if I caught it and stretched it out. All Tasmanian snakes are poisonous, so I wasn't tempted to measure it, or get close enough for a good picture. On a trail, however was a baby white lipped snake (look close at the picture and you can see the white line along the side of its face). Wikipedia tells me that babies are born in March and are about 10 cm long - the size of this snake. They are only 40 cm when fully grown, and have such small teeth that, although poisonous, usually can't actually envenomate a human.

On the way back, stopped at the Tamar Islands wetlands. The islands remind me of the "hammocks" in the Everglades: lots of tall grass well over my head, with a few forested islands sticking out. The most impressive birds are the black swans which are impressive when swimming or floating, but when they fly turn out to have large white flight feathers on the outer half of their wings which, along with their loooooooong necks, make them truly spectacular (though their necks are so long, I'm not sure how they don't just point straight down when they try to fly).

Food is quite expensive here, though when you add it up, isn't so bad - since the tax (10% GST)is included in the price and one doesn't normally tip - thus you can subtract nearly 1/4 from the listed price to get a comparable US price. Doesn't look quite so bad then. And, some is really pretty good - lots of yuppie restaurants that remind me of Boulder.

So, they run the Century Rides a bit different in Tassie

First - the ride is 160 km, so no mention of it being a century.

The flyer called for the 160 km starting at 7:30 am (sunrise was 7:22), the 100 k at 9:00, etc.

I'm used to Elephant Rock, Triple, Buffalo, etc with a few thousand riders and starting sometime between "time X and time Y" - so I I didn't make a huge effort to be there exactly 8 minutes after sunrise - and I got lost on the way there, so arrived at the start area at 7:45. Maybe 20 or 30 cars around and nobody on a bike, just a few volunteers.

The route had been changed (because of the floods) adding about 10 Km. So, off I went - not seeing another rider for about an hour. An official came by on a car to tell me that the road closure had been lifted, and the ride back as well as the whole ride for other groups would be on the original route.

Eventually a few guys (who told me they had started early) from the 100 km group came up behind (by that time I was just lollygaging casually along) I fell in with them for a while and then, here comes the peloton! Flying. Maybe 150 to 200 in mostly a double line!

OK, I got it now. These events over here are a mass start and a group gallop. And, I had missed the 160 km group - and they were long gone - thus, the nobody on the road situation.

So, I found a little gap about 2/3 of the way back, stuffed my nose in and sat in. At the turnaround for the out-and-back 100 km ride, there was an aid station. Little city park with bathrooms - which nobody used since there were bushes handy. The aid consisted of glasses of water. Glad I threw in some extra energy bars. Probably explains the surprisingly inexpensive entry fee, also. Oh, and the support vehicle which was a guy on a Harley riding at the front of the bunch.

About 10 minutes later, the gang reformed for the ride back, and I slotted in about the same spot. About 25 km from the end, the pace started to inch upward and on every hill, gaps would appear and since I was pretty far back there were some large efforts needed to close gaps and gradually work up towards the front. By the last 5 km it was pretty much flat out race pace for me, and finally a group of ten took off while I was still about 30 places back - I tried to bridge to them and got caught unable to catch up and stuck in no-man's land. By the time the next couple groups of 5 or so came up, I was cooked so couldn't hang on until the third little group for the flat-out horse race back to the stable.

Averaged 38 km (23 miles) per hour for the 50 km ride back.

So, I missed the full century (ended up with 120 km with the add-ons), didn't get out to the most scenic part of the ride. But, got a great high intensity work out and had quite a lot of fun. Unfortunately, the group was so big and moving so fast that it was really hard to carry on a conversation, so I didn't really get to meet anyone - just a few brief exchanges with folks that I met at the race last weekend.

Kids & stuff

Here's a little something different: Had a little kid, 6 weeks, who had had 2 ALTE's (apparently not common terminology, though the Paeds - yeah that's the spelling here - Reg knew the term for Apparent Life Threatening Event). Baby was attentive and active, but a bit pale and vasoconstricted. Turns out, that the nurses here aren't allowed to even try an IV start in little kids - think the age limit is 6 months or so. I hadn't started a line in one of these kids in many decades, but one of the ER registrars dropped one in 2nd try. IO here is still considered last resort - a bit further down the ladder than in the US. Making the kid cry with the IV pinked her right up, and she was heading off to the ward under care of the Paeds Reg without any definite identified etiology (aetiology to be Australian) when I left.

Doubt that it would be too useful for me to try to relearn that particular skill at this stage of my career.

Procedural sedation is a bit more of a casual event - less paperwork, and a bit more casual a setup than I'm used to.

10 year old kid with bilateral distal radius fractures, one angulated enough to require reduction. Had to take him to "theatre" for the reduction - mostly because "I-I" (Image Intensifier, or c-arm) is used and there's no physical room and/or space to separate it from other ER patients. So, off to the "theatre" where they typical do a quick Propofol general with LMA ventilation (we'd probably do it with Ketamine in the ER). The other difference: in the States, probably get a splint initially, and switch to a cast after swelling no longer an issue. Here, the kid gets a circumferential cast and is hospitalized for 24 hrs to observe and be able to bivalve the cast if needed.

Had a chat with Andrew Hughes, the only other Permanent ER Doc here (half time ER, and half time running the "retrieval service"). There's no standard as far as documentation of supervision of the residents by a consultant. The residents are asked to, and sometimes do, mention in their notes that a case was reviewed with a consultant. I've been using a continuation sheet and putting in a brief note - what we would call the "attending note" at UCH - summarizing the case. Andrew thought that was a really cool idea and far beyond what anyone else is doing. No billing, and few lawyers here, so not strictly necessary.

No ACI's (After Care Instructions). In the US, we've got all kinds of pre-printed legalese crap (in case your heart stops, follow up in sudden death clinic) that might have some useful instructions included. Here, there are a few pre-written instructions that could be printed out, but that I've never seen used. Most patients get only verbal instructions. I've done a couple things: many patients get a "referral letter" to take with them to present to a GP or specialist with whom they follow up. I've sometimes included the instructions (if brief) in the letter, and given an extra copy to the patient. Or, I've pulled up WORD, typed out some instructions and given them to the patient. Of course, there's no documentation in the record - unless you hand write what you included. System could be cleaned up a bit, but I think it's actually better than our system where a patient gets many pages of legal junk and can't find the medically important stuff.

I watched an intern yesterday while she did some pretty simple suturing (after teaching her the relatively recent "single stick" technique for finger anesthesia - if you haven't tried it you should). The mother of the teenager chatted with me about how cool it was that a "senior doctor" actually supervised the junior doctor - something she had never seen done before in her many ER visits - and gave her a lot of reassurance over prior visits when it wasn't at all clear that the intern/junior resident had the skills appropriate to the problem.

Chatting with the residents, it seems that they share that perception: some (maybe many) of the visiting consultants aren't especially attentive with oversight, nor helpful with teaching.

Had a fairly simple straightforward Bell's palsy that none of the interns nor juniors had seen before, and worked well for a quick teaching rounds.

I still haven't seen a patient here who's problem was: "I couldn't find a doctor to see me for this chronic problem." The locals tell me that it happens, but so far, seems rare.

Footy

On today's ride, stopped for a little lunch (seemed to be french fries soaked in grease rather than cooked in oil) at a game of Footy - I believe that's Australian Rules Football. I'm not sure what was going on - there was running, some tackling, a lot of kicking (punting in American style football), and there were an awful lot of people on the field - I believe about 18 per side. Wasn't too crowded, though, since the field appeared to be about the size of a typical 18 hole golf course.

I was surprised to flip on the telly just in time to hear that some guy was going to sing the national anthem before a horse race - and it wasn't Waltzing Matilda! I've been misinformed.

32%

Rode up the 32% hill yesterday. Probably a good thing that it was only 20 or 30 meters long.

My GPS agreed that it was really 32%.

Quite a challenge to keep the balance just right so that the front wheel didn't come off the ground, and the rear wheel didn't spin.

Lonnie Floods

I rode down to the Cataract Gorge. It seems that about a quarter of the population was there watching the floods - including a number of folks that I knew from the hospital.

The weather service was off by a long shot on predicting the size of the flooding (they predicted 7 meters, but it only got to 3 meters) and it never got close to going over the levees. There were some closed roads and bridges, but no evacuations or buildings damaged.

However the Gorge was pretty spectacular. It wasn't the ground shaking sort of volumes like the 200,000 CFS flood when we were in Maine, but the smaller volume squeezed down a pretty narrow canyon.

For comparison, take a look at the pictures that I posted a few days ago. And, remember that in the video looking down towards the bridge, 2 days ago a tourist boat came to about where the prominent large wave is today.

In the still picture, notice that the chairlift is still running over the river. The outdoor swimming pool is just left of center in the picture, but under enough water that we couldn't see the tops of the very large swing sets by the pool.

Life in Tassie

Interesting differences in life: Grocery stores. To motivate the return of grocery carts, same system as often seen in Canada: The carts are clipped together and you insert a $1 or $2 coin to release the clip. When you return the cart and clip it back to the row of carts, you get your coin back. Save on the carts floating through the parking lots, etc. They all get returned inside the store.

On the other hand, the North American observation that it is better to put the milk in the grocery bag before putting in the bread - hasn't been noticed here (maybe they think that since Tassie is on the bottom of the world the milk will tend to float out of the top of the bag). Repeatedly I've ended up with flat loafs of bread when the bagger throw the milk in on top of the bread. Gotta remember to hold onto the bread until last in the check out lane.

More on Aussie terminology: Speedo bathing suits are commonly called "Budgie Smugglers" (after a somewhat infamous event where a guy was caught trying to smuggle small birds, called Budgies, in his underpants). There's been some commentary over Tony Abbott, the leader of the opposition political coalition, prominently being pictured on the beach wearing his "Budgie Smugglers."

More medicine

I've finally got my own prescribing number and can therefore write my own prescriptions, instead of having to track someone down for each prescription I write. It's a remarkably cumbersome process: Triplicate forms (I haven't used carbon paper for anything in many years) but you have to past a sticky label on each of the 3 layers first, press hard enough, etc, etc. Gotta have the same pen and handwriting, or it'll get rejected, etc. And when I write for 25 Oxycodone for a guy with a clavicle fracture, the resident wonders if the guy has some problem with pain tolerance that he'd need that much pain med. Tough guys here.

One of the residents is originally from Burma. She left there and did 3 years of internal medicine residency in Jamaica while trying to get a green card for the US (where she's got a number of relatives including an uncle who's an interventional cardiologist at Baylor in Houston). Couldn't get into the US, so came to Tassie where she's had to start over, so is a PGY 1 with 3 prior years of residency - as you can imagine, she's pretty good.

The residents here work pretty rigorous schedules - 76 hours (oh, but that's per fortnight!!!! Half the workload of our US residents. That's an interesting tradeoff - half the intensity, but twice the duration for the training program.)

Sometimes I think the limitations on use of advanced imaging get counterproductive: take the 75 year old lady with RLQ peritoneal findings and a very good story and exam for appendicitis. But, also known severe sigmoid diverticular disease from a prior colonoscopy. Admitted by surgery, and watched for 24 hours before finally doing a CT which showed cecal inflammation but no appendicitis or diverticulitis. I'm not sure if that proves that local practice is right and she didn't really need the CT anyway, or if showed that a CT would have allowed earlier symptomatic treatment and discharge by proving that she didn't have any severe disease. Or, perhaps it showed that antibiotic treatment can cure appendicitis and that if you wait long enough to do the CT, the appendix will be back to normal.

Nitroglycerine tablets here are 0.6 mg rather than the 0.4 we have in the states. So, if you'd like to have a patient with a blood pressure, you break them in half (nurses know to never give a full tablet at once). Why would you design a pill that always has to be broken in half?

Air ambulance service seems to keep the local newspapers busy: front page news 2 days ago was that our air ambulance had been "hijacked" by the big island. Tassie has one helicopter based in Hobart, and one fixed wing ambulance based at Lonnie. The service is free to Tassie residents. Last week there was a patient from the big island here in Lonnie, ready for transfer home - and the trip would be paid generously by the home insurance plan. So, for $6000, the local ambulance flew somewhere way to the north on a 12 hour round trip flight - leaving Tassie with no fixed wing service during that time (just one person that was stuck waiting overnight at a little clinic on an island with a broken arm). Big news. Make the damn big islanders with lots of air ambulances come get their own patients.

Some use seems to get a bit excessive: got a 5 year old from a small town 2+ hr drive away. She had tonsillitis and scarlet fever and was a bit dehydrated. The fixed wing was in town for some other reason, so the GP at the local clinic/small hospital just loaded her up and flew her to Lonnie for her IV fluids, etc. Worked well for me - none of the residents, and not even the registrar, had ever seen a scarlet fever rash before. Good teaching case.

Here's how differences in local meds can get you into trouble: quite sick lady with anaphylaxis (BP 70). Part of the treatment is a corticosteroid. In the US we have available methylprednisolone sodium succinate (Solu-Medrol) for cases like this, and methylprednisolone acetate (Depo-Medrol) to put into joints and as a muscle injection when you want slow absorption and long duration. Depo would rarely be used in the ER, and is not stocked in the ER, so all we say is MEthylpred, or just Solu-Medrol for short. I asked for SoluMedrol - blank look. Asked for Methylprednisolone - oh, no problem, mate. Then noted the white stuff (not clear) going into the IV line. Turns out they've only got the DepoMedrol here. For fast action, you use either hydrocortisone or dexamethasone. I found references to "severe adverse effects" of using Depo intravenously, but couldn't find a reference as to what those severe effects are. Lady did fine, and I'll have to modify my practice a bit.

Well, I'm looking out the kitchen window and seeing a lot of fast-moving water in places that I couldn't see it a few days ago. The predicted peak of the flood is about an hour from now, and predicted to be the biggest flood since 1969. So, time to hop on my bicycle and ride over to the bridge and up into the Gorge and take some pictures.

Water's Rising

We finally got the predicted rain, and it rained moderately and steadily for 24 hours. Not too big a deal here. But, upstream on both the North and South Esk Rivers (which join in Launceston to form the Tamar River) the rain was quite heavy. Video I've seen of the Cataract Gorge - which was a jumble of boulders with a little water when I hiked there 2 days ago - shows a raging torrent. Reportedly 2000 CMS (54,000 CFS!) through a fairly narrow gorge. Flood warnings out for Invermay - the riverfront portion of Launceston - expected to peak at 7 meters (23 feet) tomorrow morning. I'll try to head down there and get some pictures.

The hospital and my house are on the hill, so no danger.

Postal, politics, building

Another note about the postal system: tiny mailboxes with notices "No Junk Mail." Turns out that most junk mail is delivered at the door by private delivery. Generally if you've got a sign up that so "No junk," you get none. But if some is dropped off at the door, it comes with a little note telling you when they'll be back to pick it up if you don't want it - just leave it outside the door and the delivery guy takes it away. (Except, the guy never showed up in my case, and the catalogue is still sitting there 2 days later).

Australian parliament is currently in the midst of a vociferous debate on a carbon tax proposed by the Labor Government. Last night was "Question Time," a somewhat louder, more acrimonious, nastier version of Britain's "Prime Minister's Questions." It gets extensive coverage and replays on radio and TV. The Speaker of the House tried to valiantly to keep order: the final score was 18 representatives ejected for an hour each, and one kicked out for 24 hours! At one point, the Speaker said to Julia Gillard (the prime minister): (roughly) "It is time now for the Prime Minister to sit down, and to stay seated, and to not arise again until your turn to do so. I shall also remind the Prime Minister that her task is to answer the question, not to answer any question which she cares to answer!" Watching on TV, one notes that will the prime minister or other government ministers are answering questions, Tony Abbott the opposition leader, is variously making faces, rude gestures, slouching, looking disgusted, and (rather amazingly) doing a good imitation of "Rocky - the Denver Nuggets mascot" stirring up the vocal opposition. All quite amazing.

BTW, voting in Australia is compulsory. $20 fine if you don't vote. If you don't pay the fine, they'll take you to court and you can be fined $56 plus court costs. They do things like sending people around to the hospital to collect ballots from the inpatients. And, I gather that there are polling places everywhere, so easy to vote (including in the hospital for those working that day).

Seems like most of the houses here have no basements - not too surprising since these steep ridges have basement rocks right up under the surface soil - major explosives to dig a basement.

Geologically, the Tamar River valley (with Lonnie at the upper end) is a graben - a geology feature with 2 parallel fault systems, and the terrain in the middle displaced downward. So, these steep hills are running up the wall of the graben right up the fault line (and my house is perched on the fault). Steady there, baby.

I walked home from the hospital by a different route and looked up to see a number of very modern homes with big glass windows and decks looking out over the view of the city. But, they were where I expected to see the old brick houses with decorative cast iron across the street from my house. Investigating further, a number of these old homes have been expanded or remodeled into these modern rear exposures (not sure what a facade at the back of a house is), so the front is old traditional, and the rear looks like southern california. Neat.

Today walked up through "The Gorge" I side valley out of the main valley of the Tamar. Steep walls of igneous (dolorite) rock with lots of vegetation on it (and obviously climbed judging by the bolt ladders and chalked handholds). Very rocky bed down the middle that apparently was quite a raging torrent before the lake was dammed above the Gorge in the 1950's, reducing the water flows to a small fraction of former levels.

The Birds

I'll try again on pictures of Kookaburras and white-bellied sea eagles.

Batman Bridge

The forecast today was for 4 inches of rain - but it got pushed back to tomorrow and we had only a few brief rain showers.

It's about 100 km from Launceston to the sea, but there's only one bridge across the river between Lonnie and the sea - about 40 km downstream: the Batman Bridge. It's one of those suspension bridges that only has a tower on one end with cables that diagonal out onto the span from the single tower. Doesn't look much like Batman, but that's the name.

Lots of chip seal, and some sections of road with no shoulders, but not much traffic - high speed road one side of the river, then mostly backroads on the other. Rolling farm country and pretty views over the river. Lots of large sail boats, and some power boats.

Wetland conservation area with nice bird displays. Some pretty interesting birds here: kookaburas are all over the place, and quite noisy. White bellied sea eagles are large and spectacular. And black swans are beautiful and impressive. Lots of other beasties that I don't recognize. Still looking to see a live native mammal. "native hens" seem plentiful but not too bright. Almost ran into me on my bike - had to dodge them.

Shamelessly copied from Wikipedia.

Ate lunch at the oldest continuous hotel in Australia, dating from 1831. Just had dessert - sticky date cake with butterscotch sauce. I decided that when I come to the point of requiring palliative care, I will return, eat two helpings of that dessert, walk across the street and jump into the river and die happy. It was one of the most extraordinary desserts I've ever had.

Aussie TV quiz

Last night's comic TV included a quiz of one of the guys from America's "jackass 3" - asking him the correct answer to questions loaded with Aussie slang, and included: "Where do you keep your 'map of Tassie' ?" Ans: "In your Reg Gundys."

Correct explanation to follow in a later post.

Aussie TV does seem to include a tolerance for (and delight in) a bit more raw language than available in the US.

Only late night TV that I've seen rebroadcast from the US seems to be Craig Ferguson. Did find "srubs" yesterday.

Some brief medical notes (OK, verbose and not so brief)

I've now worked 3 official shifts, and have some observations, not much organized:

The trainees - residents, and especially, registrars - work much more independently than we are accustomed to in the US. They may see and discharge some patients with no input from consultants. So, I've learned that I have to insert myself into some of the patient evaluation and treatment processes. The registrars in reality by their 2nd and 3rd years are at a level that would have graduated from residency and on to fellowship, or independent practice, or junior faculty in the US - so there is no reason for them to consult me, so I've had to push a bit that I need to share cases with them to learn the local practice patterns, and just because it's more fun to share cases - if we're not too busy.

I'm still trying to sort out exactly how the training system works - it appears that as a Registrar, you aren't really part of a "program", but rather do a series of contracts with hospitals for varying amounts of time. So, some of our registrars are here for periods up to a year, others for only a few months. Some are from other specialties doing required (and apparently sometimes resented) required time in ER.

The educational sessions for residents and registrars are on Thursday, and are usually done by visiting faculty from "the big city", Melbourne, who mostly come down for 2 days - one clinical day and one teaching day - although the guy here this week is down for the whole week. (Many of the locals claim that since Launceston was established long before Melbourne, Melbourne is really just a suburb of Lonnie - though it's about 20 times as large.)

No stirrups in the ER: pelvics are done British style with just a bed, a pad or pillow, and some contortions on the part of the resident. No plastic speculums, or built-in light sources (I'll never complain again, Ben.)

LP's are generally done sitting, and it's not clear that pressures are measured very often, and repositioning the patient for measuring a pressure after hitting CSF seemed a sketchy maneuver - I think if I want to measure a pressure again, I'll push for doing the insertion with the patient lying. On the other hand, since this was a low-CSF-pressure headache with an opening pressure of something around 4-5 - maybe we wouldn't have hit CSF in the usual lying on the side position. The resident was terribly disappointed -missed a bottle of champagne, by one RBC! Given the rices of alcohol here, I was glad for that one RBC.

BTW, food is quite expensive here, but I suspect that's because low-paid workers - such as restaurant workers are relatively much better paid.

Also, the grape orchards (lots of Tasmanian wines) are all on north-facing slopes. Still hard to wrap my head around the sun in the north

The resident and reg were both astounded to here that I generally offer a little versed to patients nervous about an LP. Not so much of that touchy-feely stuff here.

Seems to be very little Ultrasound done here. The machine in the department, is I believe one of the first 3 machines ever built by Sonosite. The screen is about 1/2 inch by 1/2 inch and has no doppler, m-mode, etc. No ability to record an image electronically or by paper. Does have a small footprint/cardiac probe and a vascular linear probe. No curved aray abdominal nor TV probes. It's interesting that I believe I'd have a hard time learning some of the techniques on this machine, but having learned on a better machine, I can actually do stuff on this machine.

For instance on the lady with the low pressure headache (HA worse when upright just like post-LP HA, slitlike ventricles on CT, low pressure on LP) she had rather small optic nerve measurements (4.1 and 3.8 mm diameters) on ocular ultrasound. I haven't seen that described, but interesting.

We had a guy with previous spontaneous pneumothoraces, with typical symptoms, a normal CXR and an unequivocal "lung point" and lack of lung sliding up right under the clavicle on ultrasound.

A couple of the residents have been pretty enthusiastic about learning to use the US for some of the stuff. Great enthusiasm when the heard that I actually use US for inserting central lines!

Quite a bit of stuff comes in from outlying hospitals to hang out in the ER while consultants (usually the registrar) work them up. Today's special seemed to be folks that had unstable angina, nonSTEMI, etc. on Friday. Spent the weekend at one of the smaller hospitals, then came here today for their cath and we just lined them up against one wall while they waited for cath (4 of them). All had gotten the full monte at the small hospitals: ASA, plavix, enoxaparin, a statin, and beta blockade, along with NTG (GTN here) while having pain. Didn't see any glycoprotein inhibitors in any of them.

On the other hand, we had a guy that came in last night who had fallen on Saturday night and hit his head. Presented with just a headache, but a moderate sized frontal contusion/ICH without mass effect. Hobart didn't have beds (we don't have a neurosurgeon) and so stayed in our ER until this morning - then flew to Hobart.

For a little variety, an 18 year old with Down's couldn't hold still for her MRI. She didn't have a local GP or pediatrician, nobody else seemed interested, and I was looking for a chance to get to know the imaging folks a bit better and perhaps get in a bit of ass (sorry, arse in Australia) kissing - so spent some time in MRI sedating the young lady. (And hearing the horror story of the child in the tube when a nurse walked in with scissors that flew all the way through the length of the tube and stuck to the back of the magnet without injuring anybody. And, the guy buffing the floor and had the whole power buffer get sucked into and jammed in the tube. They had to get a big, non-metallic block and tackle to pull the thing out of the room. The stories made the trip well worth while.)

Alright, lots of little vignettes. We do see a bit of interesting stuff. Haven't seen a single heart transplant, lung transplant, liver transplant, or pulmonary hypertension on Flolan.

There appears to be no diphenydramine/Benadryl in Tasmania - I'm trying to figure out the appropriate alternatives.

Any of you that read this whole thing have my most profound apologies and sympathy.

The Weather is now looking a bit more........

Tasmanian. There's a sheep graziers warning issued for tonight - heavy rain for the next couple days. Right now it's "not too bad" - presume that Noah's flood would be consider getting a wee bit heavy. But, from the porch, the evening sun on the rain gives a shimmering silvery fantastic look out over the bay (it's called the Tamar River, but it's so tidal that I have to think of it as a bay - I guess it is a river since it's 100 km to open ocean).

Things could ugly here: dress code in the ER - as elsewhere - is decidedly more casual than we're used to. Thursday is a big World Cup cricket match between Australia and India. Our Indian registrar, Sushant Singh, has taken to wearing his India team cricket (not sure what it's called) and taunting the Aussies. Great fun.

More Bike Racing in Tassie

First, a follow up on the mountain bike race from Wednesday: Michael had a Copperhead snake jump out of the bushes at bite him on the leg during his race! Drew blood, but didn't envenomate him, so he didn't get sick (though he spent a few hours at the ER under observation). I only heard about this later, since I left after my race but before his race.

Today, I rode a 50 km race with the NVCC (Northern Tasmania Veterans Cycling Club). They typically get 50 - 70 people out for a race - 35 years and up. Rather than strict age groups, they categorize to try to get relatively comparable abilities, so fast 60 year old and a slower 45 and a few women may comprise a group. So, a newcomer like me may be hard to figure out where to fit in the handicap scheme.

The race was rather flatish with just a few short, and not very steep climbs (the whole race was on the plateau above and southwest from Lonnie. The first half the local procedure was a fairly strictly regimented double pace line, so a reasonable pace (well below my usual race pace) with a group of about 10 - one newcomer younger guy, 3 hammerhead younger women, and the rest 60 something guys. Once we turned around (an out and back course), it heated up and after the last hill ended up me and the two young women (would've been great if it hadn't been a bike race), and one other guy a little behind, who eventually bridged back up to us, so for the finale, it was a 4 up sprint. I got a calf cramp about 75 or a 100 meters from the finish and couldn't push very hard but took the sprint from the front with a peak power output of only 780 watts.

This was on my cyclocross bike with road tires. I'm sure that those round forks, and the auxiliary brake levers cut into my power output by 2 or 3 watts. Or something.

So, if I get to do some more races, it will clearly be from the next group up the scale.

They do an interesting variation: handicap races where they start the groups in reverse order and the faster groups try to catch and pass the slower groups. That could be sketchy if the catch is close enough to the finish!

Local boy makes good: Matt Goss, Launceston native and local bike hero, and leadout man on HTC/Columbia for Mark Cavendish won Milano-San Remo this morning! The other local, seemingly even more popular, is Richie Porte riding for Saxo Bank - a GC guy for them.

Sorry, no pictures from the race.

Getting started in the ER

Finally - only one more required signature and I can work officially tomorrow. Yesterday spent most of the day getting organized, and today couldn't officially manage any patients, but since the residents don't have to have a consultant sign off on every patient as we're used to at UCH, I could organize a "teaching session" and the resident could then manage the patient. Managed to help out the registrar's on some cases, also.

So here's the players in Australian medicine. After high school, most of the Australian medical students take high school graduates straight into a 6 year medical school program without any college. A couple of the "big island" schools are considered "post graduate" medical schools on the American style of 4 years of college, then 4 years of med school.

After medical school, the internship years is a year of rotating through various services without any specialization, and that non-specialized pattern continues for 2 or 3 more years as a resident. So, the interns and residents get broad exposure and are not orienting to a specialty yet.

Then the 3rd or 4th year, they begin specialty training which continues for 3 or 4 more years. Unlike our residencies, there is more flexibility in the registrar's program: he continues the program until he passes the specialty board examinations and until he chooses to leave the registrar program (apparently the pay is good enough that some choose to continue longer than might otherwise be thought necessary).

So, the interns are chronologically quite young. The residents have not begun specialty training, but have more extensive experience as inpatient house officers than our residents. And, the registrars are considered fully ready to function on their own with minimal supervision, they have lots of experience as house officers, but in their first years as registrars, may not have as much direct ER experience.

Stay tuned for more on how that seems to work in practice. Thus far, even when just doing a "curbside" consult for the registrars, the presentations have tended to be a bit longer and more structured than I'm used to (we don't often hear a full recital of the review of systems in the UCH ER). On the other hand, that may be a function of more reliance on the history and physical than on technology. More on that little issue later.

A couple really cool things: lots of patients arrive with their "Medical Information Book" that they carry with them - an organized booklet with a listing of their medical and surgical histories, active problem list, and current medications all filled out by hand and carried about with them.

Even cooler: although the Electronic Health Record system is currently limited to not much more than a computerized control board, it does have on it a "Discharge Letter". The doctor discharging the patient has a couple computer clicks to pull up a blank space to type in a brief note: free text and as detailed, or basic as desired that will then automatically be formatted with hospital letterhead, date, MR #, and signature line, and then be printed out in multiple copies - one for the paper chart, and the rest for the patient to carry with him to his follow-up exams with GP's, or specialists, or to keep personally in case of a "bounceback" to a different ER. It's quick, flexible, easy and brainless. The patient carries it so there's no looking around and getting consents to get stuff faxed over from hospital X, it's there for the f/u MD when he needs it - without extra steps. It is sweet! Love it.

More later.

Racing again! In Tassie.

First off, I finally got the approval to go to work from the national medical board. However, the chief of the medical staff - who had to sign off on my hospital privileges - was off for the day, so I still can't work officially until tomorrow. I spent the morning and early afternoon putting together an impromptu teaching service with 3 medical students who were standing around hoping that someone would teach them something, and then a few interns and junior residents. I couldn't actually provide any medical care or direct advise, but didn't need a license to provide some teaching - some fairly indirect, and other with more direct applicability to clinical cases: "If the patient is still moving (as this one is) one could conceivably give additional propofol (like maybe another 50 mg for this guy). Actually had some interesting cases and since I wasn't "really" working, it was nice and low pressure. But with one more avoidable delay, I went home mid afternoon, since I had other offers.

Launceston's mountain bike club runs a Wedesday evening MTB twilight race series that I'd heard about from several sources - so I rode my 'cross bike over to watch. Met one of our nuc med techs, a radiologist, and an ER nurse there and road the men's course with Nick on my cross bike. It was OK at warm-up pace, but would've been problematic at race pace. But there was a "D" group that the guys convinced me to sign up for and race - the course eliminated the rocky technical section. Left me with one dismount over a log pile that was quite rideable (and for some racers, quite crashable) on a MTB. So at the start there were about a dozen teenagers, 6 or 8 women, and 2 men - me on the 'cross bike. The cross bike generated a lot of cheering, and laughter at the mount/dismount. It was a huge amount of fun.

I got to meet one of the locals who I'd been in Facebook contact with, and met perhaps another 10 of his friends - and set up plans for a ride with those guys on Saturday (and then a birthday party at his house). So, my range of acquaintances on bikes has grown rapidly and the whole experience was quite a hoot.

Spent some time after the MTB race talking about plans for a few 'cross races this fall (we're entering fall down here). Since they estimate that only 10-12 folks will show up to race, I suggested to them that a pattern similar to the Wednesday morning training races at the Elks' club in Boulder would be adequate: get one of the faster guys to just lead a warm-up lap or two to establish the course, then stop take a break, and let the carnage begin. Eliminate worrying about tape and 3 meter wide lanes and stuff. Might make life a bit easier for a first ever Tasmanian CX race.

Riding around Lonnie is amazing - the hills are only 50 - 100 meters high, and less than a kilometer in length, but there are many in excess of 20% - and I rode down one labeled as 32% on the traffic sign!! I have to admit that I didn't ride back up the same hill - took the easy one that was only 22%. I'll try the 32% some other day.

Rode out into the countryside - pretty rolling roads, gradually rising through the farmland and eventually up into eucalyptus forests with higher up some pine forest. Reminded me of the Sierra foothills around Solvang.

Found a pretty deep cut basalt canyon.

Good to be back on the roads and riding.

Contact info, trip to Australia, initial impressions of Tassie

I'm finally connected to the internet and have a phone: 011 61 04 87 230 034 if anyone wants to call. And I'm on Skype at rabbott1020 as rick abbott.

The trip seemed to take forever, but was actually not too bad - managed to sleep at the right times so that I had a 6 hour block and woke up at 6 am Australian time. Had an 8 hour layover in Sydney and went downtown, cruised around, listened to some Aborigine music on the waterfront and got some walking exercise.

Launcestone is quite an old town - early 1800's. 60 years older than Boulder! Lots of old houses, businesses, and churches. Ornate wrought iron seems to be the theme. Brick, stone construction. Metal roofs. But the interiors are quite modern in many of the buildings and homes. The house I'm living in is small - the size of one floor in our Boulder house. But recently remodeled. Fancy appliances (cooktop has a touch screen control panel, and touch sensitive burners that turn off automatically when you remove the pots & pans). Nice little backyard. The street runs across the face of a ridge (with 18% grades on the streets running up the ridge! Yeah, 18% really.) and I've got nice views across town, and down towards the harbor.

Lots of funny little things to notice that are just a bit different from the states:

Sports - lots of general news coverage of cycling. Good week for Tasmanian cyclists: at Paris-Nice this week Richie Porte took 3rd in the Time Trial, and Matt Goss won a stage - both Launceston boys. Then there is the high school lawn bowling tournament, lots of horse racing, lots of cricket news, and apparently about 29 different variations of Rugby. Then there's net ball. It got TV coverage and appears to be a hoop and net like basketball but no backboard, played by women, mostly tall, ball a bit smaller than a basketball - here's where it get weird - you can't move once you get the ball, and you can't move if you are guarding the person with the ball, so everybody else runs around, then if you finally get the ball to a player within about 8 inches of the net the player and the guard both stand there doing pretty much nothing until she throws the ball into the net. Anything from more than 8 inches away seems to have near zero chance of going through the hoop! Maybe there is something different that I don't understand.

Lots of betting shops - presumably on sports.

Tiny little mailboxes - with stickers on them that say "No advertising or catalogs accepted." The mailbox appears to have room for about 10 letters and nothing else. I guess the Postal service doesn't deliver the junk mail if you say you don't want it. What would LL Bean do????

Pedestrian walk signals - First, you can't turn (left) after stopping on a red light. Then, people actually obey the green pedestrian "walk" signals - even if there are no cars within sight, people stand there and wait (and rarely do you see someone cross between intersections - maybe never). Then when the light changes, you only get a couple of seconds of green walk, then immediately goes to flashing red - no darting across later. Understandable, since the cars have been waiting to turn and their time to turn coincides with your time to cross the side street. Step lively there, mate.

High heels - lots of them, really high (with short skirts).

I filled up the tank on my little car (about 10 gallons if I did the calculation correctly) for $82 (US and Australian dollars are within a penny of each other right now). I've never put $82 worth of gas in a tank before - not even the bigger tank on my minivan.

it's a 7 minute walk from my house to the downtown mall. Quicker to walk than to drive & look for a parking space. Really nice to be able to walk to stuff. The mall is a bit shorter than the Boulder Mall, but with a shopping area around it that is somewhat bigger than downtown Boulder. Quite a range from really fancy upscale stuff to sports recyclers to Target to a Sports Authority (?same company as in Boulder?) to a pretty upscale bike shop to fancy restaurants to take-aways with the usual Indian, Chinese, and falafel. I feel right at home.

The city is built at the end of a flat, broad, agricultural river valley - big enough for small ships on the river. 2 smaller rivers join here to form the big river. The part of town that I've explored so far is built on the very steep hills around the smaller valley. I haven't been down to the flat part of town yet (except late at night when I was lost.).

I've got some pictures, but having trouble downloading - will load them later.

Getting a job and getting there

So, I'm sitting around the house, reading and I get a phone call for Jean, from Global Medical Staffing, wondering if she's interested in working 6 months in Australia - she's not in, and probably not interested, but I might be, but not 6 months - only 3. A few more phone calls, a little paper work, a phone interview with Dr. Paul Pielage (director of the ED at Launceston General Hospital), and I've got a job offer. 3 other job offers included a smaller hospital in Tassie, and 2 hospitals in NZ. Very generous terms, so why not?

Now comes the hard part. Paperwork for assessment of a "specialist area of need", then a temporary license with the Australian Medical Council, a temporary work visa, hospital staff privileges (pretty easy, but slow). Pages and pages of documents, numerous passport photos, pulling up old documents that I hadn't thought of in years (I needed to prove that I graduated from an English-speaking high school, but couldn't find an original diploma - only copies - and my high school had lost records from the 60's in a flood. I think they finally just looked me up in a yearbook or something!), letters from organizations that didn't exist (the Nepali Medical Board???), a CV that had to be expanded to about 3 times its original length to provide the required detail, and all notarized by a single notary! When the notary I started with went on vacation, I had to get another notary to notarize a statement that the original notary wasn't available. Fed Ex stock prices skyrocketed on news that I would be doing all the paper shipping.

5 months should be plenty, right? Well, the hospital took 4 weeks to get the last couple signatures before sending their stuff to the AMC. The AMC had reorganized last July and was still backlogged, so took 6 weeks to even acknowledge that they had received my packet, and then were missing 3 pieces of paper that we had fax and FedEx receipts for, but needed to scramble to find them. Then, on to the Visa from Immigration - they were missing my blood tests - so a late night trip down to Boulder Community Hospital to print out (helpful to be an MD and know folks that can help do this) the lab tests and then fax them to Immigration. Finally had my Visa on Monday, a flurry of phone calls, and a ticket for a flight on Tuesday evening.

The original plan was to allow 5 months for all that stuff and be ready to fly on Feb 28 (with a months cushion after the expected approvals by late January), and start work on March 7. Instead, approvals on March 7, fly on March 8, and start work as soon as I get the final paperwork (one more step: drive 3 hours from Launceston to Hobart to the AMC office to show that I'm the person in the passport photos, drive 3 hours back) and do a little orientation.

Wow, this would have been tough to do on my own. Most of the hassles were borne by Amy Woods of Global Medical Staffing - without her, I may have been reducing to blithering, sniveling, burying my head in sand.

So, the packing is done, and I'm out of here in a couple hours.

Finally ready to go

Tasmania is a state of Australia, an island off the south coast of Australia's "big island". It's pretty rural - 37% is national Park and World Heritage site. It's the size of Maine, a bit smaller than Virginia and has 500,000 people in the whole place. I'll be working in Launceston, a city of just over 100,000 with a University. The hospital is 380 beds, the ER 23 beds, and has an Emergency Medicine residency. The residency is 8 years, so the "registrars" (the last 3-4 years) are more what we'd think of as fellows or junior faculty. They'll be a couple years younger though, since medical school starts straight after high school but last 6 years.

Medical care in Australia is nationalized in the sense that if you don't buy private medical insurance, you pay 1.5% of your taxable income and are automatically entered into Medicare (looks more comparable to our medicaid). So, there is 100% insurance coverage on a model very similar to Romney care in Massachusetts, or what Obamacare would be like if fully developed.

Although the latitude of Launceston is the same as Portland, Or, it's at sea level, so there's little snow. And, since the high point of the island is under 5300 feet, there's not too much snow even in the mountains (there is one little "ski field"). It's in the "roaring forties" - all water except for Tassie itself, south island of New Zealand, and the tip of Patagonia, so lots of wind and rain.

And, of great interest to me, there's an active cycling scene - both road and mountain biking (a shop in top runs a shuttle service to the top of a nearby mountain with a 3,000 foot descent on single track back into town!). For the race fans, Matt Goss the Columbia/HTC sprinter is from Launceston. There's a Facebook website for cyclocross racing in Australia which had its first year last year (both the racing and the website). One guy in Lonnie races 'cross by going up to the big island, but hopes to run a race or two locally this fall - our spring, when I'll be there.

So, I'll try to fill in the details in the near future. I'll write about the wind, and the rain and the flora and fauna, and the geology and society, and what it's like to live in Tassie, and the biking. But, most of all I'll write about what it's like to work in a system of nationalized medical care, how the system works, and what it's like working on the ground in the system. Maybe a little about the local humor, and the language.

I'll try to use headers so that folks that aren't interested in some of the stuff can skip to what they want.

I leave Tuesday march 8 and expect to be back June 20.