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.