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.