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.