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.