Muddy mountain bike racing

Mountain bike racing - a fund raiser to support efforts to save the Tasmanian Devils (estimates are that 90% have died in the last 10 years from an unusual viral caused and transmitted facial cancer) by setting up preserves that separate uninfected animals from those carrying the disease.

75 racers in 3 man teams riding a 4 Km course - about 15-18 minutes per lap for the faster riders.

We started in drizzle with wet slippery rocks and roots, the rain ramped up to torrential downpour with insanely slippery mud as well as the rocks and roots. About half single track, a number of short punchy climbs that were middle ring if you made it to the top, granny gear if you didn't get to the top before having to throttle back. Quite a lot of fun, and most people coated with mud and totally unrecognizable by the end.

I rode with a couple younger guys who were about a minute per lap faster than me and we got 4th. Couple bottles of wine and a dinner voucher at a fancy restaurant (for the team) - they took the wine, I took the voucher - use it with Jean in a couple weeks.

One of my teammates was a CT tech from the hospital - interesting to hear his side of the CT story (radiology thinks - but appears the thought has not been passed on to the guys in the ER trenches - that we order too few MRI's, and are ordering CT's when we should do MR's. That seemed clear to us in the ER, but wherever the communication fails, the message in the trenches is different: don't do so much imaging. Hmmmmm - wonder what's up.)

Ouch! that hurts

Fairly routine guy with new A Fib. Checked things over, nothing unusual, little propofol, push the button, zap. Back in sinus rhythm. Feeling fine.

20 minutes later I'm in the nursing station, doing paperwork and from his bed comes this funny nose and he bounces up off the bed - spent about 3 seconds figuring that he's joking with the nurses. But, noooooooo - the nurse had decided to clean things up getting him ready to go home, and got so efficient that she even ran the "test strip" on the defibrillator. Unfortunately, the patient (wide awake) was still attached! Apparently, the "smart" defibrillator isn't smart enough to note that it's still attached to a very awake patient.

The guy thought it was way funnier than either the nurse or I did. He apparently works as a technician doing physics labs for the high school and one of his recurring jobs is to be the guy that gets zapped by the Van de Graff generator. And, once while setting up with no one else around grabbed the electrodes on a rheostat demonstration - but had bypassed the rheostat and got the full voltage and couldn't let go until finally he had sufficient seizure activity that he got ripped free. So, he thought that being accidentally defibrillated when wide awake was pretty small potatoes compared to previous experiences and thought it was pretty funny. To quote Queen Victoria: "We are not amused."

Press Ganey, where are you when we need you?

Realllly Full

Recall we've got 19 official beds, plus 3 add-on beds and 2 "chairs", plus 2 fast track rooms, a family room and a fast track office.

Stopped by to borrow a bicycle this morning and we had: 20 inpatient boarders and a total of 40 patients as boarders, ER patients, and patients "ramped" (still on EMS stretchers) and in the waiting room. 4 of the boarders were in the fastrack rooms, office, and family room so Fastrack was out of action except for the waiting room and hallway chairs.

So the hospital had finally gone onto "Capacity Emergency" status. No other hospitals in Lonnie, so no local EMS divert. But, no patients accepted as referrals from the little outside hospitals or from GP offices. Some of the really small hospitals might be able to get help from a bigger small hospital (i.e. one with no lab or x-ray might send to a small but better resourced small hospital), but most would mean flights to Hobart or to Melbourne.

More importantly, the status puts pressure on inpatient teams to discharge, and to inpatient floors to accept inpatients to hallway bed status on the inpatient floors.

It's remarkable to me that despite the very different structural patterns and financing patterns of medicine in the US, UK, Canada, and Australia - the overcrowding issue is the same everywhere.

Keeps being interesting

We're back into stacking 'em like cordwood mode: head injuries examined and CT's and discharged without ever leaving the waiting room. The guy with typhoid from last night is still in the ER, and doing fine - no longer has that attractive gray color.

Guy with acute pulmonary edema from going into A Fib at 200. A little propofol, a little electricity, and he's fine. Biggest tongue I've seen from angioedema (probably from Augmentin, not on an ACE inhibitor) - fortunately sucked in an awake blind nasotracheal tube nicely.

All this with no space to work. Challenging. Fun.

Still working on the language

Discovered a few days ago, that when a patient is described as "average" - where not talking about the arithmetic mean. "Average" in Aussie seems to me right at the bottom of the barrel. OK, so that explains why the patient always seemed to look a bit worse than me.

Walking home tonight, beautiful clear night and I realized that the sky still has no constellations that I recognize. Where did that big dipper go?

There's a mountain bike race this Sunday - 3 man teams to do as many laps as possible in 3 hours. One of our nurses is the president of the Mtn Bike Club putting it on, and came rushing back from the triage desk today with the great news that she had found me a mountain bike to use and a team to ride on! One of her friends, just about my size, was out in triage with a broken clavicle - so his bike and spot on a team was mine. Should be fun.

Continue to get interesting cases: guy went to Fiji for a diving holiday, came back with abdominal pain, constipation, and fever. Pretty sure that it's typhoid - don't recall diagnosing that before.

As I get to know the system better (and, the system and more importantly, the people in the system, get to know me) it works a bit better. No place for nursing orders, but post-its work really well. Have to call radiologist to get approval for CT, etc after hours - but, as long as you're half-way reasonable they always try to help - even though the available resources don't allow exactly what you want. Today, I even asked for a CT (Easter Tuesday is a holiday in Tassie - so we're on part staffing) and was told that an MR would be better (which I knew) and he'd just do that instead (the MR and CT techs are cross trained, so once a tech is in, both studies are fine).

Getting to know the other specialty Registrars better, also. And that smooths interactions quite a bit.

I've had the distinct impression that Emergency Med is a second class citizen/overpaid intern sort of attitude here. But, part of the problem, I suspect is that there is so much turnover in EM, that nobody gets to know the capabilities in the ED and it isn't to unreasonable to assume the worst. Until they get the resources, and permanent staff, I expect it won't much change.

Medicine with limited imaging

Yesterday was appendicitis day: 3 of them. One was classic, straight to theatre without imaging. One had classic localized peritonitis, but a 3 day course and the localized tenderness was in the anterior axillary line rather than McBurney's point - surgery poo-pooed a bit, so we got a CT and as predicted by the ER, a retrocecal appendix wrapped around and up against the lateral abdominal wall where the tenderness was. The third had diffuse tenderness of the entire abdomen with no area that was clearly worse - until we gave him some fentanyl and he then localized nicely to the right lower quadrant - straight to theatre without imaging where he had a perfed appy with generalized peritonits - as predicted.

We've had a couple of big trauma resuscitations this week: 3 year old with isolated head injury (clipped in the head by the projecting bed of a flatbed truck), and an ultralight plane crash. We get the ICU critical care team (anethesiologists) as well as surgeons. It works remarkably smoothly (especially with the number of temporary folks here), is relatively low key - with lower ambient noise than I'm used to, and based on only 2 cases seems to work well. The drawback is that - the EM Registrars get treated as very much second class citizens in the resuscitation (not unlike the general flavor of everything here).

Inpatient beds were readily available (I presume no elective stuff over the 4 day Easter holiday, so lots of inpatient space). So, we had no boarders in the ER and it became remarkably efficient to move through fairly high volumes (it seemed to be crash your dirt bike motorcycle weekend - tons of fractures).

Politically incorrect?

Sushant had one of our computers live streaming an IPL (cricket - Indian Professional League) game last night at work. I had some paperwork to do, so sat down and watched for a little while doing the paperwork - they flashed the score of one of the teams: Mumbai Indians. I thought gee, thats funny (and very incorrect) that a team from Mumbai would choose a name from American Natives. It took a couple seconds (after the words were already out of my mouth) to realize that the team was actually "Indian" - Sushant gave me a bit of a reminder lesson on how American Indians actually got their name.

Ramped

Today's Tasmania new headlines was again about the LGH ER: Monday afternoon (glad I wasn't there) we had 48 patients in our 23 bed ER. Plus 4 more "ramped" - still in ambulances with no where to go.

No bypass here - just stack em up.

Should I visit Tassie??

I'm sure some folks wonder whether a trip to Tassie would be worth it:

Tassie's pretty interesting - small towns, bush walking, sea kayaking, cycling, beaches, surf. There's a few things that you can't see anywhere else in the world - Devils mostly. And a few things that you'll see only in Australia: kangaroos and wallabies, eucalyptus (except southern California), white bellied sea eagles, kookaburras, wombats, etc.

But, everything I did, there was always something I'd done someplace else that was a little better and that I'd recommend ahead of coming to Tassie:

Birds: try the Chitwan in Nepal

Bushwalking: try Colorado, or Utah canyon country, or Nepal

Walking on the beach and watching waves: Oregon coast, or better yet - Tofino on Vancouver Island

Southern Hemisphere rain forest: South Island of New Zealand

Cycling by the ocean: New Zealand, Western Isles of Scotland, central coast of California, northern California and Oregon, and best of all: Newfoundland - pack ice, icebergs, whales, caribou, moose - all visible from the bike.

Mountain cycling: Colorado, Canadian Rockies, Morocco

Exotic cycling: Vietnam (don't do Saigon to Hanoi like we did. Stay 4-5 days in a few different towns and ride the back roads around the towns - fat tires on a cross bike.) Morocco.

History while cycling: Great Britain - do the End-to-End or shorter rides.

Sea Kayaking: Sea of Cortez, California Channel Islands, Vancouver Island, San Juan Islands, and again best of all: Newfoundland - icebergs and whales!

All of these are trips I've done - and there are lots more I'd like to do. All of these that I've done, I'd do again in a minute. But, Tassie is fine and interesting and if you're here, there's enough to do. But, I'd never make the trip back again - there's so much more and better closer to home.

Queenstown burned down

I stayed in a little town called Queenstown my last long weekend (and took care of a lady from there that I think had carbon monoxide poisoning - but couldn't prove it).

Yesterday, something caught fire in the central block of town - either started in or spread to a machine shop with acetylene torch cylinders which exploded. Apparently most of the downtown is gone, and what is left - including my hotel - has no windows from the explosion. Glad I missed that excitement.

I haven't heard of any injuries (happened at 2 am). Presume the hotel was empty - I was the only guest the night I stayed there.

Aussie humor hits back

"How does a New Zealander find a sheep in the bush?"

"Quite delightful, thank you."

I recall being in New Zealand years ago and noting that about half of all Kiwi humor was at the expense of Aussies - that's the first Kiwi joke I've heard here.

BTW, I was walking on a beach today in Freycinet (Fry - sin -eh?) National park and a couple of sea kayakers pulled up - from Boulder of all things. NOAA researcher currently working on American Samoa and over here for a couple weeks off.

GoodNewsWeek (sort of like Wait, Wait but spoken in Australian, much more rowdy, and on TV) made quite a lot of fun of the American poll that found that 1/3 of native-born Americans would not be able to pass the US citizenship test (even those real applicants who spoke no English are reported to have done better than Sarah Palin). About 1/4 of all the jokes tonight were about Palin.

"What's the One Thing Americans don't know about America?"

"That there are places other than America."

What would you like to give William & Kate for a wedding present?"

"A job."

Lionel Richie was the American of the 8 guest/contestants- pretty funny. Didn't know he did funny.

Global warming may just give Tasmanias a chance to see what it feels like to wear shorts.

After hours CT

You've heard me talk about the necessity to call a tech in to do CT's or anything else after hours (after 5 PM or anytime on weekends in the case of CT). Part of the need to "batch" the cases grows from the radiologists have no way to read from home, and there's no contract for off-site "nighthawk" readings. So, the radiologist comes in from home and reads a few then goes home. The most organized of the the radiologists then walks over to the ER with 4 or 5 readings on a single 2x2 post-it note and runs through it with one of the consultants! That's efficiency - 5 readings, one post-it! The others just wander through and mumble a perhaps comprehensible verbal report. Better be sure you're really confident of your own ability to read before you come here.

BTW, there's a limited number of places where you can access the PACS system to look at images. Yesterday I saw the orthopedics system: Aaron, the registrar, has an iPad. He takes it up to the PACS, and takes pictures (must be an iPad 2) of the image on the PACS screen. Then, goes off to clinic or theater where the consultant is - and shows him the pictures on the iPad. Human ingenuity fills in the technology gaps!!!

Circadian rhythms

I'm not sure what computer program is used for writing schedules here, but please, Yaron, don't ever use it! If you really want to mess up somebody's circadian rhythms, you couldn't do it better than the scheduling here - routinely late evenings are followed by early evening followed by days. Thank goodness there are no nights for the consultants.

And, who cares what the coverage actually is? Supposed to be double and triple consultant coverage during the afternoon and evening with the last consultant (we'd call him and attending) leaving at midnight. But, if it's a bit inconvenient, single coverage is fine. Or, the last consultant can leave at 10 and the registrars can just suck it up for 10 hours instead of 8 hours. And, if there are some meetings for the consultant to go to (because he's the only permanent guy on staff) he can just wander off for a few hours, and the registrar can deal with whatever.

80 year old lady found in her home (after a few days of worsening headaches) obtunded, complaining of headache, vomiting, and at the rural hospital found to have bit of an elevated troponin. She woke up and the headache went away at the hospital, and some hours later she arrived at our place. Felt fine. Trop 0.8. Gotta be carbon monoxide. But, heat pump, electric water heater, no wood stove. (Forgot to ask about paint strippers.) I didn't hear about her until 8 or more hours after she was removed from her house, and the intern didn't understand how to order a carboxyhemoglogin, so we still didn't have a level reported when I left for the night and it's likely to be back to normal by then anyway. But, since they seem to use Non-Rebreather Masks for everything here - rather than nasal prongs - she'd been on high flow oxygen for a long time anyway - so had been treated. So, the medical team will probably muck about for a while and send her home with no diagnosis, and she'll strip some more paint off old furniture, or the neighbor will leave the truck running next to her window, or whatever the unidentified source is and her GP will treat her for migraines. Khe Garne. (For Drew: that case is from Strahan - really, do you pronounce it"strawn"? - no wonder people looked at me funny when I was there 2 weeks ago and pronounced it: "Stray-han".)

Gee, maybe electronic medical records are a good idea

12 year old girl with vomiting and abdominal pain. Transaminases up in the 200's, and biliribin around 4 in US numbers (that's liver problems for you nonmedical types). 2 years ago similar thing - neg viral studies, saw GI guy who worked her up for autoimmune hepatitis (and for Wilson's disease that can act just like autoimmune but is way worse and caused by copper accumulation in the liver). She had normal ceruloplasmin, and slightly elevated serum copper. Liver biopsy did not show any sign of autoimmune hepatitis, but he treated her with steroids for a couple months anyway. Couple more similar episodes of symptoms, but without the transaminase rise in the intervening 2 years.

So, I'm scrounging through her old charts trying to figure out what is going on and find misfiled among the "correspondence" a pathology report - labeled as "amended" - of a copper concentration from the liver biopsy that is 8 times the upper limit of normal, and twice the level considered diagnostic of Wilson's in UpToDate. UpToDate notes that ceruloplasmin and serum copper are imperfectly sensitive for diagnosing Wilson's, and the definitive test is the biopsy. Talked to several folks, including 2nd hand to the original gastroenterologist, and we don't know if there was an original erroneous report that got amended, or if he never saw the report since it was misfiled, or what. But, everyone seems to agree that , OH SHIT!, she does have Wilson's.

Since Wilson's can abruptly transform into fatal fulminant liver failure, good thing that the kid didn't do something too bad in the interim. Probably a good thing that this time she was seen by an anal-retentive attending rather than by a house officer who might have paid no attention to the misfiled report. (And, yes, Wilson's was on my mind and I was specifically looking for the copper studies going through the chart.)

Yesterday's Launceston newspaper had 2 editorials: one was the lead editorial talking about the failure to fund the biggest local nursing home, so that they have refused new patients - leaving a number of people at LGH for months to over a year because there is no nursing home to transfer them to. Of course, that backs up into the ER - yesterday had 16 boarders at beginning of day, down to 11 by late afternoon. That's of 19 real beds - expanded to 25 including the hall, "pit", and doubled up room beds and not counting the times when beds are just parked everywhere side to side, end to end, and chairs are elbow to elbow with really sick folks sitting in chairs.

The other was a letter to the editor saying how nice the doctors and nurses were during her 48 hours in the ER with no chance to sleep, lights on, noise, etc. But, she asked, couldn't it be made just a wee bit better. (Hold on lady, the new facility might open in less than a year. Better than the bigger ER will be the additional 10 acute medical beds.)

Last night's LP of the night: intern chickened out, Registrar chickened out, fools rush in........ so fat that I had to indent the skin by about 2 cm with the hub of the needle - actually had no idea where the spine actually was, but after the first time that I hit bone I figured that I must be in the area. 1 RBC! I was going to make the intern by me champagne, but 1 RBC foiled me. All this because some stupid neurologist in Melbourne told a GP that a lady needed an LP - when she had a straightforward post-concussion syndrome.

Keeping warm in the ER!

Here's a really cool concept (actually warm concept):

The hospital gowns at Lonnie are thick, warm, flannel. What a concept: patients are warm and comfortable (to say nothing of the convivial atmosphere of having beds spaced about 2 feet apart). They remind me of the terry robes that I hear are provided at nice hotels - I wouldn't know for sure. I bet the simple change from thin, chilly cotton gowns to thick, warm, flannel would be worth about 1.75 Press-Gainey point (Hearken well, Bruce).

Here's a weird one: for some reason that totally escapes everyone that I've asked, there is a governmental restriction on parenteral thiamine. A page of multiple blanks to fill in and sign - with no apparent reason, if you'd like to use IM or IV thiamine instead of oral. WTF???? Took a while to get the paperwork done and sent off to pharmacy so that one gentleman with unfortunate social habits, and with a wee bit of Wernicke's could get treated.

I had a guy with pneumonia sent down from a hospital at St Mary's (because of rising creatinine - although, since they had no imaging, they didn't know that he had the pneumonia as a cause for his fever and vomiting) - on the East Coast, about 2 hours away. I sorted out a few things and got him fluffed up a bit and appeared that he could be managed at a small hospital - and we were experiencing 48+ hour delays in getting people admitted from the ER (one guy spent about 4 days). I talked with the Doc at the little hospital, and at some length with the patient's wife - who happened to be the nursing supervisor of the hospital. 2 reasons for not sending him back: more flooding was going on and the road had been closed. More interestingly: the hospital is 8 beds. 1 is the ER. There is no imaging, and no lab. Each of the last 4 years they've requested an I-stat machine so that they could do simple stuff. So, since the issue that had prompted the transfer was worsening renal status (they do a blood draw, and send it to Lonnie and get the results a day later) it seemed unwise to send him back even though I was confident that his renal status was just inadequate volume replacement.

18 year old girl sent in from another little rural place. 12 weeks since last menses, had 1 home and 1 clinic positive urine pregnancy test about 8 weeks ago. Presented to little hospital with 12 hrs severe abdominal pain, one episode of heavy bleeding, and BP's in the 80's but with pulse only 90. They gave her some fluids and shipped her. We took a quick look on arrival with our 1950's era ultrasound (2 of the 3 better machines in the hospital were out for repair, and one was in use) - she had a normal uterus and a 5.5 cm complex cyst and no free fluid. But, then when she gave us urine had a negative urine pregnancy test, and 90 minutes later we had our Quant which confirmed zero. Since we have no doppler on our Ultrasound there was no way to look at flow in the cyst to make any guess as to whether the pain was torsion, or was due to what appear to be a hemorrhagic cysts (wavy little curlyQ's within the cyst). And, no hope of getting a formal US for another 12 hours. Sooooo, hopefully just a hemorrhagic cyst. Any theoryies out there in listener land as to what the scenario was? 12 weeks by dates, with positive UPT early on, but not now? Pure false positive? Early fetal demise? Of an IUP? Of an ectopic? Beats me. Somebody must know something. Hellllllp!

Observations on Tas

Walking & driving: the driving around town is pretty aggressive - diving into the roundabouts rather briskly - enough that if another guy were to make a mistake it's be tough to adjust. I'm still getting used to looking to the right - and having to look 3 entries away into the circle, because I'd still have to "give way" to a guy coming fast and aggressive from 3/4 of the way around the roundabout. Especially challenging to keep that in mind on bicycle when I've got to look to my left for a guy that will eventually catch me from the right!

And, as a walker - there is no thought of pedestrians have the right of way. Pedestrians definitely yield to the cars. Once every couple of days I'll see a car slow, or even stop to let a pedestrian across and it really messes things up because the other cars don't expect it to happen so there's sometimes a squeal of tires from behind the slowing car of the nice guy. Just stay on the sidewalk, mate!

Real estate:

The house across the street went up for sale last week. It's the most expensive listing in Harcourts' large Launceston catalogue - but with no price listed. In 2008 it was the "House of the Year" for Lonnie. From the road it's a very unassuming nicely kept up old house (1840 to be exact (with a flagpole that gets a different flag each day). Turns out that what I see is just "the cottage" - and connects via a glass passageway to "the house" which is a modern, glass-walled multilevel with great views. Totals about 3000 sq feet. The listing is for "expressions of interest" which will close at 5 PM on May 2nd. I gather that's sort of like a silent auction - our eBay in miniature. Love to see what it goes for. The pictures of the interior and the views are pretty spectacular. If your interested, got to: Harcourts.com.au and look for TLA 3001 or just rank the Launceston listing from most expensive and it's the first one.

I ate in a restaurant this afternoon, and realized that it was my first real "meal" in 6 days: up to now it's been a combination of cereal (wheat bix mostly), apples (I did buy a couple of expensive Florida grapefruits and a couple bananas - that are currently about $2.25 per banana! because 80% of the banana crop was wiped out by the Queensland floods), milk and cookies, peanut butter and jelly, and (real treat) exceedingly delicious submarine sandwiches that I buy on the way into the ER from the coffee shop/bistro right next to the hospital - very similar to Amante in Boulder, but more expensive.

Working 5 days straight, I only got in a couple of 15 - 30 minute short hard workouts, so today felt good to get out for 3 hours through the countryside/farms/eucalyptus forests and up into the hills - cold, overcast, a little rain but absolutely beautiful, relaxing, enjoyable ride with a few hard efforts during the last half. Had planned a little longer, but the road that I was on turned to dirt/mud so I turned back.

More flooding in the Northeast of Tas - hampered some of the medical transfers yesterday.

Teaching patterns

I talked with another of the Australian locum doctors yesterday. He tells me that the fly-in fly-out locums pattern of ER staffing is pretty common throughout Australia (especially at smaller hospitals).

Here at LGH, the locums appear to be considered as the "turn the crank" guys - see a lot of patients and move the meat (though that is in much smaller numbers than what we're used to. Rarely do you see anyone juggling more than 3 or 4 patients at a time. I haven't had a chance to go through the logbook to see just how many are being seen per shift, per senior doctor. But, if we see about 100-120 per day and rotate through 5 registrars and 3 consultants - that's about what it feels like - 10-15 per shift max - with some of those being seen by interns and junior residents with limited if any input from the senior staff.)

Often, the sicker patients are handled solely by a consultant or Registrar while the interns continue to plod through the less acute and serious stuff. Fortunately, the whole program is loose enough (gross understatement - loose, in the sense of totally without pattern) that I'm able to pick up a sick patient and then grab an intern to "take over" from me - and the intern gets to be primarily responsible with close oversight. They seem to like the chance to see a sick patient, get close supervision and teaching, and maybe some procedures. And, since documentation is loose - but onerous, it saves me a lot of paperwork time. Seems like a good tradeoff.

A little different style than some of the attendings, I gather.

Another sidelight: we get really annoyed at home about the "safety" stuff: Pyxis, double and triple checking, etc. Apparently, there is some virtue to all that. I started an order sheet (on a hyperkalemic guy with a cardiomyopathy who had a baseline wide QRS that was even wider) and a nurse stuck a sticker on it for me - but for the guy 1 bed over. Fortunately the guy in the next bed over had a high normal K+, though he didn't much like the taste of the Kayexelate (and, perhaps fortunately, there's a recent article that suggests that Kayexelate doesn't actually work). Anyway, all the good stuff - calcium, bicarb, albuterol, insulin - got to the correct patient, and he eventually got some Kayexelate also.

Nurses had not apparently given Calcium Gluconate "neat" before - another new Aussie term, apparently brought to the hospital from the Pub.

Gotta figure out the surgical consult pattern: resident called surg registrar to see a lady pretty sick with clinically perforated diverticulitis (fever to 39.6, tachycardia, and pretty extensive LIF (Left Iliac Fossa - our LLQ) peritoneal findings. Surg didn't want to see it - medicine should handle it. Medicine didn't know if they should do a CT. But, the ED staff gets their ass kicked if they order the CT and find something surgical and then call surgery with the (now) clearly surgical diagnosis. It's a real catch-22 deal. I've gotten to know most of the surgical registrars well enough that it's less of an issue for me, but I see it continue happening to the more junior folks.

Off to work. My best to all in the states.

I still love that bedside blood gas machine. So much information, so quickly - as long as the nursing staff notices the order for it.

Oh, that reminds me - there is no "flagging" system for orders - you just stick med orders and lab orders in with all the other paperwork and hope that someone sees them, or wander around the wilderness until you find a nurse to tell verbally that orders are ready. There is no ordering system for non-medication nursing tasks or ECG's - all verbal (give some Kayexelate to one of the guys in obs - any one will do). Hand written imaging requests - you personally walk over to radiology and find a tech to hand the paperwork to!!! 10 patients per shift - it's about right.

A few notes on ER staff

Non-medical staff in the ER works a bit differently. No techs: we have some support staff that are called just that: ER support. They function rather as traditional orderlies: stocking, patient transport, physical tasks, but nothing like our techs with wound care, IV's etc. I really miss our paramedics who are so good at all those technical patient care things like splints, IV's, wound prep, etc.

Nursing roles are much more limited also. Ranging from being less forward in requesting/reminding the docs of patient needs (Doc, the guy in 12 needs pain meds, etc.). No ability to pre-order x-rays, labs - best that seems accepted, is to hand you the order slips with a sticky label on it already.

IV starts require certification for nurses, and some seem to choose not to do so - so some RN's don't start IV's. RN's don't start nurses on little kids - gotta be a Doc, don't do male urinary catheters, or little kid urinary catheters, etc.

RN staffing faces the same sorts of shortages as the Docs: including no sick-call backup. Last night we were overloaded with patients - especially borders, and short on nurses so poor Matt had 13 patients stacked 2 to a room and in the hallway. He looked pretty downtrodden until I met him outside on my way home where he was smoking a cigarette - can't say I blamed him a little nicotine before going back in to face that mob.

Weird case of the day was the 8 year old boy with urinary retention (821 ml with the bladder scan) from a fecal impaction. When we get this with old men, I like to put in a foley catheter first (since the over-distended bladder is the most painful issue), then work on the underlying constipation/impaction. Couldn't get even a 5 French feeding tube into the kids' bladder, so decide to work the impaction next (and save a suprapubic drain as last option). So, with a finger up the kids butt, digging away, he was able to pee ('wee' in Australian) as soon as I got the first couple grams out - firing all 821 ml against the far wall - much to the relief of all. I think the interns should have gotten that case, but all the fun was over by the time one of them was free.

MRSA

We had a young guy (avid Aussie Rules Football player - promised to teach me a bit about the sport if I show up for one of his games) with a "spider bite." Of course, hadn't seen the spider. In Denver it would have been a no-brainer diagnosis: patch of black necrotic skin overlying a palpable abscess and some surrounding cellulitis. But, MRSA hasn't yet arrived in Tassie in a big way, so there were a lot of house officers scratching their heads in confusion when I first saw the guy. (BTW, I suspect that the largest source of importation of MRSA is colonized locum tenens ER Docs from the US.)

So, a quick talk about characteristics of MRSA and antibiotic choice or non-choice, and on to the I&D. Some things are the same around the world: After the first 13 swipes of the scalpel, the intern had finally made it through the epidermis and was ready to start on the dermis and eventually had a full 5 mm incision and started to work downwards into the gloom with a hemostat. When I finally "helped him a little" and extended the incision to a reasonable size and buried the hemostat the hilt, his eyes got a little big, but was reassured when only pus and not arterial blood gushed forth.

The Beach, the Southern Ocean

Not having done much running or hiking recently (a side effect of having an old dog) - and what hiking I did was on skis, so no downhill steps - yesterday's roughly 3300 feet up and (more importantly, I think) back down has generated massively painful quads today. Walking down steps is an ordeal.

So, I drove down to Strahan (I can't pretend to come close to the local pronunciation - something close to "strain" or maybe "strayin' ") and went for a walk on the beach. The beach is 33 km long - one of the longest in the world. I didn't quite make it to the end. I had read about it in a Sea Kayaking magazine article sometime back - there are no landing sites, and with the usual wave conditions of the Southern Ocean (no longer in the Indian Ocean down here - it's the Southern, or Antarctic, Ocean) - it's impossible to ever get a kayak on and off the beach, so you have to paddle the whole 33 km in one go, often in tough conditions.

Today was as good as it ever gets - very little wind, only small local waves, and a swell of only 3 meters with occasional 4 meter sets. But, the surf zone looked to be 3 or 4 hundred meters wide so would take 5 or minutes to get through. The break is typically 50% higher than the swell so you're looking at having repeatedly to try to get through surf that's well over 10 feet. Never happen - not with the strongest paddlers. 33 km to go to the next landing!

Strahan is a nice little seaport town on a quiet harbor. They've got a bunch of cruises around the (very long) harbor and up the local river, but all had left for the day and were long enough that I didn't want to stay for tomorrow's cruises. And the evening cruises only run during summer.

So, drove on to Queenstown - big Copper Mine that has torn up a very large area of the mountainside above the town. Currently shut down and a major restoration effort going on. Pretty old town, not very prosperous, but has a Wilderness Railway somewhat like the Durango narrow gauge.

Staying here in an old hotel with a grand stairway listed in the National Historical Register. They cut the wood locally, shipped it to England to be carved, then shipped the completed stairway back in 1904 to be installed.

I've got some pictures, but my camera battery ran out and I don't have my charger - so won't be able to download them until tomorrow.

One note from yesterday: the high boggy areas above treeline all have elevated boardwalks for hiking (Bushwalking) - looks like a major advantage for preservation of the environment. A step ahead of Colorado.

The hot news in Tassie is a proposed detention center for refugees. A bit of a fight between the NIMBY group, and those who want it for the jobs and income it will provide. Refugees seem to be a big deal here - with not an excessively welcoming attitude. In 2007 they came from China, Malaysia, East Timor in Indonesia, India, Pakistan, Sri Lanka, North Korea, and Lebanon. I've heard that Afghanistan is now heavily represented. Oh, and a big brouhaha about a Tassie government minister who let slip that a shadow minister had applied for a job and was only ranked 4th among the applicants - should've been confidential. Remember that Tassie is only 500,000 people - half the size of Denver. So, State Government is drawing from a small pool of competent people and well, it's small townish.

Cradle Mountain

Plateaus & Canyons from summit
Wet Tundra
Summit ridge, dolorite blocks
Raven
Fresh water fjord - Dove Lake
Cradle Mountain

Quite a drive to Cradle Mountain - it'd be a fantastic killer bike ride, with steep long climbs, and swooping descents with snaky roads - all on the wrong side.

The hike up Cradle Mountain is a net 2600 foot climb, with some up and down so the total climbing is about 3300 feet. A lot of the final 1/2 hour section is scrambling over big blocks of igneous (dolorite) rocks so is pretty slow going. Today was beautiful weather - blue skies with scattered clouds, little wind, and t-shirt the whole way. Very unlike Tasmania. I talked to a guy yesterday who had been up Cradle 3 days ago with snow and ice still all over the summit from last week's storms.

It's actually not that impressive - it'd certainly be a minor peak at home - comparable to Bear Peak from Boulder, but with more rock scrambling along the ridge to get to the summit, and looking down on more lakes.

The geology is interesting with lots of the igneous stuff on top of a limestone layer - which weathers more rapidly, and then the whole thing cut up with glacial formations. It leaves large plateaus with glaciated valleys between them, and Cradle Mountain itself is an old nunatuk on top of a glaciated plateau.

At first glance, the tundra above tree line looks very similar to that at home. On closer inspection, the plants are quite different and much more lush. And, below treeline the forest is a temperate rain forest - very thick, and with lots of stuff that is quite unrecognizable. Eucalypts in many forms, beeches - unlike American or European beeches ( I seem to recall completely unrelated), tree ferns, and giant fern-like things that I couldn't categorize. And moss.

Only saw one mammal - a rather plump wombat, standing in the trail and very uninterested in me. I had to step over him to continue on my way. It didn't seem like alpine tundra with no marmots or conies to divert one.

The Ravens here are a bit different: white tips to the flight feathers and tail feathers. Bright colored eyes (yellow and red). They had a recognizable raven croak, but some vocalizations that continued on in varying pitch and volume for at least 6 seconds. Haven't heard that before.

Tonights accommodations are a bit different. The Tullah Lake Lodge is a very pretty site on a lake. It's an old dormitory for local mine operations that is gradually being upgraded, but is still 90 % occupied by miners and contractors (including some who arrive by helicopter). The only remaining rooms when I got here were in the economy wing - pretty basic, but adequate and 1/3 last nights price. There appear to be 2 tourist couples and about 50 minors. I believe the bar may be busy.

I tried "scallop pie" - think chicken pot pie but with scallops. Shoulda gone for the hamburg.

Overall the peak (the "iconic" Tassie view) was anticlimactic to someone who has been to Colorado, or the California Sierra, or the Canadian Rockies, or Alaska.

So rather than spending more time here, I'm going on to the West Coast - home to full on exposure to the Southern Ocean. It'll add driving time, but should be interesting.

Australian News

Listening to ABC news on the radio is a bit different: one news station for the whole country (not unlike NPR), but because the population is so spotty, it can also do a lot of local news too. There's really only 5 major cities (Perth, Brisbane, Adelaide, Melbourne, and Sydney). So in about a minute, you can cover traffic for the whole nation. Since there's only 6 states and one territory, you can add 2 more small cities (Darwin and Hobart), and include all the state capitol weather reports in another minute. Neat.

The Aussie news seems to be about 1/3 - 1/3 - 1/3: Oz, US, and the World. With US news being financial, political and a few horror stories thrown in to make you glad that you live in Oz and not that horrible place the other side of the Pacific. Easy to keep up on what's happening at home.

Back to the place where I stayed last night and enjoyed the pumpkin strudel. Talked to the woman of the couple that owns the place and she explained that in Australia, pumpkin is usually thought of as part of the main meal - rather than considering it a "sweet" or dessert (as in pie) as in the US.

There were 3 guests at the hotel last night. Me, and two women (not traveling together). One was quite silent and spoke only 3-4 words that I heard - I think in American. The other was quite a chatty Aussie and went on quite a political discussion with the proprietors at breakfast this morning. After apologizing for going on about politics (Oh my, It's too early for politics), you then plunged back in on "That despicable Tony Abbott - you do think he's despicable, don't you?". I actually learned a bit by listening in.

The proprietor also introduced me to "Shazam" an app on his Android that he used to "listen" to something that was playing on the radio, that then somehow in about 15 seconds was able to "think" with its mother website and identify the song and the artist. How cool is that? Wonder if it works with Classical? If you can do that, they've gotta be able to do it with "dog". This bark means "I'm hungry", that means "It's mine," and the ever-popular"Squirrel!!!!!".

Finally! A Devil

Another day off, and after racing yesterday, a long slow ride: 82 km.

Stopped at a wild animal park. Pretty low budget, seemed to be run by environmentalist/hippie types. The guide was exceedingly knowledgeable about Tasmanian flora and fauna, and especially the Tasmanian Devils. 85% of the Devils have dies of an infectious/transmissible facial tumor disease and the park now has about 40 disease-free Devils and is putting up high tech double fencing to keep out and wild (therefore, potentially infected) Devils and earn their certification as disease free. There are now a number of such facilities on the Island, as well as on the mainland. The nature populations seem to also be starting to come back with animals returning to areas where the disease first arose and totally wiped out the population.

I've got a video that I'll post later - internet is too slow out here in back of beyond.

The park also does "rescue" and rehabilitation of injured and orphaned other animals and birds.

Anyway, it was a cute little place with kangaroos, wombats, Devils, Quolls, as well as a variety of birds including three wedge tailed eagles - big enough that they prey on baby sheep.

Rode on to Mole Creek - entryway to an area of karst/limestone (most of the island is igneous, so it's very different) with many caves. Just missed the guided tour of one of the bigger caves, and didn't have time to wait around for the next tour - so took a short walk through the rainforest. Hard to get good pictures of the rainforest - the individual plants aren't that spectacular, but the overall effect is rather amazing: moss, giant ferns, lots of other low stuff, and then a canopy of huge eucalypts.

Tomorrow I head over the ridge to the west side where I hear that it's much, much wetter and more lush.

The eucalyptus are amazingly diverse - some tall and slender, others skinny and packed together, others gigantic with rounded tops, all different sorts of different barks - but still recognizable as eucalypts. Sort of like all the different varieties of pines back home.

For dinner had a pumpkin strudel on a bed of couscous. Never had (or even heard of) anything like it. It was good enough that I'll drive 100 km to come back and have it again.

Another Tassie Race

I raced again with the Northern Vets this weekend. About 60 racers in 7 groups. After my prior massive victory in the E group, I moved up to D.

The club allows one "free" race without joining the club, but for this race I had to join the club for $90 (Aussie dollars are currently within a couple percent of US Dollars) but the races themselves only cost $6. The low cost undoubtedly relates to no road permitting, no police presence, etc. The gang just shows up, puts up a start/finish sign, makes a few announcements, has a few volunteers at intersections and the turn-around point, and starts the groups (biggest group was 12 riders) a couple minutes apart. Traffic control isn't much of an issue on the Tassie roads - I think we saw perhaps 5 cars on the 50 km race.

Today's course was similar to the previous: relatively flat with a total of only a couple hundred meters of climbing consisting of a few short steep hills, superimposed on a long gradual and imperceptible rise to the turnaround.

The stated goal of the races is to have each group matched evenly enough to finish pretty much together and ride most of the race as a group. So within a few hundred meters of the start, in each race, a double pace line forms up and continues most of the way except for breaking up on the hills. Later in the races, some folks gradually drop out of the rotation, but the double paceline action in general stays to near the end. Interesting concept.

I was having a nice race without any high stresses until 20 km from the end got a bad cramp in my calf and eventually had to pull off and stretch it out - so I was gone. I heard later that 8 of our original starters finished in a group sprint. One was unconscious on the grass when I got there, but seemed to recover pretty well - I'd love to know what his actual blood pressure was!

Very different style of racing, but entertaining.

I work next weekend, so won't race. But, the 17th is apparently the "big race" of the year - and is run as a "handicap race". Groups start in reverse order of their speeds, and are seeded a few minutes apart. I presume average speeds are higher, since you're always trying to catch the group in front or escape the group behind. Must be major chaos if you happen to catch a group anywhere near the finish! Stay tuned for a report.

I'm off for a few days off heading to Cradle Mtn National Park.

Some things that I can't figure out

Here's an example: Guy gets run over by a sheep (kinda like happens at Tuba City). Gets an intertrochanteric hip fracture - but 50 years ago he had a hip fracture and has 2 k-wires in into the femoral neck - says they tried to get the k-wires out 10 years ago, but couldn't get all of them out. So, the anatomy is distorted to begin with, the wires are bent, and we can't see on the plain films exactly where the fracture goes (in fact, there's a chance it might be just a greater trochanter fracture). It's 7 PM on Friday evening and ortho wants to do the case on Saturday morning, but needs a CT to figure out if it really is a fracture, and if so what the can to with it. So, step one, I call the radiologist. He argues - not really an emergency. Back and forth, is so, is not - like 1st grade kids. Finally, agrees that they'll do it but wait until until we have another CT to do instead of sending in a tech to do just one study. 11 PM, poor Ortho registrar is having to decide whether to try to get some sleep - he'll undoubtedly get wakened up again, or whether to stay awake a little longer hoping the CT will get done so he can plan his Saturday.

It's a system that seems insane for a developed country (even the lab techs, as well as plain x-ray techs go home at 10 and have to be called in for labs & plain films - at least then you don't have to go through a gatekeeper radiologist, but they'll drag their feet hoping to "batch" a few requests). MRI and Ultrasound are easier - don't even ask. What I don't know: Is Tasmania so poor that budgetary restraints require this sort of stuff? Or, is it such an "out-of-the-way place, that they can't hire enough lab and imaging techs, and so are forced into this sort of Mickey Mouse? Or is the ED so downtrodden and such a third class (definitely something below second class) citizen, that the other departments are just able to thumb their noses at the ER and say "Deal with it, Dude." Makes Tuba City seem downright luxurious.

Staffing in the ED itself is also pretty sketchy: Thursday is teaching day, so the overlap ED consultant (attending) works non to 6 instead of until 10. Leaves an awfully heavy load for the evening consultant (me). The boss was scheduled 2 to midnight on Friday, and I was noon to 10 and he asked if I'd do the 2 to midnight instead. No big deal for me, I had nothing planned. Silly me, I assumed it was a trade. Just worked single coverage instead of double coverage - and we were down a registrar both of those days. Then, Saturday we were down a registrar and the remaining reg got sick and went home leaving 4 interns and 2 consultants. So, the other consultant who had even less experience than me just cranked through stuff over in fast track while I tried to manage the sicker folks and do procedures with the interns in the main ED. Last I checked nobody was dead, but not completely sure in some of the back beds.

With the level of imaging support, it's nice to be comfortable with ultrasound. Even if it's a model from about 1988. I've had two swollen legs that I was very confident of my DVT studies being negative (both with readily visible Baker Cysts) and sent home at night (confirmed the next day with formal US). And, a guy sent in by private urologist for a foley after "urinary retention" after having a retrograde pyelogram earlier in the day. We don't have a printer on the Ultrasound but I was able to use my cell phone camera to take the picture of hydronephrosis, rather than bladder outlet obstruction, at the top to show to the Registrar (surgery has 2 registrars at night: one handles general and vascular, and the other registrar handles all the subspecialties except ortho - ENT, urology, etc.) when he came in to admit the guy. Picture was actually pretty good, I thought. BTW, all vascular consults have the same recommendation: "Send him to Hobart."

I saw my first injury every fro "bowling on the green" - Grandma stepped back, stepped on one of the balls (like croquet balls) and broke her wrist. Australian Rules Football seems to be a rather high risk sport. Watching Footie on TV, seems like the fatality rate should be about 1 or 2 per game - head injuries, necks that seem to snap back with about 100 g-force, etc. But for us the Saturday Footie specialty was dislocated shoulders. Reminiscent of rodeo weekend in Tuba City.

Despite the inefficiencies that make me crazy, some stuff works well - the broken wrist gets a quick splint, then to the OR in the morning for external fixator. The trimalleolars get reduced, splinted, to the OR the next morning, etc. etc. Now, granted, there are no inpatient beds available so they stay in the ER, but there's no messing around with insurance status, and waiting for a week for surgery etc. We've had a couple recent 36 hour boarders. Discharged from the ER after there cardiac cath.

I've seen 3 severe generalized allergic reactions (real life threat stuff) this week - one from Jack Jumper ants, and 2 from leeches - didn't know you could get anaphylaxis from leeches.

Had a guy with a stroke and very pure Broca's aphasia: absolutely no spontaneous verbal output or responsive verbal output, but could repeat even complex phrases (No If's, And's, or But's and the like), and had no receptive aphasia and only a very mild facial motor weakness. He came in at about 3 hours post onset, but it took us 2 hours for CT. Rather sad, I would have lysed him if we could have done it in the 4 1/2 hr window.

Ischemic Colitis

Here's our occluded Inferior Mesenteric Artery with lactate 7.9 and the unusual presentation of syncope and shoulder pain and shock and only hours later developed abdominal pain:

toxicology

It's a little harder to get a new liver in Tassie: you can't buy a bottle of Tylenol down here. Partly because it's named Panadol - but more importantly it comes in a box with no more than 24 tablets, all in little individual bubble packs. So, if you want to kill yourself, no gulping the whole bottle. You've got to individually unwrap each pill, one at a time - and you've gotta do more than one box probably. It rather take the impulsive swallow a bottle approach out of play.

Neat.