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.