Finally some time off

Jean's been here a few weeks now. We've gotten in a little riding. Nobody in Tassie rents road bikes, so she's been renting mountain bikes and cruisers and when we ride together I use the cruiser and she uses the 'cross bike with road tires - we end up about the same speed.

We've been to nature parks to see wallabies and 'roos, and wombats. Onto the beach at night to see the "little penguins" - cute little guys about a foot high. Rode out along the Tamar River - quite a beautiful rolling ride. Stopped on one ride to watch a little "footy" - may be one of the great games in the world: you can run, kick, throw, tackle, dribble - all on a field the size of Rhode Island.

Post dental bleeding

Despite the overloads, this place does have interesting stuff to do.

Yesterday a local dentist pulled an upper wisdom tooth and somehow managed to get into major arterial bleeding and brought the guy to the ER. We could temporarily control it with direct pressure, but any time the guy opened his mouth it was a major gusher. And, the guy was a "gagger" with a big tongue and limited mouth opening.Max/Fax was planning on taking him to surgery to ligate his greater palatine artery - but they were tied up for many hours in a big radical neck. So, what the hell, why not inject a little epinephrine into the palatine foramen like we "try" to do in palatine nerve blocks. So, with horrible visibility between the anatomy and blood all over the place, I used a needle like a harpoon in the general direction of the back end of the hard palate and squirted in a bunch of marcaine with epinephrine. (Not sure, might have missed and squirted it into the carotid or brainstem or something, for all I could tell.) Much to my surprise it either worked, or was performed just at about the time that the bleeding stopped spontaneously.

And to round out the day a posterior shoulder dislocation (the only one I can remember seeing that wasn't due to a seizure), a grapefruit size fungating cancer on a guy's hand (his GP had been trying various ointments on it for a ear), etc. I've cardioverted more folks in the last 3 months than I have in the last 5 years at University, and probably about 2 years worth at Boulder. And more profound bradycardias than I've ever seen.

Couple days a ago had a distal radius reduction in fastrack, so ketofol - no monitoring, no suction, etc, etc. Thankfully that went well and had been done by the Registrar before I heard about it.

Crushing workloads

It's been a while.

One of the great difficulties of an ER like Lonnie is that with the vast majority of the staffing being provided by fly-in-fly out Docs, when something happens to affect staffing there is no slack in the system. So, an illness in either a consultant or a Registrar leaves one with no backup (the administrative doctors seem to have no interest in helping with clinical coverage. It's quite entertaining to see the medical director wandering through the department with a bunch of "suits" chatting, bulshitting, and checking the dust in the air ducts - while we're short one consultant and two registrars and there are twenty in the waiting room.) 3 evenings ago, the charge nurse came to me in near tears - just didn't know what to do. We had no beds, no place to put another patient, and were at a complete standstill - about 20 waiting , with a few ill (unwell in Australian) but mostly minor complaints. Our only hope was that many would give up and go home - which was what ultimately happened.

As best I can tell, the underlying problem is one of this pattern (apparently widespread throughout Australia, except in the largest cities - all 7 of them) of fly-in-fly-out. The Docs apparently like it (the guys tell me that they make much more in their locum jobs than they do in their permanent jobs). But, it leaves most hospitals with nobody to keep pushing to get the system to work, and of course, no way to take up slack in case of an emergency - whether a crunch situation, or a staff illness.

Anyway, because of all that I've been working far too many hours and under far too much pressure. And, have had no time nor energy to keep up the blog.

Ozzie training

Learned something about Registrars that I hadn't known before:

For each specialty, a hospital may be "certified" or not certified as a training center. They may still have Registrars in the field, even if not certified. So there are "service" registrars and "training" registrars. And, even at the certified hospitals, there can be both types of registrars. The "service" registrars do the work - as an orthopedist, for instance - but aren't getting any credit towards eventual certification as a consultant orthopedist. They end up doing a lot of the routine stuff, and a lot of the consultations. While the "training" registrars are in the operating theatre doing the surgery.

Many of the guys do one or more years as a service reg while waiting for a chance to enter a training program. And, may move from hospital to hospital during that time. Some hospitals have only partial training certification, so that you can do some training but not the entire program (ER can get only 6 months credit for their time at Lonnie).

High prestige (plastics and max-facieal and dermatology) can take many years as a service reg before getting a training position. Low prestige (internal medicine and emergency medicine) "all you have to do is raise your hand, and you've got a job." (That from one of my EM Reg's). It's all very disjointed compared to the US.

I've got a bit more sense of why the ACEM board exams have to be so tough - I don't see that there is the day-to-day program of training and supervision and evaluation that we're used to, so instead there is a very tight orifice to squeeze through at the end of the tunnel.

One of my Registrars did his very first chest tube 3 days ago, and his second yesterday - and it appeared that having some supervision and guidance was an unexpected bonus for him (it was nice for me to identify the subcutaneously placed tube by palpation rather than having the embarrassment of finding it on the post placement XRay).

Later, Mates.

more crowding & chaos

Another of those days with the ER jammed to the gills. One field STEMI (heart attack) notification that I wasn't taking care of, but the cardiology registrar arrived shortly after the patient and couldn't find the patient!!! I helped him look and we eventually found him sitting in a chair down the back hallway - fortunately with his pain resolved. At least he could lay down in the cath lab when he got there (I'm not actually sure, but I hope that he didn't have to walk over).

Had a guy still "ramped" - on the ambulance stretcher, waiting in line, not yet physically into or registered into the ER - but hauled the shitty little old, beat up ultrasound out to where he was and identified the hemo/pneumothorax (from having a big tree fall on him when he cut it down).

Dragged someone else out of the "theatre" (such a cool name for the little room where they don't do anything that anyone would actually like to view for entertainment - actually did have one "viewing" Dad of a patient hit the floor yesterday) so that we could get his chest tube in. XRay appeared to be at lunch or on break, so we never did see them - but CT showed up quickly and we got our "pan scan" done very efficiently (after the 1st 700 ml of blood was already in the Pleurovac). Trauma surgery showed up sometime or other and decided that we were under control and left some admitting orders and went off elsewhere.

The place is at times so understaffed that it is astounding that more people don't get hurt, but we run from place to place doing what we can and it all feels a bit third-worldish and mostly stuff gets done.

There are a few of our specialty Registrars (and consultants) who are distinctly unhelpful - perhaps assholes would be an appropriately descriptive term - but they stand out amongst a bunch who plunge in to the chaos and try to help keep the ass-deep alligators at bay.

It falls down with stuff like the previously healthy older guy who had had 5 syncopal episodes before arriving, including several that were long enough without pulses to get CPR. He had a normal ECG that would abruptly slow (sinus still) into the 40-30-20 and full stop for 20-30 or more seconds. There are no pacer wires available in the ER, so we ran him on boluses of atropine and an isoproteronol infusion (I don't recall using that since the 1970's) and external pacer. Cardiology wasn't interested in helping since it was later than afternoon tea. WTF! I hope the guy (cards) breaks an arm sometime so that I can flop it around a few times. And then let him wait for 6-8 hours to give him 10 mics of fentanyl. Medicine was stuck managing the guy overnight.

More later.

Critical care and Emergency Medicine

One interesting aspect of the practice here: The EM registrars tend to call (or the nurses call for them) the ICU Registrar (and consultant) for every significant resuscitation. Unfortunately, those guys tend to arrive and take over - reinforcing my impression that EM here is 10-15 years behind the US in that EM is distinctly a second class specialty - a step removed from the GP's, and often treated as just overpaid interns (remember those days?). I've tried to discourage those early calls, unless we really need the help, and push the EM guys to do the resuscitation - both the diagnostic and cognitive parts of it, and the procedural stuff. Interesting how few procedures many of the guys have done, despite the large number of resuscitations we do (using the broad term resuscitation of trauma, sepsis, etc - not CPR stuff). There seem to be 2-5 folks per day needing serious attention to volume, airway management, arrhythmia treatment, etc.

On the other hand, it is fun to work with and/or watch these guys from ICU. Guess what - treating critically ill is all they do (we winnow out the chaff for them) and they are more practiced, experienced, and slick at it.

It makes me think that we really need to get one or more EM/Critical Care trained and (soon) boarded guys at DHEM/UCHSC. Someone of that ilk would be able to spend time in ICU working that end of the skill set, and share it with our residents - to the betterment of the training. Just a thought.

Mount Wellington

Jean and I (yeah, Jean's here now!) spent a few days in Hobart - the capital of Tassie, and a city of 200,000 with its suburbs. Faces south at the end of a long bay - so very well protected, but last stopping place before Antarctica. Did some mellow rides in the neighborhood and some touristy kinds of things.

Today, I took off alone to ride up Mt Wellington. Start right at the harbor, at sea level and climb to nearly 1300 meters (over 4,000 ft) in 23 km. Mellow low down, but lots of 10-12% grades up higher - through city, then suburbs and yuppie homes, up into eucalyptus forests and then above treeline tundra. Quite a dramatic ride. Cloud deck was below the summit, so intermittently in clouds but bright sunshine between. Cold winds made one of the long switchbacks brutal, but the final 3 km was a screamer uphill tailwind.

Great rock formations up high.

Huge radio transmitters at the summit. Signs all over the parking lot explaining how to get into your car if the transmitters disabled your remote key/keyless entry system and then to get your car started if the transmitters had scrambled your car's ignition system. Must be a powerful transmitter - nice to think of all those radio waves cooking my brain and other assorted body parts. Hope it didn't damage the carbon fiber bike frame.

Cycling

Finally a chance to do lots of riding. Already posted about the ride up to the ski area (BTW, looking from a distance - looks like snow down beyond treeline up there today.) 2 days of riding along the Northwest coast - faces onto the Bass Strait which separates Tas from the Big Island - 200 km wide. Pretty cold, but little wind and no big waves. Very pretty riding. 2 towns of about 20,000 each. Devenport is the terminal from the Ferry from the mainland - lots of trucks on board, and tourists. Some bring the cars over (expensive). Others travel as foot passengers, and rent a car when they get to Tassie. About 600 feet and the trip takes 11 hours.

The other port is Burnie and is where all the container traffic comes in.

Rode up onto a flat topped bluff on the edge of the ocean - turns out it's an old basalt core from a lava vent (think of the basic geology of Tassie as a lot of sedimentary limestone layers, with younger lava that pushed up through the sediments and laid down layers of igneous dolorite on top of the limestone. Lots of exposures of the dolorite, and limited exposures of the limestone. This was an area with lots of limestone and this one basaltic core pushing through it. The core was about 2 km in diameter and stuck up about 200 meters.) The top was apparently very fertile, and rolling farmland and entirely occupied by tulip fields - the largest patch of tulips in the southern hemisphere. Only one small field of purple tulips were still in bloom, but the pictures of spring when they are all in multicolored bloom look pretty spectacular.

Along the coast was a lot of sedimentary rock with large glacial erratics from hundreds of kilometers away, dumped here in the last ice age. Pretty neat.

Today rode near Lonnie and found a hill that was over 20% for 400 meters. That's a really long way to be that steep - had to do a few zig zags and stopped in a driveway for a break before finishing it off. Felt like a wimp, but I was afraid that if I blew up and couldn't turn the crank one more time, I'd never get unclipped and could roll backwards to the bottom of the hill - or something. It was really pretty insane. The rest of the ride was rolling open farmland.

Aussie politics, etc.

Yesterday was a big day - a week of breathless buildup on TV with commentary, predictions, preparations for..............Budget Day!

The Government presented its budget last night - kept secret until the presentation in parliament, and with enough hoopla leading up to it that it could be the Super Bowl.

Aussie politics is really nasty. It appears that no matter how trivial the matter, the two sides call each other uninformed, idiots, make nasty comments, etc. It's pretty bizarre. And they do it while facing each other across the middle pit of parliament - and it's always associated with a personal attack on intelligence or integrity, not just a disagreement with the policy.

Current hot topics: Australia television is currently transitioning to all digital and the government has proposed providing free installation and set top boxes to convert digital input to analog signals for old TV's of "pensioners" - retirees. Given a recent fiasco with government sponsored installation of home insulation - that in a few cases was improperly installed and caught fire and burned the house down, there is a good target for the opposition. Apparently Tony Abbott (who might really be stupid) doesn't believe that old people need to watch TV. He might be right.

Then, there's a major uproar about a deal with Malaysia: Australia will send back to Malaysia about 800 refugees who sailed here without permission ("Illegal immigrants" in US - speak), in return for 4000 who have achieved legal status as qualifying for amnesty status (I think mostly from places like Afghanistan). Aussies have a strange mix of needing highly trained immigrants to keep the economy going, and not wanting to be the dumping ground for all of South and Southeast Asia's unwanted.

On TV: Netball. Never heard of it before. It seems to get more live coverage than any other single sport (though nobody seems to discuss it). Women play it. There's a basketball style net, with no backboard - seems nearly impossible to get the ball through the hoop unless you're within about 3 feet of the net. And, when you have the ball, you can't move your feet and the person guarding you appears to not be able to move either. And, you can't jump if you have the ball. It's really fast action with lots of passing and running by everyone not having the ball, until finally you throw it to someone standing a foot from the net. Then, everything stops and she hold the ball straight over her head and throws it upwards and it occasionally goes through the hoop. Seems very popular, though I'm not aware that anyone actually watches the numerous TV broadcasts.

Footy (Aussie Football) is great for my business. 18 per side on a field that's 200-250 meters long (I counted 10 referees at one point, but could only see part of the field). You can punch the ball (but not throw it), or kick it, or run carrying it - basketball-style dribbling it once every 10 or so strides (imagine dribbling an oversized football on turf). And, you can have large numbers of people converging at high speed on a long, high kick - imagine a punt that everybody can and does try to catch - or punch the ball away from somebody else trying to catch it. Lots of concussions, lacerations, and dislocated shoulders. Saw a guy dislocate a finger, and the trainer just ran out on the field and popped it back into joint while the guy was running along - slowed down, then kept on going.

And, lots of rugby - still don't understand why they dive over the line, even while completely alone, and slide on the ground holding the ball. May relate to the amount of Foster's ingested at half time.

Interesting days, boring days

Talk about contrasting days.

Friday was challenging day: facial fractures with significant orbital hematoma and only light perception - John, one of my registrars got to do his first lateral canthotomy - after watching the YouTube video. Went very nicely, and got good decompression and quickly improving vision.

Simultaneously, had a relatively young and healthy dominant hemisphere proximal MCA stroke (visible vessel sign on non contrast CT). Aphasic, hemiplegia, field cut, - the whole dominant MCA bag. Thrombolytics would have been stretching the limits a bit - because of the size of the clot, the high NIH stroke score, and the vascular territory at risk , but I recommended that we do it (would have been in at about 2.5 hr from onset). But, there was a visiting neurologist in town for his once monthly neuro clinic, and the stroke registrar (an internal medicine reg running the stroke ward for a month) consulted him - he turned out to be a no thrombolysis is good thrombolysis kinda guy, so we didn't lyse this guy.

Incidently 3 days earlier, we had lysed an identical guy with a dominant visible vessel proximal MCA stroke with a very high stroke score. He was even sketchier to do because we didn't have a definite time of onset - and it was between 3 hrs and 4 hr 15 minutes when we started the TPA. He did well. At 3 days he was talking - not well, but talking, and using his arm and leg.

Later on Friday, we had a 3rd - almost identical dominant MCA stroke. But, he came in after 5 PM and we didn't get a CT for over 2 hours, and he was being managed by an unenthusiastic Reg (I didn't even hear about it until quite late on - after the CT). So, lysis was nowhere in the works.

Then, throw into the mix a car crash with seat belt chest injury including multiple rib fractures, sternum fractures and hemothorax. Chris, another resident got to do his first ever chest tube - went well. (I talked to the surgical Reg, and learned that the surgical Reg's here get very few chest tubes because there is no thoracic surgery - so their only chance is in the ER. So, there's a bit of a lack of teaching material for that particular procedure, and a bit of challenge to get enough balance between the 2 services. I think that not all the attendings are particularly aggressive at being sure that the EM Reg's get the experience they need. I can be reasonably confident that John wouldn't have gotten to do the lateral canthotomy with most of the attendings. Chris also got his first ever LP on Friday.)

For a grand finale, the same MVA guy had a line in his aortic arch that I'm suspicious was artifact, but we couldn't be certain wasn't an intimal tear. I later learned that in fact we might have been able to get a TEE which would have been the ideal to confirm the finding or lack of, but wasn't aware that anyone did TEE at LGH. So, we cranked up to medically manage pusle and BP and transfer to Melbourne - about 250 air miles, plus ground transfers at each end. Labetalol isn't available, and Esmolol isn't stocked in the ER. So, we started with metoprolol plus NTG (GTN when you're upside down on the bottom of the world) for rate and BP control. Then gradually collected esmolol until we had the entire hospital supply which we calculated would just about last long enough for the transfer, and then transitioned him to the esmolol.

Somewhere in there was the sickest Henoch-Schorlein Purpura I'd ever seen - lots of confluent purpura, and enough GI symptoms that we CT'd him - demonstrated total bowel edema, lots of ascites, and some pneumatosis. Not febrile, but until we got it all sorted out, consider Ricketsia and meningococcemia so did the big antibiotics for starters (no IV doxy here, but azithro apparently works fine for most rickettsia. Very nice to not have any internet sites blocked, so quick online lit searches are easy - including YouTube videos of procedures.)

So, Friday was a busy and challenging day. Then Saturday was weak and failing 80 year old day. And terrible performance on my part day. Made big deals out of stuff that the superficial and obvious first answer was the right answer, but way too much testing before I got back to the obvious.

I got reminded of one of the great drawbacks of paper medical records: the record that has disappeared into purgatory after discharge. One of the guys had been discharged a day earlier after a long hospital stay. His record was no longer on the ward, but hadn't yet gotten filed in med records. So, I didn't even have correct information as to how long he had been admitted. Only after a few hours did I stumble into one of the reg's that knew him and got the whole story - which would have clarified the issue with no testing. So, next time I complain about EMR's, I'll try to remember this.

Finally, for new onset Atrial Fibrillation, there is an Amiodarone infusion protocol which appears to never work (I recall that the literature is about a 50% conversion rate) but takes 12 hours or so. So, I've cardioverted 3 guys this week that had been in the ER for 12-24 hours, failed amio and then I buzz them and send them home. So, I've learned a bit about that whole deal. Nobody here seems to have heard about propafenone and I don't know if procainamide is available. Procainamide at least is only an hour infusion.

Local practice is that amiodarone is good for almost anything. They may put it in the water on the cardiology ward. I've not previously had a chance to see the pretty blue color that you develop if you've been on it for a while. Makes me want to give them a little oxygen. Mama, don't let your daughters go to a cardiologist that uses amiodarone a lot!

Enough for now.

Ride to the Ski Area (sorta)

I drove out of town to the beginning of the road up to the Ben Lomond ski area - Tassie's only ski area: 4 Poma's and 2 T-Bars. Looks like maybe 200 feet of vertical.

It's a gravel road - 18 km with about 1100 meter elevation gain, so use the 'cross tires on the bike. There are 3 separate climbing sections separated by long false flats. The first 2 climbs are 9-12% gradients, and then the Jacob's ladder is a switchback climbing about 200 meters gained at 13-14% the first 3 switchbanks, then 16% and 20% for the last 2. On a cross bike with cross tires, and a double crankset, that kind of gradient on gravel is touchy - a little mistake and you're off. I was cooked by the top.

The top is a long plateau false flat up to the ski area itself.

A ski lodge, a small bar/bistro, and rental lodges, duplexes and motel units that look like the've got maybe 100 rooms. Parking lot might hold 200 cars if you pack them in tight. Quaint.

Top was at 1500 meters. Last night was predicted to rain - but with snow down to 900 meters, but there wasn't any snow up there and just damp ground. Bitterly cold wind.

The switchback road section was 1 lane - I guess they expect all the skiers to go up in the morning, and all to come back in the afternoon - no passing expect a pull out at each switchback corner.

I had 2 cars pass me all day. 5 cars in the parking lot, but the restaurant was open.

Coffee shops & cafe's here don't serve brewed coffee - you have to order a "long black" for about $3 - kinda like an Americano except they put the water in the cup first and the Espresso on top so that you get a little foam. Talking to Aussies that have visited the US, they think we have awful coffeee - that horrid brewed stuff.

Ben Lomond is a plateau that is an igneous dolorite block lifted up above huge surrounding dolorite flats. About 5 by 20 km size. The dolorite has all fractured into vertical columns much like basalt, so the cliffs are quite striking. And, even at only 1500 meter (5000 feet) elevation the gently rolling summit is above treeline. Very pretty muted colors this time of year. Supposedly lots of wombats up there, but I didn't see any today.

Fog

Life in the rural medical world: guy with known CAD develops acute pulmonary edema, presents at 11 PM to a tiny hospital. They immediately decide to ship him - as they should, but fog has closed down the Launceston airport where the air ambulance is based - and it's a 5 hour drive to Lonnie, so they go for the 3 hour drive to Burnie - which is a bit better equipped than the really small place. There he's got a little troponin bump to .09 (no acute changes on ECG), and he gets nitroglycerin and Lasix. So, when the fog finally clears, EMS flights (the retrieval service) goes and gets him. By the time he gets to me - 12 hours after the 1st hospital arrival, he's no longer short of breath (never had chest pain), his chest x-ray has now cleared, his troponin has risen further to 2.24, he's already had his Plavix and enoxaparin at the second hospital, and in an hour he's off to the cath lab. Not bad considering all the travel time involved. The fog was gone and it was a beautiful sunny afternoon.

Even though we're about 3 hours from the East Coast beaches, we get stuff from out there - today was a body boarder that face planted into the sand off a large wave. Paralyzed and had to pulled out of the water by friends to keep from drowning. Largely recovered except for a little paresthesias and hand clumsiness by the time she arrived at ER. That was Saturday - they only did a plain film: normal. (Oooops.) Sunday, back to ER - CT:" normal (Ooops.) Back today - MRI showed minimal amount of cord signal, but no ligamentous injury: presumably a central cord syndrome. Treatment: nothing. OK - so the plain films, and even CT were not terribly sophisticated, but eventually all the tests we had led to the same spot: wait it out - you'll probably get back to normal or near normal.

A few other goodies: superior mesenteric venous thrombosis without clinical or imaging evidence of bowel necrosis - admitted for anticoagulation. More A Fib for cardioversion. And, lots of chaos - same as most days.