University of Tasmania Medical School

Today was my last shift - and I didn't do too much work: many of the students, interns, residents, and registrar grabbed me for performance evaluations. Not my favorite thing - i'm not good at evaluating folks' strengths and weaknesses and I'm terrible at being critical.

But, I talked with some of the students and learned a bit about the med school: 5 year school, straight out of secondary education for most. 1st 3 years are all preclinical and in Hobart at the main University Campus. Then 2 years of clinical rotations spread out to Burnie (small hospital in a city of under 30,000), Launceston, and Hobart. By reputation: Burnie has good teaching programs but a small hospital with limited patients. Living is cheap, so those on low budgets like going there. Hobart - good to stay near family, big hospital with all the specialties and lots of patient material, but poor teaching. YOYO approach - not even much in the line of lectures, supposedly. And here's the shocker: Launceston is the place to go for good teaching: plenty of lectures and programs, and REgistrars and consultants who are willing to sit down and go through patient presentations. Hmmmm!

Got home from work, and suddenly my phone rang with the ER number on it! AAAGHHHH - did I forget that I was on call? Was there a disaster and they needed more help? Turns out that some of the nurses didn't realize that I had just finished my last shift - and called - at midnight, to say goodby. Good on ya, mates.

Talked a bit with one of the Reg's about medical care in India - his home. Public hospitals and care is apparently abysmal, crowded, overworked, poor quality. And, an impenetrable barrier between private and public. The big companies all provide insurance for the employees, and the private hospitals are by his account, comparable to the more developed world - big, clean, well equipped with all the latest - and partly supported by medical tourism including from the US. His mother had a syncopal episode (fainted) last month and got a CT, MRI, and echocardiogram for $600 and got her permanent pacemaker for $6000. I believe that I could see a syncope patient at the University and the cost of cab fair to DIA, plus round trip flights, plus all that stuff would be about 1/3 of the cost to get it done at the U.

OK, probably no more medical stuff. Off to the Great Barrier Reef and mountain biking in Queensland.

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.

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.

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.

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).

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.

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!

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.