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.