Medical impressions, Baby lambs

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With apologies to those of you who are not really interested in the medical aspects of my life here, or who find this too technical: just skip to the end and admire the farm pictures!!

I have now been working in the ED about 5 weeks. I really like the nursing staff, and though we are usually moderately busy, it never seems crazy busy-although I have been assured that just since I arrived, the overall volume and admissions have increased dramatically. All I can say to that is, “MAGNET.” However, although supposedly beds have been short, we have not yet been “boarding” any patients, and generally once a decision is made to admit, the patients go upstairs pretty quickly. This is especially true for ICU and CCU patients. They are out of the ER before I even see their labs or xrays (which is OK with me!!)

The catchment area for our hospital is a radius of almost 2.5 hrs. Due to the long transport time, patients who cardiac arrest are either resuscitated at the scene or pronounced. In general, no one is transported while CPR is in progress. We also get some trauma that takes quite a while to reach us. I had about 4 injuries last weekend from some kind of a motorcycle race event, several fractures, but the most dramatic was a young man who was thought initially to have a ruptured spleen. CAT scan was negative for solid organ injury, and I suspected a duodenal injury, and he went to surgery and had a jejunal tear. And guess what? ANY of the surgeons will do a pediatric appendectomy, without a lot of fuss or tests. If they think you have appendicitis, they take it out. If they are wrong, well, you’ll never get appendicitis again!!! I find that kind of refreshing.

I know that the ER nurses at Marlton will get a kick out of this story. An elderly man came in by EMS who had collapsed while fishing locally. It was unknown how long he had been down before he was found, and he was cold and unresponsive, though he did have a blood pressure and pulse. I didn’t realize that for a “Priority one” patient, the internist and anesthestist are immediately called to the ER, so I had lots of help. In fact, I wasn’t really sure who was in charge, but since the internist would be caring for the patient in the ICU, I figured it was him. I “suggested” to the anesthetist that the patient be intubated before CAT scan, and it was done. Ultimately my entire role in the whole “code” was to push the meds for the anesthetist (they trusted me to draw them up and push them!) and to put in the foley (female nurses can’t cath males??!!) So that was my sum total contribution to the care of this patient. But I will say this, he was out of the ER in less than 30 minutes. He went straight to CAT scan, where it was found that he had a large intracranial bleed, and there was no talk of involving a neurosurgeon 2 hours away in Christchurch. They kept him on the vent until his family arrived the next day, and then they took him off.

Cardiology: there is currently no cardiologist in Timaru, so the internists take care of the cardiac issues. Anyone who fits criteria for “active” chest pain doesn’t even stop in the ER, they just go directly to the CCU where they have a triage bed for chest pain. However, the more subtle cardiac problems do show up in the ER. Last week I had a man in his 50’s complaining of dyspnea on exertion, fatigue, right pleuritic chest pain, and numbness of his nose and mouth. Now most ER nurses I know can tell you a story about someone who comes in with nose pain only and is having an MI!! However, this patient did not have an acute EKG, but I was highly suspicious for acute coronary syndrome based on his history and risk factors. When I called the particular internist on call, he was very resistant to admitting this guy. He brought up that, “you Americans over test and admit lots of things, and our mortality is no worse. “ I agree with that in some circumstances, but I countered that in a 50 yr old man the stakes were pretty high to miss cardiac disease. I asked how long it would take to get an outpatient stress test and was told “2-3 weeks.” Ultimately I informed him that I would be happy to discharge the patient and document our conversation, so that if the patient dropped dead while awaiting his stress test, it would be clear who was responsible. Not surprisingly, at this point he decided to admit the patient and stress him the next morning. He never believed me about the nose pain being an anginal equivalent, though!! Further, if the patient has a negative exercise stress test, that is the end of it. That may not be so good. Echo is hardly available, even in Christchurch. They could really use an echo tech.

We do not have Cardizem available IV at all, so Afib is treated with dig and metoprolol, just like the old days. It surprises me that cardizem is not used, since it is generic and relatively cheap. But, as I mentioned earlier, we also do not have Benadryl IV. They use Phenergan instead. I’ve had a couple of anaphylactic reactions, which of course are treated with epi (called “adrenaline”) here; but Epi pens are too expensive, so patients are given an ampule of epi and a needle.

Antibiotics: Mostly the basic ones are used, like lots of Amoxil and Augmentin. Ceftriaxone is available, though not used as much. And we don’t have MRSA here, so penicillins and cephalosporins are still used for skin infections!!Very little clinda, and I haven’t written for vanco since I have been here.

Pain meds: All that is generally available is acetaminophen (called Panadol) and ibuprofen. They do have another NSAID, Voltaren, and Tramadol is treated as something really special. Nitrous is used pretty liberally in the ER as well. Generally the only narcotics used are morphine IV or codeine PO. You can even get Panadene OTC, which is Tylenol with codeine (8 mg codeine per tab). But, this is the amazing thing; people don’t complain. They are really happy to go home with their prescription for codeine. And we don’t even have IV Lorazepam in the ER!! !Just diazepam and midazolam, which are generally not used for anxiety. I don’t know why, but I see a lot less anxiety here. In fact, I have not seen ONE drug seeker in my time here; although we do have “cast-seekers”. I guess there could be secondary gain to having a cast put on, whether you need one or not!! For some reason, there is a lot of paranoia about scaphoid fractures, and if you have a wrist injury with the least suspicion of a scaphoid fracture, you get a true cast for 2 weeks at least!! I think that in the States I saw a scaphoid fracture maybe 2-3 times per year, so I can’t imagine there are so many here!!

ORTHO: I’m being told that this is the “British” system, that the ER handles much of the acute ortho. Patients are fully casted (“plastered”) for acute fractures. For years I thought that the reason we didn’t place circumferential casts on acute fractures was due to fear of swelling, but that doesn’t seem to be a problem here. Patients return in 24 hours for a cast check, and then based on the fracture, return to the ER for cast removal without ever seeing an ortho, or sometimes they do. There is a cookbook list of instructions for how to deal with various types of fractures. In addition, the ER docs do most of the acute reductions. Last week I reduced my very first trimalleolar ankle fracture/dislocation. I did use sedation with Propofol and Fentanyl, which many of the docs are not comfortable with, but I happened to have a “house surgeon” ( a junior doc) with me who has an interest in “anesthetics, ” so she handled the airway while I pulled on the ankle. It went very well. I have yet to do a Colles on my own, and I dread the day a hip dislocation comes in. Posterior splints are occasionally used, called “backslabs.” We do have air splints for ankle sprains, and the crutches are generally the kind that go on the forearm, not the under arm type.

PEDS: The only pediatricians around are in the hospital, and GP’s handle all the routine pediatric care. So anytime they are nervous about a child, they send them in. I never saw so many LITTLE babies; from 1 week to several months old. Fortunately, the hospital pediatricians are very responsive to my calls, and they have a very low threshold to admit. Imagine if a GP sends a 2 week old on a 2 hour car ride for “trouble breathing”; you know that child isn’t going home for the night!! Also, they do all the labs and IV’s on the peds floor. Most babies appear to be breastfed, it’s much more common here than bottle feeding.

OB: I haven’t had too much contact yet with OB, but the midwives mostly run the show. More on that later.

Geriatrics: They don’t call them “nursing homes” here; they are “rest homes.” There are an awful lot of people in pretty good shape, too, in their 80’s and 90’s who live independently at home. There is more intensive care for the elderly than I expected to see, and I don’t yet have a handle on the DNR issue. Also, there seem to be fewer people on insulin; most are NIDDM. Of course, there is much less obesity in general.

The most terrifying thing is that after 11 pm the ER and the rest of the hospital has only one doc available; one of the junior doctors. Some are just PGY2’s and may have never even worked in the ER! If they have a question or problem, they call the internist or surgeon on call. The ER docs are NOT on call. Sometimes they keep patients in the ER all night for the ER doc to see in the am, or have patients return in the am. There is no routine xray or lab after 11pm, although they can be called in if needed. If a patient shows up with a sore ankle, they are told to return during the daytime!

Since I don’t have any hospital pictures to share, I’ll tell you about the afternoon last week when Randy and I were invited to the home of one of the ER nurses, Marijka, and her husband, Kees. They emigrated from Holland 30 some years ago, and they have a little farm. Marijka thought we would get a kick out of seeing the newborn lambs, so we got to meet (and hold!!) them. These animals are very used to people, not like the grazing animals we see on most of the big farms. They also have some goats, a pig, a cow, chickens that give green eggs, and a pair of male Alpacas, Wilbur and Harry. Marijka said that several days after we visited, the last sheep gave birth to twins, and she said that the alpacas were playing midwife to her all through the birth, and even helped her lick the newborns clean!!! So I will include some pictures from our visit to her farm. Next time I will tell you about our house, and our BBQ that Randy got at a garage sale!! Our decorating theme is “Salvation Army” with some lovely enlargements of pictures that Randy has taken so far in New Zea

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Photos

A Lighthouse near Timaru
We took a walk near our home one nice afternoon

near Timaru
This is the shoreline near the lighthouse

Farm Day
Feeding "sheep nuts" to the alpaca. He wasn't too picky

Harry or Wilbur?
Not sure!

Baby
I never got to hold a one week old lamb before!!

Photo 6
Just to show you how little he is

with their moms
The moms do seem to know who their own lambs are, and won't feed any but their own

Photo 9
Marijka is trying to encourage the alpacas to go into another area

Lamb outing
Randy taking a lamb over to the rest home bus that stopped to see the animals

Rest home
field trip

Harry and Wilbur
Alpaca midwives!

Comments

[Jack Hotchkiss]

A cast...of thousands???
Your cast story gives me hope for my uninteruptedness (a word?) during my call nights. It sounds like the surgeons are the proverbial "wall" and that late night "shenanigans" are relatively rare. Your observations of government run health care are very revealing. Our tickets have been purchased, we leave December 30, arriving in NZ on the !st of January, Timaru on the 2nd. Our anticipation heightens. JH