Ever Forward...

Hi there,

So, interesting few weeks. The Registrar position in Aus EDs is kind of like the Jacobi 4th year “pre-attending” position in that you run your side of the ED and check in with the Attending (here “Consultant” or “Specialist,” sometimes both) whenever there's a problem. The primary difference in Lonnie is that my “side” is the department, and the Consultant is usually at home at night. If considering coming out here, make sure you're scheduled/billed as a Consultant... Here's a picture of my schedule for the month (shift days in yellow)...

While so far no overnights alone for me (5 in a row coming up), I'm headed in that direction. Mostly it's just seeing patients, assisting with difficult cases (and certainly getting assistance), and hearing cases presented by RMOs (Resident Medical Officers) and Interns. The hang ups continue to be the fact that many lab values are in unfamiliar units (a glucose of 7 is ok, apparently) and that I'm reading my own films during the day. I still call folks over every now and again to get a second opinion, but my little follow up book is now a few pages full of films to see if I'm any good at calling pediatric,.. sorry, p_a_ediatric pneumonia. No diphenhydramine in the country-- the anti-histamine of choice is promethazine (phenergan). Also, roxithromycin is the available po macrolide (no resp. quinolones like moxi, which is odd. I'll have to double check that). Ticarcillin as opposed to piperacillin, and no etomidate. I'm using a lot of propofol for simple reductions and so on. Speaking of which, doing quite a bit more from a “procedure” standpoint than I'm used to doing. The other day during a “Fast Track” shift, I saw 2 thumb dislocations (one was a morphine/fentanyl/midazolam after nitrous and local lignocaine (what I call lidocaine) flail), one tibial fracture, one distal fibula frx I had to _cast_ and one acute kidney rejection, to name a few. It's been interesting. The use of Bier's blocks is also a new one to me, so I'm still working that out. I've done three cardioversions (one w/ amio) and one Peds arrest. No bedside sonogram, and to get one after hours and weekends we have to call in the radiographer and the radiologist. There's a lot of “can this wait till morning?” and “Have the r/o ectopic (granted, low prob, but that's why we get the tests) return tomorrow for her sono” which I'm not as familiar with. Also, had my first "swine flu" pneumonia/ARDS case the other day. So far she's doing well (we've had ~ 3 inpatient deaths so far). An additional flu clinic has been set up for people w/ "flu-like" symptoms (the commonly heard rejoinder to many of these complaints is "stop your s-whining!" [sound it out...]).

So I'm glad I picked this place in terms of the pathology not disappointing. It's busy enough to challenge some management issues, there's no buffer of "senior residents" to take away onerous procedures, I'm doing almost all my own psych and Ortho stuff (yay latter, boo former) and arranging a lot of outpatient cardiac work ups, which I'm trying to get comfortable with. No real trauma so far (rare year in which penetrating trauma cases reach double digits...) but for the most part that's fine-- those cases are really only "find the hole and plug it" anyway.

To a person so far all the patients, even the “problem” patients, have been very polite once you get past it. I actually had a guy thank me for convincing him not to sign out AMA and get evaluated. “Thank you.” Who knew?

Obviously I still have a lot to figure out about this place and Medicine in general. Everyday I have 2 or 3 things I absolutely need to get home and read about (few for several on that count). So that's cool. I'm still a little hesitant about stuff I shouldn't be (ie stuff that two months ago I was not having difficulty managing), and my conversations with others are a little tentative. Much like a wobbly, new-born colt trying to find his legs, I'd say. But I'm getting used to it. Having a few instincts confirmed as I go along, which is nice. So far, I think things look like they'll be fine, and I enjoy walking to work in the morning.

Still finding places to run. The area is like the bastard child of Parkersburg and Vienna crammed together, w/ the topography of North Hills, so even hour long runs are gruesome right now (hey, just spent 2 months in Africa w/o any exercise!) You can see my street in the pics here, w/ the hospital in the upper right distance (~ 15 min) of one.

Swung by the gym the other day and everyone is in better shape than me, so that's just great. Working on that as well. In fact, my list of Tas goals (posted on the fridge) include a 9:30 min mile for 1/2 marathon distance, getting in shape, improving posture, finishing some review material & Board Prep, and normalizing my TSH. We'll see about that last!

Thanks for all the emails and Skyp-ing. Look forward to those every day!

Until the next,