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,

a few weeks in...

It's cold here-- about 4 C in the am and 14 at a high. But it is also their depth of winter, so it's not going to get any colder. I've got the power and hot water set up finally, but the heating is still not working. Got a bank account, cell phone, internet (finally) and will start working on bathmats, window insulation, drivers license, etc. (right now driving without, which is interesting on the left...).Had a meeting with the ED director yesterday am (I'm writing this at my 09:00 on Fri am) and saw some of the ED. No one wears scrubs- the nurses' uniforms are like school uniforms (slacks, button shirts, sweaters/vests) and the docs wear their normal clothes. I'm thinking I'll have to break in the whole scrub top thing...

Tasmania is about the size of Scotland or Sri Lanka, ½ the size of Lake Superior, a bit smaller than Ireland, and has a population of around 1 million people. It's about 5-10 years behind the times, depending on who you ask. Launceston or “Lonnie” is the second-largest city in Tas, just behind the capital to the south, Hobart. There's an interesting history there, if you're inclinde to read up on it. Suffice to say that there continues to be a bit of a rivalry btwn the two centers. Lonnie has an immediate “greater” population of about 100K, which is less than Hobart. However, the north of Tasmania, an area served by the Launceston General Hospital, is home to the bulk of the population, spread out as it is, so the hospital can get a bit busy. With the flu season, confirmed to be at least partially H1N1, the past and current months are shaping up to be the busiest in the LGH ED (about 122 visits in a day, up from a prior max of 102).

One of the biggest set backs is that The Daily Show full episodes are not available in Tassie/Lonnie via the wireless... The countryside is quite amazing. The climate is temperate and forests still take up most of the island, so there's an opportunity for some “bushwalking” or hiking/camping. So far I'm walking pretty much everywhere in the city, as things are that close. Between Hobart, the capital, and Lonnie is mostly grazing (yes, sheep) country. In the city, the air is cold, and scented with woodsmoke, still a major source of heating for many in the city. The overall impression is that of Scout camp-- walking outside in the morning surrounded by the crisp fog and hint of woodsmoke, it's easy to recall mornings in Camp Katoga headed up to the Trading Post. The other memory this place evokes in me is that of the northern desert/forest of Argentina (I forget what the area was called, but it was north of my friend Augustina's home in Tucuman...) They say that smell is the sense most tied to memory... Finally, the pastoral/rural picturesque architecture and overcast skies makes me think of old BBC-America shows that my mother watched on Saturday mornings-- usually involving a “pepper-pot” old English lady solving murders.

The medicine is interesting. Just little “Royale with cheese” differences. Brand names for drugs are obviously all different. The formulary is a little different as well (roxithromycin is the macrolide of choice), and practice is very different. For example, I don't think I've ever sent home an 86 yo with chest pain after two (-) sets in the States. And I've certainly never done a Bier block on a 79 yo for her Colles frx! But, there you have it. So far I've had a woman come in in rapid afib, degenerating to sick-sinus with long episodes of asystole (you read that correctly) that increased in symptomatology and length, and a woman who showed up in shock with cyanosis, mottling, cold extermities, and perfectly intact mental status and vital signs. Still not sure about that one... apparently no brown snakes in Tassie (60% of the mainland's fatalities) and no useful history from her or her family...

People are very nice so far. By now writing the blog after my second week here (1st working week), I've met a few folks and have gotten the place and the other stuff pretty well set up, but not yet out about town very much. I've put up a clothesline inside the living room, which makes me look pretty classy... There's a 10 k race (how far is that, anyway?) in October I thinking about dying on, and apparently a mixed-martial arts club in town. We'll see... :)

I've included an email I wrote to a friend of mine asking about my ED work experience over here as it may give another POV.

Hey ---,
I'm trying to continue blogging what's up here in Tassie, so if that'll be helpful it'll be at www.doctoroffortune.blogspot.com
To try to answer your question, though, it's been good so far. I've been working for about a week as a Registrar, which is basically equivalent to a Fellow. I was told this is because I'm not Board Certified, but I'm not sure about all that. The Consultant/Specialists (“Attendings”) in Emerg where I am, and in most places it sounds like, tend to not overnight in the hospitals. They get called in for major things. So far, haven't been on overnight by myself, so not sure how that will work. The drugs are a little different, the abbreviations very much so (GORD for gastro-oesophageal reflux), and the follow-up practices different as well. The other day I was corrected for ordering an afterhours sono on a Pt to r/o ectopic in a preg vag bleeder. It was felt it could wait until morning, as she was hemodynamically stable and not peritoneal. They would've had to call in the consultant radiologist and apparently that's not easily done (“that HCT can wait until the morning-- we'll just observe the intox 82 yo potential head trauma until then...”). So that's taking some getting used to. Obviously no separate Peds ED...

I guess the bigger city trauma centers are more like what we're used to, but I don't imagine they're in much need for locums. Lifestyle is fine, though taking some getting used to. The environment and social scene where I am is a bit like where I grew up, so it's something I understand if not entirely enjoy-- things close down pretty early. But it works for me for now, hanging out, reading, getting back into some extra-curriculars I'd let go. Pleasant enough co-workers, though I do get the feeling that people say “no worries” when actually there's room for improvement if they would just tell me where!

So, hope that's helpful. Moving overseas was expensive and kind of a pain in terms of getting banks, post, internet, new phone, buying new electronics done. But the whole thing's been interesting, which is all I'd hoped for. Let me know if you have other specific questions, and I'll be happy to try to point you in the right direction...

On to Tasmania

Hey there. I'm getting back to the blog-- sorry if it's been a while. I got back in the States without a problem on July 5th. Spent about a week packing up the rest of my stuff, moved it down to storage at my lil' bro's (thanks Jon/Kelly!), and went to FL to hang with the 'rents. Now, headed out to Tasmania. I'll be spending a year there at Launceston General Hospital as a "Senior Registrar," which is like a Senior Resident/Fellow equivalent position in the US. Because I'm not Board Certified, they wouldn't accept me as a "Consultant" (ie Attending/Specialist). It's kind of a silly quirk, especially considering I just learned that an affiliate of my old program is now advertising a position that pays two-and-a-half times what I'll be making in Australia!! Whatever-- it's the experience. That's what I'm telling my creditors...

So, in any event, feel free to stop by if you're visiting Austral-Asia any time in the next year... I've uploaded a few pictures of my theoretical apartment, which is just a few kilos walk (Yay metric system!) from the hospital. As a result of the cost and time lost in heading back and forth between the States and Aus, I think I'll postpone taking the Board Exam for a year. Apparently I can do this and still not have to start counting my CME activities for certification. We'll see. It'll be nice to have that money and vacation time to hang out in New Zealand, Japan, Thailand-- whereever-- if I can have it. It probably also makes sense in terms of not really having studied for the stupid thing...

Anyway, so let me know if you have suggestions about what needs to be seen/done in Aus, where I need to head to next, etc. I hope to keep updating the blog, but if I don't it's either because my life has gotten way too interesting or waaaay to boring... Cheers,

--aws

Monrovia 5-0, or how I became a Liberian Crime Statistic

I thought I'd include the above pictures in this, my last entry about Liberia. The left is a jello mold that was discovered by Rachel and myself while looking for a pan to cook lentils in. We found it, and she said, "Why would they make a jello mold of President Tolbert?" It is of course Harry Potter, but I understand the mistake, given the uncanny resemblance. So, Harry is pictured with three leaders of Liberia for comparison (I'd think Doe before I thought Tolbert...) for Rachel's benefit.

The right picture is of our competition-- the medicine man (or manor?) is apparently a big herbalist who can cure more sicknes ses. I'm not one to argue. But it does highlight the reliance on "country medicine"-- which is herbs, etc. that are eaten or applied to improve illness prior to coming to the JFK ("just for killing") hospital. So, by the time they get there, the question is raised as to whether the liver damage is from the original illness or the country medicine used to cure it...?

So anyway. The last 48 hours in-country were... interesting.

The last week there I had been asked to review some material for the Ministry of Health's supervisor training. It was actually a bit of a bigger project than I'd realized, but was able to complete some changes to their training manual in time for a brief talk on emergency care that Thursday morning (I mention this in the video of the medical side in the ER during my discussion with Deborah). It was suggested after that morning that I go do something fun in Monrovia, given that I'd spent a lot of time in the hospital while I was there. So I thought I'd go see one of the beaches that I'd been told should be relatively safe.
You see, some of the beaches in Monrovia, especially around the hospital, aren't all that secure and are known for their criminal activity. Kind of like alleys in the States, you really don't have any business being there, especially at night, especially alone. (Of course some private beaches that are patrolled are fine).
But, let's face it, I'd gotten kind of bored and was looking for something to do besides work. So, in the early afternoon of my penultimate day, I headed out to one of the beaches that was recommended as relatively safe. I wandered around the beach for a bit and was heading back when I was approached by a group of guys. There were about 6-8 of them, and they initially asked me a few questions in order to surround me. They started yelling and grabbing my arms, while two of them waved around broken bottles and one a pair of kitchen scissors (you know, the kind with the orange handles that your mom has laying around somewhere). They gave me a few cuts to make sure I wasn't going to try anything ("uhm, there are 7 of you-- I think you win today...") and took my wallet/money and my digital camera. Through the course of the encounter, it became pretty clear these guys weren't really all that dangerous, so I followed them a little bit and asked them to drop my wallet and id, which they did. It was kind of like in the Big Leibowski-- "Are these men going to hurt us, Walter?" "No, Donnie; these men are cowards."
After all that I called for the driver from the hospital to come get me. (My phone was in one of those "change" pockets that are sometimes in jeans or "travel pants" in the hip pockets..) So Mr. Moore, one of the drivers from the hospital, and one of the hospital's plain-clothes security guys (Frances I'm pretty sure) came. We eventually located the guys who took my money (they were still in the area apparently playing craps with a bunch of US bills. Yeah, not all that subtle).

We drove back to the police station to pick some of them up and took them back to the beach. I was in this way part of my very first Liberian stake-out. Which quickly became my very first Liberian foot-chase, as the guys' lookout recognized one of the plain-clothes cops and sounded the alarm. Everyone scattered and myself and the driver in the van went around to try to cut off escape routes while the police and hospital security guys (as well as Mr. Moore, who-- as those of you who've met him might have guessed-- loved every minute of it) chased them through the little alleyways.
Eventually we rounded up about 5 guys (the 6-7 on the beach became 12 or so when we found them again) and took them to the main police station. I identified the ones I could and filled out a statement. During this, of course, they were in the room, tied together with the tails of their t-shirts. "White Man-- look at my face! It wasn't me!"
Got back to the hospital, and fortunately since I know a good ER doc got taken care of. The next day, I was told my camera had been found. Apparently there are only a few people in that area of Monrovia who can fence a digital camera, so both were followed and the one arrested. Obviously this effort wouldn't have been put into things if I weren't part of the hospital where the administration is so connected to the President, so I'm grateful for that. So in any event I survived the experience and did a little more work that last morning before packing out. An interesting aside, when I got to Brussels I checked the photos on my camera. They include the following picture of the guys who stole the camera from me. I guess they took a few shots of themselves for posterity... ;)

Video diary overload!

Hi there! Got the ol' camera back so thought I'd post a few of my close-to-last-day videos!
This first should be a quick look at the breezeway/classroom where we'd talk some to the Nurses in the morning. It's also a hall of the hospital that we'd use to walk to and from the main patient care area of the hospital and the dormitory.

This next one is a quick trip through the Trauma side of the ER. Nothing too exciting going on.


This is a quick look at the medical side, and a discussion with Deborah, one of the Head RNs

Here is a video of a trip up to the floors


Finally, this video shows a quick look at the medical wards and ICU, w/ Drs Toomey and Borbor




I tried to whip-pan (yeah, that's right-- it's an industry term) so that no one could be identified... Skills of an artist, or cinematographer. Trogdor. :)

Hysteria, Lazarus, and No mo' Flomos -- medical stuff

I had thought this text had uploaded, but I guess not... hmmm.

So some of the more interesting stories I'll try to list here.

One thing I was impressed by was the number of “hysterical reactions” or pseudoseizures that came in to the ER. I suppose I shouldn't be. I mean, I'm hesitant to diagnose depression in the Bronx (“Hey man, it's not your attitude/outlook or brain chemistry-- I agree with you, your life sucks.”) where at least you're not getting dysentery or malaria 3-4 times a year and your poverty does not preclude getting a ride thanks to public transportation. So why shouldn't there be a relatively high burden of psychiatric disease in a recently post-conflict poverty stricken nation? About once a day a girl/young woman would come in, not speaking, or unconscious, or staring. They'd usually get a dose of quinine before I was able to resuscitate them with an advanced ER procedure known as a “sternal rub.” (yes, think of it like a noogie-- except in the center of the chest. Really annoying and likely to cause you to come out of your psychologically induced coma). I can't argue with the quinine, though. Top diagnoses for acting screwy, depending on age, were cerebral malaria, HIV, hypertensive encephalopathy, and hypoglycemia.

So, they'll tell you in Liberia that the language is English. Not quite. Most people do speak a kind of “pigeon” English. I think it's equivalent to the way some Dominicans speak Spanish. Letters/sounds left off here or there, different idioms, etc. So it's not always easy. We actually started on a phrase book for the people after us. “Tryin' small small” means “getting somewhat better.” “Running stomach” means “diarrhea.” “O'Ga!” means “My Goodness, this is really painful.” And, interestingly, “Fell off” means “passed out” or “became unresponsive” or “felt weak.” (“Fell out” is sometimes used in the Bronx-- any others people know about?). So, when I came across this young man who “fell off” and has been “weak” since, I initially didn't think much of it. Get a malaria smear, give fluids, dextrose, etc. However, sometimes, “fell off” means something much more literal and in keeping with how I use the phrase. Sometimes, “fell off” means “this guy fell off the roof he was working on, landed on his head, and hasn't really been able to move his arms or legs since, so we brought him here in a wheelbarrow with his neck hanging over the back of it.” Overcoming this linguistic barrier I feel, was, in retrospect, key to his eventual care and disposition...
I decided to start calling him Lazarus. After ~ 6 weeks on the floors, getting intermittent physical therapy, he's able to stand on his own again (Partial cord syndromes, his diagnosis, have a good prognosis a few months out). He was so happy to see me when I went up on the wards that he got up and sat down several times to show me. He may not be playing soccer again anytime soon, but he's walking, so things could've been worse.

I always enjoyed Michael Jackson as much as the next person (Rock with You, Don't Stop Till You Get Enough, and Billie Jean are overplayed, The Way You Make Me Feel and Smooth Criminal underplayed), but certainly didn't get all bent out of shape when he died. (It was ridiculous, BBC and Al Jazeera- London desk were covering news, while “the Situation Room” was on Michael Jackson all-day all the time for what seemed like a week. Yay America and your declining world relevance!) Liberia, like most of the world, however, felt differently. There were two days there when everyone felt a little sadder, was a little quieter (not easy, in Liberia) in mourning for the King of Pop. In particular, one young man came in to the ER the day after the announcement. Seems that upon hearing of the death of the King, he let out his best “Dangerous”-era “O!/Hoh!” and dislocated his jaw. So, after I finished laughing at him, myself and the medical student grabbed and yanked. Not so successful, and well past the end of my shift, so I gave him some muscle relaxants and figured I'd try again in the am. Apparently, he'd relocated during the night and was able to be discharged by the overnight team. I guess it wasn't a bad dislocation. Not a Bad, Bad, really really Bad, one anyway.

I feel I should break up the text here with a picture I only got at the end of my stay, as it was from the OR. Often surgery is the diagnostic modality of choice here, so there is a certain significance to claiming that an abdomen is "surgical," especially for kids. In any event, they had thought this tyke had a typhoid fever perforation, but on opening the peritoneum, turns out it wasn't the case. Here you can see the surgeon taking out the worms (ascaris) from the small hole in the small intestine before repairing the hole and putting the kid on antibiotics and anti-helminths. Enjoy!

Early on in my stay, I was given the Liberian name “Flomo.” For almost 5 weeks, I tried to get people to tell me why I was given this name. Louie was called something that apparently means “owner of a town,” and as far as I could tell, both Marcia and Rachel were called “Kebbe,” which is a name from Lofa county. Lofa is one of the biggest counties and quite a few people who moved to monrovia after/during the war for protection are from there. It is common knowledge among hospital staff and I assume Liberians in general that Lofa women have the biggest backsides. I'm not sure how this is appropriate, because if either Marcia or Rachel attempted to tie their children to their backs with their Lappas, the way most Liberian women do, their kids would slide off to the ground. Sorry if I'm telling you something about yourselves that you didn't know Drs., but it's true.
In any event, I too, it was decided, needed a name indicating I was from Lofa County. (and yes, the children would slide off my skinny Irish ass as well, though I don't think that entered into the decision making process). So, I was called “Flomo.” The name had shown up a few times as either a first or a family name, so I was a little familiar with it, even though I was told it didn't have a “meaning” per se. But, over the course of my time there, I noticed something-- Flomos died. Like, a lot. Chances are, if you were named Flomo (first or last) and you made it to the JFK ER, you were not getting out. I mentioned this a few times to the nurses, and thought maybe a different name would be better. They all loved it. To the point where they would say in the morning “Hey, it's Dr. Flomo! Do you think he'll leave today?” One time I felt particularly uncomfortable when a nurse in triage (full of people, mind you, any number of whom could've been named “Flomo” to varying degrees), explained to another nurse that “Dr Shannon doesn't like to be called Flomo because Flomos always die.” Ha ha-- not so funny if you are overhearing this conversation and just registered your uncle, Flomo Flomo from Lofa county. And if you were Flomo and triaged to bed 19, just frickin' forget about it. Bed 19 was not kind to Flomos. Or to anyone else, for that matter. Come to think of it, Beds 19, 10, 8, 6 and 5 were just not good beds to be in. So, I instituted a “No Mo' Flomo” policy in the ER, which the nurses also loved. I would not be called “Flomo” on days I wasn't feeling well, and all Flomos under my care had to have rock-stable vital signs before I would see them-- even if this meant lying to me.

--aws

Radio Silence- pictures of ME!

I apologize for being negligent on the blogging front. TRUST me, though. Some interesting things have been happening, and I've had an action packed last week and few days. Suffice to say, I hope the scar lasts so I can pretend I'm a bad-ass... I'll post a few things in the next few days. BUT, I'm on my way home to from Brussels now, and will be back in contact shortly. A few teasers... Myself and Dr. Fowler enjoying the official hospital Jollof (or Jollah-- I saw it spelled a few different ways) rice in the cafeteria, and Joseph, Dr. Borbor and the ward nurses checking out a sonogram on one of our ICU patients. Hmmm, with the Brussels internet, maybe I'll risk posting a video before the plane leaves... Oh, no, can't-- long story as to why not, involving the Liberian National Police, my undercover operation, and the aforementioned scar. Oh, apparently the flight is oversold and they're looking for people to stay in Brussels tonight... This is God testing me after the events of the past 3 days-- Lord, no worries. I have learned that discretion is the better part of valor...
--andrew