For medical practitioners only...

So clearly this is terrible. And obviously me finding this even a little bit funny means I am a terrible person. But, I mean, _come ON_!!!

Emergency response pendant implicated in cases of strangulation, FDA warns.
MedPage Today (9/23, Petrochko) reported, "The Philips Lifeline brand of emergency response pendant may strangle its wearer if it becomes snagged, the FDA cautioned." This holds especially true for "patients who use wheelchairs, walkers, beds with guardrails, or other objects that could entangle the object." Already, "at least six occurrences of serious injury or death have occurred since 1998 when the device's cord became caught on something."


Sigh...

Merrily We Go Along...

Huh. Not much to tell recently. Working a lot because several of the other Registrars have asked to switch shifts w/ me to take exams and so on. I've been doing a few things, including my first solo Bier's block the other day. Getting the system down at work. To be honest it's still a little odd to me. “Bacteremic dialysis patient? Sure, give him some vanco and I'll follow it up in my office.” I guess you can handle it that way... And mental health services in Tassie are just beyond my understanding. Oh, the view from the hospital toward my house...

Let's see-- what else? The Daily Show is back on the web; every few days I watch an episode of Battlestar Galactica on mail-order DVDs. Finished a book a friend gave me about an emotionally distant physician who can't make a romantic commitment and then contracts TB (yeah, some people are hysterical). Made it to lesson 7 on “Introducing Guitar: Book 1,” which is just beyond “Mary had a little lamb,” though here the tune is called "Merrily We Go Along." The cold/swine flu/pneumonia complex has gone, and I'm now no longer short of breath walking to and from work, so I'll start exercising again (goal: 9:00 min mile for ½ marathon...). The ants have been subdued and a study schedule posted. Plans have been made for my first trip to Melbourne for a medical procedures seminar. Now, time to get a car to see about doing some hiking here in Tassie-- already marked some trails.

Attached are a few pictures of the environment. Many houses have this elaborate trim which is apparently typical of Victorian architecture (and knowing is half the battle). What I love is the one for sale sign that mentions the benefits of "Inner City Living." That's awesome.

All's well so far. There are definitely some frustrations at work, battles that should've been fought, etc. But all in all it's not too bad. Now that I'm feeling a bit better, it's time to do some exploring.

For those who don't know, a little wisdom from Queen and Bowie...

'Cause love's such an old fashioned word

And love dares you to care for

The people on the edge of the night

And love dares you to change our way of

Caring about ourselves

This is our last dance

This is our last dance

This is ourselves

Under pressure

Cheers,
--aws

Down time

So, still under the weather in Launceston. Not so good. Being sick sort takes the wind not only from your lungs, but also from your sails... The good part is that sleeping all day is easier in Lonnie than in NYC. No one's jack-hammering or refurbishing next door, so that's good.

As a result of not feeling all that well, been spending a lot of time on the internet at my favorite sites. For those interested, I've copied the links of a few of my favorite TED talks below. Don't know TED? Seriously, check it out. It's part of why having an internet make sense!

Also, in keeping w/ my first post ("Questions of Travel"), I've copied Robert Service's "The Men That Don't Fit In" below as well.

In terms of work, I guess I really do like the procedures and so on better than the rest. We (finally!) had an intubation the other day and I was so happy! Unfortunately, because the closest required specialist a 2-hour ambu ride away, it may have been simply a prolongation of the inevitable. Still, it kind of balanced out some terrific misses I've been making recently. Sigh. Anyway, hope all's well.

--aws

There's a race of men that don't fit in,

A race that can't stay still;

So they break the hearts of kith and kin,

And they roam the world at will.

They range the field and they rove the flood,

And they climb the mountain's crest;

Theirs is the curse of the gypsy blood,

And they don't know how to rest.

If they just went straight they might go far;

They are strong and brave and true;

But they're always tired of the things that are,

And they want the strange and new.

They say: "Could I find my proper groove,

What a deep mark I would make!"

So they chop and change, and each fresh move

Is only a fresh mistake.

And each forgets, as he strips and runs

With a brilliant, fitful pace,

It's the steady, quiet, plodding ones

Who win in the lifelong race.

And each forgets that his youth has fled,

Forgets that his prime is past,

Till he stands one day, with a hope that's dead,

In the glare of the truth at last.

He has failed, he has failed; he has missed his chance;

He has just done things by half.

Life's been a jolly good joke on him,

And now is the time to laugh.

Ha, ha! He is one of the Legion Lost;

He was never meant to win;

He's a rolling stone, and it's bred in the bone;

He's a man who won't fit in.

http://www.ted.com/talks/ken_robinson_says_schools_kill_creativity.html

http://www.ted.com/talks/dan_gilbert_asks_why_are_we_happy.html

http://www.ted.com/talks/barry_schwartz_on_our_loss_of_wisdom.html

http://www.ted.com/talks/benjamin_zander_on_music_and_passion.html

http://www.ted.com/talks/malcolm_gladwell_on_spaghetti_sauce.html

http://vimeo.com/moogaloop.swf?clip_id=2539741

http://www.glumbert.com/media/everydaynormalguy (ribald lyrics)

http://www.ted.com/talks/vusi_mahlasela_sings_thula_mama.html

http://plagiarist.com/poetry/

and of course http://www.theonion.com/ and http://www.thedailyshow.com/

For those of you interested in the saga of my pants

Reproduced below. I'm not sure if I feel worse being robbed of a good pair of pants or of the recognition that I am, in fact, hysterical....

Email to North Face's parent company, VFC something or other--

Funny story, actually: I was abroad doing some medical work when on a rare day off I went to the beach. I was wearing my North Face Paramount convertible pants at the time, converted as shorts. Suffice to say, I was mugged. To my dismay, the attackers made off with a few items including, for reasons unclear to me, the right leg of the pants (the left, I guess, they didn't feel they could sell?). Luckily, my phone was kept safe in the front right hip zippered pocket (which can now legititmately be advertised as a theft deterrant) and all ended well. Except that I am currently in the position of having a very nice pair of shorts and one left gaiter. I would obviously much prefer to have the whole thing intact. How would I go about obtaining a replacement R sided leg for a 34-inch inseam Dune beige Paramount convertible pant? I bought the item in the US, but have since moved on from Africa to Australia, so I'm not sure how to provide proof of purchase (it was originally through REI...). I'm not sure if there is even a supply of the pant legs laying about somewhere. I'd love to have the set whole again, though, as they are my favorite pants for work in the Emergency Department as well as play (why I was wearing them at the time of the incident, in fact...). Looking forward to a response. Cheers, --andrew s.

Response(s)--

Hi Bernie, Pls kindly review the case with customer below. thanks! Best Regards,Jessica

Good Evening, Andrew

Thank you for contacting us in regards to your The North Face product.
Unfortunately, we do not supply spare part to replace the missing right foot of the convertible pant.

Below stores are some places where they still stock this convertible pant for purchases:
Paddy Pallin, Anaconda, and The North Face retail store on Pitt street, Sydney.

Hope this info will assist.

Kind Regards
Bernardus

Bernie, turns out, has the title of "After Sales Manager." If nothing else, I feel gratified knowing that responding to my email gave him something to do with his day...

Cheers,

--aws

Oh, PS-- On a separate note, in looking into this, I found out that REI discontinued their line of Granite-style(?) canvass pants. These were, without question, the pants that have made me happiest thus far in my adult life, and my current pair are torn and mildly blood-stained. Shattering.

View of the Launceston dryer/living room combo-- shorts and accessory gaiter; the lonely Granite pants (my study area in background...)

Thousands dead in Launceston...

Ugh.

I hate taking antibiotics-- they are for the weak. What kind of hypocrite would I be if I told my patients there's no need for antibiotics and then took them at the drop of a hat? Besides, I absolutely believe that the end of humanity will come in the form of wars over water and resistant bacteria (or flu...?). So, it was with a great amount of soul-searching that I finally started a course of macrolides the other day. I'd been sick for almost 16 days (initially just a little swine flu...) and getting worse. Finally I was asked to stop coming to work because I was making the patients feel bad for me. Luckily, I have a few days off to convalesce. To be fair, I guess I would've diagnosed me with sinusitis or pneumonia (no chest xray, but I guess it's pretty bad when you can hear localized rales in yourself?) if I'd come in. The big thing was I was sleeping all day whenever I was off. Eight-to-ten hour shifts and I'm asleep from one to the next! What kind of New York (medical) Resident am I? Getting a little better, and no longer an infectious risk to patients (don't work for a few more days). But unfortunately I haven't felt like doing anything except laying around at home, not accomplishing any thing (car, salary packaging, running/gym...).

And I'm assuming that's when they knew it was time to strike...

Yup, completely frickin' overrun. Don't worry, after making the video I had the stamina to dispose of the bodies, so that's nice. But the live once are still crawling over the computer and in the Gatorade. I only just was feeling like walking down to the store to pick up the traps, which so far do not appear to be all that useful. I've heard it said that by mass (not just number) there are more ants on the planet than people. Well, that's certainly the case in my apartment.

So funny little anecdote: I was working with an Irish-derived locums the other day, and the ICU team comes down to talk to us about the case. We're around the PACS and talking about the case when the Aussie ICU guy says "Whoa, I didn't realize I'd have to bring a translator!" The team started laughing and I didn't get it until I realized that here, the Irish guy and I are the ones with the accents...

For the ED docs reading-- just a tiny example of how we do things differently here. 88 yo woman feeling unwell for a few days. Found to be in new afib, cheap pneumonia on chest XR, and very cheap troponin leak. You guessed it-- ED ROMI, po abx as an outpatient, start metoprolol/aspirin, and check in w/ GP in 2 days to see if afib persists and discuss A/C. WHAT?!?!? I guess that's one way to handle it... The big differences are not ones in medicine, just practice. It's a little like having the rug pulled out from under you. ED is all about disposition and what/where to do/send next. Since that's a little gone for me, I feel like I'm starting residency all over again. I keep getting frustrated that I'm sometimes allowing the fact that I don't know a lot of things (not necessarily about medicine, though sometimes that, but also management here) erode my confidence about things I do know. Common practice on how to handle persistent neck pain in a low risk MVC w/ (-) imaging? Tony once accused me of using “the Shannon Criteria” for clearing a collar. The SC for c-spine pain was basically “I don't buy it.” Here, I've been reluctant to use that criteria, but what do I say when the consult does? I guess it takes the burden of responsibility off of me, but 1) not really (still my patient and I the treating doctor) and 2) it makes the consult think I'm wasting their time. And, due to erosion of confidence, make me think I'm wasting it, too. Sigh-- so that's frustrating.

But, now that breathing is improved and hemoptysis ceased, I'll be on my feet again to run the Burnie 10 km and learn guitar (oh that's right-- you heard me...). There's always a positive. To quote myself from the other night, “Hey, if a patient's going to smack you in the face with a urinal, just be glad it was pre- and not post-.” Medicine is so glamorous and sexy.... Until the next time. --aws

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...