Royale with Cheese...

It's just the little differences, really. McDonald's is referred to as “Macca's,” Burger King as Hungry Jack's. The big things missing from my diet? Cherry coke zero, Diet Dr. Pepper and good sushi. No great loss, I hear some of you say, but do not underestimate these things. However, one awesome thing about the sushi/Japanese restaurants--

Yup, little plastic fish-shaped soy sauce capsules. They are awesome. And re-sealable.

In terms of the DEM (dept of Emergency Medicine, vs. ER or ED), there are also quite a few useful terms I've added to my vocabulary. My personal favorite is “acopia” (pronounced “a-cope-ia”), used to designate someone or someone's family member unable to deal with their issues (sometimes medical, often not) at home. It was apparently at one time an honest to God diagnosis that they would enter into the computer before a memo put an end to it-- formally at least. It's equivalent back home is my favorite (or, favourite) FTC for “failure to cope,” applied to patients in the same situation beyond the age-range of the more traditionally accepted “failure to thrive” diagnosis. Close seconds are the expressions “fronto-palmal” and “fronto-dorsal” to describe Pt “affective types”:

And the ever-popular “haema-chuk,” or what is spilled onto the floor when an upper GI bleed makes itself apparent. As an aside, to “root” for a team is an expression that has a very different meaning here and should probably not be used in polite company (though I'm curious to see what it would look like in practice...). To say you're a fan of a certain team in, Australian rules football, for example, you would say that you were a “supporter” of that team. “Root” is the unpleasant and impolite equivalent to “shag.” Similarly, “how are you doing?” is here “How are you going?” (how is “it” going does not exist), but I just can't get it in me to say, “I'm going well.” Saying so makes me feel like I'm making good time on some sort of river voyage. Not sure why.

Oh and a few other things. This sign is up in the utility room in the DEM. I tried to get it in focus, but it didn't come out right. It is a conversion chart for converting between kilogram and, wait for it, stone. That's right-- stone. As in, “He probably weighed about 13 to 14 stone.” I just have images in my head of a code in which someone is calling out drug dosages in “mgs/stone.”

For those of you who are fans of The Daily Show, you may recall their “Pantry of Shame,” which includes microwavable blueberry pancake-wrapped sausages on a stick and something called “Baconaise,” which is mayonnaise w/ bits of artificially flavored bacon already mixed in. Well, I saw this ad for Beconase, trade name of an inhaled nasal steroid, and couldn't help the mental

connection (much like the Ceylon industries bakery that produced the chocolate cookies mentioned in a previous Liberia post...).

I showed a co-worker here a section of my blog from back in Liberia that had my photo on it, and came in to sign out the next day with this as the computer wallpaper:
Apparently there's a website where you can upload your pictures and do things like this to them. With friends like these, who needs friends, right?

For those interested, I saw the group Tripod the other day on television. Like it sounds, three guys who do music and comedy. I noticed them while in Melbourne when I came upon an ad for their performance of “Dungeons and Dragons: the Opera.” I couldn't go because of my work schedule, but was really close to shelling out $300 for last minute plane fares... Anyway, they may be playing this upcoming Friday and I hope to swap shifts around to head out there. Some of the lyrics from the tv performance I saw follow. Imagine sort of a jazz quintet doing a little bossa nova number, the lyrics to which describe the lead singer's anxiety that as a bookish geeky technophile he likely does not have the skill set to compete under the new conditions created by the collapse of modern society...

“...when the polar icecaps melt and the oceans rise / just like in Waterworld, well / I'm pretty sure I don't have the upper body strength / for all that much rowing.”
“...And even if the post-apocalyptic dystopian wasteland of the future / isn't exactly like Mad Max, /
there'll probably be a healthy amount / of fending off marauders, / and I'm not very good / at
fending off marauders.”

Speaking of marauders, I awoke one morning to find this bad boy trying to die on my oven range:
He is a fine specimen of what I believe to be a “huntsman” spider, one of the rare varieties of Australian flora/fauna that are not imminently deadly to humans.

Interestingly, 10 of the 15 most dangerous snakes in the world live in Australia. Clearly, God does not want us here... :)

For the medicos out there, this is an interesting piece on the over-importance placed on medical care and documentation done for “medico-legal” reasons. I agree with his point, but the problem is as long as there's someone out there who's willing to say this or that to make a buck (which is always), it's going to be a long road to hoe.

http://journals.lww.com/em-news/Fulltext/2009/11001/The_First_Great_Lie.3.aspx

And this snippet is from the article referenced below which itself is extremely moving. But I enjoyed the emphasis this little bit puts on how our job changes our perspectives on things. Most people's jobs don't involve people dying every day, or pregnancy losses or broken relationships (“No, Miss. Regardless of what he told you, trichomonas is not something you 'just get' from having sex. Well, people who have sex with him could 'just get' it I suppose...”). I don't know-- for me personally it's led me to be a bit of a nervous Nellie when it comes to crossing cross-walks or having first aid kits and fire extinguishers in the car or not drinking on nights I'll be driving. But I also hope it's made me appreciate those moments I have with the people in my life, be more straight forward and up front about some things. Certainly this little bit is a reminder to be understanding of the people who've not had the same experiences you've had. The author is finishing describing the passengers/family involved in a collision in which one of the parents has died, and the other was driving intoxicated.

“The son has abdominal pain, which ultimately proves to be from a small bowel perforation. One laparotomy later and he's fine. (The most traumatic event of his life, possibly ever, and it warrants only 2 sentences. The ED has shifted my perspective so far that my own kids won't come to me for their minor [“trivial” to me] injuries. “Dad's only interested if there's an exit wound,” they say. This can't be good for me, my family, my patients.”

JR Suchard. Unhappy Birthday. Annals of Emergency Medicine 54(4). October 2009, Page 627

Finish off with some pictures of the Gorge, where the kayak championships were held recently, and a view of the North Esk River as it comes in to the Central Business District of Launceston.

Nice to have a little appendicitis to finish out the day

The past few days have been a little rough for a few reasons. I have to admit I'm not a huge fan of being the doctor to people I know or co-workers. It almost never goes well because you know the person, and even when it does it makes the follow-up awkward or difficult. One of the things about DEM is that it is not kind to those who re-think and wonder if they've made mistakes. Because, let's be honest, they probably did. I like the passive voice that makes its way into medical documentation. It seems like an attempt to diffuse responsibility in poor outcomes (ie “the bowel was entered inadvertently during the procedure”) in the process destroys physicians' writing abilities. Eschew the passive, say Strunk and White! So, it is kind of nice when you have a clear-cut case that you manage well-- like an appendicitis-- probably even more so than a tough case that you finally figure out after a lot of work. Poetry in action...


"But then there are the other times, when everything goes perfectly. You don't think. You don't concentrate. Every move unfolds effortlessly. You take the needle. You stick the chest. You feel the needle travel -a distinct glide through the fat, a slight catch in the dense muscle, then the subtle pop through the vein wall - and you're in. At such moments, it is more than easy: it is beautiful." –Atul Gawande from Complications


Recently went down to the local fair (“show” here). I keep telling people Tassie is a little like WV, where I'm from, and the show more or less proved it. It was a pretty typical fair situation, with little portable rides and toss-and-win games. But what was a little extra awesome was the agricultural flavor to it. There was a dog show that breeders came from across a few different states in Tassie. Favorites included the huskies and the Tasmanian “labra-doodles” (hypo-allergenic & non-shedding, apparently; http://www.labradoodle.com.au/ for those interested). Also ideal were the “suspend your child from bungee cords over trampolines,” the wood chopping competitions, the chainsaw sculptures, and the horse jumping (English saddle). Some of the pictures are attached.



Also, with all the rain down here, it had to happen sooner or later....















In other news, recently found out that an Attending and friend from my residency passed away. In the words of another good friend via email, “in case you haven't heard, today the ground shook.” This doc was one of the first EMTs that graduated through the NY training system, then went on to be one of the pillars of the system where I trained. No graduate from our program was untouched by his personality, or failed to tighten up their sign-outs when he was the one coming one-- and that included the grads who had become Attendings! One day I was wearing striped socks and working alongside him. Another Attending approached and asked “Did you see the guy with the shoulder?” His response? “Ask Dr. Seuss over there.” I remember in particular an episode when I was running Fast Track cases by him. A schizophrenic patient was there for unrelated complaints, but he seemed a little disorganized and distracted, though not actively psychotic. Still with vestiges of my undergraduate empathetic self intact, the conversation went something like this: “This guy seems all right, but I don't know-- there's some things that are a little off, he's got some flight of ideas and loosening of associations...” “Christ, the guy's not suicidal or seeing monkeys or anything, send him out!” Thus was born the eponymous “Sensori-neural Simian Criterion for Patient Reliability,” which I've used ever since-- anyone seeing monkeys should probably not be discharged.

So, in honor of Dr. Gary Lombardi, I'll post a few of the thoughts I've had when thinking about the best of my profession. I'm sure Gary would make fun of me for it...

First and foremost, EPs have to be physicians. But their most important contribution or skill, unlike surgeons (surgery) or ophthalmologists (eye exam/Rx) for example, is communication. EPs are resuscitation specialists, certainly, but surgical resusc is also in the purview of surgeons, medical resusc in the realm of internists or intensivists. So, while the spectrum of the initial management of critically ill patients is certainly our emphasis, it is our personal skill at communicating during and about the care of the critically ill, or potentially ill, or not-so-ill-but-think-they-are that sets us apart as “good” doctors or not. As team leaders during a resusc, patient flow managers in a crowded department, providers of potentially critical patient assessments to consultants over the phone, re-assurers to patients being d/c'd, it is our ability to manage information and risk, in situations in which both can be incomplete or unknown that others count on. We are the improvisational obstetricians and the midnight therapists. We are the weekend dermatologists and the after-hours sonographers. We know which pills and why and will make sure you get them. We will get the iv, the pain medication, the tube, the turkey sandwich. We are emergency physicians, and you will do our best to get you our best.


-------

As an addendum, the following anecdote was emailed to a list of graduates of my program by one of the same. It's spot on. --aws

Gary Lombardi was an imposing individual, a bit hot-headed at times, and fiercely protective of his staff. One night, about 2:00AM or 3:00AM in the middle of a very busy shift, a gentleman was acting in a somewhat menacing and combative manner toward the staff. When Dr. Lombardi heard about it the veins on his temples throbbed and he started pacing about urgently. Finally he went over to the cube, threw the curtain open, glared at the gentleman lying there, and shouted, "Do you have a problem? Maybe you want to share that problem with me! What do you say? You want to share that problem with me?" The patient was stunned into silence.

Several minutes later one of the nursing staff tugged at his shirt. "That was the wrong one. It's the guy next to him, the one to the right of him." More pacing. Veins nearly popping now. He went over to the neighboring cube, threw its curtain open, glared at this new gentleman, and shouted, "Do you have a problem? Maybe you want to share that problem with me! What do you say? You want to share that problem with me?" He too was stunned into silence.

Then he leaned back a bit, glanced into the first cube, opened up the curtain about half way, stared at the first gentleman, the one whom he had mistakenly addressed that first time, and said, "And I'm keeping an eye on you too, buddy."

Oh, how I miss the Bronx! And Gary Lombardi. How I miss him!

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