Shorn Sheep Look Ridiculous

It's true-- but I wonder if they're ok with it because they're not as hot as their un-sheared flockmates? I didn't get pictures, unfortunately. The sheep which inspired the above observation were seen from the car, driving on a trip post-hike, so we were in a hurry and didn't want to stop for pictures.






The sheep field was also located next to a poppy field, which are pretty common here (I'm told Tasmania produces about 90% of the medical use opium/morphine for the Eastern Hemisphere). So not too excited to stop the care and approach the fences (the pictures give an inkling as to why...).




Besides, it'd be a little dicey to go out of your way to spend extra time w/ sheep out in the field anyway. As I said to my friend Dale, “Cloning? I don't know-- I'm kind of leary of any scientific advancement that results from the Scotts doing strange things to sheep.”

Can you imagine if the fences broke down? A bunch of naked sheep, wandering around the countryside, high? Wobbly, naked sheep. We refer to the ability of high-addicts back home to just sort of stand there, swaying slowly side to side, eyes closed but never falling down as the “Heroin Tai-Chi." This could be a potentially difficult to deal with but at the same time hysterical agricultural disaster if these particular fences failed..

A few posts back, I mentioned the group Tripod and a performance of theirs on the TV program “The Sideshow.” Well, I didn't get my shift switched to see them in Lonnie, but I was able to find the song I was talking about online. Sorry for the earlier mis-quotes-- these guys are great. All scrawny, pale technophiles take note! It reminds me of the Onion online video commentary “Are video games doing enough to prepare our children for the coming apocalypse?” Also, watch for the appropriate use of the term “rooted.” “Bush-tucker” is a term for wild game. Sorry for the video/audio dysynchrony.

http://www.youtube.com/watch?v=xetsxpKjmQo&feature=PlayList&p=7F014126BB46D8FA&playnext=1&playnext_from=PL&index=14
For those interested, here is there homage to adult-aged males who still play Dungeons and Dragons on the weekends...

http://www.youtube.com/watch?v=0IgVPnhmVNE&feature=related

Similarly, Tim Minchin is another Aussie musical act that I've enjoyed since being down here...


http://www.youtube.com/watch?v=78XrI_2bPVA&feature=PlayList&p=E2C04E96920A17A5&index=3&playnext=3&playnext_from=PL



And I thought I'd add the following text from an email I received from a patient down here. It contrasts sharply w/ the experience a friend of mine (an OB) related of a patient opening up the initial conversation with the threat of a lawsuit. Yup, it's a different world...

"Dear [AWS], This is just the briefest note to express our appreciation of your advice and help when [E] presented at your emergency department with a Lt. basal pneumonia on 26-12 09. I am pleased to say she is responding well and almost apyrexial now. I hope to meet you sometime while you are here and will be in touch again. Yours sincerely, many thanks and best wishes, [...]"



Anyway, about to head in for another weekend of "babysit the drunk head traumas and hope no one herniates until the morning." Not to stereotype, but people love beating the hell out of each other out here. I mean, for a relatively moderately sized town, there are quite a few "bashings" a night (I heard "bashing" referred to as the cause of death of an off-duty cop on the news the other night. I guess in the States we'd say "beating death"?). So no guns, one stabbing, but plenty of blunt trauma on the weekends, which is a little unsettling. Makes me wonder if I've got post-traummatic stress disorder from my mugging... :)

A good friend of mine said, you know you're getting into a little bit of a self-pity mode about your relationships when pop songs start speaking directly to you (you know what? He was just pushing my love over the borderline..."). I think this relates to High Fidelity's point of "Did I listen to pop music because I was miserable? Or was I miserable because I listened to pop music?"

While not miserable or self-pitying, I thought I'd throw out these lyrics to a few of my favorite songs I was listening to again (gotta love the "shuffle") for good measure. 10-points for identifying the first, 20 for the second. Cheers, --aws

"Some say life / will beat you down / break your heart / steal your crown /
So I started out / for God knows where /
I guess I'll know / when I get there..."

we break and train our children just like animals
we fill 'em up with parasites of poison dreams and fear
We hand 'em false gods on a golden platter
then we remind them to wash behind their ears

We gave up our own dreams so the kid could go to college
then they grow up and resent us; accuse us of impossible psychological crimes
the normal relationship in Hell is about getting even
but you won't find that in your Sunday New York Times

Anger Sadness Hatred Envy--
these are just Fear wearing the same old cheap masks
You're doomed if you don't learn forgiveness, Sister
we're all driving around lost, we don't know who to ask

We're all stopping at abandoned gas stations to ask directions
there's no more road maps to tell us who the hell we are
raised on TV commercials, organized religion
following corrupt wisemen who've been navigating by
the wrong star...

We've reached the end of the road and find out no one else can make us happy
we've waged all the wars of drama and control
we've sacrificed it all for wives husbands money children false religion-- that old line about gaining the world but losing your soul.

Hiking: Western Tiers Region- Quamby Bluff and Meander Falls to Split Rock Trails

So, was able to get out and around the island some these past weeks. It is actually very nice country, with an interesting range. Getting transportation arranged has been a bit, but now at the point of getting to see some of the island, which is great. My friend Young has been up for coming out to some of these spots, which has been good. Of course, the whole “hiking” (here, “bushwalking”) concept has taken some getting used to for her (“Yes, there will be insects and worms. Yes, we have to carry our food and filter our water. Yes, there will be mud” [ala Daniel Day Lewis...]).

Anyway, we first tried out Quamby Bluff, which was just a bit of a day hike a few minutes south of... the hamlet?... of Deloraine. Quamby was fun, but certainly after years of New York living my wood-walking legs needed to get used to things again. And yes, I really am that pale..

Later on, headed out to Meander Falls. The first bit was fun, and though the falls themselves weren't the most impressive things in the world, the terrain felt a bit more varied than that of Quamby. Because of a late start, once at the falls we had the option of returning via the same route or taking the Split Rock trail back to Meander Road. It was reported to be a tougher track, but faster. Yeah, not so much w/ the faster part. I think the only time I was ever really worried that I would die out in the woods was during a trip to Puerto Rico w/ my girlfriend at the time when we went off-trail for a bit, got lost, and a few hours day hike ended up as an almost overnight. Luckily captain Boy Scout had brought along some food and flashlights. Oh, and another important safety tip: if you're going to rural Puerto Rico, it's important to tell your travel companion that you have an anaphylactic allergy to banana before you go. Also, it might not be a bad idea to bring along an epinephrine injector. Just a thought.

Anyway, the least amusing part of the Split Rock trail was when there was an impromptu conference on the dolerite boulder scramble (marked by questionably maintained carins only for its length) that began with “This is terrifying. I don't want to do this anymore,” was punctuated with glucose repletion, and ended with “I know this is tough going, and I'm sorry and would like to let you rest more, but we really need to get off these rocks before the sun goes down.”

The most amusing part was how many times after that I said “Not far now..” (about 15 min intervals). I felt a bit like Papa Smurf ... http://www.youtube.com/watch?v=Vi0tje6xfWs

Still, some good pictures :)

And, 35 points if you get the reference made in this video (I couldn't even find a link to the scene in You Tube!). Yes, I recognize I said "underwater" river as opposed to "underground" river.

Cheers,

Uncle Traveling aws

“I cannot be held responsible for what my giggling little hind-brain may kick up”

I found myself in a large performance space, with tiered risers and chairs and music stands arranged for the orchestra that was present. The amphitheater was filled with teen and pre-teen wunderkinds all playing violin. Along with myself, also holding a violin and bow, but not able to keep up with what was most likely Mozart's Eine Kleine Nachtmusik, K525, Allegro. So I just sat there looking at them. This is likely related to my college-age attempt to learn to fiddle, my current attempts to teach myself guitar, and the 15 year-old guitar playing psychiatric patient I'd seen the day before. After the session, I left the building and found myself walking up the slope from the Hill Theater at Kenyon College, still toying with the violin that I was carrying. I was asked if I played often by one of the early Harry Potter-esque younglings that was leaving with me. Nope, just learning.

I walked up spiral stairs that I recognized from the old Philip Mather Hall, entering a room reminiscent of one of the small-group seminar rooms of Kenyon College, perhaps Ascension?, complete with wood panels, large tables with high-backed chairs, and narrow neo-collegiate-Gothic-architecture leaded windows. You know, the kind that grace the pages of the Kenyon brochures (“Our student to teacher to cow to corn ratio is 3 to 1 to 2 to 17,000!”).

Myself, Junior Year, with Tim Shutt as Santa (Kenyon, 1997)

As I circled the table (“rectangled” the table?) to grab my seat, Mr. Campbell, my 9th grade Drama and English teacher at Jackson Junior High, looked up quizzically and asked, “Hunter transfer?” This was interesting because my only associations with Hunter College are a reference f om Terry Gilliam's “The Fisher King,” as a subway stop on the Upper East Side 6 train, and where my girlfriend completed a masters of Social Work-- the latter two being several years after Kenyon and at least a decade after junior high.
No, I was just attending as a “conditional” student-- meaning I signed up but could not be assured of a place in the class. I knew it would be good to take this apparently philosophy course for my personal education even though it wasn't my field and would be new for me. I might have to end up auditing, or taking it for no credit. Especially, Mr. Campbell pointed out to me, as I hadn't taken the required seminar the semester prior. He slid over to me a brochure of the same, which had former Kenyon President Rob Oden's picture on the cover.

The class continued with the student to my left, who turned out to be Wes Overby, a kid I knew from elementary school, but who looked like he did in high school (long hair, earring, I think a Metallica t-shirt) reading from a small booklet of what sounded like Austrian German philosophy. In Austrian German. All I know is that he seemed to be reading from the middle of the page up, to “heighten the emotional impact” of the text, he said, when Mr. Campbell pointed this out to him. And that at one point he said the word “auerwuff,” which I don't think is a real word, but which I transcribed in my book as “Airwolf?!?”

It was then my turn to read. I struggled over a few of the words, affecting a thick movie accent (half of speaking a foreign language is a fake accent anyway), before Wes and Mr. Campbell started helping me by pronouncing the words along with me. I eventually asked if the required seminar was one in which you were taught Austrio-German. Across the table, a stern looking blond body-builder type who had no business being a college student-- in fact I'm pretty sure he was the Austrian hit-man from “Tomorrow Never Dies,” the Pierce Brosnan James Bond movie-- sneered and took over reading.

So, interpretations? I'm open to them-- fear of trying new things? Too many movies seen? Too many shifts in a row? Let me know what you think. Today, I have to do some left over dishes, go grocery shopping, practice some guitar, do some of the CORD tests online for Board Prep, and head to the hospital to do some left over charts. Then hopefully head to the West Coast for some beach time. Obedient to some strange spell,

--aws

Merry Christmas!!

Just remember, I get to open my presents about 16 hours earlier than my brothers...

:)

Merry Christmas!

Apologies for the blog delay-- been trying to work a few things out here in prep for heading back home. Apparently, I'm in need of a "career." Who knew?

In any event, the days have brightened up and here the solstice in December is the longest day of the year. Back home, my brother is dealing w/ mountains of snow in DC. In HI, my other brother is I'm sure doing just fine (sigh!).

The TED website really is fantastic and I wanted to share the following link:

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

We'd heard all about General Buck-Naked while in Liberia, though I never met him (obviously).

These are a few pictures from around the 'Merican Thanksgiving table:

And here are a few of the DEM Christmas Party:

Time has gotten away from me and I need to head in for another shift. Things are a little tough @ the hospital now w/ staffing issues, so that's an excitement. I'll likely be off camping for the actual Holidays (nothing says "Christmas" like scraping a leech off your skin w/ the back of your knife...), but hope everyone enjoys them at home. There's a postal strike on in Aussie now, so I'll pretend that's why I haven't gotten your presents in the mail!!! :(

cheers, --aws

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!