Tuesday, June 19, 2012

Good as Gold

Well I have spent the past year working in the Emergency Department at Taranaki Base Hospital here in New Zealand and I thought I would convey some of my observations and experiences through some of my favorite Kiwi expressions.

Me:  "Well I am afraid the x ray shows that you have broken your humerus (upper arm bone).  We will put you in a sling, have you follow up with orthopedics and here is a prescription for Panadol (tylenol), and Ibuprofen which should control the pain."

Kiwi patient:   "Sweet as!" 

Kiwis are generally quite appreciative of what you do for them.  While there is certainly some abuse of social well fare in this country there isn't this sense of entitlement where patients feel they should get whatever they want including narcotics when ever they want.  They understand that in many cases they are not going to get certain tests done right away or may have to wait several months to get things like colonoscopys done.  I have not once been told I was racist, didn't care about the patient because they did not have health insurance, or was going to be sued for not ordering a CT scan, or an MRI after explaining why they aren't necessary at the moment.  Most shocking, I have discovered that not one Kiwi has an allergy to tylenol, ibuprofen, aspirin, tramadol, toradol, acupuncture, the north wind or any other non opiod pain medication as so many Americans do.  I have written exactly 0 scripts for vicodin or percocet since I have been here and not once has someone required IV dilaudid for pain control.  A bit of morphine or fentanyl usually works just fine.  No one has requested IV benadryl or phenergan which seem to enhance the euphoria associated with IV narcotics either.  I have sent less than 10 people home with a script for oral morphine and only for well documented reasons.  There are without a doubt people here who abuse drugs, and perhaps they are just not quite as savy as your typical American drug seeker, but the ED has yet to become the source for peoples recreational substances.  In the States we are on occasion dope dealers.  Patients come in with a myriad of pain complaints, complicated lists of allergies and have been conditioned to expect a bottle of vicodin or percocet as a parting gift for the ED visit.  The abuse of prescription drugs in America is astonishingly prevalent and a very real, often under appreciated problem.   There are multiple contributing factors but the medical community has to shoulder most of the blame.  Part of it is trying to move as many patients as possible through overburdened EDs with minimal amount of drama.  A forsaken drug seeker can get very belligerent, be physically threatening and even worse can complain to hospital administration.  Too many complaints, even from dirt balls can threaten a physicians employment.  "The patient will continue presenting until they get what they want any way, so what difference does it make if I give them 5 or 10 vicodin" is how we justify it.

Whatever you do for patients here, even if it is nothing you often get a "sweet as".  It makes me smile and feel appreciated for a bit.

Me: "Well sir it looks as if you have suffered a major stroke and may not be able to use your right arm and leg again.

Kiwi patient:  "Aw doc, she'll be right!"

There is very little wallowing in self pity among New Zealanders.   They seem to me to be a fairly optimistic people and when bad things happen they are confident they will overcome the consequences.  

Me:  "ma'm, I can see that you are breathing 40 times a minute, have an oxygen saturation of 82% and your heart is beating 130 times a minute, but tell me how are you feeling?"

Kiwi emphysema patient through forced smile:  "Good as gold!"

This kind of goes in the same category as above but patients here would generally be happier if we sent them home and I think they often feel as if their illness is a burden to others.  I have to reassure multiple patients every day that they or their family member did the right thing by calling the ambulance and that in no way are they an inconvenience to me and the rest of the staff.

Me: "Well you can tell by this repeat x ray that we were able to put your son's arm back in the correct position."
Grateful father:  "Good on ya mate!"

Usually directed at the son for sustaining his first fracture as much as at us for straightening it.
Kiwis as well as Australians use this term a lot.  It shows to me that people are generally impressed with and acknowledge others success in life.  There is very little jealousy and very little self promotion in Kiwi society.  One's worth in life is not tied to what you have or how you look, it is what you do to contribute and how much effort you put forth that matters.  People here don't care at all about what kind of car one drives or what clothes they wear.  There is no pressure come summer to get your body in swimsuit condition and very little, if any cosmetic surgery here.  Getting a "good on ya mate" makes me feel as if I have done something worthwhile.

Other favorites:

After breathing treatments the asthmatic reports that he "is feeling heaps better.  Our kids use this term frequently as in "there was heaps of candy at the party" or "I scored heaps of goals today in soccer".

Overheard at one of Owen's rugby games from a father of one of his teammates describing one of the larger kids on the opposing side.  "he is a nuggety little chap!"

As a disclaimer I will point out that I am not trying to be derogatory towards Americans, I am just trying to convey some nuances of life here that I hope to better myself with.  All Americans are not unappreciative, fat, demanding, drug seeking dirt bags and some Kiwis are exactly that but I find in general that people are a bit more sensible here.

I have found that the practice of Emergency Medicine in NZ, for me personally, includes all the great things about being a doctor any where without all the extraneous crapoola which can make practicing in America less satisfying.  The business side of medicine in the US means as a physician, you are constantly being hounded by billing personnel to have complete charts so that they can bill patients and insurers at the optimal coding level.  What this means is that you have to document that you listened to the heart of a patient with a sprained ankle,  that they are not having headaches, and they have no significant family medical history so it can be billed at a higher level.  Seems almost criminal to me but it is really just a complicated game.  Here my charting is fine as followed.  

Diagnosis: Ankle sprain
presentation: Twisted ankle
Hospital Course: x-ray shows no fracture

Not too time consuming.

Also EMTALA legislation in America has no jurisdiction here.  EMTALA in a nutshell requires anyone who presents to a hospital ED is entitled to a screening exam by a health care practitioner.   While this makes sense in a responsible community, in effect it means that patients are entitled to call an ambulance for a tooth ache, get transferred to an ED and be seen by a doctor.  Here the ambulance can refuse such transfers and the nurse at triage can in effect tell a patient that the doctor is unlikely to do anything for their tooth pain so they might as well not wait for 3 hours.  In the US such activity would open up the hospital to $50,000 in fines for failure to meet the EMTALA mandate.  

All that and the fact that you can't be sued in this country make for an enjoyable practice environment.  

Lots of snow on Taranaki.
A good friend of ours was just recently carried 1700 meters down Taranaki in an avalanche.  He was completely buried save for 1 hand.  His mate who fortunately was not buried and miraculously ended up a mere 3 meters from him was able to dig him out.  He amazingly only ended up with a dislocated ankle and several bruises.  

A big "good on ya mate" to Jenny and her mates for competing in the Naki Mud Run in Urenui a couple of weeks ago.  Five km through mud and rivers, under cargo nets and up a mud slide using a rope.  A funny event with all kinds of costumes and crazy people.  I would have done it too but someone had to watch the kids and take pictures, right. 

How are you still so clean?
Not any more! 

 "Watch out for the crabs and big eels!!" 

"You can smile all you want, I'm still not hugging you"

Candy on the right is a psychiatrist from the UK.  Goes to prove that all psychiatrists are lunatics as well. 

Friday, June 1, 2012

Happy 1st Day of Winter

    When we moved into this rental home we signed a year lease. And thank god we did because 6 months after we moved in, the owner decided he wanted to sell the house. So we got to deal with open homes, photographers coming in and taking pictures, and just the hassle of always keeping the house clean. Open homes in NZ are quite typical of the kiwi lifestyle. They last for either half an hour, or an hour. In and out, which makes it easier for the the person showing the home, as well as the agent. Our rental home sold quite quickly, but because of our year lease we could not be kicked out. Our lease ends the beginning of July so I began our search for our new home 4 weeks ago. Now let me just say that NZ is amazing. Most of the country is covered by lush green rolling hills, deserted black sand beaches, and beautiful wildlife. The cities offer an awesome array of culture, and entertainment. BUT, the rental homes in this country  leave much to be desired. Many of the rental homes reflect the relaxed, laid-back society that kiwi's are known for. Most of them are very outdated and need much TLC. For example the one I looked at yesterday had a very, very outdated kitchen. Picture something from the Brady Bunch era, and you can imagine this kitchen. Bright yellow walls, dull yellow Formica counter tops, a stove from the 70's  and no dishwasher. The house was however, very tidy and warm. Another house had the worst looking furniture I have ever seen, and hardly any of the windows closed properly. And the third house would of basically been glorified camping. Yes, we Americans have the reputation to expect the biggest and the best. So I have learned to lower my standards and expectations and I find that I am much happier. The homes here are small, and  they waste no space. There are not these silly living rooms, and dining rooms that we Americans feel the need to have, but never use. There is typically a kitchen with an eating area, a great room and then however many bedrooms. And the codes here allow people to build whatever they choose. So many of the homes reflect the personalities of those that built it. No two homes are the same so the community breathes life and character and personality just as a result of the variety of homes.
    I know I have mentioned this before but I have to mention it again only because it was 3 degrees C (36 degrees F) this morning, heat in NZ is optional, and many feel they do not need it!! The locals have been living with the dull wet cold for generations. So they do not whine about it as much as us folks from the Northern hemisphere. Insulation and central heat have not hit it big here like back in the states.  My hairdresser, who was born and raised here helped me to understand this philosophy. Heat is almost considered a luxury, the low temperatures here never reach a point where it becomes dangerous and lives could be lost. So basically (according to the locals) heat is not a need because it is not a life or death situation. Most homes, even new homes forgo central heat and opt for a wood burning stove . The only new home that I have been in that has central heat belongs to our friends from England, and their builder tried to talk them out of central heat but they stood their ground. They have the warmest house in the village, and we love going to visit!! The school has no heat, but each classroom has a wood burning stove. So those of us that did not ask what kind of heat the rental home had before renting are learning a hard, cold lesson. As much as we love this view, and boy do we love the view, I am willing to trade it for some warmth. We are moving one street back, to a cute little rental home that has a heat pump, which will make the kids and I happy and it also has an outdoor shower, which puts a big smile on my husbands face.

Owen and Skyler eating breakfast this morning. Our house warms up quite nicely once the sun hits it, but it usually takes 4-5 hours. Most women will run their errands in the morning just to get out of the house and come back once it has warmed up. 

Owen and his best buddy after their Rugby game.

Owen- player of the day in Rugby. This picture makes me smile with his missing front tooth and scruffy hair. I bet I could find a picture of Brad back in the Aspen days in his rugby uniform with scruffy hair, and a missing front tooth. Like father, like son......lord help me :)  

Skyler plays on an all boys football team. The girls here tend to play netball. And she is not afraid to mix it up, every time she goes out she gives it her all. I love to watch her out run the boys, and smile while doing it. She scored a goal and had two assist last game, and received player of the day. 


This is Netball. A strange kiwi game that the girls play. Of course it is only strange to us because we don't know the game, but kiwi's are passionate about the game and love it. I will not try and attempt to explain the game as we have only watched 3, and still don't know what's going on. All I know is Lindsey wanted to try and learn the game so she could play with her friends. Most of the girls her age play. And I couldn't be prouder of her a result. We go and cheer her and her friends on every Saturday.
This is Skyler ogling over her surfer idol Paige Hareb. The competitors were great with the younger kids. They patiently signed autographs for them as they waited  at the waters edge. 

My sweet friends who helped me celebrate my 40th. 

And yes today was the first day of winter here in NZ. Not sure why it is on the first and not the 21st. Brad and I both went out for a short surf. The air temp was 16 C, as well as the water temp. We are looking forward skiing this winter, went to a great ski swap last night and got the kids outfitted for the season. Cheers- happy summer to our friends and family back home.