Thursday, November 6, 2014

Ramblings of an Itinerant ED Doc

Cairns Base Hospital in far north tropical Queensland is poorly located if a cyclone were to ever make landfall.  The ED sits at about 1 meter above sea level and about 50 meters from the high tide line of the Coral Sea.  Apparently the Great Barrier Reef, about 30 kms off shore, would absorb most of the swell of any tropical storm but it would not take too much of a sea level rise to inundate the department.   It is however in a beautiful spot with stunning sea views, right on the Esplanade and a short walk to the town center.   I have recently returned to Taranaki after working a 3 month contract with the emergency department here.  The motivation behind this was mainly that I needed to work in a larger more academic, "accredited" center for recognition within the Australasian College of Emergency Medicine as a fellow.  I could have done this at a larger center closer to home here in NZ but I was quite keen to explore a bit more of Oz and to work in another health care system in another part of the world.  There was a  3 month position open as several of the full time physicians were on a long service leave participating in a road rally that took them from London, England to Ulan Bator, Mongolia, and I was happy and fortunate to be able to fill a spot.  Overall the experience certainly exceeded my expectations in every way and it was stimulating and challenging to be in a larger center again.  There is an interesting patient mix including Aboriginals and Torres Strait Islanders as well as numerous European tourists and backpackers (lots of STDs so use caution backpackers).  There are also tropical diseases and bites from venomous critters that we do not encounter here in NZ.  We even had a nurse, recently returned from caring for ebola patients in West Africa, come in with fever and flu like symptoms who spent 3 days in our ED isolation room while awaiting her negative tests to come back.

Pseudonaja textilis
Eastern Brown Snake

Australia has the 10 most poisonous species of snake on the planet so when I first started work I found myself walking home at night almost on tiptoes, avoiding any areas with long grass and constantly scanning the ground for anything slithering.  A few weeks in though I was informed that there really aren't any snakes in the city so I began to walk home at night with a bit more confidence.  Then someone showed me a picture on their phone of a snake under a bench right in front of the hospital so then I wasn't really sure what to think.  The three months I worked here I saw about 10 people that had been bitten by a snake however only one of them was truly envenomated.  Although highly lethal in terms of the number of humans that could be killed per drop of venom from one of the Australian snakes it seems, from my limited experience, that  true envenomations are not that common .  The Australian snakes are Elapids and do not have the long hinged fangs that Vipers like the N American Rattlesnakes have to literally inoculate their venom.  This reduces the likelihood of the venom penetrating deep enough to cause the progressive paralysis and non-coagulating blood that it is capable of.  That being said, if you are bitten by a snake in Australia you had better get to a hospital quickly because if you have received a venomous bite, they can be rapidly fatal and the antivenom is curative.

Funnel Web Spider

I saw one woman who came in after being bitten on the ankle by a spider, which she had brought to the ED with her.  It looked a lot like this little fella who is the most poisonous spider in the world and apparently has big thick fangs that inject venom very efficiently.  Rapidly lethal, also curative with antivenom.  The spider ended up being a type of tarantula which is not venomous but it was a close enough match that we had to send a photo to a spider expert for identification.

In the area there are also the worlds most deadly jellyfish, cone shell and octopus though I never saw anyone who had encountered one of these.  They say you cannot go swimming in the sea in a month with an R in it because of the jellies so I was most likely there in the wrong season for those.  People also occasionally disappear from river banks in those parts.  I did not see anyone with a crocodile bite and I think that is simply because if a croc gets a bite into you, he does not let go.

I heard from someone that the Aboriginals call the hospital the "Chop-Chop Hospital".  This is because by the time they get up to presenting to the hospital with a horrible extremity infection they have to have the limb amputated.  The hospital draws from a huge area and patients are transported from Aboriginal communities with names like Wujal Wujal and Pormpuraaw by the RFDS (Royal Flying Doctor Service) several times a day.   They will present with open fractures and infections that could be several days old and look terrible.   The Aboriginals are an interesting group of people.  I believe that they were living quite primitively when the Europeans stumbled upon them some 230 years ago and they still seem like a separate civilization all together now.  There seems to be very little interaction between them and those of other races.  They are almost ghost like in their presence, neither acknowledging passerbys nor being acknowledged by them.  I think, because of their primitiveness, that they have been grossly mistreated over the years.  Many of their children were abducted at birth and forced into orphanages and western education in an attempt to forcibly assimilate them into western ways.  This was occurring into the 1970s and shockingly it was legal to shoot "Abos" until about twenty or thirty years ago.  It is strange coming from NZ where the native Maori while maintaining many of there traditions, seem to be wholly integrated into the larger community.

I have now worked in a wide range of places from  rural Kansas, Urban Kansas City and the Bronx, provincial New Zealand and tropical Australia and I am again reminded of the exceptionalness  of emergency medicine people.  I get to work with people who are willing to work in an often chaotic, abusive work environment day or night sacrificing weekends and holidays with their families all in an effort to be there for those in need when they need it.  I have worked shifts were it is so busy that nurses will go an entire shift without having a chance to take a meal break or even get to the bathroom.  I have also been on the occasional night with only a slow trickle of patients where I have passed time getting to know many intimate details of the lives and families of those I work with.  I work with people who, in one instance will save the life of a patient too obtunded or comatose to recognize or acknowledge their efforts and in the next instance will be verbally berated by someone unhappy they waited 4 hours to be told that their viral sore throat infection will get better on its own and they do not need any medicine.  Guess which ones usually fill out the customer satisfaction scores.  I know many nurses who have been physically assaulted and paramedics who have been shot and they continue to show up for work.  I have shared many laughs with my coworkers over the folly of humanity and we have shed tears together over the occasional tragedy.  I guess I am just trying to say that I feel truly blessed and honored to work with such fine people everywhere I go.  I find it a bit discouraging to read from so many of the medical blogs and journals out there of the growing dissatisfaction with medicine and particularly emergency medicine as a career.  They talk of burning out over increased work loads, increased demands from patients and administrators, patient satisfaction scores, the ongoing spector of a malpractice claim, and the toll that shift work takes on your physical and emotional health.  To my fellow emergentologists (term borrowed from some blog which I cannot recall at the moment) if you are feeling this burnout, I would suggest to change your present work situation.  Go work a locums gig somewhere else, in a different setting, or environment, a different country perhaps.  You will rediscover that indeed you work with amazing people often doing amazing things for people when they need it most.  I am frequently greatly inspired by the stories of my patients as well the efforts of my co-workers.  That is enough to bring me back day after day and night after night.

Cairns (pronounced "Cans", no R sound) is a pretty cool spot.  I was fortunate to be there during the dry season and it was sunny and warm every single day from July through October.  It is an interesting place with tourists and local workers from all over the world.  There are great restaurants of all ethnicities even Mexican which is difficult to find in this part of the world.  There is much natural beauty and loads of outdoor activities.

Lots of pubs and drunk kangaroos

Beautiful rainforest, rivers, waterfalls etc.
Owen and good mate Connor at AFL game Suns vs Bulldogs.  Australian Rules Football is an amazingly physical game and requires a great amount of endurance.  Massive field, non stop action.  

And of course the one and only Great Barrier Reef
Found Nemo

Saw many sharks though none bigger than I am.  Mostly harmless reef sharks

Parrot fish on am dive

Skyler, Lindsey and I did an introductory scuba course with Skyler's friend Aoife and her father Arvind. They spent about 20 minutes at a depth of 6 meters.  Saw clown fish, giant clams, giant sea cucumbers and even a sea turtle.  They loved it.

Aoife and Skyler during orientation.  They were soon of on their own exploring

Nice rabbit ears Orlagh
Going tubing 

Aoife, Connor and Owen somewhere in the rainforest

Jenny and the kids were in Cairns for the first two weeks of my run there.  We all had a fun catching up with our friends Arvind and Orlagh and their daughter Aoife and son Connor.  They used to live in Oakura as well and now are in Cairns so it was nice having locals showing us around.  They also became my surrogate family during three months. Orlagh having me over for a delicious meal every week.  A nice break from all the pizza and take out Vietnamese food I had been eating.

Many thanks to all those at Cairns Base ED for the hospitality. Australia is a great country, lots of great people, beautiful scenery and I hope to explore a bit more of it some day, but I have to say I am quite pleased to be back in Taranaki which is about the most spectacular place I have ever been.  I was away from my family for about 9 weeks in total and I missed them greatly.  NZ feels like about the safest place in the world these days.  Not too much religious, racial or political tension, no suspected Ebola patients yet and I don't have to look under a park bench before I sit down.