Doctoring Down Under

Finally, Pete has wandered away from the computer so I can sneak in and write a blog.  Just kidding!  Actually I don't really enjoy writing so I have been procrastinating.  But since you all have been anxiously perched on the edge of your seats awaiting news of my hospital adventures I will grudgingly oblige you :)

My new place of work is Wanganui Hospital, a regional health center that serves the surrounding population of about 60,000 people.  It is the only hospital in town, the next closest being in Palmerston North (an hour away) and Wellington (2 hours away).  Wanganui is small by US standards, having under 100 beds-16 of them in the ED, 35 in the medical ward and 6 in the ICU.  Yes, the ICU is hardly larger than a typical patient room in a typical new US hospital! I think the hospital was built in the mid-1800's and has not seen much updating since then, except for a new ED and the turquoise paint job that likely occurred around the time of WW2.

I love the fact that the hospital is so close to our house and I don't have to spend 45 minutes commuting. On a usual weekday the sun wakes me up about 7 am (I haven't slept in this late since college!)  If I was more motivated I would get up earlier and do something constructive but please reference our prior posts on how cold the houses are here.  After eating breakfast (once again, I never did this at home but instead ate while driving in the car) I enjoy a leisurely 5 minute walk to the hospital. I don't have to be there until 8 AM, when morning report occurs.  Usually this meeting is 75% banter and 25% business; well, make that 95% banter given the jokesters in our group (see below).  They called me "weird" for taking this photo. I guess some things never change (by that I mean my weirdness).

After we all make fun of each other (in typical Kiwi fashion) I then go about my day as a "medical consultant."  Yes, I know, it sounds rather fancy doesn't it? Since we are a smaller hospital, the general medicine doctors ARE the consultants.  So if a patient has kidney failure, I am the nephrologist. If the patient has an arrhythmia, I am the cardiologist.  If there's something strange going on, who ya' gonna call?  Medical consultant! (Sung to the "Ghostbusters" theme song please.)  You can ring up the specialists from larger hospitals, but for the most part if your patient has a problem that you don't know much about, you read up on it. Yep, no fancy dialysis or cath lab or chemotherapy for us here at Wanganui, just good old docs with their brains and handy dandy stethoscopes!  Of course, if a patient needs specialized treatment or is on a ventilator longer than a couple of days then we transfer them to the appropriate hospital.

Regarding the hospital team, it is a bit like working for the United Nations. I have met physicians and nurses from Germany, India, Ireland, South African, Ghana, China, and several other countries.  Currently there are 3 Americans working in the ED on year long stints.  Where are the Kiwis you ask? Apparently in Australia because the pay is better.  The nurses wear uniforms that echo the 1950's decor of the hospital, although I think their tops are more flattering than the usual boxy nurses scrubs. I am sure these nurse also thought I was weird for taking their photo, but they (unlike my colleagues) were too polite to say so.

Hospital rounds work much as they did in the US, although I feel like I have gone through a time machine back to you-you guessed it, the 1950's.  The usual patient room has 4 beds separated just by curtains and the bathroom/shower is all the way down the hall.  No individual TV for each patient-gasp!  When I see a patient I have to be sure to pull the curtain to provide some privacy.  And then everyone pretends that the curtain also provides a magical sound barrier so everyone else in the room can't hear me say, "Mr. Johnson, your syphilis is now cured!"  There always seem to be family members visiting and it can be quite crowded and noisy so if the elderly patient is hard of hearing you may really have to shout. This results in the whole ward knowing that this poor guy had a STD! I took this photo of an empty room so as to avoid violation of patient privacy. You wonder how anyone gets any sleep at night with 4 people snoring, coughing and moaning away...

The hospital is also antiquated in its lack of electronic medical record.  The labs and discharge summaries are computerized, but everything else is on paper, including the progress notes, medication list and vital signs.  Yes, I know that electronic medical records are inevitable everywhere on the planet and are better for patient safety in many ways, but I welcome the relief from being chained to the computer all day.  On the negative side, I have had to work on my writing again, which is so terrible that one of the hospitals I previously worked at wanted me to take a remedial handwriting class (seriously).  Luckily, my current junior doctor has excellent handwriting so I rarely have to scribble anything.:) This is the typical "observation" or vital signs chart, where the nurses document blood pressure, temp, etc.

Working here has definitely been a steep learning/relearning curve.  The last time I took care of critically ill patients was over 10 years ago as a resident since most urban US hospitals have "closed ICU's" where intensivists/pulmonologists take care of the patients. In my first weeks here I have had to adjust BIPAP settings, order pressors (medication to maintain adequate blood pressure in critically ill patients), treat diabetic ketoacidosis and manage a sundry of other complex medical problems that in the states would have deferred to the expertise of specialists.  My brain is expanding by the minute!  Thank goodness for "Up to Date" (online medicine reference that is equivalent to the physician's bible).  And all of my colleagues have been very helpful in answering my many questions and you can always reach a specialist by phone.

Add to the complexity of the patient care the fact that NZ has different medications than the US (or similar meds that go by different names or dosages), labs are resulted in different units (mmoles instead of mg/dL ) and the Kiwi accent is challenging to understand, all add up to one slightly overwhelmed person.  I spent the first couple weeks walking around in a daze (although I did try to look somewhat like I knew what I was doing:) One classic moment was when I called a cardiologist from Wellington (the big hospital about 2 hours away) about a patient's low heart rate. He recommended an IV medication but for the life of me I could not understand what he was saying (nor did I remotely recognize the name of the medication).  I asked him two times to repeat himself. Finally I broke down and asked him to spell it.  It was so embarrassing that when he asked who I was I gave him a fake name. Just kidding but I did mumble in hopes he could not understand me!

My responsibilities as a consultant also include outpatient clinic as well as taking overnight call about once a week (and 1 in 6 weekends or so).  My clinic is comprised of patients who have been referred by their general practitioner for management of more complex medical problems.  I am seeing the usual medicine patient with heart failure, diabetes, etc but I also have enjoyed the challenge of treating more unusual problems that would normally go to a sub specialist in the states.  Apparently the region is really short on neurologists so I have seen patients with multiple sclerosis, epilepsy and neurofibromatosis (with advice from the neurologist over the phone).  The pace of clinic is nice- 40 minutes for a new patient and 20 minutes for a follow-up.  Sweet as! That's Kiwi slang for "awesome!

Well, that's enough for today.  I will talk more about working for a nationalized health care system in my next blog.  Cheerio (by that I mean goodbye, not the breakfast cereal!)

Cross Country race @ Aranui School

Lindsay took first place in her school's cross country race a couple weeks ago, and though she is not enamored with cross country racing, she was honored to then be invited to take part in the all-area cross country race for 10-12 year olds at the Aranui School in Castlecliff, just west of Wanganui and out by the ocean.

The race was yesterday - it was blustery, but pretty sunny - and I went out as intrepid reporter to take some film and describe the action.

The course was a pretty rugged 1.5 Km layout - it started in a horse field adjacent to the school, went back into the school grounds and then went out into the hills/dunes that surround the school grounds.  There was even a fence jumping spot and small muddy pit to go through.  From my vantage spots (at the starting line, at a mid-point, and then near the finish line) I took video and am dropping that in here.  Here is the start.

And here is a mid-point...

Unfortunately the video I have of the finish line was too large to drop in here : (

A couple of interesting cultural things at the race.  One, the area is truly bi-racial - split fairly evenly between people of European and Maori background.  The race was somewhat bi-lingual - more predominantly English, but as you may hear from the videos, there is definitely some Maori being spoken.  And the school is located in a predominantly Maori area.  But the starter gave her instruction in English only.  Kids here are expected to understand English, but, at the same time, English speaking kids are supposed to be open to hearing some instruction and cultural information in Maori.  The attempt by the government and local schools to incorporate Maori and English together is pretty fascinating (after being here longer and having a better understanding of this I hope to write more.)

Second thing to notice is that more than half of the kids were running barefooted.  And this was not exactly perfect barefoot conditions - they were going through farmland (think manure) and then also through some areas that has gorse and prickles.  Lindsay said a bunch of the kids were getting prickles in their feet but would just pull them out and weren't crying despite some obvious pain/discomfort - one kid had one that was about an inch long.  Ah, they are tougher than the average kid apparently.  Of the first 30 or so kids who finished, probably only 4 or 5 had shoes.  Interestingly, of the final 30 or so finishers, I bet only 5 didn't have shoes (so the barefoot kids were on average much faster, at least in this race.)

For info purposes, Lindsay finished seventh out of the 120 or so kids that day, so she got a special brownie from her coach for being the first Top 10 finisher in five years for her school.  What a fun day for the girls of Carlton School...here they are...

 

For Frodo!!!

Today Kendra and Lauryn fulfilled one of our many Lord of the Rings related travels on our wish list.  They visited Tongariro National Park and the Whakapapa Ski area.  If that is not ringing a bell, and I am not sure why it would, this includes Mt Ngauruhoe, which depicted Mt Doom in the LOTR movies.  Here are some pictures that Lauryn took on the drive up.

The day was arranged by our local church youth group.  They left here at 8 AM, drove the 2 hours or so to the mountain base, used their Colorado ski passes (!) to get a free lift ticket (thank you very much, Rocky Mtn Super Pass), and then spent an hour or so hiking around at the base area - they only had an hour or so at the mountain base due to some poor planning, and so...didn't actually ski : (  The mountain was very different than what they were used to - all of the ski area is above tree line, is on an active volcano (last major eruption was 1974) and most of the time is shrouded in clouds at the top.

And here are the two goofballs, trying to be cool...and succeeding where I would fail.

After visiting the ski area, they spent the day at the thermal hot springs also in the area.

This local church has been a huge blessing to us all.  The worship services have been great - very alive and energetic.  They have active and well attended youth programs, and Kendra has made a number of friends through this group.  And we have already had tea (lunch, really) with one other family we met there.

While Kendra and Lauryn were visiting a LOTR site, Lindsay contented herself with a day of soccer for the local area ("Reps") team, playing against Palmerston North and New Plymouth's area teams (the two other sizable towns in our vicinity), I wore many layers to stay warm in the wind, and Jen had her first weekend shift of call at the hospital.

Peter, Jen, Kendra, Lauryn and Lindsay

Golfing in the Shire

For those of you who don't golf, you are excused from the rest of this post.  You are also forgiven for wondering how I can write an entire post on golf.  For those of you who do, I know you will "get" how I can make an entire post about golf.

To set the scene for this post, understand that the children made me bring our sticks all the way from Colorado, and then Jen begged me to get an annual membership at the local golf club, Wanganui Golf Club (their telling of this story might be slightly different.)   Despite being, ahh, forced to play golf, I have already played seven times.  The first time I was rained out after three holes, but I went back the next day and played the full course.  I have played the 18 three more times, and the past two weekends, Jen and I played 7 holes (a circuit that starts and ends at the clubhouse) and I also played three holes with Kendra once.

It is a very casual club, made up of towns people who are all golf nuts.  Indeed, NZ is known as a golf crazed country, with more golf courses per capita than any country in the world.  My playing partners have been a mix of farmers, doctors, accountants, mechanics, policemen and shop owners. And the attire has been downright casual (blue jeans, a wool sweater, and then a barn jacket, for instance, or maybe a pair of cargos with a polo not tucked in)

It is the most laid back course I have ever been to.  You don't really check in so much as you just mill about the putting green and pair up and play.  The course is open all day I think, but it seems like the proper thing to do is play in the day's match, and so everyone shows up at the same time, around 11 AM in winter, pairs up into foursomes and plays in one large Stableford match.  Everyone must have a handicap, and plays the same set of tees (white for gentleman, yellow for ladies.)  The scoring system used is the Stableford, where you get points for your birdies, pars and bogies, based off your handicap for each hole. The matches are fun, intense, businesslike and casual all at the same time.

I learned you have to putt every ball out over here.  Absolutely no gimmes, ever.  The first round I played I had a 10 footer for par on one hole, came up a few inches short ("hit it!") and so walked up in disgust and picked up my ball, then turned to see my playing partners all gawking at me.  "I should have putt that one out, huh?"  They all laughed kind of uneasily, and told me they would give me that one "just the once."  Later in the round, I hit my best approach of the day on a blind uphill approach, and was lucky to settle in about 6 inches from the cup.  My playing partners, some of whom were already up by the green, told me what a great shot i had, indicated that it was within a foot, and then quickly reminded me to putt it out.  Dead center.

Everyone walks.  Fast.  The pace of play is unbelievable.  Hit and walk.  Repeat.  I have seen a cart once, but I am pretty sure the guy was well over 80 years old (most of the players in the mid-week foursomes are into their sixties, but I am pretty sure I am the slowest walker in the group.)   The course is easy to walk in terms of the distance between green and the next tee, but is also long and very hilly.  I am the only person I have seen who really carries my own clubs.  Everyone else has a "trundler."  We would call these things "push carts"  only that would not do them proper justice.  These things are awesome.  No two seem to be alike.  They are kind of boxy, as wide as they are deep and tall.  Lots are mechanized.  All seem to have been personalized and have enhancements.   I have already lined up a trundler from my last playing partner, Randy, and another for Jen or the girls from the club secretary.

The course is totally different to what I was used to.  At first glance I didn't really get it, and was also not very impressed visually with the upkeep of the course, which is sub-par by US standards.  However, having now played it numerous times, I love it.

The land is very shire-like, green with rolling hills, swales and bumps, and all the grass is fescue.  The design is links but with a few trees, lots of thickets of "bush" and with lots of blind shots.  On a couple holes you putt out on a green, walk back 15 meters and then tee off directly over the previous green for the next shot.  There is a burn (creek) on one hole but otherwise there aren't any water hazards.  It actually appears fairly wide open and forgiving, but the defense of the course is the wind (always a one to two club wind in some direction) and the firmness and slopes of the fairways and greens.   There are four holes I would say that not making par would be disappointing.  The other 14 all require seriously good shots to par.  The course has three par 3s and two par fives and, doing the math, 13 par fours.

Here is a pic or three of my favorite holes.  The tenth is 380 meters, plays uphill 20 meters or so, over a hill about 150 meters from the tee box, to a fairway you cannot see, with hills and bumps everywhere, and then the fairway runs downhill, with the green probably 30 meters down from the crest of that hill.  The green is very contoured and with sand traps left and right.  The hole plays generally cross or down-wind.  Awesome golf hole.  This is a pic from behind the green looking back down the fairway.

The next pic is looking back down the 3rd hole from behind the green.  The 3rd is a 360 meter down-wind and downhill hole that has a very lumpy fairway and then a green framed by bunkers front left and right, with mounding all sides of the green.  Another cool golf hole.  If you land the ball anywhere on the green, good luck keeping it on the green, it is so firm and plays downwind, so it is tough to keep spin on the ball.  A good shot is usually run in there about ten meters short of the green and then releases to the hole.

And, last, here is a picture of Jen playing her approach to the 1st hole, an uphill par four that always seems to play into a nasty cross wind (note the flag flapping in the picture.)  But forget the golf hole...this is my favorite picture because of the player in the foreground...

Golf has been famously called "A good walk spoiled", but not that day...that was a great walk, complete with a serenading we received from the cows adjacent to the 8th fairway (we weren't sure if they were having a bovine conversation, were giving birth, or what.)  Jen took a picture of the cows because it seemed like such a cool setting, and I just went to paste that in here...and when I did, it just looked like a picture of cows.  So I deleted it again.  Thought if I put pictures of cows in with a post about golf I might lose half the audience.

I hope to post tomorrow about the girls trip to a part of Middle Earth this past weekend, please check back!

Peter

Wanganui River, Tasman Sea

As we already mentioned, our home backs up to the Wanganui River.  The River flows out of the mountains in the central part of the island, and is the longest navigable river in New Zealand.  It winds its way out of Tongariro National Park and down through Wanganui National Park, and then out to the Tasman Sea at our town of Wanganui.  The River is tidal, so that at times of the day at our home a kilometer or so from the river mouth, the River will be flowing/breaking upstream, while at other times of day, it is flowing out to sea.  At low tide a sandbar appears in the middle of it.

Our first outing after arrival was a half day's drive up the Wanganui River Rd.  The road is fairly rough, paved at times, dirt or rocks in others, and really showed off the effects of the recent heavy flooding and mudslides that this area endured.  The road accesses an area of hills with very dense vegetation, and runs along the river.  Here is a pic of the River and hillside.  The scars on the hillside are mudslide scars.

The area is lightly populated, mostly by sheep farms, an occasional very small village, but also is of great cultural and historical significance to the Maori people.  From Wikipedia...

The river is of special and spiritual importance for Māori, who also refer to it as Te awa tupua - it was the home for a large proportion of Māori villages in pre-European times. As such, it is regarded as taonga, a special treasure. In recent times, efforts have been made to safeguard the river and give it the respect it deserves.

For the same reason, the river has been one of the most fiercely contested regions of the country in claims before the Waitangi Tribunal for the return of tribal lands. In fact the Whanganui River claim is heralded as the longest-running legal case in New Zealand history^[4] with petitions and court action in the 1930s, Waitangi Tribunal hearings in the 1990s and land occupations such as the ongoing Tieke Marae occupation since 1993 and the highly publicised Moutoa Gardens occupation in 1995, refer to Moutoa Island.

On 30 August 2012, an agreement was reached that entitled the Whanganui River to a legal identity, a first in the world. According to the New Zealand Herald, the river "will be recognized as a person when it comes to the law—in the same way that a company is, which will give it rights and interests".^[5][6]

So, historical and interesting history to say the least...and on our drive we saw historical Maori marae (roughly translated as a communal meeting ground for a village) and also a few historical buildings such as 19th century flour mills.  The traditional Maori villages we saw were empty when we visited, but they still are used for tribal celebrations and other events.  They are relatively well maintained, and open to the public to visit (and they just ask for a donation on your honor.)

Later that day, we went all the way back through town and out to the Tasman Sea, at a spot only a few km outside of town called Castlecliff Beach.  This is a beautiful, rugged, black sand beach, extending as far as the eye can see in either direction, with lots of drift wood forming a protective kind of dune on the beach, and then giant sand dunes protecting the interior land.  The surf is pretty awesome, too, but the water was a little chilly...so their was no "swimming," but somehow Lauryn and Lindsay ended up soaked, freezing cold, and wishing they had towels for the ride home.  The car smelled like Tasmania for a week, too.

And here is one more of Kendra - looking through the photos i just couldn't resist this very pretty picture of her...

Best to you all,
Peter, Jen and girls

Whats cooking in Wanganui?

Before arriving in NZ, we had heard about high food prices and expected the worst, but whether due to a very favorable exchange rate at moment, or because of some conspiracy to misinform me, we have not found this to be the case at all.  It helps that we have not been eating out, but rather cooking every night.  More even than enjoying the cooking, I have really enjoyed procuring food and finding the best deals for our daily meals.  Whereas in Evergreen I pretty much frequented King Soopers Supermarket...here in Wanganui I am visiting a grocery (Pal-N-Save or Countdown,) a butcher (The Mad Butcher,) a fruit and vegetable market down by the river, a bakery, and a fresh fish market as opposed to just a supermarket.  I am even contemplating driving to a farm and getting our eggs, butter, cream and milk.  I know...I am taking this a little too far, but an older woman at the supermarket told me that the milk I was about to purchase "wasn't really milk."  (Talk about conspiracies...) At any rate, prices here have actually been lower than US prices on produce and fish, comparable on meats, and a little higher on general dry goods.  Consequently we have been having lots of fresh fruit and veggies, and fresh meats and fish.... which has been awesome.  Here's a pics of the local grocery store...

Also, whereas in the US things go on sale and save you a little, things here seem to be purchased and brought to market in bulk, so whatever is in season can be downright cheap, but on the flip side, if you are looking for something specific for a recipe, and its not on sale, then you can pay crazy prices for something. Take a look in specific at the fruit markets with the huge pallets of fresh produce.

The produce is specifically awesome here.  It seems very fresh...so fresh indeed that they don't really seem to wash it.  At all.  But there is also no doubt that this seems to have been picked yesterday.  And, the fruits and specifically veggies have much stronger flavors.  If you don't grow your own carrots (and among the readers of this post, probably only my parents do,) you may have forgotten what a real carrot tasted like.

If you are not as cheap (for a nicer way to put this, think bargain-hungry) as me, you might not appreciate how much I enjoy finding these food bargains, but either way, it just seems to make sense to just go to the markets with no specific menu in mind, and acquire the foods that look the freshest and have the best prices.  I doubt I would have planned the following menu for a day I did a week ago - lamb stew in the low cooker, sautéed brussel sprouts w bacon and onions, and then kale from the garden...but it was a great meal.  Here is Lindsay having a kiwi fruit (79 cents a Kilo = eats lots of kiwi fruits)

The Mad Butcher is just that - a giant freezing meat locker where you actually put on your jacket to go into the store, and then just past the meat bins, there is a window and a lot of carcasses hanging on the other side.  At least you know where the pork in the package came from, and that its "fresh".  Something always seems to be on sale, and is inexpensive, and everything else will be in turn more expensive.  Here are a couple pics from the butcher - "mince" is their term for ground beef.  I know that these pictures are not going to win "Blog of the Year prizes" but I am looking for diehard readers : )

We also have our own gardens with lots of lettuce, spinach, kale, beets, cabbage, silverbeet (Swiss Chard,) herbs, and then lemon and orange trees.  We were lucky that the owner of our house had all of these gardens and with lots already planted and we only had to add a few other things we wanted. So its pretty often that one part of our meal is coming from the garden, and here we are in winter... Here is a picture of Lauryn picking a lemon - we made lemonade today - I wish I had my brother's old lemon juicer...

We have made a lot of fried "crumbed" fish with potatoes (Fish-n-chips) and had baked hoki fillets.  And today I got a great two-fer.  It is Father's Day in NZ today, so I got my second Father's Day of 2015 (probably to make up for the fact that i will miss out next year) and the kids got me a 12 foot river casting rod, tackle and a fillet knife.  Since we live backing up to the tidal Wanganui River, and also are only a km from the river mouth at the ocean, I am hoping to catch our own salmon/trout type fish (kahawai) for dinner starting this week, either from the dock out back, or from this spot right at the mouth.  Sorry, my intrepid fly fishing guides of EVG...no fly fishing planned yet.

Last, we kind of knew something was up when our flight over had free wine...and indeed the wine is excellent and very affordable here, with great choices of sauvignon blanc, pinot gris, chardonnay, and pinot noir.  So, whereas the beer here has been pretty uninspiring, NZ wines are great.   Kendra is even partaking a bit - the legal age is 18, and she is even able to serve alcohol at her new job at a restaurant.  She doesn't seem to like the wine at all and makes a great shuddering noise every time she has a taste, and she is sure that beer is even worse, so we figure she isn't going to be "lost to the sauce."

Well, foodies, I hope you enjoyed that...for other updates...as mentioned, Kendra got a part-time gig as a barista at a hip place called Mint, Lauryn got back from her trip to New Plymouth for a soccer tournament with her HS team.  I hope to write and post pictures about Lauryn's trip, about our first outing, maybe some on golf and Jen still plans to write about her job and the health system here.

Pete, Jen and girls