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!)
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