Saturday, August 07, 2010

Dispatch 59 Small Town Medicine

10 May - 6 August 2010

As part of my job here in Oamaru, I have agreed to alternate with my fellow medical officer between the medicine service (2 doctors, me and my supervisor) and the Emergency and Surgical Service (2 doctors, me and the ER supervisor). The medicine service is work I’ve done for years and the Emergency and Surgical Service often tests my experience and knowledge base since I’m seeing Paediatrics (that’s how they spell it here), trauma and other things I haven’t done as much of in my career (I’m not doing surgery but rather take care of post-operative patients sent home from Dunedin to finish their hospital course and rehabilitate.) As mentioned before, the medical ward is the place where the rooms sometimes have 3 patients which is a bit surreal when exactly none of them is in their right mind (all with dementia or other mental health issues). But the staff are quite accommodating and sometimes just let the more pleasantly confused patients hang out at the nurses’ office rather than wander off the premises.

One of the enduring images I will have of New Zealand is an endless parade of teenage boys arriving in the Emergency Department covered in mud in their rugby uniforms with varied injuries (head injury with bite on the forehead from collision with teammate, broken finger, knee sprain, lacerations, abrasions, sprained ankles, loose teeth, broken collar bones, separated shoulders, concussions, etc.), all with grins from ear to ear. This is a tough group of people. A current television commercial shows a grown man rugby player and a 7 year old boy sitting next to each other in the ER waiting room. The little boy looks like he’s going to cry. The man looks stoic and crosses his arms. The little boy watches him, then he too crosses his arms in imitation and looks stoic. That’s the role modelling of NZ for you!

Then there are the girls with their “net ball” injuries. Net ball is a sport similar to basketball but there is no dribbling and the basket has no backboard. Scoring and team size are different too but I haven’t worked out the nuances. I’ve seen several sprained knees and fingers and, again, injuries appear to be a mark of courage rather than anything to break down over.

This week, I took care of a 15 year old girl with possible appendicitis. She is a “boarder” at the local high school (family lives an hour and a half away and so she lives at the school). She was all alone in the hospital being observed for a day and a half. I commented to one of the nurses that I couldn’t believe her parents hadn’t come to be with her under the circumstances and the nurse said, “She a boarder—that’s the idea, she’s grown up enough to be away at school.” Still, don’t we all regress a bit when we’re sick and in pain, even tough Kiwis?

So, as I’ve alluded to before, Kiwis seem to have some inherent aversion to indoor heating. I can see the consequences of this as I examine my new admissions to the hospital. I go to pull up their shirt to listen to their lungs and up come 1, 2, 3 and sometimes 4 layers—the top layer of which might even be their pajamas! And we always have to give them a day’s notice before we discharge them from the hospital so they can get the heat turned on at the house before they go home.

We've also mentioned before that Kiwis tend not to like to wear shoes. On my on-call nights in the hospital I get a chance to visit with the late shift nurses. One of them was astounded that I didn't have to use pumice stones on my feet to soften the callouses. I explained that I don't go barefoot much, especially in the winter. She, apparently, is always barefoot at home on her farm. One day, when she was running late, she showered and dressed for work, jumped in her car, drove to work and only realized when she got there that she had forgotten to wear shoes.

And, working in a small farming community, I’ve definitely seen some things I never saw in Seattle. Here are a few of my favorites so far:

Broken facial bone and laceration in the face covered with cow dung—“Kicked in face by cow”.

Testicle pain in 20 year old—“Mashed into fence by cow.”

Extensive bruising of the whole right body—“rolled truck down 50 meter hillside on farm” (and got himself out of the truck, walked 4 kilometers to the next farm and got a ride to the hospital.)

Foot injury—“Stepped on by cow.”

Severe rotator cuff injury of shoulder—“Run over by herd of deer.” (Deer are farmed here like cows, by the way. He said “I just turned my back on them for a minute.”)

Recently, I was on my way to Dunedin Public Hospital (the university hospital which is an hour’s drive away) to finish up my Advanced Cardiac Life Support re-certification. I worked Emergency Department that morning at Oamaru, then Richard and I were going to drive down that afternoon. As luck would have it, one of the first customers of the morning was a 49 year old guy having a big, bad heart attack. After giving him clot busting medicine and arranging for transport to the University Hospital, the cardiac team in Dunedin asked if we could send him in an ambulance instead of the helicopter because they were short on doctors to go with the helicopter and they wondered if one of us could go down with him. So instead of driving with Richard, I was pushing medicines in the guy’s IV in the ambulance on my trip down to Dunedin. I wondered, do I really have to finish the course since I’m doing advanced cardiac life support right here in the ambulance? And darned if riding a curvy road in a big ambulance doesn’t feel like being in a 32 foot boat in a cross sea—I took motion sickness medicine before we left just in case.

The language barrier continues to be an issue in medicine. I was telling a patient to soak an abscess with a hot washcloth. She didn’t know what I was talking about. A washcloth here is called a “flannel.” Sweater is “jersey”, or “jumper”. Being short of breath is called “puffy”, the urinary system is referred to as “waterworks”. When you’re sick you feel “crook” and when you’re doing well, everything is “fluffy ducks.” And on it goes. Perhaps I’ll speak the language before I leave, but it’s funny how little things can really make a difference in instructions to patients. They’re often too polite to ask me to repeat or clarify I think. And they often look at me after I’ve said something quite slowly and clearly and say, “Pardon?” Excuse me, but you’d think a population whose television shows are almost all imported from the US would understand my accent!

Oh, and the trips to Dunedin for my course were an opportunity to see more of the countryside.

We saw albatross flying out on the Otago peninsula, Hooker’s sea lions roaring at each other on the beach and more yellow-eyed penguins emerging from the ocean onto the beach. We saw the last two on a beach called Sand Fly beach—thank goodness we were there in the winter with several layers of clothes on! And we explored some gorgeous waterfalls in an area called the Catlins in the very south of the South Island, a wild and extremely beautiful place with a rugged coastline. The scenery in this part of the world continues to astound and delight us and the winter, at least so far, has been mild.