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.

Dispatch 58 Small Town Life

4 June – 31 July 2010

Life continues in Oamaru, a small town with big city aspirations. We have an Opera House here which is extremely grand. It is built of Oamaru limestone and is a gorgeous building and a really fantastic show venue. Les Miserables will be showing there this September—all the big shows in New Zealand pass through Oamaru because of the Opera House. The other night I went to a show there called “Hot Pink Bits”. It was a one woman show and it was, well, hard to describe. This woman has done a fair amount of research about the sex trade since humankind began and has lots of funny bits as well as interesting facts to share about sex. By the way escort services and houses of entertainment, (nudge, nudge, wink wink know what I mean, eh), are legal in NZ and the adult entertainment ads in the papers offer a wide range of services, but back to the show. She is also outrageous and funny and a pretty good singer. She also has humongous breasts that she stuffs into a outfit that they are mostly falling out of for the show and interacts with the audience, mostly the men, in a most irreverent way. It was LOL funny. I sat next to a grandmother who had come with her 26 year old granddaughter. Clearly the two had no idea what the show was really about or they would definitely have not been there together.

Tonight, a Friday night, I was so looking forward to a relaxing evening at home after a long busy week of work. Just as I was about to leave the hospital, all the power went off. It was pitch black for about 20 seconds, and then the hospital back-up generator went on and everything returned to normal. That was the hospital. As soon as I stepped outside I realized the power to the WHOLE CITY was off! The hospital was the only place with lights. I walked home in the pitch black—a beautiful starry night that I appreciated while I contemplated what awaited me at home. We do have a fireplace which I haven’t mentioned before –actually, a quite good one that is built to throw out heat effectively. And, when we moved in, we had found candles around the place. And, when I thought back on it, there were other clues about this not being a particularly one off experience (power outages) because the prior tenant had warned us that the oven doesn’t work when the clock isn’t set which happens when the power goes off. . Hmmmm, okay I’m starting to see a pattern here. Oh yeah, and the house keys are on a key chain that includes a little flashlight, uh, I mean torch (Kiwi speak).

I arrived home, found my way to the door with the torch on the keychain, walked straight to where I left my headlamp (every good cruiser always knows where that is!), and proceeded to make a fire in the fireplace. I realized I had a little portable propane cooker from our camping days and knew I could even heat up a meal if the power didn’t go on. I exchanged a few texts with Richard (who is out of town still awaiting the catamaran delivery to Fiji, or so he says) and a local woman I have befriended. I learned this is not an unusual occurrence but the duration is a bit odd (it lasted 1 ½ hrs). Thank goodness the cell towers weren’t down too. And, at last, the power went back on. The weather was not extreme and I have no idea what turned the power off. Too many portable space heaters overloading the system?

My hospital life is really a throw back to times I spent in old Veteran’s hospitals in the US.. Although it is a modern facility, it is built with many shared rooms with beds for 3 people. This is purposeful—I guess the thinking is that patients can sort of look out for each other, which, it turns out, they do. The rooms are sex segregated except the HDU (high dependency unit which we would call a step down unit—that is, it’s not really an intensive care unit but the next level of care. My hospital doesn’t have an ICU—anyone that sick gets transferred to the big city.) There, both men and women are cared for, separated only by curtains. There is virtually no privacy. And, no need, since, it seems, everyone knows each other. In fact, as the Oncologist explained to me today in his monthly visit to the rural hospital, there’s lots of cancer here partly because everyone is RELATED to everyone. OK, never mind.

So, one night this week, one of my patients suddenly had a turn for the worse. As I was in there checking him out with the nurses, another patient of mine in the same room, who has had a stroke and is quite confused generally, said to me from his bed where he was lying quietly, “He’s been having quite a time of it tonight—I think it’s his heart.” And, this morning, I found another patient of mine who is feeling much better and told me she needs to go home because she is, “quite bored in here” helping the other ladies in the room fill out their menu requests for the next day. I greet the patients who aren’t mine with the same familiarity as my own since they are all in the room together. People in our hospital are often not very sick—there for rehabilitation as much as anything--so they are fully dressed and sometimes go home on leave over the weekend since nothing really happens in the hospital on the weekend (no lab, x-ray, PT, OT, you name it). Contrast this with the US hospital I’ve lately worked in where I often commented that they might as well do away with the dietary department because we send people home as soon as they are well enough to eat. Which brings me to another observation about my hospital. I’ve had occasion to eat the food when I’ve done overnight shifts. One night I picked the spaghetti thinking that it’s a foolproof meal. Well, apparently it is not foolproof in New Zealand. My colleague the next morning nodded knowingly and said, “You should have had the toasted sandwiches…” He’s been there for 12 years or so. Thank goodness Richard is back to bring dinner down to me. Well, actually, the evening meal here is called “tea.” Really, it is.

When I walked home in the really dark night with the power off tonight, I admired the Southern Cross, the Milky Way, the constellation Scorpio all while being serenaded by the surprisingly loud tiny blue penguins who had come in for the night (and were probably really happy about the lights being out). You, know, things really could be worse!

Dispatch 57 More Oamaru Adventures

14 May - 25 May 2010

As life went on without Richard, I became more adventurous in order to color my solo existence. So, one Sunday, I had heard about a ceremony to take place on the waterfront where the last 1 kilometer of a proposed bike trail from the Alps, (these are the New Zealand Alps not to be confused with the slightly more familiar European ones), to the Ocean was going to be officially opened. As it turns out, this is, so far, the ONLY kilometer of said bike trail to have been completed. And because the Prime Minister, Mr. John Key, is an avid bicyclist, the celebration was timed to coincide with a visit of his to the area and he had agreed to attend the dedication of this bit of the bike trail.

So off I went to join the couple hundred people milling about on a cold but sunny day. Several people were dressed in Victorian garb, something this town is known for as its heyday was during the Victorian era. The gorgeous

limestone buildings of the historic district were all alive with activity. A new historic bicycle shop which has Pennyfarthing bikes was being opened that day and there were several of those bikes in attendance being ridden by people who knew what they were doing. You know the ones, the huge front wheel, tiny back wheel with a seat nearly 2 meters off the ground. I watched as they mounted the bikes, pushing them to get momentum and balance, stepping on a small footstep and UP onto the seat. Smoothly done by those that know how to do it.

I had a vague idea that I might try to meet the Prime Minister as it is such a small town and there really weren’t that many people about. He and his wife stepped off the historic steam train and walked down to the ribbon at the start of the bike trail. I followed along with the crowds and stood while a bagpipe band performed, then the mayor made a speech, then the prime minister made a speech. The latter was a bit sheepish about the “somewhat backward” way the trail was being done, that is, last kilometer first, but he was amusing and brief in his comments. Afterward, he cut a ribbon and borrowed a bike to ride a short distance on the new trail (which ends by the way at the blue penguin center).

When he returned from his short ride, he stood with his wife and staff (if they were security this was truly low key!) while members of the community came up, introduced themselves and had their pictures taken with the PM. Well, yours truly decided, “What the hell,” and joined the small knot of people waiting to meet the country’s leader. Sure enough, my time came and I shook his hand, introduced myself as “An American doctor working here in Oamaru,” and he chatted me up for the obligatory minute or so he spent with everyone asking where I was from and telling me he had visited the area around Seattle and spent some time in Vancouver, BC as well. He was very smooth and gracious and I was, well, THRILLED. I contemplated writing to Barack Obama to tell him that I had met the leader of a foreign country before meeting the leader of my own in the vague hope that an invitation to meet him would be forthcoming and then thought better

of the whole thing. Remember, New Zealand has 4.8 million people and nearly 50 million sheep. Between the people and the sheep, the Prime Minister here would still have a much smaller job meeting everyone! (A little note on the Kiwi language. I have been chastised for using the expression “chatted me up” to describe my meeting with the PM because in Kiwi English, that basically mean “hit on me”. So, let me clarify that the PM chatted with me for a minute or so and was not hitting on me!…)

So, to cap off a truly momentous day, I walked out to the beach where the other penguins come in at sunset and tried to catch a glimpse of them. This beach is quite scenic and the Department of Conservation has built a trail out to a shack where one can watch the penguins come in from above and not disturb them. Once again, I was not alone in my vigil. It was a

cold afternoon but 25 or so people gathered to watch. There were fur seals down on the beach just lolling around. Then a little shape darted around the surf line, cruised in to shore, stood up and began that distinctive waddle that could be nothing else. Shortly after, about a half dozen of the darling little things followed suit. They waddle all the way up the beach, into the bush that forms a steep hillside and climb up. In fact, they climb up quite a ways because we were treated to a close encounter as one of the early birds climbed up the 200 feet of hillside to within 30 feet of where many of us were standing and started to squawk instructions to its mate.

These are Yellow Eyed Penguins and they are quite flash looking with yellow bands through their eyes. They are nearly twice as big as

the blue penguins (so about 2 feet tall as opposed to 1 foot tall).

When Richard rejoined me another week later, Oamaru was in the middle of a “100 year storm.” It rained nearly 10 inches in a couple days and kept raining for another 4 days. Our little town was isolated by severe flooding to the north and south so the major highway was impassable. We had to airlift a patient to our referral hospital by helicopter because the roads were closed. It was an impressive bit of bad weather with big winds to cap it off, but not necessarily the best introduction to Oamaru that Richard could have enjoyed. Finally when
the rain stopped we took a brief road trip to see the Moeraki boulders, a set of stones that are nearly perfectly round that litter a beach nearby. Our drive was still detoured as not all the flooding had receded and several trails had experienced landslides and were closed. We did see fur seal pups up on some rocks nearby, had a nice lunch and headed back to try to see the yellow eyed penguins. Alas, that trail had been closed by landslides and surf was quite high so Richard has yet to enjoy our “other” penguins.

And he’s off again on a second attempt to get the catamaran to Fiji. I’m sure he’ll be back with stories and I might have a few more of my own. I wonder what other celebrities might visit our little town this year?