My travel wings have been clipped. On Monday I started work on the medical wards (for real, since over the past two weeks I was just helping and was an extra wheel) in which I have my own team of a registrar (resident), house officer (intern) and two medical students. I am on service for the next eight weeks….straight. Our team was on call Monday (they call being ‘on acute’ here). Just a few hours into call, a little before noon, I got a stat page to go to the ED (Emergency Department) since there was a patient there with an acute stroke, who might need TPA (a drug to break up clots in the brain, which should be given as early as possible, which is what all the rush is about). I was told during my orientation there were only 3 or 4 of these stat calls each month….and here I was just hours into my first call and already I was getting a call for possible TPA…that’s not a good omen. My registrar was already in the ED when I arrived, and together we went over all the things that need to be considered before given the drug TPA; all looked good until the CT scan of brain came back, showing a small area of bleeding in the brain, and therefore we wouldn’t be giving a drug which would make the bleeding worse. We got the patient up to the stroke ward and continued on with day (the patient is doing fine).
I titled today’s post “If you like to watch….” for two reasons. First, it likely peaked your interest, wondering if perhaps I might talk about ‘mature audience’ topics, or maybe things Skype can be used for. But really the title is more about my role as a consultant in medicine in the hospital. I don’t really do very much, as long as everything is being done well. I supervise the registrar and house officer (the medical students don’t really participate in the direct care of the patients, since they are only in year four, of six, of their schooling). I make rounds in the morning with the team, wherein we see and examine the patients and discuss their problems and how we propose to fix them. I don’t write the orders, however, nor do I write notes in the chart, unless there is something specific for me to note (which is rare). It is a significant deviation from my practice back in the US, where I write a note on every patient, every day. I mostly just watch……..But there is beauty in observation, and that is particularly what I’d like to share with you.
Although my sample size is small (ask me at the end of my eight weeks on the wards, and maybe it will be different) I can say with certainty being a physician here is palpably different than it is in the US. Observing those at the transmitting end of my stethoscope (my patients) I would note that as a whole, they are less confounded with being hospitalized or being ill. The person about whom I spoke above, who had the stroke (the bleeding kind), was underwhelmed by the very acute change in life which which had just occurred. At 11am everything was fine; at noon the patient was in the hospital with difficulty moving their right arm and leg (I am keeping ages, gender, and all that vague, for patient confidentiality). I expected more devastation, but instead I got, “Oh, I see, I’ve had a stroke. Will it get better?” The patient and their spouse were together the whole time (from the ED and up the wards), and they very nice, asking where I was from, if I liked it here, and they shared their experience of a recent vacation to California driving down Highway One from Big Sur to San Diego, and how much they enjoyed that. I’m thinking (to myself), ‘you’re having a stroke, and sharing vacation memories?’ There was another person who had bent over to pick up some firewood, fell and fractured (broke) both legs. It turns out the reason one of the legs broke was there was a cancer which had spread to the bone, making it very fragile. A quick investigation demonstrated the cancer had originated in the only remaining kidney the patient had (the other having been removed decades ago, for cancer). The legs were surgically repaired, and the patient was recovering well. The appointment to see the oncologist (cancer specialist) was six weeks away (the patient was discharged from the acute hospital by this point). There was no whining about trying to see the specialist earlier, or how could this happen to me? The patient clearly understood the implications of what was happening, but just seemed to believe that things happen in life, you deal with them, and move on. The patient was robust (remember the patient was picking up firewood) and otherwise healthy, and wasn’t giving up in any sense, but instead was just going along with the plan he was given. Very matter-of-fact.
Probably because this is a smaller community, the patients in the hospital here have more visitors than I’m used to in the US. Family come to visit, of course, but lots of friends, too. It’s nice. In one room, there were four women (patients) and my medical student was telling me she had been in the room earlier that morning and it was ‘gossip fest’ between all the gals. I didn’t ask what they were talking about, sometimes it’s better not to know these things. Most of the patient’s here are in 4-bed wards. There are a few private rooms, but patients in these room are usually those which need isolation (they have some communicable infectious disease, like the flu). The 4-bed ward, where you need to draw curtains around the patient for privacy, is a little different than my (newly built in 2007) hospital back in the US, where about 85% of the rooms are private. Sometimes they even put men and woman in the same ward, although they try not to, but I remember the first time I saw that I was quite surprised.
I would also make a sweeping generalization and say many of the people here are fiercely independent. Many of the patients are widows. One of them told me today, “I’m a tough old bird.” She’s in her 90’s, and indeed, she is tough. The patient who had the stroke, and the spouse, when asked if they thought they could manage at home (discharge planning happens all around the world), said, without hesitation, “Of course.”
I am still a newbie here, though. I looked through a patient’s chart, and of the six medications the patient was taken, I recognized the name of only one (and that was aspirin, so it probably doesn’t count). All the other medications had different names than I use in the US. Even Tylenol, or acetominphen, here is called paracetemol. And the lab tests are reported in different units (SI) here. On my first day here, someone said, oh hey, the glucose is 10. That would freak me out in the US, because it’s so low (if you’re blood sugar is below 50, you’re not thinking straight), but here 10 is HIGH. A normal kidney test measurement (creatinine) in the US is 1.0; here it’s 80. It does take some time to wrap your head around all this.
Whether in the US or in Nz, though, there is no better job. I get to help people, and while there are cultural differences wherever you might go, people are still people. And, I get to teach medicine, and students of medicine (like myself) are the same world ’round.
That was a lot of medicine today….tomorrow I’ll have to mix it up.