Life in A&E

You say it's urgent.

Make it fast, make it urgent.

Do it quick, do it urgent.

Want it quick.

Urgent, urgent, emergency.

- Larry Johnson/Foreigner

My introduction to A&E (Accident & Emergency) was, fortunately, a slow transition. For the first two weeks, I have been paired with another Consultant (Attending Physician), so in essence I was an extra doctor. As a result, there was no pressure on me to see many patients or to be very efficient. This is in contrast to my usual introduction to a new ED where I have rarely had the chance to shadow another physician before being thrown into the pit. With few notable exceptions (my most recent position being one of them), my orientation is one of "Here's the coffee, here's the bathroom, here are the patient charts, and there are the patients. Have fun!"

The A&E I work in sees about 100-120 patients per day ... pretty close to what we were seeing in my last position in the U.S. The difference here is that I am a Consultant managing a department in which there are a number of Junior House Officers and Registrars seeing patients. The Reg's are pretty independent and need little supervision. The JHO's, like trainees everywhere, are of varying abilities. Some require very little oversight, and some need scrutiny of just about every decision they make. I am also responsible for staffing patients seen by medical students. If this sounds chaotic, it is. At any point in time, there might be a Reg and 2-4 JHO's seeing patients while I am directly supervising 1-2 med students. As a consultant, I will typically only see 3-5 patients of my own in a given shift. I am generally expected to pick up the easy ones to keep the department moving and allow the JHO's the more complicated patients. As a result, I spend a lot of time standing around with my hands in my pockets, trying to ignore the building list of patients waiting to be seen and the backlog of those in triage. This causes me quite a bit of angst and is a source of much humour for the other consultants. I appear to be sitting calmly, but they well know what I look like on the inside.

 "The Scream" - Edvard Munch

For the past 5+ years, I have been working in large, busy ED's in the U.S. I have worked exclusively night shift, typically a 10 or 12 hour stretch. In most cases, I have been the only physician in the ED for 6-8 hours, and in some cases I have been the only physician in the ED for the entire 10 or 12 hours. In a typical 12 hour shift, I will see somewhere between 25-35 patients. Every now and then, we get hammered by patients and I might see upward of 40.

The patient mix is different, too. In the U.S., anyone and everyone comes to the ED for care. We see everything from traumas and heart attacks, to sneezes, sniffles, and colds. ED physicians take great pride in the idea that we treat "Anyone, Anything, Anytime." While this has been a noble approach, in some ways it has come back to bite us in the collective ass.

In many places in New Zealand, lower acuity patients are turned away from A&E ... the sign in the pic above is from in front of the ED in Gisborne. Since our A&E is a large regional health centre, some of the lower acuity patients do end up here, but there is still an active campaign to discourage it.

The biggest difference I have seen here is in the process. The electronic medical record system was designed in the 70's and has been in place since the 80's ... it's DOS based! There is a mountain of paperwork, all needing to be filled out by hand. It's like they have taken the electronic and paper systems, gotten rid of what was actually helpful and useful, and bred the worst aspects of each. The resulting Frankenstein's Monster is an ugly, awkward, and petulant child. Part of the reason I only see a handful of patients in any given shift is simply because the system is so inefficient. It is nearly impossible to carry more than a couple of patients at any given time. When I tell the JHO's that I can carry 6-10 patients at once and see 30-40 patients in a 12 hour shift, they can't fathom how that is possible.

I have always maintained that medicine is medicine no matter where you go; it's the system that is different. "The medicine is easy, it's the process that can make it difficult." The problems we see in the U.S. ... obesity, heart disease, diabetes ... are the same here in New Zealand. There are a few subtle differences though. In my 10+ years since graduating medical school, I have never seen a patient with a history of rheumatic heart disease from childhood rheumatic fever. It is a relatively common condition here. Things that are rare in the U.S. are seen far more frequently in A&E.

The U.S. incidence of bacterial meningitis (approx 0.2-1.0/10K) is low enough that I have never seen a case and so rarely perform LP's ("spinal taps"). By some estimates, the incidence in NZ may be 10x that. Patients for whom I previously would have done very little testing find themselves getting a full work-up, including LP.

In the US, we almost never order emergent MRI's (when I had concern for a possible brain tumor, it took 2 weeks before I could get in for one). About the only indication for emergent MRI is suspicion for an epidural (spinal) abscess. Incidence of epidural abscess in the U.S. is about 1.3/100K. The incidence in NZ is about the same (1.4/100K) but I am 2-3 times more likely to see it here because there are only about 40 A&E's in NZ (vs 5025 ED's in the U.S.) In my previous 10 years, I have ordered 4 Emergency Dept MRI's. In two weeks here, I have already sent 3 patients to MRI. (If you are wondering about the math, 5025 U.S. ED's serve about 320 Million people and 40 NZ A&E's serve 4.7 Million people).

In short, people here are sick as shit.

 Yes, the nurses are wearing shorts.

One last comment on cultural differences. People here are just more chill than anywhere else in the world I have lived or visited. I haven't seen a coat or tie anywhere. Consultants and Reg's from other services are frequently seen wearing jeans. The focus is on providing quality, efficient care, not on the trappings. Every telephone call I make seems to involve at least 5 minutes of social chit-chat ... Little Highstead's school, week-end adventures, stories from back home, etc ... then about 2 minutes of work-related conversation. The high-pressure, high-volume, harried American inside of me wants to cut to the chase, state my business, and move on. It has taken considerable effort, but I am slowly adopting the Kiwi way.

Now my biggest fear is how I will ever function when I return.