Give Blood, Play Rugby

We few, we happy few, we band of brothers

For he today that sheds his blood with me

Shall be my brother; be he ne'er so vile

- William Shakespeare Henry V

Staying dry at the All Blacks vs Lions rugby match - July 2017

I am a rugby player. While it is true that I haven't been on a rugby pitch in many years, like a U.S. Marine (there's no such thing as an ex-Marine) I will cling to my rugby roots until my last dying breath. The foundation for many of my best memories was built on mud and grass, and several of my most-enduring friendships were solidified in sweaty scrums and dirty bar-rooms.

Galveston RFC dressed up as Beefeaters for Dickens On the Strand - mid-1990's

I grew up playing ice hockey and rugby, but my aspirations out-stripped my talents. As an athlete, I was always just good enough to make the team, but never good enough to shine ... a perpetual second-stringer. As I got older, the other players got bigger, stronger, and faster while I did not. By the time I graduated high school, I was no longer good enough to make it in competitive hockey and just hanging on with the rugby team. I almost stopped playing rugby after graduating from high school. Going to uni in Hawaii, I was at a small school with a large Pacific Islander presence. I played with the school rugby club, where I got beat up by Hawaiians, Samoans, Tongans, and Maori ... and those were my team mates.

Rugby has provided me with life-long friends, the opportunity to travel and play all over the U.S. and overseas, and some of the best nights out with mates that I will never remember. It also provided me with a broken nose (3 times), broken fingers, broken toes, and a bum knee. By the time I left Hawaii and moved to Boston, I pretty much figured my playing career was over. This made my mother very happy. I was amazed to find a rugby club at Boston U. This made my mother very unhappy.

Lone Star Mercenaries on tour to Missoula MT for the famous Maggot Fest - 2001

Growing up playing in Canada, I had more experience on the pitch than any 3 other players on the Boston U rugby team, but at 5'9" 150 lbs, I was woefully undersized. I was up against American beef-fed farm boys, football players, and wanna-be jocks with something to prove. My entire rugby career to that point had been played at flanker/wing-forward, a position that requires size, strength, and speed. Athletic prowess that I simply didn't possess. I hit the gym and worked hard on the field but was still relegated to the "B" team, and only managed to stay off the "C" (developmental) side because of my work ethic and knowledge of the game.

Sports coaches can be transformational figures in a young player's life both on and off the field. They can destroy a player's confidence and passion for the game, or they can instill lifelong dedication and love of sport. Very rarely, a coach comes along who redefines the game for his players. I have toiled through the first kind, taken inspiration from the second, and had only a brief encounter with the third. At Boston U, Mark Winder and Stuart Campbell coached me for only a little over a year, but they changed my life.

Lone Star Mercenaries on tour to Savannah GA for the St. Patrick's Day Tournament - March 2002

I was ill-suited for the position of wing-forward. I was too slow, too small, and too defense oriented. At some point, Mark said to me that I wasn't a wing-forward, but a fullback. I resisted. I had played #7 for 6 years and wasn't about to be told any different. Somewhere along the way he hit me with the reality that I could be a "B" or "C" team wing-forward for my few remaining playing years, or a 1st 15 (A-team) fullback. I accepted the challenge and Stuart Campbell set about making the transformation happen. Every day after practice, he worked with me individually on positional play. After the team practice was over, he taught me kicking techniques, how to make open-field tackles, and how to direct the "Back 3". Without the efforts of Mark and Stuart, my last rugby game likely would have been just before graduation (making my mother happy once again). Instead, I continued playing rugby into my 30s (unhappy mother), and it was the things that I learned from them on the rugby pitch that drove my success when I started racing triathlons. After I graduated, I lost contact with Mark and Stuart but I credited them with making me the competitive player that I remained for another 10+ years.

It's an interesting thing about rugby ... we put every effort into hitting each other as hard as we can on the field, then buy our opponents a pint after the match and stay in their homes. I've crashed on floors, couches, and beds of players I've never met before, and even been taken in by the parents of a player I never played with or against but only knew through a mutual friend. It was through a friend in Colorado that I recently heard about Stuart's battle with cancer and untimely death. I never got the opportunity to thank him and let him know how much of a difference he made in my life, both on and off the pitch. Out of that news, though, I re-connected with Mark and I am looking forward to lifting a pint with him once again. I'll be sure to wear my Terrier's rugby jersey when I do.

Mercenaries and other assorted scoundrels and scally-wags serenading the bride at a friend's wedding - 2007

So what does this have to do with our year in New Zealand?

Not a whole heck of a lot, I guess, but our recent sojourn to Wellington to watch the NZ All Blacks take on the British & Irish Lions got me to reminiscing.

All Blacks Haka before their match against the Lions - July 2017

The Lions are a representative touring side with players selected from each of the Home Nations (England, Ireland, Scotland, and Wales). They tour every four years, rotating among Australia, New Zealand, and South Africa. The tradition stretches back to 1888 when the Shaw & Shrewsbury Team toured Australia and New Zealand. It was during their 1924 tour to South Africa that the press dubbed them the "Lions".

The modern iteration of the team, in which professional players are selected from each of the Home Nations, began with the 1950 tour to NZ and Australia. They last toured NZ in 2005 where they won most of their provincial matches, lost to the Maori All Blacks, and lost all three of their test matches against the NZ All Blacks (a "Test Match" is a game between two international representative teams, each recognized by their national governing bodies).

ABs win their line-out ... we had pretty good seats, eh?

When we first moved to NZ, we discovered that the Lions would be coming on tour. One of the many things I wanted to do in our year here was catch an All Blacks game, and seeing them take on the Lions would likely be a once in a lifetime opportunity. Me and everyone else, it would seem. Demand for tickets was so high that they had to institute a lottery system. For each of the three matches (2 in Auckland, 1 in Wellington), Kari and I put our names in for a lottery spot. By joining the ABs fan-club, we were awarded an additional lottery chance for each game. In total, we had 12 chances of winning the opportunity to purchase up to 4 tickets.

When the lottery results were announced, we were not winners and our hopes of getting to a game were dashed. In early March, they released a limited number of additional tickets. I received an e-mail inviting me to apply to the Wellington match, Kari did not. On the morning of the second lottery, I started refreshing the web page 2 minutes before the allotted time, and when the time arrived ... my web connection crashed! I frantically tried logging back in several times until I finally got through and managed to secure 3 tickets. We were going to the game.

A wet Westpac Stadium as we queue up to go in

Kari -

Once the shock of Grant actually obtaining tickets wore off, I started to look for accommodations. You have to remember, this tour was announced a few years ago and places to stay, especially ones appealing to a one-income family, were snatched up months before we even arrived in New Zealand. However, anyone who knows me is well aware, and shouldn't be surprised, that I was up to the challenge! My glee, ego and confidence would soon be deflated. After multiple online searches with traditional acccommodation sites, BookaBach (New Zealand's version of VRBO), phone calls to the i-SITE in Wellington, and our "connection" from other apartments we have rented, Grant and I started to discuss a magical "Plan B". Hopefully, we could take the train to the game from Palmy, or another city closer to Wellington, returning that evening. 

While I love a good train ride, the thought of embracing all things rugby and enjoying the game, only to return on a train full of rowdy, spirited, beer scented rugby fans (myself included) might be a bit much for Little H. For a couple of months leading up to the game, I continued to contact the i-SITE and look online, but there were no beds to be found, well, nothing under $900/night. We also had some friends visiting New Zealand during this time period. Once I knew their travel plans and that they would be departing Wellington Airport on the day of the game, I shared my accommodation woes and suggested they start looking asap. There is one hotel on Cuba Street that we stay at pretty frequently. On their website, per i-SITE phone calls, and on booking websites, this hotel had not shown any availability for months. I decided to call the hotel directly. Jackpot! They had one room available and I jumped on it. 

With the price per night, which was more than double than we usually pay, I was expecting champagne and a firework display on our post-game arrival. That was not the case, but what we did get was an amazing experience. We were able to stay in our favourite area of Wellington and walk to and from the game, even if it was in the rain. This hotel was filled with British Lion fans, who were feeling no pain after the game, but rejoicing, celebrating and filling the hotel foyer and lobby with their winning "roar". It was amazing to see the fans the following morning as they checked-out and boarded buses to the airport, an entourage glammed up in red, smiling and allowing the big win endorphins to run rampant. "We [British Lions] never win and the All Blacks never lose!"

All Blacks' scrum

The All Blacks won the first match 30-15 in Auckland. The game was tightly contested in the first half but the ABs opened it up in the second. A late try (touchdown) by the Lions made the game seem closer than it really was. With the home team winning the first match, we had high hopes for a great 2nd test. Because of the cold and wet conditions, we bundled up in our woolies, donned plastic ponchos, and settled into our seats with a couple of beers. It rained off and on throughout the match, creating lots of turn-overs and lots of penalties. Unfortunately, the ABs failed to capitalize on a number of penalty kicks and they didn't post a try. Scoring two tries, the Lions defeated the ABs 24-21. It was their first win over the ABs since 1993 and ended the All Blacks' 47-match home winning streak. It was a great battle from the stands for those who know the game, but it was difficult to keep Little H interested.

We had a long trek back to our hotel from the stadium, dodging rain-drops and drunken celebratory Lions fans. Along the way, we got some street food (Indian hot, not Kiwi hot) and finally crashed into our beds late. The next morning, we were up early for breakfast at our favourite Best Ugly Bagels and then on the road to home. We had to get back quickly so we could pack for our week in Fiji.

Tutira mai nga iwi ~ Aue,
tatou tatou e.

Liberté, Égalité, Fraternité

There's no bread, let them eat cake

There's no end to what they'll take

Flaunt the fruits of noble birth

Wash the salt into the earth

- Peart/Lee/Lifeson (Rush), Bastille Day

Bastille Day masquerade ball, July 15, 2017

I find it curious that we celebrate other nations' holidays. Why is St Patrick's Day so popular in the U.S. and Canada when it was traditionally just a minor religious holiday in Ireland? Cinco de Mayo, the 5th of May, celebrates the Mexican army's defeat of the French at the Battle of Puebla (1862) against long odds. In the U.S., it has become a commercialized celebration of all things Mexican. Bastille Day, July 14, is celebrated in countries throughout the world. This one might be a little more understandable ... most modern Western systems of government are based on the ideals over which the French Revolution was fought. Still, it seems a little odd to me that last week we went to a French cheese tasting at our local market, and in the evening a Bastille Day masquerade ball hosted by the Alliance Française de Palmerston North.

French cheese tasting at our local market

The French refer to July 14 as la Fête nationale, but most everyone else calls it "Bastille Day". It is a celebration of the 1-year anniversary of the storming of the Bastille on 14 July 1789, a turning point in the French Revolution. The Bastille was a fortified prison, holding political prisoners and pretty much anyone else who pissed off the monarchy at the time. It also held weapons, powder, and ammunition. The people of Paris stormed the Bastille to gain access to the weapons, fearing that their representatives in government were under imminent threat of attack by the royal army and foreign mercenaries.

These home-made costumes were amazing.

As usual, Kari was our social coordinator. Always looking for unique cultural experiences, she had asked me a month or more ago if I was interested in going to the Alliance Française Bastille Day ball. I thought that was a great idea and suggested she invite some of our friends. Unfortunately, Bastille Day falls during the school winter break and most of our friends would be away. When we threw some feelers out, Holly was all over it. "How the f@*$ do you find all these things?" ... and so began our night out to the Bastille Day masquerade ball.

The entertainment consisted of a number of dancers and a singer who crooned a long list of French cafe songs. Somehow we ended up seated at the front table. More than once, I was dangerously close to catching a high-kick to the head or a dancer in my lap. Dinner was a multi-course meal, but it was really the company and laughter they engendered that were the most memorable parts of the evening. It was over too quickly, so we made plans to get tougher for dinner again later in the week. By that point, both our literal and figurative masks were long discarded.

Who are those masked women, anyway?

Holly and Matt are returning to the U.S. after living here in Palmy for the past three years. We sent Matt off in grand style with a tramp (Link: The Long Goodbye), and it was great to spend a night out with Holly and Corene, her temporary flat mate. Matt has returned to the U.S. already to get their son settled in to school there, and Holly has stayed behind until their daughter finishes school here. I see Holly in the ED as she works with people affected by domestic violence and substance abuse in our community. She is also Little H's gymnastics coach. Matt and Holly's daughter sits for LH when Kari and I need a grown-up night out. Holly and her family have become more than just friends; they have become a part of our family and we will miss them greatly when we all go our separate ways in a couple of months.

Corene, Holly, and a mysterious stranger.

The Siècle des lumières (Enlightenment) ideals that lead to the French Revolution were integral in shaping modern society. While the American Revolution (1765-1783) preceded the French Revolution (1789-1799) by 20+ years, it was the principles of scientific progress, religious tolerance, natural rights, and equality espoused by the English philosopher/physician John Locke, and French writers such as Rousseau and Voltaire, upon which the American founding fathers structured their new society. The French Revolution had far-reaching effects and influenced the global decline of absolute monarchies, leading to the establishment of republics and liberal democracies (Link: Liberal Democracy).

The French Revolution was triggered by the people's fear for their future and anger with the church and aristocracy. The people, the peasants and the bourgeoisie, saw those who were responsible to be much less affected by the suffering around them. In revolutionary France, the aristocracy and the Catholic Church didn't pay their share of taxes; it was the peasants and middle class who paid to support the structure of their society. While the "Third Estate" was the largest segment of society in terms of size and economic importance, their needs and concerns were largely ignored by the Ancien Régime.

Writing about the mood in America in 2014, James Spurgeon wrote:

The bulk of the population, the working class, is feeling as though it's paying more than its fair share and being asked to bear more and more of the burden while the wealthy get off and religious institutions are exempt.

When we return to the U.S. in a month, I certainly don't expect to see guillotines in the town square. I do, however, heed the warning of George Santayana who in The Life of Reason wrote "Those who cannot remember the past are doomed to repeat it."

Vive la France. Vive la liberté ...

Bula!

It's those changes in latitudes

Changes in Attitudes

Nothing remains quite the same.

With all of our running and all of our cunning

If we couldn't laugh, we would all go insane.

- Jimmy Buffett, Changes in Latitudes

I took my jandals off as soon as we arrived on Treasure Island and went barefoot for the rest of the week.

Fiji, Tonga, Samoa, Tahiti, Bora Bora, Vanuatu ... names of places that conjure up images of tropical paradise in most North Americans' minds. In Australia and New Zealand, they are just places people go to on holiday. Last week, we went to Fiji ... along with seemingly every other Kiwi family on school holiday. Actually, almost everyone we met was from Australia, but I digress.

We started planning our tropical holiday at the last minute ... and by "last minute" I mean 7 months ago. We thought we were jumping the gun and getting ahead of the game. In the U.S. and Canada, there's just no point in trying to book rooms and airfares much more than about three months out. If you do, you pay a premium. Quite the opposite is true here. As we started looking for places to stay, we discovered that everything was booked, not just in Fiji but at every other South Pacific destination we considered. For sure, there were a few posh, adult-style resorts with openings, but anywhere even remotely interesting for a family was locked up. We would later learn that Kiwis and Aussies book their holidays as much as 10 months in advance.

I wish I could tell you about the South Pacific
the way it actually was.

The endless ocean. The infinite specks of coral we called islands.

Coconut palms nodding gracefully toward the ocean.

Reefs upon which waves broke into spray.

And inner lagoons, lovely beyond description.

- James A Michener, Tales of The South Pacific

After several weeks of trying to sort it out on her own, Kari finally relented and went to a travel agent (yes, they still have those here).  She managed to cobble together five nights at Treasure Island, then 2 nights on the Coral Coast. On TI, we had no telephone, no WiFi (internet access was available, but it's pretty limited). We would wake up and sit on the front porch of our bure, drinking coffee and watching the sun brighten the day. After getting Little H off to Kids Club (more on that later), we would sit on the beach for an hour reading our books. An hour was about all we could take ... by 11 am it was blazing hot. After lunch, we would do a little snorkeling, and then it was cocktail hour.

Sailboats and drinks at Vuda Marina while waiting for our boat to Treasure Island.

As you might have guessed from our previous posts, this was a total departure for us. Our typical holiday usually involves a list of things we would like to do. We use the list as a guideline rather than an agenda or a series of check boxes. More often than not, we don't get to everything on the list, but we are usually up and going for most of the day. This time, by design, we had a completely disconnected week. There was nothing to do but ... well, nothing. Treasure Island is small ... it took us less than 30 minutes to walk the entire length of its shoreline at a leisurely pace. It's just a hort boat ride off-shore and sits in the middle of a marine sanctuary. There is lots of beach and water time, tons of snorkeling, and plenty of hammock time.

Blue starfish (Linckia laevigata)

It was important to us to find a place that had some kind of organized program for kids. Little H travels well, but being stuck with us all the time probably gets a little old. That and I didn't want to hear the dreaded "I'm boooooored" all day long and be compelled to provide her with entertainment. Plus, as mentioned above, Kari and I planned on doing nothing for 5 days.

The Kids Club at Treasure Island Resort far exceeded our expectations. There were three sessions daily, and kids going to the evening session ate from a buffet before the main dining room opened so parents could enjoy a leisurely dinner while the kids were away. The list of activities was extensive. Each morning, they went out on a boat to feed fish in the marine sanctuary and then returned to the island to feed the turtles in the turtle rescue program. The rest of the morning program, and the afternoon and evening programs, consisted of various activities and games. Among other things, Little H got to clean the turtles (with a toothbrush!), hunted crabs (and fed them to the turtles), learned how to husk a coconut, braided floral crowns, made a shell necklace, and danced the limbo. All of this surrounded by a mix of kids from different cultures (but mostly Australians).

Little H and friends.

We've never had to worry about Little H talking to strangers. We have a running joke in our family ... my brothers, me, my nieces and nephews, none of us are very adept at meeting people and making small talk. Little H doesn't like to talk to people she doesn't know and our normally gregarious daughter tucks her head and becomes mute when put in situations where other people are unavoidable. She generally does very well traveling with me and Kari, but when I see her in a group of other kids, smiling, laughing, and playing, I see what she is missing when it's just the three of us. At Treasure Island, LH met a number of other kids and it was through her that we met their parents. Laughing, joking, and sharing our experiences with other parents made our week that much more enjoyable.

After 5 days on Treasure Island, it was time to head to the main island of Viti Levu. It was great sitting around doing nothing for 5 days, but our wander-lust and need for adventure prevailed. We were surprised out how much we enjoyed our "stay-cation" and have decided that future travels will include 2-3 days of just hanging out.

Goodbye, Treaure Island. We will likely meet again.

The oral tradition for the origin of the Fijian people is one of travel by canoe from Tanganyika in Africa, and this is what is taught in school there. Historians and other cultural scholars dispute this and claim the Fijian people and culture are more likely descended from the early Polynesians and Melanesians. What is not in dispute is that, even into the 1800's, Fijians practised cannibalism. This period is known as na gauna ni tevoro (time of the devil). While the Dutch explorer Abel Tasman visited Fiji in 1643, and James Cook landed there in 1774, the ferocity of the people deterred further European exploration and Fiji remained unknown to the rest of the world well into the 1800's. Throughout the South Pacific, the Fijians were feared and respected warriors. Our experience in Fiji couldn't have been more different. The people were warm, friendly, inviting, and proud of their culture.

Tui (Treasure Island Resort) shares the oral history of his ancestors.

We were invited to attend church services (conducted in Fijian) in the village of Namada. Tambua Sands, our home on Viti Levu was built on village land.

Our main purpose for staying on the Coral Coast of Viti Levu was so that we could meet up with friends from the U.S. who were in Fiji to visit family. Going from the slow, lazy pace of the Mamanuca Islands to the hustle, bustle, and traffic of Viti Levu was a little bit of a shock, even after only 5 days. Our Bure at Tambua Sands was set back from the beach and adjacent to the road ... the sound of traffic zooming by was actually a little jarring. It was only a short walk to the beach though, and the lagoon was perfect for snorkeling and exploring. Little H and I even got to play a little touch rugby and table tennis.

Beach-side bure, Tambua Sands.

Lagoon and reef flats, Tambua Sands.

Touch rugby, Tambua Sands.

... the rare sight of moonlight upon tropic waters

With palm trees along the shore and a ship at the dock.

The world was beautiful that night.

It was beautiful as only a tropic night on some distant shore

can be beautiful.

- James A Michener, Tales of The South Pacific

Treasure Island sunrise.

Treasure Island sunset.

Tambua Sands sunset.

Temperatures in Palmy when we left were 12-14 C ... cold, wet, and grey. We landed in Fiji to temperatures in the 30s with clear skies and a light tropical breeze. We spent time together as a family, and had a little time to ourselves. I averaged just over a book a day! We got a little sunshine in our souls and on our skin, and had a great visit with old friends while also making new ones. Our winter week in the tropics was just what the doctor ordered ...

Vinaka ...

Catch A Wave

Here we go again

Another round-trip for all of my friends

Another non-stop

Will it ever end

- L. Tomlinson/L. Payne/One Direction Clouds

Little H surfing at Makorori Beach, Dec 2016

In one of my many lives before medicine, I was an oceanographer. I started out chasing a Marine Biology degree in Hawaii and graduated from Boston University with a degree in Biology with Marine Science Specialization. I then went on to graduate studies in Oceanography at Texas A&M Univ. From there, I went to work for an oil exploration company, mapping the sea floor looking for likely undersea oil and gas drilling sites. I love what I do as an Emergency Medicine doctor, and clearly made the right choice in my career change; however I totally dig geology, Earth sciences, physics, and marine science. Please indulge me while I geek out a little for this post.

One of the most soothing and calming experiences many people can describe is sitting and watching ocean waves roll in and crash on the beach. The sound of crashing waves is a common component of white noise sleep machines, and "music" in spas and during meditation exercises. The essentially flat ocean surface, endless horizon, and metronomic motion are calming. While neuroscientists struggle to understand and describe the effect of ocean waves on our brains, physicists have had much more success studying how waves form and what influences their shape.

Foxton Beach, May 2017

Waves appear to push the water forward, endlessly crashing on the beach. In reality, the wave travels through the water while the water itself just moves up and down (it's actually a little more complicated that that ... the water moves in small circles with no net gain in position). As the wave moves toward shore, the shallower water decreases the wave speed so wave length becomes shorter and the peak height increases. The wave peak moves faster than the water below, becomes unstable, and breaks forward. Air is trapped in the breaking wave crest and generates the distinctive and familiar sound.

While this describes how waves move and break due to velocity shear in a single liquid, like waves crashing at the beach, it does not describe how they break in deep water. For that, we have to turn to the efforts of Lord Kelvin and Hermann von Helmholtz. William Thomson Lord Kelvin (1824-1907) was a mathematical physicist at the University of Glasgow. His work was important to the formulation of the first and second laws of thermodynamics. Absolute Temperature i.e. Degrees Kelvin, is named in his honour. Hermann von Helmholtz (1821-1894) was a German scientist who made important contributions to our understanding of energy, electrodynamics, and thermodynamics. He is popularly known, however, for his work in describing how the human eye works. He was the inventor of the ophthalmoscopic, a tool hanging on the wall of almost every doctor's exam room, and one I use multiple times a day in my role as an ED physician.

Kelvin-Helmholtz clouds are thought to be the inspiration for the sky in van Gogh's Starry Night

The Kelvin-Helmholtz Instability describes how waves form when there is a velocity difference across the interface between two fluids. The most common example would be the formation of waves as wind blows over water. Kelvin-Helmholtz clouds form when there are two different atmospheric layers moving at different speeds. They form on windy days when there is a difference in air densities between layers. The faster upper layers "scoop" the top of the cloud into waves.

Kelvin-Helmholtz clouds over Palmy, June 2017

Walking into the hospital one day, Kari and I saw these clouds against the mountains and I was lucky enough to get a photo with my phone. To form, they require moist (yeah, I said it) stable air without upward movement and a steady wind source. They are generally very rare and transient. Interestingly, they have been seen and photographed by others in Palmy on at least two other occasions this year, in February and again in May. I have written previously about how persistently windy it is here in Palmy (Link: Up Hill, Both Ways!). I wonder if there is something about the local weather pattern that predisposes to this phenomenon, or if we just got lucky.

Science is fun ...

Lucky

The race is not to the swift

Nor the battle to the strong

Neither yet bread to the wise

Nor yet riches to men of understanding

Nor yet favour to men of skill

But time and chance happeneth to them all

- Ecclesiastes 9:11

Palmerston North Hospital

I firmly believe that luck happens when preparation meets opportunity. When you have an open and curious mind, and a certain amount of competence, you are able to take advantage of opportunities when they arise. You must take calculated risks, but things tend to go well when you do. Sometimes, though, you just get lucky.

The emergency department is an interesting, and often chaotic, place to practice medicine. Simply by being in the ED, people are generally having a really bad day. Many of our patients are poor historians with little understanding of their own health conditions. Occasionally, they are too sick to be able to communicate with us at all. They often leave vital information out of their story ... sometimes on purpose. Part of our job is to try to find those little nuggets of necessary data while wading through the detritus without seeming to dismiss the patient's thoughts or appear too "paternalistic". We are often called upon to make split-second, life or death decisions based on inadequate and inaccurate information. Unfortunately, we sometimes get it wrong; however, numerous studies have shown that emergency medicine physicians (EMPs) generally correctly identify serious illnesses even in the absence of confirmatory testing.

I would rather be lucky than good

- Lefty Gomez

Clinical instinct is a well recognized and accepted part of medical practice. It encompasses what experience adds to scientific knowledge and training. Most EMPs I know have a handful of stories about getting a test or study on a gut feeling rather than any evidence and having that test show the way to a correct diagnosis. Recently, I had one of the junior doctors order a head CT on a patient with an odd story but a normal exam. The junior asked why, and I didn't have a really good answer. The radiologist asked why, and I kind of made up an answer. The reality is that I don't know why I wanted that particular test at that time. The CT revealed a small area of bleeding into the brain. Rather than being reassured when this kind of thing happens to me, I wonder how many of those cases I have missed.

This week, we probably saved a child's life and it was all just because of instinct, timing, and luck. On that fateful day, the emergency department was thumping. All 30 of our beds and overflow spots were full and there were 20+ patients in the waiting room. We were working as fast as we could but it seemed that every time we dispositioned one patient, three more would check in. An ambulance arrived with a 3 year-old who's chief complaint was "unwell" ... really non-specific.

The normal procedure for an ambulance check-in is for the clerk to meet the ambulance crew and patient at the door to get name, birth date, address, etc. Simultaneously, the arrivals nurse tries to get a set of vital signs and the medical story to appropriately triage the patient. If they're not too sick, they get sent to the waiting room or have to wait in the hallway. If they're really bad off, a room is cleared for them and the patient previously in that room gets popped into the hallway. This kid didn't look too bad. He was awake and looking around, though not super active. He was a little hypotensive and appeared dehydrated, but the rest of his vital signs weren't too bad. He probably would have been placed in the hallway for an hour or two until a room came available.

In the midst of trying to do 16 other things, I kept glancing over at him while he was being checked in. I don't know what, but something didn't feel right. It's not something I would normally do, but I wandered over to listen in while the clerk and arrivals nurse got things started. Again, completely against my typical pattern, I interrupted the nurse and started asking the child's mother some pointed questions. My normal exam leaves a thorough check of a patient's skin to the very last step. I have no idea why, but the first thing I did in that hallway was lift up the child's shirt. His chest and abdomen were covered in a purpuric rash. The most likely explanation for this would be a viral illness with ITP ... a generally benign process. Far more concerning is meningococcal septicaemia.

Neisseria meningitidis is a naturally occurring bacteria carried by about 10-15% of the population as part of their normal, non-pathogenic flora. Carrier rates in New Zealand have been estimated a little higher at 20-40% of the population. Rarely, the organism can spread from a carrier to someone without immunity. When that happens, the newly infected person can develop meningococcal meningitis or septicaemia. Approximately 10% of people who develop meningitis will die. The fatality rate of meningococcal septicaemia is far more sinister ... approximately 50% will die within hours of onset. Each year in New Zealand, there are several deaths from meningococcal disease, and even more during epidemics. It is for this reason that immunizations are so important. Widespread dissemination of the vaccine has lead to sharp declines in meningococcal disease in developed countries. From 1991-2004 there were 5300 reported cases in New Zealand, with 215 deaths. From 2006-2010, for children and young adults 0-24 yo, there was an average of only 3.5 reported cases per year, though almost all of them were fatal.

Because we were so busy that day, there were already two paediatric registrars (upper level trainees) in the ED seeing other sick kids. As soon as I raised the alarm, we cleared a critical care room and had him in it. At his side we had me, two nurses, an ED registrar, and a paediatric registrar. In less than 10 minutes, we had IV access, blood and cultures drawn, and antibiotics running in. Despite our rapid and aggressive treatment, he continued to decline.

Before leaving the ED for the ICU, he was in septic shock. Over the next couple of days, he continued to worsen and he developed a condition called DIC, putting him at risk for multi-organ failure. When I followed up on his care a couple of days ago, he wasn't getting much better but his rapid slide had stopped. The ICU team was hopeful that he was turning the corner to recovery. He is still at risk for developing organ failure, deafness, blindness, permanent neurological deficits, reduced IQ, and limb amputations, but the quick reaction of the ED team at least gave him a chance.

It is because of successful vaccine programs that in 10+ years of being a doctor, I have never previously encountered a case of meningococcal disease. It is because of the rapid progression and likely fatal outcome that questions about meningococcal disease have been on nearly every test I have ever taken so I recognized it when I did. I had heard horror stories from older physicians describing watching a child go from fine to dead in a just a couple of hours, but they were stories and not my personal experience. I am fortunate that my meningococcal story is a relatively good one, and it is because of the incredible talent and dedication of every person in the ED that things went as well as they did. Without the amazing people I am surrounded by every day, responses and outcomes like this would be fewer and farther between.

Hats off to the doctors, nurses, techs and other staff in EDs the world over who work tirelessly each and every day saving lives. Remember that what you do matters.

All of my successes in Emergency Medicine can be traced directly back to the amazing faculty and staff I worked with, and the unparalleled training I received, at The University of Iowa Hospitals and Clinics Emergency Medicine Program. My UIHC friend, coach, and mentor Azeem Ahmed visited me here in Palmy when he was in NZ. I was proud to show him a small piece of his legacy.

GO HAWKEYES!