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!

Training Docs Down-under

The great themes of fiction are love and death.

Death is always a theme in medicine.

So too, I would argue, in its many spirits,

Is love.

And one of those spirits is resistance

To inhumanity, and injustice.

Love and death.

How lucky we are.

- Samuel Shem, author The House of God

Medical training in New Zealand is very different from training in the U.S. In New Zealand, I have been very fortunate to work with an amazing group of Junior Doctors and Registrars. While I am responsible for their instruction and oversight, I have been learning as much from them as they have from me.

I will attempt to make sense of the system from which they arrived and in which I now work. Since I can't really take pictures at work, I have included a selection of bird pics.

Common Raven (Corvus corax) - Yosemite Nat'l Park, April 2016

Training in the U.S.

The typical trajectory for medical training in the U.S. is four years of college/university, followed by four years of medical school, then 3-5 years of residency plus or minus additional fellowship training. I have known a handful of doctors who earned their undergraduate degree in some other discipline, but most people pursue a degree in one of the basic sciences. They identify themselves early on as "pre-med" and set about choosing coursework that will take them down that path. In the Spring of their Junior year, they sit for the Medical College Admission Test (MCAT) as the first step in a long medical school application process. There are some notable exceptions to this pathway that combine undergraduate and medical training into a 6-, 7-, or 8- year baccalaureate/MD program, combined MD/PhD programs, and people like me who came to medicine as a second career, but these represent a small minority.

The application process for medical school takes about a year starting with the AMCAS application. This is an electronic application used by most of the 140+ allopathic (MD) medical schools in the U.S. The selection process for granting interviews at each school varies, but it is usually based on some combination of undergraduate GPA, MCAT score, letters of recommendation, extra-curricular activities, and personal statements.

AMCAS applications can be submitted in June and are usually due August through October, though some schools will accept applications later. Interviews start in September and can run as late as February or March. Medical school classes start in August. In 2016 53,042 applicants submitted 830,016 applications for 21,030 medical school slots.

Red-headed Woodpecker (Melanerpes erythrocephalus) - Myrtle Beach SC, June 2012

Medical school is 4 years, generally divided into 2 years of pre-clinical classes followed by 2 years of clinical training. The first two years focus on normal and abnormal (disease) anatomy and physiology. Between the 2nd and 3rd year of training, med students take the first in a series of medical licensing exams. The 3rd and 4th years are devoted to direct patient care (though some schools do include limited patient involvement in the first year or two).

During their 3rd year, med students are expected to identify the specialty they want to pursue. They go through another nerve-wracking year of essay writing, applications, and interviews trying to secure a spot for their residency training. The process is stressful and expensive. During that third year, while learning to take care of patients on the wards and studying for each clinical rotation, they are also studying for the second round of medical licensing exams.

Blue Jay (Cyanocitta cristata) - Myrtle Beach SC, June 2012

One of the worst and most stressful periods in the lives of many U.S. medical students is the time leading up to "The Match". Applications for specialty medical training are due early in Year 4. The next several months are spent continuing inpatient medical training, and waiting to hear from residencies to which they submitted an application. Interview offers are made and students have to find the time and financing to travel to as many as possible. Once the interview period is completed, generally in January or February, students submit to the National Resident Matching Program (NRMP) a rank-list for the residencies at which they interviewed. The residency programs also submit a rank list. Residencies typically get several hundred applications and interview 100-150 med students for a dozen or fewer slots. Students may travel to only one or two interviews, but 10-15 is not unheard of.

The NRMP claims their algorithms are designed to ensure that students match as high up on their rank list as possible and residency programs fill their openings with their highest ranked students, all while ensuring that the maximum number of students are matched to some program somewhere. Of course, the algorithm isn't published and there is a lot of grumbling from both students and residency programs. Every medical student in the country finds out on the same day and time whether or not they matched to a program but not which program they matched to.

Red-bellied Woodpecker (Melanerpes carolinus) - Myrtle Beach SC, June 2012

Those students who don't match spend the next day in a "Scramble" calling every program with unmatched openings and doing telephone interviews on the spot trying to find a job. Two days later, amid much pomp, and tears of joy or frustration, medical students find out where in the country they are going to spend the most critical years of their medical education. There is no changing their placement and there is no recourse.

Once a residency position is secured, the life of a U.S. medical resident is fairly well regimented. Regardless if they are training to be a psychiatrist, family medicine physician, surgeon, emergency medicine physician, or some other specialist their course is predetermined. Residents follow a prescribed set of rotations and training segments. Residents in any given discipline will perform similar duties and functions, pre-approved and accredited, no matter where they train. The ultimate goal is board certification and the chance to establish a career. Board certification isn't always necessary to hang a shingle and start treating patients, but without it options are limited.

Eastern Bluebird (Sialia sialis) - Myrtle Beach SC, June 2012

Physicians trained in the U.S. therefore have nearly identical training when compared to their peers, regardless of where they went to medical school and where they did their residency training. Certain programs may be more rigorous, have greater exposure to research or some other sub-focus, or they may provide a small advantage in some other way; however, the basic requirements and pathway to attain them are determined by the ACGME and colleges (Medicine, Surgery, Psychiatry, Family Medicine, etc). Accredited residency training programs must adhere to these standards. (To my friends who trained at Harvard, Johns Hopkins, Wash U, Cleveland Clinic, Duke, etc ... I do recognize that your training was different, and elite, but the basic requirements were the same.)

Medical training in the U.K., while taking a slightly different pathway, is equally regimented. This is one of several reasons that we see so many U.K. trained junior doctors ("house officers") here in New Zealand where the pathway provides a little more variability.

Kotuku (Ardea modesta) - St Clair NZ, December 2016

Training in New Zealand

During their high school years, NZ students write (sit for) a series of standardized exams called the National Certificate of Educational Achievement (NCEA) Levels 1-3. The Level 2 scores appear to be the most important for entrance into an undergraduate (university) degree program.

In their first University year, students interested in a medical career must complete 8 required courses and write the Undergraduate Medical and Health Sciences Admissions Test (UMAT). There are two universities with medical faculty and they oversee 4 schools of medicine (a 5th has been proposed but does not yet exist). Admission to one of the two medical universities is based on first year university GPA, UMAT scores, and an interview. Not all eligible students are granted interviews ... in any given year, there are approximately twice as many applicants as there are interview slots. Students who aren't accepted along this "Overlapping Year One" track can go on and complete their undergraduate degree and re-apply as a "Graduate". They can only apply once as an Overlapping Year One candidate, and they can only ever apply to medical school twice regardless of the entry category.

Yellowhammer (Emberiza citrinella caliginosa) - St Clair NZ, December 2016

With Year 1 (the university "overlapping" year) behind them, NZ medical students have an additional 5 years of medical school training for a total of 6 years. The two years of pre-clinical training (Yr 2-3) are similar to U.S. medical school didactic training. This is followed by 3 years (Yr 4-6) of clinical training. Examinations are held at the end of the second, third, and fifth years. Year 6 students are called "Trainee Interns" and, the best I can tell, have a role similar to 3rd and 4th year medical students in the U.S.

After successful completion of their T.I. year, NZ medical graduates then move on to their "pre-vocational" training. In this new role, their official title is Resident Medical Officers (RMOs) but they are known as "House Officers" or "House Surgeons". Potential RMOs apply for positions within a given District Health Board for two years of general medical training. They do a variety of clinical rotations, each lasting 3 months. The equivalent training in the U.S. would be a two-year intern or transitional stint. In the U.S., the Intern would then be expected to continue on to specialist training, but in NZ they can essentially stay in this position indefinitely.

Kaka (Nestor meridionalis) - Orokonui Ecosanctuary NZ, December 2016

After at least 2 years of being a House Officer, they can apply for training in their preferred specialty. In the U.S., specialty training is chosen and applied for as a medical student and the Intern year is typically integrated into the overall program. Occasionally, residency training programs require that trainees do a "transitional" year at another institution before matriculating into the residency program. In NZ, the area of medicine for preferred specialty training isn't identified by the trainee until their RMO years. Instead of sending out a blanket application to several programs like in the U.S., potential residency trainees apply directly to the training program. For example, we have two trainees now who have asked us to sponsor their Emergency Medicine training, one of whom we suggested needed at least another year of RMO training before we would consider accepting them for training in our group.

Specialist training programs are 4-6 years depending on specialty. Once accepted for advanced training, the trainees are known as "Registrars". They continue to work in the hospital doing rotations of various duration. Interestingly, they don't stay with the same program for the entire 4-6 years. For example, our group has openings for up to 9 EM Registrars at any one time but we are only accredited to provide 12 months of training. Registrars must therefore complete their training elsewhere. The flip side of that is that we do take on Registrars who started their training at other hospitals. At the end of their Registrar training, they sit for qualification exams before becoming Consultant Specialists. Again, while the training is 4-6 years, the timeline is open. We have a "registrar" in our program who has been in this position for 12 years and has never gone on to sit for his exams.

Kakianau (Cygnus atratus) - Palmerston North NZ, November 2016

Consultant and RMO Unions

Consultant Specialists can choose to be members of a professional union, the Association of Salaried Medical Specialists (ASMS). From the ASMS website, this is how they see their role ...

1. Professional and Policy
In this role the ASMS:

• Promotes the right of equal access for all New Zealanders to high quality health services;

• Articulates our members' professional concerns and interests to the Government and its various agencies, employers and the public at large;

• Liaises with the Medical Protection Society to ensure effective representation for members facing disciplinary proceedings in clinical matters which may affect their employment;

• On the basis of our own experience and research we contribute to and promote informed public debate on matters relating to the provision of high quality health services to all New Zealanders.

2. As a union of health professions (Industrial)
We will advise and represent members in respect of their employment agreements. Our primary roles are to:

• provide advice to salaried doctors and dentists who receive a job offer from a New Zealand employer;

• negotiate collective employment agreements with employers. This includes a national collective agreement "the MECA" covering employment of senior medical and dental staff in all district health boards; ensures minimum terms and conditions for more than 4,000 doctors and dentists, representing more than 90% of this workforce;

• improve employment conditions for our members;

• support workplace empowerment and clinical leadership

We also advise members in respect of their individual employment rights and entitlemens and may represent them when those rights and entitlements are threatened. We will also review offers of employment made to members. The ASMS unashamedly promotes collective employment agreements through which we have achieved major advances for members.

RMOs can also choose to belong to a union, the New Zealand Resident Doctors' Association (NZRDA). Their mission ...

The RDA is the only organisation in New Zealand solely representing the interests of RMOs (RMO means Resident Medical Officer and includes trainee interns, house surgeons, senior house officers, and registrars). Our main purpose is to look after and to promote the interests of our members. This includes taking care of doctors' rights and your interests at work, with the health sector and in the wider community. The philosophy of the NZRDA is based on community, support and union principles such as democratic structure and quality service delivery to members. 

In short, the RDA supports RMOs, pursues RMO's interests and negotiates and enforces RMOs terms and conditions of employment. We provide advocacy advice and support for workforce issues that may arise including those related to compliance and enforcement of your employment agreement.

Torea (Haematopus unicolor) - Aramoana NZ, December 2016

For the past 6 years, I have worked nights only. I like the night shift for a whole lot of reasons, not least of which is that I actually get to see my family more than I would working days. I generally get up around 4 or 5 pm and have dinner with Kari and Little H. As they start getting ready for bed, I head off to work. I work through the night, and if I am lucky I get out as scheduled to make it home in time to kiss Little H as she heads off to school. Kari and I spend some time alone, have coffee and breakfast, and she heads off to work as I tuck myself in for the day.

Working in New Zealand, I have been on a more typical Emergency Dept schedule of shifts, working a mix of days and evenings. Over here, I haven't had to work any overnight shifts, though I do occasionally have to be on call overnight for issues the Registrars can't handle or need a Consultant to approve. In the past 4 months, I have worked no night shifts ... until last week.

The RMO's went on strike last week. Nationally, outpatient clinics, surgical cases, and many inpatient services were cancelled during the 3 day strike. Emergency Departments, here as in the U.S., are open 24/7/365. Like the post office, neither snow nor rain nor heat nor gloom of night (nor RMO industrial action) stays these couriers from the swift completion of their appointed rounds. The ED was staffed by consultant specialists and those RMOs who either were not union members or who chose to work despite the strike. I worked a total of 29 hours spread over three nights. It was a familiar rhythm, and one I enjoyed, but as the inevitable creep of time overtakes me I found night-shifts a little more difficult and a little harder from which to recover.

Kereru (Hemiphaga novaeseelandiae) - Totara Reserve NZ, January 2017

Things don't happen for a reason.

Things happen and then we give them a reason.

Right now, RMOs can work up to 12 days in a row and up to 7 nights in a row. They are asking for a maximum of 10 days in a row and 4 nights in a row. Sounds reasonable to me ... physical and mental fatigue is one of the largest factors in patient care mistakes. There are some finer points on both sides of the debate that I disagree with, but I trust that an equitable solution will be reached.

I spent three nights working while the RMOs went on strike to fight for better working hours and better working conditions, and a day later I marched. This past Saturday, January 21st, was our wedding anniversary. Kari's anniversary request was that Little H and I walk with her during the Women's March on Washington - Wellington.

My strong woman

Just so you don't think I am a total cad, we did have an amazing Anniversary dinner at Logan Brown in Wellington ...

Prosecco to start the evening

We live in a world where women are disproportionately affected by domestic violence and sexual violence. They are more likely to suffer from poverty. They are more likely to be affected by a lack of education, unemployment, under-employment, and a lack of opportunity. Women's rights are human rights. The failure of many to recognize or acknowledge this just contributes to the problem.

I marched because right now Little H thinks she can do and be anything in this world, and because of this belief, she can. Unfortunately, some day that light will dim. Too often she will be judged by the size of her tits or her ass, by how "sweet" or pretty she is, and not by her intelligence or the content of her character. If she does raise her voice and fight for what is right, she will be labelled "angry", "bitch", "strident", "cold", or worse.

I marched because I can, and in both the U.S. and abroad, many could not. I marched to lend my voice to the chorus of others, and to raise my voice for those who were too afraid to.

I marched.




May the Force be with you, and with her ...

Physician, Heal Thyself

I've got friends in low places

Where the whiskey drowns

And the beer chases my blues away

And I'll be okay

I'm not big on social graces

Think I'll slip on down to the oasis

Oh, I've got friends in low place

- Dewayne Blackwell and Earl Bud Lee

Working an Iowa football game from the luxury boxes

I love being an Emergency Medicine Physician, but if I had it to do over again I would do something different. Financially, spiritually, and emotionally the costs of getting here were too high.

When the bottom dropped out of the energy industry in 1999/2000, I was working for an oil exploration company. For every day I worked offshore and overseas, I earned a day off and my entire job description involved offshore and overseas travel. I would work for 6 weeks, then have 6 weeks (or so) off. The company paid my travel expenses and didn't care when I traveled to my destination as long as I was at the designated airport on-time to catch a helicopter out to the ship. If I wanted, they would fly me in a week or two early and I could travel in-country before getting back to work. I saw lots of South America, Alaska, and a little bit of Africa this way. When I was in the U.S. I would work at a bar as a bouncer ... better to be standing outside the door earning money than inside spending it.

As the price of oil dropped and the business got lean, I survived the first 2 rounds of lay-offs but didn't think I would survive the next one. I left Big Oil and went to work full time in the bar. I was racing triathlons and earning a little money at the bar, but mostly surviving on my oil stocks. Being youthful and financially naive, I didn't understand the concept of diversification. All my assets were tied up in energy stocks. For a while I was Duke Kahanamoku riding the big surf. I ended up losing it all.

Speedy triathlon wheels

Having to re-invent myself, I decided to go to medical school. I set about picking up pre-requisite classes and took an MCAT prep course. A year later I was applying to medical schools but I was offered few interviews and received no acceptance letters. One of the criticisms of my applications was the lack of medical experience, so I used some of my rugby contacts and volunteered at a skin bank. My job was to procure skin from cadavers and process it for medical applications (wound and burn care).

On my second go, I was wait-listed at two schools. Med School A was a prestigious program in the U.S. northeast associated with the school where I had obtained my undergraduate degree. Med School B was in the same town in Texas where I was already living and working. Late that summer, I received a phone call from the Dean of Admissions at MSA. They were putting together a short list of 3 students they could call at the last minute and asked if I was interested. Since MSA was in a town I knew well and where several friends had moved back to, I knew I could get there within 24 hours of a phone call and have a place to stay, so I said "Yes". I did tell the Dean that I was also wait-listed at another school. "If they call you," he said, "they will give you about an hour to make a decision. Use part of that hour to call me."

Sure enough, about 4-5 days later, I got a call from the Dean of Admissions at MSB. It was just after 11 am and they asked if I could be there at noon. I was working the bar at the time and told them so. "If you can't be here by noon, we'll call somebody who can." I should have known just from that sentence what the next four years would be like, but I was too blind to see it. I did call the Dean at MSA but he was out of the office for the day. I explained the situation I was in to his office manager and asked if there was any chance of them offering me a position. "I know if there is a position for you here or not, but I am not allowed to tell you. That has to come from the Dean." I thanked her for her time and asked her to pass on to the Dean that I was going to accept the offer from MSB. A couple days later he called me back, asked if I had accepted the position, and when I said "yes" he paused and finally said "congratulations". Maybe it's wishful thinking, and I read too much into that pause, but I would like to think they were going to offer me a position. I wish they had.

Rett - mascot for my undergrad alma mater

Having obtained undergraduate and graduate training at well respected universities, led a team of divers at NASA during the build-up to the International Space Station, worked my way up to a lower management position at an international company, and managed a small business, I had high hopes and expectations for medical school. I thought it would be the height of professionalism. Instead, what I encountered was the petty, fragile egos of weak academics. There were a few sympathetic kindred spirits among the faculty and my fellow students, but overall I found the entire experience soul-crushing. If not for the $250K debt I had accrued in the process, I probably would have quit and gone back to managing bars.

I had a goal of becoming an Orthopaedic Surgeon, focusing on either Trauma or Hand surgery, but railing against the system and those who run it is not a model for success. I bucked and fought for four years, suffering set-backs and failure in ways I had never done before. I finished medical school but not without bumps and bruises, and definitely without the grades and recommendations to become an Ortho doc.

The rugby team ... some of my best mates from my years on the Rock.

Not having matched into Ortho, I took a preliminary position at a General Surgery program. Through Gen Surg I could still do Trauma and there was a narrow pathway to a specialisation in Hand Surgery. The program I went to had a reputation for being particularly malignant, but I didn't have a whole lot of options at that point. I quickly discovered that I was a poor fit for either that particular program or possibly Surgery as a specialty. The two years I spent as a Gen Surg resident were some of my darkest days. I was angry and bitter all the time; hated my patients, hated going to work, and didn't want to go home to a new screaming baby and a wife I felt I had failed. I was drinking too much, not eating properly, and hadn't exercised in months. Fortunately, I self-identified before any issues arose and I made a plan to get out. I quit surgery and applied to Emergency Medicine programs.

 

Med school and Residency weren't all bad ... I met my wife and we had an awesome daughter together

My surgery program granted me time to travel for only three interviews. I looked at the program where I was doing my surgery training, a program in Texas where we had the support of family, and a flier based on the recommendation of a friend. I have no idea what Kari thought when I told her we were moving to Iowa, but she never batted an eye and set about making it happen.

There is a famous line from Field of Dreams in which the character of Shoeless Joe Jackson asks "Is this heaven?" and Ray Kinsella answers "No, it's Iowa." I'm not saying Iowa is perfect, but it turned out to be the perfect place for me at the time. Recently, I got to sit down with my faculty mentor from those years and in describing me, he said "Grant came to us broken." I was like an abused dog that is trying to figure out where the kicks are going to come from next. I brought to Iowa a solid skill set earned during my surgery program but there were also huge gaps in my knowledge base. The faculty and staff at the University of Iowa Hospitals and Clinics, especially those in the Emergency Medicine Residency program, didn't fix me. What they did was provide a safe, supportive environment in which I could learn, and grow, and heal myself. They gave me the gift of time and understanding. All of my successes as a physician can be linked directly back to them. As for my remaining faults, they tried their best. I left Iowa reluctantly, driven out by the ice, snow, and -40F winters. I left happier, more relaxed, and having established life-long friendships.

  

Digging out from an Iowa snowfall

 

 

EM residents hard at work.

  

Playing hockey for the "Shockers", a bunch of old guys from the St Luke's Emerg Dept.

 

 

Flying physician with UIHC AirCare

While medical school and surgery residency are memories I would rather not have made, I emerged from those experiences with a handful of good friends to whom I will be forever grateful. Since leaving EM residency I have caught up with a few of my professors in the U.S. and recently my mentor, coach, and friend came to New Zealand. He was here to visit a friend from his med school days but we made the time to hang out for a day. Half way around the world my family is building new bonds and forming new memories and it was amazing to share that with a familiar face. Azeem is four years younger than I am, but I look up to him like an older brother. I am forever in his debt for helping me forge my path ahead.

Old friends and new: Mike Takacs, me, and Nate Jones - Myrtle Beach, SC

  

Azeem came all the way across the pond to check up on me ... I hope I did him proud - Palmerston North, NZ

Not much NZ in this post, but the visit made me nostalgic and made me want to put my story out there. Thanks for indulging me.

Titrate to Life ...

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.