Tag: doctoring

In which patients, not doctors, get a vacation from the hospital

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Let’s talk about the idea of going on vacation from the hospital. Not for the doctors, but for the patients.

Every morning here in Whakatane we start our day with a group round. In the lounge room at the end of the hall are about twenty chairs surrounding a large table. Sometimes the table will have an unfinished puzzle sitting on it, worked on by patients and family members. At times the TV in the lounge (the only one for patients on the wards) will be turned onto the morning news show and we’ll switch it off. Just before 8 am, in file the rounding doctors for the day, the residents on duty, Nurse Managers, Social Workers, Physical and Occupational Therapists, Maori Health representatives, Respiratory Therapists, and Pharmacists. We go through the patients who are in the hospital with brief presentations so any of the support staff who need to see the patient are aware of them and their needs.

On the Friday of the first week I started working, we gathered for our usual morning rounds. About halfway through going through patients, we came to Mrs. Smith. “Mrs. Smith is going on leave this weekend,” reported her doctor that day.

“Leave?” I thought to myself. “I must have misheard.”

But, no, on he went and there was another patient who was also going on leave, which meant they were given enough pills from the hospital dispensary to take what they would need for the weekend and then were going to go home for a few days and come back on Monday for a reassessment. The physical and occupational therapist sometimes would go to the patient’s house with them to see where the deficiencies lay or at least reconvene on Monday for a discussion to see if they needed additional equipment or support.

Since then I’ve learned this is a commonplace occurrence. I had a patient who was ill with an infection and required IV antibiotics every eight hours. He was improving but still needed IV medication. On Friday, when I saw him, he asked, “Do you think I could go to church on Sunday? I usually play the organ for the choir.” I couldn’t think of a good reason why not, and off he went on Sunday between doses.

Other patients I’ve had have gone on leave as well while they wait for procedures that we can’t get easily as outpatients. A prime example is an echocardiogram, or heart ultrasound. An outpatient echocardiogram can take between one month to a year depending on how urgently it’s needed. Even at our facility we can only get them on Tuesdays and Fridays, and only four can be done on those days. If someone is generally well on say a Wednesday but really needs the test sooner than a month, we will keep them in the hospital but let them go on leave for times so they’re not stuck in their rooms.

I had another patient who was quite ill, also with an infection and was less stable, with worrisome kidney function and so weak he was unable to walk. However, his grandfather with whom he was very close had recently died, and the three-day funeral was starting the next day. Could he go on leave for the funeral activities?

This is utterly unheard of in the US, at least where I used to work. (If you’re a US based doc and this is a normal thing for you, please let me know, I’m curious.) The reasons are vast, starting with litigation. God forbid if something bad happened to someone while you’d let them leave the hospital, you would guarantee a lawsuit even if you’d gone over potential risks beforehand. People here also seem to have more family around who are able to help and stay with their loved ones – there almost always seems to be at least a few (and usually quite a lot) family members who live locally and help out regularly. We also have midlevel facilities in the States, which we don’t have here, called Skilled Nursing Facilities (SNF for short), for patients who don’t necessarily need hospital-level care but aren’t quite well enough to go home. Length of stay in the US is also typically pretty low because of that and because of financial pressures, so you’re in the hospital only as long as you can’t get the same level of care somewhere else, and then off you go. There is a stark dividing line between home and hospital – either you’re sick enough to stay in the hospital or you’re well enough to go home, and if you’re in between, then off to a SNF you go.

I get that mentality, and it took me a while to get used to the idea of leave, but I’ve grown to see it as an excellent idea. Sometimes, elderly people who seem highly dysfunctional in an unfamiliar hospital environment will do far better in their own space, where they’ve likely adapted their surroundings to work for them. A trial of a few days with family supervision seems far preferable than making a permanent decision of nursing home placement directly from the hospital setting.

It can be mentally healing as well. I had one patient who had not been doing well from a mental health standpoint. He’d been quite depressed in the hospital and just not getting much better. It looked like he was heading for permanent nursing home placement as he couldn’t get any stronger. His family said that if he could just go home for a few hours, sit on his couch, pet his dog, he’d be much improved. Despite my American doctor sensibilities, I acceded to their request. You know what? They were right. He came back with new enthusiasm and was able to be discharged home the next week.

For my patient who wanted to attend the funeral despite his own serious illness, it was clear that to miss the funeral would be something he would regret forever. Despite the risk, his family was able to arrange wheelchairs and transportation and he was able to attend at least for a few hours daily. Could something bad have happened? Sure, but we talked about the risks, he and the family accepted. Again, they made sure to time their visit around his medications so no doses were missed or late. It’s not a medically litigious society and people overall are far more comfortable with understanding that they’re taking a risk and living with it. I see some decisions like this as working with people to address other needs than just the physical, which overall impacts health.

I know this isn’t something I’ll be able to do at home, it’s just not accepted practice. But I have to wonder for people who are in the hospital for long periods of time whether a little break, a little return to normalcy and the outside world doesn’t provide a lot more benefits than I can give through an IV line.

-s

In which I learn the price of wool from one of my patients, and the kids footwear budget drops considerably

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It is perhaps unsurprising that we would find ourselves in a bit of the doldrums over the last few weeks.

It’s pretty normal in the world of expat psychology, where at some point you start to miss all that you had at home, like your friends at home, or your kitchen, or having a goddamn garbage disposal. It’s part of the usual adjustment process, but it can leave you with questions about whether or not you did the right thing by moving halfway around the world. Eventually this is followed by another up, then downs, until you reach a homeostasis of expatriation, or just another middle ground.

Even New Zealand seemed to have it out for some of us. One day it was a “mufti day” which meant that the boy could wear whatever he wanted instead of his uniform. Deciding that he loved his uniform, he decided to accessorize only with his Stitch hat with the big flappy ears. He left the house to walk to the bus stop. Eric was drinking a cup of coffee on the balcony overlooking the street.  Suddenly, he noticed a commotion below him. The seagulls had left their usual post on top of the street lights to dive towards our son. The boy was being bombarded by a flock of seagulls who apparently thought that he, in his hat, was some kind of tasty large worm. The boy ran down the sidewalk, frantically waving his hands over his head to ward off the gulls, who squawked in frustration at being blocked from their breakfast. An older man walking along the beach stopped and stared at the scene, while we howled with laughter.

As if to troll us, our new place is decorated with all sorts of seagull paraphernalia that seems to have been put up with a permanent sticking charm. The boy doesn’t wear his hat indoors here, for fear of calling out the avian demons. They’d probably leave their paintings to attack in the middle of the night.

Even the salt shakers
seagulls…
they are watching…

The girl has melted into school, and is having a ball. While she hasn’t made a lot of friends yet, she bounces out of bed every morning so excited about going to class. She loves her teacher, and one thing we’ve seen is that creativity is far more valued here than it is at home. Her homework, or “home learning” as it’s called here, is entirely open. Every two weeks she gets a sheet of paper with a variety of options for home learning – you can choose artistic options, math options, writing – so that every kid can find something to interest them at home, but without the rote tasks that homework seems to be back home.

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Homework for two weeks! You are expected to pick as many as you want to do and share at the end.

The boy is likewise enjoying school, and has a first playdate set up for this weekend. He was initially feeling a bit down about it, as NZ kids are quite sporty, and he’s…not. But he’s found his own little group of nerdlings as he does, playing chess in the school library at lunch and just this week has started introducing Dungeons and Dragons to his crew. His highlight of the last week was when he “accidentally” locked his shoes in the house when he left for the bus (we’d all already left for other destinations) and “had” to go to school barefoot. Upon arrival at school he was given the option of wearing a pair of the extra shoes they have at the office, but he declined.

kids walking and even scootering home from school, shoeless
Having a barefoot day

As for me, the hospital work keeps on. Despite my years of experience back home, learning new medications and new systems leads me to feel like a new resident much of the time, which brings back all the traumatic PTSD I have related to that time and leaves me feeling unconfident.

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These signs are all over the hospital. What sort of zombie apocalype are they expecting?!

So many times I’ll casually ask for something that Americans would see as completely normal, only to have it thrown back at me. I had a patient who had fallen and had a nasty scrape where he’d lost a fair amount of skin. Unthinkingly, I said, “let’s put some polysporin on it and cover it with a nonadhesive bandage.” The resident I was working with looked shocked. Absolutely SHOCKED. “We…shouldn’t do that. It’ll lead to antibiotic resistance.” I paused, knitting my brows, and replied, “so…you can’t just get an antibacterial ointment over the counter here? What do people put on cuts?” “We just tell them to put hydrogen peroxide on,” he replied. He then proceeded to look up antibiotic ointments that were available in the hospital, and after a search of five minutes finally came up with one that they had that used a different mechanism of action less likely to result in resistance.  WHEW. I was kind of left feeling like, “Who’s the attending here?” and wanting to say indignantly “I AM! I’m the attending!”

Hospital lobby
Entrance signage. No gang patches, and remove muddy shoes…and enter shoeless.

Sometimes people think I’m a blinking idiot because it seems I can’t grasp a basic idea they’re talking about, when it’s just that I can’t understand their accent. They then go into details of whatever they were describing like I’m a moron, at which point I’m too embarrassed to correct them and say that it was their accent I couldn’t understand since of course, I’m the one with the accent. I had a patient who was telling me that he had “hot tack” a few years ago. Thinking that this was some Kiwi traditional therapy or something, I asked what “hot tack” was, only to get a quizzical look from my resident as she described “Hot tack? Well, it’s when the heart doesn’t get enough blood and then doesn’t work as well, and they get chest pain?” Oh.  A heart attack.  Great, now both patient and my resident think that I don’t know what a heart attack is. There goes any credibility I might have had.

How to get staff to do online education modules
This cardboard cutout encouraging hand hygiene scares the crap out of me when I walk by.

That said, I continue to be amazed by the relative reasonableness of patients regarding their medical conditions. I’ve had far more conversations with ill people about their potential for death, and all of the elderly people I’ve talked with have expressed to me that they don’t want any aggressive measures to be taken and that they understand that this could lead to their death.  These are different than conversations like this I have at home, where usually the question is asked to someone who is not in extremis, and even then limits to “what can be done” is not typically discussed. People will talk about not wanting to be resuscitated, or be put onto a breathing machine, but smaller discussions don’t often take place, and there is a different attitude towards end of life.

I do feel like I can be more relaxed overall with the patients here, chatting with them and able to bring more humor into our interactions. I’ll leave you with a story from last week.

I performed a procedure to remove excess fluid from someone’s belly, and it takes a while to get the fluid out slowly as we don’t have the handy vacuum sealed flasks here that whoosh it out in a matter of minutes.  Over the 30 minutes I sat in the room, I chatted with the patient, a Maori person, and his daughter in the room. They live out in farming country, and I asked what type. “Cows, ship, pigs. All sohts of animuls.”

“Do you raise the sheep for meat or for their wool?”

“Wull. You can do it foh both…but listen to this. Theh was a farmah who hed his whole flock stolen! And thin two wiks latah, the entiah flock was returned to him, but they’d all bin sheahed! I said to myself, ‘theyah’s a man who knows the price of wul!’”

“Wait,” I said, “They brought the sheep back and no one noticed?”

“Oh yeah!” the daughter said, “And that’s when I said you know thet wasn’t no Mowri pehson stealin’ the ship because we would have kept those ship and fed them to our families!”

 

-s

In which I start my job as a doc in New Zealand

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I knew I’d have a lot to learn working as a doctor in a new country, but I didn’t think it would start before I entered the hospital.

I walked up to the hospital on my first day of work, held my badge up to the double doors and expectantly waited for them to open for me. They did not. I flashed my badge a few times, looking like a proper idiot, wondering if the doors weren’t working. I then realized that I had to manually open the doors here and walked on in. I had two days of a gentle orientation before beginning to see patients, where I got a tour of the hospital, filled out important paperwork and was introduced to nearly everyone and welcomed warmly.

On Wednesday, it was time to start the real doctoring.

Things run a lot differently here than I’ve been used to. Some of that is simply because I’m working in a small rural hospital instead of the large urban center I was at. Some of it is because I’m working with the New Zealand medical system, and some is because I’m taking care of New Zealanders and not Americans, who seem to approach their healthcare quite differently.

I came into morning report, a gathering of the doctors on for the day, the head nurse, physical and occupational therapists, pharmacists and other members of the care team. We listen to the new patients admitted overnight and then run through our list of patients to see what is needed from members of the care team. I picked up my list of five new patients to start seeing that day and met up with my house officer. The training system in New Zealand is beyond my capacity to understand – from what I can tell, the educational level of the H.O.’s is about that of a 3rd or 4th year medical student, but they function much as interns. It’s also not necessarily linear in a way that’s incomprehensible to me. My house officer, upon later conversation, casually mentioned that he was going to quit to go travel for 6 months and planned on returning. I’d like to find a residency in the States that would let that happen!

I went to see one of my first patients, a man who needed a procedure done to drain fluid out of his body. He was on a blood thinner, though, making it more dangerous. I approached this the way I do with my American patients, carefully explaining to him and his family the risks and benefits of the procedure, the possibility of increased bleeding, what we would do to prevent this from happening, and how we couldn’t do much if bleeding happened. I asked at the end if he would like to think about it and we could return later, which would be pretty typical at home. “Nah, I guess we’ll just go for it.” I blinked a few times, as it seemed a bit too easy. “You’re…sure you don’t have any other questions?” “Nah, if it’ll help me feel better let’s just do it.” We set up the procedure for the next day, and it went swimmingly.

I saw another patient who was in for a heart issue for which ultimate diagnosis would require an echocardiogram, or an ultrasound of the heart. The only problem was that it was Wednesday, and echoes are only done on Tuesdays and Fridays, and even then only four on a single day. If you’re the fifth patient, too bad, you’re going to have to wait. If you need a more urgent echo, you’ll have to be driven an hour away to Tauranga to a larger hospital. This is utterly unheard of in urban centers, where I would roll my eyes at an echo taking more than a few hours to obtain. Feeling sheepish, I went into discuss this with the patient, expecting anger and incredulity at the inefficiency of the system. “Oh, no problem,” was the reply, “If we can’t get it on Friday my daughters can just drive me up to Tauranga to get one.”  I was forced to use actual clinical skills to diagnose and treat her without the technological test, which ultimately did get done on Friday.

Another thing we don’t have available that I’m used to : consultants. There’s a surgical team and an orthopedic team, but other than that, there are no medical subspecialties here at all. If someone really needs to be seen by a cardiologist (heart) or a nephrologist (kidney) we ship them to Tauranga hospital for evaluation. Once the patient has been seen and recommendations given, they’ll be shipped back for us to continue the remainder of their hospital stay.

At home, I’m used to doing all the primary work of doctoring myself by which I mean writing notes, ordering medications and tests, following up, and taking calls from nurses if something goes wrong. Here, my house officer does all of that for me. I look up pertinent information before seeing the patient, and then we see the patient together, and then I just tell him what needs to be done and written and…it gets done. It leaves me feeling a little unmoored to be honest, and without me sitting down and looking through all the details of the chart as I write, I keep feeling like I’m missing something. Somewhere along the way I’m supposed to be teaching them something, but I’m okay with letting that slide for a couple weeks while I figure out the system myself.

Being in a nationalized health care system means that there are stricter limitations on what medications you can use in the hospital, especially antibiotics. A patient who comes in with pneumonia in the U.S. would reflexively be prescribed ceftriaxone and azithromycin or levofloxacin for treatment. There are infection nurses who look over more unusual antibiotic choices to regulate those, but no one would stop you from prescribing ceftriaxone. I had to call an Infectious Disease doctor to order it as part of a combination treatment for a patient of mine who came in with pneumonia and got worse with outpatient Augmentin pill therapy. The doctor paused for a second before she said, “I don’t think that’s necessary yet, let’s try IV Augmentin first.” I was denied. (The patient did, though, get better with the IV Augmentin, I must admit.)

There are at least a few patients daily who hear my accent and take the time to tell me what an unhinged lunatic Trump is. One guy, hardly able to breathe with a lung problem, still took time to squeak out that he thought Trump would be the last president of the United States as we know it. It’s a common feeling here, where the U.S. is currently regarded as something of a laughingstock.

All in all I’m enjoying the new gig, though I feel I’ve got a lot of learning to do before I get a handle on how things really work.

-s