Working in Dubbo – part 2 (Team work!)

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When I was working in Dubbo base hospital, I was happy that there was some really good teamwork happening, and it was nice to have specialist back-up in critical care situations. In my week there I needed to call in back up on two out of my seven nights. On one night I called in one of the most supportive bosses around in my opinion, Rose Ly, to help with the intubation of post arrest patient, and on another night I had the help of the ED director, Randall Greenberg who supported me through one of my most difficult shifts to date in managing a busy ED department on top of a motor vehicle accident and trauma. In addition to getting senior support, it was really good to work with great staff, and as usual I come away form a locum with having met some fantastic people. One of the doctor I was lucky to work with a great bunch of people, starting with being greeted by an old buddy from Wellington, NZ, who happened to be on the floor when I turned to work for my first shift– who was none other than the quietly famous Ken Looi (ED doc by night, and Unicycle world champion by day, just incase you didn’t know). I also worked with some great doctors in the ED, including but not limited to Dave my co-night doctor, and the dream team who helped out in a big way on the busiest night of the week when there was also a motor vehicle trauma. Craig, Renuka, and Rafi stayed on well beyond their shift break to keep the patients treated. Als the other specialities really pitched in, especially Jane the med reg, and the entire surgical team who were up all night. Whilst it was another non-stop night, it was good to know that everyone was part of the team, including a very friendly ward clark who I promised to email this article to when I eventually wrote it. The nurses were great too, and Mel and Sue were the two in-charge night nurses kept me in order – and I repaid the favour with a dish of guacamole on my last night.

And finally I have to mention a particular senior nurse called Rose who made my day by saying to me at the end of shift in a kind and sincere way, “You did well, and I really enjoyed working with you, I hope you come back!”. Often the end of your shift a the end of 6 in a row is when you feel like crawling into a ball and going to sleep – so thanks Rose – you’re a star in my books! And thanks alos to everyone else!


Emergency health care in the public eye

Whilst in Dubbo I met friend called David Ward who was quite passionate about giving positive feedback about hospital services that looked after and cared for his wife and premature son in an emergency situation (see newspaper article). As David and I discussed over coffee one morning, when it comes to health care, and particularly “emergency work”, it is easy to focus on what is not happening when things rarely go wrong, rather than what good is actually being done a daily basis. Whilst it is so imporant to study error, (one of the things that has motivated me into the field of medical education) it is also important to be aware of the other side of this, which is good health care delivery that occurs on a regular basis. It is easy to loose perspective of this, particulalry under sensational reporting, and I guess this situation is partly a result of lack of positive feedback – which is in a way what this post is all about! 

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Dubbo Base hospital and Locuming in Rural EDs

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It’s been just over a month since I finished working an incredibly eventful week of work at the Dubbo Base Hospital Emergency Department (ED), and I thought I’d share some reflections about the week and about doing Rural ED Locums in general. This is what I wrote in the week following my visit.

In my week at Dubbo Base I saw a diverse mix of patients and it was an interesting and challenging ED work environment. Despite being a relatively remote hospital of medium size I felt that there was a strong education focus and this feature was one of the highlights for me because “I love learning and teaching”. The Dubbo ED had Emergency Specialist cover and was accredited for ED training, and there was also a host of specialty registrars from other departments (including Medicine, Surgery, Orthopaedics, Paediatrics and Obstetrics & Gynaecology) which made it a well supported ED to work in. However, at the same time, the last week of nights was perhaps one of the most challenging weeks of work that I had done in recent years. I think this is partly due to the diversity of patients that I saw (as Dubbo covers a large area in Central NSW), which one of the added challenge of doing Rural ED Locums.

In my week I was also involved in some interesting emergency medicine, managing a range of Medical, Neurosurgical, Surgical and Orthopaedic Emergencies, which including major trauma, resuscitation and post resuscitation care. In addition to the big stuff there were plenty of regular ED presentations, and we saw lots of Paediatrics, and some O&G and acute Psychiatry. 


The challenges of describing work in the Emergency Department

Ever since I started a sting of medical research in Sri Lanka, and became interested in International Emergency Medicine, I have been in the habit of reflecting on what goes on in Emergency departments back in this part of the world. Because of this I often find myself asking the questions; – “What do we do in emergency medicine – how do these systems work? Do they make a difference?”. Because I have worked or observed medical systems without Emergency Medicine as an established specialty, my observed answer to the last question is a “Yes”. I say this for many reasons, which is why I’m so passionate about the development emergency medicine.  However, perhaps greatest difference I can notice straight away is that Emergency Medicine provides a system and process of creating “a degree of order” from within the chaos of a hospital’s acute admitting facility. Emergency Medicine’s doctrine acts promote the fastest attention to the most critically ill patients first, and also promotes the provision of a high level of medical experience early. This certainly was the case in my last week of work, as the model was operating in full swing. I was particularly impressed in the way that we dealt with Trauma patients that we dealt with at the weekend and also the instances of Resusciation during the week. 

Reality is stranger than fiction

In writing this blog post I found it difficult to capture all the professional challenges, ethical dilemmas, mixed emotions, trials and tribulations that can be encountered even in a single week of working in the ED, and conveying this scene is perhaps where theatre and film have an important role to create awareness – both for the improvement of the system, but also the education of the public.  

In addition, knowing what happens in an emergency department is perhaps helpful to the friend and family of those who working this environment, for often out of the sheer enormity of the culture shock it’s hard to describe. I for one often find it difficult to talk about what I have been doing, or going through because of a fear of being misunderstood. I think some kind of debrief is really healthy, but rarely practiced. This trailer that I saw on a TV series called “24 hours in the ER” seems to capture some of magnitude of interesting, weird and wacky, and challenging things that one sees in the emergency department.

   

I never actually watched the full series myself, but the trailer that I’ve included above looks as if it would be a good series to watch. I really like how this trailer captures not just the “bells and whistles” of the job, but it also shows some of the really challenging (and rewarding) aspects of helping people, such as dealing with the process of death. A lot of our work these has become about “end of life care”, and helping families through this process, which is quite different to the “ER” I watched as a medical student – but I guess things have as the population is getting older.

Many doctors and medical these days are blogging about their experiences which give provides a very important interface of communication between patients and health care providers. Kevin MD is a great blog that compiles as series of articles about their experiences, such as this post by about the experience of a medical student confronting death. 

 

 

 

 

Calm within the storm

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Calm within the storm,

The straw that broke the camels back,

  

Is this just ‘pressure’, or a wino drinking crack?

 

The whole world of insanity eventually comes to face,

Us all in the mirror of time and grace,

 

So slow down your pace,

And see what is there,

 

I challenge you to do this!

If you do so care?


For when we are calm ,

The chaos becomes our balm 

 

And we can apply it to ourselves others too,

You also can be part of this new “calmness brew”!?

 

And even if those who have realized this maybe few,

Join me now in hand, and perhaps we can unfold what is long overdue?

  

First few shifts in Port Hedland

It was a busy emergency shift yesterday, and it is easy to feel overwhelmed in an environment where the demand can quickly shift to outstrip the available resources. This is often the case in the world of emergency medicine, but being a Locum perhaps adds an extra challenge to the mix because you are never familiar with how things run when starting in a new place.

Lucky for me, the staff I was working with were so friendly and helpful. Last night I was surrounded by fellow doctors, nurses and allied health who gave me the support I needed. In addition the specialists (Physician, Surgeon and Pediatrician supporting the emergency department) were proactive in helping! Already I was reminded of what I have experienced before when previously working in remote and rural settings. There seemed to be a kind of communal spirit focused on what I believe all health care workers should be focused on, “serving the patient”. This is the same spirit that can easily get lost in the impersonal way that many bigger city hospitals operate. 

So in amongst the chaos of the department, I was stuck in the middle of a fire alarm drill whilst managing a patient. It was just a “fire drill” and we were all told to stand down from the high alert, but there was still a technical glitch in the alarm system leaving it ringing for almost 10 minutes (aka- an eternity!). It was at this time that I felt that I had to hold insanity by the hand which probably lead to the source of this poem – luckily I made it back to the other side – Yay for the “Calm”!

 

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Port Hedland

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Desert Skies

 

Entering into a different world,

So very dry and dusty, yet tropical and unfurled,


 

Skies as big as eyes,

And palm leaves that leave you curled,


 

Figuring it all out is just another quiz,

Bearing the answers of a why?,


 

There is peace here too,

Beyond the disturbance of a sigh,


 

And everything is once again anew,

As your eyes open to the colour and the hue. 

 

30-1-12  A new locum emergency job, and new location. Today was my first day working in the Port Headland emergency department, a part of the world that I have never before been. I left Sydney in a rush as I tried to finish my PhD outline late the night before, leaving the house without my jacket – but where I was headed I wouldn’t be needing that. Jumping on the plane was as exciting as it was scary! Even from the moment I was boarding the plane I noticed things were different – such as the fact that more than 50% of the aircraft passengers were wearing uniforms with that were either orange or yellow with reflector patches! 

The Port Headland hospital is a really nice place to work I sensed this from the first moment I was orientated (*being orientated formally in an emergency medicine job is a luxury, so today I felt very lucky!). The first day of any job is always a huge stress because in emergency medicine one of the key elements of practicing emergency medicine relies upon knowing how the local systems work, what to do by oneself, and  when to call for help, and how to call! In other words it’s about knowing the culture of local practice in that department and that particular hospital. Learning cultures takes time and when you are in a high pressured environment it is natural to want to feel like “I wish I just knew how to do things faster”! What is comforting to know is that almost everyone faces this same learning curve when they start in a new place, so we are not alone! 

Another other great challenge of first day on a new locum is to do with making diagnoses in populations that you don’t yet understand. This is something I learned from my supervisors in Toxicology, one of the key clues to the diagnosis lies in knowing what types of poisoning are prevalent in the particular community where you are working (eg a semi-conscious 28yo male coming in with pin-point pupils is opiate toxicity until proven otherwise if your hospital is next to Kings Cross, but in Rural Sri Lanka it’s more likely to be organophosphorus poisoning!).

Port Headland has a large aboriginal population and today I felt like I was in a different world – ie I encountered more aboriginal patients in one day that I have in my whole career put together. This is quite Ironic given that I have practiced medicine in Australia for over a year but this has been in Eastern Suburbs Sydney, and before that North Sydney. It was so challenging for me to treating the aboriginal people, as I there was a culture that I am still learning to understand and I’m looking forward to learning more by working in this region.  I remember when I was in rural Sri Lanka, it was in learning the culture of the villagers who made up the majority of the patients that was the key to being able to deliver service.

Well I guess it’s time to sleep – I’ve got another shift tomorrow and got to do a teaching session on one of my favourite topics – organophosphorus poising! 

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