I switched jobs this week, going from the relative comfort of the infectious disease job to the busier territory of helming a general medicine team. As at Duke and probably most other large medical centers in the world, the gen med teams are the workhorses of the hospital, as most patients being admitted fit somewhere under the umbrella of internal medicine unless they are pregnant, under the age of eighteen, or going immediately to surgery. I was actually on call on my first day, taking in a steady stream of new patients from the emergency department, as well as fielding calls from all of the other services in the hospital whenever they needed medical advice, like when a patient on the orthopedic service got chest pain and the surgeons needed advice on what to do next. That much was all familiar to me – that’s basically how I spend a lot of my time at Duke. There were some surprises, too, like when it turned out I was running the code team – would have been nice to know before my pager went off and I saw the message “cardiac arrest in room 4A-25.” When in doubt, if I’m being alerted that there’s a dead/dying patient, I figure somebody wants me to know and I should probably proceed in that direction with some haste. But I was still surprised when I arrived at the room and it turned out I was in charge.
That was followed quickly by a string of calls from district medical officers, who as it turns out are people who oversee the far-flung clinics in the territory, those places like Yarralin and Kalkarindji where I went before. These clinics are staffed day-to-day by nurses, with intermittent visits from traveling docs, so when the nurses have questions on days that there is no doctor in town, they call the district medical officer. And it turns out that when the district medical officer has a question, he calls me. So I was overseeing airlifting operations for heart attacks, sixteen-year old pregnant girls with urgent blood pressure problems, and advising on lots of less urgent outpatient issues in between. In all, it was actually pretty fun – you either embrace the job or you soil your drawers, and I didn’t bring that many extra clothes with me.
I also found a new way to make oneself extremely unpopular among the emergency room staff. You might think that it would take the cake if you show up horrifically inebriated, abusive and in some state of filth. But actually this is common enough that a seasoned ED nurse won’t bat an eye for your average (or above-average) drunk. Ditto for strange objects inserted in strange places – good for a chuckle, but not much more. It takes something more bizarre to ruffle feathers, something like a patient I saw in medical school with maggots on her leg, some of which were actively transforming into beautiful baby flies which buzzed around the emergency department. And here it the northern territory, it takes a man walking into the department carrying a squirming death adder, as a gentleman did this week. He is a drummer in a local band, and a bit of a snake enthusiast, so when he saw a snake on the road as he was driving to a gig, he decided to help it off the road so it wouldn’t meet an untimely end. But I hope he is a better drummer than snake handler, because what he identified as a nonvenomous python turned out to be the rather-more-venomous death adder, a possibility that only occurred to him when he noticed that the reticent “python” had just buried its fangs in the back of his hand. Interestingly, the death adder reportedly has the quickest strike in the world – 0.13 seconds from strike position to envenomation and then back again, not to mention that it's considered one of the ten deadliest snakes in the world – so not the ideal elapid to try to handle. So his next thoughtful decision was that he better get himself to a hospital (correct), and it would help those treating him if he captured the snake and brought it with him, alive and annoyed (incorrect). The patient did okay, but I’m afraid the death adder did not enjoy its (brief) hospital stay quite as much.
I think I’ll leave it at that today. I would give an update of my enviable social life, but instead of titillating and scandalizing you with the details, I’ll instead give my personal ratings of the books I have read here thus far. Then you can imagine for yourself how I spend most of my free time (until Josette gets here and we start traveling in 27 days, but who’s counting).
Super Duper:
Saturday, Ian McEwan
A Long Way Down, Nick Hornby
The Yiddish Policemen’s Union, Michael Chabon
Fear and Loathing in Las Vegas, Hunter S Thompson
Quite Good, Possibly Super Duper:
Waiting, Ha Jin
A Pleasant Way to Pass the Time:
Sex, Drugs, and Cocoa Puffs, Chuck Klosterman
Special Topics in Calamity Physics, Marisha Pessl
The Weaker Cousin of One of the Five Best Books I Have Ever Read:
The Moor’s Last Sigh, Salman Rushdie
Not Recommended:
Skinny Dip, Carl Hiassen
Absolutely To Be Avoided At All Costs, Even Upon Threat of Bodily Harm:
The English Patient, Michael Ondaatje
Oh, and I am heroically working through David Foster Wallace’s Infinite Jest, 384 pages into the most complex work of fiction I have read to date, a mere 700 pages to go. I am an unabashed fan of his from his nonfiction collections – I would put A Supposedly Fun Thing I’ll Never Do Again and Consider the Lobster in the “Super Duper” category above. Ergo, I am undaunted by Infinite Jest, including the 100+ characters I have met so far, and the ninety-six pages of explanatory footnotes, including footnote #123, which presents an extended proof of something called the Mean Value Theorem, requiring a working knowledge of at least basic calculus just to understand the footnote, which itself barely sheds light on the overall thrust of the narrative (which I could best summarize thus far as tales from an elite Boston tennis academy, a halfway house for crack addicts and alcoholics, and some interspersed vignettes of militant paraplegic Quebecois separatists – I guess it’s pretty obvious where this book is heading, eh?). And while I like to think I have a vocabulary appropriate for someone who has spent about twenty years in school, I’ve been keeping track of the words I don’t know as I come across them, and the list is now running about 150 items long, including one single sentence in which I found the words “sallet”, “calpac”, “harquebus”, “calotte”, “escudo”, and “shako” (and I don’t mind admitting that I’m a little bit annoyed that my spellchecker recognized all but two of those). So if in my next post I write a prolix ghazal about an etiolatated phylactery, well, you’ll know why.
Saturday, August 25, 2007
Saturday, August 11, 2007
August 11, 2007
Hi again.
I’m continuing to see interesting infectious disease cases, the kind that make you wash your hands twice when you leave the patient’s room. Crusted scabies is a big problem here, a man-eating mite infestation that in its severe form consumes great swaths of skin, building a crust harboring thousands upon thousands of mites. I don a hat, gown, gloves, and shoe covers just to enter the room, and spray my shoes with Raid when I leave, but that itchy sensation nags at me for hours anyway.
Another traveler turned up in Darwin with a fever – this time a Spanish guy who lives in Ecuador, but had been surfing in Sumatra prior to coming to Australia. He was quite ill and turned out to have both malaria and dengue fever, but pulled through okay. There is a woman now on the ward with typhoid fever, and another with acute rheumatic fever – both quite rare in the US these days. And there are three cases of necrotizing fasciitis on the service right now – the famous “flesh-eating bacteria” as it tends to be called in media outlets trying to maximize the sensational value of their story. All three guys will be okay although one has lost his scrotum – feel free to list Fournier’s gangrene on your list of diseases you don’t want to have.
For every rewarding diagnosis I am stymied by another. There is an eighteen-year old girl with a weird necrotic lesion just beside her left eye. Really very interesting – could be tuberculosis or a related mycobacterium, or melioidosis, or a fungal infection, or cutaneous anthrax. But she doesn’t want it biopsied because she’s eighteen and it’s her face and she’s scared of needles. And it’s actually getting better, so it’s hard to force a biopsy on her just because I want to know what it is. Another lady was diagnosed with osteomyelitis of the skull from an invasive ear infection. She seemed to be on the right track, improving with antibiotic therapy, and then when I came in this morning I found out she died last night. It’s hard to get authorization for an autopsy on an Aboriginal person, so I’ll never know what went wrong there. And given the cultural prohibition against talking about the dead, I can’t even ask her family what happened.
And my old friend Romanus has finally left the hospital. He actually got out a few weeks ago, transitioning to the “self-care” area where patients can go if they are well enough to leave the hospital but still need some treatment (in his case, intravenous antibiotics) that they can’t get at home. The self-care area is actually part of the staff village, so on his day of discharge I passed by him on my way home, sitting happily in the sun. He said “Hi Tom” and then about four other things that I had no prayer to understand. Then six hours later he was found by the staff lying on the floor, confused, agitated, and in a condition of some filth – I will spare you a description. I don’t know if he got back into the grog; he has very little liver function left after some years of hard drinking. Or maybe there was something I had been missing before he left. In these situations I’m always internally annoyed when I can’t understand what happened – I like to think it’s a healthy drive to want to know it all. But I’ve chosen the wrong profession, and the wrong branch of medicine, if I can’t accept that I make the majority of my decisions based on incomplete information – just gather the best data available, and fit it into the clinical scenario, and make a set of choices about how the patient should be cared for. But I was still privately fuming that I had missed something with Romanus. Anyway, he gradually got better again, and now he’s been gone almost a week, so maybe he’s on the right track.
News from the (temporary) home front - I think I have mentioned before that I am living in the staff village which is next to the hospital. There are some other doctors in the village, but most MDs come for a longer stint and choose not to stay in these mildly unappetizing accommodations. Thus most of my neighbors are actually nurses, as there seems to be a population of RNs who travel on short-term contracts, moving around Australia following the good money and travel fun. Most also have gone to the UK where the pay is good, until they can’t stand the weather any more. And like me, they don’t mind the dorm rooms for a few months. At any rate, I have fallen in with a group if ICU nurses, and on Monday we went as a group to the Carlton Cup.
The storied Carlton Cup is the Northern Territory equivalent of the Kentucky Derby. It’s a public holiday, and here in Oz doctors usually take public holidays off (a brilliant idea), so after a quick check on the service I headed to the Fannie Bay track. The female nurses were all dressed in their finest Derby-wear, with hair immobilized in various extreme creations. The male nurses had a collection of monochromatic suits over tight black t-shirts – Keith in a blazing fuchsia number, Bill in aqua blue, etc. I was sadly not included in this sartorial coordination, so there I was in khaki pants, plain white shirt, and the only (conservative) tie I brought with me. We arrived around noon, in time for the first of nine races culminating in the Cup race itself. Already there were about 15,000 people there, not bad for a town of 100,000. I suppose if I had taken time to think about it beforehand, I would have realized that the kind of town that has an annual boat race for crafts made of beer cans would not be able to take a horse race entirely seriously. In my first five minutes at the track, I saw an older man in a suit (complete with top hat) made entirely of coconut leaves – he makes one every year just for the Cup. Another gentleman was entirely nude, a dubious choice as he went from Caucasian to Pinkasian over the course of a blistering afternoon. Overall, I believe it was the largest confluence of ridiculous outfits, cleavage, tattoos, heavy drinking, and reckless gambling that I have witnessed, at least since my wedding.
I set out immediately upon a quest to make some money – how could Captain Thundabolt lose? He could finish in last place, as it turned out, and the first ten bucks of the day went down the drain. Il Duca was the safe bet in the next race, a heavy favorite who faded down the stretch and took another ten-spot with him. I took to studying the racing form more intently, breaking down each horse by overall record, performance on dry dirt tracks, time since last race, and various other factors which seemed like they could be important. I missed a quinella and chased a trifecta. I took a race off to restore my karma. I thought maybe my early two-beer-per-race pace was clouding my thinking, and tried a bit of water. Nothing worked, even as everyone around me seemed to be cashing winning tickets. By the time the Cup race came around, I had come full circle to completely irrational betting (who was I kidding anyway – how did I really expect that it would help me to know how Catwalk Minnie and Mister Raw had run on a wet track in Melbourne?). For the Cup, I noticed that one of the favorites had run very well in his last three races with a jockey who I have unfortunately come to know, as he was thrown during a race a couple of weeks ago and now resides in the Royal Darwin Hospital ICU with a devastating brain injury. It seemed like a good tribute to back his horse – wouldn’t that make for a nice story? It would, I suppose, if he hadn’t been replaced with a jockey who apparently had never seen a horse before. I actually think he may have ridden his mount backwards, flailing at empty air with his riding crop while screaming in terror. He couldn’t have done any worse if he had ridden a three-legged Jersey cow. Ah well, you win some, you lose some, except when you lose them all.
As soon as the Cup was over, an eighteen-wheeler pulled out on the track, the sides dropped off, and a band was revealed, fully set up and cranking out the rock. The crowd spilled out onto the track and started dancing to the sweet, sweet (cover) tunes of Bob Seger and Dexy’s Midnight Runners. A predictable number of inebriated males took to staging their own races out of the starting blocks. I am fairly certain that this does not happen after the Kentucky Derby although I have not been there myself. I was a model of restraint – usually the combination of ethanol and sprinting is irresistible to me. The nurses and I stayed on well into the night, and then took a packed, jovial bus on into town for more revelry. This town knows how to do a public holiday right.
I haven’t uploaded any good pictures recently, and I had camera trouble (ie I forgot it) on Cup day, so I’m waiting to get some pictures from everyone else. So I’ll give you a picture from one of my long weekend bike rides. And maybe a family picture or two. Not exactly related to Darwin, but since when did a dad ever need an excuse to show pictures of his kids.
I’m continuing to see interesting infectious disease cases, the kind that make you wash your hands twice when you leave the patient’s room. Crusted scabies is a big problem here, a man-eating mite infestation that in its severe form consumes great swaths of skin, building a crust harboring thousands upon thousands of mites. I don a hat, gown, gloves, and shoe covers just to enter the room, and spray my shoes with Raid when I leave, but that itchy sensation nags at me for hours anyway.
Another traveler turned up in Darwin with a fever – this time a Spanish guy who lives in Ecuador, but had been surfing in Sumatra prior to coming to Australia. He was quite ill and turned out to have both malaria and dengue fever, but pulled through okay. There is a woman now on the ward with typhoid fever, and another with acute rheumatic fever – both quite rare in the US these days. And there are three cases of necrotizing fasciitis on the service right now – the famous “flesh-eating bacteria” as it tends to be called in media outlets trying to maximize the sensational value of their story. All three guys will be okay although one has lost his scrotum – feel free to list Fournier’s gangrene on your list of diseases you don’t want to have.
For every rewarding diagnosis I am stymied by another. There is an eighteen-year old girl with a weird necrotic lesion just beside her left eye. Really very interesting – could be tuberculosis or a related mycobacterium, or melioidosis, or a fungal infection, or cutaneous anthrax. But she doesn’t want it biopsied because she’s eighteen and it’s her face and she’s scared of needles. And it’s actually getting better, so it’s hard to force a biopsy on her just because I want to know what it is. Another lady was diagnosed with osteomyelitis of the skull from an invasive ear infection. She seemed to be on the right track, improving with antibiotic therapy, and then when I came in this morning I found out she died last night. It’s hard to get authorization for an autopsy on an Aboriginal person, so I’ll never know what went wrong there. And given the cultural prohibition against talking about the dead, I can’t even ask her family what happened.
And my old friend Romanus has finally left the hospital. He actually got out a few weeks ago, transitioning to the “self-care” area where patients can go if they are well enough to leave the hospital but still need some treatment (in his case, intravenous antibiotics) that they can’t get at home. The self-care area is actually part of the staff village, so on his day of discharge I passed by him on my way home, sitting happily in the sun. He said “Hi Tom” and then about four other things that I had no prayer to understand. Then six hours later he was found by the staff lying on the floor, confused, agitated, and in a condition of some filth – I will spare you a description. I don’t know if he got back into the grog; he has very little liver function left after some years of hard drinking. Or maybe there was something I had been missing before he left. In these situations I’m always internally annoyed when I can’t understand what happened – I like to think it’s a healthy drive to want to know it all. But I’ve chosen the wrong profession, and the wrong branch of medicine, if I can’t accept that I make the majority of my decisions based on incomplete information – just gather the best data available, and fit it into the clinical scenario, and make a set of choices about how the patient should be cared for. But I was still privately fuming that I had missed something with Romanus. Anyway, he gradually got better again, and now he’s been gone almost a week, so maybe he’s on the right track.
News from the (temporary) home front - I think I have mentioned before that I am living in the staff village which is next to the hospital. There are some other doctors in the village, but most MDs come for a longer stint and choose not to stay in these mildly unappetizing accommodations. Thus most of my neighbors are actually nurses, as there seems to be a population of RNs who travel on short-term contracts, moving around Australia following the good money and travel fun. Most also have gone to the UK where the pay is good, until they can’t stand the weather any more. And like me, they don’t mind the dorm rooms for a few months. At any rate, I have fallen in with a group if ICU nurses, and on Monday we went as a group to the Carlton Cup.
The storied Carlton Cup is the Northern Territory equivalent of the Kentucky Derby. It’s a public holiday, and here in Oz doctors usually take public holidays off (a brilliant idea), so after a quick check on the service I headed to the Fannie Bay track. The female nurses were all dressed in their finest Derby-wear, with hair immobilized in various extreme creations. The male nurses had a collection of monochromatic suits over tight black t-shirts – Keith in a blazing fuchsia number, Bill in aqua blue, etc. I was sadly not included in this sartorial coordination, so there I was in khaki pants, plain white shirt, and the only (conservative) tie I brought with me. We arrived around noon, in time for the first of nine races culminating in the Cup race itself. Already there were about 15,000 people there, not bad for a town of 100,000. I suppose if I had taken time to think about it beforehand, I would have realized that the kind of town that has an annual boat race for crafts made of beer cans would not be able to take a horse race entirely seriously. In my first five minutes at the track, I saw an older man in a suit (complete with top hat) made entirely of coconut leaves – he makes one every year just for the Cup. Another gentleman was entirely nude, a dubious choice as he went from Caucasian to Pinkasian over the course of a blistering afternoon. Overall, I believe it was the largest confluence of ridiculous outfits, cleavage, tattoos, heavy drinking, and reckless gambling that I have witnessed, at least since my wedding.
I set out immediately upon a quest to make some money – how could Captain Thundabolt lose? He could finish in last place, as it turned out, and the first ten bucks of the day went down the drain. Il Duca was the safe bet in the next race, a heavy favorite who faded down the stretch and took another ten-spot with him. I took to studying the racing form more intently, breaking down each horse by overall record, performance on dry dirt tracks, time since last race, and various other factors which seemed like they could be important. I missed a quinella and chased a trifecta. I took a race off to restore my karma. I thought maybe my early two-beer-per-race pace was clouding my thinking, and tried a bit of water. Nothing worked, even as everyone around me seemed to be cashing winning tickets. By the time the Cup race came around, I had come full circle to completely irrational betting (who was I kidding anyway – how did I really expect that it would help me to know how Catwalk Minnie and Mister Raw had run on a wet track in Melbourne?). For the Cup, I noticed that one of the favorites had run very well in his last three races with a jockey who I have unfortunately come to know, as he was thrown during a race a couple of weeks ago and now resides in the Royal Darwin Hospital ICU with a devastating brain injury. It seemed like a good tribute to back his horse – wouldn’t that make for a nice story? It would, I suppose, if he hadn’t been replaced with a jockey who apparently had never seen a horse before. I actually think he may have ridden his mount backwards, flailing at empty air with his riding crop while screaming in terror. He couldn’t have done any worse if he had ridden a three-legged Jersey cow. Ah well, you win some, you lose some, except when you lose them all.
As soon as the Cup was over, an eighteen-wheeler pulled out on the track, the sides dropped off, and a band was revealed, fully set up and cranking out the rock. The crowd spilled out onto the track and started dancing to the sweet, sweet (cover) tunes of Bob Seger and Dexy’s Midnight Runners. A predictable number of inebriated males took to staging their own races out of the starting blocks. I am fairly certain that this does not happen after the Kentucky Derby although I have not been there myself. I was a model of restraint – usually the combination of ethanol and sprinting is irresistible to me. The nurses and I stayed on well into the night, and then took a packed, jovial bus on into town for more revelry. This town knows how to do a public holiday right.
I haven’t uploaded any good pictures recently, and I had camera trouble (ie I forgot it) on Cup day, so I’m waiting to get some pictures from everyone else. So I’ll give you a picture from one of my long weekend bike rides. And maybe a family picture or two. Not exactly related to Darwin, but since when did a dad ever need an excuse to show pictures of his kids.
Subscribe to:
Posts (Atom)
