Accident and Emergency (guest post by Steve)

Here's a glimpse into Steve's new life at "A & E" -- in his own words.  Since many of his colleagues have shown interest in what it's like to work in New Zealand, Steve decided to cite medical terms and procedures that he deemed noteworthy.  Our apologies to those who may not follow some of the medical jargon.

So, as we were preparing and planning to come to New Zealand, we had a lot to worry about.  We stressed for months about where to live, about finding a house and car that would fit our large family, furnishings, which schools would provide the best experience and environment for our kids, passports, visas, travel arrangements, etc.  Work was an afterthought.  I never lost a moment's sleep about what work would be like.  After spending 3 years training in Emergency Medicine (IU baby!) and 9 years practicing at McKay-Dee, I felt comfortable in my knowledge base and abilities.  Work was the least of my concerns.  I mean, I've practiced medicine in Mexico, Kenya, and Wishard!  How hard could New Zealand be?  Right?  Well, I was in for a rude awakening.

Let me first say that Palmerston North has been great.  Our ward has been very welcoming.  We love our house and neighborhood.  The kind people from the hospital have been outstanding from the very beginning.  Christine (recruiter) found the perfect house for us and made sure that it was furnished and ready.  That made the transition here so much easier.  Everyone was very understanding and helpful as we were trying to sort out Emily's visa, and ultimately, it was the involvement of the hospital administration that finally pressured immigration to release her visa.  We are very thankful for their help and assistance.  Our first couple of weeks here were spent settling in, meeting with immigration, filling out paperwork, going to orientation, and discovering this beautiful area.  After Emily eventually arrived and our family was back together, I was anxious to finally start working.  I was excited to work in a different environment, in a completely different health care system, with new challenges and opportunities to learn.

That enthusiasm lasted for about 30 minutes.  The very first patient that we saw on my first day of work was a young girl with congenital abnormalities who presented in respiratory distress.  I watched Dr. Cheri as he searched and searched for IV access before skillfully placing an IV in her hand, then started resuscitative measures and quickly admitted her to the peds team.  I realized immediately that nurse/doctor roles and expectations were going to be different here than in the States.  Overseeing the stabilization of sick kids, or adults, wasn't enough...the physician was expected to be placing the IVs, pushing the meds, controlling the airway, and admitting the patient.  I hadn't place an IV in kids in years.  I had gotten spoiled by working with truly excellent nurses and techs who made my job so easy.  We just expected that they would start IVs, draw labs, order EKGs, warm patients, etc.  I probably got a little too comfortable, or maybe a little lazy, after working in the same efficient hospital for so long.

The nurses, hospital staff and other doctors here have been great, and I am really starting to appreciate working in a different system.  The first few days, however, were very, very challenging.  Everything is different.  Medications have different names, or are not available.  When I started asking for zofran, or dilaudid, or lortab, all I got were blank stares.  Afib with RVR isn't treated with diltiazem, but with amiodarone, or with beta-blockers.  Pain meds are limited to morphine or fentanyl, and codeine or tramadol; consequently, we don't see many drug seekers.  Nurses won't push propofol.  It gets a little comical when I'm trying to sedate a patient to reduce and splint a fracture.  Labs are reported with different units.  My first patient here that had diabetic ketoacidosis had a blood sugar of 33, and I had to think about whether to give her glucose or insulin.  I had to find a computer (there are five in the department shared by many providers) and google a glucose conversion tool to discover that she had a blood sugar of 590!  We are sending patients home all the time with troponins in the 20s and 30s.  We don't have a cath lab.  When patients present with an acute ST segment elevation MI, we are giving them thrombolytics and admitting them to medicine.  Those are just a few examples.  I could go on, but you get the idea.  It was overwhelming at first.  I felt like an intern and wondered if we had made a mistake by coming here.  It is really sad when you are tempted to self-medicate, but don't even know how.

Thankfully, my feelings of being inefficient and inadequate have either subsided, or at least become less noticeable.  I am actually really enjoying work now.  Some of the same things that frustrated me initially I now see as positives.  I am enjoying placing IVs, and ultrasound-guided IVs.   I'm using the ultrasound all the time here, but I never had time to use it back home.  I have more time to spend with patients, either getting a more thorough history, doing procedures, or, heaven forbid, just chatting.  I enjoy working with the residents, or house staff.  They don't have nearly as much formal teaching down here, so they appreciate any teaching that you can provide.  Not working nights has been great.  We work fewer weekends.  We actually have "office days" were we get paid to work on CME, read ESPN, prepare lectures, read ESPN, administrative stuff, read ESPN, and sometimes read something not related to sports.  Not too shabby.

I'm now about two months into this adventure.  Despite the changes, frustrations and lack of college football talk in the ED, I am very grateful to be here.  I told Mindy that I really feel like this experience will prove to not only enrich, but prolong my career.  I am excited to learn and study again.  I'm learning new things and gaining new skills.  I'm being stretched clinically and enjoying the opportunities to teach.  The people have been terrific.  I've also come to really appreciate my colleagues and ED back home.  I feel so fortunate to work at McKay with truly amazing people in such an excellent hospital.