Monthly Archives: March 2012

Lessons from Emergency Departments

Things I (and others) have learnt from working in Emergency Departments:

First published 31/3/2012, please email me with more suggestions/additions. Last updated 25/09/2012.

  • If a dog is trapped, it doesn’t matter who you are to them. It will bite the you on the hand or arm needing stitches and some antibiotics
  • There are more nasty bacteria from a human bite than from a dog or cat. In addition, if that bite is from your new partner…its best to find a new one.
  • Windy day + kids + local town show = busy A&E
  • Fever, tummy pain and vomiting in a toddler. Clear chest, ears and throat, no cough, runny nose: think UTI.
  • There is no such thing as an urgent repeat script, just lazy people
  • The Noarlunga Triad:

1) Tattoo on lower back,

2) piercings (usually belly button) and

3) shaved nether regions

Female with abdo pain and above triad = high degree of suspicion for PID

  • Guesstimate a kids weight: (age + 4) x 2…then add on 1-2 kgs in this day and age
  • If you are seeing someone with a sub acute problem who is being demanding, you are entitled to ask nicely: “so why haven’t you seen your GP for this in the past 4 weeks?”
  • Some nurses are fixated on saturation levels and not signs of increased work of breathing. You should never be happy with a respiratory rate of 60 and a head bob even though the machine says 98%.
  • The patients most likely to complain about having a needle are men covered with tattoos. When you say “but look you’ve had heaps of needles for your tatts” the answer is usually “its different then” Oh what, this time I won’t be giving you Hep C?!?
  • A nurse was wondering the other day if there was a word for someone that was rude to nurse, like equivalent of misogynist. There already is a word: doctor.
  • The Sunglass Rule: If someone is wearing sunglasses inside (usually middle aged female), they are crazy.
  • When it comes to children, all vomiting is described as ‘projectile’
  • The Centrelink Reverse Acuity Scale (CRAS). The more times a patient complains or mentions their failed DSP application, the less concerned a doctor should be about whatever somatic complaint they have. This scale is increased in the early hours of the morning in ED.
  • When you ask for a sample and hand the patient a urine pot, make sure you ask them for a ‘urine specimen’. You might be surprised what comes back after 15 mins in the toilet.
  • The Westell Triad

1) Unusually spelt/hyphenated first name

2) Stuffed toy (or furry slippers)

3) Packed suitcase

= Borderline PD (if diagnosis is uncertain, weigh case notes and divide by age. Higher number, higher certainty)

  • Patients that present between 2 and 5am are either genuinely very ill, or crazy.
  • Other doctors pretend to do work in order to avoid psych and/or gynae presentations
  • If you ask a nurse ‘are you looking after this patient?’ The answer will be ‘no’ or ‘I’m going on break’
  • If you personally know a patient who presents to ED, you can say “they asked me to see the malingerer first”
  • Lewis’ First Law: everyone is stupid until proven otherwise.
  • Everyone gets a prize. Patients shouldn’t leave ED without something: script, referral, take home meds, imaging request, specimen jar, extra dressings, plaster, kick up the bum.
  • When your registrar lets you know that the psych registrar is here to see your patient, make sure they don’t say “Gerry, the psychiatrist is here for you” in front of the other patient you are seeing
  • For all of the long days and annoying patients, it only takes one thank you email or letter to make it all worthwhile.
  • Some patient think that dress shoes and scrub tops are unacceptable for doctors to wear because they think you are actually wearing cowboy boots and a bonds top.
  • Positive name sign: if a child under the age of 15 has a different sounding or spelt name, they are from a low socio-enconmic background. Current list: Linkin, Olisha, Blayze, Cursty, Scarlett Hoare, Jedediah.
  • If your admission to the general medicine registrar is for a social reason. Be upfront and tell them. Don’t try and conjure up a UTI to get them in, interns are shocking for trying to window dress patients.
  • Considine’s Pain Rule: a patients actual pain threshold is inversely proportional to the amount of times they say “…..I usually have a very high pain threshold”
  • Never assume families are caring. Bringing grandma to ED two days before Christmas with vague symptoms of dizziness is still a ‘Granny Dump’
  • If there are more than four ambulances and any number of police cars out the front of ED, its going to be a crap shift.
  • You can smell what sort of booze the patient had been drinking when taking bloods for alcohol testing.
  • Always take extra blood tubes for crossmatch and clotting on oldies, O&G, trauma and chest pain. You’ll never know when you might need a transfusion or when your consultant wants a D-dimer.
  • Ex or current nurses, doctors and paramedics can’t help using jargon when helping to explain a friends symptoms. “Ive noticed that they have been a touch diaphoretic lately” Makes them very easy to pick.
  • Some people are INTENSELY phobic of cotton wool on their skin after blood is taken.
  • Tooth to tattoo ratio. If less than 1, then patient either has pancreatitis, hepatic encephalopathy or barracks for Collingwood.
  • One of Dr Tim’s Pearls of Wisdom. If there are more than 2 rings on 2 or more fingers, your patient will be barking mad

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Flying training: Day 3

Towards the RA-Aus Pilot Certificate: @ruralflyingdoc

Day 3

The only good cat, is a....

Gee wiz, the time was flying…no pun. Already up to day three, with 7.6 hours under my belt. Prior to climbing up into the sky, we had to head out to the BOM weather station to report the findings about the sky we were about to get amongst. That meant walking over to the side of runway 26 and reading off the temperatures, rain fall etc. Earl and I then had to enter the info into a decidedly 1980’s looking DOS based interface for the Bureau. This computer was inside Steve the pirate, I mean, the airport manager’s house. Steve was away down in Adelaide getting a tooth out, so Pirie’s weather was up to us! When we left his house I spied his cat slinking around outside. Looked a bit strange from afar and as it sidled up I realised why. It was missing a tail! Perhaps strayed a bit too close to a propeller one day? 8 lives left. The walk back to the plane gave us a chance to talk about the past. As a young lad, Earl had got into flying after being taken up by a family friend from Parafield Airport just north of Adelaide after only having been a passenger on commercial flights a handful of times. It seems that he took off that morning and had never come down. Before starting his flying training career though, Earl spent a few years in the Royal Australian Air Force flying D-42s. I had never heard of this sort of plane, so I asked what sort it was. He replied quickly a ‘desk’ model, with a wooden top, four legs and two drawers. He was a self described paper-pusher for six years, but the RAAF had helped pay for some of his own flying training. So it wasn’t all office circuits.

Today was the day for nutting out real circuits, however. As mentioned in the day 2 blog, a circuit is a rectangular racetrack (see below) that an aircraft follows around the runway in use. This would usually be the runway that is more or less facing into the wind. A circuit is made up of five major components. Upwind (just after take off), crosswind, downwind, base and final (lining up for landing). Sounds simple enough until you realise that all of your radio calls and pre landing checks need to be done in this time, about 10-15 minutes for a 1000-foot circuit. Of course the idea is to practice these enough so that everything becomes second nature and you can fly and turn the plane while getting all the calls and checks done. Earl had given me a circuit diagram on a sheet with all of these things written on, but I thought that Spencer Gulf Flight Training could do with a bit of PowerPoint™ magic (DISCLAIMER: ruralflyingdoc is not affiliated with Microsoft or any of its related products).

As you can see, the downwind leg of the circuit is full of checks that go by the acronym BUMPFH. It still sounds to me like bum fluff! Doing circuits from runway 17 (so taking off roughly to the south), I was getting into a good rhythm, so much so that when came time to make the obligatory look out of the window to check the undercarriage, the same little homestead would float by beneath. Using the visual landmarks becomes an important part of doing the circuits and helps you assess where you are in the pattern and when to turn. It also is extremely comforting to know that you are in ‘roughly’ the same place each time. I started working out that for the turn onto base was just over the Pirie refuse depot and the turn for final was over Senate Rd where houses started to pop up south of the golf course (was that near your house Kirby?). Gradually the landings were getting better and better, with lots of room to improve. Earl was constantly telling me to “hold it off, hold it off, don’t let it land, not yet.” It was probably the fact that the ground was just there and I wanted to bloody land the thing and get it done. I’m sure the art of flaring and letting it touch down sedately will come in time. We decided it was time for lunch and Subway sounded like a good plan. So I thought I’d be clever and call through our order so I could just go and pick it up then shoot back to the strip. So I got to the main street Subway 10 mins after calling up and asked for the phone order. “We haven’t got any phone orders, did you call the other Subway?” Other Subway? Wha? Dammit, I’d called the Centro plaza shop. So barrelled over there and eventually got lunch back to the airport and squared away PO.

Black = ashphalt, White = gravel or dirt

Then it was time to practice some emergency procedures like engine failure just after takeoff. So I would have Jabba in a nice little climb and at about 200 ft, Earl would pull back the throttle to simulate an engine out. The procedure called for some nose forward to keep the speed up, lower full flaps and look for a suitable place to land/belly flop. Preferably somewhere flat with a good run out space and no power lines or fences. After a few of these it was time for some go-arounds. These are used if your final approach or landing is going pear shaped or something/someone is one the runway. Coming down for once such landing, Earl yelled out “cow on the runway!” So full power on with a bit of forward pressure so that the nose didn’t leap up because of the full flaps that had been set for landing. Then as the airspeed came up, I would bleed off the flaps little by little and re-join the circuit to try all over again. However, we were now using Runway 22 because of the wind. Alas, all of my nice little landmarks were no use when using this crappy natural surface strip….so a few times I got a little bit flustered. To add further pressure, Scott had flown in ready for us to that afternoon make the small puddle jump across to Whyalla (about a 15-20 min flight). He’d chucked on the high-vis tabard and walked near the runway to watch a few of the circuits. I wonder whether he guessed what all the malarkey was about after take off and before landing. Especially without any cows on the runway to explain a quick go-around! A nice finish to the day was passing the pre-solo exam with 95%. I thought that it was probably a better mark than in any medical exam I had done 🙂 So that brought up the end of day 3 and it was off to Whyalla for a retrieval and trauma workshop, hopefully no aviation related cases!

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Flying training: Day 2

Towards the RA-Aus Pilot Certificate: @ruralflyingdoc

Day 2

The lotus turns gracefully on its leg

An early start at Pirie Aerodrome this morning at 0730. Despite the early hour, it was very peaceful driving down the 30-odd kms from Port Germein with only a few cars on the road. As I pulled the car up to the office, the windsock was hanging limp in the middle of the paddock. Perhaps it was still hungover from the bull riding shenanigans on Hindley St the day before? Not a breath of wind to be felt, perfect! I had no sooner walked in the door that Earl said “lets get to it” and we were off. Walking, that is. And it was over to the large hangar for the pre-flight checks. By the time we opened up the doors, the sun was just peaking over the southern Flinders Ranges that bathed Jabba in a gold but crisp glow (ready for its morning tai chi?). Within 15 mins we were ready to go. I went though the checklist for start up: brake on, doors shut and locked, fuel lever on, avionics off, master switch on, fuel pump check, both magnetos on, throttle fully out, yell out “CLEAR PROP!,” push the starter button, set power to 1,200 rpm, check oil pressure, avionics and headsets on then a radio call for taxi and out to the holding point. Phew! The holding point is the set of dotted/full yellow lines that a plane will always hold at before entering the runway. Even large commercial planes do it, have a look for them next time. As part of the run up procedure sitting there, we pulled on carburettor heat. On a cold morning like this ice tends to build up inside of the carby due to the Venturi effect and decreases the amount of air reaching the cylinders and therefore the performance of the engine. Just two seconds after the heat was selected, the power jumped another 2-400 rpm and we knew the ice was there and had melted.

Once up in the air, Earl asked me to perform a series of turns at varying angles of bank that took us closer and closer to the lead smelter. Perhaps I might pick up some Pirie traits from the lead content? At the end of one of the turns there was a sudden and unexpected bump of turbulence on an otherwise still morning. Earl calmly explained that we had simply just flown back into our own wake turbulence. Ha! Then some basic level climbing and descending. Next was a combination of climbing/descending turns. Following that, an extended climb to 3,500 feet (which felt and looked like 30,000!) we went through a number of stalls from clean (no flaps) to fully flapped. It was amazing to see how much lower speed the stall would start and nose drop. A stall occurs simply when there is not enough airflow over the wing to produce lift and the plane loses altitude and can potientially enter a spin. It happens at low speeds and when the angle of attack is high (plane pointing up and going slow). Obviously this is best avoided when close to the ground like when landing, just when your speed is slow and the nose can be high!! Great, thanks Bernoulli.

Happy Birds: best chips ever!

I think Earl realised that my brain had soaked up enough information when I forgot the word to say on the radio to let other planes know we were finished. The word was ‘vacate’ and it had done the same from my head.  So it was a quick trip into Pirie proper for a few errands and some lunch while Earl did a flight review with another pilot. On the drive into town, I keep an eye out for the local coppers and the chance to rile up one in particular. No such luck Terry, LC evades capture again! Chucked a ‘mainy’ and ended up grabbing some hot chips from a local institution and parked at the boat ramp to finish them. When I got within sight of the strip coming back from lunch there seemed to be a bigger plane on the taxiway. I thought that the other guy Earl had taken up might have brought his private plane up? As I neared closer, it looked more like a Pilatus PC-12, a $2+ million dollars worth of pressurised turboprop aircraft. However, turning into the driveway the distinctive colours of the Royal Australian Flying Doctors (RFDS) shone through. A patient had obviously been retrieved from Port Pirie Hospital during my lunch break. No private cars had accompanied the SA ambulance, so obviously the doctors in Pirie weren’t as interested in patient care and handover as Scott and myself in Wudinna. Or perhaps they just aren’t as Aspergers-y about aviation like we are!! Soon Earl and his student landed. This other pilot was about 60 and was updating his training with a few circuits and radio calls. Before heading off himself he said that it didn’t matter that I was inexperienced as you have a tonne of luck when you start. Then as you gain hours and experience, you trade one for the other. A sobering thought!

"YEEEEE-HAAAA!"

Earl and I jumped back in Jabba to practice some circuits from Runway 17 (map of the airport to follow next blog). A circuit is a rectangular track that takes a plane around the runway in use. If you live or have lived near a busy general aviation (GA) aiport (like Parafield, Moorabbin or Bankstown) you would definitely know and curse this practice! By the 2nd or 3rd lap, the wind started to pick up. There was a tendency for a strong sou’wester to blow in the mid afternoon. “Kind of like the Fremantle Doctor” I offered. “More like the Wudinna Doctor” countered Earl. On these circuits, I was left to my devices and Earl would only chime in if I had forgotten something like carby heat or switching on the fuel pump. I was nice to take off, fly the pattern, make calls and handle the plane without much reminding or help. The landings were proving increasingly difficult with a moderate crosswind, with a few being pretty bouncy. Given the strong wind, we pointed Jabba back to the hangar and headed back. On the plus side, my taxiing was much more co-ordinated and business like, despite the continued presence of tumbleweeds. After learning how to fuel up the plane (AVGAS being about $2 a litre at the time of writing and no Coles/Wollies dockets available), Col took her up for two circuits and then back inside the hangar. While writing the days hours in my logbook outside, we watched a few of the students from Flight Training Adelaide (FTA) based in Parafield fly in for circuits and listened to their radio calls on the transceiver. It was good for my own learning watching and hearing the good and bad things about each lap around.

A different kind of learner on the tarmac

Over a beer or two at the end of the day (No more West End, I had bought a case [or deck] of Boags Premium on special!), we talked about some of the other truisms of aviation. Earl said that at one point an instructor had placed his wallet on the dashboard on top of the airspeed indicator and said bluntly “they’re the only two things you need to fly: money and airspeed.” I’d have to make sure that I have both in the future. One of the local lads who does a bit of flying popped by with some cooked blue swimmer crabs. His surname was Sleep, so of course went by the nickname “Halfa” A few jokes later (e.g. why do men’s heartbeat rise and throat tighten when there is a woman in a leather dress? Cause it smells like a new car) I called it a day and drove back to home base. As I accelerated up to 110 km/h on the main highway, I had the strangest sensation. It felt that the nose of the car was rising up (or that it should have been). Because I had been in a plane all day that naturally did that as the speed increased, my brain hadn’t separated the two! It would be just another annoying habit that I have to try and coax out of the skull. Perhaps in 2015 I’ll get me a hover conversion? Tomorrow would bring more circuits and some emergency flying procedures like engine failure and go-arounds.

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Flying training: Day 1

Towards the RA-Aus Pilot Certificate: @ruralflyingdoc

21st March 2012, Port Pirie

So it was at 0430 AEDST that I awoke in Canberra after 4 days of a General Practice conference ready for the early flight back to Port Lincoln via Adelaide. Getting to Canberra International Airport took only 15 mins with my cab driver who had got his java buzz on early. I wondered if Qantas would let me have some early hands on flying in the Boeing 737. A friend on Facebook suggested I try the long dark coat and sunglasses look and simply ask. Perhaps next time? Met up with Dr. Scott who was my flightbag and headset mule, getting them through Adelaide Airport security and meeting me in the terminal. He got chosen for bomb residue testing for his trouble (and yes an early start, very impressed). So for 5 mins, the entire medical team from Wudinna (the two of us!) walked and talked down to Gate 50 for my connecting flight to Lincoln. Now at least if I asked for ‘a go at the controls’ on the Dash-8 that was to fly us the small hop, I had a headset and a flightbag to augment the look/argument.

Lead Smelter at Port Pirie

Then a tedious five hour drive around the Spencer Gulf to get to Port Pirie. As I got closer and closer to Pirie, I started to feel my stomach getting antsy. Was it first flight lesson nerves or the dodgy Chiko roll from Port Augusta, who can be sure? I certainly did notice the wind buffeting the car as I closed on the destination. It was moving a station wagon with four wheels firmly on the ground. How would a plane with no connection with the ground fare? Cue further stomach turns, thankfully sans Chiko re-presentation. Driving past Pirie towards the aerodrome I surveyed the skyline I’d seen many times, but with fresh eyes this occasion. That huge bloody lead smelter chimney looked newly menacing. Never thought that I would be flying through the air within 3 nautical miles of that thing!

When I arrived, my car pulled up nicely next to the Spencer Gulf Flight Training facility (essentially half a small portable classroom!) Earl the chief flying intstructor,  I guessed ‘chief’ as he is the only one, greeted me inside and we got down to business. Flightbag: check. Headset: check. Logbook? No? Here you go. No stuffing about and straight over to the hangar. There were an assortment of Jabirus, Cessnas 182/172s and some ungainly homebuilts in there, possibly seven or eight in total. My ride was front and centre peering out of the hangar to the outside world. It looked like some sort of marsupial scoping out the environment wondering if was too dangerous to head out or not. In my peripheral vision I saw the windsock flailing about like a drunk on the Woolshed mechanical bull and wondered the same as my little wombat-esque plane. The aircraft itself was a Jabiru 160-D (affectionately named “Jabba” by me) an Australian designed and made light sport plane. More information on this plane here.

Jabba (the Hut)

One of the local pilots/ambo Col took me for a walk around and pre-flight inspection. We checked the engine (it was there), propeller, quality and presence(!) of fuel, hinges and bolts, removed coverings and checked the undercarriage. I had a strange urge to kick the tires…thanks Independence Day. It was time to pull the plane out of the hangar and leave it sitting facing into the wind, which at this stage was a 20-30 knot southerly. Earl and I hopped in and ran through the instruments and checklist. Today I was going to practice taxiing and get a feel of flying the plane. Memorising radio calls and checklists would come later.

Taxiing. Gosh! I remember reading online that having driven a car for any amount of time is a massive hindrance when it comes to mastering how to drive a plane on the ground. Whoever wrote that is a damn genius. Learning how to taxi was the singularly most frustrating thing about my first lesson and yet we had only been at it for 10 mins and I hadn’t even left terra firma! The problem boils down to –  the parts of your body that control speed and direction are swapped. In a car we use our feet for acceleration and braking; hands for steering. In a plane, yup, you guessed it, opposite. Hands for speed, feet for left and right. So many times in the early stages when I wanted to slow down, I jammed my left foot down on the left rudder (not the brake!) and the plane lurched that direction and vice-versa. Pretty soon though Earl had me weaving in and out of the runway centre line markings with some accuracy. The additional difficulty factor was that with the strong wind, medium to bloody huge sized tumbleweeds would flit across the runway. It was like some perverse aviation themed Frogger/Highway Crossing Frog game. At one point Earl suggested that we not only look out for circuit traffic when crossing runways, but also John Wayne. Maybe I’ll work on my accent for when radio calls start? “Howdy ma’am, joinin’ crosswind for runway 23, if its all right by you pardner?”

“You in da office baby” – Training Day

We had backtracked our way down runway 17 when Earl got me to turn the plane (using my feet…feet, feet, FEET! Remember dammit) to face into the wind. Then 15 degrees of flaps and using a simple count of 1,2,3,4, I pushed the throttle to the hilt and Jabba lurched forward. Even though Earl had his hands right near his controls, I’d be safe to say I was s**t scared! When we reached 55 knots, just a small amount of back pressure and the plane wanted to fly. Things became a lot less scary as the ground slid away below. Though my grip on the control was no less vice-like (the knuckles are still slowly losing the white hue). What followed was about 40 mins of running through the primary and secondary effects of the controls. Thanks to Scott I had already been given a crash course? No..…introduction..ah better, to these characteristics. Earl talked me through a quick circuit to land Runway 21 with a very pleasing roll out onto short final. Selecting full flaps meant leaning forward reaching across with my left hand while trying to peer over the cockpit and watch the airspeed. Once the flaps came down though, the view improved magically. With such a high headwind, the windscreen was all ground and the plane descended nicely. I managed to track down straight and was told to pull off the power at the right moment. Earl helped me ease into a nice flare as the ground effect kicked in (for non-aviation people: that little sensation of quiet floating just before touch down). We taxied back much more sedately to the hangar and enjoyed a quiet beer (West End, I know! I know!) and filled in the first 0.9 hours on my logbook.

The smile lasted for a while…

It was a long day, but a very memorable one. Driving back from the aerodrome I wondered whether the Subaru would be all over the road given my updated opposite hand/foot co-ordination. Luckily 12 years of driving came back instantly. But it was very nice to only worry about steering the car in one axis and not three at once!! Day two planned to start bright and early at 0730, easily time for a few drinks tonight settle the nerves. Update: Red wine at Port Germein has done just the trick!

If you enjoyed reading this, keep an eye out as I update this blog as the flying training progresses. Apologies for errors in tense and spelling 🙂 Thanks for your time and interest!

@ruralflyingdoc

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Breathing New Life 2012

On the 19th of March 2012, GPs, GP Registrars, interested students and junior doctors descended on the nations capital for a day that saw General Practice placed firmly “in the hot seat.” Speakers included the Federal Health Minister and her Shadow counterpart, Professor Des Gorman from NZ and others. In the audience listening along with the future faces of General Practice were GPRA patron Prof John Murtagh and Prof Michael Kidd. A number of blogs, opinion pieces and photos from this weekends conference are to come on this site. Stay tuned!

Catch up with the Tweets from the day: #bnl2012

Follow the author on Twitter: @ruralflyingdoc

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