More Medical Musings

If you aren't in the medical scene, this section may not be of much interest to you - so your choice, skip or read.

"Please take off boots before entering" sign at the entrance to the clinic. This is farm country, shorts plus gumboots or workboots and wooly socks are standard. Working with cattle and sheep in the paddocks means lots of muck so this is a cleanliness and housekeeping issue. There is actually a sock factory near-by which makes boot socks, and also wool blend including the fabulous merino wool and possum for socks and wonderful gloves.

Only two real emergencies I've handled, one deserved admission to our little hospital for intensive antibiotics: a developing peritonsillar abscess, didn't need steroids, home in less than 24 hours. The other was incarcerated epigastric incisional hernia, with prob. infarcted omentum, so shipped to the hospital.

15-minutes appointments are usually filled, but there is "A and E" clinic each day for walk-ins, "accidents and emergencies" can be anything from injuries to illness. The list of observed ailments and problems is growing, head lice now, plus "school sores" - term for impetigo (you can't go to school).

I continue to be challenged by traditional beliefs and naive status here when I try to go over medical education: salt and blood pressure response is "nobody told me that" They use U.S. second and third-line drugs as primary meds (ACE for all HTN, glipizide for all DM instead of metformin).
High school education is pretty much the norm here, rare college or higher level education, no college anywhere near -closest is 45 minutes.
There are protocols and guidelines, but I don't see much professional adherence to the standards. Followups, and labs, are irregular, not strategically scheduled. And patients are not given lab results, only told they will be notified if any abnormals. Of course who knows,or notices, if the labs are lost, or if the patient never goes to have the labs drawn. No checks and balances.

Many people are on cholesterol drugs and aspirin when no risk profile done, sometimes no labs for over a year. Smokers who have had bypass and cotinue to smoke are fatalistic "it's my life" or "I can make my own choices" This is especially true of the Maori.

It is not unusual for a patient to be on multiple meds and have no idea what they are for, as there is no labeling "one a day for blood pressure" and there is no drug information dispensed by the chemist (pharmacist) with the med. They have a modified PDR called MIMS which is a brief summary of indications, side-effects, dosage, which can be printed off the medical record, but much too deep for the average patient, even with underlining the pertinent items.

I'm not seeing many diabetic patients as they have diabetes nurses, but when I do, the usual quartet of meds we use are not in evidence. (diabetes, blood pressure/kidney protection,cholesterol,aspirin) as well as dietary and life-style education.

I rarely see asthmatics, and when I do find they don't have inhaler education, use their steroids prn, but use an awkward bulky spacer which is okay if you know how to prime and use it correctly, but I have not met anyone who knew how to use it correctly. Our standard spacers are only given for children and the elderly, or have to be purchased. So another chance to educate and to learn. Smoking is not approached aggressively, but they have had "no smoking" in place for public places including pubs for several years. Smoking is permitted on outdoor patios and courtyards of public places unless posted signs .

Most of the meds are similar to ours, but the names are challenging: sulfa drug we call Bactrim or Septra is "trisul". Our amoxil is amoxyl so difficult to look up if you spell too many letters in the computer, just put "amox".
Tyleonol is panadol, Advil is Nurofen. You can buy both with 8 mg of codeine off the shelf, but cost about 20C per unit. There are no drugstores, only pharmacies, and generics are almost non-existant. Saline nasal spray is $10-15. neosporin is $10, hydrocortisone is Rx only.

Pronunciation is another challenge: after several unsuccesful to get more details about a woman with leg rash, "do you shave your legs with a razor or use hair remover ? " Her "Weeks" product became evident only when she showed how she ripped the WAX off her leg hair, thus the inflamed rash.

Children with eczema but no rash turned out to actually have EESTMA or we would call it "Asthma". "feeling a bit off" is feeling bad,not dizzy. To throw up is to "spew" No one has urinary problems or painful urine: "pee hurts" "Lotsa poop" or (diarrhea)which is more frequent than "movements" and makes your "bum" sore. "Cross" or "crook" is feeling bad, not irritable or a thief, altho I guess feeling cross does make you irritable. And more likely to act illegally ? "Nappy" ia diaper. "Pissed" is getting drunk.

Major diagnoses and management, such as hypertension and diabetes, tobacco use, are not easily found in the computer, although there is a system for entering these and continuity format, just scattered entries, so trying to fill out form for long-term disability is maddening. Accident forms (all accidents are covered, even if you are a visitor, but illnesses are not)
work and income forms, referrals - all are needed before any progress can be made, even the acute stuff - have to call the surgical registrar at the hospital and ask permission to send the patient, so I just say the patient is on the way, rather than waiting for it to be labeled Acute, emergency, urgent or routine by the registrar.

We visited with a surgeon in larger town with a hospital, he was on call, had acute appendicitis in diabetic with GFR in the 20's who was found to have a 6 cm abdominal aortic aneurysm on CT which did show appendicitis. He was shipped to university centere as was a kid with an odontoid fracture and seizures after he went over the handlebars of his bike, no helmet. A car wreck gave another guy a skull fracture, subdural and he coded. So we are in a sleepy town with not much action, but bigger places are hopping.

Mental illness, depression, etc, are handled with "pills" and the GP is expected to manage. Really disturbed psych patients can eventually get to psychiatry, but that's almost an hour away, and may be weeks to months unless psychotic break requiring admission.

The consolidated computer system is only in use for less than a year, so there may still be considerable learning curve here. We have had ours for several years, and I still find out more every time I use it.

Nurses do a lot, and I have more contact with them than the doctors. When I try to steer patients back to their regular doctor, often they can't say who it is: "well, it was" or "it used to be" as the docs here seem to be shifting in and out, so frequently don't have a predictable long-term schedule. The docs also move around to two cover other clinics in this Tararua district,which is somewhat like several counties linked together.
I mentioned I spent a week at one, 50 mile round-trip. Glad that's over.

Re-appointments for followup are not encouraged as no additional income for extra visits, the fee for enrollment is the primary source of income.
There is often a co-pay, and un-enrolled are billed for the visit, $29 or so, children under six are free. I can't seem to make sense of billings. Accidents come under ACC which can pay up to 80% of income if employed, but self-employed (farmers/retailers) are on their own if they get hurt.