American ER Doc Gone Walkabout Episode 002
So, why, really, was my perception that so much greater a proportion of ER business in Tassie was real emergencies when compared to home? All the individual cases were recognizable (except perhaps the anaphylaxis from leech bites). And every individual work shift included a patient mix that I’d seen before.
But, after a few weeks, the gradual recognition crept up, that the whole bell-shaped curve had shifted from any of my prior US experiences. The high acuity days were high acuity and the low were low, but the whole acuity spectrum was just shifted over a few notches, and it was fun. (Realize, I’m an old guy that’s been doing this for a long time — 37 years, and emergency medicine is just flat out fun).
And that was the overall, most prominent impression that I took home with me: in Tassie, emergencies were emergencies and chronic disease was cared for outside of the ER.
So, let’s go back to a simple question: what is that stuff that I give for a fever?
Before I left for Oz, I had asked a few friends who had worked there, about differences that I might expect. The usual answers included: more clinical diagnosis, less dependence on imaging, and, of course, paracetamol.
There are some potential issues that one might think about, but aren’t really: most Americans face metric system weights and temperatures routinely during medical care, for instance, and we work with them without difficulty (although, I bet most of us would have a hard time with celsius temperatures outside of the live human being range — the temperature is 20? And you’re in shorts? Howzat?). I must admit that I had a hard time when asking an older patient his weight and getting an answer in “stone” — I still have no idea how much that guy weighed. And, I thought it was funny when I asked people their weight and height and the reply was 80 kilos and 6 foot 2. How does that work?
And that’s even before we get to millimoles — I had to fight the urge to give glucose to every patient whose glucose was “only” 10.
But, back to paracetamol. It’s interesting that when discussing differences between US medicine and the rest of the world, the most common thing that I heard was — that Tylenol/acetaminophen is Panadol/paracetamol. So, I was ready for that.
Then, on arrival into the depths of terminology: Early on during my stay, I asked for some Solu-Medrol for a leech anaphylaxis victim. Blank stare from the nurses. “Maybe some methylprednisolone?” No worries, mate, we’ve got methylprednisolone. Shortly thereafter, I noted some milky stuff going into the IV line — which we stopped — that was methylprednisolone acetate, DepoMedrol. No ill effects ensued, and I soon learned that local practice was hydrocortisone rather than methylprednisolone sodium succinate — solumedrol. OK, I can learn that.
Then, there’s Benadryl — diphenhydramine.
First, though, I’ll digress: During my orientation on arrival in Lonnie, I was reminded on several occasions that generic drug names were always preferred — as they are in the US. The generic drug name as theoretical construct is admirable. However, the reality in learning even a few new drugs and drug names gave a little more substance to the commonly noted phenomenon of many drugs being called, always, by their trade names — even when a generic form of the drug is being used — note aspirin vs acetylsalicylic acid. In the heat of battle, imagine the challenges of differentiating methylprednisolone sodium succinate from methylprednisolone acetate — rather than SoluMedrol vs DepoMedrol. Or, Zofran from ondansetron (2 vs 4 syllables), or Benadryl vs diphenhydramine, or Zosyn vs piperacillin/tazobactam — I could have to do end-of-shift handover before I finished a verbal order for the drug.
Which brings us back to Benadryl.
In the US, an H1 antihistamine that is used multiple times every ER shift — for allergies, to prevent dystonic reactions from antiemetics, for sedation. But, not available at LGH. Local practice is phenergan/promethazine as an antihistamine. Not too hard a transition, since we use promethazine fairly frequently as an antiemetic in the US, so I was familiar with it, and rather knew in the back of my head that it was an antihistamine. Although, since it is chemically a phenothiazine with the dystonic side effect profile of the antiemetics, it forced me to move another step down the pathway for treating the dystonia that occasionally pops up after phenergan use — on to cogentin/benztropine.
Just a sidelight — yesterday we had a “stroke alert” patient with aphasia, who arrived with the largest phenergan prescription I had ever seen – 90 tablets — from her GP. Her aphasia was very halting speech — with each individually fluent word separated by several moments of lip smacking, tongue protruding, and piano playing with her fingers. So, we cancelled her stroke alert, and treated her tardive dyskinesia and arranged for further evaluation of her chronic nausea. Of course, in the US where we cannot discharge a patient from the ER without some form of advanced imaging, she got a brain CT to assure the resident that there was no stroke, and an abdominal CT to look for an anatomic cause for nausea (how often is that helpful?)… And, to ensure that our radiologists would indeed be able to afford to vacation on the Great Barrier Reef this year.
I could go on about other minor terminology issues (Flomax vs Flomaxtra for tamsulosin, and such), but onto my very favorite: It appears that if you take a bottle of nitroglycerine (NTG in the US), and turn it upside down by standing on the bottom of the world, the letters reverse themselves into GTN! That is so cool! Somehow, that rearrangement didn’t stick well in my trauma and age addled brain, and until the end of my stay in Tassie, every request for a vasodilator went this route: request nitro, absorb blank stare, realize error, pronounce “GTN,” watch the hypertension dissipate. (BTW, high dose — 100 mics and higher — GTN for hyperadrenergic/flash pulmonary edema seemed to be a relatively unfamiliar management strategy in Tassie).
I also noted a few dosing variations: ketorolac (lower in Oz), piperacillin/tazobactam (higher in oz), and narcotic analgesics — analgesic dosing that I considered pretty routine seemed to be considered by the nurses and registrars to amount to intentional murder by respiratory arrest.
Enough of the variations in drug terminology and usage. We’ll push, in the future, onto such challenging topics as paperwork, financial incentives and disincentives, electronic medical records, diagnostic and imaging strategies, specific treatment strategies, ancillary staff in the ER (PA’s, paramedics, technicians) and a host of others.
American ER doc