Nightmare at Bowen

Hello all,

Well I had another doozy of a clinical coordination shift the other night.  As I previously mentioned, part of my job here is coordinate the transport/treatment of patients throughout the whole of north Queensland and it can get a bit tricky from time to time. 

The evening began with a call from a doc on Thursday Island  (TI) located at the Northeastern most tip of Australia.  There was a 18-year-old schizophrenic on Badu Island who had recently returned home from the hospital who decided to forgo his medications and self medicate with large amounts of marijuana.  Needless to say he had become acutely psychotic and was roaming his remote tropical island with a machete “looking for the aliens”.  The doc I was speaking with had been in communication with the only health care provider on the island, a nurse, and had suggested using antipsychotic medications to control the situation.  When that didn’t work, and the patient became increasing agitated, the nurse had called for help. 

So here is what I had to coordinate.   First I needed to speak to the helicopter pilot to make sure he had enough time/fuel to get to Badu.  Next I had to find and anesthesiologist who would be wiling to fly to the island, forcefully intubate (put a breathing tube in) the patient with the help of the police and bring the patient back to TI and care for the patient until we could send a plane (3.5 hours) from Cairns. Of note, it is policy that many psych patients must be intubated in order to fly on the helicopter.  It sounds extreme until you imagine an acutely psychotic patient thrashing around at a few thousand feet.  Then I had to speak to the team in Cairns about the retrieval.  If everything went according to plan, the retrieval team would arrive at about 12:30.  The caveat to this was that if the Cairns retrieval team got a call about a more acute situation (trauma/acute cardiac event), the intubated psych patient would get bumped and then be stuck in TI, where they only have one ED respirator and no ICU, until sometime the next day.  That's not good.

As that plan was being coordinated, I got my next call.  Bowen is a small town 2 hours south of Townsville and they have a VERY basic emergency department and hospital.  I picked up the phone and heard the quite panicked voice of the Bowen doc who explained that they had a patient with known COAD (COPD) who was unresponsive and they needed help.  I began by getting a bit of the history, vitals and finding out what interventions had been done since the patient arrived.  Most of the basics had been initiated, and the patient was on Bipap (a mask that helps people breathe).  When I asked for the patients GCS (measure of mental status, can be between 3 and 15), I was told 7.  At that point I quickly went into the back room where we have the ability to  video connect via satellite with a select group of smaller EDs.  This  “telehealth” system provides the coordination doc the ability to see the patient (from 2 different camera angles) and communicate with the staff.  When the screen finally came up there was an obese elderly guy with a bipap mask on his face.  He was grey, diaphoretic, and obtunded.  I focused the other camera on the monitor and started asking some questions.  This guy had been in the ED for over one hour.  He arrived with GCS 12-13, was given nebs, steroids and started on bipap.  His first gas showed a pH of 7.1 and a pC02 of 125 (VERY BAD).  One hour later his repeat gas showed a pH of 7.0 and a pCo2 of 150 (VERY VERY BAD).  Remembering that not all docs out in “the bush” have the same training, I asked if there was anyone in the hospital who could intubate.  The doc in the room quickly informed me that she could.  This was music to my ears.  This patient was clearly failing bipap and was so altered his airway was in jeopardy.  But no worries, I had someone who could intubate.  It was when I asked this doc what meds she was going to use that I began to realize that maybe I should rethink my plan.  Her reply was “I don’t know.  I was hoping you could remind me.  I’ve done 6 or 7 but they were all with different consultants (attendings)”.  My heart sunk.  I asked her of the 7 she had done, how many had been successful.  “At least half of them,” she said.  To give you an idea of what that means, I've done at least 150.

Now I have worked with Shellenberger, so I know fear, but this was something else.  One look at this guy and you could tell he would not be an easy intubation, and the only person there with any skills has intubated “at least half” of 7 total intubations.  I asked the doc and staff to hold for a minute and I ran in the other room.  I called to the helicopter coordinator and asked how long it would take to fly to Bowen with an experienced doc for an emergent intubation.   I was told it would take only 25 minutes.  I got excited again; this patient would make it yet.  The coordinator then continued.  “25 minutes on a normal day, but the helos are grounded due to the dust storms.”  My heart sunk again. 

Note:  In case you did not read it in the news, there were massive dust storms that moved across Australia recently decreasing visibility to less than 10  feet in some places.

I ran back into the telehealth room and let everyone there know that there would be no cavalry tonight.  At that point I had a decision to make.  Let the very inexperienced doc try to intubate (which I was about 95% sure would not be successful) or try something more conservative.  First do no harm. 

So I asked what the bipap settings were at… I was told 6 and 3.  I honestly didn’t even know it went down that low.  So I decided to try the conservative route and I asked the bipap to be turned up to 10/5 and repeat a gas in 20 minutes.  That’s right I made the decision to increase the bipap on the patient with the GCS of 7-8.    I ran back in the other room to take a few more calls, but had the telehealth on in the background.  20 minutes later I got a call.  The gas was now pH 7.2 and the pCo2 was 120.  THINGS WERE IMPROVING!  I told them to put it to 12/6 and call back in 30 with another gas.

The next call was from a dive boat stationed on Norman reef 4 hours off the coast in the middle of the Great Barrier Reef.  A 29-year-old novice diver had panicked at 40 feet during a night dive and removed her respirator.  No one was too sure how much seawater she had aspirated or how quickly she had shot to the surface, but she was now on deck coughing and complaining of chest pain.  I was talking to the skipper of the boat and I let him know that just based on the story alone, she would need to be brought back to shore for evaluation.  He was reluctant to move the boat considering he had 50 other divers on the boat and he asked about using a helo to winch the patient off the boat.  No can do at night I told him, too dangerous.  We contacted the Australian coast guard who agreed to head out to sea and meet the dive boat half way and take over care of the patient from there.

Just about then I got a call from Bowen.  pH 7.3, pCo2 105 and GCS 13 (MUCH MUCH BETTER).   An hour later the patient was able to give the thumbs up.

Note:  The TI patient was intubated on Badu and brought back.  Cairns never made it up that night. 

These were just the most exciting cases of the night.  In addition I had a pediatric trauma from Palm Island, a snake bite from the Whitsundays, a roo-strike from Charters Towers and a rigid abdomen from Mt. Isa.  

This one's for you, Dad

On Saturday Townsville hosted the Australian Air Defense Air Show down along The Strand. They approximated there were between 80,000 to 100,000 people, which considering the population of Townsville is only about 150,000, it was absolutely massive. We were thrilled that we didn't have to worry about parking since we live right on The Strand. The show was incredible, the highlight being the U.S.A.F. Thunderbirds and the C-130 :)

You should really check out the other photos at this link - they're spectacular. (Dad, we'll burn you a CD with the complete set of photos/videos and bring it to SFO next weekend.)

http://picasaweb.google.com/lh/photo/iIa9ZiDCeh7Ts06VsMFXqw?feat=directlink

Shakespeare and a Haircut

Today I bit the bullet and got my first haircut in Australia.  I know it's hard for some of you (as in you men) to understand, but going to a new hair salon can be extremely unnerving and very very scary.  After all, with a few exceptions, mistakes cannot be corrected.  I was also nervous about the fact that since Townsville isn't exactly a big happening metropolitan area (at least compared to Sydney/Brisbane/Melbourne/etc.), the likelihood of me finding a great stylist was slim to none. And I had a nightmare the other night where I'd ended up with the ever-so-trendy Emo hairstyle that seems to be popular here in Australia (see attached photo for an example if you don't know what I mean).

I'm a huge fan of the Aveda salon I went to in Tucson, so I had called awhile back and made an appointment at an Aveda salon in Santa Cruz where we're staying next weekend for Matt's brother's wedding.  But Matt thought I was being silly since even if I got a haircut there I'd eventually still need to find someone here for the remaining haircuts throughout the year.  Well, despite my stubbornness I listened to reason and made a hair appointment at one of the fancy salons here on The Strand.  I had to take a chance and I might as well just get it over with.

  

Well, the first 15 minutes of the appointment did little to ease my nerves.  I liked the girl a lot - she was very cute and had great hair which is always a plus - but as we were chatting away she asked me where Matt and I liked to go out on weekends "because she only sees young people out at the clubs." I swear my heart skipped 10 beats right then and thousand thoughts flooded into my head....so....is this the moment of realization that I'm not young anymore? But I'm only 30.  I wonder how old she thinks I am.  Does she think I'm 45 or something?  Do I really look 45? Maybe I should be wearing more sunscreen every day and stay out of the sun more.  Yes, that's it, it's too much sun exposure.  Or is it my clothes?  Do I look frumpy and fat? But I wore my nice jeans and shoes and halter top.  Surely it's not my clothes....Anyway, I was completely fixated on this for the remaining 2.75 hours of the appointment.  And clearly I'm still fixated on it because I'm writing about it on the blog.  Any thoughts? Yeah, the sun exposure, that's it.  

Now perhaps based on what I've just said you're expecting that I ended up with a bad haircut but after it was all said and done I spent three hours (yes, you read right) and a small fortune but got a really great cut and highlights.  I'll definitely be going back.  Even though she thinks I'm a grandma already.

The rest of this week has been relatively eventful.  Thanks to some of your emails we learned of the dust storm in Sydney and today we got some of their residual dust.  Nothing major, although it was enough to completely cover up Magnetic Island off the coast here.  It was kind of weird running along the Strand today and it looking like Maggie had really disappeared.  

On Tuesday morning I went with a friend to pick out Halloween costumes at the local costume shop Fancy Dress.  It's the earliest I've ever bothered to even think about a costume, and I'm quite pleased I won't have to spend the entire month of October stressing about it or scouring all over the town to find bits and pieces for a last minute costume.  It was a pretty weird place but had a decent selection of costumes (all rentals), and they even ask you who's party you're going to so they don't rent out two of the same costumes for the same party.  One of the benefits of being the only costume shop in a relatively small town I guess.

Later that night Matt and I went to trivia again.  It was a small group - just three of us - but we did pretty well.  It helped that a lot of the questions were centered on the U.S. and there was a DNA question in there, too.  The Aussie questions just kill us.  By the way, did you know that President Ford was born as Leslie Lynch King, Jr.?  

Wednesday night we went to see Shakespeare in the Park (Henry V) in the Queen's Gardens just down the street.   We weren't sure what to expect, but the show was absolutely fabulous.  And we even got to bring along food for a little picnic during intermission. It's always nice when you can bring your own stuff into a venue.  

I think that's about all we have to report right now. 

Cape Trib, Crocks and the 13 Sharks

After 10 days of work I had 4 days off this last weekend (the 12th-15th). We woke up at 5:15 on Saturday morning (no, that is not a typo, but it is one of the reasons I am in love with Lindsay) and we hit the road just after 6. Heading north we put on a little Johnny Cash. The first 4 hours of the drive we had done before so nothing new to report there. Between Townsville and Cairns its mostly cane fields, small cane towns, and the occasional rainforest pass. We picked up a great book on tape called Do Androids Dream of Electric Sheep by Philip K. Dick which made the trip go by in a blur. It is the book that the movie Blade Runner is based on. Perfect for a couple of sci-fi nerds.

At Cairns we refuled and continued north. At about noon we pulled into the town of Mossman, a medium sized cane town about 30 minutes south of Port Douglas. After a great lunch of really good fried chicken, we wandered the town, which was in the midst of a Saturday market. It was great to see aspects of small-town Australian life. This was the kind of thing that Lindsay and I hoped to experience by living in a place rather than just traveling to it. We meandered between the numerous stands selling fresh fruit, candles and jams while listening to some irishman playing the ukulele in a park. It was great.

After lunch we took a short drive to the local natural attraction, Mossman Gorge, a small canyon that runs through part of the Daintree rainforest.

We continued north, past Port Douglas until we came to the banks of the great Daintree River. It's famous for a cable car ferry and infamous for the numerous man eating crocks that live in its waters. Earlier this year some fisherman stood a little too long down by the water gutting his fish. CHOMP. This ferry is the only way across the river. Every 10 minutes or so it glides across the river on submerged cables transporting up to about 30 cars. It antiquated but quite nice.

From there the next 45 minutes winded throughout some beautiful virgin rainforest along the coast. One moment we were looking at thick forest and the next we were driving by a palm lined beach. During the entire drive, the side of the road was peppered with a familar sign showing a prehistoric looking creature...the cassowary. These endangered, large flightless birds live in the jungles throughout Northern Queensland and apparnetly have a propensity for getting hit by cars. I have been hoping to see one since we have been spending so much time camping. I am still hoping.

We finally arrived at our destination, Cape Tribulation. It was named this by Captain Cook himself when his ship the Endeavor ran aground on a reef nearby. This makes sense considering that the Great Barrier Reef is closer to land here than almost any other place in Australia. Cape Trib, as it is called by Aussies, is a laidback, out-of-the-way backpacker/high-end eco-lodge kind of place. There are two stores in town and a bar. We were staying at a campsite on the beach.

After going to the store for provisions (which were insanely expensive since we were in the middle of nowhere) we got to our campsite and set up. That night we went into town for pizza, beer and listened to an aboriginal raggae band.

The next day we had planned to go sea kayaking but the wind was too high. So we set off south again, crossed the Daintree River and took a hour long nature cruise down the river. It was perfect. We saw a kingfisher (bird), a green tree snake, some goofy lizard and 2 crocks. One was a female lounging on the river bank in the sun and the other was "Fat Albert", the large dominant male in that part of the river. It was a bit of a thrill. After that we crossed the river yet again and slowly made our way back to Cape Trib, stopping at lookouts and short hikes in the forest. We stopped for lunch at Cow Beach and had a picnic. We tried to listen to the U of A game with our portable internet hooked up to a laptop, but no such luck. But the salami wraps were super.

Later after a few more hikes we were getting hot. So we decided to take a dip in the ocean. We jumped in and I splashed around for a bit. Lindsay was cold as usual :) so we didn't stay in that long. After our swim we looked around and realized that although there were many people on the beach, no one was swimming. This confused us. It was hot and humid, people were wearing bathing suits, but no one was in the water. As we walked to the car we figured it out. There right in front of the beach was a large "Achtung, Attention (something similar in Japanese symbols): NO SWIMMING CROCODILE AREA!!!" Suddenly it was crystal clear. The first words out of Lindsay's mouth were "your dad is gonna freak out". On the phone three days later, she was proven correct.

That evening we had some wine and brie on the beach and then made something resembling cheese steaks at the camp BBQ. Then we went to bed.

5:15AM again and we were up Monday morning. We left the campsite at just before 6 and headed south. We had to be in Port Douglas by 8:10. We arrived nearly a half hour early and after a muffin and coffee stop we parked down at the marina and proceded to board the "Posiedon", our dive boat out the GBR (great barrier reef).

We had 3 awesome dives that day with the third being one of the best ever. It was a drift dive at a reef spot called Helms Deep. A drift dive for those that don't know is a type of dive where you jump in at one spot and let the natural current pull you to another spot where the boat picks you up. Its kind of like mixing diving and tubing down a lazy river. Its a great way to dive because you can just float and not expend much energy while seeing everything pass by. This drift was slightly different because the currents/swells were so big that we were very quickly whisked by the reef much faster than usual. In addition the coral was pristine and we saw a total of 13 sharks. It was an awsome experience.

After returning to port we found a cheap hotel and decided to cellebrate our 5 years of knowing each other anneversary. Can you guess which one of us remembered it has been 5 years since we met AND felt we should celebrate the anniversary of that date? I'll leave you guessing.

Anyway it was an excuse to not eat fast food, camp food, or ramen. So we had a drink and calamari at a sea side bar for the sunset, had a roasted pineapple daquari at a treetop bar called Nautilus (once visited by President Clinton), listened to covers of U2 performed with a didjeridoo, and had a wonderful dinner of scallops, pancetta, and ahi at a place called 2 Fish. It was a great anniversary.

The next morning we got up, put in our book on tape and 5 hours later we were home. Here are some of our photos:

http://picasaweb.google.com/matthew.berkman/CapeTribAndPortDouglas?feat=directlink

This week we finally got real internet (so now we can actually upload our videos onto this site) and last night we had a housewarming party. And we head to San Francisco soon so we will see some of you in less than two weeks.

Love Matt and Lindsay

Link to Whitsundays Photos

Here's a link to our photos from the trip to the Whitsundays:

http://picasaweb.google.com.au/matthew.berkman/Whitsundays#

We booked our tickets to Tasmania at the end of November. We'll have about 11 days to tour the island and find the devils.

Our Garden

Matt and I had a very domestic and enjoyable weekend.  We had drinks with some friends on Friday night and sampled Townsville's version of Mexican food at Cactus Jack's, which turned out to be loads better than expected.  Either that or we were both so ravenous that it could have been anything and it would have seemed fantastic.  

Saturday morning we braved the massive Townsville crowds (no, I'm not being facetious) and ventured over to one of the local malls/shopping centers.  The layout of these malls is very interesting.  They're sort of like random collections of small clothing stores, small bookstores, dollar stores, etc. in combination with one or more grocery stores and a Kmart (or Aussie version of that).  The whole concept of having a grocery store inside the mall seemed at first very weird - masses of grocery carts are strewn all over the mall areas, which adds to the chaos and crowds.  But admittedly it's quite convenient being able to pick up the liter of milk we forgot the day before without having to make an extra stop.  Speaking of grocery carts though, I have a beef with the carts over here.  You'd think that grocery carts would be the same everywhere, right?  Well, they are most definitely not.  At first I thought that I had a habit of picking broken carts, but I'd say between the two of us Matt and I have tried over 50 shopping carts and they're all the same.  I can't exactly explain what it is that's different, but it would only take you a few seconds to realize they're poorly designed.  As you push the cart forward, the stupid thing doesn't actually go forward. It turns sideways instead, crashing into the shelves of the aisle or the unlucky person next to you.  If you're really intent on having it go straight it takes some serious muscling, which after a few minutes has me completely exhausted and whispering not-so-nice things under my breath. I've found that the carts actually work best if you push them from the side, although if the store is busy you're out of luck as there's just no room in the aisles.  Anyway, I really really do love it here, but I don't feel the least bit bad about saying that the grocery carts in the US are indeed superior to the ones here. 

Sorry for digressing.  Anyway, we picked up some things we needed for the apartment at the Kmart and office supply store in the mall.  Afterwords we went down the road to Bunning's, which is more or less like Home Depot.  We finally found a suitable desk for me to set up in our guest bedroom, and we also picked up a bunch of plants and potting soil to start our little garden. Some of the plants we got were herbs, so our patio smells quite delicious.

Saturday night Matt worked a late shift and was on call, and I worked for a few hours at home as well.  Sunday morning we woke up around 8am (6pm Eastern on Saturday) and listened to the radio via internet of the Clemson football game.  We made a valiant effort to find a way to watch the football games online, but it turns out radio is about our only option.  I was initially annoyed about that (after all, I'd pay good money to watch the games!), but the radio made for an awesome football experience.  Anyway, my Tigers did well, and at half time we walked down the street to a cafe and had eggs benedict and a spinach/feta omelette. The Arizona game was scheduled to start at noon (7pm pacific time), but there was a 50 minute storm delay so we managed to squeeze in a workout and a dip in the pool before the game.  The Wildcats had a really exciting game and had no problem defeating Central Michigan.  I still feel very strongly they should have picked Nick Foles as the starting quarterback, but that's for another discussion....

Matt's back at work doing the late shift tonight and unfortunately has to be back in by 8 for the early shift tomorrow morning.  This week probably won't be terribly eventful since we'll both be working a lot, but the plan is to go up north to Port Douglas this weekend for a day of diving and some hikes in the Daintree forests.  More details to follow...

Sailing, sailing away...

Hello all,

I am sitting here at one of my coordination shifts and so far its not too busy. Last weekend Lindsay and I took a long weekend to the Whitsunday Islands about 3 hours south of Townsville. After work on Friday night, we jumped in the car and drove to Airley Beach, the main port for the islands. We stayed in a little hostel (that used to be a brothel) and had a nice dinner of calamari and beer.

The next day we drove down to the marina and boarded the "Waltzing Matilda". She is a 60 foot sail boat that holds 13 passengers and 2 crew members. After a brief orientation with Fabien our captain (who, according to Lindsay, has an "awesome" French accent), we moved through the marina and out to sea.

The weather was nearly perfect. It was between 75 and 85 the entire time. The only possible complaint was the paucity of wind. After one hour of crossing the channel by motor, the engine was stopped and the sails were raised. Off we sped at between 2 and 2.5 knots. Not exactly thrilling, but it allowed for a lot of relaxation.

For the rest of the day we sailed around a few of the 75 islands in the chain. The water was the beautiful blue/green you see in postcards. Every once in a while we would hear the wild call of the Kukaburra somewhere on shore.

That afternoon we anchored the boat and took the rubber zodiac to shore where we hiked to Whitehaven Beach. It was stunning. After taking 4 gazillion pictures, we headed down to the beach for an afternoon of swimming, frisbee and stingray spotting all trying our hardests not to "pull a Steve Irwin". May he rest in peace. In the late afternoon we returned to the boat.

We picked the Waltzing Matilda mainly because there were only 11 other passengers. We met some great folks. A couple of Aussies, a couple of Brits, several Germans, and an American girl. That evening we sat on deck, drinking boxed wine and watching the sunset. Pretty nice. The food was good too.

The second and third day we cruised around a few other islands. We did some snorkeling in the mornings and afternoons (I saw another shark) and lots of sunbathing and resting. Overall this was not our typical vacation considering we really didn't do many activities other than the snorkeling. It was incredibly relaxing, which I think made Lindsay very happy. We'll post a link to our photos later on this week.

I'm now on day #2 of working 10 shifts in a row. We're now planning a trip to do some diving on our next four day weekend at the end of the month.