Tuesday, February 15, 2011

Medicine Among The Kiwis

This blog is aimed at the medical people. It talks about what it's like to practice medicine, particularly anesthesia, in New Zealand.

This adventure is all about spending time as a family and showing the kids part of the world before they have no interest in traveling with us anymore. But to keep our life going back in Montreal and fuel the traveling here in New Zealand, I guess I have to work. Besides maybe the Kiwis will teach me a thing or two about anesthesia.

So after a couple of weeks on the job, here are some of the differences I've observed.

Palmerston North Hospital
Everyone is very polite! I haven't witnessed any temper tantrums. The anesthetists really take their time and there doesn't seem to be the production pressure that we have in Montreal. The nurses are always ready before I am and wait respectfully before asking if they can "paint". Although the surgeons are around, they don't hover and there is no deep sighing if things take a bit longer than usual.  Everyone remembers my name and the "theatres" are strictly on a first name basis, whether it be consultant (attending), registrar (resident), house officer (intern), nurse, anesthetic technician or orderly.

The day is divided into a morning and afternoon session. The morning session starts slowly at around 8ish. The surgical team will typically cut skin at 8:45! The morning session ends at 12:15 and the rooms never seem to be overbooked. For instance, tomorrow morning in 4 hours of OR time, I have a "Ceasar" and a tubal ligation. That's it! The afternoon session begins at 13:15 and formally ends at 17:15. Overall, I would say they accomplish about 60% of what we would accomplish at home. An American anesthesiologist from Missoula, Montana has noted the same thing.

One striking difference is that the anesthetist never leaves the room, except if they're working with a registrar. Each anesthetist works with an anesthetic technician, but it is the technicians that wander in and out while the anesthetist stays in the room. I've become really good at Sudoko.  I think I prefer the Canadian setup a little better, although the technicians will bring you coffee and cookies into the operating room. There doesn't seem to be any problem sipping a hot cup of coffee while charting the vitals as the surgeons work just over the barrier.

There are no respiratory therapists anywhere in New Zealand. Instead, for the ORs, there is a 3 year training stream that produces anesthetic technicians. For the ICUs, the RNs manage the ventilators.

Morgan in one of the block rooms
The OR block is huge. There are 7 ORs in a larger space than we fit 13. There is a block room outside of every OR, although because it is unmonitored, they usually use it for interviewing patients and putting in IVs or central lines.

Nurses' Hangout

The nurses have an alcove off of each OR about half the size of our ORs to store all their stuff and to open their sets. They sometimes open all the sets for the next patient before the current patient is out of the room. Once a case is finished, the orderlies help transfer the patient to the PACU and the nurses bring the used equipment into a corridor that surrounds the outer periphery of the OR block. I guess sterilization must be near there.

All the garbage and dirty utensils disappear into this corridor.

Each actual operating room is a little less than double the size of most of our operating rooms at home, is very brightly lit and has a long counter for writing on and huge flat screen TV for labs and radiology.

Big and Bright!

The ORs are arranged on the outside of a U-shaped corridor with the recovery room at the bottom of the U. On the inside of the U, at the top, is a reception area, a conference room and the "tea room", a communal lounge for everyone that works in the OR block. There are a limited supply of free sandwiches in the tea room at lunch and people break out a few bottles on Friday afternoon - nothing crazy - to celebrate the start of the weekend.

The urology team getting an early seat for the sandwiches in the "Tea Room"
Next is male and female changing rooms. Next is a 7 bedded pre-op area with the same function as our holding area, but with considerable more privacy and with pretty lax restrictions on the attendance of family members. At the bottom of the U, opposite the PACU is a small office for the anesthetists and offices for the head nurse and anesthetic technician as well as the anesthesia workroom.

Anesthesia Work Room
Although the OR block is a restricted area that can only be accessed with your ID card, you can walk around anywhere inside in street clothes without hat or mask except in the ORs themselves. Inside the OR, the only people that wear a mask are the people immediately adjacent to the OR table - scrub nurse, surgical consultant and registrars; anesthesia personnel and circulating nurses don't have to wear masks except in some arthroplasty rooms.

Wall of surgical "gumboots" that the surgeons wear in theatre
The anesthesia equipment is more or less the same. Aestiva 5's are the standard with a few ORs being equipped with Aisys. All the same drugs that we have except paracetamol IV, PO and PR and IV parecoxib. They've got Sugammadex! Although it's restricted to emergencies only. They also have etomidate, but no one uses it.

Anesthetics are chiefly Propofol, Fentanyl and Roc. Sux is suxamethonium. They have Remi and Morphine, but no Sufentanil or Dilaudid. They use a fair amount of Tramadol but rarely any NSAIDs. They use Sevo almost exclusively, but have Des on every machine; the registrars tell me they've hardly ever worked with a consultant that uses Des - my mission!

Spinals are pretty similar except that their heavy Marcaine is 0.5% and they put spinal morphine into almost everybody. They also very rarely use isobaric Marcaine - always heavy. Epidurals are very rarely used. First, there are no big laparotomies or nephrectomies or thoracotomies. Second, the surgeons are not so keen. For the cases that they do, PCA usually suffices. In three weeks, I've put in 1 epidural and that was more because the lady had an EF of 10% than the fact she was having a hysterectomy. Their epidural solution is 0.2% Ropivicaine with Fentanyl. There aren't any regional blocks to speak of. A few people will put in TAP blocks every now and then and even less will do single shot femoral nerve blocks, but that's it.

Minister of Maori affairs
As far as the patient population is concerned, I find the level of morbidity a little higher for any given age group. Certainly the degree of obesity and tobacco use is much higher than in Canada, especially amongst the Maori's (42% of adults are obese) and the Polynesians (from Figi, Tonga, Vanuatu, etc - 64% are obese). Also, the descendants of a 17th century whaler and a Maori woman represent one of the world's largest concentrations of malignant-hyperthermia susceptible patients in the world! They estimate that around 10% of their OR population are at least MH-suspect. I would say that the chief research interest within the department is MH. My emergency "ceasar" patient from the other day was a 22 year-old Maori woman with a BMI of 59 (shit!), a family history of MH and a difficult spinal for her 2nd section and a failed spinal for her 3rd section. With Ken Kardash's spinal tips echoing in my ears, I snaked a long 26 in on the first shot! Score for McGill Anesthesia!

The obstetrical epidural rate is only 15-20% here as opposed to over 90% at home. The Kiwi women chalk it up to being tougher but I think the source lies elsewhere. In Canada, labour care is delivered by RNs who find that a comfortable patient is easier to nurse, so they sell the epidurals to their patients. In New Zealand, pregnancy care including labour is with a midwife. Apparently, the standard midwife's training does not include the care of a patient with an epidural - this is extra training which most of them do not have. If their patient gets an epidural, they have to share a part of their fee with a midwife who does know how to take care of a patient with an epidural. So, most of the midwives discourage epidurals. All physicians in the public system in New Zealand are salaried, so the anesthetists are not too put off by the low epidural rate. In fact, obstetrics accounts for such a small proportion of the OR traffic that no anesthetist is assigned to OB. If there is an epidural during the day, the Duty Anesthetist (AIC), who never has a list, does it. Ceasarians are done electively on the gyne list or on the "Acutes" list (one OR per day for doing only emergencies).

I haven't spent any time in the ICU yet, so don't have much to say about that other than they refuse most patients over 75 and with any significant co-morbidity. The Kiwi views on death and dying are very different than what we've become used to at the JGH although admittedly even the JGH intensivists consider our practice pretty ridiculous. I'm worried that if I do some ICU over here, I will fill their ICU up with people they would have refused.  The ICU is exclusively run by anesthesia with the same shifts as the OR (morning, afternoon and on call each covered by a different consultant) but since the ICU calls are generally easier (there are only 5 beds!) than the OR calls, most of the more senior anesthetists do their calls in the ICU. That's just the way it works here, although the younger guys complain a lot about it.

Overall, it's been pretty easy to adapt. Why wouldn't it be - the medicine is the same -  and although they have some options that are different than we have, if I wanted to do things exactly the same as I did at home, they are certainly equipped to accommodate me. The only sense of discomfort has been in leaving very comfortable surroundings where I know which surgeons are slow and which are fast and which are morons, where I know which boxes on the anesthetic record and PCA sheets to fill in without really reading them and where I have lots of friends. But it's healthy to leave your comfort zone every now and then and that's all part of the adventure as well.

Next up: I've got some serious catching up on our travels through the South Island, around Palmerston North and to Napier and Wellington.

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