First Shift!

Even on the other side of the world, the ED currency of goodwill for nurses and secretaries remains the same.

First off, a warning- this is a medical post.   Some of the nuances may be uninteresting to those not in the medical field.   I’ve got “heaps” (new favorite word) worth to share from my first weekend alone, so this will be part one of a series on health care delivery from a New Zealand ED.  But I’ll attempt to sum up my first impressions here and keep my observations relevant.

When you walk in, the ED looks and feels like any small town community hospital.   There are nurses, secretaries, chart racks, computers, and treatment areas.   There are babies and 90 year olds, injured and ill, sick and not-sick, sane and less-sane. Mental illness and substance abuse are ever present. Socioeconomic factors contribute in the same way they do in the US to patient presentations. There are medications both familiar and yet different.   Aspirin for some reason comes in 100mg doses. Paracetamol (Acetaminophen) is ubiquitous and a cure-all.

But there are real differences in care, coming largely from what I see as the three obvious differences between our health systems:

  1. Health care is free to NZ citizens here
  2. The incidence of patients successfully suing doctors or hospitals, and the threat of litigation in general, is extremely low
  3. Patient expectations are much more in-line with physician expectations.

The impact is significant.

– For starters, patients are directed to the appropriate level of care before ever leaving the parking lot. EMTALA (http://newsroom.acep.org/2009-01-04-emtala-fact-sheet), the US federal law that requires a medical screening exam for any patient presenting to a US hospital, does not exist here. There is no threat of an EMTALA violation to a hospital that redirects a patient to a more appropriate venue for care.

– Patients give acute medical problems time to heal before seeking medical attention.   It is generally only when the home remedy doesn’t cure the problem that patients come in.   It’s too early for me to comment on why this is- its not “consumer -driven” in the traditional sense, as care is free and ED wait times are generally low. (Oddly, a primary care visit occurs a small out-of-pocket co-pay, but not the ED). But giving an acute medical problem time to sort itself out appears the cultural norm here.

– Physician charting is what it was originally designed to be- a form of communication between doctors and other health care workers. There is no extra documentation for the sake of meeting billing and coding expectations, because no one gets a bill.   I chart what is relevant to the patient visit, and what the next doctor needs to know. That’s it.  It takes half the time and communicates twice as much information about the visit.

– All advanced imaging (CTs, MRIs, etc.) requires a conversation with a radiologist- not a heated one, but a discussion between physicians about what is best for patient care. Whether in the ED, or the next day as an outpatient, urgent studies that are needed get completed in a timely fashion.  But surgeons freely admit non-specific abdominal pain for observation without a definitive diagnosis.   Medical disease is allowed time to progress and declare itself.  Delivery of care is based on medical grounds, not convenience.   As a result, there is much less radiologic testing (and unnecessary treatment in general) than one would typically see in an American hospital.  I’m on the lookout for delays in care that cause harm- as this is always one of the arguments against nationalized health care in the United States.  I haven’t seen this yet- more to come.

– Common ED medications (nausea meds, antibiotics, inhalers) are often dispensed freely directly from the hospital- again, because cost to the individual patient is not a concern. Which is not to suggest medications are overprescribed – quite the contrary. Containing cost is something that the New Zealand health system takes very seriously. There exists a fairly rigid NZ-wide formulary that outlines approved uses for ALL prescribed medications, including antibiotics. To deviate often requires higher-level approval and a litany of forms- enough to deter physicians from prescribing costly alternatives that lack a true benefit.

– Pain is part of life. Opiates are used sparingly, and rarely prescribed beyond the walls of the hospital.   I saw the worst case of shingles (a very painful condition) I’ve ever seen in 19 years of clinical practice today, and the poor guy was apologizing for taking up my time. He brought me cookies the next day.  Death and dying is also part of life- more to come on that as well.

To be fair- it’s a less efficient system than I’m accustomed to in the states, with less a sense of urgency then in the 20+ US EDs I’ve worked. But patients get the care they need.  Patients, nurses and physicians are generally happy. I’ve gotten “real” THANK YOUs from the majority of my patients- without once prescribing opiates.  I had two of my patients from my first day bring food for the staff the following day to say thanks.  As a reference point, this happens a couple times a year in the states.  Which is to say, I think patients were generally *satisfied* with the care my team provided despite the lack of an objective measure.

The breakfast treats for the staff were a hit as well- so far, so good on the work front.

Back to small-town NZ life stories next blog. I’ve had two great days in the surf already in the short time we’ve been here.  This break is about a half-mile from the house (I paddled out in smaller surf here than this video).

This is Makorori Beach, another gorgeous spot 12 minutes from home. This place is amazing.

Jesse Irwin

Jesse Irwin

It's Jesse. I'm an emergency physician and healthcare leader, a Navy veteran, a father of three children, and until recently a land-locked Washingtonian with dreams of living on the ocean. I'm also a Luddite and an unapologetic introvert. But I'm going to give you, my family and friends, and this blog my best attempt at sharing my experiences here in Gisborne.
Jesse Irwin

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