A round trip to the South Island

That's me, next to a medical transport plane, whilst the crew load a PICU transfer trolley on board...

Here is said transport plane...

This is the huge interior that the transfer team has to work with...

And this was the view out of the window for the majority of the 960 mile round trip!

Ok, now that I've got those photos out of the way onto the details. On Tuesday I did a full day on PICU. As this was my first proper day I didn't really do a great deal besides beginning to learn my way around and how things went down on the unit. However, the duty consultant did try to get me on a patient transfer in the afternoon (partly because it was in his home town and he thought it was a nice place for a student to see). Unfortunately the team was using the 'small' helicopter which only had room for the two person transfer team, crew, patient and one parent. As such I couldn't go out with them. I wasn't complaining though, it was my only my second day! So late in the afternoon, when a call came through about a child in Christchurch who may need transfer up to PICU I didn't hold out much hope about going out. That was until the consultant said the child wasn't critically unwell and could be picked up the next day. This prompted me to ask if there was any chance I could get on that transfer, and as the pictures above show, the answer was yes.

I was told by the charge nurse to call ahead at 7.15am on Wednesday morning, and to be prepared to be at the hospital before 8am. So like a good little boy I set my alarm for stupid-o'clock and when it went off, I promptly put it on snooze for another half an hour. Still, I was up and ready by 7.15, so it doesn't matter.

I called the unit and was told that they hadn't had to rush down to Christchurch in the night so the transfer was still going ahead but it was delayed until 9am due to fog. This gave me enough time to buy a coffee and breakfast so I wasn't complaining about the delay. 

When I did get to the hospital (now happily full of coffee and chocolate almond croissant) I was met by the charge nurse and told to go buy lunch as I was in for a long day. The reg on for the transfer then took me through the winding maze of corridors and lifts that made up Starship and Auckland City Hospital to go buy food (whilst also pointing out the one essential piece of information I needed for the next 3 and a half weeks, the best place for coffee on site). Upon getting back to the ward I was briefed about the patient, what to expect on a transfer and what equipment we would be taking. It turned out that all three of us going out on the transfer (myself, the registrar and the nurse) were all from the UK, so it was a very British transfer.

The last job to do prior to leaving was to get our flight suits on. Initially there was only medium or extra large and I quickly discovered three things:

1. Extra large flight suits can be used as an emergency tent;
2. The above mentioned suits are therefore a trip hazard and not ideal for going around a hospital, much less so an airport runway;
3. Flight suits which are too small have a tendency to castrate male wearers.

These groundbreaking (facebreaking in the case of the trip hazard) discoveries lead to a rummage around the tumble drier for a large flight suit. Mercifully for my face (and other appendages) one was found.

Now suited-up and ready to go we loaded the kit onto the ambulance aptly nicknamed the Baby Bus. After a quick 15 minute ride we arrived at Auckland International Airport via the back entrance. During the ride I was told several bits of information:

• If I hear a gunshot/explosion noise, it is most likely icicles that have formed on the propellers flicking off into the hull - which is conveniently reinforced with Kevlar for such an occurrence;
• It will get bumpy;
• It's quite cramped so we have to hope the patient remains stable in flight;
• Communication is only achievable via headset due to the noise of the engines;
• It'll probably get quite cold in flight;
• There's no toilet on board;
• We're carrying Nitric a pretty explosive gas which we have to inform anyone who transports us that we have it;
• It's only the nurse's second solo retrieval;
• It'll be a good day out!

To be honest I didn't care about all the bad things. When was the last time I had had the opportunity to go on a patient transfer like this? Taking a PR bleed by ambulance to the local (Cornish) hospital isn't really in the same league.
So following a couple of obligatory 'My First Patient Transfer' pictures it was time for the flight. As it was raining I was expecting the flight to be hellishly turbulent but it wasn't actually. Sure, there were a couple of bumpy moments but on the whole it was fine (one trick I found which worked for me during any turbulent bits was to just look out of the window - seemed to help for some reason).
The view, albeit cloudy at times, was spectacular. After we left North Island behind and crossed the water we approached South Island via Tasman Bay & Nelson. From there we just followed the mountains all the way down to Christchurch, which sits an area of perfect flatness surrounded on three sides by mountains and the fourth by the sea:

Compared to the rain up in Auckland the sun was glorious. We were met at the airport by the ambulance that would take us to the hospital and back for this leg of our journey. So once the gear was unloaded we piled into the back of the ambulance for the  quickest and most limited tour of Christchurch a medical student could get (airport-parks-hospital-same parks as before-airport).

Our destination was Christchurch ICU. As the hospital was used to carrying out transfers nearly everything was all ready to go. However before we took any form of handover, but obviously after introducing ourselves, we asked where the toilets were and made use of the facilities.
Freshly relieved we took the handover from the Christchurch team (see bottom of this post for the clinical details) and set about prepping the patient for transfer. Priority number one was to switch him over to our ventilator as we would need him on this for a good 20-30 minutes prior to taking a blood gas reading. That's easier said than done! For some reason the patient's CO2 was reading abnormally high once he was switched to the transfer ventilator. This in turn led to a delay in our transfer as the registrar continued to fiddle with the ventilator settings and the equipment. It was at this time that I learnt an important lesson about the role of observer - learn how to silence the monitors when they start annoying the doctor/nurse. Eventually the reg got his levels under control and an ABG showed a picture of chronic compensation (so in actual fact we had just exacerbated a chronic problem with the ventilator). The rest of the transfer happened rather quickly from that point on. The patient was switched to the transfer monitors and drivers, he was moved across to the transfer trolley and secured, and he was given a dose of diazepam and pancuronium to sedate & paralyse him for transport - as horrible as that sounds to non-medics I can assure you that this is a standard practice (not just in patient transfer but also for operations).
The crewman from the flight had also traveled with us to the hospital as his job now was to liaise with the plane, the ambulance, and a taxi to transport both him and the patient's mother to the airport.
After about an hour and a half we were ready to go so the crewman called for our transport which showed up quite quickly considering it was a busy day for the ambulances in Christchurch.
After the brief journey back to the airport we loaded the patient onto the plane and got mum settled on board. It's worth mentioning at this point that the reason for two-person transfer teams isn't just to spread the workload it is also because one of them must always have eyes on the patient and their monitors at all times (as is also standard practice in ICU). So when the patient was being transferred up into the plane it was necessary to have one team member watching everything from outside and another ready to take over on board the plane.
The flight back took about 30 minutes longer and was pretty much the same as the outbound leg. We were treated to further incredible views of both North and South Island. Naturally we experienced some more turbulence, and we were grateful that the nurses back in Christchurch had had the foresight to put a rolled up blanket either side of the patient's head along with taping his head in place. This minimised most of the wobbling caused, but it was still necessary for the reg to place her hand on his head to steady him.
Eventually we made it to the airport and then back through the city to Starship (apparently it is possible to travel the length of New Zealand without ever seeing a traffic jam, with the exception of Auckland between 5pm and 7pm). A handover was given to the receiving team up in PICU and with that we were finished for the day.
The little lad's mum was quite familiar with PICU as he had spent some time on the unit between late 2012 and early 2013. It's a shame that the family had to travel back up within the space of a year but it was for the best in terms of his care.

Just to wrap up a few lose ends that I couldn't fit into the story above:

• The patient's father flew up on a commercial flight the same evening whilst other family members looked after the other children in Christchurch;
• The flight wasn't as cold as it was made out to be;
• We did get chance to eat during the flight;
• Christchurch ICU did offer us a cup of tea (a sign of a good hospital);
• The patient had to have obs every 15 minutes even whilst in flight;
• He remained stable throughout the flight, only requiring a top-up of his sedation and a dose of antibiotics that hadn't been given prior to leaving the hospital;
• For me the day began at 6.30am when I got out of bed, I'd been at the hospital for 8am, and I eventually got away at 6.30pm, before arriving home at about 6.45 with dinner in hand - I got a pizza, don't judge me it'd been a long day without much coffee.

And for the medics, here is the briefest of patient summaries:

• Male
• Under-1
• PC - RSV+ bronchiolitis requiring ventilatory support
• PMH - VACTERL, tetralogy of Fallot, previous PICU admission
• PEG-fed, Colostomy
• Plan - support on PICU until well enough to return home

Until next time,

Dan

Starting at Starship

Now that I've got through the first week of placement I thought it was about time to go back and fill in the blanks between arriving in Auckland and now. 

As some of you reading may know, the reason I'm in Auckland is because I am doing half of my elective in Paediatric Intensive Care at Starship Children's Health - which is the largest children's hospital in the whole of New Zealand, as well as being the home of the only PICU in the country.

Being the only PICU in New Zealand means that there is always great demand on the facilities available, and not just from the North & South Islands. Starship also provides care for patients from a number of other South Pacific countries. Since I began my attachment I have already met families from Vanuatu and Fiji, which is par for the course here. Also it means that the unit conducts a large number of patient transfers & retrievals, averaging about one every day (either by ambulance, helicopter or plane).

More info about PICU can be found here.

Being an elective student at Starship...

So my time started off with a standard meet & greet with the electives coordinator for the University of Auckland. After being given the information to access the IT/library facilities at the medical school the three of us who had been present were let lose to find our respective departments (PICU/plastic surgery/adult cardiology). Having other students at this initial meeting was good as it was an opportunity to meet other students also out here and have other folks to go out with and see the sights.

As an elective student I am seen as being the equivalent of a Trainee Intern (or T.I.) who is a sixth year medical student who is ward-based and gets paid. I still haven't fathomed out where the equivalent point is in the UK programme, I guess somewhere between fifth year and F1?

Anyway, I got over to PICU and the first thing I found out was that my supervisor is away on annual leave. Now, if this was a placement back in the UK and no-one had thought to provide cover then that would've equaled a free holiday! But being the conscientious ambassador for Peninsula College of Medicine & Dentistry that I am, I decided I was too heavily invested (not academically, god no, I know f*** all medicine - just financially) in this attachment to slack off.

An hour of mild confusion later and I was greeted by one of the secretaries who in turn introduced me to the duty consultant. A nice chap, he gave me a whistle-stop tour of the unit before taking me to get my ID/door pass sorted out.

With my shiny new badge (and my slightly dirty & pen-marked door pass) in hand I made my way back to the unit. Upon getting back the consultant informed me that they were happy for me to come and go as I pleased, as it was important that I also saw as much of New Zealand as possible during my time.

I also met the other UK student currently on elective at PICU, David. He's from Newcastle medical school by way of Durham. We got on well, talking about various bits and pieces. He gave me a more thorough introduction to the unit, answering the various questions I had. We also made plans to meet up with other elective students that night to go to a comedy club.

My first impressions of the registrars and clinical fellow on PICU were definitely positive. The consultant had introduced me as being from Exeter which they all knew, as all three regs and the fellow had all worked in the UK. One admitted that he had been at the Royal Cornwall Hospital when the first proposals had been put in place for the medical school building - and he told me the old rumour that we were supposed to have loads of luxury stuff like hot tubs. The fellow also told me that his best man was a PCMD graduate and name 'Peninsula' should always be mumbled! Seems like I'll have a good laugh with them all.

By this point I'd been on the unit for about two hours, so with the words of the consultant still ringing in my ears I left to go explore New Zealand.

I've made it, I'm alive and I think I may just stay here now!

Well I made it to Auckland safe and sound (although admittedly that was about a week ago).

This is going to be quite a long post so for the TL:DR version see the bottom.

The flight over here was one hell of a drag. I left Heathrow about 12.00 on Monday 15th and landed at Auckland about 00.00 on the 17th local time. Auckland is 11 hours ahead so that works out to roughly 1pm on the 16th in the UK. Add on to that the fact I got up 8 hours before my flight and it makes for a killer journey.
At Heathrow there were the standard emotional family goodbyes that you'd expect when a loved one is going to the other side of the world for a prolonged period of time. That was probably the hardest bit of the experience so far. Annoyingly at check-in the woman at the desk said that she didn't need to weigh my hand luggage as "it looked like it'd be fine." Cheers love! Now I discover that there are staff at Heathrow airport who can weigh bags with the power of sight, when is this new method going to be rolled out to other airports? Or is it only going to be available on certain flights? Maybe as an optional extra? "Save the hassle of taking your bag off your shoulder with our new baggage service, we'll tell you if it's OK without you having to move a muscle - for a nominal fee." If I'd known this was going to be included I wouldn't have bothered taking a load of stuff out of my bag. I can't be too harsh on the woman though. When I checked in there was only one seat that she could get me on the flight which turned out to be stuck in a middle seat in the midst of a group booking. I don't know if she saw that I was a solo traveler or maybe it was the look of parental concern on my mum's face, but she told me to go and talk to her supervisor to see if he could sort me out a window or aisle seat. Thankfully he was able to do just that. I got an aisle seat right at the back of the plane - I could put my seat all the way back without ever having to worry about smashing into someone's knees...win!

The flights themselves were fine in all fairness. All the food & drink was complimentary and was actually quite nice. The staff were friendly and helpful, and the entertainment on the plane was very good for such a long journey. The only bad part was the amount of turbulence that we experienced over the Bay of Bengal. What I did find interesting on the first flight was that the stewardesses kept one of the TV screens in their reserved seating set to the compass display - which included the direction of Mecca. I soon found out the reason for this. Around one of the rear exits was a curtain and neatly folded by the door was a prayer mat. Malaysia Airlines ensured that there was a quite area of the plane where Muslim passengers would be able to pray during the 12 hours flight. I was impressed by this consideration as it displayed the forethought of the airline when ensuring they covered the needs of all passengers. The second flight was interesting just for the sheer number of under-25s travelling to Auckland for work, study or general travel.

After arriving in Auckland I had to (obviously) make my way through passport control with my nice shiny arrivals form which proudly stated I was carrying medication and my walking boots (a.k.a. a biosecurity risk). I was expecting to be in for a long night but the border security guy simply asked what the medication was for (anti-malarials if you're asking) and sent me on my way to baggage claim.

Once I had my holdall in tow I made my way for customs where, once again, I had to show my now slightly defaced (courtesy of the border security guy) arrivals form. This time I was directed to go and join a queue of people waiting to have their bags checked. As I joined the queue one of the staff told me to cut round to an empty queue, which saved me heaps of time! After showing the sole of one of my boots to the customs guy I was on my way out of the airport.

At this point I knew the name of where I was staying for the night but I had no idea how to actually get there. Being the tired naive traveler that I was I just waved down a taxi. When I told the driver where I wanted to go he turned round and said "mate there's a free shuttle bus for that hotel just over there." Well, that was a refreshing change! Here was a cabbie who could have made a quick buck out of a tired traveler and instead he actually helped me on my way.

I'll admit I didn't get a fantastic night's sleep due to sleeping on the plane and having absolutely no idea what time it was (crossing multiple time zones, seeing two sunrises/sunsets and being fed at odd times tends to screw with your body clock). After waking up between 4.30 and 5 I decided to stay up. I was treated to a nice sunrise because of this...

Once I had been picked up from the airport hotel by shuttle bus I began making my way into Auckland proper. I'll be frank and say that my first impression of the city wasn't great. I was tired, a little lost, a bit homesick and here I was in a city which wasn't visually that inspiring. I hoped deep down that when I eventually reached my accommodation that things would be different.

And they were...

I was met at my accommodation by the owners Stephen & Paul who greeted me warmly and took my bag (all 26.6kg of it) up to my room. They showed me around the house, sorted out the payment and told me the names of a couple of other medical students staying down the road at their other property. Since moving in they have continued to be very helpful with any queries that I have had. The other guests I have met and chatted to have been equally as friendly and are from a wide range of backgrounds and countries.

The weirdest moment came whilst talking to an Indian gentleman who had lived as a chartered surveyor in New York State for the past 28 years before deciding to move over to Auckland. During our conversation he asked where I was from, my default reply was, as always, "Just on the English side of the Southern Welsh border" and this normally either satisfies people or results in deeper questioning as they put their geography to the test. This time it was different, Issac (the gentleman's name) immediately replied "Oh, you mean Hereford?"and as we talked it transpired that about 30 years ago he went to boarding school in Lucton, only a few miles outside of Hereford. Damn it's a small world!!

So what have I done since arriving in Auckland?

Well, quite a bit. On the Wednesday I had a bit of a recce along Ponsonby road (awesome) and found the nearest supermarket. In the afternoon I decided to take a long walk to find the hospital which took me through a variety of areas, not all of them visually stimulating shall we say. The sheer scale of the hospital blew me away after the years of studying at a DGH in Cornwall. Following this little mission I resolved to have an early night and did just that....I was asleep by 6.30pm.

After speaking to my parents for the best part of an hour on the Thursday morning I made my way up to Ponsonby Rd. in search of a HOP card (think Oyster card) to make paying for the bus to and from placement/the city easier. After finding a corner shop that sold them I made my way by bus to Auckland Zoo. Bearing in mind it's the middle of winter here in Auckland the zoo was still busy. It made for a few enjoyable hours of wandering and photography, and I even saw a kiwi.

On Friday I decided to have a wander down in Auckland city itself. I began my explorations on the waterfront of the Wynard quarter which is in the middle of a large regeneration project which has a 20 year plan ahead of it. Unlike the UK they have already begun making progress through this plan and I think it'll be pretty incredible when it's finished. At this point I realised  that I couldn't find my passport in my bag so in a state of mild panic I made the trip back home and found it sat on my bed... I spent most of my time afterwards on Friday just wandering around downtown Auckland, learning the layout and getting a feel for the city. Downtown Auckland is pretty impressive for someone who has spent most of their life living in small cities in the middle of the English countryside. Whilst it had the look (and the crowds) of a big city it didn't have the impersonal feel of such a place. There wasn't any shoulder barging or the general rudeness I've experienced in other cities, the streets were clean and the most noticeable thing - minimal traffic.
Over the weekend I decided to try to experience some of the events going on for Matariki (Maori new year). To that end I found myself walking about 3.5 miles out of downtown Auckland to one of the domains where a kite festival was being held along with a tour of the Maori structures at the site. I'll write a post in the near future about what I have learnt about the Maori culture. The weather was ideal for the festival, just enough wind to allow the kites to soar but not strong enough to whip the string out of your hands. In the afternoon and during the day on Sunday I had a look around Silo Park which is found in the Wynard quarter. Some of these old industrial concrete silos have been painted by local artists and it is one of the locations where it is easy to see how the regeneration of the area will look as it is completed. The reason I went here was that they were holding a one-off winter market for Matariki and it was a great opportunity to see random bits & pieces.

Well I think that wraps up what happened in my first week in Auckland. I know this post is a bit delayed in getting out, I've just been a bit busy. In the next couple of days I'll try and bring it all up to date with posts that I hope will be a lot shorter!

Dan

TL:DR - Long flights, good airline, trouble sleeping for few days, Auckland is awesome, posting soon about elective placements (and stop being lazy and read the whole thing)

(All pictures copyright Daniel Bunce 2013)

Change of direction

So in the past I have used this blog to provide occasional thoughts/rants about things to do with the medical world. But I feel it’s time to change it a wee bit. I’m going to write about various bits and pieces that crop up, not just medical stuff.

To begin with I’ll be writing a few pieces whilst I’m away on elective. Now, strictly this is a medical topic but I’m hoping I can do a bit of general travel writing about the places I visit too.

I may also write a bit about the cycling I do, foodie topics, and anything else I think is interesting.

The first part of the elective blog will be up in the next couple of days.

Dan