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| Carna Clinic |
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| Gerard Hooke MD |
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| Alison, Maureen and Sandra |
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| Greg with patient |
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| Irene, community nurse |
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Deirdre, clinic nurse |
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| Johanas, nurse at Carna Nursing Home |
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| CArna Nursing Home |
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| Nursing Station, Carna Nursing Home |
Saol fada chugat
Long life to you
I suppose the weirdest thing I do in clinic is drain blood from people. You may recall that this was done hundred's of years ago, with the mis conceived notion that draining blood from a sick patient would rid them of the disease. Unfortunately, as we now know, making someone anemic when they are sick, is contrary to good medicine. Do no harm, is our promise. Hemachromatosis is a genetic disease of iron overload, where the body is unable to dump excess iron. The normal iron levels are under 200, here I have seen levels over 1,000. This is toxic to the heart and other organs. The solution is to bleed off pints of blood, following the iron level down to 50. We service a catchment of perhaps 3 thousand patients, and hundreds carry the hemachromatosis gene, which makes this population a geneticists dream.
I get to do prenatal care, but not deliveries, which was my favorite part of medicine in the USA. Here, deliveries are done in Galway, 1.5 hours away. The family physician and the OB co manage the prenatal patient.The hospital labor and deliveries are managed mainly by nurse mid wife, who will call the obstetrician if there are any complications, or if it is a privately insured patient, at the time of pending delivery. Nationally, most patients are on a public insurance plan. It is a good plan, except for specialty referrals, which can take months to years, due to access issues (some specialists not taking public insurance, and doctor shortages, same as in the USA).
Home visits are a big part of my job. I will often do 2 home visits in a day, along with seeing a full day's worth of clinic patients, and making a daily visit to the nursing home. Finding the house is the hardest part. Here, the Irish sense of direction is not great. There is definitely a cultural difference in how they describe a location. Typically, I will end up in the general area, and still have to ask 2 more people for local directions. I have so far, not scraped my car on a rock wall. Often, the roads are quite narrow, so you always park strategically, in able to exit more easily. Most homes have cats or dogs, who are outside. They are always friendly and hungry for attention. The houses are small, by American standards, and cosy. They are well kept, and during winter, the stove or fire is always going. TV is quite popular, with a wide variety of programming. The weather is as big of a topic on home visits, as it is at clinic visits. I get very accurate forecasts report from the patients, as many are farmers and fisherman families. They often have cows, donkeys, sheep, chickens and horses. I usually am offered a cup of tea, and biscuits (cookies). Sometimes, I have to call the ambulance, which, unless it is on a run, is 45 minutes away. I will wait and follow the vitals if they are sick. They need a written report before going to the ER, or they will be charged one hundred euros. There is BLS and ACLS transport available.
I have seen a wide variety of patients in the clinic. People that would normally go to the ER in the states will here see me instead, due to the cost, and proximity issues. Fractures are pretty common, we splint them and send in, as they need X rays, and casting. Lacerations are also common, which we repair, which is fun. I see a lot of respiratory infections, and the patient or parent usually expects an antibiotic. Historically, this may have been the approach due to access issues. I do my best to educate the patients about the difference in treatment for a viral vs. a bacterial infection, with predictably variable response. Sometimes, if I refuse to prescribe, the patient will be back with the same cold a day or 2 later, asking me or another doctor for antibiotics, saying I told you so....
I have one office/exam room, and no medical assistant or nurse. I do the vitals, blood draws, EKG, injections of joints, and medications like B12, antibiotics, and sometimes immunizations. A favorite injection is Diclac 75mg IM, which is an injectable Ibuprofen like medication. It works very well for pain. You can even give it to the elderly, as it bypasses the stomach. We do have a nurse once a week, who does a lot of the repeat labs (INRs, etc) and childhood immunizations. I have re learned the art of blood draws and other procedures which I had not done for twenty years. There are a lot of eye related issues, I have learned how to remove foreign bodies, and diagnose serious eye pathology. I have seen retinal artery occlusions (not good), and bad eye infections requiring hospitalization. In the states, I would have much easier access to send patients to a specialist quickly. I can only order Xrays, not ultrasounds, or other imaging tests. The specialist has to see the patient first, so there can be a delay in diagnosis. I would debate if this policy actually reduces costs. Some specialists (consultants) take months to see (unless private insurance)so a patient getting sick is sent to the ER. Once admitted, they get all necessary testing and treatment, fixing the problem. Contrary to the in states, they will get any other issues evaluated and treated too. It is sad when you expect cancer, and a patient is not sick enough to become inpatient, and you have to wait for the specialist appointment. Medications are covered, and there are more choices then in the states. There are some useful medications here which I have never seen, including injectable NSAIDs as well as topical NSAIDS. Also, more diabetic drugs, including an oral form of Byetta. We had a dispensary here, where we would give out the medications. It was quite handy, although a bit of work. When the Chemist (pharmacist) came and opened a pharmacy, we stopped routing medication distribution. Now, only in emergencies do we distribute medications.
There is a lot of high cholesterol, but interestingly not nearly as much obesity. Certainly the Irish meat and potatoes diet effects the lipids. People here are fairly active, and food is expensive (except potatoes) and it is sold and served in small portions. Costco would not make it here. I did hear they are planning a store in England. We buy our fresh fish at the post office, as the postal clerk's son fishes locally. I pay ten euros for around 3 pounds, a good deal. It is a variety of white fish. When the weather is bad, there is no fish for sale.
I have seen a variety of cancers. Colon cancer is fairly common. There are some smokers, but a pack is about eight euros, which is over ten dollars. At times, it seems like there is a lot of pathology here, but I think that is because we see all patients first. Recently I had the Coast Guard helicopter evacuate a critical patient, due to ambulance delay. They landed in the football field, it looked like half the town showed up to see what the racket was all about. Apparently, this was a rarely used transportation mode. I had to justify the life or death severity of the situation, hearing that it would be an expensive choice. This case had an unfortunate outcome.
There is a lot of heart disease. I have seen mild and severe heart attacks, some made it, and some did not. Historically, there have been cases here as young as age thirty. I would have hardly considered that diagnosis in my differential, until coming here. People know that if they have a heart attack here, we will do our best to help them, but due to the time it takes for the ambulance to get here and take them to the hospital, if they are bad off, they may not make it.
The patients always ask me how I like it here, my answer is that I like it because everyone is so friendly to our family, including our kids classmates, and the area is quite pretty. I mention my love of photography, with lots of opportunities for that expression. The first six months, our kids wanted to go home. Now, they want to stay longer! They have good friends, and they really like the beaches around here. The water is still to cold to swim in, but great in the Summer. The winter was harsh, similar to Washington, with buckets of rain,wild wind and many cloudy days. What is different about the Spring is that it may rain then sun, multiple times a day. Not to many 'dirty' days, as a local said.
Some of the younger children only speak Irish, as their parents try to get them fluent early. They teach Irish in all the schools, so most of the children are fluent. I would say that most parents speak Irish in the house, but English is not a very distant second. Ireland is trying hard to preserve their language. There are roadside signs around Connamera that say "An Gaheltach" which means 'Irish speaking region'. The only relatively local radio station broadcasts in Irish. They play some great traditional music. I am collecting some incredible local traditional music preformances, I may have to link the videos to this blog, which does not support videos well. There are 2 Irish words the kids use when describing their respiratory infections: smuish (nasal mucous), smuguis (phlegm). Also, bunyak is diarrhea.
We use paper charts, and an old electronic health records computer program. I print out prescriptions at my desk, and just hand to the patient, who sits opposite me. Patients lift up their shirt for their lung and heart exam, with out my prompting. Many of the women pull a bottle containing urine out of their pocket, even if they are not sick. I just check it with the chemistry dip stick next to my desk. They often will say ''I think I have a kidney infection''. Pain is much easier to deal with here-patients are stoic, and they don't want medication. You may convince them to take an NSAID, but they wouldn't take anything stronger. Contrast this to the states, where everyone seems to want narcotics for their pain. This is a noticeable cultural phenomena, a real eye opener. The Irish seem to function fine this way. As mentioned, I use an injectable NSAID frequently for pain.
I do see alcohol related medical issues here, although I don't think they are significantly different then in the states. Last week, I saw 2 patients with severe illness as a consequence of drinking. I think it is a challenge here, being rural and especially now with a recession and high unemployment, there can be more idle time and probably more drinking. The pubs are where people go to chat with each other, a part of the culture, especially here, where there are not many social venues. Some nights, there is great Irish music at the pubs, good craic. I see patients who say they used to drink, then they realized that was getting old, so they quit, or at least moderated. It can be an issue with the teens, although I saw this in my own upper middle class neighborhood, growing up near Seattle.
I am fortunate to work with two excellent physicians, Dr. Casey and Dr. Hooke. They both have loads of experience, and I can consult with them (either by phone when I am solo, or in person) on challenging patient situations. You tend to figure things out here a lot more then in the states, where the specialist is nearby. I use UpToDate, an excellent subscription based online physician reference, near daily. Yesterday, I was reading about coagulopathies, for instance. It feels like I have seen more pathology here in 6 months, then what I would see in a few years, at my Community Health Clinic, in the states, where there always is significant pathology. I think this is in part because I do more well child checks there, whereas here, everyone that comes to see me, has a medical complaint. Also, patients see me first, regardless of the need to go to the ER. I pronounced another patient this week, something that I would rarely do in the states. Today was fairly typical: Some interesting patients: I sent a woman to the ER for a headache, with half her tongue numb and gait imbalance. I also sent in a teenager with an impressively painful hip, as he might have an acute slipped femoral head, or joint infection, which are devastating if not caught right away. I also removed a corneal foreign body. I saw a patient at the nursing home whom I put in an IV with antibiotics for pneumonia.
Irene is the part time public health nurse associated with the clinic. She spends most of her time in the field, doing home visits, especially with the elderly. She does education and wound care, and she gives the doctors valuable insight into how the patient is living and coping with their illness.
Didi is our part time clinic nurse. She gives a lot of the childhood immunizations, does INR and other bloods on some days, does phlebotomy on iron overload patients, and does PAPs which the Irish call smears. The photo shows her at the nursing home, where she goes weekly for whatever bloods are needed.
Alison is the long time Clinic Manager. Her duties are to long to list. She has been incredibly helpful in my transition here. Maureen, Sandra and Elaine work in the front office with the usual duties. They also run the sed rates.
I enjoy near daily rounds at the fifty bed nursing home. It is located near the sea, and there are probably more one bed than two bed rooms. On Christmas and St. Patrick's Day, all the residents had a drink. The local children came in and preformed traditional music and dancing. Some of the residents like to sit in the grand entrance area, watching people coming and going. I get some nice greetings and waves as I enter. Everyone goes to a communal dining area for meals. After a meal, the folks sitting by the entrance typically have nodded off. They will also hang out in an activities room, where there are optional hobbies, and television in the background. The toughest part to handle is patients who pass away.
Like most nursing homes, there is a lot of idyll time. The residents get great attention, from an international staff. The staff includes representation from Germany, Poland, India and France. Nurses will come here from abroad for a few years commitment, then go to the big city for more money. It is a great place to train, as one gets lots of exposure with the residents. I have improved my IV, EKG, blood drawing and code skills. Also, you can treat sick people here, to a degree, as there is skilled support staff, but it forces you to think about what you can and cannot safely do, in a non hospital setting.
I get phone calls when on call. Sometimes they just hang up after I identify my self. They are loyal, to a fault. They often want Dr. Casey, who is the original doctor for this area. Sometimes they will call back, having weighed their illness and the prospect of seeing "the new doctor from the states". They are always respectful. I try to meet them at the clinic, four miles away, otherwise I go to their house. There are not to many nuisance calls.
It has been rewarding working here. Certainly a change from the clinic that I have worked at for the last 18 years, in Marysville, north of Seattle. It is good to challenge oneself, career wise. I am wiser from this work experience. I have more skills, and confidence. I will be more frugal with resources upon my return. I have made a lot of friends, from the perspective of knowing people and their families, and sharing conversations about their life.
There is a new website
http://conamaragaeltacht.com/ which was locally created, with government funding, to promote the area. Many of the photos on it are mine.
