King Country

The central west coastal areas to the north of Mt Taranaki are referred to as the "King Country". After a brief mid-19th Century movement to resist the European settlers in the land wars, the Maori king withdrew southward to this region. Although hostilities ended long ago and the king (actually a queen) is now largely symbolic, this is an area that takes preservation of Maori stewardship seriously. The caves of the Waitomo district, although managed by the state, have been returned to the descendants of those who revered them as sacred places for centuries. These are the famous "glow worm" caves. The Maori word for glow-worm translates to "stars over water", and this is an apt description.  The pictures below are all taken from this magnificent region, which stretches from mountains to the Tasman sea. 

In Marokopa (below), we observed dozens of intrepid locals wading through the incoming tide to net some "whitebait", which refers to the juvenile of several species of coastal fish that are about an inch long, translucent and quite a delicacy here. They cost over $100 NZ a kilo, and are served in omelettes, "fritters" and other styles. It is illegal to harvest them commercially, so thousands of Kiwis (the people, not the birds) patrol the coastal inlets and estuaries during the season, which lasts from August to November.  The sand is ash-black.

Between Waitomo caves and the cosat, we stopped at Marokopa Falls. Kristen took this amazing picture of the falls and mist-rainbow.

We probably take too many "bush" pics on our walks. Hey look, here's another one! (sorry)

Many places we visit, like the caves or Mangapohue Natural Bridge, are essentially impossible to photograph. 

Te Whare O Matairangi (Ward 27, Wellington Hospital)

Hi, Richard here. I'm working on the inpatient unit, and yes it's true they bring the voting machines to the unit and encourage all the inpatients vote. This is just one example of the inclusiveness of kiwi society. Another is the extent to which family (whanau), care managers and other supports participate in patient care. This means that I spend as much time meeting with these folks as I do with the patient. Notions of individualism and privacy are not as strong here as in the U.S. Rather, the expectation is that decisions are made collaboratively. Even the most psychotic patients are willing to sit for a "hui", and several such meetings may take place over the course of a hospitalization, which on average lasts over a month. This may seem exceptionally long, but all barriers to community care must be accounted for before patients can be taken "off the books", so to speak. This means that, in essence, the ward functions more like the "asylums" of old than a contemporary American unit, albeit with some distinctly kiwi twists. Patient's come and go on leave with family members, sometimes for days at a time, and are frequently granted periods of unescorted leave to take care of personal needs such as shopping and banking. Remarkably, almost no patient's go AWOL. On Fridays, there's a BBQ in the main courtyard, which is shared by family, staff and patients alike. Everyone uses first names only here, regardless of "rank", as status is a far less important concept here. Patients wander into the nurses station to ask for a smoke, tea or a snack; nobody bats an eye.

The unit itself is quite shabby, and antiquated by U.S. standards, but the staff are amazingly experienced, dedicated and competent. Moreover, all of the "scutwork"is done by a host of junior physicians under my direction. In essence, my job is to make decisions, guide treatment and to lead. The junior docs are avid for any teaching, and there is ample time for both formal and "on the fly" didactics. In addition to the care meetings that consume the better part of most afternoons, these is a morning team meeting. Wednesday mornings are occupied by peer supervision groups or presentations (followed, of course, by tea), court is held on Thursdays and we meet with the Clinical Director over a leisurely breakfast on Tuesdays. The commitment process here is somewhat byzantine, and does require formal "reports" to be submitted by the "responsible doctor". As with any former British colony, the government paperwork can be a bit silly, especially in the absence of any actual day-to-day medical documentation requirements. Overall, the pace is very laid back and I routinely find myself with stretches of free time on most days.

I guess the most important aspect of any labor is the gratification and enjoyment it provides the individual. By that standard, this is a very good job. I love going to work, genuinely like being there and could easily see myself doing it for a very, very long time.

New Zealand Psychiatry - Crisis Management

It's Kristen, here.  Here's a rundown of my job and the mental health climate in NZ from my perspective. I am on a Crisis Assessment and Treatment Team (CATT). The CAT Team provides a regional mental health service (so, covering from downtown Wellington to towns about 30-40km up the west coast). We are based in a town (Porirua) central to the overall catchment area. The team consists of two 9-5 / M-F team leaders / schedulers, two 9-5 / M-F doctors, and then the first line clinicians who are a mix of nurses and social workers who work in 12 hour shifts, two on and three off. The essential function of the team is to assess all patients in crisis (including children / adolescents) on a 24/7 basis, treat if needed, and then dispo them appropriately.

Referrals come in as self-referrals, from family members or friends, general practitioners (GPs), police, EDs, and sometimes from an inpatient medical ward. Referrals from family members are generally what you would imagine: "my 16 year old just left the house against my will with her boyfriend" and "my husband started drinking again and I don't know where he is" and "my friend has been getting more and more depressed and I think she might hurt herself." Routine stuff with routine advise given: call the police or go to the ED if an emergency, mobilze supports and problem solve otherwise. Referrals from police, ED, inpatient ward are generally more severe: many serious overdose attempts, for example. But, most of these folks get sent home with supports (i.e., NOT hospitalized). This is in marked contrast to the States, obviously. There is a huge emphasis on keeping people connected with their family / friends and not relying on institutions. (Interestingly, we see relatively few personality disorders. It's hard to tell if this is a function of the system -- few hospitalizations, reliance on social not institutional supports, separate personality disorders consult team -- or of the Kiwi personality which is very mild and modest).   

There are several options for psychiatry support in the community as well. The CAT Team will follow folks for several weeks if needed -- calling at home to check on patients / families, going to get patients for appointments, etc. There is also a Home Based Treatment Team that serves as an alternative to hospitalization. They will see people daily (more if needed) in their home to assess. There are respite facilities which are homes in the community where up to four patients can stay for 3-4 nights while in crisis. These homes are staffed 24 / 7. And, there is an Acute Day Service which is like day treatment for people who are in crisis. So, as an alternative to hospitalization, someone might stay at a respite facility at night, go to an day service during the day, and be followed by Home Based Treatment.  

So, what I do is assess folks with both the CAT Team and HBT Team for safety / disposition and medication management. I end up seeing folks all over town in all sorts of settings. Nothing too acute, generally, but certainly an interesting variety.

A note regarding commitment: The process is called the Mental Health Act here. Criteria are similar but terms run from 5 days for initial assessment then 14 days for continued evaluation then in 6 month increments from there. An interesting difference is that when someone is under the Mental Health Act they are mandated to get treatment which includes medications (i.e., there is no separate process for forced meds).

A note regarding medications: Lots of the same medications here (and, drug reps here as well), but some of the medications they don't have are Lexapro, Wellbutrin, Remeron, Librium. They do have an oral MAO inhibitor which is A selective meaning that you don't have to follow dietary restrictions. 

That's about it for now. I'll let Richard describe the inpatient setting. I can't leave without saying this though: They came on the unit to have the patients vote, here. It nearly made be cry.

Palliser, Putangirua Pinnacles & Kaitoke

A recurring sentiment: the limitation of words and images to convey experience. There is no tool to capture the sweet elusive scents of spring in the cool, deep bush; no way of following the rush of wind along the barren straits, softening over the land into a gentle accompaniment for Tui songs. Even memory degrades them. The best one can do is to tell stories. . .

And so we set out for the southeastern-most coast of the North Island. Martinborough, a quaint town gaining renown for its fine red wines, is gateway to this region. We arrived briefly at the old Martinborough Hotel to reserve a room and set aside our things, then headed down to Palliser Bay, where fur seals teem in the coastal waters. Spring means seal pups, and we counted many curled drowsily on the rocks or playing the the shallow, sheltered coves. Perched at the end of the road (literally) and atop 250 steep steps is the Palliser light house.

The view from the top is magnificent. The coastal road can be seen hugging the black, seal-laden beaches at right, an in the middle horizon the snow-capped peaks of the Kaikoura range on the South island are easily visible on a clear day (clicking on pictures will enlarge).

A few kilometers back up the road are the Putangirua Pinnacles, a sort of mini-badlands formed over millenia of erosion. For those who are fans of the Lord of the Rings films, this was the setting for the Dimwalt Road which Aragorn, Gimli and Legolas take to summon the dead army as Mordor's armies lay siege to Gondor (Return of the King). The gorge itself is quite difficult terrain, and nearly impossible to photograph with any sense of scale. In the movie, the camera reels up the pinnacles or is set above them looking down into the dry river bed.

On the way home, we stopped by Kaitoke Park, which in a sense is our "local" park, as it is less than an hour's drive from downtown Wellington. Kaitoke consists of thousands of hectares of pristine alpine bush, and is the watershed for the Hutt River, which provides half of the region's water. Kaitoke was the setting for Rivendell in the Fellowship of the Rings. We halfheartedly attempted a few photos, but none caught the feel of the place. Perhaps we will try again soon.

Word of the Day: Endemic

Endemic: Exclusively native to a place.

Here's my (Kristen, here) recap so far: long trip, little bit of a snag with getting licensed here, but all is going well. Starting work tomorrow, inpatient wards for Richard (for at least three months) and crisis team for me.

The endemic (see above) people are really nice. The endemic food is really good too. It's like fresh, simple versions of food you know. With some lamb thrown in.

Lamb: not enedmic. But incredibly cute. It's spring here so they are everywhere in the hills. I will never eat one again.

We took this weekend to see a lot of endemic flora and fauna. The long-finned eel at the Mount Bruce National Preserve didn't make the cut in terms of upload time. But, below is the view from Mount Bruce. The hills are so green it does not seem real. It is totally impossible to duplicate in a picture.

This is the kaka, an endemic parrot in NZ. Also at the Mount Bruce Preserve. The kiwi bird was there as well in a special hut with reversed day / night cycle (they're nocturnal). We've seen tui, pukeko, and the New Zealand pigeon, too, all endemic.

After the Mount Bruce Preserve, we continued north to Hawke's Bay and Napier. The weather was decidedly more mild there and the region beautiful. Not exclusive to New Zealand but certainly abundant: earthquakes. Napier was leveled by one in 1931 and the resulting rebuilding took on an art deco flavor that is still there today. We stayed at a lovely B&B just down from this stand of Victorian buildings, the "Six Sisters," so named as they they were rebuilt after the earthquake for the owners six daughters.

The drive back to Wellington took us through the Lake Taupo region, which has another of the remarkable features of New Zealand: geothermals areas. Below is a formation at Orakei Korako, formed by silica flows. There was boiling water and steam coming from the ground throughout the park and several areas where mud was boiling. It's quite otherworldly.

Well, that's it for now. Hope everyone is doing well. Cheers.

Sunset from Titahi Bay

After a couple of wet, windy cold days--as well as a series of bureaucratic irritations and a fall off the bike--the Southwesterlies turned and the skies finally cleared. Kristen started work orientation today, and left to my own devices I tried not to obsess about the US election and the "bailout". 

     We had a marvelously fresh dinner of scallops, sushi and sashimi, then drove a few minutes up the coast to Titahi Bay to watch the sunset. Flocks of birds braved the stiff crosswinds to roost on Mana Island (far right) as the sun set gloriously over the ridges of the South Island. 

     I am reminded of Keats' words (from Ode on a Grecian Urn), "Beauty is truth, truth beauty. That is all ye know on earth, and all ye need know." To see that beauty, borne of our impermanence, is to let go of impatientce, dread, or anything that prevents us living in the now, for now is all we have.