Everything I had read about this border crossing had made it sound difficult. Always an uneasy relationship, tensions between Spain and Gibraltar had been escalating in the last 12 months, prompting a Gibraltarian MP to say that they were “one shot away from military conflict”.

It was 6am when I hauled my bags out of the rain into the shelter of the border post. The previous night I had been on a night-bus from Madrid, the night before I had been in a series of airports and aeroplanes. Needless to say, in my wet and sleep-deprived state I was not in the mood for trouble.

“Kiwi huh?” the officer said, “we got a Kiwi here at border services, we call him an Australian just to annoy him.” Although I chose not to say anything, I had to agree with him- it would be pretty annoying. The official gave me my passport back and I walked back out into the wet night. After 36 hours travelling, I had arrived in Gibraltar. It was only ten minutes later that I realised how misguided the reports on the border crossing were: the official had never even opened my passport.

Gibraltar is a British-controlled peninsula at the south of Spain. Its 6 square-kilometres are dominated by the monolith “Rock of Gibraltar” with most of the population living on reclaimed land. The thirty-thousand resident Gibraltarians are served by the 200-bed St Bernard’s Hospital, where I am spending the final seven weeks of my elective. To date I have spent all my time in the Emergency Department but I will also spend some time in Orthopaedics, Gynaecology and General Surgery before I return to New Zealand.

During my time in A&E, I have seen an incredible range of medical presentations-from sprained ankles to metastatic cancer, children with colds to adults with cardiac arrests. To the eternal frustration of the thrill-seeking emergency doctors, approximately 90% of the presentations are relatively innocuous complaints- essentially General Practice in a hospital setting (highlighted by one patient I saw this week who came in for a repeat prescription).

For the most part, my days in the emergency department are filled seeing these lower acuity patients. I have been afforded a large degree of independence by the doctors – generally I see patients by myself, order any blood tests or X-rays that I deem necessary before discussing my management plan with the doctor. In many cases the doctor advises me how the patient should be managed and the patient is discharged without ever having seen a qualified doctor.

I must admit that this was pretty daunting at first (I was scared of missing some life-threatening sign) but the doctors have always been happy to review a patient when I was unsure.

Although the true emergencies are few and far between, I feel that my time in St. Bernard’s A&E department rates as some of the most valuable hospital experience I have ever had. It allowed me to polish my clinical history-taking and examination: by the time I was seeing my third patient with a sprained ankle the doctors had taught me all the questions I should have asked us first one. It was also valuable seeing low acuity patients with a full laboratory and X-ray department- they gave me diagnostic reassurance and I now feel much more comfortable in making a clinical diagnosis.

Lastly, I wanted to write about a particularly thought-provoking patient I have seen this week, who was a perfect example of the type of patient that can fall through the cracks. She was a 78-year old woman with advanced dementia- she didn’t know where she was, what year it is, she was totally incontinent and for the last three days she had reduced her food intake to an apple tart and a small milkshake each day.

After her son relayed this history to me, I went off to find a doctor as I felt this patient needed admission to hospital. The doctor I spoke to knew this patient from previous admissions and although he agreed with me, he explained to me that this patient had been in Gibraltar only 5 years. This meant that while she was eligible for medical care, she was not eligible for “social admissions” such as dementia care.

Essentially, for the ward doctors to accept her we had to find something medically wrong with her, the cruel alternative being to send her home and to wait for her to return in a state of malnutrition. In such a high-risk patient, we decided to leave no stone unturned- we ordered an extended set of blood tests, a chest X-ray and a urine sample. Awaiting the results was uncomfortable, knowing that it was in the patient’s best interests if we could discover that she had some physical ailment.

Ultimately, we found a urinary tract infection and we were able to get her admitted under the guise of that. Hoping that the patient is sick is not a state of mind I want to get used to, but I am aware that admission for dementia care is a difficult issue around the world, so at the very least I am glad for the experience.

Altogether it has been an enjoyable start to my time in Gibraltar and I now feel much more confident in both managing minor injuries and using the medical system to get what’s best for the patient. With any luck the rest of my time in Gibraltar will prove just as worthwhile.