I just wrapped up my last ER shift, and it's been an interesting experience. It's certainly not HGH, where we had traumas crashing through the door at all hours of the day. I saw aortic dissections (I wouldn't wish it on my worst enemy), car crashes, full body burns on a terrifyingly regular basis. The excitement is certainly everything I imagined of an ER. People running, doctors being paged overhead (I used to fantasize about being paged. Now I do everything to avoid being paged), and paramedics run a revolving door of patients.
It's not quite like that out here. The real traumas get sent straight to St. John's, so most of what I see here are really walk in clinics. I don't mind, in a lot of ways. I find the culture a lot less malignant than city hospitals. For one thing, without there being permanent residents based here, there's no expectation that we work around the clock.
I enjoyed being on call on internal back in clerkship, I really did. But was 4AM really the necessary time for me to consult on a patient with stable afib, going for surgery 5 days later? Not even a little bit. But I did. I did so many of those it wasn't funny. I literally fell asleep during one at the computer. I also did 'consults' on ICU transfers to our ward. Why these transfers happened at 2AM instead of 2PM the day before or after? Hell if I know.
Instead we as ER manage patients overnight if they're stable enough. We don't call our internists at 430AM for a stable afib. We don't page surgery stat for a query pancreatitis that isn't septic. We give antibiotics, we start fluids, and we monitor.
What I find harder to swallow is the state of this place's family medicine being reflected in the ER. I've lost count of how many patients came in for mind boggling minor complaints because they're concerned (rightfully so, anyone would be without medical knowledge) but have no family doctor. The waitlist doesn't even exist for some doctors because of how loaded down their practices are.
Patients come in for coughs because the waitlist at their doctors is 5 weeks long for an appointment. And that's how I end up doing insurance forms, viral coughs, and aches and rashes all day and night long. It's also one thing for patients to come in at 3PM and say they have a rash. I get annoyed when they show up at 3AM.
From their perspective I can see why they show up at 3AM. The ER is almost guaranteed to be empty. At least in the waiting room. We usually have a full house of overnight patients that I'm watching all night. From my perspective I'm just annoyed. I've been on all day, I'm exhausted, and in no medical logic is it appropriate to see an arm pain that someone's had for 4 months, unchanged, at that hour in the ER. It's not appropriate to be seen in the ER period. Especially not one that's been cleared by their family doctor and medically maximized in terms of management.
For those patients: please stay at home. I really won't be able to do anymore than what your family doctor has done. No I cannot send a specialist referral at 2AM in the morning. I can barely send them at all and you won't get in any faster than if I sent it versus your family doctor. Do yourself a favour and don't get out of bed at 1AM and drive in the moose infested dark roads. Stay home and see your family doc.
Wednesday, August 22, 2018
Sunday, August 19, 2018
The med student underground tunnel
Among the most prolific rumor mills is the under-breath whispering of all medical students and residents: past, present, and future. Not only does details of interesting cases get passed around, but the real nuggets of information are the details on rotation sites and preceptors.
Which sites have the best call rooms? Which call rooms have windows and a better wifi signal? Which parking lot was designed to scratch up your car?
The real important question is: which preceptor do you avoid?
No stranger to these questions, I've contributed a few myself. I've advised classmates on my favourite rural rotations, best sites to get hands on suturing, and, of course, which staff physicians were the bane of my existence.
Over lattes and cocktails alike, we've swapped stories of being pimped out (interrogated on our medical knowledge) in front of patients by certain doctors. I shared the story of the surgeon who made me cry on my first day of clerkship ever. That one resident who used us for nothing but scut work (non medical work like buying coffee and photocopying lists). The doctors who are hard to reach on page.
The value of these wisdom-s can't be underestimated, but sometimes they're over exaggerated. There is one site of rotation for pediatrics that all former students rage against. They called it a waste of time, extreme hours, lots of psychiatric issues and in a boring town. I got sent there with only dread knotting my stomach. What I found was a charmingly small town with great school provided housing. An amazing preceptor with whom I still keep in touch and extremely immersive work in a rigorous but educational environment.
I have just recently again been warned against one of my upcoming preceptors. They won't be my main staff, but I will have to spend at least some days with them.
I'm hoping this will be a case of over exaggeration, but like all things in the rumor mill, one can only go through it to find out.
Which sites have the best call rooms? Which call rooms have windows and a better wifi signal? Which parking lot was designed to scratch up your car?
The real important question is: which preceptor do you avoid?
No stranger to these questions, I've contributed a few myself. I've advised classmates on my favourite rural rotations, best sites to get hands on suturing, and, of course, which staff physicians were the bane of my existence.
Over lattes and cocktails alike, we've swapped stories of being pimped out (interrogated on our medical knowledge) in front of patients by certain doctors. I shared the story of the surgeon who made me cry on my first day of clerkship ever. That one resident who used us for nothing but scut work (non medical work like buying coffee and photocopying lists). The doctors who are hard to reach on page.
The value of these wisdom-s can't be underestimated, but sometimes they're over exaggerated. There is one site of rotation for pediatrics that all former students rage against. They called it a waste of time, extreme hours, lots of psychiatric issues and in a boring town. I got sent there with only dread knotting my stomach. What I found was a charmingly small town with great school provided housing. An amazing preceptor with whom I still keep in touch and extremely immersive work in a rigorous but educational environment.
I have just recently again been warned against one of my upcoming preceptors. They won't be my main staff, but I will have to spend at least some days with them.
I'm hoping this will be a case of over exaggeration, but like all things in the rumor mill, one can only go through it to find out.
Friday, August 3, 2018
Goals of care
I'm now on ER service. The first two shifts were brutal. 14 hour night shifts. I'm used to 12hr max ER shifts, which is what residents are supposedly allowed to do maximum of. But it's not like I can take off at 6AM when my staff is there until 8. I get paid a whooping 40$ per extra hour I work. Whoo... I'd pay that much for a place to sleep.
As a med student, the promise land where residents get paid seemed so glorious. Now that I'm actually here, turns out we barely scrape minimum wage, especially compared to Ontario. Hah. My on call hours is definitely sub minimum wage. We're also 2 weeks behind our pay schedule so I'm still relying on my line of credit to stay fed...
Today I had a patient who changed their goals of care on me several times. It wouldn't normally be a huge issue but this was an unstable patient that was deteriorating rapidly. More than most, the people in front lines healthcare understand that having an advanced directive, as it's so delicately put, is of immense importance. How much do you want over eager/terrified med students, hefty paramedics and strung out night call teams to be pounding on your chest and smashing rib cages when you're 50? 70? 90? When you're healthy versus when you have diabetes, previous heart attacks, and failing kidneys?
It's a painful talk but it's being honest with yourself. Will you have a good outcome? Is the outcome probabilities in your favour enough, that you want to chance it? How good is your health, really, and are you the kind that wants to hold out for any miracles, or prefer to go on your own terms?
Also, I'm starting to notice that ER patients come in waves. Yesterday and today we had two separate waves of almost identical patient populations, all with similar symptoms, all presenting around the same time.
On a more pleasant note, Newfoundland still boggles my mind. It is breath stealing beautiful. Every corner you turn there's a moment of 'holy crap how can something like this exist and why has it taken me so many years to find it'.
A few days ago my coresidents and a few dentists drove down to Salvage. WOW. There was a moment as we pulled out of Terra Nova to cross into Eastport. One of those golden, framed moments of glorious summer and youth. On the bridge over water, the ocean before us, the cliffs behind us. Windows down, sun bright and just a couple of 20 somethings, all finally escaping the drear of the hospital.
As a med student, the promise land where residents get paid seemed so glorious. Now that I'm actually here, turns out we barely scrape minimum wage, especially compared to Ontario. Hah. My on call hours is definitely sub minimum wage. We're also 2 weeks behind our pay schedule so I'm still relying on my line of credit to stay fed...
Today I had a patient who changed their goals of care on me several times. It wouldn't normally be a huge issue but this was an unstable patient that was deteriorating rapidly. More than most, the people in front lines healthcare understand that having an advanced directive, as it's so delicately put, is of immense importance. How much do you want over eager/terrified med students, hefty paramedics and strung out night call teams to be pounding on your chest and smashing rib cages when you're 50? 70? 90? When you're healthy versus when you have diabetes, previous heart attacks, and failing kidneys?
It's a painful talk but it's being honest with yourself. Will you have a good outcome? Is the outcome probabilities in your favour enough, that you want to chance it? How good is your health, really, and are you the kind that wants to hold out for any miracles, or prefer to go on your own terms?
Also, I'm starting to notice that ER patients come in waves. Yesterday and today we had two separate waves of almost identical patient populations, all with similar symptoms, all presenting around the same time.
On a more pleasant note, Newfoundland still boggles my mind. It is breath stealing beautiful. Every corner you turn there's a moment of 'holy crap how can something like this exist and why has it taken me so many years to find it'.
A few days ago my coresidents and a few dentists drove down to Salvage. WOW. There was a moment as we pulled out of Terra Nova to cross into Eastport. One of those golden, framed moments of glorious summer and youth. On the bridge over water, the ocean before us, the cliffs behind us. Windows down, sun bright and just a couple of 20 somethings, all finally escaping the drear of the hospital.
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