Houston, we have a problem

First off, as this is a Canadian blog, I don’t work in Texas…

Secondly, about two weeks ago, I came on shift and there was no space to see anyone – nothing new (see Our New Normal) – but when I looked at the “Wall of Shame” that shows the diversion notices of the facilities in the region, the ENTIRE REGION, INCLUDING US, had diversion notices up.  The regional health authority that covers the major urban centre just south of us only permits its ER’s to go on for an hour…and even then, there is a lot of explaining to do.  Here, on the other hand, some of the facilities go on for days at a time.  Only one place had the cojones to actually close the ER out permanently; the others are open solely (or so it appears to this guys)  based on the flip of a coin, day of the week (weekend ER stipends are pretty good) and the call rotation at that hospital.  One hospital even went so far as to not allow locums there to cover the ER for the summer, but got funding for coverage that is at best hit or miss.

There are many issues at play here.  Top few would include burnout, lack of staffing/lack of proper utilization of staff, egos, leadership, overuse of facilities for non-emergent reasons.  Health care in any province in Canada is always the biggest political hot potato on the go – since it’s perceived as being free, people use it without thought.  We even have 1-800 numbers to call if you’re feeling sick to talk to a nurse, who will inevitably come to the end of the algorhythm and say  “go see your family doctor, go to a walk in clinic or go to the ER”.  In our “everything must get fixed now” society, few people wait to see their family doc.  The other issue is this in itself – nobody in their right mind is going to give medical advice over the phone to someone they don’t know, about something they can’t see or touch – hence the default is always go to the ER if you’re worried.

Before you get the wrong idea about me, hard work isn’t below me, however, working extra hard because someone else isn’t puling their weight really offends me, especially if they’re getting paid a fair amount more than me to do it.  I was off handedly  asked what I thought of for solutions to some of our ER woes about a year ago and, like I’d been trained, came up with some potential courses of action with no throw away options.  All these had pro’s and con’s and would require a great deal of political and individual backbone and leadership to accomplish, but I thought they were workable.  These included centralizing control over all the usable ER’s in the region and staffing with one emergency medicine group to ensure coverage and couple this with closing a certain number of the smaller ER’s outright.  Other options were letting go or disciplining non-performers, and adding PA’s and NP’s to staffing of some areas.

In the mean time, we’re continuing to be pretty busy – wait times vary depending on how many beds we have in the dept, up stairs on the ward and in the region and how sick some people are.  To those that are facing these waits, here are some hints:

1 – Be prepared to wait – have a book or something to pass the time with.  This keeps frustration levels to a minimum.

2 – Yelling and screaming and carrying on mean your airway is open, you’re breathing and your brain is getting oxygen.  It also tells me that, more often than not, you’re not as sick as you think you are – you’re not getting in any faster because you’re being a nuisance and you might in fact be leaving earlier than you think – in hand cuffs.

3 – We’re not a restaurant or fast food outlet.  What that means is don’t come in ordering the treatment you want – it doesn’t work like that.  “I want an order of McPercocet with a  side of Azythromycin” isn’t going to get you a pleasant response.  This is how the system works –   you tell us what is wrong, we check you out, do what tests are necessary and prescribe what is best for you based on what we went to school to learn about and best current practice guidelines.  If you waited for 6 hours with a cold, don’t think we’re going to “reward” you with antibiotics for waiting (you’d be surprised how many times this happens).

4 – If you have a legitimate complaint about something, put it down on paper – we have forms for that.  I always finish encounters by asking “Questions, queries, rude comments?”.  If someone has problems, I try to fix them and if I can’t, send patients where they need to go.  If it’s about me, same same.  Conversely, if someone gave you a good experience, ensure you pass that along too, since we rarely get hear about those, only badness.  If the issue is systemic, contact the CEO of the RHA AND your MLA AND the Ministry of Health direct.  However, if you’re just whining (which some people do incidentally), please don’t bother.

5 – Showing up with a chief complaint that goes back longer than 6 months and you need sorted out NOW  (at 2 in the morning) because you’re going on a trip tomorrow ISN’T AN EMERGENCY.  Nor is a prescription refill, nor is an isolated blood pressure reading you did at the local pharmacy that reads above normal without symptoms – they are family medicine problems.  If you were to receive the bill for the actual cost the Province pays to the hospital, via your tax dollars, for an ER visit, you’d likely be back with a legitimate stroke or heart attack.   In the same vein, showing up with cold symptoms of 1-2 hours duration is not only not going to get you much sympathy, it’s also not going to get you a prescription.  Conversely, if you have an actual emergency, worry about you, not the bread rising at home (actual occurence) and don’t try to escape too early.

6 – Seeing two or three providers in one day from different clinics and then going to the ER, because you didn’t get or hear what you wanted, for  “another opinion”, will likely result in things similar to #3 and 5 as well as possibly outright derision.   Something many people don’t realize about medical folks  – we’re here to tell you things you don’t want to hear, but need to hear and listen to.  Some of us are more diplomatic about it, but I’m pretty blunt with people that abuse the system or think they’re the one special snowflake in the world.  If you want a second opinion after seeing your primary care provider, ask them for a consultation with a specialist or another primary care doctor – most will happily oblige.  The ER isn’t the place for that unless it’s actually an emergency.

Emergency departments in a publically funded health system are finite resources, but because they’re publically funded, many people feel they’re allowed to use and abuse them as they see fit.  There are also systemic problems at play as well I’ll comment on later, but at the moment, a combination of staffing and patient population are causing a great strain on the places that need to have the “dams” opened up to allow for flow.  I will conclude with this – if you’re not having a true emergency or very urgent medical problem, try to avoid the ER.  If you’re a worker in one that’s getting a little slack in the work ethic, pull your pants up and do your job.  Medicine is a team sport, from patient to super sub-specialist doctor to Minister of Health- we all have a role to play in this game and have to do our parts.

 

Becoming a patient patient

About a month ago, I went away for some medical testing to see if I’m a suitable living donor for part of my liver for a relative with advancing liver disease.  As a person that preaches patience to patients, this was a bit of a trying experience even for me.

My first day was spent in the early morning waiting for blood letting, electrocardiogram, chest X Ray and a CT scan.  The thing is appointments to me mean just that – not a lot of wiggle room.  Being military, I get a bit of a panic attack if I think I’m only going to be 5 minutes early for something, so as I watched the clock move towards the anointed CT time, I started to get antsy.  My number finally came up and off to the vampire I went, followed quickly by the EKG tech.  Both were efficient and I was 5 minutes ahead of my CT appointment time…and instead got sent for my chest X Ray first…which took more time.  You can see where this is going.

The CT scan was a bit interesting…I’ve had patients that told me they felt anywhere from weird to awful going for infused scans.  I’ll now think twice before scanning after my experience.  I’ve had an MRA before – an MRI Arthrogram is a scan with a dye shot directly into the joint being scanned.  My hip was being done and, with the joint duly injected and swollen, it felt just a little longer than normal, but not much else.  When I got the contrast dye for the CT, I honestly thought I was going to spontaneously combust and simultaneously pee the flames out; rather disconcerting experience.  On the bright side, the tech did a bang up job on the IV – I didn’t feel a thing.

My next appointment that day was after lunch.  Being a big hospital and not knowing my way around, I made an effort to be early…especially since it was to see a psychiatrist.    I got there about a half hour early…when about 45 minutes after the appointment time passed, I was beginning to wonder if this was part of the interview process to see how I’d react (shrinks make everyone paranoid on a good day).  Turned out she was running late with someone having a badder day out than me.    Interview went well.  Day One done.

My next day was a clinic meeting with the surgeon and the liaison nurse.  The surgeon was frank – I’m a little tubby, bitchy due to stressors, and a bit hypertensive.  He didn’t like that.  Neither did the nurse.  She found my BP to be high…and wanted it and my weight down.  OK fine – I’d already began running again and upping my cardio to ready myself for this.  No worries there…ish.

That night, I was out jogging prior to an MRI when I came across two fellows helping a dude that had fallen down some stairs…so helped out until the paramedics arrived.  I finished my run, got to the other hospital for the MRI (slated for 2130)  and found my appointment is an hour behind…and MRI’s take A LONG TIME.   Oh well…

So I get to bed late and am up early to meet a social worker for 1000 ish…almost an hour later after I’ve checked in, someone realised I was there and came and got me – not the person I was booked to see, or the person who was replacing the person I was booked to see.  So glad I was on leave – if I’d have been working that day I’d have lost it.  Went well otherwise.

My last appointment was great – a short, sweet, on time and very efficient echocardiogram.  It happened so smoothly I thought I was on “Candid Camera”.

Flash forward to now – we’re still up to our eyeballs in patients in my ER – some sick, some not so sick, and some that just think they’re sick.  On some shifts, we’ve been blessed with a tech from a much needed dept that makes molasses crawling uphill in the winter look like a world class sprinter on steroids.  Despite numerous incident reports, they’re still working for us.  People that are sick feel that they have the right to be grumpy, rude and obnoxious at times loud and violent even…this gets worse the longer they have to wait to see someone, get their tests done, interpreted and either admitted or released.  It’s hard to be a patient patient in this day and age…I now have a little empathy.

PS – when I was in family practice, I made all efforts to be on time all the time, even to the point of charting on my breaks and after hours.  If I was two minutes late, profuse apologies occurred.   Even today, I always apologise for the waits the patients have to endure…even if they’re not really that long and they aren’t really all that sick.  I do it so that people realise we’re not happy either, and even encourage them to complain if they feel the need…and show them where.

 

 

 

Rewards

Medicine has many rewards, some tangible and others not so much.  Some people reap huge financial rewards, others personal ego boosting and prestige, some love putting things back together nicely and still others find rewards in smiles and thank you’s.  I’m, I like to think, more towards the latter pair…don’t get me wrong, I do make a decent living, but I’ve long since stopped worrying about gongs (medals to non-military folks) and badges and such to say I did something that someone thought was extraordinarily special to make a difference in someone’s life.

Two things happened this week, well actually a number of things happened, but two in particular stand out in my mind that gave me a happy pause in my day.  The first tale is one of a young patient that came in with the beginnings of a nasty infection.  This would involve treatment by IV for a few days…something many folks, forget young kids, aren’t especially happy about.  Well, myself and my team mates got a little plan together and made sure any needles were as painless as possible, a couple popsicles were had and all walked away reasonably happy.  The next day, this youngster came back for reassessment;  when I went to see them, I found a smiley kid (always a good thing in my books) and a personally drawn picture of me and them with “Thank you for helping me” on it.  I rarely get things like that, much less from kids.  The rest of the team also got one each.  I have it proudly hanging on our bulletin board in the ER.  Things like that make you feel like it was worth going to work that week, even if it wasn’t always a good day out.

A second thing came up that was a bit of a left over from last year.  While at one of my other jobs, a person who I’d treated for a severe allergic reaction the summer previous let me know that they were still grateful and that I’d been nominated for a commendation of sorts.  They were somewhat upset though, that this had been stopped due the fact I was “only doing [my] job”…which I was.  While I appreciated the gesture, I did reply that (a) thank you was just fine for me and (b)  I certainly didn’t do anything I’d actually consider extraordinary enough to warrant something like that.   While I actually realize that there are other things at play there I’m not going to get into at this time, it’s not what I’m about – thank you is more than enough, and sometimes more than you get from some folks.

Making folks better, or at least feel better, is one of the great things about this job.   It’s a privilege to be able to do that, one I find some folks waste on the other trappings that can come with a career in medicine.  Try not to be one of those, as money comes and goes, so does prestige…but those little gestures of thanks will stick with you forever.  If you’re more worried about the other stuff, you might find yourself devoid of thanks.

 

 

MY OTHER WORK LIFE

I’m off with the Army right now on a course.  When I retired from the Regular Force, I rolled over into the CF Health Services Primary Reserve List.  After about a year hiatus, I started working with a Reserve combat medical unit in Winnipeg, keeping my foot in the door regarding management and leadership skills, austere medical practice and such.

A few weeks ago, I took time from my real job to go and give a classmate a hand at the Base Clinic in Winnipeg, where he is the Clinic Sergeant-Major.  Despite a full schedule, I had a very relaxing week there, in fact the most relaxing I’d had in over 4 months.  I’m now in Quebec doing my Intermediate Leadership Qualification – a form of middle management training I need to be promoted back to the rank I had when I left the Regular Force.  This involved 6 weeks of distance learning regarding advanced leadership and management skills, Canadian domestic and international security policy , history, and Canadian Military Ethos and Ethics.  I’m on the residential portion now where we’re putting those into practice, as well meeting key players at a national level that influence policy for us at the coal face of the military.  We have an eclectic mix of all arms and branches of the military, each of us lending our own slants to the topics we’re dealing with.

So what does this have to do with my military life – I’m a PA, who cares right?  Well, I’m not just a PA – I’m a Senior NCO and all that entails regarding leading, caring for, disciplining and administering soldiers, moulding future leaders and mentoring those below and above me in rank.   This also rolls over into my civilian job, as I’m expected to show leadership and mentor as well, be it in a stressful situation, teaching a medical or PA or nursing student, or in dealing with patients.   It also enhances skills needed to deal with those with authority over me/us, saying what needs to be said, when it needs to be said.

Should be back to regularly scheduled programming in a couple of weeks…

 

The New Norm In Our Little ER

Hey there, me again.

So I’ve just finished a fairly busy last few weeks, leaving me a bit tired.  I’m not the only one – seems many of my team mates at work are on the verge of burnout…if not that, getting somewhat beyond what I’d simply call annoyed.  Some are writing complaints, some are encouraging patients to write complaints and others are just leaving.

You see, there is an issue within this health region, and within staff management in our facility, of us being expected to do the work of everyone else.  More often than not, our ER is the only one covering and open in the region out of roughly 8 hospitals of various sizes and utility.  They very often are on some sort of diversion for their ER’s – not enough beds, no doctor or other care provider able to staff it, we even had someone go unilaterally on diversion because the XRay equipment in the hospital was down (far from everyone that walks/rolls in needs an XRay)…and accidentally (and likely accidentally on purpose) neglected to tell the ER doc on that day.  All this is resulting in a pile up of patients in our waiting room and also with pretty sick people in the treatment rooms…that can’t move or be admitted to the ward because they’re full…and the other places won’t take new patients for whatever excuse/reason…all this results in a full ER waiting room and nowhere to see anyone.

There was one point a couple of weeks ago that I was seeing patients that were basically ambulatory care issues in XRay waiting areas, blood draw chairs, etc (management  gets upset at us seeing  folks in hall ways).   This isn’t good – having to run about ensuring that the needed equipment is available, other care providers know they’re there in case something horrible/hideous occurs (these people were physically separated from the rest of the ER), confidentiality concerns, etc ad nauseum.  Nobody would get seen if we didn’t do that though.  I should add that I’m pretty sure that was the same day I came on and literally every paramedic unit in our region was in our hospital waiting room with someone to offload…and nowhere to put ANY of them.

Our ER wasn’t built and isn’t staffed to look after this sort of influx – the place was designed to see about 12-14000 patients a year.  We’re seeing somewhere along the lines of over double that now since I started there over a year and a half ago.  Yet the people just keep coming.  It doesn’t help that there are few primary care providers taking new patients, the “Doc in the Box” can only see so many people and the Quick Care Clinic only takes same day bookings, so many folks show up with primary care problems.  Unfortunately, the triage staff are contrained by not being allowed to send folks home for ailments that don’t require emergency medicine care.  One doc that I work with has a saying – “there is a lot of medicine to do to this patient, just no emergency medicine.”

There is also the insidious “Just wait until we move to the new facilityitis” that’s prevailing right now.  We’re being regaled of the new wonderful equipment and staff awaiting us when we move into the new hospital…in about a year or so.  So we’ve got stuff that’s older than Dirt’s great-grand parents, not enough of it, morale that’s lower than whale poop in the ocean, people dreaming up morale things like a dept newsletter instead of going to bat and doing something to offset what’s happening to us.

We’ve all pretty much decided that this will be our new normal to deal with.  We’re less than likely to ever clear out the waiting room, clear out a lot for our treatment bays because we’ll be holding patients awaiting admission in those same rooms.  I can foresee us losing staff in the near future as well…the ones that are really good aren’t putting up with this much longer and have essentially said they’re gone when something presents itself.

Unfortunately, what I see is people at various levels not being held accountable to the Region, the College(s), and to their patients for the actions that are leading up to this impending implosion.  People need to do what they were hired to do and if they won’t, then be dealt with the way any other employee of our own would be.  Patients need to take responsibility for their health care as well and stop using ER’s like their primary care offices.  A cold of 2 hours duration is not an emergency…no exaggeration, I’ve seen people that come in for that.  We need a system where either the triage nurse is empowered to tell people to leave with problems that have no business being there, have someone else at the triage desk to do that for them, or start billing people for frivolous visits.  I don’t want to see a New Normal 2 or 3.0.

Long Time No See…Don’t Be “One of THOSE PEOPLE”

So it’s been awhile since I’ve been here…since New Year’s, work has been incredibly busy.  Shifts and days just blur into one another, especially since we’re increasingly taking on more and more patients from peripheral hospitals whose ER’s are either full or understaffed.   Couple that with not being able to see patients in a timely fashion due to lack of non-occupied work space (the ER is becoming almost like an overflow medical ward instead of an emergency dept), well worker bees are getting annoyed, tired, other jobs, etc.

Patients themselves are being increasingly more difficult as well – some are very ill, some wish they were and others simply don’t have/can’t get into/don’t believe their family doctor they’ve already seen for their problem so feel they need to arrive and spend more tax payers’ dollars on a second or third opinion for their cold that hasn’t gone away in the 24 hours they’ve had it…and there is the problem with our health care system as it stands today.

Call me cynical, but I’m finding folks to be a lot needier than they ought to be these days – a quick twinge here, a sniffle there, something “just not right”, and they come screaming into the ER like they’re dying.  Or, they’ve decided that today is the day I should get that ache looked at that’s just that – an ache – that’s been going on for the past 3 months and haven’t even tried something over the counter for it, or they find their blood pressure a tad high at the local pharmacy and they come flying in expecting something to be done NOW.  The problem with folks like those is that they take up a lot of limited time and resources in emergency departments for things that aren’t emergencies – they’re things that family medicine folks should be dealing with.  If I had a dime for every person that yelled at someone from our or any other ER because they’ve waited too long to get seen for their cold or their refill of medication (that will not be refilled there anyway), my job would be a hobby.

The other problem these days is the sense of entitlement and need for things having to be fixed RIGHT NOW people are taking on that is at best unreasonable and worst bordering on narcissism that is really outrageous.  A person gets a cold, goes to a doctor or PA or NP and gets told it’s a cold – a viral infection – and gets mad because we won’t give them an antibiotic, which will in fact do diddly squat for that condition.  What happens next is a full on fight because the “I need to get better RIGHT NOW” person doesn’t want to hear the advice I or others have had to spend a lot of time and money learning about and get paid to dole out because “My last doctor always gave me this” for their cold.   We all know people like that, heck there might be some of you out there that are in fact “THOSE PEOPLE”.

I get that people get sick and sometimes need some help getting fixed up…even if it’s just us saying “Tincture of Time is your best remedy”.  However, hystrionics are not the way to win friends or influence care providers in busy ER’s – being calm, asking appropriate questions and answering the same will speed  up the process and get you where you need to be, whether it’s the ward, observation unit or even back home or to work.  The thing you have to understand is, we’re not here to tell you what WANT to hear and give you what you WANT to have – we’re here to tell you what you NEED to hear and give you what you NEED to get better.  “Primum non nocere” – “First do no harm” means don’t give you stuff that you don’t need or might even make you worse, just because that’s what you want.  To put that another way, healthcare providers aren’t baristas at Starbucks.

 

Teachable Moments

Everyone who’s in medicine in one way or another has been involved with “teachable moments”.  For some, they’re teaching, others are learning.  One way or another, anyone can be on either side of the coin.

The other day, I got to do the teachable side – there were some medical students coming for a tour of our health region and some little stations were set up for them to learn/practice some common things – casting, a mock code, delivery of a baby through a mock up and suturing.  I had the privilege of doing the suturing station.  We all sat down with some instruments, sutures and pig trotters from the butcher and went about repairing minor wounds and using different techniques to close things well.  A couple of the youngsters were having some problems…of the kind where a general surgeon might look at them and not so gently tell them that they are destined to be a psychiatrist or a medical microbiologist because their mental and manual dexterity weren’t that good.

A wise movie karate sensei once said “No such thing as bad student, only bad teacher.  Teacher say, student do.”  In the short time I had, I felt there was a need to try and intervene with a few to keep levels of confidence up.  One clearly had an issue of knowing what they wanted to do and how, but were trying to do everything all at the same time.  Once we had that figured out and slowed things down a little, bang, no issues.  Another was overthinking things and wasn’t listening to advice, repeating the same problem over and over.  To solve that, I had to re-think how to re-teach this person this skill…I went back to basics and had them follow the steps as I did them to make sure they were doing what they needed to do the correct way.

The science of medicine is taught in the class room, but the important stuff – the art as well as the science – is learned on the job, in the ER, the OR, the wards and clinics.  It’s passed along from one practitioner to another – everyone at one point in their clinical lives will be teaching in one way or another…and if you’re in a patient centric specialty like family or internal medicine, your job is to teach your patients, so you’ll be doing a lot of it.  Remember how people taught you – were they crappy and doing it because they had to or were they good at what they did and enjoyed passing along their little tidbits?  Everyone is a teacher in medicine, be it to students, colleagues or your patients…so learn to be good at it, that way the art of medicine remains in the profession and continues to be passed along.

SIDE EFFECTS

Seems that I spent a lot of time discussing side effect issues with medications with patients this week.  I get that people are concerned about what’s going into them and what badness  might happen, but they forget to ask about the positive things that might happen as well.

There are risk/benefit ratios for everything we do in life, be it something we say to someone, something we eat or drink, some action or inaction, all can result in positive or negative effects.  Medications are no different.  Everything we do medically is calculated, based on evidence, training and experience.  We cross reference this with what is wrong with the patient, what they’re taking, what other problems the person has, and what other medication they are taking.  The more the person has going on and is taking, the harder the decision becomes.

Then there comes the other problem of mis/disinformation and plain old ignorance about what various medications do or don’t do and the frequency of said issues.  The internet is a great thing if used properly…however, many people have a habit of not reading good sites.  Another problem is Dr’s Mom and Friend Who Knows Everything (yet has no medical training) – I often hear people saying that their friend or mom says that they need this, that and everything else.  Rarely true.

Back to the problem at hand – person comes in with complaint X and is found to have diagnosis Y.  Treatment options include A,B,C and D…however patient is deathly allergic to A, and  C and/or D aren’t likely to be effective without B.  Since I can’t make someone do anything against their will (well, almost anything), my job now is to let the person know what I think is best for them and why.  I don’t hand hold – I’m blunt about options and what I think the best ones are for that person at that time.  I’m also blunt about concerns about minutiae that may or may not happen, especially side or adverse effects that happen one in a bazillion times – and for some reason, most people think that those will be the ones that happen to them.  You have to be blunt in the ER because you can’t hold onto folks that don’t need to be there.  Some folks will all of a sudden develop a decision making disorder about what’s really a minor issue and blow it all out of proportion, expecting family to convince them, as well as me, that this is in their interest.  Luckily for me in this case, I’d had a similar intervention and was able to speak from experience from both sides of the fence and we got down to business shortly thereafter.

Side effects or adverse effects occur sometimes, but not near as often as people think.  Ask your questions, sure, but also ask balanced ones, “Like what are the benefits as well as the risks?”.

Sean K

 

 

 

 

My Week…and a Rant About Resuscitation

I just finished my recertification in Advanced Cardiac and Pediatric Advanced Life Support this week.  Over three evenings myself and several other people went through a few lectures and plenty of practice resuscitations on adult and child mannequins.  I’ve taken ACLS many times over the years and have watched as the algorhythms and guidelines have changed and been simplified each time I did it.  I also remember one thing rarely changed though in most of the times I took it – we rarely had any of our “patients” live.

Over the years, despite all science and training and public service announcements, people still die from heart attacks and sudden cardiac arrest.  Automated External Defibrillators have increased the incidence of lives being saved at time and point of arrest (and I personally know some folks that are alive today for that very reason), as well as having paramedical personnel more readily available to help when people are struck down, but despite what all the old episodes of ‘ER’ will tell you, the vast majority of cardiac arrest victims still die.

When an arrest victim is brought in, a pile of people descend upon them to try their damnedest to squeeze blood around the body and get air in and out of the lungs.  They stick needles into veins to get drugs in to try and stimulate the heart back into beating properly or even at all.  They repeatedly push, well really pound, on their chest.  CPR is a brutal, yet necessary, thing to try and get blood to the heart muscle and the brain so that the patient might have any hope of surviving.

These days, we will sometimes invite family into the resuscitation bay so that they can witness not only how hard people are fighting for their loved ones’ lives, but what that person is actually going through.  Their are times when some (not all) people are needlessly put through this process…folks with very advanced or terminal illnesses, the very frail or aged.  Some of these folks may have had “the talk” with their doctors abut how they want to be treated after a certain point in their lives or illnesses, but their families sometimes, at that moment, cave in to the emotions of the time and want all stops pulled to save their family member.  The unfortunate thing about that is the potential suffering that the patient may in fact go through as the result of a successful resuscitation may be worse than they’ve already been going through what with bruised chest, fractured ribs and the like added to whatever else may be ailing them.  I remember as a young medic one of my officers telling me about a code he was at…the fellow was a religious person and offered a prayer for the patient in question while the resuscitation went on.  This patient, while successfully resuscitated, ended up living in constant pain for another few short days.

I am not anti-resuscitation by any stretch of the word.  I’ve worked full out on a number of folks over the years, witnessed a precious few where we literally made Lazaruses out of some folks, however, the net result is still in favour of fate, Mother Nature, and the various gods that oversee us.  To paraphrase a TV physician, everything we do in medicine is to slow down the inevitable that is programmed into our DNA – humans are machines with a shelf life and a limited extended warranty plan for those that are able to pay in time and effort to look after themselves.  Sometimes we can reverse the process in mid-cycle, sometimes we can’t.  I always tell patients that there are certain laws in the physical realm we can bend to a point -the laws of genetics being some of them.  I liken those laws to the Law of Gravity like this – if you jump out of an airplane, regardless if you have a functioning parachute or not, you’re going to hit the ground eventually; the only difference is how fast and hard.  Same goes with our bodies – if we look after them, it becomes like a parachute of sorts.  If we have bad histories in our families of say, early heart disease, we can ensure that we don’t tempt fate by making sure we don’t smoke, eat reasonably well, get periodic check ups, exercise regularly, keep blood pressure a stress in check, etc ad nauseum.  If you choose to play chicken with fate though and jump without a functioning chute or reserve, you might just end up in an ER having the proverbial BIG ONE or worse, having the proverbial BIG ONE and several folks pounding on your chest.

I think that all people should give some thought to what they want done to them if their hearts and breathing fail them and make sure that your primary care givers and your families are aware of your wishes.  Have these written down somewhere and revisit them as often as things in life change.  Some of us joke about tattooing our chests with “DNR” or “Do Not Place Hands or Pads Here”…but it’s not a joke to be doing a full code on someone who has little to no hope of anything like a meaningful life IF we even manage to bring them back.  That takes a toll on families, the patient and the caregivers involved.  So have that talk.

 

SO WHY FED THROUGH THE FIREHOSE?

I’m going to jump on in here.  So, what is a PA?  What do we do?  What are we not?

To paraphrase the website for The Canadian Association of Physician Assistants, PA’s are highly trained health care professionals that work in collaboration with a physician or group of physicians as an extender of their capabilities.  They provide a high quality of care to patients in a variety of settings and under varying levels of direct and indirect supervision.  Their scope of practice is dependant upon their supervising physician’s specialty and comfort levels with the procedures they’re able to perform.  In order to receive the post-nominal of CCPA (Canadian Certified Physician Assistant), a national certification exam must be passed and a minimum number of continuing education credits must be logged annually.

PA’s in Canada were originally from the military or trained in civilian programs in the US, where PA’s have been practicing since the Vietnam War…and those original PA’s were largely ex-military medics.  The Canadian Armed Forces program at CFB Borden, Ontario,  evolved into a two year program, much like our American counterparts’ schooling.  This program became the model for 3 other ones at civilian universities.  They are at the University of Manitoba, McMaster University and a consortium of the University of Toronto and the Northern Ontario School of Medicine.   There are PA’s currently working in Manitoba, Ontario, New Brunswick, Alberta, and in remote mining/drilling camps.  PA’s are regulated by the Colleges of Physicians and Surgeons in Manitoba, New Brunswick and Alberta.  Military PA’s in Canada are chosen from the Medical Technician trade to become PA’s as a matter of normal career advancement, and generally have a minimum of 8-12 years experience before starting school.  Civilian Canadian schools have varying degrees of requirements for type and duration of prior health care experience, whereas most US institutions require a minimum of 1000hrs.

The two years of school are quite gruelling.  The first year is basic medical sciences, study of diseases at all life stages, the various major medical specialties, physical examinations entailed with each organ system, occupational and population medicine for the military folks and special population medicine for the civilian programs.  Part of our occupational health in the military included basic preventative medicine skills, including kitchen and building/quarters inspections.  Second year is full of clinical rotations – family medicine; internal medicine; pediatrics; general, urologic and orthopedic surgery; psychiatry; obstetrics and gynecology; ear/nose/throat medicine and surgery; emergency medicine; trauma medicine and surgery.  There is a lot of knowledge to take in all at once – hence the title “Fed By The Fire Hose”…I always felt all I was doing was just studying for the next exam.  You open wide, and either hold your ground and drink or get blown away.  My class lost 3 people along the way and another failed the final round of exams.

Once I graduated, I wrote my national certification exam and was posted to Victoria BC.  While there, I had the opportunity to take my Basic and Advanced Diving Medicine courses offered through the CF School of Operational Medicine in Toronto and worked off and on in the undersea medicine field and primary care at CFB Esquimalt.  PA’s also are able to take the Basic Aviation Medicine and Flight Surgeon’s courses as well.

PA’s were embraced by Manitoba roughly 10 years ago to help assist physicians and patients alike to decrease waiting lists for surgeries and in emergency department waiting rooms.  Currently, PA’s in Manitoba are practicing in emergency medicine, orthopedic, general, plastic, neurologic, and cardiothoracic surgery, oncology, family medicine, internal medicine and psychiatry.  I was originally hired to work as a pilot project in a small town as the main provider in a family medicine clinic and a personal care home with my supervising physician normally about 30 km away – we had direct supervision hours a couple times a month and I did some ER shifts to add to that.  My charts were audited and signed off electronically via the electronic medical record shared with our clinics.  He’d help with tougher cases and with those that I wasn’t legally allowed to prescribe medications for.  I worked there for three years before taking my current position working solely in emergency medicine for the past year.

My job at work is to see patients of all acuity levels in my ER – I’ll interview, examine, order appropriate labs and imaging, initiate treatment.  I’ll discuss what’s happening with my attending of the day, and then discharge, admit and refer as needed.  This includes prescribing necessary medications within my formulary – I legally cannot sign for hard narcotics for prescriptions leaving the hospital.  I can do certain procedures – suturing, casting, removal of foreign bodies, catheters, IV’s and other invasive line insertions, manage airways.  When I was in family medicine, I had normal office hours where I saw appointments, managed people’s chronic and acute health issues and looked after the residents of a small personal care home that was attached.  If I encountered something unusual or out of my scope, my supervising physician was immediately available by phone or text.  As noted earlier, my supervising doc would also come out periodically to see patients outside of my scope for prescriptive authority or for those that needed a second set of eyes.

I suppose lastly I should answer that question of “What are we not?.  I’m not a Nurse Practitioner – they are RN’s that have completed extra training, have their own licenses and scopes of practice.  While some PA’s may at one time have been RN’s, they aren’t NP’s.  Our licenses are tied to a contract of supervision with a physician/physician group.  Another frequent question I get is “When are you going to be a doctor?”.  I answer never unless I feel really masochistic and decide go to medical school and that my training is actually complete.  Lastly, I make a point of introducing myself by my first name and that I’m a PA working with Dr X…I’m not allowed to let people think that I am in fact an MD, and in fact correct people that call me “Doctor”.

Here are links to two Canadian PA websites.

Canadian Association of Physician Assistants

Physician and Clinical Assisants of Manitoba

 

Will talk with you all later.

Sean K