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 guy)  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.  I also wish it would involve a bill from the Ministry of Health.   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.