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Been Awhile…

Been a long time since I’ve been here…

Work has been interesting, sometimes in the literal and sometimes in the sarcastic sense of the word.  My current facility is getting ready to move lock, stock and barrel to a new hospital in about 6 weeks or so.  This has been a long time coming, and naturally has many of us both excited and dreading it at the same time.  The place is definitely more spacious, the ER is expanded in both beds and footprint, but it appears there isn’t much of a change in overall bed census on the wards, something that keeps us a bit clogged up.  As this is supposed to be a regional health care centre, I think there may be a lot of expectation management that needs to happen for the residents of our health region.

While we’re getting a new hospital, some in the urban area just south of us are facing closures of 3 major emergency depts., centralizing care at 3 others for high acuity problems and turning two of the other three ER’s into urgent care centres.  Other wards in those facilities will be repurposed and care of certain conditions will be centralized as well (orthopedics in one, rehab and mental health in others, etc).   These closures, ironically, were to decrease ER wait times – some places had patients stagnating in the depts. because of, surprise surprise, no discharge or movement on the  wards.  The thought process is that people of certain triage acuity will only be seen in certain facilities, as these are generally where the most appropriate staff are situated – those of lower acuity levels will be sent/told to go elsewhere (in theory).

I’m expecting/almost hoping similar things to occur here in our region – there are certain, little town hospitals/ER’s that are hit or miss if they’re open, as the docs there are getting a bit burnt out or simply don’t want to cover the ER for one reason or another.  First thing I check coming on shift in the morning is our status board and the second is “The Wall of Shame” – the area where we have the diversion notices up from our area of the health region.  More often than not, there are three plus out of eight up there – since that’s the norm now, I suppose we’d be just as well off closing some of them, since patients tend to migrate to us anyway, as they get used to their own place being close.  Cut out the middle man and close them OR set up a group that’s controlled at a regional level to make sure they’re open if it’s deemed necessary that they are, based on population and distance from higher care facilities.  Some of these places really ought to be re-roled into long term care facilities instead of acute care anyway, as one of the biggest bed blocking problems is waiting for personal care home beds anyway – the larger places can be kept for acute care or step down care so that the sick people don’t spend their entire hospital stay in the ER.

There has been talk of expanding PA roles here in our region and others to keep some of these ER’s open, using a remote coverage model much like I was used to in the military and what I did in my rural primary care practice when I left the military.  There will need to be some training and flushing out periods to ensure that the supervising physicians are satisfied with the folks going out to these facilities. but it is a reasonable solution – many PA’s in the US do solo coverage in rural ER’s and Canadian military PA’s are quite used to it as it’s their norm.  A role like this will be an exciting step forward in for our profession here in Canada and certainly benefit some patients here in my province.

Watch and see what happens next for now.

 

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.

 

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.

 

 

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.