Monday, May 18, 2015

Bad patient outcomes

They happen. But I hate them. 


I'll spend the next 72 hours straight second guessing every minute of every interaction with the patient. Even though I know I did the best I could, with the resources I had, I will still blame myself for his death. I'm not sure if or when this step in losing a patient goes away. 


Until then, the best I can do is try to be a better doctor and do what I can to keep the dark and twisties at bay. 

Saturday, May 16, 2015

The Rural to Urban Transfer, a Primer for Urban Docs

1. If the report starts with "...is a horse and buggy Mennonite, and called an ambulance to arrive here at...", know that whatever comes after means this patient needs to be transferred out ASAP. These patients will do everything they know how to do at home, waiting until the very last minute to come to hospital. If they are willing to splash out on an ambulance, there is something very wrong. Same goes for any Mennonite that shows up the ER on a Sunday. Just seeing them there on a Sunday makes my pulse race.

2. Don't assume that we have the same resources that you do. For example, I have an RT that comes in some Wednesday mornings. There is an anesthesiologist who comes in a few days a month. I do the difficult airways. I figure out the ventilator settings. When I show up to the ICU, you have more people waiting in that room to receive us than we have in our entire hospital, usually at least 3x as many. Please ask what resources we have before repatriating a patient who requires more than we can give, or assuming we can handle the case that is being consulted on.

3. We work 24+ hour shifts. I am acutely aware of the time that I am calling you at 4 in the morning. If I say that I need to discuss a case, please be sure that I really do. I've either exhausted all my internet and paper resources and need help, never seen what is in front of me, or am having a hard time organizing my thoughts after a particularly stressful day. Rural docs are proud. If we are asking for help, assume it's legit.

4. During that 24+ hour shift, for the most part, we are it. Any and all codes are run by us. I've run several in the same day plus delivered babies, saw 30+ sore throats in the ER, and talked down psychotic patients. Not every day is like that, but give us credit for being able to handle all of that and keep going. We do this because we love our communities and are dedicated to keeping our hospitals open, we love medicine, and we are masochistic idiots.

5. Nothing makes me feel more validated than having staff ready when we show up. If I tell you it's a difficult airway and you have an anesthetist and RT waiting for us when we arrive in the city, it seriously makes me feel incredibly relieved. I know that you believe us and will treat my patient well.

6. We get attached to our patients. We see them again and again in our hospital, and in truth, I may be the family doc of the patient I am transferring. I will do everything I can to keep them in our tiny hospital. When it's time for them to go somewhere else, I will fight like a dog to advocate for their proper care. You would too.

7. Rural docs are "real docs". We are generalists who are constantly studying and upgrading. After every code, every transfer, every good and bad event, we talk to each other to learn about what went well and how we can make things go better in the future. Consult notes that belittle us and derogatory comments on the phone are entirely unnecessary. We are counting on your expertise to help us in our practice, but also on your civility.

In case I forget to thank you because I've been hand ventilating a patient for 3+ hours when I finally see you during my 27th hour on call, please assume I do. I am incredibly grateful that you have chosen to work in the city in ICUs, surgery, high risk obstetrics, etc. Without you, I couldn't have the brilliant job I do.

Saturday, May 2, 2015

Benefits of being a rural doc

Include stopping at Dairy Queen after a rough transfer.