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. 

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.

Benefits of being a rural doc

Include stopping at Dairy Queen after a rough transfer. 

Professionalism, continued...

Powers That Be (the PTBs) want their medical students to be able to play well with their future colleagues.

I've talked about professionalism before.

There was too much to cover in one post, so I'm adding some more thoughts here.

1. Conferences: Students should really go to as many conferences as they can. These are fantastic places to learn how your (potential) colleagues perform in the future. To see what is actually important to them and what daily practice can be like. They are also where you can learn what is important in research if the specialty isn't all about the Twitterverse. But they should be. Talk them into making that happen while you are at the conference. Also, look around. What do you think about this group of people? Can you see yourself working with them in the future? Going out for a few beers? Is this the specialty for you?

2. Business Cards: Get business cards made. Hand them out. You want to give them to people you want to do research with, want to have elective time with, etc. Seriously. Get it done. They're dead cheap. Put your photo on it to ensure the peeps you share them with will remember who you are.

3. Committees: Sometimes annoying, sometimes difficult to deal with, but so important to learn how to deal with this kind of interaction with colleagues. Sitting on committees will teach you how to follow Robert's Rules that you will need to follow as you move through your career. It also allows you to stand up for what you think is right while you are still protected as being "just a student". Learning how to make a point so that others understand is not something that comes easily. It's worth having some practice. These skills work when you are talking to other specialties, asking administration for resources for your patients. It also teaches you when to shut up and trust your colleagues to do what's right.

4. Counselling: Everyone in medicine needs a counsellor. Trust me. Get one.

Waiting...

Little tiny hospital, almost 50% of our beds being used by patients waiting for mental health or long term care beds. 

Colleague support

When I divulge to a colleague that I'm struggling, and their answer is "just get it done, that's ridiculous", I may not have found my new home yet. 

Confidence

My frail patient sat at her dining room table as I came in to see her on house call day. 

She wears a bib like the ones we use in hospital, brown, ugly plaid. Her husband calls it her cape. I imagine her as a super hero, bib flowing behind her as she flies through the air. 

Her hands tremble as she works on her bun. She accidentally drops her finger in the butter and acts as though it didn't happen, discreetly licking her hand when I'm looking down. 

She is as frail as I would expect for someone who spent so many months in hospital and came close to dying more than once. Hunched over, looking up at me though our faces are on the same level. In her youth she was an independent, vibrant school teacher. What a change this must be for her when she looks in the mirror. 

After our check in and a brief physical exam, I ask the question I always ask, "is there anything else I can do to make things better for you?"

My patient surprised me by whispering, "give me my confidence back?"

I wish I could bottle up confidence and sprinkle it over my patients like holy water. That's precisely the intervention so many of them could use but the CDC doesn't have it available yet. 

We discuss how far she's come since her release from hospital. How difficult it is to be in a new home in a new town. How as her strength comes back with physiotherapy, so will her confidence. 

I stop and consider the last time I was truly confident. I think of when I was 5 years old and able to do absolutely anything. With my new shoes I could run faster than Superman. My body was perfect and I was the strongest person I knew. How does one prescribe "be a 5 year old" to an octogenarian?

Then I remember the art group run locally. They laugh and play and generally enjoy themselves. Everyone leaves the group feeling like they can take on the world. Their pain diminishes. They make friends of all ages and diagnoses. They heal. They help each other. 

As I talk about the art group, I see my patient's back straighten, just a tiny amount as she imagines making a giant colourful mess like she did when she was 5.