A few weeks ago, I was working an after hours GP shift at a ‘country’ hospital. I say this in inverted commas as it is only about 30-40 minutes drive to the city. The shift itself present relatively few challenges with a mixture of chest pains, general GP type presentations and some virally kids. At about 9:30pm, I was asked by the ward nurses to come and help with a patient who was getting agitated. Once this was sorted, one of the other nurses asked me to check on a patient down the corridor and replace her IV line. From the notes, the lady in her late 80s had been admitted that afternoon by her regular GP from his rooms. Given the severity of the illness, the GP had requested that the ambulance service take her from the rooms straight to a major hospital in the city. However from the ambulance crew note, it was evident that they had decided to bring her to the country hospital instead stating that going to the city hospital was “too harsh for her.” According to the GP notes, she was living at home with her daughter and independent in her ADLs. Evidently, she was quite a prim and proper lady who certainly wasn’t loaded with co-morbidities. The GP had documented some agitation, chills and that the patient was uncomfortable. He had sent off urine and bloods, but no CXR. The nurses were worried that she had deterioated and was now complaining of central chest/epigastric pain.
When I stepped into the room, this lady looked sick. Her respiratory rate was 40, pulse 94 and was sweaty and writhing in pain. The little voice in my head said “Gerry, she doesn’t belong here.” Its funny how that immediate reaction comes before any rational thoughts. But I thought through the scenario sitting back at the nurses station. Here were some of those thoughts:
- going home from my GP clinic shift in just over an hour
- two nurses on overnight for 30 inpatients
- limited access to radiology
- no monitoring available
- Usually a well lady, independent
So weighing it all up and putting it through the ‘grandparent-o-scope’ (what would I want done or do if this was my grandparent), I decided that she needed transfer to the city. Granted, this was the place that her GP originally wanted her to go. Muscle memory from working 6 hours from the city in Wudinna helped me dial the number in less than a second and I asked to be put through to the ED consultant. In the back of my mind were the handover calls that I had made from Wudinna. This is how the conversation went, I have changed the names and my parts are in bold:
ED: “Hoshsjs Ropsjnskss (unintelligible)”
GC: “Sorry, who am I speaking to?”
“Trevor Jones, ED”
“G’day Trevor, I’m Gerry a GP working up at Woopty Doo tonight. I have a quite a sick 87 yo lady I’d like to transfer down to you”
“We’re really busy here tonight”
“I understand, but I’d like to send her as I’m not at the hospital for much longer and I think she needs more care than we can provide. She was admitted by her GP for a suspected infection today, bloods and urine are still being processed. I havent got a CXR to look at but her lungs sounds pretty cruddy. She is breathing up to 40/min, temp is 38.9 and her BP is 196/88. Im wondering that she has a pneumonia or pyelonephritis.”
“Well, look you have the same antibiotics as us and we are really busy.”
“So you’re saying you want her to stay here? I havent got access to a CXR at this time and Im not here over night, Im a bit worried about this patient given her vitals.”
“What does her chest sound like?”
“There are some coarse creps in the bases”
“Well she might have a pneumonia…”
“Thats what Im worried about. Also I was wondering about some advice for her pain. She is quite distressed and I thought perhaps some morphine IV”
“That might stop her breathing”
“Ok, well maybe I’ll start with something oral to see…<click>”
Hung up. Just like that. No extra advice, no ‘ok then well send her down,’ nothing. Just click and the conversation had ended. Sod it. So I sat down and wrote up a quick review/transfer note and waited for the ambulance crew to arrive as I had already asked for them prior to the call! It was an intensive care paramedic that rocked up and we talked through the case. He was suprised by the decision by the previous crew to change the destination earlier in the day and agreed that this lady did not belong in this hospital. We got and ECG off, placed a new cannula in her and got her on her way.
Two days later I was able to drop past the city hospital ward the patient was on and had a chat with the CNC about her and the ED rudeness. The patient ended up having a nasty pyelonephritis and needed a few days of IV antibiotics. The CNC said that often the ED guys don’t understand where you are calling from and what resources you do and don’t have. Working in Wudinna last year, I could understand that clearly. But even close to the city, there are times when more intensive observation and care is needed. Unfortunately, the closer you are to the city, the more blurred the distinction becomes. People assume that you have a dedicated medical team overnight and 24 hour access to radiology and pathology. Im also getting a bit tired of the line “we’re really busy tonight” or “the ambulances are ramping” like that is going to change the outcome for the sick patient. True, it might be just a cry for acknowledgement that things are going crazy in their department, but what is it supposed to make me feel? Guilty for transferring someone who needs more care? Not a great place to put a country doctor in.
“we’re really busy tonight”
For me, the most disappointing part of the interaction was the rudeness to a fellow colleague asking for help. If you are 30 mins or 6 hours away, politeness shouldn’t change. And having worked in a city ED, I completely understand how busy they can get and how you end up trying to reduce the patient load as much as possible. But we are all in this game together. Often, I found the referrals from rural GPs to ED were great as they had been worked up with pathology sent, analgesia on board and IDC and IV lines in.
It is a shame that as a future rural GP, this has been a common experience when speaking to EDs in the city. Perhaps next time I won’t give a courtsey call and just let the patient rock up on the doorstep in an ambulance. But I believe in a handover and perfer not to be yelled at or hung up on. It made me think of this interaction that Tim Leeuwenburg had recently. So ED docs out there, think of us GPs in small hospitals without the luxuries that you may enjoy. We are transferring you the patient for a reason. Not because we want to avoid work, but for the patients best care. If we are sending them to you, it is because they need care greater than the level we can provide.
Rural GPs admit to our hospitals or discharge from clinic a lot of patients that might otherwise need transfer to the city. So be nice to us, because we could send a WHOLE lot more work if we wanted to!
Since starting my career in medicine, I have been asked to certify death on many occasions. The first few that I was called to see were in hospitals as part of a ward team or even after hours as the intern covering surgical or medical wards. Often, I had not known these patients for more than a few days and had sometimes been already non-interactive for this time. Therefore, I felt little sense of personal connection. When called to certify, I was merely formalising the passing of the patient. I would dutifully listen for heart sounds and breathing for one minute, check pupils and response to pain. Of course there were a few challenging cases…
In the country as an intern, I was called at 3am to see a patient. Of course I missed the nurses first few sentences as my brain spooled up on the phone in bed. All I heard was “…so he’s fallen and there’s a large laceration to his forehead.” My response was something along the lines of “ok, so I guess I’ll come in and stitch him up?” The nurse replied “didn’t you hear me, I said he’s dead.” An important reminder for those calling doctors in the middle of the night, summarise the case at the end of the call! At any rate, this inpatient had advanced metastatic cancer and got up out of his bed and fallen in a separate corridor. My junior tired doctor brain didn’t know whether the coroner needed to be called. So we called the office and they said not to worry, just take some photos and certify. This was the first time I’d had to assess and certify a death where the patient hadn’t passed away peacefully in bed.
On another occasion earlier in my career on the hospital ward, some of the patients family wanted to be present at the certification. I had to quickly think about how to inflict a painful stimulus in a non-dramatic way. Surely sternal rub or supraorbital pressure was out. I fell back to nail bed pressure with the cap of my pen. So after checking for a radial pulse, the pain response was covered discreetly. Then came the difficult part, what should I say as I leave and walk out the door? Sorry for your loss? I didn’t really know the patient, so it would be hard for it not to sound forced.
Interestingly working in a country town last year presented a solution to that problem of what to say. But it also raised a bigger issue. By living and working in a small community, you invariably get to know your patients a lot better than in a large hospital. You see them every fortnight or month in the clinic and then in the other times down the street, at the footy and supermarket. Some were even my close neighbours and friends. You learn their little nuances and build up something that draws me to general practice, rapport. You are part of the best and worst of their lives. Watching a new treatment work wonders for someone all the way through to the end of life. I saw many of my neighbours, patients and friends pass away last year. But unlike city practice, as a rural doctor you are the one to certify and see the final state of your patient that you have got to know. Many times, the last thing I remember of these people is certifying a lifeless body in front of me. I want to remember the laughs in the clinic, seeing them moving better with a frame in the community or having a beer at the pub. It is the burden that rural doctors take on when this happens. For this reason, I always ask the family if I can get a copy of the little funeral booklet that often tells the amazing life story of your patient. It helps me to replace the last image and moments with them in the hospital with a vibrant history and imagine the living patient again.
But it is not all doom and gloom in the country. Having been the patients doctor and friend for a longer time has allowed me to say more to the family when it comes time to edging out of the door. Previously an awkward moment of ‘what to say’ was now backed up by rapport and the patients story. I will often say: “I’ve known and looked after ‘John’ for the last 10 months now. It has been a privilege to be his doctor in that time and I’m going to miss him in the clinic.” So the extra emotional burden of losing your patient in fact helps to better talk to the family with compassion. It is real as often you are grieving as well. I’m looking forward to working in the country and being a part of the community, but how will I deal with the constant loss? If any GPs would like to comment, I’d be very keen to hear your thoughts.
A few weeks ago, my uni students were given a scenario similar to this one:
Mr Hugh Jass, 65 year old lawyer presents with headache, nausea and sweatiness. Cough, non productive. Muscle aches, dysuria and urinary frequency. No symptoms of meningism. 25 year pack history. No other relevant family or past history.
O/E: Temp 40C, HR 90, BP 110/90, RR 18. Crackles in right base. Abdo tender suprpubically, no loin tenderness. BS normal.
In the case, Hugh is referred to a tertiary ED where he has some tests. CXR shows some COPD but no consolidation and urine grows E.coli. He is evenutally seen by a urology consultant who gets a better LUTS history and does the PR and PSA test.
The question was asked, quite fairly, should we have done a PR earlier? And if so, when? GP room, first ED work up? It made me wonder “would I have done a PR in the GP room for this man?”
I also put myself out on a limb during the case conference with the other tutors and said that I probably wouldn’t have sent this man to ED. Was almost shouted down! I thought that a reasonable action (even in the peri-urban setting) may have been to check for UTI with dipstick and commence on oral antibiotics. Given his high fever and symptoms perhaps even a shot of IV antibiotics as a stat dose? Although I understand that a UTI in a male is a concern, I thought immediate referral to ED was a tad overzealous. Of course more detailed history about urinary symptoms, DRE, PSA (if symptomatic) and a referral to urology would be on the cards, but within a week or so. It seemed from the other tutors that this would be too gung-ho….
Interested for your thoughts.
Delivered on the 24th May to the 2013 RDWA Conference. First time I had to speak for 30 mins!
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“Gerry grew up for 22 years in the outer suburbs of a small Victorian town called Melbourne. So how was it that this ‘city boy’ ended up undertaking GP training and wanting to work in rural South Australia? Was it family heritage in the bush, inspiring placements, the lure of aviation or all three? Surely they will find out he barracks for Collingwood sooner or later….”
I have a favourite black jumper. In fact, its helping me write this post at this moment. Everyone has an item of clothing just like it. Unfortunately, the price paid is increased wear and tear. My black jumper started to develop a large hole under the armpit area at the start of last year. The nurses in Wudinna would give me grief when I started wearing it in the winter (sometimes for the cold, other times to disguise a non-ironed shirt…)
Eventually, enough nurses, family members and people on the street convinced me to get it repaired. Some said take it to a shop and other offered to stitch it up themselves. After politely declining on a few occasions, I found the opportunity to repair my old friend on a recent trip to Melbourne. Mum provided the obligatory box of needles, thread and scissors. But I had never fixed up any sort of material damage before, the only relevant word I knew was ‘darning’ from Elenor Rigby by The Beatles.
But the truth was I had done something like this, in fact I would do it once or twice a week. Often patients would present to the clinic with large cuts and lacerations and need stitching. Surely I could use these skills here? During a medical student and intern placement in country South Australia, I learnt a number of tips and tricks for suturing. In Jamestown, a pulley type horizontal mattress and running subcuticular stitches were taught to me by the great GPs there. To finish off each run of suture, I managed to remember how to do a hand tie. Amazing what can come back to you after three years!
So away the stitches went attempting to close the large axillary dehisence in my jumper. One aspect that was different was having to thread the cotton through the needle tip. That took steady hands and a large amount of accomodation (see cross-eyed picture above). Luckily I avoided any needle stick injuries as the material edges started to oppose. It probably took me 3 times longer than stitching up skin, but I eventually finished. And I can report that there has been no further wound separation since!
Has anyone else used medical/surgical techinques for everyday tasks? Im sure there’s more out there…(looking at you Leeuwenburg)