Wednesday, March 7, 2007

Medicine on the phone and the $30,000 question

One of the biggest challenges here in Iqaluit is the medicine you do over the phone. Like most northern hospitals, Baffin Regional Hospital takes care of patients from a number of small communities in the area. In our case the 'area' is the eastern arctic, including about a dozen smaller communities, mainly to the north of us. Some of the communities are close (1 hour by air) and some are far. Griese Fjord, the most northern community we care for (and the most northerly permanently inhabited community in Canada) is about 12 hours round trip by air.

Each community has a nursing station staffed by a few brave nurses. When things get beyond their comfort level, they call us for advice and sometimes patient evacuation. As a doctor, when I am on call in the emergency room I also field calls from all of the communities for emergencies.

Medical advice, given over the phone, is always a risky proposition. I can't see the patient, can't examine the patient, and often (because of language barriers) can't even speak directly to the patient. I have to rely on the nurses assessment and description of the patient in order to make my decisions. Most of the nurses are experienced northern nurses, and they are excellent. With staffing shortages there is the occasional less experienced nurse, or new graduate and it can be hard to tell the difference. Sometimes the nurses are from Quebec, and even though they are likely excellent they mainly speak french. What does this all add up to? Not infrequently I find myself on the phone, discussing a medical situation in English with a nurse who's first language is french, who spoke to a patient who only speaks Inuktitut through an interpreter, and they are up to 6 hours away, and if I am not familiar with the nurse I often don't really know their skill level (though most are very highly skilled). As you can see there is lots of room for medical errors to occur.

The CMPA, who provide medical malpractice insurance to all physicians in Canada, recommend that physicians avoid providing medical care by telephone, because it is fraught with medico-legal risk. With so much potential for medical error they recommend seeing the patient in person whenever possible. Obviously that is not geographically possible in Nunavut, so we are left with the alternative of doing what we can with what we have...the telephone.

The main decision made in most telephone calls is whether to MedEvac the patient or not. This decision is based on lots of factors: how sick are they, how sick have they been before, is the diagnosis clear, what type of illness are we looking at, is treatment available at the nursing station, how young or old are they...the list goes on and on. What it comes down to is a judgement call: Do I need to see this patient or not?

MedEvacs are costly. I am told that the average price for a MedEvac within the territory of Nunavut is $15,000 and the average for an evacuation from Iqaluit on to Ottawa is $30,000. There are only 30,000 people in Nunavut, so on a per capita basis those costs really add up. MedEvacs themselves are not without risks. When I was a resident and working in northern Ontario I met an air ambulance crew who had MedEvaced a patient in marginal weather and had their landing gear get stuck up. They all called their families on the satellite phone to say goodbye, dumped fuel and belly landed the plane they were in. Luckily they all survived, but it always reminds me that calling a MedEvac incurs risk to the patient and flight crew, especially if the weather is bad.

Every night on call my pager goes off and I talk to a nurse in a community hours away by air. It's late at night and they have a sick patient. Maybe it's an elder, maybe a baby, or maybe someone got in a ski-doo accident. They've done everything they can and need some advice. On my end I try to get a feel for the patient, for how sick they really are. I try to gauge the experience level of the nurse I am speaking with. Sometimes I get them to email me a picture of the patient, sometimes I try to speak to the patient directly. I look out the window and check the weather and think about putting the air crew at risk. I get all the information I can and make a judgement call, the $30,000 question.


Nancy said...

Hey, just found your blog, referral from Clare's. Haven't read further than the first page yet, but great blog so far! Good post- you know, it's funny you say that as we (I'm a nurse who does locums in Baffin, among other places) have the same wondering about the Doc we're talking to too. A few times I've talked to the doc, told my colleagues what s/he said, and they'll say "they must be new!" and then it's up in the air again as to whether we're doing the right thing or not. Obviously, none of us are to blame, it's such a tricky situtation with so many of us being locum docs and nurses, we don't get to know each other.

So, the skill testing question is, does a cut finger, where the knife has been in contact with seal meat, need antibiotic prophylaxis or not? Iqaluit docs have told me no, but the regular nurses insist yes (in the old days the directive was yes), so has the protocol really changed or not? Please research this and get back to us! (laughs!) Of course, if the answer is no, no one will believe you for a few more months! ;-)

p.s. are comments enabled? This one's not going thru, will press the button one more time (hopefully you didn't get 17 copies)...

Anonymous said...

some new graduate nurses can still be highly skilled! this assumption makes it almost unbearable to practice nursing in the north if you are young.

Anonymous said...

Great posting. I meet a colleague of yours recently, we were discussing newbie docs to the north (and HOW refreshing they are to some of us older seasoned nurses) and mentoned this great blog and so of course he said oh I know that bloke.

Brave nurse, well yes to some degree (no pun intended) and it's not just the language and cultural barriers that complicate clinical issues. Some of the best and worst nurses "come north" for all the wrong reasons and pack a lot of baggage with them.

Google "Helen Gilbert" + great adventures in northern nursing and I think you will get an accurate and more realistic sense of the patriarchal, condescending and paternalistic environment northing nursing in Canada has been born in and of. Then add the nursing (and all other health professionals) baby boom crunch "oh, they need nurses, I think I will dust off my forty year old pin and do an agency locum in the north" coupled with the end of the road mentality AKA "I need to go somewhere to hide with my addictions (men, shopping, drugs, alcohol, dogs, cats, whatever)" and the getting my/our financial house in order post student loans/divorce/bankruptcy, etc., and then the true adventurer, i.e. MSF, MEQ variety with a bit of missionary zeal thrown in and you get a pretty good cross section of the demographic.

Those of us who stay, and have for eons, love the north and all its characters with all their bumps, a lot. I remember my early years as hard, exciting, exhilarating and exhausting with a step learning curve (and not all the telehealth, daily flights, digital cameras, email, faxes and blogs the under thirties have grown up with). There were some great role models, exemplars, mentors. There are very few now and that makes it extremely stressful for both the older experienced professional and the novice newbie.

Your blog is a bridge. Be well. Do good work. Stay in touch.

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