“But I’m warning you, don’t ever do
Those crazy, messed-up things that you do.
If you ever do, I promise you,
I’ll be the first to crucify you.
Now it’s time to prove that you’ve come back here to rebuild.”
– “Call & Answer” by The Barenaked Ladies

Reaching out for help to a tertiary centre from a remote hospital.

View part 1 of this post: On Call & 100 Kilometers Away 

A few days after that stressful night on call, I was covering the emergency department in the same small coastal BC community. I admitted an older patient with sepsis. This was, unfortunately, not an unusual presentation. The team and I got him settled in with the right treatment, and I completed my otherwise unremarkable 24-hour shift.

The next morning, my patient seems to be doing well – no longer febrile, much more alert and with reasonably good looking labs. I feel good about his progress. While getting ready for my afternoon clinic, I receive a phone call from the nurse looking after him – he suddenly looks unwell, and she is worried about him. 

“I have an ECG here I think you should look at,” she reports, noting that he is increasingly short of breath and complaining of chest pressure. 

“Well, what does the computer think?” I ask, somewhat in jest – the automatic reading of the ECG is notoriously unreliable at picking up anything but the most obvious…

“It says ‘ACUTE MI’ at the top of the page…”

I drop what I’m doing and make my way back to the ward. Indeed, the ECG is extremely concerning for this most unfortunate complication, and my patient is not looking very well. His blood pressure is very low, and he is much more tired. We start the well established cardiac protocols, and I confirm his “full code” status. He receives a fluid bolus while the crash cart is wheeled into place.

In small centres like this one, an acute situation introduces multiple complications. It affects the care of not only the sick patient at hand, but also the care of more stable inpatients and even new folks presenting to the ED, who need to wait while we address the problem in progress. Keeping this in mind, I alert the patient care coordinator to the situation, so she can handle the staffing problems that this is going to cause.

My heart rate, already at a good clip, quickens further as I sit down with the patient’s chart and pick up the phone. Though we can do a lot for this patient, I know definitive management of the issue at hand will be found in Vancouver, and it is my job to get him there. A big part of that responsibility is communicating effectively with the necessary specialist physicians, something that always sparks a pang of apprehension.

My heart rate, already at a good clip, quickens further as I sit down with the patient’s chart and pick up the phone.

“Am I overcalling this?”

“They’re busy down there. Is this phone call absolutely necessary?”

“What are the key parts to the story?”

These thoughts race through my mind as I flip through the paper chart, pulling important details into my short term memory and rattling off this patient’s demographic information to the Patient Transfer Network operator. During my training, I heard horror stories of rural GP’s getting stonewalled by colleagues in larger centres. This case seems to meet the criteria for urgent transfer, but I fear being crucified for an unnoticed issue or for a missing crucial piece of information, making this call an unnecessary distraction for the specialist on the line. I feel a kinship to my nursing colleague who had called me for help a few nights earlier…

As the nurse looking after my patient reports back to me what is going on in his room down the hall, the specialist comes on the line. I force the impostor in my head to quiet down as I tell the cardiologist what was going on in our small hospital – doing my best to paint a picture of this critically ill gentleman succinctly. His terse questions indicate he is indeed being pulled in a few directions, but he agrees that this patient needs urgent care at his site and provided me with instructions on how to proceed. 

 “I force the impostor in my head to quiet down as I tell the cardiologist what was going on in our small hospital …”

Hanging up the phone, and relieved to have that task behind me, I work with the nurses to translate those instructions into a set of prioritized actions that we can achieve in our site while waiting for the medical evacuation team. My patient had stabilized a bit, but would still require a nurse escort – another all too common burden we would need to sort out. While we work away, I constantly go over the conversation in my mind – wondering if I missed anything in my presentation or interpretation of the specialist’s recommendations, worrying that it would make a potentially fatal difference in this patient’s story. 

Our team’s efforts paid off, and he remained stable until the med evac team arrived. As he is wheeled out of the hospital, I feel relieved and proud of the care we were able to provide to him. But I still ruminate on the case, wondering if when he arrives “down south” the team there, unaware of our circumstances, will find some flaw in our work here. This again was a fear that was never explicitly taught or instilled in me by any one teacher but picked up through the “hidden curriculum” of medical school and residency. 

I heard the next morning via a text from the nurse that went with him that when my patient arrived, he was immediately taken to the cath lab with no questions asked or criticisms of our care voiced, and he was doing well. 

Looking back on that experience, though I’m happy with the outcome and appreciated that feedback for myself and the team, I’ve wondered what could have made that difficult situation, and future ones, go more smoothly. Would a video link (like the ones now available) have made a big difference, allowing the specialist to see what was going on, instead of relying on my somewhat stilted recounting of events? Or would that just muddled things further, introducing more noise into the situation? Is there a way for sites to give both positive and negative feedback about such cases, beyond the personal kudos or corrections, without adding to already heavy administrative demands? How can we build, and in some cases rebuild, solid relationships and empathy between sites and services in this age of connectivity and regionalized, and ever more specialized medical care?

Do you ever feel like you are trying to bridge a gap between sites and services for your patients? Have you ever had an unpleasant experience working with a remote team, to whom you were asking for help or providing advice? What could have been different, and what do you think should or shouldn’t change about the way we communicate with colleagues?

Disclaimer: The views and opinions expressed in this blog post are those of the authors and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.