The anxiety of caring for a patient in a remote coastal site.

And if you call, I will answer
And if you fall, I’ll pick you up
And if you court this disaster
I’ll point you home

– “Call & Answer” – The Barenaked Ladies (1998)

Being on call is a universal experience for physicians regardless of their specialty. Even if only for a short time, everyone wears at some time or another this uncomfortable “backpack” eloquently and accurately described by Dr. Daniel Waters. Medicine is a challenging discipline even under the most ideal circumstances, and the added responsibility of being immediately available to handle any acute issue at any time can be overwhelming. I personally feel a ball of ice in my stomach seeing my name and phone number coming up on the schedule – I’m told that feeling never completely goes away. 

I’m feeling that chill, as I cover one of my first weekend night shifts as an attending rural locum GP exactly one year ago. Anxiety gnaws at me as I struggle to get some sleep. I’m based out of the only hospital in an area covering small communities scattered among BC’s coastal inlets. Not only am I responsible for patients presenting to the local ED, I’m also supporting remote medical stations staffed with advanced practice nurses.

Around midnight my phone goes off. A nurse from one of those communities has a sick young man and a set of very concerning vital signs to discuss with me. Thanks to my time covering the Chilliwack General Hospital as a Family Medicine resident, I’m used to waking up quickly and gathering the necessary information to make decisions. But unlike my time as a resident, the responsibility is now solely on my shoulders, and I am one hundred kilometres from my patient who is being cared for in a place I have never seen or been to.

“I am one hundred kilometres from my patient who is being cared for in a place I have never seen or been to.”

As I listen to the nurse’s story and try to picture in my mind what was going on – and more importantly, what we can do about it, I find I cannot  fill in the backdrop of this scenario. What antibiotics and fluids are available? What resources are on hand to support this patient’s respiratory efforts and maintain his airway? What interventions are within the scope of my nursing colleague? Exactly how, and how quickly, can I get my patient to the team at our local hospital, or to an even higher level of care in the middle of a cold, January night on the BC coast? 

Some of this information was covered in my orientation to the hospital, but I have limited experience in other communities to draw on. I have never been in this kind of situation before. The nurse on the other end of the line finishes her story, and falling back on first principles, we determine critical next steps that needed to happen on site.

While she gets things rolling, I muster up the courage to access the most valuable resource available to me – experienced physician colleagues. When I arrived in the community a few days prior, I was told that I could call for help at any time, and it was time to test that promise. I ring the house a few metres away, and they answer without hesitation. My colleague provides me with a roadmap on what to do next given this specific context. A conference call with the BC Patient Transfer Network, including the on-site nurse and emergency/transport medicine physician, follows. Local measures have stabilized the situation enough to have the patient be transported to me and the local team in the morning.

As I hang up the phone and sit down at my kitchen table looking out at the night through a rain covered window, I can’t help but feel grateful and impressed. From the quiet of my accommodations, I became a part of a team spanning the province, coming together in the dead of night to care for a patient who had been courting disaster.

At the same time, I feel humbled and embarrassed at my ignorance of the clinical context which my patient was coming from. Early in the call, I found myself getting frustrated with the limitations on what could and could not be done in his community in terms of medical support. The nurse on the other end of the line was doing the best she could, asking for advice on what to do next, and educating me on her scope and resources. I didn’t make the call any easier for her. Though everything worked out – I saw the patient in person the next day, and he was discharged to his home community a few days later – I wonder if things might have gone a bit smoother at the start had I known more about my colleagues with whom I was working, and the communities I was serving.

Over the last year, I’ve taken the lessons learned from that night and applied them to the communities I’ve found myself in. Though it can be challenging, I make time to get to know the context of the local referral patterns, resources and people. Now when I’m called to assist or provide direction remotely, I don’t run into the same frustration and communication issues.

I’m hopeful that telemedicine technologies currently in use and in development in BC will make this issue of context blindness less of a problem. As this technology is adopted, we will actually be able to see on a screen what our remote patients look like and exactly what resources are available to their local care teams at a glance. Until then, as we are called to support sites remote from us, physicians stationed in larger sites would benefit from appreciating and respecting the skill sets and resource limitations of our remote referral centres and colleagues.

Do you support remote communities in your practice? How familiar are you with these sites? Do you visit the communities you support to understand the context from which your patients are coming? If you are a locum or work out of multiple sites, what’s the first thing you do to orient yourself to a new community you’re supporting? Comment below.

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.