What, Me Worry?

Things that are currently taking up valuable space in my brain:

• Money (or more accurately, the lack thereof)
• I'm lonely. I don't think I've ever moved anywhere where I literally do not know one person before.
  
• The fact that I've managed to forget large amounts of emergency medicine in the year it's been since I've done any emerg-- I feel like an idiot at least 3 times a shift.
• The balance on our VISA card. It has to be paid off before I start mat leave, or it will continue to eat away at me indefinitely.
  
• I'm leaving for a month-long trauma rotation at the end of this week and don't even know where I'm staying (it's supposed to be arranged by my program)
• I'm worried that I'm never going to figure out how to get a freaking OHIP billing number, and will never get paid for the hospitalist work I've already done.
  
• The bases that my paramedic husband is working out of are anywhere from 1-2 hours away. I worry about him being on the road, particularly at the end of a night shift.
• Due to his commute, my husband is often gone for 14-16 hours for his 12-hour shift. With me out of town, I am very stressed about how we're going to manage with the dogs.
  
• The scrub tops at my new hospital fit funny-- the mediums don't fit over my expanding belly, and I swim in the larges. I always have to try on 5 or 6 of them on before I find the one random medium that is a big bigger. Gah.
• I am worried that if I feel isolated now, my maternity leave will be hellish. Having a baby in late November in Canada is the worst timing ever-- my leave will end just as the weather starts improving.
  
• As is always the case, as my anxiety rises, my appetite disappears. I'm having trouble eating (anything but freezies and popcicles anyway) which doesn't help the way I've been feeling. I'm not too worried about The Bean, since I've managed to gain nearly 10 lbs anyway.
  
• I've had a few more pre-syncopal episodes at work. As long as I'm careful to eat every 3-4 hours I'm hanging in, but I live in fear of passing out in the ER.
  
• I'm worrying about the fact that our last appliance is now nearly a month late. I want my freaking dishwasher. I've lived without one for two years, and I'm dying to have properly clean dishes again.
• I am concerned that I will never find a good weekend to take ATLS. I can't believe I put it off this long.
  
• I really want a vacation. Like, want one so badly I can taste it. The beach kind. Or the spa kind. Definitely not in the budget.
• I am worried that I am going to mess up my job as a hospitalist. I'm not used to working without backup, and not having anyone checking my orders and treatment plans. I could kill people with this kind of responsibility.
  
• Baby stuff costs money. Money we don't have.
  
• I worry that I'm never going to feel 'at home' in our new town, and will be miserable the whole time we're here.
  
• I'm worried that I'm never going to get a central line on the first try.
  
• I worry that the dogs won't take well to the new baby
• I'm very worried that I'm going to suddenly become a 'mom' when the baby comes. In the not-good way. In the high-waisted jeans, always smelling like baby vomit, out of shape, unable to talk about anything but my child's bowel movements kind of way.
  
• I am worried that even after a year of emergency medicine, I still won't feel prepared for work in the emergency room.
• I also worry about crying at work. I cry a lot. I know it's the pregnancy hormones, because I never cry. I don't even get PMS. But my coping skills are pretty much nonexistant at the moment.
• We really need to fence in the yard, but... big surprise... we can't really afford it. But if we don't do it before the ground freezes, I'm faced with bundling up a newborn in the middle of a Canadian winter to walk the damn dogs.
  
• I worry that I made the wrong decision to pursue emergency medicine when I could have joined a nice, safe family practice and started digging myself out of this financial hole.
  
• I'm worried that I'm going to be miserable away from my husband for the next two months (after trauma, I have another out-of-town rotation). I am a horrible suck when it comes to him. The last time we had to do the long-distance thing I was on elective out west during medical school-- I missed him so much I ended up stacking my shifts and coming home early.
• I'm worried that I'll never work up the motivation to unpack the rest of the house now that the important stuff is done. Let alone paint the colours we had already picked out.
  
• I'm worried that my PDA will finally figure out that I've been unable to HotSync it for over a year, and will lock me out of my desperately needed Lexi-Drug and 5 Minute Clinical Consult programs.
  
• I am worried that I will hate my post-baby body, and that no amount of diet an exercise will make things right again.
• I am now down to my last pair of dress pants that still fit. If I'm going to be moonlighting until mat leave, I'm going to need to find some maternity work clothes-- NOT something I want to spend money on at this point.
  
• I worry that our child will be born with some kind of severe disability and will be dependent on us for life.
  
• I worry that my dogs will somehow escape my watchful eye and unfenced yard and find their way onto a nearby busy street where they will be hit by a car. I didn't say that all of my fears and worries were rational ones.
• I can no longer see my own genitals. I worry that my feet won't be far behind.
• I worry that my husband will never get on with the EMS in town, and will have to commute to out-of-town bases the whole time we live here.
• I realized that next month's trauma rotation isn't an ER-trauma rotation... it's a general surgery rotation. My last general surgery rotation (as those of you who have read this blog since the beginning may remember) nearly killed me. And that was BEFORE I was pregnant. I can't do 10 hour days on my feet anymore, and I certainly can't handle assisting in the OR. I've applied for vacation to shorten the rotation by a week, but if it doesn't get approved I'm thinking of pleading sick leave on the basis of my inability to stay upright for long periods with my ongoing hypotension. And my rapidly developing anxiety disorder.
• I am worried that my inlaws, whom I love, will begin to drive me nuts now that we're living relatively nearby.
  
• I'm disappointed that Rebecca is Canada's Next Top Model. I was really rooting for Sinead.

Okay, enough bitching. More uplifting posts to come.

The Untouchables

I've never been able to figure out exactly what other specialties have against emergency medicine. As a general rule, emergentologists (I love that phrase) are seen as the cowboys of medicine-- they do the medical equivalent of balancing spinning plates on their fingers. Which also means one false move and they all come crashing down. Emerg docs seem to be viewed with a mixture of envy and derision. Generally speaking a few things make emerg docs different from other specialties. For starters, we have lives outside of medicine. We still make good money (not surgeon money, mind you, but why make buckets of money when you don't have time to enjoy it?). We play as hard as we work. When we leave the hospital, we leave the patients behind and don't get paged when problems arise. We have to know about a lot of things, but we don't know most of them beyond their initial stabilization and management (or as one of my preceptors likes to say, we know the first 10 minutes of every disease). We are always being pulled in multiple directions, often by people who are actively trying to die. We have to handle everything from the small benign stuff (like a sore throat, minor lacerations, sprains) to the worst cases (trauma, VSA, sepsis, anaphylaxis) and everything in between.

So emerg docs also end up being the scapegoat for any number of questionable medical encounters. When you're juggling several critically ill patients at a time, sometimes stuff can slip through the cracks. And sometimes, things don't get worked up as thoroughly as they could be before they're referred on. In the ED, the emphasis is on disposition-- in other words, where is the patient going to end up? If they have an acute abdomen, they're probably headed to surgery regardless of the results of their LFT's-- so it doesn't always make sense to wait for them before calling the surgeon. But then the surgeon turns around and bitches to anyone who will listen about how they got a 'bogus consult' for abdo pain that wasn't even worked up.

I think that the biggest problem in situations like this is that although emerg docs rotate through nearly every major specialty through the course of their training, specialists rarely are obligated to spend any significant amount of time in emergency medicine. So it's rare that a specialist can see things from our point of view. The surgeon might just see that they were referred something as a 'query appendicitis' on the basis of right lower quadrant tenderness, rebound tenderness, guarding, anorexia and an elevated white cell count. In spite of the increased use of ultrasound and CT, the reality is that appendicitis is still largely a clinical diagnosis. Take the same case two hours later, when the surgeon (or, more likely, surgery resident) emerges from the OR long enough to lay eyes on the consult. Suddenly, the patient's tenderness has 'magically' migrated a bit higher, there's no rebound tenderness and they're claiming to be hungry. So suddenly my 'classic appy' now looks a lot more questionable, and the surgeon rolls his eyes at the stupid consult that the ED wasted his time with.

I often feel sheepish, because I know that had I gotten the same story and/or clinical exam that the surgeon did I never would have consulted in the first place. But I have no control these things.

On Facebook (my new addition) there is actually a group devoted to "Stupid Consults from Stupid Doctors". Most of the posts to the group are from residents in academic centres complaining about things that have been sent to them from the ED-- consults which, in their eyes, are inappropriate. My response? It's easy to judge from your end of the filter. Maybe those obs/gyn residents feel like they must get referred everyone with pelvic pain or heavy bleeding, but since they don't see the 98% of patients that I send home it's hard to muster up sympathy. Refer pelvic pain? Only with a positive urine preg test. Heavy bleeding? Only with extenuating circumstances, like the woman I saw last week with the hemoglobin of 68 who was still bleeding heavily in spite of treatment with Ovral. I'm no gyne, but I think that warrants intervention.

The other side of the coin is the spread of defensive medicine. From what I understand from fellow emergency medicine bloggers, the problem isn't nearly as bad here as it is in the U.S., but it's starting to seem that way. Take ortho, for example. At the last two academic centres where I've worked, emerg docs do very few reductions of displaced fractures. As someone who wants to learn these procedures, I find this frustrating. Leaving a patient taking up an emerg bed for hours until ortho can organize themselves to come down and reduce the fracture is silly when we could get it done in just a few minutes. But as it was explained to me, "if something goes wrong with the reduction, the emerg doc would have a really hard time defending their choice to do it themselves when the experts (that would be ortho) are readily available for consult". Gah. A big part of the reason I chose to finish off my training with a year in this 'less-academic' centre is the fact that the attitude here isn't that the A-B-C's of primary assessment stand for airway, breathing and consult. Emergency medicine isn't just 'referology'. We actually do the reductions, the procedures, the conscious sedation, the airway management... it's a refreshing change.

Don't get me wrong-- inappropriate consults happen. And they probably happen more often than they should. Emerg docs aren't perfect. But we do the best we can. And until you've spent a few shifts in our shoes, give us the benefit of the doubt.

I Think I Sold Out...

So I made my decision. After talking to some more established emerg docs who have done shifts in the smallish emerg that is courting me to take shifts there, I have decided that I am in NO WAY ready to do emergency medicine. I appreciate all of the points made by commenters regarding rural medicine-- I agree, sometimes you just have to take a deep breath and jump in. But in my case, I don't think I've done enough emerg through my family medicine residency to make that jump.

But that doesn't change the fact that there is debt to be repaid. And after buying a house, the bank balances are looking awfully sparse. And we're faced with some lean times with an impending maternity leave looming. Gah.

So where does that leave me? Well, I could just keep plugging away at residency, Mr. Couz can pick up extra paramedic shifts, and we can hope for the best (financially speaking). But the bills are piling up. And since the Canadian government is holding nearly $7000 of my hard-earned cash hostage while they process all of the reassessments they've slapped me with over the last few years (I mean really... contesting my medical school tuition claims? The government is the whole REASON I paid $15K in tuition a year, and now they think I'm lying about it? The injustice infuriates me) I don't really have much of a choice. I have to moonlight.

Luckily, this month I'm doing nothing but emergency medicine, which makes for a reasonable (although erratic) schedule. So I examine my options. My new town is ripe with walk-in clinics catering to the 30K-odd "orphaned" patients in our region. Perfect. McMedicine at it's finest-- I can practice what I know (family medicine), not have to drive far to do it, and make some extra money. Problem is, I've only had an independent practice license for a couple of weeks, and I haven't even figured out how to go about getting a billing number. And the idea of figuring out billing right now is a little overwhelming.

But then the same little hospital that had been courting me to work in emerg presented another option-- they are currently desperate for hospitalist coverage. I can come in for as long as I want, as many days a week as I want and they'll pay me $130/hr to see as many inpatients as I can. They don't seem to care if I see everyone or only a few people, they just want to take the pressure off the 'on call' physicians. So I wouldn't be responsible for call at all. The on-call doc would follow-up on any tests I order, and since they send anything more unstable or critical than urosepsis or pneumonia to the centre where I am doing my ER training, the patients are usually straightforward. Hmm. Intriguing option.

So I took it. Forget the fact that I hate inpatient medicine, forget the fact that rounding on inpatients was by far the most boring and tedious part of my family medicine rotations, forget the fact that I have to drive 45 minutes each way to this outlying hospital... starting tomorrow, I am Dr. Couz... hospitalist. This has the potential to be exactly what I'm looking for, or a complete disaster. Only time will tell.

I am a medical whore.

Knowing Our Limits

So I am now the proud holder of a professional practice license. This means I'm allowed to practice medicine independently "in the areas of medicine in which Dr. Couz is educated and experienced". Or at least that's what it says on my license. My specialty of record is family medicine.

Since I still have a poorly-paid day job (emergency medicine resident), exercising my shiny new license will be confined to evenings and weekends. Moonlighting, as it's called in medical circles, means working extra shifts in addition to residency. In provinces that aren't Ontario (most of them, anyway) residents are granted limited licensure after second year, after which they are free to moonlight to make extra money. In Ontario, the only way to moonlight while still in residency is to do it like I did-- complete a residency in family medicine first, then do further training in a more specialized area.

Here's where things get sticky. Although I feel perfectly comfortable working at this point in a walk-in clinic or family doctor's office (short-term locums are a great way to make some serious cash during a week of vacation), I don't feel comfortable in the emergency room on my own. Seems obvious, considering I'm choosing to do an extra year of training in it. But since rural emergency rooms around these parts are fairly desperate for doctors, and since I have family members and inlaws in key positions at said hospital, and since I do have a considerable amount of debt to pay off... well, I can safely say that I'm feeling the pressure to start working from more than one source.

It's hard to say no. A 24 hour shift in a local 'rural' emergency room will mean $3000 in my pocket (or on my line of credit, more appropriately ). I can legally do so any time after July 1st. But ethically, I'm still hesitant.

I have already done one shift at the hospital in question, as a resident with an attending as back-up. A safety net, so to speak. And really... over that 24 hour shift, I was able to handle 98% of what came through the door. And with the exception of one case of a child with a traumatic closed head injury, I could have managed just fine on my own. But it's that nagging 'what if' that keeps me from committing to shifts.

There is actually a lot about practicing community emerg that is still unfamiliar-- no CT available, at any time. The x-ray techs go home at 5pm and need to be called in if there is an emergency. Ditto to the lab techs. I've never been in a position of having to decide if a patient needs bloodwork or imaging enough to call in the tech, or if it can safely wait until morning. It's a whole new ball game.

It actually scares me a little that freshly-minted family doctors are even allowed to do emerg shifts. I can only think of one friend of mine doing so whom I actually believe is up to the challenge-- but he started his residency in ortho, did ATLS and trauma rotations before switching programs, and was lucky enough to have a primary family medicine preceptor (the one you spend the bulk of your time with) who did a considerable amount of emerg shifts in a community ED. Although I appreciate the amount of obstetric experience I got through him, I can't help but wish I got a little more emerg. As it stands, in two years of family medicine residency all I got was two lousy months in the emergency room. My elective time was taken up by transfer credits from when I was a FRCP Emergency Medicine resident-- a month of anesthesia, a month of emergency psychiatry and two months of general surgery. All helpful and pertinent to EM, but actually EM experience probably would have been more helpful.

All that to say that even though I CAN run out and start doing shifts in local community ED's, I don't actually think I should be. I'd feel more comfortable working in a student health centre, or in some kind of walk-in clinic. The money is tempting, as is the experience, but if something came in that I couldn't handle and the patient suffered from my lack of experience I'd never be able to put it behind me. Not that I believe that I'll be able to handle anything that walks through the door with ease after my PGY-3 EM training is done, but I'll certainly be in a better position than I am now.

I'm scheduled to do ATLS this month, and my trauma rotation in August. Hopefully, I'll feel more confident afterwards.