Adventures of a Hospitalist

Before I went on maternity leave, I was moonlighting (I moonlit?) at a community hospital. It's about an hour from the centre where I'm doing my emergency medicine training, and they had originally approached me about doing shifts in the emergency room. Just before I finished my family medicine training they arranged for me to work a buddy shift with the head of their emergency department (who also happens to be the head of the ED where I'm doing my residency) to test the waters. This community is clearly recruiting hard-core. I jumped at the opportunity. Like most community ED's, 99% of the stuff I saw during that 24 hour shift was routine. Belly pain, URTI's, broken bones, lacerations... nothing that made my heart race. 

It was the other 1% that made me reconsider. Without delving into details that might compromise confidentiality, a pediatric trauma came in. A pre-teen with a traumatic head injury who was awake and alert but confused and combative. He didn't end up intubated, but was eventually transferred by air to the closest centre with a pediatric neurosurgeon (none of the adult neurosurgeons were comfortable taking the case). It scared the crap out of me, and still would if I faced the same patient today.

So I decided not to moonlight in the ED while I was completing my residency training. Certainly not before I had completed my PALS and ATLS (both of which I'm scheduled to take over the next couple of months). The decision was not made lightly-- they were offering me $3K a shift (and now have upped the ante to $4K a shift). Money I could REALLY use right now. It's hard to say no.

But the hospitalist position was a perfect compromise. The hospital was desperate for coverage, and were hoping to lure me into signing with them when my training was done. The deal was sweet-- a spot on their Family Health Team, shifts in the ED, inpatient care (in the GP-run hospital), and some work in the nursing home attached to the hospital-- all of this for $500K a year. So doing the hospitalist gig occasionally would let me get familiar with the hospital and it's staff, and help me decide if I should commit to them or not.

Instead, I learned a lesson... nurses can make or break an entire hospital. 

Working in academic centres has been a mixed blessing when it comes to relationships with nurses. They are used to working with residents (and therefore having an MD in house all the time) and therefore may end up calling the resident for relatively minor issues simply because they're there and available. There are some truly phenomenal nurses that I've worked with that have probably forgotten more medicine than I know. And although I came across the odd bad apple, it seemed that in an academic environment the damage a lazy or incompetent nurse could do was mitigated by the fact that they often worked with other (better) nurses who could advise them and pick up the slack. I've complained about the occasional nurse in this blog before, but raved about good nurses far more than I've complained about them. And now I realize that I've been spoiled. 

Among the issues I've seen/experienced in my time at this hospital:

• Orders for tests being disregarded. Seriously. If I ordered a test, it's because I think it's needed. If you disagree, tell me. Or the doctor on call. But to simply not carry out the order? You have to be kidding me.
• Along the same lines-- if I am requesting accurate ins and outs on a patient with heart failure, DO THEM. Simply writing 'to bathroom' on the fluid output sheet isn't enough. I'm not asking you to cath them, just ask them to pee in the freaking hat. 
• Please don't come to me in a panic because your patient doesn't have breath sounds on the right. Not when it is CLEARLY documented in both the admission notes and progress notes that the patient had a right lobectomy 5 years ago and NEVER has breath sounds on the right. You only have 2-3 patients in your care and none of them are particularly acute... take a second to flip through your patient's chart. 
• If there are three nurses gathered at the nursing station gossiping and a patient's family member asks if he can have a glass of water, don't sigh loudly, roll your eyes and act like breaking up the gossip party is the biggest imposition in the world. 
• You know I'm only here to round. You know that every time I come in, the first thing I do is ask the nurses if there are any urgent issues with their patients. Please be ready to answer the question. I know you've been on for three hours by the time I come in.

Some of these are minor complaints, I know. Except for the 'disregarding orders' thing. But the bottom line is the fact that these nurses just don't seem to care. Maybe I'm being naive, but I can't imagine someone with a job as important as a nurse simply going to work and going through the motions. And not even all the motions, as they seem to pick and choose the duties that they deem necessary and do the bare minimum in order to keep their jobs. The nurse manager says that she's so inundated with complaints against the nurses (from both doctors and patients) that dealing with them has become the primary focus of her job. She is planning to quit. 

The experience made me realize that no amount of money in the world will make me work in this environment. And it's no wonder they've had so many problems keeping physicians. And it made me that much more hesitant to take any emerg shifts there-- not when I feel like I can't trust the nurses.

Memo to hospital administration-- there's more to physician recruitment and retention than throwing money at the problem. Who'da thunk it. 

Looking Ahead

Already I'm stressing in advance about my return to work. I'm going back earlier than I'd like, but that's influenced by two factors. One is money-- we need it. We don't have it. Mr. Couz doesn't make enough to keep our household afloat (thanks to my med school debt) on his own, and my union only tops up our unemployment to 70% for the first 5 months or so. 

God, I hear myself whining about this and have to laugh. I know in the US, only 6 weeks of maternity leave is protected and I also know that a LOT of people don't get any top-up at all. But I live in a world where literally everyone I know who has had a baby has taken the full year as protected by law. And many of them think I'm nuts for going back early. But there's more.

The CCFP-EM exam (my last licensing exam for emergency medicine) is in early September. I must be finished my program within 3 months of this exam in order to be eligible to write it this year. I can do that if I go back after 6 months of maternity leave. Which, since I went off when I was 38 weeks pregnant and The Bean was nearly 2 weeks late, means I'll be going back when he's just 5 months old. It feels too soon. 

But my program has been wonderful. Remember how they handled the trauma rotation from hell last summer? Well, they've stepped up to the plate once again. Not only have they decided that my second month of 'community ER' doesn't actually need to be done out of town, but they've made me a schedule as family-friendly as possible. So what do I have left?

1. Ortho/plastics: Sounds horrific, but it's a clinic-only rotation with normal people hours. And no call. I might even get a lunch break.

2. Anesthesia: I'll be working 7:30am until 3-4pm. With lots of down time. And no call. In the same hospital as my town's NICU, which will be helpful if I'm still pumping at that time. Gah. The things that guys don't have to worry about.

3. ER

4. ER

5. Elective: I'm planning a sports medicine elective here in town. Again, sweet hours. No call. If it doesn't work out, I'll just do an extra month of ER. 

6. ICU Sudbury: The only less-than-ideal part. Heavy call, long hours. I'm saving a week of vacation for this one. So hopefully missing what will essentially amount to 3 weeks of my son's life won't hurt either of us too much. 

7. ER

8. ER

Sigh. I'm already stressing about how on earth I'm going to handle balancing parenthood and residency. Not to mention studying. I haven't managed to fit that into mat leave very well so far, and it's only going to get worse. I think I'm going to have to learn to survive on very little sleep. 

I loved EM Physicians recent post about balance-- you can read it yourself here. It reminds me that if I push through this last 6 months I will eventually have enough control over my life to create my own balance. And a big part of why I chose emergency medicine was in order to have the freedom to live the parts of my life that have nothing to do with medicine.

Like my family.

Yet Another Identity Crisis

I've been at a bit of an impasse lately regarding the future of this blog. As you all know, I'm currently on maternity leave. Those of you who read this blog regularly are also aware that I vowed not to let this blog turn into a 'mommy' blog. The problem is, when you've spent three months at home, two of them with a baby, and haven't done anything relating to medicine in that time, it's more than a little difficult to find something to talk about that ISN'T mommy related.

The Bean is doing great. He's quite the little porker (tipping the scales at nearly 15 lbs at his 2 month well-baby visit) and is smiling, cooing, and has recently discovered that his hands are the tastiest things ever. He sleeps well at night (usually) and hates napping during the day. And much to my relief, I am very much in love with my little man. 

It took about a month for the hormones to stabilize and for me to start to feel halfway human again. My hemoglobin came back up to 107 in spite of my intolerance to supplements-- my prenatals did the job just fine without making me sick. The only lasting effects of my pregnancy is a dull ache in my left hip and being more out of shape than I've ever been in my life. I'm very much looking forward to spring when getting outside with the Bean and the furkids isn't quite so complicated a process. 

I started going back to my academic half days when the baby was 4 weeks old. Mr. Couz um... 'lovingly encouraged' me (read: booted me out of the house because I was driving him nuts) to head back. I've been going in an attempt to clear the cobwebs from my head. The emergency medicine exam is looming, and I'm not getting any smarter. Gah. So in the meantime, if I'm not a doctor right now, what am I? 

So here I am, getting my feet wet and blogging again. Much as I'm venturing slowly back into the world of medicine. This should be interesting.

In the meantime, here's a gratuitous Bean shot: