I Just Really Need to Know...

So my job search continues. I am considering various communities both in Ontario and out. And as I spend more time in our local ED, I am considering those options even more carefully. In fact, even if I *am* offered a staff position upon completion of my training (4 months and 2 days to go!) I'm not sure I'd stay. Don't get me wrong... it would be nice not to have to move (again), and I can't even imagine the logistics of listing and selling a house with a baby and two large dogs. And Mr. Couz would keep his job, where he is rapidly accumulating seniority. And we wouldn't have to get accustomed to yet another community. And I am already familiar with how this hospital (and ED) works. And therein lies part of the problem.

As is the case in many hospitals across Canada, life isn't perfect here. We are a tertiary care centre... the trauma centre for the region, and the biggest hospital for an enormous catchment area. If it can't be handled by us, it goes to the Centre of the Universe. But we do have pretty much every specialty represented here, so really there isn't much that can't be managed by our hospital. In theory, anyway.

In reality we have MAJOR coverage issues. And this is a fact that is actually pretty well hidden from patients for the most part. On any given day (particularly during the summer months) we have sporadic coverage (at best) in plastics, ENT, maxillofacial surgery, neurology, infectious diseases, vascular surgery, and ophthalmology. This is understandably a problem, and has resulted in enormous waste of resources-- relatively minor problems being airlifted to other centres simply due to lack of coverage at worst, or at best a waste of significant amounts of the ER doc's time on the phone trying to convince someone... anyone... to see these patients. 

A recent case of acute angle closure glaucoma took 2 hours to arrange disposition... Criti-call first put us in touch with Ivory Tower Hospital (ironically, in the town the patient was actually from) who refused us because "your town is not in our area". Then we were sent to Not-so-Far Hospital, where the ophtho on call didn't have a YAG laser (required for definitive management). He suggested having the local police track down one of our town's local eye guys and bringing them in by force. Um, yeah. That will go over well. So in the end? Centre of the Universe took her. So 2 hours of wasted ED time during single coverage when the staff doc was stuck on the phone, begging various centres to manage this patient before he went permanently blind. PLUS the airlift transfer on top of that. 

But that's not even the worst of it. Even the various specialists on call are refusing consults. Few of them actually answer pages in a timely fashion. Those who do feel compelled to argue every attempt at getting them to see or admit patients. I understand not wanting to come in at all hours, but we're admitting the patient to your service, writing the holding orders and arranging all initial tests and treatments, and all you have to do is see them in the morning. What the hell is the problem? Surgery refuses to admit unless they have a documented surgical problem... makes sense, but if the diagnostic test that will confirm the existence of said problem isn't available until morning why take up an ED bed and resources in the meantime?

Another recent episode involved a patient who came in with a tendon laceration. It wasn't in the hand (and there was no plastics coverage anyway) so we called the ortho on call. It was causing significant problems with function (sorry for the vague-ness, but there's only so much I can change and still have the situation make sense) and was far too complicated for us to attempt repair in the ED. Ortho's response-- is the bone broken underneath? No? We don't do that, then. 

I would have accepted that had the orthopod not called back in 15 minutes saying that his next OR was cancelled so we could send the guy up for immediate intra-operative repair. Hm. But 15 minutes ago you "didn't do that"? Or just "didn't do that" unless there was nothing better to do?

Even the hospitalists have taken to arguing admissions. Admitting the guy for observation and serial troponins after an episode of cardiac-sounding chest pain in a low-risk patient? Call cardiology. But cardiology won't admit him unless he has ECG changes or a positive trop. So call hospitalist. See where this is going?

It's unbelievably frustrating. But I'm still at the (apparently) incredibly naive rookie stage where I think patient care should be everyone's ultimate goal. 

Tell me that it's not like this everywhere. Because THIS is the part of emergency medicine that I can imagine causing burnout in 5 years.