Knock, knock... who's there?

Who is staffing our emergency rooms these days? Around these parts, it's a hot topic. When I first moved to this town to start my residency training in emergency medicine, one of the teaching hospitals affiliated with the university had undergone a pretty dramatic upheaval. For some reason not fully understood, the hospital emergency room was being staffed by Med-Emerg, a medical staffing agency. Basically, they take over responsibility for staffing the emergency room. This was significant as it required pulling all residents out of this hospital, as Med-Emerg staff were not affiliated with the university and therefore not able to teach residents. Word around the Valium fountain in the Emergency Department was that they staffed ED's with fresh grads, most of whom didn't have any emerg training. Family doctors who got paid handsomely to drop in and staff a shift with no commitment to the hospital or the community. I'm not entirely sure why docs affiliated with this agency are instantly deemed inferior, but it definitely had an impact on the residency training in our academic centre. After the Med-Emerg one year contract with the hospital expired, the hospital was again staffed by university-affiliated staff docs. And now, residents are back in the ED there.

The Med-Emerg solution is costly, but probably better than the other alternative to EDs facing severe staffing shortages. Another ED in the region facing closure due to staff shortages managed to stay open by recruiting a CCFP-EM resident (a resident who has finished training in family medicine and is currently doing an additional year of training to specialize in emergency medicine) to cover its weekend shifts. This was widely reported in the news at the time, trumpeted as a 'partnership' between medical academia and the government to meed the regions needs.

Crazy. This wasn't a success! This was a clear failure of the system. The ED had to reach into the pool of medical trainees for staff-- while I'm impressed that the resident in question had the cojones to work without backup in a busy emergency department just two months after finishing her family medicine residency, I wouldn't have felt comfortable in that situation. Why would I be doing a third year in emergency medicine if I could just walk into an ED with nothing but my family medicine certification and an 'interest' in emergency medicine and work without concern?

This is likely to happen more and more often in a system where supply is clearly falling short of meeting demand. In Canada, there are 27 spots in FRCP Emergency Medicine each year. Twenty-seven. For ALL of CANADA. The year I matched there were about 75 applicants for these positions. Granted, these are the spots intended for academic positions in emergency medicine, but it still seems like a ridiculously small number. In the stream that I'm in, the CCFP-EM program, there are about 6 spots for each academic centre. In spite of that, there is still considerable competition for these training spots. So my point is that the lack of qualified staff to man emergency departments is certainly not from lack of interest on behalf of residents.

Now things seem to be going one step further. Out east, one politician believes that the solution lies in staffing emergency departments with nurse practitioners and paramedics. I'm not sure how, in the words of Kevin, M.D., NP + paramedic = ER doc. Paramedics are not trained in any way to diagnose disease. The paramedics scope of practice pretty much ends at assessment. Treatment is only given insofar as it fits into one of numerous protocols set forth by the BLS Manual. Advanced Care Paramedics do have an extended scope of practice, but again are not trained to diagnose disease. I do not understand the role that they are intended to play in replacing physicians at the helm of the emergency department.

I'm not putting doctors on a pedestal here. In fact, I've never really understood the difference between a primary care nurse practitioner and a primary care physician. Both may assess and examine the patient, both may order diagnostic tests, both may diagnose disease, both may prescribe and/or administer treatment. So if nurses can do all this, why have primary care physicians at all? What can they do that NP's can't?

My exposure to NP's has been restricted to academic centres. I've worked with them in the dialysis unit, in the NICU and in the PICU. Their role in those places seems to be similar to that of the Physician Assistant in the U.S. (we don't have PA's in Canada)-- but they work as members of a team, not independently from the physician. So you can understand my confusion when it comes to the role of NP's practicing independently in the community. I know this happens in remote places, but I've never had first-hand experience.

When I think about it, though, it's kind of frustrating for the primary care physician. NP's are trained in just 12 months (if they hold a university B.Sc.N) or 24 months (if they held a college nursing RN) according to this journal article. It's no wonder doctors are worried. Compare that to the university degree (4 years), medical school (4 years) and residency (2 years minimum) completed by a primary care physician and it's easy to understand why there might be resistance to declaring the two equivalent. If a NP can do a family doctor's job, why would a wanna-be family doctor bother doing medical school at all? Not when the same end may be accomplished with half the years of training and a fraction of the debt load.

Seems like a shortsighted solution to the physician staffing problem.

A model for change, or a dangerous precedent?

An Emergency Department in Florida has come up with an interesting way to curtail inappropriate use of the emergency: fees for non-emergent presentations. Remembering all of the times I had to bite my tongue to prevent myself from asking a patient "and what about your 3 month history of intermittent loose stools did you think constituted an EMERGENCY?", I have to applaud these kinds of initiatives. But I've also come to learn something important in practicing family medicine-- not everyone has the knowledge to differentiate the dangerous illnesses from the ones that are simply inconvenient.

Looking at it from the patient's point of view, it's a different story. Particularly things like abdominal pain, headache, bleeding of any kind... when all you can think of is the worst-case scenario, it's easy to get carried away. What if that headache is a brain aneurysm? And it bursts and kills me instantly because I didn't get it looked at immediately? What if my abdominal pain is a giant tumor, eating away at my insides? And a simple pill would have cured me completely, if only I had been seen in the emergency department?

Exaggerated, sure, but not by much. I've seen some crazy cases of ER abuse. Among my favorites: One frequent flier came in one afternoon with the chief complaint... "hungry". Apparently she became accustomed to the hospital meals that were passed around emerg to the patients. So when she got hungry, she came in. By ambulance, no less. Another favorite anecdote is the story of a healthy 32-year-old guy who came in with an interesting story-- apparently he had started a weightlifting program 2 months previous and wanted to see a doctor because his left tricep wasn't getting any bigger. I couldn't make this shit up if I tried.

But just when I had it bad, my husband started working shifts as a paramedic. Damn-- if I thought some of the stuff in the ER was an abuse of the system, I was shocked to hear about some of the calls that we don't see. The staff docs I've worked with assure me that you eventually become immune to it. We'll see.

Apparently, people are supposed to get charged for inappropriate use of an ambulance. In Ontario, people are charged for any use of an ambulance (I think it's about $100) but misuse of an ambulance is supposed to be charged about $350. I say 'supposed to' because it's just a rumour I've heard from a few paramedics. Apparently, there's some form that the emerg doc is supposed to fill out if the problem is clearly not emergent and they'll be charged the higher fee. Problem #1 with this situation is that no emerg doc I've ever spoken to has heard of this alleged form, let alone filled one out. Problem #2 is the fact that no one forces these people to cough up the money, whether it's $100 or $350. So more often than not, the bills go unpaid and the abuse of the system continues.

Although I think that this Florida hospital has the right idea, I fear that the fees charged would wind up in the same place that our 'ambulance fees' do... and nothing will ever change.

The Match, Redux

It happened. Again. But with a much better outcome.

So after the horror of the first match (see this blog's first three posts in August 2005 for details), I was understandably apprehensive this time around. As Novemeber 2nd approached, I had convinced myself that not only would I not match to my first choice, but I wouldn't match to any of the four programs where I had interviewed. In fact, I had already begun to think about where I'd like to set up my first locum... somewhere in the region between Sudbury and Sault St. Marie, in a Family Health Network that used electronic medical records-- preferably Mac based. I'd work in family medicine but pick up shifts in rural emergency rooms until I could either challenge the emergency medicine certification exam or apply for one of the re-entry positions later on in my career. I was clearly prepared for the worst.

Instead, I matched. Not only did I match, but I matched to my first choice program. The program with the residents that I liked, the program that was well put-together, the emergency room that saw a significant amount of volume, critical and trauma, the city with the reasonable cost-of-living and proximity to all of the outdoor pursuits that we love, and the proximity to my husband's family. Things couldn't have worked out better. My leap of faith, changing programs from emergency medicine to family medicine, paid off. Now I'll be finishing my family medicine residency in June, and will follow it up with my one-year emergency medicine fellowship which will qualify me to work in pretty much any emergency room in the province.

The only somewhat-sad part is that neither of my friends from medical school who were applying for the PGY-3 emergency medicine ended up at the same centre as I did. But I know for sure that at least one of them matched, so I'll be happy for them even though it would have been nice to train with either of them.

And as a nice perk, since I will have passed my family medicine board exams by that time, I can moonlight while completing my fellowship year. The debt will like that.

Life is good.

Overheard on a Night Shift...

Although we're not a trauma centre, we do get the occasional 'Homie Drop-Off'. This leads to exciting nights when someone's 'homies' decide to leave their injured buddy on the steps of our emergency department. Last week, we got a gunshot wound to the abdomen. It was a fairly small bullet, a .22 by the looks of it on x-ray, that ricocheted off his iliac crest, perforated his bowel and came to rest sungly against the opposite iliac crest. Small entrance wound, no exit wound.

Young, panicked thug lying on the gurney: "What's wrong with me doc?"

Staff Doc: "You got shot."

Thug: "What? Like, with a real bullet?"

Staff: "Yup."

Thug: "So how come I'm not dead?"

Staff: "Um... cause this isn't TV."

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Night shift is when you see the most interesting cases. As we're also the emergency psychiatry resource for the area, many of our interesting cases come in the form of overdoses and acutely psychotic patients. One that particuarly stands out was the 26-year-old 225lb man who came in dressed in a pink bunny suit waving a magic wand. Which would have been far more amusing had he actually been delusional and not a sexual predator of young children. Just in case you thought my job was ALL fun and games.

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Night shift is bad for the size of my ass. For some reason, the night shift means food. And lots of it. In the middle of the emergency room there is an island with a computer on it, used mostly for leaning on when things get slow. On a recent night shift, that island held 4 large bags of chips, one container of french onion chip dip, a giant caramel cheesecake that one nurse had made as a thank you to another, a large box of Timbits and a bag of chocolate-peanut-butter balls.

It made the cut up veggies I had brought to snack on look pretty pathetic.

Time Flies When You’re Having Fun

And nowhere is this more true than when I’m working in the emergency room. Unfortunately, my time is half done and I’m already dreading the return to ward medicine. Particularly when my next rotation is pediatrics.

That’s certainly not to say that my rotation has been without it’s low points. One of the doctors I’ve been assigned to work with frequently is a huge advocate of the ABC’s… or at least insofar as they stand for Airway, Breathing and Consult. He’s so quick to hand patients over to other services that I actually feel like I lose out on learning about patient management. When I’m on with this staff I can guarantee that anyone requiring a pelvic exam will be referred to gyne, anyone over the age of 75 will be referred to medicine and anyone complaining of low mood will end up in the hands of the Emergency Psychiatric Team. It definitely gets frustrating.

This may be a direct result of the fact that the hospital where I work has it’s emerg docs billing fee-for-service. Most of the other teaching hospitals in the area are on salary, which is intended to encourage teaching but discourage efficiency. Studies have shown that fee-for-service emergency rooms result in shorter wait times, and I can attest that there is no shortage of teaching at my hospital. In fact, when multiple residents are on shift at once, many of the emerg docs simply make themselves comfortable in the back and don’t see patients—they just review the patients with the residents and make suggestions regarding their treatment plans. We get more done, they bill more patients, people don’t wait as long… in short, everyone wins.

The biggest limiting factor to that approach, however, is that you have to be working with residents that you trust. Not always a given. Not everyone has the insight to know when they’re in over their head, or the guts to admit that they don’t know how to approach a particularly sticky problem. Not that I’ll be naming any names…

So apparently my dogs listen when I talk about work. I got home from my ER shift today to learn that my puppy has an infected eye that had been angry-looking and swollen shut all day. My wonderful spouse had already made a vet appointment.

The verdict? Anterior uveitis. You have to be kidding me. See picture below (two posts ago). Only in a dog-eye. Now since we're pretty sure my dog doesn't have ankylosing spondylitis (and I don't know enough about uveitis in dogs OR humans to really know what else causes it) we have no idea how it happened. She might have an allergy that set it off, she might have been exposed to something while we were at the Conservation Area yesterday, she might have had blunt trauma to the eye (possibly in the form of older dog's tooth while they were wrestling this morning)... who knows? But she definitely had cells and pus in the anterior chamber, she was markedly photophobic and her pupil was fixed and constricted. Lovely.

So as was the case with my patient last week (minus the stat opthalmology consult)... atropine drops q4h for 24 hours, then q8h, then q12h, then daily to keep the pupil dilated. Steroid ointment on the same schedule, but then twice daily for a grand total of EIGHT weeks. And the puppy is NOT impressed. But at least she won't be going blind in her left eye anytime soon. We hope.

So here's what anterior uveitis looks like in a 7-month-old puppy.


If life continues to imitate work I expect to be extracting a quarter from my dog's nose next week.

Some Things I Learn the Hard Way

For example, when the emerg psych nurses offer you Vicks VapoRub for your nose before entering the room to interview a suicidal homeless crack addict, don't put it directly in your nose. In fact, don't even put it under your nose. It's probably a much better idea to don a mask, coat the inside of the mask with the VapoRub and tell the patient you have a cold.

My eyes are still watering.

Defying the Laws of Nature

When my friends are on call and I'm in emerg, I feel less hesitant about asking them my stupid questions. Which is lucky for me, since I have many of them. The other night a friend of mine from med school was on call for general surgery, and was hanging around the ER after a consult. So I decided to bounce a case off him-- a kind of unofficial consult, as it were.

Dr. Couz: What are the chances that my 46-year-old female patient presenting with right upper quadrant pain and nausea is suffering from cholecystitis?

Surgery Resident: Pretty Good.

If she's had it before?

Even better.

If she was previously treated with a cholecystectomy for recurrent cholecystitis?

Um... well, it's still possible that she retained a stone.

And if she had a follow-up ERCP 3 months later for removal of a retained stone?

Hm. Pretty much nil.

Are you sure?

Yup. It's gotta be something else.

So, as per Murphy's Law, an hour later my patient's bloodwork comes back with elevated liver enzymes, including the one that serves as a somewhat specific marker for gall bladder obstruction.

Sigh.

Consult surgery.

This month's career-related goal and personal growth experience? Becoming comfortable with uncertainty and discharging patients without having any clue what the hell is wrong with them.

I Love my Job

And not just because the hospital is air conditioned while the rest of the world (including my house) is sweltering in the second straight week of temperatures in the mid-thirties coupled with smog and Humidex advisories. But that helps.

And as an aside, what is up with the freaking Humidex? If the Humidex makes it FEEL like it's 43 degrees, don't tell us that it's 34 degrees with a Humidex of 43... just tell us the bottom line. It's not like anyone walks around in a humidity-free bubble. It's like the windchill in the winter-- there's no point in reporting the temperature as -10 if the second you step outside a blast of icy wind makes it "feel like -20". If it FEELS like -20, it's -20! No?

Okay, I'm over it. But working 10 hour shifts nearly every day last week (they nicely gave me Wednesday off to attend my academic half day... and yes, I'm rolling my eyes as I say this) was much more tolerable when it was viewed as an escape from the heat. I need air conditioning in a big bad way.

Oddly enough, we haven't seen that many people come in with heat-related illness. In the past week, though, I've seen some interesting stuff. Although I have to admit, I feel somewhat sheepish posting about the 'interesting' stuff I've seen when I read Fingers and Tubes in Every Orifice, a kick-ass blog written by an emerg doc in the US. A regular shift for him sees more action than two weeks in this mid-sized Canadian town. On one hand, I'm envious-- I may go through an entire career without seeing a gunshot wound. But on the other hand, the constant adrenaline rush that comes from dealing with trauma must grow tiresome at best... lead to early burnout at worst. I don't know if I'd be able to cope.

So yes, I've managed one or two 'life or death' type situations. A woman came in with a ruptured thoracic aneurysm last week, just a few minutes before the end of my shift... I got to tube her, start her central line (my first one unassisted!) and more or less run the code under the watchful eye of the emerg attending. She died, but not before a daring vascular surgeon attempted an emergency thoracotomy in the middle of the ER, unwilling to wait the 10 minutes it would take to open up and staff another operating theater. She coded three times in the process before someone finally conceded defeat.

Most of the docs let me work pretty independently. Which is cool, because I'm gaining so much more confidence in my skills.With the exception of peds and neurology, both of which make me feel like a useless tit, I rarely feel like I'm in over my head. I've diagnosed a first-outbreak genital herpes in a middle-aged woman who had been treated (unsuccessfully) for a UTI and a yeast infection before she landed on our doorstep. I've seen an anterior uveitis in a young guy with ankylosing spondylitis, although it took quite a bit of fumbling with the slit lamp to do so. I've caught both a peritonsillar abscess and mono on nothing more than a hunch, and managed to catch a fractured shoulder that my staff missed on first pass. I'm not exactly saving lives, but I'm starting to feel like I might be able to eventually.

And on that note, the match website for the emergency medicine third year for family practice residents is up. Here we go again. My new match day is November 2nd. Wish me luck.

Finally!

So after one year of residency, half of which was in Emergency Medicine, I am finally in an actual emergency room full time.

I'm LOVING the shift work. Granted, the hours would be much sweeter if I didn't still have my academic half day and my family medicine clinic half day in addition to my emerg shifts, but I'm loving it none the less. I have an impressive talent for being able to fall asleep any time, any where. So it didn't take long to adjust.

The upside? Well, it's emerg. Nuf said. The downside? The hospital I've ended up at isn't the trauma centre for the region. Nor is it the cardiac cath centre. Or the stroke centre. Sigh. You can see where this is going. Calling it a glorified walk-in clinic isn't all that far from the truth. But it is the regional centre for... ready for it? Emergency Psychiatric Services. Thank God for that month I spent in Emerg Psych last year. At least I'm not completely unprepared.

The patient of the day came in the form of a 19-year-old boy brought into the ER by his father, who was requesting the services of the emergency psychiatric team. He was claiming that his son was apathetic, lacked focus and wasn't able to concentrate. Fair enough... these can all be early signs of clinical depression. When I actually interviewed the kid, however, he turned out to be the most pleasant and normal person I had encountered all day. His mood was good, he denied any suicidal ideation, and he joked with me throughout our conversation. He did admit to having trouble finishing projects... he found he just lost interest in them easily. He had also gotten into university for the fall, but it wasn't to his first choice school and he was seriously thinking of taking a year off to reevaluate his career goals. No signs of depression that I could see.

So I called in the father to join us. The father was quite distraught. I asked him straight out why he thought that his son needed a psych assessment. The father, in English heavily accented with an accent that may have originated in India (I'm not great with identifying accents) told me that their family owned a store. The father had been trying to get his son to work at the store, but all he did was sit behind the counter and watch television. He didn't want to go to university. He didn't work hard at school like his sister. He wanted to hang out with his friends and play video games. He argued with his parents. Obviously, concluded the father, his son was mentally ill. He had asked the family's doctor to provide a referral to a psychiatrist, but they were told there was a three month wait. So here they were.

It was difficult to stifle a giggle. I explained that the purpose of the emergency psychiatric team was to identify people who were at immediate risk for harming themselves or others. I assured him that I saw no signs of mental illness in his son, and that if he continued to have concerns he could see his family doctor for family counselling.

Obviously there was a cultural component here, but what was I supposed to diagnose this kid with? Teenage boy syndrome? Sigh.

Some Actual Tales from the Emergency Room

So after bitching about my first shift in the community emergency room, I should be fair and rave about my subsequent three shifts. I spent two full 10 hour shifts in the emergency room since my preceptor had headed down to Windsor for the OMA hockey tournament. Ontario was a bad place to be sick last week... all the docs were in Windsor. Then I spent an additional afternoon in the ER which I'll be continuing to do on a weekly basis until the end of my family medicine rotation.

Small town emergency room? Not so much. This place was crazier than any academic centre I had ever worked in. With the possible exception of the Royal Alex in Edmonton, which is located smack in the middle of the seediest part of town and where the safest rule of thumb is to assume your patient is an alcoholic/addict until proven otherwise. Had I followed this rule of thumb I would have prevented one of my patients from going into DT's (alcohol withdrawl seizures) just seconds after I had nicely reduced his dislocated shoulder, promptly dislocating it again. But I'm getting a little tangential...

So here's a quick sampling of the good, the bad, and the completely bizarre that I was privy to over the course of 2 and a half shifts in my sleepy, small-town emergency room.

• 5 CVA's in 5 hours. Holy crap. I am now well-versed in the criteria for clotbusters.
• One child with the worst case of chicken pox I'd ever seen. She was admitted with varicella pneumonia, a complication of chicken pox. Poor kid. Someone should have taken her picture to show all of the parents who think having chicken pox is a natural part of childhood.
• An elderly guy who came in two days post-MVC with some impressive hematomas. The bags under his eyes were filled with blood, and looked like two purple testicles hanging off his face. Even more impressive was the hematoma on his head, which although it wasn't bruised, probably measured a good 15cm in length and protruded about 3cm from his head. A few days later he came in again-- the hematomas under his eyes had receeded, leaving nothing but bruising, but the scalp hematoma was unchanged. So I got to drain it. So... cool...
• Two cases of cellulitis secondary to IV drug use. I got to cut them open, debride them and pack them. Further confirmation that most doctors are the same kids who used to pick at scabs incessantly.
• A guy who came in with a 1L pop bottle stuck in his ass. The outline was plainly visible on x-ray. That wasn't even the best part... a hooker put it there, and he was desperate that his wife not find out about it. Consult surgery!!!
• A case of what was most likely THC-induced gastroenteritis. (I've been seeing a lot of young men with abdominal pain lasting 2-4 weeks, intermittent vomiting, some weight loss but no change in bowel habits (no bloody diarrhea, in particular). The one thing that they all had in common was that they smoked pot regularly. Normal bloodwork, normal abdo ultrasound... resolves if they lay off the pot. Diagnosis of exclusion, sure, but it seems to fit the bill.)
• A 35-year-old tall, thin guy with severe chest pain that radiated through to his back. If you work in any health-related field, you're probably thinking what we did. And it was. Marfan's syndrome! Chest pain! Dissecting aortic aneurysm! Holy crap! Confirmed by CT within minutes of his arrival, but was left hanging around in resus for nearly 4 hours as CritiCall desperately tried to find a centre with an available cardiothoracic surgeon and an ICU bed that could take this guy. Three 'no room at the inn' responses later, he was on his way to the nearest American centre. And our tax dollars paid for it. Sometimes, our health care system just sucks. But the whole thing was cool to see anyway.
• More 'rule out MI' than I care to think about. Ironically, though, the only person who was actually having an acute MI was the woman who sat quietly in the waiting room whose chief complaint was 'funny feeling'.
• Four nosebleeds, one in a guy with an INR of 7.2. He apparently thought that after he was stabilized on coumadin, he didn't need to monitor his INR anymore. I became very efficient at the use of Merocel (basically, nose tampons).
• A woman who was 2 weeks postpartum with calf pain. Sure enough, big honking DVT. Ouch.
• A 'found unresponsive' who never actually became responsive. After some creative detective work and the shotgun approach to the tox screen, it was ruled a TCA overdose.
• No really cool procedures, but I got three ABG's on my first try. Hey, those count too!

Sigh. I've REALLY missed emerg. I can't believe that for a minute there I was actually doubting my resolve to do that third year of training. Family medicine is good and all, but nothing makes time go by faster than the emergency room.

Back in the Saddle Again

So I've been spending some time (quite a bit of time) back where I belong. Or at least, where I thought I belonged. Not in an academic centre, but in a community emergency room-- the same community where I have been practicing family medicine for three months. A surprisingly busy community emergency room.

My first shift was less than stellar, however. My preceptor had nicely written the emerg docs a letter of introduction. I would like to introduce my resident, blah, blah, very competent, blah, blah, good technical skills, suturing in particular, blah, blah, please be nice to her. And the morning that I was to start in the emerg, he was even nice enough to go over and remind the doctor on dury that I was coming by to work that day. Apparently, the emerg doc wasn't really listening.

When I got there he nodded curtly and gestured for me to follow him into the patient's room. So I did. And listened patiently while he assessed her. When we emerged, he started the inevitable pimping.

"How do you diagnose the patient?"

I HATE the 'guess what I'm thinking' game. What is he asking me? Does he want me to explain what I'm looking for? What tests I should order? What my differential diagnosis is? What I had for breakfast this morning?

"What do you mean?" I ask.

"Through the HISTORY and PHYSICAL, of course!!!"

Um, sure. I thought he was referring to some revolutionary test he had recently invented to decipher 'weak and dizzy old lady' into a concrete diagnosis and treatment plan. Apparently not. So then he proceded to sit me down and write out exactly what the components of a good history and physical were. I had been pretty quiet until now, but I decided to speak up.

"Sir? I *have* done this before." I said jokingly.

Apparently, the wrong thing to say. He looked up at me, clearly offended.

"I am TRYING to teach you something here. This is the sort of thing that will be on your EXAMS."

Alrighty then. So I sat, quietly and patiently, while he explained how to take a history and physical. Then, how to palpate an abdomen. Then he decided to teach me an approach to reading ECG's. He told me how to assess a headache. He asked me what the ABC's of trauma were. He also continued to pimp me, asking me random questions about appendicits, long Q-T syndrome and the administration of TPA in stroke. So I answered his questions. For six hours, I followed the attending around like a big dumb sheep.

Finally, just before shift change, he was assessing a woman with abdominal pain and asked me what was the first thing I needed to know. Easy one.

"I'd want to know whether or not she was pregnant."

"Right," he replied, "and why is that?"

"Because I'd need to rule out an ectopic."

He stopped. And eyed me suspiciously.

"Have you done much emerg yet?"

Confused by his question, I started to babble. "Well, not since I was a clerk. See, I started off in the FRCP program, but then I switched to family medicine, but I never actually DID any emerg shifts as a resident, but I..."

He cut me off. "You're a first year RESIDENT?" he asked, incredulously. "I thought you were a first year MEDICAL STUDENT."

Um, thanks. You don't think it's odd that I know about long Q-T syndrome as a first year medical student, but knowing about freaking ectopic pregnancy tips you off? Not to mention the nametag I'm wearing that clearly identifies me as DR. Couz, Medical Resident? Or the fact that my preceptor introduced me to you TWICE??? Apparently, I am clearly the world's brightest and most knowledgeable first year medical student.

Somehow, this misunderstanding was my fault.

"If I had KNOWN you were a resident... well, you should have been writing ORDERS! You should be formulating TREATMENT PLANS!"

No kidding. Sigh.

Thankfully, I don't think I'm working with this bonehead again.

It's Official... I've Defected.

There aren't many people out there likely to find this even half as big a deal as it feels like to me. But I've changed programs.

I am no longer an emergency medicine resident. Well, not really. I am now a family medicine resident. But since I have every intention of doing a third year of emergency medicine training when I am done my two years of family, I've really just gone from being an emerg doc in five years to being one in three.

Considering that it's a pretty minor switch, in the grand scheme of things, it's awfully symbolic. I've had it with academia. I have no patience for the egos or the politics. I just want to get out of the city and practice medicine. Not medicine with research and administration, just medicine. See, the five year program approaches emergency medicine as a four-headed being-- clinical medicine, administration, research and teaching. In spite of my best efforts, I could never warm up to administration. And I did make an effort... the sole reason I became a union rep was to see if there wasn't more to administration that I wasn't seeing. Now I'm locked into an elected position that bores the crap out of me for the rest of the year. So much for administration.

Research? Well, everyone assumed that since I'd done a very research-oriented master's degree before medical school that I'd take to it like a duck to water. Instead, I'm left with a very PTSD kind of thing. I realized it a few months back when I was assisting in a c-section, and the obstetrician was talking about her latest grant application. I got a viceral reaction... immediate nausea. I hate applying for money, I hate the literature searches, I hate the way you have no control over the pace of your work, I hate the pressure to publish... I hate all of it. Not good when you're expected to go into academic practice.

So I started to think about it. What kind of practice do I see myself having in 10 years? Easy. I want to practice emergency medicine in a smallish town (think Milton, Peterborough, Kingston, Orillia, Barrie, Sudbury). No research. I don't want to run the ER. I might like to continue teaching informally, like by supervising residents, but not by teaching at a university. So then I came to the realization... what the hell am I doing in the academic stream?

The 2+1 program (one year of emergency medicine after two years of family medicine) is far better suited to what I want to do. I can work in all but the biggest academic centres (even the place I'm at now has as many 2+1's working in their ER's as 5-year grads). I won't be under constant pressure to do research. I won't have to take on an administrative role that I don't want. And best of all, if I ever get burnt out (like everyone says I will... it's apparently inevitable) I can do locums or work in a walk-in clinic, which is far more appealing to me than doing research or administration full-time.

So it's done. Once I had made the decision, all that was left was going through the paperwork and telling people. That was the worst part. I was so tied up in knots over telling my program director that I didn't eat for two days. The past month has been a flurry of meetings, wheelings and dealings. I've been back and forth between the department of family medicine, the department of emergency medicine and the postgraduate education office more times than I care to think about. But now, all there is left is to submit the paperwork and have it rubber-stamped, all of which is out of my hands.

I change programs on January 1st, 2006. Hopefully this knot in my stomach will have subsided by then.

Decisions, decisions.

My medical school was a four year program-- two of the programs in Canada are squished into three. If I thought that my friends and I were forced into choosing a specialty ridiculously early, I can't imagine how the people in the three year programs do it. By the end of second year, it was already all we thought about. My two best friends were already committed to their specialties-- one was going into pediatrics, and the other into psychiatry. Since they were among the top students in the class (I was nowhere close, but comfortably sitting around the middle) they didn't have to worry about getting a spot. Of course they both did anyway, but that's the nature of the super-competitive medical school mentality... it doesn't matter how good you are, there's always that underlying fear that you're not good ENOUGH.

My first interest was plastic surgery. Not the boob-job-tummy-tuck kind of surgeon, but the kind that puts people together after horrible disfiguring accidents. I loved surgery, and I loved the variety of stuff I saw. Most of all, though, I loved that it was more careful than other surgical specialties. And you really saw the results of what you did. Most of all, though, it was cool.

There were definitely a few drawbacks to opting for plastic surgery. First and formost, it's a bloody hard specialty to match into. There are all of about 8 spots in all of Canada. You have to be the best of the best to match into it, and I definitely wasn't. I didn't have the inclination or the patience to do what was needed to secure one of those spots-- I had no urge to put in the crazy surgery hours (easily 6am-7pm on a regular day), was no good at sucking up to the 'right' people, and had too many interests outside of medicine that I had no intention of giving up. There were other things to consider too-- the surgical lifestyle, for one. It's brutal. At least it certainly is during residency, which could be anywhere from 5 to 7 years. Are you kidding me? I was late to start medical school to start with, and now I could be delaying the start of my life until I'm pushing 40? Not freaking likely. And don't even get me started on what that could mean if my biological clock ever finally kicked in...

Thankfully, that was at about the same time as I did my clerkship rotation in emergency medicine. It seemed the best of all worlds, and combined everything I loved about medicine. I got to do procedures (enough to satisfy the 'working with my hands' aspect that surgery gave me without having to endure the marathon enduro-surgeries that some of the reconstructive ones seemed to be). I got to see the variety I was craving. The pace was fast enough that I was always able to get through a shift without looking at my watch. I got along well with other emergency medicine residents and staff... they were 'my kind of people'-- friendly, outgoing, usually athletic and always with a short attention span. I felt very 'at home' in the ER environment. And I was equally interested in the sore throats and sprained ankles as I was in the heart attacks and trauma. Best of all, it was a lifestyle I could live with.

But the decisions didn't stop there. In Canada, there are two roads to working in the emergency room. The shortest and most common is to do family medicine. After a 2 year family medicine residency (of CCFP, for the Canadian Council of Family Physicians) you are free to work shifts in emergency medicine in most smaller centres in the country. If you want to be more specialized, you can add a third year onto that residency to concentrate on emergency medicine. With the 2+1 option (aka CCFP-EM) you're equipped to work in almost any emergency room in Canada. Even most of the ones in big cities like Toronto and Vancouver are staffed largely by CCFP-EM's. The second path is through the FRCP program (Fellow of the Royal College of Physicians). The FRCP program is a five year program that is meant for physicians who want to specialize in emergency medicine and work in an academic setting. This will usually combine emergency medicine with teaching, research and administration. For some reason that I continue to question to this day, I chose the latter.