Curbside Consult with Dr. Jayne 6/11/18

I’ve been doing a bit of locum tenens work lately. It’s always interesting because it exposes you to not only new people, but different healthcare technologies. It also tends to invigorate my consultant brain, as I am exposed to all kinds of people and situations.

This particular assignment was a veritable cornucopia of adventure. I was looking forward to it, because the rural emergency department I signed up to staff has an EHR system I’ve not used before. It’s always good to see whether the grass is really greener on the other side of the fence or not, but in this case it was hard to tell whether there was going to be grass there at all.

Typically, my locum agency will send me some introductory training material or links to online training if the facility has a system that I haven’t worked with before. That lets me get up to speed before I have a crash course with a super user at the site once I arrive. Depending on the contract, the facility might allow a couple of hours for training or maybe even a half day. Facilities that have scribes may not include training time, but I think that’s a bad idea since the physician still needs to be able to use the EHR in at least a rudimentary fashion. Generally, I avoid those kinds of postings, because if the facility is too cheap to include a couple of hours for training, it’s probably going to be painful in other ways.

My agency said the hospital never sent any materials despite having been asked for it several times. They didn’t even provide a version number for the software so I could do a little research on my own. Without it being clear what product was in use, I didn’t want to waste time trying to scrounge up materials, since that’s a challenge in itself because vendors don’t exactly broadcast their workflows on their websites. Not to mention that even the most straightforward product can be customized to the point of being nonfunctional. I decided to just see how it went when I got there.

I arrived in town over the weekend because I wanted to be able to check out the area, stock up on groceries, and figure out my non-work plans for the engagement. In smaller towns, the lodging facilities vary greatly and it’s worth spending a couple of hours figuring out if you’re going to be able to stock in a week’s worth provisions, whether you can cook, or whether you’re going to be working with a dorm-sized refrigerator and a sketchy toaster oven. This was one of the better assignments, with a hospital-owned apartment that they use to house locums and visiting subspecialists from a children’s hospital that sends out subspecialists a couple of days a month. I knew I’d have the place to myself the first week for my 24-on, 24-off adventure.

People always ask how I handle those long shifts, and in a rural emergency department it’s not that big of a deal since there’s not a steadily high volume of traffic. It’s possible to nap during the day and often to get at least four hours of uninterrupted sleep overnight. However, when it’s busy, it can be scary-busy since you’re the only show in town and some of the cases are challenging – patients having strokes when the nearest stroke center is hours away, patients having heart attacks, and patients with major trauma.

Often in the smaller facilities, attending physicians come into the emergency department to work up their patients, which is great as far as feeling like you have backup along with generating a sense of belonging. People also tend to do double-duty at times, such as seeing pediatric patients when they’re not a pediatric subspecialist or covering subspecialty areas that are bit outside what their specialist colleagues would practice in a larger city. I learned this all too well a bit later in the engagement.

The first day of work was uneventful, with me getting my badge, signing paperwork, having a four-hour block of training with a super-user, and then working 10 hours in the emergency department as a “training shift” with one of the full-time emergency physicians. The patient mix was pretty routine, with asthma exacerbations, pneumonia, a motor vehicle collision, some stitches, and a broken arm following toddler vs. trampoline. They were handled the same way I’d handle them in the urgent care at home, and patients didn’t mind my slowness as I documented in the room with them. I went home, ready to hit the sack and return the next morning for my first solo shift.

The next morning was pretty slow as far as emergency patients, although I was called to the medical / surgical floor a couple of times to assess patients who were having issues and there was going to be a delay in their own physician being able to get there. Most of the physicians work out of an office suite that is attached to the hospital, so it’s not a frequent problem during the day unless the attending physician has a day off without close coverage. It was kind of fun feeling like a resident again, when we could be called to see a patient on any floor for any issue, although I was much more comfortable reliving those non-glorious years in a sparsely-populated 60-bed hospital as opposed to the 600+ bed hospital of my residency days.

When I got back to my cubby after one of those sojourns, I found a printed email and packet of documents from the ED nurse. Apparently there had been an EHR upgrade over the weekend and they were just sending out the vendor’s release notes – three full days after the upgrade. This was a new one for me since I’m used to being on the other side of the equation, translating the vendor release notes into an actionable document for my end users. Maybe the unmentioned upgrade was the reason they wouldn’t send over any documentation or training materials prior to my arrival.

This particular document was not only less than timely, but included documentation of features that clinical users normally don’t see, like the charge master setup screens, along with features that the hospital didn’t even have live, such as patient portal statements and payments. Did I mention the document was 24 pages long, in spreadsheet format, and printed landscape with items wrapping from page to page? It’s unlikely that physicians are going to sit and read that, not to mention the level of distraction with irrelevant features.

The only pieces that were important to me were the fact that a medication database update was installed as was a formulary update, and those were both summarized in the email. The rest of the features were specific to other disciplines, but it was fun to see what other vendors do as far as documentation. Pro tip: less is more.

Mid-week, I was invited to attend a medical staff meeting, which seemed like a great chance to meet other physicians as well as to score a dinner I didn’t have to cook myself or eat at a local restaurant where everyone else knows each other. In reality, it was a prime opportunity to see the kind of turf war I hadn’t seen in years.

In a large city, people are always competing for business and insurance is always changing, so when patients move around, it’s not a big deal. In a small community, though, where there may only be two physicians in a given subspecialty, “poaching” may be taken as a personal affront. There are complex unwritten rules about non-solicitation of patients, even after physicians cross-cover each other’s patients, and apparently someone had stepped out of line. I thought it was going to come to blows, but the president of the medical staff did a great job disarming them. Although he is young and the squabbling physicians were his senior in several ways, he used some great de-escalation skills and leveraged other leaders in the room to calm the situation. It was like being in a role play for management training.

Over the first weekend, I had my first “pack and ship” experience, which basically means the patient is critically ill and needs to go to a facility with more capabilities, either by ambulance or by air. The facility had a great checklist and the nurses were outstanding, making all the phone calls and getting the paperwork ready while all I had to worry about was the patient. In situations like this, the first thing the physician should do is check his or her own pulse. At moments I did have to remind myself to breathe, but in less than an hour, the patient was on his way to a higher level of care. I’ve spent more time on the receiving end of those cases and have seen people at the tertiary care center belittle the work that’s done at smaller hospitals, but I have to say my team was first rate.

The second week was largely uneventful, with a steady flow of respiratory problems, orthopedic injuries, and minor trauma. The one thing I noticed was that during the time I had been there, the patients were much sicker than I saw at home and often had been referred in by their physician, who called ahead for them rather than just having patients show up. The primary physicians and orthopedic doctor in this community tended to see many walk-in patients every day and patients were happy to wait in line to be seen where they were known, rather than roll to the emergency room first. You knew when they sent someone over that they needed help – patients weren’t just coming out of convenience or lack of being able to be seen elsewhere. I had expected to see more minor sick cases since there isn’t an urgent care or retail clinic anywhere around, but it just didn’t turn out that way since they were being seen at the office.

The uneventful nature of the week came to a screeching halt, though, during the overnight portion of my second-to-last shift. I was napping in the ED call room when one of the nurses threw open the door and flipped on the light switch. Since they would never normally do that (these were nurses that apologized profusely when they had to wake you), I knew something was up. She threw me a set of shoe covers and said, “We have to go to the OR.” I knew something was up. We headed to the operating suite, where an emergency C-section was about to take place.

Long story short and intentionally left vague, I was asked to pinch-hit for a provider who was called in but couldn’t make it to the hospital. In a case like this, I suppose a family medicine doc turned ED locum tenens is better than no one when you need multiple licensed physicians in the room and lives are possibly at stake. It’s amazing how your reptilian residency brain kicks in. I started to scrub while thinking through what might happen next. My ears caught up to my brain as the staff told me which providers were already in the room and who was on the way — they only wanted me there as a precaution. I must have missed that on the way over and was glad to hear it, but still on an adrenaline rush.

I was gowned and ready, but mom and baby were stable. I got to stand there with a surgical towel over my hands, watching a midwife and a physician assistant give directions and prepare the patient until the rest of the team was in place. You can bet that my pulse slowed considerably at that moment. I was ready to head back to the ED once everyone was scrubbed in, but they asked me to stay just in case they ended up needing an extra set of hands with the baby.

As much as health IT has evolved, C-sections haven’t changed much in the decade since I last saw one, and we’re still using the Apgar score after 66 years. I did wind up helping a bit and was still hopped up on adrenaline when I made it back to the ED, so I stayed up chatting with the night nurse. Apparently, similar situations happen more often than you’d think, with weather being a challenge during the winter as well as the chance of two patients needing to unexpectedly go to surgery at the same time. Many medical leaders have the luxury of not thinking about that kind of scenario, but it was a good reminder of the fragile system of care that many Americans live with every day.

My last shift in the ED brought a cake, a couple of jars of homemade pickles and jelly to take home, and a goofy picture of me with one of the nurses at the local sale barn after I had just stepped in something less than floral but decidedly fresh. Overall, it was a great experience, and I hope they request me the next time they need a locum. At least then I’ll know what EHR to expect and I’ll remember to bring an old pair of boots.

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