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Published: September 15th 2007
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Reefton A&E Department
The A&E is not flash but it works for the community Finally, Abby, I found a second to describe a typical day at work as a rural GP locum. Apologies for the delay - hard to steal a moment to reflect what with all the nonstop fun and lifestyling over here…
The workday usually starts between 8 and 9 am with rounds at the hospital. Ours, like most rural hospitals, has long stay, acute care and palliative beds. The long stay and palliative patients are what you would expect. The acute beds are filled with whomever you admit. Our hospital lacks a lab, telemetry and radiology facilities, limiting the presentations we can manage. Typically we admit patients with pneumonia, CHF, uncontrolled diabetes, pain management issues and non-surgical internal medicine complaints. We can’t treat acute cardiac patients here. Soon we’ll be able to administer thrombolytics but we won’t likely manage MIs in our hospital without a change in the lab services. There are two doctors, myself and another locum, manning our surgery, sharing hospital responsibility weekly. Rounds can take a few minutes or over an hour, depending on how the night went. The hospital staff is knowledgeable and helpful, giving very professional care despite the technological limitaions.
The day starts in earnest at 9am, with patients booked in fifteen minute intervals. A morning and afternoon tea break is fiercely protected. It costs most patients up to $15.50 to see a doctor, so the complaints are rarely trivial. Patient presentations are no different from those at home - lots of cardiac issues, a significant number of injuries, the usual internal medicine problems, a smattering of mental health concerns. We see relatively few colds and flus, only rare gyne screening visits and almost no well babies. These presentations are managed by the nurses who are marvelous; they’re particularly good at triaging, manning the barricade effectively. Our patients are not demanding, happy to wait for an appointment and even willing to leave without a prescription if they’re told why they don’t need one. The locals are really lovely people, interested in their own health and mostly willing to change if it’s recommended. They let you into their lives and are very warm, generous with their experiences. They expect to have a very casual relationship with the doctor - while I still address most of them as Mr or Mrs, I’m Astrid to even the very young. Amazingly in such a small town, they respect boundaries, not asking about test results in the grocery store and only in the direst of circumstances calling or coming to the house.
Our clinic closes for two hours at noon - the first for a lunch break then an hour to catch up on paperwork from the morning. Usually there’s more than an hour of administration so while I was initially excited about this seeming indulgence, it’s not as decadent as it sounds.
The afternoon goes from 2 until 5. We typically see 22 patients daily, more if the hospital is busy or if any emergencies present. There is no doctor devoted to the A&E which means that we absorb these patients, tending to them between scheduled consults.
If you’re not on call, the day ends at 5 with no charts coming home. Everything is computerized using a program called MedTech - very usable with the convenient limitation that it has to be used on site. That means that for those of us who used to lug around paper charts, planning to write insurance and lawyers’ letters, that can’t be done. Instead you can go home to sample a local pinot while reading about what crime hasn’t been committed in the area and plan the next fun family activity.
A couple of days a week we attend satellite clinics in surrounding communities. There the facilities are even more basic, with a heater and a sink with no warm water being considered luxe. Attending at these clinics is very satisfying - you get to learn a lot about local issues and get a real appreciation for the rural lifestyle lived by so many with such grace.
One in three call, shared with the other doctor and a rural nurse working under standing orders, is a variable experience. Sometimes you’re in the ambulance multiple times in a day, but occasionally the pager is silent. I usually check the battery when that happens - it’s the exception. You’re on call for the ambulance, attending with volunteers to any urgent calls, and also for the hospital, managing inpatients and acute presentations. Most of the ambulance calls are for car accidents. Because the area we service is so large, by the time the ambulance gets to the scene people are usually relatively stable or dead. Mostly the injuries are minor or moderate, but having to call in a helicopter to transport more serious ones is not uncommon. While there’s telephone backup from the closest hospital an hour away, it’s rarely helpful because there’s limited cell phone coverage in the surrounding mountains from where most of the calls originate. The area hospital staff is helpful and willing to accept transfers. On the weekends the call doctor holds a walk in clinic in the afternoon for urgent care. This too is variable - sometimes you can be there for hours and sometimes only one or two people show up. People talk of The Clinic Where Nobody Came, but I think that’s an urban legend; hasn’t happened to me yet.
Overall, the experience is amazing. It’s far from easy and often incredibly stressful, but it’s an invaluable opportunity for professional growth that would be hard to get in a more familiar setting. Certainly having to trust clinical skills alone is scary, but it becomes normal fairly quickly. Initially the ambulance call was daunting but after the first couple of months I’ve even managed to sleep on the trip out to the scene. When people contact me to say they’re considering doing a similar stint I encourage them wholeheartedly. The only advice I would offer is to have ATLS and ACLS up to date, but to be prepared to ignore every protocol you’ve ever followed because very often you won’t have access to the same medications or tests or treatments, or your treatment will have to be rendered in a sheep paddock or an upturned car. It's fantastic.
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