Being a patient advocate

My elective in London (Ontario) finished on Friday, and I have to say that it wasn't great, but it wasn't bad either. London itself is a fairly quiet city; it reminds me very much of a smaller version of Edmonton. There isn't much to do, and the transit system isn't that great. That being said, if I were to move here, it's not like I would be doing much except going to the comic book store (which is amazing, may I add), eat out, and see the occasional movie, since I'm not exactly a social butterfly. And the transit wouldn't be much of an issue, since I would bring my car over and drive around.

In terms of my actual experience in hospital, I'm a little torn on how things went. My patient experiences were amazing, but I unfortunately found myself struggling every day to make sure they were taken care of at the standard of care that I felt they deserved. Since I don't want to say too much on such a public forum, I'll limit my comments to the fact that I think it's unfortunate that our system is so focused on the short-term rather than the long-term goals of the patients.

Although there were several examples of this during my time in London, one case comes particularly to mind, mainly because I fought so hard to have my patient stay in hospital. This lady came in because she had a one day history of fainting episodes. On examination and on checking her labs, it became quite clear that she was dehydrated and also had acute renal failure.

Looking further into her history, it became apparent there was more to her story than this one visit; over the last four months, she had been in hospital more often than she had stayed at home because of heart attacks, bowel surgery, and just a general sense that she was not coping well. She had in fact lost 50 pounds over this time period, and I was quite concerned. We could easily hydrate her with IV fluids and send her back home; but chances are, if we did that, she would be back again.

I had quite an argument with my team about this; my senior said that everything had been done in the past to find out the reason for her weight loss (and accompanying nausea), and there was no need to keep her in any longer than necessary. On the other hand, I was arguing that something had to be done given that we hadn't fixed the problem, just the effect of it all.

In the end, there was a compromise: my patient ended up staying in hospital longer than intended because her family 'refused' to take her back (that's a trick I learned, btw. If you think your family member should get further investigated, but the team wants to boot him/her, refuse to take them back, and then it'll buy that person some more time in hospital). We're going to try and get her into a clinic to get some further investigations and stabilize her with a feeding tube for now. However, I have a feeling that now that I'm not around, she'll be discharged pretty quickly from hospital, but at least I feel better about her situation.

The patient herself was also quite appreciative towards me, and she told me that if I'm ever back in London, to give her a call, and she'll have me over for dinner with her family.

This elective has actually made me realize that patients are quite astute when you're trying to look out for their best interests. There were many times over these past two weeks where I've had to argue for certain things to be done for my patients; and by the time I finished on Friday and said bye to them, I was surprised how many of them thanked me for what I had done. It's nice to know that I actually made an impression on some of these people!

In summary:

- London is a small city and very similar to Edmonton; which is fine, considering all I'd probably do is see the occasional movie, go to the comic book store, and go out to eat once in a while

- My actual experience was mixed. I had several frustrations with the system, but in the end, I think it was worth it because of the meaningful patient encounters that I had

- One patient that particularly sticks in my mind is one who had come to hospital on numerous occasions because of her medical issues and significant weight loss. I had to fight for her to stay in hospital a bit longer to get further investigations; and I have a feeling that now I'm gone, she'll be discharged soon. But at least I bought her some time to get a bit more testing, and she was quite appreciative of my efforts.

- Back to Edmonton I go now that this elective is at an end!

Milk bags = disaster

It's been a hectic week in London ON, but I'll go over my ward experiences later. I just thought I'd tell my rather embarrassing/amusing story about milk bags.

For those of you that don't know (since I didn't know they existed), milk bags are 4 L bags of milk that come in 3 smaller bags. They're supposed to be easy to use and cheaper than buying milk cartons/jugs. All you do is pour the milk into a jug, and voila! Use the milk to your heart's content. Sounds simple enough, right? Well, not if you're me...

The person who was staying here before me bought a 4L milk bag and never ended up using it, so the couple I'm staying with told me to use it since they don't drink milk. I was pretty happy with that, thinking I'd save myelf a few bucks. I had never seen a milk bag before, so I didn't know you needed a milk jug for the milk once you opened it.

As I'm sure you can imagine, bag #1 didn't last very long: as soon as I opened the bag, I realized that I had no way of keeping the milk in the bag after I poured my glass of milk. So, after I very messily poured that glass, that bag went down the sink...

It was at that point where I went on the internet and realized I would need to buy a jug to store the milk...so I did that and proceeded onto bag #2. I cut a hole in the corner of that bag and poured it into the jug....I made quite a mess, but at least I managed to get most of the milk; and after that, things went more or less smoothly for that bag.

It ends there, right? Nope. For bag #3, I thought I would be 'smart' (note the quotations) and to save myself from making a mess and losing all of my milk, I decided to put the bag INTO the jug, puncture a hole on the bottom, and let it drain. That started off well; but in my brilliance, I decided it was going too slowly, so tried to make a bigger opening. I was a little too aggressive at doing that, and SPLOOSH, the milk flew into the air, onto my clothes, and onto the floor. After cleaning the mess, I still salvaged most of the milk...only to find the next day that it was expired.

I shall never use a milk bag again...

Physical medicine & rehab and Vancouver

I'm currently in the middle of a 4-week elective block, where I spent the first two weeks in Vancouver, and now I spend the remaining two weeks in London, Ontario.

My time in Vancouver was spent at the G.F. Strong centre, in physical medicine and rehabilitation (PMR). I had initially gone there to see how the Vancouver hospitals are run and to potentially get a reference letter, but my latter goal changed on day one when I realized that although PMR is listed under Internal Medicine, it really isn't a subspecialty. As soon as I started, my preceptor started questioning me about neurology, and I very soon realized that I was quite out of my league in trying to impress!

While that may sound bad, I'm not too desperate in getting reference letters at this point, so I used the rest of this rotation to hone my neurological exam skills (which had admittedly been pretty poor before I started this elective). I also got the chance to speak to some of the residents about the programs in Vancouver, so it wasn't a total loss either from the perspective of residency program searching.

The patient population in physical med and rehab is unique in that they deal with a lot of stroke patients who do not always recognize that there is something wrong with them because of the nature of their brain injuries. Others were perfectly healthy prior but ended up paralyzing themselves secondary to a sports injury. All had a common theme of being extremely complex cases, and I was impressed with how well the doctors could manage the patients.

Multidisciplinary medicine is usually somewhat half-assed on the wards, but in the case of PMR, it was absolutely essential, given how many issues each patient had and how long most of them had to stay in the centre (a 'short' stay was 1-2 months instead of a couple of days). Each of these patients, although stable, still were often quite dependent on others to get their activities of daily living accomplished, and the goal of rehab was to allow them to become as independent as possible in spite of their injuries. I attended several family meetings, witnessed patient meetings in regard to driving for paraplegics (I never knew before that you could set up hand controls to let them drive!), and even got the opportunity to try joint injections on practice models.

The doctors were also great, in that they were patient with me in spite of my obvious lack of knowledge. I also appreciated how they would actually watch me perform my physical exam skills and provide suggestions for improvement. Although I'll never become a neurologist, at least I won't be completely embarrassed with reporting my findings if I need to refer to one.

I also felt more independent, as I wasn't required to report to someone every few hours, and could leave whenever I felt like it without feeling like I was shirking my responsibilities (although some days I left early because I felt like enjoying the weather).

The nice thing about the elective was that I also had a lot of free time in the evening, which was ideal since I was visiting a friend. While there were a few questionable moments (*cough* watching the House Bunny - which, despite my MSN name that someone surreptitiously changed, does NOT rock :P; losing my bank card; eating at an asian fusion place which refused to serve its lunch menu at lunch and did not have any sushi available even though it was on the menu; and almost getting my credit card broken!), all in all, I had a good time. We spent a lot of the evenings trying various restaurants in Vancouver and ended up going to the Seattle outlet stores, Richmond night market, and a store called Daiso ($2 for pretty much any item imaginable, including urine bags that solidified the urine!).

There were other moments that I rather enjoyed, including celebrating my friend's 25th birthday, having another friend join us, and getting the chance to play with my friend's dog; but certain things will remain unmentioned in case of potential backlash :P. Those two weeks passed by quite quickly, and it's going to be quite a difference when I start my next elective tomorrow, as things are a little isolated where I am, and I don't really know too many people in the city.

At least the place I'm at isn't a dump, like I was worried it would be, considering the cheap rate I got it for. Thank goodness some people still do things out of the kindness of their hearts and not to make a profit!

In summary:
- I completed my physical medicine and rehab elective. Although I didn't get a reference letter out of it, I learned a half-decent neurological exam and got to find out a bit more about the programs in Vancouver. I was also quite impressed with how well the doctors handled the complex patients they see in the program; even though they're all 'stable', they all have several issues to be dealt with and can still be quite sick when they first come in. For the amount of work that they do, these guys are probably underpaid relative to other physicians.
- Because I wasn't trying to get a reference letter, I was able to spend more time hanging out with my *much older* friend. I haven't had this much fun in a while; and even though she made me watch the Houe Bunny and poked holes into my ego, things were otherwise quite enjoyable.
- Now I'm onto an internal medicine elective. I guess we'll see if I can get a reference letter out of this experience!