After our nine month stay in our rural communities and our three-week selective in one of the core rotations, the ICC students are scheduled for electives. I chose to do electives at big hospitals in the city, and I compare the pace of the Emergency Departments between urban and rural medicine.
The ICC students have five weeks to explore any medical program in any medical school in Canada to finish off third year. (For our classmates, their elective time is spread throughout their third year.) The arrangement can be good: we are at the peak of our knowledge for a third-year medical student. The arrangement can also be challenging: there could be a big adjustment since we have limited exposure to programs outside of Rural Family Medicine.
Because I wanted a different experience from ICC, I booked several electives at urban academic tertiary care centres outside of Alberta. My frame of reference for being a physician was rural medicine, and I wanted to see what it was like in a completely new setting. Now after having finished two Emergency Medicine electives, a few differences stand out between urban and rural medicine. I’ll share my thoughts over several posts, and this entry will be about my observations about pace.
The flow of an urban Emergency Department is different from a rural ED, but it isn’t necessarily faster in the city. I’ve learned that Emergency Medicine moves at its own pace – sick patients need time for a proper workup, regardless of where they are treated. The same lab work, initial treatments, observation protocols apply to patients who come to the ED.
What is definitely different is the amount of resources. Urban EDs have an increased capacity compared to rural EDs, so more patients come in. And the level of care is often complicated or specialized, so more health professionals are involved. So since there are greater resources and manpower, there is a greater expectation to see a lot of patients. Hence, more patients are being seen at the same time, but the underlying pace for each patient is fairly constant, whether in urban or rural medicine.
One of the most helpful ways of handling patients is to sort them by how urgently they need to be seen. Urban EDs will direct patients to different sections or “pods”, which will range from Urgent Care (mostly walk-in type patients), Observation (patients that will need to be worked up and observed for an extended time in the ED), Emergent Care (higher acuity patients that need more regular treatment and follow-up), and Resuscitation (these patients are sick and need to be acted on now). This system taught me that an emergency to a patient isn’t necessarily the same as an emergency to an ED!
Positive cell phone sign: If patients are using their cell phones in the ED waiting room, they’ll live. And they can continue to wait.
The composition of the cases in an ED is variable – there will be the most patients in Urgent Care, fewer in Observation, even fewer in Emergent Care, and the fewest in Resuscitation. The same proportions generally apply to a rural hospital but in a smaller volume, and all the patients are usually seen in the same area.
That description of EDs made a lot of sense to me, and it explained my own pace and performance during my electives. I felt like I could handle myself really well in Urgent Care because I saw a lot of those types of cases in Hinton, but I had a lot of work to do in Observation and Emergent Care. Observation was the weakest area for me because I didn’t encounter many of that type of sick and complicated patients; some of the cases were things that I’ve only read about. The workup required a different level of time and attention, so it took more time to work through them.
My ICC experience became apparent in other ways. I felt like I could take a relevant history and physical from my patients, though sometimes I took too much time delving into details that weren’t relevant in the ED – that’s a carry-over from my Family Medicine training in ICC. Though I took more time, I felt like my patients appreciated the attention. Also, I was used to working in an ED and have started to practice the skill of working up patients, so I had a level of independence that my preceptors often remarked about.
So far, my electives have been going well, and I continue to learn lots within and around medicine. The EM electives at urban centres were helpful in rounding out my exposure with the various EM presentations. More posts to come!