A patient being transported via helicopter in Vanderhoof, BC
Dr. Tandi Wilkinson, rural emergency room (ER) physician and Medical Director, UBC Rural CPD Program (RCPD), has worked in several rural communities during her 20 years of practice. “ER work is a big part – and one of the more stressful parts – of rural practice,” she observes. “Rural family physicians don’t get a lot of opportunity to practice some procedures – it can be challenging to feel comfortable in the ER.” As emergency medicine continues to evolve into a specialty in its own right, Wilkinson is seeing more rural GPs and new graduates feeling less confident and less prepared to work in rural emergency rooms.
Procedures aren’t the only challenge faced by physicians in rural ERs. Depending on available resources, case management can also become complicated. Wilkinson cites an example – last year, she had a patient with a head injury, and was faced with the decision to either send the patient one hour away to Trail for a CT scan, or to a neurosurgeon located four hours away in the opposite direction. “What is the best decision for this patient?” she asks, “Do you send him for the CT scan and then to the neurosurgeon? Do you bypass CT and send the patient directly to the neurosurgeon? What if the neurosurgeon won’t accept your patient?”
Even a relatively straightforward process such as transferring a patient can become problematic in some regions of the province. Mountainous terrain and remote locations can make it difficult to evacuate patients, especially during inclement weather. Additionally, physicians who must accompany their critically ill patient during transport may not be able to find coverage for their practice while they are away.
There is no blanket policy to guide the decision-making process of rural physicians through these kinds of critical care issues, notes Wilkinson. “There is no research to say ‘this is how you should do it’ because research isn’t done in these kinds of settings.” What, then, can be done to support family physicians providing essential critical care services in rural ERs?
One of the solutions that Wilkinson and her colleagues within RCPD, the Rural Coordination Centre of BC (RCCbc) and the UBC Department of Emergency Medicine are exploring involves providing on-the-ground support for rural GPs in the ER dealing with difficult cases. “I think of it as ‘phone a friend,’” quips Wilkinson. “We’re looking at developing a system where a physician is able to have a mentor who understands the rural perspective, and maybe has a higher skill set with critically ill patients, offer support with the complex decision-making.” Wilkinson notes that while many practitioners have informally set up this type of resource within their practice, she and her colleagues are examining ways in which they can formalize this service, and make it available to any physician seeking support.
Other agencies are also finding ways to support rural ER healthcare teams. Interior Health, for example, created a critical care transport team of on-call paramedics, nurses, and physicians to accompany critically ill patients who must be transported. The program allows local doctors and nurses to remain in their community to provide coverage, while the critical care team attends the patient during transport. Wilkinson observes that while this program is very successful at keeping doctors and nurses in their communities, it can also create delays when transporting a patient. “The team is not necessarily in your hospital, and they may be involved with another case when you call, so your patient may have to wait.” There are no perfect solutions, yet.
Wilkinson points out that BC’s rural physicians are better supported in the area of continuing medical education (CME) resources than many parts of Canada. There are numerous accredited hands-on, skills-based CME workshops available that allow physicians review and renew their ER competencies in their own facilities, alongside their own healthcare teams. “There is a huge will for ‘closer to home’ skills training to happen in BC. I think that’s going to continue to improve.” Wilkinson notes that “the government has a mandate to see BC’s rural emergency departments be the best supported in the country. I think that’s starting to become a reality, in the area of education, for sure.”
Dr. Tandi Wilkinson
Dr. Tandi Wilkinson is a rural emergency physician, and the Medical Director for UBC RCPD program. She has developed and taught the Shock and Obstetrical Ultrasound Courses. her special interests include rural emergency medicine and critical care topics, bedside ultrasound, ECGs, and rural CME.