Catch and release

Prior to his current role at the West Side Community Clinic, Upstream founder Ryan Meili was a travelling locum physician in small towns all over Saskatchewan. His clinical experiences then and now reveal to him the limits of medicine and the importance of upstream action to address the social determinants of health.

Below is the full text of "Catch and Release", a chapter in the recently released compilation Surprising Lives of Small Town Doctors, Dr. Meili writes of encounters with illness and death in the early part of his career. 

Meili will join the book's editor Dr. Paul Dhillon and other contributors for the Saskatchewan launch at McNally Robinson Booksellers May 19 at 7:30. 

Doctors tend to remember their “saves,” brushes with death or dismemberment averted—at times because of their intervention, often enough despite it—in technicolour detail. In some ways, rural physicians are the manifestation of Holden Caulfield’s naive dream, the bodies catching bodies coming through the rye. It is this gatekeeper role between worlds that defines our self-image. Sure, most of our days are spent in the other gate- keeper role, determining who needs a referral to a specialist or other intervention beyond primary care, or, to paraphrase Voltaire, entertaining the patient while nature heals them.

I spent the first two or three years of my medical career as a travelling entertainer, working as a locum in rural Saskatchewan with gigs in all four corners of a province as geographically diverse as it is geometrically straightforward.

For me, it’s the most dramatic cases that first spring to mind. Transporting patients with massive myocardial infarctions or flash pulmonary edema down bad roads in deep, dark winter, feeling like Santa Claus “bagging all the way.” Delivering a thirty-two-weeker in a nursing station on a reserve while my colleague stabilizes a seizing two-year-old in the next room. The surprise of discovering that a woman didn’t lose the fractured and purple foot we’d wrapped up after she was found struck by a vehicle and left in the ditch at thirty below on New Year’s Eve. Packaging a young man with two fractured femurs and a head injury for transport to the city after he was run over by an RCMP truck on a reserve. Little miracles of a bit of good medicine and a lot of luck.

"The only cases we remember more clearly than those we catch are those we don’t."

Perhaps the most memorable of all was the sweet miracle of Entwhistle, the closest thing I’ve seen to a resurrection. A man in his mid-forties was carried into the emergency room in this small, eastern Saskatchewan, potash-mining town. He’d been found unconscious in his garage, and on the Glasgow Coma Scale – the measurement we use to tell how conscious or unconscious a patient is – he scored a three, the lowest score out of a possible fifteen. Even with a painful sternal rub (knuckles pressed hard against the breastbone), he didn’t move a muscle, twitch an eye, or make a sound. There was no history of trauma, nothing unusual about the past twenty-four hours, except that he’d had a few drinks with his buddies over cards. His family reported that he had diabetes that was well controlled with oral medications and was otherwise healthy as far as they knew. On examination, aside from being completely comatose, he was well. He was hemodynamically stable, meaning his blood pressure and heart rate were normal, as was his breathing. Despite this, he was completely out of reach.

I was more than a bit baffled by this presentation, and my mind went back to an experience in medical school when on an elective in rural Zambia. A skinny old man with long dreadlocks was laid out on the little grey cot that served as the emergency room. He, too, was dead to the world, completely unresponsive to voice or pain. My preceptor, an experienced internist who’d been visiting the region for many years, had seen this before. “I have no idea what’s in the homebrew, but we see someone like this every once in a while. Sugar seems to work.” And did it ever! She gave him an injection of IV dextrose, a high-concentration sugar solution. He sat up like a bolt, said he had to pee, and ran out of the hospital. We never saw him again.

Suprising_Lives_of_Rural_Doctors_cover_HIGH_RES_.jpgWith that story in mind, I checked the glucose of the patient in Entwhistle. It was perfectly normal, even a touch on the high side. Still, I thought it couldn’t hurt and tried the same trick with an injection of dextrose. Just like his Zambian counterpart, to the amazement of his family, the skeptical nurses, and me, too, he sat up straight and started talking as though nothing was out of the ordinary. After a few minutes of pure lucidity, alert and oriented, explaining in detail the events of the night before, he started to drift off again. Within moments, he was as unreachable as before. We repeated the dextrose, which woke him again and, despite his diabetes, started him on a regular drip of the same and made arrangements to ship him to Regina for further investigations.

I’ve asked a few fellow doctors since and have even done some research to try to find out why that worked. I’ve yet to find anyone who could give me a clear explanation, though it may be explained by neuroglycopenia, meaning different levels of glucose in the brain and the rest of the body under certain circumstances.

The only cases we remember more clearly than those we catch are those we don’t. On my office wall I don’t have my MD hanging. I have a framed transfer note that was never sent, a note about the first patient who died under my care. I was a medical student working in a rural hospital in Mozambique. At around 7 pm, on July 8, 2002, a man in his mid-forties was brought into the emergency room by his family members. They reported that he’d been complaining of headache and had been vomiting since the night before. At nine that morning, he tried to get out of bed and fell to the ground; he’d been unconscious and unable to move one side of his body since. His blood pres- sure was through the roof, he was paralyzed on one side, and he had a fever. Not understanding at that point in my training that malaria could cause a stroke, I didn’t start quinine immediately the way we did with most patients with a high fever. This meant it wasn’t started until a couple of hours later when we were able to track down the doctor on call. God only knows if it would have made any difference in such a severe case, but it should have been started right away. The patient never recovered consciousness and was dead by morning.

I’ve thought through that case a hundred times since. Thought about Berto, the often-drunk-at-work health agent who sanguinely told me not to bother with the transfer note. “You can’t save everyone.” Thought about how I shouldn’t have been in that emergency room in the first place. Thought about the fact that if I wasn’t there, no one else was. Thought about how even if doing things differently wouldn’t change the out- come, I still wish I’d done things differently.

In the winter of 2009, I spent a week in Spirit River, a mill town on the forest fringe of northeast Saskatchewan. I was working again as a rural locum, this time in a stable practice with a group of really good physicians. I worked days in the clinic and during the evenings I went exploring around town and watched bad movies I’d rented at the convenience store.

On Friday afternoon, just before my weekend of call, Betty Trotchie came in with her husband. They lived a half-hour out of town on the farm where they’d raised their kids, now grown up and spread out around the country with kids of their own. They’d both quit smoking a few years earlier, but decades of tobacco use had left their mark. Betty had a long history of chronic obstructive pulmonary disease, often referred to as emphysema, which occasionally got bad enough to require antibiotics, and once before she’d needed to come into the hospital.

She always had a cough, but that Friday it was a little heavier than usual, and she said she was “coughing up more junk.” When I listened to her lungs, there were crackling sounds at the bottom, just like you’d expect in someone with COPD. I decided to check her oxygen saturation, which turned out to be around 85 per cent. Had it been above 90 per cent, I might have just sent her home with antibiotics, but I thought it best to admit her instead. We discussed the possibility of her going to Saskatoon—the nearest tertiary care centre—for more intensive management. They didn’t want to do this, and in the same conversation we discussed end-of-life care. She and her husband were quite clear about their wishes for her treatment, and that included not wanting to have a tube to assist with her breathing.

So we kept her there at the rural hospital, starting oxygen, IV antibiotics, and other medications to help with her breathing. She settled into her room, the one in-patient bed in the whole hospital, and her husband went to the farm to get her a few things for her stay.

"Even if doing things differently wouldn’t change the out- come, I still wish I’d done things differently."

One of the local physicians, Dr. Weldon, had invited me over for supper that evening. Once I’d written up all the admission orders and Betty was settled in, I went over to his house. It was on the opposite end of town from the hospital, which in a town that size was less than a ten-minute walk away. Dr. Weldon had come to Spirit River thirty years previous with three colleagues from med school. He was the last one from the original group, and had stuck it out through good times with stable colleagues and through the rough times, too, when they were down to two docs and being on call was essentially always. He’d lived through the ups and downs of a single-industry town, living and dying the trials and travails of his patients and neighbours as one of them, not just a visiting hired hand. For his kids, this wasn’t a town their dad had decided to come and serve, it was the only home they’d known. His patients were their hockey teammates and elementary school teachers, their friends’ grandmothers. We talked Saskatchewan politics, medical education, changing small-town life, and the somewhat bleak and open-ended question of the future of medicine in towns like Spirit River. We chatted a bit about Betty as well; she was his colleague’s patient, but he knew the family well.

I checked in on Betty again that evening. Her breathing had become more difficult, and despite medications and an even higher oxygen concentration, her oxygen saturation was falling into the low eighties. I saw her again first thing Saturday morning and a few more times throughout the day, and left instructions to be called in with any changes to her condition.

At noon on Saturday, her husband asked if he should call in the family, including a daughter in Calgary, a good ten hours away. I told him I couldn’t be sure, but it might be a good idea. It was a good thing she came, as her mother’s condition only continued to deteriorate. By Saturday night, she was asleep and barely responsive. At 6 am on Sunday morning the nurse on duty called me in to tell me Betty had died. I went in to see her and sat with the family awhile. They were extremely kind to me, a stranger, and thankful for the care their mother had received. They seemed to think it was a good death, the kind of passing she would have wanted.

Patients die. They’re supposed to. Doctors hang around sick people. If the doctor’s any good, the sicker they are, the more the doctor hangs around, and, ultimately, the more patients they lose. Me, I look forward to someday being a patient well lost.

And for the most part, Betty’s passing was exactly what most of us would want. She was joking and laughing one day, and had her family gathered around to see her off the next. She made up her own mind about what needed to be done, died close to home, and avoided a potentially prolonged and invasive hospitalization.

But let’s face it, it’s not that clear-cut. Her last hours were peaceful, but were they premature? There’s a pretty good chance that if she’d gone to town, she’d still be alive today. And there’s a pretty good chance that if I’d thought she was going to die that weekend, I could have convinced her to take that trip. We talk of, and strive for, informed consent, but so much is dependent on what the attending physician thinks is likely or preferable. The consent of the patient is only as informed as the physician who seeks it. Try as I might, and I’ve wracked my brains over Betty’s case, there’s nothing about her presentation that made her stand out from dozens of other people I’d hospitalized with exacerbations of COPD.

Yet, on some level, it feels like rather than trying desperately to catch her, we stepped aside a little too easily, let her go too quietly into that good night. I’m not sure the family, or even Betty, would agree. Not all the bodies want to be caught.

Still, it nags at me.

"Me, I look forward to someday being a patient well lost."

Of course, everyone goes over the edge eventually, but that’s little solace when your job is to delay the drop. This, to me, is the wonder and the horror of rural medicine. There are EMTs and nursing staff, UpToDate (an online resource for physicians), and the on-call service in the nearest big centre, but despite all of this the decisions land on a lone doc over and over again. What to keep, what to send? Today, it’s a pneumothorax and you’ve only practised chest tubes on pigs, tomorrow a dislocated shoulder that just won’t reduce. Every day, you’re making it up as you go along, hoping you know how to catch those you can, and even harder, hoping you know which ones to let fall.

On Monday morning, bags already packed and the key to the locum apartment left with the charge nurse, I came in to finish up some charting and hand things over to Dr. Weldon. I told him about the other in-patient admitted the day before, and matter-of-factly about Betty’s passing, a physician-to-physician transaction of information. “Mrs. Trotchie died Sunday morning.”

“Really? Oh my God!” he replied, with a look of real surprise that caught me off guard. It was not the detached, professional response I’m used to. He looked shocked and disappointed, as though I was talking about a member of his own family. He may very well have been asking himself, “What if I’d been on call instead?” I was left wondering the same thing.

I’m not a rural physician anymore. I work in the inner city, a place I often describe as “so urban it’s rural,” and while the day-to-day practice reflects that, the tertiary backup around the corner changes everything. I’ve been in my neighbourhood long enough to feel some of what Dr. Weldon felt when one of my patients dies. Still, there’s something about the anonymity of the city, and the sharing of practice with so many others, that dilutes that spooky, exhilarating feeling of waiting alone in a wheat field.

 

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ryan_bio.jpgRyan Meili is a Family Doctor at the Westside Community Clinic in Saskatoon and an Assistant Professor at the College of Medicine, University of Saskatchewan, where he serves as head of the Division of Social Accountability, director of the Making the Links Certificate in Global Health, and co-lead of SHARE: the Saskatchewan HIV/AIDS Research Endeavour.