The countless Canadians who have visited a hospital emergency room after the sun goes down and waited and waited, fretting about why it's taking so long to receive treatment, will find some illumination in a new book by a veteran ER doctor.
Dr. Brian Goldman's story not only sheds light on challenges faced by health professionals during those darkest hours of the night, but also on the deep satisfaction they feel when they can send someone on their way, problem solved and on the mend.
Doctors tend to be put on a pedestal in our society. But in "The Night Shift" (HarperCollins Canada), Goldman offers a refreshing approach that reveals them to be "as human as the rest of us."
"The public isn't well served thinking of physicians and nurses and pharmacists and social workers and other health professionals as perfect," Goldman, who is also host of CBC Radio's "White Coat, Black Art," said in an interview.
"I think that when we expect people to be perfect, never tired, never making a mistake, then I think that induces a lot of shame amongst health professionals when they discover yes, that I do get tired and I do make mistakes.
"It's the avoidance of that feeling of shame that I think makes it difficult for people like me — practising health-care professionals — to come clean about mistakes, to be open about them, not just with patients and with the public, but with ourselves. And when we aren't open with each other, then we miss an opportunity to observe each other more, correct mistakes, take near misses, for instance, and do a better job of talking about them and making the system safer."
Goldman has worked for more than 20 years at Mount Sinai Hospital in downtown Toronto, and gives accounts of numerous cases — with patient identity appropriately concealed — that might arrive at an ER on a typical night. The reader is offered a glimpse of what it's like to treat a cancer patient who's having a seizure, a dislocated shoulder, someone who thought he'd been slipped a date rape drug, a woman having a miscarriage, a guy who was in a street fight, a binge drinker, a man with a swollen testicle — the list goes on.
In fact, when his wife Tamara finished reading the book, she told Goldman that for the first time she felt as if she'd gone with him to the hospital for a night shift.
In emergency, doctors are constantly learning new things, Goldman noted. It's a bit like a box of chocolates, as the character Forrest Gump would say. "You never know what you're gonna get," especially nowadays with patients being more complicated and living to an older age with more illnesses, Goldman said.
While he writes that he loves working nights and the patients who inhabit the ER at that time, he also admits to anxiety prior to his shift because "there are things I don't know and procedures I can't do as well as some of my colleagues." For instance, he writes about his difficulty intubating patients, and subsequent training he got to properly master the procedure to open an airway for a patient with breathing difficulty.
In order to stay awake, Goldman writes that he uses modafinil, a mild stimulant that "increases my alertness by about 10 to 20 per cent."
Another challenge is the need to call on specialists for complicated cases. On the night shift, this can mean waking someone up, which isn't done lightly. But Goldman relates the case of a man who was complaining that he thought he had food poisoning, when in fact he had an abdominal aneurysm and urgently needed an operation. In this case, it was an easy decision to call a vascular surgeon at 5 in the morning.
"My guardian angel directed me to put my hand on his belly to feel it and I felt it, and I called the surgeons and it got fixed," he said. "And instead of this guy dying, he went home 10 days later. Saved. There's no greater feeling than that."
But it's more difficult to decide how to handle a swollen testicle. It could be an infection called epididymitis — not a good reason to get a specialist out of bed — or possibly testicular torsion — a good reason to rouse a urologist, because the testicle has twisted around until its circulation is cut off, and needs to be untwisted by a surgeon within roughly six hours, or the testicle dies.
"You have to learn when you call right away, and when you don't," Goldman said.
It can get incredibly busy.
The triage nurse has to assess patients and determine who needs to be seen first. Delays can occur when an X-ray or lab report doesn't get sent back to ER in a timely fashion, or a doctor isn't aware that results are in. Or, a surgical resident might be tied up with a sicker patient on the wards, and can't make it to ER quickly for a consultation.
"That stuff happens all the time because we don't have robots running the system," Goldman said.
Patients and their loved ones have every right to speak up if the wait seems too long, but there's a way to do it to get better results, he advised.
"When you meet the nurse in the area, learn their name and speak to them, address them by their name ... if you approach somebody and start talking, almost like a 'hey you,' you don't get as good service as if you walk up to people, smile, be polite," he recommended.
"The second thing I'd recommend is get a feel for what is in the control ... of the person you're asking. There's no point in asking someone to do something that they can't do. For instance, I can't snap my fingers and make the surgical resident come down now, unless I call STAT (immediately). But like the boy who cried wolf, I better mean it ...
"The surgeons, the gynecologists will very quickly learn that when Goldman calls STAT, he doesn't mean STAT. So you've got to be very careful about that."
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