Saluting the true heroes of remote medicine.
Just below where the massive Hudson’s Bay finishes its plunge into the heart of the northern Canadian Shield lies a small village called Chisasibi. Nestled between the south shore of La Grande River and the northeastern shore side of James Bay, Chisasibi holds an entirely unique geographic distinction: it is the northernmost Cree village accessible by road in Quebec.
Chisasibi’s regional hospital serves a population of 17,000 souls, scattered across 2,000 square miles of boreal forest. Besides Chisasibi, most of the five other villages that fall within the regional hospital’s care, only had on-site doctors for one- to two- weeks per month at the time of this story. Extended role nurses provide the bulk of the care, working autonomously without onsite access to labs or imaging. They manage anything and everything that walks through their door and, most of the time, they are working completely alone. They really are the true heroes of remote medicine, and I have the pleasure of regularly working with them when they call the hospital in Chisasibi to consult with doctors like me. I am quite literally in awe of these nurses and what they do.
Plodding through the snow
It was a beautiful, but bitterly cold Chisasibi morning as I plodded through the snow on my way to work. Barely six months prior, just after finishing my family medicine residency in Montreal, I decided to pack up my life and move to this remote First Nations reserve. I was drawn to this community because it felt like a chance to have the kind of practice I had always dreamed about: remote medicine. I also wanted a chance to prove my clinical skills and be a part of a very tight-knit team. Chisasibi offered both.
As my blue arctic boots crunched through the crisp layer of frozen snow that lay atop the wind-carved drifts, I found myself tired, but also a little nervous. Tired because we were particularly short staffed this year and there were only three of us covering the hospital for a week. Nervous because I knew that this morning it would be my responsibility to answer emergency phone calls from the villages.
I tugged open the front door of the hospital and a welcome rush of warmth and humidity enveloped me. After peeling off my many layers (it was -46C, after all!), I headed to the office for sign over. My colleague who had been on overnight gave me a broad smile as I settled into the well-worn chair. I began to write as he spoke of a village call he had taken from an RN the night before.
Woman in her mid 40s with asthma since childhood. Smoker. No other significant history. LMP three days ago. three-day history of mild cough, wheezing and chills. Tried salbutamol at home, but not really working. Not better, but also not worse. RR 22, sats 97%, HR 94, BP 125/76, afebrile. Unremarkable exam except audible exp wheezes. RN said it looked like typical asthma attack for this patient. Prescribed salbutamol, ipatroprium and fluticasone puffers. Told to return for a reassess in AM.
This case sounded unremarkable and I soon forgot about it as the ER began to fill up and the phone rang constantly with emergencies from other communities. Managing the on-call phone was always a juggling act because it would invariably ring while you were in the middle of an in-depth conversation with a psychiatric patient or perhaps a procedure — think speculum exam — and so you were always trying to anticipate when it would ring and how on Earth you would answer it without either contaminating the phone, alarming the patient or accidentally hanging up in your rush to help!
Luckily, when the RN called again to discuss the village patient all was otherwise calm on my end. There had been no meaningful change in her symptoms, but now her temp had risen to 37.9C. Her expiratory wheezes seemed to have worsened, but the rest of the exam was unchanged and unremarkable.
This still sounded very much like a routine asthma exacerbation, so, with the on-site nurse as my eyes and ears, I decided to treat the wheezing villager with some prednisone and give her more salbutamol before sending her home with instructions to return the next day, or before if she felt worse. Without another thought, I signed out the case to the overnight doc and made my way home. The crunching of my boots was as sharp as the bitter air under the dark northern sky.
The next day I arrived for my 24-hour-shift and was relieved to hear that there had been no calls about the patient. As a junior staff member, I still had that fear of looking daft in front of my more experienced colleagues. I felt a bit of pride as I took my morning rounds, knowing I had made the right call.
But pride, as they say, always comes before a fall.
Later that day, the village nurse called again. The wheezing patient had returned. She was now markedly more dyspneic and her wheezing had significantly worsened. The nurse described her as pale and sweaty, with increased difficulty breathing and audible inspiratory and expiratory wheezes.
Her vitals were now RR 22, sats 94-95%, HR 105 (post salbutamol), BP 110/89, temp 38.5. The clinical picture the nurse painted had changed markedly and I now felt the patient likely had pneumonia with associated bronchospasm, with possibly an underlying sepsis. With no labs or x-rays available in the village, I requested an ECG (sinus tach at 108) and ordered a bolus of IV fluid along with acetaminophen and levofloxacin, and asked the nurse to arrange for a medevac plane to Chisasibi. While awaiting the plane, the RN was to give nebs as needed and call me in order to reassess the patient on a regular basis.
Soon the phone range again. It was the nurse. The weather had suddenly deteriorated and all flights had been grounded.
This was the situation: a nurse with no onsite support had a sick patient on her hands for the foreseeable future and was relying on me to help manage her — a patient for whom I had been remotely caring for over 36 hours, but who I still had yet to physically examine. I felt like a pilot flying blindly through the treacherous storm that had overtaken the village.
Over the course of that long night, the patient began to feel worse, with intensifying dyspnea; persistent wheezes; and increasing 02 needs. She received IV antibiotics, IV fluids and IV solumedrol.
She remained stable in her instability.
In the morning, I emerged bleary-eyed through a thick fog of sleeplessness and signed over the case to my colleague. The weather had cleared and I advised her that a patient with persistent wheezing and possible pneumonia and sepsis was coming to us for assessment and that they were due to land at 9:30 a.m.
I pulled on my big blue boots and plodded home. I immediately collapsed into bed, yearning for sleep. But my mind raced. This case was gnawing at my psyche. I couldn’t shake the feeling that something was wrong.
Forty minutes later, still awake, my phone rang. The patient had coded as she was being loaded into the medevac plane. Compressions were started and she was brought back to the clinic. The exhausted RN who had worked with her all night called my colleague and they ran the code over the phone.
But it was unsuccessful. This patient, my patient, was dead.
I was devastated. I was a young staff, working in an isolated area, and desperate not to harm a patient or make a fool of myself. I rushed back to the hospital and poured over my notes to see what I had missed.
Non pregnant, female in her 40s, smoker, known asthma. Felt by all to be an asthma attack. No recent travel or surgery or bed rest. Calves non-tender and no signs of edema or erythema. No medications.
It all seemed so straightforward. Except, as I later found out, I had missed something. This patient lived in the village, but she was from Montreal and had her prescriptions filled there. We eventually learned that she was taking an oral contraceptive pill and had simply never told the nursing station team. A lady in her 40s, a smoker, on an OCP.
Months later, the autopsy came back and confirmed our fears: namely, that our patient had died from a massive PE.
Anchoring on a diagnosis and worrying about our ego and reputation are two things that we all try to avoid. But this can be extremely difficult, particularly when you don’t get to see the patient in front of you. Thirteen years later, if I find myself feeling that perhaps I was too quick to jump on a diagnosis, I look back on this case and remember the terrible crunching of my bright blue boots rushing through the snow as I rushed back to the hospital to see what I had missed.
What was this feeling? Guilt? Grief? Shame? Something much more sinister that doesn’t have a name, but whispers lies to you in the darkness of the far north?
Whatever it is, I will do everything in my power to avoid ever feeling that way again.