UNIVERSITIES

Just another night in major emergency

Before you apply to medical school, spend eight hours in this doctor’s shoes

CAMERON AINSWORTH-VINCZE September 22 2008
UNIVERSITIES

Just another night in major emergency

Before you apply to medical school, spend eight hours in this doctor’s shoes

CAMERON AINSWORTH-VINCZE September 22 2008

Just another night in major emergency

Before you apply to medical school, spend eight hours in this doctor’s shoes

CAMERON AINSWORTH-VINCZE

By

the age of three it was apparent that Telisha Smith-Gorvie would become a doctor. Growing up in Winnipeg, one of four sisters, little Telisha would mix household items into margarine jars, then place them in the freezer overnight in hopes that they would turn into a magical remedy that she could use to treat an illness. Today, Telisha is more often referred to as Dr. Smith-Gorvie, a 28-yearold, fourth-year resident in the emergency wing of St. Michael’s Hospital in downtown Toronto. It’s shortly after 4 p.m. on an early August afternoon, and her eight-hour shift has just started.

She pulls a yellow hospital gown over her clothes, straps a medical mask around her head and enters Room 5 of St. Mike’s major

emergency ward. Inside, doctors from the intensive care unit and internal medicine are tending to a man in his late 30s who is dry heaving violently. He was en route to the intensive care unit after being brought in with severe breathing problems, but in the past few moments his symptoms have worsened to the point where he may need to be intubated—a process that involves inserting a plastic tube down the throat directly into the trachea to protect the patient’s airway while providing a means for mechanical ventilation. He frantically sways from side to side on the bed, struggling to inhale while constantly lunging forward as the doctors attempt to restrain him. Smith-Gorvie hovers at the foot of the bed staring at the heart monitor over the patient’s left shoulder, ready to help out with the intubation procedure if needed. And then the man’s symptoms abruptly subside and the doctors and nurses gently lie him down to rest. Smith-Gorvie realizes that her presence is no longer needed and leaves the room. “They have enough

people in there,” she says. “I’m not totally sure what the problem is. Might be an asthma attack or an infection of some sort.”

As a fourth-year resident doctor, SmithGorvie is hardly ever on the periphery. In the first two years of her five-year residency program she, like all other resident doctors across Canada, worked under more senior residents and full-time staff doctors to learn the ropes. But as a senior resident, she is responsible for running the department under the supervision of a staff emergency doctor, and she handles her own patient load while working side by side with more junior resident doctors, helping them develop their skills.

To get to this stage of her career, SmithGorvie put eight years of university education under her belt—four years of undergrad and four years of medical school—followed by this ongoing residency experience. She did a bachelor of science in microbiology at the University of Manitoba, graduating with an average of between A and A+. She stayed on to pursue her MD. And when Smith-Gor-

vie graduated in the spring of2005, she moved to Toronto after one of her tutorial leaders at U of M suggested that it was a great place to begin a career. “I spent the first 25 years of my life in Winnipeg,” she says. “I love the city, but I wanted a change.”

After exiting Room 5, Smith-Gorvie walks toward the main desk of the major emergency wing, and sits down with first-year resident Dr. Albert Allen to review the status of patients who have recently been admitted. His shift ended 20 minutes ago and Smith-Gorvie needs be brought up to speed before he heads out. The first case is Margaret (first names only are used throughout this story to protect patient privacy), a 58year-old diabetic with a history of strokes. Allen ticks off her symptoms: weakness in both legs, blurry vision, sore throat, loss of voice. He then reviews her medical history. Margaret has high blood pressure and cholesterol levels, and just three weeks ago suffered a stroke. Her symptoms began to worsen at around noon today. Allen does most of the talking while Smith-Gorvie listens. She then asks for Margaret’s electrocardiogram (ECG), which traces a person’s heart rate to pick up abnormalities, and probes him about Margaret’s trouble with her vision. “Is she having problems seeing out of both eyes, or just one in particular?” Allen is unsure. “Let’s go see her then,” says Telisha, quickly rising. She heads toward the end of the emergency department, where Margaret is lying on a stretcher in the hallway corner, her husband

by her side. Allen follows close behind.

When they arrive, Smith-Gorvie introduces herself and begins conducting tests. “How many fingers am I holding up,” she asks, repeating the test on each eye, and varying the number of fingers in front of Margaret’s face. Allen peers over Smith-Gorvie’s shoulder, listening and taking notes. Margaret looks frail and tired and her replies are barely audible, forcing Smith-Gorvie to lean in close. The patient’s husband adds that the blurry vision has been happening off and on for about four days. The two residents consult and they decide that Margaret should be sent upstairs to radiology to have a CAT scan. The CAT scan could show if there is any damage inside the brain that might have

resulted from a new stroke. But as SmithGorvie discusses with Allen as they walk away, since Margaret is recovering from a recent stroke, and it’s not her first, the CAT scan may not be able to distinguish between old and new damage.

The man in Room 5 is now sitting upright on his bed and howling, his hands firmly clutching the bed rails. His mouth is wide open but he still can’t seem to breathe enough air into his lungs. There’s a white bucket on his lap; he’s coughing up blood. Smith-Gorvie appears unfazed as she walks past the room, then sits down with the staff emergency doctor on duty to calculate the number of beds available in the ward. One of her jobs is to ensure that patients move quickly

MAKING UP FOR LOST GROUND

Until recently, Canadian medical school enrolment wasn't keeping up with population growth. In the 1980s and '90s, most provinces reduced the number of places at Canadian medical schools, as a costsaving measure. Since the turn of the century, however, provincial governments have been backpedalling and medical schools have been expanding. But relative to the size of a Canadian population that has grown more than 60 per cent over the past four decades, we still aren't training any more doctors than we were in the 1970s.

Source: Office of Research and Information Services,

Association of Faculties of Medicine of Canada; Statistics Canada

MEDICAL SCHOOL ENROLMENT

Medical schools vary in size, from the newest, Northern Ontario School of Medicine, with 166 students, to giant Université de Montréal, where enrolment stands at 1,200. Women outnumber men at all but three of 17 institutions, sometimes by a wide margin.

*Northern Ontario School of Medicine is located at Lakehead and Laurentian universities. Source: Office of Research and Information Services, Association of Faculties of Medicine of Canada

through the major emergency ward, and are released or sent elsewhere in a timely fashion. “It’s kind of like being a hotel manager,” she says. While in medical school, Smith-Gorvie, like all med students, had to decide whether she wanted to be a family doctor or specialize in another field. To become a family physician, grads must enrol in a two-year residency program accredited through the College of Family Physicians of Canada. For most other streams, such as surgery, pediatrics or emergency medicine, graduates undertake residency programs of between four and five years. The training period for some sub-specialties, such as cardiology and nephrology, is even longer. Since beginning her residency stint in Toronto, Smith-Gorvie has worked in hospitals across the city, including Sick Kids, Toronto Western, Toronto General, North York General, Sunnybrook and St. Michael’s. In years one and two, she gained experience in a range of departments, such as obstetrics, surgery, internal medicine and pediatrics. By year three she had narrowed her sights on working in the emergency ward, and this past year has worked exclusively in the emergency wing of various Toronto-area hospitals, while simultaneously completing a master’s in health

research methodology at McMaster University. Down the road, she either wants to be an academic researcher or work in emergency medicine, helping vulnerable populations like children, the elderly and immigrants. But with six hours left in her shift this evening, she has other things on her mind.

Outside in the waiting room, there are about a dozen people waiting to be seen. In contrast to the commotion unfolding within the emergency ward, the waiting area is quiet and calm. Each person here will end up in

one of the emergency wing’s three wards. Those with non-serious injuries and complaints will be sent to minor emergency. Others will go to intermediate, for non-critical chest and abdominal pains, along with psychiatric matters. The rest will be seen by Smith-Gorvie and her colleagues in major emergency. It’s 6 p.m., and almost every bed in major emergency is taken. “And the night is still young,” she adds with a smirk.

Smith-Gorvie’s next patient is Maitlin, a 43-year-old male with chronic chest pain. His

case was first handled by Josh Guttman, a fourth-year McGill medical student who is working in the emergency ward for a few weeks as a course elective. Guttman has done a preliminary assessment and after a brief synopsis they head toward Maitlin’s room, where he is lying on the bed. Smith-Gorvie introduces herself and then ask a series of questions: what time of day do the chest pains occur? How long do they last? What does the pain feel like? Where does it hurt?

Maitlin says the pressure is on his left side and it causes him to experience shortness of breath. “It feels like somebody is sitting on my chest,” he says as he pulls down the collar of his shirt and places his hand over the area that hurts the most. “It’s always there, it’s just how much.” Smith-Gorvie asks about family medical history. He mentions that his father has heart disease and that his brother suffers from a blocked artery. The pain also causes him to sweat and vomit. Maitlin’s X-ray appears normal but Smith-Gorvie recommends that he undergo a stress test—a procedure that involves speeding up the heart through exercise or an injection of medicine to determine if the heart is working properly—and gives him a combination of Tylenol and Advil to ease the pain. “We’ll keep you here just a little longer,” Smith-Gorvie tells him. “Just to make sure the pain eases and your symptoms don’t return.”

Meanwhile, Margaret’s CAT scan results are in and there are no signs of bleeding, although Smith-Gorvie’s hunch about the scan being unable to identify a new stroke has been proven right. The picture she is looking at on a computer screen shows tiny, clear holes amidst a sea of white matter—a sign of brain damage resulting from a previous stroke. Yet with no evidence of bleeding, or any other complications, Margaret will be released.

A few minutes later, Smith-Gorvie is summoned by a nurse to see an elderly woman named Maria (not her real name), who has just been admitted. “The matter is a little complicated,” explains the nurse. Maria doesn’t speak English. Sitting in a wheelchair near the entrance to the ward, she appears disoriented and scared. Smith-Gorvie and the nurse wheel Maria into a room enclosed by sliding blinds. They help her out of the wheelchair and gently lay her on the bed. Smith-Gorvie begins speaking to Maria in Italian, something she picked up in undergrad. From what Smith-Gorvie can understand, Maria is suffering from chest pains and dizziness. Maria’s daughter arrives a few minutes later and explains that during dinner, her mother’s eyes rolled back and she collapsed. “I thought she had died,” says the daughter. “All day she said her heart was going to go.” She gives her mother a soft

touch on the shoulder, pulls out a dozen prescription-filled bottles and tells Smith-Gorvie that for the past few days, her mother has been having trouble getting up the stairs and has experienced intense chest pains. She is also a diabetic with high blood pressure. SmithGorvie gives Maria an Aspirin for the pain, calls the coronary care unit on the seventh floor to request a cardiologist, and returns with a small bottle of nitroglycerin that she sprays into Maria’s mouth. The nitroglycerin

By midnight, Smith-Gorvie has seen six patients and assisted with four. It’s a pretty average evening.

will ease the flow of blood to her heart.

When it comes to taking care of elderly patients, Smith-Gorvie works hard to ensure that they feel comfortable. About a year ago, a couple in their 90s were admitted after both sustained injuries in separate falls. “He had fallen while trying to get into bed,” says SmithGorvie, “and while trying to help her husband up, she fell as well.” Although they only had minor bumps and bruises, they were placed in rooms adjacent to each other and Smith-Gorvie and the staff made a point of regularly updating each spouse on the other’s condition. And when they were released, it was arranged that they both be taken home in the same ambulance.

Appearing more relaxed and with her chest pains receding, Maria is moved to Room 5 where she will be closer to the main section

of the emergency ward. The man who was dry heaving is now upstairs in the intensive care unit. The room has been cleaned, the bucket of blood is nowhere to be seen and new sheets are on the bed.

At around 8 p.m., halfway through SmithGorvie’s shift, the emergency department is notified of a male in his early 40s who has been badly assaulted in the city’s downtown west end. An ambulance will arrive soon; the patient will go directly to the trauma unit. A trauma team quickly assembles and preparations are made for the patient’s arrival. The group includes an anaesthesia resident who is in charge of managing the patient’s airways, an orthopaedic surgery resident who will conduct tests to see if there are any fractures, a general surgery resident responsible for checking for abdominal or chest injuries, and a trauma team leader who will quarterback the proceedings. They stand ready around

a single bed as an X-ray machine is rolled into position. Smith-Gorvie stands supportively in the background, probing to get a sense if her services will be required.

St. Michael’s Hospital, founded in 1892 by the Sisters of St. Joseph to care for the sick and poor ofToronto, serves some of the city’s toughest neighbourhoods. The hospital has a staff of around 5,000, including more than 600 physicians and midwives, and 600 medical residents and clinical fellows. Last year, the hospital received nearly 58,000 emergency visits. Major trauma is not unknown. Earlier in the summer, two patients with gunshot wounds were dropped off at opposite ends of the hospital. Last year, the hospital handled 42 gunshot-related injuries.

The assault victim arrives 10 minutes later. Smith-Gorvie watches from the entrance of

the trauma room door as the team works quickly. The man, half-conscious and struggling to breathe, is moved from a stretcher to the bed. His clothes are cut off and the team begins to check for fractures and internal bleeding. There is blood on the left side of his head from where he was struck. They intubate and begin taking X-rays. A few minutes later, a police officer arrives. He places a few items of the man’s jewellery in a small plastic bag, a sign that this man is part of an investigation.

Smith-Gorvie leaves the trauma room and heads back to the main section of the emergency ward. Maitlin says goodbye and thanks her for helping him as he leaves the hospital upon being released. She stops dead in her tracks, smiles back and says: “No problem. You’re welcome.” Heading to the back of the main desk, Smith-Gorvie relaxes for a second and warms up a bowl of leftover chicken stirfry. She’s been on her feet for nearly six hours without a moment’s rest. “It doesn’t look that great,” she says with a shrug. “I think the chicken is a little congealed.” She heats it up again and while eating writes letters to the family doctors of patients she has seen since her shift started. She doesn’t have to do this but wants to keep them informed of how each situation was dealt with.

While finishing up her dinner, another resident asks Smith-Gorvie for advice on how to deal with a man who is drunk and a little testy. Food still in her mouth, she gets up and heads toward the patient’s room. She enters slowly, approaches the head of the bed and asks him what he drank. “Chinese wine,” he mumbles loudly before rolling away from her. She tells the resident to let him sleep this one off. He’ll be monitored throughout the evening and released in the morning.

By now the rest of Maria’s family has arrived and they are at her bedside in Room 5. Else-

where, a few beds have opened up and the waiting room has thinned out. The police officer is still walking around the trauma room trying to gather more information about the assault victim. He picks up the man’s bloodstained shirt with his pen, stares at it for a moment, then puts it back down on the ground.

With about two hours left in her shift, SmithGorvie grabs the chart of a 68-year-old patient named Lois who has swelling in her legs. She drove herself to the hospital on a red scooter, now stationed outside her room near the entrance of the department, “ft feels like two big bricks that I’m trying to lift,” Lois tells Smith-Gorvie. The doctor responds by asking Lois if she has any chest, heart or breathing problems. It turns out that Lois is an asthmatic and is on diuretic pills to increase the excretion of salt and water from her body. The pills make her urinate all the time. SmithGorvie checks Lois’s pulse, listens to her chest through a stethoscope, and asks her to sit up so she can check her breathing. Smith-Gorvie then rolls up her pants to examine her legs. Each one is bright red and swollen from the knees to the tips of her toes. “It’s really painful,” says Lois. Smith-Gorvie arranges an X-ray and requests a urine sample to see if Lois has a urinary tract infection from a

buildup of water in her system.

During the last hour of Smith-Gorvie’s shift, the emergency department is quiet. Only a scattering of people are in the waiting room. The last patient she will see tonight is a 53year-old diabetic named Donald. He is complaining of chest pains and having difficulty breathing. Knowing she’ll be leaving shortly, Smith-Gorvie conducts preliminary tests to ensure that it’s nothing serious, then orders an X-ray and blood work.

When her shift finally ends at around midnight, Smith-Gorvie has seen a total of six patients on her own and assisted with another four. She’s noted each one’s symptoms and treatments on a chart, has written their family doctors, and has spoken with each resident to provide feedback on their performance. As far as shifts go, this was a pretty average one. On weekends, especially long weekends, things can get a lot busier.

Smith-Gorvie stays on for a few extra minutes to update the overnight staff on the status of patients remaining within the department. The man who drank too much Chinese wine is fast asleep; Margaret is finally being moved by EMS personnel; Maria is being transported to the hospital’s coronary care unit; Donald is lying awake in bed, staring at the ceiling; while Lois is on her scooter ready to go. It turns out that she has a urinary tract infection and will be placed on antibiotics. The swelling in her legs was caused by excess water in her system; she’ll need a higher dosage of diuretic pills to decrease the amount of liquids moving down her body and into her legs. The fate of the assault victim is unknown, as is the condition of the coughing man whose screams only a few hours ago filled the entire emergency department. Every patient who entered Smith-Gorvie’s area was either treated and released or sent to another department for more extensive tests and monitoring. Part of being a doctor, she says, is playing a small role in a larger story comprised of different scenes that unfold in other parts of the hospital.

When Smith-Gorvie finally leaves, she exits via the northwest doors and walks out into the dark humid night. The streets are vacant, except for a few teens on the opposite side of the street, twirling around on their BMX bikes. She walks briskly toward the Queen Street subway station. On the train, she sits down, turns on her iPod and listens to Radiohead. Four stops later she’s making her way to her one-bedroom apartment near the busy intersection ofYonge Street and Bloor Street. After watching a little TV to relax, she’ll phone her mom in Winnipeg. She won’t conduct any medical experiments in margarine containers tonight. She’ll go over the day’s patients, and prepare for her next shift. M