Life as an Emergency Physician
PRAXES Medical Director, Doctor John Ross, shares insights on his fast-paced, dynamic career:
The role of a PRAXES emergency telemedicine physician can be unpredictable, challenging and often exciting. PRAXES Medical Director, Doctor John Ross, is dedicated to global health and wellness and takes pride in providing the most efficient and accurate telemedicine support possible. In addition to his career with PRAXES, Ross is a trauma team leader at Capital Health, a professor at the Royal College emergency training program at Dalhousie University, a published author and much more. Ross took some time out of his busy schedule to discuss what it takes to be a PRAXES emergency telemedicine physician and what makes him so passionate about what he does.
When you’re on-call with PRAXES, what would be an example of the type of call you might respond to? What steps do you follow?
Currently all calls come through on cell phone. We are on call from 0800-0800. When the phone rings, call identifier shows it is coming from the Praxes Communications Centre. The call taker tells me who is calling and where they are, generally something about the problem such as age, complaint, and often basic vital signs. We have asked callers to obtain some basic information to make the call most efficient. Calls from offshore fishing, container ships, cruise ships go through the Joint Rescue Coordination Centre (JRCC). In those cases, the next person I talk to will be their radio controller, who then connects the ship at sea. As you might imagine, the quality of the call depends on radio/phone quality, satellite transmission, caller accent and many other factors. For land based calls, they can come directly from a land phone or via satellite in the far north.
Call types are a broad spectrum. They can come from really experienced medically trained people who have a good sense of what the problem is and what to do next such as calls from the Burnside Jail from paramedics, most of whom we already know. They often call because in order to do certain things they require a physician’s approval and oversight. Other callers are skippers of boats who have very limited first aid training and little equipment – so the conversations can be dramatically different.
Once the chat is over, a plan of some sort is agreed to. It might be anywhere from ‘give two ibuprofen and see how it goes’ to ‘this person needs to be helicopter medevac-ed immediately – we’ll help get that arranged.’ Callers have different levels of medical knowledge and supplies on hand. Some can treat quite a lot – captains on Clearwater vessels and the skippers on Clipper yachts have a number of antibiotics and pain meds, other have less. Some cases will be ‘start this and that, but divert to the nearest port or other vessel or medevac.’ The decision to get someone off is made by the skipper who can guesstimate their time to port or to get within a safe helicopter to and from range. For example, if they are 300 nautical miles off the coast and the helicopter can only go 200 nautical miles including hover time for extrication, we need to consider these factors. We need to consider who is there coordinating the medevac. It might be the Coast Guard or military search and rescue technicians (SARTechs.) Sometimes that involves getting their authorizing doctor on the line to further discuss the risks and benefits. Flying out to get someone comes with lots of risks and costs.
What is your top priority when assisting a client through a medical situation from a distance?
Patient safety while considering everyone else who is at the site is a top priority. One has to remember that although I might be fairly comfortable treating a problem on board a vessel or mining site, the people there may not be. Also, weather and many factors may influence whether to medevac or transport someone. For example, they don’t sound too bad right now, but in eight hours, the weather is going to make transport impossible, so they should go just in case it becomes necessary later. It is all done as collaboratively as possible. I have the medical knowledge, but logistics and caller comfort are all part of the mix. One needs to keep an open mind and be as flexible as possible.
In your opinion, what are some of the most valuable characteristics an emergency physician with PRAXES must possess?
They need experience in caring for potentially sick, undifferentiated patients. Our emergency physicians are excellent at seeing a high volume of sick and relatively well people and being able to differentiate them. They are up-to-date in terms of managing a broad range of problems. They are good communicators. They are good team players as the ED requires seamless working with patients, families, RNs, paramedics, RTs, social workers, administrative staff, housekeeping, security and others. ‘Undiff’ means that they do not have a known diagnosis, and under the circumstances, are not going to get a definitive one with limited resources. Our PRAXES emergency physicians really like what they do.
Is there a particular PRAXES incident that you can share that stands out as being quite dramatic and memorable?
Honestly, there are so many. Just recently I had a call at 0300 from a cruise ship. The captain of the ship was the first person I spoke with after being connected by JRCC who explained their current location. The ship’s doctor was with the patient and the captain gave me some basic information. Then the doctor came on and he sounded very worried. He had done what he could and I thought he was considering the right possibilities for the elderly passenger with increasingly severe shortness of breath (SOB). SOB, chest pain, abdominal pain each have a long list of possible causes. It is impossible to know in such a setting what is the cause. It might be a combination of things. Sometimes, even at specialist hospitals the cause is not definitively found. So, he was starting several treatments at the same time for some of the possible causes and we agreed the passenger had to come off immediately. The ship could divert to the nearest appropriate port in approximately seven hours or he could be lifted off in two to three hours. It was dark and the weather was good. Time was of the essence. So, I authorized a medevac. JRCC contacted the SARTechs. I got a call 30 minutes later from someone asking about the best destination. He could go to a regional hospital in Nova Scotia and be there in 15-20 minutes after extrication, or fly longer to a tertiary care hospital. I felt he would do fine in a regional hospital. I called that hospital hours later and he was safely in the ICU and they were still trying to figure out the complexity of his problem.
You wear many hats such as trauma team leader, emergency physician, professor and author. Clearly, you are very passionate about health and wellness on a global scale. When you find some time away from work, what do you like to do?
I am still very interested in global health and building capacity in developing countries for emergency care – Tanzania for several years and now trying to establish a program in Nicaragua. I’m also interested in Canada’s far north for the same reasons. So travel and learning about the world, its networks and interdependencies and complexities are passions of mine. I try to exercise regularly to preserve my mental health. I enjoy biking, kayaking, racquet sports, and even just jumping up and down being flogged by a relentless person on a DVD when traveling! I’m always reading eclectic stuff, and trying to think outside the box while working on a bunch of weird projects. But best of all, I love hanging out with my wife and two boys whenever we have the opportunity.