I don't mind weekends on call because I've learned a lot. Not only am I on my own, having to use all the medical knowledge I've acquired over the years, but because I really have to rely on my clinical skills as most emergencies seem to happen after 6 PM. Medicine is harder here after 6 PM because that's the time of the last flight from Tinian to Saipan. Not only does it mean that I can't send patients to the hospital (well, that's not exactly true . . . I can call in Life Flight, but that's $2000!), but I can't send blood for labwork either. I can draw the blood and hold it until the morning flight and then wait for the results, but there is no such thing as STAT blood work. You know those scenes on ER where they send off the blood and even before the next commercial break they have the results? Doesn't happen here.
Two weekends ago I had two emergencies come in within 15 minutes of one another. In fact, as I have only one emergency treatment bed, I had to move one patient out of the ER and into our hospital room prior to the next patient arriving by ambulance. One was a patient with chest pain and the other a post-stroke patient who seemed to have had a seizure. For chest pain, the first thing we do (after checking for breathing and a pulse) is to give oxygen, an aspirin, nitroglycerin, and morphine for pain. Then I hooked up an EKG and saw ST-segment depression with inverted T-waves. In any ER on the mainland, you draw blood and order tests, which verify that the patient is having a heart attack prior to any real intervention. Here, I draw blood and put it on ice so that it can be sent to Saipan the next morning to verify that what I'm about to do anyway was the correct thing to do. Working like this is not a bad thing . . . it is a different way of doing things. I truly have to rely on my sense of things and my clinical exam. I actually have to listen to the heart rhythm and look at the veins in the next to see if they are distended. I have to PRACTICE medicine and I have to evaluate the odds and possibilities or "differential diagnosis."
As mentioned above, 15 minutes after this patient arrived, my suspected seizure patient arrived. No EEG, no CT scan, nothing but a good history and exam.
I've learned to rely on my instincts and gut feelings. I've learned to hold patients for observation and watch for changes. I've also learned to play the "what if" game.
If I call my radiology tech in tonight for an ultrasound and he finds "X," will that change what I do tonight? Sometimes yes but most of the time no, so I wait until my radiology tech arrives in the morning and just observe the patient for any change.
When I finally got the labs back for my chest pain patient, I found out that she really had had a heart attack and that my instincts, and my interpretation of the EKG had been right.
So I've learned to be very exacting in my physical exams and to trust my instincts.
This weekend was pretty exciting as well with injuries, minor surgery, and hospital admissions. I have great nurses here and they all know that I think by talking, so they very patiently let me work out the pros and cons and differential diagnosis and the "where do we go next"s.
By Monday, I'm exhausted but satisfied that I've learned more on this island than I would have in the states.