Moving Day

Today the entire hospital in North Bay moved to the new site.  Amazingly the whole thing went off without a hitch.  All the patients were moved by around noon and there were plenty of extra people on site to help with moving all of the equipment after the patients were moved.

Stretchers lined up waiting to transfer patients to the new hospital.

Ambulances lined up to take patients to the new site.

Front entrance of the new hospital.

Sunny main corridor in the new hospital.

Getting settled in the new NICU.

Of course there were a few small problems, mostly we were having trouble finding things when we arrived at the new site.  I needed the size 00 laryngoscope blade urgently at around 12:30 for a premature baby's delivery and it couldn't be found.  Just as we were getting ready for the baby's delivery, the blade arrived from the old hospital on a cart of NICU supplies.  The new NICU is about 5 times larger than the old one.  It's a huge improvement and we got to try it out today when the new premature baby arrived!

On Call

I am on call this weekend in North Bay.  Here's what a typical "on call" day looks like for me.

8am: arrive at the Neonatal Intensive Care Unit (NICU) to receive "handover" from Dr. Clayton who has been on call for the past two days.  Handover is a report on all the current patients given by one doctor to another.

8:30am: I speak with the NICU nurses about the babies in the NICU.  I then examine the babies and review any blood work or x-rays.  After gathering all this information, I make a plan for each baby and write a progress note as well as any orders.

Dr. Madden (in orange) with several NICU nurses who are packing in preparation for our move tomorrow!

The current NICU is extremely cramped.  The supply cart and nursing area are crammed together here.  There's really only room for 1-2 mothers to feed their babies at once, and sometimes we have 10 babies!

View from the NICU window, looking out at Lake Nipissing.

There's a baby somewhere in there...

The NICU in North Bay has 10 beds and will accept babies as young as 30 weeks gestation (term is 40 weeks).  Any babies who are younger than 30 weeks will be stabilized and transferred by air ambulance to either CHEO in Ottawa or the Hospital for Sick Children in Toronto.  These hospitals both have a neonatal transport team, consisting of a specially trained NICU nurse and respiratory therapist, who will come and pick up the baby.  If possible, any mothers presenting in preterm labor at less then 30 weeks will be transferred before delivering, since the outcome for the babies is better if they are born at a hospital which has an NICU which can care for them and don't have to be transferred.

9:30am: I leave the NICU and walk down the hall to the pediatric ward. I get a report on each of the patients from their nurse.

10-11:45am: I visit each patient.  I examine them and speak with them and their parents.  Today I had 5 patients to see.  If I think that the patient is able to be discharged then I will send them home after I see them.  I dictate a discharge summary on each patient who's discharged which gets sent to their family doctor.

Typically there are between 2 and 8 patients admitted.  Although sometimes as many as 9 or 10.  Currently pediatrics shares a ward with gynecology, however, at the new hospital, gynecology is moving into a surgical wing, so pediatrics will be alone.

Common causes for admission include bronchiolitis (a respiratory infection in babies), asthma exacerbations, jaundice requiring phototherapy, pneumonia and seizures.

11 am: My rounds on the inpatients have to be put on hold for two babies who have been brought back to have their bilirubin levels re-checked.  Often newborns are discharged home at just over 24 hrs of life and their bilirubin level may be slightly elevated and need to be repeated to ensure that phototherapy is not needed.

I examine the infants and check with the parents that their babies are breast-feeding well.  The phlebotomist comes and draws the blood and I send the babies home.  I will call each family if their infant needs to be admitted or needs to have any further checks of the bilirubin done.  I send the families home because often the result takes 2 hours to come back!

After rounding, I stop by the labor and delivery nursing station to see if there are any consults for me.  Typical consults from L&D include jaundice and any physical abnormalities which are found when a baby is born.  Today there are no consults.

I also confirm that there aren't any women who require my presence at their delivery.  A pediatrician (or resident) is required at every delivery where there is meconium (the first type of stool that a baby passes) in the amniotic fluid since this is a sign of fetal distress.  We also attend any deliveries where there is a concern about the fetal heart rate as well as all C-sections.  There is a C-section every day or two.

12:30: I drive to the pediatrician's office (less than 5 minutes away) where Dr. Madden has called in a patient who he would like me to see.  I examine the patient and then talk with the family with Dr. Madden.

2pm: I am paged by the nurses on pediatrics.  The bilirubin levels are back on this morning's babies.  I call one family back and let them know that the level is low and nothing needs to be done.  I call the second family and ask them to bring the baby back to the hospital to be admitted for phototherapy since the level is high.  The family arrives and I explain the situation and take a bit more history.  The nurses bring in the phototherapy bed and put the baby on it.  He glows blue.

This isn't my photo, but we use the same beds for phototherapy.

The phototherapy works by converting bilirubin in the skin into a water soluble form which is then excreted in the urine.  I expect that the baby should be able to go home tomorrow.  Hopefully before we move to the new hospital.

3:30pm: I go back the the NICU since the parents of one of the babies have come to visit.  I want to give them an update on their baby.  I discuss how the baby is doing and explain what to expect about how long the baby with be in the NICU for (likely until around the time of his due date).  I answer their questions and then head home.

Nursing station on the pediatric ward.

7:00pm: I receive a page from Labor and Delivery, there is a mother in labor with meconium, can I please come for the delivery.  I arrive just before the obstetrician and soon after the baby is born.  He doesn't require any resuscitation.  I write a quick note and decide on the patient's APGAR scores.

APGAR is a score given to all babies at 1, 5, and 10 minutes based on their colour, heart rate, respiratory effort, tone and irritability.  Each category gets a score out of 2, for a maximum of 10.  It helps us know if the baby had any distress at birth.

9:00pm: I'm at home when I receive a page from the NICU nurse.  The obstetrician is going to do a C-section soon.

11:15pm: Another page, this time telling me that the mother is being brought down to the operating room to start the C-section.  I head over to the hospital and get dressed for the OR (I put a gown over my clothes since you're not allowed to wear regular clothes in the OR).  The baby comes out crying and no resuscitation is needed.  We bring the baby to the NICU to be observed until the mom is awake and in her room (usually a couple of hours).

Midnight: I go home and try to get some sleep before the next call.  Thankfully I am able to sleep until 8am when I'm back at the hospital for another full day of work.

Another 10cm of snow!

More snow....more winter.

Some people have asked me to describe a typical day.  The first thing to know is that there's a very wide variety to my days.  I'm going to describe today which was a typical clinic day.

8:30 am
I arrive at the clinic at One Kid's Place where all of the North Bay pediatricians have their offices. I start by reviewing charts for new patients who are coming today.

8:45am
My first patient arrives.  Generally a new consult is booked for first thing in the morning.  This means that the patient's family doctor has requested a consult with a pediatrician because there is a specific clinical question or problem which the GP would like the pediatrician's opinion on.

In Canada, typical clinical questions include:
6 year old boy with difficulty paying attention and behavioural problems at school, could this be ADHD?
2 year old girl who is not gaining weight.
11 year old girl with a first seizure.
12 year old boy with obesity and snoring at night.

Today my first patient was having behaviour problems.  I spend over an hour talking to the family and then examining the child.  My assessment includes finding out about the mother's pregnancy, the family history, any past medical problems, hospitalizations or surgeries and the details of the current problem.

9:45am
I exit my office and cross the hall to Dr. Madden's office to discuss the case with him.  We agree about the diagnosis and return to my room to talk with the family.  Together we discuss the diagnosis and any tests or further evaluations which are needed.  Often with children who have school problems, psychoeducational testing is recommended to look at the child's IQ and for any learning disabilities.

10am
The patient leaves and I go to get my next patient from the waiting room.  Another new consult.  This time for what looks like absence seizures.  I diagnose the patient's condition after seeing a few brief seizures while examining the child.  After a quick chat with Dr. Madden, we make a plan for further testing and treatment.

11am
Another new consult, for behavioural issues again.

noon:
I stop for a quick lunch.

12:30
I see a newborn baby who I had seen last week at the hospital for a quick check up.  I order some blood work and reassure the mother.

1pm
Another new consult.  After spending an hour with the patient, I talk to Dr. Madden.  We end up spending another 30 minutes talking with the family.  Behaviour problems can be very complex and the family has a lot of questions and issues.

2:45pm
Finally a follow-up patient.  It's a quick check-up and the patient's symptoms have resolved.  I discharge them from the clinic with instructions to call and book an appointment should the problem recur.

3-4:45pm
I see a few more patients for follow up.  Several are on medications and I make sure that they're not having too many side effects and the meds are doing their job. I renew medications and examine the patients.

4:45-5:45pm
I sit down at my desk and finish all of my notes from the day.  I dictate reports on any new consults and fill out a few requisitions for tests and consults with other doctors.

6pm
I spend a while chatting with Dr. Madden about some of the cases which we saw today.  I ask a few questions about similar cases which he's seen in the past.  He's been practicing in North Bay for 24 years.  He tells me about when he started out, he was one of only a few physicians attending school meetings.  He shares some of his wisdom with me, telling me it takes 5-10 years to really become proficient after you start practicing.

Sturgeon Falls and the Deep Freeze

Today definitely was a cold medical adventure...I'm still trying to figure out how to work in some more of the warm adventures.  I could really use a month in Cuba or Mexico right now.

I had a brief visit to Ottawa this weekend and now I'm back in North Bay for a couple more weeks.  It's the heart of winter now; last night when I drove back it was -25 (plus wind chill making it feel much colder) and today it was just as cold.

Dr. Madden and I spent the day in Sturgeon Falls running a clinic. Sturgeon Falls is a small francophone community about 30 minutes west of North Bay.  Dr. Madden picked me up early this morning since we had to be there for a school meeting at 8am.  It was at least -25 when we left and I was glad that I wasn't driving since I don't have a block heater or a remote starter...(although my car did start this morning when I had to move it for my roommate to get out of our driveway).

At the school meeting, we spent an hour discussing a child's behaviour problems with his teacher, the school's behaviour/Autism teacher, a worker from the children's mental health program and his mother. Then we dashed across the street to start our clinic at the West Nipissing General Hospital.  Since Dr. Madden only comes to Sturgeon Falls once per month, the clinic was jam packed!  I saw three new consults (these generally take 1 hour each) and a number of follow-up patients.  I'm sure Dr. Madden saw at least twice that many. We had great help from an excellent and efficient nurse, Sarah, as well.

When I was at the end of my first year of medical school in June of 2005, I did a month long placement in Sturgeon Falls with a local family doctor.  It was my first experience with clinical medicine (the first year of medical school was mainly classroom based). Today was the first time that I had been back to the community since then.  It's amazing to reflect on how much I've learned and how far I've progressed in my medical career since then!  I almost can't imagine that there was a time when I didn't know how to examine a baby or write a prescription!

Okay, there was way more snow today. 

North Bay!

I am officially back from Nunavut!  Until the plane lifted off the runway in Iqaluit, I was nervous that I wasn't going to make it home.  Weather delays are legendary in the North.  I arrived home on Sunday night and Monday evening I headed to North Bay.  I'm working in North Bay for the next four weeks.  This morning I was greeted by a thick blanket of fresh snow, the first I've seen in two weeks.  It didn't snow the entire time I was in Iqaluit.

Today, I spent the day at the hospital caring for the inpatients on the pediatrics ward, in the neonatal intensive care unit and seeing a few consults from labour and delivery and doctors in more remote communities (although none as remote as Arctic Bay or Pond Inlet!).

I'll be spending the next month working with Dr. Madden.  He's an Irish pediatrician who's been working in North Bay for a number of years.  In fact, for a while, he was the only pediatrician in the community.  To give you a sense of how busy he must have been, there are now five pediatricians working here full time!

The North Bay General Hospital is moving to a brand new building next Sunday, and I'm going to be on call that day.  Tomorrow I'm getting a tour of the new site.  I was in Sudbury last year when they moved, so I guess I'm experienced at this now!  It's always a bit of an adventure with some bumps along the way.  Also there is a big prize basket for the first baby born at the new hospital, but nothing for the last baby born at the old hospital which seems a bit unfair to me!

Goodbye Iqaluit

House where I was staying (second from the left)

Today I am saying goodbye to all of the people who I have met over the past few weeks at the hospital.  It has been a wonderful experience and I hope to be able to come back in the future.

The boarding house.

The stop signs are in Inuktitut.

Hospital lobby and waiting area for Emerg.

Mural on the retaining wall and the hospital above it.

Another week, some details about Northern Life

The past few days have flown by.  I've been very busy everyday with my clinic which runs every afternoon.  In the mornings I see any inpatients who I am following as well as make a lot of phone calls.  I'm often discussing cases on the phone with a specialist from Ottawa or I'm calling a nurse at one of the Health Centres in another community to let him or her know about a patient whom I am sending home.  Because so many patients come from smaller communities and are flown to Iqaluit for hospitalization or to visit the doctor, there is a boarding home across the street from the hospital where they stay when they come down for a test or outpatient appointment.  The patients are not allowed to fly back to their communities until their papers are signed by the doctor saying that they're allowed to leave!  All of these flights are paid for by the Government of Nunavut which is one of the reasons that health care costs are so much higher up here.

For the eastern region on Nunavut all of the pregnant women are flown to Iqaluit one month before their due date. They stay at the boarding home until they deliver their babies.  Then after they're discharged they go back to the boarding house for a night before flying home.  Often the mothers are quite young; most of the moms that I have seen have been between 16-22 years old.  They get very homesick being in Iqaluit alone, waiting to have their baby.

All of the smaller communities in Nunavut have only a health centre staffed by nurses.  These nurses are responsible for seeing and often treating patients.  They're able to prescribe some medications and they handle a wide variety of medical problems on their own!  The doctors up here give a lot of medical advice over the phone.  Each family doctor is assigned to one community; they visit that community every six weeks and serve as the person who the nurses can contact for advice.

All of this is so different from what medicine is like in the southern portion of the country.

I can't believe that my two weeks are almost over!  I'm flying home (directly this time) on Sunday!

Skiing!

Sled dogs hanging out.  They're kept tied up on the edge of town.

Looking back at Iqaluit from near the airport.

Cross Country Skiing with Dr. Jetty.

We also had a husky puppy along for a run.

Skiing as the sun sets.

Today was a great adventure.  I went for a walk with Sarah, my roommate this morning.  We walked all the way out past the airport.  We saw where the sled dogs are tethered on the edge of town.  They don't seem to get cold staying outside all the time.  I am told that you only feed them a couple of times per week!

After a delicious brunch at the Frobisher Inn, waffles, Arctic char, scallops, eggs benedict, I headed out skiing with Dr. Jetty and couple of her friends.  I only found out afterwards that the friends had been to both the North and South Pole and were planning to kite-ski the Northwest Passage this spring!  Our ski must have seemed like a walk in the park for them.

Skiing was cut short by a page from the hospital, but while driving back into town, I had a great view of the Northern Lights again!

Exploring Iqaluit

Stuffed Polar Bear at the visitor's centre.

Midday looking out across Frobisher Bay. Normally the ice is smooth, for the first time since 1962 it's bunched up.

2:30pm, the sun has just set.

My office at the hospital.

Today after I finished my rounds at the hospital I walked around Iqaluit.  I visited the visitor's centre, which has an interesting exhibit on Inuit culture and history.  As well as this polar bear; which is the closest I intend to get to one of these critters!  I also checked out a local grocery store.  Cornflakes were $8.99, Colgate toothpaste was $6.99! Believe it or not the government also subsidizes the cost of some nutritious foods up here!  And they're still that expensive.

One issue that I'm confronted with when treating my patients is that fact that there are a lot of families who don't have enough food to eat. Also because of poverty many families cannot afford a crib for their baby, mainly because the cost of shipping to a remote Northern community would be several times the cost of the crib.  This means that the babies are sharing a bed with their parents.  A practice which is not recommended by the Canadian Pediatric Society because it is associated with an increased risk of Sudden Infant Death Syndrome.  The baby is at an especially high risk of SIDS if the parent falls asleep after drinking or taking drugs, substances which are very commonly used up here.

Skin Kayak at the museum.

Statue at the Visitor Centre.

Sealskin boots for my stethoscope.

Clear Skies and Below Zero Temperatures

Finally the mercury has dipped below freezing, proverbially speaking.  The clear sky of last night continues and there was a spectacular sunrise this morning around 9am.  Every week the length of the daylight increases by 30 minutes!  Today there were 4 hours and 53 minutes between sunrise and sunset (according to NASA's calculations).

Today I saw lots of chubby Inuit babies in my clinic.  They look so cute and cuddy!  Just like baby polar bears (which I have not seen any of yet).  Although my neighbours do have an entire adult polar bear skin complete with the head on their living room wall, yikes!

All of the mothers here carry their babies on their backs inside their parkas. There is a special parka called an amauti just for carrying your baby in!

Not my photo, but you get the idea of the amauti.

8:30am from my bedroom window.

Aurora Borealis

I wasn't going to post anything today.  I got too busy with babies and kids.  Until tonight when I got a call from one of the other docs telling me to go outside and check out the northern lights!  Finally the cloud cover of the past few days has lifted and the green swirling glow of the aurora borealis was visible!  I stood on my driveway watching the lights drift across the sky.  There is something ancient and peaceful about the Arctic.

Hyperactive children...

Today I held my first outpatient clinic.  Unfortunately schools and government offices were closed due to the weather and thus only half of my patients arrived.  The weather was unseasonably warm (4 degrees Celsius) and as the snow melted to expose the ice underneath it became extremely slippery.  Yikes!  It's supposed to be warm until the weekend when it will go back down to -8.

My first patient, aged 14 months was very active and was climbing all over her mom and the office.  She also had her 2 and a half year old sister with her, who proceeded to explore all the cupboards and shelves in my office.  Unfortunately there are no toys in my office!  (In case you're wondering, toys are standard equipment in a pediatrician's office.)

View from the hospital of the Frobisher Inn. 

The logo of the Qikiqtani Region Hospital. Which is used to decorate the walls and floors.  I think it's two fish and a bird.

The nursing station decked out for the holidays.  The hospital logo is incorporated into the floor.

Day 1 at Qikiqtani Regional Hospital

I woke up this morning to discover that the electricity was not working.  First I tried to turn on the lamp, which didn't work.  Then I tried the light switch, then I looked out the window and realized that the whole town was dark. From my room on the second floor I have a view of a large portion of the town and the bay.  After a week of holidays, a cup of coffee and a shower would have helped to start the day, especially considering that I had to wear the same clothes as yesterday.  This is certainly turning into an experience more reminiscent of Botswana than I had anticipated.

I spent a quiet day getting to know my way around the hospital.  It's new and very clean and colourful.  I have my own office which is used by each pediatric resident. I checked out some of the resources in my office including the Nunavut Food Guide which includes "traditional" or "country" foods, and has a picture of a whale on it!

http://www.gov.nu.ca/health/FG_english.pdf

Tomorrow I will start to see patients in my clinic!

Also my luggage has arrived.  Although it took three calls to the airport to find out.  It doesn't seem like they were going to contact me...and they refused to deliver it, despite having promised to do so yesterday...Well at least I have something clean to wear tomorrow.

Iqaluit!

I am spending the next two weeks working in Iqaluit, Nunavut.  I guess this blog is becoming about medical adventures in hot and cold places.  I arrived in Iqaluit today after boarding a plane in Ottawa which then made stops in Montreal and Kuujjuaq (northern Quebec). Total time spent squished into the window seat beside a large Inuit teenager, 6.5 hrs.  Apparently over Christmas First Air does this "milk run".  Thankfully my flight home is direct to Ottawa and only 3hrs long.

Unfortunately, my bag did not arrive!  Containing all my clothes, food, stethoscope and reading material!  I'm not sure how this happened since I never changed planes...but there's another flight tomorrow, so hopefully it will arrive then.  Meanwhile I'll be wearing hospital scrubs until a change of clothes arrives.

I arrived around 3pm and it was still light out, although within the next 30 minutes darkness descended.  The weather here is a balmy -3 degrees with high winds and blowing snow.  Definitely less intense than I was expecting.  Keith, a coordinator for the hospital, picked me up and gave me a quick tour of the town.  Population approximately 8000.  There are the usual grocery stores, government buildings and the hospital. The big difference I noticed was how far off the ground all the windows are; I presume this is because of the height of the snow in the winter.

Flying into Montreal, the first stop on the milk run.

Kuujjuaq airport, my second stop.  Weather was blowing snow.

Finally arriving in Iqaluit.  Walking to the terminal, only to find my bag had not arrived.

I'll try to keep posting about my adventures up here!  I'm hoping to go dogsledding at some point (when I'm not busy with medicine).