Dr. Perry Gray and his group

Southern Exposure

Family Physicians work in HSC’s Surgical ICU to better serve their patients in rural and remote communities

Imagine this scenario:
A critically ill patients arrives at the Health Sciences Centre in Winnipeg. She has multiple fractures, unknown internal injuries, and is currently unstable. An emergency room doctor, residents, nurses and respiratory therapists jump into action. The HSC has a general surgeon in the hospital seven days a week, 24 hours a day for this specific situation. Other specialists from surgery, anesthesia and critical care are called in for consults. Around the patient’s bed, a team of medical experts work the problems.

Now imagine this same scenario but in Thompson, The Pas, or remote communities in rural and northern Manitoba and beyond. There is one doctor making every decision aided by a couple of nurses in a four-bed or fewer emergency room. It could be overwhelming but instead, the doctor is calm and ready. Even flying solo, this family doctor has the skills and confidence to work the problems optimizing the patients chance for survival while preparing for the safest possible transfer to HSC.

Dr. Perry Gray is helping make this happen. He’s the chief medical officer at HSC. Most recently, he was also the medical director of the surgical intensive care unit (SICU). In 2012 in the SICU, he started an experiential program for family doctors practicing in rural, northern and remote communities. Family doctors from across Manitoba and as far north as the Belcher Islands in Nunavut now come to Winnipeg’s SICU to see, learn about, and treat the most critically ill patients. These patients are typically found in HSC’s SICU. It’s the province’s main resource for traumas; neurosurgery; burns; and many other tertiary surgical emergencies.

Gray’s program is not about training, per se. It’s a work experience model that exposes northern and rural doctors to critically ill patients who have complicated, multi-system problems. The clinical exposure and experience builds doctors’ confidence, self-reliance, and broadens their skills.

It’s also about having a healthy roster of skilled doctors to assist attending physicians who provide care to the complex group of patients in the SICU. The northern doctors stay for up to two weeks on staff, and then head back home. And then, over the years, they can come back regularly or periodically to work again in the SICU in Winnipeg. This hospitalist program has other outcomes.

“I’m convinced that it improves the care for patients up north,” Gray says. Dr. Sara Goulet is a perfect example of that. She had been practicing family medicine up north for seven and a half years in places like Churchill and Garden Hill.

“It was an interesting practice but I felt like I was losing some of my skills, like reading blood work,” Goulet says. “I wanted to get that back.” So in June 2014, Goulet flew south to Winnipeg for a two-week stint at the SICU.

“I was really nervous to go try this.” For two weeks, she shadowed a senior physician in the house medical officer role. She did rounds, worked 24-hour shifts, responded to critical cases and complications, all the while watching, listening and jumping in. In return, the SICU had another staff member they could rely on.

“We’re helping them out, they’re helping us out,” Gray says. Today, Goulet spends one week in Winnipeg and every second week in either Red Sucker Lake or Garden Hill in Manitoba, or Whale Cove and Sanikiluaq in Nunavut.

“The things you see in SICU are at the extreme care end. The problems are very obvious, most often. Then you go back up north to family medicine where you see problems that are much more nebulous,” Goulet says. “It makes me much more able to treat people in our ER.”

Dr. Matthew Alkana β€” another ‘graduate’ of Gray’s SICU program β€” agrees.

“If I have a critically ill patient come in, I don’t get too excited. I don’t get panicked. With the experience I have now, I am comfortable to manage the situation,” says Alkana, a hospitalist based in Flin Flon.

As a resident, he did two rotations in the SICU at HSC before graduating in July 2014. (He is also a graduate of the Northern Remote Family
Medicine program at the University of Manitoba.)

That confidence is key when rural doctors face complicated and nerve- wracking scenarios in emergency centres with less resources, fewer staff and no specialists, to speak of.

It’s also about relationship building. The opportunity to get to know your colleagues throughout the province can be priceless. Like all the northern doctors who have worked stints in the SICU, Alkana has met and worked with a wide range of specialists in Winnipeg. Alkana knows them. They know Alkana. So back in Flin Flon, if Alkana has a question about a patient, he doesn’t hesitate to call Winnipeg for a consult with a specialist.

“I have a very low threshold for calling the city for a specialist,” Alkana says. “I’m not just a voice on the phone. The specialist knows me, remembers me, and listens to me. The care we give β€” because of that personal connection β€”is much better.”

That connection has another positive side effect. Not only does it allow the northern and rural doctors a valuable learning experience it allows the Winnipeg based doctors to have a better understanding of the challenges of northern and remote practice. That’s what Dr. Colin McFee, another one of Gray’s people, has realized.

“Some doctors don’t have a complete understanding of what a rural (practice or ER) setting is like,” says McFee, who’s also a graduate and now an assistant professor of the U of M’s northern and remote family medicine program.

But that’s changing, McFee say. By virtue of proximity in the SICU, information about northern family practices and northern medical resources is informally exchanged between doctors during conversation and the course of any one day. Those conversations spark better understanding by urban physicians about care and treatment up North and in rural communities.

“There’s this crossing of knowledge between rural doctors and urban doctors,” McFee says.

Gray began the unofficial program to solve some staffing issues and help northern doctors maintain their skills in critical and complex situations.
As it has developed however, it has become much more than that. For the doctors who come to Winnipeg for their schedule in the SICU, the variety and scope of care keeps them up to date. But it also keeps their work life interesting. And it allows colleagues from all parts of the province to learn exposure to more difficult trauma cases.

And many of those doctors have told other doctors. There’s no official obligation in the first week, Gray tells them. But if they want to come back, doctors have to commit
to helping the SICU team ‘on a part time basis.’ But some of the northern doctors, like Sara Goulet of Red Sucker Lake and Whale’s Cove, now take regular shifts in Winnipeg’s SICU. Goulet is in the city half time now.

For Gray, the program is just in its infancy but it’s already seen some exciting growth, he says.

Dr. Bojan Paunovic is the Medical Director of the Winnipeg Regional Health Authority’s Critical Care Program. The program has also expanded to include the HSC’s Medical Intensive Care Unit (MICU). Gray and Paunovic work together enabling some physicians to alternate between SICU and MICU.

Dr. Gray also credits the support of Dr. Brock Wright, WRHA’s Chief Medical Officer for the program’s success. Wright immediately saw the value to HSC, WRHA and the rest of province, Gray says. However, there’s more work to do to improve care in rural and northern Manitoba and in WRHA’s Tertiary Care Hospitals.

“I would love to see a collaborative relationship between the WRHA and other Health Regions that formalizes the rotation of physicians between the tertiary hospitals and their rural practice,” Gray says. “This would enhance their ability to treat patients in their “home base” practice while providing valuable support for patients receiving the most complex care in our tertiary hospitals.”

And who knows, maybe what started out as a staffing solution for the city may now keep more doctors working up north, longer.

Here’s what other doctors are saying…

Dr. Manon Pelletier, family physician, hospitalist at the Health Sciences Centre’s CCDU; and house medical officer at HSC’s SICU.

“I started working in SICU straight out of residency. I was very green and working up North and in rural areas. The skills I acquired here have made me much more comfortable in most emergency situations that can arise, especially traumas. I am now proficient at intubating, inserting central lines, running codes, etc. It has made me a more versatile and well-rounded family physician.”

“Working in SICU, among other things, has allowed me to foresee potential complications in patients and act on issues quicker to prevent ICU admissions.”

“This program allows physicians from many different settings to expand their knowledge base, improve their comfort level in emergency situations and practice skills they do not do often otherwise. It also allows exposure to the tertiary care setting, which provides a different perspective then rural or northern practices would, along with allowing opportunity to network.”

Dr. Rafiq Andani, rural general practitioner with Prairie Mountain Health in Swan River, Manitoba.

His scope of practice includes: GP oncology; addictions medicine physician; hospitalist; ER physician; family physician in a primary care clinic; and a personal care home physician

“The skills and experiences from working in the HSC’S SICU have allowed me to effectively manage and treat critically ill patients that have presented to me in the emergency department or have been admitted to hospital in Swan River with greater comfort and confidence.”

“Working in the ICU I frequently meet and work with a multitude of specialists. The interactions are not only educational but allow me to familiarize myself with the specialties and the system they operate in.”

“Having rapport with the surgeons and specialists allows for a more streamlined referral process. Working closely with specialists means I can provide better/more appropriate referrals, set up the relevant and appropriate diagnostics and investigations for the patient, thereby making the patient specialist encounter more efficient and generally have a greater sense of collaborative care for shared patients that transcends the formal referral letter and consultation process.”