
Fancy a move to BEAUTIFUL Newfoundland ?

2 x fulltime (regional rural Cat A) FFS ER positions immediately available.

CCFP(EM) not required.

Adequately paid : current incumbents = approx $ 500k per annum, no overhead.

Walk in to your shift, walk away at the end of your shift.


Shifts cycle in a predictable templated format, with a guaranteed equitable spread of days and nights, and allows you to plan up to a year in advance.

Guaranteed income, you can't lose your allocated shift without your consent. Internal swaps prn feasible and encouraged.


Template is sequenced for optimal diurnal shifting : day / day / night / night, followed by a sequence of 4 off. Walk away and relax !


WELL supported : General Internists / General Surgeons / O&G / Peds / Anesthesia and RTs / Radiology / Hospitalists / ICU / CT scanner, what more could you ask for ?

Superb community, I've been here for 23 years and counting...

DMs or Nancy.Avery@easternhealth.ca

ER Positions in Beautiful Newfoundland: Lucrative and Flexible



Ex NL / want to come back ? Incentive $ 100k. Or others wanting change ? Consider Clarenville. 1 x FFS FTE ER MD (EM not required), $ 460-510 k pa, NO overhead. Lifestyle, walk in / walk away, focused EM shifts. Mmm, sunrise from my deck, buddy fishing in the ocean below :



$232.04 / hr. 10 hr dayshifts, 14 hr nightshifts. Dual MD 8 hrs on 3 dayshifts / week.  ER NP 8am-4pm M-F.  8 bed ER, OR, 4 bed ICU, 40 ward beds. Dedicated ER portable U/S in ER. CT scanner, . Int Med / Gen Sur / O&G / Ped / Anes / RT / Hospitalists.



50/50 mix of CTAS 1-3 vs. CTAS 4-5.

Avg 20-25 / shift, 2 / hr. Decent quality possible, NOT a numbers mill.

We are not a factory floor, people are not inanimate widgets, LEAN / X32 is not our deity : individual patients matter, and geriatric complexity is real.



Regional rural hospital. Community 10k or so, larger catchment area. NO TRAFFIC JAMS. 2 lights and 7 min from my front door to ER. Rock solid Newfoundlanders, salt of the earth. I've been here for 21 years, and wouldn't exchange it for ANYWHERE. Mmmm, sunset from my deck :


and besides, :

https://twitter.com/Lauren_CBee/status/1579595918491668481



Get out of you city rat race / off the hamster wheel : go rural, give it a try, it rocks, best kept secret ! And we ROCK at trauma :

https://twitter.com/DrEvdLinde/status/1570245010888753152



You KNOW you want it, DM me yesterday already and let's explore !



https://www.gov.nl.ca/releases/2022/health/1004n02/



https://www.cbc.ca/news/canada/newfoundland-labrador/medical-licensing-nl-doctors-1.6608829


You can read the unrolled version of this thread here: https://typefully.com/DrEvdLinde/Q8vpWHM

ER position available in Clarenville, Newfoundland



Interesting f/up =  proposed Trauma Team (tertiary sourced & based : ERPs / Surgeons / RNs / RTs), flown out to a rural site.

Sounds great, right ?

#Controversial ?

@SRPCanada  @alandrummond2  @snewbery1  @ElaineBlau
@SarahGiles10 @TheSGEM

https://twitter.com/DrEvdLinde/status/1570245010888753152




No, not necessarily.

As always, it depends.

Tertiary ≠ Rural = simple fact.

Cardinal rule = you have to know your local milieu & challenges intimately.

Relative risk : tertiary = potentially in deep water rurally, if no recent hands on exposure (and vice-versa).




Again, the rural mantra, which we live or die by : resources, distance, geography, weather, time.

Less relevant for tertiary teams = the latter four (and how you need to adjust to wisely utilize the first).

Prime example : the simple availability of a CT scanner



We have CT scanner. Used 0/8 cases, focused on that only essential to the task at hand for transfers : HR/BP stable, clinical judgement / PoCUS portable CxRs for tube confirmation & ventilation.

5/5 transfers had pan-CTs at tertiary. No change in Mx.




Why ?

Tertiary trauma : based on mechanism alone = "pan CT".

No change in Mx.

Realities : rurally, solo X Ray tech on duty  = portable X Ray tech /  CT Tech as well. Deploy them wisely : the multiple repeat portable CXRs post intubation, trump.

Adjust or perish.



Don't do CTs rurally, unless they directly immediately change Mx, & carefully consider the impact : = time, = in turn impacting medevac time & weather windows.

Pilot / medevac staff regulations = set in stone for a reason : flight safety = non-negotiable.




So = the last thing you may actually want in your rural ER are (well intentioned) tertiary folks brothers & sisters in arms, simply by the nature of the beast, are not familiar / comfortable with the rural paradigm.

https://www.youtube.com/watch?v=jhdFe3evXpk



Rural regional = local core resources to deal with < 10 critical cases. Don't need tertiary Trauma Teams, need (as per this case) a focus on effective / rapid delivery of expert HEMs for evac once stabilized = no loss ambus and RNs to transfer.

https://www.ornge.ca/about



Remember the "it depends" in 2. above ?

Yep, the concept could indeed be a great central rapid response resource, for e.g. cutoffs > 10 simultaneous critical mass casualties presenting to the average regional rural hospital.

But those events are luckily indeed rare.



Time, effort and expense related to the establishment & maintenance of such a proposed concept, = better spent on upgrading core HEMs resources to rural locations.

Because that helps not only for disasters, but the average daily critical care needs in rural Canada.


You can read the unrolled version of this thread here: https://typefully.com/DrEvdLinde/pGZUXDY



Interesting in f/up =  proposed Trauma Team (tertiary sourced & based : ERPs / Surgeons / RNs / RTs), flown out to a rural site.

Sounds great, right ?

#Controversial ?

@SRPCanada  @alandrummond2  @snewbery1  @ElaineBlau
@SarahGiles10 @TheSGEM

https://twitter.com/DrEvdLinde/status/1570245010888753152




Why ?

Tertiary trauma recommendations  based on mechanism = "pan CT".

Realities : rurally, solo X Ray tech on duty  = portable X Ray tech and functions as  CT Tech as well. Deploy them wisely : the multiple repeat portable CXRs post intubation, trump.

Adjust or perish.



Don't do CTs rurally, unless they directly immediately change Mx, & carefully considered the impact : = time, = in turn impacting medevac time & weather windows.

Pilot / medevac staff regulations = set in stone for a reason : flight safety = non-negotiable, for pts & staff.




Rural regional = (in general) local core resources to deal with < 10 critical cases. We don't need tertiary Trauma Teams flown in, what we need (as per this case) is a focus on effective and rapid delivery of expert HEMs for evac once stabilized.

https://www.ornge.ca/about



The time, effort and expense related to the establishment & maintenance of such a proposed concept, = better spent on upgrading core HEMs resources to rural locations.

Because that helps not only for disasters, but the average daily critical care needs in rural Canada.



Tertiary Trauma Teams to rural locations ?



A 🔥 rural ER Code Orange (Refinery Disaster)

Shared lessons & insights from a small regional rural hospital in Clarenville, NL (pop approx. 10 000)

#RuralRocks
#RuralMatters

@SRPCanada @alandrummond2 @snewbery1 @ElaineBlau  @SarahGiles10 @TheSGEM




Murphy's Law = a disaster will happen in a rural location leading into the Labour Day long weekend, in the context of a healthcare system already in crisis.  

https://www.cbc.ca/news/canada/newfoundland-labrador/8-emergency-rooms-closed-across-newfoundland-on-labour-day-weekend-1.6572205



Exacerbated by the pandemic / altered CPSNL licensing, decimating the traditional IMG MD supplemental workforce supply that rural NL was always heavily dependent on.

And intransigence on applying healthy discretion during a bona fide crisis.

https://www.cbc.ca/news/canada/newfoundland-labrador/dr-paul-hart-fogo-island-1.6577101



Rural population ER fundamentals = studied to death

Resources & access / distance / time / geography / weather.

The strategic location of Cat A / Cat B ERs within NL  were well designed for precisely those reasons : mess with it / degrade it at your (& systemic) peril.



Disasters = rare, but Disaster Plans / facility Code Oranges built into muscle memory, matter. 

An orchestra of integration :
On scene first aid.
Fire / RCMP / volunteer S & R response.
EMS response.
Receiving facility response.
Ultimate tertiary disposition with HEMS. 




8 pts, 7/8 CTAS 1 & 2, 6/7 I&V in 1st hour. 

3 x generalist CCFP ER MDs / 1 x ER NP / 1 x general Surgeon / 2 x general Internists / 1 x general Anesthetist / RTs / a 16-20 dream team of cross-trained RNs / 1 x general Radiologist / X Ray techs / Lab Techs / ancillaries.



Rigorous application of fundamentals was key : 

Mechanism of injury = only initial history required

Top down primary survey A-B-C-D-E paradigm, Y / N answers only (immediate intervention & not moving on if the answer was = N).

Traditional bottom up kills in 0-30 min. 



Note the (deliberate) use of "general". Yes, rural Canada needs (and thrives) on *GENERALIST* MDs and specialties.
Strewth, an Internist as an asset for trauma cases / ATLS ?! Yes, they excelled ! Hat tip  @JDwoodfine 



CCFP (EM) & retention of a full generalist scope = a failed training paradigm for rural Canada. Multiple projects confirmed the vast majority gravitate to tertiary / urban in limited EM only scopes. Penetration into rural Canada (original intent) is dismal, but improving.



Maintain big picture systemic context throughout, know your resources (+ & -) intimately, activate early for lead in times & support. 2 x admitted to our local ICU, 5 x T/F to tertiary ICU. Big big deal immediately clearing 5 / 12 beds in a tertiary ICU already full).



Crucial to the success : No questions asked / can do culture via HEMs & tertiary, in a system already stressed to the max & in crisis.

Impeccable collegiality / professionalism, & mutual rural / urban respect.

Kudos 🙏



HEMS response

https://clipchamp.com/watch/8lGZxrhPV63?utm_source=embed&utm_medium=embed&utm_campaign=watch





There is nothing, I repeat nothing better knowing that the cavalry are on the way. Our facility is a 2 hour ambu trip to St. John's, i.e. a 5 hour round trip with handover included (rural can't tolerate the loss of ambus/RN escorts).

https://youtu.be/ZgkIqU15WO0 via @YouTube

 

Our local airstrip is not IFR rated / moose fenced = no FW assets in the dark. I'm a Provincial OLMC MD for Ground Ambulances / Medical Flight Team : we've never had 3 individual expert Flight Team duos  delivered / heli's queued simultaneously rural. Hat tip @hfxjrcc 



Patient's arrived 17h00. Resuscitated / stabilized by 18h00. Heli's arriving 20h45 for packaging & egress (Cougar x 1 pt, Cormorant 2 x 2pt trips). Clarenville ER 18h00-21h00 closed except CTAS 1, back up and running by 21h00. All local ambus and RNs retained. 



The job is not over without  flawless integration into tertiary : real-time progress comms comms comms throughout.

 @JDwoodfine with duty HSC ICU Intensivist
Myself with duty HSC ERP @jstonemclean / Trauma Team alerts 

Rural / urban expertise marriage.



Celebrate / good news story for HCWs & the public for a change / PR / rural advocacy / recruitment opportunity

CBC TV : https://clipchamp.com/watch/pzlEJ2qudFi

CBC Radio : https://www.cbc.ca/listen/live-radio/1-56-st-johns-morning-show/clip/15935247-code-orange-come-by-chance?fbclid=IwAR1Y7QW474FbnaBX6VbodQJaoVGL0-XJ2iQFmmn_FYQ993NraHTD0ePOIzQ

CBC Web : https://www.cbc.ca/news/canada/newfoundland-labrador/come-by-chance-refinery-explosion-emergency-teams-gb-cross-1.6573580



#RuralMatters

Vote strategically.

Dr. A. Lafontaine CMA President @AlikaMD  : rural savvy

Dr. K. Smart CMA Immediate Past President @KatharineSmart : rural savvy

Dr. B. Bouchard CFPC President @bradybouchard : rural savvy




#RuralMatters

Vote strategically.

Dr. A. Drummond CAEP Public Affairs Co-Chair : rural savvy @alandrummond2

Dr. K. Johnson CAEP Immediate Past President : rural savvy

Dr. A. Kernick CAEP President elect : rural savvy



Mutually respectful #SRPC #CAEP collaboration.

Kudos @JIMcEwen & @john_soles for the initiative in 2016, leading to the repopulation of https://caep.ca/em-community/rural-and-small-urban-section/ with dual membership.





Tangential rant. Elect more WOMEN to key leadership : they're simply better at it, period. Men (in general) are testosterone fueled pricks with egos that get in the way.

Christia Freeland
Angela Merkel
Jacinda Ardern
Sanna Marin




I rest my case.

It doesn't help if the man is certifiably psychotic and lives in an alternate universe devoid of truth or facts.



Rural recruitment and retention of competent generalists with clinical courage matters. @MUNMed et al 

The number one reason exiting graduates fear rural solo shifted ER shifts : RSI / intubation. Sorry, a 3 day rotation in Anes during CC3 is atrocious.

No feedback on WHY it worked or didn't. Biomechanics matter. No rescue training using bougies / King LTDs / Airtraqs.



Shameless plug for AIME (no conflicts) : https://www.aimeairway.ca/

And yes, have a bit of FUN self-intubating yourself awake, you never know what you may be required to do rural !

Awake Self-Intubation with edits / practice at end https://youtu.be/S7P5WW5n8VA via @YouTube 

The breadth of required rural generalist procedural training competencies is well represented on this excellent resource @BCEmergMedNtwrk

https://www.bcemergencynetwork.ca/resource_type/procedural-video/


You can read the unrolled version of this thread here: https://typefully.com/DrEvdLinde/IFvIT3R