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When a body is discovered 10 miles out to sea, it sparks a mind-blowing police investigation. There's a man living in this address in the name of deceased. He's one of the most wanted men in the world. This isn't really happening. Officers finding large sums of money. It's a tale of murder, skullduggery and international intrigue. So who really is he?
I'm Sam Mullins, and this is Sea of Lies from CBC's Uncover, available now. This is a CBC podcast. I'm Dr. Brian Goldman. This is White Coat Blackheart. Hi, I'm Shaq. I'm one of the travel nurses. Hi, Shaq. I'm Mike Ruttel. An ER shift often begins with a huddle. It gets the doctors and nurses coming on duty up to speed on the patients.
We do huddles in the ER where I work in Toronto. They also do them at McKenzie District Hospital and Health Services. It's a tiny rural hospital on the south end of Williston Lake in B.C.
This huddle at the start of this night shift is unlike any I've ever seen because it's virtual. And by the way, I'm witnessing it virtually as well. So how are things in the eMERGE today? Right now we are almost full in eMERGE as well as we have a patient who is on four-point restraints. Oh, geez. Yeah, I think we might be going on diversion. We don't know yet.
Diversion means ambulances would bypass this ER and instead take patients to Prince George, a two-hour drive due south.
That's because they're over capacity and don't have enough nurses. Shaq Karimi, a nurse, is on duty and in person at the ER in Mackenzie. Dr. Mike Erdl is on duty, except he's in his basement in Kelowna, nearly 900 kilometers away. So that's unusual. Yeah, by diversion, that's a bit of a problem because Prince George is two hours away.
So even if you're on diversion, they might show up in our emerge anyways, right? And for stabilization. So, and then that's a bit of a potential thing.
So now I'm getting more of the yips tonight. But anyways, we'll deal with it. So, Michael, does that mean they can treat patients on an ambulance stretcher? Do they have other stretchers if necessary? Yeah, yeah. And we can treat patients in chairs as well. So we'll still see patients through the night. But I'll call Dr. Dobson now. Do you want to listen in on that? Sure. Okay. Dr. Lindsay Dobson is a family doctor in McKenzie who also works in the ER. She's been on duty and in person since 8 a.m.,
She's about to hand over to Dr. Ertl. Hello? Oh, hi, Lindsay. It's Mike. Hi, how are you? I'm great. Well, I was good until I talked to Shaq. I'll just let you know, Dr. Brian Goldman is listening in from White Coat Blackheart. But I heard about the patients from Shaq, but I'd love to hear from you. And then I think, you know, we'll still see patients through the night, but if we have to go on diversion for...
For some of the bigger stuff, we will. But if it's something serious, then we can maybe stabilize them and send them off. Yeah, sounds good. So weather up here is a disaster. What's happening? Yeah, we've probably gotten about 10 centimeters so far. So we've had nothing but snowfall all day today, which is sort of affecting our ambulance capacity. And so they weren't able to come pick up this patient. But I have four in there right now that are...
Okay. Oh, geez. Wow.
Okay, well tell me about the other three. The patient Dr. Dobson had to sedate and place in restraints is not the only challenging patient.
Next is a man with an irregular heartbeat called atrial fibrillation. Dobson fixed that. She started a medication to keep the rhythm normal and is keeping him in the ER overnight.
To protect patient privacy, we've stripped out identifying details. And the plan was for 120 tomorrow morning, 120 BID thereafter. Are you in the office tomorrow? Yeah. Wow, busy. Yeah. I know. I don't want to keep you too long. And the other two, Lindsay? As for the other two patients, one has a high potassium level, which, if not treated, can be deadly. Dobson is treating that and wants to make sure the potassium level stays down.
She's treating the other patient for vomiting, but he also has belly pain that could be appendicitis. Yeah, sure, okay. No, that's great. Great. So we'll watch him through the night and see what happens with that abdominal pain. Yeah.
So all your beds are occupied, but we'll still do what we can do? Yes. I think there is one free. Handing off to Dr. Erdl means Dr. Dobson gets to see her husband and young kids at home and sleep in her own bed. Without him, she might well have to spend the entire night in the ER, a full 24-hour shift, then work the next day at a clinic.
I wanted to ask Dobson about this new frontier of virtual emergency medicine. Are you okay if I ask you to just talk to Dr. Goldman and just, I hate to put you on the spot, Lindsay, but... Hey there. I don't want to keep you from your kids. No, no worries. Thank you so much for your interest
in this program it's been it's definitely been wonderfully helpful for us in our small community so you've got a family practice and you're and you're and you do shifts how much time do you spend in the hospital doing emergency shifts so we do about five 24 hour shifts in a given month and we run
That's a lot of work. Yeah.
So what does it mean to you to be able to have Dr. Michael Erdl at your beck and call at night? Yeah, it's a huge relief for us. We covet Wednesdays because that's our day where we get some Vera overnight coverage. They're so coveted that we actually will count how many Wednesdays we each get and make sure that they're all distributed equally because everybody wants a shift that has additional coverage.
Dobson mentioned a VERA shift. VERA is an acronym for Virtual Emergency Room Rural Assistance. This is what Dr. Ertl is doing. And it's meant a lot to our community. It's really helped. We have a huge number of diversions and not a lot of physicians covering our 24-hour care. It's a huge relief. I
I've just listened in on the handover. What does that mean for you to be able to hand over these four patients to Dr. Erdl? To me, it means that I can start to wind down for the night and I won't get potentially called for my high potassium patient or if something crops up with the psychotic patient, then I can try and sort of navigate it to start with. It's nice. It's sort of like a buffer.
So what would it be like if he and other colleagues weren't available to take call and answer questions, interact with the nurses at the hospital in McKenzie?
I mean, I think that rural Canada is really suffering right now. We have the highest number of diversion. The care that we're already trying to provide in rural communities is already challenged not only by distance but also by the resources that we've got. And, you know, we're really quite low on all of our staff and trying to run hospitals is a challenge. So I think Vera provides a huge resource
for those of us physicians who are staying in small communities trying to provide care for these communities and trying to do the best that we can with what we've got. And so it just helps support us at a time when
you know, we already start a little bit behind the eight ball. And, you know, and now with the human health resource crisis, it's just everything's harder. Did you ever think you'd be interacting with colleagues virtually in this kind of a way? No, never. Wouldn't have imagined this. It works to you. You believe it works. I believe it works. It works for me. And I think it's
the virtual services have been a great success for sure. I don't want to take up too much more of your time because I know you want to wind down and get home and get some dinner and be with your family. So thank you so much for speaking with me. No, you're very welcome and very much a pleasure and hopefully this helps the program. Thanks for talking to Dr. Goldman and taking the time and I hope I don't have to call you through the night.
Yeah, no, and if you do, no worries. Please do. I'm happy to take a call for sure. No, I know you are. You're a star. Thanks, Lindsay. Thank you. Thanks. Take care. Take care.
I just got a text from Shaq, the nurse. Edmin is on call calling about diversion. I'll let you know once I hear from them. So I'll call Shaq back. But it sounds like we have one bed if we need it. And then if somebody comes in critical through the night, we'll deal with them. But you heard about the weather, which I didn't know about.
So that's making my heart rate and blood pressure rise. Why? Because of the risk of motor vehicle collisions? Yeah, and strokes, heart attacks. I still get really nervous about sick children, and trying to get them out tonight I don't think is going to be possible. If something comes in that's critical tonight with this weather, we're going to be in the soup and we're just going to have to handle it. Wow.
So, what's the scariest kind of scenario you've had to deal with where you couldn't transport the patient out and you had to treat them virtually right there in McKenzie?
Unstable pediatric asthma for sure, yeah, and get several of those or a baby with bad croup that might need an airway. I've done this for 30 years but sick kids still make me nervous. What makes virtual docs like Ertl less nervous is that local doctors like Dobson must be available to rush back to the ER within 15 minutes should any patient need immediate life-saving care in person.
Since becoming a Vero doc, Ertl says he's had to summon the local MD on one occasion only. Can you think of a child who had severe asthma? You were talking kind of speculatively about how you would treat them or hypothetically, but you must have a picture of what they looked like and sounded like via the iPad. Can you kind of give me that description? How old were they? You know, a 14-year-old where I had to call the doc in. But just on the iPad, you're not there. You see the patient.
They have this look of panic because they can't breathe. You see the patient's parents.
They're like, I hope this guy's a good doctor. I hope he knows what he's doing. The nurses seem to know what they're doing, but my child's not getting better. And what's going to happen and where are they going to go? Is my child going to die? The local doctor came in at, I think I called him in at 6 in the morning. He knew the patient, knew that she's been like this before. I didn't. So he was, and she did very well, thank God. But I was so nervous about her all night. Wow.
Wow. So there are limits to the service you can provide virtually. Can you tell me a little bit about that? If it's a bad trauma, if somebody needs airway support, if they need to be intubated, if they have a collapsed lung and they need a chest tube, or a stroke or unstable heart attack, we'll call the docs in. It's always patient safety first. It's not about them sleeping at night. We try to keep them in bed, but if we need them, they're more than happy to come in.
So, and you've had, you've had- - Oops, sorry, I've got the ER calling me here, Brian. - Okay, all right. - Well, hi guys. - Hey, Mike, how are you doing? - Hi, who's everybody else here? All those people come from, Shaq. Hi, I'm Mike, I'm Mike Kirtel. Who are you?
Hi, Amber. Hi, Shannon. So unfortunately, tonight we're going to go on diversion. So, OK, I'll be available if somebody critical comes in because the weather is so bad. So even though we're on diversion, yeah, we're not on diversion, if you know what I mean. Right. But I get it. But we could be we could be in a bit of trouble here. Right.
Now, what about the overnight? So you're still responsible for them then as well? Yeah, call me. We don't want to wake Dr. Dobson up. She had a long day. Sure. All right. So we'll still probably be talking to you at some point, I'm sure. Totally. Okay. So do you have a one-to-one for the psychiatry patient? Well, we have the three of us here. So we have one of us for the psych, one for the unit, and one for the tele and the eMERGE people, basically. Okay. Okay. Awesome. Well, let's get through it.
We'll get through it. We always do. Okay, thank you so much. Yeah, video later after the screening too. Virtual handover complete. I get a chance to ask Dr. Ertl some more questions about being a virtual ER physician. You seem really comfortable with this, but you weren't in the beginning, were you? No, no.
I'd say within probably kind of three, four months, I was pretty comfortable with it. I wasn't sure how some of my nursing colleagues would be in some of the places and the physicians. When you see how much of a win is for the patients and for the rural docs and the rural nurses, you kind of fall in love with it. I'm sure you know that there have been some emergency physicians who
who have been quite prominently critical of the whole idea of virtual emergency medicine. I want to know what you say to them. I was probably one of those people 10 years ago. I'm not anymore. I would encourage people
to try it and do it. I would never participate in something which I didn't believe in and didn't think it was good medicine. I really do think it's the future to recruit and retain rural nurses, family doctors. Yeah, I'd love to be there in person, but
You know, we do it in so many specialties now. Why can't we do it in emergency? Is this the best way to keep those emergency departments open? Wouldn't it be better to staff them with people who are actually there on the ground?
Absolutely. Absolutely. And I hope in five to 10 years we figure that out. But does anybody think that's happening in the next couple of years? No. Right. And we can't just create nurses and doctors out of thin air. And I think we'll get it right with international graduates and increasing enrollment in medical school and all those those strategies. But until we get there, I think this is what we have to provide in the interim. But that would that would mean that that what you're providing is a kind of a bandaid, isn't it?
I would love to see us out of business. Absolutely love it. I want enough doctors and nurses in every ER. I'd prefer not to do this and just go back to my ER. But until that happens, we'll do our best to help out. Vera and a predecessor under a different name have completed nearly 500 virtual ER shifts serving 16 rural communities. So far, the program has helped prevent 5,000 hours of ambulance diversion. We'll be right back.
I'm Katie Boland. And I'm Emily Hampshire, who didn't want to be here. On our new podcast, The Whisper Network, we want to speak out loud about all the stuff that we usually just whisper about, like our bodies, our cycles, our sex lives. Basically everything I text to you, Katie. So this is like your intimate group chat with your friends. And we can't wait to bring you into The Whisper Network. This journey is a nightmare for me. I'm doing it for all of us. So you're welcome.
You're listening to White Coat Blackheart. This week, how virtual emergency doctors are helping keep small ERs in rural BC from closing. Virtual emergency medicine appears to be a success in BC, but there are critics. In 2024, the Canadian Association of Emergency Physicians, or CAPE, published a position statement saying there are many instances in emergency care where virtual cannot replace an in-person assessment by a doctor.
Atlantic provinces are also experimenting with virtual ERs. Wendy Martin, who lives in Lake Echo, Nova Scotia, feared she might be having a heart attack.
So she went to the ER at Twin Oaks Memorial Hospital in Muscadabit Harbor. She asked me sort of the typical questions, you know, why are you here today? And I explained to her, you know, that I was in the grocery store and started coughing and I thought I was going to pass out. I volunteered to her about the medication that I was on for urinary frequency. So, of course, she took all of that into account. She checked my temperature.
She checked my blood pressure and then she, you know, that was, that was pretty much it. I was with her very short period of time. Um, and then she asked me if I was okay speaking with a physician virtually from, I believe it was Toronto. Um, and I waited maybe 10, 15 minutes for him to come up on the screen.
Had our little chat and he said that he believed it was a walking pneumonia. It was very short and sweet, like not as slow as I would have expected. Like I would have, I kind of half expected, like maybe the nurse would stay in there with me and he'd say, okay, can you check her, check her lungs? Or, you know, can you check her heart or that type of stuff? But she left, he came on and then it was all just very quick.
Wendy was seen virtually by a physician in Toronto, but she was assessed in person by a nurse. Back in BC, Amber Pasichnik is an ER nurse who was born and raised in Mackenzie. She was one of the nurses who provided in-person care on the night shift when Dr. Michael Erdl was the virtual ER physician on duty. A brief note, Amber refers to the virtual doctor as a Rudy physician. Rudy stands for Rural Urgent Doctor in Aid, which was the name of the virtual program before it was renamed Vera.
How was that shift that I witnessed for you? You know what? It did not go as planned, but that's life working in rural medicine. How common is it for Mackenzie to have to go on diversion? It depends. Some of our diversions are physician diversions. So there's no physician available, for example. But many of them are actually due to shortage of nursing staff. We only have two nurses on for our whole hospital on each shift.
And we don't really have any casual nurses. When you're working with the virtual doctor and you've done that, how often have you done it? Probably about four or five times. So how weird is it having a virtual doctor on hand? Walk me through your initial introduction to that system at McKenzie.
When they introduced it, I actually thought it was a really great concept. You know, obviously the healthcare system is quite overloaded and I think any extra tool to aid in patient care is great. You know, it's hard to understand how it works until you use it. It's essentially the same. It's just a little bit different in terms of how my workflow goes when I use it.
Usually when a patient comes to ER, I do their initial assessment. I start doing diagnostic tests. Perhaps I think they might need you. I might need a urine dip. I might need to, you know, be potentially ordering an x-ray, these things. I'm still doing that. I have to anticipate a lot more about what might be going on with the patient.
so that I can have all that information on hand when I speak to the Rudy physician. I also have to stay with the iPad if I'm using it with the patient, whereas if I have a physician on site, I'm assessing a patient, giving that report to the physician, and then I'm moving on to my next patient.
So if I have a bunch of patients waiting to be seen and I'm using Rudy, sometimes it just takes a little bit longer for nursing to get through the patient mode. What are the kinds of patients where you really need to get that video link up on the iPad so that the remote doctor like Dr. Ertl is actually able to see the patient and interact with the patient directly? So I think
a lot of that comes the iPad comes in when they for example I had someone that had a really nasty laceration and you know I needed to bring the iPad in so that he could you know
confirm that it would need sutures, that kind of stuff. And sometimes they like to use it just to see the patient for themselves. You know, they can't do that physical assessment, but you can also get a lot from just seeing, you know, you walk into a patient's room and a lot of times you can see that they aren't well just by looking at them. So, you know, sometimes they don't need to use that at all. And I've also had times where, you know, we go to use the iPad and it's frozen. So we're not able to do that.
use the video component. So sometimes the system glitches. It definitely glitches because it's over Zoom and like any tech product, sometimes it doesn't work out. I'm trying to think about how patients would interact with the technology. You know, you're right there beside the patient. You're with them. There may be a family member there. How do they react when they're talking to a doctor on a tablet?
You know what, I found it different with different age groups. I find that younger people seem to accept it quite well. I find sometimes with the older population, they might be visually impaired, they might be hearing impaired.
And it's just the different concepts. So sometimes there's a difficulty to accept that. You know, what do you mean a virtual doctor? I want to see a doctor in person, you know, so it's kind of sometimes different age groups have a different acceptance level of it. You know, there's something that we haven't said that I think should be said. And that is, you know, my sense is that nurses like you are essential doctors.
to keeping emergency departments like the one in McKenzie open overnight. And even when you have a virtual physician, this system does not run without nurses like you. That's right. I think that there is a lot of focus on, you know, physicians and physicians burnout and all that stuff. And I think that's very important. But I think a lot of people don't realize that the Rudy program is actually nurse driven. So, you know, without a
nurse that's able to do a skilled assessment and all those things, that system would not work at all. So it's really nursing driven and supported by the Rudy physician. And so I think that's important. Without our nurses, we wouldn't stay open. And as you know, and we've certainly done stories about this, emergency nurses are burning out. Does a program like this address the nursing issues that need to be addressed?
I don't feel it has any impact on the nursing issues. You know, we work a lot of overtime to keep our doors open. And sometimes it's really hard when you're in a small community because, you know, if you're taking a vacation or you're having a day off and your ER is on diversion, sometimes people in the community will make comments. Well, why is our emergency room closed? Why aren't you working? And it's like, you know, we are all humans and we need self-care. So I think that...
People don't realize how much worse it would be if we didn't do what we did as nurses in small communities. And I don't think that Rudy changes that for us. Some nurses might feel like it's a deterrent for them even, you know, like some maybe for a newer nurse or a nurse that's less experienced, they might not feel comfortable using Rudy.
But I think that once they do use it, they'll realize that it is, you know, a good support tool for them. Amber, thank you so much for debriefing and for letting us know what the situation is like where you work at McKenzie. Thank you so much for speaking with us. Thanks for having me. From what Amber said, patients in McKenzie may like having a virtual ER doctor if it helps keep the ER from closing.
But patients like Wendy Martin, who saw a virtual doctor when she went to an ER in Nova Scotia, aren't sure that virtual provides optimal care. Well, I think, you know, had there been somebody right in the room with me, they may have at least checked my lungs. And had they checked my lungs, then I would know for sure if it was pneumonia or it wasn't pneumonia because you can hear it with stethoscope.
I think it would be ideal if we had a physician at the hospital or one that could at least be called in like it used to be at Twin Oaks and some of the other small community hospitals. However, in the absence of that, I do think there is some value to seeing a physician virtually. At least you know you've spoken to a physician, a professional. You can get your questions answered. So I think it's better than nothing.
Just a comment here. Wendy says she would have wanted the virtual doctor who treated her pneumonia to listen to her lungs. The technology to do that does exist and is used in some places. Back in Mackenzie, it's morning. Dr. Michael Erdl, the virtual ER doctor who worked the night shift, huddles with Dr. Lindsay Dobson, whose patients remained stable overnight.
Hello? Oh, hi, Lindsay. It's Mike. Hi, Mike. How are you? Good. How was your night? Did you get some sleep? I slept solidly through. Oh, good. Fantastic. I did not. Oh, no. It was fine. It was fine. But I'm getting paid, you're not. And BC's experiment with virtual ERs continues.
The organization that oversees Vera plans to have virtual emergency doctors available seven nights a week. And by next summer, it hopes to expand coverage to more than one shift per night. Added some liver function tests in the lipase for this morning, if that's okay? Yeah, absolutely.
Okay, that's all I got. Perfect. Thank you. So how many times did you get called through the night? I'm curious. Just a couple of texts. And then I didn't sleep much through the night because I was worried about the weather and the patient. So we chatted this morning at six o'clock with Amber and she was like, fantastic. Well, I'll let Dr. Goldman maybe ask you a question or two and then we'll let you get to work. Thanks, Lindsay.
Yeah, it does work. So, Lindsay, I'm not going to distribute too much because you've got to get your family going, but so how do you feel about having Mike overnight so that you could get a good night's sleep? My gosh, it was...
Absolutely fantastic. I don't sleep well on call. I'm a nervous person on call, and this service allows me to sleep soundly, so I was out cold. Well, thank you very much for taking a little time out to let us witness the handover, and I hope you have a great day. Thank you. You too.
Thanks, Lindsay. Thanks, Mike. Cheers. Bye. Mike, you have a good sleep. You've earned it. Thanks for speaking with us on White Coat Blackheart. Well, my pleasure. Thank you. That's our show this week. Our email address is whitecoat at cbc.ca. White Coat Blackheart was produced this week by Stephanie Dubois with help from Jennifer Warren and Samir Chhabra. Our digital producer is Ruby Buiza. Our senior producer is Colleen Ross. That's medicine from my side of the gurney. I'm Brian Goldman. See you next week.
For more CBC Podcasts, go to cbc.ca slash podcasts.