Healthcare in Nunavut
Iqaluit is the health hub of the region and provides a center for inpatient care, physician assessment and further investigations when cases cannot be managed in the community. When a patient has an issue that is more urgent, the CHN will contact the physician carrying the community pager (CP) at the Qikiqtani General Hospital. The CHN will send a completed .pdf Community Call Form to the Community Pager email to discuss a case with a physician on a more urgent basis. The physician carrying the community pager will review the case with the CHN to determine whether the patient can be managed in the community or if they require assessment in Iqaluit either via scheduled commercial flight (“schedevac”) or air ambulance (“medevac”).
When patients from the communities are in Iqaluit and not admitted to hospital, they stay either at the Boarding Home or a hotel. This is arranged by medical travel.
When a patient’s needs are beyond the scope of practice at the QGH, they are sent to Ottawa or another tertiary care centre. Similarly, this can be via medevac for urgent cases or schedevac for less urgent cases. Specialist services are provided non-urgently by e-consults (electronic consultation system with specialists in Ottawa) and through scheduled specialist visits in the specialist clinics. When a patient needs to see a specialist more urgently, they can be referred as an outpatient or inpatient to Ottawa as well.
Considering Geography
As there are no roads, airplane travel is the only means of transferring patients between communities in Nunavut and to tertiary care centers in south. Take into consideration the logistics of travel when creating management plans – for example, Pangnirtung has regular flights that are about 45 min long whereas scheduled airline travel from Grise Fiord (most Northernly community in Canada) to Iqaluit will take over 2 days each way (by schedevac).
Choosing Wisely
Judicious Ordering of Labs
Please order investigations judiciously and consider whether a test result will change your management plan. There are limited resources, including physician time for following up results. Having fewer results makes it easier for the next doctor who will receive your lab results to sort them out (think of the difficulties you may have had trying to sort out labs on patients whom you haven’t met). Fewer tests results to sift through allow the important test results to be seen sooner and improve patient care.
Judicious Timing of Investigations
Ordering investigations after hours involves bringing in laboratory, x-ray and ultrasound staff who need to work the next day and should be reserved for cases in which this is essential and will change management. For example, a stable patient admitted with pneumonia/AECOPD overnight who is already being treated and is stable can probably wait until 8am for a chest x-ray.
Many patients arriving from the communities in the evening on scheduled flights can wait until the following morning for their investigations.
Judicious Patient Transfers
Know when a patient can no longer be managed in the community or Iqaluit and get them out!
When in doubt, discuss with the CHN (community health nurse) or another physician for a second opinion.
It is important to know what level of care we can provide in our hospital setting. We have an acute care room for 1:1 nursing, but any patient who remains in there more than a few hours without improvement should transferred.
Once a patient needs a medevac, the sooner they leave the better for the patient.
Continuity of Care
Please go that extra step with patients.
While we are continually striving to improve our continuity of care, remember that our model of physician coverage, with the coming and going of locums and the broad geographic range we cover, does not lead to reliable follow-up. Please take the extra step to take advantage of each patient encounter, such as ensuring follow up of lab results, calling patients to let them know of an abnormal result, etc.
Please use your 20 min clinic appointments maximally – for instance if the patient is in for a refill of the HCTZ and is a 60-year-old smoker, please check to see if they have lipids/A1c done. Treat each appointment as a comprehensive review rather than the just the presenting issue. Having said that, often the patient comes in with a long list and this just isn’t possible. This is especially true of clinic visits in the communities, where this may be one of the few chances the patient has to see a physician.
There are a few high-risk areas where it is exceptionally important to arrange clear follow up plans (and document handover) and for which we have two clinics to improve care in these areas. To better manage early failed pregnancies, pregnancy of unknown origin and medical abortion there is an Early Pregnancy Assessment Clinic (EPAC) that is run by the obstetrics team (refer to EPAC section). To improve fracture care and follow up, there is a Fracture Clinic every Tuesday (refer to Fracture Clinic section). Please consider referring patients to these services to improve their care.
Another point to remember is to support the other professionals in your team. Please use tact if questioning the treatments or decisions of the previous health care professionals.
Tuberculosis
A special note on TB
Many physicians in Canada have never diagnosed or managed a patient with active tuberculosis. Nunavut has the highest incidence of tuberculosis in Canada and in recent years some communities including Iqaluit, Qikiqtarjuaq and Kinngait have recorded some of the highest rates of tuberculosis in the world.
Please use this as an opportunity to enhance your current knowledge about tuberculosis. We have a core team of physicians and public health nurses who provide care for patients in the TB treatment program. However, the challenge of identifying and diagnosing those patients presenting with active tuberculosis is one that falls to all of us. Whether it is in the Emergency Department, a Community Health Centre, a Prenatal Clinic, or on the Inpatient Ward, consider tuberculosis, know the signs, symptoms, and how to test. Please exercise a high index of suspicion in all your patient encounters.