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Canadian Journal of Rural Medicine
CJRM Spring 2000 / printemps 2000

Rural patient stories / physician management narratives 2. Mental health care

James T.B. Rourke, MD (Chair), James H. Goertzen, MD, George Goldsand, MD, Sharon N. Hatcher, MD, Paul W.H. Humphries, MD, Stuart J. Iglesias, MD, Sarah Mackinnon, MD, Lise Morin, MD, Sarah-Lynn Newbery, MD, Conleth O'Maonaigh, MB BCh, Paul Rainsberry, PhD, Joshua Tepper, MD, Carl Whiteside, MD, Mark E. Whittaker, MD
Working Group on Post-graduate Education for Rural Family Practice.

For a description of the Working Group please see the end of this article.

CJRM 2000;5(2):80-1


Abstract

In developing the "Postgraduate Education for Rural Family Practice. Vision and Recommendations for the New Millennium" report,1,2 the Working Group felt it was important to illustrate rural family practice with a series of rural patient stories / physician management narratives.1–4 These case studies demonstrate the broad range of knowledge, skills and attitudes used by rural family physicians in responding to the needs of their patients. They provide examples of rural maternity care,4 mental health care, long-term pediatric genetic disease care and trauma care. They are based on real-life dramas from diverse rural locations across the country. Certain details of these patient stories / physician management narratives have been altered or are based on composite examples to protect the identity of the individuals involved. The second in the series, a case study on mental health, appears here. The first, on rural maternity care, appeared in CJRM's Winter 2000 issue.4


Patient's history

A young woman was brought into the rural hospital emergency department on a Friday evening by the on-call volunteer ambulance crew. She had taken approximately one hundred 325-mg tablets of acetaminophen after an evening of drinking at a house party. Her husband had appeared at the house party and physically threatened her; this apparently was a common occurrence in their relationship. When the patient arrived at the emergency department the charge nurse noted that she smelled of alcohol, was drowsy, but was easily awakened. A girlfriend confirmed that the patient had also consumed about 6 beers.

Examination findings

The on-call family physician arrived approximately 5 minutes after his stat call to the emergency department. The charge nurse relayed the patient's available history and the admission vitals: RR 15/min, BP 110/70, HR 70/min, T 36.9ºC. In addition, the family physician noted that an IV of N/S had been established, nasal prongs initiated at 3 L/min, and the attached cardiac monitor confirmed a sinus rate with a periodic ectopic beat. A Glasgow Coma Scale of 13/15 was quickly determined. Upon rousing the patient, portions of the history were confirmed: the acetaminophen had been consumed about 2 hours earlier. As the family physician paused briefly after completing the physical examination, the laboratory technician appeared, called in by the charge nurse for the expected laboratory investigations: CBC, RBS, Na, BUN, Cr, LFTs, osmolality, acetaminophen and salicylate levels. Preparations for the arterial blood gas followed.

Knowledge: Management of poisonings, including acetaminophen overdose

Skills: Tailored physical examination, interpreting Glasgow Coma Scale, effective team communication

Attitude: Comfort in limits of knowledge in reviewing management in textbook; confidence in skills of nursing staff

Plan: As the nursing staff prepared activated charcoal, the family physician slipped into the doctor's lounge to review the protocol for management of acetaminophen overdose. The patient reluctantly drank the charcoal slurpy while the acetylcysteine infusion was being initiated. She was admitted to a critical bed in the hospital and remained stable overnight. Acetaminophen levels peaked 4 hours after admission and confirmed the necessity of the acetylcysteine. The arterial blood gas and salicylate levels proved normal.

Saturday morning the patient's family and social situation were briefly reviewed by the on-call family physician. Her psychiatric assessment revealed previous treatments for depression, mood complaints, and vegetative symptoms, thus supporting the diagnosis of a current depression. She was feeling safe in hospital and, although overwhelmed, was not suicidal. She agreed to the management plan of remaining in hospital over the weekend, starting an anti-depressant, and having further involvement with a supportive counsellor. She was transferred to the medical ward (no designated psychiatric beds in the hospital), and a referral was made to the on-call community mental health worker. Later Saturday afternoon, thorough family, social and psychological assessments were carried out by the on-call worker.

Knowledge: Spousal abuse, suicide risk, depression

Skills: Obtaining psychiatric, family and social his-tory; effective team communication, patient- centred counselling skills, crisis management

Attitude: Comfort and sensitivity with spousal abuse victims, confidence in role of team

Plan: Monday morning a hospital discharge was arranged. The patient would spend the next 2 weeks in a women's shelter, where she'd be safe from her husband. Follow-up visits with the community mental health worker and family physician were scheduled.

Over the month the patient's depression improved as a result of the supportive counselling and medication. With new insight into her abusive relationship she was able to initiate divorce proceedings and apply for an upgrading employment program.

Knowledge: Community resources for spousal abuse, management of depression

Skills: Patient-centred counselling skills

Attitude: Sensitivity to spousal abuse victims.


The Working Group was a diverse group, comprising members of the College of Family Physicians of Canada (CFPC), the Society of Rural Physicians of Canada (SRPC) and a representative from the Royal College of Physicians and Surgeons of Canada. The group included practising physicians from rural and remote communities across Canada whose practice profiles included special skills and interests in such areas as anesthesia, obstetrics and emergency work. It included physicians involved in teaching both students and residents for rural practice, family medicine residents, rural program coordinators, a postgraduate family medicine program director, and an associate dean of postgraduate medical education. The group was directed "to review the current state of postgraduate education for rural practice in Canada and to outline an appropriate curriculum to prepare new family physicians for the challenges of rural practice."1–3 The report was endorsed by the SRPC in April 1999 and approved by the CFPC Board in May 1999.

This article has been peer reviewed.

Correspondence to: Dr. James Rourke, Director, Southwestern Ontario Rural Medicine Education, Research and Development Unit, 53 North St., Goderich ON N7A 2T5


References
  1. Working Group on Postgraduate Education for Rural Family Practice. Postgraduate education for rural family practice. Vision and recommendations for the new millennium. Executive Summary. Can Fam Physician 1999;45:2698-704.
  2. Working Group on Postgraduate Education for Rural Family Practice. Postgraduate education for rural family practice. Vision and recommendations for the new millennium. Full Report. A re-port of the Working Group on Postgraduate Education for Rural Family Practice. Approved by the College of Family Physicians of Canada Board — May 12, 1999. Available at: www.cfpc.ca/ruralpaperfull.htm (accessed 2000 Mar 31).
  3. Rourke JT. What a challenge! [editorial]. Can Fam Physician 1999;45:2567-8.
  4. Rourke JTB, Goertzen JH, Hatcher SN, Humphries PWH, Iglesias SJ, Mackinnon S, et al. Rural patient stories / rural physician management narratives. Rural maternity care. Can J Rural Med 2000;5(1):21-3.

© 2000 Society of Rural Physicians of Canada