Archive for September, 2017

The impossibility of scheduling call

September 27, 2017

We know that it’s always our fate,

When the call makes us work late

And our faculties sour

Because of the hour

And it’s really the call that we hate.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed. I just finished 3 months in northern British Columbia, getting a first-hand look at the Canadian system. I’m now back picking up an occasional shift in northwest Iowa.  Any identifiable patient information has been included with permission.

I took call yesterday. The ER load included 7 patients, all of them legitimately ill.  The five who came after clinic closed arrived at intervals of 2-3 hours.

One patient ended up in surgery.

One, so ill as to necessitate transfer to a higher level of care, needed my presence in the ER as the evaluation proceeded.  While the steady rain fell, the hours clicked off from 3:00 till 6:00, and the results came back from lab and x-ray, I chatted with patient and family members.

One family member (not the patient) told me about breaking her pelvis barrel racing, a women’s rodeo event involving riding a horse as fast as possible around three barrels set in a triangle in a rodeo arena. From my experience in western Nebraska, I already knew that the more time a person spends around horses, the more bones break.  But then she revealed she stayed in the saddle.  “They called it an ‘open-book’ type fracture,” she said, and pulled a copy of the x-ray up on her phone.  The g-forces involved in a tight circle had ripped the bones asunder.  I asked about osteoporosis, and she shook her head, producing another cell phone image showing her on her horse, her face distorted in agony.  When I handed the device back, she pushed a few buttons more and showed me the post-operative x-ray, which included hardware sufficient to stabilize a brick building in an earthquake zone.

I told her I write a blog, noted that as she wasn’t the patient that HIPAA didn’t apply, but nonetheless I wouldn’t write about her without her permission. “Go ahead,” she said, “I’m already a case study at the University of Iowa.”

When I compiled all the result, the subsequent transfer process went well with the patient leaving less than two hours after I asked for the lab tech to be called back in.

In a situation where doc-to-doc communication can mean the difference between life and death, and with an approaching shift change, I had to generate a note to go with the patient, and, in this case, it had to be a Word document. My usual stellar typing performance deteriorates with sleep deprivation, and proofreading showed I’d dropped about half my t’s.

Another patient came in with ten minutes left on my shift, again needing lab and x-ray. Not used to handing patients off, I met with the doc coming on.  We had a passionate discussion about how we love our work, but we hate call.

And really, without call the facility probably wouldn’t need me. The average patient flow in the ER doesn’t justify the expense of a dedicated ER staff.  Game theory predicts the impossibility of scheduling with imperfect and incomplete information. Nonetheless, illness doesn’t punch a time clock.

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Shipping a patient: difficult, not impossible

September 22, 2017

There’s a thing or two that I’ve found

By plane, by chopper, or ground,

To move a patient who’s sick

I prefer it be quick

So as to arrive safe and sound.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed. I just finished 3 months in northern British Columbia, getting a first-hand look at the Canadian system. I’m now back picking up an occasional shift in northwest Iowa.  Any identifiable patient information has been included with permission.

3:00PM: within 30 seconds of meeting the patient I know he’s sicker than he thought, and within a minute and a half I know he belongs not in the clinic, but in the ER. (He gave me permission to write the information in this blog.)

Then I think to ask the nurse, “Wait. I’m on call.  Which means that I’m covering ER, right?”  She nods.

In the current jargon of real-world medicine, the word “dump” means transferring a patient to another service without proper work-up. In this case, though,  I can’t call it a dump if I hand off to myself.

While I wait for the ER gurney I finish my exam, and get as much history as I can.

Two nurses, pulled from the inpatient service to ER, arrive to transport the patient. I hand them a list of lab and x-ray requests and IV orders, and return to the other walk-in patients on my schedule.

3:40 PM: I quick step to radiology to look at images.  In the ER the nurses hand me copies of the lab results, giving me the start of a diagnosis and confirming that the patient needs an ICU.  I discuss findings with the patient and family.  I strongly recommend transfer.  They request a hospital 3 ½ hours distant.

4:00 PM: I weave through the hospital switchboard and phone tree to the consultant’s phone crew, who use a handset that renders speech almost unintelligible.  The consultant is not available.  Would I prefer to wait for the nurse, to leave a voice mail, or to provide a call back number?  I ask for the nurse.

4:10 PM: I run through the case with the nurse, who puts me on hold.

4:20PM PM: I present the patient to the consultant.  I run through the presentation, context, past medical history, lab, x-ray, and my working diagnosis.  I finish with a request to transfer the patient, and the consultant agrees.

In 21st century USA, a doctor cannot legally transfer a patient without a physician accepting the transfer.

4:30 PM: back in the ER to get consent-to-transfer signed.

4:50 PM: the accepting hospital calls to tell us they won’t have a bed available till tomorrow.

The nurses tell me if the patient needs fluids during transfer, we’ll need a Paramedic crew out of Sioux City, because no nurse can’t be found to accompany the patient.

I think that they want me to back off on the IV fluids, but I can’t.

Return to ER: I advise a transfer a hospital two hours closer. The patient and family agree.

5:00 PM: I have the hospital operator put my call-back number into the consultant’s pager, asking how long I should wait before calling back.  The hospital operator assures me she rechecks every 15 minutes.

The nurses point out that if I ask for a helicopter I can get the patient to the destination a lot faster. I look at the ground-transport time from Sioux City (90 minutes) and then the time to hospital, 1 1/2 to 3 1/2 hours.  I agree to the helicopter.

5:10 PM: The closer consultant calls.  My cell phone has enough signal strength to ring but not enough to keep from terminating the conversation.  The nurses usher me to a spot by a window, and I call the consultant back.

5:15 PM: I reach the consultant, who agrees transfer is appropriate, but tells me I have to call the hospitalist.

I call the hospital back to try for the hospitalist.

I didn’t ask for the helicopter lightly.  In this case the geography and gravity of the situation changes the risk/benefit ratio.

5:20 PM: the hospitalist picks up. I make my presentation, with updated vital signs and report on response to treatment.  He accepts the transfer.

5:30 PM: in the ER with the patient (who looks better but not well) and family again, I outline the progress and have them sign an updated consent-for-transfer specifying a new accepting physician and hospital.

I make small talk in the ER, then wander back to the nurses’ station.

5:45 PM: I ask, “When is the chopper due?”

The nurse shrugs. “They said 20 minutes 25 minutes ago.”

5:50 PM: the helicopter crew arrives, with a small bag of Dove chocolates.

I make sure they take the necessary papers with them.

At five minutes to six, the sweet thump-thump of the rotors reaches my ears. In less than twenty minutes, I know, the patient will have access to the personnel and services he needs.

The nurses note that I don’t look upset.  I tell them it might have taken 3 hours, but I’ve seen worse.