New Job, First Week

I laughed, and said with a snort

In the square of the town there’s a court

You could call the town small

There isn’t a mall

And friendly comes by the quart

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, and my 50^th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I saw a distressing number of serious pneumonia cases during my first week on the new job. Each patient presented differently, each brought in a life story from a family context.  And each challenged me in a different way.

We have exceptional pneumonia vaccines that don’t prevent pneumonia nearly as well as they prevent death from pneumonia.

In the last 40 years the disease has changed a good deal, and we’ve reduced the death rate, but not nearly enough.

The history and physical make the diagnosis more than anything. We listen for a crackling sound as the patient breathes in, but mostly we listen to the patient’s narrative.  Still we get blood counts, blood cultures, chest x-rays, and occasionally CAT scans.  A new blood test, pro-calcitonin, helps a lot but hasn’t made an appearance in any facility where I’ve worked.

I disappointed several patients by not finding ear wax.

I have acquired a minimalist approach to medication at this stage in my career, an approach that many of my patient appreciate. I especially enjoy stopping statins, a class of cholesterol-lowering drugs that can stop heart attacks and strokes, but will not prevent a first one after the age of 65.

The facility has a small staff and a small footprint. I counted 36 steps from my office to the ER, and 6 steps from ER to radiology.

I get a steep discount on meals, reasonable cooking served in reasonable portions.

Various licensing details have insulated me from the worst of the Electronic Medical Record (EMR) headaches, and I get to dictate my notes.

A small parking lot separates my accommodations from the ER; a landline assures good communications in the unlikely event of a sound night’s sleep.

I haven’t run into marijuana problems yet. Smokers constituted a surprisingly small proportion of the patients.  Not surprisingly, binge drinkers here, as everywhere, have difficulty with insight.

The facility has a gym, a CAT scanner, anesthesia, and a surgery program. I worked with two of the nurses here during my days in private practice, and I established a relationship with the radiologist during one of my other assignments.

Most of the referral traffic will go to Sioux City, where I still know many consultants.

And there’s an absolutely first class pizzeria about 20 minutes away.

 

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Paper Order Joys and Outpatient Dictation

If it helps to make a decision

We like a CAT scan’s precision

It sure made my day

When in truth I could say

It looks like you’ve dodged an incision.

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, and my 50^th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I arrived 15 minutes early for a brand-new gig. I started the usual orientation: meeting a lot of people whose names I forget and shuffling around a confusing geographic set-up.

No one expects me to remember everything the first day, but much like any other human learning endeavor, one has to find a starting point,

The facility has three EMRs, one each for the hospital, the clinic and the ER. The ER and hospital systems communicate with and resemble each other, but do not qualify as twins.  And I’ve used the hospital system before, in Nome and in western Nebraska.

The outpatient system, however, looks like nothing I’ve ever seen.

For reasons I don’t completely understand, my schedule keeps changing, and I covered an outlying clinic in the afternoon.

I cared for 5 patients, including 2 children, both of whom I mesmerized with my yoyo. I managed to not increase anybody’s prescription burden, recommending only agents available over-the-counter.

Not a single patient came to the ER that night, yet the vigilance of call kept me up.

I only attended 8 outpatients and an inpatient the next day, yet high-stakes clinical material dominated the landscape. I sent two patients to the CT scanner down the hall.  Surprisingly, the results swayed the decision-making process in both cases.  Neither went to surgery nor to inpatient.

A different patient became my first admission to the hospital. The wonderful nurses gave me the choice of writing my orders or entering them into the computer system.  Grinning, I took the hand-written option, and later watched a new-hire nurse struggling through an unintuitive system.

The glitch that prevents me from using the outpatient system for entering lab and x-ray orders or for electronic prescribing continues to defy resolution. The management here lets me write my orders on plain paper and have the nurse enter them into the computer. I dictate my notes.

And I finished on time. For whatever reasons, for the time being I can enjoy slow patient flows.

The patients have already started asking if I’ll move here. Forever.  I thank them, but I decline; Bethany and I still have more adventures to look forward to.

 

 

Cherry blossom time in Iowa

‘Neath the tree we snacked for an hour

For the joy of the pretty white flower

Then along we did scoot

We’ll wait months for the fruit

From the tree of the cherry that’s sour

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, I am back in Sioux City.  Any identifiable patient information has been included with permission.

I have a passion for cherries. Mostly I love the fruit, the small tart dark red berries so good in pies and preserves.  I love the larger, sweet cherries as well, but Iowa lies too far north, and those trees grow too large for our yard.

Sweet cherries have neither a true dwarf cultivar, nor a dwarfing rootstock, but sour cherries do. I have had as many as 7 trees in back of my house at any one time, but this year the population has shrunk to 3.  I chose work close to home this summer, to enjoy the trees and the garden

In a good summer, Bethany and I will spend days picking, pitting, and canning the fruit. Most years we make forays to trees owned by friends who only harvest enough for a pie or two.  One year we went through 250 pounds of sugar during the canning process.

Mostly, we give away the product, and gain many friendships thereby.   We have never had anything commercial that even comes close to the brightness and clarity of flavor of what we make.

Sometime around the turn of the century, I mentioned my cherry trees in the doctor’s lounge. A podiatrist of Japanese ancestry (who grew up in Seattle) expressed an interest in coming over for celebration of the cherry blossoms.  He brought sake and snacks and his office nurse.  On a warm, sunny spring afternoon we sat under the tree and listened to the buzzing of the pollinators and inhaled the flowery perfume and chatted.

For climatic reasons I don’t understand, this year all 3 trees blossomed simultaneously. You don’t have to be Japanese to enjoy the ephemeral beauty of the cherry blossom time that lasts at most a few days.

Friday we got take-out sushi. I warmed the sake flask in the microwave.  I found the bottle of sake bought 10 years ago.  We donned medium-weight jackets against the chill and put foam stadium seats down on the wet grass.

On a cloudy day too cold for pollinators and too cold for the aroma of the blossoms, on grass green with spring and flecked with white cherry petals torn by the previous night’s wind and rain, we ate salmon and California rolls. I drank 5 warm ounces of sake and got light-headed and enjoyed the taste; Bethany tasted and grimaced.  We chatted about our plans for the weekend and the coming week and dinner plans for the evening.

And again I reflected that if you can’t have a good time in bad weather, you just need more practice.

Sense of humor restored

 

Thinks of all the calls that I dial

And the round trips I make by the mile

And the hours on hold

Can leave my humor just cold

But it got restored with the sight of a smile.

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

I go out of my way to keep a sense of humor. But I’m only human.

I had 8 patients on the morning clinic schedule. I cured the first patient of the morning and sent him on his way.  I returned to a clipboard with 4 sheets of redundancy inherent in a government-based workman’s compensation case.

About 11:00AM nurses told me of an arriving ambulance. By that time I had 5 undictated charts.

The hundred paces to the ER disappeared rapidly under my shoes. I took the history, ordered the CT scan and some blood work, and quick-stepped back to the clinic.  I knew I faced a serious, complicated case which would require a transfer and demanded prompt action.  I finished the last three morning patients and retreated to the break room to listen to the drug rep pitch very expensive asthma drugs and bolt Chinese food.

At 12:45PM I returned to ER just as the patient got back from CT. I finished the history and physical, and awaited the radiologist’s call.

I started with a call to the transfer operator, and the basic clinical picture. Then to the hospitalist, who accepted the transfer.  I started typing up the history and physical and was 75% finished when the hospitalist called back, clarifying some historical details.  Is the patient OK for MRI?

Trips back and forth from my work area to the ER. Calls to a specialist in Minneapolis.  Holding for 10 minutes at a time, while patients waited in the clinic and the piles of unfinished documentation fermented.

No, the specialist said, not a candidate for MRI.

On hold for another 10 minutes with the hospitalist. Do not send patient without speaking with neurosurgeon.

Twenty minutes later the neurosurgeon, dithered for 5 minutes and refused the transfer, and recommended Mayo clinic.

I considered how badly things could go during the hours necessary to get to Rochester.

The nurses recommended a competing Sioux Falls hospital. I announced that my sense of humor was weakening.

Another 5 minutes on hold. The hospitalist accepted the transfer graciously.

I gave the history and physical last-minute revisions to reflect the past two hours of clinical and clerical actions.

With the paperwork all packaged, I went back to the clinic. After 3 hours of the drama, irony, and frustration inherent in trying to be two places at once; after all the tension built into a system of inefficiencies dedicated not to patient care but to the cash flow generated thereby; after literal miles of fast walking hospital hallways, I stepped into the exam room.

The patient whom I started on Parkinson’s medication last week beamed at me when I walked in. The very small doses of a very old drug had done their job; the patient (who gave permission to write more than I have) bloomed.  Now the smile went all the way to the eyes, the speech had music, and the expressions danced on the face.

In less time than it took to shake hands, my sense of humor returned.

Yes, emergency work brings me challenging cases, but I do not want to give up the satisfaction and gratification that comes with patient follow-up.

Spanish, spinal manipulation, and zoonoses

The patients come in, I’m a doc,

And I ask, Are you working with stock?

Do the animals thrive?

Are they even alive?

How big is your herd or your flock?

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

(Post generated week of 1/15 and held till now.)

I faced subzero temps and 40 MPH winds on the drive into work today. Still I came in to find my morning schedule full.

Which conflicted with a complicated ER patient, requiring hospitalization, and, eventually, a very complex transfer. So today I started counting the steps between my clinic work area and the Emergency Department.

The steps added up to 100 each way, but I lost track of the number of times I made the round trip.

Midway through the morning, I noted a holster with a pair of pliers on a patient’s belt. Obviously a quality piece of leather, and just as obviously worn daily for many years, I made the observation that even an American-made pair of pliers has a finite life expectancy if used often, and asked how many pairs of pliers he’d been through.  He chuckled.  He’d been through three pairs so far, and the holster had been custom-made for him.  He gave me permission to recount our conversation.

A lot of farmers and other agricultural workers come to see me. The rules on antibiotic stewardship do not apply to people who work with livestock.  I have concerns not only with zoonoses (diseases acquired from animals) but with the hazard to the animals if the patient transmits microbes.   I generally don’t give out antibiotics for respiratory infections under 5 days duration, but I make exceptions, for example, for those who have just removed thousands of dead or dying pigs from a hog confinement. So along with asking if a person uses tobacco, or if a woman might be pregnant, I ask, “Do you work with livestock?”

Today was a good day for speaking Spanish, relieving suffering among patients from teenagers to septuagenarians just with my fluency. I fielded the usual question:  Where did you learn Spanish (high school, but I’ve been practicing for 50 years), and also, Are you Cuban?  (no).

At one point a non-physician clinician needed an interpreter while I worked my way through clinic, and the nursing staff activated a video service. When I returned 40 minutes later I immediately recognized an accent from Spain, but I did not get a chance to chat up the interpreter.

By the end of the morning, I had cured three patients before they left (ear wax removal for one, and spinal manipulation for two). But the ER patient would stay another 3 hours until transfer could be arranged.

I left in the dark, in subzero temperatures, ferocious winds, and a light snow.

Getting a ride from the Sheriff

In Alaska in a blizzard we grinned

But here, with the howling wind

Good sense made me balk

At taking a walk

While the blades in the wind turbine spinned

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

I watched the incoming weather most of the weekend, and decided Bethany and I should drive to work the night before, rather than possibly face blizzard conditions, and we set a depart time of 3:00PM. Two hours before, I got a call from the clinic manager asking if I would mind terribly coming in early.  I didn’t have to think twice.  We’d already be in the hotel, and I might as well get paid for it.

We found the drive windy but otherwise pleasant, and, looking at the clear, dry landscape, we couldn’t imagine that the weather would change radically.

But we awoke in the morning to find that it had, indeed, changed, and more radically than we could have imagined. We couldn’t see out windows covered with blown snow, and really couldn’t tell if that side of the hotel had drifted over.

I scraped the car while the wet flakes covered my glasses. On the way to the hospital, the wind drove the snow so thick and hard that only after a half-mile did I realize that my windshield had fogged up.  Even with defrosted glass I still had to creep.

I bought pizza for the clinic crew for lunch, and the manager closed the clinic. I could stay, she said, or I could go.

I went, figuring that snow this hard would act as an effective patient repellant. But the wind drifted the snow so deep I got stuck at the parking lot exit.  I got pushed out by a woman half my age.  With visibility less than 20 feet, I inched back to the hotel.  I got stuck again.  I rocked the car, but, in the end, the 50 MPH wind blew me out.

I got called back to the ER. I had to ask the Sheriff to give me a ride; my front wheel drive Avalon doesn’t have nearly the clearance I need.

Then I faced a case where, in the usual course of events, I would get lab and x-ray.   Not positive of the diagnosis, though, I had to consider that bringing techs from their homes to the hospital would endanger lives.  I explained the situation to the patient and spouse, and they agreed.  Then the story behind the illness unfolded, a wonderful tale of lasting love and dedication that held me spellbound till the nurse came in, and told them they’d better get to the pharmacy, which would close early.

More real emergencies came in. I spoke with consultants in Sioux Falls, who cheerfully accepted referrals and gave good advice, mostly to do with delaying transfer till the weather cleared.

But one transfer could not be put off. The nurses worked magic to arrange snowplows to precede the ambulance, county by county, and across state lines.

Then the call to the Sheriff’s Office. I rode with the same deputy.  He told me the weather had closed the highway, and that law enforcement had given out a “no tow” order.

Harrowing transfers

It’s the time of year for the flu

If it’s that, we know what to do

But in transferring out

We have without doubt

The stressors come out of the blue.

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

With bad weather promised in the forecast, I decided to drive to work the evening before rather than the morning of. Fog shut down visibility and I crept the last few miles into town and hotel to await the impending major winter storm.

Overnight the temps plummeted to double negative digits, and the wind rattled the windows. I awoke to a scene of a blowing snow, but the worst of the wind had passed and the gusts stayed under 40 miles per hour.

Not surprisingly, clinic load dropped with the mercury. Through the day I cared for people with the problems of abdominal pain, a cold, a rash, another cold, the flu, a cough, another cold, ankle pain, yet another cold, and an irritated eye.  Two of the patients spoke Spanish; one of them first spoke an indigenous dialect before he started to learn Spanish at 15, thus making us equally Hispanic.

At the end of the day one of the permanent docs and I went to the Mexican restaurant. We talked a lot  about hunting and Alaska and the pragmatic parts of medical practice.

I had almost 45 seconds at the hotel before the call summoned me back to the ER to care for another person with a respiratory infection.

I took care of 3 more patients before midnight, one psychiatric and two respiratory. I did not ask for permission to write about any of them.

But I can write about the problems inherent in rural practice. Small hospitals lack the resources to deal with life-threatening problems.  Whether in Iowa, Canada, or Alaska, patient transfers can be the most harrowing part of the job: you don’t have to send well patients to referral centers.

Here I have to do a complete history and physical, just as if I intended hospitalization. I get the basic labs, and, if necessary, x-rays.  I ask the nurses where to best send the patient.

Sometimes neither nearest nor best-equipped means the same as best.

Then I make the first call. Sometimes a secure video link, much like Skype, opens up.  I generally have to go through a nurse to get to the doctor, who has final authority to say, Yes or No to the transfer.

Depending on the context, ambulance and/or law enforcement personnel need to be enlisted.

Then the harrowing wait begins. The helicopter, airplane or ambulance never shows until I have hit the outskirts of emotional exhaustion.

When the patient leaves, I start keyboarding my history and physical into the computer as fast as I can. I hand the printed copy to the nurse with the request to fax it to the accepting physician.

Then I dictate the same information into the dictation system.

I got back to the hotel shortly after midnight, too wound up to sleep. I studied for an hour and a half.  I slept surprisingly well before going back to the clinic to discuss legal threats with the manager.

Fixing a calf cramp

Type and cross has a 2 hour lead

So if a transfusion the patient might need

Stay 2 units ahead

So they don’t end up dead

If the gut gives rise to a bleed

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.

“Always stay 2 units ahead of a GI bleeder,” they said in med school and again in residency. Many years and much experience has not diminished that truism, which to this day shines as an example of game theory.  It means that when a patient loses blood from anywhere in the gut, from the esophagus (swallow tube) to the rectum, that the physician must stay prepared to transfuse 2 units (a liter, close to a quart) of blood.

One can’t transfuse blood without first typing and cross-matching the blood, a complicated lab procedure that takes 2 hours. (For one extreme trauma patient in another country, I ordered the hospital’s entire stock of 5 units of O negative blood, the so-called universal donor type.  But that country has a very different legal climate, and I had no other options.)  You can lose the patient in the time it takes to do the test.

This weekend, I had a patient come in with profuse painless blood in the stool. My small rural hospital has a very limited blood bank, and the ride to the referral hospital realistically takes 2 hours.  I explained to the patient that transferring a stable patient beats transferring an unstable patient, and asked for permission to write about the case from the perspective of how doctors make decisions.  She gave me permission to publish the entire case, and pointed out that Facebook would probably have her room number before she arrived at the referral center.

(Her family history has a disease so rare that to name it would name the patient.)

The mathematical discipline of game theory has a whole branch dealing with games of incomplete and imperfect information. The real world of medicine deals with those circumstances.  I have to live with the limit of what can be known in the time allotted in the place where I work.  I know I never have the whole story and that patients never give a completely accurate history.  I have to work with what I get.

Thus I deal with the certainty of uncertainty.  I can’t know if the patient’s bleeding will worsen or stop by itself, nor if problems will arise during transport.  I have to look at probabilities ranging from worst to best case scenarios.

The paramedics arrived, and greeted the patient by name. Everyone knows everyone here.  As the patient shifted from the gurney to the stretcher, a cramp seized her leg, and she asked the paramedic to massage her calf.

“I can make that cramp go away,” I announced, perhaps with too much assurance. But I took the outside of the middle of the patient’s upper lip as close to the nose as I could, between my thumb and forefinger, and squeezed.  Fifteen seconds later, her calf cramp disappeared.

I think that I unduly impressed the nurses and paramedics,

I learned that acupressure trick early in my career, but I don’t remember where or when. Probably before I learned to stay 2 units ahead of a GI bleeder.

 

The impossibility of scheduling call

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.

Shipping a patient: difficult, not impossible

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 21^st 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.