Posts Tagged ‘admissions’

Morning rounds before Thanksgiving.

November 22, 2012

I started my work in the dark,

At the hospital next to the park.

Up and down floors

And in and out doors

The contrast and irony stark.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

I enjoy starting early.  On Mondays and Wednesdays I do my group’s hospital rounds, and I like being in that first wave of doctors that hits the nursing floor before the chaos of shift change.

The more efficient I get, the more I enjoy inpatient work.  A doc can save a lot of time if he or she starts at the top and works down but today I started with the sickest patient admitted overnight, on the fourth floor, not the sixth.

I gained time because comatose patients don’t talk, and lost every minute trying unsuccessfully to access the outpatient record electronically.   Faced with an unconscious, non-English speaking patient, no available family members or other source of data, I did the best I could.  I left orders for social workers with interpreters to locate family and clarify the Do Not Resuscitate status.

Down the hall, the next patient, also requiring a history and physical, presented a dilemma: a narcotics addict with a legitimate, acutely painful physical problem.  I wrote orders for generous doses of narcotics in a patient-controlled anesthesia (PCA) pump.

I dealt with nurses panicking about a rumored bedbug found in the ER, pointing out that wearing infection control gowns , gloves, and caps wouldn’t do anything to prevent the spread of real bedbugs.

On the other side of the nurses’ station, I discharged a large patient with a 14 item problem list, who will need outpatient IVs for weeks.

I didn’t see the last patient on that floor, absent for treatments across town, but the ward clerk told me when to return.

Five minutes here and there add up, chasing patients wastes time, and I could feel efficiency fleeing in front of me.

I set off upstairs.

Some people don’t stop unhealthy behaviors soon enough, and physicians like me sometimes have to sit down with families and talk about time expectations measured in a week or two.  We discuss ventilators, resuscitation, and the vital business of saying what you have to say to the people in your life NOW because you might not be around to say it on Monday.  The patient said, “I’ve had a good life.  I’m not afraid to die.”  I talked with the consulting subspecialist who confirmed a very poor life expectancy, and gave me a decades-old formula . My calculator came to 63 when anything over 32 means less than a dozen days.

Three doors down I discharged another patient, mixing Spanish and English, and getting pieces of a fascinating life story, an odyssey crossing and re-crossing international boundaries.

On the other side of the building, inside the locked doors of the psychiatric unit, I discharged a person showing remarkable insight and taking complete personal responsibility, after a discussion of the fine points of a borderline vitamin B12 levels.

Two stories down, I discharged another from the orthopedic floor, who also had vitamin B12 problems and severe vitamin D deficiency.  Two doors up the hallway, the patient showed progress but not enough to leave.

Up the stairs again on the fourth floor, five minutes fled while the patient arrived from across town.  Optimism suffused the visit with four family members and a patient with a grim diagnosis and a good attitude.

Two floors down another admission involved a newborn, with the shortest of histories and the most efficient of complete physicals.  I spent more time talking with the parents than actually examining the patient.

Thus in the course of my hospital morning, I took care of 8 patients including 3 admissions and 3 discharges (with discharge summaries).  Diagnoses included metastatic cancer, end-stage liver disease, hip fracture, kidney failure, dementia, end-stage pulmonary disease, bipolar, alcoholism, depression, diastolic heart failure, sepsis, epididymitis, diabetes, hypertension, coronary artery disease, stroke, narcotics addiction, sepsis, urinary tract infection, and completely normal.  Life expectancy ranged from less than a week to 86 years.  Family involvement went from none to surrounded by warmth, and emotional impact of disease ran the spectrum from despairing acceptance to outright joy.

Contrast is the essence of meaning.  I finished before noon.  I lunched with my colleagues in the doctors’ lounge, discussing hospitalized patients with consultants. The erudition beat the chili.

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On finding the right quest

July 31, 2012

Of this I have been impressed

Some people ended up stressed

Life might be breeze

They might do what they please

But they need to follow a quest

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

I work late Mondays.  I start at the hospital between 6:00AM and 7:00AM, leaving in time so that I can start clinic at noon.  I may or may not get a breather to eat, and I care for patients till 8:00 PM. 

Tonight I got a break when my last patient of the evening, who had never been seen at the clinic before, failed to show for the appointment.  I’d guess that a substance abuse disorder lies at the base of the person’s problems, but, having never met them, I can’t say for sure.  I used the extra time to catch up on documentation, but left before 8:00PM to go to the gym. 

Yet Mondays do not rank as my usual heavy day; that distinction belongs to Tuesdays, when I usually take call.  I generally roll up to the clinic before 7:00AM, and take advantage of the quiet to sort through arriving lab results and other paperwork.  Patients start at 8:00AM, scheduled till noon, and the afternoon session starts at 1:00PM and runs till 4:30.  I continue to document at my desk till the ER calls me for an admission.  On occasion I’ve left my desk at 6:00PM when my efficiency fails.

Today I found a census of twenty-two waiting for me at the hospital.  I rounded on eleven of them, discharged four, and then I headed to the clinic.  I turned the others over to our full-time hospitalist.

In twenty-first century Iowa, most people need to lose weight, but our patient population has such a grand mix of pathology that today I took care of two who needed to gain.  

To put on weight I advise three scoops of expensive ice cream at bedtime.  (If you need to lose weight, you’re never going to do it if your bedtime snack continues.)  All the folks I take care who have lost too much weight have an identifiable illness, though sometimes it doesn’t account for all the person’s symptoms. 

I sat and philosophized with a young person I had coaxed back up across the 100-pound line.  I had correctly identified the pathology and, working with the patient, had come a long way towards correcting it.  Yet a problem in the grander scheme of things remained. 

Sometimes I talk to high school health classes, I told the patient, and if I walk into a classroom of 35 students I can usually be sure at least one has set him or herself on a quest for wisdom.  Others are born musicians or artists, photographers or historians.  Whatever that person might do for a living, if they can’t also follow their quest, something inside of them dies.

The patient nodded and said, “That’s my problem.  I haven’t found my quest.”

I said, “But not everyone has one or needs one.”

 And in fact, most people don’t.