Posts Tagged ‘call’

Trying to figure out what “call” means

June 21, 2017

When my weekend came to an end

A patient off we did send

With findings so rare

It gave us a scare

And help we needed to mend. 

 

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 finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

 

People can use the same word and mean different things, different words to mean the same thing, or even the same word in different contexts to mean different things.

Doctors use the term “call” when talking about coverage after hours and on weekends, but what does that word “call” really mean?

In Utgqiavik, the town formerly known as Barrow, it never meant anything other than 12 hours. I have been places where holiday call meant ten times that.  Depending on the location, weekend call might start on Friday or Saturday morning.  Or it could include staffing a Saturday clinic.  Sometimes it meant ER coverage only.  For a couple of decades I had to field calls from nursing homes, patients, ERs and hospital inpatient units as well as obstetrical duties.  For one former employer, if I drew the duty, I could count on sprinting between hospitals to admit patients till midnight, and a minimum of one phone call every 45 minutes requiring critical decision-making.

In New Zealand, when I worked for a North Island outfit, “call” meant staying overnight in the clinic.

On one particularly memorable assignment, it meant nothing other than having my name on a calendar slot. I had protested the marginal cell coverage at my dwelling.  Administration told me not to worry, in the event of a disaster the Sheriff knew where he could find me.

I write this while on weekend call. Sunday morning dawned very early and very clear.

During my 23 years in private practice, the docs wouldn’t talk about how the weekend went until afterwards. The same superstitious factors leading to that custom led to the many Emergency Rooms that banned the “Q word” (quiet).

What does weekend call mean here? Starts at 8:00AM Friday, ends at 8:00AM Monday, followed by a day off.

Now post call, I can say I cared for 3 people who, for one reason or another, didn’t have a chart in the local electronic Medical Record. I never cared for more than 12 people in one 24 hour period.  Several times, on the verge of leaving for the apartment, I asked people on the way in if they had come for emergency services.

At the end, a patient arrived with an extremely rare problem, so serious I called a colleague for help, and ended up riding in the ambulance to the medical center.

What does “call” mean? Don’t look in the dictionary

March 26, 2017

Consider the places I’ve been

Then tell me, what does “call” mean?

For sometimes the word “call”

Means nothing at all

And sometimes it can make me turn green

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 adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

People can use the same word to mean different things, and the same person can use a word at different times to mean different things.

For example, when I worked in the Indian Health Service, “call” started at 4:30PM and lasted until 8:00AM. Weekend call started on Friday afternoon and lasted till Monday morning.

In my years of private practice, it started at 5:00PM and went till 7:00AM. The doc who took Friday evening call worked the clinic on Saturday from 9:00AM till 2:00PM.  The physician with weekend call started Saturday as early as he or she wanted, rounded on the patients in the hospital, and took care of admissions till 7:00 Monday morning.  For a long time we saw the patients who came to the ER, but that faded over the years.  The on call doctor did the obstetrics over the weekend.

Call in Barrow (now called Utqiavik) never meant anything other than 12 hours, weekend, weekday, or holiday.

In Petersburg, the physician on call also covered the emergency room.

In western Nebraska, being on weekend call meant doing a Saturday clinic till noon, rounding on patients Saturday and Sunday, and admitting patients from the ER.

In Metlakatla, where we had no hospital beds, the two main ER nurses had excellent clinical skills. I could rely on them to know when I needed to come in and when I could safely wait to see the patient in the morning.

I have call this weekend, starting at 8:00AM on Thursday and going to 8:00AM on Monday. During that time, I’ll round on the hospitalized patients.  But someone else will work the Emergency Room.  If a patient needs admission, the Emergency doc does an admit note and writes admitting orders.  If a patient needs me to come in and see them before morning, they generally need to be at a larger facility.

I have had two nights of call so far. The first one passed without my phone going off, not even once.  The second time I worked steadily till 9:00PM stabilizing a very ill patient for transport.

But what does call really mean, here, this weekend?

I can tell you on Monday.

And I can guarantee it won’t mean the same thing a month from now.

The difference between a horse and a mule

August 23, 2012

It’s unnecessary to that much force

To run to the ground a great horse.

So don’t be a fool,

You can stop, like a mule

If your motives come from the source.

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.

Even doctors have to have doctors.

I confirmed my appointment with a subspecialist today at 12:45, and I turned to Bethany.  “He works through his lunch hour,” I said.  “Should I bring him a sandwich or something?”

“I don’t know,” she said, “Are you sure he doesn’t take a late lunch?”

“Yeah, his nurse said he was working through his lunch hour.”

“You can if you want.  But is he working for someone else?”

“No,” I said, “He owns his practice.”

“Well, when you were an owner, you did the same thing.”

Of course she was right.  “That’s the difference between a horse and a mule,” I said.

A horse has a passion to run, I explained, and riding a good horse hard ranks among the great experiences of life.  A mule has none of the fire of a horse, and the best gallop of the best mule deserves the word lackluster; the words plod and mule go well together.  Yet most riders can get a horse to run so far and so fast that the horse dies, hence our term, “ran it into the ground.”  An overloaded mule cannot be induced to move at all.

Give a horse morphine and the horse will run, give the horse an adequate amount of morphine and he’ll run himself to death even without a rider.

I approach analogies between humans and animals with caution.  But making any person, and particularly a doctor, their own boss looks a lot like giving morphine to a horse.  They don’t take enough vacation, they work very long, very productive hours, and they tend to burn out.

I wish going onto salary had made me more like a mule.  As it is, my drive to work destructively long hours has nothing to do with the money but with the action of the job and my commitment to my colleagues.  I do not want to give up the drama and irony of the hospital work, nor the intellectual challenge of having to rub elbows with docs who know more than I do.  Nor do I want to stop being part of the team, going the extra mile to lighten the load of the doctor who comes after me.

The problem comes not from the outpatient hours, but from the people who get desperately ill after hours and on weekends, and from our booming expansion.  My first two weekend calls last year had a total hospital census in the single digits, but our practice now averages seven hospital admissions per twenty-four hours and our hospital census has gone as high as forty-two. 

Yet this last weekend deserves a delicious rating.  I started early, finished rounds in good time, lunched and napped and supped, getting into bed before eleven each night.  I’m running on the same relaxed euphoria that I did a year ago.

The real question is how hard I’ll let myself get worked.

Blog reopened after a year on the job.

July 5, 2012

I find my job a delight

Even when working at night

On this I won’t budge,

I’m a doc, not a judge,

And there’s always something to write.

I have decided to reopen my blog after a year’s absence.  I miss writing, and I miss the immediacy that comes to my life when I go through my day thinking about my post.  I’ve been at my new job a year now.

My workplace runs on teamwork; I’ve never been any place where people seek out so many opportunities to help their coworkers. 

Our patients have few resources; 50% have no insurance, 35% have Medicare or Medicaid, and 15% have commercial health insurance.

I see a lot of schizophrenics, people whom our society has failed badly.   I’m sure if they could push a button and come to a closer contact with reality, they would.  As it is, they hear voices when they don’t take their meds and sometimes even when they do.  An extraordinary number also carry a diagnosis of bipolar.  Almost all smoke, and, given enough time, almost all develop insulin dependent diabetes. 

I find it easy to avoid judging the schizophrenics; they did not ask for their problems.  The less I judge my patients, the more energy I have at the end of the day.

We have so many patients from Ethiopia and Somalia that we have Oromo, Amharic, and Somali translators, and I’ve learned to say Hello, How are you, and Thank you.  Mostly hardworking, family oriented people, they came here after unspeakable horrors.

Many of the people who come to my clinic have been behind bars.  I don’t ask them why.  After all, I did not train as a judge.  Those folks have done their time and my job, as I see it, demands that I focus on what can be done in the future, not what has already passed. 

I start Mondays with hospital rounds till noon, then clinic till 8:00PM.  I’m on call 35 Tuesdays per year.  Most call nights I work straight through till after 9:00 PM.  I start Wednesdays at 7:00AM and finish around 6:00PM. 

I have Thursday off, along with Friday, Saturday and Sunday if I don’t have call.  I still put in 48 hours weekly.

Yet I worked no more than two days a week in the last six weeks, which I found unfulfilling.  I arrive at work Monday mornings cheerful and happy to be back, and I go home on Wednesdays ready for the weekend.

Saturday/Sunday call a year ago ran to fewer than 10 patients between two hospitals, but practice growth led to mission creep, and now a hospital census can run upwards of three dozen.  At any one time, we usually have three patients in liver failure, and three in active alcohol withdrawal.  A surprising number of non-alcoholics end up with cirrhosis.  About half our hospital patients also show up on the dialysis service.  Mental health census averages 5. 

Our patients get sicker younger than any patient population I’ve seen before, which surprisingly, gives me more hope.

First night call since December and I had to take it in-house

April 10, 2011

 

The question came up for debate:

To work or not to work late.

       A mistake in the roster

       A dilemma did foster  

In the morning I walked out at eight.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  After a six-week assignment in Barrow, Alaska, the northernmost point in the United States, I’m working on the North Island of New Zealand.  I’ve just finished my first night call since December.

At the end of my clinic day in Snell’s Beach I drove back to Wellsford.  Despite cognitive dissonance about who had call for the evening with my name on the roster and another doc on the computer template, I couldn’t face another forty-minute drive and made it look like I took the night’s assignment graciously. 

The anticipated chickenpox outbreak had arrived, the pharmacy (in Kiwi, the “chemist’s”) had closed, but I rooted through the after-hours drug dispensary and found a surprise supply of acyclovir.

Nitrous oxide and my yoyo tricks convinced a recalcitrant child to hold still to have a cast applied. 

As always, most of the evening’s pathology came from tobacco, alcohol and the immutable law that two objects cannot occupy the same space at the same time.

But I got the chance to quiz the people on life in New Zealand.

Agriculture supports the nation.  Farming divides into dairy and “dry stock” (sheep, cattle and deer).  An average dairy operation runs 300 head.  With one cutting of hay per year most farmers don’t know what grasses nourish their herds.  Deer produce almost as much revenue from antler velvet as they do from meat.  Wapiti (North American for elk) cross readily with English red deer and cannot jump a two meter (six-foot seven-inch) fence.

At eight, the end of the scheduled patients, I got a tour of the clinic’s emergency room, crash cart, defibrillator, lights, locks, dispensary, and alarm system.  The other doc, who had stayed to do documentation, left.  The nurse stayed longer than she had to.

I didn’t ask permission to give clinical information, but from 8:45 till 10:15 I took care of a Maori patient accompanied by family.  I got the gratification of hands-on patient care I usually delegate to the nurse.  I called an expert at a hospital an hour away, who gave me courage to use drugs in doses I’m not used to.  I found more medication in the dispensary, avoiding ambulance and hospitalization. 

I learned that the Maori language has changed in the memory of most Maori.  Some on the Maori channel speak classical Maori, a language richer in nuance than modern Maori, which is losing dialect variation.  The urge to absorb one’s enemies’ life-force and mana (a complex Maori word meaning strength, honor, and social standing) drove Maori head-hunting and cannibalism.  Traditional Maori tattooing was done with a chisel, not a needle, and went deep; any expression of pain would diminish one’s mana.

I finished with a new word in Maori, aye, meaning yes.

By the time I locked the door and turned out the lights I felt rumpled.  I stepped out downstairs into perfect temperature and smelled the early autumn and gazed at the stars. 

Fatigue didn’t slow the bouncing waves of the day’s human tragicomedy, and I didn’t have Bethany’s comfort and listening ear.  In a new bed, alone with my vigilance, shallow sleep danced with the day’s memories.

When the eastern sky lightened I dressed and snacked and read Thursday’s newspaper.  At 8:00 I gave handover (Kiwi for check-out) to the doctor coming on call, and at 8:05 I trundled out of Wellsford and onto the road back to Leigh, winding through hills greener than poetry, listening to the morning news breaking up in the valley’s radio shadows.

Chickenpox, shingles, and widows. Drama=irony, surgery=theatre

April 9, 2011

For lunch I had me a pie

I went back to work bye and bye

          I am no cheater

          If surgery’s theatre

I won’t make the audience cry.

 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  Just back from a six-week assignment in Barrow, Alaska, the northernmost point in the United States, right now I’m working on the North Island of New Zealand.

I arrived early at the clinic in Snell’s Beach and started work in the quiet of the morning.  With the doors of the clinic open to the sunny, cool air, I reviewed lab and x-ray results; four of fourteen needed follow-up.

When patients started, I refilled a lot of prescriptions, many of them for asthma.  A lot of kiwis have asthma, mostly unrelated to smoking.  The commonest combination, salbumetol and flixitide, would be called albuterol and fluticasone in the States.

In New Zealand, surgery refers to seeing outpatients.  What we would call surgery at home gets the word theatre here.  Thus whereas in the States “Have you done much theatre?” might mean anything from “What live acting credits do you have?” to “Are you gay?” the Kiwis mean “Have you done many operations?”

At lunch I stepped outside into perfect weather, with cool, breezy air and bright clear sunshine, and went to the bakery for an unhurried steak and curry meat pie.

Back at the clinic I’d started tidying up my documentation when the nurse said, “I know you’re still on your lunch break, but…” 

In fact, I’m not used to an hour lunch break; at home I got into the habit of bolting my meals.  Of course when I got the opportunity to do what the locals would call theatre to help a patient cope with the consequences of steel’s excess kinetic energy contacting flesh I said yes.

When I finished I found myself twenty minutes behind schedule.

I’d almost caught up by 4:00 when a patient asked for a letter for court.  I couldn’t contact the requesting lawyer.  I made it clear that both parties had to be comfortable with the letter, and I would only write truth but not conjecture.  I wrote, we edited, and in the end, the piece of paper left with the patient but the process took twenty-five minutes.

By 5:15 I’d seen 24 patients and written refill prescriptions for another.  One third of my patients, both male and female, mentioned their status as widows.  Half had been widowed more than once, all wanted to tell their stories, and the drama and irony of the human condition flowed raw and unrestrained.  I listened with sympathy.  At one point I mentioned the high rate of spousal death.  “Oh, yes,” the patient said, “Snell’s Beach is full of us.”

Four of the day’s patients had superficial skin infections.  One had shingles, and I remarked that if it didn’t presage a chickenpox outbreak it would constitute a unique experience in my career.

I drove the rough, narrow, winding road with dense traffic and courteous drivers to the clinic in Wellsford.  I checked in with the nurses, and a flurry of confusion followed.  With my name on the roster (as they call the schedule), and another doctor’s name on the computer template, I had the option of taking off and going home.

The thought of another forty minutes on the roads pushed my decision to take the night on call, thereby earning me a dinner break and collegial gratitude.

I walked down the street, gobbled mediocre steam-table Chinese food, and walked back in the gathering gloom.

The anticipated chicken pox outbreak had arrived, the pharmacy (in Kiwi, the “chemist’s”) had closed, but I rooted through the after-hours drug dispensary and found, to my surprise, a good supply of aciclovir.

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