Posts Tagged ‘hospital rounds’

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.

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A blizzard? Maybe not such bad luck.

December 16, 2015

It’s winter, and wouldn’t you know
It’s time for the wind and the snow
With the luck of a wizard
We had us a blizzard
And I handled it just like a pro.

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

I broke a tooth chewing on a slice of dried mango, and asked around the hospital for the name of a dentist. Good luck brought a 7:30AM appointment next day, bad luck brought a blizzard that night.
I started early next morning but cleaning the car and creeping down the ice-covered highway with low visibility took time.
I don’t mind going outside in the cold. Last winter, in Nome, Alaska, I cheerfully walked a kilometer to and from work. I frequently walked in the ditch, to get away from traffic, and when I finished that part of the walk, I climbed out.
But I mind going into a ditch if I’m in a car.
Still I attended to my hospital patient before dawn, put in orders, put off writing the note, and went out into the snow.
The temp had warmed up so that two inches of fat, wet flakes covered the car in a half hour. I brushed and scraped the car again, and crept down the hill into town.
In this sparsely populated area of the country, the dentist has a lot of out-of-town patients, and he faced a schedule full of cancellations. If I could get the prep work for the crown done that morning, it would cut my time away from clinic, and would help fill his schedule.
We saw it as a win-win situation.
I dozed in a state-of-the-art dental suite while he drilled and lasered, and walked out an hour later with a temporary crown to find 4 inches of fat, wet flakes covering the car. The white stuff came down so fast that it covered the armrest inside the door in the short time it took to put the brush in and seat myself.
Patient flow slowed to a crawl in the clinic.
I discharged my inpatient before lunch, and learned I could get free chili or chicken noodle soup in the cafeteria.
The cafeteria here doesn’t sell hot food to employees, but has a bank of 5 vending machines with a microwave, and the offer of hot soup came as a pleasant surprise.
I took care of a total 3 patients in the morning session and 3 patients in the afternoon session. My access to the EMR, NextGen, came through, and I have started the odious task of mouse clicking. I remained thankful to the blizzard that I didn’t have more time pressure while on the steepest, lowest point of the learning curve.
We closed early, at 4:00PM. I went outside to clean the car off, but the wind had picked up and the temperature dropped, so it went easier than the three times before. Visibility improved, and I arrived back at the townhome ahead of schedule.
I would have preferred a commute short enough to walk, but I benefited from very good dental services. I would have preferred better weather, but I got the work done in a timely fashion without cutting into my schedule.
Maybe the blizzard wasn’t bad luck after all.
Life is full of tradeoffs.

A great day in the face of adversity

June 26, 2013

The computers slowed down to a crawl.

A hammer would have started a brawl.

But you can give us an A

We had the best day

In all the clinical hall.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

Usually, Monday morning opens with hospital rounds.  Today I started early and finished early.  I had time to get to the VA to have my TB skin test placed and have FedEx send off a packet of materials in preparation for a 2 week job in southeast Alaska in August.  When I arrived at the clinic at noon I found the atmosphere tense.

Our Electronic Medical Record (EMR )system has problems, and every few weeks brings us another crisis.  Frustration builds as the system slows down.  By 1:00PM it made a glacier look positively zippy.  Then it started to sputter, shutting down completely from time to time.

The mood of the clinical corridor darkened as the work flow slowed.  I went downstairs and stuck my head in the Information Services room.  “Are things going to run this slow for the rest of the day?” I asked.

“I’m afraid so,” came the answer.

A lightning strike in a distant city had melted links in out communication chain.

I walked down the hall and asked an administrator to come up to experience the problem.  When we got to my computer, I demonstrated the 6 minute sign on.  The PA at the next workstation volunteered that she’d been working on the same patient for the last 45 minutes.  I showed the administrator how it took 5 minutes to change patients, but the process shut down completely.  I watched facial expressions mirroring my own.  I answered a few reasonable questions, and watched the administrator stalk out.

I turned to my two nurses.  “We’re going to have a great day,” I said.

Then I thought for a minute.  “We’ll use paper.  Call everyone on the schedule who isn’t here yet and have them cancel their appointment.”

I talked to a couple of patients by phone, emphasized that we couldn’t do anything, and acceded to a request for a mood stabilizer, to be followed by a more thorough visit later.

I looked down the hallway at all the people ready to do physical violence to their computers; the frustration and the tension became palpable entities.  If hands could have found hammers easily, terrible cybercarnage would have followed.

I thought about bicycling into a tropical storm in 1972 and singing Bob Dylan songs in the rain.  I remembered playing my saxophone in the Fourth of July parade in Barrow, Alaska in 2010 under leaden skies with mixed rain and snow and numb fingers.  I turned to my team.

“Anybody can have a good time when conditions are perfect,” I said, “But things are not perfect and we’re still gonna have a good time.  Because we’ve practiced and we’re good at it.”

And we had a great afternoon and evening.

Efficiency as the enemy of flexibility: a drawer’s maximum utility comes at 2/3rds full.

November 28, 2012

Time will flee by the slice

A slower pace would be nice.

All work and you’re dull,

If your day is too full

Efficiency comes at a price.

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.

The throes of student poverty kept me from owning a motor vehicle till I was 29, and I learned a lot about bicycles.  Efficiency rose with tire pressure as rolling resistance fell, but the efficiency came at a cost.  The extra hard tires did poorly on rough roads, skidded dangerously in the wet, could not be ridden at all on dirt, and punctured with the shortest of thorns.

My first vehicle, a Karmann Ghia, sported a Volkswagen engine, known for accessibility.  I soon found I could tune and tinker and get exceptional mileage, but I could only maintain 32 miles per gallon in ideal conditions.  Head winds or tire pressure loss from a drop in ambient temperature would shave 5 to 8 miles off of a gallon of gas; carrying a passenger made things worse.  And if the car sat for a week between trips, evaporation of gas from the tank dropped the road efficiency noticeably. 

Any system that gains efficiency loses flexibility; a drawer’s maximum utility comes at two-thirds full.

Our health care system stands as a paragon of inefficiency but it does well for flexibility.  Most years, our hospitals meet influenza’s challenge head on.  We have enough overbuilt infrastructure to handle a 30% rise in hospital cases.   

In the dark days when I worked 84 hours a week, I did so with tremendous efficiency.  I knew as soon as my foot hit the floor in the morning where my steps would take me till I dropped into bed that night.  Yet I paid a terrible emotional cost for the tiniest of delays, and I always ended up running behind before the last patient finished.

At that time I learned great efficiency in making rounds on hospital patients, but my system doesn’t tolerate glitches well. 

I need an early start.  On first arising, people don’t talk much, but by 10:00 AM the urge to speak has come to full flower.  It doesn’t spare doctors in general, nor nurses, nor this doctor in specific.

I used to joke about MYF, Morning Yack Factor, a hormone that drives people to verbosity.  Others have asserted it has more to do with caffeine finally reaching a threshold level.  Yet I don’t use the stuff and I still lapse into eloquent excess at midmorning.  I do my best to avoid physician conversations between 9:30 and lunch if I don’t have a morning running on leisure.

If our government in Washington doesn’t hold the world’s record for inefficiency, it should.  Note that we were able to wage not one but two wars without noticeably increasing the personnel in the capital. 

If the Affordable Health Care Act brings efficiency, our system will lose flexibility

Life comes down to a series of tradeoffs.

But realistically, I’ve never seen government regulation increase the efficiency of anything.