Posts Tagged ‘sepsis’

Call without flak jacket

December 22, 2013

For call, the way to prepare

Is to grit your teeth if you dare.

But this busy season

The load’s come within reason

And doesn’t hold much of a scare.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a position with a Community Health Center which dropped from 54 hours a week to part-time on December 1.  I’ve also done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego and Denver, and a trip to Mexico for our daughter’s wedding.

It’s Sunday evening and I have weekend call but the meaning of that phrase has changed substantially. Joyously and radically.

Our practice gave our adult inpatient work to both hospitalist groups.  But internists only staff those, and neither will care for patients under the age of 18.  Thus we still attend pediatric and newborn patients.

I rounded on and discharged a young teenager at one hospital and two newborns at the other yesterday.  Today I sent those two babies home and admitted another newborn.

During medical school, standard practice demanded keeping newborns in the hospital for 5 days following normal delivery and a week following Caesarean section; by the end of residency the stays had dropped to 3 and  5 days, respectively.  Down to 2 and 3 days currently, we don’t see nearly as many septic babies as we used to when we kept the children longer in the germ-laden hospital.

When I go to the hospital and I print out the census for my group, I see names of patients admitted from our practice but on whom I don’t have to round.  One hospital had 5 names and the other had 4 yesterday and today the total came to 12, when a month ago our minimum total came to 20 and frequently ran over 30.

I have to ask myself if our respectful, expert care had anything to do with the fact that he patients kept getting so sick.  Certainly I find it believable that the drinkers would fail to learn if our well-oiled alcohol withdrawal machinery did such a great job of keeping them comfortable while they sobered up.  After all, people will jump more if you keep setting up the safety net.

But I also have to ask if our sicker patients have switched to doctors offering better continuity of care.

I slept well last night; I received no calls in the critical hours between midnight and 6:00AM.  I still got up early, had a good breakfast and went to work.  But afterwards I could go to the gym, go to brunch, take a nap, do some reading, and take in a movie.

And I could do it all without vigilance ruining the experience.

 

We used to talk about the emotional preparation for taking weekend call as “getting your flak jacket on.”  That 72 hours could be physically and emotionally exhausting, but we figured if we could make it to Sunday at noon we could handle any evil that would last less than 18 hours.I look forward to getting back to the office tomorrow.

I’m really enjoying my job now; easier without a flak jacket.

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.