Posts Tagged ‘stethoscope’

Why I do and I don’t do housecalls

March 6, 2011

The number of docs is deficient

Though the need would appear quite sufficient

    If you ask me why is it?

    I’ll say a home visit

In the end remains inefficient.

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.  I just got back from a six-week assignment in Barrow, Alaska, the northernmost point in the country.

My father made house calls.

He graduated from medical school sixty years ago, when women were systematically excluded from the profession.  At that time, a physician finished an internship, hung out a shingle, worked solo practice, and took call 24/7/365. He made hospital rounds in the morning, saw patients through the day, and, after supper, made evening rounds and house calls.

Our 1960 Ford Falcon had a spotlight, like the police used, so he could see house numbers at night.

He used to take me with him, to the hospital and to patients’ homes, when I was in elementary school.  I waited in the front lobby of the hospital at a time when it constituted the main ingress, but I got to go into houses with him.  I remember the time spent with him, I don’t remember the time spent waiting.  I can see his stethoscope hanging by the front door, his electrocardiogram machine in the back seat, and his doctor’s bag with the blood pressure cuff and medications like Demerol , penicillin, and digitalis.

But in an era of generalists, my father specialized first in Internal Medicine, and then in Cardiology.  ICUs and CCUs didn’t exist, and before revascularization, statins, and beta blockers, patients with heart attacks frequently received treatment at home.  Looking back, hospital care at the time differed little from a doctor making a home visit.

I have done house calls, but I probably don’t do more than twenty a year. 

When I worked for the Indian Health Service in New Mexico, the government tore down a perfectly functional clinic and paid me to do nothing until the new clinic was built.  After two weeks I realized I had started to be mean to my kids and I hijacked the Community Health Nurse to take me on hogan visits.  I learned a lot about my patients I wouldn’t have otherwise known.

Mostly, when I care for a patient in the home now, I do so more for my convenience than for the patient’s. 

Once, when a heavy, wet snow closed the city and the clinic down in the middle of the day, I got a page from a patient with bad lungs, heart, and balance just as I was about to exit the building.  In the days before common use of cell phones, I turned around, shucked off my parka, and returned the call.  After a brief conversation, I knew I lacked certain key items of information from the physical exam to make a good clinical decision, and I didn’t want to endanger the patient by making him go to the ER in bad weather.  I asked the address, and saw that the patient resided between my clinic and my home. 

I arrived fifteen minutes later on roads I could only negotiate with four-wheel drive.  Fifteen minutes after that I asked for a towel as I washed my hands at the kitchen sink, grateful for the warmth of the water and a ritualized end to the visit.

Today, I talked with a friend and patient who lamented the absence of my house calls.  We talked about how inefficient such delivery of care is, and how we don’t have enough doctors to make the service available on a regular basis.

It’s rare that I do house calls now.  Documentation suffers the longer one waits to make one’s note.  Still, I have a dedicated stethoscope and otoscope in my car.

But I don’t carry a black bag with Demerol, digitalis, or penicillin.

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After thirty years, a case of Reiter’s syndrome, and my last Keosauqua patient shatters my complacence.

December 30, 2010

When I stopped to check out the heart,

The rhythm gave me a start.

     It was going too fast,

     And that patient, the last,

Went out on the ambulance cart.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks off, I’m having adventures, working, and visiting friends and relatives.  I’ve been on assignment in Keosauqua, in southeast Iowa.

Today I finished my last clinical day in Keosauqua.  The first patient of the day and the last patient of the day each gave their permission to write the information below.

Reiter’s Syndrome includes the triad of conjunctivitis (inflammation of the eye membranes), urethritis (inflammation of the lower urinary tract), and synovitis (joint inflammation).  Such a constellation signals the body’s abrupt inappropriate reaction to an infection; while attacking germs, the defense mechanisms start to attack the person’s own tissues. 

Separately, each of these three items comes as common as rain, and for the last thirty years I’ve asked each patient with one of them about the other two.  I also ask about fever and rash.  The interview sequence qualified long ago as low-yield, but I persisted for sake of thoroughness, and, later, from habit. 

Over the years, my interview technique has evolved.  In the beginning I listen, later on I ask focused questions.  Today, when I said to the patient, “Tell me more,” three sentences in quick succession revealed knee pain, discharge from the eye, and discharge from the penis.

For the first time, ever, today I made the diagnosis of Reiter’s Syndrome.  I started the proper lab investigation and turned the case over to a colleague.

For those interested in medical history, Christopher Columbus suffered from Reiter’s Syndrome on his last voyage.

The last patient of the day came in with a routine complaint of cough, also a frequent problem in temperate climates in the winter.  Such symptoms have been going around Van Buren County during my short stay here, and I anticipated ending my tenure routinely.

The human condition tends towards complacence.  We tend to “know” we’ll find a normal cardiac exam singing “lub-dub, lub-dub.”  If those sounds don’t come through the stethoscope, the brain tends to want to make the perceived sound fit into the expected sound.

Today it didn’t.  “Breathe normally,” I told the patient, and tried to hear the heart sounds over the abnormal breath sounds.  Unsuccessful, I said, “Hold your breath.”  The first and second heart sounds refused to distinguish themselves; the first kept shifting in timing and character.  And the rate came way too fast.

I took my stethoscope off and checked the pulse, which came through nice and regular.  I listened to the heart again.  The chaotic rhythm pounded irregularly irregular. 

The reassurance I sought from the electrocardiogram fled before my eyes.  Yet the patient had no heart symptoms at all; no chest pain or sensation of his heart racing.

I grabbed one of my colleagues and showed him the strip.  In short order we had sent the patient off in an ambulance.

We agreed that the weird stuff is out there.