Posts Tagged ‘Urgent Care’

First week back in Metlkatla

December 22, 2016

With parents, so strong, warm and brave

To them the praises I gave

Imagine the joys

In a room with 3 boys

And all of them stay well-behaved.

 

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 a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

MONDAY

Normally, I cruise right through jet lag, but with plane delays, sleep disruption on the way here shattered my usual techniques. The schedule wisely gave me Monday morning to get up to speed with the EMR, but no one to help me.   I used this system here and elsewhere in Alaska before.  Open –sourced from the Veteran’s Administration, it has functioned well for the last couple of decades.

The sun rises late and sets early here, short days mean I walk to and from work in the dark. I wake up early, more or less at the time I got up in Iowa.  But my office and the exam rooms have windows giving onto spectacular views, with evergreens and towering, snow-capped mountains.  Sometimes, during an examination, I ask patients whether they get tired of the scenery.  Uniformly, they don’t.  People move back from the cities to live here.

TUESDAY

Our clinic does a lot of treatment with nebulized albuterol, IV fluids and Zofran (ondansetron), a potent anti-vomiting drug. So far everyone needing albuterol smokes or is exposed to smoke.  Dehydration,  with the need for IV fluids, can come from a number of sources.  I get a charge when a patient feels better because of fluid replacement or breathes better because of albuterol.

Wednesday

I’ve given out a lot of Zofran since I started here three days ago; I enjoy the change on patients’ faces when the drug takes away the nausea..

Today I have call.  With the upcoming holidays and a number of permanent staff on vacation, the usual Wednesday afternoon meetings got postponed, and no one bothered to reschedule patients.  I didn’t want to face an afternoon with no work, and, as it turned out, I didn’t have to.

We have limited diagnostic and therapeutic capabilities here, and I don’t mind. With no CT, very limited lab chemistries, and no ultrasound, we send a lot of blood tests out.  If time frame permits, we make arrangements for transport by ferry for specialist consults.  But more than one person so far has required Medevac via boat to Ketchikan

THURSDAY

More permanent staffers have left on vacation. Mostly I do Urgent Care with a chance of follow-up, but sometimes I take care of people with long-term problems.

Today a family came in, both parents and three sons under the age of 10. The boys stayed well-behaved and quiet, without interruption, during the entire visit.  When not watched, the oldest took the opportunity to hug his brother.  I saw similar patterns of behavior in other families with three sons when I worked here in April: oldest hugs middle, middle hugs youngest.  At the end of the visit, I thanked the parents for the treat of caring for their children.

I didn’t say, but I wanted to: “It’s a pleasure to work in a community where families maintain such a high level of functionality.”

 

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Third week in Nebraska, and it’s a great gig.

December 21, 2015

The stuff I see is acute
But there’s chronic and puzzlers to boot
I’m not fussing or kicking
And not cherry picking
And everyone knows how to shoot.

b>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 have a pretty good gig here.

Most of the patients have a relationship, direct or indirect, to the agricultural sector. Most patients, male and female, respond if I choose to strike up a conversation about hunting, firearms, or archery.

Yesterday I had a really excellent patient age range, from 93 years to 9 months.

I take the overflow from the permanent docs. I see a lot of colds, coughs, sore throats, rashes, aches, pains, workman’s comp, anxiety, headaches, and depression, so, to a certain extent, I am doing Urgent Care.

But the workload is such that if I see a puzzling case, I get to start the work-up and see the investigation play out. I can recommend non-antibiotic treatment and tell the patient to call in 48-72 hours if they don’t improve. So I find out when I make a good call and when I make a bad call, and my life-long learning proceeds.

So far I’ve avoided the frustrating parts of chronic care, diabetes, high blood pressure, and high cholesterol. That triad starts with bad lifestyle choices having to do with diet, exercise, alcohol, and tobacco, and leads to hardening of the arteries, arteriosclerotic vascular disease. Which in turns leads to the country’s biggest killers, heart attacks and strokes.

And my practice partners, so far, don’t mind. They feel relieved that those folks calling for same-day appointments get taken care of.

Still I feel like I get more than my share of instant gratification. I don’t like the analogy of cherry picking when it comes to taking the easy stuff in medicine; I’ve done it and I know it’s hard work. I prefer to say I feel like I’m skimming the cream, which, of course, I’ve never done so I can’t speak to its difficulty.

The lab, x-ray and nursing staff do their jobs, and I haven’t run into any passive-aggressive behavior.

I have to use the Electronic Medical Record (EMR) now, which I don’t enjoy. When I get a scribe, which I sometimes do, my life gets a lot easier.

The town has everything that I want, including a selection of Chinese restaurants.

We have a lot of non-Spanish speaking Hispanics here, and I don’t know why.

A sudden call, an urgent need, and a trip east.

November 5, 2015

The Canadian woman looked nice

I said the doctors here seem in a trice

She nodded and listened

While our system was dissened

The regulations come at a price.

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. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

On Monday evening I got a call from a recruiter, naming a town where I’d worked that had a sudden need.

Despite the morbid curiosity, I decided I didn’t want to know the drama and irony that had led a colleague to back out of a commitment to work. I recognized the name of the town, I’d worked there before and I enjoyed it. I could walk from the hotel to the clinic.  I found a good hot breakfast in between.  But within a few hours, I realized that the town had the same name but the job pertained to a different clinic altogether. I said no.
My favorite recruiter asked me to please take the assignment. By way of loyalty borne of our good relationship, I accepted. A flurry of emails followed. I spent four hours filling out forms.
My five-year-old scanner printer stopped working. Which led to a great deal of frustration. Eventually, I photographed six documents with my cell phone and sent them via text.
The next morning found me on my way back to Pennsylvania. I had slept poorly, staying up late trying to get the paperwork taken care of.
At the airport in Chicago, i sat next to an attractive young woman. I glanced at her passport and said “Canadian, eh?” She chuckled. I told her that I was in the process of applying for a Canadian medical license, and she was surprised to learn about the frustrations of American doctors with ou current system. They boil down to four: electronic medical records, the meaningful use mandate, medical malpractice, and loss of autonomy.
She could not believe what I told her about the meaningful use mandate. Congress allocated funds for doctors to purchase electronic medical records, and gave them a small incentive to use them. Then, to provide proof that they were being used in a meaningful fashion, the Center for Medicare Services formulated meaningful use regulations, to be phased in over several years. Meeting them costs inordinate hours and has cut productivity of primary care doctors across the board by 25%.
And the regulations keep getting worse.
The conversation turned into a monologue and a rant, if not an outright Jeremiad. But she listened politely, and boarded her plane when called, I think with relief.

Bits and pieces from a couple of days in Urgent Care

October 16, 2015

I explained the news in a flash

About laws confusing and brash

With circumstance and pomp

In workman’s comp

We’re not allowed to take cash.

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. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

I’ll leave out the tortuous background story of why I came to speak Spanish fluently, but I find myself in 21st Century USA with a talent highly valued in the medical profession.

While the United States recognizes an employer’s moral obligation to take care of workers’ on-the-job injuries, each state has a different system and the best of them have Byzantine and incomprehensible nuances.  I have little legal vocabulary in English, and my only Spanish legal vocabulary comes from reading the translation of John Grisham’s Runaway Jury.  English language explanations carry a high level of difficulty that goes to mind-boggling on the other side of a language barrier.  The front office called me up to translate; it got worse when I explained that acceptance of cash for this particular case would have broken the law.

I got a chance to talk to a patient from Uruguay.  The mention of the patient’s hometown brings back wonderful memories and we talked with relish about the high-quality cheese and yogurt that come from the government dairy monopoly.

Occasionally the nurses need me to explain urine drug testing in Spanish to prospective new hires.

But sometimes a day or two goes by without speaking Spanish, and I miss it.

I took care of a patient with a straight-forward ear problem.  After successful resolution I confessed that making people better before they leave keeps me in the game; it’s the doctor’s moment.  Maybe because I listen well, or maybe because my face encourages people to talk, or maybe because the patient was ready, at the end of the visit I listened to a story brimming with more irony than drama but plenty of both, and not reflecting well on my profession.  I explained that as a front-line doc, someone else always knows more than I do about, for example, escalating abdominal symptoms.  At home, I said, I know exactly which doctor I’d send you to.  And then I talked about the inherent problems of being a team player and knowing nothing about the local talent.

Towards the end of the day I attended  a child.  The medical problem soon taken care of, I reached into my pocket and brought out my yoyo, as I usually do at the end of a visit if children are present.  For the first time ever, the parent brought out the telephone video camera to bring back a visual for a sibling.

I attended an English teacher, and I mentioned my writing. We agreed on the difficulty of writing to both genders, and how males in the school system get left behind when it comes to literature. I assured the patient that without me, the inciting medical problem would resolve eventually, but reading West With The Night by Beryl Markham would make for a richer life. We would both like to see English teachers have more input into curriculum.  I talked about the importance of effective written communication when physicians have to send letters or emails to non-physicians..

Eternal Verities of the Human Condition

October 8, 2015

When patients come in by the mob

And I can feel my feet start to throb

Though the place is a zoo

I can tell you it’s true

I really do love my job.

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. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

I walked into work full of energy this morning, to an Urgent Care site where I’d never worked before.

At home I generally see a patient or two a day when I’m not working, mostly informal visits.  Some people leave with concrete advice.  Sometimes I enforce an exercise prescription by going on a walk with the person.  Occasionally I’ll serve breakfast.  People most often get advice, rarely a prescription for a pharmaceutical.

Frequently a person goes to a specialist as already scheduled, with advice on how to use buzzwords, give an accurate history, or ask for lab tests.

This particular clinic has a history, and it made me appreciate the care put into other clinic’s floor plans.

Over the course of the day I saw people with broken bones, skin problems, and respiratory infections.  I brought into play recent information from the conference I attended in Denver, especially about when to use and when not to use antibiotics and narcotics.  Some people left disappointed, but no-one left without attention to their problem.

Starting slowly, I soon had a five-hour crush of patients.  At two in the afternoon things slowed down enough that I could attend to my raging hunger.  Bethany sat with me in the break room while I bolted fries and smoked brisket.

After lunch I caught up with my documentation.

A quick run through my email showed me that my planned next step had fallen through.  I have no work on schedule as of November 1.

Weight loss in 21st century America demands investigation.  People who delay treatment for trauma will generally suffer more problems than if they’d come in early.

I did most of my antibiotic prescribing in the late afternoon and evening.

I didn’t get to speak a word of Spanish.

I don’t do much surgery, but I got the chance to remove a patient’s problem and found the experience delightful.

During a slow hour I asked Bethany to bring food at six, when she showed up things had backed up badly.  But I took 4 minutes to inhale some hot sour soup and orange chicken.

Without permission, I can’t give identifying details about the last patient of the day, leaving the philosophical distillation in a jumble..  My business sees the exquisite drama and irony because of these inherent truths:  mortality tinges human love with an urgency, we all climb a ladder of development, our bodies age no matter how we try for a perfection we cannot attain, and we spring from, in Kahlil Gibran’s words, “life’s longing for itself.”

I walked out into the cool October night, full of wonder.

September 20, 2015

When it comes to care of the heart

The doctor must always play smart

Though I’m working for free

I’ve no EKG

And Urgent Care only offers a start

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 System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania, where I’m working for an Urgent Care company. Any patient information has been included with permission.

I carry my stethoscope in my car for a reason.

In a town where I’ve been a medical community fixture for more than a quarter-century, people frequently seek my advice, whether or not I have an office

At a place of business which I visit weekly on average,  the person at the counter asked me to help someone.

The patient opened up with, “I don’t know, I just can’t describe it.”  It took skills honed over 30 years to develop a useful history, always the first step to making a diagnosis.

After a good discussion and a brief exam, I could definitely not make a diagnosis.  But I could say, especially from recent experience, that cardiologic problems don’t belong in Urgent Care.  Diagnostic options there include the essential electrocardiogram.  If abnormal, the patient needs to go to the ER.  But a normal EKG doesn’t mean the patient shouldn’t go to the ER; it means that more investigation must follow, and the ER uniquely has the tools to take the process further.

Urgent Care does a lot of things well, but Urgent Care needs to leave heart problems alone.  Since the summer began, I’ve sent all patients with chest pain to the ER.  Along with those who called their chest pain “back pain” or “abdominal pain.”

I phoned a longtime colleague at the ER, gave the condensed history and saved him the use of an interpreter.

I also spared the patient a useless trip to Urgent Care, but I fear I didn’t do much more.  Still the store owner insisted on comping my purchase; I insisted on not making a charge.

I thoroughly enjoyed using my medical and linguistic skills.

When I arrived home, my email included a note from Canada; I will not possibly start working till December.  This information comes as no surprise.

Bethany and I talked it over, and in the course of less than a minute decided to go back to Navajoland, but this time to the western part of the Reservation, so as to be reasonably close to our daughter in Prescott.

Trade offs in Urgent Care

August 11, 2015

I enjoy my Urgent Care job
The patients come by the mob
But sometimes it’s our fate
We’re not done, but it’s late,
The rush just makes the staff sob.

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 System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

I enjoy my current gig for an Urgent Care facility in suburban Pennsylvania.

My nominal work hours run from 8:00AM to 8:00PM. I go late on average one night out of three. Patients generally come in with problems of short duration and intense acuity. Most have a primary care provider who can’t see them in less than 3 days. Because management has developed a patient-centered approach, I do little redundant clerical work and thus I can spend a lot more time concentrating on patient care.

So far this week slow patient flow in the morning has given way to a brisk pace in the afternoon. Staff morale stays high, the big gripe comes against the rush of patients that starts after 7:00PM (about half the time). So tension builds on quiet nights as the clock ticks out the last half hour.

Poison ivy made up half the business back in June, but is now decreasing in frequency and severity. I have sewn up a lot of finger and hand lacerations. Two or three times a day we have the joy of curing the patient before they leave, mostly by taking out ear wax; but we also drain an average of one abscess a day. A majority of the x-rays I order show fractures.

People around here like to vacation at the beach, mostly New Jersey,Virginia and the Carolinas. We get a significant number of patients with swimmer’s ear and urinary tract infections related to the travel and swimming. And also the worried well who don’t want to be sick while on vacation.

August brings in the sports physical crowd. Basically healthy, the rare surprise disqualifications justify the activity.

Then, sometimes, with such a high patient volume (I consider 30 in a 12-hour shift light), serious illness demands an ambulance or an injection. Twice so far today I’ve advised patients to go directly to ER.

Earlier this week I helped wheel a patient into her waiting vehicle. I enjoyed breathing the warm summer air and smelling growing vegetation and seeing the summer thunderheads building in the north.

Occasionally a physical finding I’ve never before seen heralds a puzzle, and I refer to a specialist.

We refer all broken bones to orthopedists.

Urgent Care has its share of joys but so much of the fun comes from the fast pace and the easy-to-solve problems that the awe and mystery of unraveling complex disease one lab result at a time gets lost. An upscale, insured population obviates the opportunity to serve the under-served. And I miss speaking Spanish.

Life always involves tradeoffs.

Trade-offs

July 3, 2015

I like to care for the sick

For me it just does the trick

But after reflection

I miss the connection

If the pace of my work goes too quick.

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 System (EMR) I can get along with. I spent the winter in Nome, Alaska, and I just finished assignments in rural Iowa and suburban Pennsylvania. After detours for my brother-in-laws funeral and a bicycle tour of northern Michigan, we’re back in Sioux City.

I got a new computer.  I paid for the set up at the big box store.

When I returned to the store to pick it up, the young man helping me asked insightful questions about my career.  I didn’t recognize him.  He, however, recognized me.  I was his doctor, and, when he grew up, we used to see each other at the gym.

I delivered him and cared for him through his adolescence.  He has grown into a knowledgeable professional.  (He gave me permission to write more than I have.)

I don’t like talking about patients’ lives in public, and I enjoy talking about myself (frequently more than people want to listen), so I kept my end of the conversation about me.  I talked a lot about Alaska, and the freedom that locum tenens work gives.

Still the conversation brought me to reflection.  The 23 years I worked in private practice brought me intense professional satisfaction, but more than that it brought me to a perspective on the human condition that could only happen by intense involvement in people’s personal lives while staying in one place for more than a generation.

But inevitably, I had to talk about my 84 hour weeks, and a pace of work and life nowhere near sustainable.  I didn’t mention the 70% overhead that made slowing down impossible.

I also talked about what a great time I’m having on my current gig.  The Urgent Care outfit I work for has the problem Figured Out.  The top management, clinicians all, keeps the corporate vision of putting the patient first.  A person can walk into one of the clinics without an appointment, be seen in a prompt fashion, and be out in less than 45 minutes (the stated corporate goal).

I find the work very gratifying: single problem visits, almost all curable, resulting in easy documentation.  The patients tend to the younger age range, and I get to take care of an unusual number of older children and adolescents.

In the beginning, I felt a little uncomfortable taking away what I regard as the easy stuff from primary care providers.  But I heard over and over from my patients that their docs couldn’t get them in for 3 days to three weeks, or even told them to go to an Urgent Care.

Trade-offs fill the human condition.  I don’t particularly enjoy chronic care of medical problems which have treatments but not cures: diabetes, high blood pressure, high cholesterol.  But if I didn’t attend those problems I wouldn’t have the perspective for the grand spectacle of family development.  I like the travel and adventure of locum tenens, but I like running into people I know all over town (like in a big box store).

I would like to think I could find an optimum or a sweet spot.  More likely I’ll have to settle for one or the other, or even an oscillation from time to time.

Finding work and meeting ex-patients

April 17, 2015

The hardware she helped me select

Then noted a pain in her neck

I derived such enjoyment

At her place of employment

No charge for a three-minute check

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 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) I can get along with. I just got back from a 3 month stint in Nome, Alaska.

I returned from Nome to Sioux City ten days ago; Testing my immediate employability theory, I woke up Monday morning with nothing on my schedule, and tried to have work by Wednesday. My time frame incorrect, in less than a week I had work lined up from the 3rd week in April until the last of September.

I don’t write in detail about these jobs until I sign contracts, sometimes not until I see plane tickets. Five out of 6 jobs fall through. This summer I’ll work Urgent Care in 12 hour shifts, from 3 to 5 days per week. And, if things go according to plan, much of my summer I’ll spend working in Pittsburgh.

I’m also talking with a Canadian recruiter. Most American docs reflexively vilify the Canadian single-payer system but few understand it. I want first-hand experience despite the fact that with one exception, every Canadian physician I’ve met hated their system.

But every day I see former patients.

At the gym, a fit-looking, slim, middle-aged woman came up to me while I sweated on the elliptical. “You saved my life,” she said, “It was eleven years ago I stopped smoking. I fist-bumped with her, genuinely glad she changed her life. Yet I believe that if my patient gets better, 80% of the credit goes to my patient, and 20% to me.

Last week at Sam’s Club, a young man approached me with the good news that he’d stopped drinking soda pop and had started drinking more water. He looked healthy.

Yesterday a former patient reminded me that 25 years ago to the day I ushered her into the world. I had the great good fortune to diagnose pregnancy, do the prenatal care, attend the delivery, and perform the well child exams. She has grown into a strong, competent, attractive young woman with an impressive array of skill sets. An asset to the city, her family, and the health care industry, I feel privileged to have watched the process.

Today at the hardware store, a staffer complained to her co-worker about knots in her neck. (She gave me permission to write this.) “I’m a doctor,” I announced, “and I can make those knots go away.” I sat her on a stool at the back of the store and put my hands onto her shoulders, finding the usual set of painful lumps, starting with the upper inside corner of the left shoulder blade, the cluster of four between the shoulder blades, along with the characteristic tightness along the back of the neck. I used a routine that I developed over the years, progressively massaging the head’s support muscles, finishing with a standing upper back crunch. She thanked me profusely.

At the end, I said, “Making your neck knots go away, that took three minutes and it’s free, but it doesn’t address the whole question of why you’re not sleeping well, which is the root cause of the problem and would take 20 minutes.” She wanted to know where I work, and I had to tell her I’m between jobs.

I didn’t tell her I so enjoy making people feel better that I quit charging for spinal manipulation. But I left my business card, and encouraged her to read my blog.

A day and half in the life

May 19, 2010

A day and a half I’m on call

I know I can’t do it all 

     I take wax from the ears

     I give Kleenex for tears

And then I just hit the wall.

My long day on call grows no shorter as I write.

I get to the office most days before 7:30; I review lab results and scanned documents, and I read a medical journal.  Patients start at 8:30.

A reasonable morning opens with a sequence of 5 diabetics in several linguistic and ethnic groups.  I do a lot of tearful goodbyes.

A thank-you note and card comes from an Hispanic family;  the note verbatim reads Para: Dr. Gordon.  De familia (family name deleted) le deseamos mucha suerte en este nuevo camino que enpieza Gracias por todo lo que nos alludo en nuestra salud.  Lo vamos a extranar.

The few brief sentences carry much warmth.

A patient, whom I have known for many years, comes in with arm pain and no trauma.  I get an x-ray on a hunch; most times such studies yield little information but this time the pattern of light and dark suggests something very unusual and much deeper.  I show the films to my partners, we nod and say, “periosteal elevation.”  I arrange for a CT of the arm for the next day.

Urgent Care calls me about noon to ask if I’ll work there; illness disrupted regular coverage.  I can’t say no because of my job description.

The drug rep brings lunch and after my sandwich and chips we chat, mostly about my future.

The afternoon stars six people with earache.  Four have normal eardrums, and, speaking from personal experience, I ask them if the short, sharp, stabbing pain, severe enough to make them wince, comes at random intervals.  I explain the problem with temporal-mandibular joint dysfunction, I get to the bottom of the problem, and treat without medication. 

Two of the people with ear pain have ear wax stuck, hard, in the ear canals, and I have the satisfaction of curing the patient before they leave.

At five Bethany shows up and I let her know about my late shift.  We go across the street to the grocery store for Chinese food.

We get the Senior Two Entree Special (I’m 60 now), an enormous amount of food, and two sets of chopsticks.  We sit in the corner dining area and share the small intimacies of our days.

Back at the office, I finish my documentation from the afternoon, and at 6:00 the first of the evening patients arrives.

I move quickly while the dusk gathers outside.  I speak Spanish and English to the patients, some of them my regular clinic patients who couldn’t get in to see me on a timely basis or who can’t take time away from work.  I send a patient with puzzling abdominal pain and chest pain to the hospital for consults with specialists, and I wonder what I would do with that patient in Barrow with the nearest surgeon 800 miles away. 

Three more patients with ear pain: one with TMJ problems, one with wax packed hard enough to have turned to stone, and one with an actual ear infection. 

I face the dilemma of treating smokers for cough.

At 8:23 I go back to my office and I try to finish my afternoon’s documentation.  I answer and dispose of email.  At 8:58 I shut down my computer, hoping to  leave promptly at 9:00

But I find the fourteenth and last patient ready at 8:59.

At 9:10 I walk out of the clinic, into the deepening night, and I smell spring running riot.  My back hurts, not as bad as it did 20 years ago. My feet hurt, but they hurt worse 30 years ago because now I have rigid orthotics. I’m tired, but not like I was tired 15 years ago; within striking distance of the end and I have slept much better since I gave up OB.  I walk straighter and stand straighter than I did when I was half my age.  Even when I’m tired.

I miss my workout at the gym, the hour and a half to sweat and watch TV.

At home I take care of more ework and roll into bed at 10:30.

In the middle of the night I take a call from the nursing home about a patient with a significant change in condition since striking their head in a fall a few hours earlier; I instruct the nurse to send the patient to the ER.

At 5:55 I get an alarmed call from St. Luke’s Labor and Delivery: come for a STAT C-section.  I am dressed and brushing my teeth in the car 4 minutes later.  I exceed the speed limit.

I arrive just as the crew gets into position, and I have time to pull on booties and scrubs before the actual surgery starts. 

With a very good obstetrician at the helm, I have absolute confidence as the secondary member of the team, and the baby arrives in short order but distressed.  Stabilized in less than 10 minutes and up to the NICU, we sit down to debrief at the nurse’s station at 6:30. 

We discuss inexplicable physical findings during the labor.  “I want to know why,” the OB says.  Then, “God humbles me weekly.  If not daily.”

I talk about how every day I see something I’ve never seen before.

When I get home at 6:50 in the morning Bethany has my lunch packed and is finishing breakfast.  I shower, eat, leave the house half an hour later than usual and have to face traffic.  My commute takes 18 minutes instead of 13 and I arrive at the office sleep deprived with hoarse voice and a sense of humor even weirder than usual. 

More people with ear problems, and the nurse and I marvel at how many of those I’ve seen in the last few dozen hours.

Gridlock seizes my rooms from 10:40 to 11:25.  A patient with chest pain needs x-ray and EKG; a patient with pain on urination needs a urinalysis; and a patient on Coumadin for a blood clot needs a protime.  I feel trapped with both lab and x-ray backed up.  The people in the waiting room get angrier and angrier. I twiddle my thumbs, powerless.

The CT scan results come back for the patient with the arm pain from yesterday; non specific abnormalities can only be elucidated with MRI, which I order.

Then the lab and x-ray start to move again and by neglecting my documentation I manage to get the last morning patient out by 12:10 PM.

By that time day has gotten longer and my voice has deepened into the subwoofer range. 

Chinese food comes to the break room courtesy of a drug rep who doesn’t even stay to pitch his product.  I eat too much of it and then I eat the fabulous sandwich Bethany has sent me (green chile, avocado, artichoke heart and baked chicken on fresh chipotle baguette).  Fatigue drives my appetite runs out of control.

I power nap for 20 minutes, then I go back to my documentation.

The afternoon brings more earaches, loss of hearing, and dizziness.  I take out plugs of wax as big as the patient’s little finger. 

A patient with broken ribs contracts pneumonia.

My tongue sticks to the roof of my mouth as I feel dehydration set in, but I can’t slow down long enough to get to the water cooler.

A bipolar alcoholic patient with migraines, and a problem of just not feeling right also has chest pain, a main complaint that can’t be delayed.  The amount of clinical material exceeds any reasonable time limits for one visit.

Patients with borderline personality have limited emotional resilience and come  at a time in my day when I am pressured, fatigued and running behind.  That patient wants to get everything taken care of right now, and when I resist, threatens to leave without being seen.

Which, of course, is a ploy.  If not a short timer, I would grit my teeth, get through the visit, and send a termination letter while I still upset.  I let the patient manipulate me.  I don’t have long to go and I don’t have to fire anyone. 

Sore throat, cough, and two well-child checks. 

The Hispanic well-child checks constitute a problem; a lot of the parents don’t speak English, and none of my partners speak Spanish.  Like all my patients since February, I have to arrange for follow-up after my departure.  I send a lot of the children to a pediatrician who speaks Spanish well. 

After I finish documenting the last visit, I walk out of the back door into the sunshine and an absolutely perfect afternoon, and I drive through the spring warmth to the gym for a workout.  I lose myself on the elliptical machine and the stationary cycle, sweating out the exhaustion.