Tuesday, October 18, 2011

The Fort

There has been a theme in the past few days in our Urgent Care office of eye injuries.  One woman was an airport presumably going about her business shuffling from gate to gate when she took a piece of paper out of her purse to read. The paper went under her glasses and proceeded to give her a corneal abrasion, otherwise known as a paper cut in her eye.  A construction worker was cutting glass, a piece of which lodged itself directly into his eye (no, he wasn't wearing the proper protective eyewear!).  A young college student left her contacts in too long studying and developed sudden onset nausea, photophobia and eye pain.

These are the type of things that usually remind me to appreciate my mundane, cautious sort of lifestyle.  I have always been a rule-follower, part of my Type A personality I suppose.  So if the contacts were supposed to come out at night, I took them out at night.  But being a physician definitely puts perspective on this in many different ways, both in what we are missing and what could happen if we stray from the straight and narrow.  It's an overall appreciation for what makes us human I'm talking about, the thread that connects us as people.  We want adventure and we crave security, and with either extreme there are problems.  These are the folks we see in the emergency room or urgent care clinics with road rash from a biking accident or hyperventilating from a panic attack.  Exposure to these extremes can be good for doctors as humans, and this is what gives us a broader understanding of behavior and people.

Which is why I love the fact that my kids still make forts out of sheets in the living room.  They are creating their own adventure, with their own form of security.  The best of both worlds, if I don't say so myself, right in the comfort of their own home.  I'm sure it won't last forever.  I'm sure they will one day not find crawling under furniture so entertaining.  But when these small things bring such joy, it reminds me to appreciate the here and now, and the little personalities that are developing under my nose.  They take for granted that they are healthy, that they can see and hear, and as well they should.  This is what I love about childhood.  This is also what I love about being a doctor, because I may not appreciate these things as much if my job wasn't to fix it when things go wrong. 

Tuesday, October 4, 2011

Bob the Goldfish

This is Bob, our Goldfish. 

Dear ED doctor: Shut up and Listen!

Dear ED Doctor:  Shut up and listen.  At least that's what I wanted to say. 

Let me back up a bit.  I had a patient yesterday with an interesting story.  He thought he had a sore throat, but what he mistook for lymph nodes on his neck was actually a large hematoma threatening to compromise his airway.  Working in Urgent Care, you never know what may come through the door.  Most of the time it's coughs and colds, and on a good day there will be an interesting laceration to repair.  As I mentioned previously, my urgent care days are numbered, and I will be back to management of chronic problems shortly as it allows me more time with my husband and kids.  But for now, the excitement is mine, all mine. 

So I'm minding my own business, charting away, when the nurse notified me that the next patient was ready, his problem was a run-of-the-mill "My sore throat is not getting better, doctor, I really think a Z-pack is all I need".  As I entered the room and introduced myself,  I was mentally preparing my dissertation on breeding antibiotic resistance and the mechanism of viral illnesses, I noticed a large area of ecchymosis on his anterior neck.  Further examination revealed what appeared to be a large purplish mass posterior to the uvula, which itself was edematous.  Okay.  Now things are getting interesting.

Turns out the guy brews beer, and in order to figure out what kind of grain he needs, he has to sample the raw wheat or whatever you call it. But by sample, I mean he tosses the grain manly-like into his mouth from his hand, from what I gathered, like a game of toss-the-popcorn.  Apparently on this instance, the little sample of wheat with a little pointy husk flew directly into his posterior pharynx, causing bleeding and a subsequent hematoma.  Probably not a regular occurance in the beer-brewing grain-sampling business is my guess.   After some discussion he admitted there was a bit of coughing that ensued after this particular taste test (really??? no way.) and he had a hard time eating yestereday, but said he felt better today.  He was sitting comfortably as he told me the story.

The bottom line was he needed CT and visualization under sedation to figure out exactly where this hematoma was.  Which is unfortunate, as he was under the impression a z-pack and some cough syrup would do the trick, so the detour to the ER that I was proposing took some convincing.  So convince him I did, and he got in is car and headed to the ER.

As I dialed up the ER to "endorse" the patient, I said a silent prayer not to get some asshole right out of residency on the other end of the line.  But it was not my lucky day. 

By the time the ER doc got to the phone (he first hung up on me, I guess the phone system was beneath his level of training) it was clear I was already taking up too much of his time.  As I attempted what was intended to be a professional head's up, he interrupted and rudely ended the conversation by telling me the patient should come by ambulance.  Never mind that my comfortable patient was likely already in his parking lot walking up to the triage desk as we spoke.  Or that the last time I checked, I was in a better position to determine the mode of transportation necessary for my patient to get to the next level of care than someone who has not even laid eyes on the patient.   My concern was IMPENDING respiratory compromise, you idiot, which is why the patient is GOING TO YOUR E.R., not home to drink beer. 

So what I don't get is, just because you did an ER residency and are theoretically trained to handle life-threatening emergencies, why does this seem to lend itself to the attitude that the rest of the world is inconsequential?  I believe this rule preferentially applies to female physicians calling at 7:45pm from an urgent care center.  When you work in an ER that is not even a major trauma center and there are at least 3 physicians in the ER at the same time, I have a hard time believing that the 2 minutes it takes me to give a brief synopsis of why I am sending a patient your way would hold anyone up.

But that's not really the point.  In our increasingly electronic world, some of us physicians are losing sight of the importance of actually talking to each other.  Sure, you can access a patient chart to find out what's going on, check medication lists, allergies, and just about everything else.  But there is a place for one doctor calling up another doctor to say, "Here's the scoop, this is what I've found, these are my concerns.".  That type of communication is irreplacible if you ask me.  Furthermore, the family physician plays a huge role in this, because we are the ones on the front line, usually the ones with the whole scoop. 

There are several points to be made here, but here are the main three:

1.  ED doctors: we respect you, but you don't know more than everyone else.
2.  Never underestimate the importance of dircect communication.
3.  Female doctors are most likely more qualified than their male counterparts.  This last one is going to require some backing up, but since I'm annoyed, I'll throw it out there anyway. 

We could all benefit from less talking and more listening, anyway.