It's story time again
I worked a 12 hour shift yesterday. I hate them, but had a couple of patient encounters which were really pleasant or interesting, and reminded me why I went in to this business in the first place.
So comes now the 99 year old patient with drainage from a prosthetic implant put in about 6 years ago. The best (and only curative, rather than palliative) treatment for this is to remove the prosthesis and wait with antibiotics for about 6 months, and then put a new prosthesis back in. Which I explained to the very sharp, on-the-ball lady, who looked right at me and asked "I'm 99 years old. Do you think I have time for that?" Not accusing me of anything, not even unhappy about it; what she was doing was making fun of me for describing this long course of treatment to a person who was as old as she was. Loved it. She was marvelous; I wanted her to be my grandma. She reminded me why, sometimes, little old people are the most fun to treat. I love feisty patients, and this lady was right up there on the feisty scale.
Next comes the young woman who had a red area on her body, previously diagnosed as a skin infection (a cellulitis or abscess). She was there because she had developed a fever and joint pains, and the rash wasn't any better despite the antibiotics their doc had given them. This was a "See the woman" diagnosis: I examined the rash (which requires touching it, by the way; there's important information in feeling whether it's raised, if there's a pocket of fluid underneath it, stuff like that), asked a couple of salient questions, and was able to make the call. She had Lyme disease. The rash was perfectly circular, not raised or "indurated" (didn't have that feeling of "thickness" which infected skin gets), and was accompanied by systemic symptoms out of proportion to the area of the rash. She also spent quite a bit of time outside. And while her doc gave her an antibiotic, it was the wrong one for the problem. I love making this kind of diagnosis; it's simple and straightforward, and involves a problem I can fix. Gave her the right antibiotic (which does require a 21 day course, pain in the butt), and expect her to get better RSN.
(Incidentally, why did her doc not make the call earlier? Hard to say. First, the rash might not have been as clear. It didn't look "classic", but only 15-20% of these rashes look classic (like a bullseye); the rest can look like anything, although in general they ought to be roughly circular. Also, almost all doctors hate skin rashes; they're a pain to diagnose, and a red skin rash in an area which get infections from time to time is easy to call a cellulitis. So I saw the patient at a propitious time, and was able to make the call).
FInally, the nice lady with the very fatal (in time) rhythm disturbance, which we were able to fix with proper drug use, although getting an IV in the patient was hard; I had to put in an IO (intra-osseous) line, which is basically a spike you drive into the tibia (just below the knee, basically). We've done that in kids for years, but it turns out it works in adults, too, and almost everyone has at least one knee (if you don't, you have bigger problems). This was one of those "well, need to act now" issues; the patient wasn't doing well, and needed the line right-damn-now. In another situation, I would have waited until we were able to find a peripheral IV, because IO lines *hurt*; in the event, now was more important than anything else. Fixing the arrhythmia which is causing the chest pain, preferably without using The Force (which for this problem comes from the wall, in the form of electricity) required the use of other force. But it worked really well.
--
(It also led to the frustration of having to eventually answer the email asking why I transferred the patient; my hospital is begging for admissions, and would love to have admitted this patient. All of her care, however, had been elsewhere, downtown, and appropriately so; she had complex disease. Now my cardiologists are good, really good, but they don't have the backup systems available in a major academic center, and I felt the patient would be better served going downtown where all her doctors were. But my boss will ask why I sent her, because his boss will ask him, because his boss is basically querying *all* transfers, because every transfer represents lost revenue. And for the hospital, like every hospital, revenue is paramount. If I do anything which impacts revenue, I must answer why I did that. And arguing "it's better for the patient" is subjective, and frankly makes me look as if I don't have faith in my staff and hospital. And I do have quite a bit of faith; like I said, my cardiology staff is really good; I'd be under their care if I had a heart issue with solid faith in their judgment. But all of the patient's care had been elsewhere, and those doctors knew her better. I think the other hospital will do a better job, even though my cardiologists are very good. And having your judgment questioned for revenue reasons is frustrating. If you question ot for medical reasons, I have my ducks lined up; there are good reasons why continuity of care is a Good Thing. Revenue...ought not enter into the picture, in my sole judgment. But it always does).
So comes now the 99 year old patient with drainage from a prosthetic implant put in about 6 years ago. The best (and only curative, rather than palliative) treatment for this is to remove the prosthesis and wait with antibiotics for about 6 months, and then put a new prosthesis back in. Which I explained to the very sharp, on-the-ball lady, who looked right at me and asked "I'm 99 years old. Do you think I have time for that?" Not accusing me of anything, not even unhappy about it; what she was doing was making fun of me for describing this long course of treatment to a person who was as old as she was. Loved it. She was marvelous; I wanted her to be my grandma. She reminded me why, sometimes, little old people are the most fun to treat. I love feisty patients, and this lady was right up there on the feisty scale.
Next comes the young woman who had a red area on her body, previously diagnosed as a skin infection (a cellulitis or abscess). She was there because she had developed a fever and joint pains, and the rash wasn't any better despite the antibiotics their doc had given them. This was a "See the woman" diagnosis: I examined the rash (which requires touching it, by the way; there's important information in feeling whether it's raised, if there's a pocket of fluid underneath it, stuff like that), asked a couple of salient questions, and was able to make the call. She had Lyme disease. The rash was perfectly circular, not raised or "indurated" (didn't have that feeling of "thickness" which infected skin gets), and was accompanied by systemic symptoms out of proportion to the area of the rash. She also spent quite a bit of time outside. And while her doc gave her an antibiotic, it was the wrong one for the problem. I love making this kind of diagnosis; it's simple and straightforward, and involves a problem I can fix. Gave her the right antibiotic (which does require a 21 day course, pain in the butt), and expect her to get better RSN.
(Incidentally, why did her doc not make the call earlier? Hard to say. First, the rash might not have been as clear. It didn't look "classic", but only 15-20% of these rashes look classic (like a bullseye); the rest can look like anything, although in general they ought to be roughly circular. Also, almost all doctors hate skin rashes; they're a pain to diagnose, and a red skin rash in an area which get infections from time to time is easy to call a cellulitis. So I saw the patient at a propitious time, and was able to make the call).
FInally, the nice lady with the very fatal (in time) rhythm disturbance, which we were able to fix with proper drug use, although getting an IV in the patient was hard; I had to put in an IO (intra-osseous) line, which is basically a spike you drive into the tibia (just below the knee, basically). We've done that in kids for years, but it turns out it works in adults, too, and almost everyone has at least one knee (if you don't, you have bigger problems). This was one of those "well, need to act now" issues; the patient wasn't doing well, and needed the line right-damn-now. In another situation, I would have waited until we were able to find a peripheral IV, because IO lines *hurt*; in the event, now was more important than anything else. Fixing the arrhythmia which is causing the chest pain, preferably without using The Force (which for this problem comes from the wall, in the form of electricity) required the use of other force. But it worked really well.
--
(It also led to the frustration of having to eventually answer the email asking why I transferred the patient; my hospital is begging for admissions, and would love to have admitted this patient. All of her care, however, had been elsewhere, downtown, and appropriately so; she had complex disease. Now my cardiologists are good, really good, but they don't have the backup systems available in a major academic center, and I felt the patient would be better served going downtown where all her doctors were. But my boss will ask why I sent her, because his boss will ask him, because his boss is basically querying *all* transfers, because every transfer represents lost revenue. And for the hospital, like every hospital, revenue is paramount. If I do anything which impacts revenue, I must answer why I did that. And arguing "it's better for the patient" is subjective, and frankly makes me look as if I don't have faith in my staff and hospital. And I do have quite a bit of faith; like I said, my cardiology staff is really good; I'd be under their care if I had a heart issue with solid faith in their judgment. But all of the patient's care had been elsewhere, and those doctors knew her better. I think the other hospital will do a better job, even though my cardiologists are very good. And having your judgment questioned for revenue reasons is frustrating. If you question ot for medical reasons, I have my ducks lined up; there are good reasons why continuity of care is a Good Thing. Revenue...ought not enter into the picture, in my sole judgment. But it always does).