My maximum patient load at any one time is 5 patients, and I got two more today. I don't know how I managed to fit them in; I still know almost nothing about the one. She's a surgery patient at the root, multiple hip dislocations and now they want to work her in to revise the prostheses. We were called to do a preop eval. As Cardiology later put it so delicately, "she's so schizoaffective, she's a very difficult historian." Patient was something less than cooperative, you see, but the one important thing she was willing to tell us was that she'd had chest pains within the last week.
Total hip reconstruction + recent chest pains + history of diabetes, hypertension, smoking, and vascular disease = automatic Cardiology consult. S made me call. S made me call all my own consults all day today. Slowly, he seems to be trying to make me do things for myself. He's still busy, though. I called cards and discussed the patient. We cancelled surgery until she can get a stress test. I was supposed to call the surgeon and tell him (this is a Very Treacherous Ground, and one I was not looking forward to) that cardiology refused to clear her until stress came back okay. "Well, call the surgeon," S says. "After lunch."
I called the operator. "Can you page Dr. W to this number?"
No, she says, he's signed out. I can page his partner who's on call for him.
She pages the partner. He calls me back. I start to explain. "Dr. W is so here," he says. "You'll have to contact him. I'm not seeing his patients."
I can't page him, the operator informs me. He's signed out. But his partner said... I'm sorry, when he's signed out I have no way to reach him. Defeated, I leave a note in the chart: "per cardiology, this patient is NOT cleared for surgery pending stress test." I stopped by again at 4. Nursing was on the phone with the surgeon's nurse. "Did you write this order?" Trepidation. Yes, do I need to talk to her? "They just want confirmation that Cardiology really needs the test." Relief. I smile. Cardiology, I say, comfortable in this role, is not comfortable with her going to surgery without the test. I get a thumbs-up from nursing. Everyone loves me, because I have saved them from being the bad guys.
Social work loves me because I came to them to discuss my patient instead of handing down imperious orders. I gave them the story, asked when they needed to get involved. PT first, she says. then we'll talk about home safety or temporary placement. She listened to my summary - I'm always on the same floor; we've chatted about my patients before - and made some suggestions for how to write my orders, thanked me. I had a great social worker on the peds floor at $hospital, I say. I owe it to her to be good to social work. Laughter. Everyone knows $hospital. "She must've been great, to work there."
His knee swelled up last night and the intern on call had to aspirate the joint. We thought we would get to see gout; he fits the typical atypical profile - elderly, on diuretics, with osteoarthritis and I started allopurinol, stupid me, yesterday. Staff this week does bedside rounds and took us down to the lab to look at the aspirate. No crystals, no gout. But pathology happened to have another slide of another joint just chock-full of them. I looked, in the dual-headed scope. Little horizontal needles of brilliant cerulean crossed by faint upstrokes of goldenrod on a strange purple-red background. Chinese lettering in artistic colours. Negatively birefringent. Pretty. Very pretty.
His family had me paged. I came within ten minutes. For that small concession to them, frustration became relief, cooperation and understanding. We talked about him, their concerns. I promised to look over his medication list carefully and explain the changes to his daughter. I offered our current differential, not just a diagnosis. They nodded, listened. We're changing the antibiotics, the bacteria in his urine cultures are resistant to levaquin. I think maybe all of this is related. Relief is on their faces. What about tomorrow? I'm going to be out of town tomorrow, I can't pick him up if he goes. Don't worry, we won't send him somewhere unsafe. He'll stay an extra day so that someone will be there for him to go home.
Incidentally, the daughter is a school counsellor. The bond is cemented as I mention that my father is also a school counsellor, in the same age range as she is. Did I answer all your questions? She smiles. She is very pretty, well-dressed, polite as she nods. Have the nurses page me if you have any more. She relaxes. "I will. Thank you."
At the end of the day, Ortho pages me to say he'd seen my patient, my difficult patient whose leg abscess has now grown methicillin-resistant staphylococcus aures, or MRSA for short, a bacteria that requires intravenous vancomycin to treat and puts him in an isolation room. He leaves to smoke, regularly, no gloves and no gown. We don't stop him. If we stop him he'll leave altogether and return to the ER when it's time for his next dose of pain pills. Catch-22. Ortho and I have been in touch several times; I try to make sure I know what his plans are because in my brief surgery rotation I never learned much about wound care or bone biopsies or abscess drainage. That would have been useful. "Keep him a few more days. We know he's going to be noncompliant when he leaves." He says things I feel in my heart are unprofessional to say about a patient; they are borne of too many years seeing difficult men whose lives are a shambles at their own bidding. He also says something we all are thinking: six weeks of vancomycin therapy, IV, is probable. That requires a go-home PICC line for a man with a history of IV drug abuse - a peripheral venous catheter, all fresh and ready for the using. We all wonder how to help him resist the temptation. I will be left to explain the probable results to this patient; I have the time, as they say. Ortho pontificates, under the pretence of discussion. I stifle another hint of irritation. His girlfriend, I will admit, is a character almost as bizarre as my patient is. But she does not - they do not - deserve to be so overtly maligned. Is this, I wonder briefly, why they tell me they wish I were a practising physician?
Ortho thanks me, taking precious precious time (a surgeon's time is always premium) to tell me he appreciates me calling, that it is a lost art, this keeping in touch with consultants, and he hopes I will continue to do it. I did not expect that, not at 4:30 on a Monday afternoon after asking one more time what he wanted to do with this most difficult of patients. I thank him; what else can I do? I will not forget.
One goes home, finally. I never did see her today. S did the discharge, wrote the scripts, did the dictation. I saw her yesterday, sweet lady who did not complain when I asked her to stay one more day for a Cardiolyte stress test. There was a note on her chart two days ago: "Patient cannot add numbers to mix insulin. She will draw up two syringes." Willing, she is, to take two injections twice a day if the doctor tells her that's what she needs to do. I wonder if she will remember what I told her about smoking and her heart. I hope she will. We put her on premixed insulin instead; no good doctor would make a patient take two shots when one will do equally well. And she always smiled at me. She started insulin in the hospital and I watched her metamorphose from terrified to triumphant, excited to tell me that she gave her own shots and "it wasn't that bad."
It isn't that bad. 0715 AM into the hospital after a drive down from Fort Wayne, got up at 0400 this morning rather than driving last night. Breakfast was a cappuccino. I have not stopped moving all day long, right down to the 1530 admission for chest pain, rule-out MI, oh and by-the-way-he-has-an-abdominal-aortic-an
Finally at 1700 (bell rings at 1600, finish your work and go home) I am ready to changeover to the on-call resident and go home. He's a transitional year student, going into something lucrative and highly competitive after this. I rattle off my patients as fast as I can, driven by the need to let him go back to taking his own H&P and doing admissions. It's straightforward: surgery patient, UTI and knee inflammation, pain control and noncompliance, oh and this guy you'll get paged with CT results, call cardiothoracic if the aneurysm's gotten bigger or there's dissection, otherwise just relax. They shouldn't be trouble. "Anything else?" No, go on home. I wish him a quiet night. He laughs.
I am exhausted when I get into my car, discover that my heel pain is due to a malfunctioning shoe and not falling arches after all. I am also smiling. It feels so good to be back, O Best Beloved, so very very good.
I have been up since 4 this morning and on my feet from 0715 to 1730, ten hours of work, crossing items off my list of items one patient, one problem at a time. Non-stop. Now I think it is time to make dinner, since I ran out of the hospital without taking advantage of my free meals.
It isn't that bad.