Diary from a Week in Practice



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Am Fam Physician. 2002 Jan 15;65(2):204-206.

Monday

JDF was in her office dictating charts while awaiting the arrival of her next patient when the commotion began. A local transportation aid appeared in the doorway and said the patient she had brought for a routine office appointment was in the van and was unresponsive. She said the patient was previously alert and conversing. JDF and RHS hurried to the van and recognized the elderly man as a long-time patient in the practice. He was unresponsive, not breathing, and extremely bradycardic. The patient was taken into the office emergency room where a full code for cardiac arrest took place. Despite the best efforts, the elderly man, who had multiple health problems, did not survive. This loss reminded us of the fragility of life, and also emphasized the importance of teamwork and constant office preparedness for emergencies.

Tuesday

RHS noted that three of the older women who had been in the office this morning had delivered during his first year of practice. Two delivered at home and one at the hospital. The one who delivered at the hospital was considered an older primigravida for that time. The two women who delivered at home were multigravidas. The home deliveries both had associated events that made them more than simple. One woman chose to have labor induced with intravenous oxytocin, and the other woman sustained a fourth-degree perineal tear. The induced labor was completed without difficulty, and the perineal tear was repaired at home while a lay midwife administered open-drop ether. Of course, neither of these scenarios should be attempted today.

These women have all remained in the practice, and we have cared for several generations of their families. The mother of one of them was a patient, and we are now looking after her great grandchild—five generations! In a fairly stable community, providing longitudinal care is one of the most rewarding aspects of family practice and provides valuable insight as we care for succeeding generations.

Wednesday

A major concern for many of our patients who are Medicare recipients or are uninsured is paying for medications. It can be difficult to convince patients to take medications when results can't be immediately appreciated (e.g., osteoporosis prevention). For patients with extremely limited finances, it can be very difficult. As a community service for our patients with the greatest need, I began enrolling them in medication assistance programs (these can be found at several Web sites, including www.needymeds.com). Each program has forms that require personal information, and most must be reviewed and resubmitted every three months.

One year later, I'm now faced with the task of keeping up with the large amount of paperwork required for the more than 50 patients enrolled (they each receive an average of two medications). Time is also required to review charts to monitor changes in medication and update labs, receive and distribute medications, and perform patient education. While it has been a worthwhile investment of resources, it would have been easier if I had implemented the program with the aid of a non-clinician (e.g., office assistant, student volunteer) to manage it. It would be difficult to drop the program because our patients who are enrolled depend on receiving their medications free each month. But, I spend at least three to four hours weekly (uncompensated) trying to “keep up.” A lesson learned…

Thursday

It was RKT's turn to work extended evening hours. Appointments during these hours are generally reserved for acute visits and quick rechecks. RKT was notified that a child who had fallen on a large cactus plant was enroute to the office. In just a few minutes, RKT was confronted with a teary eyed five-year-old. He was holding both palms out directly in front of him but wouldn't allow any of the nursing staff to evaluate his wounds. Fortunately, this young patient was the best friend of RKT's five-year-old son, and RKT knew the patient well.

While playing, the child had tripped and fallen onto a large potted cactus plant. He had braced his fall with outstretched hands, grabbing the nearest object—the cactus plant. He had dozens of small, sharp cactus spines imbedded in the palms and digits of both hands. The task of removing multiple painful cactus spines from a frightened five-year-old seemed almost overwhelming. However, this hour-long process was made possible by involving the child and the mother. RKT gave forceps to the mother and a magnifying visor to the child. With simple instructions, mother and child worked together to locate and remove cactus spines from the right palm while RKT worked on the left palm. Tears and anxiety gave way to determination as child, mother, and physician worked together on what became a most memorable encounter.

Friday

JDF was experiencing the usual Friday morning rush when a call came into the office from the local assisted living center. A 77-year-old male patient was noted to have bright red rectal bleeding. He had been discharged from the hospital yesterday after being evaluated for unexplained weight loss. On arrival at the office, he appeared thin and pale. Because of dementia, he was a poor historian and could not recount his hospital course (the hospital records were not yet available). The patient had significant hypotension, pallor, and a copious amount of blood with clots in his diaper. He was actively bleeding. Intravenous fluids were instituted and he was transported to the local emergency department. FC admitted the patient, who received six units of packed red cells to help stabilize him. Unfortunately, a gastrointestinal (GI) bleeding scan did not reveal the source of the bleeding. Finally, after GI and surgical consultations, a lower endoscopy was repeated. It was deduced that our patient had experienced a rare complication—bleeding from the polypectomy site from the first colonoscopy, which was performed less than 48 hours earlier. The second colonoscopy confirmed no further active bleeding. Fortunately, the patient was spared a hemicolectomy and is expected to make a complete recovery.

Saturday/Sunday

Weekend and after-hours coverage is an integral part of rural family practice and many factors contribute to its effectiveness. For years, our practice has benefited from the support of a dedicated and well-trained volunteer rescue squad.

This afternoon, a 72-year-old man with longstanding coronary artery disease who had previously undergone coronary artery bypass grafts collapsed and stopped breathing while watching television. His wife immediately called 911. The community's rescue squad was monitoring 911 calls and recognized the name of the caller and knew the address. They were also familiar with the man's medical situation. Even before being dispatched by the 911 operator, the rescue squad responded to the call. The patient was in full cardiac arrest with ventricular fibrillation. Electric shock cardioversion was administered, and sinus rhythm and spontaneous respiration were restored.

HBK was also monitoring 911 calls and responded to the address. By the time he arrived, resuscitation had been accomplished and HBK accompanied the patient in the ambulance to the hospital. The patient was later transferred to a tertiary care hospital where a pacer-defibrillator was installed. Cooperation among components of the local “health care team” is essential to providing optimal health care at the local level.

Robert H. Shackelford, M.D., is one of five physicians at Mount Olive Family Practice in Mount Olive, North Carolina. Dr. Shackelford and his colleagues, which include three physician's assistants and one nurse practitioner, provide all types of care (except obstetrics) to patients of all ages in their rural community.


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