Diary from a Week in Practice
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Am Fam Physician. 2002 Jun 15;65(12):2475-2476.
“I am not exactly sure why she is here,” confided the third-year medical student who was working with KS in the family practice center. The 16-year-old girl had mild nasal congestion, which she had experienced intermittently for several months. The patient's mother reported that an over-the-counter antihistamine had diminished the symptoms. KS reviewed the patient's clinic chart and noted that the young woman's last menstrual period was six weeks ago. “I always interview teenaged patients with the parents present and then politely ask the parents to wait in the lobby during the physical examination,” explained KS. “This gives me the opportunity to question these patients about sensitive subjects like smoking, drug use, and sexual activity, without the parents being present.” The medical student returned to the examination room and discovered that, indeed, the teenaged patient was sexually active and very worried that she might be pregnant. She was especially concerned that her parents might find out. After counseling the patient on birth control methods and protection from sexually transmitted diseases, arranging for a pregnancy test, and encouraging the young woman to communicate more openly with her parents, the student concluded the visit. As she began to write the progress note she commented, “At least now I know why the patient came in.”
JW was observing as one of the third-year residents examined a patient in the family practice service when a “code blue” was announced over the hospital intercom. The patient, who was in cardiac arrest, was just on the other side of the corridor. The physicians quickly excused themselves and hurried there. On arrival, they observed two nurses performing cardiopulmonary resuscitation on a middle-aged man. JW stood aside as the resident quickly assessed the situation. The nurses reported that the man had been admitted with chest pain earlier in the day. Suddenly, the monitor revealed runs of ventricular tachycardia. The nurse had hurried to the man's bedside to find him unresponsive. A nurse with a crash cart arrived seconds later. When the cardiac monitor revealed ventricular fibrillation, the patient was defibrillated and quickly converted to normal sinus rhythm. Even though the patient was not on the family practice service, the resident accompanied him to the intensive care unit while a staff member contacted his private physician. JW felt pride in the quiet confidence and skill with which the resident took charge of this critically ill patient.
TA was following a very sick patient with end-stage liver disease complicated by intractable ascites and encephalopathy. The first-year resident on the case had done a good job caring for the patient and keeping the family informed about the prognosis, which was poor. The family had signed a “do not resuscitate” order, and the goal was to keep the patient as comfortable as possible during the time he had left. So TA was surprised to discover that the resident had ordered a central line and total parenteral nutrition (TPN) for the patient. TA quickly called the resident to discuss the case. She discovered that the resident was not sure where to draw the line between “doing everything possible to prolong life” and “letting nature take its course” in a patient who was terminally ill. The two physicians decided that initiating TPN was inconsistent with the treatment goals that the family desired. They also discussed the importance of explaining all the elements of end-of-life care to patients and their family members to help them make informed and detailed decisions about treatment. TA thought to herself how, on a very busy in-patient service, the faculty often forgets that many residents are uncomfortable with end-of-life care and have a difficult time not ordering every possible treatment for these patients.
It is not every day that a family practice physician literally saves a patient's life. But it happened today when one of the third-year residents made a house call. Earlier in the week while on the emergency room rotation, JB had seen a 42-year-old man with severe abdominal pain radiating through to the back. A computed tomography scan confirmed a leaking aortic aneurysm. The patient was transferred to a nearby hospital, where a thoracic surgery team was waiting. The next morning, JB went to the hospital to check on the patient but was stunned to find that he had left before having surgery. After trying unsuccessfully to call the patient, the resident drove to his home. Relieved to find him still alive, JB urged the man to immediately return to the hospital. The man described to the resident how terrified he had felt. “I have never been in the hospital before,” he told JB, “and now I am suddenly being told that I might die! The consent forms for the surgery made me even more upset. So I decided to come home.” JB sat with the patient and his wife and calmly discussed the risks and benefits of the operation. Several hours later, he visited the man in the intensive care unit after undergoing a successful aneurysm repair. “I bet I will never make a more important house call,” he said to himself as he drove away.
KS was treating a 34-year-old woman with lateral epicondylitis. She injected the patient's elbow with a combination local anesthetic and corticosteroid and was pleased when the patient reported almost immediate pain relief. But, as the patient left the examination room, KS noticed that she was scratching her scalp and back. “I'm suddenly itching all over,” the patient said. KS immediately recognized the symptoms of an allergic reaction to the medications. She escorted the patient back into the examination room and asked a nurse to get subcutaneous epinephrine. In the few minutes that it took to draw the medication into the syringe, the patient became covered with red welts. Shortly after injection with the epinephrine, the rash and itching completely subsided. The patient was given an antihistamine, observed for an hour, and then dismissed. Fortunately, the patient did not develop respiratory distress. Afterward, KS thanked the nurse for handling the situation so smoothly and quickly. This situation served as a reminder to the entire staff to be prepared for an anaphylactic emergency every single day.
“Would you mind if a medical student took a look at your ear?” KS asked the patient. She was a 19-year-old woman with a sore throat and nasal congestion of about five days' duration. This morning she awoke with a severe earache. On physical examination, a red, bulging tympanic membrane was observed. The patient readily agreed to KS's request, so she invited the medical student to take a look—not only at the infected right ear but also to compare it with the normal tympanic membrane in the left ear. “What a great case,” he proclaimed once outside the examination room as he and KS discussed the treatment of acute otitis media. “It is so much easier to see in an adult's ear compared with a child's ear. Now I really know what to look for.” He was so excited that he found a fellow student to look in the patient's ear as well. As KS thanked the patient and showed her the way out, she was reminded that great physicians are trained one step at a time!
Kathy Soch, M.D., is a clinical instructor with the Corpus Christi Family Residency Program, affiliated with the University of Texas Health Science Center in San Antonio. This community-based program, which employs nine full-time faculty and 36 residents, primarily serves low-income, uninsured patients.
Address correspondence to Kathy Soch, M.D., 2606 Hospital Blvd., Corpus Christi, TX 78405. Reprints are not available from the author.
Copyright © 2002 by the American Academy of Family Physicians.
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