Diary from a Week in Practice



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Am Fam Physician. 2002 Sep 15;66(6):987-988.

Monday

It was a busy Monday afternoon when a 74-year-old man presented to CSJ with his mother and a close friend. He had just undergone a chest CT scan evaluating a right hilar mass. On the way home, he became intermittently unresponsive, and the friend wasn't comfortable leaving him with his elderly mother. On arrival at our office, the patient told us that he had become hypotensive during his scan, but that otherwise he had done well. As he told his story, the nurse checking his vitals wasn't able to get his blood pressure. The man was moved to an examination room so that he could lie down, but once in supine position, he complained that he couldn't breathe well. As the nurse and CSJ assisted him to a sitting position, he became unresponsive, apneic, and pulseless. CSJ called for help. Observers reported later that the entire office mobilized. Within moments, CPR was initiated, an intravenous tube was placed, and the patient was on the cardiac monitor. A few moments later, his pulse returned, and he made spontaneous breaths off and on. He even opened his eyes and smiled. He was transferred to the hospital emergency room by ambulance. The importance of a well-trained staff who performs together as a team was apparent to everyone. A periodic reminder that we are equipped and able to manage a crisis goes a long way toward a satisfying work environment.

Tuesday

A patient presented to the office today with a sprained ankle. This man has very significant cerebral palsy, and he lives in a retirement home. Whenever RHS sees a patient with cerebral palsy, he is reminded of a most unforgettable patient and friend whom he had the pleasure of knowing and serving years ago. Ernest was born in the late 1940s and was diagnosed with cerebral palsy early in infancy. He was never verbal or ambulatory, but he was extremely bright and learned to read and to type using a pencil attached to a headband. He lost both of his parents before he died at age 55, and he spent his last years in a nursing home. He communicated well and left a self-composed typed history of much of his life. Ernest was a great sports fan, a great lover of risqué stories, and a man of great faith, and he was most patient with the inconveniences caused by his disease. Those of us who are healthy should be extremely grateful.

Wednesday

As usual, Wednesday morning started off busy. One of CSJ's first patients was Mrs. Harrison, a long-time patient of the practice. At her last annual physical examination, Mrs. Harrison had been started on antihypertensive therapy, and today she needed a recheck and updated lab work. Her blood pressure was under control and things were going well, but she expressed frustration at the difficulty she was experiencing trying to lose weight. Through specific questions about her eating and exercise habits, CSJ was able to make some suggestions that could help. Later that afternoon, CSJ entered an examination room to find that Mrs. Harrison had returned, this time accompanying her 13-year-old son for his eighth grade sports physical. Nathan was a healthy adolescent, very active in sports, and a joy to talk with. As CSJ was finishing up for the day, a lab report for Mrs. Harrison's husband came across her desk—recent studies evaluating unusual paresthesias in his right hand and foot. The tests were unrevealing, and close follow-up was needed. A telephone call to the Harrison household to discuss the results wrapped up CSJ's day, and she smiled. This really is family medicine!

Thursday

Margaret was in today for another injection of parenteral antibiotic. This is a common occurrence as we try to manage her end-stage chronic lung disease with frequently recurring exacerbations of acute bronchitis. Margaret is 70 years old and has been in our practice for more than 30 years. She is always gracious and appreciative of our efforts, despite her chronically poor health and meager economic circumstances, and she is repeatedly selected by the staff for special consideration at holiday time. Margaret has a well-healed sternotomy scar, and she is frequently asked by our younger staff members when she had bypass surgery. This scar predates bypass surgery, however, and relates to the removal of parathyroid adenomas from a substernal thyroid at a tertiary medical center in 1956. Her calcium metabolism remains normal. Margaret is another example of the meaningful and reciprocal long-term relationships that accompany family practice in a stable population.

Friday

This morning, CSJ saw a patient who needed follow-up from an emergency room visit the night before. Charles was an obese man in his mid-30s with no previous medical history. He was recently married and drove a long-distance truck route for a living. For the past few months, he hadn't been feeling his best, and during the past few days he had felt worse. He reported classic symptoms of diabetes, including polydipsia, polyuria, fatigue, hunger, nausea, and vomiting. His mother, who had diabetes herself, suggested that she check his blood glucose on her glucometer. Charles agreed. The glucometer screen simply read “HI,” since it was unable to accurately measure his glucose, which was later found to be 583 mg per dL. In the emergency room, Charles had received intravenous fluids, insulin, and a prescription for an oral medication. He was instructed to follow up with us first thing in the morning. His fasting blood glucose was now 306 mg per dL, and he was feeling better. CSJ conferred with AL, a certified diabetic nurse educator, and they developed an aggressive treatment plan for Charles in order to get his blood glucose controlled. The plan included on-site diabetes education, allowing Charles to learn about his disease. Though a bit overwhelmed, Charles now knows he has resources to tap, and he has the motivation to change his life for the healthier.

Saturday/Sunday

RHS was at home at 10:30 p.m. He received a call from the local emergency services dispatcher that a single-vehicle accident at the north end of town had resulted in a fatality and a local medical examiner was needed. RHS responded, meeting the needs of the emergency medical technicians, law enforcement, and the deceased. Shortly after the state of North Carolina adopted a statewide medical examiner system in 1968, RHS and HBK became local medical examiners from Wayne and Duplin counties. The bulk of our patient population resides in these two counties. The primary objective of this undertaking was to be able provide prompt medical examiner service in our practice area. Over the years, this duty has been an interesting and informative medical experience, and it has provided necessary support for our emergency medical service teams and local law enforcement personnel. Medical mysteries have been solved, crimes have been prosecuted, and personal physicians have comforted bereaved families. RHS and HBK consider this to be an integral part of “comprehensive care.”

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 assistants, provide all types of care (except obstetrics) to patients of all ages in their rural community.

Address correspondence to R.H. Shackelford, M.D., Mount Olive Family Medicine Center, 238 Smith Chapel Road, Mount Olive, NC 28365 (e-mail rshackelford@nc.rr.com). Reprints are not available from the author.

In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.


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