Family Medicine: Winter Weather Leads to Full and Fun Fridays

Suddenly, on Monday, most of the patients for the next day call and reschedule their appointments.  "Dr., your schedule is full now and these two want in today.  They said the snow and ice tomorrow is predicted to close everything, so they don't want an appointment then.  Mrs. Smith says the baby has diarrhea and is passing some blood.  Mr. Jones is really anxious since he still has left shoulder pain in spite of the physical therapy."

This type of conversation causes a re-evaluation of the patient schedule for the next few days and some quick decisions about patient care. 

After three frozen days, it's Friday and the world is unfreezing.  Most have their electricity back on, or they stayed in a motel or with relatives.  Ohio has looked like a scene from Dr. Zhivago with the cold, all-white outdoors look for over two months.  The ice storm this week knocked out the power supply for over 90,000 people in the Dayton, Ohio area.

Who comes to the doctor in this type winter situation?  People with deteriorating chronic problems who were getting acutely ill for seven to ten days.  Children with fevers.  People just discharged from the hospital with a list of new medications and an incredible story of hospital personnel who withheld some of their chronic opiate medication.    Parents who finally caught the kids' infection after kids and spouse recovered.  Someone who slipped on the steps at the high school three days ago, now getting more pain and shortness of breath.  Check for fracture, bruised kidney, stunned lung, etc.  Kill pain, support breathing, decide on how pain fits with job situation, negotiate ideal strategy for next few days with patient.  He gets the main vote.  I advise him about the medical stuff and the drugs.
 
Then come the poor, unemployed people who used the fireplace for heat and exacerbated their emphysema.  Their cigarettes comforted them in the cold, dark night while adding to their breathing problem and sputum production.  The boy with intense cough until he vomits has no insurance.  "Just send us the bill.  We're applying for medicaid for the boy, but we knew we had to bring him in after four days of fever and his loss of appetite."  I congratulate the parent on his good judgment about his son.

Someone is in the next exam room who lost nine pounds in January by reading and acting on Healthy for Life by Ray D. Strand, MD (I recommended it) to reverse their insulin resistance.  See my post about, and listen to,  The Dr. Synonymous Show (BlogTalk Radio) on December 7, 2010 for four reference books and a discussion about Insulin Resistance  (Here).  I cheer for them and schedule a follow up lab test and office visit in two months.  The follow up visit in Family Medicine is one of the most important ways to get issues wrapped up.

People often have more confidence in lab tests than their own mirror for feedback about health.  While both can be important, seeing how the patient looks and affirming their success clinically can help with restoration of their confidence in their health.  The lab results can be icing on the cake of success, but the patient is the central player. 

A Rapid Strep test in the East Room, a nebulizer treatment with albuterol in the West Room, a Toradol injection in the Blue Room, four brief call-in notes about four patient situations requiring physician action and we're turning the corner toward the end of Friday sigh.  Re-examine the two people who had the albuterol therapy for wheezing to make a treatment decision for home, check the rapid strep result and recommend treatment for a child with fever, cough and sore throat.  Write fast, engage with eye contact, ask if there are any other questions of patient.  Hand them the chart (or parent or caretaker depending on situation) to take to check out counter, "to the people having more fun than they can stand".

Last room, last chart.  Read chart in hall (Chief complaint, vital signs, last visit note, patient written sign in sheet with reason for visit in their handwriting- note difference (s) between that initial patient note and the medical assistant note once patient is in room and responds to question about purpose for the visit).  Deep breath, focus, develop plan for initiating this encounter, knock and enter, make eye contact, greet with name and handshake (unless cough is part of chief complaint in which case I usually don't shake hands since most patients still cough on their hands.  I have to think of public health, contagious diseases and my own potential to spread infection or catch it).  Respect, Protect, Connect, Detect, Correct, Reflect.  Use the whole process every patient, every day to the extent possible.  It's more fun and satisfying that way.

Note time, reflect on entire office, who is the "late person", who needs a physician OK before they can leave.  Look through remaining pile of lab results, imaging studies and patient notes from calls quickly before releasing last MA.  Cringe at the number of tasks per unit of time that I need to deliver before I can feel comfortable leaving.  Place the piles on a work table in front of a large window.  Get twelve ounce glass of water, walk through front office, gather any remaining reports.  Translate illegible writing for staff to finalize codes for diagnoses.  Listen to issues of people or programs from people at the front, especially if there are left over intense feelings about interaction with patients or physicians.

About 18 patient issues are represented in the end of the day pile today.  Eighteen different patients with various documents to review, comments to write, forms to sign, people to contact by MA, front office person or me.  Abnormal thyroid test result -patient has work up scheduled; the Monday baby with blood and diarrhea actually didn't have blood on further clarification, but culture of diaper rash verified it was the infection I theorized and treated that came from a session in the children's hospital.  Pleased that I selected the best antibiotic now verified by the culture report.  Refill two meds for disabled senior citizen.  Put six patient call backs on Saturday MA's work pile for morning disposition, when we'll both be here.  Etc.,etc, etc.

Look at laptop for Facebook, Twitter, Blog, and email. Thirty minutes later, pack it up and leave.  Reflect on how lucky I am to be a Family Physician.