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Volume 1, Issue 2
Summer 2005:

Progress Notes: The Remains of the Day

William L. Bartholomew, MD

Cell 2 Soul. 2005 Summer; 1(2):a9

Lately my life has revolved exclusively around work, and it hasn't been pretty; I'm trying to not let things get me down.

Our healthcare system is in big trouble, and that trouble translates directly to those of us who work in primary care. We are overburdened with patients, and the numbers are made worse by the various bureaucracies who call the shots (so-called "managed care").

A couple days ago I attended two patients whose stories serve as a good example:

The first, a little old lady from a nearby city, came in complaining of abdominal pain of several months' duration. Although she had a doctor in the city, she told me that she "can never get in to see him". When she became gravely ill, instead of taking her to the hospital near her home where she usually gets care, the family decided to take her to our rural hospital, an hour away by car, so she wouldn't have to wait the customary 12 hours to be seen in the local emergency room.

After completing my examination, I arranged for her admission to our facility. Three days later, when I finally got the report of the abdominal CT scan I had ordered at the time of her admission, my hands were tied. I could not transfer her back to the city-no gastroenterologist was available to assume her care. (No specialists practice at our rural hospital.) Between having a mass in her cecum and melanotic stools, she had dropped her hemoglobin1 from 13.5 to 10.5.

After making close to two dozen phone calls, I was told that a bed and a doctor had finally been located for my patient. The patient was transferred, and several hours later I received a series of angry phone calls accusing me of transferring a patient without arranging for a doctor to assume her care!

Somehow the three specialists and the nursing supervisor on the other end had gotten their wires crossed. I talked with all of them that morning, and each had his own particular view of the situation. It was the nursing supervisor who gave us the final word, saying that one of the doctors had agreed to accept the patient. I didn't think it was necessary for me to call the doctor back again to reconfirm that she had agreed.

All of this occurred while another scenario played out.

I work with one other family doctor in a small office building across the street from the main clinic where all the patient traffic circulates. Through a series of misunderstandings, a patient across the street was sent over to see me. One of our visiting doctors had "eye-balled" this patient as one of the LPN's got ready to send him out of our urgent care center to the emergency room. This nurse decided to ask the opinion of the visiting doctor who happened to be walking by. After hearing that I was this patient's physician, the visiting doctor simply told the LPN to send the patient across the street to my office.

When I first laid eyes on him, this fellow reminded me of one of those zombies in the movies that my wife likes to watch. His pulse oxymetry was 822, and the only note scrawled in the record was "dolor en el pecho" (chest pains). The blood pressure was not recorded. An ECG showed deep ST segment depressions3 in all of the precordial leads, the kind of tracing that you see in those ECG beginner books.

Unfortunately, the office where I work is not set up to deal with emergencies. When we finally found the oxygen tank, it turned out to be nearly empty. The IV supplies and the nurse who manages them are housed across the street--where this fellow had just come from--along with the aspirin, the nitroglycerin and the morphine.

It all made for a memorable day.

The last I heard, it all ended well. After lying unmonitored in her new hospital bed for several hours, the lady with the cecal mass finally got a new specialist doctor. The other three doctors and the nursing supervisor evidently had sorted things out. My patient with the chest pain ended up in the city hospital lying on a cardiac cath table. Last I heard he was headed for bypass surgery.

Today I hope to do something a little more relaxing: work on the roof of my old house.


1 Hemoglobin is a protein found in red blood cells. The values in this patient show that she is anemic and has ongoing blood loss.

2 The pulse oxymetry value correlates with the percentage of oxygen in the blood. Normal values approach 100. The oxygen saturation in this patient's blood is abnormally low.

3 Indicative of poor oxygenation of the heart muscle itself; correlates with severe angina.

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