The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Tuesday, December 05, 2006

Reflections of a Bad Day

As I sit here on the couch, wrapped in flannel and fleece and drowning a bottle of Cabernet Sauvignion (I never said I had good coping skills ALL the time) I'm thinking back to what made it bad. No one thing in particular, I guess. So here are some random musings on my day.

It started like any other day. Almost. The alarm went off at 6am-- I sleepily asked my husband to hit the snooze button to buy me another 7 minutes of sleep. The alarm clock is on his side of the bed. The alarm was silenced, and the next time I opened my eyes the clock read 6:21am. Damn.

I'm on the road by 7:30am for the commute out to the community where my family practice is located. The commute itself is a point of contention, as I've repeatedly asked the Department of Family Medicine to put me up in an apartment there (as they do for all of the other community-based residents) which they have inexplicably refused to do. I can't even get a call room in the community hospital. Our 'compromise' is that I am reimbursed $600 a month for travel expenses for a commute which is easily an hour each way. I hate my commute. Particularly on days like today, when a sudden drop of temperature coupled with the winter's first dusting of snow made for a long drive.

First stop-- community hospital, where I round on my inpatients while my preceptor plays hockey. After the death of our palliative patient the day before, our only remaining patient is an elderly demented gentleman who consistently believes he's in Ireland and the year is 1928. I stop in to say hello and write an order to hold his digoxin, as his heart rate is 42bpm.

Then I head across the street to the office. I am fully booked with an average of 4 patients an hour. It's already 9am, but my first patient is 20 minutes late. Not a great start to the day, as I see my second patient first and squeeze my first patient in when she finally arrives. She is an 83 year old woman whose second toe had inexplicably swelled to double its size the day before-- she's finding it difficult to walk as a result. It doesn't look like gout, doesn't seem painful to palpation, she doesn't remember any trauma to that foot... I'm puzzled. I send her for an x-ray and feel useless.

A few patients later, I'm greeted by a stonefaced woman and her 14-year-old daughter. She's angry that I'm not Dr. Boss (my preceptor). I explain that her appointment was made with me, not Dr. Boss, and that should have been clear at the time that she booked it. She's not interested in seeing me. She agrees (extremely reluctantly) too allow me to see them once she's made aware of the fact that seeing Dr. Boss would delay her appointment by another two weeks. The problem today is the fact that her daughter has been refusing to go to school. She has missed so much school this year that her mother is in danger of losing her government assistance payments. I wasn't aware that school had become optional for teenagers, but apparently I was expected to compensate for mom's lack of parenting skills. Needless to say, the visit did not go well.

Another few patients go by and I'm faced with an elderly gentleman with severe spinal stenosis. Imaging suggests that his case is surgical, but no one is willing to perform delicate spinal surgery on an elderly man with COPD and cardiomyopathy. But he's in pain. Shooting pain down his legs. And the medications he's regularly taking for pain aren't working anymore. What he needs is a medication specific for neuropathic pain, but none of them are covered on ODSP and him and his wife can't afford them. I load them up with samples and schedule follow-up in two weeks. I am half hoping that the new medication won't work so the problem doesn't boil down to one of finances alone.

I spend lunch writing notes, consult letters and answering phone messages from people demanding referrals that aren't warranted and investigations that aren't indicated. For the majority, I give in. I don't have the time or energy to argue, and I don't feel I can pass the buck to the office staff.

The afternoon started with a 20-year-old guy who had a 2 day history of gross hematuria. I must have asked a thousand questions trying to tease out some previous symptoms that would support my suspicion that this is a post-infectious glomerulonephritis, but came up with nothing. I sent him off for bloodwork and urinalysis and felt perplexed. Another swing and a miss.

The day was complete with a visit from a patient who was caught by the pharmacist a week ago trying to get a refill of narcotic three days after filling a prescription that should have lasted a month. When the truth came out she confessed to longstanding abuse of Percocet, Duragesic patches and Tylenol #3's. Now her liver enzymes are through the roof and I'm very suspicious that it can be blamed on the chronic acetaminophen abuse. What she really needs is a confirmation of the radiculopathy that caused the chronic pain to begin with, a referral to a hepatologist, a referral to the chronic pain clinic and some liver imaging (and maybe a liver biopsy). But these things take time. So we meet, go over her pain diary, review her meds use and wait for things to get done. It's frustrating how slowly things move sometimes.

I saw my last patient (thankfully, a relatively simple cough that seemed viral) just before 5pm and sat down to write my notes and tie up my loose ends. With any luck, I could be on the road at 6pm and home by 7pm. But it was not to be. One of my prenatal patients called just before the phone lines were transferred-- she thinks her water may have broken. And it's important to confirm it, because she's GBS positive and will need antibiotics if they have. I make arrangements to meet her at Labour and Delivery back across the street.

Thankfully, she shows up quickly. One sterile speculum exam, an AmnioStick and a quick look under the microscope, and I've confirmed that her membranes are intact. No amniotic fluid here. I reassure her and head out.

Another hour's drive home. There's nothing on the radio, and my iTrip can't find a free radio setting to broadcast from. It's a long hour. By the time I get home, I have about an hour until I'm off to bed. I can't believe I have to do this again tomorrow. Sigh.

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7 Comments:

Blogger Ada said...

Hello Dr. Couz,

Lurker in the process of de-lurking here... Your mention about the elderly man with shooting pains that meds aren't effective for made me ask: do you ever/ would you ever offhandedly suggest a patient try smoking marijuana? Last time I checked, medicinal marijuana was legal but really hard to get.

Anyway, keep on truckin'! And be thankful that you (from the sounds of it) live in the east; there's plenty of snow here in the west.

11:31 PM

 
Blogger Medstudentgod said...

Couz,

Sorry for the tough day. I was curious if the palliative patient had been seen by Dr. X? Also, how has the family dealt with his loss when it seemed like they were so optimistic at his "improvements".

Cheers,
MSG

4:53 PM

 
Anonymous Anonymous said...

hey couz,

sorry to hear your day was so tough. i send many hugs.

dkflygirl.

5:01 PM

 
Blogger Couz said...

ada: I've never suggested medical marijuana, mostly because I don't have many patients who would fit the criteria and also because I have no idea how I would go about prescribing it. I know about the drug made with THC, but I also know it's not as effective. I guess I'll have to learn more about it.

MSG: No, he hadn't been seen by the legendary Dr. Death-- he simply went rapidly downhill later that week, was admitted to hospital and died quite peacefully. The family was by his side throughout and dealt with the loss quite admirably. They seemed to realize upon his readmission to hospital that he would be unlikely to return home.

DK: Thanks for the hugs. Miss you.

5:32 PM

 
Blogger Liana said...

Dr. Couz, sorry to hear about your hard day.

I can sympathize with your hate of commuting... I may be doing residency in a rural town but home is Calgary, and I drive back (150 km) almost every weekend. I got a Pimmsleur's language course to try and brush up on my Korean and at least I don't feel like I'm wasting 3 hours a week (an hour commute each way would be much worse, I know).

7:11 PM

 
Blogger VitaminKMD said...

Thinking of you.

-k.

6:21 AM

 
Anonymous Celia said...

This comment has been removed by a blog administrator.

8:03 PM

 

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