When Clinic Patients Become Inpatients

There it was..the sound I really did not want to hear on a Friday afternoon, the sound that will be associated with a feeling of utter despair for the remainder of my human existence...the sound of my pager. I was on call for a city hospital that was an hour commute from where I was, a hospital I was told we "rarely" get calls from. There was a patient with a badly infected foot that I needed to come and see that day.

When I arrived at the hospital, the patient seemed to recognize me right away, though I did not recognize him. He said I had seen him in clinic 2 weeks prior, but I still had no recollection. It was definitely possible, though it is nearly impossible for me to remember all of the hundreds of patients I see in clinic. The great toe on his left foot was badly infected. He was a diabetic who was not taking care of himself. He was only 38, and had already been through two previous amputations. The toe was swollen and dusky. When I examined it further, I noticed there was some crepitus...an indication that there might be gas in the tissues..gas gangrene. The patient had come in with a fever, but at the moment, he did not have one. His white blood count was not elevated (an elevated white count is one sign of infection), but clinically the toe was badly infected. This patient needed that toe amputated, or the infection would likely spread further.

I called my attending. He was on his way to a nursing home where he sees patients, and would not be available. He told me to call one of my other attendings. I called the second attending, and he told me he was at a different hospital waiting for a surgical case to begin there. I called a third attending, and he told me that he would not do the case after 7pm because he had dinner plans...I knew this case would never go before 7. He told me that since the patient did not have a white count or a fever, the case could wait until the next morning.

It was a Friday, and the hospital does not take add on cases for the weekend until the morning of the surgery. I returned to the hospital the following morning at 7:30 am. The patient's morning labs now showed a highly elevated white count. He had been running fevers all night. I added the case on, and was told it would go at 9:30. I called my attending, and he arrived just in time. The toe was amputated, but it seemed it may have been too late. The patient pointed out a few painful bumps on his leg. I examined them, and realized they were likely collections of pus...the infection had already spread up his leg. The general surgeon was called in, and he incised and drained the areas at bedside...but it was worse than I thought. The patient's white count continued to rise, and he continued to have fevers. A blood culture came back positive. This infection had already reached well beyond the patient's toe.

The patient was started on new antibiotics, but he continued to have pain in his foot and leg. A week had already passed, and it was now Friday afternoon before a holiday weekend. I spoke to the PA on call and asked her to order an MRI to rule out any deep abscesses (collections of pus) in the patient's foot or leg that may need to be surgically drained. I was told that no MRI would be performed until Tuesday because it was a holiday weekend. I continued to monitor the patient's vitals and labs until Tuesday finally arrived. I called the PA again to see what the status of the MRI was. She told me that the radiologist had called in sick, and there was no one available to approve an MRI..it needed to wait until Wednesday. The patient finally had his MRI revealing an abscess on the top of his foot that was drained the same day. Smaller abscesses on his leg were also drained. The patient improved slowly over time, and was eventually discharged from the hospital almost a month after his admission for an infected toe.

This is what happens when clinic patients become inpatients. No one has any particular interest in them. This is not the private patient of a doctor, or a patient that has good paying insurance. This is an uninsured or Medicaid patient that is passed through a system of salaried physicians that have no incentive to treat them as quickly as possible. Why spend your evening in a hospital cutting open a smelly foot when you have dinner plans?

Sometimes This Stuff Gets Emotional

You know that feeling when you are really happy about something, and you feel like you are completely unable to hold it in? The kind of feeling where you let out a little scream and shake? It is that feeling you get in high school when the girl or boy you really like asks you out, or when you get a letter in the mail that you were accepted to that college that you really wanted to go to. You feel like everything in life is going the way you want it to. Unfortunately, I can not remember the last time I had that feeling. Residency will do that to you. When I wake up on a work day (the large majority of my days), I am usually overcome with a feeling of dread as I realize what I have facing me that day...overbooked clinics, surgical cases with high strung attendings, incredibly sick inpatients, rude hospital staff, and co-residents that are just as stressed out and cranky as you are. Most of the inappropriate comments come from your attendings, and you eventually learn to let them role off your shoulder. A battle is just not worth it. You want to get through these next couple of years as smoothly as possible, and move on with your life. Unfortunately, there are those occasional moments where an inappropriate comment comes from your co-resident...you are not exactly hanging out with them on weekends, but you expect a little more from the people that are floating in the same boat as you.

Recently my co-resident...one I am pretty friendly with...poked himself with a suture needle in the operating room. It turned out that the patient was HIV +, and my co-resident needed to go on anti-viral medication for 2 months. After the surgery, he commented that when he is finished with residency, he will refuse to ever perform surgery on a gay male patient. He does not know that I am gay, but this should not matter. This was something I chose to keep to myself at work, and I guess I am glad I did! I did not realize how completely ignorant my co-residents could be! These are the people who are supposed to be objectively treating patients! These people are doctors, they are supposed to be intelligent! I lashed back with the statistics (one's he should have already learned in medical school)...worldwide, women accounted for 50% of all persons infected with the HIV virus. Even in the United States, gay men only make up 53% of those infected with the HIV virus. He shut his mouth, we moved on. I could deal with the surgeons in the OR joking that I am trying to touch their asses as I tie up their gowns, or the orthopedist's gay impression that he loves to perform...but complete ignorance was more than I was willing to handle. So, there was no little scream or a shake, but if felt pretty good to finally speak up. I think I am going to try it more often.

These are Clinic Patients

They get to clinic early in the morning, often before any of the staff have arrived. They do this because they realize they need to register early, or they might face a 2 hour wait to be seen. If they are lucky, they are able to secure a seat in the crowded waiting area, otherwise they stand in the doorways and hallways waiting for their name to be called. They are one of 40 patients waiting to be seen by one of two doctors during a 3 hour clinic session. If you do the math, this leaves roughly 9 minutes for the doctor to see each patient, and this includes the time needed to document and bill for the visit. The doctors these patients are seeing are actually residents. The attending physicians presiding over the clinics sit in a back room on the computer or phone, signing the charts as the residents bring them to their desk with hardly a glance at what is actually written. They are getting paid by the hour, and therefore have little concern for the patients themselves. As long as they are there, they are getting paid. The number of patients seen or the procedures done have no bearing on their salary, so why put in the effort? Many of these patients have no insurance. If they do have insurance, it is either medicaid or medicare.

I take a chart from the massive pile and call in the next patient. He is young male in his late 30s with diabetes. He seems shocked when I explain to him that he has a large diabetic pressure ulcer on both of his feet. He tells me he can not see his feet well, and thought that whatever was there had already healed. He explains to me that he has stopped taking his blood pressure and diabetic medications because he ran out and is unable to get an appointment with his medical doctor for months. This is common, as all of the clinics are overbooked. I suggest he go to the ER, realizing this means a 6 hour wait time since all of the other patients who can not get appointments with their medical doctors are down there as well. He realizes it also means a huge medical bill in the mail in a few weeks. I explain to him that he needs a special boot to wear to offload the ulcers so they can heal. He has no insurance, and the boot costs $150. He tells me he can not afford it, nor can he afford to take off from work in order to stay off his feet. He has few options. He is the uninsured working poor. I build a makeshift pad for his shoe with some felt padding, realizing this is only a temporary solution. I feel helpless as I send him back to the waiting room.

I pick up the next chart and call in a female in her 40s. She limps into the examination room. I review her history and discover that she is suffering from a chronic ankle sprain. She has no insurance, and is unable to afford the $700 lace up brace. She is already struggling to pay off the bill from the MRI that was performed a few months ago. She cries as she tells me she can not take this pain much longer. She is looking to me for an answer, but I do not have any cheap ones. I explain that she would probably benefit from physical therapy. She tells me that even with the payment plan, this costs $40 per session, or $80 per week. I apply another soft cast to her leg, one I realize will become dirty and fall off long before her next appointment in clinic. I explain she may want to consider surgery to repair the torn ligament in her ankle, but this would also require speaking to a hospital based financial counselor to discuss payment options. I send her back to the waiting room as well.

I sit in the quiet examination room and take half a moment to contemplate these patient's situations...I can not take too long, the massive pile of charts is still waiting, and it keeps growing larger. I count the pile..20 more. These are clinic patients..the poor, the uninsured..or just another number in the pile my attending wants me to rush through so he can leave before the traffic gets heavy. I am tired.