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?