Tuesday, September 12, 2006

Back in the Saddle

Well, here we are, back in work mode, my personal life having stabilized to some extent, the grieving process for my canine soul-mate continuing. My back pain is still with me, although somewhat diminished after a spinal injection three weeks ago, and now my step-father seems to have an apparently malignant mass in his pancreas, necessitating major surgery and other treatment. If only I could take a leave of absence to simply live my life, but no such luck.

At the office, we have the usual goings-on:

A patient dying of advanced cancer and AIDS took it upon himself (with help from his brother) to destroy a $3000 IV home infusion pump which they said "broke" on its own. They were apparently attempting to figure out how to extract the morphine from the pump to inject it all at once intravenously for a major dose of relaxation. Probably a good thing they failed----it most likely would have killed them both.

Patients struggle with psychiatric illness and the lack of services in our area. So many psychiatric outpatient facilities work on a "fee-for-service" basis, hence our patients---who tend to not show for appointments alot---get taken off lists and moved to the bottom, often losing all hope of treatment in town. That leaves us with dozens of the most fragile patients without proper psychiatric treatment. This fee-for-service idea has got to go. That's one of the things our program has going for it---we are paid an annual amount to care for our hundreds of patients and then we figure out how to care for them best. We don't bill for each contact, thus we are not desperate for visits, nor do we avoid visits which might take a number of hours to accomplish. We are relatively free from that economic disincentive to provide quality care.

That said, I struggle under a caseload of 83. How to keep that many people in my consciousness? How to remember what I need to follow up on each day? How to not lose the threads that need to be connected again in the fabric of care? I hobble along, sometimes stumbling, sometimes sprinting, sometimes collapsing from exhaustion.

A number of my patients have broken bones this year. One was hit by a car while crossing the street. Another patient with Multiple Sclerosis fell against the kitchen table and fractured her humerus. Someone else tripped on a wet floor and broke her ankle. I don't usually have this effect on people, but my patients break their bones at an alarming rate. Do they need pedestrian airbags?

Still others seem to develop multiple chronic injuries from out of the blue (sort of like I manifested a spinal cyst). This one has several meniscal tears in her knee. Another has herniated discs. Still another has a torn rotator cuff. These bodies sure take a beating.

My mind is spinning with scenarios, issues to deal with, patients to follow up on, people to call, referrals to make, treatments to assess. It seems that when you take 83 chronically ill people, put them all together in a big box, add poverty and stir generously, you get a recipe for multiple comorbidities needing a comprehensive and global approach to care managment. That's where I come in, and it is, I must confess, not an easy row to hoe.

But tomorrow's another day. And I'll be there.
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