Wednesday, April 20, 2005

I'm Being Tested

Taking into consideration the post which I wrote last night, it seems that I was being tested today. Examples:

*My 70-year-old patient with AIDS, diabetes and a host of other chronic conditions was recently in the hospital for an asthma exacerbation. While there, it was discovered that she has a mass in her chest which is pressing on her trachea and a pericardial effusion (fluid collected in the sac around her heart). Against difficult odds, I landed her a follow-up visit with a doctor at the clinic this morning. Of course, twenty minutes after the appointment time, her granddaughter calls to say that they can't make it to the appointment, but A. was feeling worse this morning. Maybe next week, she asks? My reply: maybe next week at her funeral (I said this silently, of course). I'll get another appointment for Friday if I'm lucky...

*A patient with untreated Hepatitis C and chronic pain that we treat with huge doses of methadone had been unable to move her bowels for more than a week and I feared an obstruction. We prescribed magnesium citrate and Fleet's enemas. She didn't return my calls for more than a week, and today called me an hour after her scheduled appointment with her doctor to ask if I could reshedule as she wasn't feeling well. It seems she had taken a laxative and was afraid to get on the bus since she felt like she was about to explode. She says she "forgot" that she had an appointment. (This next part is not for the squeamish) I explain that the pain in her belly and the liquid stool that she experiences could just be the watery part of the stool squeezing past the obstruction in her colon. She was not impressed.

*I visit a morbidly obese patient of mine (>350lbs!) in the hospital. She is so deconditioned and depressed (and agoraphobic) that she spends 20-22 hours of each day at home in her urine-soaked bed, surrounded by dust and detritus that only triggers further asthma attacks. I can't get her to clean her room, so I am trying to convince the local pulmonary rehab facilities to take her in for a few months of rehabilitation and specific care. They all say she's "inappropriate for their facility". So, we'll probably send her home to wallow in misery while chronic steroids weaken her bones.

*My colleague's patient needs dental work (as do all our patients). Medicaid no longer covers dental, and the one dental clinic in the area who accepts patients for free has made their free care application so difficult that most patients simply give up out of frustration. This particular patient made it through the hoops but needs transportation to his appointment. Medicaid won't pay for the van-ride to the appointment because dental isn't covered! They think they're saving money by denying poor people dental care, but they're happy to pay for ER visits when our patients have abscessed teeth and need Percocet for the pain. They also pay for the hospitalization once that infected tooth causes sepsis--infection of the blood. There's savings for you!

So many scenarios, too little time to describe them all in painful detail. What am I to do? Today's remedy was a few good bangs of the head against my desk. And a beer after work.

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