Docs Who Care

Docs Who Care is an organization in Olathe, Kansas, that helps match small hospitals with medical providers (doctors, physician's assistants, and nurse practitioners), so small town family doctors can get a break, while someone comes and provide coverage.

This past few days was my first shift working for Docs Who Care, and I was in a small town a little less than 1300 people. I was there from Sunday night until Wednesday morning, and my duties included covering the ER, acute clinic patients during the day, and inpatients during the night. The local doctor was still in town but his partner had CME (continue medical education) days off, so I think he just wanted the extra help; so, overall, not as busy as I thought it would be.

On Monday, I saw four patients in the ER, and two of them came back later, so I saw six total that day. For those not in the medical field, this is called a "bounce-back" when they come back in the same day, or within a relative short time, for the same thing, and this is NOT COOL.

One of the patients that came back is a lady who first came in for migraine headache. Before I even walked into the room, I got warned by two staff members about how she would come in often and even visit other ERs to get pain medicine. One time, I was told, she went to the ER in three different small towns on the same night or within a short time and got three different CT scans of the belly for stomach pain. Now, please correct me, my radiology friends, but I believe a CT scan is about 100-250 times the radiation one would get with a plain chest x-ray, so she got the equivalent of at least 300 x-ray radiation that night!! Since then, the nearby ER's had communicated with one another and found out she was going to different places with various complaints of pain.

Pain is one of the hardest things to live with, and it reinforces the unhealthy cycle of poor quality of life and poor physical health.

While I talked to the patient, I found out she had real physical problems, too. There were some things in her medical history that cannot be made up.  So, yes, she had been through quite a bit medically and physically, but her lack of social support (no one except for her significant other) and poor living habits (like cigarette smoking) all contribute to her non-ideal state today.

The usual treatment for a persistent migraine headache is IV fluids, toradol, phenergan, and maybe magnesium and prednisone. She said she just wanted to get the toradol and phenergan shots and go home to sleep. She didn't want the IV fluids because she had been to the hospital so many times that the veins we usually use for access were injured and difficult to find or access. When she left the ER, she said she was a little better.

In less than three hours, she came back with her friend. The headache didn't go away but returned "full blown", and she threw up once.

This time I ordered the IV fluids, but the nurses tried hard with both arms without success. He got flashback (blood return to the needle, showing the needle is in the vein), but he was not able to get the saline water to flow into the vein. It was too soon to give her another dose of Phenergan, so I gave her dexamethasone and reglan to take by mouth.

I also spent more time just talking to her. Aside from her primary care doctor, she was seeing five specialists. She had called her neurologist for a refill on her headache medicine, but she hadn't heard back from them. Her gastroenterologist wanted her to take one medicine to help her stomach, but he wanted her neurologist to take her off of another medicine, so they don't interact. She also had some psychiatric illness but hadn't been seeing her therapist because of cost and lack of transportation.

For someone with mental illness, a supportive network of friends and family would be so crucial, but this patient had poor relationship with her family, and she wasn't involved with any group of people. All she had was her significant other. She said she used to go to a church and had counseling by the pastor, which was helpful, but then she stopped going one day, her depression got worse, and she stopped calling the pastor. I encouraged her to call the pastor again because from my own experience I knew how embarrassing the thought of going to a church one hadn't been to for a while was, but I also knew, on the other side, how wonderful it was to hear from people we lost touch with but cared about. I also encouraged for her to talk to her primary care doctor (a doctor in the clinic attached to the hospital I was working at) about her medical conditions and which medications may be duplicates, with so many other doctors involved.

After a while, she said she was feeling better and wanted to go home and rest. I spent some time praying with her and her friend, because the issues in her life were too complex and broken for any one person or specialty to take care of. Only God can truly heal her completely with the new life in Christ.

As one could imagine, it'd be challenging to spend that much time talking to patient in a busy ER, so I was glad I was in a small town, where the average ER patient flow was 1-3 a day. Even though I had my reservations for how much she actually listened to me, if she truly was a master manipulative patient who had visited many ER's, I was thankful God gave me the time and concern to encourage her to make better choices in her life and brainstormed with her some ideas for implementing those changes.

The next morning I admitted an elderly woman through the ER, and I only had one clinic patient in the afternoon. Ironically, it was the lady with migraine from the day before! Well, I did tell her to see her primary care provider (PCP), and with her PCP not being available that day, I was the on-call clinic doctor to see her. Oh, God is quite humorous sometimes.

This was a continuation of a lesson God had been teaching me, though. For me, it had often been easy to be caring and put forth my effort during one encounter or one event, to take the best care of someone; but it had been challenging for me to continuously be gracious and caring and loving toward someone who repetitively sought my attention. For example, I could stay up for 30 hours and give it my all being on call, but if I had to be sleep-deprived for a week, then I would lose my altruism very quickly. Perseverance is an acquaintance I'd like to make a close friend, but we're not there, yet.

When I saw the name of the lady as my clinic patient that afternoon, I said a prayer in my heart for wisdom and strength. I walked into the exam room. She said the migraine was still there and got worse in the middle of the night. She called the neurologist's office again, but no one had called her back, or they said they couldn't leave a message because her cell phone message box was full. I thought the buck should stop here, so I called the neurologist's office, partially to verify her story, and partially because often it was easier for physicians to get a hold of other physicians.

We were able to clarify several issues during that visit, and the patient said she appreciated me calling the neurologist and wondered "how come the doctors can't communicate with one another"? She thought I was more involved in her care because her PCP wouldn't have called the neurologist for her. I said, "To be fair, it's a lot easier for me to do this when you're my only clinic patient for the day."

Maybe God put me there this weekend just so I could help her with some of the doctor-to-doctor communications that her regular PCP didn't have the time to do, or maybe I was there to encourage her to reconcile with her family and to re-establish contact with her pastor. However it turned out, I pray God will continue to work in her life and bless her, so she may live more fruitfully and joyfully, with the strength from God to handle her multiple medical conditions with grace, rather than being a "victim" of the current medical system, lost in a sea of broken communication and discontinuous care.

I'm not blaming the medical system, although it does room for improvement. I acknowledge the patient also had to take many responsibilities. For example, later a nurse who knew the patient's situation and family told me transportation was not a problem for this patient, so this could not have been an excuse for her missing appointments with her neurologist. The neurologist's nurse told me this patient had stopped medications on her own or changed her story about what worked and what didn't work for her, so it was very challenging for her doctor to know what to do with her.

This is a complex world, and we have limited resources and abilities. I thank God I'm not as gullible as when I first started residency, but I also pray I'll be able to meet each patient with the same degree of love and concern I would want for my family and friends, without the baggage of labels such as "drug seeker" or "manipulative patient". I pray God will continue to give me wisdom to discern what someone truly needs and when they're putting on a mask to hide their real problems. I pray God will keep me true.