Tag Archives: search

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Fit, function and frustration

The clinic that I have been in now since a week or two in July is an older clinic. It does not have wall mounted computers in each room and in fact, there is no desk at all in the exam rooms. As the temp, the other two doctors have priority over me in picking their rooms. I do not like the exam table in one room. It isn’t a regular exam table. It turns out to be a table for a DO to do adjustments. I am an MD, not a DO. The table might get switched out but it has not been yet.

Meanwhile the desk. We have laptops that plug into the desktop in the offices that we each share with a medical assistant. The desktops have a standard keyboard. The laptops are small, and my laptop that I am typing on now is in between the two. At first my fingers had trouble switching between three different keyboard sizes. Now it is pretty automatic.

So, no desk in the exam room. I do most of my note in the room and don’t dictate. I type reasonably fast. But I hate a laptop on my lap and anyhow, we are all sitting too much, so I stole one of the two Mayo trays from the procedure room. Mayo trays have adjustable height, are stainless steel so they can be cleaned after surgery, and they are a pretty good desk for a laptop. I choose to stand while typing in room one.

Next it turns out to be inconvenient to drag the Mayo tray back and forth from room one to room two. I am leaving it in room one. Room two has a standard exam table, so I pull out the “pull out leg rest” (yes, I looked up the name), push the step in and then I can sit on my stool and use the “pull out leg rest” as a desk.

The medical assistants have adjusted, mostly. The patients blink at first, but they seem fine with it. Sometimes I am attempting to find something and also attempting not to curse this particular electronic medical record. The other day I needed an ankle-brachial index test. Ok, not under ABI. Two were under ankle-brachial index. I chose the one that was not in our clinic, since we don’t do them. I got a message back that that was wrong. I chased the other doctor down. She called a third provider who remembered. The one I need is under “us ankle-brachial index”. Really? Hopefully I will remember that annoying local electronic medical record filing quirk, but I may not. If you are wondering what it is, it is a test for arterial disease in the legs, comparing blood pressure in arteries in the legs with the arms. The “us” stands for ultrasound.

The photograph is Elwha supervising on my desk at home.

For the Ragtag Daily Prompt: desk.

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Tenacity

Two skills needed in primary care are tenacity and listening. That is a combination that can make a diagnosis. Here is an example.

In residency, many years ago, I have a patient with developmental delay. He lives in a group home. He can’t talk though makes some noises. The group home staff bring him to me. His head is misshapen because his mother had measles in her pregnancy.

The staff says, “We think his head hurts. He just isn’t behaving right.”

“Did he fall?”

“We don’t think so.”

“Fever? Nasal congestion? Cough?”

“No.”

“How long?”

“Over the last week.”

I do an exam. I really can’t see his tympanic membranes because of his skull shape.

“Maybe he has an ear infection. I can’t see. We’ll try antibiotics, but if he is not improving, bring him back. In five days.”

They bring him back. “He’s no better.”

I get on the phone. I need a CT scan of his head and the group home say he won’t stay still. I need anesthesia to sedate him for the CT scan. It takes two tries and quite a bit of phone explaining with both the anesthesia department and the radiology department. Persistence. I am looking for a subdural bleed in his head from a fall, or a sinus infection, or something.

It is done and I get a call. Not from radiology or anesthesia but from the ear, nose and throat surgical resident. He is very excited. “Your patient!”

“Yes,” I say.

“He has a pseudocyst! In his sinuses! He has abnormally large sinuses and this is the biggest pseudocyst anyone here has ever seen!”

“Um, ok.” Honestly, I’ve never heard of a pseudocyst. It turns out to be packed nasal drainage in the sinus. Bad ones can erode through bone into the brain. Certainly that seems like the cause of the headache!

“We are taking him to surgery!”

Residency can be pretty weird, when someone gets really excited about a rare disease or interesting trauma case or whatever. I found that I was entirely happy just doing health maintenance exams and encouraging people to quit smoking and exercise and drink less. However, I was also good at finding weird things.

The ear, nose and throat surgeons in training were very happy about the surgery. The group home staff were happy too. “He’s back to his old self. Thank you!”

It took tenacity to set up the head CT. It’s important to listen to the families and caregivers too, because they know the person better than I do. They were right: his head hurt. And we found out why and were able to treat it.

For the Ragtag Daily Prompt: tenacity.

Water is tenacious too, wearing down stone and wood and glass.

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Agates

This is a song that needs a tune. Message me if you have one for it…. and thank you

Let’s go to the beach and take a walk
Wander down the sand and share a talk
You have your life and I have mine
Meet for a little while, that suits us fine

We’re searching for agates
You show me how
I’ve lost interest in beach glass now
The clear ones let the light shine through
Like a friend that is always true

Short walks, long walks, walks for miles
Talk wanders, past, present, sorrows and smiles
You show me how agates catch the sun
You find three and I find one

We’re searching for agates
You show me how
I’ve lost interest in beach glass now
The clear ones let the light shine through
Like a heart that is always true

You say in the winter the agates hide
With rain and dark you say we’ll go inside
Make music and sing and learn new songs
And see what else comes along

We’re searching for agates
you show me how
I’m getting pretty decent at finding them now
The clear ones let the light shine through
They almost shine as much as you


written 10/9/20