Juggling.

 

 

 

how-to-juggleIt’s been a week.

I’m covering for both of my colleagues this week. We have a locum physician covering their practices as they are off for the summer, but she is off as well, on a much deserved holiday. So it’s been a bit crazy.

It’s not so much the patient flow – I can handle a fully booked day with a few add-ons; it’s the lab results and the follow-up required.  Doing my own labs and clearing the decks for the day is sometimes hard enough but doing it for two other practices? That’s another story.

It’s 5pm and I just finished seeing all the patients. I start reviewing one colleagues’ lab results. Oh look. A 50-year-old woman whose platelet count is 23,000!  (Normal range is 145,000 – 400,000). She is a new patient to my colleague and so I have to spend 20 minutes reviewing her old records, only to find that yes, her platelet counts have been low in the past but apparently the previous doctor never bothered to investigate it.  It’s now 5:20pm.  I call the patient and start asking her a bunch of questions – yes, she’s been bruising a lot for no reason (and she’s complained about this to the previous physician for the past few years!!!), yes she is tired all the time, yes she is having bleeding from her gums.  Oy.  She likely has ITP.  I got her an appointment with the hematologist for next week.

Then there was the patient with a CK level of 10,000.  CK is creatine kinase; it’s an enzyme that breaks down skeletal muscle.  I didn’t know the patient, so I had to review the chart.  She’d been complaining of vague abdominal pain and muscle aches for a while now.  All manner of testing (abdominal ultrasounds, CT scans, etc) failed to reveal any pathology. She’s not on any prescribed medications (that would be easy, right?). And of course,  there wasn’t a baseline CK to compare, so now I’m supposed to figure out why she’s breaking down muscle.   Or is she?  After a phone call with the patient, I find out  she’s taking a protein whey supplement as she trains for a 20 km obstacle course run.  Hmmm … I’m not so worried anymore – the elevation in CK is likely a byproduct of the protein supplement, so I told her to stop it and recheck the levels in a few weeks.  Crisis averted! But the entire exercise took 15 minutes out of my day that I never got back.

While reviewing another colleague’s lab results, I see a very low white cell count from the end of June ordered by another physician and our office was copied on the result.  The WBC (white blood cell count) was 1.6 (normal range —  4 – 11 x 10 **9).  The differential shows a very low neutrophil count (these are the white blood cells that fit bacterial infection).  I reviewed the patient’s chart – he’s not on any medications, has no history of malignancy – so I cannot for the life of me figure out why he’s neutropenic.  Of course I have to call him now.  Has he had unexplained fevers?  Who ordered the blood test and has he been informed of the result?  The answers to both those questions was no.   Great.

And then there’s the lovely 60-ish-year-old lady who comes in for her annual check up.  Her gynecologist does her Pap tests and orders her mammograms (she had breast cancer 10 years ago).  I have repeatedly told her I am happy to do her Pap tests and order her mammograms, but she likes the gynecologist and wants to continue to see him.  Fine. Great. No problem.  So at her check up, as I’m checking her blood pressure in her left arm, I noticed a rather large bulge coming from the side of her neck.  I don’t even remember what her blood pressure was, I’m sure it was normal, but mine certainly wasn’t.  I assess the area and it’s a large mass arising from the left side of her neck. It seemed too low for a lymph node but also felt like it was in the supraclavicular fossa.   FML.

 

 

 

 

 

 

Back in medical school, I was taught that if one felt a lymph node or a mass in the supraclavicular region, it was cancer until proven otherwise.

The fact that my patient didn’t even know there was a growth there is concerning.  A painless mass that goes unnoticed (or is ignored) is concerning.  The fact that she’s already had a history of breast cancer is concerning.  The ultrasound report confirming the mass and suggesting a CT or MRI is concerning.

Could this week get any worse?

Why, yes, it can. It is kind of ridiculous that I could sit here and write about another four or five lab results.   But you know what?  I just can’t talk about it anymore. This week needs to be over.  I need to stop saying yes.  I have to learn to say no.  I can’t be the one to cover for both of my colleagues at the same time anymore.  Something is going to get missed and I don’t want it to be on my watch.  One doctor covering almost 3000 patients is insanity. Yet, I agreed to this knowing full well I’d likely feel this way. What is wrong with me???  And why is this July the worst July on record for patients?  The summer used to be dead slow.  WTF is going on??!

Rant over.

 

 

When it rains…

… it pours!  Such a cliche but it’s true, especially in family medicine. There are a handful of issues that family doctors see on a regular basis, what we call the “bread and butter” of family medicine – hypertension, diabetes, heart disease, chronic back pain, depression/anxiety.  Sometimes the “bread and butter” are clumped together.  Some days it’s one newly pregnant woman after another; some days it’s one newborn after another; some days it’s nothing but back pain, other days nothing but bladder infections.  It’s a strange phenomenon.

Part of my job is reviewing blood test results.  There are days when the results are boring, and others (like today), when almost every.single.one is abnormal and I have to deal with it immediately.  For example, there’s the late 20-something new mom who hasn’t seen a doctor in 10 years, whose laboratory results show she is severely hyperthyroid.  Then there’s the 50-something man being treated for bladder cancer whose hemoglobin has suddenly taken a nosedive for no apparent reason (ie, he’s not bleeding, has no change in bowel habits). And finally, a gentleman with human immunodeficiency virus (hasn’t seen me in 3 years), comes to see me for something completely unrelated and I note he needs a number of routine screening tests.  He agrees to the prostate screening test, after much counsel regarding it’s limitations, and his level comes back today –  it’s the highest I’ve ever seen.

Patient 1 needs to see an endocrinologist but she refuses because she wants her naturopath to handle it.  Patient 2 gets referred to a gastroenterologist to rule out another malignancy. Patient 3 gets to see a urologist for a potentially painful prostate biopsy that may or may not be positive for cancer.

I’m glad it’s almost the weekend.