Call shifts in our little hospital work slightly differently than in larger institutions.
Generally, I run a same-day clinic of urgent care type complaints and am also on call for the Emergency Department should anyone come in during the day. In addition to that, the call person is also the point person for any acute issues from the nursing home or inpatients whose attending doctors are not working that day.
It is rarely truly busy by any larger institution’s standards, but it can get a little chaotic shifting to and from such varied treatment settings multiple times a day.
On such a day, I walked into a clinic exam room to see an 83 year old complaining of blood in stool.
Harold, in clinic.
After reviewing his vitals to make sure we didn’t need to send him directly to the ED. I entered the room and greeted him.
“Hi, Harold. What brings you in today?”
“Well, Doc.” (I have come to envy the ability of patient to address me intimately, yet respectfully, without having to actually remember my name). “I noticed my poop was dark red when I went to the bathroom this morning.”
He looked well. He wasn’t pale, he was resting comfortably. I let myself shift from Emergency Department mindset to outpatient mindset. “Okay, tell me more about that.”
“This has happened before – a couple of years ago, and since I am on that blood thinner, I had to go to the city to have something done where they looked for why I was bleeding and tried to stop it, I don’t want to have go anywhere else if I don’t have to. I was hoping we might be able to nip this in the bud before it gets to that point.”
“Well, we’ll see what we can do, let me ask you a few questions.” I ran through the standard list of questions for symptomatic anemia.
“Have you been light headed or dizzy?”
“Maybe, not worse than normal, Doc.”
I listened to his heart and lungs, looked at his mucous membranes for palor. All pretty normal.
“Any chest pain, shortness of breath, fatigue?”
Any change in urination, color, belly pain?
“Well, I am going to have to do a rectal exam to test your stool for blood.”
“I figured we’d get to this, Doc. But I’m not looking forward to it.” He rolled over and slid his pants down.
“You know, It’s not my favorite part either.”
He chuckled, “Well, I suppose it probably isn’t.”
After withdrawing my finger, I used the little balsa-wood applicator to apply the stool samples to the testing kit and applied the solution. Sure enough, the blue rapid ran across the test kit paper as the solution spread.
“Well, Harold, you definitely have blood in your stool, we’re gonna have to send you over the ED for more testing to see where your blood counts and INR are sitting and we’ll decide from there what we can do.”
To the ED
I walked out of the room, told my nurse to wheel him across the parking lot to the ED. I called the RN at the ED, explained who was coming over and rattled off my list of order, start an IV, start fluids, and give him 80mg of protonix and send a type and screen, CMP, CBC, INR, etc.
Now, we don’t have the ability to do acute endoscopy. We have a general surgeon endoscopist who comes twice per month, so I walked over to the clinic manage to figure out when he would be coming. Turns out, he would be in town 5 days from then.
A plan started to form. Most of the time, even in large institutions, doctors observe GI bleeds, treat them medically, and set up an outpatient endoscopy afterwards. It is however, very nice to know the option of an urgent or emergent endoscopy is available, so most of the time, I send people with GI bleeds to larger centers.
However, Harold had been very clear that he did not want me to transfer him out of town if I could avoid it.
So, I thought, he is clearly stable, if his counts don’t drop too badly and he stays stable, we might be able to observe him locally, and set him up for any outpatient endoscopy a couple of days after discharge.
I was starting to have fun. I like creative problem solving, but with the shift to evidence based medicine and treatment algorithms (which, In general, I think are a good thing as long as they are not treated dogmatically), creativity is increasingly absent from medical care.
Again, this is probably a good thing. But, it can take some of the joy out of practicing medicine for me.
Harold’s labs came back. His INR was therapeutic, and we gave him some Vitamin K to drop it quickly. His Hgb was in the normal range and only 2 points down from a couple of months ago. Everything else looked good.
I run the plan through with Harold at his bedside.
“Okay Harold, If things stay stable and you don’t need a lot of blood transfusions or your hemoglobin doesn’t drop too fast, we could reasonably safely keep you here and have your endoscopies done on Tuesday. “
“That sounds great, Doc! I really don’t want to get into an ambulance, I am going to have a hell of a time finding anyone to give me a ride back here from the city if I have to go, so I would much rather stay here.”
Things are going well. I feel good. We are respecting a patient’s desires, stretching our staff a little, and, I think, staying within safe practice.
Seems like a win all around.
And It Doesn’t Go To Shit
The most shocking thing is, the world didn’t come crashing down. Harold did well in the hospital. We corrected his INR easily, his hemoglobin stabilized, and he discharged with plans for an endoscopy two days after discharge.
He had his endoscopy as planned, it went well. An nonbleeding AVM was located in his colon as the likely source of bleeding. I saw Harold in follow up a week or so later to discuss his blood thinner.
“Doc, I don’t think I want to go back on the blood thinner, this is the second bleed I have had in the last few years. I don’t want to take it anymore.
I reviewed the higher risk of stroke with his atrial fibrillation if he did stop it. He was comfortable with those risks. In the end, I thought it was reasonable given that we knew he still had that AVM in there, waiting to bleed again. We restarted his high dose aspirin and agreed on another follow up in a few months.
I stood up to leave the room, had my hand on the door. And Harold opened his mouth.
My heart sank, most doctors know that what whenever a patient starts talking right as you are about to leave the room, it is rarely a good thing, and usually a whole new can of worms that you weren’t planning on addressing.
“Thanks for everything.”
I smiled, not visible under my mask. “It was my pleasure, I am just happy everything worked out alright.” And, I meant it. I closed the door and walked back to my office, triumphant.
It was on of the best clinical experiences I had had in a long time. I left town that evening and drove home for the weekend.
I felt damn good.
The next week, I drive into town and walk into clinic. My MA greets me.
“Hey Doc, Harold died over the weekend, car accident in the next town over.”
I just stand there for a while, accepting my own smallness in this world, just letting steeping myself in it. I did not look for any lessons, purpose, or meaning, just let myself be in a complicated moment.
And there I was, with a patient waiting.
Image: Robert Scott Lauder 1803-1869 – Christ Teacheth Humility -_National Galleries of Scotland