Friday, May 25, 2007

Wandering Charges

From "I've Seen Ghosts" over at Surgeon's Blog:

"In no community hospital are there as many doctors present around the clock as there are in teaching places. If I get run over by a truck, get me to a trauma center in a university setting. If there are a few people running around with minimal experience, so are there plenty with plenty."


"When I was in training, I believed evangelically that the best surgical care anyone could get was right there, not despite but because of all of us trainees and attendings in the mix. After a couple of years in practice in a community hospital, devoid of students at any level, I came to feel the exact opposite (meaning the best care was in that community), and I still do, except for certain highly special situations."

As a nurse I've worked in small rural community hospitals with less than 100 beds and also in large urban level-three trauma centers with a greater number of employees than the total population of some towns in which I've lived.

In the big teaching hospitals there's always a wide variety of expert doctors from various fields and all the diverse residents to choose from when calling upon others for assistance. If there's trouble with a patient sometimes one of the first problems to be solved is just who to call first. Usually it's a resident, who might then seek out an attending doctor or consulting specialist for advice.

In the community hospitals you just "call the doctor," who in many cases is the patient's family practitioner.

I'll call this one "Dr. Lerner."

He lived along one of the lakes outside of the village and he shared an office in a beautiful old clapboard house a block away from the main street. It was one of a handful of family-practice outfits in town. We hospital nurses were on first-name basis with their office staff. We spoke to them regularly both in and out of work because we were all basically neighbors and saw each other weekly at the local mexican restaurant.

One evening I was sitting by the ICU and Telemetry monitors charting my assessments when I saw this:

The rhythm came back after a six-second pause. He'd had others but this was his best yet. I called the floor and they said the patient was fine. I called the doctor and he said he'd come in to place a temporary pacemaker and ask one of the surgeons to place a permanent one in the morning.

We wheeled the patient into an ICU room and put him on a fluoroscopy table with blocks under the wheels that held him in slight Trendelenburg.

The radiology technician had brought in the C-arm and some lead aprons so we were all ready when Dr. Lerner arrived. He even let a family member put on an apron and stand beside him to watch as he inserted a central line and threaded the pacer wire into the heart. I dialed up the device and presto, pacer spikes.

Party over.

In a big city hospital it would never have happened this way. Family practitioners just don't do that here. But out in the mountains among the lakes and forests sometimes they do.

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