Responding to the Bat-signal
I'm not typically a "theme" person, but this week has had a theme. I saw several patients that received borderline or frankly inappropriate treatment, and all share a common unfortunate thread.
I already talked about patients who want surgery but don't need it. I also saw two patients this week who came in because they had gotten surgery that they didn't need, and now have problems. And another who kept coming back to the Urgent Care with what ended up being an abscess that was "lanced" (e.g. a tiny nick in the skin was made to allow the egress of some pus, and inadvertently trap the rest of it deep inside to continue to fester) and eventually needed to go to the OR for a formal debridement, which could've been avoided had it been done correctly the first time or had the patient been admitted to the hospital sooner.
I'll give you one other illustrative example. A patient comes in because they got a cut on their arm. Yesterday, 18 hours ago. It is gaping open a few centimeters. The provider now has a choice. Do I just wash it and close it? Do I just leave it to heal by secondary intention? Do I phone a friend?
If you asked the patient what they'd prefer (and eliminated "whatever you think is best, doc" as a choice), I'm sure 9 times out of 10 they'd pick the simplest and most elegant solution: "clean & close".
The remaining 1/10 would adamantly refuse to answer on the grounds that "whatever you think is best, doc!" That would've probably been 5/10 or 7/10 a few decades ago, but with information (both good and bad) so accessible in the digital age, many patients either are truly informed or are under the false impression that they are informed.
Anyway, in an old laceration, the possibility of infection should be taken into account. Secondary intention (just let it heal on its own without stitches) is a good option but not one that I think non-surgeon providers even consider. If you wanted to close it primarily, you would need to be sure you can get a very good "washout" and get as much bacteria as possible out of there (additionally, I'd make sure to close it loosely to avoid sealing in whatever bacteria inevitably remain).
The patient I saw had their laceration closed (not loosely, and from the sound of things, possibly not even really cleaned very well), and within 2 days came back because it was infected.
Now I can't know why they made that decision exactly, but it sounds like there was probably a mix of factors. Inadequate training has to be a part of this. But providers are very reluctant these days to offer secondary intention, they think it's primitive, or sub-standard care. They may worry patients would scoff, reject the idea, or, even worse, drop their score on the ever-important Patient Satisfaction Surveys.
Satisfying patients should be a long view, though. Happy and healthy patients are satisfied. Patients are neither happy nor healthy if they develop complications. This is true even if in the short term, they felt like they got what they came for.
This was also an opportunity for education. In my field, we get feedback most times on how our procedures go. We see patients in the office for follow-up and if something doesn't work or causes problems, we can see the results. But that's not typically the case in the ED or UC.
I'd like to try, as nicely as possible, to make a teachable moment out of these scenarios, and pass along a message to the first provider. I hope I remember the right way to do this when I'm in practice next year and to maintain a positive outlook about these kinds of situations. I'm speaking to myself just as much as to whoever randomly reads this, I want to remind myself to do this correctly.
It's even better if you can do it in person, hand them a card with your cell number if you dare (or a free Google voice number - look into those, they're great), and offer them to call you any time they have a question about something in your field. Make an ally, rather than an enemy. Fielding a few extra phone calls every now and then can be a low-risk, high-reward way to improve patient care, prevent complications and inadequate/inappropriate treatment, and create a referral channel.
Also allows you to meet new people and make other connections. I had a fun interaction today with someone who, after I was done, asked if I get to go home now or have to stick around. I told him that I am on call, but I get to go home until the next time I'm needed. He said, "So you don't really get to rest or relax while at home on call? It's like being Batman. You could be called in at any time... look out the window, there's the bat-signal!"
Yep. Guess so.
I already talked about patients who want surgery but don't need it. I also saw two patients this week who came in because they had gotten surgery that they didn't need, and now have problems. And another who kept coming back to the Urgent Care with what ended up being an abscess that was "lanced" (e.g. a tiny nick in the skin was made to allow the egress of some pus, and inadvertently trap the rest of it deep inside to continue to fester) and eventually needed to go to the OR for a formal debridement, which could've been avoided had it been done correctly the first time or had the patient been admitted to the hospital sooner.
I'll give you one other illustrative example. A patient comes in because they got a cut on their arm. Yesterday, 18 hours ago. It is gaping open a few centimeters. The provider now has a choice. Do I just wash it and close it? Do I just leave it to heal by secondary intention? Do I phone a friend?
If you asked the patient what they'd prefer (and eliminated "whatever you think is best, doc" as a choice), I'm sure 9 times out of 10 they'd pick the simplest and most elegant solution: "clean & close".
The remaining 1/10 would adamantly refuse to answer on the grounds that "whatever you think is best, doc!" That would've probably been 5/10 or 7/10 a few decades ago, but with information (both good and bad) so accessible in the digital age, many patients either are truly informed or are under the false impression that they are informed.
Anyway, in an old laceration, the possibility of infection should be taken into account. Secondary intention (just let it heal on its own without stitches) is a good option but not one that I think non-surgeon providers even consider. If you wanted to close it primarily, you would need to be sure you can get a very good "washout" and get as much bacteria as possible out of there (additionally, I'd make sure to close it loosely to avoid sealing in whatever bacteria inevitably remain).
The patient I saw had their laceration closed (not loosely, and from the sound of things, possibly not even really cleaned very well), and within 2 days came back because it was infected.
Now I can't know why they made that decision exactly, but it sounds like there was probably a mix of factors. Inadequate training has to be a part of this. But providers are very reluctant these days to offer secondary intention, they think it's primitive, or sub-standard care. They may worry patients would scoff, reject the idea, or, even worse, drop their score on the ever-important Patient Satisfaction Surveys.
Satisfying patients should be a long view, though. Happy and healthy patients are satisfied. Patients are neither happy nor healthy if they develop complications. This is true even if in the short term, they felt like they got what they came for.
This was also an opportunity for education. In my field, we get feedback most times on how our procedures go. We see patients in the office for follow-up and if something doesn't work or causes problems, we can see the results. But that's not typically the case in the ED or UC.
I'd like to try, as nicely as possible, to make a teachable moment out of these scenarios, and pass along a message to the first provider. I hope I remember the right way to do this when I'm in practice next year and to maintain a positive outlook about these kinds of situations. I'm speaking to myself just as much as to whoever randomly reads this, I want to remind myself to do this correctly.
It's even better if you can do it in person, hand them a card with your cell number if you dare (or a free Google voice number - look into those, they're great), and offer them to call you any time they have a question about something in your field. Make an ally, rather than an enemy. Fielding a few extra phone calls every now and then can be a low-risk, high-reward way to improve patient care, prevent complications and inadequate/inappropriate treatment, and create a referral channel.
Also allows you to meet new people and make other connections. I had a fun interaction today with someone who, after I was done, asked if I get to go home now or have to stick around. I told him that I am on call, but I get to go home until the next time I'm needed. He said, "So you don't really get to rest or relax while at home on call? It's like being Batman. You could be called in at any time... look out the window, there's the bat-signal!"
Yep. Guess so.
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