I have another tale, in case these discussions seemed all too theoretical. It is not a tale of medical brilliance. If it were to be starting its own thread, I might call it "in the land of the blind.... a tale of medical mediocrity".
Yesterday I saw another new patient who came to see me because of a rash and weakness of 2 1/2 months duration. He had been under the care of one of our "rapid encounter" providers about 3 times. Got a Medrol pack twice, the third time some lab was ordered. 5 minute visits, which I am sure their software justified as a level 4 every time.
When he saw me he had a blood pressure of 60/40, and I had some of my own stat labs drawn before delving more deeply in to the history. When I found he had labs drawn a week and a half ago, I asked my nurse to get a release and get them faxed over. We hit a lot of resistance... "what sort of doctor is Dr. Grauman? What does he need it for?...Well, Dr. X hasn't signed off on them yet...." We insisted, and finally Dr. X came on the line. Turns out no one had looked at the lab in the week and a half since they were drawn, and his creatinine was 12 with a BUN 0f 117. The provider's comments was "well, usually the lab is supposed to call if values are out of range..."
Our labs came back worse. Creatinine of 16, and now potassium of 6. I arranged the predictable things; go to the ER, arrange for transfer to a center with full time nephrology and dialysis. Took me a little over an hour.
At no point in this encounter did I feel I exhibited more than the bare minimum of competence and involvement. I realized the guy was sick, drew basic labs, and got recent old records and looked at them. I have no idea why this guy has suddenly gone into acute renal failure; it is some illness associated with a non-specific rash and renal failure is all I know at the moment. Wiser physicians that I will figure this out as they dialyze him and work him up, and it will probably prove to be a classic case of something or other, and I will feel like a moron for not having thought of that. But, I will feel a bunch better than his 5 minute provider. Hopefully.
Leslie is totally correct. It is really a great feeling when you snatch some poor, quivering soul back from the edge. But when you get there on the back of someone else's 5 minute display of absolutely stunning indifference and sloppiness , and without a hint of stretching your training or skill, it spoils all the fun.
