Читать книгу Brainstorm - Sheldon J.D. Cohen - Страница 13

The Emergency Department (ED) at Covenant did not appear busy. Dr. Jason Pollard, head of the ED, had the rare luxury of an uninterrupted hour to concentrate on each patient. A more typical day in the ED boasted a high volume of patients, assuring Pollard and his staff an extensive and varied experience with every type of emergency condition. The Emergency Department, by volume, was one of the largest in the state. It saw over eighty thousand patients per year. It was a large rectangular shape with ten rooms on each long side of the rectangle, four rooms on one narrow side and the ambulance and patient entrance and waiting area on the other narrow side. Down the middle of the rectangle stood supply storage, counter, and desk space where the staff worked on record keeping, chart storage, patient dictation and consultation with each other on problem patients.

Both students and colleagues respected pollard. He prided himself on a lean muscular frame honed by years of active tennis competition. He had a full head of black hair and dark brown eyes. His sense of humor and occasional mind-clearing breaks along with his time on the tennis courts helped prevent early burnout, so common in emergency medicine physicians.

He breezed in and out of rooms like a private practitioner, spared the disruptive emergencies that required immediate decision-making. Behind him trailed the usual group of residents and medical students.

“This is the time to shift into second gear,” he informed his residents. “Slow your pace, give yourself time to think, and remember you’re dealing with a sick, frightened, and conscious human being who needs your full attention. They will also be filling out patient satisfaction forms, and those forms are crucial. It’s how we’re judged by the Board of Trustees. Do I make myself clear?” Everyone nodded.

Since every resident on his or her first day at Illinois General received the same talk as part of Pollard’s one-hour orientation lecture, former residents had already briefed most of the new ones. They knew you either measured up or risked removal from the program. It was due to such methods that Dr. Pollard’s program received the best rating in Illinois.

George was in severe pain when he arrived at Covenant. The ED triage nurse greeted him and recognized his distress. Without wasting time, she ushered him into an examining room, had him lay on a cart, checked his vital signs, and took a brief medical history. He remained in pain the entire time. His answers were short and delivered behind clenched teeth.

When Pollard entered the room, George was unaware of his presence because he was lying on his side with his face turned away from the doorway. Pollard scanned George’s chart before addressing his patient.

“I’m Doctor Jason Pollard. What brings you to the emergency room, Mr. Gilmer?”

George was beginning to notice some alleviation of the pain, and he turned to look at the doctor. “All of a sudden, I got a bad pain, doc,” he said, pointing to his left flank. “And here too,” pointing to his left lower abdomen.

Pollard made the diagnosis with a high degree of certainty. A good medical history could provide a diagnosis up to eighty percent of the time, and that is what George provided. More then one hundred years ago, the famous Dr. William Osler said, ‘Listen to the patient, doctor; she’s trying to tell you the diagnosis.” George’s verbal and hand-pointing description could place any responsible physician on a proper diagnostic path. Pollard suspected a kidney stone and mentioned the possibility to a surprised George.

“Mr. Gilmer, on a scale of one to ten, with one being the least pain and ten the worst, how would you now score yourself?”

George remembered the question from Dr. Crowell’s office. Staring first at the ceiling, then at the floor, he said, “A ten when it first hit me, “but it turned the corner pretty quick and now it’s a five.”

Pollard noted that the patient now seemed calm, no longer suffering from severe distress. “Have you had this before?”

George did not answer, nor was it clear that he had even heard the question. Pollard moved into position to get better eye contact. He placed his hand on his patient’s wrist. “Tell me, Mr. Gilmer,” he repeated, “have you ever experienced this pain before?”

“Yeah, once when I was working I had the same pain. I was on a ladder and it hit me all of a sudden. It lasted about half an hour.”

“Was it anything like today’s pain?”

“It was the same kind of pain, but the one today started harder.”

“Did you see a doctor the last time?”

“No.”

“Are you having problems urinating?”

“No.”

“Any nausea or vomiting?”

“No.”

“Any chills or fever?”

“No.”

“Are you normally in good health?”

“Yeah.”

Pollard observed his patient’s blank expression and assumed that his pain must have abated.

“Are you allergic to any medicine?”

“Never.”

“Never what? Never allergic or you’ve never taken any medicine?”

“I’m not allergic to any medicine I ever took, but that’s not much.”

“Could you pass me a urine specimen?”

“What.”

“A urine specimen. I need one now.” He handed George a urinal.

“Yeah, sure.”

“I’ll examine you after you finish. I’ll leave and close the curtains and you can pass the specimen right here. Urinate through this gauze, so in case you pass the stone we’ll catch it.”

Pollard returned, passed the urinalysis to the nurse for testing and proceeded to examine his patient. George’s pulse rate was eighty-four, and his blood pressure of 136 over 80. Not bad for a man who had been in pain and was visiting the threatening environment of an Emergency Department. Eyes, ears, nose, throat and thyroid were normal. Carotid artery pulsations were equal. There were no abnormal lymph nodes palpable. Lungs and heart were normal. Integument normal. Genitalia and rectal exam normal. Neurological examination was normal. The only positive finding was some left lower quadrant abdominal tenderness, and a positive Murphy punch on the left. The Murphy punch is a gentle, closed-fist punch overlying the kidney region in the back. If the kidneys are involved, it may cause a sudden deep pain in a startled patient. Everything was consistent with his initial diagnosis of a kidney stone. The clincher was the urinalysis report of blood in the urine.

Pollard made the provisional diagnosis of a kidney stone. Based on the test results, he also recommended hospitalization. For the first time, George fixed his expression on Pollard and bolted straight up on the cart.

“Hospital? No way. I don’t need a hospital. My pain is almost gone.”

“Are you certain?”

“Yes.”

“These stones can pass by themselves. If you’re sure you’re better, I could chance it and send you home.”

“That sounds good, doc.”

“I’ll tell you what. Stay awhile and walk around. Maybe this stone is passing, or it might have already passed into your bladder. I’ll come back soon to check on you, and if everything’s okay you can go home.”

“Okay, I’ll wait,” he said, “but I’ve got too much work to stay in a hospital.”

Pollard conceded that it was better to let this patient have his way, since he was agitated and his symptoms might be letting up.

Patient volume was already picking up. In the next room was a frightened ten-year-old boy with a lacerated hand. Pollard placed four sutures, administered a tetanus injection, dressed the wound and gave the mother verbal and written instructions before sending him home.

When he returned to check on George, he knew his patient’s pain had probably passed. He was pacing back and forth.

“Feeling better?”

“Yeah.”

“What about the pain?”

“It’s gone. I can go home now.”

“Your pain was five. What about now?”

“It’s ZERO.”

Pollard sighed knowing that George’s emphasis on the score was his way of insisting on going home. He told his anxious patient, “Look I’m ninety five percent sure it’s a kidney stone. Everything points to it. An X-ray could clinch the diagnosis. Sometimes the pain leaves and that could be temporary or permanent, but we can never be certain what will happen.”

“Can I take some medicine and take my chances at home?”

Pollard sensed his question inferred an ultimatum.

“Do you have a family doctor?”

“No, said George, forgetting or failing to mention Dr. Crowell.”

“All right, Mr. Gilmer. We can let you go since you are feeling better. Understand, this means you might have passed the stone into your bladder or are just having some temporary relief. If the pain returns, come right back. In the meantime I’ll give you the names of the doctor on call to follow up with.”

“Sure thing, doc.”

“Take these pieces of gauze,” offered Pollard. “Urinate through it like before so if you pass the stone out of your body you will catch it on the gauze. If that happens, take it to the doctor so that so that he or she can have it analyzed. Now, before you leave I would like to get an X-ray and some blood tests. The X-ray may help us pinpoint the stone’s location, and the blood tests may help us determine why you developed the stones in the first place. People develop stones for many reasons, including rare ones, and if you do have a stone, you have to find out why, and that takes tests.”

“Thanks, but I’ll see the doctor you give me and get them then.”

George’s response came as no surprise. He never stopped pacing the examination room, nor did he stop staring at the wall long enough to make eye contact with Pollard. He left as soon as he received written instructions, test requisition slips, and the name and phone number of the on-call doctor

Pollard watched as the patient walked away. Moments later, he heard his name called by one of the nurses.

“Dr. Pollard, we’re receiving a telemetry strip from the field. It looks like the paramedics are bringing in a sixty-one-year-old man with a possible acute myocardial infarction. Also there is a very serious ventricular arrhythmia.”

The pace was picking up. Things were getting back to normal in the Emergency Department.