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“Are you Dr. Gray?”

“Yes.”

“I’m Mr. Farquhar. You looked after my son Peyton last weekend when he got burned.”

I thought, "Oh, that's who he is! He's dropped by to say thank-you in person! Wow, isn't that considerate?"

He reached into his jacket pocket and pulled out a wad of forms.

“I need these completed ASAP so we can get our travel expenses paid. Can you do them right now?”

I was dumbfounded.

I was enraged.

I was hurt.

“If you drop those off at my office tomorrow morning, I’ll see to it they get filled out,” I said quietly.

“Sounds good.”

He turned around, marched back to his truck and drove off.

Snap!

Last Friday I was on call. During the day the emergency department was hopping. I zipped home at 7:00 p.m. for a quick bite to eat and a 30-minute power nap. At 8:00 I returned to see the evening crop of outpatients. I worked until 11:00 and then charted in Medical Records until midnight. When the paperwork was completed I dropped by the ER to make sure the coast was clear. A pink Post-It note was stuck to my knapsack. Those are never good. This one's raison d'être was to advise me that a patient named Mr. Yorke on unit 4 was short of breath and having a rapid pulse. Geez, how come no one paged me about this? I went over to the ward to investigate. As it turned out, Mr. Yorke was one hot mess and I ended up having to work on him for a couple of hours.

At 6:00 a.m. I was summoned back to the ER to stitch up yet another drunken Jethro. This particular genius had taken a swan dive onto a flotilla of empty beer bottles that had spontaneously assembled on his kitchen floor. By the time I finished with him there was hardly any point in trying to go back to sleep, so I raided the fridge on unit 4 and ate a couple of mystery-meat sandwiches at the desk. At 8:00 I started my ward rounds. I figured if I got rounds out of the way early I’d be able to enjoy the rest of the day with my family. Of the eight acute and chronic care patients I visited, Mr. Yorke was still the sickest. Our stockroom was fresh out of bags of IV Miracle, so I had to spend another hour or so getting him squared away. By 10:00 I was finished. Freedom! A sunny Saturday and no more work to do!

When I got home I asked my daughters if they wanted to ride their bikes to the park with me. It was looking like the perfect day to fly our new kites. Their answer was a resounding “Yes!” I went upstairs to get ready. Halfway through my shower the phone rang.

“Hello?”

“Hi Dr. Gray. We need a clarification on your order for Mr. Yorke’s potassium pills.”

After sorting that out I finished getting ready, rounded up the kids and herded them out the front door.

It’s not easy riding 15 blocks with a trio of girls ages five, six and seven. I was right in the middle of negotiating a busy intersection when my cell phone started ringing. I shouldered off my backpack and rummaged through its contents until I found it.

“Hello?”

“Dr. Gray, Mr. Yorke is refusing to take his potassium pills.”

Suddenly something snapped. A severely unhinged stranger who sounded a whole lot like me started caterwauling: “I don’t care! I’m not on call anymore! I did my call day yesterday! Get whoever’s on call today to deal with this crap!”

My kids goggled at me, their mouths hanging open. Passers-by edged away nervously. Small-town family medicine. What’s not to like?

Tough Call

One Friday night an elderly patient of mine presented to our emergency department with atypical chest pain. Her EKG had been chronically abnormal ever since a heart attack a few years prior, so it was difficult for the on-call physician to determine whether or not she was experiencing an acute coronary event. He increased her anti-anginal medications and watched her closely. After a period of observation in the ER she was admitted to the medical ward for further monitoring.

When I saw her during my daily inpatient rounds on Saturday morning she was surrounded by a phalanx of concerned family members. Despite the med adjustments, she was still experiencing intermittent low-grade chest discomfort. Her EKGs hadn’t changed and her cardiac enzymes were normal. I wanted advice as to how best to proceed with her, so I put in a call to our closest cardiac referral centre.

As luck would have it, my favourite cardiologist was on call. We have a very amicable working relationship, in part because I usually screen my referrals well. Most of the patients I send him ultimately prove to have significant coronary artery pathology. After I went over the details of the case with him he gave me two options: I could continue to manage the patient in our community and send her to his office in a couple of weeks for further workup, or if I was really worried about her I could transfer her to his coronary care unit via air ambulance immediately. It was a generous offer, particularly since her vital signs were rock-solid.

Deep down I knew I could probably soldier on with her a while longer, but my energy levels were low that morning and the thought of trying to unravel yet another medical mystery on what was supposed to be my day off was decidedly unappealing. I was still in the process of figuring out what to do when several of her relatives rushed to the desk to report she was having more chest pain. That did it. I told the cardiologist I’d make arrangements to have her flown down for admission to the CCU.

A week later she dropped in to see me at my office. “They didn’t think it was my heart,” she said. “In fact, they discharged me the next day. The cardiologist wants me to have a stress test in a few weeks.” I felt a sharp pang of guilt. Not only had I dumped on a colleague, I’d wasted already sparse health care resources by ordering an unnecessary air ambulance transfer. That week her discharge summary from the CCU arrived in the mail. The dictated note was polite, but reading between the lines I could tell the cardiologist was disappointed I had fast-tracked such a non-urgent case.

Three weeks later she had her stress test and passed it with flying colours. I promised myself I’d never bail out like a nervous rookie again. Nobody likes a sieve.

A month later I came in to do rounds on a Sunday morning and discovered a patient of mine had been admitted during the night with a diagnosis of pulmonary edema. Judging from the chart notes Mr. Trapper’s course in the ER had been fairly rocky, but things had settled down nicely since his transfer to the ward.

Mr. Trapper was an elderly bachelor with diabetes. He was a cheerful man who liked to crack jokes. When I went to see him he said he was feeling about 75 percent better. On examination, he still had signs of some fluid on his lungs. His EKG showed non-specific changes, and his cardiac enzymes were normal.

As I wrote out his new diet and medication orders I toyed with the idea of calling to request a transfer to the CCU. Although my patient had improved considerably, flash pulmonary edema can sometimes be associated with critical narrowing of a major coronary artery. In addition to that, diabetics are at higher risk for silent ischemia. Don’t be such a wimp, I told myself. Look what happened the last time you jumped the gun and flew someone out prematurely. Do you want them to think you’ve turned into Chicken Little? I decided to continue managing him at our facility for the time being.

By his fourth day in hospital Mr. Trapper was back to normal. A referral letter requesting outpatient investigations was faxed to the cardiologist. I wrote a prescription for his new medications and arranged for him to see me in my office the following week.

Before he went home I reminded him to call me or return to the hospital if he experienced any further difficulties. He thanked me, packed his belongings into a battered canvas suitcase, and departed.

Mr. Trapper had a massive heart attack and died alone in his cabin a few days later.