The day started out with the usual 8am grand rounds, where the inpatient doctor (aka the hospitalist) goes through all of the people that are currently staying overnight in the hospital. It's a small facility, so that's rarely more than three or four people. After that, all of the doctors (maybe six or seven), broke off into their assigned departments. I was in the ER for most of the day.
When I arrived in the department, there were already a few patients waiting, so we had to hit the ground running. Most of the cases followed a similar format. My boss doctor (the attending) would hand me a thick paper chart (usually that days notes that hadn't been entered into the computer yet, plus a paper summary of what's in the electronic medical record). He gave me a quick overview of why the patient came to the hospital, then he introduced me to him or her, and left me to play doctor. It was similar to practice cases in med school, but it actually mattered this time. It's a whole different ball game when the real doctor is counting on your information to make a real diagnosis on a real patient.
My role would generally be to interview the patient, perform a quick physical exam, and report back to the doctor. Since the staff is usually pretty busy, they count on medical students to cut down the list of possible diagnoses to two or three. This allows them to have more meaningful interactions with the patients, since they already have a pretty good idea about what they're looking for.
There's a saying that rural medical teams live up to the full capabilities of their licenses. And that couldn't be more true. Medical students, nurses and doctors all operate at the peak of their capabilities, since there are no specialists or back up staffers to toss patients off to. Long story short, I had tremendously more responsibility than I did just a week ago. It's a little empowering, and a little terrifying.
But back to the patients. My first one today was a shy, half Navajo, half Hopi teenager that injured her hand playing basketball the day before. She was very pleasant, but was clearly in a lot of pain. It was my job to walk the fine line between a detailed exam, and bringing her to tears. I think that I did alright for my first time, but she may disagree. It turned out to be a small fracture below her thumb, so we splinted her, and asked her to check back in next week.
The next patient was a huge firefighter that had injured his ankle in a traditional dance over the weekend. The exam routine was the same, but I was WAY more hesitant to push my luck in the tears department. Something about his tree-trunk biceps kept me from seeing just how far he could bend his ankle.
The next patient wasn't actually mine, but the attending called me into the lab to check out a stool sample. Gee, thanks. You could tell that this was a rural family doc, when he put on a glove, and poked at the poop himself. No need for them fancy lab-or-a-tor-ies that those swanky city slickers use. [Ed. Note: There actually is a very well appointed lab in the IHS hospital, but there's no humor in that.]
The next patient was a bit more serious. She was a young pregnant woman brought in by ambulance. She was clearly going to deliver soon. Thankfully, she was being seen regularly by the IHS doctors, so they knew that she would be a minimal-risk delivery (higher-risk deliveries are usually sent to the bigger hospitals in Phoenix or Tuba City). After nearly an hour of obvious discomfort, the woman's water still hadn't broke. The delivering doctor (another family physician) manually opened up her amniotic sac to let the water drain. This relieved some pressure on the woman's cervix, but she was still fighting back the tears. She was clearly terrified.
Her boyfriend and his mother were present in the delivery room, and the patient's mother was waiting outside. I got the distinct feeling that this wasn't planned. Abortions are exceedingly rare on the reservation, but unfortunately, teen pregnancies aren't. This particular woman was sweet and shy, but she did have some large scars on her wrist that didn't look like they got there by accident. But social factors aside, the delivery wasn't going very smoothly. After two hours of painful labor, the baby hadn't moved. It still had a strong heartbeat--and the mother was doing fine--it just didn't want to come out.
The delivering doctor was worried that the patient's pelvis was simply too small for the baby to pass through. Even thought the patient wasn't that young, she was still a small woman. The doctor called for an ambulance, and with the patient's consent, went with her to the larger hospital at Tuba City. If a surgical intervention would be necessary, that facility is much more able to handle it. I hope to find out tomorrow how the delivery went.
The attempted delivery was a little troubling to participate in. But because this is a busy hospital, I couldn't stay down for long. Just down the hall, I was scheduled to give a 14 month old child it's well-baby check up. We tested for developmental milestones, checked growth charts, and discussed when it's appropriate to feed a baby honey (any time after 1 year, if you're interested). The baby was doing just fine, and since there wasn't much diagnosing going on, she was pretty squarely my responsibility. That was a nice feeling, and it was a good patient to end on. I start again tomorrow.
-M
