WWWWF:
A Look at Wichita Falls on the Web

Groopman does a great job of peering beyond the press releases and television shows on how healthcare organizations operate. He knows the tricks

[H]e recites the ABCs he learned during his training ... "A stands for airway, meaning that the mouth, throat, trachea, and bronchi are all open; B is breathing, that the patient's lungs are able to get enough oxygen and pass it into the bloodstream; C is circulation, that the heart is pumping, the blood pressue is adequte for the blood to reach vital organs like the liver, kidneys and brain..."

And he knows the pressures

"I'm coming up with nothing," Croskerry told the triage nurse. Nonetheless, he said he was sending off blood and urine tests. This was met by considerable resistance. "Why are you doing this?" the nurse asked. "She's already been worked up." Croskerry told me he felt "palpable" pressure because it was hectic in the emergency department and the nurse needed Maxine's bed for another patient. But he insisted. About an hour later, her test results were in hand, all normal. "I reassured her that this seemed to be her irritable bowel acting up," Croskerry said. "I went over again issues about proper diet and stress management. I also emphasized to her not to be reluctant to come back." Croskerry has learned from experience never to discourage patients from seeking follow-up care.

"She broke into tears, crying that no one believed her, that no one was able to come to a diagnosis," he recalled. "She kept saying that the pain was getting worse, that it was much worse than it had been even a week before." ... He sent he home. A short time later, she was rushed by ambulance back to the ER. "She collasped while walking home," Croskerry said. She was bleeding internally and on the verge of shock. She was rushed to the OR, where a surgeon found that Maxine had a ruptured ectopic pregnancy. "It had been missed three times. I was the third miss," Croskerry told me.

And he knows the pettiness (here, I wrote a note to myself that just said I'm shocked anyone survives being in a hospital with this kind of thing)

The ecology of an emergency department includes not only patients, their families, and, of course, nurses, but also other doctors. At Highland Hospital not long ago, Alter was the attending physician when a resident in training evaluated a man in his thirties complaining of a sore throat. "It's an open-and-shut case of strep," the resident told Alter -- an "uncomplicated" patient. Alter had the sense that the resident wanted to move quickly to his next patient. Alter asked for details. "He has an exudative pharyngitis, pus near the tonsils, and painful lymph nodes," the resident siad. Alter insisted that he wanted to meet the man himself. The resident sighed in frustration.

Alter peered into the patient's throat and saw no signs of pus. He ran his fingers along the sides of the man's neck and felt small, soft lymph nodes tha were not tender. Alter pressed more firmly on them. Still no reaction from the patient. The resident had already given him a large dose of antibiotic and a prescription for more.

Alter led the resident into the corridor and told him that it didn't at all look like strep, that it was most certainly a virus causing the sore throat, and that prescribing antibiotics unnecessarily could have serious consequences. ...

A short time later, another man came in with a sore throat. "Go to room 23 and start with the patient," Alter instructed the resident. After Alter had sutured the arm of a man with a knife wound, he made his way back to room 23. "he's fine," the resident said curtly. "Another one of your favorite viruses."

Alter didn't just sign off on the resident's assessment. As he interviewed the patient, he saw that he was restless, moving around on the examining table, unable to find a confortable position to rest his head. When Alter peered into his mouth, he saw nothing abnormal. The man was breathing easily, and there was no stridor, no harsh sounds suggesting an obstruction in the upper airway. But Alter was concerned about the patient's restlessness and his fever of 101 degrees F. He lingered awhile, thinking.

"Like I said, it's a viral pharyngitis, and at Highland Hospital we don't give these people antibiotics," the resident said with dripping sarcasm. Alter ignored the baiting tone. He again moved his fingers down the sides of the man's neck, marching meticulously, this time pressing inch by inch. When he was about halfway down, the man winced in pain.

"I want a CT scan of his neck," Alter told the resident. For a long moment the juniotr doctor said nothing, but then he left and ordered the scan. The call later from the radiologist did not surprise Alter: the man had an abscess in his neck. "This is the kind of infection that can kill you," Alter said. "If it's not treated quickly with intravenous antibiotics, it can block the upper airway and you'll suffocate."