You're Fine, Go Home

Ah, clinic.

Not the ED. Being in clinic makes me respect the family practitioner. Most of the time they are given 15 to 20 minutes total, even at an academic clinic, and 10 of that gets eaten up by the nurse rooming the patient. Once they enter, they have to (and often want to) receive an update on the rest of the family.

And then they have to proceed with the sorting. Sort the lipids, sort the glucose readings, sort the thyroid hormone levels, and sort the day-in day-out wheat from the dying chaff.

Because it's very possible to miss someone sick. In the ED, at least we have the luxury of saying, 'what esoteric disease might kill this patient soon?' and then doing our work-up within the next hour for that. But in the clinic, any test takes time, most people aren't sick, and the pressure is to move them out. Improve their lipids, improve their BP.
But don't miss. To actually tell someone, 'go home, you're fine' after you've considered with a fair amount of energy all the terrible things that can happen to them is more difficult. You find yourself wondering what's in their CSF--is it meningitis (Neisseria meningitidis, as above)? Can you rule it out on history alone?

The studies say yes, sometimes. The studies say you can irrigate lacerations with tap water. But it's different to be confident enough to do it. One girl recently, 11, good in school, came in to make sure she didn't have meningitis as her mother had been admitted the other day. My thin-slice thought (immediate impression, read Blink for more) was that she was fine. But I had to check.

Any confusion? No, but really sleepy. She fell asleep in class. Did she leave early? Yes. What did she do at home? She ate and did her homework. Well, that feels better. How about today? Just tired. But she's not confused. Headache? Yes. Worst in your life? No. You've had worse? (I want to be clear). Yes.

On exam, her chin tucks all the way to her chest, smoothly. As her head travels the parabola dictated by her spine in front of me I exhale without knowing I was holding my breath. JAMA, 1999--in the absence of fever, neck stiffness, and altered mental status, an adult is 99% certain or more to not have bacterial meningitis. Go home, you're fine.

On the next afternoon, a fifty year old with a heart attack last year comes in with a cough for a month. Then he mentions palpitations. Then he says when he climbs stairs he gets pain radiating into his left chest that reminds him of his heart attack. Then he says he's sleeping on 5 or 6 pillows at night. Go home? You're fine? Er, no.

Normal ECG, normal chest x-ray doesn't help rule anything out except we're not calling an ambulance. But it's the clinic. So long story short, go home, you're maybe fine...just follow up with cardiology for a stress test. And make sure to come back if things get worse. And please, please, please, follow up. Then he left. That was stressful. That judgement is trickier than trauma.

And my respect for the family practitioner went up. I didn't have the luxury of a chest pain unit, or serial enzymes, or serial ECGs. It was 4:30 on a Friday. I had nothing. I was lucky to get the chest x-ray. Sort the lipids, sort the glucose levels, sort the blood pressures...and don't miss the MI. By the way.

Stressful, when you start to realize that people's lives are, if even for a matter of minutes, in your hands. It's not like 3rd year with residency on the horizon.