dimanche 22 juillet 2012

The one whose twisted ankle wheezed.

Emegency Room - Traumatic Care
6th year.

She is sitting in her wheelchair a sheepish smile on her face, sniffing now and then.
Her ankle is badly swollen but walking isn't that difficult.
There is no true diagnostic hesitation : the severeness of the strain will be, at most, medium.
I reluctantly fill the radio voucher.
One of my senior physicians informed me earlier that, on his shift, "Every single ankle strain coming into the ER will come out with an Xray. Even if the official recommandations are telling that it isn't necessary".
Why ? SIC ( Suing-In-Coming).

Strenghtened by my medstudent innocence, my will to do well and the total emptiness of the waiting list, i auscultate her.
They jump at my eardrums.
"- A little bit asthmatic, maybe ?"
She makes a shy smile and sniffes.
"- Yeah, not perfectly alright lately."
No kidding.

Twenty minutes later, when my senior comes in, he looks quickly at the ankle, doesn't even glare at the radio, approves my prescription and go straight to... The chest Xrays. He turns himself to look at me, his eyebrows raising.
"- She didn't sound really clear, i couldn't act as if i didn't heard."

He politely asks the girl one or two things, gives her her prescription and doesn't give her a thing for her lungs. "And if it doesn't get better, go and see your GP."

I know that the Emergency departement is there to take care about the casualties.
I know that in the trauma department the consultation motive leads straight to the prescription.
I know that the ER isn't there to take care of the common cold or the chest infections that are perfectly well (even if they occur on asthmatic people).
I know that the recording of the history and the clinical exam have to be quick because there is a lot of "urgent" people waiting for a further care and not a standard primary care of general medicine.

Nevertheless, this time I found a unstable asthma and a little chest infection going along with an ankle trauma.
What if, because of "care-optimisation" and SIC-abuse, I harvested unhelpful Xrays but missed much more critical things ?
What if i forgot the little questions leading to the current troubles ? The massive osteoporosis leading to a fracture, the badly located metastasis leading to the common backpain, the extensive melanoma  concomitant to the high bloop pressure ?

I know that we are not omniscient and that things will (hopefully) be done one step at a time.

But it is hard to give up. Yet.
I want to believe a little bit more in the "extensive scan" provided by a standard consultation. I can't yet accept the agreement consisting of leaving a lot of untrated/undiagnosed pathologies around just because the patients didn't mention anything. Or because their physisian didn't ask.

Utopia, here i am.

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