Yes, but…

I had a lot of these patients tonight. I give them my medical opinion and get a …yes, but… not just once, but seemingly dozens of times. Mom, who is a former nurse, hears rales in her 3 year old child. I hear upper airway stridor consistant with croup, but perfectly clear lungs. Was she hearing transmitted airway sounds? She wants to know if her duaghter has pneumonia, so I go ahead xray her chest, even though she doesn’t need it. The xray is normal. “Yes, but last time, were were told it was normal, and two days later we were told it was pneumonia.” Well, it’s still a normal chest xray, I think to myself. Besides, her last xray WAS normal, I compared the two AND read the radiologist’s report.

The 60 year old woman with the swollen red ear I had diagnosed with Otitis Externa. “How does it happen?” they asked me. I explained how the linign of the ear canal can sometimes be disrupted when I was interupted by her, “No, there was nothing wrong with my ear canals this morning,” she said. ‘Did you look in your ear canals this morning?’ I thought to myself. I explained to her the treatment I was going to use. “Yes, but last time they had to give me shots because they couldn’t get an IV started.” You don’t need an IV, ma’am. I’m happy to start you on oral antibiotics and ear drops tonight. “Yes, but last time I needed shots…”

We finally investigate, turns out she received IM Rocephin and then was placed on Keflex after a trial of cortisporin drops alone didn’t help. Neither Rocephin or Keflex is recommended for otitis externa, alhtough rocephin will certainly kill a lot of bugs. I had her cipro tablets out of the pixis, and her script written when the boss tells me to order up a shot of Rocephin, then start Keflex. ‘Yes, but Keflex doesn’t cover pseudomonas,’ I think to myself.

I pull a wood tick from behind a four year old’s ear. “She’s only four, I guess you can’t start doxycycline,” the boss says. So I ask him, do you always prophylax for Lyme disease? Sure, why not, he says. OK, first, it’s the wrong kind of tick. Second, it’s not very prevalent in our area. It would be a different story if we lived in Lyme, CT, but the boss doesn’t see it that way. Thankfully she’s only four, so I’m not forced to give her antibiotics.

I’m too tired to argue anymore.

WHen the man who got bit by an institutionalized teenager doesn’t argue with me for my treatment plan, I’m thrilled. The lady who lets me put a splint on her knee and send her out the door shocks me with her compliance. The old man who begins tegretol for a new diagnosis of occipital neuralgia is eager to understand his new diagnosis. Those patients are refreshing.

Twenty Five.

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