Thursday, September 18, 2008

Clinical Reflections

Yesterday, I injected steroids into a woman’s shoulder with no help. I diagnosed her, offered her the injection, verbally consented her, re-read about how to do the procedure, and mixed the steroid and anesthetic myself. She was so hysterical at the sight of the needle I had to have the PA I work with hold her hand and head and we tried to lie her down. But in that position, I couldn’t get the needle in the right space. It was stuck in the tendon and only hitting bone, so without taking the needle out, we sat the panicky patient back up and I repositioned until the milky mixture went in smoothly.
I was very glad the clinic had been generally busy, because I didn’t have much time to think about any of this during the session. I knew the injection would help her, and not to offer it because I was scared to do it would have been putting my own anxiety before the good of the patient. So I did it. I looked for an excuse not to, which is usually easy to find in a busy community health center’s walk-in clinic: Did we even have any Kenalog? Yes, we did. 1.5 inch, 22G needles? Ah, four left. Enough Xylocaine? Well, I would have to waste part of a bottle, but not a huge barrier. I would need a procedure book to remind myself of the dosages and exact steps… right there amongst the books the PA brought up from her personal library last week. Even though the day was hectic, I still took time to notice that when I really needed a piece of equipment, even just a sterile swab, we always seemed to out, but when I would have been relieved to avoid a procedure, every item was handy. Murphy’s Law abounds.
Looking back, I am astounded that the injection was successful under the circumstances. An inexperienced doctor, a screaming, restless patient, and a very large needle do not make an optimal combination. (Just to clarify, the patient really did want the injection and was extremely calm until she saw the needle approaching her arm, at which point she literally seemed to be overtaken by another spirit. She never asked me to stop but also never not have let me even hold her arm steady enough without the PA there. After it was over she returned to normal and thanked us profusely.) The difference between what happened yesterday and what would have happened a few months ago is that I didn’t give up. I was about to, to be honest. The one thing about procedures I do have a lot of experience with is giving up on them. As a resident, I so wanted them to be successful, but I felt that ethically I only had so many attempts or so much time before it was the attending’s turn. It was only fair to the patient. Now that it’s just me and I know that the patient will get a treatment from me or not at all, I’ve become more assertive. I still feel a bit astonished by this change in my approach, because it has been very natural and unforced. Yesterday was in fact peculiar in how unnaturally calm I felt. Despite this patient’s extreme behavior, I could tell that I wasn’t actually hurting her, so I kept going until I found the space. As another example, just 5 days before I had done an I&D that an adolescent who had not been able to sit down due to an abscess on his buttock. He had not tolerated the procedure well despite my honest warnings, but between his mother’s support and my refusal to let him leave with significant pus remaining in his backside, I aggressively pushed and probed the abscess until I was satisfied enough was out for him to heal.
The truth is, medicine is still gray, no matter one’s graduation past residency status. I know that I overtreat some otitis media because I’m still not confident diagnosing infant eardrums. In my two short months at the clinic I’ve written prescriptions for dosages that don’t exist, sent too many urine cultures, given out too much ibuprofen. I’ve probably missed some diagnoses and will likely never know. Is it right to do procedures that I’ve only done a few times (and never unsupervised)? Even it's the only option for the patient? Should I tell them my level of experience before they consent? Was it unethical to my future patients to give up on so many procedures during residency? I don’t know these answers, but I do know that the young man with the abscess was sitting on a stool when he reluctantly came for follow-up two days later. I know that seeing him significantly recovered increased my confidence and will help me treat the next patient better. That knowledge goes with faith, however. Faith that the mistakes won’t bring terrible harm to a patient and that they won’t cause me to pull out the needle and give up. Tonight I hope that the patient I injected is picking up her daughter with her left arm, able to sleep on that side for the first time in weeks, and not developing an infection in her joint. And I hope Murphy’s Law keeps teaching me, pushing me into responsibility and an appropriate degree of independence.

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