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Rural family practice is not always a cakewalk.

It's never a cakewalk.

So things come in waves. I had a wave of patients needing venous studies of their legs and/or arterial studies of their legs, two weeks ago, four of them. I was gone for four days with my daughter, so for one of them I faxed a letter to the nephrologist saying "I am gone, you follow it up." The nephrologist did, sending my person to the vascular surgeon. I came back to a stack of over 50 faxed labs, specialist notes, refills, reports of vascular studies, old records, emergency room reports, etc. Couldn't get them all done in Friday clinic, so spent two hours Sunday going through. Open the computer chart, read whichever thing it is, does the patient have a follow up, do I send a letter, call the patient, adjust the thyroid medicine, the neurologist wants the LDL to be under 100 and the last one was May 2015 so send the patient a letter with a lab order form.....Various patients hit the ER and do they need a follow up visit, did they get put on medicine, what did the head CT/chest xray/labs show? Document, document, document.

This week the special has been TIAs and a stroke. Three TIAs, and one stroke or two and two, I am not sure yet because the questionable one cancelled per head MRI. That one has an abnormal heart echocardiogram, is in atrial fibrillation, I talked to the cardiologist at 6 pm last night. Per heart should pump out 55-70% of the blood from the left ventricle but it's only pumping 38% which is bad and per is in atrial fibrillation which increases the risk of .... stroke. Cardiology said yes, add a beta blocker if tolerated and per was on aspirin so anticoagulate. However, I can't, because of the head MRI. I do not know if per had a stroke or not, and strokes can be a bleeding stroke or a clot stroke and like, you don't anticoagulate bleeding strokes 'cause then they bleed more. Called patient and seeing per at 8 am Monday. Per confuselled, as my mother would say, which makes stroke more likely. All of the tia/stroke people need 1. a heart ultrasound, aka echocardiogram 2. carotid artery ultrasound or artery dye study with MRI 3. MRI with and without contrast of the brain 4. before you can put contrast in them you need to check kidney function which means lab work 5. three out of four went through the emergency room so I have ER notes to review as well 6. then you have to figure out whether it WAS a tia and if they aren't on aspirin they get aspirin and a statin to lower their cholesterol and their blood pressure goal is 130/80 standing or a little below but not too low or they fall down and break their hip and if they were already on aspirin they need coumadin but you have to combine the rat poison with low molecular weight heparin until the level is right or else they can clot so levels are done daily for a bit and then some of them should be on plavix instead or the new anti coagulation agents or there's that other one I can't remember the name of......

....yeah.

And yesterday I worked 11 hours because one of my really tough little old ladies came in Thursday having fallen hiking on rock scree over a week ago. She is over 80. She and her son decided she was concussed, ok, whatever. She waited over a week to come in. Face is bruised and hurts too. I talked to the radiologist and she got a facial CT scan on Friday. She broke her face. Four bones out of position including a "blow out fracture of the left orbit".... like, that's eye socket. Geez. Ok, I call orthopedist here and he says blankly "I don't do faces." "Ok, who do I call?" So then I am calling Harborview maxillary-facial trauma and talking to a very nice surgeon. Woman. Tried to get my hospital radiology to send the CT results over, but the radiology desk person sounded entirely clueless. Called the ER and they got it done. Talked to the surgeon again and it's borderline, not QUITE bad enough to insist on surgery but she would and could see her Tuesday and operate Thursday if the patient wants. The patient definitely does not want as of yesterday. Call me back if she changes her mind. Sneeze with your mouth open not closed for 6-8 weeks and PROBABLY the eye won't sink some in the socket but it might.....

....yeah.

Primary care. All coughs and colds. The scorn of training and during medical school and residency. It's just like Ghostbusters: the thing you really need to know is who ya gonna call?

Ha, ha, I am released to work three quarters time, ha, ha. Oh, and we have new patients booked out well into October......I said I'd have to clone me and my office manager....ha, ha.

http://www.mayoclinic.org/diseases-conditions/transient-ischemic-attack/basics/symptoms/con-20021291
http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/TIA/TIA-Transient-Ischemic-Attack_UCM_310942_Article.jsp#.V7hqTlJ0cm4