Just being a doctor

The other day, while working in an off-site urgent care center, there was a guy...

...this guy was a 40ish y/o man, who was working at a construction site when a 2x4 fell and hit him on his right ear. He presented to the UCC with a 2cm laceration to the external ear, involving the cartilage. At first glance it didn't seem that bad. But, then when I realized that the cartilage was involved...I was reluctant to repair the wound. Eventhough I'm able...and know all about auricular lacerations and perichondrial hematomas (thanks to emedicine and google, and of course my EM training), and am capable and qualified to repair them as an ER doctor. But, I wasn't in the ER...and the repair seemed like it would take too long in the clinic setting. Besides, I didn't want to do it wrong, and have this guy sue me because a hematoma subsequently developed and caused a cauliflower ear for his lack of follow-up (as is typical of the innercity patient population). So, I did what every clinic doc does when they don't want to deal with a particular patient....I told him to go to the ER.

He *really* didn't want to go to the ER.

I explained the complexity of his wound, the possibility of hematoma, and the close f/u that would be indicated. I told him that there may be complications...and I, basically, didn't want to take the risk. The risk that he didn't fully understand the repercussions of improperly managing this type injury. The follow-up, the wound care, and the possibly that cosmetic appearance may be suboptimal despite perfect medical treatment. (Sometimes getting patients to understand that it wasn't *you* who dropped the 2x4 on their ear causing the damage, but rather their lawsuit anger should be directed toward the perpetrator...is a difficult task if complications develop).

He listened, and expressed understanding. Then he said "doctor, I don't care how it looks when you're done...and I don't care if I have to deal with complications; as long as you do your best, I will be happy. Please try, I don't want to go to the ER...especially if you can fix it." (hmmm...can I get that in writing? Does that count as informed consent? Will that hold up in court?).

So, the doctor in me...that part who doesn't want to base every medical decision I make on what's defensible in court, but rather do what's best (and within my capacity) for people...over took me.

I repaired his ear. And it looked nice. Tiny 6-0 sutures, all neat and tight (but not too tight). No hematoma.

I told him he'd better *better* come back the very next day!! I even gave him my direct line to call me when he arrives out to triage...as to avoid waiting (to encourage him to actually return). When he arrived, he started to check in. When he realized that there were no "short-cuts" despite the fact I told him there would be...he decided to call the number I'd given him. I arrived out to triage as he was being sent to registration. I stopped him, removed the dressing, and looked at my work his ear. Still great, no hematoma. (I did document this "visit"...but, of course, I not sure if "it'll count" since the patient didn't register). But, more than anything I felt better about doing the procedure. And the patient knew I really cared about not getting sued his injury.

After my short hallway reexamination....he handed me a gift basket from him and his family saying "thank you for being a great doctor; for going beyond what's able to be documented despite our current sue happy population, and treating me with respect."

You are welcome, Sir!!

Sometimes we are allowed to just be doctors!!


frylime said...

yay! what a happy story!

ps...i've been reading your blog for a while and love it. i'm a current M1 student, and your stories are great for someone like me to read!

ER doctor said...

Awww....shucks!! :o)

Thanks for reading.

I am a resource to you...and all med students who find my advice helpful/applicable/relevant. Feel free to ask questions as you progress...

frylime said...

thanks! i definitely will take you up on that offer, and if it's alright, i linked you on my blog! (if you want to read about silly M1 stuff...hahaha.)

Toni Brayer MD said...

Great post and we have all been there. This is truly "how doctors think" and what our litigation happy society has rendered. Glad it was a good outcome.

scalpel said...

Very nice explanation of what it's like to work in a satellite facility.

I love it when patients say "just do it." Hope it turns out well.

rlbates said...

Good post. I love it when patients feel that way too. I always try to do my best (but sometimes those hematomas happen)

NocturnalRN said...

So nice to be thanked every now and then, huh? Good job!

thestoryofhealing said...

This is encouraging. Thank you for a wonderful post. This is my first time reading you. I will surely be back! ;-)

Lynn Price said...

I found your site via Scalpel. Cool post. What saddens me is how docs have to stop and consider what they can defend in court before they treat a patient. Something is waaay out of whack, and it sucks stale Twinkie cream.

Anonymous said...

This is a great account of how we feel as ER docs. I'm in a similar situation, recently out of residency. When I first came out I was pretty defensive. I wouldn't do anything that wasn't medicolegally defensible.

Now I'm starting to allow myself to be a real doctor. I've decided I'd rather get sued a few extra times and be able to practice real medicine than hide behind defensive medicine.

(we'll see if I still feel this way after my first lawsuit...)

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