15 July 2008

There is NOTHING that I find more disturbing...

than a patient who does not have time for me. Access-a-ride, be damned.

So, there I was, clipping along my usual Tuesday patient marathon (trust me, 8A to 7P full of patients does not a happy surgeon make), when... "DrB, MsG wants to know when you will be seeing her. Her Access-a-Ride is coming soon, and she wants to know if she should reschedule," my medical assistant came into my office exactly as I pushed away from the EMR to get MsG. This automatically put me on edge. "Wait a minute," I said, "what time is her appointment?" "4:50," my assistant rolled her eyes. (She knows me too well, and could already see my blood starting to bubble.) I snapped my neck around to face the clock, "It's 5:02... twelve minutes past her appointment time. What's the problem?" Well, apparently, MsG had asked her transport service to pick her up at 5:16 (?huh?... why 16? and not, say 19? or 14, for that matter?) Well, I told my assistant to give the patient the choice (a grave error, this): stay and be seen--now--and the appointment would take roughly twenty minutes, or reschedule. "The patient will stay," my assistant soon told me. Three of the medical assistants in our 'area' (little office space in the medical center) knew of her predicament and promised to keep a look-out for her ride. They promised to make sure that the van did not leave without her.

So in she came. She was sitting in my office by 5:04PM. I acknowledged that I was running fourteen minutes behind schedule, and apologized. She, in turn, decided it was important for me to know that she had been waiting since 2PM. I (as nicely as I could muster at this point) explained to her that everybody has an appointment time, and I see patients according to the time of their appointment. It would not be fair for me to see patients out of turn. Frankly, I had been seeing patients nonstop (well, unless we count the seven minutes it took me to wolf down cold rice at 1:22PM) since 8AM, and there was no time at 2 for me to fit her in. I then quickly explained to her that I am happy to see her now, and would like to help her.

This is when the fun started. During my customary history taking, the patient was practically hanging out the window looking to see if her ride had come. I had to focus her attention back to me repeatedly, thereby wasting time (do you see the chasm here?). I called to the front to make sure that the medical assistants had not forgotten about MsG and her van--not only did they not forget, but the news had spread far and wide. More people were involved in making sure that the said van did not escape. It was not enough. That is when she started to look at her watch. But it was not a nonchalant, "Oh, let me just check the time here a second..." type of looking. NO! It was an all-out, "I need to get the f... out of here, and this damned surgeon is holding me up" kind of looking at the watch. Again, that strange dichotomy, that conflict, as I expressly told her that if she did not have time for me, we could easily reschedule her appointment. No, she said, "I'm here now..." as her voice trailed off. She was as far from here, now as possible.

I then started to examine her. She squealed even before I touched her, pushing my hands away. "Ma'am, I have to examine you. Please try to relax, as I cannot help you otherwise..." Once done, well, at least as far as she was concerned, she flew out of my office. She did not know what her treatment plan is, did not make a follow up appointment, and ran down the steps (cane waving in the air at her side) to an empty street to WAIT for the Access-a-Ride to come. (That was at 5:22PM.) I was so irritated (and busy), I did not wait to see when they finally got there to get her.

Her story? I honestly am not sure which is more disturbing--the above, or the below (what I am about to write). This lady, in her early seventies, had apparently been having trouble with her fingers (right ring and middle) for more than three years, "probably going on four," as she tells it. Her PCP attributed it to arthritis. The trouble? Locking of the fingers, so that she has to pull them, with pain, back into position. PEOPLE!! Holy moly, this is NOT arthritis (simply put, break-down of cartilage in a joint so that the bones rub against each other), it has nothing to do with arthritis. These are plain and simple trigger fingers, AKA flexor tenosynovitis or stenosing tenosynovitis.

(I have yet to master photo and drawing inserts here, so bear with me.)

Tendons are connections between the bones in the fingers and the muscles in the forearms (hence the reason that these patients will often have pain into the forearms). The flexor tendons are held in place with a pulley system (they are not like rubber bands, and therefore do not stretch, or give), of which the first annular pulley is the proximal-most in the palm. It also happens to be the tightest of the pulleys (in every person, in every finger--it is just the way we are made). When a patient has gout, or rheumatoid arthritis, or overuses a finger (always carrying heavy groceries, one on each finger), or falls on an outstretched finger, the flexor tendons will get inflamed. Once inflamed, they cannot pass fluidly past that first annular pulley. So, the person tries to bend the finger, the tendons bunch up distal to the pulley, and if the finger is forced to bend further, the tendons will clunk, or pop, under the pulley and get 'stuck,' or locked, now proximal to the pulley. So, the patient has to somehow maneuver the finger open.

If this is allowed to go on long enough, the tendons can actually get foreshortened, as the patient will eventually find it too painful to fully open and close the finger. That is, in effect, what had happened to this lady. She cannot straighten out her right ring finger at all. Not that I got a chance to explain this to her... (She also has a left middle trigger finger that has been ongoing for about 6 months.) So, what she needs is occupational therapy as optimization for surgery for the right hand, and an injection into the left.

Therapy for triggers should always include ultrasound with steroid ointment (NOT Biofreeze) and a home exercise program. This is a pet peeve of mine--for triggers, steroids, properly applied, work, Biofreeze does not.

Surgery consists of simply filleting open the first annular pulley. We have found that it is not necessary for motion of the tendon, or, for that matter, the finger. As long as the neurovascular bundles are protected, it is a fairly simple procedure (which gets hairy in fat hands). As for the injection, it is a steroid. The reason that steroids work (as an injection or an ointment--as in therapy) is that they are anti-inflammatory; they help to reduce edema around the tendon. In this way, the tendon can move in a supple manner past that A1 (first annular) pulley. The caveat is that there is a limit, as repeat injections can cause weakness, or even breakage of the tendons. I tell my patients no more than two injections per finger for your lifetime. Also be aware that in diabetics, the injection may make their sugars rise for a few days--better yet, don't just be aware, make your patients aware!!

You people have only an inkling of how much this lady upset me. I felt somehow abused. Maybe that sounds a little melodramatic, but... I did not even have a chance to go through a treatment plan with her.


Dragonfly said...

Why someone would do this in an appointment they have directly or indirectly (everyone has paid some form of tax at some point in their lives, even if not income tax)? I can believe that it happens though...
FTAs (failure to attend) is rife here, but is probably less frustrating than your experience here.

Alison Cummins said...

I have no experience with Access-a-Ride, but I know that the paratransit system here in Montreal can generate experiences just like this.

It can take hours of constant, automatic redialling to get a line, followed by hours on hold, to book a ride. For an appointment at 16h00 someone might be offered a drop-off at 11h00 and a pick-up at 15h30 and told to take it or leave it. Ultimately the ride is much more difficult to get than the appointment.

For hospital appointments they will drop someone off at the hospital and then the patient simply has a special number to dial to ask for an unscheduled pick-up after the appointment is over. But if it's not at a hospital, the ride might be the more precious commodity than the appointment.

I'm not saying your patient handled the situation appropriately, and it is certainly possible that she was the one who expressly requested a pickup at 17h12, but if Access-a-Ride has similar problems to the system I know then your patient's issues may not all have been of her own making.

DrB said...

It is true that these patients often have to take pick-up and drop-off times that are hours apart, but they do have some discretion as to the hours themselves. Certainly, if they say, "My appointment is at x time," they may get a range of x +/- 1 or 1.5 hours. It is not a "take it or leave it" system, in other words. (Sometimes, I have found, they try to abuse the system. They tell the company that the appointment is at a completely different time, and then they go to the doctor's office, expecting to be seen at whatever time they show up... then, of course, blaming Access-a-Ride.)

For this patient, however, the problem was that we had MANY people "on the lookout," if you will, for her van, and she still had no interest in being there. And, as I mentioned, at the "end" of her appointment, she ran down to an empty street to WAIT for the van to come. All very frustrating.