Sunday, July 09, 2006

The Diabetic City/ Class

Walter Payton, the great Chicago Bears running back, was known as "Sweetness." I think the medics in this town deserve the same name. While we're giving out new names, I think the town should be called "-------, the Diabetic City." We have a huge population of older black people, many to most of whom are diabetic.

It seems like everyday I am doing another hypoglycemic patient. Started today off with another one. 80 year old woman blood sugar of 48. She didn't eat. Lives at home with her husband, both on the verge of dementia. I gave her some D50, she woke up. Her daughter, who was there now after being called to come over, agreed to feed her and watch her through the day, and follow up with her MD. I also talked to the visiting nurse who was showing up as we left. She said the woman needed to be in a nursing home.

I do the ordering for our service and I order cases of D50 and we just go right through them. Same with glucometer strips. This is "The Diabetic City."


More calls.

A woman with pain in her right leg. A woman in a nursing home with a low blood pressure accoring to the staff, who said her pressure was 88/60 and she is normally in the 130's. We took it. It was in the 130's. The woman who was blind said she felt fine.

A woman who choked twice and had to have her family perform the Heimlick manuever. The only thing was she wasn't eating and hadn't coughed up any phlegm. She said she just couldn't breath or make a sound or get any air in. Odd.

Then we got called for a child who had passed out. It was at a country club. We found the young teenage girl sitting in a chair on the ground, feet up in the air with a man holding c-spine and a crowd of people standing around. They said she had been playing golf in the heat and humidity, and then wasn't feeling well after her tournament. She laid her head in her lap, then sat up and passed out and fell over backwards. They said you could hear her head crack from across the room. The only thing was she had no complaint of pain, no bump on her head. She was a little pale. I explained to the man that I was going to follow a protocol to determine whether or not I needed to c-spine her. He seemed sort of perturbed when I asked him to release cspine so I could have the girl move her head from side to side, and he stalked off. Everything was clear -- no neuro deficits, no pain on palpation, no limit of movement. Nothing. I did orthostatics. A stepping stone change from laying to sitting to standing. I asked the family what hospital they wanted to go to and they told me. I asked if they meant the affiliated kid's hospital across the street, but they said no, they would never go there. A doctor on scene had told them this was a trauma and they had to go to the trauma hospital. A couple years ago there was a big to-do when a child in a bad MVA was diverted by the trauma hospital to the kid's hospital where the child later died in the ER. I try to explain that this is a different degree of trauma. This is actually more a dehydrated related syncope than a trauma. But they insist, which is fine. I don't argue. If the hospital, which generally only takes patients 18 and over unless it is a serious trauma gets angry at me, I will just shrug and say, family insistence.

The family is very nice, but there is a little bit of the what took you so long to get here? are you sure he doesn't have a serious head injury? -- they said they could hear her head hit from across the room. No, I can't say 100 percent, but she has no signs of one. She doesn't even have a headache or a bump on her head. She is fully alert. She isn't nauseaous, she has no vision problems. When she closes her eyes briefly, the mother urges her to stay awake. I tell her if her daughter wants to rest, that's okay, she doesn't need to keep her eyes open if she is tired. I try to reassure her. I do give the child some fluid and some D50 as her sugar is in the 70's. I also put her on the monitor.

At the hospital I give the triage nurse the story and she scribbles some notes, then calls down to a nurse in the non-trauma wing we are going to and relays my story. My partner tells me later the mother is very upset with what the nurse wrote on the notes that it doesn't reflect what happened. She evidently read the nurse's notes while I was off writing my report, which I confess I put extra effort into to make certain I left nothing out.

I understand that every patient should be treated as if they are your child and that every parent has great concern for their own child and want the best, but I am a little uneasy when I feel there are two standards of care, where when you take care of a privledged child with connected parents, you feel as though you have to be more careful, more on the safe than sorry side. I suspect that at the hospital there may be the same pressures -- the family may insist the child may get a CAT scan and more tests than say an underprivledged child would get. I feel that I gave the child top flight, appropriate care. But I am left uneasy. Maybe it is because I felt the family viewed us as ambulance drivers and attendents and not as worthy as "The Doctor" at the club or their neighbor who was once a nurse before she married.

A part of me wanted to say look, I have assessed you child from head to toe, I have taken a full history. Your child is anorexic and didn't hydrate herself and she passed out and banged her head. It happens. She needs some gatorade and something to eat, and some rest in the airconditioning in front of the TV at home. But we are happy, more than willing to take her to the hospital of your choice becaue I understand she is a child and you want to be certain everything is okay. But she doesn't need a trauma center activation. But I didn't say that. I made her comfortable, explained everything I was doing, gave her IV fluid and some sugar, and transported her to the hospital of their choice.

I shouldn't feel uneasy, but I do.

I think it is the class difference in America that bothers me.

I need to ponder more.