An attempt to explain ...
... What Exactly It Is That I Do All Day ...
I've "seen" 37 patients today, the bulk of them during my normal 8am-430pm shift as a medical transcriptionist. This included, but was not limited to, boring things like routine cholecystectomies, Cesarean sections, tubal ligations, rotator cuff repairs, coughs, colds and diabetic complications.
Earlier in the day, a patient was “crashing” all over the renal floor, but an emergency AV fistula formation done in the operating room, followed by more and more dialysis brought this patient (who is suffering from Good Pasture's syndrome, of all things!) back to a point of reasonable stability.
In medicine, the words "reasonable stability" can mean a variety of things. It's amazing what a patient's body can settle for as the status quo in the land of all things reasonable and stable.
As if that was not exciting enough, a 10-year-old came plowing into the ER this afternoon after fighting and wrestling with his brother.
Somewhere during the running and tumbling, he landed, right wrist-first on a razor blade. This resulted in a deep laceration with suspected median nerve injury, lacerations to the flexor digitorum profundus and flexor digitorum superficialis tendon.
In other words, he slashed the heck out of his right wrist, and wait until his father gets home!
The surgeon spent a great deal of time repairing this, prior to his father getting home, by whip-stitching the flexor digitorum profundus tendon, grabbing up the median nerve with even more thread, and repairing the flexor digitorum superficialis tendon laceration.
When the surgery was over, the boy had full range of motion of the wrist and good blood flow and movement of all five fingers.
I'm sure he'll get hugged first, and then he’ll be grounded for about six weeks.
While he was off to recover and hear his punishment, I continued to do what it is that I do, all of it in my stocking feet, in my home office, in the bloody (albeit proverbial) trenches as a medical transcriptionist.
An already long day was extended at both ends because we had a conference call this afternoon, which took 30 of us away from our desks. That's 30 brains and 60 pairs of hands. You can do the math on the fingers, all of which, when taken away from our desks, causes a huge backlog of dictation waiting to be transcribed.
Just because we are idle doesn’t mean the patient’s sit still, and the doctors don’t ever have a quiet moment among them.
A backlog of dictation is a recipe for disaster, when it comes to patient care, and this is how I ended up working an extra partial shift tonight, in order to prevent just such a disastrous gap in patient care.
I have been asked many times in the past to explain what it is that I "actually do all day."
Recently, I have had as many as five inquiries of various natures, from people who want to get "in the biz," people who know someone they think might be perfect for this "kind of biz," or soon-to-be graduates who are ready to break into "the biz."
I'm also working on several freelance articles about "the biz," and so this article is a bit of a warmup in all of these regards.
It's difficult, in a nutshell, to explain "the biz" of medical transcription. Some inquiring minds have gone so far as to ask if they could just sit with me and “watch what it is” that I do.
Full witness, or described after the fact, I’m still hard-pressed to explain this “biz.”
I'll just suffice to say it, in the biggest nutshell,trying to cover the types of things I, and my coworkers, handle "on the job" every day. I will use tonight’s shift as prime example.
Nights are busy in the land of medicine.
If you watch "ER" on NBC, you have some idea, but also no idea at all, since medicine is never that scripted, and rarely that "easy."
If you watch the Learning Channel on cable, and have seen the live trauma units or the surgeries, you have a better idea.
If you are a healthcare worker, you know exactly what I am talking about, and if you are the lay person/patient, you may or may not have any idea what is going on.
Worse case scenario, you would rather not know.
I can only try to tell you, in so many words, no names, vague faces and locations protected. Confidentiality is key. Just about everything you can think of is modified to protect the innocent.
My second shift started at approximately 5pm this evening.
As I said, I worked it in stocking feet, in the relative comfort of my home office, with my family now home and milling about in the background (one of the many perks of working from home).
Having already completed an 8-hour day shift, I jumped right in at 5pm by rushing up to the surgery ward to remove a papillary renal carcinoma from some guy's left renal pelvis.
Boy, was he happy to see us, and have removal of same, but let's face it, no one likes to find out that he has had a papillary renal carcinoma rolling around in his renal pelvis.
As I am documenting same, he doesn't even know this yet, nor does his family, though they all may fear it. It's quite probable that the pathology of this won't make it to his bedside until the morning. Until then, it remains our secret. These kinds of secrets are difficult to safe-keep. You wish, at every turn, that you could hit "delete" and change the patient's outcome, but it simply can't be done.
There was no time to dwell on this, however, because I had to whip off the bloody surgical garb and run down to the emergency room where I transformed from surgeon to blundering ER resident.
A 30-year-old woman had come in with acute abdominal pain. She had been in 2 nights prior, but was still complaining of pain. After a cursory examination of her belly and a fly-by of her x-ray, I told her she was constipated and needed to go home and down the magnesium citrate I so expertly prescribed.
She balked at this, and wanted another pain shot, but I suspected "drug-seeking behavior" and lectured the patient on the constipating effects of heavy narcotics.
Ultimately, the patient left in a huff. I figured three more huffs and a blow and she'd work the problem out.
In the meantime, I had a 60-year-old, otherwise healthy woman lying on a gurney after having nearly fainted prior to her presentation to the ER. I could not rule out a cardiac cause, and I couldn't pull the constipation card because I had already used it on the 30-year-old patient with abdominal pain, so I called Cardiology, asked for a consult and admitted the patient to the cardiac unit for "rule out myocardial infarction."
This is called “passing the buck” because we all have a ton of other stuff to do.
Not five minutes later, I had to jump into a closet and change out of my resident's outfit and back into surgical garb, this time as a gastroenterological surgeon.
It seems a loony ER resident had just tried to discharge a woman with an acute abdomen, giving her some song and dance about being constipated, and failing to call for a surgical consult.
As it turns out, upon opening her gut, I found she had multiple adhesions built up, perhaps scar tissue from prior abdominal/female or other surgery. The adhesions were so thick that they seized up her bowel.
I ran a length of it from the ligament of Treitz to the ileocecal valve and all the way down the Virginia Turnpike, before I could deem it "all clear."
She definitely had "hard stool" in her colon, and who wouldn't if the bulk of her colon was locked up with scar tissue! There was literally, no way out that was not torsed or angry.
I made sure to get every detail of the surgery documented with a cc: to the discharging ER resident, and you can bet I wonder who the attending was that signed off on this case, prior to her discharge.
Then I took a supper break. Me. The real me. I took a supper break with my family. We had tons of leftovers and watched "Survivor!"
I took this break, because I deserved it. I am just a transcriptionist. I am not the blundering ER resident, and I’m not even sure I could play him on TV, but I do live to document everything he and the other physicians manage to do in a day, in the world of medicine.
For this, a person needs strength, and leftover Chinese take-out!
After this delightful “downtime,” I had to once again grab up my white coat and start in on the preoperative evaluations for the surgeries scheduled for tomorrow.
Anyone who is "going under the knife" has to be seen prior for operative clearance.
My first patient was a 44-year-old woman with painful "screw hardware" (don't worry, it's not what you think) in her left big toe. She recently had previous repair of a hallux valgus deformity due to degenerative osteoarthritis. The repair had been surgically stabilized with screws. The screws are now irritating the patient, from the inside out, and will need to be removed tomorrow.
After this patient was given the "good to go," my next preop arrived to be made absolutely sure that she was medically stable enough so that the surgeons can deal with her right metacarpophalangeal joint osteonecrosis of the metatarsal head, hammertoe deformity and contractures with instability of the joints. (Can you say that 8 times fast and misdiagnose an acute abdomen? … I can).
I deemed her ready and amazingly willing to undergo second metatarsal osteotomy, flexor tendon transfer and metatarsophalangeal joint arthroplasty, all tomorrow, and all without breakfast. She is "nothing by mouth" for the rest of the night.
The physicians, on the other hand, are foaming at the mouth, and so I’m right back at it with my next preop patient.
Prior preop candidates can’t hold a candle up to my next patient, a 51-year-old male who has failed all nonoperative treatment for his posterior tibial tendon dysfunction of the right hindfoot, his isolated gastrocnemius tendon contracture and his hindfoot valgus deformity.
I'm pretty sure this guy is looking forward to the day that he can walk around without cussing over the condition of his feet, so he (like the rest of the amazingly brave orthopedic patients) is ready and willing to skip snacks tonight, and breakfast tomorrow, in order to undergo a flexor digitorum longus transfer, posterior tibial tendon tenosynovectomy and calcaneal osteotomy.
You go, Guy, and he will, six weeks after surgery and with outpatient rehabilitation.
That was about it for the orthopedic preops, but there were still others to get through, including the 66-year-old female patient with total procidentia and obstructing cystocele (I'm not even going to "go there!").
She is presenting in preoperative agony, prior to clearance for her scheduled total vaginal hysterectomy, anterior and posterior colporrhaphy, sacrospinous ligament fixation, McCall’s culdoplasty and, last but not least, the faved sling urethropexy!
She can’t wait; believe me!
Neither can the 40-year-old female who presents preoperatively prior to her tubal ligation for “permanent sterilization.” She’s apparently “had enough,” and like the rest of the preops is ill-concerned about missing breakfast. She’s just looking forward to the day when she can finally put her feet up!
The 52-year-old male, who presents when she is through, is in his own way, fed up, or fed to the top with his highly obstructing bilobar prostate. Eghad!
He is status post “microwave therapy” (Do not try this at home!), but this therapy has failed on multiple occasions.
Just how long do you “mike” a prostate? I was just wondering.
Until, the men and ladies in the white lab coats figure that out, this guy’s next safest bet is a transurethral resection of the prostate. Do not try his at home, either, even if hard-pressed by suffering as this guy has been with his urgency of urination, frequency of same, and severe pain in the perineum and rectum.
Slice it to say, that he would just like all that necrotic and inflamed tissue out of there!
Tomorrow afternoon, he gets his wish. The next time we hear about him, he will have this amazingly strong urinary stream and will be busting out all over to tell about it.
That’s it for preops for the time being, and so there is time for quick “rounds” about the house to see who needs a hug and if anybody is actually still up yet, needs tucking or retucking etc. etc.
After home and hearth “rounds,” I hit the bif and stop in the cafe for another diet Pepsi before night “rounds” at the hospital start up.
My first "round" is a delightful elderly woman who continues her admission after open reduction and internal fixation of a pathological hip fracture.
As it turns out, pathological washings of the hip have revealed a recurrence of her breast cancer, this time metastatic cells in the hip. I knew this yesterday, but she is just finding out tonight. Another one of those bloody awful secrets I was forced to keep.
Despite what sounds like terrible news, she is anxious to begin ambulating, and since the rest of her checks out fine, all things considered, she gets to leave the intensive care unit and heads over to the rehabilitation unit for orthopedic rehab.
This remarkable woman is acutely aware of the time she has left, which is not considered a “terminal” time frame as yet, since the pathological fracture was like a bell going off to warn against the resurgence of the cancer, so there is plenty of time to plan for her continued efforts at living with this for some time to come yet.
This woman really gave me pause, for a moment, but then I had to rush out of “rounds” and grab up my surgical/anesthesiology gown for a bit to deal with a 29-year-old male patient in extreme pain.
He was a postop right inguinal hernia repair patient who was experiencing a mega level of post surgical pain.
Hernias, in and of themselves, or bulging out of themselves, which is usually the case, are painful in their own right. Surgery, while also painful, usual remedies the situation after a period of healing and recovery. That is, of course, unless you are this guy who is suffering from an unusually high amount of pain in the surgical incision area.
You win some, and you hack some up and make a bit of a mess. So, I had to wash the area down with alcohol and Betadine before I stuck a 22-guage short-bevel needle into the area of pain, fanning and prodding as I went to find the maximum triggering pain point, and then releasing him from this pain with a therapeutic (ah, yes!) injection which was comprised of 3 cc of 0.5% bupivacaine with 1:200,000 epinephrine contained in 40 mg of Depo-Medrol.
The needle was whipped out with ease, and the guy didn’t even hit me, so thankful he was for the injection and the added comfort of five minutes of groin pressure and massage. At the completion of the procedure, the patient stated he was “pain-free” and not just happy to see me.
I left him and headed back for “rounds” with a 75-year-old patient status post stenting of the left anterior descending artery in January of this year.
This patient returned to the hospital earlier today, suffering chest pain with cardiac enzyme and EKG evidence of a subendocardial infarction. Heart cath, performed in a stat fashion this afternoon (I was in on that too!), showed under-deployment of the previously/supposedly deployed stent.
The offending area had been revised with a new stent distal to the failed area, in a cardiac surgery late this afternoon (you guessed, it I had my hands in on that too.)
You live and you learn in the cardiac world, too.
Cypher drug-eluting stents work, and sometimes you have to go for the gusto of a Taxus stent!
They learned, and he lived.
The patient’s wife and son were at his bedside tonight. The guy is doing great, with excellent labs and vitals. He gets to move tomorrow out of ICU and into a less intensive environment.
Hello, Cardiac Step-Down Unit, the precursor to “going home!
“Rounds” were interrupted once again, because I had to gastro-consult a 77-year-old chest pain patient who has also been experiencing abdominal pain.
This male patient had the unfortunate history of prior renal stones, transurethral resection of the prostate, cholecystectomy and hernia repair. There were lots of variable to consider as the etiology for his current abdominal pain, but in the end it was deemed to be a flare of his diverticulosis gone diverticulitis (ouch!)
In the end, good old MOM (Milk of Magnesia) is what this guy ultimately needed, was given and began to feel better. I left him with the cardiac folk for his continued chest pain workup. However, this may rule out now as well for myocardial infarction, since the chest pain may have been referred abdominal pain from the diverticular flare, but the cardio guys will work him up with enzymes and serial EKGs to be absolutely sure.
Just when I thought, I'd finally get back to "rounding out" for the night; the emergency room once again beckoned me.
This time, a 3-year old came in with a near amputation of his right long finger, after getting it caught in a conveyor belt. It's probably the last time he will ever pensively set a candy bar on the conveyor at the store, in preparation to look up beseechingly at his mother to ask, "Pretty, please, may I?" … right before he nearly gets his finger ripped off!!!!
Poor little guy.
The x-rays confirmed that this was a "near amputation" with a distal phalanx fracture, and thankfully not a pending “full amputation.”
We rushed the little guy up to surgery to undergo general anesthesia for surgical examination, debridement and repair, which looks to be entirely possible with good outcome prognosed. Since his last meal was quite earlier this afternoon, and he never did get that candy bar, surgery should go without any further complications.
My prognosis, however, is guarded at this point, as it nears midnight and I need to leave the rest of "rounds" to someone else. It's time to get some shut-eye since my regular shift begins again tomorrow at 8a.m., post getting everyone out of the house for work and school, right as the coffee completes its full perk status.
I'm going to eat about six candy bars and toddle off to bed.
It's going to be a heavy day in surgery tomorrow, judging by the preoperative exams I did tonight. The orthopedic surgeries will be particularly grueling since they are nothing without their intricate detail, and no fun at all to transcribe, unless the surgeon has marbles in his mouth while dictating, which he is prone to do … just for kicks.
Transcriptionists on the day shift are also prone to go AWOL and take all manner of extended lunches and breaks when the orthopedic surgeries hit the airwaves, or when the English/Second Language docs begin their documenting for the day.
At that point, it's every transcriptionist for themselves in the bloody trenches, in our stocking feet.
I, for one, love the bloody trenches. I just wish, for once and for all, I could explain what the heck it is that I "do all day!
POSTSCRIPT: I wrote this piece, hastily at best, at the end of my mega shifts today and tonight, so it cannot go without the trademark stamp of a “stat” transcriptionist, and should bear the words “REPORT NOT PROOFREAD.”
These are magic words we sometimes apply to the end of hastily dictated and transcribed document during an extremely emergent medical situation.
The documents, obviously, have to be taken with a grain of salt all along the way, although we never cut corners on the “big stuff.”
In our extreme haste, we have to tell ourselves that typos, transposed letters an annoying grammatical errors, never killed anyone, as long as we are documenting the “big stuff,” and these reports of course are always corrected later, since transcriptionists are an on breed, and we don’t ever really sleep!