The problem is common and real
How best this problem to heal?
When the patient says no
And just will not go.
But where there is pus, let there be steel.
Synopsis: I'm a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska. Since the pandemic started, I've done telemedicine off and on in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, worked at the Veterans Administration in South Dakota, held a part-time position close to home, and worked 10 weeks in western Pennsylvania. After a couple weeks off, I've got another gig in Northwest Iowa.
I got a phone call on Saturday from a friend and colleague working on the other side of a border, with a minimum of equipment and supplies. I won't say which border, and I won't say which Saturday, so that I can put in other details.
The patient had an abscess, a collection of pus, right next to a tonsil. Doctors now speak of peritonsillar abscess, but when that problem killed George Washington, they called it quinsy.
True now, and true since before my birth, drainage treats abscesses. Hence the maxim going back centuries: where there is pus, let there be steel.
Early in my career, in my Indian Health Service days, a Navajo came in on a snowy night with trouble swallowing and breathing. When I looked down the throat, the abscess next to the tonsil pushed the uvula (that thing that hangs down from the middle of the soft palate) halfway to the other tonsil. I worried that if I went too deep with a scalpel, I'd hit the internal carotid artery.
I called the ENT consultant at the reference Indian hospital 65 miles away, an hour in good weather and uncertain success of transport on a night like that.
"You can do this," he said, "Wrap tape around the end of a 22-gauge needle, about two millimeters from the end, keeps your needle from going too deep. Wrap it about 4 times. All you have to do is make a hole and the pus will drain."
Things worked well and the patient stayed the night till the blizzard ended the next day.
Since then I've seen a handful of similar cases, and referred each one to the otorhinolaryngologist (ENT or ears/nose/throat) specialist.
Near to my friend's facility, a hospital agreed to accept their next-level patients, but the patient didn't want to go.
"You work with what you've got," I said, "Have your interpreter specify risk of death and disability, inject the one dose of ampicillin that you've got, and give penicillin pills for the next week."
Alas, they didn't have penicillin pills, either.
My colleague described a medical student on the brink of tears.
"Patient autonomy is the buzzword in our country, even if they don't have buzzwords where you are. If the patient says 'no', the patient says 'no'."
I recommended some scripts for the translator.
But later in the day I got the news that the nursing supervisor, unacquainted with the new, gentler American medicine, ordered the patient to the ER, and wouldn't take "no" for an answer.
There is no substitute for a strong nursing supervisor.
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