I tried very hard to run on time in my temp clinic yesterday and failed.

I am supposed to work from 7:30 to 5:30. I got there 4 minutes late, first patient teed up, went in with my niblick and it all went downhill from there. I got done at 6:58 and had a ten minute lunch and I "only" saw 11 people. The problem was that 7 of the 11 were not 20 minute visits unless you really really want to ignore the incipient glaring kidney failure or the heart attack that is about to happen. Anyhow, the administration wants me to see 18 daily. Deja vu. I wanted to laugh myself silly when they told me 18. I probably look stealthy or mean or get my stone face when I am trying not to laugh myself silly. No wonder the administration is antsy. The universe has an evil sense of humor.

I feel like a weird doctor version of Mary Poppins, arriving on the wind and I'll be here for six months. Assuming the administration doesn't fire my merry butt for overtime. I am planning a meeting with them sometime next week where I gently express my concern that the doctor that left and from whom I inherited the panel of patients did not seem to do the yearly test for diabetic kidney problems and that I've found 6 people in stage III and one in stage IV chronic renal failure. This is during "routine yearly" medication visits. First of all, type II diabetics are supposed to have the hgbA1C every six months and the ones on insulin every three months, but they are also supposed to have a yearly microalbumin/creatinine ratio that tells me if their kidneys are going to hell.

Since diabetes is the number one cause of ending up on dialysis, I find this omission worrisome.

So the trick is to show this to the administration, how concerned I am about the patients and how concerned I am that there is a tiny possibility that it could leave the organization open to criticism. Or even liability. What I wanted to do yesterday was run around screaming "WTF!" once I'd found my fourth kidneys going to hell patient in one day. Actually the stage IV one is pretty stable but my standard of care is stage four ought to see a nephrologist. We are rural though and I don't know the nephrologist who comes once a week. I hope he's not as backed up as the neurologists, they are 6 months out for new patients unless the patient's brain is about to explode. Stage III chronic renal failure is super common and not that worrisome in the over 80 crowd, but when someone under 80 has gone from normal to stage III and eGFR of 32 so right on the cusp of stage IV, that's an oh shit moment from Dr. Poppins perspective. Stage V means dialysis and will kill you early.

The new patient wasn't easy either, having out of control diabetes, a precancerous skin thing that needs a general surgeon update a month ago, and an infectious disease that I haven't dealt with much since residency. That 20 minute visit took 40 minutes, I think. One visit took 60, a patient I'd seen for the first time last week for shortness of breath. That one had a treadmill two days ago and it was worrisome enough that I called one of the cardiologists who agreed that the patient should have a cardiac cath. The patient then admitted to not having started the beta blocker but at least they took the damn aspirin. "Let's start a statin," says the cardiologist. Yeah, let's. "Is he unstable?" says the cardiologist, almost hopefully. "I don't think so," I say, "He looks a bit grey from the treadmill still." Patient says the treadmill is the worst thing he's ever gone through in his life and that he used to think he was strong. He's still trying to wrap his head around "Hey, we think your heart arteries are blocked and you may need your chest cracked for a bypass," but he doesn't want an antidepressant. The cardiologist will see him next Tuesday or Wednesday and meanwhile don't carry the load of wood that causes the symptoms and if it acts up anyhow call an ambulance.

We're supposed to "see people for one thing" which is utter bullshit and anyhow I chose Family Medicine to take care of the whole person. It doesn't work for renal failure anyhow because you have to look at their diabetes and look at their hypertension and drugs and supplements and DON'T TAKE FOUR MUSHROOM PRODUCTS FROM THE SEATTLE MUSHROOM DOCTOR YOUR KIDNEY FUNCTION HAS DROPPED IN HALF IN SIX MONTHS. Fun, right? And the peoples wonder why the stupid doctors insist on yearly labs but the kidneys are not the bladder and it's not about peeing. Creatinine is the cell metabolism byproduct, you could think of it as cell piss. Your kidneys are supposed to clear the creatinine without losing albumin. Thus the microalbumin/creatine ratio, which ideally is under 30. Found one patient who HAD had one tested, two years ago. It was 246. Fucking great.

I am typing this at now 3 am, because it's stressful being Dr. Poppins and resisting running around screaming "WTF!!!" and it's affecting sleep and appetite. Also I have to go to a funeral today and we are at the grundoon birthday and death time of year. Perhaps once I turn middle age, in between gundoon's birthday and death, I will be calm and mature. One can always hope.

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