There are drawbacks when multiple layers are placed between patient and physician

Modern medical practices are assisted by advances in technology but remain challenged by the costs of doing business.  Physicians and surgeons are meeting the need to deliver care to large caseloads by employing nurse practitioners and physician assistants and using patient portals to report test results, answer questions, and arrange appointments, including telemedicine consultations.  These systems are designed for efficient care-giving that enables the physician to personally address only the more complex cases, while still providing oversight for the nursing and PA staffers.  These are all sensible arrangements: Patients receive necessary care; costs are controlled.  But there are drawbacks when multiple layers are placed between patient and physician.

The system works well except when it doesn’t.

Here is my story:

The day after Christmas, a slip in the bathroom sent me crashing head-first into the tiled shower entry.  Our CCRC (continuing care retirement center) provides 24-hour emergency response, and in short order, two nurses were at our village home to assess my status; they applied a temporary dressing and gave us directions to the nearest emergency room, where I was stitched up after an MRI showed no fractures to skull or nose.  The care was swift and efficient; I was instructed to wash the wound twice a day.  My husband said, “We have some Hibiclens on hand. Will that do?”  We were assured that would be fine.

Other than a headache, broken glasses, and an unsightly wound site, I had gotten off lightly … except that my forehead seemed a bit puffy and red by the end of the following day.  The swelling increased gradually, and on the fourth day, I awoke to find my face so swollen that I looked rather like a lion.  I visited the wellness nurse on staff, who was mystified and alarmed; she recommended that I call my PCP’s office and ask to be seen.

My initial call to the office was routine; I described my problem and requested an appointment, but “We’re getting slammed,” the clerk stated.  I was told a nurse would call me within the hour to assess my issue and advise me.  Leaving no stone unturned, I also used the patient portal contact screen to describe my problem and request an appointment.

An hour and a half later, I had not received a call back.  I phoned in again, but did not reach the same clerk.  I described my unusual swelling (which was continuing to worsen.)  After I had painstakingly recounted the sequence of events, the clerk said, “I’m sending the nurse a text, and you should hear from her shortly.”  That didn’t happen.

About this time, my husband, staring thoughtfully at my puffy red face, said, “You know, this is the way you look when you get stung by a bee or wasp.”  Bingo.  That sent me to the computer to Google “Hibiclens reaction,” and there it was: chlorhexidine gluconate (an ingredient in numerous preparations) could cause side effects such as rash and swelling; anaphylactic shock and death were also possible reactions.  We consulted a pharmacist at a nearby drug store, who recommended that I use sterile saline solution alone.

At the dinner hour — ten hours from my original contact — a nurse from the PCP’s office finally called.  “The doctor said that some swelling is only to be expected, “ she told me condescendingly.

My report of extreme swelling had been passed through too many layers, like a game of Telegraph, in which the original message becomes distorted or drained of significant details by the time it reaches the intended recipient.  Patient records include social history — age, educational level, known allergies — that should have alerted someone to the fact that I would have been unlikely to call about a minor problem.  Had my allergic reaction escalated, the consequences might have been dire.

As with the original accident, I was lucky it hadn’t been worse.

Elaine Walizer is a retired special educator and co-author of Building the Healing Partnership: Parents, Professionals, and Children with Chronic Illnesses and Disabilities.

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