I did not know of any place in the United States that was more than 45 miles from a Walmart until I moved there. Meridian, Texas, the county seat of rural Bosque County, lends itself to large ranches, good people, and a short supply of health care providers. It is a place I've come to know and love. Starting my career in a certified rural health clinic has had significant challenges, but these have been paired with great rewards.
My clinic is home to a licensed vocational nurse, a receptionist, and me. We are governed by a local nonprofit health care foundation in Clifton, Texas, the next town over, which has a hospital, a clinic, and an emergency department. My supervising physician, a true "general practitioner" of nearly 40 years, works in Clifton. He visits every other week to review 10% of our patient charts and is available by phone during clinic hours. I'm sure he knows my voice by heart.
■ 7:50 AM
A typical day begins as I sign off on the results of the lab draws taken the day before. Our clinic does not have a lab, so all my specimens must be sent to the hospital in Clifton for interpretation. I make the appropriate increase to one patient's levothyroxine dosage and confirm my suspicions of iron-deficiency anemia in a young female patient. Fortunately, we have a locally owned pharmacy that appreciates having a provider just as much as the patients do. I send their scripts to the pharmacist and they will be processed shortly.
As I look at my appointments for the day, I see patients scheduled for the typical variety of problems encountered in a family medicine setting: hypertension, return visit with lab for hyperlipidemia, well-child exam, shoulder pain, a new rash, and asthma maintenance.
■ 8:52 AM
I juggle walk-in traffic along with scheduled appointments. In the middle of appointments for acute upper respiratory and urinary tract infections, I have a 9 am appointment with an inmate from the local jail. The inmate has a history of traumatic brain injury and needs follow-up care for his antiseizure medication and hypertension. His Dilantin level is below normal range, and we are trying to get him back up to a therapeutic dose. His BP is adequate and he will be back in the office next week for a lab draw.
■ 9:30 AM
I evaluate a 16-year-old girl with complaints of cough, runny nose, and a sore throat. Her HEENT exam is unremarkable, and her anterior and posterior lung fields are clear. As I begin the cardiac exam, I hear a regularly irregular arrhythmia. The ECG shows bigeminal PVCs. She admits to intermittent palpitations but just assumed that those were "normal." I get some lab specimens, order a Holter monitor, and advise her to discontinue caffeine and any stimulant cough and cold preparations. I plan to see her back here in 2 days, pending the Holter and lab reports.
■ 10:44 AM
As I'm finishing up a well-child exam on a 6-year-old, the nurse signals me out of the room with a look of mild distress and asks me to check the next patient promptly. "His blood pressure is really low," she adds. I enter the room to see a pleasant 56-year-old man, who is alert and oriented with a chief complaint of dizziness since early this morning. He denies all possible causes of trauma, has no signs and symptoms of a GI bleed, and has an otherwise normal physical exam. I do my best to hide my bewilderment that he is conscious, oriented, and conversational with a blood pressure of 80/34. I contact the local EMS and arrange for him to be transferred to the nearest ED with only the diagnosis of dizziness and hypotension.