■ 11:28 AM
The nurse from the general surgeon's office in Clifton calls to say that the surgeon did accept my consult from yesterday and performed the biopsy. This patient is a 43-year-old woman who presented to the clinic with a nonhealing skin lesion on her upper lip. She has a 23-year smoking history and stated that she has battled "this thing on my lip" for about a year. The scaling, ulcerated lesion had irregular borders with thickened edges and seemed highly suspicious for malignancy. Squamous cell carcinoma is our working diagnosis, pending a pathology report.
■ 12:15 PM
I get away for lunch burdened by the same trapping question: Mexican again, barbecue again, or Subway again? Whatever I choose, I will probably see four or five familiar faces, at least one of whom might ask me to look at something under his or her arm, or ask me about his or her sister-in-law's recent lab work, a request I politely overlook. To some degree, a clinician is never off work in a rural setting. This has taught me to closely guard my personal cell phone number.
■ 2:13 PM
After more walk-ins, I find myself in a now-familiar struggle to incorporate my Spanish language skills into an office visit with a Spanish-speaking patient. This occurs more and more often because I have established a rapport with our surrounding Spanish-speaking population. This patient is a 2-year-old boy with fever and a runny nose, and he is pulling at his left ear. I ask his mother, "¿El tiene dolor en el oreja, verdad?" (He has pain in his ear, correct?) "¿El come y toma normalmente?" (Is he eating and drinking as usual?) "¿Cuánto tiempo ha tenido él fiebre?" (How long has he had a fever?) The physical exam provides evidence of otitis media in the left ear. I write the young patient's prescription and instruct the mother, "Dos cucharaditas dos veces al día durante siete días" (Two teaspoons twice a day for 7 days), and off they go.
■ 2:45 PM
A new-patient walk-in presents with a distressing list of complaints. The 45-year-old man is complaining of diarrhea, fatigue, gradual weight loss, foot pain, and "sticky urine." He also mentions increasing numbness in his lower extremities. He has no regular medical care. He appears borderline malnourished but his physical exam is otherwise unremarkable. A quick urinalysis is significant for glucose, protein, and ketones in his urine. A random blood sugar check shows
351 mg/dL. I consult with my supervising physician and concur about the need for urgent intervention. The patient agrees to report to the ED by personal transport, and his arrival at the ED is confirmed within 30 minutes.
■ 3:32 PM
My next new patient is a referral from the local dentist. Something about a BP of 228/140 made the dentist a little leery of performing the scheduled tooth extraction. The 63-year-old man has a history of alcoholism, drug abuse, and traumatic amputation of the right upper extremity. He has not been seen by a medical professional in "years." Despite my counseling him in regard to the possibility of stroke, he refuses my advice to take EMS transport to the nearest ED. After taking 0.2 mg of clonidine, his pressure falls to 180/110. I prescribe labetolol, 200 mg twice a day, and tell him to come back in the morning. But I continue to insist he report to a more capable acute care facility. Sometimes that is the best I can do.
■ 4:24 PM
The afternoon wears on with more walk-in patients coming from school and work for whatever need. I complete a UIL physical for a 12-year-old girl who waited until the last day to have her physical. A sick 7-year-old boy makes his way to our "pedi" room in the arms of a tired mother. Shortly after those two, I perform a quick suture removal on a 43-year-old carpenter who lacerated his hand last week.
■ 5:45 PM
I finish up patient charts and return phone calls, report lab results, make med changes, and offer suggestions about lifestyle modifications. Before calling it a day, I check with
the ED on my hypotensive patient from earlier today. He has been taken by helicopter to a Dallas/Fort Worth hospital for treatment of a Dieulafoy malformation that spontaneously erupted the night before. He received a few units of blood during his transport and is now stable and being prepped for endoscopic cauterization. Just when I think I am about to treat just another runny nose, someone with a life-threatening condition walks through the clinic door.
■ 6:10 PM
I can see cows grazing from my office window as the sun descends on another day. This is a scene I had envisioned when I took this job, which I accepted against the better judgment of one of my faculty advisors from PA school. Sorry, Mr. Diemer! The view of this rural backdrop, now partially obstructed by my shoes (no cowboy boots yet) propped up on my desk, is an ever-present reminder of how important the need for health care is in rural areas across the country.
I am finding that serving as a PA in rural medicine is an
exciting and rewarding challenge. JAAPA
Tim Sayles practices in rural medicine at a certified rural health clinic in Meridian, Texas.