thefictionvixens Chapter 31 Small Temple, Big Wind
Chapter 31 Small Temple, Big Wind
Chen Yisen understood the key point after only a moment's thought.
The vast majority of community doctors are not actually directly employed by NYC H+H, but rather sign contracts with a company called Physician Affiliate Group of New York (PAGNY) and are then "assigned" to various clinics.
In other words, it's outsourcing.
Although I went through a “relocation” process at the end of my residency, I am still legally directly employed by NYC H+H.
This is why the original owner of this body resolutely refused to resign and run away even after being abandoned in the community.
In the entire Morissania clinic, only he and the medical director held this position.
To his colleagues, Chen Yisen was a fallen phoenix, an outsider whom they envied.
For the medical director, Chen Yisen was the only doctor in the entire clinic who wasn't entirely under his control.
Being isolated is perfectly normal.
On the contrary, the less conspicuous administrative and logistical staff, such as Fausto Cunhaer, although not belonging to the same union as Chen Yisen, were still direct employees of NYC H+H, so their relationship was okay.
After figuring this out, Chen Yisen completely stopped internal conflict and even deliberately increased the range of motion when preparing.
LOL, I love this feeling of you guys disliking me but being unable to do anything about it.
Of course, this awkwardness is just something to do before officially starting work.
After the clinic opened, everyone was so busy they were spinning like tops, they didn't have time to think about these things.
Take Chen Yisen for example.
The first patient he encountered was an exceptional individual.
"Dolor de pecho... Me arde el pecho!"
As Shanis helped the elderly man, who looked to be at least sixty years old, into the consultation room, he was muttering something that Chen Yisen couldn't understand at all.
have to.
This is a Bronx specialty.
An elderly Dominican man who doesn't speak English.
One of the most troublesome patient types.
According to the law, medical institutions are obligated to provide professional translators for patients who have language communication problems.
In practice, however, the clinic only had three professional Spanish translators, and even if they talked themselves hoarse, they couldn't keep up.
Therefore, they can only rely on local nurses or medical assistants who are fluent in both languages.
Fortunately, Shanis was one of them.
He said he had heartburn and something was coming back up from his stomach.
He then whispered in Chen Yisen's ear, "Dominicans often eat fried plantains and a special kind of sausage, so they have a high rate of stomach problems."
"Hmm." Chen Yisen nodded, but did not prescribe the medicine immediately.
Heartburn caused by acid reflux is easy to treat. Just take some proton pump inhibitors and antacids, and pay attention to a bland diet.
However, based on his experience, many patients, even those with a certain level of education, cannot distinguish between "heartburn" and "upper abdominal pain".
Especially when accompanied by acid reflux.
Considering the patient's age, he had to first rule out the most dangerous possibility—acute coronary syndrome.
It's a type of myocardial infarction.
This doesn't mean that Chen Yisen has any extraordinary sense of responsibility.
In reality, due to limited resources, community clinics often have to make trade-offs between efficiency and accuracy.
Pursuing accuracy for a single patient may not necessarily lead to good overall results.
As a result, dozens or even hundreds of people die every day in the Bronx due to missed or incorrect diagnoses.
But this kind of thing is a classic case of something that weighs less than two ounces on the scale, but weighs over a thousand pounds on the scale.
He was almost certain that the old man hadn't been automatically assigned by the system.
Instead, someone is deliberately targeting me.
There was a doctor in the next consultation room who was fluent in Spanish, so logically, such patients should be assigned to that doctor first.
Since he might be being watched, Chen Yisen naturally had to be extra careful.
Otherwise, if the patient dies of an acute myocardial infarction shortly after leaving home, he could be in serious trouble.
It's important to know that Morissania is by no means the worst community clinic in all of New York.
"Take his blood pressure," Chen Yisen said to Shanis.
The latter, who was in charge of the lobby, was incredibly skilled and quickly secured the blood pressure monitor.
"Let's do a 12-lead test, V3R, V4R, and V5R are all needed," Chen Yisen added.
At the same time, he also took his stethoscope and measuring ruler and came to the examination bed.
Shanis, while keeping an eye on the blood pressure readings, replied somewhat strangely, "The clinic's 12-lead CPAP machine broke down last week, and the new one is still in the procurement process... Didn't anyone tell you?"
Chen Yisen paused for a moment, then remembered that there was such a thing: "Oh... I thought I had already bought a new one."
Shanis complained helplessly, "The clinic isn't the big hospital where you used to work, Dr. Chen. Ordinary consumables are fine, but when it comes to equipment that needs to be registered, the process takes at least half a month... And the training for our clinic's nurses only covers the standard twelve-lead, I'm afraid no one knows how to do the right chest part."
Chen Yisen felt his vision go black.
The examination could be completed by a mobile medical unit dispatched from Bellevue, yet this large community clinic with an emergency care center had neither the equipment nor the personnel to perform it.
Fortunately, the symptoms of acute coronary syndrome are quite typical, and as long as the coronary artery connectivity can be observed, it can be confirmed or ruled out.
As we were talking, the blood pressure monitor had already displayed the results.
83/55 mmHg.
Normally, acid reflux would not cause such a significant drop in blood pressure.
Chen Yisen became even more convinced that his caution was correct.
"If you're worried about an acute myocardial infarction...would you like to have a bedside troponin test?" Shanis suggested.
This made Chen Yisen look at him in a different light.
Based on his request for a V5R 12-lead test, we could deduce that he suspected an acute myocardial infarction, and then we thought of testing his troponin levels.
Okay.
But it still lacks a bit of finesse.
This old man's symptoms are at most just beginning to appear; his troponin levels may not have had time to rise yet.
If you get tested now, you might get a false negative, which could be misleading.
"Go over there first and raise the head of the bed by 40 degrees." He did not directly respond to the other party's suggestion, but instead gestured for the other party to raise the bed. He then went to the right side of the patient's head, and by moving the examination light to the vicinity of the patient's neck, he placed his palm below the xiphoid process (level with the lower edge of the tenth thoracic vertebra, the upper boundary of the upper abdomen) and activated [electrical impedance tomography].
For male patients, there's no need to worry about whether to touch the chest or the back.
The heart inside the chest cavity appears to be beating strongly and powerfully.
However, throughout the entire cardiac cycle, the right ventricular region did not show any inward shrinkage of its boundary; instead, it remained a high-resistance region with blurred boundaries and almost complete stillness.
Although the impedance detection could not determine the internal details further, it clearly meant that the right ventricular wall motion had disappeared.
Chen Yisen continued to extend his palm from below the xiphoid process towards the diaphragm of the heart.
This angle allows you to see more details.
The systolic impedance beats of the inferior wall of the left ventricle are asynchronous with the apex and have very small amplitude.
This indicates that the pulsation here is not an active pumping of blood, but rather a constant shaking caused by the pulling of the myocardium in the left ventricle.
Although the high impedance region prevents direct visualization of several key blood vessels.
However, based on anatomical principles, it can be reasonably inferred that there is a major problem with the patient's coronary artery connection.
Inferior wall myocardial infarction, complicated by right ventricular myocardial infarction.
"Dr. Chen, it's all set." Just then, Shanis's voice rang out.
The elderly patient had been lifted into a semi-reclining position.
"What are you doing...?" Shanis asked curiously, noticing Chen Yisen's somewhat strange movements.
"Check the right internal jugular vein." This time, Chen Yisen wasn't deducing from the answer, but genuinely observing using the sidelight of the examination light.
Even with the naked eye, one can observe the internal jugular vein throbbing violently between the sternocleidomastoid muscle and the suprasternal notch.
"Approximately 6cm, with obvious carotid artery distension." Chen Yisen put down the measuring ruler and returned the examination light to its original position. "Jugular vein distension, clear lung auscultation, low blood pressure but no pulmonary edema... the typical triad of right ventricular infarction."
After he finished speaking, he looked at Shanis and said, "We almost made a fatal misdiagnosis."
The latter's gaze towards the hospital bed shifted slightly for a moment, but when he looked up again, it had completely returned to normal: "So, the next step..."
"I'll prescribe him 325mg of non-enteric-coated aspirin for suspected angina. You call an ambulance immediately and prepare for transfer," Chen Yisen continued, choosing the safest option.
Unexpectedly, the patient, who had been lying steadily in bed, suddenly had a violent reaction, trying to sit up while shouting long passages of Spanish.
"He said he didn't want an ambulance, and asked us to give him the referral form so he could go to the hospital himself."
Clearly, the patient can understand English.
I'm just not very good at expressing myself.
Chen Yisen was well aware that, given the old man's condition, going to the emergency room or not wouldn't make much of a difference.
He cannot afford major surgery, and simply taking medication will not help solve the core problem.
However, in terms of procedure, he cannot simply let the other party go.
Chen Yisen pulled out an AMA (Refusal of Medical Advice) form:
"If you refuse the ambulance, then you will need to sign this form."
The old man almost without hesitation prepared to pick up his pen.
But Chen Yisen immediately stopped him and said in a slower pace:
"I need to make sure you fully understand the consequences of not providing first aid. I'll ask you the next questions, and you can either nod or shake your head. Then you need to read out every item on this form, which can be done in Spanish."
The AMA form used in the Bronx is written in four languages, including Spanish.
The exchange proceeded in an extremely slow but smooth manner.
Chen Yisen gradually relaxed.
Until he noticed a detail.
One of the entries in the AMA form mentioned the "breast" area.
The corresponding Spanish translation is "pecho".
And the two sentences the patient shouted when he entered the room seemed to contain such a word.
It's important to know that if a patient's main complaint is chest pain or upper abdominal pain, then Chen Yisen doesn't need to be alarmed at all.
The standard diagnostic criteria require ruling out acute coronary syndrome first.
However, Shanis translated it as "heartburn" or "acid reflux".
In short, it does not include the chest at all.
In an instant, Chen Yisen's entire back was covered in cold sweat.
He was once again impressed by this unassuming young nurse.
This clinic.
It's true what they say, a small temple with a lot of evil spirits...