Long ago I was serving in the Charleston SC County hospital as a surgical intern on my first year rotation.  An elderly man had an open sore on his ankle for me to look at.  I took a quick history, and took a look.  Peculiar looking open sore on the outside of his ankle.  I’d never seen one quite like it.  Round, open, red rimmed, but black in the center.  Weird.  So I got a metal probe and touched the black center.  Then I realized it was something mobile and loose, and INSIDE, under the skin.  The sore was not big enough to get a better look, so I numbed it up and opened the sore up a bit wider.  Out popped the black object.  It was....a bullet!

“That’s not possible, doc!  I ain’t never been shot!”  “Oh, wait…..Yes I was, but that was in my thigh, up here (he pointed), back in ’38.”

Yes.  Incredible, but true.  He had been shot in the thigh, and it had taken about 40 years for the retained bullet to migrate down through under the skin to get to the ankle, where there wasn’t enough room to go further and the pressure of bullet on ankle bone had eroded through the skin.  With a little assistance from me, he was cured of his nasty ankle ulcer.  Well, at least the cause was removed.  Like nearly every ER visit ever, I never learned what happened after he left the ER.  

Come to think of it, how often does the ER get feedback on the patients that are not admitted to the hospital?  Not often at all.  There’s no feedback loop.  It’s a kindness to let an ER doc know when they did a great job, and far more difficult to let them know when they’ve blown it.  Both happen.  Primary care practice is at times no better, but with continuous relationships, feedback loops are easier, and in group practice can be somewhat institutionalized, both good and bad, largely BECAUSE we as doctors WANT to get better.  There’s a reason it’s called practice, after all, and that’s both a joke, and not.

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