A horse stepped on my wife in Ireland. Then things got personal.

That's a W55.12 "struck by horse" for those keeping ICD-10 score at home. We found the nearest clinic where her heel was cleaned, stitched, and bandaged. The whole ordeal took about two hours.

She has a high pain threshold and she isn't one to miss a vacation so she crutched on. She probably overdid it. A few days later it started to look infected. We sent pics back home to an MD friend, my sis (family medicine MD), my mother (PhD, NP) on a daily basis. When consensus on antibiotics was reached I set out to see what I could get my hands on. 

By then we were in Portugal. I hit a local pharmacy and explained the situation. 15 minutes and $13 Euros later, I had what I needed. She kept at it but we were both concerned that keeping the wound covered + heavy walking wasn't helping her cause. 

We returned home just yesterday and I was relieved to be reconnected to a more familiar health system. She saw her PCP the first thing this morning. 

He took an admonishing tone. She needed x-rays. The bone may be broken and/or infected. The skin would need to be debrided to remove necrosis. It would be painful. She would face weeks of healing and a nasty scar. He didn't have the facilities to help her. She needed to go to the ER immediately. 

He asked her if she has seen a dermatologist. She does so annually. Of course, he should have known that. Access to a list of services provided within the same institution was a selling point of his institution's $1.2 billion EMR upgrade. With even less effort he might have discovered the reason why in the Family History section of her record; she has had cancer and she lost her mother to melanoma a few years ago. Instead, he let her know that it was something she should do because her skin has many marks and dis-coloration.

He wrapped things up with a lecture. He does not care for patients that get their medical attention from friends. She explained that we were 3,000 miles away and doing our best to get by. It was not an acceptable excuse. He did offer one comfort. He would be willing to continue seeing her but not if she continued to behave in such ways.

I just returned from spending 5 hours in the ER with her. The Attending conducted his exam. The wound was infected. However, upon inspection of the daily pictures that we had texted to our unofficial medical team, he said it looked as though the antibiotics were doing their job. He would not debride any tissue. In fact, removing the thin layer of skin currently protecting the wound would be counterproductive. The imaging study was conducted per the PCP's order - a good 3 hours of our time there was dedicated to that task. He hadn't seen the results, saw no reason for the imaging but would take a look before we left. He removed two of the seven stitches that were no longer necessary and sent us on our way with orders to finish the antibiotics.

When I'm not on vacation dodging horse hooves, I spend my days building a business that aims to improve healthcare. It's hard. Really hard at times. Family, friends, co-workers, and investors have all placed their faith in this vision that I have sold them - this idea that we can learn from collective past experience on a daily basis. And no matter how many times I'm advised to consider it "just business," I take it all very personally. There have been times when my inability to compartmentalize the frustrations as 'just business,' has weighed heavily on me.

The experience was an unfortunate but helpful reminder that healthcare isn't just business. It never was. It is extremely personal. At many points in each of our lives, it becomes the most personal thing.

I don't know if my wife's PCP was having a really bad day or if he makes a habit of treating patients terribly. We don't bother keeping track of that. I don't know if his recommended services were completely necessary or if they would have led to pain and prolonged suffering. I do know that these decisions are extremely important and millions just like them are being made daily without the benefit of the same type of learning that others employ to more effectively sell books, post ads, or navigate our way through traffic. We can know these things. We can follow up to learn which decisions lead to which outcomes for which patients. We just choose not to. That's personal.

Instead, we invest billions in demonstrating compliance with whatever one size fits all metrics are demanded by regulators or send our teams scrambling to collect enough data to be listed in meaningless award shows like US News and World Report's Best Hospitals. We create 'improvement theater' rather than support our clinicians and their patients and families with the tools and insights to actually improve. It's just business.

Pernille will be ok. Slowing her down so she can heal will be the toughest part. I'm heading back into the grind grateful for the reminder of how personal healthcare is and should be. And that the importance of improving it far outweighs the daily frustrations and burdens of responsibility it places on us.

As for the ER bill, it will be sent along with this letter to my wife's former PCP and his employers. Nothing personal. Just business.

?Update 8/20/19: Three days after visiting the ER, it became clear that the attending's guidance to stay the course was incorrect. The space on her heel where he removed stitches opened up. The rest of the wound worsened also. We needed to do something. Maybe the PCP was right about the more aggressive path. He was wrong about where to send us. He insulted my wife to the point that she didn't feel comfortable relying on him for our next move.

Another MD friend connected us to a surgeon that cleared the dead skin and cleaned the wound on the same day. In the meantime, my wife is now signed up with a new PCP at FireFly Health - a company that I am an investor in and advisor to. Her new PCP examined and thinks we're on the right path. They do telehealth also so Pernille can send pics or video chat so they can keep an eye on this thing.

I can't imagine how hard this must be or how different this experience would unfold for someone without a family of clinicians and a strong healthcare network.