Sometimes the stars align and people come in at just the right time … and because of the circumstances I do something I normally wouldn’t do.
Sister StuffyNose lucked out.
Now that cold season is officially upon us, we’re seeing lots of patients come in with runny noses, scratchy throats, and coughs. I know that the symptoms suck, but there’s not a lot I can do to cure them. If the cough is really bad, I’ll give a few days of cough syrup with codeine. When I catch a cold, I use my sinus rinses, some generic Afrin nasal spray, and my Ricola (Ree-co-laaaa) throat lozenges. I break out the salt water gargles if the throat gets really sore.
Sister StuffyNose wanted something for her sinus pain. Her nose was running a little bit and she had a cough, but that sinus pain was really getting to her. I examined her and there wasn’t much more to it than that. She had the same thing that half of the people in the waiting room had. Those in the waiting room that didn’t have it by now were going to get it soon.
But Sister StuffyNose was different.
“I know it’s an infection,” she stated matter-of-factly.
“Fortunately for you, you don’t have the signs of a sinus infection,” I replied in a tone that was calm even for me.
“Even if it’s not an infection now, it will turn into an infection soon. It happens all the time.”
Ahhhh. The prophylactic antibiotic angle. She wants antibiotics to sterilize her snot. I did my best to explain that antibiotics were not medically indicated.
“You know that inappropriate use of antibiotics contributes to the growth of MRSA. Besides, there was a study published last year showing that antibiotics are ineffective in treatment of sinus infections. Antibiotics won’t help.”
“I know, I’ve read all the studies.”
I furrowed my brows at that one. “You’ve read the medical studies showing that antibiotics are useless but you still believe that you need antibiotics.”
“Yes, antibiotics are the only thing that will make me better.”
“Let me get something and show it to you.”
It just so happens that we got a shipment of nasal rinse samples from NeilMed a few days before her visit. Most of the ED staff had snarfed them up the day that they arrived, but we had a few left over. So I figured she’d be the perfect person for a free sample nasal wash kit. I walked out of the room and headed toward the cabinet where we keep samples.
In the 5-10 minutes that I had been in the room, three more patients had registered – one with chest pain – and we got an ambulance call that a suicidal patient was coming in. I grabbed one of the sample kits and headed back into the room.
“Here. Use this. It will help you more than just about any medication you can take for your sinus congestion.”
“You mean that you’re not going to give me antibiotics?”
“Have you listened to a word I’ve said? No. I’m not going to give you antibiotics. They won’t help.”
She started bawling. “If you don’t give me antibiotics I might have to kill myself. I just don’t know what I’ll do.”
“Whoa. Whoa. Whoa. You’re going to kill yourself if I don’t prescribe you antibiotics?”
She looked up at me with a determined face. “Yes.”
On most days, depending on my mood, I might have said something like “Now not only are you not going to get antibiotics, but you’re going to get a three day trip to the state psych facility” or “Since you’re up on all the literature, you must know that some types of bread mold secrete penicillin.” But outside the door I heard the radio go off in the ED meaning that another ambulance was on its way in. A different suicidal patient would be here any minute and we were too backed up at the moment to play games.
So I caved.
“Fine. I’ll give you a prescription for penicillin. You’ll need to see the on call physician if you’re having further problems. And I recommend that you see a psychiatrist, too. Killing yourself is not something to be joking around about.”
“Thank you, doctor,” she said with a smug look on her face.
I walked out of the room and wrote out a penicillin prescription. Doing so made me feel like a schmuck. As if I was giving up my morals because of Sister StuffyNose’s idle threats. “I’ll remember her next time,” I thought to myself.
Then something else struck me.
I marched back into the room. She was putting on her coat. I reached over onto the bed and grabbed the sinus rinse sample.
“Since the antibiotics are all that helps your sinus congestion, I guess you won’t be needing this.” I stuck the box in my pocket and briskly walked out of the room, my coat tails flapping behind me.
I know … immature.
But darned if I didn’t feel better about writing that penicillin prescription … for six pills.
Hmm..
Maybe a grade-school recess reaction.. but I think EXTREMELY appropriate.
Grr..
Oh.. and do your coat tails make that cool ‘FWAPPING’ noise?
And if she developed a resistant bug infection guess who is she going to blame. I can almost hear her whinning…”but you’re the doooctorrrr”
Geez, I wonder if people are ever going to stop going to the ED for stuff like this. EMTALA is great in some ways, but it also really sucks sometimes (e.g., for people going to ED for abx).
I wish there was a way to turn these people down, tell them we’re busy, and to follow up with a PCP. If they don’t have a PCP or can’t afford one, we should just refer them to the health department.
Or something.
Think about this.
There’s a lot of countries where you can get almost anything over the counter, no prescription needed. Yet, you don’t hear people dying left and right from overdose, etc. So maybe thats the solution here too. People will not use the ER(ED) for minor things if they can get their meds without an RX.
Case in point is this lady. She does not want medical advise, she just wants her antibiotic… or she’ll kill herself. It’s want over need.
Give them what they want, they can read and are not stupid, as the court would want them portrayed, to make us liable for everything.
Government should get out of people’s lives.
I agree that we need to have less of a “nanny state,” but I’m not sure that allowing free access to antibiotics is a good alternative, either.
While it would be nice to be able to get everything except controlled substances “over the counter”, antibacterial resistance from overuse of antibiotics for “colds” like this would probably soar. We have enough of a problem with resistant bugs.
Then again … it’s not like we’re doing a great job of limiting antibiotic use now.
I have to applaud that you only sacrificed your morals to the tune of 6 pills. AND you took back the sinus rinse. Immaturity is irrelevant. Wish I could have seen her at the pharmacy…
That dang sinus rinse thing is the best thing I have ever purchased. Wish I had done it years ago. I bought one three days ago and for the first time in months i do not have a sinus headache and can breathe through my nose. A miracle.
Ah – the “spineless jellyfish moment” that we all find ourselves with. At least you gave the most benign and least expensive one.
i’m stuck staffing the ed today with a uri.
my rule today: if you’re less sick than the doctor, no antibiotics for you!
Oh yeah, I love these. I usually tell them no, and they get mad, and storm off. The problem is sometimes they complain, and then you spend time explaining to some administrator who knows nothing about medicine, but is so concerned about their press-ganey numbers, that it was NOT indicated.
I would likely have told her that she could leave, without antibiotics, or if she really wanted to pursue the “kill myself” angle, we could certainly place her on a hold, and have her evaluated at a psychiatric institution.
I rarely cave on these, but I can see where you were kinda stuck with the other cases coming in.
I find that trying to educate them is sometimes just plain exhausting! I hate giving in too, but when the ED is crazy, it isn’t worth the time. Drug seekers are similar…give them a shot just to say I adressed their “pain”, so that I can legally get them out. Sucks. Anyone ever truly see a Torodol or Ultram allergy???
This was a horrible approach with this patient.
If you’re going to stand your ground, stand your ground. If not, just give them the abx from the get go. But never should you go back and forth until they throw a big enough tantrum, then cave in.
What did this pushy patient learn from her ED visit? If I’m pushy enough, the doctor will give me what I want. Just push harder when need be. Next time she will be even worse.
The arrogance of these types of patients really gets under my skin. YOU COME TO THE DOCTOR FOR A MEDICAL OPINION, NOT AN ANTIBIOTIC. And my favorite line is, “I know what happens when I get sick like this, I really need the antibiotic”. The implication being they have such a unique presentation of a common disease, and their own personal experience with being ill once or twice a year trumps the physician who sees countless patients every day with URI symptoms. Give me a break.
I’ll admit to occasionally caving to people, but if I do I do it early on and tell them, “this is probably NOT bacterial but if your symptoms worsen or don’t improve, you’ll have the prescription just in case. Don’t fill it just yet because you probably don’t need it and you’ll be wasting your money.”
Somehow, “wasting your money” seems to resonate with them more than an hourlong lecture about viral vs. bacterial infections.
“Wasting money” doesn’t have as much meaning when one doesn’t have one’s “skin in the game”
Suicide is the ultimate antibiotic.
Prophetic as usual.
have to agree with erdoc. even though i am practicing medicine half the world away in malaysia, i too get a lot of patients like this one. to make matters worse i am an infectious disease physician so u can imagine the moral dilemma i can find myself in. prescribing an antibiotics for a viral infections just goes everything that i have learned throughout my training! i have to fess up that i have caved before and felt miserable for a good few days afterwards.
I think that placebo meds should be made legal again just for these instances.
ERPAC, The only allergy to Ultram I’ve seen is if one is allergic to codeine you can have the same symptoms. It happened to me and my mother. The pharmacist told her to never take Ultram with a codeine allergy.
WC..do you by any chance have any stats on the incidence of resistant bugs in Mexico, or other countries where antibiotics can be had over the counter? I have a feeling the incidence is higher here where we try to sterilize every freakin’ things around us. I don’t know the answer to this but be interesting to know. thanks..
HyperAl, perhaps we also ought to be asking the question of whether any of the superbugs we see in hospitals are brought in via EMTALA immigrants from countries where abx are OTC.
Good point. However, if that is the case then the ED should be full of superbugs since it is the gateway to most of these patients and I don’t think that is the case. I also have not heard of a WHO alert, that superbugs are a big problem in these countries. Be good to know.
To answer my own question:
http://www.wpro.who.int/NR/rdonlyres/3EA2DBBF-28EB-4718-8893-E608738BD2F0/0/RC5309.pdf
Why not make everything that is only harmful to the patient OTC – opioids, benzodiazepines, et cetera. Require a triplicate prescription for antibiotics (as New York does for controlled substances).
ERPAC,
Why do you desribe antibiotic drug seekers as different from other drug seekers? They are there for drugs they do not need. They will manipulate to their heart’s desire to get their fix.
Shadowfax,
If only we could get the viruses to commit suicide.
What an idiot! If she read all the studies she should know that the nasal rinse is FAR better and works wonders for sinus infections. Not to mention she is risking a very annoying yeast infection for meds that arent going to work anyway. Love my neti pot!
I hate my sinus rinse. I had a FESS/septoplasty back in November and using the Neil Med rinse regularly for 2 months is part of my doctor’s aftercare process. I absolutely cannot stand the feeling of water in my nose. But I gotta admit that it helps my sinuses stay clearer, so I use it anyway. But man, do I dread those twice daily rinsing sessions. Bleh!
Also, if most antibiotics don’t work on sinus infections why would both my PCP and ENT prescribe multiple courses of Augmentin? I’m not a drug seeker, but I did at one point ask if there was anything else I could take for my chronic infection because it felt like the Augmentin only caused minor improvement, if any. Hm.
Who in the world said that antibiotics don’t work on sinus infections??
Dr. Kranky says:
January 21, 2009 at 11:38 am
Who in the world said that antibiotics don’t work on sinus infections??
Umm, about every study done on sinusitis in recent years has said antibiotics have little to no benefit over ‘standard’ care and of course have some harm (abx-associated diarrhea, C-diff, nausea, and of course resistance)
I’m glad you posted about the sinus rinse. This week sinus nastiness began for me, but I was able to say to myself, “Ah, WhiteCoat just posted about this! I’ll try out the nasal rinse that he mentioned!”
Thank you!
Antibiotic resistance is a bad thing:
Sometimes, Death Is Good- For A Vicious Unicellular Microorganism
There are a variety of different types of foreign bacterial infections one can get from many different sources, yet some are more common than others. If they are not beneficial for your physiology, they all should die in order to restore your health.
Bacteria are a simple life form, yet are incredibly productive and efficient. As with other life forms, it exists to reproduce. To do this, it fully utilizes all available resources and energy to develop the protein that is essential for its survival, and bacteria have the ability to adapt as needed to assure this happens.
It needs exactly 7 genes to produce the essential ribosomes for this to occur. Any more or less genes than 7, the bacteria is not maximizing its efficiency to survive and reproduce. Amazing.
Strept infections are caused by what are called gram positive bacteria, and are unique that these bacteria grow in pairs. Staph bacterial invasions are gram positive as well, yet it is the MRSA, Methicillin Resistant Staff Aureous microbes of this type often are very difficult to treat normally when a patient suffers from their damage from being invaded by these bacteria. Another difficult situation is when a patient is infected by VRE, Vancomycin Resistant Enterococci, as well.
These MRSA and VRE pathogenic or disease causing bacteria are the ones that are the most clinically concerning for the health care provider.
Group A strep infections can cause diseases such as strep throat and pneumonia. Since there are several types of bacteria, a diagnostic test called a culture and sensitivity is usually performed to assure the correct antibiotic is selected for treatment, as the bacteria are identified with this method.
Typically, fluid from the area suspected of being infected is obtained from the patient suspected to have an infection and smeared on what is called a petrie dish. And then these dishes are incubated for 2 to 3 days. Gram positive bacteria stain during this process a dark violet or blue. Gram negative bacteria would be pink in color, and are capable of harm as well to a human being.
When the culture is complete, technology offers recommendations on the appropriate class or brand of antibiotic for this bacteria present in another person- presuming the bacteria will not be resistant to the antibiotic recommended, as this happens on occasion.
Usually, classes of antibiotics that are used to treat gram positive strep infections that are not VRE or MRSA are cephalosporins, macrolides, or general penicillins. If the microbe that is causing the infection is resistant to the antibiotic from such classes that are administered to the infected patient, particularly with methicillin and vancomycin, which is the case with VRE and MRSA bacteria, then there are other more aggressive antibiotics that will be chosen for this patient.
Such brands and types of antibiotics for MRSA and VRE bacteria include Zyvox, which has both IV and oral dosage options. There are also other antibiotics, such as Cubicin. However these antibiotics for antibiotic resistant bacteria are given usually due to infections that have progressed to a more serious nature within a patient infected in such a way.
Progressive medical conditions include sepsis, or blood infection, osteomyelitis, or bone infection, or Pneumonia, which is a serious lung infection. A hospital stay is normally required with such patients, as the last antibiotics mentioned for MRSA and VRE bacterial infections are given by IV administration initially for several days, if not several weeks.
There are numerous classes and types of antibiotics available, yet bacterial resistance to most of these antibiotics constantly remains serious concern for the health care provider, and the infected patient, with MRSA at the top of the list of concerns for the health care providers.
Dan Abshear
Very nice information. Thanks for this.its great to see someone with a like mind.