A mom comes to the emergency department at 5:00 AM with 4 children in tow. She wants to be evaluated for …

An insect bite to her neck.

Yes, the emergency was a mosquito bite about the size of a dime that was causing her to itch the side of her neck.

I looked at her, looked around the room to make sure that I wasn’t being Punk’d, then told her “Yup, it’s a mosquito bite.”
“What am I supposed to do?”
[Second look around the room, just to make sure I didn't miss any cameras.]
“Ummmm … put some ice on it. Maybe put some hydrocortisone cream on it. It will go away. Trust me.”
“I also want to be checked for diseases.”
“I don’t understand.”
“Mosquitoes have diseases and I want to be checked to make sure that I didn’t get any of them from this bite.”
[After a quick glance behind the door] “Which exact diseases would you like to be checked for?”
“I dunno, you’re the doctor.”
“Maybe that’s something you can take care of at the public health department when they open … in 4 or 5 hours. We don’t routinely do those tests in the emergency department.”

She left upset.

The best part of the interaction was a comment from the nursing supervisor after the patient left.

“You could have at least told her that she didn’t have encephalitis.”
“I could have told her she didn’t have any diseases, but I couldn’t prove it,” I replied.
“You could prove that she didn’t have encephalitis.”
“Not without doing a lumbar puncture or blood tests. Besides, nothing is going to show up that early, anyway.” I was too irritated to see that I was being set up.
He nodded his head smugly.
“OK, smart guy, how can you exclude an inoculation with encephalitis based solely on a clinical exam?”
“Simple anatomy. In order to have encephalitis, you have to have a brain.”

Oooh, you’re good.

I love my job.

A patient comes in because she “doesn’t feel good” and because she gets these “waves” through her body and feels that her implanted defibrillator/pacemaker is malfunctioning and shocking her.

She’s been seen in her doctor’s office, in the cardiologist’s office where the defibrillator was interrogated and found to have discharged twice in the past week, and in the emergency department twice for the same symptoms. Each time her exam was normal and the labs were normal except for a minor elevation in her cardiac troponin that remained stable throughout the week. The cardiologist attributed the minor elevation to the discharge of the defibrillator. Since troponin can remain elevated up to two weeks and since serial troponin draws were stable, the cardiologist wasn’t concerned.

Back again for the same complaint. She showed up while I was busy with another patient and the nurse reflexively ordered another set of standard labs – CBC, metabolic panel, cardiac enzymes.

An hour or so later, I get a phone call. The secretary says that it’s the lab tech and they want to speak to me right away about a critical value.
“Dr. WhiteCoat, this is Sue in the lab. The potassium on Deborah Peel is greater than ten.”
“Whaaaat?”
“Deborah Peel’s potassium is greater than ten. Can you read that value back to me?”
I looked at Deborah Peel’s monitor. Paced rhythm of 60. Normal.
I had the nurse look at Deborah Peel in the room. Watching TV. Upset because she has now had to wait an hour and a half for me to try to decipher what “not feeling good” actually means.
The normal range for potassium is from 3.5 to 5.1 mEq/L in our lab. The highest potassium I’ve seen in a living patient is 7.6 mEq/L. That patient was on dialysis and was “just too busy” to go to the past few sessions, so came to the ED at the end of the week for emergency dialysis. Saw a potassium level of 8.1 on a patient that was brought in with a full arrest. But “greater than ten” is a new record!
About this time I’m thinking to myself that either I’m on my way to a case report published in the New England Journal of Medicine … or … the lab is screwing something up.

“Did you verify that?” I asked.
“Yes. There’s no hemolysis. Can you repeat the lab value back to me?”
This whole “repeat the labs back thing” is another JCAHO requirement with good intent that serves no purpose. Bugs the bejeebers out of me. Yeah, I understand English. No, I don’t have auditory dyslexia. I got it.

I messed with her a little.

Deborah Peel’s bicarb is greater than ten.
“No! Her potassium is greater than ten!”
“Her potassium! Are you kidding me!?!”
“No! Now can you read that back?” She was getting peturbed, so I relented.
[Sigh] “Potassium greater than ten. Please send someone to redraw patient. Can you repeat that back to me?”
[Click]
Spoiled sport.

But it doesn’t end there.

Miraculously, after about 30 minutes, we get a printout from the lab stating that the repeat potassium value was 4.2. Damn. There goes the New England Journal of Medicine. At least I don’t have to insert an emergency Quinton catheter.

Then we get a report of the entire metabolic panel. It stated that the original reported potassium was 4.2 — normal. Suddenly the panic value of >10 had disappeared.

I called the lab to request the original report with a value of >10 to be sent and then a corrected report with the normal value to be sent.
“The first value was run on a backup machine and I don’t have a printout of it, so I have to enter the printed value.”
“But I ordered a second potassium level and the patient will be charged for it. You entering a normal value makes it look like I ordered the level for nothing.”
“I’ll credit the patient’s account, then. Nothing more I can do. Sorry.”

Dealing with this separately with the administration.

It’s just scary that Happy Hospitalist and ER Stories both had similar experiences with funky lab values within the past couple of weeks.

I did notice that one woman on Yahoo Answers! was alive and typing with a potassium level of 28.2. Now that thar’s some potassium for ya.

It’s an epidemic, I tell you.

Picture credit of potassium metal here

A patient with chronic back pain (clue #1) limps in (clue #2) from out of town (clue #3) clenching copies of a report of a lumbar MRI from a couple of years ago (clue #4), requesting refills of Dilaudid (clue #5) since he ran out of a 30 day supply in a little more than 2 weeks (clue #6) because his pain was so bad. Apparently the Valium (clue #7), Norco (clue #8), and methadone (clue #9) he absent-mindedly forgot to mention that he was also taking (clue #10) just weren’t staving off the pain.

Of course, the first thing the nurse did was call the hospital in the town where he lives. Yeah, they know him (clue #11). Yeah, he had an MRI of his back done a month ago. Send us a release and we’ll fax the report to you.

Trudge back into patient’s room and give him a records release to sign.

“Why do you need to see my records from another hospital?” (clue #12)
“So we can determine how bad your back is doing.”
“If this doctor screws up my back any worse, there are going to be problems.”

Lumbar spine MRI report shows mild disc bulge at L5-S1 level, but is otherwise normal (clues #13-#18 – one for each level of the lumbar spine).

I’ll wait while those of you who fainted recover consciousness and splash water on your faces …

[whistling Jeopardy song, checking e-mail, stretching out back]

OK, ready to continue?

Meanwhile, I examine the patient and he fails all of the tests that doctors use to tell when a patient is faking back pain. I won’t describe them here because I don’t want this to turn into a manifesto on tricking ED physicians for drugs and profit, but suffice it to say that there are a half dozen of such tests and this poor chap didn’t pass one of them (clues #19-24).

I walk back into the room after learning of the MRI results and tell the patient “Gee. I’m sorry, but I’m not comfortable prescribing any more narcotics to you since you’re back is in better shape than mine and since you’re already overdosing on several narcotic medications as it is.”
“You mean you’re not going to treat my pain?”
“Oh, sure. Here’s some ‘prescription strength Motrin’ for you.”
[sarcastically] “Gee, thanks.”

As the nurse was discharging the patient (whose gait had remarkably improved upon receipt of his prescription for ‘prescription strength Motrin’), he told her:
“That’s why he became an ER doc – because he doesn’t know jack shit.”

… except how to separate drug seekers from the objects of their affection.

Just smile and wave, boys. Smile and wave.