This has happened twice to me, but I’m learning …
The first patient was several years ago. She came in with headaches. Her blood pressure was 220/110. The headache wasn’t an issue. The patient hadn’t taken her blood pressure medications that day and had a history of headaches. There was no change from prior headaches. We gave her pain medications, gave her the dose of clonidine she was supposed to be taking, and she felt better. Her repeat blood pressure was 176/96. I told her that she really needed to take her medications every day and that she could follow up with her family doc later that week for a blood pressure recheck. Then I discharged her.
Forty five minutes later, she was still sitting in the room talking with the nursing supervisor.
Then the nursing supervisor asked me if I felt comfortable discharging the patient.
Yes, yes I did.
Wasn’t I concerned about her blood pressure and her headache?
No. Her blood pressure was improved to the point that she could be discharged and her headache had resolved. She was stable for discharge.
Afterwards, I saw the nursing supervisor make a phone call, then go back in the room, then leave.
I went back in and asked the patient if there was a problem.
“No, no problem. We’re leaving.”
Then the family member in the room said “We’re going to another hospital like the nurse said. Her blood pressure is much too high for her to be discharged.”
I asked them to wait a moment while I tracked down the nurse and the supervisor.
The nurse had finished her shift and left the building, and by the time I found the nursing supervisor, the patient had left.
Lots of meetings after that incident.
Then it’s deja vu all over again.
A patient comes in with the worst headache of his life. Those are the words he says to me as soon as I walk in the room. Never had headaches before, bent over to pick up garbage and headache began. Hasn’t let up in over 8 hours. Radiates into his neck.
I already know where this visit is heading.
He got three rounds of IV pain meds and his pain was still in the “severe” range.
We ordered an “unnecessary” CT scan. After all, it came back normal.
Then I go to explain the necessity of a lumbar puncture.
Fortunately for the patient, his mother in law was a nurse educator at the nursing school in town. He ran the case by her and she said that a lumbar puncture wasn’t appropriate since it wouldn’t tell us anything that we don’t already know.
I told him about pseudotumor cerebri and meningitis and the subarachnoid bleeding that CT scans sometimes don’t pick up.
The patient’s nurse then said that MRI will see the things that CT scan doesn’t … including bleeding.
So I go to one of the textbooks and copy one of the pages showing that CT scan is much better than MRI at picking up subarachnoid hemorrhage. I give a copy to the patient and to the nurse. Her response was that I was being “vindictive.”
At that point, I threw up my hands. I told the patient that if he didn’t want the test, I’d be forced to admit him to the hospital for monitoring. If he didn’t want that, he’d need to leave AMA. I told him my concerns with him doing so and asked him to come and get me if there were any other questions.
Twenty minutes later, the patient told me that he decided to go against the advice of his nurse educator and his nurse and he reluctantly agreed to the lumbar puncture.
His pressures were on the high side, but normal.
Cell counts … one WBC. Three RBCs.
“See,” the nurse said, “no blood.”
However, the CSF protein was twice normal.
“So what do you think of the protein, then?”
“You’re the doctor. That’s why you get paid the big bucks.”
Now the differential diagnosis of elevated CSF protein is large and includes infections, tumors, abscesses, multiple sclerosis and bleeding. The problem was that acute severe pain isn’t a typical finding in tumors, abscesses, or MS and that it didn’t look like an infection based upon the CSF results.
I called the neurologist to discuss the case. She thought the patient had a small bleed and that the blood had broken down, causing the elevated protein levels. She recommended that the patient get an MRI/MRA.
So we were able to get the patient in for the test a couple of hours later and the patient ended up having a small dural tear. Oh yeah, he forgot to mention that he was in a car accident a couple of days earlier. Wasn’t having any pain from it, so didn’t’ think it mattered.
And the patient’s nurse reminded me that if I had just listened to her, I could have saved the patient a lot of time in the emergency department and he wouldn’t have had to go through cost and risk of a lumbar puncture.
It was then that I realized that the nurses are always right.
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.