WhiteCoat

Undertreatment

I was surprised by the tenacity of a mother whose 12-year-old child had twisted her ankle while running in gym class.

The exam showed minor pain and no soft tissue swelling. Perhaps a little point tenderness over the distal fibular growth plate. X-rays showed open growth plates (see orange arrows), but no other injuries. I discussed the possibility of a Type 1 Salter Harris injury and the generally excellent outcomes. I recommended rest, ice, and crutches. Asked the tech to place an air splint on the patient’s ankle.

“She can’t use crutches. She needs a wheelchair. And an air splint isn’t going to protect her ankle well enough.”
“Why can’t she use crutches?”
“The last time she injured her ankle, the orthopedic specialist told her she needed a wheelchair. He wrote her a prescription for the wheelchair. She was in it for at least a month in school.”

I looked through our medical records. No previous visits. Turns out the incident the mother described occurred in another state.

“I can’t comment on what happened before or the reason that the orthopedist believed she needed a wheelchair for a month, but it looks like she’s more than capable of using crutches now. We’ll show her how to use them before we discharge you.”

The patient apparently was on board with the mother’s plan. Even though she could hop on one foot from the wheelchair in the room onto the bed without problems, she nearly fell over twice when they were crutch-training her. One time, she landed on her bad foot and screamed in pain. That sent mom into a rage.

So they got what they wanted. Short leg splint. Wheelchair for two days. Mandatory orthopedic follow-up within that time period.

Then comes the Press Ganey comment several months later.

“Doctor was rude and dangerous. Wouldn’t listen to me when I told him that my daughter needed a wheelchair for her injury. Missed an obvious fracture through both bones on my daughter’s x-ray. Tried to get her to walk on her bad leg and when she did, she fell, causing a worse injury to her ankle.”

Of course, there is no way to respond to these untrue statements. And the complaints are taken as true by hospital administrators.

In retrospect, I probably should have just admitted her and put her in traction for a couple of weeks.

Silly me.

———————–

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.

12 Responses to “Undertreatment”

  1. exi says:

    I’m an M4 applying EM.

    Am I destined to having to deal with that nonsense, or are there still more sensible hospital admin types out there who realize that PG surveys are not gospel?

    • ThorMD says:

      There is nonsense in every speciality.

      The key is learning how to very politely say “no” to people. If you are rude or disrespectful, then they complain. If you are nice, then they don’t complain. Press Ganey doesn’t ask “did the doctor do the right thing”. They ask, “was the doctor nice”. Stupid, perhaps. But the sooner you learn how to play the game, the easier your life will be.

  2. Canuck ER MD says:

    You guys HAVE to get rid of Press Ganey : your Administrator’s NEED to understand that they are not evidence based and mean diddley-squat.

    I am so pleased I practice in a world where the “customer” is not king : I can tell a patient exactly what they need, based on evidence.

  3. Shelby says:

    This is “healthcare reform”.

  4. Felix Kasza says:

    I was going to write the exact same thing that Canuck wrote, except from the patient’s perspective. A hospital is not a f—ing Burger King, and a patient is not a customer.

    And I’d rather have disgusting food than a multi-star chef in the kitchen and a butcher providing the care.

    Oh, and it would be nice if the administrators stopped hiring more administrators and used the money for people actually providing medical care. A truly novel concept, I realise that, and one that will require taking a pruning saw to regulatory agencies, Press-Ganey, and other, like, parasites. But the blood bath in the admnistration sector will be worth it on the medical side.

    • Dina says:

      An RN once said to a pt in my hearing, “This ain’t Burger King and you can’t have it your way.” This was before Press-Ganey, of course. I frequently say that to my husband, but never to my pts – as much as I’d like to.

  5. Brighid says:

    Is it possible she did have a fracture that turned up on xrsy when she visited the orthopedist?

    I ask because my mother, at age 77, fell and hurt her hip. My father called me while the EMTs were trying to get her on the gurney and I could hear her screaming. Everyone was sure the hip was broken.

    Everyone except the ER docs, who told us the xrays showed a silent fracture from the past but nothing current.

    She couldn’t walk on the leg and was admitted for two days for pain control. Then she was discharged with mild pain medication and a prescription for physical therapy.

    She still couldn’t walk on the leg and the physical therapist urged us to get a second opinion. We took her to one orthopedist who said the xrays clearly showed a fracture, but he couldn’t get her on his surgical schedule. (It was Christmas Eve at that point.) We found a second orthopedist who also diagnosed a fracture and admitted her for a hip replacement.

    Three sets of xrays. Three orthopedists (one the consult in the ER) and an ER doc. ER doc was evidently suspicious enough to call for the consult, but not sure enough to override the orthopedist. Consult orthopedist said it was an old fracture (which somehow my mother didn’t notice). Second and third orthopedists both said it was current.

    It’s not always easy for patients to know how to evaluate medical care. But I’d have to give the ER low marks in my mother’s case (although we did not actually submit a Press-Ganey). Whatever the truth about the fracture, they released her in terrible pain and unable to walk. She went into a decline and died about 9 months later. I will always feel guilty about not fighting harder for her in the ER.

    • Ð says:

      hip x-rays can sometimes miss an acute fracture. if a patient can’t walk or has severe pain, he/she will get either a CT or admitted. you said your mom was admitted and an orthopedist was consulted in the ER. it sounds like the ER doc did his part.

      hip fractures at your mother’s age are a terrible thing and, unfortunately, her outcome is not an uncommon one, even with optimal care. i’m sorry it happened.

      • Brighid says:

        You’re right, of course; the ER doc did his part. It was the orthopedist who consulted in the ER who was really the problem. (He now practices somewhere in the Caribbean.) I guess I blame the ER because he was the face of her care, and it was when he read the xrays in the ER that he really did the damage.

        We had a little meeting with the hospital after my mother finally had her hip replacement. They told us the same thing about xrays. They also delicately suggested that maybe Mom’s hip was not really broken, but the two orthopedists who told us it was were overtreating for economic reasons. As I say, it’s hard for non-medical people to figure out the truth. Bottom line is this: although I had issues with the way the consulting orthopedist treated my mother, I don’t think he was deliberately cruel or negligent. I do think he made a mistake. I think his mistake cost my mother days and days of torment and possibly shortened her life. As her advocate, I should have worked harder to get her problem solved. It’s hard for me to fault a family member who questions treatment a patient has received, particularly if it turns out later that the problem was greater than the doctor saw at the time.

  6. DensityDuck says:

    “Steak? Naw, you’re gettin’ hamburger. Hamburger’s all you really need and besides, it’s cheaper; food’s expensive these days, you know. Oh, you wanted steak? You think you know better than me what you ought to get? Who’s wearin’ the cook hat here, you or me? Oh, right, now you’re gonna go fill out a comment card and rate me bad. Typical entitled consumer mentality, that is.”

    • Alpine, RN says:

      Except that restaurants dont HAVE to seat you and make sure you’re not suffering from acute hunger if you can’t pay for dinner…AND feed you if you need it.

  7. Pattie, RN says:

    You are talking about the first of 19.7 billion reasons I do not work in a hospital. I left when PG was a “new tool” for marketing purposes, and we all had to learn the “script” “We provide outstanding service…are you happy with our outstanding service…ad nauseum.”

    And now that it influences reimbursement, it is beyond nutty and into truly psychotic. Patients and families don’t have a rodent’s rump of an idea of the care they are getting, only about who smiles more and has the prettiest “turrkee sammiches”. Will this EVER end???

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