Archive for the ‘Medical Topics’ Category
Tuesday, December 10th, 2013
An otherwise healthy 38 year old patient was brought in by her family with vomiting and mental status changes from her pain medications.
She had repair of a tibial plateau fracture performed four days earlier and was having a lot of pain. She didn’t like taking the Percocets that she was prescribed because they made her nauseous. She took one of them the day after her surgery and she was nauseous the rest of the day, so she vowed not to take any additional Percocets. However, her knee pain was worse that morning to the point that she couldn’t stand it any longer, so she took two Percocets … on an empty stomach, no less. A couple of hours later, she was acting strange and had vomited several times.
When she arrived, she was lethargic and retching. She was afebrile, but her blood pressure was 87/50, her pulse was 120, and her respirations were 28. With a fluid bolus and some Zofran, her vital signs improved and she felt better. The option to give her Narcan was discussed with the patient and family but with the improvement in her symptoms, they didn’t want to reverse the pain relief that the medications had given her.
The remainder of her exam went along with her history. She had been sleeping a lot after her surgery and hadn’t eaten much, so her mouth was a little dry. She was awake and drinking fluids in the ED. She was tachycardic, but her tachycardia was improving with fluids. Her abdominal exam was fairly normal – perhaps a little epigastric pain with palpation, but nothing concerning. Her knee was tender and a little swollen. The orthopedist came to the ED and evaluated her and stated that her knee looked good for her post-surgical status.
The patient was observed for an hour or so and felt better. She wanted to go home and sleep. Family agreed. Nurse manager was pushing to have the patient discharged so we could move more patients into the room from the waiting room. “Discharge?” was written on the tracking board under the patient’s name.
Anchors aweigh. Time for this ship to sail back to port.
A final re-exam of the patient showed a couple of abnormalities, though. Her pulse was still in the 100-110 range. Her blood pressure was now 108/50. But her respiratory rate was 28-32. Lungs clear on exam. Pulse ox 99%.
“Let’s just do a few labs and a chest x-ray. Check a d-dimer and do a blood gas. Her respiratory rate just doesn’t make sense.”
“After two hours NOW we’re deciding to do labs? She’s still in pain – that’s why she’s breathing fast.”
The nursing director rolled her eyes.
“Sorry, everyone. We’ll try to get her out of here as soon as we can.”
An hour later, the patient was being admitted to the ICU.
Anchoring occurs when we focus on an explanation for a patient’s symptoms too early in a workup. Even though the symptoms seem plausible, by “anchoring” on one explanation, we tend to discount other symptoms or findings that don’t fit in with the diagnosis we’ve made. By focusing in on one diagnosis, we can miss other diagnoses. Anchoring is sometimes difficult to overcome.
Some of the best ways to avoid making anchoring errors include:
- Re-evaluating the diagnosis in light of all the information available
- Considering whether treatments that would normally improve the diagnosed condition have actually improved the patient’s condition.
- Considering alternate explanations for data that conflicts with the presumptive diagnosis
- When in doubt, consider additional testing
- If still in doubt, consult a colleague. Four eyes are better than two.
So why was this patient admitted to the ICU?
Pulmonary embolism? Nope. A pulmonary embolism may have explained her fast respirations and tachycardia. She was at an increased risk of pulmonary embolism after recent surgery. But her d-dimer was normal. And why would she be vomiting and dehydrated from a PE?
Adverse effect to the Percocet? Would have explained the vomiting and some of the vital sign abnormalities. But why the rapid respiratory rate and the dry mouth?
The patient was admitted to the ICU because she needed to be on an insulin drip. Her glucose was 1100. Her pH was 6.8. She was in new-onset diabetic ketoacidosis.
When the labs started coming back, the doctor almost needed to be resuscitated. He was a few mouse clicks away from discharging a patient who probably would have died if she had went home without treatment for her underlying problem.
There but for the grace of God …
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. This was a reader-submitted story. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.
Friday, August 16th, 2013
There were a couple of comments to the last post on Semantics that made me question whether or not it was proper to do a large workup on a young patient with tachycardia.
So I decided to create a poll to get everyone else’s opinion.
Assume that the patient’s use of K2 was disclosed. In a 17 year old (i.e. “young”) patient with persistent tachycardia unresponsive to treatment who uses synthetic marijuana, what testing should be performed?
Friday, January 25th, 2013
This is an interesting case for a number of reasons.
First, it shows how a little testing can turn into a lot of testing to “rule out” diseases in the emergency department.
Second, it hopefully provides some good teaching points.
Third, the comment from the attending physician gave me the giggles. That will explain the title. But you have to read through the case to understand the comment.
I’m not going to discuss all the minute details of the case, only the major findings that contribute to the flow of the case.
A patient got sent in from the nursing home because her gastrostomy tube was leaking blood and the nursing home was convinced that the patient was having GI bleeding. When the bandage over the patient’s G-tube was removed, it was fairly obvious that the skin about the G-tube site was the source of the blood. The skin was raw and was oozing dark red blood. Flushing the G-tube produced a little blood, but the blood cleared. The patient’s vital signs were stable except for a mildly elevated pulse. Proper skin care probably would have resolve the bleeding. Some people may have left it at that and sent the patient back to the nursing home. I drew labs and did an abdominal series.
Thursday, December 20th, 2012
An article written by two physicians in Time magazine questions whether we should blame doctors for the large number of chronic pain patients and the abuse of prescription pain medications.
There are two frames of reference to this article.
First, no one can argue that prescriptions for pain medications in this country are excessive. The article notes that in 2011, “enough hydrocodone was prescribed to medicate every American around the clock for a month.”
As both authors are emergency physicians, the end of their article notes that “we must stop fearing patient-satisfaction surveys and talk honestly to our patients about pain.”
Ask most emergency physicians and they will tell you that satisfaction surveys pressure physicians to overprescribe multiple medications, including antibiotics and opiates.
But where do all the medications go?
Note how many commenters to the article are upset because they or their family members are having a difficult time obtaining pain medications for their chronic medical problems.
Doctors are becoming increasingly aware that if they prescribe pain medications to a patient who dies, there’s a decent chance they’ll be dragged through administrative and legal proceedings regarding the death. So doctors then learn to fear the bad outcome and then take steps to avoid the bad outcome. Doctors can’t get sued if they don’t prescribe the pain medications.
Patients in legitimate chronic pain are paying the price – and it isn’t just in the emergency department, either. From the comments:
“their physician won’t see them anymore because they need stronger pain medication”
“His GP won’t prescribe, his GI won’t prescribe, the Pain Clinic keeps trying to push him into treatments that DO NOT WORK for his disease”
“the ER staff will still stand around and pretend like opioids don’t exist and it’s okay to let the patient lay there in pain”
Reminds me of a post I wrote nearly 5 years ago. Only this time, the solutions that our governments are proposing seem to be adding to the problem.
When we vilify, sue, and criminalize doctors whose patients die from medication overdoses, fewer and fewer doctors are going to be willing to prescribe pain medications.
I’m predicting that we’re going to see a downward trend in the amount of pain medications prescribed. The threat of incarceration is going to outweigh the threat of bad satisfaction scores.
And we’ll all be “safer” through more regulations, bad press, and blaming physicians for the bad apples … right?
Monday, November 26th, 2012
Photo credit and further story at http://www.inquisitr.com
Medical care for the morbidly obese is back on the radar.
Today this blog got several inbound clicks from a site where a bunch of apparent doctor haters have used one of my blog posts and the comments to the post as an example of how much the medical profession allegedly likes to bestow shame upon others. It seems that the discussion we had regarding whether it is ever acceptable to refuse medical care to morbidly obese patients was something that Ms. Marianne’s readers were cautioned that they may not be able to “stomach.”
The author and most of the people who commented to her article seem to believe that they have the right to demand that any doctor at any time must provide any type of services to them that they demand. Whether or not the doctor is comfortable providing those services or whether the doctor even has the knowledge and training to provide those services is irrelevant. Any doctor who doesn’t agree to their demands is hated and publicly shamed. This doctor who chose not to treat patients weighing more than 200 pounds was one example of their wrath.
I left a comment to Marianne’s rant back when she first posted it.
I don’t remember the comment verbatim, but the gist of my comment was that there are specialists for a plethora of conditions who provide care to patients when other providers are uncomfortable caring for those conditions – HIV, diabetes, organ transplants, ophthalmology, etc. Why shouldn’t doctors be able to refer obese patients to other physicians more experienced in caring for obese patients?
In addition, there is no “right” to force any person to provide you with any services against their will. The Thirteenth Amendment to the Constitution addressed that.
Finally, I noted that when there is a bad outcome related to a patient’s obesity, one of the first things that a plaintiff’s attorney will allege is that the patient should have been referred somewhere else.
My comment was never approved. Non-conforming, I suppose.
Today there also happened to be an article in the NY Post – linked by the Drudge Report – about how a morbidly obese woman with multiple health problems traveled to Hungary for a month-long stay in their family vacation home. When she tried to board a flight back to New York to resume her medical treatment, the airline refused her because she had gained water weight and could not be safely strapped into three seats. The airline tried to make alternate arrangements for the patient’s travel back to the US, but those plans also fell through due to the patient’s size.
There was no mention that the woman ever went to a hospital for care of her medical problems while trying to secure travel back to the US. Both the patient and her husband were quoted as saying that they “didn’t trust” doctors in Hungary.
Nine days after first attempting to return to the US, the woman died.
Difficult situation. Comments to the article were mixed. Some people blamed the patient for allowing herself to become so obese. Others blamed the airline because it was able to get the patient to Hungary and then left her stranded there.
This case illustrates the point that I was trying to make in my previous post about providing medical care to morbidly obese patients. At some point, the safety and well-being of the patient and of others must be taken into account when deciding whether to provide care. These decisions are made all the time in medicine. A patient with severe lung disease may be deemed too great a risk for surgery. The doctors aren’t “discriminating” against people with lung disease, they are making a decision that the risks of surgery are too great given the patient’s condition. Some orthopedists choose not to perform knee or hip replacements in morbidly obese patients. Again, not “discrimination,” but rather the significantly increased risk of complications in morbidly obese patients.
In the Hungarian patient’s situation, what if the patient suffered an injury on the plane because she wasn’t able to be properly restrained? What if the patient had a medical emergency and died on the plane over the Atlantic Ocean because of her untreated medical conditions? Would these same people then point fingers at the airline for allowing the patient to fly in the first place?
Rather than engage in a rational discussion about the issues, some people would rather sensationalize, cry discrimination, and call names.
Something about the patient’s situation just doesn’t make sense to me.
I question how much “water weight” the patient gained during her vacation.
I also wonder whether the patient and her husband checked into the flight restrictions that might be imposed on the patient before taking their trip.
And why it was appropriate for the patient and her husband to discriminate against all doctors available to provide them medical care in Hungary solely because of the doctors’ national heritage?
Apparently “doctor hating” is still socially acceptable.
See additional stories and pictures here:
Friday, November 16th, 2012
Influenza has arrived.
Some Georgia emergency departments are seeing a 25-30% increase in volumes due to people seeking care for influenza or influenza-like illness.
According to the CDC web site, there is good match between vaccines and the circulating virus strains this year. H1N1 virus strain not being seen much. H3N2 is the predominant Influenza A strain while “Yamagata lineage” is the predominant Influenza B strain in circulation. Note that there is one Influenza B strain circulating that was NOT contained in the vaccine – the “Victoria lineage” which accounts for about 15% of the total samples tested.
For an interesting look into how influenza vaccines are created each year, see this link.
It’s not too late to get vaccinated, but realize that vaccination takes about 1-2 weeks to generate an immune response in your system before it becomes effective.
One side note, there are some medications which may shorten the course of influenza when taken early in the course of the disease. One 2012 Cochrane review questioned the effectiveness of neuraminidase inhibitors (Tamiflu and Relenza) because “60% of patient data from phase III treatment trials of [Tamiflu] have never been published” and because the company that produces Tamiflu – Roche – reportedly ignored five different requests from the researchers to release the information in those studies.
According to the CDC site above, so far there is no resistance to the neuraminidase inhibitors with any of the influenza strains. There is high resistance to the less expensive amantadines in all influenza A samples (influenza B is not sensitive to amantadines).
In other words, if you get the flu, taking amantadine (Symmetrel) or rimantadine (Flumadine) would be just as effective as taking a “ZeePack” (Azithromycin) or as taking red jelly beans in making you feel better.
I’m personally not a big fan of Tamiflu and Relenza. I’ll discuss the above with patients who have influenza, and afterwards if people want to pay $50-$120 for medications that may make them feel better and may shorten the course of the disease by 12-24 hours, I’ll write them the prescription. PT Barnum philosophy in my book.
In our state, Tamiflu and Relenza aren’t on the Medicaid formulary – only amantadine. You’d be surprised how many people demand amantadine prescriptions so that they can take something to help with their symptoms – even though it has little or no effectiveness against the circulating virus strains. Seems that no one cares about amantadine’s side effects. They just want a pill.
I’d prescribe red jelly beans instead, but those aren’t on Medicaid’s formulary, either.
Good thing those folks have insurance, though.
Finally, if you want an interesting influenza anecdote to start up a conversation at parties, this year scientists discovered a new influenza virus that is entirely different from all known influenza A viruses. The hemagglutinin portion of the virus (the “H” part of the influenza designation in “H1N1”, for example) was dubbed H17. The neuraminidase portion of the virus (the “N” in the H1N1 designation) hasn’t been determined. Researchers weren’t able to grow the new influenza virus in any of the traditional methods and believe that the virus would require significant mutations before it is able to infect humans. Just to be safe, though, stay away from Guatemalan fruit bats – which were the reservoir for the new virus.
Thursday, November 8th, 2012
Here’s a medical conundrum for all of you faithful viewers of “House” out there.
I’m throwing this out there because I have never seen it before. I did some internet searching and think that I came up with the answer (.pdf file) but I’m not positive.
The basic history is that the patient is a bed-bound nursing home resident who has had a conic Foley catheter. The nursing home stated that the urine had started to turn purple over the past 2 weeks. The degree of purple discoloration got more and less, but never went away. It had become particularly bad recently, prompting the call to the ambulance. Notice how even the tubing is purple-colored.
Labs and a UA were sent from the nursing home a week prior and showed some minor renal insufficiency, but were otherwise pretty normal (except for urine color).
Labs done in the ED showed continued renal insufficiency, a mildly elevated WBC count and a UTI. Remember – the patient had no UTI on a UA performed one week prior while she was still having symptoms.
So what is causing the Case of the Purple Urine?
By the way – if you want to use this picture for other purposes, just click on it for a larger version or e-mail me and I’ll send you the high-res version.
Tuesday, October 30th, 2012
In case you didn’t catch the earlier version of this experiment that I posted, you can find that one here.
I work at several hospitals and each uses a different electronic medical record system. When I switch from hospital one to another, I obviously have my favorite EMR systems and my not so favorite EMR systems. In the previous post, I was using the EMPOWER charting system, which I liked for its simplicity, but disliked because of the layouts of the charting interface and some of the macros it contained.
After becoming rather frustrated with the function of another EMR system, I decided to repeat the experiment at a different hospital. This hospital uses the Meditech system. I also did the same thing at a third hospital using yet another EMR. Those times will be published in a future post.
I had to do the experiment at this hospital a few times because several times I wasn’t consistently busy throughout the shifts as I am at other places. In the shift that I used, I only tracked 7 hours in an 8 hour shift because the first hour had a lot of down time that wouldn’t have fairly represented the effects of the EMR on my productivity. In general, the whole shift had rather low acuity with only a couple of admits. In theory, low acuity should increase efficiency because of less charting time. It didn’t. In fact, the percentage of time that I spent with patients during this low acuity shift was just slightly more than the percentage of time I spent with patients during a much higher acuity shift which required more documentation of several more admits and a transfer.
As with the previous experiment, when there was overlap, I would generally count the time toward the task with which I was focusing most — if I was speaking to a doctor on the phone while charting, I counted the time as only speaking to the doctor.
Out of a total of 420 minutes, I calculated that I spent the following amount of time performing the following tasks:
Seeing patients: 156 minutes
Time on computer: 237 minutes including …
–Charting/entering orders and labs to be done/entering discharge documentation: 191 minutes
–Looking up old medical records: 20 minutes
–Entering admit orders/completing transfer forms: 13 minutes
–Meditech program issues: 13 minutes
Discussions with other physicians: 20 minutes
Miscellaneous down time (bathroom, food, non-work related issues): 7 minutes
Despite a lower acuity shift, more than half of my time was spent on Meditech entering data. I should take that back. Thirteen minutes were wasted due to Meditech program freezes and due to watching the little hourglass turn over and over on the computer screen while Meditech’s pages loaded. The rest of the time was spent entering data.
I lumped patient evaluations and re-evaluations into one category, so I wasn’t able to calculate the total time I spent with each patient. However, based on the numbers, it appears that time with patients averaged between 6 and 10 minutes (with a couple of outliers)
Out of a seven hour shift, I spent just over 2.5 hours with my patients and their families and I spent just under 4 hours with the computer program.
Friday, September 7th, 2012
For those medical practitioners that don’t usually read EP Monthly, there are always good articles from some of the top names in emergency medicine. Lately, there have been several articles published that are exceptionally good.
Rick Bukata has a thought-provoking article about management of simple abscesses. Definitely worth a read. The bottom line is that most abscesses resolve just fine after they are lanced (medical terminology = Incision and Drainage or “I +D”). A majority of abscesses – 50 to 66% are due to MRSA (methicillin resistant staph aureus – a “superbug”). The organisms causing the abscesses were resistant to the antibiotics prescribed in some if the studies Rick cited, but the cure rates were still quite high – and were similar to those patients taking no antibiotics at all. Kind of interesting to consider that by giving antibiotics to patients with abscesses, we aren’t helping the patients and we could be increasing the prevalence of the same organisms we’re trying to eradicate.
So why do doctors keep prescribing antibiotics to patients with abscesses? I’m going to venture a few guesses:
1. They don’t keep up with the literature. Old habits die hard.
2. Many patients expect them. If patients expect antibiotics and don’t get them, then they complain to administration or give us bad Press Ganey scores. This is one of those perverse situations in which outside influences can affect proper medical care.
3. If there is a bad outcome, attorneys and journalists will sensationalize the case and fault the doctor for not giving antibiotics. Call it defensive medicine. It is a lot easier to fault someone for doing nothing than to fault them for doing something – even if that something is of marginal benefit.
Speaking about antibiotic use, an article from a few months ago by David Neuman (who works with Graham Walker and others over at theNNT.com – an excellent resource for clinicians) explores whether antibiotics are useful in preventing infections after mammalian bites and in treating “bronchitis”. Some of the results will surprise you, some of them shouldn’t surprise you. One interesting factoid: Out of 100 patients prescribed antibiotics for “bronchitis,” none receive any benefit and about three of them are harmed by the antibiotics themselves. I’d say that every one of the patients receiving antibiotics is harmed. They pay a lot of money for medicine that doesn’t do a thing to help them.
News you can use about pediatric appendicitis from Ghazala Q. Sharieff, including scoring systems, ways to predict severity, and potential testing to use if ultrasound is equivocal.
Sunday, July 22nd, 2012
This is probably a record length post for me, but I thought it was important to respond to Mr. Dwyer’s comments to a post written on this blog regarding the article he wrote that appears in the NY Times.
I had planned to leave my comments after his, but they became too long and involved and I also wanted to paste a couple of pictures from Mr. Dwyer’s article, so I instead decided to answer his criticisms in a post.
If any of you were wondering, I was not the anonymous physician who authored the previous post on Mr. Dwyer’s article. I spent most of my afternoon creating this response because Mr. Dwyer’s original article was somewhat frustrating to me, but I found his justifications and explanations for what was contained in his article to be misleading.
See additional commentary about Mr. Dwyer’s articles here and here.
Dear Mr. Dwyer,
When re-reading your article, I absolutely agree with Rory’s wish that no other child – and no other family for that matter – should have to go through what Rory went through. He sounded like a great kid and he obviously had a close family and a bright future. As you also mentioned, Rory’s uncle was a friend of yours, so I can imagine that this incident affected you more than most other investigations you have performed. This topic hit home for me as well. My daughter nearly died from an invasive pneumococcal infection when she was younger. She was hospitalized for a week in a university medical center on triple antibiotics. Very scary times and we thank God that things turned out well.
So let’s go through your article and responses you made to the criticism about your article so that we can determine how to prevent kids from dying from sepsis due to invasive organisms.
JIM DWYER COMMENT:
1. You say that the stop sepsis campaign is for tracking severe sepsis. That misstates both the nature of the campaign and my citation of it in the article. The campaign’s goal is to aggressively identify sepsis and begin treatment within an hour. (The tracking of cases you cite is secondary.) To begin the process of identification, the initiative created a triage screening tool which gives a list of 8 signs and calls for additional investigation if a patient has three of them. As I wrote, Rory Staunton had two when he came into the ER. He had three when he was leaving. (BTW — his heart rate over a period of two hours ranged from 131 to 143. That’s in the article, too.) In the distribution literature with the screening tool, there is no distinction between pediatric and adult patients. Whether or not you think the values are relevant to a 12 year old, 5’9″, 169 lb boy, Rory was assessed for possible sepsis in triage.
Let’s look at the sepsis criteria according to the checklist that you posted. Then let’s apply them to children.
1. Pulse greater than 90. In children up to 2 years of age, a pulse rate less than 90 is considered too slow. In other words, ALL children up to 2 years of age should have a pulse rate greater than 90.
2. Respiratory rate greater than 20. In children up to 5 years of age, a respiratory rate less than 20 is considered too slow. In other words, ALL children up to 5 years of age should have a respiratory rate greater than 20.
So now in children who have entirely normal vital signs for their age, right away you have two of the three “danger signs” your article repeatedly emphasizes.
Add a temperature of 100.5 degrees which is essentially not a temperature at all.
Let’s give the child a runny nose which causes us to suspect a viral URI – the suspicion of an “infection” required by the criteria.
This two year old child, running around the room and laughing with his parents, with essentially normal vital signs for age, now has 4 of the criteria on the screening tool you cite.
According to the premise of your article, we must rigidly follow the criteria on the “screening tool,” which means that on every such child, doctors should get a mandatory serum lactate level, order immediate IV antibiotics, and hospitalize the patient. Heck, we should probably throw in a central line and urinary catheter as well to monitor central venous pressure and input/output.
Can you even begin to imagine all of the unnecessary added expense and adverse reactions from the antibiotics/invasive monitoring that would occur if every medical center in the country adopted Jim Dwyer’s rules of pediatric management? Every influenza season, there would be no hospital beds available for months as hospitals were forced to overtreat healthy well-appearing children while delays for care of other emergent patients precipitously increased.
The problem with your article, and something that you conveniently hid from your readers, was the disclaimer at the bottom of your so colorfully highlighted checklist
Doesn’t the disclaimer at the bottom of the checklist say something to the effect that it “should not be used as a substitute for clinical judgment”? Can’t really see the whole sentence because your placement of Rory’s labs just happens to obscure the rest of the wording. But I’ve read enough checklists and disclaimers to know that the disclaimer most likely states that the checklist should not be substituted for a physician’s clinical judgment.
Well, here, let me highlight the area I’m talking about. You can click on the image to get a bigger view if you want:
Yet, despite the checklist specifically telling you NOT to do so, that’s exactly what you did, isn’t it, Mr. Dwyer? You published an article asserting that regardless of the clinical judgment of a physician who has many years of training in medicine and who is described in your article as being “hyper-conscientious”, this protocol must be rigidly followed. You misused this guideline in order to inappropriately attack the qualifications of physicians you never met and to whom you never even spoke.
You state that the guideline and its literature made “no distinction between pediatric and adult patients,” yet you didn’t even know enough or didn’t care enough to ask what patient populations the guidelines were created for.
You keep asserting that Rory was the size of an adult. Fine. I agree. But he was still 12 years old. Unless you have evidence that the criteria have been validated in children – even adult-sized children - don’t assert that the criteria are valid in children. You know darn well that if the situation was different, the medical treatment involved medications not approved in “children,” and Rory died after receiving the medications, you’d be the first one writing about “warnings ignored” in giving the medication. 20/20 hindsight is just crystal clear.
See a more balanced article about the same topic at ABC News.