WhiteCoat

Archive for the ‘Patient Encounters’ Category

Quick Visit

Monday, July 7th, 2014

Lips

A mother brought her son to the emergency department with a rather non-emergent complaint … chapped lips.

The registration clerk started taking the registration information.

“Can I get the patient’s name and date of birth please?”
“Yes, it’s Johnny …”
The clerk got distracted by the patient who first licked his lips, then smacked his lips, then rubbed his finger back and forth over his lips.
“You know, you shouldn’t do that. That’s probably why your lips are so irritated.”
Back to the mother.
“His name is Johnny Smith. His date of birth …”
The kid licked his lips, made a smacking sound, and rubbed his finger over his lips again.
“Maybe you could get some Chap Stick from your mom. You really shouldn’t rub your lips like that.”
Back to the mother.
“Sorry. What was his date of birth again?”
“December 17, 2008.”
The registration clerk started typing and all of a sudden, the registration clerk slams her hand on the desk and yells “STOP THAT!”

The kid looked at her in horror.
She started to apologize.
“I’m so sorry …”
This time the mother interrupted.
“That’s EXACTLY what he needed! He don’t listen to me. You gonna listen to HER now? Huh? You gonna listen to HER when she tells you not to do that?”
The kid kept his eyes fixed on the registration clerk and slowly nodded his head.
Then the mom thanked the registration clerk, gathered her belongings, and left.

And the biggest discussion afterward was what to call the diagnosis.

Surrogate discipline training?
Rule out tardive dyskinesia?
Left without being licked?

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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.

One Way to Cure a Drug Seeker’s Back Pain

Tuesday, July 1st, 2014

Back StatueA gentleman in his 40s limped into the emergency department for evaluation of severe back pain.

He had a chronic history of back pain, but had decided to forgo recommended surgeries because he was told that there was a chance his pain could worsen. He reportedly had multiple MRIs in the past … all of which showed “severely” bulging discs. He also just moved to the area the evening prior to his visit. In all of the excitement and heavy lifting, he strained his back, he couldn’t find his pain medications, AND he lost his wallet. That meant he had no ID and he couldn’t remember his address because, of course, he just moved into his apartment last night.

He was in excruciating pain and couldn’t move without pain shooting to his legs. Oh, and his heart stopped after taking aspirin a long time ago and he was specifically told NEVER to take NSAIDs because they could kill him.

His exam didn’t show too much except that he was in a lot of pain. So we ordered a muscle relaxant and a couple of Tylenol with codeine tablets.
After about 15 minutes, he stated that the Tylenol #3 “took the edge off.”

He got a shot of Decadron and we prepared to discharge him. He requested a couple of days of Norco pills until he could find his other prescription amongst all of the moving stuff.
I gave him the benefit of the doubt and wrote him a prescription for a couple of days worth of Norco and Robaxin. However, I wrote on the prescription “DO NOT fill prescription without verifying photo ID. Please fax copy of patient’s photo ID to Metro General Hospital emergency department at 888-555-1212.”

The patient flipped out.
“What … am I some kind of criminal?”
“Sir, you’ve given us no way of verifying your identity for purposes of creating a medical record of or providing you with a bill for the services you’ve received. We need to do this for all our patients.”
Shaking the prescription at me over the desk, he said “Yeah, well I bet you don’t write crap like THIS on the prescriptions for ‘all of your patients.’”
“That’s true. But very few of our patients come into the emergency department with no identification and not knowing their address, either. You received medications to help with your symptoms. We just need to verify your identity. If you’d like, we can call the police to have them verify your identification. In fact, Mary, can you call the police and ask them to send an officer down here?”
“You’re the biggest asshole I’ve ever met in my LIFE!”
And with that, he crumpled up the prescription, threw it on the floor, and stomped out the door with nary a hint of antalgia in his gait.

Just goes to show …
Those steroids really do help back pain.

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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.

The Effectiveness of Advertising

Wednesday, June 11th, 2014

A cute little 6 year old boy was brought from home. He had autism and didn’t communicate much.

His mother stated that he would occasionally just stop eating and drinking. Then he would get dehydrated. Then he’d get constipated. Then it would be a big problem to attempt to get him un-constipated. He had to be hospitalized for dehydration a couple of times and he had to be manually disimpacted once. The mom estimated that he had gotten significantly dehydrated 4-5 times in the past few years. So the patient’s pediatrician sent him to the emergency department to get some IV fluids in order to attempt to avoid the progression of events.

I examined the boy and he did seem behind on his fluids. He hadn’t urinated since he had woken that morning and his mucous membranes were tacky.

I asked him “Won’t you drink some juice for me?”
He said “Dehydrated. Need fluids.”
OK. Interesting vocabulary for a six year old.
“I know you need fluids. Could you drink some fluids to make you feel better?”
“No. Dehydrated. Need fluids.”
The nurse brought him some juice. He turned his head away and got upset when it was offered to him.
“Dehydrated. Need fluids.”
“We’ll have to stick you with a needle to give you fluids if you won’t drink.”
“Dehydrated. Need fluids.”
His mom interjected. “He’s really good about IVs.”

Difficult situation. On one hand, the kid did seem dehydrated. But the source of his dehydration seemed entirely psychogenic. It was almost as if he wanted an IV. On the other hand, if he did have some underlying desire to get IV fluids, would giving him IV fluids just encourage him to stop eating and drinking on a more regular basis?
Then you weigh the upsides and the downsides.
Potential Upsides: IV fluids seemed to be what the primary care physician, the mother, and the patient wanted. Little harm. Hopefully a quick disposition after receiving the fluids.
Potential Downsides: Probably overkill. Would be the first point of contention if the kid kept refusing oral fluids and required hospitalization. There’s no guarantee that the kid would start drinking again after he was “tanked up.” Probably would result in unmet expectations if wasn’t done, which would likely result in complaints to the administration and possibly negative Press Ganey scores.
As an aside, this situation perfectly demonstrates the perverse notion of HCAHPS and patient satisfaction ratings. If you don’t give the patient a desired treatment that is of questionable medical benefit, you get bad reviews from the patient and the government or hospital penalizes you. If you do give the patient a desired treatment that is of questionable medical benefit, you get accused of providing “unnecessary care” and the government or hospital penalizes you. You’re put in a no-win situation where you’re guilty of some misconduct regardless of what path you choose. But that’s another story.

In the end, the potential downsides won out. The kid got an IV.

So they sat there watching TV as he got a few fluid boluses. The patient sat there intently watching the shows and even more intently watching the commercials.
“He LOVES watching TV commercials,” his mom said.
He finally urinated which was my cue that his tank was full.
The mom asked if I was planning on doing any blood tests.
“Not really. They aren’t likely to change our treatment course. Besides, kids are pretty resilient.”
Then the patient chimed in. “High cholesterol. See your doctor.”
“Wow. You did see your doctor today,” I quipped.
“High cholesterol. See your doctor.”
So I asked him “What would your doctor give you for high cholesterol?”
Without missing a beat, he said “CRESTOR!”
I looked at the mom. She shrugged and smiled.
“Well, it’s time for you to go home and drink some Gatorade.”
His eyes opened wide “Yeahhhh. The THIRST Quencher.”
“Yeahhhh,” I echoed.

Now why didn’t I think of that before we started the IV?

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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.

Diagnosis by Retrospectoscope

Thursday, May 29th, 2014

The patient was crying and shaking her hands when she rolled through the doors on the ambulance stretcher. She had been sitting at work and developed severe chest pain. There was also a little shortness of breath thrown in because she felt as if someone was sitting on her chest. She said she had been upset over something that happened at work and was “stressed out.” The pain was right in the middle of her chest and felt a fullness in her neck. She was starting to get tingling in her fingers and thought that shaking her hands would help. Paramedics gave her aspirin and nitroglycerin which she said may have helped her chest feel better.
The nurse gave the paramedics a stink eye. “Come on, now. She’s 27 years old. She ain’t having a heart attack.”
Even though she wasn’t having a heart attack, the nurse still ordered an EKG. Doesn’t it figure. Something didn’t look quite right. Little bit of ST elevation in Lead I and aVL. May just meet criteria for MI. Also a little elevation in V1 through V3. Not the tombstones you typically see. Just a hint of elevation. And there’s some T wave inversion in the inferior leads as well. Since she’s 27, there’s obviously no old EKG for comparison.
“That’s concerning. She has some EKG changes that may be ischemic.”
The nurse was quick to counter. “Yeah, right. She needs some Ativan, not a cardiologist.”
“Well, you can give her some aspirin, some morphine, and a milligram of Ativan also. If nitroglycerin helped in the ambulance, give her another dose of that as well.”

EKG

Decision time. I’m moonlighting at a rural hospital and there’s no cardiologist available. Do I treat her like an 80 year old diabetic and fly her to the medical center 60 miles away? Or do I treat her for her anxiety and watch her? She technically meets the criteria for an MI, which puts you in a no-win situation. If you send her to the referral hospital and her pain goes away, everyone thinks you’re an idiot. If you keep her at your facility, on the outside chance there’s something serious that you didn’t act upon, you get tarred and feathered by everyone who looks at the case.

After receiving some morphine and Ativan, she’s a little out of it, but is still crying and having pain that she rates as a 4 on a 1-10 scale. I call the Metro General referral center and ask to speak to the cardiologist.
“There’s a 27 year old young lady with typical sounding chest pain and EKG changes that look ischemic. Can I fax you the EKGs to look at?”
“Family history? Smoker? Drug use? Other medical problems?”
“Nope. Nope. Nope. Nope. Can I fax you the EKG?”
“Hey, you’re there seeing the patient. I’m not. If you believe that the patient is having an acute MI, just send her here. What I say about the EKG doesn’t matter.” Actively avoiding looking at the EKG. In other words, “If I look at the EKG and say it looks like a 27 year old is having a heart attack, then I look bad. If I rely on your interpretation, then you get left holding the bag.”
Labs have come back and of course they’re all normal. Not even a little bump in the cardiac enzymes. Normal d-dimer as well. Chest x-ray looks fine. She is still crying in pain.
“Okay, let’s call the helicopter,” I told the nurse . “Grab some heparin and Plavix. We’re going to treat her as if she is having a heart attack.”
“Holy sh*t. Are you kidding me? She’s 27 years old.”
“Hey. Cardiac disease doesn’t discriminate. Let’s get this show on the road.”

I walked back into the room to talk to the patient. She was crying and talking on her cell phone.
“Your EKG looks like you may be having a heart attack. We’re going to have to send you to Metro General by helicopter.”
She stopped crying immediately.
“Holy sh*t. Are you kidding me?” I wanted to say “No, I’m serious as a heart attack” but cheap blog humor didn’t seem appropriate at that point. I explained to her what was going to happen and had her sign the necessary paperwork.
I went back into the office and completed her medical records which took about another 10 minutes.
I went back into the room, the patient’s mother was standing there. She looked at me and said “Can I ask you what is going on?”
“Sure. You probably heard the unexpected news. Your daughter has changes on her EKG that make it appear she is having a heart attack .”
“Hole-lee sh*t .”
I’m getting kind of sick of hearing that phrase by now.

About 20 minutes later, the helicopter crew was walking through the door. The nurse began giving them report. The patient was still having chest pain, so we repeated her EKG. It hadn’t changed from her initial presentation. The helicopter nurse gave me a quizzical look out of the corner of his eye. I gave the same quizzical look back at him.
Now I’m getting ticked off. Just be quiet and take your damn notes. You’re getting paid regardless of whether or not I know how to read an EKG.
They loaded patient on their stretcher and wheeled her back to the elevator leading to the helicopter pad on the roof.
As I heard the helicopter blades start spinning, I started to wonder whether or not I had documented the chart well enough to survive the inquisition by retrospectoscope that would be occurring the following day. We met all of our “quality” indicators including aspirin at time of arrival and EKG within 10 minutes. But how many people would still be sitting around the conference room table the next day asking what I was thinking?

Oh well, that part of the job. Everyone’s a genius once the diagnosis is known.

Just to rub it in, during my next shift, the nurse mentioned that she had seen the patient in the grocery store two days after we transferred her.

Such is the life of a pit doc, I guess.

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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.

Acute Incarceritis Revisited

Tuesday, April 29th, 2014

Monopoly Get Out Of Jail FreeIt has happened a few times recently. Just had another case of acute incarceritis.

A man was brought in by police after drinking a little too much and then beating the heck out of his girlfriend.

Police were called to the scene and the man was arrested for domestic battery.

While riding handcuffed in the back of the police car, it happened.

Loud wailing. His bad back just gave out on him again.

A state trooper brought him to the emergency department.

“I’ve got a bunch of slipped disks in my back and the pain is about a 15 out of 10 right now.”
His back looked fine and he had a normal neurologic exam.
When his back pain didn’t seem to make the impression he desired, he added “and I’ve got diverticulosis so bad that the surgeon wanted to take out my entire colon – but I wouldn’t let him.”A rectal exam showed good tone, normal sensation to the area, and no blood or mucous.
“And my blood pressure isn’t very well controlled, so it’s making my head hurt.”
“Your blood pressure is 137/66.”
“Well it shoots up unexpectedly and I haven’t been taking my medications. I almost hit 300 one time, you know.”
“Fortunately, it’s normal now.”
“And my chest is killing me. My heart is beating out of my chest.”
“The workup is still pending, but your EKG looks fine.
“Oh, and I have a bum knee. That’s bugging me too. I can barely walk.”
“You looked like you were walking pretty well when you came into the emergency department.”
“And what about this rash?”
“Wait a minute. You mean to tell me that just after you were picked up by police for beating up your girlfriend, you simultaneously developed the worst back pain, chest pain, knee pain, and abdominal pain you’ve ever had in your life – in addition to palpitations, high blood pressure, and a rash?”

At that point the state trooper interrupted.
“Doc, he was just going to spend the night in jail here, but as long as you tell me he’s not going to die on me in the car, my captain said that I can take him to South Metro State Prison where they have a medical ward.”
The patient quickly changed his mind. “I’m OK. The pain’s better.”
The trooper responded back “Naaaah. Can’t be too careful. You’re going to South Metro.”
“But I’m feeling better now! What the f***?!?”
At that point you could tell that the patient was trying to decide whether to come up with more symptoms in a last ditch effort to get admitted or whether he would plead some more so that he wouldn’t have to go to South Metro.

I walked out of the room.

As he was being discharged, and being led out the back doors in handcuffs, it sounded like the patient was taking the latter approach.

“I was just anxious, OK? Can’t a guy get anxious?”

The trooper just walked behind him with a grin.
“Just because you play the get out of jail free card, it doesn’t mean that you’re going home.”
And the patient just had to be thinking “now you tell me ….”

Monopoly Community Chest Go To Jail

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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.

 

 

We’ve Been Facebooked — Part 1

Sunday, April 6th, 2014

4-6-2014 2-50-29 PMI’m developing an increasing dislike for certain forms of social media.

Fortunately, this first incident didn’t happen to me, but the nurses who endured the onslaught were still twitching the following day when I came into work.

The day before started out as a pleasant day, or so they said. Even pace. Good flow of patients. No holding patients in the emergency department. Waiting room nearly empty. Nurses got to take their lunch breaks. One of those days that you leave feeling refreshed. But those days are subject to change without notice.  And change, it did.

Lumbago Joe hobbled in the front door.

Lumbago Joe was a well built guy in his forties. Rough around the edges. Always walked with a limp on hospital grounds. It was almost pathetic to watch him come in the door. Chronic back pain. Surgeries didn’t help. He refused further surgeries because they only made his back worse. He had seen so many doctors who told him they couldn’t help that he kept a copy of his latest lumbar spine MRI on his iPhone. That damndable iPhone. He’d even show you pictures of his bodybuilding days many years ago. He used to be in great shape. The thing about Lumbago Joe was that when he was off hospital grounds, he was different. See him in the store and he was lifting cases of beer with no problem. In the bars he would dance the cha-cha – unless he saw someone he knew from the emergency department … and he knew EVERYONE from the emergency department. Knew their names, knew their significant others. Sometimes even knew their work schedules. So when Lumbago Joe knew he had been sighted, suddenly he’d catch himself, grab his back and put on a show, pretending he didn’t see the hospital personnel. Or sometimes he’d come up to say hello, mentioning how well his pain was in control after getting those 8mg of Dilaudid in the emergency department the other day. Yeah, Lumbago Joe was like a modern day medical Verbal Kint (by the way, if you’ve never seen the movie the Usual Suspects, don’t click the link, stop reading this right now, go rent the movie or pull it up on NetFlix, and thank me later).

So Lumbago Joe slowly limped back to his assigned room. As luck would have it, Lumbago Joe’s favorite doctor was working that day. Yes, Dr. Feelgood was in the house.

Dr. Feelgood works a few days a month at several different hospitals. He doesn’t like to spend all his time at one place and likes the “freedom” of working at several hospitals. Nice guy. Fairly good clinician. Gets great patient satisfaction scores. And boy does he write. You come in with pain, you get Dilaudid. If you even may have pain when you leave, you get Percocets for home use. Finger sprain? Dilaudid. Ankle sprain? Dilaudid. Toothache? Dilaudid. Have Narcan on standby if your back is bothering you or if you have a migraine. Yes, despite being only a part-time physician, Dr. Feelgood is at the top of the leaderboard for both Dilaudid prescriptions and for Narcan use. Little old ladies probably don’t need 4mg of Dilaudid for back pain … but they get it.

Lumbago Joe got a spring in his step … er, um … in his hobble when he caught a glimpse of Dr. Feelgood’s combover while Dr. Feelgood sat at the desk charting. The triage nurse would even recount how it initially appeared like Lumbago Joe was going to stand upright and say “Hi” to Dr. Feelgood, but caught himself and began to limp even worse.

Dr. Feelgood didn’t disappoint.
“I’ve got this,” he told the other doctor on duty.
He went into Lumbago Joe’s room and a few minutes later he came out and started pecking away at the computer.
New orders up. Start an IV line. Dilaudid 4mg IV push. Valium 10mg IV push.
To put that into perspective, 1mg of Dilaudid is the analgesic equivalent to between 6mg and 8mg of morphine.
While most people would have suffered a respiratory arrest shortly after receiving the medications, Lumbago Joe was up and walking around, back straight with perfect posture. He smiled and shook Dr. Feelgood’s hand, thanking Dr. Feelgood profusely for his kindness.
Lumbago Joe was discharged home a half hour later with a prescription for thirty Norco tablets.

To show his appreciation for the care he received, Lumbago Joe posted a Facebook update.
Apparently a Facebook “friend” of the ED secretary was also friends with Lumbago Joe. The ED secretary was therefore able to see what Lumbago Joe had posted after he left the emergency department. This makes no sense to me, but that’s because I currently do not and never will use Facebook. In fact, I call it Fecesbook. Anyway, suffice it to say that the secretary was able to see Lumbago Joe’s posts.
“Just left Metro General Hospital pain-free for the first time in several weeks. Thanks to Dr. Feelgood for his excellent care.”

About 30 minutes later, the waiting room was filling up. Sixty minutes later, it was full. Fifteen patients registered within the 90 minutes after Lumbago Joe left. Looking through the names of patients, it was like a class reunion for Ridgemont High. The complaints were overwhelmingly pain-related. Headache. Migraine. Toothache. Fell down the stairs – back pain. Low back pain. Abdominal pain. Headache. Back pain. It was a flashmob of misery.
The odd thing was that the waiting room patients in all their misery were laughing and joking … until the doors leading into the emergency department clicked then swung open. Then there was an eerie silence as the next name was called and the next patient was brought back holding a random body part in terrible pain.
The rest of the day and evening were filled with long waits and lots of opiates.

One nurse, still twitching as he recounted the afternoon, simply stated “That Lumbago Joe character facebooked us real good, he did.”

I just smiled and shook my head, being thankful that I wasn’t working that day and thinking how ironic it was that the provision of medical care would even lead to creation of such a term.

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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.

The “Punch” Line

Wednesday, March 19th, 2014

BoilerQ: How do you get a room full of little old ladies to all use obscene language at the same time?
A: Yell “BINGO!”

When elderly patients blurt out obscenities, most of the time it takes everything I can do not to laugh out loud. No offense intended. I just get flashbacks of my mom sitting and putting her fingers in her ears while watching scenes in certain movies or seeing her gasp in shock if an F-bomb catches her off guard. I don’t expect to hear obscenities from someone who just rolled by me with a walker. For example, a while ago I posted a story about one lady from a nursing home who caught me off guard with an MF-bomb.

But this post came about from another patient encounter that made me reflect about how the things that doctors say to patients can affect a patient’s perception.

Enter the elderly patient who hobbled past the nursing station and into a treatment room with the help of her walker. As soon as we saw the chief complaint of “rectal pain” pop up on the tracker, everyone hoped it was a hemorrhoid and not a stool impaction. The other doc pretended he didn’t see the patient go by and headed into another room to see a different patient. I put my name under the “assign doctor” tab and went into the room to see her.

“Hi! I’m Dr. WhiteCoat. How can I help you today?”
“I’m having pain in my rectal region, doctor.”
Then her husband jumps in “She had surgery to fix a fissure a few days …”
Esther got upset. “You let ME tell him, Herb. It’s MY rectum.”
Herb shut up.
“I had surgery to fix an anal fissure a few days ago and I’m still having pain in the area – especially when I go to the bathroom.”
I got some more history and then had her get undressed so I could look at the area. While she described what had taken place over the past few days, she was obviously upset about her outcome.
Esther wasn’t a petite woman and she wasn’t quite as mobile as most patients. The nurse had to help her get into a gown and then helped pull down Esther’s pants. I could immediately see why Esther was having pain. There was extensive bruising to the inner aspects of both buttocks.
“Have you told your surgeon about this?” I asked.
Despite having a spine contorted from years of progressive osteoarthritis, Esther managed to twist herself sideways to give me a stern look and resolutely state “I am never talking to that goddamn sonofabitch again in my LIFE!” She then flopped back onto her stomach on the bed.
Herb started to chime in. “We went to Dr. Rectum’s office yesterday and …”
Esther’s voice, muffled from the pillow, still cut him off. “Herb, it’s MY body. Shut up.”
Herb shut up.
“I saw the bruising yesterday, so we went to Dr. Rectum’s office yesterday to ask him about it.” She explained. “That sonofabitch told me that my butt was so big he had to have two fat guys from the hospital boiler room come and pull my butt cheeks apart so he could finish doing the surgery.”
Herb grinned.
I raised my eyebrows at him and softly shook my head.
“OK, Esther, we’ll get you some medicine for the pain and I’ll give one of our other surgeons a call.”

The other surgeon who covers for Dr. Rectum was out of town, so I ended up talking to Dr. Rectum himself.
“Bruising is normal after surgery like this.” He said. “Hers was a little more than usual, but she’ll be fine. Part of it is because of her size. We had a little difficulty retracting her buttocks. Tell her to take it easy on the opiate pain medications and continue the Sitz baths and cool compresses like we discussed. She can see me in a few days if she’s still having pain.”
“She’s pretty upset with you,” I told him. “She said you told her that her butt was so big that you needed two men from the hospital boiler room to come and hold her butt cheeks apart.”
“I told her that the traction from the tape we use is what probably caused the bruising. I jokingly told her that it wasn’t like two men came in from the boiler room had to hold her buttocks apart. And I never said anything about the size of her rear end.”
“That’s not how she remembers it. She’s refusing to ever see you again.”
“I’ll call her to apologize. My gosh. That didn’t go very well, did it?”

I told Esther what Dr. Rectum had said.
More profanities. No change of heart. She remembered what she heard, she didn’t think it was funny, and she was NOT ever seeing Dr. Rectum again.

Dr. Rectum is a good doc, but his misguided attempt at humor torpedoed the care he provided … and he was lucky that the patient didn’t complain to the administrators about her perception of a statement that men from the boiler room came into a surgical suite while she was under anesthesia.

So Esther was discharged with some stool softeners and a few pain pills.

As she was getting dressed, Herb nudged me and whispered “I thought it was pretty damn funny when she told me.”
I smirked a little and whispered back “Any good comedian knows his audience.”

Making cracks about the posteriors of hearing impaired little old ladies – definitely not doctor’s office material.

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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.

Problem Found

Monday, February 17th, 2014

Stuffed Cat

An 8 year old girl was brought in for a psychiatric evaluation.

The child’s mother had a laundry list of abnormal behavior in which the child was engaging. The child allegedly scratched the eyes out of all her dolls – except her stuffed cat, of course. The patient breaks glass on the bathroom floor so no one can use the bathroom. She also screams incessantly. Oh, and today she threatened to burn down the house.

According to the patient’s mother, she was suffering from post-traumatic stress disorder after being beaten by her stepfather as an infant. Then, a couple of years ago, her pet kitten was found dead on the road. Ever since that time, the girl acts out and carries around a stuffed cat with her wherever she goes. And sometimes she carries a blanket, too.
All of this has to be discussed out in the hallway so that the patient doesn’t overhear these conversations and become more upset.

The child hadn’t said a word since she arrived in the emergency department. she just watched TV in the room as she clutched her stuffed kitten. She was still dressed in her coat and gloves as she went to sit on the bed.

“You’re going to have to take off your coat and sweatshirt so we can examine you,” the nurse told her.

The mother interjected “Yeah, well that will probably just get her sexually aroused, but what-ever.”

At that moment, the staff realized that the source of the patient’s psychiatric issues was likely neither the girl’s reported neonatal beatings nor her deceased cat.

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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.

What’s the Diagnosis #18

Tuesday, February 11th, 2014

An elderly patient with hypertension, hypothyroidism, and dementia is sent from the nursing home by ambulance for evaluation of a rash to her scalp. The patient’s nurse had noted the rash that afternoon while putting the beret in the patient’s hair and is sure that the rash wasn’t there two days ago when she last cared for the patient.

Scalp Rash BeforeThe patient was reportedly sleeping more than usual the day prior to her transport. The nursing director at the nursing home was concerned that the patient had developed shingles to her scalp.

A picture of the patient’s rash is to the right (unfortunately, not the best clarity).  What’s the diagnosis and what is the treatment for this condition?

Scroll down for the answer.

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Answer: Acute Lipstick Misapplication

Scalp Rash AfterThe “rash” happened to be the same color as the patient’s lipstick. There were initially two spots. Both were removed with an alcohol wipe.
Treatment: Discharge with close follow up.

Wait … not so fast.
Upon learning of the patient’s imminent return, the nursing director from the nursing home called back the emergency department and stated that no one had addressed why the patient had slept more than usual. After all, the patient reportedly slept past breakfast the day prior to her transport.
There was a bit of a discussion between the nursing director and the emergency department nurse which then escalated to a discussion between the nursing director from the nursing home and the nursing director from the hospital. Eventually, the patient had several lab tests performed in the emergency department to rule out anemia, electrolyte abnormalities, and hypothyroidism as a cause of the patient’s acute transient hypersomnolence.
When the labs all came back normal (except a mildly low sodium), the patient’s doctor had to be contacted in order to tell the nursing director from both facilities that it was permissible to send the patient back to the nursing home.
The nursing home then had its transport van come to pick up the patient.

Wait … not so fast.
The transport van was not available. It only runs between 8AM and 2PM. It was 4:30 PM.
So an ambulance had to be called to transport the patient back to the nursing home at a cost of roughly $400 plus $37.50 per mile.

The final result was an awful expensive bit of lipstick

Discharge instructions nearly included an order to set the patient’s alarm clock for 15 minutes prior to breakfast each day, but the emergency physician decided that there were enough phone calls made to hospital administrators regarding this patient for the day.

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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.

Guaranteed Referral

Tuesday, February 4th, 2014

EarEmergency physicians are generally a good group of people. Most of the time we will go out of our way to try to help you. Sometimes, things just won’t work out, though.

For example, if you bring your child in with a bead stuck in her ear and the first words out of your mouth when the doctor walks in the room are “If my daughter so much as WHIMPERS when you’re trying to get this bead out, I will SUE you!”

Suddenly, the doctor might not feel so comfortable with his or her ENT skills.

Sure, the doctor will examine your daughter to make sure she doesn’t have an emergency medical condition. But then when there is no longer an “emergency,” the law doesn’t force us to risk a lawsuit by digging around in your child’s ear.

In that case, you might get referred to the only ENT in about a 40 mile radius … who doesn’t take your “insurance” … who requires a $200 deposit at the time of the appointment for people whose insurance he doesn’t accept … and whose appointments are probably booked up for the next couple of weeks.

And there’s a pretty good chance that if you make the same threats to him, he’ll just flat out refuse to see you.

In that case you could always call your lawyer to see if he could help you.

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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.

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