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Archive for the ‘Patient Encounters’ Category

Unconventional Sign Language

Tuesday, December 31st, 2013

Shaka Brah Gesture_raised_fist_with_thumb_and_pinky_liftedThe patient coming through the door was having trouble breathing. No doubt. You could hear the hiss of the nebulizer as the cart whisked by the nurse’s station into a room.

Most people knew the patient from prior emergency department visits.
Bad asthma
Steroid dependent
Several previous intubations
Last ED visit a couple of months ago

Unfortunately, being in the middle of doing a central line on a septic octagenarian with a systolic blood pressure less than her age makes it difficult to go evaluate a new patient.
I asked the nurse to go get me one of the PAs.
“Do me a favor,” I said to the PA, “Go take a peek at the new patient and see how she’s doing.”

After a minute, the PA came back and said “Everything looks pretty good. She’s trying to get comfortable on the cart right now. Her lungs have a few wheezes but are pretty clear. Her saturation is 100%. She even gave me the ‘Chaka Brah‘ sign.”

Good. Now I can finish getting this line in place.

A few minutes later, there was a commotion from down the hall.
“We need a doctor in Room 3 NOW!”
Room 3? That’s the asthma patient’s room. I looked at the PA. She looked back at me with horror.
“Just hold the dressing on this line until I come back and sew it in place, OK? Thanks.”

In Room 3, the asthma patient was diaphoretic and was moving very little air. She was tripoding. She gave me one look and did the “Chaka Brah” sign at me, too — pretending like her fingers were like an endotracheal tube and repeatedly poking her thumb at her lips through her nebulizer mask.
Then she started slapping the side of the bed and shaking her head.

Dammit.
We need to move fast.

“We’ve got you. We’ve got you. We’ll have the tube in in a couple of minutes. Just hang on.”
The patient spun her index finger in quick circles.
I know. I’m hurrying. Fortunately the paramedics had a line. Oxygen.
Crash cart. Ketamine. Sux. Tube in. Start the propofol.
Lung sounds bilateral but diminished. She’s not moving a lot of air. That’s why her wheezes were so faint.
Steroids and in-line nebs.
Sats good.
“Relax, kiddo. You’ll be better with the medications. We’ll keep a close eye on you.”

[Exhale]

Back to the octagenarian to do some quick suturing and some quick didactics in asthma, respiratory distress … and how to interpret unconventional sign language.

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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.

Amusing Nonsequitur

Monday, December 16th, 2013

Gas PumpsA patient gets brought in by ambulance for knee pain.

The story goes that the patient was at a gas station and finished filling up his truck. He walked inside to pay for his gas and when he turned around to leave, he said that “his leg gave out on him” and he fell to the floor. He was able to stand back up, but he wasn’t able to put a lot of weight on his leg. So he hobbled back to his truck and sat backwards onto the seat, but he wasn’t able to lift his bad leg into the truck. The gas station attendant was watching all of this and ended up calling the ambulance.

When the patient arrived, he appeared comfortable. He had no complaints as long as we didn’t try to move his leg.

Getting him off the ambulance stretcher and onto the cart was a chore. His leg caused him a lot of pain. The pain seemed to be more localized to his hip than his knee. Just to be safe, we x-rayed both of them. To everyone’s surprise, the patient had a femoral neck fracture.
“But doc! It can’t be! All I did was turn around! I didn’t fall onto it. How could I have broken it just by twisting?”
I showed him a printout of the x-ray and drew an arrow at the fracture site.
“Great. Just GREAT! I have to be at work tonight!”
“Sorry, Mr. Dwyer, you’re going to need surgery to fix this. You won’t be able to go to work for at least a few weeks.” He just kept running his fingers through his hair.

Wellens' V2 LeadSo we ordered the preoperative testing – CXR, EKG, labs, UA. To everyone’s surprise, the patient’s EKG showed Wellens’ Syndrome.
“Um … you know how we had to do those tests to prepare you for surgery?”
“Yeah …”
“Well your EKG shows something abnormal as well. Have you been having chest pain lately?”
“Not today …”
“In the past few days?”
“Yeah …”
“Well you’re going to need an angiogram before you get your hip fixed. It looks like you may have a significant blockage in your heart.”
“Are you SERIOUS?!?!?” He pounded his fist on the bed. “I was FINE this morning.”
“You’re actually lucky we caught this. This EKG finding is typical of a heart blockage called ‘the widowmaker.’”
He shook his head back and forth, randomly looking about the room. I could tell that he wanted to say something, but that he didn’t know what to say. Finally, he blurted it out.
“I’ll tell you one thing, though, doc …”
“What’s that?”
“I’m NEVER going to that f$%king gas station again in my whole god-d@%m LIFE! … NEVER!”

That statement caught me so off guard that I couldn’t hold in a laugh.
The patient’s anger slowly turned to a smile. As he thought about what he said, he started laughing, too.
“Hey. F you, doc,” the patient said with a grin.
“Oh yeah? Looks like I’ll be ordering some Narcan for that pain of yours.”
“What’s that?”
“Ask your nurse,” I said with a wink and a nod as I left the room.

I don’t say things like this too often, but I don’t think he knows how lucky he was to have broken his hip that 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.

Anchors Aweigh!

Tuesday, December 10th, 2013

Anchors

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%.

[Sigh]

“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

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.

Final Diagnosis

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 …

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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. 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.

Some Joke

Wednesday, October 30th, 2013

Yosemite_SamIf you haven’t been threatened by a patient, you haven’t been working in an emergency department very long. It’s a common occurrence that shouldn’t be so common. You can read about “patients gone wild” on this blog almost every week – and those are just the incidences that make the news. Little threats come even more often than that.

Most of the time we just laugh the threats off.

One patient was a little more convincing than some of the others, though. It wasn’t just some idle threat. This overly intoxicated patient repeatedly yelled at the doc in a loud voice reminiscent of Yosemite Sam that “I’m going to kill you.” He would randomly spout out his intended modus operandi with such phrases as “I’m going to blow your head off” and “I’m going to slit your throat.” The doctor he threatened was a nervous type and the threats got to him. He talked about what a “lunatic” the patient was that day and he made sure the patient had plenty of Ativan and stayed sedated for the remainder of his shift. Eventually, the patient slept off his alcoholic rage and was sent home with his significant other.

The following day, Doctor Ativan returned for another day at work. About half way through the day, one of the male nurses started his afternoon shift.

Dr. Ativan was in a side room dictating. The nurse witnessed what occurred the day prior and decided that he was going to play a joke on the doctor. So he went to the end of that hall and said in a loud gruff voice “Where’s that Doctor Ativan? I’ve got a score to settle with him!”

Brief silence.

“Where IS he? I know he’s working today…. Have YOU seen him?”

All of a sudden you could hear things falling on the floor in the dictation room. Dr. Ativan busts out of the room, runs into the wall across the hall, then starts running down the hallway in as much of a serpentine pattern [see below] as the walls would allow with his hands covering his head. He ran out the emergency exit, setting off the fire alarm, jumped in his truck, and sped away down the street. It took about five minutes to reach him on his cell phone and get him back to the department.

Good thing it was a slow afternoon.

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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 Incarceropathy

Friday, October 18th, 2013

OLYMPUS DIGITAL CAMERAThe chest pain patient was escorted back to a treatment room by not only the triage nurse, but also by a police officer. The patient was crying in pain. Agonizing pain. As the officer removed the handcuffs, the patient slowly and deliberately climbed onto the cot.
“I’m doctor WhiteCoat. What brings you to the emergency department today?”
Through her tears, she rolled her eyes and tilted her head toward the police officer.
“I see that, but why did the officer bring you here?”
“I – I – I am having PAIN! Pain all OVER!”
“The nurse said that you were having pain in your chest.”
“There, too! I have a complicated case of Behcet’s Disease. Any time that I have too much stress, I get a flare and all the joints in my body become inflamed.”
When she said that, the police officer rolled his eyes.

I dutifully performed an exam. Everywhere I touched, the patient would yelp … except when I touched her chest with a stethoscope to listen to her heart. Complicated Behcet’s disease must only respond to the galvanic response to another person’s fingers coming into contact with one’s skin. None of her joints felt warm or inflamed, either. Just pain all over. No eye irritation. Between breaths, she stuck out her tongue to show me the ulcerations that had “just popped up in the past hour.” She definitely did have ulcers in her mouth. However, the ulcers had obviously been there for a long time and had obviously not appeared just since her stressful event. For a complicated case of Behcets, she wasn’t on any immunomodulators. She had never taken them in the past, either.
Then came the EKG.
While the tech stuck the leads to the patient’s chest wall (which caused her absolutely no pain, mind you, because there was obviously no galvanic connection), the police officer pulled me aside.
“Is this going to take much longer? She’s got several warrants, and she got caught stealing a purse from a woman’s stroller in a department store. We’re not going to be able to release her on bond this time. She only started complaining of pain once she got caught.”
“Hopefully not …”

The EKG was normal.
The patient apparently knew it. She began to bawl louder and complain of more pain all over her body.
The nurse explained “The doctor ordered you Toradol. Toradol is a wonderful anti-inflammatory medicine. It should help quite a bit with your pain and inflammation.”
She was discharged to police custody shortly thereafter.

Technical diagnosis: Acute exacerbation of complicated Behcet’s Disease with underlying aphthous ulcers and general myalgias.
Secondary diagnosis: Acute incarceropathy with generalized incarceritis.
Plan: Release to police custody.

Since she was in police custody I had to fill out a form stating that she was medically stable. I made sure to add that she should not be subjected to any unnecessary stress while in lockup.
That made the officer chuckle.
“We’ll make her stay very stress free, doc. Very stress free.”

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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.

More Unique Chief Complaints

Tuesday, October 1st, 2013

The unique chief complaints keep coming. Maybe this should be a monthly topic …

  • The top and bottom half of my body are mismatched. No stroke. No weakness. No pain. Just “mismatched.”
  • Patient was discharged from hospital 12 hours ago for alcohol intoxication, unable to get into mother’s house because she has key and she’s at work. When informed that nothing could be done from the ED about a missing house key, stated he may feel like hurting himself if he can’t get into his mother’s home soon.
  • 19 year old healthy-appearing female who had pain with urination and was diagnosed with a UTI in doctor’s office. Sent to ED for IV antibiotics.
  • 26 year old fell off couch 1 week ago while sleeping. Was “paralyzed” by pain and just able to get up off of floor today. Walked to ED. Needs pain medications and a work note for past week.
  • Green ear wax for 3 days.
  • Right buttock hurts when sits with legs crossed … for the past year.
  • A spider bit my penis in three places. This same thing happened before and I knew it was a spider because I saw fang marks. This time I just think it was a spider because I can’t find the fang marks.

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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.

Medical Tourism Downsides

Thursday, September 19th, 2013

A patient comes into the hospital with dizziness and trouble breathing.
The story about how he developed those symptoms was a little more involved.

The patient needed some major work done on his teeth. He was having a lot of pain and couldn’t take it any longer. So he sold his favorite Harley Davidson motorcycle and had about $6,000 available to fix his teeth. After calling around to multiple dentists and clinics, the best price he could get to have all of the work done in the US was about $14,000. He read about medical tourism in a newspaper article, so he made some phone calls and sent some e-mails and found a place near a resort town in Mexico that would do the same work for $3,000.
Sold!

So he took the trip to said resort town and had the work done. With the extra money he saved, he figured that he would spend a little time relaxing with his wife at the resort. So he booked a week at the resort and still had money left over.

During one of the days at the resort, he decided to do some jet skiing. But he had never been jet skiing before, and during one of his jaunts, he hit a wave, went airborne, and came down on his ribs on the side of the jet ski. Ouch.

He went to the nearby clinic in Mexico, was diagnosed with a bad bruise, and was given ibuprofen.

The following day, he had more trouble breathing and went back to the clinic. The bruise was hurting him more when he took a deep breath. Just take more ibuprofen, they told him.

The next day he got on the plane. By the time he got home, he was having a lot of trouble breathing. He almost passed out while dragging his luggage through the airport. By the time he got to the hospital, he was saturating at 84% and his blood pressure was 80 systolic.

A few lab tests and a chest x-ray later, we had our diagnosis: Hemopneumothorax with a hemoglobin of 7.6.

A chest tube and a couple of units of blood later, he was smiling enough to see that new dental work.

The hospital bill … now that’s another story.

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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.

Unique Chief Complaints

Monday, September 2nd, 2013

I’ve had a few interesting chief complaints lately. Here is a small sampling … from different patients, of course.

  • Someone broke into the patient’s house while he was sleeping and stole only his schizophrenia medications so that he would act up and then get arrested by police and have to be admitted to the hospital. Then the perpetrator could break back into his house and take all of his belongings.
  • There are two small dots near my appendicitis scar. I think something may be inside trying to crawl its way out.
  • I started having back pain after laughing too hard.
  • My left ear had been clogged after having sex 9 days ago.
  • I ran into a glass door at Home Depot. I’m not having any pain, but make sure you send them the bill for this visit.
  • A bug crawled up into my belly button and now I can’t find the bug.
  • My scars turn blue when I get cold. What is that?
  • I had left testicle pain one month ago.
  • Nurses sent a patient by ambulance after nursing home patient found doing jumping jacks in his room. He doesn’t usually act that way.

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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.

Head trauma workup

Monday, August 26th, 2013

Sculpture Human HeadPatient’s chief complaint: “I was slapped on the back of my head with a file folder by a co-worker. I have a headache and I want a CT scan to make sure there’s nothing wrong on the inside.

In other words, “I really want to get my co-worker in trouble.”

Fortunately, it wasn’t one of those goth file folders with the spikes sticking out.

Danged if I didn’t have to consider a CT of the chest after putting my stethoscope on her chest to listen to her heart … and an MRI of her back after she laid on the table for the exam.

Sheesh.

And she’ll probably end up getting the Press Ganey survey that blasts me for performing an inadequate workup on her.

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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.

Semantics

Tuesday, August 13th, 2013

A 17 year old patient comes in by ambulance for chest pain and tachycardia. His heart rate was in the 130s. He was hypertensive. He was sweating. He had a history of ADHD and was on Adderall. No other medications. No alcohol or drugs.

His exam was unimpressive and all the testing came back negative, but the patient still remained tachycardic. So we gave him a couple doses of Ativan, thinking he may have taken a little too much Adderall. Still no better. Then we started doing some additional tests to rule out the less common reasons for his symptoms. D-dimer normal. He denied alcohol or drugs, but we checked for them anyway. Tox screen normal. TSH normal.

His heart rate remained in the 140s and he was still hypertensive on re-evaluation. So the on-call doctor gets called for admission. He wants a cardiology consult. No problem.

The cardiologist recommended labetolol. Sounded like a little overkill, but we went with his recommendations.

So the patient gets started on a labetalol drip and we place the admit orders.

We go back to the room and inform the family of the discussions we had with the other doctors. The dad is not pleased.

Could this be due to him smoking that fake marijuana crap?”

“He told me he doesn’t use drugs.”

“Yeah, well he’s a f***ing little liar. He smokes it all the time. Probably smoked a bowl right before we got here.”

The patient shrugged his shoulders.

“K2 really isn’t really a ‘drug’ because they sell it over the counter … right?”

“Ummm … no. Not really.”

It’s sad that your parents are going to be stuck with a large bill for all the tests we did so that you could argue semantics.

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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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