Archive for the ‘Patient Encounters’ Category
Friday, September 14th, 2012
By BirdStrike M.D.
Some cases burn into your brain like a hot branding iron, for whatever reason, and never really leave. This was one of those cases.
One hectic morning before my shift, my wife and I rushed around the house trying to get our kids ready for school. On this day, my daughter was to go on a field trip where the teachers would walk the kids through the city to the local park to study the small oasis of nature in the “concrete jungle”. Before such field trips I would always wonder, how the teachers can corral all those little kids safely through such a crazy city, crossing such busy streets. “We are super careful,” the room Moms would ensure everyone. My wife had gone on a couple of these field trips and she remarked at how organized they were and how good the kids listened, holding hands and singing as they walked in a long hand-holding train through the city. “Okay,” I would say, “sounds like they’ve got it under control”.
Working in the ED, I knew better. At this point in my career, I had already seen most forms of human tragedy up close and personal. Sometimes I wonder half-joking, half serious, if there is something called “PTS-ED-D”, or “Post Traumatic Stress Emergency Department Disorder”? Of course, not, that’s nonsense.
As we rushed to get the kids ready for school, my 5-year-old daughter beamed her baby-blue eyes up at me, hair curly golden-blonde and said with a life loving smile, “Daddy! Can you put my shoes on, please?” She proudly raised her adorably tiny and favorite new hot-pink glitter shoes and handed them to me. I put them on her and she blew me a kiss. “Bye Daddy! I love you,” she said.
“I love you, too. Have a great day at school,” I said. At light speed, they rushed out the door and I rushed to work for the early shift.
Two hours into my chaotically routine shift the charge nurse gets off the phone and says, “Buckle up guys. We’ve got a pretty bad one coming in. EMS will be calling in any minute: Trauma, level I, no vital signs.”
“Alright, guys. Trauma room one. Let’s go,” I say. Before any radio call, the ambulance doors blasts open and all I see is a blue swarm of huge EMS men around a rolling ambulance stretcher, one up high doing chest compressions with sweat pouring off his red face like Niagara Falls, and all the others busily working this trauma looking notably more stressed than usual. As they roll down the hallway towards us, still I see nothing but a sea of big burly EMS men and haven’t seen even a glimpse of an actual patient yet. As they roll around the door and make their left turn towards me, a tiny but searing flash of hot-pink and glitter explodes into my eyes through the sea of blue uniforms. “Oh… My… God…” I think to myself.
T H O S E S H O E S
Hot-pink. Glitter. Tiny. Time stood still.
.
.
.
I felt my heart rate dropping. I was getting dizzy. Was my worst nightmare about to come true, right here in my own ED, on my own shift? I needed to see the face. NOW. I was afraid the see the face. As “clinical” as I could be to get through the most difficult parts of my job, this was too much. As the stretcher came towards me, the sea of uniforms parted and I saw her.
A girl 5 years old, with tiny hot-pink and glitter shoes.
The hair: brown and straight. The eyes: emerald-green. A beautiful child. Someone else’s child. She was frighteningly reminiscent of mine, with the exact same shoes, but with skin now fading to a ghostly white-gray and eyes as lifeless as a doll’s.
Time exploded back into the usual frenetic light-speed trauma-code pace. Airway Breathing Circulation Line 1 Line 2 Monitor Fluids Blood X-rays Needle-chest FAST-scan Chest-tube. ATLS protocol at light speed.
We ran the code for what seemed like forever. We did everything, and then some, and then some more. We did everything we possibly could for this child who was on a school field trip, run over by a drunk driver who jumped a curb in his truck on a Monday morning.
Pulse, none.
Pressure, none.
Pupils, fixed.
Pupils, dilated.
This beautiful child was dead. Someone else’s beautiful child was dead. My worst nightmare was not coming true. Someone else’s was.
I went back to the old dictation room to regroup. I could hear the sound of co-workers trying not to cry. I could hear the sound of one of my other patients saying, “G-d d—n it! What the hell is taking so damn long!?” I had to prepare myself to break the news to the parents. There is no way to sugar coat this type of news, no way to make it any easier. I felt like I was going to die.
I walked into the room and greeted two parents on their knees crying, praying, horrified but certain we could save their child with the same miracles they had seen on TV. They looked about the age of my wife and I. Their faces were hauntingly familiar. I was about to drop a nuclear bomb on their lives. The words cracked and fumbled as they came out of my mouth. “Hi, I’m doctor Bird. Are you the parents of…?”
I’ll never.
Ever.
Forget.
T H O S E S H O E S
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This author does not divulge protected patient information or information from real life court cases. Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients. To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional. Any opinions expressed here are of the author alone and not those of epmontly or WhiteCoat.
Posted in Guest Posts, Patient Encounters | 13 Comments »
Thursday, August 30th, 2012
It was 2 AM and kind of slow. Then a “twofer” comes up to the registration desk. Mother and son both need to be seen.
Emergency medicine lore has it that when more than one patient from the same household registers to be seen at the same time in the emergency department, the likelihood of there being a true emergency is inversely proportional to the number of people registering.
Didn’t quite hold true in this case.
Earlier that morning, a teenage son and his mother decided that their cat was dirty and therefore decided to clean the cat and trim its nails. The problem was that the cat did not want to be cleaned. Its claws protect it and it cleans itself just fine with its tongue, thank you. So the cat began hissing and scratching at both of them once it saw the bath of soapy water into which the evil humans were planning to submerge it.
Mother and son were undeterred. Showing the cat how they were the boss, son and mother were somehow able to hog tie the cat, duct taping the cat’s front and rear paws together. That will teach the cat.
(more…)
Posted in Patient Encounters | 18 Comments »
Wednesday, August 22nd, 2012
Real patient encounter …
A 22 year old guy comes to the registration grabbing his chest. He’s having palpitations and chest pain.
He’s a pack a day smoker, has no family history of heart disease, and was out late the prior evening partying. So when he woke up, he was dragging a little. He had to be at his construction job in an hour, so he drank a “Monster” energy drink. When he got to work, he still felt tired, so he drank another “Monster” energy drink. That’s when the palpitations and chest pain started. He was anxious and felt a little short of breath, too.
The EKG from triage showed a mild sinus tachycardia of 106. No arrhythmia. No ischemia. His physical exam was completely normal except for his anxiety and his elevated pulse. He got an aspirin and some Ativan.
A half hour later, he wasn’t feeling any better even though his pulse was in the 80s.
Now everything points at this guy being acute “Monster” caffeine overdose. It was suggested that he be discharged with a prescription for Ativan and an order to lay off the caffeine. But because he was still symptomatic, he got an entirely unnecessary cardiac workup. His second EKG was normal sinus rhythm and still showed no ischemia. His CBC, chemistries, cardiac enzymes, and urine drug test were all normal.
Oh, and his chest x-ray showed a complete collapse of his left lung.
The problem with labeling testing “unnecessary” – even though the tests may be normal most of the time, they aren’t normal all of the time.
Where do we draw the line between what is and is not “unnecessary”?
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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.
Posted in Patient Encounters, Policy | 15 Comments »
Monday, August 13th, 2012
 They waited patiently while the emergency department staff was stabilizing several patients who had been involved in a motor vehicle accident.
“We’ll be with you as soon as we can.”
They waited patiently while the emergency department staff tended to the hypotensive nursing home patient, but were loudly telling everyone how the nursing home patient “got there after they did.”
“You’re next in line.”
When another ambulance rolled through the doors with a chest pain patient, they had enough and began demanding that their daughter be seen NOW.
So after the chest patient’s EKG was reviewed and showed neither signs of ischemia or sepsis, the doctor went into the room.
A rotund 9 year old was playing Angry Birds on her iPhone.
“What brought you here today?” the doctor asked.
“We just finished our meal at Burger King, were walking out to our car, and she got a stomach ache. When she sat down in the car, lights flashed before her eyes and she thought she was going to die, so we brought her here.”
Now the child’s vital signs were normal, which meant that she probably had two of the criteria for sepsis according to NY Times reporter Jim Dwyer’s logic (with NY Times editor Jill Abramson’s approval). It also looked like she had a pimple on her forehead, which caused a “suspicion” of a superficial skin “infection,” so according to Jim Dwyer’s logic, the medical staff should have put her into a sepsis pathway and drawn a lactate level and other labs, probably admitted her overnight, and started triple antibiotic therapy.
But, using his clinical judgment, the doctor did not perform any lab tests and examined the patient.
Symptoms gone.
Eyes normal. Visual acuity normal.
In fact, her whole examination was normal … except for the pimple, of course.
So, without so much as a blood glucose level, the patient was discharged with instructions to follow up with their family physician and/or an ophthalmologist if she continued to experience the light flashes and to return if any further problems occurred.
Ten minutes later, the family was back at the registration desk.
“She saw another flash of light in the parking lot and thought she was going to die again. AND THIS TIME THE DOCTOR BETTER DO SOMETHING!”
The patient’s vital signs were still normal, meaning that she met two criteria for sepsis under Jim Dwyer’s logic, and she still had that glaring pimple on her forehead. But she wasn’t seeing lights any more and her visions of death had subsided.
“We’ll get you into an examination room as soon as we can. Right now all the rooms are full.”
“WHAAAAT!?! We have to wait AGAIN!?!?”
“Unfortunately, all of the rooms are full. We’ll get you back into a room as soon as we can.”
“F___ THIS! We’re going somewhere else.”
And with that, the patient and her family left.
Patient and family were doing well the following day during their call to administration to complain about the lack of care and lack of blood testing during their visits to the emergency department.
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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.
Posted in Patient Encounters | 5 Comments »
Sunday, August 12th, 2012
By BirdStrike M.D.
I’m sitting in my apartment on the West Coast starving, listening to my stomach growl, waiting for my pizza to be delivered. It is taking unacceptably long. I’m going back and forth on how little I can tip the pizza delivery man without feeling too guilty to actually enjoy the pizza if and when it ever arrives. There’s a knock on the door. Thank God, I think to myself, it’s about time.
I open the door, “Pizza’s here,” says the pizza man. “You’re the best doctor in the world!”
“What?” I say. “Yeah, the doorman says you RULE! He said if I ever need to get checked out, to go see you. He says, ‘You da man!’”
“Oh, that’s just Tony the doorman,” I say shaking my head. “Don’t listen to him. He says that all the time.”
………………………………………………………………………………………………………………………………………………………….
I pick up a chart in the ER, back when there still were things called “charts”, and it says: “Tony ***** 37-year-old male. Chief Complaint: Back Pain.” I walk in the room and it is Tony the doorman of my apartment building, nervous, sweaty and pacing the room, with his jet-black hair slicked back and his gut as huge as always.
“Tony! How are you doing? Good to see you. What brings you in here, today?”
“Doc. You gotta’ do somethin’. My back’s killin’ me. I’m dyin’ here,” he says in his tough-guy accent, as he nervously paces the room.
“Where does it hurt?” I ask.
“Right here,” he says, pointing to his upper back, “right between da shoulder blades.”
“When did it start?” I ask.
“Just a couple hours ago. I didn’t do nuttin’. I was just sittin’ there and it hit me like a ton of bricks. I didn’t fall, lift anything heavy or hurt myself at all. I’m dyin’ here doc. You gotta help me. I need something for this pain,” says Tony.
“What does it feel like?” I ask.
“It feels like someone’s got a sledge-hammer on my back. Seriously, man. I’m dyin’ here. Come on. Do something doc. Make this pain go away. I need something for this pain. Please.”
“Is there anything that makes it any better? Anything that makes it hurt worse?” I ask.
“Nope,” he says.
“Does the pain move? Does it radiate?” I ask.
“No,” he says, “it’s just right there in da middle of my back?”
“By chance, is it a ‘tearing pain’ right between your shoulder blades?” I ask.
“Not really,” he says, “it just hurts!”
My gut is telling me that something is not as it appears. I have the nurse give Tony a dose of Morphine while I continue to get the history. Tony proceeds to tell me that he doesn’t drink, smoke or use any illegal or prescription drugs. Also, he reports no significant medical problems, and no significant family history. He also denies any history of chronic pain of any kind. His physical exam is completely normal including his vital signs with equal blood pressures in both arms.
“Alright, Tony, the nurse is going to give you another dose of the pain medication. We’re going to get a chest x-ray and see what that shows. I’ll be back in a few minutes,” I tell him. My gut is telling me, that there is something Tony is not telling me, but my brain is telling me that if Tony’s upper midline back pain is from a thoracic aortic dissection, and he dies from it, I’ll never forgive myself.
“Doc, it’s starting to hurt right here,” Tony says, pointing to his chest.
Bingo, I tell myself, it’s IS a dissection. I order a CT of the chest with IV contrast, d-dimer, basic labs and cardiac enzymes. Wait! His EKG? Did we do an EKG? I ask myself. I honestly can’t remember at this point. I could have sworn I looked at one and it was normal. They wheel him off to CT and I go pull up his chest x-ray. It’s normal; painfully normal. I walk over to the CT suite to look at the images as they load onto the screen and to take another look at his chart to see whether or not I had looked at an EKG. There it is, on the chart. It is in fact, completely, stone-cold normal. I breathe a slight sigh of relief. I watch as the cross sections load on the computer screen. His aorta looks as normal as can be. I’m not a radiologist, but I can usually spot a big tearing aortic dissection on a well done CT scan, and this one looks perfect. Of course it does.
I turn the corner to the main ED, and I’m hit with the all too familiar sound and smell of ambulance sirens and exhaust blasting through the double doors, monitor alarms frantically beeping, patients crying, doctors and nurses sighing.
“Tony, all of your tests came back perfectly normal. I honestly cannot tell you what is causing this pain, at this point,” I explain. I know exactly what’s causing this pain, I think to myself. “It’s probably nothing serious. Most likely it is musculoskeletal back pain or some acid reflux causing esophageal spasms. I think we’ve ruled out most of the ‘bad stuff’, however, it is concerning that this pain is so severe, especially since it is in your chest. The chance of this being a heart attack is extremely low, statistically, but I’d like to keep you in the hospital overnight. It’s just a precaution. You’re only 37 years old, you really don’t have much in the way of risk factors for heart disease, but you know what, I’d just feel better if we watched you overnight. Is that alright?”
“Doc. I need some more of that pain medicine,” says Tony.
Just then Melba, an old battle-axe ER nurse who I would shutter to ever run into in a dark alley, decides upon herself to start doing another EKG.
“Melba, we don’t need another EKG. Why are you doing another EKG? The first one was completely normal. We’re just going to give him some aspirin, nitro-paste, another dose of morphine and get him admitted. Cancel the repeat EKG. Okay? Stop,” I bark at her. Ignoring me completely, she shoots me with a glance from her evil Melba eyes and peels the EKG off the machine and flings it at me. I look at it: T O M B S T O N E S . Uh-oh. We went from a totally normal EKG, to a massive acute myocardial infarction, in a 37-year-old male with no practically no risk factors. Wow. Tony is dying.
“Tony, you alright?” I ask, as his face drains white. “Melba, put the pads on him,” I order. His eyes drift off, and his head slumps to the side. Tony’s dead. “Oh, sh–! V-Fib. Get the pads on him now! Gimme the paddles now! Charging. Everyone clear?!”
POP!
After 10 seconds of V-fib, and with a massive jolt of electricity directly through his heart, he is now back in normal rhythm. Tony’s alive. Thank God.
Off to the cath-lab goes Tony and there I stand scratching my head thinking, how in the world could I have been so wrong about this guy? I had him pegged as wanting nothing but morphine and he’s burning up myocardium. Geez. I could have seen myself sending this guy home with little or no work up. A 37-year old male? Back pain? No cardiac risk factors? Acute MI with a normal EKG on presentation? Holy crap! I almost missed it. If I had sent him home, he’d be dead!
A few weeks later, I’m practically falling asleep while walking into my apartment lobby at 8 am after the first of several night shifts. There’s Tony, back at his doorman post. I duck down and head toward the stairs trying to sneak by unnoticed, feeling like a complete idiot at having almost misdiagnosed his heart attack. “Doc! Get over here! Now!” screams Tony. I stop. I’m busted.
Tony runs over and surprises me with a M A S S I V E chest bump with his huge gut almost knocking me over and then follows it up with a huge bear hug. “You saved my life. You saved my life! You’re the best doctor in the world. I was having a heart attack. Can you believe it?! I was having a HEART ATTACK!”
“No, I can’t, I mean uh, yes actually I knew it from the minute you walked in the door. Yes. Thanks. I’m glad you are not dea….I mean I’m glad you are doing so well,” I say.
“I’m gonna tell everyone you da’ man! I’m gonna send EVERYONE to the ER to see you, doc!” he yells.
“No, please don’t do that….I’m mean, thanks, but I’m an ER doctor, and I don’t really have my own office, and you know it’s really busy there and we don’t need any more patients. Uh, I mean…you know what I mean, don’t you? But thanks, really, I’m glad everything turned out all right,” I stammer.
“I’ve never felt better in my life. Thanks again, doc,” he says.
Tony worked the door at my apartment for two years after that and suffered no ill effects from his heart attack. Then one day Tony didn’t show up to work. No one seemed to know if he quit, moved, got fired, or where he went. But for those 2 years Tony the doorman told every single relative of mine, pizza man, friend, paper boy, mail man, or random stranger in the lobby that I saved his life and that I was the best doctor in the world. I couldn’t believe it. I thought he would do it for a few weeks and forget about it, but he never did. Every chance he got for the 2 years that he worked there, he would loudly and proudly announce to everyone he could, that I saved his life. As you can probably imagine, it is not rare to save a life in the ER. However, to actually have someone go out of their way to thank the ER doctor and nurse who saved that life is rare. For whatever reason, Tony did his absolute best to say thanks not only for himself, but for everyone else that either just didn’t think to say it, or was too busy, sick, tired or stressed to do so. I don’t know where Tony the doorman is today, or if I’ll ever see him again, but if I do there’s one thing I’d like to tell him: “Tony, thanks for saying thanks.”
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This author does not divulge protected patient information or information from real life court cases. Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients. To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional. Any opinions expressed here are of the author alone and not those of epmontly or WhiteCoat.
Posted in Guest Posts, Patient Encounters | 10 Comments »
Friday, August 3rd, 2012
Cost to replace the door that you knocked off the hinges when you fell and hit your head: $127
Cost of bandages your dad used to wrap the laceration to your head when he came home from work: $6.50
Cost of food from the vending machine in the emergency department waiting room: $7
Cost of emergency department visit: $0 (thanks, state “insurance”)
Cost of CT scan that you told the doctor you thought you needed: $0 (you didn’t meet criteria for scanning)
Psych consult to evaluate why you’re giggling when the doctor is examining the cut on your head: $0 (the state cut psychiatric funding so much that we can’t get psych consults any more – but at least you have “insurance”)
Cost of the red magic marker your brother used to draw a fake laceration on your scalp: $1
Watching your dad flip out for having to wait four hours in the emergency department waiting room so that he could be the butt of the practical joke you and your brother played on him, then seeing him slap you in the head so hard that now you probably do need a head CT: PRICELESS
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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.
Posted in Patient Encounters | 1 Comment »
Monday, July 30th, 2012
 A patient comes in with dyspnea. He has a history of CHF and a history of COPD, so determining the etiology of his shortness of breath would prove to be a little tricky.
His wife, trying to be helpful, repeatedly interrupts the patient during his history.
“How long have you been having trouble breathing, sir?”
“About three …”
“It all started when my son’s nurse came to visit. My son has multiple ulcers from diabetes and is getting wound care at our home. They’re not sure if he has MRSA yet.”
“I’m sorry to hear that. Now how long have the symptoms been going on for, sir?”
“About three or four hours.”
“You’re going to check him for pneumonia, right? The home health nurse said that he should definitely be checked for pneumonia.”
“Yes, ma’am. We’ll check him for pneumonia. Now does anything make your breathing get better or worse?”
“You’re going to check his pro-time, too, right? You did know that he was on coumadin, right? He hasn’t had his pro-time checked in over a month.”
“Yes, ma’am. We’ll check his pro-time. Now is there anything that makes your breathing better or worse?”
“He was last admitted in this hospital about 3 months ago. He had heart failure then.”
“That’s good to know. I’ll …”
“Oh and I don’t know if this makes any difference, but he had two bowls of Mini-Wheats for breakfast this morning. He usually only eats one.”
“OK.”
Back in the old days, when a woman was ready to deliver her baby and a father was getting in the way of preparations to deliver the baby, the doctor or midwife might tell the husband to go boil some water. In reality, there wasn’t much of a use for boiling water when delivering a baby. But in order to boil the water, the father had to go out and build a fire, collect the water from the well, heat up the stove, and then put the kettle on the stove to boil. By the time that the father returned with the boiling water, the baby had already been delivered and the father hadn’t managed to get in the way of the delivery.
Our helpful but counterproductive young lady needed to “boil some water,” but telling to do so wouldn’t help matters much. Then an idea sprouted up.
“Wait, did you say he was on coumadin?”
“Yes.”
“What dose?”
“I don’t know. We left his medications at home when we rushed to get here.”
“I need you to go home and get those medications for me.”
“But …”
“It’s a JCAHO regulation that we have accurate medication reconciliations on every patient that comes into this emergency department. It would be very helpful to see the medications your husband is taking so that we can make sure that they aren’t causing his difficulty breathing.”
“OK. I’ll be back as soon as I can.”
“No hurry. Please drive safely.”
“Now about your shortness of breath, sir ….”
He didn’t have pneumonia. And he was admitted and waiting for a bed before his wife returned with the medications.
“Go get the medications” may just become the modern day equivalent of “go boil some water.”
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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.
Posted in Patient Encounters | 8 Comments »
Tuesday, July 10th, 2012
By BirdStrike, MD
Taking a break from my main job at the trauma center, I was covering an odd night shift at the “Little ER”, an 8 bed glorified “urgent care” type ED that actually takes ambulances, but probably shouldn’t. Susie the nurse walks calmly out of room 4 and says, “We’ve got a heroin overdose in there.” Being that the EMS radio hadn’t gone off and no crew wheeled by bagging anyone blue, I was a little surprised. “Her friend dropped her off, and we pulled her out of the car. There are syringes all over the car floor.”
I sauntered over to the room, knowing that my very experienced nurse Susie would have yanked me into the room immediately if the patient wasn’t at least somewhat stable. I walked into the room expecting to see one thing, but what I saw was quite another. Lying there on the stretcher was a tanned 19 year old, buxom blond female lifeguard that easily could have been a Victoria’s Secret model for her day job, in her bikini, breathing slowly. RR 14, HR 55, BP 100/60, O2 sat 95%.
I call out her name, “Buffy…Buffy!” There was no response. With a sternal rub, “Buffy. Buffy! What did you take? Did you shoot heroin, cocaine, what did you take?” “Leave me….leave…me…. alo…..” she trailed off. With a much harder sternal rub and the old supraorbital notch trick, I asked again, “Buffy, what did you take?” “Percocet, you d—–bag”, she muttered and fell right back asleep. A little surprised that a user advanced enough to be regularly injecting narcotics, would make the rookie mistake of injecting oxycodone with Tylenol, I asked again with a much required sternal rub, “Don’t you know Percocet has Tylenol in it? Don’t you know that if the Oxycodone doesn’t kill you, the Tylenol will if you inject enough of it?” Her answer, barely able to keep her eyes open was, “No s—t Sherlock, I used the cold water dilution technique. You think I’m stupid enough to kill my liver for a little high? Google it Einstein”, and eyes closing, she quickly fell back into her euphoric opiate twilight.
Fortunately for me, this tiny 8-bed “Emergency Department” (if you could call it that) in addition to having invested in such technologies as the “wheel”, the “pencil”, “running water” and “sterile technique”, actually did have access to “Google”, believe it or not. Feeling a little like an idiot for not knowing this particular piece of street lingo, I Google-searched, “Cold water dilution technique percocet”. Let’s just say that Google needed no more than a nanosecond to educate me on the very quick and easy technique for removing the acetaminophen from oxycodone/apap, and making freshly sterilized and purified oxycodone-water ready for injection or drinking.
Buffy’s very concerned father arrived and received the same education that I received that night. He also explained to me that she had always his “perfect child”, a straight A student, and that he was learning a few things about his “little girl” tonight that he hadn’t expected to learn. Buffy the buxom lifeguard was correct that she was smart enough to protect her liver, as her initial and repeat acetaminophen levels were zero, with normal LFTs. She came very close, but never required Narcan as she remained stable on oxygen and happy to go to detox as long as we let her sleep it off and dream her beautiful opiate dreams.
After she rolled out the door in the ambulance stretcher to be transferred to detox with her loyal father trailing, I looked at the demographic sheet and to my shock, she and her father were neighbors of mine and lived in a home I drive by every day. (I know, I should know better than to be shocked that my precious upscale community could suffer the same scourge of untreated addiction that afflicts all other less affluent and less plasticized neighborhoods.)
I had no concrete follow up for about a year, though rumor had it that she left rehab clean and sober and remained so for the past year. I took solace in that likely I had saved the life of a young person with great potential. A few days ago, I drove by their house and saw dozens of cars lining the street. I assumed that there was some sort of family celebration, party or reunion. When I ran into one of my other neighbors I was asked, “Did you hear about Buffy Smith, that gorgeous blond beauty that lives down the street?” “No,” I said, “what happened?” “She died last night. Her parent found her dead. The cops think it was an overdose. Isn’t that sad?”
“Yes,” I said. “Yes. It really is.”
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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.
Posted in Patient Encounters | 13 Comments »
Sunday, July 1st, 2012
 Mom busts through the doors with her young son.
“He’s having an allergic reaction. Someone help!”
Everyone drops what they are doing, rushes over, and brings the child into a room.
Young child looks up at all the people and gives a big grin.
“I was feeding him his bottle and some of it spilled on his chest. His chest got red almost immediately and started developing little blisters.”
“What was in the bottle?”
“Milk.”
“Is this the first time he has drank milk?”
“No he drinks it all the time, but it has never spilled on his chest before.”
After the child was unwrapped and examined, no blisters or redness were forthcoming.
“Well, they were right there.”
“He looks OK now, and it wouldn’t be likely for someone to drink milk with no allergic reaction and then have a reaction on his skin. I think he’ll be just fine.”
Mother leaves upset.
Two days later, administration gets a phone call that the patient wants her copay refunded (she didn’t have a copay) because her child wasn’t treated properly. The child’s primary care physician stated that the child should definitely have been tested for milk allergies in the emergency department and that he could have had serious consequences because the doctor didn’t tell her to stop feeding the child milk.
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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.
Posted in Patient Encounters | 4 Comments »
Monday, June 25th, 2012
 It took a while, but I now have five things on my list of rantable offenses occurring in the emergency department.
To recap …
Don’t call it the “emergency room” or the “ER” to my face, in the comments, or anywhere else. Period. It is the emergency department. “ER” is a TV show that was canceled. We don’t need to dredge up old drama. I’ll politely correct you once, then I’ll get DeNiro on you the second time. And we’re emergency physicians. We’re not “ER docs”.
If you use a cell phone while I’m examining you, talking to you, or treating you, that’s like spraying me with pepper spray.
Baby talk will probably cause me to have little twitching episodes. If I hear it, I might say something like “Hey, I speak ‘Fudd’ too” and talk back to you in the same manner. Don’t be offended.
If you come requesting a ZeePack for a “low grade fever” of 99.1 degrees you’re going to be disappointed. Look up diurnal temperature variations. It isn’t a fever.
Then there’s pain transference.
Wait. What is pain transference, you ask? Let me describe a typical experience in detail for you.
Consider a patient with a complaint of pain who comes to the emergency department accompanied by another person. The patient dons a gown and the accompanying person sits in a chair next to the stretcher.
Your thorough exam leads you to the area of the body in which the patient is having pain. You press around gently on the area … not even on the area where the patient is reporting to have pain … and then it happens. You hear a “reverse hiss” from across the bed.
Imagine making a hissing sound with your mouth. Now imagine sucking air in through your clenched teeth instead of blowing air out. The “reverse hiss” is the first sign that pain transference has occurred.
If you’ve not had this happen before, you think to yourself “what was that”?
You look up and the other person in the room invariably has a frightened look on her face.
You look at the patient.
The patient looks back at you and shrugs his shoulders.
You lightly touch near the painful area again. The patient doesn’t flinch, but you hear another reverse hiss from across the bed.
You look across the bed out of the corner of your eye. Now the person across the bed has her mouth open and is tensing those muscles that make all the skin on the neck stick out. In severe cases of pain transference, the other person in the room will even yell at you because you’re “hurting” the patient.
You look back at the patient.
“Does that hurt?”
“Ummm. I guess …”
You gently press around a little more and you hear a series of short reverse hisses. You see if you can get the person across the bed to signal “SOS” in reverse hiss Morse Code. “S … O … U” SOU? No no no. The last hiss was supposed to be short, not long. Aaahhh forget this. Didn’t work.
But to cinch the diagnosis of pain transference, you have to perform a confirmatory maneuver:
You have to lift up the sheet so that the person across the bed cannot see where or when you are touching the patient. This act of defiance interrupts the visuo-spacial pain continuum, causing immediate anger in the person across the bed, ceasing any additional reverse hissing, but also causing the patient to experience much worse pain in the same spot that wasn’t hurting only a few seconds before.
“Oooooowwwww” moans the patient.
“Why are you trying to hurt him?” Yells the advocate.
“But I just touched there a second ago and it didn’t hurt at all.”
Doesn’t matter where you touch. Doesn’t matter how hard you touch. You have now become a victim of pain transference. Studies clearly show that there is now a 24% chance of a call to an administrator and a 97% chance of Press Ganey badness.
You should have excused yourself from the room at the first “reverse hiss.”
Posted in Patient Encounters, Random Thoughts | 22 Comments »
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