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Archive for the ‘Patient Encounters’ Category

Unnecessary Testing?

Thursday, April 4th, 2013

A patient was sent to the emergency department to have an ultrasound of her uterus performed.

She had been having abnormal bleeding which coincided with about the time her period was due – only it was a little heavier and lasted a little longer than usual. She decided the best course of action would be to make an emergency appointment with the gynecologist. She was seen the day before she was sent to the ED and the gynecologist performed an ultrasound in his office … which was normal.

The patient called the gynecologist the following day and said that the bleeding was still there, so the gynecologist told her to go to the emergency department for another ultrasound and some blood testing.

The patient arrived stating “I’m here for my ultrasound. Dr. Speculum sent me.” Since patients need orders for testing to be performed, the patient was given the choice of waiting to be seen in the ED or of getting a prescription from her doctor for the exam. She chose the former.

After examining her, we performed a pregnancy test which was negative and a CBC which was normal. So I told the patient she was likely just having a heavy period and that she could follow up with her gynecologist as an outpatient.
The patient demanded an ultrasound. After all, Dr. Speculum sent her to the ED specifically to have an ultrasound done.

So I called Dr. Speculum.

“Hey, it’s WhiteCoat here. Your patient is here with metrorrhagia and I’m trying to discharge her, but she insists that you want her pelvic ultrasound repeated.”
“Yeah. Can you do it?”
“Well what are we doing it to look for?”
“Fibroids”
“OK, well if she does have fibroids, are you going to admit her? Her hemoglobin is fine.”
“Noooooo. Discharge her after the ultrasound.”
“So then why … nevermind. If all you’re looking for is fibroids, weren’t you able to see that she didn’t have any fibroids on the ultrasound you did on her in the office yesterday?”
He must have really wanted that ultrasound by his response.
“Naaaaaaah. The ultrasounds I do in my office aren’t accurate.”
Allrightey, then.

The repeat ultrasound was still normal. I guess he was more accurate than he gave himself credit for.

Wonder if she’ll be referred back to the ED tomorrow for repeat pregnancy testing.

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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.

I Made A Drug Seeker Cry Today

Thursday, March 21st, 2013

I made a chronic back pain patient who was out of his pain medications cry in my emergency department today.

Actually, he was already crying when he came in. The nurse said that he hobbled in from the waiting room bent over like an old man and using his wife’s shoulder for support. He couldn’t stand upright because of his severe pain.

I was finishing up with the patient in the room next to his when I heard him get put into the room. He was moaning and moaning. As I discussed the discharge instructions with the current patient, the moans sometimes overshadowed what I was saying.

Before going to see the patient, I looked up his old records on the computer.

He was 41 years old. According to his old chart, he had wrenched his back while fixing the tire on his car more than a month ago. Ever since then, he had been having pain in his lower back. His primary care physician gave him a couple of weeks of Percocets and some Valium. Those medications helped him somewhat, but he still had pain. When he ran out of the meds, he got one week’s refill and was referred to physical therapy. He went to physical therapy twice and it caused the pain to get so bad that he stopped going. He called his doctor back and his doctor ordered MRI of his back. I pulled the MRI report which showed multiple minor disk bulges but no other problems – definitely nothing that would cause his back pain. So his doctor set him up with a pain clinic. No appointments were available for more than a week and his doctor had cut him off from narcotic pain medications after the relatively normal MRI. This was his third ED visit in the week.

When I walked in the room, he was in a fetal position on the bed and he was crying.

“I’m Doctor WhiteCoat. How can I help you today?”
“My back, doc. It’s killing me.”

He described the whole story. I already knew most of it from notes in the computer. I also saw the several doctors from whom he had received pain medications.

He wouldn’t lay flat on the bed because he said it made his back worse. His position of comfort was laying in a fetal position or laying on his back with his knees flexed.

Back in medical school, I worked part time in a back pain clinic for a year or so (long story). After a normal neurologic exam, I thought he probably had a psoas muscle spasm. Pretty common cause of non-traumatic back pain.

So I gave him some Toradol and Valium. I told him that I thought I knew what was causing his pain and that if he trusted me, I could probably make him feel better. Fortunately, the ED wasn’t too busy that day, so I could spend a little extra time with him.

I got him to lay on his back with his legs flat. I went to see another patient.
I came back and had him roll on his stomach. I went to see another patient.
I came back and used the stretcher to extend his back a little. I went to see another patient.
I came back and used the stretcher to extend his back a little more. He moaned in pain. I went to see another patient.
After the third incremental extension, I let the bed back down. I showed him how to get out of a bed without putting a strain on his back. Then he stood upright.

No pain.

A win!

I showed him a few stretching exercises he could do to hopefully help keep the pain from developing again.

I left the room to finish discharge instructions, printed out some examples of stretches he could do and came back to hand the printouts to him. When I came in the room, he was crying again.

“I thought that your pain was gone,” I said hesitantly.
“It is. I was just telling my wife that you’re the first doctor through this ordeal that has actually sat down and listened to me and who tried to fix my pain without pumping me full of drugs. I don’t even think I’ll need the pain prescription. My back feels that good right now.”

I smiled. He reached out and gave me a firm handshake. Then he pulled me in and gave me a hug.

A little surprised by that whole man hug thing, but I was glad that I was able to help him.

I was working in the charting room (which is out of the patient’s view) when I heard him walk up to the desk and say “Tell Dr. WhiteCoat thank you again. He is an excellent doctor. And thank you for all your help.”

After he left, I had to rub it in. I walked out and said to the nurse “I heard you have a message for me?”
“What?”
“A message for me from a patient?”
“Nooo.”
“Something about being an excellent doctor. Come on now. You can say it. Ehhhhhhxellent … Ehhhhhhxcellent.”
Then the secretary chimed in.
I heard him say that you were a dork. Dorrrrrrk. Dorrrrrrk.”

The insubordination that all of us excellent physicians have to put up with some times …

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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.

WTF Moment #1071

Sunday, March 17th, 2013

523px-Sarcoptes_scabei_2What is it with some people and rashes?

The patient waits 3 hours to be seen. When I enter the room, the patient says “I had a rash on the back of my leg 2 months ago. Can you tell me what it was?”
Out of the 4 or 5 things running through my mind at that point, the least pressing one of them wasn’t about calling up the feds to get satellite video feeds of the patient’s house two months ago so I could zoom in through the window shots and hopefully identify the cause of the mysterious rash.

“The rash isn’t there now?”
“No.”
“Well, sir, I honestly don’t know what caused the rash because I can’t see it any more. As long as it isn’t there any more, I don’t think it’s going to be a problem.”
“Was it scabies?”
“I doubt it because it wouldn’t have just gotten better.”
“Well what does scabies look like?”

At this point, I should have stopped the conversation and discharged the patient. Unfortunately, my foresight gene had gone offline for a few moments.
“Scabies is usually little itchy spots or pus-filled blisters. Most commonly the spots are between the fingers or the toes. Sometimes there will be little red lines where they burrow under your skin.”
“Wait. You mean scabies are bugs?”
“They are mites.”
“Oh my God. That’s what the rash looked like. I’ve got bugs burrowing in my skin.”
“No. You don’t. The rash is gone.”
“What if they’re just sleeping? Couldn’t they still be in my house?”
“I’ll tell you what. If the rash comes back and you think it is scabies, there’s cream called elimite that you can buy over the counter to kill the mites. Until then, I wouldn’t worry too much about it.”

An hour after he was discharged, we start getting the phone calls.
“My son said you told him my house was infested with bugs. What’s THAT all about?”
“How long should he stay home from school for?”
“Can these bugs be sexually transmitted?”
“Should I be going to work? I work in a nursing home.”

[facepalm]

My shift couldn’t end soon enough.

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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.

Useless Workups

Thursday, March 14th, 2013

A patient calls his family doctor and gives a history of having chest pain on and off for the past few days. Pain worse with activity. Not having any now. Of course, you know that the family doc is going to send the patient to the Emergency Department. You just know it.

So the patient gets to the emergency department and of course the EKG is normal … and the labs are normal … and the chest x-ray is normal.

Because the patient has no history of chest pain workups, of course you know we have to recommend that the patient stay overnight and have a stress test in the morning.

“You’re kidding. I really have to stay? Everything is normal. Can’t I just go home and do it later? ”
“Well … no … not really. We can’t force you to stay in the hospital, but we really think that it would be a good idea.”

Then you start to second guess yourself. This guy’s in good health. He’s not having pain now. Of course the insurance company is going to call this an unnecessary admit.

Fortunately for everyone, you found a reason to justify the admission.

About 15 minutes later, the alarm goes off.

NSR to Torsades
Holy sh**! Torsades! Get the paddles!

It seemed like several minutes, but it ended up being more like 35 seconds until this happened.

Torsades Shock to NSR
“What happened?”
“Um. You nearly died.”

Had the patient not called his doctor, had the doctor not sent the patient to the hospital, had the patient not been brought right back and place on a monitor, or had the patient decided to leave AMA, he probably wouldn’t be here right now.

Triple vessel disease with a CABG.

Every once in a while those useless workups end up saving a life.

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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 Book and its Cover

Tuesday, February 19th, 2013

When you work in an urban hospital, sometimes it’s difficult not to become jaded.
There are certain neighborhoods that generate a disproportionate number of patients for some emergency departments. Meth is rampant. Marriage pretty much nonexistent. More bars than there are restaurants. Domestic abuse frequent, but prosecutions rare. Police know people more by their street names than by their real names.

South Heights was one of those neighborhoods.

The emergency department frequently treats South Heights kids who are neglected by their parents. I’ve seen young South Heights kids with seizures from cocaine. Now seizing kids get drug screened as part of their workup. I’ve seen more than one young South Heights kid with a lighter burn. I’ve given a lollipop to a 2 year old South Heights kid and watched the mother take the lollipop out of the kid’s mouth when she thought no one was looking, chew on the lollipop until there was nothing left, then slap the kid for crying. Many parents from South Heights can recite the names of the family court judges from memory and quite a few have had their children taken away. Social service workers know many South Heights kids personally. Based on the history of the area, many people tend to look at the kids from South Heights with pity and look at parents from South Heights with contempt.

The next patient on the board was “finger laceration.” As I walked toward the room, the nurse mentioned “they’re from South Heights.” I was already thinking about whether I’d get attacked if I had to call Child Protective Services.

The patient was a cute little girl about 5 years old. Thin stature, great smile, polite. She was holding her arm out on the table and a gauze pad with a slowly enlarging spot of blood covered her hand. Her mom was weathered. Most of her teeth were missing. Her clothes looked like they hadn’t been washed in a while. A reusable shopping bag with newspapers, empty beer cans, and a pair of headphones sat on the chair next to her.
“So what happened to your finger?” I asked the little girl.
“I cut it with a scissor.”
The mom explained that the patient was told to wait to open a bag of cookies, but didn’t do so. Instead, she grabbed a pair of scissors from the drawer and forgot to take her finger out of the way when she cut. The result was a fairly deep laceration to the outer part of the index finger.
I went through the described mechanism in my head for a second. Scissors in one hand, holding a bag with other hand, cut to opposite index finger. OK. Injuries seem to fit the explanation.

Then I went about describing what I was going to do next.
“I’m going to put some medicine into your finger to make it stop hurting. Then we have to clean it out to get rid of all the germs. Then I’ll fix it up for you. The medicine to make it stop hurting burns a little bit. Once the burn is gone, it won’t hurt any more. OK?”
The little girl looked from me to her mother and her eyes began to tear up.
She cried and whimpered, but she held completely still while I injected lidocaine into her finger. Her mom leaned over next to her, gently cupped her head and wiped away her tears.
After the wound was clean, I got everything ready to fix the wound. But the patient was a little hesitant because the lidocaine injection had hurt. Despite me showing her how her finger was numb, she cried and didn’t want me to touch her hand.
Then mom came up with an idea.
She ruffled through her shopping bag and pulled out an old iPod. She started playing a country song on the iPod.
“Do you know what this song is?” mom asked.
“My ‘I love you’ song,” the little girl said back.
While I worked fixing the little girl’s finger, I watched as her mom caressed her daughter’s face and as they softly sang the words of the “I love you” song back and forth to each other.
I finished the last suture about 15 seconds before the song ended. The little girl didn’t move a bit until the end of the song. Then she used her uninjured arm to hug her mom around the neck and tell her one more time “I love you, mommy.”
As I wrapped up the little girl’s finger, I thought how difficult it can sometimes be not to form premature impressions about people.
And as the young patient blew me a kiss with her bandaged hand while being carried out the door by her mother, I thought how desperately South Heights needs a few more moms like this one.

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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.

Spaghetti and Impaction

Saturday, February 9th, 2013

Spaghetti MeatballsStool impactions probably aren’t what most people would consider an “emergency” … until they actually have a stool impaction. Personally, I wouldn’t wish a stool impaction on someone. In chronic constipation, more and more stool collects in the colon until size of the ball of stool is too big to pass through the opening to the outside world. The major function of the colon is to absorb water from the stool, so the longer the stool sits in the colon, the larger the amount of water that gets absorbed, and the harder the blob of stool gets. By the way – the whole water absorbing function of the colon is why it is important to keep well hydrated to maintain good bowel habits.

There are a lot of ways that you can try to get rid of a stool impaction, but when the stool gets hard enough, pretty much the only way to remove the impaction is by having someone use their fingers to perform a “disimpaction.” There’s just no good way to get a big hunk of stool the consistency of clay soft enough for it to pass through the rectum. It has to be dug out.

Disimpactions aren’t fun for the doctor or the patient. They’re painful and obviously messy. I’m probably more willing than most docs to perform disimpactions because I can see how much the patients are suffering. Although unpleasant, disimpactions are an easy fix to the patients’ problem. Like I said, you probably can’t appreciate how bad impactions are until you’ve been on the other side of the gloved finger.

As I donned my mask, gown, and multiple layers of gloves to commence the procedure on one patient,  one of the nurses sent a nursing student in the room with me to observe. The student said that she had seen “many” disimpactions in the past, but the nurse wanted her to observe this one, so she reluctantly came in the room with me.

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What’s the Diagnosis #16 — Mmmmm, Eggs

Friday, January 25th, 2013

sausages_scrambled_eggsThis is an interesting case for a number of reasons.

First, it shows how a little testing can turn into a lot of testing to “rule out” diseases in the emergency department.
Second, it hopefully provides some good teaching points.
Third, the comment from the attending physician gave me the giggles. That will explain the title. But you have to read through the case to understand the comment.

I’m not going to discuss all the minute details of the case, only the major findings that contribute to the flow of the case.

A patient got sent in from the nursing home because her gastrostomy tube was leaking blood and the nursing home was convinced that the patient was having GI bleeding. When the bandage over the patient’s G-tube was removed, it was fairly obvious that the skin about the G-tube site was the source of the blood. The skin was raw and was oozing dark red blood. Flushing the G-tube produced a little blood, but the blood cleared. The patient’s vital signs were stable except for a mildly elevated pulse. Proper skin care probably would have resolve the bleeding. Some people may have left it at that and sent the patient back to the nursing home. I drew labs and did an abdominal series.

(more…)

Not Heart Failure

Friday, January 18th, 2013

I wasn’t giving in to the patient who wanted a prescription for Levaquin after the standard ZeePack didn’t cure his cough. He had a normal chest x-ray and labs the day before but was convinced that he had pneumonia. I tried explaining the difference between bacteria and viruses. I used the “RAID doesn’t work on dandelions” routine. He wasn’t convinced.

“I NEED a stronger antibiotic to break this up. Levaquin has worked in the past.”
“You know, I think I’m going to start you on some heart medications, instead. Some nitroglycerin and some Lasix for your heart failure.”
“Whaaat? I don’t have heart problems. I had a normal stress test a few months ago. Why would you want to start me on heart medications?”
“You have risk factors for heart problems and coughing is a sign of heart failure. I should probably start you on Digoxin, too. Ehhh … maybe not. That’s kind of strong medicine to start out with.”
“This is ridiculous. My chest x-ray and blood tests were normal yesterday. I don’t have heart failure. I’m calling my doctor and I’m not taking any of those medications.”
“Your chest x-ray was normal. That means you don’t have pneumonia, either. And bronchitis is a viral infection. Levaquin isn’t going to help your symptoms any more than the heart medications would. Do you see my point, now?”
[long pause]
“I’ll just call my doctor.”

I can only imagine what conversation sounded like.

———————–

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.

Unnecessary Care?

Saturday, January 12th, 2013

It isn’t much of a case, but it created questions in my mind.

A mom brings her 8 year old daughter to the hospital for a nonproductive cough. No fever. No runny nose. Just a cough. The patient had started school again this week, and so the microbiome in her nasal passages had thus begun mixing with all of the other microbiomes on school lunch tables, desks, and childrens’ shirt sleeves. The end result was that now she was coughing for a couple of days – like a majority of other children in the school.

The child looked fine. I told the mother that she likely had a “head cold” and that it would have to run its course.
The mother wasn’t convinced.
“How do you know she doesn’t have the flu”?
“Well, I don’t know for sure, but even if she did have the flu, it wouldn’t change the management right now. It would still have to run its course.”
“I want her tested for the flu.”
“Influenza testing really won’t help us much. The test itself has a high false negative rate, meaning that even if the test is negative, a large percentage of people still end up having influenza.”
“I want her tested for the flu.”
Fine, I thought. It’s your money.
Forty five minutes later, results from the influenza swab came back negative.
“So like I was saying before, this is something that will have to run its course.”
“You said that the test wasn’t accurate. There are a lot of kids in her school with influenza right now. I want her to get Tamiflu.”
“Tamiflu isn’t going to help. It is only effective within the first 48 hours. You said the cough started two days ago.”
“You know, I have always had good things to say about this hospital and I’ve never had this many problems with a doctor in the emergency department before. It hasn’t been 48 hours and I want her to get the Tamiflu.”
Nice threat.
So I gave the woman a prescription. Let her spend the $120 for a drug that won’t work.

Then I began thinking. Would some bean counting clipboard carrier claim I provided unnecessary care?

So what do you think? Knowing that rapid influenza testing has a significant false negative rate and knowing that influenza is widespread in the country, but also knowing that a patient has mild symptoms …

Is it unnecessary care to provide anti-influenza treatment to someone who tests negative for influenza?

  • Yes (76%, 185 Votes)
  • No (24%, 57 Votes)

Total Voters: 242

Loading ... Loading ...

By the way, after the visit, a pharmacist called and said that the patient was requesting a different medication since the patient was on state “insurance” and the “insurance” didn’t cover the cost of the medication.
Unfortunately, there isn’t anything else that works which was covered.

UPDATE 1/15/2012Thanks for the votes and comments.
When thinking about this situation, three issues came to my mind.
First, Tamiflu is approved by the FDA for acute uncomplicated influenza when symptoms have been present for not more than two days. It is also approved for prevention of influenza. From a technical perspective, a Tamiflu prescription was indicated if the child had influenza or if the child was being prophylaxed against influenza. The indications for use do not contain a description of any symptoms that must be present before Tamiflu is prescribed. If influenza is diagnosed or being prevented, Tamiflu is indicated.
Second, diagnosis of influenza in an inexact science. Rapid influenza testing is notoriously inaccurate. If the test is positive, there is a high likelihood that influenza is present (although about 1 in 50 patients with positive results do not have influenza). However, if the test is negative, one third of children and about one half of adults will still have influenza. A negative influenza test by no means excludes a diagnosis of influenza. Between 30 and 50 percent of influenza cases are asymptomatic and it is difficult to distinguish between a common cold and influenza early in the course of the disease.
Third, Tamiflu probably doesn’t work. A Cochrane review found that Roche funded all of the studies demonstrating Tamiflu’s efficacy, that Roche hid a majority of the data from studies about the effectiveness of Tamiflu (and still won’t disclose it), and that the study data that was released had significant bias. See also this article from Forbes.
Putting all of these facts together, then we need to consider why most people in this case thought that prescribing Tamiflu was “unnecessary”.
Was it unnecessary because Tamiflu doesn’t work? Then anyone who prescribes Tamiflu is providing unnecessary care.
Was it because the patient tested negative for influenza? How do we accurately diagnose influenza in order to prescribe the medications, then?
Was it because the patient’s symptoms weren’t severe enough? What symptoms are needed before Tamiflu can be appropriately prescribed?
In the end, when dealing with this patient’s mother, I decided that the prescription of Tamiflu ends up being an issue of medical discretion. Most people probably wouldn’t have given the medication to their children for those symptoms, but if she wanted it that bad, the medication was technically medically indicated and not prescribing the medication would have resulted in even lower patient satisfaction scores. So I gave her the prescription.

The incentive to improve patient satisfaction favored prescribing Tamiflu and I had no disincentive for doing so. If the patient’s mother wants to pay for a useless medication that has many side effects in order to treat mild symptoms – after knowing these facts – why should she be prevented from doing so. This is just one example of how emphasizing patient satisfaction adversely affects medical judgment, encourages testing and treatment which is of questionable benefit, and drives up the cost of care.
“Unnecessary care” is going to be a catch phrase in the next few years as government and insurers try to decrease expenditures in medical care by refusing to pay for testing or treatment which is deemed “unnecessary.” When you hear this phrase, ask yourself who is making the determination, how the determination is being made, and who stands to benefit.

Sage Advice

Tuesday, January 8th, 2013

Old stoveSome sage advice to my loyal readers …

When you’re cleaning up an old house, you move the stove, and you happen to a find a small metal pipe with an unknown substance inside of it, it’s probably not the best idea to take a break, pull up a chair, and smoke whatever is in the pipe.

Should you ignore this advice, you might just see nonexistent bugs wearing Harry Caray glasses buzzing around your head and notice a cadre of hot women spies surrounding the house you were in before you called 911 for a police escort to the hospital.

As a side note, it is not within the purview of an emergency department to send the police to go find the pipe so that they can bring it back to our lab and we can “see the f*** what was inside.” The reason for the demise of this portion of your neuronal network will have to remain “undetermined” in this case. If you just have to know, you could prolly send the pipe to CSI with a letter requesting analysis … along with a check for a few thousand dollars.

In the meantime, enjoy the restraints.

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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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