Archive for the ‘Random Thoughts’ Category
Wednesday, November 7th, 2012
Mrs. WhiteCoat had a patient issue and doesn’t know how to proceed, so she asked me to post the case for other people to comment upon.
A patient came to her practice 2 years ago with thyroid problems. She had been seeing an endocrinologist for several years before seeing Mrs. WhiteCoat and even the endocrinologist was having problems controlling the patient’s thyroid using medications. On the first appointment, Mrs. WhiteCoat performed an exam and found a thyroid mass which ultimately turned out to be cancerous. She referred the patient to an ENT surgeon for thyroid removal. The patient never followed up with Mrs. WhiteCoat after that.
A few days ago, the patient sends Mrs. WhiteCoat an e-mail saying that she is doing well and asking Mrs. WhiteCoat to call in a refill of the patient’s thyroid medications. Mrs. WhiteCoat wrote her back and said that she had not evaluated the patient since having her thyroid out almost 2 years ago, that she has no idea what the patient’s latest thyroid labs showed, and she doesn’t even know the patient’s medication dose. She stated that she wouldn’t call in a refill without seeing the patient in the office, examining her, and going over the patient’s labs with her.
The patient wrote back that she had “normal” thyroid labs in February and has been on the same dose of thyroid medications for the past year. She couldn’t afford to miss work any further, doesn’t want her thyroid to get out of control again, and appreciated Mrs. WhiteCoat’s understanding in calling in the prescription.
There are two ways of looking at this.
One one hand, the patient is probably stable after having her thyroidectomy and most likely will be continued on the same dose of medication if she does come in for evaluation, so an office visit would likely be low yield. That being said, when things go wrong, nobody thanks you for cutting corners to save them money. If the thyroid cancer returns, or if there are signs of metastasis somewhere and they are missed, then what happens?
On the other hand, some people may think that requiring patients to come to the office under circumstances like this is just being “greedy.” Mrs. WhiteCoat has student loans, office workers, office lease, malpractice insurance, and a dozen other expenses that she has to pay in order to keep the office running. If she provides free telephone services to all patients, then soon there may no longer be an office for patients to call for their refills.
I suggested that if another doctor is ordering lab tests on her, that doctor should be refilling her medications.
We kind of touched on this issue in a previous Open Mic Weekend, but now it’s a real situation.
What should she do?
Thursday, November 1st, 2012
The Hurricane Sandy coverage has me absolutely captivated. Hard to believe how much destruction occurred. Reading about all the hardships that people on the East Coast are going through right now makes me wish I could help somehow.
My brother lives in Hoboken and we weren’t able to get in touch with him until today. You always assume the worst when that happens. He still has 8 feet of water in his basement and wasn’t able to get out of the house until today. Still only spotty power in his area. He reports that much of lower Manhattan is still dark, tunnels are still flooded, and he spoke to police who said that lines of people trying to get into the city are “the worst they’ve ever seen.”
Seeing what they’re going through makes all of our problems seem so minor. Prayers to everyone going through this disaster. Keep strong and keep the faith.
Halloween is officially over. Son dressed up as a ghoul all in black and sat up in a tree scaring the kids who came to the house for candy. Said that he was taking after me, whatever that means. Little kids would come up and take candy from the bowl and he would shake a tree limb and stare at them. Some ran away without candy. While he was doing that, some guy in a clown suit with a chain saw (no chain) was walking up and down the street stopping and looking at people and freaking out all the parents. Funny, yet creepy.
Only went through 12 bags of candy this year, but we got smart and bought those giant bags of Dum Dums to mix in with the candy, so giving a few lollipops and a candy bar to kids at least made it look like they were getting more.
It was difficult getting our kids down to sleep. They all had a sugar buzz and a half eating all the candy they weren’t supposed to be eating. Son was up playing AC/DC at 10:30 on a school night. Oldest daughter didn’t have school today and she slept until noon.
The day after Halloween has also permitted me to discover that candy wrappers and lollipop sticks do not mix well with canine digestive systems. When sitting in the living room this morning wondering “what’s that smell?”, we eventually found two piles of doggie puke consisting of a mixture of Science Diet, candy bars, Laffy Taffy, candy wrappers, and lollipop sticks. Cleaning that up was enough to get me to skip breakfast. Mmmmmmm mmmmmm good.
Middle daughter just got word that her pictures were up for American Girl. She’s so excited and we’re so excited for her. I’d link to the page at American Girl web site, but don’t want them getting ticked at me. If you want to see her, go to AmericanGirl.com and go to the “Gift Guide”. She’s opening a present at the top of the page.
Oldest daughter just got her first IMDB movie credit, hopefully the first of many. She also found out that she made the basketball cheerleading squad. Good work, kiddo. Now that means I’m going to have to go to the basketball home games when I’m just not a basketball kinda guy, but that’s OK. I’ll be cheering loud for everyone.
Every year, our house becomes infested with fruit flies. I can’t figure it out. We keep fresh fruit in a fruit bowl and we give Master Oogway fruit in a dish a couple of times a week.
Side note: I never did tell everyone that the science teacher from middle school thought that we did such a good job taking care of Master Oogway during the winter that he gave Master Oogway to us at the end of the school year. “He doesn’t have long to live and I don’t want him to die in class” was the selling point. Mrs. WhiteCoat fell for that one hook, line, and meal worm. Here it is almost three years later and Mistress Oogway (we found out that she was a female) is still going strong.
Anyway, from the middle of October to the middle of November, we get infested with and dive-bombed by kamikaze insects. They’re particularly persistent and noticeable when I’m typing at the computer because they contrast well against the white background. I’m getting good at grabbing them out of mid-air with my hands, but it seems like just as soon as I get one of them, another one starts flying at my head in retaliation.
A neighbor mentioned putting out a glass of apple cider vinegar. Apparently, fruit flies are drawn to the aroma. He said to put a few drops of soap to break the surface tension so that the fruit flies go into the glass to sip the vinegar then they couldn’t float on the top and fly away. Hoooley smoley. Within 6 hours, there were like 40 of the things at the bottom of the glass. We put the glass in the microwave for 15 seconds to get more aroma out of the vinegar and after that, no more dive bombing. A couple of olfactory-challenged stragglers met with my swift hand of death, but what a difference. We’re buying bottles of apple cider vinegar for next year. Supposedly wine works just as well, but I’m not putting some brave vintner’s efforts to waste.
I saw a patient that made me sad the other day. She came in with a UTI. Burning with urination. Pretty uncomfortable. Initially she thought she had a yeast infection and she used some over the counter cream. That caused an allergic reaction and more burning to her sensitive areas. Her urine was normal and the allergic reaction was really her first herpes outbreak. This mope who told her he loved her and then dumped her a couple of weeks later gave her something that will last with her a lot longer. She was sixteen. I sat in the room and cried with the patient and her mom after telling them the bad news.
And then I think about how much we still have to teach our oldest daughter who is texting how much she loves her new boyfriend of less than a month. Nice kid and he’s making her happy so far, but you just never know.
Last but not least is another sappy dog picture. They’re waiting for me as I’m coming out of the pet store.
Treeeats? For us?
Wednesday, October 24th, 2012
The criminalization of society continues.
Regular readers know that I strongly disagree with state efforts to criminalize the practice of medicine. See previous posts here, here, and here for a few. Two days ago I posted an article about a doctor who was criminally charged with providing excessive pain medications to patients who died (as I expressed concern about back in 2009). Now federal agents are arresting physicians for providing fraudulent or “unnecessary” care.
This isn’t concerning to anyone?
I have no problem with taking professional action against any medical practitioner who is a danger to the public. Well, I have a little problem. Some of the assertions of “dangerous” activities I have seen made by state licensing boards make me wonder whether the board members should be charged with a crime for incompetency. In one instance, a board was prepared to file a letter of reprimand against a physician because he didn’t order a CT scan on a patient with a headache. The reason? “This patient came to the hospital by AMBULANCE and you didn’t do enough.” Action taken against license because a patient dialed 911.
I also don’t have a problem filing criminal charges against medical practitioners that break laws. Intentionally engage in fraud? You deserve what’s coming to you. Steal from patients? Go to jail.
However, throwing someone in jail for doing their job – even if they do their jobs poorly – just sends the wrong message and will lead to unintended consequences.
I’m not going to go on a long rant about this, but I wanted to illustrate how more and more professions are coming under a government attack because they allegedly don’t do their jobs appropriately.
Tarl commented about the case of the Italian scientists who were charged with manslaughter and sentenced to six years in jail because they failed to predict an earthquake that killed more than 300 Italian citizens. Prosecutors argued that the scientists offered “incomplete, imprecise and contradictory information” to the Italian citizens. As Tarl noted, scientists from around the world denounced the trial, noting that predicting earthquakes is impossible.
Think about the implications for Italian scientists in the future. Doing everything in their power to avoid a six year prison term in the future, the seismologists will now be encouraged to report to the media that an earthquake may occur and that things may not be safe every time that a truck without a muffler drives past the seismologists’ offices and shakes their equipment. Chicken Little, baby. If someone drops a cup of coffee, the sky must be falling. Run for the hills. In a few years, the population will be so sick of the false alarms that when the real earthquake does hit, they will have ignored the warning anyway.
But by criminalizing an inexact science, the buffoon Italian prosecutors have made Italy a safer place, right?
Then consider the case of attorneys for GlaxoSmithKline who were indicted for making false statements to the FDA when Glaxo was being investigated for promoting Wellbutrin for an off-label use. The in-house counsel hired a national law firm to help Glaxo respond to the FDA’s allegations. A year later, the government came after the attorney for obstruction of justice … for representing her client … alleging that the attorney had assisted Glaxo in furthering a cover-up or a crime. Even documents that are protected from discovery by the attorney-client privilege were forced to be turned over to the government.
How will the threat of criminal charges affect an attorney’s practice of criminal law? Go to jail if you defend your client too zealously? Be concerned about this, people. With the threat of criminal charges looming over attorneys who defend criminal clients, will clients really get the zealous representation to which they are entitled?
Finally, although not about employment, there is this Wall Street Journal story about how the North Carolina legislature has now made it a Class 2 misdemeanor (.pdf file) for a student to, “with the intent to intimidate or torment a school employee,” do such things as encourage others to post private, personal, or sexual information pertaining to the school employee; post an image of the school employee on the internet; repeatedly engage in e-mail or other transmissions to the school employee; or sign the school employee up for electronic mailing lists.
Take a picture of the teacher in public who is fondling a sixth-grader’s breasts? Even though the teacher is breaking the law and has no expectation of privacy, students may go to jail if they post the picture online or if they encourage others to do so. If the paparazzi hounds the same teacher for doing the same thing … that’s OK … I think.
Anyone every wonder why criminalization isn’t applied to the government officials when they allegedly don’t do their jobs appropriately? I was going to write someone in the North Carolina legislature an e-mail asking them about it, but I didn’t want to be breaking some other inane law they created.
What is happening to this country?
Wednesday, October 10th, 2012
Did you ever have one of those months where you had about a hundred things to write about, but you had no time to write about them? Yeah, that’s been me lately.
So where do I begin?
Just got back from the ACEP Scientific Assembly in Denver. Have another post about that later. So I’ll begin with the kids.
Lots of birthdays in the house this time of year. My middle daughter happened to be born on the same day as I was. By far my best birthday gift ever. One of the things that was at the top of her birthday wish list was an Orbeez Soothing Spa. The web site says that Orbeez are “wet and wacky, soft and squishy, fun and funky, bouncy and beautiful.” In reality, it’s more like some marketing genius has convinced 10-12 year old little girls that they need to come home and relax in a spa-like foot bath after a hard day at school. Us? We walked uphill both ways to school in bare feet over shards of broken glass and nobody batted an eye. Now, every kid who watches afternoon cartoons needs a foot bath. So, despite my better judgment, we got her Orbeez for her birthday. To activate these things, they must be soaked in water first. Then they go from a little pebble the size of a BB to a large squishy ball the size of a marble. once activated, then kids can put their feet into a foot spa so that they can have soothing relief or from a hard day at school. The problem is first of all that once the kids find out that these things can be squished, then you find squished Orbeez all over the house. Stepping in one unexpectedly in one’s bare feet is not pleasant. Apparently, the dogs don’t think that they taste very pleasant, either. After a few days, an odor began to waft through the house. Did Mrs. WhiteCoat just express the dogs’ anal glands? No. Did someone pour anchovy juice on a used sweatsock? Nope. It was the Orbeez foot bath. These superabsorbent polymers apparently absorb more than water.
Next year, I’m putting a loofah sponge and some moisturizer in an Orbeez box for her birthday present.
Mrs. WhiteCoat also had a birthday at the end of last month. I was going to get her more perfume, but I was scared off by all of these women in lab coats chasing me through the store. Then I noticed … the stores already have Christmas decorations. That’s just un-American. I am not buying anything from a store that has Christmas decorations up before November 1. It’s just the principle of the matter.
And if I see one Santa Claus looking all smiley at my kids before Thanksgiving, I am going to knee him in his jingle bells.
Tuesday, September 25th, 2012
This has happened twice to me, but I’m learning …
The first patient was several years ago. She came in with headaches. Her blood pressure was 220/110. The headache wasn’t an issue. The patient hadn’t taken her blood pressure medications that day and had a history of headaches. There was no change from prior headaches. We gave her pain medications, gave her the dose of clonidine she was supposed to be taking, and she felt better. Her repeat blood pressure was 176/96. I told her that she really needed to take her medications every day and that she could follow up with her family doc later that week for a blood pressure recheck. Then I discharged her.
Forty five minutes later, she was still sitting in the room talking with the nursing supervisor.
Then the nursing supervisor asked me if I felt comfortable discharging the patient.
Yes, yes I did.
Wasn’t I concerned about her blood pressure and her headache?
No. Her blood pressure was improved to the point that she could be discharged and her headache had resolved. She was stable for discharge.
Afterwards, I saw the nursing supervisor make a phone call, then go back in the room, then leave.
I went back in and asked the patient if there was a problem.
“No, no problem. We’re leaving.”
Then the family member in the room said “We’re going to another hospital like the nurse said. Her blood pressure is much too high for her to be discharged.”
I asked them to wait a moment while I tracked down the nurse and the supervisor.
The nurse had finished her shift and left the building, and by the time I found the nursing supervisor, the patient had left.
Lots of meetings after that incident.
Then it’s deja vu all over again.
A patient comes in with the worst headache of his life. Those are the words he says to me as soon as I walk in the room. Never had headaches before, bent over to pick up garbage and headache began. Hasn’t let up in over 8 hours. Radiates into his neck.
I already know where this visit is heading.
He got three rounds of IV pain meds and his pain was still in the “severe” range.
We ordered an “unnecessary” CT scan. After all, it came back normal.
Then I go to explain the necessity of a lumbar puncture.
Fortunately for the patient, his mother in law was a nurse educator at the nursing school in town. He ran the case by her and she said that a lumbar puncture wasn’t appropriate since it wouldn’t tell us anything that we don’t already know.
I told him about pseudotumor cerebri and meningitis and the subarachnoid bleeding that CT scans sometimes don’t pick up.
The patient’s nurse then said that MRI will see the things that CT scan doesn’t … including bleeding.
So I go to one of the textbooks and copy one of the pages showing that CT scan is much better than MRI at picking up subarachnoid hemorrhage. I give a copy to the patient and to the nurse. Her response was that I was being “vindictive.”
At that point, I threw up my hands. I told the patient that if he didn’t want the test, I’d be forced to admit him to the hospital for monitoring. If he didn’t want that, he’d need to leave AMA. I told him my concerns with him doing so and asked him to come and get me if there were any other questions.
Twenty minutes later, the patient told me that he decided to go against the advice of his nurse educator and his nurse and he reluctantly agreed to the lumbar puncture.
His pressures were on the high side, but normal.
Cell counts … one WBC. Three RBCs.
“See,” the nurse said, “no blood.”
However, the CSF protein was twice normal.
“So what do you think of the protein, then?”
“You’re the doctor. That’s why you get paid the big bucks.”
Now the differential diagnosis of elevated CSF protein is large and includes infections, tumors, abscesses, multiple sclerosis and bleeding. The problem was that acute severe pain isn’t a typical finding in tumors, abscesses, or MS and that it didn’t look like an infection based upon the CSF results.
I called the neurologist to discuss the case. She thought the patient had a small bleed and that the blood had broken down, causing the elevated protein levels. She recommended that the patient get an MRI/MRA.
So we were able to get the patient in for the test a couple of hours later and the patient ended up having a small dural tear. Oh yeah, he forgot to mention that he was in a car accident a couple of days earlier. Wasn’t having any pain from it, so didn’t’ think it mattered.
And the patient’s nurse reminded me that if I had just listened to her, I could have saved the patient a lot of time in the emergency department and he wouldn’t have had to go through cost and risk of a lumbar puncture.
It was then that I realized that the nurses are always right.
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.
Saturday, September 15th, 2012
It’s been about a month since the last open-mic weekend.
What’s on your mind?
All weekend everyone is welcome to post any medically-related comments, questions, observations in the comments section. Will try to answer any questions through the weekend.
Only rules are that there are no personal attacks and that the comments/questions are medically-related.
Have a safe and enjoyable weekend.
Wednesday, September 12th, 2012
Can you or an emergency physician that you work with win Nurse K’s coveted “Dr. No BS” award?
Check her blog to get rules and post your scores in the comments section or on her twitter account.
She includes science behind some of the scoring, as well.
Interesting in that some people in the comments section are already uncomfortable with some of the scoring. Have fun with it, don’t overanalyze it.
And if the contest makes you think about how you manage some patients in the ED, that’s probably a good thing.
Monday, September 10th, 2012
I’m not going to tag anyone else for this meme, but I liked the idea that Ramona Bates (Sutured for a Living and @rlbates) put out on her Twitter feed from Wing of Zock. Play along if you want and drop a comment in the comments section if you do. I’d like to read them.
Describe the three patients that had the greatest impact upon you and how they shaped your career as a physician.
Not exactly sure I can say how each of these patients shaped my career, but below are three of the patients who have had a large impact on me.
The first patient I ever saw in an emergency department as a student was probably what turned me on to emergency medicine. Before my emergency medicine rotation, I was pretty much set on going into orthopedic surgery.
It was kind of a crazy situation. Inner city emergency department. Patients stacked up in the hallways. People pushing me out of the way. Me getting lost. Where is the attending around this place? Then one patient on a bed in the corner caught my attention. She was yelling at another patient down the hall. He’d yell at her. She’d yell back at him.
Wednesday, September 5th, 2012
Not to interrupt the interesting discussion going about BirdStrike’s post regarding what a life is worth, but …
Kids are all back to school. It was funny watching three of them enter new schools this year. The video of Junior WhiteCoat trying five times to open his locker then getting mad when dad did it on the first try was priceless. The video of Mrs. WhiteCoat crying when youngest daughter got on the school bus for the first time and waved to us through the window was also priceless.
Speaking about crying … we went to see the movie “The Odd Life of Timothy Green“. Every one of the kids was bawling at the end. Apparently my kids weren’t the only ones. Critics seemed not to like the movie very much. I thought it was entertaining.
Speaking about movies … all the WhiteCoat kids are getting little movie roles lately, but they all seem to be horror flicks. Junior is going to audition for another one today. Funny that middle daughter is starring in a horror movie but if she tries to watch one, she freaks out and can’t sleep for the next week. Even talking about the plot of a horror movie makes her sick.
Speaking about getting sick … both dogs have some type of virus that the vet says is going around town. Vomit and diarrhea everywhere. Carpet cleaners must love it when this stuff happens.
By the way, if a dog vomits on the floor, licks it up, runs away when you call her name, vomits on the floor again, then licks up a little bit of it before being scooped up and carried outside in mid-heave, then vomits the same material again in the grass, does that count as one episode or three episodes of vomiting?
Mrs. WhiteCoat was upset because she thought I was letting the dogs eat their vomit. Initially, she was right. Why waste food, right? Then, after the second vomit, I realized that they would just walk around the house vomiting up the same food over and over again, leaving spots all over the carpet. That prompted a more urgent and concerted effort to get the dogs outside.
Then how pitiful is it when the dogs stare at you with those sad eyes when you’re eating dinner and they get a small serving of chicken and mashed potatoes on their plate because their stomachs are upset? Not even any gravy?
Here’s a sappy dog pic from before initiation of the exorcism. I’m just glad that whatever they have doesn’t get passed to humans.
Speaking about Mrs. WhiteCoat getting upset … we took our four kids and a few of their friends to a water park for the end of summer. Half-price. Can’t beat it. So afterwards, we go out to eat at a family restaurant before making the trip home. A gentleman in suspenders staggered in the restaurant, and while passing our table on the way to the bathroom, stopped and in his garbled speech says to Mrs. WhiteCoat “Hey, you don’t look too bad for being an OctoMom!” I had to look away. She says “there are SEVEN children at the table and THREE of them do not belong to us.” Mr. Suspenders says “Well you still don’t look too bad” and he staggered off to the bathroom.
My reminders that he was paying her a compliment and that “QuadraMom” just didn’t have the same ring were met with repeated evil stares.
In between my trips to the emergency department to rule out sepsis every time I go running or hit the gym (abnormal vital signs under Jim Dwyer sepsis criteria, you know), I’ve been kind of bogged down with work at my other job. Have lots of posts lined up, but just not enough time to get them out of my head and onto the computer screen.
But I’ve been labeled as an idiot overtester by a nursing school professor who consulted on a family member in the emergency department, and comments on this blog have been cited as an example of how all medical professionals are “fat haters”.
Should be back to blogging about these and other subjects after attending a conference tomorrow.
Friday, August 31st, 2012
If you’re an EMT, don’t start lecturing me in front of the patient you just brought in about how she was involved in a “motor vehicle collision” and not a “motor vehicle accident.” I was half joking when I asked you if you meant that she was in a motor vehicle “accident” when she rolled her car in a ditch. Your dissertation about the difference between accidents and collisions afterwards … you aren’t going to win that one.
Unless your patient was in a demolition derby or intentionally ran into another vehicle (which I haven’t seen in 15 years), the wreck was an “accident.” We’ve been using the same terminology for decades. It serves us well. We don’t need to change it.
Yes, in most cases, patients are brought to the emergency department because two vehicles “collide.” So technically, most MVAs are also “collisions.” But what about the rollover that your patient was involved in? What did her vehicle “collide” with? And if a vehicle runs into a ditch before coming to a stop on the other side of the ditch, did it really “collide” with the ditch? Collisions are usually considered a contact between two moving bodies.
I’m also aware of the old argument by “traumatologists” that motor vehicle accidents should be called motor vehicle “crashes” because most fatal crashes are caused by speeding, intoxicated, or distracted drivers, so they shouldn’t be considered “accidents.”
If you want to go all brainiac on me and use the scientific definition of “collision,” then perhaps cars do “collide” with ditches. They also collide with gravel when they’re rolling down a gravel road and I suppose that their tires even collide with the asphalt when they’re driving down the street. So if we’re going to use the scientific definition of “collision,” we probably should use it consistently.
Somehow, the following inbound report, although scientifically proper, just doesn’t work: “the car was colliding on the street asphalt when it collided less frequently with the street at a stop sign and subsequently another vehicle that wasn’t able to collide with the street at the same rate of deceleration accidentally collided with the vehicle in the rear, causing the patient’s shoulder to collide with the seat belt and the patient’s face and upper torso to collide with the air bag.”
Can’t we just agree that the report should be something like “a restrained driver was rear-ended in an MVA with air bag deployment”?
And if you give me an inbound report saying that you’re “en route to your emergency room with a patient who is A and O times four who was involved in a motor vehicle collision and has a low grade fever of 99.1″ … well … let’s just not go there.
Oh, and you left the engine running in your patient transport vehicle.
Why do we call it an “ambulance”, anyway?