A call to all the ER docs out there: how do you tactfully, non-insultingly tell patients who come in with minor complaints, “You’re fine, go home, this is not an emergency, you should not come to an ER for a problem like this?” (For example, kid with a cold and low grade temp who is otherwise playful, active, eating and drinking well, with good sats, etc.)
They always tell you the first thing you should always do when looking at an imaging study is verify the patient’s name and date of study.
Today I got nice and burned by it, but luckily the attending caught it. Nothing deathly serious, just a stupid, stupid mistake, which I will not do again.
As I’ve always said, I’d much rather make stupid mistakes as a med student than as a doctor.
It’s funny what people can live their lives with thinking it’s just normal–that everyone operates on the same assumptions. If it’s always how it’s been for you, how can you know any better?
Three patients reminded me of this fact.
The first is a teenage Russian mother. Her 4-month old adorable little baby had a terrible case of eczema. She was seen in the ER a week ago, given some medications, and told to get a pediatrician at a local clinic. A week later, she shows up in the ER again. For the eczema. There are mutterings and under-the-breath annoyed words spoken–what the hell is she doing back here with her baby’s eczema? This is not an emergency. We ask her why she didn’t go to the clinic, as instructed, and she says, “I went there and they said I was going to have to wait 3 hours.” We say, “Well, yeah, you’re going to have to wait, it’s a clinic. But if you make an appointment, you’ll be able to get in faster.” She kind of nods, and we kind of stand there for an extra beat, hoping she gets it. We re-iterate to her that we cannot manage the kid–she needs to see a dermatologist, and get a referral from her pediatrician. Once we explained how referrals work, I think she figured it out.
My instincts were to think, “What, is she stupid, does she not understand how doctors work? Does she not realize this isn’t an emergency? Is she just lazy and abusing the system?” But the more I thought about it, I think she just honestly didn’t know how the medical system works. She didn’t know how to get care, or how to get a pediatrician, or get help for her baby, so she went to the one place she knows there will be doctors: the ER.
The next is a 30-something administrative clerk at a law firm, with an exquisitely tender ingrown toenail. Ouch. She tells me she gets these rarely, and I ask, “How rare is rarely?” and she shrugs, “Oh, about once a year or so.” (She usually gets a pedicure, but was too busy with the holidays to get one this year.) She has special clippers to prevent it from happening. She is bewildered when I tell her that I think that’s pretty frequent–that most people don’t get them so regularly. “They don’t?” I tell her there are ways to remove the nail matrix causing the ingrown toenail, and suggest she ask her doctor about it.
Again: she’s had ingrown toenails since she was a kid, and just thought it was your normal, everyday thing. Maybe her family had them too, so the notion was enforced. (This also supports my theory that “All families are weird,” because you’ll hear someone describing what traditions they do for Christmas, or birthdays, or whatever, and you think it’s totally bizarre because it’s not how your family does things.)
The last is a 24 year-old student with a chronic cough. He’s got a pretty good family history of atopy and a brother with asthma. He describes the coughing fits as generally after exercising, like running on a cold day–but sometimes even after weird things like drinking a Slurpee too quickly. They last for a good hour or so–but as far as he can remember, he’s had them his whole life.
Now you may be thinking that these patients are just uneducated about their disease, or don’t have a whole lot of medical knowledge or background. But this last one is nothing of the sort. Turns out he’s a medical student. Turns out his father is a doctor. His mother is a former nurse.
Turns out that it’s me, and my cough-variant asthma.
I had no idea — no freaking clue –that other people didn’t cough and cough and cough like me–I just thought that was normal human behavior, a normal reaction to exercise, or cold air, or… Slurpees. It wasn’t until I was reading about asthma that it finally hit me, Mr. Medical Student.
Don’t make assumptions about what you know, what you think you know, or what you think your patients know. Educate, educate, educate, and if something doesn’t seem “normal” or “right,” there’s probably a good reason (or maybe you’re the weird one, and there’s no good reason at all).
Ahh, medical ambiguity.
First time seeing one of these, two weeks ago. Off to the cath lab for him!
(For the non-medical, that’s an acute MI–active heart attack–in progress. The big rounded convex lines look like tombstones for a reason.)
Some of these are inherent to going to an Emergency Department; others are just the difficulties of clinical medicine.
For next time: the great things about the ED, of which there are many.
These are the words that start to change my diagnosis from “kidney stone” to “drug-seeking.”
Two weeks ago, I pull back the curtain, introduce myself, and see a woman writhing around in (supposed) pain, tears in her eyes. She tells me she’s had 4 kidney stones previously. They’re all uric acid stones, which are generally undetectable on X-ray. That she went to a urologist, was on allopurinol, but stopped it two months ago. This all happened in Texas. She tells me where her pain is, and that it radiates to her back and down to her groin. “Kidney stone! It’s a kidney stone!” I tell myself. I am brilliant. I examine her, find some tenderness on her right flank. Her urine has already been sent to the lab. I tell her I’m going to go talk to the doctors to discuss what we can use for pain control. She warns me that she is allergic to aspirin and Tordol–a strong pain reliever but not a narcotic. (Think super-Advil.) Her mouth swells up when she takes either of these. “What terrible luck, a woman with chronic, painful kidney stones and allergies to common pain relievers!” I think. She then finishes her pain medication story: “Whenever this happens, I usually get dilaudid and phenergan, and sometimes ativan because I have anxiety attacks.” And it all goes downhill from there.
I pause, skepticism and cynicism running through my mind, but I give her the benefit of the doubt. Assume nothing , I remind myself. Moments later, the patient’s nurse chases after me in the hallway. “She’s a frequent flyer here, you know. She was just here 2 weeks asking for the same thing. And I guarantee you next she’ll ask for Fentanyl.” Add more skepticism to the pot.
So we check her name–first time she’s been at the hospital. Maybe she’s using an assumed name? We check her urine, and it’s strongly positive for both blood (going along with the stone story) and white cells, indicating an infection. We’re stuck–her story and labs say maybe she’s telling the truth, but everything else is leaning toward malingering. So we start antibiotics for her infection, give her yes, some dilaudid and phenergan for pain control, and I tell her she’s going to need a CT scan. We get the scan setup, and she continues to ask for more pain medication–“It helps for like 2 seconds and then goes away!” Just when she’s ready to go to the scan, she starts asking for some ativan (similar to valium) for anxiety, because she gets claustrophobic in the scanner. We point out her head won’t be in the scanner, just her abdomen and pelvis. She continues. We tell her she’s already had a good deal of pain medication, and we don’t want to continue giving medications that could suppress her respiratory rate. She starts crying, and starts loudly asking, “Why can’t you just help me?? I’m in pain here, I’ve never been treated like this before.”
My resident pops into the room and helps with the authority bit, and later tells me she recognizes the woman too.
She misses her chance in the CT scanner, so we wait. She, as the nurse predicts, starts asking for Fentanyl, a very strong narcotic. She then starts cycling–“I’m in pain,” then “I’m nauseous!” then “I have a headache,” then “I have a sore throat,” then “I’m anxious,” each time asking for a different medication for her symptoms. She finally just goes to the CT scanner, but leaves the scanner with an anxiety attack.
If the woman does have a stone plus an infection, the infection could start climbing up toward her kidney. She could get an infected kidney, could get septic, could die. I discuss this at length with her. I tell her we believe she needs this scan to make sure she doesn’t have such an infection. She gets upset again and says she wants to leave. (I’m leaving out plenty of copious details, as this dragged on for hours.) We talk about why this is a terrible idea, but she wants to leave anyway. I go get the paperwork for her to sign to leave Against Medical Advice. I come back and note 2 things: her hand is down near her genitalia, under the blanket. (This was the case the last time she was here.) She’s either masterbating or giving herself an infection. I try my best to ignore this, which is totally disgusting, and hand her the paperwork to sign. She can barely grab the pen, she’s so sleepy and out of it from the narcotics. She’s still complaining of pain. She signs and initials here and there, and finally leaves. (I throw away the pen.)
Meanwhile, we have 10 other patients that have been waiting to be seen by a doctor; she’s wasted a bed for at least 4 hours. I’m angry, frustrated, and annoyed–and the rest of the nurses and doctors are, too. I sigh, quickly eat a granola bar for dinner, and pick up my next chart: a woman that’s been waiting 6 hours in the lobby to be seen for a simple clogged NG tube.
Update: I forgot to mention the final kicker–the woman asked for “Vicoprofen,” which is like Vicodin, but has ibuprofen in it instead of Tylenol, which is in vicodin. (She says the Vicodin makes her throw up.) My attending was smart, and realized the real reason she asked for the vicoprofen: it has a larger amount of narcotic in it per pill than the vicodin. Another trick of the trade, apparently.
I have a habit (don’t we all?) of walking around the ER (especially in the trauma bay) to see what’s happening with patients. It’s all the rubbernecking goodness without wasting any gasoline. You see someone with some big gashes in his forearm, or an arm that’s totally deformed, and you think to yourself, “Man, that must hurt like hell. That sucks. Glad that’s not me.”
This same sick curiosity happened last week with a jaundiced patient. This guy was the brightest yellow I’ve ever seen in my life. The whites of his eyes were fluorescent-highlighter yellow. I had just caught him out of the corner of my eye, and the “Oh man, that really sucks” thoughts came flowing right in.
But then I did a double-take–I knew the guy. He was actually one of my favorite patients that I had taken care of back in February. And I felt really sick for giving him such a cursory thought–and one of pity at that. I went over and we talked for a few minutes–that I was sorry to bump into him in such circumstances, how his kids were doing, how he was feeling.
And then the conversation quickly went from superficial to serious, confiding in me that he didn’t want to be one of those poor guys that dies on the transplant list. His eyes filled with tears, and a lump grew in the back of my throat. I touched his forearm, and said I didn’t want that to happen, either. Right after that the transporter came in to take him to his bed in the hospital, and I said goodbye for the time being.
While I don’t know if I’ll ever be able to get the rubbernecking thoughts from my head, I know I’ll be less superficial with their impact–it’s not just that an arm is broken–it’s that the person’s arm is broken.
Enjoying emergency medicine, but we’ll see after this 4-day stint is up. Finished a shift last night at around midnight, now I’m back on today at 10am, then 8am on Sunday, then a day off. Our clerkship director is right–working an 8 hour shift in a busy ER is like working a normal 16 hour shift on call.
With states now allowed to make changes on eligibility requirements for Medicaid, West Virginia will be requiring many beneficiaries to sign a contract in which they promise to use the ER only for emergencies and to keep their doctors’ appointments. Failure to do so will result in loss of benefits. And why not?
Medicaid spending is out of control and is squeezing state budgets. ER visits for non-urgent conditions are hundreds of dollars more expensive than an office visit so that seems like a good place to start to try and control costs.
He goes on to note that low-income people disproportionately make up a good percentage of ER visits, and goes on to say that “only about 16% of ER visits among all patients are considered to be true emergencies so the potential exists for a substantial reduction in unnecessary ER visits among Medicaid beneficiaries.” In the comments, another doctor, Flea , agrees.
I’ll throw another mess into the pot here before drawing my conclusions. A retired orthopod, Dr. Thompson, frequently comments on my blog, and left this zinger today : “I personally see nothing wrong with health savings accounts and allowing patients to be in charge of their health care decisions.” Wha-wha-what?
What is it with these doctors? I’m at a loss. We’ll go point by point here:
Can we please,
please,
PLEASE stop with the patchwork nonsense where we try to
eliminate
limit health care for the poorest and sickest and drive all the burden onto our already-burdened-with-their-illness patients? Can we see the forest amongst those
trees? Can we see that hitting one group with this policy or that one will only create more burden in the long run, and that the only real solution is one that
affects us all? Single-payer, multi-payer, I don’t even care at this point–I just wish people would see the big picture. (And no, not the big picture of
your specialty. Zoom out one more time. The big picture of everyone.)
They don’t call it the Emergency Department for nothing.
I’m sitting there, talking with a 40 year-old woman complaining of lower back pain who had a kidney transplant, and then she adjusts herself to try to get comfortable, and shakes a couple times. She starts gasping for air; she is unresponsive to my questions. I immediately call for help, and a nurse comes in. Neither of us can get her to respond, and her eyes are glazed over. The nurse goes to get the attending, who comes in. We’re having trouble getting a good O 2 sat on her (that gives us a rough idea of the oxygen in her blood), and once we do, we realize she needs to be intubated to help her breathe. We intubate, and then have to start CPR; she now has no pulse. Her blood pressure is dropping. We code her for 11 minutes. Her pulse comes back, and she’s maxed on the medications for blood pressure support. Her heart on ultrasound is pumping, but barely.
I have my hand on her femoral artery. We lose her pulse again. We code her for 24 more minutes, and eventually the family decides to do comfort care and have some time alone with her. We lose.
I could go into all my analysis of how my resident did a great job and set a good example of following the basics–Airway, Breathing, and Circulation. But something scares me more than not knowing exactly what to do when this happens next time.
What’s really bothering me is how okay with it I feel. That we spent 2 hours trying to bring someone back to life, that she crashed right in front of me–basically died right in front of me–and I was totally okay with that. That 5 minutes after it was over, after I finished writing up what happened, I just went about my business and picked up the next chart. I moved right on.
I keep waiting for some delayed grief reaction or something, like I’m going to be just walking down the street and suddenly feel really sad or something, but it’s not happening. I mean, this person I just met died, but I’m not all that upset about it. Maybe I just didn’t know her long enough to need to grieve about her. Maybe I somehow knew that after the first code, things weren’t looking good, and I didn’t have much hope when the second one began. Maybe this makes me a great, objective, detatched doctor. Maybe this makes me a terrible, distant, detatched human. I don’t know.
I’m hoping that either my over-analysis of this event over the past week is my grief reaction, or that whatever part of me I think I’m currently missing can come back, because it seems pretty damn ironic if I’ve somehow lost my compassion and empathy during the practice of medicine. Never saw this one coming.