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Are you smarter than an Orthochick?

Neck AnatomyThe first day of her new PGY year and Dr. Orthochick is already playing “Are You Smarter Than the ER Attending?” on her blog.

She describes the case of a patient who had a “right shoulder nerve block” after shoulder surgery and who continued to have weakness and paresthesias in his arm 12 hours after the block was performed. The patient went to emergency department and the ED physician apparently ordered CT scans of the head and neck. Then Orthochick gets called and has to get out of bed at 3AM to do a consult.
With the normal CT results in hand, she comes to the conclusion that the testing should never have been performed and that the emergency physician is no smarter than Orthochick’s sister or the patient, both of whom thought that no testing should have been performed (even though the reason the patient went to the emergency department was because he thought something was wrong). Oh, and Orthochick’s ortho attending thought the emergency attending’s workup was funny, too.

Orthochick doesn’t say what kind of “shoulder nerve block” was performed on the patient. Bier block? Interscalene block? Axillary block? Orthochick also doesn’t say what kind of anesthetic was used. Most likely Marcaine with epi – which, at least according to the manufacturer (hey, what do they know) declines to insignificant levels during the next three to six hours. Why should anyone have cause for concern when their arm is weak and has decreased sensation six hours after the medicine was supposed to have worn off?

Would I personally have obtained CT scans based upon the facts that Orthochick presented? I’m not sure. Orthochick didn’t really provide enough of a history or physical exam to make a determination. Postoperative strokes occur in between 0.05% and 7.4% of patients and Orthochick didn’t give us enough information to determine whether the patient should be more toward the 0.05% or the 7.4% end of the spectrum. It’s not like there are any $15 million judgments against physicians for missing postoperative strokes manifesting themselves as weakness in the right arm or any $1.6 million settlements when doctors were sued after a patient developed numbness and weakness in his arm after surgery on the first pages of a DuckDuckGo search or anything. Yes, I realize that the patients in both of those cases had undergone carotid surgeries and the patient in Orthochick’s post had arm surgery. Not the point. The point is that numbness and weakness in the arm after a surgery can be a sign of a stroke and that in our society there is not much tolerance for missing a postoperative stroke. I’m sure that Orthochick would have been singing an entirely different tune if the patient ended up having had a postoperative stroke and the emergency attending decided to send the patient home without performing any testing.
That reminds me. There are all these red colored (at least tn Netter’s Atlas) blood carrying tubes that can get poked, leak, and form harmful collections of blood and there are also these yellow nervey things (at least in Netter’s Atlas) in the neck besides bones and joints that can get damaged when a block is being performed.

Another important point is that in the post, Orthochick says that the patient went to the emergency department because “he didn’t realize [the block] was going to last that long.” If the surgeon or anesthesiologist had told the patient how long to expect the block to last or if Orthochick’s teaching residency program had provided the patient with a simple handout informing the patient what to expect, then there wouldn’t have been a visit to the dumb “ER” attending at 3AM to begin with, now would there? Then again, if they did tell the patient the block would last for up to 12 hours and the patient didn’t seek treatment for what ended up being a stroke or a hematoma compressing vessels/causing neuropraxia or a carotid dissection or dozens of other complications, Orthochick and her jovial attending orthopedist wouldn’t be able to blame someone else for the bad outcome.

Dr. Grumpy’s comment to the post put things in good perspective: “What’s stupid is a system that makes us practice defensive medicine to this extreme, and a culture where patients often see the slightest medical error as the Golden Ticket.”

Is this where I get to tell some of my orthopedist jokes?

10 comments

  1. Pride goeth before a fall.
    Dr. Orthochick is headed for a big FDGB.
    Her response is the pilot equivalent of assuming that flashing light on the dash panel isn’t really important.

    And for the record, when patients present in the ED with post-op complications and complaints, the default presumption is that they’re right, not stupid.

    Hindsight sharpshooting doesn’t count. A consult means:
    1) Look at the situation with fresh eyes, and the same initial presentation the ED doc saw.
    2) Come in and sign the discharge without testing yourself, on your own responsibility, or STFU and consult with your fellow professionals as if you were one too.
    3) Feel free to do a 9AM consult with your insurance carrier’s legal counsel if there’s any doubt about which course of action is recommended, for future reference.

    What the hell do they feed these kids today?

    • Looking over her post:
      “you know, we see this every now and then. Patients have nerve blocks and then they come back to the ER because they’re surprised it lasted as long as it did”

      So in an admittedly rare but not unheard of case, se had specialty expertise that further illuminated the proper dispo. (I dunno, I thought that’s why you call for consults…) So rather than get quite so snippy about doing her job (and sharpshooting the ER doc to boot), she might have also said “Thanks for coming to us”, and then made sure the patient understood fully what to expect, and emphasizing what was important to call or come in for follow-up as out-of-the-ordinary vs. what was within the bounds of normal. Especially because post-op patients, people in pain, and both, tend to have the attention span of a gnat for understanding aftercare instructions until they’ve heard it about nine times.

      Then she would have made two friends that night, improved patient satisfaction, and made her practice’s service look great, and she would have had a much better blogpost to crow about.

      Just a thought.

  2. She is being well indoctrinated into the stereotyped mindset of the surgical specialties. I hope that she grows out of it.

  3. I’d expect nothing less from the blog (on which she guests), as it is full of holier than thou, high and mighty, first world problems trite drivel.

  4. First of all, I always love having my blog snarked, so thanks for that :)

    For the record, I have known Dr. Orthochick a long time, and she is just about the most kind, caring orthopedic surgeon you’ll ever meet. She works her ass off and really does her best for patients. I’m lucky enough to be privy to her private journal and I know in detail what she goes through. She’s going to be an amazing doctor.

    I feel a need to clarify her response, which was not that she should not have been called at all, I think, but that ordering head and neck CTs and being pressured to admit the patient was not the right thing to do. I don’t think she minded having to explain the situation to the patient or ER doc (she said that the patient could’ve called the surgeon instead). Just that too much work up was done.

    But if you don’t mind paying $3000 every time a patient anesthesia lasts as long as it’s supposed to, hey, fine by me.

    • It’s a damned-if-you-do, damned-if-you-don’t situation that the ED docs are put in all the time: the specialists we call OF COURSE know more about their own patients and their own speciality than we do. That’s why we call them.

      As for the studies, OrthoChick will be a rare ortho doc indeed who is willing to come see an ortho patient without films of some sort being shot first. If she is/will be, I will tip my hat to her.

    • Orthochick’s post didn’t come across as the feeling that she “should not have been called at all.” If that were the case, then why would she compare the intelligence of an attending physician to that of her sister or the patient? The implication is that her superior intellect was required to solve the problem.

      While we still don’t have enough information about the procedure, the anesthesia, or the patient’s clinical findings to engage in an objective discussion of what occurred, if Orthochick is so sure that ordering head and neck CTs is “not the right thing to do” and that “too much workup was done” in this situation, then perhaps she should author a paper. Heck, she can get her jovial attending as a co-author. Inform all the emergency physicians who apparently have IQs less than garden slugs what the differential diagnosis for patients like this should be, how often the complications occur, how to manage any complications, and what treatment is appropriate for patients with prolonged neurologic deficits after a surgical procedure.

      Or make a report to the hospital QA Committee and have someone else objectively look at the case to determine whether too much of a workup was done.

      Or at least come up with some medical conclusions in her post. Such as “Head CTs and neck CTs should never be performed in postoperative patients with neurologic deficits unless the following criteria are met …”

      Instead, Orthochick chose the path of self-aggrandizement. With normal tests in hand and a consult from her sister, Orthochick can confidently declare that she is smarter than a 23rd Grader.

      Perhaps the thing that stands out most about her post is that fact that she doesn’t have enough gonads to come and defend her own statements. I appreciate your input, but you have just as much information as we do about what happened and a character reference that she is kind, caring, and a hard worker really has no bearing on the alleged deficiencies in medical management of this patient that she raised.

      And just out of curiosity, at what point would you be concerned about persistent anesthesia in this patient and think that further workup was justified? And what would that further workup entail?

      • I chatted with Orthochick who did clarify the situation for me somewhat. Apparently, before calling the consult or doing any work up, the ER attending spoke to the ortho attending who did the surgery and the surgeon tried to reassure him that this was an expected result. The ER attending wouldn’t listen and instead went ahead with the work up and tried to bully the ortho resident into admitting the patient. And apparently, this is an ER attending who is well-known for ordering excessive studies on everyone.

        But of course, you couldn’t know that from the brief vignette that was given. I guessed the situation was something like that because I know Orthochick and she is generally very humble. She wouldn’t badmouth somebody unless they were total ass to her.

        • The problem with your Orthochick chat and the information you’ve provided is that you’re basically engaging in unopposed character assassination of the emergency physician without disclosing any facts to support your or Orthochick’s assertions: She’s a stellar, humble, caring resident who was pushed to her breaking point by the overbearing overtesting ass of an emergency physician. Great.
          How do we know that the emergency physician wasn’t the kind caring patient advocate in this encounter and that Orthochick wasn’t the whiny know-it-all second year resident who is well-known for never leaving her bed when she’s on call? We don’t. Belaboring the characters of the actors while ignoring the true issue behind Orthochick’s post only infers that she had no medical basis for her reasoning.

          We don’t know what Orthochick saw on her exam – if she even examined the patient. There is still no discussion of what you, Orthochick, or jovial Orthoattending believe the differential diagnosis for patients like this should be, how often the complications occur, how to manage any complications, and what treatment is appropriate for patients with prolonged neurologic deficits after a surgical procedure.
          You also didn’t respond to the question asking at what point would you be concerned about persistent anesthesia in this patient and think that further workup was justified and what that further workup would entail.

          You’d be laughed out of the auditorium if you presented a Grand Rounds case in this fashion.

          The fact that Orthochick presents no substantive response to her initial assertions other than the doctor didn’t listen to her and a retrospective determination that he ordered “too many tests” says a lot about her character … and it isn’t that she’s a kind, caring, humble hard-working resident.

  5. “Just that too much work up was done.”
    So in your experience, juries don’t take issue with that answer when things don’t turn out well for the patients, do they?

    Also, when one doesn’t mind doing something, it’s probably not a good call to then take a victory lap of pique in front of the entire Internet, and sharpshoot one’s medical colleagues while questioning their basic intelligence at the same time.
    Just sayin’.

    But total props, sincerely, for coming by and sticking up for her.
    She perhaps needs a little less Sharks vs. Jets, and a little more “same team” and “walk a mile in their shoes”, even especially at 3AM.
    Unless one is Louis Pasteur, the job is more about making allies than making history.
    Sleep deprivation on-call and trying to ace everything every day in residency can make it hard for anybody to remember that, sometimes.

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