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Author Archives: WhiteCoat

What’s the Diagnosis #16

A nursing home patient is brought by ambulance with a cough. Nursing home staff believe the patient may have aspirated lunch 30 minutes ago. The patient’s workup is normal except for his EKG which is shown below (you can click on it for a much larger/printable version). What’s the diagnosis? What needs to be done with the patient? Does it make any difference whether this was a new finding or an old finding? I’ll provide the answer in the comments section in a couple of days.

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Healthcare Update — 04-01-2013

This case report is entirely bizarre. Patient gets awarded more than $800,000 after visit to doctor resulted in incorrect diagnosis of cancer when the patient really had pneumonia and caused patient to have amputation of her foot. A trial was held on the case four years ago with a verdict in favor of the doctor, but the judge declared a mistrial because Washington State jurors were referring to the plaintiff’s Japanese attorney as “Mr. Miyagi” and were making other racist comments against him. Then, the article notes that the doctor had been disciplined by state regulators for making “erroneous diagnoses” and for prescribing methadone to drug-addicted patients. So now Washington State physicians’ licenses can be on the line for failing to perfectly diagnose patient symptoms and for prescribing medication for one of its intended uses. I admit we don’t have all the information behind the license actions, but the article makes the Washington State Medical Board sound a little overeager to discipline physicians. Congratulations! You delivered a healthy 6 month old! 15 lb 7 oz baby delivered vaginally in UK. More than 20 doctors reportedly assisted in the delivery. Curing patients gone wild? Australian hospital emergency department guards petitioning to carry guns at work. Medical workers claim that it will make emergency departments more dangerous. Australian patient held four days in emergency department waiting for psychiatric bed to open up. Shortage of beds creates high demand. Patient’s mother alleges that his condition worsened because of the long wait. Not that anything like this could happen in the US. Oh wait. What a coincidence. LSU is closing their mental health emergency department, resulting in other hospital emergency departments having to care for “an additional 2,000 people who are a danger to themselves or others, who are desperately in need of stabilization and potential further hospitalization.” When medical services are curtailed, the patients needing those services don’t just disappear.

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Dear Diary

My gosh. I actually get angst when I haven’t posted for a few days. Actually, I have angst for other reasons, but not posting just adds to the angst. So what’s been happening lately? First, the poor WhiteCoat children are having trying times in their love lives. Oldest daughter WhiteCoat found out from a member of her track team that her boyfriend of 6 months was cheating on her. Another member of her track team was apparently going around and telling everyone that she had a “secret boyfriend” and was also telling everyone the sordid details of the interactions she was having with her “secret boyfriend.” So daughter WhiteCoat dumped Mr. Two-Timer. Mrs. WhiteCoat called his parents to let them know what was up. Papa Two Time said that he didn’t know what we were so upset about because the other woman “pushed herself” on Daughter WhiteCoat’s ex and that the other woman was a “two bit whore” anyway. I’m kind of thinking that this breakup was a good thing. The next day, Junior WhiteCoat’s girlfriend texts him and says she “wants to be single.” The text gets posted to Instagram. Then about 60 comments later, there are accusations flying back and forth that she’s been dating someone else and that he deserves better. When I was 12 years old, I was climbing up trees with a bag of tomatoes and tossing them at cars. Now my kid is 12 and he’s in need of relationship counseling. Health hasn’t been great lately. Pretty much every person in the family has had vomicking and/or diarrhea in the past week. Zofran is our friend. But it gets a little frustrating when you’re working in the ED and patients who puked once or who have had a couple of loose stools want work notes to be off for the rest of the week. Got kind of a kick out of one patient walking into the emergency department as I was leaving work. He was heading toward his car in the parking lot and I saw him suddenly turn around and head back toward the hospital. He was walking like he had a load in his pants. He gets closer to me and he starts shaking his head. “Ya try to do the right thing and what happens? It bites you in the ass. I’m holding in my gas in the ER and I waited until I get outside to pass it … then I crapped my drawers.” He did have a load in his pants. Although if he passed gas in the ED, it probably would have been just as embarrassing. Grandma and Grandpa WhiteCoat have been having issues. Their health has deteriorated to the point that they were unable to stay independent, so they moved in with my brother. The only problem is that Grandma WhiteCoat has a few cats … like 10 … and that Grandpa WhiteCoat has a book collection … like about 30,000 … all in boxes. He also has a good thousand or so small plastic boxes of pictures that he has taken through the years. All categorized, but none of them ever seen by anyone but the person at the photo lab who initially developed them. And if you want to look at one of them, you can’t take it out of the house because you may copy it and the pictures are copyrighted. Fortunately, he converted to digital pictures about 7-8 years ago, so now it’s just a matter of storage on his computer drive and no additional plastic boxes. But then he sends pictures to ...

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Healthcare Update — 03-25-2013

Another medical issue with overweight patients: Intramuscular injections. An Epi-Pen may not work in patients who are obese since the distance through the subcutaneous fat to the muscle is greater than the length of the needle. This study showed that in more than 4 of 5 obese children, the subcutaneous fat layer was too thick for an IM injection one quarter of the way down the thigh. In nearly 1 of 5 obese children, the subcutaneous fat layer was too thick three quarters of the way down the thigh. In those patients, the study suggested injecting the calf. I suppose the manufacturer could be forced to make autoinjectors with longer needles, but then non-obese patients would theoretically risk getting a bone marrow injection of epinephrine. How good are emergency physicians at dispositioning psychiatric patients when compared to psychiatrists? Not horrible, not great. 95% of patients assessed as “definitely admit” were admitted by the psychiatrist. For other emergency department psychiatric patients, there was an 87-90% concordance rate. Sugary drinks may kill 25,000 people each year. That’s nothing. SALT [allegedly] causes one out of 10 deaths in this country each year and more than 2.3 million deaths worldwide in 2010. Wonder what that sphincter Michael Bloomberg is going to do with this information. Salt tax? Force NY City hospitals to draw serum sodium levels on all patients? Outlaw salt shakers in restaurants? Or maybe he could just go after the salt shakers with the larger holes and call them “asSALT” weapons. Bwaaaaaahahaha. Sometimes I crack myself up. Another nice article by Alicia Gallegos at AM News. Liability involving patients who overdose on medications is increasing. Families of suicidal patients who overdose on medications are blaming physicians who prescribe the medications … and winning. According to the article, physicians are having also disciplinary actions taken against them if they prescribe medications to a “doctor shopper”. This is getting ridiculous. When pain patients complain that they are treated like “drug seekers,” this is part of the problem why. Maybe the next step should be forcing all patients to sign a statement requiring them to list any doctors that have prescribed them medications, any medication that they have at home or have access to at home, and any medications or street drugs they are using or have used in the past 12 months.

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Grand Rounds Snoop Dog Style

I happened to catch on Twitter a web site where people could search up their Twitter names and get their tweets translated into gangsta talk. Probably not something you should read at work or in church, tho … yo. So I tried it with some other sites. I can’t decide which is more amusing. A newspaper story about a crime? A court opinion? A medical article? Press Ganey’s web site? Note at the bottom of the page the type of “Regionizzle Symposium” they have in 2013. Or a WhiteCoat post? Wanna be an instant YouTube sensation? Have someone video you doing a grand rounds translated by Gizoogle.

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I Made A Drug Seeker Cry Today

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 ...

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