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Patient Encounters

Unnecessary Testing

An 89 year old little old lady is brought in because she is weak and doesn’t want to eat. She hasn’t eaten in about a week and she hasn’t been out of her home in longer than that. Finally a friend visiting her convinces her to come to the hospital for some IV fluids. When she arrives, her tongue is dry, she’s tachycardic, and she has no urine output. We begin fluids and obtain labs that show she is moderately dehydrated. Otherwise, the labs and EKG look surprisingly good. We make arrangements to admit her to the on-call physician since she has no primary care physician. We’re holding patients in the emergency department because the floor is full. The on-call physician has several patients being held in the ED. The patient gets taken over to x-ray department for a chest x-ray. She returns and about a half hour later I get a phone call from the radiologist. “Your little lady with the shortness of breath has bilateral pulmonary emboli on her chest CT.” “What little old lady with shortness of breath?” “Mrs. Doroshow in Bed 4.” “She’s not short of breath and I didn’t order a chest CT on her.” [10 seconds of silence] “Ooops. We did the scan on the wrong person. Well, she still has bilateral pulmonary emboli.” “Nurse, can we get a heparin drip going on Mrs. Doroshow and hook her up to a monitor?” “Whaaaat? Why?” “You’re not going to believe this.” There but for the grace of God go I. . . . . . . . . . . . This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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Huh?

A patient comes in for evaluation of left flank pain. In her urine sample, the nurse finds a small brown pebble. Nurse, holding small plastic cup with stone inside: “Looks like I found what was causing your pain! That looks like a kidney stone!” Patient: “Well, maybe … but I do have a cat, you know.” Sometimes I wish that there were cameras in the rooms so that I could see my own confused looks.

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Cake Cures Pain?

When you come limping into the emergency department bent over and moaning because your back pain is “definitely 10 out of 10” and is “so bad you can barely move your arms,” then 20 minutes later when the doctor comes to see you in the room, you are sitting on the bed laughing with your visitor and using a fork and plate to eat a piece of a nurse’s birthday cake that you somehow managed to pilfer from our staff break room … it’s a good bet that you are not going to get your Oxycontin prescription refilled. Nope, you aren’t getting another piece of cake, either. Now give me back that fork. This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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WTF Moments #995 and #996

Psychiatric patients can be either frustrating or enjoyable, depending on their demeanor. With six of the first ten patients I saw having psychiatric issues, I got to see both sides of the spectrum today. First was a woman who was having dizziness. She also made it clear that she was “bipolar and a little schizo.” I wasn’t sure what the threshold was between “a little schizo” and “a lot schizo,” but trying to find an answer to that question wouldn’t have been very productive.  She apparently wanted to be admitted to the hospital. When we told her that she could be discharged after receiving some IV fluid and some medication for her dizziness, she was upset. Then she said she felt suicidal. The psychiatrist knew her well, evaluated her, and cleared her for discharge. Then she said she was having chest pain and forgot to tell us. We added a set of cardiac enzymes and performed a normal EKG. The old records showed that she had a clean cardiac catheterization four months ago. We dutifully ran the case by the cardiologist who also cleared the patient for discharge. As the nurse was walking out of the room after giving the patient her discharge instructions, she yelled out the door “I had brain cancer once, too, you know.” I looked at the nurse. She looked at me. We both stood there for a few seconds wondering about the significance of the statement. Then simultaneously we shook our heads, threw our hands up in the air, and went back to our business. Then, there’s the lady who came in for a disappearing lump in her armpit – for the past 8 months. The lump only appeared when she rolled on her deodorant. We couldn’t find any lump on exam – even after having the patient pretend to roll on deodorant. I told the patient that she would need to see her family physician and could bring her deodorant with her to the appointment. Then I left the room to start the discharge papers. The patient yelled “hey doc, come here” to the resident, so he went back in the room. About 30 seconds later, he came out beet red in the face. “What happened?” “She said ‘watch this!’ then she pulled up her shirt, whipped her boob out of her bra, and squeezed it. Milk squirted across the room. Then she laughed.” Then we laughed. Then came the comments. “Clean up in aisle 8!” “It does a body good. Pass it on.” “Somewhere in this world there is someone that would pay money to see that.” All this entertainment and a paycheck too … This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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Great Door to Balloon Time

Interesting but sad case that bypassed the ED but about which we later heard. An elderly female with previous coronary artery disease, diabetes, and hypertension called EMS for chest pain. Then she has a syncopal event in front of her husband. Medics arrived and found the patient in ventricular tachycardia.  They cardioverted her back to sinus rhythm, but she was still hypotensive. EMS transports her as a sudden cardiac arrest to a STEMI facility. The patient is taken directly to cath lab which had already been activated due to the EMS report of a “code STEMI.” During the angiogram, the patient remained unstable, went in and out of ventricular tachycardia, and remained markedly hypotensive, requiring fluid resuscitation and pressors. The angiogram showed severe three vessel disease. Cardiologists couldn’t get the patient stable despite pressors, IV fluids, multiple defibrillations, and ACLS drugs. Then the cardiology fellow notes that the patient’s abdomen seemed to be distended – moreso since the case started. They directed the cardiac catheter down the aorta and injected dye while doing cineangiography.  It showed contrast material going into the patient’s peritoneal cavity. Shortly afterwards, while making arrangements for the patient to be taken to surgery, she died on the table. The rest of the history came out when the husband was informed of his wife’s death. The night before, the patient had been seen at a different hospital for evaluation of abdominal pain.  They diagnosed her with “obstipation” and sent her home. Some of you are probably wondering how cardiologists missed the ruptured abdominal aneurysm when they inserted the catheter into the groin and advanced it up the aorta into her heart. Radial access is all the rage these days, so initial access was through the arm and not through the leg. Therefore, the catheter didn’t pass through the lower aorta. So why was the patient in ventricular tachycardia? The cardiologists surmised that the hypotension led to low cardiac perfusion, which, in the setting of severe CAD, caused chest pain, cardiac ischemia, and the arrhythmias. The patient probably wouldn’t have survived surgical repair of her aneurysm, but one of the down sides to that holy grail of a short door to balloon time is that it is more difficult to obtain a complete history. Ironic that sometimes hospital boards and/or administrators care more about their numbers than they do about the actual patients. When hospital boards or administrators pressure medical staff to meet unreasonably high standards for “door to balloon times,” perhaps lawyers need to start looking at the administrators and board members for reckless decisions that result in adverse patient outcomes.   This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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Entomology Clinic

Two different patients came in with strange “bug” complaints. The frustrating thing for doctors is that the patients with “bug bite” complaints are absolutely convinced that the bugs are present and are causing all kind of physical maladies. Many times they are not. The frustrating thing for the patient is that the doctors are sometimes … well … skeptical of the complaints. The first patient had small scabs on her arms and lower legs – typical of neurotic excoriations. There were scars in these same areas where previous “bug bites” had occurred and healed. No scars on the back or other hard to reach areas. According to the patient, the bugs were hiding under her skin, crawling out from under her skin, biting her, then crawling back under her skin again and hiding when she tried to kill them. I used a magnifying glass to look at the areas to show her that there were no bugs. She corrected me. She had done research on the internet and the bugs were too small to be seen – even with a magnifying lens. Besides, the bugs that had infested her integumentary system liked the dark, so they only came out when it is dark in her bedroom. “I can feel one crawling up under the skin on my leg now. Can you see that lump moving?” She pointed to an area on her skin. We both stared at her leg for about 30 seconds. Um, no. No movement. I suggested that she leave the light on at night if the bugs were afraid of the light. That didn’t work. Apparently they bugs know when she is sleeping and pick that opportunity to bite her. She had been to multiple dermatologists, family practitioners, and emergency departments. She had been told that things were “all in her head” in the past, but didn’t believe it. No it wasn’t scabies. No it wasn’t bed bugs. Knowing that I wouldn’t win this battle, I thought for a few moments while thoroughly washing my hands and came up with the cure.

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