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Patient Encounters

It's About Time

It was a busy night in the emergency department as many nights are. All of the rooms were full and there were 6 to 8 patients waiting just to get back to the emergency department. I hadn’t taken a break in several hours, and though I was hungry I just drank sips of Gatorade and ate handfuls of cashews between patients to keep my energy up and to keep my stomach from growing too loudly at me. Sometimes during nights like this it seems like the “powers that be” try to mess with your mind. Every time you discharge one patient, two more patients register to be seen. If you discharge two patients, three patients register to be seen. The more you try to get ahead, the more behind you get. Then you start thinking. If I didn’t discharge anyone, th-e-e-en how many patients would register? Snap out of it WhiteCoat. Looks like another “no dinner” night. The next patient waiting to be seen was a middle-aged man who was suffering from a cough and sinus drainage for the prior three weeks. The patient was going to be seen by his primary care physician the following morning, but did not want to wait for the appointment. He had been waiting a little more than an hour to be seen. As I opened the door, the man was laying back on the bed watching something on his iPhone. His wife sat in the chair across the room and was apparently typing out a text message on her flip phone. I could hear the Morse Code-like beeps every time she entered a letter. As I walked in the room, the woman looked up, let out a dramatic sigh and said “F-i-i-i-i-nally.” I tried to explain. “I’m Dr. WhiteCoat. I apologize about the wait, but it is a very busy night this evening. I’m trying to see patients as fast as I can. What can I help you with?” “Huh. It’s about time.” “Ma’am, I haven’t gone to the bathroom in three hours and I haven’t eaten a meal since my bowl of cereal at breakfast this morning. I’m going as fast as I can.” I then turned to the patient and asked “What is it that I can help you with?” The wife then butted in again. “Honey, can you even remember what’s wrong? It has been a while that we’ve been waiting here.” That ticked me off. Actually, I was ticked off by the wife’s attitude to begin with, but that comment was it. Rather than lash out, I decided to take a break. “Pardon me. I need to go check something.” I got up, left the room, told the charge nurse that I was taking a short break, and went to the doctor’s lounge. I emptied my bladder. Then I went down to the cafeteria and got a small dinner plate. I brought it back to the doctor’s lounge and ate while talking to one of the other staff physicians. After finishing my dinner, I went back to the emergency department. One of the nurses told me that the patient’s wife had been out to the desk to complain during the 15 minutes I was gone. The nurse had ordered a chest x-ray just to appease the patient and his wife. I nodded. I discharged a patient whose chart had been placed in the discharge rack after labs had come back normal and he was feeling better. Then I went back into the coughing patient’s room. He was still in the radiology department finishing up with his chest x-ray. The ...

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Unfulfilled Expectations

A patient came into the emergency department at 3:00 in the morning with broken peritoneal dialysis catheter. Actually, the catheter wasn’t broken, there was a small leak in the catheter at the distal end of the tubing. She had clamped the shunt off as she was instructed to do in the past and she came to the hospital because she wanted an ambulance ride to tertiary care center 100 miles away. Instead, I cleansed the area, cut about a half centimeter off of the distal end of the tubing, removed the hub from the leaking portion of the tube and inserted the hub back into the shortened tubing. I gave her a dose of vancomycin as a precaution, then discussed discharge instructions with her. “Well how am I going to get to Metro Regional?” she asked. “I checked with your dialysis nurse. You can keep using the catheter. If you’re concerned, you can follow up in their office this afternoon.” “How am I supposed to get there? I don’t have any gas money.” “You don’t need to go there. The tube is fixed.” “Oh, I’m going there.” “Well let’s say that I sent you there by ambulance. What would you do until this afternoon?” “I’d go to the emergency room down there.” “Great. How would you get home?” “I’d have to call my daughter to come and get me … but I’m not going to go calling all over town at 4 AM to try to find her for a ride down there now!” I resisted the temptation to ask her why she would have to call “all over town” to find her daughter at 4 AM. “If you want to go to see your dialysis nurse, you’re welcome to wait in our waiting room until you think it’s an appropriate time to call your daughter, then.” “My cell phone is out of minutes.” “The courtesy phone is on the desk. You just need to dial “9” before making a call.” “You’re through as a doctor if something goes wrong.” “Have a nice day! Don’t forget to fill out our patient satisfaction survey!”

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The Case of the Cyanotic Hands

I went in to see a patient whose hands suddenly turned blue at work. She stated that she couldn’t feel any of her fingertips once they started turning blue and said that she was “cleaning” before the symptoms occurred. As I walked into the room, all of the fingers on both her hands were definitely dusky appearing. Her upper arms appeared OK. Her lips weren’t cyanotic. So I sat there taking a history thinking to myself what the hell could be causing this. Raynauds doesn’t affect the whole hand like that. Sudden onset of a cyanotic heart lesion wasn’t very likely. She wasn’t working in the cold, and she was cleaning toilets with a scrub brush, so she didn’t have an exposure to some kind of industrial solvent. She didn’t have pain, so it wasn’t like she had bilateral arterial occlusions or some other vascular problem. She wasn’t taking any medications. Was she poisoned? I was clueless. I went to examine her. Her hands were warm. She had good pulses. She had normal capillary refill. Good pain sensation with a toothpick. Then I noticed that there was no blue between her fingers, only on front and back of her hands up to her wrist. Wait a minute. I grabbed a washcloth, wet it, and scrubbed the back of her hand. The washcloth turned blue and her hand turned pink. The girl’s mother did a facepalm. “We waited 2 hours to have someone wash your hands?” “Well, the toilets did have those blue drop-in tablets in them,” the patient mumbled. So I set them up for discharge and told them “at least there’s nothing serious – right?” When the nurse went in with their papers, they were all upset because I didn’t do anything to diagnose why the patient’s fingers were tingling. Um … its probably from the blue dye. See your doctor in a few days if it isn’t better. He can set you up for a neurology appointment and a nerve conduction study if necessary. When the secretary read the discharge diagnosis, she loudly said “that’s just gross.” “Why?” I asked. I saw that girl go to the bathroom twice while she was here and if you got that dye off with a washcloth and water, there was no way in heck that she washed her hands in that bathroom.” I put my drink down and went to wash my hands again after having touched the patient’s hands … just in case.

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Memories

I picked up the chart of a very nice little old lady who fell on the ice and broke her arm. When I walked in the room, her husband said “Oh good! He’s the best doctor here.” I thanked him for his compliment and went about treating her injury. All three of us joked back and forth and it was overall a very pleasant interaction for everyone involved. It just so happened that the patient’s daughter works at our hospital. She wrote me a quick e-mail thanking me for taking such good care of her mom. She also stated that her dad doesn’t like many people, but he took a liking to me after I treated him for pneumonia a couple of years back. He didn’t remember a thing about my examination, what medications I gave him, or what I said to him. Know what the only thing he remembered about me was? I was that doctor who went and got him a couple of warm blankets when he was having chills – and I tucked in his feet to keep him warm. People won’t remember how good of a doctor you are, but they will always remember how you made them feel.

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Now See Here

I’m hoping that everyone enjoyed the evening last night. We went out for dinner and, under the influence of sake, I bet each of my kids $10 that they wouldn’t be awake past midnight. I lost $40. Was also getting text messages from several people working in the emergency departments describing how crazy things were getting. An example is paraphrased below. When a drunk and belligerent [patient] is brought in by police after his girlfriend’s husband beats the snot out of him, is it OK to chart that visual acuity is fine when he is able to read “DO” from my name badge and ask for a “real doctor”? I see a new blogger in the making. Everyone have a safe and happy New Year’s Day!

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