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Patient Encounters

That Hesitation When …

… a patient’s family member comes up to you and asks “Hey. You’re Dr. WhiteCoat, aren’t you? Didn’t you work at University Medical Center like 6 or 7 years ago?” You casually look to see if there are any weapons in his hand and, seeing none, you cautiously say “Yeah.” Then the family member says “I thought that was you. Yeah. You’re a good doctor. You saved my father’s life. He talked about you up until he died a couple of years ago. Always told everyone what a good doctor you were and how if you ever had an emergency you should go to University Medical Center and ask for Dr. WhiteCoat.” Then you get a little grin on the inside and have to hold it back while you tell the family member you’re sorry about his father passing but you appreciate his comment. Then you go into the lounge with a dumb smirk on your face and think about how an offhand comment like this can make your whole day. Then the nurse sees you smirking and asks “What warped thoughts are running through your mind THIS time?” “Oh nothing.” Then you can’t decide whether the nurse’s suggestion that you have a warped mind is making you happier or is worrying you. Who cares. It’s still a better day hearing that you’ve had that much of a positive impact on someone’s life.

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Defibrillating with Soup Spoons

So I’m treating this patient the other day. He’s a little intoxicated. Got whacked in the head and needed some staples to close his scalp laceration. When I’m fixing patient’s various injuries, I feel like a barber sometimes. I strike up conversations … ask how their families are doing … how did they get in this predicament … that type of thing. This fellow comes straight out with a doozy. “When I was growing up, our next door neighbor was famous.” “Really, why?” “The husband was a surgeon in a small town hospital. There was a kid whose heart stopped beating after surgery and he saved the kid.” “That’s awesome. What did he do?” “He used two spoons to defibrillate the patient back to life.” “Spoons. Like silverware?” “Yup. Heart started beating and he lived.” By this time I already messed up one staple trying to process what happened. “Wait. Wait. Wait. He used two spoons. How did he keep from being shocked himself?” “I don’t know.” “Mmmmm hmmm. And what did he use for an electricity source? A car battery or something?” “Nope. A fan cord. He ripped it out of the fan and wrapped it around the spoon.” “Mmmmm hmmm.” “In fact, there was a story in Time Magazine about him.” “Mmmmm hmmm. Wow. That’s a great story. Must have been a great doctor.” “He was. Nice guy, too.” I don’t even know why I bothered, but I wrote myself a note to look this up online. Snopes.com … nothing. So I did a search on DuckDuckGo.com with “doctor spoons fan cord”. First result? Time Magazine. October 1959. Dr. Russell Simonetta defibrillated a 19 year old whose heart stopped after surgery – using spoons and an electrical cord. Whiskey Tango Foxtrot. One of the reasons I love my job so much is that I couldn’t make stuff like this up if I tried. I owe this guy a beer.

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Interesting Emergency Department Complaints

Here are a few of the more memorable recent emergency department complaints. My mother has had early onset dementia for 40 years. We need to see what’s wrong before the end of the year. Patient arrived December 30. Hangnail on the finger for month. She pulled it off today at work and had to leave work because she saw blood. It was her typing hand. A patient was playing with her dog earlier in the day. She was laying on the ground and the dog jumped on her stomach. She has had severe back pain since this occurred and is out of pain medications. The dog was a chihuahua. Child was in the emergency department 2 days ago and diagnosed with a cold. Mother brought 4 other children in to be checked to see if they have colds. Constipation for 4 days. Had a bowel movement the day before he came to the emergency department, but didn’t have a ride to get to the hospital until now. Wants to know why he was constipated. Patient has had a BB lodged in his elbow for several years. Wants it taken out. “I just got that Obamacare insurance.” House was cold last night. Got chills. Wants to be checked. Lips are dry. I’m guessing that the responses to some of these complaints would be amusing as well ….

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Unique Way Of Looking At It

“Doc, he’s been having some problems at home with his wife for the past few months. Took up drinking and now he’s been tipping the bottle on a daily basis.” Wasn’t exactly what we wanted to hear for a patient having chest pain. The patient’s story was concerning for heart disease and he had several cardiac risk factors, so after his initial labs came back normal (and after we excluded pancreatitis), he got admitted to telemetry for further evaluation. But it wasn’t quite that simple. When the floor nurses heard that he was a daily drinker for the past few months, they refused to accept the patient. Didn’t want him going into DTs on the floor, ya know. So he got put onto the DT pathway and sent to the stepdown unit. His initial CIWA score was elevated, so he got his first dose of Ativan in the emergency department. “What’s that for?” he asked. The nurse explained “It’s a pill that keeps your body from having alcohol withdrawal symptoms. It has effects on the brain similar to alcohol, but allows us to slowly lower the dose to keep you from having shakes or even seizures.” “Ah. I get it. A six pack in a pill, huh? I may need to get me some more of these.” “I’m sure you will, sir. I’m sure you will.”

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More Patient Satisfaction Ridiculousness

Dr. Whitecoat refused to remove something that was hurting my ear. He was rude, insensitive, and refused to help me with my medical problem. I would never come back to your hospital if I knew he was working. That little diatribe was in addition to all of the “1” scores that the patient used to rate my care. Of course, none of them were true, but satisfaction scores are a presumption of guilt, not a presumption of innocence. What did I do to deserve this scathing review? I actually remember the case. The patient’s complaint was “foreign body in the ear.” Easy enough. He was in his 70s, so it was probably just a piece of cotton from a Q-Tip. When I got into the room, it wasn’t quite so easy. The patient had a tympanostomy tube placed about a year ago. He wasn’t sure why it was placed. But the day before he came to the emergency department, he had gone to get fitted for a hearing aid and the person who did the exam noted that the tube was still in his ear.  Then he showed up on a Saturday night. “There’s a tube in my ear. I want it out,” he said, matter-of-factly. After examining him, the tube was still in place. “It’s still in your eardrum,” I explained, “I can’t take it out.” “Well … it hurts. You need to do something about it. They won’t put in a hearing aid until the tube is out.” “I don’t do ear surgery. I don’t have the experience or the equipment to take the tube out. Besides, even if we were able to take the tube out tonight, they wouldn’t put in a hearing aid immediately. You’ll need to follow up with the ENT physician who put the tube in.” “Are YOU going to get me an appointment?” “I won’t be able to do anything on a Saturday night. You’ll have to call his office on Monday.” Then the patient’s wife jumped in. “The tube is giving him ringing in his ear, also. What are you going to do about THAT?” “There usually isn’t much we can do with tinnitus. When did it start?” The patient and his wife looked at each other. “A few hours ago. And it’s really bad, too.” “You didn’t have the ringing before a few hours ago?” “No.” So I went to the medical records. The patient’s last visit with the ENT physician was six months prior to his emergency department visit. The note mentioned that the tympanostomy tube was in proper position. It also mentioned that “Mr. Smith also complained about his chronic tinnitus. We had a long discussion about this and I informed him that there wasn’t much we could do to treat it other than possibly having him fitted with a hearing aid.” I printed out a copy of the note and read it to the patient and his wife. “I’m not sure what else I can do to help you tonight.” “C’mon. We’re leaving,” the patient said to his wife, “It’s obvious that this doctor isn’t going to help me.” So, based on four whole responses rating my care from the last set of Press Ganey questionnaires, guess whose care fell far below the rest of the physicians in the department. But don’t worry. The results are statistically significant enough to compare me to the other doctors in our department and to all of the other physicians nationwide. Press Ganey says so … and their multi-million dollar business model depends on people believing it. Want to see the truth behind Press Ganey scores? Check out ...

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Emergency Diarrhea

I simultaneously love and hate nights like this. It’s not just that it seems like patients get off a bus all at the same time and wander over to the registration desk. It’s that almost everyone in the emergency department is actually having an emergency. Full arrest. Stroke. Overdose. Cardiac arrhythmia. Bowel obstruction … with a spike in the cardiac enzymes to boot. What’s that? You can’t reach the  cardiologist or his partner … and the ICU was full so we have to hold critical patients in the emergency department … and we’re short two nurses? Yeah, that’s about right. While you’re running around, patients and family members stand in the doorways of the rooms giving you the stink eye and watching you dart back and forth from the telephone to a patient room to another patient room back to telephone, then don a gown and disappear into the trauma bay amid a crowd of people. After what seemed like an eternity, we finally got the serious patient stabilized and were able to take care of some of the less critical patients … like a young patient with diarrhea. He and his family waited 3 1/2 hours to see me. There were lots of snarky comments when I grabbed a couple of charts including his including “there is a new invention called Pepto-Bismol, they should try it” and “since when is diarrhea an emergency?” I kept an open mind as I walked in the room and reflexively apologized for the wait. The patient was a little boy who was seven years old. He had diarrhea for 2 weeks. Their pediatrician was out of town and besides, they weren’t too happy with him. He never does any testing and just writes a prescription for antibiotics every time the parents bring the patient to see him, anyway. The patient missed two days of school this week because the diarrhea wouldn’t stop. Today was the worst. He was having stomach cramps and couldn’t get off the toilet. “When’s the last time he had diarrhea?” The mom scowled. “Right before we got here … like four hours ago.” That’s patient-speak for “what took you so fricking long, you lazy dickhead?” That little Jim Carrey character in the back of my head started saying “Oh reeeeeheheeallly? First, it has only been three and a half hours, not four hours — which is incidentally about twice as long as it’s been since I’ve eaten anything or used the bathroom. But that’s beside the point.” Suddenly my brain’s automatic pilot started saying “Pull up! …. Pull up!” I snapped out of it. So I started out by making small talk with the patient. “You’re sure you’re seven? You didn’t turn a year older waiting here all this time?” That got a smirk out of dad and a laugh from the patient. I did a thorough exam and explained how diarrhea that lasts longer than a week usually has to be evaluated with lab testing. The mother noted that the patient’s grandmother had Clostridium difficile colitis and that they had been to visit her shortly after the symptoms began. We needed to get a stool sample for testing. With a little extra effort, the child was able to provide a sample. Unfortunately, the wait for the results was going to be another couple of hours. So I got the parents’ phone numbers and told them that I would call them with the results in the morning. That way they didn’t have to wait even longer in the emergency department. I asked the mother “Do you have any questions? You’ve had over 4 hours to ...

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