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Patient Encounters

We’ve Been Facebooked — Part 2

My dislike for certain forms of social media continues. One of the problems with social media in the medical field is the federal privacy act known as HIPAA. HIPAA prevents medical providers from publicly disclosing any “protected health information” about patients without the patients’ permission. We can disclose the information among other medical providers providing care to the patient with few limitations, but we can’t disclose the information to the public. A patient can go to newspapers and say that a doctor committed gross malpractice by misdiagnosing her abdominal pain, but the doctor can’t respond by saying “no, actually we treated your gonorrhea appropriately, you just didn’t follow up and you gave us a fake phone number so we couldn’t contact you to tell you that it was resistant to the medications you received.” HIPAA doesn’t allow providers to disclose medical information to third parties without the patient’s permission … which leads to such difficult situations as below. A patient presents to the emergency department after leaving work for evaluation of “severe” abdominal pain which she was sure was due to a hernia surgery that she had a few months prior. She was laughing and joking in the room, eating Cheetos and watching television. Apparently, the hour or so wait became too long for her. The multiple trauma victims and patients needing mechanical ventilation were much less important than her work note. So, orange fingers and all, she pecks away on her phone and posts on Facebook how crappy the emergency department is because she had to wait. It just so happens that one of her Facebook “friends” works as a nurse on the medical floor. The nurse happened to glance at her phone between patients, notices the Facebook update, and calls to the emergency department to ask what the problem is. Emergency department secretary is frazzled by all of the sick patients and tells the floor nurse it isn’t any of her damn business what is going on in the emergency department and to worry about her own patients instead of checking out Facebook during work hours. That pisses off floor nurse who then calls hospital administration and tells them that the emergency department is slacking off … which prompts a visit from the Director of Nursing. When DON arrives, she reviews the situation and pulls the charge nurse aside and asks if we can see this abdominal pain patient ASAP. Charge nurse (who is awesome) briefly educates DON about the concept of triage and asks DON if she can help register and triage continuing influx of patients. DON says that she has a meeting to attend and leaves. When the more critical patients have been stabilized, we get in to see the patient. Her abdominal pain has essentially resolved. Actually, it resolved shortly after she arrived. But she has had this lump on her surgical scar ever since her surgery, it has been bothering her more than usual lately, and she really wants to know what the lump is. The lump is where they tied the knot for the stitches they put in under your skin. May be the mesh as well. No problems with the surgical site that we can see. You’re welcome to make an appointment with your surgeon if you still have questions. Oh, and by the way, I think I missed my last period. It’s negative. Oh, I’ll also need a work note. Your discharge papers will show when you were discharged.  Have a nice day. So about a half hour after the patient is discharged, the unit secretary suddenly blurts out “Oh … ...

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Blown Away

By Birdstrike MD I was a work today and I was given this message, “ —–‘s husband called and wants you to call back right away!  He sounded very upset.  His wife died.” Uh-oh, I thought to myself, this is never good.  It was a patient I remembered well, that I had seen repeatedly for a chronic problem, and who always came with her husband.  We seemed to get along well.  I didn’t recall any conflict, unpleasant interactions or any immediate life threat that might have been ominous. There were no complaints to administration.  I looked in the computer, and I hadn’t seen this patient in over 3 months.  I debated whether or not to call back, not knowing what beehive I would be getting into.  Did I do something wrong?  Am I being sued?  Surely I am going to be blamed for this in some way?  Maybe returning this call would not be such a good idea. I decided to call back.  After all, I knew the curiosity of not knowing what happened would torture me more than simply calling and facing whatever was coming my way.  I had a few extra minutes, so I dialed the phone and called. “Hello,” answered the familiar voice of Mrs. —-‘s husband. “Hi, this is Dr. Bird.  I got a message that you had called.  I’m sorry about the terrible news,” I said. “Yes, she died 2 weeks ago,” he said, his voice crackling and wavering.  “I thought you would want to know.” “Yes, absolutely, thank you for calling.  Again, I’m very sorry about your loss,” I said.  “What happened?”  I was afraid to hear the answer. He went on to explain that 3 months after I had last seen his wife, her condition began to deteriorate (from something unrelated to what I saw her for).  He paused and choked up repeatedly in telling the story, the tears and emotions still raw.  She ended up in the ICU and on life support.  Her condition worsened, beyond any hope.  To respect her wishes, he decided to withdraw support, as she requested.  As a result, she died.  This concluded many long and painful years of an excruciatingly painful illness.  Nevertheless, he was crushed. “She was a very strong woman and she went through a lot,” I said.  “I’m sure you miss her very, very much.” “Yes, I do,” he said.  I could hear him now choking back full tears.  “Most of all, I wanted to call and tell you thanks, for all you did trying to help her.  I want you to know she thought the world of you.” Wow.  That was a shocker.  After all the years of hurried patient interactions, the long nights, the grinding day shifts, and the routine ins and outs, unexpectedly, this one stopped me in my tracks.  I have to admit, he got me.  I was totally caught off guard, by the appreciation in the face of such a hurtful tragic loss.  I had come to expect utter negativity and un-appreciativeness at all turns. “Wow, sir.  Thank you.  Thank you for calling.  I really appreciate you letting me know,” I said, in disbelief, and humbled.  After years of being a doctor in various setting, with 30,0000 or more patient interactions and counting, I can honestly count the number of times I have received this type of thanks on one hand.  At least for the moment, this one “thank you” seemed to have made up for many thanks that likely were felt, yet not necessarily sent or expressed, and likely drowned by a much noisier negativity more demanding of ...

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Angry Betty and the Unresponsive Kid

The nervous voice on the call over the radio already sounded bad. “Emergency One en route to Interstate 88, mile marker 177 for report of car on side of road with parent witnessed performing CPR on child.” CPR on a kid? Damn. Kids aren’t supposed to need CPR. There was an eerie silence at the nurse’s station as everyone waited for the next radio report. Finally it came. “Metro General, this is Emergency One. Do you copy?”You never think much about how much information can be inferred from the tone of a paramedic’s voice until you’re in a situation like this. In this case, the paramedic was calm and taking his time. As soon as they heard his voice, three nurses, a secretary, and two doctors let out a sigh of relief. The nurse picked up the radio microphone. “This is Metro General, go ahead.” “Metro General, we have a ten year old male with no local doctor who reportedly had a witnessed cardiac arrest while driving on the highway with his parents. He regained a pulse after his mother performed CPR on him for a minute or so. Mother is a cardiologist and is accompanying us on this transport. ETA is 6 minutes. Over.”Everyone looked at each other. Female cardiologist? Nahhhh. It couldn’t be her. Not Angry Betty. Whenever you had a patient with chest pain, you HOPED that Angry Betty wasn’t on call. No matter what you said, she’d always disagree with you and then talk down to you for not knowing your stuff. Then she’d ask some esoteric and often irrelevant fact that you never were able to answer quick enough and she’d nose breathe into the phone for what seemed like an eternity while you looked for the answer.Sometimes you’d get all the labs laid out on the desk in front of you just to try to beat her.  “How stenosed was the RCA on his last angiogram and what was the date?”“40% on October 13” [fist pump in the air]“When was his last ophthalmology exam?”“June 2012” [HA! Double fist pump]“What was the last homocysteine level?” “Ummmm. Hold on.” [eyeroll … she won again][constant blow of air into the receiver of the phone]“I don’t see one in the computer.” “You don’t see one or it was never done?”“Well I can’t see what was ordered at other facilities, but there hasn’t been one done at this facility.”[more nosebreathing]“I’ll order it.”Six minutes later, everyone’s fears were realized. Paramedics wheeled in a stretcher with a 10 year old boy playing on his iPad. Angry Betty was running alongside of the stretcher with her stethoscope glued to his chest.“Your patient,” says the other ED physician working that day.“No. YOUR patient.”“Sorry, I’m going on break.”“OK, paper/scissors/rock.” Figures. I lost that one, too. “Hi, Dr. Angry. What happened with Angry Junior today?”“We were driving on the highway heading downtown when I looked in the rearview mirror and Junior was unresponsive.”“Unresponsive?”“Yes. Unresponsive. His mouth was open wide and his eyes were closed. I yelled his name and he didn’t answer. I had his sister slap his face and he barely flinched. So I pulled over, started CPR, and called 911.”“I see.”“By the time these paramedics arrived, he had return of his circulation. They did an EKG in the ambulance that was normal, but based on the symptoms, it appears cardiac in nature.”I looked at Angry Junior. He looked up from his iPad and shrugged his shoulders. “I see.”“What happened to you?” I asked Angry Junior.“I think I fell asleep,” he responded.Angry Betty interrupted. “You did NOT fall asleep. You were unconscious and difficult ...

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“You’re Next”

By Birdstrike MD I saw a story in the news about something that happened to an ER doctor.  It reminded me of something that had happened to me before, so I started writing about it.  Then my imagination got a little bit carried away.  So, let’s just say parts of this story are absolutely true, and other parts are, well…just read along.  I walk in for my ER shift.  There’s a letter in my department mailbox.  It’s a hand written letter from a patient.  I open it, “Hey doc!  I just wanted to thank you for taking care of me last week.  It was one of the low points of my life and I really had hit rock bottom.  You’re the first one to talk to me like a human being.  You convinced me to get help.  They finally let me out.  Thanks, again.  You saved my life.  You’re a great doctor.  We should hang out sometime.” Sincerely, Jerry —– Cell: XXX-XXX-XXXX” I remember the patient.  I admitted him for severe alcohol intoxication, depression and suicidal thoughts about 2 weeks ago.  It’s not that often that you get to start out a shift with a “thank you” letter, albeit with a bizarre request at the end to “hang out sometime.”   In this ER game, you take every pat on the back you can get, because they don’t come every day. I walk to the pit to see my first patient.  First up is, “Broken wrist.”  I walk into the room and it’s him, Jerry, the letter writer.  “Hi, Jerry, what can I do for you today?” “This,” he holds up his mangled right hand and wrist.  “I got pissed off and punched a wall.” “Wow, you sure did a number on yourself.  What happened?” I ask. “Did you get my letter?” he asks. “Yes.  Why do you ask?” I wonder aloud. He stares at me silently, and uncomfortably long.  “Oh, I don’t know,” he trails off, staring through me.  “Just fix me up, and we’re good.” I walk out of the room.  That was weird, I think to myself.  I put in an order for x-ray of the hand and wrist.  I put that plate up in the air to spin, and move on to: Chest pain, Migraine, “Can’t see,” Sprained knee, “Menstrual,” “Sick still,” Split lip, “Vag drip.” Jerry’s x-ray is done.  Wow.  He’s completely shattered his wrist and 4th and 5th metacarpals in his hand.  I haven’t seen a one this bad in a long time.  I walk into his room.  “Jerry, you’ve badly fractured your hand and wrist.  You’ll probably even need surgery.  I’m going to call the orthopedic surgeon.” “No.  I want you to fix it.  You owe me, big time,” Jerry says. “No, you don’t understand.  It’s badly fractured.  You need a surgeon for this, a specialist,” I explain. “Did you hear me?  I said, ‘NO ’,” he says, gritting his teeth so hard they could shatter. After years of seeing anything from little old ladies to psychopathic criminals, it takes a lot for a patient to truly bother me, but this guy is truly disturbing in a way that’s hard to describe.  It’s time to get out of this room.  “That’s the way it has to be for you to get the best care,” I say and walk out of the room. As I get to the door, he yells, “This s—t is your fault mother f—-r!  You should have called me back.  I left my cell number on the letter for a reason.  YOU shattered my hand and wrist.  This is because of ...

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It’s ALIVE

There was a lull in the patients at 2:15 AM. Conversation turned from splinting and IV drips to baby names and childrearing as two of our nurses are currently pregnant. The aroma of freshly-brewed coffee filled the air. Then the next patient registered. A girl in her early 20s. She sheepishly came up to the registration window and said “there’s something crawling inside of me.” Yes, we thought it, too. “OK, ma’am. When was your last menstrual period?” “I think it may have been a month ago … or maybe two months.” “Did you check to make sure you’re not pregnant?” “Yes, a home pregnancy test was negative about three weeks ago.” “How long has this been going on for?” “About 3 weeks.” Yes, we thought it, too. “If this has been going on for three weeks, why did you wait until 2AM today to decide to come to the emergency department?” “Well … it was worse.” “At 2:00 AM tonight?” “Yeah. Usually it feels like a chipmunk running around inside there. It will scamper around a little bit, then it will stop. Then it will scamper around a little bit more, then stop. I was trying to get my mom to feel it tonight and it wasn’t moving, but then it felt like it had hiccups or something. I couldn’t sleep.” One of the pregnant nurses and I gave each other quizzical looks out of the corners of our eyes. Then the secretary came in and handed us the results for the normal urinalysis and the negative pregnancy test. The pregnant nurse and I gave each other another quizzical look out of the corners of our eyes. “No other problems? No diarrhea? No discharge? No pain?” “No. Nothing. Just something moving. I really need to know what it is.” The patient was rather thin. Her exam was normal. Since she was so thin, it was easy to feel that there were no masses in her stomach. Nothing. “Wait! There. Do you feel it? Feel it hiccuping right there?” She grabbed my hand and held it firmly to the middle of her stomach. “You mean that regular pulsing down deep?” “Yeah! THAT! What is it?!?” “Tell me something, can you feel the same pulsing in your neck?” At that point, the pregnant nurse standing behind me blurted out “Thank GOD! I thought I was crazy! Every time my baby moves, I feel a pulsing in my neck, too. I had no idea what it was and was too embarrassed to ask. So what is it?” “She’s not pregnant, remember?” Then both of them in unison ask “So what’s causing the pulsing?” “Her pulse maybe? Here, check your wrist and see if the pulsing is going at the same rate as the movement in your stomach.” It was. “The biggest blood vessel in your body runs right down the middle where you are feeling the movement. You’re supposed to be able to feel pulsations there.” We all got a good chuckle. After the patient went home, we all sat around the nursing station telling baby stories. While she was talking, one of the nurses started rhythmically contracting her stomach … about 60 times per minute. Everyone else joined in unison shortly thereafter. The pregnant nurse turned red. “Hey, it’s my first baby. Cut me some slack.” Everyone just kept talking and rhythmically contracting. “I’m wrapping up his poopy diapers and mailing them to all of you.” “As long as you don’t bring him in for hiccups, I’ll be fine,” I said. “You’re going to be the first one for a poop bomb, WhiteCoat.” ...

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Got A Light?

By Birdstrike MD I walk into the ED for the 7:00am shift.  I’m 24 hours post-night shift so my body thinks it’s 3:00am and my brain feels like it’s been embalmed for 3 days.  I take my last swig of triple dark-roast Starbucks and sign up for my first patient. Chief complaint: “Lost light” Is that a misprint?  Maybe it’ll be a quick and easy one to start the day, I think to myself.  That’s just what I need, so my coffee will have some time to kick in.  I’ll just send this guy off the Lowe’s or Home Depot, I laugh to myself, so he can get a new light.  I walk into room 13 and there’s a man laying in a fetal position on a stretcher, with the bed sheet over his head.  I walk up to the side of the bed and say, “Hello sir, I’m Dr. Bird, what can I help you with today?” “Well, doc, I’m in a bad spot.  I was holding on to a light bulb, and it just popped right in,” he says with a whimper, avoiding eye contact.  Looking at his face, I notice he is as white as the bed sheet.  He’s pale and looks like death. “What are you talking about?” I ask him. “Lift up the bed sheet,” he says, looking behind himself. I lift the bed sheet and he is lying in a pool of blood.  The back of his gown is soaked.  I glance up at the blood pressure monitor and the automatic cuff had just rechecked his blood pressure: 88/58.  “Sir, are you having rectal bleeding?” I ask. “I guess you could say that.  The light bulb just popped right in,” he says again. “What?  Oh…I get it.  You mean…you, put it up your rectum?” I ask, now knowing exactly what happened.  For an ER doctor, things like this are not shocking.  In fact, they are part of the portrait painted for us every day; the bell curve of the ER doctor’s experience. “And it popped!” Ouch, I think to myself.  O U C H !  “It broke?” “It exploded in there,” he cries.   2 IVs, bang! Fluid bags hang. Time to call the OR gang. KUB ordered, Let’s see the x-ray. “Am I dying, Doc? Is this my last day?”   There it is on the x-ray: one homicidal light bulb clearly visible inside one rectum cut to ribbons, with its countless shattered glass shards, doing their best to bleed the life out of a man. “Am I gonna make it doc?” he asks me again. “You’re going to make it,” I answer.  “You got yourself here quickly.  If you had waited any longer, you might not have.” “Doc, can you please tell my wife…” “Wife?” I interrupt, surprised. “And my kids…” “Kids?” I ask. “Yes, doc, we’re here on vacation.  It’s our first family trip to Disneyland.  You wouldn’t understand,” he says, as he pulls the bed sheet over his head, as if to crawl under a rock to hide and never come out. Just then the OR team barges in the room commanding, “We’re ready for him.  Let’s go!” “What do you want me to tell your wife?” I ask him. “Doc, please, a hemorrhoid.  Just tell her it’s a little hemorrhoid.”   ………………………………………………………………………………………………………………………………………. This author does not divulge protected patient information or information from real life court cases. Any post that appears to resemble a real patient, real person, real co-workers or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information ...

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