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Refusing Number 12

A 16 year old patient came with her mother to the emergency department for another “kidney stone.” She was having lower abdominal cramping – mostly on the left – which had been present for the prior two days. The pain was dull and was worse when she urinated. She was sure this was a kidney stone because it was just like the twenty or so kidney stones that she had in the past.
“Wait a minute. Did you say ‘twenty’?”
“Yeah. Twenty.”
I immediately started asking about whether the patient had been worked up determine why she kept having kidney stones.
She had been diagnosed with hypercalcuria – high calcium levels in the urine. When the levels of calcium are high in the urine, then calcium is more likely to precipitate out and create stones.
Her calcium levels were chronically high and her pediatric urologist couldn’t figure out why.
And she was in a lot of pain from these kidney stones.

I ordered a few labs, some Motrin and some IV fluid, then went to look through her old medical records. 
“Radiographic studies” tab showed 11 CT scans of the abdomen and pelvis plus at least a dozen ultrasounds over the prior 6 years – and that was just in our facility. Multiple different physicians, including family practitioners, urologists, and emergency physicians had ordered the different tests. On one of the CT scans about a year ago, there were multiple small calcifications in both kidneys.
“Laboratory” tab showed 27 metabolic panels – each one with a normal calcium level. There were also six urine calcium levels – each normal or below normal.

I printed out the labs and showed them to the mother.
“Well her abnormal lab tests were at other hospitals.”
“Which other hospitals? I want to get copies for our records.”
“There have been quite a few.”
“You can just give me a couple, then.”
[ awkward pause ] Then the daughter interrupts. “It’s OK mom. I feel better now.”

And so the patient and her mother left after receiving only a dose of Motrin. Neither appeared terribly pleased.

I have trouble figuring out where the problem lies for the lapses in this patient’s care …
The patient and her mother who doctor hop and get the same workups over and over again?
Doctors who order the testing over and over again?
Or maybe a system which creates no accountability?
Perhaps a combination of all three.

But how do we fix it?

9 comments

  1. Hmm? I wonder what the angle was? Munchausens by proxy? Vicodin shopping? Really did have calcium problems documented at other hospitals? Strange case. Scary how many CTs she’s had in just your system.

    • My first thought was Munchausen’s. The mom had a similar history. Either that or it is a significant dysfunctional learned response by the daughter.
      Anther possibility is that some patients develop an anchoring bias when they are misdiagnosed. Some may confabluate to feed the bias. Those who question the diagnosis are looked on with disdain. Happens quite often.

  2. So in a real situation like this (because, of course, this one is made up for blogging purposes) – what can you do? I assume that HIPPA laws prevent you from receiving any information if you were to call other local EDs. Could you have an in if, from checking past records, you see that the patient received narcotic prescriptions at your hospital – so you’re checking for narcotic abuse?

    • HIPAA is actually pretty reasonable in this regard: there are some exceptions, but for the overwhelming majority, if it’s part of patient care, you can just call and get information.

    • Seth is right.
      If it is treatment-related, HIPAA allows medical providers to obtain the information – even without the patient’s consent.
      What to do about it … now that’s a much bigger problem.

  3. It sounds like they were trying to score some narcotics.

  4. Doctors are held accountable. Hospitals are held accountable. Nurses are held accountable. There is one very large group of people who are not held accountable-for anything. Patients. Everything is designed to protect them from themselves and even if you try to do something to protect them-they can come after you. Sure you can call that patient out. She’s going to develop a nice little pelvic cancer one day and sue every single physician who ordered a CT on her.
    My new EMR has 15 popups for “meaningful use” BS, yet my smoking, diabetic, obese, unemployed, pregnant welfare recipient gets pissed off at me for not giving her child with a cold a school excuse for 5 days and gives me a bad Press Ganey score. I’m not a doctor anymore. I am a provider.
    Provider of what, I have no idea.

    • “She’s going to develop a nice little pelvic cancer one day and sue every single physician who ordered a CT on her.”

      Well …I hope that’s NOT true.

  5. It sounds like miscommunication in all 3 areas you mentioned.

    I don’t understand why she left in that kind of pain if it was real. Obviously she has a medical history. What was she afraid of? Why not cooperate with you …since you were yet one more physician trying to help her?

    It must be hell on earth passing all those kidney stones and I wold think not so good for the ureter either.

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