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’?”
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?