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Tag Archives: Patient Encounters

Happy Marriages, Rainbows, Yin and Yang

“She’s a peach,” the nurse quipped as I clicked the link assigning the new patient to my list. “A positive review of systems … if you know what I mean,” she winked. I like getting a head’s up about patients before I go to see them, but sometimes advance notice of a difficult patient gives me anxiety. I took a deep breath and put on a big smile as I pulled back the curtain. “Hi, I’m Dr. WhiteCoat. What brings you here today.” “Didn’t you read the chart? I’m not explaining it again.” “I did read your chart, but it looks like you have a lot of things going on, so I’m going to have to get some more information from you about all of them.” She rolled her eyes, sighed loudly, and gave me a brief end-expiratory “You’ve got to be kidding me.” I listened and took notes as the patient described her chest pain, her chronic dyspnea, the dry socket she had when her wisdom tooth was pulled 6 months ago, and how a tingling sensation sometimes begins in the fingers of one hand, runs up her neck, down her back and into her leg like someone is “ripping the nerves out of her body one at a time.” My “kill them with kindness” tactic seemed to be working … at first. But the more I asked questions about her eight different complaints, the more that the patient became impatient. Finally, she snapped. “You ask too many questions. THIS is why people hate coming to the emergency department.” “Well, I need to find out more about what is bothering you so I can try to figure out how to fix the problems.” “YOU’RE the problem and YOU’RE bothering me. Why don’t you just run some tests?” “But learning more about your problems helps me figure out what test need to be run, though.” “You don’t listen very well, do you?” By this time, I was getting frustrated. “Ma’am …,” I started, but she cut me off. “I bet your wife LOVES it when you leave for work in the morning.” Ooooh. Eeee. Oww. Oww. Poke me with those pointed barbs. I was going to be a smart ass and tell her that I work nights, too, but my inner peace took over and I bit my tongue. “Tell you what. Why don’t I … order some tests … to see if we can get to the bottom of all of these problems you’re having.” Then I left the room. About 15 minutes later, the nurse hunted me down and told me that the patient had pulled off her EKG leads and walked out of the emergency department while yelling at someone on her cell phone. One of the other doctors at the nursing station smiled and shook his head. I briefly explained what had happened. “That’s nothing. Yesterday, I had a lady tell me that men like me were the reason she became a lesbian.” We both got a good laugh out of that one. Later that day, though, I had a patient and her family ask me if I had an office where they could see me as patients outside of the emergency department. Ahhhh. That’s better. The yin and yang of my day has now been re-equilibrated.

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Why the Lady With Knee Pain Got a Pelvic Exam

It was a busy night in the emergency department, so the patient had to wait for  to be seen. By the time the doctor got in the room, she was in obvious pain. Her knee was killing her. It bothered her a little two days prior. The pain got worse a day later. By the time she woke up that morning, she wasn’t able to walk on her knee. She hadn’t injured it as far as she could remember, but it looked like the kneecap was missing whenever she straightened it out. And did she mention that it was killing her? In all fairness, the patient’s knee was definitely warm and swollen. It wasn’t that her kneecap was missing, but rather that the effusion in her knee was making her kneecap disappear. Really couldn’t do much of an exam on her knee because the pain was just too bad. Whenever she moved it, she yelled in pain. She got some pain medications and an x-ray. A couple of “unnecessary” lab tests were added just in case. Of course, the xrays were normal and the labs were all abnormal. White count 20,000. Sed rate 65. CRP 19. The patient was getting a knee tap. The orthopedist didn’t want to hear about the case. “It’s gout. Don’t you know how to treat gout in the emergency department?” Sorry. The emergency department staff forgot to bow and pay homage before asking the secretary to dial your cell phone number. Forgive them. In answer to your question, “Yes, we do know how to treat gout in the emergency department. Would you prefer that we use Ancef 1 gram or 2 grams?” So after paying further homage and sacrificing a psychiatry intern to please the Bone Gods, the knee tap proceeds against the orthopedic recommendations. Even without orthopedic guidance and an intraoperative CT scan to prove proper placement, 130 ccs of yellow cloudy fluid is able to be retrieved. Lab analysis shows no crystals. Obviously that will be considered a lab error when the orthopedist reviews the slide in the morning, but for now, the white count of 28,000 with 98% segs must be addressed. The patient gets a dose of vancomycin and Levaquin. Knowing one of the more common etiologies of acute monoarticular infections in young adults, then the doctor breaks the news to the patient. “Unfortunately, we have to do a pelvic exam.” “Whaaat? Are you high or something?” “Well, one of the more common causes of arthritis in situations like this is … well … a sexually transmitted disease. So we need to check to see whether or not you have an asymptomatic infection.” Sure enough, there was yellow discharge and cervical motion tenderness. The staff engages in a moment of silence, bows toward the orthopedic wing of the hospital, and the secretary re-dials the orthopedist’s pager to relay the findings. “What do you want me to do about it? Obviously, it’s a gyne problem. Call a gynecologist.” Ahhhh, yes. Again, how dumb could the emergency medical staff be? It is common knowledge that women have babies in their knees. Heck, by the size of this patient’s knee, she’s probably six months pregnant. Another collective bow before hanging up the phone, then the gynecologist is called. He makes some comment about having a urologist look up the orthopedist’s nose, but agrees to accept the admit. The patient’s boyfriend came to visit her at about the six hour mark. As they talked, eventually he complained enough about his sore throat that the patient convinced him to register to be seen in the emergency ...

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A Free Meal

“What’s their problem?” The nurse was both upset and frustrated. The patient was a 16 year old young man. He had a fever for a few days and was vomiting … like half the other patients in the emergency department this week. Unfortunately, his mother was a hospital lab tech, so she knew a little bit about a lot of things. Her requests started about 20 minutes after they were placed in a room. “Can’t you just line and lab him before the doctor sees him?” He didn’t look that bad. Membranes moist. Vital signs were acceptable except that his heart rate was in the 140 range. OK. Fine. Here’s some IV fluid and we’ll do a couple of labs. The nurse missed the first IV. The mom refused to let her try a second stick. “Nope. You get one chance only. Call someone with more experience.” So they had to call the IV team. Which took more than an hour to arrive because they were so busy. In that time, the mom requested two pillows, blankets, grape Gatorade, and some IV Zofran. When the IV team showed up, the mom wanted the patient to have D5 .45NS instead of normal saline. After all, he hadn’t eaten in a few days and could use the extra sugar. Then the patient’s father arrived. He was reportedly a physician from another country who hadn’t been licensed in the US yet. Why hadn’t we tested the patient for sinusitis? At least we needed an x-ray of the sinuses. After trying to reason with the doctor that sinus xrays are a poor method of determining sinus inflammation, that the patient had no symptoms or sinus infection, and that the treatment wouldn’t change anyway, we just ordered the x-rays. Press Ganey scores, you know. Oh, and in case you were wondering, the x-rays were normal. All the labs were also normal … except a WBC count of 14. Great. Doctor says “obviously that means he has a bacterial infection, what are you going to do to work it up?” So we went further down the rabbit hole. More fluids. Add urinalysis and a chest x-ray. “How do you know he’s not septic?” The fact that he’s sitting there smiling and texting people on his iPhone 5 was probably a pretty good indicator. I wonder if they’ve ever done a study about iPhone use in the emergency department and severity of illness. “He doesn’t really appear septic to me.” “But what about his elevated pulse and his fever?” Flashbacks of a certain New York Times article and wayward journalist came to mind. OK, we’ll add blood cultures and a lactic acid. The nurse mentioned that it almost seemed like they wanted the patient to have all this testing done. I agreed. The rest of the tests came back normal. Finally the patient’s pulse was in the 110 range. I broached the subject of discharge. “Did you do a flu test?” “He doesn’t have symptoms of the flu. And even if he did, he is outside the treatment window, anyway. Recall that his symptoms started a few days ago.” “Maybe you could prescribe him Tamiflu just in case.” “I’m sorry, but Tamiflu isn’t indicated for your son, the medication is expensive, and it has side effects.” “Oh, and can you at give him some Claritin D before he leaves?” “No. We don’t have Claritin D in the emergency department.” “So can you at least give us a prescription for Motrin and Tylenol?” “A prescription? You can pick that up at the dollar store over the counter, you ...

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Facing One’s Own Mortality

I met a unique patient not too long ago. She was having back pain. Yeah, one of those patients. We helped make her pain better, but the story behind why she had her back pain and her attitude made a lasting impression on me. The patient was in her 50’s. She had smoked through most of her younger life, but then decided to stop about 5 years prior to developing her back pain. Always seems to happen that way. About 4 months prior to her visit, the patient began coughing up small amounts of blood. A CT scan showed she had advanced cancer. There was a large tumor mass about the middle of her lung and it appeared to be growing into the major blood vessels in her lung. She had seen several surgeons who all believed that the tumor was in too delicate of a place to try to remove. Chemotherapy and radiation therapy had only a minor effect on the tumor and caused the patient to have all kinds of side effects. So she was stuck. No treatment available. Her oncologist told her and her family that at some point, the tumor would eat through the blood vessel and that she would bleed to death. It might happen tomorrow, it might happen in a year. There was no getting around it. Her death would be bloody and quick. The doctor suggested that the family keep several dark-colored towels around the house to mop up the blood. Pragmatic advice, but not exactly empathic or very encouraging. The thing that made the biggest impression on me was the grace and dignity with which the patient carried herself. I was very interested in her story and how she was coping with her terminal diagnosis. She didn’t mind talking about it. As she relayed her story, it definitely wasn’t the typical progression through Kubler-Ross’ stages of dying. She was depressed upon hearing that the cancer was no longer treatable and she was scared that she could die at any minute. She didn’t want to be around anyone or leave the house because she didn’t want them to witness her bleed to death. That lasted about a day. Then she became determined not to spend her last days sitting in her bedroom being afraid and depressed. So she accepted her condition. She accepted that she wasn’t going to see her grandchildren grow up and that she wouldn’t get to spend another Christmas with them. She made an active effort to fully enjoy what life she had left with them. She carried a dark towel around with her everywhere she went. She figured that when the time came, she could lay on the floor and vomit into the towel so that others wouldn’t see the blood or have to clean up as much. She wrote notes to all of her family members on a regular basis. Small notes. But they all told the family members how happy they made her and how much they improved her life. She also kept a note in her pocket that she planned to pull out so that anyone seeing her vomiting blood and dying in front of their eyes would know what was happening, why it was happening, and to thank them for trying to help but also let them know that there was nothing they could do to help her. She was still afraid, but she really did appear to be enjoying her life. As I shook her hand, she smiled and said “Thanks for making an old lady’s final days a little more comfortable, doc.” I ...

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Call Me Janet

A patient is brought in by police. She wasn’t acting right. Walking down the middle of the street. Staring oddly at street signs like they’re Picasso exhibits. Messing with the windshield wipers on cars. When she gets into the room, she won’t give the secretary her name so that she can register her. She looked the secretary right in the eye and says “GOD told me not to divulge my name.” The secretary looked back at her and said “My BOSS told me to put your name in the computer.” The patient replied “GOD is more important than YOUR BOSS.” OK. Valid point So the patient was registered under “Jane Doe.” When Jane had her wristband put on, she became upset. After all, didn’t they know that Jane was Eve’s sister and look what Eve did to Adam. Didn’t know that Eve had a sister. Would have made the whole story of creation a little more interesting, that’s for sure. So “Jane” was changed to “Janet.” While Janet was waiting for results of all the blood tests that psychiatry inpatient facilities require, she became upset by the sun coming through the window in the room. So she rearranged the room to get out of the sun. She moved the bed around so the back was blocking the sunlight. She used the overhead light to block more of the sunlight. She was stopped when she started pulling on the curtains. So she was given a coloring book to distract her. It actually worked quite well. All of Janet’s lab’s came back normal so the psychiatry transfer service at the hospital across town was called to beg them to accept see whether they would accept the patient. The psychiatrist on call was put on the line. As the case was discussed, including the patient’s refusal to give her name, the psychiatrist stopped the report. “Wait a minute. Is this lady middle aged, short, and kind of heavy set with frizzy black hair? “Yeaaaaah…” “Talks a lot about God?” “Yeah …” “Hates being called “Jane”?” “Yeah …” “Oh, that’s Deborah Peel. How’d she end up over there? She’s got bipolar disorder. Never takes her medications. She’s harmless. You can discharge her. If you’re not comfortable with that, I can take her in transfer over here and then I’ll discharge her after I take a look at her.” You have just crossed over to … the Twilight Zone Now why can’t all psychiatry transfers go this smoothly? ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on DrWhitecoat.com, please e-mail me.

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The Rash

The patient was a 17 year old female. She had a rash. The number of patients with rashes in the ED seems to be steadily increasing for some reason. According to the previous records, she was diagnosed with a yeast infection. Her primary care physician started her on Diflucan and on topical ketoconazole for good measure. Her rash became worse. It had now extended up her back. The patient’s mother called the patient’s primary care physician who recommended that she go to the emergency department. Hmmmm. Probably some type of contact dermatitis or perhaps a reaction to the topical medication, I thought as I walked into the room. The first thing I noticed was the patient’s motorized wheelchair. Braces for the patient’s arms were built into the wheelchair. Sitting on the bed, the patient appeared paralyzed. She was able to move her head to some degree. The patient’s arms were propped up on pillows. Her legs were somewhat contracted. She had difficulty speaking, so her mother provided me with most of the history. So the etiology for the rash changed a little bit based upon this initial presentation. Getting the history from the mother was easy. She was intelligent, articulate, and had tried OTC medications for the rash already. She had even consulted Dr. Google to see if she could determine what the cause of the rash was. “I thought it could be a reaction to the medication, so I stopped it. I’m not a doctor, though, but if it was a reaction to the Diflucan, wouldn’t the rash be all over her body?” Exactly. I got some more history. No other medical problems. No other medications. Then I asked about immunizations. The mother remained polite, but became very curt. “No, she doesn’t get immunizations any more. She hasn’t received them since she was 13. Thank you, though.” It was a curious response, so I asked “Do you mind if I ask you why?” She became teary-eyed. “My daughter wasn’t always like this,” she said. “She was a normal kid until she turned 13. On the basketball team. Played soccer. Then I decided to protect her by giving her the Gardasil vaccine. She developed weakness 4-5 days later. A week later she was on a ventilator. Two weeks after that she coded and almost died. She was in the ICU for over a month with a trach. This is what a vaccine did to her. So hopefully you can understand why we don’t vaccinate our children any more.” I nodded my head. After examining the rash and how she sat in her chair, it appeared that the rash pretty closely matched the back of her chair. Probably contact dermatitis of some sort. I told the mom that we could give her a short course of steroids, but that hopefully the rash would resolve if she could avoid contact with the back of the chair for a short while. The mother was very gracious and thanked me. I helped the patient’s sister and her mother get the patient back into her wheelchair. The patient smiled and slowly thanked me. I was so impressed with the entire family and their graciousness, but I couldn’t help being profoundly saddened by the visit. I advocate vaccination. But I have to admit that my confidence was a little shaken by this patient’s story. And I can’t say that I won’t think twice about letting my three daughters receive the Gardasil vaccine. Irrational? Maybe. I know that vaccines have help to largely eradicate many harmful communicable diseases. But however irrational the thought may be, the picture ...

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