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Tag Archives: Patient Encounters

Caremark frustrations

Below is a link to a recent phone message from one of Mrs. WhiteCoat’s patients who was “begging” Mrs. WhiteCoat to help her because she was “going crazy with that Caremark.” Blue Cross Blue Shield Caremark Message This poor lady is 89 years old, is legally blind, and needs multiple medications. She can’t get her prescriptions because Caremark believes that she only needs to be taking one of her medications three times per day instead of four times per day as prescribed. The patient doesn’t care. All she knows is that she needs her medications, she can’t get them, and she doesn’t want to “go through this every time.” She can’t get help through Blue Cross Blue Shield because they “transfer her from one department to the next.” She can’t reach CareMark because the line is “busy busy busy.” But at least her prescriptions cost less … when they finally arrive. And if the patient has a bad outcome related to her inability to take medications as they were prescribed by her doctor, who is going to be at fault? Mrs. WhiteCoat documents in the chart in big bold letters every time places like Medco or Caremark delay filling the prescriptions that she writes for her patients.

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Thank God

As I walked into the ED for my shift, the nursing supervisor was fumbling with a syringe attempting to get medication out of a small vial. “Ummmm. Looks like you need to adjust your bifocals,” I quipped. We have a running joke about who is older and bust on each other about our ages every chance we get. When she turned around, the look she gave me signaled that it was no time to joke. Tears were running down her cheeks. “What’s …?” She cut me off. “Thank God you’re here. Get into Room 7 now.” When patients are really sick, it has been said by people much smarter than me that your worth as a physician can be judged by how people invoke deities. There are the “Oh God” docs and there are the “Thank God” docs. Being classified in the latter category by a nurse whom I admire is a compliment, but it also meant that there was something very bad behind the curtain across the hall. I set down my bag, unzipped it, and searched around for my stethoscope. The nursing supervisor grabbed my shirt and pulled me toward the room. “Use mine,” she said. She threw open the curtains and it took me a second to size everything that was going on. Despite the commotion, it was eerily quiet. In one corner, a middle aged man and his wife were sitting holding each other’s hands. Both were crying. An ambulance stretcher was pushed to the side of the room. EMTs were trying to start an IV on one arm. Two nurses were working on getting an IV in the other arm. At the head of the bed was the respiratory therapist. He had a brow full of sweat and kept wiping his forehead with his arm as he worked the Ambu bag. He told the doc who had her stethoscope on the patient’s chest “I’m barely able to get any air into her lungs.” Laying on the bed was the limp body of a 13 year old girl. Her color was between dusky and blue. “What’s going on?” I asked. “Bad asthma. She just stopped breathing on the way to the hospital,” said one of the EMTs. “We can’t tube her because her jaw is clenched down and we are having trouble bagging her because she’s so tight,” the other doc explained further. She was from an outlying area, so her transport to the hospital took 25 minutes. She was in respiratory distress when EMTs arrived, so there was at least 30 minutes of ineffective respirations. “What has she gotten so far?” I asked. “Nothing, we can’t get a line,” said one of the nurses. I grabbed the nursing supervisor. “You need to go get epi NOW.” She walked out of the room and said over her shoulder “I was doing that when you walked in.” I watched the respiratory therapist try to ventilate the patient. The problem wasn’t that her lungs weren’t getting enough air, the problem was that her lungs were full of air and the airways were so constricted that the air couldn’t get back out. I went to the side of the bed and started squeezing the patient’s chest between ventilations to force the air back out. “IV in!” Announced one of the nurses. Medications started pouring into the IV line – to improve the patient’s asthma, to sedate her, and to paralyze her muscles so that we could put her on a ventilator. I looked up at the respiratory tech. Sweat was forming a triangular wet spot down the front of ...

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When I got to work this morning, I had several people tell me that they wished that I was working the day before. A little five year old girl was brought to the emergency department for suicidal and homicidal ideations – at least according to the social worker who accompanied the patient to the emergency department. When the patient arrived, she was uncontrollable. Throwing things. Knocking over chairs and garbage cans. Trying to punch or bite anyone who came near her. All the time, the parents were just sitting there playing their little pocket electronic solitaire games and doing nothing to control their kid. That would have been it for me. You act like an animal, I don’t care how old you are. You’re going in leather restraints. I’m not endangering my staff. Then the kid went to the bathroom, locked herself inside, and wouldn’t come out. Security had to come with a special key to open the door. The patient’s actions did get her prompt placement at the children’s psych hospital – where the nurses knew the patient on a first name basis. Despite being frustrated with the way the child was acting and with how the parents were doing little to intervene, several people were giggling about what happened when the ambulance arrived. While the EMTs were getting the patient on the stretcher, the kid was actually pretty calm. She looked at the paramedic and whispered something. The paramedic didn’t hear her, so he leaned over to ask the kid what she said. WHAM! Right hook to the paramedic’s jaw. I can see the report at the receiving hospital: “We hit a bump in the road construction on the way up here and the IV pole fell over and hit the kid on the head. Really.”

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Serious Injuries

We receive this transfer from an outlying hospital for a neurology evaluation. The patient is in his 30s and was out at the bars when he was hit in head with beer bottle during an altercation. Since that event, he has complained of dizziness, headache, loss of vision in one eye, pain all over his body, and repeatedly running out of pain medications. He had multiple CT scans and an MRI looking for causes of his symptoms at the referring hospital. All were normal. He also had multiple x-rays and physical exams without positive findings. He went back to the emergency department and was reportedly “pissing himself” and “s**tting himself” – as in he was sitting on the couch watching a movie and didn’t know he urinated on the couch until his girlfriend told him that she felt something wet on the floor. Also reportedly only knew that he soiled himself when he went to take a shower and noticed his underwear contained a present. The ED physician at the transferring facility took good notes. The medical records showed that at the first visit, he was on his cell phone yelling at police why the person who threw the beer bottle at him wouldn’t be charged with a crime. After he got off the phone, he reportedly told a nurse that he had to have a “serious injury” in order for it to be further prosecuted. A cut to the head from a beer bottle wasn’t classified as a “serious injury.” The patient never seemed to have soiled clothing in the ED and he was able to walk back and forth to the bathroom without problems – even though he couldn’t tell when he needed to go to the bathroom. He also failed several tests for malingering in the hospital that sent him to us. I had to smirk just a little when I watched the well-tattooed muscular patient transfer from the ambulance stretcher to the bed holding a cell phone to his ear … and wearing an adult diaper that the previous emergency department had placed on him for the ride. The neurologist discharged him from the ED after finding no abnormalities … and after he failed the same tests for malingering in our ED. Still no criminal charges, I’m going to guess.

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No LOL Matter

It’s sad when you hear about deaths due to texting while driving. Dr. Frank Ryan recently drove off a California cliff while reportedly making a Twitter post about his dog. We recently had a 22 year old patient come in from a bad motorcycle accident. Road rash all over the place. Wasn’t wearing a helmet. As we began to examine him, it became evident that he had a spinal cord injury. He had priapism and reduced rectal tone. His legs weren’t moving. MRI showed a T6-T7 injury. It was even more sad learning how the injury occurred. He told the paramedics that he was riding his motorcycle at a high rate of speed using one hand to steer and using the other hand to talk on his cell phone. On a speeding motorcycle. He was making plans to meet a friend that evening to go out to the bars and “get some.” The only thing he “got” was a lot of IV medications, a neurosurgical consultation, and a hospital bed. Now he’s forever more likely to “get a lot less” due to a lapse in judgment. Is answering that message from your BFF this instant really worth the thought of dying … or of sitting in a wheelchair the rest of your life? Don’t text and drive. UPDATE AUGUST 28, 2010 The day after my original post and one of my first patients of the shift last night was a 21 year old young lady who gashed her head open when she was driving down the street at 40 mph and she hit a parked car … while she was texting. The 22 year old didn’t think the wheelchair would happen to him. This patient didn’t think the crash would happen to her. No one gets behind the wheel and expects to get into a major car accident. Someone just told me about Oprah’s campaign about texting and driving. Read about it. It’s not a question of IF something bad will happen to you, only WHEN it will happen to you. Don’t text and drive. ALSO see this article over at GruntDoc’s site. Definitely worth the read.

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Double Gotcha

For a few hours, our emergency department was Octogenarian Central. It seemed like every patient that registered to be seen was in their 80’s. Weakness. Dizziness. Constipation. Chest pain. More weakness. Hip pain. Eight out of ten patients were octogenarians. Family members accompanied all of the patients and helped us piece together the multiple medical problems. After my second disimpaction of the afternoon, I longed for a kid with an ear infection. Then we got an ambulance call. Patient down. Full arrest. Family trying to perform CPR. Yup … he was 81. The story was especially difficult. The patient was sitting in his living room watching TV with his wife. He suddenly had trouble breathing. He told his family to call the ambulance because he felt like he was going to die. When the ambulance got there, the patient had arrested. Paramedics did a great job getting back a pulse, but it was short-lived. When the patient hit our doors, he had no pulse. We tried to revive him, but to no avail. Another angel gets some wings. Informing the family was difficult. I’ve always said that telling families that a patient has died is one of the most difficult things in medicine. Hasn’t changed in all these years. But there was a bit of a funny twist to the sad situation. We called the coroner after the patient dies. He has to come to investigate and release the body. The coroner for this town is a great guy. Probably early 70’s himself. Every once in a while, he just randomly stops in with popcorn or ice cream for the emergency department staff. He came in wearing a baseball cap with his trademark smile. He patted me on the back and asked me what room the deceased patient was in. I was on the phone, so I pointed to the patient’s room and kept talking. The coroner walked over to the room, pulled open the curtain to the room, looked at the patient, and screamed out loud. Then the patient screamed out loud. He came back out of the room sweating and looking a bit peaked about the gills. “I thought you said that the patient was in Room 12!” “No. I pointed to Room 11.” “Holy crap, you almost gave me a heart attack. I walked into the room expecting to see a dead person and then she rolls over on the bed. My heart’s still palpitating!” The daughter of the patient in Room 12 then walks out of the room laughing nervously. “How do you think I felt … seeing the coroner walk into my mom’s room when she isn’t even that sick?”

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