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Tag Archives: Patient Encounters

The Book and its Cover

When you work in an urban hospital, sometimes it’s difficult not to become jaded. There are certain neighborhoods that generate a disproportionate number of patients for some emergency departments. Meth is rampant. Marriage pretty much nonexistent. More bars than there are restaurants. Domestic abuse frequent, but prosecutions rare. Police know people more by their street names than by their real names. South Heights was one of those neighborhoods. The emergency department frequently treats South Heights kids who are neglected by their parents. I’ve seen young South Heights kids with seizures from cocaine. Now seizing kids get drug screened as part of their workup. I’ve seen more than one young South Heights kid with a lighter burn. I’ve given a lollipop to a 2 year old South Heights kid and watched the mother take the lollipop out of the kid’s mouth when she thought no one was looking, chew on the lollipop until there was nothing left, then slap the kid for crying. Many parents from South Heights can recite the names of the family court judges from memory and quite a few have had their children taken away. Social service workers know many South Heights kids personally. Based on the history of the area, many people tend to look at the kids from South Heights with pity and look at parents from South Heights with contempt. The next patient on the board was “finger laceration.” As I walked toward the room, the nurse mentioned “they’re from South Heights.” I was already thinking about whether I’d get attacked if I had to call Child Protective Services. The patient was a cute little girl about 5 years old. Thin stature, great smile, polite. She was holding her arm out on the table and a gauze pad with a slowly enlarging spot of blood covered her hand. Her mom was weathered. Most of her teeth were missing. Her clothes looked like they hadn’t been washed in a while. A reusable shopping bag with newspapers, empty beer cans, and a pair of headphones sat on the chair next to her. “So what happened to your finger?” I asked the little girl. “I cut it with a scissor.” The mom explained that the patient was told to wait to open a bag of cookies, but didn’t do so. Instead, she grabbed a pair of scissors from the drawer and forgot to take her finger out of the way when she cut. The result was a fairly deep laceration to the outer part of the index finger. I went through the described mechanism in my head for a second. Scissors in one hand, holding a bag with other hand, cut to opposite index finger. OK. Injuries seem to fit the explanation. Then I went about describing what I was going to do next. “I’m going to put some medicine into your finger to make it stop hurting. Then we have to clean it out to get rid of all the germs. Then I’ll fix it up for you. The medicine to make it stop hurting burns a little bit. Once the burn is gone, it won’t hurt any more. OK?” The little girl looked from me to her mother and her eyes began to tear up. She cried and whimpered, but she held completely still while I injected lidocaine into her finger. Her mom leaned over next to her, gently cupped her head and wiped away her tears. After the wound was clean, I got everything ready to fix the wound. But the patient was a little hesitant because the lidocaine injection had hurt. Despite me ...

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Spaghetti and Impaction

Stool impactions probably aren’t what most people would consider an “emergency” … until they actually have a stool impaction. Personally, I wouldn’t wish a stool impaction on someone. In chronic constipation, more and more stool collects in the colon until size of the ball of stool is too big to pass through the opening to the outside world. The major function of the colon is to absorb water from the stool, so the longer the stool sits in the colon, the larger the amount of water that gets absorbed, and the harder the blob of stool gets. By the way – the whole water absorbing function of the colon is why it is important to keep well hydrated to maintain good bowel habits. There are a lot of ways that you can try to get rid of a stool impaction, but when the stool gets hard enough, pretty much the only way to remove the impaction is by having someone use their fingers to perform a “disimpaction.” There’s just no good way to get a big hunk of stool the consistency of clay soft enough for it to pass through the rectum. It has to be dug out. Disimpactions aren’t fun for the doctor or the patient. They’re painful and obviously messy. I’m probably more willing than most docs to perform disimpactions because I can see how much the patients are suffering. Although unpleasant, disimpactions are an easy fix to the patients’ problem. Like I said, you probably can’t appreciate how bad impactions are until you’ve been on the other side of the gloved finger. As I donned my mask, gown, and multiple layers of gloves to commence the procedure on one patient,  one of the nurses sent a nursing student in the room with me to observe. The student said that she had seen “many” disimpactions in the past, but the nurse wanted her to observe this one, so she reluctantly came in the room with me.

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What’s the Diagnosis #16 — Mmmmm, Eggs

This is an interesting case for a number of reasons. First, it shows how a little testing can turn into a lot of testing to “rule out” diseases in the emergency department. Second, it hopefully provides some good teaching points. Third, the comment from the attending physician gave me the giggles. That will explain the title. But you have to read through the case to understand the comment. I’m not going to discuss all the minute details of the case, only the major findings that contribute to the flow of the case. A patient got sent in from the nursing home because her gastrostomy tube was leaking blood and the nursing home was convinced that the patient was having GI bleeding. When the bandage over the patient’s G-tube was removed, it was fairly obvious that the skin about the G-tube site was the source of the blood. The skin was raw and was oozing dark red blood. Flushing the G-tube produced a little blood, but the blood cleared. The patient’s vital signs were stable except for a mildly elevated pulse. Proper skin care probably would have resolve the bleeding. Some people may have left it at that and sent the patient back to the nursing home. I drew labs and did an abdominal series.

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Not Heart Failure

I wasn’t giving in to the patient who wanted a prescription for Levaquin after the standard ZeePack didn’t cure his cough. He had a normal chest x-ray and labs the day before but was convinced that he had pneumonia. I tried explaining the difference between bacteria and viruses. I used the “RAID doesn’t work on dandelions” routine. He wasn’t convinced. “I NEED a stronger antibiotic to break this up. Levaquin has worked in the past.” “You know, I think I’m going to start you on some heart medications, instead. Some nitroglycerin and some Lasix for your heart failure.” “Whaaat? I don’t have heart problems. I had a normal stress test a few months ago. Why would you want to start me on heart medications?” “You have risk factors for heart problems and coughing is a sign of heart failure. I should probably start you on Digoxin, too. Ehhh … maybe not. That’s kind of strong medicine to start out with.” “This is ridiculous. My chest x-ray and blood tests were normal yesterday. I don’t have heart failure. I’m calling my doctor and I’m not taking any of those medications.” “Your chest x-ray was normal. That means you don’t have pneumonia, either. And bronchitis is a viral infection. Levaquin isn’t going to help your symptoms any more than the heart medications would. Do you see my point, now?” [long pause] “I’ll just call my doctor.” I can only imagine what conversation sounded like. ———————– 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 WhiteCoat’s Call Room, please e-mail me.

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Unnecessary Care?

It isn’t much of a case, but it created questions in my mind. A mom brings her 8 year old daughter to the hospital for a nonproductive cough. No fever. No runny nose. Just a cough. The patient had started school again this week, and so the microbiome in her nasal passages had thus begun mixing with all of the other microbiomes on school lunch tables, desks, and childrens’ shirt sleeves. The end result was that now she was coughing for a couple of days – like a majority of other children in the school. The child looked fine. I told the mother that she likely had a “head cold” and that it would have to run its course. The mother wasn’t convinced. “How do you know she doesn’t have the flu”? “Well, I don’t know for sure, but even if she did have the flu, it wouldn’t change the management right now. It would still have to run its course.” “I want her tested for the flu.” “Influenza testing really won’t help us much. The test itself has a high false negative rate, meaning that even if the test is negative, a large percentage of people still end up having influenza.” “I want her tested for the flu.” Fine, I thought. It’s your money. Forty five minutes later, results from the influenza swab came back negative. “So like I was saying before, this is something that will have to run its course.” “You said that the test wasn’t accurate. There are a lot of kids in her school with influenza right now. I want her to get Tamiflu.” “Tamiflu isn’t going to help. It is only effective within the first 48 hours. You said the cough started two days ago.” “You know, I have always had good things to say about this hospital and I’ve never had this many problems with a doctor in the emergency department before. It hasn’t been 48 hours and I want her to get the Tamiflu.” Nice threat. So I gave the woman a prescription. Let her spend the $120 for a drug that won’t work. Then I began thinking. Would some bean counting clipboard carrier claim I provided unnecessary care? So what do you think? Knowing that rapid influenza testing has a significant false negative rate and knowing that influenza is widespread in the country, but also knowing that a patient has mild symptoms … [poll id=”8″] By the way, after the visit, a pharmacist called and said that the patient was requesting a different medication since the patient was on state “insurance” and the “insurance” didn’t cover the cost of the medication. Unfortunately, there isn’t anything else that works which was covered. UPDATE 1/15/2012Thanks for the votes and comments. When thinking about this situation, three issues came to my mind. First, Tamiflu is approved by the FDA for acute uncomplicated influenza when symptoms have been present for not more than two days. It is also approved for prevention of influenza. From a technical perspective, a Tamiflu prescription was indicated if the child had influenza or if the child was being prophylaxed against influenza. The indications for use do not contain a description of any symptoms that must be present before Tamiflu is prescribed. If influenza is diagnosed or being prevented, Tamiflu is indicated. Second, diagnosis of influenza in an inexact science. Rapid influenza testing is notoriously inaccurate. If the test is positive, there is a high likelihood that influenza is present (although about 1 in 50 patients with positive results do not have influenza). However, if the test is negative, one third ...

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Sage Advice

Some sage advice to my loyal readers … When you’re cleaning up an old house, you move the stove, and you happen to a find a small metal pipe with an unknown substance inside of it, it’s probably not the best idea to take a break, pull up a chair, and smoke whatever is in the pipe. Should you ignore this advice, you might just see nonexistent bugs wearing Harry Caray glasses buzzing around your head and notice a cadre of hot women spies surrounding the house you were in before you called 911 for a police escort to the hospital. As a side note, it is not within the purview of an emergency department to send the police to go find the pipe so that they can bring it back to our lab and we can “see the f*** what was inside.” The reason for the demise of this portion of your neuronal network will have to remain “undetermined” in this case. If you just have to know, you could prolly send the pipe to CSI with a letter requesting analysis … along with a check for a few thousand dollars. In the meantime, enjoy the restraints. ———————– 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 WhiteCoat’s Call Room, please e-mail me.

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