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Tag Archives: Patient Encounters

WTF Moment #1036

While performing CPR on a patient for the third time in the four hours that the patient was waiting in the ED for an ICU bed, a family member shows up. The family member was invited into the room to watch us perform CPR on his grandmother. A nursing supervisor asked him whether or not the patient would have wanted to be resuscitated and remain on a ventilator. The grandson’s response: “She was into even numbers. If her heart stops beating again, then you can stop because that will be the fourth time that it happened today and four is a powerful number because it is even and it is the total of two even numbers multiplied together AND it is the total of two even numbers added together.” Several staff members just looked at each other with blank stares. Oddly enough, grandma passed away on our third resuscitation attempt. ———————– 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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That’s Some Serious Constipation

By Birdstrike M.D.   “Help.  Help!  I need something for the pain!” I hear a woman wailing from Emergency Department room 4. “What’s that all about?” I ask Veronica the nurse.  “I guess I need to see that one first, don’t I?” “No.  She says she’s got constipation and no other problems.  You need to see room 7 first, which is a 70-year-old male with back pain, hypertension and a family history of abdominal aneurysm.  He might have an actual emergency,” answers Veronica. “Definitely, and thanks for letting me know,” I say, as I walk in to see the possible abdominal aortic aneurysm (AAA) patient.  I glance at his vital signs.  They are totally normal.  I walk in the room and he’s sitting on the stretcher eating a triple cheeseburger, smiling and says, “What’s up doc?” “What brings you in here today, Sir?” I ask. “Oh, nothin’.  My back hurts.  I think I pulled a muscle,” he says. “Have you ever been told you have an abdominal aneurysm?”  I ask. Out of room 4 and into my ears, blast some more primordial screams, “Oh.  Oh!  Ooooooohhh!” “No, I’ve never had one, but my dad died of an aneurysm.  I’ve got high blood pressure, though.  You better go see that lady, doc,” he says.  “I’ll be fine.  You go check on her.” “Let me feel your abdomen,” I say.  I can’t feel any pulsating mass.  I push a little deeper: still nothing.  I feel his radial, femoral and foot pulses: they are all normal.  I finish my exam and put in an order for a CT aortogram,  along with the rest of his workup.  “Sir, I need you to put the cheeseburger down, until we get this checked out, okay?  We need to keep your stomach as empty as possible until we know what’s going on, alright?” “You got it, doc,” he answers. I move on to room 4.  “Oh.  Oh!  Heeeeeelp!   I need a laxative.  Please, something for the pain,” screams an obese 42 year-old Caucasian woman. “That should be no problem.  Just tell me a bit more about what’s going on, ma’am,” I ask as she paces the room, obviously very uncomfortable and anxious out of proportion to a case of constipation. “It’s been about a week since I had a bowel movement.  I feel  r e a l l y  bloated,” she says.  “Whoa.  Whoa!  Whoa!”  she moans, then takes a few slow, deep breaths.  “It feels like I’ve got an 8 pound ROCK stuck down there binding me up.  Please!  Give me a laxative, an enema or something.  Stick your hand up there and take it out, I don’t care what you’ve go to do.  Just do something for the pain.  I’m begging you, please!” “Where is your pain?” I ask her. “Right here,” she says pointing to her lower mid abdomen. “When was your last menstrual period?” I ask. “Oh, geez.  Oh geez!” she says, as she stops pacing and lies down on the stretcher.  She lies on her side and gets into a fetal position.  “Just give me an enema.  I’ve been disimpacted before.  Just do it.  Do it!” “Okay, I’ll have to do a rectal exam.  If there is an impaction, I’ll try to remove as much as possible and then we will give you an enema.  It will be very uncomfortable, but you’ll get tremendous relief.  Okay?”  Veronica hands me some gloves and some lubricant.  I lean over to do the rectal exam and she lets out her loudest scream yet. “I think it’s coming out!  Arrrrrrrrrrrrrrrrrrgggggghhhh!” she screams.  I lean over again ...

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NOW You Tell Me

Paramedics bring in a three year old girl who was hit in the head by a television that had fallen off some shelves. It appeared to be a glancing blow – with some bruises to the side of the face and a bump to the back of the head. The only problem was that she was just crying on the backboard and she wouldn’t move her arms or legs. Take a pen and squeeze the barrel against the base of your fingernail. Hurts like heck, right? I did that to the little girl a few times on each hand and all she did was cry. Didn’t flinch. Didn’t pull her hands away. Just cried. I lifted her hands up and dropped them over her face. Usually patients will pull their hands to the side. She let her hands flop right onto her nose. I reached through the collar and pressed on her neck. Didn’t feel any step-offs or other abnormalities. Again, she just cried when I touched her neck. Damn. “Can we get her off the backboard?” On the inside, I was freaking out a little. “Ummmm … NOOOOO. Are you out of your MIND? Can’t you see she’s paralyzed?” On the outside, I stayed calm. “Just to be safe, we should probably leave the collar on until we make sure nothing is broken.” So I bit the bullet and ordered CT scans of her head and neck. She was over in the radiology department for quite a while. I kept checking the PACS machine to look for the films. Finally, the images showed up. Normal head CT. Normal cervical spine CT. At least that’s the way that I read them. I went back into the room to check on her. She was up off of the board, her collar was removed, and she was playing on her mom’s iPad. Back to normal. I did another neurologic exam and everything was now normal. Wow. Complete neurologic recovery from ionizing radiation? So I mentioned to the patient’s parents that I was a little worried about her when she wouldn’t move her arms or legs on her initial exam. Her dad says “That? Oh she always does that when she gets upset.” “You mean she always just goes limp?” I asked. “Yeah. She comes around after 20 minutes or so. Just like she did tonight. We tell her not to do that, but … you know three year olds.” I smiled and nodded … and I thought to myself “why didn’t you tell me that BEFORE I messed my undergarments?” And I think back to the medical school gurus who used to tell us that 90% of the patients will tell you what is wrong with them if you ask the right questions. Not sure how to add this fact pattern to the history, though. ———————– 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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Chronic Hip Pain

“Careful, he’s been in here like six times in the past month and a half. Always looking for his narcs. Check the state database.” That was the report I got from the triage nurse as I picked up the chart. I humored her and checked the state database. She was right. The patient had received prescriptions for opiates from 6 different physicians in the past two months — two from the hospital across town and the rest from our hospital emergency department. Each time they were only for a handful of pills – usually 10 or 12. I went into the room with a skeptical eye. He was moaning in pain. Couldn’t tell if he was acting or not. If he was, he was doing a pretty good job at it. I examined his hip briefly and was horrified to feel his hip joint grind under my hands and watch his leg flop back and forth. Damn. He’s got a broken hip. I ordered an x-ray. Then I heard his story. He was driving to work a couple of years ago and he was broadsided by a drunk driver. Heavy vehicle damage. Suffered a broken hip and an acetabular fracture. He was taken to a trauma center and surgeons fixed his injuries. Unfortunately, the surgical site got infected. They had to remove all the hardware and inserted an antibiotic implant. Later, they planned to go back in and revise the surgery. In the interim, the patient lost his job and his insurance. He had state minimum auto insurance that didn’t cover his medical bills. The person who hit him was uninsured and undocumented. His wife left him six months ago. He lost his house and had to move several hundred miles away to live with his son a couple of months ago. After losing his job and his insurance, he applied for and received state insurance – Medicaid. Fortunately, he was insured. With his insurance change, though, he had to wait almost six months for an orthopedist appointment. He even kept the appointment slip. The orthopedist evaluated him and scheduled him for surgery the following week. When he tried to find a doctor to do a pre-op physical exam, the only doctors/clinics that would take his insurance gave him an appointment three months in the future. So the surgery had to be canceled. I hate being lied to, so I called the number on the appointment slip and checked his story out. He wasn’t lying. When he called doctors and clinics in the area, no one in a 45 mile radius would take him as a patient because of his insurance. He’d been to several emergency departments to try to get orthopedic treatment and the orthopedists all referred him back to the original orthopedist who did his trauma surgery. When I called our orthopedist, he looked at the x-rays and declined the case as well. High incidence of complications given the delay in treatment. Not likely that even the original surgeon will fix this now. The patient would most likely end up using crutches the rest of his life. I felt sorry for this guy, especially seeing how well his insurance was helping him with his problems. The only assistance he received was a pair of crutches. So I ended up doing something I’ve never done before. I gave a patient a month’s worth of Norco from the emergency department. Any of us could be a stop light and skid mark from being in his exact same position. What would you do? ———————– This and all posts about patients may ...

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The Boxer

He used to be a boxer. Those days were long-gone, though. Now he was a shell of his former self. The hands that formerly knocked opponents to the mat were now contracted and full of arthritis. Dementia had taken away his ability to tell the stories about his career. Metastatic lung cancer ravaged his body. Multiple bed sores ate away at his sacrum and his heels. Repeated courses of treatment for his MRSA and other drug-resistant infections had caused him to get clostridium difficile colitis. The diarrhea made the bed sore on his sacrum even worse. Now he was in respiratory distress. Paramedics tried to intubate him, but his contractures prevented them from being able to properly position him. He wasn’t moving enough air to sustain life. The old man’s friend wasn’t quick enough to save him. His son, the power of attorney, demanded that we “do everything.” The nursing home staff said that his son hadn’t visited the patient in over 6 months. One time a doctor was able to have the patient declared as a DNR. The son became upset and fired the doctor, then rescinded the DNR order. So we revived this shell of a man. We got the breathing tube in place. Tan-colored mucous bubbled up as we Ambu-bagged him. We looked through the chart to start him on antibiotics to which he had not developed a resistance … yet. We changed the dressings on his wounds. Of course as one of the nurses was pulling off a dressing, it flung pus across the bed and into the respiratory tech’s face. With some fluids and a lot of suctioning, the patient was ready to go to the intensive care unit. The patient’s nursing home doctor didn’t take care of inpatients any longer. In an odd twist of fate, the doctor on call for the hospital happened to be the same doctor that the son fired after he obtained a DNR order on the patient. The doctor accepted the patient, but made it clear that he would consult the ethics committee and have the patient declared DNR again. The son was called and refused to allow the patient to be admitted to this doctor. He demanded that we call other doctors to find an alternate. When we found an alternate, the son refused to allow the patient to be admitted to that physician because he “didn’t know my father’s case.” Four calls later, there was no other doctor willing to take the patient. The son demanded transfer to another hospital. Nurses called a couple of other places, but the on-call physician wouldn’t accept the transfer. Eventually, the patient was admitted to the hospital against his son’s wishes. In the back of my mind I just kept thinking that this was one fight that the patient probably would have wished he could lose. ———————– 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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Ah-HA!

I had to go back in time, but I found the post I was looking for. We were joking about patients who come to the emergency department for our help and then won’t talk to us. I remembered this story from a previous post on a blog long ago and far far away … A lady came banging on the locked door leading into the ED howling in pain. Had she been shot? No. Even worse. Her ear had been killing her for the past 3 days. And now the pain was “an eleven.” She was being difficult with everyone. When the registration clerk asked her for her identifying information, she told her to look it up in the computer. When asked if she was still employed with the last employer on record, she told the registration clerk it was “none of your f*#%ing business.” Class act. Not much more luck with the nurse. Not answering questions and not wanting to go through the triage process. Then it was my turn. I walked in the room and she was flipping through the TV channels. Tried to ask her a basic history. She didn’t answer much. Her ear hurt and it was draining pus. The right ear had no problem. On exam, the left ear was full of wax. “Which one was draining?” I asked. “I told you it was the left one.” “Well it’s full of wax and I don’t see any pus now. I’m not sure how all the pus could have gotten through the wax. Are you sure it wasn’t wax?” Rolling her eyes, she sung the word “Noooooo. Now are you going to give me some pain medication or not?” “Any fevers?” “Noooo.” “Runny nose or cough?” “Nooooo.” Then I had to ask the standard questions that we are forced to ask so that the almighty insurance companies pay us for our services. “Do you drink?” Rolling her eyes, she lets out a baritone “Nooo.” Like I should have known. “Use drugs?” “Ahhh … nooooo, ” as if she was trying out for a choir. “Smoke cigarettes?” “Yeah.” Then it slipped out of my mouth … “Ah-HA!” I was joking around, but as soon as I saw the look on her face, I was kicking myself. “What do you mean, ‘Ah-HA!’?” “You smoke. I said  ‘Ah-ha.’ That’s a positive finding.” “Yeah, but doctors don’t say ‘Ah-HA!’ when someone says they smoke. Maybe they’ll say ‘hmmm’ or ‘ah-ha’ but they won’t say ‘Ah-HA!’ So what did you mean when you said ‘Ah-HA!’?” Now all of a sudden she’s a Chatty Cathy. I started having Seinfeld flashbacks. I looked up and all I could see was George Costanza sitting there waving his arms. At this point, I held the chart up in front of my face pretending to write. In reality, I was doing my darndest to keep from laughing. I’m sure she could see my stomach contracting underneath my scrub shirt, though. If I looked at her again, I would have lost it. I let out a couple of coughs and said “Could you pardon me for a moment?” Without waiting for an answer, I scurried out the door and busted out laughing. I asked the nurse to give her some Toradol, but the patient refused. So she got Tylenol … Number Three. Then she started arguing with the nurse about how much codeine was in Tylenol … Number Three. “Listen, ma’am. Do you want the pills or not?” “Give me the shot.” I composed myself, went back into the room, and told her she’d need to follow ...

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