Home / Tag Archives: Random Thoughts (page 5)

Tag Archives: Random Thoughts

When You Don’t Know What You Don’t Know

This has happened twice to me, but I’m learning … The first patient was several years ago. She came in with headaches. Her blood pressure was 220/110. The headache wasn’t an issue. The patient hadn’t taken her blood pressure medications that day and had a history of headaches. There was no change from prior headaches. We gave her pain medications, gave her the dose of clonidine she was supposed to be taking, and she felt better. Her repeat blood pressure was 176/96. I told her that she really needed to take her medications every day and that she could follow up with her family doc later that week for a blood pressure recheck. Then I discharged her. Forty five minutes later, she was still sitting in the room talking with the nursing supervisor. Then the nursing supervisor asked me if I felt comfortable discharging the patient. Yes, yes I did. Wasn’t I concerned about her blood pressure and her headache? No. Her blood pressure was improved to the point that she could be discharged and her headache had resolved. She was stable for discharge. Afterwards, I saw the nursing supervisor make a phone call, then go back in the room, then leave. I went back in and asked the patient if there was a problem. “No, no problem. We’re leaving.” Then the family member in the room said “We’re going to another hospital like the nurse said. Her blood pressure is much too high for her to be discharged.” What? I asked them to wait a moment while I tracked down the nurse and the supervisor. The nurse had finished her shift and left the building, and by the time I found the nursing supervisor, the patient had left. Lots of meetings after that incident. Then it’s deja vu all over again. A patient comes in with the worst headache of his life. Those are the words he says to me as soon as I walk in the room. Never had headaches before, bent over to pick up garbage and headache began. Hasn’t let up in over 8 hours. Radiates into his neck. I already know where this visit is heading. He got three rounds of IV pain meds and his pain was still in the “severe” range. We ordered an “unnecessary” CT scan. After all, it came back normal. Then I go to explain the necessity of a lumbar puncture. Fortunately for the patient, his mother in law was a nurse educator at the nursing school in town. He ran the case by her and she said that a lumbar puncture wasn’t appropriate since it wouldn’t tell us anything that we don’t already know. I told him about pseudotumor cerebri and meningitis and the subarachnoid bleeding that CT scans sometimes don’t pick up. The patient’s nurse then said that MRI will see the things that CT scan doesn’t … including bleeding. Whoa. So I go to one of the textbooks and copy one of the pages showing that CT scan is much better than MRI at picking up subarachnoid hemorrhage. I give a copy to the patient and to the nurse. Her response was that I was being “vindictive.” At that point, I threw up my hands. I told the patient that if he didn’t want the test, I’d be forced to admit him to the hospital for monitoring. If he didn’t want that, he’d need to leave AMA. I told him my concerns with him doing so and asked him to come and get me if there were any other questions. Twenty minutes later, the patient told me ...

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Open Mic Weekend

It’s been about a month since the last open-mic weekend. What’s on your mind? All weekend everyone is welcome to post any medically-related comments, questions, observations in the comments section. Will try to answer any questions through the weekend. Only rules are that there are no personal attacks and that the comments/questions are medically-related. Have a safe and enjoyable weekend.

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Dr. No BS

Can you or an emergency physician that you work with win Nurse K’s coveted “Dr. No BS” award? Check her blog to get rules and post your scores in the comments section or on her twitter account. She includes science behind some of the scoring, as well. Interesting in that some people in the comments section are already uncomfortable with some of the scoring. Have fun with it, don’t overanalyze it. And if the contest makes you think about how you manage some patients in the ED, that’s probably a good thing.

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My Three Patients

I’m not going to tag anyone else for this meme, but I liked the idea that Ramona Bates (Sutured for a Living and @rlbates) put out on her Twitter feed from Wing of Zock. Play along if you want and drop a comment in the comments section if you do. I’d like to read them. Describe the three patients that had the greatest impact upon you and how they shaped your career as a physician. Not exactly sure I can say how each of these patients shaped my career, but below are three of the patients who have had a large impact on me. The first patient I ever saw in an emergency department as a student was probably what turned me on to emergency medicine. Before my emergency medicine rotation, I was pretty much set on going into orthopedic surgery. It was kind of a crazy situation. Inner city emergency department. Patients stacked up in the hallways. People pushing me out of the way. Me getting lost. Where is the attending around this place? Then one patient on a bed in the corner caught my attention. She was yelling at another patient down the hall. He’d yell at her. She’d yell back at him.

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Dear Diary

Not to interrupt the interesting discussion going about BirdStrike’s post regarding what a life is worth, but … Kids are all back to school. It was funny watching three of them enter new schools this year. The video of Junior WhiteCoat trying five times to open his locker then getting mad when dad did it on the first try was priceless. The video of Mrs. WhiteCoat crying when youngest daughter got on the school bus for the first time and waved to us through the window was also priceless. Speaking about crying … we went to see the movie “The Odd Life of Timothy Green“. Every one of the kids was bawling at the end. Apparently my kids weren’t the only ones. Critics seemed not to like the movie very much. I thought it was entertaining. Speaking about movies … all the WhiteCoat kids are getting little movie roles lately, but they all seem to be horror flicks. Junior is going to audition for another one today. Funny that middle daughter is starring in a horror movie but if she tries to watch one, she freaks out and can’t sleep for the next week. Even talking about the plot of a horror movie makes her sick. Speaking about getting sick … both dogs have some type of virus that the vet says is going around town. Vomit and diarrhea everywhere. Carpet cleaners must love it when this stuff happens. By the way, if a dog vomits on the floor, licks it up, runs away when you call her name, vomits on the floor again, then licks up a little bit of it before being scooped up and carried outside in mid-heave, then vomits the same material again in the grass, does that count as one episode or three episodes of vomiting? Mrs. WhiteCoat was upset because she thought I was letting the dogs eat their vomit. Initially, she was right. Why waste food, right? Then, after the second vomit, I realized that they would just walk around the house vomiting up the same food over and over again, leaving spots all over the carpet. That prompted a more urgent and concerted effort to get the dogs outside. Then how pitiful is it when the dogs stare at you with those sad eyes when you’re eating dinner and they get a small serving of chicken and mashed potatoes on their plate because their stomachs are upset? Not even any gravy? Here’s a sappy dog pic from before initiation of the exorcism. I’m just glad that whatever they have doesn’t get passed to humans. Speaking about Mrs. WhiteCoat getting upset … we took our four kids and a few of their friends to a water park for the end of summer. Half-price. Can’t beat it. So afterwards, we go out to eat at a family restaurant before making the trip home. A gentleman in suspenders staggered in the restaurant, and while passing our table on the way to the bathroom, stopped and in his garbled speech says to Mrs. WhiteCoat “Hey, you don’t look too bad for being an OctoMom!” I had to look away. She says “there are SEVEN children at the table and THREE of them do not belong to us.” Mr. Suspenders says “Well you still don’t look too bad” and he staggered off to the bathroom. My reminders that he was paying her a compliment and that “QuadraMom” just didn’t have the same ring were met with repeated evil stares. In between my trips to the emergency department to rule out sepsis every time I go running or ...

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It’s an MVA, dammit

If you’re an EMT, don’t start lecturing me in front of the patient you just brought in about how she was involved in a “motor vehicle collision” and not a “motor vehicle accident.” I was half joking when I asked you if you meant that she was in a motor vehicle “accident” when she rolled her car in a ditch. Your dissertation about the difference between accidents and collisions afterwards … you aren’t going to win that one. Unless your patient was in a demolition derby or intentionally ran into another vehicle (which I haven’t seen in 15 years), the wreck was an “accident.” We’ve been using the same terminology for decades. It serves us well. We don’t need to change it. Yes, in most cases, patients are brought to the emergency department because two vehicles “collide.” So technically, most MVAs are also “collisions.” But what about the rollover that your patient was involved in? What did her vehicle “collide” with? And if a vehicle runs into a ditch before coming to a stop on the other side of the ditch, did it really “collide” with the ditch? Collisions are usually considered a contact between two moving bodies. I’m also aware of the old argument by “traumatologists” that motor vehicle accidents should be called motor vehicle “crashes” because most fatal crashes are caused by speeding, intoxicated, or distracted drivers, so they shouldn’t be considered “accidents.” If you want to go all brainiac on me and use the scientific definition of “collision,” then perhaps cars do “collide” with ditches. They also collide with gravel when they’re rolling down a gravel road and I suppose that their tires even collide with the asphalt when they’re driving down the street. So if we’re going to use the scientific definition of “collision,” we probably should use it consistently. Somehow, the following inbound report, although scientifically proper, just doesn’t work: “the car was colliding on the street asphalt when it collided less frequently with the street at a stop sign and subsequently another vehicle that wasn’t able to collide with the street at the same rate of deceleration accidentally collided with the vehicle in the rear, causing the patient’s shoulder to collide with the seat belt and the patient’s face and upper torso to collide with the air bag.” Can’t we just agree that the report should be something like “a restrained driver was rear-ended in an MVA with air bag deployment”? And if you give me an inbound report saying that you’re “en route to your emergency room with a patient who is A and O times four who was involved in a motor vehicle collision and has a low grade fever of 99.1” … well … let’s just not go there. Oh, and you left the engine running in your patient transport vehicle. Why do we call it an “ambulance”, anyway?

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