Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments (2)

Much Ado About George: My Father In Law’s Trip To The ER

georgezMy father in law is 83 years old. He has high blood pressure, high cholesterol, and occasional “senior moments.” He rarely complains about anything, and spends most of his time doing household chores, playing with grand kids, and watching TV. So it was with some degree of concern that I raised my head from my morning cereal when George announced at the breakfast table that he was having chest pain.

I looked at him with narrowed, clinical eyes and began asking the usual rule out MI type questions – did it feel like pressure? Where was the pain exactly? When did it start? Does anything make it better or worse? Does it radiate down your arm or up your jaw? Have you ever had this pain before? How severe is it on a scale of 1-10?

George’s answers were neither reassuring nor specific for a heart attack. He just pooh-poohed my line of questioning, suggesting that his pain was all just part of growing old, and that maybe it was “because he was too fat” or “maybe the weather is changing.” So I asked his wife if I could look at his medication list. I saw aspirin and nitroglycerine tablets prn along with an ACE inhibitor and a beta blocker. I didn’t like the nitro. I watched him for a few minutes as he walked around the house, pausing to take some deep breaths to try to make the mild pain diminish.

“Ok, that’s it… I’m calling your PCP to see if we can at least get you an EKG right away.”

George responded that he had an appointment in a few days time so there was no need to see anyone until then. I responded that chest pain isn’t the sort of thing you wait on, and that I’d feel better if we could get him checked out. Luckily, Mrs. Zlotkus agreed with me and within minutes I was speaking to George’s on-call physician. After discussing what I had observed, his doctor suggested we call an ambulance and get him to the ER. We opted to take him there in our car to save a copay.

The hospital was clean, bright, and efficient. We got an EKG within 10 minutes of arrival and as I glanced at it as the tech tore it off its paper roll to show to the ER attending, I could tell it was normal. I breathed a sigh of relief, and the pace of the work up slowed noticeably.

The nurse assigned to George entered the room to do her assessment. “What brings you here today?” she asked.

“I’m old.” Said George with a smile.

The corner of the nurse’s mouth raised faintly. “But what about being old brought you here today?”

“I have some back pain. But I’m going to see Dr. M about it in a few days.”

I could see the nurse also relax the pace with which she was connecting him to the various monitors. She was not concerned about any “real emergency.”

“So were you lifting something heavy recently? Did you hurt it your back?”

“No, I don’t lift anything. Just laundry.”

“Uh, huh…”

“Well how bad is this pain right now on a scale of one to ten?”

“I don’t have any pain. Can I go home now?”

I rolled my eyes, wondering if I’d over-reacted in bringing George to the ER.

“Well, we’ll see what the doctor says,” said the nurse looking at me as if George’s work up was going to be a big waste of time.

Eventually a wiry 40-something doctor in blue scrubs popped his head into the room and asked George to explain why he was there.

“I’ve got stomach pain.” Said George.

“I see. Well can you point to it?”

George pointed to his sternum and his back between his shoulder blades.

The doctor tried various maneuvers to elicit the pain (including deep abdominal palpation and twisting and moving George’s arms and waist). Nothing really brought it on. He took George’s blood pressure in both arms. There was a 20 point systolic difference between the two. I mentioned that George had smoked occasionally in his youth.

“We’ll probably need to get you a CT scan to check on your big heart artery. We need to make sure you’re not having an aortic dissection. Do you have any questions?”

“Can I go to my grand daughter’s birthday party?”

The ER doctor paused, “Well when is that?” he asked.

“Now” said George.

Mrs. Zlotkus chuckled and reassured her husband that the CT scan was more important. I asked the tech if I could follow him back to the scanner and look at the images – “Why, are you a nurse?” He asked.

I had to wait out in the hallway just outside the radiology suite, but peeked in just as the white outline of his aorta flashed on the screen as the tech scrolled through the slices. It looked normal to me.

So we wheeled George back to his cozy ER room where his son Chuck (the Sargent in the photo) was waiting. The nurse arrived to announce that the second round of blood tests (cardiac enzymes) were normal.

So there I was the George and Chuck – and a bunch of normal tests – with only some elevated blood pressure to show for the whole day. I figured we’d make the birthday party after all… But just to be cautious, George’s PCP called in and asked that he be admitted to the hospital for observation over night and a stress test in the morning. As it turns out, non-emergency stress tests weren’t scheduled on Sundays so George was discharged home instead with a follow up in a couple of days.

I winced as I imagined the costs associated with this “million dollar work up,” hospital admission, and upcoming stress test. I remember blogging some fairly harsh criticisms at the ER docs who recently got a head CT on my mother in law when she had shingles on her scalp and a headache. Was I now guilty of the same waste of resources?

George was right – he was getting old. The nurse was right – there was nothing emergent going on.

The ER doc was wrong – George didn’t have an aortic dissection. And I was wrong – there was nothing actively wrong with his heart.

I feel badly that I contributed to a waste of healthcare resources, but I just couldn’t ignore a complaint of chest pain at the breakfast table.

And yes, his stress test was totally normal… The pain went away on its own after a few days, and its cause will forever remain a mystery.

I guess I should be thankful for the times when we make much ado about nothing. The alternative (a heart attack or aortic dissection) is far worse, though the “living with diagnostic uncertainty” is annoying as heck.

I need to practice my shrug.

***

George and Mrs. Zlotkus gave me permission to blog about their story.


You may also like these posts

Read comments »


2 Responses to “Much Ado About George: My Father In Law’s Trip To The ER”

  1. rlbates says:

    So happy it turned out to be “nothing”

  2. geena says:

    Medicine is more art than science. Better safe than sorry. Yeah, it feels kind of dumb when everything checks out ok (I once went to the ER with a panic attack not knowing that’s what it was. You could have knocked me over with a feather when I found out I wasn’t actually dying. Really. And then I felt dumb.)

    He has significant risk factors. I think you did the right thing.

Return to article »

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

Read more »

See all interviews »

Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »