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When Instinct Trumps Expertise

A hard thing about being an ER doctor is that I know a little, sometimes very little, about a lot of things. When I am faced with a particular condition, I often need to call the specialist for that organ, who knows way way more about it than I ever will, and they all think I’m an idiot because I don’t know as much about their organ as they do. There’s a huge asymmetry of knowledge, and it can create some tension and conflict.

I’m OK with it, because I can ignore their condescension and I am secure with what I do know, and its limits. But sometimes I get perplexing instructions from the specialists. The emergency medicine dogma can be overbroad and a little hidebound and what the specialists will do in the real world often radically diverges from what the Emergency Medicine textbooks say to do. It’s often an interesting learning opportunity for me, especially when it’s a condition I don’t encounter that much.  But I also have to work to maintain a flexible and open-minded attitude when I call a consultant and my side of the conversation consists of “Really? I didn’t know you did that for this…” You need to know and trust your colleagues in other specialties, and know when to call BS on them and push to do something else, which is really hard to do when you are talking to someone who is so much more of an expert than you are.

So I saw this guy recently, an urban hipster who was perhaps a bit too old to be riding his longboard on the hilly streets of our fair town. He didn’t seem to be too good at it, judging by the collection of crusted abrasions and aging ecchymoses he was sporting. He had been falling a lot recently — we only get about a month of sun here, so I guess he was making the most of the summer weather practicing his new hobby.  He had a variety of complaints from his recent falls, but it was a wound infection that had driven him to come in. A bit of road rash on his thigh was looking a bit cellulitic and I thought might benefit from some keflex.

I had to go through the motions of doing a more or less thorough exam, and he was pretty tender on his neck, I noticed. He said it had been hurting for about a week, since he had fallen backwards and hit his head on a car fender. He demonstrated how his neck was fully extended at the moment of impact, and the resolving goose egg on his scalp correlated. I wasn’t terribly impressed by any of his orthopedic injuries, but I did order a few plain films, just to CYA, and I included a C-spine series as well, which is rare for me since if I really think someone might have a C-spine injury, CT scanning is the imaging modality of choice.

I actually got a little short of breath when I scanned through his images and this jumped out at me:
hangmans
For those not accustomed to reading these, this is a fracture through the posterior part of the second cervical vertebra, also known as a hangman’s fracture. You might infer from the name that this is an unstable, bad injury, and you would be right. And our hipster friend had been walking around (hell, skating around and falling) for a full week with this injury!  His neuro exam, I confirmed, was rock-solid normal. We popped a C-collar on him and I called the neurosurgeon at the local spine center to arrange transfer.

I had the opportunity to hold forth, as the nurses and techs gathered around the monitor to see the image, explaining that the “hangman’s fracture” is a bit of a misnomer. Generally it is sustained from axial loading (as opposed to traction), which makes a ton of difference. The real-world mechanism is planting your forehead into a car windshield, that is, not hanging from a rope, and the spinal cord is typically uninjured in mechanisms of this sort. It’s unstable and needs to be fixed, but there are many worse c-spine fractures you could have. My audience was very appreciative and I basked in their attention.

I was quite surprised, however, when I eventually spoke to the neurosurgeon. “It’s a stable fracture,” he told me, “he’s had it for a week and his cord is fine. Put him in a hard collar and send him home. I’ll see him in clinic next tuesday.” It was one of those “What? Really?” moments I described above.

This surgeon, I should mention, was not some fly-by-night guy, nor was it the intern. He’s a very respected professor at a university-affiliated trauma center. Not someone I am predisposed to argue with. I see hangman’s fractures about, oh, once a decade, and he operates on them all the time. He clearly thought it was quite routine to send him home. And he did have a point — it had been a week, after all. So with great discomfort, I acquiesced. For lay readers, it is important to understand that there are categories of stable spinal fractures that should go home, so it’s not as crazy as it sounds. Not quite, anyway.

It seemed wrong, though, very wrong. I ran it by a couple of my partners and their eyes all got kind of big at the prospect, too. Without any clear plan, I decided to buy time and get the CT scan to better delineate the injury. After all, I reasoned, they will need it to plan the surgery when he goes to clinic next week.  (“Next week? Am I really going to send a C2 fracture home for a week without even seeing the neurosurgeon? This is nuts! I just can’t.”) I chatted with the radiologist who read the CT, who described the hangman’s fracture and blah blah blah, lots of technical details that meant nothing to me. I had radiology send the images electronically to the trauma center and sent a message to the surgeon that there was a scan available, in the hopes that might change his mind.

The surgeon called me back about ten minutes later, with a hint of anxiety in his voice. “Please tell me you didn’t send that guy home, did you? This is a really bad, unstable injury. I need to operate on him today.” To his credit, he had the grace to be embarrassed about his earlier advice and acknowledged that I was right to have stuck to my guns on this case.

I still don’t claim to fully understand the intricacies of this injury or what about it changed the surgeon’s mind. I’m not a neurosurgeon. I am very glad, though, that in this case I listened to my gut and that I didn’t send him home. My malpractice carrier is, too. Knowing when to call BS, when to say “No” is one of the hardest things about my job, because it’s pure instinct.

*This blog post was originally published at Movin' Meat*


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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.”

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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.

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