March 12th, 2008 by Dr. Val Jones in True Stories
Tags: Cancer, Emergency Medicine, Hospitals, Pain Management, Radiology, Surgery
3 Comments »
Every physician has a few traumatic patient stories forever etched in their minds. My friend Dr. Rob recently blogged about the sad case of a little boy with an ear infection – his bulging red eardrum suggested a common problem requiring antibiotics. Little did anyone know that the bacteria behind the drum would get into his spinal fluid, causing meningitis and rapid death. Another emergency medicine physician tells the story of an elderly woman whose aorta dissected right in front of the medical team, with barely enough time for the trauma surgeon to save her life.
One of my surprising moments occurred when I was an ER resident. A middle aged woman (we’ll call her Lizzy) was sent to the ER in the middle of the afternoon after a near-fainting episode in a pain management clinic. She was fairly well known to the more senior residents and staff (she was a chronic pain patient on multiple medications who came to the ER for frequent generalized pain work ups and rescue doses of her meds). So since this lady had cried wolf a few too many times, she was assigned to me – the newbie.
I had no pre-conceived notions about Lizzy, and hadn’t experienced her exaggerated and benign abdominal pain claims in the past. She was lucid, with a smoker’s cough and mildly disheveled, short hair with dark roots and blond tips. She explained that she had been at her usual pain management appointment when she got up from the waiting room chair to register and almost blacked out. She described feeling lightheaded, and needing to sit back down immediately. The clinic staff called our ER to transfer her for an evaluation.
Lizzy seemed fairly cheerful and unconcerned about her near fainting – as if swooning bought her a free ride to the ER to see her “other doctors.” But still, something didn’t seem right to me about her. She was light skinned, but not pink enough. Her blood pressure was low-normal. She had no particular pain anywhere, though on the levels of narcotics she was taking it would be a miracle if she could feel any pain at all. I decided to watch her, take serial vitals, and order a CBC and Chem 7 to see if there might be any signs of dehydration or anemia.
The second set of vitals showed a slightly lower blood pressure and a slightly higher pulse. She sat on the stretcher, watching the TV without any particular sense of urgency. Since it was an unusually slow afternoon, I got the chance to ask for more details of her medical history. Lizzy described her normal daily activities at the assisted living center, and how she had attended a party where she’d had a bit too much to drink and had fallen on a chair a couple of days ago. She said it hurt at first in her left upper quadrant, but it felt only slightly sore now.
Her CBC came back with a lowish hematocrit, and a third blood pressure reading was trending lower yet. I really wasn’t sure what was going on, but I was getting nervous. I presented the case to my attending (who knew the patient very well) and suggested that we get an abdominal CT to rule out internal bleeding.
He rolled his eyes and sneered at me. “Do you know how many CTs this woman has had already?”
“Um, no…” I winced.
“She gets one every freaking time she’s in here, and it’s always non-specific. Inexperienced residents like you are wasting hospital resources on drug seekers!”
“But she does have some anemia, low blood pressure, and a history of abdominal trauma…” I mumbled.
“She’s always slightly anemic, with low blood pressure – what would YOUR blood pressure be on high dose oxycontin?”
“But she looks pale and she almost fainted…” I tried to continue my argument.
“Alright, Jones… I’m going to let you order the CT as a learning experience for you. This is a teaching hospital, and I guess that means that we can irradiate patients at will. Go ahead… we’ll see what it shows.”
By this time I was really questioning myself. I’d gotten in an argument with one of our attendings who knew this patient intimately and had years of medical experience beyond my own. If I was wrong about her, he’d make me pay for the rest of the year – and tell all the other residents about my poor clinical judgment and wasted hospital resources. I was very nervous, but I just had to follow my instinct.
I sent the woman to the CT scanner with a reassuring pat on the shoulder. She winked at me and disappeared into the radiology suite.
Ten minutes later I was paged by the radiologist, his voice was tense – “Your patient has a splenic laceration, you’d better call in the trauma surgeons. She’s fading fast…”
Before I could put the phone down I heard the trauma team being paged overhead and some surgeons emerged from behind a curtain and started running to the CT scanner, almost knocking me off my feet in the hallway.
As it turns out, the trauma team was able to save Lizzy by removing her spleen. She spent several days in the hospital receiving blood transfusions and recovering from the operation. My attending never mentioned the incident again, though I never forgot Lizzy’s near-death experience. Maybe it was a blessing that I was a “newbie” when I met Lizzy – my lack of knowledge of her usual behavior allowed me to view her with a fresh eye, and take her complaints seriously. It’s really hard to hit that reset button with every “frequent flier” in the ER – but sometimes it can save a life.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 9th, 2008 by Dr. Val Jones in True Stories
Tags: Cancer, Colon Cancer, Personal
3 Comments »
It was really cold in NYC this weekend. Most of the little Upper East Side dogs were decked out in full coats that matched their collars, some even had booties. I spotted a couple of Italian
Greyhounds looking forlorn and trembling on their leashes. They weren’t
interested in a walk in the park on this day – they just wanted to go home to
their warm condos.
But cold as I was, I didn’t have the option to retreat. I
had come to run in the Colon Cancer Challenge with my friend Seton – a lifelong
marathon runner just finishing her second round of chemotherapy. She was in
high spirits – and laughed at my joke that this was the first race in which I’d
have a “snowball’s chance” of keeping up with her. You see, I’d always wished I could be an
athlete – but the best my genes could do is prepare me to pull the plow. So I
plod along, hoping for the day when I’ll be invited to join a caber toss – and
actually have a chance of doing something I might be good at.
But I digress.
So thousands of runners took to the 4 mile course – and as I
looked around I doubted that too many of them were actively taking chemotherapy
like Seton. She was bound and determined to run at least half of the way, and
had been training for it between IV infusions of very toxic drugs.
Seton’s husband was beaming with pride as he photographed
her at the start gate. I had vowed not to leave her side, no matter what the
pace… She had about 20 other friends who had joined the race as well and a
small handful stayed with us for the entire time. Amazingly, Seton was able to
run 3 of the 4 miles, her hands cramping in the cold, her thin legs carrying
her tingling feet past familiar landmarks. She held her head high, and never
complained – though it must have been hard for a former track star to watch people
of lesser abilities passing her on the trail. Her friends called her cell
phone every 10 minutes to find out how she was feeling/doing. They didn’t know
that it was so hard for her to even open the phone.
As Seton crossed the finish line, she held her arms up in
the air, as if she were breaking through winning tape. Cameras flashed, people
cheered, and I saw tears well up in her eyes as she tried not to show her
exhaustion. She gathered her friends around her and gave this short speech:
“I want to thank all of you for coming out and supporting me
and the fight against colon cancer today. I can’t tell you how much it means to
me to see all of your smiling faces… Although I certainly had some unlucky news
recently, I want you all to know that when I look at you, my dear friends and
family, I feel like the luckiest woman alive. I am so glad to have you all in
my life. I am truly blessed, and I’m going to beat this cancer with you all by
my side.”
There wasn’t a dry eye among us.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 1st, 2008 by Dr. Val Jones in True Stories
Tags: Hospitals, Humor, Internal Medicine, Physical Medicine And Rehabilitation, Psychiatry, Urology
3 Comments »
I was reading Keagirl’s latest post about a urology consult that she did in the psychiatric lock-down unit. Her patient was hearing voices – specifically that his left testicle was speaking to him. The good doctor was able to maintain a straight face through the exam and interview. There have been times when I suspect that my expression has given away my underlying feelings. A few of my awkward moments:
***
Dr. Val: Hello, Mr. R. I understand that you’ve had thrush in the recent past, and that your CD4 count has been as low as 25. Have you had any problems with thrush lately?
Mr. R: Oh, not at all. I found a way to cure it.
Dr. Val: Oh, very good. Tell me what works for you [expecting to hear ‘nystatin swish and swallow’ or ‘diflucan,’ I smile hopefully at the patient].
Mr. R: Well, basically since I started drinking my own urine the thrush has gone away.
Dr. Val: Oh… [pregnant pause] I see [scribbles note on clipboard as she takes one step back from the bedside.]
***
Dr. Val: [interviewing new patient in the inpatient drug detox program] So tell me a little bit about what brings you here today, Mr. S.
Mr. S: Well, you know, I have a real problem with crack cocaine, heroine, and alcohol.
Dr. Val: Yes, I see. Well, it’s good that you’re here now. [I smile genuinely].
Mr. S: But doc, I have to tell you why this all started.
Dr. Val: [Leaning forward, expecting a potentially important insight] Yes, what do you think is behind the drug addiction, Mr. S?
Mr. S: Well, I was born with a deformed penis and I think a lot of this has to do with my low self-esteem.
Dr. Val: Hmm. Well, I can see how that might be very challenging to overcome [eyebrows furrowing in a concerned expression mixed with mild awkwardness and some surprise].
Mr. S: I’d really like to show you what I’m talking about.
Dr. Val: Um… well, I uh… don’t think that will be necessary at this time. I trust you…
***
Nurse: [calling from psychiatric lock-down unit]: Is this the rehab consultant?
Dr. Val: Yes, I’m on call for rehab today.
Nurse: We have a man here with difficulty swallowing and we were wondering if you could take a look.
Dr. Val: Ok, what brought him to the psychiatric lock down unit?
Nurse: Well, he tried to kill a nurse at the transferring hospital – she got too close and he got a hold of her neck. But he’s not too hard to pry off because he has no eyes.
Dr. Val: No eyes?!
Nurse: Yeah, he cut them out several years ago during a psychotic episode. He used a piece of broken glass to gouge out his eyes and cut off his nose and ears too.
Dr. Val: Oh my gosh… that’s really terrifying. [Pauses with images of Silence of the Lambs floating through her mind] May I ask why he can’t swallow?
Nurse: I don’t know why he can’t swallow. That’s why I’m calling you.
Dr. Val: Well, I mean, how do you know he’s not swallowing? Did you see him choke?
Nurse: No he’s not drinking at all.
Dr. Val: Well, is there a cup next to him? Does he know it’s there?
Nurse: [silence]
Dr. Val: Ok, I’ll put him on my consult list…
***
You can’t make this stuff up.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 17th, 2008 by Dr. Val Jones in True Stories
Tags: Cancer, Colon Cancer, Hospitals, News, Personal
3 Comments »
As many of my regular readers know, my dear friend and Revolution Health administrative assistant (Seton) was diagnosed with stage IV colon cancer after giving birth to her first baby. She is doing well on chemotherapy, and working hard to shrink the liver tumors to a size that will allow her to have them cut out, and possibly be cured. On March 9th she’ll be participating in a Race for Colon Cancer walk/run in Central Park, and I’ll be joining her. This weekend I came to New York to practice the 4 mile run with a girlfriend of mine (Karen). Here’s what happened…
As I set out to meet my girlfriend at the southwest corner of Central Park, I became keenly aware that my light windbreaker/t-shirt combo was ill equipped to protect me against the icy wind chill. It was 8:30 in the morning, and as I bowed my head in the face of frigid temperatures, tears streamed down my cheeks while urban grit blew the very moisture out of my eyes. “Whose idea was this?” I asked myself, marveling at the occasional onlooker, bundled head to toe with hats, mittens and face masks. “Oh, yeah – mine. What was I thinking? Why didn’t I look at the weather report?”
About half a mile between my departure point and destination, I began to realize that my ears were in danger of freezing off. “I’ve got to find a hat” I thought… glancing at Citibank headquarters to the right and Meryl Lynch to the left. Where could one find a hat at this time of day, and in this neighborhood? Hmmm… a 24 hour pharmacy perhaps? As I marched towards what appeared to be a distant pharmacy I began thinking of ways to make a hat from cotton strips, Ace bandages, or maybe a shower cap. Severe cold can make a desperate mind exceedingly creative.
As I temporarily thawed myself in the warmth of the pharmacy, I began my search for a head covering. A fleeting moment of triumph gave way to disappointment when a hot pink Santa’s “little princess” elf hat (buried in a discount bin) proved to have the inelastic circumference suitable for a very small child or canine companion. But if there’s one kiddie hat in here, there must be others, I thought. So I combed through the drug store stock with a hopeful eye.
Ah-hah! I discovered a virtual treasure trove of kiddie hats, pinned to the backside of a pillar near the deodorant aisle. Of course, they were each painfully pediatric – with neon colors, gold stars, and little plastic Hello Kitty and Barney type effigies. But, I could see that they were stretchy, and came with some tiny gloves created to be a “one size fits most.” Worried that my girlfriend would have to wait in the cold for me, I hurriedly made my purchase, tore the tags off the hot pink hat and forced it down over the top half of my ears. The gloves covered my four fingers and half my thumb.
I arrived at our meeting place just in time. My girlfriend approached with a quizzical expression, noting the large “Strawberry Shortcake” girl (inside a plastic heart) emblazoned on my hat. I could see that she wondered if my fashion sense had taken a turn for the worse since my move from NYC to Washington, DC two years prior.
I assured her that I had no intention of wearing the hat again, but that desperate times called for desperate measures. She stood in front of me in a full running suit, complete with a layer of long johns, ear muffs, and two layers of Goretex. I felt utterly unprepared in my light cotton shirt and Lycra pants – but at least now that my head was half-covered, I figured that running would keep me from freezing to death outright.
And so we set off on a 4.5 mile jaunt, a hilly distance that neither of us had run in over a year. I had tried to prepare for this day with elliptical training, but wasn’t sure that my cardiovascular reserves would handle this new form of exercise.
Much to our surprise, the icy wind quickly numbed all sensation in our legs, allowing us to jog without much awareness of potential pain or exhaustion. We soon settled into a nice, slow jogging rhythm and took turns catching up on one another’s news. My uphill breathlessness tended to shorten my usually animated description of life-events, reducing me to caveman-like accounts. “Me take new job at hospital. Good.” Though I did much better on the downhill stretches.
In the end my girlfriend and I felt quite triumphant about the fact that we made it the full 4.5 miles without a break. We both knew that another 3 weeks of training should put us in good standing for the Colon Cancer Challenge, though my friend suggested that if I wore the Strawberry Shortcake hat again, she might pretend that she didn’t know me.
Today, of course, all my leg muscles are sore – but it’s nothing compared to what Seton is going through with her chemotherapy. I wish her all the best in her fight against cancer, and hope that my participation in the Colon Cancer Challenge will provide her with some encouragement, if not comic relief.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 7th, 2008 by Dr. Val Jones in True Stories
Tags: Finance, Fraud, Health Insurance
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This (hat tip to KevinMD) is one of the worst cases of attempted personal injury fraud that I’ve heard of:
It was a very busy weekend afternoon in the ED when a city bus accident occurred. What a disaster. Rarely is anyone really injured but everyone on board almost always winds up coming into the ED. The city encourages it so things can be documented and people are like “Cha-Ching!”, lawsuit! So, this particular time, about 5 people were brought in on back boards (we were lucky to get so few!) As the 3rd year resident started interviewing them one at a time (since all were stable and ambulatory (walking) at the scene), one of the patients said, “Hey Doc, that guy over there was not even on the bus at the time of the accident! He jumped on board afterwards and started complaining of back and neck pain!” The resident could have gone over and confronted him angrily (who would blame him) but instead chose a different approach. He calmly went through all the other backboarded patients, clearing them all clinically out of their cervical collars. He simply ignored the man suffering from “Allstate-itis”. The funny thing is that 2 hours went by and everyone just ignored him (although I think he was triaged at some point – damn EMTALA). All manner of stuff was going on around him. His stretcher was parked right next to the nursing station yet it was like he did not exist! Finally, the guy called the resident over and said, “Hey Doc, isn’t someone going to check me out and do x-rays?” He replied, “Well, you weren’t even on the bus so in my mind, you are already checked out!” Knowing the jig was up, the man sat up, took his C-collar off, and left the ER. I guess he was thinking, “Oh well, maybe next time I’ll hit the jackpot!”
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
