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Don’t believe everything you read in a medical chart


Continuing on with the car accident theme… A patient came to see me in the clinic. She had been run down by a bike messenger (could it have been my friend with the bleeding leg?) when attempting to step out of a bus onto a cement curb. She had a lot of pain in her shoulder and side, and was taken to the ER where a chest XRay was unremarkable. She was released with a prescription for extra strength Tylenol.

Still in pain, she made an appointment at the hospital’s orthopedic clinic for the next available time slot (she was covered by Medicaid) where she met with a young resident who suspected that she was a drug seeker and sent her away with “reassurance” and more Tylenol.

The woman, knowing that if she came back to the clinic again, she’d probably see a different physician (and could therefore get a second opinion) – made another appointment. The next orthopedic resident read her chart (where the previous resident had written that the patient exhibited drug seeking behavior) and barely listened to the woman’s story. But after the patient insisted he do something, the orthopedist did what most do with “chronic pain patients” – send them to the rehab doc.

And so, nearly 6 weeks after the accident, I met the woman in the rehab clinic. I had read the ortho notes prior to seeing the patients and was nearly convinced from their descriptions that she was a belligerent, drug-seeking nightmare.

The woman was thin and irritable. I asked her why she had come to see me, and she said she thought I was going to do some physical therapy with her. I asked if she could recount the events in her own words, and explain what exactly was troubling her. As the story unfolded, I was saddened by what she described – the endless frustration of being in pain, of being bounced around from one young physician to another in clinics overflowing with patients, and of being labeled as a drug seeker. And all this after a very painful encounter with a hit-and-run bike messenger.

I asked her to describe her pain and point to it exactly. She said it had been slowly improving, but that it hurt most when she breathed in and there was some point tenderness over her 8th, 9th, and 10th ribs. I asked her if she had had a rib series… nope just a chest XRay.

I told the woman I thought it was likely that she had fractured her ribs, and that rib fractures are often hard to see on XRays, especially chest XRays. I also told her that there wasn’t any real treatment for rib fractures, except pain management and time to heal. Her face lit up.

“So you believe me? I’m not crazy?”

“Sure I believe you,” I said. “I’ve fractured ribs in the past and I know how painful it is. When it happened to me no one believed me either. My chest XRay was normal.”

“So what did you do about it,” the patient asked, looking at me compassionately.

“The truth is, I had to sleep sitting up for a week or so, and I breathed very shallowly for a while. Eventually, though, the pain went away on its own.”

“Thank you for listening to me, doc,” she said, tears welling up in her eyes. “Even though there’s nothing I can do about the ribs, I’m glad to know what the pain is from, and that I’m not crazy.”

I wrote a short note in the chart, documenting my impressions. I did not recommend physical therapy for the patient, but to follow up if needed.

Apparently, the woman had one more clinic appointment with the orthopedic team. They read my note and ordered a rib series to confirm the diagnosis. The rib series showed healing fractures of ribs 8, 9, and 10.

I never saw the patient again, but I’m quite sure that explaining her diagnosis was the most therapeutic thing that we did for her.This post originally appeared on Dr. Val’s blog at

A tale of two car accidents

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A few years ago I was walking home from the hospital after a long shift, when I witnessed a bicycle messenger struck by a taxi cab. The cyclist was riding at high speed across a crowded intersection and the cabbie was accelerating through a stale yellow light. THUD. The man flew across the pavement, the cabbie screeched to a halt, horns honked, a crowd gathered… I ran up to the man to check him out. His right shin was bleeding (he was wearing shorts), but I didn’t see any obvious deformities or broken bones.

The man was panting, his adrenaline pumping. I asked him to stay down for a moment while I checked him out. “F-off,” he snarled, “I don’t need your help.” Since I saw him fall, I knew that he hadn’t sustained a head injury that could explain his potential disorientation and poor decision making. I called 911 on my cell phone and gave them the scene coordinates while I tried to get the man to agree to get checked out. “I don’t need a f-ing ambulance, don’t call them!” he screamed, blood dripping down his leg. I did my best to reassure him, but he was adamant. He got up and started limping towards his bike (which, quite miraculously, was not bent out of shape from the blow). I continued to plead with him to just wait a moment to let the paramedics take a look at him, but he would not be detained. Short of using brute force to keep him down, there was nothing I could do. Distant sirens sounded, he hopped on his bike, muttered “I don’t have insurance” under his breath, and rode off. The taxi driver appeared extremely relieved. The crowd dispersed, the taxi left the scene.

When the fire truck arrived, I explained the situation. They asked which direction he’d driven off in, and they pursued. I don’t know if they ever found him, but catching a cyclist with a fire truck on the crowded streets of Manhattan is unlikely.


A few weeks ago I was walking down a narrow street in DC. An ambulance was parked in the middle of the street, a small SUV was in front of it, and a middle aged woman in a dark suit was sitting on the asphalt appearing angry but unharmed. I heard from an onlooker that she had darted out behind the SUV while it was moving slowly in reverse. She had been struck lightly, but was speaking loudly about suing the driver, and was demanding that she be taken to the ER for a full check up. The EMS team interviewing her was hesitant to put her on a stretcher since it was so obvious that she could walk. The woman was refusing to get up, and they were trying to figure out how best to carry her.

I gritted my teeth and walked away, wondering what kind of legal torture the SUV driver was in for.

These two car accidents left an impression on me – the uninsured will go to extremes to avoid costly medical care, while the personal injury lawyers rack up serious cash on trumped up claims. What’s the point of this post? I guess it’s a reminder to look both ways before you cross the street, drive carefully to avoid pedestrians, and make health insurance a priority!

This post originally appeared on Dr. Val’s blog at

Hope for accident prone kids


My mother had a good deal of trouble with me, but I think she enjoyed it.

–Mark Twain

Parenting is a difficult job – and one that few would sign up for given full advanced disclosure. I suppose my parents had their share of woes – my near-death experience as an infant, my being mauled by a vicious dog as a toddler, my getting lost in the woods (collecting poisonous toad stools) at age 4, my facial surgery after a bicycle accident, my head injury from a fall out of the tree house, my toboggan versus barbed wire fence encounter, my front teeth versus metal bar incident, my rib fractures and nearly ruptured spleen from another fall from a bunk bed, and my ski accident requiring knee reconstruction surgery… I guess you could call me accident prone.

Looking back it makes sense why my parents encouraged me not to play contact sports, but pursue academics. I took to jogging and tennis instead (yes, I managed to sprain my ankle and catch a racket to the eye nonetheless), and physical training in the gym. But my redirection towards reading and homework was probably a good thing – as it helped me to develop intellectual discipline, and at the very least kept me out of the ER.

So what is the moral of this story? I guess if you have a kid who’s physically challenged – or at least seems to be a magnet for high velocity metal objects, do not lose heart. With a little direction, he or she can grow up to become a doctor who helps other kids who injure themselves repeatedly in creative and unexpected ways.

Were you an accident prone kid, or do you have an accident prone kid? I’d like to hear some of your war stories!

This post originally appeared on Dr. Val’s blog at

Informed consent & the animal guessing game


Growing up in Canada, my family spent a lot of time in the car. While my European friends would tell me how they could drive through 4 countries in a matter of hours, in Canada I couldn’t get part of the way through our smallest province in the same time period. Canadians have to travel long distances to get anywhere, which is part of the reason why they’re such a tolerant and patient lot.

So on these long drives (long before the days of portable entertainment devices) my family would have to think of ways to pass the time. Our favorite game was inspired by “20 questions.” We called it “the animal guessing game.”

It basically worked like this – you thought of the most unusual animal you knew of (perhaps something you’d seen on Animal Kingdom or in an animal encyclopedia) and the rest of the family would ask yes and no questions until they guessed what it was, or all agreed to being stumped.

Now, most of us would systematically narrow the field of possibilities by asking typical questions related to size, territory, habitat, skin type (fur, scale etc.) and so on. But my younger sister would always begin by asking the same question:

“Does it have fangs?”

At the time I thought she was hopelessly silly and incapable of systematic analysis. So few animals, after all, would fall into that category. Surely that wasn’t a good lead question.

But as I reflect on my sister’s perseverance on fangs, I realize that she was using an emotive hierarchy. To her, animals with fangs were so frightening, that she wanted to get it out of the way first thing – to be sure that we weren’t going to be spending time reviewing the life cycle and eating habits of animals with sharp teeth.

You know, it may seem funny, but I think that when it comes to matters of medicine some patients feel the way my sister did about the animal guessing game. They’re in unfamiliar territory, they are afraid of a real or perceived threat of a painful test or procedure, and they are internally focused on that threat to the exclusion of the big picture.

Doctors have the natural tendency to be removed from the emotional priorities of patients. We think that the patient is most interested in the evidence behind certain tests, the statistics, the technical aspects of a procedure – but sometimes as they try to comprehend the details of your informed consent, they really have one burning question:

Does it have fangs?

This post originally appeared on Dr. Val’s blog at

Do the right thing

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Always do right. This will gratify some people and astonish the rest.

–Mark Twain

My favorite writer of all time is Mark Twain. His keen observations and uncanny ability to combine wisdom and wit makes his writing incredibly entertaining, don’t you think? I thought it would be fun to take a few of his quotes and illustrate them with true stories from my mental archives.

Today’s quote is about doing the right thing. I remember a case where a young internal medicine intern was taking care of a 42 year old mother of 3. The mother had HIV/AIDS and had come to the hospital to have her PEG tube repositioned. Somewhere along the way, she required a central line placement, and as a result ended up with a pretty severe line infection. The woman’s condition was rapidly deteriorating on the medicine inpatient service, and the intern taking care of her called the ICU fellow to evaluate her for admission to the intensive care unit.

The fellow examined the patient and explained to the intern that the woman had “end stage AIDS” and that excessive intensive care management would be a futile endeavor, and that the ICU beds must be reserved for other patients.

“But she was fine when she came to us, the line we put in caused her downward spiral – she’s not necessarily ‘end stage,’” protested the intern.

The fellow wouldn’t budge, and so the intern was left to manage the patient – now with a resting heart rate of 170 and dropping blood pressure. The intern stayed up all night, aggressively hydrating the woman and administering IV antibiotics with the nursing staff.

The next day the intern called the ICU fellow again, explaining that the patient was getting worse. The ICU fellow responded that he’d already seen the patient and that his decision still stands. The intern called her senior resident, who told her that there was nothing he could do if the ICU fellow didn’t want to admit the patient.

The intern went back to the patient’s room and held her cold, cachectic hand. “How are you feeling?” she asked nervously.

The frail woman turned her head to the intern and whispered simply, “I am so scared.”

The intern decided to call the hospital’s ethics committee to explain the case and ask if it really was appropriate to prevent a young mother from being admitted to the ICU if she had been in reasonable health until her recent admission. The president of the ethics committee reviewed the case immediately, and called the ICU fellow’s attending and required him to admit the patient. Soon thereafter, the patient was wheeled into the ICU, where she was treated aggressively for sepsis and heart failure.

The next day during ICU rounds the attending physician asked for the name of the intern who had insisted on the admission. After hearing the name, he simply replied with a wry smile, “remind me never to f [mess] with her.”

The patient survived the infection and spent mother’s day with her children several weeks later.

This post originally appeared on Dr. Val’s blog at

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