August 11th, 2009 by Dr. Val Jones in True Stories
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I was coming to the end of my ER shift and realized that a fairly large list of patients still waiting to be seen. I scanned the chief complaints listed on our white triage board to see if there was a straight forward case that I could handle quickly before I went home. Since it was early in the morning, we had the typical extremes of patients – those who were badly injured (drunk driving is more common in the wee hours) and those who were really weird.
ER nurses are amazingly adept at capturing the seriousness of a complaint with their choice of words. Reading between the lines is a bit of an art form – and part of the natural communication in a busy ED. I understood the art fairly well, though this night I missed a big clue. Here were some of the chief complaints that I could choose from:
1. Crushing substernal chest pain x1hour
2. Butt twitching x3 months
3. Head vs. light post
4. Ear pain x2 days
First of all I made sure that a colleague was with patient #1, which left me a choice between patient #2 – clearly weird and doubtful that I’d be able to resolve his problems any time soon, patient #3 – probably going to take a lot of sutures and more time than is left in my shift, and patient #4 – a fairly innocuous-seeming issue, probably otitis media.
Needless to say, I chose patient #4… though I hadn’t recognized the subtle distinction between “ear pain” and “ear ache.” I was about to figure this out the hard way.
As I drew back the curtain to patient #4’s room, I saw a tall, thin man sitting bolt upright in the chair next to the stretcher. He was polite and respectful – but there was something odd about him. A few minutes into our interview about his ear pain, I finally put my finger on it. The guy never blinked.
After several more minutes of what could only be described as fairly straight forward answers to medical history questions – and a fully negative review of systems – I had this sneaking feeling that Patient #4’s pain wasn’t otitis media.
“I’d like to ask you a question that might seem kind of strange…” I said, peering intently at his face.
“Ok,” said the young man.
“Have you ever thought that your pain is related to a transistor radio of some sort in your ear?”
His eyes grew as large as saucers.
“Yes! How did you know?!”
And there it was – a young man with schizophrenia, experiencing his first psychotic break. It took me a few hours to get him a full work up and a discharge plan to the inpatient psych unit… and I was very late getting home from this shift. So much for a straight forward case…
I wonder what would have happened if I’d chosen patient #2?
August 11th, 2009 by GruntDoc in Better Health Network, Opinion
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One of the joys of having a blog with 10 readers is that a bunch of them actually add content. From the comments to this post (about the Collier Township, PA mass shooting) by CHenry:
Sadly a recurring pattern of tragedy. A mentally ill person: depressed, angry, frustrated and paranoid, socially isolated largely due to the behavioral features of his disordered personality (I say “his” particularly because it is true, most of these mass-killer-suicides are men) and then some event that triggers the lethal cataclysm of violence. It doesn’t even have to be something most people would think would trigger someone to break, maybe the failure of a brief relationship, or something more significant like a job loss.
U. Texas at Austin, Port Arthur, Tasmania, San Ysidro, California, Ecole Polytechnique, Quebec, Kileen, Texas, Dunblane, Scotland, Virginia Tech. All very similar, and there have been many more.
The gun control activists point to the weapons of choice. They have a point: semiautomatic firearms give an assailant a huge advantage of speed in making a body count when turned on unarmed and trapped victims. But even in places where gun ownership is tightly controlled, those with the determination to kill have found weapons of their choice.
We live in a society where it is startlingly easy to be alienated and alone, even in a crowd. For whatever reasons, the ties that bind us to one another, community, family, church, friendship and work are much more tenuous than ever before. People with thought disorders and violent tendencies have probably never been freer, both of the laws that once gave a society powers to confine them and of the observation and social controls that a world of smaller communities once imposed on their behaviors.
The lonely berserk stranger, hell-bent on wreaking as much destruction as possible before his own destruction has become the dark meme of modern living. Going postal.
I don’t see a practical answer to this problem. Good comment.
*This blog post was originally published at GruntDoc*
August 11th, 2009 by DrWes in Better Health Network, Opinion, True Stories
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It was a remarkable day in clinic yesterday.
Not because of the number of people I saw (12) or the clinical diversity seen, but rather how many people (4) asked me what I thought of the current health care reform bill before Congress.
The political spin being posed by Democrats is that people are staging town hall protests about their displeasure about the current health care reform efforts underway.
I don’t think so.
Rather, I think people are finally realizing that the health care reform proposal on the table is no longer about the “47 million” uninsured, but rather, “Hey, this health care reform thing, why, it’s about ME!”
-Wes
*This blog post was originally published at Dr. Wes*
August 11th, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips
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One of the most dangerous times for a patient is during the transition, or “handoff,” between providers. This is due to a number of reasons. First, the original provider(s) may not relay all the information he or she knows about the patient to the next provider(s). Second, the accepting team may take it for granted that everything is known about the patient, and therefore not take a complete history or perform an adequate physical examination. Third, if the patient initially looks good, the accepting providers may be lulled into a false sense of security, and not anticipate a deterioration in the patient’s condition.
We know this problem to exist in the hospital setting. Survey of doctors-in-training suggests that handoffs may commonly lead to patient harm. Last year (2008) in September, there was a blog written by Elizabeth Cooney in the Boston Globe that stated, “a 2006 survey of resident physicians at Massachusetts General Hospital found that handoffs commonly lead to patient harm, according to an article in The Joint Commission Journal on Quality and Patient Safety.” More than 50 percent “of the 161 medical or surgical residents who responded to the anonymous survey said they recalled at least one occasion in their last month-long rotation when a patient suffered from flawed handoffs.” Approximately “one in nine said the harm that resulted was significant.” The respondents said that “if the patient was coming from the emergency department or from another hospital, problematic handoffs were more likely.”
This holds true in the field. Unless the new treatment team makes the assumption that they need to begin their assessment of the patient’s condition from scratch, they are more likely to make a mistake. Obviously, such caution depends on the possible severity of the patient’s condition and the rescue/environmental situation. If I can get a decent handle on a patient’s condition, and there is little or no risk of me missing something, I will tailor my questioning and examination to suit the circumstances. However, I always start from the position that something has been hidden from me, of course not intentionally, and that the patient’s initial assessment has underestimated the problem(s).
I cannot begin to tell you how many times I have found something that was missed, or have accepted the care of a patient just as he or she began to “crash.” This is in no way a criticism of others, just a common fact of medical care. Previous rescuers may have been tired, the conditions may not have been conducive to a full examination, the patient may have been withholding information, or the situation may have just taken its natural course and worsened. Regardless, it’s my responsibility to learn what I can as quickly as I can about my patient, so that nothing slips through the cracks.
Here are some simple rules to follow:
1. If the situation permits, ask your new patient to repeat his or her history. If they are reticent to engage in a long conversation, at least try to get them to relate current relevant events.
2. Repeat as much of the physical examination as you can. Explain to the patient that you have assumed their care, and that in order to do the best that you can on their behalf, it’s important for you to understand their issues and to be able to monitor their progress based up the exam.
3. Assume that until you have talked to the patient or otherwise obtained a comprehensive history, and performed a physical examination with your own hands, eyes, and ears, that you do not know as much about your patient as you could.
4. If a patient is under your care for a prolonged time, or if you are managing a situation prone to rapid or undetected deterioration, interview and examine your patient as often as is necessary and practical. If you must be absent from a patient for a longer period than is prudent between examinations, delegate the responsibility to someone else.
image of leg splinting courtesy of www.princeton.edu
This post, Dropping The Ball In Patient Care: Provider Handoffs, was originally published on
Healthine.com by Paul Auerbach, M.D..
August 10th, 2009 by eDocAmerica in Better Health Network, Opinion
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Participatory Medicine is a cooperative model of health care that encourages and expects active involvement by all connected parties (health care professionals, patients, caregivers, etc.)
When patients are aware of such things as their weight, BMI, blood pressure, recent key laboratory results, and so on, and when they come to the office motivated and prepared, outcomes are likely to be much better. The patient who passively waits for advice and direction from the physician is more likely to forget instructions, make excuses for failures, lack the discipline to lose the needed weight or stay on the required diet, and so forth.
Patients themselves, not their doctors, must be the ones to make the essential decisions about their health. They must be able to obtain the necessary information to make key decisions, then act on them.
How does this process happen? A patient may agree with this statement and want to begin to operate in this mode, but not know how to do it. Here is a short list of the essential steps necessary to begin the practice of participatory medicine:
1. If possible, find a physician who understands, and supports, this concept, including one who is willing to communicate with you by e mail and directly answer your phone calls.
2. Consider the option of using a service like edocamerica, that is dedicated to providing you with the information necessary to make decisions about your own health care. They can supplement your physician and are available to you 24/7 and always welcome your questions. Moreover, they are dedicated the concept of PM and are oriented towards health and wellness, not just managing your diseases.
3. Start following blog and twitter posts by persons who are now actively discussing how Participatory Medicine is going to change the way health care is practiced.
4. Keep a current list of your medications, including the Brand name, generic name, dose and frequency of each one.
5. Look up the most common side effects of each of your medications.
6. Check your medications for any drug-drug interactions. You can use a web site such as drugstore.com for this.
7. Keep a list of all of your current medical conditions and review the basic information about each of them. A site such as Mayo Clinic or Medicine Net are good, trustworthy sources for this review.
8. Start making a list of questions that you want your doctor to answer for you. If he doesn’t have time to answer all of them at the next visit, ask him if you can e mail them to him. If not, ask one or two at each visit until you get them all answered. If you can’t get him to address all of your questions in a satisfactory and timely fashion, consider getting another doctor who will.
Participatory medicine, working on an equal footing with your provider, in a partnership for your optimal health, is the only way you can get the most out of the health care system. So, get on the train before it leaves the station!
Your comments and dissenting opinions are always welcome.
*This blog post was originally published at eDocAmerica*
