June 13th, 2008 by Dr. Val Jones in Medblogger Shout Outs
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Some bloggers’ clinical vignettes speak volumes about why doctors are exasperated with their day-to-day work lives. Here are a few good ones:
From White Coat Rants:
A patient from a nursing home was transferred by ambulance to our ED with the following chief complaint:
Mental status changes not responsive to albuterol [an asthma puffer].
Of course now we’re stuck trying to figure out how much this patient’s mental status has actually changed. I never could figure out how in the heck nursing homes can determine that an essentially non-verbal patient is having a mental status change. She sat in the bed, watched me walk around the room and smiled. So was she blinking less, or what?
I was waiting patiently on the next ambulance run for a patient with nasal congestion unresponsive to Ex-Lax.
From Ten out of Ten‘s Medical Jeopardy:
Answer: Massive Diarrhea
Question: What is the end result of eating nothing but beans and peaches all day?
People are so weird.
From Musings of a Dinosaur’s Anything Else?:
The perils of the open-ended question in a new patient interview:
Me: Tell me about your health.
Patient: I have hypertension and a little arthritis in my knees.
M: Anything else?
P: No, that’s all.
M: What medications do you take?
[presenting bag full of bottles, we find:]
Cozaar
Hydrodiuril
Lipitor
Zoloft
Ativan
Ultram
Celebrex
M: Why do you take the Zoloft and Ativan?
P: Oh, the Zoloft is for anxiety and the Ativan helps me sleep.
M: Anything else?
P: No, that’s all.
M: What about this Lipitor?
P: Oh, I stopped that about three years ago. It’s just for people who eat a lot of fat in their diet. I don’t think I need it.
M: Ok. When did you last have blood work done?
P: About four years ago.
M: And when did you last see a doctor?
P: About four years ago.
M: Any other medical problems?
P: No, that’s all.
M: Are you allergic to any medicines?
P: I get a rash with penicillin, and oh yeah! I have this weird rash that comes and goes. I’ve seen all the specialists downtown and no one knows what it is.
M: Anything else?
P: No, that’s all.
M: Anything run in the family?
P: My brother had a heart attack when he was 42, and oh yeah! I have a 30% blockage.
M: When did you find this out?
P: About four years ago.
M: Anything else?
P: No, that’s all.
M: Do you need any of these meds refilled?
P: Just the Celebrex.
M: Most of these other bottles also say “no refill” on them.
P: Oh, I have more at home. I just dumped them out and brought the bottles.
M: How much more do you have at home?
P: About two weeks.
M: How about if I write refills for all of them.
P: Ok.
M: Anything else?
P: No, that’s all.
M: Can I do some blood work on you today?
P: Sure. Oh, and I see a cardiologist, rheumatologist and orthopedist too. Can you send copies to them?
M: No problem.
Anything else?
P: No, that’s all.
M: Are you sure?
P: Yes.
Do you know why dinosaurs have no hair? It’s because I pulled it all out this morning.
We really do need a common, interoperable medical record system.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
May 29th, 2008 by Dr. Val Jones in Medblogger Shout Outs
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Thanks to KevinMD and the folks at Science Based Medicine respectively, I have enjoyed a good belly laugh at the following:
1. A satirical website devoted to a new EMR system: “Extormity”
“At the confluence of extortion and conformity lies Extormity, the electronic health records mega-corporation dedicated to offering highly proprietary, difficult to customize and prohibitively expensive healthcare IT solutions. Our flagship product, the Extormity EMR Software Suite, was recently voted ‘Most Complex’ by readers of a leading healthcare industry publication.”
2. A video spoof of the TV show “ER,” but run by New Age therapists. It’s called “Homeopathy ER.”
3. And as a bonus website for those of you who may not have discovered it yet, engrish.com is full of amusing foreign signs and product messages in broken English.
I hope these sites get your endorphins going!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
May 24th, 2008 by Dr. Val Jones in True Stories
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One of my colleagues at Revolution Health has a daughter who is a freshman in college (we’ll call her Julie). Julie has been struggling with a very sore throat for many months, and her mom would occasionally ask my opinion about her care.
Julie initially believed that she had a viral throat infection and tried to wait it out. Several weeks later the pain was quite severe and worsening instead of improving, so she sought help at the student health service at her university. The nurse reassured her and told her to wait a little bit longer and come back in a couple of weeks if things weren’t improving.
Two weeks later Julie was back, and was offered a monospot test (which was negative). The nurse practitioner gave her some samples of Keflex to treat her presumed strep throat, and was told to return in 2 weeks if her symptoms hadn’t resolved. Julie’s mom asked me if I thought that was ok, and I mentioned that drug resistance was not uncommon to Keflex, but that it was really cheap. I explained that Julie’s throat had been sore for an awfully long time, and that if the Keflex didn’t improve her symptoms within a few days, she might want to try something stronger.
Guess what? A week later Julie went back to the student health service with continued symptoms, and their response was to continue the Keflex for a full 10 days. Julie asked if a different antibiotic might be appropriate, and they simply replied that the health service only carried Keflex.
Julie completed the full course of antibiotics with no improvement. She called her mom to ask what she might do next and I suggested that she consider seeing a physician about an antibiotic with a lower resistance profile (like azithromycin). She was unable to get an appointment for a couple of weeks. The student health service nurse said that Julie’s throat did not appear concerning.
As it happened, Julie began having difficulty swallowing, was unable to sleep because of her throat pain, and had a low grade fever. I worried about a peritonsillar abscess (pus trapped in the deep tissues of the throat) and counseled Julie’s mom to get her to a physician right away. Julie flew to DC to be with her mom for the weekend, and was able to get an appointment with a primary care physician who gave her some azithromycin and steroids and said that there did not appear to be any visible signs of a peritonsillar abscess.
Again, Julie’s pain continued unabated. Her throat became even more swollen – and at that point I encouraged them to go to the ER to rule out an abscess. Julie was seen by an affable young ER physician who promptly ordered a CT scan of her neck. Several hours later the diagnosis was confirmed: Julie had pus trapped in the deep recesses of her throat. The ER doc numbed up the tonsil area and inserted a needle into the pus and pulled out several cc’s of thick green goo.
Man I wish I could have been there. (I know that’s a weird response, but docs LOVE pus.)
As I thought about this case, I wondered if we’ve gone too far in withholding antibiotics from deserving patients in our quest to reduce resistant bacterial strains. For every Julie there’s probably 100 others receiving (quite inappropriately) azithromycin for a viral throat infection… but Julie’s case may represent a new kind of provider problem: their own resistance to antibiotics.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 13th, 2008 by Dr. Val Jones in True Stories
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I received a panicked call from my younger sister today. She is the mother of one-year-old identical twin girls, born slightly prematurely. During her pregnancy she had a problem with twin-twin transfusion syndrome and had to lie on one side for many weeks to ensure that both girls received an adequate blood supply. She delivered by Cesarean section and fortunately both girls have been doing well. That is, until a few hours ago.
My sister described an episode in which her daughter was in the bathtub and suddenly had one of her pupils become very large. It remained dilated for several minutes, which caused her to call her husband in to take a look. He confirmed that the eye was dilated and they decided to call me right away because they’d heard that a dilated pupil might have something to do with concussions or head injuries, though the little girl had not had any recent trauma to her head.
I tried to get a full history from them – they said she was acting “totally normally” – the usual peeing, pooping, eating checks were fine. They said she was sleeping well, not vomiting or lethargic, and that her pupil had now (after several minutes) returned to normal size. They said her fontanel was not bulging, and when I asked them to shine a light in her eyes they both constricted immediately.
My sister asked me, “what could this be?”
Ugh. I’m not a pediatrician, nor an ophthalmologist, but I do know that asymmetric pupils are usually an ominous sign. All I could think of was “space occupying lesion” but I didn’t want to scare my sister unnecessarily. All the other history sounded so reassuring (the child was well, with no apparent behavior changes, the eye had returned to normal, etc.) that I had to say that they should get in touch with the pediatrician on-call.
And here’s where things got confusing. My mother called me by coincidence just after I hung up the phone with my sister. She had been visiting with the babies for a full week, and slept next to their cribs during their vacation. I told my mom about the pupil issue, and she started relaying some potential “symptoms” that she had witnessed over the past week or so. She claimed that the baby had indeed vomited recently, that her behavior was different than her twin (more irritable and emotionally labile) and that her sleep patterns were also disrupted.
Now I was more concerned – was this early hydrocephalus or maybe even brain cancer? Would I be responsible for missing a diagnosis? I was thousands of miles away from the infants and trying to piece together a story from historians with different observations. So I called some pediatrician friends of mine and asked what they made of this. One said – “anisocoria is a concerning symptom in an infant, she needs a CT or MRI to rule out a tumor pressing on her eye nerve. She should go to the ER immediately.” The other said that since there were no other current symptoms, and the eye was back to normal, it should be worked up by an ophthalmologist as an outpatient.
What a bind to be in – I have some witnesses describing very concerning symptoms, others suggesting that everything’s fine except for a fleeting period of pupil size mis-match. I have dear friends suggesting everything from an immediate ER visit with sedation of the child and a head CT or MRI to watchful waiting and distant outpatient follow up. And I have my sister relying on my judgment (as a non-pediatrician) to tell her what to do.
Here’s what I did – I got my sister and her husband on the phone and explained to them that I take their observation of pupillary dilatation very seriously. I explained that this is not a normal event, and should be followed up by an expert to make sure that there’s no underlying cause of the eye symptoms. I also said that the fact that the baby is acting normally and the eye is no longer dilated are reassuring observations. I told them that they should keep a close eye on the infant, and that if they see any hint of recurrence of the pupil problem, or anything out of the ordinary like vomiting, inconsolability, lethargy, swollen fontanel, fever, or strange body movements or seizures, they should go to the ER immediately. In the meantime they should alert the doctor on-call to the situation and discuss everything with their pediatrician during her next available office hours.
I hope that was the right approach. I will not rest easily until the baby has been fully examined by an expert. Being a doctor carries with it a lot of anxiety and personal responsibility – at any time of the day or night your peace of mind can be uprooted by an abnormal finding relayed to you by friend, family, or patient. And if anything goes wrong – or if interventions are not achieved at an optimal speed and accuracy, this question will forever plague you: “Should I have done something differently?”
Who knew that my relaxing Sunday afternoon would be turned upside down by a dilated pupil?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 12th, 2008 by Dr. Val Jones in Medblogger Shout Outs
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I recently wrote about some awkward moments that I’ve had with my patients over the years. However, I think that Shadowfax’s blog post may win the award for most distressing patient encounter.
A hospitalized, elderly man was very ill and had requested to be considered DNR (do not resuscitate). Many years prior he had had a defibrillator implanted so that his heart would be automatically shocked if it went into an abnormal rhythm. His family gathered around him as he died peacefully from old age coupled with infection. The defibrillator, however, correctly recognized an “abnormal heart rhythm” (i.e. a flat line) and continued to shock the deceased man’s heart at regular intervals, causing his chest to twitch in front of his pained family members. The hospital’s defibrillator magnet (the off-switch for the device) had been misplaced, and so physicians were left to call neighboring hospitals and cardiologists to try to shut the machine off.
In the process of trying to locate the magnet, the doctors had to identify the brand of the defibrillator – a Saint Jude device. As it happened, one of the doctors receiving the request for the magnet was Catholic, and recognized the grim irony of the situation.
Saint Jude is the patron saint of lost causes.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
