February 12th, 2010 by Shadowfax in Better Health Network, True Stories
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Sometimes in this job you just get lucky. You have an elusive and/or dangerous diagnosis just dropped in your lap. Something devastating that you would never have been able to tease out otherwise just gets handed to you by the patient. There’s a catch, though: you have to be smart enough to know when to listen to the patient, when not to blow off their crazy talk as just crazy.
So it was recently when I saw a guy with back pain. From the chart, it didn’t sound like anything complex: a middle-aged to older guy, maybe 60 or so, with a history of chronic back pain and multiple surgeries for the same. He was on Oxycontin 80 mg three times daily (a very high dose, and a red flag for an ER doc naturally suspicious of drug-seeking behavior). I went to see him, and it was clear in seconds that this dude was JPN: Just Plain Nuts. Read more »
*This blog post was originally published at Movin' Meat*
December 4th, 2009 by Edwin Leap, M.D. in Better Health Network, True Stories
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The past few days have shown me some small pleasures of my practice. I spent about 20 minutes sewing together the hand and forehead of a sweet elderly lady who fell down while being evacuated from a nursing home fire. Her skin, like tissue, came together in fragile folds; my hands moved easily with the needle and thread thanks to so many years of practice, so many hundreds of feet of sutures placed. Although I must admit that my cataract-stricken right eye left my depth perception imperfect in a way that bonded me to her. (Sitting here, with no reading glasses, I can close my left eye and all I see is a hint of lines on the page, but no letters.)
My sweet little lady smiled at me, nervously, tentatively, but was comforted at the prospect of going back to her bed. Her son eased her fear with jokes, then took her home. Read more »
*This blog post was originally published at edwinleap.com*
August 18th, 2009 by Emergiblog in Better Health Network, Health Policy, True Stories
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She didn’t eat her dinner Friday night.
By 4: 30 am Saturday, the previously healthy 65-year-old female had a fever and lower extremity weakness. A family member heard her repetitive moaning. The patient got up to void, but could barely negotiate the one step up to the hallway. As she negotiated the hallway, she staggered.
By 5:00 am she was in the ER.
*****
The patient was taken to an exam room. Vital signs were taken and it was noted that the patient’s fever was “extremely high”. The doctor came into the room and the temp was re-taken. Extremely high. The patient had no insurance and was not verbal; the doctor discussed options with the family member.
The goal: find the source of the fever and begin treatment. A CBC, Chem 14, a urinalysis, an IV and hydration would be started. No lactate level would be done; the doctor stated it would be pointless to run a test that she already knew would be elevated based on clinical presentation. Blood cultures would be drawn, but not sent immediately. As the doctor explained, they are expensive and it would take days before the test results would be back.
In this facility, payment was expected at the time of treatment and a detailed estimate was provided to the family. The low end of the estimate was the deposit.
*****
By 8:30 am Saturday, the fever was still raging; the lab tests were normal. The patient was in ice packs with a fan in an attempt to lower the fever. An IV antibiotic was initiated; hydration was on-going. An internist and a neurosurgeon were consulted as the patient was experiencing lower back pain in addition to the profound weakness. The patient was admitted.
Further tests were proposed: lumbar x-ray to rule out spondylitis and, given the patient’s age, a chest x-ray to rule out occult pneumonia. The pros and cons of each test were fully explained along with rationale and the cost.
*****
The radiographic exams were normal. A loose bowel movement that morning had been blood-tinged. The patient had been medicated for pain. A second antibiotic was started. The next step would be an abdominal ultrasound, as no obvious source for the fever had been found. The rationale for the test and the cost were discussed and the family gave the go-ahead.
The spleen. Enlarged and mottled on ultrasound. A call was made to the family to discuss needle aspiration to rule out lymphoma.
*****
Monday morning the patient’s fever was down. She was eating. She was voiding. She was still weak, still moved slowly and awkwardly. She would be discharged home on oral antibiotics with the results of her spleen aspirate pending.
*****
It’s been a week now and the patient is acting 100% normally.
The patient was my dog, a 10-year-old, 70 pound Shepherd mix. We still don’t know what nearly killed her last weekend. The spleen aspirate was abnormal, but not lymphoma. The fact that the fever responded to antibiotics (as did the weakness) leaves us with the feeling that it was an infection in such an early stage that the source was not obvious.
I realize veterinary medicine is not human medicine, and a million holes can be found in my attempt to draw a parallel between them. But a few things crossed my mind during this experience:
(a) Tests were not done just for the sake of testing or because a printed standard said they should be. This was not template medicine dictated by any outside organization or government regulations.
(b) The doctor/patient relationship was unencumbered by insurance company approvals, government regulations, billing, coding or the number of patients that had to be seen in a certain time frame.
(c) there was full transparency regarding what each test would cost.
Maybe the human health care system can take a few pointers from what the veterinary world has been doing all along.
(P.S. I just realized you can read this story from the vantage point of ME being the third-party payer standing between the vet and my dog, deciding what would be “covered” – i.e. paid for. Interesting either way….)
*This blog post was originally published at Emergiblog*
