March 24th, 2008 by Dr. Val Jones in True Stories
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I was participating in morning rounds with a team of internal medicine residents. That day was the beginning of a rotation change, and a new “house attending” (the doctor in charge of the inpatients who had no primary care physician) was getting to know his patients. The residents who had been caring for the patients took turns explaining (near the bedsides) what had gone on since their admissions to the hospital, and described their treatment plans.
One intern presented a case of a patient with “fever of unknown origin” (FUO). This particular diagnosis will make any internal medicine specialist delirious with curiosity and excitement, since it means that all the previous attempts at discerning the cause of the patients fever have failed. Generally, a fever only receives this exciting honor when it has gone on for at least 3 weeks without apparent cause.
The intern explained (in excruciating detail I might add) every single potential cause of the fever and how he had ruled them out with tests and deductive reasoning. The attending was hanging on every word, and nodding in approval of some real zebras (rare and highly unlikely causes for the fever) that the intern had thought to consider and disprove.
I must admit that my mind wandered a bit during this long exercise, and instead I looked at the patient, smiled, and examined his thick frame with my eyes. Of course, an attending has a keen sense for wandering minds, and so to “teach me a lesson” he abruptly stopped the intern’s presentation and looked me dead in the eye. You could have heard a pin drop.
“So, Dr. Jones” he snarled. “You seem to have this all sorted out, don’t you. Apparently you have determined the diagnosis?”
“Well, yes, I think I may have.” I replied calmly.
The attending’s face turned a slightly brighter pink. “Well, then, don’t withhold your brilliance from us any longer. You’re a rehab resident, are you not?” He made a dismissive move with his right hand and rolled his eyes.
“Yes, I am.” (Snickers from the internal medicine residents.) I shot a glance at them that shut them up.
I continued, “Well, Dr. ‘Attending,’ as the intern was reviewing the potential causes of FUO, I took a look at the patient. It seems that there is a pus stain on the bottom of his right sock. I didn’t hear the intern describe the patient’s foot exam.”
The intern’s face went white as a sheet.
The attending turned to the intern with an expression of betrayal. “Did you examine this patient’s feet?”
“Well I uh… well, no.” Stammered the intern. “I guess I forgot to remove his socks.”
The attending marched over to the bedside and quickly removed the patient’s right sock, a small snow storm of dried skin flakes fell gently to the hospital floor. A festering foot ulcer proudly displayed itself to the team.
The attending gingerly nodded at me. He turned to the intern and announced that he would be given an extra night of call this month so that he’d have time to examine his patients’ bodies from head to TOE.
The patient was treated with antibiotics and sent home.
The intern later went on to become a radiologist.
I am working on improving patient empowerment on a national basis through Revolution Health.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 13th, 2008 by Dr. Val Jones in News
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There have been some recent news stories about a new type of identity theft – people (presumably without health insurance) are able to get coverage by stealing your insurance information and posing as you during hospital visits. Alternatively, hospital employees can steal your information and sell it on the black market. Some people estimate that medical identity theft may account for up to 3% of all identity theft in the US. Yikes! I even blogged about an infuriating previous encounter I had with a medical identity thief in the inner city.
I had my identity stolen once about 7 years ago – it was a very sobering experience. One day my credit card company called me to ask about some suspicious activity… which led to tracing events and purchases with eventual police involvement, further investigations, culminating in a Nigerian crime ring apprehended in upstate New York. Wild stuff. But I still use credit cards.
I would hate to think that medical identify theft could stall our good faith efforts at streamlining the healthcare experience. Sharing information securely and safely is a critical piece of the continuity of care and quality puzzle. Will there be hackers? Probably. Will some people be victimized? No doubt. But the vast majority of folks (if appropriate precautions are taken) will benefit from having all their providers on the same page, their medications, tests and procedures de-duped, and accurate records available for loved ones in emergencies.
The elephant in the room is whether or not people will be excluded from insurance coverage based on their electronic health records. To me, that’s scarier than potential medical identity theft, and probably the largest reason why patients are hesitant to digitize their health information (i.e. use PHRs).
What do you think about this elephant? Is there anything that can be done about him?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 12th, 2008 by Dr. Val Jones in True Stories
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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 11th, 2008 by Dr. Val Jones in Uncategorized
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As many of my faithful readers know, Dr. Val is a big fan of Web 2.0 principles (blogging, online communities, wikis, forums, chats, podcasts, etc.) I’m even leading a weight loss group online, and there are almost 1400 members already. Although I’ve been trying hard to lead by example, I’ve had occasional hiccups in my own weight loss due to the sweet lure of fine dining. Could YOU resist silky, black sesame panna cotta with butter crunch tuile and spicy cranberry compote? Well maybe you could. For me, resistance is futile.
But I digress.
What I really wanted to point out (before my thoughts were derailed by deliciousness), is that research is now confirming what many of us bloggers have known instinctively: social networking can improve the health care experience. In the Journal of the American College of Surgeons, post operative pain and length of stay were reduced for those who had more social support. This means that the more frequent and broad your social contacts, the less likely you are to be bothered by pain, and the more likely you are to get out of the hospital faster. Let’s hear it for using CarePages, FaceBook, and other online support groups while in the hospital, and perhaps as outpatients as well.
And if feeling supported isn’t enough to get you on the right track, more research in the Archives of Internal Medicine suggests that mail reminders can improve post-heart attack medication compliance. Perhaps email reminders would work just as well (and kill fewer trees?) One thing is for sure – Health 2.0 tools can make an impact on peoples lives and I’m excited to be a part of that.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 1st, 2008 by Dr. Val Jones in True Stories
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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.
