(Another) Letter to An Angry Patient

Dear Mrs. Creamer:

I'm sorry you chose to leave prior to your evaluation. As you should have been aware, we were quite busy.

When the waiting room is packed and there is no place to sit down, that's usually an indication that it's going to take a while to see the doctor. Especially after midnight when I am the only one on duty.


As the sign on the wall states, patients are not seen in the order of their arrival. They are seen in order of their acuity. That means that as long as people who can't breathe or whose faces are bashed in keep arriving, I will have to at least go check on them before I can make it around to evaluate your butt pain from slipping at Wal-Mart.

Yes, we know you have (and are) a pain in the butt. Coming out to the nurse's station every five minutes to yell at the staff does not encourage me to see you any sooner. In fact, the opposite is true. When I noticed that you were able to walk and talk (loudly), I was then able to put you lower on the acuity scale and move you farther toward the bottom of the stack of charts. Thanks for the help.

Paradoxically, if you would have stayed in your room and kept quiet I would have seen you much sooner. I worry more about patients that I haven't yet seen than those whom I can easily tell at a glance are not severely injured or dangerously ill. Consider that as a helpful hint for your next visit.

This is the order in which I decide to see patients:
1) patients who are dying
2) patients who might die
3) patients with disfiguring facial trauma
4) kids with fevers
5) nice patients who don't yell
6) you

You have already made it clear to the entire ER that you are going to file a complaint anyway, so why should I delay the care of my other patients in order to evaluate you? I might as well try to make everyone else happy instead.

Oh, and yelling to the world that you have to go to work at 7:30 AM does not buy you any sympathy from the staff or your fellow patients.

Are you suggesting that you are more important than these other folks, or that they don't have to go to work? How insulting. Get your obnoxious (but uninjured) ass back in your room or leave. We don't really have a preference.

Sincerely,

(Almost) your ER doc

On Buying a Cowboy Hat

I'm 40 years old, I've lived in Texas all my life, and I just bought my first cowboy hat. The Rodeo ™ is coming to town pretty soon, so I decided it was about time I had a proper hat.

BestAudioCodes.com

Many of the locals wear cowboy attire to The Rodeo ™ even though most of them are city folk who have never even been on a horse before (yes, I have). Besides, ER docs are the modern-day cowboys, pardner. Now I look the part.

Like the cowboys of yore, I searched the internet to find a western wear store and preview the variety of cowboy hat selections before I made my important purchase. I really didn't even have any idea how much such an appliance might cost. I learned that you can get a basic $20 straw hat or an $800 Stetson that must be like a work of art to cowboy hat afficionados. And of course, there are a lot of choices in between.

When I walked into the store, all the salespeople were wearing cowboy hats and boots, which made me immediately uncomfortable for some reason. I sensed that they could tell I was a greenhorn right off the bat. I should have worn my cowboy boots instead of Nikes and ixnayed the golf shirt. Oh, well. I can still whip out a Texas drawl with the best of 'em.

Anyway, I didn't know what my hat size was, but I remembered that I wore a 7 3/8 helmet in my high school football days. My head was bigger than any of the linemen's even though I was a wide receiver. So I asked for a size 7 3/8. In black, if you please. Unfortunately, it was way too small.

"Yew gonna wear it way up on yore head like that?" the salesman sneered.

Their puny 10 gallon hats were no match for my ginormous head. There was only one hat I could find that would scrunch down on my head at all, so I bought that one and got the heck out of Dodge. It made my daughter laugh, so it was well worth the 80 bucks.

Even if I only wear it once a year.

Ever Get the Feeling.....

Something bad is about to happen?

The Delayed History

She said that she had been vomiting for the past six hours and thought it might be related to the chicken she had eaten for lunch. Over the last couple of hours she had developed right lower abdominal pain. With her last menstrual period reportedly three weeks prior and the absence of vaginal discharge, appendicitis was certainly a possibility.

Her examination wasn't really impressive, however, so perhaps it was the chicken. Her husband had eaten something different.

"Do you think I could be pregnant?" she asked innocently.

"We'll see. We need to get some urine from you, too" I said on the way out the door. My plan was to hydrate her with IV fluids, control her pain and nausea, and re-examine her after a bit. As we were quite busy, the hours passed quickly. She had not really improved; in fact now she was even more tender at McBurney's point, and she still had not provided a urine sample. By this time, her husband had gone home with their two children.

"Try to squeeze out some urine, even just a little bit, or we will need to catheterize you."

Of course, her urine pregnancy test was positive. More blood was sent for a serum pregnancy test, and I told her that we would need to do a pelvic ultrasound.

"Oh, I just had one of those last week," she said.

"You did? Well, we need to do another one anyway. You weren't pregnant then, and you might have a tubal pregnancy."

"Well, my gynecologist told me I had a 'chemically positive' pregnancy."

"Chemically positive? What do you mean?" Now I was starting to feel a little bit queasy myself.

"Well, my pregnancy test was positive, but she couldn't see a baby on the ultrasound."

"Wait just a minute. You saw your gynecologist last week, and you knew you were pregnant. You even had an ultrasound. Why didn't you tell me all this before now?"

"I'm sorry," she said. "I didn't want my husband to find out. I'm not sure I really want another baby."

Oh. My. God.

Doctor vs. Nurse

I do not like to get involved in the process of evaluating nurses, and the concept of formally complaining about a nurse makes me really uncomfortable. I've been fortunate to work with many excellent nurses during my career. Outstanding nurses make even the most difficult shifts seem to run smoothly. As I have mentioned before, I have actually tried to arrange my shifts so that I work with certain nurses as often as possible. Unfortunately, there will always be plenty of mediocre nurses around as well.

Mediocre nurses are not so bad, really. They get their job done and generally cause no harm. Everything just takes longer. Their assessments take longer. IVs and blood draws take longer. Admissions take longer. Orders sit in the rack longer. Nothing is anticipated. They take more frequent cigarette breaks and lunch breaks, so they often just aren't around when you need them. They tend to make a lot of personal phone calls, either whispering into a cell phone or even worse, receiving calls on the business line. I try to only prod them when things start to get dangerous. I like to think that these nurses aren't really slow, but rather the exceptional nurses are just faster. That helps me deal with the situation without going insane. I'm sure there are faster docs than me as well, and so I try to be understanding as long as patient safety is not affected. I'm really pretty laid-back.

Nevertheless, it seems to me that many nurses will complain about each other and about physicians at every opportunity. They will fire off e-mails to their bosses, my bosses, or even the CEO of the hospital about any disagreement or perceived mistreatment, whether or not it affects patient care. Everyone has to walk on eggshells or we will end up at a sensitivity training seminar or get a stern letter of reprimand. Several of our best nurses have been fired (or induced to leave) for ridiculously petty nonclinical complaints....by other nurses! Talk too loudly in the nurses' station, speak a little too bluntly to a patient, make an off color joke or tease an overly sensitive colleague around the wrong nurse and you will get burned. Even those who we think are our friends will stab us in the back. It seems to be the below-average nurses who complain the most, but even the superstars have the potential to bite. There is no discussion; they go right to the keyboard. Nurses seem to consider scathing e-mails about their colleagues the same way that malpractice attorneys consider lawsuits....it's just part of the job. An occupational hazard. Nothing personal. I find this generally disturbing, but it truly seems to be an ingrained feature of the nursing culture.

During my entire career, I have made a formal complaint about a nurse only once, and that was against my better judgement. Everyone knew that "Bertha" was the worst nurse on staff. Even after several months of experience, it was obvious that she was never going to catch on. She was below mediocre. Maybe in another facility she would have been acceptable, but compared to her peers in our ED she was unanimously known as the worst. All the doctors cringed when they saw that she was assigned to their area. The other nurses would always grumble amongst themselves because they knew that they were going to have to do much of her work during a shift. She was not only the slowest nurse ever, but she had essentially zero independent judgement and minimal medical knowledge or skills. She made everyone's job harder. There was an understood but (mostly) unspoken reason why she lasted as long as she did, but I'm not going there.

Despite her incompetence, I would still never have complained about her if one of the nurse managers hadn't beggged me to do so. She suggested that a complaint from a physician would help make the case against Bertha stronger. I told her that I would file a complaint only if she would assure me that it would help make her go away. I didn't want to complain if it wasn't going to do anything but get her mad at me. I really didn't want to complain at all, but desperate measures were called for. During every single shift there were always several potential issues to complain about, from missed orders to unrecorded vital signs to ignoring critical data. Until that point, I had simply tried to encourage her.

"What's this blood pressure of 70/30?" I would ask.

"Oh, I think the patient was just on his side. I was going to recheck it in a little bit."

"Why don't we recheck it now?" I would offer helpfully. And so on.

Finally, I wrote a letter of complaint to her supervisor regarding her care of a patient who was going to emergency surgery who had some missed orders and no vital signs for the entire shift. It was two more months before she was finally fired, and I had to work with her during several very uncomfortable shifts before she finally disappeared. Ugh. From now on, you nurses can police your own. I'd rather stay out of it.

Picture of the Week

Symbolic prediction of upcoming events?

Jan. 19: U.S. freestyle wrestler Zach Roberson, and Iran's Mehdi Rahimi, wrestle during a tournament in Tehran, Iran.

Cat of the Day

I have a fondness for big orange cats. This is the meanest cat I've ever had. Say hello to Mr. Jynx, but you'd best not approach the tree. He may look soft and fluffy, but he is ready to attack at any moment. You can see it in his eyes.

The Droopy Eye

The chief complaint was "Swollen puffy eye. Saw optometrist yesterday." Great, I thought. I get to try to figure out something that a specialist couldn't. As it turned out, it wasn't that difficult.

Her eye wasn't really puffy or swollen, but she was unable to open it. "I saw my doctor two days ago, and he gave me some antibiotics. Then I saw my optometrist yesterday and he said my eye was OK." Well, it wasn't really OK. She looked sort of like this:

Her pupils were equal in size and reacted equally to light, but she had double vision especially when she would look upward and to the left. Double vision occurs when the two eyes cannot work together properly. The rest of her cranial nerves were intact, and there were no other neurological deficits. Her blood pressure was quite elevated, however, and she did admit to a headache in the back of her head on the same side as the involved eye.

So it appeared that she had an isolated and partial third cranial nerve palsy. It really isn't that difficult of a diagnosis to make if you know what to look for. Anyone presenting with the new onset of ptosis (droopy eye) should have a thorough eye examination including pupillary response and extraocular movements, among other things.









Because her pupil was not affected, my presumptive diagnosis was infarction of the third cranial nerve. The third cranial nerve innervates the muscle which lifts the eyelid, as well as several of the muscles that control eye movement. In addition, the nerve fibers which innervate the pupillary constrictor muscles are found on the outer surface of the nerve, so a compressive lesion like an aneurysm or tumor typically causes dilation of the pupil (which is usually a sign of a true emergency). A stroke can occlude the blood supply to the nerve, which is located deep inside the nerve itself and thus can leave the pupil unaffected. This is an important distinction.

Myasthenia gravis would be another less likely consideration but not one that I pursued in the ER. I'll provide an update next week.

Bong Lung

An otherwise healthy young man presented to the ER after the sudden onset of left-sided chest pain, worse with inspiration. Although his vital signs were normal and his respirations were unlabored, he clearly was distressed about these symptoms. His examination, ECG, chest x-ray, and laboratory studies were unremarkable. A CT scan of the chest was performed, which revealed a small apical pneumothorax (collapsed lung).

Typically we see spontaneous pneumothoraces in tall/slender individuals, but this gentleman was only 5 feet 8 inches tall. He did admit to marijuana use via a bong, but not on the day in question. Bong use predisposes one to pneumothorax or pneumomediastinum via the Mueller maneuver (inspiration against resistance) and the valsalva maneuver (deep breath hold).

This patient was successfully treated with 100% oxygen by face mask, which supposedly hastens resolution of the pneumothorax by allowing the nitrogen-rich intrathoracic gas (air) to diffuse back into the lung which has been made nitrogen-poor by the addition of oxygen. Or maybe it just gives us something to do while the patient gets better anyway.

The Magic Touch

This was weird.

An elderly woman with a previous history of atrial fibrillation came in complaining of palpitations and a rapid heart rate. Her EKG showed atrial flutter with a rate of 120. I talked with her for a few minutes before examining her. As soon as I placed my stethoscope on her chest, I heard her heart skip a beat. When I looked up at the monitor she had converted to a normal rhythm, and her heart rate decreased to 80 beats per minute.

She asked me to touch her arthritic hip, but I didn't want to push my luck.

Platinum Service

Photos of a successful cerebral aneurysm repair with detachable platinum coils utilizing a minimally invasive endovascular approach.

"The interventional neuroradiologist inserts a tube, called a catheter, into an artery in the leg. This catheter is then maneuvered through the body to the aneurysm's position. Once in position, the radiologist places one or more small coils through the catheter into the aneurysm. The body responds by forming a blood clot around the coil blocking off the aneurysm."

The CT scan:


The 3D angiogram:


Threading the catheter from the groin all the way up to the brain:


Placing the coils:


The final result:


A young life saved. That is one cool procedure.

A Lump in the Throat (UPDATED)

A middle-aged gentleman presented to the ED complaining of a "lump in his throat" for 4 days. It was slightly painful, and the "lump" made it somewhat difficult to swallow. When he would lie flat, he felt like he was choking. When he would clear his throat, he noticed some streaks of blood in his saliva. He had eaten some fish a couple of days prior to the onset, and he experienced some mild pharyngeal irritation at that time but he never looked in his throat. He was afebrile, in no distress, and his respirations were unlabored. His speech was slightly muffled, there was no stridor, and he was able to swallow his saliva.

His throat looked like this (click to enlarge):











A 2 cm purplish pedunculated structure emanated from the right tonsil. It was fairly mobile about its attachment point. A CT scan of the neck was obtained, and ENT consultation was requested.

In the midst of a very busy night with a lot of workups, I was hoping for a quickie. When you hear a story like that, 98 times out of 100 it will be some sort of pharyngitis, and the other two times it might be a fish bone. I'd never seen anything like this. I actually took a step back and said "What the heck is THAT??!!"

That probably isn't what a patient wants to hear, but I couldn't help myself. It was weird. It flopped toward me like some sort of alien. What was worse, I knew that I couldn't make a disposition because I had no clue what this thing was. Was it some sort of tonsillar tumor or granuloma? A hematoma? An AVM? Was it going to rupture and drown him in his own blood? A specialist was going to have to see it. At 3 am.

Someday we'll have little endoscopes that can transmit images over the internet to on-call docs at home to view in real-time. But in 2007, the ENT doc has to get out of bed and drive to the hospital. He wasn't sure what it was either, so I don't feel so bad. I'll post updates as the diagnosis develops.

UPDATE: Final pathology
Necrotic polypoid tissue, no evidence of carcinoma.
Most likely this was a benign polypoid lesion or tonsilar tissue which underwent torsion and resulting ischemia