Weird new trend

There's a weird new trend in my ER lately. That would be physicians working a patient up for a zebra while simultaneously refusing to do anything about the most likely scenario.

One case was a young female patient in her early 30s maybe with a history of migraines. She had a headache in her usual spot with numbness, tingling, and weakness on the side opposite the migraine which hadn't occurred before with her migraines. In other words, probably a complicated migraine. I've seen patients come in with similar symptoms improve rapidly back to their baseline with just the standard Reglan and Benadryl, our usual migraine treatment.

So, I asked if I could give her migraine meds. No, you can't she's being worked up for a stroke. Um. So? She's 30 and has symptoms of a complicated migraine as well as a TIA, can't treat her for the migraine? No. Sheesh.

So, whatever, the patient suffered with her headache and anxiety over being weak and numb---I mean, who wouldn't be scared by that---until a CT and an MRI/MRA were done which were all negative of course. Then she got her migraine meds and her symptoms went away in like five minutes.

A second example was a Preggo chick who had sudden-onset dizziness and nausea, worse with movement, and no other symptoms. Preggo also landed herself a CT and a MRI/MRA. My pleas to at least try something for vertigo were met with a "she's getting a stroke work-up" as well. So, after five hours and a completely negative work-up, she got meclizine and zofran which almost completely alleviated her symptoms. "Why didn't I get these meds to begin with?" Oh, I dunno, dear, because your doctor is an asshole.

The med student musculoskeletal back pain work-up

When there are med students in the ER/ED, they influence the work-ups, at least where I work. I'm not sure why, but they do. A person who would normally get an exam and some discharge scripts might get an exam, discharge scripts, and a CT to rule out something because med students LOVE CTs and labs even more than our big work-up docs love them.

A case in point:

A middle-aged otherwise healthy hispanic lady comes in with a chief complaint of right-sided upper back pain. It's worse with movement, inspiration, and palpation. It gets worse with things like lifting her arm above her head. She has no other complaints, just that her back hurts like that. No trauma, no obvious cause of her injury.

If I were triaging her, I'd have triaged her to the fast track for a quick in-and-out visit consisting of, in all likelihood, an exam with scripts for flexeril and ibuprofen, complete with a clinic referral if needed. Trouble was, the fast track (where the urgent care-type complaints go) was closed, so she went to the regular ED/ER where she was met by The Med Student.

The Med Student is a nice dood, he's even dead-set on going into primary care, so rah-rah med student, we need ya. However, by the time he was done with her and discussed the case with the Real ED/ER doc, who happens to be a fan of overkill anyway, she ended up with the following work-up/treatments:

Liver panel, amylase, lipase
CBC w/diff
Chemistry panel
D-dimer
IV for dilaudid
Abd U/S
IVF at 125 cc/hr
NPO

I'm all, dood, you goofed up and put an abdominal pain work-up in on upper back pain lady. He's all 'dood, she had a positive Murphy's Sign'. I'm all, DOOD, she has no nausea, vomiting, abdominal pain, difficulty eating. She also had the positive "it hurts to lift my arm above my head and push on my muscles" sign. After an abdominal exam with no abdominally-related complaints, they essentially ignored her chief complaint and made up their own. The ER doc even said "we probably won't find anything." Oh, okay.

So, because the med student got excited that she looked painful as he pressed on her right upper quadrant, she ended up with a 6 hour work-up which was negative across the board. The doctor then referred her to a surgeon for a HIDA scan. I mean, yeah, hispanic females have gallbladder issues and gallbladder issues can dance around your right shoulder area, but seriously. W. T. F. If I barely press on your back and you scream, it's not hard to think that pushing on your abdomen may elicit a similar melodramatic pain response.

She'll be paying for all this out-of-pocket, by the way, including the surgical consult.

Self-diagnosis via WebMD

KevinMD linked to an article about a Canadian study about obstacles that doctors face when caring for patients. Here is one of them:

In addition, some doctors said many patients are quick to self-diagnose using the Internet, and are often resistant to the physician's diagnosis and course of treatment.

The researchers say things like patients questioning a doctor's diagnosis and treatment when it is different than what they found on the Internet "could have significant implications for patient safety".

This reminded me of one dood I had as a patient awhile ago. He came in with a chief complaint of "pneumonia, needs new antibiotics" which was really "shortness of breath" for a week. Over the course of the last week or so prior, he'd used WebMD and other websites to diagnose himself with pneumonia and used an online pharmacy to obtain penicillin from Mexico without a prescription to self-treat this "pneumonia". He was saying that maybe the penicillin from Mexico wasn't good and that he'd need something different.

Trouble is...he was really, really wrong.

I slapped him on the monitor where I found a new atrial fibrillation with RVR (rapid ventricular response) going at around 150 beats per minute or so, presumably the origin of his shortness of breath. His heart had been beating that fast for over a week in all likelihood. Something was seen on his chest xray, and a bedside ultrasound by the doc found a significant pericardial effusion as well which probably caused the atrial fibrillation.

After giving appropriate treatments to lower his heart rate and all that, I helped the patient to understand atrial fibrillation, and I smiled and said, "You going to use WebMD to diagnosis things again? You didn't do too well with the 'new-onset afib with RVR secondary to pericardial effusion'."

"Yeah, point taken," he said. Interestingly enough, as discussed in the linked article, it really took him awhile to be convinced that his breathing difficulty wasn't a LUNG problem. It never occurred to him that a breathing problem could originate from the heart. Without the false sense of security that WebMD provided for this guy, he would have probably gone old skool and went to the clinic and/or hospital in a timely fashion where the diagnosis would have been made correctly.

Lucky for him he didn't stroke out or get a cardiac tamponade waiting for that penicillin to cure his heart problem.

Fishing for cellulitis

I have this thing I like to do. Whenever a drug addict comes in with whatever chief complaint (headache, anxiety, suicidality, blah blah), I check out their skin. I mean, hello people, I know you're a drug addict. Normal people don't pace back and forth all sweaty in the room touching everything. You don't have to lie to me, but, whatever, now show me your skin.

Today's players were a withdrawing heroin addict, and a withdrawing meth-head, neither of whom had a skin-related chief complaint.

On Heroin Addict, I found two (2) areas of injection-site cellulitis, both on the arms, and on Meth-Head, I found one on the shin.

I told Meth-Head what I was doing and why and she said, "Oh I'm glad you're looking because my boyfriend had his foot amputated because he got an infection that he never did anything about."

So yeah, fishing for cellulitis: I recommend it, and it's an amazingly fruitful search most of the time.

John McCain has had a stroke

...according to Shadowfax on his own blog and THE DAILY KOS (famous far left blog if you didn't know). This is all based on a droopy eyelid, a problem he's had before. Check out my comments on Shadowfax's non-Kos blog if you want to know what I think about this.

It's okay people, despite being posted on the KOS, this is a "medical" post, DEFINITELY NOT A POLITICAL POST, NO SIRREE BOB. Shadowfax would never disguise a political post as a medical post.

According to Wikipedia, McCain is a "well-known person with ptosis". Unless Wikipedia added that today, it's not a new problem.

Oh, and by the way, please click the links before you run around declaring John McCain has had a stroke.

Shadowfax refers to my comments as "faux outrage", but seriously, if you're going to start throwing out "McCain's had a stroke" on DailyKos and your own blog posting as an ER/ED doc, you better have some really alarming evidence. Granted, Shadowfax says it could be something else, but still, you don't know his medical history and, if you were his doctor, he'd probably tell you all the about the damage his left-sided facial tumor caused, how he has the photographers only photograph him from the right whenever possible due to his facial appearance-issues, how his eyelid droops when he's tired and how bloggers go nuts about it every few months or so.

Certainly, even if Shadowfax only thinks the chances that McCain had a stroke are small, why bring it up in the first place? Oh, to get people talking about how he's "at risk" for problems and how he had melanoma that could come back, of course. Classic political tactic.

I don't think McCain nor anyone else (except DixieLaurel--see comments below) needs to tell the world why his eyelid droops in the absence of any other stroke symptoms. Maybe his left buttcheek is asymmetrically hairier than his right, but do we need to know this? No. Let the man have some privacy. If he thinks it's important, he'll tell people.

If a candidate's medical record is expected to be open-book (or candidates are expected to disclose any and all medical issues) to bloggers, voters, and media alike, then candidates would rarely seek medical treatment, at least no smart ones would. Political candidates deserve the doctor-patient relationship just like everyone else. It seems that lately important political figures do disclose relevant medical problems to the public anyway. Kennedy's brain tumor, Dick Cheney's heart issues, and Giuliani's prostate cancer come to mind.

Update 9/27: Shadowfax's "just kidding" update is here.

Masturbatory decimation of trees for the good of the people: The Joint Commission loves paper

For fun, I kept track of all the pieces paper I had to turn in with our annual *****REQUIRED!!!!***** nursing education class to demonstrate to The JC that I know how to find the Material Data Safety Sheets, apply restraints, properly do controls on everything, and dispose of hazardous waste in the appropriately-colored container in approved baggies labeled in an approved way (and other equally-as-exciting topics x 8 hours).

Nineteen pieces of paper to be exact, all of which amounted to tests "proving" my competency. You can also tack on three more pieces received for CEUs and 86 more for the photocopied pages of the presented Powerpoint slides that were given out in the beginning of class.

The JC: 1, Trees: 0

Bowel-obsession big city road trip

We have this middle-aged dood that used to come to our hospital rather frequently, at least once every couple of months, to talk about how his bowel movements were too hard, too small, too painful, or whatever. He always has qdaily bowel movements, but, gee whiz, they just aren't satisfying enough and this causes a great deal of distress. He's been doing this for the better part of a decade. He usually gets a script for dulcolax tabs or supps or instructions to increase fluids and try prune juice.

The thing is that he's really easy to remember because he always arrives in some bizarre outfit. Sometimes it's leather pants with flowing man-blouse and exposed chest hair, sometimes it's a red velvet leisure suit, and sometimes it's a cowboy get-up. Sometimes his hair is dyed a goofy color like, uh, burgundy or white-blonde. You get the idea. Basically, he always looks like he has been playing dress-up in the thrift store's Halloween section followed by a side trip to Walgreen's for a hair dye run.

At some point, he moved to a different part of the state about two hours away, a part of the state that has, yah know, hospitals and stuff. He still came to our hospital for his bowel obsession needs, however, always displaying little insight into the non-acuteness of his problems.

I was like, "Dood, haven't seen you here in awhile, what up?" A quick scan of the chart shows that the frequency of his visits had markedly decreased. Did he get a clinic doctor? Did he start going to The Local Rural ER?

He's all, "Yo. With these gas prices, I haven't been able to come up here as much to go to the hospital. I've just been dealing with this at home."

So, there you have it, people, a good side effect of high gas prices: Bowel-obsessed rural patients are avoiding ER visits for unsatisfying BMs.

Don't let the door hit your a** on the way out, pal

The only thing that keeps prescription drug addicts out of my ER are "pain" clinics* and street dealers, but the ER and clinics are cheaper than drug dealers since drug dealers don't take Medicaid. Financially-wise drug addicts will overwhelmingly choose the ER or the "pain" clinic and their $1 Medicaid co-pays over Joe-Joe on the street who charges $7 per pill.

Pain clinics try to stifle a lot of this drug-seeking and drug-abusing behavior by making patients sign a pain contract which says they will submit to random drug tests and being the patient's ONLY source for controlled-substances for pain or "pain". If the drug tests are positive for things they didn't prescribe or if the patient is found to be obtaining additional prescriptions for controlled substances elsewhere, they are often kicked out of the pain clinic's practice. No big deal to the pain doc because their waiting list to be see is often months long.

Here's a pain clinic patient that you will likely find enjoyable to read about. Not.

* = Many people that go are in real pain and are willing to try anything, narcotic or non-narcotic, many others use them as their drug dealers

Hat-tip to KevinMD.

Dying

Can you imagine having such bad hypertension that you have killed both of your kidneys (leading to thrice-weekly dialysis) and your heart (BNP >5000)? Doctors and nurses scratch their heads as having nipride and/or IV nitro running at maximal doses (ie, one of those glass bottles of nitro every hour and 15 minutes or so) only decreases your blood pressure to 210/120. Imagine doctors saying, "I don't know what else to do."

Imagine being denied a spot on the transplant list (heart and renal alike) because of your drug use.

Now imagine all this occurring before your 21st birthday.

Scary quote of the day

Family Practice Doc from Big Family Practice Clinic [to ER doctor who had just been whining about the computer]: I don't like this computer either! This guy is on allopurinol two pills daily, not one pill daily like it says on the chart. I don't know how to change that, so I guess he'll just get one a day. It's not that big of a deal, I guess.

Me (not involved in the case at all until now): Uh, I can change it?

I mean, dood, we've had computers for what, like, 2 years now, you're an attending, and you STILL haven't figured out how to change a medication dose on the computer? This is disturbing. I wonder how many people he just let have "one pill a day" because he didn't know how to switch it. It's not like patients are ever correct on their dosages.

Also, 10/10 passive way to ask for help there, pal. Sheesh.

Narcotic refills?

Today, I listened to one of our doctors call in narcotic refills, presumably for patients he'd seen in the ER/ED. I mean, there was a small chance he worked at some clinic somewhere and was doing his clinic work in his downtime, but, from the context of the overhead calls, it seemed like, no, he was taking calls from his former ER patients and calling in refills/new prescriptions for narcotics.

I mean, what the F? This CAN'T be allowed.

What's this thing for?

Whitecoat's post today reminded of this dood to whom I was describing what to do with his newly-prescribed asthma medications. I pointed at each medication (prednisone and an inhaler), what it was for, how much of it to take and blah blah. He'd been asthmatic for years, but just "dealt with it", according to him, without the involvement of any sort of physician or whatever. Despite having non-taxpayer-funded insurance (gasp!!!!!), he didn't have a clinic, no sirree, who has those anymore anyway?

So I get done talking about the medications and reasons to return to the ER. I gave our a clinic referral sheet and told him to find a doctor and use said doctor to manage his asthma.

"So, okay, I have a question," he says.

Yah?

"What's this thing for again?"

Um. Those are your prescriptions.

"What do I do with this?"

[Activate Keeping-A-Straight-Face mode] Well, you take it to the pharmacy and give it to the pharmacist and say you want those medications filled.

"Oh, that makes sense I guess. Last time I just told them what the doctor said I needed and they wouldn't give it to me. So I need to give them this paper then, I get it."

Another neuronal-anatomy crisis averted. Yes, you can't just show up at the pharmacy with a list of medicinal demands and expect them to be met.

When the triage nurse is grumpy and can barely stay awake

"I see you're giggling, joking with your friends, and eating potato chips. This must mean you have an emergency. Tell me allllllll about it."

I mean, let's start off our therapeutic relationship on an appropriate note here. You're obviously faking it, I'm obviously tired. My voice sounds like a 70 pack-year history smokers', I slept 5 hours in the last two days, my eyes are bloodshot, I ate a handful of candy for dinner and you, the one with the "emergency", are giggling and cracking jokes. I'm really thinking being condescending is the best option here. So let's get through the 8 JCAHO screening forms with the least amount of feigned drama so I can get back to my Bookworm and Foxnews.com and you can get back to the lobby TV.

Emergent chief complaint of the night

Chief complaint: "I sprained my wrist 5 weeks ago, and I think it's a little more swollen today."

[Glances at 100% normal-appearing wrist]

For more details on the case, read this. You know your "problem" isn't too bad when you flip through the channels on the lobby TV to find your preferred early am show before bothering to sign in.

This is not time for chit-chat. This is the time to hurry the F up.

I'd like to point out that where I work sometimes gets, ya know, busy. There will be an as*load of slips in triage that you and the other triage nurse have to work through. Some triage nurses are slower than others, which is to be expected, but I'd just like to tell all y'all triage nurses just one little thing:

You're in triage to see if these people are sick, not to find out about their dogs, aunts, sisters, brothers, and favorite type of Italian food.

There are 9 people that need to be triaged. This is no time to be asking if the patient has dogs and what kind and oh-I-have-weiner-dogs. This is not the time to asking about the crochet project and oh-what-a-nice-pattern. If the patient is going on and on about something stupid, you need to cut them off and get them back on track.

I mean, crap, I want to play Bookworm in triage with everyone having been triaged, not be drowning in slips because your ass can't stop talking about yourself.

You're not a floor nurse anymore

For some reason on one of my recent shifts, I ended up, with my two and half-plus years experience, being the most experienced nurse on my side of the ER. Scary, man. There were two floats and two people out of training less than 3 or 4 months.

I took over for one of the newly-minted ER types and report went something like this:

Yes, I have this type 1 diabetic patient whose blood sugar was "HI" in triage. She's breathing really fast and kinda pasty-looking. She was scheduled to go in to talk to a nurse today to have some of her questions about her pump answered since it doesn't seem to be working right, but woke up sick like this, so decided to come in. I have the number to the same diabetic educator, who just happens to be in the hospital today. I think you should call to have her come down and help the patient with her pump since she was worried about missing the appointment, happened to have all her pump stuff with her and is here anyway. She hasn't been seen by the doctor yet, but I'm friends with the diabetic educator from the floor, and I know she'll come down.

Meanwhile, I'm standing there dumbfounded. "Uh, you did what? This patient is probably in DKA. Is she lined? Does she have fluid going? Any signs of infection?"

No, I was working on this first. I thought I'd do something nice for the patient. Maybe you don't think it's nice, but I do! I can't help it, I think I'm still a floor nurse hahah.

So she gets offended at me for having the balls to mention that is not the job of the ER nurse, especially when it involves ignoring an actual medical emergency that's like bitch-smacking you across the face while saying "yo, look at me, I'm trying to kill your patient while you're on the phone".

Whatever, I go in there, watch the patient breathe really fast, put her on the monitor (hm, sinus tach at 145, thanks for mentioning that), draw 50 million tubes of blood, hang 2 liters of fluids, one liter each going into my newly-started #18 IVs (on the same arm so the other arm is free for the frequent lab draws), get the aide to throw in a cath and send a urine, and go tell the doctor to get his ass in there for the love of Jesus.

In the ER, we don't do diabetic educators, we don't do wound care consults (unless someone's colostomy bag explodes, then, by all means, please come down), we save lives. If you're not interested in telling patients that their relatively unimportant requests are going to have to wait or be done on their own time, you are not ready for this job.

FYI to bicyclists

If you have no health insurance and are T-boned by a car while you're riding across the street causing multiple non-life-threatening but really, really painful fractures and the ambulance shows up, just take it to the damn hospital even if you're uninsured.

Their auto insurance will pay for it.

Emergent chief complaint of the day

"I have a pimple here, and I have a date tonight, can you do something for that?"

Yeah, in fact, let me rush you back for a Level 1 Noxzema and concealer application.

Not at work, please

Today our monitored-transport nurse (the nurse who takes the patients who need cardiac monitoring to and from tests or up to be admitted) was wearing a scrub jacket with an "Obama '08" button proudly displayed.

What the Hell is the point of that? Nobody cares who you're voting for, especially not the scared patients who are getting their chest CT to rule out PE. Wear it anywhere else, just not at the hospital. Could I possibly, even if I tried really hard, care less if you wear it out to your trip to Wal-Mart? No. I'll just think you have poor taste in candidates and a fundamentally flawed view of economics, mental laziness, desire for dependence on foreign oil, and/or a self-guilt thing about making your own money and keeping a decent portion of it rather than all of the above plus a fundamental disrespect for your patients and hospital co-workers.

So don't do it or next time I'm gonna say something. If the transport nurses worked for the ER rather than for their own department under their own boss, I'd have said something right away.

Saturday Update: She wore it again today. *Sigh* Two days and counting.

Sunday Update: Button still there. Really, seriously, someone other than me say something.

Malingering case study

Malingering is a medical and psychological term that refers to an individual fabricating or exaggerating the symptoms of mental or physical disorders for a variety of motives, including getting financial compensation (often tied to fraud), avoiding work, obtaining drugs, getting lighter criminal sentences, trying to get out of going to school, or simply to attract attention or sympathy.
---Wikipedia

The other day I saw a good case study that exemplifies what it means to malinger. The patient had multiple psychiatric problems, multiple "yeah right" allergies, as well as multiple emergency visits for pain-related complaints, so, obviously, the red flags were up to begin with.

The patient complained of shoulder pain after tripping and falling from a standing position. I asked if it hurt anywhere else, and, no it didn't really, just the shoulder. Okay, fine. I made sure nothing appeared dislocated, nope, nothing obviously dislocated anyway. Pulses present, arms warm, denied numbness and tingling in the affected arm. No bruising nor other signs of injury.

A lot of times malingerers will F up the physical exam part, however. Since the complaint isn't real or is greatly exaggerated, the exam won't make sense given the complaint or the pain will move around or sometimes even the side of the injury will change if the patient is particularly idiotic.

I asked the patient to squeeze my fingers. She squeezed them just fine. I asked her to raise her arms above her head. As expected, she winced in pain as the "injured" arm was raised above a certain level. Then I asked her to grab my fingers again and pull me towards her. She winced in pain on the "injured" side, even though that movement didn't involve her shoulder at all and she had not complained of elbow pain.

Where does it hurt when you do that?

IN MY SHOULDER OF COURSE!

Busted!

Welcome to the ER, Newbie!

Nothing better than a good take-down and tasering as part of your ER nursing orientation.

Overheard in triage

I was walking by triage today and heard the following said in, shall we say, a very clear, difficult-to-miss voice:

Nurse to young adult patient: Oh, you're back? Are you going to stay around this time because I don't want to want to waste my time asking you all these questions if you're going leave again!

Your online BSN doesn't mean you get to avoid saving lives

Oh, so you got your online BSN, didja now? I'd congratulate you for this, but we have a little thing to discuss here.

Somehow you seem to think this online degree gives you special privileges to disappear for ages to talk to your patients about their psychosocial troubles. Know what I say to that?

Get out here right now and take ambulance report on at least one of these patients. I don't want to hear about how you need to obtain a comprehensive family history. I don't want to know what Dorothea Orem would think about your patient's decubitus ulcer. She's dead, this old dood with a history of CABG and chest pain is still alive for the time being, so worry about him.

I got the same letters after my name from a school where you need a minimum entrance GPA of 3.6 to even be considered for the program (ie not everyone is accepted if they can cough up the e-dough), but I don't seem to think that I can sit around and learn about everyone's auntie and uncle while people are in a-fib with RVR or SVT or V-tach or seizing or not breathing or whatever.

Your online BSN doesn't mean you get to avoid saving lives. If you want to avoid saving lives, carry a clipboard, hit up JCPenney's for an affordable business suit, and be done with it.

MonkeyGirl has more along the same lines here.

9-1-1 call of the day

CC: "I ran out of Fentanyl patches, I need a refill."

Well, I ran out of something too today---compassion for this kind of complaint. It's like we're "I ran out" BFFs now or something.