Monday, May 24, 2010

Last Thursday...

Early one Thursday afternoon Marylou Gravley came to call. Marylou was a chronic visitor to our ED, having decided to overdose on her multiple psychiatric medications five times in the last few weeks and still not having figured out how to do it right. (Perhaps that’s a fringe benefit of a personality disorder). She was also unable to figure out when she decided to end it all. She said she took her overdose on Sunday; when asked why she came in four days later, she said she felt like this was a Monday, so why wouldn’t it have been on Sunday. (And yes, Carpenters fans, it was raining, the usual 4 PM Florida afternoon summer thunderstorm in full roar overhead). Sometimes drama is everything.

You always ask patients why they took their overdose. Mostly you do so to better understand their true risk of suicide, but if we’re honest a small part of asking is voyeurism. In Marylou’s case, it was because her father, who had previously indicated he was going to provide her with an apartment while he and her mother cared for her child, had decided that at the tender age of 34 it was time for her to fend for herself in this cold, cold world of ours. “What do you think of that?” she asked.

While patients who delusional often fare better and are easier to manage, at least in the ED setting, if you accept their hallucination as a temporary reality, those with personality disorders sometimes need a forceful dose of reality.

“I think it sounds like he wants you to take some responsibility for yourself.”

She immediately requested to see another physician.

Later that day I met Christian Tabarez, a portly man in his is mid-forties who fell in the shower that morning and was complaining of worsening chronic back pain and new right rib pain. He smelled of alcohol, but denied drinking. “Maybe a few on the weekend, chief” he noted with deference to my clear Native American heritage. (I am a Member of the Tribe.)

Unfortunately, his statement was at odds with his blood alcohol level, which was time and a half the legal limit. “I thought you told me you didn’t have anything to drink today.” I said.

“I didn’t drink today, chief.”

“Well, then how did the alcohol level in your blood get over the legal limit?’

“I might have been drinking last night, boss. (A welcome change in syntax.) But I got up and went to work today.”

“So how much did you have to drink last night?”

“Oh, maybe three or four beers.”

Alcohol levels drop an average of 25-30 points per hour. So just for the record, if his alcohol level was leftover at 100 at 10 PM, and he stopped drinking at 2 AM the night before, his alcohol level after his last drink the prior morning would have been 600. That would have likely saved him a visit to the ED, but not one to the morgue. So call me dubious, but something’s not right.

“I don’t think that’s the case. But you drank last night, right?

“Right, chief.”

So what day was last night?’


“I thought you said you only drink on the weekends. Is Wednesday a weekend?’

No answer. Not even a “chief.”

“So did you lie to me about your drinking?

“Yes, yes I did.” He shook his head in self-disgust. “But if you give me something for pain, I’ll never lie to you again.”

My turn. “Honestly, chief,” I said, “you’re not going to get the chance.”

I’m just waiting for the administrative complaints on both of these cases. Our administration is usually pretty good about these. They have a process to do, but they also realize the scenario is never quite what it’s billed to be. Nonetheless, they don’t want to see your name on too many complaints, no matter how accurate your observations may be. Of course, the legal profession feels no such need for due diligence.

But I’m at a loss as to how you can do medicine as it’s intended…to work for the good of the individual and, in doing so, for the good of society…and not tell patients the truth, even if it’s not what they want to hear? And why is it that we can’t insist on the truth from patients we’re trying to help as a condition of care?

There’s a reason why physician don’t say what they need to, despite the exhortations of academicians, health researchers, and policymakers to do just that. It’s that once we decided that medicine was not a science or an art but a business, and our patients began to morph into customers, we accepted the idea that “The Customer is Always Right” not as a guide for service, but as a rule that must be obeyed. And concomitant with the rise of an entitlement society, where justice is defined as what can I do to others to build my own self-esteem, the truth becomes unacceptable if it means that health care may not give me what I want, but only what I need.


It dawns on me as I’m writing this that you may think the above kinds of patients are all I see each day. While some ED shifts may feel that way, it’s a far cry from the truth. In reality, most folks who come to the ED are essentially nice people looking for help. And while their definitions of an “emergency” and mine are likely to differ, I’m able to help the majority of them (even if only with reassurance), and whether they’re admitted or discharged most leave the ED feeling better.

So just to make the record complete, here are the other folks I saw, in order, during an admittedly very slow Thursday evening eight-hour shift:

Loraine Duppstadt is a young woman with diabetes placed in our local psychiatric facility for depression and suicidal thoughts. She was sent to our ED because of elevated blood sugars. A little detective work revealed that she had not had her diabetic medications since she entered the treatment center. Some fluids and insulin in the ED got her sugar down to an acceptable level. Prescription written, problem solved.

Tia Mitts had radioactive iodine treatment for an overactive thyroid last week. Two days later she developed nausea and vomiting, both of which were worse (or at least seemed worse) because of her underlying anxiety problem. She also felt that her children weren’t sleeping well over the past week, and could this be due to the radiation? Turns out she did have a urine infection, which is a perfectly good reason to feel poorly. Some IV fluids, Zofran for vomiting, Ativan (“Vitamin A”) for anxiety, and a some reassurance got everything under control.

Daryl Odea was younger than I am but has already had his first two stents placed in his coronary arteries. He had a major heart attack last year, and arrived in the ED with chest pain similar to that of his previous episode. Two nitroglycerin tablets at home didn’t help, and it took a healthy dose of morphine in the ED to get his pain under control. His electrocardiogram (EKG) looked okay, and while we were able to relieve his pain there was still the concern that his pain was related to a lack of blood supply to the heart. The best way to assess him was to admit him to the hospital for further evaluation (sometimes to only way to detect heart damage is through consecutive measurements of specific chemicals released by damaged cardiac tissues). Having already started down the barrel of the gun, he was more than willing to come in.

Max Giannone had been admitted to the hospital last week for chest and upper abdominal pain. Once a cardiac cause had been ruled out, a CT scan of the abdomen revealed a large bleeding tumor in the liver. He was doing well, at least as well as you can be when you’ve been you’re harboring a cancerous softball in your gut, and was scheduled to have a biopsy the following week to figure out what kind of tumor it was and what treatment might be of help. But earlier that morning he had seen a lot of blood in his urine. As the liver is involved in manufacturing proteins which are critical to the proper clotting of blood, this could have been bad. But his labs looked good, and he no further episodes of bleeding. Didn’t know what it was, but if it ain’t broke we tend not to fix it.

Neil Tedrow also had chest pain, but he was a newcomer to the Coronary Artery Sweepstakes. His EKG and labs were fine, but he smoked for thirty years and had a family history of heart attacks. You can’t beat both nicotine and your DNA. He was admitted for observation and a stress test. If it’s negative, at least we know what his pain is not. If it’s positive, better to have the plumbing fixed sooner rather than later.

Ted McGlamery has a rising (not an arising, nor an uprising) between the cheeks. He’s had it before, and the last time it needed surgery. He decided that this time he would come in earlier and avoid the knife. Good idea, because at the base of his spine was a swollen, red, hot area just brimming with infection. But there was no abscess, and I’m not going to cut someplace where I’m not sure there’s pus. So antibiotics, hot packs, and sit on an inflatable swim ring. I always advise the ones with the squeaky ducky heads. It’s such a conversation piece.

Hilary Swoope was a high school junior who took five sleeping tablets because she felt she was a disappointment to her family. She had never done this before, and her family was incredibly patient and understanding with both her and us. I explained to her that as long as she was able to work with us, I would be able to avoid placing her under a “Baker Act,” a legal maneuver in Florida that allows us to involuntarily hold a patient who poses a risk to themselves or others. It didn’t seem to accomplish anything to assign this label to her so early in life. That worked until we discovered that the only way we could have her admitted for help was to do the paperwork. They were even gracious about that. Don’t know that I would’ve been.

Katherine Schwartzman has what we might call a “personal” discharge. Her pelvic exam was a difficult proposition, with much writing and pulling away and gnashing of teeth, which raises the question of how in the world she was able to get a ‘personal discharge” in the first place. But pregnancy test negative, prescription written, problem fixed…until next time.

Hugh Procter has had asthma all his life. It’s well controlled with his medications, but when he runs out…which is about every three months, as he doesn’t yet have a doctor of his own…he comes in with a flare of his respiratory disease. Asthma is one of those fun things to treat in the ED. The diagnosis is clear and straightforward. The exam features a symphony of wheezes, which most often go away after a couple of breathing treatments and a steroid shot. The lungs clear up, the patient feels better, and you feel like you’ve actually accomplished something. Three asthmatics per shift would make me a very happy doctor.

Allan Sevin had just finished his daily workout in the exercise room of his seaside condominium. He got into the elevator, felt faint as he pushed the button for this floor, and woke up on the floor of the elevator as it opened on nine. Unable to get up, he reached for the button with a G, and on arrival the doors opened and he was found by a maintenance worker. Negative labs and x-rays, but he still couldn’t stand without falling to the right. Sometimes strokes don’t show up right away on a CT scan, but that’s what his symptoms suggest. And, as the old ED saying goes, “If you normally walk, talk, eat, drink, and know what’s going on, and now you don’t, you need to stay.” So he does.

Liza Pixley was young woman with left lower abdominal pain. The worst emergency to miss in a young potentially fertile female is tubal pregnancy, which can rupture and cause internal bleeding. She was able to tell me the date of her last period, but not when she last had unprotected sex. She said that pregnancy was not something I need be worried about. “Guys aren’t my thing.”

Darren Allioto was transferred to us from another hospital. As a referral center, transfers are a common part of our day. No matter what’s wrong with them, transfer patients are a piece of cake. Someone’s already done the work-up, the diagnosis is made, and my job is to simply walk into the room to make sure someone’s still breathing before I call the physician who accepted the patient for transfer to tell them so. I’ll even tell the patient that this is my job, and most of them are happy to help out by continuing to respire.

Allyson Beckerman was seen the previous day for nausea and vomiting, and she’s back for more of the same. One of the ED Rules is that if a patient comes back within 24 hours, they’re either giving you a second chance to find out what’s really wrong with them or they’re playing games. It’s up to you to figure it out. Allyson wasn’t playing; an abdominal x-ray showed signs of an early bowel obstruction, clearly different than the night before.

Serena Plotner was anxious. She was anxious about being anxious. She was anxious to know if I thought she was anxious. She wanted to make sure she had blood tests to show if she was anxious. I explained that tests could not show if she was anxious, but might help her to be less anxious about her anxiousness being form anything other then being anxious. She anxiously agreed to the tests, anxiously awaited the results, and anxiously listened as I told her that all her labs were normal and I thought she might actually be anxious. She was anxious about taking any medicine for anxiety, but anxious about waiting to see her own doctor as well. She left still anxious about her anxiousness and what was making her anxious. I stopped trying four anxiouses ago. (I also just like the sound of the word “anxious.” It’s one of those words that just sounds funny, like Dave Barry points out about the word “weasel.” Anxious Weasel would be a great name for a band.)

(As I’m writing out this list, I recognize that each of them has a story, as well as a “medical thought process,” that might be of interest. The tales aren’t as strange or funny, of course, but they do reflect the reality of what we do. Maybe I should write up more stories of normal people. What do you think?)

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