Something didn’t look right when the very large patient was wheeled into the emergency department. He was moaning in pain and had his hands over his face. Usually the people who have their hands over their faces have something to hide.
When he got into the room, he was moaning how his chest hurt. He had an aneurysm in his chest that he thought was bursting. In the past, the aneurysm had dissected into his coronary arteries, giving him a heart attack. His pain was “20” on a 1-10 scale. But he laid there comfortably, still with his hands over his face and peeking out through his fingers at what was going on in the room. His vital signs were rock solid stable. As I started to examine him, I noticed that he had sticky residue from EKG leads on his legs — making me think that he had been to another hospital in the recent past. When he took his hands down from his face, he wasn’t sweating at all. His front four teeth were missing. His heart sounds were okay, but he yelled when I put my stethoscope on his chest.
“Oh. I’m sorry.”
The pulses in his arms were equal which is a good sign when considering whether or not there is a dissecting aneurysm. I also noted that he had tape residue on his wrists which appeared to be from a recent IV site. His abdomen was quite large which prevented me from palpating any of his organs.
I got a little more history.
The patient started having “crushing” chest pain early in the morning. The pain went into his neck and into his left arm. He was also having a large amount of blood coming from his rectum. He wasn’t sure why, but he was feeling dizzy.
I moved out of the way so the tech could hook up EKG leads.
He’d been neglecting his health. He stated that the last time he had received any medical care was about five weeks ago. At that time, he was told by the doctor in our emergency department that he needed to have an angiogram, but he had other issues to take care of, so he left against medical advice and never did get to follow-up with the cardiologist as was recommended. He had just moved to the area from Montana and did not have a primary care physician. His doctors in Montana had done an extensive workup and found that he had an aneurysm in his chest that was unable to be surgically repaired. In fact, he remembered some nurse in the emergency department out there whose name began with a “K” who would never give him the medications he wanted. I got the contact information for the hospital where the patient had been worked up in Montana.
Then I went to look in his old records. He was right. The last time that he was in our emergency department was about five weeks ago. We recommend that he stay for a cardiac workup, but he had to leave against medical advice. But that wasn’t all. We also got records from his Montana hospital during that visit. They showed that the patient had been extensively evaluated for multiple complaints and no etiology for any of the complaints had ever been found. Those record suggested that he had a “somatization disorder” and on the patient’s last admission, he had been referred to a neuropsychiatrist. Hmmmm.
On a hunch, I asked the nurse to call around to some of the other hospitals in our area to see if the patient had been anywhere else recently. The first hospital that we called was across town. The emergency department nurse knew the patient by name.
“You mean the heavyset guy with no front teeth? Yeah he was here a few days ago. He got admitted.”
We requested records and lab results from their medical record department.
When we received the 14 page fax, it showed that the patient had been discharged from the hospital four hours prior to his visit to our emergency department. That would have been just about enough time for him to get home and then call the ambulance again. The patient was complaining of abdominal pain in that hospital. He had CT scans of his chest, abdomen, and pelvis performed the day prior. All were completely normal. There was no aneurysm. He also had an ultrasound of his gallbladder performed which was also negative. The morning of his discharge, he had a normal cardiac stress test.
By this time, some of the laboratory tests we performed our emergency department were coming back. They were all normal. His EKG was normal as well.
I gathered up the results of the testing that had been performed at the other hospital and brought them in to the room with me. One of the nurses tagged along behind me. “I don’t want to miss this.”
“So, you told me before that you haven’t had any medical care in five weeks. Is that right?”
“Yeah, I really need to take better care of myself.”
“That’s funny, because we got a fax from Metro General Hospital just now showing that you were just discharged from their hospital this morning.”
“No I wasn’t.”
“The fax also shows that you had normal CAT scans, a normal ultrasound of your abdomen, and a normal cardiac stress test in the past two days.”
“I haven’t had any testing done since I was here five weeks ago.”
“That’s strange. The nurse that we spoke to over there knew you by name, confirmed your birthdate, and described you as being heavyset and having ‘no front teeth.’ I have a hard time believing that they are getting you confused with another patient who is having all of this testing done.”
“Are you calling me a liar?”
“Let’s just say that I am doubting your story. By the way, why is it that you have residue from an IV and from EKG leads on your arms and legs?”
“The ambulance put those on there when they brought me here.”
“The ambulance put the IV in your other arm where it is still located and the ambulance does not put EKG leads on people’s legs. I think we need to call the police to get a positive identification on you and to sort this whole matter out.”
That was it.
“You motherf***er! You have invaded my privacy and violated the law!”
“You can file a police report on me, then. Can someone call the police, please?”
With that, the patient ripped off his EKG leads, ripped out his IV, and demanded a phone so he could call his attorney.
“But wait. We need to do some other testing to make sure that you’re not bleeding from your colon. We need to do something called an NG tube and perform a rectal exam to check for blood.”
“You’re not f***ing touching me, you QUACK.”
He pulled on his pants, and grabbed the rest of his clothing, and walked out of the room. Then, he pointed his finger at me and began yelling.
“Your job is MINE, you hear me? Your f***ing job is MINE. MIIINE!” He reminded me of this outburst by Newman on one of the Seinfeld episodes. All he needed was the faux evil laugh.
I haven’t received the official word from his lawyer yet, but, in planning ahead. So I’ll write a few more blog posts before this chap takes over.
Gosh, I’ll miss you all.[sniff]
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.