The chart said the chief complaint was “knee and ankle pain for one year.” Besides the obvious question of “what was it about your knee and ankle pain of ONE YEAR that brought you into the ER at 3:00 am,” I asked all the routine arthritis history questions. The answers were, of course, all negative. The real answer was staring me in the face. This five-foot-four patient weighed 464 pounds. Her hips spread out so wide when she sat on the bed that I could set a coffee cup on the shelf they created.
“Has anyone ever discussed with you the possibility of losing weight?” I asked gingerly.
“Not really,” she said blankly. “What’s that got to do with my knees?”
“Well,” I started slowly, “carrying all that weight can be hard on your joints.”
“You think this is all because she’s fat?” her friend chimed in incredulously. I could tell that this conversation was going to go nowhere. Looking around the room at several of her friends, I realized that at six foot five and 230 pounds, I was a full foot taller and 150 pounds lighter than anyone in the room.
“Well,” I tried again, “it could be a factor. Have you considered Weight Watchers or something like that? You might even be a candidate for gastric bypass?”
“That’s dangerous!” the whole room erupted. “He don’t know nuthin’, baby! Let’s go see a real doctor!” the friend huffed as she moved toward the door.
“Maybe you could try eating Subway sandwiches,” I whimpered as the entire herd started to move out of the room.
“I come to the hospital with a ‘mergency’ and he tells me to ‘eat a sandwich’,” the patient said as she stomped by the nurses’ station.
“Be sure to try some Motrin,” I called to her before she got to the door.
“What was that all about?” the nurse asked. I just shook my head, dumbfounded.
Later in the night I was staring at my coffee, contemplating how it is that we so often neglect to say the obvious. Not much later I had a toddler brought in by the mother who said that the child was a terror at home, screaming constantly.
“We let her stay up as late as she wants. She can eat anything she wants. She can watch all her favorite programs anytime she wants. I just don’t know what’s wrong with her,” the exasperated mother pleaded. “She must be sick or something. Could you give her something to help her sleep?” I just looked at this cute little girl in glowing health who couldn’t sit still. After a benign history and physical exam I was back to the obvious. Where do I start? I thought.
“Do you have any other children?” I asked.
“She’s my first, and maybe my last, if I don’t get something to settle her down,” she said, trying to control the constantly squirming child.
It seemed clear that she was expecting some kind of medication. I was between a rock and a hard place. I could give her some practical advice on child discipline, but what could I say in fifteen minutes that would make a difference.
“Have you and your husband considered some type of counseling or parenting classes?” I posed. Then I noticed my faux pas. She wasn’t wearing a wedding band.
“You think because I’m not married she needs a psychiatrist?” she asked defensively. “You think she has a mental illness?”
“No, no, I don’t mean that,” I said. “It just might give you some tips on how to handle her.”
“Oh, you think the problem is with me and not her,” she said even more menacingly.
“No, no, I don’t mean that, either,” I said. “It’s just that you might benefit from talking to someone who has been through the child-rearing process. Have you talked to your mother about her behavior?” She sat there in disgust shaking her head.
“You’re telling me to go talk to MY MOTHER. I guess if you’re not going to help me…” she mumbled as she picked up her things.
“I know a good book on child rearing,” I offered as she reached for the door. “It’s called Dare to Discipline. It really helped us…”
“He told me to go talk to my mother,” she said disgustedly to the nurses as she left without signing anything. They just looked at me with questioning stares.
“Another satisfied customer, I see,” the charge nurse said. “Was that ‘thunk’ I just heard your Press-Ganey score hitting rock bottom? You seem to have a knack for saying the wrong thing tonight.” I just screwed up my face in speechless frustration.
I’m really good when it comes to diagnosing a broken bone or an ischemic heart and taking the right steps to fix the problem. But if I can’t sew it up, put a cast on it, or send it to a specialist, I start to run into problems. And some things just don’t lend themselves to that kind of action. Sometimes the patient just needs some practical advice. And more often than not, they don’t want to hear it. We are supposed to be the dispensers of quick fixes. So what do you do? Like always in emergency medicine, you improvise.
I finally salvaged the night when Russell came in. Everyone has a few patients like Russell. With over a hundred pack-years of smoking, this scrawny old veteran was not about to give up the habit now. Besides, his lungs were already destroyed. But he’s oxygen dependant now and the high price of cigarettes presents a special challenge to Russell. So he smokes every cigarette down to the smallest butt possible. And this night it got him into trouble. While smoking in bed and trying to take that last deepest possible drag on his cigarette he caught his nasal oxygen canula on fire. The flame from the plastic canula was small and extremely brief, but fueled by the pure oxygen, it created a tiny blow torch right up his nostrils. The poor guy had second degree burns in his nostrils. I lobbied for admitting him out of pure sympathy. But after a full evaluation of his lung status, it was clear that the damage was superficial and he didn’t need another admission. His doctor would see him in the morning.
The quandary I found myself in was this: what do I tell Russell in his home-going instructions? After all the obvious instructions about shortness of breath and infection, what should I say about the way to prevent a reoccurrence? Stop smoking? That wasn’t going to happen. Stop, drop, and roll when you have a fire in your nose? Nah. Finally I came up with some truly practical advice that Russell might actually take: “If you must smoke, get one of those fancy long cigarette holders like the old movie stars used to use.”
As they rolled him out the door with a giant bandage on his nose he announced to the staff “I’m going to look like a movie star.”
“I don’t know what you told him,” the charge nurse said, “but it obviously made him happy.”
When I got home my wife was looking at the pictures from our recent holiday trip to our married son’s home. Everything looked great except for one picture. It was a candid shot of me and my daughter-in-law caught in profile. It was striking how the shapes of our midriffs were similar. The only problem was that she was eight months pregnant.
“Looks like the holidays were a little too good to you,” my wife quipped as she saw me staring at the photo. “Looks like you better bypass the danish and get back on the treadmill.”
“You don’t say,” I mumbled as I headed to bed.
Dr. Plaster’s Night Shift from Iraq will resume in the February issue of EPM.
6 Comments
So is it recommended that the patient have a po and iv contrast study? Or is the noncontrast CT abd enough? I guess that would have been the study done if his noncontrast ct scan had been negative. Or the HIDA scan, that takes most of the entire er shift to be performed. Is the noncontrast CT abd enough to make the diagnosis of acute biliary disease? I don’t want my patient charged for 2 ct scans.
I think this is a good point. A good use of the non-contrasted CT scan is often to facilitate diagnosis of appendicitis, GB disease and many other conditions in rapid fashion. It gives so much more information than traditional plain x-rays, which often are only good for perforation (most of the time) and (some of the time) obstruction.
With the non-contrast scan as a first study for suspected GB disease, I think you do run some risk that the initial study will be non-diagnostic. This might lead to a second CT (with contrast), or wrongly interpreting the CT as “negative for GB” when in fact the GB really is the problem.
However, on the balance, I think the non-contrasted CT will often be worth your while as an initial study for abdominal pain, especially in patients over 50 years of age and for symptoms > 12-24 hours in duration.
JD
Loved the article, so very true. Unfortunately they come to you, many of them with a preconcieved idea of what they need and most of them with that idea will not be talked out of it. Had professor in Medical School who said that “when you walk out of the room and all you want to do is kill the patient, the patient has a personality disorder” The sad truth is more and more of those are coming into the ED and we don’t always have the answers they are looking for.
Dr. Plaster’s columns are always informative and meaningful to me, no matter from which “front line” he is writing.
He writes of the obese woman presenting in the middle of the night with sore knees and the first-time mother with a crying baby. His remarks on these cases point out, with Dr. Plaster’s typical humorous bent, that we in the ED are great at emergencies, but not so great at everything else. Is there anything wrong with reassuring the patient, after taking a history and doing a focused physical exam, that no emergency exists, and suggesting some simple home remedies and, finally, emphatically urging the patient to seek follow-up with a primary care doctor for definitive diagnosis and long term treatments?
Funny. True.
I enjoyed this article very much. So often patients come to us for answers, but often do not accept the answer given because it’s not the one they wanted. Another problem I find, is that patients often have unreal expectations of what can, or will be done for them during their ER visit. They are into this “one-stop” medical treatment–they want to take care of all their medical problems in one ER visit. In addition, they think they can get any test done/procedure done that they want during that visit (like ordering at McDonands). When we tell them a test is not indicated, or a certain procedure will not be done on an emergency basis–Wrong Answer! Anyway, I thought this article was well written, and adequately portrayed just a few of the frustrations we as Emergency Physicians face everyday.