It is not a DumDum

Today was great day in the ER (sarcasm).  I was working triage and we had over 90 patients sign in over a 9 hour period.  Working triage means that I try to get labs and x-rays going on the more complex cases and discharge the easy cases.  All the easiest cases fell into 2 categories: sick for 2 hours or sick for at least 2 months — except for one case.  I called a 42-year-old gentleman back from the waiting room.  He took a seat on my triage bed.  As usual, I asked “what brings you in to see us today?”  “I don’t feel good.”  I then questioned with “Oh, for how long and tell me the story.”  He goes on to tell me how he has had cold like symptoms for 3 weeks now and it is not getting any better.  He has not tried anything or sought medical care before now.  The reason he was coming in to the ER today was that he finally  got the day off and did not have anything else to do (this is the normal reason people come in at this ER).  So I start my exam.  I listen to his heart and lungs.  Then I look in his ears with an otoscope.  Everything is looking normal – surprise, surprise.  I then ask the patient to open his mouth so I can use the otoscope to look at his throat.  I position the otoscope, like normal, about 8 inches away from his mouth when I asked him to open up.  He proceeds to open his mouth and lean forward placing the entire head of the otoscope INSIDE his mouth and close his lips around it.  It looked like he had an extra-large dumdum sucker in his mouth.  After I pulled the otoscope out of his mouth, I just sat there looking at the otoscope wondering what I was going to do it.  At the same time, I was trying to think how many people’s ears it had been in and how many more people it will come in contact with.  I had never seen an otoscope used like a lollipop.  I included pictures below to see if you  can see any similarities that would make you want to stick an otoscope in your mouth.

 

 

I’m only a little pregnant

Patient presented to the ER today stating that the OB clinic told her 4 weeks ago that she was 6 weeks pregnant. They based this off of her last "period". Today she states that it feels like she is having contractions. I called labor and delivery and told them that she looks like is about term not newly pregnant and she is having contractions. The midwife says, "there is no way those are contractions. She is only 6 weeks along. Just send her home." Well, I did not do that. Instead I ordered an ultrasound. The results were a breech 39 1/2 week baby that looks like it is about to deliver. I called labor and delivery back and they took the patient to emergent c-section due to the baby being breech. The moral of story is: not everyone knows what a "normal period" is.

When doctors disagree

A recent study ( http://www.ncbi.nlm.nih.gov/pubmed/22849819) talked about when disagreements between the ER diagnosis and the inpatient diagnosis. It goes on to say how the ER over-diagnosed pneumonia and urinary infections in older patients. All I have to say is, "You bet I over diagnosis." The ER is like a fish bowl. It is a clear glass bowl that every one can look into and criticize what you are doing but they never come in to try it themselves. This criticism usually comes after all the crap has been clean off the fan. I feel (and know because I do it) that a lot of these over-diagnosis come from just trying to get the patient care. If I call a hospitalist with an admission, they ask "what is the diagnosis?" Many times I want to tell them – "I do not have a firm diagnosis but they just do not look good." The hospitalist would laugh and tell me to call them back when I have a real diagnosis. So what do I do to avoid this, I over-diagnosis. In the ER, we call it throwing out a big net. We go and see patient. We come out of the room thinking the patient needs to be admitted but I cannot quite put my finger on why. We then throw out a big net ordering a lot of tests hoping that something comes back positive so we have a "reason" to admit the patient. The easiest are pneumonia and urinary infections. Almost all old people have a dirty urine or something on their chest xray that I can construe to be a pneumonia. Once I have one of these, I have an admission. Is this the best practice?? No. But it is what we have to do in this environment. I have to find something to get the patient admitted. There is no more admitting the patient just to watch them. The hospital and doctors will not get paid without a firm diagnosis. Also, I do not get penalized for over-diagnosing. I get penalized for missing that 1 in a million case. Old people like to hid bad disease with only small complaints. They also like to die quickly if they are missed. We find a diagnosis, give them antibiotics, and admit them. As long as the pay structure is how it is and malpractice is how it is, there will always be ER over-diagnosis. And once the ER has stabilized the train wreck patient, the rest of medicine will always critique a day later why I did not do this or that.

That’s not swelling

350lb 5 ft Patient comes into the the ER with the complaint of "my legs are swollen".

I talked with the patient for a long time and finally asked "how long have your legs been swollen?"

Patient responded with "they have always been swollen."

I am sorry but that is not swelling. Your legs are just fat.