Who Am I Treating?

Occasionally, as difficult as some patients may be to treat in the ER, for whatever reasons, that difficulty may be nothing compared to the stress and negativity brought to the encounter by their accompanying family members or friends. People who "know the patient more than they know themselves" and don't hesitate to try to dictate the course of therapy for the patient.

Don't get me wrong, I appreciate a family's or friend's input greatly. In fact, I welcome it. Sometimes, even, they can be a greater source of the patient's history than the patient himself.

But...sometimes the support person can be totally and completely obnoxious and abrupt in how they choose to communicate with our staff. "Demanding" is a word I hear often. They just know that the patient needs two pillows. Three warm blankets. A new pair of footies. A turkey sandwich. Some ginger ale, not orange juice. The patient likes to lay on their left side, not their right. They need this and this and this test, but not that one. Oh, and by the way, where do they go to get their parking ticket reimbursed for free parking?

I recognize that sometimes this is simply a vain attempt by the visitor to have some sort of control over an uncontrollable situation, sure. A spouse trying to make her sick husband comfortable. A parent trying to ease their child's pain. A best friend trying to step-up to ensure proper treatment. I fully understand all the reasoning behind these situations. More importantly, though, I respect and applaud their advocacy.

Unfortunately, though, sometimes a visitor's intentions can be detrimental to the patient, if the patient is an adult, is coherent, and can easily verbalize their problems and symptoms by themselves.

I was sitting in my hallway seat, several months ago, when I observed the triage nurse escort two women to Room 27. One woman appeared to be in her sixties, the other in her thirties. The older woman appeared irritated, grumpy almost, while the younger woman was smiling and walking alongside the older woman. Neither appeared in any distress.

Within minutes, the patient's name appeared on our computerized list of waiting patients, so I clicked on it. Surprisingly, it was the younger woman who had checked in as the patient.

I walked into the room to find the younger woman sitting comfortably in the treatment cot, a gown draping her thin frame, a smile still on her face. The older woman, who by now I assumed was the patient's mother, sat in a chair under the corner TV. She was still scowling.

I approached the patient first, my hand extended. "Hello, Ms. Brown, I'm Dr. Jim. Nice to meet you, maam." She extended her hand and we shook. "Hello," she returned, meekly. From the corner of the room I heard the other woman speak. "And I'm her mother." I left the patient's side and walked up to the mother, my hand still extended. The mother eyed my hand for several long uncomfortable seconds before finally extending her own. "Nice to meet you, maam," I added after our handshake.

I went back to the patient's bedside. "Ms. Brown," I started, "what can we do to help you today in the emergency room?"

And before Ms. Brown could even begin to answer, her mother started in. "Kathy has a seizure problem and we are due for our yearly neurology appointment and thought we would come here to get everything done."

"In the ER?" I asked. "Yes," said the mother, continuing. "She needs an EEG, an MRI, and you may as well just call the neurologist down to see Kathy as long as we are here. That way, we won't have to waste a day going to their office."

I turned back to Kathy. "Kathy," I said, "how long have you had a seizure disorder?" From the corner of the room, I heard her mother answer. "Since she was seven." I continued focusing my full attention on Kathy. "And Kathy," I said, "have you been having an increase in seizure activity?" Kathy nodded her her head "no" while, again, from the corner of the room, her mother piped-in. "No, it's just time for her annual check-up." Again, I kept my focus on the patient. "Kathy, has there been any changes recently to your anti-seizure medications?" Again, as Kathy nodded "no," I heard the familiar, interrupting voice. "Eight months ago, the doctors increased her dilantin, but otherwise she has been on the same medicines as always."

I had finally had enough. "Kathy," I asked, holding my index finger up to the mother, requesting her to wait, "are you okay to answer my questions? Or is there a reason your mother keeps answering for you?" Kathy looked at her mother to me. "No," she said, "I guess my mother just always likes to be in charge." From the corner of the room, the mother yelled out, "I do not, Kathy."

I looked at the mother and cocked my eyebrow. "What?" she asked, "I haven't been answering all of your questions." "Yes, maam," I assured her, "you have." Her scowl deepened. "I appreciate you trying to help, maam," I said, continuing, "but this is what we are going to do. I am going to ask Kathy all of my questions and then, when I finish, I will give you a chance to add whatever you want, okay?" She dismissed me with a roll of her eyes and a shrug of her shoulders.

So, I had two problems on my hand. A mother who wanted to interrupt my history-taking with every question addressed to her daughter. And, a mother who wanted an extensive work-up and consult that, unfortunately, wasn't going to happen the way she had hoped for her daughter.

Well, I guess it was just one problem, really. A vocal, demanding mother.

After I finished my interview with Kathy, who did a fine job of telling me about her history, I looked toward her mother. "Do you have anything you'd like to add, maam?" She just "humphed" at me and remained quiet. I proceeded with a physical exam that was completely unremarkable.

The triage team had ordered some baseline blood work and some medication levels on Kathy and, after those results were posted, I went in to speak to the women.

"Well," I said, "I have good news. All of your blood work has returned satisfactory. Including your anti-seizure medication levels."

Kathy gave me a grateful smile as her mother spoke up. "But what about her EEG and MRI and neurology consult? Aren't you going to get those done now?" I explained to the mother that those tests, as well as Kathy's neurology appointment, had already been scheduled and that I wouldn't be able to provide those tests through the ER. Not without an emergency concern. And, trust me, there was no emergency concern.

"But," the mother said again, speaking up, "Kathy hasn't been feeling well recently. I want all of those tests done now. We'll wait for the appointment, if that helps."

I assured the mother, again, that Kathy had a great exam, great blood work results, and would need to move forward as planned by her neurology team. In all honesty, I told her, I wouldn't even be able to get this requested workup for one of my family members, unless it was a new-onset seizure or the patient was in status (a seizure that won't stop).

"Kathy," I asked the patient, "are you okay with everything?" "Of course," she answered, sincerely, "I didn't want to come today. Mom thought we could get everything done early so we wouldn't have to waste a couple days next week."

Out of courtesy, I did call the resident on the neurology team to make them aware of this patient's treatment in the ER. They whole-heartedly agreed with our ER approach, reiterating that this patient would need to keep her outpatient appointments.

I discharged this patient to home, knowing that there was no way I was going to make this mother happy. As they walked out of Kathy's treatment room and down the hallway, I noticed that Kathy still was smiling, while her mother maintained the scowl that prevailed during her time with us.

I had to wonder to myself how Kathy maintained such a happy state. I hope her smile was genuine.

The best I could hope for, I guess, was that Kathy, and not her mother, would get the hospital questionnaire. And that she would get some good results from her non-emergent, outpatient-testing, too.

If only we could just make everyone happy...

As always, big thanks for reading. I hope you all had a great weekend. Although I'm traveling for work the next few days, the next post should be on Wednesday, June 16. See you then...anyone with similar stories to share?

I'm Going To Die!

Occasionally, a patient will come into the ER with a profound sense of foreseeing their immediate death. A foreboding that, despite their complaints and physical findings not matching up, death might be knocking on their door.

I'm not talking about how some people think they may die young. Or that they may die a tragic or traumatic untimely death. Haven't we all had that thought at one time or another? Rather, I'm talking about that patient who is lying in their cot, looking somewhat stable, piercing into your eyes with their frantic own. "Please don't let me die," they say, before you can even begin to sort out their history and perform a physical exam.

This kind of talk and behavior, as you can imagine, may be quite unsettling, both for the patient and the providing medical team. In most circumstances, that dramatic foreshadowing deserves some attention.

Recently, an elderly male had been rushed to our emergency department from the radiology department, where he had been undergoing an outpatient, IV contrast-enhanced MRI. After the MRI nurse had pushed his contrast into his IV catheter, the patient began flailing and screaming.

"I can't breathe!" Help me!" "I'm going to die!"

The MRI nurses looked for a rash. They found none. They listened to his heart and lungs. They sounded good. They reviewed his extensive MRI checklist but found no documented allergies of suspicion.

"I'm going to die!" the patient yelled again. His frantic nature became contagious and, within a few minutes, the patient was being wheeled into our department. Room 21.

I remember hearing the concerning page overhead. "We need a doctor in Room 21, stat." As luck would have it, I was just walking out of Room 22, the next-door room, after explaining some results to that patient. I hurried into Room 21 before the page was even finished.

Entering, I found an elderly male, 75 maybe, in a loosely-tied hospital gown, sitting upright in his cot. "Are you the doctor?" he asked, focusing his worrisome eyes on me. As I nodded yes, I glanced up at his cardiac monitor, which was showing a stable cardiac rhythm, good oxygenation on room air, and a slightly elevated respiratory rate. As I was looking, an automatic blood pressure reading had cycled and that, too, was normal.

"Help me, doctor," he exclaimed, his eyes remaining fixed on mine, his voice cracking, "I'm going to die!" To add a dramatic flair, one of the overhead fluorescent bulbs began flickering its last hurrah, casting intermittent shadows on the patient's face. An interrogation room atmosphere.

I quickly introduced myself, shaking this patient's hand, as I listened to a brief overview given by one of the two nurses. As she finished, I still hadn't heard what I wanted to hear--a solid reason for this patient's words and behavior.

It was time to interrogate. "Sir," I said, "has anything like this ever happened to you before?" No, he replied. "Are you having chest pain or calf pain with this shortness of breath?" No. "Have you had any recent cough or cold symptoms?" Again, no. "Any trauma or falls?" Nope. "Have you ever had any allergic reactions that may have caused a similar reaction?" You guessed it, no.

I was told this patient's brother, whom he lived with, was going to be escorted to Room 21 shortly. I looked forward to talking to him. In the meantime, I did a thorough exam on this patient and found nothing remotely concerning. He had no rash. He had no wheezing or stridor. He had normal heart sounds.

"Sir," I asked him point-blank, "do you have a history of anxiety or nervousness?" He shook his head "no." "On any new medicines?" Another nod "no."

Even though we approached this patient as a possible allergic or anxiety reaction, based solely on his MRI-department history, he still warranted a thorough work-up, because of his age and several cardiac risk factors.

We ordered a stat EKG, a portable chest x-ray, blood work, including some screening cardiac enzymes that would elevate if there were any concurring ischemia to the heart, and a d-dimer, a blood marker that, if positive, raises one's suspicion for a blood clot.

The patient's brother still hadn't arrived by the time I reviewed the patient's EKG and chest x-ray, both normal. I had someone go look for him as I reviewed the patient's blood work results, hot off the presses. Surprisingly, normal.

I was in Room 21, explaining all the good results to the patient, when a smiling, elderly man was escorted into the room by one of our techs. If you took away the patient's nervousness and sense of dread, this arriving man would have been what I imagine this patient to look like. Obviously, it was the patient's brother.

Being told that his brother had finished in MRI, this man had gone to the cafeteria to grab a bite while waiting for an official discharge. The brother had not been told of the situation in the MRI suite.

"So Frank," the brother spoke, shaking his disapproving head, exasperated, "you did it again, huh?"

"Did what?" Frank asked, now glancing sideways out of his eyes at me.

"Have another nervous attack," the brother said. "I told you to make sure you told everybody you have anxiety and are on medication for it. You didn't, did you?"

I looked incredulously at Frank, who now fully avoided eye-contact with me. I looked at the brother. "I point-blank asked your brother if he had anxiety or nervousness and he told me 'no.'"

"Of course," the brother said, "he always denies it. But he has about five or so attacks a day. He seems to be more and more preoccupied with dying these days. " He looked at his brother, the patient, before turning back to me and continuing. "Did he tell you he was going to die?"

I shook my head "yes." The nurse shook her head "yes." Frank, even, shook his head "yes." "Well," Frank's brother continued, "I hear that about five times in a day. Frank gets all worked-up, insisting that I will be living alone by the end of the day." The brother hesitated, as if he was going to add a quirky little comment to that last statement, but bit his tongue.

"How does Frank look to you now?" I asked the brother.

"Like he always does," the brother replied. That reply was music to my ears. Frank looked at his brother, piercing eyes and all, and spoke quite dramatically. "That's enough, Elmer."

Elmer wasn't intimidated. "You're right, this is enough." I stepped out of the room only after refereeing the minor argument that ensued. And ordering some Vitamin "V" for Frank.

It turns out that Frank had held his morning medications, including his valium and anti-depressant, in preparation of his MRI. Unfortunate, since some people without anxiety still require an anxiolytic to get through MRI testing. After a social service consult, I called Frank's family doctor with a report of what happened and, more importantly, to get a follow-up appointment for the next day.

The family doctor was surprised that, somehow, Frank's medications and history of anxiety were not conveyed to the MRI staff, which could have preempted an ER visit. It made me think, though, that if you point a finger, four are still pointing back at you. The family doctor had ordered the test and knew this patient better than anyone else. I would have assumed he would have alerted the MRI team to Frank's recent bouts of anxiety.

"May I ask," I questioned, still a little perplexed, "what was the reason for Frank's MRI?"

"Oh, sure," his doctor replied, "it was a brain MRI to rule out any recent or remote stroke activity. He's been getting real forgetful lately."

So, as it turns out, the forgetful patient forgot to share his anxiety issues.

I walked back into Frank's room to explain his follow-up plan, only to find Frank and Elmer both calmed down, watching a baseball game on TV. "So I'm not going to die, Doctor Jim?" Frank asked one last time.

I shook my head no. "Sorry, Frank, not today you aren't."

Not on my shift, anyway...

As always, big thanks for reading...I hope everyone had a great weekend. Next post will be Wednesday, May 12. See you then...