Friday, 31 January 2014

Cover your ass

As long as you aren't illiterate or didn't skip the title because you were trying to scroll to the disgusting picture at the end (there isn't one this time...sorry for the disappointment), then you've no doubt noticed that the title of this post is "Cover your ass".  For you with your minds in the gutter, I'm not referring to women blocking the view to their posteriors while lecherous men leer at them from behind.  No, I'm referring to the common medical practice of doing unnecessary tests for the sheer purpose of "just in case".  In case you A) have never had any experience with the healthcare system, B) just woke up from 50 years of cryogenic sleep, or C) are an alien who just landed on Earth, I'll explain what I mean:
  • A patient with multiple broken ribs getting an unnecessary full cardiac workup "just in case" his chest pain is actually from a heart attack, not his multiple broken ribs
  • A patient with a simple chest cold getting an unnecessary CT scan of the chest "just in case" it's actually a pulmonary embolus
  • A child with a simple cold getting a prescription for antibiotics from the pediatrician "just in case" the parent complains about not getting antibiotics, even though antibiotics are worthless against the cold virus
  • An ER doc calling for a ridiculous unnecessary surgical consultation for some bullshit reason just in case the doctor is brain dead and has no fucking clue how to actually work up a patient and make a diagnosis
It's that last bullet point that drives me completely batshit crazy (for obvious reasons), and I wish I were exaggerating.  In my experience, emergency physicians are notorious for calling anyone and everyone for anything and everything.  Some of them have even admitted to me that they "sell" patients to specialists so they will be admitted and out of their department sooner.  Recently it nearly drove me to throw one of them off the roof.

Dr. Halfwit (not her real name) called me to let me know she was seeing a female patient who had pain in the right lower portion of her abdomen, and she was concerned about appendicitis.  It sounded reasonable enough, so I told her to get a CT scan to rule out GPP - Girl Part Problems (that's the technical term), which can often masquerade as appendicitis - and call me with the results.  A few hours later I just happened to be in the CT scanner room as her scan was being performed, and it took me all of 1.38 seconds to see her huge ovarian cyst on her right side - clearly the source of her pain - and her perfectly normal appendix.  I told Dr. Halfwit what the CT showed and to call the gynaecologist for an evaluation, and I logically thought that would be the end.

HAHAHA, logic.  Right.  Emergency physicians seem to use logic like accountants use Erlenmeyer flasks or like lawyers use morals - not at all.

A few hours later (now around 2 AM), another ER doc (this one has perhaps 10% of a usable brain) who had taken over for Dr. Halfwit called me about the same patient whom she had not discharged and had now been in the department for over seven hours.  The gynaecologist had seen the patient, correctly diagnosed her with a large ovarian cyst (hmm, where have we heard that before?), and had cleared her to be discharged home to follow up with her own gynaecologist as an outpatient.  We have a diagnosis and a plan...so why the hell was Dr. Brainless (perhaps his real name) calling me?  Just to verify the accuracy of his name?  Maybe, though I'm not sure he even had the brain power to comprehend that he has no brain.  Or something like that.

Anyway, Dr. Brainless explained to me that he wanted me to confirm that the gynaecologist's plan was ok.  I paused as I waited for the punch line, because NOBODY can be that stupid.  Right?

When the punch line didn't come, I realised he was serious.  "Wait a second," I said.  "You actually want me, a surgeon, to tell you if a gynaecologist's plan for a patient with an isolated gynaecological problem and no surgical problem whatsoever is ok?"

"Yes", he said, "I'm just covering my ass."  He stared at me in anticipation, waiting for some sage wisdom.  I stared back at him, dumbfounded, astonished, flabbergasted, and several other synonyms.

With a mighty effort, he mustered enough brain power to explain that he didn't feel that 1) an ultrasound showing an ovarian cyst, 2) a CT scan confirming an ovarian cyst and a normal appendix, 3) a physical examination entirely consistent with an ovarian cyst and entirely inconsistent with appendicitis, and 4) a gynaecologist confirming an ovarian cyst were enough to actually diagnose a simple ovarian cyst.  No, Dr. Brainless needed a surgeon to help him with GPP.  I told him to his face that he should be embarrassed that he can't rule out appendicitis and diagnose an ovarian cyst himself, let alone with multiple doctors and studies doing the work for him.

After I thoroughly lambasted him for his complete ineptitude, he made it very clear that he refused to discharge the patient until I examined her.  I stared back at his dull, empty eyes, turned on my heel, marched into her room, performed my examination (which was shockingly consistent with an ovarian cyst), and reported back to Dr. Brainless that she did, in fact, have an ovarian cyst and that she could, in fact, go home.  Then without another word I left, confident in my own diagnostic skills but entirely doubtful of Dr. Brainless'.

If you aren't sure of a diagnosis, please call me for help.  But if you have 21st century technology available that can make the diagnosis for you, USE IT.  I understand that not every doctor can be a rocket scientist or a brain surgeon (so to speak), but I at least expect them to be smarter than a newt. 

20 comments:

  1. Oh my God. The amount of stupid...

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  2. How dare you doc. How dare you say that man has the brain power of a newt. How dare you insult newts in such a manner. EVEN NEWTS ARENT THAT STUPID!

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  3. It's interesting how you always seem to have these negative experiences with ER docs. Every single doctor at that hospital has graduated from medical school, and as a premed undergrad, I can certainly tell you that's no easy accomplishment. I volunteer at an emergency room, and I would say the ratio of stupid ER docs to stupid trauma surgeons is about equal--you just only interact with the stupid ones, because the smart ones stay off your radar.

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    1. Even the dumbest graduate of medical school is called "doctor". And having actually been to medical school (which you have not), I can definitively tell you that NOT everyone there is a genius.

      Having said that (and trying not to be too condescending), including medical school and training I've worked with over 100 ER docs in at least a dozen ERs, which I highly suspect is a larger sample size than yours. But the reason you don't hear about my good interactions with ER docs (and there have been many) is not because they stay off my radar, but rather because I don't write about them.

      After all, who wants to read a story about someone diagnosing someone correctly and making an appropriate consultation? BORING!

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    2. Yeah, Kitri the theme of the blog isn't feel good, awe inspiring stories. The title is DocBastard..... I don't think you caught the point that the posts would be about the ridiculous stuff that goes on in his life as a doctor.

      Doc, this story brought back ER memories of my suspected case of appendicitis. Mine too turned out to be GPP. I had NO idea until then GPP could soooo easily mimic symptoms of appendix problems. Thank goodness we have modern technology to be able to look at these body parts...I wonder how many appendix were removed before we could look at girl parts to rule out?

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    3. Eh, I guess I've just experienced too many asshole surgeons in the ER. I do fully understand the point of "DocBastard" being the title, but I have my own experiences from a very different point of view.

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  4. Here's how you should have illustrated this article:

    http://cblearninglog.wordpress.com/category/exercises-for-taop/taop-part-2-elements-of-design/exercise-2-the-relationship-between-points/

    (Look at the third picture)

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    1. You're right! I should have found a picture of an ass wearing a coat. My mistake. :)

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  5. To be fair, I've had the opposite problem, and it's worse - try having a very arrogant Fellow (who claims he's talked to his attending) decannulate your 3 year old special-needs daughter, despite audible snoring and gasping during overnight capping trials. Then take that child home, and have her stop breathing overnight. Needless to say, he hadn't actually spoken with his attending.

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    1. Without question, acting without thinking is far worse than overthinking. I sincerely hope your daughter managed to make it through that ordeal.

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  6. The Cover-My-Ass antibiotics piss me off. I was given a run of them for what turned out to be a viral infection. It didn't help, so I went back to my doctor, who responded by giving my a run of STRONGER antibiotics. Which didn't clear it up, but did provide a great habitat for C. Diff to set up. Thank gods I was young and healthy, I was only hospitalized for 10 days and didn't have any complications.

    Also, I had GGP masquerading as appendicitis. They didn't discover it until they took out my (fine, normal) appendix and located the endometriosis underneath it.

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  7. Not sure it's the stupid so much as what your title says - CYA. Doctors afraid of getting sued. Fear turns off common sense.

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  8. Poor patient, also. Made to wait much longer in ER than necessary. And those left waiting for attention. It's a domino effect when one doesn't properly do their job.

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  9. Having been an RN in my younger days, I confess that nurses use this term as well (abbreviate "CYA"). However, we use it in an adversarial manner, covering our (nurses') ass over screw-up physicians. Not saying that I am smarter than you (far from it), but there are some doctors in certain situations who are, frankly, questionable.

    I'll give two examples.

    While I was a student RN doing clinicals, there was a general surgeon who enjoyed a higher-than-normal post-op complication/infection rate. The RNs knew why: Dr. I-Don't-Wash-My-Hands simply let his aseptic technique go when examining post-op incisions. RNs carefully described how they may have had to reinforce a dressing, and they'd follow the doctor into the room and observe his lack of hand washing and using aseptic technique. Dr. Dirty Hands was especially fond of blaming student nurses for his high infection rate—only problem being, student RNs were never assigned his patients for that very reason!

    A second example was a family practice doctor who "misread" fetal monitoring strips in the name of ordering "emergency" C-sections on Saturdays and Sundays (I was, by this point, a licensed RN working at a small community hospital). Why would he do that? Two reasons: he didn't want to wait around for a vaginal delivery, and he could bill more for being the surgeon of said emergency C-section, especially with welfare/MediCal patients. I got to the point that I charted every 10-15 minutes, describing the fetal heart rate responses in relation to uterine contractions, and in the case of variable decelerations, initiating a maternal position change and response to the "treatment." This doctor would read a healthy variable deceleration as a "late deceleration" and decide to take the woman to the surgery suite on an "emergency" basis.

    Never did my notes match what that doctor had written. Why did I feel the need to be so adversarial? I'd taken the initiative to attend annual L&D nursing conferences, attended advanced fetal monitoring classes and was good enough at what I did to help train new grad RNs to understand fetal monitoring. I just could not be complicit in this doctor's milking the system in order to bill more...

    I think you and I would have gotten on famously, though. We both abhor a lack of critical thinking skills, as well as dishonesty and laziness.

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  10. Great story as ever Doc'. It's a sad fact of the modern world, however - fewer and fewer people are prepared to take any responsibility for anything. I have this all the time with foreign lawyers that I work with - the US are the worst.

    Just one point: My wife is a chartered accountant and also a PhD chemist!

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  11. I have been lucky to have gotten a rockstar ER doctor. Very precise exam, one confirming test and voila. Probably saved my life as it was not a common problem. He had one of the new titles, he was sort of head over all the ER doctors.

    I have had long ago the experience of a doctor who ordered every test in the book. The folks administering the tests actually joked about I must be one of so and so's patients. It did feel like she relied too much on tests and not her own ability. I moved on quickly. I sometimes feel insurance companies give incentives to doctors to do this and make more money for them.

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  12. There was only one time in my life that I did not mind waiting 3 hours in the ER. My daughter woke up one day with reddish-purple bruises and broken blood vessels all over her buttocks and legs. She could barely walk. I took her to the local ER and a physician's assistant examined her, had blood work and urinalysis done, but the look on his face, screamed something "is bad". He had me convinced by his look she had leukemia or something like that. After blood work came back (he did not tell me anything) he had the ER doctor look at her. He smiled and said I know what it is..He diagnosed her with HSP.Henoch-Schonlein Purpura. He reassured me that it was not deadly and that she would be fine. He also told me that this was only the second time in his career he had seen it. We went home with no rx's and to give her ibuprofen for the joint pain. I am glad for the second MD being there and diagnosing it promptly. I told the PA that he scared the hell out of me and to be a little less dramatic if he ever sees this again.

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  13. Why do RNs and doctors let these moronic doctors get away with this? If a doctor can't diagnose an ovarian cyst on his own (assuming he has had the training to do so), he should be removed for incompentence. If a doctor is ordering C-sections because it's quicker and more lucrative, he should lose his license and be sued. How can the colleagues of these people just stand around and let this happen? If I was a victim of this I'd hold these people complicit in this reprehensible behavior, along with the primary culprits. Patients deserve to be protected, right?

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  14. from which medical faculty did that dr graduated from?

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