Thursday, 22 May 2014

The Stupids

I've been asked several times what I think is the hardest thing in medicine to treat.  Cancer can be quite challenging, as it often involves multi-modal treatment via several different specialists, and every cancer is just a little bit different.  Brain injuries can also be a test of one's abilities, as everyone's brain seems to react differently to similar injuries - one person with a subdural haematoma may be awake and talking to me while another with the same injury may be completely comatose.  Pain disorders such as fibromyalgia and chronic pain syndrome are just as difficult to diagnose as they are to treat.

But none of these things is the most problematic medical conundrum we see.  Nay dear friends, the title of this post should have tipped you off: The Stupids is far and away the most onerous disorder on the planet.  Unlike many medical disorders, The Stupids is very easy to diagnose.  Unfortunately, as easy as it is to spot, it is equally as impossible to cure.

Allow me to introduce you to 65-year old William (not his real name), if you please.  Before you start getting aggravated at William, he did nothing wrong, save standing on a relatively short wall, losing his footing, falling off said wall, and landing on a tree stump.  As he fell he realised he would hit the ground hard, so instead of falling onto his back, he twisted around to try to fall on his front.  Well William isn't quite as limber as he used to be, so things didn't exactly work exactly as he planned.  Instead, he landed on a tree stump next to the wall.  Fortunately for William, his ribs broke his fall.

Ok, as I read that back I have to admit that was perhaps a pretty stupid thing to do, especially at his age.

William was brought to the famed "Outside Hospital" (also known as "any hospital other than where I work") where he was diagnosed with 4 broken ribs and a very tiny pneumothorax (his right lung had collapsed about 2%).  He spent the next 3 days in hospital, requiring no treatment for his rib fractures or pneumothorax (other than pain medicine) before going home.  And that's when I met him.

"Wait just one damned second, Doc!  You just said he went to an outside hospital and went home after three days!  Where the hell do you come into the picture?"

Dammit, haven't I told you to stop interrupting me!  You're messing up the story just when it was about to get good!

As I was saying, the night he got home William went to sleep, but he was awakened around midnight by a sudden shooting pain in his right chest.  Keep in mind here that he had just broken several ribs a few days prior, and that rib fractures hurt like hell for several weeks.  So the logical thing for William to do would be take a pain pill and wait, right?

No, William's wife called for an ambulance.

Ok, sounds reasonable enough.  So once the medics arrived the the logical thing for them to do now (after examining him and finding his vital signs perfectly stable, of course) would be to give him his pain pills and wait, right? 

No.  They decided to drive him to the hospital.

Ok . . . so NOW the logical thing to do would be to take him back to Outside Hospital where he had just been discharged and which was a few minutes from his house, right?  Right??

I think you see where this is going.  NO.  They decided to drive nearly 75km (over 45 miles) to my hospital for a trauma evaluation.

If you're banging your head against your desk (or facepalming if you're reading this on a smartphone, which everyone seems to be doing these days), then you are experiencing the exact same reaction I had.  I incredulously asked the ambulance crew why they had driven over an hour out of their way when William had just been discharged from his local hospital earlier that day.  Their rationale was that he had a traumatic mechanism, so he needed to go to a trauma hospital.  I tried explaining to them, slowly and using small words, that his trauma had been 3 days prior, he had no new trauma, his vital signs were perfectly stable, and his lung exam (which took me approximately 12 seconds to perform) was also perfectly normal.  All I got back was a vacant stare which told me that none of this was actually getting from his ears to his brain, which I'm not entirely certain was even there in the first place.  I do wonder how some of these people manage to remember to breathe.

Just in case someone wasn't telling me the entire story, I went through William's initial CT scan from Outside Hospital (which he was kind enough to bring with him) and then rescanned his chest.  All I found was that his tiny pneumothorax had already completely healed, he had no new injuries, and he in fact had five rib fractures initially, not four (nicely done, Outside Hospital).  The ambulance had driven him all the way across town because of a simple muscle spasm.

One of these days I'm going to give myself a subdural haematoma from hitting my head on a desk.  I really try not to do it, but it somehow makes me feel better when I encounter something like this.  Hm . . . perhaps that means I have a mild case of The Stupids too.



  1. 0_0 You can take a pain pill or go be tortured in an emergency room... 0_0

  2. In the patients' and ambulance drivers' defense: since Outside Hospital seems to employ doctors that can't even properly count to five (seriously, what the hell, OH?), I understand why they would get out of their way for a second opinion from you.

  3. Actually there are 4 stupids in your tale: William, his wife, and the two medics.

    What amazes me is that he got three days in the hospital for this. Three days to lie around and get pain medicine? Heck, people getting hip or knee replacements (here in the U.S.) are lucky if they get two days...

  4. Although I do enjoy reading your tales of woe and frustration, I thought this one was more than a bit condescending. I work in the ER of one of the largest trauma hospitals in my province, and we routinely have doctors, including trauma surgeons, arrogantly and apathetically misdiagnose and discharge patients, only to have them come back needing further medical intervention or not come back at all... If you know what I mean. The medics were probably trying to cover their asses, as well as get a second opinion perhaps due to thought of human error. Which, there was. 5 broken ribs instead of 4. Medics are our unsung heroes and could use more respect from everyone in the medical community.

    1. I would agree with you, except for a few key points:
      1) The treatment for 5 broken ribs is exactly the same as that for 4.
      2) The medics could have brought this man back to the hospital from which he had JUST been discharged a few hours before, and which was FAR closer than mine.
      3) If your ER docs and trauma surgeons are misdiagnosing that often, you've got far bigger problems than I do.

  5. So the ambulance drivers make the decision what hospital a pt goes to? I always thought they communicate with an MD. Maybe that's from watching Emergency! on Netflix where they do that.


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