Tuesday, 8 December 2015

The Hospital

The hospital is not a safe place to be.  That may sound counterintuitive to some, but those of you in the medical field know exactly what I mean.  Whenever I have a patient who is hesitant to leave even though they meet discharge criteria, I always tell them the same thing: the hospital is not where they want to be.  

"Remember, this place is a big building filled with lots of sick, infected people.  If you are not one of them, you should not be here."

That usually gets the message through. 

Having said that, not every patient even needs to be admitted in the first place.  Far from it.  In fact, most patients who are seen as emergencies and/or traumas do not needed admission, and I make every effort to prevent people who don't need to be here from being here a second longer than they have to be. 

Margaret demonstrated this point quite elegantly recently.

Transfers from outside hospital always must be taken with a grain of salt.  A very large grain of salt, approximately the size of the iceberg that sank the Titanic.  Whenever I get a call for a consultation from Outside Hospital, the rationale is always the same: they want the patient out of their hospital and in mine.  Perhaps we offer services or specialists they don't, perhaps their hospital is full, perhaps the emergency physician has a brain the size of a newt's and can't make a damned decision.  Regardless, they usually say anything they can to make that transfer happen, even when that transfer isn't at all necessary.  The emergency physician at Outside Hospital (not its real name) called me about Margaret, an elderly woman in her 70s who had fallen.

Her: Hi, Doc.  So I have this very nice 70ish year-old woman who fell and has multiple left-sided rib fractures on CT. 
Me (impressed and surprised it isn't total bullshit): Oh? That sounds bad. Tell me a little bit more about her.
Her: Well, she is 75.
Me: ...Yeah, you said that.  And?
Her: Uh, well she has a history of COPD.  She's been having increasing difficulty with pain control and has been having problems breathing since the fall because of pain.

It sounded like a reasonable request for a transfer, but something about the tone of her voice made me suspicious.

Me (suspicious): Any other pertinent history?
Her: Just hypertension, which is well-controlled.  Her vital signs are all normal and her oxygen saturation is 95% on room air {which is normal, especially for someone with COPD}
Me (more suspicious): Any other injuries?
Her: No. The CT scan shows no pneumothorax or hemothorax.
Me: (even more suspicious): Wait, when did you say her fall was?
Her: (pause)… Six days ago.
Me: …
Her: Hello?

Yes, Margaret had fallen nearly a week ago but had not sought medical care.  She had been treating her pain at home with ibuprofen and aspirin, which was (obviously) not sufficient.  Ordinarily a patient like this with isolated rib fractures would be admitted to the hospital for pain control with narcotics only for a day or two.  Once the pain is controlled, I would have sent her home with oral narcotics to allow the ribs to heal themselves, which takes 6-8 weeks.  I explained this carefully (read: slowly and repeatedly) to the emergency physician (who should have known all of this already), but she felt that I should be the one to give her narcotics.

Me: Wait, what have you given her for pain so far?  Morphine?  Hydrocodone?  Oxycodone?  Hydromorphone?  Fentanyl?
Her (whispering): Uh, nothing.
Me: NOTHING??  
Her: ...
Me: Weeeeell, instead of the added expense of transferring her to another hospital, why don't you try, I don't know, giving her some goddamned pain medicine? You can give her the exact same medicine I would give her!

There is a very large possibility that may not be exactly what I said, and there is a slight possibility that I withheld all of the other colourful language that immediately sprang to my brain.  I tried to explain to the emergency "doctor" that all Margaret needed was some pain medicine to get on top of her pain, and then a prescription for something to go home with.  If she could prevent a woman like that with COPD from staying a moment longer in the hospital than necessary, that would be ideal.

She seemed completely shocked by the idea of actually treating a patient.  Nevertheless, she grudgingly agreed to try and only call me back if she were unsuccessful. 

Perhaps surprisingly, I didn't hear back from her.  Margaret got her pain medicine and went home where she belonged.

This is not meant to be a commentary on emergency physicians (ok, maybe a bit), but rather on the importance of using your brain.  Much like a delicious dark chocolate bar (fuck you, white 'chocolate') sitting uneaten on the shelf, an unused brain is worthless.  

57 comments:

  1. to add to the complication, ambulance companies don't want their ambulances returning without a paying fare.

    so anyone who calls for an ambulance, unless they clearly don't need a hospital visit, will be encouraged to come for a ride.

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  2. I have a giant Hershey Kiss the size of my fist still sitting in the shelf of my closet from last Christmas. I keep meaning to eat it. Then I remember I have no self restraint and if open it I'll eat it all in one go. Now I have year old chocolate and I can't rationalize throwing it away OR eating it.

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    1. this is why it is best to get it over with.

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    2. Or you can simply leave it on the front desk where the volunteers sit to answer questions from the families of patients. Let them eat it or chuck it.

      All innocence and light.

      Wednesday

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  3. My grandfather used to say "stay away from the hospital, that's where people go to die"

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  6. Newsflash: I think one of the blog administrator is Mrs. Bastard. I just got that feeling.

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  7. On weekends I have to surrender all electronic equipments. I got you on weekdays. HA!

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  8. Yes, I agree. I started working at my job in a different part of one today and am learning that rather quickly.

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  9. Doc, besides your very sensible observation that *anyone* shouldn't stay in the hospital longer than necessary, there's another important reason that I believe you made the right call for Margaret.

    My own mother, who's a senior citizen and in reasonably good health for her age (she has some medical conditions that are well-controlled with proper diet and medication), always ends up in a generally-weakened physical condition even after a hospitalization of just a week or so, just because of the level of inactivity that comes with spending most of one's time in a hospital bed. She always needs about a week or so of physical therapy afterwards, just to get her back on her feet again so she can resume her normal level of activity at home.

    Getting Margaret back home ASAP, even with a bit of soreness on her left side, was surely better for her overall long-term health than subjecting her to another unnecessary hospitalization.

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    1. This comment has been removed by a blog administrator.

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    2. What do you think that might have been?

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  10. I can't believe some people are so thick. But also, there's a little type. It says 'she when home' instead of went :)

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    1. *typo

      Judge not, that ye be not judged.
      Matthew 7:1

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  11. You could tell them to take a nice cruise. It's a whole lot cheaper than a hospital stay and a lot more fun.

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  12. Sometimes its better for patients to be their own advocates and to learn everything about their medical conditions by researching to avoid injury to them and medical malpractice.

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  13. General Surgeons do not operate on ribs. That would be a job for Thoracic Surgeons.

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    1. Except I'm also a trauma surgeon. And the vast majority of rib fractures don't require any surgery anyway.

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    2. And, if I'm understanding the medical terminology part of the discussion with the ER doc, the CT showed that the rib fractures hadn't done any damage to the lungs or other surrounding tissue. So there was no need to consider surgery to reposition broken bones.

      Since Margaret had suffered the injury six days *before* seeking medical treatment, it's likely that there was already some degree of bone healing that had started. It's understandable that she was feeling some discomfort with normal breathing, coughing, and moving around, since sometimes when we experience an injury, the full extent of general muscle soreness isn't really felt until a few days afterward. Clearly, her breathing, while certainly more uncomfortable than usual, was functioning OK, since she had a normal oxygen level and no other apparent signs of serious complications.

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    3. I'm just wondering. Let's say for flail chest injuries, can a general surgeon or 'trauma surgeon' repair the chest wall by using plates, vertical bridging, wire, sutures, and struts?

      ER Doc

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    4. ER Doc - Yes. I performed just such a procedure a few weeks ago, though it was for a large (~15cm) penetrating thoraco-abdominal wound completely through the chest and abdominal walls into the lung and liver.

      Scarab - Correct.

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    5. Jurassic Surgeons. Cue Stegosaurus with a scalpel.

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  14. I end up on the other side of things. I am an LPN at a long term care and rehab facility. In their desperation to keep beds full with skilled patients they are complaining about us sending people to the hospital who are far to sick for us to care for. And we have so many elderly full code patients! Every code I have had the misfortune to be a part of could have been prevented by sending them to the hospital. Send me Margaret and you can have our elderly little man with new onset confusion, low sats with no pertinent respiratory history, and multiple co-morbidities that we are avoiding sending out.
    Frustrated LPN

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  15. To be fair, one of the points of the article is pure speculation and some would, myself included, argue is absolutely incorrect and really speaks to Doc's bias... Dark chocolate is gross...

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    1. I'm strongly considering banning you for that...

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    2. Most appropriate. Doc B., for three reasons.

      1. You are a doctor. The Hippocratic Oath, which summarizes the ethics of those who choose this healing profession, suggests that the promotion and preservation of good *health* should guide your actions.

      2. This blog is (kind of, sort of, most of the time) a forum for expressing opinions on, and sharing experiences related to, *health* and medicine.

      3. Dark chocolate is *healthier* than white chocolate. (Less sugar, more useful nutrients).

      On the other hand, the holiday season reminds us to practice the spirit of peace on earth, and good will towards humankind. Perhaps, in view of Deus Ex's history of being a dedicated reader and a valuable and respected contributor to our discussions, forgiveness might be considered :)

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    3. Adding...the fact that I'm the one who always picks out the miniature "Hershey's Dark" wrapped candy bars from the holiday mix in the candy bowl has, of course, NO bearing on MY informed opinion.... :)

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    4. I'll think about it. Maybe.

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    5. I would think admitting to stealing all the dark chocolate would not be a good strategy for ensuring ongoing membership.

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    6. It's not stealing when you know they'll be left over anyway because no one else in the family *likes* them, so they will be left behind anyhow.

      The proactive approach actually provides a useful service to others, who then have fewer items to sort through as they seek out their Krackels, Mr. Goodbars, and plain old boring Milk Chocolate favorites. Added benefit is that the disfavored Special Dark minis are spared the rough handling that happens as they are cast aside. :)

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    7. Medical students in the US are not legally required to swear an oath when they graduate. However, about 98% of them do. I don't know about the British medical students. Someone told me only 20% swear an oath.

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    8. Swearing the Hippocratic Oath is purely symbolic no matter where it is done.

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    9. I order the office supplies for our medical device company. This includes the candy for the front desk. I solved the problem of everybody hoarding all the dark chocolate minis by buying the bags that are ALL DARK Hersheys. It works out well.

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    10. @ mutzali - Obviously you are surrounded by an abundance of co-workers with good taste :)

      I am aware of the "all dark chocolate" bags of mini Hersheys, but long ago gave up buying bags of candy to keep at *my* home or office, ever mindful of the "lead me not into temptation" approach to maintaining a healthy lifestyle. Occasionally I indulge by buying just one bar for myself, or graciously accepting a gift of one of the larger bars that can be enjoyed in small pieces. Picking out the minis from the larger assortments is done at the homes of *other* friends and family members :)

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    11. @ Anon and Doc B - I understand that the oath is symbolic, and no longer an "official" requirement for medical accreditation...I just like to *think* that those involved in the healing profession still hold forth its values. Still, I realize that some doctors have a very bizarre idea about the "doing no harm" part...

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    12. @Scarab, That would make you the "algae eater" of the candy bowl then, based on your defense of picking over the chocolates :D

      White chocolate doesn't even have any chocolate in it, don't know why they bother calling it chocolate. Maybe because "almond bark" just isn't as appealing anyway...

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  16. Medical mystery in the ER anyone? Can anyone try to solve this. A true story.

    A 75 y/o male brought in by family to ER because pt. is cyanotic, "he was blue." Pt. alert and awake wearing his pajamas in the ER.

    Physical Exam

    Vitals
    Temp:36.3
    Pulse:80
    RR: 16
    BP: 118/82
    Oxygen Saturation: 97% on RA

    General
    Awake, oriented man lying in bed.

    Eyes
    Conjuctivae and lids normal,PERRL,EOM intact,no AV nicking, hemorrhages, or exudates.

    Respiratory

    BS clear

    Cardiovascular
    Normal

    GI
    Normal

    Lymph Nodes
    Nolymphadenopathy

    Skin
    Cyanotic, no rash, lesions, ulceration.

    Neuro
    Intact

    Pertinent diagnostic test

    Labs Normal
    ABG normal

    CXR Normal

    Question: Why is this patient blue without HPS or any liver problems?


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    1. my three guesses would be that he was in a cold room, that he had been overusing colloidal silver, or that he had been in contact with something that dyed his skin.

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    2. "He had been in contact with something that dyed his skin."

      You are 100% correct. It was his newly bought pajamas (blue in color).

      The family bought them in a swap meet but didn't bother washing them first. Hence, the color transfer triggered by sweat.

      Another medical mystery solved in the ER. They thought he was having a heart attack.

      I have more medical mysteries in the ER. I collect them.

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    3. Similar story with blue hands. Nurse even came to get me to see pt ahead of others as it was "getting worse." Normal exam except blue hands. I wiped his hands with an alcohol prep, and the blue came off. New jeans and sweaty hands. Bought me a little cred with the nurse as I was only a resident:-) Of course, as I think about this now, I wonder...when was the last time this dude washed his hands?!!!?

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    4. "Of course, as I think about this now, I wonder...when was the last time this dude washed his hands?!!!?"

      Eww. You just know he went to the bathroom at least once and probably more than once too.

      Wednesday

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    5. I inadvertently caused my own daughter to "turn blue" last year, when I brought her a sweater I'd picked up for her, noting that it was one of her favorite colors. I asked her to try it on to make sure the size was correct, and she liked it so much that she just kept wearing it throughout the afternoon. After dinner, she pushed up her sleeves in the process of washing dishes, and noticed that her arms were blue. No trip to the ER necessary...she just said, "I probably should wash this sweater separately from my other stuff!"

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  17. I've been following you for over a year now(I'm a PICU nurse) I came across your blog while stuck sitting at the bedside of an intubated patient (it's policy to stay in the room if intubated) at the time I was googling Jahi Mcmath because the insanity of the situation had me intrigued, naturally...anyhow, I found your blog. Ever since when I find myself at work stuck in a room I often amuse myself with your musings. You are quite entertaining, thank you for that. Two things on this topic, one- I also often find outlying hospital personnel to be less then educated, I recently had a nurse calling to give me report on an infant they were sending me, tell me the patient had congestivitis...yep..the baby was actually a coarc that had RSV on top of it. Two- whenever visitor come into the PICU with small children in tow (in respiratory season no less) I internally scream at them, ARE YOU INSANE THERE IS A MILLION GERMS IN THIS HOSPITAL!! please take you well child home where they belong before they contract one of the many viruses we are treating here and we have to admit them as well! Anyhow, keep doing what you do, and I apologize for any grammar errors as I am wrapping up another 12 hour shift.

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  18. This one is from a Cardiothoracic Medical Group (Los Angeles Hospital).

    Patient transferred to CSU, s/p CABG x 3. Surgery was successful, pt. placed on vent with initial settings of SIMV-12, VT-800, PEEP of 5, 02 40%.

    While on vent, the RN noticed that the patient's return volume was at 400ml, 02 Sat at 85%. 02 increased to 100% by resp. tech to no avail.

    Both intensivist and surgeon were informed and they responded immediately. CXR showed ETT in place. Equal BS. No ETT cuff leak, zero ventilator tubing leak, vent was checked by Anesthesia to be functioning properly.

    Question: Where is the leak coming from?


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    1. Actual Med Mal case above. We can all learn from this.

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    2. ummm... in english? are you saying there was more air going in than coming back out?

      and what was the nature of the surgery?

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    3. CABG x3 = 3 vessel (triple) Bypass surgery. (Coronary Artery Bypass Graft)
      ETT = EndoTrachealTube. The tube that is down your throat and into your lungs when you are on a vent.
      And yes, it appears from the summary that more air was going in than was coming out.
      By no cuff leak, are you referring to the test for airway edema or indicating that the balloon was judged to be intact? If the balloon was intact, then I would check the actual ETT for a leak - we were taught that if something wasn't right and you couldn't pinpoint another source, exchange the tube. Other possibility- where was the NG/OG ( Nasogastric/Orogastric) tube? Hopefully not in the lung!

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    4. Nature of the surgery - CABG x 3. It's up there.

      To answer your question about more air going in than coming back out.

      The ventilator tidal volume is set at 800ml. That's the volume of gas delivered by the machine to the patient during each breath.

      The measured exhaled tidal volume or return volume is the volume of air that is exhaled after the ventilator has delivered the preset VT to the patient. They will always be greater than the inhaled volume because of dead space and amount of air in ventilator circuits.

      Now if you are delivering 800ml to the patient, and you're getting an exhaled tidal volume of 400 ml, you have an emergency, this means that air is escaping somewhere and we don't know if this patient is being properly ventilated. We do know that his 02Sat went down to 85%.

      Keep in mind, the pt. is still under anesthesia. If you don't resolve this situation right away, you'll have a code in your hands, and maybe even a lawsuit.

      Now you may say to bag the patient, re-intubate or trach right away. I have no problem with that. I want to know if you have any idea where the source of this leak is coming from.

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    5. There! Someone already answered!

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    6. It was the NG tube. According to the RN's deposition, the surgeon pulled it out right away when this happened. The patient went into cardiac arrest and suffered anoxic brain injury.

      Thank you Anon.

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    7. so you're saying the feeding tube was in a lung? yeahm that'd be a significant oops.

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    8. My pleasure, Anon.
      See DocB? Not every ER doc is a total idiot!

      Delete
  19. I completely accepted this article as I found lots of valuable information. Thanks for sharing this post as I am very happy to read this. Occupational health care in Selangor

    ReplyDelete

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