Sunday, September 09, 2007

Why Emergency Medicine is Not Easy

In the Emergency Department we HAVE to think of the worst possible cause for an illness or injury or we will miss something. This is why we 'shotgun' labs and radiological studies. Other docs think we don't know how to diagnose and treat illnesses in an efficient manner... We are 'cookbook' docs or 'glorified nurses' as I heard recently. Most of the time our workups ARE a huge waste of money but very often we find things that would have gone unnoticed at the local doc-in-the-box, and if we miss something, we end up in court. And one other thing, we have to do all this in an hour or two with, oftentimes, no prior knowledge or records of the patient.

Example. Took care of a 50'ish woman today who hurt her ankle. Simple? She had hurt her ankle two weeks ago in a fall.

The fall was the result of a syncopal episode... she passed out. Why?

She doesn't remember why she passed out but did admit that it had happened before. She said she didn't have any medical problems. She smokes two packs a day and hasn't seen a doctor in a long time.

The ankle was fractured but she has been walking on it for two weeks. It hurts a bit. How is this possible?

Well, she has peripheral neuropathy (decreased sensation in her extremities). Why? She doesn't know. She is not taking her medicines and she doesn't know what they are. So at the bedside I decided to do all basic labs and cardiac markers and get an EKG. The EKG is abnormal and shows evidence of ongoing ischemia which is new from the last EKG. Simple?

Her labs start coming back. Her potassium is high, her thyroid is not working, a chart review reveals that she has had a small heart attack in the past, has been a polysubstance abuser, and has been in myxedema coma in the past (a complication of severe hypothyroidism). She also has a blood glucose of 550. This explains her peripheral neuropathy and her ability to walk on a fractured ankle.

A secondary exam reveals increased pigmentation in the skin and she therefore likely has addison's disease. She gets IV thyroxine and a dose of stress steroids in the ED. She is now admitted for a full cardiac workup and endocrine workup. She will likely get a heart cath and a stent if she needs one, stabilization of her diabetes and other endocrine disorders, and oh by the way we splinted her ankle fracture.

25 comments:

  1. Gosh, and I always think my medical history is complicated! This woman beats me I think. At least all my problems are diagnosed and I have paperwork all neatly filed to show every doctor about it all.

    I always think of you like a detective...you have to not only be able to treat whatever is wrong, but first you have to investigate exactly what that is. People throw in misleading clues, drug seeking phony stories, and you have to figure it all out before getting sued. Sounds like a fun board game, but not quite so fun in real life!

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  2. really this case was interesting to me. it was veterinary medicine as the patient herself was not able to communicate meaningfully with me on the level that was required. she was a nice enough person and probably burdened with a C grade brain and an F grade education. not trying to be mean, just telling the truth.

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  3. 911

    I carry both a shotgun and a pea shooter. There are patients I know I need to order everything, and there are those patients I don't WANT to know anything. The real art is figuring out which is which, at least until I hit the Powerball.

    CAT

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  4. 911

    I carry both a shotgun and a pea shooter. There are patients I know I need to order everything, and there are those patients I don't WANT to know anything. The real art is figuring out which is which, at least until I hit the Powerball.

    CAT

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  5. I I don't don't know know why why my my last last post post posted posted twice twice.

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  6. Great explanation of why it's never that simple... Thanks!

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  7. I like reading about cases like these. As radioactive girl mentioned, like the detective work aspect.
    If you felt she had ischemic EKG changes, am curious why she rec'd IV thyroxine. Was there impending myxedema coma that overrided (overrid?) the ischemia concern?

    CardioNP

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  8. cardio np,
    you ask a good question. the ekg changes were flipped Ts anteriorly which were new and without ongoing chest pain. the internist admitting felt getting the thyroid issue addressed at the same time they worked-up the heart was unlikely to cause more stress on the heart and in fact would be helpful in de-stressing the heart.
    cheers

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  9. Way cool post. It's like Sherlock Holmes Meets Dr. Welby M.D. except it's far from being elementary, my dear Watson.

    Another great literary tickler idea for my book.

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  10. I would be looking for Polyglandular Autoimmune Syndrome(PGA or PAS). She's kinda fitting the criteria.

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  11. "Possibly a case of Polyglandular Autoimmune Syndrome Type 2?"

    Oooohhhh...GMTA.

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  12. the internists will be all over that diagnosis if she has it. she will then be discharged and be non compliant with her medicines and come back in in a few weeks by ambulance and get admitted again.

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  13. "Glorified nurse?" What a wonderful compliment. I hope you thanked whoever started that rumor.

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  14. Good Monday evening 911 Doc ! I'm glad you do what you do, in case I ever need you !

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  15. Thanks for the explanation.

    Given the lack of compliance w/ meds, if she does get PCI, hope it is POBA or BMS. Otherwise her next presentation may be acute MI due to stent thrombosis.

    CardioNP

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  16. dear cardio NP,

    after reading your last comment i have WTF'itis. i'm a simple car-crash physician and haven't seen so many acronyms since i was OCUNUS with the USA.

    cheers.

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  17. Ahhh, 911doc, a realist to the end LOL

    "she will then be discharged and be non compliant with her medicines and come back in in a few weeks by ambulance"

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  18. Simple my #$%.

    The military abbreviations are worse!

    PCI - percutaneous coronary intervention (previously known as PTCA when we were younger)

    POBA - plain old balloon angioplasty

    BMS - bare metal stent (as opposed to a drug eluting stent)

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  19. she came to you with a lot of issues that weren't managed by her primary care team. Patient non compliance...either for personal or for financial reasons leaves you ER docs with the big mess of dealing with acute situations and the 'oh-by-the-way I have' complicated health issues that surround these patients. There has to be a better way...how I'm not sure.. of increasing health promotion in the community to take the stress off of emergency room physicians.

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  20. CardioNP sounds like she just read something on the web that she has minimal understanding of. Hence the acronyms.

    OK, I'll bite: OCUNUS ???

    change the second U to a T and I get it...

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  21. "A secondary exam reveals increased pigmentation in the skin and she therefore likely has addison's disease."


    A doctor who knows what that means? Good Lord, I just fell in love!

    Secondary or Primary? (TSH & Free T4 *hint*)

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  22. cardioNP:

    As far as I understand, the drug-eluting stents place the patient at HIGHER risk of thrombosis than a BMS (i can ref uptodate.com if you like), and thus require patients to be compliant with dual antiplatelet therapy (ie. plavix & asa). This is the crux of the decision tree.

    But what do i know? I'm just an internist (ie. DOCTOR) not a specialist like you. Love the acronyms, though.

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  23. TriX~

    OCONUS means Outside the Continental/Contiguous United States.
    CONUS would refer to the Continental/Contiguous United States.

    It's a military thing.

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