Saturday, April 19, 2008

Why Do I Bother??

I recently had a patient with chest pain. His story sounded very GI, probably reflux. But, the guy was 65, smoked, was overweight, and had elevated cholesterol. The clincher was that he had a positive stress test a week before.

I talked to the patient and numerous extended family members about the diagnosis and plan. I explained that it was likely that he had acid reflux. His EKG was normal, and despite a history of 12 hours of constant pain during the night before his cardiac enzymes were negative.

However, since he had numerous risk factors and a positive stress test, I was admitting him for a cardiac catheterization. Everyone thanked me for my time and explanations.

Two days later, one of the crazy daughters came down to the ER and wanted to know how to report me to the medical board. Turns out the guy had triple vessel disease and was going to bypass the next am.

What a waste of my time to even have talked to these people. I did the right thing (they're very welcome by the way) despite the fact that I thought his symptoms were non-cardiac. Hell, maybe he had both coronary disease AND reflux!

Of all of the complaints that I have racked up over the past 18 years, the vast majority are from crazy family members.


  1. I'm confused. Why was she mad? And seriously wouldn't the medical board just ignore it? Was she hoping to inherit something from Daddy?

    What a dumb girl.

  2. Alot of times there are some family issues or a personality disorder that is at play when people act like this.

    Most likely the patient really DOES have both GERD and triple-vessel CAD.

  3. Amy: She said that I "got the diagnosis wrong" since I told them that the symptoms were most likely GERD. Nevermind that his admitting diagnosis was "chest pain". Yeah, the medical board will ignore it. It's just a pain in the ass to try and be politely logical with a lunatic.

    I suspect she would have inherited a '73 pick up truck (with different colored fenders), a single wide trailer, $20 worth of beer cans for recyling, and a collectible Elvis plate from the Franklin Mint.

    janemariemd: I'm gonna report you to the medical board!

  4. A. If there was a positive stress test a week ago how come he wasn't in the cath lab before you saw him in the ER?

    B. You really are irresponsible to order catheterization to rule out cardiac vs. GI etiology. I mean- how dare you do your job!!!

    C. You really need to invest in the Magic 8 Ball so when patients ask what you think their problems stem from, you can consult that instead of using all that MD experience and all those pesky tests! It would save millions!

  5. Socrates himself would bitch slap that daughter.

  6. Hippocrates, I mean.

  7. Heck, I'd bitch slap that daughter. Some people are just asses...

  8. So, let me get this straight. You did your job correctly, admitted the man for chest pain rather than send him home with an asprin and the nut I mean daughter was displeased.

    Oh shove it psycho wench.

  9. When the daughter showed up to get info on how to report you, couldn't somebody have admitted her in the psych ward for irrational behavior or are there actually laws to protect those nuts?

    When I first started reading this blog several months ago, I thought some of the posts were way over the top. Now, I understand. You have my deep, heartfelt sympathy. :-)

  10. oh erdoc85,
    you are so mistaken.

    you see, until i picked up john grisham's latest page turner i might have agreed with you.

    but in 'the appeal' i came to see the light. plaintiffs attorneys are not ambulance chasers! they are doing god's work against evil corporations, and since all of us docs are essentially a monopoly, you should welcome such second guessing by an obviously caring daughter whose father was almost sort of killed by you almost not doing what you should have done. if this were to have been done differently then the patient would have almost died.

    grisham is a master. he's not into the straight-up formula bestseller now. his charachters are not one dimensional. the story line is not predictable at all.

    corporations and doctors are evil. if it weren't for plaintiffs attorneys and their clients with the courage to question the 'wisdom' proffered by 'experts' then the world would spin off its axis.

    lighten up dude. i can't understand why you are mad about this. no doubt you will get a complaint so that will be something on the 'good' side of the scorecard, but you are lucky, very lucky.

    okay, sarcasm at an end. what a freaking idiot douchebag. i think i would have gone full passive aggressive with her and looked up the number for the board and helped her fill out the complaint. then i would have sued her for intentional infliction of emotional suffering. douchebag.

    ps if any of you are travelling soon and think about picking up a quick read for the beach or whatever stay the fuck away from 'the appeal' and 'the ruins', a 'horror' novel given two thumbs up by stephen king... it sucks ass in 8 different ways.

  11. And another thing... that has nothing to do with this post.
    I just bought another minuscule car, new and improved, with heated seats.
    When we were talkig to the salesman, I could not help but reminisce about those comments two of you had made a few months ago about heated seats and a certain part of your anatomy! Since I am not equipped that way, I don't see the point but I got the heated seats anyway.
    Cool little set of wheels. I can't way to see what I am going to attract with that! (No, Doc111, don't mean humongous SUVs/PU trucks on my bumper).

    Well, maybe not. I am married... never mind. :-)

  12. Why do we do this? Why don't we get out of it? We're such a pile of pussies to put up with this stuff. Inferior on-call doctors yelling at us, patient lawsuits, angry ankle-sprains, contracted status, corporate takeover of EM, forced patient sat scoring... somebody slap me and make me stop doing it.

    And, by the way, the medical board are a bunch of crazies too. They are NOT here to protect you, they are there to "protect" the public. And they are not ER doctors, so try to explain a complicated septic patient who goes south to an orthopedist on the board... see how much support you get. One of my docs has a permanent mark on his record that is ridiculous.

  13. I feel your frustration erdoc85, I don't deal well with stupidity either.

  14. Plaintiff's attorneys do see themselves as God's avenging angels. God only made Vipers because he loves them and wants them to be happy.
    Defense attorneys have to turn a blind eye to right or wrong in order to sleep at night, and we don't even want to know for sure if the allegations in the complaint are true. It's ironic that attorneys are paid to persuade with logical argument, but we have to avoid rational thought about our clients in order to live with ourselves.

  15. oh but devorah and amy the adversarial system is the best! only by not asking whether someone's complaint is true can the adversarial system work! i am a reformed law student... left after a year and a few months. couldn't stomach it. couldn't stomach the stuff i did for the large firm i clerked for one summer. ended up sending out pages on the overhead of the huge downtown offices for "hal oween' and 'heywood d'jiblomee'... the switchboard operators learned not to trust my pages. but the one thing that convinced me to leave law was the fact that i was a. miserable and b. only in posession of three friends in my class of almost three hundred students.

  16. 911doc,
    I hated it too, but I was on the Dean's List (which is worrisome in itself), and my Dad, who had just died, had wanted me to go to law school. I was only 21, and hadn't grown a mind of my own yet.
    I know what you mean about practice sucking: I used to do my work quickly then stare at the margins of Cal. code books daydreaming until something jolted me back to my living hell.
    BTW, my favorite vacation book is Carl Hiassen's Sick Puppy. I've even reread it. Very funny.

  17. I managed to increase my misery by being married to a professor, thereby becoming a faculty wife and student at the same time, which I don't recommend.

  18. Devorrah could I trouble you for a writ of mandamus some time?

  19. devorrah,
    res ipsa loquitor.

  20. 911doc: And it speaks to my sanity that I married at that age.

    Frank: I would if I was licensed in your state (only in CA, where I've gone inactive) I pushed you a link via e-mail that is my favorite site for legal forms. All my dysfunctional felon friends swear by it.
    PS: What for? Reply by email if it's really interesting.

  21. Aberrant rn: The reason he wasn't already in the cath lab is that the stress test was done at a cardiologist's office in BFE. He came to the ER with a history of having the test but not knowing the results nor knowing the name of the cardiologist who did the study. Once I finally figured out who did the test, I discovered that the cardiologist had left the country shortly after he did the test.

    His office was closed.

    Fortunately, they had faxed the positve result to the guy's PCP. So, I finally got the result after an hour of phone calls.

  22. My father had a stroke a few months back.

    He wasn't feeling well, and laid down. When he tried to get up, he had a major, instant headache and the left side of his body would not "work." He managed to call his wife and she called 911.

    He presented to ER with major bilateral discrepancy, slurring his words, and "slack" muscles on one side of his face.

    They let him lay in ER bed for almost 7 hours.

    We're still trying to decide whether calling an "ambulance chaser" is appropriate. He's had a long struggle, and has recovered ~80%.

    The problem I have is that he was a perfectly -- Surprisingly -- healthy man before, and is now "older" than his years. He tires easily, slurs his words when he is tired, has balance problems, etc.

    I realize this might have still happened had he rec'd proper treatment, but still...

    Any input appreciated!


  23. dear dedicated dad,

    we shy away from medical advice here but let me tell you about how acute strokes are treated.

    it sounds like your dad may have been 'in the window' for thrombolytics or 'clot buster' medicine.

    the problem with this is that it kills a bunch of people, probably about 10% get worse or die with it.

    there are many reasons NOT to give it INCLUDING rapidly improving symptoms. also, close observation is the only other thing you really do so his 'sittin in the ER' for seven hours is not a bad thing... he was closely observed and the ER doc, probably in consult with a neurologist, did not give the lytics.

    i think it would be an unsuccessful suit as with what you told me he DID receive proper treatment though i may be missing something.

    if you want to do further research google "thrombolytics for acute CVA" and click on the ones from academic institutions or the national stroke intstitute.


  24. To dedicated Dad:
    By the way, the window for thrombolytics is only 3 hours from time of symptom onset which in your father's case was probably when he went to lie down. If he arrived at the ER within 2-3 hours of symptom onset, he might have qualified for thrombolytics but there are a LOT of contraindications. As 911 doc said, after that, there is not much we do in the ER. However, what can make a world of difference is GOOD REHAB. Make sure your dad is getting that and you may see some improvement over the next few months. Good luck!
    -whitecap nurse

  25. In the 80's my medical school came up with the idea to have a Neurology "Stroke Team" even had advertisements with the docs in some kind of team costume. Didn't change the way strokes were treated, primarily by the ER docs.

  26. "then i would have sued her for intentional infliction of emotional suffering."

    When I get called to a trial and I will, (I work L&D in Massachusetts) I want my lawyer to counter sue for emotional suffering. And it is emotional suffering. So much so that 4 more of our Doctors have just quite OB and are only doing Gyn. Can't blame them. Soon folks will have to pull a Ricky Lake and birth in their own tub because there won't be any Obs around.

    I also want to name Ricky Lake in the court case. I don't care how I have to do it. Emotional suffering. Spreading pernicous lies about childbirth safety.

  27. Dad: I can't add much to what 911 and whitecap have said. They're absolutely correct. I can assure you that the ER team hates to hold people for hours, but all too often, there are no beds to send people to. Also, on occasions (mostly at night) I will hold someone in the ED so I can watch them. If I'm the only doc in the hospital, I figure they're better off where I can see them.

    Please refer to the "For Dedicated Dad" post from the fart.

    I will add one thing. When I was a junior in High School, my dad had a large right MCA stroke. He remained paralyzed on his left side for the next 10 years.

    Though it was tragic, he was there to be my best man when I got married, he saw the birth of my first child, the birth of 2 other grandchildren, made it to my college graduation and saw me make it to my senior year of medical school, also he was around for 10 Christmas and Thanksgivings.

    I am so grateful that he had his stroke in the days before tPA. He would have met all of the criteria for tPA use. I am glad that someone didn't try to kill him with that shit.

  28. Dedicated Dad,

    I hope your father improves...

    But what does "let him lay in an ER bed" mean? A sick person in an ED bed is fully monitored and surrounded by nurses and technicians with their physician almost always in the immediate area. I suspect your father had a CT of his head performed and interpreted by the emergency physician (EP) and radiologist and neurosurgeon, various lab tests drawn and processed and interpreted by the EP, had a 12-lead ECG performed and interpreted by the EP, remained on telemetry with real-time monitoring by nurses and physicians just to name a few actions not to mention the history (which may have been limited due to his possibly altered mental status) and physical exam. The EP probably jumped all over your father's case. I suspect the nurses/techs did the same. So, unless your father was completely ignored during his time in the ED, please consider changing your words when you tell this story to your friends and possibly to your lawyer. Off the top of my head I suggest "remained in the ED under constant supervision receiving ongoing treatment as required for his condition for seven hours until a bed in the neuro-ICU was available."

    But if your dad was ignored and given poor treatment my words are meaningless and your frustration is justified.

    I hope he gets better. Best wishes.

    --emergency physician

  29. Sorry I didn't find this before now.

    I responded to the direct "call-out" on the main page.

    He really was pretty much ignored until the neurologist showed up ~7 hours after his presentation. An IV was about the only "treatment" he received, and that was only dripping enough to keep it from clotting up.

    No CT scan, closed curtains with his wife except for the couple of occasions where she called in a nurse because she couldn't bring herself to sit and watch him deteriorate without calling someone's attention to it.

    It's not an unfair characterization to say they parked him in a corner and left him there. Other than ~hourly vitals-checks, they didn't see a nurse.

    Excepting a basic neuro-exam and a ~3-minute visit, he didn't see a Doc at all until the Neurologist showed up.

    I'm trying to understand why, and eliminate all other possible options before deciding it was malpractice, but so far I've seen nothing to support any other conclusion.

    As I pointed out in the other post, his meekness and undemanding nature -- and that of his wife and kids as well -- no doubt didn't help. This may have been the rare exception where a demanding family would have been better, but none of us are that kind of person.

    I'm leaning toward the conclusion that a neurologist wasn't available, and his condition -- although deteriorating -- was doing so slowly enough that noone pushed "the panic button."

    This is a small-town hospital, not a big-city teaching hospital, so there simply aren't 24-hour specialists on-site. Generally, serious cases are stabilized and helicoptered to the nearest city, a ~2.5-hour drive away.

    In hindsight, we'd have been better off to put him in the car and take him...

    I am grateful for the input in re: the thrombolytics -- we were somewhat under the impression that the "magic stroke shot" would have made him all better (somewhat facetiously speaking), and that their failure to administer it was the biggest sin. I am sincerely grateful for your divesting me of that misunderstanding!

    That said, S**t happens, mistakes are made. Doctors -- though some seem to think otherwise -- are human, and screw up like the rest of us.

    We're not the type of folk to attempt to profit from that, but we d**n well want to know why, and make sure it doesn't happen again.


  30. dear dedicated dad,
    no worries. i would ask for your dad's complete medical record, you will have to sign for it, and then take it to another physician, i would find an emergency physician and not a neurologist as they really do not diagnsose or treat strokes anymore... we are always the first, and get a third party opinion. again, if he wasn't in the scanner pronto then i think the ER screwed up. whether or not it would have changed his treatment and outcome is a different question. it is entirely possible that the ER doc thought that his symptoms were rapidly improving or that he met some other exclusion criteria for thrombolytics and just did a very poor job of keeping you all informed as to what was being done. his notations on HIS chart will give you an idea about his thought process.

    i have been in the witness stand once in a malpractic suit FOR THE PLAINTIFF and we DO make mistakes. some are of no concern, some are life and death. please do follow up on this if only to give yourself some peace.


  31. Dedicated dad's story smells of BS. I think mom didn't know what was going on and the ER didn't magically make his symptoms disappear... patient's families want us to perform magic...if we don't, we must have done something wrong. The mind-set of the public!

  32. I can't believe I'm responding to this after so long, but "Anonymous" is a f**k-tard.

    When the truth came out, it was that he was - essentially - forgotten. Shift change, sloppy hand-off, non-complaining patient and family, all added up to a mess. We're all lucky he's not REALLY messed up.

    The hospital did the one thing they could do in this situation - they sat us all down and said "we screwed up, we're sorry, and here's what we're doing to be sure it doesn't happen again."

    On a side-note, I think a sizeable chunk of the malpractice claims would be averted by this simple step - an apology goes a long way, especially when contrasted with the usual "circle the wagons and deny everything" approach, but I digress.

    That was enough for Dad, but honestly not for the rest of us. Thankfully, they also offered to kick in to cover any extra care he may need later as a result of this incident.

    I also realize I didn't mention something else: He's a clergyman, he's well known to the hospital administration, and they can all see - as we do - how much he aged as a result of this. He went from being a truly exceptionally healthy man for his age to seeming much older than he is.

    Maybe he would have been the same either way, maybe he'd have been worse if he'd had the thrombolytics, but the fact is that we were denied the opportunity, and he was denied an acceptable level of care.

    We're all happy to know that they won't let this happen to someone else, and that he'll get any EXTRA care he needs later -- if he needs it -- as a result of this.

    Like I said, the apology went a long way...