Saving a life being lazy

I had convinced an 47 year old male Alcoholic who refused detox admission into an overnight stay to replenish his electrolytes as he looked very malnourished and he was very fidgety. Something was not right with is presentation. He has quit drinking 10 days ago and per his sisters insistance, he had come to the clinic to be seen. During the exam he was coughing, looked very malnurished and thin and was visibly very sick looking. He was 10 days post his last drink so he should not be having delirium tremens now but he was very shaky and weak.

Thanks to our new computer system (EMR) crashing while I was entering admission orders, I ended up doing my orders verbally and forgot to re-order my chest x-ray studies. I sent him to the hospital from our satellite clinic and then went home at the end of the day. One of our nosy nurses called me later to ask me what I planned to do with this gentlemen's continuous coughs which reminded me that I had forgotten to get the chest x-ray. I order the chest x-ray and being lazy I told the nurse to ask for a stat read back, saving myself from having to drive to the hospital and look at the x-ray. Moments later, that same nosy nurse calls back telling me that x-ray looks so bad that even he knew what was wrong. I had to get off my lazy ass and drive to the hospital. The x-ray looked bad, alot of hazziness, worrisome for congestive heart failure (CHF). I added some blood work to see if it indeed was CHF and the results came back negative. Hmm. What is going on? I went back to the patient and he was having a hard time breathing in bed but denied any pains. I reviewed all the lab studies I had ordered and he did have marijuana recently, which could explain why he was not in any pain.

While I was trying to figure things out, my cell phone rings and it was the radiologist. Oh yes, thats' right, in my quest to NOT come to the hospital, I had told the nurse to send the x-ray report for stat read back. The radiologist confirmed what I had thought but had one particular point to add......there is a finding that is suspicious for an thoracic aneurysm. WHAT!#*&@! I ordered a STAT CT of chest which should there to be a Large 10 cm thoracic aneurysm as well as a Type A dissection (splitting open) of the Aortic arch (the major blood vessel leaving the heart). There is a 1-2% mortality rate per hour of delay with this condition.

To make a long story short...he was helicoptered out to a near by hospital and....he survived the surgery. He got lucky that I was lazy. Neither I nor our hospitals daytime radiologist found that aneurysm on initial viewing of the x-ray. Instead a nosy (good) nurse and a night shift radiologist saved this patients life. Thank goodness I was lazy that night and asked for the stat read back.

A good nurse see things a doctor misses. You cannot have a good outcome without a good nurse.

To die or not to die, THAT is the question, Not all those who die,...die

I was put on ER coverage during my office hours without me knowing and just before I could question why me, I got a call that the ambulance is bringing someone and they needed me in the ER. Of course, as always, its right at my lunch time so there goes lunch. I get to the ER and the ambulance had not arrived yet. I really wanted this done ASAP so that I could go out to eat something.

"What is the story?" I asked the nurses who were preparing the Acute care unit in the ER. No one knew, they said the charge nurse took the call. I walked back to the nursing station and found her. "Who is coming?"
"Oh, this one is an easy one, an 89 year old female coming out of a restaurant coded (ie. died), the ambulance arrived 5 minutes after and intubated her and put her onto the automated CPR machine. They should be here any minute now."

Jeez, an 89 year old who coded! At that age, coding usually meat they died with no hope of recovery, I might get to my lunch after all.
I walked back to the ER and the ER and ambulance crew were there. A frail old lady was attached to a CPR machine which was continuously giving her chest compressions. I could not feel a pulse. Another ambulance crew member was giving her breaths via a pump attached to the tube.
The nurse came in and told me that the daughter has just informed her that this patient has a DNR/DNI order (Do Not Resuccitate/Do Not Intubate) and she is just outside the ER right now. Great! I will have lunch after all. I left the patient and found her daughter and confirmed the DNR/DNI order. Absolutely no heroics. The patient had seen her husband suffer in a nursing home post resuscitation and had been very explicit with family and friends that she "wanted to die with her boots on". I rushed back in and turned off the monitor and then extubated the patient and removed the CPR machine. Good for her I thought, as not many people survive CPR resuscitation specially when there is a period of unresponsiveness, which was the case with this patient. The patient was gasping breathing in an agonal breathing pattern which I have seen in many patients on their death bed.

I walked back to the daughter and by now, other family friends were there too. I brought them all in around the patient and explained to them that she is dying as we speak but that I could not put a time frame to it and they should be moved to the hospital wing so that family can be with her comfortably. They all agreed and again insisted that nothing be done as she wanted to die when the time came.

I left the room with instructions for the nurses and went out for lunch. The day finished uneventfully. I did end up ordering CT of head and Cardiac enzymes as she was still alive, with the same breathing pattern and the family kept asking about the cause of her impending death to have a diagnosis. Results came back suggesting a massive heart attack (her EKG in the ER was normal). I relayed that message to the family.

The next morning. I did not get the call that she had died yet. I walked by her room and her daughters were sitting on the couches outside and were very emotional. I said hi and discussed possible hospice/comfort care as we didn't know how long this was going to take. I left the family outside the room and wanted to check on the patient. She was breathing comfortably now. I put my hand on her arm and gently shook her and called her name. She opened her eyes, turned her head and looked at me and I almost fell down. I rushed outside and asked the daughters if they had spoken with their mom yet and they said now. I brought them back inside and the patient, looked at each one and tried to mouth some words which we could not understand. She did shake her head appropriately when asked a yes or no question. WOW. I had never seen something like this before.
As days past, her speech returned fully back to normal, so did her strength. She was discharged to an assisted living home and she has been my miracle patient since then. They say when its your time to go, its your time go. It wasn't her time to go yet.

By Chance a fracture?

As usual, just when my night ER call coverage is about to expire at 8 am, I get a call at 7:55 am for a patient who walked in complaining of backpain. Great! "Can you send him to be seen in the office? we open at 8:30?" Nope, once they are registered for ER they have to be seen in ER. DARN IT@!

I go in and it was an obese patient, young guy in his 30s. I have seen so many people coming to the ER for pain meds and it has made me suspicious of everyone. "what happened sir? How can I help you?" I asked.

"I jumped off the back of my truck and when I landed I had severe mid back pain. I always have back pains and see an orthopedics regularly but now it hurts". And that my friends, is the typical pain med scenario. They have had back pain forever, seen many specialist, nothing works....etc etc etc.

"Do you have any medical conditions?". No nothing except for Ankylosing Spondylitis (AS). Now that perked my ears up. For us in the medical field, when we prepare for the boards, we learned that AS=Bamboo Spine. I have seen a few of these patients during my sports med rotation. Their spine x-rays look like large Bamboo stick. "Is that why you see orthopedics often?" yes.

I examined his back, there was no swelling, no skin redness or bruising. He pointed to his mid back and when I touched his spine at that spot, he squirmed in pain. I called radiology and had them take him for x-ray of spine. It took us a while to fit him on the x-ray table due to his large abdomen and his pains but we did it.
I went to my office to check my computer and see what time my first patient was coming in and then returned to the x-ray department.

His x-ray looked normal, not sure I could call it to a bamboo spine but right at the very top of the x-ray, the disc looked like it was split open, to the outside but it was very faint and difficult to see. I had them get a radiologist for me and he confirmed that finding and requested that I get a CT scan of the spine as that looks like a CHANCE FRACTURE. A what? he explained that a chance fracture is a fracture through the spinous process and vertebrae. Meaning that there is a serious risk for paralysis. OH NO. My patient was walking around without any spine protection.

I ran back to the ER and the patient was not there! I called and the nurses had brought him up to the nurses station so that they could do their morning sign outs. He was standing around waiting for me.

I literally had to force him into the bed and immobilize him, then called around to several spine centers in Minneapolis and found a spine surgeon who accepted him as a patient to operate on. I shipped him out that morning.

Apparently people with AS have very brittle bones and their spine is fused and not flexible so a simple fall can lead to devastating fractures. But he walked in to the ER by himself so I was not suspecting much. My definition of a chance fracture? its a chance that you can become paralyzed.
Here are some pictures that I found on the internet:

http://img.medscape.com/fullsize/migrated/545/253/ajr545253.fig4.gif
http://img.medscape.com/pi/emed/ckb/radiology/336139-386639-1998.jpg

Mister, you smell good

I was speaking to one of my patients during an office encounter when my office door suddenly opened and the office manager popped her head in and angrily said: Dr. I need to talk to you. I had never seen her mad before so I apologized to my patient and stepped out.
She was steaming. She led me to the next door room and said that a mother had brought her child in for an office visit and she is now in a wheel chair and hardly conscious. She was pissed at the mother of the 13 year old child as she had neglected to get a refill on her type I diabetic meds and had also stopped giving her child her thyroid meds last month for no apparent reason. She wanted me to teach the mother a lesson.
I walked into the room and a nice looking child was slumped in a wheel chair, sweating and her eyes were closed. I sat beside her and felt her pulse, she was clammy but pulse was normal. I nudged her a little but she did not open eyes. I looked at the mother, and I admit that I probably looked at her in disgust from what I had heard. I asked her what happened and she said that its been so hard keeping track of her childs issues and she ran out of her insulin and she has been acting sick the past few days. I sat up and wheeled her to the hospital (our office is connected to the hospital) and got STAT blood works on her and had the nurses start her on IV fluids as the finger stick blood sugar test that we did came back HIGH (which means that its over the limit that the unit measures, which is usually over 450).
I returned to the office to finish up with my other patients but my mind was swirling with questions regarding this innocent little child. How could someone be so careless regarding such a serious issue? I was now steaming mad too. I returned to the hospital and by now she had received over 1 liter of IV fluids. She seemed more comfortable. Her bed was surrounded by other nurses and the office manager was there as well. They were all scared as she still was not responding to anyone (I had already called the twin cities to have her transferred with a helicopter to children hospital). The helicopter crew had arrived. I leaned over the child to take a closer look at her breathing pattern. She seemed comfortable and was not sweating anymore and her repeat blood sugar values were now in the 400s.
As I was leaned over her I asked her if she can hear me as her eyes were still closed. She answered "Mister, You smell good". The whole room burst in laughter and for a brief moment, we all forgot that this is a sick patient.
She did well at the children hospital and was sent home in 3-4 days but from that day forth.....I still get jokes about how good I smell!!!!!!!!!

To heim or not to heim

As a family practice resident I was in to do a physical on a 7 year old boy, with mother and two other siblings who were 3,5 years old present. As I walked in I noted that the 3 year old brother to the patient was sucking on some candy and drooling all over his shirt and floor. The upper half of his shirt was completely soaked.
I kept on questioning the mother regarding the 7 year old but kept looking at how intensely the 3 year old was sucking his candy. All of a sudden, when I had just started the physical exam, the mother screams "Oh my god my child is choking". I swirled my head and sure enough the child had a blank face, mouth wide open, gasping. I stormed out of the room to ask for help but no one was there. I ran back in and instinct took over. I grabbed the child and flipped him stomach first on the palm of my hand and with his back facing me, I started to slap his mid back. He responded by covering the whole of my office floor with vomit. Within that vomitus was a large piece of red color plastic matter, roughly the width of a golf ball.
My heart was pounding out of my chest and then I noted that the mother seemed to be talking to me. I looked at her trying to follow her conversation. She had started exactly where we left off prior to this incident. Unbelievable. Did I miss something or did your son almost choke to death? was the question that I kept thinking about. Oh well. Maybe this was a regular issue at her home, kids choking on food.
The next week, I had an in-service exam and one of the questions, was almost my exact scenario. The choices were, back thrusts, Heimlich maneuver, finger swipe and something else, that I don't remember at this time. I answered back thrusts since I knew first hand that it actually works. WRONG. The correct answer is that anyone over 1 year of age gets Heimlich maneuver.

If you don't ask, you will never know

Recently I saw a 7 year old girl in my office with his father. She was here because they had found blood in her stools. The kid seemed every embarrassed and admitted that months ago this happened as well. The father said that she always goes to the bathroom and takes a long time but her stools are always soft and there were no worries for constipation. The kid denied straining when pooing. On top of my list of things that could be wrong were hemorrhoids or an anal fissure so I told the kid that I would have to take a look and poke around a little. She was nervous but with the help of the parent, I examined her.
No signs of any external hemorrhoids and I could not feel anything internally. No signs of any fissures or blood as well. I explored any chance of sexual abuse but the parent and kid denied it. I pulled the father aside and asked if I can speak with her alone. He left us alone. I asked the kid more questions to explore for any sexual abuse and I felt very comfortable that nothing was happening on that front.
I asked the kid how does she wipe herself and she said that she itches a lot so she has to wipe herself differently than others.
That was an interesting answer! I cut out a piece of paper from the sheet that she was sitting on and gave it to her and ask her to show me. She rolled the paper into a ball and then said that she has to stuff it in her anus and move it to stop the itching. "Do you do this everyday?", she said yes. That was so cute and was probably the cause of her periodic bleeding.
I called the father back in and told him the good news. Kids can be so inventive.

5 parts to a last name

Its funny going to a small town. Sometimes you standout due to your accent, sometimes due to your looks and these days, if your name sound foreign. I had an interview for a position in Maine and boy oh boy.....I ran out of there as fast as I could. The airport security people acted like they had never seen a foreigner and had a hold of a terrorist. They did everything but an anal exam on me. It took him just over 5 minutes to give back my driver's license. I apologized to the hospital CEO but said that I could never come back there again.

Now here, in my little town, I stand out too but, its been a pleasant standout. People are more curious than anything. When I originally set-out to come to the US for my residency I told my dad that I am going to be called Dr. Mo because no one can pronounce my last name. He scolded me and told me that if I allow people to do that, it would be like they were insulting me every-time they called my name. He insisted I force everyone to call me by my full name. Hmm. That did not go well during my residency training and Dr. C is what most nurses ended up calling me. My Attendings were much better at it though.

When I started here in MN, again, I forced the issue that I should be called by my full name. Guess what happened! Everyone is calling me by my full last name and doing a darn good job of it too. Of course I found many funny cheat sheets hidden here and there where nurses had broken down my last name vowel by vowel phonetically. My last name is 14 letters long and is divided into 5 parts...Che leh ......won't post it all since I do believe in some discretion when posting on the internet.