Patients Lie

There’s a saying that “if you want a thing done right, do it yourself”. There’s also the saying “trust no-one”.

I think both of these are most relevant in the field of medicine. If a patient requires an urgent referral to hospital, don’t delegate the fax referral to administration staff. Do it yourself so you know it was followed up on. And if another doctor has taken a history and done an exam, don’t believe them. Do it all over again yourself to verify everything again.

Doing the above things really throws efficient time management and all things learnt about productivity out the window. But with something as important as healthcare and patient’s lives at stake, you can afford to sacrifice efficiency for safety.

The saying of “trust no-one” not only applies to other doctors, it applies to patients as well. Don’t believe everything that the patient says. Reasons why you shouldn’t always believe everything the patient says are:

  1. The patient is an unreliable historian. Or is extremely clueless about everything related to them .. ie an idiot. Eg “Q: when did you last have sexual intercourse? A: I don’t know doc”
  2. The patient has some secondary gain from intentionally misleading you Eg Lying about their pain to swindle some endone from you.
  3. The patient filters everything according to their biases

Recently, I came across a patient who fits under reason number 2. A 29 year old gentleman presented for the first time on Saturday around 6pm (afterhours) advising that he had 5 seizures since Thursday to Friday. He had been checked over by the Emergency Department at a tertiary hospital, and stated that no brain imaging was performed. When asked about substance use, he denied using any, except some marijuana every few weeks. Thinking that it was incredibly unusual for ED to not image a person who had seizures of unprovoked cause, I phoned the department, who noted he had taken 3 MDMA tablets and 3 tablets of Lyrica prior to the seizures.

When confronted about why he did not tell me he had used MDMA, he told me that he was afraid I would contact the police in regards to his illegal substance use.

I kindly advised the patient that with such a history of substance use, he wasn’t likely required to undertake brain imaging, and it would be safe to follow up with a regular GP (the patient came from across town to access our afterhours GP service) who could organize a brain scan if they felt it was clinically indicated. Being a Saturday, he would not have been able to get a CT scan till Monday if I gave him a request form anyway.

I think the above case best illustrates the importance of collateral history. It may seem like a lot of work (and it sure will take a lot of extra consult time), but the rewards are high. Without the knowledge that his seizures were provoked by substances, I would have wanted to order the panel of bloods and imaging as soon as possible, plus trying to manage the fact that this patient wasn’t likely to follow up (because he lived over 15km away, and was told not to drive due to his seizures – why would he continue follow up with me?).

 

 

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Just a little wobbly

If it was any of the organs systems that seem to scare me as a general practitioner, it is probably neurology. It is something that can be so subjective, and non specific in general, with sometimes no notable significant neurological signs. In particular, dizziness is one of my pet hates. But when there are actual demonstrable neurological signs, that’s when things get interesting.

A couple of weeks back, I had the fortune of seeing such a gentleman with significant pathology. He had spent the weekend at a location about 8 hours drive from where I work, doing a bit of crane driving for a mining project.

His daughter accompanied him in to the practice.

“Doctor, I’m concerned about my father. Today is the first day I’ve seen him back after his weekend job, but he is not himself. He can’t even walk properly. Something is seriously wrong.”

Unfortunately, it was the first time I had seen this gentleman, so I had no baseline to compare his current self with. What I did notice, was an unsteady gait however.

On exploring his history, he had apparently been involved in a truck rollover accident, for which he went to a tertiary hospital and had head scans which did not reveal any significant bleed. He was not on any anticoagulants or blood thinners, and had no significant past medical history.

Examination revealed 3-4/5 weakness of the left upper and left lower limb regions in power, with cranial nerves intact. PEARL

Thinking this could potentially be a stroke, a CT brain was ordered. The radiologist phones me up.

“The CT brain scan has some significant findings with bilateral subdural haemorrhage and a 5mm midline shift. ”

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That was all the information I needed for an urgent referral to the Emergency Department.

A few weeks later, I see the man again, and he is walking normally.

“Doc, they cut my head open and drained out all the blood. I’ve just come in to see you to determine if my staples are ready to come out yet.”

A neurological examination was completely normal. Here was a man who a few weeks ago, had trouble walking and seemed vague at times, and now he was walking normally with everything back to normal.

It was at that point that I marvelled at the wonders of modern medicine and how much of a difference could be made to the patient.

The patient later revealed that apparently, the hospital were not certain if there was a small bleed in his brain 6 weeks ago after his truck accident, and had advised him to return for regular check up with information advising him of this. He didn’t read that information, so didn’t think much of it. This may have lead to a continuous ongoing bleed, up till the time of presentation when there was too much blood present.

Antidepressant

Once upon a time, patients were less informed about the different kinds of medical conditions, much less the treatment advised for certain medical conditions. Nowadays, medical information is so ubiquitous with the internet accessible to anyone all within a pocket’s reach.

I don’t mind patients learning about their medical conditions through the internet, and coming up with questions to ask me in regards to some medical conditions. In fact, I welcome patients reading and learning about their medical conditions. What I do mind however, is the patient who relies solely on the internet, and believe this information is a substitute to the doctor. Dr Google in essence can help treat the patient’s medical condition, and all they need to see the doctor for is so that they can stamp a prescription that Dr Google has advised them they may need for their (potentially misdiagnosed) medical condition.

I have had one argument with a patient in regards to this very same issue.

One patient stands out, just in the fact of how ridiculous his demand was. He was in his 40’s, and had been on sertraline for his depression, having been started on this by another GP at my practice about 3 months ago.

“Doctor, I’ve come here for some more antidepressants. But that last one I had been given is really causing issues with erectile dysfunction. I looked up information about antidepressants, and I want to get some bupropion since it has less side effects of erectile dysfunction. Actually, the last GP that saw me even advised that I could get some bupropion in the next visit.”

I look through the past notes of his last visit, and note no mention at all about use of bupropion. I am confused in fact. Surely, bupropion is only used for smoking cessation from memory? The fact that the patient has brought this up makes me feel like I may have not learnt about the “antidepressant” properties of bupropion.

“I am fairly certain that bupropion is not recommended as a suitable antidepressant as per the guidelines, but I will double check to make sure. ”

I google bupropion, and confirm that it is definitely used for smoking cessation, and it is not used as an antidepressant.

“Having looked up the information and guidelines, bupropion is only used for smoking cessation and not used as an antidepressant. Unfortunately, I am unable to prescribe bupropion for you to use as an antidepressant.”

The patient glares at me. “I don’t understand, the previous GP said he would give it to me. Why don’t you just prescribe it to me?”

“I cannot prescribe it because it is not used as an antidepressant. I have no record in the past notes ever documenting that the previous GP recommended use of bupropion as an antidepressant either. ”

“Are you for real!!!?? You had to look up this information on Google. All you have to do is just write me the script! It’s that easy!”

“As I told you, the medication is not suitable for use as an antidepressant. I am happy to prescribe your previous antidepressant sertraline however.”

“I’m going to report you!!!!!” And with that, the patient left the consult room.

What I learned from that experience was to never let a patient pressure you into doing things just for the sake of keeping them happy.

I think at my current practice, there is going to be a whole lot of such patients who think that a 10 minute Dr Google search can replace the extensive medical training and clinical experience that I have acquired over the last 8 years. I don’t mind patients looking up information to get a better understanding of a certain condition, but I just hate it when they use that information as a substitute for proper professional medical advice.

Oxycodone

Working in a first available GP clinic gives me the wonderful opportunity to see how other doctors in my practice are managing these patients who come in to see the first available doctor. I must admit, sometimes I am scared.

Take the case of Mrs X, a woman in her mid thirties. She came on a Saturday at 7pm. Having had a read of her medical summary at the start of the consult, I note that she has had issues with back pain, having had a recent back injury, likely a simple musculoskeletal back strain. I quickly glance over at the previous treating GP’s notes, and see a few prescriptions of endone. I seriously hope she doesn’t ask me for more endone.

“What brings you in today Mrs X?”

“Well, there’s really only two things today doc. I’ve been having these flu like symptoms for the past 3 days. And the other thing was that I just wanted a pregnancy test. I’ve heard that there have been some recalls with some brands of home pregnancy kits with false negatives.”

After doing the usual history and examination, I give the patient a urine jar to collect a urine sample, and advised to come back into the room afterwards.

With the patient out of the room, I snoop back to the previous GP’s notes and the entries made.

2nd March 2017 – Presents for review of back pain. Wants Endone repeat.  


Scripts written: Endone 5mg, quantity 120. 5mg QID PO

 

15 March 2017 – Review of back pain. Needs more pain relief.


Scripts written: Endone 5 mg, quantity 120. 5mg QID PO

 

Having had a read of these notes, there are many things wrong. First are the extremely brief notes. Having read many of this doctors notes, his notes are at maximum 2 sentences. They hardly document anything at all, and I would believe theses notes will not hold up in a court should he need to give evidence.

Secondly, the fact that a whopping 120 tablets of endone needed to be given. Add to the shock, that 120 tablets should last 30 days, yet this patient has needed to get another script in just about 2 weeks.

Having been at this practice for just 6-7 weeks, I have only prescribed 10 tablets of 5mg endone to one patient who had excruciating hip pains from a work place injury. Even then, I had trialled him on just some panadeine (paracetamol + codeine) prior to stepping up to endone.

This makes me conclude that some GPs probably just end up giving anything the patient asks so that the consult won’t extend over 5 minutes (which in my opinion, is a very shocking way to practice medicine – at the end of the day, I will make my own decisions according to my own independent assessments, not on recommendation of the patient). I have had the temptation to do that at times just because it seems like the easy way out, but I always tell myself, the easy way out may sometimes be the wrong way out and end up later on, being the hard way out (eg when asked to justify decisions, or when in court for such decisions).

 

 

Postnatal Checks

Having been on obstetrics and gynaecology, I have had to do a fair few postnatal discharges as a resident.

These postnatal discharges are quite repetitive I must say, in that it’s always the same questions. You find out how they delivered their baby, what blood group they are, whether they are rubella immune or not, what complications arose in labour etc.

With any woman that has had a 3rd or 4th degree tear, they have to had opened their bowels before they are allowed home. In addition, they must be getting regular laxatives (usually lactulose) while as an inpatient.

Around the time of Christmas, I see a woman who had a 3rd degree tear. She hasn’t passed bowel motions for the last 5 days. Reading through her notes, she’s been seen by previous residents, even had a general surgery consult in regards to exclude any anal dysfunction. I panic at the prospect that I have to see her.

I eventually decide that I need to see her everyday, after looking at the anus, and noting normal anal tone. She tells me that she’s starting to get abdominal pains, and I think I can feel the poo in her tummy on palpation. Poor thing.

For the next 3 days, I see her every day, always asking if she has pooed yet, and if she has passed wind yet. Still no. It’s about 2 days out from Christmas. The patient informs me “I really do hope that I pass a bowel motion soon. My wedding anniversary is on Christmas.”

I make light of the situation (it’s too good to pass) “Oh goodness. I sincerely hope that you won’t be in hospital waiting for a poo on Christmas and on your wedding anniversary!”.

Pumping her full of laxatives, the patient questions my medical management. “Is there anything else you can do aside from just giving laxatives? I mean I’m really concerned something bad is happening”. I reassure her that the abdominal x-ray series has excluded a bowel obstruction, and that we are giving optimal medical management.

“There is no other alternative aside from either manual disimpaction or inserting a tube up your anus to flush the poo out. But with your 3rd degree tear, those aren’t really good ideas”. The patient almost faints after I explain manual disimpaction, wriggling my index finger. “How will the index finger get the poo high up out!!!???”

I think I was enjoying myself too much teasing this patient. Not in a mean way, but in a light hearted way so as to make the situation less serious.

After seeing her on the 3rd day, news gets out that she has some incontinence. Only a few mls according to the patient however. An hour later, and she has opened her bowels with a massive amount of faeces. I try to see the patient to congratulate her, but she seemed pre-occupied in the toilet. Unfortunately, I wasn’t able to see the patient as I had to rush off to the clinic. But I’m proud of the laxatives I gave this patient.

I feel happy for the patient. At least she doesn’t need to spend Christmas and her wedding anniversary waiting for a poo.

Signs of Impending Death

The title of this post may sound too medically based, since it seems to focus more on just the signs of death. But having a palliative care doctor assign me this topic to present at our next palliative ward round, I figured it would make for an interesting read.

I was 25 when I witnessed a patient who passed away in front of me. I was still an intern then, and was asked to see the patient in front of many family members. The patient had agonal breathing – periods of deep sighing breathing, followed by long pauses of silence. After a few minutes, the patient stopped breathing at all. Being fairly uncomfortable in such a situation, all I could do at the time was examine the patient, and inform the family that their loved one has passed away.

That was some 3 years ago. I have assessed many more deceased patients since then.

Having used an ebook database, I find out that some of the signs of impending death include:

  • Decreasing cardiac output: increased heart rate, hypotension, cyanosis, mottling, livedo reticularis
  • Renal failure: oliguria, anuria
  • Neurologic dysfunction: decreased level of consciousness, terminal delirium, hypo/hyperactivity
  • Reduced oral intake.

During our palliative ward round, we see a patient who seems to have signs of dying. It was an elderly man who presented due to what appears to be pneumonia. He was drifting in and out of consciousness. He had reduced oral intake. And he looked pale. The man ended up succumbing to his pneumonia, despite IV antibiotics we were giving. Realistically, he didn’t improve after 3 – 4 days of IV antibiotics, and so we had to explain to the 2 daughters that he wasn’t likely to pull through.

I remembered this man from a few weeks back. He was up and talking back then, cracking a few jokes even. I found it hard to believe that he was so well just a few weeks ago.

From what I’ve seen, disease does not discriminate against people. It attacks people of any age.

Breaking Bad News

Having been in oncology/palliative for the past couple of weeks, giving bad news was bound to happen some time.

In medical school, it was always about SPIKES. That’s:

S – Setting – Make sure you’re in the right setting for such a discussion where there is minimal interruption, and plenty of time available for discussion.

P-Perception – Gauge an understanding of what the patient knows to date about their condition so that you know how much you need to tell them.

I-Invitation – This for me seems to be the hardest to get my head around. But the invitation is the time where you essentially ask the patient how much information they want eg “with your recent CT scan, would you like me to tell you everything about it even including the not so nice information, or would you like me to skim through the results and go onto treatment options?”

K-Knowledge – This is essentially the delivery of the detailed information to the patient.

E-Empathy/emotions – Be empathetic and understanding. Essentially, if a patient is crying, offer some tissues. If they look stunned, and shocked, give them some time to process the information.

S-Summary – This is about repetition of the information given beforehand. It’s likely many patients have stopped absorbing information after the initial bad news. Repetition allows them to get the information again.

 

Having been the radiation oncology resident (in addition to the palliative/oncology resident as well – where’s my triple pay?), I was tasked into reviewing radiation oncology patients. There had been this one lady in her 70’s, who had recurrence of vaginal vault cancer, with previous groin lymph node removals for her cancer. She was undergoing radiation therapy with potential curative intent initially.

When the patient was initially admitted under radiation oncology, palliative services were provided, given the patient had pain issues on mobilizing. What didn’t help was this patient had a BMI of 53.

On the palliative ward round, the patient had advised of left hip pain as well. An examination revealed extreme tenderness on passive motion. So a CT hip scan was ordered. And then a CT chest and abdomen were ordered as well (let’s scan everything as well while we’re at it! ). The CT results weren’t good. The left hip pain – completely explained by a pathological fracture at the left hip – specifically the labrum of the hip. And the abdomen – showed that there was a right adrenal gland metastases.

With that CT scan, the patient had gone from “potentially curable” to “incurable”. Of course, being the resident to first see these results, I had the unfortunate job of breaking such bad news. The husband and the patient were lovely people, and were very friendly. Being Italian may have had something to do with it.

So, after reading and re-reading the report numerous times, I prepared to walk over to tell them the results. I was scared though. Scared that I’d break the news terribly. Scared that perhaps the husband might get angry and start shouting at me.

It wasn’t as bad as I had thought, and the patient and husband were very understanding people. On reflection, I don’t think I did invitation in the SPIKES protocol too well. But then, it seems like a really awkward way to ask a patient “if they want to know everything, or only a little of something”. I ended up just telling her “unfortunately, the scan appears to have showed that your cancer has spread to the left hip region, and to the glands sitting above the kidney”. I later explained that given the spread, the prognosis is not too good now compared to her previous well localized cancer.

The husband later ended up telling me how he appreciated my honesty and the straightforwardness of telling them. “You’re not like the last doctors that kept beating around the bush”. Well, I suppose the previous doctors had more uncertainty in breaking the news back then compared to me who had clear results from the scan.

On reflection, I think that it was a very important learning experience. I’m pretty sure as a GP next year, I’ll have lots more of these situations.

You’ll never forget a patient like me

So today, I went on an extra ED shift. I’ve been on Ward Call for the past 4 weeks, but decided on one of my days off, I’d pick up an extra ED shift for some extra pocket money (really helpful when you’re about to go on a date soon).

With the large amount of patient’s you see in ED, one is bound to find a few crazies in there. And today, I found a crazy. Not violent crazy, but pleasant crazy in a way that is just entertaining.

So I see a woman in her mid 30’s present due to a laceration of the right knee. Chased some kids up an escalator, and had a tumble, gashing it open. Why was she chasing the children? I don’t know. But she told me she had some alcohol prior, so maybe it’s alcohol induced laceration.

Anyway, I knew she was slightly crazy when she asked for something stronger than paracetamol.

“Doctor, this is the most interesting thing medically that has happened to me. Can you please give me something strong? Something like pethidine, or some knock out gas would do.”

“Erm…. No. We don’t even use pethidine anymore here in hospital. I can give you some paracetamol and ibuprofen.”

“But, but, I’ve made a massive gash in my knee! Surely it warrants something stronger than paracetamol and ibuprofen!”

“Well, I’ll be putting local anaesthetic in, so that should numb the pain when I stitch it up.”

“Can you please put in like twice the amount usual for your other patients?”

“We’ll see how things go as I inject.”

She later on reminded me a further 2 times about how pethidine or something “strong” would be great for her knee.

And so afterwards, with the laceration exposed after unwrapping bandages, I asked my registrar to cast an eye on it to decide best which stitch pattern to use (I thought I might have needed a vertical mattress, but turns out all simple interrupted sutures were all that were needed).

After my registrar left, the patient said “wow, that doctor looks grumpy. I wouldn’t want him to be doing this procedure.”

Later on as I’m stitching “Geez, that other doctor, is he always that grumpy? He looks permanently angry. He’s actually kind of cute though. Is he single, is he married?”

“By the way, are you single or married?”

Good grief…..

After putting in 8 stitches, the patient thought that falling on an escalator to make the gash in the knee was too boring of a story. So I suggested to her that maybe she could tell people that after having some alcohol, she decided she needed to do battle with the evil escalator, and in the end, knee vs escalator left her knee smashed up at the end.

“Hahaha. I bet you’ll never forget me as your patient. I’m so interesting, and you’ll remember me forever!”

Ha. Yes, she was right. I won’t forget her. But you’ll remembered as that “crazy lady with right knee gash from escalator”. And she gets to be memorialized in my blog as well.

All In A Day’s Work

For the past week, it has been extremely busy. I attribute this to the deck phone I’m holding, the patient load my team has, and just being unlucky.

Firstly, the deck phone; it’s a blocky black and grey phone, which vibrates, and plays a ring tone that makes me shudder in fear every time it rings. It’s constantly like a lottery, except it’s a lottery of bad luck. If I’m “lucky”, I might just get a call about giving a phone order for Paracetamol. If I’m “unlucky”, I might get asked to see a patient who has chest pains, or someone who is short of breath (as I was told to just this morning).

My deck phone is extremely efficient; at creating more work that is. For some reason, I’m always the one holding it, even though there is a registrar and another intern on the team. If the registrar borrows the phone to call someone, it will somehow always make its way back to me. Same with when the intern “borrows” the phone. It will be handed straight back to me. Perhaps the most amusing incident was this morning, when the registrar said to me “since you’re on phone duties, would you like to make the phone call for transport services to get this patient transported to the metropolitan hospital?” Since I’m on phone duty…. I never wanted to be on phone duty actually, but I’m always being handed the phone by you guys anyway.

On my first day on the team, I told the intern, “I’ll take the phone today, but let’s take turns holding the phones on alternate days.” Seems that somehow this conversation was forgotten. I suppose partly it is my fault in not enforcing this upon the intern.

Today was particularly bad however. As I got on the lift to see a patient downstairs, my phone rings. I need to put a cannula in a patient. The patient needs protective equipment used (gloves and gowns). Starting the procedure, and all gowned up, the phone rings. I am not allowed to answer the phone because I’m gowned up, and because I’ve already started the procedure. The phone rings once for about 20 seconds, and then hangs up. This is followed by another two times. I think that it must be urgent given how many times I was called. Is a patient dying? Finishing the procedure, I call back, only to find that I needed to write up some eye drops for a patient. 3 phone calls missed consecutively, just to write up some eye drops? My goodness, I am scared to find out how many times the phone would ring if I was unable to answer it, and it truly was for a patient that was sick/dying.

Aside from the deck phone, the patient load seems to be quite a bit lately. We’ve been getting a few patients with some being a little bit sick.

There was one patient that I had to see yesterday who was tachypneic. A very anxious elderly lady who was essentially palliative, having a left mid ureteric stone, urosepsis and end stage COPD. She was deemed too great an anaesthetic risk to have her kidney stone operated on. So, having tachypnea of 32, and then later finding out her phosphate levels were critical, and then later finding out her troponin was elevated presented a major nightmare. In addition, the consultant wanted CTPA (her kidneys were too shot to be safe for the contrast) and the patient had refused a V/Q scan. So not really knowing, I ended up just putting the patient on therapeutic clexane. But wait, the patient had haematuria a few days prior….

When I saw the patient yesterday with her daughter, I explained to her about her deterioration, and why I was giving her IV phosphate. She asked me if I could euthanize her yesterday. She still asked me if I could euthanize her again today. I had to politely explain to her that in Australia, euthanasia was illegal, and I certainly was not going to euthanize her. I ended up phoning my consultant for further management, and spoke to the ICU reg in regards to placing the patient on CPAP. I suppose the patient appreciated that I was doing what I could to help settle her SOB and tachypnea, and when my consultant came around, she told him “this doctor is really good, he’s been running around everywhere to help me”. That was perhaps one of the more uplifting moments for today for what was a relatively crappy day.

It was about 3:45 pm, and my back was aching from the busy day. Just one more patient to see. But upon seeing the final patient, they seem to have had it for me. The patient had been on isolation precautions, given that she could have had respiratory viruses. Having been visited by masked nurses, and told to stay in bed likely, I can understand the patient’s frustruation. I was just unlucky enough to come in and get blasted to smithereens by this patient’s frustration.

When it comes finally time for home time, I decide to check my email and find out the new updated roster. The person doing the rosters had decided to put me working on Sunday now, without contacting me at all. It’s almost like I’m indispensable, and not doing anything on Sunday. I email her, and tell her that I already had plans on Sunday, and to schedule me in on such short notice, the very least she could have done was call me first. Yea, I doubt I’ll have this coming Sunday off. Best crappy end to the day of a very busy day.

Now, onto the dreaded tomorrow; the intern will be off tomorrow, so it will be just me and the registrar…. I really need that Sunday off….