medical sense(less?)
Do or Don't?
NOTES:
a different opinion is not an attack. it's just not your opinion.
.
if more than one person disagrees with you, it's not necessarily a ganging against you. you are either wrong or in need of new company.
an all new whoa!!
Believe it or not, but this actually happened!
Below is a provider network text exchange:
As if that wasn't enough, another doc shares:
May 2025
liar
the fact:
* Medical networks have refined the ability to access patient records across multiple facilities at any given moment.
the case:
* The specialist finalizes his consultation in which he electronically documents his seeing and assessing the patient in Hospital Z.
* The patient is admitted to and currently resides in Hospital X.
the reflection:
* One may successfully discredit a patient, but one cannot discredit the time-stamped medical records.
* If you insist on practicing medical fraud, be a tad clever about it.
March 2025
disorganized or devilish
IUGR – Intrauterine Growth Restricted
L&D – labor and delivery
the case:
* An IUGR 35-weeker is ready to make its debut.
the act:
* Well in advance, even prior to prepping for delivery, the L&D nurse alerts the NICU nurse and RT for a possibly compromised newborn at birth.
* L&D nurse ensures that OB, NICU nurse and RT are present and ready well before pushing begins.
* As the high-risk newbie crowns, and not a moment sooner, L&D nurse calls the pediatrician.
the timing:
* Had the pediatrician quickly peed before reaching the delivery, the high-risk newbie would have been out (literally and likely figuratively too).
* Had the pediatrician, who simply rolled out of bed and raced to the room, been detained by 1 – just 1 minute, that poor little 4-lbs newbie would not have had its much-needed emergency resuscitation plan.
* The pediatrician had no time to delegate duties to the team should the baby emerge blue and unresponsive.
the point:
*The pediatrician needs to know the team to delegate duties for a timely and successful life-saving resuscitation. The worst scenario for a newbie is to have its lifesavers bumbling about like headless chickens. Poor newbie would have lost its chance before the chance had been granted.
the outcome:
* The Greatest Medicine intervened and ushered the new person into life without a hitch.
the aftermath:
Peds | Charge Nurse
“You have to call me in advance so that I can prepare a team for possible emergencies, like intubation.”
“Oh, you guys don’t get sign-out in the morning, like, between yourself.”
“Sign-out lets us know there is a 35-weeker in the hospital; yeah, I got that sign-out; but not when the baby’s coming out and who’s in the room. You can’t call me the second the baby is on the way out. Sign-out cannot tell me that.”
“Oh yeah …"
the question:
Is the pediatrician out-of-line and being a tad melodramatic for a mere oversight?
Or
Is the nurse guilty of premeditated sabotage?
October 2024
the intent? patient care vs. doctor torture
you decide ...
July 2024
what's the student's takeaway?
the case:
Suicidal patient attempted to hang herself while in the hospital.
As the patient awaited discharge to an inpatient psych facility, under the permission of the primary nurse, the nursing student assisted the patient in writing a suicide note in Spanish.
the intention:
Was this a lesson in patient sensitivity?
Was this a drill in listening?
Was this an exercise in empathy?
Or was this merely a means to offload a burden?
the matter:
Is the distinction between healing and harm evident?
Is it healing to assist suicide? Is it harmful to assist suicidal persons articulate their feelings?
Or is it keen tactic to occupy a desperate mind until discharge?
(… Or could it merely have been misguided instruction?)
June 2024
sense and sensibility
The art of deduction - is it an antiquated practice?
Order: Activity as tolerated
Order: Patient can come off monitors as needed for tests and procedures.
Response: Can pt shower?
(Yep, looks as if reasonable judgment is indeed extinct.)
March 2024
sure, might as well admissions
CC: vomiting and bloody stools, “a lot of blood, massive amounts”
HPI: Known drug-seeking 61-yo had been driving then felt nauseated and vomited blood.
Exam: Not in acute distress. Normal Vital signs normal.
Labs: Normal hemoglobin
ED Assessment/Plan: Consult GI given story of hematemesis and inability to tolerate po
GI Assessment/Plan: Admit and, since she’s coming in, might as well do an EGD.
Hospitalist:
Pt sleeping peacefully as he entered the room.
As soon as Pt spots doc, she complains of pain and asks for food.
She asks for pain medications multiple times throughout the assessment.
Hospitalist tries redirection, stating matter-of-factly that opiates are not the treatment for what sounds like gastritis.
Hospitalist explains gastritis and EGD procedure.
Pt agrees.
Hospitalist says you’ll get clear liquids until completion of the EGD.
Next Day
EGD: No bleeding. Gastritis and Esophagitis
Exam: NAD. VS normal
Labs: Hgb still normal
December 2023
hpi vs. pmh
HPI: Patient complains of persistent 1-week cough.
PMH: Cirrhosis
ROS: Intermittent melena but nothing in recent months
Vital signs are stable. Hemoglobin is 13.2. Imaging confirms pneumonia plus probable esophageal varices.
ER doc asks hospitalist to admit due to concerns about an Upper GI Bleed.
Hospitalist is uncertain about admitting the patient with stable vitals, normal hemoglobin and planned oral treatments for pneumonia.
ER doc quotes an evidence-based scoring system.
Hospitalist counters, noting the lack of clinical evidence and instability to justify acute medical treatment, then concludes the patient is stable for discharge. The hospitalist further suggests outpatient evaluation for any elective investigations.
ER doc informs hospitalist that he had earlier phoned GI, who had seconded the motion to admit.
Amiably, hospitalist excuses himself to speak with GI.
GI was unaware that the hemoglobin is 13.2. GI now seconds that the patient can go home then follow up as an outpatient. GI further suggests repeating the hemoglobin in 4 hours if the ER needs to do something prior discharge.
Repeat hemoglobin is normal.
Hospitalist hears nothing more from ER doc.
So ...
With a history of esophageal varices, in theory alone, a cirrhotic shall always be at risk for GI bleed.
This possibility shall invariably remain a viable possibility.
However, an incidental finding of varices in the absence of bleeding renders this possibility unpromising and any risk score hollow.
In medicine, the past undoubtedly plays a part in the present. Our challenge is to be certain whether the past is the present or whether the past must remain in the past.
November 2023
mullerian and wolffian are not one and the same
Excerpt from Under the Collar: Frank Conversations about Healing that Harms
-
A patient presents to the ER. As part of routine work-up, the doctor orders a pregnancy test.
The patient is a visibly ego syntonic, biological male.
-
A patient presents to the ER. As part of routine work-up, the doctor orders a PSA (Prostate Specific Antigen) for his patient.
The patient is a visibly ego syntonic, biological female.
June 2023
rhyme- & reasonless copy-cats
Cut-and-paste has become a necessary evil in electronic medicine. The absurdly proliferating, hairsplitting mandates for documentation reduces the most diligent scribes to right click.
Still, the inevitable cut-and-paste requires parameters. It must be done discerningly, germanely, sensibly.
Typically, a patient’s course changes after admission, rendering the initial H&P a mere preamble by hospital day 5. The initial note requires editing. If a snapshot were taken of the day 5 note, and it had not been altered from Day 1, the author could be sued. What rebuttal can the author pose when challenged, “What did you do for this patient, because this looks identical to the one five days ago, Doctor?”
Case:
A patient with a history of prostate cancer presents with severe hypercalcemia, stones, bones, abdominal groans, and psychic undertones. IV bisphosphonates and fluids are needed, but poor renal function precludes bisphosphonate treatment. Imaging reveals lytic lesions.
A swirling differential diagnosis impelled the admitting hospitalist to review the patient's course 3 days later.
Three days later, the rounding hospitalist’s note differs solely by the date of service. According to the rounding hospitalist’s note, none of the admitting lab results came back, no new labs were ordered, no other treatments were implemented. After 3 days in the hospital, it seems the patient still has life-threatening hypercalcemia, stones, bones, abdominal groans, and psychic undertones.
(Perhaps the patient should have stayed at home.)
February 2023
against medical = no medical
AMA – Against Medical Advice
Patient shouting:
“I WANT TO LEAVE AMA! LISTEN TO ME SO YOU CAN GET IT THROUGH YOUR THICK SKULL!”
Four hours later, nurse calls hospitalist about the patient asking for pain meds.
Hosp: He’s not my patient. He’s AMA.
Nurse: Well, the ER doc who was caring for him is gone.
Nurse waits.
Hosp: Well, I’m not prescribing him anything. Matter of fact, no one should.
questions?
-
Why is that patient still in a hospital bed?
-
The patient wanted Percocet. When should a narcotic be given to a person leaving AMA?
-
Why would anyone call about anything for a patient who is no longer a patient
November 2022
captain save the day,
be certain the day needs saving
Captain:
*The integrity of Captain’s email is unaltered.
Hello Dr. Noe Itall,
“I was reviewing Pediatric (new born) H&P and all of them are missing ROS (review of systems). According to the bylaws it is required to document ROS in history and physical. Can you please review and provide guidance on Pediatric (new born) H&P requirement of ROS?
Should Informatics flag for missing ROS in Pediatric (new born) H&P?
Thank you.”
Doctor:
Hello Mr. D. Don Key,
Thank you for bringing this to my attention. This is clearly a misunderstanding of what a newborn H&P entails.
Having been born at the time of admission, newborns have consistently failed to report preexisting ailments or disturbances.
Flagging newborn H&Ps for missing review of systems would be inappropriate.
It appears that the bylaws must be corrected to appropriately reflect newborn H&P requirements. I am happy to discuss this further if necessary.
Thank you.
July 2022
privileges versus rights
Administration assembles its hospitalists to inform them that meal privileges during work will be indefinitely suspended in the new month.
Riotous oppositions erupt across the room.
One doc scornfully blurts, “Now what I am supposed to take home to my family?!!!!!”
Is that a strong argument?
-
First, doc just justified Administration’s rule to end free food.
-
Second, doc just broadcasted that at least one hospitalist is taking advantage of the system.
-
Third, doc just admitted to insolent stealing from the company.
-
Fourth, doc just illustrated greed and petty theft are bosom buddies. (Afterall, he makes well over 6 figures.)
Finally, doc just revealed he is not the brightest bulb in the pack.
Say the passion makes said argument strong.
Fine.
But is the argument wise?
March 2022
who said what?!
Nurse interrupts collaborative rounds to inform the group that the patient has colitis.
The nurse was corrected as the discussion continued. The nurse interjects again with notes about the patient’s colitis.
The team asks why the nurse insists the diagnosis is colitis.
Nurse elucidates, “Because the patient told me.”
(Meanwhile, the EHR’s diagnosis is UTI, boldly printed prior to entering the chart.)
December 2021
easier said than done
In a hospital, the EICU fields after-hours nurse pages. While most pages can be settled remotely, occasionally the EICU doc will ask the in-house hospitalist to respond to concerns. As a result, a protracted course of action ensues:
The EICU doc pages the hospitalist.
The hospitalist calls the EICU triage.
The hospitalist waits on hold for the EICU doc to take the call.
The EICU doc gives a patient summary.
The EICU doc relays his conversation with the nurse.
The EICU doc states his petition for the hospitalist to see the patient.
The hospitalist reasons with the EICU doc if the petition is questionable.
The hospitalist concludes the conversation with the EICU doc.
The hospitalist must either see the patient or protectively document his reason for not seeing the patient.
The hospitalist returns to his pending admissions.
The hospitalist gets another round of pages for more admissions (+/- more EICU patient visits).
On this night ...
The EICU doc calls about a patient on CIWA-AR (Clinical Institute Withdrawal Assessment Alcohol Scale Revised) with Ativan prn treatment. However, the nurse told the EICU that the patient’s son told her that his father wasn’t withdrawing from alcohol but Xanax.
EICU doc: So, I was wondering if you could go see the patient and assess the patient.
Hospitalist: So, I would be assessing the patient for …
EICU doc: Well, I don’t know. I can’t tell on the phone what the patient is withdrawing from. So that’s why I’m asking you to go see the patient.
Hospitalist: So, how would I be able to tell a Xanax withdrawal from an alcohol withdrawal? (asked because there’s no difference)
EICU doc: Well, um, you wouldn’t. You, um, I mean…
Hospitalist: Yeah, because the treatment is a benzodiazepine which he’s already on. So, um, what would I be assessing him for?
EICU doc: Um, well, I think, I think the nurse would feel better if she saw your face. I think she just needs to see a doctor’s face.
September 2021
watch and watch ... and watch?
Doc noticed his 70-year-old gentleman’s creatinine bumped up from 0.7 to 1.2. Doc said drink more water then come back to the office in 6 months.
The gentleman shares his lab results with a medical friend, who notices that the BUN/Cr doesn’t support dehydration. The medical friend suggests a prostate issue that may require an ultrasound. The friend urges him to ask his doctor for reevaluation in 3 months.
Fate intervened two weeks later. The gentleman experienced increased leg swelling. He called his doctor, who ordered a repeat creatinine level. The creatinine increased to 1.7. Doc ordered a renal ultrasound and dipstick urinalysis.
Renal ultrasound revealed bladder outlet obstruction, bilateral hydronephrosis plus 2.7-3.0 liters post-void residual. On a Friday, Doc said the gentleman would be referred to a urologist.
The gentleman shared the results and plan with his medical friend, who gabbed to a urologist friend. The urologist friend said that retention screamed a chronic backup needing attention within a week. The urologist friend prompts the gentleman to contact his referred urologist office on Monday with news of an inability to pee.
Meanwhile, on Monday, the gentleman’s doctor suddenly felt pressed to expedite the referral then advised the patient to double his Cardura from the stable ten-year low dose. Urology saw the gentleman on Thursday. The urologist concluded the enlarge prostate required immediate Foley catheter placement followed by surgery within a month.
Two days later, with the Foley in place, the gentleman stood up, became light-headed and nearly fainted. He reported the occurrence to his medical friend. After discovering a systolic pressure in the 80s, the medical friend had the man outright stop the Cardura to prevent another near syncopal episode. His blood pressure remained within normal limits.
Post TURP, a renal ultrasound revealed nearly resolved hydronephrosis and the serum creatinine had normalized to below 1.0.
Everyone has moments when he doesn’t really know what to do. But, is scratching the head then shelving it for 6 entire months conservative treatment or avoidance?
June 2021
consult per usual or consult per need?
Pt with history of hypertension (160s/90s) and acute renal failure (Cr 2.0) is admitted to hospitalist service for acute appendicitis. He is growing more and more tachycardic amid fever and an elevated WBC. You see who’s usually consulted for general surgery then frown. It’s Dr. So-and-So. …
Surgeon So-and-So’s track record:
Pt 1 – History of ESRD presented with a sacral abscess. The surgeon said the ESRD is too risky for surgery and recommended antibiotics. Pt improved, escaping sepsis, but was extremely uncomfortable. Surgeon So-and-So went off service. The next surgeon in line took the patient to the OR for a successful, uneventful surgery. With good post-surgical pain control, the patient left the hospital, completed inpatient rehab then went home.
Pt 2 – A 30-something-year-old with mild hypertension and mild obesity presented with acute gallstone pancreatitis. The industry recommendation for biliary pancreatitis after resolution of acute disease is removal of the gallbladder before discharge. Surgeon So-and-So recommended outpatient follow-up for an elective cholecystectomy. Pt returned a second time for acute gallstone pancreatitis. Surgeon So-and-So again recommended outpatient follow-up for elective removal. Pt returned a third time for acute gallstone pancreatitis. A different surgeon completed a successful, uneventful cholecystectomy.
Pt 3 – Pt admitted for septic cholecystitis. Surgeon So-and-So said Pt is too unstable for surgery and, instead, recommended a cholecystostomy tube by Interventional Radiology for biliary drainage. Pt suffered an MI, landed in the ICU, developed cardiogenic shock and, now, became too unstable for surgery.
Pt 4 – Pt admitted with volvulus complicated by septic bowel necrosis. The blood pressure was stable, but Pt was tachycardic and febrile with an elevated WBC. Approaching DIC (disseminated intravascular coagulation) with an INR nearing 7, Pt also had modestly low platelets (100s). Surgeon So-and-So said Pt was not a candidate for surgery because of the elevated INR. FFP (fresh frozen plasma) can quickly reverse the INR, which can be given on the way to the OR, in the OR, and during the procedure. Pt died from septic bowel necrosis due to volvulus.
Now, as you hover over mouse and keyboard, do you still click and type the usual?
May 2021
roulette conception
30-year-old woman with poorly controlled hypertension is taking methyldopa, labetalol, and nifedipine.
Her doctor is trying to determine an alternate medication to bridle that blood pressure.
Without prompting, the woman discloses that her husband and she are considering another baby. She says she isn’t actively trying but doesn’t use any form of contraception.
The doctor suggests replacing one of the antihypertensives with a teratogenic ace-inhibitor. Doc advises the prospective conceiver to proceed with the teratogen which will be stopped once she becomes pregnant.
… but … Known or confirmed pregnancy rarely occurs the second, hour, week, (sometimes) month successful conception occurs.
So, what to do? Gamble that blood pressure into something normal with a teratogen, then start from scratch once the baby is discovered in the womb?
April 2021