“No.”
“Have you been short of breath?”
“No.”
“Are you coughing up any sputum?”
“No.”
“Any other symptoms?”
“No.”
“What made you decide to come in tonight?”
“I just thought it was about time I got some penicillin for it.”
Her examination is completely benign. Since I know what she is expecting from this visit, I carefully explain to her why using antibiotics to treat viral upper respiratory tract infections is not appropriate.
She takes a moment to mull it over, then adroitly changes her tack.
“Can I have a chest x-ray, then?”
She doesn’t need that either, but since she obviously has no intention of leaving this department empty-handed, it’s a compromise I can live with. I write up the requisition.
“The x-ray department’s closed now. Come back on Monday morning and they’ll do it then.”
As I turn to leave she says: “You know, my son should probably see you, too.”
I’m crestfallen. More business. Precisely what I do not need at this hour of the night. I don’t recall seeing anyone else in the waiting room, though.
“Where is he?”
“At home. Can you stay here while I go and get him?”
“Well, that depends. What’s wrong with him?”
“He was in a car accident.”
“A car accident? What time did it occur?”
Oh, it didn’t happen today; it was about a month ago.”
“A month ago?”
Yes. His chiropractor says he’s got whiplash, but I think we should get another opinion.”
“You want a second opinion on a Saturday at midnight?”
“Yes, I’m wondering if maybe he should be getting some other type of treatment.”
There are a number of ways I could respond to this request, but most of them would probably earn me a stern reprimand from the College of Physicians and Surgeons.
“Why don’t you bring him in on Monday morning when you come for your chest x-ray?” I suggest sweetly.
“Will you be here Monday?” she asks.
“Yes.”
“Okay, that sounds good! Good night, doctor. By the way, you should try to get more sleep – you look really tired!”
It’s Got to Be in Here Somewhere
Recently a middle-aged woman took a tumble while jogging on a dirt road. She fell with her arms extended, so her palms and wrists took the brunt of the impact. In ER lingo that mechanism of injury is known as FOOSH, or “fall on outstretched hand.” Hey, don’t look at me – I’m not the one who comes up with these half-baked acronyms. Anyway, after going home and removing as much of the gravel from her wounds as she could, she presented to our emergency department. Once I was satisfied there were no other significant injuries I applied a topical anaesthetic gel to her abrasions and scrubbed all the dirt out.
“How’s that?” I asked her when I was finished.
“Much better, although it feels like there might still be something in here,” she said, pointing to the middle of her left palm.
“Okay, I’ll send you over for an x-ray.”
Fifteen minutes later I went to the radiology department to look at her films. To my chagrin, there was a pebble-sized object in the centre of her left hand. It appeared to be right on the surface of the skin. How the dickens could I have missed such an obvious foreign body? I returned to the ER with the x-rays and carefully reassessed her hand, but I couldn’t find the offending piece of gravel. After a brief discussion we decided our only option was to go in and retrieve it.
Using her films as a map, I infiltrated her left palm with local anaesthetic, made an incision and started looking. No mysterious particle popped into view. I did some blunt dissection. Nothing. I extended the incision radially and continued the search. Nothing but blood. Several minutes passed. Where the hell was it? Every so often my patient would ask, “Find it yet?”
“Not yet, but it’s got to be in here somewhere.”
After what seemed like an eternity, one of the x-ray techs walked into the room.
“Oh, there they are,” he said. “I’ve been looking for these films all over the place. The radiologist wants to read them before he leaves.”
“Could you please ask him if he’d mind waiting for a couple of minutes? I’m using them to help me locate this foreign body.”
“What foreign body?”
“The one in her palm,” I replied, and pointed it out on the film.
“Oh that,” he said. “Didn’t you get our last memo? We’re not using the old arrow-shaped marker to show the spot where the patient has the foreign body sensation anymore. The new marker looks just like a little pebble.”
Semantics
A while back I saw an ER patient who was complaining of a persistent cough. It appeared to be nothing more than the common cold, but because it had been going on for a few weeks I elected to send him for a chest x-ray. Once the film was processed I went over to the radiology department to look at it. It was completely normal - no pneumonia, cardiomegaly, congestive heart failure, pleural effusion, pneumothorax or anything else of significance. I went back to the patient’s cubicle to wrap up the interview.
“Well, Mr. Kowalski, I don’t see anything on your chest x-ray.”
“Nothing at all?”
“That’s right.”
“Okay. Thanks anyway, doc.”
I thought he looked at me a little strangely as he left, but I figured I was just being paranoid. I moved on to the next patient.
An hour later I was back in the radiology suite reviewing another film when one of my colleagues showed up. He pulled out the chest x-ray of the patient with the cough I had seen earlier.
“I already looked at that one,” I said. “It’s normal.”
He seemed taken aback.
“What did you say to him?” he asked.
“I told him I didn’t see anything on his x-ray.”
He started laughing.
“What’s so funny?” I asked.
“He called me at my office in a big panic saying he had just had an x-ray at the hospital but the doctor who had ordered it didn’t know how to read it.”
“What made him say that?”
“You told him when you looked at his x-ray you didn’t see anything.”
Needless to say, ever since that day I’ve changed the way I tell patients their x-rays are normal.
Rocky II (The Sequel)
It’s yet another Saturday morning and I’m back for more punishment in the ER. Where did all the people in the waiting room come from? Five minutes ago the joint was empty. Maybe spontaneous generation does exist after all.
My leadoff patient is none other than the infamous Rocky. Once again he’s toxic and on the verge of hurling. Whenever he shows up like this I usually end up admitting him for a day or two to help him dry out. Things are a little different today, though – there are only two empty beds left in the entire hospital. If I admit him to one of them I’ll be snookered if I need beds for sicker patients later on in my shift. To the best of my knowledge, Rocky has never had any potentially dangerous alcohol withdrawal problems such as the DTs or seizures. After careful consideration I make an executive decision to turf him to a detoxification centre. I ask the ER charge nurse to have switchboard locate the closest detox centre’s intake worker.
“Aren’t you forgetting something?” she asks.
“What?”
“They won’t want to take him the way he is now.”
True enough. Detox centres don’t like their alcoholics drunk and barfy; they like them dry and stable. Most of them will only take “clients” who have been alcohol-free for at least a couple of days.
“Yeah, I know that.”
“So how are you going to convince them to take him?” she persists.
“I’m going to stretch the truth a little bit.”