Sunday, February 04, 2007

What's Wrong With This Picture?

Case #1: 35 year old gentleman, athletic, rides his bike for a living as a messenger. Previously admitted to our hospital for chest pain, he was thoroughly worked up for cardiac causes, all were ruled out, he was diagnosed with GERD and sent home on Nexium. 3 days after discharge, he experienced the same kind of chest pain (in the middle of his chest, radiates to his mouth), after drinking a large quantity of juice on an empty stomach. He never filled his Nexium, since he couldn't afford it. He came to the ER, where he was given Maalox (pain relieved) and admitted for a cardiac stress test. WTF???!!!

We discharged him the same day with a new prescription for another PPI.

Case #2: 75 year old lady, past history of stroke and heart disease. She was at Walmart in a nearby county with her husband, standing in a long line, when she felt a little tired. She sat down, and when she stood back up, she felt dizzy, so she sat down again.

That's it, that's all that happened: presyncopal episode.

Some concerned citizen called a helicopter to bring her to my hospital. This flight easily cost $15,000, and she really didn't even need an ambulance, let alone a helicopter.

Once in our ER, they may not have had much of a choice about admitting her since she came by helicopter emergently. She came to our service last night, was dubbed "Walmart lady", diagnosed with slight hyponatremia (likely due to her MULTIPLE anti-hypertensive medications), corrected, and left this morning.


What do these two cases have in common? WASTED RESOURCES. The unfortunate guy with GERD was a little anxious, I think, prompting an unnecessary visit to the ER. However, the ER should never have let him pass the threshold. Never. I know "chest pain" on a chart makes everyone sweat about lawsuits, but he'd seriously had the entire cardiac workup within like 2 weeks prior to this admission. All negative, all easily accessible by computer in his old chart. He had no risk factors, he was young and athletic, no problems riding his bike anywhere he needed to. AND his pain was relieved with Maalox. AND EKG AND CARDIAC ENZYMES WERE NORMAL IN THE ER.

Obviously, I don't know about all the cases that the ER refuses to admit, because I don't see them. I'm sure they do a great job on most occasions, even if we do make jokes about the "ER-bot", a machine that hits you with a head CT, chest x-ray, EKG, and shot of rocephin. Case #1, though, slipped through the cracks.

Case #2 is a weirder story. It would have taken a brave ER doc indeed not to admit someone emergently helicoptered in, I understand that. It may even be hospital policy, I have no idea. But who in God's name called the helicopter? Was it the podunk county hospital, fearing that the woman had had a stroke? Was it a concerned bystander, or the worried husband? One popular theory held that Walmart called the helicopter, fearful of a lawsuit from an injured customer.

She never lost consciousness, she had no shortness of breath or chest pain, no hemiparesis or slurred speech, she didn't have a seizure; she just felt dizzy. And she was certainly with it enough to thoroughly enjoy her helicopter ride.

As one intern said last night, "That $15,000 could have run a free clinic at [county hospital] for a month." I know the system isn't that simplistic, but still.

Another wasted resource in these cases is my team's time. Both of these patients had student H&P's, intern H&P's, orders to write, etc; then we had to round on them with the attending, so it wastes the attending's time, too. On both nights, our team capped on admissions, which means that we couldn't admit a patient in the ER because we admitted these patients.

Again, thank god for my attendings on this service, who have agreed with our plans to rapidly discharge these patients, so instead of seeing the lady with "pre-syncope" every morning for a week, I can see a patient who really needs to be seen. And the lady with "pre-syncope" can be at home, which is a much happier place than our hospital.


Jessica said...

Medicine just doesn't make sense to me. At least your attendings were reasonable about it.

I have a question for you? Any good, shiny, happy psych residencies in your neck of the woods? That a mediocre student could get in?

barbie said...

we go through that rotation in may/june. we can let you know what the residents say at that time. any good neuro residencies where you are (wherever that is)?

Phalanx said...

I am very, very proud of my wife... and she sometimes makes me very, very afraid of some of her counterparts!

(Not you, of course, Miss B. ;) )