Veterinarians and Pediatricians (and Pediatric ER Physicians too)
I’ve always thought that veterinarians have it tough. They see patients who cannot communicate. Their patients don’t speak or complain of symptoms. So veterinarians have to go by what owners have observed and by the physical exam for most of their data.
It’s kind of like a pediatrician or even a Pediatric ER physician. Little kids might not be able to complain. And when they do, they may be very vague, unable to give a good description of what they are feeling.
I recently worked a Pediatric ER shift where I saw a 4 year old patient who was transferred from another facility. The other hospital wanted us to rule out appendicitis because the patient had abdominal pain and a CT scan that was equivocal.
I went in to see this little patient who appeared to be lying comfortably in the gurney watching the TV hanging on the wall. The patient, who I’ll call Joe, didn’t seem to be in pain. So I asked his parents what the problem was. It turns out that Joe had been vomiting — up to 10 times over night — and that was why he was brought in to the ED. I asked if Joe was communicative at home. His parents told me he was.
Was Joe a child who would normally complain of pain like a stomach ache? Yes, they told me. Did Joe ever complain that his stomach was hurting? No, he didn’t.
At this point appendicitis was getting knocked down lower on my differential (list of possible diagnoses). I proceeded to sit down next to Joe and say hello. He stared back at me. I told him I was going to just take a look at his stomach and started to pull back the hospital sheet that was covering his belly.
Almost immediately he pulled it back. Apparently, this kid liked his stomach covered up. I pulled back a little and pressed on his stomach. He started crying. I tried to observe how he was crying — to see if he was just being fussy or if it was really painful. I started pressing on the left side and worked my way to the right lower area of his abdomen (where appendicitis typically presents with pain) and tried to see if his crying intensified as I neared that spot.
I finally gave up and let him cover up his stomach. But I tried one more time. This time, I pressed on his stomach through the sheet. This time Joe did not cry. I was able to press fairly deep all over his stomach without eliciting any cries of pain.
That pretty much did it for me. And, after more discussion with the parents about Joe’s symptoms at home prior to coming in to the hospital, I concluded that appendicitis was not likely in this little patient.
In the adult world, most patients are able to communicate. Sure, I’ve had adults who were unable to communicate with me, but the proportion of patients who can’t communicate is much, much less. I don’t plan on going into pediatrics or emergency medicine. But I can appreciate how difficult it can be at times. And I am thankful that there are people who choose to do it.
Source: jeffreymd.com
The Complexity of Informed Medical Decisions
sarainthought replied to your post: What the heck?
I agree its a poor example, as you say. But on a big picture, as an MD, where is the line on your beliefs & your practice? Not performing or not explaining the option? The issue comes up with birth control and it makes it quite an ethical issue.
It is a complex issue. But I do side with the majority that say it is not an obligation for an OB/GYN to perform a procedure he knows how to do if he is opposed to it and it is not an emergent situation. The OB/GYN should make a good faith effort to help the patient get in touch with a physician who is willing.
You do make a good point about explaining options, though.
I think it is very difficult, if not impossible, for most physicians to explain an issue and ALL the options without bias. We’re human. We do have a preference. And often, that preference will direct how we present information. It is what it is.
For example, an otherwise healthy patient has abdominal pain that the surgeon decides is due to gallstone. He would like to operate and remove the gallbladder. But prior to any procedure the physician must explain the risks and benefits to the patient. The benefit is that the pain could be resolved. The main risks of the procedure include bleeding, perforation of adjacent structures, and infection of the surgical site.
Now, how the surgeon frames the risks is key to selling any procedure. Most, if not all, will casually mention them and say that it’s possible but it hardly ever happens. The throw in statistics about how very few of these complications actually arise due to the procedure. For this fairly typical surgery in an otherwise healthy patient, no one is going to sit there and emphasize the risks.
It’s all how you sell it.
But often we have to sell it. Because we know it’s the best option a patient has. And we push for procedures because the numbers — the evidence — say it will offer the best outcome.
In the end, I think it is our duty to provide a patient with as much information about the options. But I also feel that it is our duty to care for the patient and to explain what we think should be done. To me, providing all the options without any guidance whatsoever is just as bad as holding back some options.
This is, I suppose, a shift in the practice of medicine. Fifty years ago, the decisions in medical care were very one-sided. The physician knew best. And He or she made the decision and the patient accepted it.
Today we have this this notion of informed consent — that the patient should be informed about his or her treatment and the available options. And this, overall, is a good thing.
We’re trying to change with the times. And I think we’re headed in the right direction.
An individual coming from an anthropocentric (person-centered as opposed to a theocentric) worldview could seriously question the validity of religious beliefs that lead individuals or groups to such horrible ends [as the Inquisition, slavery, the Ku Klux Klan]. But in the name of tolerance, these same individuals who view autonomy as the summum bonum should at least be willing to consider religious beliefs rather than dismissing them out of hand. While not determinative, religiously based claims should not be automatically dismissed as mystical, nonscientific, or irrelevant.
“You’d be surprised.”
Not long ago a classmate and I were told that there was a patient who needed his chest tube removed. The intern said one of us would do it. Initially I was going to do the pulling. But it really didn’t matter. Neither of us had ever done it.
Before we reached the patient’s room, our intern verbally walked us through the steps we needed to do in order to safely remove the chest tube. After all, you don’t want to be giving instructions at the bedside while the patient is awake and afraid.
It turned out the patient was very afraid. He had just experienced having a chest tube removed a few days ago. For reasons I was not familiar with (as I had never met him before and never looked at his chart), he had required a second chest tube. Now, though, it was time for the second one to come out.
As I bent over the bed cutting off the sutures the patient continued to express his fear. It had been very painful the last time it was done. He also wanted to make sure that we waited long enough for the pain medication to kick in (he had received some IV pain medication from the nurse right before we came in).
I finished cutting the sutures and the patient looked at me and asked if I had ever done this before. For a split second my mind froze. I didn’t want to say no. But it is bad form to lie to a patient. After gathering myself, my answer came out: “You’d be surprised. This is actually fairly common in the hospital.” At this point my classmate chimed in that chest tubes were fairly common and it was pretty routine for them to be taken out.
It worked. The patient seemed to find comfort in the fact that his procedure was simple — and in the process he appeared to move away from the question he initially posed of whether or not the two medical students in his room had ever done the procedure before.
My classmate ended up pulling the chest tube. The patient was actually quite happy about the whole ordeal; it hurt a lot less than the previous one. He even said that he wanted us doing his chest tubes next time he needed one pulled.
The way I answered my patient when he asked if I had ever pulled a chest tube was not something I came up with alone. I actually heard of it from a pediatrics attending physician. She recounted a similar incident that occurred to her while she was in residency. She told us that the patient looked at her and asked her if she had ever done a procedure before. And her answer was, “You’d be surprised how many of these I’ve done.”
By the very nature of medical education, there will always be a patient who is our “first.” Our first intubation, our first blood draw, our first whatever. Sometimes, we have to, as my attending told us, “fake it” until we make it. That’s the only way we can learn.
And for those readers who are not familiar with medical education, this may sound terrifying. But the intern, who had pulled many chest tubes, was by the bed when the time came for the pull. Should something have gone wrong, we were being supervised.
Words With Patients
Let me set up the scene. I had just met my patient and examined her in her room. She was an older woman. She was an inpatient (meaning she was staying at the hospital). We were discussing a possible trip to the OR that day. I wasn’t sure if she would go that day or if the surgery would have to wait.
Nevertheless, our conversation was pleasant and I felt that we had fairly good rapport. We laughed and smiled throughout the conversation even though she was obviously anxious about surgery. And then this conversation happened:
Me: Well, it was good meeting you. I’ll probably see you later today. If you’re here tomorrow, then I’ll see you then too.
Her: If I’m here? Where would I go?
I sensed the panic in her voice. She sounded like I had just casually mentioned that her future existence was in question.
My only thought was that she could have gone home after surgery since I didn’t think the procedure was too serious. But poor, lady. She was thinking more negatively than I anticipated.
And once again, I was reminded how important communication really is. And seemingly innocent remarks can be understood in a completely different light that it was originally intended.
Oh, and I did clarify what I meant as soon as I heard her reaction. And we laughed again.
“Every day, pick one patient that you saw in clinic a couple days before, and call the patient personally “just to check on how you’re doing.” Don’t pick a complicated patient, or a patient that’s going to talk your ear off on the phone. Just choose someone who you were able to help easily and skillfully. After that short phone call, you will recognize how you made a difference in that person’s life; meanwhile, the patient will hang up the phone feeling that they have the best doctor in the world!”—
A professor in my residency program, talking about how to keep from becoming a “jaded” doctor.
Source: cranquis
I hate when I forget things…
Sitting here on Sunday evening I realize I forgot to pass a message along to a young Patient. I spoke to Patient’s mother and she told me to tell Patient that mom loves Patient and to call mom on Patient’s next break.
But after that phone call I got caught up with things I was doing for other patients. And I didn’t see Patient because Patient was in a group.
Ugh. :(
Phone Calls, Puppies, & Babies
I don’t mind talking on the phone. That is, of course, as long as the person on the other end actually has something to say. But phone calls have been one of my least favorite parts of this week on Adolescent Psychiatry.
Whenever we have a new patient, the we are supposed to learn everything about the patient that we can. For these new patients, there are three sources of information: 1) the nursing admission note, 2) the patient, and 3) the parent/guardian.
Usually, by the time the patient becomes “ours,” the patient is already situated in the unit. The nursing note has already been done. Our job, then, is to read the nursing note to get a sense of what happened, and then find out what the story is from the patient and their parent/guardian.
The patient/guardian is a phone call away. And these phone calls often take quite a while. I suppose it is expected, though, with situations that often involve seriously disturbing relationships and circumstances. We have to discuss the current situation and the events that led up to the hospitalization. And then we discuss the patient’s history in detail.
But what I find much worse than the phone calls is what I learn from them, and what I learn as I get to know the patient more each day. As the story unfolds, I have to watch myself. I sometimes get so mad and frustrated. I find myself in disbelief at the atrocities that “my” kid has had to endure. There are stories of 7 year olds who get started on drugs and alcohol. Seven year olds! Who gives a kid drugs and alcohol?!? We have to hear about kids who were abused in every way imaginable by people who were supposed to help protect them. We talk to kids who tell us they see and hear things. We have to daily ask them if they are thinking about hurting themselves or other people — because it is a very real issue for many of them.
And I find myself disgusted that it is harder to adopt a puppy than it is for a person to become a parent. It’s ridiculous. And it sucks.
I love how some patients insist that all of our blood pressure machines and weight scales are grossly inaccurate.
It’s ok to be ugly, but it’s not ok to abuse a privilege.
