The Man Without a DVT

20 02 2013

My time in the ED is about a third of the way over at this point (one shift a week for 12 weeks), and I’m pleasantly surprised to find that I am truly enjoying my time there. 

I’d always thought that the lack of follow-up, not knowing whether my patient lived or died or what the final diagnosis was, would bother me.  It does.  The nice thing, though, is that I wouldn’t have to tolerate the endless frustrations of trying to manage patients with chronic illnesses who are relentlessly noncompliant with their treatment regimens.

Oh, sorry, non-adherent.  We aren’t supposed to say noncompliant anymore because it gives off too much of a negative connotation and implies that these patients are bad people, or some such nonsense.  Really, the terms mean the same thing and I think we should just call a spade a spade, but those thoughts will not be otherwise voiced for the duration of my medical education.

The point is that sometimes, it seems like it would be a relief to not have to follow up with every patient on a long-term basis.  While the follow-up gives the physician time to establish a rapport and potentially influence the patient to a greater degree, the medical provider can’t simply “care” a person into good health. 

One aspect of emergency medicine that consistently eats at my nerves is the lack of evidence-based medicine that I have seen practiced.  Certain negative outcomes are simply considered unacceptable.  For example, missing any heart attack.  This seems obvious to most people, but consider this: a lot of women, diabetics, and the elderly don’t have any pain at all.  Some only have shoulder pain or epigastric (upper belly) pain.  This results in a ton of EKGs that really aren’t indicated by evidence.

I had a patient two weeks ago who came in with back pain.  He had a long history of back pain, but his wife was worried about this episode and so she convinced him to come into the hospital.  His Wells score, which predicts likelihood of having a DVT, was a zero out of 9.  Nothing in his history or physical exam suggested a DVT.  However, the liability for missing one is so high that the resident ordered an ultrasound of his legs just to be on the safe side, the entire time griping about how ridiculous it was to constantly be throwing evidence out the window.   

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Of course the guy did have a clot in one of his hip veins, or I wouldn’t be telling this story.  Maybe it’s different in other places, especially the more rural EDs without so many resources.  It just makes me sad sometimes that I spend so much time learning complicated algorithms just to throw them out the window because of liability. 

It’s important in these cases to remember, too, that it isn’t about liability, it’s about lives.  In other health systems, including the military, having very small death rates when tests and algorithms don’t pick up every condition in the book is acceptable.  That’s life.  Crap happens.  Everybody suffers, everybody dies.  In the general medical system in this country, however, everyone expects that no mistakes will be made and that every life lost within the medical system should be investigated, assuming that somebody must have screwed something up.  I saw this the most in OB/GYN, but I think that emergency medicine is right up there as well. 

One of my friends from college is an EMT and very into posting things about emergency medicine on Facebook.  I’ve embedded one of the recent posts online because it makes some interesting points.  I’m not sure where it came from, likely either Canada or the UK because nobody in this country says queue.  Take a quick look.

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My first thought after seeing this was “what moron would triage a simple cut before any chest pain?”  The person symbolized by the wreath clearly didn’t die because of the people who arrived to the ED before him.  Perhaps the medical community looks at the lady with the cough and thinks, “gosh, what an idiot, why is she going to the ED for a cough?”  But nobody stops to think that maybe she is terrified because her teenage son recently died of influenza (this recently happened in my community).  What if the man with a stomach ache has a ruptured appendix?  Maybe the man with the cut had a relative got cut, infected with gangrene, and had to have a limb amputated. 

Patients outside of the medical profession are often not very good at describing or prioritizing their pain symptoms, so it’s up to the medical teams to differentiate, diagnose, and come up with a treatment plan.  It’s not up to the patients to prioritize themselves, and they are not the ones to blame in the case of an unfortunate outcome—unless, of course, another patient shoots or stabs someone.

One thing the meme does do well is convey health education to the general public.  Maybe people don’t know it’s not necessary to go to the ED for every little thing because that’s the only thing they know.  The picture presents reasonable alternatives and draws attention to the fact that in the vast majority of cases, people can make health care decisions—like calling their primary care doc or picking up some NyQuil at CVS—that do not involve the hospital.  It draws attention toward patient-centered decision making and away from the “I deserve it all, I deserve it now, and you will do it for me” attitude that has become all too prevalent in the United States. 

Something to think about.  My next post will be more light-hearted and contain funny stories :]

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2 responses

21 02 2013
Anya

Great post as always. I am lying here reason it bed and have to be up in 4 hours for an ER shift eeek! (I am a phlebo applying to med school.) My fiancé looked at the pic and was like “all those people don’t really go to the ER, this has got to be inaccurate” and I just laughed… Seems like 50-75% of our ER patients every day could have handled their problems via another provider. And even though any chest pain will be triaged first, all the minor care stuff still takes away man power and resources. Lot of food for thought here….

21 02 2013
Anya

Oops sorry for the typos/grammar, typing this on my phone with autocorrect!

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