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Reality Check

Sharing a fellow Emergency Medicine provider’s take on the system we work in.

The obviousness of long waiting times in the emergency department

The Other Side (Part I)

As health care providers, it may be many years into practicing medicine until we find ourselves on the other side of the doctor-patient relationship, either as the patient or a family member. It can be a strange feeling. It can be even more strange and daunting when it involves a critical illness requiring care in the Emergency Department. Consciously or unconsciously, it is possible to be at odds with ourselves and our role. Do we act like a patient or family member or do we keep the hat on of the clinician? We all learn that in those situations, we should remove ourselves from the role of the healthcare provider as our judgement in regards to ourselves or our loved ones will be clouded. While this most certainly can be true, it can also be easier said than done.

I was recently put in this position. While not the first time, this episode for whatever reason sticks out much more than in the past. I was finishing a meal out when I got a phone call from my Dad, “Kenny, I’m calling the ambulance for Mom. She’s in bad shape. She’s having chest pains and can’t breath”. Now, my mother has a significant history of Coronary Artery Disease with one stent, one episode of Rapid Atrial Fibrillation which she self converted after rate control, a pacemaker for 3rd Degree Heart Block, and episodic anemia due to AVM’s of the small bowel which have required blood transfusions on more than one occasion. Her symptoms can very well be from any of these issues. I calmly head to meet my parents at the Emergency Department where I work. One the one hand, I start to get a little apprehensive as my mother is also the prototypical parent who minimizes symptoms (aka doesn’t tell anyone) early on. She likes to wait until the symptoms get too severe. The clinical side of me starts going through the different scenarios of what is causing her symptoms and the anticipated treatment. It is nicely buffered by the fact I know she will get excellent care. Not just because my colleagues are caring for my mother but because my colleagues take excellent care of everyone. Yes, I know I’m biased.

I beat my parents to the ER adding a little additional apprehension by wondering if something bad happened to delay EMS’s arrival. The wait is not too long and they arrive with my mother looking quite well. I see that a colleague from my EMS days is one of the paramedics and learn she was in Rapid A-fib, did indeed look bad on scene, but improved greatly after rate control with diltiazem. After getting set up in a room, the ER physician sees her and is confident her symptoms are less than 24 hours. The plan is to check her labs and do a synchronized cardioversion. After an hour of waiting and joking with my parents and family, the labs come back fine except for her hemoglobin dropped several points from six months ago. My mother is still denying any black or dark stools. They proceed with the plan for cardioversion.

Now, I must take a moment to state we perform synchronized cardioversion in our ER quite frequently. It’s practically bread and butter for us. I’ve treated more than a few patient’s this way and knowing the proficiency of my colleagues, I would want no other group caring from my family. Despite all that, I have to say at this point the apprehension came back. As I said before, my mother cardioverted on her own the last time she had Rapid A-fib. So this was the first time when would experience this. I went back and forth in regards to whether I wanted to be in the room or wait outside. Staying out of my colleagues way while at the same time staying near to answer any questions, I ultimately decided to stay for the cardioversion. I took my mind off some of the action by talking with our student, giving her my mom’s background, and reviewing the in’s and out’s of Rapid A-fib. After getting everything set up, they were ready to cardiovert.

The first attempt did not convert my mother back into normal sinus rhythm. “No big deal” I thought to myself, this happens sometimes. It doesn’t always work the first time. However, while thinking this, I didn’t realize I was edging ever so closer to the bedside. That was until the nurse caring for my mother turned around and said to me, “OK, you have to be a son now”. She was was right. I was heading to far in the one direction. I could feel myself wanted to jump into the case. Message received. I went back out to keep my family apprised of what was going on. The nurse, who I also consider a good friend after years of working together, was not rude. She simply, quickly, and correctly realized that I needed to take off the health care provider cap for a while. She was caring for me as much as my mother. Again, I work with amazing people.

The second attempt at cardioverting my mother also did not take. After that, the ER physician thought it would be best to admit her to her cardiologist. My mother recovered from the sedation very well. She insisted that we all go home at that point as it was late and nothing else would be done. Over the next 2 days, my mother again cardioverted on her own, apparently mere minutes after we left the first night. Her hemoglobin dropped another point which initiated a blood transfusion and GI consult. She had another endoscopy which found four AVM’s, three of them bleeding, which where cauterized.

On her final day, her cardiology group expressed concern that my mother has paroxysmal A-fib and may have times she is unaware she is in the rhythm, putting her at risk for thrombus formation and stroke. Despite her history of GI bleeds / AVM’s, they still wanted to at least consider anticoagulant therapy citing several studies that stated it was safe after waiting 6 weeks. They did not need to make the decision that day. They wanted time to check her hemoglobin several times and have me review the literature on the topic before she followed up in the office and discuss it further.

And that’s when it clicked… There is a middle ground. As health care providers there is a middle ground when we or our loved ones are the patient. We don’t have to wash our hands completely of our medical training, we don’t have to be the clinician in charge of their care, but we can be the advocate. What better way is there to be there for our family? To give back to our parents? We can make sure the right questions are being asked (and answered), we can still have input when a care plan is suggested, especially when it’s not straightforward. We can keep on top of our family members to try and make sure they are being honest with their symptoms and when they are having them. We can still hold their hand, give them a hug, and just be there for them.

So, stay tuned for The Other Side (Part II) when yours truly goes in to have his gallbladder removed and gets a first person perspective of being the patient instead of the provider.

Retraction & apology

It was (thankfully) brought to my attention that I mistakenly identified a physician group in the last article I shared. I have removed the article and apologize for the error.

One Flu Over the Cuckoo’s Nest

Unlike some of my colleagues, I am not one to rally the troops and go on the offensive about the benefits of immunizations. I prefer to think I fall somewhere in the middle. While I fully support the benefits of immunizations, I also support a person’s right to choose. Consequently, I rarely get on a soap box and pontificate on the topic. However, given this year’s flu season to date, I find I must abandon my usual centrist stance on the topic. Though admittedly anecdotal, I’m hoping what I’m about to relate will make the reader capable of making a more informed decision on the issue.

While the politicians in Washington spent a good part of Fall 2014 scaring the country about an ebola outbreak that never happened, the influenza virus has decided to take advantage of the distraction and do some real damage. I have seen more influenza cases and admitted more patient’s for the flu than possibly in my last ten years of practicing medicine. All of these patients have one thing in common:

None of them had a flu shot.

I’ll say that again, none of them had a flu shot. I know this because I ask my patients (or their respective parent) and it’s one of those questions that people have little reason to lie about. Now, while most adults who contract the flu will be fine, with or without being prescribe an anti-viral, the bigger concern comes with infants, children, elderly, and the immunocompromised. These patients are at an increased risk of complications and death from the flu. As already stated, I have admitted more patient’s for influenza this year than the past ten. These patients, particularly infants and elderly, are presenting to us extremely sick. Dehydration is common. Co-existing pneumonia’s are not unusual. These populations are unable to handle the flu well and usually contract it from an adult who can.

Is the flu vaccine a guarantee? No, there are none. IT IS our best defense against getting the flu and the complications that can arise from it. If you want a guarantee, buy a toaster. Given that we are well into the flu season, if you have already been exposed to the flu virus before getting the vaccine, you may still get the flu. However, the vaccine will NOT make the illness worse.

As I said, I’m not going to go on an exhaustive campaign and demand everyone get the flu shot. This is still America, you can still make choices. All I ask is that you seriously consider the information I have presented here and consider the health of not only yourself but of those around you. I hope that you will see the benefit and protection from getting the flu vaccine.

Happy New Year 2015

I just wanted to take a moment to wish a Happy New Year to all those who follow my blog as well as to their families and friends. To start off the New Year I have updated my blog, condensing some sections, and added two new sections. The “Clinical Cases” page is for actual clinical cases from my Emergency Medicine Practice and the “Publications” page will have links to my articles published in Peer Reviewed Journals. I realize my blog activity has not been frequent and I hope to rectify that in the coming year.

Again, Thank you for following.

Happy New Year,

Kenneth Szwak, MHS, PA-C

Dermatology Clinic

A 25 year old male presents to the Emergency Department complaining of a rash to his left side. The patient stated he first noticed it after waking up 3 hours before coming to the ER. The patient denied any associated symptoms including pain, pruritus, fever, chills, myalgias, arthralgias, fatigue, headache, weakness, or swelling of lymph nodes. He further denied any new soaps, detergents, foods, medications, or topical products. ROS was otherwise negative, the patient denied no prior medical problems. The patient did report working outdoors as a landscaper but denied any known insect bites, recent wounds to affected area, or past contact allergies to plants.

Clinically, the patient was a well developed, well nourished, 25 year old male in no distress or discomfort, and appeared in excellent health. Vital signs showed he was afebrile and normotensive with a normal pulse rate. His exam was unremarkable save for the rash that appeared as follows:

 

I’m sure most will recognize the large bull’s eye pattern to the rash, which combined with the patient’s history of working outdoors created the concern for Lyme Disease. The patient was started on the appropriate course of Doxycycline, Lyme Titers were sent which ultimately returned positive as well as follow up testing.

While Lyme Disease is not uncommon and it’s associated bull’s eye rash is usually easily identified, I felt this case was worthy of note to make some finer points about the disease.

1) Lack of Symptoms: While we all learn about the constitutional symptoms (arthralgia, fevers, etc.) of Lyme Disease, it is not necessary to have them all as demonstrated by this case.

2) Time of Onset of Rash: While the average time of onset of a bull’s eye rash is 7 days, it can occur anywhere from 3 to 30 days after a tick bite. Combined with the fact that Lyme Tests typically will not seroconvert to positive for about 3 weeks and this patient tested positive from the first test, this patient did not develop the bull’s eye rash until roughly day 21 post exposure.

3) Size/Location of Rash: It can be easy to assume that the bull’s eye rash will be smaller in size. Indeed a simple google image search show most (not all) of the bull’s eye rashes to be smaller in size. In addition, they are seen on expected locations such as extremities and trunk, as with the case above. However, since the rash first appears at the site of the tick bite, the rash can occur anywhere including less thought about places such as the groin or scalp, the latter of which can be obstructed by hair.

Diabetic Ketoacidosis with a normal blood sugar

http://journals.lww.com/jaapa/Fulltext/2011/11000/What_caused_the_medical_emergency_in_this_patient.7.aspx

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