Wednesday, December 24, 2008

It's Not Always the Obvious...

We clearly see different injuries and illnesses in the ED based on the time of the year. Frequently, during the winter months, we see many viruses that are responsible for gastroenteritis (nausea, vomiting, diarrhea, abdominal cramping and often times fever). Well, it's that time of year and out of 25 patients per shift ,we are seeing at least 5 patients with acute viral gastroenteritis.

Most of these patients need a few hours of intravenous (IV) fluids and some medication given in the IV for nausea. Infrequently, I will give some IV narcotics to help with the pain as long as I am convinced that I am right about the diagnosis with ample warning given to the patient in case symptoms do not improve or worsen. The last thing I want is to think the patient has gastroenteritis and is sent home with appendicitis (it does occasionally happen but you can't CT scan everyone who has vomiting and diarrhea).

Anyway, on my last shift I picked up a chart that read, "Nausea, vomiting, diarrhea for two days." The patient was in her early seventies and allegedly had no medical issues. She fit the picture of every other patient I had seen with similar symptoms that week - low grade fever, blood pressure (BP) was normal and her heart rate was slightly increased which could be a reflection of her temperature. Her examination was benign, she had no tenderness on examination of her abdomen. She appeared slightly pale (but frequently I have seen older patients look pale and yet the have no signs of anemia on blood testing).

I did the usual - IV hydration, and IV medication for nausea, no pain medication (as she had no pain) and re-assessed her. She felt better, had no temperature, her BP was fine and the faster heart rate had improved. I could see many physicians sending her home without performing labs. But I learned a long time ago to at least check people's electrolytes and kidney function with a simple blood test under these circumstances especially with patients in the upper or lower age limits. Her kidney's were not working as well (although that could be normal as people get older) and I had performed a cell count (CBC) to check her white cells (to check for infection), her hemoglobin (a sign of anemia) and her platelet count (needed for clotting). I had noticed a bruise on her thumb and she told be she had been lightheaded and fell a few days ago.

To my surprise her CBC revealed her to have a low white count, dangerous low hemoglobin and dangerously low platelets count. It all made sense retrospectively, but I was surprised at the findings. She subsequently received IV antibiotics, along with blood products and more IV fluids and was admitted to the Intensive Care Unit. I updated her son, who felt uncomfortable with hospitals.

I wasn't certain which came first - her blood work, which suggested bone marrow suppression perhaps form a viral or bacterial infection, or perhaps even early leukemia (her mother had died of leukemia). I thought three days before Christmas...was she going to die, did she have leukemia? I told him, "Your mom is very sick and needs to be cared for in the ICU. I have contacted her doctor and she will also be seen by an infectious disease doctor and a hematologist and will require further treatment and testing." He had no further questions but I wondered if he really understood the potential of her dying in the next few days. If this was leukemia, she would live for a while even without chemo but if it was an overwhelming bacterial infection, she had a high likelihood of dying in the next 2-3 days...and Christmas was in three days. Life is so cruel, but perhaps she only had MDS (myelodysplastic syndrome - a chronic disease that affects most often elderly patients with bone marrow suppression)...time would tell. I'll follow-up to see what happens to her and pray that her family gets through the holiday season.

By the way, this is where mediocrity begins in medicine, especially emergency medicine. For physicians who don't have any interest in follow-up, business ends that day with this patient. You can choose never to do follow-up either in the form of speaking with her doctor to see what happens or checking her medical record to see how she does while in the hospital. I guess for many, you just forget it and go on with your own life, it's easier that way. Go home, enjoy the time with your family and forget about her.

I could never bring myself to practicing this way, but many would disagree. I'll keep her name on a list with others to follow-up and see how she does. Without following up patients after you admit them or discharge them you can never be certain as to whether or not you made the correct diagnosis, and if you were wrong (even though a consultant finds the right answer and the patient does OK), you have not learned from the patient and will continue to make the same wrong decisions...something that happens more often then physicians will admit or will even recognize...there is no room for mediocrity!

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