Common ground

When Wordle came out, I liked it and played every so often. My wife still sends me her blocked out results, especially when she figures it out in two guesses or less. Eventually though, I got bored. I love baseball. I’m five days late writing this column because I spent the weekend coaching my son and his teammates as they captured the U15 provincial championship. I didn’t have time to write, but I made time to play Immaculate Grid, a Major League Baseball version of Wordle. For you hockey fans, there is PuckDoku, which is just as addictive. A few Sundays ago, I was called into work two hours early. There were people everywhere. I had one room to see patients and after I assessed them, those less urgent had to go back out to the waiting room. My first six patents were fairly straightforward, so it seemed. They all went home with minimal intervention and were happy with their visit. But one came back two weeks later and received a serious diagnosis. 6 patients Patient One is exactly 60 years old. Overnight, she’d awakened with a numb left arm. She’d been sleeping on it and when she rolled to the other side, the numbness resolved. She called her doctor who suggested she get assessed in the ER. She’s fit, perfectly healthy, on no medications and has perfect vitals. “Could it be that you just slept on it? Has it ever happened before?” “Yes, but I’m 60 now, and one of my close friends just had a stroke.” I tell her that her risk is extremely low, and again, after a discussion, she’s reassured and agrees to follow up with her family doctor. I don’t blame her doctor for sending her—in fact, I’m impressed that her doctor was available to chat with her on the weekend. Patient Two is a 32-year-old woman with a 10 out of 10 headache. She’s wearing sunglasses and comes to the ER twice a year for migraines. There’s nothing new about this one—she just needs a shot of Toradol and Maxeran and wants to get back to her bed as soon as possible. After examining her quickly, I agree with her plan and ask the nurse to get her medication as soon as possible. Patient Three is in her 30s and it takes me a little while to figure out why she’s here. She’s had two days of vaginal bleeding, and the blood appears darker than usual. She’s otherwise healthy, and her periods are irregular so the timing of this bleeding isn’t completely unexpected. She doesn’t feel weak, she’s in no pain or discomfort and the bleeding hasn’t been particularly heavy. “So what are you hoping that I can do for you today?” I say. It takes several more questions but eventually I figure out that she’s had cervical dysplasia in the past and because of the pandemic, it’s been several years since her last Pap test. She has a family doctor and after telling her I haven’t even seen an endocervical brush in 10 years, she agrees to call her family doctor and schedule an appointment. Patient Four is interesting. She’s in her early 60s and tells me that four months earlier, she developed a generalized rash and then swelling in her face and neck. She’s seen many doctors and is on 11 medications, some for chronic conditions (antihypertensives and hormone replacement), and some (such as steroids) for this recent rash and swelling. When she hands me her latest medication—a diuretic—she can’t remember whether it was for hypertension or swelling. She looks like she has Cushing’s syndrome and the timeline (whether Cushing’s was the initial condition, or whether it is iatrogenic) is too hard for me to figure out in this busy ER. As with all of my patients, I’ve scoured her medical record before seeing her and am satisfied that she’s been well-investigated. I ask her to hold the steroids, and schedule an urgent appointment with our internal medicine clinic. Patient Five is mid-50s and is either coming from work or on her way. She’s a personal support worker (she holds another job as well) and is still in uniform. She tells me that she’s developed urinary frequency, pain on voiding and hematuria. “I had this three months ago and it went away with antibiotics,” she says. When I ask if she has any other medical problems, she says no, although I know she’s an insulin-dependent diabetic because she’d been admitted for an acute kidney injury earlier in the year. The discharge summary noted that she’d been a diabetic since her late 40s but abruptly discontinued her medications a few years earlier. After rehydration and insulin initiation, she was discharged in two days. I ask her if she can provide a urine sample, and when she tells me she already has, she asks how much longer this all will take. The nurses are keen to clear patients, so when I ask for her urine to be dipped as soon as possible, the results are posted within minutes. It’s strongly positive for leukocytes, blood and nitrites. I write a five-day prescription for antibiotics (the first script I’ve written so far) and ask her to come back if it doesn’t resolve. Patient Six is the third 60-something woman of the day. Her presenting complaint is “allergic reaction.” It’s her third visit in three days for the same thing. She has a fine, papular rash all over her body, most apparent on her back. On her first visit, she’d been given Benadryl. The following day, when things hadn’t improved, she’d been given steroids. On day three, nothing had changed. She’s healthy, on no other medication, and other than the rash has no symptoms. As I’m scratching my head, she remembers that two days before the rash had appeared, she’d visited a walk-in with a sore throat. “They told me it was probably viral but took a swab.” “Is your throat still sore?” “No.” I whisk out and check Connecting Ontario. Her swab result is posted—strep. And the rash? Classic scarlet fever, but not something I’d expect on someone her age in the absence of a sore throat. At her two previous visits to the ER, she’d forgotten about the throat pain and the walk-in visit earlier in the week. A week in hospital One of these patients will be back and spend a week in hospital with a new diagnosis of cancer. Fortunately, I find out because I’m the one who sees her again. For presenting complaint, Patient Five’s chart lists “uti.” She had completed her course of antibiotics a week earlier and although her symptoms improved slightly, blood persisted in the urine. Between two jobs, she’d been too busy to seek medical attention, but on the morning of her second visit she’d vomited once and developed right-sided flank pain. There’s been no fever and no other complaints other than simply feeling generally unwell. Because of unilateral flank pain, vomiting and hematuria, I order blood work and a CT scan, suspecting a kidney stone. Several hours later, her results are back. Her white count is 12.5, and her hemoglobin, which had been 122 during her stay a few months earlier, is down to 97. More concerning, however, are her creatinine and CT scan results. Her creatinine is over 400 and her CT shows severe bilateral hydronephrosis with a suspected underlying bladder lesion. During her admission, a cystoscopy and biopsy reveals a high-grade bladder cancer, and before discharge she requires bilateral nephrostomy tubes. In medical school, I was taught to find common ground with patients, and for all of these patients, we found common ground together. The overnight numbness was reassured that she’d just slept on her arm. The migraine was happy to get her shots and go home to her bed. Maybe the vaginal bleed wanted me to do a Pap test right there, but she understood that we didn’t have the equipment in the ER and assured me she’d follow up with her family doctor. The woman with Cushing’s was happy to discontinue her steroids in hopes that her swelling would subside. And because of technology, I was able to look up my last patient’s throat swab and make the diagnosis of scarlet fever. Sometimes though, common ground isn’t in the best interest of the doctor or the patient. Patient Five seemed to be in a hurry and started by telling me that the last time she’d had this problem, antibiotics made it better. The nurses (and I) were keen to dip her urine quickly and confirm the presumptive diagnosis to help clear out the ER. But her triage note described blood clots in her urine and made no mention of frequency or dysuria. At the very least, I should have ensured followup for her symptoms. Alternatively, I could have made a note of her and followed up on her urine culture, which would ultimately grow no bacteria. Often when I reveal the answers on the Immaculate Grid, I wish I’d have paid better attention, or thought about things a different way. When I review these six cases I feel the same way. Five were fairly straightforward and although the sixth seemed so, in the end it wasn’t. And I know that I could have done a better job. Dr. Raj Waghmare is an ER physician. He blogs at theoverheadpage.com. His stories come from more than 20 years of medical practice all over Ontario.

Common ground

Register for free access or login.

Related Topics