Look at the Pictures Please

I'm not a person who will get upset at being consulted.  If you want me to come and see a patient, I'll come and see the patient.  I might ask some questions to help me figure out what I'm getting myself into.  When I ask the person calling what the x-ray looks like, I get two responses.  1)  We haven't ordered any.  2)  I get read an x-ray report.  I prefer #1 to #2.  Perhaps you aren't sure what pictures need to be ordered, and you want to make sure to get the right stuff.  I'm OK with that.  I'll order the pictures for you and then I'll go and see the patient.

Reading the report to me is worthless.  Waiting all of that time before calling is a huge waste of time.  If you push on a bone and it hurts, go look at the x-ray.  Look at the picture where it hurts.  If you see a fracture, give me a call and I'll come and take care of the patient.   If you push on the bone and it hurts but there isn't a fracture, it is still OK to call.  For one, I don't depend on the report to make my diagnosis.  I, like most of my colleagues, will read the films myself.  The radiologist's read is more of a quality control issue to make sure I'm not missing something.   Additionally, maybe the patient needs another study, or in the case of snuff box tenderness in the wrist, perhaps we'll just go ahead and splint them and treat them like they have a fracture.

 

Here is an example of a scaphoid fracture that did not show up on plain films until follow-up.

Entiltement

I was called to see a patient who was being discharged from the hospital. This particular patient was brought as a trauma, received an extensive workup including CT scans, plain films, and MRIs. They were admitted to the SICU and ended up requiring surgery. The patient had therapies and was treated to all of the "amenities" our hospital has to offer. The discharge planner asked me to come in the room to talk to the patient and family, because they were upset about one of the prescriptions.

This, in itself, is not an uncommon occurrence. On occasion, I will make a mistake with a prescription, or forget to include a home medication that the patient asked to have refilled. In this instance, however, the patient and family wanted to talk to me because the hospital's prescription assistance program would only agree to fill part of one of the narcotic scripts that I had written.

This complaint, alone, isn't really that big of a deal. I have a lot of conversations with patients about their ability to pay for medications. When I write a prescription for anti-nausea medication, I write for both Zofran and Phenergan because although I prefer to give my patients Zofran, it is expensive and some insurance programs will not pay for it. If I know that the patient is self-pay, I explain the difference in cost, give them both prescriptions and let them decide which they can afford. Oxycontin, as another example, is quite expensive. It can be up to $5 per pill.

The discharge planner explained to me that the hospital had limits on what it would provide for different medications, based on cost. Not only that, the discharge planner explained that although the patient had a job (but no insurance), she didn't feel like she would be able to pay for her stay. Because of this, the hospital had agreed to pay for her stay and all of the care that she had received. When you add it all up, the bill is probably way more than $100,000. When the discharge planner asked the patient how much of their care they would be able to pay for, the answer was NONE! The patient and their family expected that all of the care would be provided by the hospital, and had no intention of paying anything.

When I went to talk to the family about the limitations of the program, they couldn't understand the hospital's position. I was left with explaining that all I could do was write two prescriptions, one for the hospital's program, and the other for the patient to fill at a retail pharmacy, which they would have to pay for. They were still somewhat upset when I left the room.

This is not an isolated incident. I have heard many comments from patients stating that they didn't intend to pay for their care. When cost is brought into a conversation about prescriptions or length of hospital stay, patients will often mention that they have a medicare card or no insurance and they will not be paying their bill.

Imagine, for a second, if I went to the nicest steak house in town to order the most expensive cut of meat and the oldest bottle of wine on the menu. Let's say I asked the waiter the cost of these items, and then after his response, commented that it didn't matter because I didn't intend to pay anyway. Do you think I would get served that steak and wine? I doubt it. In fact, I would probably be asked to leave, or even more unthinkable, to pay for my meal ahead of time. If I told that story to 100 people, not one person would find that response by the restaurant to be unreasonable. If, instead, I substituted the story above about the Oxycontin, I don't think the response would be so predictable.

What do we have to do to get across to our patients that they have a responsibility to participate in (pay for) their care? This includes paying for the services of the hospital and its staff. Is the cost of care in our country over inflated? I believe that it is. Should we charge our patients $20 for a Tylenol? Absolutely not! The answer to this problem, is not providing universal coverage to all at the cost of $0. If we expect to reform healthcare and provide coverage to everyone at a reasonable cost, I believe that we have to start from scratch.

Distal Radius Fracture

The distal radius fracture is a relatively common fracture seen in the ED.  Distal radius fractures are often the result of a fall on an outstretched hand (FOOSH).  Pattern of injury is dependent upon the position of the wrist at the time of impact.  Of note, distal radius fractures are the third most common fracture seen in patients with osteoporosis.  Post-menopausal and elderly patients that present with these injuries should have their bone density evaluated and the findings treated appropriately. 

When evaluating injury to the distal radius,  a complete physical exam and evaluation of neurovascular status should be completed.  PA and lateral radiographs should be obtained.  The wrist and elbow should be imaged.  In assesing the distal radius, several radiographic parameters are important.  The first is the radial height, which should be approximately 11mm.  Volar tilt should be approximately 11 degrees.  Lastly, radial inclination should measure approximately 22 degrees.

There are a variety of classification systems for distal radius fractures.  Most commonly, when called from the ED, the consulting physician will describe the injury or use an eponym.

Colles (top left) - This is the most common fracture pattern, with over 90% of distal radius fractures having a dorsal angulation.  These can range from simple non-displaced fractures to intra-articular fractures with disruption of the distal radial-ulnar joint (DRUJ).  This is the fracture pattern seen after FOOSH injury.
Smith (top right) - In this pattern of injury, the angulation is volar.  This injury occurs when the fall occurs onto a flexed wrist.
Barton (bottom left) - Fracture of the dital radius and dislocation of the radial-carpus articulation.
Chaffeur (bottom right) - Fracture of the radial styloid process.  These injuries are sometimes associated with disruptions of the carpal bone articulations.

 

 

Displaced fractures should undergo closed reduction in the emergency department.  A hematoma block and some IV narcotics can provide adequate anesthesia for the reduction.

Reduction of a Colles Fracture
-Hang the wrist with 5-10 pounds of weight at the elbow for 10-15 minutes.  The allows ligamentotaxis to assit in the reduction and to bring the fracture out to length.
-Extend the wrist while providing logitudinal traction.
-Use a thumb on the dorsal fragment to push and then flex the wrist to reverse the dorsal deformity of the fracture.
-The wrist should then be placed in a well-molded sugar-tong splint.  The wrist should be splinted at neutral.  Avoid over extension or flexion as this may place extra tension on the median nerve.
-Post-reduction radiographs should be obtained to confirm adequate reduction. 
-Neurovascular exam should be completed.

Non-displaced, minimally displaced, and stable fracture patterns can be treated non-operatively in a cast.  Unstable fractures and those that cannot be adequately reduced require operative fixation.  Options include percutaneous pinning, use of an external fixator or open reduction and internal fixation with either a dorsal or volar plate depending on the fracture pattern.

**As usual, information for this post taken from The Handbook of Fractures, 3rd ed.  Images have been borrowed from Dr. Google.

Nice Patients/Families Make My Day

I had the pleasure of taking care of a very nice older lady the other day.  She fell while walking to her car and fractured a few bones.  Despite her injuries, she was always in a very good mood.  When her family arrived, the nurse called and asked  if I could come and talk to them and explain her injuries.  I printed out some pictures and went to the room.

I started with showing the pictures and explaining each injury and our treatment plan for that injury.  I answered all of their questions and then we spent a few minutes talking about the surrounding area.  I made some suggestions about where the family could have some dinner and then went back to my work.

Everyone in the room was nice; smiling and laughing during our conversation.  No one complained about the hospital or griped that their family member wasn't in a private room.  When I told them to have the nurse page me if they had any other questions, or needed anything that I could help with, everyone said thanks.

Although most of the interactions that I have with patients are not unpleasant, not many are as pleasant as this particular encounter.  Maybe I'm not good enough at lightening the mood?  I don't know.  I do know, however, that something as simple as a good (or bad) conversation with a patient can have a significant effect on the day.

Lost in the Job

I've been thinking a lot recently about my transition from medical student to intern.  Seven months into the year, I have been looking back at how my attitude towards patient care has shifted.  As a student, we were all taught to know everything about our patients.  We were encouraged to spend time talking to our patients and their families.  I really enjoyed that part of my "job" as the medical student.  I'm not the world's greatest people person, but I do enjoy meeting new people, talking to them, listening to and learning from their stories.

As an intern on a busy surgical service, spending a lot of time with our patients is impossible.  On the busiest of days, seeing patients at all can be a struggle.  Patients look forward to the time when their doctor(s) visit.  They have questions and concerns that they want to address, and they are looking for someone to take some time to explain recent findings and update them on the plan.  On top of that, they are "locked up" in an unfamiliar place where bells, whistles and announcements are played all day and night long, people come into their rooms at weird hours to wake them up and ask a million questions and their privacy and dignity are sometimes taken for granted.

Although I don't have an hour to spend with each of the 20 patients on my service every day, I do have a couple of minutes to make some social rounds in the afternoons, to say hello to my patients and make sure their questions are answered and their needs are being addressed.  It's not like I don't want to talk to my patients, but more as if I get lost in the workload of being the intern, answering pages and checking and double checking to make sure that everything is being done.