View Full Version : a sobering thought....
It is depressing that care givers must live in fear of their patients...
and I thought this was a perversion reserved for american society...
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> I always feel amused when drugs with a 3 year shelf life are suddenly
> deemed 'not suitable for use' a week or so after the 3 years have expired,
> as if magically they suddenly disintegrate and become toxic at that time.
On preparation class for emergency medicine [in germany we do
not only bring paramedics to the patient but doctors as well] they
gave us the case of a doctor using some drug for a patient (still at
home, before taking him to the hospital) ... and leaving the empty
ampule behind. The drug was about two weeks over expiration date
... the patients people sued the doc for that!
As a resume they told us: As we are one of the few professions
allow to wear gloves (therefore not leaving fingerprints behind) we
should allways carry our used stuff back with us.
And, in the States, we have "defensive medicine". This is the concept of ordering multiple lab tests which the doc doesn't really need. Just so that the doc can point to all he did, when the patient sues.
The problem is that most people are pretty decent. And, I wouldn't want to leave everyone without care because of a few who are dangerous.
I always found it very funny when the AMA states that defensive medicine is only responsible for about 5% of medical cost.
You walk into any ER with a belly ache, you automatically get a acute abd workup.........lab, x-ray, sometimes ultrasound, and even CT before a full assessment by a ER Doc is done. Because if its not done and something happens the family Lawyer has a hay day in court and your out 10 million.
When some women spills hot coffee on herself and wins a court case against the fast food place because the coffee's toooooo hot. What do you think they'll do to us medical folks?
later
DA
Not in mine either (but Im not in the US), but litigation is still very common here.
cheers
Craig
RESQDOC, Craig.............I've usually find that every ER group does this. Now not all the member of the group, it just seems that the the Phy that are not overly confident with their exam techniques, the older generation of ER Phy, any Phy that has ever been in Court. The group that my wife works with 4 out of the 6 Docs order excessive testing. At my hospital, only one is really confident, one is a traffic director, and the others are average. Don't take this wrong, in Anesthesia its the same way.........the old guys will put anyone to sleep without knowing their whole history, the young guys want every test, counseltation, and every piece of emergency equiptment in their room prior to induction.
Everybody else is in between. I think it just goes with the territory in modern medicine. Until we modify the current Tort system it will stay that way. It was the same way in the Military(the true socialized medicine in the US today)Excessive x-rays and lab test...........no one had to pay for it, no one was really accountable. Uncle Sugar picked up the tab.
see ya later
DA
One more response to this and then I’m done, as I want to get back to the purpose of this forum, medical care under difficult conditions.
We must keep in mind that the general public is quite active on this forum, as they are encouraged to be. They however are not experienced in the nuances of medical speak and the intent of those of us in the medical profession, so while I understand what DA is saying from his perspective as a CRNA, understand his experiences, and what he is thinking, (and agree with his opinion of defensive medicine vs. actual patient care needs) this is not the case for the general public and I think to offer rash generalizations such as “You walk into any ER…” is neither true nor helpful to the public’s understanding of the faults (and strengths) of the medical system here, the diagnostic process, or the physician/patient relationship. Second hand observations from another’s work experiences, without specific facts or case examples are equally unhelpful. We are all entitled to our opinions. Lets however couch them as that, opinions, and avoid blanket generalizations.
Each case, each patient is different, and you must “call it as you see it” at the time. Physicians and other care providers are trained differently, have different individual experiences, work in different institutions with different resources and policies, and function in different litigation environments. We must keep in mind also that medicine is both a science and an art. If it was so clear cut that each patient with similar complaints could be evaluated in the same way every time we would have no need for physicians or nurses, and a clerk with a cookbook could simply order the appropriate workup. But guess what. It’s not quite that simple. Each patient must be evaluated individually, a history beyond the surface facts obtained, patients examined appropriately with attention to detail, and tested as needed. But what is appropriate and as needed? See the second line in this paragraph. In many cases there is no single correct way of doing things.
Your training, experiences, and personal preferences guide you and may be different from the next persons. Less experienced physicians may substitute methodical attention to detail and testing for experience and intuition. Would you rather they didn’t? Physicians on the other end of the spectrum may overly rely on experience without the methodical attention to detail and testing. You would rather they did? This is the “art” portion of medicine. What you perceive to be as incorrect, unnecessary, overkill, etc., may be a perfectly reasonable alternative. It’s just a different way of doing things. The facts of the INDIVIDUAL CASE must be examined by to determine if care was appropriate or not. Again, generalizations not only are meaningless, they are actively harmful.
An example. A 38-year-old white female presents to the office with a three-day history of left temple headache, associated with an undetermined period of loss of consciousness the morning of presentation. She reports having been traveling for the last three days at a regional high school athletic function with poor fluid and food intake. She has a history of migraine headaches, this is NOT typical of her headaches in the past. She has been taking “a lot” of over the counter aspirin type migraine headache medicine. She reports no vision changes, gait instability, loss of strength. She does report vertigo as “the room is spinning a bit” and feels unsteady when standing. She takes only plain estrogen status-post distant hysterectomy. She does not abuse drugs or alcohol to our knowledge, is a routine patient for yearly wellness exams, and is not perceived as a “nut.” Vitals are normal. Orthostatic blood pressures/pulses normal. Exam, including a detailed history far beyond what is presented here, detailed neuro exam, etc., are normal, other than mild clinical dehydration. What to do?
Differential diagnosis, in order of probability, dehydration and fatigue, viral syndrome with possible inner ear component, either or both with atypical migraine component, atypical migraine alone, rarer process such as cardiac dysrhythmias – intercranial process such as stroke or mass– vascular process such as vertibro-basilar syndrome – early meningitis – and many other possibilities. Worrisome points: history of loss of consciousness, atypical headache presentation, potential large salicylate intake, unopposed estrogen use as a potential risk factor for stroke or embolism. Reassuring points: benign exam, reliability of patient. So, what to do?
Alternate courses of action would include oral fluid rehydration and elimination of salicylate intake at home with rest and follow up if worsening/not resolving; short term admission with IV fluid rehydration plus medication for vertigo control and perhaps headache management; admission with check on electrolyte status, EKG to screen for dysrhythmias, IV fluid rehydration, vertigo control, delay in headache control until a CT of the head was performed to ensure no intercranial process; admission with all of that plus cardiac & salicylate toxicity work up and perhaps sepsis work up as well. Well, what’s right? THERE IS NO ONE RIGHT ANSWER. See the second line in the previous paragraph.
Because of the loss of consciousness, atypical headache pattern, and my intuition with THAT patient at THAT moment, I admitted her, did a CT (negative) did a screening EKG (normal) did electrolytes (low potassium & dehydration confirmed) gave IV fluids and vertigo/nausea control only – headache resolved, went home 12 hours later back to normal. Some would argue that this workup and treatment was massive overkill, others would argue that I could have missed three dozen underlying causes – and they both would be right to some extent. You call it as you see it and one person’s defensive medicine is another’s inadequate evaluation. See?
Enough of this. Back to austere medical care.
Resqdoc - I agree w/ you 100%.
I sometimes feel as if I order too many tests. I try to base my judgements on my differential diagnosis, with the hopes of narrowing the picture a bit. Taking someone to the OR is full of risks, and if it isn't necessary, we shouldn't be there.
You come in w/ a systolic of 60 and no distal pulses w/ a history of a 9cm AAA - you go to the OR (happened two days ago). You come in w/ c/o right lower quadrant pain, you get some blood work, a good H&P, maybe a CT if the exam warrants it (happened last night - exam didn't warrant it, neither did the CBC).
Sometimes the choices are easy, sometimes you need some more help in finding the right diagnosis. Tests serve to narrow the spectrum of problems so that the patient receives the appropriate care.
Sorry for rant - been up for 20 hours - time for bed :smile:
Sam
Well.........my post wasn't ment to be an attack on any one person or Profession. It was an observation of the medical system and how it reacts to changes in the legal system. Didn't mean to bruise the ego.
I will refrain from such comments in the future. Sorry
DA
It takes a tac-nuke or above to bruise my ego. (No kidding Doc, we can smell it from here...)
My comments were not directed at anyone, but for the general public who often do not understand the diagnostic process, which I might add, is our fault 95% of the time for not explaining and communicating with the patient.
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Do No Harm. Do Know Harm.
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