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November 16, 2009
Traumatic Experiences
I have just come back home from a 4 hour shift working at an Urgent Care Center here in Rhode Island with my Doctoring mentor. I learned a lot today about various conditions ranging from tenia crurus or "crotch rot" to pneumonia to shingles. Today, though I had a slightly traumatic experience with my last patient. Near the last hour of my shift, one of the nurses came up to my mentor and said "There's a woman in Room 5 that seems to have really bad bug bites. Really bad. She needs someone...experienced." When hearing that, I didn't think much of it. When I had first walked in, there was a woman who had gotten a tick bite and needed to be tested for lyme disease and afterwards, another woman had come in with a bad rash as a result of a possible bug bite allergy. I chalked this up to another case like that.
We finally got to this woman and my mentor looked at the file only to frown. He looked at me over his glasses and said "Let's go and see this one." Usually, I had gone in alone to take the history, take the vitals, and do some of the physical exam but in my excitement and my exhaustion, I was just curious about what this woman might have.
We walked into the room and there sat a middle-aged woman scratching at her arm. As soon as my mentor stepped in, she began to hurriedly explain what had happened. On her arm were circular lesions, some scabbed over yellow, others still open. She touched them as she talked saying "There are some bugs that bit me. You see these black dots [referring to the brown spots of pigmentation on her skin] - I tried to scrape them out at my dermotologist's office...they were burrowing into my skin. They keep on biting me. I didn't have these beforehand." At first, I was in disbelief wondering what kind of bugs could have caused these lesions. Then she said, "They're all over my towels, crawling around everywhere. They're on my arm too." and pointed at the brown spots on her skin. My mentor hurriedly reassured her that no bugs had bitten her and asked her calmly if she had been scratching her skin to which she hurriedly replied that bugs had did this to her. I looked at her face and noticed around her lips and mouth were white spots and discolorations. As we left the room, she continued to talk hurriedly about the bugs and wanting medication to make them go away. I went outside, shocked with my mentor afraid to verify what I thought was the problem. He wrote a prescription for flu-like symptoms as she was presenting with high fever and sinusitis. I looked at him and he looked at me simply saying, "Well, that was scary." And that's when I knew. She had done that to herself. She had scratched those lesions into her arms thinking that bugs were biting her. My doctor told the other doctor on call "to not get in any further and tell her to go see her primary care doctor." I was even more shocked. Were we just going to let her go? Hope that she would book an appointment with her primary care doctor? I sputtered out, "Why?" and to which he said "She needs her primary care doctor- In fact, her doctor is very good." I left after that patient, almost running out to my car only seeing her scratching her arms and her discolored lips frantically telling us about the bugs that bit her. I drove with my hands tightly on the wheel, knuckles white from trying to concentrate on the road and not think of her.
Who's responsibility was this patient? Was my mentor right in letting her go? Could he not have done anything else? If the patient actually goes to her primary care doctor, would that make this okay? I don't know. All I know is that tonight, she will be my last thought before going to sleep.
Here's a quote I hope that people will comment on that was made in regards to what we do when bad health care happens:
"Indeed, I suspect that our collective search for villians- for someone to blame- has distracted us and our political leaders from addressing the fundamental causes of our nation's health care crisis. All of the actors of health care- from doctors to insurers to pharmaceutical companies - work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasizes treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that - most important - remove consumers from our irreplaceable role as the ultimate ensurer of value."
- From "How American Health Care Killed My Father" by David Goodhill in the ATLANTIC Monthly Magazine (September 2009)
Full Article: http://www.theatlantic.com/doc/200909/health-care
Posted by Reshma Ramachandran at November 16, 2009 11:02 PM
Comments
Hi Reshma good article! Very thoughtful. I have to say I would have done the something similar. I do wish that he would have spent more time trying to talk her out of her delusion so that you can see how hopeless it is. The urgent care philosophy is not one that takes kindly to "getting to the root of a problem". He could have asked her her medical history, if she had meds that maybe she isn't taking, etc. Its not really his job to deal with a problem of acute delusion/psychosis. BUT I would have called the primary care doc and tried to make her appointment for her, or sent her to the ER where she may get to be in patient for awhile to stabilize. that's really easy for docs to do, even easier than for the patient. I feel that the doctors own insecurity had more to do with this than money or incentive structures. It shows how psychiatric 'emergencies' are not viewed in the same way as 'medical' emergencies (if that person had signs of acute MI she would have been sent to the ER) Unless of course you're saying if there was more emphasis on good outcomes the physician couldn't so easily let this lady go...
Posted by: Merrian Brooks at November 17, 2009 08:55 AM
We talk about this stuff at Butler sometimes, especially with regards to people who are somatizers (complain about medical ailments that don't seem to exist like pain that you can't find a cause for). It's pretty amazing because these people will typically go to all the wrong doctors looking for a cure, but won't seek the help of a psychiatrist - because they believe they are truly afflicted with a particular ailment and that they just haven't found a doctor who can diagnose it/treat it yet. I definitely think there's a parallel here with the fact that she first went to a dermatologist and then went to your clinic when what she really needs is psychiatric help... While she does need medical attention because it sounds like she's at serious risk for an infection, that is a result of her self-injurious behavior. What's worse is that it's self-injurious with psychotic features. I think it would be really interesting to know what your mentor wanted to see happen after she went to see her primary care doctor, and where he felt she should eventually be referred.
Posted by: Alissa Cerny at November 17, 2009 11:34 AM
