Demented. Demanding. Depressed

She was worried. She had lost 20 pounds in a matter of months, her blood pressure was elevated and her blood sugars were out of control. Her worry had led her to walk into the office without an appointment. As abnormal blood sugar can be dangerous in the short term (especially if it is low) this was what I focused on first.

“What have your blood sugars been?” I asked.

“I don’t know, they have been all over the place,” she replied.

“Do you have the numbers with you? Did you write them down?” I asked, hoping for some data I could rely on.

“I don’t have them with me, I left them at home,” was the discouraging answer.

The remainder of the visit was even more discouraging, which did not surprise me. I knew her answers would be unreliable. I had diagnosed her with early dementia months earlier.  At that time I had my staff call her son and ask him to come for the next visit. That visit had occurred a month before the day she walked in without an appointment. At that time I shared with them that I did not feel it was safe for her to live alone any longer. I told her son the she had not remembered to get blood tests done ordered a month prior and that it seemed her forgetfulness was worsening. Since she was a on over 10 medications for nearly as many diagnosis, I was very concerned about her safety. She clearly needed help.

When she walked in worried about her blood sugars I had not heard anything from either her or her son for over three weeks. The blood tests had still not been done, so I was in the dark about her long term diabetic control, kidney function, thyroid levels and blood chemistry. All I had to go on was what she told me and that was completely unreliable. She was also still living alone. 

She was truly concerned and worried about her blood sugars and I felt I needed to communicate that I wanted to help her but I needed more information. I told her I could not make any changes to her medical treatment because I could not be certain that she was taking all of the medications as prescribed. I did not know what changes to make because I did not know that her current status was.

I gave her instructions and wrote them down as simply as I could. I told her to get the blood work done in the morning and then to return to the office two days later. I asked her to bring her medication bottles and her blood sugar measurements when she came. I stressed the importance of each instruction as clearly as I could. She had an elderly friend with her and I stressed it with her as well. After she left I had the office call the son so I could share my concerns with him. They reached his voice mail but left a message asking him to call us back right away.

A week later she called the office. The blood work had still not been done and she had not come in for the follow up visit. Her son had not called us back either. This was disappointing but not surprising. What was surprising was the reason she gave to the receptionist for not coming back- “I know Dr. Barrett never wants to see me again.”

It seemed her memory was worse than I thought! Apparently my words that "I can't treat you without more information" had been remembered as "I can't treat you."

We tried again to reach her son. He did not return our calls, but his wife did. Unfortunately the patient had never given permission to discuss her care with anyone but her son, so I could not speak with her daughter-in-law. The staff told her to have her husband call as soon as possible. When 24 hours passed without a call I organized an impromptu office meeting to discuss what we could do to help her. I had one receptionist call the medical group to see if we could urgently send a social worker out to her home. My other receptionist, who had worked for years in a neurology office, suggested we call Adult Protective Services to see if they could help. “Do it!” Was my reply.

Within a few minutes I was on the phone with the APS case worker. I told her that my patient was a diabetic who lived alone, that I was worried about her taking her medications correctly, that she was demented and I was concerned for her safety. I told her that I had left a message for her son and had not heard back for a week. She said they would send someone out within a day. I hung up the phone thinking I had done all I could.

The following day I learned that that not everyone agreed with me.

Her son walked into the office the next morning, seething with anger. I was not in the office, so he proceeded to loudly tell the receptionist that I had abandoned his mother by telling her that I did not want to see her any longer. He said I had committed malpractice and that he was going to report me to the medical board. Not knowing what to do, the staff called me at home. I asked them to put him on the phone, hoping I could calm his anger. I attempted to explain the misunderstanding and my concern for his mother but his mind was made up. As far as he was concerned I was an arrogant and prideful doctor who had abandoned his mom. After over 10 minutes on the phone and multiple insults and accusations I gave up, finally telling him that his anger did not change the fact that I thought his mother was a wonderful lady and I was concerned about her. He made it clear that I would never see his mother again and hung up the phone.

Although they had dismissed me as their physician I made several phone calls over the next few days making sure that the social worker made it to the home and that her new doctor would see her as soon as possible. I made the calls with a great deal of sadness.

I wish I could say her son's words did not effect me but they did. On several occasions in the days that followed I found myself replaying events in my mind, wondering if there was anything I could have done differently or better. While I do not know what I could have done to better resolve this patient's situation I have gained a greater understanding of the importance of supportive and accepting families in the care of those with dementia, and of how denial can complicate matters. 

- Bart

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5 Lives Saved in 5 Days.

It was a scary week. It began with a call from the lab about a patient’s lab results. They were so abnormal that I was surprised the patient was alive, much less able to function. I sent him to the ER immediately. It took a week for the labs to approach a normal level. He was deathly ill. What was frightening was that the tests were ordered as an afterthought during a visit for a mild complaint. Just before I walked out of the exam room I remembered that the patient had a history of abnormal labs years earlier. Although this was not why the patient came in I decided to order the blood work, just to be thorough. If hadn’t the patient could have died. 

The next day a patient came in for a routine follow up visit. During the visit he thanked me for harassing him into getting a colonoscopy the previous year. He didn’t want to get it done but I argued that it could save his life. It did. He had a large precancerous polyps removed. If he had waited a few more years it might have been life-threatening.

Thursday morning my PA (Physicians Assistant) asked me to take a look at a patient she was seeing. The young man had been sick for a few days and had just started having shaking chills with a temperature over 104. I walked in, took one look at the man in his 30’s and said, “You need to be in the hospital.” He asked if he could treated in the office and I told him the only debate in my mind was whether to call 911 or let someone drive him. He was septic. Gram negative bacteria were found in his blood stream. When he walked into my office he was hours from death.

Friday morning saw a man come in for a refill on his blood pressure medications. The PA thought he didn't look right and asked me to take a look. I had known the man for years and the change in appearance since his previous visit was striking. He was severely jaundiced. He was admitted to the hospital with liver disease and a potassium that was dangerously low, low enough to trigger an irregular heart beat.

An hour later the PA grabbed me again as I came out of a room. There was another patient she was worried about. The man in his 60’s had mild chest pressure but an elevated heart rate in the 160’s. Although his blood pressure was normal and he did not feel that bad I had the staff call 911. The paramedics were there within a few minutes. They bundled him up and put him in the ambulance. Shortly after pulling away from the curb, his heart rhythm changed to ventricular tachycardia, a life threatening rhythm that can lead to sudden death. He needed to be shocked back into a normal rhythm. 

When I went home Friday afternoon I was emotionally drained. I do not typically have so many near misses in such a short period. I found myself thinking about how easy it would have been to miss these diagnoses. If we had waited to order lab tests, not pushed for the colonoscopy, given the septic patient oral medications instead of sending him to the hospital, refilled the BP meds and scheduled a follow up or not called paramedics, patients could have died. I was grateful that I have a PA who is diligent and excellent and that together we had come through for our patients.

Each case reminded me of the importance of relationship in medicine. The young man with abnormal labs is alive because I knew him and remembered his lab work from three years earlier. The man with the colon polyp trusted me as his primary care physician and as a result followed my advice. I had seen the septic patient before, and as a result I could tell in seconds that he was not himself, as I could with the man with the liver disease and jaundice. While relationship did not aid me in the diagnosis of the heart rhythm, it was the reason he was seen immediately when he called the office. 

Relationship is being devalued in health care as patients change insurance every few years and are forced to seek new doctors and hospitals. This week reminded me that relationship matters.

-Bart

A Prescription Error, A Relationship Preserved

The refill request was for a muscle relaxant, one with significant potential for addiction. I opened the patient’s chart to see when it has last been filled. I had approved a refill 25 days prior. This request was 5 days early.

Early requests are not entirely unusual, as patients are often afraid that waiting to the last minute can result in them running out of medications. A pattern of early refills can indicate a problem so I decided to log into the state controlled substance database to view the patient’s prescription history. It seemed that he had consistently been filling the medications 3-5 days ahead of the due date. I decided to investigate further.

I scrolled back through the online history and saw something that made my heart sink. The database showed that 2 months earlier the patient had filled the medication at two different pharmacies one day apart. If this was true, the patient was abusing the medication.

I could not believe it. This patient was one of my favorites, our interactions had been consistently enjoyable, often with interesting conversation. (He is a passionate and hard working man and we have much in common.) The thought that he might have been abusing his medication, that I might be forced to confront him and possibly dismiss him from the practice filled me with dread. Unfortunately, the evidence on my computer screen was hard to ignore.

I called my receptionist over and asked her to call each of the pharmacies to confirm that they had indeed filled the medications on the dates indicated. A few minutes later she handed me a note. Both pharmacies had confirmed the refills.

I wondered how to address this with the patient. The evidence was pretty clear but something just didn't feel right. I wondered if my unease was more about the possibility that I had been deceived than it was about the patient’s circumstance. I decided that I did not need to be confrontational immediately, that I would give the patient a chance to explain.

I called him on the phone and he answered immediately. “I received your refill request,” I told him, “but it was a few days early.” I went on, “ So I checked the state database to review your history, and according to them, you refilled the medication twice in January only a day apart, on the 16th and 17th.”

“Doc, there’s no way. I didn’t get two prescriptions. Let me call the pharmacies!” He was adamant, yet not defensive. I told him that I would not be able to fill the medications without him coming to the office, as we would have to address the issue and I would need to document it in the record. As much as I wanted to trust him it would be a mistake to assume that the pharmacies were at fault. I told him he would need to sign a controlled substance agreement and that his practice of using different pharmacies based on his work schedule would need to end.

He did not argue at all. “Of course, I understand. I will come in tomorrow!”

I received a text from him within a few minutes, saying he had just called and only one of the pharmacies had confirmed a refill. The state database must be wrong.

I decided to call the pharmacies myself. The first pharmacist came on the line right away and looked up the patient’s medication history. She read off the record for the date in question. “We show a prescription on January 26th that was deleted. The patient never received the medication.”

I was so relieved! The patient had been telling the truth! (When it comes to controlled medications this does not often happen.) I called the patient back and gave him the news. I told him I could refill his medications but that it would need to be on the due date, that I could not refill the medications early. He was in total agreement.

When I hung up the phone I breathed a sigh of relief. I had dodged a bullet. There was a time not so long ago when I would have assumed the worst and been more confrontational. If I had done that, a relationship might have been lost. Giving him the benefit of the doubt had made all the difference.

-Bart

An Easy Diagnosis- Missed

He was worried. He had lost over 30 pounds in the last few months and he did not know why. He had seen another doctor but the doctor did not give him an answer. Worried, he turned to a friend in the medical field. The friend referred him to me.

The visit started off as most new patient visits do, with a lot of paperwork and time spent reviewing his medical history. He had a history of high cholesterol but not much else of significance. He had no symptoms of depression and no obvious reason for the weight loss.

Until I looked at a copy of his blood work.

In December he had a fasting blood sugar of 295, nearly three times the upper limit of normal. He was diabetic. I asked him if he had been informed of the high blood sugar. He told me that the doctor had told him it was “something to keep an eye on” but that no additional tests had been recommended nor treatments suggested.

I explained to him that this was almost certainly the answer to his weight loss, as this was a common manifestation of diabetes. I ordered a repeat of his fasting blood sugar as well as additional tests to confirm the diagnosis. The results were as expected, confirming that he had been diabetic of a while.

At the end of the visit he asked why it was that the other doctor had failed to make the diagnosis. I did not have an answer for him. There was no rational reason that a blood sugar as abnormal as his would be ignored. The only explanations I could think of were ignorance, laziness or incompetence. I kept these reasons to myself, stating only that I did not know what the other doctor had been thinking.

I m not sure that the doctor was thinking at all or that he was truly concerned about the patient. The patient’s diagnosis was simple and straightforward and could have been made by most third year medical students. For several months the patient had needlessly worried about cancer or a life-threatening disease. I wished he had come in sooner and was grateful his friend had advised him to come to my office.

I wish I could say that his story was rare, but it is nowhere near as rare as it should be. Doctors are human and we make mistakes. We can get busy and distracted and we can be lazy and inattentive. Years of advanced training and education bring knowledge but they do not remove our innate tendency to mess things up. There have been many times when I was tempted to cut a corner or to tell myself I would address the problem "the next time." I have thus far been able to fight this tendency. This patient reminded me of why that is important.

- Bart

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Fighting for a Patient's Sight

The vision in his right eye had been blurry for several days. It had worsened over the weekend and when he awoke Monday morning only a sliver of the vision remained. Worried, he walked into the office without an appointment, hoping he I could see him. My office staff quickly brought him back into an exam room.

I didn't even need to examine him. His story told the story. I was near certain that he was having a retinal detachment, a true medical emergency. As it had been progressing for several days I knew his vision was in severe jeopardy. He needed to see a specialist immediately.

Without leaving the exam room I logged into the HMO website to process the referral. He was a member of a new network in town, with a limited number of specialists available. I called the office of the only general ophthalmologist on the list. My heart sank when the staff told me the doctor was not seeing patients in the office that day. Who could I find to see him?

Worried, I called the medical group. After several minutes on hold I asked the staff to call so I could move on to my other waiting patients. When I came out of the next room my heart sank a little further. I learned that my nurse had not been able to get a referral but that we needed to wait for a return call from the assistant medical director. Not wanting to wait I searched my email for the number for the Medical Director, deciding to go higher up the chain as it was nearing the lunch hour when reaching a specialist would be near impossible. She gave verbal approval for the patient to be seen by a specialist in an affiliated group. Before I could hang up the phone my receptionist had that office on the phone.

More heart sinking. The receptionist at that refused to even get a doctor on the phone. As the patient was not officially a part of that group and they were not on call, she told me there was nothing she could do. I lost my cool for a moment, saying, “I guess we should just let him go blind!” as I hung up the phone.

The assistant medical director called me back a few minutes later. I quickly briefed him on the case and he promised to arrange a referral to a UCLA affiliated specialist a few miles away. Things started to move. That office called within 15 minutes, offering to see the patient on their lunch break. It had taken over 30 minutes of effort but he was going to be seen within the hour.

I went to lunch thinking that the problem had been solved but I was mistaken. Later that afternoon the eye doctor’s office called back with an update. It was a severe retinal detachment and the patient was at high risk for permanent vision loss in his eye. Emergency surgery was needed but the surgeon did not know if it could be done on time at the local hospital. He recommended that the procedure be done at UCLA first thing in the morning. The problem was that UCLA was over an hour drive away and the patient could not get to and from the hospital. They wanted my input.

My input was that the surgery had to be done locally, even if they had to transfer care to another surgeon. The doctor reconsidered, ultimately finding an assistant surgeon and getting time in the operating room of the nearby hospital for the next morning. I agreed to add the patient to the end of my day for the pre-operative medical exam and clearance.

One more glitch remained that day. After scheduling the procedure, the eye doctor was informed that the hospital did not have an operating room scrub technician available. His office called me again asking again about doing the procedure at UCLA! I was firm, "No! We have been over this, that is not possible!”

I looked at my watch. It was 3:45. If referral to another doctor was going to be necessary, we were running out of time. I pointed this out to the surgical scheduler. “We are running out of time to get help if we need it. I do not want to be rude, but this is ridiculous. This is an emergency surgery, and this is a hospital, someone needs to make this happen. If we cannot get a scrub tech in the next 15 minutes, we are going to need to call another doctor for help.”

They found a scrub tech.

He was back in my office within the hour for the pre-operative visit.

He was frightened. Everything had happened so fast and his world had been turned upside down. He was facing not only the loss of vision, he was also facing 7 days of immobility and weeks of work. It was hard for him to wrap his mind around it all. Worse, he was alone in town and had no support system.

I completed the clearance form and faxed it to the eye doctor’s office. When 30 minutes passed without any further glitches or delays I breathed a sigh of relief.

After the patient left I realized how drained I was from the day. While there was nothing medically challenging about the diagnosis getting the appropriate treatment had taken an incredible amount of effort. Between my staff and I over 20 phone calls had been exchanged in a period of 5 hours.

It wasn't over. 

We called the eye surgeon in the morning to check on the patient's status. The surgery had gone well, but there was a new obstacle. To preserve the sight in the eye, he would need to lie face down on a special table twenty-four hours a day for 7 days, with only one 10 minute break each hour. The table rental was $300 for a week and was not covered by insurance. As he was out of work and already poor, he could not afford it. The secretary at the eye doctor's office said, "This is sad because if he cannot get the table he will likely lose his sight." She acted as if there was nothing anyone could do. I could not believe that we could not step up and cover $300 to save the man's sight. Hadn't thousands already been spend on the surgery?

Multiple more phone calls later, we got the table paid for. That left us with another more basic need. How would he eat? He lived alone and could not cook or shop. Who could help him with meals and basic survival? Desperate again, I called a Calvary Chapel Church near his home. He had told me he had a friend there. I was forwarded to the staff member who oversaw the church's compassion ministry. She was immediately receptive. Two men in their church had experienced similar issues in the last year and she understood what the man needed. She committed to making sure that meals would be provided.

Tears came to my eyes as I hung up the phone. I did not know if we were going to be able to save his sight, but I knew we had done all we could. I was proud of my office staff, and especially grateful to the church. His case reminded me of why we all do what we do. We are here to help people in need, because we can.

I pray his vision will be saved. I ask that you pray as well.

- Bart

Thanks for reading, and a special thanks to those who share posts with others. It matters! Readers can subscribe to the blog by clicking on the subscribe button (upper right on desktop, bottom page on mobile devices). I can also be followed on Twitter @bartbarrettmd