Today, I may have saved a life

Today, I saved a life.

And I wish I could tell you a story about fancy heroics — about an exploratory laparatomy, a chest thoracostomy, or a patient that coded and I was the last person to perform the chest compressions that brought them back to life.  But I can’t.  But I can tell you that I saved a life.

She was 16-years-old, and moved here four years ago from a different country.  This was her follow-up appointment for an otitis media.  It was her second time visiting a doctor in the United States.  She was seen just three weeks ago and was prescribed amoxicillin for her ear.  The doctor her told to follow-up in 2 weeks.  It’s been three weeks, and she is now coming in to the clinic.  She missed her last appointment because her mother couldn’t find the time to bring her to the doctor.

I take a look at her chart before entering the room, and I noticed that she’s in the 3rd percentile for her weight and 50th percentile for her height.  Odd proportions, if you ask me, and I decide that I am going to dig a little deeper than “how’s your ear.”

I open the door to see a bright, cheerful young girl dressed in a paper gown.  She takes one look at me, and immediately blushes and wraps the gown tighter around her frail body.  I immediately try to make her feel comfortable by making a joke or two, but I can’t seem to connect.  She’s avoiding eye contact.  She seems self-conscious, maybe?  I introduce myself to her and her mother.  Her mother speaks only Spanish, and she speaks English.  I ask her mother if it’s acceptable that I interview her in English.  She obliges.

“I understand this is your second time here, so I just want to learn a little more about you, if that’s ok with you …”

I begin to ask questions about her ear, about the antibiotic regimen, her hearing, associated symptoms.  She answers the questions, but she still seems too timid to make eye contact.  I still can’t connect.

She has absolutely no past medical history, no past surgeries, no medications, no allergies — I am flying through this history.  I begin my physical examination, and other than some mild tachycardia, she appears perfectly normal.  Even her tympanic membranes are normal.  Her ear infection has been cured.

And just as I am ready to wrap up the interview, I take one glance and notice four small scars on her wrist under her bracelets.  And in that moment, I remembered that she was in the 3rd percentile for her weight.  I think.  I walk over to the chart, and confirm my thought.

I take a careful diet history, and I find out that she doesn’t eat much.

“I am just never hungry,” she admits.

And I find it odd that a growing 16-year-old-girl isn’t hungry.  I tell her that I want to ask her more personal questions, and I ask if she would rather that I ask her mother to leave the room.  She says that her mother can stay.  And I gauge that she’s comfortable with that because her mother doesn’t understand English.  I look at her mother, and she doesn’t look at me — almost oblivious to the interview, almost negligent of her child’s health.  I mean, what parent doesn’t want to pay attention to what their child has to say, even if its in a different language?

I ask her about her menstrual period, and I find out that she hasn’t had a period in 2 months.

“Is there any chance that you might be pregnant?”

Eye contact.

After a very long five seconds, she answers, “No.”

I knew she wasn’t too sure of her answer, and I decided to take that as an opportunity to dig even deeper.  To investigate.  To get to the bottom of her lack of eye contact, missed periods, and odd scars under her bracelets.

I learn that she recently lost her virginity to her boyfriend, and he broke up with her a short time later.

“What a jerk,” I think.  But I can’t let it show.  I find it devastating how one person’s actions can take such a toll on another person, with the offender being absolutely unmindful of the damaged they have caused.

I learn that she recently started throwing up her food after she eats, mostly because she feels fat.

“I have a big belly,” she says.

I learn that she was hospitalized two months ago because she fainted in a store.

I ask her mother about this in Spanish. “It’s because she didn’t have breakfast,” she says.

I ask about the scars on her wrist, and I lose eye contact.  I walk up to her, place my hand on her hand, look in her eyes, and tell her what I know.

“I know that some people cut themselves whenever they feel angry or sad.  Do you know anyone who does that?”

She nods, hesitantly.

“Do you have any friends that have done that?”

She shakes her head, slowly.

“Have you done that?”

She looks me in the eyes, and doesn’t say one word.  And I know.

I ask her if she’s ever told anyone about any of this before — about the vomiting, the cutting.  She puts her head down, and shakes her head.

I ask her if she has friends, relatives, or a parent that she feels comfortable talking to.  She keeps her head down, and shakes her head, ever so slowly.

I ask her if she has ever thought about killing herself.  She looks me in the eyes, and doesn’t say one word.  And I know.

And just then, it occurs to me that this is a girl crying for help.  A girl who is broken behind that big, beautiful smile.  A girl who needs someone to talk to, someone to confide in, someone to listen.  A girl who might do something destructive to herself if she doesn’t get help soon.  A girl who was waiting for someone to ask the right questions.

I leave the room to consult with my attending, and we decide the best course of action is to call the ambulance to take her to the emergency room for evaluation of her electrolytes, tachycardia, and suicidal ideation.  And she leaves.

And just then, I realize that she came in for an ear infection.

Today, I may have saved a life.

Edwin Acevedo, Jr. is a medical student.

Comments are moderated before they are published. Please read the comment policy.

  • JR DNR

    You’re not a resident… you’re a med student? I don’t understand how you’re the one providing primary care to a patient.

    • RuralEMdoc

      Wow, way to miss the point entirely. He is clearly on a Fam Med rotation. That is why he went to speak with his attending after the visit.

      What is there not to understand?

      • JR DNR

        I commented with more detail above.

        And yes, everyone in the United States is intimately aware of all medical school processes and practices, which is why the average American thinks a “resident” and a “hospitalist” are the same thing.

  • Patrick Kenney

    Speaking as a fellow med student, I think you did a great job. As for the negative comments below, I wouldn’t worry. It is true that an emergency room may not be the best place for an eating disorder, but it is good for active suicidality. In a situation with a patient with few resources, there is no quicker access to psychiatric care than via the ED. Since psychiatrists are also either trained or have access to resources for eating disorders, or helps there too.

    You did well!

    • JR DNR

      He did what is convenient for the medical system, not what is best for the patient.

      The patient doesn’t show any signs of being actively suicidal, so such a referral was unwarranted.

      Looking at a med student with distrust isn’t justification to force a family without much means to face an ambulance and ER bill they can’t afford.

      • Patrick Kenney

        The problem is that there are rarely resources that can provide immediate help. The average wait time for psychiatric care was 60-90 days last time I looked at the data. Clearly the attending thought there was a risk, and was concerned enough to think it was emergent. Also when I talk about care I do mean a physician. Anorexia in adolescent females has an extraordinarily high morbidity and mortality with only a few methods shown to help. Only a few people outside of England know these methods as well, making appropriate care critical.

        • JR DNR

          These kind of over-reactions simply cause people to not seek treatment at all the next time they need help. It’s a short-sighted solution that doesn’t help the patient in the long-term.

    • JR DNR

      Let me try this another way:

      Part of the healing process for self harm (common among young girls) is admitting the problem. Don’t see it as a “cry for help” – see it as a step in healing.

      There is no quick fix to this girl’s problems. Social support is critical to recovery, and a relationship with a medical physician can play a CRITICAL part of a patient’s social support. Please don’t underestimate the value a physician can bring.

  • JR DNR

    http://allnurses.com/first-year-after/resident-vs-attending-313434.html

    Even nurses don’t know who is who in medical care, you really expect the general public to know what’s going on?

  • guest

    Nice job taking a good history, being alert to nonverbal clues about the patient’s condition, and getting her to talk about some of her issues.

    However, it’s also a great illustration of what’s wrong with our healthcare system.

    The most appropriate thing to have done would have been to do an assessment for depression and suicide risk on the spot (I teach psychiatry to Family Medicine residents so I know that they are supposed to know how to do this). If there were indications that she was at imminent risk, then a referral to the Crisis Team would have been a good idea. If she was not at acute risk, then she could have been allowed to leave after someone (the social worker for your clinic?) made an appointment for her with a Community Mental Health Center. She could have been scheduled for a follow-up visit with the clinic for the following week to check in with her and make sure she had gone to the intake appointment at the CMMHC.

    I will agree with others that shipping her off to the ED is not such a good call. It’s the most “efficient” thing to do but as someone with a background in emergency psychiatry I will say that the ED is not the best place for someone like this to get assessed for appropriate outpatient referrals. Frequently, all the ED staff do is A) feel pissed off at you for passing the buck and B) call the Crisis Team, which you could have done yourself in the clinic.

    However, I suspect that she was sent to the ED because no one had time to do the other stuff, and probably you don’t have a social worker on staff at the clinic, even though paying one would save the system a lot of money in the long run, and would help you provide better care for your patients.

    • JR DNR

      Thank you. I’ve worked with people locally to find help and I’m amazed how much assistance is out there… but many physicians are unaware it’s there.

      Maybe I’ve just found my way to be an advocate. I wonder if popping up at doctor’s offices with pamphlets would even work.

      • guest

        You know, I think that there would be many physicians who would find that extremely helpful, would appreciate your doing it, and would use the resources.

        I know I am always delighted when someone brings my attention to a resource for my patients that I didn’t know about. Just yesterday I was struggling with a referral for counseling for someone with no Medicaid and said to my social worker for the umpteenth time, “I know nobody has the time to research this and make a list of free clinics, but it sure would be helpful if somebody would do it.”

        • JR DNR

          Hmmmmm… :)

  • Dr. Ivo Robotnik

    You seem to know a fair amount about mental health resources that are available, but you are failing to recognize the reason why this patient was sent to the ER. The student and attending physician (who were actually there) decided that this patient was at risk for severe electrolyte abnormalities and she needed to be evaluated in an emergency setting. Shipping out her bloodwork only to find out 3 days later that she had a potassium of 2 is unacceptable care. There is much wrong with the system, but in this case the young woman needed more than a psychological eval (which is indeed poor in the ER), she needed a full biochemical eval. Don’t underestimate the mortality of anorexic/bulimic patients.

    • JR DNR

      The article doesn’t give us any information as to what kind of setting this is. We only know it’s a med student by the tag line. Is it a family practice rotation as someone claimed? What kind of setting is that? Is it a poverty clinic?

      I read it as being a doctor (not a med student) at an urgent care clinic passing the buck onto the ER because they don’t deal with difficult patients. At least, that’s what the article makes it sound like.

      The article doesn’t tell us why medical care and follow up can’t be done by the clinic. We don’t know what capabilities they have, so we have to make assumptions.

      As I stated: The focus of the article is on mental health, so I have to assume this is a mental health referral, since it was presented that way.

      This article does not make any argument that the patient is actually in an emergency. Rather, it plays out as if the only thing to do with someone with an emotional problem is dump them somewhere else.

      • exit 7

        My city has a 24 hour psychiatric E.D. Let me guarantee you that with her history of bulimia, low body weight and tachycardia, the psychiatrist would ship her off the E.D. for medical clearance prior to a psych clearance.

    • JR DNR

      You seem to have missed where I clearly stated:

      I am not qualified to make medical judgments, but you focused on her immediate mental, not physical, health in your article as a reason for the ER referral so I’m going with that presentation

      Which gives important context to my comment.

      • Dr. Ivo Robotnik

        It seems my last comment was moderated so I’ll have to try being nicer this time around.

        You say he focused on her immediate mental, not physical, health as the reason for ED referral. Though, at the end of the article I see “…for evaluation of her electrolytes, tachycardia, and suicidal ideation.” The first two things he mentioned were physical, not mental.

        Maybe we read different articles.

        • JR DNR

          If you’d like the public to understand the importance of something, you have to explain what it is and why it’s important.

          I read an article where a doctor states the patient had nothing alarming on exam, but then they find the patient might be self harming, the doctor confused self harm with suicide, and then declare the patient is a danger to themselves and so they are sent to the ER and their life was saved!

          Someone mentioned testing for electrolytes may not be possible on site, and that is critical to this patient – but the article doesn’t explain any of that.

          A whole paragraph before that is dedicated to what the concern is: “And just then, it occurs to me that this is a girl crying for help. A girl who is broken behind that big, beautiful smile. A girl who needs someone to talk to, someone to confide in, someone to listen. A girl who might do something destructive to herself if she doesn’t get help soon. A girl who was waiting for someone to ask the right questions.”

          This is what the med student states THEIR concerns are, and why THEY think intervention is needed.

  • JR DNR

    I don’t think any conversation here is ever “irrelevant”. Sharing information and different points of view is the purpose of the comment section.

  • Acountrydoctorwrites

    All you commenters, give the kid a break! A student, on a rotation, takes a much better history than many others would have in the same situation. He realizes intervention is needed. His attending made the clinical judgment call. The life saving act of this talented and compassionate medical student was connecting with a distressed teenager instead of just addressing the stated chief complaint. He wasn’t there to decide how soon lab results were needed or which resources to involve; that’s why he’s a student. A very good one.

    • JR DNR

      Expensive care isn’t better care.

      Why an ambulance? Is it because the family has no transportation? I’ve heard complaints about ambulance being used as taxis before and thought it was exaggerated. I guess I was wrong.

      Nothing in this article explains that the patient has a medical emergency or a mental health emergency. I do think that picking up on these problems is noble and to be commended. But nothing here tells us why this patient’s problems couldn’t be better addressed by the clinic and a mental health referral.

      Look at the patient as a WHOLE. What is best for the patient’s mental health is not an ER referral. The patient’s physical health can be addressed by the clinic, providing social support and continuity of care which will improve the patient’s mental health.

    • guest

      Nobody is picking on him for the attending’s call. But for the purposes of his own learning, he should hear that there could have been other ways to address the history that he obtained.

  • JR DNR

    What was practiced here was reductionist medicine. Look at each piece of the puzzle as a part and not a whole. The whole of the patient and their needs – both physical and mental – wasn’t taken into consideration. The patient’s physical problems have an emotional component, and the emotional component would be most helped by continuity of care, not a referral to the ER.

  • JR DNR

    Physical, Emotional, and Mental health are all important.

    When a treatment plan is considered, it should include the following:
    -How will this plan effect the patient’s physical health?
    -How will this plan effect the patient’s emotional health?
    -How will this plan effect the patient’s mental health?

    Unfortunately, in medicine, the physical health is prioritized first. Emotional and Mental health are left for “someone else to clean up”.

  • JR DNR

    I clearly stated in my comment I was not making any medical judgments.

    And when talking to patients, it’s a good idea to not use uncommon medical terminology. (Seriously, how often is “nomogram” used by the general public?)

    I personally think it’s conceited to declare a victory (I saved a life) when clearly the patient’s issues aren’t resolved and are only beginning to be addressed. And the student isn’t even the one taking responsibility to address them!

  • JR DNR

    But that’s not what the student focused on.

    Certainly, there are medical issues to be addressed with this patient, but the article doesn’t explain why those issues can’t be addressed by the clinic or why they would count as an immediate emergency.

    • Dr. Ivo Robotnik

      Perhaps the student recognized them, perhaps he didn’t. Upon reflection I supposed I am (and many others are) reading this through the colored glasses of someone in medicine. All the warning signs are there to us, without needing to be explained. We understand the increased length of time it takes to send out bloodwork rather than getting it to the ER, and the consequences that may have. When a patient presents a certain way (such as tachycardia in a bulimic patient) there are red flags that go off in our head with horror scenarios that need to be rules out.

      Apologies if I came off dismissive, it was not my intention. Your comments seem to have struck a nerve as lately I’ve been getting more than a little annoyed with people not in medicine critiquing the decisions of those in medicine without even understanding what their motives were. Or worse yet, people legislating in medicine without any medical background at all.

      • JR DNR

        I’ve been the patient sent to the ER, mocked and ridiculed by the staff, because my PCP wanted to do a CYA test.

  • JR DNR

    There has to be a balance. Emotional health is seen as something someone else has to clean up later, not something integrated into the care of the patient while they are receiving physical care. Physical wounds sometimes heal easier than mental ones.

    I’m not saying that a medical person should be providing counselling, rather, they need to be aware of the impact of their actions on a patient’s emotional and mental health so they can make the best decisions. And our health institutions have to support that as well.

    • GoCougs

      A balance, yes, but the immediate danger needs to be addressed first. And that might be something that needs to be addressed in the hospital or ER. Again, what this student (and his attending) did, was not wrong. They took into consideration the whole patient, not just the psychosocial aspect, but also the medical. You keep focusing on one aspect, and while it’s important, it’s not the thing that may have the patient in immediate harm.

      • JR DNR

        The article states there was nothing alarming about the patient except potential mental health issues, then doesn’t provide any explanation for potential health issues. So emergency health issues are never identified by the article.

        • GoCougs

          Actually it did. Malnourishment and tachycardia are medical, and those are both mentioned.

          • JR DNR

            “I begin my physical examination, and other than some mild tachycardia, she appears perfectly normal.” Then he tells us he’s wrapping up and not concerned about “tachycardia”. As a reader, I dismiss this comment because the author tells us to dismiss it.

            Think for a moment. Where does this article define the word tachycardia? It doesn’t. Where does the article explain the importance of a rapid heart beat? It doesn’t. Where does the article explain a blood test is needed to check an electrolyte imbalance? It doesn’t. Where does the article explain blood tests can’t be done in his clinic? It doesn’t. Where does the article explain the pros and cons of treating for electrolyte imbalance defensively without a conclusive test? It doesn’t.

            I’m not medical, but I can’t understand why if there is a concern the patient is dehydrated, why the patient isn’t treated for dehydration right away. I’m not medical, I don’t know. I stated that. I think it’s rather silly to send someone to the ER for a saline drip.

          • GoCougs

            He notes the 3% weight early, even before he brings up the psychosocial aspect. He also states that she does have some mild tachycardia. Taken in context, as many of us within the medical profession have stated, could be a sign of something else. We’ve pointed out that many of us saw it, you didn’t. That’s fine, you’re not trained to see it (hey, MIs don’t always have crushing chest pain, but you might want to do an EKG on an uncontrolled diabetic who has nausea). I don’t see the benefit in arguing those of us who did see something else.

          • JR DNR

            I want to provoke the thought that there may be other ways, other than what is current taught, to administer medical care.

          • GoCougs

            There are plenty of ways to administer medical care, missing a serious potential lab abnormality on an obviously malnourished teen is probably not a good way to do so.

          • JR DNR

            Honestly, that sounds like a “CYA” response.

            Even with all the information gathered, nothing can be done for this patient without a lab result?

            Lab results don’t matter unless the alter the course of treatment of the patient.

            Do you really think it isn’t clear what needs to be done for this patient based on the history alone?

          • GoCougs

            Cya or not, it doesn’t matter. There’s a potential for a serious complication, of which you obviously know nothing about.

          • GoCougs

            And yes…”Doctor, did you not realize that a young female in the 3% in weight and 50% for height, could potential be very malnourished and potentially have a serious lab abnormality that could cause a cardiac dysthrythmia? How do you explain your neglect in my clients daughters death?”

          • JR DNR

            Yes, I imagine most mothers throw around the term cardiac dysthrythmia and know what that means. :)

          • GoCougs

            No, but malpractice attorneys do.

          • JR DNR

            Ahh – so you admit this was a CYA move to prevent a lawsuit, not a move to provide the best care to the patient? See, that’s how I read the article in the first place too!

            Glad we can agree.

          • GoCougs

            No, I’m stating that there is obviously a POTENTIAL medical problem that needs to be addressed. Not doing so IS neglect.

          • JR DNR

            Well, let’s assume for a minute we could treat this ideally, not limited to the current existing systems.

            Is the reason for the ER referral really just a blood test? If it is, would the ideal solution then be for the office to be able to get a rush on blood tests when needed? Then, treat for dehydration if needed?

            If the test can’t be done immediately, what other alternatives are there? Can dehydration treatment be initiated “just in case” while waiting on test results? Would that prevent negative outcomes?

            I think that ideally there can be a lot done. Please don’t underestimate the emotional impact of the actions proposed by this article

          • GoCougs

            Lets not assume. Remember, what do we say when one assumes?
            You read this article differently than those of us who are physicians. I read this with interested in the beginning, not because of the psychosocial aspect, but because of the 3%. I was curious if this was a metabolic or cancer (why the weight loss? Surely this girl hasn’t been 3% weight and 50% height for years). Why is this difficult for you to understand? Quit being a troll.

          • JR DNR

            Yes I did read it differently, and that’s exactly why I’m commenting. To provoke a different mindset. To promote change.

            Unfortunately, you are not the only one who does not prioritize mental or emotional health in health care.

            And I do think the student did a great health history. I think taking notice of such issues is an important start. Next, we need to develop the skills to handle the results such questions bring.

          • GoCougs

            Where did I say I don’t prioritize mental health? I didn’t. What I’ve said is “let’s deal with the things that could potentially kill her today, and deal with the rest later”.
            You want to assume, fine. Assume she was the last patient of the day, assume the lab in the office is closed, and she has to go to the hospital for labwork, let’s assume neither the patient or the mother doesn’t grasp how important it is to see what her electrolytes are. Let’s assume they decide to go to the lab tomorrow. After all, it’s late and mom has to work. Let’s assume the girl dies in her bed due to hypokalemia.

          • JR DNR

            When I went in for a sore throat to my doc (mucus retention cyst), I got schedule for lab work, a physical, vaccine catch ups… all at the first appointment. I saw my doctor more in a few months than any other physician I’ve ever had. It was a whirlwind of care, but all contained in one office with one physician.

            I wish this girl had the same great care I have. She would have had a CBC the week of her first appointment, and then we’d already know her potassium status. She’d have appointments as often as necessary to follow up on her care.

            Because, my doctor tries to be all professional, but… his facial expressions betray him. He actually cares. I fear he’s a dying breed.

          • FEDUP MD

            CBC does not show potassium. It is a blood count. Not an electrolyte count. And why would one get blood work for an uncomplicated ear infection? That would provide no additional information that would be useful.

            I think you need to listen to that fact that to a physician, we all are telling you in our professional judgement that this girl was in imminent danger of her life, and that the decision that was made was the correct one in this specific setting. If she was simply depressed, or bipolar, with no concomitant eating disorder, then your argument to not send to the ED might hold water depending upon the situation.

          • JR DNR

            I’m looking at my lab work right now and my CBCs include electrolytes.

            Also, remember where it says she hasn’t had medical care in 4 years?

            And I also said I’m not making and medical judgments, just looking at what was presented as a mental health referral?

          • FEDUP MD

            A CBC is a complete blood count. It includes white blood cell count, red blood cell count, platelets, and various other markers of the cells in the blood. This can include differential of the subtypes of white blood cells, other breakdown of red blood cell markers, etc. It is completely separate from an electrolyte panel, which looks at various ions and chemicals in the blood. They are separate tests run on different machines. I have worked at many many clinics and hospitals and they are always separate tests with separate orders and separate charges, and ordered for different purposes. Sometimes you will get a lab list back and it will on the computer only list the name of the first test ordered at the top. It is a quirk of EMRs but does not mean they are all that test.

          • JR DNR

            Must be the “CMP” then, I missed that tacked on at the end. (CBC, iron, TIBC, ferritin, Vitamin D, CMP).

          • FEDUP MD

            Yes, it stands for comprehensive metabolic panel, or comprehesive electrolytes (includes liver function markers too).

          • FEDUP MD

            I also would see no reason to get a CBC or electrolyte panel on an ostensibly healthy kid, no matter how long it has been since they had medical care. There is no value to getting them without an indication. With Bayesian reasoning, if the pretest possibility is very low in a asymtomatic person, than why order a test at all?

          • JR DNR

            Hmm, I had CBC/CMP on one doc for a rash, another doc for a sore throat, both first visits. Seems rather standard.

            Also seems a little incomprehensible to the lay person:

            We’ll skip the inexpensive blood test, then pull out the ambulance ride and ER visit…

          • FEDUP MD

            I can’t speak to your specific case as I don’t know your complete story. There are situations where I can see getting these tests are useful (ie if the rash leads to concern about allergy vs. viral, or the sore throat lead to concern about mono and the concomitant risks thereof of physical activity, etc). I am taking the medical student’s story that it is an uncomplicated ear infection. There is absolutely no reason to get any blood work then. It would not change diagnosis or treatment as determined by history and physical examination- there is no reason to get tests if you already have a diagnosis and treatment without them, and if it will not change them. If there is a question after history and physical, then tests can be useful. But they are just tools and need to be treated as such.

          • FEDUP MD

            The danger is that the blood test cannot come back quickly, like in an ED. My turnaround time for a test like this is two days in my clinic. She could easily be dead by then. The reason is these lab machines are expensive to buy and run. We send all our labs out to a private company, because it otherwise would actually cost us money to run them, considering our low volume.

            Let’s say even in an ideal world we get a potassium in clinic back in an hour. It’s low, life-threateningly so. If she left, you are now trying to track her down and hoping she answers her phone and sending the police after her. If she stays, now you call an ambulance. It now takes an additional amount of time for the ambulance to come, to get an IV, etc. if during all this time she codes, as a physician you are completely screwed. You likely do not have the equipment or medications to treat her. If you send her to the ED in an ambulance immediately, she will be in a setting quickly where her life can be saved. If your suspicion is high enough that her life is in immediate danger, you do her a grave disservice having her sit in your office and hoping she doesn’t code, because you aren’t equipped to help her. The ED is.

          • JR DNR

            I guess the risk analysis is this:

            -What is the chance her potassium is dangerously low?
            vs
            -What is the chance this will worsen her condition (assuming she is anorexic, self harming, or suicidal).
            -What is the chance this will cause her to drop off the radar and not get further treatment?

          • FEDUP MD

            In this clinical setting (where it is noted she actually admits vomiting) the risk of hypokalemia is reasonably high. Of all of the psychiatric disorders, anorexia has the highest death risk. Up to 15%.

            Most of us don’t enjoy sending psych patients by ambulance to the ER. We recognize it is not a great place for care and it can be scary and potentially make things worse in some cases. However, if we think the risk of death is high enough, we’ll do it. Because emotional issues and trauma can be treated but death is permanent.

            If this were my child I would want her treated in this exact way.

          • JR DNR

            I’ve known too many suicidal friends to agree, so we’ll just have to disagree.

          • FEDUP MD

            Having known several people who committed suicide, I am also not a stranger to this. You can’t fix death.

            If my child were the child in this vignette, her risk of death would be unacceptably high, based upon known data with this clinical situation and diagnosis. One must treat the whole person, yes, but one must be alive to be treated. Otherwise the whole person is gone.

          • JR DNR

            There are worse things than death.

          • FEDUP MD

            Are you really arguing that suicide in the mentally ill is a reasonable solution?

          • JR DNR

            I was thinking more along the lines of someone being kept alive in the moment, just to turn around and die later.

            But medicine is good at ignoring the long term while focusing on the short term – especially when it comes to mental illness.

          • PrimaryCareDoc

            CBCs don’t include electrolytes. Ever. Please stop lecturing the physicians about medicine. It’s really annoying.

          • GoCougs

            Actually, no we wouldn’t know what her potassium is based upon getting a CBC. It’s not there.
            This was a routine follow up for an otitis, and a very astute medical student picked up on some very dangerous clues. That’s good medicine. Quit being a troll.

          • FEDUP MD

            Let’s make it very clear as physicians what we are worried about. Someone with an eating disorder who is malnourished (3%ile) and dehydrated (tachycardia) is at risk for severe hypokalemia, or low potassium. This is commonly due repetitive vomiting and laxative abuse. If this is severe it can cause a heart rhythm abnormality which is very hard to treat and is often fatal. Now, mind you, this is in a perfectly otherwise healthy teenaged girl. Who can end up dead very quickly. The treatment of severe hypo kalmia needs to be done in an intensive care or emergency room type setting with intensive nursing care and cardiac monitoring.

          • JR DNR

            I really appreciate you taking the time to explain.

          • FEDUP MD

            I would have sent this kid by ambulance to the ED too. I don’t picture myself talking to a malpractice attorney. I picture myself at the patient’s funeral and the parents asking me, “But we did everything we could, right… This couldn’t have been avoided?” And me having to loom them in the eye and answer yes, we could not have done anything differently with what we knew at the time. And I have been in that situation and very proud to say that I have always been able to say that.

          • FEDUP MD

            And to be clear, the treatment of severe hypokalemia is also risky. It’s not something you would treat “just in case” while you await results. You need to have a number to correct to. If you overshoot than you can kill the patient too. It really needs to be done in an intensive care setting. If you undershoot they are in danger too.

          • PrimaryCareDoc

            The answer is no, you can’t just throw IV fluid and potassium into someone on an assumption.

            JR DNR- I’m not sure why you’re being so obtuse.

          • JR DNR

            I’m not sure why you have to stoop too insults.

            Call your doctor if the dehydrated person experiences any of the following:

            Increased or constant vomiting for more than a day
            Fever over 101°F
            Diarrhea for more than 2 days
            Weight loss
            Decreased urine production
            Confusion
            Weakness

            Take the person to the hospital’s emergency department if these situations occur:

            Fever higher than 103°F
            Confusion
            Sluggishness (lethargy)
            Headache
            Seizures
            Difficulty breathing
            Chest or abdominal pains
            Fainting
            No urine in the last 12 hours

            She isn’t even in the “take to the doctor” list. From a layman’s perspective looking at this article, of course we’d quesiton what’s going on.

            And several of you are commenting and only one is capable of explaining it in patient friendly terms!

            Again – I stated I was talking about the mental health impact based on the fact that she sent to the hospital as an emergency mental health referral.

          • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

            I’ve been reading this thread carefully, as I’m interested both in the management of eating disorders, and also doctor-patient communication.

            JR-DNR, you seem uncomfortable that doctors have expertise that isn’t easily and readily explained to a layperson in a few words. I find this curious, as I doubt you hold bridge engineers to the same standard before driving over their handiwork. We all trust the expertise of others in areas we don’t know well ourselves.

            Your list above, presumably taken from a general guide for patients and their families, doesn’t cover every possibility. Naturally, even well-read laypeople will question a patient’s referral to emergency treatment when it isn’t on such a list. You’ve questioned — and you’ve been answered repeatedly. This is a special case. Even as a psychiatrist (psychotherapist mostly) who is deeply interested in the emotional wellbeing of patients, I defer to life-threatening medical risks. Your effort to turn this into an illustration of medicine running roughshod over a patient’s emotions falls flat, because in this particular case that’s not what happened. There are other cases and examples, particularly regarding psychiatric issues, where it does happen. This isn’t the place to take your stand.

          • JR DNR

            Patient that is not suicidal is given an ER psych ref for being suicidal.

            Sorry, that’s poor judgement and not good for the patient. As I stated in the beginning: I’m not judging the medical points, because I’m not medically trained.

            You also aren’t reading the 20+ deleted comments calling me names – all of those from those claiming to be doctors here.

          • JR DNR

            I’m not arguing she doesn’t need medical care. But why pass the buck on her medical care? Why not take care of her right where she is? Did the consideration of what would be best for her mental health even take place?

            I mean, most people who self harm aren’t suicidal, and I worry this article pushes the idea that self harm is a suicidal act that requires emergency evaluation.

          • GoCougs

            No you’re arguing for the sake of arguing, which is very trollish. Why can’t you accept that many of us saw some potential medical problem that needed to be address (or cleared) before the psychosocial aspect needed to be dealt with?

  • JR DNR

    I’ll rephrase your sentence:

    We will ignore the patient’s emotional and mental health while we fix the important bits. The leave the rest to someone else to clean up, cause I’m a doctor and I don’t do that stuff.

    • GoCougs

      No, please don’t rephrase. It doesn’t help. The correct statement would be “let’s fix the problems that could kill her tonight and deal with the other stuff later”. That’s fine if you want to phrase it that way.

  • JR DNR

    What good does it do to recover someone’s physical integrity, leave them in a bigger emotional mess than you found them in, which leads them to continue to neglect their physical health, which leads them back to the hospital… starting a cycle that continues over and over.

  • JR DNR

    Again – this article says nothing seemed wrong at all, until scars were noticed on the wrists.

    Therefore, since I do not have a medical education, I’m trusting the judgement of the article writer that the symptoms that were noticed, and written off as unimportant, are correct as the writer never contradicts that statement.

    If you have a medical education and know more, you can explain it in patient friendly terms. But throwing around medical terminology doesn’t improve the conversation.

    This is a patient/provider blog with many patients reading and participating in discussions, and that is important to consider when commenting.

    • GoCougs

      He first notes the 3%weight, and states that this isn’t going to be a “ear recheck”. Try rereading the article.

  • Suzi Q 38

    Good job.

  • DeceasedMD

    nice job but the sad fact is this is a very ill borderline with an eating disorder likely and in the real world there is virtually no competent help for her. And hope she does not require inpt as thatin itself would starve a pt. There is no help.

Most Popular