Three Trauma Cases

Written by Tad. Posted in Kooks

Ride Motorcycles, Not Fences

A 27-year-old man lost control of his motorcycle and ran up against a three-foot-tall chain link fence. He was brought in by ambulance complaining of severe groin pain from having been dragged along the top of the fence. The medics reported that his testicle had been amputated. They said they picked it off the fence and had it in a plastic bag. What I found in the bag was a large piece of scrotal skin. I found the testicle hanging back between his legs, attached only by the spermatic cord.

The urologist took him to the operating room to finish removing the testicle and repair the injury.

 

Dangerous Summersault

My patient was a 22-year-old female who was playing on the floor with her niece and nephew. She tried to do a forward roll or summersault. She didn’t roll over enough and came straight down on her head. This caused sudden onset of severe neck pain as her neck twisted underneath her. This was associated with numbness in her right arm that quickly went away.

My first reaction was, “No one can break her neck doing a summersault on the living room floor” but x-rays showed two fractures of the second vertebra. She was admitted to the hospital for placement of a halo brace. Here is a simple explanation of what this is: http://kidshealth.org/parent/question/medical/halo_brace.html

 

Ice Avalanche

A young man was transferred to the emergency department from a nearby chicken processing plant. He had been working in a giant room where they stored huge amounts of crushed ice used in processing the chicken. He had been assigned to break down a large amount of ice that had formed against one of the walls of the room. As he chipped away at the wall of ice, it suddenly collapsed, burying him under a huge mound of crushed ice. The paramedics reported that coworkers were able to quickly uncover his head, allowing him to breath, but it took approximately thirty minutes to free him from the ice.

On arrival in the emergency department, he was found to be hypothermic and have several minor injuries.

 

 

Banner Bag

Written by Tad. Posted in Trauma Strap Bags

When shopping at RAFT, I am always on the prowl for something that would make a cool bag. When we saw two huge banners with lots of black and orange, I bought them. I have had them rolled up under the bed for months until, on Friday night, I woke up at 2:00 and was unable to go back to sleep. It was tricky to sew the plasticized material but I was pleased with the result. The bag folds flat but unfolds to form a rectangular bottom that stands up well. Here are some pictures.

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This is what the banner looked like. I took the upper left part for my bag.

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Here is the bag with the bottom folded flat. The trauma straps cover the word “Microsemi” that was on the banner.

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Here it is with the bottom unfolded.

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Back.

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Sides.

Customer Service 2

Written by Tad. Posted in Kooks

Customer Service 2

Last week, I posted about a man who complained to Customer Service after being refused intravenous morphine. Today I will share with you another noteworthy complaint.

A middle-aged woman came to the emergency department with many complaints. From the time she arrived, the staff found her to be difficult to deal with. She was seen walking around the department in no obvious distress. Yet, she was so uncooperative that every attempt to care for her was met with disregard for the staff’s effort to address her needs.

When she decided she was going to leave, she asked that she be provided by a taxi voucher to pay for her ride home. When she was told that would not be possible, she threw herself onto the floor in the waiting room, screaming and making a huge scene. She later wrote a letter of complaint about her care.

I was Chairman of our department at that time and it fell on me to respond to her complaint. I never saw this patient but I had to review her complaint and respond to Customer Service. I wish I had her original letter but I do have the memo I wrote to Customer Service in response to her letter. I will share it with you. This is another example that shows how hard it is to make the patient a customer with a motto: “The customer is always right.”

 

To:            Customer Service

From:                        Dr. Tad, M.D.

Subject:            Patient Complaint

I have reviewed the letter of complaint and medical record of this patient. Her long letter outlines many complaints against the emergency department staff. Here is a partial list:

  1. She saw many seriously injured people getting no attention.
  2. She saw staff eating donuts.
  3. She saw staff laughing and giving each other “high-fives.”
  4. It took thirty minutes and four nurses to get her initial care.
  5. It took ninety more minutes to get the next episode of care.
  6. She was in the hospital three hours before she was diagnosed.
  7. She was told to get pain medication from Long’s Drugs.
  8. She was forced to sign the Leaving Against Medical Advise form.
  9. She was treated “without any concerns or sympathy.”
  10. She “fell unconscious at the foot of my bed” and “saw my face hitting the cold floor.”
  11. She was not allowed to make a phone call for help.
  12. She was stuck outside in the cold, unable to get up because the wheel chair was locked.
  13. She was treated with “disregard and carelessness.”
  14. She was not given a cab voucher.
  15. She was not treated for asthma.
  16. She was not “emotionally comforted.”
  17. The nurses and receptionists were having a picnic of chips and soda.
  18. Her “intelligence has been insulted and (her) private rights have been violated.”

Interestingly, she also admits in the last paragraph of her complaint that she behaved “impudently” and apologizes for her “peculiar impoliteness that evening.” Impudent is defined as “marked by contemptuous or cocky boldness or disregard for others.” I have talked to several of the people who had opportunity to care for this patient that night. From all accounts, it sounds like she has used the appropriate word in describing her behavior. The staff saw her walking around the department in no obvious distress. Yet, she was so uncooperative that every attempt to care for her was met with contemptuous boldness and disregard for the staff’s effort to address her needs.

The episode where she describes going to the ground was seen by the staff to occur when she threw herself on the floor when she was told that there was no taxi voucher for her.

The staff attempted to provide her with an appropriate exam and treatment. They tried to help her get a ride home. They were insulted and rebuffed at every attempt to help her. She signed out against medical advice rather than accept any appropriate evaluation and care in the emergency department.

It is clear this lady was not happy with our care but it is also probably true that her expectations were unrealistic. It is very clear from talking with the staff that her impudent behavior was responsible for a good part of her unpleasant experience here.

Thank you very much.

Dinner from Manu

Written by Tad. Posted in Uncategorized

On June 17th, I posted a picture of the bag I man for Manu, one of our registration staff. I was really surprised when he came in one morning with a bag full of food he had prepared, as a thank you for the bag. We made a complete, gourmet dinner. We started with an appetizer of  toasted, crustless bread spread with cream cheese, and pesto then topped with cucumber and red bell pepper. Then we had perfectly cooked tri-tip and mashed potatoes flavored with onion and cayenne. It was amazing and very much appreciated.

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A Complaint from Customer Service

Written by Tad. Posted in Kooks

I went into medicine to help people. Emergency medicine gives me a lot of opportunities to do this and relieving pain is one of the most rewarding parts of my job. Usually, making pain go away makes patients happy.

Making patients happy is more and more an important part of medicine. Hospitals survey patients and track complaints in evaluating quality of care. Insurance companies and government agencies use patient satisfaction data to determine reimbursement rates. This information is also increasingly available on the Internet to consumers who want to pick providers with high satisfaction records. In a world of increasing competition, high satisfaction scores give hospitals and doctor groups an advantage in attracting and retaining patients. This puts a lot of stress on doctors to keep their patients happy. As a result, the practice of medicine is increasingly driven by the business philosophy, “The customer is always right.” If the doctor does what the patient wants, the patient is happy. The patient gives high satisfaction survey scores and never complains. The doctor, his group and the hospital all look good and are happy.

This is wonderful as long as patients want what is good for them. When patients demand care the doctor doesn’t feel is in their best interest, a conflict develops. If the doctor says “no” to patient demands, the doctor may be rated lower on patient satisfaction surveys or even have to respond to official patient complaints. Knowing this, the doctor has to decide whether to do what he or she thinks is best for patients or just give patients what they demand.

To illustrate how this engenders conflict, I will tell you about a situation where a patient complained about my care.

A middle-aged man came in complaining of abdominal pain. He had been seen in our emergency department many times over a few months for similar complaints. I had this in mind as I took a medical history and examined him, including pushing carefully on his abdomen. I then excused myself and went to look at the documentation of his many previous visits to the emergency department.

When I returned to the exam room, I reviewed with him his many emergency department visits of the prior year. Most of them had been for abdominal pain for which he had almost always been given intravenous opiates. I told him I had no way of knowing if he were or were not a drug addict. I told him that, if he continued to come to the ED for opiates, he certainly would become addicted. I also pointed out that, as much as he uses the ED, he had to expect our staff would probably treat him as if he were an addict. I counseled him to take stock of his life patterns and do everything he could do to work with his primary care physician to avoid coming to the ED for pain medicines.

I offered to run tests to make sure he had no serious medical condition causing his abdominal pain. I offered to give him something to help his pain but told him I felt it would not be in his best interest to give him intravenous opiates. He argued with me but, when he could tell he would not get intravenous opiates, he refused further care and walked out.

I was not at all surprised when, a few days later, I was contacted by the hospital’s Patient Services Department about a complaint they received from this patient about me.

I am sure he felt like I accused him of being a drug addict. He didn’t get the opiates he had grown accustomed to getting on previous visits to our ED. I am sure he was unhappy when I told him hard truths he didn’t want to hear. While all that may be true, I think I took good care of this patient. However, patient satisfaction data alone might suggest I am not a good doctor because I didn’t make my patient happy. You can see how unfair this is and why I am frequently conflicted over how to deal with this sort of a situation.

Another Diaper Bag

Written by Tad. Posted in Trauma Strap Bags

We are expecting our first grandchild this fall. Here is a picture of our son, Philip and his prego wife, Elizabeth, with the diaper bag I made for “Genghis,” the best name they have been able to come up with so far.

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Granola Apple Cookies

Written by Tad. Posted in Cookies

This recipe is in a Pillsbury cookie cookbook I found at a thrift store. I used Granny Smith apples for crispness and tartness. I added a sprinkle of granola to the top of the dough before baking, which added a fun crunch and made them more interesting to look at. I used cinnamon, rather than nutmeg. Next time, I will try the nutmeg but would certainly put in less than the 1 teaspoon it calls for because that much nutmeg is just too much for my taste.

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Recipe By:

Pillsbury

Ingredients:

1½ cups firmly packed brown sugar
½ cup butter, softened
¼ cup milk
1 tablespoon lemon juice
1 teaspoon grated lemon peel
1 egg
1½ cups all purpose flour
1 cup whole wheat flour
1 teaspoon baking soda
1 teaspoon cinnamon or nutmeg
¼ teaspoon salt
1½ cups finely chopped apples*
1 cup granola, plus more for topping**
1 cup powdered sugar***
¼ cup lemon juice

Directions:

1. Heat oven to 375°F.

2. In large bowl, combine brown sugar and butter. Beat until light and fluffy. Add milk, 1 tablespoon lemon juice, lemon peel and egg. Blend well.

3. Add all purpose flour, whole wheat flour, baking soda, cinnamon and salt. Mix well.

4. Stir in apples and 1 ½ cups granola.

5. Drop in 2 tablespoon balls about 2 inches apart onto ungreased cookie sheets. Sprinkle with additional granola and gently press into surface.** Bake 9 to 13 minutes or until light golden brown. Immediately remove from cookie sheets. Cool until completely cooled.

6. Meanwhile, in small bowl, combine powdered sugar and ¼ cup lemon juice
lemon juice, adding enough lemon juice for desired drizzling consistency. Drizzle over cooled cookies.***

Notes:

* I used Granny Smith

** I added the granola on the surface and it made them look a lot cooler and the crunch was really fun.

*** I used almost twice as much glaze as the recipe called for.

Copyright © 2012 Bad Tad, MD