Wednesday, August 15, 2007


50ish hypertensive hypercholesterolemic male smoker.

Seen by another provider 2 weeks ago. Advised to go straight to the ER for shortness of breath, tachycardia, weakness. Told her he'd be driven there by his son, decided not to go, "I felt too sick".

Called a week ago stating he passed out at home. Advised to go to ER. Refused.

Called yesterday stating he still felt weak and dizzy. Advised to come to office immediately for appointment or to go to ER. Said he couldn't come in till today.

Appointment with me today. Hypotensive, tachycardic, normal pulse ox and EKG. Complaining of weakness and dyspnea.

I assumed my "Fear of God" voice (which I pull out on rare occasions only) and told him that he may be suffering from any number of conditions, not limited to a heart attack or blood clot in his lung, which was potentially life-threatening. And as much as I would love to be able to work him up and treat him in the office it was not possible. And that he must go to the ER for appropriate care.

I stepped out so that my nurse could do his EKG.

His comment to her, "Gosh, is she always so grumpy?"


socks said...

Calling your RADAR: was it your impression that he was really ill?

Dr. Smak said...

His vitals had me concerned.

I kicked around doing some outpatient workup, decided against it. Chances are whatever event made him tachycardic happened a couple of weeks ago and hadn't killed him yet.

But it was the first time I'd met him and he didn't strike me as Mr. Reliable. The outpatient workup assumes a good deal of cooperation.

Doc said...

I couldn't help laughing as I read it...been there so many times. I agree with the ER...if it's cardiac, he is at high risk of death, and soon.
We had a patient with a similar story, kept going AMA from the ER because she was worried about her dogs. I asked her what her dogs would do when she dropped dead at home. (I didn't mention that the one thing the dogs would not do is starve...not at first).

Ten out of Ten said...

Wondering, when you refer someone to the ER, do you call the doc to let them know they're coming?

Doc said...

Our ER is huge, so I usually call the triage desk at the ER before they hit the doors.

Dr. Smak said...


Of course I call the ER. What kind of doctor do you think I am?

Really, I ALWAYS call the ER if I'm sending a patient in after evaluation. Whether I talk to the ER doc or the triage nurse depends on my mood or who answers first. I usually send with the patient photocopies of their problem list and med list, if there's any useful information to be gleaned there.

I have yet to figure out if my phone calls are remotely useful. I'm not looking for anyone to send me a dozen roses or anything, but the usual response is either a friendly 'whatever' or an mumbly growl. "Thanks for the heads-up" would be a little more useful. Maybe it's because I don't know the docs personally?

Now, when patients call my office with something that sounds more appropriate to be worked up in the ER, I don't call the ER to let them know they are coming. I figure I wouldn't have any useful info then.

Ten out of Ten said...

Oops, sorry, no offense :)

I'd say I get a call only half the time. Which I find extremely frustrating -- it drives me crazy to take the 5-10 minutes to find out from the patient what the doc could have relayed in 45 seconds.

But I know some of the other docs in the group don't really care whether they get a call or not.

So if the community docs are getting mumbly growls for their trouble, I can understand why they're not that motivated to make the call.

But for what it's worth, I sure do appreciate it.

Dr. Smak said...

Heh heh.

Saw this gentleman again today. After asking a few questions regarding his drinking habits he upgraded me from 'grumpy' to 'straightforward'.