Consult-Liaison Education Medicine Observations

Red Herring (IV).

Five hours had passed. I was kicking myself: Maybe I should have asked that she be sent to the psychiatric side of the emergency room. It might have been quieter. Maybe she would have been evaluated sooner. If she was admitted to the psychiatric unit, then at least a medicine consultant could see her there.

But I knew that would amplify bias. This was a woman with a diagnosis of schizophrenia who had a history of self-induced vomiting. Both hospital psychiatrists and internists were susceptible to the bias that these factors were the causes of her weight loss, especially if they saw her in a psychiatric unit. I wanted her to receive a fair medical evaluation, if there was such a thing.

I also didn’t want my patient to experience a medical emergency in the psychiatric unit. Psychiatric units are the least equipped to deal with that.

The soonest appointment my patient could get with her primary care doctor was two months out. Because she was “a poor historian”, her worker accompanied her to the clinic. I told him to please call me if the internist had questions. He did: “I’m here with the patient at the doctor’s office. Dr. Checkedout wants to talk to you.”

We introduced ourselves.

“Thanks for seeing my patient. What do you think is going on?”

“She said that her teeth are bothering her, so that’s why she hasn’t been eating—”

“Wait, what? Her teeth? But—”

“Yeah, she said that she has pain in her teeth. That’s probably causing the decrease in oral intake, which is contributing—”

“Did you get the history that she has been vomiting—”

“That’s what the worker said, but the patient said that she was fine—”

I slapped the palm of my hand against my forehead.

“—and she said that her teeth hurt.”

“The patient always says she’s fine. The worker has a more detailed history and we’re concerned that something medical is causing the vomiting—”

“The patient said she’s not vomiting. Her weight is down and she knows this. She said that her teeth hurt…”

Feeling defeated and realizing that I had interrupted everything she had said thus far, I waited for her to finish.

“… and that’s probably why her weight is down. Her exam was normal. Nice woman. I asked The Worker to schedule an appointment with a dentist and to encourage her to eat more, maybe drink Ensures for now. She should come back in two or three months. By the way, I’m leaving for vacation tomorrow, so Dr. Someotherperson will be covering for me.”

Ah ha.

“Right. Can you send a copy of your note to my office?”

“Sure, sure.”

“And can you ask The Worker to call me after the appointment is done?”

“Will do.”

Ten minutes later, The Worker called me and commented, “It doesn’t sound like you were able to get through to Dr. Checkedout, either.”

“Nope. Apparently it’s just a dental problem.”

“I tried to tell her that the patient had never complained about her teeth before and that we were worried about the vomiting.”

“I know.” I trusted The Worker; he was a good man and a skilled clinician. “Well, at least Dr. Checkedout didn’t find anything alarming today. We have a follow-up appointment and we can make that dental appointment, I guess. We’ll continue to watch her.”

That was three weeks ago.

My patient had been asleep for over an hour. It was still noisy and crowded in the emergency room. I had flipped and reflipped through the two magazines.

Glancing at my watch, I realized that I had to leave to see other patients.

I grabbed a sheet of blank chart paper and copied down the contents of my typed letter. Reluctantly, I shook my patient’s shoulder. Her bleary eyes opened.

“I have to leave,” I said. She nodded. “I’m going to tie this letter to your gown. When the doctor finally sees you, make sure the doctor reads this, okay?”

She nodded and curled back up. She was soon asleep.

I wondered about HIPAA as I threaded the string of her gown through the hole punch of the paper. What if other people hovered over her and began to read the letter?

She, however, couldn’t tell the story as it needed to be told. I wished that was different.

After tying the square knot, I stood back to examine my handiwork. A nurse graciously accepted my typed letter and brought it to the clerk. After silently saying good-bye to my patient, I walked through the hallways lined with gurneys filled with suffering people and escaped the hospital.

(Part four of an ongoing series.)