RE: Scary case with Good News/Bad News

[Guest guest]

From the MD in Drain Oregon Needing feedback on a case. This is about a visiting new patient from out of town brought in by one of my patients. Patient had been unwilling to see an MD for some days, but was simply brought in by her friend anyway, and filled out the consents and registration as the line of least resistance. This 55 year old obese woman was brought to me at 5:30 PM by my patient because while visiting she was feeling weak and had had a headache since the trip started, with diarrhea and an increase in her hemorrhoids. She had Rheumatoid arthritis, and psoriatic arthritis, and had been on an immusuppressant until six weeks ago when her insurance company would no longer pay for it. Since then she had had increased pain and had

taken more of her (different physician Rx) Darvocet, sometimes up to 8 a day. Her vitals were T 97, P 92, B/P 126/68, wt 258 , BMI 43, Sats 97% with head and multiple joint pain at 6 to 8 of 10. I stopped the Darvocet, and sent her over to the cottage hospital for blood tests, scheduling her to see me at my next appointment. She did not get the tests. However, before our appointment, the next morning my patient brought her in her car to my house, saying patient was worse. I took one look at her groggy response and her poor perfusion and sent them to the ER, telling them to skip the nearest one attached to the little cottage hospital and which was always overfull and not very rapidly responsive, and getting them to go to the bigger hospital ER a few miles further that had an intensive care unit attached to it. Given where we are, the

emergency response team could have taken a half to up to an hour to get to her, which was how far she was by car from the hospital. Within 12 hours she was on dialysis for liver and kidney failure, and she apparently had septicemia. My question: As I review this, should I have seen her pulse as a key element in the problem and jumped on this the night before? I thought she was pretty anxious, and that could explain it. Nothing else would have made me think septicemia. Her headache had gone on for many days. I thought she was likely suffering from chronic acetamenophen overdose, and surely she was, but I did not think she was so far gone when I saw her, The good news is that the family knew me well enough to drop in for advice when she got worse. I think she would not have survived if she was left to

her own decisions that weekend. This is what small town practice is like. No, I am not mulling this over to punish myself. I have reviewed bad things for years, so that I can change my practice policies if needed. So suggest things, please. Joanne Holland DVM/MD

Want to be your own boss? Learn how on Yahoo! Small Business.

[Guest guest]

Joanne --

I wish you and the patient the best. But honestly, I would not comment

formally about this case. I don't think this forum should be for

discussing details of unfortunate health problems, and one never knows

what would or would not be legally relevant later.

Take care,

Tim

> From the MD in Drain Oregon

>

> Needing feedback on a case.

> This is about a visiting new patient from out of town brought in

> by one of my patients. Patient had been unwilling to see an MD

> for some days, but was simply brought in by her friend anyway,

> and filled out the consents and registration as the line of

> least resistance.

> This 55 year old obese woman was brought to me at 5:30 PM by my

> patient because while visiting she was feeling weak and had had a

> headache since the trip started, with diarrhea and an increase in

> her hemorrhoids. She had Rheumatoid arthritis, and psoriatic

> arthritis, and had been on an immusuppressant until six weeks ago

> when her insurance company would no longer pay for it. Since

> then she had had increased pain and had taken more of her

> (different physician Rx) Darvocet, sometimes up to 8 a day. Her

> vitals were T 97, P 92, B/P 126/68, wt 258 , BMI 43, Sats 97%

> with head and multiple joint pain at 6 to 8 of 10. I stopped the

> Darvocet, and sent her over to the cottage hospital for blood

> tests, scheduling her to see me at my next appointment. She did

> not get the tests. However, before our appointment, the next

> morning my patient brought her in her car to my house, saying

> patient was worse.

> I took one look at her groggy response and her poor perfusion

> and sent them to the ER, telling them to skip the nearest one

> attached to the little cottage hospital and which was always

> overfull and not very rapidly responsive, and getting them to go

> to the bigger hospital ER a few miles further that had an

> intensive care unit attached to it. Given where we are, the

> emergency response team could have taken a half to up to an hour

> to get to her, which was how far she was by car from the

> hospital.

> Within 12 hours she was on dialysis for liver and kidney failure,

> and she apparently had septicemia. My question: As I review

> this, should I have seen her pulse as a key element in the

> problem and jumped on this the night before? I thought she was

> pretty anxious, and that could explain it. Nothing else would

> have made me think septicemia. Her headache had gone on for many

> days. I thought she was likely suffering from chronic

> acetamenophen overdose, and surely she was, but I did not think

> she was so far gone when I saw her,

> The good news is that the family knew me well enough to drop in

> for advice when she got worse. I think she would not have

> survived if she was left to her own decisions that weekend. This

> is what small town practice is like.

>

> No, I am not mulling this over to punish myself. I have reviewed

> bad things for years, so that I can change my practice policies if

> needed. So suggest things, please.

>

> Joanne Holland DVM/MD

>

>

> ---------------------------------

> Want to be your own boss? Learn how on Yahoo! Small Business.

[Guest guest]

Joanne,

I agree with Tim about not wanting to

delve too far into this particular case, but I think there are general topics

that are relevant. If anything, I think this case shows why what we are doing

is so important. It shows why great access, continuity, and efficiency are

essential in good medicine. If the patient had these with her hometown doc, she

would have been able to get needed information over the phone without having to

wait days before finally being dragged into your office. She also might have been

more likely to follow-up with the ordered tests prior to becoming septic. Patients

always have the choice to make bad decisions. As long as we offer practices focusing

on access, continuity and efficiency, we stand a heck of a lot better chance of

catching them if and when they fall. Good luck!

Re:

Scary case with Good News/Bad News

From the MD in Drain Oregon

Needing feedback on a case.

This is about a

visiting new patient from out of town brought in by one of my

patients. Patient had been unwilling to see an MD for some

days, but was simply brought in by her friend anyway, and filled out

the consents and registration as the line of least resistance.

This 55 year old obese woman

was brought to me at 5:30 PM by my patient because while

visiting she was feeling weak and had had a headache since the trip

started, with diarrhea and an increase in her hemorrhoids. She

had Rheumatoid arthritis, and psoriatic arthritis, and had been on an

immusuppressant until six weeks ago when her insurance company would no longer

pay for it. Since then she had had increased pain and had taken more of

her (different physician Rx) Darvocet, sometimes up to 8 a

day. Her vitals were T 97, P 92, B/P 126/68, wt 258 , BMI 43, Sats

97% with head and multiple joint pain at 6 to 8 of 10. I stopped the

Darvocet, and sent her over to the cottage hospital for blood tests,

scheduling her to see me at my next appointment. She did not get the

tests. However, before our appointment, the next morning my patient

brought her in her car to my house, saying patient was worse.

I took one look at

her groggy response and her poor perfusion and sent them to the

ER, telling them to skip the nearest one attached to the little cottage

hospital and which was always overfull and not very rapidly responsive,

and getting them to go to the bigger hospital ER a

few miles further that had an intensive care unit attached to it. Given

where we are, the emergency response team could have taken a half to up

to an hour to get to her, which was how far she was by car from the

hospital.

Within 12 hours she was on

dialysis for liver and kidney failure, and she apparently had

septicemia.

My question: As I review

this, should I have seen her pulse as a key element in the problem and

jumped on this the night before? I thought she was pretty anxious, and

that could explain it. Nothing else would have made me think septicemia.

Her headache had gone on for many days. I thought she was likely suffering from

chronic acetamenophen overdose, and surely she was, but I did not

think she was so far gone when I saw her,

The good news is that the

family knew me well enough to drop in for advice when she got worse. I

think she would not have survived if she was left to her own decisions that

weekend. This is what small town practice is like.

No, I am not mulling this over to punish

myself. I have reviewed bad things for years, so that I can change my

practice policies if needed. So suggest things, please.

Joanne Holland DVM/MD

Want to be your own boss? Learn how on Yahoo!

Small Business.

[Guest guest]

Joanne,

Even with hindsight, you can not blame

yourself for “missing” this one. You went above and beyond

what any typical medical practice would have done, and if anyone thinks they

would have picked this up by her initial presentation, I say “No way!”

She is alive because you were willing to see her after hours as an

unestablished patient and because you had established trust with the friend

that brought her. You got her to the appropriate care as quickly as

humanly possible when you realized things were as serious as they were. You

saved a life--Give yourself a hug, girl!! Stop blaming yourself for

not having a crystal ball!

Kerry Graff

Canandaigua NY

Hospital employed MD for 4 more days, then

starting micropractice

(By the way, my hospital would not even

have allowed me to see that patient due to liability concerns, even if I had

wanted to….)

From: [mailto: ] On Behalf Of joanne holland

Sent: Monday, June 26, 2006 7:46

PM

To:

Subject: Re:

Scary case with Good News/Bad News

From the MD in Drain Oregon

Needing feedback on a case.

This is about a visiting new

patient from out of town brought in by one of my

patients. Patient had been unwilling to see an MD for some

days, but was simply brought in by her friend anyway, and filled out

the consents and registration as the line of least resistance.

This 55 year old obese woman was

brought to me at 5:30 PM by my patient because while visiting

she was feeling weak and had had a headache since the trip started, with

diarrhea and an increase in her hemorrhoids. She had

Rheumatoid arthritis, and psoriatic arthritis, and had been on an

immusuppressant until six weeks ago when her insurance company would no longer

pay for it. Since then she had had increased pain and had taken more of

her (different physician Rx) Darvocet, sometimes up to 8 a

day. Her vitals were T 97, P 92, B/P 126/68, wt 258 , BMI 43, Sats

97% with head and multiple joint pain at 6 to 8 of 10. I stopped the

Darvocet, and sent her over to the cottage hospital for blood tests,

scheduling her to see me at my next appointment. She did not get the

tests. However, before our appointment, the next morning my patient

brought her in her car to my house, saying patient was worse.

I took one look at her groggy

response and her poor perfusion and sent them to the ER, telling them to

skip the nearest one attached to the little cottage hospital and which was

always overfull and not very rapidly responsive, and getting them to go to

the bigger hospital ER a few miles further that had an

intensive care unit attached to it. Given where we are, the emergency response

team could have taken a half to up to an hour to get to her, which was how

far she was by car from the hospital.

Within 12 hours she was on dialysis for liver

and kidney failure, and she apparently had septicemia.

My question: As I review this, should I

have seen her pulse as a key element in the problem and jumped on this the

night before? I thought she was pretty anxious, and that could explain

it. Nothing else would have made me think septicemia. Her headache had

gone on for many days. I thought she was likely suffering from chronic

acetamenophen overdose, and surely she was, but I did not think she

was so far gone when I saw her,

The good news is that the family knew me well

enough to drop in for advice when she got worse. I think she would not

have survived if she was left to her own decisions that weekend. This is

what small town practice is like.

No, I am not mulling this over to punish myself. I

have reviewed bad things for years, so that I can change my practice policies

if needed. So suggest things, please.

Joanne Holland DVM/MD

Want to be your own boss? Learn how on Yahoo!

Small Business.

[Guest guest]

Joanne,

I just read Tim Malia’s email to you.

Even if she sues you after saving her life, there is no sane juror on the

planet that wouldn’t want you as his/her doctor rather than his/her own,

so I think you are more than safe. It is really sad to think about

avoiding discussing cases that really tear our guts apart because we are

worried about being sued. I can’t live my life like that and I hope

you don’t either!

Kerry

From: [mailto: ] On Behalf Of joanne holland

Sent: Monday, June 26, 2006 7:46

PM

To:

Subject: Re:

Scary case with Good News/Bad News

From the MD in Drain Oregon

Needing feedback on a case.

This is about a visiting new

patient from out of town brought in by one of my

patients. Patient had been unwilling to see an MD for some

days, but was simply brought in by her friend anyway, and filled out

the consents and registration as the line of least resistance.

This 55 year old obese woman was

brought to me at 5:30 PM by my patient because while visiting

she was feeling weak and had had a headache since the trip started, with

diarrhea and an increase in her hemorrhoids. She had

Rheumatoid arthritis, and psoriatic arthritis, and had been on an

immusuppressant until six weeks ago when her insurance company would no longer

pay for it. Since then she had had increased pain and had taken more of

her (different physician Rx) Darvocet, sometimes up to 8 a

day. Her vitals were T 97, P 92, B/P 126/68, wt 258 , BMI 43, Sats

97% with head and multiple joint pain at 6 to 8 of 10. I stopped the

Darvocet, and sent her over to the cottage hospital for blood tests,

scheduling her to see me at my next appointment. She did not get the

tests. However, before our appointment, the next morning my patient

brought her in her car to my house, saying patient was worse.

I took one look at her groggy

response and her poor perfusion and sent them to the ER, telling them to

skip the nearest one attached to the little cottage hospital and which was

always overfull and not very rapidly responsive, and getting them to go to

the bigger hospital ER a few miles further that had an

intensive care unit attached to it. Given where we are, the emergency response

team could have taken a half to up to an hour to get to her, which was how

far she was by car from the hospital.

Within 12 hours she was on dialysis for liver

and kidney failure, and she apparently had septicemia.

My question: As I review this, should I

have seen her pulse as a key element in the problem and jumped on this the

night before? I thought she was pretty anxious, and that could explain

it. Nothing else would have made me think septicemia. Her headache had

gone on for many days. I thought she was likely suffering from chronic

acetamenophen overdose, and surely she was, but I did not think she

was so far gone when I saw her,

The good news is that the family knew me well

enough to drop in for advice when she got worse. I think she would not

have survived if she was left to her own decisions that weekend. This is

what small town practice is like.

No, I am not mulling this over to punish myself. I

have reviewed bad things for years, so that I can change my practice policies if

needed. So suggest things, please.

Joanne Holland DVM/MD

Want to be your own boss? Learn how on Yahoo!

Small Business.

[Guest guest]

I also agree with the other points that have been raised. But I also want

to add that without a doubt I believe it is important for us as physicians

(general term, beyond PI list) to review efforts to provide care and

unfortunate health outcomes. And we should have safe venues to do that.

I'd suggest contacting the chief of medicine at the hospital about a

possible M & M Rounds ( " Morbidity and Mortality " Rounds) for the case so the

hospital staff and community docs have a chance to think about and discuss

this kind of case. Being a formalized setting established for

professional improvement, I believe you'd get great feedback and others

would have the opportunity to learn as well. But I'm not sure this list

is the best place for M & M discussions.

I hope that helps.

Take care,

Tim

> Joanne,

> I agree with Tim about not wanting to delve too far into this particular

> case, but I think there are general topics that are relevant. If

> anything, I think this case shows why what we are doing is so important.

> It shows why great access, continuity, and efficiency are essential in

> good medicine. If the patient had these with her hometown doc, she would

> have been able to get needed information over the phone without having

> to wait days before finally being dragged into your office. She also

> might have been more likely to follow-up with the ordered tests prior to

> becoming septic. Patients always have the choice to make bad decisions.

> As long as we offer practices focusing on access, continuity and

> efficiency, we stand a heck of a lot better chance of catching them if

> and when they fall. Good luck!

>

>

> Re: Scary case with Good News/Bad News

>

> From the MD in Drain Oregon

>

> Needing feedback on a case.

> This is about a visiting new patient from out of town brought in

> by one of my patients. Patient had been unwilling to see an MD for some

> days, but was simply brought in by her friend anyway, and filled out the

> consents and registration as the line of least resistance.

> This 55 year old obese woman was brought to me at 5:30 PM by my

> patient because while visiting she was feeling weak and had had a

> headache since the trip started, with diarrhea and an increase in her

> hemorrhoids. She had Rheumatoid arthritis, and psoriatic arthritis,

> and had been on an immusuppressant until six weeks ago when her

> insurance company would no longer pay for it. Since then she had had

> increased pain and had taken more of her (different physician Rx)

> Darvocet, sometimes up to 8 a day. Her vitals were T 97, P 92, B/P

> 126/68, wt 258 , BMI 43, Sats 97% with head and multiple joint pain at 6

> to 8 of 10. I stopped the Darvocet, and sent her over to the cottage

> hospital for blood tests, scheduling her to see me at my next

> appointment. She did not get the tests. However, before our

> appointment, the next morning my patient brought her in her car to my

> house, saying patient was worse.

> I took one look at her groggy response and her poor perfusion and

> sent them to the ER, telling them to skip the nearest one attached to

> the little cottage hospital and which was always overfull and not very

> rapidly responsive, and getting them to go to the bigger hospital ER a

> few miles further that had an intensive care unit attached to it. Given

> where we are, the emergency response team could have taken a half to up

> to an hour to get to her, which was how far she was by car from the

> hospital.

> Within 12 hours she was on dialysis for liver and kidney failure,

> and she apparently had septicemia.

> My question: As I review this, should I have seen her pulse as a

> key element in the problem and jumped on this the night before? I

> thought she was pretty anxious, and that could explain it. Nothing else

> would have made me think septicemia. Her headache had gone on for many

> days. I thought she was likely suffering from chronic acetamenophen

> overdose, and surely she was, but I did not think she was so far gone

> when I saw her,

> The good news is that the family knew me well enough to drop in for

> advice when she got worse. I think she would not have survived if she

> was left to her own decisions that weekend. This is what small town

> practice is like.

>

> No, I am not mulling this over to punish myself. I have reviewed bad

> things for years, so that I can change my practice policies if needed.

> So suggest things, please.

>

> Joanne Holland DVM/MD

>

> _____

>

> Want to be your own boss? Learn how on Yahoo!

> <http://us.rd.yahoo.com/evt=41244/*http:/smallbusiness.yahoo.com/r-index

>> Small Business.

>

[Guest guest]

A pulse

of 92 as a sign of septicemia? I have at least several patients in my

office every day with pulses in the 90’s & even low 100 range.

It is technically not even tachycardia if under 100.

Re:

Scary case with Good News/Bad News

From the MD in Drain Oregon

Needing feedback on a case.

This is about a

visiting new patient from out of town brought in by one of my

patients. Patient had been unwilling to see an MD for some

days, but was simply brought in by her friend anyway, and filled out

the consents and registration as the line of least resistance.

This 55 year old obese woman

was brought to me at 5:30 PM by my patient because while

visiting she was feeling weak and had had a headache since the trip

started, with diarrhea and an increase in her hemorrhoids. She

had Rheumatoid arthritis, and psoriatic arthritis, and had been on an

immusuppressant until six weeks ago when her insurance company would no longer

pay for it. Since then she had had increased pain and had taken more of

her (different physician Rx) Darvocet, sometimes up to 8 a

day. Her vitals were T 97, P 92, B/P 126/68, wt 258 , BMI 43, Sats

97% with head and multiple joint pain at 6 to 8 of 10. I stopped the

Darvocet, and sent her over to the cottage hospital for blood tests,

scheduling her to see me at my next appointment. She did not get the

tests. However, before our appointment, the next morning my patient

brought her in her car to my house, saying patient was worse.

I took one look at

her groggy response and her poor perfusion and sent them to the

ER, telling them to skip the nearest one attached to the little cottage

hospital and which was always overfull and not very rapidly responsive,

and getting them to go to the bigger hospital ER a

few miles further that had an intensive care unit attached to it. Given

where we are, the emergency response team could have taken a half to up

to an hour to get to her, which was how far she was by car from the

hospital.

Within 12 hours she was on

dialysis for liver and kidney failure, and she apparently had

septicemia.

My question: As I review

this, should I have seen her pulse as a key element in the problem and

jumped on this the night before? I thought she was pretty anxious, and

that could explain it. Nothing else would have made me think septicemia.

Her headache had gone on for many days. I thought she was likely suffering from

chronic acetamenophen overdose, and surely she was, but I did not

think she was so far gone when I saw her,

The good news is that the

family knew me well enough to drop in for advice when she got worse. I

think she would not have survived if she was left to her own decisions that

weekend. This is what small town practice is like.

No, I am not mulling this over to punish

myself. I have reviewed bad things for years, so that I can change my

practice policies if needed. So suggest things, please.

Joanne Holland DVM/MD

Want to be your own boss? Learn how on Yahoo!

Small Business.

[Guest guest]

Tim,

While I agree that going through a M & M at the hospital would be helpful for many reasons,

I think there are 2 major things that can affect bad outcomes. First is

clinical judgment. Essentially, did the doctor do what was appropriate for the

clinical situation? This is indeed out of the scope of this list serve and, as

I understand it, defined by peers, which would therefore best be defined by the

docs in the community.

But, the second aspect is process failures

(internally and externally). Essentially, how good is my access, continuity and

efficiency (internal) or how good is the care delivered to my patient outside

my office (externally)? I believe this aspect is pertinent to this list serve

as that is what we are all struggling to make better. If Joanne finds looking

at her processes that doing X resulted in less potential for issues with Y,

then I hope she would share. If she finds that she is having a particular issue

with external process issues (which we all are), maybe she (or the group) can

help come up with solutions that results in all our practices improving. What

do you think?

Re: Scary case with Good News/Bad

News

>

> From the MD in Drain Oregon

>

> Needing feedback on a case.

> This is about a visiting new patient from out of town brought in

> by one of my patients. Patient had been unwilling to see an MD for some

> days, but was simply brought in by her friend anyway, and filled out the

> consents and registration as the line of least resistance.

> This 55 year old obese woman was brought to me at 5:30 PM by my

> patient because while visiting she was feeling weak and had had a

> headache since the trip started, with diarrhea and an increase in her

> hemorrhoids. She had Rheumatoid arthritis, and psoriatic arthritis,

> and had been on an immusuppressant until six weeks ago when her

> insurance company would no longer pay for it. Since then she had had

> increased pain and had taken more of her (different physician Rx)

> Darvocet, sometimes up to 8 a day. Her vitals were T 97, P 92, B/P

> 126/68, wt 258 , BMI 43, Sats 97% with head and multiple joint pain at 6

> to 8 of 10. I stopped the Darvocet, and sent her over to the cottage

> hospital for blood tests, scheduling her to see me at my next

> appointment. She did not get the tests. However, before our

> appointment, the next morning my patient brought her in her car to my

> house, saying patient was worse.

> I took one look at her groggy response and her poor perfusion and

> sent them to the ER, telling them to skip the nearest one attached to

> the little cottage hospital and which was always overfull and not very

> rapidly responsive, and getting them to go to the bigger hospital ER a

> few miles further that had an intensive care unit attached to it. Given

> where we are, the emergency response team could have taken a half to up

> to an hour to get to her, which was how far she was by car from the

> hospital.

> Within 12 hours she was on dialysis for liver and kidney failure,

> and she apparently had septicemia.

> My question: As I review this, should I have seen her pulse as a

> key element in the problem and jumped on this the night before? I

> thought she was pretty anxious, and that could explain it. Nothing else

> would have made me think septicemia. Her headache had gone on for many

> days. I thought she was likely suffering from chronic acetamenophen

> overdose, and surely she was, but I did not think she was so far gone

> when I saw her,

> The good news is that the family knew me well enough to drop in for

> advice when she got worse. I think she would not have survived if she

> was left to her own decisions that weekend. This is what small town

> practice is like.

>

> No, I am not mulling this over to punish myself. I have reviewed bad

> things for years, so that I can change my practice policies if needed.

> So suggest things, please.

>

> Joanne Holland DVM/MD

>

> _____

>

> Want to be your own boss? Learn how on Yahoo!

> <http://us.rd.yahoo.com/evt=41244/*http:/smallbusiness.yahoo.com/r-index

>> Small Business.

>

[Guest guest]

this is what a small town practice is like. It is always the last

visit of the day . The pulse of 92 is not the key. Quite frankly

you needed the lab data to help you make a disposition, just not

enough time in this case. Primary care is like that. It can be

frustrating yet rewarding depending on how you look at it.

Septicemia can look like the simple flu. Many have been burned.

suggestions: this is the way it is, none

your attention should go up in a small town when

somebody present like this simply because that is the way it is, I

dealt with this issue with men coming into the office for the first

time, you better read between the lines in their chief complaint.

Good luck.

Hang in there,

Brent

>

> From the MD in Drain Oregon

>

> Needing feedback on a case.

> This is about a visiting new patient from out of town

brought in by one of my patients. Patient had been unwilling to see

an MD for some days, but was simply brought in by her friend anyway,

and filled out the consents and registration as the line of least

resistance.

> This 55 year old obese woman was brought to me at 5:30 PM

by my patient because while visiting she was feeling weak and had

had a headache since the trip started, with diarrhea and an increase

in her hemorrhoids. She had Rheumatoid arthritis, and psoriatic

arthritis, and had been on an immusuppressant until six weeks ago

when her insurance company would no longer pay for it. Since then

she had had increased pain and had taken more of her (different

physician Rx) Darvocet, sometimes up to 8 a day. Her vitals were T

97, P 92, B/P 126/68, wt 258 , BMI 43, Sats 97% with head and

multiple joint pain at 6 to 8 of 10. I stopped the Darvocet, and

sent her over to the cottage hospital for blood tests, scheduling

her to see me at my next appointment. She did not get the tests.

However, before our appointment, the next morning my patient brought

her in her car to my house, saying patient was worse.

> I took one look at her groggy response and her poor

perfusion and sent them to the ER, telling them to skip the nearest

one attached to the little cottage hospital and which was always

overfull and not very rapidly responsive, and getting them to go to

the bigger hospital ER a few miles further that had an intensive

care unit attached to it. Given where we are, the emergency response

team could have taken a half to up to an hour to get to her, which

was how far she was by car from the hospital.

> Within 12 hours she was on dialysis for liver and kidney

failure, and she apparently had septicemia.

> My question: As I review this, should I have seen her

pulse as a key element in the problem and jumped on this the night

before? I thought she was pretty anxious, and that could explain

it. Nothing else would have made me think septicemia. Her headache

had gone on for many days. I thought she was likely suffering from

chronic acetamenophen overdose, and surely she was, but I did not

think she was so far gone when I saw her,

> The good news is that the family knew me well enough to

drop in for advice when she got worse. I think she would not have

survived if she was left to her own decisions that weekend. This is

what small town practice is like.

>

> No, I am not mulling this over to punish myself. I have

reviewed bad things for years, so that I can change my practice

policies if needed. So suggest things, please.

>

> Joanne Holland DVM/MD

>

>

> ---------------------------------

> Want to be your own boss? Learn how on Yahoo! Small Business.

>

[Guest guest]

--

Absolutely agreed.

We should share thoughts, ideas, plans, etc. But let's be careful not to

cause ourselves, or others, hassles down the line.

And honestly, I don't know the legal issues related to " discussing " a case

in a forum like ours. But it seems what I've heard before is that any

formal discussion, especially printed communications, are pertinent.

Finally, due to her professional and personal skills (both quite evident

from her postings as best I can tell!) I doubt very much Joanne will have

any problems. And I always appreciate her posts and thoughts from past

experiences. But for this one example, at least at this point in time, I

would opt out of formal discussions.

Any " lessons learned " or ideas to improve systems (internal and external)

are always appreciated.

Tim

> Tim,

> While I agree that going through a M & M at the hospital would be helpful

> for many reasons, I think there are 2 major things that can affect bad

> outcomes. First is clinical judgment. Essentially, did the doctor do

> what was appropriate for the clinical situation? This is indeed out of

> the scope of this list serve and, as I understand it, defined by peers,

> which would therefore best be defined by the docs in the community. But,

> the second aspect is process failures (internally and externally).

> Essentially, how good is my access, continuity and efficiency (internal)

> or how good is the care delivered to my patient outside my office

> (externally)? I believe this aspect is pertinent to this list serve as

> that is what we are all struggling to make better. If Joanne finds

> looking at her processes that doing X resulted in less potential for

> issues with Y, then I hope she would share. If she finds that she is

> having a particular issue with external process issues (which we all

> are), maybe she (or the group) can help come up with solutions that

> results in all our practices improving. What do you think?

>

>

> Re: Scary case with Good News/Bad News

>>

>> From the MD in Drain Oregon

>>

>> Needing feedback on a case.

>> This is about a visiting new patient from out of town brought in by

>> one of my patients. Patient had been unwilling to see an MD for

> some

>> days, but was simply brought in by her friend anyway, and filled out

> the

>> consents and registration as the line of least resistance.

>> This 55 year old obese woman was brought to me at 5:30 PM by my

>> patient because while visiting she was feeling weak and had had a

>> headache since the trip started, with diarrhea and an increase in her

>> hemorrhoids. She had Rheumatoid arthritis, and psoriatic arthritis,

>> and had been on an immusuppressant until six weeks ago when her

>> insurance company would no longer pay for it. Since then she had had

>> increased pain and had taken more of her (different physician Rx)

>> Darvocet, sometimes up to 8 a day. Her vitals were T 97, P 92, B/P

>> 126/68, wt 258 , BMI 43, Sats 97% with head and multiple joint pain at

> 6

>> to 8 of 10. I stopped the Darvocet, and sent her over to the cottage

>> hospital for blood tests, scheduling her to see me at my next

>> appointment. She did not get the tests. However, before our

>> appointment, the next morning my patient brought her in her car to my

>> house, saying patient was worse.

>> I took one look at her groggy response and her poor perfusion and sent

>> them to the ER, telling them to skip the nearest one attached to the

>> little cottage hospital and which was always overfull and not very

>> rapidly responsive, and getting them to go to the bigger hospital ER a

>> few miles further that had an intensive care unit attached to it.

> Given

>> where we are, the emergency response team could have taken a half to

> up

>> to an hour to get to her, which was how far she was by car from the

>> hospital.

>> Within 12 hours she was on dialysis for liver and kidney failure, and

>> she apparently had septicemia.

>> My question: As I review this, should I have seen her pulse as a key

>> element in the problem and jumped on this the night before? I thought

>> she was pretty anxious, and that could explain it. Nothing

> else

>> would have made me think septicemia. Her headache had gone on for many

>> days. I thought she was likely suffering from chronic acetamenophen

>> overdose, and surely she was, but I did not think she was so far gone

>> when I saw her,

>> The good news is that the family knew me well enough to drop in for

>> advice when she got worse. I think she would not have survived if she

>> was left to her own decisions that weekend. This is what small town

>> practice is like.

>>

>> No, I am not mulling this over to punish myself. I have reviewed bad

>> things for years, so that I can change my practice policies if needed.

>> So suggest things, please.

>>

>> Joanne Holland DVM/MD

>>

>> _____

>>

>> Want to be your own boss? Learn how on Yahoo!

>> <http://us.rd.

> <http://us.rd.yahoo.com/evt=41244/*http:/smallbusiness.yahoo.com/r-index

>> yahoo.com/evt=41244/*http:/smallbusiness.yahoo.com/r-index

>>> Small Business.

>>

>

[Guest guest]

I agree with . A pulse of 92 alone is not enough to make me think about a

septic problem. 140 perhaps.

One reason I quit doing newborn care in the hospital is the thought that if you

do enough of them there will eventually be a bad outcome. But the same goes for

anything in medicine.

In your case, this was a friend of one of your patients whom you were seeing in

an urgent care setting, not the optimal circumstance to begin with. But even if

she were one of your patients, things can change quickly enough to surprise us.

I know you know this, and it is comendable that you are reaching out for

feedback.

I suspect your concern is more for your patient than for yourself. I think you

did all the right things in the context of the information you had. Your

patients are lucky.

Charlie Vargas

lin, NC

Date: Tue Jun 27 09:48:35 CDT 2006

To:

Subject: Re: Scary case with Good News/Bad News

this is what a small town practice is like. It is always the last

visit of the day . The pulse of 92 is not the key. Quite frankly

you needed the lab data to help you make a disposition, just not

enough time in this case. Primary care is like that. It can be

frustrating yet rewarding depending on how you look at it.

Septicemia can look like the simple flu. Many have been burned.

suggestions: this is the way it is, none

your attention should go up in a small town when

somebody present like this simply because that is the way it is, I

dealt with this issue with men coming into the office for the first

time, you better read between the lines in their chief complaint.

Good luck.

Hang in there,

Brent

>

> From the MD in Drain Oregon

>

> Needing feedback on a case.

> This is about a visiting new patient from out of town

brought in by one of my patients. Patient had been unwilling to see

an MD for some days, but was simply brought in by her friend anyway,

and filled out the consents and registration as the line of least

resistance.

> This 55 year old obese woman was brought to me at 5:30 PM

by my patient because while visiting she was feeling weak and had

had a headache since the trip started, with diarrhea and an increase

in her hemorrhoids. She had Rheumatoid arthritis, and psoriatic

arthritis, and had been on an immusuppressant until six weeks ago

when her insurance company would no longer pay for it. Since then

she had had increased pain and had taken more of her (different

physician Rx) Darvocet, sometimes up to 8 a day. Her vitals were T

97, P 92, B/P 126/68, wt 258 , BMI 43, Sats 97% with head and

multiple joint pain at 6 to 8 of 10. I stopped the Darvocet, and

sent her over to the cottage hospital for blood tests, scheduling

her to see me at my next appointment. She did not get the tests.

However, before our appointment, the next morning my patient brought

her in her car to my house, saying patient was worse.

> I took one look at her groggy response and her poor

perfusion and sent them to the ER, telling them to skip the nearest

one attached to the little cottage hospital and which was always

overfull and not very rapidly responsive, and getting them to go to

the bigger hospital ER a few miles further that had an intensive

care unit attached to it. Given where we are, the emergency response

team could have taken a half to up to an hour to get to her, which

was how far she was by car from the hospital.

> Within 12 hours she was on dialysis for liver and kidney

failure, and she apparently had septicemia.

> My question: As I review this, should I have seen her

pulse as a key element in the problem and jumped on this the night

before? I thought she was pretty anxious, and that could explain

it. Nothing else would have made me think septicemia. Her headache

had gone on for many days. I thought she was likely suffering from

chronic acetamenophen overdose, and surely she was, but I did not

think she was so far gone when I saw her,

> The good news is that the family knew me well enough to

drop in for advice when she got worse. I think she would not have

survived if she was left to her own decisions that weekend. This is

what small town practice is like.

>

> No, I am not mulling this over to punish myself. I have

reviewed bad things for years, so that I can change my practice

policies if needed. So suggest things, please.

>

> Joanne Holland DVM/MD

>

>

> ---------------------------------

> Want to be your own boss? Learn how on Yahoo! Small Business.

>

[Guest guest]

It truly sounds like you exercised excellent clinical judgement but

unfortunatley the patient dropped the ball. Even still, if I

understand the time frame you describe, there really was no adverse

outcome due to a few hours of lost time. The only thing I would add -

and I learned this from a very good nurse who would do it prior to my

seeing a sick patient - would be to do a urine dip stick. It is such a

simple and inexpensive test, but gives so much valuable information:

hydration status, infection, etc. This astute nurse would also

document the LMP on every female pateint and automatically go ahead

and do a UCG if she were even a day late. She picked up many pregnant

patients that I would have entirely missed.

, MD

Virginia Beach, VA

>

> From the MD in Drain Oregon

>

> Needing feedback on a case.

> This is about a visiting new patient from out of town

brought in by one of my patients. Patient had been unwilling to see an

MD for some days, but was simply brought in by her friend anyway, and

filled out the consents and registration as the line of least resistance.

> This 55 year old obese woman was brought to me at 5:30 PM by

my patient because while visiting she was feeling weak and had had a

headache since the trip started, with diarrhea and an increase in her

hemorrhoids. She had Rheumatoid arthritis, and psoriatic arthritis,

and had been on an immusuppressant until six weeks ago when her

insurance company would no longer pay for it. Since then she had had

increased pain and had taken more of her (different physician Rx)

Darvocet, sometimes up to 8 a day. Her vitals were T 97, P 92, B/P

126/68, wt 258 , BMI 43, Sats 97% with head and multiple joint pain at

6 to 8 of 10. I stopped the Darvocet, and sent her over to the

cottage hospital for blood tests, scheduling her to see me at my next

appointment. She did not get the tests. However, before our

appointment, the next morning my patient brought her in her car to my

house, saying patient was worse.

> I took one look at her groggy response and her poor

perfusion and sent them to the ER, telling them to skip the nearest

one attached to the little cottage hospital and which was always

overfull and not very rapidly responsive, and getting them to go to

the bigger hospital ER a few miles further that had an intensive care

unit attached to it. Given where we are, the emergency response team

could have taken a half to up to an hour to get to her, which was how

far she was by car from the hospital.

> Within 12 hours she was on dialysis for liver and kidney

failure, and she apparently had septicemia.

> My question: As I review this, should I have seen her pulse

as a key element in the problem and jumped on this the night before?

I thought she was pretty anxious, and that could explain it. Nothing

else would have made me think septicemia. Her headache had gone on for

many days. I thought she was likely suffering from chronic

acetamenophen overdose, and surely she was, but I did not think she

was so far gone when I saw her,

> The good news is that the family knew me well enough to drop

in for advice when she got worse. I think she would not have survived

if she was left to her own decisions that weekend. This is what small

town practice is like.

>

> No, I am not mulling this over to punish myself. I have

reviewed bad things for years, so that I can change my practice

policies if needed. So suggest things, please.

>

> Joanne Holland DVM/MD

>

>

> ---------------------------------

> Want to be your own boss? Learn how on Yahoo! Small Business.

>

[Guest guest]

From Drain Wow, thanks, never had that suggested to me for this purpose. I could check this next time. Joanne docboops wrote: It truly sounds like you exercised excellent clinical judgement butunfortunatley the patient dropped the ball. Even still, if Iunderstand the time frame you

describe, there really was no adverseoutcome due to a few hours of lost time. The only thing I would add -and I learned this from a very good nurse who would do it prior to myseeing a sick patient - would be to do a urine dip stick. It is such asimple and inexpensive test, but gives so much valuable information:hydration status, infection, etc. This astute nurse would alsodocument the LMP on every female pateint and automatically go aheadand do a UCG if she were even a day late. She picked up many pregnantpatients that I would have entirely missed. , MDVirginia Beach, VA>> From the MD in Drain Oregon> > Needing feedback on a case. > This is about a visiting new patient from out of townbrought in by one of my patients.

Patient had been unwilling to see anMD for some days, but was simply brought in by her friend anyway, andfilled out the consents and registration as the line of least resistance. > This 55 year old obese woman was brought to me at 5:30 PM bymy patient because while visiting she was feeling weak and had had aheadache since the trip started, with diarrhea and an increase in herhemorrhoids. She had Rheumatoid arthritis, and psoriatic arthritis,and had been on an immusuppressant until six weeks ago when herinsurance company would no longer pay for it. Since then she had hadincreased pain and had taken more of her (different physician Rx) Darvocet, sometimes up to 8 a day. Her vitals were T 97, P 92, B/P126/68, wt 258 , BMI 43, Sats 97% with head and multiple joint pain at6 to 8 of 10. I stopped the Darvocet, and sent her over to thecottage hospital for blood tests, scheduling her to see me at my nextappointment. She

did not get the tests. However, before ourappointment, the next morning my patient brought her in her car to myhouse, saying patient was worse. > I took one look at her groggy response and her poorperfusion and sent them to the ER, telling them to skip the nearestone attached to the little cottage hospital and which was alwaysoverfull and not very rapidly responsive, and getting them to go tothe bigger hospital ER a few miles further that had an intensive careunit attached to it. Given where we are, the emergency response teamcould have taken a half to up to an hour to get to her, which was howfar she was by car from the hospital. > Within 12 hours she was on dialysis for liver and kidneyfailure, and she apparently had septicemia. > My question: As I review this, should I have seen her pulseas a key element in the problem and jumped on this the night before? I thought she was pretty anxious, and that

could explain it. Nothingelse would have made me think septicemia. Her headache had gone on formany days. I thought she was likely suffering from chronicacetamenophen overdose, and surely she was, but I did not think shewas so far gone when I saw her, > The good news is that the family knew me well enough to dropin for advice when she got worse. I think she would not have survivedif she was left to her own decisions that weekend. This is what smalltown practice is like. > > No, I am not mulling this over to punish myself. I havereviewed bad things for years, so that I can change my practicepolicies if needed. So suggest things, please.> > Joanne Holland DVM/MD> > > ---------------------------------> Want to be your own boss? Learn how on Yahoo! Small Business.>

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