Yesterday (last night? I'm confused about time these days) I worked with an attending I hadn't worked with before. The other attendings I've worked with to date have been more of the "treat 'em and street 'em" type, which means get the patient stabilized, rule out anything life threatening or can easily fixed, and have them follow up with their regular doctor, who knows them and knows their history, in a couple of days. That's typically how emergency rooms work.
The attending last night, however, seemed more interested in finding out exactly what was going on. We had a 25-year-old woman complaining of abdominal pain, and although she didn't have an extensive history of visiting this ER, she had obviously had similar complaints many times in the past--she had already had both her appendix and gall bladder removed. Automatically at that point, you can rule out just about anything that has to be taken care of immediately--it's not appendicitis, since she doesn't have an appendix; bowel perforation is so rare in a person that age that we could probably write it up as a case report if that's what it was; and without a gall-bladder, she's unlikely to have a gallstone causing pancreatitis. Since she came in just as the previous set of doctors were coming off, they had me give her toradol (non-narcotic pain med) for the pain, get a urine sample to check for urinary tract infection, give her some IV fluids, and check a blood count and electrolytes.
No urinary tract infection, blood count showed that there was either a mild infection or mild inflammation, and electrolytes were normal. Oh, and the toradol didn't help the pain at all. By this time, the new attending had come in. He ordered IV dilaudid (narcotic pain med), a more complete blood chemistry panel, and an abdomen and pelvic CT. The more complete chemistry panel didn't show anything wrong with her liver or pancreas, the CT was normal, and the dilaudid helped "some". By this point, she had been in for over three hours, and still complaining of the pain, so the attending offered to admit her to the hospital for a more thorough workup, which she declined. When she was discharged, after getting more dilaudid, she walked out just fine, after a work-up that probably cost around $5000, which since she doesn't have insurance, probably won't get paid.
I don't think it's the role of the ER to find out the source of every ache and pain, but apparently, there are some who do. As a medical student, there's not much I can do about it except go along with whatever the attending wants to do. After all, it's their name on the chart, not mine.
2 comments:
Does walking out "just fine" mean the pain meds finally worked, or she thought if she stayed longer she'd be admitted? I don't know if she was helped by the exam or not; sounds like there still is not a diagnosis for the cause of the pain.
$5000 -- really?? That sounds pretty high for the tests you mentioned, since most things were ruled out already.
She wasn't writhing in pain as she walked out--that's all I know. I'm guessing it was because the pain meds finally worked.
As far as the cost, since I don't do the billing (obviously), I don't know how much it would be, but we're talking room fees, ER physician fees, blood draws, the lab tests run, and (most expensively) the CT scan of the abdomen and pelvis, which I've seen quoted on some websites as costing the patient $3000-7000 (which includes the radiologist's fee).
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