physasst Posted June 25, 2011 Share Posted June 25, 2011 And no, not any medical experience, but experience practicing medicine and diagnosing illness. THIS IS NOT intended as a slam or accusation against my fellow PA's....I have just had "a week". First, 26 y/o male presents with severe low back pain. Sneezed 3 days earlier in his truck while driving. Seen by another PA at a local ED whom I know and respect, but this person is also only 3 years out from PA school. Asked about bowel/bladder yada yada....diagnosed as an acute strain, given flexeril and T3's, worsened so seen again the next day by an NP this time. Given Vicodin and switched to Valium....comes to our ED because he wasn't getting relief. Again, DENIES bowel bladder dysfunction or saddle parethesia. Exam is benign except for an absent patella reflex on the left and an inability to bear down on rectal exam. Asked patient to urinate, and post void residual was 550ml. MRI revealed a cauda at L4-5.... Next, 84 y/o female with the complaint of vertigo...sustained a fall 5 days earlier. C/O some "double vision" (vertical diplopia), mildly slurred speech (VERY subtle), mild confusion, and difficulty walking because of the vertigo. Seen at a hospital in another state.....initial CT at time of fall is negative, and she has a black eye. NP and MD tell her that she has a UTI, and that's what caused her symptoms of confusion and vertigo. I came out of the room and told my attending that she had a posterior circulation stroke. He didn't believe me, but agreed to repeat CT and have Neuro see her.......CT reveals bilateral Cerebellar infarcts and a possible small infarct in the pontine. Next a 67 y/o female with the abrupt onset of "dizziness" not vertiginous. Also c/o worsening with standing, and intense fatigue. Seen by PA in Urgent Care.....diagnosed with BPPV.....Exam reveals a right facial nerve palsy (subtle..I sent a medical student in afterwards and they couldn't pick it up, but it was barely perceptible at the nasal fold) and a left ptosis. Her vision is diminished even with glasses on, and she has positive cerebellar signs. Medullary Stroke. Next were two gifts from Family Medicine... 1. 55 y/o female with a severe rash to the RLE....but present across body, and even on the palms of the hands. Appear in the intertrichous folds, and appear to be blisters. Quite itchy. Diagnosed as an "infection" by the NP in Family Medicine, and started on Keflex........not so much. Presents to ED with a severe Bullous Pemphigoid. Admitted to Dermatology. 2. 64 y/o male who had just been in Japan for 3 weeks. Had eaten as much of the local fare as possible, but had not eaten any puffer fish that he was aware of. He had tried triggerfish while there however. Had gotten sick in Japan, but seemed like a GI bug and symptoms resolved after 2 days. On his return to the US, began to develop numbness and tingling throughout both LE, but worse on the right. Also c/o fatigue, joint aches, and a persistent headache. Seen by a PA in Family Medicine who diagnosed him with a peripheral neuropathy, started him on Neurontin, and drew a million labs to diagnose the cause of the neuropathy. The problem is, he had a pretty classic presentation of ciguatera....which isn't going to be helped by a million dollar lab workup or Neurontin. DC'ed the Neurontin and started him on Amitryptyline. NOW, ciguatera is pretty rare, but then I started talking about it with many of my PA colleagues, and none of them had even heard of it...which was a little troubling to me. Heck, a lot of the PA's I asked, just informally, had no idea what Scombroid was, which is a bit more common than ciguatera. I mean, I don't fault someone for not knowing everything about it...but a simple. "Oh, scombroid, isn't that somehow related to fish?" would have sufficed. The point of all of this isn't to assign blame. But there is one commonality among all of these cases. They were all seen by Non Physician Providers, and with the exception of the NP who didn't diagnose the rash correctly, ALL of these providers had less than 5 years experience. The NP with the rash had 7 years experience. I think in the rush to discuss how good we are...and yes we are overall, we need to remember that there is no substitute for experience. And we need to remember to have a low threshold to involve our SP's. Just a little description of my week. Link to comment Share on other sites More sharing options...
Guest Swennerb Posted June 25, 2011 Share Posted June 25, 2011 Thank you for sharing these interesting case's- I agree there is not enough humility amongst medical providers in general. As someone only 2 years out of school, I am constantly reminded of the many things I don't know- and still always trying to become better at what I do. I wish more SP's and even older PA's were more constructive in their critique,...as such w this post. However, I do run into the occasional destructive, crude provider who points out errors like they have caught an armed robber or something. Point is- I always appreciate a learning opportunity when it is delivered in a respectful, thoughtful way from someone w *good inter-personal and communication skills*! It's easy to point out problems, ...let's use that same energy to come up w solutions and work together. I think that this post aims to accomplish that. Link to comment Share on other sites More sharing options...
Joelseff Posted June 25, 2011 Share Posted June 25, 2011 Very humbling physasst! thanks for the reminder of our limitations. Link to comment Share on other sites More sharing options...
GeneValgene Posted June 25, 2011 Share Posted June 25, 2011 great post and great reminder...humility goes a long way. it's important to know what you do know, but even more important to know what you don't know! Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 27, 2011 Moderator Share Posted June 27, 2011 I will admitt it - I had to look up both ciguatera and Scombroid - and that is with 10 yrs experience..... yikes.... the otherw I would like to think I would have gotten...... In my time in the ER I learned so much of it was based on seeing, talking and examining the patient...... sad to say but I saw many of my co-workers (MD and PA) never touch the patient in an 8 hour stay........ I never understood it and think it was just plan wrong - touch, examine, play detective, use those exam skills and see what you can uncover. Link to comment Share on other sites More sharing options...
physasst Posted June 27, 2011 Author Share Posted June 27, 2011 I will admitt it - I had to look up both ciguatera and Scombroid - and that is with 10 yrs experience..... yikes.... the otherw I would like to think I would have gotten...... In my time in the ER I learned so much of it was based on seeing, talking and examining the patient...... sad to say but I saw many of my co-workers (MD and PA) never touch the patient in an 8 hour stay........ I never understood it and think it was just plan wrong - touch, examine, play detective, use those exam skills and see what you can uncover. Well, I diagnosed all of them EXCEPT the Bullous Pemphigoid....I suck at rashes. I had 4 attendings look and none of them knew either. First time in 10 years in the ED that I actually called in a dermatologist from home at 11pm. HE made that diagnosis. Ciguatera is something I had seen 2 other times....which is why I picked up on it. The first time though, I didn't know what it was either. BUT, I involved my SP, and he was the one that listened and made the diagnosis. That was the whole point I guess....not trying to toot my own horn, as I am sure that there are presentations even today after over a decade that I might not recognize. When something seems amiss......different travel history, a rash that doesn't make sense...etc. Then, get to the bottom of it. Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 27, 2011 Moderator Share Posted June 27, 2011 this is the single biggest lesson in medicine for ALL providers - know what you know and what you don't know...... and don't be afraid to ask Link to comment Share on other sites More sharing options...
lightbearer06 Posted June 27, 2011 Share Posted June 27, 2011 I agree with all of these posts. A better title may be "There is no substitute for a well performed history and physical." There will always be zebras like scombroids, which I have heard of but which I would not have immediately gotten. It always pays to have reference sites handy like MDConsult (or google to get into the right ballpark). Link to comment Share on other sites More sharing options...
treejay Posted June 27, 2011 Share Posted June 27, 2011 Yep. It's astounding how much cockyness one can find in health care practitioners. Humility is certainly a trait I value most in someone, especially when it comes to diagnosing another's health/disease status. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 28, 2011 Moderator Share Posted June 28, 2011 also being the second person to see something sometimes makes it a lot easier because you are already pretty sure that the first person got it wrong if the pt comes back. example: last weekend at my rural em job I saw a very nice 86 yr old with what I thought was classic diverticulitis( it was). she had been seen 2 days earlier by a guy a lot smarter than me (double boarded em/im doc) who had sent her out with a dx of "constipation". Link to comment Share on other sites More sharing options...
Chica724 Posted June 28, 2011 Share Posted June 28, 2011 Well I am sure the OP had a huge boost of ego with this post, but we also have to remember that we all have to start somewhere and as we gain experience in a specialty, we will all make mistakes as we learn and grow and simply because we are human. All I have to say is I hope the OP doesn't make students feel stupid for having to learn to get decent at something. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 28, 2011 Moderator Share Posted June 28, 2011 I know the OP personally. nice guy and great instructor. I don't think he was trying to stroke his ego with the post. Link to comment Share on other sites More sharing options...
Contrarian Posted June 28, 2011 Share Posted June 28, 2011 I agree with all of these posts. A better title may be "There is no substitute for a well performed history and physical." There will always be zebras... actually caring... maintaining a level of clinical curiosity, marked determination... and up-to-date/current easily accessible point of care references... Because Physicians (MDs/DOs) with decades of experience also miss zebras daily... nationwide. Just about every PA-C here on this forum (and many PA-Ss here) can tell stories of multiple things they caught that their preceptors or SPs with years/decades of experience missed... The simple fact seems to be that regardless of how many yrs you have... if you are not looking for it and/or don't consider it in the Diff... you won't find it. YMMV Contrarian Link to comment Share on other sites More sharing options...
rcdavis Posted June 28, 2011 Share Posted June 28, 2011 simple fact seems to be that regardless of how many yrs you have... if you are not looking for it and/or don't consider it in the Diff... you won't find it. This is the true take home here.. You can't diagnose what you do not know, do not recognize, and most importantly what you do not think of. If you stop and think, for every patient, "what else other than the probable or most obvious" could this patient have?, and at least mentally consider infection, inflammatory, neoplastic, drug, neuro, endo, etc as the causative etiology of his symptoms, you will soon find that other people will be coming to you for your opinion... And that amyloid, syphilis, vascular disection, and psychpathology cause you to lose sleep at night. Link to comment Share on other sites More sharing options...
kevinchs03 Posted June 28, 2011 Share Posted June 28, 2011 Very interesting cases. I def learned something today. Thank you. Link to comment Share on other sites More sharing options...
Guest cabkrun Posted June 28, 2011 Share Posted June 28, 2011 This is an interesting post and nicely put and responded to (other than the ego comment… ouch). I can say a couple of things both from personal as well as work experience (ONLY as an MA). I think Contrarian and others kind of hit the nail on the head. If you are dismissive of your patient, arrogant, refuse to listen, start to think of that dreaded "pyscho-social" thing (because you can't think of anything else), too ego driven to not be able to admit you just don't know, worried about the costs of yet more tests to actually try to figure out the problem, too busy to actually touch your patient... you can be a Harvard trained neurosurgeon with 25 years of experience and that might just not mean squat. I've seen these kinds of things play out personally as well as while working as a Medical assistant… causing patients pain, furthering of their disease, money, time, stress and yes even a couple of times possibly their lives. I realize burn out, insurance hassles, frustration and even that occasional crazy patient can make one hardened. But as Contrarian says, caring and curiosity are key, and I hope to never forget that once I get through school and start to practice. Naive as it may be. Only my .02 cents as a starting in August PA Student. Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 28, 2011 Moderator Share Posted June 28, 2011 Only my .02 cents as a starting in August PA Student. Congrats and keep thoughts like that flowing..... Link to comment Share on other sites More sharing options...
Contrarian Posted June 28, 2011 Share Posted June 28, 2011 Only my .02 cents as a starting in August PA Student. Great Post...!!! Link to comment Share on other sites More sharing options...
browndog Posted June 29, 2011 Share Posted June 29, 2011 Okay. I am not proud. Not by a long shot. I do not hesitate to seek SP advice when I am concerned... but....crap....how can I get THERE from HERE without killing someone? This is not rhetorical. How can I gain knowledge / experience without placing myself and my patients at a disadvantage in the process? Link to comment Share on other sites More sharing options...
physasst Posted June 29, 2011 Author Share Posted June 29, 2011 Well I am sure the OP had a huge boost of ego with this post, but we also have to remember that we all have to start somewhere and as we gain experience in a specialty, we will all make mistakes as we learn and grow and simply because we are human. All I have to say is I hope the OP doesn't make students feel stupid for having to learn to get decent at something. Not really. I've missed things. I know I have.. I am almost certain I have probably killed someone along the way. Do I have a large ego? You betcha.......Do I get any boost from clinical performance?...not much, maybe a little.. I'm moving, as EMED knows, away from clinical practice altogether. I've never made students feel stupid...the only stupid question is the one that isn't asked. (Although as an economist, there are likely some stupid questions I can think of, but when it comes to clinical practice, there are no stupid questions)... Here's a mistake I made that almost killed someone....YEARS ago, when I was only about 3 years into practice, I had a young female marathon runner come into the ED with an anaphylactic reaction to a bee sting. I ordered: Solumedrol 125mg IM Benadryl 50 mg IM Epi 0.3 mg Can you see the problem? I had a young nurse, fresh out of school. She was scared to approach me to clarify, so she drew up the cardiac dose of epi and gave it IV..... I walked into the patient clutching her chest and talking about her heart pounding out of it....... If she had been 85 I would have killed her. We've all made mistakes. The point isn't making mistakes in treatment, dosing, etc. The point is making a misdiagnosis when the story doesn't match up, and not seeking help when 2+2 isn't equalling 4... As I said, the first time I saw ciguatera, I had no idea what it was...but the story was weird.....and it didn't add up. My first patient with it had just returned from a trip to Belize. THAT was the point, having the experience when I saw it the second and third times to identify it. The patient didn't need the 10,000 dollar lab test profile, or Neurontin...but could have benefitted from someone with tropical medicine knowledge, and a 10 dollar prescription for amytryptiline. THAT's what bothered me. Even the rash. The NP even commented to the patient, who asked about the blisters on the palms of her hands, that it looked rather unusual, and that he wasn't really sure what it was......but started Keflex anyway. Anyway, just reviewing a paper on the effect of Tax Increases on Physician Hours Worked that was written by a good friend. Back to it. Link to comment Share on other sites More sharing options...
Chica724 Posted June 29, 2011 Share Posted June 29, 2011 We've all made mistakes. The point isn't making mistakes in treatment, dosing, etc. The point is making a misdiagnosis when the story doesn't match up, and not seeking help when 2+2 isn't equalling 4... Ok I see your point a bit better now. I defintely agree that most of the cases you mentioned lacked the use of help when they felt they might have needed it, but it did seem as though some were actually mistakes in diagnosis where they probably thought they were right all along. I know though that as a PA I feel pressured to get patients through clinic without having my SP come in after me. I try as much as possible to avoid this especially since he is a doc who spends a ton of time with patients. So if I have to have him come in, I will sometimes have to wait a while while he finishes with the patient he is with in order to adequately explain what is going on with the patient I want him to see after me; or else he will end up repeating the whole visit and this will put him further behind. It can be difficult to balance self-confidence with knowing when to ask for help. Link to comment Share on other sites More sharing options...
physasst Posted June 29, 2011 Author Share Posted June 29, 2011 Yep, I mean, let's face it.... 90% of the diagnoses we make are pretty damn easy. They are staring you right in the face..I might even say 95% of diagnoses are this way. Most disease or trauma presentation is rather obvious.... It's that other 5%....the subtleties, the difficult diagnoses that really can only be made after years of experience and thousands of patient contacts..... Link to comment Share on other sites More sharing options...
Hemegroup Posted June 29, 2011 Share Posted June 29, 2011 Yep, I mean, let's face it.... 90% of the diagnoses we make are pretty damn easy. They are staring you right in the face..I might even say 95% of diagnoses are this way. Most disease or trauma presentation is rather obvious.... It's that other 5%....the subtleties, the difficult diagnoses that really can only be made after years of experience and thousands of patient contacts..... I diagnosed a patient with trimethylaminuria last week. Poor guy's been dealing with this since an early age, as have many of his family members (auto recessive). Never been diagnosed. I have him taking activated charcoal now and better managing his diet, so we're hopeful. Link to comment Share on other sites More sharing options...
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