Discharge Instructions

[Apollyon]

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I screwed up; the patient doesn't think so, though - he said that I "saved (his) life".

Sore throat, difficulty swallowing, fever, no airway compromise, no voice change, took Tylenol elixir and felt MUCH better, lateral x-ray negative for epiglottitis, postpharyngeal space wide (slightly) at C2, normal at C4 and C7.

I talked with radiology about the film, and the rads resident in the box and I tossed RPA back and forth, but it wasn't a slam dunk - he mentioned CT, which I knew, but my attending didn't think so, and I didn't push it. Due to the way our system goes, the prelim report didn't go into the computer until 6 hours after the pt left, and the attending readout was 1 hr later - which emphasized CT, and which the rads resident told me today his attending said to put in - but they didn't call anyone.

Patient returned today, worse, got a CT, and has a large RPA - ENT took him to the OR, and things turned out fine (although one of our attendings was incensed by getting lip from an ENT res in the background on the telephone about "did you screw another one up?").

He came back because my DC instructions included "Return if your fever continues, if you have trouble swallowing, if you get a high-pitched noise in your throat, if you are worse in any way, or you feel you need to be seen again". "If you are worse in any way, or feel you need to be seen again" are in every single DC instruction I write. The patient heard his voice go up, and he couldn't swallow, so he came back to the ED, because that is what the instructions told him. The patient says I saved his life.

Besides voluminous pages about fever and cast care and sprains, do you give germane, to the point DC instructions? From my experience, commercial programs for DC instructions give too much information to focus on what's important, and are hard to really make fit for all but the most straightforward cases. Corey Slovis and Keith Wrenn wrote a book called "A Little Book Of Emeregency Medicine Secrets", and one of those was, "good discharge instructions are better than an accurate diagnosis", which fits here.

Have you been saved (legally, or in reality) by good DC instructions, or do you scribble/type the "return if worse"?

 

[roja]

Yes. In fact, a case went to CQI and it was my discharge instructions that made it 'appropriate blah blah blah'. whatever it is they say that means, hey, your documentation was good and your discharge instructions saved your ass adn maybe the patietns.

I was on overnight in our peds ER. A 5 mo old came in with vomitting for a day or so. baby looked fine. belly soft, no masses. MMM. Nl uop. documented in the chart that baby tolerated 3-4 oz in ed without vomitting. Discharged the patient with instructions to return to the ED if baby didn't make a wet diaper in >6 hours.

about 10 hours later, baby came back because he continued to vomit, and I had told them to come back if no wet diapers. (there hadn't been any in 7 hours) baby was now dehydrated adn had an olive shaped mass.

I always give very straight forward discharge instructions.

 

[southerndoc]

We use Micromedex discharge instructions at my main hospital, and at our satellite/community hospital we use instruction sheets that cover everything (from disease conditions to the medicines we prescribe). I really like the instructions from the community hospital because it gives information on their diagnosis, websites to look up additional information, recovery information, and most importantly, it gives bulleted information on when to return. It's very much to the point.

An attending once told me: "Good judgment comes from experience. Experience comes from bad judgment." While we always strive to learn from every patients, it's our messups that really make a lasting impression. We all make them. Some have good outcomes and others do not.

 

[The White Coat Investor]

I had two "Intent to Sue" letters in my first two months of residency, one from an ED patient, one from an inpatient I saw off-service. I have become painfully aware of the riskiness associated with emergency medicine. In addition to our commercial discharge instructions, I ALWAYS type in "return if worsening" and I always talk to them before they leave saying something to the effect, "Sometimes we don't make the diagnosis the first time, so if you are worsening come back and let us take another look at you." If they've had X-rays I mention that rads will overread our X-rays within 24 hours and they'll get a call if I missed something. I also mention 1/20 x-rayed fractures are routinely missed and if they still have pain in a week they need to have another X-ray. Then I ask if they have questions. So far I haven't gotten anymore letters. (Fingers crossed)

 

[v-tach]

Yes. In fact, a case went to CQI and it was my discharge instructions that made it 'appropriate blah blah blah'. whatever it is they say that means, hey, your documentation was good and your discharge instructions saved your ass adn maybe the patietns.

I was on overnight in our peds ER. A 5 mo old came in with vomitting for a day or so. baby looked fine. belly soft, no masses. MMM. Nl uop. documented in the chart that baby tolerated 3-4 oz in ed without vomitting. Discharged the patient with instructions to return to the ED if baby didn't make a wet diaper in >6 hours.

about 10 hours later, baby came back because he continued to vomit, and I had told them to come back if no wet diapers. (there hadn't been any in 7 hours) baby was now dehydrated adn had an olive shaped mass.

I always give very straight forward discharge instructions.

Pyloric stenosis?

 

[Homunculus]

Pyloric stenosis?

at 5 months it would definitely be an atypical presentation. Not to mention that the "olive" buzzword associated with it in real life is rarely felt (and even more rarely used to make the diagnosis). I've yet to feel one even in severe cases. I've been told by attendings that the best time to feel the "olive" is immediately before surgery while they are anesthetized.

The typical case i've run across is a 1 month-ish male with progressively worsening "reflux", vigorous attempts at feeding in spite of emesis, and emesis with almost every feed. Even then it's not a surgical emergency-- surgical correction can wait until metabolic stabilization (hypochloremic, hypokalemic metabolic alkalosis is the norm) and rehydration is done. In other words, don't consult surgery late at night or on weekends for this-- call your local pediatric service. We like the PS kids. 👍

--your friendly neighborhood in search of the olive caveman

 

[v-tach]

at 5 months it would definitely be an atypical presentation. Not to mention that the "olive" buzzword associated with it in real life is rarely felt (and even more rarely used to make the diagnosis). I've yet to feel one even in severe cases. I've been told by attendings that the best time to feel the "olive" is immediately before surgery while they are anesthetized.

The typical case i've run across is a 1 month-ish male with progressively worsening "reflux", vigorous attempts at feeding in spite of emesis, and emesis with almost every feed. Even then it's not a surgical emergency-- surgical correction can wait until metabolic stabilization (hypochloremic, hypokalemic metabolic alkalosis is the norm) and rehydration is done. In other words, don't consult surgery late at night or on weekends for this-- call your local pediatric service. We like the PS kids. 👍

--your friendly neighborhood in search of the olive caveman

5 months would seem awfully late. Plus, nothing was said about the vomiting being projectile (though maybe it was). I'd be curious to hear what the situation turned out to be.