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This is great, from the Canadian J of EM:
http://www.caep.ca/004.cjem-jcmu/004-00.cjem/vol-2.2000/v21-047.htm
Vol. 2, No 1, January / janvier 2000 Humour and Humanity
Humour et Humanité
Successful hospitalization of patients with no discernible pathology
Grant Innes, MD
--------------------------------------------------------------------------------
"Take your work seriously - not yourself."
Introduction
Patients frequently present to the emergency department (ED) with complaints of chronic pain, dizziness, neurasthenia, cognitive deterioration, or neuromuscular dysfunction. Generally, they have already undergone extensive and fruitless investigation. Their clinical exam is invariably unrevealing, and even the most aggressive testing strategies turn up nothing.1 In most cases, the emergency physician's only viable option is hospitalization, but without a clear diagnosis, inpatient consultants become testy, typically spouting irritating clichés like, "be a wall."
Emergency physicians who admit patients with no discernible illness are often viewed as wimps or losers, and the admissions themselves as "dumps." Because of the lack of a useful diagnostic test, the patients in question are labelled with derogatory descriptors like dwindles, failure to thrive, weak and dizzy all over, malignant fibromyalgia, unstable chronic fatigue syndrome, supratentorial pansynaptopenia, or gomer.
Recently, however, NIH (Northern Institute of Hypochondriasis) researchers have discovered that these seemingly diverse syndromes are, in fact, variants of a single pathophysiologic entity,2 designated PWDP (patient without discernible pathology). The discovery of PWDP diagnostic criteria is a significant advance (p = 0.02); however, this entity remains a huge source of conflict for emergency physicians (EP). On a daily basis, EPs are caught between PWDP victims who require (or believe they require) admission, and inpatient consultants who cling to the outmoded belief that hospital beds should be reserved for patients with treatable problems.
Most experienced emergency physicians have developed strategies for hospitalizing patients with no discernible illness. Such strategies are critical, but they are not described in the EM literature and they are poorly represented in EM residency teaching curricula. The objective of this article is to illustrate a common PWDP presentation and to describe effective dispositional strategies for EPs.
Case report
A debilitated middle-aged male was transported to the ED by paramedics after he was found creating a disturbance in a dumpster. On arrival, he was combative and screaming obscenities. He smelled of urine, alcohol and ketones. The triage nurse quickly identified him as "Phil," a frequent flyer well known to the department. The attending emergency physician rapidly established that Phil's presentation was consistent with alcohol intoxication, drug overdose, head trauma, metabolic derangement, sepsis, intracranial hemorrhage, personality disorder, multi-organ failure or hepatic encephalopathy. Road-testing revealed that Phil could not stand or walk. His old chart documented 79 identical episodes dating back 3 decades. On each occasion he required 7 to 10 days in hospital and, on each occasion, the discharge diagnosis was "weakness secondary to chronic alcoholism." Phil had never been successfully discharged from the ED.
Using our PWDP Admission Algorithm (Fig. 1), the ED physician determined that the only viable course of action was to admit Phil to an inpatient service. It was clear, however, that no consultant would be receptive - especially after viewing the old chart - and that it would take a wily emergency physician to succeed.
The ED admission team leaped into action, resuscitating Phil according to evidence-based PWDP guidelines. The ED nurse administered 10 mg of haloperidol for motor and profanity control, then 2 orderlies stripped Phil, burned his clothing, hosed him off, lathered him with "Kwell," scrubbed him with a soap brush, trimmed his hair, shaved him and applied honeysuckle-scented socks to his feet. The ED resident selected khaki pants and a Hugo Boss sweatshirt from the clothing bin and, finally, the unit manager tucked a copy of The Wall Street Journal under his arm. The transformation was unsettling. Now - mumbling, semi-responsive, and staring, dissociated, at the ceiling - Phil looked like a surgical resident after a tough night on call.
With help from the attending EP, our senior resident selected a diagnosis from the PWDP guidelines document and notified the admitting service of Phil's arrival. On hearing that a case of Dengue fever was waiting in the ED, the admitting resident arrived moments later, breathless. She attempted to take a history but Phil just muttered incoherently, like a sick patient should. He appeared vaguely unwell but there were neither diagnostic findings, nor notable laboratory values (we had deleted his blood alcohol result from the lab database).
The resident scanned the vital signs on the chart, pausing at the temperature. She placed the back of her hand on Phil's forehead, frowned and rechecked the temperature on the chart. Seeing this, the ED nurse stepped forward and slipped an electronic temperature probe into Phil's mouth. The thermometer's digital readout quickly rose to 38.9 degrees - its pre-programmed setting (note: the HiTemp PWDP thermometer is advanced technology recently developed by our own ED researchers). Bewildered, the resident left the bedside and ordered a head CT.
The ED staff released a collective sigh of relief, and the attending EP and charge nurse exchanged high fives. Victory was at hand! The tests to rule out Dengue fever would take days, and only one thing - Phil's old chart - stood in the way of successful admission. But it wasn't really in the way; it was safely locked in a drawer in the back medication room.
One hour later, Phil rolled out of the department, trailed by 2 baffled residents. The ED staff waved a fond goodbye, knowing he was in excellent hands.
Discussion
With the discovery of PWDP diagnostic criteria (Table 1), the sheer magnitude of this problem became evident. A 1998 nation-wide ED survey3 showed that PWDP is the most common condition treated in Canadian hospitals, surpassing even "abdominal pain NYD." Every 30 seconds, a PWDP victim presents to a Canadian emergency department, requiring admission, and every 30 seconds, an unenlightened consul tant who believes that hospital beds should be limited to patients requiring hospital interventions attempts to block it. It is now clear that the need to admit patients with no discernible illness is emergency medicine's greatest challenge. The case report above and the discussion below describe easily mastered admission techniques that can be adapted to any ED.
General principles
Recognize high-risk patients. Consultants are especially resistant to admitting alcoholics, drug abusers, hypochondriacs, the demented and the mentally ill. It is critical to conceal these traits whenever possible.
When communicating the need for admission, avoid the term "chronic." Instead, substitute adjectives like "explosive, paroxysmal or unstable."
When admitting marginal patients, select an appropriate diagnosis. The ideal diagnosis is exotic, difficult to disprove, and mandates hospitalization. Some of my favourites are Tumarken's otolithic crisis, familial periodic paralysis without hypokalemia, and Oppenheimer's progressive hemorrhagic leukodystrophy.
Order a large number of tests. Physicians are more impressed by abnormal values than by sick patients. It is, therefore, helpful to order a huge battery of nonspecific tests on anyone who may require admission. A skilled ED physician should be able to generate 2 to 3 intriguing false-positives on any patient. Best bets include C-reactive protein, anti-mitochondrial antibodies, serum lactate, myoglobin, d-dimer assay, and thick smears for Malaria. Hint: Always send body fluids for India ink stains. Although they are rarely positive, it is guaranteed to impress.
Be positive. "Sell" your patient. Consider the following telephone dialogue.
YOU (the wrong approach, regarding a weak patient): "I'm sorry about this, Dr. Smith, but I have a demented, incontinent gomer who needs admission because of weakness."
CONSULTANT (angrily): "Whaddya expect me to do? Be a wall! Send him home!" Click.
YOU (the correct approach, regarding the same weak patient): "Hello, Dr. Smith. I have an interesting elderly gentleman with delirium, muscarinic overdrive and generalized muscular weakness - probably an organophosphate overdose."
CONSULTANT (fascinated): "Hmm. Get him admitted and I'll be right down."
Supplement tests with new technology. Several admission adjuncts have recently been developed.
HiTemp PWDP digital thermometer reads 38.9° regardless of patient temperature.
Admit-Tech pulse oximeter automatically adjusts saturation levels down 10%.
ED Ace© 12-lead ECG machine prints out 1 of 6 pre-programmed patterns on demand, including ST-elevation infarct, nonspecific T-wave inversion, sinus tachycardia, ventricular fibrillation, ventricular tachycardia, and complete heart block. An optional pacemaker module, which shows pacing spikes without capture, is now being beta tested and will be available early next year.
Continued.....
http://www.caep.ca/004.cjem-jcmu/004-00.cjem/vol-2.2000/v21-047.htm
Vol. 2, No 1, January / janvier 2000 Humour and Humanity
Humour et Humanité
Successful hospitalization of patients with no discernible pathology
Grant Innes, MD
--------------------------------------------------------------------------------
"Take your work seriously - not yourself."
Introduction
Patients frequently present to the emergency department (ED) with complaints of chronic pain, dizziness, neurasthenia, cognitive deterioration, or neuromuscular dysfunction. Generally, they have already undergone extensive and fruitless investigation. Their clinical exam is invariably unrevealing, and even the most aggressive testing strategies turn up nothing.1 In most cases, the emergency physician's only viable option is hospitalization, but without a clear diagnosis, inpatient consultants become testy, typically spouting irritating clichés like, "be a wall."
Emergency physicians who admit patients with no discernible illness are often viewed as wimps or losers, and the admissions themselves as "dumps." Because of the lack of a useful diagnostic test, the patients in question are labelled with derogatory descriptors like dwindles, failure to thrive, weak and dizzy all over, malignant fibromyalgia, unstable chronic fatigue syndrome, supratentorial pansynaptopenia, or gomer.
Recently, however, NIH (Northern Institute of Hypochondriasis) researchers have discovered that these seemingly diverse syndromes are, in fact, variants of a single pathophysiologic entity,2 designated PWDP (patient without discernible pathology). The discovery of PWDP diagnostic criteria is a significant advance (p = 0.02); however, this entity remains a huge source of conflict for emergency physicians (EP). On a daily basis, EPs are caught between PWDP victims who require (or believe they require) admission, and inpatient consultants who cling to the outmoded belief that hospital beds should be reserved for patients with treatable problems.
Most experienced emergency physicians have developed strategies for hospitalizing patients with no discernible illness. Such strategies are critical, but they are not described in the EM literature and they are poorly represented in EM residency teaching curricula. The objective of this article is to illustrate a common PWDP presentation and to describe effective dispositional strategies for EPs.
Case report
A debilitated middle-aged male was transported to the ED by paramedics after he was found creating a disturbance in a dumpster. On arrival, he was combative and screaming obscenities. He smelled of urine, alcohol and ketones. The triage nurse quickly identified him as "Phil," a frequent flyer well known to the department. The attending emergency physician rapidly established that Phil's presentation was consistent with alcohol intoxication, drug overdose, head trauma, metabolic derangement, sepsis, intracranial hemorrhage, personality disorder, multi-organ failure or hepatic encephalopathy. Road-testing revealed that Phil could not stand or walk. His old chart documented 79 identical episodes dating back 3 decades. On each occasion he required 7 to 10 days in hospital and, on each occasion, the discharge diagnosis was "weakness secondary to chronic alcoholism." Phil had never been successfully discharged from the ED.
Using our PWDP Admission Algorithm (Fig. 1), the ED physician determined that the only viable course of action was to admit Phil to an inpatient service. It was clear, however, that no consultant would be receptive - especially after viewing the old chart - and that it would take a wily emergency physician to succeed.
The ED admission team leaped into action, resuscitating Phil according to evidence-based PWDP guidelines. The ED nurse administered 10 mg of haloperidol for motor and profanity control, then 2 orderlies stripped Phil, burned his clothing, hosed him off, lathered him with "Kwell," scrubbed him with a soap brush, trimmed his hair, shaved him and applied honeysuckle-scented socks to his feet. The ED resident selected khaki pants and a Hugo Boss sweatshirt from the clothing bin and, finally, the unit manager tucked a copy of The Wall Street Journal under his arm. The transformation was unsettling. Now - mumbling, semi-responsive, and staring, dissociated, at the ceiling - Phil looked like a surgical resident after a tough night on call.
With help from the attending EP, our senior resident selected a diagnosis from the PWDP guidelines document and notified the admitting service of Phil's arrival. On hearing that a case of Dengue fever was waiting in the ED, the admitting resident arrived moments later, breathless. She attempted to take a history but Phil just muttered incoherently, like a sick patient should. He appeared vaguely unwell but there were neither diagnostic findings, nor notable laboratory values (we had deleted his blood alcohol result from the lab database).
The resident scanned the vital signs on the chart, pausing at the temperature. She placed the back of her hand on Phil's forehead, frowned and rechecked the temperature on the chart. Seeing this, the ED nurse stepped forward and slipped an electronic temperature probe into Phil's mouth. The thermometer's digital readout quickly rose to 38.9 degrees - its pre-programmed setting (note: the HiTemp PWDP thermometer is advanced technology recently developed by our own ED researchers). Bewildered, the resident left the bedside and ordered a head CT.
The ED staff released a collective sigh of relief, and the attending EP and charge nurse exchanged high fives. Victory was at hand! The tests to rule out Dengue fever would take days, and only one thing - Phil's old chart - stood in the way of successful admission. But it wasn't really in the way; it was safely locked in a drawer in the back medication room.
One hour later, Phil rolled out of the department, trailed by 2 baffled residents. The ED staff waved a fond goodbye, knowing he was in excellent hands.
Discussion
With the discovery of PWDP diagnostic criteria (Table 1), the sheer magnitude of this problem became evident. A 1998 nation-wide ED survey3 showed that PWDP is the most common condition treated in Canadian hospitals, surpassing even "abdominal pain NYD." Every 30 seconds, a PWDP victim presents to a Canadian emergency department, requiring admission, and every 30 seconds, an unenlightened consul tant who believes that hospital beds should be limited to patients requiring hospital interventions attempts to block it. It is now clear that the need to admit patients with no discernible illness is emergency medicine's greatest challenge. The case report above and the discussion below describe easily mastered admission techniques that can be adapted to any ED.
General principles
Recognize high-risk patients. Consultants are especially resistant to admitting alcoholics, drug abusers, hypochondriacs, the demented and the mentally ill. It is critical to conceal these traits whenever possible.
When communicating the need for admission, avoid the term "chronic." Instead, substitute adjectives like "explosive, paroxysmal or unstable."
When admitting marginal patients, select an appropriate diagnosis. The ideal diagnosis is exotic, difficult to disprove, and mandates hospitalization. Some of my favourites are Tumarken's otolithic crisis, familial periodic paralysis without hypokalemia, and Oppenheimer's progressive hemorrhagic leukodystrophy.
Order a large number of tests. Physicians are more impressed by abnormal values than by sick patients. It is, therefore, helpful to order a huge battery of nonspecific tests on anyone who may require admission. A skilled ED physician should be able to generate 2 to 3 intriguing false-positives on any patient. Best bets include C-reactive protein, anti-mitochondrial antibodies, serum lactate, myoglobin, d-dimer assay, and thick smears for Malaria. Hint: Always send body fluids for India ink stains. Although they are rarely positive, it is guaranteed to impress.
Be positive. "Sell" your patient. Consider the following telephone dialogue.
YOU (the wrong approach, regarding a weak patient): "I'm sorry about this, Dr. Smith, but I have a demented, incontinent gomer who needs admission because of weakness."
CONSULTANT (angrily): "Whaddya expect me to do? Be a wall! Send him home!" Click.
YOU (the correct approach, regarding the same weak patient): "Hello, Dr. Smith. I have an interesting elderly gentleman with delirium, muscarinic overdrive and generalized muscular weakness - probably an organophosphate overdose."
CONSULTANT (fascinated): "Hmm. Get him admitted and I'll be right down."
Supplement tests with new technology. Several admission adjuncts have recently been developed.
HiTemp PWDP digital thermometer reads 38.9° regardless of patient temperature.
Admit-Tech pulse oximeter automatically adjusts saturation levels down 10%.
ED Ace© 12-lead ECG machine prints out 1 of 6 pre-programmed patterns on demand, including ST-elevation infarct, nonspecific T-wave inversion, sinus tachycardia, ventricular fibrillation, ventricular tachycardia, and complete heart block. An optional pacemaker module, which shows pacing spikes without capture, is now being beta tested and will be available early next year.
Continued.....
