* * Anonymous Doc: How much am I supposed to be able to care if the patient doesn't?

Wednesday, January 16, 2013

How much am I supposed to be able to care if the patient doesn't?

"Sorry to call you at home so late-- your blood work just came back.  Your potassium level is 6.8.  I'm not certain of the cause, but I need you to come to the ER right away so we can redraw the labs, see if that value is real, and treat you if it is."

"I'm already in my pajamas, doc."

"I know, and I'm sorry.  I wish your appointment had been earlier in the day, and we would have had these labs back sooner.  But given the value-- and there are some other things in there that are concerning-- you need to get here tonight.  I don't feel comfortable having you wait until the morning."

"I can't get all the way to the ER."

"I know, it's a hassle.  But it doesn't have to be here.  If it's easier, you can go to the closest hospital, call 911, that's fine, and if you end up admitted, we can worry about transfer tomorrow if that makes sense.  I just want you to be seen tonight and not risk being at home."

"I'm feeling fine, doc."

"But you're not fine.  Your labs are very alarming.  I want them redrawn and I want you in a setting where you can be treated, because a potassium level that high can cause real problems, quickly.  Cardiac arrest-- your heart could stop functioning."

"Oh, come on, I'd have a higher fever--"

"No, you wouldn't.  I don't mean to be alarming you, and I'm not trying to say that in every case something terrible would happen if you waited until tomorrow--"

"Well, tomorrow's really no good for me--"

"What I'm saying is that we're not going to wait until tomorrow.  The prudent thing to do-- the only thing to do, unfortunately-- is to come in tonight.  Let's be safe here.  I don't want to play games."

"I'm really tired, doc."

"I know.  And I wish these labs had come back normal, but they didn't.  And I have to tell you to come in tonight, because if you don't, you're taking a real risk, and unfortunately it's not a risk that you should be comfortable taking.  I don't know how else to say this.  It's potentially life-or-death important, or I wouldn't have called you at home this late, and I wouldn't be trying this hard to convince you to come in."

"I'll deal with it later."

"No, you should either have someone drive you to an ER, or you can call 911 and have an ambulance bring you in.  That will get you to the head of the line and we can figure out what's going on."

"I'm not coming in tonight."

"That's not a legitimate decision to make."

"My heart is beating fine."

"There wouldn't necessarily be any warning if something were to happen.  We don't know what the potassium level was before, or where it's going.  Did you eat anything since you had the blood drawn?"

"Yeah, I had a piece of chicken and some spinach."

"Spinach has a lot of potassium.  Normally it wouldn't be a concern, but with your level that high--"

"Now you're just trying to scare me."

"I know that's how it sounds, but I don't want to regret not having you seen tonight.  And you shouldn't want to risk that.  It is better to be safe than sorry, I promise you.  Tell me what else to say.  You need to come to the hospital.  I don't know how to say it any other way.  You are at risk of death if we don't treat this."

"I'm fine.  I'm not going to die."

"Look, call 911, they'll redraw the labs, and if it's nothing, you can go right back home."

"I already brushed my teeth."

"That's fine. You need to get this checked out tonight.  You need to come in.  I can call 911 for you, if you let me.  I'll take care of it."

"You just want to make money."

"I don't get paid based on whether you come in.  You can go to any hospital, or if there's a clinic that can check your blood this late, that's fine too.  But you can't leave this untreated until the morning.  I have to document that I've explained the risks to you.  You could have a fatal event during the night given these lab results.  This is a medical emergency.  Something could definitely happen, and I'm not just saying that."

"I play Bingo in the morning."

"Your life should be more important than Bingo.  You need to be seen by a doctor.  I'm going to call your daughter and make sure she's aware of your situation and my strong, urgent recommendation.  I can't keep going in circles with you."

"My daughter always wants me to go to the hospital anyway.  I'm not listening to her."

"I'm sure she's only trying to be cautious.  And I have to call her if you won't agree to come in."

"I want to live my life, not be stuck in a hospital."

"I want that for you too.  But sometimes you need to get things checked out, to be safe."

"I'm going to sleep.  Goodbye."

"You can call 911 at any point in the--"



  1. You did give it your best shot, you couldn't have made it any clearer this patient was at risk!

  2. You did the best you could. I hope the daughter was more successful! You can't make them care about their own health, which must be mightily frustrating. But then, assuming he or she is of sound mind, they get to make their own decisions and documenting them is all you can do!

  3. Once you're out of residency, you'll quit trying so hard. I give them an ultimatum: come in now or die. If they balk, I'm done. I've only got time for people who want to get well.

  4. Was the daughter able to get him to come in?

  5. Obviously the wrong decision but I understand the patient's feelings. The hospital sucks and the ER is even worse. Everyone has a point at which they say "no more". Also I'm always amazed so much depends on the phlebotomist who frequently has only a high school education, a month or so of training and a hellish work schedule.

  6. ""No, you should either have someone drive you to an ER, or you can call 911 and have an ambulance bring you in. That will get you to the head of the line and we can figure out what's going on."

    NO NO NO NO. NOT TRUE. Please don't tell people that. I used to be a paramedic and this myth is why many people call the ambulance for non-urgent things.

    I love your blog though!

  7. How frustrating for you...it seems like sometimes being a doctor is like being a parent.

  8. "No, you should either have someone drive you to an ER, or you can call 911 and have an ambulance bring you in. That will get you to the head of the line and we can figure out what's going on."

    Oh no you didnt....

  9. Adult medicine sucks. Taking the ambulance does get you to the front of the line in Peds.

    These conversations are tough.
    Had an older gentleman with genetic cardiac disease. But after his MI at 30, he started running triathlons. But lately, had been having chest pain. The doc sent him for a stress test. He failed it with a BP of zero, and heart rate of zero, within a few minutes. But was still planning on doing the triathlon in a month.

    After half an hour of me saying "you can't run a triathlon.. You can still exercise, just not a triathlon," I had to turn to "Look, you died during your treadmill test, and you will die during the triathlon. Except there won't be anyone ready with an AED to save you. I don't know how else to say this."

    I was unable to convince him not to do the triathlon.