Case 24: Saturday Morning Dump

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The tracking board shows that there are three patients to be seen. Two have been waiting less than twenty minutes, and their charts are in my colleagues’ hands. “I can’t find this one,” one doctor says, pointing to the screen. “Angus Middleton.”

“Yeah right,” I say, elbowing him. “I’m sure you looked really hard.” He’s holding the chart of a sixteen year old with an ankle injury. There aren’t many young and healthy people named Angus. His age is listed next to his name – ninety-one. “What’s wrong with Angus?” I ask, approaching the screen. “Fecal impaction?”

“Foreign body throat,” he says.

“Great,” I say, picturing a nursing home resident trying to hork-up a tea-soaked biscuit.

An elderly man is smiling in the hallway. He’s with a younger man, one in his sixties. “Mr. Middleton?”

“Yes,” the son says.

“Have you been seen by a doctor yet?”

One shrugs and the other shakes his head no.

“Okay. Just give me a minute.”

I search for his chart, but can’t find it. I search each of the three nursing stations. Nothing. I ask the clerk if she’s seen it. Finally, I leave the E.R. and find it in a slot in the waiting room. It’s been picked out of the stream of charts headed for the E.R. I feel like I’m stealing it as I take it away.

“Is that the foreign body throat?” the nurse asks.

“Yes.”

“Why do you need that chart? He’s not for the E.R.”

“Patient hasn’t been seen yet.”

“He’s here to see E.N.T,” the nurse says.  I’ve skimmed the chart, so I already know this – that the patient was seen at another hospital, that he was seen by an Emergency Physician, and that the patient was sent to see our Ear, Nose, and Throat specialist. I know he’s not here to see me.

This is common practice, to have patients meet specialists in the Emergency Room. It’s especially common on weekends, when doctors’ offices are closed. The problem is, there’s no telling how long the patient will have to wait; Maybe the ENT is taking care of a post-tonsillectomy hemorrhage. Maybe she’s stuck in an operating room with an obstructed airway.

“When is ENT coming?” I ask the nurse.

“I paged her. She’s on her way.”

It doesn’t matter, I say. The patient isn’t sitting in a restaurant, nor is he sitting at home watching television. He’s sitting in the E.R., and he’s been here for almost an hour. The triage note says that the patient feels “full,” and that an attached CT scan suggests that there may be something stuck in the patient’s airway. I know Angus isn’t in any distress. I saw him seconds earlier, smiling, speaking clearly. But he’s in the E.R., and as long as he’s here, he’s our responsibility. There are no vital signs on his chart – no heart rate, no blood pressure, no temperature. He’s been registered as if he was in a doctor’s office, not a hospital – this too, is common practice.

I call him into a room. He tells me that he’s been feeling a blockage at the back of his throat. “About a year,” he says, when I ask how long it’s been troubling him.

“The note from the referring doctor says it’s only been since this morning,” I say.

His son clarifies: “It feels worse this morning.”

“Where do you feel it?” I ask.

His hand is huge. It covers his neck when he shows me – his neck and the top of his chest.

Other than the feeling of something in his throat, Angus is alright. He doesn’t have any chest pain, or shortness of breath. His medical history is fairly unremarkable – he has mild hypertension, and he has an irregular heart rate, both of which are medicated and controlled.

I’m about to examine him, when his son speaks. “You’re the Ear Nose and Throat specialist, right?”

“No,” I say. “I’m another E.R. doctor. I’ll be looking after your father until she arrives.”

He’s been speaking well, and swallowing without distress. Whatever is in his throat isn’t urgent, although the doctor that sent him felt it needed urgent attention. He opens his mouth and I flash a light inside. Nothing. I listen to his heart, and his lungs, and then I palpate his belly. I caught an appendicitis like this once – in a patient who came in because his eye was painful after an optometry appointment.

Angus’ belly isn’t tender. His feet, however are a little swollen. I listen to his heart again and take his pulse.

Just as I leave the room, the ENT arrives. Her cheeks are flushed, and she looks like she’s rushed over. “Is this the obstructed airway?”

I hand her the chart. “You’re going to love this. One year history of foreign body sensation. No distress. Speaking well, swallowing well.”

“The other hospital made it sound like an acute obstruction that happened this morning.”

“You’ve been duped,” I say.

“Welcome to my life,” she says. “Typical Saturday morning dump.”

“Don’t discharge him when you’re done,” I say. “I need to see him again.”

I ask for records from the hospital that sent him. The story on that chart is a little different. Angus had fallen out of bed a few days earlier, and since then, he’s had the sensation of something in his throat and difficulty speaking. He’s able to drink fluids – in fact, he was drinking a double-double in the other Emergency Room before he was assessed. A look into his throat was normal, as was air entry to his lungs, so the attending physician ordered some blood work and CT scan of the neck. Several hours later, the blood work was unremarkable, but the CT showed a mass in the back of his throat. It wasn’t small – almost half-an-inch – and so the physician paged the ENT on-call. “Acute airway obstruction,” the specialist was told, and the patient was rushed to our hospital.

Minutes after the specialist arrives, she’s finished. “I scoped him,” she says. “Nothing there except a big tongue. That’s what was on the CT scan – a tongue. It’s probably been growing slowly over the years. He’s fine from my standpoint.”

“Malingering” is a medical term. Patients who malinger, according to the dictionary, “exaggerate or feign illness in order to escape duty or work.” Doctors can malinger on behalf of their patients; They can exaggerate their patients’ illness for personal gain (in this case, to abdicate care of a ninety-something who thinks he’s choking on his own tongue).

The ENT hands me the chart and I ask the nurse for blood work and an ECG. “And he’ll need a monitored bed.”

I’d been fooled by a similar patient before. She was in her sixties, from a group home.  She took her noon pills, and felt that one was stuck in her throat. I asked if she had one with her. She did. It was tiny, pink, and powdery – it looked like it would dissolve in a tear drop. I told her not to worry. It may have irritated her throat, but it couldn’t be stuck. She was sure it was stuck. I put a camera into her nose and looked at her vocal cords. I usually find this difficult, but she was cooperative, and I had a great view. I saw nothing in her throat, and nothing around her vocal cords. She had no other medical problems, she told me, other than psychiatric. If I’d have been more thorough, I may have seen the scar at the back of her neck. I may have considered that the hardware under the scar was becoming inflamed and infected – that the choking sensation had nothing to do with the pill she’d just taken.

Angus’ tongue isn’t what’s making him feel “full.” Moreover, it isn’t what made him fall out of bed a few days earlier. It won’t take much to make Angus fall, or pass out in the E.R. either. When I listened to his heart, the beats were racing so fast, they were impossible to count. Lying flat, at rest, his ECG showed one-hundred-and-sixty beats per minute. A brisk walk down the hall could bring it up to two hundred – more than enough to make him collapse.

Angus is admitted to hospital, and is started on medication to control his heart rate. A day later, he’s feeling much better, and he’s is discharged.

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