Doctors divided

There was only one thing that bothered me about Greg Taylor’s three visits to the ER. It was a while ago, but when I replayed the conversation, I could feel the heat of anger and frustration rise from my chest to my throat. The nerve. Greg, a young man who was accompanied by his mother during all three visits, first came to the hospital late on a Wednesday. It was just after midnight when my colleague, Dr. Raydon (all names changed) saw him. Greg had rectal pain. It started with diarrhea about a week before, and over the previous few days, he’d had some blood with wiping. But on this day, he’d had pain at his bottom, and like all young people, he’d done some online research before coming in. “I think I have a hemorrhoid or a rectal prolapse,” he told my colleague. Greg was healthy: no illnesses, no surgeries, no medications, no drugs, no alcohol. On exam, he looked well—good colour, normal vital signs—but Dr. Raydon did what he needed to do: While his mother escaped from the room, Greg climbed onto the exam table, laid on his side and slid down his pants. “There’s no hemorrhoid,” Dr. Raydon said, “and certainly no prolapse. But you do have a skin tag, which can occasionally be a sign of inflammatory bowel disease in young people.” As Greg re-secured his belt, the doctor asked him a few more questions. No, there hadn’t been blood in Greg’s stool, just on wiping, and no, there had been no mucus. The diarrhea had been severe at times, with up to five watery movements a day, but he felt it was getting better. “Actually, I had my first solid poop today,” he said. “That’s good.” “But then I had diarrhea a couple times more after that.” “Let’s do some blood work,” Dr. Raydon said. “I’ll check your blood counts as well as your inflammatory markers—make sure there’s no sign of inflammatory bowel disease like Crohn’s or ulcerative colitis.” A couple of hours later, the tests were back. Everything was normal, including his inflammatory markers. “You can go home,” Dr. Raydon said. “But you should have a colonoscopy because of that skin tag. I’ll make a referral for you. And if you get worse or don’t get any better in a few days, come back.” Back to the ER Thirty-six hours later, Greg was back. His rectal pain persisted, but now he had abdominal cramping along with bright red blood in his stool. His mother added that he may have fainted that morning. To my colleague, Dr. Hammond, he still looked good, and his vital signs were normal other than an elevated heart rate, just above 120 beats per minute. He’s thin to begin with, having weighed in at 135 lbs. at his first visit. He’s down about a pound but said that he was wearing heavier clothes on Wednesday. Dr. Hammond ordered a fluid bolus and a repeat of his blood tests. He also added an X-ray, and ordered stool samples just in case Greg had picked up a bug such as salmonella. His mother told Dr. Hammond that they’ve been referred to a gastroenterologist and, incredibly, already have an appointment for initial consultation on Tuesday. A couple of hours later, his tests were back. The imaging was normal, and although a scan would have likely been diagnostic, Greg is still young and Dr. Hammond didn’t want to rush into ordering a CT scan because of radiation exposure. This time, his white count was elevated at 15.3, but his hemoglobin was stable at 118 (it had been the same 36 hours earlier), his inflammatory markers were just slightly off, his ESR elevated at 26, and his CRP at the upper limit of normal (9). “How are you feeling now?” Dr. Hammond asked as he went over Greg’s results. “I feel better.” His mother added that he had another episode of diarrhea while receiving the fluid bolus. “Maybe you should come in for admission,” Dr. Hammond said. “Get some more I.V. fluids, and maybe get your scope sooner than later.” Greg was already shaking his head no, as his mother shrugged. “It’s up to you,” she told her son. Greg told my colleague that he would like to go home and wait to see if the stool samples come back for anything treatable. He lasted two days and I met him for the first time on Sunday. He told me that since his last visit, his stools were filled with blood and mucus, and are coming almost hourly. He looked pale and on exam his abdomen was mildly tender in all quadrants. His heart rate was still high, 130 beats per minute and he was down almost five pounds since his first visit. I gave him fluids and repeated his blood tests. Although his hemoglobin was unchanged, his inflammatory markers were much worse. His CRP, which was normal two days ago, was now almost seven times normal. “You need to be admitted,” I said. “I know you have an appointment with the gastroenterologist in two days, but that’s just the initial consultation. A scope may be some time after that.” The conversation Dr. Raines, the on-call admitting doctor, had been practising a year or two. Over the phone, I explained the story from the first visit until today, and told Dr. Raines that although Greg has an appointment with a gastroenterologist in two days, he likely was going through his first—rather severe—episode of either Crohn’s or ulcerative colitis and should be admitted for hydration and a scope. There was a pause. And then, no discussion, just instruction from a deadpan voice. “No. GI consult in two days is fine. The patient can go home.” I was both disgusted and amazed at the arrogance. Without assessing or examining Greg, Dr. Raines was telling me to go back to the room and send him home. I’d been chatting with admitting doctors for years. Often there’s discussion: Are you sure the patient needs admission? What if we can call GI and arrange a scope for tomorrow morning? The patient didn’t want to stay two days earlier, are they going to want to stay now? But Dr. Raines had no interest in a discussion, and was telling me how to manage my patient without even laying an eye or a finger on him. I wasn’t sure what to say, so just in case there was some misunderstanding, I was explicit: “I’m asking you to come see the patient.” “Is the patient’s blood pressure OK?” The blood pressure was fine and Dr. Raines knew it because I’d already said so. “If you think the patient is well enough to go home,” I said, “then examine the patient and tell him yourself.” There was a sigh, loud and deliberate and then: “Fine.” When Dr. Raines came down to the ER, I wanted to say: “Do you realize that in the months that you’ve been working here, I’ve rarely called you? And that when I do call you, it’s not for nothing?” But I didn’t say anything. When I recounted the story to my colleague, he relayed a similar experience with Dr. Raines. Still fuming I was still fuming two weeks later, when I had to call Dr. Raines again about a medically fragile patient with a fever. Again reluctant to come down, Dr. Raines asked me to order a blood test and then discharge the patient if it was normal. I said I was happy to order the test, but that I wanted Dr. Raines to see the patient. In a snarky consultation note, Dr. Raines wrote that I’d asked for a consultation to review a blood test result. Fortunately, in sharing the care of my patients with other physicians, I’ve rarely encountered those reluctant to assess and care for patients. But for the few who seem afflicted with work-avoidance, it’s often consistent practice. And it’s dangerous. It isn’t inconceivable that an ER doctor would lean toward sending home a sick patient that they were on the fence about rather than enduring a difficult conversation with a physician who would rather discharge via telephone. Dr. Raines assessed Greg, and not surprisingly admitted him to hospital. The following day, when Greg’s bleeding worsened and his hemoglobin dropped by 20 points, he was scoped urgently. He was diagnosed with ulcerative colitis, started on high-dose steroids and a week later, he was discharged home. And the medically fragile patient with a fever? Maybe out of spite for me, Dr. Raines assessed the patient and sent her home, only to have her return a few hours later for a four-day admission. Dr. Raj Waghmare is an ER physician. His stories come from more than 20 years of medical practice all over Ontario.

Doctors divided

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