My "Gal" Bladder Pain

In one of my earlier posts I had talked about the different "types" of patients that you get. I talked about how I got the "flirtatious" patient. Well it was about 2 weeks ago that I got the "angry" patient.

I don't remember the cause but for one reason or another I didn't sleep well the night previous. So that day I came into clinic already wiped out. When I enter I immediately hear this high-pitched screaming and yelling coming from my patient's room...I look over at my nurse who is sitting there reading a magazine like she doesn't hear the ear full reverberating down the hall. With a bit of apprehension I read through the patient's history which, of course, is a monstrous one. The patient initially presented looking like gallbladder disease.

The gallbladder is a pretty simple organ. It's a storage organ that holds bile (used to break down fats that you eat). Sometimes it spasms, sometimes it gets plugged with a stone, sometimes the bile turns to sludge and plugs it up...regardless it always presents with right sided abdominal pain that radiates to the right arm. You can have vomiting and nausea with it.

This patient was having exactly these symptoms, so her pediatrician got an ultrasound and it turned out that the gallbladder was perfectly fine...but she had a fatty liver and her liver enzymes were high (her liver is irritated and inflamed). When I see that and check her history, she's got a BMI (body mass index) in the 40's (she's grossly obese)...and her last name is of Hispanic origin (Native American and Hispanic genetics give you a higher chance of getting fatty liver with obesity). So I'm ready to see this young woman and deliver the results...what was I thinking!!! I wasn't the slightest worried that the yelling/anger would enter our conversation...usually when the doctor walks into the room the patients get all polite...even if you have heard them screaming at their children moments before.

I sit down and introduce myself to the mother and daughter (my patient)...I get blank stares. I inform them that I've looked over her chart, but I like to have an idea about why they are here and what their concerns are.

"We want to know what the mass is on her gallbladder!", she blurts out with impatience. I'm getting this vibe that she just does not like me. At this point I'm reeling...(WHAT MASS!?!?!?! There was no mass!) My questioning in relation to this only pisses her off more, because she thinks I haven't seen the ultrasound and I'm an incompetent intern (which maybe I am, but not as incompetent as she is). I explain that I have seen the ultrasound, I relate what I saw when I looked at it and that I didn't see anything resembling a mass on the gall bladder. I calmly tell her I'm going to go outside and review the findings and double check though...I do and it's exactly what I had read previously...I even look through every single image again...and still find nothing. I step back in and question her further. What I find out is that, the patient's mother is a nurse, who apparently without any education in ultrasonography, is CERTAIN she saw something "funky" on the gallbladder..."cause I'm a nurse and I see stuff like this all the time."

That's like me saying to an engineer that, because I commute over a bridge everyday, I know beyond a shadow of a doubt that he constructed the bridge wrong and used metals with inadequate tensile strength (actually to be like her I would have had to say "dat bridge is built all crazy wrong man!".)

As it turns out the mother had some past experience with her gallbladder and she was really fearful that some "punk" doctor was going to mis-diagnose her daughter. I offer to take her out and go over the U.S. with her if she really feels there is something, but she redirects and asks "THEN WHAT IS WRONG WITH MY GIRL!!!" I calmly explain that I hadn't had a chance to tell her about the lab results in full, which I do (this whole visit is going wrong...you should never open with results...but I'm getting sucked in). I explain the fatty liver, which she then wants to know the "why?" about. I explain that her daughter is grossly obese (compared to mom she's a tooth pick though, so the mom thinks I'm full of it) and that paired with their genetics they both are set up for problems like this. I could have sugar coated the whole obese thing, but come on, if she hasn't heard it then she needs to hear it...when I told them all these things I was as calm, objective, and rational as you could be, what I was telling them had no venom in it at all (You are doing patients a disservice if they are obese and you tell them they are healthy)...apparently she hadn't heard that she was grossly obese (seriously?!?!?)...they were also super pissed that I had gotten all "racist" on them.

"We're ENGLISH!!! Just like you, pure AMERICAN!!!" I don't disagree with her I simply remind her that just as I have German ancestors she has Hispanic ones in some form or another(her name alone gives it away)...Seriously at this point the visit is a disaster, we are arguing the color of paint on the wall. I finally come to the realization this is going NO where, if she were my patient, and not my attending's, I would have explained that she is hampering her daughter's quality of care and politely ask them to leave and not return, until they can converse calmly with me...sadly I couldn't kick that mom out on her ass. So instead I tell her that I can see this isn't getting anywhere and I apologize that I've angered her so much...(I definitely was not sorry, but that's what you are taught to do/say...I had my mask fixed on tight right then). I then went out and explained the whole situation to my attending.

My attending walks in and suddenly this enraged bull of a woman is all smiles and politeness. The rest of the visit goes exactly how I had envisioned it going when I first turned the door knob to that damned room. Dr. H agrees on a plan of care with the patient and mother, then leaves the room with happy goodbyes and a "see you soon." As I say a quick and simple "good bye" (a "have a nice day" at that point would have been blatantly disingenuous) and step out of the room, my last sight of the pair is them sharing this quick mischievous smile...like devils...fat ones (I'm being unprofessional...sorry) :P.

My advice to anyone, as a patient, is to always be polite to those taking care of you (ie. don't bite the hand that feeds you). Not that we will spit in your IV fluids or dose you with a sedative (...well at least not the IV fluids thing), seriously though, we would NEVER retaliate, but what you get for all of your fury is that you push the staff away from you. Nurses and doctors, regardless of how saintly they are, will find reasons to "skip" over your room during rounds and opt not to check up as often as they normally would with the "nice" patient...it sounds bad, but it's a well known fact that in medicine the "angry" and "mean" patients get poorer care (Not for sure but I think it's actually proven by scientific study now).

Dr. H actually took this into account. She's a feisty doc and I have no doubt that she would kick a patient out of her office in an instant if they pulled that with her, but as she explained later, since they were polite and understanding with her, kicking them out for abusing me or even having a conversation about it would only hurt the patient's care (they would likely blow up and storm out), so she allowed it. I was totally drained by the end of it, but I was fine with her course of action...it sounds lame but it really is true, at least in medicine, almost always the only thing you achieve with a stunt like that is that you hurt yourself.

Newbie Doc

The Presentation

My presentation is over with!!! Whew...it was 30 minutes of pain and anguish...all on my side though luckily..I really hate standing up in front of people and talking, which (who would have guessed it) is a regular part of the whole doctor thing. You have to give educational presentations ALL the time and while you can make it as superficial or in-depth as you want, you don't want to seem like you didn't try...err on the side of beating your audience into submission with information (that's my motto...if I had a motto)...I also try to make it easy to "digest" although when your presentation throws around words like "hematochezia", "hereditary hemorrhagic telangectasia", and "hemolytic uremic syndrome"...the talk is always going to be a bit "dry", for me adding lots of pictures and graphical flags (like highlighting the areas of interest in a table filled with big words) helps ease the plate of crap you are serving down the audience's gullet. Anyways I'm glad it's over...honestly I'm glad this whole GI elective is over. If I get the chance to do it again, I would, but not because I like it. I generally dislike everything "GI", it's a lot of talking about pooping and dieting, still though I would do it again because it's one of those areas I think most docs are a little weak in (who really likes managing the crazy patients with GI problems...and most patients with GI problems ARE crazy - chicken or the egg first? I don't know). Whatever, I'm done with it...at least for a little while, and vacation awaits!!! I'm out.

Newbie Doc