Saturday, June 20, 2009


On a trip to the emergency room yesterday I caught this glimpse of the problem.

The young woman I saw was a renal dialysis patient transferred from an outlying suburb due to left sided pain and severe anemia. Gynecology was consulted immediately based on the results of a CT scan done at the other hospital.

I will admit, I looked through all the lab tests and read the CT scan report before I spoke to the patient. She even had a battery of blood work ordered by the physician who accepted her transfer. He had not seen her yet either.

She was a 24 year old woman with systemic lupus erythematous. This is a debilitating disease that can affect every organ but usually goes straight for the kidneys. She was currently on dialysis, a whole bunch of blood pressure medicine and the anticoagulant Coumadin. She was married and yes, she was sexually active, using condoms for contraception. She and her husband had a four year old son and she had a miscarriage 2 years ago when all her problems with the lupus began.

After talking with her, I took her blood pressure and pulse both sitting and lying. They did not change very much. She did not "tilt," a term used when the blood pressure decreased and the pulse rate increased as the patient sat up. This was a good sign.

My first problem came when I ask the nurse if a pregnancy test had been done since I could not find one in any of the lab work from either hospital. "Well get me some urine and I'll order one," what the terse reply.

"She doesn't make urine. She is a dialysis patient." I calmly told her. "There is all that blood work. If you will show me how to enter the order into the computer I will call the lab and ask them to run it on the blood they already have."

"Well, hasn't she had a hysterectomy or something?" The nurse frowned at me. I could tell I was too much trouble.

"No. She is still menstruating. She has a four year old and a miscarriage two years ago." I waited patiently. "After you do that I will need some help with an exam."

"Why do want to do an exam? She already had a CT scan."

I could have said something like "well, I am a doctor and I am writing up this history and physical exam." I didn't. I got all the things I needed and when into the room.

In the room the patient told me that no one had examined her at the other hospital. As a matter of fact she had not had a pelvic exam since her miscarriage. I was busy setting everything up. When we were ready the nurse said, "I haven't ever seen this before. What do I do?"

"Just stand there," I replied as I positioned and draped the patient. Five minutes later I was done. Helping the patient, I thanked the nurse.

The patient was not very tender. Her blood count was low. Her pregnancy test was negative. All the fluid on her CT scan was probably blood from a ruptured ovarian cyst. Because she is on the Coumadin to prevent her blood from clotting, bleeding was far more likely than in most people. I explained to her that we would need to watch her blood count closely but it had been stable all day while the transfer was taking place so she probably would not need surgery.

As I was leaving the ER, I thanked the staff for their help. There were three techs and an RN. Each had a computer console where they could look minute by minute at everything that was going on in each of the patient rooms. Pulse, blood pressure, EKG tracing, oxygen saturation and all of the laboratory tests right there at your finger tips. Modern medicine.

Still, there is nothing like seeing, talking to and examining the patient.
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