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Emergentology: Is There a Doctor in the House, er, Family?

Walker, Graham MD

doi: 10.1097/01.EEM.0000446054.34736.47

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications, and The NNT, a number-needed-to-treat tool to communicate benefit and harm.

Figure. D

Figure. D



I gave the commencement address at my medical school graduation, and started off by thanking the friends and families who suffered through medical school with us, by being patient with us when we were late, by tolerating our medical chitchat at parties, and by putting up with us for missing birthdays, anniversaries, and special events.

I would like to continue to extend this thankfulness to friends and loved ones today. As attendings we still work nights and weekends, and still get out late from rough shifts, but hopefully our disruptions are less surprising (or maybe just more expected). I'd like to think, however, that we're sometimes able to make up for arriving late for dinners and missing holidays when a loved one is sick.

My 87-year-old Nana (my Dad's mom) is one tough cookie: she grew up on a farm in rural Missouri during the Great Depression, and has cooked Thanksgiving and Christmas dinners for her extended family with 10 pounds of hand-mashed potatoes, rolls from scratch, jam, green beans, corn, stuffing, gravy, and turkey for more than 30 years. She still gardens, and her past medical history consists of heartburn and hypertension. She has made it through broken hips and shoulder surgeries without flinching.

Recently, she called me twice in 15 minutes (which I've only ever known her to do on my birthday) to tell me that she had fallen multiple times, had a throbbing headache, and needed assistance to walk. I knew something was wrong. You don't cook Thanksgiving dinner and then three weeks later need to hold onto your daughter to walk without something being up. Subdural? UTI? Metabolic problem?

We had the answer after a few hours in the ED: sodium, 120. Ta-da. After a little IV fluid, stopping her hydrochlorothiazide, and restricting her water a little, Nana was feeling better. She was ready to go home, and was walking by herself. She also was scheduled for an MRI for some reason. From 1800 miles away, I called the hospitalist to discuss her care. Turns out they had found some records somewhere showing some carotid stenosis, and an ultrasound in-house showed persistent narrowing. They wanted to “do an MRI to see if she was having small strokes causing her to be weak, and if she was, then she might need an angiogram.”

Did she have ataxia? Or unilateral weakness? Or signs of old strokes on her head CT? Didn't the sodium of 120 explain her difficulty walking, given that she felt better and was walking better with a higher sodium? “Yes, it does explain it,” the hospitalist acknowledged. “I'm not the one who admitted her, but they were just worried.” I let Nana decide if she wanted the MRI after discussing it with her. No surprise: she was discharged a few hours later.

Enter benefit one of being a physician: putting the kibosh on an overly aggressive workup or treatment plan. We all know the amount of CYA medicine that happens on the wards, but we can prevent it from happening to our loved ones when the case is fairly straightforward. Obviously, this is a fine line. You don't want to be the jerk trying to diagnose and treat your grandmother over the phone and you don't want to prevent her from getting necessary, appropriate testing; we've all heard those stories. But I couldn't help imagining Nana getting an MRI, then getting an unnecessary angiogram, invariably flicking off clot or dissecting a blood vessel and causing a stroke. She has made it this far on few medical interventions and just a few medicines; her body's been doing a pretty good job on its own.

We physicians are also fortunate that we can interpret the medical language and translate it — in context — for our family members. I took my grandmother to a nephrologist a couple weeks later, and after he asked her some questions about NSAID use, fluid intake, and urination, we came up with a medical plan for her hyponatremia: cut back the NSAID and the fluid to 60 ounces a day, and give the Coreg a try.

Back at home, this translated to talking with her about her aches and pains and trying to come up with a different plan besides her ibuprofen and naproxen because she thought the Percocet was too strong. And I explained that 60 ounces was about a half-gallon, one large pitcher, or five cans of 7UP. It's difficult to imagine any non-medical person being able to hear all the doctor's recommendations and figure out what they mean in the span of a 15-minute clinic visit, not to mention then being able to apply them to their daily lives.

Obviously, we may be a bit subjective in our assessments of family members, miss the forest for the trees, or perhaps not show enough sympathy to our friends and family (my friends never seem to like my recommendation of “take ibuprofen”). But as long as we don't dive too deeply into diagnosing and treating our own family members and loved ones, we can be advocates for them. When we take off our physician hats, we want what all our patients' family members want: a diagnosis and treatment plan that will make them feel better.

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