Wednesday, November 21, 2007

I was made to break one of my rules yesterday. And I wasn't happy about it.
An out-of-towner, who was referred to me for work-up of his hypercalcemia, labelled 'primary hyperparathyroidism'. Except in this case, his referring physician did a sorry-ass job of working this up.
From a mile away, you could tell this was from lymphoma. Thus, it was no surprise that his PTH was undetectable. That his sestamibi (pre-ordered) was normal. And his 1,25 Dihydroxyvitamin D was sky-high when his 25 levels low. Aside from fluids and some steroids, what is else is an endocrinologist to do? Except to consult a hematologist.
Except the waiting list is a month out. And he's from the other end of the country. And so, my consultant made me admit him to a general medical service. This otherwise well patient, who had the cheek to complain to me about how he had to wait a few hours for a PET scan (also ordered by someone else. Some people wait months for this).
I felt angry, and made it a point that I disagreed with my consultant. That, in my opinion, admitting someone into the hospital to 'facilitate evaluation' is a clear misuse of infrastructure. Having the inpatient hematology team see him, instead of the outpatient team, so because it's Thanksgiving this week, and things move slower in the clinics.
When I called the admitting resident, my first words were "I'm sorry, but I'm being made to do this..."
Because we've all been on the receiving end before. Between sick and unstable patients, you admit someone who's stable, who doesn't need to be in the hospital, purely out of convenience. It's no wonder that many US hospitals are losing money (we make money from the outpatient clinics, apparently). Besides, not properly triaging patients lead to poorer care for those who really need it. Last I heard, this patient was complaining about the TV programming and food in the hospital. I hate to imagine what the other 'real' inpatients have to deal with.
No, I don't blame the patient. I blame the referring physician, who didn't bother doing his work. And in the process a patient flies in to town to see the wrong doctor and has to wait before he sees the right subspecialist.
But, alas, I can only do what my boss tells me do to.

7 more months.

I'll be a consultant in 7 more months....


Blogger Palmdoc said...

How high was the calcium level?

3:29 PM  
Blogger vagus said...

calcium was 12.4. Not too bad, with minimal symptoms.

9:16 PM  
Blogger Saiful said...

What was the PTHrP assuming it's elevated? Did you check PPE/Bence-Jones Protein; serum ACE?
Isotope bone scan? I guess you guys go straight for the PET scan in the States.
We had a similar case recently.

3:48 AM  
Blogger vagus said...

PTHrp undetectable. SPEP normal. we didn't bother checking ACE- he already had a BM Bx documenting the lymphoma.
Bone scan was negative.
as i said, the PET was ordered by his referring physician; most of us would not do this test at this point.

8:02 AM  

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