Friday, September 24, 2010

Tough case

I'm reading a hospital discharge summary, and discovered this quote from a neurosurgery resident:


"The patient was given Valium 10mg and Haldol 10mg. He then become lethargic, with decreasing oxygen saturations. The cause of his sudden lethargy was unclear. A head CT was unremarkable, and a STAT neurology consult was called."

37 comments:

Anonymous said...

Hmmm... 10mg of diazepam AND 10mg of haloperidol? The patient should be conscious, alert, and possibly dancing...

Sue

Eileen said...

They didn't think it might have something to do with a reaction to the medication then?

WV - drogerag - a German version of what the patient experienced maybe?

Jacqueline said...

Wow....just...wow

Leigh said...

I am not a medical professional of any kind and I know what is wrong with that statement. Anyone sure this resident actually passed his exams? Please tell me, Dr. Grumpy, that you gave him an appropriately smug and smartalecky (is that a word?) response?

Grumpy, M.D. said...

I wrote the same thing I always do:

"Thank you for this interesting consult."

C said...

Nap time...zzzzzzz

Sunflower RN said...

Bang head against wall!!

I guess they wern't listening to the nurses or anyone else for that matter.

Bang, Bang, Bang!!

PhDnotMD said...

Like Leigh said: no medical training at all and even I knew what was going on! Wow.

Kat's Kats said...

@Sunflower RN Those who listeneth not to their nurses are doomed to
a) have their patients get worse and go to another doctor
b) have their patients think they're idiots and go to another doctor
c) have only idiotic patients who will do stupid things thus making them go bald at an early age
d) have no respect from their peers
e) all of the above

Of course, this is just from one patient's opinion. Mind you, due to circumstances, I've seen a plethora of doctors in my time. Some of them I've fired for this very reason... and then called the insurance company to tell them why I am changing physicians. I am a bad bad woman, I am. OTOH If I have a good doctor, I interact with them as part of my medical team, try to ensure that they get medical records from all of my other doctors, have a list of all of my medications (OTC or scrip), give all of my symptoms (my ped told me to do this in case of differential diagnosis), and follow their orders as we have discussed. Although nowadays I often ask them to write them down so I don't forget them. Harrumph!

misman - one who should act as if they are part of the human race but just misses the point.

bb said...

I would have been okay if he/she were not a neurosurgery resident but fresh out of med school simply because at this stage of the game, he/she's already had enough experience to know this. Heck, no medical training is necessary to understand that concept, LOL. Or maybe he was just tired.

Must have been annoying to be dragged to the hospital over something like this.

Betsey said...

The only reason this would not be flagrant idiocy is if the primary MD/team are the ones who ordered the meds and then flipped out and consulted neurosurgery and neurology. In that case, I can see dictating the note completely straight, because the only alternative is bludgeoning someone to death with the patient's chart. At which point I would promptly be called for a consult on my target for traumatic brain injury.

OTOH, if, as it sounds, the neurosurgery resident is the one who ordered the meds and then flipped out when they worked?
I don't know upon what planet that individual would be competent to practice medicine, but it certainly isn't this one.

Anonymous said...

typical surgeon....

Miss Kismet said...

I'd hate to see the person who wasn't lethargic after that particular cocktail O_o

RealMD said...

I had a similar encounter but with a neurology resident. He decided to give an elderly man with already altered mental status 2mg of Dilaudid and 4mg of Ativan before a lumber puncture. I was the senior resident on call for the ICU and got to intubate him an hour later when his pCO2 was 110.

Grumpy, M.D. said...

RealMD- I agree with you. For making a decision like that, I would have intubated the neurology resident, too.

Anonymous said...

the resident really cannot dictate that, after insisting on overmedicating the patient, the idiot attending demanded a stat neurology consult. or it could have been a clever ploy to get the patient transferred to your service, thereby reducing the neurosurgery workload

Rich said...

Seriously ? I have a little medical training, and I know right off hand what was wrong.

Anonymous said...

That's where a $5,000,000 liability policy comes in handy?

This is where it's handy NOT to have Pyxis (automated dispensing cabinet) in the radiology suite.

This is where memorization of Beer's Criteria is advisable.

Hopefully this is a warning about why propofol is NEVER administered without adequately trained medical personnel and access to oxygen or respiratory support?

This is where haloperidol becomes a DO NOT EVER USE again drug.

me said...

Why I always hated working at teaching hospitals...

ERP said...

Well, although technically the resident is probably smart, once they start surgical residencies, they lose all brain function related to non-cutting activities.

Swami Dil said...

In my expert non-medical-professional opinion, a head CT on the resident is called for here.

Grumpy, M.D. said...

In fairness, I don't know if the dictating resident was the one involved in giving the meds, or calling the neurologist. He may have just been the poor sucker who was told to do the dictation, and was reading the chart.

Anonymous said...

Hi Dr. Grumpy! (first time commenter)

Your post reminded me of a resident-dictated H&P I just read this afternoon. It included this section:

Surgical History: Appendectomy, Tonsillectomy, Chronic Bronchitis.

Huh?? (Hey--I know we were all residents at one time.. but I giggled anyway.) I'm sure at some point someone laughed at my H&Ps! Erhh.. Hmm.. maybe they still do.

Dragonfly said...

Bahaha. Though as an intern/resident I wonder if someone more senior might have panicked and asked for it "to be safe". Not sure what happens over there but here we don't usually ask for consults without running it past someone more senior. Depends on how senior that resident was though.

But MAN, cause, effect. Its all there :-)

SECRET PEPPER PERSON: said...

OOOHHHH! Can I have 10 and 10? Pick Me! Pick me! I long to be lethargic.

Mrs A said...

no wonder the insurance companies are charging a fortune, is there no accountability ??? How can the cause of the patients lethargy be UNCLEAR??? And to then call a neurologist???
Dont get sick people.

Outrider said...

That will sedate a horse. Literally.

South said...

"Dick F***ing Tracy!"

terri c said...

Hospice chaplain wondering if the patient had formulated advance directives before this Baffling Episode. Haloperidol is still a useful drug in palliative care but has to be deployed by someone with a brain.

On reflection the resident might need the advance directives sooner.

MOJITOGIRL said...

Duhhhh!!!! that was enough to take down a small village!!

And to think that the neurosurgical resident will someday in the VERY NEAR FUTURE grow up and become a neurosurgeon who thinks he's God's gift to the planet because of his specialty!

Heaven help us all......

Dr. J said...

Well....at least they didn't take him back to the OR

Don said...

I'm not a medical professional, so I surmise from reading the comments that the two drugs are both seditives?
Every field has their own lingo that people in it understand, while those outside it can try to puzzle it out as a mental exercise.
For example, in my own field of mechanical design, I spent the last several days wrestling with "mating conditions". And no, I don't mean giving the pieces of hardware Vi@gr@ and chocolate, as well as a motel room key.
I'm off to Wikipedia to look up the two drugs.

Anonymous said...

neurosurgeons are not god's gift. they are god incarnate.

Anonymous said...

Resident gives patient 10 mg diazepam and 10 mg haloperidol, and wonders why the patient suddenly becomes lethargic?! Lights are on but nobody is home - this is someone who should definitely not be a brain surgeon, in any sense of the term.

(Although...I must admit that a smaller dose of haloperidol would likely be more effective for my chronic insomnia than crappy old Ambien CR and all the other stuff I take along with it...)

WV: pachaut: plattdeutsch for "passed out"

Anonymous said...

Sooo...WHY did they give the patient the diazepam and haloperidol, then? What did they expect those drugs to do?

The Mother said...

Yep. Completely unclear. I think we need a neuro consult.

cushing said...

As a neurosurgery resident I dictate similar things all the time. Trauma patient comes in a little confused and combative (likely drunk) and the ER gives him sedation to calm him down. Then I get a stat page to come assess the patient with a "rapidly declining neuroexam" only to find a snowed patient with a negative head CT. I would be amazed if the neurosurg resident gave the meds, we are stingy bastards when it comes to sedation.

 
Locations of visitors to this page