Thursday, September 13, 2018

Frail

Like most neurologists, I do EMG/NCV's. This is a test that involves needles and electrical shocks.

It's nobody's idea of a fun test, but we do get a lot of information from it, and for many disorders it's the best test there is for sorting things out.

As a result, it's not uncommon for me to get a fax from another physician's office asking me to do one on a patient. They send over the insurance info and all, and Mary calls the patient to schedule it.

About a week ago I received a fax from Dr. Livingston. It was an order sheet that said "Please do EMG/NCV on Mrs. Geri, possible hand pain." Mary called her number, reached her daughter, and set up the appointment.

Mrs. Geri came in a few days later. She was in a wheelchair, pushed by her daughter. Advanced Alzheimer's disease and incapable of doing anything other than mumbling gibberish. Frail, maybe 90 pounds. Occasionally she'd randomly wave one or the other hand back and forth.

I asked her daughter why Dr. Livingston wanted the test, and her daughter told me it was because of the intermittent hand waving. She hadn't complained of pain (or pretty much anything else).

And... I couldn't do it.

Sorry, Dr. Livingston. The $250 I'd get for putting this poor old lady through an unpleasant test that she couldn't understand seemed more like an exercise in greed and torture than a diagnostic medical procedure.

Not that I really blame Dr. Livingston. I'm sure he was just trying to find out why she'd occasionally wave her hands, but to me it was immaterial. Even if I found something, after putting this sad lady through unneeded discomfort, what would really be done with that knowledge?

I explained this to the daughter and sent them on their way. The billing sheet and her insurance info went into the shredder. I took a loss on the hour and sent Dr. Livingston a polite letter explaining why I hadn't done the test.

I'm sure he can find another doctor to do it. Maybe someone hungrier than I, or less willing to ask questions.

But I just couldn't do it.

33 comments:

Anonymous said...

I would like to hope that the daughter listened to your reasons for not doing the test and decided against doing it at all. And--in an even better universe-- that Dr. Livingston might listen to what she tells him about her interaction with you and rethinks his approach with similar patients.

Officer Cynical said...

I had an EMG after a fall during a foot chase of a crook. For those who've never had one, this is how it's actually done:

1. A railroad spike is inserted its entire length under the skin, one per inch starting at the ankle and proceeding up the leg to the level of the hip.

2. After each spike insertion, 10,000 Volts of electricity are passed through the spike into your body.

3. Each spike insertion lasts 2 hours.

4. With each spike insertion, the inserter laughs hysterically as you writhe in pain.

5. When the EMG is done, the inserter curses you for acting like such a baby, kicks you out of the room, and keeps your clothes for donation to the Salvation Army.

This is how it really is. Don't let anyone tell you different.

Suzan W said...

Having recently had both hands tested I am so pleased you showed integrity and reused to test this lady. Poor thing did not need to experience that.

Ruth said...

While I don't enjoy needles I'm not usually at risk for fainting because of them.

The time they decided they needed to test my hands is the closest I have ever been to fainting. And it showed because the doctor stopped everything and told me to put my head down. When it was done I made it out of the office to the hallway, where I had to sit down for several minutes before I could make it into the elevator.

I'm very glad you passed on this.

bobbie said...

Bless you, dear man!!!

Anonymous said...

You are a wonderful person.

Anonymous said...

Thank you, Dr. Grumpy. I hope the patient's daughter said that, too.

Unknown said...

I love you.

Anonymous said...

So what I'm extrapolating from your kind and generous act is that I should shut up about my idiopathic peripheral neuropathy and not tell anyone my hands tingle.

Susan in Dallas said...

Thank you, thank you, thank you.

Cathie from Canada said...

So I have now read up on EMGs on Dr. Google, and I can definitively say that I have added this test to the already-lengthy list of medical tests I never want to have.
I wonder sometimes if there should be a course in medical school titled "Its Your Turn Now!" when prospective doctors have to go through at least two of the somewhat unpleasant tests they will likely prescribe for their patients -- a barium enema, a colonoscopy, a spinal tap, maybe also I'll add now the EMG -- just so that they won't be prescribing these thoughtlessly or without some sympathy at least.
During one of her last hospitalizations, my elderly aunt finally had a doctor who did not permit her to undergo a spinal tap which a resident had wanted to do, basically on the grounds that in her case the test wouldn't really tell anybody anything they didn't already know. I think its a useful metric to apply to any of the unpleasant medical tests expected of patients.

Ann said...

I love you for this.

southern doc said...

Good job.

In defense of Dr. Livingston, I'm guessing he probably had about 14 medical problems, 10 script refills, 5 pre-auths, and 28 quality measure to address during a 12 minute visit - anything new that's mentioned gets an automatic referral out.

Anonymous said...

What a wonderful, kind and HUMAN thing you did. Thank you for being the exception in today's messed-up world. I won't forget this blog.

Packer said...

The only thing wrong with me is that I have become very old and I am going to die , said by my 93 year old mother days before her death and at the time she refused a surgical procedure of dubious value. Thank God she had the sense to make the call.


Anonymous said...

Outstanding clinical decision. Unlikely to very unlikely that the test result would change current therapy. Might do a critical-to-survival test in that scenario, but here? Nuts.

We need more Mongolian yak herders in medicine.

Anonymous said...

Thank you for being a decent, caring, wonderful human being.

A. Marie said...

Grumpy: Loud cheers. If there was a Compassionate Doctor's Medal of Honor, I'd nominate you for it.

Moose said...

Your problem, Dr G, is that you have compassion. Stop this right now, or you'll never be super rich and able to retire to some expensive island paradise so you can hide from your children, by then doing more grown-up insane things.

I had one of those EMG tests and I found 95% of it amusing and not painful at all, until the very end when another doctor came and zapped the crap outta me. Note that after 3 (now 5) kidney stones and MRSA in one leg, I can tolerate pain, so maybe that's why it didn't hurt until the end.

The majority of the test was them sticking something under my skin and making various parts of me jerk without warning -- but it didn't hurt. Most of the time, no matter what they were expecting, one of my legs jerked. I found this hilarious and kept laughing, and the people giving me the test were about ready to contact the psychiatrists.

My body is super weird.

gloriap said...

That was very compassionate of you, Dr. Grumpy. On behalf of little old ladies everywhere, thank you.

Heidi said...

Careful, Doc. You're dangerously close to restoring my faith in humanity.

Mad Jack said...

You're a good man, Grump. Keep up the good work, and if you're ever in Columbus, OH look me up and I'll take you out drinking. You'll have a great time.

Ms. Donna said...

On behalf of the lady, Thank you.

Me? Well, my mind is not intact if I let you within 1000 yards with those needes. I hate needles.

Loren Pechtel said...

The doc who requested it obviously doesn't do the test--does he perhaps not realize what it entails for the patient?

Terry Daugherty said...

I had one of them done years ago because my hands and feet kept shaking. Mind you I had been in a coma for three months, was recovering from sepsis and had been paralyzed and was just regaining the ability to move. All through the test the Dr kept hollering at me to hold still and stop moving my hand or foot. If I could have talked d have let her know what an idiot she was. Um, hold still? You're doing the test because I can't hold still!

Macha said...

Brightens my day that a physician exists who refuses to do an unnecessary procedure on a patient who can't give informed consent. Thanks for your integrity!

Rich said...

Thank you for your compassion and common sense. Far too little of both in today's world.

Anonymous said...

How reasonable, how refreshing. Thank you for our outlook.

Similar story, my mother had terminal cancer. She wanted her teeth cleaned. She could not find a dental office that would just clean her teeth. They all insisted that she need the x-rays that she hadn't had in two years. She told them there was no point and she refused to waste her money but they wouldn't back down. She died with yellow teeth. I wish I could have found a reasonable clinic. They don't exist in this town any more.

Sabre22 said...

I have had both hands tested twice. left leg twice for sciatica. The i described it is it lights your eyeballs up from the inside.

Anonymous said...

My father was dying of pulmonary fibrosis from the unknown devastating side-effects of methotrexate. The medication left him mobile in his later years to enjoy the physical activities of life with his grandchildren despite debilitation of rheumatoid arthritis, participating in walking his dog, spelunking, hiking, climbing, travel, etc.

We didn't know how much time he had left. He was on oxygen 24/7 and his mind was going, increasingly confused due to hypoxia. His wife was adamant that he make his semi-annual appointment to the podiatrist for plantar fasciitis which plagued him from his late teens when he participated in a 850 mile march up the Alaska-Canada highway in the early '50s (there wasn't much in the way of Army-issue hiking boots at the time!). We all got him to the appointment and the podiatrist helped up on the examining table, and his feet got a real working-over. It still brings tears to my eyes to recall how gentle and supportive she was to the old codger with foot problems in that final visit.

Anonymous said...

I've been reading your blog for years, and it's the posts like these that keep me coming back. I am so very grateful there are people in the world like you. Take care, Doc.

ronstew said...

Ever hear back from Dr Livingston?

KJL said...

My litmus tests are:
Will this help you live longer? and
Will this help us find ways to make you feel better?

Thank you for being one of the good guys!

 
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