Sunday, April 17, 2011

"Always use your own clinical judgement..."

Here's a story of how I learnt a good lesson in the practice of medicine recently.

There was this patient who'd been coming to my hospital's Casualty OPD since the day I joined. He'd turn up every couple of days, at different times of the day, complaining of pain in his right knee joint.

He would walk in with this bandage tied around his knee and complain of unbearable pain. And then ask for painkillers. My senior told me he's been coming like this for quite some time, has been evaluated by many Doctors, who all say there's nothing wrong with his knee. He'd probably gotten addicted to the pain killers, or that's what everyone thought was the case. He would never go to the regular morning OPD, he just came to the Casualty OPD everyday.

So over the next month, I watched him come in multiple times. Sometimes we just gave him the drugs, sometimes we told him there's nothing wrong with him and shooed him off, sometimes we gave him placebos. But always, he would be back for more pills.

Of course, there's no such protocol followed like counseling such a patient or giving him a psychiatry reference. No one thinks it is necessary or advisable to do such things. Hell, no one even gets such ideas.

Pretty soon all the interns, all the Doctors, and all the staff started recognizing him well. Most refused to give him any treatment whenever he turned up.

One time I saw a Doctor tell him that he should wait outside quietly, come in only when he saw that particular Doctor (himself) over there, only during his shift, and then he would get the pills he needed. The Doctor then proceeded to prescribe Diazepam to him. Was that some kind of weaning tactic? I don't know. I didn't ask. We don't generally question our supervisors about their prescriptions, or about anything for that matter.

Then, after a month or so of this, he now came in during one of my night shifts and started complaining of pain in his left knee joint. Of course no one batted an eyelid or probably even noticed the difference. He came in  with three people carrying him, complaining of severe pain.

I told the on-call Medical Officer that he's been coming with similar histories all month long, since he (the MO) didn't seem to recognize him. Even the nurse recognized him, and the tons of prescriptions he had with him showed the same thing. The MO still listened to him, elicited his history. The patient mentioned that he had had a fall 4 days back, and since then developed severe pain in his left knee. This ticked something off in my mind since I clearly remembered him with a bandage over his right knee in the past.

The MO then examined him, and noticed there was a slight swelling over the knee joint. That, combined with the history, was enough to convince him. He sent him for an X-ray, and called the orthopaedician on-call to have a look. It was 12.30 am at that time.

The Orthopaedician on-call came in, took one look at the patient, got livid and started shouting at him. The patient it seems, had been coming in two-three times per day, everyday, for the last three days, complaining of pain in his left knee. But every one knew that he was a so-called addict so they just ignored him, or just gave him pain-killers and sent him off. The orthopaedician was furious that he had been called at midnight once again for that patient.

In the meanwhile, his X-Ray came. It showed a fracture lower end femur, with increased joint space, probably due to ligament tears. This man had been walking around with a fracture for four days now and no one had thought about evaluating him. In his defense, the Orthopaedician said that the patient had not given any history of trauma or fall before that particular day, so he had not thought about getting an X-ray.

Even after his diagnosis, the patient didn't want to get treated as he didn't have any money. He kept asking for some pills so it would be alright. When we asked him about addictions while taking his history, he confessed that his only 'addiction' was that he needed to take pills at night to sleep.

Finally, the patient was advised to temporarily get a cast, and arrange for more money for further surgical management, or go to a bigger hospital where a Trust Fund could be used to pay for his treatment. After he left, the MO on-call told me: "You see now what a good thing it was that I sent for that patient's X-ray? You should always use your own clinical judgement rather than listen to what others tell you. That's called practising good medicine. I saw that he had a swelling over his knee, so I sent him for an X-ray."

And that was one of the best lessons I have learnt in a long, long time.


  1. Oh, yes. This happens so often. And yet, there are several 'that' patients too. Discretion and evaluation! I am reminded of those lines from the first page of Hutchison's clinical methods: "..from too much zeal for the new and contempt for what is old.."

  2. And, even in life we must stick to what our soul asks us to do instead of following the crowd.

  3. Its a sorry state that we don't "treat" chronic cases in our setup, but rather just try to alleviate the pain. People need to realize they're being paid for their efforts, not just for giving the patients some time

  4. What about the right knee pain?

  5. @Anonymous: The right knee pain seemed to have magically disappeared for the time being!