Sunday, March 2, 2008

Excuse me, aren't you on call?

A couple of days ago, a patient of mine in the pain clinic had a seizure. This was after an epidural steroid injection. I didn't use any local except for skin infiltration. Like many epidural steroid injections he was olders. In addition he was a diabetic and a smoker.

After I checked my own pulse and reassured myself that I hadn't done anything wrong (unless you believe epidural steroids are inherently wrong), I thought what the hell is wrong here. So the differential included:

1. A sycopal epidode because of pain followed by a seizure secondary to cerebral hypoxia.
1a. In a diabetic smoker a sycopal event associated with cardiac ischemia.
2. Seizure secondary to a cerebral mass lesion exacerbated by increased ICP during epidural injection.
3. Electrolyte abnormality
4. Hypoglycemia
5. Others that I haven't thought of.

Although the seizure only lasted about 15 seconds and he wasn't very post-ictal afterwards I felt that he probably warranted further investigation and probably some observation. So I paged internal medicine on call.

The internist answered my page right away and I told him the clinical scenario. His response was, "well I don't know when I'm going to have time to see him". He told me to order some blood work and if everything was normal to send the patient home with no follow-up.

I was somewhat astounded. This wasn't a newer physician but one of the older more "respected" members of the medical staff.

I have some empathy for internal medicine. I spent 3 months on a general internal medicine service as a resident. They tend to be a dumping ground for every type of medical problem without a lucrative procedure attached; for those people who don't have much wrong with them except that they can't be sent home etc. They make a lot less than their procedurally inclined colleagues. Fine that is a problem that is at least 20 years old. I shouldn't be put out because you haven't figured out how to deal with this.

It strikes me that general internal medicine like family practice before them is in the process of getting out of the hospital and in general in looking after sick patients at all. I am told that most of them now only round 3 times a week on their inpatients which of course means that their patients don't get discharged as quickly which has meant medical patients spilling over onto surgical beds. Instead as family practice focuses more on looking after patients who really don't have anything wrong with them, internal medicine is sliding into the niche of looking after patients who only have a little bit wrong with them but are getting paid consultant rates for doing so.

Take the traditional pre-operative medicine consult. This was a cash cow for internists in the past with every consult ending with, "Fit for surgery, avoid hypoxia and hypotension." Now less than 10% of those consults were actually necessary or useful but now we very often can't even get those 10%.

I brought this up with the chief of my department who suggested reporting this to the licensing body. I am mulling it over but I really can't bring myself to rat out another doctor for only following what has become a trend in medicine.

So I put it on my blob

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