Author Affiliation: Department of Family Medicine, T. J. Samson Hospital, Glasgow, Kentucky.
If you will just listen to patients, they will tell you what's wrong with them. And if you will listen a little longer, they will tell you what to do about it.—Tom Brower, MD
In retrospect, it might seem improbable that one of the most memorable and lasting lessons learned in medical school by this primary care physician was spoken by an orthopedic surgeon. Yet, his imparted wisdom has followed me into virtually every patient encounter since then.
A.W. is a 60-year-old man with a multiplicity of problems including hypertension, diabetes mellitus, and chronic, disabling back pain. After numerous, unsuccessful back surgical procedures attempting to relieve intractable pain, A.W. had been rescued from the brink of suicide by implantation of a continuous infusion morphine pump placed into his low back. Since its implantation several years ago he had regained significant quality to his life.
Days before Christmas on an icy driveway, A.W. slipped and fell backward, striking his low back in the vicinity of his pump hard against the frozen pavement. Within 24 hours he began experiencing an increase in generalized pain and discomfort along with vomiting, diarrhea, anxiety, and a sensation of “shaking all over.” On examination by a primary care physician, he was admitted to the local hospital for further workup, including cardiologic consultation for chest pain. After an extensive evaluation with negative findings, he was discharged, only to return to the emergency department (ER) 3 days later with worsening symptoms. In the ER a diagnosis of hypokalemia was made, and he was again discharged home with a prescription for potassium.
A.W.'s wife oversees all aspects of his care and was omnipresent during his entire medical odyssey. She related that his pump allows for 2 extra doses per 24 hours as needed by activation of a monitoring device. After onset of his increased pain subsequent to his fall and on activating the monitor, the device indicated that it was malfunctioning. On contacting the office of his pain specialist, who practices in a city 90 miles away, A.W. was told that a new device would be shipped to him. The new device arrived after his hospitalization and subsequent ER visits and again indicated a malfunction. At this point, A.W. returned to his pain specialist, who confirmed that his pump was nonfunctional, and his symptoms indeed were representing classic narcotic withdrawal.
A.W.'s wife insists that at every step of their journey she informed all health care providers that her husband was maintained on a morphine pump and that his symptoms occurred after his fall onto the pump. She expresses great frustration in the feeling that no one listened to her and felt that “I was beating my head against a wall.” Much science and technology, with associated expense, was used to eliminate conditions he didn't have, while the art of listening well might surely have led to a faster, cheaper remedy.
Correspondence: Dr Bale, Department of Family Medicine, T. J. Samson Hospital, 205 Norris Ct, Glasgow, KY 42141 (firstname.lastname@example.org).
Financial Disclosure: None reported.
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