Supervising Editor: Brian Zink MD.
Doing the “Right” but Difficult Thing
Version of Record online: 20 SEP 2012
© 2012 by the Society for Academic Emergency Medicine
Academic Emergency Medicine
Volume 19, Issue 10, page 1218, October 2012
How to Cite
Sucov, A. (2012), Doing the “Right” but Difficult Thing. Academic Emergency Medicine, 19: 1218. doi: 10.1111/j.1553-2712.2012.01442.x
- Issue online: 15 OCT 2012
- Version of Record online: 20 SEP 2012
Reading the chart, I groaned—chief complaint of “needs a PICC (peripheral indwelling central catheter) line.” The nursing note indicated a 20-year-old woman with possible recurrent/chronic Lyme disease.
As I walked into the room, I tried not to let my skepticism show or project in my voice. I introduced myself to the patient and her mother, and they proceeded to give me details of 2 years of joint pains and frustration. The patient had been treated last year with a standard course of antibiotics for a rash and positive Lyme titers and had done well. Only recently had she developed symptoms again, and the connection between the Lyme disease and the joint pain seemed a bit tenuous. Remembering what our communications project had taught me, I struggled to be empathetic and supportive in my responses to their questions and fears.
I was willing to go along with the plan, but the logistics were the real issue. Getting a PICC line placed is never easy. After multiple calls, I found that I could either admit the patient to have it placed “maybe tomorrow—it depends” or refer the patient to outpatient vascular interventional radiology (VIR). This seemed promising, and I returned to the room delighted to have a plan.
At that point, I was confronted with the unfortunate reality—no insurance. VIR might be able to place the PICC line, but no one would provide the antibiotics. If I admitted her, she might have to stay for weeks—the situation was starting to get absurd.
Another alternative was intramuscular (IM) ceftriaxone daily—somewhat more realistic and not requiring a PICC line at all. I placed a call to the primary care provider (PCP), whose office could not give IM medication once, let alone daily for several weeks. I knew the emergency department could do this, but since I was not clear this was medically appropriate, I wasn’t about to propose this.
I returned to discuss options. Not surprisingly, insurance came up quickly, and I did my best to deflect them from focusing on this. I led them back to the medical issues and helped them understand that there was little time urgency to this, that I would call the PCP the next day and then get back to them with next steps.
The following day, the PCP acknowledged that it probably was not Lyme, but was not sure what else to do. I called the patient’s mother and informed her that the PCP would discuss next steps over the phone and that she was not lost in the system. She seemed cautiously accepting of the plan, but I could hear the frustration and tension. My doubts about the plan grew after I hung up the phone, and I wondered whether I had done the right thing or not. Had I projected my own beliefs into this case too much? Was I truly being the patient’s advocate? I had not provided all the options available for them to decide. Was I looking out for the system and the “public” more than this patient? Had I “harmed” other patients by my attention to her? I struggled to justify my actions to myself, my wife, and the residents.
When I called the mother 3 weeks later, she had not been seen by the Lyme clinic yet and was getting more worried that her daughter might be permanently harmed by the delays. She was hoping to get insurance for her daughter, but was not too hopeful. Another month later, I spoke with the mother who told me that the patient had been diagnosed with recurrent Lyme and was going to be getting chronic antibiotics through a hospital-associated clinic. I felt relieved that good clinical as well as public stewardship outcomes had been achieved, but frustrated that it took so much effort to achieve that outcome. We as emergency physicians struggle daily with getting our patients to the proper place for the correct treatment; on this day, I had a window into the struggles that patients and their families endure as well.