Horsing around

In a fictitious hospital, a momentary misunderstanding leads to a pun-filled visit summary.

“I've got a sick one for you,” says the ED doc.

“Go ahead,” I say, trying to hide my irritation as I think of dinner with my family delayed by an hour, at least. These late admissions before shift change are a bummer.

Chris Janowiecki MD
Chris Janowiecki, MD
Phil Kuo MD FACP
Phil Kuo, MD, FACP

Dr. Sieve tells me the patient was found down by a friend. EMS intubated him in the field. “How long the patient was down is unknown. Obviously, the patient cannot provide a history,” says Dr. Sieve, “And no family or friends have arrived yet.” (Wink-wink, nudge-nudge.)

“Great,” I say, seeing that I may not be so late for dinner after all. I book it to the ED, and walk into the patient's room to find my patient…and 2 other civilians. Sigh. Bye-bye, dinner.

I give my standard introduction. Then I ask the civilians, “And how are you related to the patient?”

“We're his friends,” they respond.

“What does Mr. ___ do for a living?” I ask.

“He works in a bridal store, with leather.”

“A bridal store?” I ask a bit quizzically. “You mean a place with wedding gown?”

“No!” says one of the friends. “With horses.”

“Horses?” I ask. I see in my mind 2 horses—one in a tux, the other in a wedding gown, standing at the altar, exchanging vows. I chuckle at the scene, but hey, “To each his own,” I say non-judgmentally in judgment.

“Bridle!” says the friend, snapping me out of my vision. “You know, like with horses,” as if that explains it.

“You know, bridle-for-horses,” chimes in a helpful ED nurse, as if she's singing a lyric from a song everybody's heard. Tennesseans and their country music, I grumble in my mind.

I extricate myself from the bottom of this pile-on and try to regain control of the interview.

Fast-forward 10 minutes. I'm out of the room, sitting at a computer. “Medicine is 1% visitation and 99% documentation,” I say to myself, as though I am the Thomas Edison of medicine. The Edison of medicine: That has a nice ring to it. “Bridle,” I think to myself. “They think they're so smart. I'll show them.”

From the physical exam, I document the patient has an S3 gallop.

I review the chest X-ray and chest CT and agree with the radiologist that there could be something obstructing the right mane-stem bronchus.

For my assessment, I document that the patient is in critical but stable condition.

Now for the plan. “Acute respiratory failure: For the right mane-stem bronchus abnormality, patient may require bronco-scopy. A good bronco-alveolar lavage may help us stirrup some positive cultures.

“PE is a consideration, too,” I tell the transcriptionist, “Need to consider a saddle embolus. Hopefully, he will not be on the vent furlong.”

So that my optimism does not confuse the stiffs at CMS worried about observation status, I quickly dictate, “But expected stay is still greater than 2 midnights, so inpatient admission.”

Renal insufficiency, unknown chronicity: Creatinine is 2.6. Probably acute kidney injury from present illness. But, given unknown baseline creatinine, it could be a chronic condition, say, from horseshoe kidney.

Acute encephalopathy: Probably from hypoxic respiratory failure, but need to rule out Eastern equine encephalitis.

Here I pause to consider how exactly to diagnose Eastern equine encephalitis. I'm about to look it up when, feeling my stomach rumble, I dictate “Get neuro consult,” and move on.

Fluids, electrolytes, nutrition: Keep the patient NPO except meds for now, even if he is so hungry he could eat a horse. “Not my best pun, but it will have to do,” I tell myself.

Discharge planning: Consult Case Manger for disposition. Potential issues include horse-ness after extubation. Consider ENT consult if that's the case. Vocal cord paralysis can be a real night-mare, I tell myself, recalling patients I've seen with that condition.

“There, that about covers it,” I think with satisfaction. I now have a better understanding of what my teachers in med school and residency were talking about when they said, “When you hear hooves, think horses, not zebras.” I thought about horses all right.

“Another satisfied customer,” I congratulate myself, looking at the patient's chart. Add Mr. ___ to the list.

My eyes do a double-take.

My patient's first name is “Ed.”

“Perfect,” I think. “I just admitted Mr. Ed!”

Just then Helpful Singing Nurse rushes out of the patient's room. “He's bucking the vent,” she says in a panic.

A horse is a horse, of course, of course, I hum. “Of course he is,” I say.

All events in this humor column are fictional and are not intended to suggest actual clinical practice.