Bad medical care: Is it better than none at all?

In my past few shifts in the emergency department, I have seen the following patients who were seeking further care after being treated by other providers.

One was a child who had been seen twice at an urgent care clinic. He had a fever of 103 degrees and wasn’t eating. The first time he went to the urgent care center, he was diagnosed with an ear infection. He was started on amoxicillin and sent home. He returned to the clinic 8 hours later because he still had the fever and still wasn’t eating. When the clinic provider looked in his mouth, he saw a red rash that appeared to be an allergic reaction. He was therefore changed from amoxicillin to Biaxin and started on Benadryl. The parents were concerned that his allergic reaction may get worse, so they left the urgent care clinic and came directly to the emergency department.

When he came to the emergency department, he still had a fever, his ears looked fine, and he had the typical enanthem of herpangina. We stopped the antibiotics, stopped the Benadryl, gave the child some stronger pain medication, and had the parents feed him popsicles and cool liquids.

Another patient had been in a bar fight several days prior. He had a cut on his knuckle and his knuckle was starting to hurt. He went to another emergency department and saw a provider who washed out the cut, started the patient on amoxicillin, and then put packing in the wound.

When he came to our emergency department, we started IV antibiotics, removed the packing … from the joint … and sent the patient for surgery to clean out the infected joint and to repair the lacerated tendon.

A third patient had been to both an urgent care clinic and an emergency department for evaluation of palpitations. The urgent care clinic diagnosed the patient with anxiety and discharged the patient with a prescription for Xanax. When the Xanax didn’t help and the palpitations were causing worsening shortness of breath, the patient went to an emergency department. There the patient was seen by a provider who performed an EKG and did a drug screen. The patient was told not to drink caffeine and given a refill for Xanax.

When she came to our emergency department, an EKG showed Wolff Parkinson White syndrome. We got a copy of the EKG from the prior hospital and it showed the same thing. Their EKG even said “Ventricular pre-excitation, WPW pattern” on it.

Finally was the patient in his 70s who was seen at another emergency department for evaluation of abdominal pain and no bowel movement for a couple of days. He had some lab tests done and the provider performed a rectal exam which showed that he had a lot of soft stool in his colon. So the patient received an enema and was discharged home with a diagnosis of constipation. He was told to take laxatives and eat more fiber.

When he came to our emergency department by ambulance later that evening because he vomited the Milk of Magnesia, his abdomen was swollen and tympanitic. He had low blood pressure, no bowel sounds, and a sigmoid volvulus with an obstruction on x-ray. He also went straight to surgery.

I understand that it is considered bad form to question the care of other practitioners. If another provider’s care is criticized, often the criticisms are met with allegations of elitism and hindsight bias followed by a plethora of anecdotes about how those commenting were able to catch some other provider’s mistakes.

You don’t know which patients, if any, were seen by physicians and which patients, if any, were seen by NPs or PAs or medical students. So step back and look at the bigger picture.

In each of the cases above, a patient required multiple medical visits to diagnose and/or treat a problem that should have been apparent on the initial examination. In at least one of the cases, a patient probably had a worse outcome from the initial treatment rendered. Perhaps some people will disagree with me on one case or another. Fine. Assume I’m right.

Providers who may not be as adept at picking out subtle (or not so subtle) findings on a patient’s physical exam and who may provide less than adequate medical care are more commonly being placed in positions of first contact with patients. 57% of all Italians fear being harmed by physicians and 44% disapprove of their national health care system. In the wake of Obamacare, should patients adopt more of a “caveat emptor” approach toward health care?