Sick relatives? Get involved!

That's the lesson FP Gil Solomon learned when family members became seriously ill.

Until a few years ago, I never acted as an intermediary between my family and their doctors because I believed that my intervention could make things worse, not better. But now I don't hesitate to advocate for my family. I've reviewed lab tests, looked at X-rays, and even dismissed physicians who've made errors. Have I gone too far? Sometimes, I think I haven't gone far enough. Let me tell you what I've learned.

A seemingly obvious diagnosis may not be obvious to another physician. I'm sure you've had relatives call you in the middle of the night when they didn't want to wake their own doctors. Ten years ago, my father-in-law, Edgar Allen (not his real name), made such a call to ask if he should take the Tylenol with codeine his doctor had prescribed for his neck pain. He was now having pain with exertion. I advised Edgar to call the doctor, and assumed he would be sent to the emergency department when he said the pain was coming with exertion.

The next morning, however, my wife learned that the doctor on call had simply told Edgar to take more of the same medicine. After she threatened to call 911, Edgar reluctantly went to the hospital, where an ECG indicated that he was scarily close to having an MI.

Now I intervene to call the physician, relay the history, and ask the doctor to call my family member back. Not only do I tend to get through sooner because I'm a physician, but I frame the history in a way that supports the diagnosis I'm most concerned about. If the physician doesn't pick up on it, I ask if he or she thinks the diagnosis I have in mind is a possibility. I would rather they tell me why not—and they often do—than have someone miss something.

There's no place like the bedside. Despite all my training, I never really knew what the minute-by-minute life of a patient was like. Now I do. I stay with hospitalized relatives as much as possible, especially when they're first admitted.

After a second bypass surgery and treatment for dehydration, Edgar was sent home. He lasted four hours before he was down to two words between breaths. I drove him back to the hospital, sat with him for four hours in the ED, then followed him to the ICU. When we arrived, the Foley bag contained only 100 cc. I told the nurse that I hadn't seen him receive Lasix in the ED and asked for a doctor to see him. A half hour later, I asked again—this time in an angry tone of voice. Ultimately, a PGY1 arrived and began taking a detailed history. "I'll make it easy for you," I said, and gave him the information he needed. Then I asked, "Now can we get Mr. Allen some Lasix?"

The diuretic was finally ordered and administered. The medical center's CHF pathway included daily weights, but they didn't weigh Edgar until I suggested it. Although he'd eaten little since his surgery, he had gained 22 pounds. If I hadn't been on hand to bug the nurse about calling the admitting team, he probably would have sat there all night without meds.

Someone has to be in charge—and it shouldn't be me. For the next few days, I checked Edgar's lab tests and fluid balance daily. Eventually, he yielded to my suggestion that we find a primary care internist to oversee his care and coordinate the efforts of multiple specialists. An internist/nephrologist I knew took over and called in the specialists he was comfortable working with.

I can speak up for my relatives. The admitting team, concerned that Edgar may have had a pulmonary embolus, ordered a V-Q scan. I knew from previous scans that Edgar was claustrophobic and couldn't tolerate a nuclear scan. After considerable urging from me, the residents did a D-dimer test and a bedside duplex scan to image the veins in the leg. They were negative for a pulmonary embolus, saving Edgar the anxiety of a nuclear test.

What you don't know can hurt someone. A few years after my experience with Edgar, my father was involved in a motor vehicle accident and couldn't move his arms and legs. The paramedics put a cervical collar on him and transported him on a backboard to a local trauma center, where he regained movement. When I arrived, the trauma surgeon told me a CT scan of the neck was normal.

The next morning Dad seemed fine, and the doctors were going to send him home. But when they took off the cervical collar and he bent his head forward, he was unable to move his right arm and his legs. I called radiology and asked them to read me the CT scan report. Without the history, the radiologist reported that there were no obvious fractures. However, when I explained the symptoms to the radiologist, he immediately focused on the C5/C6 area and agreed that movement there might be transiently compressing the cord. Had the trauma surgeon done this he would have made the diagnosis the night before.

Despite your best efforts, bad stuff happens. After my dad had his second episode of weakness, the trauma surgeon called an internist. "Your father has anisocoria, so I'm ordering an MRI of the brain along with an MRI of the cervical spine," the internist told me.

When I got there the next morning, Dad had just arrived from radiology. When he'd left the floor he could lift his right arm over his head and squeeze my fingers, but when he returned he couldn't move his arm at all. The nurse checked the orders and told me the internist had asked for a plain cervical spine film instead of an MRI. During that procedure, the X-ray technicians had removed Dad's collar and manipulated his neck. Because the internist never told me about the change in plans, I couldn't have prevented what happened.

If the doctor isn't doing a good job, you may need to fire him. I had spoken to Dad's internist about prophylaxis for a DVT, and he had mistakenly written Levaquin instead of Lovenox. This, in addition to the cervical X-ray, indicated to me that Dad needed a new doctor. I found a physician I trusted, and, with Dad's okay, I fired the other doctor.

As physicians, we can be patient advocates. Some of you may think that you'd prefer not to take care of anyone from my family. Others—especially those who've experienced an error in a relative's care—may understand. It's unfortunate that constant checking is necessary, but as a medical director who reviews grievances from Medicare patients, I find that less than optimal care is not infrequent. And I often receive detailed letters from health care professionals describing multiple deviations from acceptable care in cases involving family members. Their experiences mirror mine, and I wonder how many patients are injured because there's no trained observer to intervene when things go wrong.

How involved you wish to be in your relatives' care is up to you, but at least be aware that the view is different from the other side of the stethoscope.

The author is a family physician in West Hills, CA, and a member of the Editorial Board of Medical Economics.

 

Gil Solomon. Sick relatives? Medical Economics Nov. 7, 2003;80:38.