I took a deep breath to calm myself down and then offered to check her pulse oximetry again. It was 98%. I don’t remember why, but I decided to have her wear the pulse oximeter and walk around our clinic. Natalie took a few steps and her oxygenation plummeted to 87%. My heart almost skipped a beat. How could this be? The only plausible explanation I could come up with was a pulmonary embolism. But why would a healthy 27-year-old develop an embolism?
I explained my thoughts to Natalie and recommended that she be taken to the local emergency department (ED) immediately. She agreed. An hour after she left our clinic, the ED physician called to tell me that Natalie had been admitted to the medical floor. She had large bilateral pulmonary emboli. A
few days later, after Natalie was discharged from the hospital, she came to our clinic for a follow-up visit. She broke into tears and thanked me for being “the only doctor who took me seriously when I said I knew there was something wrong with me.” Her use of oral hormonal contraceptives was found to be the cause of her pulmonary emboli.
Natalie taught me a lesson I will never forget: Always put my prejudice and fatigue aside and treat each patient encounter with a fresh perspective, as difficult as that can sometimes be.
Words that transform
Pamela Levine, MD
It was early in my career and I had just enough experience to feel competent. It was a usual day at the clinic: On my schedule were women getting physicals, children with sore throats, babies getting their immunizations. These are the sorts of patients we care for in family medicine; we enjoy it, we receive thank-you notes and holiday cards, and we establish relationships.
And on this day, I encountered another sort of patient, one that some refer to as a “drug seeker.” These patients may or may not have pain, but they have a history of obtaining narcotic prescriptions from multiple doctors, losing prescriptions, asking to have their dose escalated, and/or selling their medication. Because the Drug Enforcement Agency (DEA) can come after a doctor who overprescribes pain medication, many of us view encounters with drug-seeking patients as adversarial. We are on guard so as not to be tricked and possibly lose our DEA license.
That was the type of patient with whom my day ended. I had stayed late to finish recording my notes. I was on call and someone had paged me with a question that required a chart. So I ventured into the dark medical records room (this was long before we had electronic medical records) and I committed myself to the unsavory task of locating the chart.
There was a loud knock at the side door. If it occurred to me that I was alone and it was dark outside, the thought flew out of my mind; I decided the knocking was probably a staffer who’d gotten locked out. That happened all the time. I would let them in, and they would help me find the missing chart.
Well, I was wrong. When I opened the door, I found a woman who was hoping our clinic was still open. She was from out of town and had never been seen at our clinic. She had chronic headaches and took a large amount of oxycodone and acetaminophen daily. And, of course, she was out of medication.
I could have just closed the door, explaining that our clinic had a policy against after-hours narcotic prescriptions. Her story was suspicious and she wasn’t even an established patient. I could have gone back to finding the errant chart, as I still had tons of paperwork and more calls coming in.
But it wasn’t so easy: There was desperation in this woman’s eyes and in her demeanor. I remember standing at that door having a conversation, one I was sure she’d had plenty of times before. With the high dose of pain medication she had been taking, had she considered that she might have a drug addiction? Had she considered that there could be other ways to manage the headaches, but that she would have to get off the narcotics first? Would she go to the emergency department and ask to be admitted to a rehabilitation facility?