Just When You Think You’ve Seen It All – Hold My Beer

I’ve been doing some clinician consulting for a few years now, gradually building up to my current residency as my knowledge base grew.  And just when you think you’ve seen it all … someone has a “hold my beer” moment.

The fundamental purpose of the DCLS is to improve patient care by reducing medical error.  We will reduce medical error by ensuring that the correct test is ordered at the correct time and interpreted correctly.  Don’t think medical error, especially diagnostic error is not a problem? Think again. Check out this study – https://www.ncbi.nlm.nih.gov/pubmed/21673294 and these were just the ones that went to malpractice – think of all of the medical errors that didn’t result in litigation!

So at this point in this blog I’ve decide to discuss some of these moments I’ve had thus far in my experience. [No, there will not be any HIPAA violations – I promise!]

Case #1: A 48 year old female presents in the outpatient family medicine setting as a new patient.  Her chief complaint: it feels like something is crawling under her skin.  This is the 5th physician she has seen for this complaint.  Previous work-ups include drug testing, drug testing, drug testing, and an attempted involuntary psychiatric hold.  All previous physician diagnoses concluded as psychiatric disorder with probable drug-induced psychosis and one that thought she had allergic dermatitis (aka she was crazy from drugs or she had rash due to an allergy for the muggles reading this blog).  While the patient was in the office, she used her fingernails to cut something out of her skin.  I was consulted at this point.  I decided to look underneath the scope at what she had dug out – what harm could it do.  Guess what? Ummmm – there’s something alive here.  OK, so I can’t make a species diagnosis but I can definitely discern there is something there that shouldn’t be; like larva of some kind.  At this point I began to interview the patient because this is something that we just don’t routinely see in the US.  Turns out the patient had been on a mission trip … to Peru … 8 months prior … and no one had ever asked.  Every single previous physician she had seen had never asked about travel history or even considered the possibility of a parasitic infection.  This patient had cutaneous larva migrans; she really did have something – a lot of something – crawling under her skin.  Final diagnosis from reference laboratory parasite identification: Ancylostoma duodenale. Did this particular case require the expertise of a DCLS?  No, but it is still a cool case and it does show that medical error occurred with 4 physicians making the same error!

Case #2: A 28 year old female presents to the hospital ER with a large “angry” abscess on her leg.  The physician assumes that it is MRSA and begins treatment as such.  I was contacted by the patient’s nurse as she said it didn’t look like most MRSA abscesses.  As I was reviewing her chart I came across some interesting information that the intake nurse had charted at the patient’s admission: over a week prior the patient had a scratch on that abscessed leg from gardening.  I then questioned the patient about her gardening activities – she had planted 16 rose bushes that day and the scratch on her leg was from a thorn on a rose bush.  I then suggested to add a fungal culture.  What happened?  Sporothrix schenckii, a fungus known to love rose thorns, eventually grew out.  The routine culture that was obtained did result light growth of MRSA, but this wound would have never healed completely without the addition of an appropriate anti-fungal and this fungus would never grow in a routine culture setup.  So this is another example of medical error because not all of the patient’s history was considered in the differential diagnosis.  Even if the physician had considered it, would the physician have even thought of this particular fungus?  Not sure.  Would they have done the gold standard fungal culture or would they have opted for the poor sensitivity antibody tests that likely would have resulted in a false negative? Don’t know. Would MLS’s be able to figure this out and suggest the correct test order?  Probably, yes, if they have both access to the patient’s chart and time to go through the chart which likely they would have neither.

These two cases are just examples of some basic medical error issues that I have resolved where both cases related to the physician(s) not considering, or even taking, a complete patient history.  I have many, many, many more cases that I plan to share on this blog highlighting the need for both laboratory consultation and the DCLS – so stay tuned!

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14 thoughts on “Just When You Think You’ve Seen It All – Hold My Beer

  1. I’ve enjoyed reading your posts but this one was really an ‘Ah ha’ as to how very important your position will be. Most of us do not have the type of access that you mentioned in this blog today!

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    1. Yes, in order to do the work of a DCLS you must have access to the full EMR which most laboratorians do not plus the tools to understand everything. The pharmacology course I took is a life-saver when understanding many of the decisions that were made by various clinicians as was learning to read and interpret EKGs. I could go on and on …

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  2. You never cease to impress me Brandy! I know I’m a tad late to the party, but this is phenomenal! Keep up the great work!

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