Comments on: Calling Dr House!

By: VMS

VMS — Mon, 03 Nov 2008 06:49:49 +0000

Better reading than the “Case Records of the Massachusetts General Hospital” in the NEJM!

By: November 3 roundup

November 3 roundup — Mon, 03 Nov 2008 06:35:30 +0000

[…] M.D.s and J.D.s in cahoots: when neuroradiologists over-read MRIs in search of “disc herniations” and “cord compression” [ER Stories] […]

By: ERP

ERP — Fri, 24 Oct 2008 11:24:22 +0000

I guess technically you are correct Thaidoc since we found the hypokalaemia was caused by the thyroid. The true PHP is genetic and of uncertain aetiology. However, I wonder how many cases of “PHP” are never fully worked up and the K+ is just replaced - they usually get better and are discharged.

By: Thaidoc

Thaidoc — Fri, 24 Oct 2008 05:23:30 +0000

This is not hypokalemic periodic paralysis. This condition is inherited and usually manifested at younger age and is not associated with hyperthyroid.
The correct diagnosis in this patient should be thyrotoxic periodic paralysis(TPP). The pathophysiology of these two conditions are totally difference. There are some feature that can distinguish these two conditions which can be found in this review article(J Clin Endocrinol Metab, July 2006, 91(7):2490-2495.) For example, TPP usually affect male, age 20-40 yo, usually sporadic, etc. It is quite common for TPP patients to present with paralysis without any history of thyrotoxic symptom. Some researchs found that the prevalence of this condition is rising in the western population.

By: ERP

ERP — Fri, 24 Oct 2008 00:17:42 +0000

Well, B McClain, the thing is that I was perplexed at first because of the timing of the onset with the injection into the C-spine. That seemed like the obvious cause at first. However, the pattern of weakness did not make anatomical sense - hence my suspicions. Also, couple that with the notoriety of the doc who did the injection and my warning lights went off. However, the important thing is that just because you suspect foul play, you can’t immediately jump to conclusions. Look a little deeper. You might find something. However, I have seen many people who fake weakness - ever heard of the Hoover sign????? Look it up, it is a good test to catch some fakers.

By: m (2)

m (2) — Thu, 23 Oct 2008 22:11:32 +0000

Geez, you get slammed on that “lack of compassion” thing no matter what you write. Kudos.

By: B. McClain

B. McClain — Thu, 23 Oct 2008 16:39:58 +0000

I find your story of periodic paralysis very intriguing. But I find your initial suspicion of secondary gain with this patient very disturbing.

The medical profession has become so tainted with the attitude that “everyone is out to make a buck” that it often hinders good medical care and social justice. This attitude has resulted in a noticeable lack of compassion in our physicians today.

It is a known fact that in the past, patients with periodic paralysis were sometimes placed in insane asylums due to limitations of the medical technology at that time. Now that we know that periodic paralysis can arise from a genetic abnormality with tests to indicate as such, these patients are now recognized having a real medical condition.

So despite the fact that a patient may present with symptoms that do not show on an MRI or blood work, does not necessarily suggest that the patient is not suffering from something real. It may very well be that the limits of our current medical technology cannot yet detect it. So your opinion that the majority of physicians and patients involved in the personal injury cases seemingly are there to “scam” the system, may be debased.

The primary motive of the majority of persons involved in personal injury claims is not “to make a buck”. The motives are to get better, to obtain the financial resources to do so, and to provide a level of social justice that is fair and reasonable. It is the inefficient and complicated legal system that blackens these genuine motives, not the patient who suffers.

Our present medical system runs on the “money game” and so does our justice system. If we could change the former, then the latter would not have as much influence. But I do not see many physicians crying out for change. I see them instead in fear about their own financial outcomes. I hear their complaints and fears of the legal system, but I do not see them making any efforts on changing their own profession to make medical care more affordable and accessible.

Your ER story had a good ending since you found significant blood results to make a diagnosis of periodic paralysis. But the next time you may not be so lucky. It is then that I hope you catch yourself placing initial suspicion on a patient’s motive, and instead, reflect on your level of compassion, as much as your level of medical skills.

B. McClain
www.cpab.info

By: Sara

Sara — Wed, 22 Oct 2008 20:40:09 +0000

I had a similar case last year…the guy was in his 30’s, healthy, had taken steroids for some days…one morning he woke up and wasn’t able to walk with proximal paralysis of arms,too…there was areflexya so we thought of Guillain Barré. Serum K was 1.7 indeed! And it was an hyperthiroidism (Graves’disease). He only had tachycardia (HR about 130) and mild repolarization abnormalities on EKG. He was treated in neurology department and he dramatically improved about 10 minutes (I’m not joking) after iv potassium was started.

By: ERP

ERP — Wed, 22 Oct 2008 16:55:52 +0000

That is the sort of thing that is so ridiculous about medical dramas on TV. Most of that stuff is completely unrealistic. I mean, technically the medical problems are accurate but the daily flow of how things happen is pure drama. Reality would be too boring! I get the most drama in the ER but even at our worst, we are almost never as exciting as a “slow” episode of “ER”.

By: m (2)

m (2) — Wed, 22 Oct 2008 15:56:12 +0000

Speaking of Dr. House… On last night’s episode, I noticed there was no anesthesiologist present during surgery, and that the patient wasn’t intubated, although she was under full sedation (and subsequently went into respiratory arrest and was saved by a cric from a doctor who rushed in at the last minute without scrubbing or wearing gloves, no less). Does that really happen (not the parenthetic part), or is it another creative liberty taken by tv?

I also notice this hospital has no (or few) nurses, nor does Seattle Grace, the alleged hospital in Gray’s Anatomy.

By: ERP

ERP — Wed, 22 Oct 2008 12:56:54 +0000

He might have - although I think his injection was more of a nerve block with Bupivicaine or something similar.

By: Robin

Robin — Wed, 22 Oct 2008 11:21:56 +0000

Cushing’s patients deal with hypokalemia all the time. Some more than others. I’ve experienced it to the point of not being able to move one time, and my cortisol level was very high. By chance, did he have a steriod injection? (I also have very low TSH…but that’s secondary to pituitary surgery…still hypothyroid with that low value.)

By: kw

kw — Mon, 20 Oct 2008 19:25:10 +0000

Great blog, interesting case!!
(and the kick in the behind that I needed. hashimoto and fed up, so I was postponing getting the bloodwork done but it’s been almost 8 months…So, oops, I know I should know better (3rd year med student))

By: whitecap nurse

whitecap nurse — Mon, 20 Oct 2008 16:23:47 +0000

You said the attacks are triggered by “alcohol, large meals and other things” - maybe the injection was a trigger. I’ve seen one similar case: Asian male in his 20’s, couldn’t get out of bed, medics were quite dismissive on arrival, but his K+ was 1.8. He perked right up after a potassium infusion.

By: SuperBadJack

SuperBadJack — Mon, 20 Oct 2008 12:32:20 +0000

Whoa.

Doc, thank you. You guys really save the day when it comes right down to it.

I know the drug seekers can get you down, but that right there is why you do what you do.

I hope I never need such a brilliant intervention, and due to my age (22) I probably wont for some time. But I hope if the day comes I do need someone like you there for me you will be.