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SJBird55 -> RE: Spondylolisthesis and testicular pain (September 8, 2007 8:57:21 AM)
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Torsion would be a medical emergency and require surgical treatment within 6 hours. It is highly unlikely that this is the condition based on the symptoms reported by tf.
Could be testicular cancer. Testicular cancer is definitely treatable and is generally curable if found in the early stages. Reality: a few days aren't going to make a difference.
Triage nurses would ask the same questions to anyone at the other end of the phone. Do you really think that physicians "make the call" as to how soon a patient is worked into a schedule? Triage nurses have certain questions that they ask to assist them in making the decision. I'm just providing the information and my recommendations. You also have to realize that there would be certain responses to the triage nurse that would put the condition in the "serious" category. And you obviously didn't read what I wrote thoroughly - I didn't leave it at, "it looks okay." I would also provide as much additional information as I could. It really doesn't have anything to do with scope of practice. I have no problems or discomfort in assisting in making decisions like that.
If a patient was to be seen in 3 days and then missed the appointment and fell through the cracks because the patient decided not to be seen and things got worse, let's be realistic, that's the patient's problem. A patient, for whatever reason, is deciding that other things in life are a priority or he/she isn't worried about the condition. Patients do control their own lives, ya know? I don't feel guilty, nor responsible nor anything when things like that happen. You can't worry about something you can't control. Would it have been better for the patient to be seen the first day? You know, I don't even enter those kinds of thoughts because that wasn't the path that was decided. Maybe on the first day it was too early to have picked up on a problem? Just to play the opposite.
Try this one... I phoned a surgeon and recommended an immediate examination of one of his patients. The patient had a recent amputation and was beginning therapy - it was about 6 months post amputation (can't remember now). Anyways, the stump just didn't "look" right and had point tenderness and the patient had been having increasing complaints of pain. (I had nothing for comparison because it was his first visit.) It looked like there might be a small infection or some irritation under the skin, but I didn't know. It didn't seem to make sense because everything should be good to go by that point in time. The surgeon got somewhat irritated - he worked him in - the patient's wife called me and gave me the, "there's nothing wrong, just a pressure spot.... blah, blah, blah." Well, 1 or 2 days later, guess who is on the phone? The wife.... she's all in a panic. Supposedly there was a ton of fluid and some blood and beats me all what coming out of the bottom of his stump. Anyways, I calm her down and tell her what to do. I then remind her to recall that we knew something was wrong a couple of days ago and now the pressure of whatever irritation has built up and has blown through the skin. Everything will be okay. I advised her to call the surgeon to see if the surgeon wanted him in the office or at the ER. To find out he was hospitalized for a few weeks because he had a bone spur that was causing tissue damage and required a further revision. Now, am I some specialist in amputations? Should I have been poking and prodding at a reddened area to make a judgment call? My role was to teach the guy how to tranfer. I'm sure the surgeon was even wondering why the heck I even looked at the stump. What's the point? I can't do anything about the stump...
What about this one? I receive a referral for a 70+ female with low back pain. She's from northern Iraq and still speaks very little English. I can't get a good grip on her exact symptoms - I know she hurts in her back and lower leg. The surgeon had an MRI ordered and it was negative. Ah... but she had breast cancer 3 years ago and was treated for that (not sure how because conversation was difficult). Was it appropriate for me to contact the surgeon's office to ask how sensitive and specific an MRI was for ruling out metastasized cancer? That this lady had a history of breast cancer 3 years ago, that I have no idea when she last saw her oncologist and that I have no idea if an MRI is the appropriate diagnostic test? Tell you what... the nurse paused quite a bit and had no idea how to respond... came back to the phone and suggested that I contact the oncologist. So.. onto a conversation at the oncologist office. The decision was to have a CT scan and bloodwork done by the oncologist. Two days later I receive a phone call from the oncologist office with the results and an expression of gratitude - they normally don't have physical therapists contacting the office with concerns of metastatic cancer on their patients and questions regarding sensitivity or specificity of MRI results. LOL Was it in my scope of practice to question an orthopaedic surgeon? I do know though that the oncologist and the patient's family appreciated it. I've treated that patient 2 other times for other problems because they appreciated that I questioned and basically required a response or some sort of action for my concerns about the patient.
Maybe some of my lack of fear and my comfort level in basically what appears to be sticking my neck out comes from working very closely with a couple of family physicians. In all honesty, they expected me to tell them what I wanted in cases like the testicular situation. In that situation, I would have walked over to their side of the building and waiting for whichever physician referred. We'd have a face to face discussion and the physician would ask a series of questions. I would always need to provide a rationale for my thoughts and describe my findings and my interpretation of those findings (and visual examination would be as far as I would go with the testicular problem). In a small way, they treated me somewhat like a resident. The docs would question my clinical thinking and decision making to the nth degree - and they did it for at least a year. They groomed me to be almost like an outside consult - they expected that additional thought to have a solid rationale. After 6 years of those kinds of expectations, it really is difficult to just say "that's out of my scope of practice. I dunno. You need to see you PCP." Another example... if a patient had high blood pressure and the patient had been prescribed Vioxx 3 weeks previously - believe it or not, they expected me to attempt to problem-solve if I could. I'd actually say that I thought that the high blood pressure was resulting from Vioxx and then ask if there could be a different medication prescribed. Definitely NOT my scope of practice... but they trained me to step it up and be a team player and attempt to think stuff through for them. And, no... they never got mad, never any lawsuit - only gratitude. And, as I was groomed that way, I also learned ways to communicate to patients a bit of what I was thinking and how to hedge my comments so that there would be no perception that I was functioning outside of my scope of practice.
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