Laughing at patients is totally unacceptable

Dear Bloggers

This is a short by very important blog today.

It is totally unacceptable to laugh at patients. Sometimes patients act unusually, as they may say and/or do unusual things. Much of the time it is out of character for them. They may be suffering from a brief organic disorder such as a electrolyte disturbance, encephalopathy, or even in the post-ictal period of a seizure. They may have more chronic disorders such as dementia, a personality disorder or suffering from a psychosis. Even if what we deem as unusual characteristics are a part of their ‘normal’ character, as a physician we need to be understanding, and appreciate the elements of what we are observing in order to potentially help the patient. That is not to say that we should not show empathy and caring. We should! That is part of the caring process as a physician and as a fellow human being.

But, when patients are confused or acting in a strange way, it is totally wrong to laugh at them. I cannot even muster a humorous emotion when considering patients. It is just not right. My moral compass will not permit it. We as physicians, are not on a high pedestal that gives us the right to act in a superior paternalistic way. It is not a matter of us and them.

We hopefully have a better understanding of the anatomy, biochemistry, pathophysiology, pharmacology and so on, to allow us to evaluate why the patient is acting the way that they do. But, we are people in a unique position of trust. As the saying goes “With great power comes great responsibility.” Without demonstrating that we, as physicians, can be the guardians of the patient’s medical, emotional and spiritual matters at a time that they are most vulnerable, then we do not deserve the title of doctor.

I have seen all too many times doctors laughing at patients, especially when the doctors are in groups, perhaps feeling that there is safety in numbers. I do not know why. To me, it shows a total lack of professionalism and common sense. But, what is the cause for such behavior? Is it too much societal degradation in terms of morality and that it is somehow okay to laugh at the person less fortunate than ourselves? I simply do not know. It is something that eats away at me. To see doctors laughing at patients, the latter who are in need of the greatest of help, actually sickness me to the stomach. I do not hold back from voicing my opinion on such rude manners shown by my fellow colleagues.

I hope whoever is reading will heed me words and give great consideration to their patients. Doctors should consider how they wish to be seen as physicians in the eyes of their patients and their fellow colleagues.

As Charlie Chaplin said “My pain may be the reason for sombody’s laugh. But my laugh must never be the reason for somebody’s pain.”

By all means, if a patient makes a cracking joke, laugh along. But just do not laugh at them when they need you as a doctor.

Have a good day.

Flapping back to blogging

Dear Readers

It’s been a while. Actually it’s been about 7 years since I last wrote on this blog. I have been busy with many things!!! But the urge to write has brought me back here. 

Today I want to briefly discuss about “flapping tremor”, otherwise known as asterixis. 

Asterixis is a rapid and brief flexion and corrective extension of the fingers when the aforementioned digits are extended and with the wrist, forearm and shoulder being held in extension. Basically it looks like someone maintaining a press-up position with their arms outstretched and the hands “flat to the floor” when instructed to do so in a supine, semi-recumbent or sitting posture. The rapid flexion and corrective extension is brief and irregular in occurrence. But it’s presence signifies possible encephalopathy and hence, when noticed by the clinician, it can lead to an important diagnosis and intervention. 

Traditionally there are three main causes including: 

• Hepatic failure (fulminant or decompensated chronic types)
  
• Uremia
  
• CO2 retention. 
  

However, common problems such electrolyte abnormalities and drugs are also sometimes implicated. 

Asterixis can sometimes be accompanied by irregular movements of the legs referred to as jactitations. This is when a supine patient’s legs rotate laterally and then medially in an irregular fashion. Again, this is a representation of encephalopathy. 

The key to diagnosing it is observation. 

Starting your physical examination by looking at the hands (instead of the eyes and conjuctivae) is the entry step towards being able to see the sign (and other important hand signs!) Even without outstretched hands the “flapping” can occasionally be seen. If suspicious of the sign then ask the patient to stretch out their hands and keep looking for perhaps up to 30 seconds or even a minute. Use your common sense. If the patient has weakness or joint pains then please do not subject your patient to this test. It will either produce a false negative result or cause unnecessary pain, respectively. 

Recently, I was consulted on a very elderly lady with mild chronic kidney disease who had experienced an osteoporotic vertebral fracture. She had been commenced on tramadol at a regular, but high-end dose four times daily. 

The nursing staff had been worried because the patient developed new onset nocturnal hypoxemia without a known cause. Her cardiopulmonary physical examination was apparently unchanged from admission and tests including a chest radiograph, and a work up for pulmonary embolism were negative. 

When asked to see her, I immediately saw the flicker of asterixis. On proceeding to ask the patient to stretch out her hands, she began to show the “flapping” sign. Bingo! Jactitations were also evident even when the patient was sitting. 

Her liver function tests were normal, her chronic kidney disease was not advanced and she had no evidence of chronic obstructive pulmonary disease. An arterial blood gas had not been performed at that time though. 

However, the drug history including tramadol and a third generation cephalosporin (for treating a urinary tract infection) are little known causes of asterixis. Tramadol, an opioid medication, can cause the “morphine twitch.” In this patient, she had normal pupils and her respiratory rate and SpO2 when awake were all normal. Her GCS was 15/15. She had no signs to signify ongoing infection and her vital signs were otherwise stable. 

Hence, reversal by naloxone was not deemed necessary. Simply discontinuing the tramadol (particularly because the back pain was resolving during the hospital admission) was all that was considered necessary. 

With increased age, both hepatic metabolism and/or renal excretion of drugs can become impaired. Therefore, the levels of certain drugs can increase leading to side effects. 

Even if the common three causes of liver disease, uremia and CO2 retention are not present, keep on thinking about the cause of asterixis and consider excluding implicated drugs (anticonvulsants are also causes but a dose reduction rather than stopping the drug permanently may be better to avoid withdrawal seizures; please consult a neurologist!) and correct electrolyte abnormalities accordingly. 

In this case, the tramadol, an opioid, was most likely the cause of asterixis and jactitations. The hypoxemia may relate to a reduced respiratory rate (a side effect of opioids) at night leading to hypoxemia. As a result, she might have nocturnal CO2 retention thereby compounding the presence of drug-induced asterixis. 

Sometimes patients can also have Cheyne Stoke respiration or obstructive sleep apnea at night which can also lead to hypoxemia. 

An important intervention would be to observe the patient sleeping at night by looking for an abnormal respiratory pattern, hypoxia, episodes of apnea, snoring and awakening in an abrupt and startling manner. Obtaining an arterial blood gas during an episode of hypoxemia and performing a sleep study would be other important meaures. 

Remember that common things are common. 

I hope that this helps. 

Time for me to flap away........