Complaints that patients need to be seen sooner than the schedule can accommodate are a reliable vital sign that a practice is busy enough. When this situation arises in my practice, the nurse usually leaves me a pile of records from the referring physician, and a note explaining why the patient needs to be seen as soon as possible. In a case where the note includes the word fibromyalgia, that pile of records moves to the bottom of the stack.
A recent note regarding a patient with gout made its way to my desk. The referring physician was from a very large and respected cardiology group, and I knew with certainty that the physicians in this group prided themselves on never considering any body part south of the diaphragm. A short note said that the patient had gout and needed to be seen as soon as possible. This struck a humanitarian cord within me. Gout is really painful, and the thought of some elderly patient with podagra due to the cardiologist’s massive administration of furosemide made me think that this is someone that deserved expedited attention.
I had the patient squeezed into my schedule at a time that I don’t usually see new patients and I opened the door expecting to find the usual pitiful scene of a patient with one shoe on and one shoe off, awaiting my words of wisdom and healing, or at least the compassion to not role the wheels of my examining stool over their gouty extremity. What I found was different than my expectation.
The patient had a blue painful toe rather than a red painful toe. As the story unfolded, it turned out that the patient had been to the emergency room a month earlier and had been given futile treatment with antibiotics for possible cellulitis. Later, the patient’s cardiologist did an angiogram of her leg, and she was diagnosed with small vessel peripheral vascular disease. The cardiologist was worried that perhaps she had gout in addition to ischemia. She saw another rheumatologist in the neighborhood who had already told her that she didn’t have gout!
"He didn’t listen to me at all," my distraught patient with the blue toe complained. "He just wanted to talk to me about my smoking and fibromyalgia."
This wasn’t untreated gout. The "emergency" was due to the patient’s dislike for the other rheumatologist. I felt cheated, but I tried to be more likeable than my maligned colleague! I listened to the whole tale of woe and carefully explained that an ischemic blue toe was better than a gangrenous black toe. She gave me a plaintive glare as she hobbled out, but she looked as if she might even stop smoking.
Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. You may reach him at rhnews@elsevier.com.