Guest post: A real life example of when not to query

By Howard Rodenberg, MD, MPH, CCDS for ACDIS CDI Blog

In one of my recent efforts for the ACDIS Blog, I mentioned that there were times when it might be better not to query. I’ve also mentioned that before one sends a query, one needs to take into account the entire context of the patient encounter. I’d like to share an example with you today.

This week I had cataract surgery on my left eye. It’s my second round; the right eye got done three years ago, and the original plan was that I would get the left one done a few weeks later. What took three years? I hate change. It’s the same reason I still drive a beat-up SAAB that sometimes gets standing water in the footwells and smells like it needs to get dunked in a vat of fluconazole, and why I truly believe that there has been no new music created since “Love Shack” in 1989. Plus, I was consistently amused by the fact that I saw two different color spectra between both eyes, such that sometimes I would sit in the supermarket parking lot looking out from the car, winking one eye and then another like a railroad crossing just for the effect, until the puzzled stares of the Cart Cowboys interrupted my reverie. But when the cataract gets so bad that you can’t catch the end of the suture with the hemostat, you can only blame it on the patient moving so many times.

I should mention at this juncture that I’m gun-shy about doctors, and ophthalmologists are no exception. It’s because I know at least one person of any given specialty found on the floor after a medical school party. So, when I think of ophthalmologists, I think of them not as fine clinicians, but as guys hoisting themselves up on the rim of the toilet, a scalpel in one hand and a bottle of vodka in the other. I was also afraid that this particular ophthalmologist, who by all indications is an excellent citizen, holds grudges. Apparently last time I was sedated, I got kind of mouthy and suggested he had an unnatural relationship with his mother. That’s probably not a good look.

(My reactions under sedation also bode poorly for me if I ever get any frontal lobe dysfunction. I’ve always believed when you lose frontal lobe regulation of your behaviors—be it from stroke, brain injury, or dementia—you become more of the person you really are. So those people we think of as “pleasantly demented” are truly nice people at heart. For me, it looks like I may as well be on a Haldol drip on the GeriPsych Unit. But on a positive note, the ophthalmologist did note that at age 58, I was considered part of his “pediatric population.”)

I spent the few days before surgery reminding myself, and especially the Beloved Dental Empress, that whatever I saw or did, it might be the last time before I died.

Me: “Look at me, I’m holding the puppy. This might be the last time I do this before I die.”

Her: “You’ll be fine.”

Me: “Look, I’m doing the dishes totally unpromoted. I want you to have a final memory of me doing my share of the housework before I die.”

Her: “You’ll be fine.” She’s having none of this. Her gaze is fixed on the Facebook page for Mommy Dentists in Business.

Maybe something romantic would get her attention.  “Okay, maybe I won’t die, but this might be the last time I gaze upon your beauty with both eyes before they rip one out.”

Then she said I was being dramatic. Imagine that.

(Did I mention that I saw one of our closest friends, who happens to be a physician in the same ophthalmology practice, the day before my surgery? Told him his partner was going to rip out my eyeball the following day. “Well, good luck with that,” he said cheerily. “You know once we take it out, we don’t put it back in.”)

At 9:15 a.m. the next morning, I marched into the surgery center. I was wearing scrub pants and a sweatshirt that said, “I Dream Of A Society Where Chickens Can Cross the Road Without Having It’s Motives Questioned.” I figured if I died, the guys who transport the body may as well get a laugh out of it. That’s me, always thinking of others.

The surgery center itself was pretty slick. It was almost like Disney World, where if the Carousel of Progress stops, it starts up again at the very word they left off no matter how long the outage. The nurses have their routines memorized to the point where if you interrupt their patter, they simply push their internal play button and resume talking. They put a “safety dot” over the eye that’s going to be worked on, then get you to lay down on the cot, start an IV, have three rounds of eye drops, and cover you with a blanket up to the neck like every sci-fi movie you’ve ever seen.

After a few moments of either quiet mediation or abject terror—you make the call—another nurse comes by and takes you to the laser room, and now you’re thinking the laser room in Goldfinger, which is why this is when they give you the first zap of Versed. Then the ophthalmologist comes by and draws something with a pen on your eyeball (probably some version of an arrow that says “cut here”), and now the Versed kicks in, and you seem to recall a discussion about someone confessing to a murder under sedation. Then I’m looking at a ring of six lights, and the Star Trek nerd in me wants to shout, “THERE ARE FOUR LIGHTS!”

I recall seeing some pink stuff being moved around my eye against a yellow background, and then I’m being helped off the stretcher and into a chair behind a small wall to hide the post-op people from the pre-op crowd, so the latter don’t run off scared. Then I’m drinking a mini can of Coke from a paper straw and then I’m in my bed with no idea how I got there.

We know that CDI tends to be a family, mostly because nobody else knows what you do, and you’ve got to talk to someone. So, when I got home, as a courtesy to my friends and colleagues, I texted:

“nor dead cant spell love Versed lors” [sic]

(The one word I got right was Versed. That suggests some kind of pathology, right?)

The rest of the day was admittedly a blur. What I do know is that I tried to be a good patient. I was docile and well-behaved. I took my eye drops at the right times, took my Advil and Tylenol, and stayed in bed. For her part, I recall the Empress as a benevolent presence. This must have been difficult for her. Did I mention that she’s a dentist? And she and I have discussed the need for her to attend Consolation 101. Until recently, her best gesture of sympathy was a gentle whack on the scalp and an inquiry as the soothing nature of the blow. It’s a work in progress.

Which led to this morning, post-op day #1. I was feeling well enough to get up and fix the morning brews.

“No, I’ll do it,” she offered.

“It’s really no problem.” I’m perpetually helpful that way.

“I WANT TO BE CARING.”

And here is the CDI implication for us all. Part of me wanted to ask what kind of Shih Tzu of Altruism had seized her brain and shook until the compassion came loose. Here’s the query:

You have exhibited caring behaviors since your boyfriend had surgery. Old records indicate this is a new finding. What do you consider the most likely cause this behavior?

           _____  Acute Encephalopathy

           _____  Other

(Remember that according to complaint query practice, we don’t have to include choices that aren’t realistic. You know, like a “sudden burst of compassion.”)

But then I realized that my query would probably get me punched in the eyeball.

So our lesson today is that when someone wants to be caring, it’s probably best not to query that. Especially when there’s firearms in the house, and only she knows where they are.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com or follow his personal blog at writingwithscissors.blogspot.com. Opinions expressed are those of the author and do not necessarily represent those of ACDIS, HCPro, or any of its subsidiaries.