The Oinkment

Gibson, Rick

Monday. Mid-afternoon. I'd spent the last week at a medical error conference. In my absence, every patient had booked an appointment and compiled a detailed list of complaints. My morning office pre-empted lunch. My afternoon was spinning out of control.

Bill was next. The booking sheet said "Urgent - needs Rx". No surprise! That would describe every visit for Bill. His 15 medications should all run out together but never actually do. He always turns up just when he's taken the last pill. He never brings me his "empties". He can't remember which drug he needs. It's always the " ... small white round pill that I take twice a day", when really it's the big bi-colored capsule that he should take once a day!

Bill smiled. "Hi, Doc. I won't take 'much of your time. All I need is my oinkment, and I'll be on my way." Bill has his own unique lingo, "oinkment" being one of his more comprehensible medical terms.

We made small talk while I brought up his electronic chart to check his list of active medications. There were no ointments, creams, or lotions. Still, a lot of topicals are prescribed "as needed", so they don't always appear on the list of "regular" medications. I flipped to another report showing every prescription for the past 5 years. My heart sank. He'd had hundreds of prescriptions! None was an "oinkment", even by Bill's liberal definitions. It was probably something I'd prescribed at the end of a visit in response to an "Oh, by the way ... ", without writing it down. So much for today's quick visit!

Trying to sound happier than I felt, I asked "So how's the ointment working for you these days?" Hoping it was no longer working all that well, I dreamed of saving the day by prescribing something new!

"Just fine, doc! The problem clears up immediately whenever I use it."

"Damn!", I thought.

"And how is the problem now?" I asked. Maybe, if he'd run out a while ago, he might have a rash or something to show me) and then I could guess what I'd prescribed.

“It's great!” he said, with a smile. “I just finished the oinkment yesterday." (Outfoxed again!)

"Did you bring the empty tube?" Now I knew I was desperate!

“No, doc, I threw it out. You must have it in the 'puter.” Bill is totally computer illiterate, which explains his touching faith in the infallibility of technology. The rest of us know better!

"Quite right, Bill! Let me check again." I ran the search function, looking for rash, redness, dermatitis, skin, topical, hydrocortisone, Polysporin, lotion, cream, and ointment, and every conceivable abbreviation, all to no avail.

In my minds eye, I could see the waiting room filling up. My dreams of supper faded. My stomach growled. I felt weak.

Then .. a thought, a glimmer of hope. “Bill, are you sure that I prescribed it? Is there any chance that you got it from a specialist or maybe at another clinic?"

He seemed shocked. I had accused him of being unfaithful! "Doc, you know I don't see anybody but you! It must be in there. I got it at the drugstore next door, just like always."

Suitably chastened, I picked up the phone and called the pharmacy. They had recently upgraded their computer. Their records now went back only three years. There were no topical medications in Bill's profile. Whatever he was using, it was old.

I could bluff no longer. Time was marching on. "Bill, tell me where you use the ointment, "

Bill snorted in disgust. How stupid could I be? "Right where you told me, doc. Up my nose, of course! I'm not stupid!"

I took a quick look up his nose, which was normal. However, looking on the bright side, there are only a few ointments that I normally prescribe for noses, so I dashed off a prescription.

"Bill, this may not be exactly the same stuff, but it should work just as well." He wandered off, clearly unhappy that I didn't just give him a refill on that stuff that had worked so well for so many years.

Within days he came back! There was an unpleasant smell in the room.

"I didn't fill that 'scription, doc. I dug through the dumpster and found that tube! You said you wanted to see it." That explained the smell.

He proudly displayed an object in a zip lock bag. Bill is one of those people who squeeze their tubes in the middle, then the top, then the bottom. His tube had been rolled and unrolled, twisted and flattened, and then cut open at the wrong end. It was covered in crumbs .... or something worse. I put On some gloves, covered the desk with an incontinence pad, held my breath. and extracted the specimen. It was every bit as greasy as it looked. It really had been an ointment! The original paint had long since separated from the metal. The pharmacy label was loose, and through years of handling and exposure had taken on the look and feel of wax paper. It fell apart when handled. The type was faded, and had disappeared completely in places.

Word fragments and random letters appeared; some on the label, others on scraps of paint. Were they part of the trade name, the generic name, the pharmacist's initials, or the instructions for use? As Bill watched impatiently, I arranged and rearranged the letters, hoping to find a match in my internal dictionary of drug names. I wondered if this could be marketed as a new word puzzle for bored old doctors with early dementia ..... "In five minutes, construct as many drug names as you can, using any or all of the following letters". I started off well enough, coming up with one long drug name within seconds. I chuckled to myself. This was going to be a piece of cake! I carried on reshuffling the letters. Five minutes later, Bill was squirming, and I still had only the one drug name.

Either I was no good at this game, or, as Sherlock Holmes once said, " ... when you have eliminated the impossible, whatever remains, however improbable, must be the truth."

At the patient safety conference we were regaled with tales of the wrong medications given to the wrong patients by the wrong route, usually the result of poor handwriting, distracted doctors or nurses, overworked pharmacists, complicated patients, and a host of other factors. I thought about my writing, which isn't always the most legible. I reflected on Bill's scattered thought processes, and how he would distract me as I was writing his prescriptions. I considered his lengthy list of medications, and his complicated list of chronic diseases. From all that I’d learned, Bill was a medical error waiting to happen, and it finally had! Still, he seemed none the worse for wear. Maybe we'd found a new indication for an old drug!

In such cases, I had learned that immediate full disclosure is the preferred option. Fearing the conversation was about to get a lot longer, and dreading the thought, I asked "Bill, when did you start putting your hemorrhoid ointment up your nose?"

Theme: Health Care Delivery | Prestation des soins de santé
Theme: Patients | Patients

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --. 




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