Patients Without Discernible Pathology

As any emergency physician worth his or her salt knows, while diagnostic dilemmas may be puzzling and intriguing, dispositional dilemmas are a right pain in the arse.

The toughest of all dispositions is the ‘patient without discernable pathology’ (PWDP) that simply cannot be discharged from the emergency department. What does the enlightened emergency physician do next?

Well, the classic elucidation of this particular puzzle was published in the Canadian Journal of Emergency Medicine in 2000, namely Grant Innes’ article titled “Successful hospitalization of patients with no discernible pathology”. (I am compelled to digress here that the fantastic-ness of the editorials and satirical interjections that interpose the original research published in this journal make it the most entertaining ‘serious’ journal in emergency medicine.)

First of all what exactly is a ‘PWDP’?

Patients frequently present to the emergency department (ED) with complaints of chronic pain, dizziness, neurasthenia, cognitive deterioration, or neuromuscular dysfunction. Generally, they have already undergone extensive and fruitless investigation…. researchers have discovered that these seemingly diverse syndromes are, in fact, variants of a single pathophysiologic entity, designated PWDP (patient without discernible pathology)

Innes G. Successful hospitalization of patients with no discernible pathology.  CJEM 2000;2(1):47-51

How do you diagnose PWDP?

The Innes PWDP diagnostic criteria:

1. Patient has no definable disease or pathology
2. Patient or family members believe hospitalisation is essential.
3. Consulting physicians believe discharge is essential.

In his landmark paper, Dr Innes describes a case illustrating the optimal management of a PWDP using his ‘PWDP Admission Algorithm’. Most importantly he offers a series of fail-proof and easy-to-master techniques for ensuring that the PDWP ‘Gets Out Of My/Your Emergency Room’ – I have paraphrased/ modified these as follows:

1. Recognize high risk patients — be sure to conceal traits such as alcoholism or dementia.
2. When referring, instead of saying ‘chronic’, say ‘paroxysmal’ or ‘explosive’.
3. Order countless investigations, especially ones with delayed results.
   “The India ink stain for cryptococcal meningitis won’t be back until tomorrow”.
4. Be positive: SELL, SELL, SELL!
   “I know he sounds like just another drunk off the street, but you’ll remember that chap with Marchiafava-Bignami disease — he was exactly the same.”
5. Use admission adjuncts — such as the HiTemp thermometer (gives readings between 38.9 centigrade and 38.9 centigrade only) and the Admit-Tech pulse oximeter (gives SpO2 measurements 10% less than the actual SaO2).

Your comments, suggestions and potential additions are awaited and will be warmly welcomed…

Better to admit a patient to the hospital dead drunk than turn him away to be discharged from the jail dead sober a little later

William Osler

Reference

• Innes G. Successful hospitalization of patients with no discernible pathology.  CJEM 2000;2(1):47-51 [fulltext]
• Nickson C. Signs of imminent admission. LITFL