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


Utopian College of Emergency for Medicine

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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