Unusual case histories and implications on care

September 18, 2019

In the course of helping patients, it is possible technicians may encounter unique situations. While some translate directly to care, other concerns regarding privacy or legalities might arise, and technicians should know what to do (or not do) if they happen to come across them.  I address three memorable cases I was involved in and review the relevant points outside of the standard medical or vision care of the patient.

In the course of helping patients, it is possible technicians may encounter unique situations. While some translate directly to care, other concerns regarding privacy or legalities might arise, and technicians should know what to do (or not do) if they happen to come across them. 

I address three memorable cases I was involved in and review the relevant points outside of the standard medical or vision care of the patient.

Case 1: PrivacySCENARIO: New patient, age 22, comes in with her boyfriend. The front desk staffer relays that both patient and boyfriend smell like they have recently been “smoking” and winks at me. I take the patient and her boyfriend back and begin the work-up.

She presents with a medical history that sounds like a corneal abrasion and clearly has a subconjunctival hemorrhage OS. She gives permission for her boyfriend to stay in the room during the work-up.
ME:  I see the red spot on your white part of your left eye. Can you tell me about that?

PATIENT: It happened earlier today. We were parked at a stop sign and as soon as the car moved forward, it happened. (She giggles and looks at boyfriend who smiles but is obviously uncomfortable.)
ME:  Did something hit you in the eye at that point? It may be important for the doctor to know.

PATIENT:  OK. (Pauses.) When the car moved, my "cigarette" hit me.  It does not hurt much even though it is a little bit blurry, but when my boyfriend saw the red spot he said we should go see the eye doctor. (She blushes.) Please don’t let my father see these records.

ME:  (Thinking: OK.)  I’ll let the doctor know. Thanks. Let me check your vision and quickly peek at your eyes, then doctor will come in to check.

I chart the history about lack of pain in that eye, but don’t write that I smell marijuana-or that she asked for the visit information not to be divulged to her father. (I was thinking: Wow, that’s a large abrasion, she’s in no pain, and they both smell like they recently smoked marijuana). 

CONCERN: Privacy has clearly been brought forward by the patient.
– What else should you ask? What shouldn't you do?
– Do you really write all that in the chart? Could I have done anything differently?
– How does our office restrict information, and what can be restricted?

Taking care of the patient’s abrasion and redness is generally straightforward.

I needed to investigate the marijuana smell and the privacy concerns I had to, so I ask the office manager and also tell the doctor before she sees the patient. 

Here is what I learned:

1. Not many people in the office knew about our policies on how to restrict chart access to outside entities. The Privacy Rule under theHealth Insurance Portability and Accountability Act (HIPAA) was implicated, so we all had to know who to ask about it.
It turns out the patient could prevent her father from finding out; that might refer to it. Some states might also have their own rules, so we checked that, as well.

2. I also learned that we needed to restrict the billing records for this visit from outside access from her regular insurance coverage because that also came up when we explained things to the patient.

Related: Technician plays key role in ophthalmic exam CASE 2:  Redness and pain that don't match upSCENARIO:Established contact lens patient presents with severe pain OS and mild pain OD. He tells me the right eye but not the left is red. “I was swimming in a lake a couple weeks ago with my contacts on. I was fine at first, but neither eye seems to be getting better,” he says.

ME:  Were you wearing your contacts while swimming? Any goggles?

PATIENT:  Of course I was wearing my contacts. I don’t have goggles.

ME:  On a scale of 10, how painful is it?

PATIENT:  In my left, it is a 10, and in my right, only a 3 or 4.

ME:  (After taking visual acuities and looking at each eye) You say the eft side is most uncomfortable?

PATIENT:  Yes. At first it was the right, but in the last few days the left is much worse. Nothing I do has helped.

ME:  Have you seen any other doctors since this began?

PATIENT:  Sure, but they did not help me so I left that out. Is that important?

ME:  I’ll be sure to let the doctor know and he can decide. Let’s get more information.

CONCERN: Lots of pain but not very red in that eye. Only a few conditions cause this.

– What do you want to know that we didn’t already ask? Part of my learning in this situation was that I should inquire next time about:
– What contact lens solutions is the patient using? How often is the patient replacing his lenses? Be sure the answer is honest.
– Were the other medications pills or drops? Who prescribed them and when? Was there a good or bad response?
– Did the patient have “person-to-person” contact with someone with an eye infection?
– When was the first onset of symptoms for each eye? Have there been changes since onset?  Did the patient use a hot tub?
– Was either cornea uncomfortable before the swimming?

Final diagnosis showed that each eye had a different problem:

1. OD: bacterial corneal ulcer. It resolved fully with treatment.Final visual acuity was 20/20 corrected.
2. OS: Acanthamoeba keratitis. Treatment of the eye may take 6+ months to resolve (if deep). Final visual acity was 20/100 corrected. The patient may eventually require a corneal transplant in this eye.
This was my first time as a tech working up a patient with this disease. After the doctor explained some things, she sent me to learn more on the Centers for Disease Control (CDC) website.

Related: Teaching skills for successful technicians CASE 3: Why is the patient wearing a facial mask?SCENARIO: Established patient returns for a follow-up visit. He was last seen two weeks ago for an intraocular pressure (IOP) check; the doctor changed his drops and he is back to see if IOP has responded.

He is wearing a surgical mask that he was not wearing on the previous visit.  His uncle comes with him to exam the room.

ME:  I show you as taking meds only for hypertension and the new eye drop.

PATIENT: Yes.

ME: May I ask why you are wearing the mask?

PATIENT: That’s because my relative is sick , and I don’t want to catch it, too.

ME: I’m so sorry. Can I help?

PATIENT: The doctors say he is going to need special medicine, but I think you might want to get a mask for yourself and also for my uncle sitting with us-he’s the sick one. I did not want to scare anyone in the waiting room.

ME:  Right away! (I get a mask and show the uncle how to put it on). The doctor will be in to check your eye pressure next. I’ll let the doctor know about your uncle, too.

PATIENT:  Thanks. We are headed to the TB clinic next. His other doctor told him he might have something called “XDR.” I don’t know what it is.

CONCERN: A communicable disease could be present in your clinic at any time. Always be aware, and if you suspect it, get all the information needed to protect yourself, your patients, and other staff.
Let the doctors know. Restrict the patient and caregiver to the exam room they are in now until cleared by your doctor. 

In this example, I learned about “extensively drug-resistant tuberculosis” (XDR-TB). Promptly ask for help on what to do next if something does not seem right. It might not be a big deal-but it could be.

Conclusion
Technicians will run into out-of-the-ordinary things at some point in their careers. Sometimes your radar goes up on the exam, and others will happen while taking the history. At either point, your actions as a technician can be sight-saving as well protect yourself and others from potentially communicable diseases. Ask for help when you are unsure.

Communicate your concerns to the doctor before she encounters the patient even if you haven’t charted it yet becausethe final decision on what should (or should not) be in the medical record lies with her.

Don’t forget that patients have privacy and legal rights and those state and legal regulations must be followed. I have also learned that having a good “poker face” is helpful.

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References:

1. U.S. Department of Health and Human Services. The HIPAA Privacy Rule. Available at: https://www.hhs.gov/hipaa/for-professionals/privacy/index.html. Accessed 9/12/19.
2. Lorenzo-Morales J, Khan NA, Walochnik J. An update on Acanthamoeba keratitis: diagnosis, pathogenesis and treatment.  Parasite. 2015;22:10.
3. Centers for Disease Control and Prevention. Acanthamoeba Keratitis Fact Sheet for Healthcare Professionals. Available at:  https://www.cdc.gov/parasites/acanthamoeba/health_professionals/acanthamoeba_keratitis_hcp.html.  Accessed 9/12/19.