Why Doctors Should Never Assume 

Yep, and don't assume that just because a child gives a different answer than their parent that the parent is correct. Especially if that child is a teenager. I had very concerning symptoms brushed off after a few very basic tests as "stop being dramatic" because my parents attitude was clearly "I'm here so you can tell my kid they are fine because they won't listen to me". Yeah, it turned out my "drama" needed surgery. Surgical recovery was a joke in comparison.

I remember getting a child up from ER to paediatrics for a lumber puncture, with a non blanching rash. She’d drawn it on herself with a felt tip pen. Had managed to panic her mum, the GP and ER staff despite being perfectly well looking. I was early on in my nursing career but my more experienced colleague just shook her head and washed it off with a swab. Paediatric consultant took great delight in phoning the ER consultant😢😂

Low blood count + high bilirubin and no pain makes me think hemolytic anemia so I would order an haptoglobin level, LDH level and I guess a Coombs test

I'm grateful for the providers who take the time to think a bit deeper and explore some options. It can make all the difference!

This is what makes the difference between an adequate doctor and a great doctor. I've had both: ones who just go to the most likely answer without much thought and those who really consider all the elements before reaching a conclusion. I am so grateful for the latter.

In Veterinary Medicine, we call that IMHA Immune-Mediated Hemolytic Anemia. There are different forms, and generally you just wait for steroids to work. Give blood and hope for the best. My first dog died of IMHA, and she's why I'm going into vet med!

Key here is "don't JUST assume" - TEST! Rule out the most likely cause until you arrive at an answer backed by a reliable positive test.

But most medical professionals get by with gaslighting, neglecting and abusing patients and saying "it's just anxiety"

My blood banking experience comes into play! I was like, they don’t even know the indirect or direct bili.

Never assume, it makes an ASS of U and ME. -Infecious Disease Attending

Thank you for paying attention during medical school! I just have a lowly English degree, but I am amazed at how many doctors I've seen that only think within a very narrow corridor. If you are outside of that, you are out of luck and on your own until you find a doctor who can think in wider terms.

What a bummer of a diagnosis, though. The body is trying to kill itself

I went to the ER as a young kid screaming my bloody head off. My parents couldn’t explain what might be wrong because as far as they’d seen I was just watching TV and suddenly started shrieking about my arm hurting. Therefore the doctors didn’t see the point of an xray and decided I was just a kid seeking attention. It wasn’t until a different doctor came by after hearing about the case from my main doc that he took one look at my arm and said “It’s dislocated.” I’d somehow managed it just by leaning back on it. If he hadn’t done that I would’ve been sent home

Great job. You paid attention to the details and did not assume. You saved her from an unnecessary surgical procedure and got her the help that she really needed for the condition that she had.

With all due respect, this isn't because you didn't assume… this is because you took the time and had the knowledge to look deeper than “most likely”. It is because you are a caring doctor who takes your time to look beyond the low hanging fruit.

This is one of the pitfalls of subspecialists in general. To anyone with a hammer, everything's a nail. We have to always ground ourselves and never forget our general medicine.

Well done. I'm sure she was glad to not have to undergo an unnecessary procedure

I have autoimmune hemolytic anemia so I got this the second you said elevated bilirubin lol.

I got the hemolytic part correct, but Im still wondering... why was the bile duct enlarged? As far as I know, hemolysis doesnt cause dilation there? Just a coincidence?

Considering how important we learned the difference between direct & indirect bilirubin to be (as a Medical Lab Scientist), the fact that unfractionated bilirubin seems to get ordered this often is a bit concerning. Great job, doc 💯

Love that. I work as a lab tech and we see this frequently.

Great advice, but if the patient had no symptoms, I don't see why you'd go for an ERCP in the first place. Why not an ultrasound first to rule out stones? And an abdo CT if you're suspecting a mass? Please, I'm always trying to learn.

Great work Doc Schmidt!

Hey Doc **Eats an Apple**

After many years of having liver disease with enzymes only slightly abnormal and high bilirubin, I found out I had Gilbert's syndrome. It was actually during an admission for unexplained edema in my legs that they decided to genetically test for it. Learned that my indirect bilirubin will always be abnormal and to use the direct bilirubin as a marker for the condition of my liver cirrhosis.

You just reminded me, I'm supposed to have asked for a secondary cardiologist opinion.

Good catch, doc!

I almost received an unnecessary appendectomy when I was in college. During class, I had a sharp pain that quickly got worse. The health center ran every test they could on me, then told me to go to the hospital. By the time I got there, I was at a Level 8-9 pain. After bloodwork and X-rays, all doctors and nurses were in agreement that I needed to get my appendix out before it burst -- Except One. He said to me that he didn't think it's appendicitis. If I'm at a Level 9 pain, it isn't going to get much worse. He wanted me to stay overnight with an IV drip and be monitored. I went with his suggestion. In the morning, I felt much better- Pain Level 6. He told me that if it had been appendicitis, I wouldn't be feeling better. It was an ovarian cyst that had ruptured, which caused the sudden sharp pain. It doesn't sound like much, but the pain was excruciating! It's scary how close I was to getting an uncessesary surgery.

Please do more of these!!!

Nice! But what about the dilated CBD? Was it just incidental & asymptomatically coexisting?

Thanks for sharing this case! I am starting in GI soon and am learning a lot from your channel!

Strong work doc!!

I hate hate hate autoimmune mediated hemolytic anemia. I'm glad your patient was ok, but that's a horrible disease. It killed my dog in under 48 hours. She went from being perfectly healthy to dead in 1.5 days. Just days later, we got a patient in the hospital I worked for, a young man with children who died almost as quickly. With my dog, transfusions were not an option, but the man obviously received many transfusions. I had literally never heard of immune mediated hemolytic anemia (I'm not clinical). Now I tell everyone about it.

Really neat!

Then what explains the dilated bile duct?

Medical doctor here. Did the patient have a cholecystectomy in the past? If so that’d explain the enlarged bile duct. Also is it possible for the common bile duct to be dilated without dilation of the intrahepatic bile ducts in the case of a blockage? Thanks :)

Pause point guess: bili is high because blood cells are being broken down, not related to bile duct

That is great

0:46 Sounds like an internal bleed. Low blood count and lack of pain would be explained by that. 1:11 eh, somewhat close. They're losing blood cells, but not by bleeding.

Well, you need to attune some basic stuff, like the patient will beheave to the medication as it's expected, otherwise there wouldn't be a quick treatment and further unnecessary analysis would be needed before giving a treatment

I think CBC with decreased Hb would solve it.

Once when I went in for a rash, I had a doctor assume I had a peanut allergy without running any tests. I was tested a month later and...nope

I thought she had a hemolytic anemia, but why was the bile duct dilated?

Why didnt they do an uktrasound first if they thought it was a stone before calling yous for ercp

cause of dilated bile duct??

The worst doctors I have experienced for assumptions (apart from those with a Doctorate in Education) are Psychiatrists.

Sounds like the patient is constipated

but then why was the bile duct dilated?

Ofcourse, only an amateur would do an ERCP at first step. It should be CT scan, if no evidence found then MRI.

The first rule of Medicine Club is to assume you should never assume 😏

Why wasn't direct and indirect bilirubin asked for in the first place? When you look for a reason of jaundice, aren't you supposed to ask ask for bilirubin (direct+indirect), ast,alt, ggt, alp, for a diff dg...

Assuming can kill. When I was 6, I developed all the symptoms of a bleeding ulcer. The doctor, following the dogma of the time, assumed that children couldn't get ulcers. He further assumed that because I was an only child, I must be faking it for attention. (Yeah, I guess a six-year old studied up on the symptoms and managed to mimic all of them perfectly, that makes perfect since, right?) Then one day I collapsed at school, curled up in a ball, and was in too much pain to move. Mom came and carried me in her arms to the only other doctor in our small town. That doctor looked at the actual symptoms and took an xray. He started to chew out my mother for not bringing me in sooner. When he paused to draw a breath, Mom told him she'd been taking me to the other doctor. He was livid. "That quack!!!" He marched over to the phone and called the other doctor. "I have a patient of yours here, a little girl you tried your hardest to kill!" A somewhat lengthy "discussion" ensued. Don't recall much, other than hearing the word "quack" several times. Even when we moved to another town several miles away, I went to that doctor until I went to another state for college.

I honestly wish you were my Dr. I feel like I wouldn't ge questioning just what the heck is going on with me and actually getting some kind of answer that doesn't involve trying to put me on medications I can't take.

And why was the bile duct dilated?

Yet "drs" still "practice" medicine up to and past what your insurance will pay for unnecissarily

I mean, I'm not a doctor. So I had no answer.

Dude, lab scientist here, probably could have told the er doc that before you were ever called just due to repeated redraws on the poor patient. Usually after we have one of our own do the phlebotomy and we know it's completely non-traumatic we're like hey doc so uh yeah you might want to consider something here.

Why is no one asking why this person was in the ER with no symptoms?

But why would the bile duct be dilated? Does it sometimes occur occasionally?

Just like life ❤

Wait, in my country, if we order a Bilirubin test, direct and indirect are included. Is it not like that in other countries?

isnt't this basic diferential? and how come Brb doesnt come fractioned already from lab? who just orders total Brb?

Rectal prolapse? 🤔 💭

I appreciate doctors who give a shit 👍

The ER doctor who calls GI for ECRP on obvious hemolytic anemia should just retire

Hemolytic anemia

I KNEW IT WAS ANEMIA 💀

The interesting part... is that they assume a ton of times, even more with women...

Im gonna guess G6PD causing hemolytic anemia and liver damage. Our MH clinics have been doing a lot of genetic testing to better prescribe MH meds. I’ve had a lot of people find they have this deficiency. I need to read up on it bc it apparently affects a lot of systems. Also I love that the alk phos is normal so hopefully no malignancy- although that’s probably more of a measure of bone issues. Ok- unpause!

My dr links everything to my weight. If I had a bone fracture she'd tell me to lose weight and it wouldn't hurt.

If I saw me as a doctor, I'd ask to see somebody else! Seriously, all the armchair wannabes haven't the chutzpah it takes to Be a Doctor. Kudos .

So, why the dilated bile ducts?

Congratulations. You used your brain and acted logically.

❤

It’s ok to assume everything the cdc says is spot on though right doctor Schmidt? Safe and effective. Don’t forget to vaccinate your kids with the Covid jab Schmidt. CDC protocol

Anddd cue the comments of a bunch of people who could barely finish high school criticizing medical doctors for being lazy or dumb

How’s this tricky, literally second year med school

YAY! I was right! I commented before end of video yay me 😊

I'm not a doctor and I don't do well at science. And though I had heard the terminology before, you would have to draw me a picture to show me where the stone and the bile duct and all that stuff was. Plus I need to watch ER sometime again soon. A few weeks ago I missed a zebra. Anyway the only word I really knew was hemolysis. You would think... no you wouldn't. Gray's Anatomy is always doing chole whatevers But they never go into the details. Anyway at least on Monday I got to the pheo (One of everyone's favorite zebras) At least half a minute before the doctor did. Yay me. I'm falling down on my fictional medicine. And a couple of seasons ago I watched two surgical residents in the ER look at a patient who was a college student with meningitis for like 45 minutes before they figured out what was wrong with them. Oh come on people! Two college roommates. Look at that thing on their skin that you are calling a rash! It looks kind of like what those kids on ER had and I think it came through more than once. Apparently now that there are vaccinations for such things doctors don't learn about them. This really isn't good. I still know what diphtheria is supposed to look like. And that's from a Cherry Ames mystery novel that I read when I was a kid. I mean like maybe 10 to 13 years old. Oh. It was in the '70s but the book was written in the '40s. And cherry Ames was the nurse version of Nancy Drew. I never did read Nancy Drew. And I don't know whether I could read Cherry Ames now either. Too much mystery, not enough medicine. But I guess we could all learn how to do a wet to dry dressing. I wonder if they have those anymore...

This is the main reason why I’m against people self diagnosing when they have symptoms. Differential diagnosis is hard even when you’re trained, if you don’t have expertise and experience it’s going to be nearly impossible for you to sort through the pantheon of possible causes for any given problem.