The Question Unasked
I read the editorial by Randy D. Danielsen, PhD, PA-C, DFAAPA, in the November issue (Preserving a “lost art.” Clinician Reviews. 2010;20[11]:cover, 14-16) with great interest, since I could relate to it so well. I was working the ED late one night when a child came in with an obvious head injury. I looked at his father and said authoritatively that we needed a CT of the C-spine and the head. His father, who was also a physician, nodded.
When I got the CT report from the radiologist that all was well, I proceeded to pass on the good news to the father. He looked somewhat relieved, but then asked why his son was complaining about his left ear feeling “full.” I said, “You never told me that.” He said, “You never asked.”
I promptly looked into the boy’s left ear, only to be shocked to see that behind the tympanic membrane, it was full of blood. I called the radiologist and he said, “If you had told me that, I would have looked closer at the basilar region.” He asked me to send the child back for “additional cuts.” He later called back to tell me there was a basilar skull fracture.
Needless to say, I always look in the ears of all my head injury patients now.
Stuart Richards, PA-C, MPAS, MHSL, Scottsdale, AZ
Following Up on Balanitis Article
I just reviewed the Grand Rounds titled “Man, 72, With Peeling Penile Skin” (Clinician Reviews. 2010;20[10]:13-15) by Jan Meires, EdD, FNP, BC, and Bridgette Futch, RN, BSN, CEN, FNP-S. Overall, I thought it was an excellent review of a fairly common clinical condition. Two important points, however, should be noted:
Topical steroid cream is often very effective when combined with an antifungal in the treatment of balanitis. We often use a more potent steroid, such as clobetasol or mometasone, rather than 1% hydrocortisone. Patients must be cautioned about overuse of topical steroid cream, as this can cause atrophy of the skin.
When treating balanitis or balanoposthitis, careful follow-up should always be recommended. I have not infrequently seen a patient with an underlying penile squamous cell carcinoma who went undiagnosed because a good physical exam was difficult when they initially presented with significant swelling and inflammation. Male patients are often in denial when it comes to the possibility of a serious clinical problem; to suggest follow-up “if no improvement is seen” leaves the clinician open to potential medical negligence. Repeat exam and biopsy if the condition persists is, without argument, the standard of care in urology.
Anthony B. Balchunas, MS, PA-C, FAAPA, PhD-c, Waco, TX
HIPAA’s Role in Mental Health Care
Regarding Dr. Danielsen’s editorial in the September issue (A medical catch-22. Clinician Reviews. 2010;20[9]:cover, 13-14): There is another aspect to helping those with mental unease (and other dis-eases) that I would like to be enlightened on, and that is how HIPAA ties our hands.
According to HIPAA, I cannot divulge information about a patient; yet seeing a patient for a short period of time really does not provide adequate information as to how they are doing outside the clinic setting. That information lies with friends and families; from school and through living, we realize that it is essential information—yet HIPAA prevents our asking.
I’m kind of old-fashioned, believing in a handshake, believing that people need support systems. I find administrators who run scared of HIPAA and consequently tend to block the building of the support systems that are needed.
Perhaps HIPAA was a mistake, catering to the loud vocal minority. Perhaps more time and resources should have been spent educating our communities that people with mental illnesses are still part of our communities, that understanding brings more healing than isolating us into smaller and smaller entities. Let’s teach people about all diseases so that shunning and ostracizing become a regretted part of our past cultures.
It seems that medicine and a lot of other institutions are being strangled by rules; and I do believe that increasing amounts of rules reflect a lessening of civil cohesiveness and courtesy.
Calvin Grady Henley, PA-C, Ely, NV