Beware the Bounce-Back!

I learned about Bounce-Backs back in my Emergency Medicine days.  A bounce-back is a patient who you saw in the ER and discharged but then returned within 48 hours with the same complaint.  A lot of time is spent in emergency medicine education talking about how to handle bounce-backs.  The basic message is “Beware! You may have missed an important diagnosis the first time!” 

Bounce-backs happen in correctional medicine, too. Bounce-backs can happen in jails, where we often deal with patients we do not know well. But bounce-backs also happen in prisons, when patients we do know well have a new complaint.  Just like in emergency medicine, a bounce-back in a jail or a prison is a patient who comes to the medical clinic with a new complaint, receives a diagnosis and treatment and then re-kites for the same complaint within a couple of days.  Here are a couple of examples. 

  • A jail patient comes to clinic with a rash and is given steroid cream for eczema.  He returns in a couple of days saying the rash is worse and spreading. 
  • A prison patient complains of a cough and shortness of breath, is treated with an albuterol inhaler, and returns two days later saying his symptoms are worse.
  • A patient returns with the same complaint of dizziness that you treated with antihistamines three days ago.

Clinicians who see the same patient for the same complaint may naturally feel irritation and frustration.  I have myself!  You think “I just saw you for this!  Give the treatment time to work!” There can be a tendency to feel threatened and to “double down” on the original diagnosis:  “I know what I’m doing!” And, most of the time, you will indeed have been correct the first time you saw the patient. 

However, if you see enough bounce-backs, you will eventually find a patient where you missed an important diagnosis. 

It is very important to remember this!   In fact, we need to train ourselves to be grateful to the patient has given us the opportunity to recheck our facts and conclusions.  Such patients can save us from medico-legal disaster. 

The following are the general rules for dealing with bounce-backs.

  1. Always do a more comprehensive physical exam the second time around.  For example, on the dizzy patient, you could do neurological tests you may not have done the first time, like finger to nose, heel to toe gait and rapid alternating movements. You could spend a little extra time looking for visual nystagmus.  For the shortness of breath patient, you could listen long and hard to the heart and lung sounds and check for JVD and edema.  Whatever you did the first time, when the patient bounces back, do a more thorough exam
  2. Seriously consider doing some other diagnostic test.  This could be a lab, like a CBC and a chemistry panel or an X-ray.  A chest x-ray might be an excellent extra test for the guy who bounced-back with shortness of breath.
  3. Consider getting a second opinion from someone else, even if it is a “curbside consult” from a friend of yours or from an online service that offers medical advice such as RubiconMD.  This might be just the thing for the rash.  I often take a picture of a bounce-back rash and send it to my friend the dermatologist. 

After doing a more detailed exam and maybe something else, most of the time, you will be left with the same diagnosis as before.  If that is the case, you also should spend extra time explaining the diagnosis to your patient. 

One cause of bounce-backs is patients expecting to get better sooner than they will.  An example is the patient who sprained his ankle and bounces back in three days saying “It’s no better!” After doing an extra-thorough exam and maybe ordering an x-ray, I need to explain to the patient that sprains typically take several weeks to heal.  If I had done this the first time, perhaps the patient would not have bounced back!

What if a patient bounces back a second time?  Again, do an especially thorough exam and then again do something you did not do before.  This could be another imaging study or more labs. You could biopsy the rash. When patients bounce back multiple times, you should seriously consider getting a formal second opinion. This could be as simple as having a colleague see the patient, or a visit with a specialist, or even sending the patient to the ER.

Bounce-backs are an inevitable part of correctional medical practice.  Take care to develop good habits with them!

As always, what I have said here is my opinion, based on my training, research and experience.  But I could be wrong! If you think I am wrong, please say why in Comments!

Do you have any good bounce-back stories?  Please Comment!

4 thoughts on “Beware the Bounce-Back!

  1. Not funny, but black humor. Young guy, kept saying something is wrong, nothing found. Finally a chest X-ray was done and surprise.. inmate yelling I told you something was wrong. Young guy with lung cancer.

  2. Two thoughts: You are exactly on target – a closer more thorough look on a bounce-back is the ‘best practice’. Had a young fellow – seen at sick call – then later the next evening on a ‘call back’ for sharp unremitting chest pain. In fact, the officer called before I got home.
    He was sent to the ED and on his way out the door the PA said – can’t find anything but lets do a chest x-ray: Thymus enlarged due to cancer.
    On the other hand, over the years, several inmates have returned – even twice in the same week – with complaints that did not seem to be much; and they weren’t. Many of these were attempts to build complaints / torts based on neglect. Of the three that actually went to court: each was found to have been examined, treated and told it was a problem not amenable to further care.
    Hence I’m a nudge about getting medical records.

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