Chapter 48: An Important Insight

December 6, 1987, McKinley, Ohio

“What happened overnight?” Nadine asked quietly after we escorted Claire to surgery and turned her over to a Fourth Year in OR 3. “Her dad was really pissed.”

“You knew she was a bounceback, right?”

“Yes.”

“That’s it. Her dad is upset because we sent them home, but Doctor Casper told the truth — her white count was normal, she had no signs on palpation, and the ultrasound showed nothing diagnostically significant, nor did the urine tests. The options were to keep her for observation or send her home. I was sure it was a stomach virus, but I was wrong.”

“Did you say that?”

“Yes. I also said I’d have kept her for four hours if the ED wasn’t busy, which it wasn’t. I felt it was better than having them drive home and drive back. Doctor Olson called it a defensible, conservative approach, but made the point that the Emergency Department isn’t meant for babysitting a patient who doesn’t meet the criteria for admission and for whom there is no immediate treatment necessary. She wasn’t vomiting enough to need Compazine or fluids. That’s why Doctor Casper sent them home.”

“You’re on until 8:00pm tonight, right?”

“Yes. Tomorrow morning for you, right?”

“5:00am! Yippee! How are you liking Pedes?”

“It’s not as exciting as running a trauma or surgery, but I get a chance to talk to the kids and it’s fleshing out what they told us about kids not just being miniature adults.”

“I do not do well with kids! And you know my style — a sedated patient is a compliant patient!”

“Spoken like a true wannabe surgeon!”

“And I need to scrub in!” she declared.

She went to the scrub room, and I headed to the elevator and rode one floor down. When I exited the elevator, I saw Doctor Olson at the nurses’ station, so I walked over and let him know we’d transferred Claire to the OR.

“What did you learn?” he asked.

“That there are always judgment calls, and they have to be made based on actual evidence, not gut feelings. There were literally no more tests to run, and short of an ex-lap, we were out of options.”

“Correct. And why no ex-lap?”

“Because there was literally nothing to indicate a need for general anesthesia and an invasive surgical technique that has an operative and post-operative mortality rate of around five percent for patients without penetrating trauma. Sure, we’d have seen signs of an inflamed appendix which weren’t appreciable on ultrasound, but it’s not worth the risk on a five-year-old.”

“Exactly. And keeping her here versus sending her home?”

“You had no diagnostic indications for admission, which you told Doctor Casper, and he judged it was best to send her home. As you said, either position is defensible. I’m curious — but are there any situations where your gut would override the appreciated symptoms and test results?”

“In a case like this? No. In a mysterious case, yes. Honestly, Mike, your diagnosis of a stomach virus was a good one, but she hadn’t vomited enough to indicate that. Heck, it could have been something she ate that didn’t agree with her, but which wasn’t sufficient to make her ill, beyond expelling it from her stomach. If there’s another lesson to learn here, it’s that we almost always are working with incomplete information. I’m sure you’ve been told horror stories about incomplete histories.”

I nodded, “They made that clear in our coursework, and I’ve almost been burned a few times because I didn’t ask the right question in the right way.”

“You and every other medical student and physician on the planet. And some things mask other things. You end up chasing your tail because all evidence points one way, but the actual answer is the opposite direction. That’s where you’ll likely lose your first patient in the ED. You’ll do everything exactly by the book and policy, they’ll die, and McKnight or his Resident will tell you where you completely screwed up, even though you didn’t. If you get what I mean.”

“My wife,” I said quietly. “Though nobody screwed up.”

“Those are the toughest cases of all,” Doctor Olson said. “When there is literally nothing we can do because we can’t even diagnose the problem.”

“I spoke with Doctor McKnight about it in detail, and he feels the new CAT scanner we’ll have up and running in January might have been able to detect it, but even so, there is no known procedure to repair it.”

“That’s even worse, and the first time you have to tell a loved one that you know what’s wrong with a patient and you can’t treat it is where you’ll discover if you’re really cut out for this mentally and emotionally. For me, the worst was during my second OB/GYN rotation with a stillbirth. The baby died in the womb the morning the woman went into labor. No known cause, even on autopsy. They called it ‘sudden in utero death’. Try explaining that one.”

“Having seen the effects of my wife’s death on her mother, I can’t even imagine losing a baby. And at that point, nobody is arguing it’s not a baby.”

“You seem to be doing OK.”

“So long as I focus on caring for my daughter and on my medical training,” I replied.

“If you can stay focused despite a personal tragedy, you belong in emergency medicine. The thing that you’ll have to watch out for is becoming too involved with your patients.”

“Something I’ve been reminded of quite regularly. And I understand, but I also feel that at times medicine is too impersonal. I do understand that a primary care physician should develop a relationship with a patient, but I also think we’d provide better care if we spend just a bit more time with patients.”

“Which you could do in just about any discipline except emergency medicine. The thing is, nobody thinks you should do anything other than what you’ve planned, because it fits your skill set. I’ve read your evaluations and every single one of them says you’re on the right career path.”

“Isn’t medicine holistic?” I countered.

“I don’t disagree, but that’s the role of the primary care physician, or less so, a service like mine. What’s your job in the ER?”

“Triage, diagnosis, and stabilization.”

“And in surgery?” he asked.

“A specific procedure.”

“And in each case, what happens when you complete your task?”

“The patient is handed to another service or directed back to their primary care physician.”

“And I suspect you think we’re sounding like broken records at this point, but the system works, and if you were in a busy ED in New York City, Chicago, Los Angeles, or Detroit, you wouldn’t have a spare second. Have you considered a rotation in an inner-city public hospital?”

“Yes, but my situation makes that difficult.”

“I think it would be both very frustrating and very instructive, and would make you a better doctor.”

“Which is the opposite of what I think will make me a better doctor.”

Doctor Olson nodded, “Obviously. And this is where you need to accept that your instructors know what they’re talking about. You’re a Third Year, Mike, and you’re in rarefied air because we all see you as a natural. That fills you with confidence, but it also feeds your ego, and that is the most dangerous thing possible at this stage in your training.

“I am not telling you to abandon your idealism or your ideas for improvement, but I am telling you to follow the training program and listen to your mentors. There’s a reason they’re all telling you the same thing, and that comes from a century of experience in training doctors. Does that mean there is no room for improvement? Of course not. But does that mean you are qualified to determine what should change? No.

“The problem, as I see it, is that you’ve actually effected change and that is giving you misplaced confidence to change anything you feel is wrong. The thing is, you don’t have the experience to understand the ramifications of changes you propose. Granted, you’ve been right, but you can’t let that go to your head.

“Let’s take the hot appy as an example. You were right, but you based that on an idea of unlimited resources. As soon as you were asked about limited resources, you changed your mind. What’s the problem with that?”

I thought about it for a moment before I answered.

“I’m not sure, actually. The resources were available.”

“Yes, they were. But you can’t predict what is going to happen in the next minute, and if a patient with no emergent condition is occupying your attention, your Resident’s attention, and nursing attention, as well as an exam room, that’s using resources and might distract you from a more serious problem. What you can’t do is think that the bounceback justified your decision, because hindsight is always 20/20.

“The facts were that she had no emergent symptoms and ‘gut feeling’ isn’t enough to expend resources. In this case, my gut was right, but that’s not science, that’s witchcraft. You need to understand the difference, and understand when it’s OK to go with your gut and when it isn’t. Decisions based on your gut have to be reserved for situations which are potentially immediately fatal and where you have insufficient data to make a fully informed decision.”

“Message received,” I replied.

Doctor Olson smiled, “Don’t pull back too far. My goal isn’t to get you to shut up, but to get you to understand how little you actually know compared to how much you’ve learned and how much you might think you know. This is a common problem for top students. You’re champing at the bit, and it’s our job to pull back on the reins gently to keep you from bolting.”

“This is a different side of you than I’ve seen.”

“The class clown schtick has its place, and you deal well with it, but right now, you need to hear me as an instructor.”

“Got it.”

“You’re doing well, Mike. Focus on learning enough to know when you’re making good suggestions. Don’t,” he smiled, “just go with your gut.”

“Thanks, Doctor Olson.”

“You’re welcome.”

I went to the lounge to update my pediatrics notebook and made notes about the conversation with Doctor Olson in my general notebook. I finished my updates and decided to go talk to some of the kids, but first stopped in the restroom. After that comfort break, I went out into the corridor and was almost bowled over by Cathy.

“Chuck is seizing!” she declared.

I hurried after her and entered the room just behind her. Doctor Olson ordered diazepam and Faith quickly injected it into his arm. Without an IV, it was an IM injection, which wasn’t as effective, but until the seizure ended, putting in an IV was impossible. The seizures continued, and after about five minutes, a second dose of diazepam was given, and that worked.

“Cathy, Ringer’s IV; Mike, portable cardiac monitor!” Doctor O’Neill ordered.

I left the room to get the portable monitor and wheeled it into the room. At Doctor O’Neill’s direction, I began hooking up the leads while Doctor Olson completed a physical exam.

“We’ll need neuro,” Doctor Olson said. “Cathy, please page them.”

“Sinus rhythm; pulse 90; PO₂ 95% on nasal cannula,” I said.

I checked Chuck’s BP and reported my findings.

“BP 180/100,” I said.

“Faith, I want a CBC, Chem-20, and ABG,” Doctor Olson ordered.

Faith drew the blood and handed the tubes to Cathy to carry to the lab.

“Vandenberg, Neuro,” Doctor Lucy Vandenberg said, coming into the room.

“Sixteen-year-old male football player; postictal after two doses of diazepam; hypertensive and tachy; suffered a concussion from a blindside tackle on Friday night.”

“First seizure?”

“Yes. He was neurologically clear until he seized without warning.”

“LOC at time of the injury?”

“Not reported,” Doctor Olson said. “He didn’t recall anything from the time he was hit until he was in the ambulance, but he recalled the details of the play where he was injured.”

“Skull series?”

“Negative. No apparent hematomas; no skull fractures. The images were reviewed by Doctor Sanders, per the chart.”

“Let’s get a complete set of films and move him to the ICU for a full-time monitored bed. Nurse, 50mg of Dilantin in the IV bag, please. Let’s stay ahead of the problem.”

Cathy administered the drug from the emergency medication cart.

“He’s stable enough for us to get him down to Radiology,” Doctor Vandenberg said.

“You don’t want anything for the hypertension?” Doctor O’Neill inquired.

“Yes, but I want to know what we’re dealing with first, if possible. I’d like to see the labs. What was ordered?”

“CBC, Chem-20, and ABG,” Doctor Olson replied.

“Let’s also get LFT, please.”

Faith drew another tube of blood and handed it to Brenda to carry to the lab, as Cathy hadn’t returned.

“We don’t want to wait for orderlies,” Doctor Vandenberg said. “Mike, Matt, you come along.”

“Do you want a portable monitor?” I asked.

“I don’t want to wait. He’s hypertensive and tachy, but his rhythm is good. Get a gurney from the corridor.”

I quickly went out to the corridor and spotted the gurney, released the brakes, and brought it into the room. After disconnecting all the monitors, I moved the IV bag, then everyone worked together to move Chuck to the gurney. In the absence of an orderly, it fell to me to push, with Doctors Vandenberg and Olson walking next to the gurney and guiding it into the elevator.

Fortunately, there was no repeat of the problem, nor did Chuck crash during the scans. Once all the images had been taken, we moved Chuck to the ICU. Doctor Vandenberg had arranged for a bed while we were in Radiology, and the ICU was ready for us. Once we turned him over to the Resident, Doctor Olson and I left and headed back to Pediatrics.

“How often does that happen?” I asked.

“There’s no pattern,” he replied. “I’m sure they’ll find a hematoma in the new films. We really need that new CAT scanner up and running.”

“About a month, right?”

“Assuming there aren’t any problems, yes. And moving radiology to their new space is step one in the complete reconfiguration of the hospital. I don’t know if you heard, but the fund-raising is ahead of schedule and it looks as if they’ll begin a few years earlier than planned.”

“I hadn’t heard,” I replied. “That’s a good thing,”

We arrived back in Pediatrics and went to see Doctor O’Neill to let her know Chuck was in the ICU.

“Matt, your appy perffed before they got her under.”

“Damn it!” he growled. “Her dad is going to lose it.”

“So quickly?” I asked. “She was asymptomatic except for nausea and a generalized complaint about her tummy hurting.”

“Sometimes it takes a week, sometimes four or five hours,” Doctor O’Neill replied. “And there is no way to predict it.”

“How is she?” Doctor Olson asked.

“They got her off the table after a lavage, and she’s on IV antibiotics, as you’d expect. Her vitals are OK. Mike, what are the risks?”

“Peritonitis or abscess are the primary concerns, but the abscess will have to be dealt with by the surgeons if one occurs. For peritonitis, IV antibiotics and close monitoring.”

“They’re sending her to the ICU. Matt, did you fill out the chart completely and accurately?”

“Yes,” he replied.

“Who decided to send her home?” Doctor O’Neill asked.

“Doctor Casper, though I agreed with him because I couldn’t take her on our service or recommend her as a surgical case based on the appreciated symptoms.”

“Was that conversation private?”

“Ghost, Mike, and me in the corridor. Her parents didn’t hear us.”

“I’ll want to see the chart, but from what you’re saying, I’d say both you and Doctor Casper made the correct decision based on the information you had available.”

“Teri,” Doctor Olson said, “just so you have all the information, Mike did suggest keeping her for four hours of observation.”

“I hope to God that was privately.”

“It was,” Doctor Olson confirmed. “Mike’s with the program.”

“Was that noted on any charts?”

“Not by me,” Doctor Olson said. “I doubt Ghost would have written it down.”

“Mike, you do not share that with anyone,” Doctor O’Neill said. “Understand?”

“Yes,” I agreed.

“What was your reasoning?” she asked.

“Besides Claire, there was basically nothing on the board except for a single rule-out MI. I felt it was better to keep her for a few hours and if nothing changed, then send her home. Doctor Olson and Doctor Casper felt she’d be more comfortable at home and that her parents could bring her back if she had new symptoms.”

“What was your reasoning?”

“An overabundance of caution,” I replied. “I sat through the EMTALA lecture and the resources were available, so why not use them? Doctor Olson made the point that we can’t know what’s going to happen, and tying up an exam room and medical staff for what might well have been a stomach virus made no sense.”

“You do have one thing to worry about,” Doctor Olson said. “And that’s that I told Mike my gut told me it wasn’t a virus.”

“Just Mike, right? Not Doctor Casper?”

“Correct.”

“Then keep that to yourself, please. Discussions with medical students are purely hypothetical and about teaching.”

“And if I’m asked?” I inquired.

“You answer the questions you are asked by anyone with the authority to ask you, including in an M & M, but medical students usually aren’t asked to participate. You don’t volunteer that information because it was based on your personal preference, not medical knowledge. Do you have a problem with that?”

“No, Doctor.”

“Somebody from legal will probably talk to both of you,” Doctor O’Neil said.

“Even if she’s OK?” I asked.

“Her dad threatened to sue, and when those words are spoken aloud, we have to consider that they are meant and take them seriously.”

“And the hits just keep on coming,” Doctor Olson said, shaking his head. “Two kids going south in a few hours sucks.”

“It does,” Doctor O’Neill agreed. “Counter that with the fact that you made the right call on the coin ingestion and saved the kid an endoscopy. Don’t let a defensible diagnostic call get you down.”

“Oh, I’m not,” he replied. “It’s the idea of being sued for not being a witch doctor!”

“There’s no malpractice here, from what I see,” Doctor O’Neill countered. “Lawsuits happen. You only worry about what the Medical Review Board has to say, and you’re completely in the clear with them when you follow established procedures. You didn’t miss anything and you have the test results to back that up! Go get some lunch.”