Let Me Call It In For You

These days they have navigators for everything.  When we got lost back in the day, we used to consult a map, or lacking a map, we would pull in to the nearest “filling station” (what we used to call gas pumps) and ask for directions from the friendly young man who would appear to wash our windshield, check the oil and the tire pressures, and of course, pump the gas.  Not anymore. These days we type the address we are seeking into our smart phones, and a nice man with a somewhat generic British accent directs us to “turn left in 0.3 miles.”  No intervention—no human interaction required. Medicine has taken navigation one step further—now it is quite fashionable to have “cancer navigators”, usually registered nurses, who help a patient from the shocking time of diagnosis, to the myriad choices for treatment, to coping with survivorship.  But so far, I have never heard of emergency room navigators, and to the best of my knowledge, this is an area ripe for harvest.

In medical school, a great deal of time is spent teaching students to take a relevant history, called the “history of present illness.”  This would seem like a simple thing, but in reality it is quite complicated.  Each patient perceives and gives weight to a different aspect of her symptoms, and the events leading up to her appearance in the emergency room at 10 pm on a Saturday night.  What takes us four years to learn in medical school often eludes patients—the pertinent parts of the history and physical symptoms which may lead to an appropriate hospital admission, or conversely a waste of a good hospital bed, or even worse an inappropriate discharge resulting in the death of a patient.  The fact is, that if a patient cannot put together a concise cogent account of the events just prior to showing up in the ER, the attending physician is disadvantaged to the point of making a serious and sometimes grave error.

A case in point—a few weeks ago a good friend of mine in another state had a skin cancer removed from her neck.  A few days after her surgery, she was feeling poorly and noticed that the incision site was reddened and tender.  I urged her to go back to the surgeon, but he had been abrupt with her and she was more comfortable going to her primary care doctor.  The primary was not used to evaluating surgical wounds, but sensing my friend’s discomfort, she prescribed a course of antibiotics to cover typical skin infections such as staph and strep.  My friend began the medicine but that evening she experienced a bone shaking chill followed by a temperature spike, and her incision opened up, allowing drainage.  She called me, barely able to speak, and I directed her to go to her nearest emergency room at once.  I offered to “call it in for her”—to speak to the triage nurse or the ER doctor.  She said she would let me know where they were going.  But she did not.

When she appeared in the emergency room, she told the ER doctor that her chief symptom was a severe headache in the posterior occipital region. It was the worst headache she had ever had.  My friend ending up getting a noncontrast CT scan, which thank goodness was negative for a brain hemorrhage or stroke.  She was given Valium and Demerol and Compazine, and then Vicodin “to go” and was told she had a bad migraine headache.  As best I can tell, no one ever looked at the surgical incision on her neck.  My friend survived, but only because she continued to take the Bactrim DS, two tablets twice a day, that her primary care MD had prescribed empirically.  She did enjoy the Vicodin and the Valium.

The moral to this story is:  when you’re sick and your fever spikes to 103 and your doctor friend offers to “call it in for you”—that is, speak to the triage nurse or the emergency room doctor—take her up on it.  It might just be a migraine, or a tension headache, or a virus.  But it might be a life threatening disease or infection.  Doctors spend years learning to decipher symptoms and to dissect out the relevant parts of a history.  We speak the same language.  Let us help you.

Atonement

At one of the boarding and training stables where I took riding lessons, there was a custom passed down through generations of instructors and eager children.  If a horse managed to unseat a young rider, the slightly bruised and dirty little victim was allowed to pull a few strands of said horse’s tail.  The instructor would braid the strands–black, or white, or grey or red—into a thin plait and secure the ends with rubber bands.  This small symbol of failure was sent home with the child with the pronouncement  “You cannot be a REAL rider until you’ve fallen off THREE times!”   Three braids of horse hair pinned to a bulletin board and a rider you shall be.

As a fourth year medical student, I eagerly embarked upon my “subinternship”, a make-or- break rotation for aspiring doctors where the student was expected to function as an intern on the admitting team, which consisted of two or three interns, a junior or senior resident, and an attending physician.  Each “Sub-I” took new patients admitted from the ER  in rotation with the real interns, and we were supposed to perform a history and physical, order appropriate tests, come up with a differential diagnosis and present the results to the attending physician on rounds the next morning.  My first “admit” was an elderly woman, massively obese, who had been found at home alone on the floor, in an altered state of consciousness.  After an EKG in the ER showed she had not had a heart attack, she was sent up to the floor to be evaluated. No one had been able to draw her blood in the emergency room—they could not find a vein and since she was stable, they sent her on up.  I was well trained in the art of blood letting, yet after two hours of poking and prodding various sites where veins were known to hide, I reported to my senior that I had not been able to coax out a single milliliter.  He said, “Well, go on home then, we’ll get the IV team to do it when they come around to start her IV.”  I arrived the next morning for rounds and terrible news.  At 2 am, my very first patient had had a cardiac arrest, and in fact she had died when the “code” team could not rescusitate her.  But, oh, they had gotten blood out of her then.  Her potassium level was 7.5, incompatible with life.  She had been in kidney failure and we had not known it.  The blood test which had not been done the evening before might have saved her life.

As a senior medical resident, in charge of such an admitting team, I rounded daily with the interns, dispensing sage advice on each patient on our floor.  Three days in a row we rounded on a lady with late stage breast cancer, in the hospital receiving chemotherapy, then given in the hospital due to significant side effects which in those days had few remedies.  Three days in a row, she had complained of leg weakness, which we attributed to the debilitating effects of her chemotherapy.  Of course she was weak, she had CANCER and was getting CHEMOTHERAPY.  On the fourth day, she was to be discharged home.  As we rounded, her complaint of leg weakness had changed.  She said, “I cannot move my legs.”  Indeed, she could not move her legs.  On our watch, she had suffered a spinal cord compression from metastatic breast cancer to her spine and was paralyzed.  Spinal cord compression is one of the most dreaded complications of cancer.  Unless detected in the early stages of weakness and numbness, it is nearly always irreversible.  Almost unbelievably, as an inpatient attended daily by a multitude of students, interns, residents and senior physicians, this woman walked into the hospital and left in a wheelchair, never to walk again.

In the emergency room, a macho mystique presides.  Again, to quote Samuel Shem in “The House of God”, the goal is to “buff and turf”:  Tune ‘em up and get ‘em out!   This somewhat testosterone fueled mentality results in an unstated reluctance to admit patients to the hospital—no senior medical resident in charge of an emergency room wants to be seen as a “wuss” by his or her peers presiding over the floors—the fewer the number of patients admitted, especially at night, the more sleep your fellow residents and interns can get, and the more they will thank you in the morning.  Each patient in the emergency room is triaged by the nurses first, and the senior residents last, nowadays with the blessing of the attending physician, but back then we were on our own in the wee hours.  One night during my senior internal medicine residency, a young healthy man in his early 30’s came into the ER, complaining of chest pain.  He was a budding young chef at an up and coming local restaurant.  He was slightly overweight, a condition which was exacerbated by his chosen profession.  To remedy this problem, he had decided to start jogging.  Earlier that day, he had gone for a three mile run.  During his run, he began to have chest pain, substernal chest pain radiating down his left arm.  The pain had subsided when he stopped, but he came to the ER to be checked out, you know, just in case.  His heart rate and rhythm were normal.  His EKG was normal.  The blood tests which we now do routinely to rule out cardiac muscle damage were in their infancy, and took 8 hours to run.  He had no family history of heart disease.  He had no heart murmur.  He was only 33, for goodness sake!  There was NO way this man could be having a heart attack. No way.  I sent him home.  But, just in case, I scheduled him for a stress test to be done a few days hence.  At 8 am, my 24 hour shift was up, and home I went.  Twenty four hours later, I returned.  In the conference room, the attending was rounding with the interns and residents.  He took report on the previous night’s admissions.  One of those admissions was a 33 year old chef who had returned to the ER less than a day after I had discharged him, clutching his chest in pain and fear, having a massive heart attack.  He was admitted to the ICU. He survived.

Perhaps it is the same with physicians as it is with children taking riding lessons—you cannot be a REAL doctor until you have made three mistakes that you will never forget.  Doctors hate making mistakes, and hate admitting them even more.  This is the reason for the conferences which take place at every teaching hospital in the country called “M and M’s”, which stands for Morbidity and Mortality.  It is where physicians, young and old,  stand up and say, “This is what happened and this is what I learned and that is why I will never let it happen again.”  Rarely do they say, “This is what happened and it was my fault and I am truly sorry.”  When I was in training, the conventional wisdom to avoid malpractice liability was to call Risk Management but to NEVER admit you were at fault.  That was for the insurers and the courts to decide.

That has changed now, for the better.  Now we are counseled that it is better to admit one’s mistakes, and to apologize.  I have my three braids of horsehair pinned to my brain, and to my heart.  And there are probably more.  I am sorry.  Truly sorry.