A Budding Emergencist
Monday, December 04, 2006
  Oh, Fickle Fate!

X-posted from my comment to Scalpel's post My Second Lawsuit.

I very recently had a similar situation. I am a rotating intern covering a surgical service. One of my general surgery attendings routinely operates on very sick patients. R.R. was very sick with recurrent acute cholecystitis and a history of being 5 years s/p double mastectomy for breast cancer. She also had brittle diabetes, requiring 40 units of Lantus twice a day, 25 units of Aspart before meals, and still hit 300mg/dl at least once a day.

Mr. R. was an active member of the community and a member of the hospital board. From 25 years of involvement in the hospital he had some knowledge of medicine, and he would routinely barge into the nursing station demanding this work-up, that consult, and the other expensive, irrelevant, time-consuming radiology study. They all turned up normal, including an extensive cardiac work up along with innumerable ekg's and serial enzymes. 2 weeks after admission the patient finally underwent laparoscopic cholecystectomy. She did well immediately post-op and was tolerating a full diet by POD#3. Everyone cheered, high fives all around and the seniors quietly disengaged themselves, leaving me and another intern to mop up the leftovers and discharge the patient post haste.

Mr.R finally relented from his Munchausen-by-proxy and agreed to a discharge plan after several days of continual reassurance by myself and the team as to Mrs. R's satisfactory recovery.

On a fateful Friday I rounded on the patient with only a preoccupied 2nd year supervising, as both senior residents and the attending were elbows deep in emergency surgeries. The patient was complaining of mild chest pain, and I could see she was a mildly of breath. We dismissed these as chronic, for the patient had had thorough workups for both issues. "Just get her out," my 2nd year whispered as we left the room. I acknowledged his meaninful stare with a vigorous nodding, and rushed off to finish the paperwork.

Mr. T., undeterred, called our attending, and demanded a pulmonary consult. 2 hours later, discharge instructions in hand, I reviewed the 2-day old CXR with the pulmonologist. I excitedly pointed out the mild cephalization, and Mr.R angrily pointed out a mild R effusion, which we had previously dismissed as sympathetic, with atelectasis. The distinguished lung doc summed up our observations, mildly pointing out the elephant in the living room--"She's in CHF".

"This is new," I thought to myself. Uh-oh.

In a mild voice, the consultant suggested sligtly increasing the lasix, repeating the chest x-ray, and matter-of-factly recommended a cardiology follow-up. He left in a hurry without leaving a note.

That left me (feeling nauseous) and Mr.R (visibly approaching critical mass) staring at each other in silence. I excused myself to call the cardiologist, double-time. The day was a-wastin', and I quickly put in for an EKG while paging the cardiologist.

The team assembled soon after. The EKG and the cardiologist arrived at the same time, and we grudgingly conceded the obvious display of a-fib with RVR. We reluctantly got yet another set of cardiac enzymes. Mr. R, while not talking to various Important People on the phone, glowered at us accusingly. CHIEF RESIDENT said to my co-intern, "now, see...where you see defeat, I see opportunity."

We brought up the idea of a transfer to medicine under the cardiologist's service, but Mr.R refused. We were astonished, but went about transferring the patient to our telemetry unit. I went home, elated that I had not been blamed. I told myself this was another false alarm, and started drinking.

Two days later I returned, grateful to find the patient had been transferred to the cardiologist's service. A Pyrrhic victory. My joy curdled when I saw the patient. In the MICU. Intubated. Transmural MI. Mitral valve rupture. Shit.

I conveyed my sincere condolences to Mr.R and left, dismayed by her clinical free-fall from stable, to fair, to guarded, to poor, to critical, in the space of essentially one 24 hour period.

Mr. R naturally wanted heads to roll, and settled his sights on CHIEF RESIDENT, and curiously, on my co-intern. Seems my co-intern, an actual surgical intern, and a damn good one, had lost it the night previously to the disaster, and had rudely dismissed all of Mr.T.'s endless criticisms and complaints, saying she was fine and would be discharged the following morning at the earliest opportunity. Mr. R blamed the intern for the entire debacle.

Strangely, Mr. T. had developed an inexplicable affection for me, going so far as to write a letter of recommendation for me to the head of the EM department through his innumerable back channels. He told me my residency spot next year was a done deal. Not only was it in the same breath as saying my co-intern would be sacked after his meeting with the chair of surgery, but I hadn't even interviewed yet. I was dumbstruck.

The whole thing is extremely weird and terrifying to me. My supposedly stable patient suffered a massive post-op MI under my nose, and I ignored the red flags my conscience raised because I was afraid of displeasing CHIEF RESIDENT. Thank God Mr.T. had the balls not to allow his wife to be discharged. I'm really frustrated by his wife's decompensation, but at the same time I'm thrilled to have such a powerful ally. I'm a bit uneasy about it, though--TAANSTAFL. My career depends on the whims of a cantankerous godfather like this? Yeesh.

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Emergency medicine, from the beginning of a new doctor's career.

Location: Big City, Metropolis, United States

Walk softly and carry a big vocabulary. Don't be inhuman. Find and greet God in every person you meet. The patient is the one with the disease. Do not get distracted. Charity begins at home. Do good and be happy. Don't just do something, stand still. Wear sunscreen. Don't get anyone pregnant, and don't go to jail, young man. Budget your luxuries first. You don't know what you don't know. People like learning, they just don't like being taught. When in doubt, go out. When life gives you lemons, make lemonade. Honey attracts more flies than vinegar.

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