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Tag Archives: Guest Posts

A Nameless Faceless Killer

By BirdStrike M.D. 1) A 40-year-old female sees her family physician for burning chest pain after she eats hot peppers. She had it only once while exercising. Her family physician sends her to the emergency department and she gets admitted for chest pain. Rather than going home with treatment for her GERD, she ends up dead. This never should have happened, but the family never learns what really killed her. 2) A 33-year-old father of 3 dies on a hospice ward, bloated with steroids, on tube feeds with a tracheostomy. He was stricken down too young, his family is told, by a rare form of brain cancer. It was an unlucky fluke, they are told, but that is not the only reason. 3) A 7-year-old boy dies in the Pediatric ICU. His family is stunned, shocked and devastated. How could this have happened? The family is told he died from an ingrown toe-nail infection that spread to his blood stream and caused a severe form of sepsis. “It could happen to any of us.” They do not know that the breeding of this superbug was fed by a nameless killer. 4) A 16-year-old girl is on a CT scan table nervously giggling. Fifteen minutes later, she goes into cardiac arrest. A short time later, a solemn nurse informs her family that the patient has died from an allergic reaction. But her cause of death is something more insidious. Each of these patients had a different doctor, but a similar contaminant. Much like a baseball slugger whose home run swing at a 100 mph fastball is thwarted when a camera flash from his biggest fan causes him to blink; the doctors were thrown off of their game. The culprit: Defensive Medicine. In each case presented, the doctor had a very rational fear of being sued for either making a mistake or even for doing everything right. During the last moment in the rapid-fire decision-making process, each doctor had a “flash in the eye.” In each case, the result was a swing and a miss. Over and over, and over again in hospital wards, emergency departments, operating rooms, and doctors’ offices in America doctors are being told they must rule out every possibility or be sued. The ones who suffer are the patients, often tragically so. Why? Rather than trusting their instincts, the treating physicians are instead asking themselves, “What could a medical malpractice attorney possibly say I should have done?” While this may seem like a dangerous way to practice medicine, often the doctors have very little choice but to do so.  Consider the stories behind the cases presented above:

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Why Some People Just Will Never Get It

By BirdStrike M.D. This post was inspired by a brilliant response by Lior to WhiteCoat’s excellent article “Jim Dwyer New York Times Pediatric Fever Article Debate” on this very blog.  First, what should not be lost in this back and forth debate are Rory Staunton and his family.  I give my deepest condolences to the family of Rory Staunton. As a parent, I cannot imagine their pain. I wish them and the rest of his family the best. I sincerely wish that this had not happened, and that this outcome never happens to a child again.  My intent is not to “take sides” or play judge and jury over the treatment in this case.  In contrast, I would like to underscore what it is like to be an Emergency Physician, and how sometimes tragic and devastating outcomes can occur, when a competent, concerned, hardworking Emergency Physician does everything right.  I think Lior gets it like very few non-medical people ever will. Put another way: 1. Common things presenting commonly- When a patient presents with something common with its usual symptoms, the diagnosis is obvious to medical practitioners and even lay people.  Runny nose, dry cough = common cold.  99% of the time that equation is correct.  We all get it. 2. Uncommon things presenting commonly- The difficulty of a diagnosis increases significantly when a patient presents with an uncommon condition, yet with its typical symptoms. Physicians typically are well trained to make such diagnoses.  Petechial rash, fever, stiff neck = devastating, fortunately uncommon, but easy to identify: Meningococcal meningitis.  Cases like this are easy, even if you’ve never seen them.  This is what doctors do. 3. Rare things presenting commonly- Once again, the difficulty of diagnosis jumps even more dramatically when a patient presents with a very rare and unlikely condition, yet with its typical symptoms. Again, physicians typically do a good job here; this is what board exams prepare for, finding the “needle in the haystack”.  A 14 year old male with tearing back pain between his shoulder blades = Marfan’s Syndrome with thoracic aortic dissection and impending death.  Rare, thank God, and easy to miss if you are not extremely careful, but right out of the textbook if you are so unfortunate to see this case and fortunate enough to recognize it. 4. Uncommon things presenting uncommonly- When a patient presents with an uncommon, or worse yet rare condition, presenting with symptoms that are unusual even for the uncommon condition itself, the difficulty of making the diagnosis increases logarithmically to the point where missing the diagnosis is essentially expected.  Others have put it like this:  there are some diseases that are so uncommon, and can present so unusually that it is essentially the standard of care to miss them.  The 11 year old boy with nausea, sweating with pain down his arm:  It’s obvious, right?  It’s obvious what this is.  It’s an early case of sepsis, from a cut on the arm, presently very strangely, correct?  After all, the heart rate is 130.  The respiratory rate is high.  The temp is 100.1 F.  “He’s just not right.”  It’s sepsis, right……?  Maybe it is a viral gastroenteritis.  Or what if I told you the boy was a chronic complainer, and faked sick to get out of school many times?  And after some nausea medicine, he says he feels a little bit better and just wants to go home… But his chest hurts, too.  And when he was younger he had Kawasaki syndrome, which was treated, but caught very late.  Would you know that he was dying in front of you ...

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Chief Violetté and the Headless Trauma

By Birdstrike M.D. It was intern year of my Emergency Medicine residency.  I was on my trauma surgery rotation and working at least 100 hours per week (pre-ACGME regulations). To say that I was burned out and sleep deprived would be an understatement.  It was three weeks into residency and I had done nothing but change dressings on my Chief resident’s patients’ putrid decubitus ulcers, run to get gauze packets, perform rectal exams, “RETRACT!”, and be the butt of senior resident jokes.  I had learned so few real skills in procedures or anything else that I was seriously ready to quit at this point, but in way too much student loan debt to do so.  I can’t tell you how many times I prayed for this guy to end up blind, impotent and in an adult diaper.  My supervising resident, Chief “Violate” … I’m sorry, let me rev up my French accent, Chief Violetté was infamous for getting his first two surgical residencies shutdown due to his generally abusive nature, not to mention his penchant for being an exquisite jerk at the perfect moment.  At his program’s ACGME site visit, when he was asked why he logged 168 work hours three weeks in a row during his first surgery rotation, his response was,“I wanted to work 170 hours, but when I got to 168, there were no more hours left in the week!”  I must say, despite being a bastard with no equal, old Chief “Violate”(as I will refer to him from now on), made me take my game to another level. It’s Saturday night.  I’m on call.  I’m dead asleep, and let’s just say I’m feeling a little “pukey” and abso-friggin’-lutely exhausted from having a little too much fun the night before at the local nursing school graduation after-party.  I hear this insanely loud pounding on my call room door and our medical student is screaming, “Wake up!  Wake up!  The Chief’s got an intubation for you!  He wants you in the trauma bay in 30 seconds!!” In a deep circadian haze, I run down to the trauma bay,  and Chief Violate grabs my ear, pulls me into trauma room 1 and says, “I’ve got a procedure for you, big boy.”  I look down at the patient on the stretcher and see a pair of boots, blue jeans, a belt, a man’s tattooed chest, a perfectly normal neck and … a bloody stump of a partial-head pouring out blood like a lawn sprinkler.  As my sphincter tone increases rapidly to diamond cutting levels, the Chief puts a Mac 3 in my left hand and a 7.5 ET tube in the other, pushes me to the head of the bed and says, “You’ve been whining about not getting any good procedures, so cock, lock and get ready to rock, tough guy!” To everyone’s shock and amazement, the guy is alive!  He’s conscious!  Choking on blood he screams, “Finish me off!  Finish me off, and put me out of my misery, you bastards!”  Apparently, instead of pointing the shotgun at the back of his throat towards his brainstem which would certainly have been instantly fatal, he put it in his mouth and pointed upwards, tearing off his upper teeth, maxilla, nose, eyes, forehead and frontal skull, leaving the key parts of his brain intact. As my heart rate creeps up to near SVT levels, the Chief painfully flicks my ear and says, “What the hell are you waiting for?  Intubate him, All-Star!  Don’t worry.  This will be the easiest airway of your life.”  Only having intubated sedated animals and rubber dummies ...

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Jim Dwyer New York Times Article – Irresponsible Journalism?

By an Anonymous Emergency Physician The opinion piece below was written by an emergency physician regarding a New York Times article by Jim Dwyer (picture at right). The author did not want to be identified due to fears of retribution from either the NY Times or from the hospital at which the physician is employed. In addition to the points the author raises below, I would add these additional points of information: 1. The “Stop Sepsis” campaign cited in Mr. Dwyer’s article specifically stated that it is only to be used for tracking patients with severe sepsis and that “only those patients who are hypotensive after being given 2L of fluids or that have an elevated lactate should be entered in the data portal for this Collaborative.” Rory was not hypotensive and no lactate level was included in the labs pictured in Mr. Dwyer’s article. Mr. Dwyer never mentions any of these facts. The Collaborative does not allow access to links on this page describing its screening tools or to how it believes that a determination for ordering a lactate level should be made. I will also note that Mr. Dwyer responded to some of the more than 1600 comments to his article, including some of the issues raised below, in this follow up article. -WC UPDATE JULY 22, 2012 Also see an important update to this debate at this link. —————————————— The New York Times published an incredibly sad story about a 12 year old boy named Rory who went into the NYU emergency department, was diagnosed with gastroenteritis (a viral stomach bug), and who was dead two days later from septic shock.  Those are just about the only facts that are not in dispute.  The rest of the New York Times article seems to build a mountain of evidence as to why the emergency physician screwed up.  However, as is frequently the case, the truth is much more complicated than the media would have you believe.  There are lots of comments from other doctors using the almighty retrospectoscope and so many clinical inaccuracies discussed that this sad story is turned into a piece of sensationalistic journalism. This post is mostly for the non-medical people that read this blog to help you understand the medical issues a little better.  This is a scientific discussion of the main inaccuracies of the article followed by what possibly could have been done better.  I say “possibly” because I did not examine the patient and all of my information is through the New York Times article.  If you have already read the article and decided that the ED doctor screwed up and nothing can change your mind, then stop reading.  If you want a fair and evidence-based discussion of the article then read on. The article references the “Stop Sepsis” campaign and says that the vital signs that should have triggered an evaluation for severe sepsis.  The article says that Rory had initial vital signs of a temperature of 102, a heart rate of 140, and then points to the Stop Sepsis guidelines.  There are two problems with this: First, the Stop Sepsis guidelines are intended to be used in adults, not in children. Second, just because a patient has abnormal vital signs doesn’t mean that they have severe sepsis.  Most patients in a pediatric ED waiting room would meet these criteria and yet they don’t have severe sepsis.  The “Stop Sepsis” guidelines are a screening tool that can suggest sepsis but they have to be used in the right clinical context.  Most physicians see pediatric patients every day who meet the “Stop ...

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