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 from a disease that almost never strikes the young? Would you think to order an EKG? Would you think that your 11 year old nephew was having a massive and fatal heart attack, 60 years before his Grandpa did?
What non-medical people just will never get, is that when “uncommon things present uncommonly” while working in real time, sometimes such a diagnosis can be a shot in the dark for even the best, most careful Emergency Physician. However, when you work backwards after the fact, it’s easy. It’s classic. Any 4th year medical student could name it. A young boy who has a rare disease called Kawasaki syndrome, and recovers, but is now at risk for having what would otherwise be unheard of: dying of a heart attack at age 11. It’s easy after the unthinkable makes itself known. But when the 11 year old boy comes in to your Emergency Room with nausea and pain down his left arm, your mind doesn’t scream, “EKG! EKG! Get an EKG idiot!” like it would if you changed the number 1 to a 6 and made him 61. Do you get it now?
In the current medico-legal climate 100% accuracy is expected 100% of the time, while at the same time being expected to decrease the tests we order to save money for “the healthcare system” under the threat of multimillion dollar lawsuits and now in 2012, slander and libel. This would equate with finding the “needle in the haystack that is disguised as a strand of hay” with a gun held to your head. This is what non-physicians, lay people, and juries do not understand, and probably never can. Very few people operate under stakes so high, with lives on the line, time pressure, lawsuit pressure, declining pay, and the requirement to be 100% accurate with diagnoses that you may have a 1 in a million shot at making. There just is nothing remotely equivalent in the worlds of most lay people, and that includes people who make more money that a doctor writing for a living. It’s like a passenger-jet pilot flying into an unexpected stormy cloud formation, with winds blowing how they don’t usually blow, with an airplane that has controls responding how they don’t usually respond. It may only happen 1 in every 250,000 flights, but when it does the results can be catastrophic by no fault of his own. I’m sure pilots get it. When uncommon things present uncommonly, pilots can pay with the lives of others and their own. I’m sure police officers get it. They may be faced with a situation they never practiced in training. A shadow comes out of the dark with a gun. Should he shoot or not? The answer is easy, right? No, it’s not. Not until you know who the dead man is. Is the shadowy figure the mad man? Or is it the officer’s partner? Does he decide now, or a 1/10 of a second later? His life, or his partner’s life, or the mad man’s life depends on the answer. He won’t know the answer until he pulls the trigger.
Big things depend on the “little decisions” Emergency Physicians make, or choose not to make in a hundredth of a second. If you’re right, the patient lives. If you’re wrong the patient loses life or limb. If you shock that mildly unstable heart rhythm, will the heart rhythm return to normal, with a life saved, or does the rhythm accelerate into fatal Ventricular Fibrillation?
I’ve had to answer these questions before, and lives have depended on my answers. I get it. Doctors get it. Pilots get it. Soldiers get it. Police officers get it. Bomb defusers get it. If you tap a keyboard for a living, you probably don’t get it. That’s okay. We’ve got it for you.
This author does not divulge protected patient information. Any post that appears to resemble a real patient is by coincidence. This author does not post, has not posted and will not post about real patients. Although these posts may be inspired by the author’s experiences, they are not about real patients, because that would violate patient confidentiality. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail WhiteCoat.