In addition to the continuous flow of patients, dozens of reports cross my desk every day. Blood tests, urinalyses, cultures, stool studies, EKGs, x-rays, ultrasounds, CT and MRI scans, bone scans, bone density studies, mammograms, Pap smears, pathology reports, pulmonary function tests, ambulatory blood pressure readings, cardiac monitor reports… . The list is endless. As I review each report I have to try to recall why the test was ordered. If the result is normal it can usually be filed away. Significantly abnormal results are flagged and dealt with promptly. Mildly abnormal results are tricky, because they require an answer to the question: Can this be safely filed, or are further investigations required? Not every abnormal test result needs to be acted upon. Part of the art of medicine is knowing when it’s appropriate to ignore a result that falls slightly outside the normal range. “Incidentalomas” abound in clinical medicine, and they don’t all require a million-dollar workup.
For as long as history has been recorded, most societies have held their healers in high esteem. This respect has usually been accompanied by a certain degree of tolerance vis-à-vis medical errors. We physicians have always been extremely grateful for this unspoken buffer zone of forgiveness. Doctors are human beings, and all human beings make mistakes. If the guy at Domino’s makes a mistake, someone could end up getting anchovies instead of mushrooms on their pizza. If I make a mistake, someone could end up dead. It’s a terrifying responsibility.
Over the past 30 years there has been a seismic shift in our collective attitude towards mistakes in North America. All of a sudden errors are no longer permissible. Now if something goes wrong, someone has to be held accountable. Our current zeitgeist fosters the belief that if you look hard enough, eventually you’ll find someone to blame. Someone to blame equals someone to sue. Successful lawsuit equals big money.
Given the prevailing cultural mindset, it’s no surprise the public’s tolerance for medical errors has all but evaporated. Nowadays if a physician makes a mistake, there’s a fair chance their patient may be more angry than forgiving. Even sympathetic patients are often tempted to initiate litigation when family, friends or the media inundate them with stories of lucrative malpractice settlements. I’ve seen sweet little old grandmothers morph into near-psychotic greedheads after having been advised what their injury might be “worth.” It’s not a pretty sight.
Between patient encounters and interpretation of test results, I estimate I make at least 50 significant decisions a day. Even if I’m right 98 percent of the time (a near-impossibility in clinical medicine), that still means I make one mistake per day. That’s a minimum of five a week, or roughly 250 per year.
All of these mistakes are incubating in an increasingly hostile milieu in which highly-informed patients are demanding perfection. Practicing medicine in North America in the 21st century is like juggling hand grenades – no matter how good you are, eventually one of them is going to go off in your face.
Humble Pie
Buried within the classifieds of our local biweekly newspaper is a small “Thank You” column. In it community members thank one another for various acts of kindness. I receive a handful of these notes every year. Jan and I have a running gag – whenever the latest paper arrives, if there are no messages in it for me she jokes that the “Dr. Gray Thank-You Supplement” must have fallen out again. Pretty droll, but it always makes me laugh.
On those occasions when she mentions there’s a note for me, I like to try to guess who sent it before I read it. Over the years I’ve learned there is surprisingly little correlation between the acuity of the illnesses I treat patients for and subsequent thank-you notes (or lack thereof). Most times it is not patients I literally snatched from the jaws of death who send a note to the newspaper, it’s people I assisted in more mundane ways. I never expect to receive thank-you notes, so it brightens my day whenever one comes along. They serve as a reminder that I really am making a difference out here in the trenches.
Mr. Anderson was an 80-year-old patient of mine. He had an acerbic wit and a flawless memory. Although he tended to be fairly cranky with most other health care providers, he always had a good yarn and a devilish wink for me. Unfortunately his body wasn’t quite as resilient as his mind, and over time his internal organs began to fail. Despite our best attempts to quell the escalating mutiny, he eventually succumbed to multi-system failure. His death saddened me.
A few days after Mr. Anderson’s funeral I was scanning the paper when I came across a thank-you note submitted by his family. It was a long one. In it they thanked several friends of the family, some hospital and Home Care nurses, a couple of ambulance attendants, their minister, the funeral home and the florist. In short, everyone but me.
I’d like to pull a John Wayne and say that the apparent oversight didn’t bother me, but it did. I kept thinking: “All those years I worked so hard at trying to keep him healthy and the florist gets thanked? Now there’s gratitude for you.” I grumbled about it all evening. I was still muttering to myself that night as I fell asleep.
When I got to my office the next morning there was a beautiful gift basket waiting for me on my desk. The card attached to it read: “Thank you for your wonderful care of Dad over the years. From the Anderson family.”
I felt like a jerk.
Every Breath You Take
Molly was a slightly anxious 40-year-old woman whom I had seen in my office a few times for minor health issues. One morning she presented to the ER intensely short of breath. Her oxygen saturation was only 70 percent and her chest was full of crackles. It took a high-flow oxygen delivery mask to bring her sats back up into the normal range. A chest x-ray was done to help rule out congestive heart failure and pneumonia. To my surprise, it showed extensive scar tissue consistent with a diagnosis of severe pulmonary fibrosis. I admitted her for further investigation.
Pulmonary fibrosis is usually an insidious process. Over the next few days I searched for a reason for her abrupt decompensation. No cause was found. Despite quitting her five-cigarette-a-day smoking habit, she wasn’t able to maintain her sats above 90 percent without supplemental oxygen. Arrangements were made for her to have home oxygen as well as an urgent consultation with the nearest available lung specialist. When everything was in place, I discharged her from hospital.
Over the next several months Molly made a number of trips to the respirologist. A lung biopsy revealed progressive pulmonary fibrosis of unknown origin, so she was started on high-dose corticosteroids.
Although she was a pleasant person, Molly had always been a loner who pretty much kept to herself. She was single and had no living relatives. As her shortness of breath worsened, so too did her anxiety. With nowhere else to turn, my office gradually became her main source of support.
The steroids failed to halt the progression of her disease, so immunosuppressants were initiated. When it became obvious that they, too, weren’t helping, she was referred further south to a transplant unit in Toronto. The team there reviewed her case carefully and concluded she was a good candidate for their program. There was only one catch – she would have to move to Toronto. This was not an unreasonable request. Due to the logistics involved in harvesting and transplanting lungs, patients on the waiting list must be able to get to the surgical centre on short notice. Our town was 800 kilometres away from Toronto.
The idea of moving petrified Molly. She agonized over the decision for a long time, but in the end she opted to go. She had no choice, really – to remain at home in our isolated town would have meant certain death.
Packing up and moving to Toronto when you can hardly breathe is no easy feat. It’s even more difficult when you have limited savings and no family. True to the spirit of the North, our town came through for Molly. After a lot of searching, a suitable place for her to stay in Toronto was found. A community member whom she barely even knew volunteered to go live with her and provide general assistance. In addition to that, a local service club held a fundraiser to help offset her mounting expe
nses. Eventually everything was organized and a departure date was set.
A couple of weeks before she was scheduled to leave, Molly came in for an office appointment. Her shortness of breath had worsened and she was feeling overwhelmed. She asked if I could admit her to our hospital until she left for Toronto. I called the medical ward and let them know she’d be coming in.
A fresh battery of tests failed to turn up any new problems. Even so, I didn’t think she was well enough to handle a commercial flight. I spoke to the transplant team and they agreed to a direct hospital-to-hospital transfer by jet in one week.
For the next six days I made a point of dropping in and chatting with her for as long as time permitted. If there was no longer anything medical I could do for her, at least I could listen.
At 5:30 on the evening before the transfer a nurse on the medical floor called me at my office to say Molly wanted to speak to me. Apparently she needed to tell me something important. It had been a long day and I was tired. I had already spent 15 minutes with her during my lunch break and I just didn’t feel like doing it again. I asked the nurse to tell her I’d see her first thing in the morning before the jet arrived.
Molly died in her sleep at 6:00 a.m. on the morning of her scheduled transfer.
Sometimes at night I lie in bed and wonder what it was she wanted to tell me.
Thank You
It’s hard to figure out where the expression “thank you” fits into the practice of modern medicine. Are people obliged to thank me when I help them? Of course not. Would it be nice? Why, yes, it would. Most people do say thanks when I help lighten their load, but a surprising number do not. When I stay up all night struggling to keep a family’s loved one alive, I obviously don’t expect any sort of material reward, but I don’t think it’s unreasonable to expect a thank-you.
Now, I know what you’re thinking: “But Slim, it’s not like you’re treating these people purely out of the goodness of your heart! You’re well-paid by the Ministry of Health to provide these services!”
Yes, I know that. However, I say thanks when the operator puts my call through. I say thank-you whenever the guy at the service station fills my car’s tank with gas. I say thanks every morning when the woman at Tim Hortons hands me my bagel and coffee. Should it not therefore be reasonable for me to expect a simple thank-you for treating someone’s hemorrhoid, headache or heart attack?
One Sunday afternoon I was paged to the ER stat. I raced into the major treatment room to find a screaming 20-month-old boy with multiple second-degree burns all over his body. An older sibling had accidently knocked a kettle off the stove and doused him with boiling water. Large blisters were welling up everywhere and he was in acute distress. He needed immediate fluid resuscitation and pain relief. Unfortunately, he was an unusually chubby little fellow and there were no accessible veins in sight.
A few weeks earlier I had attended a pediatric trauma course and learned about a relatively new way to access the circulatory system of a child. It was called an intraosseous infusion. The technique involves drilling a large bore needle through the shinbone and into the marrow beneath it. Fluids and medications can then be administered directly into the bone marrow. From there they enter the bloodstream. As soon as I got back from the course I ordered some intraosseous kits for our ER. I figured they might come in handy someday.
Several attempts at starting a regular IV were unsuccessful, so I asked one of the ER nurses to open an intraosseous kit. The device consisted of a sharp, hollow, inch-long needle attached to a round, plastic handle. I explained the procedure to the boy’s mother. She gave her consent and went outside to wait until we were finished. The nurse immobilized the child for me. While I injected local anaesthetic into his upper shin, I reviewed the procedure in my mind. In the course I had taken we had practised inserting intraosseous needles into inert chicken bones, but this was the real deal – a shrieking, writhing toddler. I pushed the needle firmly into his tibia. When it was solidly embedded I began to twist it in deeper by rotating my wrist from side to side. I could feel the metal grinding its way through the bone. It was a strikingly unpleasant sensation.
Eventually the needle punched through to the marrow. After confirming proper placement we attached it to an IV bag and began infusing morphine and fluids.
As his condition stabilized we inserted catheters and applied dressings to his wounds. I contacted a burn specialist at a pediatric hospital in southern Ontario and had him flown down for definitive care.
Over the next several days we followed his progress via a number of sources, both direct and indirect. By all accounts he was doing well and was expected to have a satisfactory recovery. We were especially proud to hear the pediatric burn unit had been impressed with the quality of care he had received at our facility. We patted ourselves on the back for a job well done.
The only thing that bothered me slightly about the case was that the mother hadn’t thanked me for looking after her child in the ER.
“But Slim, she had other things on her mind! Her son had just been badly burned!”
Yeah, I know. I was there, remember? Although I realize it sounds petty of me to even mention it, I still think a brief thank-you would have been nice. Oh, well. Life goes on.
Exactly one week later I was out in my front yard raking. My daughters were having fun running around and jumping into the piles of leaves. Suddenly an unfamiliar truck pulled up to the curb in front of our house. A man jumped out and strode purposefully across our lawn directly towards me. My kids stopped playing and eyed the stranger cautiously.
“Are you Dr. Gray?”
“Yes.”
“I’m Mr. Farquhar. You looked after my son Peyton last weekend when he got burned.”
I thought, "Oh, that's who he is! He's dropped by to say thank-you in person! Wow, isn't that considerate?"
He reached into his jacket pocket and pulled out a wad of forms.
“I need these completed ASAP so we can get our travel expenses paid. Can you do them right now?”
I was dumbfounded.
I was enraged.
I was hurt.
“If you drop those off at my office tomorrow morning, I’ll see to it they get filled out,” I said quietly.
“Sounds good.”
He turned around, marched back to his truck and drove off.
Snap!
Last Friday I was on call. During the day the emergency department was hopping. I zipped home at 7:00 p.m. for a quick bite to eat and a 30-minute power nap. At 8:00 I returned to see the evening crop of outpatients. I worked until 11:00 and then charted in Medical Records until midnight. When the paperwork was completed I dropped by the ER to make sure the coast was clear. A pink Post-It note was stuck to my knapsack. Those are never good. This one's raison d'être was to advise me that a patient named Mr. Yorke on unit 4 was short of breath and having a rapid pulse. Geez, how come no one paged me about this? I went over to the ward to investigate. As it turned out, Mr. Yorke was one hot mess and I ended up having to work on him for a couple of hours.
At 6:00 a.m. I was summoned back to the ER to stitch up yet another drunken Jethro. This particular genius had taken a swan dive onto a flotilla of empty beer bottles that had spontaneously assembled on his kitchen floor. By the time I finished with him there was hardly any point in trying to go back to sleep, so I raided the fridge on unit 4 and ate a couple of mystery-meat sandwiches at the desk. At 8:00 I started my ward rounds. I figured if I got rounds out of the way early I’d be able to enjoy the rest of the day with my family. Of the eight acute and chronic care patients I visited, Mr. Yorke was still the sickest. Our stockroom was fresh out of bags of IV Miracle, so I had to spend another hour or so getting him squared away. By 10:00 I was finished. Freedom! A sunny Saturday and no more work to do!
When I got home I asked my daughters if they wanted to ride their bikes to the park with me. It was looking like the perfect day to fly our new kites. Their answer was a resounding “Yes!”
I went upstairs to get ready. Halfway through my shower the phone rang.
“Hello?”
“Hi Dr. Gray. We need a clarification on your order for Mr. Yorke’s potassium pills.”
After sorting that out I finished getting ready, rounded up the kids and herded them out the front door.
It’s not easy riding 15 blocks with a trio of girls ages five, six and seven. I was right in the middle of negotiating a busy intersection when my cell phone started ringing. I shouldered off my backpack and rummaged through its contents until I found it.
“Hello?”
“Dr. Gray, Mr. Yorke is refusing to take his potassium pills.”
Suddenly something snapped. A severely unhinged stranger who sounded a whole lot like me started caterwauling: “I don’t care! I’m not on call anymore! I did my call day yesterday! Get whoever’s on call today to deal with this crap!”
My kids goggled at me, their mouths hanging open. Passers-by edged away nervously. Small-town family medicine. What’s not to like?
Tough Call
One Friday night an elderly patient of mine presented to our emergency department with atypical chest pain. Her EKG had been chronically abnormal ever since a heart attack a few years prior, so it was difficult for the on-call physician to determine whether or not she was experiencing an acute coronary event. He increased her anti-anginal medications and watched her closely. After a period of observation in the ER she was admitted to the medical ward for further monitoring.
When I saw her during my daily inpatient rounds on Saturday morning she was surrounded by a phalanx of concerned family members. Despite the med adjustments, she was still experiencing intermittent low-grade chest discomfort. Her EKGs hadn’t changed and her cardiac enzymes were normal. I wanted advice as to how best to proceed with her, so I put in a call to our closest cardiac referral centre.
Dude, Where's My Stethoscope? Page 11