Monday, September 17, 2007

One Story, Two Endings. Clearly I'm not a doctor yet.

The doctor looked at the patient's chief complaint on the chart. "Palpitations, SOBOE." He looked up at the nurse and made a joke out of it. "SOBOE - Shortness of breath on exertion... even I get that. Who doesn't get short of breath when they exercise?" The nurse laughed.

The doc grabbed the patient's ECG, which the nurses had already done and clipped to the patient's chart. One quick glance told him that it was a textbook example of normal sinus rhythm with the odd premature ventricular beat (PVC) - when the ventricles contract before they receive a signal from the sinoatrial node - something that happens in normal, healthy adults and is absolutely nothing to worry about.

"Hi, I'm Dr. Vitum Medicinus," said the doctor, scrawling his initials on the ECG sheet to show he'd read it, while walking into the patient's room. Dr. Medicinus took a quick history, and the patient described the thump in his chest that was consistent with a PVC. "We'll take a few blood tests and see how they turn out," said Dr. Medicinus, as he scrawled "MI Protocol" in the orders section of the chart. He was just covering his ass. He knew that the patient didn't really have a heart attack.

Sure enough, the blood tests for a heart attack were normal. "Nothing to worry about - PVCs are entirely normal if they're as infrequent as yours. You'll be just fine," said Dr. Medicinus as he walked back into the room. "If it gets worse, come on back in, but you're good to go now."

-----

The medical student looked at the patient's chief complaint on the chart. "Palpitations, SOBOE." He looked up at the doctor he was shadowing and made a joke out of it. "SOBOE - Shortness of breath on exertion... even I get that. Who doesn't get short of breath when they exercise?" The doctor laughed.

The doctor picked up the patient's ECG, which the nurses had already done and clipped to the patient's chart. One quick glance told the doctor that it was a textbook example of normal sinus rhythm with the odd PVC. Even the med student picked up on this.


"Hi, I'm Dr. Alex O'Brien," said the doctor, walking into the patient's room, "and this is Mr. Vitum Medicinus, a medical student working with me today; is it okay if he watches?" The patient nodded. Dr. O'Brien took a quick history, and the patient described the thump in his chest that was consistent with a PVC. "We'll take a few blood tests and see how they turn out," said Dr. O'Brien, as he scrawled "MI Protocol" in the orders section of the chart. Vitum thought to himself, "There's no way this patient is having a heart attack."

Vitum was right. Sure enough, the blood tests were normal. However, the doctor's years of experience told him to be cautious, and keep his mind open to other possible diagnoses. "I'm going to order one other test," he said.

Dr. O'Brien told Vitum that because the patient had just had his appendix out a few weeks ago, and was complaining of shortness of breath, he should check the patient's D-dimers - a blood test to measure if the body is breaking down a blood clot - as the patient was at risk for a pulmonary embolus - a clot in his lungs.

Vitum kicked himself. He remembered quickly dismissing the patient's complaint of shortness of breath. Actually, worse than that - Vitum had made a joke out of it.

Sure enough, the D-dimers came back slightly elevated - not too high, but enough that the doctor wanted to get a CT to make sure. An hour later the CT came back positive for a pulmonary embolus - a blood clot in the patient's lung.

---

In our pulmonary pathology lecture a few months ago, the lecturer described a pulmonary embolus as one of the worst ways to die. "I've seen somebody die from it once," the lecturer said. "The guy just gasping for air like a guppy, breathing as hard and fast as he could. The air was getting in alright, but the blood wasn't, and he suffocated to death with lungs full of air."

If I was the doctor, I would've sent that patient home. Maybe killed him. Just as described above.

Apparently it's a good thing that I'm not actually responsible for any patients yet. I'm glad thing medical school is four years, not one... I've still got a heck of a lot to learn.


6 comments:

Anonymous said...

Please don't be too hard on yourself.

That's what all that classroom time and training are for - to learn.

I think somehow that you will be a really good doctor, because you aren't afraid to recognize that you don't know everything.

Tiny Shrink said...

I probably would have done the same thing--reading the first part of the story, PE wasn't even on my list.

Someone told me once that you can't be an attending unless "you add PE to every patient's differential diagnosis." Thus, there would have been times the d-dimer was negative, the patient a little anxious, drinking too much coffee and out of shape, and you'd be back in the doctor's lounge before he'd even finished his discharge paperwork.

Great post.

incidental findings said...

In medicine, we talk about a few different ways to learn:

Learn from doing something right.
Learn from the mistakes of others.
Learn from your own mistakes.

I've killed plenty of people. We all make mistakes. The true crime is not learning from those mistakes.

Dr. Smak said...

What they said.

It's important to learn from your errors, whether as an MSIII or an attending.

And it's equally important to come to grips with the fact that you *will* screw up again. Guaranteed. Find a way to make your peace with this crazy career you've chosen.

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