Category: Real Doctor Stories

First workday in the National Health Services Corp

It’s July 5, 1982. We arrived on July 3 and, obviously, July 4 was a holiday. Yesterday we were invited to a small cookout where we met some local residents who were very nice and who told me that my physician counterpart at the clinic was on vacation that week, meaning, I was on my own. For the week. Me a physician just graduating from the somewhat sheltered life of academic medicine with no transitional mentor. Not that it mattered much, it turned out. My physician counterpart, Dr. Jones, had only completed a one year rotating internship and was planning on going into Orthopedics and had one more of his two year National Health Service Corps stint to complete. His knowledge base was fairly restricted in breadth and depth, it turned out. I was Board eligible in Internal Medicine and had been in one of the first “Primary Care Tracks” ever offered by the Internal Medicine Society, so I had done OB, Pediatrics, NICU, Orthopedics, and Outpatient GYN in addition to the array of Adult Medicine services for three years.

I was now an LMD (Local Medical Doctor) LMD’s were routinely derided where I trained (and every other academic medical center, I learned from talking with other physicians my same age).

I was told clinic hours started at 0800h, so, I arrived at the clinic at about 0745h. I met the staff, Mary, LPN, Linda, LPN and Joan, the receptionist. Janie, the clinic manager, who also managed two other clinics, wasn’t there. Mary showed me where everything was, what I was supposed to do with the encounter sheet, and said, “We have a full schedule today, 24 patients. Dr. Jones has never seen that many in a day!” I said, “I guess we’ll have to put our roller skates on!” I’d never seen more than a half dozen patients in a session of “General Medicine Clinic” while in training at Dartmouth-Hitchcock Medical Center.

The clinic had been taken over by a Community Health Care System from a Dr. Rogers. Dr. Rogers was used to seeing over 40 patients a day. Dr. Rogers turned out to be an impaired physician and was currently working for a blood bank in the Twin Cities, but he still lived in our town. He would stop by the hospital on his way home to see what was going on and he would often sneak into the OR area and sniff nitrous oxide. After reviewing his medical records, it was obvious that he wasn’t very thorough, with lots of chronic illnesses being uncontrolled.

I started seeing patients at 0800h. Blood pressure checks, a sprain, a Pap smear, a well child check, etc. Halfway into the morning, I got a call from the hospital. They wanted to know if I was going to round on the inpatients. No one had told me I was supposed to do that. There were 3 patients in the house. I told them I would see them during lunch. My next patient came in for a blood pressure check. He was on SerApEs, Dr. Roger’s go-to BP med. While I was examining him, I noticed he was having runs of tachycardia. He also wanted me to check out a growth on his chest wall. The “growth” was a quarter inch irregular subcutaneous nodule that was rock hard. We did an ECG and he was having runs of ventricular tachycardia (V-Tach). I immediately had him ushered over to the hospital (which was only an alley way from the clinic back door). They had just installed a 2 bed “ICU” at the hospital across from the (only) nursing station. I had them put him on the monitor and checked a battery of tests. It turned out his potassium was below 2.0, likely due to the diuretic in SerApEs. I ordered runs of IV potassium.

I finished up my morning patients and went over to the hospital. The cardiac monitoring main-station was on the counter top of the main (only) nurse’s station. The hospital was a 20 bed one story hospital with a small OR area and one delivery room with a one bed labor room. I checked on the patient I admitted and rounded on the other three patients, who were divided between Dr. Jones and a long-time local physician who was in a clinic about 20 miles away in the next city, Dr. Brown, who I had never met. Everyone was stable so I ate a quick lunch from the hospital kitchen and went back to the clinic for the afternoon.

About an hour into my first afternoon session, I got a frantic call from the hospital. A woman with two children had shown up at the hospital in labor. She was a single mom who had just moved up from the Twin Cites. I ran over to the hospital. I had never delivered a baby alone, having been in two rather large community hospitals with a dozen nurses and back-up OB/GYNs. Now it was just one nurse and I. The nurse showed me around the delivery room, where all the equipment was, how thing usually were done there. They had one new delivery room bassinet for evaluating newborns. The only suction device was a DeLee suction (you use your mouth to suck mucous from baby mouths and noses). There was no fetal monitoring device. A nurse had to use a hand held fetal Doppler and record what she heard in the paper chart.

I went to the labor room, met the mother in labor and started to describe the plan of care when she got up and started to get dressed and said she would be leaving to go to the Twin Cities. I had checked her cervix and she was just about in transition. I told her she likely wouldn’t make it to Minneapolis/St Paul. She called her sister who lived in our towm, signed out AMA and left with her sister. We were 98 miles from St Paul.

I left for clinic and saw the rest of my patients. Mary was impressed that I had seen the 24 patients plus all of the goings on of the day.

I went back over to the hospital. I saw my ICU patient. He still needed more potassium. He had no evidence for a heart attack, so this was mainly a metabolic problem. As I was writing my note on the patient, he had a 10-12 beat run of V-Tach. I asked the nurse to hit the button to get a strip so I could put it in the chart. But, by the time she hit the button, the V-Tach was gone and the strip was normal. This perplexed me because all of the monitoring stations I have been exposed to in training had a 10-15 second memory. The nurse said the one they were renting had no memory. This meant it was only possible to document a dysrhythmia if it lasted long enough for someone to notice and hit the button fast enough.

I asked the nurse if she knew what the rhythm was. She got up and walked over to a chart with rhythm examples that was tacked up on the wall. She scanned the chart and picked a rhythm that she thought matched the rhythm. “It looks like ventricular tachycardia”, she said. I asked. “What do you do if that rhythm doesn’t stop?” She said, “I call you.” I said, “I know you call me but what do you do while waiting for me?” She said, “ We just call you.” I asked, “Haven’t you had training on how to respond to things like this while waiting for me to arrive? I don’t have a phone yet, I’m only going to have the pager and I live two blocks from here. I won’t know why you paged me and I can’t give you phone orders.” She said, “The administration has decided they don’t have the money to train us. Another hospital (35 miles away) started an ICU and they trained the nurses, but we aren’t getting that.”

I sat there for about 45 minutes writing out protocols for the various scenarios the patient might get into during the night and went over them with the nurse. At night, there was only an LPN or an RN and a nurse’s aide in the hospital. Luckily, the patient made it through the night without incident and he had a normal potassium by the morning. We watched him one more day, through which he had no more runs of V-Tach and was discharged. Unfortunately, his chest X-ray had a mass in his lung, and the excisional biopsy of the chest lesion was metastatic squamous cell lung cancer.

The next day, right after rounding on the inpatients, I went to the administrator’s office. The administrator, Harry, was at his desk. I explained to him that the rented monitor station had to be replaced with one with memory and that the nurses required training. He said they would look into changing out the monitoring station but, there was no money for nurse training. I said, “You can’t have an ICU and not have trained nursing staff”. He said, “We’re not shutting down the ICU, it’s a money maker for us. We need the revenue. You’ll just have to make do.” I said, “You’re putting people’s lives in danger. If you don’t train the nurses you either have to shut down the ICU or I’ll transfer all ICU patients to Duluth (76 miles away).” He said, “ We’ll be informing the staff to ignore your transfer orders. We are not shutting down the ICU. We need the patients here and in our ICU.”

This is the moment when I realized that health/hospital systems do not primarily have the best interests of patients in mind. Money came first. It was a hard lesson to learn so soon out of training. Health systems are “for” patients and “quality care” as long as there is a positive margin/profit involved. Otherwise, the decision favors the bottom line.

I had our nurses query the other hospital with the ICU’s nurses to find out how they were trained and what materials they used. I had the nurses purchase the textbook, I purchased the instructor materials and text book, including ECG and ECG strip slides and spent the next six months every Wednesday night training the nurses in Cardiac Critical Care.

The nurses truly cared about the patients. The hospital, not so much.

As far as the mother in labor, she went through transition about half way to St Paul. Her sister noticed a state trooper who had stopped a car on the other side of the interstate. She stopped the car, ran across the interstate and told the trooper they were just about to have a baby. He crossed the interstate median, and, with siren blaring and calling ahead to Ramsey County Medical center, drove 90 miles an hour down the interstate with the mother in labor following. Luckily, the interstate off-ramp to the Medical Center just about ended at the ER entrance. The ER staff barely got the patient into the ER when the she gave birth. Mother and baby did just fine. The woman came back to our town and I was her and her children’s primary care physician. We always laughed about our first meeting and the day’s events.

The Three Year Old

It’s 12:00. I was just ushering my last morning patient to checkout at our clinic. The patient was an 18 month old boy who screamed every time he saw me even if I ran into him and his mother on the street. I completed all of my morning charting and headed over to the hospital to check on my inpatients and get some lunch from the hospital kitchen, hoping it wasn’t cow’s liver day. They always bread-loafed the liver exactly like the pathologists did to human livers; it looked exactly the same. Not very appetizing and I don’t like liver anyway.

I had to pass by the one bed emergency room to get to the nurses station. Just as I was passing the door to the ER, the Locum Tenens surgeon was walking out. I saw a child who looked like a 4 year old, at least, sitting at the foot of the ER exam table. He was slightly hunched over and had somewhat shallow breathing.

I asked the surgeon what was up? He said, “The kid has a really bad sore throat. I’m going to the nurse’s station to order a shot of penicillin.” I said, “Gee, if that kid was three years old or younger, I’d strongly suspect epiglottitis.” The surgeon said, “The kid is only three years old!” I asked if he minded if I saw the kid and he said, “Go ahead.”

Back in the 1980’s there were illnesses caused by a nasty little bacteria called Haemophilus influenza. You don’t hear much about this bacteria anymore because there is a vaccine for it that children get as part of their early childhood vaccine series. So now, the incidence of it causing infections is low. It doesn’t cause “the flu”, that’s caused by the influenza virus. This bacteria usually causes mild to moderate illnesses like sore throats, earaches, etc. However, it can cause two life-threatening illnesses: Meningitis and epiglottitis. The epiglottis is the little “trap door” at the top of your larynx that shuts tight when you are swallowing so you don’t aspirate food, drink or saliva down into your lungs. When H. influenza infects the epiglottis it swells so much that it blocks the throat and the larynx itself. It can completely block the larynx and cause respiratory arrest. It usually occurred in children less than four years old.

Treatment of H. influenza epiglottitis was ampicillin and intubation until the swelling goes down. The thing is, you can’t intubate a child with epiglottitis unless they are anesthetized because the gag reflect causes the epiglottis to spasm shut and you have to do a laryngotomy to get an open airway.

I walked into the ER and saw this child, sitting there with his head down, breathing with shallow breaths and drooling. These were classic symptoms of epiglottitis. The child had a fever of 102 degrees. I listened to his lungs but was afraid to look in his mouth or touch his throat until I got the key test to rule in/out epiglottitis, a lateral X-ray of the neck.

The X-ray tech wheeled the child into the X-ray room and took the picture. I was waiting in the reading room. She brought the X-ray in to me and it showed a hugely swollen epiglottitis that looked like a thumb. This was the classic “thumb sign”.

I told the X-ray tech to run to the nurse’s station and have them call the two nurse anesthetists who lived just outside of town. I ran into the ER and started an IV. I got a dose of ampicillin started and a dose of steroids (to try to reduce the swelling). The X-ray tech ran in and said the two anesthetists were up in Duluth working. I asked her to activate the volunteer ambulance crew, we had to get this kid to Duluth before he had a respiratory arrest.

The ambulance crew arrived quickly. We gently ushered the child into the ambulance and told the mother to follow in her car, but not at the speed we would be driving. I had the boy sit on the ambulance stretcher facing me. I was sitting on the bench facing him with an endotracheal tube in one hand and a laryngoscope in the other. It was 76 miles to Duluth.

The ambulance took off and when we got to the interstate, it was pedal to the medal, 90 miles per hour. It would still be at least an hour to the hospital in Duluth. I sat there staring at the boy praying we would make it there before he had a respiratory arrest. I had a headset on so I could talk to the ER staff at the hospital in Duluth. The two EMT’s were in their seats in the front of the ambulance.

About half way to Duluth, the boy sat up straight and grasped his throat. He had arrested! I couldn’t do anything until he passed out and then I had about three minutes to successfully intubate him or he would be either dead or brain dead. He started flailing, writhing. I just tried to have him not injure himself until he passed out. Finally, after about a minute, he went limp. I quickly positioned him for intubation. It was 50/50 that I was going to be able to slide the ET tube past his swollen epiglottis in good conditions. Here I was in an ambulance going 90 mph up the interstate! The vehicle was rocking and rolling with the bumps in the road. I wasn’t going to get more than one chance!

I could see the big red epiglottis through the laryngoscope. I slid the ET tube down this throat, my heart racing. When the tube passed the epiglottis there as a slight puff of air. I put the bag on the tube, put my stethoscope against his chest and gave the bag a squeeze. Yes! Breath sounds! Hallelujah!

I started bagging the boy and he pinked up but didn’t regain consciousness, which was actually a good thing since I was sure he would buck the tube if he woke up. Then, something totally unexpected happened. Pink frothy fluid started filling the ET tube. I’m an Internist, not a Pediatrician, so, I’d seen a lot of pink frothy fluid….it looked exactly like pulmonary edema.

Pulmonary edema most commonly occurs when someone’s heart is not pumping well. Actually it is usually pumping very poorly. This causes blood to back up in the lungs. The pressure builds up in the lung blood vessels and they exude fluid into the air sacs in the lungs.

Well, this was a three year old without a history of heart problems. I had to keep popping off the bag to suction the pink frothy fluid out of the ET tube to keep the airway open. I hailed the Pediatric ER in Duluth to give them the update that the child had a respiratory arrest, I had successfully intubated him and now it looked like he had pulmonary edema. The pediatrician on the other end of the line said, “ Nice job Dr Angellis, but, children don’t get pulmonary edema.” I said, “Well, OK, but I’ve seen a lot of pulmonary edema and this certainly looks like it!” He said, “It’s probably secretions from the H. influenza infection that may be in his lungs.” I thought, OK, he’s the specialist.

The ambulance screamed into the receiving bay at the hospital. The EMT’s opened the back door and there was a bunch of ER staff there waiting to receive the patient. They rushed him into an ER room and started working on him. I gave a quick summary of what I had seen and done. The X-ray tech came in and did a cross table lateral of the neck and a chest X-ray.

We usually didn’t stick around long, since we were now bystanders and we had to get back to our town. Just as we were saying our good-bye’s, the radiologist ran in waving the chest X-ray and yelling, “This kid is in pulmonary edema!” He put the X-ray up on a glow box and everyone stared at it. The lead pediatrician said to me, “Well! Unbelievable! I’ve never seen this! Good call Dr. Angellis!

We left the ER and headed back to our town. Four days later, we had to transport another patient emergently to Duluth (that was not an uncommon occurrence!). I checked with the Information Desk and found out the boy was still in the hospital, but was going to be discharged the next morning. I went up to the Peds ward wondering if the child had any brain damage from his anoxic episode. To my happy surprise, he was running around the room playing, his mother sitting in a chair watching him. I knocked and said “Hi” to his mom and asked her how he was doing. She said he was just fine and the neurologist said he had zero brain damage, all the doctors gave him a “clean bill of health.” I said I was so relieved!! She gave me a big hug and thanked me for saving her child’s life.

That’s the ultimate reward for being a doctor.

About a month later, I got a letter from one of the Pediatricians in the Duluth ER. Along with the letter was an article from the journal Clinical Pediatrics (Nussbaum E. Adult type respiratory distress syndrome in children. Clin Pediatr 1983; 22: 401–406).The article described pulmonary edema in children who had experienced increased pressure in the lungs! Exactly what had happened to my patient! It was the first published description of this condition!

Shaken Baby Syndrome

The Christmas season was in full swing, My NHSC colleague, Dan and I decided to thank the volunteer EMTs who staffed our town’s ambulance with a Christmas dinner at a well known and liked restaurant and bar in the next town.

Everyone arrived around 5:30 PM with their significant others. There was lively conversation, joking and laughter, a good time being had by all. Just as we all ordered our dinners, two EMT’s pagers went off and they jumped from their seats and ran out of the building. Within a few minutes, another EMT was paged, and he jumped up and ran out of the building. Dan and I looked at each other with a knowing look that said it was likely we were next to go. Suddenly, a county deputy sheriff came in and asked us to go with him, there was an accident with multiple injuries and we were needed in the ER.

We jumped into the sheriff’s cruiser and headed to the hospital, about 8 miles away, with siren blaring. The sheriff told us there had been a head on collision. The driver of one car, which had crossed the median line, was dead at the scene. He was later found to have been drunk. The other car was carrying a family with several children, parents and grandmother. The grandmother was dead at the scene. The parents and children were being transported to the hospital ER.

On arrival at the ER there were three children: two toddlers and an infant who was being held by the mother. They were ambulatory. The father was being wheeled in on a stretcher and was in obvious distress. The ER only had one room and bed. Dan and I agreed that I would take the father and he would assess the children and mother.

The father was hugely obese, weighing at least 400 pounds. He was stuporous and breathing rapidly. His BP was in the 80’s and his heart rate was rapid. It was obvious that he needed IV fluids immediately, as he likely had internal bleeding. We attempted anticubital access but failed. I called for a cutdown tray and while the nurse was getting that, I attempted a central internal jugular vein line, as his body mass made subclaviam access difficult. As I was in the process of inserting the line, the patient coded. This was within 5 minutes of his arrival in the ER. An ET tube was placed. CPR was performed while IV access was being attempted. There was no bone marrow access equipment at the time and that was not part of the ACLS protocol in 1982. We tried ET tube Epinephrine without success. MAST trousers were attempted but were somewhat ineffective as the patient was so large, they didn’t fit well. We were never able to get IV access and the patient was pronounced dead after about 30 minutes of CPR and line access attempts.

The mother and children had only minor injuries and were discharged with instructions for home observation. They were seen in the clinic the next day for re-assessment. The infant was three months old.

Three months later:

Our office got a call from Child Protection Services that three children were being brought to our clinic for physical exam assessments for child abuse. The children were being removed from their home. The children in question were the three children from the accident at Christmas time. The mother had hooked up with another man and there was suspicion that the boyfriend was physically abusing the children. My exam of the children revealed only minor bruises that I couldn’t definitively say were due to child abuse. The children were removed from the home anyway, but were returned to the home after 4 weeks.

Six months later:

One of my OB mothers had been coming in for pre-natal checks weekly since she was 32 weeks gestation. At 40 weeks, it didn’t appear that she was going to go into labor any time soon. I sent her up to Duluth to our back-up multispecialty group for non-stress testing on weeks 40, 41, 42 and 44. We didn’t perform C-sections since neither Dan nor I were trained to do that and there were no OB/GYN’s anywhere close to our town. I questioned why, at 44 weeks, they wouldn’t induce her. They said her “signs” were fine and I should send her back in week 45.

Two days after the 44 week non-stress test, the patient arrived at our hospital in active labor. We put her in the birthing room. Her and her baby’s vital signs were normal and her labor was progressing, but slowly. When she was 9 cm dilated, I ruptured her membranes, a common technique for speeding up the birthing process. The nurse and I were horrified to see that the amniotic fluid looked like thick pea soup. This is a medical emergency as the fluid was significantly meconium (fetal “poop”) stained due to fetal distress , and the baby was at high risk of aspirating the meconium stained fluid which results in a severe respiratory distress syndrome. I ordered the mother to be moved to the delivery room immediately.

I no sooner had that order been voiced when a nurse ran into the room and frantically said there was a 9 month old in the ER unconscious from a head injury. I had to triage the situation immediately. I delegated the woman in labor to the nurse, who, in her 15 year career, had delivered a few babies and observed many, and I ran down the hall to the ER.

What I found in the ER was the 9 month old child of the mother from the car crash and whose children had been removed from the home by Child Protection Services. The child was unconscious and had a dilated left pupil (commonly known as a blown pupil) indicative of enough intracranial pressure on the brain to move the brain inward and press on and put traction on the brain stem. This is a medical emergency requiring neurosurgery intervention. I got an IV in the child and pushed an appropriate dose of mannitol ( a drug that removes swelling from the brain) while ordering the ambulance.

The story from the mother was, the child was in a walker and accidentally fell down the flight of stairs in her home that went down to the basement. She swore there was no child abuse.

The ambulance crew arrived within 5 minutes. I picked up the child and ran through the ER doors and up into the ambulance. Just before the doors of the ambulance closed, the nurse to whom I had delegated the mother in labor, ran up to the back of the ambulance and shouted that the baby had been born, she had used the DeLee suction to clear the meconium stained amniotic fluid from the baby’s mouth and throat, and the baby was doing fine and had no signs of respiratory distress. We closed the ambulance door and sped away.

In those days, the ambulances had no significant medical equipment, just bandage material and an esophageal obturator airway. I placed the baby on her back, hung the IV and basically stared at her and took her vital signs and neurological status for the entire 80 mile trip while the ambulance screamed along at 90 miles an hour. We arrived at the Duluth hospital where we were met at the ambulance bay doors by a team of ER clinicians. After a rapid assessment in the ER, they whisked the baby up to the OR.

We got back to the ambulance and drove back to our town. Later that day, I got a call from the Pediatric resident who told me that the child had died. When they opened her cranium, she was bleeding from both sides of the brain from multiple small arteries that had been sheared, indicative of shaken baby syndrome. They had to transfuse the child with several units of blood but were unable to stop the bleeding and the child expired.

One month later:

I called the District Attorney’s office to find out if they were planning on filing charges against the mother or her boyfriend. The ADA said they couldn’t prosecute because the Medical Examiner determined that the likelihood that the injuries were caused by shaken baby syndrome was only 98% and the DA wouldn’t prosecute unless the ME said it was 100%. I was furious! Ninety-eight percent seemed high enough to me to prosecute! The ADA said there was nothing that could be done to go forward with an arrest and prosecution.

I continued to be this family’s Primary Care Physician. I had to put my feelings about the dead child aside and provide them with the care they needed. It wasn’t easy.

The Four Cardiacs

It was a Tuesday night. I was on call. I actually got home early enough to have dinner.

Then, the phone rang. It was the nursing home charge nurse. One of my nursing home patients, a fellow in his eighties, was stuporous, and they wanted me to come over ASAP to evaluate him.

Flashback about a year. The man I was called in to see was experiencing significant dementia. He lived with his wife and their children could not help her manage him. After several visits to discuss disposition, the decision was made to admit him to the nursing home. About a month later, the wife was visiting her husband when she was suddenly struck by a severe headache. The nursing home staff wheeled her over to the clinic. The nursing home was on the other side of the hospital, connected by a hallway, so this was easy to do.

The woman was in significant distress, holding her head. A neurological exam revealed deficits. Back in 1983, this was enough to suspect a subarachnoid bleed (bleeding around the brain). As CT scans were still pretty rudimentary then, the definitive test was a spinal tap/lumbar puncture. I prepped her back, anesthetized the area and inserted the spinal needle. When I attached the opening pressure attachment, dark red fluid ran out. This is indicative of a subarachnoid bleed. At the time subarachnoid bleed mortality rate was about 80%. We immediately mobilized the ambulance and I went with the patient in the ambulance to the tertiary care hospital in Duluth. She survived but, unfortunately, she suffered significant stroke symptoms, was unable to communicate, and on return from Duluth, was admitted to the nursing home in the same room as her husband. The man in the rest of this story is her husband.

I ran over to the nursing home and found the man unconscious. His physical exam revealed a heart rate of 30. An ECG revealed that the man was experiencing complete heart block. This requires immediate cardiology assessment and, if not reversible, placement of a pacemaker. We didn’t have an external pacemaker so he would have to be transported to Duluth. The patient’s guardian had designated a DNR/DNI and comfort measures only status for the patient. I called the family member who was the guardian. She verified the DNR/DNI and comfort measures only status. We moved the patient to the hospital into our two bed ICU, which was unoccupied. The family arrived and we used that venue for them to be alone with their likely dying father.

Just as I was completing the nursing home resident’s admission orders, the ambulance arrived with a man having chest pain. We got him on O2 and an IV and did an ECG. He was having an inferior Myocardial Infarction (MI) (Heart Attack). I ordered him to be admitted to our vacant ICU bed, next to the nursing home resident in heart block.

Before I could even write this MI patient’s orders, the nurse aid ran in saying an inpatient was in respiratory distress and coughing up “stuff”. Now, at night at this hospital, there was only one nurse, usually an LPN, and a nurse aid. The in-patient was an elderly woman who was sitting bolt upright in her bed, breathing rapidly and coughing up pink frothy fluid. Exam revealed signs of florid pulmonary edema, a fatal condition if not treated aggressively. Chest X-Ray confirmed pulmonary edema (fluid in the lungs).

The problem was the nurse was in the ER with the man having the MI. The only staff left to help was a nurse aid.

Back in 1983, emergency treatment for pulmonary edema was a protocol named MOISTDAMP. This stood for: Morphine, Oxygen, Intubation, Sit Up, Tourniquets (rotating), Digoxin, Aminophylline, Mercurial diuretic (really, furosemide), and Paste (Nitroglycerine). We couldn’t intubate since we had no ventilator, so we had to do all the other things on the list. I pushed the morphine, digoxin and furosemide. The nurse aid placed the oxygen. I ran to the ER and cared for the MI patient so the nurse could go to this patient’s room hang IV aminophylline and apply the paste. She ran back to the ER and I ran back to the inpatient’s room. Someone had to stay with the patient, keep her sitting up and applying rotating tourniquets. This consisted of placing tourniquets on three of the four limbs and then, every 5-10 minutes, removing one and placing it on the limb without the tourniquet. I had to teach this to the nurse aid and delegate that to her. We used blood pressure cuffs.

I ran back to the ER and got the patient ready for the ICU. The nurse wheeled him into the ICU. I ran back to the inpatient in pulmonary edema. She was improving! I told the nurse aid she was doing a great job and ran back to the ICU.

However, I never made it there. As I was walking down the hall, the ambulance arrived with a man who was in shock! Low BP, rapid heart rate, in a light stupor and complaining of chest pain. His ECG showed a massive anterior MI. The nurse called in a second nurse. I got two IV’s into the patient. The patient was started on dopamine and the ambulance crew was advised that they had to rush the patient to Duluth. At the same time, it really required a physician to accompany the patient and I couldn’t go as I had three other cardiac emergencies going on.

I had the nurse call the other physician who worked with me at the clinic. He wasn’t happy to be called in on his night off, but he came in right away and hopped into the ambulance and sped away with the patient. As I recall, the patient survived!

During the next four hours, the nursing home resident died, the inpatient in pulmonary edema had her condition clear (she survived and went home) and the man with the inferior MI’s condition was stabilized. The four cardiac patient events had all occurred within 90 minutes’ time. One doctor, one nurse, one nurse aid.

 

 

 

 

Back Pain, Back Pain, Back Pain

Back Pain #1

It was 1983. I was in the National Health Service Corps in a small town in Minnesota. The western border of the town is a river. Several miles beyond that river is a Federal Corrections facility. It’s a medium security prison with an imbedded maximum security facility for “mob snitches”. Because I was the only board certified Internist for 60 miles, I did consults there for the infirmary, which was run by a surgeon and about a half dozen Physician Assistants.

When a prisoner got ill enough, the prison sent the prisoner to our hospital. The prison would hire security guards to sit outside the door and “guard” the prisoners. These guys were usually retired and overweight. They mostly played cards and joked with the staff. There were stories about prisoners who were patients in the hospital. One of the most colorful was when a pickup truck drove up to the window of the hospital room in which a prisoner was staying and the prisoner jumped up, threw a chair through the window, jumped out into the pickup truck and they sped off, a complete jailbreak getaway.

It was different when one of the “snitches” was admitted. There was a room at one end of the hospital that had bars bolted to the outside of the windows. They put the maximum security prisoners in there and the guards were real Corrections Officers wearing flack jackets and carrying Uzi’s. Obviously, they feared a drive by shooting or something like that. We always wondered and joked about the fact that none of us (hospital staff) were ever offered a flack jacket when we were in that room.

Anyway, I got a call from the prison infirmary that they were coming in with a prisoner with back pain not responding to outpatient treatment. Of course, the prison infirmary staff thought he was malingering. Since half of the prison population went through the infirmary every day, they thought just about every one of them was malingering.

The prisoner was a 40-something black man with a lot of tattoos. This was unusual in 1983. We called him the Tattooed Man. He had been stabbed in the back in the past and had lost one of his kidneys. I did an admission history and physical. He was a pleasant guy who was deathly afraid that he had a serious kidney problem and was going to lose his only remaining kidney. I ordered the usual admitting labs and x-rays. Nothing was abnormal. I did an IVP (a now much less used imaging test for kidneys) and it was normal. Other than some tenderness in the lumbar area of his back, his physical was normal. We put him in a physical therapy program for five days and discharged him back to the prison.

Two weeks later, I got a call from the prison that they were bringing him back in; his back pain was worse and they couldn’t do anything for him. Of course, I’m wondering what the heck I could do for him, too. His readmission physical exam was still unremarkable except for some lumbar area tenderness. He was more anxious now about losing his kidney, even though his recent kidney test was normal.

Except…..this time something wasn’t normal.

I got a call from the lab technician asking me to come down to the lab. She wanted me to look at this fellow’s Complete Blood Count (CBC) and blood smear. I had a fair amount of experience reading blood smears because I personally looked at the blood smear of every patient I admitted during training and did six rotations through Hematology-Oncology. She motioned for me to look at the smear saying, “There is something seriously wrong with this guy”. His white blood cell count was over 50,000 (normal is up to 12,000). In his smear were “blasts”. These are immature precursor blood cells not usually seen in a person’s blood. In addition, the blasts had “Auer rods”, which are diagnostic of Acute Myelogenous Leukemia (AML).

I called the prison infirmary, told them what I had seen, gave them my diagnosis and told them this prisoner needed to be transferred immediately to the prison system’s tertiary hospital in Springfield Illinois. I went up to the Tattooed Man’s room and gave him my diagnosis. He thanked me for figuring out what he had. I guessed that his back pain was due to the expansion of his bone marrow in his vertebrae. The prison flew him out to Springfield the next day.

Three weeks later the infirmary surgeon called me and told me he had died.

Back Pain #2

It was 1986. I was now in New Hampshire. I was doing evening clinic. A 25 year-old man came in complaining of back pain. It just came on, he didn’t do anything to strain his back. He’d had it for about two weeks. He was healthy with no medical problems and had never had back pain before. His exam was normal except for some lumbar back tenderness.

This rang a bell in my head and I remember the Tattooed Man. I had the lab do a CBC. It was normal. I was feeling like I was being a little ridiculous about ordering the test. It’s not a test you order for back pain. I gave the patient a prescription for 800mg ibuprofen and taught him William’s back exercises. I told him if he wasn’t better in two weeks he should come back for a recheck.

I was in evening clinic two weeks later. The 25 year-old man came back in continuing to complain of back pain. It was worse. His exam was the same and he had no new symptoms. I felt compelled to order that CBC again. As I was coming out of another patient’s exam room, the lab tech was standing there in the hall. “I need you to come and look at this CBC and blood smear,” she said.

I went to the lab and saw that his CBC had a White Blood Cell count of 30,000 with blasts. I looked at the blood smear and the blasts had Auer rods. I could have been knocked over with a feather. Another Acute Myelogenous Leukemia presenting with back pain.

I had to go back to the patient’s exam room and explain what I found and what it meant. I then called Massachusetts General Hospital, got connected to the Heme-Onc resident and got the OK to send him down that night.

He got chemotherapy at Mass General and was in remission when I saw him next. He thanked me for figuring out what was going on. The Oncologists said the fact that his condition was diagnosed so early it gave him a better prognosis. They had never heard of AML presenting with back pain.

I left that practice and never heard how he made out. AML is not a good diagnosis. I always presumed he didn’t live long, but I have no idea.

Back Pain #3

It was 1991. I was in the Twin Cities, Minnesota. A 28 year-old woman I’d seen once or twice for health maintenance check-ups came in complaining of back pain. She didn’t do anything to hurt her back. She never had back pain before.

I performed a physical exam and her exam was normal except for some lumbar back tenderness. I’m getting flashbacks to the two patients above who had a similar presentation. Again, feeling a little foolish, I ordered a CBC. It was normal. I prescribed ibuprofen and taught her William’s exercises. I told her to come back in two weeks if her pain was not better.

Two weeks later, she came back in complaining of persistent back pain. Her exam was the same. I ordered a CBC. It was normal. I ordered a two-week course of physical therapy. I told her to come back at the end of her physical therapy sessions for a recheck.

Two weeks later, she came back in still complaining of the back pain, it was not any better and maybe worse. Her exam was the same. I ordered another CBC.

I got a call from the lab tech asking for me to come to the lab. Now, I was actually having an anxiety attack on the way to the lab. I looked at the CBC results and her WBC count was over 40,000 with blasts. Her blood smear blasts had, yes, Auer rods! Yikes! Another one!

I went back to the patient’s exam room and told her what I found and what it meant. I called the Oncologist and had the patient directly admitted from my office to the hospital for treatment.

For those of you who have never experienced a leukemia “induction” (that’s what they called getting high dose chemotherapy that totally wipes out your bone marrow), the patient spends 4-6 weeks (depending on how fast a patient’s bone marrow recovers) in one room in “isolation”, meaning only staff and family can enter the room and they have to be gowned, gloved and masked to prevent transmission of infection to the patient. Every other day and every weekend day I was on call, I stopped by the hospital (which was a different hospital from the one where I admitted 99% of my patients), reviewed her chart and paid her a visit. It was usually a 10-15 minute visit. She was always ingood spirits, never “down” or depressed. It was strictly a “social” visit, I never actually ordered anything for her.

She survived her induction and was sent home, but, within a month, her leukemia was back. This is always a bad sign. Again, I visited her every other day and every weekend day I was on call. About three weeks into her second induction, she got acutely ill with infection. I got a call from the Oncologist while I was in clinic informing me that she had died. It was the first week in November.

About a month later, I was seeing patients and I saw that my next “patient” was the family of this leukemia patient. We doctors always fear that something went wrong and we are about to get sued when we see something like this. I cautiously enter the exam room. There were four family members there. They explained that they were there to thank me for taking such good care of their deceased family member. I stammer out something like, “Well, I really didn’t treat her, the oncologists did everything.” One of them looked at me and said, “She always considered you to be her doctor. You were the one she identified with. We’re also here to give you something.” She handed me a Plaster of Paris ghost statue with a cast on the right leg. “She made this for you for Halloween, but she became too sick to give it to you. We wanted to make sure you got it.” I was gob-smacked!

They thanked me again and hugged me.

I still have that little Plaster of Paris statue. It’s always been a reminder to me of the power of what the patient-doctor relationship can be. If you care enough.

Here’s a photo of the statue. I keep it on my dresser.

Epilogue

I never had another patient like these three. I never ordered another CBC for a back pain patient because I never had a patient with that exact presenting story. My oncology colleagues always thought these stories were unusual, almost unbelievable. But that’s the part of practicing medicine that makes it worth-while. It’s not really the money. It’s experiences like these and patients like these.

When A Save Is Not A Save

It was about 10:00 in the morning. I was an intern where I trained. I was coming out of the stairway that emptied into the main lobby of the hospital on my way to the lab to check on that morning’s lab draw results for my patients after finishing morning rounds. All of a sudden, the loudspeaker blares, “Dr. Ambu, please report to Building 4, third floor, Dr. Ambu, please report to Building 4, third floor.”

You’re probably wondering who Dr. Ambu is. Well, where I did my residency, the hospital decided that people knew what a “Code Blue” was (that’s when someone has a cardiac arrest and they call for the code team). So, they decided to rename Code Blue to Dr. Ambu. Ambu comes from the name of the bag that is used to ventilate the patient, the Ambu bag. There are several stories about this. One is, a patient, who coded and was revived and survived, sent a letter to the hospital wanting to meet with Dr. Ambu to thank him for saving her life. That must have taken a little explaining.

Anyway, I was on the Dr. Ambu team because I was the intern on call for the ICU/CCU that day, and we had to respond to all Dr. Ambu calls. But, I had no idea where Building 4 was, and I thought I knew the hospital campus pretty well, having gone to medical school there.

I ran to the information desk and asked where Building 4 was. The lady there said it was caddy corner to the hospital across the intersection on the north side of the hospital. Without hesitating I ran out of the hospital, down the street to the intersection, crossed the street and found Building 4, a 100 year old brick building. I ran into the foyer, there was no elevator. The loudspeaker had said third floor. I ran up the very narrow 100 year old stairs to find two women doing CPR on a woman just beyond the entry into an office. As it turned out, the two women doing CPR were certified CPR instructors whose offices were on the second floor. I asked if I could spell either of them and they said not yet.

Suddenly, there was a clamor as a bunch of people came up the stairs. It was the rest of the code team with a defibrillator, hands full of meds, syringes, IV bottles and a stretcher. The resident in charge ordered me to get a femoral vein IV in, then a femoral artery blood gas and a femoral vein blood draw. After getting that done, I spelled the person doing compressions. After a couple of injections of epinephrine and lidocaine, a cardioversion from ventricular fibrillation to normal sinus rhythm was successful. We bundled up the patient with her IV, put her on the stretcher, carried her down the three flights of stairs, across and down the street, through the main lobby and up the elevator to the CCU.

We got her in bed, set everything up, got the necessary tests and followed the MI (heart attack) protocol. When I left at about 5:00 PM, she was still unconscious, but her tests confirmed that she did not have an MI. The presumption was she had a spontaneous dysrhythmia, likely the ventricular fibrillation we saw on the defibrillator screen. I went home hoping she didn’t suffer any brain damage, as her prognosis was pretty good if she didn’t have an MI.

Back in those days, you were on call every other night and had to stay until all of your patients were stable, usually about a 30 hours on, 18 hours off cycle. The next day I came into the CCU and went to her room first to do my pre-rounds rounds (you better have seen your patients before the formal rounds with the attending physician). The woman who had coded across the street was sitting up in bed, smiling, talking, like nothing had happened! Her labs and electrocardiogram (ECG) looked normal! What a save! Everyone was impressed on Attending Rounds. The plan was to put her on anti-dysrhythmic medications and discharge her when her oral medication blood levels were therapeutic.

Unfortunately, the plan didn’t go as planned. About 3:00 PM, the patient started complaining of abdominal pain. On exam, there was diffuse abdominal tenderness and absent bowel sounds. Here abdominal pain work up showed an elevated white blood cell (WBC) count. A surgery consult was obtained and the surgeon was very suspicious of a superior mesenteric artery (SMA) problem. This artery supplies blood to most of the intestine and the pancreas.

We sent her down to the radiology department for an arteriogram. The test showed a complete occlusion of the proximal SMA. What had happened was, during the low blood flow state she was in during her cardiac arrest, the SMA had clotted. There was also x-ray evidence that her intestine was “infarcting” (dying). Since the findings were so diffuse and there was no way at that time to open the SMA, the surgeon’s prognosis was that this patient would die within 48 hours. Yes, the person who had survived an out-of-hospital cardiac arrest and was deemed a miracle success story was now expected to die in 48 hours.

The attending, the resident and myself had to go to this patient’s room and inform her and her family that she now had less than two days to live. If you weren’t there, you have no idea what that was like.

We put her on comfort measures, sedated her with morphine and within 36 hours she died peacefully with her family surrounding her. It was one of the most tragic cases with which I was ever involved.

Don’t Give Up When Told To Give Up

The following three stories are about patients where I was told by hospital staff and physician consultants to give up on three patients and “let them go”. For two of them, they were unconscious, had no written expressions of their wishes and had no family with Power of Attorney. The third was conscious and did not want to give up. All three ended up being miraculously improved and survived.

The 26 Year Old

It was 1987. I was on the Med-Surg floor of a hospital where I had privileges. The hospital Social Worker approached me and asked if she could ask me a favor. I turned around to face her, having been focused on completing my patient charts for the morning so I could get to my office to start seeing patients.

“What can I do for you”, I asked. “We have an inpatient whose doctor is leaving the city and we thought you would be the best doctor to take over her case”, she said, “She’s a Healthsource Insurance member and we know you take Healthsource patients.”

I asked her to tell me about the patient, who, she said, was a 26 year-old female with Werdnig-Hoffman’s Syndrome. I had never heard of this. It turned out, the reason why was, I am an Internist, what some call an adult medicine physician. Werdnig-Hoffman Syndrome is a pediatric diagnosis. It is Type I of a series of similar syndromes called Spinal Muscular Atrophy. It looks a lot like Muscular Dystrophy. The difference is Spinal Muscular Atrophy’s cause is neurological (nerves no longer controlling muscles leading to muscles shriveling up) where Muscular Dystrophy’s cause is a problem within the muscle itself.

The patient was lucky to be alive. The life expectancy of Werdnig-Hoffman Syndrome is less than 20 years old. This patient was 26, pretty much unheard of. She was bed bound and required a caregiver in her house 24/7. Her lung function was terrible and she required aggressive pulmonary therapies to keep her lungs clear and free from pneumonias. She had been in and out of the hospital frequently due to recurrent pneumonias.

I told the Social Worker that I would be happy to take on this patient. I don’t think I ever turned down a request like this. The patient was incredibly small, a wraith, and weighing only about 60 pounds. Interestingly, she had a job, computer work at a local government defense company. She couldn’t move her arms or legs. She gurgled, due to lung secretions, with every breath. She required “pulmonary toilet” (respiratory therapists giving her nebulizer treatments then banging on her frail chest) every 4 hours 24 hours a day, which had to be painful.

She was particularly sick on this admission. I almost felt helpless treating her, she never seemed to get better. I had pulmonologist and neurologist specialists as consultants. After about two weeks, both the specialists and the staff (especially the respiratory therapists and nurses) telling me I should just stop the treatments and “Let her go”, since her treatments had to be uncomfortable, she wasn’t getting better and she had already exceeded her life expectancy by over six years. Most of these patients die of pneumonia because they can’t manage their pulmonary secretions.

So, I had a heart to heart talk with this patient. She was adamant that she did not want to stop therapies. Every day I had the staff telling me I was torturing the patient. This prompted me to, every day, re-evaluate what was going on with the patient.

At about three weeks into her hospitalization, I developed a theory that her secretions weren’t originating from her lungs. I was suspicious that she was having gastric reflux and was, nightly, drowning in liquid coming up from her stomach and going down into her lungs. None of her tests showed this and the staff and specialists weren’t convinced of this theory.

I had to try this theory out. I discussed it with the patient and she agreed to give my idea a try. The treatment had two parts: 1) position the patient so the gastric reflux fluids drained out her mouth instead of down her trachea (windpipe), and 2) start her on Prilosec, an acid reducing drug, to see if that would reduce the amount of fluid in her stomach.

Well, this treatment was like a miracle for her. Within a week her lungs were dry and I was able to discharge her. She rarely returned to the hospital during the next two years. She and her 24/7 caregiver actually took a train trip to the Grand Canyon, over 2400 miles away! She was happy and felt grateful to me for figuring out her problem.

I left the area after caring for her for about three years. The last I heard about her, she was 35 years old and doing well. I lost track of her and can’t find her on Google searches. The last time I talked to her on the phone she said she wrote a book, but I’ve never been able to find it.

I’m glad I didn’t listen to the specialists and staff!

The Spinster

It was 1986. I was on “service call” for the hospital. Service call is when you are called into the ER to see patients needing admission who don’t have a primary care physician (PCP) who has privileges at the hospital.

I got called in late in the evening one night to see a 68 year old woman who was found unconscious on the floor of her home by the police. No one knew how long she had been there. She was single, never married, and no one knew if she had a next of kin. It turned out, she didn’t.

She was a physiological mess. She had acute renal failure, rhabdomyolosis (breakdown of muscles) from lying on the floor for who knows how many hours, her metabolics were all out of whack, she was intubated, etc. What the medical profession calls a “train wreck”.

I created a flow chart of her lab tests and aggressively treated all of her physiologic abnormalities. She didn’t wake up. I weaned her from the ventilator, but I couldn’t extubate her because she remained unconscious and at risk for aspirating stomach and mouth secretions into her lungs. I had the respiratory techs put her on a T-tube (a device that attaches to the breathing tube but the patient breaths on her own and we can give her humidified oxygen or air, depending on the oxygen level in her blood).

Once I got her off the ventilator, I was able to transfer her to a Med-Surg floor in a regular bed. All of the specialist consultants told me she would never wake up and I should “just let her go”. She had no Advanced Directive and no known next of kin to ask. I figured, givien that situation, I should keep treating her.

The hospital administration started pressuring me to either “let her go” or get her transferred out of the hospital because it was now costing the hospital too much money to keep her in the hospital.

At the time, I was on the Utilization Committee of two skilled nursing facilities (SNF). I went to the administrator of one of the two and described a plan for this patient after transfer to their SNF. The patient would have to come there still on the T-tube, since she was still unconscious. To my delight, they agreed to take her. This was unusual, that they would take a patient on a T-tube.

The patient got transferred and I rounded on her daily. After about a month, she woke up! The respiratory therapist and I extubated her. She never needed to be re-intubated. She slowly improved to the point where she was ambulatory with no residual neurological deficits. The specialist consultants couldn’t believe how well she did.

She and the SNF staff decided she should be transferred (an internal transfer) to the nursing home floor of the facility. I kept her on as a patient, visiting her every 60 days. One day, while I was reviewing her chart before seeing her, one of the nurses approached me. “Going to see Ms. Smith?” she asked. “Why, yes”, I said, “Is there something going on I should know about?” The nurse said, “You know, she’s adopted you. She considers you to be the son she never had.” “Really”, I said. “Yeah”, the nurse said, “She really loves you!” I kept this information to myself.

Two years later, I was moving to another state, having had my practice taken over by a hospital, which I disliked. I made my last nursing home rounds and had to inform Ms. Smith that I was leaving the state and her care was being transferred over to another doctor as of Friday at the end of the month. She wasn’t happy about it.

I was in my office on my last day there, seeing patients. I was in a room seeing a patient when my nurse knocked on the door. It was 3:30 PM on my last day as a physician in that city. The nurse said the nursing home was on the phone and had to talk to me.

I picked up the phone, thinking they wanted a laxative order (or something like that) for one of my nursing home patients. What I heard stunned me. Ms. Smith had passed away. On the afternoon of my last day seeing patients in that city. The nursing home staff thought she died of a broken heart.

The Overdose

It was 1992. I was in my office seeing patients when I got a call from a hospital to which I rarely admitted patients. One of my patients was just admitted to the ER and they were certain she needed ICU admission. They wanted me at the hospital immediately. I ran out of the clinic hollering that the staff needed to reschedule the rest of my afternoon patients.

I arrived at the ICU and found a 35 year old woman who I had seen only for periodic health exams, and maybe only 2 or three times. She was a piano teacher, and since I was also  a pianist, we had talked about music. She had a history of depression being treated and followed by a Psychiatrist.

She was intubated, comatose, seizing and exhibiting runs of cardiac dysrhythmias, both ventricular tachycardia and ventricular fibrillation. The history I was given was, the patient was found unconscious in a car in a parking lot of a city park by a police officer. He called for an immediate ambulance and the patient was transported to the nearest hospital, a community hospital on the outskirts of the city. Her ER evaluation revealed an amitriptyline overdose with an amitriptyline blood level of 1300, the therapeutic range being 80-200. Anything over 500 causes significant adverse events. Over 1000 is considered likely lethal.

I started medications to calm the seizures and dysrhythmias, as well as applying the defibrillator paddles every 4-5 minutes,  and called for emergency consultations with Cardiology and Neurology. They came to the ICU as fast as they could, evaluated the patient, said I was doing all the right things and suggested some tweaks to my plan. I had to stay in the ICU until after midnight to manage her since it took a while for the medications to take effect. She seized many times and we had to cardiovert her many times during those next 8 hours.

The next morning, her amitriptyline levels were still over 1000. It actually took three days for her level to get below 500. The Neurologist and Cardiologist said she would never make it; that no one could survive an amitriptyline level above 500 for four days; it was unheard of. And if she survived, she would likely be a “vegetable” after all of those seizures. The neurologist said her brain was most certainly “pickled”. They advised that I not be too aggressive with her treatment. The patient had no advanced directive and there was no known next of kin we could contact.

I spent 3-4 hours a day in that ICU for five days. Once her amitriptyline level came down, she woke up. When she did, she slowly came out of a stupor and seemed normal, like I remembered her. We put her through a battery of neuropsychological tests and they were perfectly normal. Interestingly, psychiatric evaluation concluded that she was no longer depressed. It was like her overdose had been similar to electro-shock therapy. Probably, all those seizures (electro-shock therapy induces seizures).

I saw her in my office several times over the next 3 months. She was back to teaching piano, had no problems playing the piano, had no signs of depression and was on no antidepressant. The Neurologist was flabbergasted.

The patient was thrilled and not at all suicidal. For s long as I was her physician, she never attempted suicide again or needed antidepressants.

 

The Drunk Driver Walks Away

It was 1983. I was just finishing dinner when I got a call from the hospital that the ambulance was coming in with three patients: a man, a woman and what they estimated as a 4 month-old baby.

I ran down the street to the hospital, two blocks away. The nurse at the door of the ER told me that there was a collision between two pickup trucks. The EMT’s had radioed that one pickup truck had t-boned another at a “T” intersection along the two lane highway for which Bob Dylan had named one of his albums. A drunk driver in one pickup failed to stop at the “T” and T-boned a pickup with a woman and her child in it.

The ambulance arrived and it was controlled chaos.

The man was hypotensive and tachycardic. He was unconscious. His abdomen was tender. We got in two IVs running normal saline wide open and it wasn’t helping. I was sure he had internal bleeding, most likely a ruptured spleen but  other organ injuries, like fractured liver or a large artery injury, weren’t out of the question. I had the nurse and an EMT (there was only one nurse at night there) place MAST trousers (these are “pants” that you place on a hypotensive patient suspected of internal bleeding and you inflate them to compress the legs and send the leg blood to the rest of the body and brain) on the patient and get him ready for ambulance transfer to Duluth. We didn’t bother with any testing like lab or x-ray because we had a “30 minute rule”.

The “30 minute rule” was: you had to get a really sick patient out of the ER within 30 minutes of arrival. Analysis of past ER admissions showed patients spending more than 30 minutes in the ER were highly likely to die. They all required transfer and the nearest tertiary hospitals were at least an hour away. The sooner the patient got to the higher level of care, the higher the survival rate. You had to line them (put in IV’s) and stabilize them (like immobilize a broken bone) and get them out ASAP.

An EMT was holding the baby. She was alert, without bruises, breathing normally. We only had one ER bed at the time so I had to assess the baby on the counter top. She had no tenderness anywhere. She was moving all extremities.

The woman was unconscious and had a large bruise on the left side of her head. She started seizing. She had bruises mostly on her left side, likely where the truck door got pushed into her. Her left arm appeared to be broken. We got two IV’s in, gave her valium and a loading dose of Dilantin, wrapped her arm and prepared her for transfer.

We loaded all three patients into the ambulance. The man was on the right on a stretcher. The woman was on the left on a stretcher. An EMT was holding the baby in the passenger seat of the ambulance.

We roared out of the hospital parking lot.

That ride to Duluth was total chaos. I had to alternate back and forth between the intermittently seizing woman and the hypotensive man, pushing valium on the woman and changing IV bottles as they ran out to keep the man’s blood pressure as high as possible. I sure was glad to get to Duluth.

As usual, the Duluth hospital ER staff met us at their ambulance door and whisked the man right up to the OR. They took the baby and woman into the ER bays.

We didn’t stick around very long there because it was very late and we all had to get up early for work. I got an call from the Duluth hospital several days later with an update on the three patients.

The woman had a severe closed head injury, now called a TBI. Her prognosis was poor for functional outcomes, but she would survive. It turned out, her best residual functional status was equivalent to a six-year-old’s mentality. There was no way she would ever care for her child.

The baby was quadriplegic. This really shocked me as the baby looked fine in the ER. The theory was, swelling increased on the ride up and during her ER stay that cut off blood supply somehow to a section of her spine. She would be total cares and confined to wheelchair for the rest of her life.

The occupants of the “not-at-fault” pickup were neurological disasters!

As for the man, his only injury was a ruptured spleen. He successfully recovered from his abdominal exploration and splenectomy surgery and walked out of the hospital. His blood alcohol level on admission to the Duluth ER was twice the legal limit.

Another example of the drunk perpetrator ending up with the best, minimal harm outcome.

Physician as Musician

This story might read a little circuitously, but, c’è la vita!

It was November 1983. I got a call from the principal of the High School. They were planning on having a series of musical concerts for the benefit of the High School band. She was looking for acts to volunteer to play for one hour between the second Sunday in January going forward six weeks. That included the first three Sundays in February.

Now, I was playing keyboards in a three piece rock and roll band in the little bars going up an down Highway 61 (Yes, the same Highway 61 that is in the title of the Bob Dylan album, Highway 61 Revisited). And February 1984 was the 20^th anniversary of the month The Beatles first performed in the USA. So, the principal wanted to know if we could do one hour of Beatle songs. Well, of course we said yes.

Tangentially, there was a guy who lived in the next town who owned a music store in Minneapolis (98 miles away) who had set up a little music store in his garage for us locals. The guitarist in our band was looking for a new amplifier; so, we went down to this guy’s garage to see what he had. The guy was also a performing artist doing C&W with this wife at the local nightclubs and in the Twin Cities bars.

The little music store had a spinet piano in the middle of it. I sat down at the piano and started playing “Stormy Weather”, a jazz standard. About six bars into the song, I heard a beautiful woman’s voice singing the song. I looked up and it was the wife of the guy who owned the store. Her name was Phyllis. After I ended the song, she asked me if I knew any more. “Sure”, I said. The next thing I knew we went through a half dozen songs. Then she asked me if I wanted to accompany her in the same concert series I had agreed to have our band play at. The principal had called her and wanted her to perform at their last concert. Phyllis said, hearing me play those jazz standards, she immediately decided she didn’t want to do C&W with her husband, she wanted to sing “the songs my mother sang around the house when I was a child.”

Well, musicians rarely turn down a chance to play, so I said OK. We wrote out a set list, the last song being “The Party’s Over”. More about that later.

Back to The Beatles.

The band immediately started rehearsing a one hour set of Beatles tunes, starting with “Sargent Pepper’s Lonely Hearts Band”, which, of course starts with “It was 20 years ago today, Sgt. Pepper taught the band to play”. Who gets to start a Beatles-song concert with that line exactly 20 years to the month from their first USA concert!?

I went to every school Sunday concert. They were very entertaining. It was amazing how much talent was scattered through this town of 1000 people and the surrounding dairy farm land. At one concert, a 14 year old girl was the piano accompanist. She stumbled several times. It didn’t bother me, she being 14 and probably nervous.

Finally, it was the Sunday for the Beatles-song concert. We were packing the truck at my house with our musical instruments, amps, PA system, etc. when I got a call from the hospital. One of my mothers-to-be had come in in labor. This was significant because I promised all of my pregnant women patients that, unless I was out of town and unable to get back, I would be available when they came in to help deliver the baby whether I was on call or not.

I gave my pager to my wife. The nurses would page me and give a report on the patient’s status while we were setting up and then playing our concert set. Every thing was going well, but, the reports of the patient progressing through her labor suggested to me that I was going to be lucky to make it through the one hour concert before I got called in to the hospital.

We started the concert. As I announced the band and the theme at the beginning, I also announced that it was possible that the concert could be interrupted by my having to go and deliver a baby. Everyone chuckled. We went into our set of songs. At just about midway through our set, my wife came up to the edge of the stage waving her arms wildly. “They need you at the hospital NOW!” she screamed. I announced to the audience that I had to go deliver the baby, but, I should be back within 30 minute, so DON’T LEAVE! I immediately ran up the aisle, out the door, and drove the four blocks to the hospital.

I knew the laboring woman well. I had delivered another one of her babies my first year there. She was a “Multip” whose deliveries went fairly rapidly and uneventfully. When I got there the baby was just starting to crown. I had learned how to “iron” the perineum to avoid episiotomies. This went well and the baby was born without my having to do an episiotomy. The baby’s APGARs were 10/10. I suctioned the baby and handed her to the nurse. I waited as the placenta delivered, ensured there were no complications and rechecked the baby again, who was now swaddled and on the mother’s chest. I congratulated the mother and reassured her that everything looked great. She looked up at me and said, “Doc, I know you are playing in the concert at the school today. We’re fine; the nurses are great. Get yourself back there now!”

I ran out of the delivery room, tore off my scrubs, got dressed and ran out the hospital door. As I rounded the corner at the High School, I saw my son running from the corner of the school yard where he was scouting for my return.

By the time I came through the school auditorium door it was exactly 35 minutes from when I left. Everyone was in their seats. I learned later that everyone had been out in the foyer murmuring that they were going to leave, no one could possibly make it back from delivering a baby in 30 minutes! They all ran back to their seats when my son came in yelling that I was back!

I ran down the aisle and yelled, “Mother and Baby are fine!” The crowd yelled, “What was it? A boy or a girl?” I yelled, “It’s a girl.” The place exploded in applause! We finished the rest of our set. The place went wild!

You can’t make this stuff up!

Now back to the last concert with Phyllis. Since I had brought my electric keyboards with me for the Beatles-song concert, I had never played the acoustic piano there. It was undoubtedly the worst piano I have ever played. The action was horrible, I had a hard time negotiating the keys. Now I knew why that 14 year old had struggled. And several of the other concerts relied on that piano for accompaniment. As we got ready to play the last song, I said to the audience, “Before we close out the concert series with this last song, I just want to give credit to the other pianists who have had to play this piano, because it is the worst piano I have ever played. They should all be congratulated for doing so well despite this!”

We played our last song. I got off the stage, getting handshakes from audience members. Suddenly, the little 14 year old girl from that other concert came up to me, took my hand and said, “Thank you so much for saying that that piano was the worst piano you have ever played. When my father yelled at me for making so many mistakes, I told him the piano was terrible and he said, ‘Yeah, blame it on the instrument.’ You got him to apologize to me. Thank you, thank you, thank you!”

About six months later I bought a Yamaha grand piano (the smallest one). I donated my spinet piano, which was in near perfect condition, to the High School and told them to ditch the one they had. I often wonder if my donated piano is still there, 35 years later.

Beware The Impaired

Impaired physicians are part of the reality of being a doctor. It always amazed me, the amount of tolerance doctors had for their impaired colleagues. I thought there was less tolerance for this nowadays until a story emerged last year of an impaired OG/GYN physician who was behaving badly in the south part of the state I live in now, and his alcoholism and bad behavior were tolerated because of the amount of revenue he brought to the hospital.

Another example: there was the neurosurgeon in one hospital in a city I worked in who had vodka in an Aqua Velva bottle in his locker in the surgeons changing room near the operating room. Apparently, he’d take a few swigs before he went into surgery. I didn’t know this until I left that city. He had a good reputation, too. I often wondered if the physician and administrative leadership at the hospital knew this. They had to, I always thought. But neurosurgery is a big moneymaker for a hospital.

Another example: there was the internist in a multi-specialty group I worked for. I had interviewed with this physician when I was trying to get a position there. He was a jovial guy, always joking and upbeat. After I was accepted there as a Primary Care Physician, I was going through an orientation, which consisted with meeting for 15-20 minutes with all of the physicians in the group. I was, again, meeting with this physician when one of the leaders of the group came into the office to say “Hi”, when he opened a drawer in the internist’s desk and pulled out a half full bottle of whiskey, saying, “You know, this doesn’t belong here.” The internist said, “Oh, I got that as a gift from a patient. I just hadn’t taken it home yet.” After I left, I realized this guy had been drinking on the job. I was in this group for two years and that internist never went into a rehab program (or and extended “vacation”). It was simply tolerated by the group.

In one place I worked, there was a Primary Care Physician who had been there for a long time. Everyone knew he did both drugs and alcohol. He had been to rehab multiple times. The group I was in let him practice out of the office he had previously owned before the group bought up his practice. When he was in rehab, they would sent some of us over to his office to cover his practice while he was gone so his patients wouldn’t leave for another doctor outside of our group. His patients would say things like, “Hey, Dr. Brown is in rehab again, eh?” while laughing!. One guy said, “I guess Dr. Brown is in rehab again. That’s OK because when my mother was really sick, he was there for her.”

The nurses had many stories about Dr. Brown, like the day he crashed his car into the hospital as he was coming in from being called at night to see a patient. Or that he would be so drunk, he would fall off of his chair at the nurse’s station while doing his charting.

One Saturday, just as I was completing my last patient progress note, the nurse came up to me and asked me if I would be willing to see a child Dr. Brown had admitted the evening before. As usual, I followed the doctor etiquette, saying, “I really shouldn’t see other doctor’s patients without the doctor’s permission. Why do you ask?” She said, “The mother is really wanting you to check out the child and reassure her that Dr. Brown is doing the right things.” I repeated my disclaimer of not wanting to intrude on another doctor’s care of a patient. The nurse said, “Well, would you at least listen to the child’s mother’s story and decide after hearing that?”

I agreed to this, as that had nothing to do with seeing the child. Here is the story the mother told me:

“I live next door to Dr. Brown. One day, my friend and I were sitting on my front porch when Dr. Brown came out of his house, opened his garage door and got into his car. He started the car, put the car in gear, looked over his right shoulder to back out, put his foot on the gas, the car leapt forward and he crashed his car into the wall of his garage. He readjusted the shift lever, again looked over his right shoulder, put his foot on the gas, the car leapt forward and, again, crashed into the wall of the garage. He did this a third time with the same result! When he adjusted the shifter for the fourth time, again, looking over his right shoulder to back out, the care lurched backward and went speeding down the driveway, across the street and into the ditch, out from which he couldn’t get his car. He had to call a tow truck to get it out.

After seeing that, I’m really nervous that he could be making mistakes caring for my son.”

After hearing that story, I took a history, did a physical exam, reviewed Dr. Brown’s care plan and luckily was able to reassure the mother that everything was being done correctly. I never wrote a note about it and neither I nor the nurses ever told Dr. Brown about it.

The attitude of tolerance for other doctor’s bad behavior continues to this day. I had a person who was a “lay person” member of a state’s Medical Board (the folks who approve licenses, hear cases about doctors and have the power to levy sanctions and license revocations) recently tell me about her observations of what she called the “good old boys” behavior of the Medical Board physician members, frequently letting or trying to let badly behaving physicians “off the hook”. They often got away with it, too, she said. The “lay persons” often got out voted.

So….you must beware the impaired.