I don't have much of a moral

It's been a while.

I've been in a demoralizing, soul-sucking stretch of rotations for about two months. Suddenly, sleep has become more of a priority than ever before, and documenting the details of my crappy life seems less important and ultimately, less useful than ever. Still, you people seem to want to taste of every plateful of shit that's placed in front of me.

One of the more recent combo platters was served a few weeks ago, when I was on a pediatric emergency room rotation. My first night on, I saw a clinic patient of mine who had been sent into the emergency room by one of our supervising clinic doctors. The two-year old kid--I'll call him Ronnie--had shown up in the office with abdominal pain, diarrhea, and fever. The doctor who'd seen him had been concerned for a kidney infection, possibly disseminating to the blood.

When I walked into the room, Ronnie was standing on his mother's lap, painting her face with a popsicle. It was hard to get him to sit still long enough to be examined--always a good sign. His belly was mildly tender, his poop was blood-free, and a quick analysis of his urine looked contaminated, but didn't demonstrate convincing evidence of a urinary tract infection. I thought he probably had a viral gastroenteritis, and called the doctor who'd sent him in.

He looks pretty good to me, I said. But if you want us to draw blood and catheterize him for a clean urine sample, we can.

Nah, he said. I trust your judgment.

Ronnie's mother brought him in two days later with the same concerns. Again, I evaluated him, and my assessment was the same: viral diarrhea in kids can last for a week to ten days, and he was on day four of his illness.

Another two days later, while I was out for the weekend, one of the more experienced and better loved emergency room attending doctors saw Ronnie again. His assessment didn't vary from mine at all, and Ronnie again went home with a prescription of clear fluids and rest.

Twelve hours afterward, Ronnie's mother carried him into the emergency room in a panic. He was working hard to breathe and was barely conscious. On admission to the hospital, a urine sample obtained by catheterization showed a probable infection with a less common pathogen. A CT scan of his abdomen showed enormous, dilated kidneys and ureters. By this time, the infection had disseminated to his blood, and had progressed so far that he required admission to the pediatric intensive care unit.

Naturally, I felt terrible. I went to visit Ronnie in the ICU, and spoke with his parents. They didn't blame me, they said. He'd looked pretty good to them, too. The ICU attending told me he didn't blame me, either. These things can go from OK to really bad in a heartbeat, he said. Plus, your assessment was confirmed by another very good doctor. You didn't do anything wrong. My clinic attendings concurred, and thoroughly panned my suggestions that I had reacted too slowly.

It would have been jarring, but perhaps tolerable, if it had stopped there. But last week, another resident approached me to inform me that the case had been discussed in morning report. I had--anonymously, I hope--been roundly criticized by several colleagues for not drawing the labs and for not obtaining the catheterized urine on the very first visit.

The whole affair sticks in me like a splinter. The decisions I made, I did not make alone. Furthermore, my colleagues' analysis ignores the presentation and evolution of this particular child's disease. I'm normally able to put criticism in context, and to take much of it constructively and not personally. This time, that has been a little harder to do, in part because the criticism does seem personal.

It's not as though I don't feel bad already, and as though I didn't question my own judgment on a pretty deep level after this event. It seems that the role of others--especially others at my level of training--shouldn't so much be criticism as it should be support and understanding. If attending doctors aren't singling me out for censure, why are residents? So I don't have much of a moral for this story, unless you think "I am surrounded by assholes" qualifies.

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Hang in there ~ you're doing fine.

By NativeRoses (not verified) on 23 Feb 2008 #permalink

The case sounds like my niece who has been in and out of a similar illness for 15 days. What was the pathogen you finally found?
I appreciate your work, diagnosis is not a perfect art, yet in our lawsuit happy society, you always have to fear, and we tend to err on the side of too many tests, unless of course you have no health insurance!
Take care and it it's never nice to have people talk about you when they would have done the same thing themselves.

By Pat Muller (not verified) on 23 Feb 2008 #permalink

Dude. A public thrashing at morning report? You ARE surrounded by assholes! There is no way that that is an appropriate thing to do. You are a resident. You presented this kid to at last one if not two different attendings. A third attending saw the kid and agreed. I'm in the ED now and I've sent home more kids than I can count with a diagnosis of viral gastro. And viral syndrome.

We just had one of those Schwartz Center Rounds things that are so good at your institution and so crappy at my new one. (This story is relevant. I promise). This past week the topic was "The Case That Made Me Want To Quit." (See? Relevant). One of our very senior attendings, a very well respected clinician, presented a case from when he was a resident of a kid who came in to the ED with chest pain. The story and exam sounded for all the world to him like reflux. He gave her an antacid (hey - this was a few years before PPIs!) and sent her home. The next day she came in being coded by EMS. It was myocarditis, and he beat himself up over missing the diagnosis for, well, it sounded like he still thinks about it 30+ years later.

If this is your Missed Myocarditis, so to speak, you have every right to beat yourself up over it, criticize yourself and make sure you learn from this experience, but NO ONE has the right to trash you in a public setting and blame you for diagnosing viral gastro in a kid who looked like he had viral gastro! Period. I hate back seat doctoring. Learning from our mistakes: good. Criticizing others and saying "Well I would have done x, y and z differently": bad.

And, besides - a few pressors in the ICU never hurt anyone :) I'm glad he's okay. I just wish you were, too!
Long distance hug!

Dude -

Always room to learn/ never through practicing at the art of medicine.

The lesson I would humbly suggest after doing this for 20+ years is - always question yourself and everyone around you on the second presentation, certainly the third. Don't be reassured by "a more experienced doctor". Somebody's instincts are telling them something, otherwise they wouldn't have come back. The onus is on you at that point to prove a negative - which, of course, you can't actually do. But you have to do your best, and that means order/ over-order a workup for the returning patient.

Hang in there. All of us before you have been where you are.

BTW - "a few pressors in the ICU never hurt anyone" ???

Wrong. Once you get on pressors, your mortality skyrockets.

Stay vigilant and always a little unsure of yourself.

It's the asshole who never doubts himself that makes a bad doctor.

Pat: Email me if you want to talk details.

EGM: Thanks for the support. When I see you?

James: Extra thanks. I worked with one clinic attending who says, "three strikes, you're out"--meaning that with very few exceptions, the third time a patient comes in for the same complaint, they get the full workup. This happens even if the kid essentially looks fine. He says this approach is intended both to spare the hospital and insurance companies the cost of more unnecessary visits, and to reassure him that he's not letting anything big go unnoticed.

For those wondering, the kid did fine. He was off pressors within hours of starting antibiotics and was out of the ICU in 3 days. He has a followup visit scheduled with me (meaning, the family hasn't fired me) next week.


> BTW - "a few pressors in the ICU never hurt anyone" ???

It was sarcasm; a joke. Signout and I have been friends for years, she knows my sense of humor, she knows my career path may involve critical care, and she knows that *I* know that pressors aren't harmless. The perils of a public blogs - friends and strangers alike are welcome to comment, and comments between friends can often get misinterpreted. I'll try to remember that next time.

Sorry for the confusion.

Signout: Of course they didn't fire you :) And I like the "Three Strikes" rule. I'll remember that one.
See you... I dunno, wanna come play in my neighborhood?

It sucks when a mere mortal is forced to make potential life and death decisions based on inadequate information while under the restraints of insufficient time, money, effort (and sleep).

Fact is you can't get them all right.

Odds are that given a maximum effort it would have turned out to be nothing and you would be held up as a poster boy for wasting time, money and resources.

You made your best effort and a sound, well founded judgement call. As inadequate as it may look in hindsight that is, in the end, as good as it gets.

I'm not a doctor, which is probably why I don't get it... why not have tested the kid on the 2nd or 3rd times in such a short period? Was it that he was mostly unchanged? Wouldn't the mother still have had some instinct to keep bringing him in?

i hope you're feeling better now that the kid is okay and on his way home. i just finished my IM residency in a hospital in manila, and while it is a continent away, we all have the same experience when it comes to being victims of hindsight doctoring.

my most horrible moment was when we was good as reprimanded in a department conference for not taking on the primary care of a patient with a dento-alveolar abscess. the patient was admitted under otorhinolaryngology and was referred to me for evaluation of chest pain. i had early on suggested that they should explore the possibility of a contiguous infection in the neck and chest area, but they refused to go in until the patient eventually coded and became a full-blown textbook case of Lemiere's. i felt i wasn't remiss in diagnosis and i had been aggressively pushing for an OR from the start, but i was just the co-managing internist and i couldn't make the surgeons operate!

in the end, the blame was placed squarely on my shoulders in a very public venue - i would have felt better if the chair had just called me in and reprimanded me, but for it to have been done in that fashion in front of the ORL team present to witness it, to boot! i was in my 3rd year of residency, but a part of me was very, very close to quitting.

we all learn from our mistakes, and unfortunately our mistakes tend to have more dire consequences than others. nonetheless, you managed this patient according to your diagnosis and referred it to a senior who agreed with you, so you should not have been criticized for that.

There is a moral to this story, and its an old familiar one: Success has many owners, but failure is orphan. Worse: if this case is discussed and criticized by your colleagues out of context, other residents might draw another lesson from it: submit your patients to more tests, and trust your colleagues a little less, just so youre covered

It sucks when a mere mortal is forced to make potential life and death decisions based on inadequate information while under the restraints of insufficient time, money, effort (and sleep).

Fact is you can't get them all right.

This is all absolutely true! Even with all the money, sleep, etc., in the world there are still going to be ambiguous calls. You gotta remember that it is an extremely tough job! Somebody has to do it! And the comments here prove that all the rest of us really appreciate your efforts and dedication!
Dave Briggs :~)

I miss you.

The thing is, hindsight is 20/20, right? Of course these doctors criticized your response because they know the outcome and it makes them feel all superior and on-high when they can kick someone around a little bit (my guess is they were projecting their own guilt about their previous learning experiences.) In short, you have a hard job, and you work with assholes. I continue to be busting with pride about my friend and as a mom, I wouldn't have fired you either. Kids are so friggin' tricky.


By Anonymous (not verified) on 13 Mar 2008 #permalink

If you think being discussed in MMR is bad, just wait until you have to defend your decision making process in front of a jury. Sigh, this is what medicine is about. Try and remember the good times too.

I think people differ greatly on this issue. For example, if it were completely unidentifiable as my own, I would have no problem with a picture of my naked ass being posted on the Internet. Others would be absolutely horrified by the prospect.

Signout reader named Benjamin Langer, who himself has a very nice critical piece on intelligent design in the current edition of SCQ.

in the end, the blame was placed squarely on my shoulders in a very public venue - i would have felt better if the chair had just called me in and reprimanded me, but for it to have been done in that fashion in front of the ORL team present to witness it, to boot! i was in my 3rd year of residency, but a part of me was very, very close to quitting.