The race is not to the swift
Nor the battle to the strong
Neither yet bread to the wise
Nor yet riches to men of understanding
Nor yet favour to men of skill
But time and chance happeneth to them all
- Ecclesiastes 9:11
Palmerston North Hospital
I firmly believe that luck happens when preparation meets opportunity. When you have an open and curious mind, and a certain amount of competence, you are able to take advantage of opportunities when they arise. You must take calculated risks, but things tend to go well when you do. Sometimes, though, you just get lucky.
The emergency department is an interesting, and often chaotic, place to practice medicine. Simply by being in the ED, people are generally having a really bad day. Many of our patients are poor historians with little understanding of their own health conditions. Occasionally, they are too sick to be able to communicate with us at all. They often leave vital information out of their story ... sometimes on purpose. Part of our job is to try to find those little nuggets of necessary data while wading through the detritus without seeming to dismiss the patient's thoughts or appear too "paternalistic". We are often called upon to make split-second, life or death decisions based on inadequate and inaccurate information. Unfortunately, we sometimes get it wrong; however, numerous studies have shown that emergency medicine physicians (EMPs) generally correctly identify serious illnesses even in the absence of confirmatory testing.
Clinical instinct is a well recognized and accepted part of medical practice. It encompasses what experience adds to scientific knowledge and training. Most EMPs I know have a handful of stories about getting a test or study on a gut feeling rather than any evidence and having that test show the way to a correct diagnosis. Recently, I had one of the junior doctors order a head CT on a patient with an odd story but a normal exam. The junior asked why, and I didn't have a really good answer. The radiologist asked why, and I kind of made up an answer. The reality is that I don't know why I wanted that particular test at that time. The CT revealed a small area of bleeding into the brain. Rather than being reassured when this kind of thing happens to me, I wonder how many of those cases I have missed.
I would rather be lucky than good
- Lefty Gomez
Clinical instinct is a well recognized and accepted part of medical practice. It encompasses what experience adds to scientific knowledge and training. Most EMPs I know have a handful of stories about getting a test or study on a gut feeling rather than any evidence and having that test show the way to a correct diagnosis. Recently, I had one of the junior doctors order a head CT on a patient with an odd story but a normal exam. The junior asked why, and I didn't have a really good answer. The radiologist asked why, and I kind of made up an answer. The reality is that I don't know why I wanted that particular test at that time. The CT revealed a small area of bleeding into the brain. Rather than being reassured when this kind of thing happens to me, I wonder how many of those cases I have missed.
This week, we probably saved a child's life and it was all just because of instinct, timing, and luck. On that fateful day, the emergency department was thumping. All 30 of our beds and overflow spots were full and there were 20+ patients in the waiting room. We were working as fast as we could but it seemed that every time we dispositioned one patient, three more would check in. An ambulance arrived with a 3 year-old who's chief complaint was "unwell" ... really non-specific.
The normal procedure for an ambulance check-in is for the clerk to meet the ambulance crew and patient at the door to get name, birth date, address, etc. Simultaneously, the arrivals nurse tries to get a set of vital signs and the medical story to appropriately triage the patient. If they're not too sick, they get sent to the waiting room or have to wait in the hallway. If they're really bad off, a room is cleared for them and the patient previously in that room gets popped into the hallway. This kid didn't look too bad. He was awake and looking around, though not super active. He was a little hypotensive and appeared dehydrated, but the rest of his vital signs weren't too bad. He probably would have been placed in the hallway for an hour or two until a room came available.
In the midst of trying to do 16 other things, I kept glancing over at him while he was being checked in. I don't know what, but something didn't feel right. It's not something I would normally do, but I wandered over to listen in while the clerk and arrivals nurse got things started. Again, completely against my typical pattern, I interrupted the nurse and started asking the child's mother some pointed questions. My normal exam leaves a thorough check of a patient's skin to the very last step. I have no idea why, but the first thing I did in that hallway was lift up the child's shirt. His chest and abdomen were covered in a purpuric rash. The most likely explanation for this would be a viral illness with ITP ... a generally benign process. Far more concerning is meningococcal septicaemia.
Neisseria meningitidis is a naturally occurring bacteria carried by about 10-15% of the population as part of their normal, non-pathogenic flora. Carrier rates in New Zealand have been estimated a little higher at 20-40% of the population. Rarely, the organism can spread from a carrier to someone without immunity. When that happens, the newly infected person can develop meningococcal meningitis or septicaemia. Approximately 10% of people who develop meningitis will die. The fatality rate of meningococcal septicaemia is far more sinister ... approximately 50% will die within hours of onset. Each year in New Zealand, there are several deaths from meningococcal disease, and even more during epidemics. It is for this reason that immunizations are so important. Widespread dissemination of the vaccine has lead to sharp declines in meningococcal disease in developed countries. From 1991-2004 there were 5300 reported cases in New Zealand, with 215 deaths. From 2006-2010, for children and young adults 0-24 yo, there was an average of only 3.5 reported cases per year, though almost all of them were fatal.
Because we were so busy that day, there were already two paediatric registrars (upper level trainees) in the ED seeing other sick kids. As soon as I raised the alarm, we cleared a critical care room and had him in it. At his side we had me, two nurses, an ED registrar, and a paediatric registrar. In less than 10 minutes, we had IV access, blood and cultures drawn, and antibiotics running in. Despite our rapid and aggressive treatment, he continued to decline.
Before leaving the ED for the ICU, he was in septic shock. Over the next couple of days, he continued to worsen and he developed a condition called DIC, putting him at risk for multi-organ failure. When I followed up on his care a couple of days ago, he wasn't getting much better but his rapid slide had stopped. The ICU team was hopeful that he was turning the corner to recovery. He is still at risk for developing organ failure, deafness, blindness, permanent neurological deficits, reduced IQ, and limb amputations, but the quick reaction of the ED team at least gave him a chance.
It is because of successful vaccine programs that in 10+ years of being a doctor, I have never previously encountered a case of meningococcal disease. It is because of the rapid progression and likely fatal outcome that questions about meningococcal disease have been on nearly every test I have ever taken so I recognized it when I did. I had heard horror stories from older physicians describing watching a child go from fine to dead in a just a couple of hours, but they were stories and not my personal experience. I am fortunate that my meningococcal story is a relatively good one, and it is because of the incredible talent and dedication of every person in the ED that things went as well as they did. Without the amazing people I am surrounded by every day, responses and outcomes like this would be fewer and farther between.
All of my successes in Emergency Medicine can be traced directly back to the amazing faculty and staff I worked with, and the unparalleled training I received, at The University of Iowa Hospitals and Clinics Emergency Medicine Program. My UIHC friend, coach, and mentor Azeem Ahmed visited me here in Palmy when he was in NZ. I was proud to show him a small piece of his legacy.
GO HAWKEYES!
The normal procedure for an ambulance check-in is for the clerk to meet the ambulance crew and patient at the door to get name, birth date, address, etc. Simultaneously, the arrivals nurse tries to get a set of vital signs and the medical story to appropriately triage the patient. If they're not too sick, they get sent to the waiting room or have to wait in the hallway. If they're really bad off, a room is cleared for them and the patient previously in that room gets popped into the hallway. This kid didn't look too bad. He was awake and looking around, though not super active. He was a little hypotensive and appeared dehydrated, but the rest of his vital signs weren't too bad. He probably would have been placed in the hallway for an hour or two until a room came available.
In the midst of trying to do 16 other things, I kept glancing over at him while he was being checked in. I don't know what, but something didn't feel right. It's not something I would normally do, but I wandered over to listen in while the clerk and arrivals nurse got things started. Again, completely against my typical pattern, I interrupted the nurse and started asking the child's mother some pointed questions. My normal exam leaves a thorough check of a patient's skin to the very last step. I have no idea why, but the first thing I did in that hallway was lift up the child's shirt. His chest and abdomen were covered in a purpuric rash. The most likely explanation for this would be a viral illness with ITP ... a generally benign process. Far more concerning is meningococcal septicaemia.
Neisseria meningitidis is a naturally occurring bacteria carried by about 10-15% of the population as part of their normal, non-pathogenic flora. Carrier rates in New Zealand have been estimated a little higher at 20-40% of the population. Rarely, the organism can spread from a carrier to someone without immunity. When that happens, the newly infected person can develop meningococcal meningitis or septicaemia. Approximately 10% of people who develop meningitis will die. The fatality rate of meningococcal septicaemia is far more sinister ... approximately 50% will die within hours of onset. Each year in New Zealand, there are several deaths from meningococcal disease, and even more during epidemics. It is for this reason that immunizations are so important. Widespread dissemination of the vaccine has lead to sharp declines in meningococcal disease in developed countries. From 1991-2004 there were 5300 reported cases in New Zealand, with 215 deaths. From 2006-2010, for children and young adults 0-24 yo, there was an average of only 3.5 reported cases per year, though almost all of them were fatal.
Because we were so busy that day, there were already two paediatric registrars (upper level trainees) in the ED seeing other sick kids. As soon as I raised the alarm, we cleared a critical care room and had him in it. At his side we had me, two nurses, an ED registrar, and a paediatric registrar. In less than 10 minutes, we had IV access, blood and cultures drawn, and antibiotics running in. Despite our rapid and aggressive treatment, he continued to decline.
Before leaving the ED for the ICU, he was in septic shock. Over the next couple of days, he continued to worsen and he developed a condition called DIC, putting him at risk for multi-organ failure. When I followed up on his care a couple of days ago, he wasn't getting much better but his rapid slide had stopped. The ICU team was hopeful that he was turning the corner to recovery. He is still at risk for developing organ failure, deafness, blindness, permanent neurological deficits, reduced IQ, and limb amputations, but the quick reaction of the ED team at least gave him a chance.
It is because of successful vaccine programs that in 10+ years of being a doctor, I have never previously encountered a case of meningococcal disease. It is because of the rapid progression and likely fatal outcome that questions about meningococcal disease have been on nearly every test I have ever taken so I recognized it when I did. I had heard horror stories from older physicians describing watching a child go from fine to dead in a just a couple of hours, but they were stories and not my personal experience. I am fortunate that my meningococcal story is a relatively good one, and it is because of the incredible talent and dedication of every person in the ED that things went as well as they did. Without the amazing people I am surrounded by every day, responses and outcomes like this would be fewer and farther between.
Hats off to the doctors, nurses, techs and other staff in EDs the world over who work tirelessly each and every day saving lives. Remember that what you do matters.
All of my successes in Emergency Medicine can be traced directly back to the amazing faculty and staff I worked with, and the unparalleled training I received, at The University of Iowa Hospitals and Clinics Emergency Medicine Program. My UIHC friend, coach, and mentor Azeem Ahmed visited me here in Palmy when he was in NZ. I was proud to show him a small piece of his legacy.
GO HAWKEYES!
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