Go with your gut

Everyone said her father was doing better, but the author sensed they were wrong.

By Kemia M. Sarraf, MD
Internist/St. Louis

"So is the patient sick or not?" I asked the second-year medical student who'd just finished presenting her first real case.

The student looked puzzled. As a third-year internal medicine resident, I knew that look well. I decided not to leave her hanging.

"Medicine is more than just histories, diagnoses, and treatments," I explained. "Sometimes, despite all the objective evidence, you sense that your patient is sick. And that sense can be as important as any high-tech test you'll ever order."

I'd learned this lesson in a very personal way.

A nagging sense that all is not well

In my second year of medical school, I'd returned home one day to find a disturbing message on my answering machine. My mother was clearly upset but doing her best to seem calm.

She had awakened that morning to find my dad lying in a pool of blood in the hallway. Apparently, he had vomited blood and passed out. He was now in their local hospital's five-bed ICU. She wanted me to track down my sister and drive upstate as soon as possible. "Everything is fine, though, dear. Don't drive too fast. Love you." Click.

I'd picked up my sister and, disregarding my mother's advice, covered the 150 miles to my parents' home in record time.

My father's immediate problem was a Mallory-Weiss tear—a rare occurrence in a life-long nondrinker like my dad. After treating him with epinephrine and oral antibiotics, my father's doctors had sent him to the ICU for observation.

They assured us that he was fine, and he certainly looked and sounded that way, despite some puffiness. But deep in my gut, I sensed something wasn't right.

My father encouraged me to go on the rock-climbing trip I'd been planning. But my suspicions lingered, and I made up an excuse to stay.

In the early afternoon, he passed a dark and tarry stool and then, about an hour later, bright red blood from his rectum. As I watched, the gastroenterologist cauterized the small vessel pumping blood into the esophagus.

Everyone still insisted Dad was doing fine, but my doubts got stronger.

At 4 p.m., I called the teaching hospital where I'd done my medical school rotations and asked to speak with Dr. James E. Pearl, whom I knew only by reputation. A critical care pulmonologist who attended in the Shock-Trauma ICU, Pearl was brilliant, dedicated, and sometimes irascible.

I told him who I was and that I wanted to place my father in his care.

"Let me speak to your father's doctor," Pearl said.

After I'd explained that he wasn't available, Pearl demanded that I present the case.

Terrified, I stumbled through the presentation. He asked a few questions, and then sent me to check some lab results while he waited at the other end.

"Based on what you've told me, everything sounds okay," Pearl said.

"But it isn't. Something just isn't right," I replied.

"Well then, I guess you'd better send him down." Pearl said. "Let your father's physician call me when you're ready to make the transfer. Meantime, I'll arrange things on this end."

"You'll kill your father if you do this!"

When I returned to tell my dad the news, he looked pallid, his hands were icy cold, and his breathing seemed faster than before. His monitors confirmed my suspicions, so I called his nurse and suggested that she increase his oxygen flow. We then got him ready to be transferred, although we still hadn't heard from his doctor.

My dad's condition continued to deteriorate. Clearly, he was going to die if someone didn't intervene soon. I took it upon myself to order a battery of tests, including an ABG, chemistry panel, cbc, and chest films. I insisted that other measures be taken and, once the ABG results came back, that an anesthesiologist be called in immediately. Meanwhile, I instructed the nurses to make helicopter arrangements to Pearl's hospital.

The anesthesiologist wasn't happy to be called, but he calmed down when the nurses handed him the ABG results and chest X-ray. Within five minutes, he had my dad intubated.

Pearl called to check on the transfer. Suddenly, my father's doctor appeared and insisted that he had everything under control.

"I'm not authorizing this transfer," he shouted. "If you do this, you're going to kill your father!"

Up to that point, I'd been deferential. But his tone and the urgency of the situation pushed me over the edge. In rather colorful language, I informed him that, if he didn't sign, he'd soon be in need of an ICU bed himself. Grabbing the transfer papers from the nurse, he signed them and stormed out.

After the transfer, Dr. Pearl stabilized my dad before leaving him for the night with the house staff. My mother, sister, and I arrived several hours later. The duty nurse said that Pearl wanted a word with me when he came in the next morning. At that point, I was sure my days as a medical student were about to end. But at least my dad would be alive to yell at me!

Intuition and the art of medicine

The next morning, I awoke in the chair next to my dad's bed to find Dr. Pearl standing over me.

"Let's go for a walk," he said.

Moving through the corridors, he talked freely about adult respiratory distress syndrome, sepsis, and, of course, my dad's condition and prognosis. "Your dad's stable and his outlook is good," he reassured me.

"By the way, I couldn't help overhearing your conversation yesterday with your dad's physician. You have quite a vocabulary."

I braced for the worst.

"But you should know something," he continued. "When you phoned me yesterday and said you sensed something was wrong, I believed you. And you were correct. The thing is, you should never lose that intuition about your patients. It's the art aspect of the practice of medicine—and it's something that cannot be taught. I'll see you tonight when I make my rounds again.

"And by the way, Dr. Sarraf," Pearl added, "you should know you saved your dad's life."

Today, the lessons from that long-ago experience are still with me—and I do my best to pass them on. Indeed, in this era of high-tech medicine, it's easy to lose one's sense of a patient.

That's why I always thank the student, intern, or nurse who wakes me up in the middle of the night and asks that I visit a patient they have this "feeling" about.

That feeling is essential to the art of medicine.

 

Kemia Sarraf. Go with your gut. Medical Economics 2003;6:86.