A gray area of medicine: Determining when to get involved with family care

Photo: Ralph A. Yates, DO, left, with his son, Trevor, at Trevor’s first Ironman competition, four months after the event written about in this article. (Courtesy of Ralph A. Yates, DO)

Something clearly was wrong. At the start of the final leg of the 2009 Pacific Crest Half Marathon, a 13.1-mile run, the family called out encouragement as my 30-year-old son, Trevor, flashed us a smile and a "thumbs up" gesture. An experienced, sponsored, endurance-trained triathlete, he now was nearly an hour behind his projected finish time. I knew he must be in trouble.

Held in the beautiful high desert of Sunriver, Oregon, Pacific Crest attracts a national following of amateur and professional triathletes each June. Grabbing a water bottle, Andrew, a close family friend, took off running back along the course as I sought out officials. Minutes passed while I spoke to the director, who had heard nothing about my son.

Soon, Andrew appeared and hurriedly said, "He's a few minutes out. He has had a problem with his asthma and had to walk the entire run course." Far from relieved, I thanked Andrew and the director and waved over two of the medical tent paramedics, filling them in on what I suspected. Pale and drawn, Trevor finished minutes later and moved unsteadily toward me.

The paramedics whisked him into the nearby tent. To my surprise, they invited me in as well. The paramedics already were nebulizing Trevor with ipratropium/albuterol as I stepped inside the tent. They needed medical history information, and I was able to provide it.

"He is a moderately persistent asthmatic on inhaled steroids, short- and long-acting bronchodilators, cromolyn, and [montelukast] and has been under the care of asthma specialists since age 6," I told them.

One of the paramedics cocked his head and smiled slightly at me. I answered his unspoken question: "Yeah, I'm a doc. Family and sports med."

Nodding, the paramedic offered a professional summary of what they were doing. The medical team was all paramedics.

Trevor's taut facial and neck muscles, raised shoulders, and rapid breathing spoke volumes. Kneeling down next to him, I didn't have a chance to ask a question.

"I can't breathe," he gasped through the nebulization mask, his wide-eyed look confirming his increasing panic.

 In the next moment, the lead paramedic pulled me aside. "We have two problems," he said. "The one we're most worried about is his pressure. He is down to 76 over palp."

I nodded, trying to orient myself to the unfolding events. The nebulization ended as his partner called out, "He's now 68 over palp."

Turning back to me, the lead paramedic said, "I think we need to transport him to St. Charles," a regional hospital 20 miles away.

"I agree," I replied. "Let's do it."

Straightening his seated posture on the cot, Trevor firmly responded, "No. Give me two more minutes with more medicine. I think I'll be okay."

I looked at the lead paramedic and nodded. "I'm okay if you are," I told him. He gave the order for the second nebulization, this time just using albuterol.

I took a step back, trying to sort through my emotions. Throughout 30 years in practice, I have steadfastly steered clear of treating my family. As vice chairman of our state medical board, I review cases monthly, some involving family care issues. Yet here I was, smack dab in the middle of an emerging one.

I looked at my son, his breathing pattern easing somewhat. "Eighty over palp," number two announced, then 15 seconds later, "We're now 100 over 60."

You could feel the tension dissipating as a third member handed number one the results of a three-lead electrocardiogram that had just been run. "You know, I'm not that good at reading these things," he said, handing the strip to his partner.

"I'm no better than you are," his partner replied, the paper seemingly suspended between them.

With his nebulization still taking place, Trevor pointed to me, nodding affirmatively. Both paramedics first paused, then laughed. "Of course. Would you mind?" they asked.

Trevor's eyes had assumed their usual sparkle, and he was smiling behind the mask. He was going to be all right.

Studying the paper for a moment, I replied, "Looks okay, guys. I don't see anything but some T-wave changes. Probably electrolyte-induced."

Since the race, I have replayed each moment, analyzing events as they occurred. I have some suggestions for others who may find themselves thrust into a similar, acute situation with a loved one:

1. Whenever possible, remember that you are a loved one first; remain a consultant second. It is not your show, and it shouldn't be. We cannot be impartial in such instances. Offer support, encouragement, and, when asked, advice to the medical team. Be additive and collaborative.

2. As much as you can, assume a lower profile. Let the trained professionals perform their duties. At Pacific Crest, I chose to physically keep a half-step behind the medical team members, my voice softened and collegial. This approach seemed to work well.

3. As much as possible, remain in the moment, but refrain from questions. Provide your opinions to interrogatives-if and when asked. Otherwise, stay quietly observant. Above all, you do not want to impede the process at hand.

One of the most important lessons in my career that I have tried to share with colleagues is that we often are confronted with issues of medical ethics that go beyond what we learned in school and training. This occurrence is partly a reflection of how we were trained and partly a reflection of the vagaries of life itself. With time and experience, we learn that the bright lines of ethical dilemmas rarely are so well defined in the field as they were in school and training. The challenges come with the gray areas.

Leaving the gray of that medical tent for our waiting and anxious family, Trevor and I shook hands all around and offered thanks to each member of the team. Pausing outside, Trevor turned to me and said, "Thanks, Dad." It was good, and comforting, to be back in the bright desert sunlight.

The author is a family and sports medicine physician in Portland, Oregon. He practices at the Portland Clinic and is an associate clinical professor of family medicine at Oregon Health and Science University. Send your feedback to medec@advanstar.com.