Why didn't I speak up for this patient?

By Armand P. Gelpi, MD
Internist/Sonoma, CA

Hindsight tells the author he should have prodded colleagues into doing more for a very sick relative.

This is a sad story. And it should have ended in Arlington National Cemetery on that bleak January day, with the last notes of a bugle and the snapping of an American flag into tight folds before the color guard handed it to the widow. Our hero, a Navy veteran, was buried with full military honors. But there would be many months before true closure.

It all began one balmy afternoon in late October of 1998, while I sat at my brother-in-law's bedside. Bob had been battling kidney cancer, and was 10 days out of surgery to debulk his tumor. After many months of radiation, immunotherapy, and chemotherapy, he seemed to have reached a truce with his disease. He was back home and talking optimistically about travel and exercise, but just now complaining of some abdominal pain in a new location, not quite like his earlier postoperative discomfort. Then he had a shaking chill.

I took his temperature an hour later—barely elevated, at 98.9. He didn't want supper, but my wife and I, his wife, Shirley, and one of his daughters, Jean, brought our meals to the bedside to keep him company. My wife and I left for our motel early in the evening—we'd flown cross-country the day before—and told the family to wake us by phone if there were any new developments.

At 1:30 am we got that call. Bob was short of breath, he'd had another chill, and the pain was worse. Dressing quickly, I drove to his house and found Jean waiting in the SUV, the engine running. Bob was just coming out the front door, leaning on his wife. Mercifully, at that hour the freeway into the city was almost deserted. Thirty minutes later, we roared up to the emergency entrance at the teaching hospital where Bob had been released just the week before.

Inside a triage nurse greeted us, and with a minimum of history-taking she got to the vital signs. "What's your usual blood pressure, Mr. D? Your systolic is 100 right now."

Bob remembered that "my usual blood pressure is around 130 to 140."

Soon all four of us were crowded into one of the examination rooms. The ER attending strolled in about 15 minutes later, asked a few questions, briefly laid a hand on Bob's abdomen, and returned to her work station. She promised to get in touch with Bob's urologist. About a half-hour later, in walked the urology admitting team, a resident and intern. We introduced ourselves; they asked a few questions and repeated the cursory abdominal examination. The resident performed a rectal exam.

By now it was almost 5 am. Bob was groaning with pain and had vomited a couple of times. The laboratory results were unremarkable; the chest and abdominal X-rays were negative except for a couple of air-filled loops of small bowel and feces in the colon. And the urology resident, with his intern, had concluded that this was not a urologic problem—even though the patient had just been discharged from the urology service—but probably a fecal impaction resulting from post-op pain medication. Solution: Send the patient home, as his condition could easily be relieved with cleansing enemas.

Bob's wife and daughter looked really worried, and I was frustrated and alarmed. Marching out to the attending's cubicle, I told her that I thought Bob would die if he was sent home. I begged her to have the admitting team on general surgery take a look.

More than an hour went by; no surgeons in sight. Bob was now pleading for pain medication. Finally the surgical admitting team arrived, a new resident and intern. More introductions. After some perfunctory questioning, the resident went for Bob's abdomen. "Mr. D, you must relax," he said. "Your abdomen is so tense I can't examine it." He pressed deeper, Bob let out a cry, and the resident backed off. Bob then got some intravenous pain medication.

I got to thinking: I could raise hell, pull rank, bully, and threaten. But these were colleagues. It was a judgment call. We all make mistakes. And my interference might harden resistance, further delaying Bob's admission. As many of us remember from our training days, in the early morning hours disease is no longer the enemy. You can always classify disease, analyze it, understand it, attach statistics to it. It is the patient seeking admission who is the enemy. Patients appear at inconvenient times; they may be ill-tempered because of—or in spite of—illness; and they are often difficult to interview and examine. Your patient may be suffering from a fascinoma, but he or she is still the enemy.

It was approaching 8 am, and there would be a change of shift all around: new nurses and a new ER attending, who would have to familiarize herself with the problem. At no time since Bob's arrival at the hospital had we seen any evidence of any emergencies other than ours. Only an occasional patient on a gurney or in a wheelchair passed by, to be deposited in one of the examining rooms down the empty corridor.

During the breakfast hour, a cluster of doctors and nurses suddenly materialized down the hall and headed our way. We thought they might be coming to see Bob, but they all detoured into a conference area next door. They assembled, not to talk about Bob's abdominal pain and what to do about it, but to have their picture taken for an annual hospital publication.

I tracked down the emergency attending. This time, I wasn't talking doctor to doctor; I was pleading for attention and relief, like a brother. And this time she looked worried, talked sympathetically, and confessed that she was unable to get in touch with Bob's urologist. We agreed that Bob would not be leaving the hospital. But what next? Who would admit him? And when? It was now mid-morning, and Shirley and Jean were giving me that "you must do something" look. Then Shirley confided, "If anything happens to Bob because of this, I'll sue."

I didn't answer, or even indicate that I had heard. Bob was more comfortable, but he looked sick. Looking sick is something doctors are supposed to know about. The meaning of "doctoring" is elusive, but you know it when you see it. And we had not seen any real doctoring since we'd come through the hospital door.

It was almost noon. After Bob's problem was formally presented to the attending general surgeon—who listened at a comfortable distance from the patient—it was finally decided, somewhat grudgingly, that he would be admitted to the surgical service for observation. But not before some additional imaging, ultrasound and CT scan, which yielded no new information. Two hours later—and 11 hours after he'd been triaged in the emergency department—Bob was in a surgical ward with a room of his own.

Bob's admission had little to do with any of my intervention. The admitting teams just seemed to have run out of reasons for not hospitalizing a patient who had no diagnosis and no immediate prospects for surgery, but who nevertheless was finally believed to be quite ill.

By the next morning Bob was septic, on antibiotics, and in shock, not responding to pressor agents. During this critical period Bob's oncologist stopped by, learned of the debacle that had preceded his admission, and invited me to call her "anytime, if I can be of help." I met Bob's urologist briefly, later the same day, and he assured me that he had immediately ordered Bob's admission once he'd heard about the problem, some nine hours after we'd arrived at the hospital. But the surgeons had been there hours earlier, and could have made the decision.

Later that day Bob was taken to the operating room and found to have a necrotic, leaking gallbladder, without stones. He was saved, only to have his cancer spread with renewed vengeance over the following two months. At one point during the long wait before admission, he had turned to me and asked, "Do you think I'm going to make it?"

I babbled something like, "Of course you'll make it. And then some. You've got great doctors, a great hospital, enormous inner resources, and a loving family."

Bob died two months later. At the reception after the funeral, Shirley seemed at peace, composed, and resigned. As we talked, she told me how wonderful Bob's urologist and oncologist had been: "They called several times during Bob's last days. And after he passed away, they still called. I don't know what I would have done without their support."

What Shirley didn't know—until now—is that I had written both attendings to document, in detail, the 11-hour delay preceding Bob's admission to the surgical service. I had concluded with some insistent recommendations, among them, "that the hospital should take steps to ensure that responsible attendings work more closely with house staff to facilitate admissions, and to quickly override decisions that are not in the best interests of patients." She also didn't know that his doctors had never replied—probably because if Bob had been sent home from the emergency department that fateful day, I would have been transformed almost instantly into a plaintiff's witness. Finally, she never learned how I had personally failed her and her husband in their time of need.

This wasn't just a failure of the system that supposedly prepares doctors for careers in medicine; it was also a failure of patient advocacy. It's easy enough to be militant when dealing with managed care's evil empire, but it takes a little more courage to stick up for patients who are neglected or mismanaged by our colleagues. For better or worse, we hang together, when sometimes we shouldn't. Shouldn't all of us—physicians, educators, and health policymakers—acknowledge that dealing with disease may be a secondary issue in health care? Isn't the task of medicine, primarily, to care for patients, whether or not we can save them?

Eight months after the ER drama, I received a letter from the hospital's chief of staff. I had written him in despair, weeks earlier, when I hadn't heard from Bob's urologist and oncologist. In a carefully worded response, which avoided both exoneration and incrimination, he observed that I had "raised several important questions concerning quality improvement and patient satisfaction" and concluded, "Please be assured your issues have been addressed and appropriate action has been taken."

Maybe the system does work. What do you think, Bob?

 

Armand Gelpi. Why didn't I speak up for this patient?. Medical Economics 2000;13:129.