Drawing on a career launched in the first days of the specialty of emergency medicine, Dr. Paul Seward takes the reader with him into the ER in his riveting memoir.
Told in fast-paced, stand-alone chapters that recall unforgettable medical cases, Patient Care offers the fascination of medical mysteries, wrapped in the drama of living and dying. A snap judgment about a child nearly kills him, and a priest who may be having a heart attack refuses treatment. An asthmatic man develops air bubbles in his shoulders, and a pharmacist is haunted by a decision he makes.
But the book goes beyond these stories. Each chapter explores ethical questions that remind us of the full humanity of patients, nurses, coroners, pharmacists, and, of course, doctors. How do they care for strangers in their moments of crisis? How do they care for themselves?
Dr. Seward rejects doctor-as-God narratives to write frankly about moments of failure, and champions the role of his colleagues in health care. And, for all the moral dilemmas here, there is plenty of wit and humor, too. (See the patient who punches our doctor.) Readers of Patient Care will find themselves thinking along with Dr. Seward: “What is the right thing to do? What would I do?”
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About the Author
Read an Excerpt
In those days, we had a few reasons for kids to be sick which no longer exist in this country. High on the list was a tiny organism called Haemophilus Influenzae. You may have heard of it as "H.Flu." Nowadays virtually all children in the United States are immunized against it in infancy. But in those days H. Flu immunization was a distant dream.
We saw a lot of H. Flu infection(1). They happened in one of three ways.
Most commonly we saw it as children’s ear infections. No big deal: Kid has fever so look in the ears. If there is pus behind the eardrum, treat with amoxicillin. On to the next patient. (Antibiotic Resistance? Never heard of it – not then.)
The second way H. Flu attacked children was much less common but a much bigger deal. It was one of the most common causes of meningitis.
You have heard of meningitis. It’s a fancy word for an infection of the meninges, the coverings of the brain. That’s how it starts. But, left untreated, in a matter of hours to a day or so, it can spread into the brain itself. Death – or serious and permanent brain damage – follows soon after. (2)
H. Flu meningitis, wasn’t common but it wasn’t rare either. I got used to seeing three or four cases of it each year, and my associates did the same. If you diagnosed it promptly, and gave the correct antibiotics, most children did well. But it kept us on our toes.
Also, there was one other bad trick that H. Flu could play. That's the subject of this story. And even though I was still a practicing Pediatrician, it's an ER story.
As usual it was a weekend: it must have been, because weekends were the only time I would see kids in the ER instead of the office during the day. I remember the phone call from the boy's mother. She was worried. Her son – about four years old – had a fever. It had come on suddenly that day. And what worried her most was that his neck seemed to hurt and he didn’t want to move it.
High fever, sick kid, and a stiff neck? That's meningitis until I know it's not, and I have a race against time. The sooner I get him diagnosed and get some antibiotics on board, the more likely it is that he will do well. I told her to take him to the ER immediately and I would meet her there.
I got to the ER before they did. I told the nurse on duty what I was expecting, and to set up for an IV and a lumbar puncture. The IV was for the antibiotics; the lumbar puncture, or "Spinal Tap" was what we did to make the diagnosis. The infection is around the brain, and we can’t stick needles up there. However, the fluid around the brain circulates down into the spinal canal and a meningeal infection will be detectable down there as well. This is also the reason that people with meningitis also have a stiff neck. The brain is inflamed but so is the spinal canal, so moving it hurts.
I think most people have some idea how a spinal tap is done: The patient curls up in a ball. This bends the spine so that the space between the vertebrae opens a little bit, making it an easier target. Then we prep the lower back with an antiseptic, and insert a needle between two of the vertebrae in the lower back, and into the spinal canal itself. Then we allow some spinal fluid to flow out into a tube, where we collect it and examine it to see if there are pus cells or bacteria or other signs of infection.
That sounds dangerous, but it's quite safe. The spinal cord ends around two thirds of the way down the back, and all that is in the canal below that point are long thin strands of spinal nerves extending downward from the cord. They are referred to as the "Cauda Equina" or "Horse's tail," because that's exactly how they look. The point is that the chance of accidentally sticking a needle into a spinal nerve is about the same as trying to impale a hair in a horse’s tail. I couldn’t do either if I tried.
The nurse was an excellent nurse. I remember her well. She had the LP tray out, opened and ready, and was setting up the IV when the mother brought the child in.
I took them immediately to the treatment room, and checked him over. I don't remember what his actual temperature was, but it was high. I remember him as pale and breathing rapidly. I asked him if he could look down at his toes (a test for neck flexibility), but he would not bend his neck at all. I did not ask him to do more, but quickly told the mother that I was worried, that I suspected meningitis, and that I needed to do a lumbar puncture immediately. She nodded. He was already sitting on the table, so with the help of the nurse, I laid him down on his back, rolled him on his side, and began to bend him into a curled-up position so I could do the tap.
The moment I did so, he stopped breathing.
And suddenly I knew what was really going on. And after all these years, it still ranks as one of the worst moments of my medical life.
Along with ear infections and meningitis, there is one other important infection caused by H. Flu. It is called "Epiglottitis,” a quickly progressing infection of the epiglottis. We will talk about the epiglottis more in future chapters, but for now, what you need to know that it is the front door to the trachea (i.e. the windpipe). Anatomically, it is a leaf shaped flap of cartilage, attached to the front wall of the throat, just above the opening of the trachea. It is thus a sort of trapdoor, which closes when you swallow and opens when you breathe. But, when an H. Flu infection comes along, the thin, flexible epiglottis swells up until it no longer resembles a leaf as much as a fat red, thumb. And the more it swells, the more it blocks the opening of the trachea, making it harder and harder for the child to breathe.
So how does such a child look when he presents? Usually they have a fever. And they tend to look sick, unhappy and frightened. They want to sit up because that makes it easier to breathe. As it becomes more severe, they tend to tilt their head back and lean forward while supporting their upper body with their hands. This posture, called "tripoding," allows for the maximum opening of their airway.
Sometimes they make a raspy sound with each breath because of the narrowing of the windpipe. They also have a very sore throat; so sore that they don’t like to move their neck. Partly that’s because moving it makes it hurt more, but more important, bending their neck forward presses on the epiglottis, increasing the obstruction and making it harder to breathe.
In fact, fiddling with the epiglottis in any way in a patient with epiglottitis can cause an increase in the swelling and lead to disaster. For this reason, when a doctor suspects epiglottitis, she doesn’t ask the patient to say "Ah" or put a wooden stick in his mouth to look inside. She doesn’t give the child any shots, or even take a temperature. She doesn’t do much of any further exam at all.
Instead, the she turns down the lights in the room, and lets the child sit unmolested in mother's lap, and does whatever else she can to keep the child as quiet and reassured as possible – while at the same time calling the Ear, Nose and Throat specialist and telling him to get his fanny over to the hospital as soon as he can, take the child to the operating room and, with a special instrument called a bronchoscope, slide a tube into the windpipe and keep it open. When that is done, the child will breathe easier – and so will everyone else.
But that was not what I had done. Rather I had lain him down, folded him into a ball, and bent his neck forward towards his chest - in precisely the position he should never have been placed.
And now he was not breathing.
The moment that happened, every detail of what you just read, abruptly filled my mind in a single giant flash of understanding - including the realization that I had probably just killed him.
Now, what should I do?
I did the only thing I could do: I rolled him on his back, opened his mouth, positioned his head to open his airway as much as possible, put a respirator mask on his mouth and nose and began squeezing the bag, to breathe for him.
I knew it wouldn’t work; his epiglottis was occluding his airway. You can't ventilate a patient adequately through an obstructed airway without removing the obstruction.
Except....except... it turns out that – at least sometimes - you can.
It is true that you should not mess with the epiglottis in a child with epiglottitis. It is also true that if the epiglottis swells up enough and obstructs the trachea the child will be unable to breathe. But that did not mean that I could not breathe for him.
Think about it. He was a four-year-old child. I was a thirty-two-year-old man. I was a lot stronger than he was. Also, he only had his diaphragm and rib muscles to breathe with, while I had both my arms and hands. He might not have been able to suck the air into his lungs past his swollen epiglottis, but I could sure as hell push it in.
So, I did. At the same time, I asked the nurse to page the ENT doctor on call and then give the antibiotics through the IV. Then, for another half hour, I stood there with the nurse and breathed for the child with a bag and mask.
The boy was fine with it. Before I started bagging him, he had been getting tired and scared, with increasing trouble getting his breath. Suddenly he didn’t have to work anymore. Now he was getting plenty of oxygen. All he had to do was relax and rest on the gurney while his mother held him and while I squeezed the bag.
Soon enough the ENT specialist arrived. He had called ahead, so the OR team was ready. Off they went with the child. He was out of the hospital, completely recovered, in a few days.
For my part, I had learned two things. First, I learned that, just because a patient can't breathe, it is still quite possible that I can breathe for him, particularly if the patient is a child. In fact, over the next few years - before H. Flu went away, taking childhood epiglottitis with it - I saw four or five more children with this disease, two of which I wound up having to bag because of a delay in getting an ENT specialist. They all did fine.
The second thing I learned was something I already knew; but now it had been carved into me as if with a chainsaw. What I had done was the most dangerous thing a doctor can do: I had made a diagnosis without an adequate examination - in fact even before seeing the patient. Therefore, when he came in to see me, I had noted all the things that I thought he should have with meningitis – fever, stiff neck, looking sick – ascribed his rapid breathing to his fever and illness – and failed to notice the things I was not expecting - the signs of respiratory obstruction. And those were precisely the findings that should have taken me to the correct diagnosis.
I could have killed him. I damn near did.
We have to make diagnoses of course. We can’t treat disease without deciding what it is. And there is no perfect examination or test. The problem is that making a diagnosis can easily make us stop thinking, and stop looking for anything that might suggest a different direction. I make diagnoses all the time. But, when I do, I try to remember the words of Oliver Cromwell, in a letter written over 350 years ago to the General Assembly of the Church of Scotland," “I beseech you in the bowels of Christ, think it possible you may be mistaken.”
1 I talk about H. Flu in the past tense. But it hasn’t gone away. It's just that most kids are vaccinated against it so we don’t see it often. But for the unvaccinated, and in areas where vaccination is unavailable, it is ready and waiting to happen.
2 Meningococcal meningitis, (that’s the one you hear about soldiers and college kids getting) is caused by a different organism. It is still around despite immunization, and is more lethal. It can often spread to the entire body, damaging and destroying it in a way that H. Flu meningitis rarely if ever did.
Table of Contents
1 The Young Man's Friend 3
2 Shears 15
3 The Intensive Care Nursery: Baptism 25
4 The Burden of Choice 37
5 Hands 45
6 Snap Judgment 51
7 A Drowning 63
8 The Heart Is a Pump 75
9 Colors 83
10 Now and Then It's Fun 89
11 Riley 97
12 An Assault 107
13 A Rash 113
14 To Breathe 127
15 Nova 143
16 Last Rights 147
17 Last Wrongs 159
18 Graduation 169
19 An Ordinary Day 173
20 Dead Drunk 191
21 An Extraordinary Day 197