My fourth-grade teacher once asked my class what we were thinking of doing in the year 2000. I remember thinking that I would be 42 and too old to do anything.
I also remember that MC gave us statistics on high school sociology. He said some of us in the future would be criminals, some would have substance use disorder, some would be poor, some would be rich. He actually gave us statistics on the number of deaths before the age of 30. We all looked around and came to the same conclusion, of course: those numbers applied to everyone. The numbers accounted for our entire high school class after all. Surely no one in this room would become a statistic.
The crazy truth is that MC was right. Bryant and his girlfriend died at age 16 in a car accident. Charlie was murdered at the age of 22. Greg ended up in a federal penitentiary after trying to rob banks to feed a substance use disorder. I had a child when I was 19, got married, and then, predictably, got divorced. Statistics from all of us.
Statistics can predict almost anything, but no one plans to get divorced, get cancer, or go to jail. It is difficult to tell a patient that his whole life is going to change, that he becomes a statistic, that he has a mass in the pancreas or that he bleeds in the brain.
We know all the figures, but we still have to try to encourage patients and their families despite the statistics on their prognoses. Hope is always present, but not everyone can be the exception to the rule. It’s not personal; those are just numbers, right? But that’s the problem: it’s personal. It’s as personal as it gets. Nothing is the same once the diagnosis is made.
Tale of a 2 year old child
Mixtecs live in the region where I work; they are descended from the indigenous people of Mexico. They don’t have a written language and most don’t speak Spanish, but we have translators in our department for most of the day. A Mixtec mother brought in her 2-year-old daughter for vomiting after a visit eight days earlier. She was afebrile at the second visit and treated with ondansetron, and she tolerated a PO challenge and was discharged. She did well until four days later when she started vomiting again. My partner, Alicia Gonzalez, MD, saw it and expanded the toll this time.
All labs came back normal and Dr. Gonzalez hydrated her with IV fluids. His urine analysis was also normal, but a PCR test was positive for a virus. But she just didn’t look good on release, and I was asked to watch her too. I agreed that she was not recovering as expected. One of our nurses, Sam, said she might be having seizures, so we should try the Ceribell, a wearable EEG monitor new to our ward that shows if a patient is in status epilepticus at times real. We didn’t know if it worked in children. Sam placed it on the patient, and it detected continued seizure activity. However, she showed no signs of a seizure. She was somewhat quiet and uninteractive, but had normal vital signs and no tonic-clonic movements, not even a tremor.
Dr. Gonzalez contacted a neurology researcher at Stanford who said it was possible the patient was in condition, but this pattern was also seen in brain tumors. A CT, in fact, showed a tumor in the brain, and not just a tumor but a hemorrhage in it and moving from left to right. The patient was transferred to an intensive care unit, where I intubated her. She was hyperventilated, sedated, and given anticonvulsants and mannitol as well as hypertonic saline, Versed, fentanyl, and nicardipine drops.
Dr. Gonzalez and I were frantically trying to transfer her. She started showing signs of herniation with uneven pupils. I called our neurosurgeon, who told me he was unable to perform a ventriculostomy on a pediatric patient and his slit-like ventricles would have made it impossible to find anyway. He offered to do a hemicraniectomy, which we all wholeheartedly approved of. We do not have a PICU and the patient would have died before the transfer if nothing else had been done.
We searched all over the state, and our patient was finally accepted into Children’s Hospital Los Angeles. A helicopter was timed to arrive just as she exited the operating room. She underwent a hemicraniectomy, the pressure was relieved and she was stabilized before being airlifted. She was pulling on the ET tube and making deliberate movements the next day. The welcoming pediatric intensivists congratulated our team for a job well done, which was good for a change. She still has a brain tumor, but a total team effort on many levels saved this child.
Against all odds
The statistics had favored the discharge of the patient: she had vomited and had a virus. We see it all the time. Discharging her would even have been arguable in a malpractice case, as vomiting is unlikely to equal a brain tumor. Sam is my hero for suggesting the Ceribell. Explain to me: how did it happen? Now try to explain it in Mixtec.
This case will stay with me forever. It’s so disturbing and rewarding on so many levels, and I keep trying to process it over and over again. No number, percentage or statistic can explain it. One thing is certain: we are witnesses when the lives of our patients change, whether because of God, fate or chance.
We get stressed when ED goes crazy. We focus on moving patients around the department. Their satisfaction is partly based on how quickly we do it. I’ve already mentioned how much I hate layout killers, how much issues in my plan affect my personal layout. I think I need to slow down though and realize what kind of news we sometimes deliver – news that changes everything.
I like to say it’s a good day when I’m standing next to the stretcher and not in it, but one day I’ll be in the stretcher, and so will you. The stats won’t matter, but how the news is delivered will matter on that day, the day that will change everything. I’ve been trying to keep that in mind recently, and I feel like it’s more important than most other things we deem eligible. There is definitely a balance between going fast and going too fast. Leave the numbers to the metrics dealers and bean counters. Breathe, slow down and let’s be emergency doctors who haven’t forgotten what our vocation really is.
Dr. Harmonis an emergency physician at Marian Region Medical Center in Santa Maria, California. Read his past columns onhttp://bit.ly/EMN-SameShift.