Chaos and Control
During Residency there was a concept that we were taught that has really stuck with me. We push some really powerful medications and perform some risky procedures on a daily basis and, under the wrong hands, any of them can be a murder weapon. The phrase “murder weapon” is said tongue in cheek to teach us that the things we sometimes try to do to our patients can lead to their untimely death. The idea is that we shouldn’t let these interventions become so routine that we overlook the small but real potential for harm that they possess, and should actively seek to ensure their safety. The part of the Hippocratic oath that most people can recite off the top of their head states “First, do no harm” and all doctors across all specialities try to never be the source of harm. I had a case recently that reminded me of those lessons and reminded me of how close to chaos we can be even when we think everything is under control.
Chaos is, in a word, exactly how this case started. I get a call from my frantic Charge Nurse that in 3 minutes an EMS crew is arriving with an elderly man who has had continuous seizures for the last 20 minutes despite multiple medications. No vitals, no information about their respiratory status, no additional information available. I assemble my crew, handing out duties, laying out our plan of action for both the best and worst case scenario. We are fully prepared for anything between a patient in cardiac arrest to someone who can wave to us from the stretcher as he rolls in, in just under 3 minutes.
What arrives is someone who is decidedly in the middle of those two clinical pictures. Sick but safe, I would say. He is breathing on his own, his vitals are stable, but he is unresponsive to any stimulation, verbal, physical, and most importantly painful. Once he is moved from the EMS stretcher to the bed, a whirlwind of activity starts. This tiny moment in medicine is one of my favorites. It’s truly a moment of Zen. The team has a singular focus and, when done correctly, work perfectly to gather information and prepare the patient for whatever might be needed. Multi tasking would be a massive understatement. I’m receiving the report from EMS while the nurses call out vital signs and I visually asses the patient. Within another three minutes, all of the following has happened: I have checked the patient’s pupils, established that there is no gag reflex, calculated a GCS score, estimated the patient’s weight and told the nurses the weight based doses we will need if we need to intubate, established that while the patient can spontaneously move all 4 extremities, there is little coordinated response to even severely painful stimulation. There are also no obvious outward signs of continued seizures, and I’ve also taken a quick look inside the patient’s mouth and neck to assess for the possibility of a difficult intubation and listened to his heart and lungs for obvious abnormalities. Meanwhile the nurses have established additional IV access, hooked the patient up to the monitors, obtained another set of vitals including blood sugar, drawn up the medications we need if he seizes or if we decide to intubate, and sent a preliminary set of lab work to the lab for testing. Anti seizure medication is already on the way from pharmacy and respiratory therapy is on standby for definitive control of the airway should it be needed. I’ve listed all of this to illustrate that even though things started chaotically, the team was well prepared and the situation was now under control. Sick but safe, like I said.
From here on out things went as well as you could ask for. He did not seize again and his vitals remained stable. Given his complete lack of response to external stimulation, he was intubated to protect his airway and facilitate treatment. He received fluids and anti-seizure medications. Lab work was as expected and he went and had a CT scan and a chest X-ray without a hitch. We later gained some additional details regarding this patient’s history. Turns out that the patient not only had a history of epilepsy, but was also currently in rehab for alcohol and cocaine abuse, things which can independently cause seizures during their withdrawal phase. While reviewing his results in anticipation for an ICU admission, I received a call from the radiologist. He stated that while there were no definitive abnormalities on his CT scan, there was an area in his brain that did not appear normal. He said that this area could represent “possible neoplasm (tumor) versus cerebritis (inflammation) versus infarction (stroke).” Any of these could also potentially be the cause of his presentation. He recommended an MRI and said he would be willing to approve calling in the on-call technicians to have this done ASAP. This patient came late at night and all MRIs at this time require a team to be called in - sometimes a difficult obstacle to clear. I discussed each of the possibilities with the radiologist and after walking down each of those paths I decided that it would not change the patient’s management in the acute phase and that we would forgo this test for the time being. He was satisfied with my reasoning and happy to not have to wake the techs for this case. I rarely decline additional studies when they are requested by the radiologist, but in this case it may have been the best decision I have ever made. After discussion with the ICU the patient was admitted, my shift ended, and I went home.
Cruising through old charts a few days later, I saw his name pop up on my computer. Even though as ED physicians our role is stabilization of these patients with definitive management being deferred to the other hospital teams, we frequently follow up on our patients to see how things went after they left our care. I remembered his case well and thought I would look up his MRI to see what the study eventually revealed. I clicked through his imaging and stopped dead in my tracks. There have been many times I’ve been left speechless at work, but it does not usually happen days afterwards. I felt chills down my spine, and a wave of relief and disbelief crashed over me.
The patient never got the MRI. Some of his routine imaging showed an incidental finding: Bullet fragments. This by itself is not very surprising. CT scans to get a better idea of what we were dealing with delivered the bad news: one of the bullet fragments was lodged in his left internal carotid artery. That’s the big one, the one you don’t want to touch. Had I ordered an MRI and he had gone there on an emergent basis, there was a very real chance that the fragments could have damaged the vessel and killed him on the spot. There is no remedying an injury like that and if it had happened, it would have been fatal without a doubt. There was no indication that this patient had this old fragment in their body, no family or friend to tip us off. Patients do routinely get dental X-rays to check for metal in their mouth, but this would not have been seen on that. It was also too high up to be seen on a routine chest X-ray. It was a perfect miss. I was inches away from having the MRI as my murder weapon, and the thought of that brutal act of negligence was making me dizzy in my seat. I still can’t stop thinking about it. Outwardly it was a perfectly executed case, but even with the best of intentions and plans, there was a very real risk of death at my hands.
I try to keep these cases as a mental catalogue to learn from, as an active guard against complacency or arrogance. We use powerful tools every day, and manipulate physiology to improve the health of our patients, but there is always an element that is not under our control. Remembering that is both nerve wrecking and relieving. At the end of the day, it is always someone’s time to die, but at the same time you need to constantly check and recheck to make sure you are doing the right thing for your patients. And even after you’ve done everything you can, things can still go horribly wrong. Maybe I should re-evaluate that whole “sick but safe” thing.