Monday, January 10, 2005

Listening to Mini-Me

The little voice that resides way up high in my head, assigned the thankless role of acting as my better judgment was busy last weekend. I could hear him screaming and carrying on while I went about my rounds as the on-call doctor. Reproduced below are just a smattering of the admonitions he delivered, edited for family listening:

"If I've told you once I've told you a thousand times - don't let other doctors do your work for you!"

"Oh, so you're going to make an assumption, eh? You know what happens when you assume, don't you - you make an [vulgar colloquial adage censored -Ed.]

"I don't care what time of night it is! If you allow anger to influence your decisions you are a pathetic loser!"

My, but he's unpleasant, isn't he? Even worse, I pay him a royal fortune for his gratuitous verbal abuse, the little homunculus. Why don't I throw him out the left ear, you ask?

You see, he's saved my keister many a time with his obnoxious advice. Can I share with you the most recent example?

The case in point was that of a young college-aged patient who presented with a three week history of mild fatigue, sore throat, enlarged cervical lymph nodes and fever. The patient had seen the family doctor and was thought to have mononucleosis, but was asked to see my partner next week to investigate an abnormality in the white blood cells.

So far, a straightforward course it would seem...

I got involved because late Saturday night the patient drove 60 miles to another town where the parents lived, and then went to the local emergency room to get another opinion. The E.R. doctor yanked me out of the blissful fields of dreamland to announce via telephone that he wanted to transfer the patient to St. Louis because "blasts" were found in the peripheral blood.

Blasts, my friends, don't go with mononucleosis. As I sat up in bed and tried to raise the shades of my bloodshot eyes, I began to respond to the gravity of the situation. I responded (ahem) like the true professional I am - I began to whine. Who wants to see a patient with acute leukemia in the middle of the night anyway? Mercifully this caterwauling also awakened my better half - that little voice of reason who never seems to shut up when all I want to do is tell someone to get lost and then go back to sleep.

After getting chewed out by my doppelganger, I decided to take his advice and accepted the patient in transfer. The sin of Making a Decision in Anger was quashed, and of the three maxims dusted off for my education I was now one for one in compliance.

Unfortunately my batting average was about to plummet.

When the patient arrived in our emergency room the doctor there called with good news - this patient clearly had mononucleosis; why, he couldn't even understand why the patient was here in the first place. I rallied upon hearing this report and asked him tuck everyone away for the night. With not an insignificant smile I curled up under the soft folds and once again aimed the beacon towards Slumber Mountain.

The sin of Making An Assumption had just been committed.

The next day I interviewed the patient just as the Infectious Disease consultant had finished his evaluation. He was convinced that the ailment was indeed mononucleosis - nay, emphatic about it. With such reassurance I wasted little time performing such meaningless tasks like a careful physical exam or a thoughtful review of the laboratory test results. I told the patient a happy trip back home awaited the coming of the next dawn.

I had just committed the flagrant medical foul known as Relying on Other Doctors to Do Your Work.

I suppose you can guess the rest of the story. The following morning when the pathologist reviewed the patient's peripheral blood smear he saw nothing but blasts - with Auer rods, which clinched the diagnosis of acute non-lymphoblastic leukemia. I then sheepishly had to explain how this patient's world was now going to be turned upside down, in a battle to defeat a vicious enemy, instead of enjoying a quiet convalescence at home.

I guess we all have the voice of prudence and perspicacity lying in the recesses of our minds, ready to jump up and defy us in moments of laziness, contentiousness, or hubris. Given the many challenges that await us daily, I predict our ears will soon be burning with good advice from within. Let's hope we have the good sense to listen.


At 8:47 AM, Blogger Orac said...

Unless a delay in treatment of one day would make a difference in this young man's outcome, I don't see the reason you're beating yourself up so much. On the other hand, I do agree that if you let other doctors do your work for you too much sooner or later you will get burned.

At 11:44 AM, Blogger Brian Perry said...

Interesting post.

In response to the above comment, if I were in a similar situation, I think that what I'd be feeling here is that my own selfishness (tired, angry, cranky, lazy- you name it I've done it) got in the way of being a professional. Whether or not it would have an effect to wait to the next morning, I'd be doing some serious self-flagellation as well.

Of course I'm not a doctor, but this is useful advice for any profession, if not life in general! It may be a pain at times, and may take the fun out of some stuff, but thank goodness for that little voice inside. Without it, I'd be in big trouble.

At 12:54 PM, Blogger SarahW said...

I'm not oppposed to you beating yourself up. :)

From a patient's perspective, and a mother of a child with a scary problem's perspective, getting yanked around with false reassurance or useless, potentially harmful instructions is ....awful. It adds a new and probablly permanent level of anxiety to a situation already burning out the adrenals.

At a time when you want to give figuring out and solving the problem away to someone more capable, you realize you have to rely on and trust flawed human beings...who could really get it wrong, especially in the beginning.

I always have to see the tests myself. At least internally, I second-guess EVERY thing I'm told.

Those three rules are great for patients, too, BTW.

At 12:54 PM, Blogger SarahW said...

This comment has been removed by a blog administrator.

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At 8:50 AM, Blogger nope said...


I'm sorry for being intrusive in to your blog. But I am Melissa and I am a mother of two that is just trying to get out of an incredible financial debt. See my hubby is away in Iraq trying to protect this great country that we live in, and I am at home with our two kids telling bill collectors please be patiant. When my husband returns from war we will beable to catch up on our payments. We have already had are 2001 Ford repossessed from the bank, and are now down to a 83 buick that is rusted from front to back and the heater don't work, and tire tax is due in November.

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