Think back over your career in medicine to the patient encounters that are most memorable to you. Are they good ones or bad ones? Were they tragic, ending in a bad outcome or a lawsuit? Were they positive? Did you make a real difference? I want to take this opportunity to review some of the most influential cases in my life. I invite you to do the same.
AAA Repair Surgery
I’ll never forget when I was in PA school at Kings College and, as a student, I went into an operation where we were doing a AAA repair. We were in a small hospital. I remember the surgeon I was working with was bragging to people at the hospital that he had this AAA repair coming up. He was really excited about it. I went into one of the exam rooms that day to do a pre-op evaluation and there were two people: an elderly gentleman and a female. That elderly gentleman was the patient undergoing the AAA repair.
They expressed concern about having the procedure done at this particular hospital, as it was a small facility. I remember commenting, “That’s a really good question, let’s talk to the surgeon about it.” When the surgeon came in, he really tried to calm the patient, saying, “Oh this is no big deal, we do it all the time.” This was a strange patient encounter because of the way he was bragging about the procedure earlier that day. His words made me think this wasn’t done all the time and he wasn’t sharing the same story with his patient.
When I went into the operating room I was scrubbed in and I helped put the guy to sleep. I was there as he closed his eyes and I had this sinister feeling. Now, I was the third assist because there was the surgeon, a vascular surgeon and myself. I’m a student, so I’m holding equipment and suctioning when they need it. This was supposed to take four hours. However, there was an iliac artery that burst, so there was a lot of bleeding and my hands were very necessary.
Then the other iliac burst and this turned into a 10- or 12-hour case. No bathroom breaks, no meals. By the time the case was over, this gentleman was bleeding out of all of his orifices. It was clear he was going into DIC and he died right there on the table. I will never forget the surgeon leaving the OR to tell the family. I’ll never forget walking out of the OR and having all the nurses’ eyes turn to me. They knew something horrible happened, that a patient died on the table.
A Boy Struck by a Train
It was a quiet ED day and I get the call that a 16-year-old boy was struck by a train. This case bothered me more than any case in my whole career, it still does. This boy was not viable when he came in. He was dead. There was nothing I could do for him. My fear was that when they brought him in, I was going to see my son because my oldest boy was 15-years-old.
The boy they brought in was a very big young man, so he didn’t look like my son. The resuscitation was unsuccessful. There was a number of teenagers who saw this kid get hit by the train. They came in with a grief response as acute psychiatric pain. They were just screaming, this piercing screaming. It took almost two hours for the mom to get to the ER. She went to the wrong hospital. Breaking the news to the mom was absolutely horrible. It was a horrible experience.
I will never forget the pain she expressed. This case haunts me; I have scars from this one. I went to this 16-year-old’s wake to try to find a degree of peace. I did have to go through a debriefing with the nurse who was on because she was just as damaged from this case as I was.
Two Contrasting Patients
I walked onto a shift at a critical care ER and into two patients right away. One guy had chest pain and other lady had shoulder pain. The guy with chest pain was having a STEMI. I needed to thrombolyse him to try to save his life. He was desperately clinging to life as I thrombolysed him. It took me about 90 minutes before I stabilized him and could fly him off in a helicopter. I’ll never forget stabilizing him, saying goodbye and seeing him pushed down the hallway, family on either side, on his way to the helicopter. When I see a patient I was able to deeply care for, it always chokes me up to see the family saying goodbye because he is still critically ill.
In the next room was a patient at the other extreme, this woman with chronic shoulder pain. She comes in and says, “The only thing that makes this better is a shot of Dilaudid.” So we have two extremes, one guy who’s clinging to life and a woman who just wants her Dilaudid, which I was unwilling to give her. She had to wait quite a bit of time because of the STEMI too. She left very angry at me.
What Looked Like a Cold
I saw a 56-year-old two months after I graduated. This guy came into a fast track portion of the emergency room with the chief complaint of a cold. His evaluation had some wheezing, normal vital signs, no cardiac risk factors. I gave him some Proventil and some antibiotics to take home.
Then shortly after, he had an MI and died. That was my first of two lawsuits. I was deposed and charged with not diagnosing an acute coronary syndrome presentation, which really looked like a cold. Ultimately, the case was dropped after deposition, but early in my career, I was indoctrinated with the medical-legal system. I became very mindful and protective of people with chest symptoms, such as chest pain or shortness of breath.
This is when a lot of my emergency medicine mnemonics were developed. If you know anything about my teaching, I have the PAPPA mnemonic for chest pain and HORID for shortness of breath. They are flawless mnemonics and they will save lives.
A Gentleman with Chest Pain
Three or four years after I graduated, there a gentleman admitted through the ED with chest pain. I saw him on the floor with a presumptive diagnosis of acute coronary syndrome. I remember evaluating him and documenting what the ED did in their patient care, which was give him a liter of fluid because his pressure was low.
In talking to the patient, I thought his case was really peculiar. I thought he had a heart attack, some kind of acute coronary syndrome, but it didn’t make sense. If he was hypotensive from a cardiac problem, he’d be pretty sick, but he didn’t look sick. I realized he had some rails in his left base, was mildly hypoxic and his mediastinum looked big. At 3:00 in the morning, I ended up doing a CAT scan of his chest, looking for a thoracic dissection. The radiologist called me and said, “John this is a type 1 dissection.” It was unbelievable, both humbling and exciting, that I was able to make the diagnosis.
A Plane Crash
Next, as I’m working a critical access ED and I hear the EMS paged out for a two-seater plane that crashed in the woods not far from the hospital. I’m like, “All right, I’ve never had someone crash their airplane before.” They bring in one of the pilots collared and boarded. I realized the other pilot actually died in the crash.
One of the problems I always had in emergency medicine is that I’m more of a medically-trained clinician, a hospitalist, an intensivist. So my trauma has always been on the weaker side. It’s just never been my forte and at times I’ve had to think my way through situations. How can I get this guy home? In my workup, I found this co-pilot had a fractured tibia.
I remember talking to the orthopedic surgeon, who said, “Wait a second, John. This guy was in a plane crash where the pilot died. Ship him to a trauma center.” I did and there wasn’t any bad outcome. I remember the psychology of this guy being transferred to the trauma center, going, “Wait a second, as an ER critical access provider, I have to trust mechanisms.”
Another Trauma Case
I hear of a pretty bad car crash on a thruway close to the critical access hospital. I’m following the drama on EMS radio. I hear the helicopter is called out and this guy is pretty sick. Then, I hear the guy decompensated, so they’re rerouting him to our hospital. I get ready for this trauma code. Something very interesting was happening at the time; we rarely had surgical services in the hospital but this happened to be a time where the surgeon and anesthesiologist just finished up a case and were there.
I got the surgeon and anesthesiologist to come over to the ER to help me with this code. When this guy came in he had central cyanosis; he was very, very sick. There was real confusion here because I’m thinking this is trauma code or near code and the surgeon should be managing it. The surgeon is thinking I should be managing it because I’m the ER provider. Because both of us were waffling a little bit, giving half-ass commands to the nurse, the anesthesiologist jumps in and takes over. That didn’t feel right.
This guy died within a matter of minutes, but they were very chaotic minutes. The nurse didn’t know who was in control and that was my fault. I will never let that happen again. When I’m running an emergency room, even if a doc comes in, it’s still my emergency room. The doc could help me with the code, but the nurses take orders from me.
I remember talking to the surgeon and he said something that changed my practice. Anytime you have a critically ill person come in, it’s practice time. If you have someone come in with a systolic and they don’t have a tube, intubate them. Practice your tubes. When you have a trauma code, a chest trauma, you can put a chest tube in them. You don’t want to mutilate a body, but if it’s medically indicated, you should do it. If you have someone with massive facial trauma and they’re in cardiac arrest and a surgical airway is indicated, do the surgical airway. Get those procedures in.
A Nationally Ranked Wrestler
There was a 16-year-old wrestler, state and nationally ranked, who went out riding on an ATV. This kid was a really good wrestler and he knew he was not supposed to be out on the ATV, but he took it out anyway. Well, he went over the top of the ATV and when he came in, he couldn’t bear weight on his left leg. When we moved him from the stretcher to our bed, his knee moved in a way a knee should not move. I expected a fracture.
But history made it appear that the knee posterior dislocated. The X-rays showed no fractures. Good pulses in the leg, but when I called orthopedics, I said, “I got a kid here; it looks like he’s torn everything in his knee.” We knew right then and there he probably would never wrestle again. His career was over.
They told me to put him on some pain control, give him a knee immobilizer and send him home on crutches. That was all well and good until a couple of hours later. The orthopod called me because the patient had called him and said the leg is now cold, pale and really painful. The patient was immediately shipped to a trauma center, where they realized his popliteal artery was damaged. He needed vascular surgery on the leg.
This case always bothers me. I checked for pulses but I know that anytime you have problems with the proximal tibia, you should check vascular flow with something more than just your palpation or a doppler. I know it now, but that was a time I needed my orthopedic consultation to guide me.
The Greatest Cardiac Arrest
This was the greatest cardiac arrest I ever ran. I’m in a very busy emergency room and all my rooms are filled. I hear of a 38-year-old female coming in with chest pain. I’m very unimpressed with a 38-year-old coming with chest pain. But when they brought her in and put her toward the back of the ED, she went into a seizure. I think, “Wow, this a peculiar seizure.” She stopped seizing and started drooling. I realize she’s in cardiac arrest.
We whipped her into our code room and she was in ventricular tachycardia. I quickly defibrillate her and we got her back, then we lost her again, then we got back, then we lost her again. In this process, I had two ENT cases in the ER. One was an angioedema from an ace inhibitor and the other was an abscess. So ENT shows up in the ED and happens to see that I’m running this code of a 38-year-old. The ENT physician comes in and thinks, “I’m the doctor, maybe I should run this.” I tell her, “Ma’am, handle the intubation. I’ve got everything else. I’ve run lots of codes and taught ACLS for a long time.”
So she intubates and realizes I don’t need her services. I did call in my backup doc because this code went on for about 90 minutes. We’d stabilize her, but then we’d lose her, get her back, lose her, get her back. Finally, we did an EKG and she was having an anterior wall STEMI. Despite having done CPR on her, we squirt her with thrombolytics. She was transported, defibrillated a couple of times in the hospital and had a really good outcome. She survived her cardiac arrest. A few months later, she was admitted to our hospital with pancreatitis. I went up and talked to her. She didn’t remember anything about the arrest.
Interestingly enough, as I’m running the code, I’m told she was seen twice in our ED within the month for chest pain. As I pulled her charts, I saw she had typical chest pain presentation. As we all know, there are three types of people that love to have atypical presentations of chest pain: diabetics, elderly and females.
Thank you for joining me for this journey down memory lane. What are some of your most memorable cases? I’d love to hear some of the cases that left a real impact on you. I’d like to know what happened and how it affected your practice from there on out.