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2012 YP Award Essay 6
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2012 Winner - Essay 6

The Doctors Company Foundation Young Physicians Patient Safety Award

I arrived at the emergency department of a small community hospital late Sunday night. As a part of my pediatrics rotation in my third year of medical school, I was on call every fourth to sixth night to help the interns with new admissions. On this particular night, the importance of effective communication, working collectively as a team, and trusting gut instinct conflicted with my ability to manage the delicate balance that exists between acting in one’s own best interest versus that of the patient.

 

I met with the intern in the emergency department (ED) and we discussed the patient with the ED staff. Our patient, a two-month-old female, had the unfortunate history of spending the first seven and a half weeks of her life in the neonatal intensive care unit at a hospital one and a half hours away from home. She was born with a kidney tumor that was removed when she was four weeks of age. Shortly after, she developed pneumonia and wasn’t able to return home until 7 and a half weeks of age. At home, her parents paid close attention to her health. They became concerned when she did not drink her formula, seemed constipated, and had only a few “moist” diapers since returning home. After a full workup, the ED physician consulted with her nephrologist by phone who advised that the patient should be admitted to the hospital for treatment of dehydration.

 

When the intern and I entered the room to gather a history and examine the patient, the small infant lay quietly on the disproportionately large hospital bed. She hardly made an effort to open her eyes. Even during more invasive exams such as using the tongue blade to get a better look at her mouth and throat, she did not cry. I remember getting concerned at this point. Although new to the pediatrics team, I had a gut feeling that something wasn’t quite right. Then she threw up a profuse bright green vomit and I began to feel even more uneasy. The intern remained calm and cleaned the mess after a couple more episodes of bright green vomit. Her calmness did reassure me. Perhaps I was overreacting.

 

Once we left the room, I tried to discuss my assessment of the patient with the intern. I told her that I was worried the baby might have a bowel obstruction. She didn’t dismiss the idea, but she kept her attention to filling out paperwork. Without looking away from her work, she reasoned that the bilious vomit was most likely due to our examination and less likely due to any obstruction. Besides, her nephrologist had already been consulted and provided a diagnosis of dehydration. I pressed on. I expressed my concern that if the patient did have a bowel obstruction, it could lead to ischemia or death of the affected bowel if left untreated. We could order a bedside abdominal x-ray to quickly and easily evaluate the possibility of an obstruction. She did not agree. A chest x-ray had been ordered by the ED physician and the intern argued that enough of the abdomen could be visualized to see that an obstruction was unlikely. I pulled up the chest x-ray on a nearby computer to find that, at most, one-third of the abdomen could be visualized. I attempted to share this finding with her. She merely said, “I’ve already seen it.” I urged the intern to consider that if the patient’s bowel did become ischemic, a surgical emergency, that our small community hospital lacked any pediatric surgeons and she would have to be transferred. The nearest hospital equipped to care for her was one and a half hours away, a significant time delay in treatment. She remained unconcerned and so I went back to the patient’s room to ask her parents additional questions.

 

My questions focused on further evaluating the possibility of a bowel obstruction. I learned that the child’s last bowel movement was the day before with no bowel movements since. Even more worrisome, when asked if the baby had passed any gas since her last bowel movement, her mother responded, “Now that you mention it, no she hasn’t.” I asked if she could normally hear her baby pass gas and she continued, “Yeah. It usually sounds wet or as though she is having a bowel movement but when I go to check her diaper, it’s clean.” I went on to ask if the baby’s belly looked larger than usual and the mother confirmed that it did. This new information greatly supported the possibility of a bowel obstruction. I left to rejoin the intern and found her on the phone waiting to get a hold of the attending. While on hold, I explained that the baby had not passed any flatus and had a distended abdomen, supporting an obstruction. She nodded but did not respond. Shortly after, her demeanor changed from guarded to overly pleasant as she greeted the attending and explained the patient’s presentation.

 

She neither mentioned the distended abdomen nor absence of gas.

 

Later that night, within hours after being admitted to the pediatric floor, the baby’s condition rapidly worsened. Her belly “blew up” and she had unremitting vomiting that progressed to include fecal matter. She was transferred to a hospital with a higher level of care by life flight and sent directly to the operating room. She had a small bowel obstruction and lost the majority of her bowel.

 

This case elucidates several ethical issues including that of nonmaleficence and beneficence. Nonmaleficence, or “do no harm”, is an ethical guideline that “forbids physicians from providing ineffective therapies or from acting selfishly or maliciously (1).” In this case, ego played a substantial role in the care of this patient. The intern failed to mention key information to the attending that would have changed patient management. If she had included bowel obstruction in her differential, there’s no doubt the attending would have been made aware of the distended abdomen and lack of gas. Overlaping with nonmaleficience is beneficence, a guideline in which the physician has the duty to act in the best interest of the patient(1). The patient was admitted to the pediatric floor instead of being transferred to a different hospital for a higher level of care. The lack of pediatric surgeons in our local area needed to be considered when admitting this patient. Although one may argue that the patient’s diagnosis was uncertain and thus transfer to a higher level of care was not warranted, it was also in the patient’s best interest to further explore the possible differential diagnoses, something that we failed to do as a team. Instead, we submitted to the nephrologist who labeled the infant as dehydrated. The differential diagnosis of bowel obstruction could have been further explored with an abdominal xray. It’s cost effective, easy to do at the bedside, and fast. The diagnosis would have been made sooner so that the patient’s best interest to be directly transferred to a higher level of care would have been fulfilled.

 

One of the most important issues encountered in this experience involves the ethics of speaking up. The hierarchical system of attending, then resident, intern, and last medical student is such that the concerns of the medical student are often overlooked or dismissed, as in this case. Although speaking up to improve patient outcome was morally the right thing to do, doing so is often at the expense of fostering working relationships with those higher up in the hierarchical system. During a meeting to discuss the importance of recognizing a sick patient as a consequence of this case, the intern shared that she believed I was “too pushy”. This could be a dire mistake, because a medical student’s grades depend on subjective evaluations by the interns, residents, and attendings. Making matters worse, the baby’s outcome did not change as a result of my brashness.

 

On the other hand, I may not have spoken up enough or in the right manner. Often medical students “play dumb” to hint towards the diagnosis or management of a patient so that the intern or resident does not feel challenged. This way concerns and/or ideas can be voiced without jeopardizing working relationships.(2) Perhaps I was too pushy and threatened the intern’s ego. However, “playing dumb” can have its own unfavorable consequences. The subservient medical student who does not speak up or “plays dumb” will not learn how to manage conflict or how to argue for better patient care. It may also lead to an alteration of attitude towards subservience that can be carried into practice later on. Too often, as in this case, medical practitioners go along with the conclusions of other medical practitioners even if incorrect or inadequate. Although it is helpful to consult a specialist, in this case the specialist’s diagnosis undermined the patient’s actual diagnosis. Neither the intern nor ED physician explored the patient’s presentation beyond the diagnosis of dehydration as they acquiesced to the expertise of the nephrologist. Thus the medical student who remains quiet risks developing a habit of continuing to do so, putting that medical student at risk of emulating the same behavior as the intern and ED physician in this case.

 

Ultimately, it is the role of the medical student to learn. This includes learning when and how to speak up. This is an art in which the student “should consider the nature and certainty of their judgment, their specific role in the situation, the potential harm to patients, the probable effectiveness of speaking up, and the likely cost to themselves if they do speak up.”(1) Although I had a high index of suspicion that our patient had a medical emergency that warranted better care than what could be provided in our hospital, I was still uncertain of my clinical knowledge. I had never seen bilious vomiting before and questioned if that’s what I truly saw, especially when the intern and ED physician were not similarly concerned. Furthermore, in this case the intern’s expectations of a medical student’s role in patient management was made perfectly clear. The medical student’s role was to stand aside, watch, and keep quiet, making the effectiveness of speaking up unlikely with this specific intern. While I could have gone higher up in hierarchy until my concerns were addressed, the medical system is set up such that medical students have very little direct interaction with the chief resident or attending. I’ve actually never met either and wouldn’t know how to contact either if I needed to. This elucidates a major flaw in the medical “team”. It is set up such that it is difficult to find someone who will listen, because alternative avenues of communication are limited and/or prevented completely. Thus, while it is the obligation of the student or medical practitioner to speak up for better patient care, “those with more power and authority have a greater obligation to confront the problem… to change the conditions that make it so difficult for those below them to speak up.”(2) If the attending had been available directly in person rather than by telephone, I may have been able to share the information I believed to be so important in changing the patient’s management and ultimately her outcome.

 

Although I was unable to alter this child’s outcome, I will strive to prevent similar consequences of poor patient care. As I progress up the hierarchical ladder towards the “attending”, I will always remember the important lesson learned from this experience as a medical student. I will retain my inquisitive nature with the humility to understand that the best patient care is achieved through effective communication, teamwork, and personal sacrifice. ¨ 

  

*Please note that all pieces of possible identifying information (names, dates, locations, etc.) have been changed for purposes of privacy.

 

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