During 33 years of work as an academic endocrinologist and internist at a major teaching hospital, I have never been sued. I attribute this to intelligence, good common sense, and a keen gut instinct. Unfortunately, the first time my gut instinct proved me right, my patient died anyway.
My first day as an intern, I had 22 patients assigned to me. I was at a busy IM ward at a small Veterans Affairs hospital in South Carolina. This was before ACGME admission caps and duty hours restrictions. My attending was the chief of outpatient medicine, who rotated on the wards twice a year to help maintain his hospital care skills.
One of the patients I inherited was Casper, a 60-year-old Vietnam War veteran. He had been admitted to the hospital for the first time for evaluation of crampy abdominal pain and melena the night before I joined the team.
The first time I examined him, Casper was resting in bed, complaining of moderate-to-severe abdominal pain. His blood pressure was low/normal (102/44) with a pulse of 90. His skin was cool but not clammy. His abdominal exam was remarkable only for dull, diffuse pain, not worsened by palpation or percussion. Bowel sounds were present but sparse. On the rectal exam, his stool was dark, sticky, foul-smelling, and strongly hemoccult positive. He had no palpable pulses in his feet. The only medication that the admitting intern had started was an IV drip of half-normal saline at 50 cubic centimeters per hour.
The two interns on our team usually rounded very early in the morning and then met with the senior resident and attending at 10 a.m. for sit-down rounds. This was followed by the attending seeing select patients. Despite my clinical inexperience, my gut instinct told me that Casper had a high likelihood of ischemic bowel disease, and so I put him first on my list of patients to be presented to the team. My attending agreed to see Casper at the bedside.
He did a cursory exam, largely focusing on palpating the abdomen. “This could be ischemic bowel,” he said, “but because of his alcohol use I am more worried about gastric ulcer disease. His dark stools suggest upper GI bleeding. We should get the GI service to see him for upper and lower endoscopy next Monday.”
I asked if we could have the surgery service see Casper in consultation. The attending agreed, and we moved on to our many other patients. I called the surgery intern on duty when I was able to break away from rounds. Like me, he was a new, very nervous intern who had just finished medical school. His surgery team was even busier than ours, and he was already extremely stressed.
He did, however, conduct a brief abdominal exam. “I’m due in surgery in an hour and still have 10 patients to see on my service before then,” he said. “If your attending thinks this is gastric ulcer disease, I think we should follow his care plan. However, I will add him to our list and will ask our chief resident to see him with me when we have time.”
I thanked him, told Casper the plan, and, although troubled by this, went on to see my other patients.
When the surgical chief resident examined Casper the next morning, on Saturday, Casper was comfortable and had no abdominal pain. The chief resident was not impressed. “I agree with your attending,” he said. “I doubt this is an ischemic bowel. He’s too comfortable and looks too good. We’ll continue to follow him, but I think the GI service should evaluate him first.”
Casper lay quietly in bed and said nothing. Like many of his generation, the word of the doctor, and especially the surgeon, was sacrosanct.
At this point, I really did not know what else to do. My instinct told me this was ischemic bowel disease, which is a surgical emergency. My senior resident was supportive, but she was extremely harried trying to supervise two new interns. She also deferred to our attending’s plan.
Even though my instinct told me that my diagnosis was right, I could do little more than reassure Casper that he was being closely watched, and that we would get the GI service to see him first thing on Monday. He remained calm and stoic throughout my discussion, and thanked me for my care.
On Sunday morning, I arrived at the hospital to begin rounds at 5 a.m. and went to see Casper first. I found him dead in bed. He looked like he had died in his sleep.
I was granted permission for an autopsy by Casper’s family. On Monday, I found out that he had infarcted his large bowel, most of which was gangrenous, due to severe mesenteric ischemia. He also had critical three-vessel coronary artery disease and had had a myocardial infarction.
I was frustrated and angry that I had not been able to save Casper’s life. Since then, his spirit has haunted me — always there in the inner recesses of my mind.
As I have progressed in my career, my gut instinct has continued to serve me well in many instances when something was just not right. It has helped me save patients and avoid potential medical disasters. The difference now is that I have the experience and leadership skills to act on it. So, when the clinical scenario feels wrong, listen to your gut. It will usually steer you right.
When has your gut instinct proved to be right in a clinical setting?
Dr. Latham is an endocrinologist and clinical assistant professor of medicine at the Prisma Health System in Greenville, South Carolina. He teaches second-year medical students clinical reasoning and clinical skills at the University of South Carolina School of Medicine–Greenville, and medicine and medicine/pediatric residents in his endocrinology office practice.
All names and identifying information have been modified to protect patient privacy.
