She had actually called the clinic the night before. She had had a cough for three weeks and wanted to see Melisa, our nurse practitioner. It was Melisa’s day off, and she was not in the clinic. The clinic nurse told her there were other providers available if she hurried down. The nurse offered to double book her in, without even asking, as she thought as sick as the patient sounded like she should be seen ASAP.
“No, I will be OK one more day, I will see Melisa in the morning,” the patient insisted. She scheduled for Melisa's first available visit the next day, 11 a.m.
That next day I was covering the ED working up an abdominal pain. My patient had been offered my first clinic slot at 9 a.m. but she called the ER at 8:30 a.m. and said she could not wait that long and would be in shortly. I was not concerned about her as she had normal vitals, normal exam, and normal labs. Furthermore, she had a history of diarrhea-predominant IBS which her current situation could easily be an acute exacerbation of.
I was visiting another patient when there was a knock at the door. “Sean, can I speak to you outside?” It was the clinic nurse. I excused myself and stepped into the hallway, “There is an ambulance out for an unresponsive patient; she was supposed to see Melisa at 11.” I stepped back into the exam room and gave the patient the option of waiting for the lab results or having us call them. They agreed we could call the results and treatment plan.
As I made my way back to the hospital, Melisa texted me.
“Is my patient really unresponsive?”
“IDK I have not gotten to the ER yet.”
As I hit send my phone rang.
“Sean, we have a coroner case for you to go on, that EMS patient was worse than expected,” said the hospital nurse. She gave me the address and I made a 180 and went back to the clinic where I had parked my car. On the way, I texted Melisa: “Don't freak out, but your patient is now a coroner case.” I made my way to the address the hospital nurse had given me.
On the way Melisa texted me back. “Holy $&!%, she had flu-like symptoms yesterday and now she is dead?!”
As I completed my duties on the scene as deputy coroner, I wondered if even last night would have been soon enough to catch and reverse the cause of death. Before I could leave, Michelle texted the CT report for my otherwise well and not-at-all-concerning ER patient: a large bowel obstruction with pneumatosis coli, in other words, a surgical emergency. My patient with normal exam/vitals/labs who appeared just fine was hours, maybe minutes away from rupturing her colon, and possibly dying. She had come in just in time.
On the way back to the hospital, I began organizing all the paperwork needed to transfer my patient to another hospital.
Within minutes she was gone. I joked with the nurses after the patient was on the road, "You don't always have to be good, you can be lucky sometimes, too." Where my patient had just barely hit a narrow window, Melisa's patient had missed one. The only difference: one patient felt terrible but thought she could wait, the other felt not quite right and wanted to get on top of it. In the second case, it saved her life.
Melisa was torn up the rest of the day, wishing she had been in the clinic the night before to see the patient, maybe in time to save her life. She wished she could have spoken on the phone and pushed harder for a timelier visit, either the clinic or ER, patient’s choice. Fortunately, I was able to console her as the day went on. The guilt of the delay did not belong on her shoulders. We could not drag the patient in against her will. She made her decision, and while the outcome was not what any of us wanted, it was certainly not our fault.
It is hard to be perfect when practicing medicine. We do our best to have optimal outcomes, but sometimes one decision, imperfect in hindsight, prevents that perfect outcome. The butterfly's wings flap and the result is dramatically changed. I have to wonder how things could have gone the other way given just one different thought process. In some parallel universe, Melisa's patient comes to the ER right after the clinic closes. We find her sick lungs and treat them just in time. The next morning a patient with a history of diarrhea-predominant IBS presents to the clinic. We discuss how, since she stopped her IBS medicine, she has had cramping and loose stools. Her vitals are perfect, her exam benign, including bowel sounds and a non-tender abdomen. I decide no imaging is needed; this appears to be IBS exacerbation, so I restart her IBS med. The patient goes home, but later her obstruction ruptures and she goes septic and dies. I bear all the guilt of not ordering the CT (and some would say rightly so). Melisa consoles me through the day, noting the normal exam, the normal labs, and the normal vitals.
Melisa should bear no guilt for not being able to save her patient, no more than I should be allowed to gloat that I found the surgical emergency that did its best to hide from me. We will never be perfect. Sometimes we will be lucky, and sometimes luck will not be on our side. A decision made, a life altered. We can learn from the imperfect outcomes and even the near misses, with hopes of doing better in the future. Still, we will never be perfect, and we can’t blame ourselves for that.
Sean is the lead advanced practice provider at Decatur Health, Oberlin, Kansas. He enjoys writing not only online, but has published a book Through the Eyes of a Young Physician Assistant. When the outdoors call, it is to go golfing, fishing, or hunting with his sons. He tweets at @SeanConroyPAc. Sean is a 2019-2020 Doximity Fellow.
Illustration by Jennifer Bogartz