I see the living dead occasionally. They are the patients whose cause of illness is so potentially lethal it will kill them within hours or days if I miss it or mistreat it. My fear for them, and of them, haunts me after work, a wolf of worry at the edge of the forest of my thoughts.
The living dead are often clinical quicksilver; they are made slippery by the chaos of the busy emergency department, and it may be difficult to grasp the clue that makes them different from the other ill and injured. They often look and sound just like another patient, and there is no label on their foreheads saying “Save me, please. You are my last hope,” and no Grim Reaper is waiting at the bedside as a warning to me to get it right.
The living dead are why the most dreaded question in emergency medicine is: “You remember that patient with X problem you sent home last night?” Anyone who has worked in an emergency department for long knows of at least one patient who went home and died after the key diagnosis was missed.
They are, for example, the patient with a killer infection among the many patients with infections. But which patient? Last Thursday, I saw about 15 patients with infections, several of whom probably had the H1N1 (swine) flu. Most were curled up on stretchers, coughing as though trying to exorcise a lung, and looked like road kill without the road. I sent all of them home, to suffer and recover. I hope. Every one of them could be the next Mainer to die of this worldwide pandemic.
At least three of Thursday’s patients were children. If I live in fear of all the living dead, it is the children among them who are the stuff of my nightmares. When I consider how often those of us who take care of sick children must walk near that blurred line between the right decision and the disastrously wrong decision I can feel the panting of the wolf on my neck.
Head pain, fever, chest pain, abdominal pain, feeling suicidal — these complaints are among common clinical conundrums that require constant vigilance for the one patient in a hundred who looks well enough to be safely discharged but might die if sent home. Every ED shift has several patients with these complaints. Patients with chest pain are common in the ED, and every one could be the one whose ED tests look good and gets sent home with their subtle heart attack missed; one in four such patients will die in the next 24 hours.
Even admitting them may not save them. Years ago I admitted one such woman to the hospital after she returned to the ER for the fourth time in two days. She died later that night in the hospital, with my hands on her chest helplessly doing CPR, because I, too, missed the real and unusual cause of her chest pain; the biggest blood vessel in her body was tearing itself apart.
The textbooks tell you how to separate the deadly clinical wheat from the routine clinical chaff, but patients often do not read the textbooks and few doctors seem as smart in the ED as authors do in their books. A patient’s version of the disastrous illness may not have the classic presentation we were all trained to see, or maybe they did and we missed it.
In a world where I want nothing but the best for my patients, full of malpractice lawyers, and patients who want no errors made in their care, it would seem easy to eradicate all deadly risk in the care of patients in the ED. Admit them all, put heart monitors on them and CAT scan everyone from top to bottom to rule out bad things inside. There are just a few problems; the country cannot afford all of the hospital beds and tests necessary to do that, and the search for potential catastrophe in one patient by eliminating the possibility of it in every patient puts too many patients through too much testing pain and risk.
The result is that you must live with the wolf of worry, too.
Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region. He is also the interim CEO at Blue Hill Memorial Hospital.