Soup's Happy Place

It has already been quite a few years since I have finished my internal medicine residency training. I have been working in a non-academic setting, which means that I come into work every evening and see my patients by myself. I am 100% solely responsible for my patients (admissions) and the other nocturnists are 100% responsible for theirs. There are no residents or anyone in training that we oversee. Therefore I’m not babysitting nor am I being babysat. Every now and then I will have a student with me though and this provides some good educational opportunities. I like to get philosophical about things (as many of you already know about me), and tying healthcare with other topics helps to see it a little bit differently. I actually intended to make a philosophical lecture (I had a few) about this during my third year of residency, but things were cut short due the start of the COVID-19 pandemic. So here goes (sorry it will take a little bit to get to the plane story)!

Healthcare is an extremely complex structure, where you have many different people in a variety of positions all working together as best as they can. The physician will usually be at the top of the totem pole. Ideally, everyone will work together to achieve one goal. There may be different goals in mind, but they should all be centered around the same thing. The patient! This is unfortunately not always the case, where you will have providers making it about themselves, about their egos, or carry a God-complex. In the hospital setting, the go-to specialty for crapping on is emergency medicine. “Why is Dr. [INSERT NAME] such an idiot?!” “How can Dr. [INSERT NAME] miss this?!” And of course this goes on and on. But at the end of the day, the emergency medicine physician is juggling a large number of patients at the same time that range from critically-ill on a ventilator all the way to numerous “primary care within the physical walls of a hospital” patients. It’s too easy to lose sight of this and people sure do love to play the worst position in American football, the metaphorical “Monday Morning Quarterback.”

There are two moments that I think about from time to time regarding some of this. The first one was during residency. We had an “observation unit” where the patient would then be transferred to another part of the hospital if they exceed a two midnight stay and become full inpatient status. This usually goes along seamlessly, however, there was one moment where it didn’t. We admitted a patient for a COPD exacerbation, which like congestive heart failure exacerbation can end up being a coin flip in regard to staying longer than two midnights. The patient’s symptoms weren’t improving to the point of safe discharge, so we went ahead and made her inpatient. Her daughter then called and was extremely upset. What was she upset about? That her mother didn’t get 100% better within the planned observation admission and would need to stay in the hospital longer. I used one of my favorite metaphors that I still use to this day with her and told her that we unfortunately don’t have a crystal ball to see when exactly someone will be well enough for discharge. In reference to the crystal ball, she yelled out out: “I hate it when people say that!” I was interrupted repeatedly with the same thing while walking on egg shells since I had to explain that we aren’t all-knowing beings that are 100% perfect.

This was literally one of the most difficult conversations that I have ever had, only because she couldn’t fathom the fact that we aren’t all-knowing. That’s why when patients and family members are taken aback by code status discussions, I will tell them that we can’t play God. I’m not God. Neither is the emergency medicine physician when figuring out the patient’s disposition. I have changed a patient’s admission from the regular floor to stepdown unit countless times. Sometimes the patient will end up going to the ICU. Sometimes they will even be well enough for discharge from the emergency department. No other physician is God either, regardless of specialty.

Another moment that has lasted with me was later on in my career. In this case, it ended up being the perfect storm of things that had absolutely nothing to do with the admission. Had this been an academic setting, it would have made for an incredible case studio. As for my blog, I can’t go into details due to HIPAA. But I’ll give you the general gist…

Post-operative patients will sometimes have a hospitalist consult. They are then on our group’s collective unseen list, where we can pick them up. Depending on how busy the night is, I will sometimes pick them up. I had an early start that evening, and was glancing at some of the post-operative specialist consults. This patient’s chart made it on my “potential list.” He had come out from a minimally-invasive procedure earlier in the day with plans for discharge following an overnight stay. His vitals were stone cold normal. His labs were stone cold normal. There was absolutely nothing remarkable about the chart. Things picked up pretty quickly with the emergency department, so I ended up removing the patient from my potential admissions list. Then in the early hours of the morning, a rapid response was called. This may go by other names depending on the hospital, but this means that a patient is suddenly decompensating and will require immediate attention from the physician and other specialties in the hospital. Once I arrived, the patient was suddenly extremely unstable. He was then transferred to the ICU immediately. It was one of those rare instances where a stable patient with unremarkable vitals and labs suddenly becomes the sickest patient in the hospital without actually coding beforehand. He ended up having multiple specialist consults due to the extreme complexity of his different conditions. Ultimately the patient’s family decided to keep him comfortable since they wanted to respect his wishes.

Interestingly, what brought him to the ICU actually had nothing to do with procedure he had. It was a perfect storm of factors that just happened to occur while he was in the hospital. A day later, the charge nurse for the unit told me that she was going over with the staff about what they could have done differently. From the very start, this was handled exactly as it should have been. The nursing assistant performing vitals noticed that they were incredibly off. They retook the vitals again and even tried another machine. Once they realized these were legitimate, the patient’s nurse was alerted and the rapid response was called immediately. I spoke to the intensivist, and he had accepted the patient promptly without even the slightest bit of pushback. As further workup was being performed, I was in absolute shock as to how much was going on. That’s when I told the charge nurse: “Had he not been in the hospital, this would have been a case of ‘grandpa died peacefully in his sleep.’” Right place, right time? Wrong place, wrong time? I’m honestly not sure. But for all I know, had I still been in residency there would have been the same resident(s) that would have thrown me under the bus for this without a second thought. Sad but true. I feel like many physicians can relate. Unfortunately this is the reality of medical training.

^^^ All of this was an explanation without actually going into my planned lecture… Now here comes the part you were waiting for. Aside from a physician, photographer, and dog lover; I am also an “avgeek” where I’m really into aviation. I have been this way since I was a kid. One of my favorite TV shows is Air Crash Investigation (currently on season 26!), where I have seen every single episode at least once. Each episode is a dramatization of what happened and the extensive investigation after, where you see piece by piece what went wrong. After all, disasters are a chain of critical events. The same thing happens in healthcare where it’s a chain of small mistakes that lead up to disaster. Honestly, I feel like the show has taught me to think about patient care in a different way similar to the air accident investigators. There is one accident in particular that I feel would benefit anyone that works in high-stakes fields where decisions can lead to either life altering outcomes or even death. It is the crash of Swissair Flight 111 on 9/2/1998. I’m going to go through the important aspects of this accident and have made up another “perfect storm” patient scenario inspired by a recent outbreak in the United Kingdom. Both of these will show how horrible something can look in hindsight (remember that hindsight is always 20/20) and how terrible the Monday Morning Quarterback can be.

Swissair Flight 111: A raging inferno brings down a McDonnell Douglas MD-11 killing 229 people aboard when the pilot did not immediately land the plane.

Amanda Hughenkiss: A 19 year old’s life is tragically cut short when two of the patient’s doctors miss an infection affecting her brain.

Both of these sound pretty bad, right? Did the pilot and doctors screw up terribly? The following is a short clip from the Swissair Flight 111 episode on “Seconds from Disaster” that helps to explain this situation perfectly.

Only 52 minutes after taking off from New York JFK International Airport, there was a puff of smoke coming from the air conditioning vents. The pilots issued a PAN-PAN call immediately and planned for diversion to another airport. If you watched the video above, you will see that the air conditioner circulating fans pulled the smoke back so it disappeared initially from the cockpit. Before you go jumping all over the flight crew, you need to realize that something like this isn’t an uncommon occurrence. Have you ever set your smoke detectors off by turning the heat on for the first time in winter resulting in the burning dust? Do you evacuate the house and call the fire department? In this case, they were doing everything by the book and did not realize they had a raging inferno above the cockpit. If you were to rephrase this as a multiple choice medical school or boards examination, immediately descending to below 10000 feet and getting to the nearest runway would be the wrong answer. In fact, landing an overweight aircraft can be very dangerous. See Aeroflot Flight 1492 below:

Had captain Zimmerman on Swissair Flight 111 descended immediately and then landed overweight at the nearest airport, this could have spelled the end of his career. That is why he started the descent and holding pattern for fuel dumping immediately. This is also why airplanes experiencing emergencies shortly after takeoff will either burn fuel (narrow bodies) or dump fuel (wide bodies) for some time before landing. Once again, smoke isn’t a rare phenomenon and for the first few minutes the crew of Swissair Flight 111 had no reason to believe that there was a raging inferno above their heads. Now if I were to rephrase this as a multiple choice medical exam it would be like this.

Question: An otherwise healthy 8 year old male presents with his mother to the urgent care clinic for a sore throat. You see erythema and exudates on examination of his pharynx. A rapid strep test is positive. He denies any shortness of breath or cough. He does not have any medication allergies. What do you do next?

A. Send home with instructions for salt water rinses and symptomatic treatment with return to his pediatrician in 48 hours if symptoms do not improve.

B. Prescribe amoxicillin.

C. Prescribe a dexamethasone dose pack and symptomatic treatment with return to his pediatrician in 48 hours if symptoms do not improve.

D. Send to the nearest children’s hospital for broad-spectrum intravenous antibiotics consisting of a carbapenem antibiotic.

What’s the correct answer? In this case it would be pretty obvious. I hope you chose B! Both A and C are blatantly wrong since you do not treat strep pharyngitis symptomatically. D is the “gag answer.” Perhaps the medical students have been going through too many difficult exams and this answer was a freebie by the professor to make things a little bit easier (and a touch of humor). Maybe someone blurted this out as a joke during lecture or with a pediatrician attending on their rotation (I mean there is always room for some humor, right?). In the case of Swissair Flight 111, starting an immediate dive and bee line to the nearest airport is the equivalent of answer D. With the initial presentation especially with the short puff of smoke that quickly cleared for the next few minutes this would be the “gag answer.” It would not happen. Swissair Flight 111 was that 1 in a million cases that went horribly wrong. It looks absolutely awful in hindsight, especially with the description I gave earlier. Unfortunately, this is one of the ultimate cases that Monday Morning Quarterbacks drool about. But when you start at the very beginning and see what the pilots were presented with. You will see they did everything by the book, and 999,999/1,000,000 times this would have resulted in a safe landing and minor issue that caused the smoke in the first place.

And now for a “perfect storm” medical case from the depths of my imagination that is similar to what happened in Swissair Flight 111.

Amanda Hughenkiss is a 19 year old college student currently studying criminal justice at Hudson University in New York City. She lives in one of the dormitories. It is in the midst of flu season, and she woke up on Monday feeling unwell. She had a subjective fever, alternating shaking chills and sweats, headache, runny nose, non-productive cough, and myalgias. She slept through her morning classes and then went to the student health center. She had a test performed, which was found to be positive for influenza B. She was given a prescription for Tamiflu (oseltamivir) and Tessalon Perles (benzonatate) as well as documentation for missing classes. She was given instructions to go to the emergency department if anything had gotten worse.

She spent most of her time in bed, and unfortunately seemed to be feeling worse. Her boyfriend had become concerned about this, and decided to bring her to the local emergency department on Wednesday. A well-seasoned emergency department physician with many years of experience, Dr. Nick Riviera, was assigned to her case.

I’ll put the encounter in a SOAP note format for the sake of simplicity.

Subjective: The patient is a 19 year old lady with a past medical history of migraines that presents to the emergency department for worsening fever (Tmax: 102.3F), shaking chills with alternating sweats, headache, diffuse myalgias, and non-productive cough but without any dyspnea. The patient’s symptoms started upon waking on Monday causing her to miss class. She went to the student health center, where she was subsequently diagnosed with influenza B infection and was prescribed Tamiflu. This seems to be aggravating her migraines, where she rates this as a “top 10 headache” but is not the worst headache of her life. She is experiencing myalgias and “stiffness” throughout her body going from her legs all the way up to her head. She has been coughing frequently with a non-productive cough, which seems to be getting worse, but there is no associated dyspnea. She received her influenza vaccine in early October. She denies any known sick contacts, however, she lives in a dormitory at Hudson University. She has no other specific complaints at this time.

Objective:

Past Medical History:

Migraines, anxiety

Past Surgical History:

None

Current Medications:

Escitalopram, topiramate, sumatriptan, ethinylestradiol and norethindrone (birth control pill)

Medication Allergies:

NKDA

Family History:

Non-contributory

Social History:
Drugs: Denies any recreational or illicit drug use

Tobacco: Never smoked or chewed tobacco

Ethanol: Drinks 1 or 2 drinks socially when at a campus party

Sexual: Monogamous with her boyfriend but does not use condoms due to being on the birth control pill

Vitals:

Temperature – 101.7F, Blood pressure – 107/62, Heart Rate – 108, Respiratory Rate – 20, O2 Saturation – 95% via room air

Physical exam:

General: Alert, oriented x4, cooperative, no apparent distress
Head: Normocephalic, atraumatic
Eyes: PERRL, anicteric, tracking appropriately
Nose: Nares normal, no discharge, no bleeding
Throat: Lips normal, tongue normal, no exudates, mucosa normal
Neck: Supple, trachea midline, no cervical lymph adenopathy, no JVD, painful ROM
Chest wall: No tenderness with palpation
Lungs: CTAB, good air movement, no rales, no wheezing, no rhonchi, no conversational dyspnea, no accessory muscle use
CV: Tachycardia, S1 & S2 present, no rubs, no murmurs, no gallops
Abdomen: No tenderness with palpation, normal bowel sounds x4, soft, non-distended, no hepatosplenomegaly
Genitourinary: Deferred
Skin: Diaphoretic, no diffuse rashes, no obvious lesions, no lacerations, no bleeding, normal temperature
Extremities: No peripheral edema, no digital cyanosis, normal ROM
Vascular: Distal pulses present in all extremities
Neuro: CN II-XII grossly intact, moves all extremities well
Psych: Anxious, not depressed, answers questions appropriately

Labs:

WBC: 16.1 (elevated)

HGB: 14.2

Plt: 232

Na: 132 (low)

K: 3.9

CO2: 17 (low)

Cr: 0.65

Anion gap: 15

BNP: 21

Lactic acid: 2.1 (elevated)

ECG:

Sinus tachycardia with rate of 110. Otherwise normal ECG.

Imaging:

Chest x-ray 2 view: Impression – No acute cardiopulmonary process.

CTA pulmonary (ordered due to tachycardia and use of OCP): Impression – Bilateral groundglass opacities that can be seen in the setting of an atypical infection or edema. Clinical correlation recommended.

Assessment (this differs from my actual integrated assessment/plan that I personally do at work. I am using a split format and medical decision making to make things obvious for the reader):

1. Atypical pneumonia due to influenza B infection – The patient is febrile and tachycardic due to this. The CTA pulmonary confirms the presence of atypical infection associated with known influenza B. Although the radiologist says this can be edema, acute pulmonary edema would be highly unlikely in an otherwise healthy 19 year old. Pulmonary edema also would have been easier to see on the chest x-ray, which was ultimately read as negative. The BNP is negative and therefore sudden new-onset congestive heart failure is highly improbable. The hyponatremia of 132 is due to poor intake since becoming sick with the pneumonia. The patient is euvolemic on physical examination.

Plan:

1. Admit for observation (less than two midnights expected). Continue oseltamivir from prior prescription. Add doxycycline 100mg IV twice daily to cover for potential superimposed bacterial pneumonia. Intravenous fluids consisting of NaCl 0.9% at a rate of 100ml/hr.

Amanda was seen by the hospitalist, Dr. John Smith, and the plan mentioned above was set in motion once she was moved to the medical floor. Upon being moved, she states that she feels roughly the same as she did in the emergency department. She begins to feel nauseous though and asks for a bag so she can vomit. The nursing assistant quickly brings her one, where she has an episode of non-bloody bilious vomiting. The patient’s nurse asks the hospitalist for something to help her nausea. Intravenous Zofran (ondansetron) is subsequently ordered. She is also asking for something to help with her headache, which she rates as 7/10 on the pain scale. It’s a little worse compared to the emergency department, but she had just vomited and thinks this may have aggravated it. The hospitalist ordered Toradol (ketorolac) 10mg IV x1 for this. She then asked the staff to turn off the lights in the room so she could sleep. A new set of vitals were performed:

Temperature – 99.9F, Blood pressure – 116/74, Heart Rate – 99, Respiratory Rate – 15, O2 Saturation – 97% via room air

The above vitals were reassuring and per unit guidelines the next ones were due 4 hours later. Around 4 hours and 23 minutes later, the nursing assistant walked in to do a new set of vitals. The patient was snoring loudly. The nursing assistant attempted to wake the patient up, but she continued with loud snoring respirations. She sternal rubbed her and this did not work. She quickly alerted the patient’s nurse who came to assess. Once again the patient was unresponsive to any kind of stimuli. A rapid response was called immediately. Dr. Smith came to evaluate the patient at bedside. He was unable to wake her despite painful stimuli. On physical examination, the pupils were fixed and dilated. He also noticed that she was posturing with elbow and wrist flexion. The intensivist was called immediately, and performed endotracheal intubation at bedside.

A stat CT head without IV contrast was performed. The impression from the radiologist was quite alarming: “Extensive cerebral edema with transtentorial herniation. Emergent neurosurgical consultation is advised.”

She was moved to the ICU. Neurosurgery was consulted. She was started on vancomycin, ceftriaxone, ampicillin, acyclovir, and methylprednisolone for meningitis. Unfortunately despite aggressive treatment, she did not improve. She ended up passing away surrounded by her family members and boyfriend.

The day after she was admitted, two other girls from her dormitory were also admitted for meningitis.

Her cause of death was due to bacterial meningitis secondary to neisseria meningitidis.

Now let’s imagine that this had taken place at a hospital with graduate medical education. This would probably make it to the M&M (morbidity and mortality) conference. There is also a good chance that the “perfect” resident (or residents) that have never done any wrong and of course don’t live in a glass house, that would be “appalled” by the gross incompetence of both Dr. Riviera and Dr. Smith that would have “shaken them to the core.” One of them says: “How can they miss bacterial meningitis in such a young patient?! This is horrible. I just don’t know how this can happen! I’m shaken. Absolutely shaken to the core!” They are so shaken that you can almost mistake them for former Chicago Bears quarterback Jay Cutler as they play the Monday Morning Quarterback position with absolute precision and perfect QBR.

^^^ Is this an exaggeration? Maybe. But unfortunately there is enough throwing people under the bus in residency to go around.

Now let’s rewind this case and go through the subtle clues in how this medical disaster occurred. I’ll add the “kicker” statement after each one.

• She had a subjective fever, alternating shaking chills and sweats, headache, runny nose, non-productive cough, and myalgias.

Explanation: She is presenting with “flu-like” symptoms and was already diagnosed with influenza B before she had even come to the emergency department. A headache can be associated with meningitis, but she has a history of migraines and a headache in itself is not an entirely uncommon occurrence. Myalgias is pretty broad and you would need to ask about neck pain and stiffness in particular. Once again though, the flu will cause myalgias.

Kicker: There are no red flag symptoms since everything can be explained by influenza B that was confirmed that same day at the student health center.

• The patient is a 19 year old lady with a past medical history of migraines that presents to the emergency department for worsening fever (Tmax: 102.3F), shaking chills with alternating sweats, headache, diffuse myalgias, and non-productive cough but without any dyspnea.

This seems to be aggravating her migraines, where she rates this as a “top 10 headache” but is not the worst headache of her life. She is experiencing myalgias and “stiffness” throughout her body going from her legs all the way up to her head.

Explanation: We are back to the same thought process with the first paragraph here. Once again, everything that is easily explained by the influenza B infection. Dr. Riviera, however, takes things a step further and asks for elaboration on the symptoms. He starts his HPI with mentioning her past medical history of migraines. But he doesn’t necessarily discount her symptoms and asks the important question: “Is this the worst headache of your life?” She responds with “top 10” but not the worst headache of her life. He also asks for her to elaborate on the myalgias. She says it is all over the body. Although this encompasses her neck, she is not directly telling Dr. Riviera about the neck pain being any worse than the rest of her body. I have personally had patients where without even being prompted they immediately told me about neck pain and/or stiffness right off the bat. This was not the case here.

Kicker: Dr. Riviera asked the most important question about her headaches, asking if this was the worst headache of her life. She said no. Despite it certainly being up there in the top 10, there is no indication to perform a CT of her head given her history of migraines. You can argue that Dr. Rivera could have probed further about the neck due to the myalgias, but in the clinical picture of known influenza B infection, going down the meningitis rabbit hole doesn’t quite make sense.

• She denies any known sick contacts, however, she lives in a dormitory at Hudson University.

Explanation: College dormitories are known for meningitis, however, other illnesses would spread here as well. We already see above that just about everything could be fully explained by the influenza B infection.

Kicker: Amanda was unfortunately the first one to be hospitalized with meningitis. Had this been later, she likely would have been assessed for it. Otherwise, as stated numerous times previously, everything was consistent with an influenza B infection.

• She begins to feel nauseous though and asks for a bag so she can vomit. The nursing assistant quickly brings her one, where she has an episode of non-bloody bilious vomiting. The patient’s nurse asks the hospitalist for something to help her nausea.

Explanation: This is approaching the end of the chain of events. Flu-related nausea and vomiting is common. Zofran is ordered without a second thought.

Kicker: Given the entire clinical picture, this is also easily attributed to the patient’s infection.

• She is also asking for something to help with her headache, which she rates as 7/10 on the pain scale. It’s a little worse compared to the emergency department, but she had just vomited and thinks this may have aggravated it.

Explanation: This is the final step in the chain of events leading up to tragedy. The headache is worse, but is still not the worst headache of her life and she even offers her own explanation as to why it was worse. This is not a new sudden headache.

Kicker: The patient has a history of migraines. She had a headache on admission. This is still not the worst headache of her life. Had this been a sudden onset headache with the nausea and vomiting, you can certainly argue for having a stat CT performed. But the current clinical picture significantly muddies the waters.

As you can see above, Amanda had unfortunately presented as a “perfect storm” scenario with her influenza B infection being able to account for all of the subtle hints above. Now imagine that you’re in residency and have this presentation. Young patient with a history of migraines has the flu and an associated headache that is not the worst headache of her life. Go ahead and order a CT head without IV contrast. See what your attending says, or yells, at you depending on their mood. In the case above, some people may even call out Dr. Riviera for ordering the CT angiogram of the chest since her likelihood of a pulmonary embolism was low (there is no mention of a D-Dimer being performed).

So let’s rephrase her emergency department presentation into a multiple choice question.

A 19 year old lady with a past medical history of migraines presents to the emergency department for worsening fever (Tmax: 102.3F), shaking chills with alternating sweats, headache, diffuse myalgias, and non-productive cough but without any dyspnea. The patient’s symptoms started upon waking on Monday causing her to miss class. She went to the student health center, where she was subsequently diagnosed with influenza B infection and was prescribed Tamiflu. This seems to be aggravating her migraines, where she rates this as a “top 10 headache” but is not the worst headache of her life. She is experiencing myalgias and “stiffness” throughout her body going from her legs all the way up to her head. She has been coughing frequently with a non-productive cough, which seems to be getting worse, but there is no associated dyspnea. Her vitals are remarkable for tachycardia with 108. Her labs are remarkable for hyponatremia of 132 and negative BNP of 31. A CTA pulmonary is performed and indicates groundglass opacities with a differential including atypical pneumonia or pulmonary edema. What is your next step?

A. Admit patient for observation with oseltamivir and intravenous fluid hydration. Add an antibiotic with atypical coverage to cover for potential superimposed bacterial pneumonia.

B. Consult cardiology and order echocardiogram for suspected new-onset congestive heart failure due to acute pulmonary edema.

C. Send the patient home with a prednisolone dose pack.

D. Order a stat CT head without IV contrast due to the patient’s headache.

Alright, so it looks like we probably know the correct answer. It is A. Choice B should be a gag choice since with clinical correlation this would obviously be a viral pneumonia due to confirmed influenza B. You would not suspect an otherwise largely healthy 19 year old to have new-onset congestive heart failure out of the blue. Choice C is wrong because she is clearly doing worse as evidenced by her hyponatremia suggesting poor intake and tachycardia. This certainly warrants an admission for observation at the very minimum. This is why people are told to come to the emergency department if their condition worsens! Choice D is the gag answer in this scenario! The patient has a history of migraines and this isn’t the worst headache of her life. The smoking gun is the influenza B infection.

But ultimately, choosing the gag choice of a CT head without IV contrast would have saved her life! 229 lives would also have been saved had captain Zimmerman started an emergency descent and landed at literally the nearest air strip without dumping fuel. In hindsight, you can criticize captain Zimmerman and these doctors all you want. But given the information they were presented with at the time, they made the correct choices. The physician that can do no wrong and has never made a mistake in their lives can and will be a Monday Morning Quarterback in this situation. They can be “offended” and “shaken to the core” as much as they would like. But when you look at these unfortunate events from the very beginning with as fine tooth comb, you’ll see that professionals did the best they could with the information they had.

I will leave you with one pearl though that I learned in residency and always take into account with every single patient I see. It’s also an opportunity for a joke…

What is a radiologist’s favorite plant?… A hedge!

The radiologist is the hidden hero that makes the field of medicine possible. My residency program director said that as a physician, you can never ignore a radiologist. This is very true. Therefore on a typical day, err I mean night for myself, I will mostly agree with the radiologist and treat the patient accordingly. There is one huge gray area though, and that is the thorax. For instance, with a regular x-ray a radiologist may write: “Right lower lobe infiltrate that may be atelectasis or pneumonia.” The differential diagnosis of atelectasis (collapse of alveoli and is not life threatening) versus pneumonia (infection in the lungs and this can potentially kill you if left untreated) is what is referred to as “hedging.” You can certainly prove the radiologist wrong. There have been times where I have ordered a subsequent CT of the chest and it showed that this infiltrate was indeed just atelectasis. Therefore there would not be any reason to treat a non-existent pneumonia. Another common thing is with acute exacerbation of congestive heart failure. The radiologist might write bilateral pleural effusions and diffuse infiltrate. Chances are this infiltrate is going to be pulmonary edema, and not infectious. I like to order a procalcitonin to assess this further. Most times it will come out negative and if there is no leukocytosis, the treatment would be just diuresis. Antibiotics shouldn’t be given for “funsies” since they can still have negative effects. Now let’s rewind a few sentences back. If you’re treating a patient and have atelectasis and pneumonia, you better be damn sure that the patient doesn’t have pneumonia if you aren’t going to be ordering antibiotics. If you blatantly ignore the pneumonia out of laziness or for whatever reason, then you’re staking the patient’s life on it. Literally. In a case like this, the physician can and should by all means be put on the hot seat. This is where things like peer review come into place.

But for cases like Amanda where it is a perfect storm of unfortunate events, the physicians like Dr. Riviera and Dr. Smith are vindicated. Same with captain Zimmerman on Swissair Flight 111. While these events may look horrific with 20/20 hindsight, they certainly look a whole lot different when evaluated from the beginning and knowing what limited information was available at the time.

Moral of the story. Don’t play the position of a Monday Morning Quarterback. Be nice to your emergency medicine physicians. They are dealing with a whole lot of things in the emergency department. Don’t throw your colleagues under the bus while pretending you don’t live in a glass home. Life happens (and stops) in many ways, and hindsight will always be 20/20.