Sometimes It's Best to Remain Quiet - Administration and Leadership - @

Sometimes It's Best to Remain Quiet

don't speak up if you can't follow up


Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P | | Tuesday, June 12, 2007

Albert Einstein once wrote, "It has become appallingly obvious that our technology has exceeded our humanity." I should know that. In Samuel Shem's book, The House of God, the fat man reminds us that medicine is far from perfect when he said, "Delivery of medical care is to do as much nothing as possible." Now, why can't I remember that?

One night when I was attending in the ED, one of the ICU nurses came over and said, "Dr. Clark is getting ready to intubate a patient. He wanted me to ask you to come and stand by." This was not an uncommon request. Rick Clark, MD, was the consummate internist. He never got rushed and was always very careful with his procedures. He was so well respected that he was the personal physician of virtually every doctor on staff-including me. Every time he did an RSI in the ICU, he called the ED physician over just in case he had some problems which he never did.

So I walked to the ICU and found Rick wearing a surgical gown and mask, ready to intubate the poor soul on the bed. The patient was obviously unresponsive. I said, "What do you got here, Rick?" He replied, "I'm really not sure. He is a train wreck for sure."

The patient was elderly, edematous and appeared ready for a celestial discharge. I nosed around the bed and noticed that the catheter drainage bag contained almost 3 L of greenish-orange, almost phosphorescent urine. I got closer and realized that it contained flecks of some flocculent material. I swear it was like something from outer space. I think I actually saw something inside the bag move.

I said, "Rick, what's with this urine?" He replied, "Beats me. I've never seen anything like it."

"What does the urinalysis show?" I asked. Rick looked up from securing the ET tube and said, "It's the strangest thing " and was interrupted by the nurse. I picked up the chart. Virtually every test on the chemistry panel was abnormal. The complete blood count was abnormal. Half of the urinalysis report was abnormal. Evidently, the lab had never seen urine quite like that before either.

Trying to help my unfortunate colleague, I decided to help him problem solve. I said, "Rick, I vaguely remember something from medical school where a certain metabolic problem-or bacterial infection-would cause the urine to phosphoresce." Rick said, "I don't remember anything like that. The urine really doesn't phosphoresce; it just looks funky."

Convinced I was right, I tried to recall the biochemistry that could make urine become phosphorescent. I remembered something about electrons being kicked up to the next orbital shell-but that was about it. Then it struck me: I had a hypothesis, and I had to test it.

I went to the ED and retrieved the Wood's light (an ultraviolet light used for special examinations). I returned to the ICU room and began to draw a large crowd for my experiment. I pulled the curtains, turned down the lights and turned on the Wood's light. Aha! Just as I thought, the patient's urine began to glow a most brilliant phosphorescent orange. I was so proud.

Rick asked, "So, Bryan, what does that mean?" I gave him a puzzled look and said, "I don't know. You're the internist. You're supposed to know this stuff." He said, "Well maybe so, but in 15 years of medical practice, I have never seen anybody examine a urine bag with a Wood's light." I went back to the ED.

The next night, I went to the ICU to check on the patient. Rick was at the desk preparing a transfer form. I said, "Well, did you decide what's going on with our friend?" He said, "Heck, I know less than I did yesterday. Every test I order is abnormal. I've been on the phone all day with the nephrologists at the medical school, and they're intrigued by your phosphorescent urine. We're transferring him to Parkland tonight."

About a week later, I saw Rick in the doctor's lounge. He said, "Hey, you remember the train wreck with the phosphorescent urine?" I nodded, and he said, "Well, he's the case of the month at the medical school. He'll be the topic of Grand Rounds tomorrow."

I said, "That's neat. Did they ever find out what was wrong with him? Rick said, "I'm not sure. I haven't heard what they found, but the patient's sister told me he was much better."

"Weird case," I said. Rick replied, "You got that right."

About a month, later I got a copy of the formal consultation letter from the Division of Nephrology from the medical school. It was your standard "Thank you for referring this most interesting case" letter. I looked down to where it said "Final Diagnosis," and it stated "Undetermined." I thought, "That's strange."

At the bottom of the letter, they typically place their recommendations for continued care. There was but one sentence, and it read, "Hide the Wood's light from Dr. Bledsoe."

I learned a good lesson. Never order a test or perform a procedure unless you're willing to act on the results. Also, it was good to be reminded that even the best minds in medicine resort to scratching their backsides and saying, "I don't know, either." I've never touched the Wood's light since that unfortunate night-and the world is better for me not having done so.

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Related Topics: Administration and Leadership, Leadership and Professionalism, Training, The House of God, Samuel Shem, Bryan Bledsoe

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Bryan Bledsoe, DO, FACEP, FAAEM, EMT-PDr. Bledsoe is an emergency physician and Professor of Emergency Medicine and Director of the EMS fellowship at the University of Nevada School of Medicine in Las Vegas. He is the author of numerous EMS textbooks and articles.


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