The practice of medicine gives you an unparalleled opportunity to look like a goose. Of course the opposite is also true: some days bring an impressive diagnosis or even a simple procedure that saves a patient’s life and enables you to be a hero for a brief period. But what goes up must inevitably come down. I have witnessed a multitude of Doctors sink like a lead balloon in the course of everyday hospital medicine…
I recall one of the first Medical Emergency Team (MET) calls I was involved with as a freshly-graduated intern: The call was broadcast over the hospital speaker system early one afternoon stating that the MET team was required at the cafeteria. Medical staff rushed to the scene from all directions, where a senior medical Doctor had taken control in examining an elderly man who had collapsed amongst the crowds of people queuing for lunch. He thoroughly and systematically examined the patient before announcing to the multitude of onlookers that he believed the patient had suffered a serious stroke as his right pupil was dilated and not responding to light (an ominous neurological sign). He barked instructions to several other Doctors, instructing them to urgently bring a stretcher, insert an IV drip, place the patient on oxygen and sent others to organise an immediate CT scan of the brain. Junior doctors ran in all directions while the Registrar calmly examined the contents of the patient’s pockets, extracting his wallet and mobile phone. Finding the patient’s name from his licence, he immediately used the patient’s mobile phone to call his wife:
“Mrs. Brown? It’s Dr. Anderson, I’m one of the senior Doctors from the hospital. I’m afraid I’ve got some rather bad news. Your husband has taken ill. That’s right… he has collapsed in the hospital cafeteria. We are transferring him to the emergency department for urgent treatment. Do you have any children? I think you should call them and all make your way into the hospital as quickly as you can. I need the CAT scan to confirm this but after examining your husband’s eyes, I’m almost certain he has had a serious stroke.”
Mrs Brown didn’t skip a beat and in a loud voice, clearly audible to everyone watching the scene unfold she replied: “Doctor… you’re not shining the light in his glass eye are you?”
A few months later whilst on rotation in the Emergency Department, I witnessed another senior Doctor attempting to resuscitate Margaret, an elderly lady who had been brought in by ambulance extremely unwell with end-stage chronic airways disease, or emphysema, from smoking. Despite treating this lady for several hours, she had continued to deteriorate and he watched as her breathing became increasingly laboured and slow, until finally the chest stopped moving. The Doctor threw off his gloves and gown and marched into the waiting room, inviting the numerous concerned relatives to come into a private room. Once inside he quickly introduced himself and began to explain he had some bad news when there was a frantic knocking on the door.
“Sorry for interrupting Dr. Simons”, said a nurse as she popped her head around the door. “Could I see you for a minute about an urgent issue?”
“Not now” replied the Doctor firmly. “I’m just in a family meeting. Can you let one of the other Doctors know”. The nurse paused for a second before closing the door.
“Sorry about that” continued Dr. Simons, “Now where was I? Oh yes, I’m sure you all realise your mother was not a well woman and had severe lung disease. She was extremely unwell when the ambulance brought her in and unfortunately despite our best efforts she hasn’t made it through. I want you all to know we did everything we could…”
Again his train of thought was interrupted by more furious knocking on the door before another nurse entered the room.
“Dr Simons, I’m very sorry to interrupt… is it possible to have a quick word?”
“Not now!” declared the Doctor, becoming visibly annoyed. “I’m in a family meeting at the moment. Whatever it is will have to wait”.
“Are you sure I can’t just…”
“Lisa” interrupted the Doctor, “I’ll be out in 5 minutes. If it’s something urgent one of the other doctors can help you.”
The nurse shook her head slightly and left the room.
“I’m sorry about that everyone” apologised Dr. Simons. “As I was saying…”
KNOCK, KNOCK, KNOCK.
“This is ridiculous” hissed Dr. Simons under his breath. “Excuse me everyone for just one second, I do apologise” he said to the bewildered and now crying family members as he sprang out of his chair and flew to the door before opening it angrily.
“What. On earth. Is so urgent?” he yelled to a third nurse standing outside the room. “Can’t you see I’m in an important family meeting?”
“I’m terribly sorry” replied the nurse. “It’s just about Margaret in the resuscitation bay Dr. Simons. The nurse in charge thought you might like to know that she’s not dead”.
Unfortunately I was not immune from this curse. Over the course of my career there have been several occasions when I have made errors and, despite my best intentions, looked like a fool. One experience in particular stands out…
Brian Winchester was a delightful 68 year old gentleman who presented to the Emergency Department of the country hospital I was working in late one Saturday evening, complaining of high fevers, shortness of breath and a cough productive of purulent green sputum. Usually fit and well and still working as a dairy farmer, he was now wheezing and gasping for breath even walking from one room to the other at home. I was called to assess Brian as the Medical Registrar on for the weekend.
I entered the cubicle to meet an elderly man who was obviously struggling to breath.
“I used a be a footballer, young sport” he informed me as I introduced myself, “A good one too. Played for the firsts in fact. Couldn’t blow a candle out at the moment though!”
As if to emphasize the point, he soon launched into a violent hacking coughing fit and as I listened to Brian’s chest with my stethoscope I heard course crepitations throughout the right lung, suggestive of air struggling to flow through an area of lung infiltrated with infection and pus. A subsequent chest X-ray confirmed my suspicions – Brian had contracted a nasty case of pneumonia
I didn’t realise it at the time, but our paths would cross quite a few times in the years to come. From that first meeting on a wintery Saturday night, however, Brian has referred to me only as “young sport” ever since.
I admitted Brian to the High Dependency Unit (HDU) of the hospital as his oxygen levels were dangerously low, and commenced him on intravenous antibiotics, steroids and nebulised ventolin. Over the next 48 hours he remained intermittently febrile and extremely unwell, his severe shortness of breath confining him to bed. Each morning I could hear his wheezing from the end of the corridor as I entered the ward to begin my rounds. Gradually though, the antibiotics worked their magic and ever so slowly he began to improve.
“They make us tough in the country young sport” he mused good heartedly, “Not like you city folk. A touch of pneumonia would probably see you over the edge… it’ll take more than that to see me off!”
Brian was a delightful patient – someone you enjoy seeing each day. So I was surprised the following morning when there was a flurry of urgent calls from the HDU nurses asking me to review Brian immediately as he was agitated and attempting to self-discharge from hospital. I rushed up to Brian’s room to find the usually meekly mannered man standing out of bed uncontrollably shouting at the nursing staff:
“Don’t you DARE try to keep me here”, he bellowed as he ripped the intravenous cannula out of his arm, blood spurting like a fountain over the floor. “I’ve told you… I have to fly to Belgium immediately! My future depends on it. I’m meant to be buying a one-billion dollar pulp mill and if I don’t arrive on time the entire deal could be in ruined”.
He tried to continue shouting as his substantial frame was racked by bouts of violent coughing; I could see the ordeal was taking it out of Brian.
“Mr. Winchester” I yelled as I walked through the door, “What seems to be the problem? Why don’t you take a seat and let the nurses place the oxygen mask back on and we can try and sort this out.”
“I don’t have time to sort out anything young sport!” he wheezed. “I’ve told these nurses 100 times… I have to get to Brussels immediately. I’m late don’t you see and my financial future depends on this deal going ahead”.
“Why didn’t you mention this trip before Brian?” I enquired. “You’ve been here three days and this is the first I’ve heard about it”.
“Don’t give me that young sport” he retorted. “This is critical… absolutely critical. I’ve put years of work into this pulp mill deal and I must be at this meeting to sign it off. Now what do I have to do to get out of here? I’ll be lucky to make my flight if I left now”.
Red faced, Brian hunched forward as a coughing fit convulsed through his body. He wasn’t fit for a haircut let alone a long haul flight to Brussels.
“Just wait there for a few minutes while I give your wife a call” I said as I left the room.
“Don’t bring her in to this young sport” Brian screamed behind me. “This is my future… my future…”
I regrouped with the nurses in the doctors’ room, who explained that Brian had transformed from the perfect patient to this aggressive monster within the space of a few minutes.
“It must be steroid-induced psychosis” I thought to myself as I dialled Brian’s wife’s number. “Ah Hello, is that Mrs. Winchester? Oh good. It’s Dr Kirkland here from the hospital. I’m just giving you a quick call about your husband… No no, there’s nothing to worry about. Brian has become quite agitated in the last few hours about a trip to Brussels he has planned in order to buy a pulp mill. Do you know anything about that?”
“What?” declared Mrs. Winchester, her surprise obvious over the phone. “What on earth are you talking about? Brian’s a cattle farmer from Horsham. He wouldn’t know a pulp mill if it sat up and bit him!”.
“I suspected that may be the case” I informed Mrs Winchester. “I believe Brian has developed what we call steroid-induced psychosis. We do see this from time to time. The high doses of steroids we are giving to settle the inflammation in the lungs can sometimes play with people’s minds and cause them to behave in bizarre ways. Brian is pretty determined to leave hospital, but I really don’t think it is safe for him at this stage and certainly not in this frame of mind. If need be I will have to keep him here against his will until this settles.”
“You’ve got my permission to do that” replied Mrs Winchester. Brian’s hard to live with at the best of times let alone when he’s barking mad and planning to buy a pulp mill overseas. I’ve never heard anything like it!”
I returned to Brian’s room to find him just as agitated, pacing up and down yelling that he would miss the plane.
“I’ve been chatting to your wife Brian and we both agree you are just too unwell at the moment to leave hospital. Why don’t you return to bed and we’ll can reassess the situation in a few days?”
Brian turned to me with a face twisted by contempt and roared: “That… young sport…. will simply NOT do”. With that he dashed out of the room in a last and somewhat feeble attempt to abscond from hospital, lurching about 20 metres down the corridor before grasping at the nearest door handle panting and coughing uncontrollably.
“Enough of this Brian” I said firmly as two nurses escorted the still distressed man back to his bed. “You’re not leaving and that’s the end of it”.
I went outside and prescribed a sedative and an antipsychotic medication before reluctantly filling out the necessary paperwork under the Mental Health Act to ensure that Brian no longer had the right to leave hospital. Finally I contacted the Psychiatrist on duty and asked for an urgent consult.
Brian required regular sedative medication over the next 24 hours and at once stage required restraints to keep him safe, such was his intense desire to leave hospital and travel to Brussels to purchase his pulp mill. The Consultant Psychiatrist arrived to review Brian the following morning and after an extensive assessment he sought me out in the cafeteria:
“I’m not convinced it quite meets the definition of steroid-induced psychosis Ben” he mused, “but at the very least that man certainly has delusions of grandeur! It could possibly be an unusual delirium from being so unwell. Regardless, I’m happy to keep the involuntary order going for now and keep him on regular anti-psychotic medication. With a bit of luck this will settle over the next few days as the steroid dose is reduced”.
Thus began Brian’s period of enforced convalescence. Over the next five days his pneumonia gradually improved until he no longer required intensive support in the high dependency unit and could be safely managed in the regular hospital ward. I dosed him regularly with anti-psychotic medication and sedatives if he became agitated. His initial overpowering delusions of needing to travel urgently to Brussels seemed to lose their vigour and Brian slowly accepted his need for hospitalisation with better grace. On questioning he seemed almost fatalistic about the entire experience. “It’s too late now to worry, young sport” he would occasionally mutter as he gently shook his head.
Seven days after his psychotic episode Brian had improved to a point that he was safe for discharge from hospital. Still weak and needing a period of rest and recuperation at home, he no longer required oxygen and the harsh infective noises I had heard in his right lung with my stethoscope had improved drastically. While not back to the bubbly and debonair character I had initially met in the Emergency Department, he was mentally much more stable.
Later that morning, Brian’s eldest son George, who I hadn’t previously seen at the hospital, arrived on the ward to drive him home. I introduced myself and shook hands, giving a quick summary of Brian’s progress as I led George to his father’s bed.
“Nice to meet you George. Your Dad has been extremely unwell with a very nasty case of pneumonia” I explained as we walked along the hospital corridor. “Unfortunately with his past smoking history his lungs aren’t normal to begin with. It’s taken quite a while for him to turn the corner but he’s much much better now. I expect he will feel quite weak for a week or two yet, so you and your Mum need to encourage him to gradually do a little more each day. We’ll arrange for him to have a check up with his GP in a week’s time”.
“That’s fantastic news Doctor. We’re absolutely thrilled he’s improving. Mum was really worried about him last week” George replied as we entered Brian’s room. “Just between you and me though” he added, “it’s a damn shame he wasn’t able to travel with me to Brussels last week. We’re in the process of negotiating the sale of a huge pulp mill and the whole deal could be in jeopardy now. I’m surprised he didn’t mention it.”
Something inside of me fell on its side.
In that instant I experienced a vivid flashback… Brian’s desperation to leave hospital; holding him in hospital against his will; sedating him for his “delusional business trip”; plying him with antipsychotic medication. I felt absolutely sick to the stomach. I had just committed a perfectly sane man.
“Business trip… Brussels… But I spoke to your Mum”, I stammered, the enormity of the situation hitting me like a tonne of bricks. “She told me Brian was a country farmer… she had never heard of the pulp mill”.
“Oh God” George replied, “As if Mum would know anything about Dad’s business affairs.”