It was my first night at a new emergency department, so I was just getting used to the system and the people. Everything seemed to be going along smoothly. The staff was great and very welcoming. The patients were pleasant and generally not so sick as to create a stressful first shift. The PA, who functioned completely independent of me, seemed competent and knowledgeable. There was just one thing in my orientation shift that caused me a little concern.

“I assume the PAs run this part of the ED,” I said as the doc who was orienting me pointed to the fast track rooms.

“No,” he said bluntly. “The patients are all mixed up. You’ll see fast track just like the PAs.” It wasn’t that I was ‘too good’ to see fast track patients. Rather, I was concerned about the more complicated patients being seen by the PAs.

“That’s OK,” I thought. “I’ll just have to keep visibility on all the patients in the ED, whether I see them or not.” I was in the habit of doing that anyway, but I knew that I’d have to be careful not to insult the abilities of the PAs. I’d need their cooperation when things got busy. The last thing I needed was to paralyze them with the impression that I didn’t trust them.

Despite my best intentions, half way through my first shift the PA sat down and presented me with a stack of charts, mostly for patients of whom I was unaware. It was clear by the way she simply slid the stack of charts over to me – physician signature box on the back page facing up – that she expected me to simply sign them and get on with things.

“I can read through each of the charts or you can summarize each case,” I said. “Either way, I need to become thoroughly comfortable with the care on each chart before I sign it. I don’t want to insult your intelligence, but I need to know what you know before I’ll feel comfortable blindly signing your charts.”

Rather than appearing insulted or challenged, the PA seemed genuinely pleased to be given the opportunity to present her work. I knew that it could have been much different with a different PA, so I took her response with a lot of gratitude, hopeful for a good working relationship.

The cases were pretty simple and we got through them without many questions. But before we could get back to work, a young woman with a lab coat that read ‘Laboratory’ over the pocket walked up to address the PA. “I have a critical lab for you,” she said, completely ignoring me. “And I couldn’t give you a diff because all the white cells are so immature that I can’t really tell what they are.”

This case was completely new to me and had not been presented by the PA since the patient was still in the ED. “What’s the critical lab?” I interrupted.

“The platelets are only 16,000.”

“What IS the white count?” I asked with a growing alarm.

“18,000.”

I took a deep breath of concern. “Do you want to tell me about this case?” I said to the PA, trying not to sound irritated.

“Well,” she said, turning to me with an expression I couldn’t read as confusion, irritation, or mild embarrassment. “This is a 30-year-old male who presents with a high fever and a sore throat . . . which is positive for strep.”

There was a slight pause that briefly led me to think that she was going to stop there. “His past medical history is that he had leukemia five years ago, but went into remission after several rounds of chemotherapy.”

After a long silence, I launched into a long string of questions about the history and physical exam. She knew some of the answers, showing that she had simply shortened the presentation to its essence. But other questions were met with a simple, yet eager, “I don’t know. I’ll go find out.”

“He did complain that his neck was a little stiff and painful. And he has a headache,” she added as if throwing in a last bit of detail as we headed toward his room. I quickened my pace.

Upon pulling back the curtains to enter the room I was relieved to find a healthy-appearing young man. However, with the room only steps from the spot where I had been quizzing the PA, it was clear that the patient and his young wife had both overheard our conversation and were preparing for the worst news. The patient was muscular and strongly built, but his face was clouded by a stiff expression of fear and impending doom. His wife was weeping and talking on the phone to a relative.  

I breathed a deep sigh of relief as I went through my own history and physical. His fever was already under control. His neck was not stiff and the headache was minor. I had envisioned entering the room of a patient in septic shock or a hemorrhagic CVA. It was clear that this patient was in a lot more trouble than just a sore throat, but at least he wasn’t going to crash on my shift.

Somewhat relieved that a disaster was not imminent, I was tempted to step back and let the PA proceed with the treatment and disposition. It turned out to be a great teaching case, and the PA was an eager learner. However, it was clear that the patient and his wife needed the emotional reassurance of my personal involvement. No one could tell them what to expect from this, but they needed to know that we were doing everything possible to have the very best outcome. When it was time to talk to the patient’s oncologist, I first thought that it would be a good opportunity for the PA to interact directly with the specialist. But after some consideration I realized that he, too, needed to know that our institution (the patient required transfer) was giving his patient our best.

In the end, the patient was treated in an appropriate and timely fashion. A transfer was arranged and received by a grateful treating physician. And the patient, though seriously ill and frightened, was comforted and reassured by the knowledge that he had received the best medical care possible.

When I finished the shift, I knew the patient was on the right path, yet I couldn’t shake the feeling that things could have gone very, very differently that night.

*************

Throughout my career playing basketball in high school and then college, it was always a big deal to be on the ‘first team’. The ‘starting five’ were the best on the team and got introduced to the crowd at the start of the game. In a close game, the bench never stepped onto the floor. One time, however, my coach decided to start the second team. He meant well. The opponents were weak and the first team needed a rest. I’m sure he thought he could put us in if they got in trouble. But our opponents, surprised by their ability to overpower our second team, began to play ‘over their heads’. The starters, possibly overconfident by the bravado of our coach, had become disinterested in the game until we were far behind. When the coach finally put the first team in, we were sluggish and had difficulty regaining the momentum. We were cold and surprised that this “easy” team was really rolling. We fought back before a cheering crowd with a brilliant comeback, but lost a stunning upset in the final seconds. As I watched our fans sit in stunned silence while our opponents were celebrating wildly, I turned to confront our coach. Our expressions reflected the same thought. ‘This should never have happened.’ It was a lesson that has stuck with me for a lifetime.

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