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“Common sense is genius dressed in its working clothes”
-Ralph Waldo Emerson

Emergency doctors are the ultimate in the practical; we do everything with nothing, and we make things work. And yet, here I sit, reading and dissecting a series of malpractice cases which are based on the lack of common sense. Thomas Payne used the term to debate political philosophy. I will not go there, but rather use the term to speak to the practice of good medicine.

Good medicine and the Krebs cycle are only tangentially related. It is impossible to care for patients without a solid scientific base. However, most of the issues I have watched proceed through the legal system over the years have had nothing to do with the posterior ventral nucleus of the thalamus or diseases related to branch chain amino acids. In all my years as chief of a department, I never got a complaint letter haranguing us for giving too few milligrams per kilogram of Ceftriaxone. It’s about human interaction. It’s about unmet expectations. It’s about life, death and transfiguration. These are quotidian situations which drive us to momentary lapses in judgment for which we pay an unacceptably high emotional price.  

Our story begins in the South in 2007. Allow yourself to envision an Absalom Faulkneresque South with warm September nights and dust on the roads. There is no need for the characters in our three-act play to have names. Our heroine – hereafter called the plaintiff’s defendant – was a 10-year-old girl who awoke with a headache. She begged her mama and was allowed to stay home from school when Tylenol only partially relieved her head pain. Throughout the day the child complained of ear pain and general malaise. In the middle of what was a warm end-of-summer night, the child awoke with more headache and a fever. Don’t ask the height of the fever, the mother didn’t know. They often don’t know and it’s not a crime.

It really makes no difference from a scientific standpoint. When the child was awoken in the morning to go to church she was worse. This was an experienced mother and she knew something wasn’t right. At the local emergency department, they took her temperature and found it to be 104.3 degrees. The child was properly examined, the doctor dutifully heard the story, did the requisite exam, and pronounced the child as having an ear infection. As an aside, isn’t one ear always redder than the other? The family was given a standard antibiotic and told to call the family doctor the next day.

Act 2 of the play is where all of the elements necessary for high drama come together. The family called the emergency department not once but twice to relate the fact that their child was doing worse. Both times they were told that the antibiotics just hadn’t worked yet. Mother feels she was “blown off” as an overanxious, undereducated parent. No real discussion of her concerns was held as if nobody cared about this child. 

In three act plays we move from establishment to expectation to crisis and finally resolution in the final scenes. The child awoke in the morning and collapsed never to awake again. She was taken back to the same emergency department where she was seen the previous day and where the parents had called for advice twice during the night. Meningitis was diagnosed and an emergency airlift took place. For two days the child languished in a PICU before finally dying.
In the theatre the curtain would fall, bows would take place, applause, more applause, perhaps a bouquet of roses for our ingenue, but this is real life. What our child got was buried. And what our hospital got was a lawsuit. Doctors, nurses, the hospital, all involved in the second play called The Courtroom. After denials and recriminations, the case boiled down to the fact, the hospital claimed its nurses did not give advice during these two one-minute phone calls. But now it’s a “He said, she said” situation. Who knows what took place. There is no evidence on the chart that these events ever happened. And the hospital does not claim that anyone told the family to return immediately. In fact, no one remembered much of the patient’s case at all.

Again, this is life, not Broadway. There are no happy endings. The hospital is found negligent. The legal concept of respondeat superior applied to the nurses. This case was decided by judgmental opinion and the hospital, unhappy with that outcome, filed a motion for JNOV – a reversal of the judgment not withstanding the verdict. So on it goes, ad infinitum ad absurdum. But the larger questions of common sense keeps coming back. What should we do when someone calls for advice? What should we do when they were worse and we have a chart and had just seen them? Is there something here that I’m missing? Just tell everybody who thinks they are worse to come back. It costs almost nothing to see one more patient. There is no way you could assess the true mental status of a febrile child over the phone.

One look and you know which kids aren’t doing well. It’s not common, but that vapid look tells all. There are no de minimis exceptions over the phone. There isn’t an app for that. We still have value in medicine by using our judgment. Common sense would say just bring them back now.

There is no way of knowing if eight or 10 hours difference would really have changed the outcome in our play. But try explaining this to 12 people picked from the voter’s rolls. Perhaps I’m the last romantic in America, but I think we can do better than this. We have always held the banner of emergency medicine as a safety net for the American healthcare system. Without quoting Emma Lazarus, but emulating her spirit, we should honestly deal with our product and make it better. From a Shakespeare perspective, this child’s death cannot be considered a true tragedy, but is certainly a sadness which can be shared by all of us.

You will notice I make no mention of monies awarded. Does it matter? Ask yourself this: How much money would you take in exchange for your dead child? There is no reductive materialism that can answer this question.

Acta est fabula. 

 

Comments   

# Q.E.D.Louise B Andrew MD JD FACEP 2012-02-22 07:03
Beautifully written allegory which reflects a senseless tragedy that probably happens every day somewhere in the world. What DID happen to common sense? How did we get to be so confident of our infallible diagnostic skills (or so ignorant of the consequences of our own fallibility, or so overloaded or undercaring) as to have allowed this result to happen? Probably we should post this little story in every ED in the country, right next to whatever phones are being utilized for "telephone triage". Or cut the cords.
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# ?JAMES W MEADE MD FACEP 2012-02-23 08:33
What does this have to do with the emergency physician? He may have been asleep when the calls came and no one asked his advice.
I used be criticized by the nurses, administration etc. since my standard answer was nearly always "If your concerned about your child bring her/him back." In almost 20 years of practice in EM I was never sued, or cited by MQA for dereliction of standard of care.
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# Terry Geurkink, MD, FACEP 2012-02-23 13:12
Humility is a priceless trait for physicians, particularly emergency medicine physicians. This, coupled with a near fanatical committment to honesty, will certainly help the EM physician to diagnose more accurately, and maintain a high vigilence for the more serious injuries and illnesses. In this case, a 10 year old with a temp of 104.3 should certainly lead the disciplined, thinking EM physician to consider a dx other than otitis media. Indeed, some pediatric experts believe that OM does not in itself produce a fever.
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# Mike D 2012-02-27 15:29
Indeed, some pediatric experts believe that OM does not in itself produce a fever???

Who????!
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# Common SenseWilliam Franklin 2012-03-07 13:12
The best advice I ever got while exploring the career in medicine was from an anesthesiologis t in Davenport, Iowa. He tole me, "Don't let 'em educate the common sense out of you". That advice has served me well. Like a lot of people in this profession, I often jump the gun and make assumptions about the intellect of someone who came in at such and such a time with "THIS???", only to step back and realize that this is NOT someone who didn't have somewhere better to be tonight, regardless of how tired I am. I can't tell you how many times I've softened up a bit by the time I entered the room just remembering that. I find a lot more legitimate pathology that way.
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# Greg Henry Author 2012-03-12 10:21
I thank everyone for their comments. There was no intention of distrbuting blame amongst the parties involved but rather to reflect on the saddness of the situation. I think Dr Franklin said it best with his "don't let them educate the common sense out of you." Just do what you would do if it was someone you loved and it's hard to go wrong.
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