The Patient Was…

The patient was a 50-year-old woman whom I first saw in a medical setting when called for an emergency consultation.  She was close to my family, so the concerns were personal as well as professional.

She had been admitted to another hospital with fever, weakness, and slight mental disorientation. X-rays showed enlargement of her heart and congestion of her lungs. On physical examination, the doctors detected a loud heart murmur. Heart murmurs are abnormal sounds, usually heard through a stethoscope, created by turbulent blood flow through the heart, and usually imply structural abnormalities within the heart itself.

When I saw her, she had fever, difficulty breathing, and looked seriously ill. The findings of a heart murmur and the abnormalities on xrays were confirmed. At the urging of her family, she was transferred to my hospital for further care.

She was diagnosed with bacterial endocarditis, an infection of the heart due to bacteria that have invaded the body and traveled through the blood stream. The bacteria usually attack one or more of the heart valves, damaging the valve structure and creating abnormal patterns of blood flow through the heart chambers. The heart’s function is severely compromised, and patients develop heart failure which refers to inadequate pumping of blood around the body. Due to heart valve damage, blood flows abnormally back into the lungs and causes severe fluid congestion.  

When the infecting bacteria were specifically identified and tested for susceptibility to antibiotics, only one antibiotic was found to be effective against them. It was penicillin, to which she was severely allergic. With the help of specialists in infectious disease and allergy and immunity, a treatment plan was instituted. Because of the severe allergic reactions the patient experienced, she required sedation and physical restraints for the antibiotic drug to be administered.

After a harrowing period of intravenous antibiotic therapy, her infection was cured. But she had extensive damage to her mitral heart valve, which controls blood flow between the left upper heart chamber (left atrium) and left lower heart chamber (left ventricle). She consequently was in heart failure with severe congestion of her lungs. The only solution was open heart surgery with replacement of her damaged mitral valve with an artificial mechanical valve.

Valve replacement surgery carries significant risks under the best of circumstances and performing it in the setting of recent severe infection adds to the rate of complications. Her surgery, fortunately, went well and the new mechanical valve functioned normally.

One of the short-term and long-term risks of having an artificial mechanical valve, as opposed to one made of biologic tissue, is the formation of blood clots on the non-biologic valve structure. To prevent this, anticoagulant drugs (so- called “blood thinners”) are administered. These drugs interfere with the body’s normal blood clotting systems; the risk, of course, is abnormal bleeding since the normal defenses against blood loss are impaired.

At the time of this encounter, the only available anticoagulant medications that could be taken by mouth were derivatives of a chemical compound called coumarin. Safe use of these coumarin derivatives, which are still widely used, requires periodic measurement of the time it takes for the body to form a clot, if needed. Since this time-to-clot may vary depending on a number of factors, blood tests are suggested regularly. Newer anticoagulant drugs, now available for use in some circumstances, do not require periodic blood testing.

Following discharge from the hospital, cured of her infection and with a well-functioning artificial heart valve, the patient returned to her normal life. She was seen at intervals by her regular physician and was taking all of her prescribed medications.

Fast-forward to a year or so later. A Sunday morning. An emergency telephone call from the patient’s family.

The patient had awakened from sleep suddenly with a severe headache. Although she had a history of migraines, this was unlike and more severe than anything she had experienced previously. She seemed somewhat somnolent, as well, and soon became difficult to arouse at all. On my advice, an ambulance was immediately ordered and by the time they reached the Emergency Department (ED) of the hospital I was there to meet them.

The patient was essentially comatose when first seen. A tentative diagnosis of intracerebral hemorrhage (bleeding into the brain) was quickly confirmed on an emergency x-ray scan. In anticipation of confirmation of the diagnosis, I had already called for a neurosurgery consultation, and the neurology resident physician on call was in the ED. He quickly assessed her, confirmed what we already knew, took me aside, and said bluntly, “If she doesn’t have surgery soon she will die.”

There was no argument from me; I knew he was right. If we were to save her, an operation to drain some of the blood from her brain and relieve the increasing pressure inside her head was necessary. So, even before I spoke to the patient’s family, I phoned for the Attending Neurosurgeon on call for the weekend. As luck would have it, the surgeon on call was the Chief of the Neurosurgery Department at the hospital and medical school. He was a good colleague, an excellent surgeon, to whom I had referred other patients, always with good results.

I spoke to the family and explained the necessity of an operation without delay. They were not prepared for that news, expecting that some sort of medical treatment could manage the problem. To ease their concern, I told them that the Chief of Neurosurgery would do the operation; that seemed to allay their fears enough for them to give consent to proceed.

The neurosurgery resident physician had already alerted the OR (operating Room), and preparations were underway. I called the Attending Neurosurgeon to find out how long it would be until he arrived and was told by the operator that they had not been able to reach him despite several calls. The neurosurgery resident had also tried but was unable to reach his Chief.

The resident physician and I huddled briefly. He said, “I can’t reach the Chief Surgeon. I don’t know what to tell you. If we don’t operate now, the patient will die.”

“What are the options?” I asked.

“There are none,” he said. “I can do the surgery, but will the family consent? You know, I’m still just a resident.”

It’s important to understand that resident physicians are still in their training. They are full-fledged doctors but not yet full-fledged specialists. Most specialties require several years of training before their trainees can be credentialed as board-certified specialists. The neurosurgery specialty training program was seven years in duration, and the resident with me had already completed five years.

I had to make a decision quickly. I had told them the Chief surgeon was going to do the operation, and I was convinced that they would withhold permission to proceed until the Chief surgeon was there. And I was absolutely certain that the patient would die if we didn’t proceed at once.

“Go ahead,” I told the resident physician. “Operate on her. I’ll deal with the family later. We have a signed consent for surgery, and it doesn’t specify who will do it.”

The patient was taken to the OR and the operation proceeded. The blood was drained from her brain, the pressure was relieved, and the patient tolerated  the procedure well. Just as the resident surgeon was finishing up, the Chief Neurosurgeon arrived outside the OR. He apologized to me profusely, explaining that he had gone out to buy theater tickets, and had left his paging beeper behind. When he got home and saw the missed messages, he rushed to the hospital.

“What can I do,” he asked. “How can I fix this?”

“What I want you to do,” I said, “is to scrub up for surgery, go into the OR, get blood on your gown and gloves as if you just did the operation;  then come out, introduce yourself to the family, and tell them it all went well.”

“I can ‘t do that,” he said, in anguish. “I didn’t do the operation.”

“You don’t say that. You just say the operation went well, which it did. Of course, they will assume you did it and their gratitude, reassurance, and relief at the outcome will be immeasurable. You will be doing them and the patient a real service.”

He did as requested. Everybody was relieved. The patient made an uneventful recovery. Some weeks later, her husband called to tell me that the surgeon had never sent a bill. The family felt guilty that they somehow weren’t fulfilling their role in the whole affair. Paying for the surgeon’s services made them feel an important part of the patient’s recovery.

I spoke to my colleague and explained that he had to send the family a bill, and a large one. He refused, on ethical grounds, because he hadn‘t done anything. I expected nothing less, but told him to send a bill, and to put the  money into one of the resident training programs. Reluctantly, he did so, and the whole affair ended satisfactorily.

It was the only time in all my years of practice that I encouraged an uncredentialed stand-in specialist and had a patient’s unknowing family pay for it.