No: this is my patient. Part 1: The gathering storm
No. This is my patient
Part I The gathering storm
Campbelton Summer 1975:
I was caught totally off guard. It was about 09:00. I was summoned from the outpatient department where I was seeing patients, to the Board Room of the Soldier’s Memorial Hospitial in Campbelton N.B. Mrs. Hunter, the hospital CEO was sitting at the head of the table with about a half dozen men sitting along both sides of the table, a single sheet of paper in front of them. They were all looking at me as I came into the room. Sitting beside Mrs. Hunter was a man introduced to me as the hospital lawyer. Sitting on the other side of her was Dr. Simoo, wearing a smart, starched white shirt, an attractive stylish tie and a crisp white lab coat. Along both sides of the table were well dressed late middle-aged men. I was 27, and more than a little intimidated. At the other end of the table, was an empty seat. When bid to sit there, I declined.
There were few preliminaries. Everyone knew why they—and I--were there. Mrs. Hunter briefly reviewed the medical management of the patient, reading from a letter of complaint the Board received from Dr. Simoo. I had no comment regarding the outline of the case as stated in the letter. Glancing briefly at Dr. Simoo, Mrs. Hunter placed both palms on the glass over the highly polished mahogany table, looked at me and said: “Can you tell us why we should not withdraw your hospital privileges effective immediately?” A withdrawal of privileges for cause would effectively end my career as a doctor. I was totally blindsided by this. There was no hint of this when I was told I should meet with Mrs. Hunter.
In the afternoon of the previous day, a Monday, I had been in my office where I ran a family practice. The waiting room was full, and as often happens on a Monday, there were a number of walk-ins, and a number of sick people who had waited over the week-end, getting worse and worse, before they came to my office. Sarah had been booking people at 15 minute intervals. Many appointments took me way longer as I had to make arrangements for tests, phone pharmacies for prescriptions, and even arrange urgent hospital admissions. As usual I worked through lunch, but I was getting further and further behind. Some people began to walk out. Between each patient Sarah would come in furious “do you know how long you just spent with Mrs. So and So?” and more I won’t print.
Sarah knocked on the door while I was with a patient: “Joe, it’s the hospital, they need to speak to you right away”. I picked up the phone. It was Roberta, the nurse in the outpatient department.
“Dr. Fisher, there is a patient here who had an accident. His family says they want you to see him.”
“Can I see him after my office?”
“No. He has had a serious head injury and you need to see him right away.”
“Isn’t there anyone else who can see him now?”
“Dr. Salgado (the general surgeon) was walking by and we asked him to see him. The family says you are the family doctor and they want you to see him.”
I gave Sarah his name and asked her to pull the chart. Sure enough, he had seen me for an “annual complete physical”.
Sarah came into my office, closed the door and said through clenched teeth “No. You are not leaving the office. We have 16 people out there. You are not leaving.”
“I have to go.” I said. I stood up and walked out of my office and into the thronging waiting room. I cringed as I thought of a livid Sarah dealing with outraged patients who have appointments and had been waiting for hours. I looked at the mothers, the children, the old ladies, even the babies. All became quiet and turned to look at me. “I am sorry, I have an emergency in the hospital. I have to leave. Sarah will rebook..” or something to that effect as I walked through the waiting room and out the front door.
When I arrived at the hospital I walked through the nursing station and directly to the acute care room. On a narrow stretcher was a rather large man, as broad as the stretcher with legs hanging over the end. He was still wearing his clothes: polyester work pants, a T-shirt, dirty socks. There were some grass stains and caked mud on one knee and some dirt on the T-shirt like what is left from brushed off dried mud. He was agitated, turning continuously this way and that, flailing his arms, trying to sit up then falling back down onto the stretcher. The side rails were up and he was intermittently grabbing them to hoist himself up or turn to the other side. Roberta, Dr. Salgado and two orderlies trying to keep him from going off the rails (so to speak).
“What happened?”
“This is Rolland Dube. The ambulance found him in the ditch on Aaron Street. He fell off his bike and hit his head. He has a concussion.” Said Roberta “We are trying to calm him down and admit him to the ICU.”
“Thanks for coming down Joe.” Said Dr. Salgado“ I was doing my rounds upstairs when they called me down. I don’t know anything about him. Doesn’t look like a surgical case. Admit him to the ICU. Gotta go. See you later.”
Mr. Dube did not respond appropriately to questions or commands. He responded to his name but for a split second only. He was moving both sides symmetrically. I examined his arms and legs and there were no signs of broken bones. I didn’t see any signs of trauma to his head or face. I felt along his skull and neck, pressing firmly here and there. I lifted his shirt and pressed on his ribs and pelvis. No obvious signs of pain or trauma.
We couldn’t get any X-rays in his current state. The ambulance drivers had tried putting on a neck collar but Mr. Dube kept grabbing it and pulling it off. I resisted his movements and found his strength full and equal bilaterally. I took the ophthalmoscope and tried to look into his eyes. This was not easy; his eyes were rolling and he was blinking and spitting. As I lowered my face towards his to look into his eyes with the ophthalmoscope, his spitting motion sprayed droplets on my face. An orderly tried to hold his head steady. I was trying to look at the optic disc to determine if it was swollen as a sign of increased intracranial pressure. I looked into one eye while he rolled it around to give me a fleeting tour of his retina. When I looked into his other eye something looking like a little hemorrhage flitted by. I tried to look for it again. I propped myself on my elbow and pulled up his eyelid and kept looking into his rolling eye to see if I can catch a second glimpse. The light was causing him to close his eyelids. I inverted his eyelid on that eye so he could not close it and tried looking again. Finally I gave up; reverted his eyelid and wiped the spit off my face.
So, what have we here? A retinal hemorrhage is a sign of a subarachnoid bleed. A subarachnoid bleed results from a ruptured brain aneurism or other vascular malformation. If so, this requires a totally different type of management than a concussion. In this case I would call in the air ambulance run by the Canadian Air Force, that would fly him immediately to Moncton, the nearest neurosurgery service.
He could also very well have a subdural hematoma (a clot inside the skull pressing down on the brain). In that case there is no time to send him to Moncton, Dr. Salgado would drill a hole in the skull and release the pressure of the blood clot. To diagnose the hematoma would require carotid angiogram (in those days) which we couldn’t do in his present state of agitation. Sedating him is very dangerous of he has brain swelling or a hematoma (blood clot). What a dilemma!
Well, I had some hint of a subarachnoid bleed. I needed to confirm or rule out that diagnosis. To confirm the subarachnoid bleed I would need to do a lumbar puncture. This posed a dilemma. If he instead actually had a subdural hematoma (which I couldn’t rule out), then doing a LP may cause his brain to herniate through the opening to the spinal canal called “coning”. This would lead to death in minutes unless the pressure was relieved—by burrowing a hole in the skull. Sticky wicket indeed.
I phoned Dr. Salgado at home and asked him to come back in and be prepared to drill a burr hole in this man’s skull as I was going to do a LP and we may need an emergency hole in the skull.
We turned Mr. Dube on his side, scrunched up his knees and bent his head forward (the orderlies were very strong). This positioned him for the lumbar puncture (LP) and limited his range of squirming. I cleaned the skin on his back with iodine, put on sterile gloves and prepared to stick the LP needle into his back. As I was feeling for my landmarks and was about to stick the needle in, Roberta placed a piece of paper about 6 inches from my nose. It was a “consult note” from Dr. Simoo, a specialist in internal medicine. It said bla bla bla…and in capital letters at the bottom it said “LP IS CONTRA-INDICATED AND MAY BE LETHAL”
