Reflection on a Sunday: Fighting for Your Life

*This story is based upon an amalgamation of true events. This is not the patient's real name and the details of this story have been changed significantly. But the point is the same. . . . .

"I'm a lover, not a fighter."

~ Michael Jackson (from "The Girl is Mine" with Paul McCartney)

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When I was a resident, I loved a good fight in the hospital. At the start of a night on call, my classmates would say, "Oohhh, Kim's on call? She's a wall!"

"A wall." A term of endearment used to describe a no-nonsense person in the hospital. The person who won't back down. The one who won't bend when someone tries to call an inappropriate admission or who shuts down any turf war with another service in sixty seconds flat. I took pride in being a wall back then. And Lord knows, I loved a good fight.

As I grew older and became an attending, I stopped enjoying the idea of random confrontations. It wasn't so fun to halt my Emergency Department colleagues or to lose my patience with consultants. From watching my mentors, I learned that mature and professional physicians are collaborative, not obstructive. Nowadays, even though I still have the fight in me, I'm more of a lover than a fighter.

"So what did they say when you called?"

That's what I asked Max, an intern on one of my ward teams, on a busy morning after our rounds. We had just seen one of our patients together that morning who, very unexpectedly, had what looked a worrisome infection in his right leg. Totally out of the blue. A complete detour from his reason for hospitalization in the first place. But regardless of that, this was not normal. The severe pain and dusky color of the skin was concerning for something called necrotizing fasciitis--a swiftly moving bacterial infection that gnaws at the deep tissues like Pac-man.

Necrotizing fasciitis is one of the first things you learn about on your surgery rotation as a medical student for two reasons:

1. It can kill your patient if you miss it.
2. It can kill your patient even if you don't miss it.

"Nec Fash." A phrase that should you dare to even think of uttering in the hospital must be and I do mean MUST be followed by a super-urgent Surgery consult. Nec Fash? Oh yeah. It's a sho' nuff surgical emergency.

So we all agreed that our patient had what very much appeared to be just that. Everything happened in the proper order, too. Intern saw patient. Intern nearly crapped his pants and then called senior resident and attending. Senior resident and attending (me) saw patient and agreed with crap-inducing diagnosis. Intern called surgery service.

"Haven't heard back yet, but they may be in the O.R.," Max replied. "I'm waiting to hear back."

"Let me help," I said while picking up the phone at the nurses' station. "What's the pager number?"

So even though I wasn't so big on fighting anymore, I definitely knew how to flex my faculty muscle. I subsequently paged the Surgery intern, along with his chief resident--to my cell phone--just to emphasize the urgency. A few moments later our consult was in, and the ball was rolling. The patient had been started on broad spectrum antibiotics and fluids, and had also been moved to the ICU stepdown unit. After extensively speaking to the awesome nurse caring for him, we finally continued our day's work.

30 minutes later I received a call on my cell phone. It was the Surgery intern.

"Thanks for the consult, Dr. Manning. We saw Mr. Dupree, and this doesn't look like necrotizing fasciitis. It may be a cellulitis, and we agree with your antibiotic choice. Let's wait for the imaging studies to come back, but right now, your plan is fine with us," he spoke with authority. Pretty impressive for someone who just finished medical school.

"Oh, thanks for calling so promptly. Did your chief resident also get a chance to assess Mr. Dupree?"

"Yes, ma'am," he answered in a respectful tone, "We saw him together. Right now, other than the x-rays, there's nothing different you all should be doing."

I held the phone quietly and squinted my eyes. This was a curveball. What did he mean "this doesn't look like necrotizing fasciitis?" I ran through Mr. Dupree's findings in my head. Fever. Elevated white blood cell count. Severe leg pain out of proportion with clinical findings. What else could this be other than necrotizing fasciitis?

"Hmmm. . ." I said carefully, "What else do y'all think this could be? I mean, his white cells are up, he has a fever, and that leg. . . it's just. . . I mean. . . . worrisome."

The surgeon chuckled. I wasn't too sure how I felt about it either. Much more confident than my voice during internship, and so final. I've been a doctor since 1996, and I'm still not sure enough about any diagnosis to chuckle like that in the eye of a medical storm. He went on. "Could be cellulitis, like I said. . .or erysipilas. . . or. . .listen, we just don't think it's nec fash. But we will definitely be following him with you, and will look at the films when they are done."

"Uuhhh, okay," I conceded. The chief had seen the patient. They agreed that this wasn't what we thought. So there. And that was that. I had nineteen other sick inpatients who also needed me. Though my gut said, fight. . . . I backed off.

Later that morning, an x-ray confirmed our deepest fear. Free air in the soft tissues of the thigh. Consistent with necrotizing fasciitis.

Air in the soft tissues (not our patient, courtesy of click here.)

That afternoon, the patient was whisked to the O.R. where his right thigh was filleted open to reveal sheets and sheets of frank pus. The muscle was destroyed, and despite efforts to save it, the leg had to be amputated just below the hip. I knew deep down that even under the best circumstances, that this can be the outcome in necrotizing fasciitis. But it still sucked.

Later that night, he developed complications in the post-operative period. More fever. Difficulty in breathing. Altered mentation. Further workup confirmed another unfortunate diagnosis: a peri-operative myocardial infarction (heart attack.) His sixty-something year-old heart just couldn't take the stress of this near-death experience. Cardiology did all they could to assist.

Three days later, my patient died.

Back in the day, my first instinct would have been to get mad at the surgery team. I would have thought, "You cocky neophyte! I told you this was necrotizing fasciitis! I told you!" I am embarrassed to say for a few seconds, I did think that. In fact, if I'd seen that surgery intern the moment I'd heard the news of Mr. Dupree's diagnosis, I would have been deeply tempted to push his chest with two flattened palms saying,

"BOO-YOWWW! IN YO' FACE!"

But was this really the issue? Was it? What good was it to be right just for the sake of being right when someone lost their life?

Thanks to this blog, I've become a habitual reflector. I reflect on everything that happens to me in the hospital, and then I reflect on what I reflected on. It's made me see everything differently. Everything.

Fortunately, my "boo-yow" thoughts were fleeting. After allowing the reality of what happened to set in, I went to my office, put my head down on my desk, and cried. I cried in honor of Mr. Dupree, the man who was counting on me to fight for him.

Mr. Dupree was three years younger than my father. He had a son who I'd met on rounds, and who was even his namesake. An unusual first name coupled with the name "Dupree"--which wasn't exactly a "Smith" or a "Jones" kind of name. That son had a son that I met, too--a little son the same age as my Zachary--who also carried the same moniker. The first generation of that family tree was gone.

Here's the thing: Necrotizing fasciitis is a bad diagnosis--that's a fact. But here's another fact: I could have done more. This time, I should have fought.

As I said before, I've never been accused of being shy when it comes to speaking up for myself or anyone else. But this time, I allowed a first year surgical resident and his fifth year chief resident to tell me something that I knew deep-down in my soul to be untrue. . .and inaccurate. It wasn't that my young surgical colleagues were irresponsible either. They just missed the diagnosis. Period.

The hardest pill for me to swallow is that I felt strongly about this diagnosis. The minute that surgery intern called me and said, "This ain't nec fash," I should have hung up, and called his attending. No question. At Grady, our surgical attendings are amazingly responsive. Call these guys with a problem and they are all over it. I know that if I had called the attending and even said, "I'm not sure about what your intern said or with your chief's assessment" any one of a number of senior surgeons would have been at my patient's bedside before I could even put down the receiver.

I didn't though. I left it. Knowing that, even when added together, the two doctors who talked me out of what I knew to be so had not even half of the number of years of patient care experience as me. Six added together, to be exact. Against my nearly fifteen.

Before this, I had seen necrotizing fasciitis four times in my career. Three of the patients were diagnosed promptly and taken to surgery. All three of those patients died despite these efforts. The other case I saw ended in two amputations and severe disability.

So I could just chalk it up as "it's a crappy diagnosis." I could. And maybe if I weren't a habitual reflector, that's exactly what I would do. But I can't.

I should have fought more for Mr. Dupree. I should have used all of that gab that often doesn't get put to use for life-saving purposes to do just that. Fight. With urgency. With zeal. With the authority of the most senior person who had assessed this patient.

I will never know what would have happened if Mr. Dupree had been taken to the O.R. sooner. Maybe he would have died anyway, like those other three patients. Or perhaps he would have been left with some horrible disability. But maybe not.

For Mr. Dupree Sr., Mr. Dupree Jr., and Mr. Dupree the third, I will never not fight again. From now on? I'm a lover and a fighter.