Second Guess

Some days I go to work and I come home patting myself on the back for making a good call. Other days, I come home troubled with a nagging question - could I have saved that patient, or was it inevitable? Yet I think the real answer is that I do the best that I can do, with the skills that I have acquired and the knowledge I have gained from years of study - and then the rest is up to Fate, or God, or divinity, or whatever it is that one chooses to believe in. And that "rest" isn't within my control. But still I wonder - did I make the right call, was there more I could have done? Inevitably, after a while - a few hours, a day, a week - this questioning fades. Until the next patient comes along.

"Something's wrong," his wife said to me. "Something's wrong and I don't know what it is."

He had seen five doctors in the last month for the same problem - the same complaint of a nagging off-and-on pain in his chest, that no one could explain. All his cardiac tests had been negative - bloodwork, troponins, EKGs, even a cardiac catheterisation and a cardiac echogram, a stress test - none of it had yielded any sort of explanaton for his pain.

Now he was here, in the ER on my shift.

Patients like these are easy to write off. They've been seen by so many doctors that the next on to come along already feels faced with an impossible task. How would I, a young emergency medicine physician in practice for just three years, figure out what older, more experienced cardiologists could not?

I dutifully took the patient's history, did his physical, ordered his bloodwork, a chest Xray, an EKG - and, as I had expected, all of these yielded nothing.

When I gave this "good" news to his wife, she was beside herself. "Something is wrong," she said, in tears. "I just know it is, and what will I do without him?"

What were we missing? Or were we really missing anything? I felt troubled, and also frustrated.

There are a myriad reasons for chest pain. The ones that can kill you are the ones we always worry about - heart attacks, pulmonary embolisms, pericarditis. Others are not as deadly - pneumonias, muscle strains, anxiety, reflux. They say that the history is what guides the majority of your diagnosis, and this man's history was fairly benign except for cardiac disease - and yet he had had every cardiac investigation possible, and they had all been negative.

I ran it by a more senior physician, my direct supervisor L.

"The only thing I can think of, that he hasn't had done," he said, "is a CT pulmonary angiogram."

I was puzzled by this. "But his chest pain has been ongoing for four months, he isn't short of breath, he has no risk factors for a pulmonary embolus, and his Xray is clear."

"I know," my supervisor said, "I'm just saying it's the only test he hasn't had done. I can't think of anything else."

We discussed it further, and in the end elected to re-consult him to cardiology, if only because one of his cardiac enzymes was minimally elevated.

My shift ended, and I thought nothing more of it.





The next evening, I ran into a colleague.

"Did you hear?" she said. "That man you and L consulted to cardiology yesterday?"

"What happened?" I asked, but already I knew it wasn't good. It never is.

"He died," she said. "Cardiology sent him home yesterday and he came back again this morning and he arrested in the ER."

I was shocked. He had seemed fine the day before, and his investigations had been normal - we had sent him to the cardiologist based solely on a troubling feeling that there was something here we were missing. Surely he couldn't be dead.

But he was. He had been sent home, and the next morning, he had felt worse. His wife had brought him back to the ER, and he had been awaiting a repeat consultation with the cardiologist when he had suddenly arrested. They had worked on him for a long time - they always do on the young ones, and he was barely 50 - but to no avail.

They think now that he died of a massive pulmonary embolus. And it leaves questions in my mind. Would we have discovered it if I hadn't pointed out to L all the reasons not to do the CT, the only test that would have picked it up? Could this have ended differently? My colleagues, the ones of us who saw this man over the last month, they've asked themselves these questions too. And I think that all of us feel sorry. But still, we know - we have to believe - that we did all we could.

Yet in my head I can hear his wife still:

"Something is wrong, doctor - and if you can't find it, what will I do when he is gone?"

And I feel like saying, I'm sorry. I'm sorry that I couldn't find it. I'm sorry that despite all my skills and my knowledge, all the years of training and the years I've dedicated my life to medicine, that I couldn't find it.

Sometimes I think patients will never know how sorry I am that I am not God. That I don't control the "rest". But I know that this will fade. And I'll pick up my stethoscope again, tomorrow, and get out there in the trenches and maybe, just maybe, I'll save someone this time around.