17 June 2010

What's the difference between "Eureka" and "Duh"?

There are some days where you see your patients and the diagnosis is clear and obvious more or less immediately, or where at least your workups are direct and give you clear results.  Those are satisfying days.  Then you have days when the diagnoses kind of drop into your lap, which is also nice.  Then you have days like yesterday.

Every damn patient I saw had something real wrong with them, most something serious. In not a single case did I take the direct route to the diagnosis, but sort of spiraled in on it instead, with lots of tangents and dead ends along the path.

Like the guy who came in post op day 5 from a laminectomy, diffusely weak, tachycardic and hypoxic.  He had a PE, of course.  It took me hours (plural) to realize it.  Duh.  Post-op, tachycardia, hypoxemia.  Why was PE not first on my differential?  Because I'm not being fair to myself -- there was a lot of data I had to filter and a whole bunch of other diagnostic options occupied my attention, initially.

For example, as I mentioned, he had back surgery and was feeling weak, with increased back pain. My initial concern was a spinal cord lesion, like an epidural hematoma or spinal infection. So I wasted a lot of time talking to the neurosurgeon, getting the MRI, talking to radiology, etc.  Also, his blood pressure wasn't great, and with the tachycardia I was worried about a post-op infection/sepsis, so we were also doing the septic work-up as well.  And pain control was a significant challenge/distraction.  And the initial oxygen saturation that I saw was 92%, which doesn't sound too awful and in fact I kind of skimmed over, not considering that he was on supplemental oxygen at that time. So really, his room air sat (not recorded on the chart) was probably in the high 80's on arrival.  It wasn't until his oxygen requirement increased and his sat with oxygen dropped into the 80's that the nurse brought her concern to my attention.  I literally smacked my forehead with the palm of my hand when I finally managed to put 2 and 2 together and get four.  Once you realize it, you wonder how stupid you must have been not to see it before.

All of my patients were like that yesterday. This one was memorable because it had the eureka moment.  But there were way more patients with "what the hell" moments and hours of frustration.

"The most exciting phrase to hear in science, the one that heralds new discoveries, is not Eureka! (I found it!) but rather, 'hmm... that's funny...'"
- Isaac Asimov


Anonymous said...

i wouldn't say heparinizing someone with back pain and weakness 5 days after a laminectomy is such a simple thing. it sounds like your meandering course of events was pretty appropriate and the appropriate diagnoses were considered. good thing time to anticoagulation in PE isn't a core measure!

Anonymous said...

Did he survive?