I hadn’t thought about this call night in a while, as it happened three years ago. It came back into my consciousness this past week, when I re-experienced the events in a dream. (Of note, my stress dreams used to be about my car accident in 2014, which was a high-speed collision that left me in crutches. I guess I can now safely say that some call nights are actually more traumatic than living through a car crash.)
This particular night, I was taking care of inpatient floor patients while on call. Another female resident was giving me sign-out about a patient coming up to the floor from the ED. She told me, point-blank, “This patient looks absolutely terrible. She’s hard to arouse. But it’s really weird; everyone thinks it’s fine.” The “everyone” she was referring to was the male fellow, who had taken care of the patient before and the ED attending.
When the patient came to the floor, I went to see her. She was lying in bed, staring into space, and barely arousable on my exam. Nothing about her chief complaint could explain her current mental status. I immediately paged my fellow to let him know that her mental status was profoundly altered on my exam, and that I was worried about meningitis. I remember telling him, emphatically, that I had done lumbar punctures on less altered patients in the past due to concerns for meningitis. “I’ve tapped for less!”
He said that meningitis was “impossible,” after looking at her labs and seeing that the white blood cell count appeared to be within normal limits. He sounded so sure of himself. My exam — and my concerns — were irrelevant.
Looking back, I wish I had hung up the phone, possibly telling him where he could shove his opinion, and immediately called our attending and an ICU consult. There is something about the ingrained hierarchy of the medical totem pole that made me go against my better judgment and believe the inane justifications of my senior. This, right here, is the part that still gives me nightmares.
Within two hours of my fellow blowing off my concerns, as well as the concerns of the other female resident, a code blue was called for my patient. The ED attending came running upstairs; he knew immediately that he made the wrong call for this patient.
I called my fellow back to let him know about the code. He then asked, sheepishly, “Hey so can you page the attending and let her know?”
I was taken aback. Now you want me to deliver this news when this was your call?
I responded with, “Are you serious? I’m kind of busy right now. I mean, we’re in the middle of giving chest compressions!”
As it turned out, the patient did have meningitis. Over the next 24 hours, she had irreversible brain swelling and died.
There were two subsequent morbidity and mortality conferences, where the faculty asked questions about the “quality of the resident’s exam.” The event had already shaken me to my core, but I still had to sit stone-faced as they criticized my lack of a fundoscopic exam, even though I already had evidence for a life-threatening neurologic condition based on her mental status alone. Worse than the disfavor of the attendings, though, was that I felt God’s judgment on me, not just as a physician, but as a human. In the weeks that followed, it took everything I had in me to just show up to work.
There were a host of system-wide issues which were brought up at these conferences. As a result, one silver lining is that a standardized process was created to allow for trainees and the nursing staff to sound the alarm for any unstable patient who has arrived at the inpatient floor.
One issue that did not come up, however, was why the medical opinion of not one, but two, female trainees was blown off by an overconfident male fellow. Part of the reason this was not discussed is that, once again, the pressure of the hierarchy made me feel like I could not bring up the issue for fear of “throwing my fellow under a bus.”
I find it hard to believe that he would have been so dismissive of the concerns of two male colleagues. Perhaps he wrote off my exam findings and clinical judgment due to a subconscious bias that a female’s concerns are overblown and “hysterical.” It doesn’t matter in this particular incidence; someone died because of this, and I am left with the nightmares, even years later. Perhaps the one real lesson that I’ve learned is to speak up and not be afraid of disrupting the hierarchy of medical training.
I won’t let my concerns be mansplained to me again; I have found my voice of defiance.
“Defiant B, MD” is a physician and blogs at her self-titled site.
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