Fourteen: Transfer Blues
Shortly past ten on a late fall evening in 1991, our ambulance was called to the scene of a shooting. The victim was a twenty-year-old male who had evidently shot himself in the head with a .38 cal revolver. As is typical for late night self-inflicted trauma, the details of the event were ‘sketchy’. A friend of the victim stated that he had been emotionally upset lately and was using drugs, though he didn't know what had been consumed this evening. The victim, Jimmy Moreno, was conscious but not speaking clearly at the scene. After the shot was heard, his friend in an adjoining apartment called 911. The sheriff arrived before the ambulance to assess the situation. When they got to our hospital, Jimmy had a gauze dressing around his head, an intravenous line in his arm, and was babbling about his mother. When questioned directly, he admitted smoking marijuana that night but denied other drug use. I was struck most by his speech pattern. He sounded like someone very stoned on marijuana but otherwise seemed able to process thought and responded cooperatively. If he had shot himself in the head, I thought that he must have missed his brain.
I unraveled the dressing to observe a thick blood clot matting the area above and behind the right ear. Gently feeling the wound with sterile gloves, I did not feel any significant blowout of the skull bone but it was hard to be sure with hair and clot in place. My sense was that he had held the pistol up to his head at an oblique angle, and, too stoned to commit himself to certain death, pulled the trigger sending a bullet grazing the scalp. There was no evidence of an exit wound, if the evident wound was an entrance. Reasoning from basic principles, if a bullet had entered the skull at the bloodied wound and had not exited, then the bullet would have traveled through brain matter, perhaps ricocheting around causing more damage, and his resulting mental status should have been zip. He would have been dead at the scene. Therefore, with only a pot intoxicated appearing mental status, he probably did not have bullet entry and consequent brain damage. Soon, conversation began.
"Hey, man, could you get Dave for me? Did anyone call Dave yet?"
"Dave’s not here, Jimmy. We can't help you with that right now. We have to take care of your head wound. We need to get some x-rays, all right?"
"OK, man. Jeez, what happened? Oh, man, I didn’t really want to kill myself. Get Dave, now, man. Call my mother, man. I’m all screwed up. I smoked way too much."
"It’s OK, Jimmy, we’re going to take care of you. We’ll get hold of your mom as soon as we can but right now we need to do some tests to make sure you’re going to be all right."
"OK, man. Do your thing."
We sent Jimmy down to x-ray to get a look at the wound site. He remained medically stable but continued to ask for Dave, and his mom. His head wound slowly oozed blood but the total loss was not a dangerous volume. When he returned from the x-ray department, I was surprised at the findings. The bullet had indeed grazed the scalp, but it appeared that it had also grazed the skull bone causing a depression of the skull contour and leaving tiny fragments of lead in the outer two centimeters of brain. The bone was shattered into many small pieces in a one by three centimeter area of skull.
The next step was for the nurse to clean up the area and cut away hair to visualize the injury site. My job was to call the neurosurgeon down the road to arrange transfer to a facility where skull and brain trauma could be properly cared for. It was close to midnight.
The most critical aspect of patient transfer law dictates that the accepting physician be contacted and clearly agree with the transfer plan. As many specialists have to care for patients with no resources, the more common victims of violence, the referral physicians generally get burned with no monetary return for a large amount of work. This has caused many specialists to be reluctant to accept patients in transfer. The majority of physicians accept the reality of free service as part of the profession. Caring for the poor has always been a part of medicine. No other profession gives away tens of thousands of dollars of service on a regular basis. But, human nature as it is, some physicians just balk at the prospect of yet another self-destructive patient needing free care. When their difficulty becomes my problem, when they resist accepting transfer of a patient I cannot care for, I am in deep trouble. I must transfer this patient from out tiny hospital, time is of the essence, and the guy down the road couldn’t care less. Fortunately, the law has evolved so that if the hospital has the capability of caring for the patient (expertise and bed space), they must accept transfer or be liable for huge fines. If the on-call physician refuses, he is personally liable for huge fines. However, in the year this case occurred, the law was not as clear, and many crises were precipitated by transfer refusals.
The neurosurgeons in the town ninety miles south where major facilities exist (at the time of this case) fell in to two categories. The first group was the older, scholarly, exceedingly competent, gentlemen of neurosurgery, always willing to help, never questioning the insurance status of the patient. The second category was also exceedingly competent, a more recently trained group of doctors, some of whom have distinguished themselves as self centered prima donnas, unwilling to participate in the ‘we’re all in this together’ program. The worst of them was on this night.
I first called the hospital emergency department to find out which neurosurgeon was on call. They gave me his phone number and wished me luck. I called him and got his answering service that told me that he would return my call. After what seemed like an hour but was really about twenty minutes, he returned my call.
"Yes, this is Dr. Watts".
"Hello, Dr. Watts, this is Dr. Sterngold at Willits Hospital. Thank you for returning my call. I have a twenty-year-old male who shot himself in the head tonight and he needs your services. I would like to transfer him. His vital signs are stable and his mental status is sleepy but he can be aroused with a very spaced out affect and intermittent disorientation. The bullet grazed the skull causing a depressed fracture of multiple bony fragments and lead speckling of the peripheral brain tissue."
"It doesn’t sound like anything needs to be done right now. Why don't you admit him there and we’ll see how he’s doing in the morning."
"Dr. Watts, there isn’t anyone here who would feel comfortable admitting a patient with a gunshot injury to the brain. This is a small hospital with a total clinical medical staff of less than a dozen with only one general surgeon and no other subspecialists. Please help us with this one."
"Does he have any insurance?"
"No, he doesn’t, as far as I can tell at this time."
"Well, frankly, I've got a cold and I'm quite tired and I have to be in the operating room at seven in the morning. I think you folks should be able to handle this problem."
At that point my nurse called over to me, "Jon, you better come see this, now."
"Dr. Watts, could you hold the line for just a moment? Thank you."
I left the phone to get to the patient’s bedside to observe gray matter extruding from the wound site. Jimmy was oozing his brains out of the hole in his head. SURELY, this MUST be an imperative criterion for transfer to a neurosurgeon. I ran back across the hall to the phone.
"Dr. Watts, the patient is now losing brain tissue out of his wound site. Please agree to accept transfer. I've got to get him help."
"Oh, all right. Send him down." Click. End of conversation. No further discussion of care parameters, use of medications, nothing. OK, I can handle it.
Because of the possibility that the brain injury would lead to deep coma and respiratory arrest, I had to make sure he would survive the trip south. The only reliable way to insure a steady oxygen supply is to give intravenous medicines to sedate and paralyze the patient, then place a breathing tube into his trachea through the mouth and throat. This would also allow us to increase his respiratory rate (by squeezing the airbag faster, or increasing the rate on the respirator) which serves to reduce swelling of an injured brain. Less swelling, less damage and in his case, less brain squeezed out the bullet hole. Ironically, the hole in the skull and loss of brain acts to decompress the swelling brain, further reducing deeper brain damage. When the brain swells in a totally enclosed and rigid skull, everything gets squished together, which can cause total brain death.
Jimmy made it down to the reluctant neurosurgeon without further incident and was operated on promptly. The operation consisted of removal of a flap of skull bone that included the injury site. The underlying lead impregnated and badly bruised brain tissue was sucked out with a tool made for the occasion, and bleeding sites were controlled. He awakened the next day and other than the expected post operative discomforts, seemed to function normally. He had lost a seemingly non-essential piece of brain, if such a thing exists.
The left side of the brain controls speech and much of normal thought patterns. Portions of the right side of the brain control movement on the left side of the body, but otherwise, the right side is viewed as originating creative thoughts and images. The bullet damage had spared the areas that control body movement. The question remains, what was the brain tissue lost in this trauma used for?
I don't know what became of Jimmy after discharge from the hospital. He did not return to our town. Whether he ever found Dave or his mom I’ll never know but what I really wonder about is whether the lost brain was to his advantage or disadvantage. What kind of guy did he become? Would the deficit only be noticeable in an intimate encounter? Did he lose whatever creative ability he once had? Is he more or less driven to intoxication with pot or harder drugs? Has he found his own niche in the world or did he become just another SSI recipient, vegetating on our tax dollars - Dr. Watts’ and mine.
I struggle with myself over the issues of young social security dependents. Judging from the tenor of the government these days, I am not alone. I see people who are so painfully unfortunate that I freely approve of any support society has to offer. I also see those who are not that unfortunate. They are just impaired, unmotivated, and victims of their own unwillingness to get it together. Many of them would survive and perhaps thrive on the proverbial ‘desert island’. My work was so hard and the tax bite so severe, it becomes a personal issue how those ‘on the take’ (at the trough) actually suck my blood. Having no political calling by nature, I am generally at a loss how to compassionately care for those who derive their support from my sweat. Expanding the argument, how do I give my all to those who are ill because they have engaged in a life of self-destructive behavior. I am referring chiefly to tobacco use, the number one resource drain in our country. Depending on the method of calculation, the medical and work force costs of tobacco in our country approaches the level of the national debt. When faced with the 76 year old woman who has smoked all of her adult life, in medical distress, needing 20 to 40 thousand dollars in care to get her through her current illness, and the bill will be paid out of my tax dollars (Medicare) - how do I relate to her? Instinctually, I think she should either pay with her own greenbacks or reap the consequences of her behavior. Professionally, this doesn’t fly. And so, for now, to live with myself, I treat her with common respect and decency, get her admitted to the doctor who actually does the long term care, and thank my stars that my role as an ER doc is limited. I also encourage a rational advance directive!
In 1988, I seriously harmed a patient. There was no gross negligence, just an unfortunate complication which could have led to a slam-dunk-win lawsuit for pain and suffering. I don't know if I was more upset about having hurt someone or fear of suit, but I spent considerable personal energy on and with this patient. I did not get sued.
Rebecca Mason came into the emergency department one spring afternoon with exacerbation of long-standing neck and back pain. Her regular doctor was unavailable at the time, and she had no medication to help with the discomfort. She had been through physical therapy for pain in her trapezius (the large muscle of the uppermost back between the shoulder and the neck) area, with minimal improvement. Medications were used, with variable success. No one had trigger pointed (injected the painful area with a combination of local anesthetic and corticosteroid - a ‘cortisone shot’) her pain. The diagnosis was myofascial (muscle and connective tissue) pain syndrome and I offered this modality of treatment with the recommendation that it was very often effective, produced only brief discomfort, and if ineffective, was unlikely to cause any harm. I discussed the minimal risks and potential benefits of injecting cortisone medication, and she agreed to the procedure.
The only complications I had seen prior to this case, in fifteen years of doing trigger point injections, was one bicipital rupture (broken biceps tendon causing a ‘popeye’ biceps from the muscle rolling up on itself) and one subcutaneous atrophy (dimpling of the skin from temporary destruction of the fat layer). I avoid the first complication by carefully controlling the injection technique. The skin dimpling is uncommon and generally goes away with time. The complication that occurred on this day had never entered my mind. But now it is forever branded on my cerebral cortex, never to be forgotten whenever I place a needle anywhere near the upper trapezius muscle group.
Rebecca's pain was centered in the upper portion of the right trapezius, a typical myofascial trigger point. I was impressed with the convex contour of her muscle. It appeared to be enlarged, probably from chronic spasm, I thought. As I put the needle into the muscle, aiming down and forward at about 45 degrees, while pulling back on the plunger, as is the routine, air came back into the syringe. The pullback technique is to determine whether the needle is in a blood vessel. If so, the needle is moved to avoid injecting the medication into the bloodstream. I had gone only about 1.5 cm into this large muscle belly and I got air! I had to have punctured the lung! I immediately pulled back the needle into the muscle, out of the lung, and injected while praying that a tiny needle hole in her lung lining would seal itself without consequence. Ninety nine percent of the time (when done for other procedures), it does. She told me that she was suddenly in pain and I reassured her that this discomfort would pass. During the few minutes after the injection, I had her recline on the gurney, waiting for the discomfort to pass, for the local anesthetic to numb the muscle, and for the lung puncture to prove itself to be of no consequence. She tried to reassure herself that she was OK, as we both suspended reality. As she stood at the desk to sign out, I could see that her discomfort was growing and I had to admit to myself that she could have a pneumothorax - a real hole in the lung that might require aggressive surgical therapy. Maybe just a little pneumothorax, but painful and requiring quite a bit more than an aspirin and a call in the morning.
Within minutes, she was in agony with respiratory distress. Resigned to the grim reality, I got a chest x-ray that showed a large tension pneumothorax (a particularly dangerous, large, high pressure lung collapse which can be fatal if not rapidly treated with pressure release maneuvers). I was blown away. Sweat and terror conspired to confuse and disorient me, but poor Rebecca, in her helpless innocence and terrible pain, pulled me back into professional mode. It was time to tell her everything.
"Rebecca, I'm so sorry that this has happened. When I put the needle into the muscle, the tip went through the bottom of the muscle into your lung that was unusually close to the surface. At the moment the tiny needle went through, you were probably in a portion of your breathing cycle in which there was movement of the lung membrane at that spot. That caused the needle to rip a larger hole in your lung and now the air has leaked out of your lung, into your chest, and is putting pressure on the collapsing lung. This hurts a lot and must be treated by putting a tube into your chest to get out that extra air. The lung will seal itself in about three days but during that time, you will have to be in our ICU (intensive care unit) where we will take care of you, help your pain, and deal with any other problems that might arise. I can't tell you how badly I feel about having hurt you and I want you to know that I will do everything to make sure all ends well. I will give you pain medicine now and the surgeon will be here in a few minutes to put the tube in your chest. OK?"
She replied, through the veil of her distress, that this was all right and conveyed no anger towards me. Yet. Evidently the convex appearance of her trapezius was her anatomic variation with a high domed lung upper aspect (apex) under a typically thin female trapezius muscle. We started her IV, began oxygen, and the surgeon relieved this tension pneumothorax with a chest tube (insertion of a half inch plastic tube in between the ribs, through the chest, into the lung space and attached to a vacuum system). She was made more comfortable with Demerol, and was sent to the ICU. My head was spinning. How could I have done this? How could the tiniest of lung membrane punctures become a tension pneumothorax, and, how could I help make this OK for Rebecca.
After my shift was over, in the early evening, I went back to the ICU to check on Rebecca. Narcotics had relieved her terrible distress, but she was cogent enough to talk a little. I again told her of my distress at having caused such a complication, such an intimate assault, however unintended. She told me that she knew that sometimes, things just happen. She wasn't angry. I asked her about her life, her family, and her marriage. She spoke of great conflict at home, an abusive husband, and her search for happiness. I asked her if she had pursued counseling for this struggle. Not in a few years, and she couldn't afford it now. We talked until the spaces between words were filled with narcotic dozing (hers, not mine). I took her hand and told her I would be thinking about and praying for her tonight. I would be back in the morning and between now and then, if she had any questions for me, or if the nurses needed me, I would be available, even though not officially on call.
I came back the next morning to find her stable and in relatively good spirits, except for periods of pain. She was glad to see me. We talked about the discomforts of the night, the kindness of the ICU nurses, and her growing perspective on this experience. She expressed a desire to get on with her life, to get through some of the more confusing and tormenting aspects of her marriage. Searching my insides for something I could give her after taking away her health, I decided to try to arrange affordable sessions with a competent therapist I knew. Living and working in a small, close community, I was able to get a counselor to see her for whatever she could afford (if anything) for at least two sessions. Rebecca gratefully agreed to make an appointment as soon as she was well. We talked about different options for marital or post-marital life choices, and I shared with her some of my own mistakes, lessons, and shreds of wisdom. When it was time to go, she took my hand and thanked me. I was deeply moved by this new intimacy. I felt it to be stronger than her medical condition or the pressure society exerts to exact payment for bad outcomes, regardless of the big picture. Was this manipulative on my part? I don't know, maybe partly, but it was also genuine, spontaneous, and real. I cared about Rebecca and her pain. But I also cared about myself, my bad outcome and the possible price of this mistake. Which comes first? Parts of both.
Rebecca had an uneventful recovery. I visited with her every day until discharge and made sure she had an appointment for therapy. She looked forward to this. I told her that if there was anything I could do for her, she should not hesitate to call. I saw her a few weeks later. She was well and had some new plans for her life about which she was quite excited. She thanked me for my caring and I never saw or heard from her again. I spoke with the therapist who said things had gone well and she was moving on. To this day, many years later, I haven't seen or heard from her, or her attorney.
In risk management we speak of suit avoidance through bad outcome avoidance and good communication skills. We do not often get to experience not getting sued after a bad, painful outcome. Talking to the patient as a kindred spirit, on the same planet, empathetically, is a way to create the union in which the patient becomes connected enough to the caregiver to feel the impact of their (the patient’s) behavior on the doctor, thus reducing risk of suit. The patient may sue if they are angry. The patient may sue without anger, simply if there is a bad outcome, especially if the patient is kept at a distance from and by the doctor. When the doctor or the patient minimizes distance, suit is far less likely. If we all could feel the impact of our actions and thoughts on one another, we would find ourselves in an age of peace. As this is not likely to happen in our lifetime, the best we can do is to take one relationship at a time, whether at home or at work.
a doctor is sued for a bad outcome, even when no malpractice has occurred,
the attorneys tell the defendant (the physician) they must
not talk to the plaintiff (the patient). The reason stated for this is
something to the effect that the doctor may shoot himself in the foot
by saying something which could be used against him or herself. Many
of us believe this is legal subterfuge that serves to make sure the case
continues and ultimately, is self-serving for the attorney. After all,
if the doctor and patient come to some new level of understanding, the
case could evaporate. Though I have not been sued, some of the best doctors
I know have, and their tribulations have been an outrage to the human
spirit. Let there be no mistaking - the fox is guarding the henhouse.
Until this distribution of power is remedied, every patient and every
doctor will pay, more and more. Sometimes monetarily and eventually by
losing access to some of society’s best and brightest. This is
not to say that there isn’t a place for legal retribution in medical
malpractice cases. But the system that supports these actions also supports
abuse of these powers. We can only understand this when we follow the
All Rights Reserved © 2004 Jon Sterngold