The Case from Hell

by A. E. Miller, MD

Why oh why did I choose this profession?

In the final pages of the thriller The Day of the Jackal, the relentless police inspector notices something suspicious and bursts in upon the Jackal, just as he was sighting in his rifle for a kill shot of General de Gaulle.

When the inspector realizes what he’d stumbled across, he mumbles to himself the old cop’s prayer: “If this has to happen, please dear Lord, not when I’m on duty.” It is the loneliest of prayers, and I suspect most MDs are acquainted with the sentiment – particularly those small town docs who’ve been the only guy in the valley when bad stuff rolls through the door at two a.m.

Several years ago I shared a bottle of merlot and an evening of swapping yarns about our parallel careers with a good friend, Dr. Clay Morgan of Boise. Eventually the talk turned to those occasions upon which we, or our colleagues, had been “sandbagged.” Times when everything was done right – “wouldn’t change a thing if it happened again tomorrow” – however someone was dead or damaged by some problem for which there had been no good reason to fret.

There was the bride of a med school classmate, a beautiful girl, a model, who was treated for dyspepsia by the chiefs (pl.) of the gastroenterology department for three months before she died at age 24 of carcinoma of the stomach. There was the wife of the Air Force sergeant who came to the dispensary at four in the afternoon with a minor cold. The following morning she was found in her bed, cold and lifeless from causes unknown.

Once we got started, our conversation quickly became a “can you top this?” contest: each story leading to another, and that, in turn, to another. We had both accumulated decades of tales about the “IEDs” of medical practice: events that were unexpected, unannounced, and unexplained, with symptoms that were either absent, vague or misleading. It didn’t really matter who was standing nearby, professor or intern, because anyone in the area at the wrong time would be torn apart by the blast.

There was this patient with a terrible headache: long history of bad migraines, regular doctor away on vacation, vomiting, dry, unremarkable physical, uninteresting lab, and normal CT head scan. So what happens next? You control the pain and replace the fluids, right? The following morning the patient becomes obtunded; by noon the patient is decorticate. “There was a massive thrombosis with total occlusion of the cavernous and sigmoid sinuses,” so said the autopsy report. Didn’t we once read about such things, long ago in med school?

When word goes out of a former patient’s unexpected demise we check our charts and search our souls. “What could I possibly have missed?” we collectively ask ourselves. It is a proper question, because we’re all aware of our own shortcomings. Guilt goes with the territory, so learn to live with it, they say. But sometimes that’s easier said than done.

Dr. Walter Hoge was one of the good old boys who practiced in Blackfoot. Someone once asked what he would do if he performed a complete physical on some guy and pronounced him “sound as a dollar” – which in those days meant “in perfect health” – and then the guy walked out the door and dropped deader than a mackerel on the front sidewalk? Barely pausing to think about it, Hoge replied: “I’d turn his feet around so it looked like he was coming instead of going.”

So rejoice if you weren’t on call on the night that God let bad things happen, but show a little mercy for the guy whose turn it was. Lord knows, he’ll seldom find it elsewhere.