Month: September 2012

The Evolution of Authority: Confidence vs Arrogance

The journey from timid trainee to clinical leader is rarely a smooth one, and authority does not come easily to all. Lessons learnt from inevitable missteps can be as useful as the positive accumulation of knowledge and skills. By looking back at formative moments in a fourteen year career I have tracked the evolution of my own authority…and in doing so I have recognised that near the end of the path lies a trap, and it is called arrogance.


As a Senior House Officer, in conversation with my Registrar.

Registrar: “And you think the bronchospasm is what, pulmonary eosinophilia, due to migration of parasites? Why doesn’t he just have asthma?”

Me: “It’s just…this patient has made no improvement after five days. We’re getting nowhere. His renal function is off. Either an unusual infection, or something else…perhaps autoimmune, vasculitic. Shall I ask the rheumatologists to see him?”

R: “He’s a bit dry, that’s all. Speed up the fluids and his kidneys will turn around. The prednisone will kick in soon. Don’t worry.”


Next day – a SHO detains me in the corridor 

SHO: “I hear your man was transferred to intensive care.”

Me: “I’ve seen him. Blew a pupil, dropped his conscious level. I don’t understand, it doesn’t add up.”

SHO: “But you’ve heard what the diagnosis is?”

Me: “No. Not yet. Tell me.”

SHO: “Churg-Strauss syndrome. Classic presentation. ICU called the rheumatologists in. But he’s pretty far gone now, on dialysis…they’re starting cyclophosphamide this afternoon. You look shocked.”


A few years later, with some specialised knowledge under my belt, I felt confident in challenging error where I saw it developing…


In the intensive care unit, a Specialist Trainee greets me.

ST: “Thanks for coming down. Her liver is fine but her ammonia is off the scale. Very odd. Epileptic, but the EEG says she’s not in status. CT scan is normal”

Me: “Does she take valproate? An overdose would explain it – it interrupts the urea cycle.”

ST: “Yes. We figured that. But she hasn’t woken up on the filter. Have you got any ideas?”

Me: “I’ve had a look at her. She has signs of raised intracranial pressure. Clonus, sluggish pupils. She’s at risk of coning. At the moment you have no handle on the pressure, nor how aggressively to treat it. She needs a bolt.”

ST: “An intracranial pressure monitor?  Really?”

Me: “Yes, the neurosurgeons will put one in if you call them.”


Later that day

Me: “Did the neurosurgeons come down?”

ST: “No. We didn’t think it would add much.”

Me: “But it would…you have no idea what’s going on in her skull.”

ST: “But the treatment would be the same anyway. And besides, there’s no evidence of a survival advantage…”

Me: “Evidence is lacking, you’re right. But this situation is rare, the trials will never be done. Look, you asked for my advice, and I’ve given it to you.”

ST: “We’re not convinced…it’s a risky intervention…”


How far do I take this? I’m convinced it’s the right thing to do. How hard should I fight for what (I think) I know is the right decision?

Me: “This woman is at huge risk of brain death, and without quantitative assessment of the pressure you cannot treat her appropriately. If the pressure is persistently high after mannitol you’ll need to try indomethacin, consider a thiopentone induced coma, cool her right down. Where’s your
consultant? Who do I need to convince to make this happen? You clearly don’t have the experience in this unit to make the right decision.”


But I did not say that. I figured – it’s their decision, their responsibility in the end. I gave an opinion, one of many probably, and they must assess the pro’s and con’s before making the call. They may have a better understanding of the whole situation. So I said,

“I’ll review her first thing tomorrow. That will be 24 hours since she presented. If there are persistent features of raised pressure I think you’ll have to do it. Ask the neurosurgeons for their advice. You have mine.”


She never woke up. No-one can be sure what difference the bolt would have made.


Two years later I found myself arguing over a patient whose heart had stopped.


Me: “Another cycle, and then I think we’ll stop. There’s been no electrical activity since we started…all agree?”

The cardiology Registrar enters the cubicle pushing a portable echocardiography machine.

Cardiology Registrar: “I’m just going to take a look, see if there’s any ventricular activity.”

Me: “We’re just about to call it. She’s dead, unfortunately. We’ve been going for 20 minutes in asystole.”

CR: “You haven’t excluded all reversible causes yet. What about tamponade?”

Me: “There’s no reason to suspect tamponade, no instrumentation, anticoagulation, no electrical activity on the monitor…”

CR: “It will only take a couple of minutes. My consultant will want to know before you stop resuscitation.”

Me: “What! No! I’m running this arrest, we’ve given four shots of adrenaline, and the line is flat. She is dead. I’m not going to have this woman subjected to another 10 minutes of CPR while you do an echo and go and call your consultant.”

CR: “It’s protocol on the cardiology ward.”

Nurse: “That’s two minutes.”

Me: “Okay, what’s the rhythm…asystole, not compatible with a pulse. Let’s stop. Stop compressions.”

CR: “I’m calling my consultant.”

Me: “Do so. At no point in the life support algorithm does it mention echocardiograms and phone calls to consultants. We’re stopping.”


I walked away, emboldened by the challenge. Assuming authority in this situation had come easily. I felt that I had risen to the challenge, and proved my seniority.


Two weeks into my job as a consultant I conducted a ward round.  A new patient, with alcoholic cirrhosis, had been transferred to the ward.  My SHO presented him.

            “He’s been triggering all night, low blood pressure.  Down to 80 systolic.”

            “He’s septic you said.”

            “Yes, spontaneous bacterial peritonitis, confirmed.”

            “He’s passing urine, he looks alert. Lactate’s normal.  Give him more time, he should skate through without needing vasopressors.”


Later that day my SHO found me in endoscopy.

            “He’s not picking up.  We’ll need to adjust the alarm parameters if we don’t want to be bleeped about his BP every thirty minutes.”

            “This is
what cirrhotics do, run low BPs, dilated circulations, even without sepsis.  A bit more filling, another couple of days of antibiotics and he should turn around.”


Next morning she came to my office; the registrar was away.

            “I’m worried.  Sodium’s down, BP is still poor.  And he’s got a rash, all over his trunk.  It’s blue.”

            “But he’s talking, reading the paper, walking to the toilet.  I passed him on the ward this morning.  I’m not too concerned about him.”

            “But he’s just not right…”

            A brief stab of annoyance interrupted my continued reassurances – yes, we’re all worried about him, but get on with it!


On the third morning I was called to the ICU.  My patient lay dying, his skin mottled, a cardiac output monitor confirming that his heart was barely functioning.  He had been displaying signs of severe alcoholic cardiomyopathy from day one, and I had missed it. My SHO had never seen a case before, but she had sensed it, the wrongness…just as I had sensed that there must be an alternative diagnosis in the man with asthma.  I didn’t hear her, because I was sure I knew more.


The only doctor we can observe over an entire career is the one we see in the mirror every morning. We must reflect on our own experiences to truly understand how we have evolved –  and why. When the patient with Churg-Strauss syndrome was admitted I was no more than a wallflower during medical arguments. Now, if I am sure of myself, and if after reasoned argument I wish to ensure that the wrong decision is not made, I may display intransigence and will ultimately pull rank. For after all, I am right more often than I am wrong, and my senior position should ensure that what I say goes. Shouldn’t it?


Having reflected on some of the steps that led from a questioning but silent observer to a physician with the power to insist, I am reminded that the evolution of authority does not end with the progression to consultant rank. Only open mindedness, the ability to admit mistakes (to oneself if not to ones juniors), and the realization that learning occurs in both directions can prevent the sheen of hard earned authority from deteriorating into a impermeable hide of arrogance.



Compulsory resuscitation: a dose of reality

Picture the scene, in the emergency department:

            “…and if your heart stops…”

            “Eh?” [pained groans emanate from the adjoining cubicle] “What’s that you said doctor?”

            “I mean if your heart were to stop beating, would you want us to try to restart it?”

            “My heart?  But I thought you said I had a chest infection.”

            “I know, I know, but we always like to ask…sorry…” [nurse enters cubicle with casualty card and asks how long until Miss X is seen]  “…tell her twenty minutes…yes, just in case the worse were to happen I mean.”

            “I guess so.  Is it that bad?”

            “No. Not at all…I’m sure it won’t come to that, but, you know, your heart has been through a lot…it’s not as strong as it once was.”

            “Really?” [incredulous]

            “So what do you think?”

            “Can I think about it, talk it over with my daughter when she comes in?”

“When is that?”

“Tomorrow morning.”

            “Of course, of course…[aside] but please don’t arrest tonight.”


Bill is seventy five and has come to casualty because he has been coughing up blood and getting more short of breath.  He has been smoking since he joined the army in 1940, and his lungs resemble a blackened sponge, the air sacs coalescing into overlarge, inefficient holes.  He can barely walk from the lounge to the kitchen.  He does not look particularly unwell and if all goes well he’ll be home in a week.  But he might die.  It’s possible.  So, in anticipation of that misfortune, I must discuss the subject of resuscitation with him.  It could wait of course, until tomorrow when his daughter comes in, but…time is of the essence – I want to know how to respond if he arrests tonight.  As it stands, we will try to resuscitate him.  We will have to. 


 In response to the concern caused by evidence that the elderly and those with cancer were being ‘written off’, the Secretary of State for Health stated in September 2000; “Decisions on non-resuscitation should only be made following a discussion with patients and their families.”  This has been emphasised time and again, in hospital protocols, in national guidelines.  But that requirement means the DNR form will remain incomplete until a discussion has taken place.  If relatives are not in the hospital, or not contactable by phone, or ambivalent themselves, only the very senior, very confident doctor will fill out that form.  If they can make a firm case for not resuscitating they will go ahead, ready to defend themselves should the family choose to complain after their loved one’s death.  If the doctor is not minded to take that risk, the patient will be subjected to a resuscitation attempt.


The chances of getting Bill’s heart going again, should he arrest, are small.  In 1992, when the BRESUS investigato
rs counted up the number of people who had had cardiac arrests on the general medical wards of 12 hospitals, they found that only 11% were still alive a year later.  This included all age groups.  The over seventy-fives stood even less chance; those with pneumonia even less.  Quality of life was not investigated, but many of those who died within a year never left hospital.  Should I tell Bill this when I see him in casualty?


And what of the mechanics of an arrest call?  Should I give even a sanitised version of the events that take place during cardiopulmonary resuscitation; the cracking of brittle ribs, the rivulets of black blood resulting from the desperate search for vascular access, the tube down the trachea, the muttered consensus between nurses and doctors that precedes the final release?  If I do I will be making my own views on the matter very clear.


A fine balance must be achieved, between ensuring that patients are acquainted with the depressing reality of resuscitation, and the avoidance of brutality.  It is not easy bringing up the subject of death, steering the conversation  towards mortality having focussed, during the preceding thirty minutes, on the measures that you are planning to avoid it.  It requires a thick skin, a form of words, a knack – an iron hand in a kid glove if you like.  Casualty departments and admission wards are not conducive to such subtlety of communication.  Given the gravity of the discussion, it is not surprising that the presence of family members is required.  The logistical and emotional difficulties presented by this plunge into the deepest fears of a patient or a family means that the discussion may not take place at all.  The resuscitation status will therefore remain positive, by default.  However small the chance of success, however strong the feelings of the doctor, resuscitation must be commenced, for to do otherwise would be to ‘watch the patient die’.  Doctors transgress guidelines at their own peril in this litigious age.


What then is the answer?  The answer is…pragmatism. 

“What if he arrests?  He’s still for resus.  There’ll be a crash call.” the junior doctor enquires.

“Well…look, use your common sense…if you don’t get him back straight away don’t go on…” has been the traditional instruction.  This is not a casual statement.  It is an attempt to match the chance of success with the burden of treatment.  If it looks like it will work, sure, push on, go all the way, that’s what we are here for, to save life.  But if the patient is clearly not responding, pull out.  Don’t commit the patient to a prolonged death.


So the team follow the resuscitation algorithm, give the drugs, deliver the shocks, but they will not persevere for more than a few minutes, for they know that even if the attempt is ‘successful’ (ie. the heart is restarted) the end result will probably be ultimately disastrous for the patient.  So the medical profession has found a compromise.  Doctors will attempt a resuscitation in any circumstance, in order to abide by the guidelines that have been set down, but they will not subject a patient who has obviously ‘died’ to endless cycles of massage, shocks and injections, even if a small chance remains that the heart can be kicked into action.  Indeed, repeated administrations of adrenaline, a drug powerful enough to squeeze another hour’s activity out of the most tired and damaged of hearts, are often avoided.  A tidy, unambiguous death is preferable; better that than not being able to tell the waiting relatives that their loved one is dead just because the heart has not yet ceased its fitful, useless contractions.


This circumstance has come about because the ineffectiveness of resuscitation in the elderly population is not understood by the public.  Doctors, who know how harmful a resuscitation attempt can be, are not trusted to make a unilateral decision as to whether it is right or not, when the discussion has not taken place.  The pendulum has swung away from the medical paternalism of yesteryear, but in this area the opinion of an experienced doctor is trumped by caution.  Cardiac arrest is the only situation in which a doctor has no choice as to whether or not to give a particular treatment to a patient…the most unpleasant, and in some cases, the most ineffective ‘treatment’ of all.

The Limits Of Responsibility

A few months ago I looked after a patient from eastern Europe who presented with episodes of confusion and weakness.  He had lost a great deal of weight, and his skin had become pigmented* over the previous four months.  His wife, ever present, was highly critical of the care that he received even though we arranged three scans and a lumbar puncture within 48 hours of admission.  After five days I raised the possibility of heavy metal toxicity (he was an electrician, they are prone to Manganese poisoning), although the differential diagnosis was very wide.  Deliberate arsenic poisoning was on my mind, but it was way down the list.  Still, if you don’t think about these things you never make the clever diagnosis.  That’s what I tell my juniors.


Twenty-four hours later his wife arranged overland transfer to his home town in a Baltic state.  The two of them just disappeared off the ward.  The doctor who received them emailed me, asking for a summary.  Two weeks later she sent another message informing me he had died.  A post-mortem was refused.  The case bugged me.  I had a strong desire to travel out there, find the town, walk into the hospital (a grey, functional building in my mind’s eye) and demand an exhumation. Or, at the very least, find some tissue, a hair off a brush, an old toe nail, something to analyse.  But then, what did this have to do with me?  Our local heavy metal expert did not think the clinical features were typical, and really, how on earth could I achieve anything?  It was not my concern.  House might have jumped on a plane, or sent one of his photogenic protégés, but here was no professional or moral obligation for me to discover the truth.  I had reached the limit of my responsibility.


There are other occasions when I find myself trying to define the limits of my responsibility.  I have a patient who is alcoholic, cirrhotic… he is likely to die soon if he does not stop drinking.  I have referred him to the appropriate agencies, but they require patients to attend of their own volition, to demonstrate an ongoing commitment.  He will not.  His mother writes to me asking me to sort something out. What can I do?  I write to his GP and to the addiction services; I detox him when turns up in the emergency room.  But I can’t own his alcoholism.  As he walks out of the door, temporarily mended, he passes beyond my sphere of influence.  That’s the limit of my responsibility.  


Now imagine this: I travel to that Baltic state and confirm that my patient was poisoned (by his wife?). Justice is done, based on my little hunch.  Imagine I admit my alcoholic patient, detoxify him, counsel him, work on him with psychologists and addiction specialists (to hell with ‘length of stay’ pressures)…until he is freed of his terrible illness.  A phenomenal result.  The extra mile, the refusal to recognise conventional limits, the difference between adequate and exemplary.  Should I?


A more quotidien example.  I started a patient on a powerful new medication (Azathioprine) one week before going on holiday.  Foolhardy perhaps, but he was keen.  I arranged for him to have a blood test a day before his departure, and I promised to tell him if it showed any signs that the tablet was reacting badly with him.  But I was away that day and asked my registrar to look them up.  She remembered, but at the end of the day, just before heading home.  The results were not good.  His liver had become acutely inflamed.  Referring to the computerised patient information system she found that his phone number was not listed.  There was no way of telling him to stop the new medication.  She sent me a text – passing the buck back to her boss!  I worried about it that evening, and awoke the following morning no more relaxed.  I e-mailed my secretary over breakfast, at 6.30 in the morning, asking her to call the GP at 8 am, her first task on arriving at the office.  At nine, when I arrived in my off-site clinic, she e-mailed me the patient’s phone number.  I called.  He was walking out of his front door when the phone rang.  The taxi was waiting outside his house.  Situation salvaged!


On that occasion the limit of responsibility had extended beyond working hours into my mind, where the danger of the situation festered and ensured that I woke with a single mission: to contact him.  It’s a fairly unremarkable example, but it illustrates how the limits of responsibility enlarge in proportion to the risks that we take as doctors, with our patients.  Every junior doctor I know works late.  It is habitual, and it makes a mockery of the European Working Time Directive.  Nevertheless, shifts are shorter, handovers are more frequent, and it is important that juniors learn to balance the instinct to ‘complete’ with the reasonable pressure to drop what they are working on, ring a colleague and get home. 


So, while learning how to erect professional boundaries, they must also recognise the situations that demand an extra effort.  They must identify the problems that will spill over into their leisure time, distract them during the weekend, force them to pick up the phone despite their family’s disapproving  murmurs, and satisfy themselves that their patient is being looked after properly.  Not every week…just now and again.


* Yes, we excluded hypoadrenalism!