Another Story About The ER

The following is an email sent by a friend who reads the blog in response to the recent posts about my visit to the ER. It is about an experience he had with his infant daughter and I got his permission to share it as it is illustrative of many of the principles touched upon in my earlier posts:

When [my baby] was 9 days old she presented with what appeared to be an infection in her right eye (eye lid swelling, puss coming out the side, dark skin around the eye [picture attachment omitted]).

I think we waited overnight (details are a little fuzzy now that it’s been over 2 years) before doing anything because we were hoping it would resolve itself without having to go to a doctor, who might urge us to go to the ER, which we wanted to avoid if at all possible.

The next day it didn’t look better so we took her to the pediatrician, who was particularly concerned and brought another doctor into the room to examine her, we expressed our concern that we really didn’t want to go to the ER if at all possible, both doctors said we should go. They were concerned “because she’s so young” and “because the infection is so close to the brain.”

We got to the ER and it took for fucking ever to even get a room, of course you’re shoved into a massive environment of sick people dying to infect you with god knows what disease they have from living a terrible unhealthy life. It was literally like 6 hours before we finally got a room. At this point it was late at night and I kept thinking, “man, her eye looks better, if it looked like this 6 hours ago I don’t think we would’ve been sent to the ER.”

But the doctors kept saying shit like, “yeah we’ve seen things look better but actually be getting worse.”

The doctors wanted to do a blood test to see what the infection was and start her immediately on IV antibiotics. Additionally, they wanted to do a spinal tap (some advanced way of determining what the infection might be). I wanted to push the IV antibiotics back until we knew what the infection might be (as the results of a blood test might indicate), but they kept pushing and saying, “these things can move fast, we really think you should get IV antibiotics ASAP.”

Eventually we caved and agreed to the IV antibiotics (which was an awful experience in their own right because [my baby] was so small, and her veins were difficult to find, took literally 4 practitioners before they could finally access her vein — [my baby] was screaming like crazy and we were saying, “can’t you find someone else to do it?” And the girl said, “don’t feel bad, she won’t remember it.” Who says that?!) As a side note, god forbid you have to go through something like this, but if you do immediately ask for a practitioner from the neonatal intensive care unit (NICU) to insert any IV into your child, they can find a needle in a haystack.

At this point they were still pushing for a spinal tap and I said, “If the blood results come back negative, is there ANY reason to do a spinal tap?” The doctor said typically no. I said, “Well let’s see what the blood results say then.” The results came back negative, so I said I’m not doing the spinal tap. The doctor kept saying, “well, sometimes things can slip by the blood tests.” But I refused. I left to go home and get changes of clothes for me and [my wife] since we didn’t realize we’d be at the hospital for 2 days, and while I was gone [my wife] said that they sent in some other doctor (female this time) to pull at her emotions to try and get her to agree to a spinal tap, but she refused, we didn’t do it — the infection just looked so much better already (even before the god damned antibiotics).

We stayed with [my baby] in the hospital like 36 hours, during that time we were regaled with fantastical tales of babies contracting Hep B and why we should really give her the Hep B vaccine. I kept asking the doctor to give me a realistic example of how [my baby] would contract Hep B at this age. His examples were literally so absurd they’re not even worth typing them, one involved a syringe with Hep B on it being mistakenly inserted into [my baby] by someone in the hospital, it was so ridiculous I could barely listen to it. We didn’t get her a Hep B vaccine, and still haven’t, and she’s miraculously Hep B free! I also mentioned to the doctor, “even if we agreed that [my baby] should get a Hep B vaccine soon, wouldn’t this be a BAD time to give it to her given that she’s obviously fighting off some infection?” The doctor wasn’t fazed by this logic, they’re total vaccine zealots, they’d vaccinate a cadaver given the opportunity.

In any case, in thinking back on the whole situation and what I would do differently, I think I would just wait an extra few hours before going to see the doctor, and when it looked better pre-IV antibiotics, I would’ve said, “let’s wait another few hours and see how she’s doing.” I just don’t buy their insane logic that something is visibly getting better but somehow actually getting worse. I’m sure there’s some textbook case of this happening to 1 in 1,000,000 babies, but doesn’t seem worth the known risks of IV antibiotics at such a young age.

It’s so sad and frustrating that you can’t simply take a doctor’s advice and trust that he’s already thoroughly immersed himself in the risks and benefits of the trade-offs between treatment / non-treatment. All they know is how to limit their own legal liability.

Hopefully you can avoid such a mess from happening to you!

He adds in an addendum:

Since doctors in large hospitals work in shifts, you naturally see the same doctor for awhile, and then see a new doctor for awhile. When it was time for [my baby] to be released, we were given an older doctor (maybe late 50s, early 60s). Not only was he WAY more respectful than pretty much every previous doctor we had, but he literally said something to the effect of, “if you’d gotten an older doctor, you may never have been admitted to the hospital, probably would’ve suggested you wait and see how the infection progressed.”

It seems that the doctors being minted today are inculcated with one-off horror stories starting on day 1 of their education.

My Recent Trip To The ER

Three days ago I critically reflected on the idea of preventative medicine in a post where I talked about a troublesome health condition that I had developed and my experience of having it examined at a local doctor’s office. Today, I went to the ER for that same condition.

What happened?

Between Tuesday, when I first noticed discomfort in my leg, and Wednesday, when I decided to go get a doctor’s opinion before spending some family time out of town, the swelling and redness increased, but I did not develop any other symptoms. On Thursday, the swelling and redness had encircled my entire lower leg, down to my ankle (but strangely not affecting my foot) and up to my knee joint, but not beyond. On Friday, no one who had a look (and there were many prying family eyes beside mine) could tell a difference between Friday’s swelling and Thursday’s– it didn’t seem better, but it also wasn’t clear it was worse. On Saturday morning (today) we packed up and made for home, and the swelling seemed unchanged.

Some family members tried to look up bug bite sites to help guess at what caused my reaction. Others just expressed shock and concern that I wasn’t doing something, anything, to address the obvious symptoms. Suggestions were made that I visit the ER in town at our vacation spot, or at least do it when I got back.

Here is how I was thinking about this decision: the fact that the swelling wasn’t getting obviously worse seemed like a good sign, the way the body fights its fight against invaders and injuries is going on below the surface, and without some kind of evidence (increased pain, swelling, etc.) that it is slowly losing the fight, I assume it is winning it. The discoloration was more extreme and enveloping, but no increase in pain with it seemed less than frightening. I did not develop any other symptoms which suggested a spread of the condition to other vital organs– no dizziness, nausea, vomiting, confusion, etc. And as ever, I am an otherwise healthy individual who rarely experiences illnesses and generally makes speedy, fully recoveries on my own. I felt like I had a lot on my side in terms of weighing the wait.

When we got to town, I had lunch with a friend from high school who was in the area visiting relatives. His father is a doctor, and he mentioned my leg to him, to which his response was the predictable “He should get it checked out.” His dad is a good doctor and a thoughtful person in general, so I asked if he’d take a look at it to see if it was at all obvious from a visual inspection what was going on. He agreed and was surprised that I did not have tenderness or problems moving my toes up toward my shins, indicators for possible blood clot. Still, my leg looked “nasty” in his very medical opinion and he suggested I go to the ER and have them take a look. It could be a blood clot or cellulitis, an under the skin infection, both of which generally require medical intervention to treat.

The blood clot thing did concern me. I was exhibiting some of the symptoms (swelling, redness, soreness) but not all of them, and based upon my diet and exercise I assumed it’d have to be freak luck or a weird immunological response (say, to a bite?) to develop a blood clot in my leg. It seemed a really low probability, but the way to diagnose it is an ultrasound, which I’d rather not do if I don’t have to, but I don’t see as a health disaster for me for attempting.

A trip to the ER brings with it some risks– contracting an infection you didn’t come in with, incompetence in conducting routine medical exam techniques (blood draw, IV), “intervention spiral” where the medical professionals push you to treatments for diseases you don’t even have that just make your health worse, false positives. So I don’t want to go to the ER if I can avoid it. And I still think I could’ve avoided it. Aside from the swelling and redness, nothing else about my condition seemed to be getting worse and I wasn’t exhibiting any other symptoms, it seemed like it was worth taking a punt.

I decided to go to the ER based on the following:

• second opinion of a non-specialist MD was that my reaction/condition was not “normal” and may be symptomatic of conditions that are potentially tissue-damaging or fatal
• family was getting worried and doesn’t have the same mental and emotional framework for thinking about this as I do, so they’re going to increasingly see my approach as needlessly risky and stubbornly defiant over what could admittedly be a long self-recovery period
• so far, no one including myself is able to diagnose what’s likely going on with any certainty
• because I believe I am an otherwise healthy individual with a strong immune system, I think the specific risks of being exposed to an ER are pretty low for me, so I am willing to trade the potential cost of exposure to risks for gaining more certainty about my condition; my suspicion is that my condition is nothing to be worried about, but I am not prepared to take a gamble on it as we near the delivery date for our first child (best part about this, my wife was pretty skeptical and kept sending sarcastic texts to me as I explained what was going on along the lines of “What did you expect at an ER?”)

Getting admitted was even easier than going to the GP’s office on Wednesday! I filled out a half sheet of paper with my name, birth date, phone number and reason for coming to the ER. It was raining today and there were all of 2 people in the waiting room when I arrived, I got pre-screened in about 3 minutes and then walked to my private room in another 2 minutes and was seen by a nurse attendant in another couple of minutes. The doctor came in and talked to me while a scribe annotated the conversation about 5 minutes later. In total, I was at the ER from about 3pm to 6:30pm.

Before I go further, I want to make something clear: I don’t see myself as anti-Western medicine or anti-medicine in a general sense, and my observations are not supposed to be read as some unbridled skepticism or lowbrow guffawing at the “scam” of the system. I felt I was treated with concern and respect by everyone who I interacted with at the ER, and whoever is the equivalent of the General Manager of that operation is doing a great job because it runs smoothly and its clear customer service is something they’re trying to deliver. This ER is in the hospital I was born in, and which we may have to turn to in the event of a complication with our home birth plans in the coming weeks. I don’t think it’s necessary or reasonable to try to scandalize the people or the process. I simply want to illustrate my thinking about the interventionist mindset and how I experienced it at the ER.

And I knew exactly what kind of a jungle I was walking into. I made the decision when I went to the ER to also go along with (but question first) any routine intervention they’d attempt to administer unless I could get them to talk themselves out of it, or I seriously feared it posed an undue risk to my health. I’ll provide more explanation about this in a bit, but for example, they put me on an antibiotic IV– that wipes out my carefully cultivated gut bacteria and potentially exposes me to direct bacterial infection through intravenous contact, but I believe my full immunity and health profile make it statistically unlikely I will be unduly harmed by this specific intervention.

With that out of the way, I will say this: life is an uncertain enterprise.

Perfect knowledge and omniscience is not something any individual can obtain, nor need they try. We are always grasping at a little bit more illumination in our lives, more clarity when there was less focus, more understanding when before there was ignorance, and this goes for the practice of medicine as well. The contributions to the improvement of human life on this planet by innovations in medicine and physics over the last 200 years are truly astounding, so astounding that some people have concluded that we know most of what we can know about these subjects or that, at least, we need not question their conclusions. I just don’t share this conviction. I look at all actions in life as being about tradeoffs, and I see these tradeoffs being motivated by perception of uncertainty and a desire to gain more certainty. So I look at medicine as offering many answers, but not everything, and certainly not any answers that shouldn’t be questioned. Everything should be questioned, if you’ve stopped asking questions you’ve probably started to experience the knowledge dishonestly.

I went to the ER to try to relieve some uncertainty.

The nurse informed me that they planned to run a blood panel on me, which meant they needed to draw some blood. The reason for the blood panel was to see if there was any distress markers in my blood, particularly an indication of acute infection. The two theories that the doctor who saw me had were that I either had a blood clot, or an infection. Because they were going to put an IV into me to draw the blood, they decided they’d just hit me with an antibiotic drip right away as well. This was puzzling to me, because they planned to do this before confirming the results of the blood panel. The response I got from the doctor was (summarized) as follows:

MD: It’s better to be safe than sorry, don’t you think?
ME: Let’s say I have an infection, what are the chances my body could fight this on its own?
MD: (pauses for a few seconds) …mmm, 50/50. But if your wrong, and your body loses, you could lose your leg. I don’t want to scare you, but I’ve seen these things go fast, like if that’s what it is, you could be fine and then an hour later you’ve lost and it’s too late.
ME: I generally try to avoid antibiotics.
MD: Me too! I never give my kids antibiotics. Like, I won’t give them antibiotics unless they’re dying. Trust me, I wouldn’t suggest this unless I thought it was absolutely necessary, okay?

Of course, if I don’t have an infection, but a blood clot, then what good were the antibiotics? And if I have neither, what good are the antibiotics?

The nurse also informed me I’d get an ultrasound of my leg done to check for the possibility of blood clots. The doctor and the nurse worked together with a doppler to check my pulse in my legs and feet, which they were able to confirm, but their concerns about the heat emanating from my swollen leg led them to the “safe vs. sorry” compromise of ordering another test.

As the nurse walked me through the test regime I was about to run, I asked, “Any idea what this will cost me?” Of course he didn’t know, and up to this point, no one bothered checking with me about the cost of services. It ended up being $250 for the co-pay and I don’t know yet what it was for the tests. I also don’t know if the IV antibiotics costs more than an oral treatment. I asked the nurse about this and he went into a rationalization about not taking chances, etc.

The nurse was very good at drawing my blood. The injection was almost undetectable. The ultrasound technician was also efficient. We talked about her automobile purchase history and she had me all checked out in about 15 minutes. An orderly wheeled me around from room to room in my gurney bed, which enhanced my feeling that something was really wrong with me and at any moment I could crater. I noticed passing through the hall that the other patients at the ER were all males, either very elderly males probably near the end of the road who had had a fall, or gotten sick, or very young males who had just made a very poor judgment call and were now paying the price.

I couldn’t help but thinking, “What is wrong with this picture?” as my seemingly-healthy, 30-year-old trim frame was being shuttled from room to room. Two ideas came to mind: either nothing was wrong with me, and that’s why I shouldn’t be in the ER with these people, or something was REALLY wrong with me, and that is why I was suddenly in the ER with these people.

I waited another 45 minutes by myself on my bed gurney before learning of the test results. A financial admin came in and out to run my insurance and have me initial some boilerplate. I started initialing without reading it and got halfway down the list and saw something saying I agreed to have my medical history inserted in a state database. “Do I need to do this?” “No. I know, next thing you know you’re going to be getting called by a telemarketer…” (not really what I was worried about on that one). So I didn’t initial it, went back over the ones I did, finished the others and wondered what law or series of events had conspired to have a financial admin highlight for initialing the sharing of private medical data in a public database without comment or concern?

Ultrasound: no blood clot found.
Blood panel: no acute infection indicated, blood work looked very good including liver and kidney function (I made sure to ask my nurse for a copy of my blood panel so I could interpret it more fully later, since a blood panel costs $$$ and I planned to do one eventually anyway, this helped me recoup some of the cost on this unnecessary intervention visit)

So, what was wrong with me? The doctor admitted she really didn’t know. Her suspicion was that I was bit by something and it either had some bacteria on its fangs, or it triggered a strange reaction. She told me she wanted me on an antibiotic regimen “just to be sure”, and to come back immediately if my leg felt tingly or numb. She said I could take some Benadryl to try to treat the inflammation as well.

I asked the nurse to help me interpret my blood panel. How did it look? “It looks great, really good panel, no indication of acute infection…” “So then why am I being administered an oral regimen of antibiotics if there is no infection indicated?” “Well, the body is funny, it COULD be infected and it just hasn’t shown yet in the panel, but anyway, we’ve seen a lot of crazy stuff, better safe than sorry right? I mean it can’t do any harm to get the antibiotics, it can only make it better.”

He grabbed my checkout paperwork and had me look over it and sign. The paperwork says that I acknowledge the diagnosis and the treatment being recommended. The nurse says, “We don’t know what you have, but we’re calling it ‘cellulitis’.”

I gained some additional certainty that I don’t have a life-threatening blood clot and that I am not at risk, as of this very moment, of losing my leg to a bad infection as one doesn’t seem to exist. My experience led me to conclude that allergy and immunology medicine are perhaps younger, frontier sciences within the practice of medicine with higher levels of uncertainty than the practice itself. Everyone’s still uncertain about what actually happened to my leg!