Emergency room neurosurgery: modern time errors.

Key Words: clinical, emergency room neurosurgery, errors

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The young neurosurgery resident was heading for another on-call in a large tertiary medical center. His duties for the next 12 consecutive hours would include, besides caring for the neurosurgical floor and neurologic intensive care unit patients, numerous emergency room consultations. No easy access to primary health care was afforded during the night, and cases ranging from mild head injury to severe subarachnoid hemorrhage would arrive mingled up by chance at the emergency room. It was 5 minutes to 8 in the evening, and his shift was about to start. The nurses were piling up in his box the registration sheets of the people waiting for his evaluation. He entered the place with no delusions about what to expect--it was a Saturday night call.

Around 3:30 AM, he picked up a note from his box referring somebody for evaluation from an insurance doctor. He glanced quickly at the name written on the top, called twice in the crowd waiting outside the room's entrance, but there was no reply. "Inane referrals," he whispered to himself as he threw the piece of paper back onto his stand.

The next case was a middle-aged woman presenting with headache and contusions on her face after her husband had deliberately hit her at home--the third time within a week. History and physical examination were unremarkable, although she had a gloomy expression and could not communicate properly. No wonder--she was of Eastern European origin and had been in Athens, Greece, for only 10 months, trying to secure a better future for her two children. She was beset on the one hand by personal problems, her husband's alcoholism and violence, and on the other hand faced the burden of society's woes, struggling against the dismal financial lot of the modern refugee.

She insisted on having given back to her the letter her referring physician had sent along. The young resident hastily replied that no such letter had been presented to him, and concentrated on reassuring her that she did not seem to have suffered serious brain injury. The lady said that she was in great need of the letter as evidence in a legal case filed against her husband; the whole process had already taken a great psychological and monetary toll on her. The doctor decided not to pay further attention. "What else am I supposed to do in this hell?" he mumbled to himself as he rushed to the next trauma case, which was already in, with pupils unequal and limbs in extension ...

... It was now almost the next midday, and at last there were no more patients to see. As he poked his hand into his box to verify its emptiness, the resident touched again on the note from the insurance doctor, asking for an evaluation of the man he could not find some hours earlier. But this time, as he looked the slip of paper over again, an astounding fact fell to his attention. A few lines below the note's heading, he could read the name of the Eastern European woman who had asked for the referring letter.

Now he realized that the name he was calling out in the crowd was not a patient's, but that of the insurance doctor, and that the woman's name was just two lines below. The startling understanding of the misreading coupled in his mind with the unaltered sadness in the woman's face as she was leaving the emergency room. He imagined her being back home with no further courage to go on with the case against her husband, ready only for another circle of extreme social stress, another day of severe financial constraints and, most tragically, another turn of powerful blows to her soul and body. What had he done to prevent this?

As his on-call shift was coming to an end, his conscience spoke with a particularly stern voice, one belonging to a renowned neurosurgeon: "... We come therefore to the very practical question of what aspects of human faculty it is necessary for the good doctor to cultivate ... The first to be named must always be the power of attention, of giving one's whole mind to the patient without the interposition of oneself...." (1)

That morning the young resident understood that errors do not only crop up during bedside consultations, be it a history-taking or physical examination. They do not even restrict themselves to within the limits of a differential diagnosis elaboration or laboratory data interpretation--let alone percolating through operative technique. He learned the hard way that incomplete attention to the patient persecutes continuously in a mundane way the art of being a physician--not only the science. Belittled by the frenzy of evidence-based medicine, obscured by the intricacy of systems aimed at quality health care, and outdated by the hype of clinical malpractice times, all-inclusive consideration of the patient's needs seems many times to escape our notice, and its absence is threatening to become yet another elusive kind of error.

An inconvenience is only an adventure wrongly considered; an adventure
is an inconvenience rightly considered.
--Gilbert Keith Chesterton

Accepted June 4, 2004.

Reference

1. Wilford Trotter, quoted by Beeson P. The Nature of Medicine, in Beeson P, McDermott W (eds): Textbook of Medicine. Philadelphia, WB Saunders, 1975, ed 14 pp 1-4.

RELATED ARTICLE: Key Points

* The holistic approach to patient care appears to be justified today more than ever.

* Modern acute medical treatment, especially in technologically based settings, has a high chance of failing to address the multitude of patient needs.

* Physicians should be reminded that work conditions cannot and should not affect their sensitivity to the complex social ramifications of their patients' "disease."

I. Karampelas, MD, and K. N. Fountas, MD, PHD

From the Department of Neurosurgery, The Medical Center of Central Georgia, Mercer University School of Medicine, Macon, GA.

Reprint requests to Dr. Kostas N. Fountas, 840 Pine St, Suite 880, Macon, GA 31201. E-mail: [e-mail]