"wild cases" a perspective of a medical student

by Karen Kolb

lucy y liu

spring 2016


“Today, a patient came in with abdominal pain, and it turned out to be a triple A!” Jack said.


We sat at a table in the hospital cafeteria, wolfing down lunch. The four of us had run into each other from different services in the hospital – surgical oncology, emergency department, and pediatric surgery. As third year medical students, we all knew immediately that Jack was referring to an abdominal aortic aneurysm (AAA – the triple A): a deadly condition and surgical emergency if ruptured. We had read extensively about it.


“Wow. That’s awesome.”


Susan jumped in, “Last week, we had a newborn who had situs inversus. She had a malrotation of the gut and had to go under surgery.” This was a rare condition in which the patient’s organs were flipped. The heart, which is normally on the left, was on the right side in this patient. It is commonly associated with malrotation of the intestines, which could cause obstruction and inability to keep food down. It necessitated a major operation and anesthesia in a baby.


I immediately thought of a case I’d seen recently. I was on my emergency medicine rotation, seeing patients and doing a routine history and physical exam, when I heard: “Medical patient in Resuscitation Room 1. Medical patient in Resuscitation Room 1.”


Ed, the resident I was working with, immediately jumped up from his computer and walked quickly towards Room 1. I followed closely behind him. “What’s the story?”


“Young female in her teens was found unconscious by mother, coughing up blood, with a fetus and placenta between her legs. She was intubated on the scene. She has a history of multiple drug abuse.” The paramedics brought the patient in.


She was minimally conscious and struggled as she was lifted onto the exam room table. The room was rapidly filling up with personnel. Two nurses worked at each arm, putting in an IV and drawing blood for initial labs. Another began cutting her clothes away, careful to cover her with a gown. Residents began their initial assessment of the patient: making sure she was hooked up to a breathing machine, and checking her pulse and breath sounds. These were the ABCs we all learned about – airway, breathing, circulation.


I was four weeks into my clinical rotations as a third year medical student. This was my 3rd shift in the emergency department. I stood in the back with a nursing student, our backs plastered to the wall. I looked at her, sharing a look that only students have – the look that says, “I have no idea what to do. I will try to be the fly on the wall and learn as much as I can by observing. Wait until I tell my classmates about this ED shift.”


That’s when I look beyond her and see a baby, still attached to the placenta.


It looked peaceful and, though smaller than a full-term baby, had very human features and a beautiful little face. I found out later that it was a 28-week girl. I expected her to open her eyes and cry, waking up from the nap any minute. The sound of the monitors, trauma assessment coming from Ed, rustle and bustle of the resuscitation room faded into the background – I was so focused on the baby.


I suddenly realized that there was a plastic bag. She was zipped in a plastic bag, on top of a garbage can, and she was not breathing.


Suddenly, someone picked up the baby in the bag and put her in the adjacent resuscitation room. “Someone page pediatrics and OB [obstetrics]!”


I staggered into the next room. An attending arrived, took the baby out of the bag and pronounced her DOA – dead on arrival. The mother, still unresponsive in the next room, was sent up to get a CT scan and everybody dispersed from the resuscitation room. We found out later that she had a condition called acute fatty liver of pregnancy, a potentially fatal condition that could result in the mortality of both mom and baby. She remained sedated and very sick.


Dr. Thomas, the attending, came to find me. “Let’s go talk to the girl’s mother. I don’t think she has heard about her granddaughter yet.” Ann, the mother of the teenage girl, and the grandmother of the baby, sat silently in the emergency department waiting room, clutching her hands tightly. She sat a distance away from everybody else, despite having two family members close by. Nobody was touching her. Dr. Thomas led the family into a private room. He wanted me to observe how he broke bad news to families – an important concept to learn. I wanted to cry for this family, but stood silently, struggling to learn about breaking bad news.


Though I was supposed to observe, I cannot remember how Dr. Thomas described the gravity of the situation. I cannot recall the exact words, tone, or body language he used. Instead, I remember seeing Ann stiffen her spine. I remember Ann holding back tears while she told us, the medical team, that they had found an empty bottle of her pain medication in her daughter’s room. I remember when Ann’s tears finally fell, with her head bowed down in unimaginable sorrow when she heard that her granddaughter was dead.


Suddenly, the case didn’t seem so cool. I didn’t tell my classmates about this wild case I’d seen. The “wild” cases we see in the hospital all too often mean a tragedy for a family. Someone’s father was in danger of an aortic rupture. Someone’s daughter needed surgery at the young age of two months. Someone’s husband was diagnosed with metastatic lung cancer.


As third year medical students, we want to see as many patients as we can. We are told to be a sponge – our priority is to soak in as much information as we can. We are to see everything – from surgeries to ICU patients to obtaining EKGs and even fecal disimpactions. That’s the only way we can truly learn – to see and manage patients who are suffering from disease X or disease Y. Everything we see in clinical rotations is a culmination of the hours we put in reading about similar cases in textbooks and case reports. But nothing, nothing we ever read or study ever prepares us for the reality that disease X or disease Y will elicit muted emotions that is infinitely magnified in the patient and her family.


While Ann stood outside of her daughter’s intensive care unit (ICU) room, staring into the sterile space, I approached her. I wanted to say, I’m so sorry, about your granddaughter. I hope your daughter pulls through; but it seemed so trite and meaningless in my mind. I choked out, “I’m sorry,” struggling to keep my tears from falling.


Ann reached out and grasped my hands. “Thank you,” she said.


At lunch with my classmates, I snapped back to attention when I heard my name. “Lucy? You’re on the emergency department rotation, right? See any cool cases?”


I smiled and shook my head. “No. Maybe tomorrow.”


All names in this vignette are fictitious.