Man… I learned so much through just one patient encounter. I am not talking about my medical knowledge, but rather about medicine and my own character as a doctor.
1. Attendings (even those with 15 years + experience) don’t always know more than you do.
2. Emergency Department physicians should continue call consults for any and everything, even when it seems “stupid”.
3. Always look at your own radiology images.
4. Trust your gut and don’t be afraid to advocate for your patient.
5. Journal club is important!
After reading that, you are probably wondering what happened. Well, I just finished with surgery and got a phone call from the Emergency Department. This was one of those, “I just have a quick question, no need for a consult” phone calls. They simply wanted to know where one of our OB patients needed to follow up. It was presented that she had light first trimester bleeding with a normal pelvic ultrasound and blood work. I decided to look up her ultrasound myself and turns out she has a cornual pregnancy! A cornual pregnancy is a pregnancy that is not in the correct spot. When these things rupture the women can have life threatening hemorrhage. You can think of it as a BAD ectopic (tubal) pregnancy. Based on the size of the pregnancy, she was fairly far along to be presenting with the symptoms she was having.
So, I tell the story to my attending who decides the ultrasound looks pretty normal, and that they would send the patient home. I kept mentioning that the position of the pregnancy was not normal, and they decided to ask the other attending coming on shift to take a look at the images. The second attending agreed the patient could go home, but that we set up an urgent ultrasound appointment with the high-risk OB doctors the next day. Now, I found it quite curious that it’s urgent enough to need repeat imaging in 24 hours, but safe enough to go home… I decided that I would go and see the patient as a formal consult because this was not straight-forward first trimester bleeding, and I’m still convinced that she has a cornual pregnancy. I examine this woman and she is very tender on examination. I even went to review the images with the radiologist. After taking a closer look they agreed that the pregnancy was not in the right position! I present this information to my attending who still seems very apprehensive about operating on this woman. Ultimately we did get the specialists involved and operated on this woman. The surgery went very well since we caught it early. We were able to offer the appropriate management under a controlled setting.
FYI – Certain details have been changed so as not to violate patient privacy.
Now, to elaborate on the lessons I learned.
1. Attendings (even those with 15 years + experience) don’t always know more than you do. I suppose that once you are away from taking boards, perhaps the more rare diagnoses and their appropriate management can slip away from your memory. I basically had to remind two different attendings that the management for a cornual pregnancy is not outpatient management. Had we sent her home, she could have ruptured and had a life-threatening hemorrhage. The thing about being a successful resident is recognizing that it is okay to challenge your attendings, in a respectful manner. Ultimately, you have to do what’s right for your patients.
2. Emergency Department physicians should continue call consults for any and everything, even when it seems “stupid”. I have to admit, I sometimes get annoyed from the little phone calls from the ED. I mean if they are calling with a question, then it’s your obligation to look further into the story to make sure that you have all of the information to accurately answer the question. I could have easily given them the phone number for our low-risk clinic with strict bleeding precautions stating that first trimester bleeding is fairly-common. Luckily I looked up the patient’s information to be sure that I was doing the right thing for the patient. I’m happy that the ED doctor called me.
3. Always look at your own radiology images. The Radiologist may not be looking for the same things as you when they are looking at their 20th ultrasound of the day. It’s one of the best lessons I learned in medical school. I look at my own chest and abdominal x-rays, CT scans, and definitely my own ultrasounds. Although I may not always get the diagnosis correct I have more of a grasp on what is normal and what is abnormal. In this case, careful examination of the images caused the radiologist to change their report.
4. Trust your gut and don’t be afraid to advocate for your patient. As I’ve mentioned before, we are doctors because we want to help people. This woman wasn’t coming in with a diagnosis stamped on her head and a fully detailed plan typed up in her purse. No, she simply had bleeding and needed help. It’s up to us to do our part to figure out what is serious and what is not. When it’s serious, sometimes you have to be the one to convince an attending that more needs to be done. Unfortunately, the attendings have to worry about litigation (we do too) and often hope to pass the buck to someone else. That can often occur at the expense of the patient, so don’t be afraid to speak up. If I had just listened to the first attending, I would have just sent her home and who knows where she would be.
5. Journal club is important! I had never actually seen a cornual pregnancy. However, last year we had a journal club talking about the management of these types of pregnancies. I actually really enjoyed the article and remember the take home point was: cornual pregnancies are bad and need surgery.
Hope you can apply these lessons to your own experiences!
