Case 6: Do No Harm

[Triage Note: 76 yr. old male, abdominal pain. central, radiating to both sides. no nausea or vomiting. dizzy and light headed . feels faint.]

It was early-March. I walked quickly past the ambulance bay, shivering as the doors opened, a frigid gust blasting my skin. Paramedics pushed a stretcher into the hall, as a limp body gasped for air. I slowed, then turned back toward the stretcher, which was now moving away from me and heading toward resuscitation room A.

“Doc,” the tired man said when I caught up to them. “I need help.”

“What happened?” I said. “You look terrible.”

“I feel terrible.” He gripped his stomach. “My belly is killing me. I’m going to pass out.”

I grabbed his wrist. His pulse was weak, his hands cold. A nurse inserted an IV and turned to me: “Do you know each other?”

“We met here a couple of months ago,” I said.

“What’s his medical history?”

Bill spoke, his voice weak. “I didn’t have any medical history until I saw a doctor.”

SNOW STILL HADN’T  touched the ground when I met Bill Fox at the beginning of December. A strong man with a broad chest and a golden tan, he was sitting on a stretcher, chatting with an attractive middle aged-woman. He’d just returned home after a month in the Caribbean.  A widower, he’d met Colleen, twenty years his junior, on a similar trip just after he retired from banking. Eight days before our initial meeting, after an evening relaxing on the beach, Bill went to bed with an upset stomach. He woke later that night with vomiting, and later developed chest pain and shortness of breath. He visited a clinic and had “some tests,” none of which he could recall. He was prescribed antibiotics, and had taken his last dose that morning.

“So before last week, when was the last time you saw a doctor?”

Bill smiled at his companion. She shook her head, answering for him: “Not as long as I’ve known him.”

“How long is that?”

“Nine years,” she said.

Bill laughed, then fell into a coughing fit. “She says it like it’s a bad thing.”

I put a stethoscope to his back and asked him to breathe in and out. “I think it’s been a little longer than that.”

“Probably in my twenties,” Bill said. “For a work physical.”

“You’re seventy-six,” I said.

“That’s how I made it to seventy six,” he said, placing a hand on my shoulder. “Until this past week, I’ve been in perfect condition.”

“Yeah,” I said. “And suddenly you can’t breathe.” I sat on the edge of the stretcher as he called me ‘pal’ and cracked one joke after another. “How long have you been smoking?”

“Since he was eight,” the woman said. “Maybe longer.”

He laughed. “They didn’t have pacifiers back then.”

“Did the antibiotics you were prescribed help you?” I asked.

“A little, but I’m still short of breath, and I’m still bringing up phlegm.”

He reclined as if he was still in the sun, the stretcher’s mattress looking like a scrap of foam under his long, muscular frame. The blood pressure cuff inflated on his right arm, giant veins becoming quickly engorged. Small grey ECG wires were affixed to his chest. If it wasn’t for his breathing – the muscles of his diaphragm working unnaturally fast – he would have been the picture of perfect health.

“You’re wheezing quite a bit,” I said. “And when you breathe out, it takes a long time for the air to leave your lungs.”

“What does that mean?” Colleen asked.

“You likely have emphysema.”

“Can you just give me some pills, and I’ll get out of your hair?”

“I’d like to run some other tests,” I said. “You have a heart murmur as well. And you have chest pain. I want to make sure everything’s alright.”

Bill looked at Colleen: “There’s no way I’m staying overnight.”

“Let me run a couple of tests and we’ll go from there.”

Nurses came and drew blood. Porters transported Bill to x-ray, and then for a specialized test called a V-Q scan to rule out a blood clot in his lungs. After almost eight hours in the E.R., I sat down with Bill and discussed the results.

“The chest x-ray is strongly suggestive of emphysema,” I said. “I’m going to start you on an inhaler and have you follow up with a respirologist.”

“At least there’s a reason for my shortness of breath.”

“It’s not just that. Your red blood cell count is one-hundred and eight, which is a little low.”

“Any reason why?”

“I’m not sure. Have you ever had a colonoscopy?”

“Of course not,” Colleen said.

“Any blood in your stool, or black stool?”


“Weight loss?”

“A little, maybe ten pounds or so?”

“Oh come on,” Colleen said. “You’ve lost double that in the last three weeks.”

He laughed. “I’m on weight watchers.”

“He is not,” Colleen said. “He’s trying to be funny.”

“I’m going to set you up for a colonoscopy, just to make sure there’s no source of bleeding.”

“Whatever you say. Now can I go home?”

“There’s one more thing,” I said. “Your chest x-ray.”

“Oh God,” Colleen said.

“There’s a large shadow there. It might just be a large pneumonia, but it looks a little suspicious.”

“For cancer,” he said.


Bill sat up, and peeled an ECG lead from his chest. “Can’t say it didn’t cross my mind.” He began buttoning his shirt. “So where do we go from here.”

My pen raced across a pad. “Here’s a prescription for antibiotics. Dr. Lobar, the lung specialist will call you shortly with an appointment.”

“Thanks for all your help, pal.”

“One more thing before you go,” I said. “You don’t have a family doctor, do you?”

“Of course not.”

“I’m going to set you up with a friend of mine, if it’s alright with you.”

“Thanks,” Colleen said. “We really appreciate all you’ve done.”

My friend, Dr. Mark Evans, saw Bill in follow-up a week later. He wasn’t one-hundred percent yet, but the inhaler I’d given him was helping. The antibiotics were finished, and his cough had improved. Bill’s initial consultation with Dr. Lobar was a few days earlier. The lung specialist wanted to send him for a CT scan and perform a bronchoscopy – “a colonoscopy for the lungs,” Dr. Lobar had told him. And then there was the pending appointment with Dr. Gutcheck, which would happen in a week – just before the Christmas Holidays. Dr. Evans re-filled Bill’s inhalers, checked his blood pressure, and made some notes, arranging to see him after the CT scan.

A week later, Dr. Lobar placed a camera into Bill’s breathing passages and took washings from his lungs, sending the samples for cell analysis. There were no gross signs of cancer, but Dr. Lobar was still suspicious. The CT scan was not reassuring: The large collection seen on xray was still there. More antibiotics were prescribed, and more inhalers given. Tired, frustrated, and without any  answers, Bill met with Dr. Gutcheck and consented to a colonoscopy for the first day of February.

Dr. Gutcheck was through. She scoped him from the top, and then from the bottom. No signs of bleeding – no trickling ulcers in the stomach, no signs of tumors in the colon. Just as Bill was waking up from the anesthetic, he went into cardiac arrest. CPR was initiated. An oxygen mask was placed around his mouth as a respiratory therapist pumped oxygen into his lungs. Within minutes, his heart was beating again. An EKG showed no ominous changes. He was transferred to the Intensive Care Unit and was chatting with family several hours later.

“What happened?” Colleen asked the attending doctor.

“His heart stopped after the procedure.”

“Did he have a heart attack?”

“No signs of a heart attack, but we’re going to check his vessels tomorrow.”

“What else could it be?”

“We still don’t know what’s wrong with him,” the doctor said. “And we still don’t know if he has cancer or not. With your underlying illness, whatever it may be, it’s possible that the colonoscopy, along with the sedation, was simply too hard on your heart and that’s what provoked the arrest.”

“How will we know?”

“We’ll see what the angiogram shows tomorrow.”

Bill spoke: “Do we have to do it?”

“Have to what?”

“Do we have to do more testing?” He looked to Collen and his adult son, who was walking into the room. “More tests? I’m wondering whether or not you should have even revived me today.”

Colleen’s face flushed. “You don’t mean that Bill.”

“I’ll let you discuss that as a family,” the doctor said.

Bill was kept in hospital for two weeks. Dr. Lobar’s bronchial washings were negative – there was still no evidence of lung cancer. He received a blood transfusion and his energy improved. Two weeks after the cardiac arrest, Bill was discharged. “I have some good news,” Dr. Lobar said. “The washings from the lungs were negative for cancer.”

“So I’m clean?”

“I’m going to put you on two more weeks of antibiotics and hope that the infiltrate on your CT scan clears up.” He handed Bill a sheet. “This is an appointment for a repeat CT scan in early-March. We’ll see how things are going then.”

Bill had a relaxing morning at home before coming in for his 1pm scan on March 5th. Four hours later, he was wheeled into the ER on a stretcher complaining of abdominal pain. I hadn’t seen him since our initial meeting and it took fifteen minutes on the computer to get updated on all the testing that had been completed. Over the first hour, Bill’s abdominal pain worsened, and then he developed chest pain. The EKG again showed no signs of a heart attack. His blood pressure dropped. Fluids were given with little improvement. An internist and cardiologist were consulted. It had only been a couple of weeks since his angiogram; the vessels supplying his heart were clean. Something else was going on.

Blood work showed that his liver was failing. His heart was too, as fluid backed into his lungs. Two hours after presentation, Bill spiked a temperature. Bill’s white count was elevated. The specialists scoured his medical records and found a potential previous exposure to a hospital super-bug: Vancomycin-resistant Enterococcus. Broad spectrum antibiotics were given. Bill’s breathing worsened: he was intubated and placed on life-support.

Over the next several hours, Bill’s condition deteriorated. IV medications were given to maintain his blood pressure. Subsequent tests showed worsening heart and liver failure. Bill was dying. His family gathered by his bedside and by morning, they made the difficult decision to withdraw life support.

The source of the infection that tipped Bill into multi-organ failure was never identified. The day of his death, Colleen tracked me down in the ER and thanked me for the care I’d given her partner. She thanked me for being thorough, and asked me to pass along a thanks to Dr. Evans, who had coordinated Bill’s care since his first ER visit in December.

A month later, Mark Evans and I got together for a drink. “I wonder what might have happened if I’d just listened to his lungs, presumed he had pneumonia, and given him a course of antibiotics,” I said.

“Who knows.”

“If I didn’t set up the colonoscopy, or the scan, he wouldn’t have had the cardiac arrest, and he wouldn’t have spent two weeks in hospital, and he likely wouldn’t have been exposed to the infection that killed him.”

“Whatever that may be,” Dr Evans said.

“Whatever that may be.”

“Did you ever see the result of the second CT scan?” he asked. “The one that he had the day before he died?”

“No,” I said . “Cancer?”

“No. It was much better. The antibiotics wiped most of the infiltrate away.”

“Really,” Mark said. “So if we’d just given him antibiotics and left him alone, he have still been alive today?”

“Maybe,” I said. “Just maybe.”

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