Preparing his defense in a similar case may have helped this doctor spot the symptoms of a near-fatal condition.
It had been relatively quiet on the evening shift in the ED that night. About 2:30 a.m., just before quitting time, I walked around the corner to help our PA with some of the easier patients. Maybe we could both get out on time for a change, I thought. The first chart in the rack said "hemorrhoids." I pushed open the door to Room 45 to find a young man tossing and turning on the stretcher, trying in vain to get comfortable. He clearly needed help, but his problem was far from life-threatening. I prescribed suppositories and pain meds, and moved on.
The next patient was an affable, middle-aged African-American, complaining of a cough and a cold. He was sitting up on the edge of the bed, seemingly in no distress. After exchanging greetings, I asked about his symptoms. He said he'd felt fine before going to bed, but now he was a little short of breath. "Must be my asthma acting up," he told me. "That always seems to happen when I catch a virus."
I glanced at the patient's chart again. His O2 sat was a tad low at 96 percent, but nothing alarming. The rest of his vital signs were fine. I looked in his ears and throat, but didn't find much to worry about. Palpation of his neck revealed some mild tenderness over the trachea, which was a bit unusual. But he wasn't particularly apprehensive when I touched his neck again to confirm my findings.
I poked my head out the door and barked orders for oxygen and a neck film. Then I called for the charge nurse: "Let's get this guy into one of the trauma rooms. I think he's got acute epiglottitis, and I want everything ready in case things go bad and we have to tube him."
That produced a few quizzical glances from the professionals I go to war with every day, as if to say, "This guy doesn't look all that sick. What's all the fuss about?" Fortunately, we've worked together long enough to trust each other's intuitions. The well-trained crew sprang into action around our obviously bewildered patient.
When the X-ray came back, there it was, straight out of the textbook: the classic "thumbprint" of a swollen epiglottis looming over the opening to the trachea. To make matters worse, edema of the surrounding tissue had markedly restricted the man's airway, leaving him with dangerously limited access to oxygen and a tenuous hold on life. A crowd gathered around the view box, fascinated by the picture of a disease so rare that most of these veterans had never seen a case before.
When I got the on-call ENT doc on the phone, she sounded sleepy. "I've got a patient with acute epiglottitis that's about to obstruct his airway, and I need you here STAT," I told her. "On my way," she replied, suddenly alert.
A flurry of activity followed. We pushed steroids for the inflammation, and antibiotics for the infection. Under close observation, our patient weathered the crisis without the need for more heroic measures. After the excitement was over, the PA came over to talk to me.
"Thanks for saving my ass," he said, realizing that if he had treated the patient for a simple cold, and sent him home, the patient would have been dead well before morning. "I'm not sure I would have picked that up. But how did you know?"