The Emergency Room July Effect: Fear And Trembling

According to the cynical advice that circulated through my medical school,

As tends to be the case with cynical advice, underlying the implicitly sardonic veneer of this expression is a fundamental truth – about the hopelessness of the human condition.

In this instance, the verity referenced is the fact that in July a high proportion of a teaching hospital’s front line medical staff is composed of new trainees. More poignantly put, if you come to such an institution for healthcare in July, the young whippersnapper who was yesterday a mediocre medical student requiring constant supervision lest he rip out another spleen by tugging too hard on the surgical retractors is today – ta da – magically transformed into your doctor.1

And so it was that on a particularly pleasant July day 40+ years ago, DrHGuy, who had, in fact, legitimately garnered the “Dr” portion of “DrHGuy” only two weeks earlier, arrived for his first shift at the Emergency Room of Michael Reese, the medical center on the south side of Chicago where his residency – his psychiatric residency – was hosted.2

And, it was only a short time later that same day when the medical responsibility for the care of a thin, black teenage boy, who had apparently gotten on God’s bad side, settled on the shoulders of this newly minted physician.

Rural Missouri As Preparation For The Baddest Part Of Town

Let us pause the narrative at this point to reflect upon DrHGuy’s training at the University of Missouri Medical Center, a tertiary care center with a busy emergency department that drew patients from a large geographic area. Consequently, medical students and residents were exposed to many cases of acute illness and trauma, a significant portion of which were either unusual or dramatic in presentation. Had, for example, a denizen of Chicago’s south side entered DrHGuy’s ER that day in July as a consequence of coming in second best in a confrontation with a rogue combine, that would have been one lucky patient because he would have been under the care of a resident with experience in exactly that kind of accident.

On the other hand, one might or might not be surprised to discover just how few thin, black teenagers in respiratory distress found their way to that facility in the mid-Midwest where DrHGuy had, until his arrival that day at his residency, undergone the entirety of his medical training. Perhaps more to the point is the fact that the total number of young black males in respiratory distress DrHGuy had encountered professionally at that point –  if one includes the Michael Reese ER patient just described – was precisely one.

Back to our story.

DrHGuy and Patient Enter Dire Straits

DrHGuy’s reaction to the 16 year old black male, who was unable to provide information about his problem because of his desperate wheezing, was not, as one might anticipate, the stunned aspect and disabled thinking attributed to the fabled deer-in-the-headlights. The pertinent metaphorical animal was not a deer but a zebra, as in the hoary medical aphorism, When you hear hoofbeats, think horses, not zebras.3

The particular emergency room encounter, in fact, resulted in DrHGuy trying to control a stampede of zebras in the form of possible but unlikely diagnoses, including, among others,

• Vocal cord dysfunction
• Chronic obstructive pulmonary disease
• Bronchitis
• Bonchiectasis
• Endobronchial diseases and tumors (primary and metastatic)
• Aspirated foreign body
• Extra-or intra-thoracic tracheal obstruction
• Cardiogenic and non-cardiogenic pulmonary edema
• Pneumonia
• Pulmonary emboli
• Chemical pneumonitis
• Hyperventilation syndrome
• Carcinoid syndrome
• Fungal infections
• Congestive heart failure
• Psychogenic dyspnea
• Mitral stenosis

And, of course, atrial myxoma.

Cue The Cavalry

Just then, the nurse assigned to the case, encumbered with a variety of medications and all manner of associated accoutrement, addressed DrHGuy, whose differential diagnoses list was eclipsed only by the compilation of diagnostic tests he intended to order, uttering, in a skillfully modulated voice that expressed experience with, respect for, and, above all, absolute confidence in that nascent physician’s professional expertise, those five words that proved so glorious and life-changing that he’s never forgotten them:

The usual asthma setup, Doctor?

DrHGuy, happily, had enough of his wits about him to recognize an obviously correct diagnosis when he heard it and to reply “Yes, thank you, nurse.”

Most importantly, he managed to (1) forgo automatically appending to his response any phrase along the lines of “… and make it snappy” and (2) express his appreciation to that nurse without a concomitant attempt to deny the plight from which he and the patient were simultaneously rescued.

DrHGuy has a thing for nurses.

 

Note: Originally posted Sept 13, 2007 at 1HeckOfAGuy.com, a predecessor of AllanShowalter.com

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1. A lingering, unreciprocated loyalty to science compels me to note that the results of studies of the July effect are mixed. Wikipedia offers links to several such studies. [↩]
2. Michael Reese, sadly, is no more. See Last Exit From Michael Reese – The Final Days [↩]
3. This saying, sometimes phrased “When you hear hoofbeats behind you, don’t expect to see a zebra,” has enshrined “zebra” as the preferred slang medical term for an obscure and unlikely diagnosis from ordinary symptoms. [↩]