My favourite medical television show has always been Scrubs. Don’t get me wrong, the accuracy of the actual *medicine* is probably the worst of the bunch. It’s just that I’ve never felt any connection to the way doctors are portrayed in other shows, particularly ones like House. It’s physically impossible to be a successful physician and be that as much of an arsehole as Hugh Laurie in that programme. What’s more, he says how he doesn’t like “talking to patients”, preferring instead to break into their houses to find relevant evidence to diagnose them. “Is there a doctor in the house?” never felt so cliched. No – there should be no doctors in the house. I guess the motto “history-taking is ninety percent of your diagnosis” never reached ol’ Dr. Greg.
Sports Sports Sports!
Unlike with House, what I’ve always loved about Scrubs is the way it portrays the relationships and human dynamics of working in a hospital: to this day, the statement that medics are nerds and surgeons are jocks has never lost any of its accuracy. What I engage with the most, however, is that way that at the end of episode, J.D. has a moment of reflection and realises what the previous twenty minutes have taught him. This sounds pretty clichéd, I know, but I think it’s nigh on impossible to spend a day in a hospital and not feel like you’ve gained a new perspective.
There’s one episode when J.D. treats a man for a sinus infection and decides to start a particularly strong course of antibiotics. Later on, the man loses his sense of smell and blames this on him. In a scene as intense as it ever gets on Scrubs, the patient looks JD in the eyes and says “It’s your fault”.
I had a similar episode (pun intended) recently. Although I was never the one who had made the decision, I nevertheless experienced a veritable helping of guilt that such situations can invoke.
That’ll Leave a Bruise
It was during a weekend shift on my paediatrics foundation rotation. I was based in the assessment unit, where we saw children who had been referred in via their GP or from A&E. I was told about a girl who had come in with unexplained bruising and her mum had read online that this could be a sign of leukaemia.
I went to see this girl, took a history, examined her. Indeed, she was covered in bruises as well as a type of rash that is only present if your platelets are low in number. As your platelets are produced in your bone marrow, anything that causes your bone marrow to go funky will prevent them from being made. And the latin translation of leukaemia is “funky bone marrow”. True story.
I spoke to my consultant and asked if she would come and see her as well. At the end, she smiled and said that whilst leukaemia would certainly cause this type of bruising, children with this diagnosis would usually be much more unwell. This was more likely to represent a condition called ITP (idiopathic thrombocytopenic purpura – the latin translation: “non-leukaemia funky platelets”).
ITP is fairly common in children, requires no treatment and usually goes away in six months. We did a blood test, which sure enough showed a low platelet count, without any of the other features that you would expect from leukaemia. With a jaunty smile on my face, I went back to the mother and daughter, explaining confidently that she had ITP and everything was going to be fine. We would arrange another blood test in due course to make sure that things were heading in the right direction.
Fast-forward a couple of weeks, and I’m back in the assessment unit during the day, with an hour or so to go until my shift finishes. My registrar gets a phone call and writes down the name of a patient on a piece of paper. I recognise this name, but can’t put quite match it to a face.
Then my registar starts writing other things down on her sheet of paper. Things that start to jog my memory: bruising, low platelets, leukaemia.
“What was that about?” I ask, tentatively.
She sighs. “It was about a girl who came in a few weeks ago with bruising and a provisional diagnosis of ITP. She had her repeat blood test today and the haematologist thinks he can see some blasts on the film.”
Blasts = leukaemia cells. As in, they make you say “Oh, blast.” And much worse.
“I’ll have to give her mum a call and tell her to come back in.” she says, resigning herself to the worse part of her job.
At this point, I can’t help but feel anything other than a profound sense of guilt. But why? Everything about her original presentation was in keeping with ITP and I was not the one who had made that call. I would not be expected to make that call. I look back at my discharge summary, just to make sure I hadn’t missed some stupid detail, but everything seems watertight. I guess it was my cocky smile at the time.
I’m relieved that my shift will finish before this girl arrives again as I’m not sure I can deal with having to see them again. Before I go, I need to drop something off with the ward clerk by the front desk, and as I’m leaving, I notice the mum talking to the receptionist. She’s panicked, speaking very quickly about how they need to be seen as soon as possible.
She must catch sight of me as I walk out the door. The last thing I hear before I leave is her say “That was him. That was the one who said she was fine.”
That Sinking Feeling
The next morning during handover, the girl’s name comes up again. She’d had another blood test and the haematologist can’t see any blasts. It was probably a false alarm and the diagnosis of ITP is still what we’re dealing with. Nevertheless, she’s having some more thorough investigations done today anyway just to be on the safe side.
Luckily, my story has a happy-enough ending. Unlike J.D’s, whose patient’s loss of smell is permanent. However, he finds out that his choice of antibiotics was not actually the cause – so it was never his fault. “I know it wasn’t your fault, hell, the patient probably knows,” he’s told. “Maybe being able to blame someone for a second or two might make him feel a little better.”