Emergency medicine is about taking care of life's common emergencies while also picking the needle out of the haystack, even when you aren't sure the haystack actually contains any needles in the first place. The patient presenting with the "sore throat" is no better example than this. In this post, we interview Dr. D.M. Shewmaker, PGY-2 Emergency Medicine Resident at Mayo Clinic. During an intern conference trip, she was that patient
"Ha, well, it definitely wasn't on my differential when I went in! Interestingly enough, amongst the chaos when I was told I had epiglottitis, I at least felt validated for going in. Nobody that works in emergency medicine wants to go to the ED unless they absolutely have to."
What prompted you to go to the emergency department?
"I had been struggling internally with that decision for over 8 hours and seriously for about 4 of those. I had never been to an ED as a patient and the last thing I wanted to do was go on my first night in the city . . . on a conference trip . . . in the middle of the night. I couldn't swallow most foods throughout the day, which I blamed on throat pain, and it just continued to progress until it also included my own saliva. I was overdosing on ibuprofen and Tylenol all day.
What finally pushed me to go in, though, was after I switched out the hand towel I was spitting my drool into for the second time. In hindsight it obviously looks crazy that I waited so long, but you have to remember that I've never been sick in my life and who thinks they have epiglottitis?? I was clearly in denial."
What’s it like as a patient in a busy, urban ED?
"It was pretty tough just being on the other side. I wanted to be a “good patient”, so I didn't mention that I was a resident physician or in emergency medicine until a few hours in, and I really tried to play the role of a patient. I’m sure they were busy. I was seen initially by a 3rd year medical student, then by an IM resident that both told me I had strep. I had obviously looked at my throat a few dozen times throughout the day and calculated my Centor criteria (2). I knew it wasn't strep.
It’s tough when a healthy looking, afebrile, out-of-state, female comes in at 3 am and reports pain out of proportion to her exam. I've learned a lot by being on the other side to really listen to the patient. When the airway code went off for me, the filled room seemed shocked to hear that I had been drooling and tripoding even before coming in. I wasn't a great advocate for myself when I needed to be, and in return, I was in the ED for 5.5 hours before I was emergently intubated."
What were you thinking when you heard the diagnosis? What about when they recommended intubation?
"I don't know how much of a recommendation it is when you consent to having a cric!!
The funny thing is that a nurse actually handed me the radiologist lateral xray read about 3 hours into my stay that read “there is a thumbprint sign, demonstrating thickening of the epiglottis”. I took a snapchat of it and sent it to my family back in the Midwest. I blew it off, since nobody told me about it and since there was no urgency in management. I assumed since I never saw the image that the radiologist must have been overcalling it.
I wasn't told the diagnosis until the ENT attending rushed into my room during the airway code. It quickly went from fiberoptic scope to panic mode. They told me it was severe and I may need to have a surgical airway. The ENT attending told me I wasn't allowed to talk except to tell him who my 1st and 2nd POAs were, along with their phone numbers—both of whom he wrote on his scrub pants. I picked our associate program director (who was there already for the conference), and my husband, who is a restaurateur with a minimal medical background and still in Minnesota. I texted my associate program director and my entire intern class to tell them of my situation, which I maybe should have done earlier, as I really hoped someone would come and be there with me. As I was being wheeled to the OR, my co-residents were just running through the entrance. I told them they could come in for the intubation—what a great learning opportunity!!"
What’s it like being intubated?
"Although it was an awake OR intubation, I received midazolam shortly afterward so I luckily had retrograde amnesia. I was scared being wheeled into the OR with the thought that I was going to be sedated for likely a few days and possibly even cric’d. It didn't help that I had just received morphine for pain, which made me a little emotional and I was alone. I couldn't talk, as ordered by the ENT attending wheeling me in, so I just kept texting my husband, family, co-residents, and program leadership."
What was the worst part?
"Well, I know what the worst part of being hospitalized was because I literally filled 10 pages with my propofol-infused thoughts. The most common complaint: not being able to be active! Haha, I was pretty upset that I was missing my triathlon coach’s workouts with my big Escape from Alcatraz race coming up. I ended up losing a lot of muscle mass and fitness. I could barely walk up stairs after 4 days, which was shocking to me when you think of what we put most patients through."
What secondary issues arose? Complications?
"Well, it started with the recurrent epiglottitis, which came on less than 24 hours after discharge. I luckily was back in Rochester, MN with family. It was actually scarier to me then because I couldn't deny the symptoms like I did the first time. It started as a decreased ability to swallow foods and quickly progressed to tripoding in the matter of an hour. I looked at my sister, an ICU nurse who flew in from Seattle, and she knew instantly because I had tears in my eyes. I emailed Dr. Colletti (residency program director) and told him I was going to go in, “just in case”—still hoping maybe it wasn't happening again. Dr. Colletti called me a minute later from his son’s basketball game and told me he was calling the ED to have a critical bed and ENT ready for me and would meet me there. It was so reassuring to have him and my family there this time. Unfortunately, my husband was still awaiting a flight back from NYC to Minnesota. Poor guy!
After having been on 1) Vancomycin, 2) Ceftriaxone, 3) Clindamycin, and 4) Cefpodoxime from NYC and then 1) Ceftriaxone, 2) Vancomycin, 3) Piperacillin/Tazobactam, and 4) Amoxicillin/Clavulanate here in Minnesota; I, of course, acquired C. diff two weeks later. I ended up being septic with a leukocytosis of 34, so I was started on oral vancomycin. The first 48 hours of that was the worst 48 hours I've ever gone through. I felt sick. Really, really sick.
Then, shortly after finishing my 2-week course, it came back. I was then on a 6-week vancomycin taper, which ended the weekend before my triathlon season started."
How did this event change your perspective on medicine and patient care?
"Wow. Well, I truly think it’s made me such a better physician. I always thought I practiced patient-centered medicine, especially with it being such a core value at Mayo. This experience helped put it into perspective. Even though as medical providers we quickly realize most patients’ complaints aren't emergencies, I try to give them the same respect and time to tell their story and why they were so scared they felt they needed to come to the ED. Most people who come to us are in a very vulnerable state and taking the 2 minutes to hear their concerns, regardless if we assume that it’s not critical, is something I've been working on over the last year."
What was it like to hear your case on EM:RAP?
"It was pretty surreal. I remember it well. I was mid-run on October 3rd when I reached the segment, so just a few days after it was released. I knew it was my case a few lines into the podcast. I stopped running and actually started shaking. I listened to them describe the tough intubation and it really made me realize again how lucky I was to be where I was—alive, running, and pretty much mentally and physically moved on. I was nervous to hear what they were going to say about me since I knew most of my colleagues listen to EM:RAP and would know it was me.
My husband knows I love listening to the podcast, so I sent him a link to listen. He thought it was pretty cool that I was on it as well, but mentioned how very different the story was compared to what he thought happened. As more and more of my colleagues listened, the more I heard that perspective. I honestly thought it was pretty neat, but I've been known to be an optimist :)"
Any other thoughts?
"I guess I just want to say how thankful I am for my residency program, my residency class, Dr. Colletti, and Dr. Cabrera. I left this whole experience feeling so loved and appreciated. It was a very humbling experience."