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Hauntings: When the clinical mark is missed

Maurer, Brian T. PA-C

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Journal of the American Academy of PAs: June 2013 - Volume 26 - Issue 6 - p 66
doi: 10.1097/
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“So she's going to have the dermatofibroma surgically removed?”

The mother nods her head. “I tried to get her in to see one of the dermatologists you recommended, but no one would give us an appointment for 3 months, so I took her to see a podiatrist. The foot doctor said she thought it was a wart. She gave her some kind of acid to put on it every day for a couple of weeks, but it didn't work.”

I bend down to observe what is left of the lesion on the dorsum of this girl's foot. The raised, smooth, flesh-colored nodule that I documented 2 months ago now looks like a lichenified swath of thickened tissue. I turn to the mother and note the look of consternation on her face.

“I'm not happy with the way it looks,” she says, validating my own thoughts. “I told her, 'In all the years I've been taking my kids to see him, Dr. Brian has never been wrong.'”

“Thanks for the vote of confidence,” I say, then, shrugging my shoulders slightly, I add, “I suppose there's nothing for it now but to have it excised.”

“But why under general anesthesia?” the mother asks.

Why indeed? At the outset, this simple, isolated lesion could have been removed easily under local anesthesia in the office. But now, given the extended disruption of the surrounding tissue …. “Most likely she wants to be certain that she excises the entire lesion. It's unclear how deep it might be. I suppose she's planning for any contingencies,” I explain in an effort to convince both myself and this mother that the approach is warranted.

“I see,” the mother says. “Well, I guess we'll stick with the game plan. She's supposed to go to surgery the day after tomorrow. That's why she needs to have the preop physical exam today.”

As I gather the instruments and methodically make my way through the exam, this mother's words reverberate through my head: “In all the years I've been taking my kids to see him, Dr. Brian has never been wrong.” My thoughts drift back to my early years of training, when for nearly 2 years I spent every third night on call in the hospital setting.

One night still haunts me. I was paged to the pediatric ICU to draw a sample for arterial blood gas (ABG) analysis on a patient–a 7-year-old girl who suffered from end-stage muscular dystrophy. Over time, the myriad muscles necessary to perform the work of breathing had lost their strength. Soon the child wouldn't be able to breathe adequately on her own. A decision would have to be made: either intervene with life support measures or let her disease take its natural course. If she went on a ventilator, she would never come off the machine. Meantime, an ABG would provide some useful information about the child's ability to ventilate her lungs, perfuse her blood with oxygen, and clear it of carbon dioxide.

Back then, ABGs were drawn through the 12-inch tubing of a butterfly needle flushed with heparin. I carried several such needles and a bottle of heparin in the pockets of my white coat, along with normal saline and sterile water to flush lines. Before drawing the sample, I prepared the needle and syringe unit by flushing the tubing with heparin. I cleaned the skin site with alcohol, felt for the pulse, and made the stick. Immediately, I was rewarded with a backflow of bright red blood. I held the needle steady and watched the column of blood ascend the tubing. Suddenly, it froze. Aspirating the syringe didn't help; the column of blood wouldn't budge.

I pulled the needle from the girl's arm and applied a pressure dressing before making a second attempt to draw the specimen. For the second time, the needle found the vessel; for the second time, I watched the blood flash into the tubing; and for the second time, it froze halfway to the syringe.

At that point I called for assistance, and my senior resident idly picked up the vial with the purple label that I had placed on the bedside table. “This is what you used to heparinize the butterfly?” he asked. I nodded my head. He held the vial up in front of my bleary eyes, those eyes that had not seen sleep in 36 hours. “This is sterile water,” he said. “Small wonder it clotted.” I dropped my eyes in shame.

Once more I tried, this time with a properly prepared syringe. This time I obtained the specimen. The child opened her eyes and groaned. How much unnecessary pain had I inflicted on this already compromised little girl?

The following day her parents elected to forego putting her on the ventilator. Within a week she succumbed to the disease that she had suffered with her entire life.

“In all the years I've been taking my kids to see him, Dr. Brian has never been wrong.” In dealing with her children, perhaps this mother seated before me is right. But in the grand scheme of things, I know better—and only too well.

© 2013 American Academy of Physician Assistants.