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Perspectives   |    
Moments of (In)Decision
Don R. Lipsitt, M.D.
Am J Psychiatry 2011;168:776-777. doi:10.1176/appi.ajp.2011.11030463
View Author and Article Information

Introspection accepted for publication May 2011.

Address correspondence to Dr. Lipsitt (don_lipsitt@hms.harvard.edu).

Accepted May , 2011.

Copyright © American Psychiatric Association

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I lie on the floor next to my 3-year-old son's bed. With each stertorous breath or barking cough, I am wracked by indecision: Is this the moment to take him to the steam-filled bathroom, to give him ipecac (an old remedy), to call his pediatrician, to take him to the hospital? When I have called our pediatrician in the past, he has never seemed as anxious as I and his nonchalance has made me more anxious than reassured. I hesitate to call him.

Past experiences flood my mind. I was taught by my professor of pediatrics that "you do not have to see the red epiglottis to diagnose or treat croup." He also emphasized that there could be as much as a 10% death rate in untreated cases. When I was a 3rd-year "extern" and the only "doctor" on the premises of a 50-bed charity hospital, a frantic mother brought her frightened little child for examination and treatment. I had no question about the diagnosis: it was croup. I tried to comfort both child and mother by having her hold him while I watched the depth of his supraclavicular retractions. I was afraid to depress his respiration with diphenhydramine and phenobarbital but found that small doses lessened his anxiety as well as his respiratory stridor. Both mother and child seemed at least temporarily relieved.

In the meantime the nurse had prepared a crib vapor tent as well as a "trach kit." "Who's going to use that?" I asked her. "You are, doctor." Alarmed at her directness and surprised to hear myself addressed as doctor, I was anxiously aware that I had never done a tracheotomy. While the child dozed fitfully in the vapor tent, I slipped into my quarters and read a 5-minute description of how to perform a tracheotomy. I returned to the child with some confidence that I could do it if necessary but determined more than ever that I could manage this situation without extreme measures. All went well during the night as I awaited the attending, who would take charge of the case in the morning.

Learning medicine is part book reading, part lecture, part doing, and part emotion; the last is perhaps the most difficult and least attended to in medical education. One must also learn to balance a sense of when to strive for independence, judgment, and action and when to call for help. During internship, my next croup case did not turn out so well as the first. Shortly after midnight on a winter's eve, an anxious mother and her 3-year-old child arrived by ambulance at the ER. I was on duty and was called by the nurse to attend. Both mother and child were wide-eyed with fear and panic, the child coughing the telltale cough and showing considerable trouble breathing. By now I was a real doctor and even "experienced" in caring for children with croup. I was in an excellent institution, with a superb training program and a supportive staff ready and eager to help. I initiated the routine that had worked so well for my small patient in the 50-bed hospital: comfort mother and child, keep the child seated on mother's lap, use mild sedatives judiciously, and have available a steam-vapor tent (to be used only if separation from mother was not too stressful). All went well: child and mother rested comfortably.

By then it was 3:00 a.m., and I hesitantly called the pediatric resident, who was supposed to be notified of all ER child cases. I did not know him. He seemed uncomplaining about being awakened, asked the history, then took the child from the mother and as the child cried, placed him in an examination crib and asked the mother to hold the child's feet and me to hold his arms. I explained that I had not looked in his throat, having learned that it is not necessary (in the acute phase) to see the "cherry red epiglottis." With determination and tongue blade, the resident fought to look deep in the squirming child's throat. It was frightening to watch as the struggling child went into acute respiratory arrest (later determined to have been a global edematous reaction of the respiratory tree). The resident grabbed the child in his arms and ran with him to the pediatric floor. I was left to address the mother's puzzlement, panic, and anger and to learn of her loss of the child's older sibling by status asthmaticus. My enduring guilt was not so much over the current child's death (although that was bad enough) as it was over having called the resident instead of managing the case entirely myself.

Now, as I lie on the floor monitoring my son's every physiological perturbation, I struggle with the questions of personal responsibility, when to depend on others for their judgment and when to be secure with one's own decisions. I am more aware for these experiences that being a responsible doctor is more than having the degree.




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