by Jared B. Smith, MD
In many trades and skills the difference between a beginner and expert is often in the details. For example, I am an avid golfer and the difference between having the golf ball go exactly where I aim and splashing it in the pond is a matter of inches in how I deliver the golf club to the ball. In my short time as a resident physician, I have learned attention to detail can make all the difference in regard to patient care as well.
While taking care of a first-time mother and her newly delivered baby, I fell into the trap of going through the motions. The pre-natal course, labor, delivery, and short life of the baby up to this point had all been uncomplicated and gone just as you would expect. The baby was gaining weight, feeding well, and voiding and stooling appropriately, and the bilirubin level was not elevated, physical exam had been benign, and the parents had no concerns other than the fears most new parents have. Everything had been routine up to this point and mom and baby were ready to be discharged home from the hospital.
On rounds when we came to this family I went through my usual exam and all I found was what looked like a common newborn rash, erythema toxicum. I didn’t think twice about it as this was a common and normally unconcerning newborn finding. I then began educating the parents about discharging home from the hospital just as I would any family in this situation, having met all the vital milestones. It was at this point that the attending physician noted a cold sore on the mother’s lip. The cold sore alone was not the problem, but the cold sore in conjunction with a rash on the newborn was. This rash on the infant meant there was a possibility this baby could have acquired a Herpes Simplex Virus (HSV) infection from their mother’s cold sore. HSV is the same virus that causes cold sores. However, in newborns, an HSV infection can be devastating and frequently fatal. This family was notified of this possibility and they stayed for further testing of their baby and to start treatment right away for a possible infection. They were scared as any parent in this situation would be.
With further testing it was confirmed this baby indeed had an HSV infection. The infection was present in the blood stream and had spread from the blood into the fluid surrounding the spinal cord, making it even more serious. The infectious disease specialist said catching the infection early and beginning treatment right away would likely be the difference between a possibly fatal outcome and this baby clearing the infection and doing well. Had the attending physician not seen the cold sore and made the connection with the rash and we had sent this family home, the medical implications could have been awful.
As I have reflected on this experience I have asked myself why I did not link the cold sore and rash together. Was it my assumption that this was another routine newborn baby? Was it because I had worked seventeen of the last eighteen days and I was mentally and physically fatigued? Was it my inexperience as a new clinician? Was it because I was afraid to have to break bad news to this family? Was it close to lunch and I was hungry? It’s hard to say for sure, most likely it was a combination of these reasons. However, the attending physician’s attention to detail was what potentially saved this newborns life.
After this patient encounter I have tried to change how I practice medicine. When I have a situation that seems routine and possibly mundane, such as an annual physical exam in a young, healthy, and otherwise uncomplicated patient, I try to sharpen my focus and pay attention to the details. I don’t just assume it’s another predictable encounter with no complications and go through the motions to get to my next patient. I listen a little more closely to their heart for a possible murmur. I make sure I take a complete and thorough family history. I listen closely to the patients responses to my questions and watch their body language. I don’t dismiss common complaints without first considering possibly more serious conditions. I pay attention to the details.
I know I have a long journey ahead of me before I am an expert physician. However, I know that as I try to have an eye for detail and not let myself get lulled into going through the motions in routine situations, I will give better patient care and become a better doctor.
Jared Smith enjoys golfing, hiking, trail running, doing anything outdoors, walks with his German shepherd, spending time with his wife and daughter, and watching sports. As a first year resident, he appreciates the supportive residents and faculty at the University of Utah.
Family Medicine Vital Signs 