Patients benefit when we follow protocols. Judgement gets in the way of best practice. Writings of Atul Gawande, MD and others have cemented the importance of protocols in the mind of the physicians and non-physicians alike, enough for us to ask if there is any role at all for clinical expertise. Everyone says you are only as good as your last case.
A 60-year-old healthy man on no medication, came by ambulance from his gym where he’d been lifting weights then ran on the treadmill. He walked up to the desk at the gym having trouble expressing himself. Everyone thought he was having an acute stroke. He had passed a stress test only days ago with flying colors. He had a modest right body and facial weakness and halting speech and a preference to look to his left, all signs pointing to his left frontal lobe. The CT scan just done, had nothing in the brain, except the left middle cerebral artery was opacified, sign of extensive clot. EMTs reported he had complained of visual loss. Speaking haltingly, he let me know he did transiently lose vision in his left eye. Any pain? No. Well last night a minor headache is about all. Any straining? He came in sweaty. He lifts 35 pounds at most. He’s a shoo-in for the clot busting i.v. t-PA therapy by protocol. But hold on. Left eye vision loss doesn’t figure. He should have lost his vision, if anywhere, in his right visual field. No he insists, it was his left eye.
The next time I hear from the ER it is 3 AM. A poorly controlled diabetic hypertensive man comes in on account of vomiting when he eats but mentions painless double vision he has had for 2 days. Could he be having a brainstem stroke? He has had nothing but vomiting and double vision. He blames the double vision on his left eye because it is worst looking to the left. He’s been covering one eye just to get rid of the double vision. He had a similar problem years ago which went away on its own. You aren’t going to hear about a detailed eye exam over the phone from the ER. I was assured his pupils were equal or at least there wasn’t a blown pupil. Comfortable that I knew what he had I told the ER doctor, rolled over and went back to sleep. He should have an MRI of the brain and an MRA of the circle of Willis just to be sure but I didn’t think they were going to be abnormal.
When I did get to examine the 3 AM patient a few hours later he had a drooping eyelid on the right and his right eye was not following to his left. Pupils were equal. He had all the signs of a diabetic related right eye third nerve palsy, a common benign entity. So it was the right eye and not the left and not a stroke. We have to think of an aneurysm pressing on this nerve but that is painful and pupils will not be equal. The vomiting was a separate process. He told me he mostly vomits shortly after eating, something he had for a long time that might point to a problem with esophagus motion or structure or the gastroesophageal sphincter. The brain studies proved perfectly normal.
As for the healthy man from the gym as soon as I got the history of the left eye I was looking with an ophthalmoscope for little clots on the retina that might have been thrown from his carotid artery. In minutes we had him in the CT scanner again to do a CT arteriogram which showed a left carotid occlusion likely from a tear in the vessel (dissection) from intense physical activity. Even so the clot buster benefitted him as we could see flow higher up in the middle cerebral artery. All of his other vessels were pristinely perfect.
The moral of these stories which both involve the eyes, is inner vision. Thought is a path to the unexpected. Computers are very smart which we know since they will soon be driving our trucks in cities and superhighways. In the not too distant future computers will do surgeries. My own medical career started with simple calculators and needed to recall all the side effects of every drug and know their interactions. The way I practice today I am always looking these things up. Computers and protocols regularly make clinical decisions. Computers generate images I see every day and consider more beautiful than art. But they aren’t always right. I believe we are living in that short sliver of time when computers and protocols still need human supervision. I revel in that for now.