Editor’s Corner: What We Do When We Don’t Know What to Do

Alice Ma, MD
Professor of Medicine in the Division of Hematology and Oncology at the University of North Carolina School of Medicine in Chapel Hill

We are in the middle of a global “Oh, crap” moment. One of those moments when we’re in over our heads, the water keeps rising, and we don’t know how to swim. You know the moment I mean. You’ve probably been in one or two yourself.

I remember one of my own: I was moonlighting in an ER when the triage nurse called me to see a young woman who brightly announced that she had just consumed a delicious meal of smoked sausage, red wine, and aged cheeses and that she was on Nardil, a monoamine oxidase inhibitor (MAOI) known for interacting poorly with tyramine-rich foods like – you guessed it – smoked sausage, red wine, and aged cheeses. The patient declared she didn’t feel good. Her blood pressure was 240/140 mm Hg … at first. She then looked up at me, rolled her eyes back, and passed out – thunk! – and produced a blood pressure of 60/palp. Oh, crap.

The nurse looked at me and said, “Now what?”

“I’ll be right back,” I called as I sprinted for the workroom, where I frantically rifled through the pages of the textbook. (Again, this was way before the internet and smartphones.) “MAOI, MAOI, MAOI,” I chanted as I looked for the right vasopressor agent to order – one that wouldn’t kill the patient and get me sued. Luckily the answer (ephedrine) was in the portion of the textbook that hadn’t been ripped out or damaged by coffee stains. Phew.

Not all “Oh, crap” moments end so well. I was a first-year fellow when all-trans retinoic acid (ATRA) was first approved by the FDA. We gave ATRA to our first 2 patients with promyelocytic leukemia. They did great. The disseminated intravascular coagulation (DIC) stopped, the counts rose, and the patients went home. Amazing!! But, 2 weeks later, they were back and they were not doing great. White blood cell counts were 400,000/mm3. Oxygen saturation levels were in the low 80s on a 100% non-rebreather mask. Chest X-rays were whited out. I made a peripheral blood smear and found weird, agranular mature neutrophils. Lots of them. And no blasts. That can’t be right, I thought, so I made another smear. Same result. Now what? The oxygen saturation levels fell some more.

I bludgeoned my poor attending for answers. “I’m just the fellow. I check the checkboxes, but you’re supposed to make the checkboxes for me!”

“Shut up and let me think,” he snapped back, which is attending-speak for “Oh, crap.”

In retrospect, it is obvious what was happening – differentiation syndrome. But this was before we all knew what the differentiation syndrome was.

Sometimes an “Oh, crap” moment results from a combination of a lack of knowledge and a lack of resources. Back when I was a resident, the ER at Philadelphia’s Veterans Administration Hospital was staffed at night by a poor, beleaguered resident and a nursing assistant (NA). The NA could do two things: take vital signs and make phone calls. The resident was responsible for all other tasks. Put in IV, check. Do EKG, check. Set up albuterol nebulizer, check. Hang blood for transfusion, check. Mix nitroprusside drip and hang for the patient with malignant hypertension, check. One of my former attendings told me about being on call at the Philadelphia VA’s ER in 1976 when a whole bunch of Legionnaires started coming in – as in the patients for whom Legionnaires’ disease was eventually named. Taxicab after taxicab pulled up to the ER, disgorging coughing, hypoxic veterans, with just a resident and an NA to cover. Oh, crap.

And AIDS was getting to be a thing when I was a medical student. What was the causative agent? How was it transmitted? At how much risk were health-care workers who were exposed to infected patients? Why were there no T cells? OK, it’s caused by a retrovirus, but what the heck was up with the fevers? And the infections? And the cancers? We were asking all these questions while we were frantically looking and learning and trying things out. Over the years, we have continued to have more “Oh, crap” moments with HIV/AIDS. Highly active antiretroviral therapy? Great. Immune reconstitution? Oh, crap. After 30 years, HIV is now considered a chronic disease. We have effective therapies, combination pills, and can manage most side effects and cancers and infections, but there are still disparities in care and we still don’t have an effective vaccine.

Which brings us to 2020’s medical “Oh, crap” moment. Yes, I mean COVID-19. It’s morphed from a problem in China, to a problem on cruise ships, to a problem in blue states, to a problem everywhere. We’ve gone from thinking that only health-care providers taking care of infected patients need to wear a mask to, “Are you kidding?! Everyone needs to wear a mask!” And exactly what is up with the overwhelming thrombosis? Is it DIC? Is it not DIC, but like DIC?

We will swim out of this “Oh, crap” moment the way medical science and health-care providers always have: with observation, discovery, teaching, and caring – don’t forget the caring. And of course, plenty of sweating, working, and trying things that don’t work until we find the things that do work. And admitting mistakes and going down dead ends, and publicizing those dead ends and admitting when we just don’t know what to do. Out of chaos will come organized recovery and the “Oh, crap” moments will become just another set of anecdotes in our collective medical memories. Because figuring out what to do when we don’t know what to do is what we do.

*This column is written with respect to and unity with those suffering loss and grief during this global health crisis.