Being Your Patient’s Advocate

“Ouch. OUCH!” Sofia grabbed my arm and pushed it away. I looked up and saw her pale and sweaty face. “This is a 10 out of 10,” she said. Just yesterday, this same 16-year-old teenager and I had been chatting about her favorite telenovelas and laughing at my kindergarten-level Spanish.

I couldn’t understand how she could have deteriorated so quickly. Sofia presented to the pediatrics unit of our hospital after having two weeks of lower abdominal pain. A CT scan showed a ruptured appendicitis. When she came onto the pediatric floor, she looked tired, but not sick. “Only a four out of 10 for pain,” she’d said. She was laughing and making jokes with her older sister, who was her guardian. Sofia had immigrated to the United States from Guatemala four years ago. She lived with her five siblings in a one-bedroom apartment in Brooklyn. She hadn’t seen a doctor in over five years.

My team called the surgery for a consult. “She’s fine,” the surgeon said, making it clear he thought this consult was a waste of his time. “I told you already. Just keep her on antibiotics and maybe we’ll do surgery in a couple of months.” I opened my mouth to question his decision. I remembered a resident on my surgery rotation had emphasized the importance of early surgical intervention in children with appendicitis. But who was I, a second-year medical student, to question someone who probably operated on a dozen appendices every week? I’d be made the object of ridicule for sure. I shut my mouth as the surgeon rolled his eyes, turned abruptly, and walked swiftly out of the pediatrics unit.

The next morning, Sofia started to experience the 10 out of 10 intense pain. She was feverish and sweating, gripping the hospital bed with both hands. Her labs showed grossly elevated inflammatory markers. My attending agreed with my assessment and plan to get Sofia into the OR as quickly as possible. I urgently called surgery.

“She seemed okay earlier,” the surgeon said. “I put her on the list for the OR today, we’ll see what happens.”

I wanted to scream, “She is NOT okay now! Can you please come and examine the patient? Do you realize what state she’s in?!” Instead, I bit my tongue and waited. When Sofia started to continually trigger the sepsis warning, the situation escalated to involve the chief of pediatrics, the chief of surgery, and the pediatric surgeons at another hospital.

Eight hours after I first noticed Sofia deteriorating, she was finally taken to the OR. Sofia had an uneventful surgery and recovered gradually in the coming days. Still, I felt a lot of guilt for not speaking up.

Here are two things I learned from this experience:  

1. Effective communication between clinicians can mean life or death when it comes to acutely ill patients.

 2. Every patient is unique, and children aren’t small adults.

We’re told this repeatedly through our medical education. Treatment for perforated appendicitis differs in children and adults. Sofia’s surgeon primarily operated on adults and may not have been familiar with the standard of care for children. As the pediatric team, it was our role to step in to fill these knowledge gaps.

As a medical student, perhaps the most important roleI play is as a patient’s advocate. I often wonder what would have happened if I’d taken it upon myself to further advocate for Sofia instead of standing on the sidelines.Medical students are considered to beat the bottom of the totem pole in the hospital. Occasionally, our questions are met with annoyance.But sometimes those questions are key. Remembering my experience with Sofia, I will no longer think twice about asking questions and continuing to advocate for my patients.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.