Magnets and robots

This isn’t about my young grandson swallowing five magnets. It’s about how he was treated by the medical system after he did.

The urgent care doctor on Bainbridge Island apologized that there wasn’t an x-ray technician on duty (urgent care without x-rays—huh?). Thus, he directed us to a real hospital. Off we went to St Michael Hospital in Silverdale. The first staff who encountered Ari in the ER, just before I got there, ordered an x-ray, to see how far the magnets had progressed on their journey through his GI tract. I arrived in time to accompany Ari to the radiology suite, where the nice technician said that the staff (she wasn’t sure if it was a doctor or a nurse) had ordered a “KUB.” That stands for “kidneys, ureters, and bladder,” an image of the abdomen and pelvis. I told the tech that I was a gastroenterologist, and pointed out that there’s no way that the magnets could have made their way to the lower abdomen or pelvis during the less than two hours since Ari swallowed them; indeed it was possible they were still hung up in the esophagus, which isn’t seen in a KUB. So I suggested that she forget about the bladder, and aim the beam higher, to include the area a little above the diaphragm. She demurred: “I’m so sorry. A KUB was ordered, so that’s what I have to do,”

Fortunately, the magnets were visible on the KUB. They sat magnificently in the distal antrum, the last portion of the stomach, well north of the K’s, U’s, and B. The five little magnets were neatly stacked up in a row—Ari confirmed my guess that he swallowed them in one gulp after he stuck them together, rather than one portion at a time.

Then came the obvious question: Now what? After the traditionally long wait (luckily, Ari was quite comfortable the whole time), the ER doctor finally appeared. When I introduced myself as the gastroenterologist grandfather, his talk immediately went from doctor mode (addressing family and patient) to colleague mode (addressing me). But he was considerate, and occasionally remembered to talk to the family and patient.

He asked me what I would do. I said that since the magnets were small in diameter and nicely stacked up, they should have no trouble exiting the stomach through the pylorus, then wending their way downstream to eventually make an uneventful exit. I of course acknowledged the theoretical magnetic risk—that two would clamp on either side of a little chunk of intestinal lining and erode through. This certainly happens, but since the magnets were already stuck firmly together it seemed quite unlikely that they would un-stick enroute and then reconvene across an intervening bit of bowel. So I thought it was safe for Ari to go home. The doctor agreed, but said he wanted to get this plan endorsed by a pediatric gastroenterologist.

After about a hundred more hours of waiting, the ER doctor returned. He said that the expert decreed that Ari needed to come to the Mary Bridge Children’s Hospital in Tacoma, about 42 miles down the road, so that the magnets could be retrieved with an endoscope. I was quite dubious–even if retrieval were appropriate, the magnets were poised to imminently leave the stomach. Soon thereafter they would be beyond the reach of the endoscope.

But we complied. So as the magnets travelled south through Ari’s GI tract, we travelled south to Tacoma. Ari dozed on the way.

I let Ari and Emily off at the ER entrance, and parked. By the time I met up with them, they were already with the intake nurse. Knowing that Ari had swallowed magnets, she ordered not one, but two x-rays. I asked her why. “For foreign body ingestion we x-ray from nose to anus. You never know what the kid’s done with them.” I said that in general that made sense, but we already had an x-ray showing the magnets in the stomach. They could not have travelled upstream, against the current. Thus, in this case, a KUB was actually the appropriate image. She grumbled, but adjusted the x-ray requisition accordingly.

Then she began talking with Emily about starting an IV line in preparation for endoscopy. I sighed, and piped up again: It was now almost two hours after the magnets had been identified in the antrum. Didn’t it make sense to review the x-ray first to see where they were now? Because if they had progressed beyond the reach of the endoscope there would be no need for intravenous access. She grudgingly agreed, and put away her IV equipment.

We followed another technician to this second x-ray suite of the journey. He explained to Ari what was happening, and answered his many questions. This x-ray showed that not only had the stack of magnets left the stomach, but they had traversed the entire small intestine, and now appeared to be near the splenic flexure. That is, they were at least half way through the large intestine–they went south in a hurry. So no way the magnets could be retrieved by an endoscope. And anyway, they were merrily making their way toward the exit. And, it was clear, we should be too.

Eventually we were conducted to an examining room, which Ari found quite intriguing. During the long wait for a doctor, Ari asked about the function of every bit of equipment surrounding him. Particularly intriguing were all the controls on the examining bed. He said he hoped the doctor would tell him he had to spend the night there.

Finally the doctor appeared. He did a cursory physical examination, looked at the x-ray, and stated the blindingly obvious fact that endoscopy wasn’t in Ari’s future. But he had to get the OK from the shadowy pediatric gastroenterologist who ordered Ari to come to Tacoma. After yet another long wait, the ER doc returned with the required endorsement, and discharged Ari. It was almost midnight and we were all hungry, since we hadn’t eaten since lunchtime. Well, one of us had had some magnets at about 3:30. We drove around Tacoma and finally found some meager snacks at a mini-mart .

By the time Ari got to bed it was about 1:15. The magnets emerged uneventfully in the inaugural movement of the morning.

Ari did great, and everyone was very kind to him. Moreover, in their favor, not a single person asked him why he had swallowed the magnets, which would have been otiose. But what struck me most weren’t the long delays, the inefficiency, or the duplication. It was the lack of thought.

An unknown doctor or nurse mindlessly ordered a KUB. So the x-ray technician was forced to perform what was ordered. Fortunately that x-ray did show the magnets, which were clearly poised to continue their downstream journey. I believe the ER doctor’s instincts were right—just let them pass. But understandably, he wanted cover from the expert in Tacoma. It’s not clear to me that this pediatric gastroenterologist—I suspect it was a man–ever saw the x-ray. I wonder if he was automatically reacting to the diagnosis, “magnet ingestion,” and mechanically thought, ‘possibility of perforation—retrieve them’. Even though the tiny magnets were all tightly bound together. And, perhaps even more to the point, even though they were already about to leave the stomach. If he’d actually seen the x-ray, it’s hard to understand how he thought the magnets would remain perched in the antrum for well over an hour until we got to Tacoma.

And at the children’s hospital it seemed that things continued to be driven by script rather than judgement: X-ray from top to bottom. Start an IV in anticipation of endoscopy. Wait for the Wizard of Oz pediatric gastroenterologist to decree what we all already knew.

What’s the explanation for all this non-thinking? It’s easy to draw an automatic line between the presentation and the standard response. But why weren’t these general principles leavened by consideration of the particulars? Fear of liability? Avoidance of criticism for not following standard procedures? Simple laziness? For whatever reasons, it seems that in many circumstances people are trained to follow protocols, not common sense.

After I cancelled some plane reservations recently, I realized the website hadn’t told me how I’d get my refund. So I called Delta. A robotic voice asked me why I was calling. I asked whether my refund would go back to my card, or be retained by the airline as a credit. The robot replied, “Are you calling about a refund?” I reluctantly said I was. The robot then gave a speech about the circumstances under which a reservation can be cancelled for a full or a partial refund. No mention was made of how it would be made. “Did this answer your question?” the robot asked triumphantly. When I forthrightly said that it did not, I was instructed to repeat my question. I tried different words: “After I’ve been granted a full refund, how will it be credited to me?” Robot replied, “Are you calling about a refund?” My response, just before hanging up, is best not repeated in this post.

And yes, as you intuited I am indeed comparing the ER staff’s responses to that of a call center robot. The main difference seems to be the trigger words–for the robot it was “refund,” whereas for the ER staff it was “swallowed magnets.” In both cases the response was automatic, ignoring highly relevant details. But before we come down too hard on the ER staff for being robotic, I suggest that, to some extent, aren’t we all?

Here’s an example: How often, when a friend or a cashier asks, “how are you?” do we automatically answer “fine”? What about figuring out how we really are, and answering accordingly? You’ll probably say, well, I don’t really have the time, and anyway the person asking is simply applying a social convention to lubricate the interchange; they aren’t really asking a question. Of course this is probably true most of the time. But you won’t know unless you try it. Otherwise you’ll just keep starting IVs.

And what about instead of always saying “Have a nice day”—the equivalent of a robotic refund speech—what about taking a few seconds to individualize what we say to the person we’ve just been interacting with? It doesn’t take much effort to substitute “Have a nice day” with “I hope your classes go well today,” or “Good luck with your appointment,” or even, “I’m rooting for you to find a parking space right away.” This sort of individualization might not save the time and resources that an individualized response to magnet swallowing could, but would I think still be very welcome. And it might even start a good conversation.