Authentication

A friend of mine texted me yesterday: Hey, what’s your address? Using you as a passport reference again despite the last time when you told the guy to f*#k off.The blue curtain was almost completely drawn. I’d opened it just enough to enter and exit the room. I’d been standing only three metres outside the room for the last five minutes, close enough to see what was happening—compressions, ventilation, one more round of epinephrine—yet just far enough to have a phone conversation. Just far enough to clearly hear the curses of the woman on the other end. I don’t deserve this crap, I thought to myself. Here I am trying to save your father’s life and this is what I get? He’s 87 and arrived here just before 7 p.m. My resident saw him, performed a comprehensive assessment and came to tell me about him. “I’m worried about this guy,” he said, as he described the case. The patient, John, lives independently and developed severe low back pain bilaterally, right side worse than left. The pain was sudden, and started about six hours earlier with no injury—no twisting, no falls, no bending, and before this, he was fine. He denied headache, chest pain, shortness of breath, or syncope, but was chilled, sweaty and nauseated. He hadn’t vomited, and bowel and bladder function were regular. When the pain didn’t settle with Tylenol and worsened into the late afternoon, he called an ambulance.“New onset back pain, sudden, in an elderly patient,” the resident said. “I’m worried about a ruptured triple-A. I’d like to scan him.”“Does he have abdominal tenderness?” I asked.“Suprapubic,” he said, “but mild.”“Abdominal?”“Not really. Otherwise the exam is normal. Heart sounds, lungs, and pain is at the right posterior iliac crest mostly.”“OK,” I said, “let’s go see him.”He’s right, John doesn’t look well. He’s pale, he’s agitated and right now, he’s in a wheelchair while a nurse is trying to get him to the bathroom. He has to go, he says. I look at his chart. His blood pressure is 150/100, he’s slightly tachycardic at 105, he’s afebrile and his oxygen saturation and respiratory rate are normal. I’m able to palpate his abdomen and it’s non-tender. His pain is truly in his back.The nurse asks me for analgesia as she starts transferring John toward the toilet. “Sure,” I say. “Tylenol and Dilaudid. I’ll put in the order.”“Ruptured triple-A?” the resident says again.Minutes laterIt took less than a few minutes to find that the resident’s initial suspicion was likely right.I went back to my workstation to order the analgesia and looked over John’s history and medication list. He’s complicated, with a history of congestive heart failure, coronary artery disease with previous bypass, a stroke, as well as the usual conditions that lead to these catastrophic conditions: hypertension, hyperlipidemia, atrial fibrillation and a history of smoking. He’s also on a blood thinner—Eliquis—so if it turns out he’s bleeding from somewhere, this could be a disaster.For now, though, I have no compelling reason to think John’s bleeding. He hasn’t had any melena or bright red stool, he’s had no abdominal pain and his blood pressure isn’t low. Once they get him onto a stretcher, I think, we can do a bedside ultrasound.However, just as the nurse transferred John to the toilet, he became unresponsive. Pallor descended from his forehead to his arms like an automated projector screen. The nurse called for help and a stretcher arrived. A minute later, we responded to the code blue that was called overhead.“What happened?” I said as the nurse wheeled him into the large room. I felt for a pulse, then started compressions and asked for a bag-mask for ventilation. “He was just talking a minute ago.”Within seconds a respiratory therapist asked whether or not to intubate. “Are you having trouble bagging?”“No.”John’s oxygen saturation was in the 90s. “Let’s start with epinephrine and good compressions,” I said. “And do we have a code status?”The resident didn’t have a chance to go over advanced directives with John. Another physician who’d responded to the code scoured the chart. No advanced directives.For the next 10 minutes, we carried on with three rounds of epinephrine, one shock for ventricular tachycardia and excellent compressions. Despite our efforts, John remained pulseless and a bedside ultrasound showed only the occasional cardiac flicker.“Can someone find a number for next of kin?”The daughterI got on the phone to John’s daughter, Carol, and introduced myself, by name, rank and hospital. “Your father, John, was transported here by ambulance less than an hour ago, and he’s had a cardiac arrest. We’re performing CPR, and trying life-saving medications to re-start his heart. Unfortunately, nothing’s working thus far.”There was silence on the other end.“I’m calling to ask whether or not your father had any pre-existing wishes in case he were to become severely ill. Would he want aggressive measures such as CPR? Would he want to be put on a ventilator should he stop breathing?”Her voice shot back through the line. “How do I know who you are? How do I know what you’re saying is true? How do I know that this isn’t some sort of fraud?”“I can assure you that I’m telling the truth. What motivation would I have to ask whether or not your father had advanced directives such as these?”She began screaming: “I just spoke to my father over the weekend! He was completely fine except he told me that his apartment had been broken into on Friday night! So I don’t know who the f$#k you are, and unless you can prove it to me, I’m not answering any of your goddamn questions!”I reeled off John’s full name, his address and his telephone number, his birthdate and his health card number.“How do I know you didn’t steal that information from him over the weekend?!”I poked my head into the room, “Continue CPR,” before getting back to the phone.“Listen,” I said, “I know this is a shock, but I can give you the hospital number to call and you can ask for the ER and ask for me.”“How do I know you’ll give me a hospital number?”“I can give you the name of a hospital and you can look it up?”“How am I supposed to do that?”“Just Google it! Use your computer or your phone.”“I don’t have a computer handy,” she said, “and I’m on my phone!”“OK,” I said, walking back to the room. “I’m going to hand the phone to my physician navigator and you can ask her whatever you want to help you believe that this isn’t a fraudulent call.”“Wait a sec! Wait a sec!” she yelled. “Don’t hang up on me! How do I know who that is?”“Pulse-check,” the nurse called out.“I don’t have time for this right now,” I told Carol, handing the phone to my navigator. There’s still no pulse and no meaningful cardiac activity. John’s skin is pale and waxy. “How many rounds is that?” I say.“Five.”“He’s dead,” I say. “We can call it now.”My navigator hands me the phone. “She hung up on me.”Passport officeI did tell the passport guy to f*#k off. It was a cold-call from a blocked number. With a thick accent, he told me he was calling from the passport office and then asked if I could confirm my identity. He asked for my birthdate and passport number. I’d been receiving several fraudulent texts a month at that point seeking various passwords. So I told the guy off and told him to never call me back. He did call me back, about five minutes later, so I asked him to verify his identity. He did.An hour later at the hospital, I was at my workstation when my navigator handed me the phone. It was Carol. She apologized. I offered my condolences and told her that we lived in the age of two-factor authentication, and that I didn’t blame her for doubting my identity.“He likely died of a sudden ruptured abdominal aneurysm,” I told Carol. “But the coroner is coming. She was also suspicious of the sudden death after the break in.”In the end, no foul play was suspected in John’s death, and it likely won’t be long before medical professionals find a way to authenticate their identity to patients’ next of kin.Dr. Raj Waghmare is an ER physician. He blogs at theoverheadpage.com. His stories come from more than 25 years of practice.

Authentication

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