ASS-U-ME

So you probably all know the old saying about what happens when you assume, but just in case anyone is coming late to the game, I'll remind you: when you assume, you make an ass out of u and me. Nowhere is this truer than in medicine.

My 5 year-old son has a life-threatening allergy to eggs and peanuts. His allergist told us ominously a few years ago, "Kids with known peanut allergies have a life-threatening event every 4 years on average." Ever since then, we have been holding our breath, thinking that we are past due. We have been extraordinarily cautious since learning about his food allergies when he was only 4 months old. We have no peanut-containing products in our house ever, period, and have eggs at home, but keep them far from my son and cook with them only under very controlled situations (since his egg allergy is less severe). He attends a "peanut-free preschool." We have Benadryl and Epipens in every bag and car and never leave home without them, even to go for a walk down the street. We have stopped flying airlines that serve peanuts. Everyone in his life, from family members to friends to our nanny to his preschool teachers, knows that we have to read the labels on every food every time. Most of them are far more conscientious about this issue than I would likely ever have been before it touched my own life, and many have gone to great lengths to learn where to buy or how to prepare foods for him safely.

My son's preschool teacher is one of the most endearingly over-cautious individuals of the bunch. She will often dash outside on mornings when I am dropping him off to make sure that the candy they will be using for the buttons on a snowman is safe for him, even though the ingredients are literally "sugar and Blue #4". Our nanny is also meticulous about keeping him safe, having chased after me more than once when I left his Epipen behind as I headed out to the car with him, and having noticed that the same cookies we have been buying every week for 2 years, which have always been safe, now say "May contain peanuts". I really don't worry about his safety when he is in their care, and they are pretty much the only two adults I ever leave him alone with for any length of time as a result.

Yesterday was the 4th birthday of one of my son's preschool classmates, Anna. Unbeknownst to me, Anna's mother had asked their teacher weeks ago if she could bring cupcakes. The teacher told her no, not unless they were made without eggs. Apparently she also inquired about bringing in a variety pack of mini candy bars, which his teacher also rejected not only because of his allergy, but the fact that the preschool is officially peanut-free and many of those would surely contain peanuts. Anna's mother, determined not to give up, went to Costco and bought a big container of gourmet jellybeans, which she divided into little snack sacks for each of the kids and sent to preschool in Anna's backpack. Their teacher helped Anna to pass them out to each of the children, including my son, at the end of class.

I am in clinic on Wednesdays, so our nanny picks up my son. When she got there, he had his head down on the table and said he didn't feel well. She noticed that his bag of jellybeans was mostly full, unusual for my son who is a sweet fanatic. He had eaten only a couple of them, he told her, since he felt kind of sick to his stomach. But then he asked to be able to stay and play with his friends in the adjacent play area, so she forgot about it. After playing for awhile, he came back to his goodie bag and ate a few more jellybeans. Within 5 minutes, he was complaining of nausea and saying he needed to put his head down. Noting that his "nausea" coincidentally occurred as they were being asked to clean up, she didn't make much of it. By the time they got back to our house, less than 2 miles away, he was coughing and wheezing, complaining that his throat was tight, and dry-heaving. She promptly gave him Benadryl and called my cell phone, Epipen in hand. By the time I answered 3 rings later, his face was noticeably swollen. She knew he was having an allergic reaction, but to what, she said, she had no idea. He hadn't eaten anything that should have peanuts or eggs.

When I talked to my son about what had happened later that day and asked him what he thought had made him sick, he said without so much as a pause: "those speckled jellybeans I ate at Anna's party". When I asked him how he knew, he said, "the package didn't have any words on it, which means there could always be peanuts," a rule I have repeated over and over to him for the last 5 years of his life. At least he has been listening.

Ultimately with treatment, my son was fine, but how on earth did this happen? My son is extraordinarily aware of the seriousness of his allergies and routinely surprises me with his own cautiousness about foods that didn't come from our home. He was in the care of multiple people who know him, love him, and are frankly paranoid of messing this up. I called his preschool teacher later that day, quite distraught, to tell her what had happened and to let her know that he was fine, in case she had already heard through the grapevine. She had and had immediately called Anna's mother, who checked the label of the jellybean container and confirmed what I already knew: peanuts, plainly listed among the ingredients. In fact, one of the gourmet jellybean flavors was PB&J.

It turns out that Anna's mother JUST ASSUMED that jellybeans would be safe, so she never actually thought to read the label or bring the original container to preschool. Understandable. Who would suspect jellybeans might have peanuts in them? I wouldn't. His preschool teacher JUST ASSUMED that Anna's mother must have checked the label since she had asked so many questions about which foods were safe to bring to school for Anna's birthday, so she never actually asked her whether the jellybeans were definitely peanut- and egg-free. Understandable. Anna has been in preschool with my son for months, and his allergies were widely known in the class. My son JUST ASSUMED the jellybeans were safe since Anna had brought them, and his teacher had handed them to him, so he never actually asked. Understandable since he is just beginning to read and has learned he must rely on a few trusted adults, one of whom is his teacher, to tell him if a food is safe for him to eat. Our nanny JUST ASSUMED that the jellybeans must be okay for him since a friend's parent had brought them and his teacher had let him start eating them, so she never actually asked to see a list of ingredients. And our nanny JUST ASSUMED that, because he had already eaten some and was apparently okay that, when he began demonstrating the earliest signs and symptoms of anaphylaxis, which she knows very well, it could not have been the jellybeans.

This could all have been prevented had anyone NOT JUST ASSUMED. This is why two OR nurses count sponges at the end of a case, to make sure none get left inside a patient. This is why two oncology nurses independently verify the chemotherapy dose the medical oncologist has written before giving it. This is why the blood bank requires that the nurse check the hospital bracelet of the patient she has been caring for all week and match it to the name on the bag of red cells before starting the infusion. These policies realize explicitly that when you assume, it is only a matter of time before you make an ass out of u and me. And if you're a health care worker, you might kill someone in the process, too.

As I tried to think of medical examples for this post, I was struck by one thing. All of the ones that quickly came to mind involved nurses. The reality is that, on this issue, they are light years ahead of doctors, who may have historically been too proud to acknowledge their potential for error...and who in many cases remain so. The attention recently given to the alarming prevalence of medical errors has led to some positive changes in physician behavior, such as surgeons initialing the correct side of surgery while a patient is still awake before a planned amputation or joint replacement, for example. But we still have a long, long way to go before these double-checks are built into every important medical decision. And finally, let us remember that all of these practices arose from the terrible tragedies of patients, most victims of health care workers JUST ASSUMING.

If you are a medical student or a nurse or a physician in training, there is a lot of unspoken pressure to just assume that someone "superior" knows what he or she is doing and not to question that person. If you are that someone "superior," there can be a lot of unspoken pressure to appear to know what you are doing and not stop to question yourself. Please, for everyone's sake, don't assume anything. Stop to question. I can promise you that it is only a matter of time before your questioning will save someone's life.