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“You look like an angel, talk like an angel, walk like an angel, but you are the devil in disguise.” When Elvis Presley sang those words, he could have been describing my patient, a 4-month-old infant brought in by the Kaiser Permanente advice nurse because of a fever of 100.7. He had no other symptoms and had been breastfeeding well. His 3-year-old sister “had a cold a few days ago and is now fine.” His examination was entirely normal. He even smiled and looked alertly at me. This is a common scenario in any pediatric or family practice office. “Your baby probably has the same viral illness as his sister. Come back if he gets worse.”  I was about to say the same thing, but I took more time to talk with his mother who said, “He felt very warm at home.” After listening carefully, I decided to send the baby for a complete blood count, urinalysis, and blood culture. The complete blood count showed a 21 k/μl white blood cell count. The urinalysis was normal. Upon reexamination, his temperature was 100.4; he was smiling and had a normal examination. He then breastfed well in the office and smiled again. Because he had an elevated white count, I decided to treat the baby with an antibiotic. He hadn’t vomited, so he could tolerate oral amoxicillin. However, I decided to treat him with intramuscular ceftriaxone and have him return in the morning for follow-up with his regular pediatrician.  The baby returned the next day, was afebrile and again had a normal examination. While the baby was still in the office, I received a stat call from our lab: “Your patient is growing a gram negative rod in his blood that appears to be Neisseria meningitidis.” After consulting our pediatric infectious disease specialist, it was decided to simply treat the baby as an outpatient with daily intramuscular ceftriaxone for 7 days. Because he seemed entirely normal, it took a lot of convincing to have the mother return daily for the shots. The blood culture result was Neisseria meningitidis resistant to penicillin and amoxicillin and sensitive to ceftriaxone. Essentially, that first shot of ceftriaxone cured him and saved his life. Not treating him, or even giving him oral amoxicillin, would have had a catastrophic result with the baby developing septic shock and probable death within 24 hours.  Current pediatric and emergency room best practice protocols would have directed me to send the baby home without a blood test. What was it that caused me to send the baby to the lab? A gut feeling? Experience? Divine intervention? Or simply just listening carefully to the mother? Whatever it was, it allowed me to save the life of this beautiful baby—without a doubt, the greatest single achievement of my entire medical career.

the permanente journal/permanente journal

Unraveling the Devil in Disguise: How I Dodged a Bullet and Turned the Worst Possible Patient Experience into the Greatest Achievement of My Medical Career