Do you remember…?

“Hey,” I said to my colleague, Dr. Terry. “Do you remember seeing a 50-something guy with abdominal pain, nausea and vomiting? He was here yesterday?”About 15 years ago, Dr. Brian Goldman gave a TED Talk entitled “Doctors make mistakes: Can we talk about that?” He called the words, “Do you remember?” the three words that most emergency physicians dread. His lecture was brave and perhaps more relevant today than it was then. It’s also haunting. He’s right. Just hearing him say the words in his online video makes my heart fall into my stomach.The first time I’d heard those words was during residency. “Do you remember seeing an exotic dancer—”“Of course I do,” I said, before he could finish. “She was drunk and she broke a wine glass in her grasp while sitting on a client’s lap.”“She came back,” he said. “The sutures opened up. She was angry you didn’t give her specific instructions about her return-to-work activities.”I’ve heard those three words many times since, and they still make me feel sick.Dr. Terry stopped in his tracks, his eyes wide with alarm. “Why, what happened?”The patient, Mel Mitchell (all names changed) had come in the previous day with pain around his belly button, along with nausea and vomiting. Dr. Terry took a complete history. Mel was healthy, a non-smoker and occasionally took a pill for heartburn. He’d had no previous surgery.His vital signs were stable—for the most part. His blood pressure was 130/90, he was afebrile, but his heart rate was high, 130. His abdominal exam revealed tenderness in his right lower quadrant, right at McBurney’s point, with some guarding. Suspecting appendicitis, Dr. Terry ordered blood tests, an ultrasound, morphine, Gravol and intravenous fluids.Two hours later, Mel was feeling a little better. The vomiting had stopped and his pain had dissipated. His blood work showed a white count of 19, but the radiologist couldn’t see the appendix on ultrasound. Dr. Terry re-examined him and found him to still have tenderness around his appendix, so he ordered aCT scan.He ordered more IV fluids and an hour later, Mel was in the CT scanner. Two hours after that, he was reassessed. The vomiting had stopped and Mel’s heart rate was now just over 100. Dr. Terry told Mel that the CT scan result, like the ultrasound, was normal, but because his white count was high, he’d make a referral to the urgent internal medicine clinic. He examined Mel one last time before discharge and found him still tender, but less so than before, possibly because of the morphine.Next nightI saw Mel the following evening. He told me he’d had two full days of “gas pain,” with vomiting. What bothered him most was the pain.He had a low grade fever now, and his heart rate was back in the 120s. He told me about his previous visit, saying all his tests were normal, except for an elevated white count.His pain was so bad on second presentation that the triage nurse gave him a wheelchair. When I asked him to move to the examining table, he stood with great difficulty and held his gut so it wouldn’t jiggle as he took each step. I helped him lie down and found that he was tender everywhere. I ordered blood work, morphine, antiemetics and fluid. “Would you say you’re worse than you were yesterday?”“Way worse,” his wife said. “He can barely walk now.”“Did your pain go away before you were sent home?”“It was better,” his wife said, “but it never went away completely.”“I know you had a CT scan yesterday,” I said, “but I might order another one.”He’s so sore he’s holding his breath between words. “Whatever you think,” he said. “Something isn’t right.”“Just make sure you don’t eat or drink anything,” I said as I left the room and pulled up a chair in front of a computer. I reviewed the previous day’s blood tests, ultrasound and CT scan. I returned quickly to Mel’s room. “I think you have appendicitis,” I said. “I’m going to order intravenous antibiotics and page the surgeon and have him come see you.”Dr. Terry againI discussed the story with the surgeon and he told me he was on his way. Just as I got off the phone, Dr. Terry emerged from an examination room. At this point, I hit him with those three words. “Do you remember seeing a 50-something guy with abdominal pain, nausea and vomiting? He was here yesterday?”“Why, what happened?”“He’s back.”“Weird case,” he said, “abdominal pain, vomiting, high white count and normal imaging. I set him up with urgent internal medicine clinic followup.”“You should probably look at his CT again.”Most CT scan reports have a description of what the radiologist sees, mostly negative findings (“gallbladder, spleen, adrenals and kidneys are unremarkable”) as well as positive findings (“There is inflammation of the ascending colon”). At the end of these reports, there is usually a separate heading, something along the line of “impression” or “conclusion,” under which the diagnosis is summarized. Sometimes, the impression is “No cause for patient’s symptoms identified,” and other times, it’s right to the point, such as “acute uncomplicated diverticulitis.”Mel’s CT report was four short paragraphs of description with no impression or conclusion at the end. Tucked into the first paragraph were the words, “There is dilatation of the appendix measuring 1.7 cm. There is mild periappendiceal fatty streaking. This is suggestive of a tip appendicitis.”“Shit,” my colleague said, staring into the screen beside mine. “I don’t know if I just didn’t read it properly, or if I was looking at someone else’s scan altogether.”It was still strange that he’d sent him home the day before. He’d suspected appendicitis, documenting tenderness at McBurney’s point. He also documented guarding and rebound, signs of a surgical abdomen. And his white count wasn’t just mildly elevated, it was quite high. Had the CT scan been truly negative, Mel still likely warranted assessment by a surgeon. But, at times, doctors ignore their gut feeling, or as Dr. Goldman said, we “disregard a little voice deep down inside” and convince ourselves that the patient will be OK. This is only more tempting in an over-stretched healthcare system where we know our admitted patients will suffer overnight in hallway stretchers, or even worse, waiting room chairs.Dr. Terry stood and picked up his next patient’s chart. “I’ll go talk to them, and tell them what happened.”The surgeonThe surgeon took Mel to the operating room and found that his appendix had ruptured. Mel didn’t question that he was going to the operating room without another scan, nor did he question how the surgeon and I knew that he had appendicitis. He was just glad that he was getting definitive treatment. Neither the surgeon, nor I told Mel about the error Dr. Terry had made. It was Dr. Terry’s story to tell, and we left it to him.Because his appendix had ruptured, Mel had a very slow recovery—10 days in hospital on antibiotics, and he was then discharged on a week of oral antibiotics. Had his appendix been removed at his first presentation, it is likely he would have spent two days at the most in hospital.A week later, I asked Dr. Terry how Mel and his wife responded when he discussed his error. He didn’t make eye contact when he told me that he never visited them. He said that he couldn’t bring himself to do it.I felt bad for him. I know he wanted to tell them, but he couldn’t. “That’s the system we have,” Dr. Goldman said. “It’s a complete denial of mistakes.” Hand-in-hand with denial, Dr. Goldman talks about the “unhealthy shame that exists in our culture of medicine.” Dr. Terry was also afraid to tell Mel because of fear of complaint and litigation. Although our job is so hard, and we are expected to sort out dozens of undifferentiated patients that walk into the ER every day, many patients are only too eager to point angry fingers when we aren’t 100% accurate.I often write about my own missed diagnoses. I’ve written about a teenager in whom I suspected group A strep, when in fact he had malaria. I wrote about a man with shortness of breath and belly pain who ended up having a normal heart, lungs and abdomen. He was diagnosed with metabolic acidosis secondary to a new medication. He was hyperventilating in order to blow off acid, and his belly hurt from breathing so hard. My mother called me after one of these articles, and told me I shouldn’t write like this, that it makes me look bad. “I don’t always get everything right,” I told her. “None of us do, and if anyone says they do, they’re either lying or missing more diagnoses than the rest of us.”Dr. Raj Waghmare is an ER physician. He blogs at theoverheadpage.com. His stories come from 25 years of practice.

Do you remember…?

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