Student Scene
 Photo by Graham Ramsay |
Bad Outcomes: A Backdrop for Good Medicine
"She's still sick," the mother told me. It was nearly 10 p.m., the end of my evening shift when the mother and little girl came to the emergency department. The mother was a large woman. She wore a frayed T-shirt that proclaimed, "Got Frybread!" and threadbare sweatpants. Her hair was pulled carelessly into a bun with loose ends erupting at all angles. Her daughter looked to be nearly 4 years old. She slept on the gurney, twisted in a ball with her fists splayed on either side of her face. Her flushed face glistened, covered partially by her tousled, unclean hair."I don't know what's wrong, but she's not better," her mother said, rolling her chair slightly away from the bed to allow me free access to her daughter. She turned her dark eyes on me helplessly.
I paged back through the girl's chart and noted that she had been seen earlier that afternoon by one of our other pediatricians and diagnosed with a urine infection. She had been started on antibiotics by mouth and sent home.
"Is she still having pain when she urinates?" I asked the mother.
"I think so. She doesn't want to pee, and she cries." She had also thrown up a few times that evening.
| The paradox of medicine is that we can't have intuition without error. |
I quickly examined the girl, trying not to wake her up. When I touched her belly over her bladder, she winced and shifted a little in her sleep.
I was surprised that she had only the slightest fever, but after reviewing her earlier evaluation and talking with her mother, I thought that she was developing a kidney infection and needed stronger antibiotics. Belly pain and vomiting are classic symptoms of a kidney infection. I didn't call the lab to check on her urine culture results because I thought there had been insufficient incubation time to yield any useful information.
I wrote an order for IV antibiotics and fluids and prepared her discharge paperwork so that the overnight physician would have less work to do. When I left the ER, she was still sleeping. She had not yet started the antibiotics.
The Morning After
The next morning, while reviewing all our hospital admissions, the overnight doctor read a name that sounded very familiar. It took me only a minute to recognize it as belonging to the 4-year-old girl. She had been discharged per my order only to return two hours later. She now had a very high fever and was writhing in pain. She was sent by ambulance to a hospital with a surgeon, nearly 80 miles away, where she was found to have a burst appendix. Her surgery required a large incision with a drain that remained in place afterwards to drain the pus oozing from her abdomen. She spent three or four days in the hospital on IV antibiotics before being discharged home.The minute I heard her ultimate diagnosis, I immediately recognized my error. Appendicitis is one of the most commonly missed diagnoses in medicine, and patients have on average two visits to a physician before the correct diagnosis is made. Early appendicitis simply resembles too many other illnesses. With a young patient who cannot adequately describe the symptoms, there is already an increased risk for perforation. For the pediatrician who saw her in the morning, appendicitis was her diagnosis to miss. But it was mine to catch. The child's symptoms had progressed, and in retrospect, I think her exam pointed to the correct diagnosis.
Clinical Insight
Error is part of medicine, but a part that is difficult to accept. I approach every patient on a variety of levels--my intuition of whether this person is seriously ill or not, my clinical evaluation of a blood gas, my fund of knowledge regarding a particular problem. As I make clinical decisions, I evaluate the various elements and assign them different weights that change from case to case. As much as I pore over the latest studies to inform my medical care, I still rely on an inner, intangible sense about each patient. This creates a flexibility that allows me to entertain obscure diagnoses and identify confounding issues. On the other hand, this flexibility also engenders error. Sometimes I may weed out the extraneous details, but other times I might miss something important.The paradox of medicine is that we can't have intuition without error. In both of the two significant errors I have made to date, I sensed that something was not right. Both times I explained away my concerns. Both times I was wrong.
Nearly a year later, I saw the little girl again, this time for a well-child check-up. She wore bell-bottom blue jeans with flowers embroidered on the hem and a bright T-shirt. Her hair was neatly braided. Her mother recognized me from that night. I apologized for missing the appendicitis, but she seemed unconcerned. Examination of the little girl revealed a large welt on her lower abdomen. The wide scar, significantly larger than that of an uncomplicated appendectomy, peered out at me like an insult as I listened to her heart and checked her pulses.
Recently I called an older surgeon at one of our consulting hospitals for advice about a patient. A 17-year-old boy had suffered a near amputation of his fingertip when he cut it while chopping wood. When I initially evaluated the injury the week previously, it appeared to require only a simple repair. But in the meantime, my colleague's patient with a similar injury had a complication that resulted in amputation of the fingertip. As I removed the stitches from my patient, I suddenly worried that I had not taken the injury seriously enough initially. Perhaps I, too, would have a complication.
The surgeon I spoke to was a veteran, both of city hospitals with plenty of resources as well as the small reservation hospitals and clinics. "We all have bad outcomes," he said. "You can't worry about it so much. By the time you get to be my age, you'll see just how many we really have."
--Ellen Rothman, HMS '98, now practicing in northern Arizona on the Navajo Reservation
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.