Sunday, February 10, 2008

Strike One

It's been 3 days since my first 24-hour duty in a very long time. This is the first time I've seen patients in a hospital and ER setting since I became a licensed physician. It was also the time I committed my first real clinical error in judgment.

I was preparing to assist in a Cesarean section delivery that morning. I was in scrubs and was just waiting for the attending obstetrician, who happens to own the hospital where I work, to arrive. The nurse comes in and tells me that there's a patient who came in for consult at the ER. This was about 6:00 AM. So I went out of the OR complex and down to the ER. A six-year-old girl was waiting for me with her father. I greeted them and started taking the history. The girl, very early that morning, started vomiting and had already thrown up 5 times in a span of a few hours. She had no fever, no dyspnea (difficulty breathing), no cough or colds, no sore throat. She had no diarrhea. I asked her if her tummy hurt. She pointed to her epigastric-periumbilical area (that area just below her rib cage and around the belly button). She had not been ill previously and the father said that she wasn't a fussy child so it alarmed him that she had vomited that much already. I completed the history and began my physical examination of the patient. She had normal eyes, ears, and nose. She had no red throat or cervical lymph nodes. Her breath sounds were clear and her heart was fine. As I palpated her abdomen, she said her epigastric area was tender, even with just a slight touch. This made me doubt whether she really was feeling pain. The rest of the exam was normal. She was active and didn't seem sick at all.

I told the father that I thought this was a case of Acute Gastroenteritis (AGE). The history of vomiting and the epigastric pain was consistent with it. I briefly considered appendicitis but the patient had no fever and looked too healthy for me to seriously consider that diagnosis. Plus, in my mind, I had already minimized the epigastric tenderness and blew it off as the child's being OA. But that was essentially my short list of differentials: AGE or Appendicitis. The father asked whether it could be appendicitis (I did not tell him I had considered it) and I told him I didn't think so, and stated my reasons. I told him that I was sending them home with a prescription for Hydrite and an anti-emetic. I wanted to give Motilium but the bottle available at the hospital pharmacy was too big so I decided to just give them a prescription for Plasil syrup. I taught the father how to give the medicine and asked him to observe for progression of symptoms (if the pain got worse or if her daughter started having diarrhea, other indicators of appendicitis). I thought that if this was indeed appendicitis, the pain would progress and he'd have to come back to the hospital. I thought this was highly unlikely and felt confident that the hydration and anti-emetic would do just fine. I felt secure sending them home since they lived only a few blocks away. Also, I was, by this time, rushing to wrap up the consultation as I found out that the obstetrician and the rest of the OR team were waiting for me to return so I could assist in the CS. I thought that if it was appendicitis, my friend Angel, who was relieving me from duty that morning, would admit them and they'd be in good hands.

I later found out that the father and daughter had returned later that day. The little girl was initially able to tolerate the Hydrite but soon, her vomiting had worsened and she had to be brought back to the hospital. I think she was also running a fever by this time. Angel was smart enough to do a urinalysis and found that she had a Urinary Tract Infection. She was admitted to the hospital.

We were taught in Medical School that in a pediatric patient who presents with vomiting, the first three things that are to be considered are Acute Gastroenteritis, a sore throat, and a urinary tract infection. It's such a well known rule of thumb. The possibility of a UTI had never entered my mind so I never thought to ask for a urine sample. Had I done so, I would have seen pus cells and bacteria in her urine, I would have sent her home on an antibiotic and possibly an antipyretic, and she possibly wouldn't have returned to the hospital with worse symptoms because the antibiotic would have started its work sooner. As soon as I heard from Angel that the patient had UTI, I felt so incompetent as to never have considered that diagnosis. I received my MD with a cum laude under my belt, a Meritissimus in the Oral Revalida, a Medical City Most Outstanding Intern award in Medicine, in Pediatrics (in PEDIATRICS!!!), and Over-All -- and I missed such a simple diagnosis. I realized that I had bluffed my way through medical school and internship training. I'm really just playing pretend (doctor-doctoran, if you will). All the theory that I knew crumbled in the face of a 6-year-old patient and her vomiting. What if the patient had a worse diagnosis but had a lighter chief complaint? I probably would have killed that patient.

Maybe some of you reading this would think I'm just as OA as my patient (OA means over-acting, FYI). I don't think so. I'm not being overly critical of myself because any doctor can tell you that I should have considered UTI and should have done a urinalysis. My residents have always pounded that into my head. When I was finally left to my own devices, my brain turns to mush and I send her home with Hydrite and Plasil (PLASIL, for heaven's sake!). And here I was, scared of getting a code when I couldn't even properly manage one of the simplest pediatric cases known in the medical world.

Alright, I think that's enough berating of myself. I'm currently reading a book called "How Doctors Think" by Jerome Groopman, a Harvard doc and a staff writer at the New Yorker. He talks about the many cognitive errors doctors commit when thinking through their patients cases. I see myself in most situations that he writes about, and I'm sure all doctors would too. He reminded me that clinical medicine, for all its being evidence-based and research-oriented, is still an art. That means there is much uncertainty in the practice of healing and it doesn't help that the way one patient responds to a given therapy can be totally different from the next patient one sees. I am reminded that I need not only to thoroughly master my craft and know my stuff but also to consider each and every patient as a unique case -- this is where the art of medicine comes in. Doctors can't be trapped into conveniently fitting their patients into stereotypes or patterns or molds, as we're taught to do in medical school. It's true that most patients would probably fit into most of the patterns or molds available to us but there will always be that one or two who don't and since we're dealing with real God-given lives, we can't risk being careless. I never realized all this while in medical school. It seemed to me then such an abstract thing, something to be discussed in class in order to get a good grade. It's now all very real to me because now, I have a license that is at stake every time I see a patient and every time I sign a prescription or a patient record. More importantly, I am directly responsible in the care of patients, human beings and creatures of God. I'm filled with fear and awe that I have such a huge responsibility before me but I've chosen this life and I accept the responsibility glad-heartedly. It is my God-given calling. In this instance, fear is a good thing.


The Fish said...

the feeling gets worse once you start residency! can't wait till you start blogging about that.

you can only learn from a mistake after you admit you've made it. Progress is never a straight line. :)

karlmd said...

Sigh. Such is the life we entered.

I can't wait to start blogging about residency too. Haha. I'm eager to get past the early part of the learning curve.

Thanks for the words of wisdom.